Right ventricular ischemia in patients with primary pulmonary hypertension.

OBJECTIVES: The goal of this study was to determine whether right ventricular (RV) ischemia is a contributory factor in the development of RV dysfunction in patients with primary pulmonary hypertension (PPH). BACKGROUND: Patients with advanced PPH develop RV dysfunction, characterized by a decreased cardiac output, increased right atrial pressure (RAP) and/or elevated RV end-diastolic pressure, which progresses to heart failure and death. The cause of this dysfunction is unknown. Right ventricular ischemia may play a role in its development. METHODS: From 1992 to 1999, a prospective study involving 23 patients with PPH at the Instituto Nacional de Cardiologia "Ignacio Chavez" (Mexico City, Mexico) was undertaken. These patients were evaluated clinically and further studied by echocardiography, right heart catheterization and stress myocardial scintigraphy using technetium 99m sestamibi. RESULTS: Nine patients of 23 were found to have scintigraphic images consistent with RV ischemia. Significant correlation was found between RV ischemia obtained through myocardial perfusion scintigraphy and elevation of RV end-diastolic pressure (p < 0.001), elevation of RAP (p < 0.037) and a decrease in mixed venous oxygen saturation (p < 0.0001). No other clinical or hemodynamic variables showed a significant correlation with RV ischemia. CONCLUSIONS: A direct correlation exists between RV ischemia, as determined by myocardial scintigraphy, and hemodynamic alterations suggestive of RV dysfunction in patients with PPH.

[Myocardial viability. Stunned and hibernating myocardium. Usefulness of myocardial scintigraphy]. / Viabilidad miocárdica. Miocardio aturdido e hibernante. Utilidad de la centellografía miocárdica.

The diagnosis of viability in the presence of heart failure in coronary artery disease has acquired great importance due to its excellent therapeutic results. Due to its frequency it has become a public health problem. The characteristics of stunned and hibernating myocardium and the protocols to study perfusion, contractile reserve and metabolic activity are described, with emphasis in the Thallium and Tc99m-sestamibi studies.

Myocardial perfusion scintigraphy (SPECT) in the evaluation of patients in the emergency room with precordial pain and normal or doubtful ischemic ECG. Study 60 cases.

OBJECTIVES: To evaluate the diagnostic utility of myocardial perfusion by SPECT and Gated-SPECT in the diagnosis of acute coronary syndrome in patients with precordial pain associated with normal or doubtful ischemic ECG within the first 6 hrs of the last episode of pain. METHODS: Sixty such patients who sought attention in the Emergency room were included. Myocardial perfusion SPECT and Gated-SPECT (GSPECT) was performed in all patients using two distinct protocols. All patients underwent resting and pharmacological stress test. In 30 cases coronary angiogram were performed. RESULTS: Resting myocardial perfusion was abnormal or positive in 25 patients (42%) and normal or negative in 35 patients (58%). In the latter group perfusion became abnormal in 15 patients (43%) under stress with dipyridamole, while it remained normal in 19 (54%). The last subgroup presented no coronary events during the 12 months following their hospital discharge. In the group of 25 patients with resting perfusion abnormalities acute myocardial infarction was diagnosed in 7 patients, ischemia in 12 and reverse-reversibility in 6. Myocardial perfusion scintigraphy showed in the resting phase a low sensitivity of 61% (95% CI 39-74%), and negative predictive value of 71% (95% CI, 58-82%). During the stress phase, the utility of the test increased significantly, with a sensitivity of 97% (95% CI, 83-99%), specificity of 79% (95% CI, 57-92%), positive predictive value of 87% (95% CI, 72-95%) and, most outstanding, a negative predictive value of 95% CI, 73-99%). CONCLUSIONS: Myocardial perfusion studies have a sensitivity of 97% for identifying patients with acute coronary syndrome, with precordial pain and normal or doubtful ischemic ECG. For the intermediate or low risk patients with acute coronary syndrome the non-invasive diagnostic techniques of SPECT and GSPECT systems of evaluating myocardial perfusion achieve a high degree diagnostic accuracy, safety and reduces unnecessary admissions and costs.

