B-type natriuretic peptide levels are not a surrogate marker for invasive hemodynamics during management of patients with severe heart failure.

BACKGROUND: We sought to assess the utility of serial BNP measurements in patients with severe heart failure and attempted to correlate values with invasively derived data. METHODS: In a retrospective study, we analyzed serial BNP levels in patients receiving hemodynamically guided therapy for severe heart failure and sought correlation with invasively derived data. RESULTS: Thirty-nine patients with New York Heart Association Class III-IV, with an ejection fraction of 35% or less, who had a pulmonary artery catheter inserted for hemodynamically tailored heart failure therapy, were identified and serial BNP measurements reviewed. BNP was estimated on admission, at 12 and 36 hours. Normally distributed variables are expressed as mean +/- SD and otherwise as median +/- interquartile range. Mean ejection fraction was 16% +/- 6%. Mean pulmonary artery occlusion pressures (PAOP) fell with therapy and were 25 +/- 7 mmHg, 18 +/- 7 mmHg and 19 +/- 7 mmHg at admission, 12 hours and 36 hours respectively ( P < 0.05). Median BNP levels fell from 1200 +/- 641 to 771 +/- 803 at 12 hours and to 805 +/- 771 at 36 hours (P < .001). There was no correlation between BNP and any hemodynamically derived variable. A change in BNP was not associated with a change in PAOP in any individual patient. Only 42% remained alive on medical therapy at 30 days. CONCLUSIONS: In patients with severe heart failure, BNP levels do not accurately predict serial hemodynamic changes and do not obviate the need for pulmonary artery catheterization.

Survival beyond 10 years following heart transplantation: The Cleveland Clinic Foundation experience.

BACKGROUND: Long-term survival after heart transplantation is a desirable although challenging goal. METHODS: We analyzed clinical outcomes in the cohort of 170 patients who have undergone heart transplantation at The Cleveland Clinic Foundation and survived >10 years. RESULTS: We found 10-year and 15-year survival rates of 54% and 41%, respectively, in these patients, but there was also a high incidence of complications, such as hypertension, renal dysfunction, transplant vasculopathy, and malignancy. CONCLUSIONS: Long-term survival following cardiac transplantation is possible although complications are frequent. Beyond 10 years, malignancy is a major cause of death.

Donor intracranial bleeding is associated with advanced transplant coronary vasculopathy: evidence from intravascular ultrasound.

OBJECTIVES: We evaluated the impact of spontaneous intracranial bleeding (ICB) in the donor on transplant coronary vasculopathy using serial intravascular ultrasound examinations. MATERIALS AND METHODS: Between January 1995 and December 2000, 72 recipients underwent cardiac transplantation from donors who had experienced spontaneous ICB (ICB group). Their findings using serial intravascular ultrasound analysis at baseline (within 1 month) and 1 year after transplantation were compared with 90 recipients who had undergone transplantation from trauma donors (trauma group). RESULTS: Compared with the Trauma group, the ICB group showed increased coronary intimal thickness (0.55 +/- 0.33 vs 0.39 +/- 0.3 mm; P = .034), plaque volume (3.84 +/- 2.5 vs 2.28 +/- 1.65 mm(3); P = .015) and plaque burden (7.4 vs 2%) at 1 year after transplantation. CONCLUSIONS: Donor spontaneous ICB is associated with significantly increased coronary vasculopathy.

The influence of donor gender on allograft vasculopathy: evidence from intravascular ultrasound.

BACKGROUND: Allograft vasculopathy is a major risk factor for mortality following cardiac transplantation. Several immune and nonimmune factors have been evaluated as risk factors for the development of coronary vasculopathy. OBJECTIVE: We evaluated the influence of donor gender on the progression of coronary vasculopathy in heart transplant recipients. METHODS: Eighty-nine heart transplant recipients (67 men, 22 women of mean age: 56 +/- 12 years) underwent serial volumetric intravascular ultrasound analysis (IVUS) at baseline (within 1 month) and at 1 year after transplantation. Patients were divided into four groups in relation to the donor-recipient gender status: female-female, n=17; female-male, n=28; male-female, n=5; male-male, n=39. Ultrasound images were recorded during an automated pullback and with an equal number of slices (average=22 per coronary vessel). The measured IVUS indices for the left anterior descending artery were: change in maximal intimal thickness, average intimal area, total plaque volume, and intimal index. RESULTS: Patients were similar in baseline characteristics. At 1 year after transplantation, IVUS indices of coronary vasculopathy were significantly increased among recipients of female allografts (P <.05). CONCLUSION: Heart transplant recipients of female allografts display increased coronary vasculopathy progression.

