Ejection Fraction In Group Research Articles

Efficacy of combined modified and conventional ultrafiltration during cardiac surgery in children

Thirty children undergoing cardiac surgery under cardiopulmonary bypass (CPB) were prospectively studied to assess beneficial effects of modified ultrafiltration (MUF) over and above conventional ultrafiltration (CUF). Transoesophaegeal echocardiography determined ejection fraction (EF), fractional area change (FAC) and posterior wall thickness in end-diastole and end-systole were measured and compared in two groups undergoing CUF (group I) and CUF plus MUF (group II). Haemodynamic data, haematocrit, temperature drift, postoperative chest tube drainage in first 48 hours, ventilation and intensive care unit (ICU) stay were also recorded. Within group data were analysed by general linear trend and intergroup comparisons were made with t-test. EF and FAC decreased at 0 min after CPB in both groups, but both recovered at 10 and 30 min after CPB in group II. Increase in EF and FAC in group II was about 12-15 % and 3-5 % from 0 min respectively. There was also significant improvement in posterior wall thickness and haematocrit (P<0.05) in group II. Patients in group II maintained better systolic blood pressure and heamoglobin after CPB. Chest tube drainage in first 48 hours was significantly less in group 1I (100 -18 verses 85 +/-20 ml, P<0.05), but ventilation and ICU stay were not different between the two groups. Combined ultrafiltration has beneficial effect an haemodynamics with improvement in EF and FAC. It improves haematocrit and decreases chest pulse drainage.

Protective Effects of Carvedilol Against Anthracycline-Induced Cardiomyopathy

The aim of this study was to determine the protective effect of carvedilol in anthracycline (ANT)-induced cardiomyopathy (CMP). Despite its broad effectiveness, ANT therapy is associated with ANT-induced CMP. Recent animal studies and experimental observations showed that carvedilol prevented development of CMP due to chemotherapeutics. However, there is no placebo-controlled clinical trial concerning prophylactic carvedilol use in preventing ANT-induced CMP. Patients in whom ANT therapy was planned were randomized to administration of carvedilol or placebo. We enrolled 25 patients in carvedilol and control groups. In the carvedilol group, 12.5 mg once-daily oral carvedilol was given during 6 months. The patients were evaluated with echocardiography before and after chemotherapy. Left ventricular ejection fraction (EF) and systolic and diastolic diameters were calculated. At the end of 6 months of follow-up, 1 patient in the carvedilol group and 4 in the control group had died. Control EF was below 50% in 1 patient in the carvedilol group and in 5 in the control group. The mean EF of the carvedilol group was similar at baseline and control echocardiography (70.5 vs. 69.7, respectively; p = 0.3), but in the control group the mean EF at control echocardiography was significantly lower (68.9 vs. 52.3; p < 0.001). Both systolic and diastolic diameters were significantly increased compared with basal measures in the control group. In Doppler study, whereas E velocities in the carvedilol group decreased, E velocities and E/A ratios were significantly reduced in the control group. Prophylactic use of carvedilol in patients receiving ANT may protect both systolic and diastolic functions of the left ventricle.

Microvascular obstruction after successful fibrinolytic therapy in acute myocardial infarction. Comparison of reteplase vs reteplase+abciximab: A cardiovascular magnetic resonance study

Background.About one third of patients with TIMI 3 after reperfusion have evidence of microvascular obstruction (MO) which represents an independent predictor of myocardial wall rupture. This explains all efforts made to prevent MO. Magnetic resonance imaging (MRI) has proved to be particularly useful in detecting MO. The aim of this study was to evaluate with MRI if different fibrinolytic regimens in acute myocardial infarction display different effects on left ventricle (LV) volumes and ejection fraction (EF), as well as on myocardial infarct size (MIsz) and MO.Methods.Twenty male patients, mean age 58 years, affected by acute myocardial infarction, ten anterior and ten inferior, were treated with: full dose reteplase in ten, and half dose reteplase plus full dose abciximab (R+Abcx) in the other ten patients. In the fourth day after hospital admission, MRI STIR T2 images were used to quantify MIsz, while 2dflash cineloops were used after the injection of gadolinium, to quantify LV volumes, EF and to detect MO.Results.LV EF was higher in R+Abcx 51±10 than in reteplase 41±8. MIsz was similar in both treatment groups: however a close relationship was present between MIsz and EF in the reteplase group indicating that the greater the MIsz the lower the EF. In R+Abcx this relationship was no longer present, suggesting a protective effect of the drug on microcirculation. In fact extensive MO was present in 25% of all cases, 80% of which in the reteplase group while only 20% in R+Abcx.Conclusion.R+Abcx prevents MO: compared to traditional fibrinolytic therapy it allows better LV function and most likely improved long term survival.

