Emergent balloon mitral valvotomy in patients presenting with cardiac arrest, cardiogenic shock or refractory pulmonary edema.

OBJECTIVES: The present study was performed to determine the outcome of emergent balloon mitral valvotomy (BMV) in patients with cardiac arrest, pulmonary edema or cardiogenic shock. BACKGROUND: In India, many patients with mitral stenosis present in critical condition. They have high mortality despite surgical relief. The role of BMV in such patients is ill-defined. METHODS: Of 558 patients undergoing BMV between January 1993 and December 1994, 40 presented with cardiogenic shock, cardiac arrest or pulmonary edema refractory to medical treatment and underwent emergent BMV (group I). Elective BMV was performed in the remaining 518 patients (group II). RESULTS: Age ([mean +/- SD] 40 +/- 13 vs. 31 +/- 9 years, p < 0.05), incidence of atrial fibrillation (35% vs. 11%, p < 0.05), pulmonary artery systolic pressure (PAsP) (64 +/- 14 vs. 51 +/- 12 mm Hg, p < 0.001) and mitral valve (MV) score (7.4 +/- 1.2 vs. 6.4 +/- 1, p < 0.001) were higher and MV area lower (0.74 +/- 0.17 vs. 0.86 +/- 0.14 cm2, p < 0.001) in group I patients. After emergent BMV in group I, mitral regurgitation occurred in 15%, and the mortality rate was 35%. Stepwise logistic regression analysis identified MV score > or =8 (p = 0.008), PAsP > or =65 mm Hg (p = 0.023) and cardiac output < or =3.151 liters/min (p = 0.001) as significant predictors of a fatal outcome. Follow-up of 1 to 16 months (median 8) was available in 20 of 26 survivors in group I, of whom 15 were asymptomatic. The gain in MV area and the decrease in transmitral gradient and PAsP obtained immediately after BMV persisted during the follow-up period. CONCLUSIONS: Emergent BMV is feasible in critically ill patients. In-hospital survivors have excellent clinical and hemodynamic status at intermediate follow-up.

Follow-up after coil closure of patent ductus arteriosus.

A prospective serial follow-up after coil closure of patent ductus arteriosus in 84 patients showed a cumulative duct closure up to 96% at the end of 2 years. Five patients underwent transient recanalization, and 4 patients required repeat procedure for residual shunt or recanalization.

Therapeutic guidelines for congenital complete heart block presenting in pregnancy.

Congenital complete heart block presenting for the first time in pregnancy is a therapeutic challenge. Most of the reports are from an era when pacemaker therapy was in its infancy. Although isolated case reports have appeared, there are no definite guidelines for the management of such patients. We describe three cases of congenital complete heart block presenting in pregnancy. All the patients delivered normally with temporary pacing support during labor. Two of the three women remained symptomatic during the postpartum period when they were being weaned off the pacing support, so they were discharged with permanent pacemaker implantation. The third woman remained symptom-free during pregnancy, labor, and the postpartum period and was discharged without a permanent pacemaker; she is being followed with routine and 24-hour ambulatory electrocardiography. We review the literature in an attempt to formulate a therapeutic policy for such patients.

Quantitative study of the mitral valve in chronic rheumatic heart disease.

A quantitative study of the mitral valve and its tension apparatus was carried out in 54 cases of pure mitral stenosis, 13 cases of mitral stenosis with incompetence, both diseased groups due to rheumatism, and 25 normals. In the group with pure mitral stenosis, the annular size was unaltered but the annular attachment of the mural leaflet was decreased. The average circumference of the orifice was 27 mm. The leaflet length increased by 24%. In the group with mitral stenosis with incompetence, the annular size was increased by 18%. The average circumference of the orifice was 39 mm, but no significant increase in the length of the leaflets was found. The rough zone of the aortic leaflet in pure mitral stenosis is disproportionately increased, indicating greater apposition during closure. In pure mitral stenosis, the cords were severely affected as compared to combined lesion. They were totally absent in 18.5% of cases while this lesion was restricted to the aortic leaflet in 37%. The commissural, paracommissural and paramedial cords were not seen in 75, 60, and 72%. The main cords were not seen in 50% of cases. In the combined lesion, cords attached to the aortic leaflet only were absent in 7.69%. The commissural, paracommissural and paramedial cords were absent in 33, 39, and 23%, respectively. The main cords were absent in only 19%. The reduction in lengths of the cords is more marked in cases with pure stenosis. We conclude that the mitral valve is better preserved in the group having stenosis with incompetence, the incompetence being the result of a larger annulus and orifice with normal leaflets and shorter tendinous cords. In pure mitral stenosis, the incompetence through a small orifice is prevented by the longer leaflets, particularly the aortic.

