Clinical experience

Ectopic atrial tachycardia and atrial flutter Non-contact mapping has been used to facilitate ectopic tachycardia ablation. As with the electroanatomical system, navigation to regions difficult to pinpoint fluoroscopically is facilitated, pertinent structures (such as the His bundle or Figure 17.2 Non-contact system multiple electrode array (MEA). (A) In low profile, the MEA is advance through the vasculature to the chamber of interest. (B) After deployment in the chamber of interest, the MEA...

Sudden Death In Children With Primary Cardiac Arrhythmias

Most sudden cardiac deaths that remain unexplained after necropsy are probably caused by primary cardiac arrhythmias. Arrhythmias which are known to be potentially fatal, and which would leave no trace after death, include polymorphic ventricular tachycardia in congenital long QT syndrome,17 w39 other primary ventricular arrhythmias such as those described by Brugadaw40 w41 and Coumel,w42 atrial fibrillation in Wolff-Parkinson-White syndrome,w43 and congenital complete atrioventricular block....

Sudden death in Wolff ParkinsonWhite syndrome

Wolff-Parkinson-White syndrome is one of the most common causes of arrhythmias in childhood, but sudden deaths are rare. The overall mortality risk is very difficult to quantify but may be around 1.5 per 1000 patient-years.w47 Sudden death is probably caused by ventricular fibrillation which, in turn, is precipitated by atrial fibrillation in patients with a very short anterograde accessory pathway refractory period (fig 21.3). Cardiac arrest and sudden death mainly occur in adolescents and...

Sudden death in congenital atrioventricular block

Congenital complete atrioventricular block affects around one baby in every 20 000. Not all are recognised at birth, or even in infancy.w7 The risk of sudden death is probably mainly related Figure 21.3 Atrial fibrillation in Wolff-Parkinson-White syndrome in a 10 year old girl with a history of recurrent syncope. There is a rapid, irregular, wide QRS tachycardia with a morphology which matched the pre-excitation seen in sinus rhythm. The accessory pathway was ablated. Figure 21.3 Atrial...

Renal Artery Intervention For Preservation Of Renal Function

There is increasing consensus that blood pressure can be managed medically in most patients with renal artery stenosis. Therefore the preservation improvement of renal function has become the most important indication for renal revascularisation. Patients with generalised atherosclerosis may have a variety of conditions causing renal failure including (essential) hypertension, renal hypoperfusion due to congestive heart failure, atheroembolic disease, diabetes mellitus, radiocontrast...

Control Of Ventricular Rate

Control of ventricular rate aims at reducing signs of circulatory insufficiency and prevention of tachycardiomyopathy.15 This can be achieved by negative chronotropic drugs or atrioventricular node ablation and insertion of a pacemaker. Although the targeted heart rate is unclear, it is reasonable to aim at heart rates under 90 beats min in resting conditions and below 110 beats min during light and moderate exercise. Perhaps more importantly, adequate rate control during daily exercise should...

Interventional Management

Figure 34.1 Arteriosclerotic renal artery stenosis in a 69 year old male patient. (A) Subtotal occlusion of the ostium of the left renal artery. (B) After percutaneous angioplasty with stent implantation. A guiding catheter (FR 3.5, 7 French) and a steerable 0.014 inch guidewire were used to advance a 12 mm balloon expandable stent over the lesion. The stent was deployed by inflating the balloon (6 mm diameter) for 30 seconds. Figure 34.1 Arteriosclerotic renal artery stenosis in a 69 year old...

Population Screening For Unsuspected Heart Disease

The infrequency of prodromal symptoms and the absence of physical signs in children who die suddenly and are found at necropsy to have a cardiac problem may seem to be an indication for screening of the general population. However, there is no evidence that population screening of children for abnormalities such as hypertrophic cardiomyopathy is either feasible or appropriate, and no evidence that either early detection or treatment in the absence of symptoms has any effect on outcome. The only...

