Thromboembolic complications in patients with arrhythmogenic right ventricular dysplasia/cardiomyopathy

AIMS

Incidence and clinical presentation of thromboembolic complications in patients with arrhythmogenic right ventricular dysplasia/cardiomyopathy (ARVD/C) were analysed. In reports on ARVD/C, thromboembolism is rarely mentioned. The possible risk factors are: right ventricle (RV) dilatation, aneurysms, and wall motion abnormalities.

METHODS AND RESULTS

A group of 126 patients (89 male, 37 female, aged 43.6+/-14.3) with ARVD/C was retrospectively analysed for the presence of thromboembolic complications. The mean follow-up period was 99+/-64 months. Thromboembolic complications, i.e. pulmonary embolism (n=2), RV outflow tract thrombosis with severe RV failure (n=1), and cerebrovascular accident associated with atrial fibrillation (n=2) were observed in 4% of the patients. Spontaneous echogenic contrast was observed in seven patients with severe damage to RV. In four of them supraventricular arrhythmias resulting in heart failure were reported. Annual incidence of thromboembolic complications was 0.5/100 patients.

CONCLUSIONS

(i) ARVD/C may be complicated by thrombosis. Annual incidence of such complications is significantly lower than reported for left ventricle failure. (ii) Anticoagulation should be used in ARVD/C patients with large, hypokinetic RV and slow blood flow. (iii) Patients with severe forms of ARVD/C, thrombus formation in the RV and/or spontaneous echocardiographic contrast are at higher risk of a poor outcome.

Arrhythmogenic right ventricular cardiomyopathy in two pairs of monozygotic twins

Arrhythmogenic right ventricular cardiomyopathy (ARVC) is an inheritant disease with an autosomal dominant mode of transmission with incomplete penetrance and variable expression. Linkage analysis in affected families succeeds in identifying 9 loci determining 9 subtypes of the disease. Genotype phenotype correlation is unclear and the influence of various environmental factors is discussed.

OBJECTIVES

Genotype phenotype correlation in 2 pairs of monozygotic twins with ARVC and the role of environmental factors are analyzed.

PATIENTS AND METHODS

Among 40 pts with ARVC and their 195 relatives there were 2 pairs of monozygotic twins: brothers, age 47 y; and sisters, age 48 y. History, ECG, Holter monitoring, 2D and Doppler Echo, and MRI were analyzed.

RESULTS

Twin brothers: ARVC was diagnosed in the proband after the episode of VT with LBBB morphology (enlarged right ventricle, focal hypokinesia of apex, MR evidence of adipose tissue in RV wall). Identical morphology of RV was seen in asymptomatic twin brother. The patient presenting arrhythmia has been rowing for 4 years. Twin sisters: diagnosis was done during family screening. Both were asymptomatic. RV morphology typical for ARVC was found discrete in one of them (bulges adipose tissue in the RV apex); the latter showed changes suggesting RV abnormality (mild segmental dilatation of infundibulum, adipose tissue in a free wall of the RV). No differences in previous viral infections and sports involvement were observed.

CONCLUSIONS

1. Clinical picture of ARVC in monozygotic twins is not identical. 2. Strenuous effort may be a factor triggering the arrhythmia in pts with ARVC.

Familial form of arrhythmogenic right ventricular cardiomyopathy

BACKGROUND

Arrhythmogenic right ventricular dysplasia (ARVD) is characterised by fatty and fibrous infiltration of myocardial muscle. Clinical symptoms include dangerous cardiac arrhythmias and heart failure in the advanced form of the disease. ARVD is genetically determined in at least 50% of cases and is characterised by a marked variability of clinical presentation within one family.

AIM

To assess the prevalence of the familial form of ARVD in Poland, the mode of inheritance and the risk of sudden cardiac death as well as heart failure development in asymptomatic patients, in whom ARVD was detected during family screening.

METHODS

211 relatives of 40 patients with ARVD were examined. Thirty two families were identified in which at least two members had the disease. The analysed parameters included family history, physical examination, ECG, echocardiography and magnetic resonance.

RESULTS

Abnormalities of the right ventricle and/or cardiac arrhythmias suggesting ARVD were found in 71 subjects (mean age 32.4 years). In 28 cases ARVD was diagnosed. From this group, one patient had aborted sudden death. In the remaining 43 subjects a borderline form of the disease was detected. Of this group, one patient died suddenly. The degree of morphological changes in cardiac muscle correlated with patients' age.

CONCLUSIONS

1. The familial form of ARVD is frequent in Poland. 2. ARVD is inherited in an autosomal dominant mode. 3. Sudden cardiac death may be the first symptom of the disease, even in subjects with borderline ARVD. 4. ARVD is a progressive disease. Concomitant left ventricular involvement is not rare and probably represents a late stage of the disease.

[Which echocardiographically unrecognised complications of native aortic valve endocarditis may be found during operation?]

The aim of the study was to determine the type and localisation of complications of aortic valve endocarditis, that have not been recognised on transthoracic (TTE) and/or transesophageal (TEE) echocardiographic study. The echocardiographic findings were retrospectively compared and contrasted with direct surgical inspection in 156 consecutive adults operated on native aortic valve endocarditis in our institute during the last 8 years. We analysed recognition of abscess, pseudoaneurysm, fistula and cusp rupture. Periannular complications were detected at operation in 51 pts, cusp rupture in 97 pts. Sensitivity of TTE in recognition of abscesses was 55%, TEE--60%; pseudoaneurysm--TTE--64%, TEE--100%; fistula--TTE 60%, TEE 100%; cusp rupture--TTE 65%, TEE 81%. Both echocardiographic methods have some inherent limitations while diagnosing complications of aortic valve endocarditis. In particular, these include small abscesses and cusp rupture. Using both modalities in a complementary way seems to offer the best approach in overall definition of the extent of inflammation.

Day-to-day reproducibility of Holter beat-by-beat analysis of repolarisation

Reproducibility of Holter QT analysis is not well established and has been assessed only in one study.

STUDY DESIGN

We evaluated the day-to-day reproducibility of different QT parameters--mean and max (four beats basis) 24h QT and QTc (Bazett formula), QT for heart rate 55-60 [QT60], 75-80 [QT80] and 95-100 [QT100] beats/min and QT/RR slope (calculated in moving window of 3000 beats in 50 beat steps). QT intervals were measured from 48h digital ECG (sampled at 256 Hz) recordings using Del Mar Medical's QT software in beat-to-beat fashion. The analysed group consisted of 6 women and 24 men--13 patients with hypertrophic cardiomyopathy, 5 healthy family members of the patients with hypertrophic cardiomyopathy, 7 patients with CAD and 5 with other diseases (hypertension, arrhythmia, aborted sudden death without organic heart disease). Reproducibility was analysed with the methods proposed by Bland and Altman.

RESULTS

The overall reproducibility of repolarisation parameters was acceptable. Coefficient of reproducibility for mean 24h QT was 24ms, mean QTc 12ms, max QT 22ms, max QTc 24ms. The best reproducibility was observed for QT60, QT80 and QT100 - 12ms, respectively. The poorest day-to-day reproducibility was recorded for the QT/RR slope parameters, which was related to lower heart rate reproducibility.

