Documented development of severe stenoses of previously confirmed normally functioning aortic valves.
Explore the source record for details and available documents.
Aged↗
Biomedical subjects
C L McIntosh
Publications and source records attributed to C L McIntosh.
Atrioventricular valve replacement in the idiopathic hypereosinophilic syndrome.
Three patients with the idiopathic hypereosinophilic syndrome and the associated endocardiopathy are described who underwent atrioventricular valve replacement after intractable congestive heart failure secondary to valvular dysfunction developed. Following valve replacement, all three patients sustained striking improvement in exercise tolerance and control of congestive heart failure. Thus, atrioventricular valve replacement may be beneficial to selected patients with congestive heart failure associated with the endocardial process of the idiopathic hypereosinophilic syndrome.
Adult↗
Inward stent-post bending of a porcine bioprosthesis in the mitral position: cause of bioprosthetic dysfunction.
Explore the source record for details and available documents.
Bioprosthesis↗
Intracuspal hematomas in implanted porcine valvular bioprostheses: clinical and experimental studies.
Intracuspal hematomas were found in three of 57 porcine valvular bioprostheses implanted as substitute cardiac valves in 50 patients and in 11 of 29 similar bioprostheses implanted in sheep. The three values implanted in patients had been in the mitral position for 27, 65, and 107 months. Of the valves implanted in sheep, six had been in the mitral position and five in the tricuspid position for periods of time ranging from 20 minutes to 7 months. In each patient and in four of 11 sheep, the hematomas involved more than one cusp. These lesions were localized in the spongiosa, extended from the basal region toward the free edge of the cusp, and formed a plane of dissection which involved the spaces left in the spongiosa by the removal of proteoglycan material during preimplantation commercial processing. In one patient, the hematomas limited the mobility of the cusps and appeared to have been the cause of clinically significant prosthetic mitral stenosis; in the other two patients and in the experimental animals, the hematomas were smaller and of uncertain hemodynamic significance. Intracuspal hematomas may become sites of eventual formation of calcific deposits. The pathogenesis of intracuspal hematomas is related to the entry of blood into the space between the sewing ring and the most basilar region of the bioprosthetic tissue. This space extends throughout the circumference of the bioprosthesis and is continuous with the spongiosa, the layer in which the hematoma develops. The blood penetrates into this space through the suture line between bioprosthetic tissue and sewing ring on the inflow surface of porcine valvular bioprostheses which have been mounted on atrioventricular type stents. Intracuspal hematomas were not found in bioprostheses mounted on aortic type stents, in which these sutures are more protected and more closely spaced, or in pericardial bioprostheses, which do not have a spongiosa.
Adolescent↗
Mitral valve replacement after closed mitral commissurotomy.
Closed mitral commissurotomy (CMC) was performed at the National Heart Institute in 303 patients (73% women, 27% men; mean age 40 years) with acquired isolated mitral stenosis between 1954 and 1980. The average mean mitral valve gradient decreased from 14.2 +/- 0.4 to 5.3 +/- 0.4 mm Hg (p less than 0.001), and mitral valve area index increased from 0.7 +/- 0.03 to 1.4 +/- 0.9 cm2/m2 (p less than 0.001). The perioperative mortality was 2%. Ninety-two percent of patients improved one or more functional classes after CMC. Actuarial survival was 95%, 82% and 70% at 5, 10 and 15 years after CMC, respectively. Fifty-four patients (18%) required mitral valve replacement (MVR) a mean of 9.6 years after commissurotomy (range 1-26 years). Before CMC, factors associated with later MVR included preoperative functional class, calcification of the mitral valve, and the absence of an opening snap. After CMC, poor functional improvement, congestive heart failure, atrial fibrillation, and the necessity for a repeat CMC were associated with late MVR. Catheterization after CMC showed that patients who later required MVR had a smaller decrease in left atrial pressure (p less than 0.001), more mitral regurgitation (p less than 0.001), and were more likely to have pulmonary hypertension (p less than 0.05). The indications for MVR were residual stenosis with or without mild mitral regurgitation in 33 patients (61%), restenosis in 15 (28%), and moderate-to-severe regurgitation in six (11%). Perioperative mortality for valve replacement was 13%. Among survivors, 88% improved at least one functional class after valve replacement. Actuarial survival was estimated to be 95% at 5 years and 74% at 10 years after MVR. This study confirms that CMC provides excellent long-term hemodynamic and clinical improvement in appropriately selected patients. When symptomatic deterioration occurs late after CMC, MVR restores clinical and hemodynamic improvement in many patients. CMC continues to be performed at the National Heart Institute in selected patients with acquired mitral stenosis.
Adult↗
Intracuspal hematomas in bioprosthetic valves: pathologic findings and clinical implications.
