Poor Left Ventricular Function Research Articles

Utilidad de la ecocardiografía transtorácica focalizada en emergencias hemodinámicas intraoperatorias

Echocardiography represents one of the most important advances in the monitoring of critical patients. Initially available only in cardiovascular surgery, currently, there is transesophageal echocardiography (TEE) and transthoracic echocardiography (ETT) in non-cardiac surgery, for anesthesiologists. The advantages of ETT is a non-invasive tool, of lower cost than the transesophageal transducer and therefore more feasible to be overcrowded and available in the pavilion. To evaluate the usefulness of TTE in patients with hemodynamic compromise during non-cardiac surgery. In a prospective manner between April 2016 and September 2018, patients were studied who during their intraoperative period presented a compromise of their hemodynamic state, defined as an average blood pressure under 55 mm Hg, for more than 3 minutes and without response to the usual therapy based on vasopressors and volume. Each of these patients had a prospective protocol for focused ETT looking for the cause of this disorder, by a duly trained operator. 124 patients, with an average age of 67 years (range 42 to 93 years) were evaluated. In all cases, at least one echocardiographic window was obtained that allowed a diagnosis to be made and/or to guide the therapy. The main causes of hemodynamic compromise were hypovolemia (52%), poor left ventricular function (21%) and other causes such as pericardial effusion, suspected pulmonary thromboembolism, pulmonary pathology and suspected myocardial ischemia. The ETT could be a feasible tool to use in acute hemodynamic events, since it offers good quality windows that allow new decisions based on the diagnosis and also allows to guide the selected therapies. In addition, it has been shown to positively impact clinical behaviors in the perioperative period. ETT is a non-invasive monitor, reasonably easy to learn to use; In addition to directly visualizing cardiac structures, it allows differential diagnoses of the causes of intraoperative hypotension. The therapies can also be decided according to the echocardiographic images and control how they generate changes in the cardiac cavities and in the hemodynamic state of the patient.

P175 Cardiac device infection: to extract or not to extract, that is the question

Abstract Introduction The incidence of infectious complications related to intracardiac devices has been increasing in recent year and is associated with a poor prognosis, which is determined not only by the infectious process but also by the severity of the underlying cardiac pathology and the spectrum of comorbidities presented. Appropriate antibiotic therapy and extraction of the devices are fundamental in the management of these patients. Case report We describe the case of a 66-year-old patient on a waiting list for transplantation due to non-ischemic dilated cardiomyopathy with poor left ventricular systolic function (LVEF of 10%), with severe functional mitral regurgitation and severe pulmonary hypertension, who received a CRT-D for secondary prevention (non-responder). He was admitted for decompensated heart failure (NYHA functional class IV and "dry-cold" profile) requiring inotropic support becoming dependent on dobutamine. During hospitalization, there was a progressive increase in inflammatory markers accompanied by recurrent febrile peak and inflammatory signs of the central venous catheter, with catheter-tip and serial hemocultures positive for Morganella morganii. Piperacillin / tazobactam was started. Due to the lack of response to pathogen directed antibiotic therapy, he underwent a transesophageal echocardiogram (TEE) that revealed several filiform images associated with the electrodes, with no image of valvular vegetations, which led to the association of gentamicin and device extraction (DE), according to the Pisa technique, that occurred without complications. On the 7th day after DE, there was a progressive clinical deterioration in spite of increasing doses of inotropes and vasopressors. It was considered that patient would not be candidate for cardiac transplantation or mechanical ventricular assist, and died on the 118th day of hospitalization in refractory cardiogenic shock. Conclusion Device endocarditis is a class I indication for intracardiac DE and TEE is fundamental in its diagnosis. Despite being a considered a non-responder to cardiac resynchronization therapy based on clinical and echocardiographic criteria, this case illustrates how the loss of cardiac resynchronization may have contributed to the patient’s hemodynamic deterioration and have played a fundamental role in the clinical outcome.

