Nicardipine versus nitroglycerin for hypertensive acute heart failure syndrome: a single-center observational study / Journal of Rural Medicine

Objective: Nitroglycerin is a first-line treatment for hypertensive acute heart failure syndrome (AHFS). However, nicardipine is frequently used to treat hypertensive emergencies, including AHFS. In this study, we compared the effectiveness of nicardipine and nitroglycerin in patients with hypertensive AHFS.Patients and Methods: This single-center, retrospective, observational study was conducted at the intensive care unit of a Japanese hospital. Patients diagnosed with AHFS and systolic blood pressure 140 mmHg on arrival between April 2013 and March 2021 were included. The outcomes were the time to optimal blood pressure control, duration of continuous infusion of antihypertensive agents, duration of positive pressure ventilation, need for additional antihypertensive agents, length of hospital stay, and body weight changes. Outcomes were compared between the nicardipine and nitroglycerin groups. We also compared these outcomes between the groups after excluding patients who received renal replacement therapy.Results: Fifty-eight patients were enrolled (26 and 32 patients were treated with nitroglycerin and nicardipine, respectively). The nicardipine group had a shorter time to optimal blood pressure control (2.0 [interquartile range, 2.0–8.5] h vs. 1.0 [0.5–2.0] h), shorter duration of continuous anti-hypertensive agent infusion (3.0 [2.0–5.0] days vs. 2.0 [1.0–2.0] days), less frequent need for additional anti-hypertensive agents (1 patients [3.1%] vs. 11 patients [42.3%]), and shorter length of hospital stay (17.5 [10.0–33.0] days vs. 9.0 [5.0–15.0] days) than the nitroglycerin group. The duration of positive pressure ventilation and body weight changes were similar between the groups. The outcomes were similar after excluding patients who received renal replacement therapy.Conclusion: Nicardipine may be more effective than nitroglycerin for treating hypertensive AHFS.

Establish the nomogram prediction model of septic cardiomyopathy based on the afterload-corrected cardiac performance / 中华危重病急救医学

Objective:To establish a nomogram prediction model for the prognosis of patients with septic cardiomyopathy (SCM) based on afterload-corrected cardiac performance (ACP), in order to identify septic patients with poor outcomes and treatment.Methods:The data of patients admitted to the department of critical medicine of the Second Affiliated Hospital of Guangzhou Medical University from June 2016 to June 2019 were analyzed. All patients were monitored by pulse indication continuous cardiac output (PiCCO) monitor more than 24 hours and diagnosed as SCM with ACP less than 80%. The predictors of 30-day death risk of SCM patients were screened by univariate Cox regression analysis. Multivariate Cox regression analysis was used to establish the prediction model for 30-day death risk of SCM patients, which was displayed by the nomogram. Finally, the discrimination and calibration of the model were analyzed by receiver operator characteristic curve (ROC curve) and consistency index (C-index).Results:A total of 102 patients with SCM were included and the 30-day mortality was 60.8% (62 cases). Among 102 patients with SCM, 57 patients (55.9%) had mild impairment of cardiac function (60%≤ACP < 80%), and the 30-day mortality was 43.9% (25/57); 39 patients (38.2%) had moderate impairment of cardiac function (40%≤ACP < 60%), and the 30-day mortality was 79.5% (31/39); 6 patients (5.9%) had severe impairment of cardiac function (ACP < 40%), and the 30-day mortality was 100% (6/6). There was significantly difference in mortality among the three groups (χ 2 = 24.156, P < 0.001). The potential risk factors for 30-day death of SCM patients screened by univariate Cox regression analysis were included in multivariate Cox regression analysis. The results showed that the independent risk factors for 30-day death of SCM patients were acute physiology and chronic health evaluation Ⅱ [APACHEⅡ, risk ratio ( HR) = 1.031, 95% confidence interval (95% CI) was 1.002-1.061, P = 0.039], vasoactive inotropic score (VIS, HR = 1.003, 95% CI was 1.001-1.005, P = 0.012), continuous renal replacement therapy (CRRT; HR = 2.106, 95% CI was 1.089-4.072, P = 0.027), and ACP ( HR = 0.952, 95% CI was 0.928-0.977, P < 0.001). The nomogram model was established based on the above independent risk factors and age, and the area under the curve (AUC) was 0.865 (95% CI was 0.795-0.935), P < 0.001; C-index was 0.797 (95% CI was 0.747-0.847), P > 0.05. Conclusions:The nomogram model based on age, APACHEⅡ score, VIS score, CRRT and ACP has a certain clinical reference significance for the prediction of 30-day mortality of SCM patients. The discrimination and calibration are good, however, further verification is needed.

