Ageing is associated with deterioration of calcium homeostasis in isolated human right atrial myocytes

Aims

Ageing-related cardiac disorders such as heart failure and atrial fibrillation often present with intracellular calcium homeostasis dysfunction. However, knowledge of the intrinsic effects of ageing on cellular calcium handling in the human heart is sparse. Therefore, this study aimed to analyse how ageing affects key mechanisms that regulate intracellular calcium in human atrial myocytes.

Methods and results

Whole membrane currents and intracellular calcium transients were measured in isolated human right atrial myocytes from 80 patients with normal left atrial dimensions and no history of atrial fibrillation. Patients were categorized as young (<55 years, n = 21), middle aged (55–74 years, n = 42), and old (≥75 years, n = 17). Protein levels were determined by western blot. Ageing was associated with the following electrophysiological changes: (i) a 3.2-fold decrease in the calcium transient (P < 0.01); (ii) reduction of the L-type calcium current (I_Ca) amplitude (2.4 ± 0.3 pA/pF vs. 1.4 ± 0.2 pA/pF, P < 0.01); (iii) lower levels of L-type calcium channel alpha-subunit (P < 0.05); (iv) lower rates of both fast (14.5 ± 0.9 ms vs. 20.9 ± 1.9, P < 0.01) and slow (73 ± 3 vs. 120 ± 12 ms, P < 0.001) I_Ca inactivation; and (v) a decrease in the sarcoplasmic reticulum calcium content (10.1 ± 0.8 vs. 6.4 ± 0.6 amol/pF, P < 0.005) associated with a significant decrease in both SERCA2 (P < 0.05) and calsequestrin-2 (P < 0.05) protein levels. In contrast, ageing did not affect spontaneous sarcoplasmic reticulum calcium release.

Conclusion

Ageing is associated with depression of SR calcium content, L-type calcium current, and calcium transient amplitude that may favour a progressive decline in right atrial contractile function with age.

[Massive haemorrhage after bivalirudin anticoagulation in two heart transplant patients]

Heparin-induced thrombopenia is a common autoimmune complication. It is a prothrombotic state due to the formation of antibodies against heparin/platelet factor 4 complexes. In this situation drugs other than heparin must be used for anticoagulation during extracorporeal circulation (bypass) surgery. Two cases of heart transplantation are presented in whom bivalirudin was used as an anticoagulant during the cardiopulmonary bypass. Severe bleeding complications were observed in both patients. The diagnosis of heparin-induced thrombopenia needs to be improved, as well as the development of protocols for using new drugs other than heparin. For this reason, we have reviewed current protocols and alternative therapies to heparin.

Development of an ionic liquid-based dispersive liquid-liquid microextraction method for the determination of nifurtimox and benznidazole in human plasma

Dispersive ionic liquid-liquid microextraction combined with liquid chromatography and UV detection was used for the determination of two antichagasic drugs in human plasma: nifurtimox and benznidazole. The effects of experimental parameters on extraction efficiency-the type and volume of ionic liquid and disperser solvent, pH, nature and concentration of salt, and the time for centrifugation and extraction-were investigated and optimized. Matrix effects were detected and thus the standard addition method was used for quantification. This microextraction procedure yielded significant improvements over those previously reported in the literature and has several advantages, including high inter-day reproducibility (relative standard deviation=1.02% and 3.66% for nifurtimox and benznidazole, respectively), extremely low detection limits (15.7 ng mL(-1) and 26.5 ng mL(-1) for nifurtimox and benznidazole, respectively), and minimal amounts of sample and extraction solvent required. Recoveries were high (98.0% and 79.8% for nifurtimox and benznidazole, respectively). The proposed methodology offers the advantage of highly satisfactory performance in addition to being inexpensive, simple, and fast in the extraction and preconcentration of these antichagasic drugs from human-plasma samples, with these characteristics being consistent with the practicability requirements in current clinical research or within the context of therapeutic monitoring.

Inferior vena cava obstruction by a cardiac mass: unusual presentation of primary antiphospholipid syndrome

We present a previously healthy 43-year-old woman with a cardiac mass that caused almost total occlusion of the inferior vena cava at its junction with the right atrium. The resected mass proved to be a thrombus. Preoperative imaging tests could not distinguish it from other intracardiac tumors such as myxoma. A postoperative immunological study revealed a primary antiphospholipid syndrome. This case presents an unusual diagnosis of antiphospholipid syndrome and a rare location of a cardiac thrombus.

The Sorin Freedom SOLO stentless aortic valve: easier implantation technique with potentially less risk of complications

Aortic valve replacement by bioprosthesis is increasingly being used. Among these, stentless bioprosthesis is becoming a valid choice due to its potential hemodynamic improvement. The Sorin Freedom SOLO stentless aortic valve (FS) (Sorin Biomedica Cardio, Saluggia, Italy) is widely used, with initial and midterm promising results. It is designed to be deployed in a straightforward manner in the supraannular position with a single running suture due to its reproducible implantation technique. Few specific valve-related complications, such as transient thrombocytopenia or rare thrombotic events, are known. Our experience, after the implantation of 33 Freedom SOLO, suggests that using the classical implantation technique, the noncoronary sinus adopts a conformation that increases the difficulty of the implant. Besides, it could also be distorted increasing the risk of periprosthetic leakage and hypothetically becoming the origin of thrombus. We present an easy and safe variation in the implantation technique of the FS that decreases the technical difficulty of the implantation, reduces the risk of periprosthetic leakage, and may additionally reduce the risk of thrombosis.

Ruling out coronary artery disease with noninvasive coronary multidetector CT angiography before noncoronary cardiovascular surgery

PURPOSE

To assess the usefulness of preoperative coronary computed tomographic (CT) angiography in the detection of coronary artery disease (CAD) in nonselected patients scheduled to undergo noncoronary cardiovascular surgery to avoid unnecessary invasive coronary angiography (ICA).

