Precardiopulmonary bypass right ventricular function is associated with poor outcome after coronary artery bypass grafting in patients with severe left ventricular systolic dysfunction

Patients with severe left ventricular systolic dysfunction (LVSD) undergoing coronary artery bypass grafting (CABG) have an increased risk for morbidity and mortality. The purpose of this study was to assess the association of pre-CABG right ventricular (RV) function with outcome for patients with severe LVSD. We performed a retrospective evaluation of 41 patients with severe LVSD (left ventricular ejection fraction [LVEF] < or =25%) scheduled for nonemergent CABG. Data were obtained from review of medical records, transesophageal echocardiography tapes, and phone interview. The pre- and post-cardiopulmonary bypass (CPB) LVEF and the RV fractional area of contraction (RVFAC) were calculated by using intraoperative transesophageal echocardiography. Group 1 patients had an RVFAC < or =35% (n = 7), whereas Group 2 patients had RVFAC >35% (n = 34). The durations of mechanical ventilation and of intensive care unit and hospital stays are presented as the median. Pre-CABG LVEF was similar between Groups 1 and 2 (15.8% +/- 3.3% versus 17.8% +/- 3.9%). Compared with Group 2, Group 1 patients required greater duration of mechanical ventilation (12 days versus 1 day; P < 0.01), longer intensive care unit (14 versus 2 days; P < 0.01) and hospital (14 versus 7 days; P = 0.02) stays, had a more frequent incidence and severity of LV diastolic dysfunction, and had a smaller change in LVEF immediately after CPB (4.1% +/- 8.3% versus 12.5% +/- 9.2%; P = 0.03). All Group 1 patients died of cardiac causes within 2 yr of surgery; five died during the same hospital admission. Three Group 2 patients died: one of colon cancer at 18 mo after CABG and two of cardiac causes 24 and 48 mo after surgery. A fourth patient was awaiting cardiac transplantation 4 yr after surgery. The remaining Group 2 patients were New York Heart Association Classification I or II. For patients with severe LVSD undergoing CABG, pre-CPB RV dysfunction was associated with poor outcome. Patients with RVFAC >35% had a relatively uneventful perioperative course and good long-term survival, whereas patients with RVFAC < or =35% had a poor early and late outcome. Assessment of RV function is useful to further assess the risk of CABG. IMPLICATIONS: Right ventricular function before cardiopulmonary bypass is associated with poor outcome after coronary artery surgery in patients with poor left ventricular function.     

Outcome of Isolated Coronary Artery Bypass Surgery in Octogenarians

A bstract Background : 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 octogenarians.     

Evaluation of right ventricular function by intraoperative transesophageal echocardiography for patients with left ventricular dysfunction

We evaluated right and left ventricular function by intraoperative transesophageal echocardiography for the patients with left ventricular dysfunction (left ventricular ejection fraction (LVEF) < or = 40) who underwent isolated coronary artery bypass grafting (CABG). We divided these patients into two groups; group 1 who had difficulty of weaning from cardiopulmonary bypass due to hypotension (n = 8) and group 2 who did not have any difficulty of it (n = 17). Basement characteristics (age, gender, history of myocardial infarction, congestive heart failure, LVEF, severity of the right coronary artery disease) of both groups were not different significantly. Intraoperative characteristics (the number of distal anastomoses, duration of aortic cross-clamp and cardiopulmonary bypass, and bypass to the right coronary artery) were also not different between two groups. However, mean duration of ICU stay and in-hospital mortality were significantly longer and higher in group 1 than group 2. On the other hand, right ventricular systolic function was severely impaired, particularly postoperatively, in group 1 compared with group 2. Right and left ventricular systolic function of group 2 was fairly improved postoperatively. These results may indicate that right ventricular dysfunction is a potent predictor of postoperative morbidity and mortality for the patients with left ventricular dysfunction who undergo isolated CABG.     

