[Analysis of risk factors of the paroxysmal atrial fibrillation after valve replacement in patients with aortic stenosis]. / Napadowe migotanie przedsionków po leczeniu operacyjnym zwezenia zastawki aortalnej--ocena czynników ryzyka.

UNLABELLED: Paroxysmal atrial fibrillation (PAF) is a frequent complication (10-60% of pts) after cardiac surgery. In our study we analyze the influence of clinical, echocardiographic and 24 h ecg parameters on the risk of postoperative PAF in 266 pts with aortic stenosis (88 women and 178 men; mean age 58 +/- 10). PAF was observed in 74 (28%) patients. Statistically significant factors of risk of PAF were (univariate analysis): age-relative risk 1.08 (1.04-1.11), history of PAF--4.3 (1.4-12.5), more than 100 supraventricular ectopic beats during 24 h ecg--2.9 (1.6-5.1), presence of SVT during 24 h ecg--2.6 (1.5-4.5) and presence of SVT > 140/min--relative risk 3.5 (1.8-6.7). Left atrium diameter and coronary artery bypass grafting during valve replacement had no impact on the risk of PAF. In multivariate analysis three factors remained significant--age, history of PAF and presence of SVT > 140/min during 24 h ecg. In discriminant analysis this model of 3 factors enabled the correct risk assessment in 72% of patients. CONCLUSIONS: 1. The factors that increase the risk of postoperative PAF in pts with aortic stenosis are: age, history of PAF and presence of SVT > 140/min during preoperative 24 h ecg. 2. Postoperative PAF is not related to left atrium diameter in this group of patients. 3. Coronary artery bypass grafting during aortic valve replacement does not increase the risk of PAF.

[Airway function disturbances reversibility after mitral valve replacement]. / Odwracalnosc zmian czynnosciowych dróg oddechowych u chorych po operacyjnej korekcji wady mitralnej.

Dyspnea, cough, recurrent airway infection, hemoptysis are the most common pulmonary symptoms of mitral valve disease and heart failure. Pathophysiological mechanism of those disturbances is complex and airway status is one of the most important. The aim of the study was to assess airway function disturbances reversibility after mitral valve replacement. The study group consisted of 30 patients qualified to mitral valve surgery. Patients were assessed by clinical cardiac noninvasive investigation and airway function study. Post-operative study was performed minimum 6 months after mitral valve replacement (mean after 8 months) and again after minimum 3 years (mean after 40 months). In most of assessed--22 patients (74%) airway obstruction was noticed, in 8 patients without obstruction nonspecific histamine provocation test was performed. Increased airway reactivity was found in 4 patients only, in another 4 patients (13%) there was no airway function disturbances. After mitral valve replacement significant improvement in all cardiac parameters including NYHA functional class was observed. No airway function improvement occurred. Only small tendency to improve airway function was noticed as far as it concerns VC, FEV1, MEF50, MEF75 iTGV with exclusion of Raw. Analysis after dividing study group into 3 subgroups with increasing airway function disturbances (from predicted to hyperreactivity and obstruction) was also performed. The improvement in airways function was noticed only in 6 patient (20% studied). In patients with mitral valve disease airway function disturbances as obstruction and bronchial hyperreactivity persist in long term follow-up after mitral valve replacement.

[Attempt of estimation of Q fever endocarditis frequency in Poland]. / Próba oceny czestosci wystepowania zapalenia wsierdzia w przebiegu przewleklej goraczki Q.

Up to now no Q fever endocarditis (caused by rickettsia Coxiella burnetii) has been diagnosed in Poland. Potential endocarditis caused by Coxiella burnetii strains can be related to a group of strains present in Poland or sensitivity of Polish Population. The aim of the study was to estimate frequency of Q fever endocarditis is patients of National Institute of Cardiology and to characterize Coxiella burnetii strains and correlation between frequency of Q fever endocarditis and the group of strains. In all patients infective endocarditis and valvular heart disease were diagnosed. In all cases vegetations on TTE or TEE and negative blood cultures were confirmed. No fungal antigens or elevated anti-Candida and anti-Aspergillus antibodies were found. Serological investigations as far as it concerns C. burnetii antibodies were negative in all cases. No Coxiella burnetii infection were found in patients with infective endocarditis and negative blood cultures in the National Institute of Cardiology. However due to high probability of occurrence of such an infection in Poland further investigations in other centers would be useful.

