Assessment of left ventricular function with ESS-ESVI relationship in patients undergoing aortic valve replacement for aortic regurgitation]

Aortic valve replacement (AVR) for aortic regurgitation (AR) results in the reduction of left ventricular dimensions. But postoperative death or congestive heart failure may occur in patients with left ventricular dysfunction. Pre- and postoperative stress (ESS)-volume (ESVI) relationship by M-mode echocardiography was examined in 30 patients undergoing AVR. Postoperatively, 23 patients (Group A) achieved a normal left ventricular dimension (LVDd less than 55 mm, LVDs less than 45 mm) and 7 patients (Group B) had persistent left ventricular dilation (LVDd greater than or equal to 55 mm, LVDs greater than or equal to 45 mm). Correlation between preoperative ESS and ESVI was significant (r = 0.92, p less than 0.001), and the ESS/ESVI was greater in Group A of 1.62 +/- 0.29 kdy/cm2/ml/m2 than in Group B of 1.18 +/- 0.19 kdy/cm2/ml/m2 (p less than 0.001). Three patients with ESVI greater than 180 ml/m2 and ESS/ESVI less than 1.2 kdyn/cm2/ml/m2 died after operation. Echocardiographic variables correlated with ESS/ESVI were ESVI (r = -0.57), FS (r = -0.53) and CSA (r = -0.47). The changes in LVDs (delta Ds) after AVR correlated with ESS/ESVI in 12 patients with severe left ventricular dilatation. Postoperative left ventricular function could be predicted by ESS-ESVI relationship by preoperative DBcAMP infusion test. ESS/ESVI is sensitive to changes in the left ventricular contractility. The patients with ESVI greater than 180 ml/m2 and ESS/ESVI less than 1.2 kdyn/cm2/ml/m2 may result in poor prognostic outcome.     

Evaluation of ventricular arrhythmias late after coronary artery bypass graft surgery--relation to clinical variables

This study was undertaken to evaluate ventricular arrhythmias (VA) using ambulatory ECG monitoring in 150 patients 33 +/- 22 months (mean +/- SD) after successful CABG in relation to severity of coronary artery disease (LS: Leaman score, Circulation 1981), revascularization ratio (RI: preop. LS-postop.LS/preop.LS), preoperative myocardial infarct size (Selvester score: SQS, Circulation 1982), LV function and other variables. They were divided into two groups according to the Lown classification; 42 patients with serious VA (group A: grade 4 to 5), and 108 without them (group B: grade 0 to 3). Group A was older than group B (60 +/- 5 vs. 57 +/- 9; p less than 0.05). There were no significant differences in follow-up period, coronary risk factors, LS and RI between the groups. Group A had significantly higher SQS (7.5 +/- 3.2 vs. 2.6 +/- 1.9; p less than 0.01), LVEDP (preop.: 14 +/- 7 vs. 11 +/- 5 mmHg; p less than 0.05, postop.: 14 +/- 7 vs. 11 +/- 5 mmHg; p less than 0.05), LVESVI (preop.: 53 +/- 27 vs. 31 +/- 17 ml/M2; p less than 0.01, postop.: 53 +/- 35 vs. 30 +/- 14 ml/M2; p less than 0.01), LVEDVI (preop.: 93 +/- 28 vs. 72 +/- 22 ml/M2; p less than 0.01, postop.: 90 +/- 36 vs. 74 +/- 21 ml/M2; p less than 0.01), and lower LVEF (preop.: 44 +/- 15 vs. 58 +/- 11%; p less than 0.01, postop.: 44 +/- 15 vs. 60 +/- 10%; p less than 0.01) than group B.(ABSTRACT TRUNCATED AT 250 WORDS)     

Mitral regurgitation progression following isolated coronary artery bypass surgery: frequency, risk factors, and potential prevention strategies.

