A nested case-control study on dietary fat consumption and the risk for gallstone disease

BACKGROUND

Gallstone disease (GD) incidence and prevalence rates differ between populations. Diet and lifestyle may be involved in GD development. To our knowledge, no study to date has evaluated quantitative data on diet when studying the relationship between fat consumption levels and GD in an Argentinean population. The present study aimed to assess the association between dietary fat intake and GD.

METHODS

A nested case-control study design was applied. Data were taken from subjects who participated in a previous cross-sectional study carried out in a random sample of asymptomatic people in Rosario, Argentina. Participants underwent a personal interview, and current weight and height, ancestor's ethnicity, and socio-economic status were recorded. Applying a food-frequency questionnaire and a food photography atlas, quantitative dietary data were estimated by combining the intake frequency, portion size and food composition. Logistic regression analysis was used to compute odds ratios and 95% confidence intervals adjusted by age, sex, ancestor's ethnicity, body mass index and daily total energy intake as potential confounders.

RESULTS

In total, 114 patients were studied (49 cases and 65 controls), without any statistically significant differences for age, sex, socio-economic status, body mass index and ancestry. The mean energy intake was higher in cases than in controls, and significant differences were found for dietary fat consumption. Obese or overweight people have a higher GD risk than subjects with normal weight. Increased GD risks were associated with high intakes of energy, total fat, and saturated and monounsaturated fatty acids.

CONCLUSIONS

According to our results, total fat, saturated and monounsaturated fatty acids high intakes are associated with increased GD risk.

Morphological and demographic associations of biliary symptoms in subjects with gallstones: findings from a population-based survey in Rosario, Argentina

BACKGROUND

Gallstone disease is a frequently encountered disorder in subjects living in Rosario. The reasons for the presence or absence of symptoms are unknown.

AIMS

To determine associations between biliary symptoms and ultrasonographic features of gallbladder and gallstones.

SUBJECTS

A random study was conducted on 1,173 subjects, inhabitants of 20 years and older, in the city of Rosario, Argentina.

METHODS

High-resolution abdominal ultrasound examinations were performed. Biliary pain was defined based on previously published definitions.

RESULTS

Gallstones were found in 149 subjects (101 female, 48 male) of whom 51% of females and 35% of males with cholelithiasis were symptomatic. Mean age was 53 years in symptomatic and 55 in asymptomatic subjects. Gallbladder size was normal in 97% of symptomatic and in 96% of the asymptomatic participants. There were no significant differences between the groups as far as concerns size and gallstone number. Impacted stones were observed in 10% of symptomatic and in none of the asymptomatic subjects (p<0.01).

CONCLUSIONS

Subjects' age and gender, gallstones size and number, as well as ultrasonographic features of gallbladder and biliary tract did not differ significantly between symptomatic and asymptomatic subjects. Only impacted stones were significantly more frequent in symptomatic subjects.

[Early intervention in acute coronary syndromes (unstable angina and non-Q wave infarction]

The timing for coronary angiography and revascularization in unstable angina and infarction without Q-wave in patients without high-risk characteristics after arrival to the hospital is uncertain. If high-risk patients are not considered, there are several therapeutical strategies for the diagnosis and treatment of the patients. The first is a conservative approach, in which coronary angiography and revascularization is done only in patients presenting angina or electrocardiographic changes of ischemia after arrival to the hospital. The other one is an invasive approach, in which coronary angiography and revascularization procedure are done few days after arrival to the hospital. Several studies, in the last decade, have compared both types of therapeutical strategies in patients with unstable angina and infarction without Q-wave (TIMI IIIB, FRISC II and VANQWISH). The results of these studies were uncertain and showed that there are no advantages regarding mortality or infarction with either therapeutic approach. However, some subsets of patients benefited from the invasive approach (patients > or = 65 years, angina or electrocardiographic changes in S-T segment during the time of hospitalization). On the other side, all these studies showed that with the invasive approach there is less incidence of recurrent ischemic events during the time of hospitalization and at long range, as well as an improvement in the functional class of ischemia, and in long-range quality of life as well as a marked reduction in hospital stay. In conclusion, an early invasive approach could be justified in patients with unstable angina presenting low and intermediate risk factors.

