[Severe tricuspid insufficiency as main manifestation of hyperthyroidism]. / Insuficiencia tricuspídea severa como manifestación principal de un hipertiroidismo.

The cardiac manifestations of the hyperthyroidism (HT) are diverse and frequent. However, sometimes, the initial symptoms are atypical and are difficult to diagnose. We present the case of a patient whose HT began with heart failure secondary to a severe tricuspid regurgitation (IT). This data suggests that when confronted with IT of unclear etiology, a possible HT must be investigated.

Percutaneous right brachial artery approach with 5F catheters for studying coronary artery disease.

We prospectively studied 60 ischemic patients with 5F catheters (Pigtail and Amplatz) using the percutaneous right brachial artery approach (group I), in order to compare this technique with two groups of 100 patients each randomly studied by the femoral route with either 5F (group II) or 8F (group III) catheters (Pigtail and Judkins). The following parameters were analyzed: need to change the initially elected catheter diameter or/and artery approach; technical difficulty for obtaining LV, LCA, and RCA angiograms; total time of X-ray exposure; quality image of LV, LCA, and RCA angiograms; incidence of arterial puncture related hematomas or total arterial occlusion; and duration of local compression after sheath removal. There were no differences between 5F brachial and femoral approaches except for the arterial compression time (p less than 0.01) and the X-ray exposure time (p = 0.03) which were longer with the brachial approach. Whatever the route used, 5F showed a mild increase difficulty (brachial p = 0.001; femoral p = 0.01) and a mild decreased quality image for LCA (branchial p = 0.006; femoral p less than 0.05). Mild hematomas were more frequent with 8F catheters (p less than 0.05). The procedure could be completed by the elected first artery and type of catheter (5F or 8F) in 57/60 patients in group I, in 95/100 in group II, and in 96/100 in group III (nonsignificant differences). Thus, the percutaneous right brachial artery approach using 5F catheters is similar to the femoral artery approach with the same catheters. Although both of them showed a mild increased technical difficulty and a mild decreased quality image compared to 8F, mainly for LCA angiograms, they allowed complete and reliable angiograms reading and analysis.

[Coronarography using high-flow 5F catheters. Percutaneous technic using the femoral and brachial routes]. / Coronariografía con catéteres 5F de alto flujo. Técnica percutánea por vías femoral y braquial.

In order to validate 5F catheters for assessing ischemic heart disease either by the femoral and the right brachial approaches, we prospectively studied with these catheters 125 patients by means of left ventriculogram and coronary artery angiograms. Twenty-five patients were studied with pigtail and Amplatz catheters using the right brachial approach (group I) and 100 patients were studied by the femoral route with pigtail and Judkins catheters (group II). Results were compared to those obtained in a control group of 100 patients prospectively studied by the femoral route with 8F catheters (group III). The following parameters were analyzed: need to change the initially elected catheter diameter or/and artery approach; technical difficulty for obtaining left ventriculogram, left coronary artery, and right coronary artery angiograms; total time of X-ray exposure; quality image of left ventriculograms; incidence of arterial puncture related hematomas or total arterial occlusion; and duration of local compression after sheath removal. There were no differences between groups I and II except for the arterial compression time (p less than 0.0001), and the X-ray exposure time (p = 0.02); both were longer in patients studied by the brachial approach (group I). Whatever the route used, 5F showed a mild increased difficulty (brachial p = 0.001; femoral p = 0.01), and a mild decreased quality image for left coronary artery (brachial p = 0.006; femoral p less than 0.05). Among patients studied by the femoral route a reduction in mild hematomas (p less than 0.05) and in the arterial compression time (p less than 0.0001) were observed in those studied with 5F catheters.(ABSTRACT TRUNCATED AT 250 WORDS)

Five French versus eight French catheters and the Judkins technique. Advantages and limitations for studying coronary artery disease.

In order to compare 5 French versus 8 French catheters for assessing ischemic heart disease, we prospectively studied 2 groups of 100 patients each, one with 5 French (group I) and the other with 8 French (group II) catheters by the Judkins technique. Significant differences were found in the greater easiness to catheterize LV (p less than 0.05) and LCA (p = 0.01) in group II and in better quality image for LCA in group II (p less than 0.05), although all patients in both groups had acceptable image quality. Pressure curves quality was better in group II (p less than 0.01); X-ray exposure time was longer in group I (p less than 0.001) and arterial compression time in group II (p less than 0.0001). Group I showed 3 and group II 10 mild hematomas (p less than 0.05). The procedure could be completed by the elected first artery and type of catheter in 95 patients in group I and in 96 in group II. Thus, the Judkins technique with 5 French catheters is as valid as with 8 French for assessing ischemic patients, reducing arterial morbidity, although mildly increasing technical difficulty and mildly decreasing quality image.