BACKGROUND: Though de novo mitral regurgitation (MR) is frequently seen in patients who have undergone coronary artery bypass surgery (CABG), its incidence, predictors, and mechanisms are not known. METHODS: Our surgical registry was screened for patients undergoing isolated CABG who had preoperative and postoperative resting echocardiograms performed at our institution with 相似文献   

Late postoperative left ventricular function and ventricular hypertrophy after prosthetic valve replacement for aortic regurgitation]

Forty-two of 50 patients, who had undergone aortic valve replacement for acquired aortic regurgitation from Jan 1979 to Dec 1985, received late postoperative cardiac catheterization two years after operation. Their ages ranged between 10 and 69 years old (mean +/- S.D., 45.8 +/- 12.2 y.o.) and 37 men and 13 women were included. Postoperative left ventricular end-diastolic volume (LVEDV), end-systolic volume (LVESV) and left ventricular mass (LVM) decreased significantly compared to preoperative levels, respectively (p less than 0.001). Both postoperative left ventricular end-systolic stress/end-systolic volume ratio (LVESS/ESVI) and tension volume ejection fraction (TVEF) increased significantly (p less than 0.01) compared to preoperative levels. Positive correlations were recognized between preoperative and postoperative values in LVESV, LVM, LVESS/ESVI, TVEF and LVEF. In the patients who had showed preoperative values of LVEDVI less than 180 ml/m2, LVESVI less than 90 ml/m2 and LVEF more than 0.52, their postoperative values were expected to be normal. There were also negative correlations between LVESVI and LVEF, and between LVM and contractile properties. Nineteen patients, who had recovered normal ventricular volumes at the time of postoperative cardiac catheterization, showed normal LV dimensions and % fractional shortening between five and ten years after operation. These results demonstrate the limitation of recovery in LVM and contractile properties in spite of normalization in ventricular volume and ejection performance.     

Defective glucose utilization in patients with functioning beta-cell tumors persists after tumor excision.

Glucose utilization was assessed before and after operation in five patients with insulin-secreting tumors using the euglycemic clamp. Two groups of age, sex, and weight-matched controls were studied under conditions of either acute (3 h, N = 7) or chronic (48-72 h, N = 6) hyperinsulinemia (46 +/- 4 microU/mL). The rate of glucose infusion (M = mg/kg/min) required to maintain steady-state euglycemia was taken as index of glucose utilization. M was higher both in postoperative patients and in chronic controls than in preoperative patients (2.1 +/- 0.1 and 1.8 +/- 0.2 vs. 1.0 +/- 0.2, p less than 0.01), yet never achieved levels seen in acute controls (3.3 +/- 0.3, p less than 0.01). Also reported is one subject who had a predominantly proinsulin-producing tumor with little insulin secretion, who also manifested a similar defect in glucose utilization. Excision of this tumor resulted in partial reversal of the peripheral defect in glucose metabolism. In conclusion, chronic endogenous hyperinsulinemia (and hyperproinsulinemia) in humans is associated with a defect in peripheral glucose utilization that is only partially resolved 2 years after tumor removal.     

Change of c-Myc expression and cardiac hypertrophy in patients with aortic valve replacement

BACKGROUND: Long-term volume overload to the left ventricle (LV) due to aortic regurgitation (AR) tends to cause severe impairment in LV function that cannot be reversed even with aortic valve replacement (AVR). Recently, we reported that the protooncogene c-myc is related to the onset of the cardiac hypertrophy and LV dysfunction in patients with chronic AR. However, it is still unclear whether c-myc is related to reversibility of the cardiac hypertrophy or LV dysfunction after AVR. METHODS AND RESULTS: Twenty patients with isolated chronic AR who underwent AVR were included in this study. LV function was calculated before and after AVR. After AVR, end-systolic volume index (ESVI) and enddiastolic volume index (EDVI) were improved, but not mass index (LVMI). However, normalization of ESVI and EDVI was observed only in 12 and 9 patients, respectively. Preoperatively, c-Myc protein was expressed in the myocardium of 16 out of 20 patients with an average point count of 35+/-30%. After AVR, c-Myc protein was observed only in 2 patients. Preoperative ejection fraction (EF), ESVI, and postoperative end-systolic stress (ESS)/ESVI had significant correlation to postoperative cell diameter (CD). Percent c-Myc protein expression before the operation was significantly correlated to postoperative CD, ESVI, and ESS/ESVI. Average c-Myc expression was higher in patients who showed normalization of CD and ESS/ESVI after AVR than the patients who did not. CONCLUSIONS: These data suggest that preoperative expression of c-Myc can be indicative of the reversibility of myocardial cellular hypertrophy and LV dysfunction.     

