[Elevation of the diaphragma after cardiac surgery]. / Uniesienie przepony po operacjach kardiochirurgicznych.

Phrenic nerve injury and diaphragmatic dysfunction can be induced by cardiac operation. We evaluated nonconsecutive 34 patients (pts) with elevation of the diaphragma after cardiac operation. 27 pts have coronary artery bypass grafting, 7 pts have prosthetic valve implantation. We have impression that ice/saline slush used along with cold cardioplegia for heart arrest can cause hypothermic damage of phrenic nerve. Palsy of that nerve results in raised hemidiaphragm and delayed recovery of the pts. In our pts normalisation of the diaphragm we observed 6 months after operation in 41% pts and 12 month after in 93% pts. We suggest that results depends on early and well rehabilitation.

Use of 99Tcm-MIBI scintigraphy in the evaluation of perfusion improvement after myocardial revascularization with the use of the left internal thoracic artery.

In spite of successful revascularization, in a significant group of patients myocardial ischaemia is present after surgery. The final effect of surgery depends on preoperative left ventricular function, initial coronary artery status, completeness of revascularization, the use of arterial or venous grafts, and many other factors. The aim of our 99Tcm-MIBI scintigraphy study was to examine the improvement of perfusion in the left anterior descending artery (LAD) vascular territory after revascularization with the use of the left internal thoracic artery (LITA), with respect to the LAD diameter and use of additional venous graft to diagonal artery. The study group consisted of 45 subjects (42 male, three female) aged 34-68 years (mean age 50.9+/-8.3 years) recruited from patients in whom LITA was grafted into LAD. The operation and postoperative period was uneventful in all patients. Two weeks before, and 3-4 months after surgery, dipyridamole-rest sestamibi SPECT were performed. The revascularization significantly improved both stress (deltaPI = 0.77+/-0.66; P < 0.001) and rest (deltaPI = 0.32+/-0.60; P < 0.001) perfusion of the LAD territory. The improvement was slightly better in patients who received two grafts (deltaPI = 1.42+/-0.91) for the LAD territory in comparison to the group revascularized only with LITA (deltaPI = 0.80+/-0.69; P = patients who received an arterial bypass to the LAD artery the perfusion was abnormal in all eight patients after anterior myocardial infarction and in 39% of patients without a history of infarction. The perfusion improvement was the best when the diameter of LAD was > or = 1.5 mm (deltaPI = 0.88+/-0.95). The independent predictors of perfusion improvement were the number of segments with reversible perfusion defect within the revascularized area (beta = 0.84, P < 0.001), the diameter of revascularized artery (beta = 0.17, P = 0.03) and the presence of pathological Q wave at preoperative ECG (beta = -0.20, P = 0.02). We conclude that the degree of perfusion improvement in the LAD territory after revascularization with the use of LITA depends on the diameter of bypassed coronary artery, completeness of revascularization and the reversibility of preoperative perfusion defect.

Do patients over 40 years of age benefit from surgical closure of atrial septal defects?

OBJECTIVE: To determine the value of surgical closure of atrial septal defects in patients over 40 years of age. METHODS: Retrospective analysis of 76 patients (63 women, 13 men), age range 40-62 years (mean (SD) 45.8 (5.1) years), who underwent surgical repair of atrial septal defect. Pre- and postoperative clinical status (New York Heart Association (NYHA) functional class) was assessed, and ECG, x ray, and echocardiographic investigations performed. Follow up was between 1 and 17 years. RESULTS: One operative and one late death occurred during the study period. Before operation, 47 patients (61.8%) were in NYHA functional classes III and IV. After operation, 61 patients (82.4%) were in classes I and II. Four patients had atrial fibrillation before surgery versus nine after surgery. Before operation, 52 patients had intensified pulmonary vascularity compared with only seven after operation. Echocardiographic examination showed a significant reduction in right ventricular dimension (4.10 (0.91) v 2.95 (0.36) cm, p < 0.001). No residual intracardiac shunts were identified on echocardiographic follow up. CONCLUSIONS: Surgical closure of atrial septal defects in patients over 40 years old can improve their clinical status and prevent right ventricular dilatation and insufficiency.

