Wall motion and perfusion analysis of transmyocardial laser revascularization

OBJECTIVE: Transmyocardial laser revascularization (TMLR) creates channels in the myocardium. The aim of the treatment is to relieve angina in patients with end-stage coronary artery disease. We studied the effect of TMLR on myocardial function and perfusion with the combination of cine magnetic resonance imaging (MRI) and thallium scintigraphy. DESIGN: Eight patients with severe triple-vessel coronary artery disease were studied with MRI and thallium scintigraphy before and 6 months after laser treatment. RESULTS: TMLR did not improve global left ventricular (LV) function or myocardial perfusion. However, systolic wall thickening deprived in segments with fixed perfusion defects in 6 months and laser treatment prevented this deprivation (p = 0.03). In addition single photon emission computed tomography (SPECT) imaging indicated that TMLR prevented conversion of reversible into fixed defects. CONCLUSION: In severe, progressing coronary artery disease TMLR does not improve global LV function or myocardial perfusion, but it preserves systolic wall thickening in fixed defects (scar). It also prevents changes from ischemic myocardial regions to scar.     

Autologous porcine heart cell transplantation improved heart function after a myocardial infarction

OBJECTIVE: Fetal cardiomyocyte transplantation improved heart function after cardiac injury. However, cellular allografts were rejected despite cyclosporine (INN: ciclosporin) therapy. We therefore evaluated autologous heart cell transplantation in an adult swine model of a myocardial infarction. METHODS: In 16 adult swine a myocardial infarction was created by occlusion of the distal left anterior descending coronary artery by an intraluminal coil. Four weeks after infarction, technetium 99m-sestamibi single photon emission tomography showed minimal perfusion and viability in the infarcted region. Porcine heart cells were isolated and cultured from the interventricular septum at the time of infarction and grown in vitro for 4 weeks. Through a left thoracotomy, either cells (N = 8) or culture medium (N = 8) was injected into the infarct zone. RESULTS: Four weeks after cell transplantation, technetium 99m-sestamibi single photon emission tomography demonstrated greater wall motion scores in the pigs receiving transplantation than in control animals (P =.01). Pigs receiving transplantation were more likely to have an improvement in perfusion scores (P =.03). Preload recruitable stroke work (P =.009) and end-systolic elastance (P =. 02) were greater in the pigs receiving transplantation than in control animals. Scar areas were not different, but scar thickness was greater (P =.02) in pigs receiving transplantation. Cells labeled with bromodeoxyuridine in vitro could be identified in the infarct zone 4 weeks after transplantation. Swine receiving transplantation gained more weight than control animals (P =.02). CONCLUSION: Autologous porcine heart cell transplantation improved regional perfusion and global ventricular function after a myocardial infarction.     

Prediction of cardiac risk before abdominal aortic reconstruction: comparison of a revised Goldman Cardiac Risk Index and radioisotope ejection fraction

BACKGROUND: A revised Goldman Cardiac Risk Index has been suggested to identify patients at higher risk for cardiac complications in patients who undergo major noncardiac surgery. The aim of this study was to test the usefulness of this model in an independent series of patients who underwent abdominal aortic surgery and to compare the index with the multiple gated acquisition (MUGA) scan in the prediction of cardiac complications. METHODS: We studied 77 patients who underwent MUGA scan before elective abdominal aortic reconstruction. The revised index was calculated for each patient after recording the following five risk factors: history of ischemic heart disease, congestive heart failure, cerebrovascular disease, insulin-dependent diabetes, and creatinine level more than 2 mg/dL. Technetium-99m MUGA scan provided information about the resting left ventricular ejection fraction (LVEF) and the presence of regional wall motion abnormalities. RESULTS: Fourteen patients (18%) had cardiac complications develop. The index proved to be a satisfactory predictor of postoperative cardiac events (P =.008), and an abnormal LVEF failed to do so (P =.1). The presence of wall abnormalities, with or without an abnormal LVEF, predicted cardiac complications (P =.004 and P =.006). Patients with a higher index score showed a tendency to have a lower LVEF (Spearman rank correlation, r = -0.43; P <.001). Wall abnormalities, with or without an abnormal LVEF, were more frequent in patients with higher scores (P =.03 and P =.009). Combining the index with the LVEF or the wall abnormalities or both could further stratify the cardiac risk (P =.004, P =.0003 and P =.0006, with chi(2) test for trend). CONCLUSION: For those patients who undergo elective abdominal aortic surgery, the revised Goldman Cardiac Risk Index is a simple method of evaluating cardiac risk with minimum resource implications. MUGA scan can offer additional stratification in patients judged with the index to be at high risk.     

