Predictors of response to exercise training in severe chronic congestive heart failure.

We prospectively assessed whether baseline central hemodynamics and exercise capacity can predict improvement of VO2 at ventilatory threshold (VT) after exercise training in patients with severe chronic congestive heart failure. Eighteen patients (mean +/- SEM; age 52 +/- 2 years), half of them listed for transplant, underwent 3 weeks of exercise training (interval cycle and treadmill walking; 5 x/week) and 3 weeks of activity restriction in a random-order crossover trial. Baseline data were not significantly different for groups with exercise training first and activity restriction first: cardiac index at rest (2.1 +/- 0.1 L/m2/min), maximum cardiac index (3.1 +/- 0.2 L/m2/min) (Fick), and echocardiographic ejection fraction (21 +/- 1%). The same was true for cardiopulmonary exercise data (cycle ergometry; up 12.5 W/min): VO2 at VT (9.3 +/- 0.4 ml/kg/min), maximum VO2 (12.2 +/- 0.7 ml/kg/min), VT in percentage of predicted maximum VO2 (31 +/- 2%), heart rate at VT (95 +/- 4 beats/min), and decrease of dead space-to-tidal volume ratio from rest to VT (33 +/- 1 --> 29 +/- 1). Improvement of VO2 at VT after training (2.2 +/- 0.4 ml/kg/min; p <0.001) was not related to baseline central hemodynamics (r = <0.10 for each), but was greater in patients with a lower baseline VO2 at VT (r = -0.65; p <0.01), peak VO2 (r = -0.66; p <0.01), VT in percentage of predicted maximum VO2 (r = -0.74; p <0.001), heart rate at VT (r = -0.63; p <0.01), and smaller decrease of dead space-to-tidal volume ratio from rest to VT (r = 0.65; p <0.01). Ejection fraction after exercise training (24 +/- 2%) and activity restriction (23 +/- 2%) did not differ significantly compared with baseline, and patient status (heart failure and cardiac rhythm) remained stable. Three parameters accounted for 84% of the variance of improvement in VO2 at VT: VO2 at VT in percent predicted maximum VO2, decrease of dead space-to-tidal volume ratio, and heart rate at VT. The findings suggest that there was a greater increase in VO2 at VT after exercise training in patients with greater peripheral deconditioning at baseline. The improvement was unrelated to central hemodynamics. Clinically stable patients with severe chronic congestive heart failure, potential heart transplant candidates, and those awaiting transplantation may benefit from involvement in a short-term exercise training program.

Effects of short-term exercise training and activity restriction on functional capacity in patients with severe chronic congestive heart failure.

Previous exercise training studies in patients with chronic congestive heart failure (CHF) were performed for periods lasting > 2 months, and effects of activity restriction on exercise induced-benefits were not systematically assessed. With one exception study, patients were not reported to be transplant candidates. In this random-order crossover study, effects of 3 weeks of exercise training and 3 weeks of activity restriction on functional capacity in 18 hospitalized patients with severe CHF [(mean +/- SEM) age 52 +/- 2 years; ejection fraction 21 +/- 1%; half of them on a transplant waiting list] were assessed. The training program consisted of interval exercise with bicycle ergometer (15 minutes) 5 times weekly, interval treadmill walking (10 minutes), and exercises (20 minutes), each 3 times weekly. With training, the onset of ventilatory threshold was delayed (p < 0.001), with increased work rate by 57% (p < 0.001) and oxygen uptake by 23.7% (p < 0.001). On average, there was a 14.6% decrease in slope of ventilation/carbon dioxide production before the onset of ventilatory threshold (p < 0.05), and ventilatory equivalent of carbon dioxide production by 10.3% (p < 0.01). At the highest comparable work rate (56 +/- 5 W) the following variables were decreased: heart rate (7.3%; p < 0.05), lactate (26.6%; p < 0.001), and ratings of perceived leg fatigue and dyspnea (14.5% and 16.5%; p < 0.001 each). At peak exercise, oxygen uptake was increased by 19.7% (p < 0.01) and oxygen pulse by 14.2% (p < 0.01). There was a correlation of baseline peak oxygen uptake and increase of peak oxygen uptake due to training (r = -0.75; p < 0.004). Independently of the random order, data after activity restriction did not differ significantly from data measured at baseline. Patients with stable, severe CHF can achieve significant improvements in aerobic and ventilatory capacity and symptomology by short-term exercise training using interval exercise methods. Impairments due to activity restriction suggest the need for long-term exercise training.