Norepinephrine-induced blood pressure rise and renal vasoconstriction are not attenuated by enalapril treatment in microalbuminuric IDDM

Background: In non-diabetic subjects, an attenuated systemic norepinephrine (NE) responsiveness may contribute to the mechanisms of action of angiotensin-converting enzyme (ACE) inhibitor treatment. We determined whether ACE inhibitor treatment influences systemic and renal haemodynamic responsiveness to exogenous NE, as well as urinary albumin excretion during NE, in microalbuminuric insulin-dependent diabetic (IDDM) patients, representing a patient category that benefits by strict blood pressure control. Methods: In seven microalbuminuric IDDM patients, systemic and renal responsiveness to NE, infused at individually determined threshold (&Dgr;mean arterial pressure (MAP)=0 mmHg], 20% pressor (&Dgr;MAP=4 mmHg) and pressor (&Dgr;MAP=20 mmHg) doses, were compared before and after 8 weeks treatment with enalapril, 10 mg daily. Blood glucose was clamped at 5 mmol/l and insulin was infused at 30 mU/kg/h. Results: Enalapril decreased MAP (P<0.05) and microalbuminuria (P<0.05), whereas effective renal plasma flow (ERPF) increased (P<0.01) and glomerular filtration rate remained unaltered. The filtration fraction tended to decline (P=0.09). The ACE inhibitor-induced fall in MAP disappeared at NE pressor dose, and the overall mean increase in MAP in response to NE was even higher with than without enalapril (P<0.05). After enalapril, the ERPF remained higher at all NE doses (P<0.05), but the magnitude of the NE-induced fall in ERPF was not altered by ACE inhibition treatment. Overnight urinary albumin excretion fell with ACE inhibition (P<0.05), but this effect was not seen during NE infusion. The angiotensin II/active renin ratio and serum aldosterone levels remained lower with enalapril at all NE doses (P<0.05). <It>Conclusions:Enalapril does not attenuate systemic and renal vascular responsiveness to exogenous NE in microalbuminuric IDDM despite adequate inhibition of the renin-angiotensin-aldosterone system. These findings suggest that the effect of NE on vasoconstriction is not counteracted effectively by ACE inhibition treatment alone.     

Aortic valve replacement: a safe and durable option in patients with impaired left ventricular systolic function.

BACKGROUND: The natural history of aortic valve disease associated with ventricular dysfunction is dismal. Aortic valve replacement (AVR) is associated with increased mortality in patients with left ventricular dysfunction and the long-term outcome in these patients is not well-known. We evaluated perioperative outcomes and long-term results in patients with impaired left ventricular systolic function undergoing AVR. METHODS: Retrospective analysis identified 132 consecutive patients with a left ventricular ejection fraction (LVEF)<40% who underwent AVR with or without concomitant coronary artery bypass grafting (CABG) between 1990 and 2003. Patients with other valve pathology were excluded. RESULTS: Ages ranged from 29 to 94 years (mean 63+/-12), and 117 patients (89%) were male. Preoperatively, 82% were in NYHA III-IV. Sixty patients (45%) underwent AVR for severe aortic stenosis (AS) whilst 72 (55%) had aortic insufficiency (AI). In the AS group, the mean LVEF and aortic valve area were 26+/-4% and 0.8+/-0.4 cm(2), respectively. AI patients had a mean LVEF of 27+/-6% and a mean left ventricular end systolic diameter of 52+/-9 mm. Fifty-seven (43%) required concomitant CABG. There were only three perioperative deaths (2.3%) and no strokes. One patient (0.8%) had postoperative renal failure, and one suffered a myocardial infarct. Nine patients (6.9%) required a postoperative IABP. LVEF increased to 29+/-10% and 34+/-12% after six months in the AS and AI groups, respectively. The mean follow-up period was 6.1 years and no differences between the AS and AI groups were observed with respect to either perioperative or long-term outcomes. Overall survival was 96%, 79% and 55% at 1, 5 and 10 years, respectively. CONCLUSIONS: The long asymptomatic course of AS and AI means that many patients have impaired ventricular function at diagnosis. This study demonstrates that AVR in such patients can be performed with low perioperative morbidity and mortality. The outlook after surgery is excellent. A 10-year-survival of 55% compares favourably with heart transplantation and particularly with medical therapy. AVR is a safe, effective and durable option, which should not be denied to patients on the basis of low LVEF alone.     

Does off‐pump coronary artery bypass grafting beneficially affect renal function?

