Crosswire for recanalization of total occlusive coronary arteries

Coronary angioplasty of total occlusions is technically difficult and is associated with limited success rates. The procedural outcome is mainly determined by the underlying pathological process. Recanalization of total occlusions is aimed at finding the passage with least resistance, without causing dissection or perforation. Several techniques have been advocated to improve the overall success rate. Recently, a new 0.014" Nitinol wire (Crosswire, Terumo) has been introduced as a tool, to achieve higher success rates for total occlusion angioplasty. The wire consists of an extremely flexible Nitinol-core, a platinum/iridium coil at the distal tip, and a hydrophilic polymer coating. Balloon angioplasty was attempted in 30 totally occluded coronary arteries with mean age of occlusion being 5 +/- 4 months (range 2-14 months). The initial five procedures were performed following failure of the conventional angioplasty guidewires. Subsequently, Cross-wire was used electively in all the cases. The lesion was crossed successfully in 90% (27/30) cases. Dissection of the coronary artery with subintimal entry was seen in two (7%) cases, and the rest (three cases) could not be crossed. Balloon angioplasty and stenting (n = 21) were performed with good immediate angiographic results. There were no myocardial infarctions or deaths. Fourteen of 16 patients, who had completed 6 months follow-up, were asymptomatic. Angiographic evidence of in-stent restenosis was demonstrable in one case. Successful recanalization of total coronary occlusions by using Cross-wire can be expected in 83% cases, with reasonable safety.

Cross-sectional and Doppler echocardiographic diagnosis of anomalous origin of the left coronary artery from the pulmonary artery and right coronary artery from posterior aortic sinus

A six-year-old asymptomatic child on evaluation for a cardiac murmur, was found on cross-sectional and Doppler echocardiography to have an anomalous origin of the left coronary artery from the pulmonary artery and right coronary artery from posterior sinus of aorta. Doppler studies revealed a continuous signal in the pulmonary artery, indicating a left to right flow. The diagnosis was subsequently confirmed at cardiac catheterization and surgery.

Balloon aortic valvuloplasty in young adults by antegrade, transseptal approach using Inoue balloon

Transvenous, transseptal, antegrade balloon aortic valvuloplasty (BAV) was successfully performed in 16 consecutive young adults with noncalcific aortic stenosis using Inoue balloon catheter. There were 13 males and three females, with a mean age of 20.4 +/- 5.8 years (range 14-30 years). All the patients had normal left ventricular systolic function. All procedures were performed electively by the antegrade technique, except the initial index case in whom, the stenosed aortic valve could not be crossed retrogradely. Dilatation was performed using stepwise technique keeping the balloon:annulus ratio < or = 100% in all the cases. Transaortic peak systolic gradient decreased from 113.4 +/- 42.6 (range 70-210) mm Hg to 11.2 +/- 9.2 (range 4-32) mm Hg; P = 0.0005. Following BAV, three patients developed grade 2+ aortic regurgitation, who were managed medically. None of the patients developed tamponade, vascular complications, excessive bleeding, or thromboembolism. Significant left to right atrial shunt (Qp/Qs > or = 1.5:1) was observed in one case. The average procedure time was 20 +/- 8 min (range 18-35 min). On follow-up (n = 11 patients) at 4 +/- 1.5 months (range 2-7 months) all the patients were asymptomatic. Doppler transaortic peak systolic gradient was found to be 15 +/- 10.3 mm Hg (range 4-36 mm Hg). Antegrade BAV technique using Inoue balloon for noncalcific aortic stenosis in young adults is safe, effective and may be technically advantageous.

Pulsed Doppler echocardiographic study of left ventricular diastolic function in patients with idiopathic dilated cardiomyopathy