Effects of cardiac sympathetic blockade on left ventricular diastolic function in patients with dilated cardiomyopathy and severe heart failure

To investigate the effects of cardiac sympathetic blockade on left ventricular diastolic function in patients with dilated cardiomyopathy and severe heart failure (HF). Thirty-nine consecutive patients with dilated cardiomyopathy and severe HF with a left ventricular ejection fraction < 35% were randomly divided into 2 groups: control group (n = 16, 12 males and 4 females, aged 56 +/- 16, undergoing routine anti-HF treatment), and cardiac sympathetic blockade (TEB) group (n = 23, 18 males and 5 females, aged 51 +/- 13, undergoing sympathectomy at the interspinal space T3 - 4 or T4 - 5 in addition to the routine anti-HF treatment). Transthoracic echocardiography was conducted before the treatment and 1 month after the treatment to measure the left atrial diameter (Lad), left ventricular diastolic end diameter (LVDEd), ejection fraction (EF), peak early and late diastolic mitral inflow velocity (Em and Am) at 6 mitral annular sites, and the mean values of Em and Am (MEm and MAm). The Lad of the TEB group was 40.4 +/- 5.3 mm, significantly shorter than that of the control group (45.2 mm +/- 7.3 mm. P < 0.05). The LEDEd of the TEB group was 66 mm +/- 6 mm, significantly shorter than that of the control group (71 mm +/- 6 mm, P < 0.05). The EF of the TEB group was 35% +/- 7%, significantly higher than that of the control group (23% +/- 6%, P < 0.05). The MEm of the TEB group was 5.7 cm/s +/- 1.5 cm/s, significantly faster than that of the control group (7.1 cm/s +/- 1.7 cm/s, P < 0.05); and the MAm of the TEB group was 7.1 cm/s +/- 2.1 cm/s, significantly faster than that of the control group (5.4 cm/s +/- 1.8 cm/s, P < 0.05). In the control group the values of Lad, LVDEd, EF, Am, MEm, and MAm did not change significantly, and the Em values significantly increased only at 2 mitral annular sites after the treatment. Sympathetic blockade reduces the left ventricular cavity and boosts up the ejection performance, thus improving the left ventricular diastolic function.

Aminoterminal B-type Pro–Natriuretic Peptide as a Marker of Recovery After High-risk Coronary Artery Bypass Grafting in Patients With Ischemic Heart Disease and Severe Impaired Left Ventricular Function

Aminoterminal B-type pro-natriuretic peptide (NT-proBNP) is a reliable indicator of heart failure severity. Levels of NT-proBNP are markedly increased in patients with coronary artery disease (CAD) and severely impaired left ventricular (LV) function. The aim of our study was to assess the impact of NT-proBNP levels after high-risk coronary artery bypass grafting (CABG) with regard to recovery potential. Between 1998 and 2004, 121 patients with CAD and severely impaired LV function, who were undergoing CABG, were investigated. Their mean age was 64 +/- 11 years. All patients were in New York Heart Association (NYHA) Class III/IV status; LV ejection fraction (EF) was 20 +/- 6%. All survivors underwent follow-up (59 +/- 34 months) spiroergometric, electrocardiographic (ECG) and echocardiographic assessment and were tested for routine blood controls and NT-proBNP levels (Roche, Mannheim, Germany). The survival rate after 8 years was 70%. All survivors received follow-up assessment. Among survivors the median NT-proBNP level at follow-up was 896 (521 to 1,687) pg/ml. The maximum oxygen uptake was 14.6 +/- 4.9 ml/min/kg, and EF increased to 42% at follow-up among all survivors. On dichotomizing survivors into two groups with NT-proBNP levels above and below the median, the post-operative body mass index was significantly higher in the high NT-proBNP group (p = 0.036). EF (p = 0.028) and NYHA classification (p < 0.05) improved significantly in both groups, with a tendency toward higher EF in the low NT-proBNP group. Patients undergoing a high-risk CABG procedure have a survival rate comparable to heart transplantation patients and show a potential for clinical and myocardial recovery. NT-proBNP use a useful marker for recovery after a high-risk CABG procedure, with significant correlation with clinical parameters.

