Comparison of low-dose dobutamine ventriculography with low-dose dobutamine echocardiography for predicting regional improvement in left ventricular function after coronary artery bypass grafting.

The demonstration of a contractile reserve during low-dose dobutamine echocardiography (LDDE) identifies viable myocardium and predicts recovery of left ventricular (LV) function after myocardial revascularization in patients with chronic coronary artery disease. However, a technically difficult transthoracic visualization may limit the use of LDDE, thus requiring an alternative diagnostic procedure. The present study compares LDDE with low-dose dobutamine ventriculography (LDDV) in predicting an improvement in regional LV function after surgical revascularization. We studied 18 patients with coronary artery disease and LV dysfunction who were to undergo coronary artery bypass grafting. Preoperatively, all patients were evaluated for the presence of viable myocardium using LDDE and LDDV. Follow-up echocardiography at rest and left ventriculography were performed 4 months after successful revascularization to assess recovery of LV function. The sensitivity and specificity of LDDE to identify dysfunctional segments capable of recovering function were 63% and 71%, respectively, with a diagnostic accuracy of 68%. The sensitivity, specificity, and diagnostic accuracy of LDDE improved to 81%, 72%, and 76% when patients with optimal transthoracic evaluation were selected, whereas they were 30%, 77%, and 57%, respectively, in those who underwent suboptimal evaluation. The sensitivity, specificity, and diagnostic accuracy of LDDV were 66%, 75%, and 71%, respectively, with no difference in subgroups of patients. This study demonstrates that LDDV can be considered a useful technique for identifying the presence of myocardial viability and may provide an advantage over LDDE in patients with suboptimal echocardiographic visualization.

Surgical treatment of left ventricular post-infarction aneurysm with endoventriculoplasty: late clinical and functional results.

OBJECTIVE: The temporal response to endoventriculoplasty (EVP) has not been well defined. We have evaluated the long-term clinical and functional results of this technique. METHODS: From 1988 to 1997, 121 patients underwent aneurysmectomy by EVP associated with myocardial revascularization for anteroapical left ventricular postinfarction aneurysm. Among these, 39 patients (43%) underwent early post-operative cardiac catheterization (within 3 months maximum), and were available to be revaluated after a mean follow-up time of 56+/-28 months, by means of a new hemodynamic study. Left ventricular silhouettes were analyzed by means of a special software. RESULTS: The mean New York Heart Association functional class decreased from 2.5+/-0.9 to 1.6+/-0.8 (P<0.001) late postoperatively. The global ejection fraction improved early postoperatively from 43+/-13 to 61+/-13% (P<0.001), and late postoperatively slightly decreased to 42+/-13% (ns) versus preoperative values. Left ventricular end diastolic pressure early postoperatively fell from 16.8+/-7 to 15.7+/-6.7 (ns), and late postoperatively increased to 21.6+/-8.8 (ns) versus preoperative values. Pulmonary artery pressure rose early postoperatively from 31.5+/-6.4 to 32.1+/-6.7 (ns), and late postoperatively to 34.9+/-8.9 (ns). The global contractility score decreased early postoperatively from 42.3+/-9.6 to 28.4+/-13.6 (P<0.001); the global late postoperative contractily was 35+/-14 (ns) versus preoperative values. Patients who benefit most from the operation were those with a normal postoperative contraction pattern, where ejection fraction improved respectively early postoperatively from 43+/-13 to 63+/-11% (P<0.001), and late postoperatively to 49+/-10% (P<0.001) versus preoperative values. Occlusion or critical stenosis of bypass grafts occurred in 10 patients (25.6%). There were no significant differences in hemodynamic data and hypokinesis score changes between patients with patent or occluded bypass graft, and between patients with mono or multivessel disease. The operative mortality was 6.3%, and 8.8% needed intraaortic balloon counterpulsation. The actuarial survival rates at 5 and 7 years were 73+/-6 and 61+/-6%. The mean follow-up period was 68 months (with 112 months maximum). CONCLUSIONS: We conclude that, in our patients group, EVP of left ventricular aneurysm associated with coronary grafting improves clinical status after operation. We registered a trend for a mild hemodynamic worsening, irrespective of coronary artery disease except in those patients who had shown a normal postoperative contraction pattern.