Cardiomegaly and abdominal mass in an acromegalic patient.

We herein report the case of a 53-year-old white acromegalic patient with an abdominal mass due to massive cardiomegaly. The patient suffered from long lasting acromegaly refractary to bromocriptine, transsphenoidal surgery and radiotherapy. He had been previously diagnosed as having systemic hypertension, ischemic chest pain and congestive heart failure with marked cardiomegaly. The present admission was due to asthenia, anorexia and weight loss that were finally attributed to adrenal insufficiency secondary to radiotherapy. Plain abdomen X-ray suggested the presence of supramesocolic mass. A large cold area in the left hepatic lobe was detected on the radionuclide liver scan. Radionuclide angiography surprisingly identified the cold area as a vascular structure corresponding to the heart. A body CT scan revealed the heart was expanding between stomach and liver. Two-dimensional echocardiography showed marked enlargement of left ventricle. Cardiomegaly was probably multifactorial (chronic hypertension, ischemic heart disease and acromegaly). To our knowledge, this is the first reported case of massive cardiomegaly behaving as an intraabdominal mass. This possibility must be considered when invasive intraabdominal diagnostic procedures are to be done, particularly in an acromegalic patient.

Venous digital angio-radiography: an accurate and useful technique for assessing coronary bypass graft patency.

Digital angiography has been reported to be a valid technique for anatomical studies of the peripheral cardiovascular system and for dynamic studies of ventricular function. The purpose of the present study was to assess the usefulness and accuracy of venous digital angiography (2 images per second) for imaging coronary bypass grafts after coronary artery bypass surgery, comparing its results with those of selective angiography. Fifty-two patients with 108 grafts (101 venous grafts and 7 internal mammary artery grafts) were studied by venous digital angiography and selective angiography. Venous digital angiography correctly diagnosed 95 out of 97 patent grafts and the 11 occluded grafts visualized by selective angiography. These results are better than those obtained in the very few studies so far reported in the literature. We were not able to adequately visualize distal anastomoses in most patients although we could identify the distal portion of 7 out of 8 patent sequential bypass grafts. Thus, these results suggest that venous digital angiography is a useful and accurate technique for assessing coronary bypass graft patency.

Probable early acute hepatitis with parenteral amiodarone.

A patient with acute changes suggesting acute hepatitis after parenteral amiodarone administration is described. A 77-year-old man with previous myocardial infarction was admitted with chronic left heart failure and atrial tachycardia. Initial hepatic function tests were strictly normal. After therapy with parenteral amiodarone (2300 mg in 3 days) and other measures, signs of congestive heart failure disappeared; subsequently the patient developed jaundice, marked increase in serum transaminase levels and fall in prothrombin time, and histologic changes of severe centrilobular necrosis were observed in hepatic biopsy. Clinical, laboratory (absence of others markers of hepatic disease), and histological findings seem to rule out common causes of hepatic disease. Therefore, parenteral amiodarone was implicated as the cause of acute hepatitis in this patient. In addition, there were findings suggesting a possibly immunologically mediated mechanism.

Direct non-invasive techniques for assessing coronary bypass graft patency.

Venous digital subtraction angiography (vDSA) and computed tomography (CT) are two non-invasive techniques that allow direct imaging of coronary grafts. Neither of them is 100% accurate when compared to selective angiography. We studied 52 patients with 107 coronary grafts (101 saphenous and 6 mammary artery grafts) by CT and vDSA. Fifty patients had control selective angiography and 2 had control digital arterial aortography. CT correctly diagnosed 88 of the 95 patent grafts and 8 out of the 12 occluded grafts (in 1 patient 3 patent grafts could not be well analyzed owing to artifacts from pacemaker wires). vDSA correctly identified 93 patent grafts and the 12 occluded grafts, allowing the correct diagnosis of the 11 non/or misdiagnosed CT grafts. CT allowed the correct identification of the 2 misdiagnosed vDSA grafts. These results show that when there was agreement between CT and vDSA there were no diagnostic errors and that the combination of these two non-invasive techniques may avoid selective angiography for studying coronary bypass graft patency.