[Heart interventions in Switzerland 1992. PTCA and Fibrinolysis Study Group of the Swiss Society of Cardiology].
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Angioplasty, Balloon, Coronary↗
Biomedical subjects
M Rothlin
Publications and source records attributed to M Rothlin.
The internal mammary artery 'string phenomenon'. Analysis of 10 cases.
The internal mammary artery (IMA) string sign has been described as a narrowing of IMA grafts in the late course after coronary artery bypass grafting. It has been assumed that this phenomenon was due to competitive flow in grafts connected to only mildly stenosed coronary arteries. We analyzed 10 cases of IMA string sign operated on between March 1988 and June 1991. Bilateral IMA was used in six cases and unilateral IMA in four. The mean interval between operation and reangiography was 14 +/- 11 months. String sign of the whole length of the IMA was detected in nine cases, and of the distal part between two sequential anastomoses in one. In all cases, the stenosis of the vessel bypassed with the narrowed graft proved to be only mild (50% or less) at reangiography. In all six cases with bilateral IMA grafts, the contralateral IMA was widely patent. These were all connected to highly stenosed or occluded coronary arteries. With respect to this observation, there is a high index of suspicion that the string phenomenon occurs due to competitive flow in only mildly stenosed coronary arteries. We decided, for our strategy in coronary artery surgery, still to aim at complete revascularization using IMAs as much as possible, but to avoid connecting IMA grafts to only mildly or moderately stenosed coronary arteries.
Coronary Angiography↗
[Developments in mitral valve surgery].
Between 1987 and 1990 we operated on 104 patients for mitral valve disease. If possible the valve was reconstructed according to CARPENTIER's technique: 8 of 28 stenotic, 43 of 57 regurgitant and 2 of 7 mixed lesions were repaired. Twelve patients underwent re-replacement of a previously inserted mitral prosthesis. Six patients died early (7.8% after replacement, 8% after isolated replacement, 3.7% after repair and 2% after isolated repair). Five of these six patients were in NYHA class IV preoperatively. Seven patients died late after a mean observation period of 18 months (5 after replacement, 1 after double valve replacement and 1 after repair and multiple coronary bypass surgery). Prognosis is best for patients whose valve can be repaired and who are not already in NYHA class IV. The postoperative NYHA class for surviving patients is excellent (1.3 in the replacement group and 1.2 after repair).
Adult↗
[Emergency surgery for PTCA complications: tactics and results].
Incidence, risk and results of emergency coronary bypass surgery after failed percutaneous transluminal coronary angioplasty (PTCA) have been analyzed in a retrospective study. Failed PTCA has been defined as visible pathology (dissection, occlusion) of the dilated vessel associated with acute chest pain and ECG changes. From 3-1-1987 to 11-30-1990, 23 patients of 433 (5%) underwent emergency surgery for failed PTCA (19 male, 4 female, mean age 55 +/- 8 years). PTCA was performed in 16 cases of one-vessel-disease, 3 cases of two-vessel-disease and 4 cases of three-vessel-disease. All had an ejection fraction beyond 40%. 19 patients remained in stable hemodynamic condition. In average 2.1 vessels have been bypassed; in 13 cases the internal mammary artery (IMA) has been used, in 10 cases the saphenous vein (VSM) only. No early nor late death occurred. The perioperative infarction rate is 30%. Comparing the group with IMA and the group with VSM only, no difference could be found regarding the number of unstable hemodynamics, the use of catecholamines nor the perioperative infarction rate. After a mean follow-up period of 14.3 months, 21 patients are in NYHA class I, 2 in NYHA class II. Emergency coronary bypass surgery can be performed with low risk and favorable results, if the operation is timed without delay after the onset of acute chest pain and ECG changes in failed PTCA. The infarction rate is remarkably higher than in elective coronary surgery. The use of the IMA seems to be no additional risk factor.
Angioplasty, Balloon, Coronary↗
[Long-term course of hypertrophic cardiomyopathy: drug versus surgical therapy].
