Milovan Bojić

Early changes in left ventricular function in chronic asymptomatic alcoholics: relation to the duration of heavy drinking ☆

OBJECTIVES This study sought to assess preclinical cardiac abnormalities in chronic alcoholic patients and possible differences among alcoholics related to the duration of heavy drinking. BACKGROUND Chronic excessive alcohol intake has been reported as a possible cause of dilated cardiomyopathy. However, before the appearance of severe cardiac dysfunction, subtle signs of cardiac abnormalities may be identified. METHODS We studied 30 healthy subjects (age 44 +/- 8 years) and 89 asymptomatic alcoholics (age 45 +/- 8 years, p = NS) divided into three groups, with short (S, 5-9 years, n = 31), intermediate (I, 10-15 years, n = 31) and long (L, 16-28 years, n = 27) duration of alcoholism. Transmitral early (E) and late (A) Doppler flow velocities, E/A ratio, deceleration time of E (DT) and isovolumic relaxation time (IVRT) were obtained. Left ventricular (LV) wall thickness and volumes were also determined by echocardiography, and LV mass and ejection fraction (EF) were calculated. RESULTS The alcoholics had prolonged IVRT (92 +/- 11 vs. 83 +/- 7 ms, p < 0.001), longer DT (180 +/- 20 vs. 170 +/- 10 ms, p < 0.01), smaller E/A (1.25 +/- 0.34 vs. 1.40 +/- 0.32, p < 0.05), larger LV volumes (73 +/- 8 vs. 65 +/- 7 ml/m2, p < 0.001 for end-diastolic volume index; 25 +/- 4 vs. 21 +/- 2 ml/m2, p < 0.001 for end-systolic volume index), higher LV mass index (92 +/- 14 vs. 78 +/- 8 g/m2, p < 0.001) and thicker posterior wall (9 +/- 1 vs. 8 +/- 1 mm, p < 0.001). Ejection fraction did not differ between the two groups (66 +/- 4 vs. 67 +/- 2%). Deceleration time of the early transmitral flow velocity was longer in groups L (187 +/- 18 ms) and I (185 +/- 16 ms) compared with group S (168 +/- 17 ms, p < 0.001 for L and I vs. S), whereas A was higher in group L compared with S (43 +/- 10 vs. 51 +/- 10 cm/s, p < 0.005). Multiple regression analysis identified duration of heavy drinking as the most important variable affecting DT and A. CONCLUSIONS Left ventricular dilation with preserved EF and impaired LV relaxation characterized LV function in chronic asymptomatic alcoholic patients. It appeared that the progression of abnormalities in LV diastolic filling related to the duration of alcoholism.

Partial left ventriculectomy for idiopathic dilated cardiomyopathy: early results and six-month follow-up

BACKGROUND Recent reports show that partial left ventriculectomy improves hemodynamic and functional status in patients with dilated cardiomyopathy. This study sought to determine the effects of partial left ventriculectomy on clinical outcome and left ventricular function during 6-month follow-up. METHODS Twenty-two patients underwent partial left ventriculectomy. Mitral valve repair was performed whenever possible, otherwise the valve was replaced. Hemodynamic and functional data were obtained at baseline, as well as 2 weeks and 6 months postoperatively. RESULTS Overall, 7 of 22 patients died; there were three early and four late deaths. One-year survival was 68%+/-10%. Ejection fraction increased from 23.9%+/-6.8% before the operation to 40.7%+/-12.5% at 2 weeks and to 36.8%+/-7.7% at 6 months (p<0.001, for both). The cardiac index before the operation, at 2 weeks, and at 6 months was 2.3+/-0.8, 2.9+/-0.6, and 3.4+/-1.0 L/m2 per minute, respectively (p = 0.035, and p = 0.009, compared with baseline). The increase in ejection fraction 2 weeks postoperatively was less in patients with left circumflex artery dominance (10.9%+/-3.2% compared with 19.9%+/-10.7%, respectively, p = 0.017). At 6-month follow up, all surviving patients except one improved New York Heart Association functional class when compared with preoperative status (from 3.8+/-0.4 to 1.4+/-0.6, p = 0.0002). CONCLUSIONS Early hemodynamic improvement after partial left ventriculectomy was maintained during midterm follow-up.

