Safety and efficacy of bariatric surgery in patients with coronary artery disease.

OBJECTIVE: To determine the safety and efficacy of bariatric surgery in obese patients with documented coronary artery disease (CAD). PATIENTS AND METHODS: Among patients with class II or III obesity who underwent bariatric surgery between March 1995 and January 2002 at the Mayo Clinic in Rochester, Minn, the rates of major in-hospital cardiovascular complications and mortality of 52 patients with clinical CAD were compared with those of 507 patients without CAD. The efficacy of bariatric surgery was measured by changes in body weight and other cardiovascular risk factors at follow-up. RESULTS: There were no in-hospital deaths in either group. Three patients with documented CAD (5.8%; 95% confidence interval, 0%-12.2%) and 7 patients without CAD (1.4%; 95% confidence interval, 0.4%-2.4%) had cardiovascular complications (P=.06). After a mean follow-up of 2.5 years (range, 77-2403 days) of patients with CAD, the following values decreased postoperatively (all at P<.001): weight, from 147+/-36 kg to 103+/-22 kg; body mass index, from 50+/-11 kg/m2 to 36+/-9 kg/m2; fasting serum glucose, from 149+/-52 mg/dL to 113+/-31 mg/dL; glycosylated hemoglobin, from 9%+/-3% to 6%+/-2%; and blood pressure, from 142/82 mm Hg to 132/73 mm Hg. Low-density lipoprotein cholesterol decreased postoperatively from 116+/-31 mg/dL to 75+/-26 mg/dL, and triglycerides decreased from 198+/-85 mg/dL to 119+/-52 mg/dL (P<.01 for both). CONCLUSION: Bariatric surgery should be considered for treating patients with CAD and class II or III obesity.

Hydroxychloroquine-induced cardiotoxicity in a 39-year-old woman with systemic lupus erythematosus and systolic dysfunction.

A 39-year-old woman with a history of systemic lupus erythematosus developed chest pain and conduction abnormalities. An echocardiographic examination revealed systolic dysfunction and ventricular thickening. Because of the unclear nature of her cardiac disease, right ventricular endomyocardial biopsy was performed. Light microscopy showed diffuse myocyte vacuolization without myocarditis, and transmission electron microscopy demonstrated sarcoplasmic myelinoid and curvilinear bodies, diagnostic of hydroxychloroquine toxicity. Among patients with autoimmune connective disorders, cardiac dysfunction may be a result of the disease or occasionally of its treatment. Although the nature of the cardiac disease (myocardial, valvular, or pericardial) can generally be evaluated echocardiographically, endomyocardial biopsy may be indicated to rule out diseases with a specific microscopic appearance, such as myocarditis or hydroxychloroquine cardiotoxicity.

Immediate and long-term hemodynamic and clinical effects of sildenafil in patients with pulmonary arterial hypertension receiving vasodilator therapy.

OBJECTIVE: To determine the immediate and long-term effects of adding sildenafil, a phosphodiesterase-5 inhibitor, to the medical regimen of patients with pulmonary arterial hypertension (PAH). PATIENTS AND METHODS: Thirteen patients with PAH received empirical adjunctive sildenafil treatment at the Mayo Clinic in Rochester, Minn, between November 1, 2000, and August 31, 2001. All received a 25-mg dose of sildenafil, increased by 25 mg at 8-hour intervals, if tolerated, up to 100 mg during hemodynamic monitoring for 24 to 48 hours. Long-term effects on right heart hemodynamics were assessed by noninvasive right ventricular systolic pressure, right ventricular index of myocardial performance, and a 6-minute walk test. RESULTS: Sildenafil significantly increased cardiac output (CO) (P = .04) and decreased pulmonary artery systolic pressure, mean pulmonary artery pressure, pulmonary vascular resistance, and mean arterial pressure (P < or = .01) at peak measurements (obtained 1-2 hours after highest dose). At trough measurements (obtained 8 hours after highest dose), sildenafil significantly decreased pulmonary artery systolic pressure, mean pulmonary artery pressure, and mean arterial pressure (P = .01). Ten patients discharged from the hospital were taking the highest-tolerated dose of sildenafil every 8 hours. The right ventricular systolic pressure and right index of myocardial performance showed no significant improvement at follow-up (117 +/- 70 days), although concomitant treatment with epoprostenol could be tapered in 2 patients. Changes in New York Heart Association classes were inconsistent, and improvements in the 6-minute walk test were not significant. CONCLUSION: Sildenafil has an immediate pulmonary vasodilator effect in patients already receiving vasodilators for PAH. Its long-term effects on right heart function and functional status are equivocal. A large, prospective, well-designed study is needed to determine the effects of sildenafil on PAH, both in untreated and concurrently treated patients.

Pulmonary hypertension in the setting of acquired systemic arteriovenous fistulas.

We describe 2 patients who presented with symptoms and clinical evidence of pulmonary hypertension. The first patient, who had severe pulmonary hypertension, underwent correction of an acquired arteriovenous (AV) fistula, which led to improvement according to clinical and noninvasive hemodynamic criteria. The second patient had severely symptomatic pulmonary hypertension associated with a large, previously unrecognized, superior mesenteric AV fistula after intra-abdominal surgery. Surgical correction of the fistula resulted in normalization of pulmonary hemodynamics assessed by right heart catheterization. Truly reversible substrates of pulmonary hypertension are rare. Acquired systemic AV fistulas are a less recognized cause of secondary pulmonary hypertension. It is unknown whether high blood flow peripheral AV shunts ultimately lead to endothelial proliferation, vascular smooth muscle hypertrophy, plexiform lesions, and other histopathologic changes that are seen in patients with left-to-right shunts due to atrial septal defects, ventricular septal defects, and patent ductus arteriosus.