Percutaneous catheter closure of the ductus arteriosus in children and young adults.

The double-disk occluding device suitable for use in infants and children with patent ductus arteriosus, developed by Rashkind and Mullins, has been available to this institution since December 1987 on an investigational basis. Results of 43 nonsurgical ductal closure attempts using this device in children and young adults between December 1987 and October 1988 are presented. Successful implantation was achieved in 42 patients (98%). In 25 patients a residual shunt was seen on angiography immediately after implantation. In 12 patients a residual ductal shunt was detected by Doppler 24 hours after implantation; 6-week follow-up studies showed a small residual shunt in only 3 patients. After a second occluder device was implanted in 2 of these patients, complete closure of the patient ductus arteriosus was achieved. In 1 patient, early in the series, the occluder device embolized to the left pulmonary artery, necessitating surgical removal at the time of ductus division. This event was the only serious complication; there were no deaths.

Surgical risk factors in total anomalous pulmonary venous connection.

Eighty-three patients underwent surgical correction of total anomalous pulmonary venous connection (TAPVC) between 1973 and 1986. There were 46 boys and 37 girls. Median age at operation was 60 days (1 to 240) and median weight 3.9 kg (1 to 22). The anatomic types encountered included infracardiac connection (16 patients), supracardiac connection (32) and pulmonary venous drainage connected directly to the coronary sinus (27). Mixed anomalous drainage or pulmonary venous return connected directly to the right atrium occurred in 8 patients. Diagnosis was established by cardiac catheterization and angiography (56 patients), clinical examination (3) and cross-sectional echocardiography alone in 24 of the last consecutive 28 patients. Pulmonary hypertension was present in 26 (55%) of those who underwent cardiac catheterization. The median pulmonary vascular resistance was 4.2 units/m2 (body surface area) for all the patients, whereas in those with infracardiac pulmonary venous connection the median value was 10 units/m2. The median interval between admission and operation was 72 hours. Surgical correction was performed using profound hypothermia and circulatory arrest in 68; for the remainder, conventional cardiopulmonary bypass with profound to moderate hypothermia was used. Ten patients developed 1 or more pulmonary hypertensive crises during the early postoperative period. These were diagnosed in 8 by direct pulmonary artery pressure measurement and in 2 by clinical examination. Late reoperation was necessary in 6 patients (10%). Analyses of risk factors for 30-day survival for all patients showed that the risk of early death was associated with the type of anomaly (infradiaphragmatic), occurrence of pulmonary hypertensive crises, year of the operation, set of the patient and pressure of preoperative congestive heart failure.(ABSTRACT TRUNCATED AT 250 WORDS)

Mechanism of mitral valve area increase by in vitro single and double balloon mitral valvotomy.

The mechanism of mitral valve area increase by double balloon mitral valvotomy in vitro has not been defined, nor have the mitral valve area results achieved by single versus double balloon mitral valvotomy technique been compared. After a selection of 29 intact mitral valves excised at cardiac surgery from patients with a mitral valve area less than or equal to 1.5 cm2 was made, double balloon mitral valvotomy was attempted in 14 valves using two 20-mm diameter balloon catheters (group 1) and single balloon mitral valvotomy using a 20-mm balloon was undertaken in 15 valves (group 2). In group 1 the mitral valve area increased from 0.9 +/- 0.03 to 1.9 +/- 0.05 cm2 (mean +/- standard error of the mean) (p less than 0.001), with a mean anterior commissural split of 5.3 +/- 0.2 mm and a posterior split of 4.1 +/- 0.2 mm. Following single balloon valvotomy (group 2), the mean mitral valve area increased from 0.8 +/- 0.03 to 1.2 +/- 0.03 cm2 (p less than 0.001), with the mean anterior commissural split being 2.6 +/- 0.2 mm and the posterior 2.1 +/- 0.2 mm. Ten mitral valves from group 2 underwent a second dilatation using the double balloon technique and the mitral valve area increased further from 1.2 +/- 0.06 to 1.9 +/- 0.06 cm2 (p less than 0.001). Overall, commissural splitting occurred preferentially in calcified commissures (81%), as opposed to only 56% of noncalcified commissures. Commissural splitting is the manner in which mitral valve area increases after double balloon mitral valvotomy.(ABSTRACT TRUNCATED AT 250 WORDS)

Aortic valve repair using bovine pericardium for cusp extension.