Effects of partial left ventriculectomy on left ventricular performance in patients with nonischemic dilated cardiomyopathy

OBJECTIVES This study sought to assess the effects of partial left ventriculectomy (PLV) on left ventricular (LV) performance in a series of consecutive patients with nonischemic dilated cardiomyopathy. BACKGROUND Reduction of LV systolic function in patients with heart failure is associated with an increase of LV volume and alteration of its shape. Recently, PLV, a novel surgical procedure, was proposed as a treatment option to alter this process in patients with dilated cardiomyopathy. METHODS We studied 19 patients with severely symptomatic nonischemic dilated cardiomyopathy, before and 13+/-3 days after surgery, and 12 controls. Single-plane left ventriculography with simultaneous measurements of femoral artery pressure was performed during right heart pacing. RESULTS The LV end-diastolic and end-systolic volume indexes decreased after PLV (from 169 to 102 ml/m2, and from 127 to 60 ml/m2, respectively, p < 0.0001 for both). Despite a decrease in LV mass index (from 162 to 137 g/m2, p < 0.0001), there was a significant decrease in LV circumferential end-systolic and end-diastolic stresses (from 277 to 159 g/cm2, p < 0.0001 and from 79 to 39 g/cm2, p = 0.0014, respectively). Ejection fraction improved (from 24% to 41%, p < 0.0001); the stroke work index remained unchanged. CONCLUSIONS The PLV improves LV performance by a dramatic reduction of ventricular end-systolic and end-diastolic stresses. Further studies are needed to assess whether this effect is sustained during long-term follow-up and to define the role of PLV in the treatment of patients with dilated cardiomyopathy.

Single center experience on eversion versus standard carotid endarterectomy: a prospective non-randomized study.

BACKGROUND AND PURPOSE The prospective studies that have compared the outcomes of eversion and standard longitudinal carotid endarcterectomy (CEA) have been few and small and available data to reach definitive conclusions are still scarce. This prospective, non-randomized study sought to compare eversion and standard CEA for early and late mortality and morbidity and the incidence of late restenosis. METHODS Between 1992 and 1997, we performed 2806 CEAs in 2469 patients (2124 eversion CEAs in 1859 patients and 682 standard CEAs in 610 patients). All patients underwent preoperative neurological examination and cervical duplex scanning. Patients were followed up by neurological evaluation and duplex scanning at 1 and 6months after CEA, and yearly afterwards. RESULTS Demographics and neurologic inidications for CEA were similar in both groups. Mean clamping time was shorter in the eversion CEA group (13.5+/-6.1 vs 19.9+/-19.1min, P<0.001). Early (30-day) postoperative mortality due to major stroke was lower after eversion CEA (10/2124 vs 9/682, P=0. 037), as well as total cardiovascular mortality (16/2124 vs 12/682, P=0.038). Early carotid occlusion was more frequent in standard CEA group (12/2124 vs 11/682, P=0.017), as well as total early morbidity (112/2124 vs 53/682, P<0.001). During follow-up (mean 56 months, range 6-92), restenosis rate was lower in the eversion CEA group (0. 5 vs 1.8%, P=0.006). CONCLUSIONS Our data indicate that eversion CEA as compared to standard CEA technique is associated with lower total cardiovascular perioperative mortality and mortality due to major stroke, shorter clamping time, lower early occlusion rate, and lower late restenosis rate.

Partial left ventriculectomy: which patients can be expected to benefit?

BACKGROUND Although some patients with end-stage heart disease will benefit from a partial left ventriculectomy, no criteria have been found for identifying this group preoperatively. Our experience with partial left ventriculectomy at two institutions-the Texas Heart Institute in Houston, TX, USA, and Dedinje Cardiovascular Institute in Belgrade, Yugoslavia-showed a higher survival rate and better postoperative myocardial function in the Yugoslavian patients. METHODS We reviewed data from 42 patients (21 at each center) who had idiopathic cardiomyopathy, a left ventricular end-diastolic dimension of more than 70 mm, wall thickness of 1 cm or greater, and New York Heart Association class III or IV symptoms. The only significant difference in preoperative status between the two groups was duration of symptoms. Histologic specimens, blinded as to origin, were graded with regard to myocyte hypertrophy, cytoplasmic vacuolation, and fibrosis. Computer-assisted myocyte and nuclear morphometry was also performed. RESULTS Immediately postoperatively, there were no significant intergroup differences in the reduction in cardiac dimension or in corrections of mitral regurgitation. During 6-month follow-up, however, the Texas Heart Institute patients had a lower cardiac index (1.8 versus 3.0 L x min(-1) x m(-2); p = 0.001) and left ventricular ejection fraction (24% versus 34%; p = 0.006) than the Dedinje Cardiovascular Institute patients. The Texas Heart Institute patients differed from the Dedinje Cardiovascular Institute patients in the degree of severe or moderate changes in myocyte hypertrophy (90% versus 29%; p = 0.0003) and fibrosis (71% versus 29%; p = 0.006), as well as in the measurements of median myocyte diameter (35 +/- 7 microm versus 27 +/- 4 microm; p = 0.0002) and median nuclear size (15 +/- 4 microm versus 12 +/- 2 microm; p = 0.0029). CONCLUSIONS In the Texas Heart Institute patients, the significant intergroup difference in clinical outcome may have been related to increased myocyte hypertrophy and fibrosis. Further studies should be performed to determine the usefulness of these criteria in selecting patients for partial left ventriculectomy.