Left ventricular global and regional function during lumbar epidural anesthesia in patients with and without angina pectoris. Influence of volume loading

The influence of lumbar epidural anesthesia without cardiac sympathectomy on global and regional left ventricular function was investigated prior to surgery in eight normal subjects (group 1) and in ten patients suffering from stable mild effort-related angina (group 2). In both groups, epidural blockade was performed with 10 ml 0.5% plain bupivacaine. To differentiate the effects due to epidural blockade from those related to volume expansion, three sets of measurements were obtained: control, epidural blockade without volume loading, and epidural blockade with volume loading (500 ml lactated Ringer's solution). Radionuclide angiography was used to determine cardiac output, left ventricular ejection fraction, end systolic and end diastolic volumes, and to analyse left ventricular wall motion. Peak systolic pressure-end systolic volume ratio was used as an index of myocardial contractility. Seventy-two hours postoperatively, a thallium 201 myocardial scintigraphy obtained after iv dipyridamole detected myocardial defects in all patients with a history of angina. These defects were fully redistributed in eight out of ten patients. Throughout the procedure, patients with a history of angina exhibited neither chest pain nor ECG evidence of myocardial ischemia. At control, left ventricular ejection fraction (LVEF) and systolic pressure-volume ratio (SPVR) were lower in group 2 than in group 1 (LVEF: 0.54 +/- 0.02 vs. 0.64 +/- 0.02, P less than 0.01), (SPVR: 2.3 +/- 0.2 vs. 3.3 +/- 0.4 mmHg/ml, P less than 0.05). In addition, 19 hypokinetic sectors were found in group 2.(ABSTRACT TRUNCATED AT 250 WORDS)     

心脏移植长期存活患者冠状动脉病变一例

目的　探讨 1例心脏移植长期存活患者冠状动脉病变的原因、诊断和处理。方法　对1例心脏移植术后存活 8年的患者进行长期随访。结果　术后患者生活质量好 ,恢复正常工作 ;血液生化正常 ;心电图无心肌缺血改变 ;肱动脉内皮依赖性血管舒张功能正常 ;心内膜心肌活检未见急性排斥反应征象 ;同位素心肌显像提示左室壁心肌放射性分布进行性减低 ;冠状动脉造影显示左冠状动脉弥漫性狭窄、右冠状动脉近段有一局限性严重狭窄 (>90 % )、远端为轻度弥漫性狭窄 ,行右冠状动脉近段成形和支架植入 ,同位素心肌显像示左室壁心肌放射性分布明显改善。结论　慢性排斥反应可能是导致移植心冠状动脉病变的重要原因 ;定期行同位素心肌显像检查有助于了解心肌血液供应 ;严重的局限性冠状动脉病变可应用冠状动脉成形和支架植入予以治疗。     

The impact of left ventricular systolic dysfunction on survival after renal transplantation

BACKGROUND: Gated single photon emission computed tomography (SPECT) provides information on myocardial perfusion and left ventricular ejection fraction (LVEF), which correlates with risk of cardiac events in patients with known or suspected coronary artery disease (CAD). We hypothesize that decreased LVEF at time of renal transplant evaluation is an independent risk factor for cardiac death and nonfatal events after transplant. METHODS AND RESULTS: A total of 653 recipients of renal allografts between 1998 and 2005 had stress SPECT imaging before transplantation. One hundred and nineteen (18%) patients had left ventricular (LV) systolic dysfunction (LVEF 相似文献   

Noninvasive assessment of cardiac risk in insulin-dependent diabetic patients being evaluated for pancreatic transplantation using thallium-201 myocardial perfusion scintigraphy

