Ronald Siegel

Mitral valve prolapse requiring surgery. Clinical and Pathologic study

The clinical, hemodynamic, surgical, and pathologic findings in 30 patients who required mitral valvular surgery and who had a preoperative diagnosis of mitral valve prolapse were reviewed. The mean age of the patients was 59.5 years; 28 patients were over 45 years of age and 10 were over 60 years. Surprisingly, 20 were males. A long history of systolic murmur was common, whereas symptoms of heart failure were of abrupt onset. At the time of surgery, a local holosystolic murmur typical of mitral regurgitation was present, although a mid- to late systolic click was not heard in any of the patients. Electrocardiographic abnormalities were present in all patients, with 13 patients demonstrating atrial fibrillation. Only four patients had a normal heart size radiographically. Echocardiography confirmed the radiographic findings, in that 27 patients demonstrated left atrial and ventricular enlargement. All 29 patients undergoing cardiac catheterization and angiography demonstrated a prolapsing mitral valve with severe regurgitation. Surgical and pathologic examination revealed findings characteristic of a myxomatous valve in all patients, with 19 also demonstrating ruptured chordae tendineae. This study demonstrates that heart failure requiring valvular surgery occurs in a subset of patients with mitral valve prolapse. In this subset, males predominate and most are over 50 years of age. These patients may be asymptomatic for many years, demonstrating mild to moderate mitral valvular regurgitation, before heart failure develops.

Long-term survival after prehospital sudden cardiac death

One hundred thirty-nine survivors of prehospital sudden cardiac death were followed after their hospital discharge. Eighty patients were studied with coronary angiography and cardiac catheterization; 34 of these underwent coronary bypass surgery. After a maximum follow-up of 105 months, 89 patients were still alive. The probability of survival at 6 months, 1 year, 2 years, 3 years, 4 years, and 5 years was 88%, 86%, 78%, 70%, 63%, and 59%, respectively. Of the 43 cardiac deaths, 37 (86%) were secondary to documented recurrent ventricular fibrillation or occurred suddenly. Twelve percent of the total population had recurrent ventricular fibrillation in the first year following the initial cardiac arrest, 16% within 2 years, and 22% within 3 years. Of the 37 survivors dying from recurrent ventricular fibrillation, 32% died within the first 3 months following hospital discharge, 46% in the first year, 64% within 2 years, and 78% within the first 3 years. Most survivors were capable of resuming normal activities after hospital discharge. Only 7% demonstrated permanent neurologic impairment. Sixty-eight percent of the patients who were employed at the time of their prehospital sudden cardiac arrest returned to full-time employment. In the subset of 34 surgically treated patients, there have been six (18%) cardiac deaths. Four of these deaths were related to recurrent ventricular fibrillation, with one of these deaths occurring in the immediate postoperative period. The other three deaths related to recurrent ventricular fibrillation occurred 36 months (two deaths) and 49 months following the initial prehospital cardiac arrest.

Cyclosporine-associated central neurotoxicity after heart transplantation.

Cyclosporine central neurotoxicity has been described after bone marrow, kidney, and liver transplantation but has not been well documented after heart transplantation. This case illustrates severe reversible neurotoxicity after heart transplantation with characteristic radiographic changes in magnetic resonance imaging.

Mitral Valve Prolapse in the Elderly

This study included 40 patients over 60 years of age with echocardiographic findings of mitral valve prolapse (MVP). Most of these patients were unaware of any cardiac disorder until the time of echocardiography. In the majority, the clinical manifestations were benign, and the duration of symptoms variable. Congestive heart failure (CHF) was noted in 10 patients (25 percent) who were unaware of having any cardiac disorders until the onset of their symptoms. In 5 patients (4 with CHF and 1 with endocarditis), surgical replacement of the prolapsed mitral valve was necessary. Endocarditis was present in 4 patients (10 percent), none of whom had been instructed in the prophylactic use of antibiotics. The physicians awareness of mitral valve prolapse in the elderly patient is important, since the disorder may not be as benign in aged patients as in younger ones, and life‐threatening complications may occur.

Management of Sudden Coronary Death

Twenty-three survivors of out-of-hospital sudden coronary death (SCD) have been followed subsequent to initial hospitalization, cardiac catheterization and coronary angiography, and ultimate coronary revascularization (11 patients) or medical treatment (12 patients). All were treated at the Milwaukee County Medical Center. History of previous myocardial infarction (10 patients) and predominance of triple coronary artery disease (20 patients) with associated ventricular dysfunction (21 patients) demonstrated advanced coronary disease in both groups. Selection for revascularization (mean, 3 grafts per patient) was not randomized, but was based on precarious coronary anatomy and was reinforced by post-SCD ventricular dysrhythmias and angina. During an average follow-up of 13 months, there were 2 perioperative surgical deaths (1 recurrent SCD) and 3 medical deaths (2 recurrent SCDs), giving a mortality rate of 22%. This is an improvement over reported post-SCD natural history and may support a policy of offering revascularization to all SCD patients who have precarious coronary anatomy.

Effects of anticoagulation on recurrent systemic emboli in mitral stenosis

Abstract Systemic arterial embolization can be expected in at least 20% of patients with mitral stenosis (MS) and recurrence without treatment may be expected in as many as 60% of these patients. 1 Embolization may occur as the first manifestation of MS, and may occur in patients without significant cardiac functional impairment. 1,2 In patients with significant cardiac functional impairment, the treatment to prevent recurrence of embolization is clearly surgical; however, when there is little or no cardiac functional impairment, treatment is controversial. Surgical therapy is recommended by some, while long-term anticoagulant therapy without surgery is the choice of others. 1,3