Predictors for biventricular repair in pulmonary atresia with intact ventricular septum.

BACKGROUND: Pulmonary atresia with intact ventricular septum (PA-IVS) is a complex congenital heart defect with a large variety of right heart-sided morphologies. METHODS: We undertook a retrospective review of 86 patients with PA-IVS with a special emphasis on the angiographic findings. The aim of the study was to determine predictors for biventricular repair. Initial surgical procedures depended on the right ventricular morphology, the tricuspid valve size and coronary anomalies. RESULTS: Fifty-five patients (64%) underwent decompression of the right ventricle (RV) as an initial procedure; 16 of them required an additional systemic-to-pulmonary artery shunt. Twenty-six patients (30%) had only a systemic-to-pulmonary artery shunt as their initial procedure. Five patients underwent interventional procedures performed by pediatric cardiologists. Biventricular repair was possible in 56 patients (65%). Univentricular palliation was achieved in 16 patients. Fourteen patients had only palliation with a systemic-to-pulmonary artery shunt. Mean tricuspid valve size was significantly bigger in patients with biventricular repair (z-score -3.6 +/- 2.6) than in patients who did not undergo biventricular repair (-5.2 +/- 1.7, P = 0.003). Predictors for biventricular repair were right ventricular decompression with or without systemic-to-pulmonary artery shunt ( P < 0.001), tripartite right ventricle ( P < 0.001) and the absence of coronary fistulae ( P < 0.001). Long-term survival was 80% +/- 13% at 25 years for patients undergoing biventricular repair. CONCLUSIONS: Decompression of the RV as an initial surgical procedure improves the possibility of achieving biventricular repair with good long-term results. However, morphological factors such as right ventricular size and the absence of coronary fistulae are significant predictors for biventricular repair.

Outcome after surgical repair/palliation of congenitally corrected transposition of the great arteries.

BACKGROUND: The surgical concepts for patients with congenitally corrected transposition of the great arteries (CCTGA) address discordant connections and associated lesions. The outcomes after biventricular repair without correction of discordant connections ("classic repair", or with its correction "anatomic repair") and after "univentricular palliation" were investigated. METHODS: All patients with CCTGA who underwent "classic repair" (n = 39), "anatomic repair" (n = 6), or "univentricular palliation" (n = 11) between 1978 and 2006 were analyzed. The most frequently associated lesions were ventricular septal defect (n = 48), tricuspid insufficiency (TI) (n = 20) and functionally single ventricle (n = 11). RESULTS: Thirty-day mortality was 4 % (2/56). Mean follow-up for early survivors was 7.2 +/- 7.1 years. Eight patients died late, two after heart transplantation. Survival was not significantly different between patients who underwent "anatomic" or "classic repair", or "univentricular palliation": 83.3 +/- 15.2 %, 79.7 +/- 6.9 %, 90.9 +/- 8.7 % at 10 years, respectively. In multivariate analysis, the presence of TI emerged as the only risk factor for late death ( P = 0.004). Twenty patients required reoperation, mainly for TI (n = 10) and conduit failure (n = 6). Freedom from reoperation was lower after "anatomic repair", but ventricular function was better and atrioventricular valves were more competent than after "classic repair". CONCLUSIONS: Biventricular "anatomic" or "classic repair" and "univentricular palliation" yield equivalent survival rates in the mid-term. Biventricular "anatomic repair", when feasible, should be promoted because of its better long-term outcome.

How well are patients doing up to 30 years after a mustard operation?

BACKGROUND: Right heart failure and baffle complications may affect the health status of patients with transposition of the great arteries after an atrial switch operation. METHODS: This study aims to identify risk factors for late death, the incidence of reoperations, and the functional status of 88 patients who underwent a Mustard operation with a mean follow-up of 20.9 +/- 10.0 years. RESULTS: There were 7 early and 19 late deaths. Follow-up was complete for 97 % of the hospital survivors. Survival and freedom from reoperation of the hospital survivors at 20 years was 83.7 +/- 4.2 %, and 70.6 +/- 5.4 %, respectively. Seven reoperations were performed for systemic ventricular failure, and 24 for baffle complications, with no operative mortality. Presence of a ventricular septal defect at the time of the Mustard operation was predictive for late death in multivariate analysis ( P = 0.040). At follow-up, 82 % of the patients were able to work full-time, 11 % part-time, and 7 % experienced noticeable limitations of their activities. CONCLUSIONS: Presence of a VSD at the time of the Mustard operation defines a distinct subgroup with an increased risk for late death. Long-term survivors were in a good functional status but had to be reoperated frequently due to baffle complications that seemed to increase in adulthood.

