Predictors of poor mid-term health related quality of life after primary isolated coronary artery bypass grafting surgery

OBJECTIVE

To assess the determinants of poor mid-term health related quality of life (HRQoL) at one year after primary isolated coronary artery bypass grafting (CABG).

METHODS

463 patients who underwent primary isolated CABG for multivessel disease and came for their annual follow up at the outpatient clinic during one year at Harefield Hospital, Middlesex, were approached to participate in the present study. Prospective clinical data were collected as part of the clinical care of the patients and were retrospectively analysed when the patients consented to participate in the study at their outpatient visit. After their consent they were given three HRQoL assessment questionnaires. Scores, together with clinical data, were analysed by both univariate and multivariate analyses with regard to poor HRQoL outcome.

RESULTS

437 (94.4%) patients consented to participate in the study and filled in the HRQoL questionnaires. Ten variables were identified in the univariate analysis as potential predictors of poor scores of the physical element of HRQoL; however, only three variables-gastrointestinal problems, congestive heart failure, and type D personality trait-predicted poor physical scores independently. Eleven variables were identified in the univariate analysis as potential predictors of poor scores of the mental element of HRQoL; however, only three variables-peripheral vascular disease, infective complications, and type D personality trait-predicted poor physical scores independently.

CONCLUSION

Preoperative gastrointestinal problems, preoperative congestive heart failure, and type D personality trait were independent predictors of the poor physical component of HRQoL. Peripheral vascular disease, infective complications, and type D personality trait were independent predictors of the poor mental component of HRQoL. Interestingly, patients with type D personality were more than twice as likely to have poor physical HRQoL and more than five times as likely to have poor mental HRQoL.

[Uterine carcinosarcoma in a teenager: report of a case macroscopically mimicking rhabdomyosarcoma]

Uterine carcinosarcoma (malignant mixed mullerian tumor) is uncommon. We report the case of a 17-year-old patient who complained of pelvic pain and abnormal genital bleeding, and had a voluminous hemorrhagic tumor protruding through the vaginal os. Hysterectomy was performed. The histopathologic and immunohistochemical evaluation led to the diagnosis of uterine carcinosarcoma. Adjuvant chemotherapy was given. In spite of the surgical treatment, the evolution was fatal with widespread metastases. From data of the literature, we discuss the diagnosis, histogenesis and treatment of this rare tumor.

Tracking of target motion using physically based modelling of organs

In this paper, we describe a general methodology for the realistic reconstruction and animation of anatomic organs. In fact, in the scope of conformal radiotherapy and hadron therapy applications, we want to simulate the motion and the shape alteration of the internal anatomical objects and to input this knowledge to treatment planning. For the reconstruction, particle systems are used: firstly, surface shape of the considered organ is computed from a set of CT scan sections. Next, the volume defined by this surface is filled with particles. The coherency of the object is maintained due to the use of the classical Lennard-Jones inter particles force. This work permits to study the impact of the organs movement on the treatment of prostate and lung cancer. Our particle system has been suitably integrated in a radiation dose evaluation software, developed within an European BIOMED2 project and is currently supported by the French ETOILE project.

Quality of life and coping following minimally invasive direct coronary artery bypass (MIDCAB) surgery

Minimally invasive direct coronary artery bypass (MIDCAB) surgery has been shown to be a promising technique for surgical treatment of single or double vessel disease. However, little is known about quality of life, mood state or coping in this group of patients. The records of 55 consecutive patients who underwent MIDCAB surgery at Harefield Hospital between April 1999 and May 2001 were reviewed. In order to assess quality of life, mood state and coping, patients were contacted by telephone to conduct a semi-structured interview and were subsequently sent four questionnaires. The measures used were the Hospital Anxiety and Depression Scale, the Short Form Health Survey, the WHOQoL-BREF and the COPE. Forty-eight patients were contacted by telephone, forty-four of whom returned the completed questionnaires. Overall ratings of quality of life were excellent for the majority of patients, and rates of anxiety and depression were lower than previously found following coronary artery bypass surgery. It is concluded that following MIDCAB surgery quality of life and mood state outcomes are encouraging. However, a prospective, longitudinal study is now required to further elucidate the relationship between quality of life, mood state and coping and to identify predictive factors for physical and psychological outcome following this new surgical technique.

