Syndrome of reversible cardiogenic shock and left ventricular ballooning in obstructive hypertrophic cardiomyopathy

Background Cardiogenic shock from most causes has unfavorable prognosis. Hypertrophic cardiomyopathy (HCM) can uncommonly present with apical ballooning and shock in association with sudden development of severe and unrelenting left ventricular (LV) outflow obstruction. Typical HCM phenotypic features of mild septal thickening, outflow gradients, and distinctive mitral abnormalities differentiate these patients from others with Takotsubo syndrome, who have normal mitral valves and no outflow obstruction. Methods and Results We analyzed 8 patients from our 4 HCM centers with obstructive HCM and abrupt presentation of cardiogenic shock with LV ballooning, and 6 cases reported in literature. Of 14 patients, 10 (71%) were women, aged 66±9 years, presenting with acute symptoms: LV ballooning; depressed ejection fraction (25±5%); refractory systemic hypotension; marked LV outflow tract obstruction (peak gradient, 94±28 mm Hg); and elevated troponin, but absence of atherosclerotic coronary disease. Shock was managed with intravenous administration of phenylephrine (n=6), norepinephrine (n=6), β-blocker (n=7), and vasopressin (n=1). Mechanical circulatory support was required in 8, including intra-aortic balloon pump (n=4), venoarterial extracorporeal membrane oxygenation (n=3), and Impella and Tandem Heart in 1 each. In refractory shock, urgent relief of obstruction by myectomy was performed in 5, and alcohol ablation in 1. All patients survived their critical illness, with full recovery of systolic function. Conclusions When cardiogenic shock and LV ballooning occur in obstructive HCM, they are marked by distinctive anatomic and physiologic features. Relief of obstruction with targeted pharmacotherapy, mechanical circulatory support, and myectomy, when necessary for refractory shock, may lead to survival and normalization of systolic function

The impact of left ventricular hypertrophy on early and long-term survival after coronary artery bypass grafting

Background: Left ventricular hypertrophy (LVH) can itself contribute to increased rates of cardiovascular events. We sought to determine the impact of LVH on in-hospital and long-term mortality after coronary artery bypass grafting (CABG). Methods: Between 1992 and 2003, 4140 consecutive patients underwent CABG. Long-term survival data (mean follow-up 7.0 years) were obtained from the National Death Index. The impact of LVH on in-hospital mortality was determined by multivariate logistic regression analysis. Patients with and without LVH were compared by Cox proportional hazard models and risk-adjusted Kaplan-Meier curves. Results: There were 977 patients (23.6%) with LVH. Their mean EuroSCORE was 7.4 +/- 3.4 and there were 40 in-hospital deaths (4.1%) in this group. Multivariate logistic regression showed that patients with LVH had less elective operations, higher Canadian Cardiovascular Society Functional Class, more previous myocardial infarctions and higher percentages of 3-vessel disease, hypertension, current congestive heart failure, malignant ventricular arrhythmias, chronic obstructive pulmonary disease, calcified aorta, low ejection fraction, intravenous nitroglycerine, previous percutaneous coronary interventions and smoking. After adjustment for all available pre,intra and postoperative variables LVH was not an independent predictor for in-hospital mortality (OR 1.04, 95% CIs 0.60-1.81, P=0.891). Risk-adjusted Kaplan-Meier survival curves showed decreased long-term survival in patients with LVH after the first 3 years (HR 1.24, 95% CIs 1.06-1.44, P=0.006). Conclusions: Patients with LVH showed similar in-hospital mortality when compared with patients without LVH. However, LVH was a detrimental risk factor for late mortality, especially after the third postoperative year. These data suggest the need for a more frequent long-term follow-up among patients with LVH undergoing CABG. (C) 2008 Elsevier Ireland Ltd. All rights reserved

Impact of early and delayed stroke on in-hospital and long-term mortality after isolated coronary artery bypass grafting

Stroke after coronary artery bypass grafting (CABG) is an infrequent, yet devastating complication with increased morbidity and mortality. We sought to determine risk factors for early (intratoperatively to 24 hours) and delayed (> 24 hours to discharge) stroke and to identify their impact on long-term mortality after CABG. We studied 4,140 consecutive patients who underwent isolated CABG from 1992 to 2003. Long-term survival data (mean follow-up 7.4 years) were obtained from the National Death Index. Independent predictors for stroke and in-hospital mortality were determined by multivariate logistic regression analysis including all available preoperative, intratoperative, and postoperative risk factors. Independent predictors for long-term mortality were determined by multivariate Cox regression analysis. One hundred two patients (2.5%) developed early stroke and 36 patients (0.9%) delayed stroke. Independent predictors for early stroke were age, recent myocardial infarction, smoking, femoral vascular disease, body mass index, reoperation for bleeding, postoperative sepsis and/or endocarditis, and respiratory failure, whereas those for delayed stroke were female gender, white race, preoperative renal failure, respiratory failure, and postoperative renal failure. Early stroke was an independent predictor for in-hospital (odds ratio 3.49, 95% confidence interval [CI] 1.56 to 7.80, p = 0.002) and long-term (hazard ratio 1.70, 95% CI 1.30 to 2.21, p < 0.001) mortalities. Delayed stroke was not an independent predictor for in-hospital (odds ratio 0.90, 95 % CI 0.23 to 3.5 1, p = 0.878) or long-term (hazard ratio 0.66, 95% CI 0.38 to 1.17, p = 0.156) mortality. In conclusion, risk factors for early in-hospital stroke differ from those of delayed in-hospital stroke after CABG. Early stroke is an independent predictor for in-hospital and long-term mortalities, suggesting the need for a more frequent follow-up and appropriate pharmacologic therapy after discharge. (C) 2008 Elsevier Inc. All rights reserved

Postoperative and Long-Term Outcome of Patients With Chronic Obstructive Pulmonary Disease Undergoing Coronary Artery Bypass Grafting

Background. Chronic obstructive pulmonary disease (COPD) has been conventionally associated with increased operative mortality and morbidity after coronary artery bypass grafting. Some studies, however, challenge this association. Moreover, the effect of COPD on long-term survival after coronary artery bypass grafting has not been adequately assessed. Thus, in this clinical setting, both early and late outcome require further examination. Methods. We studied 3,760 consecutive patients who underwent isolated coronary artery bypass grafting between 1992 and 2002. The propensity for COPD was determined by logistic regression analysis, and each patient with COPD was matched with 3 patients without COPD. Matched groups were compared for early outcome and long-term survival (mean follow-up, 7.6 years). Long-term survival data were obtained from the National Death Index. Results. There were 550 patients (14.6%) with COPD. Multivariate analysis showed that patients with COPD were older and sicker. However, propensity-matched groups did not differ in terms of hospital mortality or major morbidity, although COPD was associated with a slightly longer hospital stay. In contrast, COPD patients had increased long-term mortality, with a hazard ratio of 1.28 (95% confidence intervals, 1.11 to 1.47; p = 0.001). Freedom from all-cause mortality at 7 years after CABG was 65% and 72% in matched patients with and without COPD, respectively (p = 0.008). In patients with COPD, the hazard estimate was consistently increased up to 9 years postoperatively. Conclusions. Chronic obstructive pulmonary disease, although not an independent predictor of increased early mortality and morbidity in this series, is a continuing detrimental risk factor for long-term survival