P1485Left atrial reservoir function is associated with major adverse cardiac events in patients undergoing transarterial valve implantation for isolated severe aortic stenosis

Background

Left atrial (LA) reservoir function as measured by LA global longitudinal strain (LAGS) is an independent predictor of left ventricular (LV) performance and has prognostic value.

Purpose

To evaluate by speckle tracking echocardiography (STE), LAGS and other myocardial deformation indices changes after transarterial valve implantation (TAVI) for severe isolated aortic stenosis (AS) in relation to the outcome measures.

Methods

Of 995 pts who underwent TAVI at our Institution between 2017–18, 120 (age = 82.8±7.7 years, 74% female, AVAi = 0.37±0.09 cm2/m2, LVEF = 61.6±11.3%, no > than 2+ mitral or aortic regurgitation, all in NSR) underwent 2-D echocardiography and STE, pre (21±34 days) and post (16±27 days) TAVI. LAGS was measured at QRS onset, and LV global longitudinal strain (LVGS) and RV free wall strain were recorded. The velocity index = peak vel LVOT/AV. Phillips IE 33 scanners (frame rates 60–80 Hz) were used and one observer analyzed data on QLAB software. The median follow-up was 208 days (range 20–763). The outcome variable was a composite of death, atrial fibrillation and hospitalization for heart failure (MACE). Univariate and multivariable logistic regression were used to determine independent predictors of LA, LV and RV free wall global strain changes (covariates; age, sex, BSA, LVEF, systolic blood pressure, LA volume index) and, separately, for predictors of MACE (covariates; age, sex, AVA index, LVEF and E/e'). Intra- and interclass correlation coefficients (ICC) were calculated.

Results

The intra- and inter-observer ICC was 0.70–0.90 and 0.90–0.95, respectively. In the absence of LA volume change, LAGS improved post TAVI in 54% of pts. Overall, mean change was 2.2±11.6% (95% CI; 0.05, 4.3) and it was significantly associated in multivariable analysis with RV free wall strain (OR=2.7, 95% CI; 1.2, 6), velocity index (OR=0.4, 95% CI; 0.2, 1), LVEF (OR= 0.3, 95% CI; 0.2, 0.8) and LVGS (OR=3.8, 95% CI; 1.4, 10), yielding together an AUC of 0.90. LVGS improved in 64% of pts by −2.8±7.5%, (95% CI: −4.2, −1.5) and the velocity index independently predicted the LVGS change (OR = 0.6; 95% CI: 0.4, 0.9). The other deformation indices did not significantly change. At follow-up, there were 6 hospitalizations for heart failure, 5 atrial fibrillation events and 6 deaths. At multivariable logistic regression analysis, post TAVI LAGS was the only variable independently predicting MACE (OR (in units of 1%) = 0.90, 95% CI; 0.82, 0.98), estimating that a 1% increase in post-LAGS decreases the likelihood of MACE by 10%.

Conclusions

1. There was no relationship between LA systolic volume and LAGS change after TAVI. 2. Within a month after the procedure, LAGS improves in less than half of pts and is directly associated with both ventricles systolic function and AS severity. 3. At a median of 9 months after TAVI, post procedural LAGS is an independent predictor of MACE and could be used in the risk stratification of such pts.

Isolated acute anterolateral papillary muscle rupture presenting as a sole manifestation of acute myocardial infarction and mimicking mitral valve vegetation

We present here a case of an acute myocardial infarction presenting solely as rupture of the head of anterolateral papillary muscle of the mitral valve with an echocardiographic appearance of a mitral valve vegetation. A 61-year-old male patient presented to the hospital with cardiogenic shock. Transesophageal echocardiography revealed normal left ventricular global and regional systolic function with the echocardiographic appearance of a large vegetation attached to the anterior mitral valve leaflet and severe mitral regurgitation. Intraoperatively, an infracted and ruptured head of the anterolateral papillary muscle was found with no evidence of vegetations. Papillary muscle rupture is a rare complication of acute myocardial infarction, is usually associated with inferior myocardial infarction and rarely seen as the only clinical and echocardiographic finding. Transesophageal echocardiography is more sensitive than transthoracic echocardiography but misdiagnosis can still occur.

