Persistent endothelial dysfunction in calcified aortic stenosis beyond valve replacement surgery.
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Aortic Valve Stenosis↗
Biomedical subjects
J Turina
Publications and source records attributed to J Turina.
[Double aortic arch: clinical aspects, diagnosis and therapy in children and adults].
Double aortic arch is a rare vascular anomaly which usually causes tracheal and esophageal compression in the first few months of life. During the last 30 years, 7 children, 2 to 24 months old, and one 29-year-old woman with double aortic arches have been treatedatour institution. Symptoms, diagnosis and treatment of these patients were evaluated. Dyspnoe, stridor, recurrent pulmonary infections, feeding problems and failure to thrive were the leading symptoms. Despite typical symptoms from early childhood, the diagnosis was missed in our adult patient. Typical compression of the esophageus and the trachea was visualized by esophagography by 7 and bronchoscopy/-graphy by 6 patients. Angiography was performed in all children, whereas magnetic resonance angiography and computed tomography were done in the adult patient. Resection of the smaller aortic arch, left in 3 and right in 5, through a right or a left posterolateral thoracotomy was uncomplicated and fully resolved the symptoms in all patients. Typical symptoms in early childhood should lead to prompt diagnosis and surgical treatment of double aortic arch. Surgical resection of the smaller aortic arch should also be performed in oligosymptomatic patients to prevent complications later. Preoperative angiography can be replaced by the less invasive magnetic resonance imaging and computed tomography.
Adult↗
Predictors of long-term survival after valve replacement for chronic aortic regurgitation; is M-mode echocardiography sufficient?
AIMS: The clinical importance of pre-operative and follow-up echocardiographic studies in patients operated on for chronic severe aortic valve regurgitation is still a matter of debate. The prognostic significance of M-mode echocardiography has never been directly compared with clinical and angiographic data. METHODS AND RESULTS: Univariate and multivariate analyses of cumulative survival were performed for clinical, echocardiographic and angiographic data of 125 patients operated on between 1975 and 1983, and followed for 13.3+/-6.4 years. Ten and 20 year survival rates were 77% and 48%, respectively. Age, NYHA class, angiographic volumes, ejection fraction, as well as M-mode echocardiographic end-systolic dimension and shortening fraction were the main pre-operative prognostic parameters for long-term survival. In a multivariate analysis the angiographic end-systolic volume index, age and preoperative NYHA class were independent pre-operative prognostic variables of long-term survival. A postoperative reduction in end-diastolic dimension of >20% predicted a significantly better late survival (74% vs 44% after 20 years, P<0.001). CONCLUSIONS: Age, pre-operative NYHA class and left ventricular systolic function are the main determinants of long-term survival after valve replacement for chronic aortic regurgitation. Despite a slightly lower predictive value of echocardiography when compared to angiography, it appeared sufficient for everyday clinical decision making for valve replacement. Echocardiography within 6 months postoperatively is able to detect recovery of left ventricular function, and enables additional risk-stratification, regardless of pre-operative findings.
Adolescent↗
Shone's anomaly complicated by ascending aortic aneurysm in a pregnant woman.
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Adult↗
Microembolic signal counts increase during hyperbaric exposure in patients with prosthetic heart valves.
BACKGROUND: Patients with prosthetic heart valves have an increased risk of thromboembolic events, and transcranial Doppler sonography reveals microembolic signals. Whereas microembolic signals were initially assumed to be of particulate matter, recent studies suggest that they are partially gaseous in origin. If this is true, alteration of environmental pressure should change microembolic signal counts. We undertook this study to evaluate the influence of hyperbaric exposure on microembolic signal counts in persons with prosthetic heart valves. METHODS AND RESULTS: Microembolic signal counts were monitored by transcranial Doppler sonography of both middle cerebral arteries under normobaria (normobaria 1), 2 subsequent periods of hyperbaria (2.5 and 1.75 bar), and a second period of normobaria (normobaria 2) in 15 patients with prosthetic heart valves. Each monitoring period lasted 30 minutes. Compression and decompression rates were 0.1 bar/min. Microembolic signal counts increased from 20 (12-78) at normobaria 1 to 79 (30-165) at 2.5 bar (P <.01 vs normobaria 1 and 2), decreased to 44 (18-128) at 1.75 bar (P <.01 vs normobaria 1 and 2.5 bar; P <.001 vs normobaria 2), and returned to 20 (8-96) at normobaria 2 (values are medians and 95% confidence intervals). CONCLUSIONS: Our results strongly suggest that gaseous bubbles are underlying material for part of the microembolic signals detected in patients with prosthetic heart valves.
