Preoperative End-systolic Volume Index Research Articles

Sudden Cardiac Death in Patients With Ischemic Heart Failure Undergoing Coronary Artery Bypass Grafting: Results From the STICH Randomized Clinical Trial (Surgical Treatment for Ischemic Heart Failure).

The risk of sudden cardiac death (SCD) in patients with heart failure after coronary artery bypass graft surgery (CABG) has not been examined in a contemporary clinical trial of surgical revascularization. This analysis describes the incidence, timing, and clinical predictors of SCD after CABG. Patients enrolled in the STICH trial (Surgical Treatment of Ischemic Heart Failure) who underwent CABG with or without surgical ventricular reconstruction were included. We excluded patients with prior implantable cardioverter-defibrillator and those randomized only to medical therapy. The primary outcome was SCD as adjudicated by a blinded committee. A Cox model was used to examine and identify predictors of SCD. The Fine and Gray method was used to estimate the incidence of SCD accounting for the competing risk of other deaths. Over a median follow-up of 46 months, 113 of 1411 patients who received CABG without (n = 934) or with (n = 477) surgical ventricular reconstruction had SCD; 311 died of other causes. The mean left ventricular ejection fraction at enrollment was 28±9%. The 5-year cumulative incidence of SCD was 8.5%. Patients who had SCD and those who did not die were younger and had fewer comorbid conditions than did those who died of causes other than SCD. In the first 30 days after CABG, SCD (n=5) accounted for 7% of all deaths. The numerically greatest monthly rate of SCD was in the 31- to 90-day time period. In a multivariable analysis including baseline demographics, risk factors, coronary anatomy, and left ventricular function, end-systolic volume index and B-type natriuretic peptide were most strongly associated with SCD. The monthly risk of SCD shortly after CABG among patients with a low left ventricular ejection fraction is highest between the first and third months, suggesting that risk stratification for SCD should occur early in the postoperative period, particularly in patients with increased preoperative end-systolic volume index or B-type natriuretic peptide. URL: http://www.clinicaltrials.gov. Unique identifier: NCT0002359.

Changes in left ventricular volume and predictors of cardiac events after endoventricular circular patch plasty

The aim of this study was to identify predictors of cardiac events after endoventricular circular patch plasty (Dor operation) by analyzing our experience with Dor operation. Thirty patients with left ventricular aneurysm and/or ischemic cardiomyopathy who underwent Dor operation were included in this study. Hemodynamic and clinical results were analyzed, and the predictors of cardiac events were examined. Hospital mortality was 3.3%. Postoperative clinical status and left ventricular (LV) function in all survivors significantly improved. The survival rates at 1, 3, and 5 years after operation were 93%, 89% and 89%. The corresponding cardiac event-free rates were 75%, 67% and 49%. Pre- and postoperative LV function and volume did not differ significantly between patients with or without cardiac events. However, the proportion of reduced end-diastolic volume index (EDVI) (preoperative EDVI-postoperative EDVI) to preoperative EDVI was significantly higher in patients with cardiac events than in cardiac event-free patients. Postoperative LV volume re-increased in the cases with cardiac events during follow-up. Cox regression analysis confirmed that preoperative clinical premature ventricular contraction and end-systolic volume index (ESVI), postoperative EDVI, ESVI, and ejection fraction were independent predictors of late cardiac events. There was a significant positive correlation between preoperative ESVI and postoperative EDVI. Though LV function significantly improved after Dor operation, LV reconstruction with excessive reduction can cause restarting LV remodeling and increasing mortality and morbidity. Therefore, LV reconstruction of appropriate sizes and shapes, considering the function of residual myocardium, has a significant effect on prognosis. It is highly reasonable to expect that preoperative ESVI can predict the optimal size of reconstructed left ventricle.

Efficacy of coronary artery bypass grafting in patients with a dilated left ventricle due to myocardial infarction.

