[Evaluation of the effectiveness of an ambulatory after-care rehabilitation program]. / Effektevaluation eines ambulanten nachstationären Rehabilitationsprogramms.

Effects of an outpatient cardiological rehabilitation programme that is offered to patients following their inpatient treatment in a rehab clinic are measured and compared with the data collected from an untreated group. The study group consists of 155 cardiological patients (after heart attack, bypass operation and heart-valve prosthesis) in the treatment group as well as 136 in the non-treatment group. The outpatient programme takes place twice a week in a cardiological rehab clinic, with patients participating for a maximum period of twelve weeks. Data are collected at the beginning, the end and three months after the end of the programme from the treatment group resp. twice with a six months interval from the non-treatment group. The used outcome measures are a number of medical variables (e.g. stress ECG, BMI, blood pressure), variables concerning vocational reintegration, plus a questionnaire. This questionnaire consists of a Functional Limitation Scale, a Mood Check List, a "Health Locus of Control"-Scale as well as a number of items regarding health-related behaviour and heart complaint symptoms. The project duration was 36 months, starting in June 1993. The funding source is the "Landesversicherungsanstalt Westfalen", a regional division of the German Statutory Old Age Insurance. As data concerning vocational reintegration indicate, the programme can be a meaningful complement to a larger amount of reintegrated patients (66.9%) compared to the non-treatment group (50.2%). To estimate the long-term effects of the programme, a 24-month-follow-up was started in January 1996.

[Possibilities for greater flexibility in a cardiologic rehabilitation clinic by supplementary ambulatory/partial inpatient therapeutic services]. / Flexibilisierungsmöglichkeiten in einer kardiologischen Rehabilitationsklinik durch ergänzende ambulante/teilstationäre Therapieangebote.

This study shows that additional outpatient/partially inpatient treatment provided in a cardiological rehabilitation hospital effectively complements inpatient rehabilitation treatment but does not replace it. Our flexible system which comprises a shorter stay in hospital and subsequent partially inpatient treatment allows more intensive treatment of the patient in the early phase of rehabilitation. It supports patients when they have returned home and have to test out how they manage with their restricted physical and mental performance in their social environment. It appears possible to develop criteria to select the individually appropriate form of treatment. The introduction of outpatient/partially inpatient therapy in a cardiological rehabilitation hospital does not appear to entail disadvantages for the patients. It contributes to more flexible, and in particular to more individualized, treatment. The ongoing pilot projects will show whether in the final analysis this will also entail a saving of costs. Not only in view of their specialist competence are the cardiological rehabilitation hospitals suitable and able to participate in measures to increase the flexibility of cardiological rehabilitation. They should therefore either completely integrate outpatient/partially inpatient methods in their concept of therapy or after a shortened inpatient treatment. They should then evaluate these methods so as to be able to contribute to an informed discussion on this topic. This also would mean that available resources would be better utilized, which would in addition be of particular importance at present, in a situation dominated by discussions of costs.

[Heart operations in patients older than 75. Results and postoperative rehabilitation]. / Herzoperationen bei Patienten älter als 75 Jahre: Ergebnisse und postoperative Rehabilitation.

A total of 164 patients with a mean age of 78.6 +/- 2.7 years and often critical preoperative conditions [New York Heart Association (NYHA) class III + IV, 78.7%] underwent cardiac operations [coronary artery bypass grafting (CABG) 97; valve replacement, 33; CABG + valve replacement, 18; replacement of ascending aorta and others, 18] with an in-hospital mortality of 8.5% (n = 14). Follow-up was completed for 147 patients (98%) after 16.5 +/- 10.8 months. Most patients were in a good clinical condition (NYHA I + II, 79.6%; late deaths, 8 patients, 5.4%) and more than 95% of patients lived at home or with relatives. Charges for hospital treatment dropped to one third after the hospitalization period for surgery in the first postoperative year compared to the year immediately preceding the cardiac operation.

[Inpatient length of stay and physical capacity after aortocoronary bypass operation, after heart valve replacement and myocardial infarct]. / Stationäre Behandlungszeiten und körperliches Leistungsvermögen nach aorto-koronarer Bypassoperation, nach Herzklappenersatz sowie nach Myokardinfarkt.

