Rune Jonasson

Work capacity and central hemodynamics thirteen to twenty-six years after repair of tetralogy of Fallot.

Exercise tests and cardiac catheterization were performed in 53 patients, 13 to 26 years after intracardiac repair of tetralogy of Fallot. At the time of repair, the median age was 7 years, and 60% of patients with cyanosis had had a previous palliative procedure. The right ventriculotomy was closed without a patch in 21 patients (40%), a patch restricted to the right ventricle was inserted in 18 patients (34%), and in 14 (26%) the patch extended across the pulmonary anulus. At follow-up, 94% of the patients were free of symptoms. Symptom-limited work capacity was 87% of the predicted value (95% confidence limits, 82% to 94%). Work capacity was inversely related to age at follow-up, to right ventricular systolic pressure at rest, and to presence of moderate or severe pulmonary valve regurgitation. Cardiac output in relation to oxygen uptake was reduced in 74% of patients during exercise. In 12 patients (23%), systolic pressure at rest in the right ventricle was 50 mm Hg or higher. Systolic pressure during exercise in the right ventricle was lower in patients without a patch than in those with a patch and was abnormally high in all groups compared with healthy subjects. The ratio of right to left ventricular pressure was significantly lower than measurements taken immediately after repair. An intracardiac left-to-right shunt was present in 6 patients (11%). Three patients required invasive treatment as a result of our follow-up. We conclude that work capacity was moderately reduced 13 to 26 years after repair of tetralogy of Fallot and was adversely influenced by right ventricular hypertension and pulmonary valve regurgitation. Intermittent lifelong surveillance is advocated, because patients without symptoms may have hemodynamic abnormalities that necessitate intervention.

Late Sudden Deaths after Repair of Tetralogy of Fallot: Electrocardiographic Findings Associated with Survival

Of 141 hospital survivors after intracardiac repair of tetralogy of Fallot, eight died suddenly 6-23 years later. Compared with the other 133 patients, these eight were older at operation, with higher post-repair systolic right ventricular pressure and more often complete atrioventricular block; ventricular arrhythmia was diagnosed before death in three cases. In follow-up totalling 2255 patient years, the linearized rate of sudden death was 0.35%/year. The instantaneous risk of sudden death showed continuous increase with the length of follow-up. Of 80 survivors electrocardiographically evaluated 13-26 (median 20) years postoperatively, none had complete block, but 79 had complete right bundle branch block, including seven with left anterior hemiblock. Ventricular extrasystoles were recorded in 1% at rest, in 34% during exercise and in 83% during 24-hour ambulatory monitoring, with Lown Grade > or = II in 27%. Old age and possibly presence of fibrosis and/or fibroelastosis in right ventricular outflow Lown Grade. A patient with Lown grade III died suddenly 2 years after our follow-up. Old age at repair thus was associated with increased risk of late sudden death and with frequent ventricular arrhythmia in long-term survivors.

Pulmonary function thirteen to twenty-six years after repair of tetralogy of Fallot

Lung function was evaluated in 68 patients 13 to 26 (median 19) years after repair of tetralogy of Fallot. Age at repair was 7 years (9 months to 42 years) and 51% had a palliative shunt. An outflow patch was inserted in 56%. Median vital capacity was 84% of predicted, forced expiratory volume in 1 second 83%, maximal voluntary ventilation at 40 breaths/min 70%, and diffusing capacity for carbon monoxide 77% of predicted. Scintigraphy demonstrated abnormal pulmonary perfusion in 86%. Average right lung perfusion was 57% (predicted 52%). Regional hypoperfusion could in some patients be explained by previous palliative shunt, pulmonary artery obstruction, or presence of aortopulmonary collaterals. Median symptom-limited work capacity was 82% (95% confidence limits 78% to 90%) of predicted. Twenty-eight physically active patients had high values for symptom-limited work capacity, vital capacity, forced expiratory volume in 1 second, and maximal voluntary ventilation at 40 breaths/min compared with those of inactive patients. Lung function variables were related to physical exercise and previous palliative shunt. Moderate or severe pulmonary valve incompetence had negative but not significant influence on lung function. There was no significant influence of acyanosis before repair, use of transannular patch, duration of follow-up, or smoking. We found moderately reduced work capacity and lung function late after repair of tetralogy of Fallot that did not cause symptoms. Lung function variables were high in young active male patients and low in patients with previous palliative shunt. A better lung function in active patients indicates that physical activity should be encouraged after repair of tetralogy of Fallot.