BACKGROUND: Off-pump coronary artery bypass grafting (CABG) has been reported to beneficially affect renal function, but this remains to be confirmed. The purpose of the present paper was to study the effects of off-pump CABG on renal function and analyse predictors of postoperative renal impairment in patients who received off-pump CABG. METHODS: A total of 451 patients who underwent isolated CABG between January 1999 and August 2003 were retrospectively studied. No patient was receiving dialysis. A total of 300 patients (228 men) underwent off-pump CABG (off-pump group) and 151 patients (104 men) underwent on-pump CABG (on-pump group). Perioperative serum creatinine levels and creatinine ratios (peak postoperative creatinine level/preoperative creatinine level) were compared between the groups. RESULTS: Renal impairment (serum creatinine >1.5 mg/dL) developed postoperatively in 12.7% of the off-pump group and 18.5% of the on-pump group (P = 0.1). The creatinine ratio was significantly lower in the off-pump group (1.2 +/- 0.4) than in the on-pump group (1.4 +/- 0.7, P = 0.003). Logistic regression analysis demonstrated that the strongest predictors of postoperative renal impairment in off-pump CABG were left ventricular dysfunction (odds ratio 10.8) and multivessel grafting (odds ratio 4.3). CONCLUSIONS: Off-pump CABG provides better renal protection than on-pump CABG. However, perioperative renal function should be closely monitored in patients who have left ventricular dysfunction or who undergo multivessel grafting, even when off-pump CABG is performed.     

冠状动脉旁路移植术后急性肾功能不全的危险因素分析

目的探讨冠状动脉旁路移植术（CABG）后急性肾功能不全（ARI）的危险因素。方法回顾性分析1997年7月至2006年7月完成的2242例CABG的临床资料,统计术后ARI的发生率并对其危险因素进行分析。结果CABG术后219例发生ARI,占总例数的9．8％,单因素分析显示年龄370岁、糖尿病、术前慢性肾功能不全、左主干病变、射血分数（EF）40．35、急诊CABG、体外循环下CABG、升主动脉粥样硬化、术后呼吸功能不全与术后低心排与CABG术后ARI有关,Logistic多元回归分析提示年龄370岁（P=0．031）、术前慢性肾功能不全（肌苷清除率≤60ml／min,P=0．023或血清肌苷含量≥150μmol／L,P=0．041）、体外循环下CABG（P〈0．001）、术后呼吸功能不全（P=0．013）与低心排综合征（P=0．004）是CABG术后ARI的独立危险因素。结论年龄370岁、术前慢性肾功能不全、体外循环下CABG、术后呼吸功能不全与低心排是影响CABG术后发生ARI的危险因素。     

Coronary artery bypass grafting in the patients with renal dysfunction

We studied coronary artery bypass grafting (CABG) in patients with renal dysfunction. From April 1994 to October 1999, 59 patients with renal dysfunction underwent CABG. The patients were divided into 2 groups: group A: 18 patients with end stage renal disease who were receiving hemodialysis, group B; 41 patients with creatinine levels higher than 1.5 mg/dl who were not supported by dialysis. We compared and analyzed the findings of there 2 groups. Regarding preoperative factors, the incidence of old myocardial infarctions, diabetes mellitus and old cerebral infarctions did not differ significantly between the 2 groups. Regarding perioperative factors, the incidence of the number of vessel diseases, emergency operations, operation times and blood transfusions did not differ significantly between the 2 groups. Regarding the post-operative course, the hospital mortality rates demonstrated low levels in 2 groups. The graft patency of group A was 95%, while it was 99% in group B. The post-operative in-hospital days was 24.8 days in the group A, while it was 30.1 days in the group B. No significant difference was observed between the 2 groups. As a results, post-operative hemodialysis was needed in 8 of the patients who underwent on-pump CABG from group A. The actual survival rates were 75.3% in group A and 84.3% in group B at 4 years. The cardiac event free rate for group A was 93.3%, while it was 97.5% in group B at 4 years. In conclusion, CABG may improve the post-operative outcome in renal dysfunction patients. In addition, the use of off-pump CABG is also considered to achieve a better renal function than on-pump CABG.     

