Subaortic left ventricular pseudoaneurysm of obscure origin.

Subaortic pseudoaneurysms of the left ventricle are rare acquired cardiac defects. They are usually associated with previous valve surgery, trauma, or aortic valve endocarditis. We describe the appearance of subaortic pseudoaneurysm 10 years after left heart catheterization in a patient with both aortic stenosis and regurgitation. The differential diagnosis of such lesions is presented.

A technical approach to tracheal and oesophageal injuries.

Twenty patients with acute trauma to the trachea and oesophagus were managed in the last 6 years with a new technique. There were 2 female and 18 male patients with an average age of 26 years. The approach is direct, easy and reproducible. The approach is direct, easy and reproducible. The oesophageal rents are approached through the anterior and posterior tracheal lacerations without tracheal mobilisation. Muscle interposition was electively not used and cervical wounds not drained. Wound dehiscence was not experienced.

[Coronary endarterectomy: has the time come for randomized evaluation of clinical research?]. / Koronární endarterektomie: nadesel jiz cas pro randomizované zhodnocení klinického významu?

The authors review contemporary and hitherto not uniform views on the clinical impact of endarterectomy in the surgical treatment of diffuse coronary disease. Exact evaluation of this problem is still lacking. The authors suggest an original, prospective project for the objective evaluation of this therapeutic method by a randomized study called PROCESS. Initial experience indicates that revascularization procedures with endarterectomy are in the early postoperative stage associated with a higher mortality and morbidity than conventional surgery using only bypasses without endarterectomy of diffusely altered coronary arteries. Hypothetically it is possible that the long-term fate of patients with more complete revascularization, i.e. with reconstruction of diffusely altered arteries, will be more favourable than the prognosis of patients with partial reconstruction of the coronary circulation. The objective of the proposed project is to test this hypothesis. This will be, however, possible only after a longer time interval.

Suspension of the papillary muscles during valve replacement for mitral stenosis.

Of 94 patients who underwent intravalvular mitral valve replacement with CarboMedics bileaflet mechanical prosthesis, 10 presented with heavily calcified stenotic valves. After total excision of the mitral valve in these patients, both papillary muscles were reconnected to the annulus with Goretex sutures. Repeat cardiac catheterization was completed in six of these 10 patients two to 24 months after surgery. Global and segmental left ventricular function was estimated using the MEDIS program (Thorax Centrum, Rotterdam) for analysis of left ventricular function. In five of the six patients re-examined, the ejection fraction was improved, the global ejection fraction increasing from 54% +/- 6% to 63% +/- 10%. We conclude, even though the number of followed patients is extremely small, that mitral valve replacement with suspension of the papillary muscles is surgically feasible and has beneficial effects on the contractility of the left ventricle in patients with mitral stenosis.

[The importance of annulo-ventricular integrity in replacement of the mitral valve. Experience with the double-disc low profile Carbo Medics mechanical valve]. / Význam annuloventrikulárnej integrity pri náhradách mitrálnej chlopne. Skúsenosti s dvojdiskovou nízkoprofilovou mechanickou chlopnou Carbo Medics.

In the submitted paper the authors compare the results of the conventional replacement of the mitral valve with total excision of the subvalvular apparatus and the results of mitral replacement with a completely or partly preserved or reconstructed integrity of the annulopapillary structures. During the last five years the authors operated by the former method 115 patients (group A) and the second surgical method was used in 93 patients (group B). In both groups the authors compared 33 demographic, clinical, peroperative, postoperative and echocardiographic indicators. Group B comprised substantial more patients with severe myocardial disorders. In the latter group significantly more frequently a mechanical double-disc valve Carbo Medics was implanted than other types of synthetic valves which were used mostly in patients of group A. In patients of group B the operation took longer and after operation they needed more frequently intense inotropic support. Despite that their mortality on hospitalization was lower -3.2% than in group A where it was 6.9%. The late echocardiographic results were also in favour of group B where, contrary to group A, after operation the left ventricular function improved. The authors' experience support the view that preserving the integrity of the annulopapillary apparatus is nowadays one of the demands in surgical correlation of a mitral defect and is of decisive importance for the subsequent fate of the thus treated patients.

Percutaneous transarterial balloon dilatation of the mitral valve: five year experience.

