Coarctation of the aorta: review of 362 operated patients. Long-term follow-up and assessment of prognostic variables

362 patients operated upon for coarctation of the aorta from 1961-1980 were analyzed retrospectively. Age at operation was <2 years in 74 (group A ) and ≧2 years in 288 patients (group B). Associated cardiovascular malformations were common, especially in group A patients. Early mortality was 12-2% for group A and 1-4% for group B patients. 336 patients were followed for 6 months to 21 years (mean 8.9 years). Late mortality was 0.8% per patient year. Associated cardiac defects and postoperative hypertension were responsible for most of the late deaths. Late reoperations were performed because of aortic valve disease, residual coarctation (with persistent hypertension) and aortic aneurysms at the site of anastomosis. The incidence of hypertension decreased from 82.5% preoperatively to 33.5% at discharge from the hospital. It decreased further during follow-up in patients operated <10 years of age, but remained constant in the older patients. In conclusion, morbidity and mortality after operative repair of coarctation are determined mainly by (1) associated cardiac malformations, and (2) postoperative hypertension. Patients with isolated coarctation and postoperative normal blood pressure have an excellent prognosis. Patients operated upon from between 2-9 years of age carry the lowest risk for residual coarctation and late postoperative hypertensio

Isolated aortic valve replacement with the Björk-Shiley tilting disc prosthesis and the porcine bioprosthesis

Between 1977 and 1978, 239 patients underwent aortic valve replacement with either a bioprosthesis (100, BIO) or a Björk-Shiley tilling disc prosthesis (139, BS). Early mortality was 2%, late mortality 4%. There was no statistically significant difference between the two groups. Anticoagulation was maintained indefinitively in patients with a BS, after implantation of a BIO only for three months except in the presence of atrial fibrillation or a history ofeinboli. Thromboembolic complications and anticoagulant hemorrhages were almost twice as frequent in patients with BS than with BIO (5.3 versus 2.8 episodes/100 patient years). This difference however is statistically not significant. There were an equal number (two) of reoperations because of paravalvular leaks due to endocarditis or torn sutures in the two groups. A regurgitant murmur, though hemodynamically not significant, occurred more frequently in patients with BIO than with BS (10% versus 2%, P < 0.05). Its cause and importance cannot yet be determined. Postoperative results judged by the NYHA classification and reduction of heart size were similar in both groups. Of all patients, 13% with preoperative valvular incompetence and 15% with stenosis showed little or no reduction of the cardiothoracic ratio on X-ray indicating a worse long-term prognosis. The porcine BIO has become our preferred valvular substitute because of its low thromboembolic complication rate. The BS is mainly reserved for patients already on anticoagulants for other reaso

Echocardiographic findings late after myectomy in hypertrophic obstructive cardiomyopathy

Postoperative echocardiograms of 50 patients undergoing myectomy for hypertrophic obstructive cardiomyopathy between 1965 and 1982 have been evaluated. In 21 patients a comparison with preoperative echocardiograms showed that postoperatively there was a significant reduction of septal and free wall thickness, an increase of left ventricular end-diastolic as well as outflow tract dimensions and a reduction or disappearance of systolic anterior motion of the mitral leaflet. Postoperative examination at intervals > 3 years revealed a significant increase of left ventricular and left atrial cavity size with unchanged contractile parameters and little reduction of left ventricular hypertrophy. In 4of 12 patients evaluated > 8 years after myectomy, left ventricular dilatation was observed and 3 of these 4 patients developed congestive heart failure. Development of leftventricular dilatation was independent of whether a transventricular and/or transaortic approach was used for myectomy. These data indicate that the late course after myectomy in hypertrophic obstructive cardiomyopathy may be complicated by dilatation of the left ventricular cavit

Does exercise-induced myocardial ischaemia cause enhanced platelet activation and fibrin formation in patients with stable angina and severe coronary artery disease?

In this study, betathromboglobulin (BTG) and fibrinopeptide A (FPA) in peripheral venous blood were measured in 20 patients with stable angina pectoris before and immediately after exercise-induced myocardial ischaemia; in 5 of the 20 patients stable angina was associated with typical peripheral artery disease. A total of 10 patients with angiographically documented peripheral artery disease without angina and 10 normal volunteers were taken as control groups. BTG and FPA in the 15 patients with stable angina before exercise were 41±14 ng ml-1 and 2.3±09 ng ml-1 and were not statistically different from the values in normal controls; after exercise-induced myocardial ischaemia no significant increase occurred in these patients. Conversely, in the 5 patients with stable angina associated with peripheral artery disease BTG and FPA before exercise were 6l±10 ng ml-1 and 3.5±0.8 ng ml-1 and increased to 114±14 ng ml-1 (P<0.001) and 4.l±0.5 ng ml-1 (P<0.01): These results were similar to those found in the 10 patients with isolated peripheral artery disease. We conclude that BTG and FPA in peripheral venous blood in patients with stable angina are not elevated either at rest or after exercise-induced myocardial ischaemia. Elevated values of BTG and FPA in patients with stable angina may reflect a major interaction between blood and atherosclerotic vessel wall, suggesting the presence of associated atherosclerotic lesions in peripheral artery diseas

