Prediction of prognosis by echocardiography in patients with midgut carcinoid syndrome.

BACKGROUND: The association between malignant midgut carcinoid tumours and right-sided cardiac lesions is well known, but the pathogenetic link between tumour secretion and valvular disease is still obscure. The purpose of this investigation was to describe the morphological and functional changes of valvular heart disease in a large patient series and to correlate these findings with hormonal secretion and prognosis. METHODS: Of 64 consecutive patients with the midgut carcinoid syndrome followed between 1985 and 1998, valvular heart disease was evaluated in 52 patients by two-dimensional echocardiography, Doppler estimation of valvular regurgitation and flow profiles. A majority was also evaluated with exercise electrocardiography and spirometry. RESULTS: Structural and functional abnormalities of the tricuspid valve were found in 65 per cent of patients, while only 19 per cent had pulmonary valve regurgitation. Long-term survival was related to excessive urinary excretion of 5-hydroxyindole acetic acid of over 500 micromol in 24 h, but the main predictor of prognosis was the presence of severe structural and functional abnormalities of the tricuspid valve. Although advanced tricuspid abnormalities were prevalent in this series, only one patient died from right ventricular heart failure. CONCLUSION: Tricuspid valvular disease is a common manifestation of the midgut carcinoid syndrome and advanced changes are associated with poor long-term survival. Active surgical and medical therapy of the tumour disease reduced the hormonal secretion and, combined with cardiological surveillance, made right ventricular heart failure a rare cause of death in these patients.

Gender differences in patients with severe aortic stenosis: impact on preoperative left ventricular geometry and function, as well as early postoperative morbidity and mortality.

OBJECTIVE: In patients with severe aortic stenosis, we studied the impact of gender on preoperative left ventricular geometry and function, as well as on early postoperative mortality and morbidity. METHODS: Prospective Doppler echocardiographic evaluation was performed in 99 female patients and 96 males. RESULTS: The patients had severe aortic stenosis and the mean pressure gradients were similar in females and males. Left ventricular diastolic volume adjusted for body surface area (BSA) was larger in males, 55+/-17.4 ml/m2 versus 43+/-13.1 mL/m2 (mean+/-standard deviation; P = 0.0001). The ejection fraction was similar in females (55+/-14%) and males (55+/-13%), and patients of both sexes had significantly lower stroke volume and cardiac index than healthy controls. The relative wall thickness (wall thickness/diastolic diameter ratio) was higher (P = 0.03) in females (0.47+/-0.10) than in males (0.43+/-0.10) Consequently, the diastolic diameter/wall thickness ratio (a substitute for wall tension) was higher (P = 0.02) in males (4.2+/-0.99) than in females (3.9+/-0.80). Compared with survivors, patients who died within 30 days of the operation (n = 17, 11 females) had a smaller body surface area (1.70+/-0.19 vs. 1.82+/-0.19 m2, P = 0.012), smaller left ventricular outflow tract (20.8+/-0.21 vs. 22.0+/-0.22 mm, P = 0.023), higher incidence of abnormal intraventricular flow velocity (33 vs. 8%, P = 0.018) and increased relative wall thickness (0.52+/-0.17 vs. 0.45+/-0.09 P = 0.039). Gender was of no independent importance for early mortality when age and left ventricular outflow tract diameter were accounted for. CONCLUSIONS: Cardiac adaptation to aortic stenosis seems to be influenced by gender, males presenting larger left ventricular volumes and higher wall tension. The echocardiographic findings of a narrow left ventricular outflow tract, abnormally increased intraventricular velocity and increased relative wall thickness identified patients with increased risk of early postoperative mortality. However gender had no independent impact on early postoperative outcome.

Central nervous and cardiovascular effects of i.v. infusions of ropivacaine, bupivacaine and placebo in volunteers.

