Ramesh L. Patel

A prospective study of changes in the quality of life of patients following mitral valve repair and replacement

OBJECTIVE The primary aim of medical care and surgery for mitral valve disease is to improve the overall functional capacity and health of patients. AIM To assess whether there was an actual improvement in quality of life (QOL) of patients 3 months following primary mitral valve repair (MRr) or mitral valve replacement (MVR). METHODS Prospective study of 61 consecutive patients (34 males, mean age 64+/-12) who underwent primary, isolated mitral valve repair (MRr, n=40) or mitral valve replacement (MVR, n = 21) from April 1997 to October 1998. QOL parameters using the validated short form 36 (SF-36) questionnaire were determined before and at 3 months after surgery and analysed using the Wilcoxon matched pairs rank test. RESULTS Mean QOL scores (scale 0-100) for all patients following mitral valve surgery showed clinical and statistically significant improvement in seven of eight QOL parameters, namely (i) physical function (post, 60+/-31 vs. pre, 44+/-29; P = 0.0001); (ii) role limitation due to physical function (50+/-42 vs. 23+/-36; P = 0.0002); (iii) social function (76+/-31 vs. 59+/-36; P = 0.0006); (iv) role limitation due to emotional problems (65+/-42 vs. 44+/-45; P = 0.003); (v) energy (57+/-24 vs. 40+/-24; P < 0.0001); (vi) mental health (73+/-20 vs. 66+/-21; P = 0.007); and (vii) general health perception (68+/-19 v 56+/-22; P = 0.0001); but not pain (73+/-29 v 71+/-30; P = 0.4). Following MRr there was significant improvement in seven of eight QOL parameters and following MVR there was significant improvement in three of eight QOL parameters. Whilst patients with ejection fraction > or = 50% showed significant improvement in seven of eight QOL parameters, there was no significant improvement in any QOL parameters in patients with impaired left ventricular (LV) function. Similarly, patients with mitral regurgitation with end-systolic dimensions of > or = 45 mm showed no significant improvement in any QOL parameters at 3 months follow-up. CONCLUSIONS Our study suggests that following mitral valve surgery there was significant improvement in the QOL of patients especially in those patients requiring mitral valve repair. However, patients with impaired LV function and those with MR with end-systolic dimensions > or = 45 mm were unlikely to demonstrate a significant improvement in QOL at 3 months follow-up.

Pulmonary Valve Vegetations Detected With Echocardiography

In a patient with pseudomonas endocarditis a pulmonary regurgitant murmur developed. Sequential echocardiography demonstrated the initial absence of vegetations, the evolution of pulmonary valve vegetations with relapse and finally the apperance of vegetations on all cardiac valves. The findings were confirmed at autopsy. Echocardiography, a useful technique for evaluating mitral, aortic and tricuspid vegetations, can also detect pulmonary valve vegetations.

Effect of aortic valve replacement on plasma soluble P-selectin, von Willebrand factor, and fibrinogen

We measured indexes of platelet activation (soluble P-selectin), endothelial dysfunction (von Willebrand factor), and fibrinogen in 54 patients who underwent aortic valve replacement (AVR): after mechanical AVR implantation, there was a significant increase in plasma levels of soluble P-selectin and von Willebrand factor levels 3 months after surgery, with no change in mean plasma fibrinogen levels. No significant changes in measured indexes were noted in patients undergoing biologic AVR, suggesting that mechanical AVR results in abnormal endothelial damage and/or dysfunction and platelet activation, which is not apparent among patients undergoing this procedure.

Massive intrapericardial lipoma, a rare cause of breathlessness. Investigations and management.

Massive intrapericardial lipoma is a rare cause of breathlessness. We describe a case, review the literature and discuss the presentation, investigation and management of this disorder.

Von Willebrand Factor, Fibrinogen, and Soluble P-Selectin Levels After Mitral Valve Replacement Versus Mitral Valve Repair