The presence of intracuspal hematomas (ICHs) was investigated in 156 valvular bioprostheses, including 57 (all porcine aortic valvular bioprostheses) that had been implanted in patients and 99 (64 porcine aortic valvular bioprostheses, 29 bovine pericardial bioprostheses and six human dura mater bioprostheses) that had been implanted in sheep. ICHs were found in three mitral bioprostheses in patients and in 14 porcine aortic valvular bioprostheses (nine mitral and five tricuspid) in sheep. Hematomas were not found in the dura mater or pericardial bioprostheses. In each patient and in six of the 14 sheep, the hematomas involved more than one cusp and consisted of erythrocyte accumulations in the spongiosa. They extended from the basal region toward the free edge of the cusp and formed a plane of dissection that involved the spaces left in the spongiosa by removal of proteoglycan material during commercial processing. ICHs may become sites of formation of calcific deposits. ICHs result from entry of blood into the space between the sewing ring and the most basilar region of the bioprosthetic tissue. This space extends throughout the circumference of the bioprosthesis and is continuous with the spongiosa, the layer in which the hematoma develops. The blood penetrates this space through the suture line between bioprosthetic tissue and sewing ring on the inflow surface of porcine valvular bioprostheses mounted on atrioventricular-type stents. ICHs were not found in porcine valvular bioprostheses mounted on aortic-type stents, in which the sutures are more protected and more closely spaced, on in bioprostheses constructed of tissues (parietal pericardium and dura mater), which lack a spongiosa.
Adolescent↗
Five creatine kinase isoenzymes in serum of a patient with severe heart disease.
Abnormal creatine kinase (CK) isoenzyme patterns were observed in the serum of a 64-year-old woman with severe heart disease. Agarose electrophoresis revealed the presence of all the usual CK isoenzymes (MM, MB, and BB) plus an extra band between MM and MB. Total serum CK activity was within the normal range. Within 2 h after the patient suffered cardiorespiratory arrest, a fifth CK isoenzyme appeared, cathodal to MM. After cardiac valve replacement, the patient's serum showed a high activity of CK, but the isoenzyme pattern showed only MM and, transiently, an MB band. With return of the serum CK activity to normal, the CK isoenzymes pattern also became normal, virtually ruling out genetic variant(s). The abnormal CK isoenzyme patterns might have been the consequence of severe hypoxemia in the patient, thus such patients may represent an ominous prognostic sign. The association of the abnormal pattern upon admission with rapid deterioration of the condition of the patient suggests prompt attention for the prevention of complications.
Alanine Transaminase↗
Congenitally bicuspid aortic valve causing severe, pure aortic regurgitation without superimposed infective endocarditis. Analysis of 13 patients requiring aortic valve replacement.
Although stenosis and infective endocarditis are commonly appreciated complications of the congenitally bicuspid aortic valve, pure severe aortic regurgitation complicating this congenital malformation, unassociated with either stenosis or infection, is not well recognized. Among 189 patients who had aortic valve replacement at the National Heart, Lung, and Blood Institute because of isolated pure aortic regurgitation, the congenitally bicuspid aortic valve, never the site of infective endocarditis, was responsible for the aortic regurgitation in 13 (7 percent). This report describes certain clinical and morphologic findings in 13 men, aged 26 to 65 years (mean 43), who required aortic valve replacement because of severe aortic regurgitation secondary to a noninfected, nonstenotic congenitally bicuspid aortic valve. Although not generally recognized, the noninfected congenitally bicuspid aortic valve is an important cause of pure aortic regurgitation severe enough to warrant aortic valve replacement.
Adult↗
Mitral valve replacement with the Hancock bioprosthesis: five- to ten-year follow-up.
Explore the source record for details and available documents.
Actuarial Analysis↗
Serratia ficaria isolated from a human clinical specimen.
The first isolation of Serratia ficaria from a human source is reported. Investigation into the eating habits of the patient revealed the probable source as figs, which are one of the natural reservoirs of this organism. How this and other normally saprophytic Serratia species can be distinguished from Serratia marcescens is reviewed.
Female↗
Aortic valve replacement without myocardial revascularization in patients with combined aortic valvular and coronary artery disease.
To test the hypothesis that coronary artery bypass grafting (CABG) is not routinely required in patients undergoing aortic valve replacement (AVR) who have coexistent coronary artery disease (CAD), we compared the results of operation in 55 consecutive symptomatic patients who had CAD and underwent AVR without CABG with results in another 142 patients without CAD who underwent AVR during the same period, and with published results from other centers in which CABG was used in patients with CAD who underwent AVR. Operative mortality was 4% in patients with CAD and 5% in patients without CAD. Late survival was not significantly different between the two groups when analyzed for the entire population (80% survival at 3 years in CAD patients, 82% for non-CAD patients), or for the subgroup of patients with aortic stenosis, aortic regurgitation or aortic stenosis plus regurgitation. Eight patients with CAD (15%) developed recurrent angina after AVR (mean follow-up 43 months); only three patients (6%) required CABG because of medically refractory angina (12-43 months). Operative mortality, operative infarction (9%), recurrent angina and long-term survival in patients with CAD after AVR were similar to those at other centers after AVR plus CABG. These data suggest that preoperative detection of CAD does not necessitate CABG in all patients at the time of AVR.
