The clinical course of new-onset atrial fibrillation after elective aortic operations.

BACKGROUND: The onset of atrial fibrillation (AFIB) in the postoperative setting has been associated with increased morbidity and mortality in patients undergoing major noncardiothoracic operations. The purpose of this study was to determine the incidence, associated complications, and outcomes of AFIB after open aortic operations. STUDY DESIGN: We studied 211 consecutive patients undergoing elective aortic operations at a single hospital during a recent 6-year period. Postoperatively all patients had continuous ECG monitoring in the ICU for a mean (+/- SD) of 6 +/- 8 days and routine cardiac enzyme determinations. RESULTS: AFIB developed in 22 of the 211 patients (10%), a mean (+/- SD) of 2 +/- 1 days after operation, and it lasted for a mean of 4 +/- 6 days after onset. Sixteen patients spontaneously reverted to normal sinus rhythm, 3 required cardioversion (2 chemical, 1 electrical), and 3 continued in AFIB at discharge. Four of the 22 patients suffered additional cardiac complications, including antecedent MI in 3 (14%) and sustained cardiogenic shock requiring electrical cardioversion in 1. By comparison, the incidence of MI in the other 189 patients was 4% (no significant difference [NSD]). There were no deaths in the AFIB patients. Cardiac emboli developed in none of the 22 patients, and all patients had normal sinus rhythm on ECG obtained a mean of 14 +/- 10 months after discharge. Comparing the 22 patients with AFIB with the 189 patients without AFIB, there were no differences in the mean duration of ICU stay (6 +/- 4 versus 6 +/- 8 days), total length of hospital stay (10 +/- 5 versus 11 +/- 10 days), or hospital mortality (0% versus 0.5%). AFIB patients were older (71 versus 66 years, p = 0.016), but there was no difference in gender or use of beta-blockers between the two groups. CONCLUSIONS: These data suggest that AFIB is not uncommon after aortic operations but is not associated with increased morbidity, mortality, or length of hospital stay. Although a minority of affected patients can have other cardiac complications such as MI, these complications are usually recognized before the onset of AFIB. AFIB does not affect the outcomes of aortic operations. Most patients will revert spontaneously to normal sinus rhythm and do not require longterm anticoagulation to prevent thromboembolic complications.

Rotational atherectomy.

Rotational atherectomy is used most often to treat stenoses that are calcified, located at an arterial ostium or at the site of a bifurcation, or resulting from in-stent restenosis. The atherectomy device debulks soft and calcified plaque while minimizing injury to adjacent normal arterial segments. In a randomized comparison with excimer laser and balloon angioplasty, rotational atherectomy achieved a statistically higher procedural success rate without an increased incidence of major complications. Patients with lesions that were more complex derived the greatest benefit from rotational atherectomy. To date, rotational atherectomy usually is performed in conjunction with a) the intracoronary infusion of a "cocktail" containing verapamil, heparin, and nitroglycerin; b) the intravenous infusion of a glycoprotein IIb/IIIa receptor antagonist, such as abciximab; c) a stepped burr approach, leading to a burr:artery ratio of 0.8; d) burr rotations <30 seconds in duration; e) avoidance of burr deceleration; and f) low-pressure balloon angioplasty. Under these circumstances, it has a procedural success rate of 98% and a major complication rate of <2%.

Percutaneous mitral balloon valvuloplasty.

Almost all mitral stenosis (MS) is rheumatic in etiology. The patient with MS who is symptomatic despite medical therapy should undergo percutaneous mitral balloon valvuloplasty or mitral valvular surgery (commissurotomy or replacement). The choice of procedure is determined by patient preference and the echocardiographic morphologic features of the valvular and subvalvular apparati. With balloon valvuloplasty, the rate of success is > 90%. At institutions where operators are experienced with balloon valvuloplasty and open surgical commissurotomy, their acute and long-term results are comparable. Balloon valvuloplasty occasionally is associated with complications, including death in 0 to 1%, moderate or severe valvular regurgitation in 3 to 5%, and systemic embolization in 1 to 3%.

Hepatic lipase (LIPC) promoter polymorphism in men with coronary artery disease. Allele frequency and effects on hepatic lipase activity and plasma HDL-C concentrations.

Hepatic lipase is an important determinant of plasma HDL concentration and LDL subclass distribution and may therefore influence susceptibility to coronary artery disease (CAD). To assess the effect of genetic variation in hepatic lipase activity on CAD susceptibility, we determined the frequency of the -514T allele of hepatic lipase in white men with CAD and in controls who did not have CAD. In men with CAD, postheparin plasma hepatic lipase activity was 15% to 20% lower in heterozygotes and 30% lower in homozygotes for the -514T allele. Allele frequencies were similar in cases and controls, however, and were consistent with Hardy-Weinberg expectation in both groups. This finding was confirmed in a second group comprising cases with premature symptomatic CAD and controls who were free of disease. These data indicate that a primary decrease in hepatic lipase activity of as much as 30% does not influence susceptibility to CAD in white men.

