Echinococcosis of the heart: clinical and echocardiographic features in 19 patients

We describe clinical and echocardiographic features in 19 patients with cardiac echinococcosis. Wide variability in the location and number of cysts inside cardiac cavities, septum, and pericardium is observed. The central role of two-dimensional echocardiography in making the diagnosis is stressed. This report has a significant clinical value in view of the large number of cases of a relatively rare condition.

Dyslipoproteinemias in atherosclerosis, thrombosis and restenosis after coronary angioplasty

Lipids play a vital role in normal metabolic function in mammals. However, dyslipoproteinemias have been implicated in the pathophysiologic process of atherogenesis, thrombogenesis and restenosis after interventional procedures. Lipoproteins provide important chemical linkages among these three complex phenomena. Lipoproteins participate in atherogenesis and play a major role in plaque fissuring, the pathophysiologic common denominator of acute ischemic syndromes. Thrombogenesis is majoraly affected by the action of lipids on platelets, coagulation and fibrinolysis. LDL tend to destabilize platelet membrane activity, macrophages, endothelial and smooth muscle cell function; HDL tend to reverse these abnormalities. The metabolism of arachidonic acid, a metabolite of the essential polyunsaturated lipoprotein, linoleic acid, is integral to platelet and endothelial cell membrane formation, via the cyclooxygenase-prostanoid pathway. Arachidonic acid also is metabolized by the lipoxygenase-leukotreine pathway in neutrophils and monocytes. The relationship of dyslipoproteinemias (increased LDL and Lp(a); decreased HDL) to restenosis after angioplasty has been reported, though there is not universal agreement about causality. Lipid lowering regimens and other pharmacotherapy have had favorable effect slowing the rate of atherogenesis, decreasing the frequency of cardiac events (perhaps by "stabilizing" vulnerable plaques) and causing regression in some atheromata. The salutary effect of lipid-lowering agents upon the incidence of restenosis after angioplasty is problematic. Some investigators have found a statistically significant correlation, while others have not; but studies have not been standardized. In conclusion, the study of lipid metabolism across a wide range of physiochemical activities and the interaction of these phenomena describe complex, genetically determined linkages which instruct (and often humble) investigators in their study of lipids in health and disease.

Multiple coronary artery aneurysms in an adult associated with extensive thrombus formation resulting in acute myocardial infarction: successful treatment with intracoronary urokinase, intravenous heparin, and oral anticoagulation

A 37-yr-old white female was admitted to hospital with an evolving anterior myocardial infarction. Coronary arteriography revealed multiple aneurysms in the left anterior descending (and right) coronary arteries. In the left anterior descending artery, there was evidence of extensive thrombus formation. The patient was successfully treated with intracoronary urokinase, intravenous heparin, and oral warfarin. There was partial thrombolysis in 16 hr and complete thrombolysis noted 6 wk later. This case of multiple coronary aneurysms, secondary to presumed Kawasaki disease, is the first documentation of antemortem intra-aneurysmal coronary thrombosis treated successfully by thrombolytic and anticoagulant therapy.

Coronary angioplasty in octogenarians: comparisons to coronary bypass surgery

Coronary angioplasty was performed in 74 patients 80 years of age and older (mean 83 +/- 3). Single vessel coronary disease was present in 34% and multivessel coronary disease in 66%. Angioplasty of a single vessel was performed in 51 patients (69%), while 23 (31%) had angioplasty of multiple vessels. Angioplasty was successful in 59 of 74 patients (80%). Angioplasty was unsuccessful but uncomplicated in 12 (16%) due to (unyielding) calcified lesions or (impassable) old occlusions. Of these 12, 8 were discharged on medical therapy and 4 underwent elective uncomplicated bypass surgery prior to discharge. Three (4%) patients required emergency coronary bypass surgery due to abrupt vessel closure during the angioplasty procedure, with one hospital death (1.4%). Follow-up (mean 24 +/- 22 months) was obtained in all patients. Of the 59 successful angioplasty patients, late mortality was 10% (cardiac 7% and non-cardiac 3%). Survival and survival without myocardial infarction were both 90%; survival without either infarction or bypass surgery was 86%. Actuarial 3-year survival was 91% and 3-year freedom from death, infarction or bypass surgery was 87% by life-table analysis. Repeat angioplasty for restenosis was performed in 7 patients (12%) without complications.

