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Isolated surgicalcoronary revascularization in patients withsevere left ventricular dysfunction
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Journal of Cardiac Failure Vol. 4 No. 3 Suppl. 2 1998
085 ISOLATED SURGICALCORONARY REVASC ULARIZATION IN PATIENTSWITHSEVERE LEFT VENTRICULAR DYSFUNCTION Hiroshi Nlshida, Chizuo Kikuchi, Yasuko Tomizawa, Akihiko Kawai, MasahiroEndo, Hitoshi Koyanagi Department of CardiovascularSurgery, The Heart Institute of Japan, Tokyo Women's Medical University, Tokyo 162-8666, Japan The objective of this study waste investigate the indication of heart transplantation for ischemic cardiomyopathy in Japan through the analysis of clinical results of CABG in such patients. From November 1977 to April 1998, 43 patients with left ventricular ejection fraction (LVEF) of 20% or less underwent isolated CABG. The age ranged from 35 to 71 with a mean of 57.0 years and 24 patients (56%) were 60 years or younger. There were 42 males and one female. The postoperative follow-up ranged from 4 months to 20 years with a mean of 4.4 years. There were 1 re-do CABG and 11 emergency CABGs (26%). The preoperative LVEF ranged from 6% to 20% with a mean of 17.6%. All but one patient had ahistory of myocardial infarction and 13 patients had a history of multiple ventricular arrythmia.Thirty one patients (72%) had either triple vessel or left main disease. Six patients were on hemodialysis due to chronic r~na[ failure and 4 patients were in cardiogenic shock atthe time of operation. The mean number of distal anastomoses was2.51. Since December 1989, all35 patients received atleast one arterialgraft and 24 patients (56%) received two or more distal anastomosis with arterialconduits. There were 3 operative deaths within 30 days of the operation (7.0%) and 3 hospital deaths (7.0%). During the follow-up period, there were 12 (27.9%)latedeaths (cardiac-8,sudden death-2, non-cardiac-2) and actuarialsurvival rate including early deaths and non-cardiac deaths was86.0% at 1 yearand 65.9% at5 year. Inconclusion, in patients with severe left ventricular dysfunction but with viable myocardium associated with graftable coronary arterylesions, CABG can be still atreatment of choice in acountry with almost no heart transplantation due to severe donor shortage.
087 IS MITRAL VALVE REPLACEMENT EFFECTIVE TO THE PATIENTS WITH MITRAL REGURGITATION WITH DILATED LEFT VENTRICLE? Nobuaki Hirata, Yoshiki Sawa, Shigeaki Ohtake, Aldra Amemiya, Taichi Sakaguchi, Yasuhiko Kobayashi, Kei Sakai, Hikaru Matsuda First Department of Surgery, Osaka University Medical School, Osaka 565-0871, Japan We reported that patients with mitral regurgitation (MR) with dilated left ventricle (= left ventricular end-systolic volume index (LVESVI) is over 100 ml/m 2 ) had poor prognosis. In order to elucidate the efficacy of mitral valve replacement (MVR) to those patients, we assessed pro- and postoperative factors. We studied five patients whose preoperative LVESVI was over 100 ml/m 2 . Preoperative LV ejection fraction (EF), LVESVI, and LV end-diastolic volume index (EDVI) were 42"+'8%, 110-1-7 ml/m 2, and 193___26 ml/m 2, respectively. Postoperatively, LVEF, LVESVI, and LVEDVI were 33+-7%, 1 1 2 ± 3 2 ml/m2, and 1 6 6 ± 3 4 ml/m2, respectively. All the values did not change. Two patients had sudden death, the other tWo patients died of heart failure and the other remained in NYHA functional class II1. In conclusion, those patients had no improvement of LVEF, and had no reduction of LV volume even after MVR. Those results suggest that Batista procedure as well as mitral valve repair may be effective to those patients with MR with dilated LV.
