Clinical improvement after ventricular aneurysm repair: prediction by angiographic and hemodynamic variables

Surgical repair of a left ventricular aneurysm is associated with significant perioperative mortality and substantial mortality in the first 2 years after operation. In a retrospective review of 42 patients undergoing repair of an anteroapical aneurysm, two cardiac catheterization variables were identified that predicted a good surgical outcome, defined as perioperative survival and improved functional status. Specifically, patients with an ejection fraction of the contractile section (nonaneurysmal) of the left ventricle of 35% or greater and a left ventricular end-diastolic pressure of 25 mm Hg or less had a low perioperative mortality rate (6.5%), experienced no late mortality and had sustained clinical improvement of at least one New York Heart Association functional class (93.5%). In contrast, patients with a contractile section ejection fraction of less than 35% or a left ventricular end-diastolic pressure greater than 25 mm Hg had a higher perioperative mortality rate (27.3%), experienced a substantial late mortality rate (27.3%) or had no significant functional class improvement (9%); only 36.4% had sustained clinical improvement. This study suggests that the postoperative results of left ventricular aneurysm repair are dependent on the hemodynamic status of the nonresected left ventricle.     

Sensitivity and specificity of M mode echocardiographic signs of mitral valve prolapse

To assess the sensitivity and specificity of previously described M mode echocardiographfc signs of mitral valve prolapse, 100 subjects with a mobile mid systolic click and 100 matched normal control subjects were prospectively studied. Late systolic posterior motion and holosystolic hammocking of the mitral leaflets were common, highly specific signs of mitral valve prolapse. When these signs were combined as a single criterion, sensitivity was 85 percent and specificity was 99 percent. Other signs, including systolic echoes in the mid left atrium, systolic anterior motion, early diastolic anterior motion of the posterior mitral leaflet and shaggy or heavy cascading linear diastolic echoes posterior to the mitral valve, were highly specific but uncommon. They occurred only in combination with late systolic posterior motion or holosystolic hammocking. The remaining signs tested did not differentiate subjects with mitral valve prolapse from normal persons.     

Doughnut pattern of technetium-99m pyrophosphate myocardial uptake in patients with acute myocardial infarction: a sign of poor long-term prognosis.

Thirty survivors of acute myocardial infarction with 3+ or 4+ positive technetium-99m pyrophosphate myocardial scintigrams were followed up for 28 +/- 3.1 months (mean +/- standard deviation). Three patient groups were identified from the pattern of radioactive uptake in the scintigram: Group I, 16 patients with focal uptake (anterior in 7, lateral in 2, posterior in 3 and inferior in 4); Group II, 6 patients with anterior myocardial infarction and a doughnut pattern of uptake; Group III, 8 patients with nontransmural myocardial infarction and a diffuse pattern of uptake. Late complications developed in all patients with the doughnut pattern of uptake compared with 43 percent of patients with the focal pattern and 12 percent of patients with the diffuse pattern. After discharge from the hospital, five of six patients with a doughnut pattern of uptake died (mean survival time 9.8 months after the initial myocardial infarction). This mortality rate (83 percent) was significantly greater than that of patients with a focal (mortality rate 6 percent) or diffuse (no mortality) pattern of uptake. The doughnut pattern of technetium-99m pyrophosphate myocardial uptake in patients with acute myocardial infarction appears to identify a subgroup of patients with a very poor long-term prognosis.     

Sensitivity and specificity of commonly used electrocardiographic criteria for left atrial enlargement determined by M-mode echocardiography