CONCLUSIONS

We can conclude that day-to-day reproducibility of Holter repolarisation analysis is acceptable. QT measurement in narrow heart rate windows has the best reproducibility. Accurate QT analysis requires good quality recording, T wave amplitude above 0.2mV and an interactive QT measurement tool which includes verification, editing abilities.

The rupture of periaortic infective aneurysm into the left atrium and the left ventricular outflow tract: preoperative diagnosis by transthoracic echocardiography

We present a rare complication of infective endocarditis, perforated periaortic abscess with fistulous communication between the aortic root, the left atrium, and the left ventricular outflow tract. Preoperative transthoracic echocardiographic diagnosis was confirmed intraoperatively. The patient was treated successfully by aortic homograft implantation.

[Echocardiographic evaluation of left atrial function in dilated cardiomyopathy with restricted and non-restricted Doppler transmitral flow]

Left atrial (LA) function is of great importance in left ventricular (LV) filling. There is evidence that echocardiographic Doppler evaluation of transmitral flow, routinely used for LV filling estimation, is dependent on LA function. Information regarding the relation of LA size and function to transmitral flow in heart failure is limited. We used 2D echocardiographic acoustic quantification methods to assess LA function in patients with dilated, (non-ischemic) cardiomyopathy (DCM) and a control group. The DCM group was divided into 2 subgroups: Group 1-with restrictive LV Doppler filling pattern-18 patients (DCM-R) and Group 2-with non-restrictive LV Doppler filling pattern-11 patients (DCM-NR) with similar heart rate, age and degree of mitral regurgitation. LA maximal area, total emptying fraction and absolute and fractional area change during rapid emptying and atrial contraction were calculated. The LA was enlarged only in DCM-R. Both DCM groups had decreased total emptying fractions and rapid emptying area changes compared to controls. An enlarged LA area and more decreased total emptying were found in DCM-R with high LV filling pressures compared to DCM-NR. The restrictive group had a significantly smaller LA rapid emptying area change, as well as a smaller LA area change and emptying fraction during atrial contraction compared to DCM-NR. Within < or = 2 hrs after the echocardiography study, cardiac catheterization was performed in the DCM group. We found significantly higher LV filling pressures and lower LV ejection fractions in DCM-R compared to DCM-NR. Significant correlations were found between LA function and invasive parameters like capillary wedge and LV enddiastolic pressures and LV EF.

CONCLUSION

Patients with DCM-R had significantly enlarged LA areas with more depressed total emptying fractions and smaller LA area changes during contraction compared to DCM-NR. Thus, left atrial function plays an important role in LV filling and its dysfunction can be a marker of poor prognosis.

Clinical and echocardiographic assessment of a right-to-left shunt across an atrial septal defect secondary to tricuspid regurgitation

OBJECTIVE

Cyanosis in conjunction with atrial septal defect does not necessarily indicate the Eisenmenger syndrome. Exceptionally, the right-to-left shunt may result from tricuspid regurgitant flow and its unusual direction.

METHODS

We describe thirteen patients with atrial septal defect and accompanying tricuspid regurgitation. In all of them, the tricuspid regurgitant jet was oriented towards the interatrial septum. This was found on the basis of echocardiographic examination and subsequent frame-by-frame analysis of videotape.

RESULTS

Of thirteen patients, cyanosis was observed in 7 (53%). Among those seven, three had moderate pulmonary hypertension (pulmonary artery systolic pressure (PASP) between 40 and 60 mm Hg). The remaining four patients with marked pulmonary hypertension (PASP > 60 mm Hg) underwent cardiac catheterization, which demonstrated low values of pulmonary artery resistance. Except for the one patient with a history of the cerebral embolic event, all were qualified for cardiac surgery. In the postoperative observation they were uneventful and showed clinical recovery and echocardiographic improvement.

CONCLUSIONS

Appreciable arterial desaturation and cyanosis in patients with ASD, regarded as uncomplicated, should be followed by careful investigation for the direction of tricuspid regurgitant flow.

[Analysis of risk factors of the paroxysmal atrial fibrillation after valve replacement in patients with aortic stenosis]

Paroxysmal atrial fibrillation (PAF) is a frequent complication (10-60% of pts) after cardiac surgery. In our study we analyze the influence of clinical, echocardiographic and 24 h ecg parameters on the risk of postoperative PAF in 266 pts with aortic stenosis (88 women and 178 men; mean age 58 +/- 10). PAF was observed in 74 (28%) patients. Statistically significant factors of risk of PAF were (univariate analysis): age-relative risk 1.08 (1.04-1.11), history of PAF--4.3 (1.4-12.5), more than 100 supraventricular ectopic beats during 24 h ecg--2.9 (1.6-5.1), presence of SVT during 24 h ecg--2.6 (1.5-4.5) and presence of SVT > 140/min--relative risk 3.5 (1.8-6.7). Left atrium diameter and coronary artery bypass grafting during valve replacement had no impact on the risk of PAF. In multivariate analysis three factors remained significant--age, history of PAF and presence of SVT > 140/min during 24 h ecg. In discriminant analysis this model of 3 factors enabled the correct risk assessment in 72% of patients.

CONCLUSIONS

1. The factors that increase the risk of postoperative PAF in pts with aortic stenosis are: age, history of PAF and presence of SVT > 140/min during preoperative 24 h ecg. 2. Postoperative PAF is not related to left atrium diameter in this group of patients. 3. Coronary artery bypass grafting during aortic valve replacement does not increase the risk of PAF.

Transvenous closure of moderate and large secundum atrial septal defects in adults using the Amplatzer septal occluder

The aim was to determine the feasibility of using the Amplatzer septal occluder for closure of moderate and large secundum atrial septal defects in adults. Fifty patients aged 16-76 years (mean +/- SD, 40 +/- 15.5), underwent successful device implantation. Flow ratios of 1.4-8.5 (mean +/- SD, 2.6 +/- 1.6) were calculated. The defects were: centrally placed (n = 31), antero-superior with partial or total deficiency of aortic rim (n = 19), multiple (n = 3) and with aneurysmal septum (n = 23). They measured 4-25 mm (median 14) on echocardiography and balloon sized 7-31 mm (median 19.5). Devices of 7-34 mm (median 20) were implanted. Patient follow up for 1 month (50/50 patients), 3 months (40/50) and 12 months (13/50), achieved respective rates of 90%, 92% and 98% of complete occlusion. In one patient a transient atrioventricular block (2:1) developed, and one had a transient STT elevation. One female had an episode of 30 min loss of vision over the lateral aspect of the left eye 3 months after implantation. In conclusion, transvenous occlusion of secundum atrial septal defects with the Amplatzer septal occluder in adults is safe, and can be performed without significant complications. Large defects, defects with a very deficient or absent aortic rim, defects with an aneurysmal septum as well as some multiple defects can be closed with an almost 100% early complete occlusion rate. This makes the procedure an alternative to surgery for selected adult patients.

Myocardial perfusion and function of the systemic right ventricle in patients after atrial switch procedure for complete transposition: long-term follow-up

OBJECTIVES

Our purpose was to assess the right ventricular (RV) function and identify patients with RV impairment long after the Mustard or Senning operation.

BACKGROUND

Systemic ventricular failure can cause myocardial perfusion abnormalities in thallium scintigraphy correlating with hemodynamic deterioration.

