Predictor Of Long-term Adverse Outcomes Research Articles

An Elevated Ratio of Placental Growth Factor to Soluble Fms-like Tyrosine Kinase-1 Predicts Adverse Outcomes in Patients with Stable Coronary Artery Disease

To investigate the predictive values of placental growth factor (PlGF) and its endogenous antagonist, soluble fms-like tyrosine kinase-1 (sFlt-1), for the long-term prognosis of patients with stable coronary artery disease (CAD). Both PlGF and sFlt-1 play important roles in the pathological mechanisms of atherosclerosis. We recently demonstrated that the plasma levels of these molecules are correlated with the severity of coronary atherosclerosis. We enrolled 464 patients with stable CAD who consecutively underwent coronary angiography. Baseline blood samples were collected from the femoral artery immediately before coronary angiography (after the administration of 20 units of heparin), and the plasma levels of PlGF and sFlt-1 were measured. A Cox proportional hazard regression analysis was performed to evaluate the relationship between these parameters and the occurrence of all-cause death (ACD) and total cardiovascular events (TCVE) during a median follow-up of 3.3 years. A total of 31 ACDs and 51 TCVEs occurred. Patients with higher PlGF/sFlt-1 ratios (>4.22×10(-2)) had a significantly higher risk of both ACD and TCVE than patients with lower ratios (<4.22×10(-2)) (hazard ratio [HR]: 3.32, 95% confidence interval [CI]: 1.43 to 7.72, p=0.005, and HR: 2.23, 95% CI: 1.23 to 4.03, p=0.008, respectively). A multivariate analysis showed the PlGF/sFlt-1 ratio to be an independent predictor for ACD, but not TCVE. The baseline PlGF/sFlt-1 ratio is an independent predictor of long-term adverse outcomes in patients with stable CAD.

Impact of culprit plaque volume and composition on myocardial microcirculation following primary angioplasty in patients with ST-segment elevation myocardial infarction: Virtual histology intravascular ultrasound analysis

BackgroundAn impaired myocardial perfusion state after primary angioplasty is a strong predictor of long-term adverse outcomes in patients with STEMI. We assessed the relationship between culprit plaque characteristics and myocardial perfusion state after primary angioplasty in patients with ST-segment elevation myocardial infarction (STEMI). MethodsA total of 101consecutive patients with de novo STEMI were divided into 3 groups according to the state of myocardial perfusion assessed by ST-segment elevation resolution (STR): Group A (complete: STR ≥70%, n=26), Group B (partial: STR<70% but ≥30%, n=55) and Group C (none: STR<30%, n=20). We analyzed plaque features by virtual histology intravascular ultrasound (VH-IVUS) and assessed the relationship between culprit plaque characteristics and STR after primary angioplasty. ResultsTotal plaque volume was significantly higher in Group C than in Groups A and B (146.4±38.0mm3vs. 93.3±29.1mm3 and 105.8±31.5mm3, p<0.001, respectively). Necrotic core (NC) volume was also significantly higher in Group C than in Groups A and B (25.4±8.0mm3, vs. 11.9±6.3mm3 and 17.3±9.7mm3, p<0.001, respectively). Analysis of receiver-operating characteristic curves revealed that total plaque volume and NC volume had the best diagnostic accuracy of all the VH-IVUS parameters to predict STR<30%. The optimal cutoff values (sensitivity/specificity) were 123.4mm3 (75.0%/75.3%) for total plaque volume and 20.3mm3 (75.0%/74.1%) for NC volume. ConclusionsCulprit plaque with large plaque burden and high NC volume is closely associated with poor STR after revascularization.

