Constrictive pericarditis: early and late complication of cardiac surgery.

Constrictive pericarditis is not considered a complication of cardiac surgery. However, three cases are presented in which equalization of diastolic pressures and the ventricular pressure pattern of early diastolic dip-late diastolic plateau, characteristic of restrictive disease, appeared after cardiac surgery. In one patients cardiac constriction developed less than 2 weeks after surgery, and loculated clotted and unclotted viscous blood was removed from the pericardial space. In the other two patients the pericardial space was obliterated by dense adhesions. Thus constrictive pericarditis should be considered in postoperative patients who either do not recuperate satisfactorily after surgery or whose condition deteriorates after initial recovery.     

The effect of normalization of serum complement and anti-DNA antibody on the course of lupus nephritis: a two year prospective study

A prospective study was carried out in 25 patients with systemic lupus erythematosis (SLE) on the effect of normalizing serum complement (CH50) and anti-DNA antibodies on the course of lupus nephritis. In 16 of the 25 patients, CH50 was maintained within the normal range for two years. Urinary protein excretion increased or remained low in all 16. Repeat renal biopsies were performed in 10 of these 16, and disclosed either stabilization of glomerular disease or diminution. In the nine patients in whom CH50 could not be normalized with tolerated doses of drugs, urinary protein excretion increased or remained increased. Repeat renal biopsies in six of these nine patients were carried out and showed worsening of glomerular disease in five. No clear-cut correlation was found between urinary protein excretion or renal disease and the serum levels of anti-DNA antibody. We conclude from these observations that continuous normalization of CH50 by drug therapy in patients with SLE is associated with stabilization or diminution of lupus nephritis.     

Ectopic hyperparathyroidism (pseudohyperparathyroidism) in esophageal malignancy: Report of a case and a review of the literature

Described here is a patient with esophageal carcinoma who had hypercalcemia, an elevated serum level of parathyroid hormone and normal parathyroid glands. A review of the literature reveals that a total of 25 other patients with ectopic hyperparathyroidism in esophageal malignancy have been described, four of whom had documented elevations of serum parathyroid hormone levels. Esophageal neoplasms should be added to the list of tumors associated with ectopic secretion of parathyroid hormone.     

Group B streptococcal arthritis in adults

Group B Streptococcal arthritis in adults is uncommon. This report describes seven cases seen at these institutions over the past five years and reviews the previous 17 documented cases. Of seven adults, three were diabetics, three had prosthetic hips, and one had undergone splenectomy. Six had undergone no prior dental, genitourinary, or gastrointestinal procedures. The most common clinical presentation was fever and acute joint pain. Five patients had monoarticular arthritis; two had multiple joint involvement. Underlying joint abnormalities included osteoarthritis (two), prosthetic hip (three), and neuropathic joint (one). Bacteremia was documented in three and suspected in the remaining four patients, often without a primary source. Therapy included parenteral antibiotics, usually penicillin G, and drainage of the involved joint. Two of three patients with prosthetic implants required Girdlestone procedures; the third was apparently cured. The three diabetic patients died, one with resolution of group B Streptococcal arthritis. The seventh patient was cured. Group B Streptococcal arthritis is a serious infection in adults with diabetes and late prosthetic hip infections.     

Coronary steal: Its role in detrimental effect of isoproterenol after acute coronary occlusion in dogs

Using epicardial electrograms others have established that infusion of isoproterenol increases myocardial injury after acute coronary occlusion. To define the contribution of alterations in collateral blood flow to this increased ischemia, isoproterenol was administered to 10 dogs. After pretreatment with practolol in doses that successfully block inotropic but not vascular effects of beta adrenergic stimulants, intracoronary isoproterenol continued to enhance the magnitude of S-T segment elevation in ischemic areas. Thus, vasodilation induced by isoproterenol appears to divert flow from the ischemic area. To test this hypothesis, intracoronary adenosine was given to cause coronary vasodilation without enhancing inotropy. S-T segment elevation at ischemic and adjacent sites was significantly increased. Neither agent had systemic effects, but each increased coronary blood flow while concomitantly decreasing collateral flow as evidenced by a reduction in retrograde coronary flow and peripheral coronary pressure. In addition, adenosine significantly diminished the rate of xenon-133 clearance from the ischemic myocardium. Thus, isoproterenol, in addition to its positive inotropic effect, increases myocardial injury by its vascular action. Collateral blood flow to acutely ischemic myocardium is diminished by the production of a coronary steal. Intravenously administered isoproterenol additionally diminishes collateral flow by decreasing coronary perfusion pressure. It is postulated that any agent that causes either a primary or secondary coronary vasodilation may cause a coronary steal and subsequently enhance myocardial injury.     