Epidemiology of gallstone disease in Argentina: prevalences in the general population and European descendants

To assess gallstone disease prevalence in Argentina, a random sample of the Rosario City population was studied, considering already known associated factors, and analyzing ethnic groups living in the city. A total of 1,173 participants (69% response), both sexes, 20 years and older were studied. Each subject underwent an abdominal ultrasound examination, a blood test, and a standardized questionnaire. It was seen that gallstone disease prevalence (gallstones or cholecystectomy), overall was 20.5% (23.8% in women and 15.5% in men; (P = 0.0005), and was associated with age and body mass index in both sexes, and with pregnancy number and hypertriglyceridemia in women. As regards ancestors' nationalities, Italian and Spanish descendants presented higher prevalence rates for all age groups than those described in Italy and Spain. Thus far, in a subsample of 78% of nonparticipants submitted to a new home visit, presence of cholecystectomy or symptoms did not differ from participants, supporting the validity of our results.

[Late thrombolysis and electrical stability in acute myocardial infarction. Role of the collateral flow]

We evaluated 249 patients (pts) with first acute myocardial infarction: 1. Pts without thrombolysis, n = 119, 2. Pts treated with thrombolysis within 6 hours following MI, n = 80 and 3. Pts treated with thrombolysis between 6-12 hours after MI. Arrhythmic events were evaluated during follow up. All underwent heart rate variability studies and coronary angiogram where anterograde flow (TIMI) and collateral flow (Rentrop scale 0-2 = poor collateral flow and 3 = good collateral flow) were determined. Pts in group 2 and 3 showed a better anterograde and collateral flow than group 1 (p < 0.001). A lower spectral power in the high frequency band and a higher ratio low/high frequency band were observed in group 1 (p < 0.05). Conjunctive consolidation analysis showed more malignant arrhythmias in TIMI 0-2 with poor collateral flow than TIMI 0-2 with good collateral flow (17/138-12.3% vs 0/14-0%). Kaplan Meier analysis was able to demonstrate more cardiac sudden death events in TIMI 0-2 with poor collateral flow than TIMI 0-2 with good collateral flow or TIMI 3 (x2 = 7.22, p = 0.028), independently of thrombolytic treatment.

[The no-reflow phenomenon: its incidence and clinical characteristics in a series of cases]

The no-reflow phenomenon refers to the inability to reperfuse myocardial tissue despite removal of an occlusion of a coronary artery. No reflow is a complication that may occur after revascularization of patients. This study examined the incidence and, clinical characteristics of no-reflow in a patient population treated with conventional percutaneous transluminal coronary angioplasty at the Instituto Nacional de Cardiología "Ignacio Chávez". We reviewed 204 elective angioplasties and 62 direct angioplasties; 14 patients were included (4 from the first group and 10 from the second group). No-reflow were more frequently in men, the mean age was 56 years and diabetes and smoking were the risk factors more frequently reported. No-reflow was found in left anterior descending coronary artery in 7 patients, the time of reperfusion, in direct angioplasty, was 10.6 hours (mean) and the strategy most frequently used to reestablish normal anterograde flow was intracoronary verapamil. The overall incidence of no-reflow for the two modalities was 5.2% (16.12% for direct angioplasty and 1.9% for elective angioplasty). The current study shows that the no-reflow phenomenon is not uncommon after angioplasty; no-reflow appears higher than the previous reports for both modalities of treatment.

[Usefulness of SPECT (single-photon emission-computed tomography) in the detection of coronary disease]

OBJECTIVE

To evaluate the clinical usefulness of cardiac SPECT in the detection of coronary artery disease, and the relation with the site, number and severity of the angiographic lesions.

METHOD

We studied 216 patients; with myocardial perfusion imaging with SPECT (T1-201 and/or Tc-99 Sestamibi) and coronary angiogram. We defined the localization of myocardial perfusion defects (anterior, inferior, septal, lateral or apex), and their correlation with coronary angiogram, based on the location, number and severity of coronary angiographic lesions. We considered significative coronary stenosis obstructions of 60% or more.

