Quantitative regional contraction analysis of cineventriculography: reporting, filing, and retrieval functions using a personal computer

Surgical treatment of left ventricular post-infarction aneurysm with endoventriculoplasty: late clinical and functional results

OBJECTIVE

The temporal response to endoventriculoplasty (EVP) has not been well defined. We have evaluated the long-term clinical and functional results of this technique.

METHODS

From 1988 to 1997, 121 patients underwent aneurysmectomy by EVP associated with myocardial revascularization for anteroapical left ventricular postinfarction aneurysm. Among these, 39 patients (43%) underwent early post-operative cardiac catheterization (within 3 months maximum), and were available to be revaluated after a mean follow-up time of 56+/-28 months, by means of a new hemodynamic study. Left ventricular silhouettes were analyzed by means of a special software.

RESULTS

The mean New York Heart Association functional class decreased from 2.5+/-0.9 to 1.6+/-0.8 (P<0.001) late postoperatively. The global ejection fraction improved early postoperatively from 43+/-13 to 61+/-13% (P<0.001), and late postoperatively slightly decreased to 42+/-13% (ns) versus preoperative values. Left ventricular end diastolic pressure early postoperatively fell from 16.8+/-7 to 15.7+/-6.7 (ns), and late postoperatively increased to 21.6+/-8.8 (ns) versus preoperative values. Pulmonary artery pressure rose early postoperatively from 31.5+/-6.4 to 32.1+/-6.7 (ns), and late postoperatively to 34.9+/-8.9 (ns). The global contractility score decreased early postoperatively from 42.3+/-9.6 to 28.4+/-13.6 (P<0.001); the global late postoperative contractily was 35+/-14 (ns) versus preoperative values. Patients who benefit most from the operation were those with a normal postoperative contraction pattern, where ejection fraction improved respectively early postoperatively from 43+/-13 to 63+/-11% (P<0.001), and late postoperatively to 49+/-10% (P<0.001) versus preoperative values. Occlusion or critical stenosis of bypass grafts occurred in 10 patients (25.6%). There were no significant differences in hemodynamic data and hypokinesis score changes between patients with patent or occluded bypass graft, and between patients with mono or multivessel disease. The operative mortality was 6.3%, and 8.8% needed intraaortic balloon counterpulsation. The actuarial survival rates at 5 and 7 years were 73+/-6 and 61+/-6%. The mean follow-up period was 68 months (with 112 months maximum).

CONCLUSIONS

We conclude that, in our patients group, EVP of left ventricular aneurysm associated with coronary grafting improves clinical status after operation. We registered a trend for a mild hemodynamic worsening, irrespective of coronary artery disease except in those patients who had shown a normal postoperative contraction pattern.

Myocardial revascularization in patients with ischemic cardiomyopathy: functional observations

OBJECTIVE

A prospective angiographic study was undertaken to investigate, with an objective analysis, the global and regional wall response to myocardial revascularization.

METHODS

Thirty-one patients (30 men and 1 woman, mean age, 61 years) with a left ventricular ejection fraction of less than 0.30 were admitted to our institution between 1992 and 1995 for two- or three-vessel coronary artery disease requiring myocardial revascularization. All patients underwent isolated coronary artery bypass grafting and were studied 3 months later with angiography. Preoperative and postoperative wall motion were analyzed using special software that computed a segmental left ventricular ejection fraction, generating a segmental score. Computerized analysis allowed us to distinguish patients with diffuse hypokinesis and a symmetric contraction pattern from patients with akinesis involving at least two segments and an asymmetric contraction pattern.

RESULTS

There were no operative deaths and no patient required intraaortic balloon counterpulsation. One patient had postoperative enzymatic evidence of myocardial infarction. Postoperative angiography showed a graft patency rate of 84%. Global analysis showed a small but significant rise in the left ventricular ejection fraction (0.25 +/- 0.51 to 0.31 +/- 0.70, p < 0.001) and a fall in the left ventricular end-diastolic pressure (23.7 +/- 10 to 16.5 +/- 9 mm Hg, p < 0.01). Mean scores always have been lower after the operation than before it, with the best results obtained for the apex and the worst for the anterobasal segment. The group with a symmetric contraction pattern showed a trend toward a better hemodynamic response than the group with an asymmetric contraction pattern. Regression analysis revealed two important predictors of segmental functional improvement: (1) the absence of an echocardiographic scar, and (2) the presence of a collateral circulation.

CONCLUSIONS

Coronary artery bypass grafting produced a small but substantial improvement in patients with ischemic cardiomyopathy. The greater benefit occurred in patients with a symmetric contraction pattern. The absence of an echocardiographic scar and the presence of a collateral circulation predicted segmental functional improvement.

