Nursing and psychosocial issues of patients on mechanical support.

Mechanical support technology continues to evolve. Ongoing research has led to more efficient devices allowing for discharge to outpatient or home settings. From December of 1991 to July 31, 2000 the Cleveland Clinic Foundation has placed 240 mechanical support devices. These include 173 HeartMate devices of the Pneumatic or Vented Electric models, 56 Novacors, and 11 Thoratecs. Patients placed on mechanical support potentially proceed through six phases of support. This begins with the evaluation process and progresses through the perioperative phase, the intensive care phase, the regular nursing floor phase, discharge, and transplantation. We have developed a specialized team to care for this patient population. As a result, the nursing and psychosocial care of patients on mechanical support has advanced over years of experience. We have been able to identify specific nursing and psychosocial issues that develop through the phases of support. Becoming aware of these issues will assist in a successful outcome for the patient.

Results of partial left ventriculectomy for dilated cardiomyopathy: hemodynamic, clinical and echocardiographic observations.

OBJECTIVES: The study was done to prospectively measure the echocardiographic, hemodynamic and clinical outcomes after partial left ventriculectomy (PLV). BACKGROUND: Although PLV can improve symptoms of advanced heart failure, immediate postoperative echocardiographic findings remain abnormal. METHODS: Fifty-nine patients with cardiomyopathy and advanced heart failure underwent PLV and concomitant mitral valve surgery between May 1996 and December 1997. Thirty-nine percent were on inotropic therapy. All were New York Heart Association (NYHA) functional class III or IV. Mechanical circulatory support (LVAD) and transplant were provided for rescue therapy when hemodynamic compromise occurred. Patients were followed for a mean of 405+/-168 days, and clinical, echocardiographic and hemodynamic measures were obtained preoperatively, immediately postoperatively, and at 3 and 12 months prospectively. RESULTS: Comparing preoperative and 12-month postoperative values in event-free survivors, we found: NYHA functional class improved from 3.6 to 2.1, p < 0.0001; peak oxygen consumption increased from 10.8 to 16.0 ml/kg/min, p < 0.0001; LV ejection fraction increased from 13+/-6.0% to 24+/-6.9%, p < 0.0001; LV end diastolic diameter decreased from 8.2+/-1.03 to 6.2+/-0.64 cm, p < 0.0001, and volume was reduced from 167+/-60 to 105+/-38 ml/m2, p = 0.02. Central hemodynamics did not normalize after surgery. CONCLUSIONS: Partial left ventriculectomy can provide structural remodeling of the heart that may result in temporary improvement in clinical compensation. However, perioperative failures and the return of heart failure limit the propriety of this procedure.

Real-time three-dimensional echocardiographic study of left ventricular function after infarct exclusion surgery for ischemic cardiomyopathy.

BACKGROUND: Infarct exclusion (IE) surgery, a technique of left ventricular (LV) reconstruction for dyskinetic or akinetic LV segments in patients with ischemic cardiomyopathy, requires accurate volume quantification to determine the impact of surgery due to complicated geometric changes. METHODS AND RESULTS: Thirty patients who underwent IE (mean age 61+/-8 years, 73% men) had epicardial real-time 3-dimensional echocardiographic (RT3DE) studies performed before and after IE. RT3DE follow-up was performed transthoracically 42+/-67 days after surgery in 22 patients. Repeated measures ANOVA was used to compare the values before and after IE surgery and at follow-up. Significant decreases in LV end-diastolic (EDVI) and end-systolic (ESVI) volume indices were apparent immediately after IE and in follow-up (EDVI 99+/-40, 67+/-26, and 71+/-31 mL/m(2), respectively; ESVI 72+/-37, 40+/-21, and 42+/-22 mL/m(2), respectively; P:<0.05). LV ejection fraction increased significantly and remained higher (0.29+/-0.11, 0.43+/-0.13, and 0.42+/-0.09, respectively, P:<0.05). Forward stroke volume in 16 patients with preoperative mitral regurgitation significantly improved after IE and in follow-up (22+/-12, 53+/-24, and 58+/-21 mL, respectively, P:<0.005). New York Heart Association functional class at an average 285+/-144 days of clinical follow-up significantly improved from 3.0+/-0.8 to 1.8+/-0.8 (P:<0.0001). Smaller end-diastolic and end-systolic volumes measured with RT3DE immediately after IE were closely related to improvement in New York Heart Association functional class at clinical follow-up (Spearman's rho=0.58 and 0.60, respectively). CONCLUSIONS: RT3DE can be used to quantitatively assess changes in LV volume and function after complicated LV reconstruction. Decreased LV volume and increased ejection fraction imply a reduction in LV wall stress after IE surgery and are predictive of symptomatic improvement.

Cardiac exercise hemodynamics late after partial left ventriculectomy.