Hipertensión arterial pulmonar:: progresión, pronóstico e impacto

La hipertensión arterial pulmonar es una enfermedad infrecuente, caracterizada por el aumento de postcarga del ventrículo derecho. La adaptación del ventrículo derecho a esta postcarga se relaciona con el pronóstico de los pacientes. La estratificación pronóstica se basa en una valoración multiparamétrica. Los parámetros clínicos, funcionales, la valoración del ventrículo derecho y la evaluación hemodinámica van a definir la situación de riesgo de los pacientes, en función de la mortalidad a un año. La situación de bajo riesgo a un año de seguimiento se ha relacionado con mayor supervivencia. El algoritmo terapéutico actual incluye como estrategia inicial la mono, doble y triple terapia. Se debe realizar escalada terapéutica con el objetivo de mantener a los pacientes en bajo riesgo durante el seguimiento.

Pulmonary arterial hypertension is an infrequent disease, characterized by an increase in afterload of the right ventricle. The adaptation of the right ventricle to this afterload is related to the prognosis of the patients. The prognostic stratification is based on a multiparametric assessment. The clinical, functional parameters, assessment of the right ventricle and hemodynamic evaluation will define the risk situation of the patients, depending on the one-year mortality. The situation of low risk at one year of follow-up has been related to greater survival. The current therapeutic algorithm includes monotherapy, double and triple therapy as an initial strategy. Therapeutic escalation should be carried out in order to keep patients at low risk during follow-up.

A hipertensão arterial pulmonar é uma doença infreqüente, caracterizada por aumento da pós-carga do ventrículo direito. A adaptação do ventrículo direito a essa pós-carga está relacionada ao prognóstico dos pacientes. A estratificação prognóstica é baseada em uma avaliação multiparamétrica. Os parâmetros clínicos, funcionais, avaliação do ventrículo direito e avaliação hemodinâmica definirão a situação de risco dos pacientes, dependendo da mortalidade em um ano. A situação de baixo risco em um ano de seguimento tem sido relacionada à maior sobrevida. O algoritmo terapêutico atual inclui como estratégia inicial a monoterapia e a terapia dupla e tripla. O escalonamento terapêutico deve ser realizado a fim de manter os pacientes em baixo risco durante o acompanhamento.

The application value of afterload-related cardiac performance in patients with sepsis-induced cardiomyopathy / 中华急诊医学杂志

Objective@#To investigate the application value of afterload-related cardiac performance(ACP) in patients with sepsis-induced cardiomyopathy.@*Methods@#A total of 148 patients with septic shock admitted by the department of critical care of Wuhan fourth hospital from April 2013 to March 2018 were retrospectively included, all included patients were divided into LVEF < 50% group and LVEF≥50% group according to left ventricular ejection fraction (LVEF), the mortality rate at 28 days and ACP value were compared in the 2 groups. All included patients were divided into normal group (ACP > 80%), mild heart function impairment group (60% < ACP≤80%), moderate heart function impairment group (40% < ACP≤60%), and severe heart function impairment group (ACP≤40%) according to ACP value, the mortality rate at 28 days was compared in the 4 groups. The measurement data were compared by grouped t test, the rates were compared by chi-square test.@*Results@#The mortality rate was 58.2% in the LVEF < 50% group, and 30.9% in the LVEF≥50% group, with statistically significant differences (χ2=11.171, P<0.01). The values of ACP in the LVEF < 50% group were (39.3±16.4) %, and those in the LVEF≥50% group were (69.1±14.9) %, with statistically significant differences (t=11.571, P<0.01).The mortality rate was 14.81% in the normal group, 44.00% in the mild, 58.82% in the moderate and 90.00% in the severe group. The differences between the normal group and the mild and moderate groups were statistically significant, while those between the severe group and the mild and moderate groups were statistically significant.@*Conclusion@#Afterload-related cardiac performance is of great value for the diagnosis and prognosis in patients with sepsis-induced cardiomyopathy.

