Hassan Rastegar

Clinical experience in seventy-seven patients with the automatic implantable cardioverter defibrillator.

Seventy-seven patients with drug-refractory sustained ventricular tachycardia (VT) (28 patients) or ventricular fibrillation (VF) (49 patients) underwent implantation of an automatic cardioverter defibrillator (AICD). The 67 men and 10 women, with a mean age of 60 +/- 12 years (range 18 to 79), had coronary artery disease (60 patients), idiopathic cardiomyopathy (eight patients), mitral valve prolapse (four patients), hypertensive heart disease (one patient), Ebsteins anomaly (one patient), long QT syndrome (one patient), and primary electrical disease (two patients). The mean left ventricular ejection fraction was 35 +/- 16% (range 10% to 75%). Sustained VT/VF was induced in 64 patients (83%) at baseline electrophysiologic testing. A mean of 4.1 +/- 1.3 antiarrhythmic drugs failed to control the arrhythmia. Associated surgery at AICD implantation included coronary artery bypass in 19 patients, coronary bypass with aneurysmectomy in six patients, and aneurysmectomy alone in one patient. Five patients had only prophylactic patches implanted during aneurysmectomy or coronary bypass and the AICD device was subsequently implanted under local anesthesia to prevent arrhythmia recurrence or to control persistently inducible VT. Operative mortality was 2.6% with two deaths from intractable VF. Fifty-two patients (69%) continued receiving antiarrhythmic drugs to suppress spontaneous VT. During a mean follow-up of 15 +/- 13 months (range 1 to 63), six patients died: two suddenly due to probable pulse generator failure (greater than 2 years old), one of acute myocardial infarction, two of heart failure, and one of respiratory failure.(ABSTRACT TRUNCATED AT 250 WORDS)

Clinical benefits of endoscopic vein harvesting in patients with risk factors for saphenectomy wound infections undergoing coronary artery bypass grafting

OBJECTIVEnThe influence of endoscopic harvesting techniques on the prevalence of leg-wound complications after coronary artery bypass grafting remains to be defined for patients at high risk for the development of wound infections.nnnMETHODSnAmong 1473 patients undergoing coronary artery bypass grafting who had the saphenous vein harvested by either a continuous incision or skip incisions leaving intact skin bridges, we determined the prevalence of wound infections to be 9.6%. The following variables were entered into logistic regression analysis to identify significant risk factors that might be predictive of wound infection: diabetes, peripheral vascular disease, obesity, renal failure, steroid use, age, sex, and type of closure. We then prospectively randomized 132 patients found to be at high risk of wound infection to either endoscopic vein harvesting or a continuous open incision.nnnRESULTSnUnivariate analysis showed female sex (P =.04), diabetes (P <.001), and obesity (P <.001) to be predictors of wound infection. In a multivariate model diabetes (P =.02) and obesity (P =.001) were independent predictors. In patients at high risk, the prevalence of wound infection was 4.5% for the endoscopic group versus 20% for the open group (P =.01). Vein procurement time was greater in the endoscopic group (65 minutes vs 32 minutes, P <.001), as was the number of vein repairs required (2.5 vs 0.6, P <.001).nnnCONCLUSIONnThe use of endoscopic vein harvesting decreases the prevalence of postoperative leg-wound infections in high-risk patients with diabetes and obesity. Whether this translates into an economic benefit that justifies the additional cost of that technology requires further analysis.

Efficacy of Retrograde Coronary Sinus Cardioplegia in Patients Undergoing Myocardial Revascularization: A Prospective Randomized Trial

The efficacy of retrograde coronary sinus cardioplegia (RCSC) administered through the right atrium compared with aortic root cardioplegia (ARC) has not been examined critically in patients undergoing coronary artery bypass grafting (CABG). Twenty patients having elective CABG were randomized prospectively to receive cold blood ARC (Group I, 10 patients) or cold blood RCSC (Group II, 10 patients). Patient demographics were similar in both groups. Ventricular function was assessed preoperatively by radionuclide ventriculography and postoperatively by simultaneous hemodynamic and radionuclide ventriculographic studies with volume loading. There was no change in ejection fraction (EF) (preoperative versus postoperative value) in Group I (50 +/- 6% versus 53 +/- 6%) but in group II, at similar peak systolic pressure and similar left ventricular end-diastolic volume index (LVEDVI), LVEF improved significantly (49 +/- 6% versus 60 +/- 12%, p less than 0.05). Postoperative ventricular function (stroke work index versus EDVI) for the left ventricle and right ventricle were similar in both groups. Evaluation of postoperative LV systolic function (end-systolic blood pressure versus end-systolic volume index) and diastolic function (pulmonary capillary wedge pressure versus EDVI) were also similar in both groups. Retrograde coronary sinus cardioplegia is as effective as ARC for intraoperative myocardial protection, and provides excellent postoperative function in patients undergoing elective CABG.

