Relationship between absorptiometry and ultrasound measurements of abdominal subcutaneous fat tissue in postmenopausal women

The purpose of this study was to describe the association of abdominal subcutaneous adipose tissue (SAT) as assessed by ultrasound with fat tissue in the abdomen, trunk, and other areas as measured by DXA in 101 postmenopausal Caucasian women (62.5 years; 27.3 kg/m(2); 43.0% body fat). Ultrasound SAT thickness was calculated with electronic calipers positioned at the skin-fat and fat-muscle computer screen interface, at the suprailiac (SUPT) and abdominal (ABDT) sites. Pearson correlation showed significant ( p<0.001) coefficients between SAT by DXA at both ABDT ( r=0.644) and SUPT ( r=0.537). Other DXA measurements were also associated ( p<0.001) with SAT assessed by DXA and ultrasound. In postmenopausal women, DXA estimates of subcutaneous and total adiposity are moderately associated with ultrasound measures of fat in the abdomen. Future research at our and other laboratories should clarify the clinical and practical significance of these findings.

A new vascular sealant (Sealgel) to achieve rapid hemostasis after percutaneous angioplasty in anticoagulated patients: clinical feasibility and preliminary results

The aim of this study was to assess the feasibility of a new vascular sealant (Sealgel) to provide rapid hemostasis in anticoagulated patients after percutaneous transluminal angioplasty (PTA). Sealgel was designed with ancrod (10 mg) and tranexamic acid (80 mg) dissolved in a hyaluronic acid gel (3 ml). Fifty anticoagulated patients (heparin, aspirin, ticlopidin) who underwent PTA of coronary artery were enrolled in the study. Sealgel (3 ml) was delivered under manual compression through a 9-F cannula at the arterial puncture site after the introducer sheath removal at the end of PTA procedure. Hemostasis time as well as complications were recorded. Sealgel was successfully delivered in 98 % of patients. Hemostasis occurred within 15 mn of manual compression in 82 % of patients, within 25 mn in 98 %, and failed in 1 patient (2 %). Hematoma (6-cm diameter) was observed in 1 patient and late bleeding in another one. There were no clinical signs of embolism, inflammatory swelling, local infection, vascular fistula, or pseudoaneurysm. No surgery or blood transfusion was required. Sealgel application after PTA in anticoagulated patient is feasible and secure. Preliminary results suggest that the Sealgel brought about rapid hemostasis; however further studies are needed to determine its clinical efficacy.

[Rheumatic fever--a review of cases]

OBJECTIVE

To analyse clinical presentation of rheumatic fever (RF), with special emphasis on cardiac involvement, electrocardiographic and echocardiographic findings and the outcome of the cases referred to Maria Pia Children's Hospital from January 1990 to September 1999.

METHODS

We retrospectively analyzed the clinical files of all cases referred to pediatric cardiology clinics with the suspicion of acute RF (Group 1) or with rheumatic valvular disease and heart failure (Group 2). In group 1 we studied the following: age and sex distribution, year of diagnosis, presence of Jones criteria treatment and outcome. In group 2 we analysed provenance, age of initial onset of RF, age of cardiology referral, treatment and outcome.

RESULTS

Thirteen cases were identified, 8 in groups 1 and 5 in group 2. Group 1 included 3 girls and 2 boys, mean age of 10 years. The diagnosis of RF was based in the presence of 2 major and 1 minor manifestation (4/8), 1 major and 2 minor manifestations (1/8) and chorea in 3 cases associated with clinical carditis in one and subclinical carditis in another. Colour Doppler echocardiography showed pathological mitral regurgitation jet in 6 cases, associated with aortic regurgitation in 2 and dilatation of left ventricle in 3. All were treated with penicillin associated with anti-inflammatory drugs in 5 and haloperidol in 3. Group 2 included 3 girls and 2 boys, mean age 9.56 years. Four were from African countries (Angola and Guinea), and one came from the north of Portugal. The elapsed time between the initial acute attack and cardiology referral varied from 5 months to 3 years. All presented severe mitral insufficiency associated with aortic and/or tricuspid valve lesions, and heart failure. All five underwent valve surgery. The secondary prophylaxis was recommended in every patient. There was a recurrence in a child who had interrupted chemoprophylaxis. The patients from African countries were lost for follow-up.

CONCLUSIONS

RF still remains a problem in present times, with serious cardiac sequela in African countries. Colour Doppler echocardiography is a valuable tool for the detection of pathological valvular regurgitation and subclinical carditis if strict criteria are used. The need for appropriate treatment of streptococcal pharyngitis and secondary prophylaxis is emphasized.

Subacute and chronic benign superior vena cava obstructions: endovascular treatment with self-expanding metallic stents

OBJECTIVE

Our purpose is to report our clinical experience with patients who underwent endovascular treatment with Wallstents for subacute or chronic benign obstruction of the superior vena cava (SVC).

SUBJECTS AND METHODS

Twelve patients who were an average of 54 +/- 12 years old were referred for treatment of severe SVC syndrome related to implanted central venous catheters (n = 8), postradiation fibrosis (n = 2), a permanent pacemaker (n = 1), or a benign tumor (n = 1). Symptoms were present for an average of 16 weeks (range, 4-48 weeks) before treatment. Diagnosis of SVC obstruction was confirmed with helical CT and pretherapeutic phlebography. Four patients had Stanford's type II stenosis; two, type III; and six, type IV. The mean clinical and radiologic follow-up intervals were 11 months (range, 1-36 months) and 7 months (range, 1 week to 32 months), respectively.

RESULTS

Recanalization was successful in all patients. Fifteen stents were implanted in the 12 patients. Stents were placed after percutaneous balloon angioplasty in nine patients, and primary stent placement was attempted in three patients. We immediately achieved a satisfactory SVC diameter in all patients, whose symptoms were relieved completely within 1 week of stent placement. No technical or clinical complications occurred. SVC syndrome recurred in one patient 2 months after stent placement and was treated by placing a second stent.

CONCLUSION

Endovascular treatment with stent placement should be considered relevant and safe for refractory benign SVC syndrome. However, a larger series and a longer follow-up period are needed to define the role of stent placement for this syndrome.

Brain "embolism" detected by magnetic resonance imaging during percutaneous mitral balloon commissurotomy

PURPOSE

The common finding of thrombi between the bifoil balloons when they were extracted after mitral dilation prompted us to look for evidence of minor brain embolisms using the sensitive technique of BMRI (brain magnetic resonance T2-weighted imaging).