Efficacy of additional Dor approach to coronary bypass grafting in severe left ventricular dysfunction with large akinetic area

Between January 1994 and August 1999, we experienced 16 cases of coronary artery bypass grafting (CABG) in severe left ventricular dysfunction with left ventricular ejection fraction (LVEF) < or = 40%. Four had additional endoventricular patch plasty in large postinfarction akinetic scars, the so-called Dor approach, to CABG (group D). Eleven had only CABG, or CABG and mitral annuloplasty (group C). One had linear repair after the resection of the left ventricular aneurysm. One died of sustained low output syndrome 5 months after the operation in group C. Fractioning shortening and left ventricular diastolic diameter were not changed after the operation in group C. On the other hand, in group D, there were no complications after the operation, LVEF was significantly improved from 31.5 +/- 4.9% to 62.5 +/- 5.9% (p < 0.01) and the left ventricular end-diastolic volume index was reduced from 118 +/- 23 ml/m2 to 74 +/- 12 ml/m2 (p < 0.01). The Dor approach is considered to be a safe and effective additional procedure to CABG in severe patients with a large akinetic antero-septal segment.     

Late Results with Concomitant Coronary Artery Bypass Grafting and ICD Implantation

A bstract Background : 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 time of surgery.     

Effects of angiotensin converting enzyme inhibition on sodium excretion in patients with hypoxaemic chronic obstructive pulmonary disease.

BACKGROUND--Some patients with hypoxaemic chronic obstructive pulmonary disease (COPD) develop cor pulmonale with sodium and water retention. The sodium retention has been explained as a result of increased plasma levels of aldosterone. If this was true angiotensin converting enzyme (ACE) inhibition would be expected to lower plasma levels of aldosterone and improve the renal excretion of sodium. METHODS--Six patients with stable hypoxaemic COPD (PaO2 < 8.0 kPa) and a history of an oedematous exacerbation received an intravenous hypertonic saline load (6 ml/kg body weight of 2.7% saline over one hour) before and while taking 4 mg/day perindopril, an ACE inhibitor, for one month. Aldosterone, antidiuretic hormone (ADH), plasma and urine electrolyte levels, osmolality, and volume were measured over four hours. The repeatability of the saline load test was assessed in six patients with a similar severity of hypoxaemic COPD. For comparison the saline load test was also performed in six patients with mild COPD. RESULTS--The hypertonic saline load test results were repeatable. Perindopril reduced the mean (SD) plasma level of aldosterone from 142 (88) pg/ml to 54 (24) pg/ml at 0 minutes before the saline infusion, and from 64 (35) pg/ml to 30 (17) pg/ml after the infusion without improving the urinary volume or sodium excretion. Before starting treatment with perindopril 43.7 (6.9) mmol (20%) of the sodium load was excreted compared with 49.6 (7.9) mmol (22% of load) when taking perindopril. Patients with mild COPD excreted more sodium (77.6 (21.4) mmol (38.7% of load)) despite having similar plasma aldosterone levels to those in the patients receiving perindopril. CONCLUSIONS--Patients with stable hypoxaemic COPD have an impaired ability to excrete sodium which is not improved by the administration of an ACE inhibitor. ACE inhibition lowered the plasma level of aldosterone without improving sodium excretion. This suggests that the inability of patients with hypoxaemic COPD to excrete sodium is not caused by their increased plasma levels of aldosterone.     

ACE inhibitors captopril and enalapril induce regression of left ventricular hypertrophy in hypertensive patients with chronic renal failure

Background. Left ventricular hypertrophy is frequently noted in patients with moderate to severe chronic renal failure not requiring dialysis. Recently, several studies have shown reversal of myocardial hypertrophy in end-stage renal disease with long-term pharmacological control of blood pressure, but it is unclear whether left ventricular mass regresses or normalizes with antihypertensive treatment of patients with earlier stages of chronic renal failure. Methods. Seventy-two undialysed patients with chronic renal failure, chronic mild-to-moderate hypertension, and left ventricular hypertrophy were randomly assigned in a prospective study to either the captopril (n = 36) or enalapril group (n = 36). Blood pressure measurements, echocardiographic and Doppler parameters were evaluated before treatment and at 6 and 12 months of therapy. Results. During follow-up, six patients developed side-effects including dry cough, taste disturbances, skin rash and gastric intolerance. In the captopril group there was a decrease in mean left ventricular mass index by 12% after 6 months of treatment, which decreased by 20% after 12 months treatment. For enalapril, the average reduction of myocardial mass after 6 months treatment was 14% and after 12 months treatment, the decrease was 19%. In both treatment groups there was significant improvement of left ventricular filling dynamics. No deterioration of left ventricular systolic function was observed. Conclusions. Our results confirm that antihypertensive monotherapy with the ACE inhibitors, captopril and enalapril, in patients with chronic renal failure results in regression of left ventricular mass index associated with a significant improvement in the diastolic function of the left ventricle without a demonstrable deterioration in left ventricular systolic performance.     