Surgical closure of atrial septal defect in patients older than 30 years: risk factors for late death from arrhythmia or heart failure.

BACKGROUND: Little is known about prognostic markers for late cardiac-related death after surgical atrial septal defect (ASD) closure in adults. METHODS: Long-term follow-up data of 281 patients who underwent surgical secundum ASD closure when they were older than 30 years, were retrospectively examined. RESULTS: Mean age at surgery was 43.8 +/- 10.0 years (30 to 76 years). There were 2 early deaths. Mean follow-up was 14.1 +/- 8.4 years (0.4 to 28.9 years). Death from arrhythmia or heart failure occurred in 9 patients (3.6 %) at a mean time of 8.5 +/- 6.6 years after the operation. Patients > 43 years exhibited significantly higher pulmonary artery pressures. Preoperative systolic pulmonary artery pressure > 36 mmHg, and mean pulmonary artery pressure > 21 mmHg were predictive of late death from arrhythmia or heart failure. However, age at operation was not. CONCLUSIONS: Older age at the time of ASD closure is not a risk factor for late death from arrhythmia or heart failure in adults. However, older patients presented more often with pulmonary hypertension. Since elevated pulmonary artery pressure is predictive of late death from arrhythmia or heart failure, timely ASD closure is warranted.

[Recurrent hemoptysis as initial symptom of a thoracic angiomatosis in an adult patient]. / Rezidivierende Hämoptysen als Erstsymptom einer thorakalen Angiomatose beim Erwachsenen.

HISTORY: A 24-year-old man presented with recurrent hemoptysis and decreased exercise capacity. DIAGNOSTIC FINDINGS: The chest radiograph demonstrated multiple disseminated pulmonary nodules. In addition the patient developed a hematopericardium with tamponade. The further diagnostic approach revealed an extensive thoracic angiomatosis affecting the lung and the heart. TREATMENT AND COURSE: Tumor resection could not be performed. A therapy with Interferon alpha-2a was initiated. After 3 month a significant regression of the pulmonary angiomatosis was documented. On the other hand the cardiac tumor showed no therapeutic response. CONCLUSION: Thoracic angiomatosis should be considered in the differential diagnosis of otherwise unclear hemoptysis or hematopericardium. Diagnosis intra vitamin requires an aggressive and invasive approach. Interferon alpha-2a is effective in palliative treatment of diffuse angiomatous diseases. But not all angiomatous processes respond to that therapy.

Fulminate intracardiac thrombosis associated with Budd-Chiari-syndrome and inferior vena cava thrombosis.

The most common cause of edema of the legs and dyspnea is congestive heart failure. Further differential diagnosis such as renal or hepatic failure have to be considered. We report the case of a previous healthy 65-year-old woman who developed dyspnea and massive edema of the legs followed by acute hepatic and renal failure. Imaging studies showed a thrombosis of the inferior vena cava (IVC) caused by a tumor between the right kidney and the IVC. Histological examination revealed a leiomyosarcoma of the IVC. Hepatic failure due to venous outflow obstruction (Budd-Chiari syndrome, BCS) was diagnosed. Coagulation profile showed a complex disorder due to acute hepatic failure. Factor V Leiden and prothrombin gene mutation G20210A could be excluded. The thrombosis extended from the femoral veins up to the right atrium. After 11 days of anticoagulation with heparin platelet counts decreased by more than 50%. Suspecting a heparin-induced thrombocytopenia the patient was placed on recombinant hirudin (lepirudin) for anticoagulation. Hepatic venogram showed a thrombosis of the hepatic vein orifices but not of the hepatic veins. The tumor and the thrombi were removed surgically. When the cardiopulmonary bypass was terminated new intracardiac thrombi occurred. Despite immediate surgical intervention the patient finally died due to right ventricular failure caused by the fulminate intracardiac thrombosis. In conclusion, thrombosis of the IVC may mimic congestive heart failure and may cause BCS. Neoplasms and coagulation disorders may cause thrombosis of the IVC.