We examined the value of thallium-201 myocardial perfusion scintigraphy in noninvasive assessment of cardiac risk in 36 insulin-dependent (type 1) diabetic patients being evaluated for pancreas or combined pancreas/kidney transplantation. An extensive cardiovascular evaluation including electrocardiogram was performed in all patients, and most patients were also evaluated by two-dimensional and Doppler echocardiography. Exercise thallium studies were performed in 31 patients. Five patients were unable to exercise and underwent dipyridamole-thallium study. The thallium images were abnormal in 12 patients, 10 of whom underwent coronary arteriography. Significant coronary artery disease was found in 7 of these patients. Nineteen patients underwent pancreatic (3 patients) or pancreato-renal (16) transplantation without any occurrence of cardiac death or nonfatal myocardial infarction peri-operatively or on follow-up ranging from 7 months to 21 months. In contrast, 3 cardiac events occurred in 12 patients not approved for transplantation, each of whom had an abnormal thallium study exhibiting significant ischemia. Resting left ventricular global and regional function was not helpful in determining perioperative risk. Thus, thallium-201 myocardial perfusion scintigraphy may be useful in identifying diabetic patients at low risk for pancreas transplantation and may obviate the need for routine coronary angiography in these patients.     

Routine measurement of radioisotope left ventricular ejection fraction prior to vascular surgery: is it worthwhile?

OBJECTIVE: To determine whether estimation of left ventricular (LV) ejection fraction (EF) by means of multiple gated acquisition (MUGA) scanning could reliably stratify cardiac risk prior to elective major vascular surgery. METHODS: A review of the English-language literature. RESULTS AND CONCLUSIONS: Twenty-two studies enrolling a total of 3096 patients were identified from 1984 to date. Selection bias, blinding of the results, different cut-off limits, and several retrospective studies were some of the problems preventing a comprehensive analysis. The resting LVEF was not found to be a consistent predictor of perioperative ischaemic cardiac events. In the perioperative phase, poor LV function was, mainly, predictive of congestive heart failure, and, in the long-term, of cardiac outcome. The presence of myocardial wall motion abnormalities was also associated with both a higher chance of postoperative cardiac complications and a worse long-term cardiac outcome. Although measurements of LV function seem to play a key role in defining a patient's long-term prognosis, the value of routinely measuring LVEF preoperatively is limited and, therefore, MUGA scanning cannot be recommended as a general screening test. Despite this, it has been widely used for cardiac risk assessment in vascular surgery, and only recently its popularity has started declining. Other tests, such as stress-echocardiography and myocardial perfusion imaging, used selectively in moderate-risk patients can refine prediction of cardiac risk. In the future, gated stress myocardial perfusion scintigraphy, perhaps combined with ANP/BNP plasma level determination, may become a first choice test in preoperative cardiac risk assessment.     

Functional outcome of bone marrow stem cells: mononuclear versus mesenchymal stem cells after cellular therapy in myocardial scar in Wistar rats

Experimental studies have suggested that a bone marrow stem cell transplant into the heart produces a favorable impact on tissue perfusion, yielding a new perspective on myocardial regeneration. Studies in human beings have demonstrated an improved clinical and functional cardiac state, which has been explained mainly by the angiogenic potential of the stem cells. Our objective was to compare the functional outcome of mononuclear stem (MoSC) and mesenchymal stem (MeSC) cell therapy after myocardium infarction in rats. Forty-two rats with myocardial infarctions underwent autologous transplantation of MoSC and MeSC in animals with ejection fractions lower than 40%. The functional analysis was performed using echocardiography at baseline and at 1 month after direct injection into the ventricular wall using: 5 x 10(6) MoSC (n = 08) or 2.5 x 10(6) MeSC (n = 13) or medium controls (n = 21). Statistical significance was accepted when P < .05. Intragroup comparisons of baseline versus 1-month follow-up were performed with paired t tests. Kruskal-Wallis was used as appropriate. There was a difference in baseline left ventricular ejection fraction (LVEF) and left ventricular-end dyastolic volume between all groups. After 1 month, LVEF decreased in the control group but remained unchanged in MoSC and MeSC groups. In all groups we observed myocardial remodeling. In conclusion, we have not demonstrated functional effectiveness with either MoSC or MeSC cell type, but potentially improved myocardial perfusion needs to be analyzed.     