[Quality of life assessment 3 months after surgical treatment of acquired heart valve disease]. / Ocena jakosci zycia w 3 miesiace po operacji nabytych wad zastawkowych serca.

The quality of life in 114 patients with acquired heart valve disease 3 months after surgical treatment was estimated. The significant improvement of quality of life in the matter of physical, psychical and social factors after mitral, aortic and double valve replacement was noted. It was accompanied by increase of exercise capacity measured in 6-minute walk test and changing of NYHA functional classes. No correlation was found between age of patients, selected echocardiographic parameters and quality of life improvement.

Evaluation of serum cytokine concentrations in patients with infective endocarditis.

BACKGROUND AND AIM OF THE STUDY: Early diagnosis of infective endocarditis is important for clinical outcome, as mortality increases if diagnosis is delayed. Diagnosis is based on clinical features, echocardiography and blood culture findings, but negative blood cultures have been reported in 5-15% of proven cases. The study aim was to investigate serum cytokine levels in patients with infective endocarditis, and the possible use of these data in diagnosis and monitoring of the disease. METHODS: The study group comprised 40 patients with acquired rheumatic valvular heart disease and ongoing infective endocarditis. A diagnosis of infective endocarditis was established by clinical examination, echocardiography, laboratory investigations (inflammatory parameters) and positive blood cultures (n = 34). Two control groups included patients with acquired rheumatic valvular heart disease: 15 without infective endocarditis, and 15 with active urinary tract infection with significant bacteriuria. Serum interleukin-1alpha (IL-1alpha), interleukin-6 (IL-6) and tumor necrosis factor-alpha (TNF-alpha) levels were measured on three occasions during antimicrobial treatment (mean period 14 +/- 7 days). RESULTS: Serum IL-1alpha and TNF-alpha levels were not elevated in the study group, or in controls (IL-1alpha <3.9 pg/ml; TNF-alpha <10 pg/ml). Serum IL-6 levels were elevated on all occasions in patients with infective endocarditis (first measurement: 37.0 +/- 44.3 pg/ml; second 18.7 +/- 16.4; third 8.5 +/- 5.2) with a significant tendency to decrease during treatment (p <0.01, ANOVA). In all controls without infection the serum IL-6 concentrations were below calibration range (<3.2 pg/ml). In the control group with active urinary tract infection, IL-6 concentrations were slightly (but not significantly) elevated (4.49 +/- 1.82 pg/ml, p = NS). CONCLUSION: Elevated serum IL-6 levels may suggest ongoing infective endocarditis and might be used to aid in diagnosis and monitoring of treatment of the disease. Serum IL-1alpha and TNF-alpha levels were not affected. A further understanding of the role of serum cytokine concentrations in the diagnosis, prognosis and monitoring of infective endocarditis might be valuable in clinically uncertain diagnoses, especially when blood cultures are negative.

[Analysis of airway function in patients with mitral valve disease in various stages of progression]. / Analiza stanu czynnosciowego dróg oddechowych u chorych z wada mitralna o róznym stopniu zaawansowania.

UNLABELLED: The aim of the study was to assess an airway function in patients with mitral valve disease at different stages. The study group consisted of 105 consecutive patients with rheumatic mitral valve disease (21-20% pts with mitral stenosis and 84-80% with combined mitral valve disease with a stenosis prevalence). 77 (73%) females, 28 (27%) males, at a mean age 50.4 (28-68) years. EXCLUSION CRITERIA: aortic valve disease, ischemic left ventricular damage, uncontrolled hypertension, pulmonary and allergic diseases. Each patient was assessed by clinical, echocardiographic, X-ray chest, electrocardiographic examination and airway function studies. An airway obstruction was diagnosed when MEF50 < 60% of predicted value or Raw > 0.3 kPa/lxs-1. To assess airway obstruction reversibility test with fenoterol was performed. In the others nonspecific bronchial provocation test with 0.1% histamine was assessed. Similar number of patients was qualified to II (37%), III (33%) and IV (30%) NYHA functional class. Airway function disturbances were diagnosed in 98 patients (93.5% of all). In most of them airway obstruction was observed (70.5%). Bronchial hyperreactivity was detected in 24 patients (23%). Both airway function disturbances could enhance dyspnoea and fatigue. In the whole study group significant correlations between airway parameters indicating peripheral obstruction or restriction and some cardiological parameters were found. This suggests that peripheral obstruction is proportional to development of a valvular heart disease. Airway resistance which generally represents in 80-90% function of main bronchi was not correlated with any of the analysed cardiological parameters. We conclude that central obstruction is an additional and independent of development of valvular disease part of airway function disturbances.