MATERIALS AND METHODS

The institutional review board approved the study protocol; informed consent was given. This prospective study involved 161 consecutive patients who underwent coronary calcium scoring and coronary CT angiography before undergoing noncoronary cardiovascular surgery. Seven patients were excluded because of contraindications to CT angiography. The major indication of noncoronary cardiovascular surgery was valvular heart disease (121 patients). Follow-up was performed at a median of 20 months to define ischemic events described as acute coronary syndrome or death secondary to acute coronary syndrome, arrhythmias, or cardiac failure. Multivariate analysis was performed to determine predictors of nondiagnostic coronary CT angiography. Kaplan-Meier analysis was performed to evaluate outcome at follow-up.

RESULTS

Twenty-one patients did not undergo surgery, which left 133 patients as the study group. Atrial fibrillation was present in 45 of 133 patients. The interquartile range of the Agatston coronary calcium score was 0-471. Coronary CT angiography was diagnostic in 108 of 133 patients. Of these, 93 of 108 had no significant CAD (≤ 50% stenosis), and noncoronary cardiovascular surgery was performed in them without preoperative ICA. No patients in this group had postoperative ischemic events at follow-up. Coronary CT angiography was nondiagnostic in 25 of 133 patients who were referred for preoperative ICA. Multivariate analysis showed Agatston score to be the only independent predictor of nondiagnostic coronary CT angiography (odds ratio = 1.002; 95% confidence interval: 1.001, 1.003; P = .001). The best Agatston score cutoff for diagnostic coronary CT angiography was 579.

CONCLUSION

In nonselected patients scheduled to undergo noncoronary cardiovascular surgery, preoperative coronary CT angiography was diagnostic in 81% of cases. Preoperative ICA could be safely avoided in patients without significant CAD by using coronary CT angiography. The Agatston score, but not the presence of atrial fibrillation, was an independent predictor of nondiagnostic coronary CT angiography.

SUPPLEMENTAL MATERIAL

http://radiology.rsna.org/lookup/suppl/doi:10.1148/radiol.10100384/-/DC1.

Host cell-derived cardiomyocytes in sex-mismatch cardiac allografts

BACKGROUND

Mesenchymal precursor cells are able to respond to tissue signals and differentiate into a phenotype characteristic of mature cells of that tissue. We sought to investigate whether adult human cardiomyocytes can be derived from recipient precursor cells in sex-mismatched cardiac allografts.

METHODS

We studied four male patients who received hearts from female donors, and four female patients who received an allograft from a male donor. Four sex-matched transplant patients, two of each sex served as controls. Combined fluorescence in situ hybridization with probes specific for X- and Y-chromosomes and immunohistochemistry with alpha-actin was used to identify cardiac muscle cells 4 and 12 months after transplantation. Slides were examined with a fluorescence microscope to detect the presence of male cells with one X and one Y signal in the nucleus, and female cells containing two X signals.

RESULTS

Mature cardiomyocytes from the host (1-2%) were found in five endomyocardial biopsy specimens at 4 months, and in three specimens at 12 months. In addition, recipient cells negative for cytoplasmic alpha-actin were also identified (1-21% per slide). The number of infiltrating recipient cells was not associated with the degree of rejection of the sample or with the number of prior rejection episodes. Echocardiographic evaluation showed no improvement in cardiac performance in hearts from patients with more than 10% chimeric recipient cells.

CONCLUSIONS

Our data confirm the existence of mature cardiomyocytes derived from host cells, likely mesenchymal precursors, in the adult cardiac allograft in vivo.

[Severe abdominal complications in patients treated with heart transplantation: the problem of clinical inexpressiveness]

INTRODUCTION

In transplanted patients, immunosuppressive drugs can mask habitual pathologies that impede their diagnoses and management. Abdominal pathology gives up to 2-20%, 50% of which is surgical, with a mortality of 10-40%. The most frequently detected pathologies are: acute pancreatitis, peptic ulceration and intestinal obstruction.

OBJECTIVES

To determine the alarm parameters, more adequate diagnostic procedures and the most frequent causes of morbidity and mortality in order to attempt to avoid them.

METHODS

In our center 225 heart transplantations were performed from May 1984 to October 1997. The severe abdominal complications, time of appearance, implication of immunosuppressive drugs and presence of rejection were studied in these patients.

RESULTS

35 severe abdominal complications were detected (incidence 12.9%), with the majority differing (> 1 year following transplant). The most frequently detected pathologies were digestive hemorrhages and perforations. Acute pancreatitis was 11%. The immunosuppressive drugs used were prednisona, cyclosporin and azathioprine. In 12 out of 29 patients the abdominal complication was in the context of acute rejection.

CONCLUSIONS

Even with some non-specific abdominal symptoms in these group of patients it is important to rule out severe pathologies such as acute pancreatitis or empty viscera perforation. The detection of amylases and lypases in the blood and an echographic or tomographic abdominal study should be performed early with a digestive hemorrhage it is important to perform an endoscopy. If the surgical intervention seems imminent it's better to perform it without any delay, because it has been demonstrated that the delay is worse than the probable rejection.

Burden of myocardial damage in cardiac allograft rejection: scintigraphic evidence of myocardial injury and histologic evidence of myocyte necrosis and apoptosis

BACKGROUND

Because myocardial damage determines morbidity and outcomes in heart transplant rejection, assessment of total burden of myocardial damage is highly desirable. In addition to myocyte necrosis, programmed cell death, or apoptosis, has recently been shown to contribute to cardiac allograft rejection. In the present study, we noninvasively determined myocardial damage by antimyosin scintigraphy and compared it with necrotic and apoptotic myocardial damage in endomyocardial biopsy (EMB) specimens.

