摘要:

AbstractBackground: To determine the influence of left ventricular function on the long‐term survival of patients with coronary artery disease and lethal ventricular arrhythmias, who undergo concomitant coronary artery bypass grafting (CABG) and implantable cardiovertor defibrillator (ICD) implantation, we studied survival in 54 consecutive patients who underwent CABG and ICD implantation.Methods: Group I consisted of 35 patients with left ventricular ejection fraction (LVEF) ± 35% (mean 25.3 ± 5.6) and Group II consisted of 19 patients with LVEF>35% (mean 47.5 ± 6.6). The two groups were similar with regards to age, gender, clinical presentation, induced arrhythmias, and the number of grafts placed at the time of surgery. Results: Two in‐hospital deaths (3.7%) occurred, both in Group I. During follow‐up (42.5 ± 21.8 months), there were 10 deaths in Group I (1 noncardiac, 1 sudden, and 8 heart failure), and 1 death in Group II (heart failure) (p<0.04).Conclusions: Concomitant CABG and ICD implantation can be performed with an acceptable in‐hospital mortality, even in patients with poor left ventricular function. Although freedom from sudden cardiac death remains excellent, overall long‐term survival is limited by refractory heart failure, especially in those patients with left ventricular dysfunction at the ti

ISSN:0886-0440    

DOI:10.1111/j.1540-8191.1996.tb00034.x

出版商:Blackwell Publishing Ltd    

年代:1996

数据来源: WILEY

摘要:

AbstractBackground: Between 1989 and 1992 100 consecutive patients aged 80 or older underwent isolated coronary artery bypass grafting (CABG) in our institution. Eighty‐six percent had angina grade III or IV symptoms.Methods: Emergency surgery was required in 31, urgent surgery in 30, and elective surgery in 39 patients. The average left ventricular ejection fractions (LVEF) in these groups were 36%, 43%, and 45% respectively. The operative mortality was 8% for these octogenarians compared to 2% in the younger cohort (p = 0.002). It was zero in elective cases and 13% (8/61) in urgent and emergency cases. It was increased by preoperative admission to coronary care unit (CCU) (p = 0.02), urgency of operation (p = 0.02), the use of intra‐aortic balloon pump (IABP) (p = 0.0002), preoperative renal dysfunction (p<0.03), and ± 3 grafts (p<0.04). The late mortality was increased by LVEF ± 20% (p = 0.03) and operation from CCU (p<0.05). On multivariate stepwise logistic regression analysis, the use of IABP (p<0.0003) and preoperative renal dysfunction (p<0.02) were independent predictors of operative mortality. LVEF ± 20% was the only independent predictor (p<0.02) of late mortality.Results: Actuarial survival was noted to be 87%, 80%, 77%, and 73%, respectively, at 1, 2, 3, and 4 years, with two cardiac‐related late deaths. Long‐term follow‐up revealed that 97% of patients had no or minimal anginal symptoms.Conclusions: Due to increasing use of nonsurgical options, the profile of elderly referred for CABG currently involves gravely ill patients with comorbidities. CABG under elective conditions, before deterioration of left ventricular function, can achieve normal life expectancy and good symptomatic relief in o

ISSN:0886-0440    

DOI:10.1111/j.1540-8191.1996.tb00035.x

出版商:Blackwell Publishing Ltd    

年代:1996

数据来源: WILEY

摘要:

AbstractBackground: Between January 1985 and June 1995, more than 1800 consecutive patients underwent implantation of a new permanent cardiac pacemaker at our institution. Thirty‐six patients (0.02%) had 45 reinterventions for infected pacemaker systems. Methods: In group A, 24 of 27 patients received simultaneous implantation of a new pacemaker. One had reimplantation of the same pacemaker in the same pocket, and two did not require reimplantation. The leads were retained in 19 (70%) of the patients. In group B, nine patients underwent cardiopulmonary bypass or “pursestring” surgery for removal of an infected pacemaker; a new epicardial pacemaker system was simultaneously implanted in seven patients. Results: Identification of an infectious agent failed in 17 patients (47%), and Staphylococci were found in 15 patients (42%). The time from pacemaker implantation to onset of infection ranged from 1 month to 11 years (mean 31 months; median 19 months) and the time from onset of infection to surgical treatment from 1 month to 7 years (mean 7 months; median 2 months). The mean follow‐up time is 74 months (range, 1 month to 10 years; median 5 years). There were 9 reoperations in 3 patients (16%) of group A for recurrent infection of their retained leads ultimately necessitating the use of open cardiac surgery. There was no early death; six patients died late due to unrelated causes. Conclusions: Complete removal of all pacemaker leads is recommended; open heart surgery with the use of cardiopulmonary bypass is indicated in selected cases and is effective a

