Probability of a return to work after either coronary balloon dilatation or coronary bypass surgery.

To examine whether coronary angioplasty has a different effect on work resumption than has coronary artery bypass surgery, we studied the work status of patients before and at least 1 year after either intervention. The population consisted of men aged less than 60 years, submitted to these procedures from September 1983 to July 1984. Of the 261 eligible patients, 219 (84%) participated, 94 after an angioplasty and 125 after a bypass procedure. 6 months preceding the intervention, 52% of the men were working. This had decreased to 47% at follow-up. Multiple logistic regression analysis showed that failure to resume work was correlated with bypass surgery vs balloon dilatation (rate ratio 1.8; 95% CI, 1.0-3.4), not working beforehand (rate ratio 6.5; 1.2-4.3), age greater than 55 years vs less than or equal to 50 years (rate ratio 2.6; 1.3-5.4) and with angina at follow-up (rate ratio 1.8; 1.0-3.3). Taking these additional risk factors into account permits a prediction of the probability of a return to work.

Disturbed liver function in heart transplantation candidates: two case reports.

Heart transplantation candidates frequently have a disturbed liver function. Two cases with jaundice are described in whom the cause and prognosis of the associated liver disease were analysed. In the 4-yr period during which heart transplantation patients with a disturbed liver function were investigated, "cirrose cardiaque" was not encountered; liver tests usually normalized after a successful heart transplant.

Can we assess the changes of ventricular filling resulting from acute allograft rejection with Doppler echocardiography?

We investigated the value of several Doppler echocardiographic measurements for the diagnosis of acute allograft rejection after orthotopic heart transplantation. In all, 144 transmitral flow velocity curves and 159 internal jugular venous flow velocity curves were recorded by continuous wave Doppler echocardiography, and the results were compared with the histologic findings. The recordings were evaluated with a computer-aided analysis system. The Doppler measurements did not show any significant correlation with the biopsy results. Only one recording obtained during a moderate acute rejection episode supported the hypothesis about the relation between jugular venous flow and cardiac rejection. We conclude that these Doppler echocardiographic measurements are not suitable to detect acute allograft rejection noninvasively.

Treatment with cyclosporin and risks of graft rejection in male kidney and heart transplant recipients with non-O blood.

In a consecutive series of 146 kidney transplant recipients treated with cyclosporin A a strong correlation between matching for the HLA-A, HLA-B, and HLA-DR loci specificities and outcome of the grafts was observed in male recipients with non-O blood groups. Such a beneficial effect of matching was not found in female patients or male patients with blood group O. In these patients survival of the grafts at one year was good irrespective of the number of HLA-A, B, and DR mismatches. Also in 47 male heart transplant recipients immune responsiveness against mismatched HLA antigens was related to blood group. A significantly higher incidence of rejection episodes was observed in male patients with non-O blood groups (n = 32) than in those with blood group O (n = 15). Matching for HLA-DR reduced the number of acute rejection episodes in male patients with non-O blood. These findings may help explain the controversial reports about the importance of HLA matching in organ transplantation. Furthermore, as most candidates for heart transplantation are male and not of blood group O, the higher incidence of graft rejection in these patients underscores the need for an exchange strategy of donor hearts.

Incidence, risk, and outcome of reintervention after aortocoronary bypass surgery.

Reintervention was required in 123 (12%) individuals during a follow up (mean 7.5 years, range 5-14.5) of 1041 patients with consecutive, isolated, first aortocoronary bypass operations. In 89 patients the intervention was a repeat bypass operation, in 24 it was angioplasty, and 10 had both. Procedure related mortality was significantly higher at reintervention (5.6%) than at the primary operation (1.2%). Survival probability after a single bypass procedure was 90% at six years and 82(3)% at nine years. Corresponding figures six and nine years after reintervention were 89(6)% and 87(7)% respectively. Stepwise multivariate analysis showed that survival was significantly correlated with left ventricular function (rate ratio 1.82) and with extent of vascular disease (rate ratio 1.80) but not with reintervention (rate ratio 1.45). Symptomatic improvement occurred in 89% of the survivors with or without reintervention. Repeat procedures are often necessary after coronary artery bypass grafting but they appear to provide appreciable relief of symptoms without reducing any long term improvement in survival brought about by the original operation.