Coronary artery bypass grafting in patients with severe left ventricular dysfunction--early and mid-term outcomes

BACKGROUND: The prevalence of patients with severe left ventricular dysfunction (LVD) referred for coronary artery bypass grafting (CABG) is increasing. The aim of the present study was to assess the outcomes of patients with severe LVD undergoing CABG. METHODS: Outcomes of 115 consecutive patients with severe LVD (left ventricular ejection fraction [LVEF]30% (HEF). To further evaluate the LVD patients, they were divided into three subgroups base on LVEF: 0% to 10%, 11% to 20%, and 21% to 30%. Data were collected prospectively and entered into the departmental database of the Society of Thoracic Surgeons. RESULTS: Patients in the LVD group had increased incidence of diabetes, chronic obstructive pulmonary disease (COPD), peripheral vascular disease, prior myocardial infarction (MI), congestive heart failure, and less elective procedures compared to the HEF group. Despite this greater risk profile, operative mortality (LVD 2.6% vs. HEF 1.2%, p = 0.19), the incidence of stroke (2.6% vs. 1.0%, p = 0.13), and perioperative MI (0.9% vs. 0.7%) were not statistically different between the groups. The incidence of respiratory (14.8% vs. 1.9%, p < 0.001), renal (5.2% vs. 1.0%, p < 0.001), and vascular (5.2% vs. 0.5%, p < 0.001) complications was significantly higher in the LVD group, resulting in a longer hospital length of stay (8 +/- 8 vs. 6 +/- 4 days, p < 0.0001). In a multivariate analysis, advanced age was as an independent predictor of hospital mortality. Average follow-up in 108 (94%) LVD patients was 36 +/- 22 months (range 2 to 78 months). Twenty-one patients expired during the follow-up, for nine the causes were cardiac-related. Three- and 5-year survival rates were 91 +/- 3% and 76 +/- 6%, respectively. Independent predictors of mid-term mortality in the LVD group by a multivariate analysis included female gender, renal failure, respiratory complications, and grade I/II mitral regurgitation (MR). At the time of follow-up, 72% of LVD patients were in functional class I/II. There were no statistically significant differences in short- and mid-term outcomes among the LVD subgroups. CONCLUSION: CABG in patients with severe LVD can be performed with a low mortality, albeit with higher morbidity and longer length of hospital stay, than patients with LVEF >30%. Low ejection fraction per se was not a predictor of hospital mortality. CABG should be considered a safe and effective therapy for low ejection fraction patients with ischemic heart disease. Mitral valve repair/replacement in the presence of moderate degree of MR should be considered at the time of the initial operation.     

Ischaemic preconditioning has a beneficial effect on left ventricular haemodynamic function after a coronary artery biopass grafting operation

OBJECTIVE: Ischaemic preconditioning (IP) is the most effective procedure for endogenous myocardial protection. However, studies on the effects of IP in cardiac surgery are rare and controversial. The present aim was to investigate whether IP improves the haemodynamic recovery of CABG patients. DESIGN: The study included 40 stable CABG patients with 3-vessel disease, randomized into an IP group (n = 20) and a control group (n = 20). In the IP group two cycles of 2-min ischaemia following 3-min reperfusion before cross-clamping were induced. The haemodynamics of the patients were followed-up to the first postoperative morning. RESULTS: The cardiac index decreased at 1 and 6 h after surgery in the control group but increased in the IP group (-0.33 vs 0.09 l/min/m2, p = 0.02 and -0.15 vs 0.57 l/min/m2, p = 0.001, respectively). Depressions in the left ventricular stroke work index and the right ventricular stroke work index at 6 h after surgery were more severe in controls and were statistically significant (p = 0.049 and 0.007, respectively). Less inotropic support was used in the IP group. There were no differences in serum CK-MB, cardiac troponin I, myoglobin or lactate values between the two groups. CONCLUSION: IP has a beneficial effect on left ventricular haemodynamic recovery after a CABG operation.     