The present investigation was performed to determine the dependence of the length of stay in community hospitals and rehabilitation clinics from patient characteristics and physical activity at the end of treatment. Comparing age, end-diastolic volume index, left ventricular ejection fraction, number of stenosed coronary arteries, number of bypass grafts, levels of physical exercise, body mass index and the ratio total cholesterol/HDL-cholesterol, no significant differences were found in patients, who reached the rehabilitation clinic in the early postoperative period (7.4 +/- 2.0 days, n = 98), after 15-28 days (n = 74) or later than 28 days (n = 156) after bypass-surgery. Similar results were observed in 103 patients after heart-valve replacement, who arrived at the rehabilitation clinic after a corresponding length of hospital care like the bypass patients. Also, no significant differences in the clinical characteristics and physical activity appeared in patients who were admitted in the early phase (9.2 +/- 4.5 days) after transmural myocardial infarction (n = 37) and those entering the rehabilitation clinic after 26.7 +/- 9.4 days of hospital stay (n = 32). The absence of any relationship between the length of stay in hospitals on the one hand and severity of the heart disease on the other hand points out that the whole duration of stay in community hospitals and rehabilitation clinics after surgical intervention and also after transmural myocardial infarction could be drastically shortened by an optimal cooperation of both, hospitals and rehabilitation clinics, without any impairment of clinical results.

Time course of recovery during cardiac rehabilitation.

PURPOSE: Exercise-based rehabilitation programs improve effort tolerance in patients with cardiovascular disease. Little is known regarding the time course of recovery of objective and subjective indices of exercise tolerance. METHODS: Twenty-six patients were studied at 0, 4, 8, and 12 weeks following early entry into rehabilitation following acute myocardial infarction (AMI), coronary artery bypass graft surgery (CABGS), or valve surgery. Exercise tolerance was assessed objectively by percent predicted cycle power output (%PO), and subjectively by a self-efficacy questionnaire for ambulatory (ASE) and muscular (MSE) items and by a disease-specific, health-related, quality-of-life questionnaire (HRQL). RESULTS: With the exception of percent predicted cycle power output, all exercise tolerance measures improved throughout the rehabilitation program. Extrapolation of recovery curves suggest that recovery to 85% predicted can be achieved in 10, 11, 18, and 21 weeks for a disease-specific, health-related, quality-of-life questionnaire, self-efficacy questionnaire for ambulatory items, muscular items, and power output, respectively. CONCLUSIONS: The data demonstrate that evaluation of both objective and subjective indices of exercise tolerance may be important in documenting outcomes of participation in structured rehabilitation programs. The time course of recovery of objective and subjective indices of exercise tolerance may not be highly correlated.

Triple prótesis valvular mecánica cardiaca y embarazo / Triple valvular, mechanical, cardiac prosthesis and pregnancy

Se presenta un caso poco usual de una mujer de 36 años, multigesta, portadora de triple protésis mecánica cardiaca, anticoagulada con cumarínicos, que evolucionó en su sexta gestación sin complicaciones cardiovasculares, obteniendo un recién nacido, con peso de 1,700 g. sin malformaciones. Se discuten los problemas de manejo, seguimiento y resolución del embarazo así como los factores que influyen en un resultado óptimo para el binomio materno-fetal

Quantifying and predicting recovery after heart surgery.

The validity of the biopsychosocial approach to the study of health and illness is reaffirmed by the prospective findings of the Recovery Study. This is a multidisciplinary examination, conducted in four teaching hospitals, of the predictors of symptoms of cardiac illness in 463 patients 6 months after coronary artery bypass or cardiac valve surgery. We found that the following preoperative measures predict freedom from cardiac symptoms 6 months after surgery: low levels of all of the following: angina pain, shortness of breath, fatigue and sleep problems, lifetime cigarette usage, and preoperative hospitalization for cardiac treatment; low levels of anxiety, depression, and hostility, and few life change events; high levels of all of the following: self-esteem, well-being, vigor; prevalence of activities and hobbies, social participation, and social support. The six variables in bold print contributed independently in a multiple regression equation that accounted for 21% of the variance of the symptoms score and was associated with an estimated 45% difference in success of recovery. The statistical strength and general nature of many of the predictors indicate that the predictors may also be important in recovery from other health crises. Psychosocial and biomedical factors correlate across time (predictively), as well as cross-sectionally, indicating that psychological, social, and biological mechanisms may be parts of a single general multifaceted process influencing recovery of health. A clinical trial could determine if psychological, social, or behavioral interventions will hasten and improve recovery from physical illness or trauma.