We have compared the incidence of CNS symptoms and changes in echocardiography and electrophysiology during i.v. infusions of ropivacaine, bupivacaine and placebo. Acute tolerance of i.v. infusion of 10 mg min-1 was studied in a crossover, randomized, double-blind study in 12 volunteers previously acquainted with the CNS effects of lignocaine. The maximum tolerated dose for CNS symptoms was higher after ropivacaine in nine of 12 subjects and higher after bupivacaine in three subjects. The 95% confidence limits for the difference in mean dose between ropivacaine and bupivacaine were -30 and 7 mg. The maximum tolerated unbound arterial plasma concentration was twice as high after ropivacaine (P < 0.001). Muscular twitching occurred more frequently after bupivacaine (P < 0.05). The time to disappearance of all symptoms was shorter after ropivacaine (P < 0.05). A threshold for CNS toxicity was apparent at a mean free plasma concentration of approximately 0.6 mg litre-1 for ropivacaine and 0.3 mg litre-1 for bupivacaine. Bupivacaine increased QRS width during sinus rhythm compared with placebo (P < 0.001) and ropivacaine (P < 0.01). Bupivacaine reduced both left ventricular systolic and diastolic function compared with placebo (P < 0.05 and P < 0.01, respectively), while ropivacaine reduced only systolic function (P < 0.01).

Body weight and fat cell size in young men with mild blood pressure elevation.

The aim of the study was to assess the relationship between body fat distribution and blood pressure. Forty-four men, aged 19-22 years, with mild blood pressure elevation (MBPE) and 29 normotensive controls (NC) were investigated. Body fat distribution was assessed by calculating fat cell size in biopsy samples of adipose tissue from different subcutaneous depots. The subjects in MBPE group were heavier than those in NC group (79.7 +/- 2.7 and 71.5 +/- 1.6 kg, p < 0.05). Total body fat was also significantly higher in the MBPE group (12.5 +/- 1.6 and 8.1 +/- 1.3 kg, p < 0.05) but not the lean body cell mass (36.8 +/- 1.1 and 34.7 +/- 0.9 kg, n.s.). Fat cell size (microgram/cell) in the lower abdominal area were significantly bigger in MBPE than in NC (respectively 40.9 +/- 4.4 and 28.0 +/- 3.1, p < 0.05). The same differences applied for fat cell size in the upper abdominal (respectively 43.1 +/- 3.0 and 26.8 +/- 3.0, p < 0.001) and averaged abdominal areas (respectively 40.1 +/- 3.4 and 26.8 +/- 2.8; p < 0.05). Fat cell size in gluteal, femoral and averaged gluteofemoral areas did not differ between MBPE and NC. Therefore, the abdominal/gluteofemoral ratio was significantly higher in MBPE than in NC (respectively 1.1 +/- 0.1 and 0.7 +/- 0.1; p < 0.005).(ABSTRACT TRUNCATED AT 250 WORDS)

Incessant ventricular tachycardia with a right bundle-branch block pattern and left axis deviation abolished by catheter manipulation.

A 22-year-old man underwent electrophysiological evaluation for incessant wide QRS complex tachycardia with a pattern of right bundle-branch block and left axis deviation. The right and left ventricles were enlarged and hypokinetic consistent with dilated cardiomyopathy. Ventricular tachycardia was diagnosed by demonstrating capture and fusion beats, atrioventricular dissociation, and His potential activation that began after the onset of each QRS complex. Atrial extrastimuli and rapid atrial pacing failed to terminate the tachycardia and, although ventricular stimulation was successful, the tachycardia spontaneously restarted after one or two sinus beats. The tachycardia was unexpectedly abolished during catheter manipulation in the left ventricle and has not recurred during three-years of follow-up. The picture of a cardiomyopathy resolved. The ease with which the tachycardia was abolished by catheter manipulation implicate a therapeutic potential for catheter ablation of this type of tachycardia.

Does hyperkinetic circulation constitute a pre-hypertensive stage? A 5-year follow-up of haemodynamics in young men with mild blood pressure elevation.