Myocardial beta-adrenergic and muscarinic receptor density in cardiac pressure or volume overload.

Decreased myocardial beta-adrenergic receptor density has been demonstrated in experimental and clinical models of cardiac disease. Nevertheless, the individual role played by pressure or volume overload in determining the receptor downregulation has never been described in humans. Moreover, no data have been reported about the reversibility of the downregulation after non-pharmacological improvement of cardiac function. In the present study, we measured the myocardial beta-adrenergic and muscarinic receptor density, using an autoradiographic method, in 14 patients with cardiac pressure overload (aortic stenosis) and in five patients with cardiac volume overload (aortic regurgitation). Five patients with aortic stenosis were studied again six months after successful valve replacement. A significant lower density of beta-adrenergic receptors was observed in patients with a chronic pressure overload compared to those with a chronic volume overload (20+/-2 and 28+/-2 fmol/mg protein, respectively P<0.05). No significant differences were found between the two groups regarding beta-adrenoceptor sub-types proportion and muscarinic receptor density. Six months after successful aortic valve replacement, we observed a significant upregulation of the beta-adrenoceptor density (delta 29+/-9 fmol/mg protein P<0.05). In conclusion, these observations indicate that: (a) the type of left ventricle haemodynamic overload may be a quantitative determinant factor in the myocardial beta-adrenoceptor downregulation; (b) the reduction of a pathological cardiac load leads to an upregulation of these receptors.

Improvement of left ventricular function and cardiovascular neural control after endoventriculoplasty and myocardial revascularization.

OBJECTIVE: To investigate the effects of endoventriculoplasty (EVP) and myocardial revascularization on left ventricular function and on sympathovagal balance modulating sinus node and vasomotor activity, we studied patients with left anterior, septal or anteroseptal ventricular aneurysm, before and after surgery. It has been demonstrated that, compared to the standard aneurismectomy, EVP associated with coronary grafting has a lower operative mortality and improves ventricular function, clinical status and prognosis. METHODS: We collected pre- and post-operative echocardiographic and angiographic data to determine morphological and hemodynamic changes. The pre- and post-operative neural cardiovascular control was assessed by power spectrum analysis of heart rate and systolic arterial pressure (SAP) variabilities during rest and tilt. RESULTS: As expected, post-operative ventricular function improved significantly: ejection fraction increased from 33 +/- 2 to 46 +/- 3% (p < 0.01) when assessed by echocardiography and from 40 +/- 4 to 55 +/- 5% (p < 0.01) when assessed by angiography; left ventricular end-diastolic pressure fell from 22 +/- 3 to 13 +/- 2 mmHg (p < 0.05). Pre-operatively sympathovagal balance responsiveness was blunted: tilt test did not induce, in respect to resting values, any significant change in low frequency (LFRR) and high frequency (HFRR) components of RR variability (in normalized units, n.u.) and in LFSAP. Post-operatively, tilt induced significant changes in LFRR and HFRR (in n.u.), in LF/HF ratio and LFSAP in respect to resting values. The pre- and post-operative percent differences--delta%--, from rest to tilt, of LFRR, HFRR, LF/HF and LFSAP were also significantly different (p < 0.01, p < 0.05, p < 0.05, p < 0.05). In addition, we compared data obtained from survivors and non-survivors (6 out of 19 patients died within 4 months because of heart failure). Non-survivors were characterized by significantly lower RR variance (184 +/- 80 vs. 1193 +/- 309 ms2 at rest, 196 +/- 87 vs. 546 +/- 104 ms2 during tilt, p < 0.05) and lower LFRR (15 +/- 7 vs. 61 +/- 6 at rest, 23 +/- 10 vs. 58 +/- 6 during tilt, in n.u., p < 0.01). CONCLUSIONS: (1) The improvement of ventricular function induced by EVP and myocardial revascularization is accompanied by a restored capability to oscillate of cardiovascular neural regulatory mechanisms; (2) the drastic reduction of variance and LF component from RR variability seems to be associated with an ominous outcome.