ISSN:0886-0440    

DOI:10.1111/j.1540-8191.1996.tb00036.x

出版商:Blackwell Publishing Ltd    

年代:1996

数据来源: WILEY

摘要:

AbstractBackground: The aortic flap above the facing commissure after removal of the coronary button from the aortic sinus can be utilized for reconstruction in an arterial switch operation.Methods: The free flap was used to reconstruct the coronary artery in two cases, as a medially based trapdoor. A rotational flap was inserted into the cut‐open right pulmonary artery to augment the neopulmonary arterial anastomotic site in another case.Results: All patients are doing well at mid term follow‐up.Conclusions: The indications of each method and reported tricks to avoid coronary artery kinking during an arterial switch operation are discus

ISSN:0886-0440    

DOI:10.1111/j.1540-8191.1996.tb00037.x

出版商:Blackwell Publishing Ltd    

年代:1996

数据来源: WILEY

ISSN:0886-0440    

DOI:10.1111/j.1540-8191.1996.tb00038.x

出版商:Blackwell Publishing Ltd    

年代:1996

数据来源: WILEY

摘要:

AbstractDynamic cardiomyoplasty is an operation that is undergoing worldwide clinical evaluation. It had been developed to utilize the patient's own skeletal muscle to assist the failing heart. Although the clinical and quality of life benefits of cardiomyoplasty have been reported in most patients, the results of quantitative hemodynamic analyses have been less consistent. This has prompted the reevaluation of the mechanisms of dynamic cardiomyoplasty other than simple cardiac compression by the wrapped muscle. There is good evidence to suggest that the following, either together or in part, comprise some of the mechanisms of dynamic cardiomyoplasty: (1) direct systolic assist; (2) myocardial (wall stress) sparing effect; (3) remodeling/girdling effect; and (4) angiogenesis. Current concepts and potential additional mechanisms are discussed and integrated, based on a review of the literature and our own recent studies.

ISSN:0886-0440    

DOI:10.1111/j.1540-8191.1996.tb00039.x

出版商:Blackwell Publishing Ltd    

年代:1996

数据来源: WILEY

摘要:

AbstractBackground: This paper unveils some of the clinical lessons we have learned from caring for cardiomyoplasty patients over the past 7 years. We examine both the clinical and scientific rationale for expanding the time frame of “procedural mortality” from 30 days to 90 days.Methods: Utilizing this definition of procedural mortality, preoperative patient variables were applied to postoperative patient outcomes in order to develop a risk sensitive method of patient selection. Preoperative atrial fibrillation, elevated pulmonary capillary wedge pressure, decreased peak oxygen consumption, and the requirement of intra‐aortic balloon pump at the time of cardiomyoplasty, were all found to be independent risk factors for early death following cardiomyoplasty.Results: This analysis, which has been previously published, is reviewed and enhanced with the mathematical equations for duplicating these relative risk calculations. The mathematical model presented herein allows a method of risk stratification, which obviates the need for randomized congestive heart failure controls in the future. In the absence of a statistically regulated control population, we also examine the 1‐year clinical outcomes of the nonrandomizd control group of patients, who were followed during the North American FDA Phase II Cardiomyoplasty Trial.Conclusions: This quality of life comparison with cardiomyoplasty patients at 1 year revealed a significant decrease in intensive care unit patient‐days, a significant increase in activity of daily living score, and a significant improvement in New York Heart Association functional class as compared t

ISSN:0886-0440    

DOI:10.1111/j.1540-8191.1996.tb00040.x

出版商:Blackwell Publishing Ltd    

年代:1996

数据来源: WILEY

摘要:

AbstractBackground: The purpose of this article is to provide an overview of the current indications, results, and perspectives of dynamic cardiomyoplasty in the treatment of patients with dilated cardiomyopathy. Particular emphasis is placed on the clinical experience with 36 patients operated at the São Paulo Heart Institute between 1988 and 1995.Methods: Based on several clinical reports, the mechanisms of action of dynamic cardiomyoplasty in these patients include the enhancement of left ventricular systolic function, by the direct action of synchronized skeletal muscle flap contraction and the reversion of chamber remodeling. Moreover, both mechanisms seem to be responsible for improved diastolic function properties and for the decrease of ventricular wall stress. Besides the acceptable hospital mortality observed for patients with dilated cardiomyopathy ranging from 0% to 8% with this surgical procedure, clinical improvement after dynamic cardiomyoplasty has been demonstrated as a prevailing and significant outcome.Results: Nevertheless, the 1‐year survival for these patients ranges from 82% to 86% and the 5‐year survival on the order of 41% to 49%. In addition, the analysis of factors influencing the outcome showed that cardiomyoplasty long‐term survival was significantly affected by the severity of preoperative clinical compromise and cardiac function impairment. On the other hand, patients with dilated cardiomyopathy who were operated in functional Class III or intermittent Class IV and with pulmonary vascular resistance below 4 Wood units, present survival rates on the order of 79% at 2 years and of 64% at 5 years of follow‐up, which are similar to those reported after cardiac transplantation.Conclusions: Furthermore, technological advances incorporated in the new cardiomyostimulators may ameliorate skeletal muscle flap performance at long term. Other developments are also discussed in th

