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PubMed2003

Early and midterm clinical outcome in patients with severe left ventricular dysfunction undergoing coronary artery surgery.

BACKGROUND: Patients presenting with severe left ventricular (LV) dysfunction undergoing coronary artery surgery are at increased risk of perioperative morbidity and mortality. The present study investigated early and midterm outcomes in a consecutive series of patients with severe LV dysfunction undergoing coronary surgery at our institution. METHODS: Data on 5,195 consecutive patients undergoing coronary artery bypass grafting (CABG) alone (in-hospital mortality 1.35%) from April 1996 to August 2002 were prospectively recorded in the Patient Analysis and Tracking System. Two hundred and fifty patients (median age 65 years [interquartile range, 57 to 70]) with preoperative left ventricular ejection fraction less than 30% (74 off pump; 29.6%) were identified and early and midterm clinical outcomes analyzed. Propensity scores were used to take account of the imbalance in the distribution of prognostic factors between the on-pump and off-pump groups. RESULTS: Patients undergoing on-pump surgery were less likely to have current congestive heart failure, insulin-dependent diabetes, a history of hypertension, have had gastrointestinal tract surgery or an ulcer, or unstable angina. They had on average lower Parsonnet scores and New York Heart Association and Canadian Cardiovascular Score ratings. However they were more likely to have more extensive coronary artery heart disease and to require more grafts than those undergoing off-pump surgery. After adjustment for consultant team and propensity scores no differences between groups with regard to in-hospital mortality and morbidity were found. The only in-hospital outcome to show a significant difference after adjustment was the need for intraoperative inotropic support, which was higher in the on-pump group (odds ratio 5.1; 95% confidence interval 2.55 to 10.2; p < 0.001)). The median follow-up times for the on- and off-pump groups were 3.4 years and 1.4 years respectively. Three-year survival was higher with on-pump surgery (87% on-pump versus 73% off-pump) but this difference did not reach statistical significance after adjustment for prognostic variables (hazard ratio 0.54, 95% confidence interval 0.22 to 1.26, p = 0.16). CONCLUSIONS: In-hospital mortality and morbidity in patients presenting with severe LV dysfunction is low with comparable results with both on- and off-pump coronary artery surgery. Midterm clinical outcome is encouraging and seems to justify surgical revascularization for this high-risk group of patients.

Aged↗
PubMed2002

Right ventricular dysfunction and risk of heart failure and mortality after myocardial infarction.

OBJECTIVES: The aim of this study was to determine the prognostic value of right ventricular (RV) function in patients after a myocardial infarction (MI). BACKGROUND: Right ventricular function has been shown to predict exercise capacity, autonomic imbalance and survival in patients with advanced heart failure (HF). METHODS: Two-dimensional echocardiograms were obtained in 416 patients with left ventricular (LV) dysfunction (ejection fraction [LVEF] < or = 40%) from the Survival And Ventricular Enlargement (SAVE) echocardiographic substudy (mean 11.1 +/- 3.2 days post infarction). Right ventricular function from the apical four-chamber view, assessed as the percent change in the cavity area from end diastole to end systole (fractional area change [FAC]), was related to clinical outcome. RESULTS: Right ventricular function correlated only weakly with the LVEF (r = 0.12, p = 0.013). On univariate analyses, the RV FAC was a predictor of mortality, cardiovascular mortality and HF (p < 0.0001 for all) but not recurrent MI. After adjusting for age, gender, diabetes mellitus, hypertension, previous MI, LVEF, infarct size, cigarette smoking and treatment assignment, RV function remained an independent predictor of total mortality, cardiovascular mortality and HF. Each 5% decrease in the RV FAC was associated with a 16% increased odds of cardiovascular mortality (95% confidence interval 4.3% to 29.2%; p = 0.006). CONCLUSIONS: Right ventricular function is an independent predictor of death and the development of HF in patients with LV dysfunction after MI.

Aged↗
PubMed1989

Nursing implication for pulmonary artery balloon counterpulsation: a treatment for right ventricular dysfunction after cardiac surgery.

