[Outcome and monitoring of children following cardiac surgery]

The spectacular advances in the surgery for congenital heart disease in children and infants have led to the appearance of a new pathology, late complications which warrant a systematic cardiological surveillance, to allow the patient to lead as normal a life as possible, compatible with the potential sequelae of this type of surgery. These complications arise essentially after ventricular open heart surgery, especially for tetralogy of Fallot and for interventricular communications. The ventricular function may be altered, even if the functional status appears to be good, so it must be systematically monitored, in particular by isotope methods. Arrhythmias and conduction disorders require special attention as they are often delayed in their appearance and can be serious, even causing sudden death, hence the value of electrophysiological investigations and, more especially, Holter monitoring and stress tests. The problems are even more complex when the operation was only aimed at a physiological correction, especially after operations for complete transposition of the great vessels and so-called "ortho-terminal" operations for tricuspid atresia or a single ventricle. In these cases, as well as ventricular dysfunction, we also see arrhythmias which can sometimes be severe, requiring anti-arrhythmic treatment and sometimes electro-systolic pacing.

[Psychological aspects of the rehabilitation of patients after the surgical treatment of heart defects]

Modern methods of clinico-psychological examination employed in 726 patients with heart diseases disclosed psychopathological changes in 18.7% of patients with congenital and in 82.1% of cases with acquired heart diseases. Oeration with extracorporeal circulation had no detrimental effect on the psychic development of children. Some psychic deviations were encountered in patients after correction of heart diseases, in particular, a cardioprosthetic psychopathological syndrome in patients with artificial heart valve prostheses. Patients who undergo operation for a heart disease require purposeful psychic rehabilitation. The methods and the main principles of such rehabilitation are described and its efficacy is demonstrated.

[Rehabilitation in various types of heart diseases]

The occasions on which reevaluation, re-establishment, readaptation, and rehabilitation in the true sense should be used are discussed, and the concept of both psychological and physical rehabilitation as an indivisible whole is underscored. It is also made clear that rehabilitation must not be limited to the heart patient himself, but be seen as the reintegration of the subject (and not the object) of rehabilitation in his family, social, occupational and recreational environment. Rehabilitation begins during hospitilisation and short- or long-term programmes are prepared. Full rehabilitation requires readjustment of the patient's surroundings and the removal of preconceptions and misunderstandings that may often make communication dramatically impossible.

[Method of early activation of patients after heart surgery]

Methods employed in an early activation of patients operated on a "closed" heart and under extracorporeal circulation are described. The authors began activating theri patients 2--3 hours after surgery and 16--20 hours therafter inst tuted a physical effort test (walking) over a distance of 50--100 m for 2.5--5 minutes). It was shown that the re-establisment of the hemodynamics indices, factors of external respiration and internal environment in patients managed post-operatively in accordance with the routine methods took much longer time than with the active method of managing the early post-operative period. The abolishment of a protracted hypodynamia regimen against the background of a quick normalizatiion of homesotasis is conducive to an earlier adaptation of patients to new conditions reduces the incidence of post-operative complications and curtails the patients' staty in hospital.

[Medical rehabilitation of patients having undergone cardiovascular operations]

Among the measures of medical rehabilitation of patients who survived cardiovascular surgical procedures an important place belongs to the problems of physical readaptation. Its degree is determined by exercise tests, among which veloergometry has gained wide recognition. The methods of bicycle tests are discussed with reference to this category of patients. A study of the exercise tolerance and of the nature of the response conducted according to several cardiovascular functional indices in patients following closed mitral commissurotomy and surgical correction of non-cyanotic congenital heart diseases indicated that a certain discrepancy exists between the commonly accepted evaluation of the results of surgery and the degree of physical readaptation. The latter depends on several factors: the duration of the history of the disease, relapse of rheumatism, pulmonary hypertension, atrial fibrillation. In order to evaluate the effect of physical training on the degree of readaptation a comparative study is necessary between the rehabilitation group and a "control" group. In patients operated for symptomatic hypertension (renovascular, adrenal, coarctation of the aorta) the assessment of the results of surgery should not be limited by the determination of the decrease or normalization of the arterial pressure alone, but should be supplemented by a general clinical evaluation of the state of the patients. Rational hypotensive therapy significantly improves the results of surgery. The exercise tests permit to establish the functional reserves of the patients, to properly determine the tactics of their treatment and their occupational prognosis.

[Evaluation of physical adaptation of patients after surgical correction of congenital non-cyanotic heart defects]

A successful surgical correction of congenital non-cyanotic heart diseases (patent arterial duct, ventricular and atrial septal defects, isolated pulmonary stenosis) results in full normalization of the haemodynamics. But the long-lasting existance of the pathology, the limited phsical activity of the patient result in the development of a state of lack of training. In such cases the degree of the physical adaptation of the patient after surgery had to be assessed which will permit to determine the program of his physical rehabilitation. The studies conducted by means of bicycle tests and running on the spot with recording the pulse rate, respiration rate, arterial pressure and ECG have demonstrated that the degree of the physical adaptation of the patients varies, although the general results of surgery are qualified as good. No correlation of this adaptation with the clinical factors could be revealed in this study. Further investigations are necessary in order to take into account the effect of the training regimens on the degree of physical rehabilitation.

Rehabilitation following cardiac surgery

Of 120 vocational rehabilitation clients having cardiac surgery between July, 1966 and December, 1968, seven were lost to follow-up, and the operative and late mortality totaled 14%. Ninety-six patients were seen for voluntary outpatient evaluation with a mean postoperative evaluation time of 22 months. Two-thirds of the patients had acquired heart disease and were in functional class III or IV preoperatively. After surgery 76 were in functional class I or II with 20 in functional class III. The electrocardiogram and radiographic heart size had returned toward normal in over 50%, and 76% of those having preoperative exercise tests demonstrated improved exercise capacity postoperatively.

The rehabilitation effort was successful in 83% of those surviving surgery and 77% of the entire series. Medical and surgical physical factors were found to be more important than psychosocial factors in determining the vocational outcome after surgery. The duration of unemployment was the most important preoperative variable in predicting the rehabilitation result. The importance of medical follow-up after cardiac surgery is emphasized by the detection of a significant number of residual medical problems.