Experience with coronary sinus lead implantations for cardiac resynchronization therapy in 244 patients.

INTRODUCTION: Cardiac resynchronization therapy (CRT) using coronary sinus (CS) leads is a new method for the therapy of congestive heart failure (CHF). Because the intervention is more complex than regular pacemaker implantations, information on the feasibility and side effects of this method are of interest. METHODS: From 1999 to June 2005, CRT implantations were attempted in 244 patients (pts; mean age 64+/-12 years, range 14-90 years), 82% were male, 44% had coronary artery disease, 29% were in atrial fibrillation, 71 had preexisting pacemakers. RESULTS: In 97% of the pts the intervention was successful (27% of the systems with defibrillation capabilities). In 285 interventions, 255 CS leads were positioned according to CS vein anatomy in 130 posterolateral, 97 anterolateral and 28 anterior side branches (16 patients received 2 CS leads). Over-the-wire leads were used in 88%, 71% were additionally preshaped. We observed no mortality but 37 complications (12.5%): CS dissection in 9, CS perforation in 1, ventricular fibrillation in 4, asystole in 5, pulmonary edema in 1, pneumothorax in 2, need for early CS lead revision in 19 (dislodgement n=7, phrenic nerve stimulation n=12) and infection with explantation in 2 cases. An improvement in NYHA functional class was found in 88% of pts (only 55% if anterior lead position). CONCLUSION: Perioperative complications during CS lead implantation occur in 10-15% of cases. Most patients responded well to CRT. Patients should be informed about the possible need for a reoperation. During implantation, immediate defibrillation and stimulation capabilities must be available. Anterior lead positions should be avoided.

[Excimer laser extraction of pacemaker and defibrillator leads]. / Excimer-Laser Extraktion von Schrittmacher- und Defibrillatorelektroden.

BACKGROUND: Pacemaker infection or some lead dysfunctions are an indication for removal of all foreign material. The use of laser energy is a new method for extraction of fixed leads that have been in place for a long time. There are only a few reports on results and complications of laser extraction in comparison to conventional methods. Therefore, this study compares results of laser lead extraction and conventional methods. METHODS: Since January 1999 we have made use of the laser lead extraction system of Spectranetics, Inc. Inner traction of the leads was performed using a "lead locking device" (LLD) and for laser application 12, 14 und 16 French "laser sheaths" were used. As the energy source, an excimer laser device was used (CVX-300). The intervention was performed under heart-lung machine backup. Results of the laser procedure in 24 patients and 45 leads (including 3 defibrillator leads) are compared to results of manual traction (23 patients, 53 leads), traction devices (24 patients, 38 leads), snare catheters (6 patients, 6 leads) and thoracotomy (5 patients, 9 leads) from the years 1995-1998. RESULTS: The mean operation time of the laser method (93 +/- 50 min) was not significantly different from manual traction (82 +/- 48 min,) or traction devices (100 +/- 45 min). The mean fluoroscopy time (9.4 +/- 50 min) was similar to traction devices (8.4 +/- 5 min, p < 0.05). In one patient a percardial tamponade developed with the need for urgent thoracotomy. This patient died on the fourth postoperative day due to cerebral hypoxia. The other 23 patients had an uneventful course. All but one lead could be removed without fragmentation, including a malpositioned lead in the left ventricle (success rate 96%). In 62 patients and 97 conventional extractions (53x manual, 38x device, 6x snare) from 1995-1998, one fatal (sepsis due to lead fragmentation) and four severe complications developed (pericardial tamponade, pulmonary abscess, pulmonary embolism, sepsis). In 15/62 patients with conventional methods, lead fragments remained (success rate 76%). Of five patients from 1995-1998, in whom leads with vegetations or tricuspid valve insufficiency were removed by thoracotomy and cardiopulmonary bypass, one patient died perioperatively. CONCLUSIONS: In contrast to conventional methods, excimer laser pacemaker or defibrillator lead extraction allows total removal of all foreign material. This prevents late complications from lead fragments left in place. However, life-threatening complications can occur with conventional as well as with the laser method. Therefore, this intervention should be done only in specialized centers using extended monitoring (invasive blood pressure, TEE).