Válvula mitral en "paracaídas": informe de un caso / Parachute mitral valve: Clinic case

Se informa de un lactante que después de haber tenido un periodo neonatal normal presentó una pobre ganancia de peso, fatiga al ser alimentado, infecciones de repetición. A la radiografía del tórax mostró cardiomegalia, con flujo pulmonar aumentado; y en el ecocardiograma, dilatación de la aurícula izquierda, con la válvula mitral con pendiente EF disminuida (12 m/seg), con un sólo músculo papilar y flujo diastólico transmitral turbulento, con área valvular estenótica (0.7 cm²). Con estos datos se hizo el diagnóstico de estenosis mitral por válvula mitral en "paracaídas". Fue llevado a cirugía a los 11 meses de edad y, ante la imposibilidad de hacerle la plastía, se le colocó una prótesis mitral mecánica. La evolución ha sido satisfactoria, con tratamiento médico a base de coumadin, dipiridamol y furosemida. Se resaltan las ventajas de la valoración no invasiva y el éxito de la cirugía

[The use of the results of current instrumental methods of cardiological examination in the sociomedical expert assessment of patients with rheumatic heart defects]. / Primenenie rezul'tatov sovremennykh instrumental'nykh metodov kardiologicheskogo obsledovaniia pri mediko-sotsial'noi ékspertize bol'nykh s revmaticheskimi porokami serdtsa.

Altogether 103 patients with rheumatic heart disease were examined within different times after prosthetics of heart valves (mitral or aortal). The purpose was to elaborate the principles of applying the data of instrumental methods of cardiological examination to the improvement of disability criteria. The examination included echocardiography, tetrapolar chest rheography and ECG exercise test. The data allowed one to estimate myocardial reserves and to specify the intensity of functional disorders of the cardiovascular system. The expert medical conclusions on the working ability were revised in 47 patients, bearing in mind the data obtained. Before the examination 70 patients (68%) were considered to completely lose the working ability. However, after the examination their number dropped to 34 (33%), whereas the number of persons able to work rose from 5 to 12%.

Exercise tolerance and working capacity after valve replacement.

Between 1978 and 1987, 1270 patients who survived single aortic or mitral valve replacement at the Rehabilitation Center in Bad Krozingen, Germany, underwent a comprehensive rehabilitation program. The preoperative diagnosis was isolated aortic stenosis in 425, isolated aortic regurgitation in 159, mixed aortic lesion in 211, isolated mitral stenosis in 208, isolated mitral insufficiency in 137 and mixed mitral lesion in 130 cases. Follow up examinations were carried out one and six months after surgery, and at yearly intervals thereafter. Exercise testing was performed with an electrically braked bicycle ergometer in the supine position, and the load was increased by 25 or 50 watts every two minutes until fatigue, severe angina, more than 0.3 mV ST-segment depression, or 80% of the age predicted maximum heart rate was achieved. Patients after aortic valve replacement had a better exercise performance one month after operation than did those after mitral valve replacement. Those with mitral stenosis showed more severe impairment of exercise tolerance than did the mitral insufficiency group. There was a steady increase in exercise tolerance between one and six months postoperatively, both in patients with aortic and those with mitral valve replacement, but the difference in performance between the two groups was still present (72% versus 57% of normal). The results of univariate and multivariate analyses showed that the preoperative employment status was the most important factor for postoperative return to work, followed by gender (male > female), exercise tolerance and valualar lesion (aortic > mitral).(ABSTRACT TRUNCATED AT 250 WORDS)

Aortic valve replacement in octogenarians.

In a consecutive series of 1109 patients undergoing aortic valve replacement (AVR) between January 1988 and December 1990, there were 48 patients (33 female, 15 male) over 80 years of age (mean age 83.5 years, median 82.9 years). Of those, 33 had aortic stenosis and 15 combined aortic valve disease, with additional coronary artery disease being present in 36. Isolated AVR was performed in 25 patients, and it was combined with coronary venous bypass grafting, with 1-4 (mean 1.8) peripheral anastomoses in 23. Two patients died within 30 days (early mortality 4.2%). Non-fatal complications included one hemiparesis, four transient cerebral disorders, two cases of pneumonia which led to ventilatory assistance, three rethoracotomies because of postoperative bleeding, 15 tachycardias and one transient AV block. Late results were obtained after a median follow up time of 22 months. There were eight late deaths (four cardiac related, four not related) and a low incidence of non-fatal complications (two episodes of gastrointestinal bleeding while on oral anticoagulation, one cerebral transient ischemic attack and one acute left ventricular failure). Nine patients are in NYHA Class I, 12 in Class I-II, 11 in Class II, three in Class II-III and three in Class III. Of the surviving 38 patients, four are currently living in a home for the aged or a nursing home, while all the others are living in their own homes and are able to sustain a relatively independent life-style. We conclude that in very old patients with aortic valve disease, AVR can be performed with low mortality and few non-fatal complications.

