Right ventricular endomyocardial fibrosis. Diagnosis and management.

The clinical course, noninvasive and invasive diagnostic findings in 4 patients (pt) with endomyocardial fibrosis are reported. All patients (16-50 years) were in functional class III-IV (NYHA). Central venous pressure with large a- and v-waves was elevated in all; liver enlargement and peripheral edema were also noticed in all pts, and ascites in 3. An apical 2/6 systolic murmur was present in 2, and a right parasternal pansystolic murmur 2-4/6 with positive Carvallo's sign in all pts. ECG was non-specific and chest x ray showed right atrial enlargement in every case. A right-sided diastolic plateau which was higher than left ventricular end-diastolic pressure was present in all pts. Echo-, angiocardiography and computed tomography of the heart revealed obliteration of the right ventricular cavity, predominantly localized at the apex. Two pts who underwent endocardial resection and tricuspid valve replacement are alive and well after 9 and 8 years, respectively. One pt died early in the postoperative period and one died waiting for surgical therapy. In conclusion, echo-, angiocardiography and computed tomographic findings are diagnostic. A satisfactory differentiation from other cardiac disorders with restrictive hemodynamics and right-sided heart failure is possible.

Chronic traumatic tricuspid insufficiency.

Isolated tricuspid insufficiency (TI) is relatively uncommon and mostly of traumatic origin. We report clinical noninvasive and invasive findings and surgical results in 5 cases. All patients had complete clinical, noninvasive and invasive studies including right and left catheterization, and coronary angiographies in 3 patients. All but 1 patient had nonpenetrating trauma. All had large jugular V waves, right precordial impulse, systolic liver pulse, positive Carvallo sign documented also by noninvasive techniques. Right heart failure was present in 3 patients. Chest x-ray showed prominent right atrium and distended vena cavae. Electrocardiogram showed normal sinus rhythm in 4 patients and atrial fibrillation in 1. Two patients had right bundle-branch block, and 2 presented RSR'-pattern. Echocardiogram showed large right atrium (RA) (6-10 cm), floppy tricuspid valve (TV) in all, dilated right ventricle (RV) in 2 patients. Findings of left heart were normal in all. Three patients had right-to-left shunt. In RA A waves were 4-8, Y waves 1-3, and V waves 12-22 mmHg, respectively (mean RV and PA pressures were 23/3 and 23/10 mmHg, respectively). Four patients had anuloplasty, 2 of them repair of valve and chordae. Surgical results were good in 2 patients with valve repair, satisfactory in 1; there was significant TI resistance in 1 case. We conclude that TI has distinctive clinical findings and must be ruled out in all patients with chest trauma. Surgery must include not only anuloplasty, but, cusps and chordae must also be evaluated and reconstructed if necessary.

Congestive heart failure in valvular heart disease in pregnancies with and without valvular prostheses and anticoagulant therapy.

The course and complications of pregnancies in 46 patients with valvular disease and congestive heart failure with or without valve prostheses are described. In group I consisting of 33 women without valve replacement and without anticoagulant therapy one thromboembolic event was seen, emergency closed or open heart surgery was necessary five times. One still-birth happened after open heart surgery. In group II, of 13 patients with prosthetic valve replacement and anticoagulation therapy there was no thromboembolism, but 2 spontaneous abortions and 2 premature stillbirths; 2 fetuses died after delivery, 3 had congenital abnormalities. Pregnancies in patients with valvular disease and congestive heart failure can be sustained relatively safely for the mother, even if emergency heart surgery becomes necessary. Heart surgery and anticoagulation treatment carry a higher risk for the fetus. Uterine blood loss is not increased, if coumadine treatment is switched to heparin administration shortly before delivery.

Severe tricuspid valve stenosis. A cause of silent mitral stenosis.