139 patients with hypertrophic cardiomyopathy (HCM) have been followed up for 1-28 years (mean 8.9 years). Group 1 consisted of 60 patients (mean age 38 years) without indication for septal myectomy (SM) (no pressure gradient at rest in 8, pressure gradient less than 50 mm Hg in 52 cases); group 2 consisted of 79 patients (mean age 36 years) who had SM (pressure gradient at rest 70 mm Hg). Management in group 1 was the following: (1a) propranolol (n = 20) (160 mg/d), (1b) verapamil (n = 18) (360 mg/d) and (1c) no therapy (n = 22). 19 patients died in group 1 (mortality 3.6% year); 17 died in group 2 (mortality 2.4%/year). 10 year survival in group 1b was 80% and in groups 1a und 1c 67% and 65% respectively. Patients of group 1b had a higher survival rate (p less than 0.05) than the other subgroups. Surgery patients treated with verapamil (120-360 mg/d) (n = 17) had a 10-year survival rate of 100% compared to 78% for surgery patients (n = 34) without such treatment (p less than 0.05). In summary, it can be said that the overall survival rate after SM is better than that with medical treatment. Under verapamil, however, survival is not different from that after surgery. The most favorable outcome was observed in surgery patients under long-term therapy with verapamil, probably due to the reduction of systolic pressure overload (SM) and improvement in diastolic function (verapamil).
Adult↗
Coarctation of the aorta: review of 362 operated patients. Long-term follow-up and assessment of prognostic variables.
362 patients operated upon for coarctation of the aorta from 1961-1980 were analyzed retrospectively. Age at operation was less than 2 years in 74 (group A) and greater than or equal to 2 years in 288 patients (group B). Associated cardiovascular malformations were common, especially in group A patients. Early mortality was 12.2% for group A and 1.4% for group B patients. 336 patients were followed for 6 months to 21 years (mean 8.9 years). Late mortality was 0.8% per patient year. Associated cardiac defects and postoperative hypertension were responsible for most of the late deaths. Late reoperations were performed because of aortic valve disease, residual coarctation (with persistent hypertension) and aortic aneurysms at the site of anastomosis. The incidence of hypertension decreased from 82.5% preoperatively to 33.5% at discharge from the hospital. It decreased further during follow-up in patients operated less than 10 years of age, but remained constant in the older patients. In conclusion, morbidity and mortality after operative repair of coarctation are determined mainly by (1) associated cardiac malformations, and (2) postoperative hypertension. Patients with isolated coarctation and postoperative normal blood pressure have an excellent prognosis. Patients operated upon from between 2-9 years of age carry the lowest risk for residual coarctation and late postoperative hypertension.
Aortic Aneurysm↗
Early results after mitral valvuloplasty for pure mitral regurgitation.
In this study we present the results of 105 consecutive patients with pure mitral regurgitation who underwent surgical treatment. In all patients mitral regurgitation was associated with mitral valve prolapse: 54 patients underwent mitral valvuloplasty and 51 patients mitral valve replacement. Clinical assessment and echocardiography were used as follow-up criteria at one year after surgery. After mitral valvuloplasty, NYHA decreased from 2.7 +/- 0.8 to 1.1 +/- 0.7 (P less than 0.01) and workload capacity increased from 65 +/- 28% to 96 +/- 25% (P less than 0.001); left endsystolic atrial dimension and enddiastolic dimension decreased from 6.2 +/- 0.8 to 4.8 +/- 1.2 cm (P less than 0.001) and from 7.2 +/- 1.3 to 5.9 +/- 0.8 cm (P less than 0.01); ventricular contraction fraction did not change significantly. After mitral valve replacement, clinical and echocardiographic improvement was significant but less remarkable than after valvuloplasty; ventricular contraction fraction fell from 39 +/- 7% to 29 +/- 8% in contrast to patients undergoing mitral valvuloplasty in whom no significant change occurred. Complications were rare in both groups though only a minority of patients undergoing mitral valvuloplasty received anticoagulants. We conclude that mitral valvuloplasty in patients with pure mitral regurgitation when compared with the patients after mitral valve replacement.
Echocardiography↗
Echocardiographic findings late after myectomy in hypertrophic obstructive cardiomyopathy.
