Late results of surgical and medical therapy for patients with coronary artery disease and depressed left ventricular function

Aims To compare acute and chronic ventricular function between patients, without cardiac failure, paced at either right ventricular apex or outflow tract.

Methods Twenty patients, 10 paced apically and 10 in the outflow tract, underwent two radionuclide ventriculograms. Eight parameters of systolic or diastolic function were compared at each assessment, as were changes within each group over time.

Results No differences were identified in systolic function between pacing sites 6 weeks after pacing or 23 weeks later. Peak filling rate was lower ( P =0·04) at the second assessment with outflow tract pacing. No other diastolic differences were identified. Between assessments, time to peak filling rate prolonged ( P =0·04) with apical pacing, while left ventricular area reduced ( P =0·04) and peak filling rate decreased ( P =0·04) with outflow tract pacing. Septal motion was better preserved with outflow tract pacing. No other parameter changed over time. ECG measures were similar at 14·7 months.

Conclusions No major differences were identified in systolic function between pacing sites. Some systolic parameters were better preserved with outflow tract pacing and diastolic function deteriorated subtly over time in both groups. Right ventricular pacing adversely affects left ventricular function.

/pdf/evolution-of-ventricular-function-during-permanent-pacing-12fdxxa564.pdf

Evolution of ventricular function during permanent pacing from either right ventricular apex or outflow tract following AV-junctional ablation for atrial fibrillation.

Postinfarct risk stratification.

The efficacy of coronary artery surgery

Current status of cardiac valve replacement: selection of a prosthesis and indications for operation.

The efficacy of myocardial revascularization in improving left ventricular function and prognosis in patients with severe left ventricular dysfunction is controversial. This study was designed to determine the effect of coronary bypass graft surgery on rest and exercise ventricular function in patients with left ventricular dysfunction. Nineteen patients with coronary artery disease who had left ventricular ejection fractions of 40% or less were studied at rest and during maximal upright bicycle exercise using first-pass radionuclide angiography to measure ejection fraction, wall motion and end-diastolic volume pre- and postoperatively. These same patients had repeat coronary arteriography 10–14 days postoperatively. In addition, 15 presumably healthy, young male volunteers were studied by the same technique to serve as controls and illustrate the normal response to upright exercise. The normal response, as previously demonstrated, was maintained or improved ventricular function with exercise; i.e., ejection fraction does not decrease, regional wall motion disorders do not appear and significant left ventricular dilatation does not occur. In contrast, preoperatively, the patients with coronary artery disease showed the following: 14 of 19 had a decrease in ejection fraction, 16 developed regional wall motion disorders and seven had marked left ventricular dilatation. After myocardial revascularization, the resting ejection fractions improved. With exercise, 16 of the 19 patients demonstrated a response toward normal, with a maintenance or increase in ejection fraction and no deterioration of regional wall motion. One other patient showed marked ventricular dilatation with exercise. Postoperative coronary arteriography revealed unsuccessful or incomplete revascularization in three of the four patients with an abnormal response to symptom-limited maximal exercise. The data suggest that left ventricular function at rest and during exercise can be improved by myocardial revascularization in the patient with coronary artery disease and severe left ventricular dysfunction.

Bypass graft surgery in severe left ventricular dysfunction.

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Bypass graft surgery in severe left ventricular dysfunction.