086 OUR EXPERIENCES OF MITRAL VALVE REPLACEMENT(MVR) FOR SECONDARY MITRAL REGURGITATION(MR) DUE TO SEVERE LEFT VENTRICULAR DYSFUNCTION Modaki Inoko, Chisato Izumi, Shoji Kitaguchi, Toshiro Hirozane, Yoshihiro Himura, Kanji Iga, Hiromitsu Gen, Takashi Konishi, "~Jichi Ueda* Department of Cardiology, and Department of Cardiovascular Surgery*, Tend Hospital, Tenri 632-0015, Japan The effectiveness of MVR for secondary MR caused by global LV dysfunction is a major concern. We report two cases that were suffered from NYHA IV heart failure due to diffuse LV hypokinesis and MR, and recovered to NYHA II after MVR. They were 56 and 63years old men. They had episodes of myocardial infarction and had undergone coronary artery bypass grafting (CABG), but thereafter were hospitalized several times for recurrent pulmonary congestion. In the last admission, both were treated by usual medial therapies, but their conditions did not improve. LV ventriculography (LVG) revealed enlarged and diffusely hypokinetic LV (LV enddiastolic volume index; 204, 209ml/m 2, LV ejection fraction; 25, 30%) and severe MR. The pulmonary artery wedge pressure (PAWP) was 30 and 34mmHg, and the cardiac index ((31)was 2.1 and 2.81J'min/m2, respectively. After intensifying vasodilating therapy, the hemodynamics improved (PAWP 12 and 25, CI 4.2 and 4.3) accompanied by the regression of holosystolic heart murmur and v wave in PAWP wave form. These observations indicated that the MR was mainly due to mi~al annular dilatation and variable according to afterload in these patients. They underwent MVR successfully, and recovered to NYHA I1.Their clinical courses suggest that a subgroup in patients suffered from congestive heart failure due to LV dysfunction and secondary MR, in which the severity of MR is variable and normal cardiac output is attained by vasodilatation, may derive benefit from MVR.
088 Adenovirus-Mediated Gene Transfer of CTLA41g is Highly Efficient and Prolongs Cardiac AIIograft Survival Izumi Nakagawa, Hiroshi Okamoto, Satoru Chiba, Hideki Kumamoto, Keiji Yoneya, Masashi Watanabe, Masaaki Murakami, Toshimitsu Uede Cardiovascular Medicine and Institute of Immunological Science, Hokkaido University We developed a highly efficient method to transfer CTLA41g, which might be an important strategy to reduce T cell-mediated immune responses in allograff rejection and in elimination of virusinfected cells, Interaction of the T cell receptor with its specific peptide/MHC counter receptor is required for T cell activation. Ligation of CD28 on the T cell and B7 receptors expressed on antigen presenting cells is the main costimulatory signal that contributes to T cell activation. CTLA41g could inhibit the costimulatory signal and induces antigen-specific T cell anergy. In general, adenovirus vectors have a serious limitation in that gene expression lasts no more than several weeks because of the cytotoxic T cell r e a c t i o n , We c o n s t r u c t e d an a d e n o v i r u s v e c t o r , AdexlCACTLA41gG (Ax), containing the extracellular domain of murine CTLA4 and the Fc portion of human immunoglobulin Gt. We investigated the duration and efficacy of Ax, as well as the inhibitory effect of Ax on cardiac allograft rejection. Ax was inoculated into CBA/J mice and blood samples were collected periodically. Serum concentration of CTLA41g was determined by ELISA, The maximum concentration of CTLA41g was 25 mg/ml one week after inoculation of Ax (7.8 X 109 pfu). It was 8 mg/mll00 days after administration. Whole hearts from donor neonatal C57BL/6 mice were removed to a subcutaneous pocket in the ear pinnae of CBA/J recipients. Ax (9.0 X 109 pfu) was inoculated into recipients one week before transplantation. AIIograft survival was determined by electrocardiogram. Mean graft survival in the group treated with Ax was significantly longer than in the control (33.0 vs 14.0 days, p<0.05). In conclusion, we developed a highly efficient method to transfer CTLA41g. In the mouse cardiac allograft model, Ax administration could significantly prolong allograft survival.