This study was designed to clarify the efficacy of coronary artery bypass grafting (CABG) on left ventricular (LV) function in 16 patients with a dilated LV due to myocardial infarction (LV end-systolic volume index: LVESVI >60 ml/m2). All had attained complete revascularization. To estimate the LV wall motion quantitatively using echocardiography, a wall motion score (WMS) was used (LV was divided into 17 segments with a four-point scale: akinesis=3, severe hypokinesis=2, hypokinesis=1, normal=0 and then summed). Exercise stress tests were performed after surgery, revealing that anginal symptoms had vanished in all the patients. In 5 patients with a preoperative end-systolic volume index (ESVI) >100 ml/m2, the ejection fraction (EF) did not change, and both were under 30% (before to after: 26+/-4 to 26+/-4%). Neither the ESVI (148+/-50 to 133+/-39 ml/m2) nor the end-diastolic volume index (end-diastolic volume index (EDVI): 198+/-62 to 180+/-37 ml/m2) changed; the WMS did not change (33+/-2 to 33+/-3). During exercise, in spite of the increase in heart rate (HR) (at rest, 81+/-20; HR during exercise, 111+/-21 beats/min, p<0.005) and LV end-diastolic pressure (EDP) (22+/-9; 35+/-13 mmHg, p<0.02), both cardiac index (CI) (2.4+/-0.3; 2.6+/-0.4 L/min x m2) and minute work (MW: 4.0+/-1.1; 4.1+/-0.4 kg x M/min) did not increase. In 11 patients with a preoperative ESVI <100 ml/m2, EF was extremely increased in 5 patients (more than 10%, 35+/-4 to 60+/-6%, p<0.005=improved subgroup) in whom the EDVI (130+/-16 to 120+/-13 ml/m2) did not change whereas the ESVI (82+/-14 to 48+/-7 ml/m2) was reduced. However, in the 6 remaining patients (ie nonimproved subgroup), neither ESVI (78+/-8 to 74+/-12 ml/m2), EDVI (115+/-10 to 115+/-20 ml/m2) nor EF (31+/-7 to 35+/-3%) changed. During exercise, HR (at rest, 88+/-13; during exercise, 108+/-11 beats/min, p<0.005), LVEDP (20+/-6; 29+/-7 mmHg, p<0.01), CI (2.5+/-0.6; 3.3+/-0.5 L/min x m2, p<0.05), MW (4.6+/-1.0; 6.5+/-1.5 kg x M/min, p<0.05) increased. The WMS in the nonimproved subgroup did not change (29+/-6 to 27+/-2), but in the improved subgroup it reduced after surgery (27+/-3 to 19+/-4, p<0.01). These data suggested that CABG in patients with a dilated LV was effective against anginal symptoms, but was restricted to left ventricular function. It may be possible to estimate postoperative LV function, including exercise tolerance, from the preoperative LVESVI.

Relation of impaired left ventricular function in mitral regurgitation to left ventricular contractile state after mitral valve replacement

To reevaluate the postoperative contractile state and survival, 34 patients (19 men and 15 women; average age 45 years, range 23 to 65) undergoing conventional mitral valve replacement between 1980 and 1990 were studied. There were 5 cardiac deaths (2 early and 3 late). Four of 5 deaths occurred in patients who had a preoperative left ventricular end-systolic volume index >100 ml/m 2. Sixteen patients with an end-systolic volume index >100 m1/m2 (group 1), and 5 with an index >100 ml/m 2 (group 11) underwent repeat catheterization 8 months (range 4 to 17) after surgery. The ratio of end-systolic wall stress to end-systolic volume index increased significantly after surgery in group 1, whereas it remained reduced in group II. The postoperative end-systolic wall stress/volume index ratio correlated significantly with the preoperative end-systolic volume index (p <0.001). In the relation between end-systolic wall stress and ejection fraction, all patients in group II had values that were less than the 95% confidence limits for the normal relation. In conclusion, patients with a preoperative end-systolic volume index >100 ml/m 2 appeared to be at high risk of incurring irreversible depressed myocardial contractility, with a high postoperative mortality.

