anchavinnin P

Coronary-Artery Bypass Surgery in Patients with Left Ventricular Dysfunction

BACKGROUND The role of coronary-artery bypass grafting (CABG) in the treatment of patients with coronary artery disease and heart failure has not been clearly established. METHODS Between July 2002 and May 2007, a total of 1212 patients with an ejection fraction of 35% or less and coronary artery disease amenable to CABG were randomly assigned to medical therapy alone (602 patients) or medical therapy plus CABG (610 patients). The primary outcome was the rate of death from any cause. Major secondary outcomes included the rates of death from cardiovascular causes and of death from any cause or hospitalization for cardiovascular causes. RESULTS The primary outcome occurred in 244 patients (41%) in the medical-therapy group and 218 (36%) in the CABG group (hazard ratio with CABG, 0.86; 95% confidence interval [CI], 0.72 to 1.04; P=0.12). A total of 201 patients (33%) in the medical-therapy group and 168 (28%) in the CABG group died from an adjudicated cardiovascular cause (hazard ratio with CABG, 0.81; 95% CI, 0.66 to 1.00; P=0.05). Death from any cause or hospitalization for cardiovascular causes occurred in 411 patients (68%) in the medical-therapy group and 351 (58%) in the CABG group (hazard ratio with CABG, 0.74; 95% CI, 0.64 to 0.85; P<0.001). By the end of the follow-up period (median, 56 months), 100 patients in the medical-therapy group (17%) underwent CABG, and 555 patients in the CABG group (91%) underwent CABG. CONCLUSIONS In this randomized trial, there was no significant difference between medical therapy alone and medical therapy plus CABG with respect to the primary end point of death from any cause. Patients assigned to CABG, as compared with those assigned to medical therapy alone, had lower rates of death from cardiovascular causes and of death from any cause or hospitalization for cardiovascular causes. (Funded by the National Heart, Lung, and Blood Institute and Abbott Laboratories; STICH ClinicalTrials.gov number, NCT00023595.).

Multivariate analysis in the prediction of left atrial thrombi in patients with mitral stenosis

The prediction of left atrial thrombi based on clinical and investigative data was evaluated prospectively in 100 consecutive patients with significant mitral stenosis. Nineteen patients had left atrial thrombi by surgical findings. Age, atrial fibrillation, and mitral valve area were the variables that predicted the presence of left atrial thrombus, whereas sex, dimension of left atrium, history of systemic embolism, history of previous mitral valvuloplasty, and associated significant mitral regurgitation were not. Patients with atrial fibrillation have a sixfold increase in risk of atrial thrombi compared with patients in sinus rhythm. Transthoracic echocardiography detected 11 (58%) of 19 and transesophageal echocardiography detected 17 (89%) of 19 thrombi found by surgical inspection. Multivariate analysis showed that age and atrial fibrillation were the best predictors of left atrial thrombus. In general clinical practice, these variables could be used to predict left atrial thrombi in patients with mitral stenosis. However, in certain situations such as prior percutaneous balloon mitral valvuloplasty or prior electrical cardioversion, transesophageal echocardiographic examination should be used for high accuracy in the detection of extent and location of left atrial thrombi.