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Introduction Mitral annular calcification is a degenerative process of the fibrosus support structure of the mitral apparatus, usually spreading over the posterior mitral leaflet. Case Outline A 66-year-old woman with shortness of breath and palpitations was referred to our institution. Echocardiography showed a round, echo-dense mass, resembling a tumour, in the posterior mitral annulus, with the third degree mitral regurgitation. Based on the findings, surgical treatment was suggested involving removal of the tumour and correction of mitral valve insufficiency. During surgery the posterior annulus was incised, whitish caseous material was aspirated and the developed cavity was closed. A bioprosthetic valve was placed in the mitral position. The aspirated material was sent to bacteriological and histological analysis. Eight days after surgery control echocardiography and CT scan of the heart showed absence of the mass. Pathohistological finding was nonspecific. Bacteriology showed Staphylococus spp. Thirteen days after surgery the patient was discharged in stabile condition. Conclusion Mitral annular calcification is a common degenerative disorder particularly in elderly persons. As the diagnosis very often remains unrecognised imitating a tumor formation, precise diagnostics is necessary before possible surgery. .

Introduction Heparin-induced thrombocytopenia (HIT) is an acquired, prothrombotic disorder, caused by antibodies to a complex of heparin and platelet factor 4 (PF4) that activates platelets, resulting in the release of procoagulant microparticles, thrombocytopenia occurrence, generation of thrombin, and frequent thromboses. Case Outline We present a case of severe HIT in a 68-year-old female, which occurred after cardiosurgery of the left atrial myxoma with the aim to point out the importance of differential diagnosis of thrombocytopenia in patients recently exposed to heparin. Platelet count dropped on the eleventh postoperative day, six days after unfractioned heparin and enoxaparine treatment, to 4×109/l. The correct diagnosis failed to be made at first. Since thrombocytopenia remained refractory to a corticosteroid treatment and platelet transfusion, the patient was hospitalized on the 13th postoperative day at the Institute of Hematology. The diagnosis of HIT was confirmed with the high-probability clinical score (4T's) and strongly positive antiheparin-PF4 (PaGIA) test as well as positive platelet aggregation test. The treatment started with a smaller therapeutic doses of danaparoid than recommended of 750 U intravenous bolus and was followed by continuous infusions of 100 U per 1 h and intravenous gammaglobulins in full dosage for four days. The platelet count started to rise on the third day and it was completely normalized on the 5th day of the therapy. Conclusion Treatment of severe HIT with small doses of danaparoid supplemented by intravenous gamma globulin was successful. Additional awareness of heparin-induced thrombocytopenia is needed, especially of HIT in differential diagnosis of thrombocytopenia in patients recently exposed to heparin.

An abstract of the article "Semiquantitative histomorphometric analysis of myocardium following partial left ventriculectomy: one-year follow-up," by J. D. Vasiljevic et al., is presented.

Abstract Background Prognostic value of concomitant aprtic regurgitation (AR) in patients operated for severe aortic stenosis (AS) is not clarified. The aim of this study was to prospectively examine the impact of presence and severity of concomitant AR in patients operated for severe AS on long-term functional capacity, left ventricular (LV) function and mortality. Methods Study group consisted of 110 consecutive patients operated due to severe AS. The patients were divided into AS group (56 patients with AS without AR or with mild AR) and AS+AR group (54 patients with AS and moderate, severe or very severe AR). Follow-up included clinical examination, six minutes walk test (6MWT) and echocardiography 12 and 104 months after AVR. Results Patients in AS group had lower LV volume indices throughout the study than patients in AS+AR group. Patients in AS group did not have postoperative decrease in LV volume indices, whereas patients in AS+AR group experienced decrease in LV volume indices at 12 and 104 months. Unlike LV volume indices, LV mass index was significantly lower in both groups after 12 and 104 months as compared to preoperative values. Mean LVEF remained unchanged in both groups throughout the study. NYHA class was improved in both groups at 12 months, but at 104 months remained improved only in patients with AS. On the other hand, distance covered during 6MWT was longer at 104 months as compared to 12 months only in AS+AR group (p = 0,013), but patients in AS group walked longer at 12 months than patients in AS+AR group (p = 0,002). There were 30 deaths during study period, of which 13 (10 due to cardiovascular causes) in AS group and 17 (12 due to cardiovascular causes) in AS+AR group. Kaplan-Meier analysis showed that the survival probability was similar between the groups. Multivariate analysis identified diabetes mellitus (beta 1.78, p = 0.038) and LVEF < 45% (beta 1.92, p = 0.049) as the only independent predictor of long-term mortality. Conclusion Our data indicate that the preoperative presence and severity of concomitant AR has no influence on long-term postoperative outcome, LV function and functional capacity in patients undergoing AVR for severe AS.

