High-risk coronary angioplasty assisted by active hemoperfusion. A feasibility study.

We assessed the effectiveness of distal hemoperfusion support during gradual, prolonged balloon inflation during percutaneous transluminal coronary angioplasty in high-risk patients. The patients were identified as having a poor left ventricular ejection fraction ( < 35%), > 50% of viable myocardium at risk percutaneous coronary balloon angioplasty, or both. A total of 64 procedures were performed in 61 patients. Angiographic success was achieved in 83 of 86 (96.5%) lesions treated with hemoperfusion support. Hospital complications included 1 patient who had a non-Q-wave infarction, 1 who had to undergo redo percutaneous coronary balloon angioplasty, and 5 who required coronary artery bypass operations. The hospital mortality was 7.8% (5 patients). This preliminary study indicates that hemoperfusion support can enable expeditious, simple, economical, and effective percutaneous transluminal coronary balloon angioplasty in a subset of labile patients in whom procedural failure frequently leads to sudden death.

Early and late mortality of patients undergoing aortic valve replacement after previous coronary artery bypass graft surgery.

BACKGROUND: In a small number of patients who undergo coronary artery bypass graft surgery (CABG), a hemodynamically significant aortic valve lesion requiring aortic valve replacement (AVR) develops as they grow older. In a limited number of studies in small patient groups, high mortality has been shown in patients undergoing AVR after CABG. We undertook this study to determine the mortality risk factors for patients who undergo AVR after CABG procedures. METHODS AND RESULTS: The outcome of 104 patients treated at our institution between January 1983 and December 1993 was retrospectively reviewed. The initial surgery was CABG in all patients. The patient population included 86 men (83%) and 18 women (17%); their mean age was 67 years. Overall, 70% of patients had congestive heart failure, and 96% had multivessel coronary artery disease. The diagnosis was aortic stenosis in 68% of patients, aortic insufficiency in 16%, and combined aortic stenosis and aortic insufficiency in 16%. Postoperative complications included worsening congestive heart failure (35%), perioperative myocardial infarction (13%), and bleeding (28%). The early mortality was 14%, and the late mortality was 17% (mean follow-up, 35 months). The risk factors for early mortality were number of diseased vessels (P = .028), renal failure (0.000), and prior myocardial infarction (P = .028). A perioperative predictor of early mortality was cardiopulmonary bypass time (P = .000). The risk factors for late mortality included preoperative diabetes mellitus (P = .007), postoperative acute respiratory distress syndrome (P = .011), and ventricular arrhythmias (P = .0001). The survival at 1, 5, and 10 years was 96%, 75%, and 49%, respectively. CONCLUSIONS: Risk factors were identified for early and late mortality in patients undergoing AVR after previous CABG. Although early morbidity and mortality were high, the longterm outcome of the survivors was favorable.

Potential mechanisms of improvement after various treatments for hypertrophic obstructive cardiomyopathy.

In sum, systolic dysfunction of the ventricle associated with left ventricular outlet obstruction and often with mitral valve regurgitation may be improved by myotomy, myomectomy, mitral valve replacement, and perhaps by the creation of left bundle branch block via DDD right ventricular pacing. Diastolic dysfunction of the ventricle may be improved by prolonging the diastolic filling period, shortening the isovolumic relaxation period with calcium channel blocking drugs, or perhaps by altering the atrioventricular activation time with a DDD pacemaker. The symptoms and complications of associated arrhythmias may be improved by medication, particularly with beta-blockers, which tend to stabilize the atrial rhythm and perhaps the ventricular rhythms. In treating patients with demonstrated ventricular arrhythmias, other antiarrhythmic agents may be helpful. (Table II summarizes the abnormalities, causes, and treatments of hypertrophic obstructive cardiomyopathy.) Epicardial coronary atherosclerosis is not rare in these patients, and arteriographic confirmation may lead to improvement by surgical bypass treatment. Since stroke volume is nearly fixed, cardiac output depends very much on heart rate. For this reason, each patient needs to receive the appropriate dosage of medications to achieve the optimal heart rate for his or her own physiologic state.