Cardioprotective effect of des-Aspartate-angiotensin-I (DAA-I) on cytokine gene expression profile in ligation model of myocardial infarction

We investigate the influence of des-Aspartate-angiotensin-I (DAA-I) on the cytokine expression profile in a rodent model of myocardial infarction. Myocardial infarction model was created in female Wistar rats by coronary artery ligation. Animals were randomized to receive intravenously either a daily dose of 1.2 μg DAA-I/kg body weight (group 1; n = 60) or saline (group 2; n = 60) for 14 days after infarction. Heart function was assessed by echocardiography. Animals were euthanized at 1, 3, 7, 14 and 31 days. Morphometric analysis using tetrazolium chloride staining revealed that infarct size was reduced by 32.2% ( p < 0.05) in group 1 after 14 days of DAA-I treatment. Left ventricular ejection fraction in group 1 improved significantly (73.4%) as compared to group 2 (47.7%; p < 0.001). Immunostaining for immune cells at the infarct site showed that CD8 + lymphocytes infiltration at the infarct site declined in group 1 (15 ± 5 cells) as compared to group 2 (50 ± 6 cells; p < 0.001). Infiltration of monocytes and macrophages remained high at day 14 in group 2 (126 ± 40 cells) as compared to group 1 (49 ± 11 cells; p = 0.006). Multiplex PCR was done for differential gene expression of various pro-inflammatory cytokines. IL-6, TNF-α, TGF-β and GM-CSF expression were significantly down-regulated in the infarct, peri-infarct and contra-lateral zones of the left ventricle in group 1 as compared to group 2. IL-6, TGF-β and GM-CSF expression started to decline from day 1 of DAA-I treatment while TNF-α expression only reduced after 7 days of DAA-I treatment. We conclude that DAA-I prevented infarct expansion through suppression of inflammatory cytokines and immune cell infiltration in the infarct region.

Low‐Dose Dobutamine Stress Echocardiography to Predict Reversibility of Mitral Regurgitation with CABG

The optimal management of moderate (grade 2-3+) ischemic mitral regurgitation (MR) in patients undergoing coronary artery bypass grafting (CABG) remains controversial. While CABG alone can reverse regurgitation in some patients with moderate MR, adjunctive mitral repair may be necessary in others. We performed low-dose dobutamine stress echocardiography (DSE) in 60 patients with moderate MR who were about to undergo CABG. Group I, 25 patients who demonstrated reduction in MR during DSE, had CABG alone. Group II, 35 patients in whom MR was unchanged during DSE, had mitral valve repair as well as CABG. MR was reduced postoperatively in both groups (P < 0.0001). Postoperative ejection fraction in Group I (12.2%) improved more than that in Group II (9.3%) (P < 0.01). We conclude that CABG alone may be sufficient to correct moderate MR when MR is reduced during DSE.

Interaction between pulse wave velocity, augmentation index, pulse pressure and left ventricular function in chronic heart failure

Pulse wave velocity (PWV), the carotid augmentation index (AIx), and pulse pressure (PP) may be prognostic factors in heart failure, but the possible influence of the ejection fraction (EF) and other simple haemodynamic variables on them has not been investigated in this setting. Noninvasive methods were used to measure carotid-radial (CR), carotid-femoral (CF) PWV and AIx, and brachial PP, in 135 consecutive patients with stable symptomatic chronic heart failure. The patients were divided into two groups, with preserved (>or=40%) or reduced (<40%) EF. CF-PWV, AIx and PP were lower in the decreased EF group (8.85+/-2.77 versus 10.60+/-2.75 m/s, P<0.001; 121+/-21 versus 132+/-24, P=0.009 and 41+/-19 versus 67+/-17 mmHg, P<0.001), but CR-PWV values were similar regardless of the EF status. These results were not modified after adjustment for age and sex. Multiple regression analysis showed that AIx and PP were systematically related to time domain parameters (heart rate or ejection duration) and EF, whatever the group. CF-PWV was weakly related to time domain values and unrelated to mean blood pressure (BP) or EF in the preserved EF group, whereas it was related to both mean BP and EF in the low EF group. In conclusion, whatever the EF level, PP and AIx were strongly modulated in the time domain, by pressure and by the EF level. The same relationships were found with CF-PWV, but only in the reduced EF group. Whether CF-PWV is the best prognostic factor in patients with 'diastolic' heart failure must be confirmed in a prospective study.