[Radionuclide diagnosis of tricuspid regurgitation as a method of estimating the significance of tricuspid insufficiency with concurrent mitral valve disease]. / Diagnostyka radioizotopowa wielkosci fali zwrotnej trójdzielnej jako metoda okreslania istotnosci niedomykalnosci trójdzielnej towarzyszacej wadzie mitralnej.

UNLABELLED: A mitral valve replacement without simultaneous correction of a concomitant tricuspid regurgitation aggravates remote postoperative results. Nowadays diagnostics of a degree of tricuspid regurgitation bases on semi-quantitative methods, which are not unequivocal criteria of a significant tricuspid insufficiency. The aim of the study was to investigate diagnostic usefulness of a radioisotopic method of determination significant tricuspid insufficiency. The study group consisted of 35 patients with rheumatic mitral valve disease and tricuspid regurgitation (30 females, 5 males) at a mean age of 55 years qualified for operative treatment. Physical and noninvasive examinations were performed in all patients: chest X-ray (relative heart volume--RHV) and echocardiographicy (tricuspid regurgitation and right ventricle pressure). Final determination of a significant tricuspid insufficiency based on intraoperative diagnosis. The radioisotopic method relies on first pass technique with a determination of a tricuspid regurgitation index (TRI) and a right ventricular ejection fraction. Intraoperatively the patients were divided into two groups: with significant tricuspid regurgitation--21 patients and without--14 patients. Statistically significant differences, considering clinical and echocardiographic assessment between the two groups were noticed. The TRI index did not differentiate two groups. Noninvasive parameters that could affect diagnosis of significant tricuspid regurgitation were proved by a logistic regression analysis. Among them the TRI Index could have a separate value. CONCLUSIONS: Presented radioisotopic method of determination a degree of tricuspid regurgitation with the new TRI Index is of value in diagnosing significant tricuspid insufficiency when assessed with other noninvasive parameters. Estimation of a clinical usefulness of the method needs further investigation and bigger study group.

[Ventricular fibrillation as a symptom of prosthetic valve dysfunction that was caused by thrombosis on mitral valve. Surgery or thrombolytic treatment?]. / Migotanie komór jako objaw dysfunkcji sztucznej zastawki spowodowanej skrzeplina na sztucznej zastawce mitralnej. Leczenie operacyjne czy trombolityczne?

We discuss the case of 49 years old woman with recurrent thrombosis of prosthetic mitral valve with ventricular fibrillation as the complication. For the first time thrombotic prosthetic valve Carbo Medics 33 had been removed and the new valve--Medtronic Hall 31 mm was implanted in the mitral position. After diagnosis of the repeated thrombosis on the replaced prosthetic valve, the patient refused the subsequent operation. The fully effective thrombolytic therapy was then performed. The patient was discharged from the Department and was asymptomatic 4 month follow-up.

Risk factors for coronary artery stenosis in valvular heart disease.

BACKGROUND AND AIMS OF THE STUDY: The study was performed to establish the frequency of significant coronary artery stenosis (SCS) in patients with valvular heart disease (VHD), and in particular its correlation with the incidence of angina pectoris and presence of coronary risk factors. The need for coronary arteriography to be performed in all patients with VHD before surgery was also investigated. METHODS: Retrospective examinations were performed in 1292 patients with VHD (mean age 51 years) who underwent selective coronary angiography before surgery between 1982 and 1990. In each patient the presence of angina pectoris and the following risk factors were noted: cigarette smoking, systemic hypertension, family history of ischemic heart disease, elevated fasting serum lipids, history of diabetes mellitus and overweight. RESULTS: The incidence of SCS was 13%, was higher in patients with angina, and correlated significantly with coronary risk factors of smoking, hypertension, history of ischemic heart disease, elevated lipids and diabetes, but not with overweight. The incidence of SCS increased progressively with the number of coronary risk factors, from 2% in patients without risk factors, to 6% with one risk factor, and to 21% with two or more risk factors. SCS was not found in patients without coronary risk factors and without angina pectoris below 55 years of age. CONCLUSIONS: A statistically significant correlation was found between increasing numbers of coronary risk factors and significant coronary artery disease. These results suggest that coronary angiography may not be an obligatory diagnostic step before valve replacement in patients aged < 55 years who have neither risk factors nor angina pectoris.

