Biomedical subjects
Publications and source records attributed to V Vondrácek.
Mycotic aneurysm of the coronary artery occurs in less than 1% of patients with infective endocarditis and only few cases of successful treatment has been described in the literature. The paper presents a case of 64 years old man with infective endocarditis of the mitral valve, complicated with a development of mycotic aneurysm of the right coronary artery, who was successfully surgically treated.
BACKGROUND: Retrospective study of 303 patients with mitral valve surgery operated in the last 7 years is evaluated. A mitral valve replacement was done in 271 patients (89.4%), mitral valve reconstruction in 32 patients (10.6%). Only the replacement of mitral valve was done in 70 patients (23.1%), replacement in combination with some other intervention, most frequently the revascularization was done in 27 patients. METHODS AND RESULTS: The total mortality in mitral valve replacements was 7.7% with the prevalence of combined surgery, including the acute cases. Mortality for patients with prosthetics was 8.6% during 1996 to 98, and only 6.5% in the following years. From patients with the mitral reconstruction four has died (12.5%), all were acute or emergent cases with combined surgery. The average length of hospitalisation was 7.5 days. Postoperative Q-IM occurred in one patient (0.41%), revision for bleeding was necessary in 16 patients (5.3%), neurological complications developed in 14 patients (4.6%). CONCLUSIONS: Results of early mitral replacements are comparable or in some combined surgeries better to the results given in the literature or in the international register. In the aetiology of disease, a comparative decrease of rheumatic origin and an increase of ischaemic and degenerative disorders become apparent. The paper demonstrates improving results in this field of cardiosurgery, shows the new trends in the development of surgical treatment of the mitral valve and it also stresses the necessity of early indication to the surgery.
OBJECTIVES: To evaluate mid-term results and one-year graft patency of less invasive coronary artery bypass grafting through a median sternotomy. METHODS: From January 1, 1998, to December 31, 1999, 250 patients had coronary artery bypass grafting (CABG) without cardiopulmonary bypass (CPB) through a median sternotomy. The patient base of 188 men and 62 women averaged 61.7 years, mean ejection fraction (EF) was 55.1%. An average of 2.7 (range 1 to 5) distal anastomoses per patient was achieved. Results are compared with a CPB subgroup of patients operated on through a median sternotomy in the same time (N = 1126). In a random subgroup of 100 patients (50 per group) an angiographic control of graft patency was done. RESULTS: A non-CPB group showed lesser occurrence of postoperative acute myocardial infarction (p = 0.038), atrial fibrillation (p = 0.029) and lower incidence of renal (p = 0.033) complications. We observed lower operative mortality (p = 0.019), as well as the occurrence of low cardiac output syndrome (p < 0.001) in the off pump group. The follow-up is 36 +/- 12 months and the number of patients with recurrent angina (5.4%), late AMI (0%) and late death (0.4%) is acceptable. We did not find an inordinate number of vein grafts occlusions (2.2%) and stenoses (7.8%) at anastomotic sites. None of the arterial grafts in both groups were occluded. CONCLUSIONS: We detected lower incidence of postoperative complications and decreased operative mortality in a non-CPB group. Angiographic assessment displayed an excellent run-off in both groups of patients. Off-pump coronary bypass grafting is associated with sufficient short-term graft patency and mid-term clinical outcomes.