Postoperative echocardiograms of 50 patients undergoing myectomy for hypertrophic obstructive cardiomyopathy between 1965 and 1982 have been evaluated. In 21 patients a comparison with preoperative echocardiograms showed that postoperatively there was a significant reduction of septal and free wall thickness, an increase of left ventricular end-diastolic as well as outflow tract dimensions and a reduction or disappearance of systolic anterior motion of the mitral leaflet. Postoperative examination at intervals greater than 3 years revealed a significant increase of left ventricular and left atrial cavity size with unchanged contractile parameters and little reduction of left ventricular hypertrophy. In 4 of 12 patients evaluated greater than 8 years after myectomy, left ventricular dilatation was observed and 3 of these 4 patients developed congestive heart failure. Development of left ventricular dilatation was independent of whether a transventricular and/or transaortic approach was used for myectomy. These data indicate that the late course after myectomy in hypertrophic obstructive cardiomyopathy may be complicated by dilatation of the left ventricular cavity.
Adolescent↗
[Heart surgery in patients older than 70 years].
Between 1980 and 1983, 103 patients over the age of seventy (average 72.5 years) underwent cardiac surgery. It comprised 41 aortic valve replacements, 11 mitral valve operations, 7 aortic and mitral valve procedures, 18 valve replacements with concomitant coronary artery bypass grafting, 17 coronary revascularizations, 7 operations for VSD after acute myocardial infarction and 2 procedures for dissecting aneurysm of the ascending aorta. Early mortality was 7.8% and late mortality 10% after a mean follow-up of 29.3 months. Preoperative NYHA-class IV is an incremental risk factor for early and later cardiac death. Early and late results are very satisfactory in patients with isolated valvular lesion, with or without concomitant coronary artery disease, and for isolated coronary atherosclerotic heart disease, whereas there is a high risk of early and late death in patients with multiple valvular lesions or VSD after acute myocardial infarction.
Age Factors↗
[Coronary reoperation--yes or no?].
From 1979 to April 1984, 51 patients were reoperated on for postoperative angina pectoris. Three patients died early and 4 late. The cause of death was cardiac in all cases. After the second operation the mean observation period was 24.2 months and the mean functional class 2.0. These results were somewhat worse than was to be expected after the first operation. The single significant risk factor was an ejection fraction reduced below 50%. The indication for reoperation should therefore be confined to patients with severe angina, good left-ventricular function, bypassable coronary arteries and sufficient graft material available (saphenous vein, internal mammary artery).
Adult↗
Improved late survival in patients with chronic aortic regurgitation by earlier operation.
Between 1970 and 1979, 156 patients with severe chronic aortic regurgitation underwent aortic valve replacement. Early mortality was 2.5%; 5 and 10 year survival rates were 85.9% and 69.2%, respectively. Early mortality decreased from 3.5% (2/56) in the period from 1970 to 1974 to 2.0% (2/100) in the period from 1975 to 1979; first-year survival rate was similar in the two periods (94.2% and 94.7%); 5 year survival rate increased from 80.1% in the period from 1970 to 1974 to 90.6% in the period from 1975 to 1979. The frequency of late death from heart failure decreased from 5/13 in the period from 1970 to 1974 to 0/9 in the period from 1975 to 1979. Preoperative NYHA class decreased from 2.7 (10 patients in class IV, none in class I) during 1970 to 1974 to 2.1 (one patient in class IV, 15 in class I) during 1975 to 1979 (p less than .001). From 1970 to 1974 preoperative cardiothoracic ratio (0.60 vs 0.57; p less than .001) and left ventricular end-diastolic pressure (33 vs 19 mm Hg; p less than .001) were higher and left ventricular ejection fraction (50% vs 54%; p less than .05) was lower than values during 1975 to 1979. The patients who died of heart failure were in a higher NYHA class before surgery, cardiothoracic ratio and left ventricular end-diastolic pressure were higher, and left ventricular ejection fraction was lower than those in patients who died suddenly. In all patients of both groups left ventricular end-diastolic volume exceeded 200 ml/m2.(ABSTRACT TRUNCATED AT 250 WORDS)
Adult↗
[Progression of coronary stenosis following aorto-coronary bypass surgery].
In a prospective study (238 men, mean age 53 years) the changes in native vessels were studied 3 months after aorto-coronary bypass operation and 5 months after preoperative angiography. Progression was defined as increase in stenoses of at least 20% or new total occlusion. Progression was significantly more frequent in vessels with bypass than without; it was located proximally to the anastomoses in most cases, less frequently at the anastomoses and very rarely distally to the anastomoses. Proximal progression was significantly more frequent with open bypasses than with occluded ones. Stenoses at the anastomoses were significantly more frequent with occluded bypasses than with open ones. More severe stenoses had a stronger tendency to progression than less severe stenoses. Regression was rare and nearly always caused by surgery.
