The natural history of closed mitral commissurotomy--a 20 year follow-up

AIM

To study the natural history of mitral stenosis in a Portuguese population submitted to closed commissurotomy. METHODS-POPULATION: All the patients submitted to closed mitral commissurotomy in Pulido Valente Hospital. The commisurotomies were performed from 1956 to 1978 and included a total of 1,134 patients (220 males). Based on the clinical records, we studied the baseline characteristics of all the patients (n = 1134) at the time of surgery. An average of 20 years after surgery, we sent a questionnaire to all these patients. The patients who filled out the questionnaire (n = 352) represented the total Population in terms of the principal clinical characteristics. Based on these answers, we studied the long-term results of closed commissurotomy.

RESULTS

Closed commissurotomy was performed before the age of 20 in about 10% of the patients and after the age of 49 in only 1.6%. The initial symptoms occurred at 22.0 years and commissurotomy was performed at 30.4 years (averages). The procedure was successful: 99% of patients improved significantly after commissurotomy and two thirds had major or total improvement.

CONCLUSIONS

In the natural history of these commissurotomized patients the events were early, with symptoms in their twenties and surgery in their thirties. The events occurred earlier in males than in females. Closed commissurotomy presented, in this study and with these patients, very good results with improvement in 99% of the patients. The positive results the commissurotomies were important and long lasting: there was a low rate of re-intervention (16%) and hospitalization (35%) twenty years after surgery and 53% of the patients are still alive. These good results can be, at least in part, explained by the low age of this population at the time of surgery.

Evaluation of the antimicrobial potency of tannins and related compounds using the microdilution broth method

The antimicrobial activity of a total of 27 tannins and related compounds was evaluated against 8 microorganisms, including 2 Gram-positive (Bacillus subtilis, Staphylococcus aureus), 4 Gram-negative bacteria (Escherichia coli, Klebsiella pneumoniae, Pseudomonas aeruginosa, Proteus mirabilis), and 2 yeasts (Candida albicans, Cryptococcus neoformans). The compounds tested were generally found to possess only weak to moderate antibacterial, but fairly high anticryptococcal activities. Attention is given to structure-activity relationships with emphasis on simple galloyl esters, hydrolyzable tannins and proanthcyanidins among this class of secondary products.

[The variability of the heart rate in the first 24 hours after fibrinolytic therapy in acute myocardial infarct]

AIM OF THE STUDY

The role of heart rate variability changes in the appraisal of reperfusion after fibrinolytic therapy in acute myocardial infarction is still controversial. The aim of this study was to analyze the influence of reperfusion and infarct site on heart rate variability within 24 hours after infarction.

PATIENTS AND METHODS

We studied 45 patients with a mean age = 56.3 +/- 12.4 years, 25 with anterior infarction and 20 with inferior infarction. The reperfusion was defined by the simultaneous presence of three classic noninvasive criteria (fast relief of pain, fast regression of ST segment elevation and early peak of CK). We studied heart rate variability parameters in time-domain and frequency-domain on a 24-hour Holter ECG started at the same time as fibrinolytic therapy.

RESULTS

Thirty-three patients showed reperfusion. We did not find significant differences in the several parameters of heart rate variability between patients with reperfusion and patients without reperfusion, but the patients with anterior wall infarction showed a significant reduction in SDNN in comparison with patients with inferior wall infarction (84 +/- 28 ms vs 102 +/- 30 ms; p = 0.05). pNN50 (5.3 +/- 7.2 ms vs 10.5 +/- 9.8 ms; p = 0.04), LF (618 +/- 591 ms2 vs 1374 +/- 1761 ms2; p = 0.05) and TP (1415 +/- 1199 ms2/Hz vs 3015 +/- 4243 ms2/Hz).

CONCLUSION

These data suggest a relationship between infarct severity and sympathetic activation and/or reduction of vagal modulation, but a potential beneficial effect of reperfusion on autonomic nervous system alterations was not evident in the first day of acute myocardial infarction.