OBJECTIVE: Introduction of the new method of videoassisted multiple direct revascularization of the heart muscle from left-sided minithoracotomy (LAST--Left Anterior Small Thoracotomy) using an automatic connector of central anastomoses Symmetry (St. Jude Medical ATG, Inc., St. Paul, MN) in patients indicated for re-operation of bypasses of the coronary arteries or with pathological conditions of the sternum and for the cosmetic effect of submammary incisions in women. METHOD: From September 2001 to the end of February 2002 15 patients with affections of three arteries had an operation from a LAST approach with videoscopic construction of central anastomoses by means of a Symmetry connector with portal entries and the use of extracorporeal circulation introduced from the groin without cardioplegic arrest. Nine men and six women were operated with a mean age of 68.7 years and a mean ejection fraction (EF) of 58.2%. In seven instances reoperation of aortocoronary bypasses was involved; two patients with multiple myelomas (morbus Kahler) had a brittle and cavernously altered sternum, all six women wanted a small skin incision below the breast. The criterion for ruling out the mentioned procedure was marked atherosclerotic affection of the ascendent aorta, affection of the arteries in the aortoiliac area and affection of one or two coronary arteries suitable for miniinvasive revascularization without extracorporeal circulation. Fourteen patients had an angiographic check up examination of the patency of grafts before they were discharged. RESULTS: The total number of distal anastomoses per patient was 3.13 +/- 0.6, the median period of extracorporeal circulation was 112 +/- 34 minutes and the mean time of operation 186 +/- 52 minutes. Blood losses were on average 425 ml/24 h without necessity of revision on account of haemorrhage. Eleven (73%) patients were subjected to an ultra fast track protocol with extubation on the operating table. The mean time spent in the postoperative department was 8.6 hours and the total hospitalization period 5.5 days. None of the operated patients died. Peroperative ischaemia of the heart muscle was not observed, in one instance the authors observed a newly developed atrial fibrillation. During an angiographic check-up the authors detected 6 (13.6%) stenoses and occlusions in 44 checked bridged vessels. CONCLUSION: The alternative approach reduces the risk of cardiac injury during reoperation and the danger of impaired healing of the sternotomical wound in patients with pathological conditions of the sternum, with contamination of the surrounding tissue (e.g. in tracheostomy) or malignant disease. The cosmetic effect of the submammary incision, the small inguinal incision and endoscopic saphenous vein harvesting should be considered in elective direct revascularization of the heart muscle in women. Bridging of the coronary arteries with optical assistance from minithoracotomy and with an automatic connector of central anastomoses seems to be a safe alternative of standard sternotomy only with methodological but not anatomical or functional restriction.
The authors submit a retrospective group of 245 patients operated in the course of 6 years at the Second Surgical Clinic of Cardiovascular Surgery of the General Faculty Hospital and First Medical Faculty Charles University on account of mitral valve disease. The early results of mitral valve prostheses are comparable or in some combined operations better than reported in world statistics. In the etiology the authors found a relative decrease of rheumatic defects and higher incidence of ischaemic affections. The general mortality in mitral valve prostheses was 7.1%, combined operations incl. acute ones being predominant. In mitral plastic operations the authors lost 4 patients, i.e. 19%. In all instances acute combined operations were involved and the result is consistent with the predicted mortality according to the Merged Cardiac Registry. The mean hospitalization period was 7.52 days. A postoperative QIM was recorded in one patient, i.e. in 0.46%, revision after mediastinitis also in one patient (0.41%) and revision after haemorrhage in 14 patients, i.e. in 5.7%. Neurological complications were recorded in 10 patients i.e. 4%. The work emphasizes the trend of improving results in this important area of cardiosurgery and indicates further possibilities and ways of development in the treatment of mitral valve diseases.