Intravascular ultrasound imaging after cardiac transplantation: advantage of multi-vessel imaging.

BACKGROUND: Intravascular ultrasound is a sensitive tool to study transplant vasculopathy. However, there is no consensus regarding the methodology for imaging protocol. The impact of single versus multiple epicardial vessel imaging in determining the prevalence of transplant vasculopathy has not been determined. This study examines the benefit of three-vessel imaging versus one-vessel imaging in detecting transplant vasculopathy. METHODS AND RESULTS: One hundred eleven transplant recipients with intravascular ultrasound imaging at baseline (within 2 months of transplantation) were studied: 107 at 1-year, 53 at 2-year and 41 at 3-year follow-up. A total of 222 arteries, 519 segments and 772 sites were analyzed (94 LAD, 65 LCX and 65 RCA). The prevalence of transplant vasculopathy lesions was 27%, 41% and 58% at 1 year, 39%, 55% and 71% at 2 years and 39%, 55% and 74% at 3 years for patients with one-, two- and three-vessel imaging, respectively. Single- or two-vessel disease was present in 23% (7) and 32% (10) patients with three-vessel imaging, leading to the potential mislabeling of these 17 (55%) patients as "disease free" if they underwent only single-vessel imaging. CONCLUSIONS: Multivessel imaging is more sensitive in detecting the transplant vasculopathy lesions compared to single-vessel imaging. This important variable should be considered when designing and interpreting trials utilizing intravascular imaging derived end-point.

Posttransplant lymphoproliferative disease after cardiac transplantation. Two unusual variants with predominantly plasmacytoid features.

Two patients who developed posttransplant lymphoproliferative disorder with plasmacytoid changes in the lymphocytes after heart transplant are described. The first case is one of multiple myeloma, and the second is a case of lymphoma with plasmacytoid features. The clinical course and the etiologic role of the immunosuppressive therapies that the patients received for heart transplantation are described. A review of posttransplant multiple myeloma and discussion of the etiology and prognosis of this entity are presented.

Hemodynamic effects of a single intravenous injection of synthetic human brain natriuretic peptide in patients with heart failure secondary to ischemic or idiopathic dilated cardiomyopathy.

Synthetic human brain natriuretic peptide (sBNP) is a polypeptide with the same amino acid sequence as the naturally occurring hormone. Preclinical studies have demonstrated that BNP has potent hemodynamic, diuretic, and natriuretic effects that might be beneficial in treating patients with heart failure. This study was a randomized, double-blind, placebo-controlled, ascending-dose trial of sBNP administered as a single intravenous bolus in 27 heart failure patients. Six groups of patients received sequentially increasing doses of sBNP (0.3, 1, 3, 10, 15, and 20 micrograms/kg, respectively) as a single intravenous injection, and hemodynamics were assessed by pulmonary artery monitoring catheter. The 10 and 15 micrograms/kg doses of sBNP resulted in significant reductions in pulmonary capillary wedge pressure (-73%, p < 0.001), mean pulmonary artery pressure (-41%, p < 0.001), mean arterial blood pressure (-28%, p = 0.001), and systemic vascular resistance (-53%, p = 0.004). Significant increases occurred in cardiac index (68%, p < 0.001) and stroke volume index (72%, p < 0.001). The magnitude and duration of hemodynamic changes were dose dependent. There were no adverse effects. sBNP injected as a single intravenous bolus in heart failure patients improves hemodynamics in a dose-related fashion. Further clinical investigations to determine the use of sBNP in decompensated heart failure are clearly warranted.