METHODS

BMRI was performed within 48 hr before and after a percutaneous mitral balloon commissurotomy (PMBC) in each of the 63 patients in this study.

RESULTS

There was evidence (hyperintensity foci: HI) of a previous asymptomatic brain embolism in 38 of 63 patients before PMBC and a new HI appeared in 18 of 63 patients after the procedure. New HI signals were found exclusively in the white matter in 8 of 18 patients and in only 3 of 18 were HI signs larger than 1 cm. One patient, with an HI signal > 1 cm in the thalamus and another < 1 cm in the brain stem, presented diplopia accompanied by other minor clinical signs. The differences in HI rate among four subgroups (1, older vs younger than 43 years; 2, sinus rhythm vs atrial fibrillation; 3, echo score < 8 vs > 8; 4, patients from western countries vs the others) were not statistically significant, probably because the number of patients in each subgroup was low. Patients in atrial fibrillation had slightly more (not significant) HI before PMBC (15/20, 75%) than patients in sinus rhythm (23/43, 53%), but after PMBC their HI frequencies were similar (atrial fibrillation: 5/20, 25%; sinus rhythm: 13/43, 30%).

CONCLUSION

Brain microembolism is frequent during PMBC, but is often anatomically limited and free from clinical signs in most cases. Brain embolism seems to be related mainly to the procedure itself and not the features of the patient.

Brain "embolism" detected by magnetic resonance imaging during percutaneous mitral balloon commissurotomy

PURPOSE

The common finding of thrombi between the bifoil balloons when they were extracted after mitral dilation prompted us to look for evidence of minor brain embolisms using the sensitive technique of BMRI (brain magnetic resonance T2-weighted imaging).

METHODS

BMRI was performed within 48 hr before and after a percutaneous mitral balloon commissurotomy (PMBC) in each of the 63 patients in this study.

RESULTS

There was evidence (hyperintensity foci: HI) of a previous asymptomatic brain embolism in 38 of 63 patients before PMBC and a new HI appeared in 18 of 63 patients after the procedure. New HI signals were found exclusively in the white matter in 8 of 18 patients and in only 3 of 18 were HI signs larger than 1 cm. One patient, with an HI signal >1 cm in the thalamus and another <1 cm in the brain stem, presented diplopia accompanied by other minor clinical signs. The differences in HI rate among four subgroups (1, older vs younger than 43 years; 2, sinus rhythm vs atrial fibrillation; 3, echo score <8 vs >8; 4, patients from western countries vs the others) were not statistically significant, probably because the number of patients in each subgroup was low. Patients in atrial fibrillation had slightly more (not significant) HI before PMBC (15/20, 75%) than patients in sinus rhythm (23/43, 53%), but after PMBC their HI frequencies were similar (atrial fibrillation: 5/20, 25%; sinus rhythm: 13/43, 30%).

CONCLUSION

Brain microembolism is frequent during PMBC, but is often anatomically limited and free from clinical signs in most cases. Brain embolism seems to be related mainly to the procedure itself and not the features of the patient.

Comparison of two methods of therapy level calibration at 60Co gamma beams

The accuracy and traceability of the calibration of radiotherapy dosimeters is of great concern to those involved in the delivery of radiotherapy. It has been proposed that calibration should be carried out directly in terms of absorbed dose to water, instead of using the conventional and widely applied quantity of air kerma. In this study, the faithfulness in disseminating standards of both air kerma and absorbed dose to water were evaluated, through comparison of both types of calibration for three types of commonly used radiotherapy dosimeters at 60Co gamma beams at a few secondary and primary standard dosimetry laboratories (SSDLs and PSDLs). A supplementary aim was to demonstrate the impact which the change in the method of calibration would have on clinical dose measurements at the reference point. Within the estimated uncertainties, both the air kerma and absorbed dose to water calibration factors obtained at different laboratories were regarded as consistent. As might be expected, between the SSDLs traceable to the same PSDL the observed differences were smaller (less than 0.5%) than between PSDLs or SSDLs traceable to different PSDLs (up to 1.5%). This can mainly be attributed to the reported differences between the primary standards. The calibration factors obtained by the two methods differed by up to about 1.5% depending on the primary standards involved and on the parameters of calculation used for 60Co gamma radiation. It is concluded that this discrepancy should be settled before the new method of calibration at 60Co gamma beams in terms of absorbed dose to water is taken into routine use.

Coronary embolization of the membrane fixing a "Multilink" stent to its delivery balloon

We report on a case of coronary embolization of an elastic membrane fixing the ACS RX Multilink stent over its balloon, after a successful stent delivery. The membrane was dislodged from the balloon in the ostium of the right coronary artery as the delivery balloon was being pulled back into the guiding catheter. All attempts to retrieve the membrane, to cover it with another stent, or to push it into a terminal segment of the artery to limit the jeopardized myocardial mass were unsuccessful. No CABG was performed because the left coronary system was normal and the procedure occurred 2 months after an incomplete inferior myocardial infarction. There was no increase in cardiac enzymes nor electrocardiographic signs of a new myocardial infarction at discharge or at 1-mo follow-up. It seems preferable to avoid further use of stents tied to their balloons with an intermediary, and possibly detachable, element.

Acute hemodynamic effects of amlodipine 15 days after a myocardial infarction in normotensive patients treated with atenolol