Excimer laser-assisted extraction of an infected bipolar left ventricular pacing lead implanted 10 years ago.

Routine intraoperative transesophageal echocardiography (TEE) revealed a previously undiscovered ventricular positioning of an infected ventricular lead left in place for 10 years. This case report describes successful removal of this lead from the left ventricle by means of excimer laser and discusses some important aspects to be considered.

Results of aortic valve replacement with pulmonary and aortic homografts.

BACKGROUND AND AIM OF THE STUDY: Aortic valve replacement with cryopreserved human pulmonary or aortic valves (homografts) is an attractive alternative to the implantation of mechanical valves or bioprostheses, as anticoagulation can be avoided and a near-normal anatomy restored. However, few reports exist on the long-term follow up of patients with this type of valve. METHODS: Between 1990 and 1997, a total of 64 homografts were implanted in 62 adults (mean age 42 +/- 12 years) with non-endocarditic valve lesions (insufficiency, n = 16; stenosis, n = 20; combined lesions, n = 12; redo, n = 16). In total, 23 pulmonary grafts (PG) and 41 aortic grafts (AG) were used. Valves were obtained from the European Homograft Bank in Brussels. Two patients with aortic homografts were lost to follow up; the others were examined clinically and echocardiographically at yearly intervals (mean 3.6 +/- 2.0 years). Children aged less than 16 years (n = 21), and patients receiving a homograft due to endocarditis (n = 28) or during a Ross procedure (n = 16) were excluded from the study. RESULTS: Three patients (5%) died due to early postoperative complications (two with AG, one with PG). Three PG had to be explanted due to primary malfunction, and five (total 35%) during further follow up due to severe aortic insufficiency (at a mean of 3.3 +/- 1.8 years). In contrast, all AG were functioning at the end of the observation period (log rank test, p = 0.0001, chi-square test 13.9). The mean echocardiographic degree of regurgitation for PG was significantly higher than for AG (2.2 +/- 1 vs. 0.75 +/- 0.7, p <0.0001). The peak transvalvular gradient did not differ between groups (PG 12.3 +/- 9 mmHg vs. AG 16.7 +/- 10 mmHg, p = NS). In respect of perioperative parameters, patients with PG showed a significantly higher body temperature during the first seven postoperative days (37.3 +/- 0.6 degrees C vs. 36.8 +/- 0.3 degrees C, p = 0.003). All three patients with acute graft malfunction in long-term follow up had a perioperative febrile response without overt bacterial infection. CONCLUSION: In contrast to grafts of aortic origin, pulmonary homograft valves should not be used for aortic valve replacement because of their high rate of malfunction, both acutely and chronically. Higher postoperative body temperatures should lead to further investigations of possible enhanced immunoreactions against pulmonary homografts.

Combination therapy with carvedilol and amiodarone in patients with severe heart failure.

