Prostate Artery Embolization in Patients With Acute Urinary Retention

BackgroundThis prospective study assessed the efficacy of prostate artery embolization after failure of a trial without catheter in patients suffering a first episode of acute urinary retention as a result of benign prostatic hyperplasia (BPH).MethodsPatients with failure of a trial without catheter despite alpha-blocker therapy were invited to participate in this protocol. Twenty patients were included in the study, and all underwent prostate artery embolization with calibrated polyvinyl alcohol (PVA) microspheres (Bead Block, BTG Ltd., Farnham, UK).ResultsSuccessful removal of the indwelling bladder catheter and spontaneous voiding was achieved in 15 of 20 (75%) patients, and the overall clinical success at 6 months after prostate embolization was 14 of 20 (70%). No patient experienced severe adverse events.ConclusionsProstate artery embolization might be a valuable treatment after a failure of a trial without catheter. Further studies are needed to better define its place in this setting.     

Coronary sinus blood flow at rest and during isometric exercise in patients with aortic valve disease: Mechanism of angina pectoris in presence of normal coronary arteries

In 46 patients with aortic valve disease, coronary sinus blood flow was measured using a continuous thermodilution method both at rest and during isometric handgrip excercise. All patients had normal coronary angiograms. The patients were separated into three groups: Group I, 12 patients with aortic stenosis (systolic gradient 72 ± 12 mm Hg); Group II, 15 patients with both aortic stenosis and regurgitation; Group III, 19 patients with aortic regurgitation. At rest, the coronary sinus blood flow was two to three times normal. However, when corrected for left ventricular mass (ml/100 g), flow was within normal limits. The ratio diastolic pressure-time index/systolic pressure-time index ($\text{DPTI}\text{SPTI}$) was decreased in all three groups at rest. During isometric exercise, coronary sinus blood flow increased significantly: by 60 percent in Group I, by 88 percent in Group II and by 118 percent in Group III. There was a significant reduction of the $\text{DPTI}\text{SPTI}$ ratio.Of the 18 patients with angina on effort during the test, 7 were in Group I, 6 in Group II and 5 in Group III. There were no differences in the coronary sinus blood flow between the patients with angina and those who were pain-free, either at rest or during exercise. Angina pectoris does not appear to be caused by a failure of coronary blood flow to increase. There was no discrepancy between myocardial demand, as measured by the pressure-time index and coronary blood flow. However, the $\text{DPTI}\text{SPTI}$ ratio was significantly lower during exercise in the patients with angina than in those who were pain-free. Underperfusion of the subendocardial muscle seems to be a causative factor in the patients with angina.     

Assessment of plexectomy in the treatment of severe coronary spasm in patients with normal coronary arteries

Surgical denervation of the heart by plexectomy was performed in 3 patients with variant angina, documented coronary spasm, and normal findings on coronary angiography. In all cases, spasm had already been responsible, preoperatively, for myocardial infarction and recurred thereafter in another territory despite medical therapy with a combination of nitrates and calcium antagonists. Plexectomy was performed using a standardized technique. The effectiveness of surgical suppression of cardiac autonomic innervation was confirmed postoperatively by pharmacologic tests. In 2 patients inferior myocardial infarction developed in the early postoperative period; in the third patient, coronary spasm recurred 3 weeks after plexectomy. Thus plexectomy, despite an adequate suppression of autonomic innervation, was ineffective in all cases and may even have been harmful in 2 patients. These data contradict the good results obtained by plexectomy associated with aortocoronary bypass in patients with variant angina and fixed stenotic coronary arteries. This discrepancy may be accounted for by a different pathophysiologic mechanism of vasospasm in normal coronary arteries and in diseased arteries at the site of the atheromatous stenosis. Thus, plexectomy should not be considered in the treatment of vasospasm involving normal coronary arteries, even if medical therapy fails to achieve satisfactory control of variant anginal attacks.     

Response of normal and abnormal sinus node to right ventricular stimulation

Right ventricular pacing at progressively increasing rates was performed in 25 patients with complete ventriculoatrial block, before and after autonomic blockade with intravenous propranolol and atropine. At the end of each ventricular pacing stage a right intraatrial electrogram and electrocardiographic leads were simultaneously recorded. The relation between right ventricular pacing and atrlal rates was studied from the recordings obtained at each pacing stage in both group I,8 patients with sick sinus syndrome, and group II, 17 patients with normal sinus function. Right ventricular pacing was associated with an increment in atrial rate that was significantly smaller (probability [p]<0.001) in patients In group I (mean ± standard error of the mean 8 ± 6 beats/mln) than in group II (mean 25 ± 10 beats/min). The maximal atrial rate reached during right ventricular pacing exceeded 80 beats/min in all patients In group II but remained less than 74 beats/min in patients in group I. Because autonomic blockade did not significantly Influence the preceding results, it is concluded that a mechanical effect on the sinus node may explain this phenomenon.     