METHODS AND RESULTS

Forty scintigraphic and histologic studies were simultaneously performed. Of these, 19 patients had no EMB evidence of allograft rejection (group I, International Society of Heart and Lung Transplantation [ISHLT] grade 0/4), 12 had mild rejection (group II, ISHLT grades 1A and 1B), and 9 had evidence of moderate allograft rejection (group III, ISHLT grades 2, 3A, and 3B). None of the biopsies demonstrated severe allograft rejection (ISHLT grade 4/4). The severity of global myocyte damage in 40 patients was assessed by antimyosin scintigraphy. Endomyocardial biopsies were performed in these patients within 48 hours of imaging study; biopsy specimens were characterized for presence of myocyte necrosis and apoptosis. Evidence of myocyte necrosis was observed in 9 (23%) of 40 EMB specimens. Nineteen EMB specimens of group I had no inflammation and no myocyte necrosis, 12 of group II specimens showed interstitial mononuclear cell infiltration (only) but no myocyte necrosis, and all 9 of group III specimens had evidence of cellular infiltration and myocyte damage. Myocyte necrosis was assessed by hematoxylin-eosin and trichrome staining of EMB specimens. On the other hand, apoptosis of myocytes, as assessed by TUNEL staining of DNA fragments, was seen in 22 (55%) of the 40 biopsy specimens: 47%, 58%, and 67% in groups I, II and III, respectively. Abnormal antimyosin scan findings, indicating presence of myocardial damage, were observed in 9 of the 19 patients in group I and in all patients in groups II and III. Although positive antimyosin scan results in group III patients are concordant with the presence of histologic myocardial necrosis, myocardial uptake of antimyosin antibodies in groups I and II (no apparent myocyte damage at light microscopic examination) could reflect either sampling error of the biopsy or ongoing apoptotic myocyte damage.

CONCLUSIONS

Apoptosis of myocytes is frequently observed during cardiac allograft rejection. The presence of apoptotic myocytes in the absence of histologic rejection activity in patients with antimyosin uptake suggests that apoptosis could be an additional mechanism of transplant-associated myocardial damage.

Efficacy of augmented immunosuppressive therapy for early vasculopathy in heart transplantation

OBJECTIVES

The present study was undertaken to prospectively and comparatively evaluate the role of serial myocardial perfusion imaging and coronary angiography for the detection of early vasculopathy in a large patient population and also to determine the short- and long-term efficacy of augmented immunosuppressive therapy in the potential reversal of the early vasculopathy.

BACKGROUND

Allograft vasculopathy is the commonest cause of death after the first year of heart transplantation. Anecdotal studies have reported the efficacy of augmented immunosuppressive therapy after early detection of vascular involvement. However, no prospective study has evaluated the feasibility of early detection and treatment of allograft vasculopathy.

METHODS

In 76 cardiac allograft recipients, 230 coronary angiographic and 376 scintigraphic studies were performed in a follow-up period of 8 years. Angiography was performed at 1 month and every year after transplantation, and thallium-201 scintigraphy at 1, 3, 6 and 12 months after transplantation and twice a year thereafter. Prospective follow-up of 76 patients showed that 18 developed either angiographic or scintigraphic evidence of coronary vasculopathy. All episodes were treated with 3-day methylprednisolone pulse and antithymocyte globulin.

RESULTS

Twenty-two episodes of vasculopathy were diagnosed and treated in these 18 patients. Of these 22 episodes, two were detected only by angiography, seven by both angiography and scintigraphy, four by scintigraphy and histologic evidence of vasculitis and nine episodes only by thallium-201 scintigraphy studies. Angiographic and/or scintigraphic resolution was observed in 15 of the 22 episodes (68%) with augmented immunosuppression. The likelihood of regression was higher when treatment was instituted within the first year of transplantation (92%) than after the first year (40%) (p = 0.033). Eighty percent of patients who responded to follow-up.

CONCLUSIONS

The present study suggests that early detection of allograft coronary vasculopathy is feasible with surveillance myocardial perfusion or coronary angiographic studies. When identified early after transplantation, immunosuppressive treatment may result in regression of coronary disease.

[Intramural hematomas of the ascending aorta]

We present four patients with intramural hematomas in the ascending aorta. Diagnostic suspicion was aortic dissection in two of them. Prompt surgical procedures were performed in all of them. After reviewing other series, we conclude that ascending aorta hematomas should be treated as true aortic dissections.

[Minimally invasive aortic valve replacement]

INTRODUCTION

Minimally invasive surgery is being applied to certain procedures in cardiac surgery. Aortic valve replacement presents the highest number of cases in which this approach is feasible.

MATERIAL AND METHODS

Fifteen patients, aged 16 to 75 years, underwent aortic valve replacement through a 10 cm incision at the level of the second intercostal space. Cardiopulmonary bypass was instituted through cannulation of the aorta and the femoral vein.

RESULTS

Adequate exposure of the aortic root was achieved in all cases. Valve replacement was accomplished with a mean ischemic time of 50 +/- 6 minutes and a pump time of 80 +/- 14 minutes. Mean chest drainage was of 310 +/- 251 ml. The patients were discharged between the third and the fifth day of the postoperative course.

CONCLUSIONS

A transverse incision at the level of the second intercostal space provides an excellent exposure for aortic valve replacement. Surgical times are not excessively prolonged and patient's recovery is faster and less painful than with the standard midline sternotomy.

Assessment of the appropriateness of the decision of heart transplantation in idiopathic-dilated cardiomyopathy

One hundred thirty patients with idiopathic-dilated cardiomyopathy were referred for heart transplantation to our center and followed for 18 months. Heart transplantation was performed on 63 patients, 17 patients died before transplantation due to heart failure, and 50 patients never had transplantation. Clinical, electrocardiographic, echocardiographic, and hemodynamic data of the 50 nontransplanted survivors and the 17 patients who died were used to identify independent risk variables with discriminant analysis. Using a statistical model based on the results of discriminant analysis, each of the remaining 63 transplanted patients were predicted as being alive or dead in absence of transplantation. The discriminant analysis identified right atrial pressure, cardiac index, and the New York Heart Association functional class as the strongest predictors of 18-month outcome. The accuracy of the model in predicting survival without transplantation in the nontransplanted group of patients, based on the concordance between actual and predicted outcome, was 85% (kappa = 0.62). Subsequent application of this model to the transplanted group of patients suggested that the decision for transplantation was appropriate in 41 of the 63 patients, and could have been premature in the remaining 22 patients predicted as alive. These results suggest that two-thirds of patients receiving transplants would have died without intervention, but the decision to transplant could have been premature in the remaining patients.

