Aortic regurgitation in coronary artery bypass grafting: implications for cardioplegia administration.

BACKGROUND: Echocardiography can detect aortic regurgitation (AR) that may interfere with the adequate delivery of cardioplegia solution to the myocardium during cardiac operation. When aware of this lesion, the surgeon can modify the operative technique accordingly. We sought to evaluate the ability of intraoperative transesophageal echocardiography to detect AR and to correlate the severity of the lesion with the need for retrograde cardioplegia administration. METHODS: Eighty-four consecutive patients undergoing coronary artery bypass grafting were evaluated. When AR was noted by intraoperative transesophageal echocardiography, a cannula was placed in the coronary sinus for possible retrograde cardioplegia administration. The surgeon was unaware of the severity of AR. After operation, the severity of AR was quantitated using the ratio of the regurgitation jet width to the left ventricular outflow tract diameter. RESULTS: The AR patients who required retrograde cardioplegia had a significantly higher ratio of regurgitation jet width to left ventricular outflow tract diameter than those AR patients who did not (0.36 +/- 0.06 versus 0.19 +/- 0.06, p < 0.005). CONCLUSIONS: Transesophageal echocardiography can provide accurate information regarding the presence and severity of AR. The calculated severity of AR on transesophageal echocardiography is associated with the need for retrograde cardioplegia administration.

Dyspnea during pregnancy. Distinguishing cardiac from pulmonary causes.

Dyspnea is common during normal pregnancy; however, a variety of significant cardiac and pulmonary disorders present with this as a cardinal symptom. This article describes the cardiopulmonary and clinical findings of pregnancy as well as specific disease indicators in the more common causes of cardiac and pulmonary dyspnea during pregnancy.

Effect of oral milrinone on mortality in severe chronic heart failure. The PROMISE Study Research Group.

BACKGROUND: Milrinone, a phosphodiesterase inhibitor, enhances cardiac contractility by increasing intracellular levels of cyclic AMP, but the long-term effect of this type of positive inotropic agent on the survival of patients with chronic heart failure has not been determined. METHODS: We randomly assigned 1,088 patients with severe chronic heart failure (New York Heart Association class III or IV) and advanced left ventricular dysfunction to double-blind treatment with (40 mg of oral milrinone daily (561 patients) or placebo (527 patients). In addition, all patients received conventional therapy with digoxin, diuretics, and a converting-enzyme inhibitor throughout the trial. The median period of follow-up was 6.1 months (range, 1 day to 20 months). RESULTS: As compared with placebo, milrinone therapy was associated with a 28 percent increase in mortality from all causes (95 percent confidence interval, 1 to 61 percent; P = 0.038) and a 34 percent increase in cardiovascular mortality (95 percent confidence interval, 6 to 69 percent; P = 0.016). The adverse effect of milrinone was greatest in patients with the most severe symptoms (New York Heart Association class IV), who had a 53 percent increase in mortality (95 percent confidence interval, 13 to 107 percent; P = 0.006). Milrinone did not have a beneficial effect on the survival of any subgroup. Patients treated with milrinone had more hospitalizations (44 vs. 39 percent, P = 0.041), were withdrawn from double-blind therapy more frequently (12.7 vs. 8.7 percent, P = 0.041), and had serious adverse cardiovascular reactions, including hypotension (P = 0.006) and syncope (P = 0.002), more often than the patients given placebo. CONCLUSIONS: Our findings indicate that despite its beneficial hemodynamic actions, long-term therapy with oral milrinone increases the morbidity and mortality of patients with severe chronic heart failure. The mechanism by which the drug exerts its deleterious effects is unknown.

Fatal acute congestive heart failure in a patient with idiopathic hemochromatosis and cocaine use.

Cardiovascular complications from cocaine use have been recognized in increasing frequency in recent years. We report the case of a young man with a history of intranasal cocaine use presenting with acute congestive heart failure who, on postmortem examination, was found to have idiopathic hemochromatosis. It is speculated that cocaine played a synergistic role in depressing myocardial function in a heart which had already been compromised by the diffuse iron deposition associated with hemochromatosis.