The diastolic rumbling murmur of mitral stenosis (MS) may be attenuated in the presence of low cardiac output, right ventricular enlargement, Lutembacher's syndrome, pulmonary emphysema, and obesity. In this report we would like to stress that the presence of tricuspid stenosis (TS) is an additional significant cause of silent MS. The clinical material consisted of 73 patients with rheumatic TS who had undergone cardiac surgery. Five of these cases had clinical findings of TS without auscultatory findings of MS. They were found to have severe MS at the time of operation and to require mitral valve surgery. At cardiac catheterization the mean diastolic gradient (MDG) across the mitral valve (MV) was less than 3 mmHg and pulmonary arterial systolic pressure was 29-42 mmHg. The MDG across the tricuspid valve was 6-17 mmHg. In conclusion, TS can mask clinical and hemodynamic findings of MS. The reason for this is the mechanical barrier imposed by TS proximal to the MV.

[Rheumatic tricuspid stenosis--a clinical overview with surgical considerations]. / Die rheumatische Trikuspidalstenose--Eine klinische Ubersicht einschliesslich operativer Ergebnisse.

73 patients are reported on who ad different and multiple valvular heart lesions, always including tricuspid stenosis (TS). The pre- and postoperative hemodynamic and clinical findings are presented (as well as the results of surgical treatment). The conclusion is arrived at that TS is frequently involved in rheumatic valvular heart disease and that it needs special attention. It should be confirmed by simultaneous measurements of the right ventricular and right atrial pressures. The surgical results are encouraging. Tricuspid commissurotomy is the favored method, leaving the least gradient. Surgical mortality was 2.7%. Postoperative clinical improvement could be seen in 96% of all patients.

Persistent left superior vena cava draining into the left atrium, atrial septal defect, and absence of the coronary sinus. Recognition and surgical correction.

The diagnosis of atrial septal defect (ASD), persistent left superior vena cava (LSVC) and absence of coronary sinus was established by cardiac catheterization in a 20 years old female. At surgery the coronary vein ostia were located in the left atrium. LSVC was ligated and pericardial patch was sutured around the orifices of the coronary veins and extended to the ASD to redirect the coronary blood flow into the right atrium and close the defect. The postoperative cardiac catheterization and hemodynamic studies revealed good result.

Constrictive endocarditis. Report of a case with successful surgery.

An 18-year old white youth presented with severe right heart failure and was found to have an obliterated and funnel-shaped right ventricle, massive tricuspid regurgitation, and mitral regurgitation. The haemodynamic findings were those of cardiomyopathy with obliteration on the right side. He underwent surgery consisting of decortication and peeling off of a thickened right ventricular endocardium, tricuspid valve replacement, and mitral valve repair. After surgery there was pronounced haemodynamic as well as clinical improvement. The pathological picture was that of constrictive endocarditis. We recommend this method of treatment for patients with obliterate cardiomyopathy on either side of the heart.

Rheumatic tricuspid stenosis. A clinical overview.

The clinical, hemodynamic findings and surgical results of forty patients with rheumatic tricuspid stenosis are presented. It is concluded that tricuspid stenosis is a frequent lesion. Its signs should be sought carefully and documented by simultaneous measurements of the right ventricular diastolic and right atrial pressures. Tricuspid stenosis is usually associated with other valvular lesions, whose clinical and hemodynamic findings might be altered. Surgical procedures on these patients involved tricuspid valve repair, commissurotomy or prosthetic valve replacement, in addition to the procedures necessary to correct other associated valvular lesions. Results of surgery were gratifying with significant improvement in 87 percent of patients and a mortality of 3 per cent.