Late results of CABG for postinfarction angina--relation to preoperative myocardial infarct size

We evaluated the late results of coronary bypass grafting (CABG) in 85 patients. The patients were divided into two groups according to preoperative MI size estimated by the Selvester QRS score; 24 with MI size of larger than 20% of LV muscle (group A; average 28 +/- 11%), and 61 with MI size smaller than 20% (group B; average 10 +/- 9%). New York Heart Association classes of both groups following CABG improved significantly (from 2.8 +/- 0.7 to 1.3 +/- 0.4 in group A; p less than 0.01, from 2.5 +/- 0.6 to 1.2 +/- 0.5 in group B; p less than 0.01). There was higher incidence of serious ventricular arrhythmias in group A than in group B (83% vs. 21%, p less than 0.01). In Group A, LVEF and LVESVI did not improve following CABG (from 17 +/- 9 to 16 +/- 8 mmHg, from 39 +/- 15 to 40 +/- 15%, from 66 +/- 28 to 69 +/- 40 ml/M2), while in Group B, those improved significantly (from 13 +/- 6 to 11 +/- 5 mmHg; p less than 0.01, from 53 +/- 14 to 58 +/- 10%; p less than 0.01, from 39 +/- 23 to 32 +/- 14 ml/M2; p less than 0.05). The exercise-to-rest LVSWI ratios increased significantly following CABG in both groups (from 86 +/- 25 to 160 +/- 56% in group A; p less than 0.05, from 92 +/- 31 to 140 +/- 37% in group B; p less than 0.05).(ABSTRACT TRUNCATED AT 250 WORDS)     

A New Technique for Bridging to Heart Transplantation: Feasibility of Monoventricularization of Bilateral Ventricles with LVAD

Because the prognosis of ventricular septal perforation (VSP) and mitral regurgitation (MR) after acute myocardial infarction (MI) is remarkably poor, heart transplantation would be necessary for many of those patients. A new bridging technique was examined in canine models. The bilateral ventricles communicating through VSP were monoventricularized with mitral valve closure and maintained the pulmonary circulation, which had low vascular resistance. The systemic circulation was maintained by a left ventricular assist device (LVAD) placed between the left atrium and the aorta. VSP and MR were made in eight mongrel dogs (pulmonary to systemic flow ratio = 2.24 +/- 0.90). They were then monoventricularized and equipped with LVADs. The hemodynamic state was evaluated (a) in intact hearts, (b) after VSP and MR were made, and (c) after monoventricularization and assisted circulation by LVAD. Cardiac output was (a) 90.60 +/- 23.16, (b) 42.23 +/- 15.76, and (c) 73.43 +/- 15.14 ml/min/kg (a vs. c: not significant; a vs. b and b vs. c: p less than 0.001); mean aortic pressure was (a) 96.75 +/- 24.69, (b) 30.25 +/- 11.08, and (c) 66.50 +/- 18.40 mm Hg (a vs. b: p less than 0.01, a vs. c and b vs. c: p less than 0.05); central venous pressure was (a) 4.76 +/- 1.68, (b) 8.94 +/- 2.17, and (c) 10.68 +/- 2.43 mm Hg (a vs. c: p less than 0.01, a vs. b: p less than 0.05, and b vs. c: not significant). Mean pulmonary arterial pressure and mean left atrial pressure did not show any significant difference among the three groups.(ABSTRACT TRUNCATED AT 250 WORDS)     

Surgical management of tricuspid regurgitation in patients undergoing mitral valve surgery--analysis of the amount of tricuspid valve annular dilatation]

As a means to determine whether correction for tricuspid regurgitation (TR) in mitral valve surgery is necessary, pulsed Doppler echocardiography was used to study 61 patients (age 49.5 +/- 9.5 years) who underwent mitral valve surgery. Early postoperative tricuspid regurgitation (average 9 +/- 3 postoperative days) was evaluated by a comparison with tricuspid valve annular dilatation and systolic annular shortening in preoperative right ventriculography. Kishimoto's method was used to measure the angiographic maximal early systolic (TVD) and minimal end-systolic diameters where as the shortening of the tricuspid annulus (STA) was expressed as a percent reduction in the maximal diameter by Ubago's methods. Patients were categorized into two groups, i.e., a group having had tricuspid annuloplasty (TAP group n = 23), and a NON-TAP group (n = 38). Preoperative right ventricular volume and hemodynamic indicator were studied with respect to both the TVD and the STA. Results are as follows: 1) The TVD significantly correlated with the end-diastolic right ventricular volume index (EDVI), regurgitant fraction of the tricuspid valve (RF), end-systolic right ventricular volume index (ESVI), pulmonary vascular resistance (PVR), mean pulmonary artery pressure (PAm), mean right atrial pressure (RAm), and right ventricular end-diastolic pressure (RVEDP) (p less than 0.01). 2) The STA was significantly correlated with EDVI, RF, ESVI, RAm and RVEDP (p less than 0.01). In the NON-TAP group, the TVD was significantly larger in patients with residual TR (average 32.5 mm/m2) than in patients having postoperative disappearance of TR (average 25.7 mm/m2) (p less than 0.05).(ABSTRACT TRUNCATED AT 250 WORDS)     

