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To link to full-text access for this article, visit this link: http://dx.doi.org/10.1016/j.jtcvs.2009.11.063 Byline: Bishow Pokhrel, Tomomi Hasegawa, So Izumi, Atsushi Ohmura, Hiroshi Munakata, Yutaka Okita, Kenji Okada Abbreviations: BP, blood pressure; MPO, myeloperoxidase; MTS, modified Tarlov scale; OD, optical density; SCI, spinal cord ischemia; SCR, spinal cord reperfusion; tc-MEP, transcranial motor-evoked potential; TUNEL, terminal deoxynucleotidyl transferase-mediated deoxyuridine triphosphate nick-end labeling Abstract: We have demonstrated that therapeutic augmentation of systemic blood pressure during spinal cord ischemia plays an important role in minimizing spinal cord injury in both experimental and clinical aortic surgery. However, there remain concerns that excessively high blood pressure during spinal cord reperfusion may aggravate the reperfusion injury. The purpose of this study is to investigate the effect of high blood pressure during spinal cord reperfusion on postoperative neurologic outcomes after aortic surgery in rabbits. Author Affiliation: Department of Surgery, Divisions of Cardiovascular Surgery, Kobe University Graduate School of Medicine, Kobe, Japan Article History: Received 2 September 2009; Revised 6 November 2009; Accepted 26 November 2009 Article Note: (footnote) Disclosures: None.

To link to full-text access for this article, visit this link: http://dx.doi.org/10.1016/j.amjsurg.2009.08.040 Byline: Donald W. Buck (a), Jordan P. Steinberg (a), Jonathan Fryer (b), Gregory A. Dumanian (a) Keywords: Ventral hernia; Separation of parts; Components separation; Dysmotility; Abdominal compartment syndrome; Intra-abdominal hypertension; Small bowel resection; Bowel obstruction Abstract: Hernia patients with a history of recurrent bowel obstructions, chronic bowel dysmotility, and bowel distension have few options for return to a 'normal' life. Return of the bowel and adhesiolysis seems the logical surgical solution, but the return of a swollen distended bowel into the abdominal cavity would put patients at a high risk for the development of abdominal compartment syndrome. Hernia repair with large pieces of mesh under tenuous skin flaps to incorporate the bowel into the abdominal cavity has its own set of devastating complications, including mesh infection, extrusion, and fistula formation. Author Affiliation: (a) Division of Plastic and Reconstructive Surgery, Northwestern University, Feinberg School of Medicine, 675 N St Clair Street, Galter 19-250, Chicago, IL 60611 (b) Division of Transplant Surgery, Northwestern University, Feinberg School of Medicine, Chicago, IL, USA Article History: Received 4 June 2009; Revised 17 August 2009

To link to full-text access for this article, visit this link: http://dx.doi.org/10.1016/j.jtcvs.2009.08.038 Byline: So Izumi, Kenji Okada, Tomomi Hasegawa, Atsushi Omura, Hiroshi Munakata, Masamichi Matsumori, Yutaka Okita Abbreviations: BP, blood pressure; HBP, high blood pressure; LBP, low blood pressure; LLI, lower limb ischemia; MAP, mean arterial pressure; MTS, modified Tarlov scale; SBP, systemic blood pressure; SCBF, spinal cord blood flow; SCI, spinal cord ischemia; SSEP, somatosensory evoked potential; tc-MEP, transcranial motor evoked potential; TUNEL, terminal deoxynucleotidyl transferase-mediated deoxyuridine triphosphate nick-end labeling Abstract: Paraplegia from spinal cord ischemia remains an unresolved complication in thoracoabdominal aortic surgery, with high morbidity and mortality. This study investigated postoperative effects of systemic blood pressure augmentation during ischemia. Author Affiliation: Department of Surgery, Division of Cardiovascular Surgery, Kobe University Graduate School of Medicine, Kobe, Japan Article History: Received 12 May 2009; Revised 15 July 2009; Accepted 9 August 2009 Article Note: (footnote) Disclosures: None.

To link to full-text access for this article, visit this link: http://dx.doi.org/10.1016/j.jtcvs.2008.11.007 Byline: Gorav Ailawadi, Christine L. Lau, Philip W. Smith, Brian R. Swenson, Sara A. Hennessy, Courtney J. Kuhn, Lynn M. Fedoruk, Benjamin D. Kozower, Irving L. Kron, David R. Jones Abbreviations: ATGAM, antithymocyte globulin; CMV, cytomegalovirus; COPD, chronic obstructive pulmonary disease; ECMO, extracorporeal membrane oxygenation; Fio.sub.2, fraction of inspired oxygen; ISHLT, International Society for Heart and Lung Transplantation; LTX, lung transplantation; NO, nitric oxide; OI, oxygenation index; OPO, organ procurement organization; P/F, Pao.sub.2/Fio.sub.2; PGD, primary graft dysfunction; PPH, primary pulmonary hypertension; RI, reperfusion injury Abstract: Severe reperfusion injury after lung transplantation has mortality rates approaching 40%. The purpose of this investigation was to identify whether our improved 1-year survival after lung transplantation is related to a change in reperfusion injury. Author Affiliation: Department of Surgery, University of Virginia, Charlottesville, Va Article History: Received 9 May 2008; Revised 21 August 2008; Accepted 6 November 2008 Article Note: (footnote) Read at the Eighty-eighth Annual Meeting of the American Association for Thoracic Surgery, San Diego, Calif, May 12-14, 2008., Supported in part through National Institutes of Health Cardiovascular Surgery Research Training grant T32 HL007849 (to PWS).

To link to full-text access for this article, visit this link: http://dx.doi.org/10.1016/j.amjsurg.2005.05.035 Byline: John R. Gosche, Saleem Islam, Scott C. Boulanger Keywords: Branching morphogenesis; Congenital diaphragmatic hernia; Pulmonary hypertension; Pulmonary hypoplasia Abstract: Pulmonary hypoplasia and hypertension are the primary causes of morbidity and mortality in infants with congenital diaphragmatic hernia (CDH). At present, the origin of CDH and the causes of pulmonary hypoplasia and hypertension are unknown. Author Affiliation: Division of Pediatric Surgery, University of Mississippi Medical Center, 2500 N. State St., Jackson, MS 39216, USA Article History: Received 13 April 2005; Accepted 15 April 2005

High blood pressure in the brain rather than increased blood flow may cause the seizures that occur in women with a serious complication of pregnancy called preeclampsia. A study of 192 pregnant women with preeclampsia found that blood flow in the brain was normal but blood pressure was higher than normal.

Hypertension during pregnancy may lead to lower birth weights, according to a study of 237 women. This was especially true if diastolic blood pressure was elevated. The link between low birth weight and hypertension may be due to a genetic susceptibility to hypertension.