Dilated cardiomyopathy is basically regarded as a disease of left ventricular systolic dysfunction. There are only a few studies evaluating diastolic function in patients with dilated cardiomyopathy. To assess the LV diastolic function, 25 patients with idiopathic dilated cardiomyopathy and 20 age and sex matched normal subjects were studied with transmitral spectral tracings derived from pulsed Doppler echocardiography. All cardiomyopathy patients were in New York Heart Association class III to IV with dilated left ventricles and reduced systolic function (mean ejection fraction of 36.6 +/- 6.7 Vs 65 +/- 6 in normal subjects, p < 0.001). Patients with cardiomyopathy demonstrated an increased ratio of early to late diastolic velocity (E/A) (1.89 +/- 0.59 Vs 1.50 +/- 0.27 m/sec, p < 0.05), short deceleration time (E-E/2) (57.05 +/- 13.36 Vs 70.20 +/- 16.56 msec, p < 0.01) and short isovolumic relaxation time (IVRT) (53.5 +/- 22.7 Vs 72 +/- 12 msec, p < 0.05) as compared to normal subjects. The early filling fraction (EFF) was higher (0.71 +/- 0.11 Vs 0.66 +/- 0.06, p < 0.05) and atrial filling fraction (AFF) was lower (0.28 +/- 0.11 Vs 0.33 +/- 0.06, p < 0.05) in cardiomyopathy patients than in normal subjects. Our observations in a select group of dilated cardiomyopathy patients with advanced disease demonstrate a restrictive pattern on pulsed Doppler echocardiography.

Combined mitral and aortic valvuloplasty by antegrade transseptal approach using Inoue balloon catheter

OBJECTIVE

The purpose of this paper is firstly to highlight the ease with which the antegrade balloon aortic valvuloplasty can be performed with the Inoue balloon and secondly, the utility of the Inoue rubber nylon self-positioning balloon catheter used for twin valve dilatation.

STUDY DESIGN

Percutaneous balloon valvuloplasty is being increasingly practised for treatment of multivalvular stenoses. We describe the case of a young (21 years), male who successfully underwent combined dilation of rheumatic mitral and aortic stenosis via the transseptal antegrade approach using Inoue balloon catheters for both valves.

RESULT

Following the procedure, the mitral valve area increased from 0.6 cm2 to 1.7 cm2 and the peak systolic gradient across the aortic valve decreased from 100 mm Hg to 8 mm Hg without causing significant regurgitation at either.

CONCLUSIONS

This report highlights the ease of performing balloon aortic valvuloplasty via the antegrade transvenous route and utilizing the advantages of Inoue balloon catheter.

Cardiac myxomas: clinical and echocardiographic profile

We reviewed our clinical and echocardiographic experience in 70 consecutive patients with 73 cardiac myxomas, diagnosed over an 11 year period. There were 21 males and 49 females, ages ranged from 18 to 80 years. Only in 5.7% cases was the diagnosis of myxomas made clinically. 88.6% cases were initially diagnosed as having: mitral valve disease (70%), tricuspid valve disease (10%), ischemic heart disease (5.7%), cardiomyopathy (2.9%), and the remaining 5.7% were detected during family screening and follow-up. The mean duration of symptoms was 10.6 months. The commonest symptom was dyspnoea (80%), followed by constitutional symptoms (45.7%), embolization (30%), palpitation (25.7%), syncope (15.7%), pedal oedema (15.7%) and pain chest (12.9%). The sites of myxomas were as follows: left atrium, 58; right atrium, 9; and, biatrium, 3. All myxomas except 3 were attached to the interatrial septum. The site, size, shape, attachment, mobility, prolapse into ventricle, and surface characteristic of myxomas were accurately assessed by 2D-echocardiography and confirmed in all (65 of 70) who underwent surgery. When the morphological characteristic of myxomas were studied and correlated with clinical features large left atrial myxoma size was closely related with constitutional symptoms, congestive heart failure, with syncope and auscultatory findings suggestive of mitral valve disease, whereas smaller myxoma size and irregular surface were associated with embolization. Constitutional symptoms were only present in left atrial myxoma. Post-operative mean echocardiographic follow-up of 60 months showed no recurrence except in 2 with familial myxoma. We conclude that the majority of myxomas mimic many cardiovascular diseases and were detected in symptomatic patients, so a high index of clinical suspicion is important for its early and correct diagnosis. The size and appearance of the myxomas correlated with the presenting symptoms.

Comparative evaluation of transthoracic and transesophageal echocardiography in detection of left atrial thrombus before percutaneous transvenous mitral commissurotomy. Do all patients need transesophageal examination?