Two-dimensional echocardiographic monitoring during percutaneous endomyocardial biopsy.

The use of two-dimensional echocardiography in four successive views was assessed to determine the optimal view for localizing a transvenous percutaneous bioptome in 23 consecutive patients undergoing right ventricular endomyocardial biopsy. The biopsy catheter tip was viewed in 21 (91%) of the 23 patients. The apical four chamber view allowed visualization of the bioptome head in 19 patients (83%), the subcostal view in 8 (34%) and the long-axis view in 4 (17%). The parasternal short-axis view was not helpful in any patient. Biplane fluoroscopy was not reliable in localizing the bioptome head against the interventricular septum and did not identify inadvertent septal perforation in one patient. Echocardiography also can be used to immediately identify possible complications.

Unsuspected vascular disease: a potential limitation to the use of the intra-aortic balloon.

Since vascular tortuosity of stenosis may preclude placement of the intra-aortic balloon, 63 consecutive patients (37 men) having routine Judkins' cardiac catheterization had an aortogram prior to withdrawal of the last catheter. No patient had a history of claudication, palpable aneurysms, pulse deficit, or bruit. No complications occurred. Significant peripheral vascular disease was found in ten patients: three had aortic, one had iliac, and six had femoral stenosis or tortuosity. All were men. The age of patients with peripheral vascular disease was 61.4 +/- 7.7 years, while those without were 56.9 +/- 9.3 years (P = NS). No difficulty was encountered entering the femoral artery in any patient; there was difficulty advancing the catheter in five of ten (50%) patients with peripheral vascular disease and in three of 54 (6%) patients without (P less than 0.002). Fifteen patients without peripheral vascular disease had normal coronary arteries, while none with peripheral vascular disease was normal. In patients with coronary disease, the number of vessels involved was the same in both groups. Peripheral vascular disease that might preclude placement of the intra-aortic balloon occurs in 14% of patients undergoing cardiac catheterization and 18% of patients with coronary artery disease. Aortography may be safely performed and should be considered during routine cardiac catheterization in patients who may require intra-aortic balloon placement.

Atrial fibrillation--a marker for abnormal left ventricular function in coronary heart disease.

Retrospective study of 1176 patients with known coronary heart disease by cardiac catheterisation disclosed 10 patients (0.8%) with atrial fibrillation. Comparison with 25 randomly selected patients with coronary heart disease with sinus rhythm showed that atrial fibrillation correlated significantly with impaired haemodynamic function, mitral regurgitation, and abnormalities of left ventricular contraction. Atrial fibrillation is, therefore, a useful marker of extensive myocardial dysfunction.

Left atrial size and left ventricular function in coronary artery disease: an echocardiographic-angiographic correlative study.

M-mode echocardiography was used to determine left atrial size in 100 patients with coronary artery disease undergoing cardiac catheterization. Patients were divided in two groups on the basis of left atrial diameter (greater than or equal to 40 mm in 40 patients and less than 40 mm in 60). Patients with larger left atria had a higher frequency of electrocardiographic evidence of left atrial abnormality (p less than 0.01) and myocardial infarction (p less than 0.001). Pulmonary capillary wedge and left ventricular end-diastolic pressures were higher (p less than 0.005) in patients with larger left atria. An abnormal end-diastolic volume (greater than 100 ml/M2) was observed in 13 patients with enlarged left atria compared to none with normal left atrial size (p less than 0.001). Triple vessel disease was more frequent (63% vs 32%) and single vessel disease less frequent (10% vs 37%) in patients with larger left atria (p less than 0.005). Abnormal left ventricular contractile patterns were noted in 45% of patients with normal left atrial diameters compared to 80% in those with an enlarged left atrium (p less than 0.001). An abnormally low ejection fraction (less than 0.5) was observed in 25% and 80%, respectively, in patients with normal and enlarged left atria (p less than 0.001). Of 58 patients with normal ejection fractions, only 17% had left atrial diameters greater than or equal to 40 mm compared to 71% of 42 patients with abnormally low ejection fractions (p less than 0.001). Of 18 patients with left atrial diameters greater than 42 mm, only two had normal ejection fractions. The mean ejection fraction for patients with left atrial diameters less than 40 mm was 0.63 +/- 0.13 compared to 0.41 +/- 0.18 for those with diameters greater than or equal to 40 mm (p less than 0.001). The sensitivity, specificity, and predictive value for an enlarged left atrium in identifying an abnormal ejection fraction were, respectively, 71, 83, and 75%. These findings indicate that M-mode echocardiographic left atrial enlargement is a useful marker of advanced hemodynamic and angiographic abnormality in patients with coronary artery disease.