RESULTS

Of the 216 patients studied, 181 (83.8%) were male and 35 (16.2%) female. Age ranged between 30 and 82 years; 143 males and 23 females had a previous myocardial infarction. The SPECT sensitivity for diagnosing ischemia of one, two and three vessel disease was 94%, 96% and 100%. The sensitivity for diagnosing disease in specific vascular territories was 91.6% for LAD 100% for RCA, 92.8% for CX and 100% for left main.

CONCLUSIONS

Myocardial perfusion imaging with SPECT has high sensitivity for diagnosing coronary artery disease. The sensitivity and specificity were more accurate in proximal anterior descending artery disease, left main and three-vessel coronary artery disease. We found correlation in the site, number and severity of the angiographic lesions and in myocardial perfusion defects.

Prognostic value of hepatic venous pressure gradient measurements in alcoholic cirrhosis: a 10-year prospective study

BACKGROUND & AIMS

Different parameters are considered predictors of bleeding and death in alcoholic cirrhosis. The aim of this study was to establish the prognostic value of a prospective and sequential evaluation of portal pressure, variceal size, and Pugh's score in portal-hypertensive patients with alcoholic cirrhosis but no previous bleeding.

METHODS

Thirty patients were evaluated for 42 +/- 5 months (median, 39 months). After baseline studies, 30 patients underwent an additional evaluation (follow-up 1; median, 10 months), 20 patients a second evaluation (follow-up 2; median, 25 months), and 13 patients a third evaluation (follow-up 3; median, 45 months). No prophylactic treatment for bleeding was given. End points were bleeding and/or death.

RESULTS

Seventeen patients died, and 10 patients bled. At follow-up 1, portal pressure decreased both in survivors and nonbleeders (from 18.7 +/- 1.0 to 15.2 +/- 1.3 mm Hg [P < 0.01] and from 18.9 +/- 0.8 to 16.5 +/- 1.0 mm Hg [P < 0.05], respectively). On multivariate analysis (Cox model), portal pressure at follow-up 1 had the best prognostic and independent value for both bleeding and survival. Subsequent studies showed similar trends.

CONCLUSIONS

Measurements of portal pressure provide unique prognostic information for predicting portal hypertensive-related bleeding and mortality in patients with alcoholic cirrhosis.

[Directional coronary atherectomy after unsuccessful angioplasty]

Directional coronary atherectomy (DCA) is a percutaneous revascularization procedure. The basic indications are complex lesions (excentricity, irregular borders with ulceration and in non-calcified lesions in large coronary vessels or in vein grafts). DCA in recent years has been a useful procedure in several circumstances, in which initial results with conventional coronary angioplasty had failed, specifically in those conditions like acute occlusions, threatened closure or "elastic recoil" phenomenal, focal dissection or residual stenosis > 50% due to hare atherosclerotic plaque. In this report two cases of "rescue" DCA due to residual stenosis > 50% because of "elastic recoil" are presented. One of them had a concentric lesion and the other a marked excentricity. Both cases had primary success. Atheroma was shown by histopathology. Rescue DCA is a useful feasible alternative procedure in selected cases, in which conventional coronary angioplasty had initially not been successful.

[Coronary angioplasty with the Monorail system via 6 French diagnostic catheters]

We studied the use of "Monorail" system with Express (Scimed) balloon catheters for coronary angioplasty through 6 French (F) "high-flow" diagnostic catheters (Novoste, USCI). Prospectively, from July 1992 to January 1993, angioplasty of 31 lesions in 24 patients was attempted (1.3 lesions/procedure). Twenty procedures were of a single lesion and four were multi-vessel angioplasty. Fourteen lesions were in the left anterior descending or in its branches, 10 in the left circumflex or in its branches, 6 in the right coronary artery, and one in the distal anastomosis of an internal mammary artery graft. Thirteen lesions (42%) were type A, 17 (55%) type B and one (3%) type C. Balloon sizes varied between 2.0 and 3.5 mm. Twenty-nine lesions could be successfully dilated (93.5%); two cases were unsuccessful due to an acute occlusion in one and residual stenosis of more than 50% in the other. For only one case, another balloon catheter different from the "Monorail" system was necessary to complete a multi-vessel angioplasty. Coronary visualization and manipulation of the balloon through the tip of the diagnostic catheter were satisfactory in all cases, except with the 3.5 mm balloon catheter. Coronary angioplasty with "Monorail" system balloon catheters through 6 F "high-flow" diagnostic catheters is feasible and provides a high success rate in simple and moderately complex selected lesions, including multivessel angioplasty with advantages of smaller artery punction and the feasibility of performing coronary angioplasty with the same catheter used for diagnostic angiography.