To assess the sensitivity and specificity of 6 commonly used electrocardiographic criteria for left atrial (LA) enlargement, the rest ECGs of 99 patients in normal sinus rhythm were analyzed. Fifty-seven of the patients had LA enlargement and 42 had a normal LA dimension as determined by M-mode echocardiography. The 6 criteria studied and their respective sensitivities and specificities were as follows: (1) duration of the negative phase of the P wave in lead V1 greater than 40 ms: sensitivity, 83%; specificity, 80%; (2) notched P wave in any standard lead with an interpeak duration greater than 40 ms: sensitivity, 15%; specificity, 100%; (3) P terminal force (depth X duration of the terminal portion of the P wave) in lead V1 more negative than -0.04 mm X s: sensitivity, 69%; specificity 93%; (4) depth of the negative phase of the P wave in lead V1 greater than or equal to 1 mm: sensitivity, 60%; specificity, 93%; (5) total P-wave duration greater than 110 ms in any standard lead: sensitivity, 33%; specificity, 88%; (6) total P wave duration/P-R interval duration greater than 1.6: sensitivity, 31%; specificity, 64%. Combining 2 or more of these criteria did not substantially improve sensitivity and specificity.     

Percutaneous balloon aortic valvuloplasty: results in 23 patients

Percutaneous balloon aortic valvuloplasty (BAV) was performed in 23 consecutive patients with valvular aortic stenosis with no associated cardiac defects. The patients were 2 to 17 years old and were referred from 12 hospitals in 4 states. The balloon was positioned across the aortic valve and inflated to pressures of 80, 100, then 120 psi. Each inflation lasted 5 to 10 seconds. The arterial and venous catheters were connected together outside the groin to avoid excessive increase in left ventricular pressure during total aortic valve occlusion with the inflated balloon. Peak systolic aortic valve pressure gradient and cardiac output were measured before and 15 minutes after BAV. There was no significant change in cardiac output, but all patients had a lessened gradient. The gradient before BAV was 113 +/- 48 mm Hg, decreasing to 32 +/- 15 mm Hg after BAV (p less than 0.01). The left ventricular peak systolic pressure decreased from 221 +/- 54 to 149 +/- 21 mm Hg (p less than 0.01). No aortic regurgitation was noted in 13 patients and very mild aortic regurgitation was noted in 10 patients after BAV. The balloons were 10 to 20 mm in diameter, chosen at least 1 mm smaller than the diameter of the aortic valve anulus. Pressures of 100 to 120 psi were required to achieve full inflation of the balloons. Six patients had repeat cardiac catheterization studies 3 to 9 months after BAV. In none was there a significant change in peak systolic aortic valve pressure gradient or cardiac output compared with the study immediately after valvuloplasty.     

Historical perspectives on the renin-angiotensin-aldosterone system and angiotensin blockade

Advances leading to recognition of the relation of the renin-angiotensin system to aldosterone include: (1) development of analytic techniques for measuring aldosterone, (2) discovery of an aldosterone-stimulating factor in circulating plasma, (3) the finding that a potent aldosterone-stimulating factor is secreted by the kidney, (4) evidence that synthetic angiotensin II increases aldosterone secretion, (5) fractionation of crude kidney extracts and the finding that aldosterone-stimulating factor is renin, (6) the observation that high plasma renin activity occurs in secondary aldosteronism, and (7) recognition that the renin-angiotensin-aldosterone system occurs in congestive heart failure and in renovascular and malignant hypertension. The early use of blocking agents for the renin-angiotensin system is described along with the landmarks of progress. These include the observations that: (1) arterial pressure decreases in experimental renovascular hypertension in response to angiotensin blockade, (2) angiotensin provides important support for arterial pressure in low cardiac output states including congestive heart failure, (3) the kidney participates in this important compensatory mechanism, and (4) cellular receptors for angiotensin are present in the two inner zones of the adrenal cortex.     

