No abstract

Cardiopulmonary bypass (CPB) during pregnancy is associated with a high fetal and maternal mortality. Contributing factors are timing of the operation, emergency situations, and placental vasoconstriction. Experimental evidence suggests that pulsatile perfusion might prevent placental vasoconstriction. We report on 4 patients who underwent cardiac surgery during pregnancy with pulsatile perfusion and detailed fetal monitoring.

No abstract

The long-term course (mean 15 years) of 336 patients with valvular incompetence who underwent Starr-Edwards ball valve implantation between 1962 and 1971 was reviewed. Eighteen patients (10%) with aortic valve replacement and 24 (16%) with mitral valve replacement died early postoperatively. Mortality remained high (31%) in the first 3 years after aortic valve replacement; it was highest (13%) in the first year after mitral valve replacement and then approached the normal rate. The most common mode of death was sudden death after aortic and cardiac failure after mitral valve replacement. At follow-up, 76% of survivors had improved symptomatically. Three instances of primary valve malfunction occurred. The probability of freedom from thromboembolism at 15 years postoperatively was 56% for aortic valve replacement and 52% for mitral valve replacement. The Starr-Edwards valve prosthesis is durable over prolonged follow-up period, but thromboembolism remains a persistent problem. Survival may be normal for patients surviving the early postoperative years.

SUMMARY Aortic dissection occurred in a nineteen year old woman during the thirty seventh week of pregnancy. Immediate elective delivery of a normal baby by caesarean section was followed by aortic root replacement 48 hours later. It was decided not to proceed immediately to operation on the aortic root because it was believed that the anticoagulation necessary for cardiopulmonary bypass might provoke dangerous haemorrhage from the raw placental site. Case reportA nineteen year old woma-n booked in for her first pregnancy at the local hospital. She remained well and fetal growth was normal until the thirty seventh week when she complained to her general practitioner of dizziness and a discomfort in her neck and chest radiating through to her back. Clinical examination at that time was normal. Two days later, however, her husband noted vibration in her chest and the family doctor confirmed the presence of new cardiac murmurs.She was admitted to the local district hospital, and one week later was referred to the regional centre. On admission she had mild chest discomfort and tiredness. Clinical examination showed no signs of heart failure. She was normotensive with a blood pressure in both arms of 105/55 mmHg. A systolic thrill was present to the right of the upper part of the stemum, and on auscultation an ejection systolic and early diastolic murmur were heard.A chest radiograph showed an enlarged cardiac shadow but the upper mediastinum was normal (Fig. 1). The electrocardiogram was normal. Cross sectional ultrasound examination showed that the aortic root was 7 cm in diameter; in the short axis view the aortic root was shown to consist of a normal sized main lumen with a large false lumen on the right side (Fig. 2).

Asymptomatic ("silent") ischaemia has been shown to be of prognostic significance in patients with stable and unstable angina and more recently in patients recovering after myocardial infarction. No therapeutic regimen has yet been shown to improve the prognosis of patients with silent ischaemia after infarction, which can be found in as many as a third of these patients. Attempts to achieve therapeutic revascularisation in all these patients may be undesirable, but early revascularisation could be especially beneficial in some selected high risk patients. Two hundred and fifty consecutive clinically stable survivors of myocardial infarction who had predischarge submaximal exercise tests were followed up for a year. Silent ischaemia was found in 27% of these patients; 15% had symptomatic ischaemia. Patients with a positive exercise test were prescribed a beta blocker before discharge. Mortality in patients with silent (9.4%) and symptomatic (5.4%) ischaemia in the first year after infarction was not significantly different. Patients with symptomatic ischaemia were more likely to have undergone coronary artery bypass grafting in the first year. Patients with silent ischaemia were, however, significantly more likely to die than patients with a negative exercise test (relative odds 12:1). Patients with silent ischaemia and an abnormal blood pressure response or who could not complete a submaximal exercise protocol were at particularly high risk, being 32 times more likely to die than those with a negative test (95% confidence interval from 3.3 to 307 times more likely). First year mortality in this group was 22%. The benefits of therapeutic revascularisation in this high risk group need to be studied.

SUMMARY A case is described in which rupture of the right sinus of Valsalva occurred at 37 weeks' gestation. The ruptured sinus was successfully repaired one week after the delivery of a healthy infant by caesarean section.Rupture of a sinus of Valsalva has not been reported in pregnancy before. We describe such a case, and outline a successful management strategy. Case reportA 22 year old Turkish Cypriot woman in week 37 of her first pregnancy attended her local hospital because of palpitation and chest pain. She had become aware of a sudden increase in her heart rate one week before when hanging out washing: there had been some retrosternal discomfort at the time. Subsequently a dry cough, dyspnoea, and orthopnoea had developed and a heart murmur was heard.Examination showed tachypnoea on minor exertion. She had a sinus tachycardia of 110 beats/min.

No abstract