Jatene Correction of the Ventricular Geometry in Postinfarction Left Ventricular Aneurysm: Results of 62 Operations

Jatene correction of left ventricular aneurysm was performed on 62 patients (including 11 emergency operations) with mean age 60 years, 80% of them in NYHA class 3–4, with mean left ventricular ejection fraction c. 30% and mean left ventricular end-diastolic pressure c. 24 mm. Concomitant bypass grafting was performed in 58 cases (mean grafts per patient 3.7). Perioperative mortality was 12.9%. One patient had peroperative myocardial infarction. Postoperatively 13 patients had low cardiac output, requiring intra-aortic balloon pump in seven cases. There were no bleeding problems and 28 patients (45%) had no postoperative complications. The average hospital stay was 10.2 days. Left ventricular cavity size (echocardiography) showed significant reduction 1 week postoperatively, which was unchanged after 1 month. The left ventricular ejection fraction was significantly increased 1 month postoperatively. After follow-up averaging 15 months there was significant improvement in mean NYHA class. One patient underwent heart transplantation and died, but there were no other late deaths or cardiac-related complications. Jatene correction of left ventricular aneurysm is simple, carries acceptable mortality and low morbidity and significantly improves left ventricular function.     

Aortic regurgitation after surgical relief of subvalvular membranous stenosis. A long-term follow-up study

A postoperative follow-up study of 21 cases of discrete membranous subvalvular aortic stenosis is presented. The age at operation was 6-47 (mean 16) years, and the follow-up time 0.6-16 (mean 6.7) years. Preoperatively most patients were in NYHA function class II or III and had high peak systolic pressure gradient, left ventricular hypertrophy and/or cardiothoracic index greater than 0.50. At follow-up all but six patients were in NYHA class I, the Doppler-estimated peak systolic gradient was 0-36 (mean 18) mmHg, the cardiothoracic index unchanged and the mean left ventricular hypertrophy score had declined from 4.3 to 2.3. Of 13 patients without aortic regurgitation preoperatively, eight had regurgitation at follow-up (group I) and five did not (group II). The interval to follow-up was significantly longer and the preoperative peak systolic gradient was greater in group I than in group II. Aortic regurgitation may develop even after surgical relief of discrete membranous subvalvular aortic stenosis, possibly associated with high preoperative pressure gradient and time from operation. Regular postoperative Doppler echocardiography is therefore recommended.     

Long-term follow-up after repair of tetralogy of Fallot

One hundred sixty-six patients with tetralogy of Fallot including 15 extreme type-patients repaired since 1971 were analyzed with respect to their physical activities, school or social life, hemodynamics, ECG, reoperation and late mortality. Follow-up period ranged from 1 to 19 years with an average of 9.1. There were 9 late deaths including 4 sudden deaths. Actuarial survival rates at 10 and 19 years were 95.2% and 90.5%, respectively. Eighty-five patients (72.0%) of 118 replied were in NYHA functional class I, 31 (26.3%) in class II and 2 (1.7%) in class III. Thirteen patients (7.8%) demonstrated right ventricular/left ventricular systolic pressure ratio over 0.80 because of inadequate relief of the pulmonary stenosis or obstruction, hypoplasia of the pulmonary artery or external conduit stenosis. Although the left ventricular ejection fraction was maintained at normal range (0.65 +/- 0.09), that of the right ventricule was below normal level (0.52 +/- 0.09). Two patients developed complete heart block postoperatively and underwent pacemaker implantations. Complete right bundle branch block was observed in 85 patients including 6 with left axis deviation. It is concluded that early correction even in the early infancy, adequate enlargement of the right ventricular outflow tract and minimal right ventriculotomy should be applied for correction of tetralogy of Fallot.     

Primary repair of complete atrioventricular septal defect in infancy.