Byline: S.Scott Huerd, T.N. Hodges, F.L. Grover, J.R. Mault, M.B. Mitchell, D.N. Campbell, Salim Aziz, P. Chetham, F. Torres, M.R. Zamora Abstract: Objective: Primary and secondary pulmonary hypertension have been associated with poor outcomes after single lung transplantation. Some groups advocate double lung transplantation and the routine use of cardiopulmonary bypass during transplantation in this population. However, the optimal procedure for these patients remains controversial. The goal of our study was to determine the safety of single lung transplantation without cardiopulmonary bypass in patients with secondary pulmonary hypertension. Methods: We retrospectively reviewed 76 consecutive patients with pulmonary parenchymal disease who underwent single lung transplantation from 1992 to 1998. Recipients were stratified according to preoperative mean pulmonary artery pressure. Secondary pulmonary hypertension was defined as parenchymal lung disease with a preoperative mean pulmonary artery pressure of 30 mm Hg or more. Patients with primary pulmonary hypertension or Eisenmenger's syndrome were excluded from analysis. Results: Eighteen of 76 patients had secondary pulmonary hypertension. No patient with secondary pulmonary hypertension required cardiopulmonary bypass, whereas 1 patient without pulmonary hypertension required bypass. After the operation, no significant differences were seen in lung injury as measured by chest radiograph score and PaO.sub.2/FIO.sub.2 ratio, the requirement for inhaled nitric oxide, the length of mechanical ventiliation, the intensive care unit or hospital length of stay, and 30-day survival. There were no differences in the forced expiratory volume in 1 second or 6-minute walk at 1 year, or the incidence of rejection, infection, or bronchiolitis obliterans syndrome greater than grade 2. Survival at 1, 2, and 4 years after transplantation was 86%, 79%, and 65%, respectively, in the low pulmonary artery pressure group and 81%, 81%, and 61%, respectively, in the group with secondary pulmonary hypertension (P > .2). Conclusion: We found that patients with pulmonary parenchymal disease and concomitant secondary pulmonary hypertension had successful outcomes as measured by early and late allograft function and appear to have acceptable long-term survival after single lung transplantation. Our results do not support the routine use of cardiopulmonary bypass or double lung transplantation for patients with this disorder. (J Thorac Cardiovasc Surg 2000;119:458-65) Author Affiliation: From the Divisions of Cardiothoracic Surgery,.sup.a Pulmonary Medicine,.sup.b and Anesthesiology,.sup.c University of Colorado Health Sciences Center, Denver, Colo Article History: Received 22 April 1999; Revised 15 June 1999; Revised 8 November 1999; Accepted 16 November 1999 Article Note: (footnote) [star] Read at the Seventy-ninth Annual Meeting of The American Association for Thoracic Surgery, New Orleans, La, April 18-21, 1999., [star][star] Address for reprints: Frederick L. Grover, MD, Department of Surgery, Division of Cardiothoracic Surgery, Campus Box C-310, University of Colorado Health Sciences Center, 4200 E Ninth Ave, Denver, CO 80262.

Byline: Brian P. Fitzsimmons, Michael W. Bebbington, Margo R. Fluker Keywords: Multiple pregnancy; assisted reproduction; perinatal outcomes Abstract: Objective: Our purpose was to test the hypothesis that multiple pregnancies resulting from assisted reproductive therapy have a better outcome than those resulting from spontaneous conception. Study Design: This was a retrospective cohort study. Cases came from pregnancies from assisted reproductive techniques. Controls were identified from spontaneous multiple pregnancies delivered in the same time period. Matching was done for maternal age, parity, fetal number, and presence of maternal medical problems. A total of 72 cases (56 twins and 16 triplets) and 124 controls (108 twins and 16 triplets) were studied. The primary outcome was perinatal mortality. Secondary outcomes were preterm delivery, birth weight, maternal complications, neonatal morbidity, and length of hospitalization. Results: Perinatal mortality is significantly increased in spontaneous twin gestations compared with twins resulting from assisted reproductive techniques (24 vs 2, P = .003). No difference is seen in the perinatal mortality in triplets. Mean gestational age at diagnosis was lower for twins and triplets resulting from assisted reproductive techniques (9.4 vs 13.3; P < .001 and 8.8 vs 15.8; P < .001, respectively). Rate of cerclage and number of prenatal visits was higher for triplets in the assisted reproductive techniques group (P = .05 and .02, respectively). Mean gestational age at delivery, birth weight, rate of preterm labor, preterm premature rupture of membranes, pregnancy-induced hypertension, and incidence of gestational diabetes were not significantly different between the groups. No significant differences in neonatal morbidity were detected. Conclusions: Assisted reproductive techniques-associated twins have lower perinatal mortality than spontaneously conceived twins. Perinatal and neonatal morbidity, gestational age at delivery, and birth weight are not affected by assisted reproductive techniques, even with closer surveillance and earlier gestational age at diagnosis in this group. Differences may be due to a higher frequency of monochorionic placentation in the spontaneously conceived group. (Am J Obstet Gynecol 1998;179:1162-7.) Author Affiliation: Vancouver, British Columbia, Canada Article Note: (footnote) [star] From the Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of British Columbia,a and the Department of Obstetrics and Gynecology, University of British Columbia, Genesis Fertility Center.b , [star][star] Reprints not available from the authors., a 0002-9378/98 $5.00 + 0 6/6/93538

Byline: Oguz Tasdemir, Kerem M. Vural, Haldun Karagoz, Kemal Bayazit Abstract: Objective: A total of 2052 patients operated on with the off-pump technique (coronary artery bypass grafting on the beating heart without the use of extracorporeal circulation) between June 1993 and March 1996 are retrospectively reviewed. Predictors for early mortality, perioperative myocardial infarction, and low cardiac output state were statistically analyzed. Method: Our indications for an off-pump procedure were either patients with technically suitable coronary lesions (the vast majority) or patients who could not tolerate cannulation, hypothermia, or cardiopulmonary bypass because of the poor left ventricular function (198 patients) and/or associated diseases or conditions (73 patients). Results: Overall operative mortality was 1.9% and perioperative myocardial infarction occurred in 59 patients (2.9%). According to logistic regression analysis, associated bronchial asthma (p = 0.0001), hypertension (p = 0.05), poor quality of the left anterior descending artery (p = 0.02), and ungrafted circumflex coronary artery disease (p = 0.007) were the early mortality predictors. Nonbypassed circumflex disease was also associated with a high incidence of perioperative myocardial infarction and low cardiac output state. No homologous blood or packed red cell transfusion was required in 74.2% of the patients. Conclusion: On the basis of the presented data, off-pump coronary artery bypass grafting appeared to be a safe and effective technique in selected patients with appropriate coronary lesions. (J Thorac Cardiovasc Surg 1998;116:68-73) Article History: Received 1 July 1997; Revised 14 October 1997; Revised 17 February 1998; Accepted 23 February 1998 Article Note: (footnote) [star] From the Cardiovascular Surgery Department at Turkiye Yuksek Ihtisas Hospital, Ankara, Turkey., [star][star] Address for reprints: Kerem M. Vural, MD, N. Tandogan cad. 5/6 Kavaklidere 06540, Ankara, Turkey., a 12/1/89804

