Prognostic implications of left ventricular function during exercise in asymptomatic patients with aortic regurgitation.

Few data are available that address the prognostic implications of the response of the left ventricle (LV) to exercise in asymptomatic patients with aortic regurgitation (AR) who have normal resting LV function. Thirty-one such patients were contacted two to seven years after rest and exercise radionuclide ventriculography. Eleven had had significant cardiovascular events. Event-free survival at forty-eight months was 64%. Ten of eleven events occurred in 21 patients with decline in ejection fraction (EF), but the magnitude of decline did not further separate the group with regard to prognosis. Eight events (73% of total events) occurred in the 11 patients (35% of total patients) with an EF during exercise of 0.55 or less. The short and intermediate outlook for asymptomatic patients with AR and normal resting LV function is good regardless of the response of the EF to exercise, but an exercise EF less than or equal to 0.55 does identify a relatively high-risk subset for deterioration beyond twenty-four months.

Scintigraphic features of giant cell tumor.

The scintigraphic appearance of giant cell tumor of bone in six patients is presented. Patients were studied by means of Tc-99m MDP bone scanning. On early blood pool and delayed imaging, markedly increased activity was noted, characteristically displaying a "ring" pattern that is readily discernible from patterns seen in bone cysts and nonosteogenic fibroma. The extent of the lesion, as judged by scintigraphic techniques, was roughly equal to estimates of extent by other radiographic modalities. Only one example of a different lesion mimicking giant cell tumor was encountered in over 100 cases of a variety of primary bone neoplasms reviewed. We conclude that giant cell tumor has a characteristic scintigraphic appearance.

Relation of ST-segment elevation after healing of acute myocardial infarction to the presence of left ventricular aneurysm.

Persistent ST elevation after healing of myocardial infarction (MI) is often cited as an electrocardiographic sign of left ventricular (LV) aneurysm. This sign is rare in patients with coronary artery disease who have normal or only mildly deranged LV function and is most often associated with QRS patterns indicative of large MI, especially anterior wall MI. To determine whether ST elevation identifies a distinctive abnormality of LV function that might be labeled LV aneurysm, global and regional LV function in 12 patients with QRS patterns of anterior MI and ST elevation were compared with that in 12 patients with similar QRS abnormalities but without ST elevation by means of radionuclide ventriculography. All measured parameters of ventricular function were similar in the 2 groups. ST elevation could not be demonstrated to predict a distinctive abnormality that might be labeled LV aneurysm.

The electrocardiogram as an index of left ventricular function in coronary heart disease.

To determine the utility of conventional electrocardiographic criteria for the assessment of left ventricular function, we applied pre-determined criteria to the analysis of the ECGs of 171 patients with chronic coronary disease. Eighty patients had no criteria for infarction. Seventeen had a criterion for anterior, 59 a criterion for inferior, three for strict lateral, four for true posterior and eight for combined infarction. Of the 59 with inferior infarction, 25 had QaVF greater than or equal to 0.03 sec. These 25 together with the 25 with anterior or combined infarction constituted a subgroup of 50 patients which included 35 of the 44 (80 percent) of those with an ejection fraction less than 0.50. Among the remaining 121, only nine (7 percent) had a depressed ejection fraction. Thus, the ECG criteria identified correctly 147 (86 percent) patients with regard to the presence or absence of left ventricular dysfunction.

Minidose heparin in transurethral prostatectomy.

A double-blind prospective study was performed on 34 patients undergoing transurethral resection of the prostate (TURP). Seventeen patients, selected at random by computer, were given 5,000 units of subcutaneous heparin three hours preoperatively and every twelve hours thereafter for forty-eight hours. The other 17 received normal saline injections in a similar manner. All patients had pre- and postoperative lung scans. The blood loss was measured during and for seventy-two hours after surgery. There was no statistically significant difference in the bleeding in comparing the two groups. Two patients from the heparin group were diagnosed to have pulmonary emboli by lung scan preoperatively and showed no change postoperatively. In 1 patient from the control group an asymptomatic pulmonary embolism developed in the postoperative period. The use of subcutaneous heparin in TURP is safe and is recommended for patients with an increased risk of pulmonary embolism.