Carotid Intervention

Carotid endarterectomy under general anaesthetic carries a low mortality in fit patients. Cardiac disease was responsible for 49 of deaths in one large series of patients undergoing carotid endarterectomy with mortality due to myocardial infarction.3 Those with severe cardiac or respiratory dysfunction can be treated under cervical block or local anaesthetic, which has the advantage that neurological events are immediately identified and corrected by shunting. There is a requirement for the...

Gala

P-galactosidase 201 gallopamil 12 ganciclovir 47 gas exchange monitoring 57 GATA-4 199, 201, 202 GeneChips 204 gene enhancers 197, 198 gene expression 197-8 control points for 198-200 methods for measuring 201-5 gene promoters 197, 198, 200-1 General Medical Council (GMC) 211 genes 197 genetics dilated cardiomyopathy 139 myotonic dystrophy 250-1 primary pulmonary hypertension 152 see also myocardial molecular biology genetic SCD syndrome 132 genetic testing hypertrophic cardiomyopathy 70...

Sudden Death In Young Athletes

Deaths during sports attract publicity but they are rare events. Estimates from the USA suggest that 5 per 100 000 young athletes (including children, teenagers, and young adults) have a predisposing condition and that about 10-25 such deaths per year occur in the US population of 260 000 000.18 The most common structural abnormalities identified at necropsy are hypertrophic cardiomyopathy, coronary artery abnormalities, right ventricular cardiomyopathy, and aortic valve stenosis.16 Unexplained...

Avoidance of competing risk

A related issue is that of so-called competing risk. A general principle in trial design is to exclude certain patients who are at increased risk of developing the clinical outcome that investigators are trying to prevent. For example, in a lipid lowering trial with all cause mortality as the primary outcome, patients with an increased risk of dying from reasons unrelated to lipids lipoproteins are excluded. This would, for example, apply to those with cancer or serious kidney or liver damage...

Why Offpump Bypass Surgery

The first milestones in coronary revascularisation were surgical. It all started after the second world war with the implantation of the internal mammary artery indirectly into the cardiac muscle (the Vineberg procedure). A few years later, procedures for direct coronary artery revascularisation were designed, initially including endarterectomy, followed by the construction of an anastomosis between a donor artery or vein and the coronary artery. Interestingly, these first operations were...

Electroanatomic Mapping

The CARTO system (Biosense, Diamond Bar, California, USA) correlates electrophysiologic characteristics with endocardial anatomy by continuously recording mapping catheter location. A locator pad placed beneath the operating table generates ultra-low intensity magnetic fields that code the mapping space around the patient's chest with spatial distinguishing characteristics. The pad's three coils each generate a magnetic field that decays in strength as a function of distance from that coil. A...

Management Of Sudden Cardiac Death Risk

SCD risk may be generated by the presence of a primary disorder of cardiac electrical activity in the absence of any structural heart disease (considered here as SCD syndromes), or may be secondary to a cardiac disease process (most often myocardial in origin), which by its legacy of myocardial scarring and dysfunction creates the electrical substrate for sudden lethal arrhythmia, without premonitory symptoms. The evidence base shows that the most effective treatment for SCD prevention is to...

Studies Comparing Mechanical With Biological Prostheses

There have been two large randomised trials comparing results of mechanical valve with porcine valve replacement. Both trials used the Bjork-Shiley mechanical valve before the introduction of the convexo-concave model which subsequently proved liable to strut fracture. The Department of Veterans Affairs (VA) trial randomised 575 male patients undergoing single valve replacement in 13 centres between 1977 and 1982 to receive either a Bjork-Shiley tilting disc prosthesis or a Hancock porcine...

Management Of Asymptomatic Carotid Stenosis

Asymptomatic carotid stenosis carries a stroke risk of approximately 2 per year. This stroke risk appears related to the severity of stenosis and remains constant with time, unlike the risk following a neurological event in a symptomatic carotid stenosis.2 A trial comparing surgery to aspirin for asymptomatic carotid stenosis showed no benefit from surgery although randomisation was incomplete.10 In a multicentre trial of 1662 patients (asymptomatic carotid atherosclerosis study, ACAS) with...

