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A high incidence of ventricular arrhythmia has been observed during the follow-up of patients with valve replacement buy arimidex 1 mg overnight delivery breast cancer 5k topeka ks, especially those who had aortic stenosis generic arimidex 1mg mastercard women's health center katoomba, multiple valve surgery best arimidex 1 mg breast cancer kd, or cardiomegaly arimidex 1 mg with mastercard menopause 6 years after hysterectomy. Sudden death during follow-up was associated with ventricular arrhythmias and thromboembolism. Mitral Valve Prolapse Mitral valve prolapse is prevalent, but probably less so than previously thought, and is associated with a high incidence of annoying low-risk cardiac arrhythmias (see Chapter 69). Endocarditis of the Aortic and Mitral Valves Endocarditis of the aortic and mitral valves may be associated with rapid death resulting from acute disruption of the valvular apparatus (see Chapter 73), coronary embolism, or abscesses of valvular rings or the septum. However, such deaths are rarely true sudden deaths because conventionally defined tachyarrhythmic mechanisms are uncommon. Coronary embolism from valvular vegetations can trigger fatal ischemic arrhythmia on rare occasion. In a later study evaluating the impact of thrombolytic therapy versus the prethrombolytic era experience, the incidence of pure right bundle branch block was higher, but that of bifascicular block was lower, as were late complications and mortality. However, survival appears to depend more on the nature and extent of the underlying disease than on the conduction disturbance itself. Sodium channel gene mutations have been associated with progressive conduction system disturbances, 81 along with aging, and some are variants of Brugada gene expression. Less often, but not rarely, such mutations may occur de novo or may be transmitted from an apparently normal mosaic 84 parent. The concept of modifier genes interacting with the 86,87 primary defect or physiologic contributors to expression is being explored. Moreover, it is important to identify and to manage medically relatives who carry the mutation and may be at risk. It had also been reported in intensive weight reduction programs that involved the use of certain liquid-protein diets and in patients with anorexia nervosa. Persistent type I electrocardiographic patterns, syncope, gender, and life-threatening arrhythmias, in various combinations, 93 are thought to be the best predictors. B, The typical repolarization changes associated with Brugada syndrome (arrowheads) were elicited by a single oral dose of flecainide, 400 mg. A pattern not associated with that genotype appeared to be more likely in older patients (young adults), usually women. Electrical Instability Resulting from Neurohumoral and Central Nervous System Influences. Stress-induced arrhythmias are better supported than stress-induced risk for mortality, which requires further study. Data from the 1994 Los Angeles earthquake identified an increased rate of fatal cardiac events on that day, but the event rate was reduced during the ensuing 2 weeks, thus suggesting triggering of events about to happen rather than independent causation. A variant of torsades de pointes characterized by short coupling intervals between a normal impulse and the initiating impulse has been described (eFig. It appears to have familial trends and to be related to alterations in autonomic nervous system activity. They are subject to spontaneous episodes of polymorphic ventricular tachycardia (torsades de pointes), which may degenerate into ventricular fibrillation. Panels A, B, and C are not continuous but are three separate episodes of nonsustained polymporphic ventricular tachycardia. The phenomenon of “voodoo death” has been studied in pockets of isolation in underdeveloped countries. Isolation from the tribe, a sense of hopelessness, severe bradyarrhythmias, and sudden death appear to be associated. Limited clinical observations and experimental data modeling voodoo death have suggested a mechanism related to parasympathetic overactivity, as opposed to the evidence of an adrenergic basis for syndromes related to acute emotional stress. Vulnerability as a result of various mechanisms of dysfunctional central respiratory control, both inherent 105 and related to prematurity, is likely to interact with sleep position as a multicomponent mechanism. Other common causes included myocarditis, hypertrophic and dilated cardiomyopathy, congenital heart disease, and aortic dissection. Examples of the latter include intense conditioning exercise and basic military training. Among adolescent and young adult competitive athletes, the estimated incidence was 1 per 75,000 annually in Italy, versus less than 1 per 125,000 for the general nonathlete population in the same age-group. In a survey of high school athletes in Minnesota, the frequency of sudden unexpected death related to cardiovascular disease during competitive sports was approximately 1 per 100,000 individual student athlete participants, a figure similar to that in the general 106 population in that age-group. Most athletes and nonathletes have a previously known or unrecognized cardiac abnormality. Whether exercise contributed to the initiation of plaque disruption or preexisting disruption simply set the stage for the fatal response during exercise remains unclear. Air Force recruits, a surprisingly large fraction of those who died suddenly during exertion had unsuspected myocarditis. Blunt chest wall trauma by sports objects, such as baseballs 109 and hockey pucks, can initiate lethal arrhythmias, a syndrome known as commotio cordis. Attention to recreational athletics and high-level conditioning activities