Is haemorrhagic myocardial infarction more common with streptokinase?

Autopsy reports and clinical data of 226 consecutive myocardial infarction deaths in whom postmortem studies could be carried out during the period 1980 to 1996 were analyzed retrospectively for the presence of haemorrhagic myocardial infarction (HMI). Of 53 autopsies done from 1980 to 1986 [prior to use of streptokinase (SK) therapy in our institution] none of the specimens showed haemorrhagic infarction. Of 173 autopsies done from 1987 to 1996 (intravenous SK therapy was utilised in this period), 20 specimens showed haemorrhagic infarctions. Sixteen of these 20 patients had received SK, while 66 of the remaining 153 non-haemorrhagic myocardial infarction patients received SK (statistically significant association of SK with HMI, p < 0.005). Acute mechanical complications [ventricular septal rupture (n = 10), papillary muscle rupture (n = 2), cardiac free wall rupture (n = 7)] were seen in 19 cases. Of these, 16 were HMIs and 14 of these patients had received streptokinase. These observations suggest a strong association of HMI with SK therapy and with acute mechanical complications.

Balloon angioplasty for native aortic coarctation.

From May 1987 to August 1990, eighteen patients underwent balloon angioplasty for native aortic coarctation. The age of the patients ranged from four to fifty six years (mean age 17.5 years). The procedure was successful in all cases with a reduction in the peak gradient across the coarctation from 61 +/- 19 mm Hg to 11.7 +/- 8.1 mmHg (p < 0.05). The coarcted segment increased from 4.5 +/- 1.9 mm to 10.7 +/- 3.9 mm (p < 0.05). Peak gradient at six to twelve months follow up, obtained in ten patients, was 19.8 +/- 10.1 mmHg (p = NS). There were no life threatening complications, although seven patients had local vascular problems after the procedure. In two patients, there was persistence of hypertension necessitating drug therapy. On haemodynamic and angiographic restudy in 10 patients, one patient had restenosis and none had aneurysm formation. We conclude that balloon angioplasty is a safe, and less invasive alternative to surgery for native aortic coarctation with gratifying immediate and short term results.

Long term results of percutaneous transluminal valvuloplasty in patients with valvular aortic stenosis.

The results of percutaneous balloon aortic valvuloplasty (PBAV) in 62 consecutive patients with valvular aortic stenosis are reported. The age of the patients ranged from 11 months to 72 years (mean 28 +/- 12 years). Hemodynamically successful dilatation was achieved in 58 out of 62 patients. This was associated with marked clinical improvement in these patients. The left ventricular aortic peak to peak gradient decreased from 96.67 +/- 38.4 to 28.14 +/- 26.5mmHg (p < 0.01). There were no deaths during the procedure. Only one patient died in the hospital during the same admission. There was an increase in aortic regurgitation (AR) by at least one grade in 25 (40.3%) patients. Femoral arterial thrombosis was seen in 9/62 patients, 5 of them requiring surgical intervention. Follow up was available in 28 (45.1%) patients over a period of 2-15 months (mean 9 +/- 3 months). Two patients died during the follow up period. Doppler evaluation of gradients was done in all 28 patients with 15 consenting to undergo repeat cardiac catheterisation. Although hemodynamically the restenosis rate was 35.7% (10/28), only 2 of these patients showed symptomatic deterioration. The success of dilatation and restenosis rate were independent of the etiology of aortic stenosis, presence of calcification and the number of balloons used. This study demonstrates that PBAV is feasible in valvular aortic stenosis at low risk and is able to produce significant clinical and hemodynamic improvement in most cases with a restenosis rate of 35.7% at a follow up period of 9 +/- 3 months.

