Left ventricular regional wall motion, ejection fraction, and geometry after partial left ventriculectomy. Influence of associated mitral valve repair.

OBJECTIVE: Left partial ventriculectomy has been proposed for treatment of heart failure. We investigated the effects of isolated left partial ventriculectomy and left partial ventriculectomy associated with mitral annuloplasty on refractory heart failure due to idiopathic dilated cardiomyopathy. METHODS: Nineteen patients underwent partial left partial ventriculectomy associated with mitral annuloplasty and six patients isolated left partial ventriculectomy. In two patients the left partial ventriculectomy associated with mitral annuloplasty was combined with tricuspid annuloplasty. We evaluated before and after the surgery (24+/-14 days): the functional class, left ventricular ejection fraction (LVEF), right ventricular ejection fraction (EF), regional wall motion, hemodynamics, mitral regurgitation, left ventricular geometry and coronary angiography. RESULTS: For the overall group LVEF improved from 14.5+/-8.0 to 30.3+/-12.2% (P<0.0002) and right ventricular EF from 21.2+/-7.1 to 28.4+/-8.3% (P<0.002). In patients who underwent left partial ventriculectomy associated with mitral annuloplasty LVEF increased from 14.5+/-8.6 to 29.5+/-12.2% (P<0. 002). Isolated left partial ventriculectomy increased LVEF from 13. 5+/-7.5 to 31.5+/-11.1% (P<0.04). Distal segments of marginal branches of the circumflex artery were not visualized by coronary angiography. Left partial ventriculectomy associated with mitral annuloplasty reduced the wedge pressure from 25.0+/-12.1 to 18.0+/-7. 0 mmHg (P<0.03) and increased cardiac output from 3.8+/-0.8 to 4. 6+/-1.1 l/min (P<0.004), while isolated left partial ventriculectomy increased cardiac output from 3.7+/-1.0 to 4.8+/-1.3 l/min (P<0.03). Regional wall motion increment was more evident in anterolateral region from 4.2+/-6.8 to 14+/-8.3% (P<0.002) except in two patients. Left ventricular geometry changed in most patients, but a homogeneous pattern was not identified. Seven patients died during a mean follow-up of 546+/-276 days. Survivors had improvement in functional class. Augmentation of LVEF >5% was associated with a favorable clinical outcome with improvement in clinical status without death. CONCLUSIONS: Effects of left partial ventriculectomy are not necessarily dependent upon reduction of mitral regurgitation or changes in left ventricular geometry. However, risk of death after the surgery must be reduced for a clinical application.

Exercise and heart failure. Relation of the severity of the disease to the anaerobic threshold and the respiratory compensation point.

OBJECTIVE - To identify, the anaerobic threshold and respiratory compensation point in patients with heart failure. METHODS - The study comprised 42 Men,divided according to the functional class (FC) as follows: group I (GI) - 15 patients in FC I; group II (GII) - 15 patients in FC II; and group III (GIII) - 12 patients in FC III. Patients underwent a treadmill cardiopulmonary exercise test, where the expired gases were analyzed. RESULTS - The values for the heart rate (in bpm) at the anaerobic threshold were the following: GI, 122+/-27; GII, 117+/-17; GIII, 114+/-22. At the respiratory compensation point, the heart rates (in bpm) were as follows: GI, 145+/-33; GII, 133+/-14; GIII 123+/-22. The values for the heart rates at the respiratory compensation point in GI and GIII showed statistical difference. The values of oxygen consumption (VO2) at the anaerobic threshold were the following (in ml/kg/min): GI, 13. 6+/-3.25; GII, 10.77+/-1.89; GIII, 8.7+/-1.44 and, at the respiratory compensation point, they were as follows: GI, 19.1+/-2. 2; GII, 14.22+/-2.63; GIII, 10.27+/-1.85. CONCLUSION - Patients with stable functional class I, II, and III heart failure reached the anaerobic threshold and the respiratory compensation point at different levels of oxygen consumption and heart rate. The role played by these thresholds in physical activity for this group of patients needs to be better clarified.

Growth hormone for optimization of refractory heart failure treatment.

It has been reported that growth hormone may benefit selected patients with congestive heart failure. A 63-year-old man with refractory congestive heart failure waiting for heart transplantation, depending on intravenous drugs (dobutamine) and presenting with progressive worsening of the clinical status and cachexia, despite standard treatment, received growth hormone replacement (8 units per day) for optimization of congestive heart failure management. Increase in both serum growth hormone levels (from 0.3 to 0.8 microg/l) and serum IGF-1 levels (from 130 to 300ng/ml) was noted, in association with clinical status improvement, better optimization of heart failure treatment and discontinuation of dobutamine infusion. Left ventricular ejection fraction (by MUGA) increased from 13 % to 18 % and to 28 % later, in association with reduction of pulmonary pressures and increase in exercise capacity (rise in peak VO2 to 13.4 and to 16.2ml/kg/min later). The patient was "de-listed" for heart transplantation. Growth hormone may benefit selected patients with refractory heart failure.