P868 Dissecting myocardium

Abstract Introduction Incomplete rupture is a relatively uncommon type of free-wall rupture. It is found in 10% to 15% of total free-wall ruptures. Case report A 68-year-old male patient, heavy smoker, with medical history of diabetes mellitus and hypertension, had experienced an attack of acute retrosternal chest pain associated with dyspnea grade II-III one week before presentation. He presented to our facility complaining acute chest pain. Upon examination, the patient had stable vital signs and an unremarkable clinical examination except for distant heart sounds on auscultation. Electrocardiogram showed deep Q waves in V1 to V4 with residual ST segment elevation. Routine lab investigations were unremarkable including a negative troponin. A Chest X-ray showed an enlarged cardiac shadow. Echocardiography revealed a poor left ventricular systolic function due to an akinetic anterior wall and a dyskinetic apical cap containing a large highly mobile thread like mass which was suspected to be a thrombus. Coronary angiography revealed proximal 85% stenosis followed by mid segment total occlusion of the Left anterior descending (LAD) artery, proximal 75% stenosis of the left circumflex (LCX) artery and a tight lesion in the mid segment of the right coronary artery (RCA). The patient was diagnosed to have multi-vessel coronary artery disease and was maintained on medical treatment. Cardiac MRI was requested to detect myocardial viability before revascularization. Subsequently, cardiac magnetic resonance (CMR) revealed a dilated left ventricle with very poor systolic function, akinetic inferior wall, aneurysmally dilated apex and anterior wall with the same large highly mobile mass. Late gadolinium enhancement revealed scarred anterior, septal and inferior walls including all apical segments and surprisingly the mobile intra-ventricular mass also contained a scar tissue continuous with the anterior myocardial scar which means it is a part of the myocardium which was dissected or partially ruptured. Unfortunately, the patient suddenly experienced an attack of ventricular arrhythmia which was not resuscitated successfully. Conclusion Incomplete rupture is a rare type of free-wall rupture. It is thought that the infarcted myocardium wall is made weak in part by activation of metalloproteinases, which degrade the myocardial matrix. Structural weakness is associated with increased intra-cavitary pressure which predisposes the myocardial wall to rupture. Although Echocardiography is a good method of diagnosis but CMR is superior due to its high spatial resolution and good tissue characterization, plus the use of late gadolinium enhancement helps in identifying the location and the extent of prior infarctions guiding us to the next step in management. Abstract P868 Figure. Myocardial dissection with scarred flap

On Pump Beating Heart CABG is Superior to Conventional CABG in Poor Left Ventricular Function

Coronary artery bypass graft (CABG) surgery is one of the treatment modalities of coronary artery disease (CAD) patients. There are multiple selection criteria for CABG and multiple procedures like conventional CABG, on pump beating heart CABG and off pump beating heart CABG (OPCAB). This study was intended to compare between conventional CABG and on pump beating heart CABG. Total 60 patients were selected for the study, of which 30 patients had undergone conventional CABG and 30 had undergone on pump beating heart CABG. Different preoperative and postoperative variables shows clear and significant superiority of on pump beating heart CABG. So it may be an alternative surgical procedure where OPCAB is not feasible in poor left ventricular (LV) .function.
 Journal of Surgical Sciences (2014) Vol. 18 (1) : 20-27

The feasibility of surgical patch osteoplasty in isolated left main coronary stenosis.

Background: Coronary artery bypass grafting (CABG) is perceived as the most common treatment for left main coronary artery (LMCA) disease with good results compared to left-main stenting or medical therapy. Surgical patch angioplasty (SPA) may present a substitute to the standard CABG in patients with isolated LMCA disease, and it offers physiological antegrade myocardial perfusion, keeps ostial patency and saves bypass material. The objective of this study is to demonstrate the feasibility of patch osteoplasty in patients with isolated LMCA stenosis.
 Methods: This is a retrospective study performed on eight patients with angiographically proven ostial or proximal LMCA stenosis who underwent surgical patch angioplasty. Two of them had associated right coronary artery bypass grafting. All patients were performed with cardiopulmonary bypass and saphenous vein patch. An anterior approach with transverse aortotomy was utilized in all cases. Patients were followed-up clinically for a mean period of 14 months (ranging from 26 to 6 months) for recurrence of symptoms and any postoperative complications.
 Results: The early postoperative period was uneventful in all patients. No perioperative mortality was reported. Two patients had postoperative atrial fibrillation, and one patient with poor left ventricular function required preoperative intra-aortic balloon pump. Angiography was done in the first three cases, and all showed no restenosis and no vein patch dilatation.
 Conclusion: Surgical patch angioplasty may be a safe and suitable alternative to CABG in selected patients with isolated ostial LMCA stenosis. Further studies are needed to compare the results of the SPA with those of standard CABG and LMCA stenting.

