Contralateral recurrence of atrial myxoma - case report and review of the literature.

Cardiac myxomas are the most frequent cardiac tumors, and they have the capability for recurrence years after resection, in the same or in different cardiac chambers. Hence, follow-up is important. Contralateral recurrences of myxoma are uncommon. We report a 7 year old boy who had a right atrial myxoma resected, and who had recurrent myxoma in the left atrium. The literature regarding such recurrence is reviewed.

The use of transesophageal echocardiography guidance of thrombolytic therapy in prosthetic mitral valve thrombosis.

BACKGROUND AND AIM OF THE STUDY: The aim of the study was to assess the use of transesophageal echocardiography (TEE) to guide thrombolytic therapy in prosthetic mitral valve thrombosis. METHODS: Twenty-nine consecutive cases of prosthetic mitral valve thrombus diagnosed between January 1995 and May 1998 were managed according to data obtained by TEE. Three patients with pedunculated thrombus and five in NYHA functional classes I-II were referred for surgery. Patients who refused surgery or who were in NYHA classes III-IV and had unpedunculated thrombus were selected for thrombolytic therapy. Twenty-one patients (seven males, 14 females; mean age 47 +/- 8 years) received streptokinase for thrombolysis. RESULTS: The mean period from valve replacement surgery was 36 +/- 23 months, and mean time from onset of symptoms 9.2 +/- 14.3 days. Anticoagulant use was inadequate in 18 (86%) patients. Fourteen cases (66%) were NYHA class IV, four (19%) in class III, and three (15%) in class II. Ten patients (48%) were in atrial fibrillation. During the first 24 h of thrombolytic therapy, mean mitral valve peak and mean gradients fell from 25.6 +/- 4 and 13.8 +/- 2.5 mmHg to 11.7 +/- 5.3 and 7.1 +/- 3.1 mmHg respectively (p <0.0001). Five cases with inadequate response to thrombolysis were treated for an additional 24 h. The mitral valve area increased from 1.0 +/- 0.1 cm2 to 2.3 +/- 0.7 cm2 after the first month (p <0.0001). Complete early success in thrombolysis was achieved in 17 (81%) cases, three cases (14%) had partial success, and one case (5%) was referred for surgery on the third day because of failed thrombolysis. Two minor skin bleedings (9%) not requiring transfusion were attributed to thrombolytic therapy. One case (5%) of successful thrombolysis had a non-fatal stroke after therapy and one (5%) was referred for surgery for recurrent prosthetic mitral valve thrombosis at six months' follow up. None of the surgically treated patients died. CONCLUSION: Guidance of thrombolysis by TEE may reduce, but not eliminate, the risk of thromboembolic complications. Response to thrombolysis became apparent within 24 h, but extending treatment beyond this time provided no additional short-term benefit.

Congenital aortic insufficiency due to aortic cusp stretching: 'kite anomaly'.

Aortic insufficiency may be either acquired or congenital. A 46-year-old male had a congenital pathology which resulted in aortic insufficiency due to the presence of a fibrous band that stretched from the non-coronary cusp to the aortic wall. The patient underwent successful aortic valve replacement. At surgery, the fibrous band was stretching the non-coronary cusp so that it prevented coaptation of the aortic valve. The situation was termed by us as the 'kite anomaly'.

Left atrial thrombus detection with multiplane transesophageal echocardiography: an echocardiographic study with surgical verification.

BACKGROUND AND AIM OF THE STUDY: The detection of left atrial thrombus (LAT) is especially important in patients being evaluated for percutaneous mitral valvuloplasty and elective cardioversion for atrial fibrillation. Transesophageal echocardiography (TEE) is widely used for this indication. This study was undertaken to validate the use of multiplane TEE to detect LAT in the setting of rheumatic mitral valve disease. METHODS: The study population comprised 262 patients (103 men, 159 women, mean age 42.2+/-13.1 years) who underwent open heart surgery for rheumatic mitral valvular disease between January 1994 and October 1997. Of these patients, 178 had mitral stenosis and 84 mitral regurgitation. All patients were examined with multiplane TEE less than three days before valvular surgery. RESULTS: The presence or absence of LAT was confirmed at surgery by direct inspection of the left atrium. Left atrial thrombi were detected by TEE in 34 patients (14 men, 20 women; mean age 51+/-8 years). The presence of all 34 thrombi found by multiplane TEE was confirmed during surgery. Only one thrombus was confirmed surgically among 228 patients shown thrombus-negative by multiplane TEE. The sensitivity, specificity, positive and negative predictive value and diagnostic accuracy for multiplane TEE were 97, 100, 100, 99.6 and 99.6%, respectively. CONCLUSION: Multiplane TEE is exquisitely sensitive for the detection of LAT.

