Is it coincidental or correlative between reversible splenial lesion syndrome and atrial septal defect?: A case report

RATIONALE

Reversible splenial lesion syndrome (RESLES) is a recently identified clinico-radiological syndrome, the etiology is miscellaneous. Atrial septal defect (ASD) as an underlying etiology for RESLES has not been reported. We first report a rare case of RESLES associated with ASD. The clinical, radiological, and ultrasonic profiles were presented and the pathophysiological mechanism was analyzed.

PATIENT CONCERNS

A 23-year-old man presented with headache, drowsiness, occasional paraphasia, and paroxysmal dry cough. Brain magnetic resonance imaging (MRI) on admission showed an ovoid isolated lesion in the splenium of corpus callosum, which exhibited hyperintensity on diffusion-weighted imaging and hypointensity on apparent diffusion coefficient, and completely disappeared on the follow-up MRI 14 days later. ASD was found by transthoracic echocardiography, Right-to-left shunts were detected on color Doppler of transesophageal echocardiography, and microemboli were captured by transcranial Doppler ultrasound.

DIAGNOSES

According to his clinical history and imaging results, we confirmed the diagnosis of RESLES associated with ASD.

INTERVENTIONS

The patient was treated by oral aspirin and lopidogrel sulfate to inhibit platelet aggregation. In addition, oral nimodipine to suppress vasoconstriction.

OUTCOMES

After 14 days treatment, all the symptoms presenting on admission resolved completely. Subsequently, a repair surgery of ASD under thoracoscopy was successfully performed.

LESSONS

To our knowledge, this is the first reported case of ASD may be an underlying etiology for RESLES and need require an etiotropic treatment.

The myocardial protective effect of monosodium phosphate cardioplegia in cardiopulmonary bypass in infants with an atrial septal defect

This study aimed to investigate the myocardial protective effect of liquid sodium phosphocreatine cardiac arrest in extracorporeal circulation surgery treating infants with atrial septal defects.Eighty-four infants with atrial septal defects who required extracorporeal circulation surgery treatment at our hospital from January 2016 to June 2018 were divided into an observation group and a control group through a digitally randomized method, with 42 cases in each group. The control group adopted the conventional modified St Thomas II high potassium cold liquid crystal cardiac arrest, while the observation group adopted the liquid sodium phosphocreatine cardiac arrest.The myocardial enzyme indexes of the 2 groups 3, 6, 12, and 24 hours postoperatively were higher than before establishing the cardiopulmonary bypass and the enzyme indexes of the control group at the same time were higher than that of the observation group; adenosine triphosphate, adenosine diphosphate, and other energy levels and the postoperative recovery rate energy levels of the observation group were higher than those in the control group, the difference was statistically significant (P < .05).Liquid sodium phosphocreatine cardiac arrest used in extracorporeal circulation surgery treating infants with atrial septal defects can reduce myocardial ischemia-reperfusion injury, maintain energy supply during ischemia, strengthen the St Thomas II effect, and aid postoperative cardiac function recovery of high potassium cold liquid crystal cardiac arrest used in infants with atrial septal defects and treated with extracorporeal circulation surgery.

Persistent sexual arousal in a woman with associated cardiac defects and raised atrial natriuretic peptide

The persistent sexual arousal syndrome (PSAS) is a newly described entity where the woman becomes involuntarily genitally aroused for extended periods of time in the absence of sexual desire and is distressed by this situation. The cause of this sexual problem is not well understood. We describe such a case where the subjective feelings were confirmed by observing genital engorgement. In her case, PSAS came on after initiation of fludrocortisone given for hypotension and bradycardia that was associated with an atrial septal defect (ASD). We argue that the combined effect of the ASD and fludrocortisone may be associated with an increase in her levels of atrial natriuretic peptide (ANP). ANP causes profound vasodilation and vascular leakage. We postulate that the high serum levels of ANP in her case may be contributory to her PSAS.

Low molecular weight heparin microcapsule coated occluder for atrial-septal defects

BACKGROUND

Whether the low molecular weight heparin microcapsule coated occluder is helpful to endothelialization in atrial-septal defect models is uncertain. This study aimed to investigate the best conditions for low molecular weight heparin coated NiTi alloy occluder and provide the evidence of the efficacy and safety of atrial-septal defect occluders in vivo.

