Preoperative Left Ventricular End-diastolic Pressure Research Articles

Factors associated with morbidity, mortality, and hemodynamic failure after biventricular conversion in borderline hypoplastic left hearts

ObjectiveA subset of patients with borderline hypoplastic left heart may be candidates for single to biventricular conversion, but long-term morbidity and mortality persist. Prior studies have shown conflicting results regarding the association of preoperative diastolic dysfunction and outcome, and patient selection remains challenging. MethodsPatients with borderline hypoplastic left heart undergoing biventricular conversion from 2005 to 2017 were included. Cox regression identified preoperative factors associated with a composite outcome of time to mortality, heart transplant, takedown to single ventricle circulation, or hemodynamic failure (defined as left ventricular end-diastolic pressure >20 mm Hg, mean pulmonary artery pressure >35 mm Hg, or pulmonary vascular resistance >6 international Woods units). ResultsAmong 43 patients, 20 (46%) met the outcome, with a median time to outcome of 5.2 years. On univariate analysis, endocardial fibroelastosis, lower left ventricular end-diastolic volume/body surface area (when <50 mL/m2), lower left ventricular stroke volume/body surface area (when <32 mL/m2), and lower left:right ventricular stroke volume ratio (when <0.7) were associated with outcome; higher preoperative left ventricular end-diastolic pressure was not. Multivariable analysis demonstrated that endocardial fibroelastosis (hazard ratio, 5.1, 95% confidence interval, 1.5-22.7, P = .033) and left ventricular stroke volume/body surface area 28 mL/m2 or less (hazard ratio, 4.3, 95% confidence interval, 1.5-12.3, P = .006) were independently associated with a higher hazard of the outcome. Approximately all patients (86%) with endocardial fibroelastosis and left ventricular stroke volume/body surface area 28 mL/m2 or less met the outcome compared with 10% of those without endocardial fibroelastosis and with higher stroke volume/body surface area. ConclusionsHistory of endocardial fibroelastosis and smaller left ventricular stroke volume/body surface area are independent factors associated with adverse outcomes among patients with borderline hypoplastic left heart undergoing biventricular conversion. Normal preoperative left ventricular end-diastolic pressure is insufficient to reassure against diastolic dysfunction after biventricular conversion.

Abstract 18664: Left Ventricular End-Diastolic Pressure is a Predictor of Survival in Patients Undergoing Coronary Artery Bypass Graft Surgery with Left Ventricular Dysfunction

There is an association between depressed left ventricular ejection fraction (ejection fraction &lt; 35%; LVEF) and increased mortality in patients undergoing coronary artery bypass graft (CABG). There are a few studies suggesting that elevated pre-operative left ventricular end-diastolic pressure (LVEDP) is an independent predictor of operative mortality for patients undergoing CABG, and could be a greater risk than LVEF &lt; 35%. It is unclear if LVEDP is a better predictor of long-term survival than LVEF in patients undergoing CABG. We hypothesized that LVEDP may add further prognostic value than LVEF alone. We studied 6790 consecutive patients from 2004-2011 undergoing isolated CABG at our institution. Patients were divided into four groups based on LVEF and LVEDP: Group 1 (LVEF≥35%, LVEDP&lt;18mmHg), Group 2 (LVEF&lt;35%, LVEDP&lt;18mmHg), Group 3 (LVEF≥35%, LVEDP≥18mmHg), and Group 4 (LVEF&lt;35%, LVEDP≥18mmHg). The 4 groups had similar pre-operative characteristics of age, history of stoke, renal failure, peripheral vascular disease (PVD), hypertension, and hyperlipidemia. Patients with a low LVEF (Groups 2 and 4) had a higher incidence of chronic obstructive pulmonary disease (COPD), congestive heart failure (CHF), smoking and history of myocardial infarction (p&lt;0.001). The Kaplan-Meier survival curves identified that the groups with preserved LVEF had improved long-term survival compared to groups with depressed LVEF (p&lt;0.001). As well, there was no significant correlation between elevated LVEDP and decreased survival in patients with a preserved LVEF (Group 1 versus Group 3, p=0.84). However, in patients with depressed LVEF&lt;35%, an elevated LVEDP was associated with worse long-term survival when compared to patients with an LVEDP&lt;18mmHg (Group 2 versus Group 4, p&lt;0.001). The independent predictors of death by Cox proportional hazards modeling were: LVEF&lt;35%, advanced age, COPD, PVD, dialysis dependent renal failure, and CHF (p&lt;0.001); while elevated LVEDP≥18mmHg was not significant. We conclude that elevated LVEDP≥18mmHg is not an independent risk factor for mortality in patients undergoing isolated CABG; however, in patients with depressed LVEF&lt;35%, an elevated LVEDP further prognosticates a significant decrease in long-term survival.

