A clinical comparison of mitral valve repair versus valve replacement in ischemic mitral regurgitation.

Severe mitral regurgitation caused by acute myocardial infarction has been a particularly difficult management problem with disappointing clinical results. Over a 75-month period, ending March 31, 1987, 611 patients underwent mitral valve operations at Duke University Medical Center. Within this group, 55 patients had clearly defined ischemic mitral regurgitation, and 37 of these required emergency operations. Thirty-one of the 55 patients had isolated posterior papillary muscle dysfunction, nine had papillary muscle rupture, and 15 had severe ventricular dysfunction and generalized annular dilatation. Thirty-two patients were treated with primary mitral valve replacement, and 23 had mitral valve repair. In 18, repair was accomplished by a transventricular approach, combining the techniques of commissural annuloplasty, papillary muscle shortening or reimplantation, and infarct exclusion. Transventricular mitral valve repair proved to be safe, expeditious, and effective in restoring valve competence. Although the repair and replacement groups were similar with respect to all relevant baseline characteristics, improved operative survival was observed after valve repair, as compared to replacement, both for the overall group (p = 0.03) and for acute papillary muscle dysfunction (p = 0.05). These data suggest that a policy of predominant mitral valve repair, when appropriately applied in patients with ischemic mitral regurgitation, offers the potential for improving therapeutic results.

Relation between QRS changes and left ventricular function after coronary artery bypass grafting.

Preoperative and serial postoperative electrocardiograms (ECGs) were reviewed in 104 patients undergoing rest and exercise radionuclide angiocardiography before and 1 to 12 months after coronary artery bypass grafting (CABG). Five patient groups were defined by ECG findings before and after CABG: Group I--normal ECG before and no ECG change after CABG; Group II--prior myocardial infarction by ECG before but no QRS change after CABG; Group III--all patients with a minor QRS change (less than 0.04-second Q wave, loss of R-wave amplitude) after CABG; Group IV--all patients with a major QRS change (greater than or equal to 0.04-second Q wave) after CABG; Group V--all patients without new Q waves or loss of R-wave amplitude but with a major QRS change (conduction disturbance) after CABG. Mean resting ejection fraction changed little after CABG in all groups, although the 0.03 increase in Group I was significant (p less than 0.05). Group IV had the largest decrease in resting ejection fraction after CABG (0.04), but this was not statistically significant. Mean exercise ejection fraction increased significantly (p less than 0.0001) in Groups I, II and III but not in Groups IV and V. QRS changes do not consistently reflect impairment of left ventricular (LV) function after CABG.

The role of radionuclide angiocardiography in the preoperative prediction of pain relief and prolonged survival following coronary artery bypass grafting.

Radionuclide angiocardiography (RNA) provides noninvasive measurements of left ventricular function during rest and exercise, which appear to reflect the magnitude of fibrosis and ischemia in patients with coronary artery disease. This investigation evaluated the usefulness of these measurements for providing prognostic information, useful in selecting therapy. The RNA study group included 278 patients with a low resting ejection fraction and coronary artery disease documented by angiography. Patients were followed for up to three years to define survival and incidence of complete pain relief. The 172 patients treated medically had less favorable survival and pain relief than the 106 surgically treated patients. In the medically treated patients, a positive RNA defined a subgroup of 113 patients, with a 20% lower 3-year survival than the 59 patients with a negative RNA. Moreover, comparison of patients receiving medical and surgical therapy following a positive RNA documented a clear improvement in both survival and pain relief for those who showed significant ischemia during exercise and subsequently underwent coronary bypass procedures. In patients with a negative RNA, medical and surgical therapy resulted in a similar survival rate and little difference in pain relief. Calculations comparing the maximal potential increase in survival and complete pain relief, using multiple criteria known to provide prognostic information, identified the exercise response on RNA as the single most important variable for selection of therapy. Therefore, the left ventricular response to exercise provides important prognostic information in patients with low resting ejection fractions, and the results of this procedure can be used to define subgroups of patients who will and will not benefit from coronary artery bypass grafting.

The force-interval relationship of the left ventricle.

We have carried out a quantitative analysis of the force-interval relationship of the human left ventricle and compared it to previous studies done in both intact subjects as well as isolated muscle. The characteristics of the force-interval relationship of the normal patient resembed those of normal isolated mammalian muscle (except when exposed to high levels of catecholamines). The relationship in group 2 (patients with increased left ventricular dimensions and normal pressure indices) resembled those obtained from isolated muscles from hypertrophied hearts. The relationship from group 3 (patients with increased left ventricular EDDs and depressed pressure indices, two of whom were in clinical heart failure) resumbled those induced in normal muscles exposed to high levels of catecholamines, and those obtained from experimentally induced heart failure. The force-interval relationships of the four patients who fell into the third group were strikingly different from the other groups. This suggests that the force-interval relationship may be useful to describe changes in the inotropic state of the patient's heart.

Effects of stressful conditions on the development and movement of reproductive cells in Schistosoma mansoni.

Adult S. mansoni exposed to 3H-thymidine to label reproductive cells were cultured in vitro, maintained intraperitoneally, and transplanted to the hepatic portal vein of hamsters in unisexual infections. Daily samples were taken, processed for autoradiography, and observed for abnormal morphological and development characteristics. Males cultured in vitro did not produce labeled sperm and the testes exhibitied necrotic changes by the 5th day. Vitelline cell formation was normal for the first 5 days, but after that time both vitellaria and ovary showed degenerative changes. Males and females were still alive after 18 days of culture. Worms transferred to the peritoneal cavity were dead after 3 days, and no signs of reproductive development occurred during that time. Most males and a few females were encapsulated by cells thought to be of host origin. Males transplanted into hamsters in unisexual infections produced sperm in the normal time period and showed no morphological deterioration after 8 days. Females similarly handled were degenerating by day 3 and dead by day 6. Development and movement of reproductive cells was not detected in these females.

The timing of reproductive cell development and movement in Schistosoma mansoni, S. japonicum, and S. haematobium, using techniques of autoradiography and transplantation.

Tritiated thymidine was incorporated into gonial and vitelline cells of male and female Schistosoma mansoni, S. japonicum, and S. haematobium after 2 hr of incubation. Spermatogonial cells developed into labeled mature sperm after 6 days of transplantation in all species. Insemination of females was detected on the same day indicating copulation is frequent. Oogonia labeled in the initial incubation matured into primary oocytes after 7 days of transplantation for S. mansoni and S. haematobium and after 6 days in S. japonicum. Cytoplasmic thymidine label was observed after 2-hr incubations in the primary oocytes of all species. Initial label in the vitellaria was scattered and heavy. After 3 days of transplantation, label was considerably diluted and by day 6 was undetectable in vitelline glands. These times for development and movement of reproductive cells are considered to be standards against which the effects of stressful conditions on the reproductive system can be assessed.