Partial left ventriculectomy: the 2nd International Registry Report 2000.

BACKGROUND: Partial left ventriculectomy (PLV) has been performed without standardized inclusion or exclusion criteria. METHODS: An international registry of PLV was expanded, updated, and refined to include 287 nonischemic cases voluntarily reported from 48 hospitals in 11 countries. RESULTS: Gender, age, ventricular dimension, etiology, ethnology, myocardial mass, operative variation, presence or absence of mitral regurgitation, and transplant indication had no effects on event-free survival, which was defined as absence of death or ventricular failure that required a ventricular assist device or listing for transplantation. Preoperative patient conditions, such as duration of symptoms (> 9 vs < 3 years; p = 0.001), New York Heart Association (NYHA) class (Class IV vs < Class IV; p = 0.002), depressed contractility (fractional shortening [FS] < 5% vs > 12%; p = 0.001), and refractory decompensation that required emergency procedure (p < 0.001) were associated with reduced event-free survival. Five or more cases in each hospital led to significantly better outcomes than the initial four cases. Rescue procedures for 14 patients nonsignificantly improved patient survival (2-year survival 52%) over event-free survival (2-year survival 48%; p = 0.49), with improved NYHA class among survivors (3.6 to 1.8; p < 0.001). Outcome was better in 1999 than in all series before 1999 (p = 0.02) most likely due to patient selection, which was refined to avoid known risk factors such as reduced proportion of patients in NYHA Class IV, FS < 5%, and hospitals with experience in 10 or less cases. A combination of these risk factors could have stratified 17 high-risk patients with 0% 1-year survival and 26 low-risk patients with 75% 2-year event-free survival. CONCLUSION: Avoidance of risk factors appears to improve survival and might help stratify high- or low-risk patients. Although less symptomatic patients with preserved contractility had better results after PLV, change of indication requires prospective randomized comparison with medical therapies or other approaches.

Partial left ventriculectomy: history, current status, and future role.

Whereas discouraging clinical results and lack of scientific evidence decreased the initial interest in partial left ventriculectomy (PLV), factors contributing to success and failure have now been identified by clinical observations, theoretical analyses, and data from an international registry, which are herein reviewed to outline the current status and future role of this procedure as a treatment of heart failure.

Partial left ventriculectomy in children and adolescents.

Theoretical aspects, pediatric indications and initial results of a new operation, partial left ventriculectomy, are presented.

Congenital heart disease in the adult.

With improved medical and surgical care, more patients with congenital heart disease are now surviving to adulthood and presenting with previously unobserved problems. This review discusses the course of older operated and unoperated patients as far as physical and psychosocial problems and suggests methods of dealing with these previously unencountered clinical situations.

Normal thymus simulating pericardial disease: diagnostic value of magnetic resonance imaging.

Normal enlargement of the thymus in infancy can often lead to erroneous clinical suspicion of cardiomegaly. Roentgenographic differentiation is not always definitive but echocardiography is generally effective in differentiating cardiac pathology from an enlarged thymus. In this patient, magnetic resonance imaging was necessary to differentiate benign thymic hyperplasia from pericardial or mediastinal pathology. Thymic involution with a severe neonatal illness, followed by thymic rebound, which later subsided, added to the interest and initial confusion in this patient.

Two-dimensional echo-cardiographic estimation of left atrial volume and volume load in patients with congenital heart disease.

To estimate the left atrial volume (LAV) and pulmonary blood flow in patients with congenital heart disease (CHD), we employed two-dimensional echocardiography (TDE). The LAV was measured in dimensions other than those obtained in conventional M-mode echocardiography (M-mode echo). Mathematical and geometrical models for LAV calculation using the standard long-axis, short-axis and apical four-chamber planes were devised and found to be reliable in a preliminary study using porcine heart preparations, although length (10%), area (20%) and volume (38%) were significantly and consistently underestimated with echocardiography. Those models were then applied and correlated with angiocardiograms (ACG) in 25 consecutive patients with suspected CHD. In terms of the estimation of the absolute LAV, accuracy seemed commensurate with the number of the dimensions measured. The correlation between data obtained by TDE and ACG varied with changing hemodynamics such as cardiac cycle, absolute LAV and presence or absence of volume load. The left atrium was found to become spherical and progressively underestimated with TDE at ventricular endsystole, in larger LAV and with increased volume load. Since this tendency became less pronounced in measuring additional dimensions, reliable estimation of the absolute LAV and volume load was possible when 2 or 3 dimensions were measured. Among those calculation models depending on 2 or 3 dimensional measurements, there was only a small difference in terms of accuracy and predictability, although algorithm used varied from one model to another. This suggests that accurate cross-sectional area measurement is critically important for volume estimation rather than any particular algorithm involved. Cross-sectional area measurement by TDE integrated into a three dimensional equivalent allowed a reliable estimate of the LAV or volume load in a variety of hemodynamic situations where M-mode echo was not reliable.

Infective endocarditis: a review. I. Incidence, etiology, pathology and clinical features.

In this paper demographic characteristics, etiology, pathology and clinical features of infective endocarditis are reviewed simultaneous presentation of the data from our series of 50 cases with infective endocarditis. The peak incidence of infective endocarditis is between 11 and 15 years. Both sexes are equally affected. Patients with congenital or acquired heart disease tend to have hemodynamic trauma to the endocardium and vascular endothelium. These sites form the nidus for circulating bacteria of either spontaneous origin or the result of any oro-dental, genitourinary or other surgery or procedures and produce vegetations characteristic of infective endocarditis. The location of the vegetation is dependent upon the predisposing cardiac lesion. Embolic phenomenon is another cardinal feature of endocarditis and may occur in any organ system. Although a large variety of microbes have been known to cause endocarditis, streptococci and staphylococci remain the most frequent offenders. Clinical diagnosis of infective endocarditis is difficult because of the insidious onset and varied clinical features. A high degree of suspicion is essential for early diagnosis. Any patient with known heart disease and unexplained fever should be suspect for endocarditis. Splenomegaly, petechiae and embolic phenomena support this diagnosis. New or changing murmurs, splinter hemorrhages, Osler's nodes. Janeway's lesions and Roth's spots may be present. Elevated sedimentation rate, microscopic hematuria, leukocytosis with a shift-to-the-left and anemia may further support the diagnosis. Congenital or acquired heart disease and fever are all that will be present in many cases. Only isolation of the causative agent from the blood can confirm the diagnosis.

Infective endocarditis: a review. II. Diagnosis and treatment.

Early diagnosis of infective endocarditis is difficult because of the insidious onset and varied clinical presentation. High degree of suspicion and blood culturing for the causative agent are essential to confirm the diagnosis. General principles of management include selection of antibiotics based on the antibiotic sensitivities of the causative organism, use of bactericidal rather than bacteriostatic drugs, usage of a combination of two or more antibiotics to enhance the synergic bactericidal activity, and their administration by the intravenous route for prolonged periods (6 weeks). Monitoring the serum bactericidal activity to confirm the biological effectiveness of the antibiotics used and adjusting the level of 1:8 to 1:16 is recommended. Specific drug therapy for each type of endocarditis is discussed. Supportive measures and indications for surgical intervention are also discussed. A summary of preventive aspects of infective endocarditis is also presented.