BACKGROUND: Carvedilol and at least in some studies, amiodarone have been shown to improve symptoms and prognosis of patients with heart failure. There are no reports on the outcome of combined treatment with both drugs on top of angiotensin-converting enzyme inhibitors (ACEI), diuretics and digitalis. METHODS AND RESULTS: In 109 patients with severe heart failure submitted for heart transplantation at one single center between the years 1996 and 1998 [left ventricular ejection fraction (LVEF) 24.6+/-11%, 85% males, 52% idiopathic dilated cardiomyopathy (DCM), mean observation time 1. 9+/-0.4 years] a therapy with low-dose amiodarone (1000 mg/week) plus titrated doses of carvedilol (target 50 mg/day) was instituted. In addition, patients received a prophylactic dual chamber pacemaker (PM) in order to protect from bradycardia and for continuous holter monitoring. The devices were programmed in back-up mode with a basal rate of 40 i.p.m. with a hysteresis of 25%. Significantly, more patients were in sinus rhythm after 1 year than at study entry (85% vs. 63%, P<0.01). In 47 patients, under therapy over at least 1 year, the resting heart rate fell from 90+/-19 to 59+/-5 b.p.m. (P<0.001). Ventricular premature contractions in 24-h holter ECGs were suppressed from 1.0+/-3 to 0.1+/-0.3%/24 h (P167 b.p.m. detected by the pacemaker (1.2+/-2.8 episodes/patient/3 months vs. 0.3+/-0.8 episodes/patient/3 months after 1 year (P<0.01). The LVEF increased from 26+/-10 to 39+/-13% (P<0.001). NYHA class improved from 3. 17+/-0.3 to 1.8+/-0.6 (P<0.001) as well as right heart catheterization data. From the total cohort, seven patients (6%) developed symptomatic documented bradycardic rhythm disturbances requiring reprogramming of their pacemakers to DDD(R)/VVI(R) mode with higher basic rates. Two of these patients developed AV block, four sinu-atrial blocks or sinus bradycardia and one patient had bradycardic atrial fibrillation. During the observation period five patients died (3 sudden, 1 due to heart failure and 1 due to mesenteric infarction). Two patients had undergone heart transplants. The 1-year survival rate (Kaplan-Meier) without transplantation was 89%. Compared to historic control patients with amiodarone only (n=154) or without either agent (n=283) this rate was 64 and 57% (P<0.01). CONCLUSIONS: Heart failure patients benefit from a combined therapy with carvedilol and amiodarone resulting in a markedly improved NYHA stage, an increase in LV ejection fraction, a stabilization of sinus rhythm, a significant reduction in heart rate, a delay of electrical signal conduction and a suppression of ventricular ectopies. Approximately 6% of patients under such a regime became pacemaker-dependent in the first year. Compared to historic controls prognosis was better and the need for heart transplantation was lower. The exact role of either agent in combination or alone should be clarified in larger randomized studies.

[Aortic valve replacement with homografts. An overview]. / Aortenklappenersatz mit Homografts. Eine Ubersicht.

The implantation of fresh or cryopreserved human heart valves (homografts) in aortic position is a tool in cardiac surgery since 30 years. Homografts are attractive alternatives to the implantation of mechanical or xenobiological prostheses, because anticoagulation can be avoided and a near normal anatomy can be restored. Physicians should know about the several kinds of grafts and operative techniques to adequately take care of the patients in follow-up. This overview on the literature covers methods of harvesting, preparation and conservation of homografts according to standard protocols of the European Homograft Bank in Brussels. Their use in the therapy of human valvular disease is discussed with special emphasis to operative techniques (subcoronary, root) and the Ross procedure and in pediatric surgery. Complications and aspects of postoperative care are discussed including immunologic phenomena. Homografts are useful tools for aortic valve replacement, especially in juveniles, in the presence of contraindications for anticoagulation and in endocarditis. Whereas aortic homografts have excellent long-term results, pulmonic homografts show a significant rate of malfunction. Further studies should be performed to clarify the role of the Ross operation or stentless xenografts compared to homografts in aortic position. In pediatric cardiac surgery homografts are of value especially for the reconstruction of the right ventricular outflow tract. Homografts in mitral position show disappointing results up to now. The major limitation in the use of homografts is the mismatch of availability and request, therefore homografts can only be used for the above mentioned special indications.

Tumor marker determination after orthotopic heart transplantation.

