Complete resection of a right atrial intracavitary metastatic melanoma.

We report a case of complete resection of a very large intracavitary metastatic melanoma of the right atrium. We describe a technique for resecting without damaging the atrium and for preventing the narrowing of the right atrium. In such cases, complete resection may be indicated despite widespread disease.

Left ventricular outflow tract obstruction and hemolytic anemia after mitral valve repair with a Duran ring.

We report a case of mitral valve repair with a Duran ring that was complicated by left ventricular outflow tract obstruction, mitral regurgitation, and hemolytic anemia. A 59-year-old man with severe mitral valve regurgitation underwent mitral valve repair, including a Duran ring annuloplasty. Postoperatively, left ventricular outflow tract obstruction developed and echocardiography revealed severe systolic anterior motion of the mitral valve. The patient then underwent mitral valve replacement with a 29-mm St. Jude valve.

Flail tricuspid leaflet after multiple biopsies following orthotopic heart transplantation: echocardiographic and hemodynamic correlation.

Flail tricuspid leaflet has been reported as a relatively uncommon complication of endomyocardial biopsy in orthotopic heart transplant recipients. However, the relationship of this complication to the number of biopsies performed and to the site of access for biopsy is not known. The objectives of this study were to assess the prevalence of flail tricuspid leaflet/torn chordae tendineae in our recent transplant population, define the relationship of this complication to endomyocardial biopsy, and to correlate echocardiographic assessments of tricuspid regurgitation severity with hemodynamic data obtained at cardiac catheterization. From January 1991 to March 1993, 181 patients who had undergone orthotopic heart transplantation at our institution were evaluated with echocardiography for the presence of a flail leaflet or torn chordae tendineae of the tricuspid valve and tricuspid regurgitation. After identifying this complication in patients, we reviewed their hemodynamic tracings and biopsy protocols from the catheterization laboratory. The hemodynamic tracing chosen was that which was done at the time the flail leaflet was first diagnosed. Of the 181 patients, 21 (11.6%) had flail leaflet or torn chordae tendineae of the tricuspid valve. The group comprised 18 male and 3 female patients. The mean duration from the time of transplantation was 42 months (range, 1 to 87 months). The mean number of biopsies performed per patient was 15.5 (range, 2 to 27). The mean severity of tricuspid regurgitation by echocardiography was grade 3 (moderate); seven patients (33%) had severe regurgitation. The mean right atrial v wave by catheterization was 15 mm Hg (range, 6 to 26 mm Hg).(ABSTRACT TRUNCATED AT 250 WORDS)

Relation between procedural activated coagulation time and outcome after percutaneous transluminal coronary angioplasty.

OBJECTIVES: The purpose of this study was to determine whether a low procedural activated coagulation time is associated with a high rate of in-hospital complications and to identify whether there is an activated coagulation time range that may be associated with a low rate of complications. BACKGROUND: In recent years the activated coagulation time has come into widespread use for monitoring anticoagulation in the catheterization laboratory. However, considerable controversy exists as to the standards by which to judge "adequate" anticoagulation for interventional procedures. METHODS: From a total of 1,469 consecutive patients with percutaneous transluminal coronary angioplasty, we retrospectively identified 103 (Group I, 7% of the overall population) with major complications of death or emergency or urgent coronary artery bypass graft surgery and compared them with 400 patients without complications (Group II). Group I patients had more high risk clinical characteristics, such as type B and C lesions, class III and IV angina, recent myocardial infarction and recent thrombolytic treatment. Activated coagulation times were compared between Groups I and II at baseline, after administration of 10,000 U of heparin and at the end of the procedure. RESULTS: There were no differences in baseline activated coagulation times between Groups I and II. Group I had significantly lower activated coagulation times after heparin therapy and at the end of the procedure: 61% < 250 s, 20% between 250 and 275 s, 11% between 275 and 300 s and 8% > 300 s; 279 of Group II had activated coagulation times 27% < 250 s, 17% between 250 and 275 s, 35% between 275 and 300 s and 21% > 300 s (p < 0.0001). Complications occurred in all patients with final activated coagulation times < 250 s but in only 0.3% of patients with final activated coagulation times > 300 s. CONCLUSIONS: A diminished activated coagulation time response to an initial bolus of heparin is associated with major in-hospital complications after coronary angioplasty, although patients with complications did have a higher risk before the procedure. It remains to be determined whether there is an ideal "target" activated coagulation time for interventional procedures.

Echocardiographic evaluation of anuloplasty rings. Comparison of continuity equation and pressure half-time methods.