Echocardiographic evaluation of left-ventricular diastolic function in patients with chronic pulmonary hypertension

Different patterns of left-ventricular (LV) diastolic dysfunction were reported in patients with pulmonary hypertension (PHT). There are no data regarding the relationship between the severity of PHT and LV diastolic dysfunction. In order to determine the severity of PHT at which LV diastolic dysfunction occurs and to identify its pattern, we studied by Doppler echocardiography 120 patients with PHT (57 with severe PHT and 63 with mild or moderate PHT) and compared them with 75 normal controls. Systolic pulmonary artery pressure (SPAP) was measured by tricuspid regurgitant jet method and the usual transmitral LV diastolic indices were recorded. LV diastolic dysfunction of impaired relaxation type is most commonly seen in patients with severe PHT. No differences were observed between patients with mild and moderate PHT regarding LV diastolic function. A SPAP > or =60 mm Hg is needed to induce changes in the LV diastolic filling pattern.

Interrogation of the tricuspid annulus by Doppler tissue imaging in patients with chronic pulmonary hypertension: implications for the assessment of right-ventricular systolic and diastolic function

BACKGROUND

Chronic pulmonary hypertension (CPHT) has a great impact on both right-ventricular (RV) systolic and diastolic properties and the assessment of those properties is not always feasible by traditional echocardiographic examination. Doppler tissue imaging (DTI) interrogation of the tricuspid annulus (TA) identifies the pattern of TA motion (TAM) and can help to assess RV function when other methods are not feasible.

AIMS

To determine RV systolic and diastolic function in patients with CPHT using DTI parameters of the TA.

METHODS

Eighty-seven patients with CPHT and 90 normal controls were studied. DTI parameters were measured including early diastolic, late diastolic and systolic velocities and time velocity integrals (TVI) of the TAM at both its lateral and medial aspect.

RESULTS

Early diastolic and systolic velocities, the ratio of early to late diastolic velocities and TVI of TAM at both lateral and medial aspects were significantly decreased in patients with CPHT compared to controls. No significant differences were seen in late diastolic velocities and TVI in both groups. Systolic velocity of the TAM at both its lateral and medial aspects significantly correlated with RV systolic function as measured by fractional RV area change.

CONCLUSIONS

DTI of the TAM can be used to assess RV systolic and diastolic properties in patients with CPHT.

Elevated cardiac troponin levels do not predict adverse outcomes in hospitalized patients without clinical manifestations of acute coronary syndromes

The prognostic significance of elevated cardiac troponin levels (CTL) in hospitalized patients with no other evidence of myocardial ischemia or injury is largely unknown. Fifty patients (mean age 61 +/- 15 years, 15 women) out of 580 consecutive hospitalized patients were selected based on normal CK-MB and at least 3-fold increase of CTL. The medical charts of these patients were reviewed and a 1-year follow-up was performed. The most frequent admission diagnoses were exacerbation of congestive heart failure (22%), stroke (20%) followed by respiratory failure (6%), cirrhosis (6%), gastrointestinal bleeding (6%), end-stage renal disease (4%), atrial fibrillation (4%) and metastatic malignancies (4%). Abnormal CTL prompted a cardiology consult in 48% of patients, an echocardiogram in 44%, myocardial perfusion study in 10% and coronary angiography in 1 patient. Of 21 deaths, only 1 was related to an acute coronary event. The measurement of CTL in patients without definite clinical or electrocardiographic evidence of myocardial ischemia and with a wide spectrum of clinical diagnoses does not predict in-hospital and at 1 year cardiovascular complications and/or cardiac death.

Aortic sinotubular atherosclerotic debris associated with cerebral embolic events can be identified by transthoracic echocardiography

OBJECTIVE

To evaluate the association between the presence of aortic sinotubular debris (STAD) identified by transthoracic echocardiography (TTE) and embolic strokes.

BACKGROUND

The presence of atherosclerotic debris in the ascending aorta or aortic arch detected by transesophageal echocardiography or epiaortic echocardiography has been well established to be correlated with embolic stroke or other thromboembolic events. No data are available on the role of TTE in describing aortic pathology in thromboembolic events.

