Severe Left Ventricular Failure Research Articles

Portal vein pulsatility ratio and heart failure.

Heart diseases can alter liver volume, morphology, and circulation. The Doppler pulsatility of the portal vein and its pulsatility ratio (PR) have been reported as being closely associated with the right atrial pressure and with the New York Heart Association (NYHA) class. We examined the relationships between measurements of liver and spleen dimensions and blood flow in portal and hepatic veins, assessed noninvasively by Doppler sonography, and compared them with echocardiographic data. The study group comprised 87 inpatients with heart failure. The mean age was 64+/-12 years. Patients underwent duplex Doppler sonography of the heart and portal and hepatic veins. Patients with more severe left ventricular failure (NYHA class III-IV) showed more dilatation of the left ventricle and atrium, reduced systolic function, and reduced portal vein mean velocity compared with patients with milder heart failure (NYHA class I-II); in addition, the hepatic vein diameter was increased and portal vein PR was reduced. Considering all patients, significant positive correlations were found between portal vein PR and left ventricular shortening fraction (r= 0.34, p < 0.01) and ejection fraction (r= 0.38, p < 0.001). Significant negative correlations were found between PR and hepatic vein diameter (r= -0.44, p < 0.001), right ventricle diameter (r = -0.38, p < 0.001), left ventricular end-diastolic volume (r = -0.31, p < 0.01), and left atrium diameter (r = -0.33, p < 0.01). Patients with hepatic vein dilatation had increased left ventricular volumes, reduced systolic function indices, and portal vein alterations (increased diameter, reduced mean velocity, and reduced PR). In patients with an ejection fraction of no more than 50%, only PR was significantly reduced, while other sonographic liver measurements were not significantly different. The effects of cardiac failure on portal blood flow, which declines progressively with worsening cardiac function, is shown better by the pulsatility pattern of the portal vein than by morphologic caval and hepatic vein measurements. PR can be used as a reliable adjunctive sign of heart failure.

Successful Bridge to Heart Transplantation in a Patient with Ebstein's Anomaly

A 52-year-old female was diagnosed with Ebstein's anomaly and an associated atrial septal defect. She underwent closure of the atrial septal defect and tricuspid valve replacement. Severe left ventricular failure was found after discontinuation of cardiopulmonary bypass, thus biventricular mechanical support was established. Four days later the patient underwent successful heart transplantation and was discharged without any complications.

Development of a direct mechanical left ventricular assist device for left ventricular failure.

We have developed a direct mechanical left ventricular assist device (DMLVAD) for severe left ventricular failure. The DMLVAD was attached to the left ventricle and compressed the heart by a pneumatic driving unit. In a mock circulation model with an extracted nonbeating heart, a cardiac output (CO) of 1.93 L/min was obtained at a driving pressure of 200 mm Hg. In a canine left ventricular failure model induced by injection of sodium hydroxide into the myocardium, the systolic arterial pressure, systolic left ventricular pressure, maximum LV dP/dt, peak flow, and CO increased by 21, 24, 58, 144, and 37%, respectively. The mean left atrial pressure also decreased by 15% when the DMLVAD was driven. These effects were most prominent when the mean left atrial pressure was over 15 mm Hg, and the driving pressure was over 100 mm Hg. Compression at late systole was more effective in obtaining greater CO. We suggest that the DMLVAD could be an optional circulatory assist device for patients with left ventricular failure awaiting heart transplantation.

