Comparison of Coapsys annuloplasty and internal reduction mitral annuloplasty in the randomized treatment of functional ischemic mitral regurgitation: impact on the left ventricle.

BACKGROUND: Functional mitral regurgitation is associated with both annular and ventricular distortion. Aggressive reduction annuloplasty for functional mitral regurgitation acts primarily at the annulus, with variable impact on the left ventricle. The Coapsys device externally reshapes the left ventricle to correct functional mitral regurgitation. Left ventricular reshaping was analyzed in a randomized study. METHODS: The RESTOR-MV study randomizes patients with coronary artery disease and functional mitral regurgitation to either reduction annuloplasty and coronary artery bypass grafting (the RA group) or Coapsys annuloplasty and bypass grafting (the CO group). The Coapsys device consists of epicardial pads connected by a cord. It was placed without cardiopulmonary bypass under echocardiographic guidance and sized to reduce annular dimension and improve leaflet coaptation. Internal reduction annuloplasty was performed by device placement. Intraoperative transesophageal echocardiograms were analyzed in 7 patients having reduction annuloplasty and 7 having Coapsys annuloplasty. RESULTS: Baseline mitral regurgitation (0-4 scale) was similar for the RA (3.0 +/- 0.6) and the CO groups (3.0 +/- 0.6). Intraoperative mitral regurgitation was reduced from 2.86 +/- 0.7 to 0.5 +/- 0.7 (P < .01 pre vs post) for the RA group and from 2.64 +/- 0.9 to 05 +/- 0.7 (P < .01 pre vs post) for the CO group. Annular anteroposterior diameter was reduced with both techniques: RA, 3.45 +/- 0.39 to 2.34 +/- 0.37 cm (P < .01 pre vs post); CO, 3.40 +/- 0.27 to 2.85 +/- 0.34 cm (P < .05 pre vs post). Long-axis dimensions were unchanged with both techniques. Short-axis dimensions measured at three levels were significantly reduced only in the CO patients: basal diameter 4.77 +/- 0.58 to 3.58 +/- 0.38 cm (P < .01 pre vs post); mid diameter 4.88 +/- 0.55 to 3.57 +/- 0.43 cm (P < .01 pre vs post); and apical diameter 4.39 +/- 0.46 to 3.38 +/- 0.34 cm (P < .01 pre vs post). CONCLUSIONS: Coapsys and reduction annuloplasty techniques both acutely reduce functional mitral regurgitation and annular dimension. The Coapsys device provided significantly greater left ventricular reshaping than did reduction annuloplasty. Further evaluation will assess the long-term valvular function and ventricular geometric stability associated with both techniques.

Comparison of transmyocardial revascularization with medical therapy in patients with refractory angina.

BACKGROUND: Transmyocardial revascularization involves the creation of channels in the myocardium with a laser to relieve angina. We compared the safety and efficacy of transmyocardial revascularization performed with a holmium laser with those of medical therapy in patients with refractory class IV angina (according to the criteria of the Canadian Cardiovascular Society). METHODS: In a prospective study conducted between March 1996 and July 1998 at 18 centers, 275 patients with medically refractory class IV angina and coronary disease that could not be treated with percutaneous or surgical revascularization were randomly assigned to receive transmyocardial revascularization followed by continued medical therapy (132 patients) or medical therapy alone (143 patients). RESULTS: After one year of follow-up, 76 percent of the patients who had undergone transmyocardial revascularization had improvement in angina (a reduction of two or more classes), as compared with 32 percent of the patients who received medical therapy alone (P<0.001). Kaplan-Meier survival estimates at one year (based on an intention-to-treat analysis) were similar for the patients assigned to undergo transmyocardial revascularization and those assigned to receive medical therapy alone (84 percent and 89 percent, respectively; P=0.23). At one year, the patients in the transmyocardial-revascularization group had a significantly higher rate of survival free of cardiac events (54 percent, vs. 31 percent in the medical-therapy group; P<0.001), a significantly higher rate of freedom from treatment failure (73 percent vs. 47 percent, P<0.001), and a significantly higher rate of freedom from cardiac-related rehospitalization (61 percent vs. 33 percent, P<0.001). Exercise tolerance and quality-of-life scores were also significantly higher in the transmyocardial-revascularization group than in the medical-therapy group (exercise tolerance, 5.0 MET [metabolic equivalent] vs. 3.9 MET; P=0.05); quality-of-life score, 21 vs. 12; P=0.003). However, there were no differences in myocardial perfusion between the two groups, as assessed by thallium scanning. CONCLUSIONS: Patients with refractory angina who underwent transmyocardial revascularization and received continued medical therapy, as compared with similar patients who received medical therapy alone, had a significantly better outcome with respect to improvement in angina, survival free of cardiac events, freedom from treatment failure, and freedom from cardiac-related rehospitalization.

Heart transplantation in Lincoln, Nebraska: the Nebraska Heart Transplant Program experience.

The results of the Nebraska Heart Transplant Program are presented. Survival at one and four years, cost, waiting time and return to work rates are reported and compared to known standards. Survival is 91 percent at one year and 76 percent at four years after transplant. These data as well as costs, waiting time and return to work compare favorably with published and reported data. We conclude the results of the Nebraska Heart Transplant Program by all parameters evaluated are excellent. Referral of patients to distant programs causes needles inconvenience and higher patient costs, and is not justified.

Postcardiotomy shock: clinical evaluation of the BVS 5000 Biventricular Support System.