Effects of treatment with sulfonylurea drugs or insulin on ischemia-induced myocardial dysfunction in type 2 diabetes

In patients with diabetes and coronary artery disease, the potential negative role of sulfonylurea drugs is under intensive investigation. We assessed the effects of treatment with glibenclamide or insulin on the extension of left ventricular myocardial dysfunction induced by acute ischemia. Nineteen consecutive patients with type 2 diabetes and coronary artery disease entered the study. Each patient was randomly assigned to either insulin or glibenclamide therapy. Treatment was crossed over after 12 weeks and maintained for another 12 weeks. At the end of each treatment, left ventricular myocardial function at rest and during dipyridamole infusion was studied by two-dimensional echocardiography under the same conditions of metabolic control. Glibenclamide or insulin treatment did not influence the rest values of left ventricular dimensions, left ventricular ejection fraction (LVEF), or wall motion score index (WMSI). Dipyridamole infusion, in patients receiving glibenclamide treatment, decreased LVEF (43 +/- 7 vs. 37 +/- 12%, P < 0.005) and increased WMSI (1.4 +/- 0.28 vs. 1.98 +/- 0.24, P < 0.001) compared with baseline values; during insulin treatment, LVEF (46 +/- 8 vs. 45 +/- 11%, NS) and WMSI (1.4 +/- 0.29 vs. 1.6 +/- 0.4, NS) did not change significantly. Peak stress LVEF was higher (45 +/- 11 vs. 37 +/- 12%, P < 0.001) and WMSI lower (1.6 +/- 0.4 vs. 1.98 +/- 0.24, P < 0.001) in patients receiving insulin. The results indicate that in patients with type 2 diabetes and coronary artery disease, ischemic myocardial dysfunction induced by dipyridamole infusion is less severe during treatment with insulin than with glibenclamide. Restitution of a preconditioning mechanism in insulin-treated patients may be the potential beneficial mechanism.     

Left ventricular function and infarct size 20 months after primary angioplasty for acute myocardial infarction

OBJECTIVE: To study changes in left ventricular function and infarct size during long-term follow-up after acute myocardial infarction treated with primary angioplasty. DESIGN: From 1996 to 1998, 100 consecutive patients were treated with primary angioplasty for acute ST-elevation myocardial infarction. Angioplasty was successful in 95% of the patients. Global left ventricular ejection fraction (LVEF) was determined by radionuclide ventriculography before discharge, after 6 weeks and after a mean follow-up time of 20 months. Infarct size was assessed by technetium 99m-tetrofosmin myocardial perfusion tomography (SPECT) at rest, performed at the same time intervals. RESULTS: Mean LVEF was 56% at discharge, 55% after 6 weeks and 57% after 20 months of follow-up. No significant improvement in LVEF was observed. Only 8% of the patients at follow-up had LVEF lower than 40%. After 1 week, a mean perfusion defect of 19% was measured by SPECT. After 6 weeks and 20 months of follow-up, the mean perfusion defects were reduced to 14% (p < 0.001) and 15%, respectively. CONCLUSION: Left ventricular function was well preserved with a mean LVEF of 57% 20 months after primary angioplasty for acute myocardial infarction. No significant change in LVEF was observed from 1 week after angioplasty to follow-up. Infarct sizes as assessed by SPECT imaging with tetrofosmin were reduced from 1 to 6 weeks, but did not change further during long-term follow-up. The reduction in the perfusion defects over time was probably due to gradual relief of stunning.     

Effects of transmyocardial revascularization on myocardial perfusion and systolic function assessed by nuclear and magnetic resonance imaging methods

OBJECTIVE: There is no obvious explanation, except placebo, to the symptomatic effect of transmyocardial laser revascularization (TMR) in patients with refractory angina. Whether TMR improves myocardial perfusion or relieves symptoms without altering cardiac function is not clarified. METHODS: One hundred patients with refractory angina were randomized 1:1 to TMR (CO2 laser) and medical treatment, or medical treatment alone. Technetium 99m (99mTc)-tetrofosmin myocardial perfusion tomography (SPECT), quantitative myocardial perfusion gated SPECT (QGSPECT), technetium 99m (99mTc) multiple gated acquisition radionuclide ventriculografi (MUGA) and cine-magnetic resonance imaging (cine-MRI) were performed at baseline and after 3 and 12 months. RESULTS: Following TMR, a slight reduction in left ventricular ejection fraction (LVEF) (p < 0.05) was observed (MUGA and QGSPECT) compared to baseline. Inclusion of incomplete studies (QGSPECT) revealed a significant reduction in LVEF and increase in left ventricular end-diastolic volume (LVEDV) (p < 0.05) compared to a control group. Otherwise, no between-group comparisons showed statistically significant differences. CONCLUSION: TMR did not improve myocardial perfusion, but led to a reduction in LVEF and increase in LVEDV, however not significantly different from the control group.     