[Surgical treatment of ischemic heart disease complicated with severe left ventricular dysfunction: experience in 200 cases]. / Il trattamento chirurgico della cardiopatia ischemica associata a severo deficit funzionale del ventricolo sinistro: esperienza con 200 casi.

BACKGROUND: The study was designed to evaluate short and long-term benefits of coronary artery bypass graft in patients with coronary artery disease and severely depressed left ventricular ejection fraction and to identify contemporary risk factors associated with significantly greater mortality in this high-risk subgroup. METHODS: From 1985 to 1995, 200 consecutive pts with EF < or = 0.30 underwent CABG. Among these patients, 60% were older than 70 years. NYHA functional class III/IV was present in 31% of pts. Preoperative mean cardiac index was 2.7 +/- 7 l/min/m2, mean pulmonary artery pressure was 29.9 +/- 7 mm Hg and contractility score (generated by appropriate software for left ventricular kinesis analysis) mean value was 50.1 +/- 11.6 points. Urgent operation was required in 32 pts (16%). The majority of pts were completely revascularized. RESULTS: Operative mortality was 9% (18 pts). Low output syndrome was the most common postoperative complication (13.5%) followed by ventricular arrhythmia (8%), mean length of postoperative hospitalization for survivors was 13 +/- 10 days. Of 23 possible operative risk factors evaluated, four were associated with significantly greater mortality: cardiac index < or = 2.1 l/min/m2, urgent operation, contractility score > or = 80 and associated surgical procedures. Survivors experienced significant improvement in CHF class (p < 0.001) and follow up EF (p < 0.001). Kaplan-Meier estimate of survival at 1 year, 5 years and 8 years was 85%, 65% and 54%. CONCLUSION: Through more careful assessment of preoperative risk factors, patients selection and perioperative management, actually coronary artery bypass graft may be offered to pts with low ejection fraction with reduced morbidity and mortality.

[Myocardial revascularization in the patient over 70: our experience]. / La rivascolarizzazione miocardica nel paziente ultrasettantenne: la nostra esperienza.

Since September 1985 to June 1994, 252 patients (70 years and older) underwent coronary artery bypass grafting isolated or combined with other surgical procedures. Mean age was 73 +/- 4.3 years (range: 70-84). Associated non-cardiac diseases were present in 131 patients (52%). Concomitant surgical procedures were performed in 34 patients (13.5%). Myocardial revascularization was accomplished under emergency conditions in 18.1% of patients. Overall operative mortality was 5.5% (n = 14). Isolated coronary artery bypass grafting operative mortality was 3.9% (n = 10). In-hospital death rate was higher (11.7%; n = 4) for coronary artery bypass grafting associated with other procedures. During the same period, the overall mortality rate for patients younger than 70 years was 3.4% (p = NS). The 30-days in-hospital mortality was significantly higher for emergency procedures (8.7%) than for elective surgery (4.9%) (p = 0.01). Multivariate stepwise logistic regression analysis identified concomitant diseases as independently significant risk factor. Morbidity was 36.1% (n = 91). Mean intensive care unit stay was 2.8 +/- 2.2 days vs 2.1 +/- 1.2 days for patients < 70 years (p = 0.01). Total charges per case for surgical treatment were 15% higher for elderly patients. Follow up ranged from 1 to 108 months, averaging 32 months. Long-term survival was 92%, 78% and 58% at 1, 5 and 10 years from operation. With current techniques, cardiac surgery is performed in the elderly with acceptable mortality and morbidity and with slightly increased average costs.

