M. Amrani

Randomized Controlled Study Investigating the Effect of Biatrial Pacing in Prevention of Atrial Fibrillation After Coronary Artery Bypass Grafting

BackgroundAtrial fibrillation (AF) is a common problem after CABG. Prevention with prophylactic drug therapy has had limited success, therefore alternative approaches are required. This study investigated the role of biatrial pacing compared with no pacing on AF incidence after isolated first-time CABG. Methods and ResultsDuring surgery, temporary pacing leads were placed in the lateral wall of the right atrium and at the roof of the left atrium in Bachmann’s bundle to allow bipolar pacing and sensing at each site. After surgery, all patients were connected to an external pacemaker (Chorum ELA) that also acted as a Holter monitor. Patients were consecutively randomized to either 4 days of biatrial pacing at a base rate of 80 bpm or to no pacing (control group, base rate 30 bpm). End points included an episode of AF lasting >1 hour on pacemaker Holter, clinically detected AF, intensive care unit (ICU) and hospital stay, and postoperative complications. One hundred thirty patients were randomized. Biatrial pacing significantly reduced both monitored (13.8% versus 38.5%, P =0.001) and clinical (10.8% versus 33.8%, P =0.002) episodes of AF. Median ICU (19 versus 24 hours, P =NS) and mean hospital stay (7.7±6.9 versus 9.7±10, P =NS) did not significantly change. The number of postoperative complications was lower in the biatrial group (13 versus 35, P =0.001). ConclusionsBiatrial pacing after CABG significantly decreases the incidence of AF. This is associated with reduced postoperative complications and a trend toward reduced ICU and hospital stay.

Searching for the second best graft for coronary artery bypass surgery: a network meta-analysis of randomized controlled trials

OBJECTIVES There is a lack of unequivocal evidence basis for selecting the best second conduit in coronary artery bypass grafting (CABG). We thus aimed to perform head-to-head relative effect estimate on angiographic outcomes for second conduits, including the right internal mammary artery (RIMA), radial artery (RA), right gastroepiploic artery (RGEA) and saphenous vein graft (SVG) by means of network meta-analysis of randomized controlled trials (RCTs). METHODS Databases were searched for RCTs comparing angiographic outcomes (≥4 weeks) of second conduits in CABG. Odds ratios (95% confidence intervals) were computed with Markov Chain Monte Carlo simulation. RESULTS A total of nine RCTs were identified, including 2780 patients and 1620 angiographic results available for analysis to compare RIMA (n=145) versus RA (n=871) versus RGEA (n=92) versus SVG (n=845). The mean time to angiographic follow-up ranged from 1 to 7.7 years. An SVG was significantly associated with a 4-fold (1.67-16.00) and 3-fold (0.78-22.20) increased risk of late (≥4 years) functional graft occlusion when compared with the RIMA and RA, respectively. A RIMA was associated with a non-significant 27% absolute risk reduction for functional graft occlusion when compared with the RA. CONCLUSIONS The present network meta-analysis consistently demonstrated an angiographic superiority of RIMA and RA over SVG. The RIMA is expected to achieve a better patency rate than the RA, but further studies are needed.

Intrathoracic organ transplantation from donors with meningitis: a single-center 20-year experience.