Byline: James S. Gammie, Jung Cheul Lee, Si M. Pham, Robert J. Keenan, Robert J. Weyant, Brack G. Hattler, Bartley P. Griffith Abstract: Objectives: To assess the effect of cardiopulmonary bypass on allograft function and recipient survival in double-lung transplantation. Methods: Retrospective review of 94 double-lung transplantations. Results: Cardiopulmonary bypass was used in 37 patients (CPB); 57 transplantations were accomplished without bypass (no-CPB). Bypass was routinely used for patients with pulmonary hypertension (n = 27) and for two recipients undergoing en bloc transplantation. Cardiopulmonary bypass was required in eight (12.3%) of the remaining 65 patients. Mean ischemic time was longer in the CPB group (346 vs 315 minutes, p = 0.04). The CPB group required more perioperative blood (11.4 vs 6.0 units, p = 0.01). Allograft function, assessed by the arterial/alveolar oxygen tension ratio, was better in the no-CPB group at 12 and 24 hours after operation (0.54 vs 0.39 at 12 hours, p = 0.002; and 0.63 vs 0.38 at 24 hours, p = 0.001). The CPB group had more severe pulmonary infiltrates at both 1 and 24 hours (p = 0.005). Diffuse alveolar damage was more common in the CPB group (69% vs 35%, p = 0.002). Median duration of intubation was longer in the CPB group (10 days) than in the no-CPB group (2 days, p = 0.002). The 30-day mortality rate (13.5% vs 7.0% in the CPB and no-CPB groups) and 1-year survival (65% vs 67%, CPB and no-CPB) were not significantly different. Conclusions: In the absence of pulmonary hypertension, cardiopulmonary bypass is only occasionally necessary in double-lung transplantation. Bypass is associated with substantial early allograft dysfunction after transplantation. (J Thorac Cardiovasc Surg 1998;115:990-7) Article History: Received 10 March 1997; Revised 21 May 1997; Revised 11 December 1997; Accepted 11 December 1997 Article Note: (footnote) [star] From the Division of Cardiothoracic Surgery, The University of Pittsburgh Medical Center, Pittsburgh, Pa., [star][star] Address for reprints: James S. Gammie, MD, University of Pittsburgh, Division of Cardiothoracic Surgery, C-700 Scaife, 200 Lothrop St., Pittsburgh, PA 15213., a 12/6/88211

Byline: Jonathan M. Chen, Howard R. Levin, Robert E. Michler, Chad J. Prusmack, Eric A. Rose, Keith D. Aaronson Abstract: Objectives: Right-sided circulatory failure resulting from severe preoperative pulmonary hypertension is a source of mortality early after cardiac transplantation. We undertook the present study (1) to analyze the association of elevated pulmonary hemodynamic indices with 30-day mortality, (2) to define threshold ranges associated with an increase in 30-day mortality, and (3) to evaluate the effect of vasodilator reversibility on 30-day mortality. Methods: Preoperative hemodynamic profiles were evaluated in 476 patients who ultimately underwent cardiac transplantation. From these data, receiver-operating characteristic curves and stratum-specific likelihood ratios were generated to compare the efficacy of each hemodynamic index. A subset of patients with elevated hemodynamic profiles at baseline additionally underwent graded sodium nitroprusside infusion. Results: Analysis of receiver-operating characteristic curves demonstrated no statistically significant difference among the indices in their ability to predict 30-day mortality. Analysis of stratum-specific likelihood ratios demonstrated three risk strata that correlated with significant differences in 30-day mortality, with patients in the high-risk stratum having a 3.2 to 4.4 increase in odds of 30-day mortality when compared with patients in the low-risk stratum. Nitroprusside data demonstrated that although 30-day mortality was better in patients with reversible pulmonary hypertension than in those with fixed pulmonary hypertension, it was not comparable with that of patients without pulmonary hypertension at baseline. Conclusions: Candidates for cardiac transplantation may be categorized into three risk strata on the basis of their preoperative pulmonary hemodynamic profile; the association of this profile with 30-day mortality is not linear. Reversibility with nitroprusside appears to confer some improvement in the risk of 30-day mortality, but it may not eliminate the risk entirely. (J Thorac Cardiovasc Surg 1997;114:627-34) Article History: Received 6 December 1996; Revised 14 January 1997; Revised 12 May 1997; Accepted 16 May 1997 Article Note: (footnote) [star] From the Departments of Surgery (Division of Cardiothoracic Surgery)a and Medicine (Division of Circulatory Physiology),b Columbia University College of Physicians & Surgeons, New York, N.Y., [star][star] Address for reprints: Jonathan M. Chen, MD, Department of Surgery, Presbyterian Hospital No. 295, 622 West 168th St., New York, NY 10032., a 0022-5223/97 $5.00 + 0 12/1/83414

Byline: Andrea G. Witlin, Steven A. Friedman, Robert S. Egerman, Antoine Y. Frangieh, Baha M. Sibai Keywords: Cerebrovascular disorders; eclampsia; pregnancy Abstract: OBJECTIVE: Our purpose was to investigate the problems encountered in the diagnosis and management of cerebrovascular disorders associated with pregnancy and the puerperium. STUDY DESIGN: Pregnancies complicated by cerebrovascular disorders were identified by retrospective chart review (1985 to 1995). Events associated with trauma, neoplasm, drug ingestion, and infection were excluded. RESULTS: The study population comprised 24 women with a variety of cerebrovascular disorders: 14 with infarction (5 arterial, 9 venous), 6 with intracranial hemorrhage (3 anatomic malformation, 3 unknown etiology), 3 with hypertensive encephalopathy, and 1 with an unruptured aneurysm. Blood pressure reflected physical condition at presentation and did not predict diagnosis or outcome except in the 3 women with hypertensive encephalopathy. Only 4 of 14 women with infarction and 1 of 6 with intracranial hemorrhage had a diastolic blood pressure [greater than or equal to]110 mm Hg. Presumption of eclampsia delayed the diagnosis in 10 women (41.7%). In addition, patient delay in seeking medical attention complicated 10 cases. After review, none of the adverse maternal outcomes were deemed preventable by earlier physician intervention. Seven maternal deaths occurred (29.2%). Neonatal outcome was related to the gestational age and the maternal condition at presentation. CONCLUSION: Cerebrovascular disorders are an uncommon and unpredictable complication of pregnancy that are associated with substantial maternal and fetal mortality. Suspected eclampsia unresponsive to magnesium sulfate therapy warrants an immediate neuroimaging study. Interestingly, in women with intracranial hemorrhage, severe hypertension was not an associated predictive factor. (Am J Obstet Gynecol 1997;176:1139-48.) Author Affiliation: Memphis, Tennessee Article Note: (footnote) [star] From the Department of Obstetrics and Gynecology, University of Tennessee, Memphis., [star][star] Reprint requests: Baha M. Sibai, MD, University of Tennessee, Memphis, 853 Jefferson, E102, Memphis, TN 38103., a 0002-9378/97 $5.00 + 0 6/6/81341

