Long-term follow up study on 64 elderly patients after balloon aortic valvuloplasty.

BACKGROUND AND AIMS OF THE STUDY: The aims of this study were to evaluate symptomatic improvement and event-free/overall survival after balloon aortic valvulotomy in patients with significant sclerotic aortic valve stenosis. METHODS: Sixty-four patients with calcified aortic stenosis, in NYHA class III-IV, and of mean age 79.0 years, underwent a total of 75 scheduled attempts at balloon aortic valvulotomy, with single balloon catheters between December 1987 and June 1993. Patients were either considered as poor surgical candidates or themselves preferred such valvulotomy. RESULTS: Periprocedural major complications, including death in 6%, occurred in association with 16% of the procedures. Among 57 patients in whom initial dilatation was successful, the average period of symptom relief was 9.4 months (median 7.0, range: 0 to 47 months). Independent predictors for longer duration of symptom relief and survival were systolic arterial pressure > 115 mmHg and female gender; ejection fraction > or = 30% was only predictive of survival. Actuarial survival rates at one, two and three years were 77, 48 and 36% respectively. CONCLUSIONS: Balloon aortic valvulotomy is followed by a short period of symptomatic relief and carries a low periprocedural mortality, but considerable morbidity. By comparison, aortic valve replacement patients aged over 70 and with serious physical limitations (NYHA class IIIB-IV) showed much better overall survival. As contraindications to surgery are in most cases relative, aortic valve replacement should always be considered as the only choice in the surgical decision-making.

Right internal mammary artery for myocardial revascularization: early results and indications.

The right internal mammary artery (RIMA) was used for coronary artery bypass grafting in 258 patients from October 1985 to October 1991. The RIMA was inserted as the only graft in 8 patients and in combination with the left internal mammary artery (LIMA) in 231 patients, the right gastroepiploic artery in 19, and autologous vein in 184. The patients received a total of 1 to 8 distal anastomoses (mean number, 3.3). A total of 64% of the RIMAs were anastomosed to the left anterior descending coronary artery. The primary indication for use of the RIMA was small-vessel disease in 86 patients, repeat bypass grafting in 32, varicose or stripped saphenous veins in 61, and "selected routine case" in 79. The early (< or = 30 days postoperatively) mortality rate in these four groups was 8.1%, 6.3%, 0%, and 0%, respectively (p < 0.01). Independent risk factors (logistic regression analysis) for early mortality were small-vessel disease, insufficient grafting, repeat coronary artery bypass grafting, diabetes, history of smoking, age of 60 years or older, and family history of ischemic heart disease. Combined into a risk index, these risk factors identified six risk groups with early mortality of 0% in the four low-risk groups and 5.6% and 58.3% in groups V and VI, respectively (p < 0.0001). No RIMA-related variables were risk factors for significant postoperative myocardial enzyme release. Intraoperative electromagnetic flow measurements revealed no differences between the RIMA and LIMA. Early angiographic patency in 50 patients was 98% for the RIMA and 93% for the LIMA.(ABSTRACT TRUNCATED AT 250 WORDS)

Multiarterial coronary artery bypass grafting with special reference to small vessel disease and results in women.

From 1985 to 1991 a total of 220 patients underwent coronary artery bypass grafting (CABG) with at least two native pedicled artery grafts. Bilateral internal mammary artery (IMA) grafting was performed in 201 patients, IMA combined with gastro-epiploic artery (GEA) grafting in five, and double IMA plus GEA grafting in 14; in addition 156 patients received 1-3 vein grafts. The primary indication for elective multi-arterial CABG was coronary arteries of small calibre (small vessel disease) in 77 patients, repeat CABG in 17 (without small vessel disease), varicose/stripped saphenous veins in 57 (without small vessel disease), while the remaining 69 were routine cases; the distribution differed between women (42, 0, 47, and 11%, respectively) and men (33, 10, 19, and 38%, respectively; P < 0.0001). The women also were older (62 +/- 7 vs 56 +/- 9 years; P < 0.001), and had higher prevalences of systemic hypertension, diabetes mellitus, and hypercholesterolaemia. The number of artery grafts and total number of grafts were, however, similar for women and men. Early mortality (< or = 30 days) was 5.6% in women and 2.4% in men (ns). Early mortalities in relation to primary indications were: 7.8% for small vessel disease, 5.9% for repeat CABG, and 0% for both varicose/stripped saphenous veins and routine cases (P < 0.05). Logistic regression analysis identified small vessel disease, insufficient grafting, age of > = 60 years, a history of smoking, a family history of ischaemic heart disease, and female gender as independent risk factors for early mortality.(ABSTRACT TRUNCATED AT 250 WORDS)

A "new" intraabdominal artery. The pedicled right gastroepiploic artery for myocardial revascularization.