[Peritoneal migration of defibrillator implanted behind the rectus abdominis]

Automatic Implantable Cardioverter Defibrillator (AICD) has become a therapeutic option to malignant ventricular tachyarrhythmias. Its bulky device responds for discomfort and the likelihood of generator extrusion or migration, when implanted under the subcutaneous tissue. Among alternative sites, pre-peritoneal location has several advantages but hides its own risks. We present a generator peritoneal migration from a pocket made behind the rectus abdominis.

The Spanish Monostrut Study Group: a ten-year experience with 8,599 implants

BACKGROUND

The Monostrut valve is a pyrolytic carbon, tilting-disc prosthesis with no welds. After the first implantation in Spain in May 1983, the Spanish Monostrut Study Group was established to evaluate prospectively the performance of the valve using uniform protocols.

METHODS

During a 10-year period, 8,599 Monostrut valves were implanted in 7,317 patients in 22 centers. Mean age was 53.3 +/- 11 years. Of the total group, 3,229 underwent aortic valve replacement, 2,806 had mitral valve replacement, and 1,282 had double valve replacement. Follow-up was 96% complete, with a mean period of 4.3 years and a total of 29,155 patient-years.

RESULTS

The operative mortality rate was 7.2%. The 10-year probability of freedom from valve-related complications and linearized rates (event/100 patient-years in parentheses) were as follows: structural deterioration, 100% (0); nonstructural dysfunction, 96% +/- 0.5% (0.51); thromboembolism, 82.9% +/- 1.5% (1.32); anticoagulant-related hemorrhage, 87.6% +/- 1.4% (0.98); and prosthetic valve endocarditis, 96.1% +/- 0.5% (0.48). There were five obstructive valve thromboses (0.017/100 patient-years). Actuarial freedom from reoperation was 95% +/- 0.5% at 10 years. Actuarial freedom from all valve-related morbidity was 70.2% +/- 1.6%; freedom from all valve-related morbidity and mortality (including operative and sudden deaths) was 62.6% +/- 2% (70.1% +/- 2% for aortic valve replacement, 56.9% +/- 2% for mitral valve replacement, and 59.8% +/- 3% for double valve replacement; p < 0.0001). Clinically, 5,988 patients (94%) are in New York Heart Association class I-II.

CONCLUSIONS

The Monostrut valve has shown no structural failures and a low rate of valve-related complications over a 10-year period in a large patient population.

[Etiologic and pathologic study of respiratory disease in lambs from intensive breeding facilities in southern Spain]

Between 1991 and 1993, it was observed epidemiologically that respiratory disturbances in lambs are associated with high temperatures during the summer. The etiological agent isolated is principally Mycoplasma ovipneumoniae; moreover, Actinobacillus pleuropneumoniae biovar A has been isolated in a high number of samples. Histopathologically, an interstitial bronchopneumonia was the main lesional finding; this lesion is associated with previous mycoplasma infection.

Doppler-derived gradients in normally functioning Monostrut Björk-Shiley prostheses

In summary, reference values of Doppler gradients obtained in a large number of patients with normal-functioning mitral and aortic Monostrut Björk-Shiley prostheses are reported. It is shown that the value of the transprosthetic gradient increases with decreasing valve size in patients with aortic prostheses. No individual significant variations of the transprothetic Doppler gradient during a 3-year follow-up were observed.

[A report of a rare case of primary angiosarcoma of left atrium and a review of the literature]

A 66[correction of 60]-year-old female patient was admitted to hospital for clinical signs of pericardial tamponade. The pericardiocentesis revealed an hematic effusion and a left appendage mass was diagnosed by transesophageal echocardiography. At surgery, a left atrial tumour was resected which histological examination showed to be an undifferentiated angiosarcoma-endothelioma with difficult histological classification. The tumoral screening was negative and the patient was discharged from the hospital. Seven months later the patient was readmitted for two parasternal tumours which anatomopathologic study revealed to be subcutaneous metastases. The rare localization in the left atrium and subcutaneous metastatic spread were discussed.

[Cardiovascular surgery in Spain in 1992. The Registry of Operations of the Spanish Society of Cardiovascular Surgery (SECCV)]

The Spanish Society of Cardiovascular Surgery Registry of 1992 includes data from 41 centers. Within this year a total of 24,127 patients were operated on, with an average of 588 operations/center. Twelve thousand twenty-two of these were cardiac operations under extracorporeal circulation, with an average of 300 cases/hospital. The average of cardiac surgeons/hospital was 5.9 and the average of open heart operations/surgeon was 50. For the first time, the number of coronary bypass surgeries was superior to that of valvular procedures (5,049 vs 4,951). In the coronary bypass patients the average of grafts/patient was 2.43. The number of valvular prostheses implanted was 5,526 and 81% of these were mechanical. The number of patients operated on for congenital cardiac defects was 2,251 (1,278 open heart surgeries and 973 closed). The global mortality in the patients operated on under extracorporeal circulation was 7.6% (7.0% in valvular, 7.9% in congenital and 5.4% in coronary bypass). There were 6,054 patients subjected to surgery for peripheral vascular disease.

[Complications associated with nonfunctioning pacemaker electrodes retained within the cardiovascular system]

INTRODUCTION AND OBJECTIVE

The aim of the present study was to evaluate the complications in patients with functionless pacing leads retained in the cardiovascular system.

PATIENTS AND METHODS

We retrospectively studied 39 patients: 31 underwent surgery for electrical or mechanical failure (group I) and eight for cutaneous pocket infection (group II). The follow-up was 45 +/- 34 months.

RESULTS

Only one patient (3%) from group I presented infectious complications probably related to the retained pacing lead. Seven patients (87%) in group II presented recurrence of the infection with persistent fever and/or septicemia due to skin erosion and unnoticed pacing lead infection (p < 0.0005). Removal of the infected generator was performed in 8/39 (21%) of the patients. Thoracotomy to explant the infected retained leads was required in five of them (62%). No patient presented lead migration or venous thrombosis during the follow-up.