The acute hemodynamic effects of 20 mg iv amlodipine were evaluated in a placebo-controlled study in 16 normotensive patients 15 +/- 1 days after an acute myocardial infarction by covariance analysis. Atenolol was given orally for at least 1 week before the study to maintain the heart rate between 50 and 60 beats/min. All patients were given two doses of 10 mg of amlodipine, or 10 ml of a placebo twice, in i.v. infusion lasting 2 minutes each. Hemodynamic data were collected during the control period and 15 minutes after each of the two amlodipine or placebo infusions. At the time of the last measurements, 15 minutes after the second amlodipine or placebo infusion, the plasma amlodipine level was 31 +/- 16 micrograms/l and the plasma atenolol level was 773 +/- 564 mu/l in the amlodipine group versus 795 +/- 916 micrograms/l in the placebo group. There were no chronotropic, dromotropic, or inotropic effects. The main hemodynamic effect was a fall in systemic vascular resistance (1548 +/- 591 dynes.sec.cm-5 to 1176 +/- 526 dynes.sec.cm-5, p = 0.045) with decreases in aortic pressure and in the left ventricular stroke work index. The left ventricular ejection fraction was 51 +/- 12% in the placebo group and 56 +/- 15% in the amlodipine group (ns) during the control period, and did not change after infusion of placebo or amlodipine. Left ventricular compliance seemed to be enhanced by amlodipine, because the end-diastolic left ventricular volume index rose from 82 +/- 11 ml/m2 to 87 +/- 11 ml/m2 (p = 0.026) 15 minutes after the beginning of the second infusion of 10 mg of amlodipine, without any change in end-diastolic left ventricular pressure. Intravenous infusion of 20 mg of amlodipine is well tolerated 15 days after acute myocardial infarction in normotensive patients without deeply depressed left ventricular systolic function and chronically treated with atenolol. The main hemodynamic effects observed are potentially useful for such patients.

A rapid and inexpensive method for processing induced sputum for detection of Pneumocystis carinii

The authors describe a method to process induced sputum specimens for detection of Pneumocystis carinii which is simple, rapid and inexpensive. Induced sputum and bronchoalveolar lavage (BAL) were obtained within a 24-hour period from 41 patients who were HIV-positive and had pulmonary symptoms suspicious for P carinii pneumonia. Induced sputum or BAL fluid was placed into Saccomanno's fixative, blended, and centrifuged. The sediment was stained for P carinii cysts by a modified method with Fungi-Fluor Solution A (Polysciences, Warington, PA) and the Genetic Systems Pneumocystis carinii Immunofluorescence Antibody (Genetic Systems, Seattle, WA). The Genetic Systems stain on the BAL specimen was positive in 35 patients and was the standard for comparison. With a single induced sputum, the Genetic Systems stain detected 31 (89%) positive patients, whereas the Fungi-Fluor stain detected 21 (60%). The sensitivity for detecting P carinii cysts in induced sputum was significantly greater (P < 0.05) for the Genetic Systems stain.

[Myocardial infarction with normal coronary angiography. Apropos of 9 cases. A retrospective and comparative study]

This retrospective study was designed to determine the characteristics of myocardial infarction with normal coronary arteries. The files of consecutive patients admitted to hospital for a first infarction in 1992 and 1993 were analysed. Patients younger than 70 years of age, who had undergone coronary angiography during their admission to hospital were selected. A total of 109 infarctions complied with these criteria and 9 of them were associated with angiographically normal coronary arteries. In this series, patients with angiographically normal coronaries tended to be younger than those with at least one stenotic coronary artery (47 +/- 13 years vs 55 +/- 11 years, p = 0.07). The sex ratio did not differ between the two groups. The body mass index of patients with normal coronary arteries was significantly lower (22.9 +/- 3.9 kg/m2 vs 26.3 +/- 3 kg/m2; p = 0.02). These patients more frequently reported a history of phlebitis (3/9 kg/cm2 vs 26.3 +/- 3 kg/cm2; p = 0.02). These patients more frequently reported a history of phlebitis (3/9 vs 2/100). The frequency of anterior and posterior infarctions was virtually the same. Myocardial infarction with normal coronary arteries appears to be less severe, as reflected by the creatine phosphokinase peak (867 +/- 268 IU/l vs 1921 +/- 1389 IU/l), the maximal sum of ST elevation (5 mm vs 16 +/- 12 mm; p = 0.05), the percentage of left ventricular akinesia on angiography (25.5 +/- 4 vs 38.7 +/- 11.8; p = 0.01), and the lower ventricular end-diastolic pressure (11.5 +/- 3.5 mmHg vs 38.7 +/- 11.8 mmHg; p = 0.02). Fewer complications were observed during the acute phase, with no deaths. During the subsequent follow-up, with a median of 2 years, no recurrent infarctions, no cardiac decompensation and no deaths were observed in the group with normal coronary arteries. Two patients presented an episode of angina and one developed a recurrent episode of phlebitis. In the other group of 100 patients, 12 deaths were observed during the acute period, followed subsequently by 2 other deaths, 10 episodes of recurrent angina, 2 recurrent infarctions and 12% of patients developed heart failure. In this series, infarction with normal coronary arteries therefore appears to have a good prognosis, possibly because of more limited myocardial necrosis. No abnormalities of haemostasis or coagulation were observed in these patients.

Results of percutaneous transseptal mitral commissurotomy in patients 40 years and above with those under 40 years of age: immediate and 5-year follow-up results

Patients with mitral stenosis in Western countries are relatively old. It is anticipated that percutaneous transseptal mitral commissurotomy (PTMC) may have more complications and may not be as effective in this group of patient as in younger patients due to more calcification and fibrosis of the mitral valve. We analysed the clinical, hemodynamic, echocardiographic data in 296 consecutive patients divided prospectively into two groups; group 1 consisted of 184 patients > or = 40 years and group 2 of 112 patients < 40 years coming mostly from developing countries. The immediate gain in valve area was 2.18 +/- 0.61 cm2 in group 1 vs. 2.31 +/- 0.65 cm2 in group 2 (P = ns). The incidence of acute regurgitation requiring surgical intervention was similar in both groups. Follow-up data up to 5 years after PTMC was available in 170 patients (92.4%) in group 1 (mean 20 +/- 13 months) and 83 patients (74.1%) in group 2 (mean 29 +/- 17 months). Restenosis by Doppler method (valve area less than 1.5 cm2 with loss of at least 50% initial gain in valve area) was found in 33 patients in group 1 (29.2%) vs. 11 (14.9%) in group 2 (P < 0.05). Events free from death, need for mitral valve replacement or repeat PTMC at 5 year follow-up was 76% in group 1 vs. 87% in group 2 (P < 0.05). We conclude that the immediate effectiveness and acute complications of PTMC in patients 40 years and above are comparable to younger patients. Restenosis is clearly higher and there is a trend towards need for mitral valve replacement in patients 40 years and above at follow-up. However, the continuing benefit for the majority of the patients 40 years and above (76% free from adverse events) would suggest that PTMC is an appropriate treatment modality even in the older patients.