Severe diastolic dysfunction after endoventriculoplasty.

Endoventriculoplasty with pericardial patch has been advocated to repair anteroseptal ventricular aneurysm, but not studies have reported the influence of this technique on diastolic left ventricular function. We have evaluated the changes on ventricular filling by means of pulsed Doppler recording of diastolic transmitral flow. Doppler analysis reveals three distinct spectral patterns: (1) normal, (2) inverted, and (3) restrictive. We have found an abrupt change from a preoperative normal to postoperative restrictive pattern in a significant minority of patients (8%) who underwent endoventriculoplasty. These patients had clinical and hemodynamic signs (New York Heart Association class, time from anterior myocardial infarction, left ventricular end-diastolic pressure, pulmonary hypertension, and mitral regurgitation) of severe impairment but no differences were found in ejection fraction, aneurysmal extension, or remote myocardial function. Moreover, after operation they had a satisfactory ejection fraction, a low end-diastolic volume, and an apex-base length shorter than the predicted value for a normal population. The presence of a postoperative restrictive pattern of diastolic filling is a strong predictor of 3-month mortality and makes the medical treatment difficult. Caution must be taken to perform endoventriculoplasty in patients who are severely ill, especially those recently affected by myocardial infarction. When the clinical conditions dictate the operation, a nonenthusiastic volume reduction seems to be a prudent option.

Intravenous amiodarone vs propafenone for atrial fibrillation and flutter after cardiac operation.

The safety and efficacy of amiodarone and propafenone in converting atrial fibrillation or flutter after cardiac surgery were compared in a randomized double-blind trial. Eighty-four patients with sustained atrial tachyarrhythmias of more than 30 min' duration, stable hemodynamic status and neither preoperative atrial arrhythmias nor treatment with other antiarrhythmis drugs, were randomized to receive amiodarone (46 patients: 5 mg/kg over 15 min and then 15 mg/kg over the subsequent 24 h for non-converting) or propafenone (38 patients: 2 mg/kg over 15 in and then 10 mg/kg over the subsequent 24 h for non-converting). Nine of the 46 patients (19.5%) receiving amiodarone converted to sinus rhythm within 1 h following bolus injection compared with 17 of 38 patients (44.7%) treated with propafenone (P < 0.05). Within the 24 h study, 38 of 46 patients (82.6%) given amiodarone and 26 of 38 patients (68.4%) given propafenone were converted to sinus rhythm (P = NS). A significantly progressive reduction in ventricular response, already evident at 10th min from the start of treatment, was achieved in both groups of patients. Side effects occurred in six patients given propafenone (15.7%) and in five given amiodarone (10.8%) (P = NS). The two drugs were equally effective in converting postoperative atrial fibrillation and/or flutter after 24 h although propafenone was superior within the first hour.

Surgical timing in aortic regurgitation: left ventricular function analysis by contractility score.

In 32 patients with aortic regurgitation, angiographic evaluation of global left ventricular performance before and after aortic valve replacement was carried out by means of a computer-analyzed contractility scoring system. A strong correlation was detected between the preoperative and postoperative contractility score. Postoperatively, the score decreased in all but 3 patients, becoming normal or near normal in 21 of 27 patients whose preoperative value had been less than 40. However, all 5 patients with a preoperative contractility score of 40 or greater exhibited a persistently elevated score after operation that indicated the presence of irreversible contractile dysfunction. Patients in groups A and B (preoperative score, 0 to 40) experienced a good surgical outcome, and at 5-year follow-up were in New York Heart Association functional class I. Patients in group C (preoperative score, > 40) altogether had a very poor surgical outcome, although they did experience a short to midterm period of symptomatic relief. It is important to offer aortic valve replacement to patients with aortic regurgitation before their chances for a good functional result are lost. The computer-analyzed contractility score may be a useful index for determining the optimal timing of operation in these patients, particularly those who show features consistent with impaired left ventricular function but are asymptomatic and who should undergo aortic valve replacement before symptoms of definitive left ventricular failure develop.

