F. Loogen

Doppler versus contrast echocardiography for diagnosis of tricuspid regurgitation

Sixty-eight patients (mean age 49 years) were studied with contrast echocardiography (CE) and Doppler echocardiography (DE) to evaluate both methods for detecting and grading tricuspid regurgitation (TR). In all patients, right ventricular (RV) angiography was performed. The severity of TR was graded on a 4-point scale. Only 68 of 88 patients who underwent RV angiography (77%) could be evaluated, but 65 of 68 patients who underwent CE (96%) and all 68 who underwent DE (100%) could be evaluated. TR was present in 33 patients as seen on RV angiography. CE and DE correctly diagnosed 27 and 30 patients, respectively, corresponding to a sensitivity of 82% for CE and 91% for DE. Specificity was 100% for CE and 86% for DE. CE and DE grading, respectively, of TR vs RV angiographic grading showed no difference in 50 and 47 patients, a 1-level difference in 8 and 13 and a 2-level difference in 7 and 5 cases. (CE-RV angiography, r = 0.84, p less than 0.001; DE-RV angiography, r = 0.82, p less than 0.001). Thus, CE and DE are accurate methods for routine diagnosis of TR, with DE having higher sensitivity and easier grading. Considering the possibility of false-positive findings of our standard RV angiography, sensitivity and specificity of CE and DE could be even higher.

Death due to transprosthetic catheterization of a Björk-Shiley prosthesis in the aortic position.

Abstract In patients with aortic valve prostheses, left ventricular catheterization can be done by transseptal 1 or retrograde, transprosthetic approaches 2,3 to objectify a concomitant mitral valve lesion or aortic prosthesis function. MacDonald et al 4 reported retrograde catheterization of the left ventricle through tilting disc prostheses and stated that this technique can be easily performed without apparent risk. 4 We recently studied findings from a patient who died during transprosthetic catheterization of a Bjork-Shiley aortic valve prosthesis.

Klinische Bedeutung der His-Bündel Elektrographie

SummaryMethodical problems, indication and clinical implication of His bundle electrography are discussed. In 200 successive patients undergoing His bundle electrography and atrial stimulation the indication was as follows: Intraventricular conduction defects in 24%, A-V block in 21%, sick sinus syndrome in 20%, preexcitation in 17%, and complex arrhythmias in the remaining cases. In 38% of the patients did the HBE prove to be of help by providing information not available after analysis of the surface ECG. In 22% this technique contributed essentially to the management of these patients. In spite of deficiencies of our knowledge of the basic mechanisms, specific therapy, and prognosis of various arrhythmias His bundle electrography is clinically useful in selected patients. Therefore, this method has become a routinely used clinical tool.ZusammenfassungAn Hand des eigenen Krankengutes und den Angaben der Literatur werden methodische Probleme, Indikation und Wertigkeit der His-Bündel Elektrographie unter klinischen Gesichtspunkten besprochen. Bei 200 konsekutiv untersuchten Patienten bestand in 24% eine intraventrikuläre Leitungsstörung, in 21% ein A-V Block, in 20% ein Sinusknotensyndrom und bei 17% ein Präexzitationssyndrom. Den Rest bildeten unklare Rhythmusstörungen. Im Vergleich zu konventionellen EKG-Ableitungen konnte in 38% der Fälle durch die His-Bündel Elektrographie eine neue Information gewonnen werden, in 22% wurde durch die Untersuchung eine therapeutische Entscheidung herbeigeführt. Trotz unserer lückenhaften Kenntnisse über Pathophysiologie und Prognose vieler Herzrhythmusstörungen sowie Fehlen einer spezifischen Therapie hat die His-Bündel Elektrographie bei richtiger Indikationsstellung eine große klinische Bedeutung. Das Verfahren ist daher heute zu einer Routinemethode geworden.

Mitral Valve Replacement Using Different Prosthetic Valves

6 ,, I I 5 ,, ,, 4 , + 3 •,,, 2 •I, 21 Fig. 2 Diastolic pressure gradients in patients with mitral valve prostheses of equal tissue annulus diameters. The comparison is limited by the small number of patients in the Hail-Kaster group. hemodynamics and thrombogenicity is expected as a result of its central flow pattern and the total pyrolytic carbon construction (3). 40 patients with Bjork-Shiley, 22 pts. with St. Jude Medical and 6 pts. with Hall-Kaster valves were restudied one year after operation (Fig. 1). The preoperative data were not different in these 3 groups. About 65% of the pts. had had predominant mitral stenosis. More than 70% had been classified as class III (NYHAj, the others as class IV. Mitral valves Prosthetic valves Cardiac surgery

Is the Late Outcome of Heart Valve Replacement Influenced by the Hemodynamics of the Heart Valve Substitute

Although many of the problems of the early years of heart valve replacement seem to be solved, other problems still remain. For example, the high operative mortality of the early years has decreased to less than 5% (1); today operative long-term complications (2) and insufficient recovery from preoperative myocardial dysfunction (3) are of much more concern.

Erworbene Herzklappenfehler: Konservative Therapie, Indikationen zur chirurgischen Intervention, postoperative Ergebnisse

Mit dem drastischen Ruckgang des rheumatischen Fiebers in Mitteleuropa nach dem Zweiten Weltkrieg (1) haben die rheumatisch bedingten, sich in der Regel nach rezidivierender rheumatischer Karditis manifestierenden Herzklappenfehler deutlich an Haufigkeit abgenommen (2). Bei der Mehrzahl der heute operierten Patienten mit rheumatischen Herzklappenerkrankungen liegt das rheumatische Fieber Jahrzehnte zuruck. Neben diesen Patienten mit sehr langsamem chronischem Verlauf werden zunehmend haufig Zweiteingriffe nach vorausgegangener, klappenerhaltender Operation (Mitralkommissurotomie) erforderlich.

Prosthetic Valve-related or Valve-induced Complications

All artificial heart valves are associated with a high rate of valve-related (mechanical dysfunction) or valve-induced complications (1,2). The valve-related complications can be direct consequences of hemodynamic disturbances persisting postoperatively (intravascular hemolysis), of the implanted artificial material (mechanical dysfunctions) or of both factors (prosthetic valve endocarditis, thrombosis of the prosthesis, thromboembolic events).

Valve Malfunction and Heart Valve Replacement in Patients at Risk

Since its early beginnings prosthetic heart valve replacement has been related to some specific problems, the importance of which has changed in the last decades, but which continue to be matters for discussion. First, this includes a consequent diagnosis of prosthetic valve malfunctions, made in time to initiate an early therapy. Frequently, this therapy consists in surgical revision of the malfunctioning prosthesis; sometimes reoperation can be avoided by early induction of conservative therapy (prosthetic valve endocarditis, prosthetic valve thrombosis). Regarding prosthetic valve malfunctions, paraprosthetic leakages and dysfunctions of the valve occluder itself which may be caused by infective endocarditis, prosthetic valve thrombosis, tissue ingrowth, material defects or a degeneration of the biological valve material must be differentiated. A variety of case reports document the importance of diagnostics in due time and immediate initiation of an adequate therapy for the successful management of prosthetic valve malfunctions (1,2). Normally noninvasive examinations before initiating adequate therapeutic measures are sufficient to achieve an accurate diagnosis of a prosthesis malfunction (cf. chapter 7.2).