The application value of afterload-related cardiac performance in patients with sepsis-induced cardiomyopathy / 中华急诊医学杂志

Objective To investigate the application value of afterload-related cardiac performance(ACP) in patients with sepsis-induced cardiomyopathy.Methods A total of 148 patients with septic shock admitted by the department of critical care of Wuhan fourth hospital from April 2013 to March 2018 were retrospectively included,all included patients were divided into LVEF ＜ 50％ group and LVEF ≥ 50％ group according to left ventricular ejection fraction (LVEF),the mortality rate at 28 days and ACP value were compared in the 2 groups.All included patients were divided into normal group (ACP ＞ 80％),mild heart function impairment group (60％ ＜ ACP ≤ 80％),moderate heart function impairment group (40％ ＜ ACP ≤ 60％),and severe heart function impairment group (ACP ≤ 40％) according to ACP value,the mortality rate at 28 days was compared in the 4 groups.The measurement data were compared by grouped t test,the rates were compared by chi-square test.Results The mortality rate was 58.2％ in the LVEF ＜ 50％ group,and 30.9％ in the LVEF ≥ 50％ group,with statistically significant differences (x2=11.171,P＜0.01).The values of ACP in the LVEF ＜ 50％ group were (39.3±16.4) ％,and those in the LVEF ≥ 50％ group were (69.1±14.9) ％,with statistically significant differences (t=l 1.571,P＜0.01).The mortality rate was 14.81％ in the normal group,44.00％ in the mild,58.82％ in the moderate and 90.00％ in the severe group.The differences between the normal group and the mild and moderate groups were statistically significant,while those between the severe group and the mild and moderate groups were statistically significant.Conclusion Aflerload-related cardiac performance is of great value for the diagnosis and prognosis in patients with sepsis-induced cardiomyopathy.

Facilitating noncardiac surgery for the patient with left ventricular assist device: A guide for the anesthesiologist

The introduction of left ventricular assist device (LVAD) has improved survival rates for patients with end-stage heart failure. Two categories of VADs exist: one generates pulsatile flow and the other produces nonpulsatile continuous flow. Survival is better for patients with continuous-flow LVADs. With improved survival, more of such patients now present for noncardiac surgery (NCS). This review, written for the general anesthesiologists, addresses the perioperative considerations when the patient undergoes NCS. For best outcomes, a multidisciplinary approach is essential in perioperative management of the patient.

Interacciones cardiopulmonares: de la fisiología a la clínica / Cardiopulmonary Interactions: from Physiology to Clinic

Resumen: Las Interacciones Cardiopulmonares (ICP) corresponden al conjunto de interrelaciones entre el sis tema respiratorio y el cardiovascular, durante el ciclo respiratorio y cardíaco. Estas interacciones varían dependiendo de si el paciente se encuentra en ventilación espontánea o mecánica, afectando en distintos grados la precarga y postcarga, tanto del ventrículo derecho e izquierdo. El entender estas interacciones, resulta esencial al momento de manejar pacientes críticamente enfermos, en donde las manipulaciones de la precarga y postcarga, son de especial importancia al momento de optimizar el débito cardíaco y la entrega de oxígeno a los tejidos. En este artículo se presentan los principios fisiológicos que permiten entender las interacciones cardiopulmonares en ventilación espontánea y en ventilación mecánica, aplicadas a situaciones clínicas específicas, lo que nos ayudará a utilizarlas como herramientas en el manejo de los pacientes.

