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The first palliative operations of congenital heart disease in the 1940s and 1950s, and then open heart surgery in the 1960s, have resulted in survival of patients whose follow-up is now over 30 years. Problems of patients with congenital heart disease are cardiac (pulmonary hypertension, systemic hypertension, dysrhythmias, endocarditis, cerebral insults, etc.), and noncardiac (scoliosis, intrathoracic adhesions, cosmetic problems, pregnancy, physical activity, employment, etc.). A pediatric cardiologist usually follows up such patients until adolescence, however, after that time they remain without physician's care who followed them in their childhood, being transferred for further controls and follow-up to internists-cardiologists. Many difficulties arise since internists-cardiologists are not properly trained in this particular sense, and pediatricians are not trained to follow-up adult patients. The care for a patient should be coordinated. To care for an adolescent, who was the child with congenital heart disease, pediatrician and cardiologist have to work at the same medical centre. The follow-up should continue as a team work, in which, besides pediatrician and cardiologists, cardiosurgeon, psychologist, psychiatrist, obstetrician, specialist for physical medicine and social worker should be included. A correction of educational plan is mandatory.
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PMID:[Problems in adolescents and adults with congenital heart defects]. 853 60

A great variety of cardiac disorders have been reported in HIV-infected patients: pericarditis, myocarditis, cardiomyopathies, endocarditis, cardiac involvement through malignancies, pulmonary hypertension, arrhythmias and thromboembolic disease. In general, these disorders are asymptomatic and often diagnosed in echocardiographic studies or autopsies. Pericardial involvement is the most common disorder. Pericardial effusions are asymptomatic and non-specific in a great proportion, but in some instances opportunistic infections or malignancies may lead to cardiac tamponade and are associated with an increased risk of mortality. The etiopathogenesis of myocarditis and cardiomyopathies is uncertain. There is controversy about the role of HIV as the primary etiologic agent. Opportunistic infections, cardiotoxic substances, nutritional deficiencies and autoimmune reactions have also been implicated as etiologic agents of myocardial damage. Short-term prognosis worsens as clinical manifestations of heart failure appear. Valvular involvement usually presents as marantic or infectious endocarditis, the latter most frequently in IVDU. This article reviews the main cardiovascular manifestations in AIDS.
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PMID:[Heart pathology of extracardiac origin (I). Cardiac involvement in AIDS]. 941 63

Forty-three horses with mitral regurgitation (MR) and congestive heart failure were examined, using M-mode, 2-dimensional real-time and Doppler echocardiography. There was no breed or sex predisposition when compared to the general hospital population. The mean +/- s.d. age of affected horses was 7.6 +/- 8.1 years. Horses with MR and congestive heart failure had significant increases in mean values for left ventricular chamber size, left atrial size and heart rate and significant decreases in interventricular septal and left ventricular free wall thickness. Significant increases in pulmonary artery diameter were detected compared to aortic diameter. Mean values for fractional shortening were not significantly different from normal. All horses had a Grade 3-6/6 holosystolic or pansystolic murmur with its point of maximal intensity in the mitral to aortic valve area. Atrial fibrillation was found at presentation in 24 horses with MR and congestive heart failure. One horse presented with atrial tachycardia and subsequently developed atrial fibrillation. Seven horses had ventricular premature contractions. Exercise intolerance (n = 34), respiratory signs (n = 31), and fever (n = 21) were the most common presenting signs. Thickening of the left atrioventricular valve leaflets, endocarditis, flail valve leaflets, rupture of a chorda tendineae, and mitral valve prolapse were detected echocardiographically. Doppler echocardiography confirmed the presence of a large systolic regurgitant jet in the left atrium in all horses in which it was used, and in many horses, concurrent tricuspid and pulmonary regurgitation was detected. All horses died or were subjected to euthanasia due to the severity of their MR and/or lack of response to therapy. Post mortem examinations were performed in 35 horses and confirmed the echocardiographic findings. The echocardiographic detection of a flail mitral valve leaflet was significantly associated with the detection of a ruptured chorda tendineae at post mortem examination. There was a significant association between echocardiographic detection of a dilated pulmonary artery and its presence at post mortem examination. M-mode, 2-dimensional real-time, and Doppler echocardiography should be used to accurately characterise the valvular abnormalities and assess the severity of mitral regurgitation. Pulmonary artery dilatation, an echocardiographic indication of severe pulmonary hypertension, should be considered a grave prognostic indicator and may indicate impending pulmonary artery rupture.
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PMID:Severe mitral regurgitation in horses: clinical, echocardiographic and pathological findings. 945 95