Functional results of left ventricular reconstruction.

From 1988 to 1991, 48 patients with left ventricular aneurysm underwent endoventriculoplasty with a circular patch to preserve the left ventricular geometry. Of these patients, 98% underwent concomitant myocardial revascularization, and in 77% the left anterior descending coronary artery was bypassed. The overall operative mortality rate was 4.1%. The 3-year survival rate was 91%, and 67% of patients had no further cardiac complications. Cardiac performance was assessed postoperatively by ventriculography in 28 patients. The global ejection fraction rose from 0.39 +/- 0.11 to 0.57 +/- 0.14 (p < 0.001); the left ventricular end-diastolic pressure fell from 20 +/- 7.5 mm Hg to 15 +/- 7.8 mm Hg (p < 0.05). Computerized analysis of regional contraction revealed a significant improvement in the anterolateral and apical segments and in the transitional zone. In 61% of the patients, a normal contraction pattern resumed, whereas in the remaining 39%, a residual deformity of the left ventricular chamber was present. The best results were obtained in patients with a preserved proximal septum at echocardiography.

Left ventricular geometry after endoventriculoplasty.

From 1988 to 1992, 65 patients underwent endoventriculoplasty (EVP) for anteroapical left ventricular aneurysm. The operative mortality was 4.6%, and 9.2% needed intraaortic balloon counterpulsation (IABP). Forty-three patients were restudied by ventriculography and the preoperative and postoperative silhouettes were analyzed by means of a special computer program. In 24 patients computerized analysis showed a restored left ventricular (LV) geometry with symmetrical contraction pattern and a contractile apical segment. Residual deformity of the LV chamber associated with an asymmetrical contraction pattern was present in 19 cases. Data from these 43 patients were analyzed to detect predictive factors for successful heart geometry reconstruction. Univariate analysis revealed that the preoperative ejection fraction, global contraction score, and a non-aneurysmatic segments contraction score did not determine successful reconstruction. The presence of a preserved proximal septum (2.5 cm or more) on echocardiography was the only significant predictor. We would recommend liberal use of the EVP technique in patients with anteroapical LV aneurysm and preserved proximal septum in order to restore satisfactory LV geometry with a low operative risk. Caution must be taken when performing EVP in patients with fibrotic proximal septum.

[Surgical treatment of diffuse coronary disease]. / Il trattamento chirurgico della malattia coronarica diffusa.

Considering the morphological aspects of diffuse coronary disease one must argue that, in their presence, myocardial revascularization can be performed only by coronary endarterectomy (EA), together with conventional bypass grafting. A variety of EA techniques ("blind" and "open" EA) are analyzed. Indications, long and short-term results (operative risks, symptomatic improvement, grafts patency) of each procedure are evaluated on the basis of the current experiences. We conclude that EA is a valuable complement to coronary artery bypass grafting which allows: a) a larger number of conventionally inoperable patients to benefit from the surgical treatment; b) more complete revascularization in patients with diffuse coronary disease.

Technical progress in coronary surgery.

This report reviews the most recent technical advances that improve the results of coronary artery bypass grafting and discusses advantages and limitations in revascularization by extensive employment of arterial grafts. There is evidence that the use of the second internal mammary artery for coronary grafting, in selected cases, gives excellent long-term results. The use of alternative arterial conduits in conjunction with both internal mammary arteries in order to achieve complete revascularization with arterial grafts only has yielded good short-term results. However, for late results further and larger studies are necessary. In diffuse coronary artery disease, complex vessel endarterectomy and reconstruction procedures are currently performed by several surgeons with low operative risk and good midterm clinical results. Favorable results concerning the patency of the endarterectomized coronary arteries and related grafts have been reported.