Survival at 5 to 10 years after aorto-coronary bypass operations in 1041 consecutive patients.

To evaluate longterm survival, 1041 consecutive patients with aorto-coronary bypass operations were followed for a mean of 7.5 years (range 5 to 14.5). The peri-operative mortality was 12 (1.2%). Of the 131 late deaths, 97 (74%) were cardiac in origin. The survival probability at 5 years was 92 +/- 2% and at 10 years 79 +/- 4%. Figures for a matched general Dutch population are 94% and 87%, respectively. Stepwise multivariate analysis revealed an association between death rate and impaired left ventricular function (rate ratio impaired function versus normal: 1.82, P = 0.0007) and extent of vascular disease (rate ratio 3 vessel-versus 1 vessel disease: 1.80, P = 0.01) while no relation was found with sex or age at operation. Surgery seems to provide a good probability of survival, although in patients with extensive vascular involvement and/or a decreased left ventricular function at the time of operation, the longterm outlook is less favourable than for those without these characteristics.

Rational management following diagnosis of myocardial ischemia.

Assuming one knows that myocardial ischemia is present, rational management will first require a careful history to assess the severity of symptoms, such as angina, the lifestyle of the patient, his/her age, and the availability of resources. When a patient is greater than or equal to 70 years, has little angina, even the demonstration of ischemia will not require early arteriography; pharmacological therapy on a trial basis is the preferred approach. Judging the response to oral nitroglycerine, isosorbide dinitrate, beta blockers and calcium antagonists, (often combined and in modest doses) is good rational management. If symptoms persist despite therapy or when the patient is younger and has symptoms which cannot be alleviated by changes in lifestyle and/or workload, the established ischemia assumes much greater significance and nearly always requires a coronary arteriogram for proper management. Once the coronary arteriogram has been analyzed in terms of severity of flow impairment, correlation with the tests showing the extent of myocardial ischemia must be made, best during exercise. If single vessel disease is found with a local dyskinetic (echo, scintigraphy, or angio) segment, which corresponds to a stenosis of greater than or equal to 70%, particularly when found in the anterior descending artery, balloon dilatation (PTCA) or bypass surgery (CABG) should follow. When tests, such as the ECG, are obtained during an attack of angina, the Chahine classification may be used first. In Class IIa with pure ST-segment elevation significant atherosclerotic lesions are absent in most patients, while local spasm can be shown upon provocation. Here rational management can be limited to calcium antagonists sometimes combined with beta blockers.(ABSTRACT TRUNCATED AT 250 WORDS)

Revascularization as a means of reducing sudden death.

From this brief overview the arguments have become clear why further studies are needed to verify that the problem of unnecessary sudden cardiac death can best be tackled by a strategy aimed at early and complete revascularization. Whether such a strategy begins with intravenous injection of rt-PA at home or requires subsequent intracoronary manipulation when obstruction persists, whether by thrombolysis with other agents, PTCA or bypass surgery, is in itself a moot point. The main aim should be to offer this strategy as the best chance to reduce the unnecessary sudden death rate which presently accounts for between 25 and 50% of all cardiac deaths. This approach deserves consideration particularly since earlier approaches employing cardioprotective efforts by beta blockade or by anti arrhythmic agents have patently shown that they cannot tackle the problem in a convincing manner.

Prophylaxis of infective endocarditis for dental procedures. Report of a working party of the European Society of Cardiology.

Bacterial endocarditis still remains a serious disease with significant morbidity and mortality. In patients with known valve disease, most cases are caused by oral viridans streptococci. These organisms are present in vast numbers on the gum margins and in gum pockets. They cause transient bacteraemia during eating and tooth brushing. More substantial, but short-lived bacteraemia can occur during dental treatment such as extraction and scaling. Bacteria may then become attached to abnormal endocardium leading to the development of infective endocarditis. Prophylaxis of endocarditis during dental procedures in patients with known valve disease should thus be aimed at reducing the number of bacteria entering the blood stream and eliminating those that get there. This can be sought first by good oro-dental hygiene and secondly by the use of prophylactic antibiotics. In this paper, we set out simple guidelines for practitioners in those countries that do not already have recommendations of their own. They are based on guidelines already in use in the United Kingdom, France, Switzerland and the United States.

Aorto-coronary bypass surgery in 62 patients with severe left ventricular dysfunction--a follow-up study.

