Left heart pump-assisted beating heart coronary surgery in high-risk patients

A simple technique of left ventricular assistance, offering the advantages of both cardiopulmonary bypass and off-pump revascularization, was adopted for high-risk patients. It was used in 56 patients with critical left main stenosis and occluded right coronary artery, severely reduced ejection fraction and/or unstable angina. All patients underwent complete and successful myocardial revascularization (3.4 grafts per patient). Weaning from the pump was uncomplicated, and none required conversion to full cardiopulmonary bypass.     

Metabolic and hemodynamic features of elderly patients undergoing beating heart coronary artery bypass graft surgery

AIM: Coronary artery bypass graft (CABG) surgery, nowadays, is increasingly performed in patients who are older and have more comorbidities than subjects operated on a decade ago. In this study, we investigated metabolic and hemodynamic features of elderly patients with single vessel coronary artery disease (CAD), undergoing beating heart coronary artery bypass graft (BHCABG) surgery. METHODS: Twenty-five elderly patients, ages 73-78 years, with isolated left anterior descending artery (LAD) disease, were enrolled and compared to a younger similar group of 25 patients, mean age 48+/-1.2 years. A single vessel left internal mammary artery (LIMA) to LAD BHCABG was performed in all patients. Duration of temporary LAD occlusion was 9.8+/-0.5 min in the elderly group, and 10+/-0.4 min in the younger group. Myocardial arterial-venous differences in glucose, lactate, and creatine phosphokinase (CPK) were performed at different time points: preoperatively in the operating room (T0); at the end of the grafting procedure (T1); and before closing the chest (T2). Left ventricular stroke work index (LVSWI), as an indicator of global function of left ventricle, were recorded at T0, T1, T2, 6 (T3) and 48 (T4) hours postoperatively. RESULTS: Preoperative glucose extraction, observed in both groups, did not augment during and after surgery. In addition, neither lactate nor CPK were released in the coronary sinus during temporary LAD occlusion and following reperfusion in either group. Similarly, no significant changes in LVSWI were observed intra- and perioperatively between the two groups. CONCLUSIONS: Cardiac metabolism, hemodynamic parameters and global left ventricular function were not affected in either group by brief LAD occlusion during BHCABG, suggesting that BHCABG is a well-tolerated surgical approach, which can be safely attempted in patients of any age.     

Coronary bypass surgery on the beating heart and surgery of an abdominal aortic aneurysm. Immediately sequential surgical treatments

The authors report sequential association during the same general anaesthetic of coronary bypass surgery on the beating heart and surgery of an abdominal aortic aneurysm. Two aorto-coronary bypass grafts were carried out without cardiopulmonary bypass using the two pediculated internal mammary arteries (without manipulation of the ascending aorta), followed, after closure of the chest and monitoring in the operating theatre for one hour, by reinstallation of the patient for treatment of an infra-renal abdominal aortic aneurysm by classical prosthetic implantation. The postoperative course was uncomplicated. Sequential management of coronary revascularisation without cardiopulmonary bypass and aortic aneurysmal lesions during the same anaesthetic provides an alternative to classical two-stage surgery in selected patients.     

依达拉奉在心脏不停跳手术中的肺保护作用

目的探讨依达拉奉在心脏不停跳手术中对肺功能的保护作用。方法将60例需行二尖瓣置换术的风湿性心脏病患者随机分成实验组、对照组各30例。实验组于预充液中按0.5 mg/kg加入依达拉奉,对照组加入等量生理盐水。分别于术前、转机30 min、停机、术毕、术后24 h、术后72 h各时点检测血浆IL-6、IL-8含量,并于术前、停机、停机后1 h、术毕记录气道峰压、潮气量,并行动脉血气分析,计算动态肺顺应性、肺泡—动脉血氧分压差、氧合指数。结果两组IL-6、IL-8浓度水平均随体外循环及手术时间逐渐增高,于手术结束时达高峰,术后24 h下降,实验组IL-6、IL-8低于对照组（P〈0.01）。两组气道峰压、肺泡—动脉血氧分压差自手术开始后升高,动态肺顺应性、氧合指数自手术开始后下降,依达拉奉组结果优于对照组（P〈0.01）。结论依达拉奉可清除体内过量生成的氧自由基及减少炎性因子的生成,减轻全身炎性反应及肺组织损伤,具有减轻体外循环急性肺损伤的作用。     