[Iatrogenic left main coronary artery stenosis after aortic and mitral valve replacement]. / Jatrogenne zwezenie pnia lewej tetnicy wiencowej po operacji wszczepienia sztucznej zastawki w ujscie aortalne i mitralne.

A case of 48-year old patient, who developed anginal symptoms 3 months after aortic and mitral valves replacement was presented. The patient underwent coronary angiography, which revealed severe left main coronary stenosis. Successful surgery was done with grafting of left anterior descending and circumflex arteries. Opinions on etiology, diagnosis and management of this rare complication are discussed.

[Pulmonary function in patients with rheumatic mitral valve disease. Preoperative evaluation]. / Stan-czynnosciowy dróg oddechowych u chorych z poreumatyczna wada zastawki mitralnej. Badania przedoperacyjne.

UNLABELLED: The aim of the study was to observe the mechanism of cardiac-airway interaction in patients with rheumatic mitral valve disease. 61 pts with combined mitral disease and 9 with isolated mitral stenosis (42 females, 28 males; mean age 47 y) were studied. They were in NYHA functional class II-IV (36 pts in II, 22 in III, 12 in IV class). Each patient was assessed by clinical, noninvasive cardiological investigation (estimation of left atrium dimension, mitral gradient, mitral area and right ventricular systolic pressure on echocardiographic examination and relative heart volume on fluoroscopy) and lung function studies i.e. spirography, plethysmography, flow-volume curve and histamine provocation test. The bronchial hyperreactivity was found in 20 pts (75% undergoing test-mean PC40 = 0.1474 mg/ml). In 7 pts histamine test was negative. The reversible airway obstruction (after 200 micrograms FNT) was observed in 43 (61%) pts. CONCLUSION: In pts with mitral valve disease we observed significant bronchial hyperresponsiveness to histamine and reversible airway obstruction with no correlation between pulmonary function parameters and cardiological status.

Mitral and aortic valve replacement in a patient with ectodermal anhydrotic dysplasia. A case report.

Ectodermal anhydrotic dysplasia is a rare, usually X-linked recessive malformation of ectodermal tissues and organs. The case of a 17-year-old boy with ectodermal anhydrotic dysplasia and concomitant combined mitral valve disease and aortic insufficiency is described. The surgical risk was considered to be high due to severe atrophia of the laryngo-pharyngeal mucosa complicating endotracheal intubation and the possibility of postoperative temperature control disturbances. Double valve replacement was performed late in the autumn, after laryngo-pharyngeal pharmacological treatment preparing for endotracheal intubation. The peri-operative course was managed without any complication related to the hereditary malformation. Our experience suggests that patients suffering from ectodermal anhydrotic dysplasia may undergo open heart surgery after appropriate preparation. Potential postoperative problems related to the hypohydrosis and impaired spontaneous temperature control could be prevented in our patient.

[Concurrent coronary artery disease and acquired rheumatic mitral valve disease]. / Wspólistnienie choroby wiencowej z nabyta, poreumatyczna wada zastawki mitralnej.

The aim of this study was to estimate coincidence of coronary artery disease (CAD) and rheumatic mitral valve disease in 264 patients treated in the National Institute of Cardiology (1976-1990). Severity of stenoses on coronary angiography with respect to age, sex, symptoms and risk factors were also estimated. Stenoses over 70% of artery lumen in relation to artery diameter before lesion and over 50% for left main coronary artery were stated as severe. There were 180 (68%) females and 84 (32%) males in the studied group; mean age was 52.5 year. Patients were divided into two groups: with angina--126 pts and without CAD symptoms--138 pts. 8 females (4%) had severe stenoses and 45 (25%) non-severe. Respectively 14 males (16.7%) had severe stenoses and 14 non-severe. Severe lesions were present in a group of females older than 50 years and in a group of males older than 45 years. Both in group with or without angina prevalence of coronary artery lesions was similar. Sensitivity and specificity of CAD clinical symptoms was low (less than 50%). Significantly more risk factors were present in pts with coronary stenoses than in pts free of CAD. No correlation between high pulmonary artery pressure and angina in patients without coronary stenoses occurred.