In a previous haemodynamic examination, 44 young men (18-22 years) with blood pressure elevation above the 98th percentile, mean arterial blood pressure (MAP) greater than or equal to 95 +/- 6 mm Hg, showed an increased cardiac index (dye-dilution) and an enhanced resistance at maximal vasodilation of the hand (venous occlusion plethysmography during hyperaemia). This latter finding suggested arteriolar wall hypertrophy. However, the subgroup with the highest cardiac index (greater than or equal to 3.86 1 min-1 x m2) (n = 18) displayed normal vascular resistance at maximal dilation in comparison with the normotensive control group (n = 29). Consequently, functional signs of arteriolar hypertrophy were restricted to individuals with normal or low cardiac index. At the re-investigation 5 years later, a significant reduction in blood pressure was observed in the normotensive control group (MAP: from 88 +/- 7 to 85 +/- 7 mm Hg, P less than 0.05). There was no change in individuals with initially elevated blood pressure. Furthermore, cardiac index fell significantly with time in this latter group. Thus, the blood pressure elevation in the hypertensive group, previously mainly dependent on high blood flow was, 5 years later, more related to an increased total peripheral resistance, (delta total peripheral resistance = 8%). However, no definite evidence indicating development of hypertrophy of the resistance vessels of the hand was observed during the follow-up period. Since the hyperkinetic subgroup did not display a concomitant fall in blood pressure with cardiac output, our results do not support the theory that the hyperkinetic form of borderline hypertension is a temporary phenomenon, explained by the inclusion of anxious individuals afraid of the experimental situation. Hyperkinetic hypertension may be the initial phase of sustained hypertension in a subgroup of the future hypertensive population.

Ventricular dimensions and wall motion assessed by echocardiography in patients with arrhythmogenic right ventricular dysplasia.

Twenty patients with arrhythmogenic right ventricular dysplasia (ARVD) and 20 healthy volunteers underwent cross-sectional echocardiographic examination for the assessment of ventricular dimensions and wall motion. Right ventricular cavity diameters and wall segments were selected from the inflow and outflow tracts and the right ventricular body. The measurement error for measuring cavity dimensions was low throughout and the reproducibility of wall motion scoring was high in both the normal subjects and the patients. All except one patient had increased dimensions and/or abnormal wall motion in the right ventricle. The right ventricular inflow tract was dilated in nine patients, the outflow tract in 11 patients and the short- or long-axis diameters of the right ventricular body were increased in seven patients. Right ventricular wall motion abnormalities, being the most frequent finding, ranged from mild hypokinesia only to dyskinesia or sacculations, and were fairly evenly distributed among the segments studied. Left ventricular abnormalities, found in eight patients, were generally mild. Cross-sectional echocardiography thus provides highly reproducible measurements of right ventricular size and contraction patterns even in patients with wall shape deformities, and is therefore a feasible non-invasive method for the evaluation of right-sided myocardial abnormalities in patients with ARVD. The diagnostic accuracy of this technique warrants further clarification.

Left ventricular function before and after kidney transplantation. A prospective study in patients with juvenile-onset diabetes mellitus.

The aim of the present investigation was to discover whether disturbed left ventricular (LV) function limits renal replacement therapy in patients with juvenile onset diabetes mellitus. Seventeen patients given functioning kidney grafts were studied non-invasively (M-mode echocardiography, apexcardiography, phonocardiography) before renal transplant and an average of six, 13 and 44 months after transplant. The main pretransplant findings were pronounced LV hypertrophy with impaired diastolic LV function (prolonged relaxation time + signs of decreased LV distensibility) and a hyperdynamic circulation. Most of these abnormalities were significantly less severe after successful kidney transplantation. LV mass decreased by 37% 44 months after transplant (p less than 0.01) and LV diastolic and systolic volumes decreased with a subsequent increase in ejection fraction from 0.65 to 0.78 (p less than 0.01). The LV distensibility and filling pattern improved significantly while the prolonged relaxation time was unchanged. These findings imply that pretransplant disturbances in LV function are related more to factors such as hypertension, volume overload and uraemia than to diabetes per se because no pronounced improvement in the metabolic disorder resulting from diabetes can be expected, even after the most successful transplant. Disturbed LV function should not, therefore, exclude uraemic diabetics from renal replacement.