Patients with mitral valve disease undergoing surgery are at an increased risk of thromboembolism. We hypothesized that this may be due in part to abnormalities in platelet activation, endothelial damage or dysfunction, and plasma fibrinogen in such patients. To test this hypothesis, we measured indexes of platelet activation (soluble P-selectin), endothelial damage or dysfunction (von Willebrand factor [vWf], enzyme-linked immunosorbent assay) and fibrinogen (modified Clauss) in 56 consecutive patients (35 women, mean age 65 years) admitted for isolated mitral valve repair (n = 39) or replacement (using mechanical implants, n = 17). Samples were taken from a peripheral vein before and at 3 months after valve surgery. Baseline results were compared with 56 healthy age- and sex-matched controls. Compared with controls, patients with mitral valve disease had higher levels of vWf (mean +/- SD 132 +/- 28 vs 101 +/- 35 IU/dl; p <0.001), but there were no significant differences in mean fibrinogen (p = 0.418) or soluble P-selectin (p = 0.855) levels between cases and controls. There was a significant increase in plasma vWf after mitral valve replacement: 142 +/- 25 IU/dl preoperatively, increasing to 161 +/- 33 IU/dl at 3 months after surgery (p = 0.0261). However, there were no significant changes in plasma fibrinogen (p = 0.306) or soluble P-selectin levels (p = 0.191). Patients undergoing mitral valve repair did not have any significant changes in mean vWf (p = 0.25), soluble P-selectin (p = 0.77), or fibrinogen (p = 0.22). There was a significant negative correlation (Spearman, r = -0.4, p = 0.003) in postoperative plasma vWf levels and the size of valve prosthesis used. Thus, patients with mitral valve disease have increased plasma vWf levels when compared with healthy controls, suggesting endothelial damage or dysfunction, with a further increase in levels after mitral valve replacement. Conversely, patients undergoing mitral valve repair do not demonstrate any significant changes in fibrinogen, or indexes of endothelial dysfunction or platelet activation.

Pathologic correlations in a case of complete heart block with split his potentials resulting from a stab wound of the heart

A 23 year old previously healthy man was stabbed in the anterior chest. This resulted in a ventricular septal defect and complete atrioventricular (A-V) block. The electrocardiogram revealed complete A-V block with a QRS pattern of right bundle branch block. His bundle recordings 26 days later revealed A-V dissociation with split His potentials (P-H1 interval of 100 msec and H2-V interval of 40 msec). During the study the escape QRS shifted from right to left bundle branch block with H2 potentials still preceding each QRS interval with H2-V intervals of 40 msec. A permanent pacemaker was implanted because of persistent congestive heart failure and bradycardia due to A-V block. The patient subsequently became asymptomatic. He died suddenly 3 1/2 years later. Pathologically there were sizable openings in both the tricuspid and mitral valve substance and a ventricular septal defect involving the pars membranacea and part of the adjacent muscular septum. Serial sections of the conduction system revealed total destruction and fibrous replacement of the bifurcation and beginning of the right and left bundle branches and subtotal fibrous replacement of the branching bundle. Thus, the bifurcation of the bundle of His was totally absent at autopsy despite apparent electrophysiologic evidence of its existence 26 days after the stab wound. A possible explanation for this discrepancy is the subsequent fibrosis of the bifurcation produced by hemodynamic changes at the lower margin of the ventricular septal defect.

Hyperlipidaemia Management after Primary Coronary Artery Bypass Surgery: A Survey of Patients and General Practitioners

Background It is well established that, in patients with increased cholesterol concentrations and vascular disease, decreasing the cholesterol concentration significantly reduces the risk of coronary events. After coronary artery bypass graft surgery (CABG), the risk of further coronary events is likely to be reduced if there is effective control of cholesterol concentrations. The aim of the survey was to review awareness among general practitioners and patients of the need for maintenance of serum cholesterol values, frequency of serum cholesterol checks, dietary advice and lipid-decreasing medication in patients after CABG. Methods Hospital notes of 200 patients who underwent primary, coronary artery bypass surgery from January 1994 to 1996 were examined and postal questionnaires sent to patients and their general practitioners inquiring whether they had had their serum cholesterol tested in the past 3 years; whether dietary advice had been given if cholesterol concentrations were increased to more than 5.2 mmol/l; whether a repeat serum cholesterol test was performed 3 months later if values were greater than 5.2 mmol/l; and (for those with serum cholesterol values greater than 5.2 mmol/l), whether they were on lipid-decreasing medication. Results We considered 146 (76%) replies to be complete. Hospital and general practitioner records of these patients showed, that in the previous 3 years, after CABG, only 63% (n = 92) had their serum lipid profile checked and, of these, 74% (n = 68) had increased serum cholesterol concentrations of more than 5.2 mmol/l. Only 46% (n = 31) received dietary advice alone. After dietary advice had been given, serum cholesterol was rechecked in 26% (n = 8) of patients and only 3% (n = 1) had a decrease in serum cholesterol to less than 5.2 mmol/l. Among the patients with increased serum cholesterol, 50% (n = 34) received lipid-decreasing medication, but serum cholesterol was rechecked in only 52% (n = 17) of patients. In 9% (n = 3) of these, serum cholesterol concentrations had decreased to less than 5.2 mmol/l. Among the 146 complete replies from patients, 95% (n = 139) indicated that control of serum cholesterol was important, 82% (n = 120) had received dietary advice and 39% (n = 57) were on lipid-decreasing medication. Conclusion General practitioners and patients were generally aware of cholesterol control after CABG. However, a relatively low proportion of patients underwent serum cholesterol checks and received documented dietary advice, lipid-decreasing medication, or both. Dietary advice alone may be inadequate in controlling lipid concentrations and, in many cases, needed to be supplemented with adequate lipid-decreasing therapy.