22. Systemic onset juvenile idiopathic arthritis with multi-organ failure in a teenager

IntroductionSystemic onset juvenile idiopathic arthritis (JIA) is an often severe and potentially life-threatening subtype of chronic arthritis starting under the age of 16 years. It is characterised by fevers, rash and arthritis, although this may not be apparent until later in the disease course, which can add difficulty to making the diagnosis. We present a case of systemic onset JIA with multi-organ impairment to showcase its mimicry of other diseases and highlight importance of awarenessCase descriptionA 15-year-old girl presented with a 7 day history of fever, cough, sore neck, enlarged lymph nodes and widespread macular rash. She had been started on penicillin in the community for presumed scarlet fever, but was hospitalised due to worsening symptoms. Differential diagnoses discussed were lymphadenitis and EBV, due to ongoing fevers, high inflammatory markers, and raised liver function tests. She then developed an acute kidney injury and profound hypotension. She was treated with immunoglobulin for possible Kawasaki disease, broad spectrum antibiotics for possible toxic shock syndrome/sepsis, and transferred to the regional PICU for ongoing inotropic support and management of her multi-system illness.She was found to have a non-dilated cardiomyopathy with poor left ventricular function, low complement and positive anti-streptolysin titres. No postive cultures or focus of infection were found. Antibody tests including dsDNA were negative. She required CPAP for respiratory support and was treated with pulsed methylprednisolone for systemic onset JIA. She then received a weaning course of prednisolone over several months and made an excellent recovery.DiscussionThis was an interesting case for those involved because the initial symptoms, evolving signs and investigation results didn’t easily tie together to give one suitable diagnosis. Several avenues of treatment were explored, including a range of antibiotics and immunoglobulin, before methylprednisolone. The patient also remained remarkably ‘well’ looking despite her multi-organ impairment.Key learning pointsThis case highlighted the importance of awareness of systemic onset JIA and its complications, particularly in a non-typical age group, for the general paediatrician. Early discussion with and involvement of tertiary rheumatology services served to optimise management and outcome, and will hopefully also improve long-term prognosis.Conflicts of interestThe authors have declared no conflicts of interest.

Effect of Levosimendan Compared to Conventional Inotropic Agents on Hemodynamics and Outcome in Patient with Poor LV Function Undergoing Cardiac Surgery.

BACKGROUND:Patients undergoing heart surgery involving cardiopulmonary bypass (CPB) experience global myocardial ischemia with subsequent reperfusion which, despite cardioplegic protection, may result in different degrees of transient ventricular dysfunction. Levosimendan is a “calcium sensitisers”, it improves myocardial contractility by sensitising troponin C to calcium without increasing myocardial oxygen consumption and without impairing relaxation and diastolic function.AIM:To evaluate the adding effect of a calcium sensitiser (levosimendan) compared to the conventional inotropic and vasoactive agent used in the patient with poor left ventricular function undergoing cardiac surgery on different measured hemodynamic variables and the effect on the outcome.METHODS:It is prospective observational studies were patients were divided into 2 groups of 30 patients each. The first Group received conventional inotropic and vasoactive treatment at different doses, while the other group received levosimendan additionally at a loading dose of 6-12mic/kg according to mean arterial pressure over 0.5 hr followed by 24 hrs infusion at 0.05 to 0.2 mic/kg/min. Hemodynamic data were collected at the end and 30 minutes after CPB, after that at 6, 12, 24, and 36 hours post CPB. Mean arterial pressure (MAP), central venous pressure (CVP), heart rate (HR), mixed venous saturation (Svo2), and base deficit (BD) were measured.RESULTS:Levosimendan had significantly improved postoperative hemodynamic values as in the mixed venous pressure at different times postoperative (p < 0.05), also the base deficit at different times postoperative (p < 0.05), while there was a significant reduction in systemic vascular resistance as decreased mean arterial pressure in levosimendan group compared to conventional group at 6hrs postoperative mean 77.50 ± 10.81 vs 83.73 ± 10.81 with (p = 0.029), and at 12 hrs postoperative mean 77.37 ± 10.10vs 84.23 ± 13.81 with (p = 0.032), and there was no significant difference in heart rate at different times postoperative between both groups (p > 0.05), while there was no significant effect on mortality between both groups (p = 0.781).CONCLUSION:Levosimendan had improved hemodynamic parameters significantly with no effect on mortality compared to conventional inotropic agents in a patient with poor left ventricular function undergoing cardiac surgery.

