Preoperative Left Ventricular End-diastolic Diameter Research Articles

Pre-implant left ventricular dimension is not associated with worse outcomes after left ventricular assist device implantation.

BackgroundLeft ventricular dimension has the potential to impact clinical outcomes following implantation of left ventricular assist devices (LVAD). We investigated the effect of pre-implant left ventricular end-diastolic diameter (LVEDD) on outcomes following LVAD implantation.MethodsPatients implanted with a continuous-flow LVAD between 2004 and 2018 at a single institution were included. The primary outcome was death while on LVAD support. Secondary outcomes included adverse event rates such as renal failure requiring dialysis, device thrombosis, and right ventricular failure. The LVEDD measurements were dichotomized using restricted cubic splines and threshold regression. Survival was determined using Kaplan-Meier estimates. Multivariable logistic regression was used to determine risk-adjusted mortality based on LVEDD.ResultsA total of 344 patients underwent implantation of a continuous flow LVAD during the study period. The optimal cut point for LVEDD was 65 mm, with 126 (36.6%) subjects in the <65 mm group and 165 (48.0%) in the >65 mm group. The LVEDD <65 mm group was older, had more females, higher incidence of diabetes, more pre-implant mechanical ventilation, and more admissions for acute myocardial infarctions (all, P<0.05). Importantly, post-implant adverse events were similar between the groups (all, P>0.05). Risk-adjusted survival at 1-year (OR 1.3, 95% CI: 0.6–2.5, P=0.53) was also comparable between the groups. Furthermore, incremental increases in LVEDD when modeled as a continuous variable did not impact overall mortality (OR 0.98, 95% CI: 0.9–1.0, P=0.09).ConclusionsPreoperative LVEDD was not associated with rates of major morbidities or mortality following LVAD implantation.

Anomalous Origin of the Left Coronary Artery From the Pulmonary Artery: A Retrospective Multicenter Study.

We aimed to describe characteristics and operative outcomes from a multicenter cohort of infants who underwent repair of anomalous left coronary artery from the pulmonary artery. We also aimed to identify factors associated with major adverse cardiovascular events following anomalous left coronary artery from the pulmonary artery repair. Retrospective chart review. Twenty-one tertiary-care referral centers. Infants less than 365 days old who underwent anomalous left coronary artery from the pulmonary artery repair. None. Major adverse cardiovascular events were defined as the occurrence of postoperative extracorporeal membrane oxygenation, cardiopulmonary resuscitation, left ventricular assist device, heart transplantation, or operative mortality. Factors independently associated with major adverse cardiovascular events were identified using multivariable logistic regression analysis. We reviewed 177 infants (< 365 d old) who underwent anomalous left coronary artery from the pulmonary artery repair between January 2009 and March 2018. Major adverse cardiovascular events occurred in 36 patients (20%). Twenty-nine patients (16%) received extracorporeal membrane oxygenation, 14 (8%) received cardiopulmonary resuscitation, four (2%) underwent left ventricular assist device placement, two (1%) underwent heart transplantation, and six (3.4%) suffered operative mortality. In multivariable analysis, preoperative inotropic support (odds ratio, 3.5; 95% CI, 1.4-8.5), cardiopulmonary bypass duration greater than 150 minutes (odds ratio, 6.9 min; 95% CI, 2.9-16.7 min), and preoperative creatinine greater than 0.3 mg/dL (odds ratio, 2.4 mg/dL; 95% CI, 1.1-5.6 mg/dL) were independently associated with major adverse cardiovascular events. In patients with preoperative left ventricular end-diastolic diameter measurements available (n = 116), left ventricular end-diastolic diameter z score greater than 6 was also independently associated with major adverse cardiovascular events (odds ratio, 7.6; 95% CI, 2.0-28.6). In this contemporary multicenter analysis, one in five children who underwent surgical repair of anomalous left coronary artery from the pulmonary artery experienced major adverse cardiovascular events. Preoperative characteristics such as inotropic support, creatinine, and left ventricular end-diastolic diameter z score should be considered when planning for potential postoperative complications.

Left ventricular remodeling after mitral valve repair and papillary muscle approximation.