Aortic Valve↗
Echocardiography in the evaluation of systolic murmurs of unknown cause.
PURPOSE: Systolic murmurs are common, and it is important to know whether physical examination can reliably determine their cause. Therefore, we prospectively assessed the diagnostic accuracy of a cardiac examination in patients without previous echocardiography who were referred for evaluation of a systolic murmur. SUBJECTS AND METHODS: In 100 consecutive adults (mean [+/- SD] age of 58 +/- 22 years) who were referred for a systolic murmur of unknown cause, the diagnostic accuracy of the cardiac examination by cardiologists (without provision of clinical history, electrocardiogram, or chest radiograph) was compared with the results of echocardiography. RESULTS: The echocardiographic findings included a normal examination (functional murmur) in 21 patients, aortic stenosis in 29 patients, mitral regurgitation in 30 patients, left or right intraventricular pressure gradient in 11 patients, mitral valve prolapse in 11 patients, ventricular septal defect in 4 patients, hypertrophic obstructive cardiomyopathy in 3 patients, and associated aortic regurgitation in 28 patients. In 28 (35%) of the 79 patients with organic heart disease, more than one abnormality was found; combined aortic and mitral valve disease was the most frequent combination (n = 22). The sensitivity of the cardiac examination was acceptable for detecting ventricular septal defect (100% [4 of 4]), isolated mitral regurgitation (88% [26 of 36]), aortic stenosis (71% [21 of 29]), and a functional murmur (67% [14 of 21]), but not for intraventricular pressure gradients (18% [2 of 11]), aortic regurgitation (21% [6 of 28]), combined aortic and mitral valve disease (55% [6 of 11]), and mitral valve prolapse (55% [12 of 22]). In 6 patients, the degree of aortic stenosis was misjudged on the clinical examination, mainly because of a severely diminished left ventricular ejection fraction. Significant heart disease was missed completely in only 2 patients. CONCLUSION: In adults with a systolic murmur of unknown cause, a functional murmur can usually be distinguished from an organic murmur. However, the ability of the cardiac examination to assess the exact cause of the murmur is limited, especially if more than one lesion is present. Thus, echocardiography should be performed in patients with systolic murmurs of unknown cause who are suspected of having significant heart disease.
Adolescent↗
Reoperative surgery for degenerated aortic bioprostheses: predictors for emergency surgery and reoperative mortality.
OBJECTIVE: The long-term outcome of patients with aortic bioprosthetic valves could be improved by decreasing the reoperative mortality rate. METHODS: Predictors of emergency reoperation and reoperative mortality were identified retrospectively in 172 patients who had the first bioprosthetic aortic valve replacement between 1975 and 1988 (mean age 46+/-13 years) and were subjected to replacement of the degenerated bioprostheses between 1978 and 1997 (mean age 56+/-14 years). Emergency reoperation had to be performed in 31 patients (18%). RESULTS: The operative mortality was 5.2% (9/172), 22.6% for emergency (odds ratio 11.17; 95%-confidence limit 4.33-28.85) and 1.4% for elective replacement of the degenerated aortic bioprosthesis (P<0.0001; OR=20.3). Patients who died at reoperation had higher transvalvular gradients before the primary aortic valve replacement (P=0.007), received smaller bioprostheses at the first operation (P=0.03), had later recurrence of symptoms after the first aortic valve replacement (P=0.04), a higher pre-reoperative New York Heart Association (NYHA) class (P=0.02), and a higher incidence of coronary artery disease (P=0.001) and pulmonary artery hypertension (P=0.009). Endocarditis before the primary aortic valve replacement (P=0.004), postoperative pneumonia at the first operation (P=0.005), pulmonary hypertension (P=0.0004) acquired during the interval, later recurrence of symptoms (P=0.04) after the first operation, a lower ejection fraction at the time of reoperation (P=0.03) and acute onset of bioprosthetic regurgitation (P=0.00002) were predictors for emergency surgery. Higher transvalvular gradients at the primary aortic valve replacement (P=0. 006), coronary artery disease (P=0.003) acquired during the interval, the need for concomitant coronary artery revascularization (P=0. 001), sex (P=0.02) and size (P=0.05) and type of the bioprostheses used (P=0.007) were incremental predictors for reoperative mortality which were independent of emergency surgery. CONCLUSIONS: Elective replacement of failed aortic bioprostheses is safe. Patients undergoing emergency reoperation have a considerably higher mortality. They can be identified by a history of native aortic valve endocarditis, higher transvalvular gradients at primary aortic valve replacement, smaller bioprostheses, and pulmonary hypertension or coronary artery disease acquired during the interval. A failing bioprosthesis must be replaced at its first sign of dysfunction.