METHODS

Low molecular weight heparin microcapsules were investigated using gelatin as microcapsule material. The prepared low molecular weight heparin gelatin particles were subjected to nickel and titanium alloy occluder coating by sodium hyaluronate. A dog model of atrial septal defects was established after treatment with low molecular weight heparin microcapsule coated occluder (n = 4) and uncoated occluder (n = 4). Endotheliocytes and fibroblastic cells in occluders were observed. And the rate of endothelialization was detected.

RESULTS

When the concentration of gelatin was 1%, the diameters of particles were mostly about 100 microm, and the particle size was uniform. The envelope efficiency of low molecular weight heparin microcapsule was about 80%. The endothelialization of occluder in the model was more obvious in the coated group than in the uncoated group (P < 0.0001).

CONCLUSIONS

Low molecular weight heparin can be prepared into microcapsules with their particle size in nanometric grade. The antithrombotic properties are kept in the nickel and titanium alloy occluder successfully coated with sodium hyaluronate. The endothelialization after the interventional occlusion in the coated group is obvious, indicating that low molecular weight heparin is helpful to the growth of endothelial cells in the occlude and the healing after the interventional occlusion.

Paradoxical embolization in an adult cystic fibrosis patient

Cystic fibrosis patients with an implantable venous access device (IVAD) and a patent foramen ovale (PFO) are at an increased risk of developing paradoxical embolism. A 33-year-old patient who had a cerebrovascular accident in the above setting is described. She had been anticoagulated because she had thrombosis of the tip of the indwelling catheter, and her PFO was closed percutaneously followed by replacement of her IVAD. She made a full neurological recovery. Echocardiography and prophylactic closure of the PFO, when present, as primary prevention for paradoxical embolism may be warranted in cystic fibrosis patients before placement of an IVAD.

Prevention of Ischemic Stroke: Antithrombotic Therapy in Cardiac Embolism

Ischemic stroke secondary to cardiac disease accounts for approximately 30% of all stroke subtypes and it may be due to a large list of conditions. Stroke secondary to heart disease causes more severe deficits, higher mortality, and increased costs that other stroke subtypes. Therefore, proper identification of cardioembolic stroke is crucial for adequate selection of optimal preventive strategies. Identification of stroke prone individuals with heart disease could also have an important therapeutic impact. This manuscript reviews the interaction between the heart and brain with a particularly emphasis in the current state of older and newer antithrombotic drugs for stroke prevention in patients with atrial fibrillation. Other neuro-cardiological issues reviewed include current antithrombotic strategies in patients with a host of heart conditions which include pacemakers, acute myocardial infarction, congestive heart failure, cardiac procedures, patent foramen ovale, valve disease, endocarditis, or cardiac tumours.

Patent foramen ovale and cryptogenic stroke. A critical review

The underlying causes of ischemic stroke in young patients are often difficult to find, despite systematic investigations concerning heart, coagulation system or any other type of vascular disease, thus the definition of 'cryptogenic'. In patients with cryptogenic stroke, the prevalence of a patent foramen ovale is about 45%, versus 25% of the general healthy population, leading to many speculations about a potential role of intracardiac right-to-left shunts in determining ischemic cerebral disease. Since a possible mechanism has been thought to be paradoxical embolism, percutaneous closure of the foramen ovale is currently discussed, at least until the appearance of data from the ongoing randomized trials. However, recurrent paradoxical embolism in patients with an aneurysmal atrial septum and a patent foramen ovale is currently the only unequivocal indication for percutaneous closure. Professional divers may benefit from the procedure as well, whereas migraine is still not considered an indication. In the pediatric population, closure of the patent foramen ovale seems to be safe and effective to prevent recurrent stroke. As the complication rate for device implantation decreases, the threshold for percutaneous closure is likely to decline.

Transit Thrombus Entrapped in Patent Foramen Ovale Resolved Without Clinical Embolic Events

We describe a case of impending paradoxic embolism in a 35-year-old woman who had a diagnosis of metastatic breast carcinoma. The patient presented with acute pulmonary embolism and was treated with anticoagulation therapy without any sign of a clinical embolic event.

Dramatic decrease in the pulmonary artery systolic pressure and disappearance of the interatrial shunt with sildenafil treatment in a patient with primary pulmonary hypertension with atrial septal aneurysm and a severe right to left shunt through the patent foramen ovale

This report describes a patients with PPH with atrial septal aneurysm and a severe right to left shunt through the patent foramen ovale who showed a dramatic decrease in the pulmonary artery systolic pressure and interatrial shunt disappeared after sildenafil treatment.