Treatment of IgA nephropathy with ACE inhibitors: a randomized and controlled trial

Some retrospective studies have suggested a beneficial influence of angiotensin-converting enzyme (ACE) inhibitors on the progression of IgA nephropathy (IgAN), but prospective and controlled studies demonstrating this effect are lacking. Forty-four patients with biopsy-proven IgAN, proteinuria > or = 0.5 g/d, and serum creatinine (SCr) < or = 1.5 mg/dl were randomly assigned either to receive enalapril (n = 23) or to a control group (n = 21) in whom BP was controlled with antihypertensives other than ACE inhibitors. Primary outcome was renal survival estimated by a 50% increase in baseline SCr. Secondary outcomes were the presence of a SCr > 1.5 mg/dl at the last visit and the evolution of proteinuria. Baseline clinical findings were similar at baseline between enalapril-treated and control group, and there were no differences in BP control during follow-up. Mean follow-up was 78 +/- 37 mo in the enalapril group and 74 +/- 36 mo in the control group. Three patients (13%) in the enalapril group and 12 (57%) in the control group reached the primary end point (P < 0.05). Kaplan-Meier renal survival was significantly better in enalapril group than in control group: 100% versus 70% after 4 yr and 92% versus 55% after 7 yr (P < 0.05). Three patients in the enalapril group (13%) and 11 (52%) in the control group showed SCr > 1.5 mg/dl at the last visit (P < 0.05). Proteinuria significantly decreased in the enalapril group, whereas it tended to increase in the control group (P < 0.001 between groups). In conclusion, ACE inhibitors significantly improve renal survival in proteinuric IgAN with normal or moderately reduced renal function.     

The analysis of renal function in off-pump coronary artery bypass grafting

OPCAB (off-pump coronary artery bypass grafting) is useful for preventing post-operative neurologic complications. On the other hand, the effect of OPCAB on post-operative renal function is still unclear. We analyzed the post-operative renal function in 39 patients. Thirty-two patients had normal pre-operative renal function (CRE < or = 1.4 mg/dl). Thirty-one patients were doing well in terms of post-operative renal function. Only 1 patient needed hemodialysis (HD) because of systemic infection in early post-operative period. Another 7 patients had pre-operative renal dysfunction (CRE > or = 1.5 mg/dl). Three cases with high-grade pre-operative renal dysfunction (CRE > 3.0 mg/dl and CCR < 20 ml/min) needed temporary HD or continuous hemo-diafiltration (CHDF) in early post-operative period, and then they needed maintenance HD for the treatment of chronic renal failure within 3 weeks after OPCAB. Three of 4 cases with low-grade pre-operative renal dysfunction (CRE: 1.9-2.7 mg/dl and CCR: 22-42 ml/min) needed temporary HD or CHDF in early post-operative period. These 3 patients were relieved of the early post-operative renal failure, but required maintenance HD in the late periods. In summary, OPCAB could not prevent the development of acute renal failure in the patients with pre-operative renal dysfunction.     

Differential survival after coronary revascularization procedures among patients with renal insufficiency.

