Spontaneous coronary artery dissection in patients with renal transplantation.

We describe two patients with spontaneous coronary artery dissection (SCAD) while on immunosuppressive therapy following renal transplantation. The role of cyclosporine A as a potential etiologic factor in spontaneous coronary artery dissection is discussed. A review of the recent literature on spontaneous coronary artery dissection highlights the changing clinical presentation and management of these patients.

Mitral valve resistance as a hemodynamic indicator in mitral stenosis.

Variability of the valve area calculated by the Gorlin formula has been noted in bioprosthetic and aortic valves, but few data are available for native stenotic mitral valves. Valve resistance has been proposed as an alternative hemodynamic indicator; however, its value in mitral stenosis has not been assessed. Thirty-four patients had simultaneous recordings of left atrial and ventricular pressures, 26 after percutaneous balloon mitral dilatation (PBMD). Patients with shunt or mitral regurgitation were excluded. Mitral valve resistance correlated exponentially with Gorlin mitral area (y = 133*[area]-1.5; p less than 0.0001). Both Gorlin mitral area and mitral resistance improved after PBMD (0.89 +/- 0.07 cm2 to 2.22 +/- 0.15 cm2; p less than 0.001; and 166 +/- 20 to 40 +/- 8 dynes.s.cm-5; p less than 0.001). Gorlin area and mitral resistance correlated with New York Heart Association functional class. After infusion of isoproterenol in 17 patients, there was an increase in Gorlin area (baseline 1.77 +/- 0.22 cm2, change 0.23 +/- 0.10; p less than 0.03), whereas mitral resistance did not change (baseline 96 +/- 16 dynes.s.cm-5, change 2 +/- 5; p = not significant). Mitral resistance is valuable in the assessment of mitral stenosis. It varies less than Gorlin mitral area under changing hemodynamic conditions.

Plasma hormones in patients with chronic heart failure before and early after orthotopic heart transplantation.

The aim of this prospective study was to investigate both vasoconstricting and vasodilating plasma hormones and plasma factors regulating the circulatory homeostasis in patients with endstage congestive heart failure before and early after orthotopic heart transplantation and to evaluate factors which may influence their regulation. 19 patients with endstage congestive heart failure were analyzed serially before and 3-4 weeks after orthotopic heart transplantation. A significant decrease in plasma concentrations of noradrenaline (457 +/- 202 vs. 204 +/- 88 pg/ml; p less than 0.001), adrenaline (43 +/- 32 vs. 26 +/- 11 pg/ml), atrial natriuretic peptide (341 +/- 218 vs. 139 +/- 64 pg/ml; p less than 0.005), cyclic guanosine monophosphate (13.8 +/- 7.8 vs. 6.6 +/- 2.2 pmol/ml, p less than 0.05) and in plasma renin activity (16.6 +/- 13.0 vs. 2.0 +/- 2.4 ng AI/ml/h; p less than 0.01) was found after transplantation. The data indicate that the marked increase in plasma catecholamine concentrations and renin activity in endstage congestive heart failure is reversible as early as 3-4 weeks after heart transplantation. This is most likely the consequence of normalization of cardiac function. While elevation of atrial natriuretic peptide and cyclic guanosine monophosphate as well as increased vasoconstrictor activity in heart failure appear to be related to impaired ventricular function, the persistent moderate elevation of both vasodilating agents after transplantation may be compensatory to counteract cyclosporin-induced arterial hypertension after heart transplantation.

Increased incidence of cholelithiasis in heart transplant recipients receiving cyclosporine therapy.

The introduction of cyclosporine to immunosuppressive therapy greatly improved the results of organ transplantation. The clinical use of cyclosporine, however, is associated with several serious side effects. Because the drug is primarily eliminated via biliary secretion and thus probably alters bile composition, we investigated the incidence of gallstones in 29 heart transplant recipients receiving immunosuppressive therapy with cyclosporine. Two of three female patients and none of the male patients had gallstones before heart transplantation. After operation, in nine of the 26 male patients cholelithiasis developed during cyclosporine therapy; seven cases of gallstones occurred within the first postoperative year. High cyclosporine blood levels, obesity, and diabetes mellitus in the early postoperative period appeared to be predisposing factors for formation of gallstones. Prevention of biliary calculous disease in heart transplant recipients is especially important because immunosuppressive therapy poses an additional risk on potential complications of cholelithiasis. An immunosuppressive regimen aimed at lower cyclosporine blood levels may help to avoid hepatobiliary complications.

Correlation of continuous-wave Doppler assessment of chronic aortic regurgitation with hemodynamics and angiography.

Fifteen patients with chronic aortic regurgitation (AR) were studied by cardiac catheterization and continuous-wave (CW) Doppler echocardiography. The slope of the AR CW Doppler signal was higher in patients with severe AR (5.7 +/- 2.1 m/s2) than in those with moderate (2.5 +/- 1.3 m/s2) or mild (1.8 +/- 0.7 m/s2) AR (p less than 0.05). The slopes in patients with mild (less than or equal to 18 mm Hg), moderate (19 to 24 mm Hg) and severe (greater than 24 mm Hg) elevation of left ventricular end-diastolic pressure were significantly different (1.9 +/- 0.6, 3.3 +/- 1.2 and 7.1 +/- 0.4 m/s2, respectively, p less than 0.05). Patients with severe AR had shorter pressure half-times than those with mild AR (283 +/- 141 vs 820 +/- 393 ms, p less than 0.05). There was a significant correlation between the slope and left ventricular end-diastolic pressure (r = 0.80, p less than 0.001) and a weaker inverse correlation between pressure half-time and left ventricular end-diastolic pressure (r = -0.59, p less than 0.05). The end-diastolic pressure gradient estimated from CW Doppler using a simplified Bernoulli equation correlated poorly with the catheter measured gradient (r = 0.59, p less than 0.02). The slope of the CW Doppler signal is a better predictor of severity than pressure half-time and is affected by left ventricular end-diastolic pressure in addition to angiographic severity of AR.

A method for repositioning or extraction of lacrimal system silicone tubes.

A method of repositioning extruding silicone tubes is described by reintubation with a second Crawford intubation set. The method and indications are described.