Can preoperative myocardial perfusion scintigraphy predict changes in left ventricular perfusion and function after coronary artery bypass graft surgery?

OBJECTIVES We wanted to evaluate whether preoperative myocardial perfusion scintigraphy (MPS) could predict changes in cardiac symptoms and postoperative myocardial perfusion and left ventricular function after coronary artery bypass grafting (CABG). METHODS Ninety-two patients with stable angina pectoris (and at least one occluded coronary artery) underwent MPS before, and 6 months after, undergoing CABG. The result of the MPS was kept secret from the surgeons. RESULTS Before CABG, 90% of the patients had angina. After CABG, 97% of the patients were without symptoms. Overall graft patency was 84%. Before CABG, one patient had normal perfusion; in the rest of them the defects were classified as follows: reversible (60%), partly reversible (27%) and irreversible (12%). Following CABG, 33% had normal perfusion; in the rest the defects were reversible in 29%, partly reversible in 12% and irreversible in 26%. Left ventricular ejection fraction (LVEF), which was normal before operation in 45%, improved in 40% of all patients. The increase in LVEF was not related to the preoperative pattern of perfusion defects. Of 30 patients with normalized perfusion after CABG, 29 (97%) had reversible defects and one patient had partly reversible defects. Of 83 perfusion defects, which were normalized after CABG, 67 were reversible (81%) or partly reversible (12%). Seventy-five percent of all reversible coronary artery territories before CABG were normalized after operation. CONCLUSIONS Our results indicate that reversible or partly reversible perfusion defects at a preoperative MPS have a high chance of normalized myocardial perfusion assessed by MPS 6 months after operation. Normal perfusion is obtained almost exclusively in territories with reversible ischaemia. Symptoms improved in nearly all patients and LVEF in a significant fraction of the patients, not related to preoperative MPS.     

Autologous stem cell transplantation in acute myocardial infarction: The ASTAMI randomized controlled trial. Intracoronary transplantation of autologous mononuclear bone marrow cells, study design and safety aspects

OBJECTIVES: Intracoronary transplantation of different cell populations has been used in acute myocardial infarction (AMI) with promising results. The primary objective of the Autologous Stem cell Transplantation in Acute Myocardial Infarction (ASTAMI) study is to test whether intracoronary transplantation of autologous mononuclear bone marrow cells (mBMC) improves left ventricular ejection fraction (LVEF) after anterior wall AMI. DESIGN: The ASTAMI study is a randomized, controlled, prospective study. One hundred patients with acute anterior wall ST-elevation myocardial infarction (STEMI) treated with acute percutaneous coronary intervention (PCI) are randomized in a 1:1 way to either intracoronary transplantation of autologous mBMC 5-8 d after PCI or to control. Left ventricular function, exercise capacity, biochemical status, functional class, quality of life and complications are validated at baseline and during a 12-month follow-up. RESULTS: By August 2004, out of 1004 patients with STEMI, 49 patients have been included in the study. Twenty-four patients have been randomized to intracoronary mBMC transplantation. Twenty patients had chest pain and 16 patients had ischemic ECG changes during the mBMC transplantation procedure. One patient had ventricular fibrillation 24 h after transplantation. CONCLUSIONS: Intracoronary transplantation of autologous mBMC in the acute phase after AMI is feasible and seems safe in the short term.     

Transmyocardial laser revascularization in ischemic cardiomyopathy.

