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Role of collateral circulation of the infarcted area in patients with postinfarction cardiac rupture
38
Journal of Cardiac Failure Vol. 5 No. 3 Suppl. 1 1999
133
134
Use of the Abiomed BVS 5000® Ventricular Assist Device - Four Year Results Daniel Marelli, Hillel Laks, Deborah A. Meehan, Daniel Fazio, Jaime Morigui~ chi; Cardiothoracic Surgery, UCLA School of Medicine, Los Angeles, CA
Thoracic Biaimpedence Accurately Determines Cardiac Output in Patients with Left Ventricular Assist Devices Marc A. Silver, Deborah Lazzara, Mark Slaughter, Szabolcs Szabo, Pat Pappas; Heart Failure Institute, Christ Hospital and Medical Center, Oak Lawn, IL
The Abiomed BVS 5000® is an external pulsatile ventricular assist device that is designed for short-term use in the event of life threatening cardiac failure. Since January 1995, 53 patients have required either univentricular (left or right) or biventricular support as treatment for pump failure from multiple etiologies. Thirty-nine of the patients were transferred to this referral center as potential candidates for heart transplantation, 21 of whom were already being supported with the BVS 5000. There were 33 males and 20 females, with a mean age of 49 years.
Among the approaches being utilized to support patients with advanced heart failure, surgical therapies such as implantable left ventricular assist devices (LVAD) are of great promise because of their ability to substantially alter heart size, structure and function. Lessons learned from patients receiving LVAD include the facts that even greatly impaired muscle may recover biochemically and functionally following device support, and this information, in turn, has raised the promise of using LVAD to support patients until a period of recovery is attained. Accurate knowledge of cardiac output (CO) is readily available when patients are being fully supported with LVAD; however, for patients in whom recovery is anticipated, a method of determination of CO and the participation of the native heart during periods of reduced support or weaning are needed. We therefore studied the accuracy of a commercially available thoracic bioimpedence (TBI) device (BioZ, CardioDynamics)to measure CO in patients with LVAD. Nine simultaneous determinations of LVAD CO and CO measured by TBI were performed in patients following insertion of LVAD for advanced heart failure; because these patients had contraindications to heart transplantation, bridge to recovery is the destination option for them. The patients ranged from 38 to 68 years and determinations of CO were made from 2 to 80 days post device implantation. For the TBI measured CO the mean value was 5.24_+0.95 liters/ minute and for the LVAD determined CO the mean value was 5.17_+0.60 liters/minute (p=NS). Another useful value obtained by TBI is the baseline impedence and this value reflects thoracic fluid status. The thoracic fluid status of these patients was varied as patients progressed from a decompensated and early post-operative stage towards a period of compensation and clinical stability. The CO values remained accurate even across this wide range of conditions.
Heart Failure Etiology Number Weaned / Converted Transplanted Discharged Post-cardiotomy Dilated CM RVAD only Myocarditis S/p MI
32 i0 6 2 3
8 I 4 2 0
8 5 3 0 0
7 (22%) 4 (40%) 3 (50%) 2(100%) 0
The BVS 5000 is a safe and effective tool to use for short-term support of patients with end-stage cardiac failure. It can maintain end-organ function if the anticipated wait for a orthotopic heart transplant is short. Use of the device in patients with myocarditis may allow for recovery of the myocardium. It can also be used to stabilize the patient until they can tolerate the stresses associated with cardiopulmonary bypass and implantation of a chronic LVAD. Improved results can be anticipated with better patient selection and earlier institution of support.
In summary, non-invasive measurement of CO using TBI in patients with LVAD is accurate and TB1 measurement may be a useful tool in assessing ability to wean patients and degree of recovery of left ventricular function during periods of reduced LVAD support.