High flow coronary fistula closure by percutaneous coil packing

Few cases of transcatheter coronary fistula closure have been reported. High flow coronary fistulae are usually treated by surgery. This case report presents a 5.4 liters/min flow coronary fistula percutaneously closed by steel coils. This large flow needed the packing of 25 coils, 10-15 cm long, for its total occlusion.

Balloon mitral valvotomy by using the Twin-AT catheter: immediate results and complications in 110 patients

Balloon mitral valvotomy, using a new Twin AT catheter (two balloons attached side by side over one shaft), was performed in 110 consecutive cases. The age of the patients ranged from 19-78 yr (mean 46 +/- 15). From a total of 94 females and 16 males, 23 of the patients (22%) had mitral valve calcification, 47 patients (46%) had atrial fibrillation, and 39 patients (37%) had mitral regurgitation (< +2). Twenty patients (18%) presented with restenosis following surgical commissurotomy. Total catheterization time was 101 +/- 26 min and the duration of the valvotomy procedure was 37 +/- 21 min in these cases. For the entire population, there was a significant reduction in mitral valve gradient (15 +/- 6 to 4.8 +/- 2.6 mmHg, p < .001), an increase in mitral valve area (MVA) (1.1 +/- 0.3 to 2.35 +/- 0.7 cm2, p < .001), and a decrease in mean pulmonary arterial pressure (31 +/- 12 to 26 +/- 11, p < .002) after the balloon mitral valvotomy. Sixteen patients (14%) developed significant left to right shunt, and in 22 patients (20%) mitral regurgitation increased moderately but without resulting in emergency valve replacement. There was one incidence of embolic episode and one pericardial tamponade. Adequate hemodynamic results (MVA > 1.5 cm2 and % increase in MVA > or = 50%) without major complications were obtained in 99 cases. In 9 patients with severely diseased valve (2 previous commissurotomy, one restenosis after balloon valvotomy), or small left ventricular cavity, insufficient results were obtained by the Twin-AT catheter.(ABSTRACT TRUNCATED AT 250 WORDS)

Inoue balloon usefulness in case of failure to stabilize bifoil catheter balloons during percutaneous mitral valvotomy

A new bifoil balloon catheter has been used in the last 120 percutaneous mitral valvotomies carried out in our institution. The shaft segment between the two balloons of the bifoil catheter has been adjusted to the guide-wire diameter, allowing its introduction through a 14F sheath. This thinner shaft does not always offer enough back up to the balloons during inflation. An Inoue balloon replaced an unstable bifoil balloon in 5 cases of mitral dilatation failure due to balloon instability, regularly providing firm stability until full balloon inflation.

The role of percutaneous transvenous balloon mitral valvuloplasty in the treatment of patients with symptomatic mitral stenosis

Since its introduction in 1984, percutaneous transvenous mitral balloon valvuloplasty (PTMV) has emerged as an effective technique in the treatment of selected patients with severe mitral stenosis. The most important factors determining the haemodynamic and clinical outcome after PTMV are the anatomic and pathological features of the mitral valve apparatus. In patients with pliable, non-calcified valves, immediate success rates of well over 90% are achieved. Short-term follow-up studies of such patients after PTMV demonstrate a low rate of valve restenosis, with the vast majority of patients remaining much improved clinically. Less favourable immediate and short-term results are observed in patients who have non-pliable, calcified valves. Major acute complications of PTMV include thromboembolic events and the production of severe mitral regurgitation. It appears that, as a result of increased operator experience, better patient selection and refinements in the technique of PTMV, the rates of these acute complications are now very low. Follow-up studies will be needed to assess the long-term efficacy of the procedure. The first publications on this field are encouraging.

[Left bifascicular block and percutaneous mitral valvuloplasty]

In some patients, the inflation of balloons through the mitral orifice during percutaneous mitral valvuloplasties may impair intraventricular conduction. In some cases, this appears to correspond to a block of the anterior and middle network within the left branch of the bundle of His. This left "biblock" is characterized by extreme left axial deviation of AQRS, of about -60 to -70 degrees, with a QS aspect on D2 and D3, RS on V1 and R on V6 with no major prolongation of ventricular activation time. If this hypothesis is correct, it would support the "trifascicular" concept of the left branch of the bundle of His.

Fluoroscopic guidance in transseptal catheterization for percutaneous mitral balloon valvotomy

A percutaneous mitral balloon valvotomy (PMBV) was attempted on 190 patients with fluoroscopic guidance of atrial septal puncture for transseptal catheterization; in 3 cases, the procedure could not be performed. The left atrium was always reached on the first attempt, when the relationship of the Brockenbrough needle to the aortic catheter was previously observed in 3 fluoroscopic views: anteroposterior, 45 degrees right anterior oblique, and lateral. The atrial septal puncture site was located immediately below the aortic valve level, probably in the fossa ovalis, for the first 80 patients, and at mid distance between the aortic valve level and the diaphragm for the last 110. Hemodynamic data were similar in both groups. Fluoroscopic guidance for atrial septal puncture seemed capital for patients with scoliosis or in whom a vascular distortion (e.g., advanced pregnancy, right inferior vena cava absence) prevented a perfect parallelism between the needle curve and the needle outer index.

[Influence of preload changes on the filling function of the left heart ventricle studied by Doppler echocardiography]

Left ventricular filling may be studied non-invasively by Doppler echocardiographic recording of transmitral blood flow. This study reports the variations in this flow induced by changing cardiac preload by administering trinitrin or by vascular filling in 27 patients undergoing catheterisation. Left ventricular end diastolic pressure (LVEDP) was measured by the pig-tail catheter used for ventriculography. Transmitral flow was recorded by pulsed Doppler using the apical view. The parameters studied were those of the early diastolic E wave and the end diastolic A wave. The hemodynamic and echocardiographic measurements were performed under basal conditions, after trinitrin and after vascular filling. Trinitrin was given to 14 patients and led to a fall in LVEDP from 17.6 +/- 4.5 to 6.7 +/- 1.4 mmHg (p less than 0.001). The amplitude of the mitral E wave decreased and the E/A ratio fell from 0.93 +/- 0.37 to 0.71 +/- 0.32 (p less than 0.001). Thirteen patients underwent vascular filling which increased LVEDP from 10.9 +/- 5 to 27 +/- 4 mmHg (p less than 0.001). The mitral E wave increased and the E/A ratio rose from 0.96 +/- 0.32 to 1.27 +/- 0.23 (p less than 0.01). The patients received trinitrin and then underwent vascular filling. The LVEDP decreased from 16 +/- 3.9 to 8 +/- 2.9 mmHg (p less than 0.001) and then rose to 28.3 +/- 3.5 mmHg (p less than 0.001). The E/A ratio fell after trinitrin from 0.91 +/- 0.40 to 0.58 +/- 0.30 (p less than 0.01) and then rose to 1.42 +/- 0.60 (p less than 0.05).(ABSTRACT TRUNCATED AT 250 WORDS)