The right gastroepiploic artery (GEA) was used as a pedicled conduit for direct coronary artery revascularization in 20 patients presenting with more or less exhausted saphenous vein resources. The early angiographic patency of the GEA conduit appears to be satisfactory when it is connected to the right coronary artery system. A distinct disadvantage of GEA grafting is the necessity to enter the abdominal cavity, which may lead to probably rare and as yet unrecognized morbidity. Future abdominal surgery may injure the GEA conduit unless its topographic relations to the prepyloric antrum, liver and diaphragm are properly recognized. The surgeon must then be prepared to encounter antegastric, retrogastric, antehepatic, transhepatic and retrohepatic routes of the redirected intraabdominal artery. The present paper addresses this problem. Preoperative angiography of the celiac trunk and superior mesenteric artery may be helpful in decision-making when a patient reports or records show that a graft has been harvested from the abdominal cavity.

Epicardial fat causing pitfalls in CT and MR imaging of the pericardium.

To study the complex anatomy of the pericardium and the pericardial recesses, notably the transverse sinus and the recess behind and under the common pulmonary artery, cryomicrotomy sections of 4 frozen cadaver specimens were correlated with CT and MR imaging in multiple planes. In addition, CT chest studies of 254 patients and MR chest studies from 78 patients were reviewed. Epicardial fat interposed between the transverse sinus of the pericardium and the ascending aorta was a normal finding confirmed by cryomicrotomy studies and seen by CT in 23 of 245 patients and in MR imaging in 3 of 78 patients. Epicardial fat indenting the pericardial sac below the common pulmonary artery caused an inhomogeneous signal, mimicking lymphadenopathy on coronal T1 weighted MR images in 4 patients.

Left internal mammary artery flap aortoplasty.

In 14 consecutive 9- to 18-year-old patients with preductal aortic coarctation and isthmic hypoplasia, we resected the coarctation ridge through a longitudinal aortotomy and widened the aorta with an in situ left internal mammary artery flap. This technique resulted in no surgical complications. At 6-month follow-up examination, the average decrease in systolic pressure across the repair was 8.8 mmHg; all patients showed a clear reduction in arterial hypertension at rest and during exercise. Femoral pulses were easily palpable in all cases. Angiography and magnetic resonance imaging showed no aneurysm formation. The narrowest internal diameter of repair was 88% +/- 12% (mean +/- SD) of the diameter of the aortic arch. The internal mammary artery flap technique, which reflects the basic principle of autogenous arterial grafting in situ, allows appropriate circumferential widening of the aorta in many patients with coarctation and hypoplasia of the aortic isthmus involving delayed repair. This procedure should be considered when the internal mammary artery is of good caliber and quality and the anatomic conditions are not ideal for classic end-to-end anastomotic repair.

Ascites after rupture of dissecting aortic aneurysm into the right atrium.

We report successful repair of an aneurysmal aorta-right atrial fistula causing intractable ascites. The clamped "ascending aorta" was drained for mixed return after perfusion through the femoral vessels and opened during hypothermic arrest. Return cannulation through the fistula permitted definitive repair.

Pericardial effusion and pericardial compartments after open heart surgery. An analysis by computed tomography and echocardiography.

Thirty-three patients with pericardial effusion after open heart surgery were investigated with computed tomography (CT). Twelve of the 33 patients also underwent echocardiography prior to pericardiocentesis. The effusions were typed according to the results of the CT investigation. Because of postoperative adhesions, typical patterns of localized pericardial effusions were found in 16 patients. The localized compartments were seen on the right and left side of the heart and around the aorta and the pulmonary artery. CT was therefore shown to be of value for selecting the approach for drainage with catheter pericardiocentesis.

Myocardial revascularization with three native in situ arteries. Gastroepiploic and bilateral internal mammary artery grafting.

Three native arteries were used for coronary artery bypass grafting in six patients in whom complete revascularization was not feasible because of varices or previous venous stripping. The right gastroepiploic and both internal mammary arteries were placed as pedicled conduits, and four patients additionally received a total of six vein grafts available from the greater or lesser saphenous system. Surgical complications were minimal and complete relief from angina was obtained in all patients, even in maximal stress testing. All 24 grafts were angiographically checked: 23 (96%) were patent and one gastroepiploic artery was occluded. All patients had at least three patent grafts. These native arteries are excellent conduits when suitable veins are not available. They should also be used on individual indications to replace occluded grafts.

Magnetic resonance imaging and angiography for the assessment of coarctation of the aorta.

Fifteen patients ranging in age from 9 to 25 years (median age 10 years), with coarctation of the aorta, were investigated with magnetic resonance (MR) imaging pre- and postoperatively. Three patients were examined because of suggested re-stenosis. Both MR examination and cineangiography were performed in 11 patients. The two techniques were comparable concerning the evaluation of both the site and the severity of coarctation as well as of the occurrence of collateral vessels. MR was considered suitable to replace angiography in the pre- and postoperative assessment of coarctation. The patients were preferably examined with a surface spine coil with ECG-gated sagittal, transverse and parafrontal images. The parafrontal images were necessary in order to minimize mistakes due to partial volume effects at the coarctation site. A surface coil placed over the sternum considerably improved the visualization of the internal mammary arteries.