[Simultaneous assessment of perfusion and myocardial viability with 2 isotope studies (thallium at rest and sestamibi in exercise). Initial experience in Mexico and Latin America]. / Valoración simultánea de la perfusión y la viabilidad miocárdica a través del estudio de dos isótopos (Talio reposo/MIBI esfuerzo). Experiencia inicial en México y América Latina.

UNLABELLED: Rest-stress sestamibi single photon emission computed tomography (SPECT) has sensitivity and specificity similar to those of thallium 201 SPECT for detection of coronary artery disease. However, sestamibi is not ideal agent to study myocardial viability. There is not published experience in Latin American using dual isotope SPECT protocol to evaluate myocardial perfusion and viability. We studied 44 consecutive patients with coronary artery disease, 37 of them with previous myocardial infarction. Coronary angiography was performed in all patients. We used a 3 mCi rest T 201 SPECT followed by stress and 25 mCi sestamibi injection. Sestamibi SPECT was performed 30 minutes after exercise or 1 hour after pharmacologic stress with dipyridamole. To validate perfusion findings patients returning next day for rest sestamibi injection and SPECT. Scintigraphic data were read by two blinded expert using 20 SPECT segment analysis and each segment was scored using 5 points scoring system (0 = normal, 4 = absent uptake). The segmental score agreement between rest thallium 201 and rest sestamibi and the comparison of defect reversibility percentage and non reversibility between both protocols was 90.7%. CONCLUSION: Separate acquisition dual isotope myocardial perfusion SPECT is accurate for coronary artery disease evaluation. It showed a good agreement with rest-stress sestamibi SPECT for assessment of rest perfusion defects and reversibility and it was a better method to evaluate myocardial viability.

[Usefulness of SPECT (single-photon emission-computed tomography) in the detection of coronary disease]. / Utilidad del SPECT (tomografía computada por emisión de fotón único) en la detección de enfermedad aterosclerosa coronaria.

OBJECTIVE: To evaluate the clinical usefulness of cardiac SPECT in the detection of coronary artery disease, and the relation with the site, number and severity of the angiographic lesions. METHOD: We studied 216 patients; with myocardial perfusion imaging with SPECT (T1-201 and/or Tc-99 Sestamibi) and coronary angiogram. We defined the localization of myocardial perfusion defects (anterior, inferior, septal, lateral or apex), and their correlation with coronary angiogram, based on the location, number and severity of coronary angiographic lesions. We considered significative coronary stenosis obstructions of 60% or more. RESULTS: Of the 216 patients studied, 181 (83.8%) were male and 35 (16.2%) female. Age ranged between 30 and 82 years; 143 males and 23 females had a previous myocardial infarction. The SPECT sensitivity for diagnosing ischemia of one, two and three vessel disease was 94%, 96% and 100%. The sensitivity for diagnosing disease in specific vascular territories was 91.6% for LAD 100% for RCA, 92.8% for CX and 100% for left main. CONCLUSIONS: Myocardial perfusion imaging with SPECT has high sensitivity for diagnosing coronary artery disease. The sensitivity and specificity were more accurate in proximal anterior descending artery disease, left main and three-vessel coronary artery disease. We found correlation in the site, number and severity of the angiographic lesions and in myocardial perfusion defects.

[Study, using non-invasive methods, of prostheses manufactured at the Instituto Nacional de Cardiología Ignacio Chávez]. / Estudio por métodos no invasivos de las prótesis manufacturadas en el Instituto Nacional de Cardiología Ignacio Chávez.