Sensitivity and specificity of two-dimensional echocardiographic signs of mitral valve prolapse

The sensitivity and specificity of previously described 2-dimensional echocardiographic signs of mitral valve prolapse (MVP) were assessed in 70 patients with MVP and in 100 normal control subjects. Specificity of individual signs was uniformly high, ranging from 88% for excessive motion of the posterior mitral ring to 100% for several signs including systolic arching in the parasternal long-axis view, excessive posterior coaptation and diastolic doming of the anterior mitral leaflet. Sensitivity of individual signs was low to moderate, ranging from 1% for whip-like motion of both mitral leaflets to 70% for excessive posterior coaptation of the mitral leaflets in the apical 4-chamber view. The highest sensitivity value (87%) was associated with the presence of systolic arching of 1 or both mitral leaflets in the parasternal long-axis view or systolic bowing of 1 or both mitral leaflets in the apical 4-chamber view or excessive posterior coaptation of the mitral leaflets or a combination. This increase in sensitivity was achieved without sacrificing specificity (97%). Thus, the individual 2-dimensional echocardiographic signs tested possess uniformly high specificity, but only low to moderate sensitivity; however, sensitivity can be markedly enhanced without sacrificing specificity by using selected combinations of echocardiographic signs.     

Computerized echocardiographic analysis to detect abnormal systolic and diastolic left venticular function in children with aortic stenosis.

Experience with computer analysis of M mode echocardiograms for the evaluation of left ventricular function in patients with left ventricular pressure overload is reported. In order to study systolic and diastolic left ventricular function, endocardial surfaces of the septum and posterior wall were digitized and analyzed by minicomputer. The subjects included 52 normal children and 30 children with catheterization-proved aortic stenosis with (13) and without (17) coarctation. Compared with the normal children, the patients with aortic stenosis had a statistically smaller and thicker walled left ventricle and increased fractional shortening of the left ventricular minor axis. Continuous tracings of minor axis dimension and the first derivative of these tracings were plotted. The tracings allowed measurement of the maximal velocity of shortening and lengthening. Maximal velocity of shortening (normal = 96.8 ± 3 mm/sec [mean ± standard error of the mean]) was depressed to 80.8 ± 4.7 mm/sec) in the group with pressure overload. Maximal velocity of lengthening (normal = 116.4 ± 3 mm/sec) was also depressed (88.4 ± 5.2 mm/sec) in this group. Although the velocity measurements allowed separation of the normal from the abnormal group, they did not correlate closely with either left ventricular wall thickness or left ventricular systolic pressure and therefore they cannot be used to assess the severity of the left ventricular pressure overload or the need for surgical correction. Nonetheless, the study provides a method for analyzing left ventricular diastolic and systolic dynamic function from a ventricular M mode echo alone and suggests abnormal systolic and diastolic left ventricular performance in some children with aortic stenosis and left ventricular hypertrophy.     

Peritoneal access and related complications in continuous ambulatory peritoneal dialysis

Over a four-year period, 50 patients underwent continuous ambulatory peritoneal dialysis. After 24 months, 48 percent of the patients continued to receive continuous ambulatory peritoneal dialysis treatment (including those who underwent continuous ambulatory peritoneal dialysis with bottled solutions from 1977 to 1978). Using solutions in plastic bags, 63 percent of patients continued to undergo continuous ambulatory peritoneal dialysis after 24 months. The mortality rate at 24 months was 23 percent overall and 15 percent for those using plastic bags. There was an overall average of 2.4 episodes of peritonitis a year per patient and 1.3 episodes a year per patient from 1979 through 1980, when only the technique with plastic bags was used. The number of days a patient was hospitalized averaged 48 per year, and 37 days per year In 1979 and 1980. Fifty-five percent of catheters remained functional at 24 months. Other complications included 15 hernias, 15 skin and tunnel infections, 12 leaks, and five cuff extrusions. Improved catheters and further reductions in the incidence of peritonitis will most likely result in a decreased number of patients who withdraw from continuous ambulatory peritoneal dialysis therapy.     

Role of M mode echocardiography in congenital aortic stenosis

M mode ultrasonic recognition of a bicuspid aortic valve or congenttally stenotic aortic valve rests on detection of the following criteria: eccentricity index, increased leaflet thickness, multiple diastolic cusp lines and presence of a central systolic line. In this investigation, M mode ultrasonic tracings from 118 children were interpreted by evaluators who did not know the diagnosis. Twenty-eight records from children with aortic valve stenosis (25 with a bicuspid valve and 3 with a tricuspid valve), were intermixed with records of 90 children with a catheterization-proved normal aortic valve to determine how many criteria were present in each tracing. Additionally, tracings were reviewed for overall visual appearance of the criteria, without measurement, to attempt to identtty those with an abnormal aortic valve. Finally, all echoes were viewed simultaneously and ranked from the most normal in appearance to the most abnormal aortic valve image. Rankings were then compared with measured pressure gradients across the aortic valve.