BACKGROUND: Acute myocardial infarction, cardiac arrest, and other cardiac events are the major cause of mortality among patients with renal insufficiency. Previous studies of interventions for coronary artery disease among patients with renal insufficiency have not controlled for potentially confounding factors such as coronary artery disease severity and left ventricular function. This study investigates the comparative survival for patients with renal insufficiency and coronary artery disease following coronary artery bypass graft (CABG) surgery as compared with percutaneous coronary artery intervention (PCI), while controlling for confounding factors. METHODS: This retrospective cohort study of patients undergoing CABG surgery or PCI discharged between 1993 and 1995 uses the New York Department of Health databases and Cox proportional hazards analyses to estimate the mortality risk associated with CABG as compared with PCI for patients with renal insufficiency. Renal function was categorized as creatinine <2.5 mg/dL (N = 58,329), creatinine > or =2.5 mg/dL (N = 840), and end-stage renal disease (ESRD) requiring dialysis (N = 407). RESULTS: Patients with either ESRD or serum creatinine > or =2.5 mg/dL had more severe coronary artery disease and a greater frequency of comorbid conditions as compared with patients with creatinine <2.5 mg/dL. Creatinine > or =2.5 mg/dL and ESRD were both associated with an increased mortality risk among all distributions of coronary artery disease anatomy. Among patients with ESRD, the risk ratio (RR) of mortality for patients undergoing CABG compared with PCI was 0.39 (95% CI, 0.22 to 0.67, P = 0.0006). Among patients with creatinine > or =2.5 mg/dL, CABG surgery did not convey a survival benefit over PCI (RR, 0.86, 95% CI, 0.56 to 1.33, P = 0.50). CONCLUSIONS: This study demonstrates a survival benefit among patients with ESRD undergoing CABG surgery as compared with PCI, while controlling for severity of coronary artery disease, left ventricular dysfunction, and other comorbid conditions. These results suggest that management decisions among patients with coronary artery disease should be made in the context of not only location and severity of coronary artery lesions, but also on the presence and severity of renal dysfunction.     

Coronary artery bypass surgery in patients with severely impaired left ventricular function]

The efficacy and problem of coronary artery bypass grafting (CABG) in patients with severely impaired left ventricular function (left ventricular ejection fraction < or = 30%) were assessed in 27 patients of whom 17 (group 1) underwent emergent CABG and 10 (group 2) elective between Jan 1984 to Aug 1990. As a whole, history of myocardial infarction (24/27, 88.9%), large left ventricular volume with reduced ejection fraction (LVEDVI 126.08 +/- 25.91 ml/m2, LVESVI 93.04 +/- 21.02 ml/m2, LVEF 25.04 +/- 4.75%) and multiple vessel disease with at least one vessel total occlusion (20/27, 74.1%) were characteristically seen in these patients. The patients of group 1 were significantly older (mean 66.12 +/- 5.68 vs 57.10 +/- 8.08, p < 0.01) and needed more frequent preoperative support with IABP (17/17 vs 4/10, p < 0.01). Using Thallium-201 scintigraphy, in 10 patients of group 1 and 9 of group 2, myocardial viability in the proposed bypass area was evaluated before operations. Average 2.37 +/- 0.79 grafts were placed and continuous retrograde cold blood cardioplegia via the coronary sinus was employed for myocardial protection. Two mitral annuloplasty (MAP) for ischemic mitral regurgitation and 2 cryoablation for the treatment of ventricular tachycardia were performed concomitantly. Operative mortality was 47.1% in group 1 and none in group 2 (p < 0.05). Two cases of MAP died, but two cases of cryoablation survived. Postoperative LVEF was improved significantly only in group 2 (p < 0.05), but during the follow-up period of 7 months to 6 years, all 19 survivors expect one remains with NYHA class I or II.(ABSTRACT TRUNCATED AT 250 WORDS)     

Long-term effects of angiotensin-converting enzyme inhibition and metabolic control in hypertensive type 2 diabetic patients

