Early mitral regurgitation after acute myocardial infarction does not contribute to subsequent left ventricular remodeling

BACKGROUND

It is well known that mitral regurgitation may lead to left ventricular dilation; however, the relationship between progressive left ventricular dilation after acute myocardial infarction (MI) and mitral regurgitation has not yet been clarified.

HYPOTHESIS

This study tested the hypothesis that early mitral regurgitation contributes to left ventricular remodeling after acute MI.

METHODS

We prospectively evaluated 131 consecutive patients by serial two-dimensional and Doppler echocardiography on Days 1, 2, 3, and 7, after 3 and 6 weeks, 3 and 6 months, and 1 year following acute MI. Patients were divided into two groups: those with mitral regurgitation in the first week after acute MI (Group 1, n = 34) and those without mitral regurgitation (Group 2, n = 81).

RESULTS

Over 1 year, a significant increase in end-diastolic volume index (from 62.1 +/- 12.9 to 70.5 +/- 23.6 ml/m2, p = 0.001) with a strong linear trend (F = 15.1, p < 0.001) was noted. Initial end-diastolic volume index was higher in Group 1 (65.6 +/- 13.3 vs. 60.4 +/- 12.5 ml/m2, p = 0.047), but this difference remained constant throughout the study (F = 1.76, p = NS). Therefore, the pattern of end-diastolic volume changes was similar in both groups during the period of observation.

CONCLUSIONS

These data indicate that early mitral regurgitation after acute MI does not contribute to subsequent left ventricular remodeling in the first year after myocardial infarction.

Preinfarction angina prevents left ventricular remodeling in patients treated with thrombolysis for myocardial infarction

BACKGROUND

It has been shown that preinfarction angina may have beneficial effects on infarct size and mortality. However, there are no studies that have serially assessed the impact of preinfarction angina on left ventricular (LV) function in a large series of patients.

HYPOTHESIS

The study was undertaken to determine whether preinfarction angina (within 7 days before infarction) influences LV remodeling.

METHODS

In all, 119 consecutive patients with acute myocardial infarction were serially evaluated by 2-dimensional echocardiography (on Days 1, 2, 3, and 7; at 3 and 6 weeks; and at 3, 6, and 12 months following infarction). Left ventricular volumes were determined using Simpson's biplane formula and normalized for body surface area. Wall motion score index and sphericity index were calculated for each study. Coronary angiography was performed before discharge.

RESULTS

Preinfarction angina was detected in 39 of 119 patients. Initial echocardiographic and clinical data as well as the incidence of patent infarct-related artery and collaterals were similar for patients with and without preinfarction angina. In the subset of thrombolysed patients, patients with preinfarction angina showed decrease of LV end-diastolic and end-systolic volumes during the follow-up period (p = 0.033 and p = 0.001, respectively), and improvement of wall motion score index (p < 0.001) and ejection fraction occurred (p = 0.001), without changing of LV shape (p > 0.05); in addition, patients with preinfarction angina had smaller LV volumes and higher ejection fraction than did those without angina, from 3 weeks onward. These favorable effects were not detected in patients not treated with thrombolysis.

CONCLUSIONS

These data indicate that preinfarction angina has an inhibiting effect on long-term LV remodeling in patients who underwent thrombolysis for first acute myocardial infarction. It appears that preinfarction angina has no impact on infarct size and early postinfarction LV function.

Detection of significant residual stenosis of the infarct-related artery after thrombolysis by high-dose dipyridamole echocardiography test: is it detected often enough?

BACKGROUND AND HYPOTHESIS

It has been reported that high-dose dipyridamole echocardiography test (DET) can be successfully used for the detection of critical residual stenosis of the infarct-related artery (IRA). However, we have recently noticed low sensitivity of DET for the detection of residual IRA stenosis in patients with single-vessel disease. This study sought to determine the value of DET for the detection of significant residual stenosis of the IRA after thrombolysis.

METHODS

Dipyridamole echocardiography test was performed in 55 consecutive patients after a first acute myocardial infarction before hospital discharge. All patients underwent coronary angiography 23 +/- 6 days after infarction.

RESULTS

Nine of 19 patients with positive DET revealed new adjacent asynergy and all of the patients had patient and significantly stenotic IRA. Sensitivity and specificity of DET in identifying significant residual stenosis of the IRA were 24 and 100%, respectively. Among 49 patients with significantly stenotic of occluded IRA, 40 patients without adjacent asynergy during DET had higher baseline wall motion score index (WMSI) compared with 9 patients who revealed adjacent asynergy during DET (1.45 +/- 0.30 vs. 1.24 +/- 0.18; p < 0.05). When all patients with positive DET (adjacent or remote asynergy) were compared with those with negative DET, no difference in baseline WMSI was found (1.37 +/- 0.24 vs. 1.44 +/- 0.24; p > 0.05).

CONCLUSIONS

Our data indicate that sensitivity of DET in detecting significant residual stenosis of the IRA after thrombolysis is low. It seems that the extent of myocardial infarction affects the ability of DET to detect adjacent, but not remote asynergy.

Short early filling deceleration time on day 1 after acute myocardial infarction is associated with short and long term left ventricular remodelling

OBJECTIVE

To assess the relations between early filling deceleration time, left ventricular remodelling, and cardiac mortality in an unselected group of postinfarction patients.

DESIGN AND PATIENTS

Prospective evaluation of 131 consecutive patients with first acute myocardial infarction. Echocardiography was performed on day 1, day 2, day 3, day 7, at three and six weeks, and at three, six, and 12 months after infarction. According to deceleration time on day 1, patients were divided into groups with short (< 150 ms) and normal deceleration time (>/= 150 ms).

SETTING

Tertiary care centre.

RESULTS

Patients with a short deceleration time had higher end systolic and end diastolic volume indices and a higher wall motion score index, but a lower ejection fraction, in the year after infarction. These patients also showed a significant increase in end diastolic (p < 0.001) and end systolic volume indices (p = 0.007) during the follow up period, while ejection fraction and wall motion score index remained unchanged. In the group with normal deceleration time, end diastolic volume index increased (p < 0.001) but end systolic volume index did not change; in addition, the ejection fraction increased (p = 0.002) and the wall motion score index decreased (p < 0.001). One year and five year survival analysis showed greater cardiac mortality in patients with a short deceleration time (p = 0.04 and p = 0.02, respectively). In a Cox model, which included initial ejection fraction, infarct location, and infarct size, deceleration time on day 1 was the only significant predictor of five year mortality.