Forty infants with complete atrioventricular septal defect have undergone primary repair within their 1st year of life. The mean age at time of surgery was 4 months (range 1-12 months) and the mean weight 4.2 kg (range 2.9-7.0 kg). Either the one- or the two-patch method was used. Four patients died (10%). There were no late deaths. Three patients needed reoperation due to mitral valve insufficiency. Postoperative complications were: 1 total atrioventricular block in an infant with an absent ventricular septum 3 weeks after surgery, 9 complete right bundle branch blocks, 3 small residual ventricular septal defects. Mean follow-up of the 36 survivors is 22 months (3-46 months). Thirty (83%) are in NYHA functional class I, 4 (11%) in NYHA class II and 2 (6%) in NYHA class III. No atrioventricular valve regurgitation is detectable by the color Doppler technique in 19 (53%) patients. Mitral incompetence is mild in 13 cases (36%) and moderate in 4 (11%). In ten recatheterized patients the average systolic pulmonary to systemic artery pressure ratio dropped from 1.0 to 0.42 and the average pulmonary arteriolar resistance was reduced from 5.5 to 3.9 U/m2. All but one patient gained weight and underwent adequate statomotoric development. Primary repair should be performed at the age of 5-6 months or even earlier, if pulmonary arteriolar resistance exceeds 5 U/m2.     

Surgical repair of congenital supravalvular aortic stenosis in children.

OBJECTIVE: Supravalvular aortic stenosis (SVAS) is an uncommon congenital cardiac anomaly characterized by varying degrees of left ventricular outflow tract obstruction beginning distal to the aortic valve. METHODS: Between March 1962 and December 2000, 101 consecutive patients underwent surgical correction for congenital SVAS at Riley Children's Hospital. There were 61 male (60%) and 40 female (40%) ranging in age from 3 month to 17 years (medium age, 6.1 years). Fourteen patients (14%) had Williams syndrome. Preoperatively, 11 patients were in New York Heart Association (NYHA) functional class I, 55 in class II, 28 in class III, and seven in class IV. Of the 101 patients, 73 (72%) had localized type SVAS and 28 (28%) diffuse type SVAS. RESULTS: Those with localized SVAS were successfully treated with patch aortoplasty, whereas those with diffuse SVAS required either an apical aortic conduit or extensive endarterectomy with patch aortoplasty. The overall mean pressure gradient was reduced to 21 mmHg (P<0.001) in the early postoperative period. There were one early death (<30 days postoperatively) (1%), two (2%) late deaths, and 14 patients (14%) underwent one or two additional operation (n=17) in a follow-up period ranging from 6 months to 30 years (medium 9.4 years). Postoperatively, there were 72 patients (73%) in NYHA functional class I and 26 (27%) in class II. Overall survival including operative mortality was 98% at 10 years, 97% at 20 and at 30 years. CONCLUSION: Good surgical outcome of congenital SVAS can be achieved with the appropriate method of treatment in patients with both localized and diffuse SVAS.     

Early surgery for severe aortic regurgitation

One hundred and fourteen consecutive patients who underwent aortic valve replacement (AVR) for isolated aortic regurgitation (AR) from 1965 to 1981 are presented. Sixty eight (60%) were preoperatively in NYHA class I-II and 46 (40%) were in NYHA class III-IV. Eighty-two patients had left and right heart catheterization prior to the operation and the severity of regurgitation was assessed angiographically in 93% of those in functional class (FC) I-II. Left ventricular (LV) end-diastolic volume index and end-systolic volume index were elevated even in the mildly symptomatic patients (156.1 and 61.0 ml/m2 respectively). The ratio of LV end-systolic pressure to LV end systolic volume index was diminished in the FC I-II patients. Two patients in FC III died in hospital (operative mortality: 1.7%) and there were 21 late deaths with a 5-year survival of 82.7%. Late survival differed significantly between patients who were preoperatively in FC I and II or III and IV (P less than 0.03). These data suggest that severe AR with altered LV function is an indication for early operation regardless of the presence of absence of symptoms.     