Aerobic capacity and functional classification of patients with severe left-ventricular dysfunction.

Classes I/II and III of the classification systems of the New York Heart Association (NYHA), Canadian Cardiovascular Society (CCS) and American Medical Association (AMA) were compared with each other and with the Weber classification (O2 uptake, VO2/kg during treadmill walking) in 35 male patients with severe left ventricular dysfunction. Measured end points were ventilatory threshold (VT) and peak exercise. Also investigated was whether the CCS and AMA scales, due to their more stringent differentiation, are more precise than the NYHA system in determining a limited physical capacity and whether there are other differentiating factors useful in classification which may be derived from cardiopulmonary exercise testing. At the VT, the mean VO2/kg did not differ significantly in any classification system between classes I/II and III (12.8 +/- 2.5 vs. 11.1 +/- 2.3 ml/kg/min) and corresponded to Weber class B. At peak exercise, the mean VO2/kg only differed significantly within the NYHA classification; classes I/II (16.3 +/- 3.1 ml/kg/min) corresponded to Weber class B, and class III (13 +/- 3 ml/kg/min) to Weber class C. The individual values displayed a large scatter. Factors differing in classes I/II and III of all three systems at peak exercise were the ventilatory equivalent of O2 and CO2 as well as end-tidal partial pressure for O2 and CO2. At VT these factors showed a separating character only in the AMA classification. It is not possible to determine objective functional impairment by use of the NYHA, CCS and AMA systems because they are not analogous to the Weber system. Nevertheless, these classification systems can be used for clinical assessment and follow-up.

Influence of different exercise protocols on functional capacity and symptoms in patients with chronic heart failure.

This study compares hemodynamic, metabolic, and gas exchange responses, catecholamine levels, and symptoms in 35 male patients with chronic heart failure (CHF) ([mean +/- SD] age 53 +/- 11 yr; ejection fraction 24 +/- 11%) during three differently graded exercise test protocols. On three consecutive days patients performed cycle ergometry supine, with prolonged steps (prol BE) and right heart catheterization, ramplike cycle ergometry sitting (ramp BE), and ramplike treadmill walking (TMW). As in routine clinical practice, the prol BE was terminated when pathologic central hemodynamics and/or increased symptomology occurred, and ramp BE and TMW due to increased symptomology and/or physician's decision. During prol BE at ventilatory threshold (VT) the VO2 (8.6 +/- 1.8 ml.kg-1.min-1) was lower than during ramp BE (9.3 +/- 2.1 ml.kg-1.min-1) (P < 0.017) and TMW (11.8 +/- 2.3 ml.kg-1.min-1) (P < 0.0001). Prol BE, ramp BE, and TMW also differed significantly with respect to ventilation (22 +/- 7 l.min-1; 26 +/- 6 l/min-1; 29 +/- 7 l.min-1; P < 0.01) and heart rate (100 +/- 15 beats.min-1; 103 +/- 18 beats.min-1; 110 +/- 16 beats.min-1; P < 0.017). No differences were found in lactate levels, catecholamine levels, and ratings of leg fatigue and dyspnea. At test termination, the peak VO2 during prol BE (100.8 +/- 3.3 ml.kg-1.min-1) was lower than during ramp BE (13.3 +/- 4.1 ml.kg-1.min-1) (P < 0.0001) and TMW (14.7 +/- 3.4 ml.kg-1.min-1) (P < 0.0001). Peak norepinephrine value during ramp BE (4.531 +/- 2.788 nmol.l-1) was higher than during prol BE (3.707 +/- 2.262 nmol.l-1) (P < 0.001). Among the three tests, no significant differences were found for peak values of heart rate, lactate, and ratings of dyspnea. Although the VO2.kg-1 at VT was significantly higher during ramp BE and TMW compared to prol BE (P < 0.001), the values expressed as a percent of peak VO2.kg-1 were significantly lower (70 +/- 4%; 72 +/- 6%; 79 +/- 3%; P < 0.017). A systematic effect on aerobic capacity with reduced peak values during ramp BE and TMW was demonstrated when test termination was based primarily on pathological findings of central hemodynamics from prol BE.