Step 1 immediate resuscitation measures

The goal is to prevent devastating end organ injury while the patient is being transported for definitive treatment. Maintenance of adequate mean arterial pressure to prevent adverse neurologic and renal sequelae is vital. Dopamine or noradrenaline (norepinephrine), depending on the degree of hypotension, should be initiated promptly to raise mean arterial pressure and be maintained at the minimum dose required. Dobutamine may be combined with dopamine at moderate doses or used alone for a low...

Pathobiology a comment

Clinical and experimental studies have identified potentially important structural and functional abnormalities, but whether these are a cause or a consequence of the disease remains to be determined. Experimental models of PPHN have demonstrated that the term endothelial dysfunction does not apply to all aspects of endothelial function, but to specific signal transduction pathways in certain segments regions of the pulmonary vascular bed. Functioning pathways should be identified and...

Myocardial scarring secondary to coronary artery disease

The risk of ventricular arrhythmia both near and distant to myocardial infarction is well established. Myocardial re-entry is allowed by the complex interaction of viable myocardium with scarred myocardium in and around infarct territories. These patients represent the majority of patients presenting with ventricular arrhythmias. Antiarrhythmic drug treatment may have a role in suppressing arrhythmia occurrence and thereby reduce the morbidity of such arrhythmias, but the data to support...

Prothrombotic factors

Several prospective studies have demonstrated an association between fibrinogen and CHD. Increased concentrations are associated with glucose intolerance, cigarette smoking, and hypercholesterolemia. A fibrinogen concentration of > 3.1 g l is associated with relative risks of CHD of 1.6 in men and 2.9 in women. Case control studies have shown an association between increased concentrations of tissue plasminogen activator inhibitor (PAI-1) and CHD although prospective data are lacking....

Sudden death in children with postoperative congenital heart disease

In the 1960s and 1970s sudden cardiac death most often occurred in children with irreversible pulmonary vascular disease associated with unoperated congenital heart disease or in children with unoperated aortic valve stenosis.w8 w9 In recent years surgical repair has been performed earlier and more effectively so that those most at risk of sudden death now are children with repaired heart disease. In a population based study of late postoperative sudden death, Silka and colleagues identified an...

Methods For Lowering Perioperative Cardiac Risk Coronary bypass surgery

Recently, attention has turned to evaluating the effectiveness of methods for intervening to lower risk of cardiac complications during elective surgery. Coronary revascularisation is one such intervention. A retrospective review by Eagle and colleagues of the CASS (coronary artery surgery study) registry data supports such a protective effect.7 These data demonstrate that patients undergoing elective vascular surgery, who had previously undergone coronary artery bypass grafting, did better...

Abbreviations

ALK1 activin receptor-like kinase BMPR2 bone morphogenetic protein receptor-II FPPH familial primary pulmonary hypertension NO nitric oxide PPHN persistent pulmonary hypertension of the newborn PVOD pulmonary vascular obstructive disease TGF- transforming growth factor VEGF vascular endothelial growth factor which co-localises with TGFP1. VEGF induces endothelium dependent relaxation, which may help ensure continued perfusion of the capillary bed. But it is also a potent angiogenic factor, and...

Practical Recommendations For Screening

Screening individuals with a family history of premature CHD is encouraged by all the current guidelines on CHD prevention, namely the Joint British Societies,5 the Joint European Societies,17 and the US National Cholesterol Education Program (NCEP).4 Each advocates using risk factors to calculate the 10 years absolute risk of a CHD event although they differ in the methodology used and the level of risk above which drug treatment should be commenced. The Joint European Societies guidelines are...

Echocardiography in acute coronary syndromes key points

The negative predictive value is high (approximately 95 ), but the positive predictive value is much lower and more variable.14 This may partly relate to interpretation difficulties in the presence of prior infarction, and aggressive interpretation of minor abnormalities by physicians anxious to avoid false negatives. From these studies, echocardiography appears more sensitive than standard criteria for the diagnosis of infarction it is also sensitive for the diagnosis of myocardial...

