Closed mitral valvotomy for mitral restenosis: experience in 113 consecutive cases.

The costs of heart operations and the problems related to anticoagulation after prosthetic valve replacement are among the limitations faced by patients in nonindustrialized countries with mitral stenosis caused by chronic rheumatic heart disease. The young age at which these patients are seen also compels the surgeon to preserve the native valve. The least costly and optimal way to achieve this objective is by closed mitral valvotomy. After closed mitral valvotomy, mitral restenosis is commonly encountered. We report here our 10-year experience with operation on 113 consecutive patients with mitral restenosis. Closed transventricular revalvotomy was performed with Tubbs dilator in 105 of 113 patients. Mean age was 343 years, with a male to female ratio of 1:1.5. Most patients were in New York Heart Association functional classes III and IV (74.3% and 19.4%, respectively). Mean interval between first and second valvotomy was 9.4 years, Hospital mortality rate was 2.8%, trivial postoperative mitral regurgitation occurred in 16.1%, and moderately severe regurgitation occurred in 1.9%. Early postoperative systemic embolism occurred in 3.8% of the cases. Moderate to excellent symptomatic improvement was noted in 89.4% of the cases and poor results were seen in 10.2%. Late follow-up of 76 patients ranged from 2 to 10 years (mean 3.8 years), with 39.4% patients in New York Heart Association class I and 50% in class II. Close mitral revalvotomy is thus an economical, simple, and safe palliative procedure that carries good long-term results.

Protection against Fas receptor-mediated apoptosis in hepatocytes and nonparenchymal cells by a caspase-8 inhibitor in vivo: evidence for a postmitochondrial processing of caspase-8.

Lymphocytes can kill target cells including hepatocytes during various inflammatory diseases by Fas receptor-mediated apoptosis. Caspase-8 is activated at the receptor level, thereby initiating the processing of downstream effector caspases. The aim of this study was to investigate the time course of caspase-8 activation and to evaluate the efficacy of the caspase-8 inhibitor IETD-CHO in a model of Fas-induced apoptosis in vivo. C3Heb/FeJ mice were treated with the anti-Fas antibody Jo-2 (0.6 mg/kg). Western blot analysis demonstrated increased cytochrome c in the cytosol (20 min), which was followed by the progressive activation of caspase-3, -9 (40-120 min), and caspase-8 (120 min). At 90 and 120 min, extensive hemorrhage was observed, indicating damage to sinusoidal lining cells. In addition, high plasma ALT levels (997 +/- 316 U/L) and histological evaluation indicated severe parenchymal cell injury. Parenchymal and nonparenchymal cells showed a similar increase in caspase-3 activity and DNA fragmentation. Treatment with IETD-CHO (10 mg/kg) attenuated the increase in caspase-3 activity and DNA fragmentation by 80-90% and completely prevented hemorrhage and parenchymal cell damage. IETD-CHO also prevented the early release of mitochondrial cytochrome c and the processing of caspase-3, -8, and -9. Thus, our data support the hypothesis that Fas-mediated apoptosis is dependent on caspase-8 activation in hepatocytes and nonparenchymal cells. However, the bulk of procaspase-8 is processed late, suggesting that only a small amount of procaspase-8 may actually be activated at the Fas receptor. This initial signal may be amplified by further activation of caspase-8 by effector caspases, i.e., after mitochondrial activation. Caspase-8 is a promising therapeutic target for inhibition of Fas-mediated apoptosis.

Cardio-vascular effects of vecuronium & pancuronium in patients undergoing elective closed mitral valvotomy.

Vecuronium, a monoquaternary analogue of pancuronium, the neuromuscular blocker, was compared with pancuronium in 50 patients undergoing elective closed mitral valvotomy. The patients were randomly divided into two groups of 25 each, and the muscle relaxants were administered in a dose of 0.1 mg/kg body weight. Both the agents produced identical intubating conditions at 3 min. Vecuronium showed a significantly shorter onset of action, as compared to pancuronium. The latter significantly increased the heart rate throughout the period of study whereas vecuronium significantly decreased the heart rate, 25 min after administration. There was significant increase in the mean arterial pressure (MAP) at tracheal intubation in both the groups, which persisted throughout the period of study in pancuronium group. There was a significant fall in MAP at 30 min after relaxant in vecuronium group. The incidence of arrythmias was similar and significant in both the groups. Vecuronium, thus showed a quicker onset of action with minimal haemodynamic effects, as compared to pancuronium in patients undergoing closed mitral valvotomy.

Midazolam as an induction agent in mitral stenosis patients for closed mitral commissurotomy.

In 30 patients of rheumatic heart disease with mitral stenosis (MS) belonging to NYHA class II and III scheduled for closed mitral commissurotomy anaesthesia was induced with morphine 0.15 mg/kg followed by either thiopentone (group A, n = 15) or midazolam (group B, n = 15) titrated to produce sleep. Patients were intubated with pancuronium bromide in a dose of 0.12 mg/kg. Minimum mean arterial blood pressure following induction was significantly lower in thiopentone group (77 +/- 7 mm Hg) than midazolam group (85 +/- 6 mm Hg; P < 0.05). After intubation blood pressure was significantly higher in thiopentone group (99 +/- 8 mm Hg) than midazolam group patients (89 +/- 7 mm Hg). Heart rate was significantly higher in thiopentone treated patients both before and after endotracheal intubation. During surgery, three patients in group A had hypotensive episodes (mean arterial blood pressure 20% below basal at two successive readings 5 min apart) while one in group B had a hypotensive episode. Average duration of surgery was comparable between the two groups (102 +/- 15 and 95 +/- 18 min) and postoperatively there was no significant difference in sedation score and incidence of nausea and vomiting between the two groups.

Giant congenital left ventricular aneurysm in an adult--a case report.

Congenital cardiac aneurysms are extremely rare. The echocardiographic features of this condition have never been described. The authors report a case of giant congenital left ventricular aneurysm wherein the diagnosis was made by echocardiography and confirmed at cardiac catheterization. The aneurysm was surgically removed. The histologic examination showed that the aneurysmal wall was only 1.5 to 2 mm thick but contained all the layers of the heart.