Vigorous physical training after aortic valve replacement: analysis of 10 patients.

Improved prosthetic aortic valves have reduced the incidence of complications to a point where it can be hypothesized that functional class I subjects after aortic valve replacement (AVR) should adapt to a vigorous training program without a significant increase of hemolytic activity or clinical signs of prosthesis malfunction. To test this hypothesis, 10 men (mean age 52 years) who had undergone AVR (7 Björk-Shiley and 3 Lillehei-Kaster) were submitted to an 8-week training program on ergometer, 3 times/week, from 60 to 80% of individual maximal heart rate. Ten other men who had undergone AVR but did not participate in the training program were control subjects. The exercise program produced significant improvements in posttraining maximum tolerated ergometer work load (210 kpm, p less than 0.001), in maximum total body oxygen consumption (5 ml/kg X min-1, p less than or equal to 0.01) and in double product at submaximal work load (-5,126, p less than or equal to 0.01). After training, hemoglobin decreased by about 1 g% (p less than or equal to 0.05) and hematocrit, reticulocyte counts and haptoglobin did not change significantly. Serum LDH and serum AST did not increase. Pre- and post-training echocardiograms did not show detectable alterations. Thus, patients with AVR who are in functional class I can adapt to a physical exercise program without significant adverse effects.

Echocardiographic changes in the thickness of porcine valves with time.

To assess the ability of M-mode echocardiography to detect the incidence and frequency of porcine xenograft valve thickening, echocardiograms were obtained in 147 mitral and aortic porcine xenograft valves implanted in 131 patients. The patients were divided into an early group in whom the echocardiograms were performed within two months of valve replacement, and intermediate group studied two to 48 months after surgery, and a late group 48 months or longer after surgery. The porcine cusp echoes were visualized with proper gain settings, enlarged, and then recorded on a strip chart. The mean thickness of both the mitral and the aortic cusps was measured with the valve in the coapted position. The mean thickness of the porcine mitral valve increased from 1.23 +/- 0.12 in the early group to 2.3 mm +/- 0.19 in the late group (P less than .02). Aortic valve thickness increased from 0.91 mm +/- 0.07 in the early group to 2.1 mm +/- 0.37 (P less than .05) in the late group. A significant change in valve thickness was not observed in the intermediate group. In the late group of valves, 21/82 (27 percent) had a thickness greater than 3 mm. Nine of these valves (43 percent) have required replacement because of clinical dysfunction. Only 1.6 percent (1/61) of the valves in the late group with a thickness of less than 3 mm had or developed severe porcine valve insufficiency (P less than 0.001). In all ten instances, the echocardiographic assessment of valve thickness was validated on gross examination of the valve removed at surgery. This study indicates that the thickness of both mitral and aortic porcine valves can be measured by M-mode echocardiography. Valve thickness increases after 48 months and those valves with thickening of 3 mm or more are at a higher risk of developing clinical evidence of valve dysfunction.

Clinical and hemodynamic assessment of the Angell-Shiley porcine xenograft.

Valve replacement with an Angell-Shiley bioprosthesis was accomplished in 449 patients. To evaluate the bioprostheses from this total series, 344 patients who did not undergo associated operation, had no previous operations, or had no other valve substitutes were selected. Hospital mortality was 2.6% for aortic (4 out of 156), 7.2% for mitral (9 out of 125), and 12.7% for multiple-valve replacements (8 out of 63). The 323 patients discharged from the hospital were followed for 6 to 36 months. There were 15 late deaths. Hepatitis, bleeding, thromboembolism, endocarditis, and residual valvular incompetence, always periprosthetic, were the major complications. Forty-five patients with single-valve replacement (16 mitral and 29 aortic) without clinical valve dysfunction were electively recatheterized to assess hemodynamic performance. Measurements were recorded at rest and during exercise on a bicycle ergometer. Functional aortic valve orifice averaged 1.23 +/- 0.33 cm2 and the mean systolic gradient was 21.51 +/- 6.68 mm Hg at rest. During exercise, aortic gradient increased to 26.60 +/- 7.54 mm Hg and mean functional area to 1.51 +/- 0.34 cm2. In the mitral position, the mean diastolic gradient at rest was 8.44 +/- 3.17 mm Hg and the functional orifice area averaged 1.67 +/- 0.51 cm2. Exercise increased the mean gradient to 11.92 +/- 3.8 mm Hg and the mean orifice area to 2.05 +/- 0.57 cm2.

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.

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)

Medtronic-Hall prosthesis: valve related deaths and complications.