This prospective trial evaluated the safety and efficacy of a new pulsatile, temporary ventricular assist device, the BVS 5000. Patients were eligible for treatment if they were hemodynamically unstable despite maximal pharmacologic and intraaortic balloon pump therapy, were free of concomitant complications, and were less than 6 hours from the first attempt to separate from cardiopulmonary bypass. Fifty-five postcardiotomy patients were enrolled; 31 met all selection criteria and the remainder failed to meet criteria (n = 15) or were not successfully supported (n = 9). The BVS 5000 effectively restored hemodynamics: Mean arterial pressure increased (77.1 +/- 8.0 mm Hg on-support versus 50.1 +/- 15.3 mm Hg presupport; p = 0.0001). Cardiac index increased (2.3 +/- 0.3 L.min-1.m-2 on-support versus 1.6 +/- 0.6 L.min-1.m-2 presupport; p = 0.0013). Left ventricular filling pressure decreased (11.9 +/- 4.5 mm Hg on-support versus 23.8 +/- 8.7 mm Hg presupport; p = 0.0030). The most frequent complication was bleeding in 42 patients (76%). Of the patients meeting all criteria, 17 (55%) were weaned from support and 9 (29%) were discharged. Survival was significantly influenced by presupport cardiac arrest events. Survival among patients not experiencing arrest was 47%. Eight patients are long-term survivors and were asymptomatic in New York Heart Association class I or II at 1-year follow-up. The BVS 5000 restored hemodynamics, permitted myocardial recovery, and improved survival in a group of patients who would have otherwise died.

Cardiac transplantation--first year experience in a community hospital: a three year follow-up.

This is a report of ten consecutive patients with end-stage cardiac disease treated with orthotopic cardiac transplantation in a community hospital, during the first year of its heart transplantation program. All patients were followed for a minimum of 33 months and a maximum of 45 months with 100% survival at two years and 90% at three years. All survivors are presently in N.Y.H.A. Class I or II. The entire group of patients received the same triple immunosuppressive therapy. The incidence of infection and rejection during the first three months post-transplantation was 0.3 and 0.6 episodes per patient respectively. Every patient developed some degree of deterioration in renal function and 80% of the patients now receive treatment for systemic hypertension. The in-hospital institution cost for the transplant admission varied from $25,084 to $74,164. To date, 30 patients have undergone heart transplantation in our program and 26 are long-term successes. This study again proves that renal insufficiency and hypertension remain the major side effects of Cyclosporine therapy. We further conclude from our experience that cardiac transplantation can be successfully and cost effectively performed in a community hospital even with a somewhat lower caseload.

Two episodes of cytomegalovirus-associated colon perforation after heart transplantation with successful result.

A patient with end-stage heart disease was discharged from the hospital on postoperative day 7 after orthotopic heart transplantation. Three weeks from the day of operation, he developed sigmoid colon perforation, which required Hartmann's procedure, and 2 weeks later he had cecal disruption. A pathologic specimen showed underlying diverticular disease with associated cytomegalovirus colitis. Subsequently, the patient had multiple complications. Three months after colon perforation, the patient left the hospital, and now 1 year after transplantation he continues to do well. To the best of our knowledge, this is the first reported case of a patient who survived multiple colon perforations soon after heart transplantation.

True aneurysm of the pancreaticoduodenal artery: a case report and review of the literature.

A case of aneurysm of the pancreaticoduodenal artery is reported. Its differences from false aneurysms of the same artery are defined. The use of CT as a screening instrument and angiography as the definitive diagnostic tool is suggested to avoid undue delay in corrective treatment.

Unusual symptom in patient with pseudoaneurysm of the left ventricle and review of the literature.

A case of pseudoaneurysm developing 2 years after left ventricular aneurysmectomy and single coronary artery bypass graft is reported. A hypothesis that pseudoaneurysms developing after transmyocardial incision begin in surgery or shortly thereafter is postulated. Chest X-ray films as a preliminary test to direct attention to the diagnosis are recommended. An aggressive surgical approach is suggested. To our knowledge, this is the sixth known reported case in the literature with hemoptysis as the chief symptomatic feature.

Intrasplenic abscess: two case reports and review of the literature.

The occurrence of splenic abscess, sickle cell trait, and drug addiction is described in two patients. The coincidence of sickle cell disease and drug addiction in the possible etiology of splenic abscess should be noted. The first patient had a splenic abscess in the inferior pole of the spleen with signs and symptoms of left upper quadrant peritoneal irritation. The second patient had an intrasplenic abscess in the superior pole with pleuritic type chest pain and large left pleural effusion. In both cases, the upper gastrointestinal series was of aid in establishing the diagnosis. In one case, a splenic scan was helpful. Clostridium perfringens were cultured from the abscess of one patient; and Clostridium species, Staphylococcus aureus and Propionibacterium acnes were cultured from the other. Both patients were successfully treated with splenectomy and drainage of the splenic bed.

Secondary sternal closure: a method of preventing cardiac compression.

A patient with severe congenital pulmonary stenosis who underwent pulmonary valvulectomy is reported. Acute cardiac compression and left ventricular failure developed in the immediate postoperative period. Because of extreme cardiac dilatation, the chest wall could not be closed. A technique of secondary sternal closure is described.

Retrosternal dislocation of the clavicle producing thoracic outlet syndrome.

Following traumatic retrosternal dislocation of the clavicle, the patient presented with thoracic outlet syndrome 6 months postinjury with swelling and cyanosis of the right upper extremity, and cramps of the right arm and forearm after heavy manual work. When open reduction of the dislocated clavicle failed, the medial half of the clavicle was resected. Four years postoperation, the patient is doing well, and is asymptomatic. A review of the literature, anatomy, mode of injury, mechanism of injury, pathology, clinical picture, diagnosis and treatment are discussed.