Max Haalebos

Effectiveness of intraaortic balloon pumping without cardiac surgery for patients with severe heart failure secondary to a recent myocardial infarction

Twenty-five patients with class III or class IV left ventricular failure (Myocardial Infarction Research Unit criteria) after a recent myocardial infarction were treated with intraaortic balloon pumping between December 1, 1972 and December 1, 1976. Three patients had no improvement and died during pumping. Two patients with improvement died during at attempt at weaning from circulatory assistance. Of 20 patients successfully weaned, 6 died within 3 months, 5 of these within 10 days after the weaning procedure. Of 14 patients who survived for more than 3 months, 13 were alive on February 15, 1977. Twelve of these 13 were in functional class II and 6 had resumed professional activities. Intraaortic balloon pumping proved an effective method for treating severe left ventricular failure after an acute myocardial infarction. Even withour surgery, 14 of 25 patients survived 3 or more months after an acute infarction complicated by serious pump failure.

Postoperative regression of left ventricular dimensions in aortic insufficiency: A long-term echocardiographic study

The ability of preoperative M-mode echocardiography to predict the clinical course and the decrease in left ventricular size was assessed in 42 patients after uncomplicated valve replacement for isolated aortic insufficiency. During follow-up study, one patient died of chronic heart failure. The New York Heart Association functional class of the 41 survivors improved from 2.4 to 1.2. All patients had a preoperative M-mode echocardiogram. Serial echocardiographic measurements, available in 33 patients, showed a sustained decrease in left ventricular end-diastolic dimension after the first postoperative year from 73 +/- 8 to 57 +/- 9 mm at 6 to 12 months and to 53 +/- 9 mm at 3 years postoperatively (p less than 0.01). Left ventricular cross-sectional area decreased from 31 +/- 8 to 26 +/- 7 cm2 and then to 23 +/- 5 cm2 at the latest follow-up study (p less than 0.01). At 3 years postoperatively, M-mode echocardiograms were available in 37 patients: 24 had a normal left ventricular dimension (group 1), while 13 still had an enlarged left ventricle (group 2). The clinical course in these two groups was similar. The best preoperative predictor of persistent left ventricular enlargement was the end-diastolic dimension (p less than 0.05), whereas fractional shortening and the end-diastolic radius/thickness ratio were not predictive.(ABSTRACT TRUNCATED AT 250 WORDS)

Survival in 1041 patients with consecutive aorto-coronary bypass operations.

The first 1041 patients who underwent an isolated aorto-coronary bypass operation in the same institution since it opened in 1971, were followed for up to 10 years to determine their prognosis. The mean follow-up time was 3.5 years. The probability of survival at five years was 94 +/- 2% (95% confidence limits). This was similar to the survival of the general Dutch population matched for age and sex. Multivariate survival analysis with the proportional hazards model did reveal a relationship of the rate of death with sex and age at operation; however this was not significant. There was a trend to a higher death rate with more vascular involvement (rate ratio of 3 vessel-versus 1 vessel disease of 1.9, N.S.) and a significant association with a low ejection fraction (EF) (ratio EF less than or equal to 0.30 v. EF greater than or equal to 0.55 of 2.7. P less than 0.05). Though surgery seems to eradicate the poor longterm outlook for patients with more serious vascular disease, the adverse influence of decreased left ventricular function on survival is not changed.

Surgical versus non-surgical management of patients soon after acute myocardial infarction.

Of 510 patients admitted to hospital with acute myocardial infarction, 34 had coronary artery bypass grafting before discharge (6-43 days (median 20) after infarction). The patients who were given grafts generally had a smaller infarction with less functional impairment than the 476 patients who were not. The outcome of coronary artery bypass grafting was investigated in a retrospective matched pair study. Patients were matched on the basis of the presence of postinfarction angina, left ventricular ejection fraction, location of the infarction, peak creatine kinase activity, Killip clinical class, and severity of coronary disease with 34 patients who were given medical treatment only. At one year follow up fewer of the operated patients had symptoms than did the matched non-operated patients. Survival at one year in the operated and non-operated groups respectively was 94% vs 91%; angina within one year occurred in 3% vs 68%; congestive heart failure in 3% vs 6%; and 0% vs 32% were referred for later bypass grafting or coronary angioplasty. It is concluded that coronary artery bypass grafting can be performed safely soon after myocardial infarction provided that left ventricular function is not seriously compromised. Such treatment is more effective than medical treatment for relief of angina during the first year after infarction.

Reoperation after aortocoronary bypass procedure. Results in 53 patients in a group of 1041 with consecutive first operations

Of 1041 patients with consecutive aortocoronary bypass operations, 53 (5.1%) underwent reoperation during a mean follow-up time of three and a half years. The operative mortality of first operations was 1.2%, and of reoperations 3.8%. The anatomical reason for reoperation was failure of the bypass graft in 41 (77%) patients, which in 18 was accompanied by progression of disease. Progression alone was seen in seven (13%). When symptoms occurred within six months after the first operation, failure of the bypass graft(s) was nearly always found--in 32 out of 36 instances. Progression in non-bypassed arteries was seen only when symptoms occurred later. Late results in angina pectoris were less favourable in the group undergoing reoperation: 31 (65%) of the 48 operated on twice and 406 (46%) of the 877 patients operated on once still had angina at late follow-up. The same fraction in both groups was improved by operation: 88% versus 89%.

Early coronary bypass or coronary angioplasty after successful reperfusion in acute myocardial infarction

The point of no return and the beginning of irreversible necrosis becomes evident somewhere between 5 and 30 minutes after the occlusion of a major nutrient artery to the human myocardium. Depending on the subsequent duration of complete obstruction and the time of reperfusion, the pre-existing load on the ventricle (mainly the product of afterload and heart rate) as well as the extent of available collaterals, the size of the infarction distal to the site of obstruction will vary from a minor lesion via major dyskinetic area to ‘sudden death’.