METHODS

Myocardial perfusion at rest and at peak exercise was assessed in 61 patients, aged 7 to 23 years in mean time 10.0 +/- 2.9 years after surgery using technetium-99m methoxyisobutyl isonitrile single-photon emission computed tomography. Ventricular function was assessed by first-pass radionuclide angiography at rest. Exercise capacity was determined with a modified Bruce protocol.

RESULTS

The mean RV ejection fraction was 36.1 +/- 7.7%, and left ventricular (LV) ejection fraction was 52.1 +/- 9.4%. Moderate or severe perfusion abnormalities on the rest scan were observed in 20 patients (33%). On exercise perfusion worsened in another 13 patients (21.3%). Patients with perfusion defects on stress scan had significantly lower RV and LV ejection fraction (33.2 vs. 39.4%; p = 0.002 and 49.2 vs. 55.5%; p = 0.01, respectively). They were also older (16.6 vs. 13.0 years; p = 0.002), operated on at an older age (4.0 vs. 2.4 years; p = 0.05) and had longer follow-up (12.5 vs. 10.5 years; p = 0.003).

CONCLUSIONS

Myocardial perfusion defects are common findings in patients in long-term follow-up after atrial switch operation. Despite excellent exercise tolerance, the extent of myocardial perfusion abnormalities correlated well with impaired RV and LV function, and greater perfusion defects were seen more frequently in older patients with longer follow-up. It is likely that myocardial perfusion defects could be a sensitive predictor of systemic ventricular impairment.

[Transcatheter closure of patent foramen ovale in patients after cryptogenic stroke]

Paradoxical embolism through a patent foramen (PFO) is a possible mechanism of ischaemic stroke in patients with cryptogenic stroke. Occlusion of PFO in such patients is considered by some authors as most effective in stroke prevention. We present our initial experience with transcatheter closure of PFO with the new self-expanding device--the Amplatzer PFO occluder in three young patients (age < 50 years). Each of them experienced at least one ischaemic stroke episode, without a left heart or carotid source and each had an interatrial communication with right-to-left shunting during Valsalva manoeuvre on echocardiography. The PFO's were closed completely without complications, under transoesophageal echo guidance in general anaesthesia. Complete closure was confirmed at one-month follow-up echocardiogram in each patient. No repeat cerebral accidents occurred at that time. The procedures were relatively easy and the clear presentation of the implant on TEE and fluoroscopy, made implantation fully controlled. The unique feature of the device is, that until release it can easily be retrieved, repositioned or removed. Transcatheter closure of PFO with the Amplatzer PFO occluder may become the new therapeutic option for patients with cryptogenic stroke and presumed paradoxical embolism.

Left ventricular outflow tract gradient decrease with non-surgical myocardial reduction improves exercise capacity in patients with hypertrophic obstructive cardiomyopathy

OBJECTIVES

This study was undertaken to evaluate mid-term clinical results of non-surgical myocardial reduction in patients with hypertrophic obstructive cardiomyopathy.

METHODS

Twenty-five patients with left ventricular outflow tract obstruction (mean gradient of 84. 54+/-31.38 mmHg) and symptoms of dyspnoea, angina and/or syncope were treated with non-surgical myocardial reduction. The patients were followed-up for a mean period of 10.44+/-1.8 months. In all patients clinical examination with echocardiography was repeated after every 3 months of follow-up, and a symptom-limited treadmill test was repeated at the 6 month follow-up. Eighteen patients underwent simultaneous respiratory gas analysis.

RESULTS

Clinical follow-up examinations were achieved in all 25 patients. Persistent left ventricular outflow tract gradient reduction was seen in 23 patients. Seventeen patients had a reduction of left ventricular outflow tract gradient >50% of baseline value. Twenty patients showed a clinical improvement from 2.8+/-0.5 up to 1.2+/-0.5 NYHA class (P<0.001). The clinical improvement was matched by an improvement in objective measures of exercise capacity in patients with significant left ventricular outflow tract gradient reduction. Exercise time increased from 571.9+/-192.2 to 703.5+/-175.4 s, P<0. 001, and peak VO(2)increased from 14.6+/-5.2 to 20.5+/-8.6 ml. kg(-1)min(-1), P<0.05.

CONCLUSION

Significant left ventricular outflow tract gradient reduction with exercise capacity improvement was achieved in the majority of patients treated with non-surgical myocardial reduction. We recommend this method as an alternative to surgery for symptomatic patients with hypertrophic obstructive cardiomyopathy.

[Usefulness of dobutamine stress echocardiography in qualification of patients to angioplasty of infarct related artery]

Late angioplasty of an infarct-related artery (IRA) performed weeks or months after myocardial infarction (MI) may restore blood flow in IRA and would result in improvement of regional wall motion. This study was designed to assess dobutamine stress echocardiography (DSE) in predicting the improvement of regional left ventricular (LV) function in patients after late PTCA of IRA.

MATERIAL AND METHODS

44 patients (36 M 8 F, mean age 54 +/- 7 year) who had a MI 15 +/- +/- 8 weeks earlier, were qualified to angioplasty of IRA when DSE showed the change in wall motion at the infarct zone--improved during low dose infusion (5-10 micrograms/kg/min) and/or worsened during a high dose dobutamine (up to 40 micrograms/kg/min). Regional wall motion was assessed by DSE performed at 2-7 days and 6-month after successful angioplasty. Wall motion score index (WMSI) decreased from 1.51 +/- 0.29 at rest to 1.31 +/- 0.28 at low-dose dobutamine infusion (p > 0.001) before angioplasty. Early after PTCA regional wall motion improves and baseline, exercise and rest values of WMSI decreased, compared with values before angioplasty. At baseline echocardiography 248 of segments were dyssynergic (112 hypokinetic, 125 akinetic and 10 dyskinetic). Viability during DSE was more frequent in segments with biphasic reaction during DSE than in segments showed monophasic reaction. In 34 patients control angiography (CA) was performed 6 month after successful PTCA. In this selected group CA showed significant restenosis of IRA in 12 pts (35% =, 9 of them showed positive DSE. Their base WMSI increased from 1.36 +/- 0.28 to 1.47 +/- 0.30 and peak stress WMSI from 1.32 +/- 0.29 to 1.60 +/- 0.30 (p < 0.001), respectively, between the exam just after PTCA comparing with the exam which detected restenosis.

CONCLUSIONS

In some patients with infarction and a narrowed or occluded IRA the myocardium remains viable for a prolonged period. Improvement of wall motion during low-dose DSE and/or worsened during high dose DSE at infarct zone is a very useful tool in predicting of viable myocardium at infarct zone. DSE is an excellent method to demonstrate an immediate improvement in regional LV dysfunction after angioplasty of IRA. At 6 months' follow-up restenosis of IRA is often seen.

[Pulmonary hypertension in adult patients with secundum atrial septal defect before surgery and in long-term follow-up]

The aim of the study was to determine pre- and postoperative systolic pulmonary pressure in adult patients with ASD II. The study group consisted of 224 pts who had undergone surgical repair of ASD II in between 1987-1993. The mean postoperative follow-up was 7.5 y. The group (160 F, 66 M aged 17-66 years) was divided on 3 subgroups: age under 20 y--27 pts; 20-40 y--131 pts; and older then 40 y--66 pts. We analysed pre- and postoperative parameters: pulmonary hypertension (PASP-Doppler) and functional class (NYHA). Preoperative pulmonary pressure was 35-50 mm Hg in 69 pts (30.8%) of the group, and over 50 mm Hg in 29 (12.9%). In long-term follow-up of 98 (43.8%) operated patients with coexisting pulmonary hypertension, significant reduction of pulmonary pressure was observed in all patients, even in patients over 40 y. Functional class of heart failure NYXHA improved as well in all patients.