Echocardiographic Diagnosis of a Case with Giant Right Atrial Aneurysm

Right atrial aneurysm (RAA) is a very rare anomaly. Rarer still is its association with atrial septal defect (ASD). We reported a case of a 42-year-old woman with giant RRA and secundum type ASD detected by means of transthoracic echocardiography.

Transcatheter closure versus medical therapy of patent foramen ovale and presumed paradoxical thromboemboli: a systematic review

BACKGROUND

The optimal strategy to prevent recurrent presumed paradoxical emboli in patients with patent foramen ovale is unknown.

PURPOSE

To synthesize the current knowledge about and qualitatively assess the relative benefits of transcatheter closure versus medical therapy for patent foramen ovale.

DATA SOURCES

English-language and foreign-language journals listed in the MEDLINE database from January 1985 to July 2003 were systematically searched. Secondary sources were also used.

STUDY SELECTION

Secondary prevention studies of transcatheter closure or medical therapy for patent foramen ovale were required to include at least 10 patients followed for more than 1 year and to report recurrent neurologic events.

DATA EXTRACTION

Data from published studies were manually extracted and summarized.

DATA SYNTHESIS

Ten studies of transcatheter closure (1355 patients) and 6 studies of medical therapy (895 patients) for patent foramen ovale were included. Overall, the 1-year rate of recurrent neurologic thromboembolism with transcatheter intervention was 0% to 4.9%, and the incidence of major and minor complications was 1.5% and 7.9%, respectively. Medical management was associated with a 1-year recurrence rate of 3.8% to 12.0%. However, limitations resulting from uncontrolled data, nonstandardized definitions, vigilance of follow-up, and baseline imbalances preclude definitive conclusions about the superiority of a particular approach. General differences in study samples included older age, greater proportion of men, and higher prevalence of diabetes and smoking among medically treated patients. Patients undergoing treatment with a transcatheter device were more likely to have had multiple thromboembolic events at baseline.

CONCLUSION

Transcatheter closure of patent foramen ovale may prevent a substantial proportion of cryptogenic strokes. Randomized clinical trials are needed.

Successful management of pregnancy in a patient with eisenmenger syndrome with epoprostenol

Pregnancy in the setting of pulmonary hypertension and Eisenmenger physiology is associated with a substantial maternal and fetal risk. Such patients are advised against pregnancy. We report a case of a woman with an Eisenmenger atrial septal defect diagnosed during the last trimester of pregnancy. On presentation, she was critically ill and there was evidence of fetal distress. She was emergently treated with IV epoprostenol, and her status improved. She underwent cesarean section and delivered a male infant with Apgar scores of 8 and 9. Her dyspnea improved, and she was characterized as World Health Organization functional class II on a subsequent clinical visit. Although pregnancy should be discouraged in women with Eisenmenger syndrome, we have demonstrated that IV epoprostenol successfully treated a woman with Eisenmenger syndrome diagnosed in the third trimester.

Secundum atrial septal defect and pulmonary hypertension in an 86-year-old woman: a case report and review of the literature

A case of well tolerated secundum atrial septal defect in a woman who died at 86 years of age is described and the lesions responsible for pulmonary hypertension are discussed. Previous reports of over-70-year-old patients with untreated secundum atrial septal defect are also reviewed.

Transcatheter closure of patent foramen ovale in patients with paradoxical embolism: intermediate-term risk of recurrent neurological events

Closure of patent foramen ovale (PFO) has been proposed as an alternative to anticoagulation in patients with presumed paradoxical emboli. We report our preliminary intermediate results of patients who underwent transcatheter PFO closure for paradoxical embolism using DAS-Angel Wings occluder or Amplatzer devices. Eighteen patients (8 male/10 female) underwent catheter closure of their PFOs at a median age of 42 years. The complete closure rate was 67% immediately after the procedure and 100% at a mean follow-up interval of 2.2 +/- 1.8 years. The mean fluoroscopy time and procedure time in the Amplatzer group were 8.5 +/- 3.2 min and 65 +/- 21 min, respectively, which were significantly shorter than those of DAS-Angel Wings group (18.9 +/- 4.7 min and 137 +/- 28 min, respectively). There were no recurrent embolic neurological events following device placement in this subset of patients. No complications were encountered either during or after the closure procedure. In conclusion, transcatheter closure of PFO seems to be an effective alternative therapy in the prevention of presumed paradoxical emboli. Further study is needed to identify patients most likely to benefit from this intervention.

