Echocardiographic selection of patients with chronic heart failure for vasodilator therapy

LETTERS TO THE EDITOR

67:716-E. 3. Froknan W. Disorders 01 circulation: thrombosis. embolism. infarctkn. In: Srunson JG, Gall EA. eds. Cooceprs of Disease-Textbwk of hhan Pathology NW YwkMacmillan. 1971. 4. Glenn WL, Galebrew C, Goodyr AVN, et al. Mitral valvuiotomy. il. Operative results after closed vaiwiotcmy. A report of 500 cases. Am J SWQ 1969:117:493-501.

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CORONARY ARTERY DISEASE, LEFT VENTRICULAR DYSFUNCTION AND AORTIC VALVE REPLACEMENT

The conclusion of Thompson et al.1 that poor left ventricular function does not increase the risk of aortic valve replacement for aortic stenosis is, in general, well supported but should be qualified with respect to the severity of left ventricular dysfunction and the presence of coronary artery disease. In their group with subnormal left ventricular function before operation the lowest ejection fraction was 0.18, and at least half the patients appear to have had an ejection fraction greater than 0.30. We2 reported on a series of 12 patients receiving aortic valve replacement for aortic stenosis, all with extreme left ventricular dysfunction (mean ejection fraction 0.13; range =O to 0.20). Of five with coronary disease (all with aortocoronary bypass grafts), four died during or shortly after operation, three clearly because of continued left ventricular failure, whereas all seven without coronary disease survived operation with gratifying clinical improvement and increase of left ventricular ejection fraction toward normal. We concluded that in the absence of coronary disease even the most extreme left ventricular dysfunction can be reversed by replacement of the stenotic aortic valve but that the presence of coronary disease accompanying advanced left ventricular dysfunction presents a significant barrier to successful surgical outcome. It is important for patient management that the principle that left ventricular dysfunction attributable to aortic stenosis is always reversible be widely disseminated. It is equally important that the influence of coronary disease at the extreme of left ventricular dysfunction be recognized. Robert P. Croke, MD, FACC Roque Pifarre, MD, FACC Henry Sullivan. MD, FACC Rolf M. Gunnar, MD, FACC Henry S. Loeb, MD, FACC Veterans Administration Edward Hines, Jr. Hospital

Hines, Illinois References I. Thanpm R, Yacoub M, Almad Y. SOebraoarwrO II, Rkhuds A, Towem II. influence ofpecperativelettveob~furctbnonregultsofhomoganreplacementofmeaatic valve for aortk stwosls. Am J Cardloi 1979;43:929-36. 2. Croke RP, Pilarra R, Sullivan H, Gunnaf RY, Loeb HS. Reversal of advanced ielt ventrkulaf dyshwztion followingaottlc valve replacement for awtic stenosis. Ann Thorac s",Q 1977;24:3543.

ECHOCARDIOGRAPHIC SELECTION OF PATIENTS WlTH CHRONIC HEART FAILURE FOR VASODILATOR THERAPY

We agree with Packer et al.l that the various vasodilating drugs must be used with more caution in patients with refractory chronic heart failure and that a screening test for selecting patients and choosing an individual vasodilator would be very useful. We have had a good experience with echocardiography as a screening method for predicting hemodynamic response to different vasodilator drugs in our patients.2 Baseline hemodynamic variables were calculated from the left ventricular chamber dimensions, after which the

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The American Journal of CARDIOLOGY

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1. Response of ejection fraction to nitroglycerin (NTG) test in 34 patients

hemodynamic response on the test dose of vasodilator with different mechanisms of action-on preload, afterload, or both-was evaluated. The response was nonuniform and unpredictable: Some patients showed a favorable hemodynamic reaction, some did not react at all, while in a few the hemodynamic status deteriorated. With this screening procedure we could predict the hemodynamic response in an individual patient with chronic heart failure during treatment with vasodilator drugs and select the vasodilator with the best effect on cardiac performance in an individual patient. Our initial experience with long-term treatment with vasodilators in previously tested patients confirms the value of this procedure. Figure 1 shows the influence of the nitroglycerin test (5 to 10 mg sublingual nitroglycerin) on basal ejection fraction in 34 patients with chronic heart failure. Two groups of patients were evident: In the first group of 23 patients the ejection fraction was significantly increased; in the other 11 it declined or did not alter. Thus, only patients in the first group would be candidates for therapy with nitroglycerin. When vasodilators with other mechanisms of action were tested, similar nonuniform results were obtained. We find this method a simple, noninvasive and rapid screening test for selecting patients with chronic heart failure for vasodilator therapy. Therefore we propose that it should be used as a routine test before vasodilator therapy is started. Ivo Cikeg, MD Institute of Cardiovascular Diseases Medical Faculty University of Zagreb Zagreb, Yugoslavia References 1. Packer Y, Melier J. Oral vasodilator therapy for Lhronic heart Mure. a plea for caubon Am J Cardiii 1978:42:666-9. 2. elk& I, Subanj GJ. Ivan& R. Echocardiographic selection of patients vith chrome heart failure for vasodilator therapy. In: Abstracts, VIII Wofld Congress of Cardiology. Tokyo, 1976~515.

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PEAK LEFT VENTRICULAR SYSTOLIC PRESSURE/ END-SYSTOLIC VOLUME RATIO

Nivatpumin et al.’ propose that an index equal to the ratio left ventricular peak pressure/left ventricular end-systolic volume can be used to detect left ventricular disease. This ratio, which

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