Ventricular-load optimization by inotropic stimulation in patients with heart failure

Ventriculo-arterial coupling and mechanical efficiency with remifentanil in patients with coronary artery disease

BACKGROUND

Optimum transfer of energy from the left ventricle to the arterial circulation requires appropriate matching of these mechanical systems. Left ventricular-arterial coupling describes this relationship between the ventricular elastance (Ees) and arterial elastance (Ea). The ratio of these elastances defines the efficiency of myocardium and provides in our study a useful technique for assessment of the actions of remifentanil. The purpose of this study was to evaluate the effects of remifentanil on ventriculo-arterial coupling in cardiac surgery in patients with coronary artery disease.

METHODS

Fourteen patients with coronary artery disease, submitted intraoperatively to cardiac anesthesia for myocardial revascularization, were examined prospectively. With the use of transesophageal echocardiography (TEE) and different dicrotic arterial pressures, we determined the ventricle elastance (Ees), the arterial elastance (Ea) and myocardial efficiency before and after administration of a slow-bolus of remifentanil (1 micro kg(-1)).

RESULTS

Remifentanil decreases significantly the ventricular elastance (from 6.09 mmHg ml-1 m(-2) to 4.88) (P < 0.05), with a less, but however, significant decrease of arterial elastance (from 3.68 mmHg ml(-1) m(-2) to 3.13) (P < 0.05). Despite causing simultaneous declines, maintains a good myocardial efficiency (0.64-0.68) with no significant difference.

CONCLUSION

Although remifentanil depresses ventricular and arterial elastance, preserves a good left ventricular-arterial coupling and mechanical efficiency, despite a little increase of coupling. However, these effects are maintained only during a slow intravenous infusion and are dose-dependent with impairment of coupling, that may contribute to decline in overall cardiovascular performance, at higher anesthetic dose and rapid infusion in patients with a severe myocardial dysfunction.

Pressure-volume relationships in pediatric systolic and diastolic heart failure

The left ventricular pressure-volume relationship has been used to examine ventricular systolic and diastolic function as well as to evaluate myocardial energetics and ventricular-vascular coupling. Preload, afterload and contractility can be separately examined using indices derived from simultaneous pressure and volume measurement. Due to the development of new instrumentation and diagnostic tools, these techniques now can be more readily applied to the evaluation of patients in heart failure. Indices of function can be examined on-line during diagnostic cardiac catheterization. Pharmacologic interventions can be evaluated using these methods, allowing for assessment of therapeutic interventions. Medical therapy can be optimized during these studies, allowing more effective and individualized treatment.

Effects of reconstructive surgery for left ventricular anterior aneurysm on ventriculoarterial coupling

OBJECTIVE

To investigate left ventricular elastance (Emax) and effective arterial elastance (Ea) in postinfarction left ventricular aneurysm and evaluate their role in left ventricular function improvement after endoventricular circular patch plasty (EVCPP). Ventriculoarterial coupling has never been studied in these patients.

PATIENTS

22 consecutive patients (49 to 73 years) with left ventricular anterior aneurysm.

METHODS

Haemodynamic studies were done before and two weeks after EVCPP. Ventriculography was performed during atrial pacing (100 beats/min). Pressure/volume loops were analysed and derived parameters measured. Emax was estimated by applying the "single beat" method. Ea was calculated as end systolic pressure/stroke volume.

RESULTS

Left ventricular volumes and Ea decreased after surgery: end diastolic volume index from mean (SD) 155 (53) to 106 (29); end systolic volume index from 112 (51) to 62 (30) ml/m2 (both p < 0.0001); Ea from 1.65 (0.70) to 1.39 (0.41) mm Hg/ml (p = 0.04). Ejection fraction and Emax increased, without significant changes in stroke volume and work. The decrease in Ea was directly correlated with its preoperative value. The time interval between left ventricular pressure upstroke and peak systolic pressure decreased, from 237 (39) to 191 (41) ms (p < 0.0001), paralleling morphological changes in pressure tracings.

CONCLUSIONS

After EVCPP, ventriculoarterial coupling improves because of the fall in Ea caused by end systolic pressure reduction. The improvement is related to aortic pressure waveform changes and improved relaxation.

Acute cardiovascular effects of OPC-18790 in patients with congestive heart failure. Time- and dose-dependence analysis based on pressure-volume relations

BACKGROUND

OPC-18790 is a water-soluble quinolinone derivative that shares the pharmacological properties of vesnarinone and that may be useful for treating heart failure. We studied the contribution and relative dose sensitivities of the inotropic, lusitropic, and vascular effects of OPC-18790 in patients with dilated cardiomyopathy.