Prevalence Of Risk Factors In Patients With Premature

A large study of the prevalence of modifiable risk factors in US men with angiographically documented coronary artery disease before the age of 60 showed that virtually all had one or more risk factors.11 Compared with controls, the frequency of hypertension was 41 v 19 , of diabetes 12 v 1 , of cigarette smoking 67 v 28 , and of a low HDL cholesterol 63 v 19 . However, the frequency of a raised LDL cholesterol was similar in the two groups, 26 v 26 , reflecting the high prevalence of...

Primary pulmonary hypertension

Treatment for PPH is treatment for life. The therapeutic regimen has to be tailored to meet the needs of each individual and adjusted as and when required according to changes in clinical and haemodynamic status. Children need close monitoring of the clinical course to ensure that a satisfactory response to treatment is sustained, with recatheterisation if necessary. Optimising the management of these patients greatly improves quality of life and survival. Children with a positive response to...

High Risk Hypertensive Patients

Some patient groups have such high CVD risk and chance of benefit that they require antihypertensive treatment even for mild hypertension (> 140 90 mm Hg) without formal calculation of absolute risk. Patients with any form of symptomatic atherosclerotic vascular disease, including previous myocardial infarction, bypass graft surgery, angina, stroke or transient ischaemic attack, peripheral vascular disease or atherosclerotic renovascular disease need treatment of even very mild hypertension...

Sudden cardiac death in infancy

Sudden death in infancy is usually caused either by infection or by sudden infant death syndrome. A few neonatal or infant deaths are caused by unrecognised congenital cardiovascular malformations, particularly duct dependent abnormalities or obstructive left heart malformations.6 Primary arrhythmias are rare causes of death in infancy but fatal ventricular arrhythmias are described.6 Complete atrioventricular block is usually recognised in utero or soon after birth but may cause death if...

Apoptosis In The Heart

The adult cardiomyocyte has limited (if any) ability to proliferate. Correspondingly, apoptosis is observed infrequently in adult hearts. In contrast, cardiomyocyte apoptosis plays a critical role in heart formation, such as formation of septa between cardiac chambers and valves. This evidence suggests that defects in apoptosis can result in congenital heart disease. Major foci of apoptosis include zones of fusion of the atrioventricular or bulbar cushions, and both aortic and pulmonary valves...

Investigation of syncope

The history is of paramount importance in the assessment of children ith syncope. Common but benign causes such as vasovagal syncope or hyperventilation are usually easily recognised. A history of syncope during or immediately after exertion, syncope preceded by palpitations, or syncope in the presence of a family history of premature sudden death, congenital long QT syndrome or hypertrophic cardiomyopathy should lead to referral for specialist evaluation. Detection of a cardiac murmur (or...

Diagnostic Definitions Of Pulmonary Hypertension

Pulmonary hypertension is defined as a pulmonary arterial pressure > 25 mm Hg at rest or > 30 mm Hg on exercise, although pulmonary hypertension in childhood is usually associated with considerably higher pressures. Pulmonary hypertension can be described as either primary, being of unknown aetiology, or secondary resulting from cardiac or parenchymal lung disease. This description is unsatisfactory, however, since it takes no account of the similarities in pathobiology and response to...

Management Of The Disease Process

Atherosclerosis should be treated by correction of risk factors such as hyperlipidaemia, smoking, hypertension, diabetes, and polycythaemia. In the presence of classic symptoms and appropriate carotid stenosis a decision to intervene can be based on duplex scan alone. Unless there is a contraindication, aspirin 300 mg day will significantly reduce the incidence of further neurological events. The role of new antiplatelet agents such as clopidogrel and ticlopidine have not been subjected to...