A randomized controlled trial of epoprostenol therapy for severe congestive heart failure: The Flolan International Randomized Survival Trial (FIRST)

This trial evaluated the effects of epoprostenol on patients with severe left ventricular failure. Patients with class IIIB/IV congestive heart failure and decreased left ventricular ejection fraction were eligible for enrollment if angiography documented severely compromised hemodynamics while the patient was receiving a regimen of digoxin, diuretics, and an angiotensin-converting enzyme inhibitor. We randomly assigned 471 patients to epoprostenol infusion or standard care. The primary end point was survival; secondary end points were clinical events, congestive heart failure symptoms, distance walked in 6 minutes, and quality-of-life measures. The median dose of epoprostenol was 4.0 ng/kg/min, resulting in a significant increase in cardiac index (1.81 to 2.61 L/min/m 2 ), a decrease in pulmonary capillary wedge pressure (24.5 to 20.0 mm Hg), and a decrease in systemic vascular resistance (20.76 to 12.33 units). The trial was terminated early because of a strong trend toward decreased survival in the patients treated with epoprostenol. Chronic intravenous epoprostenol therapy is not associated with improvement in distance walked, quality of life, or morbid events and is associated with an increased risk of death. (Am Heart J 1997;134:44-54)

Calcified Sinus of Valsalva Aneurysm Eroding into the Interventricular Septum

A 12-year-old male patient with complete heart block was diagnosed by cardiac catheterization to have an unruptured aneurysm of the sinus of Valsalva eroding into the interventricular septum. Aortic regurgitation was absent and he underwent permanent pacemaker implantation. Three years later, he was readmitted with severe aortic regurgitation and left ventricular failure. The pacemaker was replaced and the patient underwent successful patch closure of the aneurysm and aortic valve replacement. The mode of presentation, noninvasive methods of evaluation, and surgical management of this rare cardiac pathology are discussed.

An adjustable, percutaneously placed helical coil: Control of left ventricular filling pressure during cardiopulmonary bypass in severe left ventricular failure

since 1969, when Dot ter ~ initially inserted stainless steel coils as a vascular stent in canine popli teal arteries. Clinical endovascular placement of straight stent grafts for the t reatment of aortic dissection has already been reported, 4 but placement of these stent grafts was limited to sites that did not include the origin of the major aortic arterial branches. With the branched graft, we succeeded in endovascular repair of type B dissection with intimal tear just beyond the left subclavian artery. If long-term results are favorable, endovascular repair of larger dissections in patients with type B dissection would be possible. Careful long-term evaluation and further improvement in devices and techniques will, however, be necessary for extensive clinical use. R E F E R E N C E S 1. Inoue K, Htay T, Kida M, Fujiwara H. Percutaneous implantation of aortic endovascular graft for created aneurysm: animal experiment [abstract]. Circulation 1991;84(Suppl):II421. 2. Inoue K, Htay T. Long-term follow-up of percutaneously placed aortic endovascular graft: animal experiment [abstract]. Circulation 1992;86(Suppl 1):I636. 3. Dotter CT. Transluminally-placed coilspring endoarterial tube grafts: long-term patency in canine popliteal artery. Invest Radiol 1969;4:329-32. 4. Dake MD, Miller DC, Semba CP, Mitchell RS, Walker PJ, Liddell RP. Transluminal placement of endovascular stentgrafts for the treatment of descending thoracic aortic aneurysms. N Engl J Med 1994;331:1729-34.

Is a bioprosthesis preferable in tricuspid valve replacement?

We reviewed clinical data on 29 patients (17 acquired disease and 12 congenital disease) who underwent tricuspid valve replacement using a Carpentier-Edwards porcine valve or a St. Jude Medical valve at Niigata University Hospital between January 1978 and October 1995, and analyzed risks related to the outcome. Age ranged from 8 to 62 years, and 17 females were included. New York Heart Association functional class was IV in 9 patients (31%). Previous valve surgery had been performed in 10 patients (34%). An urgent surgery was required in 4 patients and simultaneous mitral (with aortic) valve replacement in 13 (45%). Mean follow-up period was 6.7 years. Hospital mortality occurred in 5 patients (17.2%) and all of them had acquired valvular diseases with functional class IV. There were 6 late deaths and none of them related to the tricuspid prosthesis. Nonfatal morbidity occurred in 2 patients (a thrombosed valve and a chronic hemolytic anemia) with a St. Jude valve. Late functional class was I or II in all patients except 3 with severe left-ventricular dysfunction or bioprosthetic failure. Late postoperative echocardiographic examination showed moderate tricuspid stenosis or regurgitation in 3 patients with a Carpentier-Edwards valve. By the Kaplan-Meier method, functional class (P < 0.01) and baseline diseases (p < 0.05) were found to affect probability of freedom from cardiac- and/or valve-related mortality including hospital death. In conclusion, the present study indicates that similarly good outcome would be expected whether using a St. Jude Medical valve or a Carpentier-Edwards porcine valve, and that both functional class IV and combined acquired valvular disease are risk factors for mortality after tricuspid valve replacement. Patient-specific selection of the prosthesis would be preferable in tricuspid valve replacement.