CONCLUSIONS

A short deceleration time on day 1 after acute myocardial infarction can identify patients who are likely to undergo left ventricular remodelling in the following year. These patients have a higher one year and five year cardiac mortality.

Single-day loading dose of oral amiodarone for the prevention of new-onset atrial fibrillation after coronary artery bypass surgery

BACKGROUND

Various regimens have been proposed for the prevention of postoperative atrial fibrillation, including the use of intravenous and oral amiodarone. The purpose of this study was to determine the effectiveness of a single-day loading dose of oral amiodarone in prophylaxis of atrial fibrillation during the 7 days after coronary artery bypass surgery.

METHODS

We conducted a double-blind, randomized, placebo-controlled study encompassing 315 consecutive patients who underwent coronary artery bypass surgery. They received either amiodarone (159 patients) or placebo (156 patients). Therapy consisted of a single oral loading dose of 1200 mg of amiodarone 1 day before surgery, followed by the maintenance dose of 200 mg daily during the next 7 days. Only episodes of atrial fibrillation lasting more than 1 hour or associated with hemodynamic compromise were taken into consideration.

RESULTS

Overall, the incidence of atrial fibrillation was similar in patients who received amiodarone (31/159, 19.5%) and placebo (33/156, 21.2%) (P = .78). However, amiodarone reduced the incidence of atrial fibrillation in elderly patients (age > or = 60 years): it occurred in 20 of 75 (26.7%) patients on amiodarone and in 28 of 65 (43.1%) patients in the placebo group (P = .05). There were no differences between the study groups regarding the postoperative intrahospital morbidity and mortality and the duration of hospital stay.

CONCLUSIONS

A single-day loading dose of oral amiodarone (1200 mg) does not prevent postoperative atrial fibrillation in a general population of patients undergoing coronary artery bypass surgery. However, it appears that this regimen reduces the occurrence of postoperative atrial fibrillation in elderly patients.

Myocardial fibrosis assessment by semiquantitative, point-counting and computer-based methods in patients with heart muscle disease: a comparative study

AIMS

No study has directly compared different histomorphometric methods of quantification of myocardial fibrosis. Therefore we compared the results of semiquantitative, point-counting and computer-based methods in the assessement of myocardial fibrosis in a consecutive series of endomyocardial biopsy samples from patients with heart muscle disease.

METHODS AND RESULTS

Histological samples (at least three per patient) were obtained by endomyocardial biopsy from 11 patients with focal myocarditis and from 24 ambulatory patients with idiopathic dilated cardiomyopathy, or during surgery in 10 patients who underwent partial left ventriculectomy. Samples were cut and stained with Masson-trichrome for better contrast. From each sample, a representative field was digitized, and the amount of fibrosis was assessed by semiquantitative scoring, by point-counting, and by computer-based software. Semiquantitative scoring correlated with both point-counting (Spearman's r = 0.69, P < 0.0001) and computer-based (Spearman's r = 0.83, P < 0.0001) methods. There was also a good correlation between point-counting and computer-based methods (r = 0.71, P < 0.0001). However, when compared with the point-counting method, the computer-based method overestimated percent fibrosis by 3.0 +/- 6.7% (P = 0.004). This overestimation correlated with the mean percent fibrosis (r = 0.38, P = 0.014).

CONCLUSIONS

Our data show good correlations between the three methods of myocardial fibrosis assessment. However, systematic differences between them emphasize that this should be taken into consideration when comparing results of the studies using different methods of fibrosis assessment.

Spontaneous ventricular arrhythmias following partial left ventriculectomy for nonischemic dilated cardiomyopathy: relation to hemodynamics and survival

The study assessed the value of ambulatory electrocardiogram (AECG) monitoring for identification of patients who are at increased risk for cardiac death or arrhythmic event following partial left ventriculectomy (PLV). Furthermore, the impact of PLV and its hemodynamics on the occurrence of spontaneous ventricular arrhythmias was assessed in long-term survivors. In 32 idiopathic dilated cardiomyopathy patients who underwent PLV, ambulatory ECG (AECG) was performed preoperatively, early postoperatively, and 6 months and 12 months after surgery. In 17 of 19 patients who survived > 12 months after the procedure, left ventricular (LV) angiography was performed at the same time points and was used to calculate LV ejection fraction, and end-diastolic and end-systolic wall stress. During a mean follow-up of 478 +/- 405 days, 11 cardiac events occurred. Cox univariate regression revealed frequency of premature ventricular contractions > 30/hour at baseline (p = 0.0213) and duration of heart failure symptoms (p = 0.0226) as predictors of cardiac death or arrhythmic event after PLV. In a multivariate analysis, only frequency of premature ventricular contractions > 30/hour was a significant predictor. There was no change in the frequency or severity of ventricular arrhythmias after PLV. However, frequency of premature ventricular contractions correlated with LV end-diastolic stress (r = 0.35, p = 0.013), and ejection fraction (r = -0.34, p = 0.016). Preoperative AECG monitoring may help stratification of PLV patients. Serial AECG did not show that PLV influence the incidence or the complexity of spontaneous ventricular arrhythmias. In contrast, it appears that a hemodynamically "successful" procedure may decrease the incidence of ventricular arrhythmias.

Functional capacity late after partial left ventriculectomy: relation to ventricular geometry and performance

OBJECTIVES

While partial left ventriculectomy (PLV) may improve functional status, the duration and determinants of this improvement are poorly known. This study sought to assess the relationship between left ventricular (LV) shape and function and functional status in late survivors after PLV for non-ischemic dilated cardiomyopathy (DCM).

METHODS

We assessed the relations between LV shape and function and functional status in 17 consecutive patients who survived >12 months after PLV for non-ischemic DCM. Invasive diagnostic studies were performed before, early after, at mid-term after, and late after PLV. According to their functional status after >12 months of follow-up, patients were divided into responders (n=10) or non-responders (n=7).