[Atrial natriuretic peptide in rheumatic mitral valve disease]. / Przedsionkowy hormon natriuretyczny w poreumatycznej wadzie zastawki mitralnej.

The aim of the study was to analyze atrial natriuretic peptide (ANP) plasma level in patients with rheumatic mitral valve disease in correlation with NYHA functional class and selected hemodynamic parameters based on noninvasive diagnostic procedures. Echocardiographic (2-D, Doppler) and X-ray chest examination were performed to measure left atrium dimension, mitral gradient and relative heart volume (RHV). Control group consisted of 10 healthy subjects. ANP were measured (radioimmunoassay) in 35 patients before valve replacement. Mean values for ANP were significantly elevated in all patients compared to control group (p < 0.001). No significant difference between ANP secretion in pts with sinus rhythm (mean ANP level 25.3 +/- 6.9 pmol/l) and pts with atrial fibrillation (mean ANP level 26.7 +/- 7.6 pmol/l) occurred. Positive correlation between left atrium dimension and ANP level were found (r = 0.964) and also between RHV and ANP level (r = 0.9) and between NYHA class and ANP level (r = 0.63). The conclusion is that ANP secretion is elevated in all patients with heart failure due to mitral valve disease proportional to its stage.

[Surgical treatment of bacterial endocarditis of the tricuspid valve]. / Bakteryjne zapalenie wsierdzia zastawki trójdzielnej leczone operacyjnie.

We present a rare case of bacterial endocarditis of tricuspid valve caused by temporary intracardiac pacing. The 48-year old male patient developed complete a-v block during the 1st day of acute inferior myocardial infarction. Intracardiac electrode was inserted for temporary pacing. After 4 days signs of bacterial endocarditis developed. Patient was markedly febrile, moderate tachycardia with gallop rhythm and systolic murmur of tricuspid valve insufficiency were present. Dullness to percussion was audible at the base of right lung. Hepato- and splenomegaly appeared during the second month of hospitalization. Laboratory tests revealed: elevated ESR, leukocytosis with a shift to the left, several blood cultures were positive to Staphylococcus aureus. On repeated chest X-ray patchy infiltrates with thin-walled translucent pools were visible. Transthoracic and transoesophageal++ echocardiography provided more precise informations. Bacterial vegetations were visualised on the tricuspid valve. Coronary angiography revealed proximal occlusion of the right coronary artery and 75-80% stenosis of the left circumflex artery. Antibacterial treatment guided by blood cultures was begun: vancomycin combined with netilmycin, then tienamycin and diflucan--after 10 weeks treatment was decided to be unsuccessful and the decision about surgical treatment was made. In extracorporeal circulation posterior left leaflet together with granular bacterial growths was excised. Septal and anterior leaflets were found normal. Cultures made of excised tissue were positive for Staphylococcus aureus and subsequent treatment with fluoroquinolones gave satisfactory result. Postoperative echocardiography revealed only small tricuspid valve insufficiency. Coronary by-pass surgery was performed later because of the high risk of simultaneous operation.(ABSTRACT TRUNCATED AT 250 WORDS)

[Propionibacterium acnes in the etiology of endocarditis]. / Propionibacterium acnes w etiologii zapalenia wsierdzia.

