INTRODUCTION: Cardiac rupture (CR), involving left ventricular free wall, interventricular septum or papillary muscles, accounts for 15% of all deaths in the acute phase of myocardial infarction (MI). After cardiac arrhythmias and cardiogenic shock, CR is the third most common cause of death in acute MI. In spite of progress in the treatment of MI, mortality due to CR did not change in recent years.Aim. To assess the incidence, clinical course and outcome in patients with acute MI complicated by CR who were treated in our centre. METHODS: The study group consisted of 697 consecutive patients who were hospitalised due to acute MI with ST segment elevation (STEMI). The in-hospital and three-month follow-up data were analysed in 27 (3.9%) patients who developed CR. In 20 patients CR occurred in the left ventricular free wall, in 5 interventricular septum, in one both of these structures, and in one papillary muscle. The diagnosis of CR was based on clinical presentation and echocardiography. RESULTS: The overall mortality in 697 patients with STEMI was 10.5%. Mortality rate in patients with CR was 55.6% (15 patients) which accounted for 20.5% of all deaths. Nine patients with CR underwent cardiac surgery whereas 18 were treated conservatively. Two (22.2%) patients from the former group and 13 (72.2%) patients from the latter group died. CONCLUSIONS: 1. Mortality due to CR was increased in patients who were treated conservatively, who received thrombolysis and those who were females. 2. Rapid and accurate diagnosis, proper correction of hemodynamical disturbances and timely introduction of cardiac surgery improve prognosis in patients with CR complicating STEMI.

Adult↗

PubMed2004

[Use of coronary artery multislice spiral computed tomography (MSCT) to identify patients for surgical revascularisation].

Conventional coronary angiography is the undisputed gold standard for the detection of coronary artery disease. A small but not negligible risk related to the procedure, cost, and radiation exposure have given rise to the development of noninvasive alternatives such as multi-slice computed tomography, and magnetic resonance coronary angiography. In some patients classic X-ray coronary angiography involves high risk and technical difficulties. Fast, non-complicated and easy to use non-invasive imaging procedures should be developed to avoid unnecessary or technically difficult, uncomfortable situations for patients with documented myocardial ischemia. We present three cases of patients who underwent coronary artery bypass graft surgery or were disqualified from it on the basis of MSCT imaging.

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PubMed2004

[Low ejection fraction as risk factor after aortic valve replacement].

UNLABELLED: The aim of the study is to estimate the operative risk of aortic valve replacement for severe aortic valve stenosis in patients with distinctly impaired left ventricular function (ejection fraction below 40%). From the population of 2512 pts, who underwent aortic valve replacement in the years 1990 to 1999 because of acquired malformation, a group of 108 pts (4.3%), fulfilling the above mentioned conditions was selected. Between them prevailed men, 92 (85.2%), and the average age was 53.4 +/- 14.5. All pts remained in the NYHA functional class III/IV. The average ejection fraction was estimated 28.2 +/- 14.3%. The pts demonstrated concentric left ventricular hypertrophy, severe aortic valve calcifications, the average valvular area was 0.91 cm2, and the pressure gradient over the valve was 71 +/- 44 mmHg. The pts were operated on by different surgeons but after the same protocol of extracorporeal circulation and cardioplegia administration. Low output syndrome occurred in ca 40% of pts, and cardiac failure was the main cause of death. The hospital mortality was 8.6%, and it was over two times higher then the whole population of pts, who underwent aortic valve replacement. All survivors (91.4%) demonstrated clinical improvement already during the early observation. CONCLUSIONS: Low ejection fraction is an important risk factor of surgery for aortic valve stenosis. However, the elevated operative mortality, comparable to other institutions, may be accepted taking for consideration, that surgery is the only way of treatment and improvement may be expected in about 90% of pts, including anatomical and hemodynamic parameters, as well as life longevity and comfort. In the extreme cases the HTX should be considered.

Adult↗

PubMed2004

Indications for reoperation for valvular prosthesis dysfunction in urgent and elective patients.