Out-of-hospital cardiac arrest in patients treated with primary PCI for STEMI. Long-term follow up data from EUROTRANSFER registry

ObjectivesOur aim was to describe long-term outcome of OHCA patients in a cohort of STEMI patients treated by primary PCI based on the EUROTRANSFER Registry data. BackgroundThe occurrence of cardiac arrest is associated with impaired survival. There are limited number of studies reporting outcome of STEMI patients with out-of-hospital cardiac arrest (OHCA) treated by primary percutaneous coronary intervention (PCI). The recently published resuscitation guidelines of the European Resuscitation Council (ERC) support immediate angiography/PCI or fibrinolysis in these patients in order to improve survival. MethodsConsecutive data on 1650 STEMI patients, transferred for primary PCI in hospital STEMI networks between November 2005 and January 2007 from 7 countries in Europe were gathered. Patients were divided into two groups: OHCA group – 42 patients and no OHCA group – 1608 patients. ResultsBaseline demographics, clinical characteristic on admission to cathlab and past medical history were similar in both groups. Cardiogenic shock on admission or acute heart failure defined as Killip 3+4 was more frequently observed in OHCA group. The in-hospital mortality was similar, however, 1-year mortality was 19.1% in the OHCA group vs 8.1% in no OHCA group (p=0.011) and remained significant after exclusion of patients in cardiogenic shock on admission. ConclusionsSTEMI patients treated with primary PCI with out-of-hospital cardiac arrest have higher long-term mortality than no OHCA patients. However, resuscitation prior to cathlab admission is not an independent predictor of long-term adverse outcome. No differences in in-hospital mortality were noticed.

Worsening kidney function in decompensated heart failure: treat the heart, don't mind the kidney

This editorial refers to ‘Changes in renal function during hospitalization and soon after discharge in patients admitted for worsening heart failure in the placebo group of the EVEREST trial’, by J.E.A. Blair et al. doi:10.1093/eurheartj/ehr238. In a post-hoc analysis of the Efficacy of Vasopressin Antagonism in Heart Failure Outcome Study with Tolvaptan (EVEREST), Blair and co-workers found that worsening kidney function shortly after hospitalization and in the early post-discharge period independently predicted cardiovascular mortality and re-hospitalizations because of heart failure (HF).1 These findings confirmed previous evidence that worsening kidney function following hospitalization for decompensated HF is a strong independent predictor of long-term adverse outcomes. An intriguing finding of the above study, however, was that worsening kidney function was also associated with a decrease in body weight and circulating levels of the B-type natriuretic peptide (BNP), changes that reflected an amelioration of fluid congestion and that per se were expected to predict improved outcomes in the long term. To explain this apparent paradox, we have to go back to the old days of Arthur J. Merril who in 1946 measured renal plasma flow and the glomerular filtration rate (GFR) by using the sodium para -amino hippurate and inulin renal clearance techniques, in 37 subjects admitted because of HF from different aetiologies.2 In these patients, the renal plasma flow was reduced to one-third to one-fifth of normal, whereas the cardiac output was rarely reduced below half the resting value. On the basis of these findings, he suggested that in HF there is a specific diversion of blood away from the kidneys, organs which normally receive ∼20% of the cardiac output. Despite the large reduction in …