[Long-term follow-up of supraventricular tachyarrhythmia in adult patients with secundum atrial septal defect before and after surgery]

The frequency of arrhythmias was determined pre- and postoperatively in adult patients with secundum atrial septal defect. The study group consisted of 224 pts who had undergone surgical repair of ASD II in between 1987-1993. The mean postoperative follow-up was 7.5 y. The group (160 F, 64 M, aged 17-66 y) was divided on 3 subgroups: I--age under 20 y--27 pts, II--20-40 y--131 pts, III--over 40 y--66 pts. We analysed pre- and postoperative parameters: 1) arrhythmias in the 24-h Holter recording, 2) pulmonary hypertension (PASP-Doppler), 3) coexisting diseases, 4) functional class of heart failure (NYHA). Most common abnormalities found were supraventricular tachyarrhythmias (22.8 pre- and 40.6% postoperatively). There was significant increase in frequency of arrhythmias after surgery in the subgroups II and III. Arrhythmias were most frequent in patients with coexisting arrhythmogenic diseases.

Long-term follow-up results of balloon valvuloplasty for congenital aortic stenosis: predictors of late outcome

AIMS

Long-term follow-up of patients with aortic valve stenosis undergoing balloon valvuloplasty was evaluated with respect to survival, the need for repeat intervention and factors predicting late outcome.

METHODS AND RESULTS

Forty-five patients between 3.5 to 23 years old (mean 11.7 +/- 4.5) were followed for 62 +/- 30 months (range 11-122). The transvalvar aortic gradient decreased from 84 +/- 20 to 36 +/- 10 mmHg (p < 0.001) and remained significantly lower (50 +/- 26 mmHg; p < 0.001) at follow-up. At that time, 10 patients (including 4 with significant valve incompetence) had gradients >/= 60 mmHg. The procedure resulted in significant valve incompetence (grade >/= 3) in 8 patients (17.8%). There was a progression of incompetence and 13 patients (28.9%) had significant regurgitation at follow-up. All survived. Fifteen patients (33.3%) required re-intervention 51 +/- 24 months after valvuloplasty. The indications were: aortic stenosis in 5 patients; regurgitation in 6 patients; and stenosis with regurgitation in 4 patients. Actuarial freedom from re-intervention at 2, 4, 6 and 8 years was 96%, 88%, 61% and 56% of patients, respectively. The residual post-valvuloplasty gradient was the only predictor of re-intervention for valve stenosis (odds ratio = 3.2 for every 10 mmHg gradient increase; p = 0.017). A residual post-valvuloplasty gradient >/= 40 mmHg increased the relative risk of re-intervention sixfold. The immediate post-valvuloplasty aortic regurgitation grade was the only risk factor of re-intervention for regurgitation (odds ratio = 34 for every incompetence degree increase; p = 0.0019). Incompetence grade >/= 2 increased the risk of re-intervention tenfold.

CONCLUSIONS

Valvuloplasty carries the risk of development of valve incompetence, which progresses with time. Some patients develop restenosis. The </= 10 year survival after the procedure is excellent, and 56% of patients are free of re-intervention at 8 years. The immediate post-valvuloplasty incompetence grade and transvalvar gradient are the predictors of late re-intervention.

Mechanical valve replacement in congenital heart disease in children

BACKGROUND AND AIM OF THE STUDY

The study aim was to analyze predictive factors of long-term results after mechanical heart valve replacement in children.

METHODS

Forty-four patients (19 males, 25 females; mean age 8.9+/-3.9 years, median 7.0 years, range: 1.3 to 15 years) underwent heart valve replacement with mechanical prostheses. Of these patients, 25 had left atrioventricular valve replacement (LavVR) (18 mitral, six tricuspid in corrected transposition of the great arteries (TGA), one common in a univentricular heart), 13 had aortic valve replacement (AVR) and six had tricuspid valve replacement (TVR). The etiology of the valvular disease was congenital in all patients, and complicated by infective endocarditis in seven (16%). Fifteen patients had undergone previous procedures and 16 required simultaneous repair of associated lesions. The mean size of the implanted prosthesis was 26 mm (range: 19-29 mm) for LavVR, 29.7 mm (range: 23-33 mm) for TVR, and 21.9 mm (range: 19-25 mm) for AVR. Postoperatively, all patients received oral anticoagulation. The mean follow up was 6.8+/-3.5 years (total 290 patient-years).

RESULTS

There was no early mortality, but three patients (7%) died later; all late deaths occurred in patients with LavVR. There were two sudden deaths, both in patients with complex congenital heart disease and heart failure (before the ACE inhibitor era), and one valve-related death from thrombotic occlusion of a mitral prosthesis. Five patients were reoperated on; three for patient-prosthesis mismatch, one for periprosthetic leak, and one for aortic dissection due to Marfan's syndrome. Thrombotic obstruction occurred in three patients; two in the tricuspid position were treated successfully with thrombolysis, but one in the left atrioventricular position proved fatal. After seven years, the survival rate was 93.4%.

CONCLUSIONS

Mechanical heart valve replacement in children aged over one year with congenital heart disease can be performed with satisfactory early and late results. Mechanical valves of >23 mm diameter in the atrioventricular position in the systemic ventricle, and >21 mm in the aortic orifice, can offer excellent long-lasting hemodynamic performance. However, mechanical valves in the tricuspid position are prone to develop thrombotic occlusion.

Ischemic neurologic event in a child as a result of ventricular septal aneurysm

Aneurysm of the interventricular septum without a shunt was found by means of transthoracic echocardiography in a 6-year-old boy with acute hemiparesis. Until the time of the incident, he had been healthy. The aneurysmal sac contained 2 clots, presumably resulting in the ischemic cerebral infarct. On the basis of the echocardiographic scan, successful surgery was performed. To the best of our knowledge, this is the first report describing such dramatic sequelae of interventricular septal aneurysm.

Captopril or nifedipine? Comparison of rest and exercise acute effects and long-term therapy in chronic isolated asymptomatic moderate to severe aortic regurgitation

The effects of both single and long-term oral captopril or nifedipine treatment on cardiac parameters at rest and during exercise in patients with moderate to severe aortic regurgitation was investigated.

METHODS

Thirty-one asymptomatic patients with chronic, isolated, previously untreated, moderate to severe aortic regurgitation (AR) of mean grade 3.1 +/- 0.6, had left ventricular end-diastolic diameter (LVEDD) 64 +/- 5 mm, left ventricular end-systolic diameter (LVESD) 41 +/- 5 mm, ejection fraction (EF) 66 +/- 6% and fractional shortening (FS) 37 +/- 5% measured by echo-Doppler. Bedside Swan-Ganz measurements at rest and at peak exercise (75 W) were conducted before (baseline) and at 75-90 min after oral administration of 20 mg nifedipine. Repeat testing was performed 24 h later, at 75-90 min after oral administration of 25 mg captopril.