Mitral valve repair with papillary muscle approximation (MVr-PMA) for severe secondary mitral regurgitation (MR) decreases MR recurrence compared with MVr alone. This study assessed the effects of MVr-PMA on left ventricular (LV) remodeling and shape, systolic function and strain mechanics. Forty-eight patients who underwent MVr-PMA for severe secondary MR and had follow-up echocardiograms available for review were identified. Student's t-test, linear regression modeling, and receiver-operating characteristic curves were used in the statistical analyses. Median follow-up time was 14.9 months. MVr-PMA was associated with significant LV reverse remodeling with a smaller LV end-diastolic diameter, Systolic Sphericity Index, and interpapillary muscle distance at follow-up. Nine patients (18.8%) experienced moderate recurrent MR. When compared to recurrent MR patients at follow-up, those with durable MVr-PMA had a greater LV ejection fraction (32.8 vs. 22.0%, P=0.03), a smaller end-diastolic diameter (59.6 vs. 67.3 mm, P=0.03), Systolic Sphericity Index (0.35 vs. 0.47, P=0.03), and end-systolic interpapillary muscle distance (16.3 vs. 21.1 mm, P=0.03). A durable MVr-PMA also resulted in stable global longitudinal strain when compared with pre-operative values, while the recurrent MR group experienced a further decline (no recurrent MR: -8.4 vs. -7.5%; recurrent MR: -8.2 vs. -5.4%; P<0.05). A pre-operative LV end-diastolic diameter ≥ 64 mm was a discriminative predictor of MR recurrence (sensitivity=100%, specificity=51%, AUC=0.756, P=0.02). A durable MVr-PMA confers improved LV geometry and function, and stable LV mechanics. The extent of baseline LV remodeling identifies patients at risk for recurrent MR.

Blunted beta-adrenoceptor-mediated inotropy in valvular cardiomyopathy: another piece of the puzzle in human aortic valve disease.

Heart failure induced by valvular cardiomyopathy occurs in a substantial proportion of patients undergoing heart valve surgery. We aimed (i) to quantify beta-adrenoceptor (beta-AR) function by measuring the inotropic effect of isoprenaline in left ventricular (LV) tissue and (ii) to correlate beta-AR-mediated inotropy with clinical markers of heart failure. A total of 179 LV myocardial samples were obtained from 104 consecutive patients who underwent aortic valve (AV) surgery between 2017 and 2019. Beta-ARs were stimulated by increasing the concentrations of isoprenaline, followed by a single high concentration of forskolin and calcium. Beta-AR sensitivity was estimated as the concentration to achieve half maximum effects (EC50). Maximum effect size was calculated as the relative beta-AR-mediated inotropic response compared to the force in the presence of high calcium [FISO/Ca (%)]. In vitro data were correlated with the clinical indicators of LV disease. FISO/Ca was independent of age and sex and amounted to 79.6 ± 20.5%. In a multivariate regression model, we found a significant inverse association between FISO/Ca and preoperative left ventricular end-diastolic diameter increase per 10 mm (OR -9.24, 95% CI -16.66 to -1.82; P = 0.015). Furthermore, patients with end-stage heart failure showed a strong tendency towards more severe reduction of max beta-AR response, as indicated by reduced FISO/Ca in a multivariate model (OR -29.60, 95% CI -61.92 to 2.72; P = 0.055). Our study indicates that in vitro myocardial contractility testing can quantify beta-AR dysfunction in patients with AV disease. We found a significant association between reduced beta-AR sensitivity and increased LV diameter, which may indicate a role of beta-AR dysfunction in the development of heart failure in patients with AV disease.

Midterm results of transventricular mitral valve repair: Single-center experience