METHODS AND RESULTS

Pressure-volume (PV) analysis was performed in 17 patients who received either 5 micrograms.kg-1.min-1 (low dose, n = 10) or 10 micrograms.kg-1.min-1 (high dose, n = 7) OPC-18790 by 1-hour IV infusion. Right heart pressures and flow and left heart PV relations (conductance catheter) were measured at baseline and every 15 minutes during infusion. Transient inferior vena caval obstruction was used to determine PV relations. Both doses produced venodilation reflected by a 10% decline in left ventricular end-diastolic volume and a 30% fall in atrial and pulmonary artery pressures. Arterial dilation was four times greater at the high dose, with an approximately 40% fall in effective arterial elastance and systemic resistance. Contractility rose by 25% to 100% (depending on PV index) with both doses. Ventricular-arterial coupling (ratio of ventricular end-systolic to arterial elastances) was approximately 0.25 at baseline and doubled (or tripled) at low (or high) dose, correlating with improved efficiency. Isovolumetric relaxation shortened, whereas the diastolic PV relation was generally unchanged. Heart rate was unaltered.

CONCLUSIONS

OPC-18790 has potent venous and arterial vasodilator effects and moderate inotropic and lusitropic effects without a change in heart rate. These combined actions suggest a unique potential of OPC-18790 for heart failure treatment.

A new methodology for non-invasive clinical assessment of cardiovascular system performance and of ventricular-arterial coupling during stress

The objective of the study was to develop a non-invasive method for the quantitative evaluation of cardiovascular performance and ventricular-arterial (VA) coupling during varying physiological states. VA-coupling was represented by the ratio between the arterial and ventricular elastances-Ea/Ees. Approximate indices of the relative change of Ees and VA-coupling during stress were developed and tested. These indices can be evaluated directly from non-invasive measurements of ejection fraction values (for VA-coupling) and measurements of stroke volumes and systolic and diastolic arterial pressures (for Ees). Additional relative indices can be evaluated from these data (e.g., stroke work, cardiac output) to yield a complete representation of the cardiovascular response to stress. The present methodology was applied to assess the exercise stress response in healthy subjects (H, n = 8) and in patients with left ventricular dysfunction (n = 24). Left ventricular volumes were determined by nuclear angiography and arterial pressures were measured non-invasively by a new, validated method. Using published data obtained invasively, we found that the relative indices of Ees and VA-coupling showed a high correlation with the invasive ones (r > 0.8, P < 0.01). The patients were subgrouped by their maximal exercise capacitance (P2-50W, P3-75W). At rest, the two patient groups had similar ejection fraction values (45 +/- 15% and 48 +/- 16%), which were significantly different from those of the healthy subjects (66 +/- 7%, P < 0.05). During stress, a larger increase in stroke work and cardiac output was found in the healthy subjects. All three groups showed similar relative increases in Ees and heart rate, but relative Ea increased in P2 and decreased in H, while the opposite was found for the end-diastolic volume. The relative VA-coupling index in P2 was significantly larger than that in P3 and H (P < 0.05). The present non-invasively based indices can be used to quantitatively monitor the individual cardiovascular response to stress testing or drug interventions and to evaluate the importance of VA-coupling in the clinical setting.

Ventriculoarterial coupling during exercise in normal human subjects

To examine the relative roles of ventricular contractility and loading conditions for cardiovascular adjustment during exercise, 10 normal human subjects were studied using a framework of ventriculoarterial coupling. Anaerobic threshold was evaluated to determine the work rates of aerobic and anaerobic exercise. Ventricular contractile properties were quantified by the slope of the end-systolic pressure-volume relationship (ventricular elastance) and arterial system properties were expressed by the end-systolic pressure-stroke volume relationship (arterial elastance). During aerobic exercise, left ventricular end-diastolic volume and stroke volume were increased by 14 and 33%, with plasma norepinephrine levels being doubled. Arterial elastance was reduced by 30%, but ventricular elastance did not change significantly. During anaerobic exercise, ventricular end-diastolic volume returned to the resting value, while stroke volume remained increased by 31%. In contrast to aerobic exercise, ventricular elastance rose substantially by 89% in association with about a 10 times increase in plasma norepinephrine. Arterial elastance remained the same as in aerobic exercise. Thus, the increase in stroke volume was primarily mediated by changes in loading conditions during aerobic exercise and by enhanced contractility during anaerobic exercise.