A comparison of surgical and medical therapy for atrial septal defect in adults.

BACKGROUND: The surgical closure of an atrial septal defect is frequently recommended for patients over 40 years of age. However, the prognosis for such patients with unrepaired defects is largely unknown, and the outcome for patients operated on after the fourth decade of life has not yet been compared with that for medically treated patients in a controlled follow-up study. METHODS: In a retrospective study, we examined the clinical course of 179 consecutive patients with isolated atrial septal defects diagnosed after the age of 40. The 84 patients (47 percent) who underwent surgical repair were compared with the 95 patients (53 percent) who were treated medically. The mean (+/-SD) follow-up period was 8.9 +/- 5.2 years (range, 1 to 26). RESULTS: Multivariate analysis revealed that surgical closure of the defect significantly reduced mortality from all causes (relative risk, 0.31; 95 percent confidence interval, 0.11 to 0.85). The adjusted 10-year survival rate of surgically treated patients was 95 percent, as compared with 84 percent for the medically treated patients. In addition, surgical treatment prevented functional deterioration, as measured by the New York Heart Association class (relative risk, 0.21; 95 percent confidence interval, 0.08 to 0.55). However, the incidence of new atrial arrhythmias or of cerebrovascular insults in the two groups was not significantly different. CONCLUSIONS: The surgical repair of an atrial septal defect in patients over 40 years of age, as compared with medical therapy, increases long-term survival and limits the deterioration of function due to heart failure. However, surgically treated patients should be followed closely for the onset of atrial arrhythmias so as to reduce the risk of thromboembolic complications.

Reproducibility of Doppler echocardiographic quantification of aortic and mitral valve stenoses: comparison between two echocardiography centers.

Doppler echocardiography has been widely used as a noninvasive method to quantify valvular heart diseases. This study assessed the variability between 2 echocardiography centers concerning 2-dimensional and Doppler echocardiographic results in the quantification of mitral and aortic valve stenoses. Forty-two patients were studied by 2 different echocardiography centers in a blinded, independent fashion. In patients with aortic and mitral valve stenosis, mean and maximal flow velocities were measured. The aortic valve orifice area was calculated according to the continuity equation. Mitral valve orifice area was determined by direct planimetry and by pressure half-time. In patients with an aortic valve stenosis, a close relation between the 2 centers was found for the maximal and mean flow velocities (coefficient of correlation, r = 0.72 to 0.92; coefficient of variation, 3.7 to 7.7%). A close correlation and a small observer variability was found for the flow velocity ratio determined by flow velocities measured in the left ventricular outflow tract and over the stenotic valve (r = 0.88; coefficient of variation, 0.01 +/- 0.009). In contrast, there was a poor correlation between the diameter of the left ventricular outflow tract and the aortic orifice area (r = 0.36 and 0.59, respectively). In patients with a mitral valve stenosis, mean and maximal velocities were closely correlated (r = 0.85 and 0.77, respectively). Velocities were not found to be significantly different between the 2 centers. Variability between the 2 centers for the mitral valve orifice area was 9.8% (2-dimensional echocardiography) and 5.7% (pressure half-time).(ABSTRACT TRUNCATED AT 250 WORDS)

[Primary atrial heart tumors--a review of 21 cases]. / Primäre atriale Herztumoren--eine Ubersicht über 21 Fälle.

Between 1978 and 1986, atrial heart tumors were found in 21 of our patients, all of them subsequently underwent surgery. Pathological-histological examination in 20 patients confirmed the diagnosis of a myxoma; the one remaining case was a female patient with primary cardiogenic osteosarcoma. Of the 20 patients, 15 (75%) were females; in four female patients (20%) the tumor was localized in the right atrium. The main symptoms and findings were elevated erythrocyte sedimentation rates (80%), stress-induced dyspnea or paroxysmal dyspnea (71% resp.), and diastolic mitral or tricuspid murmurs (62%). The patient with osteosarcoma died of cachexia on the basis of generalized diffuse metastases. One female patient with a preoperative history of severe left ventricular impairment on the basis of dilative cardiomyopathy died 5 weeks after surgery. Relapse of atrial myxoma has not yet occurred during follow-up since 1978.