RESULTS

After PLV, the LV systolic major-to-minor axis ratio was higher in responders at early, mid-, and late follow-up (P=0.003, P=0.008 and P=0.04, respectively). LV circumferential end-diastolic stress decreased early after PLV, but increased afterwards in non-responders only (P=0.049). LV ejection fraction was similar in the two groups at baseline, and at early and mid-follow-up, but was lower in non-responders at late follow-up (P=0.006). However, LV end-diastolic and end-systolic volumes, and LV end-systolic circumferential stress showed no difference between the two groups.

CONCLUSIONS

It appears that poor functional capacity in late post-PLV survivors is related to postoperative LV geometry.

Single center experience on eversion versus standard carotid endarterectomy: a prospective non-randomized study

BACKGROUND AND PURPOSE

The prospective studies that have compared the outcomes of eversion and standard longitudinal carotid endarcterectomy (CEA) have been few and small and available data to reach definitive conclusions are still scarce. This prospective, non-randomized study sought to compare eversion and standard CEA for early and late mortality and morbidity and the incidence of late restenosis.

METHODS

Between 1992 and 1997, we performed 2806 CEAs in 2469 patients (2124 eversion CEAs in 1859 patients and 682 standard CEAs in 610 patients). All patients underwent preoperative neurological examination and cervical duplex scanning. Patients were followed up by neurological evaluation and duplex scanning at 1 and 6months after CEA, and yearly afterwards.

RESULTS

Demographics and neurologic inidications for CEA were similar in both groups. Mean clamping time was shorter in the eversion CEA group (13.5+/-6.1 vs 19.9+/-19.1min, P<0.001). Early (30-day) postoperative mortality due to major stroke was lower after eversion CEA (10/2124 vs 9/682, P=0. 037), as well as total cardiovascular mortality (16/2124 vs 12/682, P=0.038). Early carotid occlusion was more frequent in standard CEA group (12/2124 vs 11/682, P=0.017), as well as total early morbidity (112/2124 vs 53/682, P<0.001). During follow-up (mean 56 months, range 6-92), restenosis rate was lower in the eversion CEA group (0. 5 vs 1.8%, P=0.006).

CONCLUSIONS

Our data indicate that eversion CEA as compared to standard CEA technique is associated with lower total cardiovascular perioperative mortality and mortality due to major stroke, shorter clamping time, lower early occlusion rate, and lower late restenosis rate.

Early changes in left ventricular function in chronic asymptomatic alcoholics: relation to the duration of heavy drinking

OBJECTIVES

This study sought to assess preclinical cardiac abnormalities in chronic alcoholic patients and possible differences among alcoholics related to the duration of heavy drinking.

BACKGROUND

Chronic excessive alcohol intake has been reported as a possible cause of dilated cardiomyopathy. However, before the appearance of severe cardiac dysfunction, subtle signs of cardiac abnormalities may be identified.

METHODS

We studied 30 healthy subjects (age 44 +/- 8 years) and 89 asymptomatic alcoholics (age 45 +/- 8 years, p = NS) divided into three groups, with short (S, 5-9 years, n = 31), intermediate (I, 10-15 years, n = 31) and long (L, 16-28 years, n = 27) duration of alcoholism. Transmitral early (E) and late (A) Doppler flow velocities, E/A ratio, deceleration time of E (DT) and isovolumic relaxation time (IVRT) were obtained. Left ventricular (LV) wall thickness and volumes were also determined by echocardiography, and LV mass and ejection fraction (EF) were calculated.

RESULTS

The alcoholics had prolonged IVRT (92 +/- 11 vs. 83 +/- 7 ms, p < 0.001), longer DT (180 +/- 20 vs. 170 +/- 10 ms, p < 0.01), smaller E/A (1.25 +/- 0.34 vs. 1.40 +/- 0.32, p < 0.05), larger LV volumes (73 +/- 8 vs. 65 +/- 7 ml/m2, p < 0.001 for end-diastolic volume index; 25 +/- 4 vs. 21 +/- 2 ml/m2, p < 0.001 for end-systolic volume index), higher LV mass index (92 +/- 14 vs. 78 +/- 8 g/m2, p < 0.001) and thicker posterior wall (9 +/- 1 vs. 8 +/- 1 mm, p < 0.001). Ejection fraction did not differ between the two groups (66 +/- 4 vs. 67 +/- 2%). Deceleration time of the early transmitral flow velocity was longer in groups L (187 +/- 18 ms) and I (185 +/- 16 ms) compared with group S (168 +/- 17 ms, p < 0.001 for L and I vs. S), whereas A was higher in group L compared with S (43 +/- 10 vs. 51 +/- 10 cm/s, p < 0.005). Multiple regression analysis identified duration of heavy drinking as the most important variable affecting DT and A.

CONCLUSIONS

Left ventricular dilation with preserved EF and impaired LV relaxation characterized LV function in chronic asymptomatic alcoholic patients. It appeared that the progression of abnormalities in LV diastolic filling related to the duration of alcoholism.

Active infective endocarditis: low mortality associated with early surgical treatment

BACKGROUND

Early surgical treatment is important for successful outcome in selected cases of active, either native (NVE) or prosthetic valve endocarditis (PVE). The aim of this study was to evaluate the early results of the surgical treatment of active NVE and PVE.

METHODS

During a 3-yr period (January 1 1996-December 31 1998), 57 out of 60 patients (pts) with active, either NVE (46 pts) or PVE (11 pts) underwent surgical treatment. There were 11 women (23.9%), average age of the group being 43.3+/-9.1yr (18-73). They were operated on 12-35days, mean 17.7+/-7.5days (for NVE) and 5-33days, mean 13.2+/-10.1days (for PVE) after the diagnosis of endocarditis was first suspected. All pts had at least one absolute indication for early surgical treatment, the most frequent being (in NVE) worsening heart failure (19 cases) and inability to control the infection (10 cases), while in PVE it was valve dehiscence (8 cases). In 8 cases of NVE and 2 cases of PVE fresh, antibiotic sterilized aortic homograft was used to replace the aortic valve.

RESULTS

Operative mortality was 1.8% (1/57) and hospital mortality 5.2% (3/57). Three pts with PVE died before they were operated on, giving an overall mortality of 10% (6/60). Postoperative morbidity included valve dehiscence in two pts (probable late onset recurrent endocarditis - 3.5%), three episodes of acute renal failure (5.3%), four cases of respiratory insufficiency (7.0%) and one chronic pleural effusion (1.8%). All pts that were discharged from the hospital (54/60), are still alive and well 1-35months postoperatively (mean 20.3+/-9.6months), including pts with recurrent endocarditis and valve dehiscence, after they were successfully reoperated.

