Colin L. Schamroth

Contribution of echocardiography and immediate surgery to the management of severe aortic regurgitation from active infective endocarditis

The timing of surgery in patients with severe aortic regurgitation and left ventricular (LV) failure, particularly when associated with active infective endocarditis (IE), is of the utmost importance. From July 1982 to May 1984, 34 patients, aged 15 to 60 years, with severe aortic regurgitation underwent immediate (within 24 hours of diagnosis) aortic valve surgery. All patients were in New York Heart Association class IV for LV failure. Eighteen patients had right-sided heart failure. Decision for immediate surgery was based on the echocardiographic demonstration of diastolic closure of the mitral valve or of vegetations on the aortic valve. Premature closure of the mitral valve was demonstrated echocardiographically in 17 patients, 13 of whom had diastolic crossover of LV and left atrial pressure tracings recorded at surgery. IE of the aortic valve was confirmed at surgery in 29 patients, 27 of whom had vegetations on echocardiography. Seven patients required replacement of both aortic and mitral valves. Antibiotic therapy for IE was started immediately after blood cultures were taken and continued for 4 to 6 weeks postoperatively. The mortality rate within 30 days of surgery was 6% for the group as a whole and 7% for those with IE. Mean follow-up period for the 32 survivors was 10.6 months. There were 2 late deaths. No patient had periprosthetic regurgitation or persistence of endocarditis. Procrastination in referral for surgery of these extremely ill patients is not justified and is likely to be associated with higher risks of morbidity and mortality.

Pulmonary arterial thrombosis in secundum atrial septal defect

Nineteen adolescent or adult patients with secundum atrial septal defect (ASD) underwent pulmonary arteriography to evaluate the presence of proximal pulmonary arterial (PA) thrombosis. This procedure demonstrated proximal PA thrombosis in 8 patients (group 2). These patients had a distinctive hemodynamic profile, consisting primarily of significant PA hypertension. None of the 11 patients with normal angiograms (group 1) had severe PA hypertension (p less than 0.0001). Proximal PA thrombosis appears to be the major factor in the development and progression of PA hypertension in adult patients with ostium secundum ASD. Pulmonary angiography should be undertaken in all adult patients with ostium secundum ASD who have at least moderate PA hypertension. Long-term anticoagulation is advocated for patients with PA thrombosis irrespective of a decision for surgical intervention.