135
136
Exercise Capacity after Heart Transplantation: Comparison with Heart Failure Patients Roberto Bonelli, Anna Picozzi, Antonio Laporta, Roberto Pedretti; Cardiology, Fondazione S. Maugeri - Care and Research Institute, Tradate, VA, Italy
Role of Collateral Circulation of the Infarcted Area in Patients with Postinfarction Cardiac Rupture Kalman Csapo, Laszlo Voith, Tibor Szuk, Zsolt Koszegi, Istvan Czuriga, Istvan Edes; Department of Heart and Lung Diseases, University Medical School of Debreceu, Debrecen, Hungary
Heart transplant (HTx) is purposely performed to restore a physiological pump function. For a better understanding of the relation between the HTx and working capacity, we compared hemodynamic (Hemo) and cardiopulmonary upright bicycle test data, in two patients (Pts) groups: Group A (89 Pts, 78M/1 IF, with ischemic or non-ischemic dilated cardiomyopathy, ejection fraction <.35%, maximal oxygen consumption (MVO2) <20 ml/Kg/rnin and NYHA class II-III) and Group B (18 age matched Pts, 14 M/4 F, on week 10-+2 from orthotopic HTx after a mean physical training period of 27-+7 days). Hemo data were collected at rest and during a supine bicycle exercise (20 W steps every 3 rain.), using a 7F Swan-Ganz fiberoptic catheter placed in right pulmonary artery. Hemo data and exercise time are reported (mean-+ ISD) in the following table (SexT-supine exercise time; UexT=upright exercise time). rest CI peak CI rest PCWP peak PCWP rest TPR SexT rain UexT rain A 2.5_+.7 4.7-+1.9 B 3.1+.7 6.5-+i.6 p <0.05 <0.001
18.8-+10 37.8-+11.5 8.6+4.3 21.7+9.7 <0.001 <0.001
521-+344 247+12 <0.01
6.5-+4 6.4-+2 NS
11.6+4 12.9+6 NS
MVO2 was similar in the two study groups. Pts of group A showed a severe central and peripheral Hemo impairment. In HTx Pts, a normal Hemo profile was not associated to an improvement in either exercise time or MVO2. These results support t!~e hypothesis that the morpho-functional status of skeletal muscle and the loss of motory units due to chronic hypoperfusion in pre-HTx, may be critical determinants of short-term exercise capacity in HTx Pts.
Myocardial rupture is one of the leading causes of in-hospitai death from myocardial infarction. The aim of the present study was to examine the role of collateral circulation in the development of myocardial rupture. The anterograde plus collateral flow was examined by conventional coronary angiography in a total of 47 patients with diagnosed myocardial rupture following acute myocardial infarction. These patients were divided into three subgroups: 23 patients with septal rupture (group A), 17 patients with mitral incompetence due to papillary muscle rupture (group B), and 7 patients with rupture of the free left ventricular wall (group C). Sixty patients with myocardial infarction but no rupture were assigned to the control group. The anterograde plus collateral flows supporting the infarcted zone were evaluated by the conventional score index technique (TIM1 and collateral score). The incidences of multi-vessel disease in the patients in groups A, B and C were 14 of 23 (61%), 12 of 17 (70%), and 7 of 7 (100%), respectively. Total occlusion of the infarct-related artery in the same patient groups involved 18 of 23 (78%), 7 of 17 (44%), and 7 of 7 (100%), respectively. Collateral vessels supporting the infarcted zone were observed in 42.5% of all cases. The patients in groups A and C exhibited significantly lower collateral and perfusion (collateral flow plus anterograde flow) indices as compared with the controls or the patients in group B. No significant difference in the collateral and perfusion indices was noted between group B and the controls. When the data on all patients with myocardial rupture (groups A, B and C) were combined, a significant (p=0.022, r=0.37) correlation was observed between the grade of collateral circulation and the duration of previous cardiovascular history. Moreover, the perfusion index was found to correlate (p-0.045, r=0.33) with the time score of the appearance of myocardial rupture. These findings indicate that the perfusion of the infarcted zone may be important for the prevention of certain forms (free left ventricular wall and septal rupture) of cardiac rupture.