Impact of Fontan conversion with arrhythmia surgery and pacemaker therapy

Objective: In the long-term period after Fontan operation, atrial arrhythmia was one of the important factors to decide the postoperative quality of life. We reviewed the impact of Fontan conversion with arrhythmia surgery and pacemaker therapy. Methods: Thirty-eight patients underwent Fontan conversion using extracardiac conduit from 1992, and 22 patients with atrial arrhythmia underwent maze procedure simultaneously using cryoablation or radiofrequency ablation and epicardial DDD pacemaker implantation and 16 patients had regular ‘sinus’ rhythm before Fontan conversion. Mean follow-up period was 52 months. Pre- and postoperative clinical course were analyzed. Average weight, age at Fontan conversion, and years after first Fontan operation were 49.0 kg, 25.8 years old, 14.7 years, respectively. Nineteen percent of patients were in New York Heart Association class I (NYHA I), and 74% of patients were in NYHA II, and 7% were in NYHA III, respectively. Results: Except three early deaths, actual survival rate at 1 year and 5 years were 80% and 64%, respectively. In survivors, 80% of the patients obtained regular heart rhythm including artificial pacemaker rhythm, although only 43% of the patients had regular ‘sinus’ rhythm before the Fontan conversion. Postoperative average cardiothoracic ratio and oxygen saturation (SpO₂) were 50% and 94%, and 74% of patients were in NYHA I and 26% were in NYHA II, respectively, after Fontan conversion. Conclusions: Mid-term results of Fontan conversion with arrhythmia surgery and pacemaker therapy were acceptable. Restoration of regular rhythm might improve the postoperative NYHA status and the activity of the daily life.     

后环缝缩矫正二尖瓣关闭不全

目的总结二尖瓣后环缝缩治疗二尖瓣关闭不全（ＭＩ）的临床经验。方法回顾近１０年采用后瓣环缝缩成形治疗ＭＩ的３５例,其中２７例合并先天性畸形,轻度ＭＩ３例,中度ＭＩ２４例,重度ＭＩ８例。全后瓣环缝缩７例,部分后瓣环缝缩２８例,同时行腱索成形７例,瓣叶成形１４例。结果全组无手术死亡。２１例（６００％）完成纠正ＭＩ,１１例（３１４％）基本纠正,３例（８６％）仍轻中度ＭＩ。随访３个月～１０年,３４例心功能Ｉ级,１例术后５年因肺动脉高压死于右心衰。结论二尖瓣后环缝缩是一种简单、安全和有效的瓣环成形方法     

Multivariate analysis of operative mortality and late outcome after coronary bypass surgery

A multivariate discriminant analysis was made to find out the variables that could offer the greatest amount of predictive power on the long term results after myocardial revascularization. A total of 202 consecutive patients who underwent CABG operation in 1981 were reviewed 5 years later. Most of the patients (76.5%) had 3-vessel disease, previous AMI (70.2%), hypertriglyceridemia (61.7%), positive family history of CAD (68.0%) elevated blood cholesterol level (48.1%), hypertension (41.9%) or were smokers (61.9%). In 48.1% of the cases IMA was used for revascularization and in the rest saphenous vein graft alone. The 5-year survival of the entire group was 87%. The late mortality was related to 3 independent variables in multivariate analysis: 1) positive family history of CAD (p less than 0.05), 2) preoperative ejection fraction less than 0.30 (p less than 0.01) and 3) revascularization without IMA (p less than 0.02). The vast majority of patients (70%) had a better NYHA class 5 years postoperatively (the 95% confidence interval was 65-77%). These patients had experienced an average improvement of 2.0 NYHA categories. Eight per cent of patients had an unaltered and 5% a worse NYHA class than preoperatively. When the patients were grouped into those having a better NYHA class and into those who had an unchanged or worse NYHA class or who had died from CAD the only variable which was associated with poorer outcome appeared to be positive family history of CAD (p less than 0.01). It can be concluded that hereditary factors, utilization of internal mammary artery in revascularization and preoperative ejection fraction are the major predictors of late outcome after CABG.     

