Subsequent fertility in women who undergo cardiac surgery.

A retrospective review was undertaken on all pediatric and reproductive-aged females who underwent cardiac surgery and required cardiopulmonary bypass from 1958 through 1986. The purpose of this study was to define the fertility of these patients after surgery and to compare their reproductive performance with that in the general population. Analysis was complete for 208 patients. These patients make up the following cardiac surgical categories: septal defect repairs, 92; commissurotomies, 60; valve replacements, 46; tetralogy of Fallot repairs, 6; and coronary artery bypass procedures, 4. Of 208 patients, 68 (32.7%) attempted pregnancy after surgery. Infertility was defined in five women as follows: endometriosis, 3; ovulatory dysfunction, 1; unknown, 1. A total of 64 patients conceived 121 pregnancies with the following outcomes: live births, 98; spontaneous abortion, 9; ectopic pregnancy, 2; therapeutic abortion, 12. Our results suggest that infertility is not an apparent disorder after cardiac surgery and that subsequent pregnancy outcomes are similar to those in the general population.

Short-term infarct vessel patency with aspirin and dipyridamole started 24 to 36 hours after intravenous streptokinase.

The duration of intravenous heparin therapy required to maintain patency of the infarct-related artery after intravenous streptokinase is uncertain. Twenty-eight patients were prospectively treated with 1.5 million units of intravenous streptokinase within 4 hours of onset of chest pain. Intravenous heparin was begun after the streptokinase infusion was complete and was discontinued within 36 hours. Aspirin, 325 mg daily, and dipyridamole, 75 mg three times a day, was begun before the heparin was discontinued. Coronary angiography was performed both at 2 hours after completion of the streptokinase infusion and again at a mean of 8.7 (+/- 3.2) days after the initial catheterization. One patient died after treatment with streptokinase but before early angiography. In 21 of 27 patients (78%), Thrombolysis in Myocardial Infarction trial (TIMI) grade 2 or 3 perfusion in the infarct vessel was observed on initial angiography. Repeat angiograms were available in 17 of the 21 patients with initially patent vessels. Continued patency (TIMI grade 2 or 3) was found in 15 of the 17 patients (88%). Two of the four patients who did not undergo repeat angiography died, and the remaining two patients required coronary artery bypass grafting for unstable angina. Bleeding complications occurred in 6 of 27 patients (22%), with two (7%) requiring surgical evacuation of a groin hematoma. There were no instances of intracerebral bleeding and only two patients required transfusions. Thus, the combination of aspirin and dipyridamole following 36 hours of systemic heparinization after intravenous streptokinase infusion is associated with a reocclusion rate comparable to that which has been reported for more prolonged systemic anticoagulation with fewer hemorrhagic complications.

Acute myocardial infarction associated with single vessel coronary artery disease: an analysis of clinical outcome and the prognostic importance of vessel patency and residual ischemic myocardium.

The long-term outcome and the significance of residual ischemic myocardium, as assessed by predischarge exercise thallium scintigraphy and vessel patency, were studied in 97 patients with single vessel coronary artery disease by angiography 12 +/- 4 days after uncomplicated myocardial infarction. During a mean follow-up period of 39 +/- 17 months, no patients died, 6 (6%) had a recurrent nonfatal infarction and 25 (26%) experienced rapidly progressive angina requiring hospitalization. Although neither exercise-induced angina nor ST segment depression was predictive of a recurrent cardiac event, the mean number of infarct zone scan segments showing thallium redistribution (1.0 +/- 1.0 versus 0.5 +/- 0.8, p = 0.01) and the percent of patients with infarct zone redistribution (61 versus 39%, p = 0.05) were greater in those patients who experienced a late ischemic event. Kaplan-Meier analysis demonstrated a lower event-free survival rate in patients with redistribution (n = 45) than in those without redistribution (n = 52) (p = 0.019). Although no patient received immediate thrombolytic therapy, the infarct-related vessel was angiographically patent in 40 patients (41%). Vessel patency did not influence event-free survival, although a patent vessel, as compared with an occluded vessel, was associated with a greater prevalence of non-Q wave infarction (58 versus 21%, p less than 0.001), fewer persistent infarct zone thallium defects (1.2 +/- 1.1 versus 2.0 +/- 1.2, p = 0.001), more reversible infarct zone thallium defects (1.0 +/- 1.0 versus 0.5 +/- 0.9, p = 0.02) and a trend toward a higher left ventricular ejection fraction (53 +/- 10% versus 49 +/- 12%, p = 0.07). In summary, uncomplicated myocardial infarction in patients with single vessel coronary artery disease is associated with a very low incidence of subsequent death and reinfarction. The presence of infarct zone thallium redistribution, compared with its absence, is predictive of a higher cardiac event rate. These data should be considered when recommending prophylactic percutaneous transluminal angioplasty after uncomplicated myocardial infarction in asymptomatic patients with single vessel coronary disease. On the basis of these results, future randomized trials designed to evaluate the therapeutic efficacy of revascularization in asymptomatic postinfarction patients with single vessel disease should limit enrollment to those patients with residual ischemia located within the infarct zone.