BACKGROUND: Because the risk of developing malignant tumors after heart transplantation is approximately 100-fold higher, methods for rapid diagnosis must be developed to allow early and aggressive treatment in these patients. Although tumor markers have been used frequently for surveying already detected cancer, we studied their value in screening for tumors in heart transplant patients. METHODS: The levels of the tumor markers CEA, CA19-9, CA125, CA72-4, TPA, TPS, and CYFRA 21-1 were determined prospectively in 3-month intervals in 91 heart transplant patients between 1993 and 1998. RESULTS: In eight patients a definite diagnosis of cancer was made during the marker survey (mean observation time 2.85 +/- 1.3 years), including bronchogenic carcinoma in six, renal carcinoma in one, and colon cancer in one. All patients with bronchogenic carcinoma were smokers. The markers had a sensitivity below 60% to detect cancer. Given a 2-fold cutoff level (10 ng/mL), the CEA was the only marker with sufficient specificity (93.8%, only one false-positive result). Two patients were symptom-free even though they had elevated CEA levels. In one of those patients, disseminated intractable cancer was diagnosed at first evaluation, whereas no tumor was found in the other case at first evaluation. Subsequently, by means of fluorodeoxyglucose positron emission tomography, a hypermetabolic region was found in the right upper mediastinum. Control computed tomographic scan 4 weeks after the first investigation showed disseminated intractable disease also in this patient. Another heart transplant patient with colon cancer showed a normalization of the CEA after hemicolectomy and an increase in the CEA when liver dissemination developed. There was a relationship between cardiac death and CA125 and TPS in some heart transplant patients. CONCLUSIONS: We conclude that the CEA is the only tumor marker with adequate sensitivity and specificity to detect subclinical malignancies in the follow-up of heart transplant patients. However, because of several limitations (limited diagnostic and therapeutic possibilities and enormous costs), we cannot recommend screening by tumor markers on a regular basis. Because of the elevated risk of cancer in patients who had organ transplantation, further prophylactic measures, especially smoking cessation programs, must be developed. Once a malignancy is diagnosed, tumor markers can help target clinical decisions. Additionally, nonspecific increases in CA125 and TPS levels might be related to nonmalignant circulatory disturbances and cardiac death.

Sudden death and tailored medical therapy in elective candidates for heart transplantation.

BACKGROUND: Due to the shortage of donor organs there is a long waiting time for heart transplantation. As a consequence, a high mortality rate on the waiting list diminishes the potential benefit of the procedure. Tailored medical therapy optimized according to the individual patients demands was introduced to select responding HTx candidates for continued management without transplantation. The development of modes of death over time (heart failure, sudden arrhythmic) in this population is unknown. METHODS: In 434 elective candidates for heart transplantation, submitted to our institution in the years 1984-1997 (50% coronary artery disease, mean age 51.6 +/- 12 years, 86% males) medical therapy was adjusted according to the results of repeated right heart catherizations. Adjuncts to conventional therapy with ACE inhibitors, digitalis and diuretics were amiodarone, beta-blockers, spironolactone, oral anticogulants, molsidomine or nitrates. Only patients not responding to these measures were processed to HTx. Clinical events (death, mode of death, HTx, resuscitation) were noted and analyzed by the Kaplan-Meier method and related to patients characteristics by multivariance analysis. RESULTS: During the mean follow-up of 2.36 +/- 2.4 years only 113 patients (25%) received a donor heart. One hundred-sixteen patients (26%) died without transplantation. Eighty-three (72%) of the deaths were sudden, 24 (20%) due to progression of heart failure and 9 (8%) due to other reasons. A shift from heart failure to sudden death was observed. Including 8 successful resuscitations due to documented VT/VF, there is a 20% risk of having a major arrhythmic event during the first two years of observation. Long-term (>1 year) medical responders had better hemodynamics at entry. Patients who died suddenly had similar clinical and hemodynamic data at entry than patients who needed an early transplant, but were in a comparable NYHA stage before death than long-term medical responders (2.15 +/- 0.8 vs 1.82 +/- 0.6, NS). Patients dying suddenly had significant more ventricular premature beats (1.6 +/- 2.9%/24 hours vs 1.06 +/- 2.8%/24 hours, p < .01) and complex ventricular arrhythmias (7.3 +/- 2.7/24 hours vs 1.98 +/- 5.6/24 hours, p < .01) than long-term responders. Seventy-five percent of all sudden death occurred during the first 2 observation years. CONCLUSIONS: The rate of heart failure death in elective candidates for heart transplantation under optimized medical therapy is low when patients are followed closely and transplant can be done rapidly after deterioration is recognized. Sudden death represents the highest risk for most patients. This event occurred predominantly in stable patients under tailored medical therapy without indication for HTx at that time. Our results strongly demand strategies for risk stratification and the investigation of prophylactic measures in this population.

Fluctuations of tumor markers in heart failure patients pre and post heart transplantation.