Total correction of tetralogy of Fallot in adults

A series of 42 patients who underwent total correction of tetralogy of Fallot as adults is presented. Previous palliative operation had been performed in 33 cases: Blalock-Taussig shunt in 28 (bilateral in 6), Brock operation in four and Potts' anastomosis in one case. Severe cyanosis (average hemoglobin 203 g/l), thrombotic complications and hypoxic spells were the most pertinent of the clinical manifestations necessitating the total repair. Blalock-Taussig shunt had closed spontaneously before the intracardiac operation in 14 cases (3 bilateral) and in 11 it was ligated. In six cases the shunt was left untreated, being hemodynamically insignificant at operation. Three of the 42 patients died in association with the intracardiac operation. A-V block developed in two patients and required permanent pacemaker. During follow-up periods of up to 13 years, a residual ventricular septal defect was found in seven patients. Two of the defects were surgically closed. Five were not corrected, as the patients were doing well and the pulmonary/systemic flow ratio was less than 1.5 at repeat catheterization. Two-thirds of the patients were in NYHA class I at re-examination, and the others were in class II. The subjective functional improvement was greater than could have been expected from results of exercise tolerance tests.     

Complete Surgical Repair of Tetralogy of Fallot in Adults,Is It Ever Too Late?

A minority of patients with Tetralogy of Fallot (TF) survive into adulthood. These patients have been subjected to a prolong period of cyanosis and hypoxia. The aim of this study is to assess the benefits of total correction of TF in this adult population. From August 1995 to March 2005, fifty one patients underwent total correction of TF. The mean age was 22.2 years (range 16 to 38 years). There were 31 males and 20 females. Twenty two percent of patients were in NYHA functional class III prior to the operation. The mean gradient across the right ventricular outflow tract was 81.7 mmHg (range 30 to 130 mmHg). The operation was performed through the right ventricle in the majority of patients. Transannular patch was used in 33 patients. The mean follow-up period was 42 months ranging from 1 to 116 months. Hospital mortality was 1.9% (1 patient), and one patient died three months after the operation. Post-operatively 87.3% of patients were in NYHA functional class I. During the follow-up period four patients required re-operation; two for residual ventricular septal defect, one for residual pulmonary stenosis and one had pulmonary valve replacement for severe pulmonary regurgitation. Complete repair of TF in adults is feasible with acceptable mortality and morbidity. The main benefit of the operation is functional improvement in this patient population.     

Pulmonary valve insertion late after repair of Fallot's tetralogy.

OBJECTIVES: To analyze the results of pulmonary valve insertion late after initial repair of Fallot's tetralogy. Pulmonary insufficiency (PI) after correction of Fallot's tetralogy is usually well tolerated in the short term, but is associated with symptomatic right ventricular dilatation and an increased risk of ventricular arrhythmias over longer periods of time. METHODS: From 1993 to July 2000, 51 patients were reoperated for PI at a mean age of 25.7+/-11.9 years. The mean age at initial repair was 6.4+/-7.2 years. Patients with a conduit inserted at initial operation, with absent pulmonary valve syndrome or with a more than moderate ventricular septal defect at reoperation were excluded from the study. A cryopreserved pulmonary (96%) or aortic (4%) homograft was implanted in the orthotopic position with the use of cardiopulmonary bypass 19.3+/-9.1 years (2.7-40.3 years) after initial correction. Preoperative symptoms (New York Heart Association, NYHA class), degree of PI (echo-Doppler, MRI), right ventricular dimensions (MRI) and QRS duration were compared to findings at last follow-up. RESULTS: Follow-up is complete and had a mean duration of 1.7+/-1.4 years. Hospital mortality was 2%. No serious morbidity occurred. Severe PI was present preoperatively in all patients. At last follow-up echo-Doppler studies showed PI to be absent or trivial in 96% and mild in 4% of patients. In 13 patients MRI studies were performed both pre- and postoperatively: in this group PI was reduced from a mean of 48 to 4%. After 6 months NYHA capacity class had improved significantly from 2.3+/-0.6 to 1.4+/-0.5. After 1 year end-diastolic and end-systolic right ventricular volumes were reduced significantly. Right ventricular ejection fraction and QRS duration remained unchanged. CONCLUSIONS: PI late after correction of Fallot's tetralogy may lead to serious symptomatic right ventricle dilatation. After pulmonary homograft insertion right ventricular dimensions decrease rapidly and functional improvement is observed in almost all patients.     

