Use of continuous-wave Doppler ultrasound to evaluate and manage primary pulmonary hypertension.

Doppler ultrasound was used to assess the response to serial drug testing in a patient with primary pulmonary hypertension. There was a close correlation between the pressure estimated by Doppler and the pulmonary arterial systolic pressure measured invasively (r = 0.98). Continuous-wave Doppler ultrasound, although not a substitute for initial Swan-Ganz catheterization, may obviate the need for repeat invasive procedures and permit closer monitoring of patients during treatment.

Quantitative assessment of pulmonary hypertension in patients with tricuspid regurgitation using continuous wave Doppler ultrasound.

Doppler ultrasound examination was performed in 69 patients with a variety of cardiopulmonary disorders who were undergoing bedside right heart catheterization. Patients were classified into two groups on the basis of hemodynamic findings. Group I consisted of 20 patients whose pulmonary artery systolic pressure was less than 35 mm Hg and Group II consisted of 49 patients whose pulmonary artery systolic pressure was 35 mm Hg or greater. Tricuspid regurgitation was detected by Doppler ultrasound in 2 of 20 Group I patients and 39 of 49 Group II patients (p less than 0.001). Twenty-six of 27 patients with pulmonary artery systolic pressure greater than 50 mm Hg had Doppler evidence of tricuspid regurgitation. In patients with tricuspid regurgitation, continuous wave Doppler ultrasound was used to measure the velocity of the regurgitant jet, and by applying the Bernoulli equation, the peak pressure gradient between the right ventricle and right atrium was calculated. There was a close correlation between the Doppler gradient and the pulmonary artery systolic pressure measured by cardiac catheterization (r = 0.97, standard error of the estimate = 4.9 mm Hg). Estimating the right atrial pressure clinically and adding it to the Doppler-determined right ventricular to right atrial pressure gradient was not necessary to achieve accurate results. These findings indicate that tricuspid regurgitation can be identified by Doppler ultrasound in a large proportion of patients with pulmonary hypertension, especially when the pulmonary artery pressure exceeds 50 mm Hg. Calculation of the right ventricular to right atrial pressure gradient in these patients provides an accurate noninvasive estimate of pulmonary artery systolic pressure.

Evaluation of aortic stenosis by continuous wave Doppler ultrasound.

Twenty-four patients with suspected aortic stenosis (Group I) were evaluated noninvasively by continuous wave Doppler ultrasound before undergoing cardiac catheterization. Twenty normal subjects served as the control group (Group II). Maximal velocity measurements in the ascending aorta ranged from 3.0 to 5.8 m/s (mean 4.34 +/- 0.65) in Group I versus 1.0 to 1.6 m/s (mean 1.28 +/- 0.16) in Group II (p less than 0.001). Using the Bernoulli equation, the peak pressure gradient across the aortic valve was calculated from the maximal velocity in the Group I patients. The results correlated well with the peak aortic valve gradient obtained at cardiac catheterization (r = 0.79). In 20 of these 24 patients, the peak Doppler gradient was within 25% of the gradient found at cardiac catheterization. In three patients, the Doppler study under-estimated the gradient by slightly more than 25% but still detected the presence of significant aortic stenosis. The Doppler technique failed to detect critical aortic stenosis in only one patient. Significant overestimation of the gradient by Doppler measurement did not occur in any patient. The technique was particularly helpful in older patients in whom other noninvasive tests often yield inconclusive results. An important but infrequent limitation of the technique is underestimation of the gradient that occurs when the angle of incidence between the ultrasound beam and aortic blood flow is too large. The findings indicate that continuous wave Doppler ultrasound provides a reliable estimate of the valvular gradient in most patients with aortic stenosis.

Intrapericardial instillation of sodium hydroxide: failure to produce pericardial symphysis.

Previously reported clinical studies have suggested sodium hydroxide as an effective agent in causing pleural symphysis. To explore the sclerosing potential of this agent, we instilled 0.5% sodium hydroxide into the pericardium of four dogs. Normal saline was instilled into the pericardium of one control dog. Echocardiograms, 24 hour EKG monitoring and intracardiac pressures were recorded. One dog was sacrificed at the end of 24 hours, another at the end of seven days and three other dogs were sacrificed at the end of 28 days. ST elevations and prolonged episodes of supra-ventricular and ventricular tachycardia were noted during and within 24 hours after the intrapericardial instillation of sodium hydroxide in all the dogs. No arrhythmias were noted in the control dog. None of the dogs showed pericardial symphysis. These results suggest that sodium hydroxide causes serious cardiac arrhythmias when instilled intrapericardially and is of limited value in causing pericardial symphysis.

Left ventricular outflow obstruction after aortic valve replacement: detection with continuous wave Doppler ultrasound recording.

A 33 year old woman developed left ventricular outflow obstruction due to a fibrous subvalvular membrane 2 years after insertion of a Hancock modified orifice, porcine aortic valve prosthesis. M-mode and two-dimensional echocardiographic studies failed to detect the membrane. Continuous wave Doppler study revealed a maximal velocity of 4.8 m/s and a calculated peak pressure gradient of 92 mm Hg between the left ventricle and aorta. This finding was in close agreement with the peak gradient of 100 mm Hg obtained at cardiac catheterization. Because of its ability to accurately measure valvular gradients, continuous wave Doppler ultrasound study appears to be a useful noninvasive technique in the evaluation of patients with suspected prosthetic valve dysfunction.

Devic's syndrome and systemic lupus erythematosus: a case report with necropsy.

Systemic lupus erythematosus (SLE) rarely occurs coincident with demyelinating disease and, to our knowledge, only one previous case of Devic's syndrome with SLE has been reported.

Severe mycoplasma pneumonia with pleural effusions in a patient with sickle cell-hemoglobin C(SC) disease. Case report and review of the literature.

We describe a patient with sickle cell hemoglobin C(SC) disease in whom severe pneumonia developed complicated by large bilateral pleural effusions and respiratory failure. Mycoplasma infection was not initially suspected but was subsequently proved serologically. The course of the illness was unusually long. A review of the literature showed occurrence of large pleural effusions to be infrequent for pulmonary infection with Mycoplasma in adults, with only eight such cases previously reported. The possibility of Mycoplasma pneumonia should not be dismissed merely because of the severity of the illness or the presence of pleural effusions.