Kinetics and hemodynamic effects of intravenous nicardipine modified by previous propranolol oral treatment

Intravenous nicardipine, 5 mg, was administered in two comparable groups of eight patients with chronic coronary artery disease but no clinical signs of heart failure. One group had received no previous treatment and served as a control group, and the other had received long-term treatment with large oral doses of propranolol. Blood concentrations of nicardipine were higher, and the area under the plasma concentration curve was greater in the group previously treated by propranolol. The total clearance of nicardipine was decreased in patients taking propranolol, without a change in the half-life of the drug. Typical hemodynamic responses, namely, a decrease in aortic pressure and in arterial resistances, were greater and more lasting in patients previously treated orally by propranolol. Filling pressure remained stable in both groups. The nicardipine infusion did not induce signs of dromotropic or inotropic negative effects in either group. The greater and more lasting hemodynamic effects of nicardipine in the group previously treated orally by propranolol do not seem to be related to an overall hemodynamic action of propranolol, but are probably due to higher nicardipine plasma levels, and may be caused by a decrease in hepatic blood flow induced by propranolol, with a consequent decrease in nicardipine clearance and by a smaller nicardipine volume of distribution in the propranolol group.

[Percutaneous valvotomy in the combination of mitral and tricuspid valve stenosis. Report of 3 cases]

The authors report the results of a series of 3 cases of double valvuloplasty with a balloon catheter in young patients with combined mitral and tricuspid stenosis. Haemodynamic and Doppler echocardiographic evaluation after the procedure showed comparable results to those of surgical commissurotomy without significant secondary valvular regurgitation. Clinical and echocardiographic follow-up showed that valvular opening remained satisfactory in the 2 cases examined. Percutaneous valvuloplasty would seem to be a valuable alternative to surgical commissurotomy in selected patients with combined mitral and tricuspid valve stenosis.

Swan-Ganz catheter-induced rupture of the pulmonary artery: successful early management by transcatheter embolization

An 84-year-old patient with severe aortic valve stenosis suffered Swan-Ganz catheter-induced massive pulmonary hemorrhage. Immediate therapeutic embolism of the segmental artery by using a liquid, tissue-adhesive, occlusive agent (isobutyl-2-cyanoacrylate) controlled bleeding.

[Mitral and tricuspid valvuloplasty with balloon catheterization in the same procedure. A case report]

Percutaneous mitral and tricuspid balloon valvuloplasty was realized in the same procedure using a double lumen exchange catheter that could accommodate two guide wires and two balloons (19 mm and Trefoil 3 c 10 mm--Schneider) with simultaneous insufflation. Hemodynamically successful was accomplished as evidenced by a decrease in mean mitral gradient from 34 mmHg to 1 mmHg and a decrease in mean tricuspid gradient from 5 mmHg to 3 mmHg. These results were confirmed by serial Doppler echocardiographic studies and by correspondent reduction in symptoms.

[Percutaneous mitral valvuloplasty using balloon catheterization. Immediate results in 80 cases]

In our first 80 attempts of percutaneous double balloon mitral valvuloplasty (BMV) 77 procedures have been successful. The mean patients age was 44 +/- 17 years, there were 16 men; 12 patients had previously been operated, 29 patients had important valvular deterioration (calcifications, thickening or unpliability) or of subvalvar system. For technical failure BMV was performed with only one balloon in 8 patients. BMV resulted in significant improvement in haemodynamic values: the mean capillary pressure fell from 22 +/- 6 to 12 +/- 5 mmHg (p less than 0.001), the mean mitral gradient from 15 +/- 6 to 5 +/- 3 mmHg (p less than 0.001). Cardiac index remained unchanged. The hemodynamic valve area, by Gorlin formula, increased from 1.09 +/- 0.29 to 2.19 +/- 0.72 cm2 (p less than 0.001). Doppler and echocardiography data were similar to haemodynamic data. Mitral valve area obtained with BMV was equivalent to the area usually obtained in closed mitral commissurotomy. There were 3 tamponades. The first, in a patient to whom BMV was not successful. For the 2 others, surgically evacuated, intracavitary pressures were measured after surgical pericardial drain. BMV was of little efficacy in one patient who died 3 days thoracotomy. The three tamponades were caused by straight tip balloon left ventricle perforation. There was no tamponade with pigtail tip catheter balloon. Mitral valve regurgitation was never increased more than 1 + Interatrial septal defect with QP/QS greater than or equal to 1.5 and less than 2 was present in 5 patients. BMV may be a useful alternative to surgery with low incidence of complication. Mitral valve area increase is similar with both treatment.

[Liaison psychiatry: a new perspective on mental health in Latin America]

The situation of Mental Health in Latin America is analyzed. Urgently creating a system able at handling the psychiatric disease increase in the years to come is a conclusion this paper strongly aims at. The beginning of Psychiatry is reviewed, and the importance of Psychiatry at the General Hospital is outlined as well as its rapprochement toward the community, which led to a better control and prevention in the field of Mental Health. A definition of Psychiatry is proposed, as a branch of Medicine which stands in between mental hospitals and communities. Active teamwork, coupled with the physician's work and the tasks other members of the health personnel are engaged in, has led to a more integrated approach onto the ill thus benefiting not only patients but also the whole community.