BACKGROUND: In ischemic cardiomyopathy (left ventricular ejection fraction [LVEF] < or = 30%), myocardial revascularization by coronary artery surgery has better results than heart transplantation, provided there is sufficient ischemic but viable myocardium. The mode of action of transmyocardial laser revascularization (TMR) is still being debated, but if the procedure induces improved myocardial perfusion it could be a "bridge," or alternative, to heart transplantation. METHODS: We retrospectively analyzed 194 patients, who underwent TMR between July 1997 and October 1999. Patients with TMR as an adjunct to coronary artery surgery (n = 30) and those who did not provide written consent to the procedure (n = 8) were excluded; 126 patients had normal or moderately reduced left ventricular function, and 30 patients with ischemic cardiomyopathy (LVEF < or = 30%) were included. RESULTS: After 12 months, the Canadian Cardiovascular Society (CCS) score dropped significantly from 3.6 (3 to 4) to 2.4 (1 to 4) and maximum work load increased significantly from 58 W (25 to 100 W) to 73 W (25 to 120 W). However, thallium score and LVEF did not improve significantly (27% [15% to 30%] to 32% [15% to 45%]). Prior to the TMR procedure, all 30 patients had a "low risk" or "medium risk" of death according to the Aaronson classification. The 30-day, 1-year, and 2-year survival rates were 83%, 50%, and 47%, respectively. CONCLUSIONS: We conclude that TMR in ischemic cardiomyopathy (LVEF < or = 30%) has a perioperative risk comparable to that for heart transplantation, but there is no improvement of myocardial performance or life expectancy. Therefore, TMR cannot be regarded as a "bridge," or alternative, to transplantation. However, in individual cases with contraindications for transplantation the anti-anginal effect may justify use of the procedure.     

Prognostic value of myocardial perfusion studies in patients with end-stage renal disease assessed for kidney or kidney-pancreas transplantation: a meta-analysis

The prognostic utility of myocardial perfusion studies (MPS) such as thallium scintigraphy and dobutamine stress echocardiography (DSE) for stratifying cardiac risk among candidates for kidney or kidney-pancreas transplantation is uncertain. This study is a meta-analysis to determine the prognostic significance of MPS results on future myocardial infarction (MI) and cardiac death (CD) in patients with end-stage renal disease (ESRD) assessed for kidney or kidney-pancreas transplantation. MEDLINE was searched using combinations of MeSH headings and text words for transplantation, coronary artery disease, prognosis, end-stage renal disease, and noninvasive cardiac testing (nuclear scintigraphy and DSE) for primary studies. Studies were included if they reported MPS results and cardiac events in patients assessed for kidney or kidney-pancreas transplantation. Methodologic study quality and outcome data were independently abstracted in duplicate by two researchers. The relative risks (RR) of MI and CD were calculated using a random effects model. Twelve articles met all inclusion criteria; 12 studies reported CD, and 9 reported MI. In eight studies, thallium scintigraphy was used (four with pharmacologic stress, four with exercise stress), whereas four used DSE. When compared with negative tests, positive tests had a significantly increased RR of MI (2.73 [95% CI, 1.25 to 5.97]; P = 0.01) and CD (2.92 [95% CI, 1.66 to 5.12]; P < 0.001). Subgroup analyses of studies of diabetic patients indicated that positive tests were associated with a RR of CD 3.95 (95% CI, 1.48 to 10.5; P = 0.006) and a RR of MI 2.68 (95% CI, 0.95 to 7.57; P = 0.06) when compared with negative tests. In studies evaluating mixed populations of diabetic and nondiabetic patients, positive tests were associated with a RR of CD 2.52 (95% CI, 1.25 to 5.08; P = 0.01) and with a RR of MI 2.79 (95% CI, 0.85 to 9.21; P = 0.09) when compared with a negative test. The presence of reversible defects was associated with an increased risk of MI in diabetic patients and of CD in both subgroups; fixed defects were associated with an increased risk of CD but not MI. It is concluded that positive MPS are useful in identifying patients with significantly increased risk of future MI and CD in both diabetic and nondiabetic ESRD patients.     