Unstable angina and coronary angioplasty

Of 2,122 consecutive patients undergoing elective coronary angioplasty from 1982 to 1985, 62% had stable angina pectoris (SAP), and 38% had unstable angina pectoris (UAP). There were differences between the two groups in clinical and morphological factors and in initial and late results of angioplasty. UAP patients were more likely than SAP patients to be smokers and to have had prior myocardial infarctions. Lesions in UAP patients were more severe, longer, more eccentric, more irregular, and more likely to have intracoronary thrombi than were lesions in SAP patients. Coronary angioplasty success was achieved in 84% of UAP and in 88% of SAP patients (p less than 0.05), and complications occurred in 6.7% of UAP and in 4.7% of SAP patients (p less than 0.05). Hospital death rates were low and similar, 0.2% for both groups. Follow-up (mean, 37 months) showed recurrent Canadian Cardiovascular Society (CCVS) class III/IV angina in 30.1% of UAP and in 25.2% of SAP patients (p less than 0.05). There was a return to work in 86% of UAP and in 91% of SAP patients (p less than 0.05). When UAP patients' durations of symptoms were further fractionated, it was found that the earlier angioplasty was performed after onset of angina, the lower was the success rate and the higher the complication rate and incidence of late follow-up untoward events. When coronary angioplasty was performed within 1 week of onset of angina ("early"), success was 79.1%; when angioplasty was performed 2 weeks or more after onset of angina ("later"), success was 86.3%. Major cardiac events occurred in 11.5% in the early group and in 4.8% in the later group (p less than 0.05).(ABSTRACT TRUNCATED AT 250 WORDS)

Cardiac surgery in patients over the age of 80 years

The risk-benefit relationship of open heart surgery in octogenarians is not well established. Eighty consecutive patients over the age of 80 who underwent cardiac operations under cardiopulmonary bypass were evaluated. Twenty-five patients were in functional class IV, 42 in class III, and 13 in class II. Forty-four patients had only coronary artery bypass grafts (CABG), 12 only aortic valve replacement (AVR), 6 only mitral valve replacement (MVR), 12 CABG and AVR, 4 CABG and MVR, 1 CABG and aneurysmectomy, and 1 had resection of left atrial myxoma. Operative mortality (within 30 days) was 12.5% for the group. Mortality was related to bleeding, left ventricular failure, primary ventricular fibrillation, pulmonary failure, and renal failure. Mortality was higher in patients with (1) advanced functional class, (2) mitral valve replacement, (3) postoperative hemorrhage, and (4) associated pulmonary disease. While a generally conservative approach is recommended for octogenarian patients, many with life-threatening cardiac disease, especially those free of major multisystem illnesses, should not be denied the benefit of surgical treatment.

Atrioventricular block in accidental hypothermia--a case report

The finding of second-degree and high-grade atrioventricular block in a patient with severe accidental hypothermia is described. Additional findings included atrial fibrillation, severe sinus bradycardia, and prominent J (Osborn) waves. This case represents, to the authors' knowledge, the first report of advanced spontaneous AV block not induced by atrial pacing in severe accidental hypothermia. Reversal of the block, and other characteristic changes, suggest a relationship to low temperature.

Sinus node suppression in acute strokes--case reports

The authors report on 5 patients, 4 of them observed over a period of only two months in one community hospital, who developed profound sinus node suppression in the early phase following acute strokes. This complication resulted in the death of 2; in the remaining 3, it was controlled by electrical cardiac pacing or intravenous atropine. In 3 patients, the strokes were due to subarachnoid hemorrhage, and in 2, they were secondary to vascular occlusion. In at least 4 patients, the prognosis seemed favorable from a neurologic standpoint. Vagally mediated sinus node arrest may, therefore, represent a potentially fatal complication of strokes and may be more frequent than currently appreciated. Continuous monitoring in the early phase of acute strokes and pacemaker therapy may be lifesaving in some patients. This and the general phenomenon of functional failure of the sinus node due to a variety of causes are discussed.

Sustained ventricular tachycardia associated with influenza syndrome in a young girl--a case report

Ventricular arrhythmias in children with no demonstrable heart disease are rare. In a thirteen-year-old girl, a typical influenza syndrome was complicated by sustained ventricular tachycardia. Exercise tests, echocardiography, electrophysiological studies, and endomyocardial biopsy were negative. Viremia, fever, or medications may be responsible for this unusual complication.

Ruptured abdominal aortic aneurysms: experience with 70 cases

During the period 1965-1983, 270 patients underwent resection of abdominal aortic aneurysm. In 70 patients (26%) the aneurysm was ruptured. Overall hospital mortality of patients with ruptures was 34%. Five patients died before the graft could be completed. Common denominators associated with mortality were hypotension, renal failure, cardiac arrest, and postoperative hemorrhage. The average age over the first 10 years was 68, but subsequently, has risen gradually, with a corresponding increase in mortality despite improved surgical technique and postoperative care. Only with more widespread elective resections and earlier diagnosis of rupture followed by prompt operative management, can the outlook for patients with abdominal aortic aneurysm be improved.

Iatrogenic left main coronary artery stenosis following PTCA or valve replacement

We report three patients who developed iatrogenic severe left main coronary artery stenosis. In two, it was secondary to coronary cannulation during aortic valve replacement and in one it followed distention of the artery during balloon dilatation of a proximal lesion in the left anterior descending artery. In all three, the stenosis was clinically manifest a few months after the intervention. All were successfully treated by aortosaphenous coronary bypass. A common mechanism for the three cases may be mechanical distention of the left main coronary artery resulting in intimal damage with secondary fibrosis and stenosis. The percutaneous transluminal coronary angioplasty-related stenosis is, to our knowledge, the first reported case of this nature, and represents a previously unrecognized complication of this procedure.

