Severe CHF Research Articles

Placebo-controlled study of oral enoximone in congestive heart failure with initial and final intravenous hemodynamic evaluation

Seventeen patients with stable congestive heart failure (class II and III New York Heart Association) received intravenous and oral enoximone in a 2-part study. Hemodynamic data were first obtained after intravenous administration of 0.75 mg/kg of enoximone; data were again obtained after 12 weeks of therapy with either oral enoximone (150 mg 3 times daily) or placebo. The efficacy and safety of oral enoximone were also studied in a 12-week, doubleblind randomized format. In the intravenous study, enoximone was delivered over 5 minutes and hemodynamic data were measured for up to 12 hours after. Cardiac index increased 2.76 ± 0.63 to 3.42 ± 0.72 liters/min/m 2), pulmonary wedge pressure decreased (19.5 ± 8.8 to 14.6 ± 8.0 mm Hg) as did mean arterial blood pressure (101 ± 14.8 to 85 ± 13.7 mm Hg) and systemic vascular resistance (1,880 ± 573 to 1,254 ± 383 dynes s cm −5). Heart rate increased slightly (82 ± 17 to 86 ± 14 beats/min). All these changes were maximal 1 to 2 hours after infusion and lasted 8 hours at least. Patients were then randomized double-blind to oral treatment. Baseline values showed that the 7 patients who received placebo had more severe CHF. Therefore, comparison might be biased. Patient overall assessment showed a continuous benefit in both groups. Ejection fraction improved from 30.1 ± 6.8% to 33.9 ± 9.9% in the enoximone group while it remained unchanged with placebo (23.4 ± 6.5% to 23.4 ± 1.5%). Mean exercise time (cycloergometer) increased with enoximone (9.0 ± 3.3 to 10.6 ± 3.7 minutes, p < 0.05) and did not change with placebo (7.1 ± 3.2 to 7.1 ± 4.0 minutes). Minimal side effects were reported. Two patients withdrew from the study, 1 in each group because of increased reversible liver function test values. One patient in the placebo group died. No changes in the electrocardiogram, no aggravation of existing arrhythmias and no appearance of new arrhythmias occurred either during intravenous or oral treatment (initial and final 24-hour Holter recordings). At the end of the 12-week oral treatment patients again received 0.75 mg intravenous enoximone and hemodynamic data were measured. In the patients who were taking oral placebo, compared with the initial intravenous evaluation, the same changes occurred. Patients taking enoximone had a further increase in cardiac index (3.52 ± 0.63 to 4.04 ± 0.83) and decrease in pulmonary capillary wedge pressure (13.3 ± 4.6 to 10.0 ± 2.1 mm Hg), similar changes in mean arterial blood pressure and systemic vascular resistance and a smaller increase in heart rate. Intravenous enoximone produced significant long lasting hemodynamic improvement, which could be reproduced after long-term oral treatment suggesting the absence of tachyphylaxis. Oral 12-week treatment consistently increased exercise time with minor side effects and no arrhythmogenic action.

CI 930: produces positive inotropic and haemodynamic effects in this small study of patients with severe CHF

CI 930: produces positive inotropic and haemodynamic effects in this small study of patients with severe CHF

Haemodynamic and ECG Effects of Milrinone in Severe CHF

Haemodynamic and ECG Effects of Milrinone in Severe CHF

Enoximone: compares favourably with dobutamine in patients with severe CHF

Enoximone: compares favourably with dobutamine in patients with severe CHF

Captopril Appears Superior to Prazosin in Severe CHF

Captopril Appears Superior to Prazosin in Severe CHF

Oral Ibopamine Unsuccessful in Severe Refractory CHF

Oral Ibopamine Unsuccessful in Severe Refractory CHF

Effects of enalapril on different aspects of the clinical state in congestive heart failure.

In patients with moderate to severe CHF, enalapril improves symptoms and is well tolerated. It increases functional capacity in the form of exercise time and reduces the left ventricular dimensions. Enalapril also has favourable effects on electrolytes and, although it increases renal blood flow, it reduces the glomerular filtration rate.