This study was undertaken to compare pressure half-time and continuity equation methods in the postoperative evaluation of anuloplasty rings. We performed 2-dimensional echocardiography and Doppler studies in 39 patients who had undergone valve repair for mitral regurgitation. In patients with a pressure half-time of 110 msec or more (9/39), there was no significant difference in calculated valve area between the 2 methods (p = 0.696). A significant difference was shown between the 2 methods (p < 0.001) in patients with a half-time less than 110 msec (30/39). When patients were classified according to the type of ring they had received, no significant difference was noted between the 2 groups with regard to peak and mean mitral gradients. In patients placed in subgroups according to half-times of less than 110 msec and half-times of 110 msec or more, no difference was noted between groups in terms of mean mitral gradient, presence of mitral regurgitation, left atrial size, left ventricular function, or heart rate. The continuity equation appears to provide much more homogeneous results in the calculation of valve area in patients who have undergone valvular repair for mitral valve regurgitation.

Activated clotting times and activated partial thromboplastin times in patients undergoing coronary angioplasty who receive bolus doses of heparin.

The accurate assessment of coagulation status is an important part of interventional procedures performed in the cardiac catheterization laboratory. While the traditional clinical means of assessing heparin anticoagulation has been with the activated partial thromboplastin time (APTT), the activated coagulation time (ACT) has come into widespread use in the catheterization laboratory as an assay of whole blood clotting time which can be performed rapidly at the bedside. The purpose of the present study was to (1) assess the anticoagulant effect of a 10,000 U bolus of heparin in PTCA patients and (2) document the relationship between ACTs and APTTs in a subset of these patients. Baseline and postheparin ACTs were measured using a HemoTec coagulation timer in 545 unselected PTCA patients. The average baseline ACT was 120 +/- 22 sec. After a 10,000 U bolus of heparin the average ACT was 249 +/- 44 sec; 58% of patients had an ACT less than 250 sec, 17% had an ACT between 250 and 275 sec, 12% had an ACT between 275 and 300 sec, and 13% had an ACT greater than 300 sec. A total of 175 paired ACT and APTT measurements were obtained in a random subset of these patients at baseline, after heparinization, and at 4-6 hr intervals after the procedure. The APTT was limited by absolute upper and lower limits of 150 and 22 sec; there were no such limits on the ACT. When limiting values were excluded, there was a strong overall correlation between ACT and APTT measurements (r = 0.92, p less than 0.001).(ABSTRACT TRUNCATED AT 250 WORDS)

Prolapsing large aneurysm of the atrial septum simulating a right atrial mass.

An unusual case of a large, prolapsing atrial septal aneurysm in a patient with an otherwise normal heart is described. The aneurysm caused right atrial obstruction and resulted in a "tumor effect." The patient experienced debilitating symptoms for years before receiving an appropriate diagnosis and curative surgical treatment.

Balloon mitral valvuloplasty: clinical experience at the Texas Heart Institute.

For treatment of symptomatic mitral valve stenosis, balloon valvuloplasty has emerged as an alternative to surgery. This report describes our initial clinical experience with balloon mitral valvuloplasty in 45 patients (37 women and 8 men; age range, 34 to 79 years) treated from December 1986 through March 1991. Thirty-nine of the 45 patients (87%) underwent a complete procedure (that is, they had at least 1 balloon inflation and did not require emergency surgery). Pre- and post-procedural catheterization showed that these patients had a significant improvement in mean mitral valve area, from 1.0 +/- 0.3 cm(2) to 1.9+/-0.8 cm(2). Catheterization data revealed a decrease in transmitral gradient, from 16.3 +/- 7.6 mmHg to 7.6 +/- 3.7 mmHg, and an increase in cardiac index, from 2.5 +/- 0.7 L/min/m(2) to 2.9 +/- 0.8 L/min/m(2). These improvements were all statistically significant (p <0.0005). A clinically successful balloon mitral valvuloplasty was defined as an uncomplicated procedure yielding either a final mitral valve area > 1.5 cm(2) or a 40% increase in mitral valve area, and an immediate post-valvuloplasty mitral regurgitation grade 2+ increase in mitral regurgitation (4 patients). In 6 patients, the procedure was considered incomplete because of technical failure or complications. Two of these patients had nonfatal cardiac tamponade, and 1 had a torn mitral annulus that resulted in severe mitral regurgitation requiring emergent mitral valve replacement. In another patient, we were unable to cross the mitral valve with a 2nd valvuloplasty balloon after the 1st one proved unsatisfactory. There were 2 in-hospital deaths, only 1 of which was related to the procedure. Over time, our success rate has improved from 60% in the 1st 20 patients to 80% in the subsequent 25 patients, reflecting a learning curve. In particular, we attribute this improvement to increased operator experience, refinements in balloon technology, and, in more recent procedures, the initial use of smaller balloons. The improvement also reflects a change in demographic pattern, characterized by recent application of the procedure to younger patients with fewer concomitant illnesses. Because long-term follow-up data are available for only 23 patients, we cannot comment on the long-term efficacy of this technique. Overall, however, our short-term experience indicates that balloon mitral valvuloplasty is a safe, effective alternative for treating symptomatic mitral valve stenosis in carefully selected adults.