BACKGROUND: Elevated plasma levels of tumor markers may be caused by diseases other than malignancy, i.e. kidney, liver or circulatory disturbances. These conditions are not well defined, especially since there are only sparse reports on fluctuations of tumor markers related to cardiac function. PATIENTS AND METHODS: During our routine pre- and postoperative follow-up tumor marker determinations in heart failure patients were made in order to screen for possible occult neoplasm's which may either be a contraindication or a sequela of heart transplantation. The markers CA 12-5, CEA, CA 19-9, CA 72-4, TPA, TPS and CYFRA 21-1 were determined at three month intervals, besides clinical examination and hemodynamic measurements in a total of n = 118 patients pre- and n = 74 patients post heart transplantation. RESULTS: The results were grouped according the clinical status (NYHA-stage 1-4): CA12-5 (29.4 +/- 40.63 omega 151, 174 +/- 345 and 491 +/- 633 U/ml, p < 0.001 between all groups) and TPS (64 +/- 32, 118 +/- 153, 163 +/- 311 and 181 +/- 232 U/ml, p = 0.06 between all groups) were increasingly elevated in NYHA stages 1, 2, 3 or 4 respectively. A direct correlation to right atrial pressure (r = 0.41, p < 0.0001) and pulmonary capillary wedge pressure (r = 0.27, p < 0.001) was only found for CA 12-5. After heart transplantation a normalization of elevated pre-OP levels could be found. Comparable to heart failure patients poor graft function was also associated with elevated levels of CA 12-5 (113 +/- 99 vs 21.6 +/- 31 U/ml, p < 0.0001), CA 72-4 (8.4 +/- 3 vs 3.6 +/- 4, U/ml p = 0.03) and TPS (154 +/- 133 vs 66 +/- 28 U/ml, p < 0.001). The individual time course of the markers, especially of CA 12-5, correlated nicely to clinical events and hemodynamic measurements in some patients. Another finding was that CYFRA 21-1 levels were correlated to renal function. CEA, CA 19-9 and CYFRA 21-1 serum levels were not influenced by circulatory disturbances. CONCLUSION: We concluded that the tumor markers CA 12-5 and TPS (but not CEA, CA 19-9 and CYFRA 21-1) are associated with congestion and the clinical course of heart failure and HTx patients. These "nonspecific" changes have to be considered when tumor markers are determined in cancer patients with heart failure. Whether CA 12-5 blood levels may yield additional prognostic information in the management of cardiovascular patients has to be determined in further studies.

CA 125 and its relation to cardiac function.

BACKGROUND: CA 125, known as a marker for ovarian cancer with hypothetical but hitherto uncharacterized biologic functions, was reported to be elevated in some not-well-defined benign conditions. There are no reports on fluctuations of CA 125 related to cardiac function, especially the failing heart and neurohumoral factors such as norepinephrine or atrial natriuretic peptid/e. METHODS AND RESULTS: CA 125 blood levels were determined in patients with heart failure before and after heart transplantation (HTx). In 71 patients, parallel determinations of norepinephrine, atrial natriuretic peptide, pulmonary capillary wedge pressure, and right atrial filling pressure were done. CA 125 levels also were prospectively studied in patients with heart failure with stabilization (n = 25) or worsening of the clinical status (n = 9) and after HTx (n = 25). Parallel determinations of the tumor markers CEA, CA 199, CA 153, TPS, and TPA were also done. The results were grouped according to the clinical status (New York Heart Association class) of the patients. CA 125 was significantly correlated with neurohormones and filling pressures. Follow-up investigations revealed a decrease of CA 125 levels after HTx (401 +/- 259 U/L vs 33 +/- 22 U/L, P <.001, n = 25) or stabilization (429 +/- 188 U/L vs 78 +/- 35 U/L, P <.001, n = 25) and an increase during worsening of heart failure (42 +/- 25 U/L vs 89 +/- 32 U/L, P <.01, n = 9). In 4 patients after HTx, unexpected death was preceded by rising CA 125 levels. CEA, CA 199, CA 153, TPS, or TPA did not correlate with heart failure status or clinical events. CONCLUSIONS: CA 125 is a marker of the clinical and hemodynamic status and the course of patients with heart failure before and after heart transplantation. The determination of CA 125 serum levels may be an additional tool in the management of these patients. In patients with cancer, these "nonspecific" changes must be considered when CA 125 levels are determined. Whether CA 125 has a specific biologic role in heart failure deserves further studies.