Vascular reactivity to norepinephrine and hemodynamic parameters in borderline hypertension

Pressor response to norepinephrine, cardiopulmonary blood volume, and hemodynamic parameters were studied in 41 borderline hypertensive patients in comparison with 42 permanent essential hypertensive patients and 28 normal subjects. Borderline hypertensive subjects had a high cardiac index (p < 0.0001), normal total peripheral resistance, and low total blood volume (p < 0.005). The ratio between cardiopulmonary blood volume (CPBV) and total blood volume (TBV) was significantly higher in comparison with normal subjects (p < 0.01) and permanent hypertensive subjects (p < 0.001). The pressor dose of norepinephrine was elevated (p < 0.0001) and was directly correlated with the basal values of the cardiac output (p < 0.005), the cardiopulmonary blood volume (p < 0.001), and the $\text{CPBV}\text{TBV}$ ratio (p < 0.01). None of these results was observed in permanent hypertensive subjects: the only significant result was a negative correlation between the pressor dose of norepinephrine and the basal diastolic arterial pressure (p < 0.0001). This study provides evidence that the cardiac output elevation in borderline hypertensive subjects was related to increased venous return and enhanced sympathetic venous tone.     

Clinical significance of anti-Sm antibodies in systemic lupus erythematosus

Case records of 34 patients with systemic lupus erythematosus (SLE) were analyzed. Twelve patients had both anti-DNA and anti-Sm antibodies (Group I) and 22 had anti-DNA antibodies only (Group II). The disease patterns were comparable, except for (1) cutaneous vasculitis, which was observed in six of 12 patients in Group I and one of 22 in Group II (p less than 0.01); (2) pulmonary manifestations, nine of 12 in Group I and two of 22 in Group II (p less than 0.001); (3) cardiac manifestations, eight of 12 in Group I and four of 22 in Group II (p less than 0.01); and (4) renal biopsy, which showed milder lesions in Group I than in Group II (p less than 0.05). Evolution was fatal in four patients in Group I and in none in Group II. It is suggested that in SLE, the presence of anti-Sm antibody is associated with a much higher incidence of vasculitis, resulting in peculiar visceral manifestations, which can be poorly responsive to therapy. Whether there is a direct association between anti-Sm antibody and vasculitis or whether the common denominator is a genetic selection remains to be determined.     

Total effective compliance of the vascular bed in essential hypertension

Total effective vascular compliance, hemodynamic parameters, cardiopulmonary (CPBV) and total blood volumes (TBV) were determined in 31 men, including nine normotensive controls and 22 permanent essential hypertensive patients. The effective compliance was calculated from the changes in central venous pressure recorded simultaneously with the changes in blood volume obtained after a rapid dextran infusion. In hypertensives, compliance was significantly reduced (1.55 +/- 0.6 vs 2.25 +/- 0.11 ml./mm. Hg/Kg. in controls) (P less than 0.001) and negatively correlated with blood pressure (P less than 0.01), cardiac index (P less than 0.01), and the CPBV/TBV ratio (P less than 0.01). These results suggest that venous compliance contributes to the control of cardiac output in essential hypertension.     

Detrimental effect of propranolol in patients with coronary arterial spasm countered by combination with diltiazem

This study determines, with quantitative variables, if propranolol is detrimental in patients with documented coronary arterial spasm and if this drug can be used in combination with calcium antagonists. Eleven patients with documented coronary spasm were entered prospectively in a study with 4 phases of 2 days each: (1) control, (2) diltiazem or propranolol (mean 225 ± 75 mg/day), (3) propranolol or diltiazem (360 mg/day), (4) propranolol and diltiazem. The effects of the drugs were assessed by the detection of ischemic electrocardiographic episodes (24-hour electrocardiographic monitoring) and provocative tests with ergonovine. During the period of treatment with propranolol, the number and the duration of attacks increased and provocative tests had positive results in all patients. Diltiazem completely abolished spontaneous episodes, but 6 of 11 patients remained sensitive to the administration of ergonovine. The association of the 2 drugs led to a disappearance of ischemic episodes. In conclusion, propranolol is ineffective in patients with coronary artery spasm. It can be used in combination with diltiazem, but without any advantage over diltiazem alone.     