[Diagnostic problems associated with intestinal amoeboma: case report]

Amoeboma is an inflammatory mass of the colon. It is uncommon with most cases occurring in Latin America and South Africa. When amoeboma is the presenting symptom of amoebiasis, it poses the problem of differential diagnosis of colon cancer. This report describes the case of a 60-year-old patient who presented a painful mass in the left hypochondrium. Radiologic and endoscopic examinations depicted a ring-like stenosis of the transverse colon in association with a mesenteric reaction. The presumptive diagnosis was colon cancer and the patient was referred to the National Oncology Institute for surgical treatment. Histological examination of the surgical specimen after segmental colectomy confirmed diagnosis of intestinal amoeboma. The patient was treated medically using metronidazole. Since intestinal amoebiasis is common in our country, amoeboma must be considered as a rare but potential diagnosis in patients presenting masses of the colon. Differential diagnosis of carcinoma is necessary to avoid the risks associated with unnecessary surgery.

Mathematical modeling of phosphorus losses from land application of hog and cattle manure

Mathematical models may provide a means to estimate phosphorus (P) losses from land application of manure. Phosphorus losses typically occur during brief episodes of runoff and erosion. Models must be able to simulate P losses during these episodes by representing the basic chemical, physical, and biological processes by which these losses occur. The mathematical model ecosys combines dynamic distributed flow of solutes and nonsolutes through runoff and erosion with convective-dispersive transport of solutes, and both biologically and thermodynamically driven transformations between solutes and nonsolutes. This model was tested against P lost in runoff, erosion, and leachate measured during 90 min of controlled rainfall at 65 mm h(-1) on soils from six sites at which different rates of manure had been applied over the previous 3 to 6 yr. Transport and transformation kinetics in the model enabled it to simulate changes of dissolved inorganic phosphorus (DIP) in runoff from >1.0 to <0.05 mg L(-1) and changes of total phosphorus (TP) in sediment from 15 to 3 mg L(-1) measured during controlled rainfall on soils with diverse P contents. Results from 60-yr model runs using these kinetics with different application rates of cattle manure indicated that (i) a positive interaction exists between annual rainfall and application rate on P losses and (ii) rates greater than 30 Mg ha(-1) yr(-1) would cause TP concentrations in water leaving the site to rise above acceptable limits. The interaction between rainfall and rate suggests that P losses from manure application at any site should be assessed under the upper range of likely rainfall intensities.

Multi-vessel off-pump coronary artery bypass grafting can be taught to trainee surgeons

BACKGROUND

Although, Off-Pump Coronary Artery Bypass (OPCAB) surgery is being increasingly explored and practised in many cardiac units worldwide, there have been only few reports documenting the training of surgeons in this new technique. The purpose of this study was to address the reproducibility of the OPCAB in a unit where this technique is used extensively.

METHODS

Registry data, notes and charts of 64 patients who were operated on by four trainee cardiac surgeons over a period of thirteen months at Harefield Hospital, were reviewed retrospectively. These trainees were part of an accredited training programme for cardiothoracic training and were trained by a single consultant trainer in a cardiac unit after it has had an established recent experience in performing non-selective OPCAB for all coming-in patients. Five (7.8%) patients (with 17 distal anastomoses) consented and underwent early postoperative angiography to check the quality of the grafts and anastomoses.

RESULTS

The mean age of the study patients was 65.6 and the mean Parsonnet score was 9.4. There was a mean of 2.9 grafts per patient and circumflex territory anastomoses were performed in 48 (75%) patients. No operation required conversion to Cardiopulmonary Bypass (CPB). Angiography of the five patients revealed satisfactory seventeen (100%) distal anastomoses.