Septal myotomy-myomectomy versus mitral valve replacement in hypertrophic cardiomyopathy. Ten-year follow-up in 185 patients.

Between 1963 and 1985, 185 patients with hypertrophic cardiomyopathy (HCM) were treated with septal myotomy-myomectomy (MM) or mitral valve replacement (MVR) at our institution; 127 of these underwent septal MM, and 58 underwent MVR alone. The 1-month mortality was 4.7% for the septal MM group and 6.9% for the MVR group (p = NS). The mean time of postoperative follow-up was 118 months, ranging between 1 and 196 months. The annual mortality was 0.7% for the septal MM group and 1.3% for the MVR group (p = NS). In the MVR group, 98% of patients had been assigned to New York Heart Association (NYHA) functional classes III and IV before surgery; only 24% were classified as such at 10-year follow-up (p less than 0.001). In the septal MM group, 90% were in NYHA functional classes III and IV before surgery whereas only 27% were in these two classes postoperatively (p less than 0.001). A comparison of preoperative and postoperative hemodynamic findings revealed a significant reduction in left ventricular outflow gradient at rest: from 69 +/- 41 mm Hg preoperatively to 10 +/- 22 mm Hg postoperatively (p less than 0.001) in the septal MM group and from 75 +/- 45 mm Hg preoperatively to 10 +/- 21 mm Hg postoperatively (p less than 0.001) in the MVR group. In addition, the MVR group had a significant postoperative reduction in mean left ventricular end-diastolic pressure, from 21 mm Hg preoperatively to 15 mm Hg postoperatively (p less than 0.05).(ABSTRACT TRUNCATED AT 250 WORDS)

Mitral valve replacement and septal myomectomy in hypertrophic cardiomyopathy. Ten-year follow-up in 80 patients.

Between 1970 and 1980, 80 patients with hypertrophic cardiomyopathy were treated with mitral valve replacement (MVR) at our institution; 54 of these (Group 1) underwent MVR alone, and the remaining 26 (Group 2) underwent MVR plus septal myomectomy. The 1-month mortality was 7.4% for Group 1 and 7.6% for Group 2. After 10 years of follow-up, the annual mortality was 1.5% for Group 1 and 1.6% for Group 2 (this difference was not significant). Sixty-nine percent of the patients in both groups continued to experience marked symptomatic improvement. In Group 1, 96% of the patients had been assigned to New York Heart Association (NYHA) functional class III or IV before surgery; only 17% remained in these two classes postoperatively (p less than 0.01). In Group 2, 98% had been assigned to NYHA functional class III or IV before surgery, whereas only 20% remained in these two classes postoperatively (p less than 0.01). A comparison of preoperative and postoperative hemodynamic findings revealed that the left ventricular end-diastolic pressure was significantly reduced from 20 to 14 mm Hg in Group 1 and from 20 to 15 mm Hg in Group II (p less than 0.05). There was also a significant postoperative reduction in left ventricular outflow gradient at rest (from 79 to 6 mm Hg in Group 1 and from 75 to 7 mm Hg in Group 2) (p less than 0.01). These findings indicate that, in patients with hypertrophic cardiomyopathy who require surgical treatment, MVR alone or in conjunction with septal myomectomy offers significant improvement of symptoms and hemodynamic values.(ABSTRACT TRUNCATED AT 250 WORDS)

Pentoxifylline therapy: a new adjunct in the treatment of pulmonary hypertension?