Aortic valve repair with the use of individually tailored bovine pericardial extensions to the native cusps was performed in 20 patients (mean age 22 years) with severe rheumatic aortic valve incompetence. After aortic valve repair, the diastolic pressures increased significantly from a mean (+/- standard deviation) of 49 +/- 14 to 73 +/- 8 mm Hg (p less than 0.001), and cardiac catheterization showed a marked reduction or total correction of the angiographic degree of aortic regurgitation. All the patients were free of symptoms over a mean follow-up period of 7.5 months (1 to 23 months); the first 11 patients have had a mean follow-up period of 12 months. Attention is called to this short period of follow-up. Aortic valve repair with the use of bovine pericardium for cusp extension may prove to be an effective method of treatment for rheumatic aortic valve incompetence.

Cardiac operations during active endocarditis.

Between December 1982 and March 1990, 65 patients with active infective endocarditis underwent cardiac operations. Their mean age was 28.6 years (range 1 to 65 years). The most common infecting organisms were staphylococcus (33.8%), streptococcus (18.5%), and brucella (16.9%); 11 patients (16.9%) had cultures negative for infection. A rheumatic, native valve, most commonly the aortic, was involved in 40 patients, a prosthetic valve (with the mitral most common) in 18 patients, and in seven patients the infection involved a congenitally abnormal valve. Aortic root abscess developed in 21.5% of patients. In 30 patients operation was performed within 3 days of the start of intravenous antibiotic therapy, usually within 3 days of admission (group A); this resulted in fewer preoperative complications and a significantly lower postoperative complication rate than in those 35 patients who underwent operations more than 3 days after starting antibiotic therapy (group B). Preoperative embolic phenomena occurred in eight (12.3%) of the 31 patients who had large, mobile vegetations (2/16 [12.5%] in group A and 6/15 [40%] in group B). Overall there was no reinfection. No postoperative paravalvular leaks developed in group A. Nine patients died in the hospital (13.8%) (four in group A and five in group B); in all patients the infecting organism was staphylococcal or fungal. There was one late death. Early operation should always be considered in active infective endocarditis, especially when a prosthetic valve is involved or the infecting organism is staphylococcal or fungal. The disclosure of moderate to large vegetations by two-dimensional echocardiography is an indication for operation.

Valve surgery in acute rheumatic heart disease. One- to four-year follow-up.

Six patients with acute rheumatic carditis and intractable left ventricular failure, all in class 4 NYHA classification, underwent successful valve surgery combined with medical therapy. Two-dimensional echocardiography and Doppler studies showed all of them to have left ventricular dilatation, with good systolic function, together with severe mitral regurgitation; two patients also had severe aortic regurgitation. Over a mean follow-up period of two years, no mortality was recorded, and all six patients were in NYHA class 1-2. We conclude that valve replacement is not contraindicated in acute rheumatic carditis and may be preferable to repair.

Antiplatelet drugs and the incidence of thromboembolic complications of the St. Jude Medical aortic prosthesis in patients with rheumatic heart disease.