RESULTS

At rest, nifedipine significantly reduced systemic vascular resistance (SVR) compared with baseline (704 +/- 152 versus 880 +/- 216 dynes.s.cm-5; p < 0.0001) and captopril treatment (800 +/- 176 dynes.s.cm-5; p < 0.0001). Despite significant improvement of effective left ventricular (LV) stroke volume (LVSVef) after both nifedipine and captopril over baseline (103 +/- 20 ml), LVSVef did not differ between nifedipine and captopril (110 +/- 17 versus 110 +/- 22 ml; NS). Nifedipine significantly increased effective cardiac output (COef) from baseline (6.7 +/- 1.3 l/min) to 8.2 +/- 1.5 l/min; p < 0.0001, but this was due to an increase in heart rate (HR) (66 +/- 10 versus 75 +/- 1 beats/min; p < 0.0001). In contrast, captopril affected neither COef nor HR. In addition, captopril reduced pulmonary capillary wedge pressure (PCWP) more than nifedipine (8.7 +/- 2.5 versus 11 +/- 2.9 mmHg; p < 0.0001). At exercise, both drugs caused similar reductions in blood pressure and systemic vascular resistance (SVR). By comparison with exercise baseline, LVSVef was increased by captopril (139 +/- 24 versus 147 +/- 27 ml; p < 0.01) but was unchanged after nifedipine. Compared with baseline, nifedipine increased COef (from 14.4 +/- 2.0 to 15.5 +/- 2.1 l/min; p < 0.0001) due to a significantly higher HR, while COef and HR were unchanged after captopril. A smaller increase in PCWP was also seen after captopril than nifedipine and baseline (both p < 0.0001). After long-term therapy (33 +/- 12; range: 12 to 53 months) with captopril (75 mg/day, n = 13) or nifedipine (40 mg/day; n = 12) there was no change in LVESD, and in left ventricular EF and FS in either groups. None of the patients became symptomatic. Compared with baseline, captopril significantly reduced AR grade by 0.9 +/- 0.6 (p < 0.01), but not significantly so versus nifedipine. LVEDD was reduced in captopril patients by 4.0 +/- 2.6 mm (p < 0.0002), but not significantly so in nifedipine patients. LVEDD was normalized in five captopril patients, and in four treated with nifedipine.

CONCLUSIONS

Single captopril treatment caused a greater hemodynamic improvement than nifedipine, notably during exercise; these findings were confirmed by long-term therapy with both drugs. Therefore, captopril may delay the development of left ventricular dysfunction and thus the time for corrective surgery.

[Dobutamine stress echocardiography in the monitoring of post-angioplasty myocardial contraction and in detection of restenosis]

The expanding role of percutaneous transluminal coronary angioplasty (PTCA) in the selected patients with coronary artery disease (CAD), requires the noninvasive method for the assessment of the influence of PTCA on left ventricular function and the detection of restenosis. Forty two patients (pts) with angina, undergoing PTCA, were evaluated with dobutamine stress echocardiography (DSE) 1 day before, 2-7 days after, 3-4 months and 1 year after successful angioplasty. Two-dimensional echocardiographic images were collected during incremental doses of intravenous dobutamine infusion (up to 40 micrograms/kg/min). In 31.7% of examinations atropine was added (0.5-1 mg). Echocardiograms were assessed at baseline and during low- and high-dose of dobutamine infusion. An echocardiographic test positive for restenosis was defined as showing a new wall motion abnormality induced by dobutamine 3-4 months or 1 year after PTCA, compared to DSE 2-7 days after PTCA. Whereas before angioplasty, the wall motion score index (WMSI) increased from 1.40 +/- 0.34 at rest to 1.56 +/- 0.34 at peak stress (p < 0.0001); after angioplasty WMSI decreased from 1.29 +/- 0.30 at rest to 1.24 +/- 0.28 at peak (p < 0.0001). In 20 patients control angiography (CA) was performed because of positive DSE (11/20) or for clinical reasons only (9/20). In this selected group CA showed significant restenosis in 10 patients with high DSE sensitivity and specificity, 83% and 91% respectively. In this group peak stress WMSI increased from 1.21 just after PTCA to 1.60 during the examination detecting restenosis (p < 0.01).

CONCLUSION

1. A reduction in myocardial ischaemia, as assessed by DSE, is seen early after angioplasty. 2. Serial DSE records changes in regional function, thus being a valuable tool in PTCA follow up.

Increased frequency of organ-specific cardiac antibodies in healthy relatives of patients with dilated cardiomyopathy: evidence for autoimmunity in Polish families

BACKGROUND AND HYPOTHESIS

Autoantibodies represent markers of autoimmune involvement and are found with increased frequency in patients and their symptom-free relatives at risk compared with normal controls. Cardiac-specific autoantibodies, detected by immunofluorescence, were found in 20% of symptom-free relative of patients with dilated cardiomyopathy (DCM) from England and Italy. The role of autoimmunity may vary in DCM patients from Poland due to ethnic differences in genetic susceptibility to autoimmune disease.

METHODS

We assessed the frequency of the organ-specific cardiac autoantibodies in 162 symptom-free relatives of DCM patients [85 male, mean (SD) age 27 (18) years] and 80 control subjects from Poland. Familial DCM (> 1 affected member) was present in 4 families, nonfamilial DCM in the remaining 24 pedigrees. We performed antibody screening and noninvasive cardiological assessment in the whole group.

RESULTS

The frequency of cardiac-specific autoantibodies was higher among patients with documented DCM (probands and relatives) (50%) and their symptom-free relatives (38%) than in unrelated normal subjects (10%; p = 0.0001). In 24 (86%) of the pedigrees studied, autoantibodies were found in the proband and/or in at least one family member and tended to be more common in familial than in nonfamilial DCM (50 vs. 35%, p = NS). Echocardiographic indices of left ventricular size and function were similar in relatives with and without detectable antibodies.

CONCLUSIONS

The presence of cardiac-specific autoantibodies in symptom-free relatives of DCM patients provides evidence for autoimmunity in the majority (86%) of our pedigrees, including both familial and nonfamilial forms of DCM.

Determinants of prognosis in nonischemic dilated cardiomyopathy

BACKGROUND

Dilated cardiomyopathy, a heart muscle disease of unknown cause, is characterized by high mortality and is a major cause of cardiac transplantation. It has become, therefore, increasingly important to identify patients at higher risk. The aim of this study was to assess which of the data obtained at the time of diagnosis are the best predictors of survival.

METHODS AND RESULTS

One hundred forty-four patients with dilated cardiomyopathy (118 men; mean age, 39 years) were assessed clinically, noninvasively, and hemodynamically. The effect of variables derived from the evaluation on outcome (death or heart transplantation) was examined. During a mean follow-up time of 4.1 years, 68 patients (47%) died and 9 (6%) underwent heart transplantation. The 1-, 2-, and 5-year transplant-free survival rate was 79, 69, and 44%, respectively. Cox multivariate regression analysis identified three variables as independent predictors of outcome: (1) pulmonary artery systolic pressure, P = .0001; (2) left ventricular ejection fraction, P = .0013; and (3) left ventricular end-diastolic dimension, P = .007. The prognostic index was constructed from regression coefficients and parameters significant in the Cox model. The minimal prognostic index in the study group was 1.4 and the maximal was 6.0 with a corresponding 1-year survival of 98 and 18%, respectively. The validity of the prognostic index was tested in the consecutive group of 81 patients, who were followed for a mean 2.3 years. The prognostic index of the poor outcome group differed significantly from that in survivors (3.7 vs 2.9, respectively, P < .01). The sensitivity and specificity of model predictions were 68 and 52%, respectively.