18 Patients presenting with anaemia undergoing primary PCI appear at significantly higher risk of an adverse outcome

<h3>Background</h3> Previous studies have demonstrated a relationship between pre-existing anaemia and inpatient mortality after percutaneous coronary intervention (PCI). There is limited data looking at the impact of baseline Haemoglobin and long term outcome after primary PCI. <h3>Methods</h3> Clinical information was analysed from a prospective database on 2357 STEMI patients who underwent Primary PCI between January 2004 and May 2010 at a London centre. Information was entered at the time of procedure and outcome assessed by all-cause mortality information provided by the Office of National Statistics via the BCIS/CCAD national audit. Anaemia was defined according to WHO definition of Hb greater than or equal to 12 g/dl for females and 13 g/dl for males. <h3>Results</h3> 471 (20%) patients were anaemic at presentation. The anaemic cohort, were older (72.2 vs 62.4, p&lt;0.0001), had higher incidence of diabetes (27% vs 15%, p&lt;0.0001), hypertension (42 vs 35%, p=0.01), hypercholesterolaemia (40 vs 30%, p=0.007), previous PCI (13 vs 7%, p=0.01), and previous MI (23% vs 12%, p&lt;0.0001). There were similar incidences of three-vessel disease and cardiogenic shock. Over a 3-year follow-up period there was significantly higher all cause mortality in the anaemic group compared to the normal Hb group (20.4% vs 13.5%, p&lt;0.0001). See Abstract 18 figure 1. After adjusting for comorbidities, anaemia remained an independent predictor of long-term adverse outcome (OR=2.4, 95% CI=1.1 to 3.7, p&lt;0.001). Patients with baseline anaemia who received a blood transfusion were significantly more likely to suffer an adverse outcome than those that did not receive a transfusion (21% vs 6%, p&lt;0.0001). <h3>Conclusion</h3> Patients presenting with anaemia undergoing primary PCI appear at significantly higher risk of an adverse outcome. This risk increases further in population receiving RBC transfusions during index hospitalisation.

16 Acute stent thrombosis resulting in ST elevation myocardial infarction (STEMI) is associated with worse clinical outcomes than STEMI due to native coronary thrombosis

<h3>Background</h3> Stent thrombosis (ST) is a recognised cause of ST Elevation Myocardial infarction (STEMI) in patients with previous percutaneous coronary interventions (PCI). The incidence is increasing and to date outcomes are not well characterised, though there is a suggestion that there is a worse clinical outcome. We therefore sought to compare STEMI caused by ST vs de novo coronary thrombosis to evaluate procedural risk and clinical outcome. <h3>Methods</h3> Clinical information was analysed from a prospective database on 2421 patients who underwent Primary PCI following STEMI between October 2003 and May 2010 at a London centre. Information was entered at the time of procedure, diagnosis of stent thrombosis made at the time by primary operator and outcome assessed by all-cause mortality information provided by the Office of National Statistics via the BCIS CCAD national audit. <h3>Results</h3> Stent thrombosis (ST) accounted for 7.4% (180/2421) of all STEMIs with a frequency that has increased over time (5.4% in 2005 to 9.8% 2009). ST occurred early (0–30 days) in 36% (65/180), late (30 days–1 year) in 22% (40/180) and very late (&gt;1 year) in 42% (75/180) of pts. Drug-eluting stents (DES) accounted for 48% of ST overall and 70% over the past 3 years. Proposed mechanisms included premature discontinuation of anti-platelets (11%), under-deployment of previous stent insertion (22%) and underlying prothrombotic conditions (eg, SLE) (6%). Pts with ST compared to native artery occlusion had higher rates of previous MI (53.9% vs 11%, p&lt;0.0001) and incidence of multi-vessel disease (59.8% vs 51.7%, p=0.04 There was no difference in age, diabetes or cardiogenic shock. See Abstract 16 table 1. Infarct size based on peak enzyme markers was similar (2.5 vs 2.2, p=0.45). In patients with ST, angiographic success (postprocedural Thrombolysis In Myocardial Infarction grade III flow) was worse than in patients with de novo STEMI (87.2% vs 93.7%, p=0.02). Pts with STEMI due to ST had higher in-hospital MACE (11% vs 3%, p=0.0001), MACE at 30 days (19% vs 6%, p&lt;0.0001), this persisted up to 3 years (41% vs 12%, p&lt;0.0001). See Abstract 16 figure 1. MACE was driven by higher rates of MI (7% vs 2%, p&lt;0.0001), TVR (14% vs 3%, p&lt;0.0001) and death (18% vs 6%, p=0.0001). After adjusting for comorbidities, stent thrombosis was an independent predictor of long-term adverse outcome (OR=2.1, 95% CI=1.3 to 2.8, p&lt;0.001). <h3>Conclusion</h3> Primary PCI for treatment of ST is less effective, and these patients are at increased risk for in-hospital and long-term mortality compared with patients undergoing primary PCI due to de novo STEMI.