OBJECTIVE: To examine the value of transarterial balloon dilatation of the mitral valve for treatment of patients with mitral stenosis over a period of five years. DESIGN: Analysis of patients' functional state, and haemodynamic and echocardiographic variables, before and immediately after the procedure and during a follow up of up to five years. SETTING: A cardiovascular centre in Belgrade, Yugoslavia. PATIENTS: Two hundred and ninety four patients who underwent percutaneous transarterial dilatation of the mitral valve between February 1985 and February 1990. RESULTS: Mean mitral valve area was enlarged by 109%. Complications included death (0.7%), severe mitral insufficiency (2.3%), mild mitral insufficiency (9.9%), cerebral embolism (2%), and injury to the femoral artery (2%). Two more patients died at two and 11 months after the procedure. Late cardiac surgery was needed in eight patients (mitral insufficiency in three, restenosis in three, thrombus in one, and endocarditis in one. Restenosis occurred in seven patients. Four of these underwent repeat dilatation and three had surgery. Improvement of symptoms was seen in 94% of patients during the follow up. CONCLUSION: Transarterial balloon dilatation of the mitral valve gave good results with acceptable morbidity and mortality and had some advantages over the anterograde approach.

The effect of allopurinol on free oxygen radicals in myocardial reperfusion.

The transmyocardial turnover of lactate, oxidized and reduced glutathione, malondialdehyde, and the isoenzyme CK-MB before and after restoration of myocardial blood flow was studied in 18 patients undergoing coronary artery surgery. Of this number, ten patients were given oral allopurinol preoperatively; the remaining patients made up the control group. Allopurinol significantly reduced the levels of free oxygen radicals. The enzymatic methods employed did not make it possible to evaluate the protective effect of allopurinol on reperfusion myocardial injury.

[Surgical treatment of diffuse coronary disease]. / Chirurgická lécba difúzní koronární nemoci.

In order to obtain an idea on contemporary opportunities of surgical treatment of diffuse coronary disease the authors compared the results of surgery in 103 patients whose finding called for endarterectomy and bridging of at least one coronary artery (KEA) with the results in 220 patients where it was possible to overcome all significant changes by coronary bypasses only (KBP). Patients in group KEA had more infarctions before operation than patients in group KBP. Diffuse changes of the coronary arteries were found only in patients in group KEA. All patients were operated with extracorporeal circulation and local cooling of the myocardium. Surgery took longer in patients of group KEA than in group KBP. Early mortality was higher in group KEA--4.8% than in group KBP--0.9%. This difference was not statistically significant. Early morbidity in group KEA did not differ, from the morbidity in group KBP. Using effective peroperative protection of the myocardium by local cooling, the risk of KEA is only insignificantly higher than the risk of KBP. KEA makes safe and effective revascularization of the heart muscle in patients with diffuse coronary disease possible.

Selective coronary angiography versus two-dimensional echocardiography for diagnosis of left atrial thrombi.

Coronary angiographic findings indicative for left atrial thrombi (neovascularization in the region of the left atrium) were compared with echocardiographic ones. Of 214 patients who had mitral surgery, the authors had all the available data for 161 (31 of whom had left atrial thrombi). The presence of a neovascularization had a sensitivity of 61%, a specificity of 100%, predictive accuracy of 100%, and predictive value of 92%, while echocardiography had a sensitivity of 52%, specificity of 96%, predictive accuracy of 76%, and predictive value of 89%. There was no difference in the sensitivity of both methods for the detection of thrombi located in the left atrium as a whole cavity (p less than 0.05). However, coronary angiography was superior to echocardiography in the diagnosis of thrombi located in the left atrial appendage (p less than 0.05). The diagnosis of left thrombi could be improved by using both methods (specificity 77%, predictive value 95%). Thus, selective coronary angiography is a useful diagnostic method, in addition to echocardiography, in the diagnosis of left atrial thrombi.

[Coronary surgery in patients with severely impaired left ventricular function]. / Koronárni chirurgie u nemocných s tezce omezenou funkcí levé komory.

Views on surgical treatment of patients with coronary disease and severely restricted left ventricular function are still controversial. In the present work the authors compare the results of direct reconstruction of the coronary arteries in 184 patients with satisfactory or medium restricted left ventricular function (SLV) with a group of 77 patients with severely restricted left ventricular function (RLV). Twenty-three clinical, angiographic, peroperative and postoperative indicators were compared. Patients with RLV had more frequently a myocardial infarction before operation, on average a more restricted functional capacity and lower ejection fraction of the left ventricle than patients with SLV. The mortality during hospitalization was 1.1% in patients with SLV and 5.2% in patients with RLV. These results confirm that reconstruction of the coronary arteries is safe also in patients with a significantly restricted left ventricular function. An essential prerequisite of successful operation is perfect peroperative protection of the heart muscle by the method of continuous local cooling.