Surgical treatment of postinfarction anterior left ventricular aneurysms: linear vs. patch plasty repair

The patch plasty repair is increasingly advocated over linear closure in the surgical treatment of postinfarction anterior left ventricular aneurysm (LVA). A comparative estimate of the clinical results of these two techniques seemed in order. Between 1985 and 2004, 53 patients (mean age of 64.2+/-8.3 years) underwent repair of anterior LVA. Twenty-seven patients underwent linear repair (group 1) and 26 patients patch plasty (group 2). The mean left ventricular ejection fraction was 33.9+/-8.2% in group 1 vs. 29.7+/-10.2% in group 2 (P=0.118). Preoperatively 85.2% of patients in group 1 were in NYHA functional class III or IV vs. 88.5% in group 2 (P=0.71). All patients had preoperative recurrent ventricular tachycardia (VT) and non-guided encircling cryoablation for treatment of VT was performed in all patients. Coronary revascularization was performed in 29.6% of patients in group 1 and 42.3% in group 2 (P=0.398). The overall in-hospital mortality was 1.9% as one patient died of low cardiac output (LCO). LCO was the most frequent early postoperative complication and was observed in 66.7% of patients in group 1 vs. 65.4% in group 2 (P=1.000). LCO was related to right coronary artery disease on multivariate analysis (odds ratio 6.9, P=0.0097). Mean follow-up was 6.4+/-4.8 years (range 1 day-17.5 years). Overall survival at 10 years was 65.5% of patients in group 1 vs. 60.6% in group 2 (P=0.395). At 10 years, 91.5% of patients were free from VT or sudden death in group 1 vs. 81% in group 2 (P=0.269). At follow-up the patients' functional status improved and among survivors 76.9% in group 1 were in NYHA functional class I-II vs. 62.5% in group 2 (P=0.432). Deaths from congestive heart failure (CHF) occurred in 38.5% of patients in group 1 vs. 55.6% in group 2 (P=0.632). On multivariate analysis a preoperative left ventricular end-diastolic pressure above 20 mmHg was a predictor of mortality from CHF (odds ratio 9.6, P=0.038). Our study did not reveal significant differences between linear closure and patch plasty repair in the short- and long-term. The choice of repair technique should be adapted to each patient's anatomical and physiological characteristics.

CABG in octogenarians: Early and late events and actuarial survival in comparison with a matched population