Background and Aims: The question of when and how to treat truly asymptomatic patients with severe aortic stenosis (AS) and normal left ventricular (LV) systolic function is still subject to debate and ongoing research. Here, the results of extended follow-up of the AVATAR trial are reported (NCT02436655, clinical trials.gov)., Methods: The AVATAR trial randomly assigned patients with severe, asymptomatic AS and LV ejection fraction ≥50% to undergo either early surgical aortic valve replacement (AVR) or conservative treatment with watchful waiting strategy. All patients had negative exercise stress testing. The primary hypothesis was that early AVR will reduce a primary composite endpoint comprising all-cause death, acute myocardial infarction, stroke or unplanned hospitalization for heart failure (HF), as compared to conservative treatment strategy., Results: A total of 157 low-risk patients (mean age 67 years, 57% men, mean Society of Thoracic Surgeons score 1.7%) were randomly allocated to either early AVR group (n=78) or conservative treatment group (n=79). In an intention-to-treat analysis, after a median follow-up of 63 months, the primary composite endpoint outcome event occurred in 18/78 patients (23.1%) in the early surgery group and in 37/79 patients (46.8%) in the conservative treatment group (hazard ratio [HR] early surgery vs. conservative treatment 0.42; 95% confidence interval [CI] 0.24-0.73, p=0.002). The Kaplan-Meier estimates for individual endpoints of all-cause death and HF hospitalization were significantly lower in the early surgery compared with the conservative group (HR 0.44; 95% CI 0.23-0.85, p=0.012 for all-cause death, and HR 0.21; 95% CI 0.06-0.73, p=0.007 for HF hospitalizations)., Conclusions: The extended follow-up of the AVATAR trial demonstrates better clinical outcomes with early surgical AVR in truly asymptomatic patients with severe AS and normal LV ejection fraction compared with patients treated with conservative management on watchful waiting., Trial Registration Number: NCT02436655 (ClinicalTrials.gov)., (© The Author(s) 2024. Published by Oxford University Press on behalf of the European Society of Cardiology. All rights reserved. For commercial re-use, please contact reprints@oup.com for reprints and translation rights for reprints. All other permissions can be obtained through our RightsLink service via the Permissions link on the article page on our site—for further information please contact journals.permissions@oup.com.)

Background and Objectives : The saphenous vein graft (SVG) remains the most frequently used conduit worldwide, despite its common disadvantage of early graft failure. To solve the problem and reduce the SVG damage, Souza implemented a new technique where a vein is harvested with surrounding fascia and fat tissue (the so-called no-touch technique). Materials and Methods . A prospective study conducted from February 2019 to June 2024 included 23 patients who underwent myocardial revascularization using a no-touch vein, with follow-up control examinations using computed tomographic angiography to detect graft stenosis or occlusion. Results . Of the entire patient group, 17 (73.9%) were male, with a mean age of 67.39 ± 7.71 years. The mean follow-up period was 25 months. There were no major adverse cardiovascular or cerebrovascular events (MACCEs) during hospitalization, although one patient died in the hospital. Another patient died due to malignancy, but no MACCEs occurred during the follow-up period. According to multi-slice CT coronary angiography, the results were impeccable, with an astonishing 100% patency observed in all 20 IMA grafts and 58 no-touch SVGs examined. Conclusions . The excellent patency rate during the early follow-up period confirmed that the no-touch technique is a good option for surgical revascularization.

Background: The STICH trial (Surgical Treatment for Ischemic Heart Failure) demonstrated a survival benefit of coronary artery bypass grafting in patients with ischemic cardiomyopathy and left ventricular dysfunction. The Society of Thoracic Surgeons (STS) risk score and the EuroSCORE-2 (ES2) are used for risk assessment in cardiac surgery, with little information available about their accuracy in patients with left ventricular dysfunction. We assessed the ability of the STS score and ES2 to evaluate 30-day postoperative mortality risk in STICH and a contemporary cohort (CC) of patients with a left ventricle ejection fraction ≤35% undergoing coronary artery bypass grafting outside of a trial setting., Methods and Results: The STS and ES2 scores were calculated for 814 STICH patients and 1246 consecutive patients in a CC. There were marked variations in 30-day postoperative mortality risk from 1 patient to another. The STS scores consistently calculated lower risk scores than ES2 (1.5 versus 2.9 for the CC and 0.9 versus 2.4 for the STICH cohort), and underestimated postoperative mortality risk. The STS and ES2 scores had moderately good C statistics: CC (0.727, 95% CI: 0.650-0.803 for STS, and 0.707, 95% CI: 0.620-0.795 for ES2); STICH (0.744, 95% CI: 0.677-0.812, for STS and 0.736, 95% CI: 0.665-0.808 for ES2). Despite the CC patients having higher STS and ES2 scores than STICH patients, mortality (3.5%) was lower than that of STICH (4.8%), suggesting a possible decrease in postoperative mortality over the past decade., Conclusions: The 30-day postoperative mortality risk of coronary artery bypass grafting in patients with left ventricular dysfunction varies markedly. Both the STS and ES2 score are effective in evaluating risk, although the STS score tend to underestimate risk., Clinical Trial Registration: URL: https://www.clinicaltrials.gov. Unique identifier: NCT00023595.