全保留二尖瓣及瓣下结构在重症二尖瓣关闭不全患者二尖瓣置换术中的应用

目的探讨全保留二尖瓣及瓣下结构在重症二尖瓣关闭不全患者二尖瓣置换术中的应用经验,评价其临床效果。方法回顾性分析2011年6月至2013年1月在广东省人民医院心血管外科因重症二尖瓣关闭不全行全保留二尖瓣及瓣下结构二尖瓣置换术17例患者的临床资料,其中男14例,女3例;年龄38~82（63.41±11.82）岁;合并心房颤动13例;术前纽约心脏学会（NYHA）心功能分级Ⅲ级5例,Ⅳ级12例;缺血性二尖瓣关闭不全7例,退行性二尖瓣关闭不全9例,风湿性二尖瓣关闭不全1例。结果所有患者均行全保留二尖瓣及瓣下结构的二尖瓣置换术,同期行冠状动脉旁路移植术4例;其中生物瓣11例,机械瓣6例。全组患者住院期间无死亡,均顺利出院,住院期间未并发低心排血量综合征,无左心室破裂。17例患者均随访,随访时间2~25（16.44±5.02）个月。随访期间1例患者因术后2个月发生二尖瓣重度瓣周漏死亡。其余患者人工二尖瓣功能良好,无抗凝和瓣膜引起的并发症,心功能较术前明显改善,心功能NYHA分级恢复至Ⅰ级11例,Ⅱ级4例,Ⅲ级1例。术后早期及随访期间心胸比率、左心房内径、左心室舒张期末内径及收缩期末内径与术前相比均明显减小。而术后早期左心室射血分数（LVEF）与术前相比有所降低[（50.94%±8.78%）vs.（55.31%±10.44%）,P=0.04],术前LVEF与随访期间的差异无统计学意义[（55.31%±10.44%）vs.（56.13%±9.67%）,P=0.73],随访期间LVEF与术后早期相比显著增加[（56.13%±9.67%）vs.（50.94%±8.78%）,P=0.02]。术后早期与随访期间人工二尖瓣压力减半时间（PHT）差异无统计学意义[（95.06±19.00）ms vs.（94.56±19.19）ms,P=0.91]。结论全保留二尖瓣及瓣下结构在重症二尖瓣关闭不全患者二尖瓣置换术中应用安全有效,可以改善左心室重构及术后心功能。     

Plastic correction of aortic stenosis in two- and three heart valve diseases]

Plastic correction of aortic stenosis with simultaneous intervention on the mitral and, in some cases, on the tricuspid valve was performed on 50 patients whose ages ranged from 25 to 53 years (average age 43.2 years); 15 were in NYHA functional class III and 35 in class IV. There were 38 females and 12 males. Correction of the aortic stenosis was achieved by open valvulotomy and additional plane resection of the cusps, suture plastic was conducted whenever necessary. In 6 cases calcinates were removed form the cusps simultaneously. Mitral valve prosthetics was undertaken in 42 patients, and open mitral commissurotomy in 8 patients. In 17 patients aortic and mitral stenoses were attended by defect of the tricuspid valve which called for plastic correction. Among the 50 patients who underwent operation 8 (16.0%) died. there were no fatal outcomes among patients related to the NYHA functional class III. In 41 cases the result of aortic stenosis correction was satisfactory, which was confirmed by clinical and echocardiographic data. After the operation, opening of the aortic valve cusps during echocardiography in the M-regimen increased, on average, from 12 +/- 2.0 to 18 +/- 2.6 mm. According to doppler-echocardiogram, the gradient on the aortic valve reduced, on average, from 45 +/- 5.0 to 26.5 +/- 4.0 mm. Only in one female patient aortic incompetence started progressing after the operation and called for prosthetics 6 months later.     