Mitral valvuloplasty with sutures used for aortic prosthesis implantation.

BACKGROUND: The purpose of this study was to analyze surgical treatment for aortic valve lesions with coexisting mitral regurgitation (MR). METHODS: Seventy-five patients were divided into two groups according to intensity of MR (group 1, MR less than or equal to II; group 2, MR greater than or equal to II/III). There were two control groups (control 1, only patients with implantation of aortic valve; control 2, patients with implantation of both aortic and mitral prostheses). During implantation of a mechanical aortic prosthesis, the same suture for fixation of a mechanical prosthesis and for suspension of mitral commissural regions and lifting the base of anterior mitral cusp was used. RESULTS: In all patients, no early death occurred. There were two late deaths, one due to endocarditis, and the other to heart failure. All patients from both groups had decreased MR. Selected echocardiographic parameters improved: end diastolic and end systolic diameter and ejection fraction in group 2 improved in proportion to patients in whom mitral valves were implanted (control 2). CONCLUSIONS: Simultaneous suspension of the mitral commissure area during mechanical aortic prosthesis implantation reduces associated MR. This technique seems to be efficient during implantation of aortic prostheses in patients with coexisting MR.

[Coronary artery bypass grafting in patients with left main coronary artery occlusion]. / Operacje rewaskularyzacji bezposredniej miesnia sercowego u chorych z niedroznoscia pnia lewej tetnicy wiencowej.

The paper describes 3 men aged 43, 62 and 66 years with left main coronary artery occlusion. In all patients well-developed collateral circulation from right to left coronary artery was present. They were operated in cardiopulmonary bypass and two bypass grafts were implanted in each of them. There were no deaths in the perioperative period. Actually all the patients are alive and have no angina.

Results of repair of partial anomalous pulmonary venous connection and sinus venosus atrial septal defect in adults.

BACKGROUND AND AIMS OF THE STUDY: This retrospective study evaluated late results of surgical treatment of partial anomalous pulmonary venous connection (PAPVC) concomitant with sinus venosus-type atrial septal defect (ASD) with the use of pericardial patch technique. METHODS: Between 1981 and 1995, 25 consecutive patients (18 females, seven males) underwent surgical repair of PAVPC with ASD. Mean age at surgery was 37.8 +/- 13.0 (range: 16 to 62 years). All patients underwent the procedure of covering both defect and vein with pericardial patch to direct blood flow from anomalous pulmonary veins through the ASD into the left atrium. Mean follow up was 7.8 +/- 4.0 years (range: 2 to 16 years). No patients were lost to follow up. RESULTS: There were no early deaths. One patient died 11 months after surgery from progressive heart failure. At follow up, 10 (42.7%) patients were clinically asymptomatic. One patient had clinical signs of superior vena cava (SVC) obstruction. Electrocardiography showed no abnormalities in seven (29.2%) patients. Chest radiography revealed normal pulmonary vascularity in 22 (91.7%) patients and no residual shunts were found in the SVC. CONCLUSION: The patch method of repair of PAPVC with sinus venosus ASD in adults with use of autologous pericardium is a safe and effective procedure.

Restoration of mechanical atrial function after electrical cardioversion of chronic atrial fibrillation in patients after surgical treatment of mitral valve disease--hemodynamic effects and prognostic value of maintenance of sinus rhythm.