ObjectiveThe study objective was to evaluate the midterm outcomes of transventricular mitral valve repair and its association with the initial anatomy of the mitral valve. MethodsThis nonrandomized observational study included 88 patients (mean age, 60 years; 69% were men) who underwent transventricular mitral valve repair for severe degenerative mitral regurgitation between 2011 and 2017. Mitral valve function was assessed by echocardiography at 1 and 6 months and annually after the procedure. According to the location of mitral valve pathology, all patients were stratified into 4 anatomic types (A, B, C, and D). Results were assessed using Kaplan–Meier method, mixed-effects continuation ratio model, and multivariable Cox regression. ResultsMedian follow-up of 42 months (interquartile range, 27-55) was complete for 83 patients (94.3%). There were 3 late deaths: 2 cardiac and 1 noncardiac. Recurrent mitral regurgitation greater than 2+ was observed in 29 patients (33%), and 18 patients (20.5%) underwent repeat surgery. Device success was 82% in type A at 6 months and thereafter; 87%, 85%, and 75% at 6, 12, and 36 months in type B, respectively; and 53% at 1 month and 20% at 24 months in type C. Probability of postoperative mitral regurgitation progression was higher in patients with greater preoperative left ventricular end-diastolic diameter, type B pathology, and type C pathology (P < .05). Risk factors of mitral regurgitation recurrence included increased left ventricle size (hazard ratio, 1.11; 95% confidence interval, 1.04-1.20; P = .001) and type C pathology (hazard ratio, 5.99; 95% confidence interval, 1.87-19.21; P = .003). ConclusionsInitial acceptable mitral regurgitation reduction after transventricular mitral valve repair of isolated P2 prolapse was possible but found durable in only 82% at 3 years. Higher risk of mitral regurgitation recurrence occurred with complex degenerative pathology.

Risk factors of chronic left ventricular dysfunction after cardiac valve surgery.

BackgroundTo analyze the risk factors of chronic left ventricular dysfunction (LVD) after cardiac valve surgery.MethodsA retrospective analysis of 860 patients who underwent heart valve surgery in our center from January 2017 to December 2018, including 650 males and 210 females, aged 58±5.8 years. Inclusion criteria: (I) the patient was clinically diagnosed with heart valve disease and met the surgical indications for mitral valve replacement (MVR), mitral valve repair (MVP), aortic valve replacement (AVR) and double valve replacement (DVR); (II) if atrial fibrillation, coronary artery disease, and tricuspid regurgitation are combined before surgery, radiofrequency ablation, coronary bypass and tricuspid angioplasty were performed contemporarily. Exclusion criteria: (I) preoperative LVEF <50%; (II) aortic dissection underwent Bentall and right heart valve replacement procedures; (III) cardiopulmonary resuscitation and death during perioperative period and 6 months after operation; (IV) postoperative CRRT, IABP, or ECMO assistance; (V) postoperative cardiac dysfunction due to valvular dysfunction, perivalvular leak, or infective endocarditis. Patients were divided into LVD group (LVEF <40%) and control group (LVEF ≥40%) based on cardiac LVEF at 6 months after surgery. Logistic regression was used to analyze the risk factors of postoperative LVD.ResultsThere were 126 cases in LVD group and 734 cases in control group. There were significant differences in preoperative coronary artery disease, atrial fibrillation, pulmonary hypertension, NYHA classification, left ventricular end diastolic diameter (LVEDD), and left ventricular end systolic diameter (LVESD) between the two groups (P<0.05). The differences in the changes of LVEDD and LVESD before and after operation between the two groups were statistically significant (P<0.05). Logistic regression analysis showed that preoperative LVEDD >55 mm, preoperative LVESD >40 mm, preoperative combined atrial fibrillation, preoperative combined pulmonary hypertension, preoperative NYHA III–IV, and preoperative combined coronary artery disease were the risks of postoperative chronic LVD.ConclusionsThe left ventricular diameter, preoperative coronary artery disease, NYHA III–IV, preoperative atrial fibrillation, and preoperative pulmonary hypertension are risk factors for chronic LVD after heart valve surgery.

P819 Outflow graft twist occlusion in the heartmate 3 left ventricular assist system in 7 cases: analysis of potential mechanisms using computed tomography

Abstract Background Twist of the outflow graft (OG) of the HeartMate 3 left ventricular (LV) assist device (HM3) with subsequent occlusion is a rare, but life-threatening complication. Purpose We evaluated if potential implantation technique dependent mechanisms of OG twist can be predicted by multislice computed tomography (MSCT). Methods We retrospectively analyzed clinical, echocardiographic and MSCT data of 7 patients with angiographically proven and surgically corrected OG twist and of 11 consecutive patients without any type of pump obstruction. MSCT parameters were: position of inflow cannula related to anatomical LV apex (1), angulation of axis of inflow cannula related to LV axis (2), orientation of outflow channel of the pump housing related to LV axis (3), OG course (4). Echocardiographic parameters were LV end-diastolic diameter (LVEDD) and aortic valve opening. Results Mean time from implantation to twist was 563 ± 161 days. Preoperative LVEDD (64.6 ± 9.8 mm vs. 67.4 ± 10.2 mm, p = 0.563) was similar. LVEDD reduction after implantation (20% vs. 28%) and prevalence of aortic valve opening was higher in the twist group (71% vs. 45%). The MSCT measurements showed a high degree of heterogeneity in both groups: (1) differed from superior to infero-lateral; (2) varied from cranial to caudal, lateral and medial; (3) varied from antero-septal to inferior. (4) showed an incidence of non-obstructive kinking of 29% and 36%, respectively. Conclusion Marked heterogeneity of the measured MSCT parameters was observed in both groups. No specific pattern or geometric relation could be attributed to the OG twist phenomenon.