Enhanced transcardiac I-norepinephrine response during cold pressor test in obstructive coronary artery disease

An increase in cardiac sympathetic activity can enhance coronary vasomotor tone and lower the ventricular fibrillation threshold. We compared the transcardiac I-norepinephrine responses during cold pressor test of 20 patients with normal coronary arteries with those of 23 patients with obstructive coronary artery disease. Baseline hemodynamic data did not differ in the 2 patient groups except for left ventricular end-diastolic pressures; mean values (± standard deviation ¦SD¦) were 10 ± 3.7 and 15 ± 4.5 mm Hg in patients with normal and abnormal coronary arteries (p < 0.01). Baseline I-norepinephrine contents averaged 295 ± 152 (normal coronary arteries) and 250 ± 134 pg/ml (coronary artery disease) in the arterial blood, and 273 ± 152 and 250 ±115 pg/ml, respectively, in the coronary sinus blood. Hemodynamic responses during cold stimulus were similar in both groups. Also, cold pressor-induced increases in arterial and coronary sinus I-norepinephrine contents were balanced in patients with normal coronary arteries, averaging 19 ± 30 and 17 ± 37%, respectively. In patients with coronary artery disease, however, a 26 ± 58% increase in arterial I-norepinephrine contents was associated with a 58 ± 62% increase in coronary sinus I-norepinephrine contents (p < 0.02), suggesting myocardial I-norepinephrine net release. It is concluded that transcardiac I-norepinephrine responses during cold stimulus are enhanced in patients with obstructive coronary artery disease. This response to a relatively mild sympathetic stress, reproducible by a variety of analogous stressful situations during daily life, could present an increased risk for acute cardiac events.     

Right ventricular function in valvular heart disease: relation to pulmonary artery pressure

Right ventricular angiography was performed in 46 patients with acquired valvular heart disease and 8 normal subjects. Right ventricular ejection fraction (RVEF) correlated highly only with right ventricular peak systolic pressure (RVPSP) and mean pulmonary artery pressure, both in patients with and without tricuspid insufficiency. For the group, RVEF = -0.33 RVPSP + 63 (correlation coefficient [r] = -0.76, probability [p] less than 0.001). Of 20 patients with moderate or severe elevation of pulmonary artery pressure, 17 (85%) had an abnormally low ejection fraction (less than 47%), while 19 (73%) of 26 patients with normal or mildly elevated pulmonary artery pressure had a normal right ventricular ejection fraction. In seven patients with elevated pulmonary artery pressure, a second ventriculogram was performed during intravenous nitroglycerin administration. Nitroglycerin produced a significant decrease in right ventricular peak systolic pressure (59 +/- 22 to 49 +/- 18 mm Hg, mean +/- standard deviation) (p less than 0.05) and in end-systolic volume (71 +/- 16 to 59 +/- 11 m1/m2) (p less than 0.05), and an increase in ejection fraction (43 +/- 9 to 48 +/- 7%) (p less than 0.05). Thus, at least part of the depression of ejection fraction in patients with elevated pulmonary pressure is reversible with a decrease in pulmonary artery pressure.     

Discordance between ambulatory monitoring and programmed stimulation in assessing efficacy of class IA antiarrhythmic agents in patients with ventricular tachycardia

Concordance between programmed stimulation and 24 hour ambulatory electrocardiographic (Holter) monitoring was studied in 54 patients with sustained ventricular tachycardia during 84 therapeutic trials with class IA antiarrhythmic agents. During baseline studies before treatment, all patients had frequent (greater than or equal to 30/h) ventricular premature complexes on Holter recordings and sustained ventricular tachycardia inducible by one to three extrastimuli. During treatment, programmed stimulation and Holter monitoring were repeated. Efficacy of treatment determined by programmed stimulation (ventricular tachycardia no longer inducible or nonsustained) was compared with three Holter criteria of efficacy: I = 83% or more reduction of ventricular premature complexes and abolition of ventricular tachycardia; II = 50% or more reduction of ventricular premature complexes and 90% or more reduction of couplets and abolition of ventricular tachycardia; III = abolition of ventricular tachycardia in patients with ventricular tachycardia during a baseline Holter recording. Treatments were judged effective by programmed stimulation criteria in only 25% of cases but in 51, 63 and 75% of cases by Holter criterion I, II and III, respectively. Results of programmed stimulation and Holter monitor were discordant (effective by one criterion but ineffective by the other) in 50% of cases using Holter criterion I, in 54% using Holter criterion II and in 61% using Holter criterion III. In the majority of discordant results, treatments appeared efficacious by Holter criteria but ineffective by programmed stimulation criteria, suggesting insensitivity of efficacy by Holter criteria or nonspecificity of induced ventricular tachycardia during treatment, or both.     