With important demographic changes in cardiac surgical practice, more older patients are undergoing complex cardiac operations. Controversy exists as to whether the expenditure of healthcare resources on the growing elderly populations represents an effective approach in maintaining a meaningful quality of life. From January 1982 through April 1991, 121 consecutive octogenarians underwent a surgical procedure that included coronary artery bypass grafting. Retrospective review of patient medical records was performed; follow-up information was obtained via telephone contact with the patient, the patient's family, or the patient's physician. There were 67 men (55%) and 54 women (45%). Mean age was 82.1 years (range, 80 to 89 years). Sixty-nine percent of the patients were having class III or IV symptoms. There were 11 hospital deaths (9.1%); risk factors included longer cardiopulmonary bypass time (p = 0.01), higher preoperative left ventricular end-diastolic pressure (p = 0.02), advanced age (p = 0.05), history of renal disease (p = 0.02), and myocardial infarction (p = 0.04). Late death occurred in 34 patients (30.9%) at a mean of 27 months postoperatively; univariate risk factors included chronic obstructive pulmonary disease (p = 0.009), higher left-ventricular end-diastolic pressure (p = 0.03), and recent myocardial infarction (p = 0.03). Actuarial survival, including hospital death, was 32.8% at 80 months, compared with 37.6% for an age; sex; and race-matched population (p > 0.3). Most late survivors (84%) were in New York Heart Association class I or II. We conclude that coronary artery bypass grafting can be performed in octogenarians with an acceptable, although increased risk. Hospital survivors have a good late functional status but are at risk for pulmonary and other atherosclerosis-related events, which impair overall survival.

Early and late-phase events after valve replacement with the St. Jude Medical prosthesis in 1200 patients

From May 1982 to August 1991, 1200 patients underwent valve replacement with the St. Jude Medical (St. Jude Medical, Inc., St. Paul, Minn.) valve: 615 men (51%) and 585 women, mean age 58 years. Preoperatively, 830 patients (69%) were in functional class III or IV. A total of 611 patients (51%) had the aortic valve replaced, 490 (41%) the mitral valve, 2 (0.2%) the tricuspid valve, and 97 (8%) multiple valves. There were 81 hospital deaths (6.8%). Risk factors included older age (p = 0.0001), female gender (p = 0.02), higher preoperative left ventricular end-diastolic pressure (p = 0.05), previous cardiac operation (p = 0.003), longer aortic crossclamp time (p = 0.0001), and longer cardiopulmonary bypass time (p = 0.0001). Follow-up was 98% complete (3153 patient-years). There were 152 late deaths; 32 (21%) were considered valve-related: six thromboembolism, four valve thrombosis, five anticoagulant-related hemorrhage, eight prosthetic valve endocarditis, one paravalvular leak, and seven sudden death. The 5-year actuarial survival was 75%. Risk factors for late death included older age (p = 0.03), lower preoperative ejection fraction (p = 0.005), longer aortic crossclamp time (p = 0.001), longer cardiopulmonary bypass time (p = 0.0001), previous cardiac operation (p = 0.02), and higher preoperative functional class (p = 0.0001). Actuarial freedom at 5 years from major thromboembolic events and anticoagulant-related hemorrhage was 97% and 95%, respectively. This value for valve thrombosis was 99%, for reoperation 96%, for prosthetic valve endocarditis 98%, and for paravalvular leak 96%. Actuarial freedom from all valve-related events and valve-related death at 5 years was 74% and 94%, respectively. We conclude that the low incidence of valve-related events and low mortality supports the continued use of the St. Jude Medical valve.

Predictors of exercise benefit after operative relief of left ventricular outflow obstruction by the myotomy-myectomy procedure in hypertrophic cardiomyopathy

To determine predictors of exercise benefit in patients with hypertrophic cardiomyopathy after operative relief of left ventricular (LV) outflow tract obstruction, 30 patients underwent catheterization and exercise testing before and 6 months after operation, and hemodynamic measurements were obtained. The increase in maximal oxygen consumption (VO 2max) during treadmill exercise testing was chosen as an index of exercise benefit. Univariate analysis showed a significant positive correlation of operative change in VO 2max with preoperative LV end-diastolic and pulmonary arterial wedge pressures, operative change in exercise duration, and operative reductions in LV end-diastolic and pulmonary arterial wedge pressures and resting LV outflow tract gradient, and a significant negative correlation with preoperative VO 2max and percent predicted VO 2max. Multivariate analysis by stepwise linear regression of only significant univariate variables selected only preoperative percent predicted VO 2max, and operative reduction in LV end-diastolic pressure and resting LV outflow tract gradient as significant predictors of postoperative change in VO 2max. Stepwise regression analysis, applied only to preoperative exercise and catheterization hemodynamic variables, selected only preoperative percent predicted VO 2max and preoperative LV end-diastolic pressure as predictors of improvement in exercise capacity. Thus, patients with obstructive hypertrophic cardiomyopathy, after failing medical therapy, are most likely to demonstrate improvement in exercise capacity if preoperative exercise testing demonstrates limited exercise capacity and if surgery achieves reduction in elevated resting LV outflow tract gradients and LV filling pressures.