The incidence of thromboembolic complications after St Jude Medical aortic valve replacement was evaluated in patients who received antiplatelet drugs alone (aspirin and dipyridamole). This report includes 107 consecutive patients undergoing aortic valve replacement with the St. Jude Medical prosthesis from February, 1980, until December, 1983. There were three perioperative deaths (2.8%). Thirty-seven of these patients received life-time warfarin anticoagulation and therefore were excluded from further analysis. The remaining 67 patients receiving antiplatelet drugs were followed up for 22 +/- 8 months (range 5 to 54 months) with a total observation period of 123 patient-years. Group 1 consisted of 52 patients having single St. Jude Medical aortic valve replacement (mean age 27 +/- 10 years). Group 2 included 15 patients having St. Jude Medical aortic valve replacement with additional mitral valve replacement (mean age 27 +/- 11 years). There were no postoperative embolic events in Group 1, but two St. Jude Medical aortic prostheses became thrombotic (2.1 per 100 patient-years) 19 and 32 months after the operation. Emergency aortic valve replacement was done in one of these patients and aortic thrombectomy in the other. Both patients are alive and doing well. In Group 2, three patients (10 per 100 patients-years) had thrombosis of the St. Jude Medical aortic valve 10, 12, and 30 months after the operation, and two of them required emergency aortic value replacement. One of these patients also had a massive left coronary embolus and could not be weaned from cardiopulmonary bypass. The third patient, who was asymptomatic, was prescribed warfarin anticoagulation and has been well. None of the seven patients in this group with St. Jude Medical aortic and mitral prostheses has had a thromboembolic event. These results indicate that antiplatelet drugs alone are associated with a very low risk of embolism but are insufficient to prevent thrombosis of St. Jude Medical aortic valves, even when the patients have sinus rhythm.

Brucella infective endocarditis. Successful combined medical and surgical therapy.

Five cases of Brucella infective endocarditis are described involving a native aortic valve, two native mitral valves, a mitral valve bioprosthesis, and a ventricular septal defect patch. The diagnosis of Brucella infective endocarditis was established from the clinical features, with a high Brucella serologic titer in each case. Blood and tissue cultures were positive in four of five patients. Two-dimensional echocardiograms demonstrated moderately large vegetations on the three affected native valves and the patch and also revealed the development of vegetation on the mitral bioprosthesis as the disease progressed. All the patients were successfully treated by combined surgical and medical therapy, the latter consisting of co-trimoxazole, tetracycline, and streptomycin/gentamicin for 6 weeks; the affected valves and the ventricular septal defect patch were all replaced. There were no operative deaths and there has been no recurrence of infection to date. One patient died suddenly of an unknown cause 1 year after the operation.

Management of Brucella endocarditis with aortic root abscess.

Three cases of Brucella endocarditis with aortic root abscess are reported. Two patients were successfully managed by a combination of medical therapy and surgery. The third patient died suddenly 36 hours after admission to hospital.

Does aprotinin increase the myocardial damage in the setting of ischemia and preconditioning?

BACKGROUND: Aprotinin reduces postoperative bleeding in cardiac operations, but its association with perioperative myocardial infarction remains controversial. Ischemic preconditioning is a novel method of myocardial protection. METHODS: To answer whether aprotinin increases postischemic myocardial damage and also to characterize the effect of aprotinin on ischemic preconditioning, four groups of sheep were fully heparinized to keep activated clotting time readings greater than 750 seconds and subjected to 60 minutes of normothermic regional ischemia (diagonal artery occlusion) with 3 hours of reperfusion. Group I was the control with no treatment, group II received aprotinin (1 million KIU load followed by 250,000 KIU/h), group III underwent ischemic preconditioning (three 5-minute intervals of ischemia and reperfusion) before prolonged 1-hour ischemia, and group IV underwent similar ischemic preconditioning and received aprotinin. Area at risk was delineated by monastryl blue pigment, and infarction size by tetrazolium staining. RESULTS: The ratios of weight of area at risk to left ventricular weight and left ventricular weight to body weight were constant between groups. Infarction size to area at risk ratio data demonstrated that aprotinin increases infarction size by 60% (infarction size to area at risk ratio from 52% +/- 10% to 84% +/- 10% for I versus II; p < 0.001). Aprotinin also attenuates the protective effect of ischemic preconditioning (infarction size to area at risk ratio from 25% +/- 4% to 41% +/- 6%; p < 0.001). CONCLUSIONS: In the setting of ischemia, aprotinin increases myocardial damage. If, however, the heart is provided with protective preconditioning, then the deleterious effect of aprotinin may be neutralized. From these data we suggest that aprotinin should not be used routinely in cardiac operations unless extensive blood loss is anticipated, such as in redo open heart operations.

