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Three female patients, a 22-year-old Moroccan woman, a 25-year-old Turkish woman and a 35-year-old Iraqi woman, became increasingly dyspnoeic during their pregnancy; this was a symptom of congestive heart failure due to mitral valve stenosis. Since all patients were refractory to medical treatment, they underwent invasive therapy by percutaneous transvenous mitral balloon valvotomy (PTMV). In two patients this therapy was successful, but in one patient a closed mitral valvotomy was needed. All three women delivered healthy infants, two immediately following the PTMV; at follow-up 2-4 years later, the women and infants were all doing well. The prevalence of mitral valve stenosis in the western world is increasing because of changing immigration patterns. When pregnant patients start complaining about dyspnoea, especially if they are immigrants, one should be aware of the possibility of mitral valve stenosis. PTMV is a safe and successful treatment for these patients and is preferred above surgical therapy because of its low morbidity and mortality for both mother and foetus. PTMV must be performed in a thoracic surgery centre by an experienced team and the X-ray exposure should be minimised.

Dilated congestive heart failure due to systolic left ventricle dysfunction frequently leads to intraventricular conduction disturbances with a prolonged QRS complex (120 ms). The prolonged conduction time in the ventricles causes electrical asynchrony of the ventricles and contributes to a further reduction of systolic function, changes of filling and relaxation intervals, and promotes mitral valve insufficiency. Chronic simultaneous stimulation of both the right and left ventricle in patients with severe heart failure improves functional status, quality of life, and exertion tolerance. At present the implantation of a biventricular pacemaker is time consuming because the positioning of the lead in a left ventricular epicardial vein is difficult. As congestive heart failure is frequently associated with an increased risk of ventricular fibrillation, the combined implantation of a biventricular stimulator and an implantable automatic defibrillator is sometimes necessary. Preliminary calculations show that about 750 patients per year with severe congestive heart failure are eligible for a biventricular stimulator.

To carry out a survey of the numbers of patients in the Netherlands who received a pacemaker in 1984-1997 and the types of pacemaker.Retrospective, descriptive.Information on pacemaker patients and pacemakers in the Netherlands during the years 1984-1997 was obtained from the Dutch Pacemaker Patient Registration organisation and those in 15 other West-European countries from the European Working Group on Cardiac Pacing. Both organisations use the European Pacemaker Identification Card. Demographic information was collected via Statistics Netherlands.In the Netherlands, 23 and 28 primo-implantations/100,000 inhabitants were carried out in 1984 and 1997 respectively. The increase was primarily due to a higher number of implants in people65 years of age. The 1997 implant figures were lower than the average in Western Europe (34/100,000). In 1997 there was no difference in gender, mean age at the time of first implant, indications and aetiology between the Netherlands and Western Europe. With respect to the choice of type of pacemaker implanted--VVI(R) or DDD(R)-in Western Europe, the Netherlands lay in the middle. Between 1984 and 1997, the number of Dutch centres with 1-25 implants/year decreased while the number with 51-130 implants/year increased.In 1997 the number of primo-implantations at Dutch centres increased in comparison with 1984, but less than the West European average. Implants were increasingly performed in high-volume centres.

To compare the long-term results of surgical modification and of radiofrequency (RF) catheter modification of the atrioventricular node (AV node), to combat recurrent atrioventricular nodal re-entrant tachycardia (AVNRT).Retrospective descriptive.St. Antonius Hospital, Nieuwegein, the Netherlands.In the period 1988-1992, 26 patients underwent surgical modification and in 1991-1996, 120 patients were subjected to RF catheter modification of the AV node for recurrent AVNRT. The follow-up amounted to at least one year.Surgery was immediately successful in 96%, and RF catheter ablation in 92%. A recurrence AVNRT was seen in 12 and 17% respectively, the ultimate success rates (after retreatment) were 100 and 98%. Three patients (3%) in the RF catheter ablation group developed a second or third-degree AV block necessitating pacemaker implantation. No third-degree AV block was seen in the surgical group. Mean follow-up was 53 months in the surgical group and 28 months in the RF catheter ablation group. Both procedures were accompanied by other supraventricular tachycardias, viz. in 27% of the surgical and in 11% of the RF catheterization ablation group.RF catheter ablation for the treatment of AVNRT had early and long-term results comparable with those of rhythm surgery. Since catheter treatment is far less taxing to the patient than rhythm surgery, RF catheter ablation now constitutes the most appropriate method for treatment of this arrhythmia.

To describe the results of treatment of patients with a life-threatening arrhythmia by implantation of an second generation implantable cardioverter defibrillator with transvenous electrodes.Descriptive.St.-Antonius Hospital, Nieuwegein, the Netherlands.In the period October 1991-February 1996 the ICD with transvenous electrodes was implanted in 44 patients. After a year the quality of life was assessed by written questionnaire.The in-hospital mortality was 1/44 (2%), without peroperative death. During follow-up 4 patients died: 3 due to congestive heart failure and 1 due to sudden cardiac death. Within one year 50% of the patients had a therapeutical ICD discharge. In 30/44 (68%) patients antiarrhythmic drugs were prescribed to reduce the number of ICD discharges or because they were suffering from paroxysmal atrial fibrillation with high heart rates, which could result in an inappropriate ICD discharge. Quality of life analysis showed a good acceptance of the ICD, although 86% of the patients considered it a very serious limitation that they were not allowed to drive a motor vehicle anymore.The ICD constitutes a major step forward in the treatment of life-threatening ventricular arrhythmias because the implantation is easier and follow-up shows adequate antiarrhythmic effects and survival.

From 1980 to 1988 direct arrhythmia surgery was performed in 121 patients suffering from postinfarction drug-refractory ventricular tachycardia (VT). By 1986 the initially high in-hospital mortality of 26% (18 of 69 patients) had decreased to 1.9% (1 of 52 patients). The 3-year actuarial survival of patients operated since 1986 is 90%. From 1985 the results of surgical therapy of VT have improved: 86% of the patients remained arrhythmia-free without drugs; none died suddenly. Residual left ventricular function was related to the prognosis, but the interval between the last myocardial infarction and time of surgery or the surgical technique were not. These results demonstrate that direct surgery has become a valuable method in the treatment of postinfarction VT, at least in patients with sufficient residual left ventricular function.