Byline: Jean-Paul A. Couetil, Michael J. Tolan, Didier F. Loulmet, Alain Guinvarch, Patrick G. Chevalier, Antoine Achkar, Peter Birmbaum, Alain F. Carpentier Abstract: The scarcity of small donors has significantly limited lung transplantation for pediatric and small adult patients. Use of single lobes procured from size-unmatched donors has overcome this difficulty, but only in a few selected cases and, in addition, it represents a waste of lung tissue. In an animal model we have shown that it is possible to divide one lung with careful partitioning of the vascular and bronchial structures and thus obtain two viable lobar grafts suitable for bilateral implantation in a smaller animal. We have now applied this procedure clinically in seven patients operated on between May 1993 and November 1994. The indications were cystic fibrosis in three children, primary pulmonary hypertension in two adults, bronchiectasis in one, and idiopathic pulmonary fibrosis in one. There were three children aged 13 to 17 years (median 14) and four adults aged 40 to 53 years (median 45). There was a 46% to 50% discrepancy for weight between recipient and donor and a 12% to 17% discrepancy for height. The surgical technique consisted of careful partitioning of the left donor lung, bilateral anterior thoracotomy in the recipient, and, with the use of cardiopulmonary bypass, implantation of the lower lobe in the left hemithorax and the upper lobe in the right hemithorax. Vascular and bronchial connections were facilitated by leaving a long pedicle on the recipient side. The pulmonary artery anastomosis for the donor left upper lobe was done with the 'fissure' side of the artery to ensure an anastomosis without tension. An end-to-end bronchial anastomosis overcame the problem of size discrepancy. Six patients are alive and well 10 to 27 months (median 19) after operation. One patient with cystic fibrosis died of systemic aspergillosis infection. All were discharged from the hospital within the first or second postoperative month. No technical problems were identified: repeated bronchoscopy has demonstrated satisfactory healing without early stricture formation. All patients remain well subjectively with good exercise tolerance and all patients achieve greater than 70% of predicted values of forced expiratory volume in 1 second. Perfect adaptation of the transplanted lobes to the recipient pleural space has been demonstrated by postoperative computed tomographic scan. In conclusion, bilateral lobar transplantation from a single donor lung is possible in small adults or children when there is a large size discrepancy with the donor. This may help resolve the problem of donor availability in the pediatric population. (J Thorac Cardiovac Surg 1997;113:529-37) Article History: Received 22 December 1995; Revised 28 March 1996; Revised 4 September 1996; Accepted 24 September 1996 Article Note: (footnote) [star] From the Department of Cardiothoracic Surgery,a Broussais Hospital, Paris, and the HA[acute accent]tel Dieu Hospital,b Paris, France., [star][star] Read at the Seventy-fourth Annual Meeting of The American Association for Thoracic Surgery, New York, N.Y., April 24-27, 1994., a Address for reprints: Jean-Paul A. Couetil, MD, Department of Cardiovascular Surgery, Broussais Hospital, 96, Rue Didot, 75014 Paris, France., aa 0022-5223/97 $5.00 + 0 12/1/78174

PURPOSE: Blood pressure in individuals who have sickle cell disease has been reported to be lower than published normal values. We determine whether and to what degree this is true, using data obtained as part of a large natural history study. PATIENTS AND METHODS: Blood pressure was measured annually for 3,317 subjects with sickle cell disease who were 2 years old or older. Values obtained were compared with those reported by the National Health and Nutrition Examination Survey I and II (NHANES I and II). They were further analyzed with respect to age, sex, height, weight, hematologic diagnosis, blood urea nitrogen and creatinine, stroke, and death. RESULTS: Blood pressure was significantly lower in subjects with sickle cell anemia than published norms for age, race, and sex, a difference that increased with age. It correlated with body mass index, hemoglobin, measures of renal function and age, but the strength of the correlation varied among age and sex subgroups. The risk for occlusive stroke increased with systolic but not diastolic pressure. Mortality was related to elevated blood pressure in males (P [is less than] 0.05) and to a lesser extent in females (P = 0.10). In subjects with hemoglobin SC disease, blood pressure also deviated from normal but to a lesser degree. CONCLUSION: Blood pressure is generally lower than normal in individuals with sickle cell anemia. Those with high values relative to this population had an increased risk of stroke and death. Blood pressure should be monitored but values obtained must be assessed relative to the lower values expected for patients with this disease. Those with blood pressure values above 140/90 mm Hg should be evaluated and considered for treatment.

To link to full-text access for this article, visit this link: http://dx.doi.org/10.1016/S0002-9378(97)80033-6 Byline: Andrea G. Witlin, William C. Mabie, Baha M. Sibai Keywords: Cardiomyopathy; pregnancy; maternal outcome Abstract: OBJECTIVE: Our purpose was to review and characterize the initial presentation, etiology, and prognosis of peripartum cardiomyopathy. STUDY DESIGN: Cases of peripartum cardiomyopathy confirmed by echocardiography were prospectively collected between 1986 and 1994. RESULTS: A total of 28 patients without an antecedent history of heart disease were diagnosed with peripartum cardiomyopathy. Common associated disorders included preeclampsia or chronic hypertension (19), alcohol abuse (2), family history (2), and multiple tocolytic therapy (2). Five deaths occurred (18% mortality), 3 patients received heart transplants (11%), 18 continued with cardiac impairment (64%), and only 2 patients (7%) had regression of cardiomyopathy. The perinatal mortality rate was 36 per 1000 births. Six patients had seven subsequent pregnancies; 4 patients decompensated earlier in the subsequent pregnancy, 1 patient remained well compensated on medical therapy in spite of poor systolic function and a dilated left ventricle, and 1 patient had two subsequent pregnancies without recurrence of cardiac compromise. CONCLUSION: The unique hemodynamic stresses of pregnancy unmask previously undiagnosed cardiomyopathy in otherwise medically stable individuals. The prognosis for these patients is guarded. (Am J Obstet Gynecol 1997;176:182-8.) Author Affiliation: Memphis, Tennessee Article History: Received 17 April 1996; Revised 13 June 1996; Accepted 6 August 1996 Article Note: (footnote) [star] From the Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of Tennessee, Memphis., [star][star] Reprint requests: Baha M. Sibai, MD, E.H. Crump Women's Hospital, Suite E102, 853 Jefferson Ave., Memphis, TN 38103-2896., a 6/1/77096

Byline: Andrea G. Witlin, William C. Mabie, Baha M. Sibai Abstract: Objective: Our purpose was to review and characterize the initial presentation, etiology, and prognosis of peripartum cardiomyopathy. Study Design: Cases of peripartum cardiomyopathy confirmed by echocardiography were prospectively collected between 1986 and 1994. Results: A total of 28 patients without an antecedent history of heart disease were diagnosed with peripartum cardiomyopathy. Common associated disorders included preeclampsia or chronic hypertension(19), alcohol abuse(2), family history (2), and multiple tocolytic therapy (2). Five deaths occurred (18% mortality), 3 patients received heart transplants (11%), 18 continued with cardiac impairment (64%), and only 2 patients (7%) had regression of cardiomyopathy. The perinatal mortality rate was 36 per 1000 births. Six patients had seven subsequent pregnancies; 4 patients decompensated earlier in the subsequent pregnancy, 1 patient remained well compensated on medical therapy in spite of poor systolic function and a dilated left ventricle, and 1 patient had two subsequent pregnancies without recurrence of cardiac compromise. Conclusion: The unique hemodynamic stresses of pregnancy unmask previously undiagnosed cardiomyopathy in otherwise medically stable individuals. The prognosis for these patients is guarded. Author Affiliation: Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of Tennessee, Memphis, Tennessee USA Article History: Received 17 April 1996; Revised 13 June 1996; Accepted 6 August 1996

