Jacob Federman

Oral beta-adrenergic blockade with metoprolol in chronic severe dilated cardiomyopathy

A double-blind crossover trial was performed to assess the effect of metoprolol in 10 patients (mean age 55 years) with severe dilated cardiomyopathy. All patients clinically had idiopathic dilated cardiomyopathy; however, at coronary angiography, four had occult coronary disease. All were in New York Heart Association functional class III with a left ventricular ejection fraction less than 35% as assessed by rest radionuclide ventriculography. Studies were performed before treatment, after 4 weeks of metoprolol therapy and after 4 weeks of placebo administration. Erect bicycle sprint exercise was used to determine maximal work load. Hemodynamic variables and radionuclide left ventricular ejection fraction were recorded at rest and during graded supine bicycle exercise. Cardiac medications were unchanged throughout the trial. The mean (+/- standard error of the mean) dose of metoprolol was 130 +/- 13 mg/day. Metoprolol did not change symptoms, chest X-ray findings or exercise tolerance (baseline 700 +/- 73, placebo 690 +/- 85, metoprolol 710 +/- 81 kilopond-meters [kpm]/min). Metoprolol produced a significant decrease in heart rate at rest and during exercise (p less than 0.001). Mean blood pressure and left ventricular filling pressure did not differ significantly in the baseline, placebo and metoprolol studies. There was a slight, but significant (p less than 0.05) decrease in cardiac index with metoprolol compared with placebo and baseline studies. The small, but significant increase in left ventricular ejection fraction from baseline to the metoprolol and placebo studies (p less than 0.001) was considered a result of spontaneous improvement rather than of therapy. No significant differences were found between the patients with and without coronary disease.(ABSTRACT TRUNCATED AT 250 WORDS)

Feasibility and short‐term efficacy of percutaneous mitral annular reduction for the therapy of functional mitral regurgitation in patients with heart failure

Background: While functional mitral regurgitation (MR) commonly accompanies heart failure and contributes to heart failure progression, mitral repair in the setting of HF is not routinely practiced because of the attendant significant morbidity and mortality. This limitation has fostered the development of percutaneous devices to reduce MR, and our group has recently reported the short‐ and long‐term effectiveness of a percutaneous mitral annuloplasty device placed in the coronary sinus (Percutaneous Mitral Annuloplasty Device (PMAD), Cardiac Dimensions®, Inc., Kirkland, WA) in reducing MR in experimental animal models of heart failure with associated MR. In this article, we report results of a “first‐in‐human” study of temporary placement of the PMAD device. The aim of this study was to demonstrate the feasibility and safety of temporary deployment of this device in patients with functional MR in association with heart failure. Methods: Five patients undergoing scheduled coronary angiography with heart failure and functional MR (mean age 52 ± 9 [SD] years) were recruited, and four had anatomy suitable for deployment of the device. Transthoracic echocardiography and coronary angiography were performed before and after temporary placement and tensioning of the PMAD via the right internal jugular vein. Results: Temporary deployment of the device resulted in a significant reduction in the septal‐lateral mitral annular dimension from 35.5 ± 4.7 to 32.2 ± 4.6 mm (P = 0.02), with evidence of a reduction in the MR color Doppler area from 98.3 ± 43.6 to 83.3 ± 35.1 mm2 (P = 0.09). There were no complications. Conclusions: This first‐in‐human study of a novel device for percutaneous treatment of functional MR has shown that temporary placement of this device in the coronary sinus/great cardiac vein of patients with heart failure and MR is feasible and safe. Evidence of temporary reduction in MR and a reduction in mitral annular area indicate promise for device effectiveness in chronic implantation.

Incremental value of clinical assessment, supine exercise electrocardiography, and biplane exercise radionuclide ventriculography in the prediction of coronary artery disease in men with chest pain

The incremental value of clinical assessment, exercise electrocardiography (ECG) and biplane radionuclide ventriculography (RVG) in the prediction of coronary artery disease (CAD) was assessed in 105 men without myocardial infarction who were undergoing coronary angiography for investigation of chest pain. Independent clinical assessment of chest pain was made prospectively by 2 physicians. Graded supine bicycle exercise testing was symptom-limited. Right anterior oblique ECG-gated first-pass RVG and left anterior oblique ECG-gated equilibrium RVG were performed at rest and exercise. Regional wall motion abnormalities were defined by agreement of 2 of 3 blinded observers. A combined strongly positive exercise ECG response was defined as greater than or equal to 2 mm ST depression or 1.0 to 1.9 mm ST depression with exercise-induced chest pain. A multivariate logistic regression model for the preexercise prediction of CAD was derived from the clinical data and selected 2 variables: chest pain class and cholesterol level. A second model assessed the incremental value of the exercise test in prediction of CAD and found 2 exercise variables that improved prediction: RVG wall motion abnormalities, and a combined strongly positive ECG response. Applying the derived predictive models, 37 of the 58 patients (64%) with preexercise probabilities of 10 to 90% crossed either below the 10% probability threshold or above the 90% threshold and 28 (48%) also moved across the 5 and 95% thresholds. Supine exercise testing with ECG and biplane RVG together, but neither test alone, effectively adds to clinical prediction of CAD. It is most useful in men with atypical chest pain and when the ECG and RVG results are concordant.

Control of Refractory Supraventricular Arrhythmias After Unsuccessful Closed‐Chest His Bundle Ablation

Six palients underwent attempted catheter ablation of the His bundle for control of refractory supraventricular tachyarrhythmias. Permanent complete heart block was achieved in only three patients. All six patients have remained asymptomatic withoul anfiarrhythmic medicolions over a follow‐up period of six to 17 months (mean 10 months). There were no complicalions of the procedure apart from mild elevation of creatine kinase levels in three patients. In this series, resumption of atrioventrcular (AV) conduction following attempted His bundle ablation was not associated with recurrence of symptomatic arrhythmias. Preservation of AV conduction may also obviate the need for permanent ventricular pacing.