Dobutamine Stress Echocardiography for Predicting the Postoperative Recovery of Left Ventricular Function in Patients with Chronic Severe Aortic Regurgitation: A Comparative Prospective Study

AbstractBackground: Patients with chronic severe aortic regurgi-tation often present to our practice at a late stage. Patients with poor left ventricular function may or may not improve functionally or by left ventricular dimensions after surgery.Aim of Study: We aim to answer this question; can dob-utamine stress echocardiography predict the postoperative recovery of left ventricular function in patients with chronic severe aortic regurgitation?Patients and Methods: This is a comparative prospective study from December 2014 to December 2015 in which we studied 49 patients undergoing aortic valve replacement for chronic severe aortic regurgitation. Patients were divided into 2 groups according to their resting ejection fraction, Group I with ejection fraction 50%. Group I was further divided into Ia and Ib. Group IA included 16 patients who respond to dobutamine infusion by increase in ejection fraction >30%. Group IB included 16 patients who respond to dobutamine by increase in ejection fraction <30%. All the relevant clinical data was collected from all patients pre-operatively and 3 month follow-up visit. All patients in were stressed by infusion of dobutamine 20ugm/kg/min and the change in their End Systolic Volume (ESV) and End Diastolic Volume (EDV) and Ejection Fraction (EF) were evaluated.Results: There was no hospital or 3 months mortality for the whole group. For Group II, the comparison between the response to aortic valve replacement and peak dobutamine reveals: The mean 3 months post-operative EF 56.87±6.03%. The peak dobutamine EF was 68.3±7.5%. There was statisti-cally significant difference between the 2 values (p-value <0.001) i.e there relation was not obvious in this group.For Group IA; the mean 3 months post-operative EF was 44.27±8.78%. The peak dobutamine EF was 47.2±10.69%. There was no statistically significant difference between the 2 values (p-value=0.177). For Group IB; the mean 3 months post-operative EF was 37.75±13.7%. The peak dobutamine EF was 41.33±7.44 %. There was no statistically significant difference between the 2 values (p-value=0.175). Conclusion: Dobutamine stress echocardiography was found to be predictor for post-operative left ventricular function in patients with chronic severe aortic regurgitation and impaired function.

Influence of left ventricular assist device pressure-flow characteristic on exercise physiology: Assessment with a verified numerical model.

Current left ventricular assist devices are designed to reestablish patient's hemodynamics at rest but they lack the suitability to sustain the heart adequately during physical exercise. Aim of this work is to assess the performance during exercise of a left ventricular assist device with flatter pump pressure-flow characteristic and increased pressure sensitivity (left ventricular assist device 1) and to compare it to the performance of a left ventricular assist device with a steeper characteristic (left ventricular assist device 2). The two left ventricular assist devices were tested at constant rotational speed with a verified computational cardiorespiratory simulator reproducing an average left ventricular assist device patient response to exercise (EXE↑) and a left ventricular assist device patient with no chronotropic and inotropic response (EXE→). According to the results, left ventricular assist device 1 pumps a higher flow than left ventricular assist device 2 both at EXE↑ (6.3 vs 5.6 L/min) and at EXE→ (6.7 vs 6.1 L/min), thus it better unloads the left ventricle. Left ventricular assist device 1 increases the power delivered to the circulation from 0.63 W at rest to 0.67 W at EXE↑ and 0.82 W at EXE→, while left ventricular assist device 2 power shows even a minimal decrease. Left ventricular assist device 1 better sustains exercise hemodynamics and can provide benefits in terms of exercise performance, especially for patients with a poor residual left ventricular function, for whom the heart can hardly accommodate an increase of cardiac output.

Effect of coronary artery bypass surgery on ventricular functions in patients with poor left ventricular function

Objectives: The aim of the present study was to compare preoperative / postoperative ventricular functions of patients with ventricular dysfunction who were planned for coronary artery bypass grafting (CABG) using echocardiography and angiography, and to evaluate whether there was a significant improvement in ventricular function. Methods: This prospective study included 30 patients with poor ventricular function who had undergone CABG at the Cardiovascular Surgery Clinics of Bursa Yüksek Ihtisas Hospital. The patients' ventricular functions were compared preoperatively and postoperatively at the 2nd, 6th and 12th months. Results: Of the patients, 28 were males, and the mean age was 60.1 ± 8 years (range 39-71). In these cases, functional capacity improved within the early postoperative period, and global ventricular functions improved within the postoperative first year. The improvement in ejection fraction results was statistically significant at 6 months and 12 months (p &amp;lt; 0.05). A significant decrease was observed in left ventricular enddiastolic pressures within one year (p &amp;lt; 0.001). For the performance score, improvement was significant from the 2nd month (p &amp;lt; 0.05). Conclusions: Our findings show that CABG improves ventricular function in terms of EF, PS, LVEDP and NYHA classification. In conclusion, we consider that CABG is a significantly effective option in patients with poor ventricular function.

