Ephraim Glassman

The incidence and natural history of pericardial effusion after cardiac surgery--an echocardiographic study.

One hundred twenty-two consecutive patients (104 men; 18 women) were studied to determine the incidence and natural history of pericardial effusion occurring 2, 5, 10, and 20 to 50 days after cardiac surgery. Three patients had pericardial effusions before and 103 patients (91 men; three women) had effusions after surgery. Effusions were first recorded on the second postoperative day in 72 patients, on the fifth postoperative day in 29 patients, and on the tenth postoperative day in two patients. In 96 of these patients, effusions reached their maximum size by postoperative day 10. Of the 103 patients with effusions, 66 (64%) were followed to complete resolution. A specific pattern was observed in most resolving effusions. The echo-free space diagnostic of pericardial effusion became progressively more echo-dense as the effusion diminished in size. As the effusion became echo-dense, the posterior pericardium, which had been motionless, resumed its normal systolic anterior motion. One patient developed cardiac tamponade on postoperative day 3. We conclude that pericardial effusion occurs frequently after cardiac surgery, but that associated complications are rare.

Discrete atherosclerotic coronary artery aneurysms : a study of 20 patients

The incidence, angiographic features and natural history of discrete atherosclerotic coronary aneurysms were evaluated in 20 patients with 22 aneurysms (0.2% of 8,422 patients referred for coronary angiography). Fifteen aneurysms (68%) were in the left anterior descending, four (18%) in the circumflex, two (9%) in the right and one (5%) in the left main coronary artery. Aneurysm diameter ranged from 4 to 35 mm (mean 8); 95% of aneurysms were adjacent to a severe obstruction. Seventy-five percent of patients had severe triple vessel disease that included severe left main disease in 15%. Total obstruction of one or two arteries was present in 75%. In patients with wall motion abnormalities, 78% of the abnormalities were in the distribution of the aneurysm. Follow-up (range 1 to 90 months [mean 30]) was obtained in all 20 patients. There were two cardiac and two noncardiac deaths; 12 patients had coronary bypass surgery and of 16 survivors, 13 were angina-free. In conclusion, discrete coronary aneurysms are much less common than diffuse ectasia. Unlike ectasia, they are never found in arteries without severe stenosis, and are most common in the left anterior descending coronary artery. Associated coronary artery disease is more severe in patients with discrete aneurysms than in those with diffuse ectasia. Discrete coronary aneurysms do not appear to rupture, and their resection is not warranted.

Methionine intolerance: A possible risk factor for coronary artery disease

Homocystinuria, an inherited disorder associated with premature atherosclerosis, represents a severe form of methionine intolerance. To analyze the importance of milder forms of methionine intolerance in the genesis of vascular disease, the relation between provokable methionine intolerance and coronary artery disease was investigated. In a group of 138 men, aged 31 to 65 years (mean 53), referred for cardiac catheterization, plasma homocystine was measured before and 6 hours after an oral l-methionine load (0.1 g/kg). Thirty-nine subjects found to have normal coronary arteries had a mean post-load plasma homocystine level of 0.59 +/- 0.37 mumol/liter. A criterion at the 95th percentile (1.64 SD above the mean) was selected and applied to the remaining 99 subjects with coronary artery disease (0.70 +/- 0.68 mumol/liter). Sixteen (16%) of 99 subjects with coronary artery disease exceeded this level as compared with 1 (2%) of 39 subjects without coronary artery disease (p less than 0.04). The risk of coronary artery disease in men with provokable methionine intolerance was increased sevenfold as estimated by the odds ratio. By correlation matrix and multivariate regression analyses, provokable homocystinemia was predictive of coronary artery disease and was independent of tobacco smoking, hypertension, diabetes mellitus, serum cholesterol and age. It is proposed that men with mild methionine intolerance exposed to the high methionine content of the Western diet may develop intermittent homocystinemia and thus may be at greater risk for the development of coronary artery disease.

Release of adenosine from human hearts during angina induced by rapid atrial pacing.