PPRVD is a phenomenon frequently observed in the operating room. Its development can be attributed to a single or many factors associated with cardiac operation. Namely, its presence is precipated by injury to the RV myocardium or changes in the normal hemodynamic functions of the RV. While PPRVD occurs in isolation, it is usually seen with concomitant LV dysfunction. When conventional medical management of LV dysfunction does not improve yet unmasks RV dysfunction, some type of ventricular assist device to support RV dysfunction may be needed to wean patients from cardiopulmonary bypass such as PABC. PABC has been demonstrated to be useful in the management of mild to moderate PPRVD and weaning from CPB. Severe PPRVD has not been demonstrated to benefit from PABC. The major concern in managing PPRVD is the lack of quantifiable criteria for determining levels of RV injury. Research is continuing in this area. Likewise, investigations are under way to develop a transvenous PABC catheter. This catheter would allow for increased PABC use as it would not require surgical placement or removal. The present PABC model could potentially be used in any hospital that uses conventional intra-aortic balloon counterpulsation. The patient presented in this case was cared for in a 350-bed community hospital in the Northeast section of the United States. A PABC patient can present a unique nursing challenge. It is hoped that this article will assist nurses in the future management of these patients.

Aged↗
PubMed1989

Emergency coronary angioplasty in patients with severe left ventricular dysfunction or cardiogenic shock after acute myocardial infarction.

Emergency percutaneous transluminal coronary angioplasty (PTCA) was performed during an acute myocardial infarction (AMI) after either systemic or intracoronary thrombolytic therapy in six patients with severe ischaemic left ventricular dysfunction or cardiogenic shock, among 37 patients (17%) who were treated with PTCA during AMI over a 13-month period. Thrombolytic therapy with streptokinase (1.5 x 10 Units) was initiated after a mean (+/- SD) time delay of 5.5 +/- 1.3 h from the onset of symptoms. The infarct-related artery was found to be occluded (TIMI grade 0-1) in three patients and partially reperfused (TIMI grade 2) in the remaining patients at baseline coronary angiography. Intracoronary administration of urokinase (100-200,000 Units) was ineffective in those patients failing systemic thrombolysis and resulted in only a slight increase of residual lumen in three patients. The coronary artery could be opened by a guidewire mechanical technique in patients with persistent coronary artery occlusion and coronary dilation could be done in all patients. The mean percentage diameter stenosis of the infarct-related vessel was reduced from 98.8 +/- 2% to 27 +/- 11% (P less than 0.005). After the procedure, left ventricular ejection fraction increased from 27 +/- 8% to 41 +/- 7% (P less than 0.02), systemic blood pressure and cardiac index increased respectively from 86 +/- 10 to 126 +/- 14 mmHg (P less than 0.005) and from 2.2 +/- 0.6 to 3.3 +/- 0.6 (P less than 0.01). Left ventricular end-diastolic pressure decreased from 26 +/- 8 to 18 +/- 3 mmHg (P less than 0.05). Severe mitral regurgitation was relieved in one patient.(ABSTRACT TRUNCATED AT 250 WORDS)

Adult↗
PubMed1997

Comparison of myocardial revascularization without cardiopulmonary bypass to standard open heart technique in patients with left ventricular dysfunction.

OBJECTIVE: To compare myocardial revascularization without cardiopulmonary bypass to standard open heart technique in patients with left ventricular (LV) dysfunction. METHODS: 117 patients with LV dysfunction (ejection fraction (EF) < 35%) underwent coronary artery bypass surgery between January 1991 and July 1994. Sixty-four (group A) were operated on without a cardiopulmonary bypass, and 53 (group B) with one. Prevalence of EF < 20% (17 vs. 6%) and emergency operations (22 vs. 7%, P = 0.03) was higher in group A. The average number of grafts was 1.9 +/- 0.8/pt in group A and 3.5 +/- 0.9/pt in group B (P < 0.01), and the internal mammary artery was used in 54 (84%) and 42 (79%) patients, respectively. Only 16 patients (25%) in group A received a graft to a circumflex marginal artery compared to 51 (96%) in group B (P < 0.0001). RESULTS: Two patients (3.1%) died perioperatively in group A compared to 7 (13%) in group B (P = NS). In two patients from group A (3.1%) and in four (7.5%) from group B intra-aortic balloon pump was inserted postoperatively (P = NS). One year actuarial survival was 91 and 79% (P = 0.03) and 2-year survival was 86 and 65% (P = 0.04), respectively. Return of angina occurred in five (8%) and three (6%) patients (P = NS). CONCLUSIONS: These results show a trend for lower operative risk resulting in better overall survival in selected patients with LV dysfunction undergoing coronary artery bypass surgery without cardiopulmonary bypass.