METHODS

We identified 60 transthoracic echocardiographic studies from 11,275 studies, in which STAD was diagnosed. The charts of these patients (group 1; mean age 67 +/- 10 years) were reviewed and compared with those of 57 patients (group 2) without STAD, matched for age, gender and risk factors for advanced atherosclerosis. The results of brain imaging procedures, carotid duplex and coronary angiography were also reviewed.

RESULTS

Ischemic stroke was found in 15 of group 1 (25%) and 4 patients of group 2 (7%, odds ratio = 4.4; 95% confidence interval, 1.3-19.4, p = 0.008). The average thickness of STAD was 0.7 +/- 0.2 cm in stroke patients and 0.6 +/- 0.2 cm in patients without stroke (p = n.s.). STAD was associated with </=40% carotid artery stenosis.

CONCLUSION

STAD detected by TTE is strongly associated with embolic strokes. Our findings expand the role of TTE in the evaluation of patients with embolic strokes.

Transseptal puncture guided by intracardiac echocardiography during percutaneous transvenous mitral commissurotomy in patients with distorted anatomy of the fossa ovalis

Positioning of the transseptal needle during percutaneous transvenous mitral commissurotomy (PTMV) can become a difficult and risky procedure when distortion of the interatrial septum exists. We present two cases where intracardiac echocardiography (ICE) facilitated the transseptal puncture in the presence of bulging of the fossa ovalis into the right atrium.

Metastatic ocular melanoma to the left ventricle inducing near-syncope attacks in an 84-year-old woman

Cardiac tumors may represent mechanical causes for syncope by limiting left ventricular filling and/or by obstructing the left ventricular outflow tract. Malignant melanoma is known to metastasize to the myocardium or pericardium, but there are only a very limited number of reports describing endocardial involvement by the tumor. We describe herein an 84-year-old woman who presented with daily near-syncope episodes, 9 years after treatment for a choroidal melanoma. The echocardiography and the pathologic examination revealed a metastatic melanoma. This is the first reported case of an ocular melanoma metastasizing to the heart and presenting as a left ventricular intracavitary pedunculated mass.

Echocardiographic diagnosis of left ventricular outflow tract obstruction caused by an acquired subaortic membrane after mitral valve replacement

Although an acquired subaortic membrane has been reported as a cause of left ventricular outflow tract (LVOT) obstruction in various clinical settings, it previously has not been reported after mitral valve surgery. We describe 3 cases of acquired LVOT obstruction that resulted from development of a subaortic membrane after mitral valve replacement. This report emphasizes the role of an acquired subaortic membrane in LVOT obstruction after mitral valve replacement, the use of echocardiography in diagnosing this condition, and the importance of early intervention.

PTCA in angulated segments: effects of balloon material, balloon length, and inflation sequence on straightening forces in an in vitro model

We sought to determine the effect of balloon material, balloon length, and inflation sequence on the straightening forces generated during percutaneous transluminal coronary angioplasty (PTCA) in angulated segments. Using an in vitro model consisting of a curved channel (3/4" radius) with a displaceable pressure sensor, we examined four different balloon materials: compliant (POC), semicompliant (PE600 and Duralyn), and noncompliant (PET), two balloon lengths (20 mm and 40 mm), and two inflation sequences (rapid and slow) with continuous recording of straightening force during each balloon inflation. Three balloons were tested for each combination of materials, length, and inflation sequence. Long balloons exerted significantly lower straightening forces. There were significantly higher straightening forces with noncompliant, particularly short, balloons. Varying the inflation sequence had no significant effect. For PTCA in angulated segments: (1) long balloons produce lower straightening force, (2) noncompliant balloons produce higher straightening force, particularly with short balloons, and (3) varying the inflation sequence has no significant effect on straightening force.

The outcome of patients with acute myocardial infarction ineligible for thrombolytic therapy. Israeli Thrombolytic Survey Group

PURPOSE

The aim of this study was to determine the proportion of patients with acute myocardial infarction (AMI) excluded from thrombolytic therapy on a national basis and to evaluate the prognosis of these patients by reasons of ineligibility and according to the alternative therapies that they received during hospitalization.