Journal of Cardiac Failure Vol. 5 No. 3 Suppl. 1 1999
133
134
Use of the Abiomed BVS 5000® Ventricular Assist Device - Four Year Results Daniel Marelli, Hillel Laks, Deborah A. Meehan, Daniel Fazio, Jaime Morigui~ chi; Cardiothoracic Surgery, UCLA School of Medicine, Los Angeles, CA
Thoracic Biaimpedence Accurately Determines Cardiac Output in Patients with Left Ventricular Assist Devices Marc A. Silver, Deborah Lazzara, Mark Slaughter, Szabolcs Szabo, Pat Pappas; Heart Failure Institute, Christ Hospital and Medical Center, Oak Lawn, IL
The Abiomed BVS 5000® is an external pulsatile ventricular assist device that is designed for short-term use in the event of life threatening cardiac failure. Since January 1995, 53 patients have required either univentricular (left or right) or biventricular support as treatment for pump failure from multiple etiologies. Thirty-nine of the patients were transferred to this referral center as potential candidates for heart transplantation, 21 of whom were already being supported with the BVS 5000. There were 33 males and 20 females, with a mean age of 49 years.
Among the approaches being utilized to support patients with advanced heart failure, surgical therapies such as implantable left ventricular assist devices (LVAD) are of great promise because of their ability to substantially alter heart size, structure and function. Lessons learned from patients receiving LVAD include the facts that even greatly impaired muscle may recover biochemically and functionally following device support, and this information, in turn, has raised the promise of using LVAD to support patients until a period of recovery is attained. Accurate knowledge of cardiac output (CO) is readily available when patients are being fully supported with LVAD; however, for patients in whom recovery is anticipated, a method of determination of CO and the participation of the native heart during periods of reduced support or weaning are needed. We therefore studied the accuracy of a commercially available thoracic bioimpedence (TBI) device (BioZ, CardioDynamics)to measure CO in patients with LVAD. Nine simultaneous determinations of LVAD CO and CO measured by TBI were performed in patients following insertion of LVAD for advanced heart failure; because these patients had contraindications to heart transplantation, bridge to recovery is the destination option for them. The patients ranged from 38 to 68 years and determinations of CO were made from 2 to 80 days post device implantation. For the TBI measured CO the mean value was 5.24_+0.95 liters/ minute and for the LVAD determined CO the mean value was 5.17_+0.60 liters/minute (p=NS). Another useful value obtained by TBI is the baseline impedence and this value reflects thoracic fluid status. The thoracic fluid status of these patients was varied as patients progressed from a decompensated and early post-operative stage towards a period of compensation and clinical stability. The CO values remained accurate even across this wide range of conditions.
Heart Failure Etiology Number Weaned / Converted Transplanted Discharged Post-cardiotomy Dilated CM RVAD only Myocarditis S/p MI
32 i0 6 2 3
8 I 4 2 0
8 5 3 0 0
7 (22%) 4 (40%) 3 (50%) 2(100%) 0
The BVS 5000 is a safe and effective tool to use for short-term support of patients with end-stage cardiac failure. It can maintain end-organ function if the anticipated wait for a orthotopic heart transplant is short. Use of the device in patients with myocarditis may allow for recovery of the myocardium. It can also be used to stabilize the patient until they can tolerate the stresses associated with cardiopulmonary bypass and implantation of a chronic LVAD. Improved results can be anticipated with better patient selection and earlier institution of support.
In summary, non-invasive measurement of CO using TBI in patients with LVAD is accurate and TB1 measurement may be a useful tool in assessing ability to wean patients and degree of recovery of left ventricular function during periods of reduced LVAD support.