Dichotomous pattern of coronary atherosclerosis 1 to 9 years after transplantation: insights from systematic intravascular ultrasound imaging.

OBJECTIVE: The aim of this study was to evaluate the extent and distribution of coronary atherosclerosis after transplantation. BACKGROUND: Transplant coronary artery disease is an important cause of death after cardiac transplantation. Unlike coronary angiography, intravascular ultrasound is a sensitive tool for detection and quantitation of this disease. METHODS: We performed intravascular ultrasound imaging in 132 (106 men, 50 +/- 10 years) patients, 1 to 9 years after transplantation using a 30-MHz ultrasound catheter. RESULTS: All three coronary arteries were visualized in 49, two in 62 and one in 21 patients. Of the 1,188 coronary artery segments, 706 were imaged (74% proximal, 64% mid- and 40% distal). At least one site with atherosclerosis (intimal thickness > or = to 0.5 mm) was found in 83% of patients. Atherosclerosis was noted in 64% of proximal, 43% of mid- and 26% of distal segments. Disease was diffuse in 48% and focal in 52%, circumferential in 66% and noncircumferential in 34%. Focal atherosclerosis was more common in proximal (59%) than mid- (48%) and distal segments (27%) (p=0.001). Noncircumferential plaques were more common in the proximal (42%) than mid- (28%) and distal segments (12%) (p=0.001). This pattern of focal and noncircumferential disease proximally, diffuse and circumferential disease distally, was observed irrespective of the time from transplantation. CONCLUSION: Atherosclerosis was detected in more than 80% of patients, with proximal segments most frequently involved. Diffuse and circumferential atherosclerosis was more common in mid- and distal segments. However, focal and noncircumferential involvement was more frequent proximally, a similar pattern to native atherosclerosis. These findings suggest that transplant coronary artery disease has a dual etiology based on the dichotomous pattern of atherosclerosis seen by intravascular ultrasound.

Occult and frequent transmission of atherosclerotic coronary disease with cardiac transplantation. Insights from intravascular ultrasound.

BACKGROUND: Transplant coronary artery disease is a major cause of morbidity and mortality after cardiac transplantation. However, limited data exist regarding the potential contribution of coronary atherosclerosis in the donor heart to cardiac-allograft vasculopathy. METHODS AND RESULTS: We performed quantitative coronary angiography and intravascular ultrasound imaging in 50 of 62 consecutive heart-transplant recipients (40 men, 10 women, mean age, 53 +/- 9 years) 4.6 +/- 2.6 weeks after transplantation. The donor population consisted of 30 men and 20 women (mean age, 32 +/- 12 years). Ultrasound imaging visualized all three coronary arteries in 22 patients, two coronary arteries in 23, and one coronary artery in 5. Ultrasound imaging detected coronary atherosclerosis (intimal thickness > or = 0.5 mm) in 28 patients (56%). However, the angiography was abnormal in only 13 patients (26%). The sensitivity and specificity of coronary angiography were 43% and 95%, respectively. With ultrasound, the average atherosclerotic plaque thickness was 1.3 +/- 0.6 mm and the cross-sectional area narrowing was 34 +/- 16%. Atherosclerotic involvement frequently was focal (85%), eccentric (mean eccentricity index, 87 +/- 8), and near arterial bifurcations. Donors of the transplant recipients with coronary atherosclerosis were older than those without atherosclerosis (37 +/- 12 versus 25 +/- 10 years, P = .001). Maximal intimal thickness correlated with donor age (r = .54, P = .0001). Multivariate analysis demonstrated that donor age (P = .0001), male sex of donor (P = .0006), and recipient age (P = .03) were independent predictors of atherosclerosis. CONCLUSIONS: Coronary atherosclerosis is frequently but inadvertently transmitted by means of cardiac transplantation from the donor to the recipient. Long-term outcomes of donor-transmitted coronary artery disease will require further evaluation.

Left ventricular diastolic dysfunction in lymphocytic myocarditis as assessed by Doppler echocardiography.