Left ventricular papillary fibroelastoma. An unusual cause of cerebral emboli.

We describe the case of a 63-year-old woman with a cardioembolic neurologic deficit secondary to papillary fibroelastoma, a rare intracardiac tumor. Diagnosis was made by use of 2-dimensional and transesophageal echocardiography. The tumor was surgically resected, and the patient had an uneventful recovery. In this report, we discuss the embolic potential of papillary fibroelastoma and the appropriate diagnostic and surgical approaches for patients with this rare disorder.

Recurrent left ventricular pseudoaneurysm: diagnosed by color-flow Doppler echocardiography.

The effects of left ventricular pseudoaneurysm following transmural myocardial infarction can be devastating; therefore, prompt diagnosis and surgical resection are warranted. We report a rare case of recurrent left ventricular pseudoaneurysm in which color-flow Doppler echocardiography was useful in establishing the diagnosis.

The probe, a balloon-on-the-wire: clinical experience with a new low-profile, fixed-wire balloon catheter system.

We reviewed the clinical records of the 1st 144 consecutive patients in whom the Probe trade mark, a balloon-on-the-wire, was used for percutaneous transluminal coronary angioplasty at the Texas Heart Institute. The goal of our retrospective study was to establish the efficacy and safety of this new balloon catheter. The Probe was used in 227 lesions, most of which were considered severe and difficult to pass. The Probe was the 1st catheter used in 160 lesions (70%), and in 67 lesions (30%) the Probe was used after other balloon catheters. In 70.9% (161/227) of lesions treated, the Probe reduced the stenosis to less than 50% of the luminal diameter. Of 144 patients treated, 116 (81%) had a successful result: 98 of these had adequate recanalization of all vessels treated, while 17 had adequate recanalization of the most significant vessels. A relatively high number of lesions (17 lesions, 7.5%) became totally occluded during the procedure. Eight patients (6%) required emergency surgery because of impending infarction. No hospital deaths occurred, and there were only 2 patients who suffered transmural myocardial infarction. Of the 160 Probe devices used, 23 (14%) malfunctioned: the balloon ruptured in 11 procedures; the balloon twisted, causing "balloon volvulus," in 5; the balloon failed to deflate in 4; and the tip detached in 3. The Probe has significant advantages over other balloon systems for treating severe coronary lesions because of its low profile, but it is also less reliable and safe. Our results show that the Probe should be used with great care, and only in treating lesions not amenable to treatment with removable-guidewire catheters.

Successful replacement of a fractured Björk-Shiley aortic valve prosthesis.

We report successful surgical intervention following the diagnosis of total aortic valvular incompetence which was caused by the uncommon fracture and disc embolization of a Björk-Shiley aortic valve prosthesis implanted ten months previously.

[Cardiac autonomic neuropathy in the diabetic patient]. / Neuropatía autonómica cardíaca en el paciente diabético.

The importance of cardiac autonomic neuropathy (CAN) derives from its remarkable frequency and its clinical impact. The clinical features are postural hypotension and resting tachycardia, these abnormalities may be overlooked in a high number of patients asymptomatic. Although rarely life threatening, CAN causes considerable morbidity, which can be ameliorated by its identification and appropriate treatment. Circulatory reflexes were studied in 48 diabetic patients and 14 normal control subjects. Twenty-six of the diabetic patients had normal response. The remaining 22 had evidence of neuropathy and abnormal cardiac response during these tests. Only one patient had postural syncope but he had severe orthostatic hypotension. The others remained asymptomatic. All the control subjects had normal reflexes. Beat-to-beat variation with deep breathing (sinus arrhythmia), carotid body massage and mental stress, were important for the detection of CAN (86, 90 and 90% sensitivity respectively). The Valsalva maneuver and sinus arrhythmia showed 82 and 92% of specificity for the diagnosis of CAN. Our findings suggest that CAN in diabetic patients can be detected by these relatively simple test. We propose a rational approach to the diagnosis. Our method is applicable as a clinical routine examination for cardiac neuropathy.

Alteraciones ecocardiograficas en el feocromocitoma. / Echocardiographic changes in pheocromocytoma

Se presentan 5 casos de pacientes con feocromocitoma, a los cuales se les practico ecocardiograma modo "M" antes y despues de cirugia. En 4 de ellos se encontraron datos ecocardiograficos que sugieron dano miocardico provocado por la accion de las catecolaminas, los cuales desaparecieron con la intervencion quirurgica