E. Bos

Coronary angioplasty for early postinfarction unstable angina.

Coronary angioplasty was performed in 53 patients in whom unstable angina had reoccurred after 48 hr and within 30 days after sustained myocardial infarction. Single-vessel disease was present in 64% of the patients and multivessel disease in 36%. The preceding myocardial infarction had been small to moderate in size in the majority of the patients. The left ventricular ejection fraction was more than 50% in 80% of the patients. Forty-five patients were refractory to pharmacologic treatment; eight were initially stabilized but once again became symptomatic with light exertion. Angioplasty was performed in 35 patients 2 to 14 days and in 18 patients 15 to 30 days after infarction (average 12 +/- 7 days after infarction). The initial success rate was 89% (47/53). The success rate of the patients treated at 2 to 14 days was lower (29/35, 83%) than that of patients treated at 14 to 30 days (18/18, 100%) but did not reach statistical significance (p less than .06). There were no deaths related to the procedure. In four of the six failures, emergency bypass surgery was performed and two patients sustained a myocardial infarction. Furthermore, a myocardial infarction complicated the angioplasty procedure in two other patients; thus the overall procedure-related myocardial infarction rate was 8% (4/53). At 6 months follow-up 26% (14/53) of all the patients who underwent angioplasty had recurrence of angina, which was successfully treated with repeat angioplasty, bypass surgery, or medical therapy. There were no late deaths. Late myocardial infarction occurred in two patients. Thus the total myocardial infarction rate after angioplasty at 6 months was 11% (6/53 patients).(ABSTRACT TRUNCATED AT 250 WORDS)

Incidence, risk, and outcome of reintervention after aortocoronary bypass surgery.

Reintervention was required in 123 (12%) individuals during a follow up (mean 7.5 years, range 5-14.5) of 1041 patients with consecutive, isolated, first aortocoronary bypass operations. In 89 patients the intervention was a repeat bypass operation, in 24 it was angioplasty, and 10 had both. Procedure related mortality was significantly higher at reintervention (5.6%) than at the primary operation (1.2%). Survival probability after a single bypass procedure was 90% at six years and 82(3)% at nine years. Corresponding figures six and nine years after reintervention were 89(6)% and 87(7)% respectively. Stepwise multivariate analysis showed that survival was significantly correlated with left ventricular function (rate ratio 1.82) and with extent of vascular disease (rate ratio 1.80) but not with reintervention (rate ratio 1.45). Symptomatic improvement occurred in 89% of the survivors with or without reintervention. Repeat procedures are often necessary after coronary artery bypass grafting but they appear to provide appreciable relief of symptoms without reducing any long term improvement in survival brought about by the original operation.

Survival in 1041 patients with consecutive aorto-coronary bypass operations.

The first 1041 patients who underwent an isolated aorto-coronary bypass operation in the same institution since it opened in 1971, were followed for up to 10 years to determine their prognosis. The mean follow-up time was 3.5 years. The probability of survival at five years was 94 +/- 2% (95% confidence limits). This was similar to the survival of the general Dutch population matched for age and sex. Multivariate survival analysis with the proportional hazards model did reveal a relationship of the rate of death with sex and age at operation; however this was not significant. There was a trend to a higher death rate with more vascular involvement (rate ratio of 3 vessel-versus 1 vessel disease of 1.9, N.S.) and a significant association with a low ejection fraction (EF) (ratio EF less than or equal to 0.30 v. EF greater than or equal to 0.55 of 2.7. P less than 0.05). Though surgery seems to eradicate the poor longterm outlook for patients with more serious vascular disease, the adverse influence of decreased left ventricular function on survival is not changed.

Determinants of survival after surgery for mitral valve regurgitation in patients with and without coronary artery disease

Mortality and its determinants were assessed in 181 consecutive patients undergoing primary mitral valve surgery for pure mitral regurgitation with coronary artery disease (MR + CAD, 79 patients) or without (MR no CAD, 102 patients). Early mortality (C10% vs. 3%) and 6-year estimate of survival (55% +/- 7.1% vs. 82% +/- 4.4%) were significantly different. Mortality was not significantly different in patients with CAD + MR of an ischemic (49 patients) or a non-ischemic etiology (30 patients). Multivariate testing using Cox regression models of overall mortality in patients with MR + CAD indicated that preoperative renal dysfunction, high right atrial pressure, ejection fraction less than 45% as well as qualitatively reduced left ventricular function and left ventricular end-diastolic volume index greater than 120 ml/m2 are associated with decreased survival. Multivariate testing in patients with MR no CAD only identified insertion of a mechanical prosthesis and a degenerative etiology of mitral valve disease as independent predictors of survival. Thus, a common denominator of preoperative pathology (renal dysfunction) and indices of right and left ventricular dysfunction determined overall survival of patients with MR + CAD. Survival of patients with MR no CAD was determined by the valve prosthesis and the etiology of valve disease.

