Transthoracic electrical bioimpedence cardiac output: comparison with multigated equillibrium radionuclide cardiography.

INTRODUCTION: Thoracic electrical bioimpedance (TEB) for measuring cardiac output (CO) is being explored increasingly as an alternative to pulmonary artery catheter. The major advantage of this technology is that it is non-invasive and easy to perform. Several studies have compared it to thermodilution cardiac output using PA catheter, with variable correlation. Multigated radionuclide equilibrium cardiography (RNEC) method of cardiac output measurement is known to be reliable. OBJECTIVE: To compare cardiac output measured by thoracic electrical bioimpdenace with that measured by multigated radionuclide equilibrium cardiography. PATIENTS AND METHODS: CO studies were performed sequentially at a single sitting by TEB and RNEC methods among patients with cardiac symptoms referred for radionuclide study as part of their evaluation. TEB CO was measured by placing two pairs of electrodes on either side of neck and two other pairs on either side of the lower chest. Stroke volume was estimated from the sequential changes in transthoracic electrical bioimpedance induced by rhythmic aortic blood flow, using Kubicek equation. RNEC-CO was measured by intravenous injection of radio-active Technitium-tagged RBCs followed by ECG gated blood pool imaging over the chest (MUGA study). Bland-Altman analysis was used to compare the measurements. RESULTS: A total of 32 subjects with proven or suspected ischemic heart disease, but without overt cardiac failure, edema or arrhythmias were studied (M:F::26:6; mean age: 48 +/- 12 years). The mean TEB-CO was 3.54 +/- 1.052 l/min and mean RNEC-CO was 3.907 +/- 0.952 l/min. Correlation coefficient (r) for these measurements was 0.67 (p < 0.01), with bias: -0.421 l/min; precision: 1.557 l/min; and percentage error of measurement: 42.35%. CONCLUSIONS: This study observed a moderate correlation between TEB and RNEC methods of CO measurement. Further studies are indicated to explore the relative utility of TEB in comparison with RNEC as well as other methods of CO measurement before considering its use in patients with ischemic heart disease.

Non-invasive cardiac output by transthoracic electrical bioimpedence in post-cardiac surgery patients: comparison with thermodilution method.

OBJECTIVE: Thoracic electrical bioimpedance (TEB) cardiac output (CO) is being explored increasingly as a non-invasive alternative to the pulmonary artery catheter (PAC). This study compared TEB-CO measured using a new instrument--NICOMON (Larsen & Toubro Ltd. India) with thermodilution (Td) CO in post-cardiac surgery patients. METHODS: Postoperative cardiac surgical patients requiring a PAC for their management were studied. TEB-CO was measured by passing a 4 mA RMS alternating current across the chest and measuring the analog bioimpedence across the thorax. Kubicek equation was used to estimate TEB-CO. Td-CO was measured using a PAC. Bland-Altman analysis was used to compare paired data. RESULTS: One hundred and ninety-seven pairs of CO measurements were made by the two methods among 35 patients. Mean TEB-CO was 5.15 +/- 1.27 l/min and mean Td-CO was 5.22 +/- 1.28 l/min. Pearson correlation coefficient (r) for these measurements was 0.856 (P < 0.01), with bias -0.0651 l and precision: +/-1.37 l/min. The percentage error of measurement of this precision was 26.44%. Cardiac index also correlated among the two methods (r = 0.789; P = 0.01). CONCLUSIONS: Thoracic electrical bioimpedance cardiac output compares favorably with thermodilution method among post-cardiac surgery patients. Further studies are indi- cated with this instrument to validate its efficacy in various clinical situations and utility in monitoring hemodynamic interventions.

Raised serum IgE levels in chronic inflammatory lung diseases.