Effects of coronary artery bypass grafting on ventricular arrhythmias: results with electrophysiological testing and long-term follow-up.

Myocardial revascularization was performed in 56 patients with coronary artery disease who presented with ventricular tachycardia (VT) (n = 39) or ventricular fibrillation (n = 17). There were 46 men and 10 women, aged 65 ± 10 years. Three vessel (n = 42) or left main disease (n = 4) was present in 82%. Left ventricular ejection fraction averaged 36%± 11%. Electrophysioiogical studies were performed preoperatively in all patients; 50 (89%) had inducible ventricular arrhythmias. Sustained monomorphic VT was induced in 40 patients (cycle length 284 ± 61 msec). Reproducible symptomatic nonsustained VT was induced in four patients and ventricular fibrillation in six patients, while six patients had no inducible arrhythmia. Preoperatively the patients with inducible VT failed 3.3 ± 1.2 drug trials during electrophysiological studies. In addition to coronary bypass, 22 patients also received an automatic implantable cardioverter defibrillator (ICD), 26 patients received prophylactic ICD patches, and 1 patient had resection of a false aneurysm. There were no perioperative deaths. Postoperative electrophysiological studies were performed in all 56 surgical survivors. Ventricular tachyarrhythmia could not be induced in the six patients who had no inducible VT preoperatively and in 13 of 40 (33%) with preoperatively inducible sustained VT or in 19 of 50 (38%) patients with any previously inducible ventricular arrhythmia, thus a totaJ of 25 patients (45%) had no inducible VT postoperatively. Of the remaining, 11 patients were treated with antiarrhythmic drugs alone, 11 had already received an ICD (combined with drugs in 7), and another 9 received the ICD postoperatively (combined with drugs in 4). At a mean foJJow‐up of 28 ± 21 months there were 11 deaths (20%): 2 sudden, 5 nonsudden cardiac, and 4 noncardiac deaths. There were 16 nonfatal VT recurrences (29%): 14 among patients with persistently inducible arrhythmias, and onJy 2 among those with no inducible arrhythmia postoperatively (P = 0.004); 13 occurred in patients with an ICD (P = 0.01). Thus among these patients with malignant ventricular arrhythmias who underwent revascuJarization, 45% had no inducible arrhythmia postoperatively with 33% of those with preoperatively inducible sustained VT apparently rendered noninducible by revascularization, while the majority (70%) remained free of major arrhythmic events during long‐term follow‐up. We conclude that myocardial revascularization alone can result in no ventricular arrhythmia induction in selected patients with VT inducible prior to surgery. Long‐term follow‐up of such patients indicates a low sudden death and arrhythmia recurrence rate. Furthermore, in patients with persistently inducible ventricular tachyarrhythmias after coronary revascuJarization, the sudden death rate is low despite a high frequency of nonfatal arrhythmia recurrence when antiarrhythmic medications are guided by programmed stimulation or an ICD is used.

Low operative mortality achieved with surgical septal myectomy role of dedicated hypertrophic cardiomyopathy centers in the management of dynamic subaortic obstruction

Treatment of progressive heart failure, due to left ventricular (LV) outflow tract obstruction and elevated intraventricular systolic pressures, has been a major component of hypertrophic cardiomyopathy (HCM) disease management for 50 years [(1–3)][1]. Throughout this time, septal myectomy has

Perioperative and Long-term Results With Mapping-Guided Subendocardial Resection and Left Ventricular Endoaneurysmorrhaphy