Surgical Ablation of Atrial Fibrillation in Patients With Tachycardia-Induced Cardiomyopathy

Atrial fibrillation (AF) is a common cause of tachycardia-induced cardiomyopathy (TIC). This study evaluated the outcomes of the Cox-Maze IV procedure in patients with TIC and significant left ventricular dysfunction. Between January 2002 and January 2017, 37 consecutive patients with a left ventricular ejection fraction (LVEF) of 0.40 or less underwent stand-alone surgical ablation of AF. After dilated and ischemic cardiomyopathies were excluded, 34 of 37 patients met the criteria for the diagnosis of TIC. Patients were a mean age of 56 ± 11 years, and 24 (70%) had long-standing persistent AF. The median AF duration was 72 months (interquartile range, 9 to 276 months). Seventeen patients (50%) had at least one catheter-based ablation that failed. Mean LVEF was 0.32 ± 0.08. There were 11 patients (32%) with New York Heart Association Functional Classification III/IV symptoms. There was one (3%) 30-day mortality caused by a pulmonary embolus, despite full anticoagulation. At 12 months, freedom from atrial tachyarrhythmias on or off antiarrhythmic drugs was 94% and 89%, respectively. Postoperative echocardiograms were available for 27 of 33 patients (82%). The LVEF improved to a mean of 0.55 ± 0.08 (95% confidence interval, 0.51 to 0.58; p < 0.001). Of the 11 patients with New York Heart Association Functional Classification III/IV symptoms, 8 patients were in class I/II at the last follow-up (p= 0.02). Restoration of sinus rhythm with the Cox-Maze IV was associated with significant improvement in the LVEF in patients with AF and TIC. This retrospective study illustrates the efficacy of the Cox-Maze IV in this patient population both at restoring sinus rhythm and improving ventricular function. Patients with TIC and poor left ventricular function in whom other treatments have failed should be strongly considered for surgical ablation.

A comparative study between custodiol and warm blood cardioplegia in coronary artery bypass graft operation with poor left ventricular function

Background Cardioplegia is responsible for myocardial protection during open heart surgery. Cardioplegia was first presented as an agent for hypothermic hyperkalemic arrest. Blood was then introduced as a vehicle to convey potassium to the heart. Custodiol Histidine-Tryptophan- ketoglutarate (HTK) solution is safe and used as a single dose, which can last for up to 3 h. The comparison of the clinical outcomes of this particular solution with warm blood cardioplegia in coronary artery bypass graft (CABG) with poor left ventricular (LV) function has received little attention. Objective To compare the clinical outcomes of custodiol solution with warm blood cardioplegia in CABG with poor LV function. Patients and methods This single-center randomized prospective study was carried out from January 2017 till January 2018, at National Heart Institute of Egypt. Overall, 50 patients with poor LV function undergoing isolated CABG were divided randomly according to type of myocardial protection during revascularization into two groups: group A included 25 patients who received warm blood cardioplegia, and group B included 25 patients who received custodiol cardioplegia. Data from each group were collected and compared with each other. Results Baseline demographic and intraoperative data showed no significant difference between the two groups. The need for intra-aortic balloon pump was similar in both groups. The need for inotropic support, length of mechanical ventilation, and ICU stay was statistically nonsignificant between the two groups. Postoperative arrhythmia was significantly higher in custodiol group [nine (34.62%)] compared with warm blood group [two (8%)] (P = 0.021). Overall mortality shows a statistically nonsignificant difference. Improvement in left ventricular ejection fraction after surgical revascularization was observed among both groups. Conclusion Both custodiol cardioplegia and warm blood cardioplegia offer a satisfactory method for myocardial protection in low ejection fraction ischemic heart disease, with increased incidence of postoperative arrhythmia in custodiol cardioplegia.

Trends in mitral valve prolapse: a tertiary care center experience in Jeddah, Saudi Arabia.