CONCLUSIONS

Retained pacing leads in the cardiovascular system are well tolerated. However, in spite of adequate antibiotic treatment, patients with local and pacemaker system infection may present recurrence of the infection with persistent fever and/or septicemia. Early surgical pacemaker system removal is recommended in these patients due to the high morbidity.

[The National Data Bank of the Spanish Society of Cardiovascular Surgery. The pilot experience]

Since 1988, the Spanish Society of Cardiovascular Surgery has been enjoying through its National Intervention Registry a complete information about the number and type of cardiovascular surgical operations, yearly performed all over the country. However a computerized National Data Bank would probably offer a more specific, quick and complete information, although its organization is more complex. We want to demonstrate that the creation of a National Data Bank is possible in our country. The following condition has been essential to carry out this initial work on the National Data Bank: The previous existence of a National Intervention Registry, the edition of an universally accepted questionnaire of 33 questions with multiple answers for each question, which includes quantitative and qualitative aspects like mortality, the acquisition of the software Pats Programme by most cardiovascular centers, and finally the enthusiastic dedication of 6 surgical groups. The results of this work also shown in multiples figures, are the final product of the computerized fusion of 6 cardiovascular centers data on operations performed through the year 1991. The results clearly offer a more specific, detailed and extensive information about quantitative and qualitative aspects of the surgical data, than that obtained through the National Intervention Registry. These results should not be extrapolated at national level, as the surgical groups involved in this work are not homogeneous and its number is quite small. This initial study shows that the creation of the National Data Bank of the Spanish Society of Cardiovascular Surgery or other scientific society is possible in our country. Its usefulness is beyond any doubt.

[The implantation of a sequential endocavitary pacemaker in a patient with transposition of the great vessels after the Mustard correction]

A 31-year-old male patient, underwent Mustard operation in childhood for complete transposition of the great arteries. He required a sequential (DDD-mode) pacemaker due to a complete symptomatic auriculoventricular block, 25 years after the operation. Wires were inserted through the left cephalic vein and placed in the systemic atrium and ventricle, achieving correct sensing and stimulating thresholds. Atrial rhythm disturbances, specially sinus node dysfunction, are frequent after Mustard's operation and increase through the years following the surgical procedure. Atrioventricular conduction disturbances are rare. Treatment by endocavitary pacemaker implies a correct knowledge of the special anatomy in this congenital disease and its surgical correction.

Subacute cardiac rupture: repair with a sutureless technique

Thirteen patients with ages between 53 and 74 years had development of free wall left ventricular rupture after a myocardial infarction (mean interval, 3.8 days). All patients showed clinical signs of cardiac tamponade. Diagnosis was established by bedside multiple pressure monitoring and echocardiography, which showed pericardial effusion with compression of the right ventricle. Cardiac catheterization was not performed. A new surgical technique was employed for the repair. After the pericardium was opened and cardiac tamponade was relieved, the myocardial tear was identified. A Teflon patch was applied over the area and glued to the heart surface with a surgical glue (cyanoacrylate). Cardiopulmonary bypass was not used except in a patient with a posterior tear. The method was consistently effective in controlling bleeding from the myocardial tear. All patients survived the operation and were discharged from the hospital a mean of 15 days after the operation. Follow-up extending up to 5 years (mean, 26 months) shows a 100% survival, 11 asymptomatic patients, and 2 patients with mild exertional angina. The technique is a simple, effective, and safe method for repair of subacute cardiac rupture and obviates the need for suturing on an infarcted ventricle.

[Cardiovascular surgery in Spain in 1991. Registry of operations of the Spanish Society of Cardiovascular Surgery (SECCV)]

The Spanish Society of Cardiovascular Surgery has sent a questionnaire to all 37 cardiovascular surgical groups to know the number and type of cardiovascular operations carried out in our country during 1991. The questionnaire was answered by 36 out of 37. In the year 1991, 21,771 cardiovascular patients have been operated upon and 10,913 interventions with extracorporeal circulation have been carried out: 42.4% in valvular disease, 37.2% in coronary and 11.2% in congenital. The number of operations was 5,415 for vascular disease, 4,627 for valvular, 3,168 for coronary, 1,896 for congenital and 3,741 for pacemaker implantation. The total number of operations in 1991 comparing to those performed during 1988 is similar; but the number of open heart operation and the number of these per cardiac unit and per million population during 1991 have increased 20.5, 13.9 and 24.3% respectively. Coronary and valvular operations have also increased 11 and 27% respectively, as well as the number of pacemaker implanted (30%). The number of congenital cases remains the same and the number of vascular operations has decreased by 7.9%.

[An aortobronchial fistula 11 years after the resection of a posttraumatic aortic aneurysm]

A case of a 47-year-old white male who developed an aortobronchial fistula eleven years after resection of a posttraumatic aneurysm of the descending aorta is presented. The clinical picture, the diagnostic problems as well as the treatment are presented and commented.

Hemodynamic effects of prostaglandin E1 and isoproterenol early after cardiac operations for mitral stenosis