Surgical treatment versus medical treatment in hypertrophic obstructive cardiomyopathy

Sixty-three patients operated upon for HOCM and 49 patients selected for non-surgical treatment have been followed-up for 15 years. Pre-operatively, surgical patients had a higher left ventricular outflow tract gradient at rest and, on the average, more severe symptoms than non-surgical patients. Septal myectomy relieved the pressure gradient and symptoms more consistently than long-term treatment with β-blockers or verapamil. Within an average observation time of 7½ years, there was late deterioration or death in almost half of the non-surgical patients but in less than one-quarter in the operated patients. The 10 year mortality rate was 80% in the surgical series and 71% in the non-surgical series. In operated patients, pre-operative symptomatic status was significantly related to early and late mortality. In medically treated patients, mortality was unrelated to symptoms; however, it was significantly lower in patients receiving long term treatment with β-blockers or verapamil. In conclusion, a high basal pressure gradient associated to limiting symptoms is a clear-cut indication for surgery. Other indications are more debatable. In medically treated patients, long-term administration of β-blockers or verapamil is beneficial even without symptoms as it appears to improve prognosi

Early results after mitral valvuloplasty for pure mitral regurgitation

In this study we present the results of 105 consecutive patients with pure mitral regurgitation who underwent surgical treatment. In all patients mitral regurgitation was associated with mitral valve prolapse: 54 patients underwent mitral valvuloplasty and 51 patients mitral valve replacement. Clinical assessment and echocardiography were used as follow-up criteria at one year after surgery. After mitral valvuloplasty, NYH A decreased from 2.7±0.8 to 1.1±0.7 (P<0.01) and workload capacity increased from 65±28% to 96±25% (P<0.001); left endsystolic atrial dimension and enddiastolic dimension decreased from 6.2±0.8 to 4.8±1.2 cm (P<0.001) and from 7.2±1.3 to 5.9±0.8 cm (P<0.01); ventricular contraction fraction did not change significantly. After mitral valve replacement, clinical and echocardiographic improvement was significant but less remarkable than after valvuloplasty; ventricular contraction fraction fell from 39±7% to 29±8% in contrast to patients undergoing mitral valvuloplasty in whom no significant change occurred. Complications were rare in both groups though only a minority of patients undergoing mitral valvuloplasty received anticoagulants. We conclude that mitral valvuloplasty in patients with pure mitral regurgitation associated with mitral valve prolapse gives excellent results, particularly regarding left ventricular function when compared with the patients after mitral valve replacemen

Platelet inhibitors versus anticoagulants for prevention of aorto-coronary bypass graft occlusion

The effects of the antiaggregant substance ticlopidine and of the anticoagulant acenocoumarol on patency rates of aorto-coronary bypass grafts were compared in a prospective randomized trial. Ticlopidine, 250 mg b.i.d. was administered orally from the first postoperative day till angiography, while anticoagulation with acenocoumarol was initiated on the second to third postoperative day. Side-effects of ticlopidine were rare and patient management with the standard dosage of this drug was easier than oral anticoagulation. From an initial group of 166 randomized patients 149 completed the trial by coronary angiography three months postoperatively. The 78 patients in the ticlopidine group showed a compliance of 85%. The average prothrombin time in the 71 patients receiving acenocoumarol was 26.9%. Detailed statistical analysis of the two study groups revealed no reason to doubt the correctness of randomization. Coronary angiography showed an average patency rate per patient of 84% with ticlopidine and of 82% with acenocoumarol. This and various other measures of graft occlusion did not reveal any substantial difference in graft patency of patients receiving ticlopidine or acenocoumarol. It is concluded that ticlopidine may well be used instead of anticoagulants forprevention of postoperative occlusion of aorto-coronary bypass graft

Echocardiographic findings late after myectomy in hypertrophic obstructive cardiomyopathy

Postoperative echocardiograms of 50 patients undergoing myectomy for hypertrophic obstructive cardiomyopathy between 1965 and 1982 have been evaluated. In 21 patients a comparison with preoperative echocardiograms showed that postoperatively there was a significant reduction of septal and free wall thickness, an increase of left ventricular end-diastolic as well as outflow tract dimensions and a reduction or disappearance of systolic anterior motion of the mitral leaflet. Postoperative examination at intervals > 3 years revealed a significant increase of left ventricular and left atrial cavity size with unchanged contractile parameters and little reduction of left ventricular hypertrophy. In 4of 12 patients evaluated > 8 years after myectomy, left ventricular dilatation was observed and 3 of these 4 patients developed congestive heart failure. Development of leftventricular dilatation was independent of whether a transventricular and/or transaortic approach was used for myectomy. These data indicate that the late course after myectomy in hypertrophic obstructive cardiomyopathy may be complicated by dilatation of the left ventricular cavit