PATIENTS AND METHODS

During a national survey, 1,014 consecutive patients with AMI were hospitalized in all the 25 coronary care units operating in Israel.

RESULTS

Three hundred and eighty-three patients (38%) were treated with a thrombolytic agent and included in the GUSTO study. Ineligible patients for GUSTO were treated: (1) without any reperfusion therapy (n = 449), (2) by mechanical revascularization (n = 97), or (3) given 1.5 million units of streptokinase (n = 85) outside of the GUSTO protocol. The inhospital and 1-year post-discharge mortality rates were 6% and 2% in patients included in the GUSTO study; 6% and 5% in those mechanically reperfused; 15% and 10% in those treated with thromoblysis despite ineligibility for the GUSTO trial, and 15% and 13% among patients not treated with any reperfusion therapy.

CONCLUSIONS

Ineligibility for thrombolysis among patients with AMI remains high. Patients ineligible for thrombolysis according to the GUSTO criteria, but nevertheless treated with a thrombolytic agent were exposed to an increased risk.

Myocardial revascularization with laser. Preliminary findings

BACKGROUND

We assessed the transmyocardial laser revascularization (TMLR) as sole therapy in patients with symptomatic coronary artery disease refractory to interventional or medical treatment.

METHODS AND RESULTS

Thirty-one patients were evaluated with positron emission tomography (PET), dobutamine echocardiography, 201Tl single-photon emission computed tomography (201Tl-SPECT), and multigated acquisition radionuclide ventriculography (MUGA). TMLR was performed in 21 patients who had demonstrable ischemia in viable myocardium. The mean Canadian Cardiovascular Society (CCS) angina class was 3.70 +/- 0.7 (4 patients with unstable angina). Untreated septal segments were used as controls. At 3 months, (n = 15 patients), the mean CCS angina class was to 2.43 +/- 0.9 (P < .05). On dobutamine echocardiography, the mean resting wall motion score index was improved by 16% in lased segments (P < .03 vs control), and mean LVEF at peak stress increased by 19% (P = NS vs baseline). On 201Tl-SPECT, perfusion of lased and nonlased segments did not change. On PET, the mean ratio of subendocardial to subepicardial perfusion (SEn/SEp) increased 14% over baseline (P < .001 vs control). At 6 months (n = 15 patients), the mean CCS angina class was 1.7 +/- 0.8 (P < .05). The mean resting wall motion score index was up by 13% in lased segments (P < .05 vs control). Resting LVEF was unchanged. Stress LVEF increased 21% (P = NS vs baseline). Myocardial perfusion remained unchanged by 201Tl-SPECT. On PET, 36% of the lased segments were better, and 25% were worse compared with baseline. The resting SEn/SEp by PET was up 21% (P < .001 vs control). All deaths (two perioperative and three late) occurred in patients with preoperative congestive heart failure. Two patients required repeat revascularization of new coronary lesions.

CONCLUSIONS

These results suggest that TMLR improves anginal status, relative endocardial perfusion, and cardiac function in patients who do not have preoperative congestive heart failure.

Plasma fibrinogen levels and their correlates in 6457 coronary heart disease patients. The Bezafibrate Infarction Prevention (BIP) Study

The association between fibrinogen measured in healthy individuals and subsequent development of ischemic heart disease is well established, but studies reporting fibrinogen levels in coronary heart disease patients are scarce. Plasma fibrinogen was determined for 5729 men and 728 women (aged 45 to 74) with established coronary heart disease, screened for participation in the Bezafibrate Infarction Prevention study, with the following lipid profile at the time of the first screening visit: total serum cholesterol < or = 270 mg/dl, high density lipoprotein cholesterol < or = 45 mg/dl and triglyceride < or = 300 mg/dl. Increased age was associated with augmented plasma fibrinogen values. Age-adjusted fibrinogen levels were higher in women than in men. A direct association was found between mean fibrinogen levels and low density lipoprotein cholesterol. On the other hand, the correlation with high density lipoprotein cholesterol was inverse. Fibrinogen was also associated with body mass index, behavioral variables and severity of coronary heart disease. In a multivariable linear regression analysis performed, risk factors considered explained merely 6 and 4% of fibrinogen variation for men and women, respectively. Therefore, most of the fibrinogen level variability in coronary heart disease patients is accounted for by factors that remain to be established by further research.