Renal function and renal function reserve in insulin-dependent diabetic patients during (near) normoglycaemia

Twenty-three normoalbuminuric (N) and 7 microalbuminuric (M) insulin-dependent diabetes mellitus (IDDM) patients were studied under (near) normoglycaemic conditions. They were reasonably well controlled during the period preceding the renal function test (HbA1: N = 7.6 +/- 1.3%, N = 8.0 +/- 2.2%; normal less than 6.0%). Glomerular filtration rate (GFR) and effective renal plasma flow (ERPF) were measured using the clearances of 125I-thalamate and 131I-hippuran, respectively. The renal reserve filtration capacity (RRFC) was tested by using a combination of a liquid mixed meal and an amino acid infusion. Blood glucose levels were kept as constant as possible throughout the testing procedure, both under baseline (BL) conditions and after stimulation (S). Under such (near) normoglycaemic conditions, no BL GFR values exceeding 150 ml/min/1.73 m2 could be established. Furthermore, a RRFC could be established in all patients. Both groups showed a comparatively larger increase in GFR (N 13.0 +/- 3.8%, M 10.8 +/- 3.6%) than in ERPF (N 4.8 +/- 7.0%, M 2.2 +/- 5.8%; % delta GFR vs. % delta ERPF p less than 0.01), resulting in a higher filtration fraction (FF) during stimulation (N: BL FF 0.25 +/- 0.03 vs. S FF 0.27 +/- 0.03, p less than 0.01; M: BL FF 0.25 +/- 0.01 vs. S FF 0.27 +/- 0.01, p less than 0.05). This suggests afferent vasodilation during stimulation in these (near) normoglycaemic, reasonably well-controlled IDDM patients, a situation comparable to that in non-diabetic subjects.(ABSTRACT TRUNCATED AT 250 WORDS)     

Hyperaluminemia in renal failure: the influence of age and citrate intake

Following the occurrence of aluminum encephalopathy in four patients with chronic renal failure, we studied 34 azotemic patients seen during the same year and five volunteers who took varying combinations of aluminum hydroxide and an alkalinizing citrate (Shohl's) solution. We found that the four encephalopathic cases were older than the 34 azotemic patients (68 years +/- 14 SD, vs 50 +/- 13, p less than 0.05), had a higher mean serum aluminum value (727 micrograms/l +/- 320 vs 92 +/- 73, p less than 0.005), had taken more aluminum hydroxide (5 g/day +/- 0.9 vs 1.6 +/- 1.8, p less than 0.01), and more Shohl's solution (64 ml/day +/- 19 vs 20 +/- 29, p less than 0.01). In all 38 patients the serum aluminum values correlated directly with age (p = 0.01), aluminum hydroxide (p = 0.001) and concomitant citrate intake (p = 0.004). In the five healthy volunteers the 24-hour urinary aluminum excretion increased from a baseline of 22 micrograms +/- 19 SD to 167 +/- 109 (p = 0.05) during aluminum hydroxide intake, rising to 580 +/- 267 (p = 0.01) during the simultaneous intake of citrate and aluminum hydroxide. Corresponding serum aluminum values were 11 micrograms/l +/- 2 SD, 44 +/- 34 (p = 0.1), and 98 +/- 58 (p less than 0.05). Thus citrate seems to enhance aluminum absorption and may cause encephalopathy in patients with chronic renal failure, especially the elderly.     