Journal of Cardiac Failure Vol. 4 No. 3 Suppl. 2 1998
085 ISOLATED SURGICALCORONARY REVASC ULARIZATION IN PATIENTSWITHSEVERE LEFT VENTRICULAR DYSFUNCTION Hiroshi Nlshida, Chizuo Kikuchi, Yasuko Tomizawa, Akihiko Kawai, MasahiroEndo, Hitoshi Koyanagi Department of CardiovascularSurgery, The Heart Institute of Japan, Tokyo Women's Medical University, Tokyo 162-8666, Japan The objective of this study waste investigate the indication of heart transplantation for ischemic cardiomyopathy in Japan through the analysis of clinical results of CABG in such patients. From November 1977 to April 1998, 43 patients with left ventricular ejection fraction (LVEF) of 20% or less underwent isolated CABG. The age ranged from 35 to 71 with a mean of 57.0 years and 24 patients (56%) were 60 years or younger. There were 42 males and one female. The postoperative follow-up ranged from 4 months to 20 years with a mean of 4.4 years. There were 1 re-do CABG and 11 emergency CABGs (26%). The preoperative LVEF ranged from 6% to 20% with a mean of 17.6%. All but one patient had ahistory of myocardial infarction and 13 patients had a history of multiple ventricular arrythmia.Thirty one patients (72%) had either triple vessel or left main disease. Six patients were on hemodialysis due to chronic r~na[ failure and 4 patients were in cardiogenic shock atthe time of operation. The mean number of distal anastomoses was2.51. Since December 1989, all35 patients received atleast one arterialgraft and 24 patients (56%) received two or more distal anastomosis with arterialconduits. There were 3 operative deaths within 30 days of the operation (7.0%) and 3 hospital deaths (7.0%). During the follow-up period, there were 12 (27.9%)latedeaths (cardiac-8,sudden death-2, non-cardiac-2) and actuarialsurvival rate including early deaths and non-cardiac deaths was86.0% at 1 yearand 65.9% at5 year. Inconclusion, in patients with severe left ventricular dysfunction but with viable myocardium associated with graftable coronary arterylesions, CABG can be still atreatment of choice in acountry with almost no heart transplantation due to severe donor shortage.
087 IS MITRAL VALVE REPLACEMENT EFFECTIVE TO THE PATIENTS WITH MITRAL REGURGITATION WITH DILATED LEFT VENTRICLE? Nobuaki Hirata, Yoshiki Sawa, Shigeaki Ohtake, Aldra Amemiya, Taichi Sakaguchi, Yasuhiko Kobayashi, Kei Sakai, Hikaru Matsuda First Department of Surgery, Osaka University Medical School, Osaka 565-0871, Japan We reported that patients with mitral regurgitation (MR) with dilated left ventricle (= left ventricular end-systolic volume index (LVESVI) is over 100 ml/m 2 ) had poor prognosis. In order to elucidate the efficacy of mitral valve replacement (MVR) to those patients, we assessed pro- and postoperative factors. We studied five patients whose preoperative LVESVI was over 100 ml/m 2 . Preoperative LV ejection fraction (EF), LVESVI, and LV end-diastolic volume index (EDVI) were 42"+'8%, 110-1-7 ml/m 2, and 193___26 ml/m 2, respectively. Postoperatively, LVEF, LVESVI, and LVEDVI were 33+-7%, 1 1 2 ± 3 2 ml/m2, and 1 6 6 ± 3 4 ml/m2, respectively. All the values did not change. Two patients had sudden death, the other tWo patients died of heart failure and the other remained in NYHA functional class II1. In conclusion, those patients had no improvement of LVEF, and had no reduction of LV volume even after MVR. Those results suggest that Batista procedure as well as mitral valve repair may be effective to those patients with MR with dilated LV.