Effect of orlistat on blood cyclosporin concentration in an obese heart transplant patient.

OBJECTIVE: We detected markedly decreased cyclosporin blood levels in a heart-transplanted patient after the gastrointestinal lipase inhibitor orlistat was accidentally added to the treatment program to control for his obesity. Therefore, we determined cyclosporin plasma concentration time kinetics with and without orlistat reexposition in this patient. METHODS: Plasma concentration time kinetics of whole blood cyclosporin levels in an obese heart-transplant patient were measured using a standard monoclonal fluorescence polarisation immunoassay. Results were obtained in hourly intervals up to 12 h without and with co-therapy of 3 x 120 mg orlistat (Xenical, Roche Ltd., Switzerland). The orlistat re-exposition was started the day before taking blood samples. RESULTS: Cyclosporin trough levels (98 ng/ml vs 52 ng/ml), maximum concentrations (532 ng/ml vs 74 ng/ml) and the area under the blood drug concentration-time curve (2832 ng h ml-1 vs 700 ng h ml-1) were greatly reduced with orlistat. CONCLUSIONS: Orlistat markedly decreased blood cyclosporin concentrations, possibly due to an interference with its absorption in the small intestine. To avoid potential dangerous under-immunosuppression, orlistat should not be used in patients taking cyclosporin.

[Status of intensified therapy and regionalized allocation of donor hearts in the management of patients with terminal heart failure]. / Stellenwert von Therapieintensivierung und regionalisierter Spenderherzallokation in der Versorgung terminal herzinsuffizienter Patienten.

BACKGROUND AND OBJECTIVE: The medical management of heart failure improved greatly during the last decade. Heart transplantation (HTx) as surgical alternative is an established measure but operation numbers stagnated due to the lack of donor organs and still the 1 year mortality is about 20%. Rising numbers of new registrations led to long waiting lists with a high mortality rate. Solutions are intensified therapeutic concepts and improvements in organ allocation. This study was done to show if a combined intensified medical management and a regional donor allocation system may improve outcome in heart transplant candidates. PATIENTS AND METHODS: A cohort of 396 elective candidates for heart transplantation from the years 1984-1997 without contraindications and at least in NYHA stage III at entry were investigated for total mortality, modes of death and the probability of heart transplantation. Patients were divided in two groups (group A: submitted from 1984-1994, n = 256, group B: 1995-1998, n = 150). RESULTS: The groups were comparable in clinical and hemodynamic baseline characteristics. Patients of group B had a better long-term prognosis after 2 years (87% versus 73.5%, p = 0.009) and had a significantly lower rate of heart transplantation (HTx rate in group A and B after 2 years: 35% and 15%, p = 0.002). Only two patients died due to heart failure in the years 1995-1998 compared to 20 heart failure death from 1984-1994. The waiting time for a donor heart fell from 81.8 +/- 80 days in group A to 22.1 +/- 21 days in group B. The main problem is the unchanged sudden death rate in patients with stable hemodynamics prior to the event. CONCLUSIONS: A combination of tailored medical therapy for heart failure plus regionalization of donor heart allocation with short waiting time seems to be the best way to treat patients with end-stage heart failure. A specialized cardiomyopathy program is necessary for such an approach. Sudden death in heart transplant candidates has to be studied more intensively.

Results of transmyocardial laser revascularization in non-revascularizable coronary artery disease after 3 years follow-up [ssee comments].