Risk of combined coronary artery bypass and mitral valve replacement

During a period of 6 years and 5 months, a group of 26 men and 16 women between 53 and 80 years of age underwent combined coronary artery bypass and mitral valve replacement. All patients were catheterized preoperatively, and hemodynamic and surgical variables were noted. In accordance with the variables, operative mortality was evaluated and compared among subgroups. Eight patients died, and the factors found to adversely change successful treatment were instability of ischemia, advanced New York Heart Association functional class, severe mitral regurgitation, associated aortic regurgitation, extensive coronary artery disease, the extent of left ventricular dysfunction as estimated by left ventricular end-diastolic pressure and ejection fraction, and elevated pulmonary vascular resistance. Prolonged operative time was also significant. The only variable that did not seem to influence mortality was the pathology type of mitral valve involvement. Analysis of our data confirms the high risk of coronary artery by pass combined with valve replacement for mitral regurgitation reported by others, and it appears advisable at present to exercise caution in recommending combined coronary artery by pass and mitral valve replacement in patients with extensive coronary artery disease and advanced left ventricular dysfunction. Pre-and postoperative utilization of afterload reduction, with the use of circulatory assist devices, may prove effective in some patients, and deserves special evaluation.

Carotid surgery without angiography

We propose that circumstances exist in which angiography is not necessary or is unwarranted for the diagnosis and treatment of carotid arterial disease. High quality real-time B-mode ultrasonographic imaging, combined with both pulsed gated, and continuous wave Doppler analysis, shows a remarkably close correlation with the pathologic abnormality identified at operation. Scanning in the vascular laboratory not only provides quick, noninvasive, accurate assessment of the atherosclerotic disease, it can also provide plaque and blood flow detail not previously attainable. Carotid surgery can be effectively and safely performed in selected patients with the aid of ultrasonography and Doppler analysis without the need for invasive angiographic imaging.

Surgical experience following percutaneous transluminal coronary angioplasty

Percutaneous transluminal coronary angioplasty (PTCA) was attempted in 600 patients, 97 of which were considered unsuccessful. Review of our surgical experience in a large series of these procedures helps to confirm some facts regarding the unique interaction between these two modalities of myocardial revascularization. Serious complications are still relatively common, even when PTCA is performed in centers with broad experience. While emergency operation is not required in all major complications, about 7% of patients need immediate surgical intervention, which is usually performed on unstable patients, and thus associated with increased morbidity and mortality. The combined incidence of major complications, such as coronary dissection, occlusion, and spasms, still approaches 20% of attempts. In contrast to other studies, surgical mortality and morbidity do not appear to be higher in our series of operations on patients with complicated PTCA than in coronary bypass operations in general. This fact may attest to our practice of alerting all surgical services in anticipation of problems. Our short complication-to-operation completion time, averaging 123 minutes, may be partially responsible for the good results. We conclude that standby open-heart services for PTCA are warranted in most hospitals; however, it should not be performed in hospitals without surgeons who are experienced in the practice of open-heart surgery.

Sequential internal mammary-coronary artery bypass

Since April, 1977, a total of eight patients have undergone sequential bypass grafting of the internal mammary artery (IMA) to the coronary arteries at our institution. The indication for this newly described procedure was either insufficient supply of adequate veins (four patients) or the presence of a diseased aortic wall (two patients). Operative procedures included left IMA bypass to the left anterior descending (LAD) artery and its major diagonal branch in six patients; to the obtuse marginal branch and distal circumflex artery in one patient; and to two consecutive sites on the LAD in one patient. All patients became angina-free after operation for a follow-up period lasting up to 6 years. Recatheterization studies were performed in four patients, in all of whom the IMA sequential grafts were found patent. We believe that IMA sequential grafting is an important option available to the cardiac surgeon in managing some patients with coronary artery disease.

Internal mammary coronary artery bypass surgery: experience with 1000 cases

A study of 813 men and 187 women who underwent internal mammary artery (IMA) bypass from 1976 to the present time is presented. In approximately 10% of patients, only the IMA was used for coronary artery bypass, and in approximately 90%, one to four saphenous vein grafts were used additionally. Hospital mortality in the series was 1.8%. The IMA, when properly selected and carefully harvested, is considered an excellent conduit for myocardial revascularization. Disadvantages include its limited application to the proximal portions of one (or two) coronary vessels, a relatively delicate and difficult anastomosis, and an allegedly high incidence of postoperative chest wall discomfort with pulmonary complications. However, this experience with IMA coronary artery bypass supports the view that it is an ideal conduit for the anterior wall when conditions permit its use.