Results of biventricular repair of congenital cardiac malformations: definitive corrective surgery?

OBJECTIVES: Congenital cardiac malformations are usually corrected in the neonatal period or in early infancy. Corrective surgery may not always be definitive, especially in complex malformations. Long-term morbidity is influenced by reoperations and their risk. METHODS: This study analyzes our single-center experience over more than 20 years in a selected group of patients. Data were gathered, with special focus on causes and incidence for reoperations, respectively. RESULTS: Freedom from reoperation after 5, 10, and 15 years for each cardiac malformation was determined. The numbers describe in the following order patient years (y), number of patients (n), and freedom from reoperation at follow-up interval (%), respectively: atrial septal defect (15,864y, n=1198, 99+/-0/99+/-0/99+/-0), partial atrioventricular septal defect (2506y, n=234, 95+/-2/93+/-2/93+/-2), total anomalous pulmonary venous connection (742y, n=141, 93+/-1/91+/-0/91+/-0), complete atrioventricular septal defect (1715y, n=377, 81+/-3/76+/-3/72+/-4), tetralogy of Fallot <1 year (1503y, n=197, 94+/-4/85+/-1/74+/-3), transposition of great arteries (1459y, n=375, 88+/-2/83+/-4/73+/-7), interrupted aortic arch (IAA) (481y, n=98, 63+/-6/52+/-7/45+/-8), common arterial trunk (CAT) (599y, n=109, 64+/-6/24+/-6/11+/-5). CONCLUSIONS: In most congenital malformations surgical correction is definitive and the rate of reoperations is low. In complex anomalies, such as CAT and IAA, reoperations at long-term are more common. Analysis of such results and recognition of a sometimes inevitable operative morbidity helps to predict long-term outcome and influences the follow-up.

Performance of allografts and xenografts for right ventricular outflow tract reconstruction.

BACKGROUND: We compared the long-term durability of allografts and xenografts implanted for reconstruction of the right ventricular outflow tract. METHODS: A total of 401 patients were studied from January 1974 to June 2000 (145 xeno- and 256 allografts), follow-up being 98% complete. We analyzed freedom from reoperation and allograft specific factors that may indicate degeneration. RESULTS: The age at implantation was 2 days to 31 years (median 4.0 years). Conduit exchange rate was similar (p = 0.2) for conduit diameters less than 15 mm (41%+/-9% for allografts, 30%+/-6% for xenografts), but significantly different (p = 0.02) for diameters of 15 mm or larger (60%+/-8% for allografts, 30%+/-10% for xenografts). Diagnosis-related 20-year survival analysis showed a significantly (p = 0.01) better survival of patients with tetralogy of Fallot/pulmonary atresia (83%+/-5%) and Rastelli-type surgery (81%+/-8%) compared with patients with truncus arteriosus communis (69%+/-8%). ABO-compatibility, preservation method, and aortic or pulmonary allograft could not be identified as risk factors for allograft longevity. CONCLUSIONS: For smaller diameters (less than 15 mm), allografts exhibit no advantage over xenografts, whereas in larger diameters (15 mm or larger) allografts are the conduit of choice for the right ventricular outflow tract.

[Acute thrombosis of a mechanical heart valve caused by inadequate anticoagulation with low molecular weight heparin]. / Akute Thrombose einer mechanischen Herzklappe durch inadäquate Antikoagulation mit niedermolekularem Heparin.

CASE REPORT: A 55-year-old woman with a mechanical aortic prosthesis was admitted with pulmonary edema and suspect of valvular malfunction. The patient had a anticoagulation therapy at the time with low-molecular-weight heparin only. Echocardiography confirmed a failing mobility of a prosthetic valve leaflet. Emergency aortic valve replacement was performed. CONCLUSION: According to international approved guidelines an adequate anticoagulation after mechanical prosthetic heart valve replacement is provided either by oral anticoagulants, or, in the case of pregnancy or surgical procedures, by unfractioned heparins. The use of low-molecular-weight heparin as sole anticoagulant remains a matter of controversy in the literature. In recent years low-molecular-weight heparins were mainly administered for prevention and treatment of deep vein thrombosis, pulmonary embolism, stroke, and instable angina.