S-V-4 IABP補助83例の臨床的検討

S-V-4 IABP補助83例の臨床的検討

Milrinone: a positive inotrope and vasodilator in patients with severe CHF

Milrinone: a positive inotrope and vasodilator in patients with severe CHF

Haemodynamic Responses to Nifedipine and Nitroprusside in Severe CHF

Haemodynamic Responses to Nifedipine and Nitroprusside in Severe CHF

THE HEMODYNAMIC EFFECTS OF BUCINDOLOL IN CHILDREN WITH CONGESTIVE HEART FAILURE (CHF)

The investigational drug Bucindolol has intrinsic sympathomimetic activity and direct vasodilating actions in animal models and adult humans with CHF and/or hypertension. Five children (2 1/2 - 21 mos; 4.0 - 10.4 kg) with ventricular septal defect or endocardial cushion defect and CHF had baseline pulmonary to systemic flow ratios (Qp/Qs) ≥ 3.0 at cardiac catheterization. After informed consent, each received a .05mg/kg, 5 min. infusion of Bucindolol. Hemodynamic measurements showed significant increases in pulmonary resistance/ systemic resistance (Rp/Rs), and Rp (Wood units); significant decreases, in indexed pulmonary flow (Qp), left to right shunt (L→R), and (Qp/Qs) in 100% of the children; but no significant change in pulmonary mean pressure (PA), aortic mean pressure (AO), Qs, Rs or indices of ventricular function. CHF improved transiently in all children and most dramatically in the ones with more severe CHF. The pre and post drug means (X̄) and mean % changes (% Δ) from pre drug values were:We conclude that Bucindolol is of potential value in managing CHF in infants with congenital heart lesions having high pulmonary flow.

Left ventricular outflow obstruction caused by a Starr-Edwards mitral prosthesis

ranged from 400,000 to 800,000/mm3. The final hospital admission at age 22 years was necessitated by severe CHF and ischemia of the distal left fourth finger. Cardiac output and blood pressure diminished progressively and the patient died 10.5 months after the acute MI. At necropsy (Medical College of Ohio #A-82-2), the heart weighed 450 g. The apical half of the anterior LV free wall was replaced by dense scar at and adjacent to the LV aneurysectomy incision (Fig. I). The posterior LV wall was also scarred. The LV apex contained mural thrombus adherent to underlying endocardial fibrous tissue. Fresh and organized mural thrombus also covered the LV outflow tract (Fig. 2). The R and LAD were totally occluded proximally; the length of the LAD occlusion was approximately 2 cm and that of the R 4 cm. The other portions of the LAD and R and the entire left circumflex artery were normal. Branches of the major epicardial coronary contained discrete focal severe narrowings with normal intervening areas. Histologic examination of the narrowed coronary arterial segments showed fibrocellular intimal profileration without foam cells, cholesterol clefts, pultaceous debris or calcific deposits (Fig. 3). In some segments, the lumen contained several small channels, and a platelet-fibrin thrombus was present in the LAD (Fig. 3). The intima of the narrowed coronary arteries was similar histologically to the thickened fibrous tissue on the LV mural endocardium (Fig. 4). Histologic examination of LV myocardium disclosed necrosis adjacent to the healed MI and multiple small intramural coronary vessels with plateletfibrin thromboemboli (Fig. 4). Both the spleen and lung contained discrete infarcts. The aorta was free of atherosclerotic plaques. The bone marrow, specifically the megakaryocytes, was normals The kidneys contained focal hyaline sclerosis of glomerular capillary tufts consistent with organized microthrombi, but no other abnormalities to explain the hematuria and proteinuria throughout childhood. (Sections of kidney were examined by John M. Kissane, MD, a recognized renal expert, who agreed with our renal diagnosis.)

Aortic thrombosis presenting as congestive heart failure: An umbilical artery catheter complication

UMBILICAL ARTERY CATHETERIZATION is used in the management of critically ill newborn infants requiring frequent measurement of blood gases and arterial pressure. However, complications of the procedure occur frequently.' 10 We report two infants who developed congestive heart failure after UAC removal, resulting from completely occlusive aortic thrombi. CASE REPORTS Patient 1 was the 4,300 gm female product of a postterm gestation, and had had perinatal asphyxia, hypoglycemia, hypocalcemia, and apnea. UAC was maintained for monitoring and for fluid and blood administration ~br five days. Ten hours after catheter removal, tachypnea, tachycardia, oliguria, and absence of palpable femoral pulses were noted. The chest radiograph showed cardiomegaly. The patient was treated with digoxin and furosemide, and transferred to this hospital. She was in moderately severe CHF and was taken to emergency cardiac catheterization. No intrinsic cardiac structural defects were found. Pressures in the ventricles were equal (105/30 mm Hg) and diminished pressure (74/70 mm Hg) was noted in the abdominal aorta. Angiocardiography revealed poor biventricular contractility, moderate tricuspid and mitral insufficiency, and a completely occlusive aortic thrombus at the level of the celiac axis. A catheter embolectomy was unsuccessfully attempted via a right femoral arteriotomy. The patient remained anuric and became progressively acidotic. Abdominal ultrasound demonstrated an aortic intraluminal echo, compatible with thrombus (Fig. 1). A transabdominal distal aortic arteriotomy was performed and a wellformed thrombus was removed. Embolectomies of the thoracic

