Faculty Bibliography

Chronic heart failure (CHF) has become an epidemic in the United States, with approximately 550,000 new cases annually. With the evolution of pharmacotherapy targeting neurohormonal pathways, the annual mortality in subjects with New York Heart Association (NYHA) class IV CHF has dramatically improved from 52% in the seminal CONSENSUS trial to less than 20% in more recent trials. Suppression of the renin-angiotensin-aldosterone system remains the first line of neurohormonal blockade followed by the addition of selective beta-adrenoreceptor blockers. For patients with NYHA class I and II symptoms, mortality rates have decreased to approximately 5% or less per year with the use of angiotensin-converting enzyme inhibitors, beta-blockers and aldosterone receptor blockers. However, after achieving optimal doses of the indicated pharmacotherapy, and despite the additional benefits obtained with biventricular pacemakers, there are still many patients who continue to experience signs and symptoms of CHF. Recognizing the beneficial effects of the above treatments on left ventricular (LV) remodeling, strategies have been developed to surgically reshape the left ventricle in patients with LV dilation who have associated poor LV function. This review will discuss the techniques and recent developments regarding surgical reshaping of the dilated, dysfunctional, and remodeled left ventricle

BACKGROUND: Mild and moderate functional ischemic mitral insufficiency present at the time of surgical revascularization present clinical uncertainty. It is unclear whether the relatively poor outcomes in this cohort are dependent on valvular function or related to left ventricular dysfunction. The purpose of this study was to examine the early and late outcomes in patients with less-than-severe functional ischemic mitral insufficiency at the time of isolated coronary artery bypass grafting (CABG). METHODS AND RESULTS: From 1996 through 2004, 2242 consecutive patients undergoing isolated CABG were identified as having none to moderate mitral regurgitation (MR) and no valve leaflet pathology. All of the patients at this single institution routinely had an intraoperative transesophageal echocardiography, prospectively quantified MR, and ejection fraction (EF). The New York State Cardiac Surgery Reporting System infrastructure was used to prospectively collect in-hospital patient variables and outcomes. Social Security Death Benefit Index was used to determine long-term survival. Odds ratio and significance (P value) are presented for each determined risk factor. There were 841 patients (37.5%) with no MR, 1137 (50.7%) with mild MR, and 264 (11.8%) with moderate MR. The patients with moderate MR were more likely to be older, female, and have more renal disease, previous MI, congestive heart failure, previous cardiac surgery, and lower EFs. Hospital mortality was independently and significantly associated with renal disease, decreasing EF, increasing age, previous cardiac operation, and cerebral vascular disease. Multivariable analysis revealed decreased survival with increasing age, previous operation, congestive heart failure, diabetes, nonelective operation, decreasing EF, and the presence of moderate MR (expbeta = 1.49; P=0.007) and mild MR (expbeta = 1.34; P=0.033). CONCLUSIONS: Independent of ventricular function, mild and moderate functional mitral insufficiency are associated with significantly decreased survival in patients undergoing CABG. Whether correction of moderate functional MR at the time of CABG improves outcome still needs to be determined

We present the case of a 40 year-old man with biventricular nonvalvular vegetations presenting with acute onset of unilateral hearing loss and headache as a result of septic emboli. The medical literature involving the rare diagnosis of mural vegetation is reviewed and unusual features of this case are discussed

To plan effective management of congenital heart disease, one needs the clearest understanding of the anatomy. Although echocardiography and angiography are the dominant imaging modalities in patients with congenital heart disease, magnetic resonance (MR) imaging and computed tomography (CT) are valuable noninvasive adjuncts. MR imaging and CT are effective in demonstrating the complex cardiovascular morphology present in congenital heart disease, especially the extracardiac morphology. In patients with tetralogy of Fallot with complex pulmonary artery anatomy, MR imaging and CT are useful in demonstrating the pulmonary artery anatomy, along with the significant aortopulmonary collateral vessels. In the heterotaxy syndromes, patients often have unusual atriovenous connections. MR imaging allows accurate identification of the hepatic, systemic, and pulmonary veins and their relationships to both atria. CT and MR are the imaging modalities of choice in a patient who is thought to have a vascular ring. Treatment of aortic coarctation is usually performed on the basis of typical clinical and echocardiographic findings. In patients with atypical clinical or echocardiographic findings, MR imaging and CT yield helpful information that can change the treatment plan. The enhanced preoperative understanding of congenital heart disease provided by MR imaging and CT simplifies surgical decision making and consequently may improve outcome

This study investigated the controversial relationship between reduction in internal mammary artery (IMA) graft blood flow and left ventricular function in a canine model. Ten dogs underwent IMA grafting to the left anterior descending coronary artery. The left anterior descending coronary artery proximal to the IMA graft was intermittently occluded while IMA flow was mechanically controlled for 5-minute periods to produce four IMA flow groups representing 100%, 75%, 50%, and 25% of unoccluded IMA graft blood flow. As a control, the left ventricle was reperfused with native left anterior descending coronary artery flow between each IMA graft flow period to allow return to steady state. Sonomicrometry was used to obtain stroke work end-diastolic dimension relationship data for regional and global left ventricular function for each of the four flow groups. The global pressure recruitable work area relationship showed a significant rightward shift at 25% of unoccluded IMA flow, whereas the regional pressure recruitable work area relationship shifted at 50% of unoccluded IMA flow. Thus, regional myocardial function is more sensitive to reductions in IMA blood flow than is global left ventricular performance, and there is a significant IMA flow reserve for global left ventricular function