CONCLUSIONS

Along with early diagnosis and appropriate antibiotic treatment, aggressive surgical attitude is of importance for the successful outcome in this group of seriously ill patients. Our data indicate that early surgical treatment in cases of active endocarditis may be associated with low mortality and morbidity.

Partial left ventriculectomy improves left ventricular end systolic elastance in patients with idiopathic dilated cardiomyopathy

OBJECTIVE

To assess the effect of partial left ventriculectomy (PLV) on estimate of left ventricular end systolic elastance (Ees), arterial elastance, and ventriculoarterial coupling.

PATIENTS

11 patients with idiopathic dilated cardiomyopathy before and two weeks after PLV, and 11 controls.

INTERVENTIONS

Single plane left ventricular angiography with simultaneous measurements of femoral artery pressure was performed during right heart pacing before and after load reduction.

RESULTS

PLV increased mean (SD) Ees from 0.52 (0.27) to 1.47 (0.62) mm Hg/ml (p = 0.0004). The increase in Ees remained significant after correction for the change in left ventricular mass (p = 0.004) and end diastolic volume (p = 0.048). As PLV had no effect on arterial elastance, ventriculoarterial coupling improved from 3.25 (2.17) to 1.01 (0.93) (p = 0.017), thereby maximising left ventricular stroke work.

CONCLUSION

It appears that PLV improves both Ees and ventriculoarterial coupling, thus increasing left ventricular work efficiency.

Immediate reoperation for perioperative stroke after 2250 carotid endarterectomies: differences between intraoperative and early postoperative stroke

PURPOSE

After carotid endarterectomy, intraoperative findings and outcome of immediate reoperation of patients who had an intraoperative stroke were compared with those of patients who had an early postoperative stroke.

METHODS

We retrospectively analyzed 2250 carotid endarterectomies performed between 1980 and 1997. Intraoperative stroke (group A) was detected after 41 of the 2250 operations (1.8%), whereas early postoperative stroke (group B) developed after 18 of the 2250 operations (0.8%). Patients from both groups were reoperated on within 1 hour after neurological examination.

RESULTS

Positive intraoperative findings that could be corrected during immediate reoperation were: (1) thrombotic occlusion of the carotid artery that was operated on caused by technical error, which was found in nine of 41 patients (22%) in group A and in 11 of 18 patients (61%) in group B (P =.009); (2) mural thrombus caused by technical error without occlusion, which was detected in seven of 41 patients (17%) in group A and in two of 18 patients (11%) in group B (P >.05); and (3) technical error without a thrombus, which was found in eight of 41 patients (20%) in group A and in three of 18 patients (17%) in group B (P >.05). A patent carotid artery was found in 17 of 41 patients (42%) in group A and in two of 18 patients (11%) in group B (P =.046). Twenty of the 41 patients (49%) in group A died, and four of 18 patients (22%) in group B died (P > 0.05). Major neurological deficit remained in nine of 41 patients (22%) in group A and four of 18 patients (22%) in group B (P > 0.05). Total recovery occurred in seven of 41 patients (17%) in group A and in eight of 18 patients (45%) in group B (P = 0.058).

CONCLUSION

Carotid artery thrombosis during immediate reoperation was more frequent in patients who had an early postoperative stroke than in patients who had an intraoperative stroke. It appears that patients who had an intraoperative stroke have a higher incidence of uncorrectable lesions.

Early predictors of mitral regurgitation after acute myocardial infarction

We analyzed early predictors of mitral regurgitation after myocardial infarction in 131 consecutive patients with first acute myocardial infarction. Our data revealed that elderly patients with larger infarcts, multivessel coronary disease, and papillary muscle region asynergy are more likely to develop mitral regurgitation in the first year after infarction.

Low incidence of cardiac abnormalities in treated trichinosis: a prospective study of 62 patients from a single-source outbreak

PURPOSE

The reported incidence of cardiac involvement in trichinosis is highly variable, ranging from 21% to 75%. This study sought to determine the incidence and type of cardiac lesions in trichinosis using serial echocardiographic examinations.

SUBJECTS AND METHODS

Sixty-two consecutive patients admitted to the Banja Luka Medical Center during an outbreak of trichinosis (November to December 1996) were included in the study. Diagnosis was made by typical clinical presentation, positive epidemiologic history, serologic testing, and the detection of Trichinella larvae in contaminated meat. All patients underwent serial electrocardiograms and two-dimensional and Doppler echocardiographic examinations within 20 days after the onset of symptoms. Repeated echocardiographic examinations were performed weekly during the hospital stay in all patients with electrocardiographic abnormalities or an abnormal initial echocardiogram.

RESULTS

Cardiac involvement (electrocardiographic and/or echocardiographic changes) was detected in 8 (13%) of the 62 patients. Nonspecific transient electrocardiographic ST-T changes were found in 6 patients (10%); 1 patient had frequent premature ventricular complexes. Echocardiographic examinations revealed pericardial effusions in 6 patients (10%), 5 of whom had minimal effusions without impairment of global and regional left ventricular systolic function. One patient had hypokinesis of the interventricular septum with a small pericardial effusion, both of which resolved within 2 weeks. Only 2 of the patients with electrocardiographic abnormalities lacked echocardiographic evidence of cardiac involvement. At 6-month follow-up, none of the patients had electrocardiographic or echocardiographic abnormalities.

CONCLUSIONS

The incidence of cardiac involvement in trichinosis appears to be lower than previously reported. Pericardial effusion is the most common manifestation of cardiac involvement, and nonspecific transient electrocardiographic changes, traditionally ascribed to myocarditis, more frequently reflect pericarditis.

Association of Killip class on admission and left ventricular dilatation after myocardial infarction: a closer look into an old clinical classification

BACKGROUND

Early identification of patients in whom left ventricular dilatation is likely to occur may have important therapeutic implications. Thus the purpose of this study was to evaluate the relation between Killip class on admission and subsequent left ventricular dilatation after acute myocardial infarction.