Echocardiographic evaluation in 485 aeronautical workers exposed to different noise environments

INTRODUCTION

Vibroacoustic disease (VAD) is a heterogeneous and systemic entity, caused by long term (> or =10 yr) exposure to noise environments characterized by large pressure amplitude and low frequency (LPALF) (> or =90 dB SPL, < or = 500 Hz), and not explained by other possible etiologic agents. The goal of this study was to identify possible structural changes in hearts of men with suspected VAD.

METHODS

A total of 485 men were divided into 3 noise groups: no noise exposure (< or =70 dB), n = 48 (Group I); moderate noise exposure, (>70dB and < 90 dB), n = 113 (Group II); and intense noise exposure (> or =90 dB), n = 324 (Group III). Echo-Doppler studies were performed (HP SONOS 1500) and recorded on coded videotapes. Three observers performed blinded evaluations of 26 echo-Doppler parameters. For the purpose of the present study only 12 morphological parameters were compared among the groups: thickening of the mitral, aortic, tricuspid, and pulmonary valves, pericardium and endocardium; mitral valve regurgitation, prolapse and ruptured chordae tendinae; and inflow velocities. Thickness and severity of the applicable parameters were scored in seven-grade scale (0,0.5,1, ...,3).

RESULTS

All evaluated parameters were statistically significantly different in Group I vs. Group III, except flow velocity E. Comparison of Group I vs. Group II revealed statistically significant differences in mitral, aortic, tricuspid and pericardial thickening, with the strongest evidence for mitral and pericardial structures.

CONCLUSIONS

This confirms the results of previous studies. Occupational exposure to noise environments characterized by LPALF noise causes structural changes in the heart. Mitral valve and pericardial thickening constitute the first signs of VAD.

[Thrombolysis in pulmonary embolism - initial experience]

Pulmonary embolism (PE) is a clinical situation difficult to diagnose, at times of great clinical instability, above all when it is massive, which leads to difficulties in the approach and treatment of patients. The treatment has not had any major innovations in recent years, being conventional the use of heparin and more rarely embolectomy. Recently, some clinical trials have defended the use of thrombolytics. The objéctive of this paper is to present our experience, although the series is still small. From April 1996 to November 1997, 11 patients were admitted to our Cardiac Intensive Care Unit with the clinical suspicion of PE, 5 of which with great hemodynamic instability and suspicion of massive PE. The clinical presentation was sudden dyspnea and loss of consciousness in 2 patients, dyspnea and hypotension in 2 patients and shock and respiratory arrest in one case. Gasimetry revealed acute hypoxemia and hypocapnia in all cases, average partial blood pressure in O2 (pO2) of 59 mm Hg and CO2 (pCO2) of 19 mm Hg. ECC and thorax x-ray contributed to the diagnosis in 3 patients, transthoracic echocardiography was decisive for the diagnosis in 5 cases, with visualisation of the thrombus by transesophageal echocardiography in 3 patients. All patients were monitored by Swan-Ganz catheter, the average systolic pulmonary artery pressure (PAP) was 74 mm Hg. Thrombolysis with rTPA (10 mg bolus followed by 90 mg in perfusion in 2 hrs) was administered in 6 episodes in 5 patients. Only in the case of the patient in shock were other complications related to the use of thrombolytics namely high digestive hemorrhage. There was a clear clinical improvement in all cases with great relief of dyspnea reduction of cyanosis and jugular engurgitation. The patient in shock recovered systemic pressures and improved the hemodynamic state. A significant reduction in PAP was observed (average of 32.5 mm Hg). PE recurred in two cases: with one death and therapeutic thrombolytic was repeated in the other patient with good results. After discharge, all patients remained asymptomatic under oral anticoagulation.

IN CONCLUSION

Despite this small series, the results favour the use of thrombolytics in PE with a clear clinical and hemodynamic improvement.

Phenolic Compounds from Cyclopia intermedia (Honeybush Tea). 1

The processed leaves and stems of Cyclopia intermedia contain 4-hydroxycinnamic acid, the isoflavones formononetin, afrormosin, calycosin, pseudobaptigen, and fujikinetin, the flavanones naringenin, eriodictyol, hesperitin, and hesperidin, the coumestans medicagol, flemichapparin, and sophoracoumestan B, the xanthones mangiferin and isomangiferin, the flavone luteolin, and the inositol (+)-pinitol.