The purpose of this retrospective study was to assess the clinical performance of the Medtronic-Hall prosthesis based on a review of all valve related complications over a period of nine years. From January 1978 until December 1986, 502 prostheses were implanted in 450 patients. There were 200 aortic valve replacements, 198 mitral valve replacements and 52 double valve replacements. There were 234 associated procedures performed, the most frequent being coronary grafting in 129 patients and tricuspid annuloplasty in 35 patients. The mean age of the patients (230 men and 220 women) was 54.08 +/- 11.7 years. Preoperatively, 92.2% were in NYHA class III or IV. Early mortality was 7.1% and late mortality 16.7%. The follow-up totalled 1733 patient-years (mean 49.8 +/- 31.7 months). Over a period of nine years, the valve related complication rate was 4.4% per patient-year. Thromboembolic events occurred in 37 patients (2.1% per patient-year), anticoagulant related hemorrhage in 23 patients (1.3% per patient-year), endocarditis in 11 patients (0.6% per patient-year), perivalvular leak in six patients (0.3% per patient-year) and death and reoperation in 28 patients (1.6% per patient-year). At eight and one-half years, the survival rate was 71.28 +/- 2.7% for the whole group. The actuarial rate of patients free from all valve related complications was 75.92 +/- 2.7%, rate of freedom from thromboembolism was 86.01 +/- 2.4%, freedom from anticoagulant related hemorrhage was 92.7 +/- 1.6%, freedom from endocarditis was 97.17 +/- 0.8%, freedom from perivalvular leak was 98.27 +/- 0.7% and freedom from death and reoperation was 90.70 +/- 1.9%.(ABSTRACT TRUNCATED AT 250 WORDS)

Differences in recovery from cardiac surgery: a profile of male and female patients.

The specific aim of this study is to compare and contrast the biophysical and psychosocial profile of men and women undergoing cardiac surgery (coronary artery bypass graft and valve replacement) during the perioperative and home recovery period. Coronary artery disease appears to be qualitatively worse in women than men although the prevalence in women does not approach that in men until the seventh decade. Valvular disorders also reveal a different profile by sex with the greater valvular problems in women related to the fact that women have more rheumatic heart disease. A prospective, longitudinal design with a convenience sample of 117 patients undergoing cardiac surgery and their spouses (234 subjects) from five Northern California hospitals was used to tap patient response at three critical perioperative data points. Female patients were observed during the perioperative period to have significantly more shortness of breath, poorer cardiac functional status (New York Heart Association), significantly longer intensive care unit stays, and proportionately more deaths. At 1 and 3 months after discharge, however, their recoveries did not differ significantly from men's when they were compared on sexuality, recreation, or return-to-work variables. Surprisingly, female patients had significantly less mood disturbances as measured by the Profile of Mood States than their male counterparts, and they scored higher on measures of family satisfaction than did male patients. Implications of the study involve early recognition of heart disease in women, preparation of families for longer intensive care unit stays, and appreciation of different psychosocial responses to surgery.

[Work capacity evaluation in patients with valvular prostheses]. / Valutazione della capaciptà lavorativa nei portatori di protesi valvolare.

The possibility of evaluating the capacity for work of subjects wearing heart valve prostheses is analysed. The many factors affecting the return to normal life after operations for valvulopathies are not considered. In strictly medical terms cardiac terms cardiac function can be adequately evaluated by anamnestic and clinical surveys, supplemented by standard non-surgical instrumental examination with particular emphasis on echography, computerised radioisotope angiocardiography and physical exertion tests.

[Thrombolytic therapy in a case of prosthetic aortic valve thrombosis]. / Trombolíticos en el tratamiento de un caso de trombosis valvular protésica en posición aórtica.

We present the case of a 40 year old woman, who had an aortic prosthetic valve, of the Björk Shiley type. Three months before admission she began with progressive dyspnea. She was admitted to the Cardiovascular Care Unit with a global cardiac failure. An aortic prosthetic valve thrombosis was diagnosed clinically (absence of the prosthetic click) and by radioscopy (a decrease in the movement of the valve disk, with an incomplete shunt). It was attributed to a secondary failure of the anticoagulant treatment. Despite the treatment she quickly developed a cardiogenic shock. A treatment with 750,000 UI of streptokinase in 30 min was started, followed by 100,000 UI during 12 hours, with total reversion of the hemodynamic features, as judged by clinical examination (recurrence of the prosthetic click), radioscopy (recurrence of the valve movement) and by Doppler echocardiography (reduction of the transvalvular gradient). No complications were observed, and in a follow up of 12 months she persisted asymptomatic. The prosthetic valve thrombosis is an infrequent and almost fatal complication. The classical therapy consists in surgery which is a procedure with a high mortality in patients with severe cardiac failure, and an emergency procedure, as it occurred in our patient. Despite the known success of the thrombolytic therapy in the prosthetic valve thrombosis of the right heart (tricuspid position) it was only in the last years that this treatment was reported in aortic or mitral position. Peripheric embolies were found in 13% of the cases, always with transitory symptoms. There are only 45 cases described in the world, and more experience is needed for definitive conclusions.(ABSTRACT TRUNCATED AT 250 WORDS)