Aortic Valve Stenosis↗
[Early ergometry following acute myocardial infarction?].
One hundred and twenty patients underwent a symptom limited submaximal exercise test (SSET) 8-40 days after acute myocardial infarction. No complications occurred during the exercise test. Sixty-two patients (52%) showed a normal SSET. ST-segment depression (greater than or equal to 1 mm) was detected in 21 (17.5%). Dyspnea, fatigue, inadequate blood pressure response and angina pectoris without changes in ST-segments were the end-point in 33 patients (27.5%). Furthermore, significant premature ventricular contractions occurred in four cases (3%) and limited the SSET. An SSET soon after myocardial infarction can be performed without risk. High specificity of ST-segment depression in lead V5 was confirmed by the coronary angiographic findings. Apart from ST-segment depression there were other, more frequent nonspecific end-points of SSET which require further examination regarding their prognostic value.
Aged↗
Asymmetric septal hypertrophy in patients with aortic stenosis: an adaptive mechanism or a coexistence of hypertrophic cardiomyopathy?
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Adult↗
Comparison between internal mammary artery implantation and aorto-coronary vein bypass grafting in coronary artery disease with significant left anterior descending stenosis.
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Adult↗
[Changes in the unmodified vessels after aortocoronary bypass surgery].
In a prospective study (238 men, mean age 53 years) the changes of the native vessels were studied 3 months after a-c-bypass operation and 5 months after preop. angiography. Progression was defined as increase of stenoses of at least 20% or new total occlusion. Progression was significantly more frequent in vessels with than without bypass and was located proximally to the anastomoses in most cases, less frequently at the anastomoses and very rarely distally to the anastomoses. Proximal progression was significantly more frequent with patent than with occluded bypasses. Stenoses at the anastomoses were significantly more frequent with occluded than with patent bypasses. Stenoses of higher degrees had a stronger tendency for progression than slighter stenoses. Regression was rare and nearly always caused by surgery.
Angina Pectoris↗
[Occupational rehabilitation following aorto-coronary bypass operations].
Resumption of work after aorto-coronary bypass surgery was studied in 317 patients with a mean age of 51 years. 217 patients who underwent surgery between 1975 and 1978 were studied retrospectively (group I) and 100 patients operated upon between 1979 and 1980 prospectively (group II). A coronary control study was performed in 106 patients of group I and in all patients of group II. Age, postoperative NYHA class, and pre- and postoperative ejection fraction did not differ in the two groups. Significant differences between the two groups were found regarding preoperative NYHA class (2.9 vs 2.5), amount of diseased coronary vessels (2.3 vs 2.6), number of bypass grafts (2.4 vs 3,2, all p's less than 0.001) and graft patency rate (70 vs 80%, p less than 0.025). One year after surgery 78% in group I and 84% in group II were back at work (ns). However, among the patients not working before surgery, 54% in group I and 73% in group II had returned to work (p less than 0.005), which indicates a greater success rate for aorto-coronary bypass grafting in recent years. Best predictors for resumption of work after surgery are relief of symptoms, normal work capacity in the bicycle test, duration of inability to work before surgery and type of occupation.
Adult↗
[Pregnancy and labor after closed mitral valve commissurotomy].
Among 171 women who had undergone mitral valvulotomy at childbearing age, 47 had a total of 62 postoperative pregnancies. The cardiological findings before and after valvulotomy show the patients with pregnancy to be a positive selection of all patients who had mitral valvulotomy in Zurich. 10% of the pregnancies were complicated by atrial fibrillation or heart failure. Three deaths related to pregnancy and birth were registered. The NYHA functional classes III and IV are considered to be contraindications for postoperative pregnancy. Other risk factors are discussed. Based on physical examination, electrocardiography, chest x-ray, ergometry and echocardiography, a woman wishing to have a child after mitral valvulotomy should be advised of the cardiological risk. During pregnancy, regular follow-up by both obstetrician and cardiologist must be expressly required.
Abortion, Spontaneous↗