Gastric acid secretion in uraemia and circulating levels of gastrin, somatostatin, and pancreatic polypeptide.

Basal circulating levels of gastrin, somatostatin, and pancreatic polypeptide were measured in 30 chronic haemodialysis patients. Five patients had considerably raised serum gastrin (greater than 400 pmol/1) and also gastric achlorhydria while 75% of the patients who had normal (less than 55 pmol/1) or moderately increased (less than 400 pmol/1) serum gastrin had raised maximal acid outputs. Patients with serum gastrin greater than 400 pmol/1 had significantly lower plasma concentrations of somatostatin compared with both healthy individuals and uaremic patients with normal gastrin levels. Raised serum concentrations of pancreatic polypeptide were observed in the majority of the patients but no correlation was found between this peptide and gastric acid secretion or circulating levels of gastrin and somatostatin, respectively. Prolonged circulation time for gastrin and pancreatic polypeptide was demonstrated after food stimulation. Prolonged gastrin stimulation of the parietal cell mass may lead to work hypertrophy and gastric acid hypersecretion. Whether long-standing over-stimulation by gastrin also may induce atrophy of the cells remains to be studied.     

Extensive surgery for left atrial leiomyosarcoma diagnosed by echocardiography. A case report

A case of malignant leiomyosarcoma presenting as a left atrial cardiac tumor is described and its echocardiographic features are discussed. Tumor masses invading the atrial walls were extensively resected and the atrial wall was reconstructed with two patches of bovine pericardium.     

Surgical treatment of carcinoid heart disease

Right heart failure in patients with carcinoid heart disease is a serious prognostic sign. Consideration and adequate timing of valvular operations seem essential for the postoperative outcome. Without any relation to duration or progression of the metastasizing tumor disease, right heart failure developed and increased rapidly for a period of 12 to 17 months in four patients with classic carcinoid syndrome. Invasive hemodynamic and cardiac ultrasound investigations revealed severe carcinoid heart disease, and medical decompensation treatment gradually failed. Tricuspid and pulmonic valve replacement operations resulted in dramatic improvement in three of the patients, and these patients were still free of cardiac symptoms 10, 12, and 38 months postoperatively. One patient died 5 days postoperatively probably of septicemia. The preoperative and postoperative development of the cardiac disease is evaluated clinically, by cardiac ultrasound and plasma atrial natriuretic peptide concentrations, and related to the tumor disease. Surgical anatomy and operative technique are reported, and the beneficial value of prophylactic treatment of the effects of tumor-released vasoactive substances by a somatostatin analog is emphasized.     

Carcinoid heart disease: relationship of circulating vasoactive substances to ultrasound-detectable cardiac abnormalities

Cardiac ultrasound investigation of 68 prospectively studied patients with histologically proven midgut carcinoid tumors showed right heart disease in 66%. The abnormal findings included morphologic and functional aberrations of the tricuspid valve in 52% and 83%, respectively, right atrial and ventricular enlargement in 53% and 30%, and paradoxical systolic septal contractions in 19%. The patients with the most pronounced right heart disease had significantly higher (p less than .01) plasma levels of the tachykinins neuropeptide K and substance P as well as higher (p less than .001) urinary excretion of the serotonin metabolite 5-hydroxyindoleacetic acid. These patients also had the most extensive tumor disease. The occurrence of echocardiographic abnormalities of the left heart was similar to that in healthy individuals of the same age, but abnormalities were less frequent among the patients with severe right heart disease. Electrocardiographic changes were nonspecific. Right heart disease thus seems to be present more often than previously reported in patients with malignant midgut carcinoid tumors. The severity of cardiac involvement does not seem to be related to the duration of carcinoid disease but more to the extent of the disease, i.e., higher plasma levels of serotonin and tachykinins.     

An echocardiographic study of right and left ventricular adaptation to physical exercise in elite female orienteers.