Social skills training for drug prevention in high-risk female adolescents

BACKGROUND

The effectiveness of social skills training/social network restructuring in the primary and secondary prevention of drug use was examined in a multiethnic cohort of 296 female adolescents ages 14 to 19 years who were pregnant or parenting and/or at risk for drug use.

METHODS

Subjects were randomly assigned to one of two conditions: (a) PALS Skills Training or (b) a control intervention involving no skills training. PALS Skills Training is a combination of cognitive and behavioral techniques to improve social skills and to restructure the teens' social network. All students also participated in a 16-week normative education "Facts of Life" course.

RESULTS

The prevalence of alcohol and any drug use increased significantly over the three assessment periods in the PALS Skills group but not in the No Skills group. Teens in the PALS Skills group who reported no drug use at baseline were 2.9 times as likely to be using marijuana than teens in the No Skills group at 3 months postintervention. PALS Skills Training was no more effective in the secondary prevention of drug use than the control intervention.

CONCLUSIONS

Social skills training was found to be ineffective as a means of primary prevention among non-drug-using high-risk adolescents and may even be counterproductive as a means of primary prevention of marijuana use in this population. When combined with normative information on drug use prevalence, acceptability, and hazards, social skills training is no more effective as a means of secondary prevention than normative education alone.

[Variability of heart rate]

AIM

The basic principles of the physiological mechanisms of heart rate variability are discussed. The different methods used in its assessment are evaluated. An overview of its clinical utility is presented.

STUDY DESIGN

We reviewed the papers on this area until May 1994 we thought relevant. The more or less succinct description of their conclusions is made and commented.

RESULTS

Heart rate frequency and its oscillations are regulated by the autonomic nervous system. Heart rate variability analysis is an easy non invasive means of investigating the autonomic control of the heart. There is a wealth of experimental and clinical evidence linking abnormalities of the autonomic nervous system with the development of serious ventricular arrhythmia and sudden death, and it has been clearly shown that decreased heart rate variability is associated with increased mortality in diabetes and after myocardial infarction. Abnormal heart rate variability has been detected in several other disorders such as hypertension, neurologic diseases, heart failure, renal failure, etc., although here its clinical usefulness is yet to be set. Heart rate variability is influenced by various drugs whose potential protective cardiovascular effect is under investigation.

CONCLUSIONS

Heart rate variability analysis is a promising method that can be used as an index of cardiac autonomic balance and has been shown to be of significant clinical value. RR interval variation is controlled by the activity of cardiac sympathetic and parasympathetic nervous system, the function of which is influenced by many factors such as age, sex, position, breathing, hour of the day, therapeutics, etc. Different methods and results have been used by various authors. Standard values are not yet available to be used or compared in different settings. From the interest it has raised all over the world it is expected that very soon this method will have a widespread use in clinical practice, providing useful tools both for diagnostic and prognostic purposes and to monitor and guide therapeutic interventions.

Flavan and procyanidin glycosides from the bark of blackjack oak

The bark of blackjack oak contains (+)-catechin, (-)-epicatechin, (+)-3-O-[beta-D-glucopyranosyl]-catechin, catechin-(4 alpha-->8)-catechin, epicatechin-(4 beta-->8)-catechin as well as the novel 3-O-[beta-D-glucopyranosyl]-catechin-(4 alpha-->8)-catechin and 3-O-[alpha-L-rhamnopyranosyl-(1-->6)-beta-D-glucopyranosyl]-catechin, as major components. The latter rutinoside of catechin is especially interesting because of the exceptionally small J2,3 C-ring coupling. The glucoside of catechin-(4 alpha-->8)-catechin is only the second proanthocyanidin found in nature in which a 3-O-glycoside is present in the upper 'extender unit' of a dimer.

