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PubMed1997

Aortic valve replacement for aortic stenosis with severe left ventricular dysfunction. Prognostic indicators.

BACKGROUND: Aortic valve replacement for aortic stenosis (AS) carries an increased risk in the presence of left ventricular (LV) systolic dysfunction. Few data are available on the outcome of such patients. METHODS AND RESULTS: Between 1985 and 1992, 154 consecutive patients (107 men and 47 women) with LV systolic dysfunction (ejection fraction [EF] < or = 35%) underwent aortic valve replacement for AS. The mean preoperative characteristics included EF, 27 +/- 6%; aortic valve mean gradient, 44 +/- 18 mm Hg; aortic valve area, 0.6 +/- 0.2 cm2; and cardiac output, 4.1 +/- 1.5 L/min. Simultaneous coronary artery bypass graft surgery was performed in 78 patients (51%). Perioperative (30-day) mortality was 9% (14 of 154 patients). Fifty patients died during follow-up. Coronary artery disease (P = .002) and a reduced preoperative cardiac output (P = .03) were significantly related to reduced overall survival rate by multivariate analysis. Postoperative improvement occurred in most patients; 88% were New York Heart Association class III or IV before surgery versus 7% after surgery. Postoperative EF was assessed in 76% of survivors; 76% of these demonstrated improvement. By multivariate analysis, change in EF was inversely related to coronary disease (P = .002) and preoperative aortic valve area (P = .03). CONCLUSIONS: Despite LV dysfunction, the risk of aortic valve replacement for AS was acceptable and related to coronary artery disease and mean aortic gradient, and long-term survival was related to coronary disease and cardiac output. Improvement in symptoms and EF occurred in most patients.

Adult↗
PubMed2002

Chronic treatment of enbrel in rats with isoproterenol-induced congestive heart failure limits left ventricular dysfunction and remodeling.

OBJECTIVE: To investigate the effect of chronic treatment of enbrel (EB), a TNF-alpha antagonist, in a well defined congestive heart failure (CHF) rat model and test the hypothesis that chronic treatment of EB in CHF rats may limit the progression of Left ventricular (LV) dysfunction and structure remodeling and decrease cardiac IL-1beta levels. METHODS: We measured cardiac conformation, contractile performance and cytokines level in 8 age-matched normal adult rats (control group) and 8 rats with isoproterenol (ISO)-induced Heart failure (ISO group) and 8 rats with ISO-induced lesion but received EB treatment (EB group). RESULTS: LV end diastolic diameter and LV end systolic diameter in EB group were significantly less and LV fractional shortening was significantly larger than ISO group (9.2 +/- 0.3 mm vs 9.5 +/- 0.2 mm, 5.8 +/- 0.5 mm vs 6.5 +/- 0.3 mm, 0.37 +/- 0.03 vs 0.31 +/- 0.02, P < 0.05, P < 0.01, P < 0.01 respectively , but there was no significant difference of LV posterior wall thickness at end diastole between the two groups; LV end systolic pressure (P(ES)) dp/dt(max) in EB group were significantly greater than ISO group (104.8 +/- 4.6 mm Hg vs 98.4 +/- 4.9 mm Hg, 8395 +/- 940 mm Hg/s vs 6898 +/- 612 mm Hg, P < 0.05 P < 0.01 respectively), and LV end diastolic pressure (P(ED)) dp/dt(min), time constant of LV relaxation were significantly lower than ISO group (3.8 +/- 0.6 mm Hg vs 7.1 +/- 0.8 mm Hg, -5963 +/- 475 mm Hg/s vs-5030 +/- 316 mm Hg/s,15.4 +/- 0.8 ms vs 21.3 +/- 1.4 ms, P < 0.01, respectively . Although cardiac contractile performance in the EB group was greatly improved, there still was a big gap when compared with the control group. The ratio of LV weight to body weight in the EB group was significantly higher than control group 2.82 +/- 0.07 mg/g vs 2.28 +/- 0.08 mg/g, P < 0.01 but there was no significant difference when compared with the ISO group. There was no significant difference between the serum level of TNF-alpha in EB group and ISO group the it could not be detected in control group. TNF-alpha levels in LV of EB group was significantly higher than control group, 757.6 +/- 46.8 pg/g vs 367.5 +/- 22.7 pg/g, P < 0.01 but there was no significant difference when compared with ISO group. The IL-1beta level in LV of EB group was significantly lower than ISO group 356.2 +/- 28.5 pg/g vs 518.4 +/- 32.5 pg/g, P < 0.05 and it could not be detected in control group. The serum level of IL-1beta could not be detected in any rats. CONCLUSION: EB administered as soon as possible when ISO induced myocardial necrosis occurs can greatly improve cardiac contraction, and the improvement may be partly due to a decrease in the IL-1beta level in LV, besides the direct blocking effect of EB on TNF-alpha. EB can alleviate cardiac remodeling by its effect on LVEDD.