[The effect of volume status of the right-left shunt in a patient with a patent foramen ovale]

This is a description of the anaesthetic management of a patient with a flow patent foramen ovale undergoing intramedullary nailing of the femur. In order to detect the flow patent foramen ovale, we used transoesophageal echocardiography. During the ventilation maneuver with positive airway pressure of 20 cmH2O, a right-to-left interatrial shunt was observed. After the administration of 500 ml hydroxy-starch solution (6%) intravenously, detection of the right-to-left shunt flow was no longer possible. This case report shows that the volume status in a patient with a patent foramen ovale could influence the right to left interatrial shunt during general anaesthesia.

Bisoprolol treatment for cyanotic spells--a 69-year-old female with uncorrected pentalogy of Fallot

Pentalogy of Fallot is a rare cyanotic congenital heart disease characterized by biventricular origin of the aorta above a large ventricular septal defect, obstruction of the pulmonary outflow, right ventricular hypertrophy (tetralogy of Fallot), and an atrial septal defect. Mortality due to syncope, arrhythmia or congestive heart failure is about 75% by the age of 10 years and 97% by the age of 40. We report a 69-year old female with uncorrected pentalogy of Fallot who suffered from recurrent syncope during classic cyanotic spells. Treatment with bisoprolol is recommended in symptomatic children and also improved symptoms in our patient. We conclude that single patients with pentalogy of Fallot reach the seventh decade and that cyanotic congenital heart disease is a rare cause of syncope in the elderly.

[Mechanism of selenium defending against free radical damages during myocardial ischemia/reperfusion in human]

OBJECTIVE

To investigate the modulate mechanism of selenium (Se) on glutathione peroxidase expression in the myocardium by defending against free radical superoxidizing during myocardial ischemia/reperfusion (I/R) period.

METHODS

46 patients with ASD or VSD were separated into control (23 patients) and Se (23 patients) groups. Patients in the Se group received 400 micrograms Se supplementation each day for 7 days before heart surgery. Biochemical techniques, atomic absorption, RT-PCR, cDNA sequence testing were taken to evaluate and compare the changes in myocadial MDA level, GPX activity, GPX mRNA expression, GPX cDNA nucleotide sequence, and Se, Ca and Mg concentrations during I/R.

RESULTS

In Se group, Se supplementation by oral administration neither changed plasma Se content nor blood cells. At 30 minute of myocardial reperfusion, in Se group, Se content in the myocardium did significantly increase but decreased in RBCs, and the elementary rate of GPX activity was lower than that in control. Se group had higher myocardial GPX mRNA expression with a normal nucleotida sequence pre- and post-reperfusion.

CONCLUSION

Se supplement, which promotes the myocardial Se content and mainly improves GPX mRNA expression during I/R, can defend against free radical superoxidizing damages to the myocardium.

Oxygenation improvement with nitric oxide in right-to-left shunt without significant effects on pulmonary arterial pressure

Following surgical closure of an interventricular communication complicating an anterior myocardial infarction, a 74-year-old woman developed severe right ventricular failure and hypoxemia due to the opening of a patent foramen ovale (PFO). Mean pulmonary artery pressure was 24 mm Hg. Treatment with inhaled nitric oxide (5 ppm) increased PaO2 from 47 to 90 mm Hg (FIo(2)1). The present observation points out that nitric oxide inhalation could be useful in the management of severe hypoxemia from a right-to-left shunt due to a PFO even when there is no significant pulmonary hypertension present.

[Pulmonary embolism and thrombus trapped in a patent foramen ovale. Cure by heparin therapy]

The authors report the case of a 84-year old patient admitted to hospital for pulmonary embolism. The diagnosis was made by ventilation and perfusion pulmonary scintigraphy. Transthoracic echocardiography was performed routinely and showed a thrombus wedged across a patient foramen ovale, confirmed at transoesophageal echocardiography. Spiral thoracic computerised tomography showed thrombus in the two main pulmonary arteries and the inferior vena cava. Thrombolysis or thrombectomy under cardiopulmonary bypass, was thought to carry an excessive risk at that age and with the left-sided position of the thrombus. The alternative was therefore anticoagulation which led to dissolution of the thrombus without recurrence of pulmonary embolism or cerebrovascular accident.