Immediate reoperation for perioperative stroke after 2250 carotid endarterectomies: Differences between intraoperative and early postoperative stroke

PURPOSE After carotid endarterectomy, intraoperative findings and outcome of immediate reoperation of patients who had an intraoperative stroke were compared with those of patients who had an early postoperative stroke. METHODS We retrospectively analyzed 2250 carotid endarterectomies performed between 1980 and 1997. Intraoperative stroke (group A) was detected after 41 of the 2250 operations (1.8%), whereas early postoperative stroke (group B) developed after 18 of the 2250 operations (0.8%). Patients from both groups were reoperated on within 1 hour after neurological examination. RESULTS Positive intraoperative findings that could be corrected during immediate reoperation were: (1) thrombotic occlusion of the carotid artery that was operated on caused by technical error, which was found in nine of 41 patients (22%) in group A and in 11 of 18 patients (61%) in group B (P =.009); (2) mural thrombus caused by technical error without occlusion, which was detected in seven of 41 patients (17%) in group A and in two of 18 patients (11%) in group B (P >.05); and (3) technical error without a thrombus, which was found in eight of 41 patients (20%) in group A and in three of 18 patients (17%) in group B (P >.05). A patent carotid artery was found in 17 of 41 patients (42%) in group A and in two of 18 patients (11%) in group B (P =.046). Twenty of the 41 patients (49%) in group A died, and four of 18 patients (22%) in group B died (P > 0.05). Major neurological deficit remained in nine of 41 patients (22%) in group A and four of 18 patients (22%) in group B (P > 0.05). Total recovery occurred in seven of 41 patients (17%) in group A and in eight of 18 patients (45%) in group B (P = 0.058). CONCLUSION Carotid artery thrombosis during immediate reoperation was more frequent in patients who had an early postoperative stroke than in patients who had an intraoperative stroke. It appears that patients who had an intraoperative stroke have a higher incidence of uncorrectable lesions.

Early predictors of mitral regurgitation after acute myocardial infarction

We analyzed early predictors of mitral regurgitation after myocardial infarction in 131 consecutive patients with first acute myocardial infarction. Our data revealed that elderly patients with larger infarcts, multivessel coronary disease, and papillary muscle region asynergy are more likely to develop mitral regurgitation in the first year after infarction.

Myocardial Tissue Characterization After Acute Myocardial Infarction With Wavelet Image Decomposition A Novel Approach for the Detection of Myocardial Viability in the Early Postinfarction Period

BACKGROUND Only a few texture measures can be used for texture characterization of infarcted myocardium and detection of reperfused myocardium early after infarction. This study was conducted to establish the relationship between texture properties of infarcted myocardium and infarct-related artery patency by quantitative computer analysis of 2-dimensional echocardiographic images with the wavelet-based method for texture characterization, evaluate the relationship between texture properties and myocardial viability, and correlate histopathologic changes after experimental infarction with the texture measures. METHODS AND RESULTS We analyzed 2-dimensional transthoracic echocardiographic images in 18 patients at different time points after infarction using the wavelet transform method. Regional wall motion of infarcted segments was analyzed on a follow-up echocardiographic study obtained 6 months after infarction. To verify the accuracy of the proposed texture measure and energy difference cutoff value, we prospectively evaluated another group of 19 patients. In addition, histopathologic changes in 9 dogs with experimental infarction were correlated with the texture measures. Sensitivity, specificity, and accuracy of the wavelet method for detection of reperfusion in the study group were 73%, 86%, and 78%, respectively, on day 2; 91%, 86%, and 89%, at 1 week; and 100%, 100%, and 100% at 3 weeks. Among 9 patients with improvement in regional wall motion on a follow-up study, 7 on day 2, 8 at 1 week, and 9 at 3 weeks were classified into the reperfused group by the wavelet method. Histopathologic features associated with the classification of reperfusion by the wavelet method were infarct transmurality (P=0.024) and degree of necrosis (P=0.028). CONCLUSIONS Our clinical and experimental data suggest that the wavelet method can be used to differentiate between viable myocardium with recovery potential and definite myocardial necrosis in the early postinfarction period.