Propionibacterium acnes is the gram positive anaerobic bacteria belongs to the normal skin and oral microbial flora. The participation of this microorganism in the infective endocarditis is still controversial. The aim of the study was to perform the diagnostic and therapeutic difficulties in 5 patients with infective endocarditis caused by Propionibacterium acnes. In 3 out of 5 patients the infective endocarditis developed after prosthesis valve replacement, in 2 others on the native valves. The inserted prostheses were mechanical ones, propionibacterium acnes was identified as causative organisms in all of the causes (two positive blood and/or valve culture). The bacterial strains were sensitive to the antibiotics as: penicillins, cephalosporins, clindamycin, and vancomycin, however cephalosporins used at the beginning of the treatment in 3 patients and clindamycin in 1 patient had limited clinical efficacy. Later treatment with timentin, augmentin and tienamycin was successful in 3 patients; one patient was cured with vancomycin. One patient died because of septic, embolic complication in early stage of illness. We conclude the effectiveness of penicillins in combination with clavulanic acid and tienamycin in therapy of infective endocarditis due to Propionibacterium acnes. The treatment should be lasted during 4-6 weeks.

[Analysis of remission of pulmonary hypertension after mitral valve replacement]. / Analiza odwracalnosci nadcisnienia plucnego po leczeniu operacyjnym wady zastawki mitralnej.

In a group of 32 patients with mitral valve disease and extreme pulmonary hypertension, the efficacy of mitral valve replacement (MVR) was analysed. In all patients hemodynamic and clinical data were obtained and compared before and after operation. After surgery a statistically significant differences (p < 0.01) of the pressure was observed in right atrium and ventricle, pulmonary artery and capillaries, the pulmonary resistance was decreased, the cardiac index was increased. The improvement of hemodynamic parameters correlated well with clinical data. But it has not influenced for return to the job.

[Treatment results in patients with mitral valve disease in IV functional class of NYHA. I. Surgical treatment]. / Wyniki leczenia chorych z wada mitralna w IV okresie czynnosciowym wg NYHA. Czesc I: Leczeni operacyjnie.

In the group of 142 patients with mitral valve disease (61% in IV and 39% in III functional class of NYHA) the efficacy of mitral valve replacement (MVR) was analysed. In all of the patients clinical, noninvasive and invasive investigations were obtained and compared before an after surgery. After MVR a statistically significant differences (p < 0.05 or p < 0.01) of RHV, noninvasive and hemodynamic data was observed. The survival during ca 1836 days after surgery of patients in IV class of NYHA was 72%. The improvement of activities correlated well with changes of functional class of NYHA.

[Treatment results of patients with mitral valve disease in IV functional class of NYHA. II: Conservative treatment]. / Wyniki leczenia chorych z wada mitralna w IV okresie czynnosciowym wg NYHA. Czesc II: Leczeni zachowawczo.

In the group of 60 patients with mitral valve disease (67% in IV and 33% in III functional class of NYHA) the efficacy of medical treatment was analysed. In all of them clinical, noninvasive and invasive investigations were obtained. The conclusion is that survival during ca 1643 days was 15% of the patients in IV class of NYHA. The death was mostly due to severe heart failure.

[Concomitance of coronary artery disease with acquired aortic valve disease]. / Wspólistnienie choroby wiencowej z nabyta wada zastawki aortalnej.

Incidence of concomitant coronary disease and extent of coronary artery lesions were assessed in 250 patients with acquired post-rheumatic aortic valve disease treated between 1976 and 1986 in National Institute of Cardiology. Patients' age ranged from 30 to 72 years. Hemodynamic examination with selective coronarography were performed in patients with typical effort or rest angina pain, with electrographically documented myocardial infarction in the past and also in those without (CAD clinical symptoms, but older than 45 years. Patients were divided into two groups: with isolated or dominated aortic valve stenosis (139 patients) and with isolated or dominated aortic valve incompetence. Patients younger and older than 45 years were separately analyzed. Concomitant CAD was proved if at least one coronary artery stenosis was stated. Lesions degree was proportionally graded: stenosis more than 70%, between 50-70% and 20-50% of a vessel lumen in relation to its diameter before lesion. Data were analyzed using ICL ME 29 computer. Study results indicate, that symptoms of coronary failure were observed in 82.8% of patients with acquired aortic valve disease. In 37% of cases there were critical stenoses requiring simultaneous aortic valve replacement with coronary artery by-pass grafting. Severe coronary artery stenosis was stated in 45% of patients with dominated or isolated aortic valve incompetence, whereas only in 29.3% with dominated or isolated aortic valve stenosis. 88.5% of patients younger than 45 years nevertheless coronary failure symptoms had normal coronary arteries.