CONCLUSION

With appropriate training, it is possible for trainees to learn OPCAB and perform multi-vessel revascularization in relatively high-risk patients with good results.

Integrated approach to off-pump coronary artery bypass surgery

BACKGROUND

The Off-Pump Coronary Artery Bypass (OPCAB) technique is becoming more popular in many cardiac units throughout the world. This relatively new technique has prompted surgeons and anaesthetists to review and modify the routine approach to Coronary Artery Bypass Surgery (CABG). In this study we reviewed and analysed the outcome of an integrated anaesthetic and surgical peri-operative approach that allowed routine use of OPCAB and avoided the use of cardiopulmonary bypass (CPB).

METHODS

We reviewed and analysed the data on the first consecutive 285 patients who were operated on using the OPCAB technique. These represent our initial experience with applying the OPCAB technique non-selectively for all patients over a period of 16 months.

RESULTS

All patients had at least 2-vessel disease. 807 grafts were performed (mean 2.8 per patient) of which 647 (80%) were arterial (mean 2.3 per patient). 179 (63%) patients underwent total arterial revascularization. Eight patients required cardiopulmonary bypass; all other operations were completed off-pump. Complications--mortality 3 (1%); renal failure 24 (8%); stroke 3 (1%) and atrial fibrillation 60 (21%).

CONCLUSION

This retrospective analysis shows that provided a combined and integrated anaesthetic and surgical approach is used, beating heart technique for CABG can be safely offered to all patients with a good outcome.

Aortic-left ventricular discontinuity of noninfectious origin

The existence of a cavity of noninfectious origin between the annulus of the ascending aorta and the left ventricle is described. Aortic-left ventricular discontinuity occurred as a late complication of aortic valve replacement in an octogenarian. A patient with severe symptomatic aortic valve stenosis underwent aortic valve replacement and aortic root enlargement into the noncoronary sinus with pericardial tissue. Four months after her valve surgery the patient presented with shortness of breath. Angiocardiography and transoesophageal echocardiography revealed a complex, irregular pouch at the right coronary cusp side of the valve with paravalvular leakage back into the left ventricular outflow tract. Reoperation was performed, the disconnection between the aortic annulus and the left ventricle was repaired and the valve was replaced. The aortic-left ventricular discontinuity did not involve the area where aortic root enlargement was performed. No evidence of infection was found and the most likely cause of the reported complication is mechanical in nature.

An evaluation of existing risk stratification models as a tool for comparison of surgical performances for coronary artery bypass grafting between institutions

OBJECTIVE

Risk stratification systems are used in cardiac surgery to estimate mortality risk for individual patients and to compare surgical performance between institutions or surgeons. This study investigates the suitability of six existing risk stratification systems for these purposes.

METHODS

Data on 5471 patients who underwent isolated coronary artery bypass grafting at two UK cardiac centres between 1993 and 1999 were extracted from a prospective computerised clinical data base. Of these patients, 184 (3.3%) died in hospital. In-hospital mortality risk scores were calculated for each patient using the Parsonnet score, the EuroSCORE, the ACC/AHA score and three UK Bayes models (old, new complex and new simple). The accuracy for predicting mortality at an institutional level was assessed by comparing total observed and predicted mortality. The accuracy of the risk scores for predicting mortality for a patient was assessed by the Hosmer-Lemeshow test. The receiver operating characteristic (ROC) curve was used to evaluate how well a system ranks the patient with respect to their risk of mortality and can be useful for patient management.

RESULTS

Both EuroSCORE and the simple Bayes model were reasonably accurate at predicting overall mortality. However predictive accuracy at the patient level was poor for all systems, although EuroSCORE was accurate for low to medium risk patients. Discrimination was fair with the following ROC areas: Parsonnet 0.73, EuroSCORE 0.76, ACC/AHA system 0.76, old Bayes 0.77, complex Bayes 0.76, simple Bayes 0.76.