180 HYPERTROPHIC OBSTRUCTIVE CARDIOMYOPATHY (HOCM) IN NEW- BORN AND EARLY INFANCY PERIOD

Clinical course and diagnostic studies in 6 infants under 8 weeks with HOCM are presented. One presented with severe CHF, one with severe arrhythmias; both died. In 4, findings were subtle; VSD-like murmurs, mild tachypnea and cardiomegaly. ECGs showed a superior axis in 5 and WPW in 1. Initial M-mode echos were inconclusive. Sector Scans done on 3 were diagnostic in 1, but became more specific at a later age. Cardiac catheterization (CC) was performed at age 1-49 (mean 18) days. Initial resting LV-AO gradient was 50±11 (n=5). Three showed the Brockenbrough response and in 2 no adequate post ectopic beat was recorded. Angiography showed severe septal hypertrophy, hypercontractility, distortion of LV cavity and compression of RV. In 4, the mitral valve (MV) was visualized and showed SAM. In 1 an additional fixed subaortic obstruction was suspected. A second CC in the survivors 18±4.25 mos. later showed a larger gradient, 80±8.17 in 3, and an unchanged gradient in 1. Followup period was 9-54 (mean 23) mos. and all survivors are well on beta blockers. Diagnosis was confirmed at autopsy in 2 and surgery in 1. Conclusion: 1) Prognosis was not related to pressure gradients. 2) Those presented with severe symptoms died. 3) Since physical findings, ECGs and echos in this age are atypical, a high index of suspicion and possibly CC is needed for accurate assessment.

175 EFFECT OF AMRINONE ON CARDIAC FUNCTION IN CHILDREN WITH SEVERE CONGESTIVE HEART FAILURE (CHF)

Amrinone (A), a newly synthesized bipyridine derivative, has been shown to exert a positive ionotropic action when administered to adults with severe CHF. There are no published data regarding its affect on children.Two children, 12 years old, fulfilled rigid criteria for inclusion in A protocol: failure to respond to conventional therapy, cardiac index (CI)<2.2 L/Min/M2, and left ventricular filling pressure (PCW)>18 mHg. A was given by IV bolus 1 mg/kg and a sustaining infusion of 10 μg/kg/min, followed by oral administration of 50 and 75 mg TID respectively. Non-invasive and Swan-Ganz monitoring were utilized to establish efficacy of the drug. Maximum benefit was as follows:Both children had sustained improvement of cardiac function, though the first died of cardiomyopathy 4 days after A was begun. The second patient continues to show symptomatic and objective improvement with mild thrombocytopenia as the only adverse reaction. Limited experience with this new ionotropic agent in children with intractible CHF is encouraging.

Hydralazine in chronic CHF.

In summary, there investigations indicate that oral hydralazine produces beneficial hemodynamic effects in patients with chronic CHF. These favorable hemodynamic response are observed in the presence or absence of mechanical defects, such as mitral or aortic regurgitation. The predominant hemodynamic effects of hydralazine are substantial increase in CO and SV with decreased systemic vascular resistance. These investigations further suggest that hydralazine therapy not only improves resting cardiac performance, but also cardiac performance during exercise. There is also evidence that improved cardiac performance is sustained at least in some patients during maintenance hydralazine therapy. The impact of hydralazine therapy on the long term prognosis of patients with refractory CHF, however, remains unknown. Nevertheless, the preliminary retrospective studies suggest that in certain subsets of patients with severe chronic CHF, such therapy may provide a better prognosis compared to that expected with conventional therapy.

Infective Endocarditis Caused by Slow-Growing, Fastidious, Gram-Negative Bacteria

In a review of endocarditis caused by fastidious, slow-growing gram-negative rods, similarities in the spectrum of disease overshadow differences among cases grouped by specific organisms. Cardiobacterium hominis, Actinobacillus actinomycetemcomitans and Haemophilus species usually seed previously damaged cardiac valves presumably during bacteremia from an upper respiratory site. The clinical presentation resembles that of Streptococcus viridans endocarditis and is usually subacute or chronic. Despite bacteriologic cure, severe CHF and/or systemic embolization frequently develops during or following the course of antibiotics, resulting in significant morbidity and a high mortality rate. This report of nine cases diagnosed at five hospitals in a 7-year period suggests that endocarditis due to these organisms is more common than previously appreciated and frequently goes unrecognized. This is probably due to a lack of attention to the requirements for culture of this group of bacteria with propensity for granular growth in broth. We have proposed specific cultural techniques appropriate to the search for these organisms in patients with apparent culture-negative endocarditis.