Re: Ejection Fraction

Posted By CCF Cardio MD-SGM on December 12, 1997 at 20:20:48:

In Reply to: Ejection Fraction posted by Ed T. on December 03, 1997 at 20:40:03:







: Following is information I received from my doctor.  Unfortunately, I do not understand what all of this means and my doctor has not returned my call in 8 days.  I am hoping that you can help me to better understand what I have and also suggest possible treatments, or further testing I may require?
Patient:  76 year old male - no known allergies
Current Medications:  
Deltasone  - 5mg once per day
Aspirin - 81mg once per day
Tylenol - PRN
Dulcolax - PRN
Problem List:
1) Coronary Artery Disease
2) Status post coronary artery bypass surgery 1996
3) Status post trasduodenal resection of an ancillary tumor
4) Hypertension
5) Atrial Fibrillation
6) Hypercholesterolemia
7) Status post radial frequency ablation of questional focal atrial fibrillation complicated by pericardial effusion.
8) Minimally symptomatic PVC's
Cardiac Risk Factors:
Hypertension; Hypercholsterolemia; Documented Coronary Artery Disease.
HISTORY:
The patient underwent coronary aratery bypass grafting approximately one year ago.  The patient underwent surgery for an ancillary tumor. Post operatively, the patient had what he describes as irregular rapid heart beat.  From the chart and notes that we obtained and reviewed, it appears that the patient had atrial fibrillation.  The procedure was apparently complicated by pericardial effusion.  The patient was then placed on beta pace and had too slow of a heart rhythm and was subsequently taken off.  The patient has not had any more episodes of rapid palpitations.  Occasionally, he feels forceful palpitations that occur when he is at rest and occasionally he notices a skipped beat.  He has not had any pisodes of syncope of presycope. He does notice lightheadedness when he changes from sitting down to standing up and when he was also taking Cardura.  The patient denies any chest pain or arm pain which was his anginal equivalent.  The patient has no symptoms of congestive heart failure, there is no exertion PND or orthopnea.  
PHYSICAL EXAM:
Reveals a well developed male.  BP: 140/82 taken in the left arm; Pulse: 92; Temp: 98.2; Ht: 5'8"; Wt: 188 lbs.; His lungs are clear.  His cardiac exam is significant for a regular rate and rhythm.  There is a normal S1 and S2.  There is no S3 or S4 gallops.  There are no murmurs present. Patient's carotids are 2+ bilaterally, without bruits.
DATA REVIEWED:
Holter Monitor, which demonstrated frequent episodes of monomorphic PVC's as well as monomorphic non-sustained ventricular tachycardia.  These were asymptomatic; Persantine Dual Isotop Scan (10/8/97), which demonstrated normal profusion without evidence of ischemia or scar. Of note the patient's ejection fraction calculated at 31% with what was described as lateral wall motion abnormality.  Gaited Nuclear Scan, demonstrated potential mild global hypokinesis, but this is difficult to interpret; Two Echocardiograms, which demonstrated normal left ventricular function.  I suspect that patients ejection fraction is most likely normal given his normal profusion scan.
ASSESSMENT:  1) Atrial Fibrillation: The patient has had no further documented episodes of atrial fibrillation and I feel that an atrial fibrillation is most likely due to the post operative hypercatacoming state.
2) PVC's most likely due to right ventricular outflow tract PVC's given his left bundle inferior axis morphology and monomorphic nature that was seen on 12 electrocardiograms. At this point given that the patient is non-symptomatic from these, I would not treat them.
3) Of concern is the patient's relatively low EF calculated by gaited nuclear study.  I would recommend that the patient undergo an echocardiogram again to further assess this.  If the echo is normal, we will not do any further arrhythmia evaluation on the patient.  If he does in fact have a reduced left ventricular EF we will have the patient return for an electrophysiology study to ensure that what appears to be right ventricular outflow tract VT is not a more significant type of underlying conduction disease from coronary artery disease.
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that is all of it, although I cannot understand 90% of what is said.  Please help?
Thank you so much for taking time to do this..
Ed



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Dear Ed,
You have sent a complete record of your history and physical examination as recorded by a specialist in cardiac disease.  I would be happy to answer any particular questions you may have, although constraints of time and space don't allow me to thoroughly review your overall medical history.  However, you entitled your question "ejection fraction", so I will focus on this aspect of your history.  It appears that your heart's pumping function after bypass surgery is normal.  Although the nuclear scan describes a low ejection fraction of 31% (normal ejection fraction is about 55-70%), your doctor makes note of two echocardiograms that show normal ventricular function.  As echocardiograms are more precise and accurate tests of ventricular function, I would disregard this particular finding of the nuclear medicine study.  If you wish, it isn't unreasonable to repeat an echocardiogram to once again assess ventricular function, as your doctor recommends in his comments.  However, given that you have no symptoms of congestive heart failure, which is essentially "low ejection fraction", I don't know that I would continue to pursue this point.    
I would refer you to your personal physician to discuss the issues of PVC's, or irregular premature contractions of the ventricle.  There are many causes for this problem, and you can find detailed discussions of PVC's in this particular forum.  
Information  provided in the Cardiology Forum is for general medical informational purposes.  Specific diagnosis and therapeutic recommendations can only be provided by your personal physician.