BackgroundMitral valve prolapse (MVP) is the most common cardiac valvular abnormality in developed countries and it is associated with considerable morbidity and mortality.Aim of workTo study the clinical presentations, risk factors, and echocardiographic features of patients with MVP in Jeddah, Saudi Arabia.Materials and methodsA retrospective chart review study was conducted in King Abdulaziz teaching hospital in Jeddah, Saudi Arabia, from 2007 to 2017. All patients with MVP who were admitted at the hospital during this time period were recruited to this study, and demographic, clinical, and echocardiographic variables were analyzed using IBM SPSS.ResultsNinety-seven patients were recruited to this study, with a mean age of 43.82±16.16 years. Females constituted 67%. The body mass index (BMI) was 24.9±6.3 kg/m2. Hypertension, diabetes, and dyslipidemia occurred in 19.6%, 5.2%, and 5.2% of patients, respectively. A single patient had Marfan syndrome. Chest pain, palpitations, and dyspnea were the presenting symptoms in 23.7%, 11.3%, and 9.3% of patients, respectively, with elderly individuals presenting disproportionally (93.3%) with palpitations. Fifty-five percent of patients had an anterior leaflet prolapse. The presence of posterior leaflet prolapse and severe mitral regurgitation (MR) was significantly associated with left atrial and left ventricular dilatation (P<0.05 and P<0.001, respectively).ConclusionMVP is more prevalent in women and middle-aged individuals with normal BMIs in this population. The most common clinical presentations were chest pain, palpitations, and dyspnea, which did not differ significantly with age or gender. The anterior leaflet was the most commonly prolapsed in the studied patients and presented with mild MR. Posterior leaflet MVP, while of low prevalence, was associated with severe MR and poor left ventricular function.

Cardiac Resynchronisation Therapy in New Zealand

Background: The All New Zealand Acute Coronary Syndrome Quality Improvement (ANZACS-QI) Device registry is a national registry designed to collect data on all cardiac implantable electronic devices implanted in New Zealand (NZ). This study aimed to provide a contemporary analysis comparing the clinical characteristics of patients receiving cardiac resynchronisation therapy pacemakers (CRT-P) and primary prevention cardiac resynchronisation therapy defibrillators (CRT-D). Method: Complete datasets of CRT-P and primary prevention CRT-D implants from the ANZACS-QI DEVICE registry from 1 January 2014 to 31 December 2017 were analysed. Results: A total of 175 CRT-P and 155 primary prevention CRT-D implants were identified. Patients who received CRT-P were older (median age, 74 vs 66 y) and more likely to be female (38.3% vs 19.4%). There was a higher proportion of Māori patients in the CRT-D group (16.1% vs 8.6%). Patients receiving a CRT-D had longer mean QRS duration (169.2 ms vs 160.8 ms) and poorer left ventricular function (mean LVEF 24.2% vs 28.7%). There was a history of atrial fibrillation in 39.4% - 42.3%, 87.5% - 88.6% had New York Heart Association II - III symptoms, and 87.7% - 89.1% had left bundle branch block. Left ventricular lead position in the CRT-D cohort was most common in the mid-ventricular, posterolateral position. Conclusion: This analysis provides contemporary data on CRT use in NZ. Compared with primary prevention CRT-D, patients receiving CRT-P were older and more likely to be female.

Outcomes of Pulmonary Embolectomy for Acute Pulmonary Embolism.

Acute pulmonary embolism (PE) is a major threat to the health and lives of hospitalized patients. This study was conducted to clarify the real-world outcomes of pulmonary embolectomy.Methods and Results:Retrospective investigation of 355 patients who underwent pulmonary embolectomy for acute PE was conducted using the Japanese Cardiovascular Surgery Database. Risk factors for operative death within 30 days after pulmonary embolectomy and major adverse cardiovascular events (MACE), including operative death, postoperative stroke and postoperative coma, were analyzed. Cardiopulmonary resuscitation (CPR) was required preoperatively in 27.6%, and preoperative veno-arterial extracorporeal membrane oxygenation was performed in 26.5%. Urgent or emergency operation was performed in 93% of patients. Operative mortality rate was 73/355 (20.6%). Incidence of MACE was 97/355 (27.3%). In univariate analysis, preoperative predictors of death were obesity, renal dysfunction, chronic obstructive pulmonary disease, liver injury, recent myocardial infarction, shock, refractory shock, CPR, heart failure, inotrope use, poor left ventricular function, preoperative arrhythmia and tricuspid regurgitation. In multivariate analysis, independent risk factors for operative death were heart failure (P=0.013), poor left ventricular function (P=0.007), and respiratory failure (P=0.001). Poor left ventricular function (P=0.033), preoperative CPR (P=0.002) and respiratory failure (P=0.007) were independent risk factors for MACE. The outcomes of pulmonary embolectomy were acceptable, considering the urgency and preoperative comorbidities of patients. Early triage of patients with hemodynamically unstable PE is important.