BACKGROUND Availability of cadaveric organs continues to be the key factor limiting the number of transplants performed. Donor with bacterial meningitis is often considered to be controversial for organ retrieval. The purpose of this retrospective study was to review the long-term outcome of orthotopic heart and lung transplantation at our institution, from donors who died as a result of meningitis. METHODS Between July 1986 and July 2006, 39 adult patients who underwent heart and lung transplantation performed with organs from cadaveric donors with bacterial meningitis were retrospectively studied. Donors and recipients were identified by a prospectively kept database. Bacterial meningitis was identified either with positive blood or cerebrospinal fluid culture and positive signs and symptoms. All patients had one or more of these criteria. There were 15 heart, 12 lung (4 bilateral), and 12 heart-lung transplants. RESULTS All donors had identified pathogens: Neisseria meningitidis (n = 21; 53.8%), Streptococcus pneumoniae (n = 16; 41%), and Haemophilus influenzae (n = 2; 5.2%). Adequate antimicrobial therapy before organ retrieval and after transplant was administered. The hospital mortality was 10.2% (n = 4). There were no infectious complications caused by meningeal pathogens. Other causes of hospital mortality were rejection (n = 2), intracranial bleeding (n = 1), and staphylococcus sepsis (n = 1). The mean posttransplant follow-up was 5.35 +/- 5.54 years (range, 1 month to 18.9 years). CONCLUSIONS Intrathoracic organ transplantation using donors with bacterial meningitis is an acceptable strategy. No organism (Neisseria meningitides, Streptococcus pneumoniae, and Haemophilus influenzae) could be identified as contraindication because no recipient died of infectious-related diseases.

Outcomes in Patients Receiving HeartMate II Versus HVAD Left Ventricular Assist Device as a Bridge to Transplantation

OBJECTIVE Ventricular assist devices have become a standard treatment for patients with advanced heart failure. We present data comparing results after implantation of HeartMate II (HM II) versus HVAD (HW) left ventricular assist devices (LVADs) for the past 7 years at our institution. METHODS From July 2006 to August 2012, 121 consecutive patients underwent LVAD implantation: 70 (57.9%) received HM II and 51 (42.1%) HW. Patient demographics, perioperative characteristics, and laboratory parameters as well as postoperative outcome were compared retrospectively. RESULTS Patients in the HM II group were significantly younger (P < .01), with more deranged liver function (higher bilirubin [P = .02] and alanine aminotransferase [P = .01] levels), and had a significantly higher rate of preoperative infections requiring antibiotic treatment (P = .02) and a higher body core temperature (P < .01). Other demographic and preoperative parameters did not show statistical differences. Most postoperative characteristics were also similar between the two groups. HM II patients had a significantly higher transfusion rate, but there were no differences in incidence of resternotomy (P = .156). Recovery and VAD explantation were more likely in the HM II group (P = .02). Although there was no significant difference in survival (log rank test: P = .986; Breslow test: P = .827), HM II patients were more likely to develop a percutaneous site infection (P = .01). CONCLUSIONS Both HM II and HW provide similar early postoperative outcome and good long-term survival. The differences observed between the groups may be related to demographic and preoperative factors rather than the type of the device used.

Epicardial haematoma: rare cause of acute myocardial ischaemia

Pericardial effusion and coronary dissection are well known complications of percutaneous transluminal coronary angioplasty (PTCA). We report a rare case of sub-epicardial haematoma after PTCA, leading to local compression and cardiogenic shock. We discuss the successful management of this problem.

Mitral commissurotomy through the left ventricle apical orifice with Heart Ware left ventricular assist device implantation

Diseased, replaced or repaired mitral valve can lead to restricted blood flow to left ventricle and inadequate flow in left ventricular assist device (LVAD). A middle age woman with ‘burnt out’ hypertrophic cardiomyopathy had mitral valve repair for mitral regurgitation. She needed LVAD to support severe decompensating heart failure. Repaired mitral valve posed a risk of restricted flow through the device. Mitral commissurotomy was performed on beating heart through the left ventricular apical hole created for insertion of inflow cannula of LVAD.