Objective: Whether right ventricular dysfunction affects clinical outcome after coronary artery bypass grafting with or without surgical ventricular reconstruction is still unknown. The aim of the study was to assess the impact of right ventricular dysfunction on clinical outcome in patients with ischemic cardiomyopathy undergoing coronary artery bypass grafting with or without surgical ventricular reconstruction., Methods: Of 1000 patients in the Surgical Treatment for Ischemic Heart Failure with coronary artery disease, left ventricular ejection fraction 35% or less, and anterior dysfunction, who were randomized to undergo coronary artery bypass grafting or coronary artery bypass grafting + surgical ventricular reconstruction, baseline right ventricular function could be assessed by echocardiography in 866 patients. Patients were followed for a median of 48 months. All-cause mortality or cardiovascular hospitalization was the primary end point, and all-cause mortality alone was a secondary end point., Results: Right ventricular dysfunction was mild in 102 patients (12%) and moderate or severe in 78 patients (9%). Moderate to severe right ventricular dysfunction was associated with a larger left ventricle, lower ejection fraction, more severe mitral regurgitation, higher filling pressure, and higher pulmonary artery systolic pressure (all P < .0001) compared with normal or mildly reduced right ventricular function. A significant interaction between right ventricular dysfunction and treatment allocation was observed. Patients with moderate or severe right ventricular dysfunction who received coronary artery bypass grafting + surgical ventricular reconstruction had significantly worse outcomes compared with patients who received coronary artery bypass grafting alone on both the primary (hazard ratio, 1.86; confidence interval, 1.06-3.26; P = .028) and the secondary (hazard ratio, 3.37; confidence interval, 1.36-8.37; P = .005) end points. After adjusting for all other prognostic clinical factors, the interaction remained significant with respect to all-cause mortality (P = .022)., Conclusions: Adding surgical ventricular reconstruction to coronary artery bypass grafting may worsen long-term survival in patients with ischemic cardiomyopathy with moderate to severe right ventricular dysfunction, which reflects advanced left ventricular remodeling., (Copyright © 2015 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.)

Background: Patients with ischemic left ventricular dysfunction have higher operative risk with coronary artery bypass graft surgery (CABG). However, those whose early risk is surpassed by subsequent survival benefit have not been identified., Objectives: This study sought to examine the impact of anatomic variables associated with poor prognosis on the effect of CABG in ischemic cardiomyopathy., Methods: All 1,212 patients in the STICH (Surgical Treatment of IsChemic Heart failure) surgical revascularization trial were included. Patients had coronary artery disease (CAD) and ejection fraction (EF) of ≤35% and were randomized to receive CABG plus medical therapy or optimal medical therapy (OMT) alone. This study focused on 3 prognostic factors: presence of 3-vessel CAD, EF below the median (27%), and end-systolic volume index (ESVI) above the median (79 ml/m(2)). Patients were categorized as having 0 to 1 or 2 to 3 of these factors., Results: Patients with 2 to 3 prognostic factors (n = 636) had reduced mortality with CABG compared with those who received OMT (hazard ratio [HR]: 0.71; 95% confidence interval [CI]: 0.56 to 0.89; p = 0.004); CABG had no such effect in patients with 0 to 1 factor (HR: 1.08; 95% CI: 0.81 to 1.44; p = 0.591). There was a significant interaction between the number of factors and the effect of CABG on mortality (p = 0.022). Although 30-day risk with CABG was higher, a net beneficial effect of CABG relative to OMT was observed at >2 years in patients with 2 to 3 factors (HR: 0.53; 95% CI: 0.37 to 0.75; p<0.001) but not in those with 0 to 1 factor (HR: 0.88; 95% CI: 0.59 to 1.31; p = 0.535)., Conclusions: Patients with more advanced ischemic cardiomyopathy receive greater benefit from CABG. This supports the indication for surgical revascularization in patients with more extensive CAD and worse myocardial dysfunction and remodeling. (Comparison of Surgical and Medical Treatment for Congestive Heart Failure and Coronary Artery Disease [STICH]; NCT00023595)., (Copyright © 2014 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.)