Prevalence Of Risk Factors In Asymptomatic Relatives Of Patients With Premature

A large US study of persons developing CHD before the age of 60 showed that an LDL cholesterol concentration of > 4.1 mmol l was more than twice as common in their asymptomatic siblings below the age of 60 as in the population at large (38 v 16 ).13 Analogous but much less pronounced differences were observed in the European atherosclerosis research study (EARS) which investigated young adults with a paternal history of myocardial infarction before the age of 55.14 In this study the best...

Renal Artery Intervention For The Treatment Of Hypertension

Mitral Regurgitation

Most patients with arteriosclerotic renal artery disease do not have renovascular hypertension. Rather they have essential hypertension that has been complicated by atherosclerosis and the development of a stenotic renal artery lesion. Therefore the correction of renal artery stenosis is unlikely to cure the hypertension, since the exposure of the non-stenotic kidney to the increased blood pressure results in (subclinical) renal injury. Such subtle renal damage is increasingly recognised as an...

Volumetric approach to quantification

In general the approach to regurgitant quantification can be divided into two broad areas volumetric assessment and direct assessment. The volumetric assessment relies on measuring stroke volume in two regions of the heart, one of which includes the regurgitant volume, the other of which includes only the systemic stroke volume.5 The difference between these two stroke volumes is the regurgitant volume through the valve (fig 25.2). For example, in the case of mitral regurgitation, measuring...

Persistent pulmonary hypertension of the newborn

Failure of the pulmonary circulation to adapt normally to extrauterine life causes PPHN, a condition with a high morbidity and mortality despite the advent of inhaled nitric oxide (NO) therapy. PPHN is multifactorial in origin, although commonly associated with congenital and acquired hypoxic lung disease and congenital heart defects. Rarely, it is idiopathic. Irrespective of aetiology, during the first few days of life the intrapulmonary arterial wall structure is similar to that seen in fetal...

References

1 Helmcke F, Nanda NC, Hsiung MC, et al. Color Doppler assessment of mitral regurgitation with orthogonal planes. Circulation 1987 75 175-83. This early paper outlined the use of colour jet area in the assessment of mitral regurgitation, particularly as a proportion of left atrial area. Although it has many limitations, this method is still frequently used. 2 Thomas JD, Liu CM, Flachskampf FA, et al. Quantification of jet flow by momentum analysis. An in vitro color Doppler flow study....

Limitations to the proximal convergence method

There are four important limitations to the proximal convergence method flattening of the contours near the orifice, constraint of the flow by proximal structures, uncertainty in localising the regurgitant orifice, and variability in the regurgitant orifice throughout cardiac cycle. These will be dealt with in turn. Since the regurgitant orifice is in fact not infinitely small, the hemispheric shape of the isovelocity contours is not maintained all the way into the orifice rather, they flatten...

Ctaf 126

Cyclo-oxygenase (COX2) 154 cyclosporine 46, 48 cystic medial degeneration 231, 232 cytochrome C16 218 cytokines 45, 46, 53, 140, 141-2, 152, 219 cytomegalovirus 47 cytosine 197 daclizumab 46 daunorubicin 142 DDD pacing 66 deacetylases 199 death rates, heart failure patients awaiting treatment 43 death receptors, apoptosis via 217-18 deletion analysis, gene promoter 201 denervation, cardiac pharmacology 46 de novo nucleotide synthesis inhibitors 46 dense scar 120 depression, ICD patients 111,...

What Information Is Needed To Define

The severity of symptoms is defined by history but as many patients limit progressively their physical activity, performing exercise testing in asymptomatic patients,31 in particular with oxygen consumption measurement, may unveil unexpected exercise limitations. Left ventricular function is usually assessed by echocardiography. An ejection fraction < 60 or left ventricular end systolic diameter > 45 mm are considered as signs of overt left ventricular dysfunction. Degree of mitral...

Definitive Structure Of The Atrial Septum

Concepts of development, if correct, must provide the basis for understanding definitive atrial structure. When the right atrium is opened parietally, there is, at first sight, an extensive area of potential communication with the cavity of the left atrium (fig 33.7). Sectioning across this area (fig 33.8), however, shows that only a small part is a septal structure, when a septum is defined as that part which can be removed without exiting from the cavities of the heart.16 The parts that can...

