Pregnancy after mustard repair for transposition of the great arteries.

BACKGROUND: Since the introduction of surgical repair procedures, women with complete transposition of the great arteries are surviving into their reproductive years. Only three successful pregnancies in such women have been described previously. CASES: Three women with transposition of the great arteries repaired in childhood became pregnant in 1991. Two pregnancies were complicated by failure of the systemic ventricle and one by preterm labor. Labor was managed with antibiotic prophylaxis against endocarditis, clinical hemodynamic assessment, epidural anesthesia, avoidance of maternal expulsive efforts in the second stage, and low forceps delivery. Three healthy infants were delivered vaginally between 34-39 weeks' gestation. CONCLUSION: With close cooperation between the cardiologist and obstetrician, successful pregnancy is possible after surgical repair of transposition of the great arteries. However, failure of the systemic ventricle is common and should be diagnosed and treated promptly.

Myocarditis: unresolved issues in diagnosis and treatment.

Myocarditis is an enigmatic disease. Lymphocytic myocarditis is most commonly viral in origin. Considerable evidence suggests that myocardial damage is due to an immune-mediated mechanism rather than to direct effects of the virus itself. The presentation is variable, ranging from a clinically inapparent or relatively benign illness to acute progressive heart failure and death. Although examination of the endomyocardial biopsy specimen is the "gold standard" for the diagnosis of myocarditis there are problems with this technique, relating particularly to sampling error and histologic interpretation. Considerable evidence, both animal and human, suggests that a link between viral myocarditis and dilated cardiomyopathy does exist. There is a rational basis for the use of immunosuppressive therapy in myocarditis. Although many favorable responses have been reported with the use of these agents, the results of more definitive studies are awaited to determine the role of immunosuppressive therapy in myocarditis more clearly. Recommendations for the practical management of patients with myocarditis are made. Whenever possible, patients with this diagnosis should be entered into the ongoing NIH trial.

Improvement in left ventricular ejection fraction after surgery for mitral stenosis.

It is recognised that patients with mitral stenosis may have impaired left ventricular function. The reasons for this are speculative and the effects of surgical relief of stenosis on left ventricular function unknown. Five patients showed dramatic improvement in left ventricular ejection fraction after surgery. Possible reasons include altered loading conditions, changes in ventricular interaction and partial restoration of the normal anatomical structure of the mitral valve complex.

Doppler evaluation of changing cardiac dynamics during Cheyne-Stokes respiration.

For the purpose of elucidating the mechanisms and/or effects of the cardiovascular changes occurring during Cheyne-Stokes respiration, we utilized Doppler echocardiography to determine intracardiac flow velocity profiles during the changing phases. Left ventricular inflow (LVI) and outflow (LVO) were examined in ten patients, nine with heart failure and one with a cerebrovascular accident. The mean LVI, peak early (E) and late diastolic (A) and LVO velocities were measured at the end of both the hyperpneic and apneic phases. The phasic hemodynamic changes observed during Cheyne-Stokes respiration by Doppler profile could be explained by the development of LV diastolic dysfunction and a decrease in LV stroke volume during the apneic phase of Cheyne-Stokes respiration. Alternatively, an increase in PCO2 during the apneic phase may increase pulmonary vascular resistance lowering preload and stroke volume, whereas during the hyperpneic phase, pulmonary vascular resistance is reduced with resultant increase in left ventricular preload and increase in stroke volume. Both theories are speculative and the precise hemodynamic changes associated with Cheyne-Stokes respiration requires further investigation.

Flow characteristics in the dilated left ventricle with thrombus: qualitative and quantitative Doppler analysis.

In an attempt to determine whether mural thrombus in a dilated left ventricle is associated with specific flow patterns, a study was undertaken to assess qualitatively and quantitatively the flow characteristics by conventional pulsed and two-dimensional Doppler color flow examination. Forty patients with cardiomyopathy formed the study group (20 with an apical thrombus and 20 without). The groups did not differ with respect to age, gender, origin of ventricular dysfunction, ventricular size and ejection fraction. Guided by the Doppler color flow pattern, a quantitative analysis of flow velocity profile in the ventricular inflow and outflow "compartments" was performed by serial pulsed wave Doppler sampling. Inflow velocity at the ventricular apex was significantly lower in the thrombus group than in the no thrombus group (11.7 +/- 15.3 versus 28.3 +/- 10.5 cm/s, p less than 0.0001). Flow velocities were generally lower in the thrombus group at the other levels in the inflow compartment (that is, mitral anulus, leaflet tips and papillary muscle level). The systolic flow velocity at the apex was similarly significantly lower in the thrombus group than in the no thrombus group (7.1 +/- 8.1 versus 15.3 +/- 7.0 cm/s, p less than 0.001). Additionally, a higher prevalence of mitral regurgitation was noted in the no thrombus group (14 patients) than in the thrombus group (3 patients). Thus, specific abnormal flow profiles are associated with a left ventricular thrombus. Whether the abnormal flow is a primary event in the genesis of left ventricular thrombus or occurs secondary to development of the thrombus cannot be determined from this study.