65岁以上老年冠心病患者PTCA治疗

目的总结老年冠心病患者的冠状动脉病变特征、PTCA治疗结果和预后情况.方法53例老年冠心病患者中,男35例,女18例,33例为急性Q波心肌梗死,2例为急性非Q波心肌梗死,14例为不稳定心绞痛,4例为冠心病合并严重心力衰竭.采用传统的PTCA方法,必要时插入预防性临时起搏器.如涉及小血管病变、多支血管弥漫性病变或一次行2支血管PTCA,术后使用肝素治疗.结果老年冠心病患者多存在多支、弥漫性严重冠状动脉粥样硬化,病变复杂,手术难度大,手术成功率为98%,住院期间死亡率为11%.30例病人接受了(8.7±5.4)个月的临床随访,11例(36%)病人有心绞痛复发,1例病人(3.5%)发生心肌梗死,1例(3.5%)病人在术后2个月发生脑梗死死亡,其余17例(57%)无症状.结论对老年冠心病患者进行介入治疗是可行的.老年冠心病患者病变复杂,手术难度大,住院期间死亡率和后期的症状复发率都较高.但是只要对病情估计充分、操作得当,老年冠心病患者的介入治疗仍是优于单纯内科保守治疗的方法.     

Results of video-assisted mitral surgery in a non-selected population

A prospective 'analysis of operative risk and results in video-assisted mitral valve surgery performed in a non selected population is reported. Seventy two consecutive patients (1997-2004) with mean age 60 +/- 12 years underwent a video-assisted mitral valve procedure using a femoral CPB. A transthoracic direct aortic clamping was done in 28 patients (TT) and an endo-aortic occlusion balloon was used in 44 patients (Endo). The surgical approach was a right lateral minithoracotomy in all cases; 16 patients had a previous cardiac surgery. The expected mitral operation (39 repairs, 33 replacements) was done in all cases, without conversion. There were 4 early deaths (1 st month), all in Endo group: 1 aortic dissection, 1 heart failure and 2 sudden deaths. Postoperative complication occurred in 17 patients with 5 reoperations for hemostasis of the thoracic wall. Cumulative rate of mortality and morbidity was 29% in Endo and 28% in TT (ns). Hospital stay was 8 +/- 2 days. At discharge, 4 patients had a residual grade 2 echocardiographic mitral regurgitation after valve repair. In January 2005, with a 1.8 years follow-up, there were 4 late deaths, 3 patients underwent a valve reoperation, 2 patients were still in NYHA class 3 and 5 patients had a residual grade 1 or 2 mitral regurgitation. The 3-year actuarial survival was 86 +/- 10% and the 3-year probability to be free of reoperation was 95 +/- 6%. In mitral valve surgery, video-assisted approach is reliable, the operative risk is controlled and midterm results are not compromised. Video-assisted mitral valve surgery is a new less invasive standard; it is the procedure of choice in valve replacement, in reoperation and in non complex valve repair with good cosmetic results.     

First clinical experience of a novel penetration catheter for patients with severe coronary artery stenosis.