OBJECTIVES: To explore the surgical technique, anaesthesiological management, immediate and mid-term results, graft patency and effectiveness of less invasive coronary artery bypass grafting through a median sternotomy. METHODS: From January 1998 through December 1999, 144 patients had coronary artery bypass grafting (CABG) without cardiopulmonary bypass (CPB) done by one surgeon through a median sternotomy. The cohort of 107 men and 37 women averaged 60.8 years, mean ejection fraction (EF) was 51.8%. An average of 2.7 (range 1 to 5) grafts/patients was achieved. Results are compared with a CPB subgroup of patients operated on through a median sternotomy in the same time (N = 234). In a random subgroup of 100 patients (50 per group) an angiographic control of graft patency was done. RESULTS: A non-CPB group showed less postoperative acute myocardial infarction (0.7% vs. 3.8%, p < 0.05) and atrial fibrillation (14.6% vs. 26%, p < 0.05), lower incidence of renal (2.8% vs. 5.1%, p < 0.05) and respiratory complications (2.0% vs. 3.8%, NS). We observed lower operative mortality (0.7% vs. 3.4%, p < 0.05), as well as the occurrence of low cardiac output syndrome (0.7% vs. 5.6%, p < 0.05) in the off-pump group. The follow-up is 36 +/- 12 months and the number of patients with recurrent angina, late AMI and late death is acceptable. We did not find an inordinate number of vein grafts occlusions (0.7% vs. 1.8%, NS) and stenoses (6.6% vs. 6.7%, NS) at anastomotic sites. None of the arterial grafts in both groups were occluded. CONCLUSIONS: There was little known about the efficacy of the less invasive coronary artery bypass grafting at the beginning of our study. Starting with pioneering the operative technique, we have discovered and proposed three types of a heart verticalization and a reusable stabilizing device. We detected lower incidence of postoperative complications and decreased operative mortality in a non-CPB group. Angiographic assessment displayed an excellent run-off in both groups of patients. Off-pump coronary bypass grafting is associated with sufficient short-term graft patency and mid-term clinical outcomes.
BACKGROUND: While the effect of neurohormones is often studied in congestive heart failure, their role in aortic stenosis needs to be elucidated. METHODS: 54 consecutive patients with symptomatic aortic stenosis without overt heart failure were studied at the age of 64.4 +/- 9.3 yrs with echocardiography, x-ray and catheterization. Levels of circulating atrial natriuretic factor endothelin-1, catecholamines, plasma renin activity, immunoreactive insulin and C-peptide were assessed, related to hemodynamic data and compared to those in 23 healthy controls, aged 59.2 +/- 12.8 yrs. RESULTS: Patients had significantly higher plasma levels of endothelin-1 (z-value 0.64 +/- 1.19, p = 0.019), atrial natriuretic factor (z-value 2.46 +/- 2.46, p < 0.001) and dopamine (z-value 0.91 +/- 2.33, p = 0.02). Levels of endothelin-1 and ANF positively correlated with mean (r = 0.631, p < 0.001) and wedged pulmonary artery pressures and with left atrial diameter index (r = 0.602, p < 0.001). Endothelin-1 levels correlated negatively with aortic valve area (r = -0.306, p = 0.041). No correlation was found between neurohumoral plasma concentrations and left ventricular mass index. CONCLUSIONS: In patients with symptomatic aortic stenosis without overt heart failure, elevated plasmatic levels of endothelin-1, atrial natriuretic factor and dopamine were documented. The increase of ET-1 levels is related to pulmonary hypertension and severity of the disease. Left ventricular hypertrophy is not related to neurohormonal levels. Neither circulating system renin-angiotensin nor noradrenaline are activated in these patients.
Left ventricular (LV) hypertrophy is a strong predictive factor for cardiovascular morbidity and mortality. LV structure and function are influenced by many variables, including genetic background. The potential role of gene polymorphisms of different components of the renin angiotensin system remains controversial. The aim of this study was to determine the influence of deletion/insertion (D/I) polymorphism of the angiotensin-converting enzyme (ACE) gene and M235-->T polymorphism of the angiotensinogen (AG) gene on left ventricular morphology and function in young normotensive men. The study included 110 normotensive healthy males (mean age 24 +/- 4 years, age range 18 to 34 years) who were assessed by echocardiography for LV structure and function. In all subjects ACE D/I polymorphism was evaluated using a polymerase chain reaction (PCR) method. M235-->T polymorphism assessment was available in 98 individuals. Significant differences between groups according to ACE I/D or AG M235-->T polymorphisms were not found for parameters of LV morphology or for parameters of systolic and diastolic function. When subjects with DD or ID genotypes were grouped, their LV mass index was higher than that in subjects with II genotypes (86 +/- 14 vs 79 +/- 15, r = 0.033, p = 0.05). There were no significant differences among other variables. In a population of young normotensive men where the influence of confounding variables such as age, gender and associated pathological conditions is minimized, the gene polymorphisms of ACE I/D and AG M235-->T are not important determinants of LV structure and function.