086 OUR EXPERIENCES OF MITRAL VALVE REPLACEMENT(MVR) FOR SECONDARY MITRAL REGURGITATION(MR) DUE TO SEVERE LEFT VENTRICULAR DYSFUNCTION Modaki Inoko, Chisato Izumi, Shoji Kitaguchi, Toshiro Hirozane, Yoshihiro Himura, Kanji Iga, Hiromitsu Gen, Takashi Konishi, "~Jichi Ueda* Department of Cardiology, and Department of Cardiovascular Surgery*, Tend Hospital, Tenri 632-0015, Japan The effectiveness of MVR for secondary MR caused by global LV dysfunction is a major concern. We report two cases that were suffered from NYHA IV heart failure due to diffuse LV hypokinesis and MR, and recovered to NYHA II after MVR. They were 56 and 63years old men. They had episodes of myocardial infarction and had undergone coronary artery bypass grafting (CABG), but thereafter were hospitalized several times for recurrent pulmonary congestion. In the last admission, both were treated by usual medial therapies, but their conditions did not improve. LV ventriculography (LVG) revealed enlarged and diffusely hypokinetic LV (LV enddiastolic volume index; 204, 209ml/m 2, LV ejection fraction; 25, 30%) and severe MR. The pulmonary artery wedge pressure (PAWP) was 30 and 34mmHg, and the cardiac index ((31)was 2.1 and 2.81J'min/m2, respectively. After intensifying vasodilating therapy, the hemodynamics improved (PAWP 12 and 25, CI 4.2 and 4.3) accompanied by the regression of holosystolic heart murmur and v wave in PAWP wave form. These observations indicated that the MR was mainly due to mi~al annular dilatation and variable according to afterload in these patients. They underwent MVR successfully, and recovered to NYHA I1.Their clinical courses suggest that a subgroup in patients suffered from congestive heart failure due to LV dysfunction and secondary MR, in which the severity of MR is variable and normal cardiac output is attained by vasodilatation, may derive benefit from MVR.
088 Adenovirus-Mediated Gene Transfer of CTLA41g is Highly Efficient and Prolongs Cardiac AIIograft Survival Izumi Nakagawa, Hiroshi Okamoto, Satoru Chiba, Hideki Kumamoto, Keiji Yoneya, Masashi Watanabe, Masaaki Murakami, Toshimitsu Uede Cardiovascular Medicine and Institute of Immunological Science, Hokkaido University We developed a highly efficient method to transfer CTLA41g, which might be an important strategy to reduce T cell-mediated immune responses in allograff rejection and in elimination of virusinfected cells, Interaction of the T cell receptor with its specific peptide/MHC counter receptor is required for T cell activation. Ligation of CD28 on the T cell and B7 receptors expressed on antigen presenting cells is the main costimulatory signal that contributes to T cell activation. CTLA41g could inhibit the costimulatory signal and induces antigen-specific T cell anergy. In general, adenovirus vectors have a serious limitation in that gene expression lasts no more than several weeks because of the cytotoxic T cell r e a c t i o n , We c o n s t r u c t e d an a d e n o v i r u s v e c t o r , AdexlCACTLA41gG (Ax), containing the extracellular domain of murine CTLA4 and the Fc portion of human immunoglobulin Gt. We investigated the duration and efficacy of Ax, as well as the inhibitory effect of Ax on cardiac allograft rejection. Ax was inoculated into CBA/J mice and blood samples were collected periodically. Serum concentration of CTLA41g was determined by ELISA, The maximum concentration of CTLA41g was 25 mg/ml one week after inoculation of Ax (7.8 X 109 pfu). It was 8 mg/mll00 days after administration. Whole hearts from donor neonatal C57BL/6 mice were removed to a subcutaneous pocket in the ear pinnae of CBA/J recipients. Ax (9.0 X 109 pfu) was inoculated into recipients one week before transplantation. AIIograft survival was determined by electrocardiogram. Mean graft survival in the group treated with Ax was significantly longer than in the control (33.0 vs 14.0 days, p<0.05). In conclusion, we developed a highly efficient method to transfer CTLA41g. In the mouse cardiac allograft model, Ax administration could significantly prolong allograft survival.