Adult↗
Long-term hemodynamic assessment of the porcine heterograft in the mitral position. Late development of valvular stenosis.
We undertook a study of patients who had porcine mitral valves in place for more than 5 years and who had no clinical signs or symptoms suggestive of valve dysfunction. Of the first 54 patients who had porcine valves implanted in the mitral position, 18 were available for catheterization; all had a routine hemodynamic study postoperatively (mean 7 months) for comparison. Mean follow-up was 85 months (range 61-111 months). Compared with the early postoperative data, there was a significant increase in mean mitral valve gradient, from 5.9 +/- 0.7 to 8.6 +/- 0.7 mm Hg (p less than 0.01), and a significant decrease in calculated mitral valve area, from 2.2 +/- 0.2 to 1.7 +/- 0.2 cm2 (p less than 0.01). Moreover, seven patients showed a decrease in valve area greater than 1.0 cm2, five with valves in place for more than 80 months and only two of 11 patients with valves in place for 80 months or less (p less than 0.05). We conclude that there is a significant incidence of hemodynamic deterioration of porcine heterografts in the mitral position for greater than 5 years, even in patients who are clinically stable.
Adolescent↗
Hemodynamic function of the Hancock standard orifice aortic valve bioprosthesis.
Reports that the hemodynamic performance of the standard orifice aortic bioprosthesis in less than optimal have prompted recommendations that mechanical prosthesis or anulus-enlarging procedures be used in adult patients with a small aortic root. The hemodynamic function of the Hancock bioprosthesis was evaluated in 77 patients who underwent cardiac catheterization of rest and with isoproterenol infusion (15 patients) an average of 6 months after operation. The average peak systolic gradient (basal conditions) was 7 mm Hg (range 0 to 37 mm Hg); 35 patients had no resting gradient. Fifteen patients received 21 mm diameter valves and had an average systolic valve gradient of 10 mm Hg (range 0 to 30 mm Hg); the average effective valve orifice area was 1.27 +/- 0.17 cm2 for 21 mm, 1.46 +/- 0.11 cm2 for 23 mm, 1.72 +/- k0.20 cm2 for 25 mm, and 1.97 +/- 0.06 for 27 mm bioprostheses. Isoproterenol infusion, elevating cardiac output 66%, increased the peak systolic gradient from an average of 11 mm Hg (range 0 to 37 mm Hg) to 44 mm Hg (range 10 to 85 mm Hg). It is concluded that small-diameter (21 and 23 mm) Hancock bioprostheses can be used with acceptable clinical and hemodynamic function in patients with a small body surface area.
Adult↗
Observations on the optimum time for operative intervention for aortic regurgitation. I. Evaluation of the results of aortic valve replacement in symptomatic patients.
Fifty consecutive patients undergoing aortic valve replacement for isolated aortic regurgitation were studied prospectively by echocardiography, electrocardiography and cardiac catheterization. Good quality echocardiograms were obtained in 49 of the 50 patients. Left ventricular (LV) dilatation was present in all 49 patients. LV systolic function, as assessed by echocardiographic percent fractional shortening, was normal in many patients but was moderately to severely reduced (less than 25%) in 14 patients (29%). Echocardiographic studies 6 months postoperatively revealed significant reductions in LV end-diastolic dimension (73.8 mm vs 58.7 mm; p less than 0.01), and serial echocardiographic studies early and late after operation revealed that the decrease in LV size had occurred by the time of the early study (8-22 days postoperatively), with little additional change thereafter. Operative deaths occurred in three of the 49 patients (6%). Eight of the 49 patients (16%) died of congestive heart failure (CHF) after hospital discharge at times ranging from 5-43 months after operation. Preoperative echocardiographic measurements of the LV end-systolic dimension and percent fractional shortening were strongly associated (p less than 0.01) with these late CHF deaths. Preoperative LV end-systolic dimension greater than 55 mm and fractional shortening less than 25% identified the high-risk group: nine of 13 patients (69%) in this group died either at operation or subsequently from CHF. In contrast, of 32 patients with LV end-systolic dimension less than 55 mm, only one died at operation and one died late from CHF. Thus, the population at high risk of late death from CHF was identified before operation by echocardiography.
Adult↗
Evaluation of aortic valve replacement in patients with valvular aortic stenosis.