A comparison of surgical and medical therapy for atrial septal defect in adults

BACKGROUND

The surgical closure of an atrial septal defect is frequently recommended for patients over 40 years of age. However, the prognosis for such patients with unrepaired defects is largely unknown, and the outcome for patients operated on after the fourth decade of life has not yet been compared with that for medically treated patients in a controlled follow-up study.

METHODS

In a retrospective study, we examined the clinical course of 179 consecutive patients with isolated atrial septal defects diagnosed after the age of 40. The 84 patients (47 percent) who underwent surgical repair were compared with the 95 patients (53 percent) who were treated medically. The mean (+/-SD) follow-up period was 8.9 +/- 5.2 years (range, 1 to 26).

RESULTS

Multivariate analysis revealed that surgical closure of the defect significantly reduced mortality from all causes (relative risk, 0.31; 95 percent confidence interval, 0.11 to 0.85). The adjusted 10-year survival rate of surgically treated patients was 95 percent, as compared with 84 percent for the medically treated patients. In addition, surgical treatment prevented functional deterioration, as measured by the New York Heart Association class (relative risk, 0.21; 95 percent confidence interval, 0.08 to 0.55). However, the incidence of new atrial arrhythmias or of cerebrovascular insults in the two groups was not significantly different.

CONCLUSIONS

The surgical repair of an atrial septal defect in patients over 40 years of age, as compared with medical therapy, increases long-term survival and limits the deterioration of function due to heart failure. However, surgically treated patients should be followed closely for the onset of atrial arrhythmias so as to reduce the risk of thromboembolic complications.

Congenital heart disease with ductal-dependent systemic perfusion: Doppler ultrasonography flow velocities are altered by changes in the fraction of inspired oxygen

BACKGROUND

An unfavorable balance in systemic and pulmonary perfusion may occur in neonates with ductal-dependent systemic perfusion while being treated with prostaglandin E1 before surgical palliation or transplantation. At our institution, we adjust the fraction of inspired oxygen, with supplemental nitrogen if needed, to control pulmonary vascular tone and maintain systemic oxygen saturations near 75%.

METHODS

We performed a noninvasive Doppler ultrasound study in 10 patients to determine whether velocity time integrals in the descending aorta and middle cerebral arteries and the peak velocity at the foramen ovale were acutely altered by changes in the fraction of inspired oxygen. Measurements were performed after 10- to 15-minute intervals of breathing 14% to 19%, 21%, and 35% oxygen.

RESULTS

Antegrade descending aortic velocity time integrals did not change significantly when these patients breathed different amounts of oxygen; however, the retrograde velocity time integral in the descending aorta and the peak velocity of left-to-right shunt at the foramen ovale increased with increasing amounts of inspired oxygen. The ratio of antegrade to retrograde velocity time integrals in the descending aorta was greater with supplemental nitrogen than with supplemental oxygen. Middle cerebral arterial velocity time integrals were not significantly greater with supplemental nitrogen than with supplemental oxygen (p = 0.061).

CONCLUSIONS

Systemic and interatrial Doppler velocities are acutely influenced by the fraction of inspired oxygen in neonates with ductal-dependent systemic perfusion.

Natural history of secundum atrial septal defect in adults after medical or surgical treatment: a historical prospective study

OBJECTIVE

To compare outcome in patients with medically treated secundum atrial septal defect (ASD) first diagnosed after the age of 25 with the long-term outcome in a similar group of patients after surgical closure.

DESIGN

A historical, prospective, unrandomised study.

SETTING

A tertiary referral centre.

PATIENTS

All patients with ASD followed up since 1955 who fulfilled the entry criteria and had reached a current age of over 45 years--that is, 34 medical and 48 surgical patients with a mean follow up of 25 years.

MAIN OUTCOME MEASURES

Survival, symptoms, and complications.

RESULTS

There was no difference in survival or symptoms between the two groups and no difference in the incidence of new arrhythmias, stroke or other embolic phenomena, or cardiac failure. No patient in either group developed progressive pulmonary vascular disease.

CONCLUSION

Outcome in adults with ASD was not improved by surgical closure. Because progressive pulmonary vascular disease did not develop in any of these patients its prevention is not a reason for advising closure of ASD in adults.