OBJECTIVES: Comparison analysis of indications for operation, early clinical outcomes and hospital mortality between patients reoperated for valvular prosthesis dysfunction urgently and electively. MATERIAL AND METHODS: Retrospective data analysis of 94 patients (pts) reoperated for valve prosthesis dysfunction at Department of Cardiovascular Surgery and Transplantology in Kraków, Poland between January 1999 and December 2002. RESULTS: Valvular reoperation was elective procedure in 69 pts (73.4%)--group A: 46 males (M), 23 females (F), age 23-71 (av. 51.31 +/- 10.2). Urgent operation was performed in 25 pts--group B: 17 M, 8 F, age 29-77 years (av. 5.41 +/- 13.26). In group B: 9 patients underwent reoperation for dysfunction of aortic valve (2 allogenic, 7 mechanical), 13 pts for mitral valve dysfunction and 3 pts for both aortic and mitral valve dysfunction. In group A: 24 pts for mitral valve dysfunction, 37 pts for aortic valve dysfunction (25 allogenic, 12 mechanical) and 8 pts for both aortic and mitral valve dysfunction. In group B: 16 pts (64%) were operated in NYHA class IV; 8 in cardiogenic shock; on which 8 pts with active endocarditis, 3 pts with sepsis and 1 patient in septic shock. Average operative risk calculated as Euroscore was 30.86 in group B and 13.15 in group A (p<0.05). Overall hospital mortality was 12.6% (12 pts). In group B: 7 pts died (28%), 3 pts due to multiorgan failure, 1 patient due to sepsis, 2 pts due to aorta rupture and 1 due to left ventricle rupture during cardiopulmonary rescuscitation. In group B 5 pts died (7.2%). CONCLUSION: Patients reoperated urgently for valve prosthesis dysfunction were in worse preoperative state, had significantly higher preoperative risk and in hospital mortality than patients reoperated electively.

Adult↗

PubMed2004

[Use of cardiovascular magnetic resonance (CMR) in preoperative assessment of aortic stenosis--case report].

PURPOSE: CMR is a helpful additional diagnostic method in cardiac imaging. Thanks to high spatial and temporal resolution and high quality of obtained images this method is used in patients with poor echocardiographic acoustic window. We present a case of a patient, in whom CMR was conclusive as a non-invasive method of aortic valve stenosis assessment before qualification to cardiosurgery. METHODS: CMR was performed in a 70-year-old female A. C. who was under cardiological control due to symptomatic aortic stenosis. Because of difficulties in echocardiographic examinations (TTE) the aortic valve area was impossible to evaluate and aortic gradient value was difficult to assess and it differed in consecutive TTE performed over a short period (maximal gradient: 66-91 mmHg; mean gradient: 37-50 mmHg). The patient underwent CMR (Magnetom Vision Plus 1.5 T, Siemens) with the use of cine gradient echo sequences which made possible morphological and functional assessment of the valve and left ventricle. LV mass indices, IVS thickness, EF, aortic valve area, maximal aortic valve gradient were measured. RESULTS: CMR revealed: left ventricle muscle hypertrophy (IVS--1.8 cm; LV mass index--210 g/m2), EF--70%, no regional contractility disturbances and aortic valve area less than 1 cm2. In aortic valve and anulus extensive calcifications were visualised as low intensity signal area. Turbulent flow through aortic valve was found, maximal gradient about 64 mmHg. On the basis of all clinical symptoms and measurements based on imaging methods, the patient was qualified for cardiosurgery which was held in the Department of Cardiovascular Surgery and Transplantology. Coronary angiography revealed no significant stenosis. The operation was performed in extracorporeal circulation, general hypothermia and cardioplegia. Calcified aortic valve leaflets were excised and replaced by artificial valve (St. Jude Medical 21A Masters). The patient is in good health and was discharged. CONCLUSIONS: CMR is a valuable non invasive imaging method complementary to TTE in morphological and functional assessment of aortic valve and left ventricle, especially in patients with poor acoustic window in TTE.

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PubMed2004

[Effect of the dispersion of calcium deposits on allogenic aortic valves durability. Mineralization phases].