is emerging. The remainder occurred during recreational athletic activities, usually cycling, jogging, or soccer. Analysis of suspected underreporting suggested that the incidence of sports-related sudden death throughout France might be as high as 5 to 17 new cases per million population per year. Case participants were predominantly male (95%) and had no previous history of heart disease. In the latter, the victim has usually exercised excessively in hot weather, often with athletic gear that impairs heat dissipation and sometimes with the use of substances such as ephedrine that may cause vasoconstriction, impairing heat exchange. This leads to collapse with greatly elevated core body temperatures and, ultimately, irreversible organ system damage. Other Causes and Circumstances Associated with Sudden Death A small group of victims has neither previously determined functional abnormality nor identifiable structural abnormalities at postmortem examination. The idiopathic category is decreasing as the subtle molecular causes become better defined, including recognition by postmortem genetic studies. Limited data suggest that higher risk persists primarily in patients with subtle cardiac structural abnormalities, in contrast to patients who are truly normal. Sleep apnea is associated with a risk for nocturnal death, including deaths attributable to cardiac causes (see Chapter 87). The 23 risk for death peaks during the night rather than in the early-morning hours. Another respiratory system– based cause of sudden death is the “café coronary,” in which food lodges in the oropharynx and causes an abrupt obstruction at the glottis. The “holiday heart” syndrome is characterized by cardiac arrhythmias, most often atrial, as well as other cardiac abnormalities associated with acute alcoholic states. It has not been determined whether potentially lethal arrhythmias occurring in such settings account for the reported sudden deaths associated with acute alcoholic states. Peripartum air embolism caused by unusual sexual practices has been reported as a cause of such sudden deaths. Such abnormalities include aortic dissection (see Chapter 63), acute cardiac tamponade (Chapter 83), and rapid exsanguination. A series of 200 cases in which information was available from both routine autopsies and referral 113 evaluations yielded a 41% discrepancy in final diagnoses.
In these deairing maneuver on the right side of the heart can be ﬁgures arimidex 1 mg low price womens health professionals albany ga, the artist depicts the distal pulmonary artery recon- accomplished by release of the vena cava slings (not shown struction in a favorably placed distal main pulmonary artery cheap 1mg arimidex with mastercard breast cancer 2b. This technique will shift blood return to tricular to pulmonary artery conduit can be measured to size the heart and will facilitate the deairing maneuver generic 1 mg arimidex free shipping menstrual question. This is a rather impor- separation from cardiopulmonary bypass order arimidex 1 mg mastercard women's health center bayonne nj, the conduit should tant part of the operation. This anatomic conﬁgura- result in distal pulmonary artery compression and right ven- tion will help to avoid sternal compression and facilitate tricular hypertension. A segment that is too short can result mediastinal reentry when conduit replacement becomes in undue anastomotic tension and can lead to disruption in necessary. The cor- lar to pulmonary conduit placement to the right of the rugated graft allows for some leeway in this regard, as the ascending aorta, traversing across the midline. The inset of graft is manufactured with a certain amount of stretch poten- Figure 15. The surgeon can be comforted that though an accurate closed sternum, presenting the disadvantages of conduit ste- measurement is preferable, it is often not necessary, because nosis and unfavorable position during resternotomy for con- of the inherent graft speciﬁcations. Most authors agree that these complicated anatomic anomalies challenge an operation that is already complex enough and recommend a single ventricular repair in these unusual circumstances. Bidirectional Glenn shunt in association with congenital heart repairs: the 11⁄2 ventricular repair. Gone are the venous pathway valves, the right atrial connections to small subpulmonic ventricles, and atriopul- Figures 16. The standard therapy for orthoterminal diac, nonfenestrated Fontan operation in a patient with a (Fontan) correction is determined by three distinct time peri- prior bidirectional Glenn shunt. Though a distinct minority ods: The ﬁrst is the neonatal management of pulmonary of surgeons prefer to perform this operation without cardio- artery ﬂow (by systemic to pulmonary artery shunt, pulmo- pulmonary bypass, we believe that it is preferable to use nary artery band, or observation). The second stage takes standard aortobicaval cardiopulmonary bypass techniques place at about 6 months of age; it includes systemic to pul- without aortic cross clamping. At about 2 years of age, bypass and right atrial clamping across the inferior vena the Fontan operation is usually performed. Care is taken to place a large vas- duction of atrial fenestration, some surgeons have used this cular clamp across this junction and well onto the right obligatory right-to-left shunt in all cases, but some use it atrium—with special attention to avoiding injury to the right selectively and others, not at all. Most surgeons now use the coronary artery and tricuspid valve—before attempting to fenestration selectively, especially in cases with borderline transect the inferior vena cava. This is an important maneu- ventricular function, small pulmonary arteries, abundant aor- ver, as the operation is