Abstract: Cardiopulmonary Interactions (CPI) refer to the interplay between the respiratory and cardiovascu lar systems during the respiratory and cardiac cycle. These interactions vary depending on whether the patient is in spontaneous or mechanical ventilation and affect the preload and afterload of both ventricles at different levels. Understanding CPI is essential to the management of critically ill pa tients, where preload and afterload manipulations are specialy important to optimize cardiac output and oxygen delivery to the periphery. The present article reviews the physiological principles required to understand CPI in patients both in spontaneous and mechanical ventilation using specific clinical scenarios to facilitate its use as part of day to day clinical practice.

Impact of Valvuloarterial Impedance on Concentric Remodeling in Aortic Stenosis and Its Regression after Valve Replacement

BACKGROUND: Left ventricle (LV) in patients with aortic stenosis (AS) faces a double hemodynamic load incorporating both valvular stenosis and reduced systemic arterial compliance (SAC). This study aimed to evaluate the impact of global LV afterload on LV hypertrophy (LVH) before and after aortic valve replacement (AVR). METHODS: The study cohort included 453 patients (247 males; mean age, 64 ± 11 years) who underwent AVR. Pre- and post-AVR echocardiographic examinations were retrospectively analyzed including an index of valvuloarterial impedance (Z(VA)) and LV mass index/LV end-diastolic volume index (LVMI/LVEDVI) as a parameter of LVH. RESULTS: Pre-AVR LVMI/LVEDVI was 2.7 ± 0.9 g/mL with an aortic valve area (AVA) of 0.6 ± 0.2 cm². Z(VA) was 5.9 ± 1.9 mm Hg/mL/m² and showed a stronger correlation (β = 0.601, p 1 year after AVR. CONCLUSION: Z(VA) is a major determinant of concentric remodeling in AS before AVR and LVH regression after AVR, which should be incorporated in routine evaluation of AS.

Tensión arterial y masa corporal en mujeres infértiles con síndrome de ovario poliquístico y su relación con el perfil hormonal / Blood pressure and body mass in infertile women polycystic ovary syndrome and its relation to the profile hormone

Objetivo: Evaluar perfil hormonal, índice de masa corporal y tensión arterial en 40 mujeres infértiles con ovario poliquístico. Métodos: En la consulta del Centro de Atención Integral de la Universidad de Los Andes se valoró talla, peso y tensión arterial. Durante la fase folicular del ciclo menstrual en ellas se midió en sangre las hormonas sexuales e insulina (basal y 2 horas poscarga glucosada) por electroquimioluminiscencia. Resultados: El índice de masa corporal se correlacionó directamente con el valor de tensión arterial sistólica, la relación LH/FSH y la testosterona sérica; e inversamente con las hormonas FSH y PRL. Los datos clínicos y de laboratorio se observaron dentro de los límites de referencia; sin embargo, la testosterona guardó relación directa con LH/FSH, índice de masa corporal y tensión arterial sistólica. Al compararse dos grupos de paciente con base al valor de la mediana poblacional, los grupos masa corporal > 24 kg/m2 y tensión arterial sistólica >120 mmHg mostraron niveles de DHEA-S e insulina (basal y 2 h) más elevados que en mujeres con índice de masa corporal y tensión arterial sistólica más bajos. Conclusiones: Existe correlación entre niveles séricos de andrógenos con sobrepeso e hipertensión arterial por mecanismos etiológicos interrelacionados. Síndrome de ovario poliquístico es de origen multicausal eventualmente con hiperandrogenemia. La falla metabólica debe controlarse en estas pacientes, lo que permitiría bajar el efecto de los andrógenos y favorecer el estado de fertilidad, pero sobre evita a largo plazo complicaciones como obesidad, diabetes mellitus tipo 2 e hipertensión arterial.