Animals↗
PubMed2001

Myocardial glucose utilization and optimization of (18)F-FDG PET imaging in patients with non-insulin-dependent diabetes mellitus, coronary artery disease, and left ventricular dysfunction.

UNLABELLED: In patients with non-insulin-dependent diabetes mellitus (NIDDM), FDG PET imaging is often problematic because of poor uptake of FDG. Different protocols have been used; however, these have not been directly compared in patients with NIDDM who have both coronary artery disease (CAD) and severe left ventricular (LV) dysfunction, for which defining viability is most relevant. The aim of this study was to better define the optimal means of FDG PET imaging, assessed by image quality and myocardial glucose utilization rate (rMGU), among 3 imaging protocols in patients with NIDDM, CAD, and severe LV dysfunction. METHODS: Ten patients with NIDDM, CAD, and severe LV dysfunction (mean ejection fraction, 29.8% +/- 7.1%) underwent dynamic FDG PET scanning using 3 different protocols: the standard protocol, consisting of oral glucose loading or a supplemental insulin bolus based on fasting glucose; the niacin protocol, consisting of pretreatment with niacin to lower free fatty acids; and the insulin clamp protocol, consisting of hyperinsulinemic euglycemic clamp. Image quality was satisfactory with at least 1 approach in 8 patients, who formed the primary analysis group. RESULTS: Myocardium-to-blood-pool ratios were significantly higher with the insulin clamp (standard, 1.7 +/- 1.2; niacin, 1.6 +/- 1.0; insulin clamp, 3.4 +/- 2.5 [P < 0.05 vs. standard and niacin]). Values for rMGU were higher with the insulin clamp (standard, 0.11 +/- 0.07 micromol/g/min; niacin, 0.12 +/- 0.11 micromol/g/min; insulin clamping, 0.22 +/- 0.12 micromol/g/min [P = 0.004 vs. standard and 0.07 vs. niacin]). CONCLUSION: The hyperinsulinemic euglycemic clamp yielded the highest FDG PET image quality and the highest rMGU in a comparison with the standard and niacin protocols in this difficult group of patients with NIDDM, CAD, and severe LV dysfunction. The hyperinsulinemic euglycemic clamp may be the preferred method for FDG PET viability imaging in this population. Larger clinical trials are needed to assess whether accuracy is greater with this approach.

Coronary Artery Disease↗
PubMed1998

Left ventricular dysfunction following rewarming from experimental hypothermia.