Myocarditis in legionnaires' disease.

A case of Legionnaires' disease is described in which the characteristic features of multilobar pneumonia, rhabdomyolysis, renal failure, hepatic and CNS involvement are accompanied by the previously undescribed complication of myocarditis. Clinical and laboratory findings of myocardial involvement included overt heart failure, a new gallop, an abnormal ECG, elevated myocardial specific enzymes and an abnormal thallium scan. All of these abnormalities resolved completely after recovery.

Cardiovascular complaints. Correlation with cardiac arrhythmias on 24-hour electrocardiographic monitoring.

Long-term ambulatory electrocardiographic (Holter) monitoring is frequently used to evaluate patients with various cardiovascular complaints, including palpitations, dyspnea, discomfort in the chest, dizziness, and syncope. In the present study, 518 consecutive 24-hour electrocardiographic recordings were reviewed to determine correlations between cardiac diagnoses, presenting complaints, and specific electrocardiographic abnormalities. Two hundred seventy-four patients (53 percent) had significant arrhythmias; 212 (41 percent) had significant ventricular arrhythmias, and 106 (20 percent) significant atrial arrhythmias, including 44 patients (8 percent) with both. No presenting complaint or cardiovascular diagnosis correlated closely with any specific cardiac arrhythmia. Major arrhythmias, including supraventricular and ventricular tachycardias, often occurred asymptomatically (in 44/54 and 37/40 patients, respectively); however, among 371 patients with accurate historic logs, only 176 (47 percent) had long-term electrocardiographic studies in which their typical symptoms occurred during the monitoring period. Fifty (13 percent) of the 371 patients had concurrence of their presenting complaints with an arrhythmia, and 126 patients (34 percent) had their typical symptoms associated with a normal electrocardiogram, which was helpful in excluding an abnormality of rhythm or conduction as the primary cause for their complaints.

Mitral valve prolapse syndrome in agoraphobic patients.

Twenty-five agoraphobic women were compared with 23 controls for the presence of mitral valve prolapse syndrome (MVP). All subjects underwent cardiac examination, electrocardiography, phonocardiography, and echocardiography. Eleven of the agoraphobic patients had MVP; 5 had echo findings alone, 3 had both auscultory and echo findings, and 3 had auscultory findings alone. Two controls had evidence of MVP, both with echo findings alone. Echo chamber size and wall motion were similar in both groups. One patient had inferior T wave changes on ECG while all controls had normal tracings. The authors conclude that a significant number of agoraphobic patients have MVP and discuss the thoretical and clinical implications of this association.

The clinical and hemodynamic significance of mitral regurgitation in coronary artery disease.

To evaluate the significance of mitral regurgitation in coronary artery disease (CAD), clinical, electrocardiographic, and angiographic data in 100 coronary artery disease patients with mitral regurgitation were compared to data in 100 coronary artery disease patients without mitral regurgitation. Mitral regurgitation was mild (1+) to moderate (2+) in 94 patients. Heart failure, cardiomegaly, and anterior myocardial infarction were more common in mitral regurgitation patients than in controls (33 vs 4;47 vs 8;22 vs 5, respectively, P < 0.001). The frequency of inferior myocardial infarction was equal in both groups. Significant left anterior descending and circumflex disease was equally frequent; however, right coronary disease was more frequent in patients with mitral regurgitation (87 vs 68, P < 0.001). Total vessel occlusions and triple-vessel disease were more frequent in patients with mitral regurgitation (113 vs 78, P < 0.01; 60 vs 40, P < 0.001, respectively). No localized area of asynergy was more common in patients or controls,, but left ventricular aneurysms and generalized hypokinesis were more common in patients with mitral regurgitation (6 vs 0; 23 vs 2; P < 0.001). These data suggest that mitral regurgitation is most often mild, but is associated with significant left ventricular dysfunction and advanced CAD.