This investigation was aimed at comparison of calcium content and calcium dispersion in allogenic aortic valve leaflets removed due to dysfunction, to establish the influence of both parameters on graft durability. Calcification was assessed histochemically (von Kossa) as well as physicochemically using atomic absorption spectroscopy (AAS). The morpho-metric data (leaflet area involved in the calcification process) were obtained by computer-assisted image analysis system. The dry weight content of leaflet calcium and phosphorus were assessed by atomic absorptive spectroscopy (AAS) and Ca/P ratio was calculated. Calcium dispersion coefficient (Dc) was established according to the formula: Dc = 1/Ca(c)/Ap, where Ca(c) = calcium dry weight concentration; Ap = percent of leaflet area involved in calcification. We found biphasic correlation between calcium concentration and area involved in calcification. The first one was characterized by rising dispersion of calcium deposits while for the second one saturation with hydroxyapatite of formerly calcified areas was predominant, negatively influencing graft durability. Allograft durability was correlated with calcium dispersion (Dc) (p<0.001), while no significant correlation was found with calcium concentration. Decreased Dc was characteristic for 93.8% of low durability grafts (<11.6 years). Our results suggest that lowered calcium dispersion decreasing allograft lifetime and is a better predictor of allograft durability than the total calcium content.

Adolescent↗

PubMed2004

[Mineralization of homograft aortic valves stored in a nutrient solution].

BACKGROUND AND AIM OF THE STUDY: Mineralization of the homograft aortic valve cusps is a complex process leading to their degeneration and decreasing durability. Factors that play a decisive role in regulation of mineralization, growth of hydroxyapatite crystals are still open questions. We studied development of mineralization in the homograft aortic valves prepared for transplantation stored in the Parker's solution with antibiotics. METHOD: The aortic valves were explanted from 12 donors <18 hours after death. All the cusps were divided into halves. One half of each cusp was stored in the Parker's solution with antibiotics for 28 days at 4 degrees C. Concentrations of several elements (P, S, Cl, K, Ca, Mn, Fe, Ni, Cu, Zn i Sr) in incubated and control samples were determined using energy dispersive X-ray fluorescence (ED-XRF). RESULTS: The study showed that the concentration of Ca and Ca/P increased during incubation that may indicate development of mineralization. CONCLUSIONS: The homograft aortic valve cusps underwent mineralization during in vitro incubation. This may aggravate mineralization in the aortic valve recipients and decrease valve durability which indicate a need for modification of storing condition.

Adult↗

PubMed2004

[Early results of surgical treatment in acquired heart diseases during endocarditis in own material].

BACKGROUND: Endocarditis can concern natural as well as artificial heart valves. In conservative treatment mortality reaches 24-60%. Surgical procedure is the only way to save these patients in most cases. METHODS: Between 1998-2001, 114 patients underwent surgery because of valve endocarditis, 86 male and 28 female. 43 patients underwent mitral valve replacement (MVR), (13 MV reoperation), 51 aortic valve replacement (AVR), (16 AV reoperation) and 20 patients underwent MVR and AVR (3 both valves replacement). Three groups were similar regarding age, gender, emergency or elective procedures and NYHA class four. All patients underwent open heart surgery in ECC with hypothermia and crystalloid cardioplegia done by the same group of surgeons. RESULTS: Operative mortality in the MVR group was 11.6% (five of 43) compared to 3.9% (two of 51) AVR patients and 25% (five of 20) MVR and AVR group. The highest mortality rate was in both infected artificial valves procedures. There was growth of the bacteria in intraoperative material in 37.6% (33) of cases, mainly Staphylococcus epidermidis and Staphylococcus aureus. Incidence of postoperative sepsis, multiorgan failure, high grade atrio-ventricular block or low cardiac output was the highest in MVR and AVR patients. Independent predictors of operative mortality included increasing patient age, female gender, infected valve reoperation, and history of stroke. CONCLUSIONS: Our study suggests that patients with endocarditis and compromised hemodynamic status can be operated with acceptable morbidity and mortality. If echocardiography shows the cuspids perforations or vegetations, chords tendinous rupture or perivalvular leak, the patients should undergo cardiac surgery as soon as possible, in order to avoid severe embolic complications.

Adult↗

PubMed2004

Dysfunction of primary aortic valve prosthesis--allogenic versus mechanical--preoperative differences.