Cell transplantation: Differential effects of myoblasts and mesenchymal stem cells

Background Cellular transplantation has emerged as a novel therapeutic option for treatment of ventricular dysfunction. Both skeletal myoblasts (SM) and mesenchymal stem cells (MSC) have been proposed as ideal cell for this aim. The aim of this study is to compare the efficacy of these cells in improving ventricular function and to evaluate the different histological findings in a rat model of severe post-infarct ventricular dysfunction. Methods Myocardial infarction was induced in Wistar rats by left coronary occlusion. Animals with resulting ejection fraction (EF) lower than 40% were included. Heterologous SM were obtained by lower limb muscle biopsy and MSC by bone marrow aspiration. Nine days after infarction, rats received intramyocardial injection of SM ( n = 8), MSC ( n = 8) or culture medium, as control ( n = 11). Echocardiographic evaluation was performed at baseline and after 1 month. Histological evaluation was performed after HE and Gomori's trichrome staining and immunostainig against desmin, fast myosin and factor VIII. Results There was no difference in baseline EF and left ventricular end diastolic (LVEDV) and systolic volume (LVESV) between all groups. After 1 month a decrease was observed in the EF in the control group (27.0 ± 7.10% to 21.46 ± 5.96%, p = 0.005) while the EF markedly improved in SM group (22.66 ± 7.29% to 29.40 ± 7.01%, p = 0.04) and remained unchanged in the MSC group (23.88 ± 8.44% to 23.63 ± 10.28%, p = 0.94). Histopathology identified new muscular fibers in the group that received SM and new vessels and endothelial cells in the MSC. Conclusion Skeletal myoblasts transplantation resulted in myogenesis and improvement of ventricular function. In contrast, treatment with mesenchymal stem cells resulted in neoangiogenesis and no functional effect.

Atrial fibrillation in heart failure: High mortality risk even if ventricular function is preserved

The purpose of this study was to determine if patients with atrial fibrillation (AF) and heart failure (HF) have a better prognosis when systolic function is preserved as compared with those with depressed systolic function. Data from consecutive patients presenting to the emergency department at Brigham and Women's Hospital from January 1997 to December 2002 who had a diagnosis of AF and HF and a measure of ejection fraction (EF) were reviewed. Vital status was determined from the Social Security Death Index. Of 478 patients (mean age 74 +/- 13 years; 47% women), EF was preserved (> 50%) in 46%. Those with preserved left ventricular (LV) function were older (76 vs 72 years, P < .0020), included more women (62 vs 35%, P < .0001), more likely to have a history of hypertension and pulmonary disease and less likely to have had a prior myocardial infarction. At 5 years, mortality was similar between the preserved and depressed EF groups (50% vs 48%, P = .74). In multivariable analysis, age > 75 years, history of cancer, cerebrovascular disease, aortic valve disease, serum creatinine > 2.0 mg/dL, and serum sodium < 130 mmol/L were associated with increased mortality. Therapy with beta-blockers and angiotensin-converting enzyme inhibitors/angiotensin receptor blocker were associated with lower mortality. Patients who present to the emergency department with AF, HF, and preserved LVEF have a similarly high mortality as compared with those with depressed LVEF. Further study is needed to assess the impact of therapies and clarify the reasons for the poor prognosis.