We study the phonocardiogram, M mode, two-dimensional and Doppler pulsed echocardiogram of 30 patients, who underwent implantation of a bovine pericardial bioprosthesis manufactured at the Instituto Nacional de Cardiología Ignacio Chávez. We describe 26 patients with prosthesis in mitral position, 22 females and 4 males, with age between 19 to 60 years. After surgery, 22 were in functional I and 2 in class II of the New York Heart Association Criteria. Two patients (6.6%) died of extracardiac complications. Phonocardiogram: Mitral prosthesis closing click (MPCC) were recorded at all, the interval Q wave-MPCC was of 0.09 +/- 0.02 sec. The interval second sound-mitral prosthesis opening click (S2-MPOC) measured 0.10 +/- 0.01 sec. Mid-diastolic murmur were recorded in 8 patients (30.7%). The O-F slope of the apexcardiogram was of 82 +/- 40 mm/sec. Ten patients had tricuspid insufficiency. Echocardiogram: The D-E velocity of mitral prosthesis opening was of 318 +/- 99 mm/sec and the E-F slope velocity of 15 +/- 6.2 mm/sec. All patients except one showed paradoxical motion of the intraventricular septum. The prosthesis stents distance was of 14.1 +/- 2 mm, the internal diameter of 17.8 +/- 2.9 mm and the valvular area was calculated in 2.5 +/- 0.08 cm2. The flow velocity/diameter was 62.6 +/- 26.8 cm/sec/mm and the flow velocity/opening area of 52.5 +/- 26.1 cm/sec/cm2.(ABSTRACT TRUNCATED AT 250 WORDS)

[Cardiac involvement in ankylosing spondylitis]. / La afección cardíaca en la espondilitis anquilosante.

Ankylosing spondylitis is a rheumatic disease that affects the axial skeleton and has predilection for young men. Of its extraarticular manifestations, the cardiac involvement, reported up to 48%, has been pointed out in recent years. It seems to exist a racial variation in the features of the spondylitis and since most of the studies have been performed in northern countries therefore it appears inadequate to extrapolate the conclusions of such studies to our society. We studied 23 patients with definitive diagnosis of ankylosing spondylitis. All of them had a complete physical examination, electrocardiography and X-ray of the chest; eight patients underwent a Holter study of 24 hours and seven patients were examined by echocardiography. The mean age of the group was 36 years; there were 21 men and two women. The mean duration of the rheumatic disease was 11.5 years. In only 4 (17.4%) of the patients we found cardiac involvement that would not be related to another etiology. By the clinic examination we found two patients with isolated aortic insufficiency; one case had a right bundle branch block. The Holter study did not show modifications, except in the one with isolated aortic insufficiency and right bundle branch block, in whom this block became of variable degree. The echocardiographic study showed the mentioned aortic valvular lesions and did reveal the same lesion in another patient in which the other studies were normal. It is emphasized that it is adequate to search for signs of ankylosing spondylitis in every patient with isolated aortic insufficiency or/and conduction disturbances of unknown etiology and also to performe cardiac careful in each patient with ankylosing spondylitis examination.

[Pneumonitis caused by hypersensitivity to the antigen(s) of pigeons. I. Clinical study]. / Neumonitis por hipersensibilidad a antígeno(s) de palomas. (I). Estudio clínico.

We studied twenty six patients with hypersensitivity pneumonitis due to pigeon antigens (pigeon breeder's disease). This insidious illness, causes an interstitial lung disease, with restrictive pattern and also pulmonary hypertension. Most of the cases showed circulating antibodies against pigeon serum proteins, polyclonal hypergammaglobulinemia and rheumatoid factor. Treatment based on avoidance of pigeon droppings and glucocorticoids gave good results.

[Usefulness of echocardiography in the diagnosis of infectious endocarditis]. / Utilidad de la ecocardiografía en el diagnóstico de la endocarditis infecciosa.