Reoperation after aortocoronary bypass procedure. Results in 53 patients in a group of 1041 with consecutive first operations

Of 1041 patients with consecutive aortocoronary bypass operations, 53 (5.1%) underwent reoperation during a mean follow-up time of three and a half years. The operative mortality of first operations was 1.2%, and of reoperations 3.8%. The anatomical reason for reoperation was failure of the bypass graft in 41 (77%) patients, which in 18 was accompanied by progression of disease. Progression alone was seen in seven (13%). When symptoms occurred within six months after the first operation, failure of the bypass graft(s) was nearly always found--in 32 out of 36 instances. Progression in non-bypassed arteries was seen only when symptoms occurred later. Late results in angina pectoris were less favourable in the group undergoing reoperation: 31 (65%) of the 48 operated on twice and 406 (46%) of the 877 patients operated on once still had angina at late follow-up. The same fraction in both groups was improved by operation: 88% versus 89%.

Severe right ventricular inflow obstruction by non-Hodgkin lymphoma

A 73-year-old man was admitted because of progressive dyspnea on exertion for 4 months, fever and night sweats. He had no past medical history except symptomatic lumbar stenosis. Physical examination showed a tachypnoeic man with increased central venous pressure and leg oedema. A 12-lead electrocardiogram showed low voltages, intraventricular conduction delay and a (pseudo-) infarction pattern with Q waves and ST segment elevation in leads V1–V3 (left). A transthoracic echocardiogram (second from left) demonstrated a large mass (asterisk) in the right ventricular free wall and pericardial effusion. A cardiac magnetic resonance imaging (MRI) scan (second from right) showed the same mass (asterisk) invading the right ventricular wall, atrial wall and tricuspid valve thereby causing right ventricular inflow obstruction. Cine images (see supplemental data) showed severe right ventricular inflow obstruction with right atrial enlargement and left atrial diastolic collapse, signifying a severely endangered circulation. The right coronary artery (arrow) was embedded in the mass and patent. Peripheral blood analysis showed an IgG-kappa paraprotein. Immunophenotyping of the pericardial effusion demonstrated a kappa monoclonal B-cell population (right). Bone marrow morphology showed lymphoplasmacytoid cells (arrow). Bone marrow immunophenotyping showed infiltration with a kappa monoclonal population of B lymphocytes and plasma cells. No lymph node enlargement was found. Altogether, these findings resulted in a diagnosis of a stage IVB B-cell non-Hodgkin lymphoma with localization in the pericardial fluid and right ventricular wall. A primary cardiac lymphoma, defined as a lymphoma that predominantly involves the heart, comprises only about 1% of all cardiac tumours and usually involves the right ventricle or atrium. Involvement of the other heart chambers is less common and extension into the valves, as demonstrated here by MRI, is rare. An acute myocardial infarction, as observed in this case, may be simulated by diffuse myocardial infiltration. Analysis of pericardial effusion often is diagnostic. When diagnosed early, chemotherapy may prolong survival and induce regression of even extensive tumour mass. In this case, the usefulness of (cine-) MRI in delineating cardiac tumour masses relative to adjacent cardiac structures was demonstrated. Despite this diagnostic analysis, this patient chose not to receive chemotherapy and was discharged after pericardial drainage with diuretics and spironolactone.

Intraoperative two-dimensional echocardiography for guiding surgical correction in subvalvular aortic obstruction

Congenital obstructive lesions of the left ventricular outflow tract vary in nature and often are complex [1, 2]. Although the hemodynamic features are resemblant, the anatomy between the different types varies and so does the prognosis after surgical intervention.

Early coronary bypass or coronary angioplasty after successful reperfusion in acute myocardial infarction

The point of no return and the beginning of irreversible necrosis becomes evident somewhere between 5 and 30 minutes after the occlusion of a major nutrient artery to the human myocardium. Depending on the subsequent duration of complete obstruction and the time of reperfusion, the pre-existing load on the ventricle (mainly the product of afterload and heart rate) as well as the extent of available collaterals, the size of the infarction distal to the site of obstruction will vary from a minor lesion via major dyskinetic area to ‘sudden death’.

Outcome of Re-interventions After Aorto-Coronary Bypass Operations

As more time passes since the introduction of the aorto-coronary bypass graft operation, it is becoming increasingly obvious that this form of treatment of angina pectoris is not a definitive one. After a revascularization procedure the atherosclerotic process is not quiescent, nor do the venous grafts remain unaltered by their new role as coronary arterial channel [1]. Many patients therefore come back after a bypass graft operation with unrelieved or recurring angina pectoris [2–4]. A second intervention, either a repeat bypass operation or a percutaneous transluminal angioplasty, is necessary in an increasing number of cases [5–7]. This study was undertaken to enhance our insight into the frequency and outcome of re-intervention procedures.

Transösophageale und intraoperative zweidimensionale Echokardiographie

Die bedeutende Rolle der Echokardiographie als diagnostische Methode ist zuruckzufuhren auf die rasche Entwicklung im Bereich der Geratetechnik. Wahrend der letzten 5 Jahre wurde die Moglichkeit des Einsatzes der Echokardiographie mit Hilfe des transosophagealen oder epikardialen Ansatzes zur intraoperativen Diagnostik gepruft.