Propranolol compared with propranolol plus isosorbide dinitrate in portal-hypertensive patients: long-term hemodynamic and renal effects

The long-term hemodynamic and renal effects of propranolol were compared with those of propranolol plus isosorbide dinitrate in 44 portal-hypertensive alcoholic cirrhotic patients. Eight control patients, 8 patients receiving propranolol and 14 patients receiving propranolol plus isosorbide dinitrate were hemodynamically evaluated. Renal function was studied in a fourth group of 14 patients receiving propranolol plus isosorbide dinitrate. Portal pressure decreased more (p < 0.05) with combined therapy (-21.6%, from 19.5 +/- 4.8 to 15.4 +/- 4.3 mm Hg) than with propranolol alone (-12.5%, from 19.9 +/- 1.2 to 17.4 +/- 1.8 mm Hg). Serum urea and creatinine levels, plasma sodium concentration, urine volume and urinary sodium excretion showed nonsignificant changes in all groups studied. Combined therapy induced a significant (p < 0.05) decrease in plasma renin activity (from 4.42 +/- 4.7 to 1.59 +/- 1.9 ng/ml/hr) and nonsignificant reductions in plasma aldosterone concentration and creatinine clearance. None of the eight patients with ascites or history of ascites not receiving isosorbide dinitrate showed evidence of impairment in renal sodium metabolism during the study period. In contrast, 8 of the 14 patients (57%) with ascites or history of ascites receiving isosorbide dinitrate showed impairment in renal sodium metabolism (p < 0.01), as reflected by the development or worsening of ascites and the need of higher diuretic requirements. Long-term combined administration of propranolol plus isosorbide dinitrate is superior to propranolol alone in the pharmacological treatment of portal hypertension.(ABSTRACT TRUNCATED AT 250 WORDS)

[Variations in hemostasis and fibrinolysis during the treatment of acute myocardial infarct (AMI) with tissue-type plasminogen activator (TTPA). A study of 17 cases]

The aim of this trial was to estimate changes in the coagulation and fibrinolysis systems during the thrombolytic treatment with recombinant human tissue-type plasminogen activator (rt-PA) in patients with acute myocardial infarction and correlate with hemorrhagic complications. We studied 17 patients with a 3 hours-continuous systemic infusion of 100 mg of rt-PA. Prothrombin time, activated partial thromboplastin time, thrombin time, fibrinogen splits products, plasminogen, alfa-2-antiplasmin (a-2AP) and antithrombin III (AT-III) were performed before, during and after infusion. Most patients showed lengthening coagulation times. Fibrinogen and plasminogen were decreased and PDF was increased. No variations in alpha-2AP or AT-III were observed. The recuperation of fibrinogen levels occurred in 3 hours and there was hyperfibrinogenemia after day 3. No hemorrhagic complication was observed in patients with abnormalities in these coagulation or fibrinolytic tests.