Patients with markedly elevated pulmonary vascular resistance, whether caused by primary pulmonary hypertension or by congenital heart disease, have a grave prognosis, regardless of the type of therapy they undergo. This brief report presents our experience in treating 6 patients (4 women and 2 men) having pulmonary vascular obstructive disease, by administrating pentoxifylline (Trental), a drug that has been used in patients with chronic occlusive systemic arterial disease. Our patients underwent treadmill testing before the study and again 1 to 3 months after initiation of the study. Duration of exercise was short in all patients; however, it increased significantly while patients were taking pentoxifylline. These preliminary results are encouraging; however, we were unable to confirm other physiologic improvement with noninvasive study, and placebo effect was not ruled out. Therefore, we believe that use of pentoxifylline in patients with pulmonary vascular obstructive disease warrants further investigation by means of detailed direct hemodynamic measurement.

Ventriculoarterial discordance revisited: angiographic presentation and discussion of a typical case.

This article reexamines the subject of ventriculoarterial discordance in the light of a case report and the recent literature. The angiographic method of studying complex cardiac defects is illustrated by example, in order to stress the need for a systematic, step-by-step, segmental approach to diagnosis. We favor use of the term "ventriculoarterial" discordance to refer to a defect that involves incongruence of ventricular and arterial morphologies, as predicated on the loop rule. This rule calls for anticipation of certain spatial relationships between aortic and pulmonary trunks, given certain ventricular morphologies: with a right-sided, anatomically right ventricle, for example, the ascending aorta is expected to be on the right side, whether with normally crossed or transposed great vessels (D-loop derivatives). As in the case presented here, ventriculoarterial discordance features the ascending aorta on the opposite side of the anatomically right ventricle. The influence of the formation of an abnormal cardiac apex (as in crisscrossed or superoinferior hearts) on the cardiac segments' configurations is discussed, since this too can affect the spatial relationships between the great vessels.

Severe diffuse obstructive coronary artery disease in an infant.

Severe diffuse obstruction of the coronary arteries was diagnosed in an 18-month-old girl who presented with signs and symptoms of severe congestive cardiomyopathy. Most reported cases of myocardial infarction in neonates or infants have been secondary to obstruction of a single major coronary artery owing to thrombosis or embolism; diffuse multiple obstruction involving the entire coronary artery system, as in our case, has not previously been described. Although the exact cause of the obstruction remained unknown, the most likely mechanism was in situ thrombosis.

Total correction of tetralogy of fallot in adults: surgical results and long-term follow-up.

From 1962 to 1983, 117 patients between the ages of 16 and 72 years (mean, 25 years) underwent total correction of tetralogy of Fallot. All patients were operated on because of recent deterioration. Eighty (68%) had had previous surgical palliation. Complications occurred in 38 cases (32%) before total correction and were more frequent in older patients. The hospital mortality was 7.8% and was highest in older patients and those with a previous Potts shunt. Fifty-nine patients were followed up for as long as 23 years (mean, 9.2 years) after total correction. The probability of survival at 5, 10, and 15 years after total correction was 96%, 96%, and 84%, respectively. The actuarial freedom from any significant cardiovascular event at 5, 10, and 15 years was 84%, 73%, and 50%, respectively. Reoperation was required in ten cases (17%), in which there was one operative death. Late death occurred in four cases (6.8%). Left ventricular dysfunction was documented in ten patients (17%), three of whom had mural thrombi and two of whom had cerebrovascular accidents. A significant rhythm disorder was present in 13 patients. Fifty-four of the 55 surviving patients were in New York Heart Association (NYHA) functional class I or II at last follow-up. We conclude that 1) total correction of tetralogy of Fallot in adults is associated with a low operative mortality, similar to that in children, and offers symptomatic relief in most cases; 2) the long-term survival is excellent, but late sequelae become more frequent at late follow-up; 3) "corrective" reoperation can be done with a low risk; and 4) most of the survivors are in NYHA functional class I or II and lead normal, productive lives.

Progression of hypertrophic cardiomyopathy into a hypokinetic left ventricle: higher incidence in patients with midventricular obstruction.