Early and mid-term results of aortic valve replacement in patients with severe aortic regurgitation

BackgroundAortic regurgitation (AR) represents pressure and volume overload resulting in left ventricular (LV) dysfunction. Poor LV function was shown to be reversible after aortic valve replacement (AVR) which is the only effective treatment. The surgical risk increases in the presence of LV dysfunction. The aim of this study was to determine effect of AVR on LV functions in severe AR. MethodsSixty patients were included with severe chronic AR with NYHA classes III and IV, diagnosed clinically and by imaging studies as transthoracic echocardiography (TTE) and cardiac catheterization. Patients were followed up postoperatively at regular intervals by TTE examination. ResultsTTE values at discharge and 6 months after AVR were compared with pre-operative findings. We found no significant statistical difference between LV functions pre-operatively and at discharge. However, there was statistical improvement in these functions at 6 months post-operatively compared to their values at discharge. ECHO findings of NYHA class III and IV at 6 months post-operatively showed evidence of improvement in LV functions of class III patients while those in class IV didn't show change or even some deterioration in the ECHO findings. ConclusionsLV functions showed mild or no improvement in early follow-up while after 6 months it showed that patients in NYHA class III got benefits more than those in class IV.

Workup and Management of Patients With Paradoxical Low-Flow, Low-Gradient Aortic Stenosis.

About 60% of patients with paradoxical low-flow, low-gradient (PLF-LG) aortic stenosis (AS) have a severe disease that justifies aortic valve replacement (AVR). The first step in patients with symptomatic PLF AS should be to rule out measurement errors and treat hypertension. The second step is to distinguish pseudo-severe from true severe AS (TSAS). The third step is to select the optimal treatment modality at the right time. Regarding the second step, projected aortic valve area calculated using stress echocardiography is superior to traditional severity criteria (AVA < 1.0cm2 and mean gradient ≥ 40mmHg) to unmask TSAS and predict outcomes. Aortic valve calcification score quantitated by computed tomography is helpful to identify TSAS by applying thresholds of 2000 and 1200AU, respectively, for men and women. This modality should be considered, particularly if stress echocardiography is either not feasible or inconclusive. Once AS severity is confirmed, a risk stratification based on symptomatic status and the importance of left ventricular (LV) systolic impairment will guide therapeutic decision. Symptomatic assessment should not solely rely on patient-reported symptom status, but rather include an objective exercise test. The presence of symptomatic PLF-LG TSAS is a class IIa indication for AVR in the guidelines. In asymptomatic patients, a markedly reduced stroke volume, the presence of myocardial fibrosis by cardiac magnetic resonance imaging, a poor longitudinal LV function as assessed by speckle tracking echocardiography, and/or a moderate to severe LV diastolic dysfunction are predictors of poor outcome in PLF-LG patients and may indicate the need of early AVR. The type of AVR should be discussed within a multidisciplinary team, bearing in mind that transcatheter AVR (TAVR) is superior to medical treatment in inoperable patients. Furthermore, TAVR may be a useful alternative to surgical AVR (SAVR) in high-risk patients. Nevertheless, the potential benefits of TAVR, including the lower risk of severe patient-prosthesis mismatch, should be weighed against the risk of paravalvular regurgitation, which is likely poorly tolerated by patients with PLF-LG who often harbor a small and non-compliant LV cavity.