Mechanism of nitroglycerin effect in valvular aortic stenosis

The hemodynamic effects of nitroglycerin taken sublingually were studied during cardiac catheterization in 10 patients with valvular aortic stenosis. Hemodynamics and cineangiographic left ventricular volumes were determined before administration of nitroglycerin and at peak nitroglycerin effect. Diastolic pressure-time and ejection pressure-time product were used to evaluate left ventricular energy supply and demand. Pressurevolume loops and left ventricular wall tension were calculated. There was a decrease (P < 0.05) in aortic systolic pressure, but heart rate and aortic diastolic pressure did not change significantly. Left ventricular ejection pressure-time declined by more than 20 percent and diastolic pressuretime did not show a significant change. Thus, the ratio of diastolic pressure-time to ejection pressure-time increased from 0.59 ± 0.07 (mean ± standard error) to 0.71 ± 0.09 (P < 0.05). There were significant declines in left ventricular peak systolic and end-diastolic pressures, endsystolic and end-diastolic volumes and peak left ventricular wall tension. Thus, the peripheral unloading effects of nitroglycerin were reflected in the left ventricle despite the fixed aortic valve obstruction. There was no significant change in any measure of left ventricular contractility after administration of nitroglycerin.

It is concluded that sublingual nitroglycerin in aortic valve stenosis: (1) improves indirect indexes of left ventricular energy supply/demand ratio, (2) decreases left ventricular preload and afterload, and (3) does not change left ventricular contractility.     

The effect of continuous normalization of serum hemolytic complement on the course of lupus nephritis: A five year prospective study

We have completed a five year prospective study of the effect of continuous normalization of serum hemolytic complement (CH₅₀) in 25 patients with lupus nephritis. At the end of five years 22 patients were being actively followed; 13 in a CH₅₀ controlled group and nine in a CH₅₀ uncontrolled group. Serial renal biopsy specimens were obtained from 19 patients. The results demonstrate a trend toward stabilization of renal histology, creatinine clearance and serum creatinine at a lower final mean dose of prednisone in the complement controlled group.     

Comparative effects of nitroglycerin and isosorbide dinitrate on coronary collateral vessels and ischemic myocardium in dogs

To determine the effect of isosorbide dinitrate on ischemic myocardium, this agent was administered to dogs with well developed coronary collateral vessels 8 to 14 weeks after embolization and subsequent occlusion of the left anterior descending coronary artery. After thoracotomy the left coronary artery was cannulated and perfused with blood from the femoral artery. The distal left anterior descending artery was cannulated to monitor peripheral coronary pressure. Regional contractile force in the normal left circumflex and potentially ischemic left anterior descending regions was measured with isometric strain gauge arches sewn to the epicardium. Moderate decreases in coronary perfusion pressure averaging 27 mm Hg produced selective ischemia in the myocardium beyond the site of occlusion of the left anterior descending artery. Under these conditions the average increase in peripheral coronary pressure produced by intracoronary injection of isosorbide dinitrate was 9.0 mm Hg, whereas contractile force in the ischemic region increased by 30 percent. The contractile force was unchanged in the normal regions. Therefore, isosorbide dinitrate can dilate coronary collateral vessels and improve contractile force in ischemic areas. Intracoronary injection of nitroglycerin had similar effects. The durations of responses to isosorbide dinitrate and nitroglycerin were remarkably similar: 6.4 and 6.7 minutes, respectively. Although isosorbide dinitrate can directly dilate coronary collateral vessels, its effects are not longer lasting than those of nitroglycerin.     

Obese young men have elevated plasma estrogen levels but obese premenopausal women do not

The 24 hr mean plasma concentrations of estrone (E1) and estradiol (E2) were measured in 18 healthy, regularly cycling obese women; 16 healthy, regularly cycling nonobese women; 18 healthy obese men; and 33 healthy nonobese men. The obese men showed significant elevations of both E1 (67 pg/ml versus 49 pg/ml control; P < 0.005) and E2 (37 pg/ml versus 28 pg/ml; P < 0.005), but the obese women showed no significant elevation of either E1 or E2. The most likely explanation for the absence of significant hyperestrogenemia in the obese women despite evidence that such women have increased androstenedione-to-estrone conversion is that the latter source of estrogen is too small in comparison with estradiol secretion to cause a statistically detectable increment in plasma estrogen levels.     