Effects of coronary artery bypass grafting for patients with totally occluded left anterior descending arteries]

Between April, 1987 and March, 1991, 21 patients with totally occluded left anterior descending arteries (TOLAD) underwent coronary artery bypass grafting (CABG) in our institute. All of them were diagnosed as angina pectoris and 15 (71%) of them have had episodes of myocardial infarction. Graftability of TOLAD was 90% (19/21) and two of the TOLADs were not suitable for CABG because severe atherosclerosis of these arteries were observed intraoperatively. There was no operative death. Short term (1-2 months) patency was 64% (7/11) for saphenous vein grafts (SVG) and 100% (8/8) for left internal thoracic artery grafts (LITA). Left ventricular wall motion assessed by left ventriculography showed impaired regional wall motion in 63% segments of the segment #2, #3 and #6 preoperatively. However, the regional wall with impaired motion decreased to 31% after CABG. Thallium-201 scintigraphy showed impaired perfusion in 62% segments of the left anterior wall, apex and interventricular septum preoperatively. However, the regional wall with impaired perfusion decreased to 42% after CABG. Exercises tolerance assessed by treadmill test was improved from 3.8 +/- 0.7 Mets preoperatively to 6.5 +/- 0.7 Mets with patent coronary bypass grafts. These data suggested that CABG can improve the wall motion of the regions perfused by TOLADs and the LIMA is more suitable than the SVG for CABG to TOLAD.     

Long-term effects of surgical angiogenic therapy with fibroblast growth factor 2 protein

OBJECTIVE: The long-term effects of surgical fibroblast growth factor 2 therapy are examined. METHODS: In a randomized, double-blind study, fibroblast growth factor 2 (10 microg or 100 microg) or placebo (n = 8 each) was delivered in the ungraftable myocardial territory of patients concomitantly undergoing coronary artery bypass grafting. Patients were followed up to 32.2 +/- 6.8 months postoperatively with clinical assessment and nuclear perfusion imaging. RESULTS: Baseline patient characteristics were similar between the 3 groups. There were 2 late deaths, one of pancreatic cancer and one of undetermined cause (both in the 100-microg fibroblast growth factor 2 group). Two patients (both in the control group) underwent a total of 6 repeat cardiac catheterizations for recurrent coronary events. Mean Canadian Cardiovascular Society angina class improved at late follow-up from baseline in all groups (P < or = .02); however, patients treated with either dose of fibroblast growth factor 2 had significantly more freedom from angina recurrence than those treated with placebo (P =.03). Late nuclear perfusion scans revealed a persistent reversible or a new, fixed perfusion defect in the ungraftable territory of 4 of 5 patients who received placebo versus only 1 of 9 patients treated with fibroblast growth factor 2 (P =.02). The overall sum of left ventricular stress perfusion defect scores was also lower in fibroblast growth factor 2-treated patients than in control subjects (1.3 +/- 1.4 vs 3.9 +/- 2.1, respectively; P =.04). A trend toward a higher late left ventricular ejection fraction was noted in fibroblast growth factor 2-treated patients (55.1% +/- 14.6% vs 44.3% +/- 6.5%, fibroblast growth factor 2-treated patients versus control subjects; P =.12). CONCLUSIONS: These data suggest that surgical angiogenic therapy with sustained-release fibroblast growth factor 2 may result in a prolonged myocardial revascularization effect that could translate into clinical benefit.     

Cardiac response and complications during endovascular repair of abdominal aortic aneurysms: a concurrent comparison with open surgery