[The serum potassium level during and after cardio-pulmonary bypass in children: a comparative study of the effects of the preoperative administration of digitalis and diuretics (author's transl)]. / Die Wirkung der präoperativen Digitalis und Diuretika-Behandlung auf Serum-Kalium-Spiegel während und nach Bypass bei Kindern

The serum potassium levels were determined in 2 groups. The first group (40 children) was treated preoperatively with digitalis and diuretics. The second group (20 children) received none of these drugs and served as a control group. During the period of bypass, all patients received potassium-chloride, 1 m Eq/per Kg/h, which was infused into the heartlung machine. The serum potassium levels were determined before, during and after extracorporeal circulation. The first group showed a significant decrease in the serum potassium level during and after the bypass. The lower serum potassium levels (less than 4 m Eq/L) had to be corrected by injection of potassium aspartate. In the second group, an increased serum potassium level was observed. It is advisable to reduce the amount of potassium administered by half in patients not pretreated with digitalis and diuretics. In those who have been pretreated with these drugs, hypokalaemia should be avoided by frequent serum potassium estimation and potassium administration if needed.

Limits of coronary artery surgery. Clinical and postmortem findings.

In the first series of 90 continuous patients with coronary artery disease 9 patients died after aorto-coronary bypass procedures (10%). There were 7 operative deaths, and 2 postoperative deaths (respiratory failure after bronchopneumonia and bleeding duodenal ulcer; acute necrosis of the liver following hepatitis). The study of the deceased patients made evident that postoperative impairment of left ventricular function is caused by ventricular aneurysms. This fact can be shown by the poor ventricular function with an elevated left ventricular enddiastolic pressure (LVEDP) of more than 18 mm Hg. The results in patients with congestive heart failure could not be improved by multiple bypass-grafts. Probably the prolonged surgical intervention may cause additional stress to the predamaged myocardium. So, in our group the indication for using multiple grafts in cases with ventricular aneurysm is confirmed with great caution.

[Comparing studies on the influence of dopamine and orciprenaline on cardiac and renal function of patients after cardiac surgery (author's transl)]. / Vergleichende Untersuchungen über den Einfluss von Dopamin bzw. Orciprenalin auf Herz- und Nierenfunktion nach kardiochirurgischen Eingriffen

Cardiac and circulatory function (cardiac output, stroke volume, heart rate, mean arterial pressure = MAP, total peripheral resistance = TPR), further renal function (PAH- and inulin clearance, filtration fraction, urinary excretion, renal sodium- and potassium excretion) were measured on 15 patients undergoing cardiac surgery to whom Dopamine and Orciprenaline were administered in increasing doses of 100 mug - up to 500 mug/min (Dopamine) and 10 mug - to 20 mug/min (Orciprenaline). An infusion of Dopamine up to 250 mug/min caused a dosis-related increase of the cardiac output up to 31% (2P less than 0.001) without essential increasing of the MAP and of the heart rate. Dopamine caused a decrease of the TPR up to 24%. Doses of Dopamine over 250 mug/min cause an increase of the MAP and of the heart rate without a real increase of the cardiac output. Renal function improved under increasing doses of Dopamine, effective renal plasma flow (ERPF) up to 74%, urinary excretion up to 130%, sodium and potassium excretion up to 60% respectively. After administering Orciprenaline in a dosis of 20 mug/min cardiac output increases up to 28%, MAP and heart rate up to 12% and 17% respectively. After the administration of Orciprenaline (20 mug/min) and Dopamine (500 mug/min) frequent extra systoles were observed without any increase of the cardiac output; MAP increased by 12%, TPR decreased by 16% after 20 mug/min of Orciprenaline. ERPF decreased slightly after Orciprenaline. Urinary excretion was reduced by a half.

[Pulmonary embolism: indication for and results of embolectomy under cardio-pulmonary bypass (author's transl)]. / Lungenembolie. Indikation und Ergebnisse der Embolektomie mit Anwendung der extrakorporalen Zirkulation

Pulmonary embolectomy under cardio-pulmonary bypass was performed in five patients with massive embolism. Two survived and were ultimately discharged; two died after 40 and 101 days, respectively, of the underlying disease; one patient--operated on under a mistaken diagnosis--was maintained under assisted circulation but died after four days of the underlying disease (cardiac failure). Indications for pulmonary embolectomy under cardiopulmonary bypass should be widened, as it is the only life-saving measure in most cases. After moderately severe pulmonary embolism (lobar embolism) indications for surgical intervention must be individualised from case to case.