Pulsed-wave Doppler echocardiography of left ventricular (LV) inflows was performed in 30 consecutive patients with biopsy-proven lymphocytic myocarditis. There were 21 men and 9 women (mean age 50 +/- 15 years). LV ejection fraction was < or = 30% in 73% of the patients. Sixty-six percent were in New York Heart Association functional class III to IV. Peak early (E) velocity, late (A) velocity, deceleration time and filling pattern were assessed. These values were compared with a control population. E velocity in lymphocytic myocarditis was significantly higher than in control subjects (79 +/- 34 vs 67 +/- 14 cm/s, p = 0.0034). A velocity was lower in patients with myocarditis than in control subjects (38 +/- 20 vs 49 +/- 12 cm/s, p = 0.0001). Correspondingly, the E/A ratio was greater in the myocarditis group (2.5 +/- 1.3 vs 1.5 +/- 0.5, p < 0.0001). In particular, mean deceleration time in patients with myocarditis was significantly lower than that of control subjects (151 +/- 52 vs 194 +/- 30 ms, p < 0.0001). Diastolic filling patterns were abnormal in 29 of 30 patients (97%) with lymphocytic myocarditis, revealing a restrictive pattern in 25, abnormal relaxation in 4 and a normal pattern in 1. Lymphocytic myo-carditis is therefore associated with LV diastolic dysfunction of a predominantly restrictive pattern.

Coronary artery aneurysms: an unusual case report and a review of the literature.

Coronary artery aneurysms (CAA) were first recognized in postmortem studies. More recently they have been recognized in antemortem and angiographic studies and are reported to occur at an incidence of 1-2%. Left main coronary aneurysms (LMCA) are extremely rare with an incidence of 0.1%. Most of the aneurysms discovered in these angiographic studies have been in patients with cardiac symptoms of angina or acute myocardial infarction who subsequently were found to have severe narrowing of the coronary arteries. Angiographic and clinical data of a patient with a large aneurysm of the left main coronary artery and with aneurysmal disease of the thoracic and abdominal aorta are presented along with a review of the literature.

Lymphocytic myocarditis and dilated cardiomyopathy: treatment with immunosuppressive agents.

Thirty-four patients with history of congestive heart failure, dilated cardiomyopathy, and biopsy-proven lymphocytic myocarditis were treated for six months with immunosuppressive agents (prednisone and azathioprine) in addition to standard therapy for congestive heart failure. Seventy-three percent had improvement or resolution of the lymphocytic infiltrate, whereas 27% had persistent infiltrates. Improvement in myocardial histologic findings was unpredictable and did not correlate with age, gender, duration of symptoms, initial functional class, severity of left ventricular dysfunction, intensity of initial inflammatory infiltrate, or degree of myocardial cell injury. Histologic response was associated with significant improvement in left ventricular ejection fraction, but not cardiothoracic ratio, left ventricular dimensions, or survival. Functional class improved equally whether patients' disease did or did not respond to the treatment, and was not necessarily associated with objective improvement in cardiac function. Immunosuppressive therapy resulted in serious or fatal side effects in 24% of patients. Overall long-term survival was 79% at one year and 76% at two years. Poor survival was related to left ventricular ejection fraction less than 20%, male sex, age less than 50 years, and marked left ventricular dilation, but not to myocardial histologic findings. These findings indicate that the potential benefits nu the risks of immunosuppressive therapy must be weighed carefully in the individual patient.

Removal of surgically induced fibrous arterial plaques by argon ion laser angiosurgery using a multifiber delivery system. An experimental study in the dog.

Removal of intravascular atherosclerotic obstructions by laser irradiation has gained the attention of many investigators, but has proven to be considerably more difficult to accomplish than initially envisioned. We tested, in an animal model, an argon ion laser delivery system that permits control of (1) laser power, (2) exposure time, and (3) laser beam spot size. The study was conducted on surgically, induced focal fibrous plaques in the carotid arteries of nine dogs. Plaque removal, vessel patency, and healing were evaluated angiographically and by light and electron microscopy at intervals up to 60 days after treatment. Results showed that intravascular obstructions could be removed, healing occurred, and vessels remained patent for up to 60 days.