METHODS AND RESULTS

We serially evaluated 129 consecutive patients by two-dimensional and Doppler echocardiography on days 1, 2, 3, and 7, at 3 and 6 weeks, and at 3, 6, and 12 months after infarction. Killip class on admission >1 was found in 29 of 129 (22.5%) patients, and they had significantly higher end-systolic and end-diastolic volume indexes and wall motion score index from day 1 onward compared with patients with Killip class 1, whereas ejection fraction was lower during the follow-up period in these patients. Patients with Killip class >1 showed the progressive increase of end-diastolic (68.2 +/- 2.99 to 88.0 +/- 7.55 ml/m2, p = 0.001) and end-systolic volume indexes (43.9 +/- 2.67 to 56.3 +/- 6. 18 ml/m2, p = 0.004) during the follow-up period, whereas ejection fraction and wall motion score index remained unchanged. In patients with Killip class 1, end-systolic volume index did not change (30.8 +/- 1.06 to 33.8 +/- 2.15 ml/m2, p = 0.064), ejection fraction increased (49.3% +/- 0.99% to 51.8% +/- 1.17%, p = 0.027), and wall motion score index decreased (1.50 +/- 0.03 to 1.35 +/- 0.04, p < 0. 001). End-systolic volume index was the major independent correlate of Killip class, followed by history of diabetes and peak creatine kinase level. No association was found between Doppler indexes of diastolic filling and Killip class on admission.

CONCLUSIONS

Killip class >1 on admission is associated with both acute and long-term left ventricular dilatation. On the other hand, Killip class 1 is associated with favorable left ventricular functional indices, and it appears that left ventricular function in these patients may improve over time. Initial end-systolic volume index but not ejection fraction is the major correlate of Killip class.

Partial left ventriculectomy for idiopathic dilated cardiomyopathy: early results and six-month follow-up

BACKGROUND

Recent reports show that partial left ventriculectomy improves hemodynamic and functional status in patients with dilated cardiomyopathy. This study sought to determine the effects of partial left ventriculectomy on clinical outcome and left ventricular function during 6-month follow-up.

METHODS

Twenty-two patients underwent partial left ventriculectomy. Mitral valve repair was performed whenever possible, otherwise the valve was replaced. Hemodynamic and functional data were obtained at baseline, as well as 2 weeks and 6 months postoperatively.

RESULTS

Overall, 7 of 22 patients died; there were three early and four late deaths. One-year survival was 68%+/-10%. Ejection fraction increased from 23.9%+/-6.8% before the operation to 40.7%+/-12.5% at 2 weeks and to 36.8%+/-7.7% at 6 months (p<0.001, for both). The cardiac index before the operation, at 2 weeks, and at 6 months was 2.3+/-0.8, 2.9+/-0.6, and 3.4+/-1.0 L/m2 per minute, respectively (p = 0.035, and p = 0.009, compared with baseline). The increase in ejection fraction 2 weeks postoperatively was less in patients with left circumflex artery dominance (10.9%+/-3.2% compared with 19.9%+/-10.7%, respectively, p = 0.017). At 6-month follow up, all surviving patients except one improved New York Heart Association functional class when compared with preoperative status (from 3.8+/-0.4 to 1.4+/-0.6, p = 0.0002).

CONCLUSIONS

Early hemodynamic improvement after partial left ventriculectomy was maintained during midterm follow-up.

Effects of partial left ventriculectomy on left ventricular performance in patients with nonischemic dilated cardiomyopathy

OBJECTIVES

This study sought to assess the effects of partial left ventriculectomy (PLV) on left ventricular (LV) performance in a series of consecutive patients with nonischemic dilated cardiomyopathy.

BACKGROUND

Reduction of LV systolic function in patients with heart failure is associated with an increase of LV volume and alteration of its shape. Recently, PLV, a novel surgical procedure, was proposed as a treatment option to alter this process in patients with dilated cardiomyopathy.

METHODS

We studied 19 patients with severely symptomatic nonischemic dilated cardiomyopathy, before and 13+/-3 days after surgery, and 12 controls. Single-plane left ventriculography with simultaneous measurements of femoral artery pressure was performed during right heart pacing.

RESULTS

The LV end-diastolic and end-systolic volume indexes decreased after PLV (from 169 to 102 ml/m2, and from 127 to 60 ml/m2, respectively, p < 0.0001 for both). Despite a decrease in LV mass index (from 162 to 137 g/m2, p < 0.0001), there was a significant decrease in LV circumferential end-systolic and end-diastolic stresses (from 277 to 159 g/cm2, p < 0.0001 and from 79 to 39 g/cm2, p = 0.0014, respectively). Ejection fraction improved (from 24% to 41%, p < 0.0001); the stroke work index remained unchanged.

CONCLUSIONS

The PLV improves LV performance by a dramatic reduction of ventricular end-systolic and end-diastolic stresses. Further studies are needed to assess whether this effect is sustained during long-term follow-up and to define the role of PLV in the treatment of patients with dilated cardiomyopathy.

Myocardial tissue characterization after acute myocardial infarction with wavelet image decomposition: a novel approach for the detection of myocardial viability in the early postinfarction period

BACKGROUND

Only a few texture measures can be used for texture characterization of infarcted myocardium and detection of reperfused myocardium early after infarction. This study was conducted to establish the relationship between texture properties of infarcted myocardium and infarct-related artery patency by quantitative computer analysis of 2-dimensional echocardiographic images with the wavelet-based method for texture characterization, evaluate the relationship between texture properties and myocardial viability, and correlate histopathologic changes after experimental infarction with the texture measures.

METHODS AND RESULTS

We analyzed 2-dimensional transthoracic echocardiographic images in 18 patients at different time points after infarction using the wavelet transform method. Regional wall motion of infarcted segments was analyzed on a follow-up echocardiographic study obtained 6 months after infarction. To verify the accuracy of the proposed texture measure and energy difference cutoff value, we prospectively evaluated another group of 19 patients. In addition, histopathologic changes in 9 dogs with experimental infarction were correlated with the texture measures. Sensitivity, specificity, and accuracy of the wavelet method for detection of reperfusion in the study group were 73%, 86%, and 78%, respectively, on day 2; 91%, 86%, and 89%, at 1 week; and 100%, 100%, and 100% at 3 weeks. Among 9 patients with improvement in regional wall motion on a follow-up study, 7 on day 2, 8 at 1 week, and 9 at 3 weeks were classified into the reperfused group by the wavelet method. Histopathologic features associated with the classification of reperfusion by the wavelet method were infarct transmurality (P=0.024) and degree of necrosis (P=0.028).