Hemodynamic study of 85 patients with borderline hypertension

Hemodynamic changes in supine and upright position (50 ° head-up tilt) and during exercise were studied in 40 normal subjects and 85 patients with borderline hypertension. The latter were classified in 2 groups, according to the level of cardiac index. In group I, with patients in the supine position, cardiac index, stroke index, heart rate and plasma volume were normal, but total peripheral resistance was increased (P < 0.01). During upright tilt, orthostatic decrease of mean arterial pressure (P < 0.05) was observed, and the increase in total peripheral resistance was not greater than in normal subjects. The hemodynamic response to exercise was similar to that of normal subjects. In patients in group II, cardiac index, stroke index and heart rate were increased (P < 0.001), but plasma volume was decreased (P < 0.01) and total peripheral resistance was below normal (P < 0.001). With patients in the upright position, diastolic orthostatic hypertension was observed (P < 0.001) and total peripheral resistance was greater than normal (P < 0.01) despite an abnormal fall of cardiac index (P < 0.05). The hemodynamic response to exercise indicated that total peripheral resistance did not decrease as in normal subjects and in patients of group I (P < 0.001). This study provides evidence that (1) total peripheral resistance is abnormal in patients with borderline hypertension, but only during upright tilt and exercise in patients with high cardiac index, and (2) 2 main disorders seem to be important in the early stage of hypertension: abnormality of blood volume (or blood volume distribution, or both) and impaired neurogenic activity.     

Transient ST segment elevation occurring without anginal pain. Correlations with Prinzmetal's angina.

Two cases presenting with episodes of marked ST segment elevation occurring with, but most often without, anginal pain are reported. The changes were recorded through continuous ECG monitoring during Prinzmetal's angina and in the course of myocardial infarction. Such transient asymptomatic ECG abnormalities reveal silent acute myocardial ischemia and are often unrecognized. However, they may lead to severe arrhythmias or myocardial infarction, and sudden deaths occurring in the course of ischemic heart disease are likely to be explained on this basis. Transient episodes of silent ST segment elevation similar to those occurring in Prinztal's angina have been reported in various circumstances. They bring into discussion the delimitations of variant angina pectoris.     

Treatment of prinzmetal's variant angina: Role of medical treatment with nifedipine and surgical coronary revascularization combined with plexectomy

This study describes three forms of treatment of Prinzmetal's variant angina. Coronary spasm, frequently found at coronary arteriography in patients with Prinzmetal's variant angina, can be treated with intravenous or intracoronary injection of nitroglycerin as well as of nifedipine. Nifedipine (0.2 mg) was injected directly into the involved artery in 12 patients and suppressed spasm in 9; in 3 patients, nifedipine increased coronary sinus flow, which had been decreased by spasm in one of the branches of the left coronary artery.Patients with Prinzmetal's variant angina who have spasm superimposed on atherosclerotic lesions can benefit from coronary arterial bypass grafting combined with partial denervation of the heart. This combination yielded acceptable results (83.4 percent favorable outcome); recurrence of attacks occurred in only 6.7 percent of this group. In those forms of angina in which spasm occurs in angiographically normal coronary arteries, therapy is essentially medical. In 13 patients treated with oral nifedipine (30 to 40 mg/day), suppression of attacks was achieved in 11 instances. During the period of treatment, the methergine provocative test, which had been consistently positive before treatment, converted to negative in 12 patients. Transient withdrawal of nifedipine caused recurrence of pain in two patients.     

Failure in the rate adaptation of the atrial refractory period: its relationship to vulnerability

We evaluated the relationship of rate-dependent changes in atrial refractoriness to atrial vulnerability in 39 patients. Vulnerability was considered present when sustained atrial tachyarrhythmias, lasting longer than 1 minute, could be provoked with one to three extra stimuli. Adaptation of atrial refractory period duration to rate was defined as: normal: steep rate reduction with a linear correlation slope value of 0.08 or more; non-adaptation: absence of rate reduction, the slope value being 0 to 0.01; poor adaptation: slight reduction with rate, the slope having values of 0.02 to 0.07. Increased vulnerability was demonstrable in 16 of 17 patients with non-adaptation of the effective refractory period (ERP), and in 10 of 10 with a similar defect of the functional refractory period (FRP); in the intermediate category (poor adaptation) the results for ERP and FRP were 7/11 and 5/6. By way of contrast when both measurements showed normal adaptation, vulnerability was elicited in 2/9 patients. The significance between these groups showed P less than 0.005. Of 17 patients with atrial arrhythmia by Holter, 14 showed poor or non-adaptation of the ERP. It is suggested that poor or absent rate adaptation of the atrial refractory period, and a propensity to atrial fibrillation or flutter, constitute a clinical entity not previously described.