A rare case of multiple right heart myxomas.

Primary tumours of the heart are rare. Myxomas are the most common primary cardiac tumours with an estimated incidence of 0.5 per million population per year. Myxomas are most commonly found in left atrium and are solitary in more than 90% cases. Familial myxomas are rarer and tend to be multiple. We report a rare case of multiple myxomas in the right heart which occurred sporadically, presenting with an episode of pre-syncope.

Derivation and validation of a clinical scoring system to predict the need for an intra-aortic balloon pump in patients undergoing adult cardiac surgery.

The spectrum of patients receiving cardiac surgery are increasing in age and severity of illness. With the reduction of complications caused by the placement of an intra-aortic balloon pump (IABP) there is increasing interest in the placement of an IABP prophylactically. We sought to derive a scoring system to guide the placement of IABPs. A total of 3927 patients from the Blackpool Victoria Open Heart Registry were used to derive a range of clinical decision scores using a range of established and novel statistical techniques. This database included 127 patients who received an IABP. The derived scores and rules were then validated on the North Staffordshire Open Heart Registry, containing 3070 patients, and 161 patients who received an IABP. We derived and validated a clinical score that has a sensitivity of 50% and a specificity of 96.5% in the prediction of those patients requiring an IABP. This was robust in the validation dataset and outperformed the Parsonnet score in this context. Our validated clinical scoring system will be useful both to guide individual clinical decision making and to compare variation of IABP usage among institutions.

Angiotensin converting enzyme (ACE) gene expression in the human left ventricle: effect of ACE gene insertion/deletion polymorphism and left ventricular function.

AIMS: We investigated the effect of the angiotensin converting enzyme (ACE) I/D polymorphism and left ventricular (LV) function on ACE gene expression in tru-cut LV myocardial biopsies from 50 consecutive patients (II: 18, ID: 18, DD: 14; 40 males) with ischaemic heart disease undergoing coronary artery bypass grafting (CABG). METHODS: The polymerase chain reaction was used for ACE genotyping. LV function [normal (n=22) or impaired] was determined by left ventriculography at cardiac catheterisation prior to bypass surgery. ACE expression was determined (n=46) by a competitive quantitative reverse transcription PCR assay using 5x10(5), 12. 5x10(5) and 20x10(5) copies of a mutant DNA internal standard (IS). PCR products were analysed by negative film photography and laser densitometry to determine the number of ACE transcripts present. RESULTS: Mean age was similar (II: 59.1+/-10.4, ID: 57.0+/-10.6, DD: 61.4+/-6.2; P=NS) with no differences between groups in sex (P=0. 25); hypertension, P=0.31; previous myocardial infarction, P=0.44; LV function, P=0.23; and ACE inhibitor therapy, P=0.06. ACE expression per 100 ng of total RNA varied with genotype [<5x10(5) copies in II: 6, 5-12.5x10(5) copies in II: 6, ID: 16, DD: 4; and >12.5x10(5) (II: 4, ID: 2, DD: 8), Kendall's tau-b coefficient (tau(b))=0.43, P=0.003]. Impaired LV function also correlated with higher levels of ACE expression, Kendall's tau(b)=0.40, P=0.001. CONCLUSION: ACE gene expression in the left ventricle varied with ACE genotype and LV function in IHD patients undergoing CABG.

Acute renal failure after cardiopulmonary bypass: a possible association with drugs of the fibrate group.

BACKGROUND: Renal failure is a recognized, but infrequent, complication following cardiac surgery. The causes for this condition are multifactorial, and a major concern is that the occurrence of postoperative acute renal failure is still associated with a high mortality rate. METHODS AND MATERIALS: We report unexpected acute renal failure occurring in 4 patients after uncomplicated cardiac surgery. Each patient was taking a fibric acid derivative at the time of surgery. Renal failure occurred rapidly within 3 days of surgery and was associated with increased concentrations of skeletal muscle-derived creatine kinase (CK). One patient developed myoglobinuria, and another developed a malignant hyperthermia-like syndrome. CONCLUSIONS: These cases show that patients receiving lipid lowering medications could be at higher risk of developing acute renal failure after cardiac surgery. This association merits careful evaluation in large prospective studies and, if proved, would suggest that patients taking either statins or fibrates should discontinue doing so before cardiac surgery.

