Mild Congestive Failure Research Articles

The Long-term influence of Coronary Bypass Grafts on Myocardial Infarction and Survival

Approximately 1,000 coronary bypass procedures were performed at New York University between February 1968 and December 1973. This report reviews all elective operations performed for angina between 1968 and 1972, a total of 448 patients. In this five-year period the percentage of diseased arteries bypassed rose from 40% to 84%, and operative mortality decreased from 28% to less than 3%. There were a total of 28 operative deaths, mostly from myocardial infarction and low cardiac output. Operability was nearly 95%. The only fixed contraindication was chronic congestive failure. Over one-half of the patients had an abnormal ventriculogram, and there was some history of mild congestive failure in nearly 20%. Elevation of left ventricular end-diastolic pressure above 20 mm before operation was associated with a higher operative mortality, but the late mortality was similar to those with a normal preoperative end-diastolic pressure. In 383 surviving patients, angina was eliminated or greatly improved in 86%, unimproved in 12% and worse in 2%. Late angiograms were performed on 201 patients, studying a total of 445 venous grafts with an overall patency rate of 71%. Graft occlusion was sporadic and unpredictable, but over 90% of patients with multiple grafts remained with at least one patent graft. A late myocardial infarction occurred in 32 out of 420 patients surviving operation, and was fatal in eight. The cumulative incidence over a period of five years was 17%. Twenty-three deaths occurred following discharge from the hospital. Life-table analyses showed a five-year survival of 77% when all deaths were included, and a five-year cardiac survival of 81% when non-cardiac deaths were withdrawn alive at the time of death. The expected survival in a comparable population group without coronary disease was 92%, while data published by Sones of patients treated without operation showed a five-year cardiac survival of 66%. Current operative techniques have an operative mortality of 2-3% and a subclinical infarction rate of 5-10%. The ideal graft is yet evolving, but data with internal mammary artery grafts are most encouraging. A future goal should be a five-year graft patency of at least 80%. Because many infarcts probably develop from a relatively small decrease in coronary blood flow, either during rest or mild activity, the likelihood that future data will demonstrate a marked increase in longevity with bypass grafting is great.

Right duct lymph flow in experimental heart failure following acute elevation of left atrial pressure.

We measured the pulmonary lymph flow in dogs with mild congestive failure before and after acute elevation of the left atrial pressure to 40 cm of water. The creation of an aorticocaval fistula and the administration of desoxycorti-costerone trimethylacetate and a salt enriched diet in 6 dogs produced mild pulmonary edema and partial expansion of the pulmonary lymphatics 10 to 12 days postoperatively. Elevation of the left atrial pressure to 40 cm of water under pentobarbital anesthesia led to an immediate increase in right duct flow in the "mild failure" dogs, in contrast to a delayed flow in normal dogs. The average peak flows in the 10- to 12-day dogs after increasing the left atrial pressure were higher than the peak flows observed in normal dogs. In addition, the mild failure dogs survived twice as long as normal dogs after acute elevation of the left atrial pressure. These results suggest that an animal with an expanded pulmonary lymph system is better able to withstand the stress of acute elevation of left atrial pressure than a normal animal. The pulmonary lymph system may serve as an important compensatory mechanism in the prevention of fulminating pulmonary edema.

Course of mercurial diuresis during Pitressin infusion in mild congestive heart failure

In an attempt to assess the influence of diminished filtration rate on the renal response to a mercurial diuretic, with particular emphasis on anisosmotic (free) water reabsorption, six patients with mild congestive failure were given Mercaptomerin, 2 ml, i.v., while receiving a constant infusion of Pitressin 2 μ/kg/hr. During the control collection periods, the anisosmotic water reabsorption was less than that encountered previously in a group of normal subjects. With the onset of diuresis, free water reabsorption rose to the same levels as that of normal individuals and, thereafter, followed the same course. The changes observed are compatible with the hypothesis that free water reabsorption is limited by either of two factors, at low flows, the concentration gradient along the tubule and, at higher flows, the maximal ability of the anisosmotic segment to reabsorb water at a given level of hydration and antidiuretic activity. Submitted on November 13, 1958