Long-term effects of angiotensin-converting enzyme inhibition and metabolic control in hypertensive type 2 diabetic patients. BACKGROUND: In hypertensive type 2 diabetic patients, treatment with angiotensin-converting enzyme (ACE) inhibitors is associated with a lower incidence of cardiovascular events than those treated with calcium channel-blocking agents. However, the long-term renal effects of ACE inhibitors in these patients remain inconclusive. In 1989, we commenced a placebo-controlled, double-blind, randomized study to examine the anti-albuminuric effects of enalapril versus nifedipine (slow release) in 102 hypertensive, type 2 diabetic patients. These patients have been followed up for a mean trial duration of 5.5 +/- 2.2 years. We examined the determinants, including the effect of ACE inhibition on clinical outcomes in these patients. METHODS: After a six-week placebo-controlled, run-in period, 52 patients were randomized double-blind to receive nifedipine (slow release) and 50 patients to receive enalapril. After the one-year analysis, which confirmed the superior anti-albuminuric effects of enalapril (-54%) over nifedipine (+11%), all patients were continued on their previously assigned treatment with informed consent. They were subdivided into normoalbuminuric (N = 43), microalbuminuric (N = 34), and macroalbuminuric (N = 25) groups based on two of three 24-hour urinary albumin excretion (UAE) measurements during the run-in period. Renal function was shown by the 24-hour UAE, creatinine clearance (CCr), and the regression coefficient of the yearly plasma creatinine reciprocal (beta-1/Cr). Clinical endpoints were defined as death, cardiovascular events, and/or renal events (need for renal replacement therapy or doubling of baseline plasma creatinine). RESULTS: In the whole group, patients treated with enalapril were more likely to revert to being normoalbuminuric (23.8 vs. 15.4%), and fewer of them developed macroalbuminuria (19.1 vs. 30.8%) compared with the nifedipine-treated patients (P < 0.05). In the microalbuminuric group, treatment with enalapril (N = 21) was associated with a 13.0% (P < 0.01) reduction in 24-hour UAE compared with a 17.3% increase in the nifedipine group (N = 13). In the macroalbuminuric patients, enalapril treatment (N = 11) was associated with stabilization compared with a decline in renal function in the nifedipine group, as shown by the beta-1/Cr (0.65 +/- 4.29 vs. -1.93 +/- 2.35 1/micromol x 10-3, P < 0.05) after adjustment for baseline values. Compared with the normoalbuminuric and microalbuminuric patients, those with macroalbuminuria had the lowest mean CCr (75.5 +/- 24.1 vs. 63.5 +/- 21.3 vs. 41.9 +/- 18.5 mL/min, P < 0.001) and the highest frequency of clinical events (4.7 vs. 5.9 vs. 52%, P < 0. 001). On multivariate analysis, beta-1/Cr (R2 = 0.195, P < 0.001) was independently associated with baseline HbA1c (beta = -0.285, P = 0.004), whereas clinical outcomes (R2 = 0.176, P < 0.001) were independently related to the mean low-density lipoprotein cholesterol (beta = 2.426, P = 0.018), high-density lipoprotein cholesterol (beta = -8.797, P = 0.03), baseline UAE (beta = 0.002, P = 0.04), and mean CCr during treatment (beta = -0.211, P = 0.006). CONCLUSION: In this prospective cohort analysis involving 102 hypertensive, type 2 diabetic patients with varying degrees of albuminuria followed up for a mean duration of five years, we observed the importance of good metabolic and blood pressure control on the progression of albuminuria and renal function. Treatment with enalapril was associated with a greater reduction in albuminuria than with nifedipine in the entire patient group, and especially in those with microalbuminuria. In the macroalbuminuric patients, the rate of deterioration in renal function was also attenuated by treatment with enalapril.     

No effect of enalapril on progression in autosomal dominant polycystic kidney disease.

BACKGROUND: Angiotensin-converting enzyme (ACE) inhibitors are capable of reducing proteinuria and microalbuminuria with preservation of renal function in diabetic and non-diabetic renal disease. We designed a study investigating the effect of enalapril on the protection of renal function in autosomal dominant polycystic kidney disease (ADPKD). METHODS: We studied 61 normotensive and 28 hypertensive ADPKD patients. The normotensive group participated in a randomized double-blind placebo-controlled study, using enalapril. The hypertensive group was randomized for open label treatment with enalapril or the beta-blocker atenolol. The follow-up was 3 years, and renal function was established repetitively by measuring the clearance of inulin. RESULTS: In the normotensive group, renal function at baseline was 112 +/- 3 ml/min and decreased by -8 +/- 2 ml/min (P < 0.001). The loss of renal function in the patients treated with enalapril or placebo was similar (-7 +/- 3 vs -9 +/- 1 ml/min; P = 0.4). Although blood pressure significantly decreased with enalapril treatment, it had no effect on microalbuminuria. In the hypertensive group, renal function at baseline was 89 +/- 2 ml/min. The mean decline in renal function was -12 +/- 2 ml/min (P < 0.001), and was equal in patients treated with enalapril and those treated with atenolol. The patients treated with atenolol required more additional treatment to control blood pressure, but no difference on microalbuminuria was observed between the two treatments. CONCLUSION: This study was unable to detect a beneficial effect of ACE inhibition on loss of renal function in ADPKD patients.