Is dietary fiber beneficial in chronic ischemic heart disease?

OBJECTIVES: To evaluate the benefit of a dietary fiber preparation (Fibernat) in patients with chronic ischemic heart disease (IHD). METHODS: From January 1997 to March 1998, 114 consecutive patients with chronic IHD were enrolled in this prospective double blind randomized placebo controlled trial. The fiber (F) and placebo (P) groups were comparable at baseline. All patients were given advice regarding dietary and lifestyle modifications. Concomitant drug therapy was not altered. The drug (consisting of soluble and insoluble fibers obtained from fenugreek, guar gum and wheat bran) and placebo were administered for six months (10 grams twice daily). RESULTS: The following parameters improved in both groups: HDL cholesterol (32 to 39 mg/dl, p < 0.0009 in F and 33 to 38, p < 0.007 in P), total: HDL cholesterol ratio (6.7 to 5.6, p < 0.0007 in F and from 7.0 to 6.0, p < 0.01 in P) and weight (64.0 to 63.0 kg, p < 0.002 in F and 60.3 to 59.5, p < 0.002 in P). The Apolipoprotein B increased (101 to 129 mg/dl, p < 0.00001 in F and 98 to 127, p < 0.0008 in P). The following parameters improved only in group F: LDL cholesterol (146 to 134, p < 0.027), Apolipoprotein A-1 (105 to 139, p < 0.001), body mass index (24.9 to 24.5, p < 0.03) and waist circumference (37.2 to 36.7, p < 0.03). Total cholesterol, VLDL cholesterol, triglycerides, hip circumference, W:H ratio, exercise time and blood sugar were unchanged in both groups. CONCLUSIONS: Fibernat is well tolerated, safe and had favorable effects on LDL cholesterol, Apolipoprotein A-1, body mass index and waist circumference.

Pre-natal echocardiographic diagnosis and neonatal balloon dilatation of severe valvar pulmonic stenosis.

A case is presented below where pre-natal echocardiographic diagnosis of critical pulmonic valvar stenosis was made at 36 weeks of gestation. In view of the severe heart failure, successful balloon valvotomy was performed on day 4 of life. The child was asymptomatic at one month follow-up.

Right-ventricular myxoma presenting as right-ventricular outflow-tract obstruction--case report and review of the literature.

Myxoma of the right ventricle is of very rare occurrence. An adult male patient presented with Class III dyspnoea and occasional haemoptysis and clinically was suspected to have pulmonary stenosis. Magnetic resonance imaging study revealed presence of myxoma arising from the right-ventricular free wall and prolapsing into the pulmonary artery but not involving the pulmonary valve. The myxoma was excised via right ventriculotomy using cardiopulmonary bypass. The patient had an uneventful recovery. The relevant literature is reviewed.

Unusual case of pacemaker lead migration.

Pulmonary artery migration of pacemaker lead is rare and may result in pulmonary emboli originating from the thrombus around the infected catheter and causing multiple pulmonary infarcts. We report an unusual case of pacemaker lead migration to the right pulmonary artery with septic pulmonary embolism. While being treated with intravenous Cefuroxamine, the patient had spontaneous migration of the lead to the left pulmonary artery with subsequent left pulmonary embolism.

Anthropometry, lipid profile and dietary pattern of patients with chronic ischaemic heart disease.

The anthropometry, lipid profile and dietary characteristics of 114 patients with chronic ischaemic heart disease (IHD) were evaluated. There were 91 (80%) men and the mean age was 56 +/- 9 years. The body mass index was near normal (24.4 +/- 3.4), but the waist: hip ratio was high (0.94 +/- 0.06) suggesting central obesity. This was well in accordance of the step II recommendations of the NCEP guidelines as regards their caloric intake and its break-up in terms of carbohydrate, protein and fat (including saturated, mono-unsaturated and poly-unsaturated fatty acids) content. Their daily cholesterol intake (31 +/- 32 mg/day, range 4-180) was very low. The total cholesterol (212 +/- 37 mg%) was marginally elevated, HDL cholesterol (33 +/- 7.5 mg%) was low, LDL cholesterol (148 +/- 39 mg%) was high and the total: HDL ratio (6.8 +/- 2.0) was significantly abnormal. The serum triglyceride level (154 +/- 68 mg%) was on the higher side of normal. These observations give further credence to the recently evolving view that there are different and hitherto unrecognised risk factors of IHD in Indians, who seem to have the highest incidence of IHD amongst all ethnic groups of the world despite consuming a diet low in fat and cholesterol content.

