T. Barry Levine

Effects of high-dose Lisinopril-isosorbide dinitrate on severe mitral regurgitation and heart failure remodeling

In long-term, 1-year follow-up, uptitration of angiotensin-converting enzyme inhibitor and nitrate therapy over established doses can further improve severe functional mitral regurgitation in patients with dilated cardiomyopathy due to a reversal of heart failure-related left ventricular remodeling. With marked left ventricular enlargement, >6.8 cm end-diastolic diameter, heart failure remodeling may be irreversible and resistant to further medical intervention.

Regional blood flow supply and demand in heart failure

Heart failure results not only in a fall in cardiac output but also in a redistribution of blood flow favoring some regional beds (the brain and the heart) at the expense of others (the kidney and working skeletal muscle). The chronic resting hypoperfusion of striated muscle is further compromised with exercise. Maladaptive vasoconstrictor control mechanisms prevent the redirection of blood flow from nonworking muscle and liver to working muscle. This inappropriate preservation of nonworking organ perfusion further compromises the functional capacity of working muscle and is associated with evidence for metabolic deconditioning with reduced oxygen extraction and impaired oxidative phosphorylation. It is becoming increasingly clear that the clinical response to the inotropic and vasodilator therapy used in heart failure is in part dependent on the differing regional blood flow profiles of the various agents studied. The ability of the angiotensin-converting enzyme inhibitors to redirect blood flow away from nonworking regional beds to exercising muscle, and thereby to reestablish an appropriate physiologic response to changing metabolic needs, may be the overriding reason for their long-term efficacy. Certainly in the future the comprehensive therapy of heart failure will have to take into consideration not only central hemodynamic but also regional blood flow/supply and demand issues.

Clinical status of patients removed from a transplant waiting list rivals that of transplant recipients at significant cost savings

We retrospectively contrasted the medical outcome of patients removed from the heart transplant consideration list because of clinical improvement with that of transplant recipients. Of 60 patients awaiting transplantation, 18 were removed from the list (group A), and 42 required transplant or died (group B). Group A significantly improved regarding exercise oxygen uptake, ejection fraction, and hemodynamics. For more than 2 years after transplantation or delisting, both groups had comparable symptoms (New York Heart Association class I to II) and cardiovascular mortality (1 of 18 for group A vs 3 of 32 for group B) but lower hospitalizations for group A (0.5 +/- 0.6 of 27 months per patient) versus group B (2.8 +/- 2.1 of 23 months per patient) (p = 0.0002). Despite two patients who had been removed from the list requiring transplantation, savings for delisting exceeded

Cardiovascular responses of cardiac transplant patients to arm and leg exercise

2.2 million. Thus medical therapy allows transplant recipient list removal with clinical improvements sustained for 1 to 3 years at significant cost savings.

Hemodynamic response of a canine model of chronic heart failure to intravenous dobutamine, nitroprusside, enalaprilat, and digoxin

AbstractThis investigation compares the cardiovascular responses of normal (n=10) and cardiac transplant (n=14) subjects to peak arm and leg exercise. It also tests the hypothesis that the higher heart rate (fc) in normal subjects during light (30 W) submaximal arm versus leg exercise is due to cardiac innervation. In cardiac transplant patients, power output, oxygen consumptionn

Acute reversibility of pulmonary hypertension predicts neither long-term hemodynamic response nor outcome in patients awaiting heart transplantation

dot VO_2

Effects of vasodilator therapy on survival in patients with chronic heart failure

n,fc and rate pressure product were 54%, 28%, 7%, and 8% lower during peak arm than leg exercise, respectively. In normal subjects, power output,n