The echo Doppler spectrum of valvular abnormalities in the hospitalized octogenarian.

Cardiac valves thicken and become more opaque with advancing age. As more individuals live longer and as more treatment modalities such as valvuloplasty evolve, the presence and significance of these valvular abnormalities become important. We retrospectively studied 628 octogenarian patients to try and define further the presence and significance of these abnormalities detected by Doppler echocardiography. A group of 547 patients were suitable for analysis. Age ranged from 80 to 96 years (mean 84.4). The female:male ratio was 1.9:1. Mitral, aortic, and tricuspid regurgitation (MR, AR, and TR) were significant if the jet moved greater than 2 cm from the plane of the valve away or toward the transducer, depending on transducer position. Mitral regurgitation was detected in 331 patients (60.5%) and was significant in 82 patients (15%). Aortic regurgitation was detected in 276 patients (50.5%) and was significant in 70 patients (12.8%). Tricuspid regurgitation was detected in 131 patients (23.9%) and was significant in 30 patients (5.5%). Regurgitant lesions were detected in two valves in 150 patients (27.4%) three valves in 57 patients (10.4%), in all four valves in 17 patients (3.1%). Aortic stenosis was detected in 160 patients (29.3%). The gradient range was 16-156 mmHg (mean 47.8). Significant aortic stenosis was present in 70 patients (12.8%) (gradient greater than 50 mmHg), of whom 54 had isolated pure aortic stenosis and 16 had mixed lesion. In 40% of these patients, significant aortic stenosis was an unexpected finding at two-dimensional echocardiography. Valvular pathology is common in the octogenarian population.(ABSTRACT TRUNCATED AT 250 WORDS)

Aspects of the value of continuous ambulatory ECG monitoring in the detection and management of ischaemic heart disease. Case reports.

In 2 patients admitted for evaluation of chest pain occurring mainly at rest, organic disease of the nondominant circumflex artery only, with normal left anterior descending and right coronary arteries, was demonstrated in each case. Continuous ambulatory ECG monitoring by the Holter system revealed episodes of ST-segment elevation probably due to coronary artery spasm, allowing specific treatment to be instituted. Some aspects of the value of continuous ambulatory Holter monitoring in patients with ischaemic heart disease are discussed.

Syndrome of inappropriate antidiuretic hormone secretion in association with herpes zoster of the chest wall. A case report.

The syndrome of inappropriate antidiuretic hormone secretion (SIADH) occurs in a number of diverse medical conditions. We report a case in which SIADH and herpes zoster of the chest wall occurred concurrently. In the absence of other recognized causes we suggest that the two conditions may have been related and speculate on possible mechanisms.

Pulmonary fibrosis following long-term nitrofurantoin therapy.

Three patients who developed pulmonary fibrosis following prolonged treatment with nitrofurantoin for chronic urinary tract infections are presented. They had received the drug for 3--4 years; all gave histories of 2--3 years of progressive shortness of breath and an unproductive cough. On examination, all 3 patients had bilateral crackles and 1 had finger clubbing. Chest radiographs showed bilateral shadowing and lung function tests a restrictive defect with reduced gas transfer. Lung biopsies showed extensive fibrosis in 2 patients and advanced honeycomb formation in 1. The response to steroid therapy in 2 patients was excellent, with resolution of symptoms, clearing of the chest radiographs and improvement in lung function. It is proposed that nitrofurantoin has no place in the long-term treatment of chronic urinary tract infections and that its use in acute infections should be questioned.

The role of coronary artery spasm in anginal syndromes.

The role of coronary artery spasm in the production of angina at rest is emphasized. Three case reports of variant angina are presented to illustrate the spectrum of presentation and to stress the principles underlying the therapy of coronary artery spasm. This entity should be suspected and diagnosed more frequently in order that patients may derive the benefit of relatively specific therapy which consists of calcium antagonists and long-acting nitrates.

Leptospirosis experience at Groote Schuur Hospital, 1969-1979.

The diagnosis of leptospirosis requires a high index of suspicion and a knowledge of the wide variety of syndromes with which these patients present. The clinical and laboratory features of 14 patients with leptospirosis seen at Groote Schuur Hospital, Cape Town, between 1969 and 1979 are described.