Surgery of atrioventricular septal defects. Review of the first 100 cases

From 1972 to 1985, the first 100 children suffering from some form of atrio-ventricular septal defect underwent surgical correction. In all cases, corrective surgery was carried out primarily except in 3 children who presented with a total defect and first underwent palliative surgery. In 48 children, a complete form was present, in 5 an intermediate form, and in 47 a partial form. There were 43 males and 57 females. Thirty-eight percent of patients suffered from Down's syndrome. The mean age at operation was 42 (range 2-143) months. A prosthesis was implanted in the left atrio-ventricular valve at primary correction in 9 patients. Up to 1980, the overall mortality was 20% and from 1981 to 1985 it was 3.3%. There was late mortality in 3 children (2 with a complete form and 1 partial). In 32 cases, postoperative cardiac catheterization was performed. Nine patients were reoperated upon (9%), 2 due to a residual shunt, 4 due to serious mitral incompetence (in all cases a prosthesis was used), and 3 due to valvular thrombosis. In this series, only 2 patients remained in complete atrio-ventricular block (1 affected by the complete form and the other partial). Long term survival is related to the severity of left valvular insufficiency. In this series with a mean follow-up of 3.83 +/- 2.78 years, we had an a cumulative survival of 86.7% +/- 3.43%. At the last control, most of the survivors had a good quality of life: 91% were in class I and 9% in class II according to the NYHA scale.     

A study of isolated tricuspid valve surgery late after left heart valve operation

Management of severe tricuspid regurgitation late after left heart valve operation is controversial. There has been reluctance to the operation due to the high risk of repeat operation, coexistent right ventricular dysfunction and pulmonary hypertension. We investigated 6 cases of isolated tricuspid valve surgery (tricuspid valve replacement: 2, tricuspid valve plasty: 4) late after left heart valve operation. Before operation, these patients showed poor general condition (4 cases were NYHA III or IV) but good left ventricular function [mean ejection fraction (EF) 66 +/- 9.6%]. Hospital mortality was 0% and the mean mid-term actual event-free survival over 2 +/- 1.8 years was 80%. Most of patients demonstrated NYHA I and improvement of hepatomegaly after operation. There were many complications in 2 cases that had been performed previous operation more than 20 years before. In summary, the patient who complained symptoms due to right heart ventricular failure and showed good left ventricular function after left heart valve surgery should be considered to undergo tricuspid valve operation before the occurrence of other complications.     

Constrictive pericarditis: Clinical profile and management

One-hundred and sixteen patients were surgically treated for constrictive pericarditis over a period of 18 years. Twenty-eight patients were less than 15 years old. All patients had exertional dyspnoea and elevated jugular venous pressure. Eighty-eight patients had NYHA class III or IV functional disability. Only 2 cases had atrial fibrillation. Seventeen patients had roentgenographic evidence of pericardial calcification. Fluoroscopy showed diminished cardiac movements in 110 cases. Cardiac catheterisation in 77 patients demonstrated classical haemodynamic pattern of constrictive pericarditis. All our patients underwent subtotal pericardiectomy through a left anterolateral approach. Seventy-one patients had histological evidence of tuberculous pericarditis. Nearly 88 per cent of the followed up cases reported good to excellent relief. The hospital mortality was 6.9 per cent. Our observations and inferences are compared with those of other published reports.     

Williams综合征合并先天性心血管病的外科治疗

目的总结Williams综合征合并心血管病的诊断及治疗经验。方法1996年10月至2003年6月收治8例Williams综合征合并主动脉瓣上狭窄和肺动脉狭窄患者,7例行手术治疗,1例未手术。男6例,女2例,平均6.4岁。局限性主动脉瓣上狭窄3例,弥漫性狭窄5例;2例合并多发肺动脉狭窄。单片法修补加宽主动脉6例,“人”字形补片1例。术前心功能NYHA分级Ⅱ级5例,Ⅲ级3例。结果手术死亡1例,肾功能不全1例,主动脉瓣上血流速度从术前2.9～6.8m/s[平均(4.6±1.1)m/s]降为1.2～3.2m/s[平均(1.7±0.6)m/s],压差从术前42～156mmHg[平均(91±47)mmHg,1mmHg=0.133kPa]降为11～35mmHg[平均(18±10)mmHg]。6例随访16～91个月,心功能NYHA分级Ⅰ级5例,Ⅱ级1例。结论Williams综合征合并主动脉瓣上狭窄手术治疗结果满意,合并周围肺动脉狭窄者手术治疗效果不佳。     

