Aortic valve replacement with a pulmonary autograft: case studies of the Ross procedure.

The Ross procedure is an old surgical technique that is gaining popularity some 30 years after its introduction. The patient's own pulmonary valve is essentially used as a "spare part" to replace the diseased aortic valve. The Ross procedure has become an accepted and attractive option for patients with a life expectancy of more than 20 years and for patients in whom long-term treatment with anticoagulants is undesirable or problematic. Careful preoperative evaluation and postoperative management, as well as proficient surgical techniques, are all necessary to achieve good outcomes.

The importance of atrial contribution: a case study of dual-chamber pacing in hypertrophic obstructive cardiomyopathy.

Beta blockers and calcium channel blockers are the mainstay of therapy for hypertrophic obstructive cardiomyopathy. Recent evidence suggests that dual-chamber pacing may also relieve symptoms in a subset of patients. Proper interval programming is critical to the success of this intervention-as well as maintenance of the atrial contribution to preserve left ventricular diastolic filling. This report illustrates the importance of atrial contribution, as well as the loss of atrial capture, which can lead to hemodynamic deterioration and recurrence of symptoms.

The electrocardiogram predicts one-year outcome of patients with unstable angina and non-Q wave myocardial infarction: results of the TIMI III Registry ECG Ancillary Study. Thrombolysis in Myocardial Ischemia.

OBJECTIVES: We sought to determine the prognostic value of the admission electrocardiogram (ECG) in patients with unstable angina and non-Q wave myocardial infarction (MI). BACKGROUND: Although the ECG is the most widely used test for evaluating patients with unstable angina and non-Q wave MI, little prospective information is available on its value in predicting outcome in the current era of aggressive medical and interventional therapy. METHODS: ECGs with the qualifying episode of pain were analyzed in patients enrolled in the Thrombolysis in Myocardial Ischemia (TIMI) III Registry, a prospective study of patients admitted to the hospital with unstable angina or non-Q wave MI. RESULTS: New ST segment deviation > or = 1 mm was present in 14.3% of 1,416 enrolled patients, isolated T wave inversion in 21.9% and left bundle branch block (LBBB) in 9.0%. By 1-year follow-up, death or MI occurred in 11% of patients with > or = 1 mm ST segment deviation compared with 6.8% of patients with new, isolated T wave inversion and 8.2% of those with no ECG changes (p < 0.001 when comparing ST with no ST segment deviation). Two other high risk groups were identified: those with only 0.5-mm ST segment deviation and those with LBBB, whose rates of death or MI by 1 year were 16.3% and 22.9%, respectively. On multivariate analysis, ST segment deviation of either > or = 1 mm or > or = 0.5 mm remained independent predictors of death or MI by 1 year. CONCLUSIONS: The admission ECG is very useful in risk stratifying patients with non-Q wave MI. The new criteria of not only > or = 1-mm ST segment deviation but also > or = 0.5-mm ST segment deviation or LBBB identify high risk patients, whereas T wave inversion does not add to the clinical history in predicting outcome.

Circadian variation in the onset of unstable angina and non-Q-wave acute myocardial infarction (the TIMI III Registry and TIMI IIIB).

Circadian variation has been demonstrated in several types of acute cardiovascular disease, including acute myocardial infarction (AMI), sudden cardiac death, silent ambulatory ischemia, and thrombotic stroke. In contrast, no diurnal variation was observed in 1 study of non-Q-wave AMI, and limited data are available for unstable angina. To assess whether circadian variation is present in unstable angina and non-Q-wave AMI, we examined the time of onset of ischemic pain in 7,731 patients who were prospectively identified in the Thrombolysis in Myocardial Ischemia (TIMI) III Registry, 3,318 of whom were enrolled in the prospective study, and in 1,473 patients enrolled in the TIMI IIIB trial. A circadian variation in the onset of pain was observed, with an increase in the number of patients experiencing the onset of pain in the morning hours between 6 A.M. and 12 noon (p <0.001). This circadian variation was observed both in patients with unstable angina and in those with evolving non-Q-wave AMI. A similar circadian pattern was observed in all subgroups tested. These findings were confirmed in the TIMI IIIB trial and complement previous studies suggesting that circadian variation exists in the onset of the full spectrum of myocardial ischemic syndromes.

Cardiac-specific troponin I levels to predict the risk of mortality in patients with acute coronary syndromes.

BACKGROUND: In patients with acute coronary syndromes, it is desirable to identify a sensitive serum marker that is closely related to the degree of myocardial damage, provides prognostic information, and can be measured rapidly. We studied the prognostic value of cardiac troponin I levels in patients with unstable angina or non-Q-wave myocardial infarction. METHODS: In a multicenter study, blood specimens from 1404 symptomatic patients were analyzed for cardiac troponin I, a serum marker not detected in the blood of healthy persons. The relation between mortality at 42 days and the level of cardiac troponin I in the specimen obtained on enrollment was determined both before and after adjustment for baseline characteristics. RESULTS: The mortality rate at 42 days was significantly higher in the 573 patients with cardiac troponin I levels of at least 0.4 ng per milliliter (21 deaths, or 3.7 percent) than in the 831 patients with cardiac troponin I levels below 0.4 ng per milliliter (8 deaths, or 1.0 percent; P < 0.001). There were statistically significant increases in mortality with increasing levels of cardiac troponin I (P < 0.001). Each increase of 1 ng per milliliter in the cardiac troponin I level was associated with a significant increase (P = 0.03) in the risk ratio for death after adjustment for the base-line characteristics that were independently predictive of mortality (ST-segment depression and age > or = 65 years). CONCLUSIONS: In patients with acute coronary syndromes, cardiac troponin I levels provide useful prognostic information and permit the early identification of patients with an increased risk of death.