Severe diastolic dysfunction after endoventriculoplasty

Endoventriculoplasty with pericardial patch has been advocated to repair anteroseptal ventricular aneurysm, but not studies have reported the influence of this technique on diastolic left ventricular function. We have evaluated the changes on ventricular filling by means of pulsed Doppler recording of diastolic transmitral flow. Doppler analysis reveals three distinct spectral patterns: (1) normal, (2) inverted, and (3) restrictive. We have found an abrupt change from a preoperative normal to postoperative restrictive pattern in a significant minority of patients (8%) who underwent endoventriculoplasty. These patients had clinical and hemodynamic signs (New York Heart Association class, time from anterior myocardial infarction, left ventricular end-diastolic pressure, pulmonary hypertension, and mitral regurgitation) of severe impairment but no differences were found in ejection fraction, aneurysmal extension, or remote myocardial function. Moreover, after operation they had a satisfactory ejection fraction, a low end-diastolic volume, and an apex-base length shorter than the predicted value for a normal population. The presence of a postoperative restrictive pattern of diastolic filling is a strong predictor of 3-month mortality and makes the medical treatment difficult. Caution must be taken to perform endoventriculoplasty in patients who are severely ill, especially those recently affected by myocardial infarction. When the clinical conditions dictate the operation, a nonenthusiastic volume reduction seems to be a prudent option.

Surgical timing in aortic regurgitation: left ventricular function analysis by contractility score

In 32 patients with aortic regurgitation, angiographic evaluation of global left ventricular performance before and after aortic valve replacement was carried out by means of a computer-analyzed contractility scoring system. A strong correlation was detected between the preoperative and postoperative contractility score. Postoperatively, the score decreased in all but 3 patients, becoming normal or near normal in 21 of 27 patients whose preoperative value had been less than 40. However, all 5 patients with a preoperative contractility score of 40 or greater exhibited a persistently elevated score after operation that indicated the presence of irreversible contractile dysfunction. Patients in groups A and B (preoperative score, 0 to 40) experienced a good surgical outcome, and at 5-year follow-up were in New York Heart Association functional class I. Patients in group C (preoperative score, > 40) altogether had a very poor surgical outcome, although they did experience a short to midterm period of symptomatic relief. It is important to offer aortic valve replacement to patients with aortic regurgitation before their chances for a good functional result are lost. The computer-analyzed contractility score may be a useful index for determining the optimal timing of operation in these patients, particularly those who show features consistent with impaired left ventricular function but are asymptomatic and who should undergo aortic valve replacement before symptoms of definitive left ventricular failure develop.

Functional results of left ventricular reconstruction

From 1988 to 1991, 48 patients with left ventricular aneurysm underwent endoventriculoplasty with a circular patch to preserve the left ventricular geometry. Of these patients, 98% underwent concomitant myocardial revascularization, and in 77% the left anterior descending coronary artery was bypassed. The overall operative mortality rate was 4.1%. The 3-year survival rate was 91%, and 67% of patients had no further cardiac complications. Cardiac performance was assessed postoperatively by ventriculography in 28 patients. The global ejection fraction rose from 0.39 +/- 0.11 to 0.57 +/- 0.14 (p < 0.001); the left ventricular end-diastolic pressure fell from 20 +/- 7.5 mm Hg to 15 +/- 7.8 mm Hg (p < 0.05). Computerized analysis of regional contraction revealed a significant improvement in the anterolateral and apical segments and in the transitional zone. In 61% of the patients, a normal contraction pattern resumed, whereas in the remaining 39%, a residual deformity of the left ventricular chamber was present. The best results were obtained in patients with a preserved proximal septum at echocardiography.

Residual coronary reserve despite decreased resting blood flow in patients with critical coronary lesions. A study by technetium-99m human albumin microsphere myocardial scintigraphy

BACKGROUND

Experimental data demonstrate the persistence of a transmural vasodilator reserve in the face of depressed resting myocardial perfusion. The present study was designed to determine whether resting myocardial hypoperfusion indicates exhausted coronary reserve (CR).

METHODS AND RESULTS

Fifteen patients with stable angina, isolated left anterior descending coronary artery (LAD) stenosis, and no previous myocardial infarction were evaluated by means of 99mTc human albumin microsphere scintigraphy. Regional myocardial perfusion and CR were assessed at baseline and after LAD papaverine (10-12 mg) by means of two microsphere injections in the left ventricle and compared with five normal subjects. Two 300-second scans were obtained with a mobile gamma camera positioned in the 70 degrees left anterior oblique projection; actual microsphere distribution after papaverine was obtained by image subtraction. The two arterial input functions (basal and papaverine) were measured from the first-pass time-activity curves and validated with the reference arterial sample technique. From the comparison of circumferential profile analysis between patients and normal subjects, nine patients (group 1A) showed perfusion defects at rest (reduction of percent radioactivity below 2 SD of normal subjects) in the LAD territory, and the other six (group 1B) showed homogeneous perfusion. CR (papaverine/resting perfusion) was 3.8 +/- 0.2 and 1.51 +/- 0.27 in normal subjects and in ischemic patients, respectively (p < 0.01). Despite resting hypoperfusion, group 1A showed a papaverine-recruitable CR similar to that of group 1B (1.57 +/- 0.33 and 1.43 +/- 0.16, respectively, p = NS).

CONCLUSIONS

In patients with stable angina pectoris, isolated LAD stenosis, and no previous myocardial infarction, microsphere scintigraphy disclosed a high incidence of resting perfusion defects; in those patients, a residual CR was observed despite decreased resting blood flow.