MYOCARDIAL CITRATE METABOLISM OF HUMAN HEART STUDIED BY CORONARY SINUS CATHETERIZATION

The myocardial citrate metabolism was investigated coronary sinus catheterization in 49 human subjects, including 8 healthy individuals, 6 hypertensive patients without ST-T abnormalities in electrocardiogram (Group I), 16 hypertensive patients with abnormal ST-T findings (Grou II), 9 patients with coronary sclerosis with normal blood pressure and abnormal ST-T findings, 5 patients with mild congestive heart failure due to various kinds of valvular diseases, 4 anemic patients and one thyrotoxic case. Studies were performed at resting state and effects of vasoacting drugs were observed. The drugs examined were vasopressors as norepinephrine and epinephrine, antihypertensive drugs as hexamethonium and hydralazne, coronary dilating drugs as nitroglycerine, papaverine and theophylline-ethylendiamine, and high oxygen tension. The results obtaind were as follows. 1. In the healthy individuals, the average arterial citrate concentration (Ca) was 0.87±0.18mg per 100ml, the coronary venous citrate concentration (Cs) 0.65±0.11mg per 100ml. and the coronary arterio-venous citrate difference (ΔC) 0.20±0.13mg per 100ml/ Cs and ΔC tended to vary with arterial lavel and the relationship of the Cs or ΔC to Ca was demonstrated by the following thentative formula. Cs=0.44Ca+0.27; ΔC=0.56Ca-0.27 2. In patients with hypertension, coronary sclerosis, or mild congestive failure, myocardial citrate extraction was decreased or negative, showing a significant fifference from mormals, Similar tendency, theough statistically not significant, wsa seen also in anemia and thyrotoxicosis. 3. When the blood pressure was elevated in healithy cases by intravenous drop infusion of epiephrine, it was noticed that the relationship between Ca and Cs showed a beviation from that of mormals. In contrast, myocardial citrate metabolism of hypertensive hearts tended to be normalized by slow intravenous in jection of antihypertensive durgs such as hexamethonium or hydralazine. 4. As coronary dilating drugs, the effects of nitroglycerine administered sublingually and papaverine and theophyllin-ethylendiamine given intravenously were examined. It was clarified the, as the effects on the myocardial citrate metabolism were concerned, each drug had different action; disturbance of myocardial citrate metabolism was improved by nitroglycerine of papaverine, whereas it was aggravated by theophylline-ethylendiamine. 5. By inhalation of 50 or 100% oxygen, the disturbance in citrate metabolism was improved. 6. In patients with hypertension, sopontaneous blood pressure variation was reflected on the change of myocardial citrate metabolism. 7. From the above described data, it was concluded that the disturbance of citrate metabolism was present in the heart muscle of patients not only with hypertension, coronary sclerosis, & congestive failure, but with anemia and thyrotoxicosis, and that it might be resulted from the sequel of hypoxia in myocardium.

Effect of acetazoleamide (diamox) on the electrolyte patterns of ambulatory patients with mild congestive failure.

Effect of acetazoleamide (diamox) on the electrolyte patterns of ambulatory patients with mild congestive failure.

The response of the peripheral venous pressure to exercise in congestive heart failure

1. 1. The resting venous pressure and the rise in venous pressure during exercise were determined in twenty-seven patients with heart disease of varying degrees of severity, in twelve patients with pulmonary disease, and in twenty patients without cardiac or pulmonary disease. 2. 2. In general, both the resting venous pressure and the rise in venous pressure during exercise increased with the severity of the congestive heart failure. 3. 3. In patients with mild congestive failure, one-half of the determinations of venous pressure at rest were abnormally high, whereas approximately three-fourths of the determinations of the rise in venous pressure during exercise were abnormally increased. Almost all the patients with more severe congestive heart failure had both an elevated venous pressure at rest and an abnormally increased rise in pressure during exercise. The venous pressure response to exercise is, therefore, a somewhat more sensitive index of the milder degrees of congestive heart failure than the venous pressure at rest; in severe congestive failure it offers no advantage.