CONCLUSIONS

The severity of pulmonary hypertension and left ventricular dysfunction provides an independent insight into the prognosis of patients with dilated cardiomyopathy. The prognostic index is useful when assessing prognosis and may be helpful in the timing of heart transplantation.

Left ventricular enlargement is common in relatives of patients with dilated cardiomyopathy

Idiopathic dilated cardiomyopathy is characterized by dilation and impaired contractility of one or both ventricles. Long-term prognosis is poor. Early diagnosis has the potential for substantial reduction of morbidity and mortality. Recent studies, based on echocardiographic assessment of relatives of the patients have shown that familial dilated cardiomyopathy is relatively common. The authors studied 215 relatives (mean age, 27 years; 111 male) of 38 index patients with idiopathic dilated cardiomyopathy by clinical examination, electrocardiography, and two-dimensional, M-mode and Doppler echocardiography. Seven relatives (3%) from six families were shown to have dilated cardiomyopathy. Thus, 6 of the 38 index patients (16%) had familial disease. Furthermore, left ventricular enlargement either during diastole or systole was found in 66 of 174 healthy relatives (38%). This is significantly more frequent than in our normal control population of 100 unrelated subjects studied in the same way (18%; P < .0001). These 66 relatives with left ventricular enlargement belonged to 27 of the 38 examined families (71%). Dilated cardiomyopathy was found to be familial in 16% of patients. Of the relatives examined, 41% had left ventricular abnormalities. These findings provide further evidence for a genetic background of dilated cardiomyopathy. Relatives with left ventricular enlargement may have an early stage and/or latent form of the disease.

Organ-specific cardiac autoantibodies in dilated cardiomyopathy. Frequency and clinical correlates in Polish patients

Organ- and disease-specific cardiac autoantibodies are found in a third of dilated cardiomyopathy patients from the U.K. and Italy and represent markers of autoimmune involvement. The role of autoimmunity may vary in dilated cardiomyopathy patients from different countries due to differences in genetic susceptibility to autoimmune diseases. The aim of this study was to assess the frequency of organ-specific cardiac autoantibodies detected by immunofluorescence in a consecutive series of patients with dilated cardiomyopathy and in disease and normal control subjects from Poland. The study groups included 79 patients with idiopathic (WHO criteria) dilated cardiomyopathy, 55 patients with other cardiac disease and 60 normal subjects. Cardiac antibody tests were performed by indirect immunofluorescence on human heart; skeletal muscle was used to identify cross-reacting antibodies. The frequency of organ-specific cardiac autoantibodies was higher in patients with dilated cardiomyopathy (21/79, 27%) than in controls with other cardiac disease (1/55, 2% P < 0.001) or in normal subjects (7/60, 12% P < 0.02). Conversely, cross-reactive antibodies were detected in similar proportions in patients with dilated cardiomyopathy (5/79, 6%), disease controls (7/55, 13%) and normal subjects (6/60, 10%, P = ns). The organ-specific antibody was more common in patients with dilated cardiomyopathy with insidious onset of disease (17/34, 50%) compared to those who did not exhibit this feature (4/45, 9%, P < 0.0001). Organ- and disease-specific cardiac autoantibodies were found in 27% of Polish patients with dilated cardiomyopathy at diagnosis; this is evidence for autoimmune involvement in a subset of patients from our country, as seen in a previously reported series of Western European origin. The association of antibody status with insidious onset of symptoms is in keeping with the long latency period observed in other autoimmune disorders.

Long term follow up after percutaneous mitral commissurotomy with the Inoue balloon-incidence of restenosis

The long term outcome of 300 consecutive patients following percutaneous mitral commissurotomy (PMC) with the Inoue balloon was analyzed with regard to the incidence of restenosis. There were 256 females and 44 males (mean age 44.4 +/- 9.9 years, range 18-69 years), 52 had previous surgical commissurotomy, 96 were in atrial fibrillation, and 16 had a history of embolism. PCM was carried out with a success rate of 84% (no significant mitral regurgitation and mitral valve area (MVA) > 1.5 cm2). Two hundred and seventy patients were available for clinical and serial echocardiographic studies at six months, 12 months and once a year thereafter (18 patients operated on for mitral regurgitation less than six months after PMC, three patients lost to follow up, nine patients refused to return). MVA increased with PMC from 1.18 cm2 +/- 0.3 to 2.0 +/- 0.3 cm2 and then decreased to 1.8 +/- 0.3 at a mean follow up of 24.0 +/- 13.5 months (range 6-55). Echocardiographic restenosis (RS) (MVA at follow up < 1.5 cm2 with a 50% loss of the initial gain) was found in 38 patients (14%). Twenty-five (66%) of them remained in NYHA class I or II. Restenosis free survival according to the Kaplan-Mayer curve was 93%, 86%, 77% and 73% at 12,24,36 and 55 months respectively. None of the 24 clinical, hemodynamic, echocardiographic or procedural variables used on the Cox proportional hazard regression analysis identified predictors of restenosis free survival.

CONCLUSIONS

The overall incidence of echocardiographic restenosis post PMC is low (12.6%) in patients followed for a mean period of two years and often occurs without worsened clinical symptoms. It may be difficult to define clinical, echocardiographic or procedural factors as significant predictors of restenosis free survival.

[Familial dilated cardiomyopathy with autosomal mode of inheritance. Case report]

Familial occurrence of dilated cardiomyopathy is estimated by 2-20%. We present a family with dilated cardiomyopathy inherited in an autosomal dominant way. We examined 9 members of the family, most of them are asymptomatic.

[Coronary ultrasonography. More exact than coronary angiography? Description of two case histories]

Coronary angiography as the "golden standard" in diagnostic imaging, guiding and assessing the results of interventional therapy has well known limitations inherent to the two dimensional imaging of three dimensional structures. Intravascular ultrasonography provides cross-sectional images of coronary artery, allowing an accurate calculation of cross-sectional luminal area and assessment of the degree of eccentricity of plaque and its structure including fissures, dissections and intracoronary thrombi. Case 1: Coronary angiography was performed in a 60 y. male patient with unstable angina revealing only a 40% stenosis in proximal LAD. The inconsistency of clinical presentation with angiography findings led to perform an intravascular ultrasound (IVUS) examination of LAD. The angiographic 40% stenosis was found to be over 80% on IVUS. Subsequent PTCA procedure led to a good IVUS and clinical result with no obvious changes in angiography. Case 2: PTCA of 80% Cx stenosis was performed with good immediate angiographic result, without dissection nor residual stenosis. However, IVUS immediately after PTCA assessed a dissection of the plaque with a flap protruding into the lumen. The patient was sent back to coronary angiography several hours later with clinical and ecg symptoms of acute myocardial ischemia. An important, occlusive dissection was found at the PTCA site. Angioplasty was performed again restoring a wide lumen at intervention site. IVUS was able to clarify the ambiguous angiographic findings with an important impact on interventional therapy. The immediate results of invasive procedures were readily and safely assessed by intravascular ultrasound.

