Biomedical subjects
Christine H Attenhofer Jost
Publications and source records attributed to Christine H Attenhofer Jost.
Sinus venosus atrial septal defect: long-term postoperative outcome for 115 patients.
BACKGROUND: Sinus venosus atrial septal defect (SVASD) differs from secundum atrial septal defect by its atrial septal location and its association with anomalous pulmonary venous connection (APVC). Data on long-term outcome after surgical repair are limited. METHODS AND RESULTS: We reviewed outcomes of 115 patients (mean age+/-SD 34+/-23 years) with SVASD who had repair from 1972 through 1996. APVC was present in 112 patients (97%). Early mortality was 0.9%. Complete follow-up was obtained for 108 patients (95%) at 144+/-99 months. Symptomatic improvement was noted in 83 patients (77%), and deterioration was noted in 17 patients (16%). At follow-up, 7 (6%) of 108 patients had sinus node dysfunction, a permanent pacemaker, or both, and 15 (14%) of 108 patients had atrial fibrillation. Older age at repair was predictive of postoperative atrial fibrillation (P=0.033). No reoperations were required during follow-up. Survival was not different from expected for an age- and sex-matched population. Clinical improvement was more common with older age at surgery (P=0.014). Older age at repair (P=0.008) and preoperative New York Heart Association class III or IV (P=0.038) were independent predictors of late mortality. CONCLUSIONS: Operation for SVASD is associated with low morbidity and mortality, and postoperative subjective clinical improvement occurs irrespective of age at surgery. Postoperative atrial fibrillation appears to be related to older age at operation. SVASD repair achieves survival similar to that of a matched population and should be considered whenever repair may impact survival or symptoms.
Validation of noncompaction criteria in dilated cardiomyopathy, and valvular and hypertensive heart disease.
BACKGROUND: Echocardiographic characteristics typical of isolated left ventricular noncompaction (IVNC) have been well defined. The aim of this study was to validate diagnostic criteria of IVNC in valvular or hypertensive heart disease (HHD) or dilated cardiomyopathy. METHODS: We conducted a retrospective analysis of records and blind review of videotapes of all 19 patients with IVNC seen within 7 years in comparison with randomly selected patients from the same study period with dilated cardiomyopathy (31 patients), HHD (22 patients), and chronic severe valvular heart disease: mitral regurgitation (22 patients); aortic regurgitation (20); and aortic stenosis with bicuspid (22) or tricuspid (22) valves. RESULTS: Clinical characteristics and electrocardiographic findings did not differ between IVNC and other diseases. In IVNC, all patients had noncompacted (NC) segments with a 2-layered structure and wall thickening, and in most patients perfused recesses (95%) or hypokinetic segments (89%) were present. Both hypertrabeculation or presence of a meshwork were specific for IVNC, but the sensitivity for IVNC was only 11% for hypertrabeculation, respectively, 68% for meshwork. In dilated cardiomyopathy, perfused recesses (48%) and a 2-layered structure (26%) were seen but without wall thickening of these segments; all NC criteria including wall thickening were fulfilled in one patient (3%) only. In valvular heart disease or HHD, perfused recesses and a 2-layered myocardium were rare: two patients (5%) with aortic stenosis and one patient with HHD (5%) had NC. Although in IVNC wall thickening was confined to the 2-layered myocardial segments, it was diffuse in other diseases. CONCLUSIONS: Although some NC criteria are occasionally found in other heart disease, the combination of all criteria is very specific. All criteria of NC are rarely met in other disease than IVNC (< or = 5%).
Concepts and questions in programming cardiac resynchronization devices.
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Left heart lesions in patients with Ebstein anomaly.
