Characterization of post-discharge atrial fibrillation following open-heart surgery in uncomplicated patients referred to an early rehabilitation program.

BACKGROUND: Atrial fibrillation (AF) is frequently observed after open-heart surgery, following discharge from the cardiac surgery clinic. Compared to those usually reported in the early postoperative period, this arrhythmia is delayed in onset and is often a cause of re-hospitalization. Post-discharge AF has never been characterized in the literature. METHODS: We retrospectively analyzed post-discharge AF occurring within 30 days of coronary artery bypass graft or of valvular procedures in 376 patients referred to an early postoperative rehabilitation program. To investigate the probability of the persistence of post-discharge AF, we prospectively examined 232 patients who had undergone valvular procedures. RESULTS: An arrhythmia was recognized in 61/376 patients (16%), resulted in worsening of the NYHA functional class in 27 (44%) and in life-threatening hemodynamic effects requiring urgent cardioversion in 5 (8%). Events were predicted by the occurrence of postoperative AF (6-fold higher risk), left ventricular hypertrophy, an enlarged left atrium and valvular pathology (3-fold) and by the lack of beta-blocker protection (5-fold). AF persisted in 20/232 (9% of the study population, 18% of patients who had post-discharge AF) and had a relevant impact on the patient's clinical status. Predictors of events were older age, an enlarged left atrium and a lower left ventricular ejection fraction. CONCLUSIONS: Post-discharge AF following open-heart surgery is frequent in patients undergoing valvular procedures and often persists over time. The clinical impact of the arrhythmia is relevant, it might cause re-hospitalizations in many circumstances and, consequently, may have an impact on hospital resources. Events are much less frequent in patients taking beta-blockers than in those who do not, and they can be predicted by simple variables observed in the early stages after surgery.

[Tolerability and clinical effects of carvedilol in patients over 70 years of age with chronic heart failure due to left ventricular dysfunction]. / Tollerabilità ed effetti clinici del carvedilolo nei paziente anziano ultrasettantenne con insufficienza cardiaca cronica associata a disfunzione sistolica ventricolare sinistra.

BACKGROUND: A number of studies showed the improvement in left ventricular (LV) function and clinical outcome that carvedilol produces in patients with severe congestive heart failure (CHF). However, no data are available regarding beta-blocker treatment in older patients with CHF. The purpose of this study was to assess the tolerability and efficacy of carvedilol in patients > 70 years with CHF associated with LV systolic dysfunction. METHODS: Thirty-seven patients in NYHA functional class III-IV with LV ejection fraction < 45% and a mean age of 76 +/- 6 years were prospectively studied. They received carvedilol which was associated with conventional therapy for CHF (ACE-inhibitors + diuretics + digitalis). The changes over time in clinical and echocardiographic variables (evaluated at baseline and every 6 months) were compared with those of 23 patients treated with the sole conventional therapy. RESULTS: During a follow-up of 13 +/- 8 months, 5 patients interrupted carvedilol due to side effects (tolerability 87%). Among the 32 remaining patients, 8 died. NYHA functional class improved in the 56% of survivors, LV ejection fraction increased (30 to 42%, p = 0.0002), mitral regurgitation and pulmonary capillary wedge pressure markedly decreased (2.0 to 1.0, p = 0.0001, and 19 to 13 mmHg, p = 0.0004, respectively). None of these variables was changed at the end of follow-up in the control group. Mortality was similar between the carvedilol (25%) and control group (22%). CONCLUSIONS: In the very elderly patients with LV systolic dysfunction and CHF carvedilol is well tolerated and safe. The addition of this drug to conventional therapy for CHF provides an important improvement in functional class, LV function and hemodynamics.

[Reversibility of left ventricular dysfunction in elderly patients with dilated cardiomyopathy undergoing treatment with carvedilol. Report of a case]. / Reversibilità della disfunzione ventricolare sinistra nell'anziano affetto da cardiomiopatia dilatativa sottoposto a trattamento con carvedilolo. Descrizione di un caso.

Owing to recurrent episodes of congestive heart failure, an 88-year-old man with moderate aortic stenosis and dilated cardiomyopathy was treated with carvedilol and closely followed up. At the beginning of the treatment the patient was in NYHA functional class IV and presented with severe global left ventricular hypokinesia with an ejection fraction of 15%. Carvedilol was started at a dose of 3.125 mg twice daily and progressively increased to 12.5 mg twice daily. Six months later the left ventricular volumes had become almost normal, wall motion abnormalities had completely reversed and the ejection fraction was markedly increased (62%). The patient was classified in NYHA functional class II. This case shows the recovery of left ventricular systolic function during the administration of carvedilol in an old patient with dilated cardiomyopathy and chronic congestive heart failure.

[Tachycardia caused by sinus-node and atrial re-entry with associated depression of A-V conduction]. / Tachicardie da rientro nel nodo del seno e nell'atrio con associata depressione della conduzione A-V

The authors report two clinical cases (one with WPW syndrome) of paroxysmal supraventricular tachycardia caused, in one case, by sino-atrial node or perisinusal nodal tissue re-entrance and in the other case by re-entry in the lower atrium and the high part of the A-V node junction. Both present A-V node Wenckebach periodism, which can be distinct from reciprocating tachycardias, through an anomalous pathway or within the A-V node, which have a typical A-V conduction in the ratio of one to one. But A-V node Wenckebach periodism makes it hard to differentiate between reciprocating and ectopic atrial tachycardias, as the latter often has an A-V block. The effects of two antiarrhythmic drugs (Verapamil, Amiodarone) on echo-zone duration, on initiation and on prophylactic long-term treatment of paroxysmal tachycardias are also reported and discussed.