Time course and extent of improvement of dysfunctioning myocardium in patients with coronary artery disease and severely depressed left ventricular function after revascularization: correlation with positron emission tomographic findings.

OBJECTIVES: This study was performed to evaluate the prevalence, time course of recovery and extent of improvement of segments with a positron emission tomographic (PET) flow-metabolism mismatch and match pattern, as well as of PET segments with normal perfusion but with impaired myocardial function. BACKGROUND: Previous studies have shown that scintigraphic techniques evaluating myocardial viability provide predictive information about the improvement of regional wall motion. However, there are little data concerning the time course and extent of improvement of segments according to preoperative scintigraphic patterns. METHODS: Twenty-nine patients with ischemic cardiomyopathy (ejection fraction 18% to 35%) underwent preoperative PET viability assessment and were functionally assessed by two-dimensional echocardiography preoperatively and at 11 days, 14 weeks and >12 months after coronary artery bypass graft surgery. RESULTS: In 168 (70%) of 240 dysfunctional segments, a "normal" scintigraphic pattern was present, whereas a "mismatch" pattern was observed in 24% (p<0.01). Mismatch areas were associated with more severe preoperative wall motion abnormalities and incomplete postoperative recovery. After one year, 31% of normal scintigraphic segments, compared with only 18% of mismatch segments, showed complete functional restoration (p<0.05). CONCLUSIONS: These data suggest that in patients with severe left ventricular dysfunction, a scintigraphic pattern of normal perfusion and normal metabolism is more prevalent than a flow-metabolism mismatch pattern. Functional recovery is more frequent in normal scintigraphic segments, whereas in mismatch segments, postoperative recovery remains incomplete even after one year.

Reconstruction of the RVOT with valved biological conduits: 25 years experience with allografts and xenografts.

OBJECTIVE: The reconstruction of the RVOT in congenital heart disease often requires the implantation of a valved conduit. Although allografts are considered the conduit of choice their availability is limited and therefore xenografts are implanted as well. We compared the long-term durability of both grafts in the RVOT over a 25-year period. METHODS: Between January 1974 and August 1999, 505 patients (median age 4.0 years, range 2 days-31 years; median weight 14.5 kg, range 2.2-76.6 kg; median body length 103 cm, range 48-183 cm) with congenital malformations (PA 25.3%, TOF 14.5%, TOF+PA 2.4%, DORV 4.2%, TGA+PS 8.7%, TAC 24.8%, and other 20.2%) received their first valved conduit (174 xenografts: median diameter 14 mm, range 8-27 mm; 331 allografts: median diameter 19 mm, range 8-30 mm). RESULTS: Follow-up is 3017 patient-years. The 10-year survival-probability for all patients. was 66% with a mean reoperation-free interval for conduit-exchange of 13.3 years (mean reoperation-free interval for allografts, 16.0 years; mean reoperation-free interval for xenograft, 10.3 years). One hundred and thirteen patients underwent a conduit-exchange, mostly due to conduit stenosis. Fourteen patients had a second exchange and three patients a third exchange. For patients with conduit diameters <18 mm (n=235: allograft n=116, xenograft n=119; median age 9 months, range 0-27.3 years), the mean reoperation-free interval was 11.2 years (mean interval allograft, 13.1 years; mean interval xenograft, 8.6 years, P=0.03). For conduit diameters >/=18 mm (n=270: allograft n=215, xenograft n=55, median age 7.4 years, range 0-34.3 years) the mean interval from freedom of conduit exchange was 15.1 years (for allografts 14.1 years, for xenografts 12.5 years, P<0.01). Comparing xenografts to allografts, we found no difference in patient survival probability (P=0.62). There was no significant difference between antibiotic (n=198) preserved vs. cryopreserved (n=133) allografts (P=0.06). Blood group compatibility of allografts to recipients had no significant influence on allograft function (P=0.42). The donors allograft origin, whether aortic or pulmonary valve, had also no significant influence on allograft long-term function (P=0.15). CONCLUSION: For the reconstruction of the right ventricular outflow tract (RVOT) allografts show significantly better long-term durability than xenografts regardless of the age at implantation and the diameter.