Renal arteriovenous fistula masquerading as severe valvar heart disease.

Two patients with renal arteriovenous fistulae are described, who presented in high output failure. Murmurs were detected in these patients on routine physical examination years before, and when cardiac failure ensued they were assumed to have decompensated valvar heart disease. Full investigation revealed the arteriovenous fistulae and both patients made a good recovery after surgical ligation.

Cardiac hypertrophy in response to dynamic conditioning in female athletes.

Ten female field hockey players were studied to determine if prolonged dynamic conditioning results in an increased left ventricular internal dimension at end diastole (LVIDD) and if this increase correlates with maximal oxygen consumption (VO2max). At peak season, echocardiograms were obtained and VO2max determined during maximal treadmill exercise. VO2max, LVIDD index (LVIDD/body surface area (BSA)), and ventricular septal and posterior wall thickness were compared to agematched nonathletic women. Mean LVIDD index was significantly greater in athletes than in controls: 29.3 +/- 0.9 mm/m2 vs. 26.3 +/- 0.6, P less than 0.005. Echocardiographic wall measurements did not differ significantly in the two groups. Mean VO2max for the athletes was significantly greater than controls: 51.7 +/- 4.0 ml O2.kg-1.min-1 vs. 41.2 +/- 2.1, P less than 0.001. VO2max correlated significantly with LVIDD index; r = 0.92, P less than 0.001. Female athletes show an increased LVIDD in response to dynamic conditioning similar to that seen in male athletes. The proficiency of athletic performance as measured by VO2max may be related to the heart's ability to increase LVIDD since there is a high correlation between VO2max and LVIDD index.

Fascicular conduction distrubances after coronary bypass surgery.

Two hundred patients underogoing coronary bypass graft surgery were studied to determine the frequency and significance fo new fascicular conduction distrubances. The follow-up period ranged from 13 to 39 months. New disturbances developed in 39 patients (20 percent). Isolated right bundle branch block (6 percent) and left anterior hemiblock (6 percent) were the most common disturbances. Righ bundle branch block was usually transient and was not associated with further complications in the follow-up period. However, patients with either transient or persistent left bundle branch block or left anterior hemiblock, or both, had (1) increased later mortality compared with patients without new fascicular conduction disturbances (5 of 26 versus 11 of 161; P less than 0.02), and (2) increased late myocardial infarction (2 of 26 versus 2 of 161; P less than 0.05). New left fascicular conduction disturbances after coronary surgery identified a subset of patients with more extensive ischemic heart disease, suggesting that these patients require close follow-up care.

Acute severe aortic regurgitation. Pathophysiology, clinical recognition, and management.

Acute severe aortic regurgitation is a relatively unfamiliar, though life-threatening, disease. We review its diverse causes, anatomic faults, and hemodynamic sequelae and set the stage for an understanding of the clinical manifestations in light of their physiologic mechanisms. Clinical information includes the natural history, physical signs (physical appearance, systemic arterial pulse, jugular venous pulse, precordial palpation, auscultation), electrocardiogram, and chest roentgenogram. Echocardiographic features are especially emphasized and the need for prompt diagnosis and surgical intervention underscored, even in the setting of active infective endocarditis.

Tissue factor (thromboplastin): localization to plasma membranes by peroxidase-conjugated antibodies.

Peroxidase-conjugated antibodies were used to determine the histologic and cytologic localization of bovine and human tissue factor (thromboplastin). Tissue factor antigen was found in highest concentration in the intima of blood vessels, particularly in the plasma membranes of endothelial cells and in human atheromatous plaques. Tissue factor was also found limited to the plasma membranes of many cell types. The presence of tissue factor in the plasma membranes of endothelial cells and atheromata suggests that it may play a significant role in hemostasis and thrombosis.