Direct measurement of sound velocity in various specimens of breast tissue.

RATIONALE AND OBJECTIVES: Previous studies using ultrasound CT or clinical amplitude/velocity reconstruction imaging ultrasound may indicate that cancers differ from normal breast tissue by increased sound velocity. However, only limited experience with direct measurements of sound velocity exists. This study aimed to investigate sound velocity measured directly in a variety of breast specimens. METHODS: Sound velocity was measured directly by forceps in fresh breast specimens chosen to contain one type of tissue only. Eighty specimens (31 cancers, 18 benign changes of glandular/fibrous tissue, 22 fatty tissues, 5 fibroadenomas, 2 compound tissues, 1 phylloides tumor, and 1 inflammation) were analyzed. RESULTS: Ultrasound velocities in carcinoma, benign changes, fibroadenoma, inflammation, and the phylloides tumor were very similar, with almost complete overlap. In contrary, the ultrasound velocity of fatty tissue was significantly lower. Compound tissues containing fat had an intermediate sound velocity. CONCLUSIONS: Sound velocity may add complementary information to echogenicity (B-scan). Because fat lobules exhibit low ultrasound velocity and carcinomas do not, a locally exact combination of ultrasound velocity information and reflexivity information should allow improved breast cancer detection by ultrasound.

[Direct in-vitro measurement of ultrasound velocity in carcinomas, mastopathic tissue, fatty tissue and fibroadenomas of the female breast]. / Direkte In-vitro-Messung der Ultraschallgeschwindigkeit in Karzinomen, mastopathischem Gewebe, Fettgewebe und Fibroadenomen der weiblichen Brustdrüse.

PURPOSE: The study aimed to investigate ultrasound velocity (SV) in carcinomas, fibrocystic changes, fibroadenomas and fatty tissue of the female breast by means of direct in-vitro measurements. We intended to test whether or not differences in SV exist between the various types of tissue and whether the SV is a useful criterion to differentiate the different tissues. METHOD: SV was measured by comparing transmission time of the ultrasound beam through the specimen and through water. Altogether 40 specimens (12 cancer, 14 fibrocystic changes = FCD, 10 fatty tissues, 3 fibroadenomas, and 1 mixed tissue) were analysed. RESULTS: Velocity differed significantly between fat (1478.5 +/- 6.5 m/s) and tumor (1523.1 +/- 5.9 m/s) (p approximately 10(-11)) and between fat and FCD (1526.0 +/- 9.0 m/s) (p approximately 10(-12)). No significant differences and much overlap were seen between the ultrasound velocities of tumors and FCD. Ultrasound velocity in fibroadenomas (1533.2 +/- 3.8 m/s) was comparable with that in carcinomas and FCD. CONCLUSIONS: We conclude that ultrasound velocity may add complementary information to echogenicity (B-scan). Thus, a locally exact correlation of echogenicity and sound velocity might allow for an improved tissue characterization.

Transesophageal echocardiographic detection of complications after Cabrol's procedure.

Cabrol's procedure represents an improvement on earlier surgical techniques used in the management of a patient with aortic insufficiency associated with an aneurysm of the ascending aorta. We report a patient in whom the diagnosis of complications after a Cabrol procedure was facilitated by transesophageal echocardiography. The role of transesophageal echocardiography in the follow-up of these patients is discussed.

Neoplastic angina: a case report.

A 54-year-old Caucasian woman, with a 1-year history of exertional angina was investigated by means of coronary angiography. On injection of contrast into both coronary arteries an unusual area of capillary blushing was seen around the point of a left main stem stenosis. At surgery a mass was seen arising from the area of the aortic root extending around the left main stem. Histology confirmed this to be an aortic paraganglioma. Three-vessel coronary artery bypass grafting was performed and at 6-month follow-up the patient remained symptom free.