Editorial on “coronary artery bypass grafting in patients with an ejection fraction of twenty percent or less”

Editorial on “coronary artery bypass grafting in patients with an ejection fraction of twenty percent or less”

Surgical treatment of ischaemic valve disease

Mitral valve regurgitation secondary to ischaemic heart disease carries a significant mortality even after open-heart surgery. In this study, 21 patients with mitral regurgitation associated with ischaemic heart disease were evaluated with respect to valvular pathology. Pathological examination of the mitral valve revealed chorda elongation or rupture in seven patients (group 1), papillary muscle dysfunction in 10 (group 2), and papillary muscle rupture in four (group 3). Significant preoperative characteristics in each group were subacute haemodynamic deterioration in group 1, chronic severe left ventricular failure in group 2, and a high incidence of acute renal failure associated with haemodynamic shock in group 3. Mitral valve plasty was performed in six patients and mitral valve replacement, using the St Jude Medical valve, in 15. Fourteen patients underwent mitral valve surgery combined with coronary artery bypass grafting. Mitral plasty was applied to the patients with low left ventricular function with mean(s.d.) fraction shortening of 19.2(6.2)% compared with 30.2(8.4)% in patients with mitral valve replacement. There were no operative deaths. Of four late deaths, two in group 1 resulted from infection and myocardial infarction, respectively, and one in group 2 resulted from arrhythmia. One patient in group 3 died from renal failure. It is suggested that incorporation of these therapeutic concepts may lead to satisfactory results in the surgical treatment of ischaemic mitral regurgitation.

Spontaneous Incessant AV Reentrant Tachycardia Related to Left Bundle Branch Block and Concealed Left‐Sided Accessory AV Pathway

Three patients in whom permanent AV reentrant tachycardia became the clinical manifestation of Wolff-Parkinson-White syndrome are described. The substrate for the arrhythmia was created by coexistence of a concealed left-sided accessory pathway and an ipsilateral bundle branch block. Pharmacologic therapy in all three patients failed to control the tachycardia, which in two cases led to severe left ventricular failure. After successful radiofrequency ablation of the accessory pathway (in two) or AV junction (in one), left ventricular function gradually returned to normal.

Optimal management of older patients with atrial fibrillation.

Long term oral warfarin should be administered to elderly patients with atrial fibrillation who are at high risk for developing thromboembolic stroke and who have no contraindications to anticoagulant therapy. Oral aspirin (acetylsalicylic acid) 325mg daily may be given to elderly patients with chronic atrial fibrillation who have contraindications to anticoagulant therapy or who are not at high risk for developing thromboembolic stroke. Management of atrial fibrillation includes treatment of the underlying disease and precipitating factors. If patients have paroxysmal atrial fibrillation with a very rapid ventricular rate associated with hypotension, severe left ventricular failure or chest pain due to myocardial ischaemia, immediate direct-current cardioversion should be performed. Intravenous verapamil, diltiazem or a beta-blocker should be used for immediate slowing of a very rapid ventricular rate associated with atrial fibrillation. If a rapid ventricular rate associated with atrial fibrillation persists at rest or during exercise despite digoxin, then oral verapamil, diltiazem or a beta-blocker should be added. Low dosages of oral amiodarone (200 to 400 mg/day) may be used in selected patients with symptomatic life-threatening atrial fibrillation refractory to other therapy. No medication which depresses atrioventricular conduction should be given to patients with atrial fibrillation and a slow ventricular rate. Cardioversion should not be performed in asymptomatic elderly patients with chronic atrial fibrillation. This author would use a beta-blocker for control of ventricular arrhythmias and following conversion of atrial fibrillation to sinus rhythm. Should atrial fibrillation recur, beta-blockers have the additional advantage of slowing the ventricular rate.