[Formation of left ventricular thrombus in acute myocardial infarction: significance of the determination of fibrinogen, of products of fibrinogen degradation, and of plasminogen]

OBJECTIVE

To evaluate the significance of the fibrinogen, the plasminogen and the fibrinogen degradation products levels as marks of left intraventricular thrombosis (LIVT) in acute myocardial infarction (AMI).

METHODS

219 consecutive patients of AMI admitted in a Coronary Care Unit of an University Hospital, were prospectively studied. All protocols included a clinical evaluation, an M-mode and 2D echocardiographic study and blood samples, at day 1, 3, 7 and at hospital discharge. In the intraventricular thrombus evaluation just the 4 Asinger grade was considered. In the laboratory evaluation we used: the Clauss chronometric method for the fibrinogen, the colorimetric method for the plasminogen and the agglutination in plaque for the FDP. The patients with ECO in the 2 or 3 Asinger grades and those in which ECO and laboratory study were not performed in the same day, were excluded. 101 patients remained on the study, and they were divided in two groups: 53 patients with LIVT and 48 patients without it.

RESULTS

In both groups the fibrinogen raised along the first six days of the AMI, however in the group with LIVT this level didn't raise as high as in the group without LIVT (p < 0.001). In the FDP evaluation two peaks were found, one at 48 hours and another on the 6 th day, but there were no differences between the two groups. The plasminogen values raised along the first week of AMI, in a similar way in both groups.

CONCLUSIONS

a) Fibrinogen levels raises in AMI, but this elevation is significantly smaller in the group with LIVT, which suggests fibrinogen consume in fibrin formation of the thrombus. b) FDP and plasminogen levels raise along the first week of AMI, but in a similar way in the two groups. c) None of these parameters permitted to individualize patients with thrombus formation.

[A case of incessant junctional tachycardia in a female patient with aneurysm of the interauricular septum]

A permanent supraventricular tachycardia (SVT) was diagnosed in a 54-year-old hypertensive but cardiologically asymptomatic female patient, admitted to a surgery department for biliary lithiasis and hepatic echinococcosis. Heart rate was about 130 bpm and ECGs showed negative P waves in leads I, II, III, aVF, and precordial leads V2 to V6, being the RP' interval longer than P'R interval. Pharmacological intervention during Holter monitoring (20 hours) was instituted: following i.v. propranolol (4 mg), heart rate progressively decreased (to 112 bpm), mainly due to an increase in SVT RP' interval, and brief, spontaneous SVT interruptions occurred, preceded by P'R interval prolongation; SVT stopped after P' recording, and resumed after 2 sinus beats, (showing enlarged P waves and slightly prolonged PR interval), induced by cycle length shortening; later on, under i.v. amiodarone infusion (100 mg/hour) and coincident with the sleeping period, SVT cycle length progressively increased (to 600 msec), due to equivalent increases in P'R and R'P intervals. Two premature ventricular contractions (PVC) occurred during Holter monitoring at a coupling interval of 80-85% of SVT cycle length (480 msec): one PVC apparently originated in left ventricle lateral wall, captured the atria, which were activated 75 msec earlier than expected; the other PVC, apparently originated in left ventricle septoapical region, did not interfere with SVT cycle length. Before these data, a diagnosis of circus movement tachycardia, incorporating a concealed accessory pathway with slow retrograde conduction and ventricular insertion in the postoroseptal or left posterior paraseptal region, and showing minor impairment of antegrade AV nodal conduction, was made. Invasive electrophysiological study was then discarded. With combined oral antiarrhythmic therapy (amiodarone, 600 mg/d), plus propafenone, 450 mg/d), sinus rhythm was permanently restored, with evidence of intraatrial block, slightly prolonged PR interval and no preexcitation. Transesophageal echocardiography revealed a small atrial septal aneurysm associated with a small atrial septal defect; echocardiographic features were consistent with the hypothesis of incomplete regression of the atrial septal aneurysm after partial closure of the atrial septal defect. Abdominal surgery (cholecystectomy plus partial hepatic pericystectomy) was performed without any complications or SVT recurrences. During a 6-month follow-up period, maintaining amiodarone (200 mg/d) and propafenone (450 mg/d), the patient remained SVT-free, and Holter monitoring performed at 3 and 5 months showed permanent sinus rhythm and 1:1 AV conduction with slightly prolonged PR interval (less than 0.29 sec and shortening at faster heart rates). This case documents Holter monitoring capability for the evaluation of tachycardia mechanisms in patients with permanent SVT.