CONCLUSIONS

Our clinical and experimental data suggest that the wavelet method can be used to differentiate between viable myocardium with recovery potential and definite myocardial necrosis in the early postinfarction period.

Predictors of left ventricular thrombus formation and disappearance after anterior wall myocardial infarction

AIMS

This study sought to determine predictors of left ventricular thrombus formation and resolution after acute anterior wall myocardial infarction.

METHODS AND RESULTS

We have analysed clinical, echocardiographic and angiographic data in 53 consecutive patients with anterior myocardial infarction. Two-dimensional and Doppler echocardiographic examinations were performed on days 1, 2, 3 and 7, after 3 and 6 weeks, and 3, 6, and 12 months following infarction. Coronary angiography was performed in 44 patients before hospital discharge. Left ventricular thrombus was detected in 30/53 patients (29/30 in the first week after infarction). Univariate analysis showed that left ventricular thrombus formation was associated with a higher initial end-systolic volume index (beta = 0.04, P = 0.001), and end-diastolic volume index (beta = 0.03, P = 0.03), a larger infarct perimeter (beta = 0.02, P = 0.01), a lower initial ejection fraction (beta = 0.06, P =0.001), a higher initial wall motion score index (beta = 1.75, P = 0.023), a higher peak creatine kinase level (beta = 3.90, P = 0.01), Killip class >1 (beta = 1.11, P = 0.003), infarct expansion (beta = 0.78, P = 0.04), occluded infarct-related artery (beta = -0.87, P = 0.04) and non-thrombolytic therapy (beta = -0.76, P = 0.047). According to the Cox proportional regression model, independent predictors of thrombus formation after anterior myocardial infarction were high end-systolic volume index (beta = 0.06, P = 0.001) and high peak creatine kinase level (beta = 5.17, P = 0.046). Thrombus disappeared in 11/30 (36.7%) patients during one-year echocardiographic follow-up. The only independent predictor of thrombus disappearance after acute myocardial infarction was the absence of apical dyskinesis 6 weeks after infarction (beta = -1.53, P = 0.045).

CONCLUSIONS

Our data demonstrate that the best predictor of left ventricular thrombus formation after acute anterior myocardial infarction is a high initial end-systolic volume. Thrombus resolution is more likely to occur in patients without apical dyskinesis at the end of the healing phase of infarction.

Time-related trends in the preoperative evaluation of patients with valvular stenosis

To investigate time-related trends in the use of preoperative invasive hemodynamics in patients with pure valvular stenosis, the preoperative evaluations and preoperative echocardiograms of consecutive patients who underwent aortic or mitral valve surgery from 1986 to 1994 at the Cleveland Clinic Foundation were reviewed. The study group consisted of 1,985 patients, 1,476 with aortic stenosis and 509 with mitral stenosis. Preoperative cardiac catheterization was performed in 1,456 patients with aortic stenosis (99%) and 488 with mitral stenosis (96%). Measurement of invasive hemodynamics (including transvalvular gradients and estimated valve areas) during catheterization decreased over time both in patients with aortic (from 64% in 1986 to 30% in 1994, test for trend p <0.0001) and mitral stenosis (from 63% in 1986 to 18% in 1994, test for trend p <0.0001). After adjusting for age, gender, and other characteristics, the only predictors of performance of invasive hemodynamics in patients with aortic stenosis were more recent surgery (inverse relation, p = 0.0001) and New York Heart Association class (p = 0.01); in patients with mitral stenosis the only predictor was also more recent surgery (inverse relation, p = 0.0001). Thus, use of preoperative invasive hemodynamics in patients with valvular stenosis has markedly decreased over the last decade. This is an example of how a noninvasive modality can supercede an invasive one, even when surrounding a procedure as fundamentally invasive as valvular heart surgery.

Pericardial effusion after streptokinase for acute myocardial infarction: an echocardiographic 1-year follow-up study

Since the reported incidence of pericardial effusion following thrombolysis is highly variable, we have evaluated 80 consecutive patients with first acute myocardial infarction treated with streptokinase. Two-dimensional echocardiographic studies were performed on days 1, 2, 3, and 7, at 3 and 6 weeks, and 3, 6, and 12 months following acute myocardial infarction. Throughout the study, pericardial effusion was found in 7 of 80 (8.75%) patients, being small in 5 patients, moderate in 1, and large in 1 patient. No clinical, angiographic, or echocardiographic variable was associated with pericardial effusion formation. The incidence of pericardial effusion found in our study is almost three times lower than in other echocardiographic studies on pericardial effusion in thrombolysed patients. Whether this differences results from the beneficial effects of streptokinase is not clear.

[Aorto-caval fistula due to abdominal aortic aneurysm rupture]

INTRODUCTION

Most frequently, abdominal aortic aneurysm (AAA) ruptures into retroperitoneal space. The rupture of AAA into inferior vena cava is an uncommon event. The incidence of this complication of AAA is 2 to 10%. Surgeons' awareness of this rare entity is the most important factor for the early diagnosis and treatment. In this paper we report two cases of AAA rupture into inferior vena cava. As to our knowledge, in domestic literature such cases have not been previously reported.