Technical refinements in myocardial protection: infants--adults.

The aim of intraoperative protection is to prevent damage to function and structure of the myocardium. None of the methods employed today can guarantee this, on the other hand the result of any surgical intervention has to be regarded as a multifactorial process, myocardial function in particular depending on e.g. the preoperative state, the mode of protection, temperature of the patient, collateral flow, unloading of the left ventricle, and other factors during ischemic arrest. Daily use of cardioplegic solutions requires standardized procedures keeping it safe and simple. Thus we use in adults 1000ml of 2 degrees Bretschneider solution infusing it at rate of 80 - 120ml/min 8-10 minutes; in infants and children 40ml/kg as a single infusion are administered. The temperatures of the patients are various. As a result of myocardial protection, in the follow-up, besides survival, myocardial function should be a decisive parameter. Of particular interest are the results in patients with preoperatively reduced myocardial function and the effect of myocardial protection techniques. In addition, examples of long-term survivors after congenital operations will be discussed in accordance to the cardioplegic regimen used. Recent work has shown that reperfusion may aggravate the damage imposed on the heart during ischemia. An additional inflammatory reaction is observed which may compromise function. There is evidence that, under experimental and clinical conditions, the donation of nitric oxide may limit the amount of postischemic cardiac inflammation. Simple, safe, and reproducible myocardial protection together with careful, sophisticated, and perfect operative technique are the main requirements for successful cardiac surgery.

Long-term results after repair of complete atrioventricular septal defects: analysis of risk factors.

BACKGROUND: We analyzed data from 320 patients to evaluate the impact of different preoperative, operative, and postoperative factors on the outcome after repair of complete atrioventricular septal defect. METHODS: Between October 1974 and December 1995, 320 patients with complete atrioventricular septal defect not associated with major cardiac anomalies were operated on. Two hundred seventy-four patients underwent total repair. Sixty-three patients (23%) were less than 6 months old. One hundred ninety-eight (72.2%) underwent primary repair. Seventy-six patients (27.7%) had a previous palliative operation. RESULTS: Operative mortality in patients who underwent primary repair decreased from 17.6% (1974 to 1979) to 5.0% (1990 to 1995) despite an increase in the number of patients younger than 6 months. In patients undergoing a two-stage procedure operative mortality was 3.9% (late mortality, 7.9%). Young age (<6 months) was an incremental risk factor (p = 0.008) for operative mortality in the early study period. Coarctation of the aorta (p = 0.02) and severe dysplastic left atrioventricular valve (p = 0.001) were associated with a higher risk for operative mortality. Freedom from reoperation at 10 years was 82.5% +/- 3.8%. CONCLUSIONS: In patients with complete atrioventricular septal defect, primary repair is the treatment of choice and can be accomplished with good results. In our experience over a period of more than 20 years, earlier date of operation, young age (<6 months), dysplastic left atrioventricular valve, and coexisting coarctation were incremental risk factors for hospital death. The presence of a previously placed pulmonary artery band did not alter the outcome of repair. The reconstructed atrioventricular valve shows a good and long-lasting performance.

Operative correction of traumatic tricuspid insufficiency.