[Results of heart valve replacement. Prognosis--occupational and general disability--occupational rehabilitation]. / Ergebnisse des Herzklappenersatzes. Prognose--Arbeits- und Leistungsfähigkeit--Berufliche Wiedereingliederung.

The success of valve surgery has led to a marked improvement in prognosis, quality of life and exercise tolerance in patients with symptomatic valvular heart disease. The degree of subjective and objective improvement depends on multiple preoperative factors like NYHA status, left ventricular function, valve lesion and type of valve replaced as well as peri- and postoperative factors like the occurrence of a perioperative myocardial infarction, the degree of intraoperative myocardial damage, the type of valve replaced and the speed and degree of postoperative regression of left ventricular hypertrophy and dilatation. The postoperative exercise tolerance is a major determinant for postoperative vocational rehabilitation. Therefore the individual functional assessment of patients postoperatively is of major importance.

Cambios seriados en dimensiones y masa ventricular izquierda luego del reemplazo valvular en insuficiencia aórtica crónica / Serial changes in left ventricular dimension and mass after aortic valve replacement in patients with chronic aortic insufficiency

El objetivo del presente trabajo es evaluar los cambios en dimensión y masa ventricular izquierda después del reemplazo valvular en pacientes con insuficiencia aórtica crónica. 33 pacientes (edad promedio 40 años, 27 hombres) que recibieron un reemplazo valvular aórtico (25 con prótesis mecánica y 8 con prótesis biológica) fueron estudiados preoperatoriamente y antes y después de 6 meses de postoperatorio y fueron seguidos clínicamente por un promedio de 50 meses. Los diámetros ventriculares se midieron por ecocardiografía (Sociedad Americana de Ecocardiografía), y la masa ventricular se estimó por la fórmula de Devereux. Ecocardiogramas tecnicamente satisfactorios en pre y postoperatorio se obtuvieron en 21 pacientes. El diámetro diastólico del VI disminuyó precozmente en un promedio de 26.3% y continuó disminuyendo hasta un promedio de 32.5% en el postoperatorio tardío. Esta disminución se observó incluso en enfermos con marcada dilatación ventricular preoperatoria. La masa disminuyó precozmente en un 45.3%, sin observar mayor cambio en el control tardío. Estos cambios se correlacionaron con una buena respuesta clínica, con mejoría de CF que era III o IV en 11 pacientes a CF I en 30 y II en 3. Estos resultados confirman que el reemplazo valvular aórtico produce significativa reducción del tamaño y masa del VI que se inician precozmente después de la operación. La dilatación ventricular continúa reduciéndose en el postoperatorio tardío

[Evaluation of functional reserves of the oxygen transport system in cardiac surgery patients]. / Otsenka funktsional'nykh rezervov sistemy transporta kisloroda u kardiokhirurgicheskikh bol'nykh.

The informative value of determination of the restoration rate of spiroergometric parameters was examined in cardiosurgical patients who had undergone exercise testing. All the patients were divided into 3 homogeneous groups: (1) those without disorders; (2) those with moderate restoration; and (3) pronounced restoration. There was a moderate relationship between the restoration rate and the function of the oxygen transport system (OTS) and a high relationship between the rate and exercise tolerance in decompensated metabolic acidosis and left ventricular function. Analysis of the restoration of spiroergometric parameters provided a final assessment of the functional reserves of OTS in cardiosurgical patients and serves as a non-invasive technique to study left ventricular function in the patients.

[Experience in the use of Soviet-made disk prostheses EMIKS and LIKS]. / Opyt primeneniia otechestvennykh diskovykh protezov EMIKS i LIKS.

Experience in the application of and disc prostheses in 614 patients in generalized. Mitral prosthetics was conducted in 256, aortic in 229, and mitral++-aortic in 129 patients. Hospital lethality was, respectively, 3.9, 4.8, and 8.5%. In postoperative follow-up periods of up to 7 years 92.1% of patients were examined. Survival was 88.1 +/- 0.71% in the mitral, 87.0 +/- 0.62% in the aortic, and 80.2 +/- 0.84% in the mitral-aortic group. No thromboembolic complications occurred in 88.7 +/- 0.64%, 96.9 +/- 0.31%, and 88.3 +/- 0.68% of patients, respectively. In the mitral position the mid-diastolic gradient was 4.0 +/- 0.31 mm Hg on the prosthesis and 3.8 +/- 0.82 mm Hg on the prosthesis; in the aortic position the peak systolic gradient was, respectively, 23.2 +/- 0.58 and 22.4 +/- 0.7 mm Hg. At the time of examination 97% of patients belonged to I and II functional classes.