This study was aimed at elucidating whether ventricular hypothermia-induced dysfunction persisting after rewarming the unsupported in situ dog heart could be characterized as a systolic, diastolic, or combined disturbance. Core temperature of 8 mongrel dogs was gradually lowered to 25 degreesC and returned to 37 degreesC over a period of 328 min. Systolic function was described by maximum rate of increase in left ventricular (LV) pressure (dP/dtmax), relative segment shortening (SS%), stroke volume (SV), and the load-independent contractility index, preload recruitable stroke work (PRSW). Diastolic function was described by the isovolumic relaxation constant (tau) and the LV wall stiffness constant (Kp). Compared with prehypothermic control, a significant decrease in LV functional variables was measured at 25 degreesC: dP/dtmax 2,180 +/- 158 vs. 760 +/- 78 mmHg/s, SS% 20.1 +/- 1.2 vs. 13.3 +/- 1.0%, SV 11.7 +/- 0.7 vs. 8.5 +/- 0.7 ml, PRSW 90.5 +/- 7.7 vs. 29.1 +/- 5.9 J/m. 10(-2), Kp 0.78 +/- 0.10 vs. 0.28 +/- 0.03 mm-1, and tau 78.5 +/- 3.7 vs. 25.8 +/- 1.6 ms. After rewarming, the significant depression of LV systolic variables observed at 25 degreesC persisted: dP/dtmax 1,241 +/- 108 mmHg/s, SS% 10.2 +/- 0.8 J, SV 7.3 +/- 0.4 ml, and PRSW 52.1 +/- 3.6 m. 10(-2), whereas the diastolic values of Kp and tau returned to control. Thus hypothermia induced a significant depression of both systolic and diastolic LV variables. After rewarming, diastolic LV function was restored, in contrast to the persistently depressed LV systolic function. These observations indicate that cooling induces more long-lasting effects on the excitation-contraction coupling and the actin-myosin interaction than on sarcoplasmic reticulum Ca2+ trapping dysfunction or interstitial fluid content, making posthypothermic LV dysfunction a systolic perturbation.

Animals↗
PubMedDate not supplied

Combined assessment of left ventricular function and rest-redistribution regional myocardial thallium-201 activity for prognostic evaluation of patients with chronic coronary artery disease and left ventricular dysfunction.

BACKGROUND: This study evaluated the prognostic value of combined assessment of left ventricular (LV) function and regional myocardial thallium activity in patients with nonrecent myocardial infarction and LV dysfunction. METHODS AND RESULTS: Eighty-two patients with previous myocardial infarction (>8 weeks) and echocardiographic evidence of LV dysfunction underwent thallium-201 rest-redistribution tomography and cardiac catheterization. During the follow-up period (mean 25 months) there were 18 cardiac events (14 deaths and 4 nonfatal myocardial infarctions). Multivariate Cox regression analysis on clinical, angiographic, and thallium variables showed that the number of echocardiographic dysfunctional segments with preserved thallium uptake (> or =50% of peak activity; chi-square 11.03; p<0.005) and age (chi-square 8.12, p<0.01) were predictive of poor outcome. At incremental analysis, combined echocardiographic and thallium data provided significant additional information to clinical, thallium, and LV functional data, increasing global chi-square value from 22.4 to 31.5 (p< 0.01). Similarly, combined data gave additional information after considering clinical, echocardiographic, and LV functional data, increasing global chi-square from 17.8 to 22.3 (p <0.05). Differently, the number of diseased vessels at coronary angiography did not add further prognostic information. CONCLUSIONS: In patients with previous myocardial infarction and chronic LV dysfunction, the combination of echocardiographic and thallium rest-redistribution imaging data gives prognostic information incremental to those of clinical and LV functional data and to those of each technique considered separately.

Cardiac Catheterization↗
PubMedDate not supplied

Exercise-test Tc-99m tetrofosmin SPECT in patients with chronic ischemic left ventricular dysfunction: direct comparison with Ti-201 reinjection.