being performed in a beating, non- topulmonary artery collaterals, and single-lung physiology. Clamp dislodgement will result in difﬁculty The fenestration can be performed easily in the lateral tunnel in performing the occlusive atrial suture line. Even worse, it Fontan operation, but not so easily in the extracardiac Fontan could allow air to enter the cardiac chambers, leading to a operation. Once the clamp is placed and secured, a suture is placed in the oriﬁce of the inferior vena cava before completion of the transection, to ensure expo- sure and prevent retraction below the diaphragm. The infe- rior vena cava transection is then completed, and the right atrium is closed with the clamp in place (Fig. The extracardiac conduit is now cut to size and on a bevel in preparation for the anastomosis to the inferior portion of the right pulmonary artery. Mavroudis construct the conduit without tension and without redun- dancy, to avoid any compromise in venous ﬂow patterns. The thicker the wall, the more difﬁcult it is to assess the actual size of the anastomo- Constructing a fenestration with an extracardiac conduit sis. Another method is to make a hole in the conduit and requires strategies to avoid air entry to the left side. One suture the wall of the incised atrium around the oriﬁce of the strategy is to use aortic cross clamping and cardioplegic fenestration without placing the sutures into the oriﬁce. This strategy requires a more extensive aortic dissec- way the actual fenestration is assured. Nevertheless, it is probably Another method that requires aortic cross clamping and car- the best way to accomplish the fenestration without the pos- dioplegic arrest is to perform a side-to-side anastomosis with sibility of introducing air into the left side. Alternatively, aor- the extracardiac conduit and a portion of the inferior vena tic cross clamping can be avoided if side-biting clamps are cava, as in Figure 16. The most effective reconstruction is used on the atrium, with careful anastomotic techniques. It has been our practice to use the techniques in chances of unwanted air entry into the left side. Some surgeons prefer to use the lateral tunnel for all Fontan completion operations, regardless of the single-ventricle diagnosis, because of the ease and consistency of performing the atrial fenestration. Preliminary reports have suggested that the lateral tunnel Fontan operation produces more atrial arrhythmias than the extracardiac Fontan operation, but no prospective studies have conﬁrmed these results. At the pres- ent time, whether to use the extracardiac Fontan or lateral tunnel Fontan, with or without fenestration, depends on the experience of the operating team. Some surgeons place a 4- or 5-mm fenes- tration, depending on the clinical circumstances. The large arrow indicates the path of the pulmonary venous return from the pulmonary veins, through the atrial septal defect and into the right ven- tricle. The smaller arrows signify the ﬂow through the fenes- trations into the common atrium. When a bidirectional Glenn shunt and not a hemi-Fontan reconstruction is used en route to orthoterminal correction (Fontan operation), the lateral tunnel and inferior vena cava pathway to the right pulmonary artery is quite different, as noted in Figure 16. Doing so may threaten the sinoatrial node, a concern for any incision performed in this area. The operation is performed under aortobica- large and small arrows indicate the blood ﬂow of the pulmo- val cardiopulmonary bypass, aortic cross clamping, and car- nary venous return and shunted right-to-left atrial ﬂow, dioplegic arrest. Some surgeons have expressed concern about to the oriﬁce of the inferior vena cava. Keeping he could apply partial right heart bypass by way of a bidirec- the left ventricular pressure subsystemic for optimal coro- tional, cavopulmonary anastomosis to unload the small right nary artery ﬂow helps to stabilize the interventricular sep- ventricle and still provide pulsatile pulmonary artery blood tum, preventing right ventricular distention and helping to ﬂow. The concept was expanded and now is an avoid tricuspid regurgitation on the basis of papillary muscle integral part of some congenital heart repairs, which are stretching. The second application of the 1½ ventricular repair for Perhaps the most successful application of this strategy is patients with congenitally corrected transposition of the for patients with small but functioning right ventricles with great arteries is the double switch operation, when the sur- distinct inlet, body, and outlet portions (Group A, geon feels that the atrial bafﬂe is too complex to include the Figure 16. Under these circumstances, a pericardial bafﬂe is patients with pulmonary stenosis or atresia, an intact ven- constructed to direct inferior vena cava ﬂow to the tricuspid tricular septum, and a right ventricle functioning at least valve and the right ventricle, which will become the pulmo- 40 % of normal. Though some surgeons leave an atrial fen- nary ventricle after the arterial switch operation. There have been reports of a 1½ ventricular repair in advanced Ebstein’s anomaly of the tricuspid valve. Unloading patients with atriopulmonary Fontan operations for tricuspid the right ventricle in this situation shifts the Starling curve to atresia who experienced right ventricular growth. Intra-atrial bafﬂes are prone to monary artery continuity with a bidirectional Glenn shunt obstruction and arrhythmias, so this strategy has been applied (Fig. The hemodynamic satile pulmonary artery blood ﬂow, and resolution of the result is favorable unless there is a left pulmonary artery ste- protein-losing enteropathy in these relatively rare cases.
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