Influence of clinical and hemodynamic variables on risk of supraventricular tachycardia after coronary artery bypass

The influence of 45 variables on risk of postoperative supraventricular tachycardia was evaluated by univariate and multivariate analysis of data from 800 consecutive patients who underwent isolated coronary artery bypass during a 6-year interval. Postoperative supraventricular arrhythmias occurred in 186 patients (23%) but did not contribute to any of the six early deaths (30-day mortality rate, 0.8%). Mean (+/- standard deviation) length of hospital stay was longer (9.8 +/- 5.7 versus 8.3 +/- 3.5 days; p less than 0.0001) and mean age was older (65 versus 60 years; p less than 0.002) in patients with postoperative supraventricular tachycardia than in those with regular rhythm. Risk of supraventricular tachycardia was increased in patients with a history of atrial arrhythmias (45% versus 22%; p less than 0.002) or premature atrial contractions on the preoperative electrocardiogram (48% versus 22%; p less than 0.002). Multiple logistic regression analysis identified age 65 years or more, history of atrial arrhythmia or preoperative premature atrial contractions, and preoperative left ventricular end-diastolic pressure 20 mm Hg or more as independent predictors of postoperative supraventricular tachycardia. Six percent of patients converted to sinus rhythm spontaneously; 82% of patients converted within 1.1 +/- 1.9 days after onset of supraventricular tachycardia on treatment with digoxin or beta-adrenergic blocking drugs or both. Only 10% of patients with supraventricular tachycardia required electrical cardioversion. We conclude that the risk of supraventricular tachycardia after coronary artery bypass is influenced by patient-related variables and is effectively managed by conventional therapy. Prophylactic treatment should be reserved for elderly patients, especially those who have atrial arrhythmias or have preoperative left ventricular end-diastolic pressure 20 mm Hg or more.

Treatment of life-threatening ventricular arrhythmias with nonguided surgery supported by electrophysiologic testing and drug therapy

Forty-six patients who had coronary artery disease, left ventricular aneurysm and life-threatening ventricular tachyarrhythmia underwent surgical treatment to eliminate or facilitate control of the arrhythmia. Surgery was performed without the assistance of intraoperative mapping techniques. Forty-three patients underwent preoperative or postoperative electrophysiologic testing, or both, and antiarrhythmic therapy was added, when indicated, postoperatively. The patients had a mean age of 63 years, a mean preoperative left ventricular ejection fraction of 27 ± 9% and a mean preoperative left ventricular end-diastolic pressure of 23 ± 9 mm Hg. Twenty-one patients (46%) underwent surgical treatment within 2 months of their last myocardial infarction.The overall operative mortality rate was 6.5% (three patients). Eighteen of the 43 operative survivors were discharged from the hospital on no antiarrhythmic therapy, whereas 25 received additional antiarrhythmic treatment. During a mean follow-up period of 36 months (range 2 to 88), there were 13 deaths; eight patients died suddenly, three died of congestive heart failure, one of myocardial reinfarction and one from a noncardiac cause. The overall cumulative cardiac mortality rate at 1, 2 and 3 years was 16, 22 and 35%, respectively, whereas the sudden cardiac death rate was 5, 12 and 20%, respectively.This experience suggests that high risk patients who undergo nonguided surgery for life-threatening ventricular arrhythmia and left ventricular aneurysm have a relatively low surgical mortality and a better long-term survival than previously reported. However, if utilized, such an approach must be systematically supported by perioperative electrophysiologic testing to determine the need for supplemental antiarrhythmic therapy.