CASE REPORT

Patient 1. A 65-year-old man was admitted to the hospital because of low back pain and haemorrhagic shock. He was anaemic with haemoglobin of 80 g/l, systemic blood pressure was 70 mmHg, pulse rate 100/min, and central venous pressure 12 cm H2O. Pulsatile abdominal mass with continuous bruit and thrill and leg oedema were present. Physical examination revealed global heart failure. The patient was anuric. Because of the critical condition and evident clinical signs of ruptured AAA, the patient was operated on immediately without any other diagnostic procedure. Transperitoneal approach was used. Intraoperative findings were consistent with the rupture of the frontal aneurysmal wall into retroperitoneal space, with large retroperitoneal haematoma and aorto-caval (AC) fistula on the posterior aneurysmal wall, large 2 cm in diameter. Using digital compression for venous bleeding control, the fistula was closed with interrupted polypropylene 2-0 sutures with patches. After closure of the fistula, the urine flow resumed. Then, the aneurysm was replaced with bifurcated Dacron graft. The postoperative recovery was successful. The patient has a 13-year follow-up, without any sign of cardiac or renal failure as well as arterio-venous insufficiency of legs. Patient 2. A 62-year-old man was admitted to the Zemun Clinical Hospital Cenre because of suddenly occurred tachycardia, dyspnea and low back pain. Abdominal ultrasound examination revealed the existence of a possible fistula between the abdominal aorta and inferior vena cava. The patient was immediately transported to our institute. At admission, he was anaemic (haemoglobin was 85 g/l), with systolic blood pressure of 100 mmHg, pulse rate of 100/min and central venous pressure of 20 cm H2O. Also, he had pulsatile abdominal mass with continuous bruit and thrill, as well as legs and scrotal oedema. He was oliguric and haematuric. Translumbar aortography showed AAA with AC fistula (Figure). Transperitoneal approach was used for the operation. Intraoperatively, a small retroperitoneal haematoma without retroperitoneal rupture was found. After aneurysmal opening, a massive venous bleeding started, followed with cardiac arrest. The bleeding was controlled using digital compression and cardiopulmonary resuscitation was successful. AC fistula, large 3 cm in diameter, was on the posterior aneurysmal wall, and it connected the inferior vena cava and the left common iliac vein with AAA. The fistula was closed with interrupted polypropylene 2-0 sutures with patches. The aneurysm was replaced with impregnated tubular Dacron graft 16 mm. The postoperative recovery was successful. The patient was followed-up for 2.5 years, and there were no signs of cardiac or renal failure and arterio-venous insufficiency of legs.

DISCUSSION

AC fistula as a complication of ruptured AAA was reported for the first time by Syme in 1831. The first attempt to repair this lesion was done by Lehman in 1935, but it was unsuccessful. In 1954, the first successful repair was performed by Cooley. According to Matsubara, by the end of 1989, 250 cases of this lesion were reported in England, German and French literature, and only 25 in Japanese. In 1991, Brewster et al. reported 14 new cases, while Italian authors reported 36 new cases in 1994. Retroperitoneal and intraperitoneal ruptures of AAA have different clinical presentation comparing with the rupture of AAA into inferior vena cava. (ABSTRACT TRUNCATED)

Hypertensive crisis associated with cerebellar embolization due to left atrial myxoma

In this article, we present an unusual case of hypertensive crisis associated with nonhemorrhagic cerebellar infarction due to embolization of loose tumor fragments of left atrial myxoma.

Wavelet image extension for analysis and classification of infarcted myocardial tissue

Some computer applications for tissue characterization in medicine and biology, such as analysis of the myocardium or cancer recognition, operate with tissue samples taken from very small areas of interest. In order to perform texture characterization in such an application, only a few texture operators can be employed: the operators should be insensitive to noise and image distortion and yet be reliable in order to estimate texture quality from the small number of image points available. In order to describe the quality of infarcted myocardial tissue, we propose a new wavelet-based approach for analysis and classification of texture samples with small dimensions. The main idea of this method is to decompose the given image with a filter bank derived from an orthonormal wavelet basis and to form an image approximation with higher resolution. Texture energy measures calculated at each output of the filter bank as well as energies of synthesized images are used as texture features in a classification procedure. We propose an unsupervised classification technique based on a modified statistical t-test. The method is tested with clinical data, and the classification results obtained are very promising. The performance of the new method is compared with the performance of several other transform-based methods. The new algorithm has advantages in classification of small and noisy input samples, and it represents a step toward structural analysis of weak textures.

Association of ventricular arrhythmias with left ventricular remodelling after myocardial infarction

OBJECTIVE

To assess the relation between ventricular arrhythmias after myocardial infarction and left ventricular remodelling.

DESIGN

Prospective study with consecutive patients.

METHODS

97 patients with acute myocardial infarction underwent serial echocardiographic examinations (days 1, 2, 3, and 7, and after 3 weeks) to determine end diastolic volume, end systolic volume, and ejection fraction; volumes were normalised for body surface area and expressed as indices. Holter monitoring was performed on the day of the final echocardiogram. Coronary angiography was performed in 88 patients before hospital discharge.

RESULTS

Complex ventricular arrhythmias (defined as Lown class 3-5) were found in 16 of 97 patients. In logistic regression models, variables predictive of complex ventricular arrhythmias were end systolic volume index on admission (b = 0.054, P = 0.015) and end diastolic volume index after three weeks (b = 0.034, P = 0.012). Complex arrhythmias were also related to the increase of end diastolic and end systolic volume indices throughout the study (F = 5.62, P = 0.046, and F = 6.42, P = 0.017, respectively by MANOVA). A two stage linear regression model of ventricular volume versus time from infarct showed that both intercept (initial volume) and slope (rate of increase) were higher for patients with complex arrhythmias in both diastole and systole (P < 0.001 for all).

CONCLUSIONS

Complex ventricular arrhythmias after myocardial infarction are related to the increase of left ventricular volume rather than to depressed ejection fraction. Complex arrhythmias may be an aetiological factor linking left ventricular remodelling with higher mortality, but larger follow up studies of patients with progressive left ventricular dilatation after myocardial infarction are necessary to answer these questions.