Persistent abnormalities of left ventricular wall motion in patients with chronic coronary artery disease can be reversed by successful coronary artery bypass surgery or coronary angioplasty. The identification of hibernating myocardium has therefore important therapeutic and prognostic implications. Echocardiography with low dose dobutamine infusion can detect viable myocardium in patients with chronic left ventricular dysfunction. We have studied 32 patients with angiographically confirmed coronary artery disease and left ventricular dysfunction. The effect of dobutamine infusion (5 micrograms/kg/min. followed by 10 micrograms/kg/min) on left ventricular function was evaluated before coronary revascularization (PTCA, n = 20); CABGm b = 12) and compared with early period after revascularization (1-7 days) and 6-7 months later. Before revascularization 226 segments were hypokinetic, akinetic or dyskinetic, improvement was observed in 122 segments during dobutamine echocardiography. Mean (+/- SD) segment score indexes were 2.50 +/- 0.17 at baseline, 2.04 +/- 0.19 (p < 0.001) after dobutamine infusion, 2.24 +/- 0.25 (p < 0.001) early after and 1.87 +/- 0.25 (p < 0.001) late after revascularization. Sensitivity of dobutamine infusion to predict improvement early and late after revascularization was 84% and 85% respectively, specificity was 85% and 90% respectively. Echocardiography during low dose dobutamine infusion is save and accurate method for identifying of hibernating myocardium and predicts early and late reversibility of wall motion in selected patients with coronary artery disease and chronic left ventricular dysfunction.
In this report, we dealt with ventricular activation abnormalities in 30 patients with previous non-Q myocardial infarction (MI) by means of the CARDIAG 128.1 device, which enables analysis of ECGs, VCGs and body surface potential maps. The diagnosis was verified by left ventriculography, echocardiography and perfusion scintigraphy. Twenty-nine healthy subjects served as the control group. Morphological findings confirmed the presence of a significant subgroup with serious left ventricular asynergy. Seven electrocardiological variables, which significantly differed from control values, disclosed that non-Q MI is responsible for localized activation time prolongation, and that inferoposterior scars tend to delay the entire activation of ventricles, and to cause disturbances of the terminal depolarization phase together with a decrease in voltage production during QRS. Lesions of the anterior wall and the apicomesial part of the inferoposterior wall affect the distribution of the Q wave more often than the posterior basal ones. The probability of such abnormalities increases with the degree of asynergy. Some VCG criteria increase the sensitivity of electrocardiological analysis. These parameters will be used for evaluating the diagnostic value of electrocardiological analysis in the chronic non-Q MI. Non-Q myocardial infarctions represent a heterogeneous group of infarctions from both electrophysiological and morphological aspects.
In 22 patients with ischaemic heart disease and conditions after infarction and angina pectoris a coronarographic examination was made as well as other auxiliary examinations incl. a complex analysis of the electrical cardiac field (KAESP) (23), using a Cardiac apparatus (manufacturer ZPA Cakovice). Using the KAESP method fibroses in the heart muscle were found in all 22 patients, while a classical electrocardiogram revealed them only in 12 patients (54.5%). Post-infarction fibrous changes on the inferior cardiac wall were detected by ECG in 10 patients, KAESP revealed this localization of changes in 17 patients. The difference was particularly marked as regards localization on the anterior cardiac wall, according to ECG it was in 2 patients, according to KAESP in 17 patients. The authors investigated also on isopotential repolarization maps focal changes caused by cardiac ischaemia associated with organic affection of the appropriate coronary artery as revealed by coronarography. Identical sites were proved in 18 patients by the two methods, i. e. in 81.8%. In the discussion the authors analyse the causes which influence the accuracy of assessment of the coronary artery in KAESP. In KAESP in addition to isopotential maps also other maps were used such as isointegral, iso-areal, asynchronic potential maxima and minima, isochronic maps, maps of negative isodivergencies, profile sections etc. (20).