The relation of clinical outcome to dissection and thrombus formation during coronary angioplasty. Heparin Registry Investigators

BACKGROUND

Although the development of thrombus or dissection during percutaneous transluminal coronary angioplasty (PTCA) increases the risk of abrupt vessel closure, the magnitude of the effect is difficult to define.

OBJECTIVE

The aim of the study was to determine prospectively the effect of the development of thrombus or dissection on PTCA procedural outcome.

METHODS

Data from 591 consecutive angioplasty procedures involving 756 lesions at 9 clinical centers were included in a prospective registry with a core angiographic laboratory.

RESULTS

Clinical success (defined as < 50% stenosis of all target lesions assessed in a core angiographic laboratory, with no major complications of death, Q wave or non-Q wave myocardial infarction or emergency CABG) was achieved in 497 patients (84%). Major complications occurred in 45 (7.6%). Abrupt vessel closure, including both established closure (TIMI grade 0 or I flow) and impending closure (> 50% stenosis, TIMI grade 0-2 flow, plus use of additional interventions) occurred in 65 patients (11%). Angiographically visible dissections developed in 40% of lesions; more severe grades of dissection were associated with reduced success rates, and increased incidence of and abrupt vessel closure and major complication. Angiographic evidence of thrombus (filling defects) developed in 12.3% of lesions; the presence of thrombus was associated with significantly lower procedural success (61% vs. 86%) and significantly higher rates of abrupt vessel closure (28% vs 7%) and major complications (24% vs. 6%). With multivariable analysis, thrombus was identified as an independent predictor of procedural success, abrupt vessel closure, and major complications.

CONCLUSIONS

The development of severe dissections or thrombus following PTCA is associated with significantly lower procedural success rates and higher rates of abrupt vessel closure and major complications. Patients who develop severe dissection or thrombus may be appropriate candidates for more aggressive forms of therapy.

Left atrial metastasis from hepatocellular carcinoma: a case report

This is the second reported case of a patient with hepatocellular carcinoma in whom the presence of a solitary, left atrial metastatic tumor was confirmed with the aid of transesophageal echocardiography. The tumor was discovered during computed tomography scanning at a follow-up examination after a 3-month regimen of chemotherapy. The patient had exhibited no signs of cardiac involvement, which may have been the result of the relatively small size of the tumor. Surgical excision of the tumor was successfully undertaken, and the patient's postoperative course was uneventful. In this case, transesophageal echocardiography was valuable in providing information regarding the exact location of the tumor and its relation to surrounding anatomical structures.

Progressively intractable seizures, focal alopecia, and hemimegalencephaly

We report a 3-year-old boy with the neurocutaneous combination of unilateral alopecia, ipsilateral hemimegalencephaly, and intractable seizures. He was born with an asymmetric hair pattern consisting of absent patches of hair, a small left eyebrow, and less eyelashes on the left eye; he had normal development until age 17 months, when he experienced right focal seizures with fever. Two months later, fever triggered new seizures characterized by flurries of head and body flexion and adduction of the right arm. He had left hand preference and language regression. EEG manifested left hemihypsarrhythmia, and MRI showed left hemimegalencephaly with marked enlargement of the temporal lobe with ventriculomegaly. Seizures were refractory to treatment with phenobarbital, adrenocorticotropic hormone, pyridoxine, sodium valproate, clonazepam, carbamazepine, phenytoin, and felbamate. This may represent a previously undescribed neurocutaneous syndrome.

Persistence of normal right ventricular Doppler filling pattern early after tricuspid valve excision

Two patients with acute tricuspid bacterial endocarditis in which a normal right ventricular Doppler filling pattern was demonstrated early following valvectomy are reported. After surgery, on pulsed Doppler examination, the sample volume positioned at the right atrioventricular level revealed a normal M-shaped filling pattern. A pathologic monophasic pattern was documented a few months later. Our findings suggest that early after surgery the preserved gradient throughout ventricular diastole leads to a passive and active filling similar to normal. Only at a later stage is the grossly dilated right atrium unable to maintain active filling, and the 'A' wave disappears despite the fact that sinus rhythm is maintained. Tricuspid valve diastolic motion represents a product of the several factors that determine atrioventricular gradient, but the valve itself appears not to be involved in the generation of a normal filling pattern.