We postulated that the sensitivity of transthoracic echocardiography in detection of left atrial cavity or appendage thrombi is better in south-east asian patients with rheumatic mitral stenosis. This was considering that these patients are generally younger, have lesser body weight and thinner chest walls resulting in better transthoracic echogenecity than their western counterparts. We prospectively performed transthoracic and transoesophageal echocardiography in 150 consecutive Indian patients (mean age 28.8+/-7.2 years; 78 men) being evaluated for percutaneous transvenous mitral commissurotomy. The overall sensitivity of transthoracic echocardiography was 74% (95% C.I. 59-88%). This was significantly higher than the pooled estimate from five western reports which evaluated similar patients (overall sensitivity 12%; 95% C.I. 0-25%; P<0.0001). The sensitivity rose to 83% when patients with poor echogenecity were excluded. Amongst patients with good echogenecity (81% patients) the diagnosis of left atrial thrombi was correctly made or suspected on transthoracic examination in all patients subsequently shown to have thrombi on transoesophageal echocardiography. Significant savings in cost may be safely achieved by limiting transoesophageal echocardiography to patients in whom left atrial cavity or appendage is not adequately visualized on transthoracic examination due to poor echogenecity, or in whom there are shadows suggestive but not diagnostic of thrombi.

Balloon mitral valvotomy: comparison between antegrade Inoue and retrograde non-transseptal techniques

AIMS

The results of percutaneous mitral valvotomy performed by the antegrade transseptal method using the Inoue balloon (n = 1000; group 1) and by the retrograde non-transseptal technique using a polyethylene balloon (n = 100; group 2) were compared in a retrospective, non-randomized study.

METHODS AND RESULTS

Both the groups were similar with respect to baseline characteristics. The success rate was 95% in group 1 and 93% in group 2. There was a significant increase in mitral valve area estimated by Gorlin's equation (Group 1: from 0.8 +/- 0.5 to 2.1 +/- 0.8 cm2; Group 2: from 0.8 +/- 0.3 to 1.9 +/- 0.8 cm2, both P < 0.001) and by Doppler echocardiography using the pressure half-time method (Group 1: from 0.9 +/- 0.4 to 2.2 +/- 0.6 cm2; Group 2: from 0.9 +/- 0.3 to 2.0 +/- 0.7 cm2, both P < 0.001). However, the calculated immediate post-valvotomy mitral valve area was larger with the Inoue technique (2.1 +/- 0.8 vs 1.9 +/- 0.8 cm2; (P < 0.02). Results were considered optimal when the mitral valve area increased to > or = 1.5 cm2, the percentage increase was > or = 50, and mitral regurgitation was < or = 2/4. Out of the total successful procedures, optimal results were obtained in 95% patients in Group 1 and 94% in Group 2. Incidence of significant mitral regurgitation (> or = grade 3/4) was similar in two groups (Group 1: 4% vs Group 2: 5%, P = ns). A significant left to right atrial shunt (Qp/Qs > or = 1.5:1) in 2.5% and tamponade in 2% of cases occurred exclusively with the Inoue technique, while conduction disturbances, such as transient (< 24 h) left bundle branch block (28%) and complete heart block (2%) were noted with the retrograde technique (Group 2). Local complications were significantly higher in Group 2 (3% vs 0.5%, P < 0.01). The procedure time with the Inoue technique was shorter than with the retrograde (Group 1: 15 +/- 8, range 10 to 35 min; Group 2: 22 +/- 14, range 15 to 45 min, P = 0.05). Echocardiographic follow-up at 1 year showed no significant difference in mitral valve area between the two groups (Group 1 (n = 300): 1.8 +/- 0.8 vs Group 2 (n = 60): 1.9 +/- 0.9 cm2; P = 0.3).

CONCLUSIONS

Balloon mitral valvotomy using the Inoue balloon and the retrograde non-transseptal technique results in significant immediate haemodynamic and symptomatic improvement. The Inoue technique achieved a larger immediate post-valvotomy mitral valve area, but the difference was not apparent at 1 year follow-up. Incidence of significant mitral regurgitation was similar with both the techniques; however, local complications occurred more frequently with the retrograde technique. Both techniques may complement each other in technically difficult cases.

Atypical lipoma as a potential pitfall in the cytodiagnosis of subcutaneous tumors. A report of two cases

BACKGROUND

If well-differentiated liposarcomas of lipomalike type occur in the subcutis, they behave as benign neoplasms. For these tumors the term atypical lipoma was introduced in 1975. Fine needle aspiration (FNA) findings in these tumors may raise a false impression of malignancy.