BACKGROUND: Although some patients report favorable activity levels late after partial left ventriculectomy (PLV), their exercise physiology has not been well described. METHODS AND RESULTS: We performed upright bicycle hemodynamics in 10 patients (9 men) aged 56+/-12 years at 1.7 years after PLV. Ejection fraction was 25+/-4%. Patients biked 10+/-7 minutes. With exercise, the mean pulmonary arterial pressure rose from 36+/-12 to 52+/-10 mm Hg (P:=0.0003). The mean pulmonary capillary wedge pressure rose from 25+/-14 to 36+/-9 mm Hg (P:=0.0566), and the cardiac index rose from 2.2+/-0.5 to 3.8+/-1.6 L. min(-1). m(-2) (P:=0.0077). The mixed venous oxygenation with exercise declined from 44+/-9% to 24+/-17% (P:=0. 0220), and the pulmonary vascular resistance increased from 2.0+/-0. 9 to 2.3+/-1.1 Wood units (P:=0.5566). CONCLUSIONS: In late follow-up after PLV with exercise, the cardiac index is significantly augmented. However, there are further rises in pulmonary artery and pulmonary capillary wedge pressures, suggesting abnormal compliance, with marked decline in mixed venous oxygenation. Elucidating late physiology after PLV may help pave the way for future innovative heart failure surgeries.

Left ventricular reduction surgery with mitral valve repair.

The echocardiographic changes and functional outcome from mitral valve repair, combined with partial left ventriculectomy (PLV), the Batista procedure, were investigated. From May 1996 to August 1997 the operation was performed on 57 patients, primarily (95%) transplant candidates with idiopathic dilated cardiomyopathy. All had been Class IV (36.8% had improved to Class III by the time of surgery) on medical therapy, including 40% hospitalized on inotropes and 3 patients on intra-aortic balloon pumps. The mean cardiac index was 2.1+/-0.6 L/min/m2, with a wedge pressure of 24+/-8 mm Hg, and norepinephrine levels of 855+/-500 pg/mL (normal 80-526 pg/mL). There were 2 in-hospital mortalities (3.5%). At 3 months there were significant persistent changes in LV end-diastolic diameter (8.1+/-1.0 cm-6.3+/-0.9 cm) and ejection fraction (13.6+/-6%-23+/-7.7%). Subjective improvement included a mean change in NYHA functional class from 3.7 to 2.2, and objective changes included improvement in peak oxygen consumption from 10.6+/-4 mL/kg/min to 15.4+/-4.5 mL/kg/min. Actuarial survival at 1 year was 82.1%; and freedom from death, relisting for transplantation, and need for LVAD support was 58%. The earliest "learning curve" experience with this relatively unstudied operation warrants careful investigation. Many questions remain to be answered, but many patients have demonstrated early subjective and objective improvement.

Surgical therapy for heart failure: care of the patient with partial left ventriculectomy.

Partial left ventriculectomy (PLV) surgery has gained significant attention worldwide as a possible alternative to heart transplantation or as a therapy to treat heart failure. This procedure offers an attractive choice to patients and physicians because of the lack of need for immunosuppressive medications and a decrease in the risk of rejection associated with transplantation. PLV surgery is currently under investigation in several centers worldwide, but long-term outcomes have yet to be definitively evaluated. The Cleveland Clinic Foundation began performing PLV surgery in May 1996. Since that time, 57 patients have received the procedure with actuarial survival of 82% at 1 year. The purpose of this article is to highlight the clinical management of the postoperative PLV patient.

Early results with partial left ventriculectomy.

OBJECTIVE: We sought to determine the role of partial left ventriculectomy in patients with dilated cardiomyopathy. METHODS: Since May 1996 we have performed partial left ventriculectomy in 53 patients, primarily (94%) in heart transplant candidates. The mean age of the patients was 53 years (range 17 to 72 years); 60% were in class IV and 40% in class III. Preoperatively, 51 patients were thought to have idiopathic dilated cardiomyopathy, one familial cardiomyopathy, and one valvular cardiomyopathy. As our experience accrued we increased the extent of left ventriculectomy and more complex mitral valve repairs. For two patients mitral valve replacement was performed. For 51 patients the anterior and posterior mitral valve leaflets were approximated (Alfieri repair); 47 patients also had ring posterior annuloplasty. In 27 patients (51%) one or both papillary muscles were divided, additional left ventricular wall was resected, and the papillary muscle heads were reimplanted. RESULTS: Echocardiography showed a significant decrease in left ventricular dimensions after resection (8.3 cm to 5.8 cm), reduction in mitral regurgitation (2.8+ to 0), and increase in forward ejection fraction (15.7% to 32.7%). Cardiac index did not increase significantly (2.2 to 2.4 L/min per square meter). Eight patients (15%) required a perioperative left ventricular assist device; one died and was the only perioperative mortality (1.9%). At 11 months, actuarial survival was 87% and freedom from relisting for transplantation was 72%. CONCLUSIONS: Improved selection criteria are necessary to avoid early failures, and much more follow-up and analyses of data are mandatory. However, the operation may become a biologic bridge, or even alternative, to transplantation.