Effect of the administration of recombinant activated factor VII (rFVIIa; NovoSeven) in the management of severe uncontrolled bleeding in patients undergoing heart valve replacement surgery.

Recombinant activated factor VII (rFVIIa; NovoSeven, Novo Nordisk A/S, Bagsvaerd, Denmark) is being increasingly used to secure haemostasis in difficult clinical situations. The role of rFVIIa in the treatment of patients undergoing open-heart surgery for valvular heart disease was evaluated in an open pilot study. Study objectives included evaluation of blood loss, haemostatic effect and safety and laboratory parameters following rFVIIa administration. To date, we have treated five patients (one child aged 2.5 years and four adults) undergoing surgical procedures including arterial switch, closure of atrial septal defect and De Vega's procedure (mitral valve replacement with tricuspid valve repair). Four patients received rFVIIa intraoperatively, while the fifth received it postoperatively. Satisfactory haemostasis was achieved with a single dose (30 microg/kg) of rFVIIa. Four hours after treatment mean blood loss was 262.5 ml for adults (220-334 ml) and 85 ml for the child. No significant adverse events were reported. Laboratory parameters indicated a mean 18.5-fold (range 3.7-42) increase in FVII levels at 30 min postinjection and a mean reduction of 12 s (range 3-39 s) in prothrombin time. In conclusion, rFVIIa represents an effective and well-tolerated treatment for serious bleeding episodes both during cardiac surgery and postoperatively.

Coronary bypass surgery in patients with Sheehan's syndrome.

We present a small series of patients with Sheehan's syndrome (postpartum panhypopituitarism) and coronary artery disease. All four had uneventful coronary bypass grafting. We have successfully managed these patients peri-operatively by using intravenous hydrocortisone and oral thyroxin replacement.

Frequency of occurrence of cytomegalovirus and Chlamydia pneumoniae in lymphocytes of atherosclerotic patients.

Forty-three blood samples from atherosclerotic donors and 28 samples from normal individuals were analyzed to determine the frequency of occurrence of cytomegalovirus (CMV) and Chlamydia pneumoniae DNA sequences in lymphocytes of Saudi Arabian donors using Polymerase Chain Reaction (PCR). In non-atherosclerotic donors, no CMV DNA was detectable and only one sample was positive for C-pneumoniae DNA sequences. Of the 43 atherosclerotic patients, 22 were infected with CMV, 23 were infected with C-pneumoniae and 11 showed no infection. Thirteen of the 43 donors showed simultaneous infection with both CMV and C-pneumoniae. These results demonstrate that atherosclerotic patients are more frequently infected with CMV or C-pneumoniae or both.

Total correction of tetralogy of Fallot--retrospective study of early morbidity and mortality.

Records of 165 patients who underwent total correction for Tetralogy of Fallot were analysed for early postoperative morbidity and mortality in the Intensive Care Unit. Eighty three patients (50.3%) had one or more pulmonary complications; 18 (10.9%) developed an infection; 10 (6%) developed acute renal failure requiring peritoneal dialysis; 9 (5.5%) required Total Parenteral Nutrition; there was no intraoperative death, but 6 patients (3.5%) died in the Intensive Care Unit, 4 of them aged < = 24 months. Patients aged < = 24 months at surgery (Group I) showed a significant increase in the incidence of pulmonary complications, infection and longer length of ICU stay compared to those aged > 24 months (Group II). Patients with a bypass time > 120 minutes had significantly more pulmonary complications (63.8%), compared to those < = 120 minutes (34.4%); the longer bypass time group had significantly more pulmonary complications (78%) in patients aged < = 24 months at surgery compared to those aged > 24 months (50%).

Orthotopic heart transplantation in the prince sultan cardiac center.