Aortic Valve↗
Double aortic arch: diagnosis missed for 29 years.
Double aortic arch is a rare vascular anomaly which causes tracheal and esophageal compression usually in the first months of life. Typical symptoms in the early childhood should lead to prompt diagnosis and surgical treatment of this malformation. In adults this anomaly is extremely rare. A case of a severely 29-year-old symptomatic woman is presented. Despite characteristic symptoms, the diagnosis was missed during childhood. The importance of different diagnostic procedures and operative therapy is discussed. Preoperative angiography can be replaced by the less invasive magnetic imaging and computed tomography. Surgical operation should also be performed in oligosymptomatic patients to prevent late complications.
Adult↗
Resolution of protein-losing enteropathy with standard high molecular heparin and urokinase after Fontan repair in a patient with tricuspid atresia.
At 6 years of age, a girl with tricuspid atresia underwent a Björk modified Fontan procedure with implantation of a Carpentier Edwards bioprosthesis between the right atrium and the right ventricle. Ten years later she developed increasing edema, ascites and pleural effusions. The work-up showed severe stenosis of the bioprosthesis and protein losing enteropathy with a massive decrease of the albumin level to 14 g/l (normal 40-50 g/l). At 17 years of age, the bioprosthesis was replaced with a direct anastomosis between the cavoatrial junction and the right pulmonary artery. Within one month post-operatively, extensive thrombosis of the superior vena cava, anonymous and subclavian veins occurred. Protein-losing enteropathy persisted with an albumin level of 17 g/l. Parallel to the successful treatment of these thrombi with high molecular heparin and urokinase, protein losing enteropathy and hypoalbuminemia resolved completely as long as the antithrombotic treatment with high molecular heparin was continued. Oral anticoagulation was ineffective. Chronic antithrombotic treatment with high molecular heparin may thus be the treatment of choice in these forms of protein-losing enteropathy associated with venous thrombosis.
Child↗
[Pulmonary artery malformations].
We report on two patients with pulmonary arteriovenous malformations (PAVM). An almost asymptomatic young man and an elderly woman with severe dyspnoea illustrate paradigmatically various aspects of the clinical manifestation, diagnostic approach and treatment of this rare disorder. New aspects with respect to genetics, diagnosis and therapy are discussed. PAVM are often manifestations of hereditary teleangiectasia, which also affect blood vessels of the skin, mucous membranes, brain and liver. Transcatheter embolotherapy is a safe, effective and minimally invasive treatment option, which seems to be replacing surgical resection as first-line therapy in many cases.
Adult↗
Predictors of the long-term outcome after combined aortic and mitral valve surgery.
BACKGROUND: The influence of preoperative clinical, hemodynamic, and surgical procedures on long-term prognosis after combined aortic and mitral valve surgery is not well known. METHODS AND RESULTS: One hundred seventy patients (mean age, 50.5 years; 102 men and 68 women) who underwent surgery for chronic combined aortic and mitral valvular disease between 1975 and 1989 were followed up for an average of 10.6 years. Additional repair of tricuspid valve was performed in 29 patients (17%), and aortocoronary bypass graft surgery was performed in 7 patients (4.1%). The perioperative mortality rate was 4%, and 10- and 20-year survival rates were 61% and 33%. Only 12 of 94 deaths (11%) were non-cardiac related. At 10 and 20 years, 57% and 21% of patients were free of reoperation, respectively. The main predictors of late survival in univariate analysis were age at surgery (P=0.0002), preoperative left ventricular ejection fraction (P=0.002), cardiac index (P=0.007), tricuspid surgery (P=0.03), pulmonary vascular resistance (P=0.03), NYHA class (P=0.04), and additional aortocoronary bypass graft surgery (P=0.04). Duration of symptoms, gender, cause of valvular disease, and type of prosthesis were not predictive of postoperative outcome. In multivariate stepwise Cox analysis, ejection fraction (P=0.0008), age at surgery (P=0.0011), and tricuspid surgery (P=0. 007) were independent predictors of late survival. CONCLUSIONS: In combined aortic and mitral valve disease, preoperative myocardial function is the main predictor of long-term survival. Low operative mortality rates and good late outcome make valve replacement mandatory before deterioration of myocardial function occurs. Additional tricuspid valve disease requiring surgery significantly decreases the late survival rate.
Aortic Valve↗
[Cardiovascular disease in pregnancy].