Timing of operation for aortic regurgitation: relation to postoperative contractile state

With angiography and pressure measurement, we determined left ventricular volume, wall stress, and systolic performance in 30 patients with aortic regurgitation before and after successful aortic valve replacement. End-systolic wall stress was greatly elevated preoperatively and decreased to normal postoperatively. Systolic pump performance assessed as ejection phase indexes was severely depressed preoperatively and improved to normal or near-normal postoperatively in most patients. The ratio of end-systolic wall stress to end-systolic volume index (ESS/ESVI), an index of myocardial contractility, was greatly decreased before operation. Postoperatively, the ratio increased in all patients, becoming normal in 12 of the 13 patients who had a preoperative ESS/ESVI of 2.9 or greater. However, 15 of 17 patients in whom the ESS/ESVI ratio was less than 2.9 still had subnormal ratios, which indicates the presence of irreversible contractile dysfunction. Stepwise multivariate analysis showed that preoperative ESS/ESVI was the only independent discriminator of postoperative normalization of the contractile function as assessed by ESS/ESVI. After aortic valve replacement, myocardial contractile state does not return to normal in a considerable number of patients. It is important to offer aortic valve replacement for aortic regurgitation before the chance for a good functional result is lost. The ESS/ESVI ratio may be a useful index in determining the timing of operation in patients with aortic regurgitation.     

Pulsed Doppler echocardiographic observation of left ventricular filling dynamics after aortic valve replacement in patients with chronic aortic regurgitation]

The 23 patients who underwent aortic valve replacement (AVR) for aortic regurgitation (AR) from 1977 to 1990 were studied with pulsed Doppler echocardiography. The patients were divided into two groups. The A group consisted of 5 patients whose end-systolic volume index (ESVI) were more than 200 ml/m2 and/or left ventricular ejection fraction (EF) were less than 0.35 before AVR. The B group consisted of 18 patients whose ESVI were less than 200 ml/m2 and EF were more than 0.35 before AVR. A Doppler volume sampler was placed at the center of mitral orifice to measure the transmitral inflow velocity after AVR (mean 28 months). Left ventricular filling dynamics were assessed by the peak velocity in the rapid filling phase (R), the peak velocity in the atrial contraction phase (A) and the ratio of A by R (A/R ratio) of mitral flow velocity pattern. The deceleration rate of early diastolic rapid inflow (DeR) determined as the slope a straight line drawn between the peak of early diastolic inflow and a point at half peak velocity on the fall side of the envelope. Result was as follows; 1) The DeR showed significant correlation with the EF (r = 0.56, p < 0.01). The DeR showed significant inverse correlation with the ESVI (r = -0.52, p < 0.05). 2) The R velocity (mean 43.9 +/- 7.9 cm/sec) in group A was significantly lower than in group B (mean 61.4 +/- 18.6 cm/sec), (p < 0.05).(ABSTRACT TRUNCATED AT 250 WORDS)     

Lipoprotein lipid abnormalities in healthy renal transplant recipients: persistence of low HDL2 cholesterol

There is disagreement about the prevalence and character of lipoprotein lipid abnormalities in renal transplant patients. To test the hypothesis that these abnormalities may be related to the coexistence of medical conditions and medications which affect lipoprotein metabolism in these patients, triglyceride (TG), cholesterol (C), high-density lipoprotein (HDL) and HDL-C subfractions were measured in 26 transplanted patients (10 F/16 M), control subjects matched for age, sex, weight and race and uremic patients being treated with hemodialysis. Female transplant recipients had higher TG (181 +/- 47 vs. 68 +/- 6 mg/dl; p less than 0.001), C (242 +/- 19 vs. 165 +/- 9 mg/dl; p less than 0.01), and low-density lipoprotein (LDL)-C (155 +/- 15 vs. 93 +/- 8 mg/dl; p less than 0.01) than controls. Levels of HDL-C were similar, but HDL2 was significantly lower in the transplanted patients (9 +/- 2 vs. 19 +/- 2 mg/dl; p less than 0.01). Compared to the uremic patients, female transplanted patients had higher C (242 +/- 19 vs. 178 +/- 22 mg/dl; p less than 0.01), LDL-C (155 +/- 15 vs. 94 +/- 18 mg/dl; p less than 0.01), HDL-C (51 +/- 5 vs. 32 +/- 4 mg/dl; p less than 0.001) and HDL3-C (42 +/- 4 vs. 26 +/- 2 mg/dl; p less than 0.001); however, HDL2-C levels were not significantly different.(ABSTRACT TRUNCATED AT 250 WORDS)     

The effect of preoperative atrial fibrillation on survival following mitral valve repair for degenerative mitral regurgitation.