Bilateral renal artery embolism: a diagnostic and therapeutic problem.

A case of bilateral renal artery embolism in a patient occurring after coronary artery bypass operation is reported, describing the diagnostic techniques and therapeutic aspects of management of this unusual disease. The diagnosis should be suspected in patients with underlying cardiovascular disease who have acute renal failure.

Acute non-Q wave myocardial infarction associated with early ST segment elevation: evidence for spontaneous coronary reperfusion and implications for thrombolytic trials.

The clinical significance of early ST segment elevation in patients with non-Q wave infarction is unknown. Therefore, 150 consecutive patients with creatine kinase isoenzyme-confirmed acute uncomplicated myocardial infarction who had ST segment elevation of 1 mm or more in at least two contiguous leads on the admission electrocardiogram were analyzed. None received thrombolytic therapy or acute coronary angioplasty. Predischarge angiography, radionuclide ventriculography and exercise thallium-201 scintigraphy were performed 10 +/- 3 days after myocardial infarction. Based on serial electrocardiograms (on days 1, 2, 3 and 10), all 150 infarcts were classified as Q wave (n = 115 [77%]) or non-Q wave (n = 35 [23%]). Although patients with Q wave infarction exhibited greater ST elevation, the amount observed in the non-Q wave group was appreciable, as reflected by the number of leads with ST elevation (3.8 +/- 1.8 versus 3.1 +/- 1.2, p = 0.007) and the sum of the ST elevation (9.6 +/- 7.4 versus 6.2 +/- 6.2 mm, p = 0.016). When compared with the Q wave group, patients with non-Q wave infarction had a shorter time to peak creatine kinase (23.0 +/- 9.1 versus 15.8 +/- 7.9 hours, p = 0.0001), a higher infarct vessel patency rate (24 versus 57%, p = 0.001), lower peak creatine kinase values based on 4 hour sampling (1,372 +/- 964 versus 664 +/- 924 IU/liter, p = 0.0002) and a higher left ventricular ejection fraction (46 +/- 12% versus 54 +/- 9%, p = 0.0003).(ABSTRACT TRUNCATED AT 250 WORDS)

A prospective clinical, scintigraphic, angiographic and functional evaluation of patients after inferior myocardial infarction with and without right ventricular dysfunction.

To elucidate the functional and prognostic significance of right ventricular dysfunction after acute inferior wall myocardial infarction, 74 consecutive patients with inferior infarction were prospectively evaluated with gated equilibrium blood pool imaging at rest, submaximal exercise thallium-201 scintigraphy and coronary angiography before hospital discharge. In addition, symptom-limited stress thallium-201 scintigraphy was performed in 61 patients at 3 months, and all patients were followed up clinically for 23 +/- 15 months. Utilizing predetermined radionuclide angiographic criteria, 47 patients (Group I) had normal right ventricular function, 12 patients (Group II) had mild to moderate dysfunction and 15 patients (Group III) had severe right ventricular dysfunction. There were no significant differences among the groups with regard to age, history of prior myocardial infarction, peak creatine kinase values, maximal Killip functional class, number or type of in-hospital complications, left ventricular ejection fraction, prevalence of multivessel disease or the distribution and severity of disease affecting the infarct-related vessel. Exercise tolerance as assessed by treadmill time, blood pressure-heart rate product and peak work load in METS was comparable among the three groups, both before hospital discharge and at 3 month follow-up. No differences in indicators of exercise-induced ischemia were noted among the groups, including the prevalence of redistribution thallium-201 defects, ST segment depression or symptoms of chest pain. Finally, cardiac mortality, reinfarction rate and the incidence of medically refractory angina pectoris were similar in the three groups. Thus, right ventricular dysfunction after acute inferior wall myocardial infarction does not appear to limit exercise tolerance or identify a subgroup of patients at higher risk for recurrent cardiac events.