Byline: Ko Bando, Mark W. Turrentine, Thomas G. Sharp, Yasuo Sekine, Thomas X. Aufiero, Kyung Sun, Eri Sekine, John W. Brown Abstract: Background: Management of pulmonary hypertension, a potentially fatal complication of operations to correct congenital heart disease, has evolved through the last 15 years. Monitoring of pulmonary arterial pressure and mixed venous saturation became available, and prophylactic use of [alpha]-blockers and other vasodilators increased. This study examines risk factors for morbidity and mortality from pulmonary hypertension after operations to correct congenital heart disease and evaluates the impact of management changes on outcomes. Methods: By means of multivariable logistic regression analysis, 880 high-risk patients with congenital heart disease (of 2484 patients undergoing cardiopulmonary bypass between January 1980 and December 1994) were analyzed to determine which were at risk for postoperative pulmonary hypertension and its associated morbidity and mortality. Results: Patients with atrioventricular canal (n = 182), truncus arteriosus (n = 47), total anomalous pulmonary venous connection (n = 90), transposition of great arteries (n = 97), hypoplastic left heart syndrome (n = 50), and ventricular septal defect (n = 414) demonstrated a higher risk of postoperative pulmonary hypertension. By multivariable logistic regression, preoperative pulmonary hypertension (p < 0.0001), absence of mixed venous saturation monitoring (p < 0.0001), and absence of prophylactic [alpha]-blockade (p = 0.0004) significantly increased postoperative pulmonary hypertension. Preoperative pulmonary hypertension (p < 0.001) and absence of prophylactic [alpha]-blockers (p = 0.0004) were significant risk factors for in-hospital death related to pulmonary hypertension. Repair at older age (except in the case of total anomalous pulmonary venous connection) was a significant risk for postoperative pulmonary hypertension (p = 0.03). Conclusion: Mixed venous saturation monitoring and [alpha]-receptor blockade reduced the incidence of pulmonary hypertension after operations for congenital heart disease. Early definitive repair reduced morbidity and mortality from postoperative pulmonary hypertension. (J Thorac Cardiovasc Surg 1996;112:1600-9) Article History: Received 6 May 1996; Revised 26 June 1996; Revised 29 July 1996; Accepted 31 July 1996 Article Note: (footnote) [star] From the Section of Cardiothoracic Surgery, James W. Riley Hospital for Children and Indiana University Medical Center, Indianapolis, Ind., [star][star] Read at the Seventy-sixth Annual Meeting of The American Association for Thoracic Surgery, San Diego, Calif., April 28-May 1, 1996., a Address for reprints: Ko Bando, MD, Section of Cardiothoracic Surgery, Indiana University Medical Center, 545 Barnhill Dr., EM 215, Indianapolis, IN 46202-5123., aa 0022-5223/96 $5.00 + 0, acents 12/6/77142

Byline: Ko Bando, Mark W. Turrentine, Kyung Sun, Thomas G. Sharp, Gregory J. Ensing, Andrew P. Miller, Kenneth A. Kesler, Robert S. Binford, Glenn N. Carlos, Roger A. Hurwitz, Randall L. Caldwell, Robert K. Darragh, Joyce Hubbard, Timothy M. Cordes, Donald A. Girod, Harold King, John W. Brown Abstract: Creation of a competent left atrioventricular valve is a cornerstone in surgical repair of complete atrioventricular septal defects. To identify risk factors for mortality and failure of left atrioventricular valve repair and to determine the impact of cleft closure on postoperative atrioventricular valve function, we retrospectively analyzed hospital records of 203 patients between January 1974 and January 1995. Overall early mortality was 7.9%. Operative mortality decreased significantly over the period of the study from 19% (4/21) before 1980 to 3% (2/67) after 1990 (p = 0.03). Ten-year survival including operative mortality was 91.3% [+ or -]0.004% (95% confidence limit): all survivors are in New York Heart Association class I or II. Preoperative atrioventricular valve regurgitation was assessed in 203 patients by angiography or echocardiography and was trivial or mild in 103 (52%), moderate in 82 (41%), and severe in 18 (8%). Left atrioventricular valve cleft was closed in 93% (189/203) but left alone when valve leaflet tissue was inadequate and closure of the cleft might cause significant stenosis. Reoperation for severe postoperative left atrioventricular valve regurgitation was necessary in eight patients, five of whom initially did not have closure of the cleft and three of whom had cleft closure. Six patients had reoperation with annuloplasty and two patients required left atrioventricular valve replacement. Five patients survived reoperation and are currently in New York Heart Association class I or II. On most recent evaluation assessed by angiography or echocardiography (a mean of 59 months after repair), left atrioventricular valve regurgitation was trivial or mild in 137 of the 146 survivors (94%) examined; none had moderate or severe left atrioventricular valve stenosis. By multiple logistic regression analysis, strong risk factors for early death and need for reoperation included postoperative pulmonary hypertensive crisis, immediate postoperative severe left atrioventricular valve regurgitation, and double-orifice left atrioventricular valve. These results indicate that complete atrioventricular septal defects can be repaired with low mortality and good intermediate to long-term results. Routine approximation of the cleft is safe and has a low incidence of reoperation for left atrioventricular valve regurgitation. (J THORAC CARDIOVASC SURG 1995;110:1543-54) Author Affiliation: Indianapolis, Ind Article Note: (footnote) [star] From the Section of Cardiothoracic Surgery,a Division of Pediatric Cardiology.b Indiana University School of Medicine. Indianapolis, Ind., [star][star] Read at the Seventy-fifth Annual Meeting of The American Association for Thoracic Surgery, Boston, Mass., April 23-26, 1995., a Address for reprints: John W. Brown, MD, Section of Cardiothoracic Surgery, Indiana University Medical Center, Emerson Hall Room 212, 545 Barnhill Dr., Indianapolis, IN 46202., aa 0022-5223/95 $5.00 +0, acents 12/6/68245