[Improved flow through aortocoronary venous bypasses after anticoagulant therapy. A prospective randomized study]. / Verbesserte Durchgängigkeit aorto-koronarer Venen-Bypasses nach Antikoagulantientherapie. Eine prospektive randomisierte Studie.

To evaluate the effect of oral anticoagulant therapy on graft patency rate during the first 2 months after bypass surgery 174 patients were randomly assigned to treatment with phenprocoumon (89) or to a control group (85) starting on day 7 after bypass surgery. Until day 7 all patients received low dose heparin. There was no significant difference between the two groups with respect to age, sex distribution, number of vessels diseased, left ventricular enddiastolic pressure, preoperative exercise tolerance or number of grafts constructed per patient. All patients underwent angiographic evaluation 8 weeks after bypass surgery. Graft patency rate was 90.4% in the treatment group versus 83.6% in the control group (p less than 0.015). None of the grafts with a flow rate of greater than 90 ml/min was occluded 8 weeks after surgery. Oral anticoagulation improved the patency rate of grafts with a flow of less then 90 ml/min.

Improved graft patency with anticoagulant therapy after aortocoronary bypass surgery: a prospective, randomized study.

We conducted a prospective, randomized study to evaluate the influence of oral anticoagulation on graft patency early after aortocoronary bypass surgery. Eighty-nine patients who received 251 distal venous anastomoses were treated with phenoprocoumon, a vitamin K antagonist, starting on the seventh postoperative day; 84 patients with 238 distal venous anastomoses received no anticoagulation. Both groups were comparable with respect to age, exercise hemodynamics, extent of coronary disease and left ventricular dysfunction. In each group, 2.8 distal anastomoses were constructed per patient. Graft patency after surgery was 90.4% in the treatment group and 84.6% in the control group (p less than 0.015). All anastomoses were patent in 81% and 67% of patients, respectively (p less than 0.02). Flow measurements in 279 grafts suggest that grafts with a flow of less than 90 ml/min benefit from oral anticoagulation. No graft with a flow of more than 90 ml/min was occluded.

[Progression and regression of coronary heart disease in chronic infarction stage in patients under 40]. / Progression und Regression der koronaren Herzerkrankung im chronischen Infarktstadium bei Patienten unter 40 Jahren.

500 patients under the age of 40 with a history of myocardial infarction underwent a first coronary angiography. 193 patients who had had a first angiogram more than 3 years before were asked to undergo a repeat study irrespective of symptoms during that time interval. 34 patients did not respond, 27 refused, 13 had died, and 5 were excluded for medical reasons. 114 underwent a repeat study on average 3.8 years after the first angiogram. Progression or regression of coronary artery disease was assumed where a difference of 2 grades based on the AHA-classification of stenosis was found. The majority of patients exhibited no change in coronary morphology. Progression was equally frequent in all three vessels. Regression was almost exclusively seen in patients with unilocular disease, occurred predominantly in the LAD and was more frequently seen in patients below 35 years than in the 35-39 age group. Patients with progression of stenosis included a significantly larger number who continued to smoke during the observation period.

Endarteriectomy of the left coronary artery (LCA) as a supplementary surgical means of myocardial revascularization with aortocoronary vein bypass procedure.

In order to establish a satisfactory vein bypass anastomosis during myocardial revascularization, 2 findings are of special importance: the local wall quality and the actual lumen of the coronary artery, both altered by the arteriosclerotic disease. In certain cases, with diffuse triple vessel disease, the intraoperative decision for an endarteriectomy as a supplementary surgical means appears to be a logical consequence. In our own patient group of 50 restudied patients with an endarteriectomy of the LCA, we had a patency rate of 72%; in a subgroup it was as high as 84%, if performed locally and under full vision. Compared with extended core extraction, the latter technique only showed minor vessel irregularities proximal and distal to the bypass anastomosis and thus, in a long-term view, it opens up additional revascularization possibilities for severe coronary artery sclerosis.