Coronary Artery Bypass Grafting in Patients With Low Ejection Fraction

Patients with low ejection fraction (EF) are at a higher risk for postoperative complications and mortality. Our objective was to assess the effect of low EF on clinical outcomes after coronary artery bypass grafting (CABG). We analyzed 55,515 patients from New York State database who underwent CABG between 1997 and 1999. Patients were stratified into 1 of the 4 EF groups: Group I (EF< or =20%), Group II (EF 21% to 30%), Group III (EF 31% to 40%), and Group IV (EF>40%). History of previous myocardial infarction, renal failure, and congestive heart failure were higher in patients with low EF (all P<0.001). Group I experienced a higher incidence of postoperative respiratory failure (10.1% versus 2.9%), renal failure (2.5% versus 0.6%), and sepsis (2.5% versus 0.6%) compared with Group IV. In-hospital mortality was significantly higher in Group I (6.5% versus 1.4%; P<0.001). Multivariate analysis showed hepatic failure [odds ratio (OR), 11.2], renal failure (OR, 4.1), previous myocardial infarction (OR, 3.4), reoperation (OR, 3.4), emergent procedures (OR, 3.2), female gender (OR, 1.7), congestive heart failure (OR, 1.6), and age (OR, 1.04) as independent predictors of in-hospital mortality in the low EF group. The discharges to home rate were significantly lower in Group I versus Group IV (73.1% and 87.7%, respectively; P<0.001). Patients with low EF are sicker at baseline and have >4 times higher mortality than patients with high EF. However, outcomes are improving over time and are superior to historical data. Therefore, CABG remains a viable option in selected patients with low EF.

Quantitative assessment of harmonic power doppler myocardial perfusion imaging with intravenous levovist™ in patients with myocardial infarction: comparison with myocardial viability evaluated by coronary flow reserve and coronary flow pattern of infarct-related artery

BackgroundMyocardial contrast echocardiography and coronary flow velocity pattern with a rapid diastolic deceleration time after percutaneous coronary intervention has been reported to be useful in assessing microvascular damage in patients with acute myocardial infarction.AimTo evaluate myocardial contrast echocardiography with harmonic power Doppler imaging, coronary flow velocity reserve and coronary artery flow pattern in predicting functional recovery by using transthoracic echocardiography.MethodsThirty patients with anterior acute myocardial infarction underwent myocardial contrast echocardiography at rest and during hyperemia and were quantitatively analyzed by the peak color pixel intensity ratio of the risk area to the control area (PIR). Coronary flow pattern was measured using transthoracic echocardiography in the distal portion of left anterior descending artery within 24 hours after recanalization and we assessed deceleration time of diastolic flow velocity. Coronary flow velocity reserve was calculated two weeks after acute myocardial infarction. Left ventricular end-diastolic volumes and ejection fraction by angiography were computed.ResultsPts were divided into 2 groups according to the deceleration time of coronary artery flow pattern (Group A; 20 pts with deceleration time ≧ 600 msec, Group B; 10 pts with deceleration time < 600 msec). In acute phase, there were no significant differences in left ventricular end-diastolic volume and ejection fraction (Left ventricular end-diastolic volume 112 ± 33 vs. 146 ± 38 ml, ejection fraction 50 ± 7 vs. 45 ± 9 %; group A vs. B). However, left ventricular end-diastolic volume in Group B was significantly larger than that in Group A (192 ± 39 vs. 114 ± 30 ml, p < 0.01), and ejection fraction in Group B was significantly lower than that in Group A (39 ± 9 vs. 52 ± 7%, p < 0.01) at 6 months. PIR and coronary flow velocity reserve of Group A were higher than Group B (PIR, at rest: 0.668 ± 0.178 vs. 0.248 ± 0.015, p < 0.0001: during hyperemia 0.725 ± 0.194 vs. 0.295 ± 0.107, p < 0.0001; coronary flow velocity reserve, 2.60 ± 0.80 vs. 1.31 ± 0.29, p = 0.0002, respectively).ConclusionThe preserved microvasculature detecting by myocardial contrast echocardiography and coronary flow velocity reserve is related to functional recovery after acute myocardial infarction.

The effect of resistance training on left ventricular function and structure of patients with chronic heart failure

Introduction Resistance training (RT) has been shown to improve chronic heart failure (CHF) patients' functional ability and quality of life. Despite these benefits RT has not always been recommend as a form of exercise principally because of a concern for acceleration of the left ventricular (LV) remodeling process. This study investigated the effects of 8 weeks RT on the LV structure and function of patients with CHF. Method Fifteen men who suffered from CHF were divided into either a RT program or non-training control group. Before and after 8 weeks of training patients underwent resting echocardiography to assess their end-diastolic and end-systolic dimensions (EDD and ESD, respectively), ejection fraction (EF), fractional shortening (FS) and stroke volume (SV). Results A repeated measured ANOVA showed that 8 weeks of RT had no significant effect on the LV measurements (group×time, p>0.05). Post training comparison, however, revealed that the EF and FS of the training group was significantly higher than in the control group (40.9±10.5% vs. 30.3±4.6%, p=0.029 and 25.0±7.0% vs. 17.4±3.1%, p=0.020 respectively). Conclusion RT is a suitable method of training for CHF patients since it does not cause a reduction of LV contractility function or enhance myocardial deterioration as measured by EF and FS.