Acute and long-term effects of thrombolysis after anterior wall acute myocardial infarction with serial assessment of infarct expansion and late ventricular remodeling

This study investigates the impact of thrombolysis on infarct expansion and subsequent left ventricular (LV) remodeling in patients with anterior wall acute myocardial infarction (AMI). We evaluated 51 consecutive patients (24 treated with thrombolysis) with anterior wall AMI by 2-dimensional echocardiography in the following sequence: days 1, 2, 3, and 7, after 3 and 6 weeks, and after 3, 6, and 12 months. LV end-diastolic and end-systolic volume indexes were determined from apical 2- and 4-chamber views using Simpson's biplane formula. Infarct and total LV perimeters were determined in the same views and their ratio expressed as infarct percentage. Infarct expansion was defined as: (1) an increase in infarct percentage and total perimeter >5% on days 2 to 3 in either of the views, or (2) initial infarct percentage >50% with an increase in total perimeter >5% on days 2 to 3. Coronary angiography was performed in 43 patients before discharge, and patency of the infarct-related artery was assessed using Thrombolysis in Myocardial Infarction trial criteria. Infarct expansion was detected in 23 patients. Infarct perimeter steadily decreased in patients with versus without thrombolysis and in patients with patent versus occluded infarct-related arteries. Furthermore, by logistic regression, thrombolysis (p = 0.007) and potency of the infarct-related artery (p = 0.02) were strong negative predictors of expansion, whereas initial infarct perimeter (p = 0.009) was directly associated with subsequent expansion. End-systolic volume index was higher in patients with expansion from day 1 (p = 0.003) through the end of the study (p = 0.021), and end-diastolic volume index was higher in these patients from day 2 (p = 0.012) through 12 months (p = 0.015). Thus thrombolysis, initial infarct size, and infarct-related artery patency are major predictors of infarct expansion after anterior wall AMI.

Positive high-dose dipyridamole echocardiography test after acute myocardial infarction is an excellent predictor of cardiac events

To determine the prognostic value of the high-dose (0.84 mg/kg over a 10-minute period) dipyridamole echocardiography test (DET) after a first acute myocardial infarction (AMI) in comparison with clinical, electrocardiographic, echocardiographic, and angiographic variables, follow-up data over an average period of 16 months were obtained in 93 consecutive patients. There were 41 total cardiac events (TCE): one death, two reinfarctions, 13 postinfarction anginas, five percutaneous transluminal coronary angioplasty procedures, and 20 coronary artery bypass graft procedures. TCE without revascularization procedures were considered adverse cardiac events (ACE). The DET result was positive in 28 of 41 patients with TCE and in only 4 of 52 patients without TCE (p < 0.001). The sensitivity, specificity, and accuracy of positive DET in predicting TCE were 68%, 92%, and 82%, respectively. According to Cox's proportional regression model the best predictor of TCE was positivity of DET (p = 0.002, relative risk ratio 4.3), followed by multivessel coronary artery disease (p = 0.018, relative risk ratio 2.9) and patent infarct-related artery (p = 0.042, relative risk ratio 2.9). DET was positive in 12 of 16 patients with ACE and 20 of 77 patients without ACE (p = 0.001). The sensitivity, specificity, and accuracy of DET in predicting ACE were 75%, 74%, and 74%, respectively. According to Cox's proportional regression model significant predictors of ACE were positivity of DET (p = 0.002, relative risk ratio 29.4) and ejection fraction < or = 40% at the time of DET (p = 0.017, relative risk ratio 22.2).(ABSTRACT TRUNCATED AT 250 WORDS)

Independent impact of thrombolytic therapy and vessel patency on left ventricular dilation after myocardial infarction. Serial echocardiographic follow-up

BACKGROUND

It has been shown that successful reperfusion of the infarct-related artery by thrombolysis can prevent left ventricular dilation after acute myocardial infarction; these beneficial effects were detected from several days to several months after infarction. To date, however, no study has shown that these effects can be demonstrated within hours after the onset of infarction. Furthermore, data are scarce on the independent impact of thrombolytic therapy and late vessel patency on ventricular volume and function. The aim of this study was to assess separate effects of thrombolysis and patency of the infarct-related artery on left ventricular size and function by serial two-dimensional echocardiographic examinations.

METHODS AND RESULTS

We evaluated 131 consecutive patients with first acute myocardial infarction by two-dimensional echocardiography in the following sequence: days 1, 2, 3, 7, and after 3 and 6 weeks. Intravenous streptokinase was administered in 81 patients, and 50 patients were treated without thrombolysis. Left ventricular end-diastolic volume, end-systolic volume, and ejection fraction were determined from apical two- and four-chamber views using the Simpson biplane formula and normalized to body surface area. Coronary angiography was performed in 107 patients after a mean of 26.0 +/- 20.2 (mean +/- SD) days after infarction. Patency of the infarct-related artery was assessed using TIMI criteria, with 54 considered patent (TIMI 3) and 53 with TIMI grade < 3. On day 1, end-systolic volume was significantly higher in patients not receiving thrombolysis (37.7 +/- 15.3 versus 33.0 +/- 10.6 mL/m2, P = .045). End-systolic volume (ESVi) was significantly higher in patients treated without thrombolysis throughout the study, whereas significant differences in end-diastolic volume (EDVi) were detected from day 3 (P = .041) onward and in ejection fraction (EF) from day 2 (P = .025) onward, all differences becoming progressively more significant with time (6-week values: EDVi, 78.8 +/- 25.4 versus 65.9 +/- 15.7 mL/m2, P = .001; ESVi, 45.4 +/- 22.6 versus 33.9 +/- 15.1 mL/m2, P = .002; EF, 45.1 +/- 11.6% versus 50.2 +/- 10.1%, P = .018). Patients with an occluded infarct-related artery (TIMI < 3) demonstrated highly significant differences at 6 weeks compared with patients with patent vessels (EDVi, 76.8 +/- 24.7 versus 65.2 +/- 15.6 mL/m2, P = .006; ESVi, 44.6 +/- 23.3 versus 31.9 +/- 12.2 mL/m2, P = .001; EF, 45.0 +/- 11.6% versus 52.1 +/- 9.0%, P < .001), but these differences developed more slowly than that seen among the thrombolytic subgroups. Indeed, multivariate analysis demonstrated that thrombolysis was the major determinant of initial volumes (P = .08, .02, and .08 for EDVi, ESVi, and EF, respectively), while vessel patency was the overwhelming determinant of subsequent changes (P = .0033, .0002, and .0024 for EDVi, ESVi, and EF, respectively). Additionally, ventricular volumes were significantly higher and ejection fractions lower in patients with anterior versus inferior infarction, but even adjusting for these differences as well as those associated with age, sex, and initial ventricular volume, the additive and independent impact of thrombolysis and infarct vessel patency persisted.

CONCLUSIONS

These data indicate that the beneficial effect of thrombolysis on left ventricular size and function can be demonstrated in the earliest phases of acute myocardial infarction and that subsequent changes are mediated primarily through patency of the infarct-related artery. Thrombolytic therapy and late vessel patency thus have an additive and complementary impact in reducing ventricular dilation after myocardial infarction.