OBJECTIVE: To study the serum IgE response in nonallergic subjects with chronic inflammatory lung diseases. SETTING: Christian Medical College Hospital, Vellore. SUBJECTS: Twenty six patients with bronchiectasis, five with pulmonary mycosis referred from all over India and 30 healthy subjects. MAIN OUTCOME MEASURES: Serum IgE value (determined by radioimmuno assay) above the upper limit of normal control range (136 to 948 iu/ml) was considered as raised level. RESULTS: Of the 26 patients with bronchiectasis 13 had pyogenic infections, six had pulmonary tuberculosis; in six patients sputum culture was sterile while another patient had herpes zoster. Five cases of mycosis included one each of actinomycosis, aspergillosis, blastomycosis, cryptococcosis and nocardiasis. The serum IgE levels were raised in 20 (65%) of the 31 patients. CONCLUSION: Associated bacterial, fungal and parasitic infections were probably responsible for inducing an hyper-IgE response in these non-allergic subjects.

alpha 1-Antitrypsin deficiency in Indian patients with chronic obstructive airways and other pulmonary diseases.

OBJECTIVE: To determine alpha 1-antitrypsin (A1AT) deficiency in patients with chronic obstructive airways disease (COAD) and other pulmonary diseases. DESIGN: Observation study. SUBJECTS: 45 patients with COAD, 20 with bronchiectasis, 11 with pulmonary tuberculosis, 25 with chest malignancies and 42 healthy subjects. SETTING: Christian Medical College Hospital, Vellore, India. MAIN OUTCOME MEASURE: Serum A1AT level of 10% or less of the mean serum value of the control group was recognised as severe deficiency and A1AT level between 10 and 60% was considered as intermediate deficiency. RESULTS: 26 patients (18 with COAD, 2 with bronchiectasis, 3 with tuberculosis and 3 with chest malignancies) had intermediate A1AT deficiency. CONCLUSION: The finding of an A1AT deficiency in over a quarter of the patients comprising various categories of pulmonary diseases emphasises the need to explore the possibility of an underlying acquired cause existing either alone or in association with genetic defect in patients showing such a deficiency.

Chest malignancies & serum immunoglobulin E.

Serum IgE levels were measured by the radioimmunoassay technique in the sera of 53 patients with neoplastic chest diseases. Forty seven patients had malignant chest tumours and another 6 had benign tumours or mediastinal cysts. They included 33 smokers and 20 non-smokers. For comparison, 30 normal non-smoking controls matched for age and sex were included. The serum IgE levels in patients with chest malignancies showed an increase as compared to controls. The IgE levels increased significantly in adenocarcinoma (P < 0.01) and squamous cell carcinoma (P < 0.001), while they were not raised in poorly differentiated carcinoma. There was no significant difference between the serum IgE levels of 32 smokers and 15 non-smokers with malignant chest tumours.

Clinical spectrum of pulmonary hydatidosis and raised serum IgE levels in the Indian southern peninsula.

Fifteen patients with surgically proven hydatid disease of the lung aged between 4 and 51 years were studied. The disease spectrum varied from single to multiple cysts of different sizes, with associated pyogenic chest infections or parasitic infestations of the gut. The serum IgE level varied widely in these cases and very high levels were found in 60% of the patients. This high IgE response was related to the vitality of the cysts, associated bacterial infection of the chest, infection with helminths and smoking habit.

Mitral valve replacement for an annular submitral aneurysm of the left ventricle.

Successful surgical repair of an annular submitral aneurysm of the left ventricle in two patients is described. In both cases the diagnosis was made at surgery and they were treated successfully by transatrial closure of the aneurysm with Teflon felted sutures and mitral valve replacement. This is the first report of the use of mitral valve replacement for this condition.

Unruptured aneurysm of the sinus of Valsalva: a potential source of cerebrovascular embolism.

An unruptured aneurysm of the right sinus of Valsalva with intraluminal thrombus that displaced the right coronary artery ostium was diagnosed in a 30 year old Omani man who was investigated for uncontrolled grand mal epilepsy and residual left hemiparesis caused by occlusion of the right middle cerebral artery. Surgical intra-aortic closure of the aneurysm, which necessitated a saphenous vein graft to the right coronary artery, was successful. An aneurysm of the sinus of Valsalva is an unusual cause of a thromboembolic cerebrovascular accident.

Giant emphysematous bullae of the lung.