OBJECTIVE: There is conflicting evidence with regard to the impact of preoperative atrial fibrillation (AF) on the post mitral valve (MV) repair on the early and late outcome. METHODS: A total of 349 patients undergoing various MV repair procedures for degenerative mitral regurgitation (MR) between 1997 and 2003 were studied. Preoperatively, 152 (44%) of these patients were in AF and 197 (56%) patients were in sinus rhythm (SR). The clinical features and the outcome in these two cohorts of patients were compared. RESULTS: The patients in the AF group were older than their counterparts in the SR group (66+/-7 vs 62+/-9 years) (p=0.01), had a higher mean NYHA class score (2.4+/-0.6 vs 2.2+/-0.7) (p=0.04) and were more likely to have impaired left ventricular function (60% vs 36%) (p<0.0001). A similar proportion of patients in the AF (38%) and SR (30%) groups had additional cardiac surgical procedures (p=0.12). Operative mortality was 3.9% in AF group versus 0.5% in SR group (p=0.04), and operative morbidity was 27% versus 17%, respectively (p=0.03). At latest follow up, 4% of patients that were in SR preoperatively developed AF; conversely, 2% of the patients in the AF group converted to SR. The rates of recurrent grade II or III MR (4% vs 5%) (p=0.8) and MV re-operation (2.6% vs 2.5%) (p=1.0) were similar in the AF and SR groups. Kaplan-Meier survival at 7 years was 75+/-6% versus 90+/-3% (p=0.005). On Cox proportional hazards regression model, impaired LV function [(p=0.02), hazard ratio 0.25 (95% confidence intervals (C.I.) 0.078-0.84)] and AF [(p=0.03), hazard ratio 2.70 (95% C.I. 1.09-6.68)] were significant adverse predictors of survival. CONCLUSIONS: This study shows that in patients undergoing MV repair for degenerative MR, preoperative AF has a major negative impact on the early and late survival.     

Atrial fibrillation and plasma troponin I elevation after cardiac surgery: relation to inflammation-associated parameters

BACKGROUND: Recent studies have demonstrated correlation between inflammation to plasma troponin (cTnI) levels elevation and atrial fibrillation (AF) in noncardiac surgery settings. The goal of this prospective study was to examine the relation between inflammation associated parameters (IAPs) to post cardiac surgery cTnI elevation and AF. METHODS: A single post CABG cTnI measurement was assessed in 156 consecutive patients. Clinical, operative and postoperative data, IAPs (hypophosphatemia, preoperative statin treatment, immediate postoperative fever, and prolonged mechanical ventilation) and in-hospital AF episodes were prospectively recorded. RESULTS: Mean cTnI level was 14.4 +/- 12.4 ng/mL. In the two in-hospital deaths (1.2%) cTnI concentration was less than 12 ng/mL. Cardiac troponin-I levels were significantly higher in patients not preoperatively treated with statins (21.6 +/- 4.1 vs. 13.3 +/- 0.9, p = 0.05), in patients who needed intraoperative cardioversion (16.7 +/- 2.2 vs. 12.2 +/- 0.9, p = 0.07), in patients with postoperative hypophosphatemia (16.9 +/- 10.0 vs. 11.1 +/- 13.7, p = 0.04), postoperative fever (18.6 +/- 3.0 vs. 13.7 +/- 1.0, p = 0.07) and postoperative respiratory complications (23.9 +/- 4.3 vs. 13.5 +/- 1.0, p = 0.04). Step-wise logistic regression analysis revealed the following parameters as independently associated with elevated cTnI levels: preoperative statin treatment (CI 95%-15.9; -1.7, p = 0.02), intraoperative ventricular arrhythmia (CI 95%-0.7; 13.8, p = 0.08), hypophosphatemia (CI 95% 0.9; 8.6, p = 0.02), postoperative fever (CI 95% 0.9; 11.0, p = 0.02), and postoperative respiratory complications (CI 95% 0.1; 0.5, p = 0.01). Of the 156 patients, 50 (32.1%) had postoperative AF. The first episode of AF occurred between postoperative day 1 and 6 (mean-day 2). Mean duration of AF was 21.8 +/- 8.1 hours. Postoperative AF was significantly associated with age above 75 (50% vs. 29.4%, p = 0.01), hypertension (37% vs. 18%, p = 0.02), preoperative calcium channel blockers treatment (44% vs. 26%, p = 0.02), furosemide treatment (58% vs. 30%, p = 0.05), and preoperative left atrial diameter above 40 mm (56% vs. 29%, p = 0.01). Postoperatively, AF was significantly associated with postoperative renal failure (70% vs. 29%, p = 0.01), respiratory complications (61% vs. 29%, p = 0.02), and prolonged hospital stay (OR 1.1; CI 1.0-1.3; p < 0.05). No association was found between troponin levels and postoperative AF. Multivariable analysis found only left atrial enlargement and prolonged hospital stay independently associated with AF. CONCLUSIONS: A significant correlation between clinical IAPs and cTnI plasma level elevation was found after cardiac surgery. There was no correlation between these parameters and postoperative AF, and there was no correlation between postoperative plasma cTnI levels and the occurrence of AF. Preoperative treatment with statins may be beneficial in reducing postoperative inflammatory response but further study has to be carried out.     