Actuarial Analysis↗
PubMed2006

Selective matrix metalloproteinase inhibition attenuates progression of left ventricular dysfunction and remodeling in dogs with chronic heart failure.

Matrix metalloproteinases (MMPs) contribute to the progression of left ventricular (LV) dysfunction and remodeling associated with heart failure (HF). The present study examined the long-term effects of a selective MMP inhibitor PG-530742 (PG) on the progression of LV dysfunction and remodeling in dogs with HF. Chronic HF [LV ejection fraction (LVEF), </=36%] was produced by multiple sequential intracoronary microembolizations in 24 dogs. Two weeks after the last embolization, dogs were randomized to 3 mo of therapy with either high-dose (HD) PG (3.5 mg/kg, n = 8), low-dose (LD) PG (0.2 mg/kg, n = 8), or to a matched placebo (PL, n = 8). PG has been shown to produce complete inhibition of MMP-2, -3, -9, and -13, while sparing MMPs-1 and -7. Hemodynamic and echocardiographic measurements were made before and 3 mo after initiating therapy. In PL and LD dogs, LVEF decreased significantly, and LV end-systolic volume (ESV) and LV end-diastolic volume (EDV) increased significantly during the 3-mo follow-up period. Whereas in HD dogs ejection fraction increased from 36 +/- 1 to 40 +/- 1% (P = 0.003), EDV and ESV decreased (59 +/- 4 vs. 57 +/- 4 ml, P = 0.02; and 38 +/- 2 vs. 34 +/- 2 ml, P = 0.00001, respectively). When compared with controls, HD-treated dogs showed 30% reduction in replacement fibrosis, 29% reduction in interstitial fibrosis, and 28% reduction in myocyte cross-sectional area. mRNA expression of selective MMPs was also reduced in LV tissue in HD- but not LD-treated dogs. In conclusion, in dogs with moderate HF, long-term monotherapy with HD selective MMP inhibitor PG prevents LV remodeling and the progression of global LV dysfunction.

Animals↗
PubMed1990

[Value of the handgrip apex cardiography test for detection of early diastolic ventricular dysfunction in patients with angina pectoris].

Left ventricular (LV) diastolic dysfunction is the earliest manifestation of myocardial ischemia. There are no simple stress tests for detecting ischemia by assessing abnormal changes of early (relaxation) and late (end-diastolic compliance) LV diastolic function. This study attempts to establish the diagnostic accuracy of the handgrip-apexcardiographic test (HAT) for detecting exercise-ischemia-induced diastolic dysfunction. Apex- and phonocardiogram were obtained during a 2-min handgrip (40% of maximal voluntary contraction using a balloon dynamometer). Indices of LV diastolic function were provided by relative A-wave to total height (A/H) of ACG, total apexcardiographic relaxation time (TART), TART corrected for heart rate (TARTI), and diastolic amplitude time index (DATI). HAT was performed in 63 patients with typical stable angina pectoris and 202 healthy volunteers. Positivity of HAT is defined by the presence of at least one of the following new criteria: 1) A/H during or after handgrip greater than 21% (= largest individual value in controls), 2) TART during greater than TART before handgrip greater than 143 ms or TARTI during handgrip less than 0.14 (= lowest individual value in controls), and 3) DATI during handgrip less than 0.27. According to this definition, all controls showed a negative HAT (specificity: 100%). By contrast, HAT was positive in 54 out of the 63 angina patients (sensitivity: 86%). These results demonstrate that HAT is a highly sensitive stress test for identifying patients with angina pectoris by assessing LV diastolic abnormalities. Thus, this quick and simple exercise method represents a new aspect in the clinical evaluation of angina patients for the practicing physician.

Adolescent↗
PubMed1993

Effects of beta blockers on ventricular dysfunction after myocardial infarction: tolerability and survival effects.