Emphysematous bullae may at times assume large proportions. We report a case of symptomatic giant bullae in a female which were removed surgically. The relevant literature has also been reviewed.

Interrupted aortic arch with tetralogy of Fallot. A report of an unsuccessful surgically treated case.

Interrupted aortic arch is a complete discontinuity of two segments of the aorta. Although associated with a number of conditions, it does not occur in association with pulmonary stenosis. We report a case unsuccessfully treated but from which we have learnt a lesson.

Surgical management of coarctation of aorta.

Between 1961 and 1988, 68 patients underwent operation for coarctation of the aorta. The average age of presentation of these subjects was higher than in other series. 7.1 percent were asymptomatic, a finding which is not seen in reports from the west. Operative procedures included resection and end to end anastomosis, resection and graft interposition, bypass grafting, patch aortoplasty and subclavian flap aortoplasty. However, the technique of patch aortoplasty, routinely performed in the last 24 years of this series seemed by far the most satisfactory procedure. Subclavian flap aortoplasty was carried out in a selected group of younger children. Associated cardiac anomalies influenced the results adversely. The overall operative mortality was 5.8 percent. Hypertension did not regress in 11.7 per cent of patients inspite of a successful operation as judged by the return of peripheral pulses in the lower limbs. Re-coarctation was not seen in this series. The overall results of operation for coarctation of the aorta have been very satisfactory and comparable with those in other published series.

A bypass technique for aneurysms of descending aorta.

Uniformity of opinion does not exist regarding optimal surgical strategy for descending aortic aneurysms. We present a surgical technique for bypass during aortic cross clamp while operating on such aneurysms. Five patients have undergone surgery using this technique. All of them are alive, doing well with no complications.

Valve replacement in the young patient with rheumatic heart disease. Review of a twenty-year experience.

During a 20-year period 303 young subjects between 9 and 20 years of age (mean, 16.2 +/- 2.72 years) with rapid and relentlessly progressive valvular disease from rheumatic fever underwent valve replacements. The Starr-Edwards ball valve prosthesis remains the device of choice, although other valves have been implanted. The overall hospital mortality rate was 9.6% in the mitral valve, 3.5% in the aortic valve, and 4.2% in the double valve replacement groups. Actuarial survival at 10, 15, and 20 years was 78.4% (+/- 3.3%), 70.0% (+/- 5.8%), and 59.3% (+/- 11.1%), respectively, for patients with mitral valve replacement. The rates for aortic valve replacement were 85.9% (+/- 4.6%) at 10 and 15 years and 72.7% (12.8%) at 20 years. In the double valve replacement group the survival rates after 5 and 10 years were 79.9% (+/- 5.1%). The incidence of thromboembolism was 0.41, 0.59, and 1.04 per 100 patient-years for the mitral, aortic, and double-valve prostheses, respectively. The prospect of childbearing seems promising in those young women who were subsequently married. Our favorable and gratifying experience in this review bears testimony to the physiologic advantages of the Starr-Edwards valve as the device of choice in the rehabilitation of patients with advanced and severe valvular disease after rheumatic fever.

Closed mitral valvotomy in the older subject. Results in 367 consecutive patients.

To determine the safety, efficacy, operative mortality, and long-term results, we reviewed 367 patients with mitral stenosis above the age of 40 who underwent mitral valvotomy. In this study, the majority of the subjects belonged to functional Class III and IV (97%) of the New York Heart Association (NYHA). Atrial fibrillation was associated in 38 percent and mitral valve calcification in 24 percent. The hospital mortality was 6.3 percent. Only 1 patient developed severe mitral regurgitation requiring emergency valve replacement. Early postoperative embolism occurred in only 1% of those who were in atrial fibrillation and had preoperative anticoagulation. Long-term results indicate an 85.6 percent survival at the end of 24 years with a very low incidence of restenosis. Late death occurred in 4.6%. These findings support our continuing experience and impression that closed transventricular valvotomy remains the most effective palliative operation in the treatment of most patients with mitral stenosis. With the increasing need for cost containment in health care, this technique of closed transventricular valvotomy assumes even greater importance.