Objectives: The aim of this study was to assess the feasibility, safety, and preliminary efficacy of a novel percutaneous left ventricular partitioning device (VPD) in patients with chronic heart failure (HF) and a prior anterior myocardial infarction., Background: Anterior myocardial infarction is frequently followed by left ventricular remodeling, HF, and increased long-term morbidity and mortality., Methods: Thirty-nine patients were enrolled in a multinational, nonrandomized, longitudinal investigation. The primary end point was an assessment of safety, defined as the successful delivery and deployment of the VPD and absence of device-related major adverse cardiac events over 6 months. Secondary (exploratory) efficacy end points included changes in hemodynamics and functional status and were assessed serially throughout the study., Results: Ventricular partitioning device placement was not attempted in 5 (13%) of 39 subjects. The device was safely and successfully implanted in 31 (91%) of the remaining 34 patients or 79% of all enrolled patients. The 6-month rate of device-related major adverse cardiac event occurred in 5 (13%) of 39 enrolled subjects and 5 (15%) of 34 treated subjects, with 1 additional event occurring between 6 and 12 months. For patients discharged with the device to 12 months (n = 28), New York Heart Association class (2.5 ± 0.6 to 1.3 ± 0.6, P < .001) and quality-of-life scores (38.6 ± 6.1 to 28.4 ± 4.4, P < .002) improved significantly; however, the 6-minute hall walk distance (358.5 ± 20.4 m to 374.7 ± 25.6 m, P nonsignificant) only trended toward improvement., Conclusions: The left VPD appears to be relatively safe and potentially effective in the treatment for patients with HF and a prior anterior myocardial infarction. However, these limited results suggest the need for further evaluation in a larger randomized controlled trial., (Copyright © 2012 Mosby, Inc. All rights reserved.)

Background: Prognostic value of concomitant aprtic regurgitation (AR) in patients operated for severe aortic stenosis (AS) is not clarified. The aim of this study was to prospectively examine the impact of presence and severity of concomitant AR in patients operated for severe AS on long-term functional capacity, left ventricular (LV) function and mortality., Methods: Study group consisted of 110 consecutive patients operated due to severe AS. The patients were divided into AS group (56 patients with AS without AR or with mild AR) and AS+AR group (54 patients with AS and moderate, severe or very severe AR). Follow-up included clinical examination, six minutes walk test (6MWT) and echocardiography 12 and 104 months after AVR., Results: Patients in AS group had lower LV volume indices throughout the study than patients in AS+AR group. Patients in AS group did not have postoperative decrease in LV volume indices, whereas patients in AS+AR group experienced decrease in LV volume indices at 12 and 104 months. Unlike LV volume indices, LV mass index was significantly lower in both groups after 12 and 104 months as compared to preoperative values. Mean LVEF remained unchanged in both groups throughout the study. NYHA class was improved in both groups at 12 months, but at 104 months remained improved only in patients with AS. On the other hand, distance covered during 6MWT was longer at 104 months as compared to 12 months only in AS+AR group (p = 0,013), but patients in AS group walked longer at 12 months than patients in AS+AR group (p = 0,002). There were 30 deaths during study period, of which 13 (10 due to cardiovascular causes) in AS group and 17 (12 due to cardiovascular causes) in AS+AR group. Kaplan-Meier analysis showed that the survival probability was similar between the groups. Multivariate analysis identified diabetes mellitus (beta 1.78, p = 0.038) and LVEF < 45% (beta 1.92, p = 0.049) as the only independent predictor of long-term mortality., Conclusion: Our data indicate that the preoperative presence and severity of concomitant AR has no influence on long-term postoperative outcome, LV function and functional capacity in patients undergoing AVR for severe AS.

Aims: To assess short-term safety defined as the successful delivery and deployment of the ventricular partitioning device (VPD) implant, as well as 12-month functional, clinical, and haemodynamic effectiveness., Methods and Results: Ventricular partitioning device implantation was successful in 15/18 (83%) patients with anteroapical regional wall motion abnormalities following myocardial infarction. In one patient, the VPD was removed 3 days post implantation and the patient subsequently died due to extra-cardiac sepsis. When compared with baseline, there was significant improvement at 6 and 12 months following VPD implantation in NYHA class (2.21 +/- 0.57 vs. 1.28 +/- 0.46 vs. 1.23 +/- 0.4.3, respectively, P < 0.001 for both), left ventricular (LV) end-systolic volume (189 +/- 45 vs. 142 +/- 29 vs. 151 +/- 48 mL/m(2), respectively, P < 0.001 for both), and LV end-diastolic volume (260 +/- 47 vs. 208 +/- 33 vs. 222 +/- 58 mL/m(2), respectively, P < 0.001 for both). After 12 months, an improvement in LV ejection fraction was noted (28 +/- 7 vs. 32 +/- 7 vs. 33 +/- 9%, respectively, P = 0.02) as well as improvement in 6 min walk distance (382 +/- 123 vs. 409 +/- 7 vs. 425 +/- 140 m) when compared with pre-procedural values., Conclusion: Our data indicate that VPD implantation is safe and feasible, and that VPD implantation improves LV haemodynamics and functional capacity in the 12 months following the procedure.