Reversal of Severe Heart Failure With a Continuous-Flow Left Ventricular Assist Device and Pharmacological Therapy

Background— We have previously shown that a specific combination of drug therapy and left ventricular assist device unloading results in significant myocardial recovery, sufficient to allow pump removal, in two thirds of patients with dilated cardiomyopathy receiving a Heartmate I pulsatile device. However, this protocol has not been used with nonpulsatile devices. Methods and Results— We report the results of a prospective study of 20 patients who received a combination of angiotensin-converting enzymes, &bgr;-blockers, angiotensin II inhibitors, and aldosterone antagonists followed by the &bgr;2-agonist clenbuterol and were regularly tested (echocardiograms, exercise tests, catheterizations) with the pump at low speed. Before left ventricular assist device insertion, patient age was 35.2±12.6 years (16 male patients), patients were on 2.0±0.9 inotropes, 7 (35%) had an intra-aortic balloon pump, 2 were hemofiltered, 2 were ventilated, 3 had a prior Levitronix device, and 1 had extracorporeal membrane oxygenation. Cardiac index was 1.39±0.43 L · min−1 · m−2, pulmonary capillary wedge pressure was 31.5±5.7 mm Hg, and heart failure history was 3.4±3.5 years. One patient was lost to follow-up and died after 240 days of support. Of the remaining 19 patients, 12 (63.2%) were explanted after 286±97 days. Eight had symptomatic heart failure for ≤6 months and 4 for >6 months (48 to 132 months). Before explantation, at low flow for 15 minutes, ejection fraction was 70±7%, left ventricular end-diastolic diameter was 48.6±5.7 mm, left ventricular end-systolic diameter was 32.3±5.7 mm, m&OV0312;o2 was 21.6±4 mL · kg−1 · min−1, pulmonary capillary wedge pressure was 5.9±4.6 mm Hg, and cardiac index was 3.6±0.6 L · min−1 · m−2. Estimated survival without heart failure recurrence was 83.3% at 1 and 3 years. After a 430.7±337.1-day follow-up, surviving explants had an ejection fraction of 58.1±13.8%, left ventricular end-diastolic diameter of 59.0±9.3 mm, left ventricular end-systolic diameter of 42.0±10.7 mm, and m&OV0312;o2 of 22.6±5.3 mL · kg−1 · min−1. Conclusions— Reversal of end-stage heart failure secondary to nonischemic cardiomyopathy can be achieved in a substantial proportion of patients with nonpulsatile flow through the use of a combination of mechanical and pharmacological therapy.

Does grafting of left anterior descending artery with right internal mammary artery have an impact on late outcomes in the context of multiple arterial grafting

Background Universally, anastomosis of the left internal mammary artery (LIMA) to the left anterior descending artery (LAD) is accepted as the gold standard in coronary artery bypass grafting. The use of the right internal mammary artery (RIMA) for grafting the LAD has recently emerged as an alternative to avoid composite configuration in multiple arterial grafting using bilateral internal mammary arteries. Whether this recently emerged alternative strategy of RIMA to LAD is as effective as the well-established gold standard LIMA to LAD remains unknown. We investigated the impact of using RIMA for grafting of LAD on late outcomes in the context of multiple arterial grafting.

Reversal of Severe Heart Failure With a Continuous-Flow Left Ventricular Assist Device and Pharmacological TherapyClinical Perspective: A Prospective Study