C reactive protein

C reactive protein (CRP) is a non-specific marker of inflammation and concentrations are raised in a wide variety of inflammatory disorders. High sensitivity assay methods allow accurate measurement of small increases in CRP and there is evidence that raised concentrations are an independent risk factor for myocardial infarction, peripheral vascular disease, and stroke. The reference range for CRP is 0-2.5 mg l Figure 3.2 Relative risks of myocardial infarction in apparently healthy men...

Problems With Targeting Absolute Risk

The principle of targeting treatment at high absolute CHD risk rather than high cholesterol is now accepted for statin treatment, but the similar policy for antihypertensive treatment is less widely known and practised. Antihypertensive treatment was targeted at defined blood pressure thresholds for decades, and the idea that treatment to lower blood pressure should not be targeted at blood pressure but at CHD risk is difficult for some to grasp. This difficulty is compounded by the intense...

Importance Of Absolute Risk In Hypertension

Hypertension is consistently associated with an increased risk of cardiovascular complications, including stroke, myocardial infarction, heart failure, and renal failure. Antihypertensive treatment decreases the risk of all cardiovascular complications by about 25 , largely through reducing stroke by 38 and coronary events by 16 .6 A key point is that the relative risk reduction, 25 , is approximately constant across all groups of patients,2 meaning that it is similar in men and women, young...

Other Major Risk Factors

Major risk factors other than LDL cholesterol and diabetes are listed in table 3.1. Age, blood pressure, and high density lipoprotein (HDL) cholesterol, as well as total cholesterol, are used as continuous variables to calculate CHD risk in the current Joint British Societies' guidelines, together with cigarette smoking and diabetes as categorical variables.5 Alternatively age, hypertension, low HDL cholesterol, and family history of premature CHD can all be used as categorical variables to...

Info

Figure 12.2 Cumulative incidence of progression to aortic valve replacement in initially asymptomatic patients with severe aortic regurgitation and normal left ventricular function randomised to treatment with digoxin 0.25 mg daily or nifedipine 20 mg twice daily. Reproduced from Scognamiglio etal2 with permission of the Massachusetts Medical Society. Figure 12.2 Cumulative incidence of progression to aortic valve replacement in initially asymptomatic patients with severe aortic regurgitation...

Congenital heart disease

Intrauterine pulmonary vascular disease is unusual, and the disease generally starts at birth.12 The rate of change depends on the type of intracardiac abnormality, but some exceptional children appear to be genetically predisposed to develop an accelerated form of the disease. Endothelial cell damage, medial smooth muscle cell hyperplasia, hypertrophy, and site specific changes in cell phenotype are well described in early infancy12 (fig 22.2). Respiratory unit arteries, about half of which...

Arrhythmia Management General Considerations

Antiarrhythmic treatment of AF can be divided in three strategies termination of the arrhythmia in paroxysmal and persistent AF, maintenance of sinus rhythm in paroxysmal and persistent AF, and finally control of ventricular rate during paroxysmal, persistent, and permanent AF (table 18.1). Removal of precipitating factors such as pericarditis, pulmonary embolism, thyrotoxicosis or excessive alcohol intake may result in disappearance of the arrhythmia. For this reason, a thorough diagnostic...

Control Points For Gene Expression

All of the stages of gene expression are points at which regulation can be exerted. However, the primary point of control is at the level of transcription. Many promoters and enhancers of myocardial genes have been cloned and transcription factors Table 28.1 Some examples of key transcription factors expressed in the heart MADS box family MADS box family SAP domain family CTA(A T)4TAG CC(A T)6GG (AcrG box) Does not bind directly to DNA, but binds to SRF as co-factor TNNAGTG (high affinity) C(a...

