An overview of intermittent inotropic therapy for severe congestive heart failure.

Congestive heart failure (CHF) is a major problem in the field of medicine in the U.S. Over 4 million people in the U.S. have CHF with 400,000 new cases per year. This diagnosis creates 6 million hospital days with a Medicare cost of billions of dollars. There are limited options for patients >65 years of age who have resistant heart failure on maximum medical therapy. There is considerable debate surrounding intermittent inotropic therapy. This paper is a review of the literature regarding this form of therapy; 20 studies are described. All but one of these studies disclose beneficial effects. The major criticism of these studies is that they are small and not randomized or placebo controlled. Larger well controlled studies are needed to determine the effect and safety of this treatment. Researchers must develop and evaluate all forms of therapy fairly to help decrease hospitalizations, decrease mortality, and improve quality of life.

Value of reversed saphenous vein in minimally invasive direct coronary artery bypass graft procedures.

BACKGROUND: Minimally invasive direct coronary artery bypass graft procedures are gaining acceptance for revision as well as primary coronary revascularization. When suitable, the left and right internal mammary arteries are preferred as bypass conduits; in other cases, the greater saphenous vein, used for standard coronary artery bypass graft procedures, may be useful to revascularize coronary artery branches during minimally invasive direct coronary artery bypass graft procedures. METHODS: We used the greater saphenous vein on three occasions during minimally invasive direct coronary artery bypass graft procedures (1) to revascularize the left anterior descending coronary artery by anastomosis to the left axillary artery in the infraclavicular region, (2) as an extension to the left internal mammary artery to reach the left anterior descending coronary artery, and (3) as a bridge from the splenic artery to bypass the distal right coronary artery. RESULTS: Postoperatively, all 3 patients had relief from symptoms of coronary artery insufficiency and none has been readmitted to the hospital with symptoms. Angiography or thallium studies were not performed to confirm graft patency because all patients were elderly and the risks of these procedures were considered to outweigh their potential benefit. CONCLUSIONS: The greater saphenous vein is a potential bypass conduit for use in minimally invasive direct coronary artery bypass graft procedures as well as for coronary artery bypass graft procedures.

Cardiac rehabilitation/exercise in patients with implantable cardioverter defibrillators.

There have been no specific exercise or daily activity guidelines determined for patients with automatic implantable cardioverter defibrillators. Two patients, one with a Ventritex Cadence Model V-100 defibrillator and one with a CPI Ventak Model 1550 defibrillator were enrolled in monitored cardiac rehabilitation. One patient had symptoms of syncope and cardiodefibrillation during a vigorous short walk prior to cardiac rehabilitation and became fearful of any activity. Stress testing on this patient was terminated early because his atrial fibrillation rate approached the defibrillization rate. A low dose of beta blockade was added to his regimen. He underwent repeat stress testing and was placed in cardiac rehabilitation. This patient had no further shocks, and it was assumed that his shock was due to high atrial fibrillation rates. The second patient experienced recurrent shocks on amiodarone, propafenone, and mexiletine with presyncope. However, stress testing did not disclose abnormalities. The patient was fearful of any activity and was placed in cardiac rehabilitation. During an average of 26 sessions of cardiac rehabilitation, no symptoms have been noted, and the patients have returned to a more normal lifestyle. Specific exercise and lifestyle criteria should be given to patients with cardioverter defibrillators. Stress testing with monitored exercise can develop such a program. Larger numbers of patients need to be studied.