[Ultrasonic evaluation of chronic aortic regurgitation. Personal investigations]

Decision for valve replacement in valvular heart disease is actually based on non-invasive assessment without cardiac catheterization. This decision is particularly difficult in asymptomatic patients with aortic regurgitation (AR). Semiquantitative and quantitative assessment of the AR was performed in 74 pts aged 11-66, mean 34.9, 26 women, 48 men. M mode, 2D, Doppler PW, CW, color flow mapping in parasternal long, short axis, 4.5 CH and suprasternal view were obtained by Hewlett Packard Sonos 500 or 1000 with 3.5, 2.5 and 1.9 MHz transducer. LV internal diastolic diameter (LVIDD), stroke volume (SV) of the left and right ventricle, regurgitant fraction (RF), regurgitant volume (RV), regurgitant orifice (RO), LVEDP, deceleration slope, pressure half time (PHT) of regurgitant flow and proximal color flow regarding aortic valve diameter were calculated. The value of RF was 19-81%, mean 53 +/- 16% and correlated with SV (r = 0.72) Relation of the RF and LVEDP should be noticed. Positive correlation with observed up to 20-25 mmHg LVEDP. Further increasing LVEDP caused decreasing of the RF. High LVEDP confined regurgitant volume, because of diminished aorta (Ao)-LV diastolic pressure gradient. Ao-LV diastolic gradient dynamics is a very important supplement of LVEDP assessment. Deceleration in this group was 147-805 cm/s2 mean 270 +/- 120. PHT 128-812 ms mean 270 +/- 161 and correlated well with LVEDP (r = 0.87 and r = 0.85). Proximal color width in parasternal long axis correlated with RF (r = 0.76) and RO (r = 0.77). LVIDD was 4.3-8.8 cm mean 6.2 cm correlated with LVEDP r = 0.60, PHT = -0.69.(ABSTRACT TRUNCATED AT 250 WORDS)

[Left ventricular outflow obstruction as a result of external cardiac compression by a mediastinal tumor]

A case of left ventricular outflow tract stenosis resulted from compression of the heart is presented. This symptomatic cardiovascular lesion was produced by extensive growth of mediastinal tumour. Numerous noninvasive methods were necessary to establish this difficult diagnosis. The patient underwent surgery that disclosed a benign process (of neurofibroma). After tumour's resection marked hemodynamic signs subsided.

[Spontaneous echo contrast in transesophageal echocardiographic examination: clinical ultrasonic analysis]

The clinical and echocardiographic variables related to spontaneous echo contrast were evaluated in a consecutive series of 600 patients undergoing transesophageal echocardiography with a 5-MHz single plane transducer. The spontaneous contrast was observed in 110 patients (18%). It was seen mainly in the atria; in the left atrium in 98, in the right atrium in 2 patients, in both atria 7, in the vena cava superior and right atrium in 1, in the left atrium and ventricle in 1, and in the false lumen of dissected aorta. Spontaneous atrial contrast was never seen in the absence of cardiac abnormality. There was a high incidence of atrial spontaneous echo contrast in cases of significant mitral stenosis, mitral valve prosthesis, atrial fibrillation, enlarged left atrium and absence of significant mitral regurgitation which were showed by univariate analysis. Multivariate analysis showed that atrial fibrillation, significant mitral stenosis and enlarged left atrium were independent factors for the presence of spontaneous contrast. Thus, spontaneous echocardiographic contrast detected by transesophageal echocardiography is a common finding in patients with mitral stenosis, atrial fibrillation and enlarged left atrium, in the absence of significant mitral regurgitation.

[Surgical closure of atrial septal defect--when is it too late?]

We describe a 41 year-old patient with atrial septal defect combined with mitral stenosis, severe pulmonary hypertension and tricuspid regurgitation. Despite high pulmonary vascular resistance, surgical intervention was decided on. Follow up proved to be successful. The role of echocardiography and hemodynamics data to establish a preoperative diagnosis is discussed.

Percutaneous mitral commissurotomy with the Inoue balloon for severe mitral stenosis during pregnancy

Percutaneous mitral commissurotomy using the Inoue balloon was performed in seven pregnant women between May 1990 and November 1991. The mean age of the group was 31.5 years (range 28-35 years). The mean gestation time was 29 weeks (range 20-38 weeks). All patients presented with severe symptoms; two had a recent history of pulmonary oedema, the rest exhibited marked shortness of breath, and mild exercise and paroxysmal nocturnal dyspnea. All were in sinus rhythm. Two patients had previously undergone closed mitral valvulotomy five and 14 years before their recent hospitalization. Echocardiographic examination revealed severe mitral stenosis, with the mitral valve area being less than 1.2 cm2 in all but one patient. None of the patients had left atrial thrombi or mitral regurgitation as seen on two-dimensional and Doppler echocardiography. Four patients (two with restenosis) had severe lesions of the subvalvular apparatus with thickening and marked shortening of the chordae, as assessed by echocardiography. Successful percutaneous mitral valvulotomy was completed in all seven patients using 25-28 mm Inoue balloons. There was one, transient maternal complications. Fetal complication did not occur. It is concluded that percutaneous, transseptal, mitral balloon valvulotomy during pregnancy with the Inoue balloon is a safe procedure, which can be recommended for suitable clinical cases.

[Recurrent bacterial endocarditis with involvement of the tricuspid valve after surgical correction of congenital heart defect]

A case of recurrent tricuspid valve endocarditis after surgical closure of ventricular septal defect is presented. Intensive medical treatment lasting nearly ten years completely failed. There were still vegetations attached to the septal leaflet of the tricuspid valve with positive cultures (Ps. aeruginosa). Persistent sepsis without signs of heart failure required surgical intervention. Tricuspid valvuloplasty with excision of infected patch was successfully performed. Six months later the patient remained symptomless.

[Increased tension on the sympathetic nervous system in arrhythmogenic right ventricular dysplasia. Participation in etiopathogenesis?]

To evaluate the suspected role of sympathetic nerve tone in pathogenesis of arrhythmogenic right ventricle dysplasia (ARVD), noradrenaline (NOR) and adrenaline (AD) plasma levels were determined by radioenzymatic method in 10 pts with ARVD (mean age 36 y, VT-8 pts, syncope-5) at rest and during peak exercise. 9 healthy men (mean age 28 y) served as control.

RESULTS

[table: see text]

CONCLUSION

Significant increase of norepinephrine serum level during peak exercise suggests essential role of sympathetic nerve tone in pathogenesis of ARVD.

[Electrocardiography of high resolution in the diagnosis of arrhythmogenic dysplasia of the right ventricle]

To assess the diagnostic value of high resolution ECG in ARVD which is a rare and diagnostically difficult disease, cardiac micropotentials were evaluated in 32 pts with ventricular arrhythmias with LBBB pattern and right axis deviation. Typical ECG-, ECHO-, angiographic features of ARVD were found in 9 pts (mean age 36 y, VT 8 pts, MAS-5). Normal right ventricle (NRV) (Echo, Tc99) was seen in 23 pts (mean age 36 y, VT-14 pts, MAS-6). 25 healthy man (mean age 28 y) served as control (C).

RESULTS

[table: see text] Morphology of total QRS complex in pts with ARVD, comparing to NRV pts and C, was exceptionally characteristic: it was composed of high frequency notches seen not only as prolonged LP but also within fundamental QRS complex.

CONCLUSION

In pts with ARVD beside presence of LP, significantly prolonged TVAT and characteristic notches within QRS complex are observed, therefore the high resolution ECG is a promising method in noninvasive diagnosis of ARVD.