Active infective endocarditis: low mortality associated with early surgical treatment.

BACKGROUND Early surgical treatment is important for successful outcome in selected cases of active, either native (NVE) or prosthetic valve endocarditis (PVE). The aim of this study was to evaluate the early results of the surgical treatment of active NVE and PVE. METHODS During a 3-yr period (January 1 1996-December 31 1998), 57 out of 60 patients (pts) with active, either NVE (46 pts) or PVE (11 pts) underwent surgical treatment. There were 11 women (23.9%), average age of the group being 43.3+/-9.1yr (18-73). They were operated on 12-35days, mean 17.7+/-7.5days (for NVE) and 5-33days, mean 13.2+/-10.1days (for PVE) after the diagnosis of endocarditis was first suspected. All pts had at least one absolute indication for early surgical treatment, the most frequent being (in NVE) worsening heart failure (19 cases) and inability to control the infection (10 cases), while in PVE it was valve dehiscence (8 cases). In 8 cases of NVE and 2 cases of PVE fresh, antibiotic sterilized aortic homograft was used to replace the aortic valve. RESULTS Operative mortality was 1.8% (1/57) and hospital mortality 5.2% (3/57). Three pts with PVE died before they were operated on, giving an overall mortality of 10% (6/60). Postoperative morbidity included valve dehiscence in two pts (probable late onset recurrent endocarditis - 3.5%), three episodes of acute renal failure (5.3%), four cases of respiratory insufficiency (7.0%) and one chronic pleural effusion (1.8%). All pts that were discharged from the hospital (54/60), are still alive and well 1-35months postoperatively (mean 20.3+/-9.6months), including pts with recurrent endocarditis and valve dehiscence, after they were successfully reoperated. CONCLUSIONS Along with early diagnosis and appropriate antibiotic treatment, aggressive surgical attitude is of importance for the successful outcome in this group of seriously ill patients. Our data indicate that early surgical treatment in cases of active endocarditis may be associated with low mortality and morbidity.

Low incidence of cardiac abnormalities in treated trichinosis: a prospective study of 62 patients from a single-source outbreak

PURPOSE The reported incidence of cardiac involvement in trichinosis is highly variable, ranging from 21% to 75%. This study sought to determine the incidence and type of cardiac lesions in trichinosis using serial echocardiographic examinations. SUBJECTS AND METHODS Sixty-two consecutive patients admitted to the Banja Luka Medical Center during an outbreak of trichinosis (November to December 1996) were included in the study. Diagnosis was made by typical clinical presentation, positive epidemiologic history, serologic testing, and the detection of Trichinella larvae in contaminated meat. All patients underwent serial electrocardiograms and two-dimensional and Doppler echocardiographic examinations within 20 days after the onset of symptoms. Repeated echocardiographic examinations were performed weekly during the hospital stay in all patients with electrocardiographic abnormalities or an abnormal initial echocardiogram. RESULTS Cardiac involvement (electrocardiographic and/or echocardiographic changes) was detected in 8 (13%) of the 62 patients. Nonspecific transient electrocardiographic ST-T changes were found in 6 patients (10%); 1 patient had frequent premature ventricular complexes. Echocardiographic examinations revealed pericardial effusions in 6 patients (10%), 5 of whom had minimal effusions without impairment of global and regional left ventricular systolic function. One patient had hypokinesis of the interventricular septum with a small pericardial effusion, both of which resolved within 2 weeks. Only 2 of the patients with electrocardiographic abnormalities lacked echocardiographic evidence of cardiac involvement. At 6-month follow-up, none of the patients had electrocardiographic or echocardiographic abnormalities. CONCLUSIONS The incidence of cardiac involvement in trichinosis appears to be lower than previously reported. Pericardial effusion is the most common manifestation of cardiac involvement, and nonspecific transient electrocardiographic changes, traditionally ascribed to myocarditis, more frequently reflect pericarditis.