CONCLUSIONS

This study suggests that two of the scores may be useful in comparing institutions. None of the risk scores provide accurate risk estimates for individual patients in the two hospitals studied although EuroSCORE may have some utility for certain patients. All six systems perform moderately at ranking the patients and so may be useful for patient management. More results are needed from other institutions to confirm that the EuroSCORE and the simple Bayes model are suitable for institutional risk-adjusted comparisons.

Validation of four different risk stratification systems in patients undergoing off-pump coronary artery bypass surgery: a UK multicentre analysis of 2223 patients

BACKGROUND

Various risk stratification systems have been developed in coronary artery bypass graft surgery (CABG), based mainly on patients undergoing procedures with cardiopulmonary bypass.

OBJECTIVE

To assess the validity and applicability of the Parsonnet score, the EuroSCORE, the American College of Cardiology/American Heart Association (ACC/AHA) system, and the UK CABG Bayes model in patients undergoing off-pump coronary artery bypass surgery (OPCAB) in the UK.

METHODS

Data on 2223 patients who underwent OPCAB in eight cardiac surgical centres were collected. Predicted mortality risk scores were calculated using the four systems and compared with observed mortality. Calibration was assessed by the Hosmer-Lemeshow (HL) test. Discrimination was assessed using the receiver operating characteristic (ROC) curve area.

RESULTS

30 of 2223 patients (1.3%) died in hospital. For the Parsonnet score the HL test was significant (p < 0.001) and the receiver operating characteristic curve (ROC) area was 0.74. For the EuroSCORE the HL test was also significant (p = 0.008) and the ROC area was 0.75. For the ACC/AHA system the HL test was non-significant (p = 0.7) and the ROC area was 0.75. For the UK CABG Bayes model the HL test was also non-significant (p = 0.3) and the ROC area was 0.81.

CONCLUSIONS

The UK CABG Bayes model is reasonably well calibrated and provides good discrimination when applied to OPCAB patients in the UK. Among the other three systems, the ACC/AHA system is well calibrated but its discrimination power was less than for the UK CABG Bayes model. These data suggest that the UK CABG Bayes model could be an appropriate risk stratification system to use for patients undergoing OPCAB in the UK.

[Pelvic actinomycosis simulating adnexal malignant tumor]

The purpose of this report is to describe the case of a 35-year-old patient admitted to the National Oncology Institute in Rabat, Morocco for pelvic pain and deteriorating general status ongoing for 8 months. Clinical and ultrasonographic examination showed a heterogenous mass measuring 7 cm in maximum width located inferior and lateral to the inferior aspect of the right side of the uterus. These findings were suggestive of a malignant tumor of the right ovary. Ovariectomy and omentectomy were performed. Histological examination of surgical specimens demonstrated right tubo-ovarian actinomycosis associated with peritonitis. Genital tract actinomycosis is an uncommon finding in women of childbearing age. It is due to colonization by a pyogenic bacteria (Actinomyces) usually secondary to a gastrointestinal infection, e.g. ileocecum, and sometimes in association with the presence of an intrauterine device or foreign body. Based on this case report, the authors discuss abdominopelvic actinomyocosis with emphasis on tumor-like findings that can lead to misdiagnosis by clinicians and radiologists.

Human papillomavirus DNA in cervical lesions from Morocco and its implications for cancer control

To determine the types of human papillomaviruses (HPV) in northern Morocco, information which is needed for the design and use of HPV vaccines, we have analysed 129 cervical biopsies from this region. In our study, 91 cases were HPV positive, 45 cases had HPV-16 DNA, and 20 cases had HPV-18 DNA. This distribution of virus type was similar in inflammatory cervical lesions and in invasive cervical carcinomas. In conclusion, the HPV type distribution in Morocco is similar to that in other African Mediterranean countries, where the proportion of HPV-18 cases is significantly higher than in Europe. Determination of virus-type distribution is essential for vaccination programs.