Predictors of Long-Term Adverse Outcomes in Elderly Patients Over 80 Years Hospitalized With Heart Failure - A Report From the Japanese Cardiac Registry of Heart Failure in Cardiology (JCARE-CARD) -

Aging is associated with adverse outcomes in patients with cardiac diseases. Whether elderly patients hospitalized with heart failure (HF) had increased risks for mortality and rehospitalization compared with younger patients during the long-term follow-up was examined. The predictors of these adverse outcomes were also identified. The Japanese Cardiac Registry of Heart Failure in Cardiology (JCARE-CARD) studied prospectively the characteristics and treatments in a broad sample of 2,675 patients hospitalized with worsening HF and the outcomes were followed up. The majority of elderly patients were female, had lower body mass index (BMI), a higher rate of ischemic, valvular, and hypertensive heart disease as etiologies of HF, a lower estimated glomerular filtration rate (eGFR), lower hemoglobin, and higher left ventricular ejection fraction values. Even after adjustment for covariates, the elderly patients were associated with higher risks of adverse outcomes. The predictors for all-cause death were: lower eGFR, lower BMI, male sex, sustained ventricular tachycardia or fibrillation (VT/VF), and the use of diuretics at discharge. Among patients hospitalized with HF, elderly patients had a worse prognosis than younger patients. Lower eGFR, lower BMI, male sex, sustained VT/VF, and diuretic use were independent predictors for all-cause death in these patients with higher risk.

Renal Dysfunction in Acute Heart Failure

During treatment of acute heart failure (AHF), worsening renal function is often complicated and results in a complex clinical course. Furthermore, renal dysfunction is a strong independent predictor of long-term adverse outcomes in patients with AHF. Traditionally, the predominant cause of renal dysfunction has been attributed to impairment of cardiac output and relative underfilling of arterial perfusion. Recently, emerging data have led to the importance of venous congestion and elevated intra-abdominal pressure rather than confining it to impaired forward cardiac output as the primary driver of renal impairment. Relief of congestion is a major objective of AHF treatment but therapy is still based on the administration of loop diuretics. The results of the recently performed controlled studies for the assessment of new treatments to overcome resistance to diuretic treatment to protect kidneys from untoward effects have been mostly neutral. Better treatment of congestion in heart failure remains a major problem.

Major Predictors of Long-Term Clinical Outcomes After Coronary Revascularization in Patients With Unprotected Left Main Coronary Disease

Background— The clinical characteristics that identify high-risk subsets of patients with unprotected left main coronary artery disease undergoing percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG) have not been well established. Methods and Results— Between January 2000 and June 2006, 2240 patients with unprotected left main coronary artery disease underwent PCI (n=1102) or CABG (n=1138). Twenty-six preprocedural parameters were evaluated by univariate and multivariate Cox regression analysis to identify independent predictors of all-cause mortality and target-vessel revascularization. Interaction tests were performed to compare heterogeneities of effects of preprocedural parameters depending on the revascularization methods. During follow-up (median of 3.1 years), 187 patients died (78 PCI and 109 CABG) and 149 patients had target-vessel revascularization (121 PCI and 28 CABG). EuroSCORE ≥6 was an independent predictor of death in both groups. Additional independent predictors were chronic renal failure and previous congestive heart failure in the PCI group and age ≥75 years, atrial fibrillation, right coronary artery disease, and left main distal bifurcation disease in the CABG group. Interaction analysis showed no heterogeneities of the effects of variables depending on the revascularization methods. Independent predictors of target-vessel revascularization were acute coronary syndrome and left main distal bifurcation disease in the PCI group and history of coronary intervention in the CABG group. The interaction between previous PCI and treatment remained after adjustment for all independent predictors of target-vessel revascularization (interaction P =0.0345). Conclusions— Several clinical characteristics were identified as important preprocedural predictors of long-term adverse outcomes after percutaneous or surgical revascularization in patients with unprotected left main coronary artery disease.