BACKGROUND: A considerable body of echocardiographic studies has described how athletic training induces morphological adaptation of the left ventricle in male endurance athletes, but only a few studies have described left ventricular adaptation in female endurance athletes. In contrast to changes in the left ventricle far less attention has been directed towards right ventricular changes due to extensive physical exercise. The purpose of this study was to obtain normal values and to determine if there are any differences in right and left ventricular cavity and wall dimensions between female orienteers and females with a mainly sedentary lifestyle. METHODS: Echocardiography was performed in 42 highly trained elite female orienteers and 32 healthy female students with a predominantly sedentary lifestyle. The 74 females had no history of cardiac disease, a normal electrocardiogram and showed no echocardiographic abnormalities. M-mode and two-dimensional measurements of the right and left ventricular cavity and wall were obtained in elite orienteers and sedentary females. For the right ventricle and wall, multiple cross-sections were used and measurements were obtained from the right ventricular inflow and outflow tract. RESULTS: The left ventricular end-diastolic cavity dimension and the left ventricular wall thickness were significantly greater in the athletes compared with the sedentary controls. The right ventricular inflow tract measurements were all significantly greater in the orienteers compared with the controls but the right ventricular outflow tract measurements were comparable in the study groups. The right ventricular wall thickness, calculated as the mean of three different wall measurements was an average of 13% greater in the athletes compared with the sedentary controls. CONCLUSION: This study suggests symmetrical cardiac enlargement with a concomitant increase in both the right and left ventricular wall, probably reflecting the increased haemodynamic loading in the female athletes.     

Transoesophageal echocardiography improves the diagnostic value of cardiac ultrasound in patients with carcinoid heart disease.

Transthoracic and transoesophageal cardiac echocardiography and Doppler investigations were performed in 31 consecutive patients with malignant midgut carcinoid tumours. The transoesophageal images allowed measurement of the thickness of the atrioventricular valve leaflets and the superficial wall layers on the cavity side of both atria. The mean thickness of the anterior tricuspid leaflet was significantly greater than that of the mitral valve--a difference not seen in a control group of age-matched patients without carcinoid tumours and with normal cardiac ultrasound findings. In addition, the edges of the tricuspid leaflets were thickened giving them a clubbed appearance. Tricuspid incompetence was detected transoesophageally in 71% of the patients with carcinoid compared with 57% by transthoracic investigation. The inner layer of the right atrial wall in the carcinoid patients was significantly thicker than that of the left atrium and that of both atria in the controls. Furthermore, patients with other signs of severe carcinoid heart disease had significantly thicker mean right atrial luminal wall layer than those with less or no signs of right heart disease. Transoesophageal cardiac ultrasound investigation improved the diagnostic accuracy and seemed to show the structural changes typical of carcinoid heart disease established by histopathological investigations.     

Non-invasive assessment of systolic left ventricular function in systemic sclerosis

Systemic sclerosis is a multisystemic disorder, also affecting the heart. To evaluate its influence on systolic left ventricular (LV) function, we investigated 30 consecutive patients (age 54.5 +/- 2.4 years, 15 men and 15 women) and 48 controls matched for age and sex. All subjects were investigated by phonocardiography, pulse curve recordings, M-mode echocardiography, and by pulsed and continuous wave Doppler. Heart rate, blood pressure and peripheral resistance did not differ, but patients weighed less than controls (P less than 0.01). Systolic time intervals indicated systolic impairment, with an increased pre-ejection period to LV ejection time (LVET) ratio (0.37 +/- 0.02 vs 0.30 +/- 0.01 P less than 0.001), and also an increased isovolumic contraction time to LVET ratio (0.17 +/- 0.02 vs 0.12 +/- 0.01, P less than 0.02). The latter difference remained when LVET was adjusted for heart rate. Echocardiographic E-point to septal separation was increased in patients (8.3 +/- 1.3 vs 4.8 +/- 0.3 mm, P = 0.001), also after adjustment for LV dimension (P = 0.0001), while septal fractional thickening was decreased (P less than 0.01). End systolic wall stress (P = 0.0002) and stress to volume ratio (P = 0.03) were lower in systemic sclerosis. Peak LV emptying rate was also lower in the patient group when measured by echocardiography (P = 0.03). There was no difference between groups regarding LV dimensions, fractional shortening or mean velocity of circumferential fibre shortening. While aortic Doppler peak emptying rate did not differ between groups, it occurred later in systole in the patient group (P less than 0.01) as did peak velocity (P = 0.0001).(ABSTRACT TRUNCATED AT 250 WORDS)     