BACKGROUND: Transmyocardial laser revascularization is a new therapeutic option for end-stage coronary artery disease if no other cardiological or cardiosurgical intervention is possible. Data are few on how patients fare after more than 1 year follow-up. METHODS AND RESULTS: From a total of 157 patients who were suggested for transmyocardial laser therapy in the years 1995-1997, 126 were judged to have non-revascularizable coronary artery disease (mean age 61.9 +/- 14 years, 80% men, mean left ventricular ejection fraction 46.2 +/- 17.1%). Sixty-six patients had a good clinical response to intensification of the antianginal therapy and were therefore treated further medically. In 60 patients with refractory angina, sole transmyocardial laser revascularization without cardiopulmonary bypass or additional grafts was performed. The transmyocardial laser revascularization group was 32% female; 78.3% patients had had bypass operations; the mean left ventricular ejection fraction was 53.6 +/- 15%. Eighty five percent of the transmyocardial laser revascularization patients had demonstrable ischaemic regions, as visualized by dipyridamol-MIBI scintigraphy. The percentage of patients with some hibernating myocardium in positron emission tomography studies was 70%. Good early relief of angina symptoms was experienced by patients who had undergone laser treatment. After 3 months the Canadian Cardiovascular Society class fell from 3.31 +/- 0.51 to 1.84 +/- 0.77 in 49 patients (P < 0.0001), but increased in the total group to 2.02 +/- 0.92 after 6 months (n = 47), to 2.26 +/- 0.99 after 1 year (n = 42), to 2.47 +/- 1.11 after 2 years (n = 38) and to 2.58 +/- 0.9 after 3 years (n = 19). MIBI/positron emission tomography data at rest and after 6 months was worse in patients in whom pre- and postoperative studies were complete (n = 22). The peri-operative mortality was 12% (n = 7: peri-operative myocardial infarction, low output syndrome, arrhythmia). Mortality after 1 and 3 years was 23% and 30%, respectively. The risk of transmyocardial laser revascularization was significantly elevated in patients with left ventricular ejection fraction < 40%. Late deaths (n = 9) were due to sudden arrhythmias or pump failure. There was a high rate of cardiac events and reinterventions in the transmyocardial laser revascularization group, including percutaneous transluminal coronary angioplasty in newly developed lesions (n = 7), valve replacement (n = 2), need for intermittent urokinase therapy (n = 5) and heart transplantation (n = 2). CONCLUSION: Fifty percent of patients with non-revascularizable coronary artery disease submitted for transmyocardial laser revascularization can be stabilized medically. Transmyocardial laser revascularization led to a rapid early relief of symptoms, but with a trend towards worsening over time and showed a high peri-operative risk (> 10%) dependent on the pre-operative ejection fraction. Our data were in contrast to other published reports on the more beneficial effects of transmyocardial laser revascularization and should lead to further investigation of this experimental method. Transmyocardial laser revascularization should only be performed after failure of maximal anti-anginal therapy, and should be avoided when the left ventricular ejection fraction is < 40%.

Long-term hemodynamic benefit of atrial synchronization with A2A2D or A2A2T pacing in sinus node syndrome after orthotopic heart transplantation.

BACKGROUND: Exercise capacity after heart transplantation (HTx) may be limited by sinus node disease of the donor heart and atrioatrial dissociation. The role of pacemaker therapy in this setting is not well defined. The purpose of this study was to compare clinical and hemodynamic data of heart transplant recipients with acquired sinus node disease treated with atrial synchronized pacing and patients with other pacing modes or without pacemakers 1 year after operation. METHODS: Our cohort comprises a total of 112 HTx recipients from the years 1984 to 1996. Atrial synchronized pacing was performed in 21 patients with donor sinus node disease and recipient sinus rhythm. There was no associated morbidity or death for the pacemaker implantation. Fourteen patients received a dual-chamber pacemaker programmed with a short atrioventricular-Delay in A2A2D mode (donor atrial pacing triggered by recipient atrial sensing or both atria stimulated on demand); in the last 6 consecutive patients a single-chamber pacemaker was implanted with two unipolar leads to the atria connected with a Y adapter programmed in A2A2T mode (both atria were sensed and stimulated by triggering each other). RESULTS: Signals and thresholds remain stable over time. When clinical and hemodynamic data of 12 A2A2D/T patients with complete 1 year follow-up were compared to age- and sex-matched control HTx recipients with other pacing modes or without pacemakers, a significant benefit of atrial synchronization could be shown regarding rise in heart rate response to exercise (+38% vs 30% vs 16% at 50 watt), New York Heart Association classification (1.6 vs 1.8 vs 2.2), Roskamm staging (1.3 vs 2.5 vs 1.5), cardiac index at rest (3.2 vs 2.78 vs 3.1 L/min x m2), cardiac index at 50 watt (5.5 vs 4.5 vs 5.2 L/min x m2), stroke work at rest (51 vs 38 vs 42 pondmeter [PM]), stroke work at 50 watt (66 vs 48 vs 51 PM), pulmonary wedge pressure at rest (7 vs 13 vs 8 mm Hg) and pulmonary wedge pressure at 50 watt (14 vs 24 vs 18 mm Hg). CONCLUSION: It is concluded that electromechanical synchronization of the atria was of long-term benefit in heart transplant recipients with recipient sinus rhythm and donor sinus node disease.