Gas volume quantitation during argon ion laser ablation of atheromatous aorta in blood and 0.9% saline media with an optically shielded catheter.

Using an optically shielded fiber optic laser catheter, the amount of gas produced when firing an argon ion laser into 0.9% saline solution or blood alone and into atheromatous aorta in either a blood or 0.9% saline medium was quantitated. Energies from 0.25 to 4 joules (J) were used at powers of 2, 5, and 8 W. We found that total volume of gas produced is small not only at equilibrium (0.3 +/- 0.1 microliter/J when firing in blood alone and also when ablating aorta in blood or saline media) but also at peak (2.5 +/- 0.2 microliters/J firing in blood alone and 1.0 +/- 0.1 microliter/J or 0.9 +/- 0.1 microliter/J when ablating aorta in saline or blood, respectively). Because these volumes are small, a clinically significant event from a gas embolus is unlikely during intravascular laser ablation of atheromatous plaque in the energy and power range studied. No gas was quantitated when firing the argon ion laser into 0.9% saline solution alone. The peak gas volume when firing in blood alone was significantly greater than that produced in the other chamber environments. This is thought to be due to increased absorption of argon laser light by hemoglobin. The gas volumes produced by lasing aorta in 0.9% saline or blood were not statistically different.

Effects of varying argon ion laser intensity and exposure time on the ablation of atherosclerotic plaque.

Using continuous wave (CW) argon ion laser light, a total of 253 laser exposures of varying power (1.5, 3, 5, 8 or 10 W) and duration (20-1,333 ms) were delivered to four segments of human atheromatous aorta obtained at autopsy. Exposure conditions were controlled by using an optically shielded laser catheter that provided a 500 micron spot of light of known power. Two thresholds for consistently reproducible ablation could be defined-an intensity threshold at 25.5 W/mm2 and a fluence threshold at 3.2 J/mm2. Above threshold, a fluence of 5.1 J/mm2 was found to produce the most efficient ablation, ie, removed the greatest volume (mm3) per energy delivered (J) compared to other fluence levels employed (p less than 0.0001). Between aortic segments, however, considerable variability in efficiency (mm3/J) was observed, possibly owing to different optical properties and/or plaque composition. Low-intensity laser radiation produced inconsistent ablation and extensive coagulation effects to surrounding tissue. When a fluence of 5.1 J/mm2 was constructed with a high-intensity laser beam and a short exposure time, consistent and efficient tissue removal resulted without histologic evidence of coagulation necrosis.

Survival of non-surgical patients with mild angina or myocardial infarction without angina.

A group of 408 catheterised patients who had mild angina or myocardial infarction without angina was selected in conformity with the criteria for entry into a previously reported randomised trial. Medical treatment had been chosen initially by the cardiologist, referring physician, or the patient, although 27% had late operation. Five year survival rates were 91% and 72% for mild angina with high or low ejection fractions and 85% for those who had myocardial infarction without subsequent angina. Survival rates were 95%, 88%, and 80% for one, two, and three artery disease respectively. For patients who had ejection fractions of at least 0.50, five year survivals were 95%, 89%, and 83% for one, two, and three artery involvement respectively. Good left ventricular function, single artery disease, and a short history were favourable prognostic variables in multivariate analysis of patients who had angina pectoris. Statistical methods of dealing with patients who had late operation influenced calculated survival, especially for patients at relatively high risk. The lower survival rates for the whole group and most subsets compared with survival rates in the randomised trial may be of clinical importance.

Percutaneous angioplasty of internal mammary artery graft stenosis using the brachial approach: a case report.

Cannulation of the internal mammary artery (IMA) via the ipsilateral brachial approach offers a complementary alternative to the transfemoral approach for IMA graft angioplasty and can offer potential advantage in terms of catheter stability and ease of IMA cannulation. This report describes successful IMA graft stenosis angioplasty using the ipsilateral brachial approach.