Patients with mitral stenosis and some degree of right ventricular failure may benefit from inotropic or pulmonary vasodilator drugs in the early postoperative period. Thirty patients undergoing an operation for mitral stenosis were randomized into three groups. In group I (n = 10), isoproterenol (5 micrograms/kg/min) was started in the immediate postoperative period. In group P (n = 10), prostaglandin E1 (0.08 microgram/kg/min) was given, and in group C, the control group (n = 10), no drugs were used. After the operation and before drug therapy was begun, basal measurements of cardiac index, mean pulmonary arterial and mean arterial pressures, and pulmonary vascular resistance were taken. Measurements were repeated at 6, 12, and 24 hours. Mean measurements of cardiac index (basal up to 24 hours) were as follows: 1.39 +/- 0.3, 1.92 +/- 0.4, 2.4 +/- 0.5, and 2.34 +/- 0.3 L/min/m2 for group C; 1.54 +/- 0.5, 2.64 +/- 0.4, 2.68 +/- 0.7, and 2.2 +/- 0.6 L/min/m2 for group I, and 1.57 +/- 0.3, 2.2 +/- 0.6, 2.72 +/- 0.7, and 2.27 +/- 0.4 L/min/m2 for group P (p less than 0.05 between groups C and I at 6 and 12 hours). Mean pulmonary artery pressures were as follows: 19.5 +/- 3.2, 24.8 +/- 7, 27.7 +/- 7.3 and 28.8 +/- 5.7 mm Hg in group C; 21.4 +/- 8.7, 25.7 +/- 7.2, 26.4 +/- 7, and 29.4 +/- 8.6 mm Hg in group I, and 19.1 +/- 4, 19.2 +/- 3, 20.4 +/- 6, and 20.7 +/- 5 mm Hg in group P (p less than 0.05, group P versus groups C and I at 6, 12, and 24 hours). Mean pulmonary vascular resistances were as follows: 3.9 +/- 2.4, 3.9 +/- 1, 3.36 +/- 2, and 3.2 +/- 1.4 Wood units in group C; 4.84 +/- 4, 3.37 +/- 2.2, 3.69 +/- 3, and 4.69 +/- 4.1 Wood units in group I, and 3.29 +/- 1.3, 1.71 +/- 0.5, 1.61 +/- 0.5, and 1.96 +/- 0.8 Wood units in group P (p less than 0.05, group P versus groups C and I at 6, 12, and 24 hours). There was no difference in mean systemic arterial pressure among the three groups. Our results indicate that patients subjected to mitral valve operations have a low cardiac index. Isoproterenol increases cardiac index but has little effect on pulmonary resistance. At low doses, prostaglandin E1 effectively decreases pulmonary vascular resistance without altering systemic arterial pressure or heart rate.

The Monostrut Björk-Shiley valve. Seven years' experience

The results of cardiac valve replacement with the Monostrut Björk-Shiley prosthesis (Shiley, Inc., Irvine, Calif.) during a 7-year period are presented. A total of 984 valves were implanted in 820 patients from May 1983 to April 1990. Aortic valve replacement was performed in 378 patients, mitral replacement in 294, and multiple replacement in 148. In addition, 180 patients (22%) underwent associated procedures. Mean age was 52.6 +/- 11 years. Operative (30 days) mortality was 5.9% (49 patients): 3.9% (15 patients) for aortic, 7.8% (23 patients) for mitral, and 7.4% (11 patients) for multiple valve replacement. All patients were given long-term anticoagulation therapy. Follow-up was 99% complete (eight patients were lost to follow-up), with a closing interval of 3 months, and totaled 2422 patient-years. Valve-related complications, expressed as percentage event-free (+/- standard error) at seven years were as follows: structural deterioration, 100%; nonstructural dysfunction, 98.3% +/- 0.6%; thromboembolism, 90.2% +/- 1.7%; anticoagulant-related hemorrhage, 88.7% +/- 2.8%; and prosthetic valve endocarditis, 98.1% +/- 0.8%. There were no cases of valve thrombosis. Actuarial survival (free from operative, valve-related, and sudden death) was 88.4% +/- 1.2% at 7 years. Freedom from reoperation was 96.8% +/- 0.1%. Probability of being free from all valve-related morbidity and mortality was 70% +/- 3%, and 708 (93%) of the survivors were in New York Heart Association class I or II. Serial Doppler echocardiograms were done prospectively in 243 patients (with 154 aortic and 120 mitral prostheses), both postoperatively and at regular intervals up to 3 years. Mean prosthetic gradients ranged from an average of 20.9 to 7 mm Hg in the aortic prostheses (21 to 29 mm) and from 6.1 to 4.8 mm Hg in the mitral prostheses (25 to 31 mm). The gradients in each patient did not change significantly during the follow-up period. Our 7 year's experience with the Monostrut valve shows a low rate of valve-related complications, a durable design, and good hemodynamic and functional results.

[An obstruction of a valve prosthesis implanted in the tricuspid position]

Dysfunction of a prosthesis implanted in tricuspid position is a severe complication that may develop with minimal symptoms. A patient who presented clinical manifestations of heart failure for two weeks due to obstruction of a mechanical prosthesis in tricuspid position is described. Fibrinolytic treatment was given unsuccessfully, therefore prosthetic replacement was performed. In the removed prosthesis, a fibrotic pannus which developed in the strut and disc was seen. We review the clinical manifestations, the diagnosis and treatment of the dysfunction of a prosthesis implanted in tricuspid position.

[The long-term results of aortocoronary bypass surgery in patients with a severe preoperative left ventricular dysfunction]

We analyze retrospectively the short- and long-term results of coronary artery bypass surgery in 50 patients with severe left ventricular dysfunction operated in a period of 11 years. Sixty-six percent of patients had unstable angina and 12% of total presented angina post-acute postmyocardial infarction. Thirty-eight percent of patients were in preoperative functional class III-IV of NYHA. Three-vessel disease was present in 70% of the patients, two-vessel in 30%, and the main trunk was affected in 12% of the global. Hospital mortality was 4% (2/50) due to low cardiac output syndrome. Follow-up was available in all the survivors and ranged 6 months-11 years (mean: 4.8 +/- 3.1). During follow-up, 13 patients died, but in only six was due to cardiac cause. The 35 patients followed were in functional class I-II of NYHA. Eighty-eight percent of the patients were angina free at follow-up. Actuarial analysis, after exclusion of 3 patients who died of causes no directly related to the heart, showed an intrahospital survival rates of 96%; at first year was 92, at 3rd was 78%, and 5th year survival rates were 75%. In conclusion, patients with symptomatic angina and preoperative severe left ventricular dysfunction, coronary artery bypass graft has a low hospital mortality, is effective in improving angina and heart failure, and the long-term survival is acceptable.

[The single coronary artery. Presentation of a case]

A patient with a single coronary artery originating in the right coronary sinus is presented. The condition was diagnosed during aortic valve replacement surgery and later confirmed by coronary angiogram. The clinic significance in relation to the anomalous course of the coronary artery and the importance of correct diagnosis prior to cardiac surgery is discussed.