Measurement of spectral reflectance and colorimetric properties of Vita shade guides

Spectrophotometric measurements were done on Vita shade guides. Three shade guides were spectrally analysed. A model was developed for a standard shade guide that can be used repeatedly employing reflectance spectroradiometers.

[The patient with acute cerebrovascular disorders: assessment of associated diseases]

We performed a prospective study in 106 patients with acute stroke. The main purpose was to evaluate the associated diseases and to determine their prevalence and incidence in two different types of cerebrovascular disease: the intracerebral hemorrhage (HI) and ischaemic events (AI). The studied population included 54 men and 52 women with a mean age of 66.8 +/- 10.3 years. A clinical examination was performed in all patients by different specialists and all were submitted to diverse complementary tests, including a computed tomography scan of the brain (TAC) and an echocardiogram (ECO). We found 24 (23%) HI and 82 (77%) AI. In the past history, previous stroke were more prevalent in AI (p less than 0.01). Heart disease was present in 87 (82%) patients but, among them, only atrial fibrillation which was found in 19 (18%) patients, was significantly more frequent in AI (p less than 0.02). Hypertension (HTA) existed in 79 (75%) patients, respiratory complications and periferic vascular disease in 9 (8%), diabetes in 44 (42%) and dyslipidemia in 31 (29%) patients. No significant difference was found between the two groups of stroke regarding these diseases; however, there was a tendency for HTA and diabetes to be more prevalent in HI and for periferic vascular disease in AI. In the blood tests, high haematocrit was found in 35 (33%) patients, anemia in 21 (20%), hypercholesterolemia in 17 (16%), hypertrigliceridemia in 18 (17%) and uremia or creatinemia or ionic alteration in 32 (30%) patients, without any difference in their prevalence and incidence in the two groups of stroke. In conclusion, in this prospective study of patients with an acute stroke, there was 23% of HI and 77% of AI, a high prevalence of previous stroke, heart disease and HTA, but only the previous stroke and, within heart disease, the atrial fibrillation were significantly more frequent in the AI group. Also, periferic vascular disease had a tendency to be more frequent in AI, as well as diabetes and HTA had in HI.

[The importance of heart disease in the various types of cerebral vascular disease. A prospective study]

A prospective study was performed in 106 patients with acute stroke. The main purpose was the cardiac evaluation in the different types of cerebrovascular disease: Intracerebral hemorrhage (H), Cortical ischaemic events (C) and Subcortical ischaemic events (SC) and also to evaluate the interest of echocardiography in detecting occult cardiac sources of emboli. The study population included 54 men and 52 women with a mean age of 66.8 +/- 10.3 years. A thorough neurologic and cardiologic study with a computed tomography of the brain (TAC) and an echocardiogram (ECO) were performed in all patients. It was found 24 (23%) of H, 40 (38%) of C and 32 (30%) of SC. In the past history, heart diseases were more prevalent in C (p less than 0.04); previous stroke and systemic hypertension (HTA) were less prevalent in H (p less than 0.008) and in C (p less than 0.004), respectively. Atrial fibrillation (FA) was more frequent in ischaemic stroke (p less than 0.02) and within these in C (p less than 0.005). No more clinical and functional cardiac features or echocardiographic aspects had any difference in their prevalence in different types of stroke. Without clinical heart disease there were 19 (18%) cases but only in 10 were found in their echocardiograms a potentially embolic heart disease (PEHD) but 8 of them had questionable pathologic significance.

IN CONCLUSION

C had more heart disease in their past history; FA is more frequent in C; it is difficult to diagnose a cerebral embolism with only a coexistent C and CPE, but if there is FA or a past history of heart disease in a C, the diagnosis of cerebral embolism is more probable; finally, echocardiography is of limited value to diagnose a PEHD in the elderly, however it makes possible to better evaluate most cardiac situations.