Introduction: Heparin-induced thrombocytopenia (HIT) is an acquired, prothrombotic disorder, caused by antibodies to a complex of heparin and platelet factor 4 (PF4) that activates platelets, resulting in the release of procoagulant microparticles, thrombocytopenia occurrence, generation of thrombin, and frequent thromboses., Case Outline: We present a case of severe HIT in a 68-year-old female, which occurred after cardiosurgery of the left atrial myxoma with the aim to point out the importance of differential diagnosis of thrombocytopenia in patients recently exposed to heparin. Platelet count dropped on the eleventh postoperative day, six days after unfractioned heparin and enoxaparine threatment, to 4x10(9)/I.The correct diagnosis failed to be made at first. Since thrombocytopenia remained refractory to a corticosteroid treatment and platelet transfusion, the patient was hospitalized on the 13th postoperative day at the Institute of Haematology. The diagnosis of HIT was confirmed with the high-probability clinical score (4T's) and strongly positive anti-heparin-PF4 (PaGIA) test as well as positive platelet aggregation test. The treatment started with a smaller therapeutic doses of danaparoid than recommended of 750 U intravenous bolus and was followed by continuous infusions of 100 U per 1 h and intravenous gammaglobulins in full dosage for four days. The platelet count started to rise on the third day and it was completely normalized on the 5th day of the therapy., Conclusion: Treatment of severe HIT with small doses of danaparoid supplemented by intravenous gamma globulin was successful. Additional awareness of heparin-induced thrombocytopenia is needed, especially of HIT in differential diagnosis of thrombocytopenia in patients recently exposed to heparin.

Introduction: The goal of this study was to show early and midterm results of surgical treatment of cardiac neoplasma., Methods: Between 2000. and 2008., sixty-seven patients with a cardiac tumor or a subdiaphragmatic neoplasma with right atrial extension were operated in our institution. In 22 patients (32.8%), not only a simple extirpation of neoplasma, but an additional surgical procedure was done., Results: A patient reoperated for a recurence of biatrial myxoma died early after operation (1.5% mortality rate). During follow-up period of 3.3 years, two patients (3.4%) out of 58 that were contacted died because of the neoplasma (Methastasis of adenocarcinoma, Carcinoma renis)., Conclusion: Surgical treatment of cardic tumors resulted in low early mortality and an excellent survival rate after a follow-up period of 3.3 years.

The administration of glucose-insulin-potassium (GIK) solution has beeen shown to exert cardioprotective and immunomodulatory properties in coronary disease. 49 patients (pts.) for coronary surgery were randomly assigned to receive high-dose GIK treatment (30% glucose, insulin 2 IU.kg(-1).l(-1) and K(+) 80 mmo/l solution; 1 ml/kg/h); low-dose GIK treatment (10% glucose, insulin 32 IU l(-1) and K(+) 80 mmol/l solution; 1 ml/kg/h) or control treatment (Ringer solution 1 ml/kg/h). Haemodynamic measurements were done for four time points: T1 - after induction of anaesthesia; T2 - after the operation; T3 - 6 h after the operation and T4 - 24 h after the operation. Significant recovery of cardiac function was evident in high-dose GIK (H-GIK) and low-dose GIK (L-GIK) groups after 24 h (cardiac index improved considerably (p = 0.0002)), with a statistically significant difference between the groups (p = 0.005). LVSWI covariated with PCWP, improved over time in group H-GIK (p = 0.0008) and between the groups (p = 0.046). Oxygen supply-consumption ratio evidently improved in the GIK groups, while inotropic drug support was used in 5.5% pts. in group H-GIK vs. 13% in group L-GIK and 31% pts. in control (C) group. Glucose-insulin treatment has a potential cardioprotective effect in coronary surgery. The effect is independent of the glucose-insulin concentration and amount.

Background: The ventricular partitioning device (VPD) (Cardiokinetix Inc., Redwood City, Calif) is a novel device that is deployed percutaneously in the left ventricle in patients with anteroapical regional wall motion abnormalities after a myocardial infarction (MI) to partition the ventricle and segregate the dysfunctional region. In this case report we present the first implantation of the VPD in a human, with a 12-month efficacy and safety follow-up., Methods and Results: A 48-year-old man had an anterior MI in 2004. A coronary angiogram showed an occlusion of the proximal segment of the left anterior descending artery with no stenosis on other major epicardial vessels. Echocardiography revealed a dilated left ventricle (62 mm) with anteroapical wall motion abnormalities, no apical thrombus, a calculated ejection fraction of 26.8% (by Simpson biplane formula), and an end-systolic volume index (ESVi) of 76.8 mL/m(2). The VPD implant was delivered percutaneously from the femoral artery by the standard techniques for left-sided heart catheterization. The postimplantation course was uneventful. Echocardiography on discharge showed the VPD implanted at the apex, with a left ventricular ejection fraction of 30.9% and an ESVi of 57.2 mL/m(2). Left ventricular ejection fraction and ESVi remained improved during the 12-month follow-up., Conclusion: This case report demonstrates that VPD implantation in this particular patient was feasible and that it may provide a nonsurgical approach to prevent or reverse left ventricle remodeling.