Comparison of Kay's and De Vega's Annuloplasty in Surgical Treatment of Tricuspid Incompetence: Clinical and Haemodynamic Results in 62 Patients

This paper compares the late results of Kays and de Vegas annuloplasty in the management of tricuspid incompetence. The operations were done in 62 consecutive patients during the nine-year period 1969-77 and included simultaneous correction of acquired valvular lesions (58/62) and congenital malformations (4/62). Kays bicuspidalization and de Vegas annular plication were performed in 27 vs. 35 patients and these two groups were similar in the most important respects. Tricuspid regurgitation was recognized in 44/62 patients (71%) before surgery, whereas in 18/62 patients (29%) it was diagnosed at intra-operative exploration. The majority of cases (84%) were functional in origin and 16% had anatomical lesions causing or contributing to significant incompetence. Most of the patients (90%) belonged to functional class III or IV (N.Y.H.A.) before operation. The type of tricuspid repair had no bearing on early (11% vs. 14%) and late mortality (5.8%/year vs. 5.0%/year). Re-evaluation in 50 patients showed that Kays bicuspidalization and de Vegas annular plication gave similar and good late result in about 70% of the cases. The risk of over-correction was low in that only 1/30 cardiac catheterization revealed signs of mild tricuspid stenosis. Recurrent or residual tricuspid incompetence is probably related to the severity of the individual cases. Some of these failures were evident already on the patients discharge from hospital but, unfortunately, not predictable from the pre- or intra-operative evaluations.

Aortic Valve Replacement in Patients Over 70 Years

Twenty-seven patients 70 years of age or more were operated upon with aortic valvular replacement with an early mortality rate of 7%. No more patients died during a mean follow-up period of 28 months. The Björk-Shiley standard tilting disc valve was implanted in 15 cases and the new convexo-concave model in 12 cases. Sixty-seven per cent of the patients had narrow aortic roots (21 and 23 mm prosthesis diameters) compared with 40% of younger patients. Thrombo-embolic complications occurred in 2 patients who had not received anticoagulant treatment. No such complications were recorded in the remaining 23 surviving patients treated with anticoagulants. All the surviving patients (except one who was re-operated because of a thrombotic encapsulation of the disc) were markedly improved postoperatively. High age alone is no longer an absolute contra-indication for aortic valve replacement. The convexo-concave Björk-Shiley tilting disc prosthesis is suitable in these patients because of its low resistance of flow at small diameters. The importance of anticoagulant treatment even in elderly patients is emphasized.

Late Results of Operation for Coarctation of the Aorta in Patients More than 35 Years of Age

Between the years 1957 and 1965, 20 patients over 35 years of age were operated upon for coarctation of the aorta, 13 with end-to-end anastomosis and 7 with Dacron graft. There was one hospital death, due to rupture of the suture line, and three late deaths, two of them of aortic valvular disease and one of colonic carcinoma. The remaining 16 patients were followed-up 12–19 years after surgery, 13 with a thorough investigation. Aortic valvular disease was diagnosed in 6 of them, all being in functional capacity class (N.Y.H.A.) II or III, whereas 6 of 7 patients without valvular disease were in class I. The incidence of verified aortic valvular disease in the whole material was 50%. Hypertension (above 160/90 mmHg) was found in 50% of the patients, compared with in 9% in our long-term follow-up of patients operated upon before 16 years of age. There was no difference in the results between patients with end-to-end anastomosis and those with Dacron graft. At catheterization a small pressure difference was ...

Late Results of Operation in Children with Coarctation of the Aorta

The first nineteen consecutive Swedish children operated upon for coarctation of the aorta by Crafoord during the years 1944 to 1952 were followed-up in this study. Seven of them had no symptoms pre-operatively. A blood pressure above 130/80 mmHg was found in all the patients. At operation resection of the coarctation with end-to-end anastomosis was performed in all cases. One patient died postoperatively in necrosis of the small bowel. Five others had died during the follow-up period, three of them probably due to valvular lesions. One patient was successfully re-operated on for an aneurysm of the anastomosis. Another patient with residual coarctation was re-operated on after 7 years with a diamond-shaped Dacron patch graft. He later developed an aneurysm and was re-operated on a second time with a tubular Dacron graft and has thereafter been without complications for 6 years. Two patients, who were in good health, would not consent to a hospital investigation. Follow-up examinations were performed in 11...