There are controversies regarding the possibility of returning of A wave (mitral flow at left atrial contraction) after electroconversion (EC) in patients with persisting chronic atrial fibrillation in spite of successful surgical treatment of mitral valve disease. Twenty-four hours before successful EC, thereafter daily for 1 week and then on the 14th, 21st and 28th day and 6 months after EC, ECG, M-mode, two-dimensional and Doppler echocardiography were performed in 55 patients. A wave (>0.1 m/s) appeared on the 1st day in 31 patients, on the 2nd day in the next 6, on the 3rd in 5 patients, on the 4th and 5th days in 1 patient and on the 7th day in 4 patients. In 7 patients A wave did not restore. Maximum velocity of A wave increased from 0.48 +/- 0.22 to 0.86 +/- 0.28 m/s (p < 0.05) during the follow-up. In 92% of patients with A wave 24 h after EC, significant increases in stroke index from 35 +/- 12 to 47 +/- 15 ml/m2 (p < 0.04), ejection fraction from 46 +/- 9 to 55 +/- 8% (p < 0.01) and pulmonary acceleration time from 94 +/- 26 to 107 +/- 22 ms (p < 0.05) were observed. Sinus rhythm was still present on the 28th day in 34 patients (62%) and after 6 months in 31 patients (57%), all of them with A wave. observation shows the increase in pulmonary acceleration time, the decrease in the left atrial area and the increase in its systolic function in patients with A wave. Appearance of A wave determined the hemodynamic improvement, but we did not observe a correlation between maximal velocity of A wave and hemodynamic improvement. Appearance of A wave had a low predictive value for maintaining sinus rhythm (sensitivity 58% and specificity 45%). Relative increase in A wave velocity during the 1st week after EC correlated positively with long-term maintenance of sinus rhythm (r = 0.62; p < 0.001).

Results of long-term medical treatment of patients with arterial hypertension complicated by aortic dissection.

UNLABELLED: The purpose of the study was to analyse results of ambulatory treatment of patients with arterial hypertension complicated by aortic dissection. Twenty patients (19 men, one woman), aged between 39 and 72 years, underwent full physical examination. In all cases the diagnosis of aortic dissection was confirmed by at least two different imaging methods (ultrasonography, digital subtractional angiography, computer tomography or nuclear magnetic resonance). During follow-up (3-75 months, mean 34.3 months), physical examination was performed every 6-8 weeks, chest radiograph was taken once a year. All patients controlled their blood pressure (BP) at home. According to the mean number of in-home BP measurements per month all patients were divided into two groups: group I good (n = 10) and group II bad compliers (n = 10) (28 +/- 30 vs 3 +/- 2 in-home BP measurements a month). Ten patients (6 in group I, 4 in group II) underwent 24 h automatic BP measurement examination. Blood samples were collected for serum cholesterol and uric acid measurements. All patients suffered from arterial hypertension and in five cases at least one parent suffered from this disease. Only three of 20 have never smoked cigarettes. Elevated serum cholesterol was observed in 10 (50%) cases and elevated uric acid in six (30%). Proximal (type A) aortic dissection (DeBakey classification type I and II) was found in 13 patients, distal aortic dissection (type B) in seven patients. All patients were treated with beta-blockers. In 75% of 20 cases three or more hypotensive drugs were used simultaneously to control BP. In the group I lower values of mean of maximal SBP (160 +/- 10 vs 177 +/- 7 mm Hg, P < 0.05) and lower mean circadian heart rate (58.6 +/- 7.5 vs 80.9 +/- 7.9 beats/min, P < 0.005) were observed. The most frequent complaints were intermittent claudication, 9 (45%); angina pectoris 8 (40%), other chest pain, 4 (20%). During follow-up period (3-75 months, mean 34.3 months) five of 20 patients (25%) died (all had proximal, type A dissection) and 15 of 20 patients (75%) are still alive. All deaths in group II were sudden, whereas the only one in group I was because of chronic renal insufficiency. Mortality rate in the two groups were 10% (one of 10) vs 40% (four of 10), respectively, in groups I and II. IN CONCLUSION: patients who control their BP more often have the lower values as well as lower heart rate and therefore a better prognosis.