Dobutamine stress echocardiography in clinical practice with a review of the recent literature

Stress echocardiography has been developed in recent years as an effective noninvasive test for the detection and assessment of coronary artery disease. This method combines exercise with 2-dimensional echocardiography, which can assess regional and global left ventricular function during stress. Dobutamine infusion, a pharmacologic means of producing cardiovascular stress, appears to be an excellent alternative to exercise in echocardiographic studies. Currently, it is reserved for patients who cannot exercise at a meaningful level because of advanced age, physical deconditioning, or other factors. This review evaluates the current clinical application of dobutamine stress echocardiography and compares its efficacy with that of exercise echocardiography and nuclear perfusion imaging.

The value of dobutamine stress echocardiography in evaluation of patients after the first uncomplicated acute myocardial infarction

Dobutamine stress echocardiography (DSE) is an already established method to investigate coronary artery disease (CAD). We performed a regional wall motion score based on the DSE test in a group of 36 consecutive patients (24 men and 7 women; mean age 57 years) 19 of whom were treated with thrombolytic agents a week after a first uncomplicated myocardial infarction and compared the results with a submaximal exercise test--regarding symptoms compatible with myocardial ischemia, test duration, peak heart rate, systolic blood pressure, ECG changes and arrhythmias. Seventeen of these patients underwent coronary angiography and the results were compared with the DSE score. In total, 576 myocardial segments were analyzed according to coronary artery distribution. Except for 2 patients, we found a good correlation between mean wall motion abnormalities and significant angiographic findings. No complications occurred during DSE.

IN CONCLUSION

predischarge DSE after a first acute myocardial infarction (AMI) is a safe and useful method to investigate the severity of CAD. These preliminary results indicate that DSE is an important contribution to the evaluation of patients after AMI.

Balloon aortic valvuloplasty in the elderly: useful when there is no alternative

Of 63 elderly patients with calcific aortic stenosis in whom balloon aortic valvuloplasty was performed, 26 treated with the new technique of Cribier and Letac are the subject of this report. Patients were referred for the procedure because they were at high surgical risk, or were not candidates for surgery. Seven matched patients who fit the criteria for balloon valvuloplasty but refused the valvuloplasty procedure served as controls. Aortic gradient decreased from 78 +/- 27 mm Hg to 35 +/- 20 mm Hg and aortic valve area increased from 0.47 +/- 0.16 cm2 to 0.83 +/- 0.38 cm2 (P < 0.0001). Symptomatic improvement was immediately obtained in each patient. Complications were rare, with only one patient needing vascular repair for femoral artery occlusion. Three patients died during the initial hospitalization (none during the procedure). Valvuloplasty patients were followed for a mean period of 9.6 +/- 9.4 months. Three months survival was 87%, 6 months survival was 76%, and 12 months survival was 61%. Four of seven patients in the control group (57%) died within 3 months after initial referral. Balloon aortic valvuloplasty is a useful treatment in elderly patients who are poor surgical candidates. It may have a positive influence on short-term survival.

Successful outcome of a left ventricular free wall rupture in a community hospital: case report

Rupture of the myocardium in the setting of acute myocardial infarction has a universally grim prognosis. The time that elapses between diagnosis and definitive therapy is the most critical determinant of the patient's outcome when death is not instantaneous. Survivors of this catastrophic event have not been frequently reported. We present a case of free wall left ventricular rupture in a patient with an acute myocardial infarction hospitalized in the Cardiac Care Unit of a small community hospital. The patient was successfully transferred to the referral institution for surgery. Rapid diagnosis, primary bedside therapy, and utilization of new surgical techniques helped obtain a good outcome.