Thirty-four patients with clinical diagnosis of infective endocarditis were studied with M mode and/or two-dimensional echocardiography. of them. Twenty-two were men; their ages ranged from 9 to 67 years. In 23 cases surgical or post mortem confirmation of the echocardiographic diagnosis was obtained. The clinical features as well as history of previous cardiopathy (94.1%) and its type (congenital 38.2%, rheumatic 29.4%, rheumatic with valvular prosthesis 23.5%) were analyzed. In the 23 patients with proven endocarditis, the echocardiographic diagnosis was positive in 19 (82%); vegetations were evident in 13. In 6 patients vegetations were not found. There were 3 false positive cases and one false negative, giving a sensitivity of 0.81 and a specificity of 0.85. The causes of false negative and false positive findings were analyzed. These were closely related to the duration of the disease and time which elapsed between the echocardiographic study and confirmation in surgery or necropsy as well as the size of the vegetations. The echocardiographic diagnosis was difficult when a valvular prosthesis was present. Echocardiography is a useful technique for diagnosis and follow up of patients with infective endocarditis.

[Acquired systemic arteriovenous fistulas. Experience of 33 cases]. / Fístulas arteriovenosas sistémicas adquiridas. Experiencia de 33 casos.

We analyzed 33 cases of Acquired Systemic Arteriovenous Fistulas (FAVSA) seen in the INC-ICH between 1945 and 1981. The most frequent causes were traumatic (gunshot and knife wounds) and iatrogenic (surgery). The most affected vessels were femoral, carotid, axillary and subclavian. The FAVSA produced a hyperkinetic hemodynamic syndrome of high output that frequently resulted in fistular cardiopathy. Fistular cardiopathy and heart failure became evident from 4 days to 31 years after the initial insult and was related to the magnitude of the arteriovenous shunt. The latter depended on the distensibility of the communicating ring (the development of perifistular fibrosis did not allow dilatation of the fistular opening). Heart failure was a result of the magnitude of the shunt, even when the patient was young with a healthy heart. A detailed traumatic or surgical history was extremely important in the diagnosis. Relevant physical signs included: bounding pulses, a wide pulse pressure, the presence of a continuous murmur and thrill, a positive Nicoladoni-Branham's sign with a decrease in the heart rate and an increase in systemic blood pressure when the FAVSA was compressed. The existence of the condition became suspicious when heart failure appeared otherwise unexplained by an obvious cardiac lesion. Other important signs included the development of distal venous insufficiency and the presence of a palpable pulsatile mass. Fistular cardiopathy was observed in 60% of the cases studied, although the ECG was normal in 33%; 73% had cardiomegaly which improved with correction of the FAVSA. The treatment is necessarily surgical and required the appropriate technique.

[Ligation of the inferior vena cava and the Mobin-Uddin filter in the treatment of recurrent pulmonary embolism. Comparative study]. / La ligadura de la vena cava inferior y el filtro de Mobin-Uddin en el tratamiento de la embolia pulmonar recurrente. Estudio comparativo.

Twenty six cases of inferior vena cava interruption for the treatment of recurrent pulmonary embolism are reviewed. Ten patients were treated with inferior vena cava ligation while in the other 16 a Mobin-Uddin umbrella was placed. The recent and late complications of both groups were analyzed. The most common complication of the inferior vena cava ligation was edema of the lower extremities in 40% of the patients. In the Mobin-Uddin group, the most frequent complication was the recurrence of thrombophlebitis in lower limbs, that appeared in 50% of the cases studied. We conclude that inferior vena cava ligation may be more beneficial to these patients because the long term complications are fewer in number and severity.

Behavior of the pulmonary circulation in chronic obstructive pulmonary disease. Pathogenesis of pulmonary arterial hypertension at an attitude of 2,240 meters.