Variability and reproducibility of quantitative left ventricular angiography

To evaluate the reproducibility of left ventricular angiography for the assessment of left ventricular (LV) function and regional wall motion, two ventriculographies were performed in the 30 degrees right anterior oblique (RAO) projection, at 15-minute intervals, in 19 patients undergoing coronary angiography. Heart rate, left ventricular systolic pressure, and end-diastolic pressure were measured 15 minutes after the first angiography returned to the baseline values (71.0 +/- 14.1 vs. 72.2 +/- 15.5 beats/minute, 153.6 +/- 18.0 vs. 152.8 +/- 19.9 mm Hg, 21.7 +/- 8.6 vs. 20.9 +/- 7.3 mm Hg, respectively). Global and regional LV performance was analyzed by two observers with a computer-assisted technique. Intraobserver mean variation of end-diastolic volume and ejection fraction was less than 3% of the control value. Interobserver mean variations for the same parameters were less than 4% of control values. For both observers, there was no significant variation of LV end-diastolic volume and ejection fraction from one study to the other. Under stable hemodynamic conditions, the mean observed variations were, depending on the observer, 5-6% of the control value for LV end-diastolic volume and 5% for ejection fraction. Analysis of segmental wall motion was also highly reproducible. The mean intraobserver variation (% of control value) of wall motion ranged from 4.4% to 9.2%, depending on the sectors studied. The mean interobserver variation, whatever the sector, ranged from 6.9% to 13.5%.(ABSTRACT TRUNCATED AT 250 WORDS)

Aortic percutaneous transluminal valvuloplasty in elderly patients by balloon larger than aortic anulus

Twenty-four elderly patients (79 +/- 7 years) with long-standing calcified aortic stenosis have been divided in two comparable groups of 12. The first group was treated with 19 mm balloon percutaneous transluminal valvuloplasty, where the balloon diameter was always smaller than the aortic anulus diameter. Peak-to-peak aortic valve gradient decreased from 76 +/- 32 mmHg to 30 +/- 19 (P less than .05), and the aortic valve area, calculated by Gorlin formula, increased from 0.40 +/- 0.17 cm2 to 0.57 +/- 0.17 (P less than .05). The second group was treated with a trefoil 25 mm balloon, always larger than the aortic anulus diameter. In this second group, peak-to-peak aortic valve gradient decreased from 73 +/- 34 mmHg to 23 +/- 15 (P less than .05), and aortic valve area increased from 0.47 +/- 0.14 cm2 to 0.88 +/- 0.36 (P less than .05), increasing thus more than in group I (P less than .05). Clinical tolerance to balloon inflation was not the same according to individual patients but was similar between the two groups; complications were comparable in the two groups. These results suggest that aortic valvuloplasty by trefoil balloon larger than aortic anulus can provide wider aortic valve area without increasing complication rate.

Retrograde catheterization of left ventricle through mechanical aortic prostheses

Twenty-three patients who had undergone aortic valve replacement with a mechanical aortic valve prosthesis (ball-valve: 17, tilting-disc: 6) were investigated by retrograde left ventricular catheterization using a 6 F pigtail catheter. Twelve of these 23 patients also had had combined aortic and mitral valve replacement. To assess the magnitude of the catheter-induced aortic regurgitation and its effect on left ventricular and mitral valve function, 10 patients (group 1) were simultaneously investigated by the transseptal route (8 patients) or direct left ventricular puncture. The 13 other patients (group 2) were studied only by the retrograde crossing of the aortic valve prosthesis. In group 1, placement of the catheter across the valve induced an increase in heart rate (+12%), in left ventricular end-diastolic pressure (from 17.2 +/- 9.6 to 33.3 +/- 12.0 mmHg), a decrease in aortic systolic (-19%) and diastolic (-25%) pressures, and left ventricular systolic pressure (-10%). Transvalvular aortic pressure gradient increased from 15.4 +/- 8.2 to 23 +/- 12.1 mmHg. Pre- and post-crossing pressure gradients were linearly correlated (r = 0.93). Left ventricular end-diastolic volume increased slightly but significantly (+9%), ejection fraction remained unchanged. Pre- and post-crossing regurgitation fractions were linearly related (r = 0.98). Hence, the magnitude of catheter-induced aortic regurgitation averaged 27% whether or not a pre-crossing regurgitation was noted. In group 2, retrograde crossing of the aortic valve prosthesis induced similar hemodynamic changes. There were no catheterization-related complications.(ABSTRACT TRUNCATED AT 250 WORDS)

Acute hemodynamic effects of intravenous nicardipine in patients treated chronically with propranolol for coronary artery disease

Intravenous nicardipine, 5 mg, was infused over 5 minutes in 2 comparable groups of 8 patients with chronic coronary artery disease but no clinical signs of heart failure. Eight patients had received no previous treatment and served as a control group; 8 other patients had received long-term treatment with large doses of propranolol. The hemodynamic responses to nifedipine were similar in the 2 groups, but was greater in patients taking propranolol. At 10 minutes, systemic vascular resistance decreased by 47% in patients taking propranolol and by 39% in the control group; mean aortic pressures decreased by 25% and 10%; heart rate increased by 23% and 19%; and cardiac index increased by 45% in both groups. At 20 minutes, left ventricular end-systolic volume index decreased by 20% in patients taking propranolol and 15% in the control patients; angiographic stroke index increased by 19% and 8%; left ventricular ejection fraction increased by 22% and 11%; and mean circumferential fiber velocity increased by 46% and 32%. Intravenous nicardipine infusion (5 mg) did not induce negative inotropic effects in patients with chronic coronary heart disease, and no evidence of congestive heart failure was seen, even in patients receiving large doses of propranolol. Nicardipine counteracted the potential deleterious effects of propranolol; increased peripheral vascular resistance and left ventricular stroke work and decreased cardiac output.

Could inspiratory apnea disturb left ventricular volume assessment by contrast angiography?

To assess the influence of postinspiratory apnea on the measurement of the left ventricular volumes, contrast ventriculography was performed on 19 patients during spontaneous breathing and then in postinspiratory apnea. Data obtained were similar for end diastolic volumes (81 +/- 29 ml/m2 vs. 83 +/- 25; NS), end systolic volumes (35 +/- 20 ml/m2 vs. 34 +/- 19; NS), systolic index (46 +/- 13 ml/m2 vs. 49 +/- 12; NS), and ejection fraction (0.57 +/- 0.11 vs. 0.59 +/- 0.12; NS). Postinspiratory apnea suppressed the overlapping of the left ventricle with abdominal viscera in 15 of 17 patients. Diaphragmatic immobility permitted the assessment of regional left ventricular function in all 19 patients. However, pressures recorded in inspiratory apnea can no longer be compared to a transmural pressure, and, to assess ventricular compliance, intrapleural pressure must be measured simultaneously. We conclude that left ventricular volume assessment by contrast ventriculography is not disturbed by inspiratory apnea. This maneuver improves the quality of the images and allows a better evaluation of left ventricular segmental function. Spontaneous breathing can be recommended to simplify left ventricular compliance study.