Objective: To evaluate hormonal profile, body mass index and blood pressure in 40 infertile women with polycystic ovary. Methods: In the out patien clinic of the Centro de Atencion Integral de la Universidad de Los Andes, height, weight and blood pressure were assessed. During follicular phase of the menstrual cycle in blood of them sex hormones and insulin (basal, 2 hours post glucose load) were measured by electrochemiluminescence. Results: The body mass index was directly correlated with the value of systolic blood pressure, ratio LH/ FSH and testosterone in serum, and it was inversely correlated with the hormones FSH and PRL. Clinical and laboratory data were observed within the reference limits, but kept directly related to testosterone LH / FSH, BMI and systolic blood pressure. When comparing two patient groups based on the value of the population median, body mass groups > 24 kg/m2 and systolic blood pressure > 120 mmHg, they showed levels of DHEA- S and insulin (basal and 2 h) higher than those women with lower values of BMI and systolic blood pressure. Conclusions: There is a correlation between serum androgen levels with overweight and hypertension by aetiological mechanisms interrelated. Polycystic ovary syndrome is multicausal origin eventually with hyperandrogenemia. Metabolic failure should be monitored in these patients, which would lower the effect of androgens and promote fertility status, but prevents long-term complications such as obesity, type 2 diabetes mellitus and high blood pressure.

Impact of Afterload on the Assessment of Severity of Aortic Stenosis

BACKGROUND: Aortic stenosis (AS) is increasingly diagnosed in current aging society. Echocardiography is the most important tool in the assessment of AS and its severity. However, load-dependency of Doppler measurement could affect the accuracy of AS severity assessment. We tried to evaluate the impact of afterload on the assessment of AS severity by modification of afterload using pneumatic compression (Pcom). METHODS: Forty patients diagnosed as moderate or severe AS [effective orifice area of aortic valve (EOAAV) by continuity equation of < 1.5 cm2] were consecutively enrolled. Patients with severely uncontrolled hypertension, severe left ventricular (LV) dysfunction, and other significant valve disease were excluded. Comprehensive echocardiography was performed at baseline to assess AS severity. Then, pneumatic compression of the lower extremities by 100 mmHg was applied to increase LV afterload. After 3 minutes, echocardiography was repeated to assess AS severity. RESULTS: Mean blood pressure was significantly increased under Pcom (p < 0.001), while heart rate remained unchanged. Peak aortic valve velocity (Vmax) was slightly, but significantly decreased under Pcom (p = 0.03). However, Doppler velocity index and EOAAV by continuity equation were not affected by Pcom. CONCLUSION: AS severity assessment by echocardiography was not dependent on the change of LV afterload imposed by Pcom. AV Vmax was slightly decreased with LV afterload increment, but these changes were too small to alter treatment plan of AS patients. EOAAV and Doppler velocity index are more stable parameters for AS severity assessment.

Assessment of Afterload by Doppler Aortic Flow Velocity Measur ement / 대한흉부외과학회지

BACKGROUND: Afterload as well as myocardial contractil ity is an important factor for the adequacy of circulation after cardiac surgery . To noninvasively assess alterations in afterload, we evaluated the changes in aortic blood velocity waveform. MATERIAL AND METHOD: Ascending aortic blood flow was measured by continuous wave Doppler echocardiography befo re and after afterload manipulation in eight open-chest dogs. Nitroprusside was administered singly and simultaneously with epinephrine in various combinations. Left atrial pressure as an index of preload was maintained by saline administra tion. RESULT: The infusion of nitrop russide produced dose-dependent decreases in blood pressure and index of systemi c vascular resistance(ISVR) (all p<0.05 vs baseline), which was associated with increases in peak velocity(PV), mean acceleration(MA) and minute distance, and w ith a decrease in acceleration time(all p<0.05 vs baseline). ISVR obtained durin g nitroprusside infusion had a better correlation with both PV(r=-0.60, p=0.001) and MA(r=-0.52, p=0.003) than with velocity time integral(VTI) or the Doppler t ime intervals. The combined infusion of nitroprusside and epinephrine, unless IS VR was elevated, produced synergistic effects on PV, MA and VTI, but these Doppl er indexes tended to diminish with an elevation in afterload. CONCLUSION: Doppler measuremen t of PV and MA in the ascending aorta may be used to noninvasively assess change s in afterload.