Severe mitral regurgitation-relations between magnetic resonance imaging, echocardiography and natriuretic peptides

BACKGROUND: Assessment of the severity of mitral regurgitation by echocardiography can be technically demanding in certain patients and supplementary methods are therefore desirable. This study addressed the agreement between magnetic resonance imaging (MRI) and echocardiography, and their relations to natriuretic peptides (NT-proANP and NT-proBNP), in quantifying severe mitral regurgitation. METHODS: Eighteen patients with severe mitral regurgitation scheduled for surgery underwent MRI, echocardiography and assay of natriuretic peptides preoperatively for clinical assessment. RESULTS: MRI and echocardiography were comparable in measuring severity of regurgitation qualitatively but not quantitatively, mitral regurgitant fraction (mean difference 27.5 (11) ml). There was a correlation between increasing regurgitant fraction on MRI and increased levels of plasma NT-proANP and NT-proBNP. In echocardiography, increasing vena contracta width and increasing PISA correlated to increased levels of plasma NT-proANP and NT-proBNP. No other correlation was found between measures on MRI and echocardiography and natriuretic peptides. CONCLUSIONS: MRI and echocardiography were comparable grading the severity of mitral regurgitation with qualitative measures but not with quantitative measures. MRI might be a complement to echocardiography when a more distinct measure of the regurgitant volume is needed, as in paravalvular leakage.     

Plasma atrial natriuretic peptide in carcinoid heart disease

Plasma atrial natriuretic peptide (ANP) concentration was determined and cardiac ultrasound studies were performed in 50 patients with malignant mid-gut carcinoid tumors. The extent of carcinoid-related heart disease varied among the patients. The patients with the most severe right-sided heart disease, who often had signs of right ventricular failure, had significantly (p less than 0.001) higher plasma ANP concentrations than either patients with less or no abnormal ultrasound findings or age- and sex-matched healthy control subjects. ANP levels were serially determined for 0.5 to 4 years (median 2.1) in 12 patients. The levels increased above the reference range in patients with clinical findings of right ventricular failure. In patients without cardiac decompensation the levels remained within the reference range. In 3 patients who had successful tricuspid and pulmonary valve replacements, signs and symptoms of right ventricular failure disappeared and plasma ANP levels declined and normalized. Five patients with progressive right ventricular failure and increasing plasma ANP levels during follow-up eventually died from cardiac decompensation. This study demonstrates the predictive value of serial determinations of plasma ANP in carcinoid heart disease. Such measurements can be an additional guide in the clinical management of these patients.     

Optimal timing of aortic valve replacement for aortic stenosis--are we operating late?

OBJECTIVE: To evaluate the adherence to current guidelines for surgery in patients with aortic valve stenosis. DESIGN: From 1 January 1997 to 31 May 1999, 99 patients were accepted for aortic valve surgery with preserved left ventricular function and normal coronary angiogram. On admission for operation, 20 patients were evaluated regarding symptoms, exercise capacity, and left ventricular morphology and function. RESULTS: There were 14 men and 6 women, mean age 64.3 years. Years from symptom onset varied from 2.1 to 3.2. Dyspnoea was the most common limiting symptom. Thirty per cent of the patients were classified as NYHA IIIB. Physical capacity was reduced to 79% of the expected. Left ventricular hypertrophy was present in 14/20 patients. Left ventricular systolic function was reduced with mean ejection fraction of 0.46. Diastolic dysfunction (E/A ratio <1) was present in 12 patients. CONCLUSION: Many patients accepted for aortic valve replacement due to aortic stenosis show advanced disease and are referred for surgery later in the disease process than is recommended in the current guidelines.