Predictors of Long-Term Adverse Outcomes in Patients With Congenital Coronary Artery Fistulae

Significant morbidities, including angina, symptomatic heart failure, and myocardial infarction, have been reported after coronary artery fistula (CAF) closure; however, predictors that may be associated with adverse outcomes have not been established. The goal of this investigation is to describe the long-term outcomes witnessed in patients with either treated or untreated CAF at our institution and to investigate whether certain features predicted adverse outcomes. The records and angiograms of patients with CAF who underwent a diagnostic cardiac catheterization at Children's Hospital Boston from 1959 through 2008 were reviewed. Of 76 patients identified, 20% were associated with additional congenital heart disease. Forty-four underwent transcatheter closure, 20 underwent surgical repair, and no intervention was performed in the remaining 12 subjects. Three patients who had initially undergone surgical closure had a second intervention, 1 underwent repeat surgery, and 2 underwent transcatheter closure. One patient who had undergone transcatheter closure underwent a second transcatheter closure for residual fistula. Major complications, including myocardial infarction, angina with coronary thrombosis, and symptomatic cardiomyopathy, occurred in 11 (15%) patients. The sole angiographic feature that was predictive of adverse outcome was drainage of the CAF into the coronary sinus (P<0.001). Clinical predictors associated with adverse outcomes included older age at diagnosis (P<0.001), tobacco use (P=0.006), diabetes (P=0.05), systemic hypertension (P<0.001), and hyperlipidemia (P<0.001). Long-term complications of CAF closure may include coronary thrombosis, myocardial infarction, and cardiomyopathy. CAF that drain into the coronary sinus are at particularly high-risk of long-term morbidities after closure, and strategies including long-term anticoagulation should be considered.

Anemia is an Independent Predictor of Long-Term Adverse Outcomes in Patients Hospitalized With Heart Failure in Japan A Report From the Japanese Cardiac Registry of Heart Failure in Cardiology (JCARE-CARD)

Anemia is common in patients with heart failure (HF) and is associated with worse outcomes. However, the effects of anemia are unknown in an unselected group of HF patients encountered in routine clinical practice in Japan. The impact of anemia on long-term outcomes including mortality and rehospitalization among patients hospitalized with HF was thus assessed. The Japanese Cardiac Registry of Heart Failure in Cardiology (JCARE-CARD) prospectively studied the characteristics and treatments in a broad sample of patients hospitalized with worsening HF and the outcomes were followed. Study cohorts (n=1,960) were classified into 4 groups by discharge hemoglobin quartiles: <10.1 g/dl (n=482), 10.1-11.9 g/dl (n=479), 12.0-13.6 g/dl (n=487), and >or=13.7 g/dl (n=512). Of the total cohort of HF patients, 57% had anemia, defined by using the World Health Organization definition. Patients with lower hemoglobin quartiles had higher rates of all-cause death, cardiac death, and rehospitalization due to worsening HF. After multivariable adjustment, the risk for all-cause death, cardiac death, and rehospitalization significantly increased with low hemoglobin concentrations. Anemia was quite common especially in patients with HF encountered in routine clinical practice in Japan, and lower hemoglobin was independently associated with long-term adverse outcomes in these patients.

Prevalence, predictors and prognostic value of acute impairment in renal function during intensive unloading therapy in a community population hospitalized for decompensated heart failure