[Coronary angioplasty in patients not accepted for surgical treatment. The initial experience of the Ignacio Chávez Instituto Nacional de Cardiología]

Coronary angioplasty has shown its efficacy in "high-risk" patients for surgical treatment (severe left ventricular failure, serious pulmonary or systemic disease). We studied a subgroup with multivessel coronary heart disease treated with coronary angioplasty because they were no candidates for surgery due to unsuitable coronary anatomy. Revascularization rate was determined in each patient as revascularization percentage obtained, compared with all the technically suitable lesions for coronary angioplasty. Ten patients (mean age 63 years) were studied, eight of them had unstable angina. Overall, 44 lesions were considered technically suitable for angioplasty and thirty-five could be dilated, technical success rate was 88% (31/35 lesions) and revascularization rate was 71% (31/44 lesions). Primary success rate was achieved in nine patients. Clinical follow-up varied from two to thirteen months (mean 7.8 months); eight patients have remained asymptomatic (class I of NYHA), another patient had stable angina and the other one had sudden death six months after the procedure. In conclusion, we demonstrated a high success rate in a short and long term with coronary angioplasty in a subgroup of patients with multivascular coronary heart disease that had been rejected for surgery due to unsuitable coronary anatomy.

[The primary outcome in transluminal coronary angioplasty: the recent experience of the Instituto Nacional de Cardiología (1991-1992)]

Percutaneous balloon coronary angioplasty had a slow start in Mexico, and until recently only a relatively small number of procedures have been performed. Since March 1991, the Instituto Nacional de Cardiología has state-of-the-art fluoroscopic imaging and easy access to a variety of balloon coronary angioplasty catheters and accessories. Under these conditions, an increasing number of PTCAs have been performed (221 procedures in an initial 15 month period). The primary results of PTCA in this patient population is presented as a reference source for results of PTCA in our population. Indication for PTCA was stable angina in 31%, unstable angina in 64% and AMI in 5%. Forty-two percent of the procedures were for multivessel PTCA, with a total of 355 lesions approached (1.6 segments per patient). There were 34% type A, 51% type B and 15% type C lesions. Mean percent stenosis was reduced from 81% to 29% (p < 0.001). There was a 94% success rate in type A lesions, 89% in type B and 77% in type C lesions. Six patients required urgent CABG (2.7%), thirteen had a myocardial infarction (5.9%) and mortality was 1.35% (including one patient with cardiogenic shock who had a noncomplicated failure and had a late in-hospital death). We conclude that with adequate support and equipment, angioplasty results compare favorably to those reported by more experienced groups in developed nations. Also, the necessary number of procedures for the maintenance of competence in PTCA can be done in our country.

Magnum/Magnarail versus conventional systems for recanalization of chronic total coronary occlusions: a randomized comparison

The Magnum/Magnarail system consists of "over-the-wire" balloon catheters and a 0.021 inch (0.53 mm) guide wire with a 1 mm olive-shaped tip. To compare it to conventional systems, 100 consecutive unselected patients with chronic total coronary occlusions were randomly assigned to one of two groups. If the balloon could not be placed within 20 minutes of fluoroscopy time with the allocated system, a crossover to the other system was imposed. The Magnum group comprised 50 patients and 52 occlusions, and the conventional group included 50 patients and 51 occlusions. There were no significant differences with regard to the length of the occlusions (Magnum 1.4 +/- 1.3 mm, conventional 1.6 +/- 1.7 mm) or the duration (Magnum 1.4 +/- 1.9 months, conventional 1.4 +/- 1.8 months). The primary success rate before crossover with the Magnum/Magnarail system was 67% versus 45% with conventional systems (p less than 0.05). The Magnum/Magnarail system as a second tool after crossover was successful in 11 of 28 patients (39%) versus 2 of 16 patient (12%) in whom success was achieved with a conventional system as a second tool (p less than 0.05). An increase in the creatine kinase level (more than twice normal) was seen in one patient (2%) in the Magnum/Magnarail group and none in the conventional group. Q wave infarctions were not seen. There was one in-hospital death (2%) in the conventional group. There were no significant differences with regard to the number of guiding and balloon catheters or fluoroscopy time. The Magnum/Magnarail system proved superior to conventional systems for balloon recanalization of chronic total coronary occlusions in terms of higher success rates.

