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A patient with an asymptomatic aortic right ventricular fistula acquired after aortic valve and mitral valve replacement is presented. This was diagnosed by two-dimensional and pulsed Doppler echocardiography, and confirmed at cardiac catheterization.
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The quantitative potassium and sodium contents in the separate regions of the heart and m. rectus abdominis in cases of sudden and violent death were investigated. The disturbances of the electrolyte metabolism of potassium and sodium were established to be the earliest changes in coronary disease (acute coronary insufficiency resulting from functional disturbances of the coronary circulation and myocardial infarction). The decrease of the quantitative potassium contents and sodium increase in myocardium depend on the ischemia duration and the stage of the myocardial lesion. The highest potassium decrease was observed in the left ventricle and right auricle. Not very high but even decrease of potassium and sodium contents in the separate heart regions was observed in the deceased by electrocution and strangulation, the decrease being most negligible in the deceased by electrocution. The changes observed in potassium and sodium contents are not pathognomic signs of coronary disease. Only the sharp, focal decrease of the contents of those element is a reliable sign of myocardial infarction.
Over the last three decades there has been a world-wide decline in the incidence and severity of rheumatic fever and rheumatic heart disease, but the death rate in Singapore from chronic rheumatic heart disease has risen from 3.6 per 100,000 population in 1966 to 4.4 per 100,000 in 1977. Valvular lesions from rheumatic heart disease are very common, and between 1967 to 1979, 715 surgical procedures were performed for rheumatic valvular disease, and of these, 654 procedures involved the mitral valve which was most commonly affected by the disease process. Since many of the patients were female and in the child-bearing age, conservative procedures on the mitral valve were performed whenever possible. Mitral valvotomy for mitral stenosis relieved symptoms effectively; and for restenosis of the mitral valve, more than half of the patients underwent a second valvotomy with functional improvement. Mitral valve replacement was reserved for the severely distorted valve, sometimes calcified, and where there was stenosis associated with incompetence. Between 1971 to 1979, 162 mitral valves were replaced and actuarial studies showed 80% survival five years after surgery. 30 aortic and mitral valve replacements were performed in this same period with an operative mortality of 16.7%. Only 75 aortic valves were replaced for rheumatic valvular disease and 14 of these also had associated mitral and triscuspid valve disease. The prosthetic valves commonly used for replacement were the Starr-Edwards non-cloth covered valves, models 6120 and 1260. All patients that had valve replacements were treated with long-term anticoagulation with Warfarin. The incidence of thromboembolism was low, being 8% for mitral valve replacement and the majority of these episodes occurred in the first three months after surgery.
The authors summed up the main principles of performing anesthesia and artificial blood circulation in cardiosurgical interventions in 5 women with 20-27 week pregnancy. In pregnant women with progressing cardiac failure due to a heart disease, thrombosis of the cardiac valve prosthesis, acute infectious endocarditis with the altered valve, large size tumor of the heart with disturbed valve function an emergency operation must be performed under conditions of artificial circulation. Operative treatment is the only effective method for saving life of the mother and fetus. The proposed complex preoperative preparation, intra- and postoperative management of the patients are thought to be an effective method of supporting operations on the heart under conditions of artificial blood circulation in pregnant women. In order to prevent possible complications antioxidants should be included in the complex of anesthesiologic means. During operations with artificial circulation in pregnant women it is necessary to strive for performing normothermal perfusions with high volume velocities.
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Transesophageal echocardiography (TEE) represents a substantial methodological extension of the transthoracic approach (TTE). Limitations of TTE can be overcome, furthermore cardiac regions - for instance atrial appendages - can be scanned, which are only difficult to valuate by TTE. The introduction of the endoscope succeed in above 95% of the patients without problems. The transducers work with 30, 48 or 60 single elements and frequencies of 3.5 to 7.5 MHz. The clinical indications for this procedure have included severe cardiac pathology, insufficient TTE, thoracic aortic dissection, prosthetic cardiac valve dysfunction, detection of intracardiac and paracardiac masses, structure lesions and complications of endocarditis, intraoperative monitoring and assessment of critical ill patients in an intensive-care unit. Attending to the prerequisitis and contraindications TEE growth up to an important method for cardiac surgery with regard to prae-, intra- and postoperative diagnostic and evaluation of treatment effectiveness.
In the mid-seventies, echocardiographic devices for clinical use have been developed to generate real-time cross-sectional images of the heart with a rate of about 30 frames per second. This technique improved the diagnostic power of M-mode echocardiography by visualizing the chambers, valves and walls of the heart in a variety of planes. Cross-sectional echocardiography provides important information for example in the evaluation of left ventricular function, diagnosis of congenital heart diseases, endocarditis, hypertrophic cardiomyopathies, cardiac tumors and others, that cannot be determined adequately by M-mode echocardiography alone.
In order to evaluate the influence of a significant coronary artery disease in patients with valvular heart disease or with prosthetic valves, we reviewed literature and our own experience. The incidence of coronary artery disease in valvulopathies has been diffusely studied and reported and, in a consecutive series of our hemodynamic studies, resulted 11%. The influence of a coronary artery disease on early and late results of a surgical procedure is different whether the coronary artery disease is operated or not. In particular, the combined surgery shows a higher early mortality, but a much better long-term prognosis. In addition, sometimes surgery introduces rare causes of coronary artery disease. Finally, it seems that coronary artery disease arises very rarely in patients undergone valvular surgery or, at least, patients rarely complain anginal symptoms in the post-surgical follow-up. In our experience on 529 patients only 6 complained typical angina and only 2 showed a coronary artery disease not present at the time of operation.
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