[The effect of hemodilution and autotransfusion on diagnostic levels of digoxin in serum of patients operated on with extracorporeal circulation]. / Wplyw hemodylucji i autotransfuzji na stezenie digoksyny w surowicy chorych operowanych w krazeniu pozaustrojowym.

In many patients operated on for valvular heart diseases indications are present to digitalis administration in the preoperative period. During extracorporeal circulation fluctuations occur of blood potassium concentration which increase the risk for toxic effect of digitalis. In the work, digoxin concentration was studied in the serum of patients operated on in extracorporeal circulation in whom administration of this drug was discontinued 48 hours before the operation. The first digoxin dose (0.5 mg) was given directly after withdrawal of extracorporeal circulation, and another 0.5 mg was given after 4 hours. Digoxin concentrations were determined by fluorescence-polarization-immunological method using TD* Abbott device. The digoxin concentration increased rapidly and reached its peak after 6 hours (1.9 ng/ml), decreasing after 12 hours to 0.9 ng/ml and persisted at this therapeutic level in further samples. The present studies demonstrated that digoxin administration directly after withdrawal of extracorporeal circulation and within 24 hours after the operation in commonly accepted doses provided therapeutic concentration of the drug and caused no increase of the risk for toxic reaction development.

[Does effective cardioversion after surgery for valvular heart disease improve hemodynamic indicators?]. / Czy skuteczna kardiowersja po operacji wady zastawkowej serca poprawia wskazniki hemodynamiczne.

In 55 patients aged 47 +/- 6 years successful electrical cardioversion of atrial fibrillation was made. 24 hours before and after cardioversion, ekg and M-mode, 2-D and Doppler echocardiography was performed. Important improvement in ejection fraction (Simpson method), (p < 0.005) and in stroke index (Simpson method, p < 0.01; Doppler method, p < 0.005) was found in 64% of pts. Pts with haemodynamic improvement (HI) were significantly younger, had smaller, left atrial area in apical two-chamber view and left ventricular diastolic diameter and longer pulmonary acceleration time. In pts with HI the duration of AF was significantly shorter and closed mitral commissurotomy less frequent (p < 0.05). Restoration of mechanical atrial function (A-wave) was found in 44% of pts. In pts with A-wave HI was more often (p < 0.001). There was no correlation between maximal peak A-wave flow velocity and HI.

[Magnesium protects myocardium during electric cardioversion but does not increase effectiveness]. / Magnez chroni miesien serca podczas kardiowersji elektrycznej ale nie zwieksza jej skutecznosci.

Transient elevation of serum enzyme level and abnormalities of repolarization following electrical cardioversion (EC) are usually observed. We aimed to alleviate these alterations by pretreatment with magnesium sulfate (MgSO4). The study group consists of 100 patients (aged 19-65 years) who had EC (300 W/sec) for chronic atrial fibrillation after mitral and/or aortic valve surgery. They were randomly divided into two sub groups: 50 patients in whom MgSO4 was administered intravenously (dose 100 m/kg b.w.) and 50 control subjects. Total serum magnesium level and CKMB level were recorded before and 8 hours after EC. Recovery to sinus rhythm, QTc interval, segment shifts were recorded immediately before and after EC. Results (mean +/- SE): [table: see text] Our results suggest that MgSO4 administered before EC has a significant cardioprotective effect and reduces abnormalities of repolarization.

[Isolated congenital tricuspid valve insufficiency--case report]. / Izolowana, wrodzona niedomykalnosc zastawki trójdzielnej--opis przypadku.