Randomized evaluation of 5 French catheters for coronary angiography with or without the CO2 powered Hercules syringe

To evaluate the CO2 power-assisted hand-held Hercules syringe (Cordis) for diagnostic coronary angiography using 5 French catheters (Judkins number 4 exclusively), 200 consecutive patients (excluding patients with valve disease and prior bypass surgery) were randomized to conventional manual or Hercules injections. The angiography was done through a femoral artery with or without a sheath. Total duration and fluoroscopy time from the end of the ventriculogram to the end of the procedure, quantity of contrast medium required, length of cinefilm, quality of film (good, satisfactory, or bad), streaming, technical ease [scale 1 (easy) to 6 (difficult)], and need for larger catheters were analyzed. Adequate quality angiograms were obtained in 193 patients (97%). Crossover to a larger catheter was required in 7 patients due to difficulty in engaging coronary ostia (right 6, left 1). No significant differences between manual or Hercules injections were seen in total duration of the procedure (12.0 +/- 4.6 versus 12.9 +/- 8.5 min), fluoroscopy time (4.0 +/- 3.1 versus 4.2 +/- 4.8 min), quantity of contrast medium (81 +/- 28 versus 89 +/- 29 ml), and length of the film (1.1 +/- 0.6 versus 1.3 +/- 0.7 min). The conventional method was found to be easier (facility scale: conventional 1.7 +/- 0.5, Hercules 2.3 +/- 1.2, p less than 0.05) because there was significantly less dislodgement of the catheter from the coronary ostia during contrast injections. Five French number 4 Judkins catheters permit adequate diagnostic coronary angiograms in 97% of routine coronary patients.(ABSTRACT TRUNCATED AT 250 WORDS)

[Percutaneous mitral commissurotomy with Inoue balloon. Short-term results. Initial experience at the Ignacio Chavez National Institute of Cardiology]

Percutaneous transvenous mitral commissurotomy (PTMC) using balloon catheters has emerged as an alternative to surgery for patients with mitral stenosis. This report details our recent experience of PTMC with the Inoue balloon in 20 consecutive patients with mitral stenosis from april 2 to july 27, 1991. Mean age was 35.6 +/- 9.5 years. Mitral valve area increased form 1.04 +/- 0.3 to 2.32 +/- 0.5 cm2 (p less than 0.0001). Mitral valve gradient decreased from 19.2 +/- 8.8 to 6.6 +/- 2.3 mmHg. (p less than 0.0001). Two patients developed mitral regurgitation greater than 2+/4 after the procedure. In none the residual left to right shunt was greater than 1.2L. There was no mortality. We conclude that in selected patients, excellent results are obtained PMTC with the Inoue balloon. Complications are minimal.

Coronary angioplasty with 7F guiding catheters

The performance of 7F guiding catheters for percutaneous transluminal coronary angioplasty (PTCA) was investigated in 300 patients. A total of 233 patients had single-vessel PTCA and 67 had multivessel PTCA. Angioplasty was attempted for 371 lesions (141 [38%] in the left anterior descending, 124 [33%] in the right coronary artery, and 95 [26%] in the left circumflex coronary artery or their branches; 10 [3%] in a bypass graft, and one in the left main stem). The mean degree of stenosis was 86 +/- 11% (range 60% to 100%). The monorail technique was used in 83%, and balloon-on-a-wire devices were used in 6% of cases. The balloon sizes varied between 2.0 and 4.25 mm. There was a 98% technical success rate for the 325 nontotal lesions. Five could not be crossed with the wire. Exchange to an 8F guiding catheter was done in four cases (1.2%) and yielded success in two of them. In 46 occlusions the success rate was 72%. Nine were failures due to an inability to cross the wire, another two were balloon failures, and in two cases the residual stenosis was greater than 50%. The mean residual stenosis of successful cases was 24 +/- 18%. Overall, the primary success rate was 95%. The complications were: in-hospital death in five patients (1.7%); infarction in 12 (4%); emergency bypass surgery in one; and significant inguinal hematoma in five (1.7%). Coronary angioplasty through 7F guiding catheters yields a high success rate with less coronary wedging and a smaller puncture hole.