[Aortic subvalvular annular aneurysm after closed thoracic traumatism. Presentation of a case]

A case of a 29 year old man with congenital aortic stenosis who developed a subvalvular annular aneurysm of the left ventricle after being run by a car is presented. At surgery his aortic valve was replaced and the opening of the aneurysm was closed with a patch of Dacron. Due to the dense adhesions to the aorta and left atrium no attempts were made to excise the sac, that was not compromising the dynamics of any one of these structures.

[Long-term results in patients with tricuspid prosthesis]

A retrospective study was undertaken of 31 patients submitted to tricuspid valve replacement between 1977 and 1988, either alone or associated to mitral or aortic replacement. The cause of the tricuspid lesion was rheumatic in 19 patients, congenital in seven, prosthetic valve thrombosis in two and miscellaneous in the remaining 3 patients (endocarditis, carcinoid syndrome, iatrogenic operative tricuspid regurgitation). Of the 31 tricuspid prostheses reviewed, 26 were mechanical (St Jude, Björk-Shiley) and five of the biological type (Ionescu, Hancock). Results showed that 25% of patients died in the hospital; 75% of them had been operated previously. With a follow-up averaging 3.9 years the complications related with the prosthesis were: thrombosis of the tricuspid prostheses in 1 patient (1.2% patients-year) and hemolytic anemia in another. Ninety percent of patient included in the follow-up were in NYHA class I or II. Three patients (14%) died due to a cause not directly related to the prosthesis. An actuarial analysis showed intrahospital survival rates of 55%, 100% and 75% in patient with 3, 2 and 1 prostheses, respectively; at 6 months postoperatively the figures were 55%, 87% and 75%, and at a follow-up of 3 years, 55%, 67% and 66%. In conclusion, in patients submitted to a tricuspid valve replacement mortality is high before hospital discharge, and is related to the clinical situation. A sustained improvement is observed in survivors once discharged, independently of the number of prostheses implanted. Complications related to the tricuspid prosthesis are comparable to those observed with prostheses in mitral or aortic position.

Reversal of rejection-induced coronary vasculitis detected early after heart transplantation with increased immunosuppression

Four patients who underwent heart transplantation, in whom coronary obstruction was seen early after transplantation, are described. Repeated acute rejection episodes were detected within the first 2 months in each patient. Coronary obstruction or ischemia was shown through a combination of T1-201 isotopic study findings, evidence of vasculitis of a small coronary arteriole seen at endomyocardial biopsy, or coronary angiographic results. Vigorous treatment for rejection (antithymocyte globulin and bolus methylprednisolone) was given, and coronary artery lesions or myocardial ischemia resolved after treatment. Rejection-induced coronary obstruction should be considered in patients with repeated acute rejection episodes who are predisposed to the development of vascular rejection. Early after transplantation such obstruction is caused by diffuse vasculitis of small and medium-sized vessels and may be reversed with increased immunosuppression.

Dopamine treatment of locally procured donor hearts: relevance on postoperative cardiac histology and function

Administration of catecholamines can lead to myocyte damage. Dopamine treatment is often used in potential cardiac donors to attain hemodynamic stability. Donor hearts exposed to dopamine are rejected or selected for transplantation without clearly defined criteria. A prospective study was undertaken to analyze the clinical relevance of dopamine-induced myocardial lesions in 25 hearts (21 male, 4 female; 15-40 years, mean: 26 +/- 7) that were later used for transplantation. Donors were divided into those who had received dopamine and those who had not. Dopamine doses ranged from 2-12.5 micrograms/kg/min (mean: 6.3 +/- 3). Time of administration was 3-26 hours (mean: 16 +/- 8). Use of dopamine was unrelated to donor electrocardiographic findings, intra- or postoperative death, or difficulty coming off by-pass. Postoperatively, filling pressures were similar in both groups of patients at 2 and 10 days postoperatively. Left ventricular ejection fraction was similar in the two groups. Dopamine requirements were significantly higher in the dopamine-treated hearts (P = 0.05). Histologic findings at first biopsy revealed infiltration and cell damage in a similar proportion of patients in both groups.

IN CONCLUSION

donor hearts exposed to dopamine can be accepted for transplantation if doses ranging from 2-12.5 micrograms/kg/min have been administered up to 24 hours.

Sutureless repair of postinfarction cardiac rupture

A 62-year-old female with a history of progressive angina experienced an acute myocardial infarction. Seven days later, cardiac rupture ensued. She underwent surgical repair without the aid of extracorporeal circulation. A Teflon patch was glued over the myocardial tear with medical adhesive. She recovered and is leading a normal life, 15 months after surgery.

Non-invasive preoperative assessment of chronic valvular heart disease by Doppler ultrasound

Between February 1986 and June 1987, 306 consecutive patients were included in a programme of non-invasive preoperative assessment of valvular heart disease using M-mode and cross-sectional echocardiography and Doppler ultrasound. In 285 cases (93%), echocardiography provided all the necessary preoperative information. Coronary angiography was performed in 74 patients because of angina and in 55 because of their age. Invasive investigation was needed in 21 cases because of discrepancies between clinical data and echo-Doppler results. The results were definitely misleading in six patients, mainly due to erroneous assessment of valvular regurgitation. One hundred and ninety one patients underwent valve surgery (179 evaluated exclusively by echocardiography, 79 with coronary angiography as the sole invasive procedure). No discrepancies were observed between echo-Doppler diagnosis and macroscopic evaluation of valvular heart disease at surgery. Operative mortality (3.6%) was not significantly different from that observed during the preceeding period when preoperative catheterisation was performed (3.3%). It is concluded that echo-Doppler techniques are perfectly satisfactory for the preoperative assessment of patients with valvular heart disease. Cardiac catheterisation is only infrequently required, although coronary angiography remains mandatory in a selected group of these patients.

