Is the severity of congenital heart disease associated with the quality of life and perceived health of adult patients?

OBJECTIVE: To explore whether the severity of congenital heart disease is associated with the quality of life and perceived health status of adult patients. DESIGN: Descriptive, cross sectional study. SETTING: Adult congenital heart disease programme in one tertiary care centre in Belgium. PATIENTS: 629 patients (378 men, 251 women) with a median age of 24 years. MAIN OUTCOME MEASURES: Disease severity was operationalized in terms of initial diagnosis (classification of Task Force 1 of the 32nd Bethesda Conference), illness course (disease severity index), and current functional status (New York Heart Association (NYHA) class, ability index, congenital heart disease functional index, and left ventricular ejection fraction). Quality of life was measured by a linear analogue scale, the satisfaction with life scale, and the schedule for evaluation of individual quality of life. Perceived health status was also assessed with a linear analogue scale. RESULTS: Scores derived from the disease severity classification systems were weakly negatively associated with quality of life and health status, ranging from -0.05 to -0.27. The NYHA functional class and ability index were consistently associated with quality of life and perceived health. CONCLUSIONS: This study showed that the severity of congenital heart disease is marginally associated with patients' quality of life and perceived health. Functional status was more related to patients' assessment of their quality of life than was the initial diagnosis or illness course.

Repair for partial and complete atrioventricular septal defect: single centre experience and long-term results.

BACKGROUND: The number of adult patients with surgical repaired congenital heart defects increases continuously. We were interested to compare late outcome after partial and complete atrioventricular defect repair (pAVSD and cAVSD, respectively) and to determine the most important reason for re-intervention. METHODS: All patients older than 16 years, who underwent partial or complete atrioventricular defect repair, were selected from the database. The medical files were reviewed for descriptive statistics. Kaplan Meier analysis was used to determine event free survival for both groups. Log rank testing was performed where applicable. RESULTS: One hundred thirty-eight patients were included. Two patients in each group with early post-operative mortality were excluded (pAVSD: 33/30 male/female, mean age 35.9 +/- 15.6 years; cAVSD: 27/ 44 male/female, mean age 25.7 +/- 11.9 years). Fourteen pAVSD-patients and 23 cAVSD-patients needed a surgical re-intervention: in two and 13 patients, respectively, a mitral valve repair was performed, and in five and one patient, respectively, a mechanical valve was replaced. Eight cAVSD-patients and 10 pAVSD-patients developed atrial arrhythmias. Seven patients (3 cAVSD and 4 pAVSD) received a pacemaker. Median event-free survival time was significantly shorter in the cAVSD-group (22.9 (95% CI 15.4-30.5) years) when compared to the pAVSD-group (34.0 (95% CI 20.1-47.9) years) (Log rank testing, P=0.017). CONCLUSION: Late outcome was characterized by a longer event free follow-up time of pAVSD-patients when compared to cAVSD-patients. The most important reason for re-intervention in both groups was mitral valve regurgitation. However, atrial arrhythmias and conduction disorders were not uncommon late after atrioventricular septal defect repair.

[Delayed respiratory arrest following spinal anesthesia]. / Später Atemstillstand nach Spinalanaesthesie.

A 71 year-old woman was admitted for transurethral resection of bladder carcinoma. The procedure was performed under spinal anaesthesia with mepivacaine 4% hyperbaric. The procedure was carried out without any technical problems. Despite appropriate positioning the patients spinal anaesthesia spread slowly cephalad. 60 minutes after injection of the local anaesthetic aphonia and respiratory insufficiency occurred. The patient was intubated and controlled ventilation was started. 4 hours later the tube could be removed again. 6.5 hours after performing the block no residual block could be detected. The authors discuss the aetiology of this rare complication. It is recommended to keep all patients under continuous anaesthesiologic supervision where the spread of spinal anaesthesia is not definitely declining.

Influence of parenteral fat administration on the pulmonary vascular system in man.

In 16 patients with multiple injuries the effect of parenteral administration of a fat emulsion on the pulmonary vascular system has been studied. Using the Hewlett Packard 5600 A Intensive Care System, which allows vital parameters to be sampled at a rate of two values per min, pulmonary artery pressure (PAP) was monitored before, during, and after the administration of Lipofundin S 20% (0.24 g/kg/h). In addition right ventricular stroke work index (RVSWI), alveolar-arterial oxygen difference (A-aDO2) and pulmonary shunt (Qs/Qt) were calculated. The results indicate that there are no changes of the PAP, the RVSWI, and the A-aDO2 during the period of observation.

Perioperative noninvasive recognition of the TUR-syndrome in transurethral resections.

Easily manipulable, noninvasive techniques for the immediate recognition of absorption of irrigating solution in transurethral prostate resections have not previously been available. For this reason, a way was sought to bring about an improvement in this situation: changes in the thoracic ground impedance were studied perioperatively by use of impedance cardiography during 16 transurethral resections. Furthermore, measurement of central venous pressure and arterial blood gases was done simultaneously as well as registration of myocardial function by systolic time intervals. Most important among the changes caused by absorption of irrigating solution which were registered with impedance cardiography are a significant increase in cardiac output and a considerable decrease in arterial oxygen pressure. Furthermore, a strong correlation was found between the increase of central venous pressure and the decrease of thoracic ground impedance. The relation of the preejection period to the left ventricular ejection time showed a significant increase due to impairment of myocardial function. The results show that impedance cardiography can monitor the time and extent of absorption of irrigating solution exactly and immediately and thus allows immediate therapy. This noninvasive technique can thus be used for perioperative supervision of the patient during transurethral prostate resections.