Byline: Patrick W. Domkowski, John T. Cockerham, Peter A. Kot, Jeff L. Myers, Robert B. Wallace, Richard A. Hopkins Abstract: Current therapeutic modalities for treatment of newborn pulmonary hypertensive crisis include but are not limited to the administration of nitric oxide (endothelium-derived relaxing factor). However, few data are available on the role of endogenously produced endothelium-derived relaxing factor in the modulation of pulmonary vascular tone in the neonate. In the current study, we investigated the acute effects of NI-nitro- L -arginine (a potent competitive inhibitor of endothelium-derived relaxing factor synthase) on the pulmonary vasculature of anesthetized open-chest 48-hour-old (n = 8) and 2-week-old (n = 7) Yorkshire pigs. After baseline data were acquired, all animals received a 10 mg/kg per minute infusion of NI-nitro- L -arginine for 10 minutes. To discern distal and proximal pulmonary arterial vessel changes, input mean and characteristic impedance were respectively determined. Pulmonary vascular resistance was also calculated (units determined in dyne acents sec acents cm.sup.-5 plus or minus the standard errorof the mean). Results showed NI-nitro- L -arginine infusion did not significantly alter baseline pulmonary arterial pressure (22,370 [+ or -]1473 dyne/cm.sup.2), pulmonary vascular resistance (5171 [+ or -]805 dyne acents sec acents cm.sup.-5), input impedance (6343 [+ or -]806 dyne acents sec acents cm.sup.-5), or characteristic impedance (2073 [+ or -]418 dyne acents sec acents cm.sup.-5) in 48-hour-old pigs. In 2-week-old pigs, infusion of NI-nitro- L -arginine elevated pulmonary arterial pressure (18,162 [+ or -]1415 dyne/cm versus 23,838 [+ or -]1810 dyne/cm , p = 0.015), pulmonary vascular resistance (810 [+ or -]137 dyne acents sec acents cm.sup.-5 versus 1519 dyne acents sec acents cm.sup.-5 , p = 0.030), and input impedance (2302 [+ or -]251 dyne acents sec acents cm.sup.-5 versus 2900 [+ or -]255 dyne acents sec acents cm.sup.-5 , p = 0.018). Characteristic impedance was not altered in 2-week-old pigs. These data indicate that NI-nitro- L -arginine infusion resulted in pulmonary arteriolar vasoconstriction in 2-week-old pigs, but not in 48-hour-old pigs. This finding suggests that endothelium-derived relaxing factor does not modulate basal pulmonary arteriolar tone during the early newborn period, but does play a significant role in 2-week-old pigs. These data also suggest that the functional role for endothelium-derived relaxing factor is confined to the distal arteriolar pulmonary bed and does not extend to the larger proximal arterial vessels. (J THORAC CARDIOVASC SURG 1995;110:1486-92) Author Affiliation: Washington, D.C. Article Note: (footnote) [star] From Georgetown University School of Medicine, Departments of Surgery, Physiology and Biophysics, and Pediatrics, Washington, D.C., [star][star] Supported in part by an American Heart Association (Nation's Captial Affiliate) grant., a Read at the Seventy-fifth Annual Meeting of the American Association for Thoracic Surgery, Boston, Mass., April 23-26, 1995., aa 0022-5223/95 $5.00 +0, acents Address for reprints: Richard A. Hopkins, MD, Georgetown University Hospital, 3800 Reservoir Rd., N.W., Washington, DC 20027., acentsacents 12/6/68106

Byline: Jean Paul A. Couetil, Didier P. Houssin, Olivier Soubrane, Patrick G. Chevalier, Bertrand E. Dousset, Didier Loulmet, Antoine Achkar, Michael J. Tolan, Catherine I. Amrein, Alain Guinvarch, Romain J. Guillemain, Peter Birnbaum, Alain F. Carpentier Abstract: Patients with cystic fibrosis who have end-stage respiratory failure and associated liver cirrhosis have been considered poor candidates for lung transplantation because of high morbidity and mortality resulting from hepatic insufficiency after the operation. Since April 1989, our policy has been to combine heart-lung or lung and liver transplantation in this group of patients. Between June 1990 and March 1995, among 25 patients accepted in the program for combined transplantation, nine died awaiting transplantation and 10 underwent one of the following procedures: heart-lung-liver transplantation (n = 5), en bloc double lung-liver transplantation (n = 1), sequential double lung-liver transplantation (n = 3), and bilateral lobar lung transplantation from a split left lung and reduced liver transplantation (n = 1). There were 5 male and 5 female patients. The ages of the recipients ranged from 10 to 24 years. Mean forced expiratory volume in 1 second was 29% and mean forced vital capacity was 35% of predicted values. All patients were infected with resistant Pseudomonas, three with Pseudomonas cepaceia, and two patients had Aspergillus species in addition. All patients had severe cirrhosis with portal hypertension. Four patients had a history of esophageal variceal bleeding and two had had previous portosystemic shunts. The operation was performed as a two-stage procedure, the intrathoracic operation being completed before the abdominal stage was begun. Cardiopulmonary bypass was used in all patients because of poor clinical condition. Immunosuppression consisted of azathioprine, cyclosporine, and prednisone, as for isolated lung transplantation. There were two perioperative deaths, one caused by primary liver failure and the second by early lung dysfunction. For the first 3 months after transplantation pulmonary infection was the most common cause of morbidity. Other complications included tracheal stenosis (n = 1), bronchial stenosis (n = 1), biliary stricture (n = 2), and severe ascites (n = 3). All were successfully treated. Obliterative bronchiolitis developed in three patients. This was stabilized with FK 506 in two patients; the other patient underwent retransplantation at 38 months but eventually died of bleeding. Actuarial survival was 70% at 1 year and remained unchanged at 3 years. Significant functional improvement was observed in all survivors. For patients who have chronic respiratory failure with advanced cirrhosis, lung transplantation combined with liver transplantation can be performed with a satisfactory outcome. (J THORAC CARDIOVASC SURG 1995;110:1415-23) Author Affiliation: Paris, France Article Note: (footnote) [star] From the Department of Cardiovascular Surgery, Broussais Hospital,a and the Department of Surgery, Cochin Hospital,b Paris, France., [star][star] Read at the Seventy-fifth Annual Meeting of The American Association for Thoracic Surgery, Boston, Mass., April 23-26, 1995., a 0022-5223/95 $5.00 +0, aa Address for reprints: Jean-Paul Couetil, MD, Department of Cardiovascular Surgery, Broussais Hospital, 96, rue Didot, 75014 Paris, France., acents 12/6/67868

Byline: George T. Christakis, Richard D. Weisel, Karen J. Buth, Stephen E. Fremes, Vivek Rao, Kostas P. Panagiotopoulos, Joan Ivanov, Bernard S. Goldman, Tirone E. David Abstract: Although small body size and coronary artery diameter are recognized as major contributors to the increased risk of coronary artery bypass grafting in women, few studies have established the independent influence of body size and gender on outcome. We studied 7025 consecutive patients (5694 men, 1331 women) undergoing isolated coronary artery bypass grafting between 1990 and 1994. Women were older, had higher preoperative prevalences of urgent operation because of unstable angina, diabetes, peripheral vascular disease, hypertension, and single-vessel coronary artery disease (p < 0.0001), and a lower prevalence of left ventricular ejection fraction 40% or less (p < 0.0001). The prevalences of operative mortality (men, 1.8%; women, 3.5%), low-output syndrome (men, 6.6%; women, 14.8%), and myocardial infarction (men, 2.8%; women, 5.5%) were higher in women (p < 0.0001). Patients were divided into quartiles for body surface area, weight, height, and body mass index. For both men and women, there was no difference in operative mortality between the highest and lowest quartiles of body size. Women, however, had a higher prevalence of operative mortality than men in the lower quartiles of body surface area, height, and weight and in the higher quartiles of body mass index. Among men, the prevalence of low-output syndrome increased p < 0.0001) with decreasing body surface area, weight, and body mass index, suggesting that body size did influence the prevalence of low-output syndrome. However, women had a higher prevalence of low-output syndrome than men in every category and quartile of body size (p < 0.0001). Multivariable analysis identified gender as a significant determinant of operative mortality (odds ratio 1.83, 95% confidence interval 1.27 to 2.64) and low-output syndrome (odds ratio 2.52, 95% confidence interval 2.05 to 3.11). When multivariable adjustments were made for body size and preoperative risk factors, gender remained a predictor of both operative mortality and low-output syndrome. Multivariable assessment of risk for men and women separately identified that urgent operation was a predictor of operative mortality (odds ratio 2.52, 95% confidence interval 1.32 to 5.61) and low-output syndrome (odds ratio 1.57, 95% confidence interval 1.14 to 2.17) in women but not men. In conclusion, the increased risk of coronary artery bypass grafting in women may be explained in part by dramatic differences in preoperative risk factors between men and women. In both men and women, small body size did not increase the risk of operative mortality, but may have contributed to the risk of low-output syndrome. After adjusting for preoperative risk variables and body size, gender remains a significant independent predictor of operative mortality and low-output syndrome. (J THORAC CARDIOVASC SURG 1995;110:1344-58) Author Affiliation: Toronto, Ontario, Canada Article Note: (footnote) [star] From the Divisions of Cardiovascular Surgery, Sunnybrook Health Science Centre, and the Toronto Hospital, University of Toronto, Toronto, Ontario, Canada., [star][star] Supported by grant B2317 from the Heart and Stroke Foundation of Ontario., a Read at the Seventy-fifth Annual Meeting of The American Association for Thoracic Surgery, Boston, Mass., April 23-26, 1995., aa Address for reprints: Geore T. Christakis, MD, Sunnbrook Health Science Centre, 2075 Bayview Ave., Suite H406, Toronto, Ontario M4N 3M5, Canada., acents J THORAC CARDIOVASC SURG 1995;110:1344-58, acentsacents 0022-5223/95 $5.00 +0, a[bar] 12/6/67829