A case of congenital, isolated tricuspid regurgitation is reported. A 48 year old woman has been admitted because of shortness of breath and progressive fatigue. Although the heart murmur had been heard in her childhood, the first symptoms appeared when she was 25. One year later she underwent a plastic surgery of tricuspid valve. During the following 20 years she remained asymptomatic, until dyspnea and fatigue developed again. On admission she was cyanotic and positive, systolic jugular venous pulse was seen. Atrial flutter was present and no systolic cardiac murmur was heart. The liver was enlarged without peripheral oedema. Echo-Doppler examination and cardiac catheterisation revealed huge right cardiac chambers and significant tricuspid regurgitation. During reoperation a valve consisting of only two cusps was found with extremely dilated valvular anulus. A Bex valvuloplasty was successfully performed. One month later a control echo-Doppler showed the diminution of right ventricle and right atrium with hardly visible regurgitant jet. The pathogenesis and the course of this extremely rare disease have been also discussed in the paper.

[Diagnostic effectiveness of Rtg-TV, echocardiography and computerized tomography in mitral valve calcinosis]. / Skutecznosc diagnostyczna Rtg-TV, echokardiografii i tomografii komputerowej w wykrywaniu zwapnien zastawki dwudzielnej.

The aim of the study was a comparative evaluation of the three diagnostic procedures: fluoroscopy (Rtg-TV), echocardiography (ECHO) and computer assisted tomography (CT) in detection of mitral valve calcifications. These methods were applied to the 46 patients with mitral valve disease (24 males and 22 females which age was 24-56 years). The results were compared with radiograms of isolated valves after surgery. We found that the most efficient diagnostic method is CT which provided following results: sensitivity--100%, specificity-- 89% efficiency--95%, false positives and false negatives rates 11% and 0% respectively. The same diagnostic indices in the other methods were: ECHO--92%, 77%, 85%, 22%, 7%; Rtg-TV--50%, 100%, 75%, 0%, 50%. The last method can not be used as a routine examination in detecting of the mitral valve calcifications because of its low sensitivity+ and high grade of false-negatives rate.

[Echocardiographic evaluation of delayed outcome of artificial valve implantation in patients with aortic semilunar valve insufficiency]. / Ocena echokardiograficzna odleglych wyników wszczepienia sztucznej zastawki w przebiegu niedomykalnosci platków pólksiezycowatych aort.

An average follow-up period of 16 patients was 28 months following an implantation of the artificial aortic valve for its insufficiency. In 10 operated patients who were able to continue their occupation exercise tolerance increased by two classes, according to NYHA. Blood pressure gradient decreased significantly from 61.8 to 37.5 mmHg, cardiac volume index decreased from 639 to 602 ml/m2. Echocardiographically measured muscle mass of the left ventricle, end-diastolic and end-systolic volumes, and the left atrial dimensions decreased significantly following surgery. A significance of the relation of the left ventricle volume to its mass <4 as a prognostic factor in aortic valve replacement has also been confirmed.

[Intensity of tone and opening snap, and morphology of the bicuspid valve in patients with mitral valve disease]. / Intensywnosc I tonu I stuku otwarcia, a morfologia zastawki dwudzielnej u chorych z wada mitralna.

The purpose of this study was to investigate the correlation between mitral valve morphology and amplitude of the first heart sound and the opening snap. The material consisted of 21 women and 19 men with mitral valve disease. They ranged in age from 24 to 56 years. 36 patients had pure or dominant mitral stenosis and 4 patients had combined mitral valve disease with dominant regurgitation. Phonocardiograms were recorded in all patients before mitral valve replacement. We analyzed the presence and the amplitude of opening snap and the amplitude of the first heart sound at the apex. The amplitude of the opening snap was expressed in mm and as a ratio to the maximal vibration of the second sound in the same cycle. The amplitude of the first sound was expressed in mm and as a ratio of the maximal vibration of the first sound to the maximal vibration of the first sound to the maximal vibration of the second sound in the same cycle. All amplitude measurements were made in 10 consecutive cardiac cycles and were then averaged. Then we studied all mitral valves removed in a uniform manner by one surgeon. Excised valves were fixed in 5% solution of formaline. The extent of calcification was determined by radiographs (fig. 1). The mitral valve area and calcification area were estimated by planimetry of radiographs. Then we analyzed the localization of calcification and we calculated the ratio of calcification area to valve area. Valves were divided into three groups according to the degree of the fusion of subvalvular structures ("a funnel") (fig. 2).(ABSTRACT TRUNCATED AT 250 WORDS)

[The mitral valve in mitral valve defect. Histological and clinical correlations]. / Zastawka dwudzielna w wadzie mitralnej. Korelacja histologczno-kliniczna.