Change of Coronary Flow Reserve in the Dogs: Influence of Atrial and Ventricular Pacing, Ventricular Preload and Afterload

BACKGROUNG AND OBJECTIVES: The aim of this study was to analyze the influence of changes in ventricular preload and afterload, atrial and ventricular pacing on the coronary flow reserve (CFR). METHOD: Five open chest anesthetized dogs were studied in five sequential stages:baseline, saline solution volume loading (293.8+/-29.2 ml for 10 min), atrial and ventricular pacing (120, 140, and 160 bpm), and aortic clamp. Coronary blood flow (CBF) was measured with electro-magnetic flowmeter. CFR was defined as the ratio of hyperemic CBF (hCBF) to resting CBF (rCBF). Hyperemia was induced by IV adenosine infusion (1 mg/kg/min). RESULTS: 1)After volume loading wtih saline solution, CFR significantly decreased (p<0.05) because rCBF was increased while hCBF remained unchanged. 2)Atrial pacing produced increase in rCBF but did not change hCBF. Consequently CFR singificantly reduced when heart rate (HR) increased from sinus rhythm to 120, 140, and 160 bpm (p<0.01). 3)Ventricular pacing produced decrease in hCBF but did not change rCBF. Consequently CFR significantly reduced as HR increased from sinus rhythm to 120 (p<0.05) , 140 (p<0.01), and 160 (p<0.01) bpm. 4)After aortic clamp, CFR significantly decreased (p<0.01) because rCBF increased while hCBF remained unchanged. CONCLUSION: We found that CFR is dependent on the changes in volume loading, HR, and ventricular afterload that may commonly occur in clinical situations.

Influência da elevação sustentada da pressão arterial sobre a dP/dt do ventrículo esquerdo mantendo-se constante a pressão diastólica do ventriículo esquerdo / Influence of Sustained Elevations of Arterial Pressure on the Left Ventricular dP/dt Keeping Constant the Left Ventricular end Diastolic Pressure

PURPOSE: To evaluate the influence of sustained elevations of arterial pressure on dP/dt values, while the left ventricular end diastolic pressure was kept constant. METHODS: Thirteen anesthetized dogs, mechanically ventilated and submitted to thoracotomy and pharmacological autonomic block (atropine-0.5 mg/kg i.v. + oxprenolol-3 mg/kg i.v.) were studied. The arterial pressure elevation was obtained by mechanical constriction of the descending thoracic aorta. Analyses were made in control (C) situation and after two successive increments of arterial pressure, sustained for 10 min, called hypertension 1 (H1) and hypertension 2 (H2), respectively. The end diastolic left ventricular pressure was kept constant by utilization of a perfusion system connected to the left atria. RESULTS: Heart rate did not change (C: 125 +/- 13.9 bpm; H1: 125 +/- 13.5 bpm; H2: 123 +/- 14.1 bpm; p > 0.05); the LVSP increased (C: 119 +/- 8.1 mmHg; H1: 142 +/- 7.9 mmHg; H2: 166 +/- 7.7 mmHg; p < 0.01); the AoDP increased (C: 89 +/- 11.6 mmHg; H1: 99 +/- 9.5 mmHg; H2: 120 +/- 11.8 mmHg; p < 0.01); the LVEDP (C: 6.2 +/- 2.48 mmHg; H1: 6.3 +/- 2.43 mmHg; H2:6.1 +/- 2.51 mmHg; p > 0.05) and the dP/dt (C: 3068 +/- 1057.1 mmHg/s; H1: 3112 +/- 995.7 mmHg/s; H2: 3086 +/- 979.5 mmHg/s; p > 0.05) did not change. CONCLUSION: dP/dt values are not influenced by a sustained elevation of arterial pressure, when the end diastolic left ventricular pressure is kept constant.