Peak left ventricular systolic pressure/end-systolic volume ratio: a sensitive detector of left ventricular disease.

The purpose of this study was to evaluate $\text{peak pressure}\text{systolic volume}$ ratio as a detector of cardiac disease. To validate that tracings obtained through fluid-filled catheters were accurate for this purpose, in 35 patients left ventricular pressure-volume loops were constructed from tracings recorded with a micromanometer-tipped angiographic catheter. Comparisons were made between the peak ratio of left ventricular pressure to volume (E_max) using the micromanometer-tipped angiographic catheter and the ratio between peak left ventricular pressure before angiography and end-systolic volume during angiography ($\text{peak pressure}\text{systolic volume}$ ratio) using the fluid-filled lumen of the same catheter. The relations of E_max and that of $\text{peak pressure}\text{systolic volume}$ ratio to ejection fraction were similar and curvilinear. $\text{Peak pressure}\text{systolic volume}$ ratio was approximately 10 percent higher than E_max, with a correlation coefficient between 0.99 of the two ratios. Therefore, $\text{peak pressure}\text{systolic volume}$ ratio, which is easily obtained in clinical practice, can be used instead of E_max.Retrospective analysis of the $\text{peak pressure}\text{systolic volume}$ ratio and ejection fraction was made from routine diagnostic catheterization data obtained using fluid-filled catheters in 115 subjects, of whom 17 were normal, 60 had coronary artery disease without asynergy, 23 had aortic valve disease and 15 had mitral valve disease. In subjects with a normal ejection fraction (more than 60 percent) the $\text{peak pressure}\text{systolic volume}$ ratio separated those groups with a diseased heart from those with a normal heart. Those with a diseased heart had a greater end-systolic volume than normal subjects. Thus, the $\text{peak pressure}\text{systolic volume}$ ratio is more sensitive than ejection fraction in detecting subtle changes in myocardial function in human beings.     

Radionuclide ventriculographic responses to graded supine and upright exercise: Critical role of the Frank-starling mechanism at submaximal exercise

To assess the influence of work load and posture on the response to exercise, 25 patients with coronary artery disease (CAD) and 17 normal subjects underwent graded supine and upright exercise radionuclide ventriculography. In both groups, end-diastolic counts increased with supine exercise (p < 0.001). The ejection fraction and peak systolic pressure-end-systolic volume relation increased in normal subjects (p < 0.02), but not in patients with CAD. At upright rest, end-diastolic counts decreased in both groups (p < 0.001) and then increased with exercise (p < 0.001). The increase in end-diastolic counts was most pronounced on the transition from upright rest to the 150-kpm work load and resulted in a significant increase in stroke counts (p < 0.05) for both patients with CAD and normal subjects, without a measurable change in the ejection fraction or the peak systolic pressure-end-systolic volume relation. Later in exercise, end-diastolic counts plateaued, and the ejection fraction and the peak systolic pressure, end-systolic volume relation increased only among normal subjects. Thus, lowlevel upright exercise is highly dependent on the Starling mechanism in both normal subjects and patients with CAD, with enhanced contractility apparent only during more vigorous exercise in normal subjects.     

Triad of glomerulonephritis, antinuclear antibodies, and positive skin immunofluorescence. Variant of systemic lupus erythematosus

We are reporting findings in 13 patients who presented with glomerulonephritis without evidence of systemic disease, but who were found to have positive antinuclear antibody results and immunoglobulin and/or complement deposits at the dermal-epidermal junction of normal skin not exposed to light. There was no evidence of other organ involvement, and serologic tests for systemic lupus erythematosus (SLE) gave negative results. The renal disease is characterized by severe proteinuria, focal or diffuse proliferative glomerular lesions on biopsy, with variable patterns of immunoglobulin deposits. No clinical manifestations or serologic results typical of SLE have developed during prolonged observation. HLA phenotyping carried out in eight of the 13 patients revealed DR2 or DR3 alloantigens or both in seven of the eight patients, an incidence similar to that in patients with overt SLE. Because of the specificity of the skin biopsy immunofluorescence, the similarity of HLA-DR antigens, and a favorable response of the renal disease to therapy, we believe that these patients have a variant of SLE.