Calcium antagonists in patients with heart failure. A review

The presence of calcium ions is essential to the normal function of the cardiovascular system. Drugs such as calcium antagonists can modulate the interaction between these ions and specific cells at different levels, interfering with myocardial contraction and relaxation, vascular tone, specific conduction tissues and neuromuscular function. Vascular beds play a crucial role in adjustment of myocardial function to different body oxygen requirements; compensatory mechanisms in congestive heart failure (CHF) involve the vascular system to a large extent and paradoxically may worsen myocardial performance. Vasodilating drugs represent an important step forward in achieving better symptomatic results in CHF patients, and may also increase their survival. Of the different classes of vasodilator drugs calcium antagonists may represent an attractive alternative due to their anti-ischaemic and antiarrhythmic effects. Despite the overall good response to the acute use of these drugs in CHF, long term studies in which first generation calcium antagonists (nifedipine, diltiazem, verapamil) were used have produced disappointing results. Their main drawbacks were negative inotropism, lack of preload reduction and activation of neurohormonal mechanisms with a subsequent adverse effect on cardiovascular function, the latter effect being the most significant. A few long term studies, of between 1 and 52 months, have not demonstrated a consistent improvement in functional class in spite of apparently good initial results. The second generation of calcium antagonists have more potent and selective vasodilating properties with less negative inotropic effects; these properties might justify their use in the therapy of CHF, but no clear recommendations can be given due to the lack of large, long-term, controlled studies. Overall, the existing clinical trials with calcium antagonists in CHF have not proved the superiority of this group of drugs when compared to other vasodilators. If the aetiology of CHF is related to the presence of coronary artery disease or arterial hypertension, calcium antagonists might be considered as additional therapeutic options. Diastolic dysfunction may be corrected or improved and coronary tone may be diminished, both of which may lead to a better myocardial oxygen supply. Systolic myocardial function must be evaluated in CHF patients before starting therapy with calcium antagonists in order to avoid possible deleterious effects. Further studies may shed more light on this matter and may indicate decisively whether or not calcium antagonists should play a role in the therapeutic pharmacological arsenal of selected CHF patients.

Dissecting aortic aneurysm--failure of standard noninvasive and invasive diagnostic techniques

The diagnosis of cardiac tamponade due to dissection of an ascending aortic aneurysm in a middle-aged woman was not confirmed by the usual noninvasive and invasive procedures. The decision for surgery was based on clinical grounds only, resulting in an unnecessary delay of surgical intervention. Although some of the current noninvasive techniques seem to be most useful in the investigation of these patients, the clinical findings remain the cornerstone of a correct diagnosis.

MRI visualization of bilateral quadriceps tendon rupture in a patient with secondary hyperparathyroidism: implications for diagnosis and therapy

Many musculoskeletal conditions have in the past been best defined on a clinical basis. However, because of pain, limitation of motion and hematomas, tendon ruptures can often be misdiagnosed clinically and it would be quite helpful to the clinician to have a noninvasive imaging technique. This communication defines the role of MRI in the early diagnosis of a nontraumatic rupture of the quadriceps tendons bilaterally in a patient with renal failure and known secondary hyperparathyroidism. The imaging techniques accurately defined the presence of hemorrhage extending into muscle from the ruptured tendons as well as the actual site and extent of tendon rupture. Since tendons have low mobile proton content and have low signal on MRI--disruptions are easily seen--MRI is the ideal noninvasive imaging technique for tendon injury, acute.

Spinal epidural lipomatosis: a serious complication of iatrogenic Cushing's syndrome

Our experience and review of the literature demonstrate that spinal epidural lipomatosis is a rare but serious neurologic complication of iatrogenic Cushing's syndrome. Most patients develop slowly progressive paraparesis over months, but a subgroup exists which presents with acute, irreversible paraplegia. We consider therapeutic options.

Spontaneous perforation of the ureter diagnosed on technetium 99m DTPA excretory urography

A case of nontraumatic rupture of the ureter secondary to a nonopaque calculus is presented. Because of the inherent high image contrast caused by the leak of technetium 99m-DTPA-labeled urine, the technetium 99m-DTPA excretory urogram is seen as an alternative to the intravenous urogram or contrast-enhanced computed tomography in selected cases of suspected ureteral rupture.