The hemodynamics of the pulmonary circulation were examined in 28 patients with severe and stable chronic obstructive pulmonary disease (COPD) who were born and raised at high altitude (2,240 meters) (COPD-A). All patients had mean pulmonary pressures (PAP) greater than 16 mmHg. We observed: (1) a low correlation between pulmonary arterial diastolic pressure (PAd) and arterial oxygen saturation (r = 0.38, p less than 0.05); (2) similar PAP in patients with COPD living at sea level (COPD-S) and patients with COPD-A (COPD-S, 32 +/- 7 mmHg; COPD-A, 27.5 +/- 11 mmHg; p = NS), despite more unsaturation in patients with COPD-A (COPD-S, 84.6 +/- 6%; COPD-A, 77.5 +/- 9%; p less than 0.05) and similar arterial pH; (3) lower levels of PAP in COPD-A (COPD-S, 51.7 +/- 10 mmHg; COPD-A, 33.6 +/- 12 mmHg; p less than 0.001) for the same degree of unsaturation (COPD-S, 71 +/- 6%; COPD-A, 71 +/- 8%; p = NS) and a lower arterial pH in COPD-S (COPD-S, 7.34 +/- 0.03; COPD-A, 7.39 +/- 0.04; p less than 0.01). We conclude that pulmonary hypertension caused by chronic alveolar hypoxia is present in COPD-A, but it seems to be decreased when compared with that observed in COPD-S.

The role of hydralazine therapy for pulmonary arterial hypertension of unknown cause.

Hydralazine was administered acutely to 12 patients who had pulmonary arterial hypertension of unknown cause. All of the patients were studied at rest and nine during exercise. On the basis of hydralazine response at rest, the patients were divided in two groups. In six patients (group A), pulmonary arteriolar resistance (Rp) decreased from 8.4 +/- 1.4 to 4.8 +/- 1.4 U/m2 (p less than 0.001), cardiac index (CI) increased from 3.47 +/- 0.3 to 5.86 +/- 0.5 1/min/m2 (p less than 0.005) and systemic resistance (Rs) decreased from 25 +/- 4 to 14 +/- 2 U/m2 (p less than 0.01). The Rp/Rs ratio did not change significantly after hydralazine (0.32 +/- 0.03 vs 0.33 +/- 0.07, NS). In the other six patients (group B), Rs decreased from 25 +/- 2 to 17.0 +/- 1 U/m2 (p less than 0.01), but the other variables did not change significantly. Our results suggest that the pulmonary vasodilatory effect of hydralazine caused a marked reduction in right ventricular afterload in group A. In group B, a marked systemic vasodilatory effect occurred and right ventricular afterload was not reduced. On the basis of the previous hemodynamic response, only group A patients were treated with oral hydralazine (50 mg every 6 hours). Hemodynamic measurements were repeated 48 hours after hydralazine, both at rest and during exercise, as well as 8 months later in five of the six patients in whom the beneficial hemodynamic effects persisted. These data suggest that hydralazine can reduce Rp in selected patients (pulmonary arterial pressure less than 60 mm Hg, Rp less than 15 U/m2 and Rp/Rs ratio less than 0.7) with pulmonary hypertension of unknown cause.

[Respiratory function in extrinsic allergic alveolitis caused by pigeons. Clinical, pathological and functional correlation]. / La función respiratoria en la alveolitis alérgica extrínseca por palomas. Correlación clínica, patológica y funcional.

Lung function tests (LFT) were performed in 71 patients with proven extrinsic allergic alveolitis due to pigeons (EAA-P), and they were correlated with lung biopsy (LB) findings. Lung function studies were analyzed to evaluate the clinical course of these patients treated with corticosteroids. Restrictive pulmonary function impairment was found in all cases (vital capacity 38 +/- 4%), residual volume was increased in 9 out of 14 patients (64%) (RV = 0.51 +/- 0.06 L.) and bronchial obstruction was a feature in 11/14 patients (78%) (MMEF = 53 +/- 4%). In all cases a low Pa02 was observed (44 +/- 2 mmHg) and in six an increase in PaC02 was detected. The vital capacity did not correlate with the degree of inflammation or fibrosis observed by LB. A significant negative correlation was found between Pa02 and the degree of inflammation (r = 0.68, p X 0.05) as well as with fibrosis + inflammation degrees (r = -0.63, p less than 0.05). In general, initial LFT and clinical improvement occur simultaneously. Lung function tests support the diagnosis of EAA-P, but are not capable of separating inflammation from lung fibrosis.