Dwight E. Harken

Cardioversion of atrial fibrillation. A report on the treatment of 65 episodes in 50 patients.

ATRIAL fibrillation is one of the most prevalent of the chronic rhythm disorders of the heart. It is a derangement with serious implications. Even when the patient is asymptomatic the arrhythmia is...

Pharmacologic Control of Thromboembolic Complications of Cardiac-Valve Replacement

Abstract Either dipyridamole, a vasodilator known to reduce platelate adhesiveness and aggregation, or a placebo was given in a daily dose of 400 mg as a random, blind trial to 70 patients who had undergone prosthetic cardiac-valve replacement. Patients in both groups were given anticoagulation with warfarin sodium. Of 36 patients in the placebo group followed for 557 months systemic arterial embolism occurred in 17 per cent. Twenty-seven patients in the dipyridamole group followed for 393 months gave no clinical evidence of arterial embolism. Dipyridamole was discontinued shortly after surgery in seven patients, and these were followed for 110 months. In two of them cerebral emboli developed six months after treatment was discontinued. It is tentatively concluded that the addition of dipyridamole to a program of anticoagulation reduces the frequency of postoperative arterial emboli originating on prosthetic cardiac valves in patients who can tolerate the drug.

Early Reduction of Pulmonary Vascular Resistance after Mitral-Valve Replacement

PULMONARY-artery pressure rises out of proportion to the left atrial, pulmonary venous and pulmonary capillary pressure in some patients with elevated left atrial pressure secondary to mitral steno...

The Clinical Results in the First Five Hundred Patients with Mitral Stenosis Undergoing Valvuloplasty

A report is made of the clinical results in the first 500 patients operated on by mitral valvuloplasty in whom a preoperative diagnosis of predominant mitral stenosis had been made. The operation appears to offer some protection against late peripheral embolization. Four hundred forty of 442 surviving patients have been followed for periods of from six months to five years. Seventy seven per cent of the entire group are significantly improved. Thirty one per cent have had one or more attacks of a postoperative syndrome, but in only 7 per cent has there been clear-cut evidence of active rheumatic fever. Improvement in objective clinical findings, in particular in cardiac murmurs, heart size and the electrocardiogram, have been less striking than the subjective improvement.

Reoperation for Mitral Stenosis: A Discussion of Postoperative Deterioration and Methods of Improving Initial and Secondary Operation

A series of 80 reoperations for mitral stenosis in 79 patients is reported and analyzed. The most important causes of deterioration after valvuloplasty for mitral stenosis are inadequate initial operation, restenosis, and mitral insufficiency. Generally more than one of these factors pertain. An adequate mitral valvuloplasty requires the complete opening of both the anterior and posteromedial commissures and the mobilization of the chordae tendineae from each other and from the wall of the ventricle. The advantages and limitations of closed reoperation, open reoperation, the right-sided approach, and the use of the transventricular valvulotome are reviewed. More complete correction of stenosis with mobilization of posteromedial, anterior, and subvalvular chordae is emphasized. This is attained by operating from both the ventral and dorsal aspects of the patient through a left posterolateral thoracotomy incision. An Ivalon operating tunnel sutured to the left atrial wall at reoperation makes it possible to carry out the more extensive valvuloplasty at reoperations. A lower operative mortality, better longterm results, and fewer instances of deterioration are anticipated when this concept of improved valvuloplasty is effected initially.