Obesity

Obesity commonly precedes the development of hypertension, glucose intolerance, and dyslipidaemia. Several studies have shown a strong positive correlation between the degree of adiposity and fasting triglycerides, even after correcting for other variables. Plasma cholesterol is also positively correlated with body mass index, although less strongly than triglyceride, whereas HDL cholesterol is inversely correlated. The pattern of obesity is also important in that the metabolic effects of...

Epidemiology And Classification Of Dm1

The incidence of DM1 is estimated to be 1 in 8000 births and its worldwide prevalence ranges from 2.1 to 14.3 100 000 inhabitants.1 Based on the age of onset and on its clinical features, DM1 can be divided into three forms congenital, classical, and minimal, which may occur in the same kindred. Congenital DM1 presents at birth or during the first year of life in a severe form. It is characterised by neonatal hypotonia, facial diplegia, joint contractures, frequent and often fatal respiratory...

Fishing with chips the rise of microarrays

Increased use of robotics in molecular biology has led to ways of planting far more genetic information in the form of cDNA or oligonucleotide sequences onto solid matrices than achievable before. Indeed, a complete cDNA library can now be grid-ded onto a single filter (called a gene array), rather than the dozen or so we might have expected to use five years ago. The move to miniaturisation is exemplified by the development of DNA microarrays, where DNAs or oligonucleotides are printed onto...

Impaired glucose tolerance

Impaired glucose tolerance predicts cardiovascular events whether or not this is manifested as overt diabetes. Hyperinsulinaemia is a common accompaniment of impaired glucose tolerance and, as mentioned earlier, the two are frequently associated with other risk factors such as hypertension, obesity, and dyslipidaemia in the metabolic syndrome. Table 3.1 Major risk factors for CHD, other than LDL cholesterol and diabetes.4 Hypertension (> '40 90 mm Hg or on antihypertensive medication) Low HDL...

Aortic Stenosis

Calcific aortic stenosis may be caused by progressive calcification of a congenitally bicuspid valve, when it typically presents in the fourth and fifth decades of life, or senile calcification of a morphologically normal tricuspid valve when it tends to present later in life (fig 12.1). The disease appears to be an active process that has much in common with atherosclerosis and is probably mediated by mechanical stress (wear and tear), lipid deposition, and inflammation significant coronary...

Timing Of Surgical Correction Of Mitral Regurgitation

Mitral Jet

The timing of mitral surgery translates into a simple categorical answer when the patient is seen that is, should we advise the patient to have mitral surgery promptly or should we advise follow up with conservative management This process can be stratified according to aetiology and severity of mitral regurgitation. Severe mitral regurgitation patient has overt symptoms or left ventricular dysfunction These patients with severe mitral regurgitation with overt severe consequences should be...

Clinical And Research Implications Related To

Psychosocial and QOL interventions for ICD patients Table 16.2 details each of the studies available that used psychosocial intervention for ICD patients. General methodological problems are consistent across studies. Firstly, the studies report on very limited sample sizes and incur a resulting low statistical power. Secondly, most of the studies were conducted using a support group format, which typically involves a participant led, unstructured approach rather than a professional led,...

Practical Issues In Exercise Testing

Exercise testing with concurrent measurement of gas exchange parameters can be undertaken using either treadmill or bicycle exercise protocols (table 9.1). Peak Vo2 has been found to be 10-20 higher on treadmill exercise compared to bicycle exercise. Patient familiarity is important and subjects who are unaccustomed to riding bicycles may be unable to sustain bicycle exercise for as long because of leg fatigue. It is important that patients are given time to become accustomed to the...

Consequences Of Erratic Compliance

Stopping and restarting an antihypertensive medication can be dangerous. Studies have demonstrated that omission of dose of a short acting calcium channel blocker or P blocker resulted in significantly increased systolic and diastolic pressure and heart rate during the following two days, with three patients developing rebound hypertension.14 Abrupt discontinuation of non-intrinsic sympathomimetic activity blockers can also result in rebound hypertension.15 Doxazosin, a peripheral vasodilator,...