BACKGROUND: This study was designed to compare the results of exercise-rest technetium-99m tetrofosmin single photon emission computed tomography (SPECT) with those of thallium-201 reinjection at rest after exercise-redistribution imaging in the same patients with chronic ischemic left ventricular (LV) dysfunction. METHODS: Within 1 week, 33 patients with chronic myocardial infarction and LV dysfunction underwent exercise-rest tetrofosmin SPECT and Tl-201 reinjection at rest after exercise-redistribution imaging. In each patient, regional tetrofosmin and Tl-201 activity was quantitatively measured in 22 myocardial segments. Regional LV function was assessed in corresponding segments by echocardiography. RESULTS: Agreement in the evaluation of regional perfusion status between tetrofosmin and Tl-201 imaging was observed in 78% of the 726 total segments, with a kappa value of 0.61. In segments with normal function at echocardiography (n = 436), no difference between Tl-201 and tetrofosmin uptake was observed. In hypokinetic segments (n = 138), exercise tetrofosmin uptake was lower (P < .01) as compared with exercise Tl-201 activity, whereas no difference was observed between tetrofosmin uptake at rest as compared with Tl-201 activity on redistribution and reinjection images. In segments with severe functional impairment (akinetic or dyskinetic, n = 152), tetrofosmin uptake on exercise images was reduced (P < .01) as compared with exercise Tl-201 activity; furthermore, tetrofosmin uptake at rest was lower (P < .01) as compared with Tl-201 activity on both redistribution and reinjection images. In these segments, concordance in the detection of myocardial viability between tetrofosmin and Tl-201 imaging was observed in 138 (91%) of the 152 segments, with a kappa value of 0.77. CONCLUSIONS: In patients with chronic coronary artery disease and LV dysfunction quantitative exercise-rest tetrofosmin and Tl-201 reinjection SPECT provide similar information in the assessment of perfusion status and in the detection of myocardial viability.

Adult↗
PubMed1995

Early intervention in patients with heart failure and left ventricular dysfunction.

The focus of this article is to review the process of left ventricular remodeling and discuss the results of several published large clinical trials that have demonstrated the benefit of early intervention in heart failure to prevent left ventricular remodeling and progression of cardiac dysfunction. The knowledge gained from this review should help define a strategy for the internist to initiate therapy early in the course of development of heart failure.

Angiotensin-Converting Enzyme Inhibitors↗
PubMed2005

Levosimendan improves hemodynamics and coronary flow reserve after percutaneous coronary intervention in patients with acute myocardial infarction and left ventricular dysfunction.

BACKGROUND: Positive inotropic agents may be associated with increasing myocardial ischemia or malignant arrhythmias. Levosimendan, a new calcium sensitizer, with its little effect on myocardial oxygen demand is better tolerated by patients with acute coronary syndromes. We evaluated the acute effects of levosimendan on hemodynamics and coronary flow velocities in patients with left ventricular (LV) dysfunction undergoing percutaneous coronary interventions (PCIs) for an acute myocardial infarction (AMI). METHODS: Patients with AMI and LV dysfunction undergoing primary PCI were randomized to intravenous infusion of levosimendan (10 minutes bolus with 12 microg/kg followed by 0.1 microg/kg per minute for 24 hours) or placebo, 10 minutes after a primary PCI. Evaluation of hemodynamics and of coronary flow reserve (CFR) were performed at baseline and after bolus. RESULTS: Twenty-six consecutive patients (mean age 57 +/- 5.4 years, 18 males) were included into the study. At baseline, mean values of hemodynamics and coronary flow velocities were comparable between groups. After bolus, patients with levosimendan (n = 12) showed a significant decrease of pulmonary capillary wedge pressure (from 24 to 19 mm Hg) and a significant increase of cardiac index (from 1.8 to 2.4 L/m2 per minute) resulting in a significant decrease of systemic vascular resistance (from 1366 to 1075 [dyne . s]/cm2). Moreover, CFR on infarct-related artery and on reference vessel significantly improved in patients treated with levosimendan (from 1.6 to 2.0 and from 2.1 to 2.4, respectively). On the other hand, no statistically significant changes have been observed in the placebo group (n = 14). CONCLUSIONS: Levosimendan, given intravenously after a PCI procedure in patients with AMI and LV dysfunction, significantly improves hemodynamics and CFR, compared with placebo.

Angioplasty, Balloon, Coronary↗
PubMed1983

Unsuspected right ventricular dysfunction in shock and sepsis.