Late revascularization reduces mortality in survivors of myocardial infarction.

In survivors of acute myocardial infarction, the restoration of antegrade flow in the infarct-related coronary artery may improve prognosis by a mechanism that is independent of its influence on left ventricular systolic performance. Furthermore, survival may be improved even when antegrade flow is restored days or even weeks after the acute event. In several retrospective studies of survivors of infarction, we and others have shown a) that long-term survival is substantially better in those with-as opposed to those without-antegrade flow in the infarct-related coronary artery, and b) that the mechanical restoration of flow in an occluded infarct-related artery (accomplished with balloon angioplasty or bypass grafting) markedly improves long-term survival. The late restoration of antegrade flow in the infarct-related artery appears to render the so-called border zone of infarction less electrically unstable, thereby reducing the likelihood of ventricular tachyarrhythmias and sudden death.

Thrombolysis versus primary percutaneous transluminal coronary angioplasty for acute myocardial infarction.

For the patient with acute myocardial infarction (MI), both primary percutaneous transluminal coronary angioplasty (PTCA) and intravenous thrombolytic therapy are effective in restoring antegrade coronary blood flow, improving left ventricular systolic function, and reducing mortality. Primary PTCA is effective when performed quickly by experienced operators. It is the preferred therapy in the patient a) with a contraindication to thrombolytic therapy, b) aged 70 years or older, and c) in whom thrombolytic therapy is likely to be ineffective (ie, the patient with cardiogenic shock). Thrombolytic therapy is widely available and can be given quickly and easily. As a result, it remains the treatment of choice for most patients with acute MI. The goal of therapy for the patient with acute MI is the rapid and sustained restoration of coronary blood flow. For the individual patient, the better therapy-primary PTCA or thrombolytic therapy-is the one that can be given more safely and expeditiously.

Predictive value of prominent right atrial V waves in assessing the presence and severity of tricuspid regurgitation.

Neither "prominent" right atrial V waves nor an elevated mean right atrial pressure reliably predicts the presence of moderate or severe tricuspid regurgitation. On the other hand, the absence of prominent right atrial V waves and an elevated mean right atrial pressure are relatively specific for the absence of moderate or severe tricuspid regurgitation.

Effects of the intracoronary infusion of cocaine on left ventricular systolic and diastolic function in humans.

BACKGROUND: In dogs, a large amount of intravenous cocaine causes a profound deterioration of left ventricular (LV) systolic function and an increase in LV end-diastolic pressure. This study was done to assess the influence of a high intracoronary cocaine concentration on LV systolic and diastolic function in humans. METHODS AND RESULTS: In 20 patients (14 men and 6 women aged 39 to 72 years) referred for cardiac catheterization for the evaluation of chest pain, we measured heart rate, systemic arterial pressure, LV pressure and its first derivative (dP/dt), and LV volumes and ejection fraction before and during the final 2 to 3 minutes of a 15-minute intracoronary infusion of saline (n=10, control subjects) or cocaine hydrochloride 1 mg/min (n=10). No variable changed with saline. With cocaine, the drug concentration in blood obtained from the coronary sinus was 3.0+/-0.4 (mean+/-SD) mg/L, similar in magnitude to the blood cocaine concentration reported in abusers dying of cocaine intoxication. Cocaine induced no significant change in heart rate, LV dP/dt (positive or negative), or LV end-diastolic volume, but it caused an increase in systolic and mean arterial pressures, LV end-diastolic pressure, and LV end-systolic volume, as well as a decrease in LV ejection fraction. CONCLUSIONS: In humans, the intracoronary infusion of cocaine sufficient in amount to achieve a high drug concentration in coronary sinus blood causes a deterioration of LV systolic and diastolic performance.

Coronary arterial anatomy in patients with left ventricular systolic dysfunction without chest pain or previous myocardial infarction.

Patients with left ventricular systolic dysfunction without chest pain or previous myocardial infarction are unlikely to have 3-vessel coronary artery disease and are very unlikely to have coronary anatomy suitable for bypass grafting. Of our 108 subjects, only 3 (3%) had 3-vessel coronary artery disease thought to be suitable for revascularization.

Repeat coronary angiography in patients with chest pain and previously normal coronary angiogram.

Patients with chest pain and normal coronary angiograms have excellent long-term survival and are unlikely over the ensuing years to develop clinically significant atherosclerotic coronary artery disease. Specifically, of the 17 subjects with a previously normal coronary angiogram who had repeat angiography an average of almost 9 years later, 15 showed no appearance of coronary artery disease and 2 developed single-vessel coronary artery disease, 1 of whom had a myocardial infarction.