Determinants of outcome following left ventricular aneurysmectomy.

The determinants of outcome after left ventricular aneurysmectomy are not well understood. We analyzed preoperative follow-up information on 38 patients who had undergone left ventricular aneurysmectomy. At a mean follow-up of 39 months (range 6 to 68), 25 patients (66%) improved by at least one functional class (New York Heart Association) (Group I), and 13 patients (Group II) either died (n: 8) or had persistent congestive heart failure (n: 5). Patients in Group I had significantly higher left ventricular ejection fraction before surgery than patients in Group II (38 +/- 12% vs. 29 +/- 14%, P less than 0.04). The volume of the aneurysm at end-diastole was smaller among patients in Group I than Group II (42 +/- 32 ml vs. 73 +/- 47 ml, P less than 0.04). The contractile indices of the nonaneurysm segment, contractile segment ejection fraction, basilar half ejection fraction, and basilar fractional area shortening were not significantly different between the two groups. There was no difference between the two groups in the preoperative left ventricular end-diastolic pressure, cardiac index, pulmonary artery wedge pressure, pulmonary artery pressure, extent of coronary artery disease, number of bypass grafts inserted, or aortic cross-clamp times. 1) The ejection fraction and volume of the aneurysm are more important predictors of outcome after left ventricular aneurysmectomy than the contractile indices of the nonaneurysmal left ventricle and 2) symptomatic improvement occurs in 66% of patients after left ventricular aneurysmectomy.

Coronary artery bypass grafting in patients with ejection fractions below forty percent: Early and late results in 466 patients

The outcome of patients undergoing coronary artery bypass grafting with preoperative ejection fractions below 40% was evaluated to determine if a specific level of ventricular dysfunction resulted in unacceptably poor short-term or long-term survival rates. Left ventricular ejection fractions were segregated into groups of five percentage points each starting from 35% to 39% and progressing down to 10% to 14%. In evaluating the six ejection fraction groups between 10% and 39%, we found no significant differences among them with regard to previous myocardial infarctions, left ventricular end-diastolic pressure (LVEDP), age, preoperative New York Heart Association (NYHA) class, or number of vessels bypassed. Eighty-four percent were men and 16% women. From 1976 through 1982, 466 patients were distributed among these groups, all having ejection fractions below 40% (mean 30% +/- 3% SEM). There were significant differences (p = 0.001) in both the hospital and long-term survival (36 months) of patients with preoperative ejection fractions from 20% to 39% (425 patients) as compared to those with preoperative ejection fractions from 10% to 19% (41 patients). Hospital survival rate was 89% for patients with ejection fractions from 20% to 39% but only 63% for patients with ejection fractions below 20%. Similarly, at 3 years, patients with ejection fractions of 20% to 39% had an average survival rate of 60% as compared to an average survival rate of 15% for those with ejection fractions below 20%. Neither the preoperative LVEDP nor the intraoperative ischemic arrest time significantly predicted survival. In all survivors, NYHA class decreased from an average of 3.00 to 1.25 in surviving patients following bypass at a mean follow-up of 29 +/- 5 months. It is concluded that ejection fraction is an excellent predictor of short-term and long-term survival following coronary artery bypass grafting. Patients with ejection fractions of 10% to 19% have a significantly reduced short-term and long-term survival rate as compared to patients with ejection fractions of 20% or more.

Calculated Preoperative Mean Left Atrial Pressure as a Guide to Volume Load at the Termination of Aortocoronary Bypass Operation

The routine use of an arbitrary fixed left atrial (LA) pressure during volume load after aortocoronary bypass operation was compared with use of an individualized postoperative target LA pressure according to a calculated preoperative LA pressure in two groups of consecutive patients. The preoperative LA pressure of each patient was calculated from the preoperative left ventricular enddiastolic pressure (LVEDP) by the formula: mean LA pressure = 1.16 × LVEDP – 8.53. Left atrial pressure, mean arterial pressure, mean right atrial pressure, and cardiac output were measured simultaneously on arrival at the intensive care unit and 60 minutes later. Cardiac index (CI) and systemic vascular resistance (SVR) were calculated from the variables already mentioned. Results indicated a significantly higher CI and significantly lower SVR in patients in whom volume load was aimed at the calculated preoperative LA pressure. It was concluded that the optimal postoperative LA pressure is specific for each patient and depends on the preoperative LVEDP.