Serial changes in patients with isolated VSD during adolescence have not previously been investigated. Hemodynamic status, diameter of the defect, and growth were studied yearly in 106 children with VSD. The mean duration of the follow-up was 13.16 years and ranged in 80% of subjects from 7 to 19 years (1395 patients years). The mean ages at pre- and postpuberty were 8.62 and 16.67, respectively. The presented longitudinal study, in which losses due to death and operation were minimal (4%), ideally reflected the natural history of VSD. Although weight showed retardation during prepuberty, this lag was caught up by the end of adolescence. Stature showed no retardation in pre- and postpuberty. Cardiothoracic ratio decreased significantly from a mean of 0.48 to 0.44 and showed normal variation. Although the mean defect diameter at prepuberty was 5.33 mm, this decreased to 2.7 postpubertally. The individual decrease (1.7 +/- 2.34 mm) was significant (t = 5.349, p < 1/10(5)). The defect closed spontaneously in 24 (22.6%). In the 75 patients without pulmonary hypertension and with mild left-to-right shunting, 52 remained in the same class and spontaneous closure was observed in 23. In the 24 patients with moderate to severe left-to-right shunt, this decreased in 23 and only one remained stable. The 2 patients (1.9%) with Eisenmenger syndrome remained stable and 1 died. Aortic regurgitation developed in 10 patients (9.4%); however, this was of mild degree in most of them. No infective endocarditis was observed. It is concluded that patients with VSD should be followed closely through adolescence, because the diameter of the defect, as well as left-to-right shunting, can decrease, and it is concluded that the spontaneous closure of the defect is to be expected in a considerable 23%, and aortic prolapse or mild regurgitation may develop in approximately 10%.
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PMID:The natural course of isolated ventricular septal defect during adolescence. 956 19

The authors report two cases of Bartonella endocarditis in native valves. The first case was a 15 year old North African Girl who lived in poor social conditions and was admitted to hospital with pyrexia and congestive heart failure. Investigations revealed massive mitral regurgitation due to ruptured chordae tendinae, vegetations on the pulmonary valve with severe pulmonary hypertension due to persistent ductus arteriosus. After antibiotic therapy, the patient underwent surgery for mitral valve replacement, pulmonary valvuloplasty and closure of the patent ductus arteriosus. The second case was a 39 year old man with no fixed abode with a history of alcoholism who presented with a recurrent ischaemic stroke in a context of infection with a murmur of aortic regurgitation. Echocardiography showed a vegetation on the aortic valve with grade III/IV regurgitation requiring aortic valve replacement with a homograft after antibiotic therapy. The aetiological diagnosis was made a posteriori by the finding of high antibody titres and specific genetic amplification of Bartonella. In patients with negative blood cultures, Bartonella infection should be looked for systematically especially in those living under poor social conditions. The practical diagnostic investigation of endocarditis with negative blood cultures is reviewed.
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PMID:[Bartonella endocarditis on native valves. Apropos of 2 cases]. 983 93

Between 1.6.1991 and 31.5.1995, 62 patients underwent heart valve replacement with Sorin Bicarbon bileaflet prosthetic valve, age 16-83 years (mean 60.5). The valve disease was rheumatic in 37 cases, degenerative in 17, congenital in 4 and miscellaneous etiologies in the other 4. The valve lesion was AS in 24 patients, AR in 5, AR+MS in 2, MS in 13, MR+MS in 6, MR in 6, tricuspid prosthetic stenosis in 1, A+M disease in 3, and a clotted prosthetic valve (Sorin disc) in 1. CAD was present in 14 patients (23%) and AF in 19 (31%). 11 had moderate pulmonary hypertension and 4 severe. Preoperatively 6 patients were in FC II, 40 in FC III and 16 in FC IV. Operative procedures included AVR 18, AVR+CABG 13, AVR+T annuloplasty 1, AVR and open M valvotomy 1, MVR 7, MVR+T annuloplasty 7, MVR+AVR (Medtronic) 1, MVR+AVR 1, TVR, prosthetic valve replacement 1, and MVR+CABG 1. Hospital mortality was 3 (4.8%) -- one due to ruptured A-V groove and two due to LoCO. Postoperative complications: LoCO necessitating IABP -- 3 patient; 3 transient CVA and 1 CVA with hemiplegia. One patient had aortic prosthetic valve endocarditis 18 months following the operation necessitating reoperation. Other cases were treated for positive blood cultures. One patient had CVA after anticoagulant were discontinued. 28 patients are in FC I, 22 in H, 4 in III and 1 in IV. 4 patients are lost to follow-up. These data suggest that the Sorin Bicarbon Prosthetic valve can be safely and effectively used for heart valve replacement.
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PMID:Early experience with the Sorin bileaflet prosthetic valve. 1006 47