The purpose of this study was to determine the effects of the addition of amino acids to blood cardioplegic solution and the value of terminal cardioplegia enhancement techniques in routine myocardial protection. Forty-five open-chest adult dogs were instrumented with sonomicrometry crystals to measure left ventricular long axis, midequatorial short axis, and wall thickness. The aorta was clamped for 120 minutes of cardiopulmonary bypass. Animals were randomly separated into four myocardial protection groups: (1) blood cardioplegic solution with amino acids and no terminal cardioplegia (n = 12); (2) blood cardioplegic solution with amino acids and warm amino acid terminal cardioplegia (n = 11); (3) blood cardioplegic solution with amino acids and cold amino acid terminal cardioplegia (n = 12); and (4) blood cardioplegic solution plus cold terminal cardioplegia (no amino acids, n = 10). Data for preload recruitable stroke work were obtained by inflow occlusion before bypass (baseline) and at 30 and 60 minutes after reperfusion and analyzed for changes in x-intercept and slope. A significant rightward shift in x-intercept did not occur in any group. When cardiac function was expressed as a percentage of baseline preload recruitable stroke work slope, improved functional recovery was seen at both 30 and 60 minutes in groups 2 (88.6% and 91.8%), 3 (85.8% and 86.9%), and 4 (88.6% and 92.6%) compared with group 1 (77.3% and 79.2%, p < 0.05). No significant difference was found in the degree of functional recovery among groups 2, 3, and 4. These results suggest that for myocardial protection of 2 hours in nonischemic hearts, a terminal dose of blood cardioplegic solution before unclamping is beneficial, but this positive effect is independent of amino acid supplementation and temperature

To assess the results and incremental risk factors affecting outcome after multiple-valve operation in the early blood cardioplegia era of cardiac surgery, follow-up data (mean +/- SD 3.1 +/- 2 years) were obtained on 97% of 513 patients (mean age +/- SD 58.8 +/- 10.5 years) who underwent a multiple-valve procedure between June 1976 and August 1985. Preoperatively 41% of patients were in New York Heart Association functional class III and 54% in class IV. Three groups accounted for 98.6% of the patients: 57.7% had an aortic and mitral valve procedure, 29% had a mitral and tricuspid valve procedure and 11.9% had a triple-valve procedure. The overall hospital mortality rate was 12.5% and overall 5-year survival rate was 67.1%. Hazard function analysis for all deaths revealed systolic pulmonary artery pressure (p less than 0.0001), age (p = 0.005), triple valve procedure (p less than 0.005), concomitant coronary bypass operation (p less than 0.005) and prior cardiac surgery (p less than 0.002) as the significant incremental risk factors predicting decreased survival in the early hazard phase; diabetes (p less than 0.005) predicted decreased survival in the late hazard phase. Postoperatively the condition of 80% of the patients improved to functional class I or II; only 0.6% remained in functional class IV. The 5-year rate of freedom from late combined valve-related morbidity was 81.7% and that of freedom from late combined valve-related morbidity and mortality was 71.7%. These results demonstrate excellent clinical improvement and late survival after multiple valve operation in patients with advanced valvular heart disease, justifying aggressive surgical therapy in these patients.(ABSTRACT TRUNCATED AT 250 WORDS)

Although retrograde cardioplegia has been shown to provide adequate overall protection to the myocardium, delivery of cardioplegic solution to the right ventricle and septum is poor. We used an animal model of occlusion of the left anterior descending coronary artery to study the effects of modifying the conditions of retrograde cardioplegia administration on delivery to the right and left ventricles. Adult mongrel dogs (n = 12) were each given five retrograde injections of microsphere-labeled cardioplegic solution at 10-minute intervals. Four injections were made directly into the coronary sinus with ostial balloon occlusion at the following dosages and pressures: (1) 10 ml/kg at 30 mm Hg, (2) 20 ml/kg at 30 mm Hg, (3) 10 ml/kg at 50 mmHg, and (4) 20 ml/kg at 50 mm Hg. A fifth dose (20 ml/kg) was given directly into the right atrium at 50 mm Hg. Delivery of cardioplegic solution to the left and right ventricles was significantly reduced when the right atrial route was compared with the coronary sinus route at the same dosage and pressure (for left ventricle, 6.0% +/- 1.4% versus 22.7% +/- 11.4%/100 gm, p less than 0.001; for right ventricle, 0.7% +/- 0.2% versus 4.1% +/- 0.4%/100 gm, p less than 0.001). Septal delivery was less than that to the anterior and posterior left ventricle (10.4% +/- 1.3% versus 30.3% +/- 3.9% and 27.9% +/- 3.1%/100 gm, p less than 0.0001) for all injections. Delivery to the body of the right ventricle was less than that to the inflow and outflow tracts (1.8% +/- 0.2% versus 4.5% +/- 0.7% and 8.4% +/- 1.5%/100 gm, p less than 0.0001). These results indicate that, in this model, (1) the right atrial route provides less overall cardioplegic solution to both ventricles than direct retrograde coronary sinus cardioplegia and (2) regional abnormalities in distribution with direct retrograde coronary sinus cardioplegia are not affected by changes in the dosage or pressure of injection