Effects of beta-adrenergic blocking drugs on sensitivity and specificity of radionuclide ventriculography during exercise in patients with coronary heart disease.

We examined the impact of beta-adrenergic blocking drugs on the sensitivity and specificity of radionuclide ventriculography in 95 patients with angiographically proved coronary disease and in 22 angiographically normal subjects. Sixty of the former and seven of the latter were receiving beta-adrenergic blocking agents. All had normal regional and global left ventricular function at rest. Exercise-induced asynergy and failure of exercise to increase ejection fraction by at least 0.05 were considered abnormal findings. The specificity of the criterion, failure to increase ejection fraction, was so impaired (0.87 vs 0.29) by these agents as to negate the usefulness of that observation for the diagnosis of coronary disease. The utility of the ejection fraction measurement to assess the severity of occlusive disease is also compromised, since that response is ameliorated by these drugs. An exercise-induced decline in ejection fraction of at least 0.05 was observed significantly less frequently in patients receiving beta blockers (30% vs 54%; p less than 0.025).

Radionuclide ventriculography following coronary bypass surgery: correlation with arteriographic findings.

Radionuclide ventriculography demonstrates improved left ventricular performance during exercise following coronary bypass operation, but few data are available that compare the nuclear ventriculographic findings with arteriographic evaluation. We report the findings in 25 patients in whom both tests were performed within a short period of time. coronary bypass operations had been performed six weeks to nine years previously. Ejection fraction (EF) increased during stress in 5 completely revascularized patients. Exercise provoked deterioration in regional wall motion in 9 of 20 (45%) patients with incomplete revascularization, and EF failed to rise during exercise in 15 (75%). Although resting EF was similar in both completely revascularized patients and in those who were not (0.06 versus 0.58), EF during exercise was significantly greater in completely revascularized patients (0.68 +/- 0.02 versus 0.55 +/- 0.03, p less than 0.01). Exercise-provoked decline in EF in patients with coronary artery bypass grafts reflects continued significant occlusive disease.

Radionuclide evaluation of the interventricular septum following coronary artery bypass surgery.

The cases of 25 consecutive patients who had undergone radionuclide ventriculography both before and after coronary artery bypass surgery and who had had normal septal motion before surgery were reviewed. Abnormal septal motion was present in 22 patients (88%) postoperatively. In contrast, a new motion abnormality appeared following surgery in the apical segments of only 5 of 21 patients (24%) and in the lateral segments of 1 of 22 (5%) patients. All patients improved clinically following surgery, and only two had evidence of intraoperative myocardial infarction. Postoperatively, thallium imaging revealed normal septal perfusion in all six patients who underwent this examination. Thus, it appears that ischemic injury does not always account for this phenomenon, which is a potential source of confusion in patients after coronary bypass operations. It is concluded that radionuclide ventriculography identifies the same aberration of ventricular septal motion that is seen during echocardiographic examination of patients who have undergone surgery.

Thyroid scanning of the patient with history of childhood irradiation.

The utilization of external radiation for the treatment of benign conditions of the head and neck is no longer employed because of the discovered association of local irradiation with the development of thyroidal cancer. This practice was widespread until two or three decades ago. It is also known that there is a very long latent period between previous radiation and the development of thyroid cancer. In consequence, a substantial number of persons can be expected to develop thyroidal malignancy each year until the turn of the millenium, and even later. If this association is real, then early diagnosis is especially important because of the excellent therapeutic results that can be obtained with early diagnosis. Physical examination performed on a regular basis is the most important single diagnostic aid. A statistically significant improvement in sensitivity is obtained when palpation is performed in conjunction with radioisotopic thyroid scanning. The scan helps by identifying areas of abnormality and--even more importantly--by allowing distinction of those nodules which are hypofunctioning and thus more likely to be malignant.

The radionuclide cardiac ventriculogram. Evaluation of results in twelve hundred consecutive patients.

