Chylous ascites caused by constrictive pericarditis.

Chylous ascites is an uncommon clinical entity associated with lymphatic obstruction usually caused by underlying malignancy. The authors describe a patient with chylous ascites caused by constrictive pericarditis in the absence of mechanical lymphatic obstruction. Pathophysiological mechanisms for the development of chylous ascites in constrictive pericarditis include augmented lymph production and high impedance to lymph drainage caused by central venous hypertension. After pericardiectomy, the patient's ascites and edema resolved. Constrictive pericarditis should be considered a rare but potentially curable cause of chylous ascites.

Intracoronary thrombolysis in acute myocardial infarction: clinical course following successful myocardial reperfusion.

We reviewed the clinical course of 73 patients who had attempted intracoronary thrombolysis, with emphasis on follow-up. Fifty-nine patients (81%) had coronary reflow sufficient to control pain and injury current: 52 received thrombolysis alone and seven had thrombolysis combined with acute coronary angioplasty. Recurrent ischemic events in hospital were frequent and occurred in 17 patients (29%). These included silent reocclusion (four patients), recurrent angina (eight patients), and recurrent infarction in the same myocardial zone (five patients). Late ischemic events occurred in 11 patients (19%) and included silent reocclusion (two patients) and angina (nine patients). Although acute coronary angioplasty resulted in a high rate of successful myocardial reperfusion, long-term vessel patency was infrequent. The results of coronary bypass surgery, performed in hospital for severe residual coronary stenosis and angina and later for recurrent angina, were uniformly good. At follow-up of 6 to 36 months (mean 18.5 +/- 8.1), total mortality was five patients (8%). Only 16 reperfused patients (27%) were alive and well without recurrent ischemia or interventions. We conclude that reopening an acutely occluded coronary artery by thrombolysis and/or angioplasty can be performed in the majority of patients but must be regarded as initial therapy in view of the high incidence of recurrent ischemic events. Reperfused patients with stable myocardial blood supply post infarction have low long-term mortality.

Limitation of infarct size with thrombolytic agents--electrocardiographic indexes.

Forty-four patients with acute transmural myocardial infarction underwent cardiac catheterization 4.7 +/- 1.3 hours (+/- SD) after the onset of persistent chest discomfort. Thirty-nine patients had total occlusion of infarct-related vessels; 27 of these 39 had successful intracoronary thrombolysis. Twenty of these 27 patients (74%) had reperfusion arrhythmia. Accelerated idioventricular rhythm was most often observed with reperfusion of all myocardial zones, while sinus bradycardia and hypotension accompanied reperfusion of the inferoposterior left ventricle. Three patients with spontaneous accelerated idioventricular rhythm had patient, stenosed, infarct-related vessels on the initial coronary angiogram. Patients with unsuccessful intracoronary thrombolysis did not demonstrate these specific arrhythmias. While there is rapid control of injury current with successful intracoronary thrombolysis, Q waves develop rapidly after reperfusion; however, in the days after intracoronary thrombolysis, there is a decline in Q wave with partial regrowth in R wave amplitude in some patients. Thus, specific arrhythmias, most notably accelerated idioventricular rhythm, are useful markers for the occurrence and timing of successful coronary arterial recanalization. In addition, rapid control of injury current and partial regrowth of R waves are electrocardiographic markers of myocardial salvage.

Transseptal left heart catheterization: utility of a sheath technique.

This report describes our experience with a modified sheath transseptal catheter system. The sheath technique allows for introduction of various catheters into the left heart, including a uniquely designed pigtail catheter intended for use with this system. Fifty-three patients underwent successful transseptal catheterization, 44 of whom had severe native aortic valve stenosis and seven with suspected prosthetic aortic valve dysfunction. The technique provides optimal ventriculographic and hemodynamic information as well as improved access to the left heart in patient with aortic valve disease.

A safe and rapid technique for retrograde catheterization of the left ventricle in aortic stenosis.

The present report describes our experience in 82 patients with a pigtail-straight guide wire system for crossing stenotic aortic valves. The technique was successful in 95% of all the attempts and the average fluoroscopic time was three minutes. There were no major complications of the procedure. The technique allowed for consistent, high quality ventriculograms in 73 patients enabling us to define the severity of concomitant mitral regurgitation in 27 of the patients, as well as a preoperative ejection fraction in all 73 patients. We conclude that the technique as described is a safe and efficient way to obtain both hemodynamic and angiographic information at minimum risk in patients with severe aortic stenosis.