Aneurysmectomy and endocardial resection for ventricular tachycardia: Favorable hemodynamic and antiarrhythmic results in patients with global left ventricular dysfunction

Sixty-two patients underwent aneurysmectomy and endocardial resection for control of recurrent sustained ventricular tachycardia (VT). Forty patients also had coronary artery bypass grafting (CABG) (1.5 grafts per patient). The mean preoperative left ventricular end-diastolic pressure (LVEDP) was 18 ± 8 mm Hg, cardiac index (Cl) was 2.7 ± 0.7 L/min/m 2, and ejection fraction (EF) was 28 ± 10%. In a subset of 32 patients with clearly demarcated aneurysmal and contracting ventricular sections, the mean EF of the residual contracting section (CSEF) was 35 ± 13%, and 26 of these patients had a CSEF < 45%. There were five operative deaths (8%). No hemodynamic findings distinguished the patients who died during surgery. Patients with an LVEDP above the group mean or an overall EF below the group mean had an operative mortality of 10% and 7%, respectively. In the subgroup of 26 patients with a CSEF < 45%, the operative mortality was 12%. In the surgical survivors as a whole the LVEDP decreased from 17 ± 8 to 14 ± 5 mm Hg ( p < 0.005) and the overall EF increased from 28 ± 9% to 39 ± 10% ( p < 0.001) while the normal CI did not change. Linear regression analysis revealed that patients with the highest preoperative LVEDPs and the lowest overall EFs were most likely to have improvement in these parameters postoperatively. Patients with a preoperative CSEF < 45% had similar postoperative changes in their LVEDP (17 ± 6 to 15 ± 4 mm Hg) and overall EF (24 ± 7% to 38 ± 11%). In addition, the incidence of inducible VT postoperatively was similar in patients with a preoperative CSEF < 45% (4 of 23) and in the rest of the group (8 of 34, p = NS). We conclude that: (1) patients with ventricular aneurysms and medically refractory VT often have marked dysfunction of the residual contracting LV section; (2) aneurysmectomy and endocardial resection is an effective mode of therapy for VT and can be performed with a low operative mortality in this patient population; and (3) postoperatively the angiographic EF usually increases and the LVEDP often decreases, especially in patients with the most marked preoperative LV dysfunction.

Experience with Left Ventricular Apicoaortic Conduits for Complicated Left Ventricular Outflow Obstruction in Children and Young Adults

Six patients, ranging in age from 8 to 20 years, underwent left ventricular apicoaortic conduit construction for treatment of complicated left ventricular outflow tract obstruction. All patients had severe left ventricular hypertrophy as determined by echocardiography and electrocardiography. The preoperative gradient across the left ventricular outflow tract was 84 ± 17 mm Hg (mean ± standard deviation) (range, 65 to 110 mm Hg), and the preoperative left ventricular end-diastolic pressure was 20 ± 7 mm Hg (range, 12 to 28 mm Hg). Conduits were placed retroperitoneally with the distal anastomosis to the infrarenal aorta; the porcine valve was positioned in the left upper quadrant. Relief of left ventricular hypertension was complete; the minimal gradient measured intraoperatively was 13 ± 8 mm Hg (range, 0 to 20 mm Hg). With an average follow-up of 18 months (range, 6 to 24 months), all patients have improved and are in Functional Class I. Four patients were catheterized 12 months postoperatively. They all showed excellent relief of left ventricular hypertension; the conduit was effectively decompressing the left ventricle. This experience suggests that this approach is effective in relieving complex left ventricular outflow tract obstruction with good early results, and that it deserves more frequent application in children.