OBJECTIVE: To identify the incidence of left heart abnormalities in patients with Ebstein anomaly, recognizing that left-sided lesions in this patient group have been overlooked. PATIENTS AND METHODS: According to the echocardiography database at the Mayo Clinic in Rochester, Minn, 106 consecutive patients with Ebstein anomaly underwent echocardiography between July 1, 2001, and February 28, 2003. Clinical data as well as electrocardiographic and echocardiographic reports and images were reviewed. RESULTS: Ebstein anomaly was severe in 76 patients (72%). Previous tricuspid valve surgery was reported in 46 patients (43%), and previous closure of an atrial septal defect or patent foramen ovale was reported in 34 patients (32%). Left ventricular (LV) myocardial changes resembling noncompaction occurred in 19 patients (17.9%), LV systolic dysfunction in 7 patients (7%), LV diastolic dysfunction in 34 (36%) of 95 patients, and LV dilatation in 4 patients (4%). Additional left-sided cardiac lesions included mitral valve prolapse in 16 patients (15%), bicuspid aortic valve in 8 (8%), mitral valve dysplasia in 4 (4%), and ventricular septal defect in 8 (8%). Wolff-Parkinson-White syndrome occurred in 22 patients (21%). The QRS axis tended to be different in LV noncompaction with a mean +/- SD axis of 12 degrees +/- 74 degrees vs 36 degrees +/- 66 degrees overall (P=.08). Otherwise, there were no differences in clinical or surgical data between the groups with normal and abnormal LV myocardium. CONCLUSIONS: In patients with Ebstein anomaly, left heart abnormalities involving the myocardium or valves were observed in 39% of patients. Ebstein anomaly should not be regarded as a disease confined to the right side of the heart.
Noncompacted myocardium in Ebstein's anomaly: initial description in three patients.
Exercise intolerance in Ebstein's anomaly is usually attributed to desaturation secondary to right-to-left shunting as a result of a small or distorted left ventricle (LV), significant tricuspid valve regurgitation, right ventricular dysfunction, or a combination of these. We observed one boy (age 15 years) and two women (ages 20 and 29 years) with severe Ebstein's anomaly and strikingly abnormal LV myocardium resembling the features described for LV noncompaction. LV size and systolic function were normal in the two women; the boy had a dilated LV with severely diminished ejection fraction. The LV myocardium was found to be unusually coarse and hypertrabeculated, with small intertrabecular recesses and an irregular endocardial surface. The findings in these 3 patients represent the whole spectrum of mild to severe LV noncompaction. Diastolic dysfunction was present in 2 of the 3 patients. Exercise tolerance was diminished in all. There was no mitral or aortic valve disease. The 15-year-old boy underwent heart transplantation 6 months later for biventricular failure. Thus, Ebstein's anomaly does not seem to be a pathology confined to the right ventricle, but may rarely lead to LV noncompacted myocardium. This LV pathology may be an additional explanation for exercise intolerance or signs of left heart failure in patients with Ebstein's anomaly.
Atropine for inconclusive exercise tests: a beautiful solution or just cosmetics?
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Mechanical complications after myocardial infarction reliably predicted using C-reactive protein levels and lymphocytopenia.
We assessed the accuracy of C-reactive protein (CRP) levels and lymphocyte counts to predict a mechanical complication (MC) after myocardial infarction (MI). Within 10 years, we identified 36 patients with 39 echocardiographically confirmed MC within 30 days of MI: ventricular septal defect (17 cases), papillary muscle rupture (10 cases), and left ventricular free wall rupture (12 cases). They were compared to 41 controls with an uncomplicated hospital course after MI. Peak CRP levels and minimum relative lymphocyte counts obtained within 96 h of the acute MI (AMI) and before diagnosis of the complication were compared with clinical parameters. Prior to the MC, peak CRP levels were significantly higher (p < 0.001) and relative lymphocyte counts lower (p < 0.001) than in controls while creatine kinase levels did not differ (p = nonsignificant). Using multivariate logistic regression, the following score was identified to have excellent prognostic significance for MC: CRP (mg/l) - 10 x Lyc (%). The area under the receiver-operating characteristic curve was 0.90 +/- 0.05 (p < 0.001). Combined use of CRP levels and relative lymphocyte counts may be helpful in accurately predicting an MC after AMI and should therefore be routinely assessed.
Remodelling after surgical repair of atrial septal defects within the oval fossa.