The study aimed to evaluate the efficacy of a novel penetration catheter for severe coronary artery disease. Severe coronary artery diseases such as chronic total occlusions or severe calcified stenoses sometimes obstruct the subsequent crossing of balloon catheter after successful wire crossing. A novel penetration over-the-wire catheter has been developed for severe coronary artery disease. The main shaft is a coreless stainless coil that consists of eight stranded stainless wires to cross through a severe stenosis by manual rotation. This device was applied during percutaneous coronary intervention for patients with severe coronary artery disease obstructing the subsequent crossing of balloon or microcatheters after successful wire crossing. Initial results were examined. Fourteen eligible patients were enrolled consecutively. Among those, 10 patients had chronic total occlusion and 7 patients showed severe angiographical calcification. The device was successfully crossed through the lesion and enabled subsequent dilatation in all patients without any complication. This new device enables the crossing of severe coronary artery stenoses and therefore favors further dilatation in this lesion subset.     

The heart in systemic lupus erythematosus. Study in 32 non-selected patients (author's transl)

Cardiovascular manifestations of Systemic Lupus Erythematosus (SLE) in 32 unselected patients, with active disease were reviewed. Primary cardiac disease manifested as pericarditis (22%), myocarditis (16%), and valvular disease (9%), was recognized along with secondary disease as heart failure with or without systemic hypertension. Comparison with previous work by others, suggest that our cases are more representative of actual clinical picture of cardiac SLE. It is interesting to notice tht 9% of our patients had valvular disease, and this alteration is only occasionally found in other Hospitals. Valvular disease is rarely noticed during life, although is highly prevalent in autopsy series. We stress the diagnosis and management of the cardiac manifestations of SLE, in order to lower the morbidity and mortality of this condition.     

Effect of coronary occlusion on left ventricular function with and without collateral supply during beating heart coronary artery surgery

OBJECTIVE: To study the effects of coronary occlusion and collateral supply on left ventricular (LV) function during beating heart coronary artery surgery. DESIGN: Prospective intraoperative study, performed at baseline, during wall stabilisation, coronary artery occlusion, and 2 and 10 minutes after reperfusion. Transoesophageal M mode echocardiograms, simultaneous high fidelity LV pressure, and thermodilution cardiac output were measured. LV anterior wall thickening, thinning velocities, thickening fraction, regional work, and power production were derived. Asynchrony during the isovolumic periods was quantified as cycle efficiency. SETTING: Tertiary referral cardiac centre. PATIENTS: 14 patients with stable angina, mean (SD) age 62 (7) years, undergoing left anterior descending artery grafting using the "Octopus" device. RESULTS: Collaterals were absent in nine patients and present in five. Epicardial stabilisation did not affect LV function. Results are expressed as mean (SD). Coronary occlusion (15.6 (2) minutes) depressed anterior wall thickening (1.4 (0.6) v 2.6 (0.6) cm/s) and thinning velocities (1.4 (0.5) v 3.0 (0.6) cm/s), regional work (2.2 (0.8) v 4.6 (0.6) mJ/cm2), and power (21 (4) v 33 (5) mW/cm2) in patients without collaterals (p < 0.05 for all), but only wall thinning (3.5 (0.5) v 4.8 (0.5) cm/s, p < 0.05) in patients with collaterals. All returned to baseline within 10 minutes of reperfusion. Cycle efficiency and regional work were impaired at baseline and fell during occlusion, regardless of collaterals. Within 10 minutes of reperfusion both had increased above baseline. CONCLUSIONS: Coronary occlusion for up to 15 minutes during beating heart coronary artery surgery depressed standard measurements of systolic and diastolic anterior wall function in patients without collaterals, but only those of diastolic function in patients with collaterals. Regional synchrony decreased in both groups. All disturbances regressed within 10 minutes of reperfusion.     

First experience with a new active fixation coronary sinus lead.