Coronary angioplasty with second generation Monorail catheters

The Monorail system (Schneider) consists of a balloon catheter in which the guidewire passes through the balloon itself, exits the catheter proximal to the balloon, and runs alongside its small shaft (3 French) through the length of the guiding catheter. It offers distinct advantages over conventional systems of coronary angioplasty. It facilitates contrast injections and permits rapid balloon exchanges. This system was used for coronary angioplasty in 273 unselected consecutive patients (age 59 +/- 10, mean 35 to 73 years). There were 216 patients (84%) undergoing single-vessel and 57 patients (16%) with multi-vessel coronary angioplasty. A total of 335 coronary stenoses were dilated, which included 35 total occlusions. The size of balloon used ranged from 2.0 to 4.25 mm (3.0 +/- 0.5 mm) and the severity of stenosis was 85 +/- 11%. Technical success was defined as a residual stenosis of less than 50% as determined angiographically. Clinical success was defined as technical success, and absence of a major inhospital complication defined as absence of myocardial infarction, lack of need for coronary arterial bypass surgery, and survival. The Monorail system was technically successful in 294/300 stenotic lesions (98%). It was clinically successful for 281 lesions (94%). Of the 35 total occlusions, technical success was obtained in 25 (71%). The residual stenosis of successful cases was 26 +/- 21%. The Monorail system was also successful in 5 patients with stenosis of more than 90% in whom conventional systems failed. The complications included acute occlusion causing acute myocardial infarction in 13 cases (5%), emergency coronary arterial bypass surgery in 1 patient (0.4%), and death in 4 patients (1.5%).(ABSTRACT TRUNCATED AT 250 WORDS)

[Papillary muscle dysfunction in acute myocardial infarct: a clinical and Doppler echocardiographic study]

The "papillary muscle dysfunction" concept includes a disrupted sequence of one or more structures of the mitral valve complex and not merely a disturbance of a papillary muscle itself. We studied a group of seventeen patients, 14 men and 3 women (mean age 51 and 39 years, respectively). Acute myocardial infarction was the first evidence of heart disease. In all of them, Doppler and M mode echocardiography were performed and correlation clinical features were done. In addition a tricuspid regurgitation flow patterns was scanned on each patient. Mitral regurgitation was found in 29% of them by Doppler echocardiography and only 17% had a mitral systolic murmur suggestive of this entity. In those patients with mitral regurgitation-flow patterns, the infarct site was similar to those with anterior and inferior infarction and serum CPK-level was greater in these patients than the non-mitral regurgitation flow pattern group. The evidence of tricuspid regurgitation by pulsed-Doppler echocardiography was associated with mitral regurgitation in 80% of patients, mainly those with right ventricular extension of acute myocardial infarction, and with the greatest hemodynamic impairment. It seems likely in this study, that mitral regurgitation was due to valve ring dilation with an increase of left ventricular diameter and a decrease on ventricular systolic function.

Coronary balloon angioplasty through diagnostic 6 French catheters

We investigated the use of ultralow profile balloon catheters (Scimed ACE, USCI Probe, Cordis, Orion) for coronary angioplasty through 6 French diagnostic catheters (Schneider, Cordis). Contrast injection was assisted with a Hercules pump (Cordis) in all cases. During 21 procedures, angioplasty of 27 lesions in 20 selected patients was attempted (1.3 lesion/procedure). Twelve lesions were in the right, 10 in the left anterior descending, and 5 in the left circumflex coronary artery. Balloon size varied between 2.5 and 3.5 mm. Twenty lesions could be successfully dilated (74%) through the 6 French catheter and 7 lesions required an exchange to a 7 French angioplasty guiding catheter. For 5 cases, another balloon was also necessary to complete the procedure. The final overall success rate was 100% per patient and per lesion and there were no major complications. Despite the small internal catheter lumen (1.22 mm) coronary visualization was adequate, and mechanical support was good. Failures of 6 French catheters were attributed to insufficient torque control and excessive friction when the balloon crossed the tapered end of the diagnostic catheter. Coronary angioplasty through a diagnostic 6 French catheter is feasible and may represent a reasonable alternative for simple cases that are done during the same session as the diagnostic angiography. Once available, 6 French high flow angioplasty guiding catheters without a tapered tip should improve success while retaining the advantage of a small femoral puncture site.