Percutaneous transluminal balloon valvuloplasty of adult aortic stenosis: report of 92 cases

Percutaneous transluminal balloon valvuloplasty was attempted in 92 adult patients with severe calcific aortic stenosis. The mean age was 75 +/- 11 years (range 38 to 91) and 35 patients were more than 80 years old. Most of the patients were severely disabled; 66 were in New York Heart Association functional class III or IV, 27 had syncopal attacks and 21 had severe angina pectoris. Because of unacceptably high surgical risk or contraindication to thoracic surgery, 42 patients could not be considered for valve replacement. Other patients either were in a category of high operative risk or refused the surgical intervention. Valvuloplasty was performed by way of the femoral route (82 patients) or the brachial route (10 patients). Catheters of size 15, 18 and 20 mm were successively placed across the aortic valve and three inflations were usually done with each of them, lasting 80 seconds on average, until a decrease in peak to peak systolic pressure gradient to 40 mm Hg or less was attained, a result considered satisfactory. The inflated balloons were not totally occlusive in most cases and clinical tolerance of inflation was good. Valvuloplasty resulted in a reduction of mean systolic gradient from 75 +/- 26 to 30 +/- 13 mm Hg (p less than 0.001); the final gradient was less than 40 mm Hg in 78 patients. Mean calculated aortic valve area increased from 0.49 +/- 0.17 to 0.93 +/- 0.36 cm2 (p less than 0.001). Immediately after the procedure, ejection fraction increased from 48 +/- 16 to 51 +/- 16% (p less than 0.01).(ABSTRACT TRUNCATED AT 250 WORDS)

Nitroglycerin-induced decrease of carbon monoxide diffusion capacity in acute myocardial infarction reversed by elevating legs

Hemodynamic and respiratory variables were measured in 18 supine patients with acute myocardial infarction uncomplicated by left ventricular failure. Measurements were done during a control period and then when pulmonary capillary bed filling was decreased by iv injection of 3 mg nitroglycerin (NTG) and finally when pulmonary capillary bed filling was increased by raising the patients' legs. Heart rate increased significantly (p less than .05) ventricular filling, and mean aortic pressures dropped significantly (p less than .001) after NTG injection. Heart rate and mean aortic pressure returned to control level and ventricular filling pressures increased significantly (p less than .001) after elevating patients' legs. Mean carbon monoxide diffusion capacity decreased significantly (p less than .01) from 9.8 +/- 3.4 to 8.5 +/- 2.9 ml/min X mm Hg after NTG injection and increased significantly (p less than .02) to 9.3 +/- 3.5 ml/min X mm Hg after elevating patients' legs. Pulmonary wedge pressure decreased significantly (p less than .001) from 15 +/- 5 to 8 +/- 4 mm Hg after NTG injection and increased significantly (p less than .001) to 10 +/- 4 mm Hg after elevating patients' legs. We conclude that NTG reduces pulmonary capillary filling and pulmonary diffusion by reducing the available pulmonary gas exchange surface.

[Percutaneous transluminal aortic valvuloplasty using a balloon catheter. A new therapeutic option in aortic stenosis in the elderly]

Aortic valvular dilatation with a balloon catheter was performed in 44 patients, 20 men and 24 women, most of whom were very elderly (average age 77 years). The indication for valvular replacement had not been retained in these cases because of surgical contra-indications or a very high operative risk and in 3 cases because of patient refusal. Twenty-nine patients were in functional classes III or IV of the NYHA classification; 12 had syncopal episodes and 18 had invalidating angina. The dilatation was performed by a femoral arterial approach in 34 cases, and by a brachial arterial approach in 10 cases. MEDI-TECH catheters with 15, 18 or 20 mm diameters when inflated were used in the majority of cases. Several inflations lasting 10 to 240 seconds were performed in each case with balloons of increasing size. This was well tolerated in all but one patients who had a sharp syncope. The immediate results confirmed valvular dilatation. The average transvalvular pressure gradient fell from 76 +/- 25 mmHg to 30 +/- 13 mmHg (p less than 0.001). The aortic valve surface area calculated by the Gorlin formula increased from 0.5 +/- 0.18 cm2 to 1 +/- 0.42 cm2 (p less than 0.01). After dilatation the gradient was less than or equal to 40 mmHg in 37 cases; aortic valve surface area was greater than or equal to 1 cm2 in 14 cases and less than or equal to 0.7 cm2 in only 5 cases. The left ventricular ejection fraction increased immediately after valvuloplasty from 44 +/- 16 p. 100 to 49 +/- 15 p. 100 (p less than 0.01). In the 18 cases in which it was less than 40 p. 100 before valvuloplasty, it increased from 30 +/- 6 p. 100 to 36 +/- 9 p. 100 (p less than 0.02). Residual aortic regurgitation was only observed in one case. Two patients died in the hospital period (4.6 p. 100). There were no other serious complications. During an average follow-up period of 60 days (3 weeks to 6 months) there was a big improvement in symptoms in the great majority of cases and, in particular, syncopal and anginal attacks disappeared. Only 4 patients remained in functional classes III or IV after valvuloplasty. Percutaneous aortic valvuloplasty is a new, relatively simple, low risk, economic and very effective therapeutic procedure in all cases in which aortic valve replacement is contra-indicated or refused by the patient.(ABSTRACT TRUNCATED AT 400 WORDS)

Percutaneous transluminal valvuloplasty of acquired aortic stenosis in elderly patients: an alternative to valve replacement?

Percutaneous transluminal balloon catheter aortic valvuloplasty (PTAV) was carried out in three elderly patients with acquired severe aortic valve stenosis. Transvalvular systolic pressure gradient was considerably decreased at the end of the procedure, during which there were no complications. Increased valve opening was confirmed by angiography and echocardiography. Subsequent clinical course showed a pronounced functional improvement. PTAV is recommended as a simple alternative to aortic valve replacement in elderly and/or high-risk patients.