Balloon valvoplasty of mitral bioprosthesis.

We describe a case of percutaneous balloon valvoplasty of a stenotic Ionescu-Shiley mitral bioprosthesis with the help of an original emboli-protecting device. The procedure reduced diastolic gradient from 29 to 9 mmHg. The calculated area of the orifice increased from 0.7 to 1.7 cm2. At 10 months follow-up examination there was no change of hemodynamic parameters.

Systemic and pulmonary flow in mitral stenosis: evidence for a bronchial vein shunt.

We measured pulmonary and systemic flows in 22 patients with mitral stenosis and in 7 controls. In patients with mitral stenosis, pulmonary flow index averaged 2.33 +/- 0.41 l/min/m2 and systemic flow index averaged 2.15 +/- 0.60 l/min/m2, p = 0.045. There was a strong correlation between the difference in pulmonary and systemic flow indexes and the difference in mean left and right atrial pressure (r = 0.749, p = 0.00008). After a successful dilatation in 17 patients, there was a significant drop in the difference between pulmonary and systemic flow indexes (0.26 +/- 0.41 vs. 0.07 +/- 0.37 l/min/m2, p = 0.048). We conclude that chronic elevation of left atrial pressure leads to a left to right shunt probably through bronchial veins.

Double-umbrella device for transvenous closure of patent ductus arteriosus and atrial septal defect: first experience.

A new device for transcatheter closure of heart defects was constructed and used to close a patent ductus arteriosus (PDA) in seven adult patients and an atrial septal defect (ASD) in six adult patients. The device consisted of two self-opening umbrellas and a piece of Ivalon. A Dacron patch was sewn on the "male" umbrella for the ASD closure. The device required a 9 Fr introducing venous sheath for PDA and a 14 Fr sheath for the ASD. The venoarterial (right femoral vein-PDA or ASD-left femoral artery) long wire track was arranged. The "male" umbrella and the Ivalon were inserted transvenously one after another, advanced over the long wire across the PDA or ASD and extruded into the aorta or left atrium, respectively. The "female" umbrella was advanced transvenously over the long wire into the pulmonary artery (for PDA) or into the right atrium (for ASD). The metal conus on the long wire was used to pull the "male" umbrella while a special stiff pusher was used to bring the "female" umbrella to the "male" umbrella along the long wire. By these means the umbrellas interlocked at the defect level and closed it. The long wire was then removed through the left femoral artery. Protrusion of the interlocked device through the PDA occurred in one patient and through the ASD in two patients. In all three patients the device was kept on the wire until surgery and an early postrelease device embolization was avoided. In all other patients the defects were successfully closed. The follow-up of 3-27 months was uneventful in all patients. These results indicate that the described procedure is effective and safe, and warrants further clinical trial.

Percutaneous transarterial balloon mitral valvuloplasty: 30 months experience.

Between February, 1985, and August, 1987, 76 patients with mitral stenosis underwent percutaneous transarterial mitral balloon valvuloplasty (MVP). There were 58 females and 18 males aged from 15 to 69 years (mean 39 +/- 11). In 31 patients the mitral valve was pliable (40%) and in 45 patients (60%) the valve was nonpliable. Calcified mitral stenosis was found in 24 patients (31%). Transseptal catheterization was used to place one or two 0.035" (350 cm long) exchange wires into the ascending aorta in order to be snared, retrieved and exteriorized, each one through a femoral artery. Over these wires, the balloon dilation catheters were advanced through the femoral artery, retrogradely, across the mitral valve, for mitral dilation. Single (25 mm in diameter, trefoil 3 x 12 mm, bifoil 2 x 19 mm) and double (18 and 15 mm, 18 and 18 mm, 18 and 20 mm) balloons were used in 24 and 52 patients respectively. Transarterial mitral valvuloplasty produced immediate improvement of mitral valve area (MVA = 1.1 +/- 0.3 to 2.4 +/- 0.4 cm2, p less than 0.001), mitral valve gradient (19 +/- 4 to 8 +/- 6 mmHg, p less than 0.001), echocardiographic left atrial diameter (LAD = 58 +/- 6 to 54 +/- 5 mm, p greater than 0.05) and echo-MVA (0.9 +/- 0.4 to 2.1 +/- 0.7, p less than 0.001). In three patients no MVA enlargement was achieved. A significant mitral regurgitation was produced in two patients. A stroke occurred in three patients (3.9%), one of these patients subsequently died (1.3%), one recovered and one remained hemiplegic. No atrial septal defect was found after valvuloplasty.(ABSTRACT TRUNCATED AT 250 WORDS)

Percutaneous mitral valvuloplasty: retrograde, transarterial double-balloon technique utilizing the transseptal approach.