Perioperative left ventricular failure: the rationale for use of vasoactive drugs

Patients with pre-existing left ventricular failure undergoing surgery and those who develop left ventricular failure subsequent to anaesthesia and surgery are at risk of perioperative cardiac death and, consequently, represent a challenging task to all involved in their perioperative care. Perioperative left ventricular failure encompasses a broad spectrum of abnormalities in left ventricular function, ranging from asymptomatic dysfunction, through cardiogenic pulmonary oedema and low cardiac output syndrome, to cardiogenic shock. The prevention and treatment of perioperative left ventricular failure requires a proper understanding of the regulation of cardiac output and venous return and of the complex interplay of the determinants of left ventricular function. The haemodynamic management must be based on close monitoring of both left ventricular function and global and regional haemodynamic performance. The existing data are then used to assess the actual structural and functional abnormalities of the cardiovascular system, to choose appropriate therapy and to evaluate its efficacy continuously. The understanding and application of the pathophysiological concepts such as systolic and diastolic left ventricular failure, afterload mismatch, left ventricular remodelling and stunning can be helpful for evaluation of the failing left ventricle. The treatment of perioperative left ventricular failure is primarily based on optimizing oxygenation of the arterial blood, heart rate, effective blood volume and left ventricular preload. This goal can be usually achieved by means of supplementary oxygen, positive airway pressure breathing or ventilation, analgesia and sedation, pacing or electroconversion of tachyarrhymias, and the use of diuretics and vasodilators. The next step is the enhancement of myocardial contractility with positive inotropic agents and restoration of an adequate arterial pressure. Because in severe perioperative left ventricular failure the efficacy of pharmacological interventions can reach their limits, the addition of mechanical circulatory support must be considered whenever indicated.

Diuretics in postinfarction heart failure

Severe left ventricular failure, as evidenced by radiographic pulmonary edema or raised left ventricular filling pressure, accompanying acute myocardial infarction, carries a high mortality risk. In this situation, the intravenous loop-diuretic furosemide induces a rapid reduction in the raised left ventricular filling pressure due to an immediate and substantial increase in systemic venous compliance accompanied by increasing diuresis. This diuretic-induced venodilatation is probably due to the release of prostaglandins. The transient systemic arterial constriction and small increase in systemic blood pressure that follows intravenous furosemide probably results from the release of renin and subsequent activation of angiotensin. These diuretic induced hemodynamic changes are accompanied by restoration of the vasodilator reflex, which enables the heart to accommodate an acute volume load. Orally administered loop diuretics achieve slower, but similar, directional hemodynamic changes. There is no information on hemodynamic or neuroendocrine dose-response effects of loop diuretics, and there is no information pertaining to the use of other diuretic groups in this situation. The hemodynamic changes induced by furosemide summate with the changes induced by other anti-heart-failure drugs. In this subset of patients with acute myocardial infarction and severe heart failure, the influence of the diuretics on morbidity incidence and mortality risk remains to be measured.

Severe ischemic left ventricular failure: Coronary operation or heart transplantation?