In this report we attempt to demonstrate the efforts involved in establishing and organizing the heart transplant program at the Armed Forces Hospital in Riyadh, Saudi Arabia. From 1986 to date, 25 orthotopic heart transplants were performed at this center. Patient age ranged from 22 months to 57 years; 4 patients were below 12 years of age and 4 aged 50 years and above. The incidations for transplantation were cardiomyopathy in 15 patients, ischemic heart disease in 6 patients, and valvular heart disease in 4 patients. Fourteen recipients have died. Three of them were classified as hospital deaths, occuring before the patient could be discharged after the procedure; the reminder died from rejection and associated problems. Eight patients of them died within the first year. The longest survival period was almost 8 years. The overall 8 years survival rate was 45%, which is comparable to the international figures. Shortage of donors may affect the future of the transplant programs. Increasing the awareness of the public about the importance of organ donation and transplantation is crucial in this regard.

Percutaneous double-balloon mitral valvotomy for rheumatic mitral-valve stenosis.

Percutaneous transatrial mitral valvotomy with a double-balloon technique produced striking symptomatic improvement in 7 of 9 patients with severe mitral stenosis. In 7 patients the mitral valve area (Gorlin formula) increased significantly and the mitral end-diastolic gradient fell significantly. Similar improvements were noted in follow-up haemodynamic studies at 6 weeks. There were no procedure-related complications. It is concluded that percutaneous double-balloon mitral valvotomy may be an alternative to surgical treatment for mitral stenosis.

Traumatic papillary muscle dysfunction: attempted mitral-valve repair and eventual prosthetic replacement.

A previously healthy young man sustained a deceleration chest injury. Severe mitral regurgitation was confirmed by Doppler and cardiac catheterisation. The mitral valve and subvalvular apparatus appeared normal at the subsequent surgery. Papillary muscle dysfunction was considered to be the principal cause of the regurgitation. Mitral-valve repair failed to preserve the competence of the valve, leading to successful mitral-valve replacement. Histology of the papillary muscle showed necrosis, confirming the original diagnosis. Post-traumatic papillary muscle dysfunction is concluded to be one of the cause of severe mitral regurgitation. Appropriate treatment is valve replacement rather than attempting conservative management.

Mediastinitis due to Mycobacterium fortuitum infection following Fontan operation in a child.

Here we report a case of mediastinitis due to Mycobacterium fortuitum infection in a child after a Fontan operation. To our knowledge this is the first report of atypical mycobacterial mediastinal infection after congenital heart surgery. Atypical mycobacteria can be the cause of "culture negative" sternal and thoracotomy wound infections. A brief review of the literature is included in the discussion.

Repair of the mitral valve because of pure rheumatic mitral valvar incompetence in the young.

Between January 1985 and April 1994, 42 children aged between 7 and 14 years (mean 11.3 years) underwent repair of severely incompetent rheumatic mitral valves with no accompanying mitral stenosis. In 19 patients the tricuspid valve was severely incompetent, while 8 patients had severe aortic incompetence. Overall, the repair incorporated shortening of elongated tendinous cords and insertion of a Duran or Carpentier prosthetic ring. The repair was the sole procedure in 15 patients, whilst 19 patients also had a De Vega tricuspid valvar annuloplasty and 8 had repair or replacement of the aortic valve. There were no hospital deaths. Postoperative transthoracic echocardiographic studies revealed trivial residual mitral valvar regurgitation in 6 patients, mild regurgitation in 18, moderate in 15, and regurgitation severe enough to warrant replacement of the mitral valve in 3 patients. The mean follow-up period was 37 months (maximum 120 months, minimum 1 month). Of 39 patients followed-up, 28 attended for more than 5 years. Of these, 7 underwent replacement of the mitral valve for severe regurgitation within 4 years of the repair. Severe mitral regurgitation in 3 patients was controlled by medical therapy. One was eventually lost to follow-up, and one patient died of causes unrelated to surgery. The remaining 16 patients had absent to moderate mitral valvar regurgitation. These results contrast with 10 repairs of congenital mitral incompetence, where no patients required re-operation in the immediate 5 years period of follow-up. Every effort should be made in children with rheumatic mitral incompetence to preserve the natural valve by conservative repair, despite the fact that repair of the incompetent rheumatic mitral valve is not so durable as repair of congenitally incompetent valves.