Long-term follow-up of 62 consecutive patients with severe left ventricular dysfunction (ejection fraction = less than 0.30) and disabling angina pectoris following aorto-coronary bypass surgery was investigated. Prior to surgery all patients had angina pectoris and a history of remote myocardial infarction, 35% were in congestive heart failure (CHF). Significant stenoses in 3 major coronary vessels were present in 51 patients (82%). An average of 3.5 grafts per patient were employed. Operative mortality (30 days) rate was 4.8% (3 patients) and 13 patients died during the following period. The average follow-up was 37 months (range: 6 to 116 months). At follow-up, the 5-year survival probability for these patients was 70% (SD = 9%). Thirty-one patients (67%) of the 46 survivors had complete relief of angina, but signs of CHF were still evident in 17 patients (36%). Compared to patients with ejection fractions above 0.30% (surgical mortality 1.4% and 5-year survival rate 94% (SD = 3%] the outcome of coronary artery bypass grafting in patients with poor left ventricular function showed a significantly higher surgical mortality (P = 0.03) and impaired long-term survival (P = 0.02). However, aorto-coronary bypass grafting can be performed in patients with severe left ventricular dysfunction with reasonable relief of angina and with an acceptable surgical mortality.

Survival in 1041 patients with consecutive aorto-coronary bypass operations.

The first 1041 patients who underwent an isolated aorto-coronary bypass operation in the same institution since it opened in 1971, were followed for up to 10 years to determine their prognosis. The mean follow-up time was 3.5 years. The probability of survival at five years was 94 +/- 2% (95% confidence limits). This was similar to the survival of the general Dutch population matched for age and sex. Multivariate survival analysis with the proportional hazards model did reveal a relationship of the rate of death with sex and age at operation; however this was not significant. There was a trend to a higher death rate with more vascular involvement (rate ratio of 3 vessel-versus 1 vessel disease of 1.9, N.S.) and a significant association with a low ejection fraction (EF) (ratio EF less than or equal to 0.30 v. EF greater than or equal to 0.55 of 2.7. P less than 0.05). Though surgery seems to eradicate the poor longterm outlook for patients with more serious vascular disease, the adverse influence of decreased left ventricular function on survival is not changed.

Angina pectoris, one to 10 years after aortocoronary bypass surgery.

The incidence of angina pectoris (AP) after bypass surgery was assessed in 1041 patients operated on consecutively between 1971 and 1980. Of the 977 survivors, 920 (94%) participated in the study with a followup time varying from 1 to 10 years (mean 3.5 years). Post-operative angina pectoris was present at 1 year in 277 patients (30%), at 3 years in 46%, at 8 years in 50%. The pain limited usual physical activities in 17.5%, 30% and 25%, respectively at these times. Nonetheless, 89% of the respondents felt improved by surgery. Factors without predictive value for late outcome were sex, number of pre-operative diseased vessels, and pre-operative ejection fraction. A correlation was found between post-operative AP and younger age at surgery in the males only (P less than 0.001); between AP and patency rate of the bypass graft (P less than 0.005) and with the status of the coronary arterial tree at three years post-operatively (P less than 0.001) in both sexes. The percentage of patients with recurrent AP increased with time after surgery up to 3 years, but remained stable thereafter. In conclusion, post-operative AP seems initially related to decreased functioning of the bypass graft, later to progression of coronary sclerosis in the native circulation.

Reoperation after aortocoronary bypass procedure. Results in 53 patients in a group of 1041 with consecutive first operations.

Of 1041 patients with consecutive aortocoronary bypass operations, 53 (5.1%) underwent reoperation during a mean follow-up time of three and a half years. The operative mortality of first operations was 1.2%, and of reoperations 3.8%. The anatomical reason for reoperation was failure of the bypass graft in 41 (77%) patients, which in 18 was accompanied by progression of disease. Progression alone was seen in seven (13%). When symptoms occurred within six months after the first operation, failure of the bypass graft(s) was nearly always found--in 32 out of 36 instances. Progression in non-bypassed arteries was seen only when symptoms occurred later. Late results in angina pectoris were less favourable in the group undergoing reoperation: 31 (65%) of the 48 operated on twice and 406 (46%) of the 877 patients operated on once still had angina at late follow-up. The same fraction in both groups was improved by operation: 88% versus 89%.