[Systolic time intervals during increasing left ventricular filling pressure following extracorporeal circulation. A comparative impedance-cardiographical study (author's transl)]. / Systolische Zeitintervalle bei steigenden linksventriculären Füllungsdrucken nach extracorporaler Zirkulation. Eine vergleichende impedanzcardiographische Untersuchung.

In 26 patients invasively measured haemodynamic parameters and impedance cardiographically determined systolic time intervals have been compared after open heart surgery with cardio-pulmonary bypass (aortic valve replacement, AVR (n = 7); mitral valve replacement, MVR (n = 7); aorto-coronary bypass, ACB (n = 10)). In both the AVR and ACB group an increase of left atrial pressure resulted in 1) a significant increase of left ventricular stroke work index (LVSWI), 2) a significant decrease of the relation of the pre-ejection period to left ventricular ejection time (PEP/LVET), and 3) a significant increase of cardiac output (thermodilution technique and impedance cardiography), whereas no significant alterations were found in the MVR group. Furthermore cardiac output determination using both the direct thermodilution technique and the indirect impedance method revealed a close correlation (n = 63, range cardiac output 1.5-12.51/min, r = 0.852). These data clearly demonstrate the utility of the non invasive impedance cardiography method compared with invasive methods with respect to measurement of cardiac and haemodynamic parameters, even in critical situations.

[Leakage of irrigating solution during transurethral prostatectomy. An impedance cardiography study (author's transl)]. / Einschwemmung von Spülflüssigkeit bei transurethraler Prostataresektion. Impedanzcardiographische Untersuchungen.

The aim of this study was to investigate the influence of the incorporation of irrigating solution during transurethral prostatectomy on the pulmonary and cardiovascular system. In 16 patients the changes of thoracic ground impedance were compared with those of the central venous pressure. Myocardial function was evaluated semiquantitatively by use of the systolic time intervals and pulmonary gas exchange by arterial blood gas analysis. There was a significant correlation between the increase of central venous pressure and the decrease of thoracic ground impedance. There was also a significant increase of the relation of pre-ejection period (PEP) to left ventricular ejection time (LVET) meaning an impairment of myocardial function, an increase of cardiac output, and a severe decrease of arterial oxygen pressure. The influence of the incorporation of irrigating solution on the pulmonary and cardiovascular system is discussed, the noninvasive character and simplicity of handling the impedance cardiography is pointed out, and the possibilities of monitoring critically ill patients undergoing transurethral prostatectomy by this method is demonstrated.

[The influence of LAP and cardiac output on the pulmonary gas exchange. Intraoperative studies in cardio-surgical patients (author's transl)]. / Einfluss des linken Vorhofdruckes und des Herzzeitvolumens auf den pulmonalen Gasaustausch. Intraoperative Untersuchungen bei kardiochirurgischen Patienten.

In 21 patients haemodynamic parameters and pulmonary gas exchange were investigated after open heart surgery with cardio-pulmonary bypass (aortic valve replacement, AVR (n = 8); mitral valve replacement, MVR (n = 6); aorto coronary bypass; ACB (n = 7). For describing gas exchange function of the lung the O2-CO2 diagram was used. Stepwise increase of left atrial pressure (LAP) was followed by increasing cardiac output (CO) only in the AVR and ACB groups, whereas in the MVR group CO did not increase. Rising venous admixture (Qs/Qt) under these circumstances was related to CO only in the AVR and ACB groups. In the MVR group Qs/Qt did not change. Qs/Qt is related to low VA/Q areas in the lung. Increased CO leads to rising Qs/Qt from these low VA/Q-areas.

[Optimal left ventricular filling pressure after cardiopulmonary bypass (author's transl)]. / Optimal linksventrikuläre Füllungsdrücke nach extrakorporaler Zirkulation.

To determine the optimal left ventricular filling pressure (LAP) after cardiopulmonary bypass (CPB) left ventricular function curves were constructed in ten patients with coronary heart disease, seven with aortic stenosis and normal left ventricular filling pressures (NLVFP), eight with aortic stenosis and pathologic elevated left ventricular filling pressure (ELVFP), and nine with mitral valve disease, cardiac index = CI, stroke index = SVI, left ventricular stroke work index = LVSWI were plotted against left atrial pressure = LAP and correlated with myocardial lactate extraction. After CPB, CI and LVSWI increased 52 to 53% and 50 to 80%, respectively, in the patients with NLVFP. In the patients with preoperatively ELVFP SVI did not increase significantly with increasing LAP, resulting in no augmentation of CI and LVSWI. Total systemic resistance increased in these patients, and myocardial lactate metabolism shifted to production in the patients with severe aortic stenosis. Thus, the results show that SVI, CI and LVSWI cannot be augmented by increasing LAP above 15 mm Hg if preoperative left ventricular function is already impaired. Elevation of LAP above 20 mm Hg can induce myocardial ischemia and cause low cardiac output with increased peripheral vascular resistance.

[Influence of left atrial pressure on left ventricular function after extracorporeal circulation (author's transl)]. / Steuerung des linken Vorhofdruckes zur Optimierung der linken Ventrikelfunktion nach extrakorporaler Zirkulation.

In 10 patients with coronary heart disease, in 9 with advanced mitral and in 11 with aortic valve disease left ventricular function curves were constructed by volume loading immediately after cardiopulmonary bypass. After aortocoronary bypass surgery an approximately linear correlation between both cardiac index and stroke volume index and left ventricular filling pressure was demonstrated. After aortic and mitral valve replacement increase in left ventricular filling pressure above 15 mm Hg failed to result in significant increase in CI and SVI. Apparently, volume loading has limited effects in regulating left ventricular function in advanced aortic and mitral valve disease.