Long-term experience with valve-sparing root reimplantation surgery in tricuspid aortic valve.

To analyze our long-term experience with valve-sparing reimplantation technique in treating aortic root aneurysm, aortic regurgitation, and aortic dissection in patients with tricuspid aortic valve. Between March 1998 and October 2018, 303 consecutive patients underwent valve-sparing reimplantation in our institution. The mean age of this cohort was 52.9 ± 15years. Time to event analysis was performed with the Kaplan-Meier method. Risk of death, reoperation, and aortic regurgitation (AR) recurrence were analyzed using the cox-regression method. In-hospital mortality was 1% (n = 3) of which two were admitted for acute aortic dissection. Median follow-up was 5.81years ([IQR]: 2.8-10years). Thirty-nine patients (14.4%) died during follow-up. At 5 and 10years, overall survival was 92 ± 2%and 75 ± 4.9%, respectively. Seventeen patients required late aortic valve reoperation. Freedom from valve reoperation was 95 ± 2% and 90 ± 3%. Freedom from AR > 2+ and AR > 1+ at 10years was 91 ± 4% and 71.5 ± 4.6%, respectively. Significant multivariate predictors of death included age, New York Heart Association dyspnea class (NYHA), type A acute dissection (TAAD), and preoperative left ventricular end-diastolic diameter (LVEDD). Significant multivariate predictors of AR recurrence included indication for surgery, previous cardiac surgery, and presence of preoperative AR. Freedom from events like major bleeding, thromboembolic events, and infective endocarditis at 10years were 97%, 98%, and 96%, respectively. Aortic valve-sparing with the reimplantation technique has been performed for over two decades in our institution, and the results in patients with tricuspid aortic valve (TAV) are excellent in terms of survival and freedom from valve-related adverse outcomes including valve reoperation. These results continue supporting the use of valve sparing root replacement using the reimplantation technique (VSRR) in patients with aortic aneurysm, irrespective of whether they have preoperative AR or not. VSRR is safe, durable, and reproducible, but further follow-up, well into the second decade is still necessary.

Can We Predict Failure of Mitral Valve Repair?

Objective: To identify echocardiographic and surgical risk factors for failure after mitral valve repair. Methods: We identified a total of 77 consecutive patients from our institutional mitral valve surgery database who required redo mitral valve surgery due to recurrence of mitral regurgitation after primary mitral valve repair. A control group of 138 patients who had a stable echocardiographic long-term result was included based on propensity score matching. Systematic analysis of echocardiographic parameters was performed before primary surgery; after mitral valve repair and prior to redo surgery. Risk factor analysis was performed using multivariate Cox regression model. Results: Redo surgery was associated with the presence of pulmonary hypertension ≥ 50 mmHg (p = 0.02), a mean transmitral gradient > 5 mmHg (p = 0.001), left ventricular ejection fraction ≤ 45% (p = 0.05) before surgery and mitral regurgitation ≥moderate at time of discharge (p = 0.002) in the whole cohort. Patients with functional mitral valve regurgitation had a higher tendency to undergo redo surgery if preoperative left ventricular end-diastolic diameter exceeded 65 mm (p = 0.043) and if postoperative tenting height exceeded 6 mm (p = 0.018). Low ejection fraction was not significantly associated with the need for redo mitral valve surgery in the functional subgroup. Conclusions: Recurrent mitral regurgitation is still a valuable problem and is associated with relevant perioperative mortality. Patients with severe mitral regurgitation should undergo early mitral valve repair surgery as long as systolic pulmonary artery pressure is low, left ventricular ejection fraction is preserved, and LVEED is deceeds 65 mm.

