Chronic aortic counterpulsation with latissimus dorsi in heart failure: clinical follow-up.

BACKGROUND: Dynamic aortomyoplasty is an alternative technique to heart transplantation. The goal of our study was to evaluate the benefits of aortic counterpulsation obtained by dynamic thoracic aortomyoplasty in patients with heart failure refractory to pharmacologic treatment and contraindications to heart transplant or cardiomyoplasty. METHODS: In this study we compared preoperative and postoperative data from five out of six carefully selected patients who were treated with dynamic thoracic aortomyoplasty. This surgical technique wraps the right latissimus dorsi muscle flap around the ascending aorta. This muscle flap was electrically stimulated during diastole, following a muscle-conditioning protocol, to obtain diastolic augmentation. At the 6-month follow-up period we evaluated, invasively and noninvasively, the hemodynamic and clinical effects of aortomyoplasty. RESULTS: We observed a significant decrease in the number of hospitalizations (P = 0.01), NYHA functional class (P = 0.01), cardiothoracic ratio (P = 0.02), right ventricular diameter (P = 0.03), left atrial diameter (P = 0.04), and pulmonary artery systolic pressure (P = 0.04); and a significant increase in the 6-minute walking test (P = 0.01), cardiac index (P = 0.04), noninvasive evaluation of diastolic augmentation (P = 0.01), left ventricular shortening fraction (P = 0.01), and radioisotopic left ventricular ejection fraction (P = 0.02). We also found a nonsignificant decrease in the left ventricular diameter (P = 0.08) and wedge pressure (P = 0.19); and a nonsignificant increase in peak oxygen consumption (P = 0.13). CONCLUSIONS: Dynamic thoracic aortomyoplasty in heart failure resulted in an important improvement of hemodynamic parameters, heart functional data, and clinical functional class, when comparing preoperative data with the 6-month follow-up data.

Dynamic aortomyoplasty: clinical experience.

Dynamic aortomyoplasty has been the subject of experimentation for the treatment of congestive heart failure during the last few years. This method consists of diastolic counterpulsation of the ascending aorta through the stimulation of the latissimus dorsi wrapped around it. This report describes the results of aortomyoplasty in a patient with dilated cardiomyopathy resulting from Chagas' disease and contraindications for heart transplantation or cardiomyoplasty.

Spinal cord stimulation for severely ischemic limbs.

Severe atherosclerosis of the lower limbs causes rest pain, skin ulcerations and gangrene. In such situations and when standard surgical treatment had failed or it is impossible to employ, spinal cord stimulation (SCS) seems to be of value. Since April 1985, we have used this technique on 19 patients. The results have been beneficial in 70.6% of the cases and have shown some evidence of increasing cutaneous flow. However, randomized series are required before accepting it as having a special place in the fight against atherosclerotic disease.

Efficacy of flecainide in the management of ventricular arrhythmias: comparative study with amiodarone.

The effects on ventricular arrhythmias of a new class IA drug, flecainide, were compared with those of amiodarone in 10 patients with frequent, chronic, and stable ventricular ectopic beats (VEBs). The study consisted of an initial 1-week, placebo-controlled, baseline period followed by two 12-day, randomized, crossover, double-blind treatment periods with incremental dosage and 1 month of placebo between drug periods. Frequent VEBs, which were present in all 10 patients during both placebo control periods (30 or more VEBs/hour every hour, during 24-hour Holter monitoring), were markedly suppressed (reduction greater than 80%) in nine patients with both drugs (p less than 0.01). There was almost total abolition of the VEBs in six patients with flecainide, and the satisfactory results with a minimal dose in three demonstrate its fast onset of action. Side effects from either agent were infrequent and no discontinuation was necessary. We conclude from our study that flecainide is a highly effective antiarrhythmic agent.

Transverse dissociation of the human His bundle.

"Completed" and "abortive" alternating Wenckebach periods occurred in a symptomatic female with calcification of the mitral annulus. These arrhythmias were attributed to transverse dissociation of the His bundle into two horizontal levels "connected in series," with 2:1 block in the "distal" level and Wenckebach periods in the "proximal" level. Intra-Hisian alternating Wenckebach periods resembled those resulting from transverse dissociation of other infra-AV nodal structures in that they are rare, usually symptomatic and require pacemaker implantation. This contrasts with the variety of rhythms resulting from transverse dissociation of the AV node which occur frequently, are not always malignant, and generally are not treated with implanted pacemakers.

Antiarrhythmic effect of tiapamil in patients with acute myocardial infarction.

The efficacy of intravenously administered tiapamil in treating premature ventricular contractions (PVCs) in the acute phase of acute myocardial infarction was evaluated in 20 patients using 24-hour continuous ECG monitoring (Holter). All patients presented frequent and/or complex ventricular arrhythmias (Lown classification II-V). Tiapamil reduced the number of PVCs to a statistically highly significant degree (p less than 0.01), i.e. 82-85% in the 4th hour of treatment. The number of PVCs increased again after therapy was discontinued. Where supraventricular ectopic beats were present in addition to PVCs, tiapamil reduced them by 93% in the 3rd and 4th hours of treatment. These results suggest that tiapamil could be an effective antiarrhythmic agent in acute myocardial infarction.