Myocardial Protective Effects of Nicorandil During Percutaneous Coronary Intervention in Patients With Unstable Angina

The purpose of the study was to prospectively evaluate the protective effect of nicorandil during percutaneous coronary intervention (PCI) in patients with unstable angina (UAP). Two hundred patients (61+/-10 year-old, male 143) diagnosed with UAP at an emergency medical center were randomly assigned to 2 groups: intravenous isosorbide dinitrate, Group I (n=100), or intravenous nicorandil, Group II (n=100). PCI was performed 12-48 h after infusion of each agent. Serum concentrations of creatine kinase-MB (CK-MB), cardiac troponin T (cTnT), and I (cTnI) were measured before and 6, 12, 24 h after PCI. Patients with non-coronary chest pain, requiring emergency coronary angiogram, temporary pacemaker or glycoprotein IIb/IIIa receptor blocker were excluded. PCI was successfully performed in 96 patients (Group I=54, 61.7+/-8.2 years, 32 males; Group II=42, 60.4+/-11.7 years, 27 males). No significant differences in clinical or coronary angiographic characteristics were observed between the 2 groups. The concentration of CK-MB was elevated in 9 patients (17%) of Group I and 6 (14%) of Group II, cTnT in 16 (30%), 6 (14%) and cTnI in 25 (46%), 9 (21%) after PCI. Elevation of any troponin was less frequent in Group II [28/54 (52%) vs 10/42 (24%) patients, p=0.01]. Major adverse coronary events during the 6-month clinical follow-up occurred in 9 (17%) of Group I and 5 patients of Group II (12%, p=NS). Follow-up echocardiography revealed lower left ventricular ejection fraction in Group I than in Group II (65.4+/-7.2% vs 71.0+/-6.7%, p=0.03). Nicorandil has a myocardial protective effect during PCI in patients with UAP.

Echocardiographic measurements in infants of diabetic mothers and macrosomic infants of nondiabetic mothers

To compare echocardiographic findings of infants of diabetic mothers (IDMs), macrosomic infants of nondiabetic mothers and healthy full term appropriate-for-gestational-age (AGA) infants. Included in this study were 83 infants, admitted to our Neonatology Unit. Thirty-three IDMs, including both macrosomic and nonmacrosomic, comprised Group A, 25 macrosomic infants of nondiabetic mothers comprised group B, and 25 healthy full term AGA infants comprised group C. Echocardiographic measurements were performed in the first three days after birth and compared by using one-way ANOVA, Post Hoc Tukey HSD and Student's t tests. The left ventricular end-systolic/left ventricular end-diastolic diameter ratio of group A was significantly smaller than that of group C (P<0.05). The interventricular septum/posterior wall thickness ratios of groups A and B were greater than those of group C (P<0.05). The left ventricular mass index of group A was greater than those of groups B and C (P<0.05). The shortening fraction and ejection fraction of group A were increased in comparison to group C (P<0.05). When comparing the values of echocardiographic measurements of macrosomic IDMs (n=9) with nonmacrosomic ones (n=24), and infants of pregestational diabetic mothers (n=11) with those of gestational diabetes mothers (n=22), no statistical difference was found. The present study suggests that underlying mechanisms common to both macrosomic infants of nondiabetic mothers and IDMs lead to less cardiac alterations in the macrosomic infants of nondiabetic mothers than in IDMs.