Role of percutaneous veno-arterial extracorporeal membrane oxygenation as bridge to left ventricular assist device.

Percutaneous veno-arterial extracorporeal membrane oxygenation (VA-ECMO) provides emergency circulatory support for cardiogenic shock patients and is used as a bridge to a left ventricular assist device (LVAD). The purpose of this study was to determine risk factors for LVAD implantation in patients who required percutaneous VA-ECMO as a bridge to long-term LVAD. We retrospectively investigated 32 consecutive LVAD patients who required percutaneous VA-ECMO as a bridge to long-term LVAD. Twenty-nine patients (91%) were intubated, and their serum creatinine and total bilirubin levels before LVAD implantation were 2.1±2.0 and 3.7±3.7mg/dl, respectively. Patients were supported by LVAD for 495±393days, during which 15 died, 6 recovered native cardiac functions and LVAD was explanted, and 11 underwent heart transplantation. Multivariate logistic regression analysis revealed that a preoperative left ventricular end-diastolic diameter (LVDd) ≤54mm was a significant predictor of 90-day mortality after LVAD implantation (OR 13.64; 95% CI 1.081-172.0; p=0.0433) and freedom from death during LVAD support was significantly worse in patients with an LVDd ≤54mm. Furthermore, preoperative LVDd was positively correlated with postoperative right ventricular stroke work index (r=0.739, p<0.0001) and patients with an LVDd ≤54mm had significantly worse postoperative right ventricular, renal, and hepatic functions. We demonstrated that percutaneous VA-ECMO could be utilized as a bridge to long-term LVAD in selected patients. Our results suggest that preoperative LVDd is a useful predictor of mortality and right ventricular function after LVAD implantation in patients requiring VA-ECMO, in whom assessment of right ventricular function is challenging.

Magnetic resonance imaging in interventional therapy of patients with acute myocardial infarction prior to and after treatment.

The aim of the study was to investigate the cardiac magnetic resonance (CMR) imaging in interventional therapy of patients with acute myocardial infarction prior to and after treatment. Fifty-six cases of AMI patients with elective treatment by percutaneous coronary intervention (PCI) were continuously selected. Patients with an incidence of 7–10 days were treated with CMR and echocardiography to evaluate the quality of myocardial infarction, visual score method (VSM), wall motion score abnormality, left ventricular end-diastolic diameter (LVEDD), left ventricular end-systolic diameter (LVESD) and left ventricular ejection fraction (LVEF). Patients with an incidence of 10–14 days were treated with PCI, and CMR and echocardiography were evaluated after 6 months, after which the occurrence of major adverse cardiac events (MACE) were compared. The infarction quality, VSM score and wall motion abnormality (WMA) score were significantly reduced following surgery, and the difference was statistically significant (P<0.05). Ultrasound evaluation of LVEDD, LVESD, and LVEF prior to and after surgery was compared, and the difference was not statistically significant (P>0.05). Evaluation of the magnetic resonance imaging (MRI) in LVEDD prior to surgery was increased compared with that of the ultrasound in LVEDD, whereas MRI in LVESD and LVEF was decreased compared to that of the ultrasound obtained for LVESD and LVEF. Additionally, postoperative LVEDD was reduced compared with preoperative LVEDD, whereas LVEF was increased, and the difference was statistically significant (P<0.05). However, the evaluation of LVESD using the two methods exhibited no significant change. MACE occurred in 7 (12.5%) of 56 cases. The infarction quality of patients in the MACE group following surgery indicated that VSM and WMA scores were significantly higher than the group without MACE, while LVEF was lower than the MACE group following surgery, and the difference was statistically significant (P<0.05), albeit the ultrasound results of LVEF indicated no difference. In conclusion, CMR evaluation of AMI patients with elective PCI treatment in myocardial remodeling and cardiac function were more sensitive and accurate than with cardiac ultrasound.