At least 44 randomized trials of beta blockade in acute myocardial infarction have been reported. All of these trials excluded patients with moderate-to-severe clinical signs of acute left ventricular dysfunction (LVD). Several of the larger trials did include high-risk patients with a history of compensated heart failure or with symptoms and signs suggesting mild LVD. Data from these trials indicate that beta-blocker treatment was well tolerated by patients with LVD, both in the acute phase of myocardial infarction and during long-term follow-up treatment. Further, data for LVD patients indicate that mortality in the beta-blocker group was reduced by 20-30% when compared with the placebo group. A similar mortality reduction was obtained for the entire patient population in the trials. Because of the high mortality among patients with mild LVD, the absolute gain in numbers of lives saved per 100 patients treated with beta blockers is even larger than that in patients without LVD. Data from two long-term trials indicate marked (47% and 43%) reductions in the likelihood of sudden death among LVD patients treated with beta blockers. These results suggest that all patients with LVD who can tolerate beta blockade may benefit from treatment with these agents.

Adrenergic beta-Antagonists↗
PubMed1981

Doxorubicin cardiotoxicity: assessment of late left ventricular dysfunction by radionuclide cineangiography.

Radionuclide cineangiography was used to evaluate 32 patients who sustained long-term remission of soft tissue sarcoma after adjuvant therapy with a cumulative doxorubicin dose from 480 to 550 mg/m body surface area. Left ventricular ejection fraction at rest was below normal (less than 45%) in eight of 32 patients. The abnormal response of ejection fraction to exercise identified an additional 12 patients with diminished left ventricular functional reserve. Ejection fraction determined at rest or during exercise did not differ 1 to 9 months) and those studied 30 months (range, 21 to 43 months) after completing doxorubicin treatment. Sequential studies in 13 patients, done 6 to 15 months after initial post-doxorubicin evaluation also showed persistent depression of average ejection fraction at rest and with exercise, with the continued deterioration of left ventricular function in six patients. Left ventricular dysfunction, evident in over half of asymptomatic patients even long after "acceptable" cumulative doses of doxorubicin, may persist for years.

Adolescent↗
PubMed2006

Coronary artery bypass grafting in patients with left ventricular dysfunction.

BACKGROUND: Coronary artery bypass grafting surgery (CABG) remains a challenge for patients with coronary artery disease and left ventricular (LV) dysfunction. The aim of this study was to evaluate the result of CABG in patients with LV dysfunction. METHODS: Medical records of 1,847 patients who underwent primary, isolated CABG at Taipei Veterans General Hospital from January 1, 1991 to December 31, 2002, were reviewed. The mortality rate associated with clinical and operative variables was compared between patients with LV ejection fraction (LVEF) > or = 35% and patients with LVEF < 35%. RESULTS: Patients with LVEF < 35% had more episodes of myocardial infarction (57.5% vs 28.9%, p < 0.001) and history of congestive heart failure (18.1% vs 3.2%, p < 0.001), higher New York Heart Association (NYHA) class, and higher angina class. Longer cardiopulmonary bypass time (147 +/- 44 minutes vs 137 +/- 40 minutes, p < 0.001) but fewer left internal mammary artery (LIMA) grafts (46.8% vs 65.7%, p < 0.001) were used in patients with LVEF < 35%. Patients with LVEF < 35% had significantly higher hospital mortality (6.6% vs 2.2%, p < 0.001), higher major morbidity (23.3% vs 16.1%, p < 0.01), and longer hospital stay (25 +/- 23 days vs 21 +/- 16 days, p < 0.01). CONCLUSION: Although patients with LV dysfunction had higher mortality and morbidity, CABG could be done in these high-risk patients with acceptable results.

Adult↗
PubMed2002

Evidence for left ventricular dysfunction in patients with obstructive sleep apnoea syndrome.