Standard risk evaluations of future heart complications may not apply to women undergoing elective vaginal surgery. Researchers used the New York Heart Association functional classification of heart disease and the Goldman cardiac risk index to measure heart problems in 406 surgery patients. Women over 55 years old or those who had their ovaries removed were classified as postmenopausal. Among 168 postmenopausal patients, there were two distinct risk factors associated with cardiac complications during surgery. These risk factors were hypertension and ischemic heart disease, which is constriction of blood vessels supplying the heart. Other factors, such as glucose intolerance, cardiac arrhythmia, and estrogen replacement therapy, did not predict heart problems. Eight menopausal women required intensive care following cardiac morbidity during surgery. Two patients died from heart attack. Gynecological surgery patients may not fit the general risk categories of heart disease.

Byline: John M. Armitage, Geoffrey Kurland, Marian Michaels, Lynne A. Cipriani, Bartley P. Griffith, Frederick J. Fricker Abstract: Forty children (aged 1 to 18 years, 27 female and 13 male) have undergone heart-lung (21), double lung (17), and single lung (2) transplant procedures at our center from 1985 through April 1994. The indications for transplantation have been diverse, primary pulmonary hypertension (10), cystic fibrosis (11), congenital heart disease (10), arteriovenous malformation (3), emphysema (1), graft-versus-host disease (1), rheumatoid lung (1), cardiomyopathy (1), desquamative interstitial pneumonitis (1), and Proteus syndrome (1). The actuarial 1-year survival was 73% (mean follow-up 2 years). One-year actuarial survival for disease groups ranged from 60% for cystic fibrosis to 90% for congenital heart disease. We have identified six issues critical to the patient and programatic survival of pediatric lung transplantation. Our experience and management strategies in these areas are reviewed. Cytomegalovirus : Cytomegalovirus disease developed in six of eight patients with cytomegalovirus mismatching (donor +/recipient -) and in seven of 32 patients who survived more than 30 days (23%). All but cytomegalovirus donor -/recipient-patients were treated with ganciclovir for 4 weeks after transplantation. Obliterative bronchiolitis : Obliterative bronchiolitis developed in seven of 32 (25%) patients who survived more than 30 days. Obliterative bronchiolitis was manifest within the first posttransplantation year as a rapid decline in small airway function. Aggressive augmentation of immunosuppression has been used with little success.Posttransplantation lymphoproliferative disease : Posttransplantation lymphoproliferative disease developed in five of 32 (15%) patients who survived more than 30 days developed. One patient died (17% mortality) despite retransplantation. In four patients the disease resolved with reduction in immunosuppression alone, and one required the addition of interferon alfa. Cystic fibrosis : We have changed our management strategies to avoid triple drug immunosuppression, perioperative blood and bronchial cultures, aggressive antimicrobial therapy, and exclusion of patients with panresistant organisms; this has resulted in elimination of infectious mortalities thus far in the pediatric cystic fibrosis group. Airways : In 21 heart-lung recipients with tracheal anastomoses we have had no airway complications. The double and single lung transplant recipients accounted for 34 bronchial and one tracheal anastomoses. Three (9%) bronchial stenoses developed. Two were treated with silicone stents and one with balloon dilation. Finances : The average charge for lung transplant evaluation was $18,000 and for transplantation, $175,000. (J Thorac Cardiovasc Surg 1995;109:60-5) Author Affiliation: Pittsburgh, Pa. Article Note: (footnote) [star] Read at the Seventy-fourth Annual Meeting of The American Association for Thoracic Surgery, New York, N.Y., April 24-27, 1994., [star][star] Address for reprints: John M. Armitage, MD, Associate Professor of Surgery, University of Pittsburgh Medical Center, C700 PUH-UPMC, 200 Lothrop St., Pittsburgh, PA 15213., a 0022-5223/95 $3.00 + 0, aa 12/6/60137

Byline: Miguel Sousa Uva, Lorenzo Galletti, Francois Lacour Gayet, Dominique Piot, A. Serraf, Jacqueline Bruniaux, Juan Comas, R. Roussin, A. Touchot, Jean Paul Binet, Claude Planche Abstract: Between 1980 and 1993, 20 patients less than 1 year of age underwent operations for congenital mitral valve disease. Ten patients had congenital mitral incompetence and 10 had congenital mitral stenosis. Mean age was 6.6 [+ or -] 3.4 months and mean weight was 5.6 [+ or -] 1.5 kg. Atrioventricular canal defects, univentricular heart, class III/IV hypoplastic left heart syndrome, discordant atrioventricular and ventriculoarterial connections, and acquired mitral valve disease were excluded. Indications for operation were intractable heart failure or severe pulmonary hypertension, or both. Associated lesions, present in 90% of the patients, had been corrected by a previous operation in seven. In congenital mitral incompetence there was normal leaflet motion (n = 3), leaflet prolapse (n = 2), and restricted leaflet motion (n = 5). In congenital mitral stenosis anatomic abnormalities were parachute mitral valve (n = 4), typical mitral stenosis (n = 3), hammock mitral valve (n = 2), and supramitral ring (n = 1). Mitral valve repair was initially performed in 19 patients and valve replacement in one with hammock valve. Concurrent repair of associated lesions was performed in 12 patients. The operative mortality rate was zero. There were six early reoperations in five patients for mitral valve replacement (n = 4), a second repair (n = 1), and prosthetic valve thrombectomy (n = 1). One late death occurred 9 months after valve replacement. Late reoperations for mitral valve replacement (n = 2), aortic valve replacement (n = 1), mitral valve repair (n = 2), subaortic stenosis resection (n = 1), and second mitral valve replacement (n = 1) were performed in five patients. Actuarial freedom from reoperation is 58.0% [+ or -] 11.3% (70% confidence limits 46.9% to 68.9%) at 7 years. After a mean follow-up of 67.6 [+ or -] 42.8 months, 94% of living patients are in New York Heart Association class I. Doppler echocardiographic studies among the 13 patients with a native mitral valve show mitral incompetence of greater than moderate degree in one patient and no significant residual mitral stenosis. Overall, six patients have mitral prosthetic valves with a mean transprosthetic gradient of 6.2 [+ or -] 3.7 mm Hg. These results show that surgical treatment for congenital mitral valve disease in the first year of life can be performed with low mortality. Valve repair is a realistic goal in about 70% of patients and possibly more with increased experience. Reoperation rate is still high and is related to complexity of mitral lesions and associated anomalies, but late functional results are encouraging. (J Thorac Cardiovasc Surg 1995;109:164-74) Author Affiliation: Paris, France Article Note: (footnote) [star] From The Department of Pediatric Cardiac Surgery, Marie Lannelongue Hospital, Paris, France., [star][star] Read at the Seventy-fourth Annual Meeting of The American Association for Thoracic Surgery, New York, N.Y., April 24-27, 1994., a Address for reprints: Claude Planche, MD, HA[acute accent]pital Marie Lannelongue, Departement de Chirurgie Cardiaque Pediatrique, 133, Avenue de la Resistance, Plessis Robinson 92350, France., aa 0022-5223/95 $3.00 + 0, acents 12/6/60138