A Study of the Assessment of Left Vertricular Function in Non-Rheumatic Aortic Stenosis after Aortic Valve Replacement

BACKGROUND: The nature of depressed left ventricular ejection performance in chronic pressure-overload hypertrophy due to aortic stenosis is controversial. Patients with aortic stenosis and congestive heart failure who responded well and those who responded poorly to aortic valve replacement may represent two distinct groups, rather than opposite ends of a spectrum. Whereas excess afterload accompanied by inadequate hypertrophy of functioning cardiac muscle was been suggested as the cause of impaired left ventricular shortening, intrinsic depression of contractility of the hypertrophied myocardium was also been considered, at least in part, to be the cause of altered ejection performance. METHOD: We studied 20 patient with non-rheumatic aortic stenosis using echocardiogram and cineangiocardiography. The patients were divided into two groups according to the level of LVEF and New York Heart association [NYHA] functional class. In group 1, 7 patients had an echocardiographically determined LVEF less than 40% and clinical presentation of severe congestive heart failure(NYHA functional class III or IV). In group 2, 13 patients had LVEF more than 40% and NYHA functional class I or II. Left ventricular volumes and ejection fraction were determined from the echocardiogram obtained in short axis view. As a measure of left vertricular afterload, meridional end-systolic wall stress was calculated. This method is based on the determination of end-systolic left ventricular dimension, wall thickness and peak systolic pressure. RESULTS: 1) End-systolic meridional wall stress was significantly elevated in the patient with aortic stenosis & severe congestive heart failure(group 1) compared with the patient with aortic stenosis and mild congestive heart failure(group 2)(320.09+/-72.09 vs 177.52+/-76.43 dyne x 10(3)/cm2, p<0.005). With group 1 and group 2, there was a significant inverse linear relationship between LVEF and end systolic meridional wall stress(r=-0.907, p<0.001). 2) There was significantly more decreased ratio of end-systolic meridional wall stress to end-systolic volume index(ESWS/LVESVI) of group 1 than that of group 2(5.64+/-2.65 vs 15.30+/-7.77 dyne x 10(3)cm2/ml/m2, p<0.05). And there was a significant linear relationship between LVEF and end-systolic meridional wall stress to end-systolic volume index(ESWS/LVESVI)(r=0.86, p<0.001). 3) Twenty of 20(100%) survived after surgery : 19 of these 20 showed clinical improvement. There was significant improvement of ejection performance(LVEF, % FS) in group 1 except from 1 patient(LVEF 35.43+/-6.90 VS 47.29+/-3.45%, % FS 18.76+/-4.87 vs 28.20+/-3.40, p<0.05). CONCLUSION: Thus, both altered contractility and increased afterload are operative in depressed left vertricular ejection performance in patients wth aortic stenosis ; which one predominates may have major prognostic importance. We found encouraging results for aortic valve replacement in patient with depressed preoperative left ventricular function. The majorty of patients in this series had left ventricular failure because of excessive afterload predominantly.

Influência da elevaçäo transitória e da elevaçäo sustentada da pressäo arterial sobre a primeira derivada temporal da pressäo ventricular / Influence of transient and sustained elevations of arteri al pressure on the left ventricular rate of pressure rise