BACKGROUNDnSurgical ablation of the arrhythmogenic focus in patients with life-threatening ventricular tachyarrhythmias can be curative. However, the surgical techniques have been plagued by a high perioperative mortality rate (averaging approximately 12%). Reconstruction of the left ventricle may reduce mortality.nnnMETHODS AND RESULTSnReconstruction of the left ventricle with a pericardial patch, or endoaneurysmorrhaphy, was performed with mapping-guided subendocardial resection for recurrent ventricular tachycardia in 25 patients over a 5-year period. Postoperatively, electrophysiological studies were conducted to assess the results of surgery, which were further evaluated during long-term follow-up with survival analyses. The study included 25 patients, 60 +/- 9 years of age, with coronary artery disease, discrete left ventricle aneurysms, and malignant ventricular tacharrhythmias. Left ventricular ejection fraction was 24 +/- 6% preoperatively. Left ventricular endocardial mapping, endocardial resection, and endoaneurysmorrhaphy were performed in all patients. There was no operative or postoperative (30-day) mortality. Postoperative ventricular tachycardia was induced in 2 of the 25 patients (8%); left ventricular function increased to 32 +/- 9% (range, 19% to 52%). At a mean follow-up of 37 +/- 16 months (range, 6 to 65 months), there had been 6 deaths, including 1 sudden cardiac death, 2 congestive heart failure deaths, and 3 noncardiac deaths. Analysis of multiple variables failed to identify predictors of postoperative inducibility, sudden cardiac death, cardiac death, or total mortality.nnnCONCLUSIONSnEndoaneurysmorrhaphy with a pericardial patch combined with mapping-guided subendocardial resection frequently cures recurrent ventricular tachycardia with low operative mortality and improvement of ventricular function. Long-term follow-up demonstrates low sudden cardiac death rates.

Asymptomatic large coronary artery saphenous vein bypass graft aneurysm: a case report and review of the literature.

Relatively few cases of saphenous vein graft (SVG) aneurysms have been reported since the introduction of saphenous vein coronary bypass grafting in 1968 by Favaloro. 1,2 The majority of reports are descriptions of true aneurysms of the body of the SVGs or pseudoaneurysms located at or near the anastomosis sites. 3-37 We report an unusual case of a large SVG aneurysm that presented as an asymptomatic mediastinal mass. To our knowledge, this is the largest reported asymptomatic true aneurysm of a saphenous vein aortocoronary bypass graft.

Primary Lymphoma of the Heart

Apreviously healthy 65-year-old woman presented with palpitations and positional chest discomfort 3 weeks after she sustained chest wall trauma in a motor vehicle accident. Physical examination revealed occasional premature ventricular beats and low-grade fever. Her erythrocyte sedimentation rate was elevated (66 mm/h). Transthoracic and transesophageal echocardiography revealed a 3×3-cm, well-demarcated, homogeneous, round mass moving with the heart adjacent to the right atrium (Figures 1A, B). There was invagination of nearby cardiac chambers but no obstruction to right heart filling. MRI showed a circumscribed mass with dense tissue characterization (isointense to myocardium) not consistent with blood or fat (Figure 2A). There was minimal enhancement of the mass after gadolinium injection. Coronary angiography was normal. Two weeks later, …

Significance of left ventricular apical–basal muscle bundle identified by cardiovascular magnetic resonance imaging in patients with hypertrophic cardiomyopathy

AIMSnCardiovascular magnetic resonance (CMR) has improved diagnostic and management strategies in hypertrophic cardiomyopathy (HCM) by expanding our appreciation for the diverse phenotypic expression. We sought to characterize the prevalence and clinical significance of a recently identified accessory left ventricular (LV) muscle bundle extending from the apex to the basal septum or anterior wall (i.e. apical-basal).nnnMETHODS AND RESULTSnCMR was performed in 230 genotyped HCM patients (48 ± 15 years, 69% male), 30 genotype-positive/phenotype-negative (G+/P-) family members (32 ± 15 years, 30% male), and 126 controls. Left ventricular apical-basal muscle bundle was identified in 145 of 230 (63%) HCM patients, 18 of 30 (60%) G+/P- family members, and 12 of 126 (10%) controls (G+/P- vs. controls; P < 0.01). In HCM patients, the prevalence of an apical-basal muscle bundle was similar among those with disease-causing sarcomere mutations compared with patients without mutation (64 vs. 62%; P = 0.88). The presence of an LV apical-basal muscle bundle was not associated with LV outflow tract obstruction (P = 0.61). In follow-up, 33 patients underwent surgical myectomy of whom 22 (67%) were identified to have an accessory LV apical-basal muscle bundle, which was resected in all patients.nnnCONCLUSIONnApical-basal muscle bundles are a unique myocardial structure commonly present in HCM patients as well as in G+/P- family members and may represent an additional morphologic marker for HCM diagnosis in genotype-positive status.

Pulmonary Artery Balloon Counterpulsation for Right Ventricular Failure: II. Clinical Experience

The use of pulmonary artery balloon counterpulsation (PABC) provided immediate salvage following cardiac surgical procedures in 2 patients with biventricular failure in whom inotropic drugs and intraaortic balloon counterpulsation did not provide sufficient support to allow weaning from cardiopulmonary bypass. Although both patients eventually died, the hemodynamic effectiveness of PABC was documented. The various clinical settings for right ventricular as well as biventricular failure are reviewed, the currently available options for treatment are summarized, and the directions for future laboratory investigation and possible clinical applications are presented.