Acute aortic regurgitation due to spontaneous rupture of a bicuspid aortic valve: detection by echocardiography.

A 42-year-old man was admitted with acute severe aortic regurgitation. There were no signs of a systemic infection. M-mode and two-dimensional echocardiography revealed bicuspid aortic valve and echocardiographic features consistent with aortic leaflet rupture. The diagnosis was confirmed at surgery. This report illustrates that spontaneous rupture of a bicuspid aortic valve should be considered in acute aortic regurgitation without infective endocarditis.

The Monostrut prosthetic valve. Predictors for valve-related events during an eight years' experience.

All postoperative complications, including transient ischaemic attacks (TIA) and cerebrovascular accidents (CVA) of 259 patients, in whom a total of 301 Monostrut tilting-disc valves were implanted between January 1985 and December 1991 were evaluated retrospectively. The follow-up was maximally 8 years, with a mean of 3.5 years, and totaled 914 patient-years. In this study we found no mechanical deterioration of the Monostrut valve and demonstrated the elimination of valve thrombosis in patients receiving adequate anticoagulation. The actuarial probability of being free of thrombo-embolism was 94.7% +/- 1.7% and free of anticoagulant related hemorrhage 95.4% +/- 1.5% at 8-years. In comparison with earlier reports by others, our findings show a lower ratio of thromboembolic and hemorrhagic events. We demonstrated a correlation (p < 0.05) between thrombo-embolic and hemorrhagic complications. In addition, a lower incidence of CVA's (0.22 per 100 patient-years), but a higher incidence of TIA's (0.66 per 100 patient-years) in comparison with the general Dutch population was found. At eight years follow-up, all patients were in Class I or II of the New York Heart Association Classification. Although the overall valve related event-free survival at eight years was only 47.9%, 93.5% of the patient were satisfied with their operative result. Predictive factors for late mortality were the occurrence of paravalvular leakage (p < 0.01), the age of the patient at the time of operation (p < 0.01) and the number of diseases coronary arteries (p < 0.01).(ABSTRACT TRUNCATED AT 250 WORDS)

Efficacy and safety of a blood conservation program including low-dose aprotinin in routine myocardial revascularization.

OBJECTIVES: We attempted to analyze the efficacy and safety of an extensive blood saving program applied in a large cohort of patients. MEASURES: Blood saving included reinfusion of intraoperative predonated blood, aprotinin (2 million KIU) in the prime solution, reinfusion of any residual volume, postoperative acceptance of normovolemic anemia (hematocrit > or = 25%) and autotransfusion of shed blood. SETTING, EXPERIMENTAL DESIGN AND PATIENTS: In our general hospital with a heart surgery service (1150 cases/year), we studied the records of 527 non-selected consecutive patients, who were prospectively treated with this program being applied in primary myocardial revascularization between. RESULTS: We avoided the use of donor blood in 86.9% of the patients requiring a mean of 0.2+/-0.01 unit of donor blood per patient. No repeat thoracotomy for bleeding was needed in any patient. Univariate analysis revealed that female gender, a low level of hematocrit, high age, a small stature, weight, body surface area, and red cell volume prebypass significantly (p<0.001) were correlated to treatment with donor blood. Multiple regression showed that a small red cell volume and a low prebypass hematocrit were the most (p<0.0001) significant predictors for the use of donor blood. Observing a low incidence of morbidity (myocardial infarction, gastrointestinal, neurological thromboembolic, renal and wound complications), the safety of this program seems to be emphasized. CONCLUSIONS: Extensive blood saving including low-dose aprotinin reduced effectively and safely the need for donor blood in a large cohort of patients.

Mechanisms of spinal cord injury after cross-clamping of the descending thoracic aorta.

Cross-clamping of the descending thoracic aorta for surgical correction of coarctation carries a risk of injury to the spinal cord, which is usually attributed to insufficient blood supply along the spinal arteries. To detect inadvertent interruption of spinal cord perfusion, lumbar pressure was monitored during operation on the aorta in eight patients. One patient incurred ischemic damage of the spinal cord, resulting in paraparesis. In this patient, spinal fluid pressure increased to such high levels that it may have caused tamponade of the cord. The pressure increase resulted from expansion of cerebral vessels caused by an acute rise of arterial pressure after clamping, probably aggravated by the administration of a vasodilating drug. During operations in which the circulation of the spinal cord is compromised long enough to cause ischemic damage, the femoral artery and spinal fluid pressures should be monitored. If the pressure difference between femoral artery and lumbar cavity drops to a dangerously low level, a shunting procedure should be performed.

Muscle oxygen tension, hemodynamics, and oxygen transport after extracorporeal circulation.

In eight patients who underwent elective coronary bypass operation, skeletal muscle PO2 was measured with a polarographic needle electrode as an index of peripheral tissue perfusion to study recovery after extracorporeal circulation. Measurements of skeletal muscle PO2 and O2 supply to the tissues were obtained immediately after ICU admission and after 2, 4, 8, and 16 h. During the first 2 h, mean arterial BP was high, mixed venous PO2 decreased, the arteriovenous O2 difference increased, and skeletal muscle PO2 decreased. The P50 of the O2 dissociation curve on ICU admission was decreased and thereafter increased to a maximal value at 8 h, and normalized again after 16 h. After the initial decrease, the median of the skeletal muscle PO2 returned to normal values, but decreased again after 16 h. The results showed that, during the first 4 h postoperatively, microcirculatory changes occurred despite normal cardiovascular and respiratory variables.

Acute myocardial ischaemia and cardiogenic shock after percutaneous transluminal coronary angioplasty; risk factors for and results of emergency coronary bypass.

Between 1 September, 1980 and 1 January, 1989, 4142 patients underwent percutaneous transluminal coronary angioplasty (PTCA). We retrospectively studied the 155 [3.7%; 119 males, mean age 53.4 years, (range 33-78 years) and 36 females, mean age 59.6 years (range 40-74 years)] who required urgent coronary artery bypass grafting (CABG) (Group I) and a select control group of 155 patients, in whom PTCA was performed without complications (Group II). Before PTCA, 14 Group I and 42 Group II patients had angina Class II, and 78 Group I and 49 Group II patients had angina class IV (chi 2-test, P less than 0.05). There were 445 complications in the 155 group I patients: 303 (68%) early (during PTCA) and 141 (32%) late (within 24 h). On arrival in the operating room 126 patients were stable; five were in cardiac arrest and 19 in cardiogenic shock (AS-group; 24 patients). In the AS-group and control group, respectively, angina Class II occurred in 2/24 (8.3%) and 42/155 (27.1%) patients, angina Class IV in 14/24 (58.3%) and 49/155 (31.6%) (P less than 0.05), single-vessel disease in 8/24 (33.3%) and 85/155 (54.8%), triple-vessel disease in 7/24 (29.2%) and 23/155 (14.9%) (P less than 0.05); elective PTCA in 11/24 (45.8%) and 92/155 (59.4%), urgent PTCA in 12/24 (50%) and 48/155 (30.9%) (P less than 0.05), PTCA of the left anterior descending artery (LAD) in 18/24 (75%) and 86/166 (51.8%), PTCA of the right coronary artery in 2/24 (8.3%) and 47/166 (28.3%) (P less than 0.05).(ABSTRACT TRUNCATED AT 250 WORDS)