135
136
Exercise Capacity after Heart Transplantation: Comparison with Heart Failure Patients Roberto Bonelli, Anna Picozzi, Antonio Laporta, Roberto Pedretti; Cardiology, Fondazione S. Maugeri - Care and Research Institute, Tradate, VA, Italy
Role of Collateral Circulation of the Infarcted Area in Patients with Postinfarction Cardiac Rupture Kalman Csapo, Laszlo Voith, Tibor Szuk, Zsolt Koszegi, Istvan Czuriga, Istvan Edes; Department of Heart and Lung Diseases, University Medical School of Debreceu, Debrecen, Hungary
Heart transplant (HTx) is purposely performed to restore a physiological pump function. For a better understanding of the relation between the HTx and working capacity, we compared hemodynamic (Hemo) and cardiopulmonary upright bicycle test data, in two patients (Pts) groups: Group A (89 Pts, 78M/1 IF, with ischemic or non-ischemic dilated cardiomyopathy, ejection fraction <.35%, maximal oxygen consumption (MVO2) <20 ml/Kg/rnin and NYHA class II-III) and Group B (18 age matched Pts, 14 M/4 F, on week 10-+2 from orthotopic HTx after a mean physical training period of 27-+7 days). Hemo data were collected at rest and during a supine bicycle exercise (20 W steps every 3 rain.), using a 7F Swan-Ganz fiberoptic catheter placed in right pulmonary artery. Hemo data and exercise time are reported (mean-+ ISD) in the following table (SexT-supine exercise time; UexT=upright exercise time). rest CI peak CI rest PCWP peak PCWP rest TPR SexT rain UexT rain A 2.5_+.7 4.7-+1.9 B 3.1+.7 6.5-+i.6 p <0.05 <0.001
18.8-+10 37.8-+11.5 8.6+4.3 21.7+9.7 <0.001 <0.001
521-+344 247+12 <0.01
6.5-+4 6.4-+2 NS
11.6+4 12.9+6 NS
MVO2 was similar in the two study groups. Pts of group A showed a severe central and peripheral Hemo impairment. In HTx Pts, a normal Hemo profile was not associated to an improvement in either exercise time or MVO2. These results support t!~e hypothesis that the morpho-functional status of skeletal muscle and the loss of motory units due to chronic hypoperfusion in pre-HTx, may be critical determinants of short-term exercise capacity in HTx Pts.
Myocardial rupture is one of the leading causes of in-hospitai death from myocardial infarction. The aim of the present study was to examine the role of collateral circulation in the development of myocardial rupture. The anterograde plus collateral flow was examined by conventional coronary angiography in a total of 47 patients with diagnosed myocardial rupture following acute myocardial infarction. These patients were divided into three subgroups: 23 patients with septal rupture (group A), 17 patients with mitral incompetence due to papillary muscle rupture (group B), and 7 patients with rupture of the free left ventricular wall (group C). Sixty patients with myocardial infarction but no rupture were assigned to the control group. The anterograde plus collateral flows supporting the infarcted zone were evaluated by the conventional score index technique (TIM1 and collateral score). The incidences of multi-vessel disease in the patients in groups A, B and C were 14 of 23 (61%), 12 of 17 (70%), and 7 of 7 (100%), respectively. Total occlusion of the infarct-related artery in the same patient groups involved 18 of 23 (78%), 7 of 17 (44%), and 7 of 7 (100%), respectively. Collateral vessels supporting the infarcted zone were observed in 42.5% of all cases. The patients in groups A and C exhibited significantly lower collateral and perfusion (collateral flow plus anterograde flow) indices as compared with the controls or the patients in group B. No significant difference in the collateral and perfusion indices was noted between group B and the controls. When the data on all patients with myocardial rupture (groups A, B and C) were combined, a significant (p=0.022, r=0.37) correlation was observed between the grade of collateral circulation and the duration of previous cardiovascular history. Moreover, the perfusion index was found to correlate (p-0.045, r=0.33) with the time score of the appearance of myocardial rupture. These findings indicate that the perfusion of the infarcted zone may be important for the prevention of certain forms (free left ventricular wall and septal rupture) of cardiac rupture.