Effects of ultrasound on agglutination and aggregation of human erythrocytes in vitro.

A new experimental approach has shown that human erythrocytes of different blood groups were induced to form more agglutinates at a sound pressure of 70-240 kPa in vitro than the control erythrocytes. Similar effects were observed for alcian blue and dextran stimulated aggregation and for spontaneous aggregation. The increase of agglutination or aggregation was reversible. Heating and acoustic cavitation were shown not to be responsible for this effect. Bulk fluid movement produced by ultrasound irradiation appeared to cause the described phenomenon. Possible underlying mechanisms connecting the acoustic streaming and agglutination or aggregation behaviour of the cells are proposed.

Dynamic cardiomyoplasty in chronic left ventricular failure: an experimental model.

Dynamic cardiomyoplasty continues to attract interest as a therapeutic option in the management of heart failure. In a large animal model of ischemic heart failure, we have compared dynamic cardiomyoplasty with both adynamic cardiomyoplasty and a control group. Heart failure was induced by coronary artery ligation in sheep, and under the same anesthetic dynamic cardiomyoplasty (n = 5), adynamic cardiomyoplasty (n = 4), or no further procedure was performed (n = 5). After recovery the animals were housed for a further 3 months. The dynamic cardiomyoplasty underwent a recognized muscle transformation protocol during this period. At terminal studies, the animals were hemodynamically assessed, both under baseline conditions and after colloid volume loading. The data at baseline were compared with unpaired t tests, and the function curves created by volume loading were compared by analysis of variance. Although the changes at baseline were small, there were highly significant improvements in the function curves in the dynamic cardiomyoplasty group when the stimulators were turned on compared with stimulators off (p = 0.005) for cardiac output; p = 0.035 for left ventricular end-diastolic pressure; p = 0.002 for pulmonary artery capillary wedge pressure; p = 0.004 for stroke volume; and p = 0.003 for cardiac power). There were also significant improvements in indices of cardiac performance when the dynamic cardiomyoplasty group was compared with both the control and adynamic cardiomyoplasty groups. We conclude that there is experimental evidence that cardiomyoplasty augments cardiac function in a model of chronic left ventricular failure.

Effects of ultrasound on the steady-state transmembrane pH gradient and the permeability of acetic acid through bilayer lipid membranes.

The irradiation of bilayer lipid membranes with continuous ultrasound of a frequency of 8.2 MHz and a spacial peak time average (SPTA) intensity of 0.4 W/cm2 reduces the thickness of the unstirred layer up to 40% of its initial value under our conditions. This result was obtained from measurements of the transmembrane potential which appears after the addition of a protonophore in the presence of a gradient of acetic acid. Ultrasound exposure decreases this potential when the pH of the buffer solutions is much higher than the pK of CH3COOH and has no effect at low pH values. The latter can be explained by a simultaneous increase of the permeability of acetic acid and the buffer substances, respectively, due to ultrasound irradiation.

[Assessment of hemodynamics in the cerebral cortex in newborn infants]. / Die Erfassung der Hämodynamik im Bereich der Hirnrinde bei Neugeborenen.

Determinations of blood velocity in vessels of cerebral cortex have been done using a 20 MHz impulse Doppler unit. In comparison we registered the blood flow pulsation curves at the anterior cerebral artery with aid of a 5 MHz-cw-Doppler system. The peripheral resistance index was calculated and it could be proved a strong correlation between the results of the anterior cerebral artery and the vessels of cerebral cortex. Another study showed that the results of the method could be reproduced. The problem of the impulse Doppler examinations of cerebral cortical vessels is the fact, that the exact topography of the vessels examined cannot be defined exactly.

[Sonographic evaluation of changes in testicular tissue by ultrasound spectroscopy]. / Sonographische Beurteilung von Hodengewebeveränderungen durch die Ultraschallspektroskopie.