Left Ventricular Remodeling after Myocardial Infarction in Antecedent Hypertensive Patients

Antecedent hypertension adversely affects mortality and heart failure after myocardial infarction (MI). In addition, accelerated ventricular remodeling is a contributor to the increased mortality observed after MI. The purpose of this study was to assess the relationship of antecedent hypertension to ventricular remodeling after MI. Ninety-four patients presenting with a first acute MI who were treated with reperfusion therapy within 12 h of their symptom onset were enrolled in this study. All of them underwent left ventriculography immediately after reperfusion therapy and again at 6 months after the occurrence of MI. Patients were divided into two groups: a hypertensive group and a normotensive group. End-diastolic volume index (EDVI), end-systolic volume index (ESVI), and ejection fraction (EF) values in the acute phase were compared to those at 6 months after acute MI in either group. The hypertensive group showed a significant increase in both EDVI and ESVI after 6 months, whereas the normotensive group did not. In addition, there was no change in EF in the hypertensive group, whereas EF increased significantly after 6 months in the normotensive group. As a result, the percent changes in ESVI and EF were significantly different between the hypertensive group and normotensive group. The results demonstrated that antecedent hypertension interacts with ventricular cavity dilatation after MI.

Monocyte Chemoattractant Protein 1-Induced Monocyte Infiltration Produces Angiogenesis but Not Arteriogenesis in Chronically Infarcted Myocardium

Monocyte chemoattractant protein 1 (MCP-1) stimulates the invasion of monocytes into ischemic tissue with concomitant adhesion to endothelial cells. Monocyte stimulation has been shown to be involved in the induction of arteriogenesis, which is the development of functional arterioles resulting in improvement of perfusion. However, angiogenesis (newly developed capillaries contribute to improved tissue perfusion) in several models has not resulted in any improvement in blood flow. The effects of MCP-1 on potential angiogenesis and arteriogenesis as well as changes in left ventricular function were tested in a chronic infarct model in rat hearts. Anesthetized rats were subjected to open-chest ligation of the left coronary artery with subsequent myocardial infarction. After 6 weeks, animals were randomized to receive either MCP-1 (3 microL in 0.15 mL NaCl, group 1, n = 9) or saline (0.15 mL, group 2, n = 9), which was injected into the myocardium at the border zones of the infarcts. For assessment of left ventricular dimensions and global cardiac function, transthoracic two-dimensional echocardiography was performed at baseline, 6 weeks after myocardial infarction, and 4 weeks after MCP-1 or saline injection, by use of a 12-MHz pediatric transducer. For light microscopic analysis, myocardial tissue was stained with Elastica-van-Giesson and von Willebrand factor for blood vessels and endothelial cells, respectively. In a subset of animals, hearts were excised 24 hours after MCP-1 administration (n = 4) or saline administration (n = 4) for assessment of monocyte infiltration by immunohistologic staining of the CD31 antigen. Left ventricular dimensions and ejection fraction changed after coronary occlusion (from 60.4% +/- 2.85% to 24.8% +/- 5.01% ejection fraction in group 1, and from 58.4% +/-2.06% to 26.3% +/- 4.3% ejection fraction in group 2 at 6 weeks, P < .005) without any further change 4 weeks after treatment (ejection fraction in group 1, 26.3% +/- 2.7%, ejection fraction in group 2, 25.0% +/- 5.18%). The MCP-1 group resulted in 390.6 +/- 10.36 endothelial cells compared with 285.2 +/- 13.56 in group 2 (P < .005) at the injection site. Monocyte infiltration was observed at the MCP-1 injection site with an increase in capillary growth (angiogenesis). However, there was no difference in the number of arteriolar structures between animals treated with MCP-1 and saline animals (group 1, 19.0 +/- 1.52 vs group 2, 16.4 +/- 0.68, P > .05). A single intramyocardial injection of MCP-1 into the infarct border zone resulted in neo-angiogenesis and monocyte infiltration but not arteriogenesis in the rat heart. There was no functional change of chronically infarcted myocardium in the present model.

Selecting patients with mitral regurgitation and left ventricular dysfunction for isolated mitral valve surgery