Coronary artery disease represents one of the most prevalent and serious diseases in the western world. In consequence, there is considerable need for a reliable method for its diagnosis. Until now the best available laboratory methods were the EKG treadmill test and arteriography. The former suffers from the disadvantages of suboptimal sensitivity and specificity, while the latter is both expensive and invasive. The recent introduction of the nuclear cardiac ventriculogram offers new hope for the non-invasive diagnosis of this condition. Based on an experience of more than two thousand patient studies, we consider that this procedure represents a significant advance in the ability to distinguish between the normal and abnormal left ventricle.

Role of bone scanning in carcinoma of the breast.

This paper consists of a review of the current literature, as well as the authors' experience, concerning the diagnosis and treatment of carcinoma of the breast with special reference to the role of radioisotopic bone scanning. Recommendations are made regarding the appropriate use of this technique at the time of initial diagnosis and over the course of subsequent management.

The usefulness of radionuclide ventriculography for the identification and assessment of patients with coronary heart disease.

To assess the usefulness of radionuclide angiography for the identification and evaluation of patients with coronary heart disease, we analyzed 100 consecutive patients who had undergone that examination and coronary arteriography. Regional wall motion abnormality during exercise was detected in 65 of 76 (86%) patients with occlusive coronary disease and in one of 11 (9%) with normal coronary arteries and normal left ventriculograms. The changes in the left ventricular ejection fraction in response to exercise were not helpful for the identification of individual patients with coronary disease, since changes were often small and within the error of the technique. Substantial decline of the ejection fraction during exercise indicated multivessel disease or severe proximal left anterior descending artery occlusion.

Specificity of 99mTc-pertechnetate in scintigraphic diagnosis of Meckel's diverticulum: review of 100 cases.

Numerous reports in the recent literature have questioned the value of abdominal scanning with pertechnetate in the diagnosis of Meckel's diverticulum. In an attempt to evaluate further the specificity of pertechnetate in this condition, the clinical data and scintigrams of 100 patients with suspected Meckel's diverticulum were reviewed. The scintigram correctly identified Meckel's diverticulum before operation in seven of eight patients. One false-negative study occurred in 33 patients who underwent laparotomy. Conditions suggested as possible causes of false-positive studies (hydronephrosis, arteriovenous malformations, and intussusception) were found to give negative scans.

Sequential blood volume changes in patients undergoing total hip arthroplasty.

Adequacy of transfusion based exclusively on clinical observations of hemodynamic changes and quantities of blood lost during total hip arthroplasty (THA) in 15 adults was tested by serial measurements of 51-Cr red-cell volume (RCV), 125-I RISA plasma volume (PV), and peripheral hematocrit (Hv) determined immediately before and 2 and 48 hours after operation. Blood transfusion and intravenous-fluid therapy were based on clinical observations and designed to restore blood volume (BV) to within 10 percent of its preoperative level prior to the isotopic determination 2 hours postoperatively. (When that determination showed a BV less than 90 percent, transfusions were given to restore it to between 90 and 100 percent). Isotopic data 2 hours after operation showed that the BV reduction--thought clinically to be less than 10 percent in every case--averaged 21.6 percent (range: 6 to 39 percent) and was shared by RCV and PV. Isotopic measurements 48 hours after operation showed that patients whose BV at 2 hours was within 10 percent of the preoperative BV were able to compensate for an average continuing RCV reduction of 23.9 percent by expansion of PV, resulting in an average BV reduction of 11.4 percent. Hv was a valuable guide for transfusion therapy at 48 hours, but not 2 hours after operation. In view of inadequacy of blood replacement based on clinical observations and the magnitude and variability of the 2 hour postoperative isotopically measured BV reductions in our patients, we recommend obtaining a derived BV by measuring PV and Hv preoperatively and 2 hours postoperatively as a further guide to transfusion therapy for each patient under-going THA. This is simpler and more practical than the two-isotope technique and is more sensitive than clinical observation alone. If clinical observation had been supplemented with a derived BV in our 15 cases, 80 percent instead of 30 percent would have had their BV restored to within 10 percent of the preoperative BV.