Dual chamber cardiac pacemakers restoring an impaired atrioventricular synchrony meet a demand of contemporary so-called physiologic cardiac pacing. 39 dual chamber (DDD) pacers were implanted in 1982-1991 in our center. They improved both well-being and hemodynamic values (doppler echocardiography) more distinctly than common ventricular demand devices did. P-wave driven ventricular pacing in normal sinus node function (in 40 per cent of our DDD patients) made a frequency response in physical exercise possible. A short atrioventricular delay in DDD pacing proved to be helpful in the treatment for reentry tachycardias refractory to antiarrhythmic drug administration. Demanding implant, high price, lengthy programming as well as a higher incidence of complications (30.7 per cent) as compared to ventricular pacemakers (7.6 per cent) were the main problems of DDD ones.
The authors describe the clinical picture and results of some auxiliary examinations in 18 patients with the X syndrome, i.e. with angina pectoris with a normal angiographic finding on the coronary arteries. For the diagnosis of ischemic cardiac changes, which are an integral part of this syndrome, the authors used a complex analysis of the electric cardiac field by means of a Cardiac 128.1 apparatus (manufactured by ZPA-Cakovice). In patients with the X syndrome they observed a significant reduction of some potential and integral values, as compared with an equally sized group of healthy subjects. On maps of the electric manifestation of cardiac activity on the chest surface ischemic changes were revealed on the antrior and lower cardiac wall but also in its lateral and posterior wall. These changes were older and were found in the subendocardial layer or concurrently in another area of the heart with affection of the subepicardial layer. Minor non-transmural fibroses, most frequently on the septum, in some instances spreading to the anterior and lower cardiac wall, were a surprising finding. At present it is not possible to differentiate merely by analysis of the electric cardiac field the X syndrome and ischemic heart disease. This should be made possible by further comparative studies. The present paper is the first description of ischemic and fibrous cardiac changes in X syndrome diagnosed by a complex analysis of the electric cardiac field in the professional literature published in Czechoslovakia and other countries.
The authors summarize in standard protocols the spectrum of possible examinations made by means of a modern echocardiographic apparatus in valvular defects and prostheses and in septal atrial defects. They discuss some evaluations and their practical importance. Standardization contributes towards a comprehensive and more illustrative character and facilitates comparison of findings. A structured concept of the protocol is selected with the perspective of its deposition in a data base of an interactive external computer. The work should serve as a stimulus for discussion in other echocardiographic departments and elaboration of their own working procedure.
The authors examined by one- and two-dimensional echocardiography 28 patients with valvular prostheses, divided into groups, depending on the type and position of the prosthesis. They assessed the excursions of the disc or ball, the speed of opening and closure, time intervals A2-MVO and S1-AVO and the size of the left cardiac compartments. They investigated the occurrence of paradoxical movements of the interventricular septum, the diastolic wave in mitral prostheses and the flutter of the anterior cusp of the mitral valve in aortic prostheses. The results of these observations were confronted with data in the literature. In the investigated group of patients no pathological findings were detected. In mitral ball prostheses greater excursions were recorded than in eccentric disc-shaped prostheses. The closing speed was always greater than the opening speed. The A2-MVO interval was approximately double, as compared with S1-AVO. It was found that the paradoxical movement of the interventricular septum persists longer than reported in the literature. One-dimensional echophonocardiography and 2-D echocardiography retains its importance for the follow-up of patients with valvular prostheses.
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