This study was designed to determine whether human hearts release adenosine, a possible regulator of coronary flow, during temporary myocardial ischemia and, if so, to examine the mechanisms involved. Release of adenosine from canine hearts had been reported during reactive hyperemia following brief coronary occlusion, and we initially confirmed this observation in six dogs hearts. Angina was then produced in 15 patients with anginal syndrome and severe coronary atherosclerosis by rapid atrial pacing during diagnostic studies. In 13 of these patients, adenosine appeared in coronary sinus blood, at a mean level of 40 nmol/100 ml blood (SE = +/-9). In 11 of these 13, adenosine was not detectable in control or recovery samples; when measured, there was concomitant production of lactate and minimal leakage of K(+), but no significant release of creatine phosphokinase, lactic acid dehydrogenase, creatine, or Na(+). THERE WAS NO DETECTABLE RELEASE OF ADENOSINE BY HEARTS DURING PACING OR EXERCISE IN THREE CONTROL GROUPS OF PATIENTS: nine with anginal syndrome and severe coronary atherosclerosis who did not develop angina or produce lactate during rapid pacing, five with normal coronaries and no myocardial disease, and three with normal coronaries but with left ventricular failure. The results indicate that human hearts release significant amounts of adenosine during severe regional myocardial ischemia and anaerobic metabolism. Adenosine release might provide a useful supplementary index of the early effects of ischemia on myocardial metabolism, and might influence regional coronary flow during or after angina pectoris.

Transesophageal echocardiography to detect atrial clots in candidates for percutaneous transseptal mitral balloon valvuloplasty

Left atrial thrombi are common in patients with mitral stenosis. When percutaneous balloon mitral valvuloplasty is performed on such patients, there is a potential risk of thrombus dislodgment and embolization. In this study conventional transthoracic echocardiography and transesophageal echocardiography were performed for percutaneous balloon mitral valvuloplasty on 19 consecutive candidates (6 men, 13 women, 23 to 81 years old). In five patients (26%), transesophageal echocardiography revealed a left atrial thrombus; in only one of these was there a suspicion of left atrial thrombus on transthoracic echocardiography. Balloon mitral valvuloplasty was canceled in four of the five patients. Three underwent mitral valve surgery that confirmed the echocardiographic findings. Transesophageal echocardiography is better than conventional transthoracic echocardiography in detecting left atrial clots in candidates for balloon mitral valvuloplasty. Because of the potential risk of embolization, transesophageal echocardiography is recommended in all candidates for balloon mitral valvuloplasty.

Ten-year experience with aortic valve replacement in 482 patients 70 years of age or older: Operative risk and long-term results

A retrospective analysis of an institutional experience with aortic valve replacement (AVR) in patients 70 years of age or older during 1976 to 1987 was performed. The study was prompted in part by the current interest in palliative aortic valvoplasty, an interest based to a certain extent on the impression that AVR in the elderly has a high mortality. The mean age of the patients was 75.0 +/- 4.0 years (+/- the standard deviation) (range, 70 to 89 years). Eighty-three percent of patients received porcine valves and 17%, mechanical valves. Preoperatively 32% were in New York Heart Association class III, and 59% were in class IV. Operative mortality was 5.6% for elective isolated AVR for aortic stenosis (19% of all patients), 8.2% for all isolated AVR (38%), and 12.4% overall. Concomitant operative procedures were done in 62.0%; AVR with coronary artery bypass grafting (42%) had an operative mortality of 14.3%. Multivariate analysis showed significant predictors of operative mortality to be emergency operation (p less than 0.01), isolated aortic regurgitation (p = 0.01), and previous cardiac operation (p = 0.02). Follow-up (34 +/- 27 months) was 94% complete. Five-year survival from late cardiac-related death was 81.0%. The constant yearly hazard rate for late death for patients 70 years of age or older who underwent AVR was 5.42% per year, which is similar to the 5.77% per year rate calculated for age-matched and sex-matched controls. Five-year freedom from reoperation was 99%; from late thromboembolic complications, 91%; and from late anticoagulant-related complications, 94%. Freedom from all valve-related morbidity and mortality was 61% at 5 years.(ABSTRACT TRUNCATED AT 250 WORDS)

Comparison of cardiac catheterization and Doppler echocardiography in the decision to operate in aortic and mitral valve disease

Clinical decisions utilizing either Doppler echocardiographic or cardiac catheterization data were compared in adult patients with isolated or combined aortic and mitral valve disease. A clinical decision to operate, not operate or remain uncertain was made by experienced cardiologists given either Doppler echocardiographic or cardiac catheterization data. A prospective evaluation was performed on 189 consecutive patients (mean age 67 years) with valvular heart disease who were being considered for surgical treatment on the basis of clinical information. All patients underwent cardiac catheterization and detailed Doppler echocardiographic examination. Three sets of two cardiologist decision makers who did not know patient identity were given clinical information in combination with either Doppler echocardiographic or cardiac catheterization data. The combination of Doppler echocardiographic and clinical data was considered inadequate for clinical decision making in 21% of patients with aortic and 5% of patients with mitral valve disease. The combination of cardiac catheterization and clinical data was considered inadequate in 2% of patients with aortic and 2% of patients with mitral valve disease. Among the remaining patients, the cardiologists using echocardiographic or angiographic data were in agreement on the decision to operate or not operate in 113 (76% overall). When the data were analyzed by specific valve lesion, decisions based on Doppler echocardiography or catheterization were in agreement in 92%, 90%, 83% and 69%, respectively, of patients with aortic regurgitation, mitral stenosis, aortic stenosis and mitral regurgitation. Differences in cardiac output determination, estimation of valvular regurgitation and information concerning coronary anatomy were the main reasons for different clinical management decisions. These results suggest that for most adult patients with aortic or mitral valve disease, alone or in combination, Doppler echocardiographic data enable the clinician to make the same decision reached with catheterization data.