Acute hemodynamic effects of converting enzyme inhibition in children with intracardiac shunts

The short-term hemodynamic effects of intravenous enalaprilat were assessed in 26 infants and children, aged 6 months to 15 years, with intracardiac shunts undergoing cardiac catheterization. Pulmonary and systemic pressure, flow, and resistance indices were measured by the direct Fick method before and 30 min after enalaprilat at 0.06 mg/kg. Aortic and pulmonary artery pressure decreased 15 and 20%, respectively, by 10 min, with little further change at 30 min. The heart rate did not change significantly and there was no reduction in systemic flow. In those with a large ventricular septal defect and normal or near-normal pulmonary resistance (less than 3.5 u.m2, n = 8), the mean pulmonary-systemic flow ratio decreased from 2.9 +/- 0.3 to 2.4 +/- 0.3 (p less than 0.05) and the mean left-to-right shunt from 7.4 +/- 0.8 to 5.9 +/- 0.7 L/min/m2 (p less than 0.02). Those with an elevated pulmonary vascular resistance (greater than 5 u.m2, n = 8) showed a varied response. Two children, both with Down's syndrome, an atrioventricular canal defect, and reversible pulmonary hypertension (as assessed by an infusion of isoproterenol), had no decrease in pulmonary vascular resistance with enalaprilat. There were no adverse effects. Converting enzyme inhibitors may benefit "heart failure" associated with large ventricular septal defects and normal or mildly elevated pulmonary resistance.

[Clinical study of the pharmacodynamics of drugs used for premedication]

The use of premedication varieties in surgical treatment of 52 patients with heart diseases of varying etiology has demonstrated that the most effective were antihypoxic agents (sodium hydroxybutyrate), substances reducing myocardial requirement of oxygen (cardiac glycosides) and decreasing load of the heart (anapriline, verapamil), normalizing myocardial function (a polarizing mixture, cardiac glycosides), antithrombotic substances (heparin), antihistamine and antishock agents (diphenhydramine, pipolphen, morphine, promedol, prednisolone, neuroleptics, tranquilizers), and substances that enhance the neutralizing liver function (vitamins B and C). Drug correction of the functional and biochemical indicators should be strictly individualized with regard to the patient's age, type of pathology, and the scope of the coming surgical intervention.

Symptomatic atrial septal defect in the neonate and infant

Atrial septal defect, secundum type, is rarely diagnosed and seldom produces symptoms in infancy. 7 patients, aged between 2 weeks and 8 months, who developed congestive failure, are presented. 6 of them had an atrial LR-shunt documented at cardiac catheterization. 1 diagnosis was made at post mortem in the only infant who died. The clinical signs of an ASD do not vary from those normally found in the older child; the causes for early failure are probably rapidly decreasing pulmonary vascular reistance and disturbances of left ventricular compliance. 6 infants improved with conservative or no treatment, although spontaneous closure or significant diminution of the shunt did not occur. Surgical closure can be deferred to a later optimal age for operation. ASD secundum type should be considered as a cause of heart failure in the neonate and infant.

Assessment of proximal tubular sodium reabsorption during water diuresis in patients with heart disease

In order to examine the relation between cardiac state and the capacity to excrete a water load, 10 normal subjects and 61 patients with heart disease were studied during water diuresis. Under these conditions, urine flow approximates to the rate of delivery of filtrate, and therefore of sodium, from the proximal tubule of the kidney to the loop of Henle, while free water clearance is a function of distal sodium reabsorption. In 12 patients with complete heart block, ventricular pacing was associated with increased urine flow and free water clearance. Oral propranolol in 3 normal subjects and in 9 patients with intact atrial septa caused a reduction, and oral practolol in 4 normal subjects and 8 patients caused no change. In 6 patients with atrial septal defect, propranolol was without effect. Maximum urine flow correlated with left ventricular end-diastolic pressure but not mean left atrial pressure in 16 patients with chronic rheumatic heart disease. In 7 patients with ischaemic heart disease, maximum urine flow was higher than in those with chronic rheumatic heart disease and similar increase in left ventricular end-diastolic pressure. These results reflect a close relation between proximal tubular sodium reabsorption and cardiac state, and suggest that inappropriate sodium reabsorption at this site may contribute to fluid retention in heart disease.