Experimental investigations were carried out under in vitro conditions on 25 normal human testicular specimens and on 60 pathological testicular specimens to ascertain the ultrasound attenuation using an ultrasound spectroscopic measuring technique. The ultrasound attenuation was established by calculating the ultrasound attenuation coefficient alpha. The average values of ultrasound attenuation (alpha) in normal testicular tissue were distinctly lower than in pathologically altered testicular specimens. A comparison of the various pathologically altered testes showed higher attenuation in the case of malignant neoplasms whilst the highest average values of wore recorded for non-neoplastic pathological alterations in the testicular tissue. The results of the investigations show that certain alterations in the tissue can be ascertained by ultrasound spectroscopy. The analysis of further acoustic parameters in future investigations, such as ultrasound back-scattering and velocity, along with the recording of ultrasound attenuation, gives scope for improved assessment of the tissue. Thus ultrasound spectroscopy increases the sonographic accuracy acquired through analysis and the weighing up of symptoms of tissue dependent ultrasound parameters.

Doppler sonographic pulse curve analysis for estimation of the haemodynamic function.

Experience with Doppler sonographic pulse curve analysis is given from 40 glaucoma patients (examination of the temporal posterior ciliary artery), and from premature babies (blood flow in the anterior cerebral artery). In the latter group the reaction to pain and stress connected with blood sampling was studied. In the glaucoma patients focus was on the influence of IOP level on vascular autoregulation, and the possible response to therapy with beta-blockers. Describing an averaging technique, methodological problems are discussed as relevant for the detection of changes in flow and velocity in small blood vessels.

Experimental model of left ventricular failure.

A model of chronic cardiac failure has undergone extensive hemodynamic investigation. Under anesthesia the homonymous and second diagonal coronary arteries of sheep have been ligated. The resulting myocardial infarction caused significant acute hemodynamic impairment (paired two-tailed t tests), mean pulmonary artery pressure increasing from 7.31 +/- 0.94 to 13.80 +/- 1.19 mm Hg (p less than 0.001), pulmonary artery diastolic pressure increasing from 4.94 +/- 1.03 to 11.13 +/- 1.27 mm Hg (p less than 0.001), and directly measured left ventricular end-diastolic pressure increasing from 9.31 +/- 1.52 to 17.42 +/- 1.82 mm Hg (p less than 0.001) after infarction documented with invasive monitoring. There was a hemodynamically significant left ventricular aneurysm (paired two-tailed t tests) in animals studied 3 months later, with increased mean pulmonary artery pressure from 7.20 +/- 1.15 to 13.80 +/- 2.00 mm Hg (p = 0.009), an increase in pulmonary artery diastolic pressure from 4.60 +/- 1.30 to 12.10 +/- 2.06 mm Hg (p = 0.006), and an increase in left ventricular end-diastolic pressure from 11.00 +/- 1.94 mm Hg before infarction to 17.00 +/- 2.69 mm Hg (p = 0.038). We conclude that this is a useful model of chronic left ventricular failure that is reproducible and applicable to investigations of therapeutic options in chronic heart failure.

False aneurysm of the right internal mammary artery.

False aneurysm of the internal mammary artery is an uncommon complication of median sternotomy. Clinical and radiological findings of 2 such cases are presented. At operative exploration neither was directly related to the presence of a sternal wire.

Right ventricular dynamic cardiomyoplasty: an experimental model.

The effectiveness of dynamic cardiomyoplasty as a means of haemodynamic support in heart failure remains controversial. We have undertaken a study of right ventricular dynamic cardiomyoplasty in sheep using intravenous propranolol to provoke heart failure. Muscle conditioning was performed with cardiomyostimulators following a previously established protocol. We performed multiple invasive measurements of haemodynamic parameters including arterial blood pressure, cardiac output, pulmonary artery capillary wedge pressure, right ventricular dp/dt and end diastolic pressures. These were performed before induction of heart failure, after induction of heart failure, and with pacing of the cardiomyoplasty flap in established heart failure. Our results confirm that we were able to establish significant heart failure and that subsequent pacing of the conditioned muscle flap was able to return cardiac output and right ventricular function to their pre-failure control levels.