In vivo early and mid-term flow-mediated endothelial function of the radial artery used as a coronary bypass graft

OBJECTIVES

We sought to evaluate the in vivo endothelial function of the radial artery (RA) used as a coronary graft.

BACKGROUND

The RA is becoming a recognized alternative coronary bypass conduit. In vivo endothelial function is a possible predictor of long-term performance.

METHODS

Sixty consecutive patients underwent coronary artery bypass graft surgery (CABG); all received RA and left internal mammary artery (LIMA) grafts. Three weeks after CABG, 36 patients underwent angiography under basal conditions, during pacing and after intragraft injection of glyceryl trinitrate (GTN). Angiography was repeated at six months in 20 patients.

RESULTS

The estimated mean difference of 66 segments of the radial graft on the first QCA study was 0.170 mm (95% confidence interval [CI] 0.101 to 0.258, p < 0.001) between baseline and pacing, and 0.310 mm (CI 0.225 to 0.401, p < 0.001) between baseline and GTN. At six months, the differences between baseline and pacing and baseline and GTN were 0.112 mm (CI 0.062 to 0.162, p < 0.001) and 0.274 (CI 0.192 to 0.353, p < 0.001), respectively. The difference between baseline values at three weeks and six months was 0.416 mm (CI 0.236 to 0.603, p < 0.001). In the LIMA segments, the difference between baseline and pacing and baseline and GTN were 0.206 mm (CI 0.136 to 0.278, p < 0.001) and 0.304 mm (CI 0.213 to 0.396, p < 0.001), respectively. At six months, the differences between baseline and pacing and baseline and GTN were 0.098 mm (CI 0.014 to 0.173, p < 0.001) and 0.218 mm (CI 0.130 to 0.298, p < 0.001). The difference between baseline values at three weeks and six months was 0.061 mm (CI 0.064 to 0.176, p > 0.05).

CONCLUSIONS

In vivo flow-mediated dilation of the RA is comparable to that of pedicled LIMA. The increased dilation both at baseline and after pacing at six months represents a time-related improvement in the vasomotor function of the RA, which could have implications for its performance as a coronary conduit.

Epicardial haematoma: rare cause of acute myocardial ischaemia

Pericardial effusion and coronary dissection are well known complications of percutaneous transluminal coronary angioplasty (PTCA). We report a rare case of sub-epicardial haematoma after PTCA, leading to local compression and cardiogenic shock. We discuss the successful management of this problem.

Subjective patient outcomes following coronary artery bypass using the radial artery: results of a cross-sectional survey of harvest site complications and quality of life

OBJECTIVES

To assess patient-based outcomes following radial artery harvesting for coronary artery bypass surgery (CABG).

METHODS

A cross-sectional telephone survey of 127 patients who underwent radial artery grafting was undertaken. The parameters assessed included symptoms related to the radial artery harvest site (functional impairment, sensory symptoms, and wound infection) and health related quality of life.

RESULTS

A high percentage of patients (67.7%) reported altered sensation, in the hand, in particular around the thenar eminence, in the forearm, or in relation to the incision; this was self-limiting and clinically insignificant in the vast majority of patients. Twelve patients reported residual insignificant symptoms after a median follow-up of 17.5 months. Four patients reported a subjective decrease in grip strength. Patients reported a good quality of life, and there was no association between this and the presence or absence of symptoms related to radial artery harvest. Some patients volunteered a 'preference' for the radial artery harvest site when compared with concomitantly harvested long saphenous vein (LSV), and there was a lower wound infection rate at radial artery harvest sites compared with vein harvest sites (6 vs. 15%).

CONCLUSIONS

Sensory symptoms following radial artery procurement occur more frequently than previously reported, but are largely self-limiting and are usually clinically insignificant. Patients appear to have a good quality of life following CABG using the radial artery. Radial artery harvest may be associated with lower wound infection rates and greater patient satisfaction than LSV harvest, however, the presence of residual sensory symptoms may be of relevance when obtaining informed consent.