A double blind clinical trial of the alpha-adrenergic blocker, Ea-0643 tablet, in the treatment of neurogenic bladder

The clinical effectiveness, safety and usefullness of the alpha-adrenergic blocker, Ea-0643 tablet, for the treatment of the neurogenic bladder were evaluated by the double blind test method. A total of 61 patients was treated. Five of them were excluded or dropped out. Eighteen patients (group-A) received a 1.0 mg tablet of Ea-0643, 20 patients (group-B) received a 0.5 mg tablet of Ea-0643 and 17 patients (group-C) received a placebo tablet. Each tablet was administered orally three times a day for two weeks. There was no significant difference in the background factors between the three groups. The rate of effectiveness for subjective symptoms was 22.2% in group-A, 30.0% in group-B and 35.3% in group-C. There was no significant difference between the three groups. The rate of effectiveness for residual urine, judged by decrease in value of residual urine rate after treatment of less than 25%, was 55.6% in group-A, 35.0% in group-B and 17.6% in group-C. The rate of effectiveness in group-A was significantly higher than that in group-C. The mean value of net decreased residual urine rate after treatment in group-A was significantly higher than that in group-C. Decrease of maximal urethral pressure by more than 5 cm H2O was seen in 44.4% of group-A, 35.0% of group-B and 41.2% of group-C. There was no significant difference between the three groups. The rate of improvement for flow rate was 66.7% in group-A, 46.2% in group-B and 36.4% in group-C.(ABSTRACT TRUNCATED AT 250 WORDS)     

Mechanisms of insulin resistance following injury

To assess the mechanisms of insulin resistance following injury, we examined the relationship between insulin levels and glucose disposal in nine nonseptic, multiple trauma patients (average age 32 years, Injury Severity Score 22) five to 13 days postinjury. Fourteen age-matched normals served as controls. Using a modification of the euglycemic insulin clamp technique, insulin was infused in 35 two-hour studies using at least one of four infusions rates (0.5, 1.0, 2.0 or 5.0 mU/kg min). Basal glucose levels were maintained by a variable infusion of 20% dextrose using bedside glucose monitoring and a servo-control algorithm. The amount of glucose infused reflected glucose disposal (M, mg/kg.min). Tracer doses of (6,6,2D2) glucose were administered in selected subjects to determine endogenous glucose production. At plasma insulin concentrations less than 100 microU/ml, responses in both groups were similar. However, maximal glucose disposal rates were significantly less in the patients than in the controls (9.17 +/- 0.87 mg/kg . min vs. 14.3 +/- 0.78, mean +/- SEM, p less than 0.01). Insulin clearance rates in the patients were almost twice that seen in controls. To further characterize this decrease in insulin responsiveness, we studied six additional patients and 12 controls following the acute elevation of glucose 125 mg/dl above basal (hyperglycemic glucose clamp). In spite of exaggerated endogenous insulin production in the patients (80-200 microU/ml vs. 30--70 in controls), M was significantly lower (6.23 +/- 0.59 vs. 9.46 +/- 0.79, p less than 0.02). In conclusion, this study demonstrated that (1) the maximal rate of glucose disposal is reduced in trauma patients; (2) the metabolic clearance rate of insulin in the injured patients is almost twice normal and; (3) insulin resistance following injury appears to occur in peripheral tissues, probably skeletal muscle, and is consistent with a postreceptor defect.     