Structural and functional changes of postoperative small left ventricle patients

To explore the perioperative features of surgical treatment in valvular patients with small left ventricle, and investigate the postoperative early structural changes of left ventricle and its correlation with cardiac function. A total of 51 patients with small left ventricle underwent mitral valve replacement from January 2003 to August 2008. There were 7 males and 44 females with mean age of (48 +/- 5) years old. The mean pathologic course was (18 +/- 9) years old. The concomitant procedures included aortic valve replacement in 6 cases, coronary artery bypass grafting in 1 case, tricuspid valvular plasty in 48 cases, left atrial thrombi scavenging in 36 cases, and left atrium folding in 42 cases. The perioperative mortality was 3.9% (2/51). Fourteen patients (27.5%) suffered from severe low-output syndrome in the earlier period postoperatively. Among them, 5 patients needed secondary cardiopulmonary bypass (CPB) to assist circulation, with the result of 1 patient died of weaning off CPB unsuccessfully, 1 patient revived with intra-aortic balloon pump assisted for another 2 d after termination of CPB and another 1 patient died of multiple organ failure (MOF) 10 d later. Eleven cases complicated with MOF. Five patients complicated with ventricular arrhythmia. The echocardiographic examinations showed that the left ventricular dimensions didn't expand significantly postoperatively at 7 to 14 d postoperatively. Left ventricular end-diastolic diameter (LVEDD) was (36.5 +/- 3.2) mm preoperatively and (38.6 +/- 5.3) mm postoperatively (P > 0.05). Preoperative LVEDD index (LVEDDI) was (45.9 +/- 3.8) ml/m(2) and postoperative LVEDDI was (48.2 +/- 7.4) ml/m(2) (P > 0.05). The contract function of left ventricle was improved postoperatively but with no statistical significance. Ejection fraction was 48.6% +/- 6.7% preoperatively and 52.8% +/- 8.3% postoperatively. Left ventricular fraction shortness was 25.5% +/- 3.3% preoperatively and 27.1% +/- 1.3% postoperatively. For the patients with small left ventricle usually, the postoperative emphases should be put on the management of low output syndrome. The decreased dimension of left ventricle doesn't expand in the early period after valvular operation.

Midterm clinical and echocardiographic results and predictors of mitral regurgitation recurrence following restrictive annuloplasty for ischemic cardiomyopathy

Although mitral restrictive annuloplasty plus coronary artery bypass grafting are considered the best therapeutic strategies for ischemic cardiomyopathy with chronic mitral regurgitation, some recurrences are still reported. We evaluated predictors for late recurrence of ischemic cardiomyopathy with chronic mitral regurgitation. Hospital outcome and serial clinical and echocardiographic (preoperative, discharge, 6 months, end of follow-up) follow-up assessments were recorded for 82 consecutive patients with ischemic cardiomyopathy with chronic mitral regurgitation having coronary artery bypass grafting + mitral restrictive annuloplasty (2 sizes ring downsizing). Recurrent ischemic cardiomyopathy with chronic mitral regurgitation was defined by grade >or= 2 at echocardiography. Hospital mortality was 4.9%; 17.7 +/- 1.7 (standard error) months (range 1-55) survival was 95.5% +/- 2.5%. Two-year Kaplan-Meier freedom from reintervention was 94.2% +/- 4.2%; from rerevascularization, 87.5% +/- 11.7%; from congestive heart failure, 83.8% +/- 5.7%; from ischemic cardiomyopathy with chronic mitral regurgitation grade >or= 2, 46.5% +/- 11.2%. Recurrence of ischemic cardiomyopathy with chronic mitral regurgitation gave lower 2-year Kaplan-Meier freedom from death (P = .03) and lower 2-year freedom from congestive heart failure (P = .0001), reintervention (P = .034), and tricuspid insufficiency (P = .0001). Ischemic cardiomyopathy with chronic mitral regurgitation recurrence correlated with worsened New York Heart Association class (P = .0001), left ventricular ejection fraction (P = .024), pulmonary arterial pressures (P = .0001), left ventricular end-diastolic diameter (P = .004), left ventricular end-systolic diameter (P = .014), indexed left ventricular mass (P = .008), and coaptation depth (P = .0001). Independent predictors for recurrent ischemic cardiomyopathy with chronic mitral regurgitation were previous anterior + posterior myocardial infarction (odds ratio 3.70; confidence interval 2.93-5.41; P = .001), preoperative left ventricular end-diastolic diameter >or= 70 mm (odds ratio 3.91; confidence interval 2.65-5.22; P = .001), and coaptation depth at discharge >or= 0.5 cm (odds ratio 11.9; confidence interval 5.91-21.34; P = .0001). Preoperative left ventricular end-diastolic diameter >or= 70 mm correlated with higher congestive heart failure (P = .002), recurrent ischemic cardiomyopathy with chronic mitral regurgitation (P = .0001), worsened New York Heart Association class (P = .0001), and higher diuretics (P = .0001). Coaptation depth < 0.5 cm at discharge accounted for better survival (P = .010), lower incidence of congestive heart failure (P = .0001), lower need for diuretics (P = .0001), and improved New York Heart Association class (P = .0001). Failure of mitral restrictive annuloplasty is responsible for follow-up mortality and congestive heart failure and correlates with absence of cardiac reverse remodeling. Prognosis of patients having mitral restrictive annuloplasty for ischemic cardiomyopathy with chronic mitral regurgitation is good, as long as a low postoperative coaptation depth is achieved. Patients with significant left ventricular dilation should be considered for different surgical strategies.