[Physical activity and the work capacity of patients with artificial heart valves before and after rehabilitation]. / Fizicheskaia aktivnost' i rabotosposobnost' bol'nykh s iskusstvennymi klapanami serdtsa do i posle reabilitatsii.

The physical condition of patients how underwent operations for prosthetics of one or more valves was appraised in five groups (as recommended by N. M. Amosov and Y. A. Bendet) according to the PWC170 value of the threshold load level. On admission to the department, rehabilitation (in 17 days after the operation, on the average) of 50% of patients was referred to group IV. One year after operation the physical working capacity of patients grew markedly: 40.7% were referred to group II.

[Clinical and social aspects of vocational rehabilitation of patients after heart valve prosthesis]. / Klinicheskie i sotsial'nye aspekty vozvrashcheniia k trudu bol'nykh posle protezirovaniia klapanov serdtsa.

Clinical and social factors that determined the effect of occupational rehabilitation were analyzed in 71 patients after prosthetic valve implantation. In addition to objective factors, resuming work depended on a number of subjective ones as well, as the number of working individuals was virtually similar among the preoperative and follow-up patients, while the number of invalids increased, in spite of the fact that functional condition had improved by 1 or 2 functional classes, according to NYHA, in 52.8% of postoperative patients. There were no significant differences in physical working capacity, as evidenced by bicycle ergometry, between working postoperative patients and those who failed to resume working.

[Bicycle ergometry training during the sanatorium stage of patient rehabilitation after insertion of aortic valve prosthesis]. / Veloérgometricheskie trenirovki na sanatornom étape reabilitatsii bol'nykh posle protezirovaniia aortal'nogo klapana.

A sanatorium stage in the rehabilitation of patients who have aortic valve prosthesis is of great importance. The impact of bicycle ergometric trainings on these patients' physical rehabilitation had been little studied. Bicycle ergometric testing prior to and following the training and examination of external respiratory parameters enabled their efficiency to be increased. Bicycle ergometric trainings were demonstrated to improve the patients' status, to increase their physical working capacity, to result in a positive dynamics in heart rates and oxygen consumption. Following 1 year, the patients who had had trainings showed higher physical fitness for work, better indices in oxygen consumption, oxygen pulse, and metabolic units.

[Evaluation of the cardiorespiratory system during rehabilitation of patients after prosthesis of the mitral and annuloplasty of the tricuspid valves]. / Otsenka funktsii kardiorespiratornoi sistemy v protsesse reabilitatsii bol'nykh posle protezirovaniia mitral'nogo i annuloplastiki trikuspidal'nogo klapanov.

Twenty-five patients undergoing rehabilitation for 2 to 3 years after surgery were examined. External respiratory parameters were investigated by means of bicycle spiroergometry, and the pump and contractile functions of the heart were assessed using tetrapolar chest rheography. In addition to positive clinical developments and improved functional class, physical working capacity of the patients was found to be increased. External respiratory function was improved accordingly. The efficacy of surgical correction of the defect was evidenced early after surgery by the normalization of minute flow volume and only slightly reduced stroke volume at rest. Hemodynamic support of physical working capacity that increases progressively in the course of rehabilitation is characterized by overstrain of inotropic mechanisms, uneconomically increased minute volume, and insufficiently increased stroke volume, mostly due to the incompetence of the Frank-Starling mechanism associated with tachycardia that is inadequate to the effort.

[Evaluation of patient rehabilitation effectiveness after aortic valve prosthesis based on spiroergometric study data]. / Otsenka éffektivnosti reabilitatsii bol'nykh posle protezirovaniia aortal'nogo kaplana po dannym spiroérgometricheskogo issledovaniia.

Patients after surgery introducing aortal valve prosthesis in cases of rheumatic aortal defect or defect due to bacterial endocarditis were examined using spiro- and bicycle ergometry. Two groups of patients were compared: those subjected to rehabilitation procedures and a control group undergoing no rehabilitation program. Functional results were better in post-rehabilitation patients. By the end of the rehabilitation program, the examined spiroergometric parameters were significantly closer to those of normal subjects, as compared to the controls. Spiroergometric investigation in patients with newly applied aortal valve prostheses supplements clinical data in providing a more profound functional evaluation of surgical results and rehabilitation efficiency.