Cocaine-induced myocardial ischemia and infarction: pathophysiology, recognition, and management.

As cocaine abuse has become widespread, it has been associated with various cardiovascular complications, including angina pectoris, myocardial infarction, and sudden cardiac death. Cocaine's principal effects on the cardiovascular system are mediated via alpha-adrenergic stimulation and include (1) an increase in the determinants of myocardial oxygen demand (heart rate and systemic arterial pressure), and (2) a concomitant decrease in myocardial oxygen supply (caused by vasoconstriction of the epicardial coronary arteries). beta-adrenergic blocking agents may exacerbate cocaine-induced coronary arterial vasoconstriction, thereby increasing the magnitude of myocardial ischemia. In contrast, nitroglycerin and verapamil reverse cocaine-induced hypertension and coronary arterial vasoconstriction; therefore, they are the agents of choice in treating patients with cocaine-associated chest pain.

Preoperative left ventricular peak systolic pressure/end-systolic volume ratio and functional status following valve surgery in patients with mitral regurgitation and enlarged end-systolic volumes.

This study was done to determine if the left ventricular (LV) peak systolic pressure/end-systolic volume (PSP/ ESV) ratio predicts symptomatic improvement with valve replacement or repair in patients with mitral regurgitation (MR) and an enlarged LV ESV. Patients with MR and LV ESV <30 ml/m2 consistently improve symptomatically with valve surgery, whereas the response of those with an ESV >30 ml/m2 is heterogeneous. The LV PSP/ESV ratio, an easily acquired measure of LV performance, may discriminate those who improve with valve surgery from those who do not. Accordingly, in 40 patients (15 men and 25 women, aged 14 to 74 years) with moderate or severe MR, no other cardiovascular abnormalities, and a LV ESV >30 ml/m2, we assessed the utility of clinical, hemodynamic, and angiographic variables routinely measured preoperatively to predict symptomatic improvement with valve replacement or repair. Of the 40 subjects, 3 died during or within 6 months of surgery. Six months after valve surgery, symptoms had improved in 34 patients, were unchanged in 1, and had worsened in 2. By univariate analysis, only the preoperative pulmonary capillary wedge pressure was predictive of a change in functional class (p = 0.05). The PSP/ESV ratio was not predictive of a change in functional class after valve surgery. Thus, the PSP/ESV ratio does not identify which patients with MR and an enlarged LV ESV will manifest symptomatic improvement with valve surgery.

The "open artery hypothesis" in survivors of myocardial infarction.

In survivors of acute myocardial infarction, the restoration of antegrade flow in the infarct-related coronary artery may improve prognosis by a mechanism independent of its effect on left ventricular function. Survival may be enhanced even when restoration of flow is accomplished days or weeks after the acute event. In a series of retrospective studies of survivors of a first myocardial infarction, it was shown that long-term survival is significantly better in those with than in those without antegrade flow in the infarct-related artery. It is hypothesized that late restoration of antegrade flow in the infarct-related artery renders the border zone of the infarction more electrically stable, thereby diminishing the incidence of ventricular tachyarrhythmias and sudden death.

Restoration of coronary flow in myocardial infarction by intravenous chimeric 7E3 antibody without exogenous plasminogen activators. Observations in animals and humans.

BACKGROUND: Coronary thrombus is composed of platelets and fibrin, and during thrombolytic treatment, reflow may be slowed by platelet deposition. It may be possible to initiate coronary reflow without exogenous plasminogen activators by blocking platelet aggregation while fibrin generation is impeded with heparin. METHODS AND RESULTS: In 14 dogs, left anterior descending coronary artery thrombosis was produced by endothelial trauma and thrombin instillation in the presence of stenosis distally. Reflow was monitored by flow probe during treatment with (1) heparin, (2) heparin and aspirin, and (3) heparin, aspirin, and intravenous 7E3. Eighty percent of dogs treated with the third combination showed stable reflow (> or = 25% of prestenotic flow) in 50 +/- 9 minutes. In addition, 13 patients were studied during intravenous administration of c7E3 10 minutes before primary angioplasty for acute myocardial infarction and Thrombolysis In Myocardial Infarction (TIMI) grade 0 or 1 flow. Pretreatment included heparin and oral aspirin. Flow increased during a 10-minute period by at least one TIMI grade in 11 (85%) of 13 and reached TIMI grade 2 or 3 in 7 (54%) of 13 patients. Average TIMI grade flow increased from 0.31 +/- 0.5 to 1.54 +/- 0.8 (P < .001). Thrombus length 10 minutes after c7E3 was 5.1 +/- 3.5 mm. All but 1 patient then underwent angioplasty. There were no complications. CONCLUSIONS: Coronary reflow can be initiated by intravenous 7E3 administration in the presence of heparin and aspirin. In human patients, this flow can be observed in 10 minutes without exogenous thrombolytic agents.