Left ventricular function following internal mammary implantation

Multiple myeloma associated with serum amino acid disturbance and high output cardiac failure

We experienced a plasma cell leukemia (PCL) patient complicated with high output cardiac failure (HOCF), proved as his elevated cardiac index and pulmonary artery wedge pressure and decreased systemic vascular resistance index in a hemodynamic study. We found no possible causes of HOCF. Interestingly, HOCF was improved as PCL responded to intensive chemotherapy. On the other hand, he showed consciousness disturbance, and had frequent attacks of generalized seizure. His electroencephalogram showed slow waves, and a spike and wave complex. Hyperammonemia and abnormal amino acid distribution were also found. This abnormal serum amino acid distribution, especially elevated glycine level, was different from that seen in chronic liver failure, and he had no hepatic disease. After intensive chemotherapy, the serum ammonia level and glycine level decreased. In this patient, PCL seemed to be responsible for HOCF, hyperammonemia, and abnormal amino acid distribution. We experienced two more cases of multiple myeloma (MM) with HOCF, hyperammonemia, abnormal serum amino acid distribution, and consciousness disturbance of unknown origin. Those two cases showed slow waves in the electroencephalogram. Improvement was seen in their HOCF, hyperammonemia, and abnormal amino acid levels after chemotherapy. The possibility of MM as a cause of HOCF is discussed.

Changes in maximal exercise performance in the evaluation of saphenous vein bypass surgery

To evaluate the improvement in myocardial oxygen delivery following saphenous vein graft surgery (SVG) for angina pectoris (AP), 46 patients underwent a multistage treadmill test of maximal exercise capacity before and 3-22 (average 8) months after SVG. Variables from exercise testing were correlated with symptomatic response, left ventricular hemodynamics, and graft patency.

Functional capacity (NYHA) improved in 38 (85%), while 27 (59%) had a significant improvement in exercise performance. Functional aerobic impairment (FAI), or the percentage deviation from expected V O O2 max , improved by a mean of 16% ( P < 0.001). Maximal systolic pressure-rate product/100 increased 36 ( P < 0.002). Twenty of 29 (66%) with presurgical S-T segment depression had a normal response after surgery.

Thirty-three patients were studied for graft patency and had quantitative angiography. Seventeen had all grafts patent and demonstrated a mean improvement of 21% in FAI ( P < 0.0007). Those with occluded grafts showed no improvement in exercise performance. Sixteen of 22 (73%) with severe exercise impairment showed significant improvement, but only four of 14 (29%) with mild impairment showed a significant improvement. There were no mean changes in left ventricular end-diastolic pressure, cardiac index, contraction plot, or systolic ejection fraction (SEF) in any of the patients. Preoperatively nine had a depressed SEF (<50%), and no improvement in exercise performance could be demonstrated.

Maximal treadmill testing has demonstrated objectively that SVG can improve functional capacity and that it is correlated with graft patency. Ideal surgical candidates appear to be those with severe exercise impairment and unimpaired ventricular performance.