OBJECTIVES: Comparison of preoperative characteristics between patients reoperated for allogenic and mechanical aortic valve prosthesis dysfunction. METHODS: Retrospective data analysis of 47 patients reoperated for aortic valve prosthesis dysfunction at Department of Cardiovascular Surgery and Transplantology in Kraków, Poland between January 1999 and December 2002. RESULTS: In analyzed group 27 patients were operated for dysfunction of allogenic valve (Gr. A), 20 pts for mechanical valve (Gr. B). Group A: 21 males (M), 6 females (F), age 23-68 years old (av. 47.10 +/- 11.71); Group B: 18 M, 2 F, age 38-77 (av. 54.73 +/- 11.03), p<0.05. Time between operations in group A was 69-258 months (av. 164.34 +/- 66.02) months and in group B 0.5-348 months (av. 77.27 +/- 98.29) p<0.01. In group A, 5 pts and in group B, 7 pts were in NYHA group IV preoperatively. Echocardiography revealed that diastolic left ventricular dimension (LVDD) was larger in group A: av. 6.7 cm and 5.36 cm in group B, p<0.05. 2 pts from group A and 7 pts from group B were operated urgently (p<0.05), including 3 pts with aortic dissection. Definite infective endocarditis was diagnosed in 6 pts from group A and 11 pts from group B, p<0.05. In group A, 1 patient was urgently operated for infective endocarditis with vegetations, he died due to multiorgan failure. In group B, 6 pts died including all 3 with aortic dissection. CONCLUSIONS: Patients reoperated for allogenic aortic valve prosthesis dysfunction are: younger, reoperated after a much longer period of time with slower valve dysfunction progress (larger LVDD), most frequently reoperated electively, less frequently with endocarditis as the cause of valve dysfunction than in patients reoperated for mechanical aortic valve dysfunction.

Adult↗

PubMed2004

[Quality of life after homograft aortic valve replacement and reoperation].

AIM: To evaluate quality of life (QoL) in patients after aortic homograft implantation for aortic valve disease and in those who had undergone reoperation due to homograft dysfunction. METHODS: QoL was assessed in 354 patients (72 women and 282 men, mean age 55.1 +/- 11.5 years, range 13-69) after aortic homograft implantation. Patients were divided into two groups: I--patients after aortic homograft implantation without reoperation (291 patients) and II--patients after reoperation (68 patients). We used two questionnaires: SF 36 (Short Formulation 36) and a self-developed questionnaire for patients after cardiac operation (SDQ). SF 36 has three levels: a) 36 items; b) eight scales: physical activity, social activity, limitations in every day activity, body pain, mental health, emotional problems, vitality and health perception; c) two summary measures that aggregate scales; general physical health which constitutes of physical activity, limitations in every day activities, body pain, health perception and general mental health which constitutes the rest of four scales: social activity, mental health, emotional problems, vitality. Each scale is standardized from 1 to 100 with > 50 indicating better than general population average. SDQ is focused on social and demographic factors, clinical symptoms before and after operation, risk factors and physical and occupational activity. RESULTS: By SF 36, only health perception was below general population average. We found a statistically positive relationship between QoL and high physical and occupational activity in both groups (p<0.05). The presence of dyspnea, chest pain, palpitations, edema, faints, fear/anxiety and hypertension were related to decreased general physical and mental health in both groups (p<0.05). CONCLUSIONS: Patients after aortic homograft implantation have high QoL. This holds also for those after reoperation for homograft dysfunction. Symptomatic patients have lower QoL. Higher QoL is associated with physical and occupational activity. There is no difference in general physical health in both groups. General mental health is decreased in reoperated patients. Since reoperated patients more often suffer from emotional problems, they may particularly benefit from the psychological support.

Adolescent↗

PubMed2004

[Left ventricular systolic function in patients with refractory angina pectoris treated with percutaneous myocardial laser revascularisation, results of long-term follow-up].