AIMS: Coronary sinus (CS) lead implantation is a technically challenging procedure owing to variable vein anatomies and a high dislocation rate. Therefore, CS lead technology has undergone evolutionary changes during the last 10 years. The mode of fixation has been a passive one up to now. We want to describe our first clinical experience with the newly available active fixation lead 4195 in terms of dislocation rate and stability of thresholds compared with conventional models. METHODS AND RESULTS: From 1999 to February 2007, we implanted 403 CS leads in 368 patients. Leads were categorized into three different groups on the basis of their fixation mechanism: straight (Easytrak I and Situs OTW; n = 54), curved (Attain 4193 and 4194, Corox, Aescula, Situs ULD; n = 308), and active (Attain 4195; n = 41). Operative and follow-up data were prospectively noted and checked for significance between groups during the first 3 months after implantation. Kaplan-Meier analysis of long-term lead function was also performed. Straight and curved CS leads suffered from significantly more dislocations compared with active fixation (P < 0.001). The active fixation lead (4195) has a stable threshold over time compared with a significant rise after 24 h and thereafter in straight (62%) and curved leads (20%). However, retraction of an active fixation CS lead may be a difficult issue as outlined in two cases requiring pullback of a 4195 lead owing to phrenic nerve stimulation (one unsuccessful despite vigorous traction). CONCLUSION: The active fixation lead 4195 using retention lobes yielded stable thresholds over time and seems to be superior to conventional leads in terms of dislocation. However, extraction may be a difficult or even impossible task.     

Biventricular pacing as a treatment for advanced heart failure. Preliminary experience in a series of 22 consecutive patients

BACKGROUND AND OBJECTIVES: Recent data suggest that biventricular pacing may play an important role in treating advanced heart failure in the presence of a significant interventricular and/or intraventricular conduction disorder by correcting cardiac dysynchrony. In this article, we review the initial technical and clinical experience with cardiac resynchronization therapy in an electrophysiology laboratory. METHODS: The first 22 consecutive patients with severe congestive heart failure, ejection fraction < 0.35, NYHA functional class III or IV, and QRS duration > 120 ms who were implanted biventricular pacemakers were studied. Clinical, electrocardiographic, and echocardiographic evaluations were made before and three months after pacemaker implantation. Acute functional capacity testing with peak oxygen uptake was measured during biventricular pacing and during intrinsic rhythm or right ventricular pacing three months after the implantation procedure. RESULTS: The success rate of pacemaker implantation was 95%. Pre-discharge left ventricular pacing was achieved in 91%, with an average pacing threshold of 1.53 (1.04) volts. NYHA functional class improved (p = 0.039) from 3.4 (0.7) to 2.3 (0.78). The rate of hospitalization for heart failure decreased from an average of 3.12 (0.58) three months before the procedure to 1.38 (0.34) three months after the procedure. Peak oxygen uptake was significantly greater (p = 0.028) during biventricular pacing: 14.89 (2.1) ml/min/kg, than during intrinsic rhythm or right ventricular pacing: 12.65 (2.3) ml/min/kg. CONCLUSIONS: Cardiac resynchronization therapy can be performed safely and with a high success rate in the electrophysiology laboratory. Biventricular pacing seems to improve the symptoms of congestive heart failure in patients with evidence of atrioventricular and/or interventricular/intraventricular dysynchrony. An acute benefit in peak oxygen uptake was associated with biventricular pacing after the implantation procedure.     

Case series of acute hepatitis in a non-selected group of HIV-infected patients on nevirapine-containing antiretroviral treatment

OBJECTIVE: To evaluate the characteristics of patients who developed acute clinical hepatitis in an unselected outpatient population. METHODS: Patients who started a nevirapine-containing regimen in the period January 1999-February 2001 and presented with clinical symptoms in accordance with increased transaminase values within 12 weeks of initiation of nevirapine were considered possible cases of clinical hepatotoxicity. Patient characteristics, co-medicated drugs, HIV-1 RNA levels and clinical chemistry parameters were collected from outpatient medical records and clinical medical records. RESULTS: At the defined period, 306 patients started a nevirapine-containing regimen, of whom eight developed an acute hepatitis (2.6%) in a median of 24 days [interquartile range (IQR) 20-25 days]. Transaminases peaked at 28 days (IQR, 27-32 days). Injury pattern was in general mixed-hepatocellular. Withdrawal of the antiretroviral agent led to rapid restoration of transaminase levels and resolution of clinical symptoms. The reason for developing this hepatic reaction was not clear in every case as no specific risk factor(s) covering all patients in this case series could be identified. CONCLUSIONS: It is very important to monitor closely transaminase levels of all patients starting a nevirapine-containing regimen, including patients with no specific characteristics that put them at risk. The rapid onset of the clinical symptoms pleads for transaminase monitoring at a very early stage (i.e., within 2 weeks of initiation) of the nevirapine-containing regimen.     