Arterial embolization in relation to mitral valvuloplasty

Abstract The present study is based on our experience of peripheral arterial embolization in 1,500 consecutive patients with predominant mitral stenosis who underwent mitral valvuloplasty. The purpose of this study has been to define the conditions under which such embolization takes place. It has been shown that the presence of atrial fibrillation, increasing severity of heart disease, and the occurrence of preoperative embolization all increase the risk of operative embolization, which remains an inherent risk of the procedure and is a major factor in deaths from operation. Our findings suggest that an embolus within 8 weeks of operation carries a higher risk of operative embolization than does a preoperative embolus occurring earlier. Our present findings confirm our previous reports with respect to the protective value of mitral valve operation against future embolization. Late postoperative emboli have occurred in 38 patients of the entire group followed up for a mean period of 6 years, an incidence of 0.46 to 0.64 per cent per patient-year. Our figures show no beneficial results from preoperative anticoagulant therapy as given—for most it was given for a short period and stopped several days prior to operation—but shed no light on anticoagulant treatment given intensively for longer periods or through the period of operation. The low incidence of embolization after the immediate operative period would suggest that the routine administration of anticoagulant agents is unnecessary in the postoperative period, either early or late. The formation of peripheral emboli is an indication for mitral valvuloplasty in patients with mitral stenosis, even without symptoms. In certain patients the increased risk of operative embolization is about balanced by the increased hazard of recurrent spontaneous embolization.

The effect of age and other factors on the early and late results following closed mitral valvuloplasty

Abstract A report is made of a consecutive series of 1,817 patients with predominant mitral stenosis operated by closed mitral valvuloplasty between 1949 and June 30, 1966, with a follow-up since operation. Particular attention was paid to the influence of various factors on the operative mortality rates and the results at 5 and 10 years after surgery. Severe disability (Group IV), atrial fibrillation, moderate to marked valvular calcification or insufficiency, all adversely affected operative mortality, but the effect of age per se was not in general statistically significant. The same factors which adversely affected operative mortality also militated against good results at 5 and 10 years with the exception of atrial fibrillation. In addition, advancing age adversely affected the results. A group of 56 patients 60 years and over at the time of surgery showed, in general, the same trends as patients 40 to 59 years old. The present study delineates those patients that can be expected to do well or poorly after closed mitral valvuloplasty and hence sets up guidelines for studies of patients operated by open techniques and valve replacement. Until it can be clearly demonstrated that such open operations can be done as safely and the late results are better, closed mitral valvuloplasty remains the operation of choice in properly selected patients with mitral stenosis.

Long-term management of patients with coronary artery disease.

D R. LAURENCE B. ELLIS: (hir coiifereiice today is on the long-term management of patients with chronic coronary artery disease, with particular emphasis on the more radical methods of therapy. This is intended to be a practical discussion for practicing physicians and our hope is to put into perspective the special methods of treatment that have been advocated, either directly or by implication, as the result of some of the more recent investigations. Anyone who reads medical journals or even any of the printed matter offered by the pharmaceutical houses is bombarded by various special methods of treating coronary disease. One can but wonder whether he may not be neglecting some useful therapeutic device that might benefit the future course of his patients. With the aid of experts in several special fields I shall attempt to separate some of the wheat from the chaff in this important and perplexing problem. I need not remind you that coronary atherosclerosis occurs to a greater or lesser extent almost universally in human beings and its fatal consequences are so numerous that the (lisease is niow the leading cause of death in

FACTORS INFLUENCING THE LATE RESULTS OF MITRAL VALVULOPLASTY FOR MITRAL STENOSIS

Excerpt The successful surgical correction of mitral stenosis has been a dramatic therapeutic milestone. Sufficient time has now elapsed to prove that surgical intervention may be life-saving. One ...

The effect of preoperative systemic blood pressure on closed mitral valvuloplasty: a study of 1,630 patients with up to 15 year follow-up.

Abstract A total of 1,630 consecutive patients with predominant mitral stenosis who underwent closed mitral valvuloplasty have been reviewed. Preoperative blood pressures were used to classify the patients into three categories: normotensive, borderline hypertensive, and hypertensive patients. In terms of operative mortality rate, late improvement, reoperations, and survival, preoperative hypertension, in general, carried a poor prognosis. No meaningful association between the presence of hypertension and postmortem renal infarction or between the presence of atrial fibrillation and postmortem renal infarction could be found. It was felt that preoperative hypertension should be considered as another, hitherto largely unrecognized, adverse prognostic factor in selecting patients for mitral valvuloplasty.