Monitoring of ventricular function by central venous (CVP) and pulmonary wedge pressures (PCW) was compared with ejection fraction and end-diastolic volume (gated pool scan) in patients resuscitated from hypovolemic and septic shock. Sixteen patients were studied within 24 hours of resuscitation and all showed depressed right ventricular ejection (RVEF) and/or an increased end-diastolic volume (RVEDVI). Group I (eight patients, hypovolemia and sepsis) had low RVEF (mean, 0.30), high RVEDVI (mean 129.2 ml/m2), and nearly normal left ventricular function (LVEF 0.63 and LVEDVI 63.6 ml/m2), compared to angiographic normals (RVEF 0.52, RVEDVI 55.8 ml/m2; nL LVEF 0.59, LVEDVI 52.3 ml/m2). Group II (3 patients, all septic) had better RVEF (mean, 0.54) but high RVEDVI (mean, 121.1 ml/m2) with normal LVEF (mean, 0.67) and high LVEDVI (mean LVEDVI 107.2 ml/m2). Group III consisted of five patients (hypovolemia and sepsis) who had biventricular depression (RVEF 0.25 and LVEF 0.29) and elevated EDVI. The mortality rate for group I (25%) was significantly less than for groups II and III (100% and 80%, respectively), and could be correlated with failure to improve RV function. Follow-up studies in ten patients showed improvement in seven which correlated with increased RVEF and reduced RVEDVI. Comparing survivors to non-survivors showed no predictability on the basis of initial studies but a significantly larger RVEDVI and RV stroke work index in non-survivors' follow-up studies. No correlation could be made with left ventricular performance, and there were no correlations between PCWP and LVEDVI or CVP and RVEDVI. A significant negative correlation was seen between RVEF and pulmonary vascular resistance (r = -0.34, p less than 0.05). Both LVEDVI and RVEDVI were correlated significantly with cardiac index and with each other. RV dysfunction occurs after resuscitation of hypovolemia and sepsis without reliable alteration in filling pressure and is likely related to myocardial ischemia as well as increased pulmonary vascular resistance. Survival seems to depend on improvement in RV performance, which can be measured at the bedside by cardiac scintigraphy.

Adult↗
PubMed1998

Endothelin-1 has haemodynamic effects at pathophysiological concentrations in patients with left ventricular dysfunction.

OBJECTIVES: Plasma levels of immunoreactive endothelin-1 (ET-1) are raised in chronic heart failure. Whether plasma ET-1 contributes to the haemodynamic derangement found in chronic heart failure is not known. We investigated the effects of exogenous ET-1 on the pulmonary and systemic vasculature in patients with left ventricular systolic dysfunction (LVD), with or without overt heart failure. METHODS: ET-1 was infused at 1, 5 and 15 pmol/min into a distal pulmonary artery of ten patients with LVD to achieve plasma concentrations of ET-1 similar to those found in patients with heart failure and pulmonary hypertension. Haemodynamics were measured using a pulmonary thermodilution catheter and an arterial line. Intravascular Doppler and local pulmonary angiography were used to assess local pulmonary blood flow in the first four patients. RESULTS: Systemic haemodynamic changes occurred with ET-1 infusion: mean arterial pressure (100 +/- 3 [standard error of the mean]) to 107 +/- 3 mmHg; p < 0.01) and systemic vascular resistance (1699 +/- 118 to 2033 +/- 135 dynes s/cm5; p < 0.001) rose, while the cardiac index fell from 2.43 +/- 0.17 to 2.20 +/- 0.16 l/min/m2 (p < 0.002). Mean pulmonary artery pressure (21 +/- 2 mmHg) and pulmonary vascular resistance (151 +/- 14 to 147 +/- 14 dynes s/cm5) did not change however. CONCLUSIONS: Exogenous ET-1, when infused to achieve plasma concentrations similar to those in severe heart failure and pulmonary hypertension, causes systemic but not pulmonary vasoconstriction.