Pre-natal echocardiographic diagnosis and neonatal balloon dilatation of severe valvar pulmonic stenosis.

A case is presented below where pre-natal echocardiographic diagnosis of critical pulmonic valvar stenosis was made at 36 weeks of gestation. In view of the severe heart failure, successful balloon valvotomy was performed on day 4 of life. The child was asymptomatic at one month follow-up.

Is haemorrhagic myocardial infarction more common with streptokinase?

Autopsy reports and clinical data of 226 consecutive myocardial infarction deaths in whom postmortem studies could be carried out during the period 1980 to 1996 were analyzed retrospectively for the presence of haemorrhagic myocardial infarction (HMI). Of 53 autopsies done from 1980 to 1986 [prior to use of streptokinase (SK) therapy in our institution] none of the specimens showed haemorrhagic infarction. Of 173 autopsies done from 1987 to 1996 (intravenous SK therapy was utilised in this period), 20 specimens showed haemorrhagic infarctions. Sixteen of these 20 patients had received SK, while 66 of the remaining 153 non-haemorrhagic myocardial infarction patients received SK (statistically significant association of SK with HMI, p < 0.005). Acute mechanical complications [ventricular septal rupture (n = 10), papillary muscle rupture (n = 2), cardiac free wall rupture (n = 7)] were seen in 19 cases. Of these, 16 were HMIs and 14 of these patients had received streptokinase. These observations suggest a strong association of HMI with SK therapy and with acute mechanical complications.

Anthropometry, lipid profile and dietary pattern of patients with chronic ischaemic heart disease.

The anthropometry, lipid profile and dietary characteristics of 114 patients with chronic ischaemic heart disease (IHD) were evaluated. There were 91 (80%) men and the mean age was 56 +/- 9 years. The body mass index was near normal (24.4 +/- 3.4), but the waist: hip ratio was high (0.94 +/- 0.06) suggesting central obesity. This was well in accordance of the step II recommendations of the NCEP guidelines as regards their caloric intake and its break-up in terms of carbohydrate, protein and fat (including saturated, mono-unsaturated and poly-unsaturated fatty acids) content. Their daily cholesterol intake (31 +/- 32 mg/day, range 4-180) was very low. The total cholesterol (212 +/- 37 mg%) was marginally elevated, HDL cholesterol (33 +/- 7.5 mg%) was low, LDL cholesterol (148 +/- 39 mg%) was high and the total: HDL ratio (6.8 +/- 2.0) was significantly abnormal. The serum triglyceride level (154 +/- 68 mg%) was on the higher side of normal. These observations give further credence to the recently evolving view that there are different and hitherto unrecognised risk factors of IHD in Indians, who seem to have the highest incidence of IHD amongst all ethnic groups of the world despite consuming a diet low in fat and cholesterol content.

Balloon angioplasty for native aortic coarctation.

From May 1987 to August 1990, eighteen patients underwent balloon angioplasty for native aortic coarctation. The age of the patients ranged from four to fifty six years (mean age 17.5 years). The procedure was successful in all cases with a reduction in the peak gradient across the coarctation from 61 +/- 19 mm Hg to 11.7 +/- 8.1 mmHg (p < 0.05). The coarcted segment increased from 4.5 +/- 1.9 mm to 10.7 +/- 3.9 mm (p < 0.05). Peak gradient at six to twelve months follow up, obtained in ten patients, was 19.8 +/- 10.1 mmHg (p = NS). There were no life threatening complications, although seven patients had local vascular problems after the procedure. In two patients, there was persistence of hypertension necessitating drug therapy. On haemodynamic and angiographic restudy in 10 patients, one patient had restenosis and none had aneurysm formation. We conclude that balloon angioplasty is a safe, and less invasive alternative to surgery for native aortic coarctation with gratifying immediate and short term results.