There is limited information on the development of left ventricular (LV) dysfunction in patients with obstructive sleep apnoea (OSA) in the absence of lung and cardiac comorbidity. This study aimed to investigate whether OSA patients without heart morbidity develop LV dysfunction, and to assess the effect of continuous positive airway pressure (CPAP) on LV function. Twenty-nine OSA patients and 12 control subjects were studied using technetium-99m ventriculography to estimate LV ejection fraction (LVEF), LV peak emptying rate (LVPER), time to peak emptying rate (TPER), peak filling rate (LVPFR) and time to peak filling rate (TPFR) before and after 6 months of treatment with CPAP. A significantly lower LVEF was found in OSA patients, compared to control subjects, (53+/-7 versus 61+/-6%) along with a reduced LVPER (2.82+/-0.58 versus 3.82+/-0.77 end-diastolic volumes x s(-1)). Furthermore, OSA patients had significantly lower LVPFR (2.67+/-0.71 versus 3.93+/-0.58 end-diastolic volumes x s(-1)) and delayed TPFR (0.19+/-0.04 versus 0.15+/-0.03 s) in comparison with the control group. Six-months of CPAP treatment was effective in significantly improving LVEF, LVPER, LVPFR and TPFR. In conclusion, obstructive sleep apnoea patients without any cardiovascular disease seem to develop left ventricular systolic and diastolic dysfunction, which may be reversed, either partially or completely, after 6 months of continuous positive airway pressure treatment.

Female↗
PubMed1980

Right myocardial infarction with predominant right ventricular dysfunction.

Two patients with right ventricular myocardial infarction are described. In both cases, the hemodynamic criteria established for this diagnosis were fulfilled, namely, right-side pressure values (central venous pressure and right atrial pressure) equal to or higher than left-side pressure values (pulmonary capillary wedge pressure and left ventricular end-diastolic pressure). ECG tracings showed acute diaphragmatic myocardial infarction. The lungs were clear both clinically and radiologically. The diagnosis of right ventricular myocardial infarction was confirmed in the first patient by hemodynamic studies and at autopsy, and in the second patient, by hemodynamic and echocardiographic studies. Only in the second care was the administration of massive quantities of fluids and dopamine followed by good results. The importance of establishing a precise diagnosis of right ventricular myocardial infarction is emphasized, since therapy for this condition is different than that for left ventricular myocardial infarction.

Aged↗
PubMed1994

Late survival up to 20 years after isolated coronary by-pass surgery using internal mammary artery in patients with severe left ventricular dysfunction.

Coronary patients with left ventricular ejection fraction (LVEF) < 40% and abnormal motion of all left ventricular walls on cineangiography but without significant valve disease or left ventricular aneurysm were selected for this study. From January 1970 to December 1990, 155 patients meeting the above criteria consecutively underwent coronary by-pass surgery; preoperatively, 149 patients had angina class III or IV, and 49 patients had dyspnea class II or III. LVEF was 31 +/- 7%. During this 20-year period, two different surgical techniques have been used: from 1970 to 1981, 79 patients (group I) received internal mammary artery upon left anterior descending artery with associated simple saphenous grafts, under intermittent aortic cross clamping; from 1982 to 1990, 76 patients (group II) received internal mammary artery upon left anterior descending artery with associated sequential saphenous vein graft, under oxygenated cardioplegic myocardial protection. The mean number of by-pass was 1.6 in group I and 3.7 in group II (p = 0.001). Early mortality rate was lower in group II than in group I: 2.6% vs 7.6% (p = 0.01). After a follow-up of 79 +/- 14 months, there were 51 late deaths, 6 patients were lost to follow-up and 90 patients were still alive; 80% of all deaths were from cardiac causes, including 38% due to heart failure. Actuarial survival rate at 5, 10, 15 years was 79 +/- 7%, 63 +/- 10%, and 36 +/- 15% respectively. The 5-year survival rate was 71 +/- 10% in group I and 88 +/- 8% in group II (p = 0.02).(ABSTRACT TRUNCATED AT 250 WORDS)

Actuarial Analysis↗
PubMed1993

Myocardial revascularization in the patient with severe left ventricular dysfunction.

In the past, poor ventricular function was considered a contraindication for myocardial revascularization. More recently, however, patients once considered to be a prohibitive risk for coronary artery bypass procedures are undergoing surgery with acceptable operative mortality and successful long-term outcomes. In fact, reparative surgical results often exceed those achieved through medical management and/or transplantation.

Female↗
PubMed2005

Inaccuracy of dipyridamole echocardiography or scintigraphy for the diagnosis of coronary artery disease in patients with both left bundle branch block and left ventricular dysfunction.