There is a heterogeneous population of young women with cardiovascular disease contemplating pregnancy. Many of the conditions are rare and require teams with expertise in the management of such patients. A specific congenital or acquired cardiovascular anomaly and its physiology must be understood. The nature of prior surgical procedures and the residua and sequelae following therapy are essential to manage a pregnant woman with cardiovascular disease. Physiologic changes during pregnancy and after delivery must be known. Counseling includes maternal and fetal risk stratification and genetic counseling regarding inherited disorders. The outcome of pregnancy is favourable in many women with good functional class. These patients can be reassured. A multidisciplinary approach may be crucial to manage this population during pregnancy, labour, delivery and in the postpartum period to avoid serious maternal and fetal complications. Women with intermediate and high risk pregnancy must be followed and managed in a high risk pregnancy unit and a team from obstetricians, cardiologists, anesthetists, pediatricians, neonatologists and cardiac surgeons who are skilled in high risk pregnancies. Vaginal delivery is the method of choice in many women (class 1 woman) and cesarean section is seldom a cardiac indication. Contraindications for pregnancy are: poor maternal functional class, poor ventricular function, severe cyanosis without pulmonary hypertension (oxygen saturation < or = 85%), pulmonary vascular disease, severe mitral stenosis, severe left ventricular outflow tract obstruction, Marfan syndrome with aortic dilatation (> 40 mm) and aortic valve involvement (moderate to severe aortic regurgitation), symptomatic hypertrophic obstructive cardiomyopathy. Preconception counseling must be offered if unfavourable outcome is likely. Tubal ligation is probably the safest and most appropriate method of sterilization if there is a high risk pregnancy.
Adult↗
Valve replacement in chronic aortic regurgitation. True predictors of survival after extended follow-up.
BACKGROUND: The influence of preoperative clinic, hemodynamic, and surgical procedures on extended long-term prognosis after valve replacement for chronic aortic regurgitation is still unclear. METHODS AND RESULTS: One hundred ninety-two patients (mean age, 44 years) who underwent valve replacement for chronic aortic regurgitation between 1970 and 1983 were followed for 13 to 26 years (mean follow-up, 13.8 years; surviving patients, 18.7 years). Perioperative mortality was 2.6%; survival rates after 10 and 20 years were 76% and 55%; 65 of 80 deaths were cardiac; 21% of patients were free of cardiac complications after 20 years; and 83 of 100 long-term survivors were in NYHA classes I and II. In a univariate analysis, age at operation (P < 0.0001), higher preoperative NYHA class (P < 0.0001), lower left ventricular (LV) ejection fraction (P = 0.0001), higher end-systolic volume (P = 0.0007), history of endocarditis (P = 0.0004), and additional surgical intervention besides valve replacement (P = 0.004) were the main predictors of late survival. In a multivariate stepwise Cox analysis, age (P = 0.0004), high LV end-systolic volume (P = 0.0004), higher NYHA class (P = 0.01), and previous endocarditis (P = 0.006) were independent predictors. CONCLUSIONS: In chronic aortic regurgitation, symptoms and LV systolic function are the main predictors for extended long-term outcome after valve replacement. Low operative mortality and good extended survival make valve replacement mandatory in mildly or asymptomatic patients when LV systolic function decreases and considerable enlargement of systolic dimensions occur.
Adolescent↗
Long-term follow up of patients with endomyocardial fibrosis: effects of surgery.
AIMS: To determine the long-term outcome of patients with endomyocardial fibrosis and to compare echocardiographic and haemodynamic data before and after ventricular endocardial resection. PATIENTS: Seventeen patients (11 women and six men; mean age 35.5 years) diagnosed with endomyocardial fibrosis at the University Hospital in Zurich, Switzerland from 1971 to 1995. Twelve patients (70%) had partial obliteration of both ventricles and in five patients (30%) the fibrotic lesions were limited to the left ventricle. METHODS: Fourteen of the 17 patients had surgical resection: fibrosis was resected from both ventricles in five patients and from the left ventricle only in nine patients. Ten patients had mitral valve replacement and two had tricuspid valve replacement. Left ventricle endocardial resection was done without reconstruction or replacement of the atrioventricular valve in three patients. Preoperative and postoperative echocardiographic data were available for 11 patients and haemodynamic data for six patients. Patients were followed up for 0.4-19 years (mean 8.6). RESULTS: Preoperatively four patients were NYHA functional class IV and 10 were class III; postoperatively one patient was class III, seven class II, and six class I. Preoperatively, echocardiography showed obliteration of the left ventricular apex and inflow tract in all patients, which decreased or disappeared after surgery. Left ventricular end diastolic pressure decreased from 25 mm Hg before surgery to 14 mm Hg after successful resection of the fibrosis. Left ventricular and diastolic volume (normal 93 (17) ml/m2) increased from 65 ml/m2 to 97 ml/m2 (p < 0.05) after surgery. Ejection fraction was normal preoperatively (57%) and decreased slightly (52%) after surgery. One patient died five months after surgery from heart failure. Four surgically treated patients died during the follow up period: one each from systolic dysfunction, recurrence of endomyocardial fibrosis, pneumonia, and food poisoning. Overall survival was 65% at five years and 59% at 10 years; the survival rates of the operated patients was 72% and 68%, respectively. Only one of the medically treated patients survived longer than three years from diagnosis. CONCLUSIONS: Endomyocardial fibrosis is a rare disease in European countries and is found mainly in women. The clinical picture is characterised by severe congestive heart failure but heart size is only moderately increased. Systolic performance is normal or only slightly depressed despite severe restriction to filling, atrioventricular valve regurgitation or both. Partial obliteration of the right and/or left ventricle may be detected by echocardiography. Endocardial resection with atrioventricular valve replacement is the treatment of choice with appreciable postoperative improvement and 10 year survival of approximately 70%.