Smoking after heart transplantation: an underestimated hazard?

OBJECTIVE: Risk factors for the development of vasculopathy and malignancies as the most important causes of morbidity and mortality after heart transplantation are not well defined. METHODS: Univariate and multivariate Cox regression analysis of the data derived from our 84 survivors of more than 3 months after orthotopic heart transplantation between 1984 and 1996. Measurement of carbonmonoxide-hemoglobin blood levels with an ABL 520 analyzer. RESULTS: Recipient or donor age, the mode of immunosuppression, total-, LDL- and HDL-cholesterol, the HDL/LDL-ratio, triglycerides, hypertension, diabetes mellitus, CMV status and rejection episodes had no independent influence on total mortality or the occurrence of graft vasculopathy or cancer. By means of an intensive questionnaire (in case of deceased patients, by their relatives) and measurement of CO-Hb blood levels we detected a high rate of patients who smoked after transplantation (22/84 = 26%). Four patients confessed smoking after undergoing the blood test. Non-smokers were defined as denying it in the questionnaire and having CO-Mb levels < 2.5% in repeated measurements. All but one were smokers before heart transplantation. Mean consumption was 11 cigarettes per day. Five and 10 years survival was significantly reduced in smokers vs. non-smokers (37 vs. 80% and 10 vs. 74%, respectively, P < 0.0001). Survival curves diverged dramatically after 4 years of observation. Smokers had a higher prevalence of transplant vasculopathy as revealed by coronary angiography and/or autopsy (10/22 smokers vs. 2/62 non-smokers, P < 0.00001) and a higher rate of malignancies (7/22 smokers developed cancer, as compared to 4 cancers in 62 non-smokers, P = 0.0001). The primary site of cancer was the lung in 5/6 smoking and lymphoma in all non-smoking cancer patients. CONCLUSIONS: Our data show that the prevalence of smoking after heart transplantation may be relatively high, especially in former smokers. Repeated measurements of CO-Hb could be helpful in its detection. Despite a relatively low cigarette count, smoking is a major risk factor of morbidity and mortality after heart transplantation (HTx). Approximately 4 years of exposure time is needed to uncover its negative influence. These findings should lead to aggressive smoking screening and weaning programs in every HTx center.

Estimulaçäo com adaptaçäo de freqüência controlada pelo sistema nervoso autônomo - uma avaliaçäo clínica / ANS controlled rate-adaptive pacing: a clinical evaluation

Para o tratamento da incompetência cronotrópica, marcapassos com adaptaçäo em freqüência baseados em diferentes sinais de sensores têm sido desenvolvidos, visando restaurar o mecanismo fisiológico em malha fechada e utilizando informaçäo fornecida pelo sistema nervoso autônomo (SNA). A medida da impedância cardíaca unipolar permite a monitorizaçäo do estado de contraçäo do coraçäo, diretamente relacionado ao tônus simpático. Marcapassos uni ou bicamerais com sistemas responsivos controlados pelo SNA foram implantados em 262 pacientes em vários centros clínicos. Protocolos de exercícios clíncos, monitorizaçäo por Holter, testes de estresse psicológico e estudos adicionais visando uma variaçäo intencional do tônus simpático confirmaram a resposta fisiológica em freqüência para os vários tipos de mudanças hemodinâmicas.