Hemodynamic effects of intravenous diltiazem in patients treated chronically with propranolol

In the search for any deleterious hemodynamic effects of the acute administration of intravenous diltiazem (0.25 mg/kg), in patients on beta blockers, studies were performed in two comparable groups of eight patients with chronic coronary heart disease without clinical signs of heart failure. In the first group, with no previous treatment, the only significant variations observed were a decrease in systemic vascular resistance (p less than 0.01) and an increase in cardiac index (p less than 0.01), which were noted only at 5 minutes. In the second group, receiving long-term oral doses of 120 to 240 mg/day of propranolol, at 5 minutes, despite a slight decrease in peak positive first derivative of left ventricular pressure (p less than 0.05), cardiac index and systolic index increased (p less than 0.05 and p less than 0.01) with decreases in systemic vascular resistance (p less than 0.01) and mean blood pressure (p less than 0.05); at 15 minutes, systemic vascular resistance was still decreased (p less than 0.05) and cardiac index and systolic index were still increased (p less than 0.05). In conclusion, intravenous administration of diltiazem (0.25 mg/kg) to patients with chronic coronary heart disease and no evidence of congestive heart failure, who were receiving propranolol, was safe and prevented, in these patients, the potential deleterious effects of beta blockers, that is, increased peripheral vascular resistance and decreased cardiac output.

Arteriovenous shunt measured by bolus dye dilution: reproducibility and comparison between two injection sites

Twenty-eight brachial arteriovenous fistulae (AVF) flows were assessed by the Stewart and Hamilton method by bolus dye injection. These measurements were divided in two groups: a first group with dye injection into the AVF artery and a second group with dye injection into the efferent vessel of the AVF in close proximity. The increase and the decrease of dye concentration were regular and the circulation occurred very late in both groups. Reproducibility was assessed by the usual index: the mean of the differences between two successive measurements of each series related to the first of these two and expressed as a percentage, m(Qn - Qn - 1)/Qn%. In the two groups, the reproducibility index was at 10.1%, similar to the index applied to Grimby's results, measuring successive cardiac output by dye bolus injection at 9.8%. Theoretical criteria of validity of the Stewart and Hamilton method were checked for all measurements. Even when the duration of the measurement was very short, arteriovenous flow fulfilled the criteria of validity in the same way as cardiac output. Two AVF flows were measured successively at both injection sites with no difference between the obtained values. The same reproducibility of the efferent vessel injection site group suggests that an arterial puncture is not necessary for a correct assessment of AFV flow.

[Two-dimensional contrast echocardiography during the drainage of hemopericardium with tamponade]

In patients with cardiac tamponade, withdrawing blood during pericardiocentesis raises questions as to its origin: pericardium or cardiac cavities? These questions can be answered by bidimensional contrast echocardiography after reinjection of a few millilitres of the blood-stained fluid removed. Microcavitations surrounding the heart and vanishing within a few minutes indicate that blood comes from the pericardium. Microcavitations obscuring the right atrium or ventricle and washed away by the blood flow in a matter of seconds indicate that these cavities have been punctured.

Hemodynamic effects of arteriovenous fistulae in chronic hemodialysis patients at rest and during exercise

The effects of arteriovenous fistulae (AVF) on cardiac output (CO) and cardiac filling pressures were studied at rest and during exercise in 16 chronic hemodialysis patients. After the occlusion of the AVF, average CO fell but cardiac filling pressures remained unchanged, seven patients had a drop in CO greater than or equal to 1.0 l/min (group A) and nine patients had a drop in CO less than or equal to 0.9 l/min (group B). At rest, average CO was higher in group A than in group B, but cardiac filling pressures were the same in group A and in group B. During maximal exercise, average CO and cardiac filling pressures were the same in both groups.

Treatment of early postinfarction ventricular aneurysm by intra-aortic balloon pumping and surgery

In nine patients with medically refractory left ventricular failure and/or ventricular arrhythmias, secondary to acute formation of a ventricular aneurysm, intra-aortic balloon pumping (IABP) was instituted 24 to 36 hours before diagnostic angiographic studies. Ventricular irritability was reduced and heart failure was controlled in all patients. Eight patients underwent operation, four within 3 weeks of an acute myocardial infarction and four within 3 months. All had resection of the recent infarction and two had myocardial revascularization as well. Two of the eight patients died in the early postoperative period from intractable ventricular fibrillation. All six patients who survived the operation (mean follow-up 12 months) had excellent clinical results. Ventricular irritability was suppressed and only one patient had residual heart failure. However, there was one late death 7 months after operation. The results suggest that surgical therapy may be effective in the management of medically unresponsive arrhythmias and/or congestive heart failure in the acute or intermediate postinfarction phase. IABP assistance was helpful in supporting the circulation and reducing ventricular irritability during the preoperative and postoperative periods.

Regional left ventricular function assessed by contrast angiography in acute myocardial infarction

The relationship of segmental left ventricular (LV) wall motion abnormalities to LV function 2-6 days after acute transmural myocardial infarction (MI) was investigated in 45 patients by quantitative contrast ventriculography. Patients were divided into four classes according to the MIRU criteria. Segmental wall motion was assessed by determining the percentage of systolic shortening (deltaS) along nine hemiaxes and the extent of akinetic or dyskinetic abnormally contracting segments (% ACS) expressed as a percentage of end-diastolic perimeter. When compared with that in 17 normal control-subjects, the LV end-diastolic volume was increased only in patients in class III and class IV; the LV end-systolic volume increased progressively from normal through class IV. Ejection fraction had a negative linear correlation with %ACS (r = 0.97). The size of ACS was larger in anterior (34 +/- 14%) than in inferior MIs (23 +/- 7%), resulting in greater LV dysfunction. However, for a comparable size of ACS, infarct location alone did not influence LV function parameters. In the noninfarcted zone, deltaS was increased when the size of ACS was less than 25% and reduced when the size of ACS was greater than 25%. Thus, the size of ACS is a major determinant of LV dysfunction in acute MI. The compensatory mechanisms operate either through an augmented mechanical function of residual myocardium when the infarct is small, or through the Frank-Starling mechanism when the infarct is large.

Reversibility of alcoholic cardiomyopathy with abstention from alcohol

A 46-year-old chronic alcoholic patient with typical and severe congestive cardiomyopathy was studied hemodynamically on two separate occasions. The second study followed after a 1 1/2-year period of virtually complete abstention from alcohol and revealed that the left ventricular dysfunction had disappeared. Depsite persisting atrial fibrillation, the response to moderate exercise and to plasma volume expansion was within the normal range. When last seen, 29 months after initial hospitalization, the patient was symptom-free and was not given any treatment.