An eccentricity index value greater than 1.5, thought to be indicative of a bicuspid aortic valve, was found in 29 percent of patients with aortic stenosis and 20 percent of normal children. Mean eccentricity index values for the two groups were statistically similar. Increased leaflet thickness was not detected in any tracing. Multiple diastolic cusp lines were present in 64 percent of patients with aortic stenosis and 60 percent of normal children. None of these criteria were sensitive or selective for dlagnosing aortic stenosis from an M mode tracing of a given patiënt. On the basis of subjective visual appearance, 39 percent of tracings of patients with aortic stenosis were identified correctly. No useful correlation existed between the ranking an M mode tracing received for degree of valve normality or abnormality and the aortic pressure gradient. This investigation shows that M mode echocardiography of the aortic valve, despite prior recommendations to the contrary, has limited usefulness in diagnosing congenital aortic stenosis.     

Combined hyertrophic subaortic stenosis and calcific aortic valvular stenosis.

A well documented case of combined hypertrophic subaortic stenosis and calcific aortic stenosis is reported. Detection of multilevel involvement in cases of left ventricular outflow obstruction requires a high index of suspicion and precise hemodynamic and angiographic documentation. Careful analysis of the total data base is necessary for proper management of the patient. The pathogenesis of this combined lesion is unclear: Asymmetrical septal hypertrophy may occur as a consequence of the valvular stenosis, or it may be that abnormal leaflet motion in patients with hypertrophic obstruction produces leaflet thickening, calcification, deformity and stenosis.     

Critical aortic coarctation: patch aortoplasty in infants less than age 3 months.

Twenty-three infants less than age 3 months (mean age 31 days) underwent patch aortoplasty for relief of coarctation of the aorta. All had intractable congestive heart failure, despite aggressive medical therapy. Each infant had other cardiac anomalies, including patent ductus arteriosus (83 percent) and ventricular septal defect (74 percent). All patients underwent closure of the ductus arteriosus and patch angioplasty of the aorta to produce a luminal diameter of at least 16 mm. In addition, 9 of the 17 patients (53 percent) with a large shunt ventricular septal defect underwent pulmonary arterial banding. There was one hospital death 42 days after operation secondary to bowel perforation and sepsis. Hospitalization beyond 21 days postoperatively was always due to other unrepaired cardiac lesions. The three late deaths at 3, 9 and 18 months after operation were associated with additional major anomalies. Fourteen patients have had postoperative catheterization. No gradient was found across the site of coarctation repair, but one patient had a gradient between the left carotid and left subclavian arteries. Surgical repair of critical coarctation of the aorta in infants can safely be offered despite the presence of other cardiac anomalies.     

Supravalvular aortic stenosis in adults

Supravalvular aortic stenosis in adults, in contrast to the form seen in infants and children, is usually not associated with mental retardation, peculiar facies or severe peripheral pulmonic stenosis. Subtle clinical findings serve to distinguish it from valvular aortic stenosis, a differentiation of great importance if surgery is a consideration. Diagnosis is made by aortic and left ventricular angiograms. The severity of the clinical disease correlates better with abnormalities of the coronary arteries than with the severity of the obstruction, although both are frequently significant. Once symptoms occur, the prognosis is poor without surgical correction. Surgical mortality rates are high, primarily as a result of incomplete preoperative diagnosis.     