[State of the left-cardiac cavities after mitral valve prosthesis]. / Dinamika levykh polostei serdtsa posle protezirovaniia mitral'nogo klapana.

The article discusses the results of dynamic X-ray examination of the left heart cavities in 86 patients who underwent mitral valve prosthetics for mitral valvular disease. The follow-up period was 42 months. The left-ventricular volume was measured by a special method. It was established that positive time course of the left heart cavities in patients with the sinus rhythm is encountered in 1-3 months after the operation, and by the end of the first year the left cavities are stabilized and often attain their normal size. In patients with cardiac fibrillation, the left heart cavities decrease in size less frequently and at later periods, and total normalization does not occur.

[Rehabilitation of patients with an aortic valve prosthesis and coronary insufficiency]. / O reabilitatsii bol'nykh s protezom aortal'nogo klapana i koronarnoi nedostatochnost'iu.

The article deals with the problem of coronary insufficiency in patients who underwent operation for aortal valve prosthetics. Dynamic follow-up of patients with prosthesis of the aortal valve for a period of 2 years after the operation showed that signs of coronary insufficiency persist in some of them. These signs restrict the functional possibilities of the patient during entire follow-up period, and coronary insufficiency in some patients is of a latent character. The bicycle ergometry test is a primary importance in detecting latent coronary insufficiency and in appraising the degree of the insufficiency. The more severe the coronary insufficiency, the lower is the tolerance to exercise. It proves possible to reduce the degree of coronary insufficiency and increase tolerance to exercise in most patients during rehabilitation.

[Patient physical rehabilitation after mitral or aortic valve prosthesis]. / Fizicheskaia reabilitatsiia bol'nykh posle protezirovaniia mitral'nogo ili aortal'nogo klapana.

Physical rehabilitation of patients after prosthetics of the mitral or aortic valve at the stage of regular medical surveillance is discussed. The method for determining the physical working capacity of patients and methods for its improvement are described. A program of physical rehabilitation for patients of this group is given. Two groups are analyzed: patients fulfilling a program of physical rehabilitation and patients subject to physical loads below training level. Under the effect of physical training the physical working capacity in patients of group four improve considerably, according to their physical condition, one year after operation. These patients should be the first to be sent for physical rehabilitation.

[Sinus rhythm restoration in atrial fibrillation after heart valve prosthesis in rheumatic defects]. / Vosstanovlenie sinusovogo ritma u bol'nykh s mertsatel'noi aritmiei posle protezirovaniia klapanov serdtsa pri revmaticheskikh porokakh.

The rehabilitation program for patients who underwent heart valve prosthetics must include restoration of the sinus rhythm. On the basis of the results of electric-pulse therapy and quinidine therapy in 88 patients, it is shown that the first method is more effective than the second, but in view of the sufficient efficacy and safety of quinidine therapy with the use of medium daily doses (not more than 2 g) it may be used in some of the patients. It is advisable to restore the sinus rhythm in periods of 3 months to 3 years after operation on the heart. Restoration of the sinus rhythm improves the general condition of patients after heart valve prosthetics, normalizes hemodynamics, increases the physical capacity for work considerably, and provides greater possibilities for the return of convalescents to their jobs.

[Rehabilitation problems with heart valve prosthesis patients]. / Voprosy reabilitatsii bol'nykh a protezami klapanov serdtsa.

A vast experience of over 1500 patients with prostheses of the heart valves is being summarized. A method of physical and psychological rehabilitation of these patients is described and data are given proving the efficacy of such measures: increased physical endurance in work by 92%, decrease of psychic disorders by 41.5%. The efficacy of the sanatorium stage of post-operative treatment is shown. Not infrequently the degree of invalidity of patients with cardiac valve prostheses is exaggerated, it is stressed that the use of exercise tests by the rehabilitation commission is essential.

[Rehabilitation of patients after heart surgery: experience and problems]. / Reabilitatsiia kardiokhirurgicheskikh bol'nykh: opyt i problemy.

The problem of rehabilitation of cardiac surgical patients is of great humane and socioeconomic significance. Over years, a great scientific and practical experience has gained in rehabilitating patients with acquired and congenital heart diseases after surgical correction. Stages of rehabilitation, a complex of medical, somatic, psychological, and socio-occupational measures are specified. Substantial shortcomings in medical labour examination of operated patients lead to an increase in the number of disabled persons. There is a lag in the study into the problem of patients with coronary heart disease after aortocoronary bypass.