INTRODUCTION: Percutaneous myocardial laser revascularisation (PMLR) has been developed for treatment of patients with refractory angina pectoris. This study was designed to evaluate long-term impact of PMLR on left ventricular systolic function. MATERIAL AND METHODS: Ten patients with refractory angina pectoris who underwent PMLR were studied with dobutamine stress echocardiography before procedure, at early follow-up after 1-3 months and at long-term follow-up after 2-3 years post procedure. Wall motion score index (WMSI) and ejection fraction (EF) were calculated at rest as well during infusion of dobutamine with low and high rate. RESULTS: Mean WMSI at rest decreased significantly from 1.71 +/- 0.24 before PMLR to 1.55 +/- 0.21 at early follow-up (p=0.0189) and 1.48 +/- 0.26 (p=0.009) at long-term follow-up. Mean WMSI during low-rate dobutamine infusion decreased significantly from 1.39 +/- 0.29 to 1.25 +/- 0.25 (p=0.0276) at early follow-up, but was not significantly different in long-term. Mean WMSI during high-rate dobutamine infusion decreased significantly from 1.83 +/- 0.21 before PMLR to 1.56 +/- 0.2 at early follow-up and 1.57 +/- 0.29 (p<0.03) at long-term evaluation. Mean EF at rest increased significantly from 48 +/- 8.6% before PMLR to 56.9 +/- 7.9% (p=0.0189) at early follow-up. At long-term follow-up mean EF at rest was 52.7 +/- 8.3% and was not significantly different from baseline. Mean EF during low-rate dobutamine infusion was not significantly different from baseline both at early and long-term follow-up. Mean EF during high-rate dobutamine infusion increased significantly from 44.5 +/- 8.6% before PMLR to 58.1 +/- 7.0% (p=0.0093) at early follow-up while in long-term it was 51.3 +/- 9.8%, which was not significantly different from baseline. These changes were accompanied by significant decrease of mean CCS score from 3.52 +/- 0.51 before procedure to 2.54 +/- 0.78 (p<0.0001) after 1 month and 2.78 +/- 0.65 after 24 months. CONCLUSIONS: In patients with refractory angina pectoris treated with PMLR significant early improvement of systolic left-ventricular function is observed with trend toward improvement in long-term. It is accompanied with significant long-term angina relief.

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PubMed2004

[Atrial fibrillation in a long-term follow-up after mitral valve replacement].

UNLABELLED: The aim of the study was to analyse cardiac rhythm after mitral valve replacement and to define pre-operative predictive factors for persistence of atrial fibrillation. MATERIAL AND METHODS: The study group consisted of 76 consecutive pts (54 F, 22 M), mean age 54.8 +/- 8.2 (38-71) years in whom mitral valve replacement was performed due to mitral stenosis (15 pts), regurgitation (18 pts) or mixed lesion (43 pts). The prevalence of AF after the procedure was analysed with relation to age, gender and the following preoperative echocardiographic parameters: left atrial size, mitral valve area, mitral regurgitation, tricuspid regurgitation and left ventricular ejection fraction. RESULTS: Chronic AF was present in 51 pts (67.1%) before the procedure and in 34 pts (44.7%) after 17.3 +/- 11.9 months (6-46) follow-up, p<0.005. Patients with AF after operation had larger left atrium size (58.6 +/- 10.9 vs 51.3 +/- 10.1 mm, p<0.005) and lower ejection fraction (53.8 +/- 7.9 vs. 59.9 +/-8.4%, p<0.01) as compared with pts in sinus rhythm. Among 51 pts with preoperative chronic AF, 21 pts recovered to sinus rhythm (subgroup I) and 30 pts remained in AF (subgroup II) after operation. The only significant differences between subgroup I and II were: higher prevalence of mitral regurgitation (85.7 vs 60%, p<0.05), larger mitral valve area (1.4 +/- 0.3 vs 1.1 +/- 0.6 cm2, p<0.025) and higher ejection fraction (58.9 +/- 7.3 vs. 53.4 +/- 8.4%, p<0.025) in subgroup I. CONCLUSIONS: 1. The prevalence of AF diminishes significantly after mitral valve replacement. 2. Patients with pure mitral stenosis are at higher risk of remaining in AF after operation. 3. Preoperative left atrial dimension and LV ejection fraction are the most important predictive parameters for persistence of AF.

Adult↗