Objetivo - Avaliar a influência de elevaçöes transitórias e de elevaçöes sustentadas da pressäo arterial (PA) sobre a primeira derivada temporal da pressäo ventricular esquerda (dp/dt). Objetivo - Foram estudados 13 cäes anestesiados, toracotomizados, ventilados mecanicamente e submetidos a bloqueio autonômico (oxprenolol 3,0 mg/Kg + atropina 0,5 mg/Kg). A elevaçäo da PA foi obtida por constriçäo mecânica da aorta torácica descendente. Em todos animais estudados foram aplicados dois protocolos: Hipertensäo Arterial Transitória (HAT) e Hipertensäo Arterial Sustentada (HAS). Nas diversas condiçöes dos dois protocolos foram analisadas as seguintes variáveis: freqüência cardíaca (FC); pressäo sistólica (PSVE) e diastólica final (PdVE) do ventrículo esquerdo e a primeira derivada temporal da pressäo ventricular (dp/dt). No protocolo HAT as variáveis foram analisadas na condiçäo basal (To) e no momento em que a PA atingia valor máximo (Tm) durante elevaçäo pressárica fugaz. No protocolo HAS as variáveis foram estudadas na condiçäo basal (Ho) e após duas elevaçöes pressóricas sucessivas sustentadas durante 10 minutos: Hipertenso 1 (H1) e Hipertenso 2 (H2). Resultados - Näo houve variaçäo significante da FC durante todo o experimento. Em HAT a PSVE foi elevada de 133 ñ 22 mmHg para 180 ñ 27 mmHg. Durante HAS os valores da PSVE foram: Ho = 129 ñ 25 mmHg; H1 = 152 ñ 23 mmHg; H2 = 182 ñ 24 mmHg. As elevaçöes pressóricas se acompanharam de elevaçäo da PDFVE. Em HAT a PDFVE elevou-se de 7 ñ 2 mmHg para 13 ñ 2 mmHg (p < 0,05); durante a HAS a PDFVE aumentou (p < 0,05) de 7 ñ 2 mmHg em H1 e para 14 ñ 3 mmHg em H2. Näo houve variaçäo significante da dp/dt durante a HAT (3.303 ñ 598 mmHg/s para 3.350 ñ 653 mmHg/s; p > 0,05) enquanto que em HAS ocorreu aumento significante da dp/dt (Ho = 3.233 ñ 576 mmHg; H1 = 3.831 ñ 667 mmHg/s; H2 = 4.594 ñ 833 mmHg/s; p , 0,05). Conclusäo - Elevaçöes sustentadas da PA resultam em aumento significantes da dp/dt, à medida que se acentua a carga cardíaca. As sobrecargas pressóricas sustentadas desencadeiam ajustes cardíacos, tempo-dependentes, que resultam em estimulaçäo inotrópica, provavelmente, por interferência do mecanismo de Frank-Starling

The Effects of Handgrip and Cold Pressor Test on Mitral Flow in Patients with Left Ventricular Hypertrophy

BACKGROUND: Handgrip and cold pressor test may increase the afterload of the heart. And in left ventricular hypertrophy, it is known that mitral flow pattern is affected by decreased left ventricular compliance. We investigated the effects of handgrip and cold pressor test on mitral flow pattern in patients with left ventricular hypertrophy. METHODS: Handgrip and cold pressor test were performed in 12 subjects with left ventricular hypertrophy and in 14 healthy normal subjects. In supine position, blood pressure, heart rate and Doppler echocardiographic parameters(early peak flow velocity : E, atrial peak flow velocity : A) were obtained at rest, 1 and 3 minutes after the onset of tests respectively. RESULTS: In both groups, handgrip and cold pressor test increased blood pressure slightly without a statistical significance. In left ventricular hypertrophy group, there were significant increments in heart rates at 1 minute of handgrip (78+/-12min-1, p<0.001) and cold pressor test(77+/-7min-1, p<0.05) as compared to that at rest (73+/-12min-1). Mitral flow velocities did not show significant change after the tests in control group. A waves after 1 minute of handgrip(85.2+/-18.4cm/sec, p<0.05) and cold pressor test (87.3+/-17.8cm/sec, p<0.001) showed significant increases as compared to that at rest (79.1+/-14.9cm/sec) in left ventricular hypertrophy group whereas E waves did not. CONCLUSION: Although handgrip and cold pressor tests did not affect the mitral flow significantly in control group, each test raised A waves in left ventricular hypertrophy group. These results suggest that increased A waves may be due to a rise in afterload and decreased left ventricular compliance caused by handgrip and cold pressor test in left ventricular hypertrophy group.