Background— We have previously shown that a specific combination of drug therapy and left ventricular assist device unloading results in significant myocardial recovery, sufficient to allow pump removal, in two thirds of patients with dilated cardiomyopathy receiving a Heartmate I pulsatile device. However, this protocol has not been used with nonpulsatile devices. Methods and Results— We report the results of a prospective study of 20 patients who received a combination of angiotensin-converting enzymes, &bgr;-blockers, angiotensin II inhibitors, and aldosterone antagonists followed by the &bgr;2-agonist clenbuterol and were regularly tested (echocardiograms, exercise tests, catheterizations) with the pump at low speed. Before left ventricular assist device insertion, patient age was 35.2±12.6 years (16 male patients), patients were on 2.0±0.9 inotropes, 7 (35%) had an intra-aortic balloon pump, 2 were hemofiltered, 2 were ventilated, 3 had a prior Levitronix device, and 1 had extracorporeal membrane oxygenation. Cardiac index was 1.39±0.43 L · min−1 · m−2, pulmonary capillary wedge pressure was 31.5±5.7 mm Hg, and heart failure history was 3.4±3.5 years. One patient was lost to follow-up and died after 240 days of support. Of the remaining 19 patients, 12 (63.2%) were explanted after 286±97 days. Eight had symptomatic heart failure for ≤6 months and 4 for >6 months (48 to 132 months). Before explantation, at low flow for 15 minutes, ejection fraction was 70±7%, left ventricular end-diastolic diameter was 48.6±5.7 mm, left ventricular end-systolic diameter was 32.3±5.7 mm, m&OV0312;o2 was 21.6±4 mL · kg−1 · min−1, pulmonary capillary wedge pressure was 5.9±4.6 mm Hg, and cardiac index was 3.6±0.6 L · min−1 · m−2. Estimated survival without heart failure recurrence was 83.3% at 1 and 3 years. After a 430.7±337.1-day follow-up, surviving explants had an ejection fraction of 58.1±13.8%, left ventricular end-diastolic diameter of 59.0±9.3 mm, left ventricular end-systolic diameter of 42.0±10.7 mm, and m&OV0312;o2 of 22.6±5.3 mL · kg−1 · min−1. Conclusions— Reversal of end-stage heart failure secondary to nonischemic cardiomyopathy can be achieved in a substantial proportion of patients with nonpulsatile flow through the use of a combination of mechanical and pharmacological therapy.

Reversal of Severe Heart Failure With a Continuous-Flow Left Ventricular Assist Device and Pharmacological TherapyClinical Perspective

Background— We have previously shown that a specific combination of drug therapy and left ventricular assist device unloading results in significant myocardial recovery, sufficient to allow pump removal, in two thirds of patients with dilated cardiomyopathy receiving a Heartmate I pulsatile device. However, this protocol has not been used with nonpulsatile devices. Methods and Results— We report the results of a prospective study of 20 patients who received a combination of angiotensin-converting enzymes, &bgr;-blockers, angiotensin II inhibitors, and aldosterone antagonists followed by the &bgr;2-agonist clenbuterol and were regularly tested (echocardiograms, exercise tests, catheterizations) with the pump at low speed. Before left ventricular assist device insertion, patient age was 35.2±12.6 years (16 male patients), patients were on 2.0±0.9 inotropes, 7 (35%) had an intra-aortic balloon pump, 2 were hemofiltered, 2 were ventilated, 3 had a prior Levitronix device, and 1 had extracorporeal membrane oxygenation. Cardiac index was 1.39±0.43 L · min−1 · m−2, pulmonary capillary wedge pressure was 31.5±5.7 mm Hg, and heart failure history was 3.4±3.5 years. One patient was lost to follow-up and died after 240 days of support. Of the remaining 19 patients, 12 (63.2%) were explanted after 286±97 days. Eight had symptomatic heart failure for ≤6 months and 4 for >6 months (48 to 132 months). Before explantation, at low flow for 15 minutes, ejection fraction was 70±7%, left ventricular end-diastolic diameter was 48.6±5.7 mm, left ventricular end-systolic diameter was 32.3±5.7 mm, m&OV0312;o2 was 21.6±4 mL · kg−1 · min−1, pulmonary capillary wedge pressure was 5.9±4.6 mm Hg, and cardiac index was 3.6±0.6 L · min−1 · m−2. Estimated survival without heart failure recurrence was 83.3% at 1 and 3 years. After a 430.7±337.1-day follow-up, surviving explants had an ejection fraction of 58.1±13.8%, left ventricular end-diastolic diameter of 59.0±9.3 mm, left ventricular end-systolic diameter of 42.0±10.7 mm, and m&OV0312;o2 of 22.6±5.3 mL · kg−1 · min−1. Conclusions— Reversal of end-stage heart failure secondary to nonischemic cardiomyopathy can be achieved in a substantial proportion of patients with nonpulsatile flow through the use of a combination of mechanical and pharmacological therapy.