On-pump beating heart versus conventional coronary artery bypass grafting: comparative study on early and long-term clinical outcomes

We reviewed our experience with on-pump beating (OPB) heart coronary artery bypass grafting (CABG) to evaluate the impacts of obviating aortic cross-clamping and cardioplegic arrest on clinical outcomes compared with conventional CABG (C-CABG). Between 2006 and 2012, elective isolated cardiopulmonary bypass (CPB)-assisted CABG was consecutively performed in 645 patients (mean patient age 63.3±9.1 years, 471 women) with 254 (39.4%) undergoing OPB-CABG and 391 (60.6%) undergoing C-CABG. The early and long-term clinical outcomes were compared between the two groups after adjusting for risk profiles through propensity score (PS) analyses. The OPB-CABG group presented significant morbidities more frequently than the C-CABG group, including severe chronic kidney disease (CKD) (P=0.026), severe chest pain (P<0.001), and poor left ventricular function (P<0.001). Early mortality occurred in 6 (2.4%) and 2 (0.5%) patients in the OPB- and C-CABG group, respectively (P=0.087). The number of distal anastomosis was comparable between the two groups (3.0±0.9 vs. 3.0±1.0, P=0.816). After PS matching, the incidence of major complications such as stroke (P>0.99) and new-onset dialysis (P=0.109) was comparable. During a median follow-up of 81.0 months (quartiles 1-3, 66.6-95.0 months), 118 patients died and the PS-matched models showed no significant between-group differences in the risk of overall death [hazard ratio (HR), 1.19; 95% confidence interval (CI), 0.72-1.95; P=0.507] and major adverse cardiac events (MACE) (HR, 1.49; 95% CI, 0.67-3.31; P=0.328). The OPB strategy may be as safe and effective as the conventional strategy during CABG among patients with similar risk profiles. A prospective randomized trial is warranted to better ascertain the beneficial impact of OPB-CABG as both a viable and a durable alternative strategy to C-CABG.

Prevalence, Temporal Evolution, and Impact on Survival of Ventricular Conduction Blocks in Patients With Acute Coronary Syndrome and Cardiogenic Shock

Changes in QRS duration and pattern are regarded to reflect severe ischemia in acute coronary syndromes (ACS), and ventricular conduction blocks (VCBs) are recognized high-risk markers in both ACS and acute heart failure. Our aim was to evaluate the prevalence, temporal evolution, association with clinical and angiographic parameters, and impact on mortality of VCBs in ACS-related cardiogenic shock (CS). Data of 199 patients with ACS-related CS from a prospective multinational cohort were evaluated with electrocardiogram data from baseline and day 3. VCBs including left or right bundle branch block, right bundle branch block and hemiblock, isolated hemiblocks, and unspecified intraventricular conduction delay were assessed. Fifty percent of patients had a VCB at baseline; these patients were older, had poorer left ventricular function and had more often left main disease compared with those without VCB. One-year mortality was over 2-fold in patients with VCB compared with those without VCB (68% vs 32%, p<0.001). All types of VCBs at baseline were associated with increased mortality, and the predictive value of a VCB was independent of baseline variables and coronary angiography findings. Interestingly, 37% of the VCBs were transient, i.e., disappeared before day 3. However, 1-year mortality was much higher in these patients (69%) compared to patients with persistent (38%) or no VCB (15%, p<0.001). Indeed, a transient VCB was a strong independent predictor of 1-year mortality. In conclusion, our findings propose that any VCB in baseline electrocardiogram, even if transient, identifies very early patients at particularly high mortality risk in ACS-related CS.

Outcome of CABG with or without Coronary Endarterectomy in Bangladesh: A Retrospective Cohort Study

Objective: In this review, we assess the outcome of surgical revascularization technique, coronary artery bypass grafting (CABG) with or without coronary endarterectomy (CE) for patients with diffuse coronary artery disease in a single surgeon’s practice.Methods: We retrospectively reviewed 2189 patients who experienced OPCABG with or without CE between January 2009 and December 2016. The following variables were compared in this study- Intubation time, ICU stay, Postoperative MI, Arrhythmia, renal impairment, stroke and ICU mortality.Results: Of 2189 patients, 1000 patients required coronary endarterectomy in addition to OPCABG. Initially, there was a higher mortality rate and incidence of postoperative blood transfusion in the group of patients who had CE in addition to CABG, with no significant difference in other outcomes. But postoperative use of Heparin, Warfarin and Double antiplatelet agent was associated with decreased mortality significantly in our study. In comparison to other group, the patients in the combined CE with CABG group had a higher incidence of male sex, past MI, and poor left ventricular function. However,emergency CABG, renal impairment, poor left ventricular function, and also peripheral vascular disease were associated with higher mortality in both group of the patients; CE was not a predictor of postoperative mortality.Conclusions: Total surgical revascularization is attainable and accomplishes, when Coronary endarterectomy is performed in addition to Off-pump coronary artery bypass graft in patients when there is no other choice for satisfactory revascularization.Bangladesh Heart Journal 2017; 32(2) : 77-84