Role of endogenous endothelin on coronary reflow after cardioplegic arrest

OBJECTIVE

Endothelin plays a role in the regulation of basal coronary tone. We hypothesized that low coronary reflow and reduced cardiac function after prolonged ischemia may be due to increased release of endogenous endothelin.

METHODS

Using an isolated perfused rat heart, we examined the effect of the addition of various endothelin antagonists during reperfusion after 4 hours of cardioplegic arrest at 4 degrees C. Hearts were freeze-clamped at the end of reperfusion for analysis of high-energy phosphate levels. Results are expressed as the percentages of preischemic values.

RESULTS

The addition of bosentan or Ro61-0612 (nonselective endothelin antagonists) resulted in a significant increase in the recovery of coronary flow after 30 minutes of reperfusion (100.9% vs 85.3% [P =.03] and 122.4% vs 83.7% [P <.001], respectively, versus controls). The addition of PD155080 (endothelin A antagonist) had a similar effect (129.5% vs 91.4%, P =.008). BQ788 (endothelin B antagonist) and phosphoramidon (endothelin-converting enzyme inhibitor) had no effect. Myocardial adenosine triphosphate levels were significantly (12.1%) higher after reperfusion with Ro61-0612 (18.1 +/- 0.4 micromol/g vs 16.2 +/- 0.5 micromol/g, P =.01). There was no difference in the recovery of cardiac mechanical function with any of the antagonists studied.

CONCLUSION

These results suggest that endogenous endothelin plays a role in low coronary reflow after prolonged cardioplegic arrest but does not impair recovery of myocardial function.

The clinical outcome of off-pump coronary artery bypass surgery in the elderly patients

OBJECTIVE

There has been a body of evidence showing that off-pump coronary artery bypass (OPCAB) may reduce morbidity and mortality in the elderly patients. We reviewed our experience, retrospectively, on elderly patients aged 75 years and older who were operated on using the OPCAB technique. We compared their outcome to a similar group of elderly patients who were operated on using conventional coronary artery bypass grafting (CABG) with cardiopulmonary bypass (CPB) during the same period of time.

METHODS

Registry data and patients' notes and charts were reviewed for 56 consecutive elderly OPCAB patients (age 78.5+/-3.5 years) and 87 consecutive CPB patients (age 77.2+/-2.4 years, P=0.01). Both groups had similar risk factor profiles: Parsonnet score 17.4+/-4.4 (OPCAB) versus 16.6+/-5.2 (CPB), P=0.19. We studied in detail their preoperative and postoperative data in order to compare the outcomes of both techniques.

RESULTS

The length of stay in the intensive therapy unit (ITU) was 35.4+/-52.9h for OPCAB patients and 77.6+/-144.9h for CPB patients (P=0.0008). No patient died within 30 days in the OPCAB group, whilst ten (11%) CPB patients (P=0.0066) died within 30 days. The incidence of serious complications (including pulmonary oedema, septicaemia, permanent stroke and renal dysfunction requiring haemofiltration or haemodialysis) was one (2%) in the OPCAB group and 11 (13%) in the CPB group (P=0.028). CPB patients required a significantly higher number ten (12%) of intra-aortic balloon pumps (IABP) inserted compared to only one patient (2%) in the OPCAB group who required IABP insertion (P=0.05). Nine (11%) CPB patients were re-operated on for bleeding compared to no OPCAB patient (0%) needing re-operation, P=0.011.

CONCLUSIONS

Although the mean age of the OPCAB group was significantly higher than the CPB group, the OPCAB group showed a significant reduction in postoperative serious morbidity, ITU stay and mortality. We believe that such a conclusion may have some effect on the decision-making and cost-effectiveness when performing coronary bypass surgery on the elderly population.