Restrictive Mitral Annuloplasty Cures Ischemic Mitral Regurgitation and Heart Failure

Restrictive mitral annuloplasty with revascularization is considered the best approach to ischemic mitral regurgitation with heart failure, but late results are controversial. We report late outcome in relation to preoperative left ventricular end-diastolic diameter (LVEDD) cutoff values, previously identified to predict intermediate-term left ventricular reverse remodeling. One hundred consecutive ischemic mitral regurgitation patients underwent restrictive mitral annuloplasty (stringent downsizing by two ring sizes; median size, 26) and coronary revascularization. Survivors were clinically and echocardiographically assessed at intermediate (18 months) and late (mean, 46 months) follow-up. Early mortality was 8%, and late mortality was 18%. Actuarial 1-, 3-, and 5-year survival rates were 87% +/- 3.4%, 80% +/- 4.1%, and 71% +/- 5.1%. Mortality predictors (Cox regression) were preoperative inotropic support (hazard ratio, 6.2; 95% confidence interval, 2.3 to 16.9) and preoperative LVEDD greater than 65 mm (hazard ratio, 4.5; 95% confidence interval, 1.9 to 10.9). Five-year survival rate for patients with LVEDD of 65 mm or less was 80% +/- 5.2%, versus 49% +/- 11% for LVEDD greater than 65 mm (p = 0.002). At 4.3 years' follow-up, New York Heart Association functional class had improved from 2.9 +/- 0.8 to 1.6 +/- 0.6 (p < 0.01). Mitral regurgitation grade was 0.8 +/- 0.7, and was less than grade 2+ in 85% of patients. Left ventricular reverse remodeling was sustained with time for the LVEDD of 65 mm or less group. Late deaths did not show intermediate-term systolic left ventricular reverse remodeling, indicating a more extensive intrinsic left ventricular abnormality. At 4.3 years' follow-up, intermediate-term cutoff values for left ventricular reverse remodeling proved to be predictors for late mortality. For patients with preoperative LVEDD of 65 mm or less, restrictive mitral annuloplasty with revascularization provides a cure for ischemic mitral regurgitation and heart failure; however, when LVEDD exceeds 65 mm, outcome is poor and a ventricular approach should be considered.

DOES A ROTARY PUMP PROVIDE FULL CARDIAC DECOMPRESSION AND CIRCULATORY SUPPORT? -FROM CLINICAL EXPERIENCES OF HEARTMATE II WITH SEVERE CONGESTIVE HEART FAILURE PATIENTS-

Purpose: Rotary pumps such as the Heartmate II left ventricular assist device (LVAD) (Thoratec Corporation, Pleasanton, CA) are small, non-pulsatile pumps designed for long-term use. However, its capability for providing full cardiac decompression and circulatory support has been questioned and indeed some have felt that the only safe way rotary pumps can be used is in an assistive mode. Methods: Three patients (Ischemic cardiomyopathy: 2, Post-partum cardiomyopathy: 1, ejection fraction: 10–20%) implanted the HeartMate II LVAD were followed using regular transthoracic echocardiography (TTE). Pump rpm, aortic valve opening (AVO), and left ventricular end-diastolic diameter (LVDd) were measured while changing pump rpm. Results: Full cardiac decompression and circulatory support were observed in all three patients. With the increasing of pump rpm, LVDd and the frequency of AVO decreased in inverse proportion. At an appropriate pump rpm setting, the aortic valve closed completely and LVDd decreased to 60–70% of preoperative LVDd without causing suction by the apical cannula. Long-term renal and circulatory function was normal without heart failure symptoms. Considerations: The Heartmate II provides sufficient circulatory support at an appropriate pump rpm setting in patients with severe congestive heart failure. Long-term full circulatory support can be achieved which is a requirement for destination therapy.