Severe left ventricular failure in ischemic heart disease may contraindicate conservative surgical procedures. To redefine therapeutic indications, the clinical and angiographic data of 143 patients (137 men and 6 women) with ischemic heart disease and a left ventricular ejection fraction less than 0.30 who were seen by us between June 1985 and December 1990 were retrospectively analyzed. Patients were divided into three groups according to therapy: medical only, 72 (group 1); myocardial revascularization, 20 (group 2); and heart transplantation, 51 (group 3). Clinical status was poorer in group 3, with congestive heart failure as predominant symptom; angina was more frequent in group 2. No difference was noted in hemodynamic variables. Four early deaths (20.0%) occurred in group 2 and 7 (13.7%) in group 3. Follow-up ranged from 1 to 64 months (mean, 22 ± 19 months), with an actuarial survival of 28% ± 9%, 80% ± 8% and 82% ± 5% at 5 years in groups 1, 2, and 3, respectively. Even though postoperative New York Heart Association class was better in group 3 (1.0 versus 2.3 in group 2; p < 0.01), the difference in survival was not significant. Although in patients with ischemic heart disease and low left ventricular ejection fraction heart transplantation offers the best clinical results, considering the donor shortage, we conclude that myocardial revascularization may still be performed with good midterm results.

Experimental evaluation of the hemodynamic efficiency of dynamic cardiomyoplasty in the surgical treatment of severe left ventricular failure

Experimental evaluation of the hemodynamic efficiency of dynamic cardiomyoplasty in the surgical treatment of severe left ventricular failure

INITIAL CLINICAL EXPERIENCE WITH THE HAEMOPUMP LEFT VENTRICULAR ASSIST DEVICE

The Haemopump is an intra-arterial, axial flow, temporary left ventricular assist device. The intra-cardiac pump assembly is connected by a flexible drive shaft to a high speed motor and a drive console. The pump is placed in the left ventricle via the femoral artery, iliac artery or abdominal aorta. Blood is withdrawn from the left ventricle and pumped in a continuous, non-pulsatile fashion into the descending thoracic aorta. We report the use of the Haemopump to provide circulatory assistance in 2 patients with severe graft dysfunction following cardiac transplantation. Both patients were successfully weaned from the Haemopump after 6 and 3 days of support. The first patient subsequently died of overwhelming fungal sepsis and the other remains well 3 months after transplantation with normal left ventricular function. The Haemopump is an effective temporary cardiac assist device for application in severe left ventricular failure.

Resolution of lactic acidosis after sedation of a patient with acute myocardial infarction and left ventricular failure

The hemodynamic and metabolic effects of sedation in patients with acute myocardial infarction complicated by severe left ventricular failure have not been well studied. We report a patient with this diagnosis, in whom sedation resulted in resolution of lactic acidosis

Steroid responsive cardiomyopathy

Heart disease responsive to steroids is well described in many disorders, including sarcoidosis, systemic lupus erythematosus, polyarteritis nodosa, myocarditis and Churg-Strauss syndrome. The underlying disorder is oftern obvious and the response is usually slow. We describe a woman who had severe left ventricular failure, cardiac dilatation and pericardial effusion which were rapidly rectified by steroid therapy. Steroid withdrawal led to recurrence of signs, which were reversed by recommencing steroids. The aetiology was not determined.

Hemodynamics During PEEP Ventilation in Patients with Severe Left Ventricular Failure Studied by Transesophageal Echocardiography

The effects of mechanical ventilation with PEEP were investigated in five patients with normal cardiopulmonary function (group A) and in 11 patients with severe left ventricular failure (group B). Cross-sectional area of the right and left atrium (RA/LA), left ventricle (LV), and right ventricle (RV) was determined at EDA/ESA using transesophageal echocardiography. Hemodynamic parameters and transesophageal pressure were measured simultaneously at PEEP levels 0, 4, 8, 12, and 16 cm H2O. End-diastolic area of the right atrium decreased significantly in both groups. The RA pressure increased, while transmural pressure remained unaltered. The CI decreased in both groups. The decrease in cardiac output by PEEP ventilation was related to the decrease in RV filling volume by external compression. In patients with congestive heart failure, PEEP ventilation with 8 to 10 cm H2O did not worsen LV function.

急性左心不全に対する新しいdouble lumen catheterを用いた積極的左心補助循環法の効果に対する研究

急性左心不全に対する新しいdouble lumen catheterを用いた積極的左心補助循環法の効果に対する研究