PURPOSE: The purpose of this study was to assess and to compare perioperative changes in left ventricular function and the incidence of adverse cardiac events in two groups of patients with abdominal aortic aneurysms, one during endovascular aneurysm repair (EAR) and the other during open aneurysm repair (OAR). METHODS: One hundred twenty consecutive patients who underwent EAR (49 patients) or OAR (71 patients) were prospectively studied. During the operation, the left ventricular function was assessed by the recording of the left ventricle stroke work index (SWI) and the cardiac index (CI) with a pulmonary artery catheter. Measurements were performed before, during, and after stent-graft deployment or aortic cross-clamping. Both maneuvers were defined as aortic occlusion (AO). Transesophageal echocardiography was performed to identify signs of wall motion abnormalities of the left ventricular wall, which indicated myocardial ischemia. Six-lead electrocardiograph monitoring was maintained until discharge from the intensive care unit. Postoperative cardiac complications were diagnosed by clinical observation, 12-lead ECG analysis at 1, 3, and 7 days after the operation, transthoracic echocardiography at 1 month, and measurement of cardiac enzymes. RESULTS: The two study groups were comparable with regard to most clinical aspects. The baseline myocardial performance was worse in patients who underwent EAR compared with patients who underwent OAR, as indicated by a reduced SWI (33.1 and 37.4, respectively; P =.03). During AO there was a comparable increase of the CI in both groups. However, after AO the rise in CI was higher in patients who underwent OAR compared with patients who underwent EAR (0.7 and 0.2, respectively; P <.01), representing a more pronounced hyperdynamic state. In addition, the SWI demonstrated a decrease in patients who underwent OAR compared with an increase in patients who underwent EAR during AO (-1.4 and +1.9, respectively; P =.04) and after AO (-0.9 and +2.6, respectively; P =.01). These findings represent more severe myocardial stress in patients who underwent OAR. The incidence of postoperative clinical cardiac adverse events was comparable in the two study groups. However, myocardial ischemia, as indicated by electrocardiography and transesophageal echocardiography, had a higher incidence in patients who underwent open surgery as compared with patients whose condition was managed endovascularly (57% and 33%, respectively; P =.01). CONCLUSION: Hemodynamic alterations during endovascular repair were not as severe as those in patients with open surgery and indicated less myocardial stress in the former category. These findings may explain a lower incidence of myocardial ischemia that was observed during endovascular repair. A lower frequency of clinical perioperative cardiac events in patients undergoing endovascular treatment may ultimately be expected.     

Gene therapy with adenovirus-mediated myocardial transfer of vascular endothelial growth factor 121 improves cardiac performance in a pacing model of congestive heart failure

BACKGROUND: Myocardial ischemia is the most common cause of congestive heart failure. Angiogenic therapy has recently been demonstrated to enhance myocardial perfusion in the ischemic setting. We therefore hypothesized that administration of adenovirus encoding for vascular endothelial growth factor could be used to enhance myocardial function in a pacing-induced model of heart failure. METHODS: Yorkshire swine underwent a left thoracotomy with placement of a ventricular epicardial pacing system. Animals received adenovirus coding either for the 121-amino-acid isoform of vascular endothelial growth factor (Ad(CU)VEGF121.1 group, n = 8) or a null vector coding for no genes (AdNull group, n = 8). The adenovirus was administered in the left ventricular free wall as 10 transepicardial injections of 100 microL each (total dose of 10(11) particle units). After a 1-week recovery period, animals were paced at a rate of 230 beats/min for 7 days to induce heart failure. Transthoracic echocardiographic and sonomicrometric measurements were performed before pacing (baseline), on termination of pacing (day 0), and then weekly for 3 weeks. RESULTS: The fractional area change was significantly decreased in AdNull animals at day 0 after pacing compared with the Ad(CU)VEGF121.1 animals (29% +/- 14% vs 46% +/- 8%, P =.02). The fractional area change recovered to baseline values within 7 days in the Ad(CU)VEGF121.1 animals (62% +/- 7%) but remained significantly impaired in the AdNull group compared with that in the Ad(CU)VEGF121.1 animals up to day 21 (P =.04). Similarly, fractional wall thickening demonstrated a decrease at day 0 after pacing that was greater (P <.05) in the AdNull group compared with that in the Ad(CU)VEGF121.1 group in 5 of 6 segments. Fractional wall thickening returned to levels approximating prepacing values in all segments within 7 days in the Ad(CU)VEGF121.1 group but remained significantly impaired compared with prepacing fractional wall thickening (P <.05) in the AdNull group in 5 of 6 segments up to day 21 after pacing. Segmental shortening, as measured by sonomicrometry, also was significantly decreased at day 7 in the AdNull group compared with that in the Ad(CU)VEGF121.1 group (10% +/- 4% vs 16% +/- 3%, P =.004) and remained significantly impaired (P <.05) in the AdNull group at day 14 and 21 when compared with baseline values. CONCLUSION: Preservation of cardiac performance and a more rapid recovery of myocardial function can be achieved in a model of pacing-induced cardiomyopathy with adenovirus-mediated administration of vascular endothelial growth factor compared with that seen in a null virus control group. These data suggest that angiogenic therapy may be useful clinically in treating cardiomyopathy.