Background and Methods: An international registry of left ventricular volume reduction (LVVR) procedures, including partial left ventriculectomy, has been expanded, updated, and refined to include 568 cases voluntarily reported from 52 hospitals in 12 countries., Results: Gender, age, ventricular dimension, ethnology, myocardial mass, presence or absence of mitral regurgitation, as well as transplant indication, had little effect on event-free survival, which was defined as either absence of death or ventricular failure requiring mechanical assist or transplantation. Poor preoperative patient condition such as New York Heart Association classification IV, depressed contractility and decompensation requiring an emergency procedure were associated with reduced event-free survival. Other risk factors included an early surgery date, lack of experience, dilated cardiomyopathy as the underlying pathology and extended myocardial resection. Performance of LVVR reached a peak by 1998, but was largely abandoned by 2001, except in Asia, where experienced institutes continue to perform it in patients in better condition with preserved myocardial contractility., Conclusion: Avoidance of risk factors appears to have contributed to the recent survival improvement and may help stratify patients for LVVR. While performance has been decreasing, the concept has been extended to other LVVR and less invasive procedures, which are now under clinical trials.

Background: Although partial left ventriculectomy (PLV) may have beneficial clinical effects in patients with dilated cardiomyopathy (DCM), there are no reports on effects of PLV on myocardial histology. The objective of this study was to assess histological properties of the LV myocardium 1 year following PLV as compared to histology at the time of the operation., Methods: The study group consisted of 15 consecutive PLV survivors, predominantly male (13/15), aged 45+/-12 years. Surgical specimens and endomyocardial biopsies, taken 12 months postoperatively, were processed routinely and stained with Masson-trichrome. The following morphometric parameters were assessed semiquantitavely: (1) degree of hypertrophy and attenuation; (2) nuclear evidence of hypertrophy; (3) myofibrillar volume fraction; (4) degree of degenerative vacuolar changes; and (5) fibrosis volume fraction., Results: Both New York Heart Association (NYHA) functional class and ejection fraction (EF) improved 12 months following surgery as compared to preoperative values (2.40+/-0.69 vs. 3.33+/-0.49, p<0.001, and 33.21+/-12.05% vs. 20.21+/-9.07%, p<0.001, respectively). Morphometric analysis demonstrated postoperative decrease in the degree of attenuation as compared to preoperative values (1.40+/-0.51 vs. 2.47+/-0.64, p<0.01), as well as a decrease in fibrosis volume fraction (2.07+/-0.80 vs. 2.67+/-0.49, p<0.001) and nuclear hypertrophy (1.27+/-0.46 vs. 1.67+/-0.62, p<0.05). On the other hand, postoperative increase in myofibrillar volume fraction (1.87+/-0.61 vs. 1.40+/-0.61, p<0.01) was noted., Conclusion: One year postoperatively, PLV has favourable effects on myocardial morphology that parallels improvement in the patient's functional status and LV systolic function.

Background: An international registry of partial left ventriculectomy (PLV) has been expanded, updated, and refined to include 440 cases voluntarily reported from 51 hospitals in 11 countries., Results: Gender, age, ventricular dimension, etiology, ethnology, myocardial mass, operative variation or presence or absence of mitral regurgitation as well as transplant indication had no effects on event-free survival, which was defined as either absence of death or ventricular failure requiring ventricular assist device or listing for transplantation. Preoperative patient condition such as NYHA functional class IV, depressed contractility, and decompensation requiring an emergency procedure were associated with reduced event-free survival. Other risk factors included early date of surgery, lack of experience, and extended myocardial resection. Performance of PLV reached a peak by 1998 and was largely abandoned by 2000 except in Asia, where experienced institutes continue to perform PLV in patients in better condition with preserved myocardial contractility., Conclusion: Avoidance of delineated risk factors appears to improve recent survival and may help stratify high- or low-risk patients for PLV. An integrated approach with mechanical and biological circulatory assist may improve prognosis for patients with dilated failing hearts. While frequency of PLV has decreased, the concept of ventricular volume reduction has been extended to other volume reduction procedures and less invasive procedures now under clinical trial.

Coronary artery bypass surgery in patient with bad left ventricular function is a challenge for surgical time. Specially important is monitoring of haemodynamics. We performed this open, prospective, randomized study with the aim to assess haemodynamics and oxygen profile monitoring. 34 pts for coronary surgery (EF < 40%) were divided in two groups. Group A, 17 pts. Received glucose-insulin-potassium (GIK) solution. Group B, 127 pts. Received Ringer solution. Haemodynamic and oxygen metabolism parameters were measured in four time points. I after the induction in anesthesia; II after the operation; III 6 hours post op.; IV 24 hour post op. Data are expressed as mean +/- SD, Anova for repeated measures followed by Newman-Keuls testing were used. In both groups were evident deterioration of cardiac function during first 6 h as well as VO2 and DO2, more prominent in Group B. Significant recovery and improvement of cardiac function were evident in Group A after 24 h. CI during the time in Group A improves significantly (2.14 +/- 0.36 v. 3.05 +/- 0.55; p = 0.0002) and difference during the time between groups was p = 0.005. LVSWI improved significantly during the time him Group A (AIII vs. AIV) p = 0.007. Simultaneously. VO2 improves significantly in Group A (103 +/- 21 vs. 164 +/- 30, p = 0.00001) while difference between groups in DO was p = 0.037. Importance of oxygen metabolism monitoring for both, left ventricular function and haemodynamics assessment was evident in our study.