Mitral valve repair for degenerative disease: is pericardial posterior annuloplasty a durable option?

Biological and prosthetic rings are available for supporting mitral valve repair (MVR). Contrasting data are reported on the durability of pericardial ring annuloplasty. This retrospective study was undertaken to assess the durability of MVR for degenerative regurgitation with posterior annuloplasty performed with glutaraldehyde-treated autologous pericardium. From August 1995 through December 2000, 133 patients underwent mitral repair for degenerative regurgitation (86 men, age 62.9+/-11.5 years). Thirty patients (22.6%) underwent combined coronary artery bypass graft and fourteen (10.5%) underwent tricuspid annuloplasty. Associated aortic disease, previous cardiac surgery and endocarditis were considered exclusion criteria. Seventy-seven patients (57.9%) received a Carpentier-Edwards ring and 56 received (42.1%) an autologous pericardium ring. Thirty-day mortality was 3.8%. Mean follow-up, 98.3% complete, was of 35.6+/-18.7 months. Five-year freedom from reoperation and recurrence of mitral regurgitation> or =3+/4+ was significantly higher in the prosthetic ring group (90.1% - CL90%: 81.9-98.3%) compared with the pericardial ring group (62.6% - CL90%: 43.1-82.1%; P=0.027). Prosthetic ring implantation (P=0.004; RR=0.11) and preoperative New York Heart Association (NYHA) class< or =II (P=0.011; RR=0.16) were independently related to a lower risk of reoperation and recurrence of mitral regurgitation> or =3+/4+, by multivariate analysis. Five-year overall survival was 91.4% (CL90%: 87.9.7-95%). A higher preoperative left ventricular end-diastolic diameter (P=0.006; RR=1.17) and the severity of associated coronary artery disease (P=0.021; RR=2.00) were independent predictive factors for poor survival by multivariate analysis. Posterior pericardial annuloplasty can jeopardize reproducibility and durability of MVR for degenerative regurgitation.

Evidence against a myocardial factor as the cause of left ventricular dilation in active rheumatic carditis

Objectives. The aim of this study was to determine whether left ventricular dilation and congestive heart failure in patients with acute rheumatic fever with carditis are accompanied by left ventricular contractile dysfunction.Background. Acute rheumatic fever with carditis involves both the myocardium and endocardium, with consequent valvular regurgitation. The relative contribution of volume overload induced by valvular regurgitation and myocardial dysfunction due to rheumatic myocarditis to the overall degree of left ventricular dilation and congestive heart failure in these patients is unknown.Methods. To investigate this, we evaluated 32 patients (15 male, 17 female, mean age 14 ± 3 years) with documented active carditis and congestive heart failure. All 32 patients were found to have significant isolated mitral regurgitation or combined mitral and aortic regurgitation. Echocardiographic analysis of left ventricular dimensions and systolic performance was performed before and after isolated mitral or combined mitral and aortic valve replacement and the results were compared with those in 19 control subjects matched for age, gender and body surface area.Results. Both preoperative left ventricular end-diastolic diameter and percent fractional shortening were significantly increased in patients compared with control subjects (57 ± 7 vs. 43 ± 3 mm, p < 0.001, and 38 ± 6% vs. 33 ± 1%, p < 0.001, respectively). After valve replacement, left ventricular end-diastolic diameter decreased significantly (57 ± 7 to 47 ± 6 mm, p < 0.001). Although percent fractional shortening decreased significantly postoperatively (38 ± 6% to 32 ± 6%, p < 0.001), the postoperative percent fractional shortening did not differ from that in control subjects (32 ± 6% vs. 33 ± 1%, p = NS).Conclusions. The results of this study indicate that left ventricular dilation and heart failure in patients with acute rheumatic carditis rarely occur in the absence of hemodynamically significant regurgitant valve lesions. Furthermore, rapid reduction in left ventricular dimensions and preservation of fractional shortening after isolated mitral or combined mitral and aortic valve replacement suggest that rheumatic carditis is not accompanied by any significant degree of myocardial contractile dysfunction.