Non-invasive diagnosis of coronary artery disease (CAD) in patients with left ventricular (LV) dysfunction and left bundle branch block (LBBB) remains challenging, and there is no consensus on the role of myocardial sesta-MIBI perfusion scintigraphy with pharmacological stress (dip-MIBI) or dipiridamole echocardiography (dip-ECHO). We thus performed a prospective study to test the diagnostic accuracy of such non-invasive tests. 27 consecutive patients with both LV dysfunction and LBBB undergoing diagnostic work-up for CAD were studied simultaneously with dip-ECHO and dip-MIBI. The sensitivity for CAD for dip-ECHO and dip-MIBI was respectively 42% and 67%, with specificity 93% and 53%, and likelihood ratio (LR)-positive 6.3 and LR-negative 0.6 for both. Given the low accuracy of both dip-ECHO and dip-MIBI in detecting CAD in patients with concomitant LV dysfunction and LBBB, coronary angiography should be performed as the default diagnostic strategy in such patients.

Aged↗
PubMed1980

Left ventricular dysfunction--bedside Valsalva manoeuvre.

Thirty-seven patients were evaluated before cardiac catheterisation by bedside physical examination, including Valsalva manoeuvre, to assess the value of the sphygmomanometrically determined arterial pressure responses during the Valsalva manoeuvre and to compare its sensitivity, specificity, and predictive accuracy in the detection of left ventricular dysfunction with that of the commonly used diagnostic signs including the chest x-ray. Patients not on beta-blockade treatment could be separated into three distinct arterial pressure responses detectable at the bedside which corresponded well to three statistically different groups with regard to left ventricular ejection fraction (0.29 +/0 0.11, 0.48 +/0 0.15, 0.69 +/0 0.11) and left ventricular end-diastolic pressure (38 +/- 5 mmHg, 24 +/- 10 mmHg, 14 +/- 5 mmHg) at subsequent cardiac catheterisation. In patients not on beta-blockade it was shown for the first time that (1) the height of the systolic arterial pressure overshoot was directly related to left ventricular ejection fraction and inversely related to left ventricular end-diastolic pressure, and that (2) the bedside sphygmomanometrically determined arterial pressure response during Valsalva manoeuvre provided a semiquantitative estimate of left ventricular function and was unsurpassed in its ability to do so by any of the standard diagnostic signs including the chest x-ray film.

Blood Pressure↗
PubMed1987

Sex differences in exercise induced left ventricular dysfunction in patients with syndrome X.

Clinical, electrocardiographic, and scintigraphic data were reviewed from 32 patients (18 men and 14 women) who had syndrome X (chest pain, evidence of ischaemia, and normal coronary arteries without coronary vasospasm). The mean (SD) resting left ventricular ejection fraction, determined by first pass radionuclide angiography was 62.6 (9.2)% and was greater than 50% in all subjects. There was no significant difference between men and women. On exercise, left ventricular ejection fraction decreased significantly to 57.4 (13.0)%. In 17 of 32 subjects there was a fall in left ventricular ejection fraction of greater than 5%, and regional wall motion abnormalities developed in 12 subjects. The fall in left ventricular ejection fraction on exercise was significant in women (from 61.9 (8.5)% at rest to 54.0 (9.8)% on exercise) but not in men (from 63.2 (9.8)% at rest to 60.0 (14.8)% on exercise). Exercise left ventricular ejection fraction fell by greater than 5% in 10 (71%) of 14 women and in seven (39%) of 18 men. Dyskinetic segments developed in eight (57%) of 14 women and only four (22%) of men. Exercise duration in women was significantly shorter than in men (4.1 (1.5) vs 6.6 (2.1) minutes) and was the only one of several clinical and scintigraphic variables that correlated with the change in left ventricular ejection fraction on exercise. In this selected group of subjects with chest pain and angiographically normal coronary arteries, exercise induced left ventricular dysfunction, as shown by a fall in ejection fraction or the development of regional abnormalities, is a common finding. These are more likely to occur in women than men and are associated with a lower exercise capacity. The data suggest that the sex of the patient is important in the interpretation of the non-invasive evaluation of subjects suspected of having syndrome X.

Adult↗