Carvedilol improves functional class in patients with severe left ventricular dysfunction referred for heart transplantation

PURPOSE: Limited options are available to improve the functional class of patients awaiting cardiac transplantation. We assessed the effect of carvedilol on New York Heart Association (NYHA) class, heart rate (HR), blood pressure (BP), jugular venous pressure (JVP), electrolytes and renal function in patients with markedly decreased left ventricular (LV) function referred for cardiac transplantation assessment. METHODS: Sixty-one patients (age = 52 +/- 12 yr, EF = 23 +/- 7%, VO2 max = 16 +/- 5 mL/kg/min) referred to the cardiac transplant clinic were reviewed before and after the addition of carvedilol (starting dose 3.125 mg twice daily to target dose of 25 mg twice daily) to usual heart-failure therapy. Over a 1-yr period, at each visit prior to initiation, at baseline initiation visit and at each follow-up visit, NYHA class, BP, HR, JVP, electrolytes, and renal function were obtained. Statistical analysis was performed using random effects regression approach. A multiple logistic regression analysis was performed on 52/61 patients to determine possible associations between NYHA improvement and the following patient characteristics: sex, etiology of cardiomyopathy, initial NYHA class, and dose of carvedilol. RESULTS: Three patients died (2 after stopping carvedilol) and 3 were transplanted. Median follow-up was 100 d. Sixteen patients reached the target dose after a mean of 137 d (2.75 visits). Estimated time-to-target dose is 8 months (5.6 visits). BP tended to increase (p = 0.07 for change in trend) with no change in JVP, electrolytes or renal function. HR decreased 6 +/- 3 b.p.m. (p = 0.03). Of 14 patients NYHA class I/II at baseline, none were class III/IV at last follow-up visit. Of 47 patients NYHA class III/IV at baseline, 25 were class I/II, and 22 were class III/IV at last follow-up (p < 0.001). Multiple logistic regression analysis did not demonstrate any factor predictive of subsequent NYHA class improvement. CONCLUSIONS: Despite less than target doses in most patients, a favorable effect of carvedilol on functional class in patients with severe congestive heart failure (CHF) referred for transplant was observed. Those with good functional status remained stable and those with poor functional status improved or remained stable. No baseline patient characteristic predicted improvement. The shortage of donor organ requires optimal use of medical regimens which may improve functional class while awaiting transplantation and which may delay the necessity for heart transplantation. Therefore, addition of carvedilol to usual medical therapy may be beneficial even in patients with severe LV dysfunction and poor NYHA classification.     

LC术中CO_2气腹对心功能不全患者心功能的影响

目的 :探讨腹腔镜手术时不同气腹压力对心功能不全患者心功能的影响。方法:选取2005年1月—2013年12月在我院择期行腹腔镜胆囊切除术(LC)的患者,按心功能等级分组,分别采用标准压力气腹和低压力气腹,观测患者血浆脑钠肽(B N P)及左室射血分数(LV EF)的变化。结果:心功能正常和心功能Ⅰ、Ⅱ级患者行LC时,所有时间点标准压力气腹组(H组)和低压力气腹组(L组)患者LV EF值差异无统计学意义(P0.05);心功能Ⅲ级患者采用低压力气腹在术后24、72 h的LV EF明显高于H组(P0.05)。心功能正常和心功能Ⅰ级患者行LC时,所有时间点H组和L组患者B N P值差异无统计学意义(P0.05),心功能Ⅱ级采用低压力气腹的患者在气腹后30 m in时B N P值明显高于H组(P0.05),心功能Ⅲ级患者采用低压力气腹在气腹40 m in和气腹后30 m in时B N P值明显高于H组(P0.05)。结论:对于N Y H A分级较高的心功能不全患者,采用低压力气腹行LC可能减轻C O2气腹对其心功能的影响。