Tracheal obstruction due to congenital tracheomalacia in a child. Case report.

Congenital tracheal obstruction, though not notably uncommon in infancy, is rarely due to isolated tracheomalacia, especially when characterized by complete absence of cartilaginous rings. A 5-year-old boy underwent successful tracheal resection and anastomosis following severe tracheal obstruction due to aplasia of cartilaginous rings.

[Cardiac echinococcosis: 2 cases treated surgically]. / Echinococcosi cardiaca: due casi trattati chirurgicamente.

Cardiac hydatid disease represents 0.02-2% of the possible locations of the parasite. In these last few years we have seen an increase in the percentage of cardiac hydatid disease treated with surgery. The Authors report on two patients who underwent surgery for the excision of cardiac hydatid cysts. The Authors agree that in spite of the rarity of cardiac hydatid disease it should be investigated routinely by two-dimensional echocardiography in the presence of hepatic or pulmonary hydatid disease in order to prevent the possible spread of the parasite throughout the body.

[Primary tumors of the right ventricle: apropos of a case of hemangioendothelioma treated surgically]. / I tumori primitivi del ventricolo destro: a proposito di un caso di emangioendotelioma trattato chirurgicamente.

Primary tumours of the heart are uncommon and, among them, hemangioendotheliomas are exceptionally rare. The purpose of this paper is to present a rare case of right ventricular hemangioendothelioma treated surgically with success.

[Myocardial revascularization using both internal mammary arteries. Clinical results and surgical strategy]. / Rivascolarizzazione miocardica con entrambe le arterie mammarie interne. Risultati clinici e strategia operatoria.

To improve the benefits from coronary artery grafting with internal mammary artery (IMA) several technical manoeuvres and methods have been developed to increase the number of coronary arteries and their branches that can be bypassed with internal mammary arteries. Between November 1985 and December 1986, 50 patients underwent a surgical myocardial revascularization procedure using both internal mammary arteries by single or sequential anastomoses and supplemental saphenous vein graft. In 42% of these patients complete revascularization was achieved employing only internal mammary artery grafts. One hundred and twenty-six internal mammary artery grafts (77% of the total coronary bypass performed), were placed. One patient developed perioperative myocardial infarction. Reparative surgery to control immediate post-operative bleeding was required in two patients. Post-operative coronary angiography performed in 30 patients showed all patent internal mammary artery grafts but one. No late deaths occurred. Mean follow-up of 10 months was complete in 50 patients, of whom 94% are symptom free. We conclude that bilateral internal mammary artery grafting can be performed with low operative risk and can provide excellent long-term functional improvement and survival employing only high patency arterial conduit. Moreover, it doesn't significantly increase surgical morbidity.

Coronary endarterectomy combined with vein patch reconstruction and internal mammary artery grafting: experience with 18 patients.

Over a 19-month period (from November 1985 to June 1987), 18 patients underwent open coronary endarterectomy combined with vein patch reconstruction and internal mammary artery (IMA) grafting. All 18 patients had disabling angina and severe, diffuse coronary atherosclerosis that prevented revascularization by conventional means. Thirteen underwent open endarterectomy of the left anterior descending coronary artery, and the remaining five had open endarterectomy of the right coronary artery. All patients received additional bypass grafts to other coronary arteries (2.6 grafts per patient). There was no operative mortality, but one patient had a perioperative myocardial infarction that was unrelated to the open endarterectomy. Postoperative angiography in 16 cases showed that only one of the grafts to the endarterectomized artery was occluded. After a mean follow-up of 8.7 months, all the patients but one were angina-free. No late deaths occurred. Although the long-term clinical results and graft patency have yet to be evaluated, the early results of this series encourage us to continue using this technique in patients whose diffuse coronary artery disease is untreatable by conventional means.