The case of a patient with mitral and aortic mechanical valve prostheses is presented who developed early postoperative infective endocarditis and, subsequently, a fistulous communication between the posterior aortic sinus and both the left atrium and the left ventricle. A diastolic murmur of apparent aortic prosthesis regurgitation was heard, although an abnormal aortic valve function could not be demonstrated in the transthoracic echocardiographic study. Instead, the presence of a systolic high velocity flow by continuous wave Doppler suggested prosthetic mitral leakage. The clinical presentation of progressive congestive heart failure and pulmonary hypertension by Doppler prompted a further study by means of transesophageal echocardiography with multiplanar probe showing the above mentioned double fistulous communication. The diagnosis was later confirmed by angiography and also at surgery.
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PMID:[A double fistulous communication between the aortic root and both left cardiac chambers. Its diagnosis by multiplanar transesophageal echocardiography]. 1007

Cirrhosis is associated with several circulatory abnormalities. These include hyperkinetic systemic and splanchnic circulation, hepatopulmonary syndromes including pulmonary hypertension, and cirrhotic cardiomyopathy. Hepatopulmonary syndrome generally refers to hypoxaemia seen in patients with chronic liver disease and appears to be relatively common, although often subclinical. However, significant pulmonary hypertension occurs in 0.2-0.7% of cirrhotic patients. Nitric oxide and/or other vasodilators appear to be involved in the pathogenesis of hepatopulmonary syndrome through induction of pulmonary capillary dilatation which increases the alveolar-arterial oxygen gradient. Cirrhotic cardiomyopathy refers to abnormal left ventricular function which is manifested under conditions of physiological or pharmacological stress. The emergence of liver transplantation as an effective treatment for end-stage liver disease has led to recognition of previously subclinical cardiomyopathy and congestive heart failure accounts for significant morbidity and mortality after this procedure. Diminished myocardial beta-adrenergic receptor function has been shown to play an important role in the pathogenesis of this condition. The contributions of other factors including nitric oxide, catecholamines and membrane fluidity changes are under investigation. Cirrhotic patients also have an increased incidence of other cardiac abnormalities, such as endocarditis and pericardial effusions.
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PMID:Cardiopulmonary dysfunction in cirrhosis. 1038 72

Acquired immunodeficiency syndrome is a serious problem worldwide. Recent advances in the knowledge about human immunodeficiency virus (HIV) replication and the treatment of HIV infection have improved survival in HIV patients. Because of the longer survival in HIV patients, the more manifestations of late-stage HIV infection will be seen, including HIV-related cardiac diseases. The common cardiac manifestations in patients with the acquired immunodeficiency virus are pericardial effusion, myocarditis, dilated cardiomyopathy, endocarditis, pulmonary hypertension, malignant neoplasms, and drug-related cardiotoxicity. This review focuses on these cardiac manifestations in patients with the acquired immunodeficiency syndrome.
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PMID:Cardiac manifestations of acquired immunodeficiency syndrome. 1092 47

The number of women with congenital cardiac disease, who mature into adulthood is increasing. Unfortunately, there are no prospective data published about the relative risk of different forms of contraception for these patients. Most women with congenital cardiac disease can safely use oral contraceptives, especially low-estrogen combination or progestin-only preparations, with the exception of those, who are at particular risk because of thromboembolic complications (especially in cyanosis, pulmonary hypertension, Eisenmenger reaction, rhythm disturbances), fluid retention (especially in reduced ventricular function and congestive heart failure), arterial hypertension (important in coarctation), infectious complications (endocarditis) or hyperlipidemia. Oral contraceptives should be avoided in patients at increased risk for thromboembolic events. Intrauterine devices are very effective, have no metabolic side effects and merely carry a small risk of endocarditis. Newer devices containing progesterone only may put the patients at a still smaller risk. Contraceptive subdermal implants (e.g. levonorgestrel) are used with good results in the United States for patients with contraindications to estrogen-containing oral contraceptives and may well become more widely accepted in patients in Germany in the coming years. Barrier methods can be used, but have a higher failure rate, which may be unacceptable in patients at risk (e.g. Eisenmenger's). Especially in Eisenmenger's, permanent sterilisation should be advised.
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PMID:[Contraception in patients with congenital heart defects]. 1095 86


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