In a retrospective study, we analysed the data from 101 adults with echocardiographic follow-up after surgical repair of defects within the oval fossa at a mean age of 35 +/- 17 years; 56% of the cohort being above the age of 30 years. Mean age at follow-up was 44 +/- 18 years, and length of follow-up was up to 40 years (11 +/- 12 years). At follow-up, atrial fibrillation or flutter was present in one quarter. Dilation of the right atrium, found in 64%, of the left atrium, found in 44%, and of the right ventricle, found in 29%, were also frequent, as well as pulmonary arterial hypertension, which was found in 30%. Diminished right ventricular ejection fraction, in contrast, was very rare, found only in 1%, and abnormal left ventricular ejection fraction was not encountered. By multivariate analysis, predictors for right or left atrial, or right ventricular, dilation were age at follow-up, degree of tricuspid regurgitation, pulmonary hypertension, and/or atrial fibrillation. In a subset of 21 patients in sinus rhythm, we correlated prospectively the diastolic and systolic function of both ventricles with levels of brain natriuretic peptide, comparing values to those of 20 age-matched controls with a mean age of 46 +/- 14 years. Levels of brain natriuretic peptide were significantly higher in patients than in controls (p = 0.006), and correlated significantly with diastolic dysfunction (p = 0.007) and left atrial size (p < 0.0001). In the long-term follow-up after surgical repair of defect within the oval fossa, therefore, complete normalization of heart size and function is rare. Despite preserved systolic function, persistent diastolic dysfunction is common and is associated with elevated levels of brain natriuretic peptide, which may explain the late occurrence of atrial arrhythmias.
Spectrum of reoperations after repair of aortic coarctation: importance of an individualized approach because of coexistent cardiovascular disease.
OBJECTIVE: To determine the indications for and spectrum of late reoperations in adults who had previously undergone coarctation repair. PATIENTS AND METHODS: We reviewed clinical, cardiac catheterization, and echocardiographic data and criteria for reoperation, surgical procedures, and outcome in 43 patients who underwent 54 reoperations between 1972 and 1996. RESULTS: Of the reoperations for recoarctation or associated cardiovascular disease (or both), 20% were performed in asymptomatic patients and 80% in symptomatic patients. Associated cardiovascular disease included bicuspid aortic valve in 36 patients (84%), aortic arch hypoplasia in 12 (28%), true or false aortic aneurysm in 6 (14%), mitral valve disease in 6 (14%), and subvalvular aortic stenosis in 5 (12%). Surgical procedures included 22 recoarctation repairs and 32 other cardiovascular interventions. Simultaneous repair of recoarctation and associated cardiovascular disease was performed as a single-stage repair in 5 reoperations through a median sternotomy using an extra-anatomic, ascending-to-descending aortic bypass, with no complications. One patient died (surgical mortality, 1.9%) of preexisting severe pulmonary vascular obstructive disease. CONCLUSIONS: After coarctation repair, associated cardiovascular diseases are the most common cause for reoperation. An individualized surgical approach is important and may range from valve replacement or recoarctation surgery to extra-anatomic bypass combined with other cardiovascular procedures, enabling simultaneous repair of recoarctation and associated lesions. Despite complex surgical techniques and multiple reoperations, morbidity and mortality were low in our series.
Gender and noninvasive diagnosis of coronary artery disease in women and men.
OBJECTIVES: The purpose of this prospective study was to investigate the impact of the gender of physicians and patients on the accuracy of diagnosing coronary artery disease (CAD) based on the patient history only. METHODS: Screening involved 1082 consecutive patients undergoing coronary angiography for suspected CAD. Known CAD was an exclusion criterion. The inclusion criteria were met by 144 patients (47 females). All patients were inverviewed by both an experienced male cardiologist (n=6) and an experienced female cardiologist (n=5), who had to state before coronary angiography if CAD was present relying solely on the patient interview. Eligible subjects also answered a questionnaire. Diagnostic performance to assess the presence or absence of CAD by history taking by male and female cardiologists, exercise testing, patient self-assessment, and the questionnaire were compared. RESULTS: Coronary angiography showed significant CAD in 20 females (43%) and 70 males (72%). Diagnostic accuracy was not different between male (79%) and female (79%) cardiologists and comparable to the results of exercise testing (74%) but better than self-assessment by the patients (65%, p=0.01) or a questionnaire (68%, p=0.01). The accuracy of female physicians was better in men than in women (85% vs. 66%, p=0.01). The specificity of male physicians tended to be better in women than in men (74% vs. 59%, p=0.25). Female cardiologists overestimated the presence of CAD in women (specificity 48% vs. 74%, p=0.04). CONCLUSIONS: The female cardiologists did not assess women more accurately than did their male colleagues. The diagnostic accuracy of these male and female cardiologists was quite good. However, both tend to assess patients of the opposite gender more specifically. There may be an impact of the gender of the physician on the accuracy of diagnosis of CAD by history taking.