Determinants of perioperative morbidity

C Extent of coronary artery disease c Ventricular function c Comorbid conditions c Extent of the surgical trauma c Use of cardiopulmonary bypass c Global ischaemic cardiac arrest c Manipulation and instrumentation of the ascending aorta return by utilising the Trendelenburg position with or without additional fluid load and inotropic support.w25 Conventional bypass surgery via full sternotomy and CPB with a decompressed and arrested heart provides sufficient visibility and space to construct...

Echocardiography

LVH on ECG, defined as increased voltage plus T wave abnormality, doubles CHD risk. However, LVH with T wave abnormality is uncommon in hypertensive patients. Echocardiography is more sensitive for detecting LVH in patients with hypertension. Many doctors equate higher sensitivity with more powerful risk prediction and believe that echo-cardiography is superior to the ECG for CHD risk estimation. This is incorrect. Because echocardiographic LVH is more prevalent it is a much less powerful...

Dilated Cardiomyopathy

Indications for transplantation are a guide to the spectrum of causes of severe heart failure. Dilated cardiomyopathy remains the principal indication for cardiac transplantation in children worldwide throughout childhood, apart from infancy when congenital heart disease is a more common indication. The prognosis for dilated cardiomyopathy is around 60 at five years from presentation (fig 20.1), with a high attrition within six months of presentation.1 The genetics of dilated cardiomyopathy...

Pulmonary hypertension and portal hypertension

An increased pulmonary arterial pressure can sometimes complicate the question of liver transplantation and necessitate careful haemodynamic assessment. The pathological features can resemble those found in hypertensive congenital heart disease, possibly caused by vasoconstriction because the damaged liver cannot degrade circulating vasoconstrictor mediator(s). But generalised pulmonary arterial dilatation can also occur. Pulmonary hypertension is not usually a contraindication to liver...

Aneurysm formation and left ventricular thrombus

True aneurysms complicate transmural infarction and are caused by dilatation of an area of scar (fig 24.5). An aneurysm is defined as deformation of both the diastolic and systolic LV contours with dyskinesis in systole. TTE is a sensitive tool for the diagnosis but occasional false negatives occur, usually when the aneurysm involves a small part of the apex or the Figure 24.3 (A) Subcostal long axis transthoracic image showing a large post-infarction rupture (arrow) in the mid inferior...

Development Of The Atrial Septum

During early development, the initially tubular heart is suspended along its length by a dorsal mesocardium. It is at this stage that the so-called straight tube can be recognised, albeit that it has been shown that, with time, this part of the tube gives rise only to the ventricular component of the definitive heart.1011 At the stage when the developing heart tube is straight, the outflow tract, the atrioventricular canal, and the primary atrium have all still to form. With continued growth,...

Paul Schoenhagen Steven Nissen

N 1856 the pathologist Vircho published his no classic observations on atherothrombosis based on the examination of postmortem tomographic artery sections. The Vircho triad describes three components contributing to the atherothrombotic disease process the vessel all, the blood constituents, and blood flo. In vivo coronary imaging techniques became available more than 100 years later ith the introduction of selective coronary angiography in 1958 by Mason Sones. Selective coronary angiography...

Accuracy Of Framingham Risk Estimates

Framingham risk estimates are acceptably accurate in North American, UK, and northern European populations, but underestimate absolute risk in populations with much lower rates of cardiovascular disease than North America for example, some Far Eastern and Mediterranean populations. Framingham may not be accurate in individuals from certain ethnic groups such as British Asians. The Framingham function incorporates the most powerful predictors of cardiovascular disease and omitted family history...

External and internal DC cardioversion

Since the description of direct current electrical cardioversion of AF by Lown in 1962, this procedure has been widely used for restoration of sinus rhythm.5 External cardioversion may be applied in the anterolateral or anteroposterior position and is successful in up to 90 of cases. Outcome depends on a carefully performed procedure using firm pressure on appropriately placed paddles and a sufficient amount of energy. Biphasic shocks are more effective than conventional monophasic shocks.w24...