Introduction: In most prospective, randomized studies, severely depressed left ventricular function is found to be the independent predictor of increased morbidity and mortality after myocardial revascularization [3]. Surgical treatment in this particular group of patients results in superior long-term results [1, 2]. Internal thoracic artery (ITA) is considered to be superior compared to venous grafts in myocardial revascularization for the majority of patients with ischaemic heart disease. However, its value in patients with already severely depressed left ventricular function (EF < or = 30%) is still a matter of debate. There are no prospective, randomized studies, so far. In some studies it was shown that revascularization with ITA graft resulted in superior long-term results (10- and 15-year follow-up) in all subgroups of patients, including those with severely depressed left ventricular function [4, 5]. Some authors find it still unacceptable, if this result would be possible at the expense of higher early mortality (due to use of ITA). The purpose of this study is to analyze the early and long-term results of myocardial revascularization using ITA graft in patients with severely depressed left ventricular function (EF < 30%)., Material and Methods: Over the period from November 1986 through March 1999, 2860 pts have received ITA (alone or with additional vein grafts) for myocardial revascularization. In 431 pts EF was < or = 30% (15.1%), average EF being 25.7% (by echocardiography); 33 were women, 29 were diabetics, while average age was 56.7 +/- 8.4 years. The control group consisted of 430 pts, with similar preoperative characteristics, who received vein grafts alone., Results: Operative mortality in the ITA group was 2.55% (11/431), and postoperative morbidity was 7.4% (32/431). In the group with vein grafts only the mortality was 3.25% (14/430) and morbidity 6.7% (29/430)--Table 2. The average postoperative hospital stay was 9.1 days (range 7-32). There was no difference in operative and postoperative parameters (extracorporeal time, ischaemic time, duration of mechanical ventilation, need for inotropic support, mortality, morbidity and hospital stay) compared to the group with vein grafts alone, except for the blood drainage--significantly higher in the ITA group--p < 0.00001)--Table 3. Multivariate analysis showed that independent predictors of unfavorable outcome were the presence of peripheral vascular disease (beta--0.9; p = 0.02) and aortic cross-clamp time (beta--0.02; p = 0.01). Long-term results in 14 pts with ITA graft operated on from 1986 to 1992 (6-12 years of follow-up) showed the survival of 92.7%., Discussion: Superior long-term patency of ITA graft resulted in its practically routine use in myocardial revascularization. However, in some studies it was shown that ITA flow might be insufficient during the maximal effort [6]. This may result in hypoperfusion, low cardiac output syndrome and cardiac arrest. This frequently happens at the end of the operation, and may be accentuated with the use of vasopressors that can further decrease the ITA flow [9]. In patients with already severely depressed left ventricular function preoperatively, the use of vasopressors at the end of procedure when the myocardium may be quite vulnerable, is to be expected. Friesewinkel et al., [18] showed that there was an impairment of the regional contractility of the left ventricle early (up to 4 hours) after myocardial revascularization, when one or both ITA grafts were used. Since this was not the case if vein grafts were used, they advised to be careful in patients with "depressed left ventricular function". However, Elefteriades et al., [1] found no higher mortality in patients with "bad left ventricle" in whom ITA was used, but point out that patients with elective operation and without need for intensive care treatment preoperatively had much better outcome. Jagaden et al., [19] found very good results in these patients, after the routine use of ITA, during a 20-year follow-up. In our study EF < or = 30% was present in 861 patients, 431 with ITA graft and 430 with vein grafts only. There was no difference between groups considering all possible preoperative and operative factors of importance for the outcome. We found no increased early morbidity and mortality in patients in whom ITA was used compared to patients with vein grafts only. In patients operated on from 1986-1992 (follow-up of 6-12 years), we noted the survival of 92.7%. This was not statistically different compared to patients with vein grafts (survival of 88.9%). Despite the small number of patients, we found these long-term results very encouraging., Conclusion: ITA graft is a very good and absolutely acceptable choice in patients with severely damaged left ventricular function, particularly if we consider its long-term superiority. These pts should not be deprived of the long-term benefit of ITA graft, since early results are very good.