Clinical and hemodynamic results of cardiac valve replacement with the Monostrut Björk-Shiley prosthesis

Between May 1983 and April 1986, 318 patients underwent cardiac valve replacement with the Monostrut Björk-Shiley prosthesis. There were 136 aortic valve replacements, 128 mitral valve replacements, and 54 multiple replacements. A total of 373 valves were implanted. Associated procedures were done in 79 (25%) of the patients. Hospital (30-day) mortality rate was 5.6% (18 patients): 2.9% (n = 4) after aortic, 7.8% (n = 10) after mitrals and 7.4% (n = 4) after multiple valve replacement. Follow-up was obtained in all 300 operative survivors, for a total of 500 patient-years (mean 18 months). Actuarial survival rate, excluding operative deaths, at 4 years was 94.7% +/- 1.5% (mean +/- standard error of the mean). There were 16 thromboembolic episodes (3.2/100 patient-years). Freedom from all valve-related complications was 87% +/- 2.4% at 3 1/2 years. Neither valve thrombosis nor structural failure has been observed. Eighty percent of the patients are in New York Heart Association functional class I. Forty-two patients (26 with aortic and 16 with mitral valve replacement) underwent cardiac catheterization a mean of 6 1/2 months after the operation. In the aortic position, peak gradients were an average of 6.9 +/- 1.2 mm Hg. Mean systolic gradients were 12.4 +/- 6.3 mm Hg and did not increase with exercise. In the mitral position, end-diastolic gradients were an average of 2.1 +/- 2 mm Hg and mean gradients, 5.9 +/- 2 mm Hg. Discharge coefficient (estimated orifice area/geometric area) was 0.63 +/- 0.2 for the aortic and 0.53 +/- 0.2 for the mitral prostheses. Disc opening was maximal in most patients. These results indicate that the Monostrut prosthesis has a low rate of thromboembolic events, no structural failures or thrombotic obstructions and excellent hemodynamic performance, especially in the small aortic sizes (discharge coefficient for 19 and 21 mm valves, 0.77).

Long-term results of mitral valve surgery in patients with severe pulmonary hypertension

Mitral valve surgery was performed in 88 patients with severe pulmonary hypertension (average systolic pulmonary artery pressure, 94.7 +/- 22 mm Hg; range, 70-180 mm Hg) over a 10-year period. Sixty-four patients (73%) were in New York Heart Association Functional Class III or IV. There were 64 valve replacements and 24 open mitral commissurotomies. Operative mortality was 5.6% (5 patients) and was not related to the degree of pulmonary hypertension, surgical procedure performed, or type of valve lesion. A 100% follow-up was obtained, ranging from nine months to 10 years, with a mean of 44 months. Six late cardiac deaths (7.2%) occurred, 5 in patients with valve replacement and 1 in a patient who underwent a commissurotomy. Actuarial survival was 86 +/- 3% at five years and 83 +/- 4% at 10 years. Fourteen patients underwent right ventricular catheterization a mean of 24 months following operation. Systolic pulmonary artery pressure had decreased from a mean preoperative value of 101 +/- 22 to 40.5 +/- 7 mm Hg (p less than 0.001). Cardiac index increased by 55% of the preoperative values. Functional status improved markedly; 71 survivors (93%) were in New York Heart Association Class I or II. These results indicate that, in patients with mitral valve lesions and severe pulmonary hypertension, (1) surgical procedures can be performed with an acceptable operative mortality; (2) excellent long-term survival and functional results can be obtained; and (3) pulmonary hypertension decreases significantly after operation.(ABSTRACT TRUNCATED AT 250 WORDS)

Spontaneous rupture of the ascending aorta

A case of non-traumatic rupture of the ascending aorta in an hypertensive patient is presented. The clinical findings suggested acute aortic dissection but the typical angiographic features of this entity were not found.

Creation of an atrial septal defect for acute postperfusion right ventricular failure

Acute postperfusion right ventricular failure following mitral and aortic valve replacement in a patient with severe double-valve incompetence secondary to endocarditis is presented. The situation was reversed by creating an atrial septal defect that decompressed the right ventricle and increased left ventricular filling pressure.

Surgical management of aortic coarctation associated with ruptured cerebral artery aneurysm

We report two patients with coarctation of the aorta who were admitted to the hospital with ruptured cerebral artery aneurysms. In both patients, we surgically treated the coarctation and later repaired the intracranial lesion. One patient, a 34-year-old woman, is alive and well after 3 years; whereas, the other, a 19-year-old man, did not survive. We discuss the sequence for surgery, which continues to be subjected to debate.

Prediction of hematocrit changes in open-heart surgery without blood transfusion

The changes in hematocrit during the intra and postoperative period were studied in 50 patients who underwent uncomplicated open-heart procedures and who did not receive blood or blood products during their hospital stay. Priming of the extracorporeal circuit and blood volume replacement postoperatively was done with crystalloid solutions exclusively. Mean preoperative hematocrit was 44% and dropped to 30.8% during the pump run. Lowest postoperative hematocrit was on the fourth day (mean: 29.3%) but it never went below 50% of the preoperative value. The percentage of the initial hematocrit was calculated for all patients at each time point and a median curve was constructed. Then, the curve of each patient was compared to this median curve. Patients with values below the median curve at one point at least had a larger amount of intra and postoperative fluid replacement than patients that stayed above the median at all times. We conclude that non-transfused open-heart surgical patients do not develop severe anemia and that changes in the hematocrit values can be predicted according to the median curve constructed and to the amount of crystalloid solution given during and after surgery.

Clinical evaluation of a new temporary pacemaker wire

A newly designed temporary pacemaker wire has been tested in 20 patients who underwent open-heart operations. This new device has a small tip that stays securely buried in the myocardium, thus greatly reducing the risk of accidental dislodgment. In addition, the increase in thresholds during the postoperative period is slighter than with the standard electrode.

"Shoehorn technique" for inserting Ionescu-Shiley valves in the mitral position

A technique is described for safer and easier insertion of the Ionescu-Shiley valves at the mitral level by using the same principle that applies in the use of a shoehorn.