The influence of the resolution of reciprocal ST segment changes on in-hospital complications of acute myocardial infarction after percutaneous coronary angioplasty.

We studied 120 patients (M:F 105:15, mean age 57.5 +/- 10.1 years) with acute myocardial infarction (MI) successfully treated with percutaneous coronary angioplasty (PTCA) to analyze the influence of the resolution of the ST segment elevation and depression after intervention to 1 month composite endpoints of reinfarction or reocclusion, development of congestive heart failure (CF) and death. Sum of preintervention and postintervention ST segment elevation and depression and the rate of resolution of these ST segment elevations and depressions were recorded for every patient. A total of 17 (14.2%) composite endpoint events (events group) were recorded (7 reocclusion or recurrent MI, 9 CF, and 1 death). On univariate analysis, events group patients were older (53.3 +/- 9.9 vs. 58.8 +/- 9.1 years, P = 0.032), had lesser resolution of ST segment elevations (85 +/- 24% vs. 44 +/- 55%, P = 0.017) and depression (72 +/- 26% vs. 52 +/- 30%, P = 0.009), had greater preintervention ST segment elevation (17.49 +/- 12.95 mm vs. 28.38 +/- 20.41 mm, P = 0.045), had lower ejection fraction (59.3 +/- 10.2% vs. 43.6 +/- 9.4%, P < 0.001), and had more frequent multivessel disease (71% vs. 47%, P = 0.048) compared to the nonevents group. Time from angina to reperfusion, residual stenosis, sex, infarct location and infarct-related vessel distribution were similar. On multivariate analysis (logistic regression with backward likelihood ratio) only older age (P = 0.0752), lesser rate of resolution of ST segment depression (P = 0.0262) and lower ejection fractions (P = 0.0014) were retained as predictors of the composite endpoints. Relative risk conferred by less than 50% resolution of ST segment depressions for composite endpoints were 3.78 (95% CI 1.63-8.73). We conclude that the lack of resolution of the sum of reciprocal ST segment depressions identifies a subgroup of acute MI patients with greater morbidity after primary PTCA.

The Feasibility of Using Patent Foramen Ovale During Mitral Balloon Valvuloplasty.

This study was undertaken to examine the feasibility of searching and finding probe patency during mitral balloon valvuloplasty and whether the duration of procedure and/or the incidence and severity of iatrogenic atrial septal defect decreased in this patient population. Sixty consecutive patients treated with mitral balloon valvuloplasty (MBV) were studied; data from 55 patients were analyzed. Fifteen patients out of 55 (27.3%) had probe patency. The duration of the procedure was shorter (26.2 +/- 7.0 vs. 35.6 +/- 10.1 min; p < 0.01), incidence of atrial septal defect was lower (40% vs. 72.5%, p < 0.01), and the severity of atrial septal defect as measured by the jet area was smaller (1.68 +/- 0.23 vs 2.6 +/- 1.3 cm2; p < 0.01) in the probe patency group compared to patients without probe patency. At 6 month follow-up, all of the atrial septal defects present in the probe patency group disappeared, but 4 (10.2%) persisted in patients without probe patency. It was concluded that searching probe patency during mitral balloon valvuloplasty was feasible and worthwhile, would not unduly prolong the procedure, and would decrease the incidence and severity of complicating atrial septal defect.

Percutaneous mitral valvulotomy in the presence of atrial septal aneurysm.

In this report, we discuss the feasibility of percutaneous mitral valvulotomy in the presence of mitral stenosis and concomitant atrial septal aneurysm. Our data suggest that percutaneous mitral valvulotomy can be safely performed if the atrial septal aneurysm does not involve the entire interatrial septum.