PURPOSE: To investigate the prevalence of certain chronic conditions among the elderly and to estimate the relative risk for pneumonia associated with each condition. PATIENTS AND METHODS: Medical records of all inhabitants aged 60 years or more (4,175 persons) in one township (population 24,716) in Finland were reviewed, seeking 15 chronic conditions. Which patients had pneumonia in the same population was prospectively ascertained over a period of 3 years (185 patients). RESULTS: Hypertension was the most frequent chronic condition (36.4%) in the study population. Other common conditions were heart disease (23.7%, with chronic compensated heart failure in 96.3% of these), other cardiovascular disease (13.1%), and diabetes (13.1%). The prevalence of any other condition was less than 5%. The following conditions were significantly more common among pneumonia patients than among control subjects: heart disease (38.4% versus 23.0%), lung disease (13.0% versus 3.8%), bronchial asthma (11.9% versus 3.1%), immunosuppressive therapy (2.7% versus 0.8%), alcoholism (2.2% versus 0.3%), and institutionalization (8.6% versus 3.9%). By multivariate logistic regression analysis, independent risk factors for pneumonia were alcoholism (relative risk [RR] = 9.0, confidence interval [Cl] = 5.1 to 16.2), bronchial asthma (RR = 4.2, Cl = 3.3 to 5.4), immunosuppressive therapy (RR = 3.1, Cl = 1.9 to 5.1), lung disease (RR = 3.0, Cl = 2.3 to 3.9), heart disease (RR =1.9, Cl = 1.7 to 2.3), institutionalization (RR = 1.8, Cl = 1.4 to 2.4), and age (70 years or more versus 60 to 69 years; RR = 1.5, Cl = 1.3 to 1.7). One third of the study population and 57% of the pneumonia patients had one or more of these risk factors. Diabetes, chronic pyelonephritis, and malignancies of sites other than the lungs were not associated with increased risk for pneumonia. CONCLUSION: We found which elderly persons have an increased risk for pneumonia. Although the highest relative risk was associated with alcoholism, that condition was rare in this elderly population. Chronic obstructive lung diseases were more common and were also associated with a high relative risk. Heart disease had the highest public health impact because it was very common among the elderly and increased the risk of contracting pneumonia almost twofold; it also increased the risk of pneumonia-related death. These population-based data confirm and extend previous findings derived from selected patient groups and are useful for designing cost-effective pneumonia prevention programs.

Oral contraceptives (OCs), IUDs and long-acting progestins may be suitable contraceptive choices for women with high blood pressure, mitral valve prolapse or angina pectoris. Angina pectoris is pain in the chest caused by a lack of oxygen flowing to the heart. This lack of oxygen is associated with coronary artery disease. Patients with high blood pressure or angina are at increased risk for heart attack if they become pregnant due to the additional demands placed on the circulatory system. Though OCs have been associated with an increase in blood pressure, the degree of elevation is usually low. Women with high blood pressure can generally take OCs provided that their blood pressure can be controlled through diet, exercise or drug therapy. OCs may prevent the progression of atherosclerosis, a condition which restricts blood flow through the arteries. If women with angina have no other risk factors for cardiovascular diseases, OCs may be a viable option. Mitral valve prolapse is a generally benign disease and women who have no other symptoms can use OCs. IUDs and long-acting progestins are generally safe contraceptive options for women with cardiovascular diseases.

Hyperinsulinemia, hypertension, hypertension, hypertriglyceridemia and obesity are independent risk factors for coronary artery disease and are often found in the same person. This study investigated the effects of an intensive, 3-week, dietary and exercise program on these risk factors. The group was divided into diabetic patients (non-insulin-dependent diabetes mellitus [NIDDM], n = 13), insulin-resistant persons (n = 29) and those with normal insulin, [is less than or equals to] 10 [mu]U/ml (n = 30). The normal groups had very small but statistically significant decreases in all of the risk factors. The patients with NIDDM had the greater decreases. Insulin was reduced from 40 [+ or -] 15 to 27 [+ or -] 11 [mu]U/ml, blood pressure from 142 [+ or -] 9/83 [+ or -] 3 to 132 [+ or -] 6/71 [+ or -] 3 mm Hg, triglycerides from 353 [+ or -] 76 to 196 [+ or -] 31 mg/dl and body mass index from 31.1 [+ or -] 4.0 to 29.7 [+ or -] 3.7 kg/[m.sup.2]. Although there was a significant weight loss for the group with NIDDM, resulting in the decrease in body mass index, 8 of 9 patients who were initially overweight were still overweight at the end of the program, and 5 of the 8 were still obese (body mass index > 30 kg/[m.sup.2]), indicating that normalization of body weight is not a requisite for a reduction or normalization of other risk factors. Insulin was reduced from 18.2 [+ or -] 1.8 to 11.6 [+ or -] 1.2 [mu]U/ml in the insulin-resistant group, with 17 of the 29 subjects achieving normal fasting insulin (

Research has been conducted on superimposed preeclampsia in women with chronic hypertension. The authors have investigated midtrimester homocystein concentration levels in predicting preeclampsia, and they report that homocystein concentration levels cannot help in preeclampsia prediction in these women.

Byline: Imelda Tio, Krishnansu Tewari, Keith D. Balderston, Jeffrey C. Milliken, Manuel Porto Keywords: Mitral stenosis; pulmonary hypertension; cardiac surgery Abstract: A case of critical mitral stenosis with severe pulmonary hypertension in a twin pregnancy is presented. On therapeutic evacuation at 15 weeks' gestation the patient became critically unstable, necessitating emergency open heart surgery with mitral valve replacement. (Am J Obstet Gynecol 1998;179:270-2.) Author Affiliation: Orange, California Article History: Received 24 November 1997; Accepted 31 December 1997 Article Note: (footnote) [star] From the Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology,a and the Section of Cardiothoracic Surgery, Department of Surgery,b University of California, Irvine, Medical Center., [star][star] Reprint requests: Manuel Porto, MD, Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of California, Irvine, Medical Center, Building 25, Room 174, 101 The City Dr, Orange, CA 92868., a 0002-9378/98 $5.00 + 0 6/1/88552