Echocardiographic and hemodynamic studies were obtained in 42 consecutive patients undergoing aortic valve replacement for isolated aortic stenosis. Concentric left ventricular (LV) wall thickening, the most common preoperative abnormality, occurred in 95% of patients. LV dilation with reduced fractional shortening was noted in approximately 25% of patients but was severe in only one patient. Six months after operation, LV wall thickness had decreased on average but had not returned to normal and fractional shortening was unchanged. Repeat measurements in 13 patients an average of 37 months after operation were unchanged compared with measurements made 6 months after operation. When patients were subdivided into those with LV dilatation and those without, we found that patients with dilated ventricles preoperatively had a greater decrease in LV internal dimension and mass than those without preoperative dilatation. The patient data also were examined for possible association with mortality. One operative (2%) and five late cardiac (13%) deaths occurred. No preoperative or 6-month postoperative echocardiographic or hemodynamic measurement was strongly associated with these deaths, nor were any late deaths due to congestive heart failure. Compared with preoperative measurements in symptomatic patients who were operated for isolated aortic regurgitation, patients with aortic stenosis had smaller left ventricles with less depression of systolic function, as well as less aortic root and left atrial dilatation. Our data do not support the concept that the aortic valve should be replaced before the onset of symptoms to prevent irreversible LV damage in patients with isolated aortic stenosis.
Adult↗
Preoperative exercise capacity in symptomatic patients with aortic regurgitation as a predictor of postoperative left ventricular function and long-term prognosis.
Forty-five symptomatic patients with aortic regurgitation underwent graded treadmill exercise testing before operation. Twenty-seven patients (group A) could not complete stage I of the National Institutes of Health exercise protocol because of limiting symptoms (exercise duration less than or equal to 22.5 minutes); 18 patients (group B) completed this stage without limiting symptoms (exercise duration > 22.5 minutes). Patients in group A had higher resting pulmonary capillary wedge pressures (mean 19 vs 13 mm Hg, p < 0.05) and left ventricular (LV) end-diastolic pressures (mean 24 vs 16 mm Hg, p < 0.05) than those in group B, but did not differ with respect to LV systolic dimension or fractional shortening by echocardiography or LV ejection fraction at rest or during exercise by radionuclide cineangiography. Among 32 patients with subnormal preoperative LV fractional shortening on echo, nine of 17 in group A and 0 of 15 in group B have died (p < 0.01); seven of the nine deaths were from late congestive heart failure. Group A patients also had less decrease postoperatively in LV diastolic size by echocardiography (mean decrease 8 vs 23 mm, p < 0.001) and less increase postoperatively in LV ejection fraction during exercise by radionuclide cineangiography (mean increase 11% vs 23%, p 0.05) than group B patients. No group A patient and 60% of group B patients had normal exercise ejection fractions postoperatively (p < 0.01). The differences in postoperative mortality and function were not predicted by the differences in preoperative hemodynamics between the two groups. Thus, exercise capacity is imprecise in assessing preoperative LV function in symptomatic patients with aortic regurgitation, but is useful in predicting long-term survival after operation and reversibility of LV dilatation and systolic dysfunction.
Adult↗
Marfan cardiovascular disease without the Marfan syndrome. Fusiform ascending aortic aneurysm with aortic and mitral valve regurgitation.
Explore the source record for details and available documents.
Aged↗
Candida esophagitis following cardiac operation and short-term antibiotic prophylaxis.
Dysphagia and retrosternal pain are common complaints in patients after cardiac operations, and most often they result from the median sternotomy and/or endotracheal intubation. Although Candida esophagitis is a recognized cause of similar symptoms, it is usually not suspected except in immunologically compromised hosts. This report describes the case histories of five patients, not immunosuppressed or cachectic, who developed persistent dysphagia during recovery from cardiac operations; four patients received only 4 days of preoperative and postoperative prophylactic antibiotic treatment with cefazolin (Kefzol) and cephalexin (Keflex). A nasogastric tube had been used for less than 24 hours in the postoperative period. The fifth patient developed symptoms following prolonged and varied antibiotic therapy. Candida esophagitis was diagnosed by a combination of coexisting oral candidiasis (5/5), roentgenographic appearance on barium swallow (5/5), endoscopy (4/4), and biopsy or culture (2/4). Initial therapy consisted of antireflux measures and antacids (4/5), cimetidine (4/5), oral nystatin in methylcellulose base (1,000,000 units every 4 hours) (4/5), and termination of other antibiotic therapy (1/5). These measures were effective in clearing the infection in only two patients. A third patient required prolonged massive oral nystatin therapy, and in two patients intravenous Amphotericin B was necessary to control infection. Two patients subsequently developed strictures which necessitated multiple esophageal dilatations. One of these patients developed endocarditis during home dilatation therapy. All patients are currently free of disease. Current measures utilized to recognize and treat the disease are discussed.
Adult↗