Depressed myocardial contractility and normal ejection performance after aortic valve replacement in patients with aortic regurgitation

Left ventricular cineangiography and pressure measurement were performed in 33 patients with chronic aortic regurgitation before and after aortic valve replacement and in 25 normal control subjects. Stress and volume were analyzed. The 33 patients were divided into three groups based on preoperative end-systolic volume index: 15 with an index of less than 100 ml/m2 (group I), 12 with an index of 100 to 200 ml/m2 (group II), and six with an index of more than 200 ml/m2 (group III). Afterload estimated as end-systolic stress, which was significantly elevated in all groups before operation, returned to normal postoperatively. Systolic pump function improved postoperatively in all groups; group I and group II showing the most improvement with group III still having an abnormal ejection fraction. The ratio of end-systolic stress to end-systolic volume index, which is an index of contractile state that is relatively independent of preload and afterload, was abnormal in each group preoperatively. Postoperatively, the ratio improved in each group (from 2.8 +/- 0.5 to 4.8 +/- 0.9 for group I, from 1.4 +/- 0.3 to 3.2 +/- 0.6 for group II, and from 0.8 +/- 0.2 to 2.6 +/- 0.8 for group III, compared with 5.9 +/- 1.0 for control subjects). Group I had normal values whereas group II and group III had subnormal ratios, suggesting a depressed contractility. All 15 patients in group I had values that fell within the 95% confidence limits of the linear inverse relationship between ejection fraction and end-systolic stress for control subjects. Nine of the 12 patients in group II and all six in group III had values that fell below the 95% confidence limits of the normal ejection fraction-end-systolic stress relationship. Aortic valve replacement may reduce afterload and improve systolic pump function in many patients with aortic regurgitation. However, there is a subgroup of patients who, despite normal or near-normal pump performance as assessed by ejection fraction, have depressed myocardial contractility characterized by an abnormal relationship between end-systolic stress and either ejection fraction or end-systolic volume.

Comparison of Preoperative Left Ventricular Function With Postoperative Left Ventricular Response to Exercise in Patients With Chronic Aortic Regurgitation and Aortic Stenosis

The relation between preoperative left ventricular (LV) systolic function at rest and postoperative LV response to exercise was assessed in 13 patients with aortic regurgitation (AR) and nine patients with aortic stenosis (AS). Preoperative end-systolic volume index (ESVI) and ejection fraction (EF) determined by LV angiography were compared with postoperative exercise-induced changes of LV fractional shortening (delta %FS) and mean velocity of fiber shortening (delta mVcf) assessed by echocardiography. Preoperative EF and ESVI in 13 patients with AR correlated well with postoperative delta %FS and delta mVcf. Similarly, preoperative EF and ESVI in nine patients with AS correlated well with postoperative delta %FS and delta mVcf. Our study demonstrated that preoperative LV systolic function in AR and AS patients closely reflected postoperative LV response to exercise. Preoperative smaller ESVI will be warranted to expect a favorably good postoperative LV response to exercise.

Preoperative left ventricular function: Minimal requirement for successful late results of valve replacement for aortic regurgitation

Postoperative survival and left ventricular function were studied in 62 patients who underwent aortic valve replacement for isolated, chronic aortic regurgitation between 1978 and 1985. The average follow-up period was 3.8 years. There were three in-hospital and six late deaths. Five (56%) of the nine postoperative deaths were of cardiac-related causes. The mean 7 year survival rate was 83 +/- 5%. Preoperative left ventricular end-systolic volume index was the most important indicator (p less than 0.001) for subsequent cardiac death. The 6.5 year survival rate was 92 +/- 4% for patients with an end-systolic volume index less than 200 ml/m2 compared with 51 +/- 16% for those whose index was greater than 200 ml/m2. None of the 48 patients with an end-systolic volume index less than 200 ml/m2 died of cardiac-related causes. Twenty-three of the 48 patients with an end-systolic volume index less than 200 ml/m2 (Group 1) and 6 of the 12 patients with a higher index (Group 2) underwent repeat catheterization 26 months postoperatively. Preoperative afterload, assessed by end-systolic wall stress, was elevated in both groups, but decreased postoperatively, becoming identical to the afterload in 20 normal control subjects. Although the preoperative ejection fraction was depressed in both groups, the great majority of patients in Group 1, compared with none in Group 2, exhibited normal ejection fraction postoperatively. Thus, in patients who recently underwent surgery for aortic regurgitation, satisfactory late results in both long-term survival and reversal of left ventricular dysfunction were obtained when the preoperative end-systolic volume index was less than 200 ml/m2.