Chronic heart failure (CHF) is often associated with impaired renal function. Diuretics and vasodilators may lead to aggravated renal dysfunction (ARD), particularly among patients with decompensated CHF. Although the prevalence of ARD has been evaluated in patients awaiting heart transplantation, little is known about ARD in the community sample of CHF patients. Accordingly, we prospectively assessed the prevalence, predictors and prognostic value of ARD in 79 consecutive patients admitted to our general community hospital for decompensated CHF undergoing intensive unloading therapy (intravenous nitroprusside and furosemide). ARD was defined as a >or= 25% increase in serum creatinine between admission and maximal value of >or= 2 mg/dl. Sixteen patients (20%) developed ARD with a mean increase in serum creatinine of 31% (from 1.74 +/- 0.6 to 2.27 +/- 0.9 mg/dl). ARD persisted at 8-day evaluation in seven of 16 subjects (44%) whereas it was reversible in nine (56%). Lower creatinine clearance at baseline [exp beta = 0.93, 95% confidence interval (CI)=0.87-0.99] and the higher dose of furosemide (exp beta=1.02, 95% CI=1.01-1.03) emerged as independent predictors of ARD. During a follow-up of 11 +/- 8 months, death and hospitalization for worsening CHF occurred more frequently in ARD than non-ARD patients (69% versus 17%, P=0.0001; 69% versus 29%, P=0.003, respectively). Persistent ARD was a powerful independent predictor of long-term adverse outcome (odds ratio=11.1; 95% CI=1.12-36.1; P=0.04). Intensive unloading therapy is associated with the development of ARD in one-fifth of the community population hospitalized for decompensated CHF. The magnitude of this phenomenon is not greater than that observed in younger selected populations with advanced CHF, and depends on baseline renal function and increased diuretic dosage. ARD persisting after 8 days from starting intensive unloading is a powerful predictor of subsequent worsened clinical outcome.

Long-term outcomes of venous thrombosis in children

Venous thromboembolism has become an increasingly recognized clinical entity in children over the past decade. Recently, important efforts have been made to track post thrombotic outcomes. The present review discusses the knowledge gained from seminal studies in the field over the past decade, with particular emphasis on the findings of numerous published reports on outcomes of various types of venous thromboembolism in the pediatric literature from January 2003 to January 2005. Large cohort studies involving acute venous thromboembolism of all types in children have recently confirmed a rather low frequency of recurrent venous thromboembolism, but have shown a lack of thrombus resolution following standard-duration anticoagulant therapy in as many as 50% of patients. In addition, the development of the post thrombotic syndrome has been demonstrated in greater than one third of children with venous thromboembolism involving the extremities. Persistent thrombosis despite adequate anticoagulation has been independently associated with complete vaso-occlusion at diagnosis. Furthermore, the presence of elevated levels of factor VIII and D-dimer either at diagnosis or following three to six months anticoagulation has now been defined as a predictor of adverse long-term outcomes of pediatric thrombosis. This body of work indicates that the various forms of venous thromboembolism in children are in general associated with a considerable degree of adverse outcomes, particularly in the form of venous thromboembolism-related mortality, recurrent thromboembolism, and development of post thrombotic syndrome. Advances in the prediction of post thrombotic outcomes have begun, and must continue to facilitate a risk-stratified approach to antithrombotic management in children, and to ultimately achieve meaningful improvements in long-term outcomes.

Electrical storm is an independent predictor of adverse long-term outcome in the era of implantable defibrillator therapy

Electrical storm (ES) is a life-threatening arrhythmia complication affecting patients treated with an implantable cardioverter defibrillator (ICD). Despite its increasing importance, existing data on prognosis and management of ICD patients affected by ES are limited and conflicting. We prospectively studied 169 consecutive patients receiving an ICD. Thirty-two patients presented with at least one episode of ES during the period of observation (33+/-26 months). ES patients were older (64+/-9 vs. 59+/-13 years, P=0.013) with more advanced congestive heart failure (CHF) but a similar incidence of an underlying organic heart disease. Long-term total and cardiac mortality were both increased among ES patients. Seventeen of the 32 ES patients died as opposed to 19 of the 137 ICD patients without ES (53 vs. 14%, P<0.001). In multivariate Cox regression analysis adjusted for the main confounders, history of ES was significantly and independently associated with total and cardiac mortality (risk ratio (RR)=2.13, P=0.031 and RR=2.59, P=0.019, respectively). ES is a relatively frequent complication affecting ICD patients treated for secondary prevention of sudden cardiac death (SCD). Although the acute management of this serious arrhythmia complication is usually successful, occurrence of ES is a strong independent predictor of poor outcome in ICD patients.