Long-term hemodynamic effects of ketanserin, a 5-hydroxytryptamine blocker, in portal hypertensive patients

Ketanserin, a 5-hydroxytryptamine-2 receptor blocker, has been shown to decrease portal pressure in recent acute hemodynamic studies that have been performed both in experimental animals and portal hypertensive patients. The present study was designed to investigate the effects of chronic oral administration of ketanserin in portal hypertensive patients with cirrhosis. The mean baseline hepatic venous pressure gradient in the 13 patients with alcoholic cirrhosis who completed the study was 15.7 +/- 2.7 mmHg. It decreased significantly to 13.3 +/- 2.0 mmHg (p less than 0.001) after ketanserin was administered at a mean dose of 51 mg per day for a mean period of 32 days. This 14.6% reduction in hepatic venous pressure gradient resulted mainly from a decrease in mean wedged hepatic venous pressure (from 22.2 +/- 4.0 to 20.1 +/- 3.6 mmHg) and was accompanied by significant decreases in cardiac index (18.8%) and in mean arterial pressure (8.1%). However, changes in cardiac index or in mean arterial pressure were not predictive of modifications in the hepatic venous pressure gradient. Eight of 16 patients entered in the study developed side effects, the most significant being a reversible portosystemic encephalopathy, which occurred in three patients who had poor liver function. This study confirms evidence in favor of a role for 5-hydroxytryptamine in portal hypertension and adds a new group of agents for the chronic treatment of portal hypertensive patients.(ABSTRACT TRUNCATED AT 250 WORDS)

Acute and chronic hemodynamic effects of propranolol in unselected cirrhotic patients

Different and contradictory results concerning the use of propranolol in the treatment of portal hypertension have been reported. This study was designed to investigate the hemodynamic effects of short- and long-term administration of propranolol in portal hypertensive patients. Portal pressure, cardiac index, heart rate and blood pressure were obtained in 18 unselected alcoholic cirrhotic patients with esophageal varices before and 60 min after the oral administration of 40 mg propranolol and again after 106 +/- 35 days of continuous oral administration (mean dose = 158 +/- 63 mg per day). Baseline portal pressure was 21.7 +/- 7.2 mm Hg. It decreased after 60 min to 17.2 +/- 5.5 mm Hg (p less than 0.01) and after long-term administration of propranolol to 16.1 +/- 5.7 mm Hg (p less than 0.01). No decrease in portal pressure was noted in 9 of 18 (50%) patients after acute administration and 5 of 17 (30%) patients after long-term administration. Baseline cardiac index was 5.1 +/- 1.2 liters X min-1 X m-2. It decreased after 60 min to 3.9 +/- 1.4 liters X min-1 X m-2 (p less than 0.01) and to 3.6 +/- 1.0 liters X min-1 X m-2 after long-term administration (p less than 0.001). Baseline heart rate was 85 +/- 11 beats per min. It decreased after 60 min to 75 +/- 9 (p less than 0.001) and after long-term administration to 62 +/- 6 (p less than 0.001) beats per min. Baseline mean arterial pressure was 108 +/- 11 Hg. It decreased after 60 min to 97 +/- 14 mm Hg (p less than 0.01) and after long-term administration to 103 +/- 14 mm Hg (not statistically significant).(ABSTRACT TRUNCATED AT 250 WORDS)

Coronary artery aneurysms in Kawasaki disease: the Puerto Rican experience

Kawasaki disease is a newly recognized clinical entity of unknown origin that occurs in the pediatric age and is characterized by multisystemic involvement. Pathologically, widespread vasculitis is present and approximately 10 to 20% of affected children have coronary aneurysms. The latter are mostly silent but 1-2% of them progress to coronary artery obstruction and death from myocardial infarction. Such aneurysms can be visualized by echocardiography and 50% of them apparently resolve, although in some cases, residual coronary artery damage persists after resolution of the aneurysm. The local experience with 116 patients of KD is reported. In only 4 of them significant coronary artery involvement was present. They all remained asymptomatic, the affected arteries were slowly recovering and no fatalities were present. The low incidence of coronary aneurysms and the uneventful course of the disease suggests a milder, less virulent course of KD in our environment. Residual changes in the affected coronary arteries are considered a late risk factor for coronary artery disease in man.