The purpose of this study was to investigate the correlation between the histologic changes in the excised mitral valves and the clinical findings in patients with mitral stenosis (with or without regurgitation). The Study group consists of 26 men and 23 women ranged in age from 24 to 56 years. The mitral valves were removed in a uniform manner by one surgeon during mitral valve replacement. The controls were 13 mitral valves removed at necropsy from patients who died of extracardiac causes. Excised valves were fixed in 5% solution of formaline. The extent of calcification was determined by radiographs. Tissue from the center of the anterior and posterior leaflet were selected as the samples. The blocks were paraffin embedded and processed in the conventional manner. For histological examination 11.5 um thick sections were stained with haematoxylin and eosin, Alcian blue, Van Gieson and Von Koss stain. Then the sections were examined under light microscope. We estimated the degree of fibrotic disorganization of architecture, vascularization, acid mucopolysaccharide content, number of fibroblasts, and the presence of calcific deposits and lymphoid infiltrates. The control valves had normal architecture with thick "fibrosa". In all stenotic mitral valves we found complete or partial disorganization of architecture. The most common change was hyalinization present in 94% valves, vascularization in 84% and calcification present in 66% of valves. In 33% of stenotic valves were present infiltrations by lymphocytes. We found a significant correlation (p less than 0.05) between the presence of lymphoid infiltrates and the duration of disease prior to surgery.(ABSTRACT TRUNCATED AT 250 WORDS)

[Electric cardioversion after surgical correction of the mitral valve defect. Prognostic value of the two-dimensional and Doppler echocardiography in the assessment of its long-term effectiveness]. / Kardiowersja elektryczna po chirurgicznej korekcji wady mitralnej wartosc prognostyczna (ocena skutecznosci odleglej) echokardiografii dwuwymiarowej i metody dopplera.

In 82 patients after mitral valve surgery (59--commissurotomy, 23--valve replacement--Björk-Shiley or St. Jude prosthetic valve), 2-D and Doppler echocardiography were performed one day before electrical cardioversion. Regular sinus rhythm was maintained to 180 days in 28 patients (34%), over 180 days in 54 patients (66%). The statistical differences (p less than 0.05) between the following echocardiography parameters of these two groups were determined: parasternal long axis view: aortic, atrial, right and left ventricular dimensions (not significant--NS); apical four-chamber view: left and right atrial, left and right ventricular areas--NS; apical two-chamber view: left atrial area--p less than 0.05; pulmonary valve: peak flow velocity--NS, acceleration time--NS; mitral valve: effective area--p less than 0.05, pressure half-time--p less than 0.05, mean gradient--NS, mean flow--NS, E-wave max. flow velocity--NS. These data suggest, that left atrial area less than 30 cm2 derived from two-chamber view and Doppler effective mitral area more or equal 2, 10 cm2 may be important and good predictors of long-term results of cardioversion in patients after mitral valve surgery.

[Primary chylopericardium. Diagnosis and therapy]. / Pierwotne chylopericardium. Diagnostyka i terapia.

Authors presented the first 3 described in Polish literature patients with primary chylopericardium. 2 of them underwent surgery. Literature review was performed based on presented till now 44 cases with this rare disease. Causes, diagnostics and therapy methods of chylopericardium were discussed especially emphasizing significance of the operation based on pericardium fenestration and supradiaphragmatic thoracic duct ligation.