Relation of coronary arterial spasm to sites of organic stenosis

Among 63 patients with Prinzmetal's variant angina, coronary arterial spasm responsible for attacks of variant angina was documented arteriographically in 9 patients. In each observed episode (11 attacks in nine patients), coronary spasm producing myocardial ischemia occurred at and was superimposed on a site of preexisting organic stenosis. Measurements of normal portions of "spastic" and "nonspastic" vessels suggested a generalized uniform constriction of all major coronary arteries during attacks, with "spasm" limited to the site of an organic lesion in most cases. In two cases the magnitude of constriction in all vessels was consistent with generalized coronary hypercontractility or spasm. Among 104 patients with organic coronary artery disease and documented single vessel coronary spasm (foregoing 9 patients combined with 95 others from published reports), there were 70 patients with essentially single vessel organic coronary disease in 90 percent of whom the spasm involved the diseased vessel. Of 60 cases abstracted from the literature in which the relation of coronary spasm to the site of organic disease was described, 88 percent had the spasm causing ischemia localized to the site of an organic lesion. Hypotheses attempting to describe the pathophysiologic aspects of coronary spasm in variant angina must account for the intimate association of spasm with sites of organic stenosis in the majority of cases.     

Lack of objective improvement in ventricular systolic function in patients with myocarditis treated with azathioprine and prednisone

Six patients with myocarditis documented by biopsy, after a baseline right heart catheterization and echocardiogram, underwent treatment with azathioprine and prednisone. After 3 months of treatment, biopsy, right heart catheterization and echocardiogram were repeated. In addition to the immunosuppressive therapy, most patients received additional conventional medications for heart failure between evaluation periods (mean number of cardiac drugs increased from 1.7 +/- 1.0 to 2.7 +/- 0.05, p = 0.041). Mean heart rate decreased (105 +/- 14 to 84 +/- 13 beats/min, p = 0.016), as did pulmonary wedge pressure (23 +/- 8 to 12 +/- 4 mm Hg, p = 0.012). There were no significant changes in cardiac index (3.1 +/- 0.8 to 2.9 +/- 1.0 liters/min), end-diastolic dimension (62 +/- 13 to 62 +/- 12 mm) or fractional shortening (11 +/- 6 to 12 +/- 3%) with treatment. Complications from immunosuppressive therapy included severe soft tissue infection, acute psychosis and adrenal insufficiency in one patient each. The benefits from prednisone and azathioprine in this group of patients have not been demonstrated. Although heart rate and pulmonary wedge pressure decreased, these changes could be ascribed to increases in the conventional therapy for heart failure. Finally, there is a high incidence of side effects from prednisone and azathioprine therapy. These findings suggest that this unproven therapy for myocarditis should be limited to experimental protocols.     

Influence of plasma drug level and the presence of conduction disease on the electrophysiologic effects of procainamide.

Electrophysiologic measurements were made in 16 patients before and after the intravenous administration of procainamide. The drug was administered at two different dose levels. The lower plasma procainamide level (6 to 7 μg/ml) caused small decreases in cycle length (848 ± 13 versus 799 ± 42 msec), sinus nodal recovery time (1,166 ± 81 versus 1,024 ± 90 msec at a paced rate of 120 beats/min) and sinoatrial conduction time (105 ± 11 to 90 ± 9 msec). Sinus or atrial echo zones, whether or not they caused supraventricular tachyarrhythmia, were abolished by procainamide in 11 of 13 instances. The higher plasma level of procainamide (10 to 11 μg/ml) generally caused greater changes in electrophysiologic measurements. Atrial refractory periods tended to increase but changed significantly only at higher plasma levels. The latter effect was blunted in patients with a prolonged sinoatrial conduction time. The A-H interval and atrioventricular nodal functional refractory period tended to decrease at higher plasma levels, but not significantly. The H-V interval increased slightly from 48 ± 2 to 52 ± 2 msec; this effect was blunted in patients with bundle branch block.It is concluded that procainamide could be useful in managing supraventricular tachyarrhythmia because it abolishes atrial and sinus echo zones that trigger supraventricular tachyarrhythmia and because its widespread effects make it capable of blocking reentry at several sites. The electrophysiologic effects or procainamide are less predictable in patients with conduction disease, and some effects occur only at high plasma levels.