Between 1975 and 1991, 5 patients were operated for traumatic tricuspid insufficiency. The patients, all male, with the age at surgery of 15 to 61 years (mean 39 years), suffered previous nonpenetrating trauma to the chest 0.1 to 23 years (mean 13.2 years) earlier. Symptoms were known for 0 to 18 years (mean 10.5 years). The patients were in NYHA class II to IV (mean 2.9). Preoperative angiography showed moderate to severe tricuspid insufficiency. Mean right atrial pressure was 9.6 +/- 1.7 mm Hg and mean pulmonary artery pressure 14.0 +/- 2.4 mm Hg, the mean cardiothoracic ratio was 0.59 +/- 0.04, 4 patients were in sinus rhythm and 1 patient was in atrial fibrillation. Intraoperatively 4 patients showed rupture of the anterior chordae tendineae, 1 patient had multiple ruptures of the leaflets and the anterior papillary muscle, all tricuspid valves showed massive annular dilatation. A primary valvular reconstruction was undertaken in 3 patients of whom only 1 patient was successful in controlling tricuspid insufficiency. Finally, 4 tricuspid valves had to be replaced, 3 with a bioprosthetic and 1 with a mechanical valve. One patient died early, 2 patients died late during a total follow-up of 35.3 years after 7 and 9 years, 2 patients are alive 9 and 10 years after the operation and are presently in New York Heart Association class II to III and I. Traumatic tricuspid insufficiency is a rare event, but is not infrequently overlooked for a long period of time inspite of present symptoms. Results after operative correction seem to be comparable with the results in patients following tricuspid repair or replacement for functional and organic lesions.

Bioprosthetic and mechanical valves in the elderly: benefits and risks.

There is controversy over whether elderly patients benefit from the durability of mechanical valves when balanced against the risk of anticoagulation. From 1976 to 1993, 576 patients 65 years old or older underwent isolated valve replacement with mechanical (n = 250) or bioprosthetic valves (n = 326). Total follow-up was 2,222 patient-years. Probability of survival and freedom from thromboembolism and prosthetic valve endocarditis were not different between the two groups. There was a significant difference (p = 0.015) in freedom from anticoagulant-related hemorrhage. Two patients with mechanical prostheses and 7 patients with bioprostheses were reoperated. However, actuarial freedom from reoperation was not different (p = 0.73) in both groups, with no hospital mortality, whereas mortality from thromboembolic events and anticoagulant-related hemorrhage was three times higher in patients with mechanical prostheses as compared with patients with bioprostheses (1.08% versus 0.36% per patient-year). The benefit from the durability of mechanical valves, compared with bioprostheses, is smaller than expected because of the limited number of patients exposed to the onset of bioprosthetic structural deterioration. Elderly patients without absolute indication for anticoagulation should preferentially receive bioprostheses for valvular replacement.

Surgery for tricuspid insufficiency: long-term follow-up after De Vega annuloplasty.

Between 1975 and 1991, 97 consecutive patients underwent De Vega tricuspid annuloplasty either isolated or in combination with mitral, aortic, or mitral and aortic valve procedures. Preoperatively 96.9% of the patients were in New York Heart Association functional class III or IV. Causes of tricuspid insufficiency were functional tricuspid ring dilatation and a combination of dilatation and different organic tricuspid valve lesions. There were 17 early deaths (17.5%), primarily due to cardiac failure, none was related to the tricuspid annuloplasty. 80 perioperative survivors have been followed up for a mean of 4.7 +/- 4.1 years with a total of 462 cumulative patient-years. Actuarial 5-, 10-, and 15-year survival rates, including early deaths, were 64% +/- 5%, 48 +/- 6%, and 26% +/- 10%. Recurrence of tricuspid regurgitation was rated as moderate in 15% and severe in 18.8%. Ten patients required reoperation (2.2%/patient-year), of whom 8 were associated with tricuspid regurgitation (1.7%/patient-year). Although in all patients but one the De Vega annuloplasty was intact, the tricuspid ring was dilated; 4 patients had additional tricuspid organic valve lesions. 6 of the 8 patients had concomitant mitral valve or mitral prosthesis dysfunction. 26 patients died late (5.6%/patient-year) due to chronic cardiac failure in 50% and after reoperation in 7% of the patients. 4 patients had implantation of a permanent pacemaker (0.9%/patient-year). 54 patients (67.5%) are still alive, with 43% having no and 17.5% having only mild residual tricuspid regurgitation. De Vega annuloplasty is indicated with tricuspid insufficiency due to functional ring dilatation.(ABSTRACT TRUNCATED AT 250 WORDS)

Estimation of the operative risk of mitral valve replacement by multivariate logistic regression analysis.