Influence of race, sex, and age on management of unstable angina and non-Q-wave myocardial infarction: The TIMI III registry.

OBJECTIVE: To investigate the natural history and response to treatment of patients with unstable angina or non-Q-wave myocardial infarction (MI). DESIGN: Inception cohort. SETTING: Patients in general community, primary care, or referral hospitals. PATIENTS: All patients with an episode of unstable exertional chest pain or chest pain at rest presumed to be ischemic in origin lasting 5 minutes or more but without persisting ST-segment elevation greater than 30 minutes or the development of Q-waves were identified and enumerated in 18 participating hospitals. A subset of enumerated patients was selected to be followed prospectively using specific sampling strategies that would provide adequate numbers of black, women, and elderly (aged > or = 75 years) patients for comparison with their respective counterparts. MAIN OUTCOME MEASURES: The primary analysis compared the incidence of death or MI at 42 days after entry into the prospective study according to race, sex, and age. Other outcomes considered were recurrent ischemia and the combined outcomes of death, MI, or recurrent ischemia by 42 days after entry. RESULTS: A total of 8676 admissions with unstable angina or non-Q-wave MI were enumerated and, of these, 3318 patients were selected for the prospective study. The direct adjusted mean age of 3318 patients was 63.8 years. There were 943 blacks and 2375 nonblacks. Compared with nonblacks, blacks were less likely to be treated with intensive anti-ischemic therapy for their qualifying anginal episode and less likely to undergo invasive procedures (risk ratio [RR], 0.65%; 95% confidence interval [CI], 0.58 to 0.72; P<.001). However, of those who underwent angiography (45% of blacks and 61% of nonblacks), blacks had less extensive and severe coronary stenoses than nonblacks. The incidence of death and MI was similar for blacks and nonblacks, but blacks had a lower incidence of recurrent ischemia. There were 1678 men and 1640 women. Women were less likely than men to receive intensive anti-ischemic therapy and less likely to undergo coronary angiography (RR, 0.71; 95% CI, 0.65 to 0.78; P<.001). Women had less severe and extensive coronary disease and were less likely to undergo revascularization, yet had a similar risk of experiencing an adverse cardiac event by 6 weeks. There were 2490 patients aged 75 years or less and 828 patients aged more than 75 years. Elderly patients received less aggressive anti-ischemic therapy and were less likely to undergo coronary angiography than their younger counterparts. Elderly patients had more severe and extensive coronary disease but fewer revascularization procedures than younger patients and experienced a much higher incidence of adverse cardiac events both in hospital and by 6 weeks. CONCLUSIONS: Among patients presenting with acute ischemic chest pain without persistent ST-segment elevation, blacks appeared to have less severe coronary disease, received revascularization less frequently, and had less recurrent ischemia compared with nonblacks. Women were also found to have less severe coronary disease and were treated less intensely than men, but experienced similar outcomes. Elderly patients had more severe coronary disease than younger patients on coronary angiography, but were more likely to be treated medically, and they experienced far more adverse outcomes. These data suggest that more aggressive strategies should be directed to those patients with the greatest likelihood of adverse outcomes.

Patterns in Maryland Medicaid enrollment among persons with AIDS.

The percentage of persons with AIDS (PWAs) enrolling in Medicaid is increasing by 3.7% annually. This paper examines the trends in Medicaid enrollment among PWAs and uses a Markov model to analyze the patterns in Medicaid eligibility as enrollees move between assistance categories. We found most Medicaid-eligible PWAs were Medicaid recipients prior to their AIDS diagnosis and differed significantly from non-Medicaid PWAs. The PWAs shifted considerably among the various Medicaid eligibility categories and we found distinct, predictable patterns among different subpopulations. A high percentage of PWAs were enrolled in a state-funded category, which is detrimental to both the PWAs and the state.

Chylopericardium following aortic valve replacement and coronary artery bypass surgery: a case report and discussion.

The incidence of chylopericardium after cardiac surgery is unusual, but there are documented cases. Those caring for these patients need to be aware of the symptoms and management of chylopericardium because, if left untreated, it may cause catastrophic consequences.

Rhythm disturbances in the patient with pulmonary disease.

Many factors contribute to cardiac dysrhythmias in patients with pulmonary disease. The treatments themselves, as well as the clinical state of hypoxemia, can produce rhythm disturbances. A thorough understanding and awareness of the causes and treatments of the dysrhythmias of this patient population will guide the nurse in the delivery of care.

Signal-averaged electrocardiography: a new technique for determining which patients may be at risk for sudden cardiac death.

Signal-averaged electrocardiography is a useful diagnostic tool and screening test for those patients at risk for the development of VT. It is also useful in the evaluation of the patient after MI and the patient with unexplained syncope. The prognostic value of the signal-averaged ECG process is gaining popularity. More investigation is needed, especially in the areas of technique and significance of abnormalities, before the signal-averaged ECG becomes a routine test in diagnosing dysrhythmias. The signal-averaged ECG provides the health care team with a new, non-invasive test. Knowledge of its use and application can provide the clinician with additional information that can aid in the screening process for patients at risk for sudden cardiac death.