Background American College of Cardiology/American Heart Association (ACC/AHA) Guidelines state that patients with an ejection fraction (EF) of 30% or less should not undergo mitral valve replacement for mitral regurgitation (MR). We sought to establish, using a national cardiac surgery database, whether patients with left ventricular dysfunction may safely undergo mitral valve surgery for MR, and if so, which ones. Methods We queried the Society of Thoracic Surgeons (STS) National Database to identify patients who had isolated mitral valve replacement or repair for MR between 1998 and 2001. Mortality and morbidity outcomes were compared by EF category (≤ 30% vs > 30%), and observed mortality compared by EF group, stratified by predicted risk for mortality. A classification and regression tree (CART) model was then used to determine which patient characteristics contributed most to designate the high-risk patient. Results Of the 14,582 patients who had mitral valve surgery, 727 had an EF of 30% or less and 13,855 had an EF of more than 30%. Observed mortality rates were higher for patients with an EF of 30% or less (5.4% vs 3.1%). However, for low-risk to medium-risk patients, mortality rates remained fairly constant across levels of EF. Mortality is notably increased in the high-risk patients (predicted risk > 10%). A classification tree identifies three key characteristics for high risk: age more than 75 years, renal failure, and emergent or salvage procedure. Conclusions When the predicted mortality risk is less than 10%, EF has minimal impact on operative mortality for mitral regurgitation. In contrast to the ACC/AHA Guidelines, our data show that operative risk for mitral valve surgery is not prohibitive for most patients with ventricular dysfunction.

Determination of right ventricular function by transesophageal echocardiography: impact of proximal right coronary artery stenosis

Study objective To investigate whether transesophageal echocardiography (TEE) can provide accurate information on right ventricular (RV) function in patients with right coronary artery (RCA) stenosis, given that a decrease in blood supply from the RCA may invalidate the use of single 2-D echocardiography imaging plane as a guide to RV function. Design Prospective, nonblinded study. Setting University hospital. Patients 30 adult patients undergoing elective cardiac or vascular procedures. Interventions Patients were classified into two groups according to the presence or absence of the proximal RCA (segment 1 or 2) stenosis. Group A patients had no obstructive lesions in the proximal RCA (n = 15). Group B patients had 75% or greater obstructive lesions in the proximal RCA (n = 15). Measurements and main results After induction of anesthesia, RV function was evaluated by both fast-response thermodilution pulmonary artery catheter and TEE. Transesophageal echocardiography-derived RV fractional area change (FAC) and tricuspid annular plane systolic excursion ratio (TAPSE ratio) were compared with thermodilution-derived RV ejection fraction (EF) using linear regression analysis. Transesophageal echocardiography-derived RV end-diastolic area (EDA) was compared with thermodilution-derived end-diastolic volume (EDV). Both methods showed a good correlation in RV, EDV, and EF in Group A, but no correlations in Group B. Conclusions Transesophageal echocardiography does not provide reliable information on RVEF and EDV when proximal RCA stenosis is present.

The $alpha;1-adrenergic blocker urapidil improves contractile function in patients 3 months after coronary stenting: a randomized, double-blinded study

The recovery of left ventricular function (LVF) after revascularization takes time. α-Adrenergic blockade acutely improves coronary blood flow and LVF, whereas the effects of more prolonged α-adrenergic blockade on LVF recovery after stenting are unknown. In 32 patients (age 58 ± 12 y) with an 82% ± 6% stenosis, ejection fraction (EF) and systolic thickening (%Th) were measured by transthoracic echocardiography before and 30 minutes to 2 hours after revascularization. In a double-blinded protocol, either 200 μg/kg urapidil or placebo was given intravenously, and LVF was measured 10 minutes later. Two hours later, oral treatment with 30 mg/d drug or placebo was started, and LVF measured again after 24 hours and 3 months. Before revascularization, EF was 49.4% ± 8.5% (±SD) and 51.3% ± 8.8% in the urapidil-treated and the placebo groups, respectively. Thirty minutes to 2 hours after coronary stenting, EF was unchanged. After intravenous drug administration, EF increased to 56.5% ± 9.7%). At 24 hours and 3 months after revascularization, EF became 59.5% ± 7.9% and 59.6% ± 8.2% in the urapidil-treated group, respectively, whereas EF in the placebo group did not change (50.4% ± 5.7% and 49.7% ± 4.9%, respectively). Revascularization did not acutely improve %Th. Intravenous urapidil improved %Th from 31.4% ± 17.6% to 44.2% ± 11.6%, whereas there was no change in the placebo group. At 3 months, %Th was 49.5% ± 12.9% in the urapidil-treated group and 39.7% ± 8.9% in the placebo group. These data suggest that long-term α-adrenergic blockade might improve LVF at midterm after coronary revascularization. (Am Heart J 2004;147:e6.)