Adolescent↗
Clonal cytogenetic abnormalities in pediatric brain tumors: cytogenetic analysis and clinical correlation.
The use of contemporary techniques in genetics has resulted in identifying a number of recurring abnormalities in pediatric brain tumors. This information has potential significance in the diagnosis and subtyping of these tumors. Although recurring genetic alterations have been identified in specific tumor types, there are some indications that pediatric brain tumors may be different cytogenetically from adult tumors. In addition, cytogenetic aberrations in certain tumors are associated with unfavorable outcome. In this report we present the cytogenetic characteristics of 14 brain tumors. The clinical outcome is correlated with cytogenetic abnormalities. Clonal abnormalities were observed in 6 of 14 (43%) tumors. All 7 cases had abnormalities specific to histologic subtype. Five of 6 cases with clonal abnormalities (83%) and 2 of 8 with a normal karyotype (25%) were observed in patients with poor prognosis. We also describe the cytogenetic aberrations associated with progression in a rare pediatric brain tumor. This data suggests that cytogenetic analysis of pediatric brain tumors may not be entirely different from their adult counterpart and like the latter may be clinically relevant not only in diagnosis but also as a prognostic indicator.
Adolescent↗
[Endocarditis in heart defects--incidence, diagnosis and prevention].
Infectious endocarditis remains a serious complication of valvular heart disease, before and after surgery, and is associated with a considerable morbidity and mortality. The incidence of endocarditis in different cardiac diseases, the modern requirements for its diagnosis, with special emphasis on the importance of echocardiography, and the guidelines for prophylaxis are reviewed and comprehensively summarized.
Adult↗
[Influence of combination therapy (isosorbide dinitrate and molsidomine) on the incidence of angina pectoris in patients with coronary heart disease].
UNLABELLED: Angina pectoris in patients with severe 3-vessel-disease refractory to treatment is a challenge for the treating physician. We have therefore tested the treatment efficacy of isosorbide dinitrate combined with molidomine on the frequency of angina pectoris in patients with symptoms refractory to treatment. PATIENTS AND METHODS: 15 patients with severe coronary heart disease were included in the study. The protocol included a 2-weeks stabilisation phase, followed by a 4-weeks treatment phase with 100 mg isosorbide dinitrate in the morning as well as 8 mg slow-release molsidomine at 6 p.m. RESULTS: Initially all of the 15 patients reported about daily angina pectoris attacks. After 4 weeks of treatment 4 out of 15 patients became free of symptoms. From the other 11 patients 6 reported an improvement, 5 an unchanged frequency of attacks. DISCUSSION: Combination treatment with isosorbide dinitrate with molsidomine in a slow-release form (in the nitrate free interval) showed a distinct improvement in patients with angina pectoris refractory to treatment with reduction of complaints. The effect of the combination is possibly based on a prolonged vasodilatation of the stenosed vessels and a prolonged reduction of filling pressure (reduction of preload).
Aged↗
[Should every patient with atrial fibrillation get anticoagulants?].
Embolic complications are very common in patients with atrial fibrillation. Patients over 60 years with organic heart disease, arterial hypertension, diabetes mellitus and previous embolic complications are prone to embolic complications. In these high risk groups anticoagulation should be introduced when no contraindications exist. Long term anticoagulation therapy should be evaluated for each patient individually balancing pro and contra. For patients with a low risk of embolism aspirin is a valuable alternative to anticoagulation. Patients below 60 years without heart disease and without additional risks do not need any therapy.
Aged↗