Electrocardiographic and serum enzyme changes of myocardial infarction after coronary artery bypass surgery

Serial preoperative and postoperative electrocardiograms were obtained in 50 patients undergoing coronary artery bypass surgery, 15 undergoing aortic valve replacement and 13 undergoing mitral valve surgery. Postoperative infarction was defined as the appearance of new Q waves on the postoperative electrocardiogram. Infarction occurred in 5 of 50 patients (10 percent) who underwent coronary artery bypass surgery. Age, preoperative hypertension or a pattern of left ventricular hypertrophy on the electrocardiogram did not correlate with infarction. Coronary disease was more severe in patients with than in those without infarction (mean of 3.2 vessels with 50 percent stenosis compared to 2.4 vessels). There was no correlation with bypass time or use of cross-clamping of the aorta during surgery. Postoperatively, 4 of 5 patients (80 percent) with infarction had serum values for glutamic oxaloacetic transaminase (SGOT) and creatine phosphokinase (CPK) of more than 200 and more than 2,000 international units, respectively, whereas 3 of 45 (7 percent) without infarction had this pattern (P < 0.001). Of patients undergoing aortic valve replacement, 3 of 15 (20 percent) had postoperative infarction. All 3 of these patients had a serum glutamic oxaloacetic transaminase value of more than 200 and a creatine phosphokinase value of more than 2,000 units, compared to 2 of 12 (17 percent) without infarction. None of the 12 patients who underwent mitral valve surgery had postoperative infarction, and none had a serum glutamic oxaloacetic transaminase value of more than 200 or a creatine phosphokinase value of more than 2,000 units. Myocardial infarction after coronary artery bypass surgery is more likely in patients with at least three-vessel disease but appears to be unrelated to pump time or aortic cross-clamping. Localized snaring or clamping of coronary arteries may be important. Postoperative serum glutamic oxaloacetic transaminase and creatine phosphokinase levels correlate with electrocardiographic evidence of infarction.

Surgically remediable complications of myocardial infarction

S HOCK and ventricular failure after acute myocardial infarction generally are related to the degree of loss of contractile muscle and therefore complicate large infarctions or repeated infarction of previously damaged hearts.’ Less frequent but often more dramatic complications of acute infarction follow disruption of strategic structures, such as the interventricular septum or papillary muscles, producing shock and acute or chronic ventricular failure. Infarction of the free wall may be followed by acute rupture or by the development of chronic and sometimes disabling aneurysms. Surgical correction of septal and papillary muscle rupture and of chronic aneurysms antedated coronary artery bypass grafting, and the indications for surgery have become more clearly defined. The management of patients with these complications in the critical period preceding operation has also evolved considerably in recent years. Catheterization of the right heart at the bedside now permits rapid diagnosis of acute septal or papillary muscle rupture and allows continuous monitoring of the effects of treatment with vasodilators, intraaortic balloon counterpulsation, and inotropic or systemic pressor agents.‘.3 Such monitoring helps to predict the need for emergent surgery. Radionuclide imaging methods are of increasing help in estimating ventricular function and assessing wall motion4.’ Definitive cardiac catheterization, with ventriculography and coronary angiography, has proved safe even after recent infarction.h Induction of anesthesia for surgery has been improved by monitoring of right heart pressures and by the use of vasodilators and intraaortic balloon counterpulsation when needed. Early physiologic and pathologic changes in the infarcted heart determine the proper timing of surgical therapy and are therefore reviewed briefly here.

Transesophageal Echocardiography During Percutaneous Mitral Valvuloplasty

Transesophageal echocardiography was performed during mitral balloon valvuloplasty. It provided valuable information about the position of the transseptal needle, wires, and balloon catheter throughout the procedure, and it helped in the immediate evaluation of its results. Transesophageal echocardiography was well tolerated and there were no complications.