ISSN:0886-0440    

DOI:10.1111/j.1540-8191.1996.tb00041.x

出版商:Blackwell Publishing Ltd    

年代:1996

数据来源: WILEY

摘要:

AbstractBackground: Correct timing of mechanical interaction between wrapped latissimus dorsi muscle (LDM) and the heart during cardiac systole has been poorly understood and remains a controversial issue. Therefore, left ventricular pressure‐volume relations were analyzed in acute cardiomyoplasty while changing the synchronization delays.Methods: Effects of different delays between the sensed cardiac R wave and wrapped muscle contraction were studied in goats submitted to acute left cardiomyoplasty. Conductance and micromanometer catheters were used to evaluate hemodynamics. Systolic contribution of the wrapped muscle was studied in preassisted and assisted beats, whereas diastolic effects were studied in assisted and postassisted beats.Results: At best settings, cardiomyoplasty resulted in a significant (p<0.05) increase in left ventricular ejection fraction (from 42.2 ± 9.2 to 56.7%± 13%), in stroke work (from 2769 ± 1140 to 4271 ± 1717 gm/m2), in dP/dt (from 1185 ± 342 to 1510 ± 285 mmHg/sec), in end‐systolic pressure (from 93.5 ± 22.5 mmHg to 97.3 ± 22.3 mmHg), and in peak ejection rate (from 282 ± 64 to 533 ± 241 mL/sec). Stroke volume showed a mean increase of 35% (from 42.2 ± 9.9 mL to 56.9 ± 20.1 mL) during assisted beats. Diastolic function was not substantially impaired at optimal stimulation delay. Incorrect timing of LD contraction resulted in suboptimal improvement or no change in comparison with unassisted hemodynamics.Conclusions: Our study documents support of cardiac performance by LDM. Incorrect timing of heart/wrapped muscle interaction led to suboptimal hemodynamic results. Muscle contraction timing is an important factor in cardiomy

ISSN:0886-0440    

DOI:10.1111/j.1540-8191.1996.tb00042.x

出版商:Blackwell Publishing Ltd    

年代:1996

数据来源: WILEY

摘要:

AbstractBackground and aim of the study: Cardiomyoplasty (CMP) has been proposed as a treatment for pediatric patients, but restriction of cardiac growth by the muscle wrap is a potential source of concern. This possibility was investigated in an immature animal model.Methods: Six‐week‐old rats (body weight 203.8 ± 5.4 g, mean ± SEM) underwent either left thoracotomy with CMP (group I, n = 7), or thoracotomy without CMP (group II, n = 8). A third group (group III, n = 7) served as untreated controls. Final measurements were made 20 weeks later after body weights had reached a plateau.Results: Preoperative body weights were not significantly different between the groups. At elective sacrifice, the body weights of animals that underwent surgery did not differ significantly (group I, 558.0 ± 21.5 g and group II, 617.3 ± 20.3 g), but were significantly less than those of control animals (727.6 ± 13.3 g, p<0.001 and p<0.01, respectively). Cardiac ventricular weights in the CMP group were significantly less than those of control animals (group I, 1.21 ± 0.06 g; group III 1.45 ± 0.04 g; p<0.01), but were not statistically different from those of the sham thoracotomy group (group II, 1.36 ± 0.05 g). Mean left ventricular end‐diastolic volumes were similar in all groups (group I, 0.67 ± 0.07 mL; group II, 0.66 ± 0.07 mL; and group III, 0.69 ± 0.10 mL; p = ns).Conclusions: A major surgical procedure impairs growth in juvenile rats. No evidence emerged from this study for additional restriction of cardiac development due to cardiac wrapping. However, studies that include stimulated muscle wraps are needed before CMP should be considered for the ped

ISSN:0886-0440    

DOI:10.1111/j.1540-8191.1996.tb00043.x

出版商:Blackwell Publishing Ltd    

年代:1996

数据来源: WILEY