Central Haemodynamics at Rest and During Exercise before and after Combined Aortic and Mitral Valve Replacement with the Björk–Shiley Tilting Disc Valve Prosthesis

Pre- and postoperative haemodynamics were compared in 36 patients with combined aortic and mitral valvular disease. These patients suffered from markedly restricted cardiac function in terms of cardiomegaly, low physical working capacity, hypokinetic central circulation and pulmonary hypertension. Valve replacement was performed with the Björk-Shiley Delrin disc (10) and pyrolytic carbon disc (26) prostheses and followed by subjective improvement in the majority of patients. Heart volume decreased and working capacity increased in average significantly, but were not restored to normal. The main response to surgery was a shift towards a normokinetic circulation, although many patients remained hypokinetic. There was also regression of pulmonary hypertension as a result of reduced left atrial pressure and pulmonary vascular resistance. In spite of a significant decrease in left atrial mean pressure, it remained elevated with prominent v-waves in many patients, particularly during exercise. Marked v-waves in the right atrial pressure curves were also noted in one third of the patients. Only one patient, however, suffered from clinically manifested tricuspid incompetence. This study shows the benefits of combined aortic and mitral valve replacement, even in patients with longterm haemodynamic burden on the myocardium. Although the central haemodynamics were almost normalized at rest, abnormal responses persisted during exercise.

Haemodynamic changes after tricuspid valve surgery. A recatheterization study in forty-five patients.

Changes of the central haemodynamics at rest and during exercise were evaluated in 45 patients who underwent tricuspid valve surgery. Tricuspid valve disease was associated with left heart valvular lesions in 42 patients, while isolated tricuspid valve lesions were present in 3 patients. The pre-operative evaluation showed marked impairment of cardiac function expressed by cardiomegaly, low physical working capacity, hypokinetic central circulation, elevated right atrial pressure and pulmonary hypertension in the majority of patients. Nineteen patients underwent tricuspid valve replacement and 26 tricuspid annuloplasty. The left heart valvular lesions were corrected by prosthetic valve replacement in all patients but one, who underwent mitral commissurotomy. The Björk-Shiley tilting disc valve prosthesis was used for all valve replacements. At postoperative evaluation the patients were classified in 3 groups: (1) Group TVR- 19 patients with well-functioning tricuspid valve prostheses; (2) Group TAP - 16 patients with good functional results in tricuspid annuloplasty; and (3) Group TAP-Failure - 10 patients in whom significant tricuspid incompetence was observed. The overall response to surgery in groups TVR and TAP was about the same, leading to an increase in working capacity and cardiac output and a decrease in heart volume, right atrial pressure and pulmonary hypertension. In the TAP-failure group, this response was limited to an increase in cardiac output and mainly attributable to the corrected left heart lesions. Sustained pulmonary hypertension, failing left ventricular myocardium, residual left heart lesions and anatomical tricuspid valve changes were the likely causes of TAP-failure, which could not be predicted from the pre-operative evaluation.

Effort dyspnea after coronary bypass surgery

One hundred consecutive patients were followed up for 6-36 months after coronary artery bypass surgery (CABS) for angina pectoris. Of the 98 survivors, 35 reported effort angina. Of the 63 angina-free patients, nine (14%), also had to interrupt ordinary activities such as walking upstairs/uphill, though now because of dyspnea. In exercise tests all nine denied chest pain, the limiting symptom being dyspnea. Chest radiograms were normal in these nine cases, and spirometry was largely unchanged from the preoperative findings (normal in 3 cases). Exercise tolerance was normal or near normal in six patients. The other three underwent pulmonary scintigraphy and cardiac catheterization at rest and during supine exercise. The scintigrams revealed no pulmonary emboli. Catheterization showed hypokinesis and raised pulmonary capillary wedge pressure during exercise in all three patients. The cause of the left myocardial failure was not established. Long-term evaluation of CABS should take into account both effort angina and effort dyspnea.