Aged↗
PubMed1998

Changes in left ventricular mass and volumes in patients receiving angiotensin-converting enzyme inhibitor therapy for left ventricular dysfunction after Q-wave myocardial infarction.

OBJECTIVES: We evaluated global and segmental left ventricular (LV) mass and LV mass/volume ratio in patients with LV dysfunction receiving angiotensin-converting enzyme (ACE) inhibitor therapy after acute myocardial infarction (MI). BACKGROUND: ACE inhibitors attenuate LV dilatation and compensatory hypertrophy after acute MI in animal models. However, LV remodeling in patients after acute MI has been largely defined on the basis of changes in chamber volume alone. METHODS AND RESULTS: Twenty-nine patients with LV ejection fraction <40% received the ACE inhibitor ramipril (range 2.5 to 20 mg/day) within 5 days of their first Q-wave MI. Magnetic resonance imaging was performed at baseline and at 3 months, providing global and regional LV volumes and mass from summated serial short-axis slices. Mean arterial blood pressure was unchanged from baseline to 3-month follow-up (89 +/- 10 to 92 +/- 17 mm Hg). LV mass decreased (90 +/- 25 to 77 +/- 21 gm/m2, p < 0.0005) as LV end-diastolic volumes increased (65 +/- 13 to 73 +/- 22 ml/m2, p < 0.01). Global LV mass to volume ratio decreased from 1.40 +/- 0.28 to 1.08 +/- 0.18 gm/ml (p < 0.0001), as did circumferential wall thickness to volume ratio of noninfarcted myocardium at the base of the LV (0.06 +/- 0.02 to 0.05 +/- 0.02 mm/ml, p < 0.001). LV ejection fraction increased from 35 +/- 6 to 40 +/- 9% (p < 0.001) in the presence of an increase in calculated end-systolic wall stress (185 +/- 57 to 227 +/- 54 gm/cm2, p < 0.01). CONCLUSIONS: ACE inhibitor therapy was associated with improved LV function in the face of a decrease in mass to volume ratio of the LV as well as a decrease in wall thickness to volume ratio of noninfarcted myocardium. Whether ACE inhibitor therapy had direct or indirect effects on these changes in LV mass and function are open questions that require further investigation.

Adult↗
PubMed2000

Usefulness of the ejection fraction response to dobutamine infusion in predicting functional recovery after coronary artery bypass grafting in patients with left ventricular dysfunction.

Quantification of dysfunctional but viable myocardium has high prognostic value for improvement of left ventricular (LV) function after coronary artery bypass grafting (CABG). Dobutamine stress echocardiography (DSE) can assess viable myocardium by segmental wall motion changes during stress. However, analysis of wall motion is subjective with only moderate interinstitutional agreement (70%) and frequently overestimates functional improvement after CABG. In contrast, calculation of ejection fraction (EF) is less subjective and allows a more precise quantification of global contractile reserve. The aim of the study was to compare the prognostic value of EF response and segmental wall motion changes during DSE for the prediction of LV functional recovery after CABG. Forty patients underwent DSE before CABG. EF responses were assessed at rest, low-dose dobutamine, and at peak stress using the biplane disk method. Wall motion was scored using a 16-segment 5-point model. Resting radionuclide ventriculography (RNV-LVEF), performed before and 8 +/- 2 months after CABG, was used as an independent reference. Five patients were excluded because of perioperative infarction or poor echo images. In 11 of 35 patients, RNV-LVEF recovered >5%. Improvement in EF during dobutamine infusion predicted RNV-LVEF recovery after CABG significantly better than segmental wall motion changes (72% vs 53%, p = 0.03). A biphasic EF response (i.e., improvement in > or =10% at low dose and subsequent worsening at peak stress) had the highest predictive value (80%) for late functional recovery. In conclusion, EF response to dobutamine infusion was superior to segmental wall motion changes in predicting RNV-LVEF recovery after CABG.

Coronary Artery Bypass↗