Neuropeptide Y modulates vasoconstriction in coronary microvessels in the beating canine heart

The purpose of this study was to determine whether neuropeptide Y has a direct vasoconstrictor effect at low doses, mimicking the physiological plasma concentration on the specific site(s) of coronary arterial microvessels in in situ beating canine left ventricles. Coronary microvessels were directly observed by means of an intravital microscope and video system equipped with a floating objective. Epi-illuminated fluorescence coronary microangiography was performed in open-chest anesthetized dogs (n = 14) to examine the changes in internal diameter of epimyocardial arterial microvessels. Flow velocity of fluorescently labeled microshperes in capillaries was also measured (n = 6). To eliminate secondary effects of neuropeptide Y on coronary microvessels via autonomic nervous modulation, experiments were conducted under pharmacological blockade of the regional autonomic nervous system by intracoronary injection of propranolol, 50 micrograms/kg; phentolamine, 100 micrograms/kg; and atropine, 5 micrograms/kg. Aortic pressure and heart rate were kept constant during the experiments. Intracoronary infusion of three different doses of neuropeptide Y (1, 10, and 100 pmol/kg/min) for 5 minutes significantly constricted small microvessels (less than 100 microns in diameter) (-5.2 +/- 1.4%, -8.5 +/- 1.5%, and -14.0 +/- 1.7%; p less than 0.05 versus before neuropeptide Y at each dose), medium microvessels (100-200 microns in diameter) (-5.5 +/- 1.6%, -10.6 +/- 1.8%, and -16.8 +/- 2.1%, p less than 0.05 versus before neuropeptide Y at each dose), and large microvessels (greater than 200 microns in diameter) (-3.6 +/- 0.6%, -5.8 +/- 0.8%, and -10.0 +/- 1.1%; p less than 0.05 versus before neuropeptide Y at each dose) in a dose-dependent manner. Capillary flow velocity was reduced by 17.2 +/- 3.1% by an intracoronary dose of 100 pmol/kg/min of neuropeptide Y (p less than 0.05). The present study indicates that low doses of neuropeptide Y exert a homogeneous direct vasoconstrictor effect on various sizes of coronary arterial microvessels and reduce capillary flow velocity. These results suggest that neuropeptide Y may play a physiological role in modulating coronary microvascular tone.     

Resting heart rate and one year mortality association in patients with coronary heart disease

Heart rate is one of widely investigated new risk factors for the progression of coronary heart disease. Aim of this study was to assess association between admission resting heart rate (HR) and one-year survival in patients with coronary heart disease in dependence on gender, age and clinical expression of coronary heart disease (acute or chronic ischemic heart disease). Methods. We randomly selected 3268 patients with acute myocardial infarction (MI), unstable or stable angina admitted to Kaunas University Clinic of Cardiology in 2005. In 1 year we collected data on outcomes of 1824 patients. Statistical analysis was performed using SPSS and MS Office Excel statistical programs. Results. One-year mortality risk was significantly increased in patients with HR more or equal 67 bpm (p=0.017). Significant interaction was found between resting HR, clinical expression of coronary heart disease, and age. Mortality was significantly increased in patients with HR>75 bpm and chronic coronary heart disease (p=0.015) and with HR >71 bpm in patients with acute coronary syndrome (p=0.016). HR more or equal 72 bpm more than doubled risk of death during 1 year in patients younger than 60 and older than 75 years (p=0.047).