Background: Although some patients with end-stage heart disease will benefit from a partial left ventriculectomy, no criteria have been found for identifying this group preoperatively. Our experience with partial left ventriculectomy at two institutions-the Texas Heart Institute in Houston, TX, USA, and Dedinje Cardiovascular Institute in Belgrade, Yugoslavia-showed a higher survival rate and better postoperative myocardial function in the Yugoslavian patients., Methods: We reviewed data from 42 patients (21 at each center) who had idiopathic cardiomyopathy, a left ventricular end-diastolic dimension of more than 70 mm, wall thickness of 1 cm or greater, and New York Heart Association class III or IV symptoms. The only significant difference in preoperative status between the two groups was duration of symptoms. Histologic specimens, blinded as to origin, were graded with regard to myocyte hypertrophy, cytoplasmic vacuolation, and fibrosis. Computer-assisted myocyte and nuclear morphometry was also performed., Results: Immediately postoperatively, there were no significant intergroup differences in the reduction in cardiac dimension or in corrections of mitral regurgitation. During 6-month follow-up, however, the Texas Heart Institute patients had a lower cardiac index (1.8 versus 3.0 L x min(-1) x m(-2); p = 0.001) and left ventricular ejection fraction (24% versus 34%; p = 0.006) than the Dedinje Cardiovascular Institute patients. The Texas Heart Institute patients differed from the Dedinje Cardiovascular Institute patients in the degree of severe or moderate changes in myocyte hypertrophy (90% versus 29%; p = 0.0003) and fibrosis (71% versus 29%; p = 0.006), as well as in the measurements of median myocyte diameter (35 +/- 7 microm versus 27 +/- 4 microm; p = 0.0002) and median nuclear size (15 +/- 4 microm versus 12 +/- 2 microm; p = 0.0029)., Conclusions: In the Texas Heart Institute patients, the significant intergroup difference in clinical outcome may have been related to increased myocyte hypertrophy and fibrosis. Further studies should be performed to determine the usefulness of these criteria in selecting patients for partial left ventriculectomy.

Unlabelled: Internal thoracic artery (ITA) is the graft of choice in myocardial revascularization. However, superiority of the ITA graft in patients (pts) with left main coronary artery disease is still a matter of debate., Patients: In the period from November 1986 through February 1999, ITA graft was used for myocardial revascularization in 2860 pts. Stenosis of the left main stem was present in 229 patients (8.0%); there were 39 women (17.0%) and 26 diabetics (11.4%). Severely depressed left ventricular function was present in 32 pts (14.0%), while the average age was 56.4 +/- 7.2 years., Results: Operative mortality was 1.3% and postoperative morbidity was 5.2%. Average postoperative hospital stay was 7.9 days (6-29). There were no differences in analyzed parameters between patients who received ITA graft and similar group of 240 patients who received vein grafts only, during the same period of time. All 16 patients operated on in the period 1986-1992 (6-12 years follow-up) are alive., Conclusion: It is safe to use ITA graft for myocardial revascularization in patients with left main coronary artery stenosis. Early operative results are favorable and these patients should not be denied the benefit of the ITA graft, since long-term results are proved to be good as well.

Internal thoracic artery (ITA) has superior histological, physiological and pharmacological properties over the venous grafts, and it is considered to be the graft of choice for myocardial revascularization. It has low incidence of late atherosclerotic lesions, and excellent long-term patency. Usage of ITA yields improved clinical results in all subgroups of patients with coronary artery disease, including patients with poor left ventricular function (EF%), left main stenosis, diffuse coronary artery disease and octogenarians. Since superior long-term results (to be expected only 10-15 years after the operation) may be outweighed with slightly higher incidence of early morbidity and mortality, many cardiac surgeons are reluctant to use it routinely. However, this attitude is difficult to justify, since early operative results in patients that have received ITA graft are superior as well, compared to patients that have received vein grafts only.

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.

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.

Inability to wean a patient from the cardiopulmonary bypass after open heart procedure is reality of the clinical practice. The only realistic chance for these patients is some form of mechanical circulatory support. Over the period from November 1988 to November 1993, in 17 patients the roller-pump mechanical assist device was inserted, i.e. 0.47% of 3589 patients were operated on during this period. Thirteen patients required mechanical circulatory support immediately after surgical procedure due to inability to wean them from cardiopulmonary bypass. In three patients the roller-pump was inserted preoperatively (percutaneous insertion), and in one patient mechanical circulatory support was started six hours after the procedure for sudden cardiac deterioration. Partial and temporary "bypass" of the damaged left ventricular function is achieved by insertion of inflow cannula into the left atrium, and outflow cannula into the ascending aorta. Depending on the inflow cannula size and volume load, we were able to achieve blood flow of 3.5 to 5 liters/minute. Using this system we were able to improve the left ventricular function in eight patients (47%), and five patients were discharged from hospital (29.4%). The roller-pump mechanical circulatory support proved to be efficient, reliable, easy to monitor and operate. Overall results are comparable to the published data as well as to other types of more versatile and costly devices for mechanical circulatory support.