Prognosis with chest pain and normal thallium-201 exercise scintigrams.

The goal of this study was to determine the prognostic value of a normal exercise thallium-201 (TI-201) scintigram by quantitative criteria in a consecutive series of 349 patients with chest pain. Follow-up was obtained in 345 patients (99%) from 8 to 45 months (mean 34 +/- 7). Of these, 60% were men, 26% had typical angina, 21% had chest pain during exercise testing, 29% were unable to achieve 85% or more of maximal predicted heart rate, and in 9% ischemic ST depression (1.0 mm or greater) developed during exercise. At the time of exercise testing, 45% of patients were taking nitrates and 38% were receiving a beta-blocking drug. During the follow-up period, there were 5 cardiac deaths (0.51%/year), of which 2 were sudden, 6 patients had a nonfatal myocardial infarction (MI) (0.61%/year). Two of the 5 patients who died and 1 who had MI had angiographically normal coronary arteries. The event rate was significantly higher (p less than 0.01) in patients referred for early catheterization (5 of 53; 9%) compared with the rate for those not undergoing early angiography (6 of 298; 2%). However, the event rate was similar in those who underwent catheterization with angiographically normal coronary arteries and in those who had significant coronary artery disease.(ABSTRACT TRUNCATED AT 250 WORDS)

A decade of experience with the Model 103 and 104 Beall valve prostheses.

Mitral or tricuspid valve replacement with the Beall Model 103 or 104 prosthesis has been associated with a high incidence of late prosthetic malfunction which has necessitated reoperation. Between 1972 and 1975, 57 patients underwent single valve replacement (55 mitral and two tricuspid) with Beall Model 103 or 104 valvular prostheses and survived at least 2 years. The mean follow-up time was 73.7 months (range 24 to 119 months). Of these patients, 22 required explantation of the prosthesis; there was an operative mortality of 27%. Major prosthetic malfunction occurred in four patients: Two occluders were embolized and two occluders were fixed in the open position. All four patients required urgent operation, and two of them died. The development of symptoms of congestive heart failure, systolic murmur, or hemolysis were the reasons for cardiac catheterizations and possible reoperation. Nineteen patients had cardiac catheterization. Fifteen of these subsequently underwent reoperation, with a mortality of 26%. Three patients were considered inoperable. Cardiac catheterization data revealed significant prosthetic regurgitation in all patients: pulmonary capillary pressure 29.9 mm Hg +/- 6.7 (standard deviation); V wave 31.5 mm Hg +/- 12.0; left ventricular end-diastolic pressure 18.0 mm Hg +/- 7.8. Comparison of hemolysis indicators in this group to those of asymptomatic patients revealed that the former had a significant elevation in lactic dehydrogenase (p = 0.038) and a lowered hematocrit value (p = 0.017). Waiting for severe symptomatic deterioration to justify reoperation risks the development of left ventricular dysfunction and possible emergency reoperation with a high operative mortality.

Double-blind, placebo-controlled trial of propranolol given once, twice and four times daily in stable angina pectoris: a multicenter study using serial exercise testing.

To determine if propranolol given twice daily (b.i.d.) or once daily (q.d.) was as effective as 4 times daily (q.i.d.) for treatment of stable angina pectoris, 78 patients with exercise-induced ST depression of 1.5 mm were randomized to q.i.d., b.i.d., q.d. and placebo groups. All patients received 5 tablets per day, and propranolol groups received 80, 160 and 320 mg/day on successive weeks. At weekly visits, patients underwent treadmill exercise testing before the 8:00 AM dose and at 2 and 9 hours afterward. Exercise duration (seconds) was significantly improved at the final visit compared with baseline by b.i.d. (120 +/- 36 [mean +/-] standard error of the mean p less than 0.001 n = 18) and q.i.d. (100 +/- 37, p less than 0.01; n = 17) regimens, but not by the q.d. (30 +/- 33; n = 18) and placebo regimens (27 +/- 37; n = 17). There was a significant decrease from baseline in the magnitude of ST depression at the final visit, measured at maximal common exercise duration in b.i.d. (-0.96 +/- 0.20 mm, p less than 0.001), q.i.d. (-0.84 +/- 0.20 mm, p less than 0.01) and q.d. (-0.58 +/- 0.18 mm, p less than 0.05) groups, but not in the placebo group (0.03 +/- 0.2 mm). Hourly heart rate by Holter was reduced in all 3 propranolol groups; however, the mean serum propranolol level was significantly lower just before the first dose with q.d. group (56 +/- 20 ng/ml) compared with b.i.d. and q.i.d. groups (146 +/- 22 and 119 +/- 28 ng/ml) with 320 mg/day (p less than 0.01).(ABSTRACT TRUNCATED AT 250 WORDS)

Prediction of cardiac events after uncomplicated myocardial infarction: a prospective study comparing predischarge exercise thallium-201 scintigraphy and coronary angiography.