The development of segmental or generalized left ventricular hypokinesia is an unusual occurrence in patients with hypertrophic cardiomyopathy. To determine the incidence and possible pathophysiologic mechanisms responsible for this process, the serial clinical and laboratory data of 62 patients with the diagnosis of hypertrophic cardiomyopathy were analyzed. During a mean follow-up period of 8 years (range 2 to 21), 5 patients (Group A) developed left ventricular hypokinesia, whereas the remaining 57 patients (Group B) continued to exhibit the clinical and laboratory findings of hypertrophic cardiomyopathy. Three patients developed a dilated left ventricle with generalized hypokinesia; two other patients had segmental left ventricular wall motion abnormalities. None of these five patients who developed left ventricular hypokinesia had fixed coronary artery disease. The mean age, sex, mean duration of follow-up, presence of coronary myocardial bridges and angina pectoris, and an interventricular gradient were all similar in Groups A and B. Midventricular obliteration was seen in 4 (80%) of the 5 patients in Group A and in 4 (7%) of the 57 patients in Group B (p less than 0.001). Findings from this study reveal that segmental or generalized left ventricular hypokinesia can develop in patients with hypertrophic cardiomyopathy in the absence of fixed coronary artery disease. Such hypokinesia can occur after an acute myocardial infarction or it can develop gradually without clinical or electrocardiographic evidence of infarction. Patients with the mid-ventricular obliteration variant of hypertrophic cardiomyopathy are at a higher risk of developing segmental or diffuse left ventricular hypokinesia.

The echocardiographic spectrum of atrial myxoma: a ten-year experience.

We analyzed the echocardiograms of 28 patients with a left atrial myxoma and two with a right atrial myxoma. Our purpose was to evaluate the value of echocardiography for the diagnosis of these cardiac masses. Only 59% of the m-mode echocardiograms in patients with a left atrial myxoma showed the characteristic findings of multiple diastolic echoes within the mitral orifice as well as abnormal systolic echoes within the left atrium. M-mode echocardiograms were atypical for left atrial myxoma in the remaining patients, and a definitive diagnosis could not be established on the basis of this procedure in six of the patients (22%). Two-dimensional echocardiography showed the presence of a left atrial mass in all 16 patients who had the procedure, and aided in understanding the atypical m-mode recordings. There was a close relationship (r =.82) between two-dimensional echocardiographic measurements of the myxomas' size and pathologic measurements. Both right atrial myxomas could be identified on the m-mode echocardiogram. Our experience indicates that two-dimensional echocardiography is superior to the m-mode technique for the diagnosis and characterization of left atrial myxomas.

The QS2/QT ratio as an index of appropriate left ventricular response to autonomic and inotropic stimuli.

Dissociation between duration of electrical and mechanical systole has been seen with increase of myocardial shortening velocity or adrenergic activity. We found a decrease of the QS2/QT ratio after exercise in 10 pts with semisitting bicycle maximal exercise test and a normal radionuclide angiogram. No change was seen in 9 patients with a normal study with beta blockade, and in pts with a abnormal radionuclide test, without beta blockade (11 pts). In 19 normal active individuals, a significant QS2/QT decrease (p less than 0.001) was seen after a submaximal exercise treadmill test, which was inhibited by beta blockade. We believe that QS2/QT diminution is suggestive of an increase of the inotropic state of the left ventricle with exercise, produced through adrenergic stimulation. It is not seen either when an ischemic left ventricle cannot adequately respond to exercise or after beta blockade.

Atypical phasic coronary artery narrowing.

Four unusual cases of phasic (occurring only in systole or only in diastole) coronary artery narrowing are reported. In two cases, diastolic compression of the left anterior descending coronary artery was due to tight pericardial adhesions in patients with aortic insufficiency; in the third case, systolic compression of two right ventricular coronary branches was associated with hypertrophic cardiomyopathy and a normotensive right ventricle; and in the fourth case, a large aneurysm of the inferior wall of the left ventricle caused systolic compression of the posterior descending coronary artery, which was epicardial. The diagnostic and pathophysiologic characteristics of each case are discussed.