Angiographic no-reflow phenomenon as a predictor of adverse long-term outcome in patients treated with percutaneous transluminal coronary angioplasty for first acute myocardial infarction

OBJECTIVESWe sought to elucidate the long-term prognostic importance of angiographic no-reflow phenomenon after percutaneous transluminal coronary angioplasty (PTCA) for acute myocardial infarction (AMI).BACKGROUNDAngiographic no-reflow phenomenon, a reduced coronary antegrade flow (Thrombolysis in Myocardial Infarction [TIMI] flow grade ≤2) without mechanical obstruction after recanalization, predicts poor left ventricular (LV) functional recovery and survival in the early phase of AMI. We hypothesized that angiographic no-reflow phenomenon also predicts long-term clinical outcome.METHODSWe studied 120 consecutive patients with their first AMI treated by PTCA without flow-restricting lesions. The patients were classified as either no-reflow (n = 30) or reflow (TIMI-3) (n = 90) based on post-PTCA cineangiograms to follow up (5.8 ± 1.2 years) for cardiac death and nonfatal events.RESULTSPatients with no-reflow had congestive heart failure (p < 0.0001), malignant arrhythmia (p = 0.038), and cardiac death (p = 0.002) more often than did those with reflow. Kaplan-Meier curves showed lower cardiac survival and cardiac event-free survival (p < 0.0001) in patients with no-reflow than in those with reflow. Multivariate analyses disclosed that no-reflow phenomenon was an independent predictor of long-term cardiac death (relative risk [RR] 5.25, 95% confidence interval [CI] 1.85 to 14.9, p = 0.002) and cardiac events (RR 3.71, 95% CI 1.79 to 7.69, p = 0.0004). At follow-up, survivors with no-reflow had higher end-diastolic and end-systolic LV volume indices and plasma brain natriuretic peptide levels, and lower LV ejection fractions (p = 0.0002, p < 0.0001, p = 0.002, p < 0.0001, respectively) than did those with reflow, indicating that no-reflow may be involved in LV remodeling.CONCLUSIONSAngiographic no-reflow phenomenon strongly predicts long-term cardiac complications after AMI; these complications are possibly associated with LV remodeling.

Venticular aneurysmectomy:indications,operative findings and outcome at a single centre

We assessed all patients (n = 120) who underwent left ventricular aneurysmectomy as part of a cardiac surgical procedure at the Groby Road Hospital subregional cardiothoracic centre (1980-1990). Of these, 71% had had only one prior myocardial infarction and 84% had symptoms generally associated with aneurysms (congestive cardiac failure, ventricular arrythmias or systemic embolism). The indication for surgery was a combination of angina and aneurysm-related symptoms in 43%, one or more aneurysm-related symptoms in 35%, and angina alone in 22%. The majority of patients (57%) underwent aneurysmectomy and coronary artery bypass grafting, although 35% underwent aneurysmectomy alone. Most (61%) aneurysms were > 6 cm in size, and 75% were located at the apex of the left ventricle. Forty per cent had a mural thrombus, and there was no relationship between prior warfarin use and occurrence of mural thrombus. Overall perioperative mortality was 17% (20 patients), although mortality halved between the first and second halves of the study period. The main reason for perioperative was pump failure. Seventeen patients died late during follow-up (mean 52.5 months), the main cause being further myocardial infarction. Nevertheless, 65% were still alive at 5 years, and 81% and 66% of survivors were still better than pre-operatively at 5 and 8 years, respectively. Post-operative improvement was equally as good in patients who underwent aneurysmectomy alone, or those operated on for aneurysm-related symptoms, as in the whole group. In logistic regression analysis, the only predictor of adverse long-term outcome was the number of previous myocardial infarctions.(ABSTRACT TRUNCATED AT 250 WORDS)