The ability of predischarge quantitative exercise thallium-201 (201T1) scintigraphy to predict future cardiac events was evaluated prospectively in 140 consecutive patients with uncomplicated acute myocardial infarction; the results were compared with those of submaximal exercise treadmill testing and coronary angiography. High risk was assigned if scintigraphy detected 201T1 defects in more than one discrete vascular region, redistribution, or increased lung uptake, if exercise testing caused ST segment depression greater than or equal to 1 mm or angina or if angiography revealed multivessel disease. Low risk was designated if scintigraphy detected a single-region defect, no redistribution, or no increase in lung uptake, if exercise testing caused no ST segment depression or angina, or if angiography revealed single-vessel disease or no disease. By 15 +/- 12 months, 50 patients had experienced a cardiac event; seven died (five suddenly), nine suffered recurrent myocardial infarction, and 34 developed severe class III or IV angina pectoris. Compared with that of patients at low risk, the cumulative probability of a cardiac event was greater in high-risk patients identified by scintigraphy (p less than .001), exercise testing (p = .011), or angiography (p = .007). Scintigraphy predicted low-risk status better than exercise testing (p = .01) or angiography (p = .05). Each predicted mortality with equal accuracy. However, scintigraphy was more sensitive in detecting patients who experienced reinfarction or who developed class III or IV angina. When all 50 patients with events were combined, scintigraphy identified 47 high-risk patients (94%), whereas exercise-induced ST segment depression or angina detected only 28 (56%) (p less than .001). The presence of multivessel disease as assessed by angiography identified nine more patients with events than exercise testing (p = .06). However, the overall sensitivity of angiography was lower than that of scintigraphy (71% vs 94%; p less than .01) because three patients who experienced reinfarction and 10 who developed class III or IV angina had single-vessel disease. Importantly, 12 (92%) of these 13 patients with single-vessel disease who had an event exhibited redistribution on scintigraphy. These results indicate that (1) submaximal exercise 201T1 scintigraphy can distinguish high- and low-risk groups after uncomplicated acute myocardial infarction before hospital discharge; (2) 201T1 defects in more than one discrete vascular region, presence of delayed redistribution, or increased lung thallium uptake are more sensitive predictors of subsequent cardiac events than ST segment depression, angina, or extent of angiographic disease; and (3) low-risk patients are best identified by a single-region 201T1 defect without redistribution and no increased lung uptake.

Quantitative thallium-201 exercise scintigraphy for detection of coronary artery disease.

In 140 patients with chest pain quantitation of regional myocardial TI-201 activity was performed by serial scintigraphic images after treadmill exercise. Criteria for an abnormal thallium scintigram included: (a) greater than or equal to 25% persisted reduction in TI-201 uptake in anterolateral, anteroseptal, posterolateral, and inferoapical segments, or greater than or equal to 35% reduction in the inferior segment; (b) an initial defect with delayed redistribution; and (c) abnormal TI-201 washout. Of 110 patients with significant coronary artery disease (CAD), 100 had abnormal TI-201 scintigrams, while 27 of 30 patients with angiographically normal coronary arteries had normal scintigrams; 91% sensitivity, 90% specificity, and 97% predictive accuracy. Sensitivity and specificity were not significantly different when the 95 patients with diagnostic (greater than or equal to 85% maximum heart rate) and 45 with inconclusive (less than or equal to 85% maximum HR) Ex tests were compared. Comparison of qualitative and quantitative image analyses in a subset of these patients showed that both specificity and multivessel disease prediction were greater when the quantitative approach was used (90 against 73% and 78 against 39%, respectively). Sensitivity for CAD detection was reduced by 10% with visual interpretation alone. Thus, quantitative exercise TI-201 scintigraphy appears highly sensitive and specific for CAD detection in patients with chest pain.