[Percutaneous pulmonary valvuloplasty in 135 patients]

We present our 7 years experience with 135 pts aged 1.4-44 years (mean 10-yrs) in whom percutaneous balloon valvuloplasty (BPV) for congenital pulmonary stenosis was attempted. In 4 pts we failed to place the balloon at valvar level, in another four BPV was repeated so, 135 procedures in 131 pts were performed. Balloon diameter/pulmonary anulus diameter ratio (BD/PD) ranged from 0.9 to 1.85 (mean 1.37). In 10 cases double balloon technique was used. Immediate results: in the whole group of 131 pts the right ventricular-pulmonary artery gradient (RV-PAG) was reduced from 74 +/- 42 to 34 +/- 34 mm Hg, and right ventricular systolic pressure (RVSP) decreased from 92 +/- 41 to 54 +/- 34 mm Hg just after BPV. 86 pts (65.6%)--group I, had good immediate result of BPV (RVSP less than 50 mm Hg). 4 of them had dysplastic pulmonary valves (DPVs). RV-PAG in 82 pts with normal valves decreased from 53 +/- 25 to 15 +/- 7 mm Hg right after BPV. In 45 pts (34.4%)--group II, immediate result of valvuloplasty was recognised as unsatisfactory (RVSP greater than or equal to 50 mm Hg): in 4 of them BD/PD was smaller or equal 1.2 (subgroup IIa); 34 others had significant subpulmonary obstruction (SPO) that appeared or increased after BPV (subgroup IIb); and in remaining 7, DPVs were noticed (subgroup II c).(ABSTRACT TRUNCATED AT 250 WORDS)

[Multi-electrode mapping from thoracic surface in patients with Wolff-Parkinson-White syndrome]

Body surface potentials mapping is a new method of heart electric phenomena visualisation. Attempts of accessory conduction pathways localisation in 9 patients with overt and in 1 with concealed WPW syndrome are presented. In 4 pts the preexcitation with QRS complex > 120 ms was clearly seen, in next 4 individuals that symptom was less evident and in one case the retrograde conduction through the accessory pathway was hardly noticed. The isopotential maps allowed precise localisation of the accessory pathways ventricular insertion in all patients with QRS > 120 ms and in one with QRS < 120 ms. After successful dissection of accessory pathways, isopotential maps became normal. In patients with slight signs of preexcitation, noninvasive (transesophageal) or invasive atrial stimulation could improve the visibility of accessory pathways localisation.

[Early results of surgical treatment of patients with Wolff-Parkinson-White syndrome]

Successful dissection of accessory pathways (AcP's) was performed in 19 of 20 patients. 15 pts had single, 4 double and 1 patient had 3 accessory pathways (AcP's). The patient with 3 AcP's was operated twice. During the first operation two AcP's were eliminated. The third one was revealed during the postoperative electrophysiologic study. Verapamil facilitated its manifestation and localisation. No patient had syncope or atrio-ventricular tachycardia after the operation. In 3 of 10 patients who had atrial fibrillation before the operation, episodes of AF occurred in the early postoperative period. Conduction to the ventricles was through the normal conduction system. Dissection of AcP's prevented extremely fast ventricular response and syncope. After discontinuation of amiodarone more frequent ventricular premature beats occurred in patients with long history of cardiac arrhythmias, on drugs for a long time and in patients who had heart dilatation. Several months after the operation VEB were less frequent, probably because tachycardias did not occur, left ventricle geometry improved, and cardiodepressant drugs were discontinued. Previously these patients had been treated usually with combination of 2-3 such drugs. After the successful dissection of AcP's the patients lost the feeling of illness and do not feel being imperilled. Children can attend schools normally and some adult patients resumed their professional activities.

[Concomitance of coronary artery disease with acquired aortic valve disease]

Incidence of concomitant coronary disease and extent of coronary artery lesions were assessed in 250 patients with acquired post-rheumatic aortic valve disease treated between 1976 and 1986 in National Institute of Cardiology. Patients' age ranged from 30 to 72 years. Hemodynamic examination with selective coronarography were performed in patients with typical effort or rest angina pain, with electrographically documented myocardial infarction in the past and also in those without (CAD clinical symptoms, but older than 45 years. Patients were divided into two groups: with isolated or dominated aortic valve stenosis (139 patients) and with isolated or dominated aortic valve incompetence. Patients younger and older than 45 years were separately analyzed. Concomitant CAD was proved if at least one coronary artery stenosis was stated. Lesions degree was proportionally graded: stenosis more than 70%, between 50-70% and 20-50% of a vessel lumen in relation to its diameter before lesion. Data were analyzed using ICL ME 29 computer. Study results indicate, that symptoms of coronary failure were observed in 82.8% of patients with acquired aortic valve disease. In 37% of cases there were critical stenoses requiring simultaneous aortic valve replacement with coronary artery by-pass grafting. Severe coronary artery stenosis was stated in 45% of patients with dominated or isolated aortic valve incompetence, whereas only in 29.3% with dominated or isolated aortic valve stenosis. 88.5% of patients younger than 45 years nevertheless coronary failure symptoms had normal coronary arteries.

Hall effect transducer for apexcardiography and sphygmography

Recording of mechanograms (Recording of mechanical activity of internal organs and vessels, often non-invasively eg. apex cardiogram) can be performed by applying different kinds of mechano-electric transducers. In this paper the idea and construction of a new transducer with Hall-generator are presented. This transducer is self-adjusting in the range of its linear characteristics, and exerts practically constant touching pressure independent of the configuration of the patients thorax. This facilitates the measuring process and allows for calibration of the obtained records. The sensitivity of the transducer is 250 mV/mm, frequency bandwidth 0-45 Hz and it has a linearity of +/- 1.5% in the range of displacements +/- 1.5 mm. The transducer also generates the signal of the first derivative of the investigated vibrations. Assessment of the transducer was carried out in a cardiology clinic on 27 patients with a normal heart and with different kind and degree of heart damage. The mechanograms obtained from different transducers for each patient were compared in respect of the essential time intervals and morphological elements. The comparison shows a good detecting capability, correctness and reproducibility of the data obtained by means of the Hall-effect transducer. Some recordings of mechanograms (apexcardiograms and different kinds of pulse) from patients with normal heart, valvular aortic stenosis and atrial heart defect are shown and discussed in the paper.

Recurrent cardiac tamponade after replacement of three heart valves. A case report

Delayed pericardial effusion and cardiac tamponade are rare late complications of open-heart surgery. A case after replacement of all three heart valves with the Björk-Shiley tilting disc valves with an unusual clinical course is presented in the following. Unsuccessful subsequent medical treatment, subsequent surgical intervention and its results are described and discussed. The need of further reports on similar observations is emphasized.

Arrhythmia during mitral commissurotomy

The authors studied in detail arrhythmias recorded during 110 operations of mitral commissurotomy. In all cases supraventricular and ventricular arrhythmias developed and their type, as well as frequency, depended on the stage of operation. Life-endangering ventricular arrhythmias (ventricular flutter or fibrillation) were never observed and ventricular tachycardia occurring when the orifice was being dilated always regressed spontaneously when a Dubost dilator was removed. Rapid differential diagnosis of arrhythmias is facilitated greatly by additional ECG recording from oesophageal lead. Indications for pharmacological treatment are discussed. This treatment was used, however, in several cases only.