Timing of operation based on evaluation of postoperative left ventricular contractility in patients with aortic regurgitation

To evaluate the effect of aortic valve replacement on left ventricular function in aortic regurgitation, the ratio of end-systolic wall stress to end-systolic volume index (ESS/ESVI) and standard ejection phase indexes of left ventricular function were measured angiographically in 29 patients with isolated, chronic aortic regurgitation before and an average of 26 months after aortic valve replacement. The patients were divided into three groups based on preoperative left ventricular volume at end-systole (ESVI); 12 patients had an ESVI smaller than 100 ml/m2 (group I), 11 had an ESVI of 100 to 200 ml/m2 (group II) and 6 had an ESVI greater than 200 ml/m2 (group III). Postoperatively, end-diastolic volume index and ESVI decreased markedly in all 3 groups and end-systolic stress also decreased. Systolic pump performance assessed as ejection phase indexes improved in all groups with group I and group II showing normal or near-normal ejection fraction, while group III still had a depressed ejection fraction. Left ventricular contractile function as assessed by ESS/ESVI improved significantly in each group postoperatively. After operation, group I patients had normal values. However, both group II and group III still had a subnormal ratio, suggesting a depressed contractility despite normal or near normal systolic pump performance. Surgical correction for aortic regurgitation should be considered before a preoperative ESVI exceeds 100 ml/m2, to preserve postoperative left ventricular contractility.     

The influence of preoperative anticoagulation on heparin response during cardiopulmonary bypass.

The effect of preoperative anticoagulant therapy on intraoperative heparin response in patients undergoing cardiac operations was examined in a prospective study. The study included 45 patients with different preoperative anticoagulant treatments: 10 patients received treatment with phenprocoumon (a warfarin analogue) (group M), 12 patients received treatment with intravenous heparin (group Hiv), and 13 patients received treatment with subcutaneous heparin (group Hsc). The control group consisted of 10 patients who did not receive anticoagulant therapy before operation (group C). Preoperative antithrombin III activity was highest in group M (85% +/- 6%) and lowest in group Hiv (70% +/- 15%, p less than 0.05). The activated clotting time, determined 10 minutes after bolus injection of 250 IU (group M) or 375 IU heparin (all other groups), was 529 +/- 109 seconds in group C, greater than 1000 seconds in group M, 483 +/- 99 seconds in group Hsc, and 406 +/- 63 seconds in group Hiv (p less than 0.05). Heparin consumption during cardiopulmonary bypass varied between 4.6 +/- 1.4 IU/kg.min (group Hiv) and 2.6 +/- 0.9 IU/kg.min (group M) (p less than 0.05). Despite this increased heparin consumption, the patients who had received heparin before operation demonstrated increased activation of coagulation at the end of cardiopulmonary bypass (thrombin-antithrombin III complex, 19 +/- 4.1 ng/ml in group M and 61 +/- 7 ng/ml in group Hsc, p less than 0.05; cross-linked fibrin fragments, 257 +/- 92 ng/ml in group M and 875 +/- 152 ng/ml in group Hiv, p less than 0.05). Increased platelet activation was also found in patients with preoperative heparin therapy (beta-thromboglobulin at the end of cardiopulmonary bypass was 585 +/- 88 ng/ml in group M versus 1341 +/- 190 ng/ml in group Hsc, p less than 0.05). Drainage from the chest tube 24 hours after operation was 815 +/- 305 ml in group C, 644 +/- 238 ml in group M, 1133 +/- 503 ml in group Hsc, and 950 +/- 505 ml in group Hiv (p less than 0.05 for group M versus group Hsc). This study suggests that patients who receive heparin therapy before operation face a high risk of insufficient anticoagulation during cardiopulmonary bypass if standard heparin doses are used. Therefore, for patients who receive preoperative heparin therapy, a larger (500 IU/kg) initial bolus of heparin is recommended before cardiopulmonary bypass. On the other hand, patients who undergo preoperative treatment with phenprocoumon receive sufficient anticoagulative effect with a heparin bolus of 250 IU/kg.(ABSTRACT TRUNCATED AT 400 WORDS)