Pregnancy and Cushing's syndrome: example of endocrine interaction

Pregnancy rarely occurs in women with Cushing's syndrome, and when it does, fetal mortality and morbidity are very high. We describe a 30-year-old woman who was found to have severe Cushing's syndrome in the 22nd week of her first pregnancy, after a year of unsuccessful attempts to conceive. The patient had the majority of the symptoms and signs characteristic of the syndrome. Laboratory examinations revealed hypokalemia of 2.7 mEq/l, serum cortisol 39.5 micrograms/dl without diurnal variation, free urinary cortisol 1,850 to 3,500 micrograms/24 h, 17-hydroxycorticosteroids (OHCS) 52.5 mg/24 h, 17-ketosteroids (KS) 12 mg/24 h, and ACTH 29 pg/ml. No suppression was observed upon dexamethasone administration (2 and 8 mg). Ultrasound examination of the adrenal glands revealed a left adrenal tumor with a diameter of 4.2 cm. An adrenocortical adenoma was successfully excised in the 24th week of pregnancy. During the 37th week of pregnancy, she delivered a normal baby girl. Postoperatively, the patient was put on maintenance therapy. One year after delivery, mother and child are in perfect health.

Severe sexual impairment produced by morbid obesity. Report of a case

A 45-year-old man, was admitted for investigation of severe sexual impairment. During 20 years of marriage, he had had no normal sexual intercourse and the couple was childless. Physical examination disclosed a severely obese man (weight 300 kg, height 1.75 m), with a relatively small and invaginated penis and small (5 ml) soft testes. Laboratory examinations disclosed the following: low serum testosterone (1 ng/ml), with a reduced response to HCG (3.8 ng/ml). Sex hormone binding globulin was at the lower limit of normal (0.38 microgram/dl), serum free testosterone was low (0.98% of total testosterone) as well as non-SHBG bound testosterone (22% of total testosterone). Daily total urinary estrogen excretion was increased (107 micrograms), the plasma estrone (78 pg/ml) and estradiol (74 pg/ml) were elevated. The gonadotropins were normal and responded adequately to LRH. Plasma growth hormone was decreased, prolactin, T4 and adrenal steroids were normal and responded normally to stimuli and inhibitors. Chromosomal constitution was 46XY. Thus, in this man the marked obesity produced a significant increase in estrogens which subsequently induced a severe decrease in testosterone and its free counterpart in excessive impairment of sexual function.

Recurrent sustained ventricular tachycardia solely responsive to verapamil in a patient with a remote myocardial infarction

A 49-year-old man with a silent remote postero-inferior wall myocardial infarction exhibited recurrent episodes of sustained ventricular tachycardia which was hemodynamically well tolerated. Ventricular tachycardia was neither terminated nor prevented by therapy with multiple class I and class III antiarrhythmic drugs. In contrast, ventricular tachycardia was repeatedly terminated within a few minutes following intravenous administration of 10 mg verapamil and did not recur during oral therapy with verapamil (360 mg daily). Electrophysiologic study suggested that ventricular tachycardia was due to a reentrant mechanism rather than to triggered or abnormal automaticity. Thus, in contrast to previous reports, findings in this patient indicate that verapamil may be very effective and safe in certain types of ventricular tachycardia occurring late after a myocardial infarction.

Pneumococcaemia as a presenting sign in 3 cases of multiple myeloma

Multiple myeloma was diagnosed in 3 patients following episodes of pneumococcaemia associated with neutropenia and decreased serum concentration of normal immunoglobulins. Severe pneumococcal infection is commonly encountered during the course of multiple myeloma, but has not been stressed as a presenting feature of the disease.

Hypertrophic Pulmonary Osteoarthropathy in Pulmonary Metastases

Hypertrophic pulmonary osteoarthropathy is most commonly encountered in association with bronchogenic carcinoma and tumors of the pleura. Its association with pulmonary metastases from extrathoracic neoplasms is rare, with only 44 documented cases in the literature. Three additional cases are reported. Nearly half of the reported cases have been sarcomas, mainly of bone and soft tissues; among the rest are tumors of the nasopharynx and uterus and cervix. It has recently been noted that symptoms can be dramatically relieved by intrathoracic or cervical vagotomy.