Heat shock protein 70 gene transfection protects mitochondrial and ventricular function against ischemia-reperfusion injury

BACKGROUND

Upregulation of heat shock protein 70 (HSP70) is beneficial in cardioprotection against ischemia-reperfusion injury, but the mechanism of action is unclear. We studied the role of HSP70 overexpression through gene therapy on mitochondrial function and ventricular recovery in a protocol that mimics clinical donor heart preservation.

METHODS AND RESULTS

Hemagglutinating virus of Japan (HVJ)-liposome technique was used to transfect isolated rat hearts via intracoronary infusion of either the HSP70 gene (HSP group, n=16) or no gene (CON group, n=16), which was heterotopically transplanted into recipient rats. Four days after surgery, hearts were either perfused on a Langendorff apparatus for 30 minutes at 37 degrees C (preischemia studies [n=8/group]) or perfused for 30 minutes at 37 degrees C, cardioplegically arrested for 4 hours at 4 degrees C, and reperfused for 30 minutes at 37 degrees C (postischemia studies [n=8/group]). Western blotting and immunohistochemistry confirmed HSP70 upregulation in the HSP group. Postischemic mitochondrial respiratory control indices (RCIs) were significantly better preserved in HSP than in CON hearts: NAD(+)-linked RCI values were 9.54+/-1.1 versus 10.62+/-0.46 before ischemia (NS) but 7.98+/-0.69 versus 1.28+/-0.15 after ischemia (P<0.05), and FAD-linked RCI values were 6.87+/-0.88 versus 6.73+/-0.93 before ischemia (NS) but 4.26+/-0.41 versus 1.34+/-0.13 after ischemia (P<0.05). Postischemic recovery of mechanical function was greater in HSP than in CON hearts: left ventricular developed pressure recovery was 72.4+/-6.4% versus 59.7+/-5.3% (P<0.05), maximum dP/dt recovery was 77.9+/-6.6% versus 52.3+/-5.2% (P<0.05), and minimum dP/dt recovery was 72.4+/-7.2% versus 54.8+/-6.9% (P<0.05). Creatine kinase release in coronary effluent after reperfusion was 0.20+/-0.04 versus 0.34+/-0.06 IU. min(-1). g wet wt(-1) (P<0.05) in HSP versus in CON hearts.

CONCLUSIONS

HSP70 upregulation protects mitochondrial function after ischemia-reperfusion injury; this was associated with improved preservation of ventricular function. Protection of mitochondrial function may be important in the development of future cardioprotective strategies.

Incremental importance of peak-exercise plasma levels of endothelin-1 and natriuretic peptides in chronic heart failure

Chronic heart failure (CHF) studies investigating the clinical, hemodynamic, and therapeutic importance of endothelin-1 (ET-1), atrial natriuretic peptide (ANP), and brain natriuretic peptide (BNP) are largely based on resting plasma levels, which may vary with prior exertion and postprandial status. This study investigated the importance of peak-exercise plasma levels of ET-1, ANP, and BNP in the assessment of left ventricular (LV) systolic function. Thirty-six male-patients ages 58 +/- 10 (mean +/- SD ) with NYHA class I-IV CHF due to coronary artery disease or idiopathic dilated cardiomyopathy were enrolled. LV systolic function was assessed by echocardiography and radionuclide ventriculography. Resting and peak cardiopulmonary exercise venous blood sampling and treadmill exercise testing were performed in the fasting state. Resting plasma levels of ET-1, ANP, and BNP were elevated compared with reference laboratory normal values. Exercise induced significant (p < 0.0001) increase in plasma levels of ET-1, ANP, and BNP. On univariate analysis peak-exercise plasma levels of ET-1, ANP, and BNP were more closely related to echocardiographically determined LV end-diastolic diameter and end-systolic diameter than their resting values. Multiple step-wise regression models identified resting and peak-exercise plasma levels of ET-1 and ANP but only the resting BNP as independent predictors of LV dimensions and systolic function. Peak exercise plasma levels of ANP and ET-1 are potentially more reliable and important than their resting levels as markers of LV systolic dysfunction and LV dimensions in patients with heart failure.