The knowledge of factors determining the risk of postoperative myocardial failure (MF) should allow a more rational approach to the timing and the management of mitral valve replacement (MVR). Using multivariate logistic regression analysis the influence of 41 preoperative and perioperative variables on MF was assessed in a training group of 353 consecutive patients undergoing isolated primary MVR between 6/76 and 12/82. Early MF mortality was 4.2%. Strongest independent preoperative predictors of MF were advanced NYHA functional class (p less than 0.001), hepatomegaly (p = 0.001), and reduced body weight (p = 0.01). Amongst preoperative and perioperative variables independent determinants of MF were NYHA functional class (p less than 0.001), hepatomegaly (p = 0.002), hypotension during extracorporeal circulation (ECC) (p = 0.005), body weight (p = 0.007), ECC duration (p = 0.008), female sex (p = 0.061) and the absence of cardioplegia (p = 0.065). From the combination of these determinants estimates of the probability of MF were calculated and adjoined to low or high risk by means of an optimum cutoff point. The sensitivity of this test performed before and after operation was 0.80 and 0.93, the specificity 0.92 and 0.94, respectively. The reliability of this prognostic test was prospectively evaluated on data of 107 consecutive MVR patients between 1/83 and 12/84. The observed diagnostic characteristics of the test group were comparable to those predicted from the training group. Multivariate logistic regression analysis selects independent determinants, estimates the risk of MF or other modes of postoperative events and identifies patients with low or high risk with a definable validity as an objective aid for medical decision-making.

[Age-dependent regulation of cardiac glycoside receptors]. / Altersabhängige Regulation der Herzglykosidrezeptoren.

Specific binding of cardiac glycosides to their receptors precedes their actions on the myocardium. Thus changes in the number and affinity of these membrane bound receptors will vary the response to cardiac glycoside therapy and the incidence of side-effects. Several studies have reported an age-dependent decrease in the number of cardiac glycoside receptors in animals as well as in human erythrocytes. These results may explain the increase in cardiac glycoside sensitivity with age which is not accounted for by the reduction in kidney function. Furthermore, changes in both binding affinity and capacity are known to occur in several diseases which are more common in older patients. Therefore, we have measured the number and affinity of cardiac glycoside receptors in atrial samples from 209 patients and in papillary muscle samples from 59 patients taken during coronary bypass graft surgery or mitral valve replacement. Further, the maximal increase in force of contraction was measured using papillary muscle strips from some of these patients. Our results show no significant age-dependent alteration in the characteristics of the cardiac glycoside receptors but a reduced myocardial receptor density in males (3.47 +/- 0.14 X 10(14)/g protein) compared with females (4.44 +/- 0.21 X 10(14)/g protein) (p less than 0.001) which is more pronounced in older patients. About 30% fewer cardiac receptors either per g protein or per g wet weight are present in patients with coronary heart disease or dilative cardiomyopathy. The maximal inotropic effect of ouabain in human papillary muscle strips is correlated with the number of cardiac glycoside receptors present.(ABSTRACT TRUNCATED AT 250 WORDS)

The diagnosis of acute renal failure (ARF) following cardiac surgery with cardio-pulmonary bypass.

The diagnostic value of renal concentrating capacity expressed as free water clearance (CH2O), in comparison with other routine criteria for the early identification of acute renal failure (ARF), was evaluated in 1,203 adult patients undergoing cardiac surgical procedures. On the basis of the appearance of pathologic CH2O values in the range of -20 to 0 ml/hour or more positive, reversible or irreversible ARF was observed in 90 (= 7.5%) of our patients. Mortality in the presence of ARF was 47%; total ARF mortality was 3.5%. CH2O was pathologic for the first time on an average of 1.6 days after operation. In contrast, routine ARF criteria reported in the literature, such as serum urea and creatinine at varying substrate levels or oliguria, allowed diagnosis 1 to 5.5 days later. Moreover, these parameters only partially and less frequently met the criteria for ARF at the different levels. Likewise, the incidence of ARF decreased to a minimum of 1.7% and the total ARF mortality to 1.3%, depending on the severity of the criteria used. Altogether, the occurrence of pathologic CH2O values proved to be the earliest, most frequent and most reliable criterion for the recognition of ARF following cardiac surgery with cardiac-pulmonary bypass.