Between February 1985 and May 1987, 72 patients with mitral stenosis (MS) underwent percutaneous transluminal mitral valvuloplasty (PTMV). The retrograde transarterial double-balloon technique was used on 54/72 patients (75%); 16 males, 38 females; mean age: 39 +/- 11 years. Transseptal catheterization was used to place two 0.035", 350-cm exchange wires into the ascending aorta in order to be snared, retrieved, and exteriorized, each through a femoral artery. Over these wires, the balloon dilation catheters were advanced through the femoral artery, retrogradely, across the mitral valve, for PTMV. The transmitral mean gradient fell [18 +/- 4 to 9 +/- 5 mmHg (P less than 0.001)]; the cardiac output increased [5.1 +/- 0.8 6.1 +/- 0.8 L/min (P less than 0.001)]; the hemodynamically calculated valve area increased [1.2 +/- 0.2 to 2.3 +/- 0.6 cm2 (P less than 0.001)]; and the short axis two-dimensional echocardiographic valve area increased [1.1 +/- 0.3 to 2.2 +/- 0.7 (P less than 0.001)]. PTMV was unsuccessful in two patients (4%), due to the inability to maintain the inflated balloons in the mitral position. Significant complications were encountered in two patients: two strokes (3.7%) and one mortality from the stroke (1.4%). Significant mitral regurgitation occurred in two patients (3.7%); no post-PTMV hemodynamically significant atrial septal defects were detected. Follow-up (mean time: 11 +/- 6 months) of 43 patients showed a persistent improvement in echocardiographic findings in 27 (63%) and hemodynamically measured mitral valve area in the 16 patients in which cardiac catheterization was repeated. The retrograde, transarterial double-balloon technique can successfully accomplish PTMV with good results and an acceptable low morbidity and mortality.

Bedside intracoronary thrombolysis in the coronary care unit.

Using a mobile X-ray unit in the coronary care unit (CCU), intracoronary streptokinase (IC STK) administration was performed in 20 patients with acute myocardial infarction who arrived 2 to 5 hours after onset of symptoms. IC STK was infused at a rate of 4000 U/min. Of 20 patients, 17 had complete and 3 subtotal occlusion of the infarct-related artery. The IC STK infusion resulted within 15 to 80 min in reperfusion in 12 of 17 patients with occluded artery (70%). One patient died, 4 patients underwent early bypass grafting, in one PTCA was attempted and in one a femoral A-V fistula caused by the procedure required surgical revision. IC STK infusion is much more economical if performed in the CCU and the 24-hour coverage can be provided by an experienced invasive cardiologist on call service.

Transarterial balloon mitral valvuloplasty.

Between February 1985 and November 1986, 36 patients, aged between 15 and 67 years (mean 39 years), with moderate (27 patients) and severe (9) mitral valvular stenosis (MS) underwent percutaneous transarterial balloon mitral valvuloplasty (PTBMV). Originally, a right femoral vein-LA-LV-aorta-left femoral artery track had been formed with a long guide wire, which had been advanced transseptally through the Brockenbrough catheter to the LV, where its distal end was caught by means of a retriever set and exteriorized through the femoral artery. Introduction of the transseptal sheath through the LA-LV to the aorta with the Swan-Ganz catheter as a guidance, made the formation of two long guide tracks much easier and enabled the application of the double balloon technique. PTBMV was performed in 15 patients using the single balloon technique with a balloon of 25 mm in diameter and in 19 patients using double-balloon technique (18 + 15 mm in one patient, 20 + 18 mm in two patients and 18 + 18 mm in 16 patients). The mitral valve gradient decreased from 18 +/- 4.3 to 8.4 +/- 4.4 mm Hg (p less than 0.001) and the mitral valve area (MVA) enlarged from 1.26 +/- 0.025 to 2.3 +/- 0.66 cm2 (p less than 0.001) (87%) immediately after valvuloplasty. PTBMV produced significant mitral regurgitation in two patients (grade IV and II). Enlargement of the MVA by 127% was achieved in patients with type A MS and only by 53% in patients with type B MS.(ABSTRACT TRUNCATED AT 250 WORDS)