Iliac aneurysmo-colonic fistula. A case report and review of literature.

A case of a 47 year old man with an aneurysmo colonic fistula is presented. This rare complication presents problems in diagnosis and management. The presentation of this case and operative management without the use of a graft is discussed along with a review of literature.

Relapsing polychondritis--a case report and review of literature.

A case of relapsing polychondritis with aortic aneurysm is presented and relevant literature reviewed. Only one case of relapsing polychondritis has been previously reported in Indian literature. Increased awareness of this relatively rare, multi-system disease is warranted, to facilitate the diagnosis.

Early and late results of pericardiectomy in 118 cases of constrictive pericarditis.

The medical records of 118 patients (86 male, 32 female, age 10-50 (mean 27) years) who underwent pericardiectomy for constrictive pericarditis at the Christian Medical College Hospital, Vellore, from 1954 to 1985 were reviewed. All had appreciable pericardial constriction. Preoperatively 97 of the 118 were in class III or IV of the New York Heart Association classification and 100 had peripheral oedema or ascites. Tuberculosis was proved as the cause in 72 patients. Pericardiectomy was accomplished through a standard anterolateral thoracotomy (107 cases), median sternotomy (3 cases), or bilateral thoracotomy (8 cases). Postoperatively an apparent low cardiac output state was seen in 34 patients, 12 of whom died. Hospital mortality in the last 12 years was 11%. Mortality was higher in NYHA class III and IV patients. The improved surgical results recently may be related to increased use of inotropic support and prolonged ventilation. At follow up there were 72 patients in whom functional capacity could be assessed; 63 were in class I or II. The poor results of pericardiectomy in some patients are likely to be related to advanced preoperative disability and early pericardiectomy is therefore recommended.

Coexistent mitral valve disease with left-to-right shunt at the atrial level: clinical profile, hemodynamics, and surgical considerations in 67 consecutive patients.

Between January, 1963, and June, 1985, 67 patients underwent corrective surgery for this complex anomaly. Symptoms and signs of atrial septal defect were dominant in the majority of subjects. History of rheumatic fever (46%), paroxysmal nocturnal dyspnea (33%), presence of an opening snap, mitral diastolic murmur, or pansystolic murmur provided clinical clues to document associated mitral valve disease. Open mitral valvotomy was accomplished in 39 subjects, while in the remainder (28 subjects) the valve required replacement. Partial anomalous venous connection was encountered in 12 subjects. Recognition and attention to the associated tricuspid incompetence is a high priority, and 21 subjects underwent concomitant annuloplasty. The overall hospital mortality was 13.4%, with no deaths in the last 22 consecutive patients. The period of follow-up ranged from 1 year to 22 years, with a mean +/- SD of 9.34 +/- 6.61 years. We believe, with other authors, that since the hemodynamic and therapeutic considerations are very similar, both the stenotic and regurgitant lesions should be included in the same syndrome.

Development of a coagglutination (COA) technic to detect Candida antigenemia. I. COA versus Candida isolation.

A coagglutination (COA) test to detect Candida antigenemia was developed using locally produced Candida antiserum and COA reagent. All 68 controls had normal results. Two patient groups were included in this study. In Group 1, consisting of eight patients, with definite systemic or deep candidiasis proved by repeat Candida isolation, COA detected antigenemia in 100% as against 50% by counterimmunoelectrophoresis (CIE). In Group 2, 9 of 19 patients had respiratory infection; 4 patients revealed antigenemia by COA, 2 of whom had no Candida isolation. In these 2 patients therapy was initiated based on COA results. Of another nine patients with hematologic and malignant diseases, five (56%) revealed antigenemia by COA, three of whom had no Candida isolation; two died and one was discharged against advice. Transient antigenemia was detected by COA in a single patient with ulcerative colitis with Candida isolation. Thus, the COA test was found to be rapid, sensitive, and specific for the detection of Candida antigenemia. Furthermore, it had early diagnostic (seven days) as well as prognostic value, as revealed by response to therapy and decrease in COA titer. Being highly cost effective, this test is recommended as a simple test within the reach of any routine diagnostic laboratory.