CASES

Females aged 34 and 48 years presented with well-defined subcutaneous nodules in the left supraclavicular region and on top of the head, respectively. FNA showed fragments of mature fat tissue and numerous dispersed, large, hyperchromatic, often bizarre nuclei. Lipoma with atypical cells was diagnosed cytologically in one case and atypical lipoma in the other. Histologically both cases were evaluated as atypical lipoma.

CONCLUSION

A correct cytologic diagnosis of atypical lipoma can be established if cytomorphologic features are coupled with clinical data.

Versatility of Inoue balloon catheter

Inoue rubber nylon single balloon catheter is being used worldwide for performing balloon mitral valvuloplasty (BMV). The popularity of Inoue balloon is attributed to its self-positioning configuration, size-adjustability, rapid inflation-deflation sequence and the ease of performance. We report its use in performing various non-mitral interventions. Its utility in treating patients with mitral stenosis and combined mitral and tricuspid stenosis is well established. Seventeen patients with valvular pulmonic stenosis (age 32+/-16 years; 11 males and 6 females) achieved significant reduction of peak systolic gradient (PSG) from 125+/-28 to 32+/-16 mmHg (P<0.005). Four patients with inferior vena-cava obstruction (age 20-48 years; 3 males and 1 female) derived symptomatic benefit following successful dilatation. Inoue balloon was used to create percutaneous pericardial window in four cases (age 43-68 years; 2 males and 2 females) of recurrent pericardial collection secondary to carcinoma lung/breast, thus alleviating the symptoms of tamponade. One patient each with coarctation of aorta (32 years, male), discrete subaortic membrane (16 years, female), and critical valvular aortic stenosis (13 years, male) derived immediate hemodynamic improvement with Inoue balloon dilatation. No major complications were encountered. We conclude that Inoue balloon can be used to successfully manage various stenotic lesions.

Our experience with Palmaz-Schatz coronary stent

Between September 1993 and August 1994 we have implanted Palmaz-Schatz coronary stents in 44 patients. Twenty eight patients presented with stable angina and 16 with unstable angina. Stenting was carried out for denovo, focal lesions in large coronary arteries (n = 27), significant dissection during PTCA with acute threatened closure (n = 9), suboptimal results (n = 5), restenosis after PTCA (n = 2) and saphenous vein graft stenosis (n = 1). Successful delivery of the stent was achieved in 43 cases. Percent diameter stenosis was reduced from 77 +/- 11% to 10 +/- 8% and minimal luminal diameter increased from 1.08 +/- 0.28 mm to 2.92 +/- 0.39 mm. There was 1 death due to left main dissection secondary to guiding catheter trauma in a patient taken up for bail out stenting. Vascular/bleeding complications occurred in 3 patients (6.7%). There was no instance of acute or subacute stent thrombosis. Forty patients are symptom free. Eighteen patients underwent six month angiography. Restenosis (> 50% diameter reduction) was seen in 2 and a new lesion distal to stent occurred in 1 case. All have been successfully redilated. A high rate of successful delivery of the Palmaz-Schatz coronary stent can be achieved in a wide spectrum of patients with very few complications. Long term results are very gratifying and encouraging.

Noninvasive estimation of pulmonary artery wedge pressure by dual-M-mode-echocardiography

Pulmonary artery wedge pressure (PAWP) measurement is invasive, associated with complications, contraindications and its high cost limits its use in clinical practice. We evaluated the use of dual-M-mode-echocardiography as a possible noninvasive alternative method in 20 patients for estimating the PAWP. The interval from the Q-wave of the electrocardiogram (ECG) to the mitral valve closure on the mitral valve M-mode-echocardiogram (Q-MVC), the interval between the aortic valve closure and mitral valve E point (AVC-E) on aortic and mitral valve M-mode-ECG respectively and the ratio of these intervals (Q-MVC/AVC-E) was correlated to the mean PAWP measured at catheterization. The mean PAWP correlated excellently with Q-MVC/AVC-E ratio [r = 0.89, p < 0.0001, y = 14.51 (Q-MVC/AVC-E) + 6.71]. The estimation of PAWP by a dual-M-mode-ECG offers a useful estimate of mean PAWP noninvasively.

Percutaneous balloon mitral valvuloplasty: analysis of echocardiographic and other variables related to outcome

To determine whether mitral valve (MV) morphology influences the result of balloon mitral valvuloplasty (BMV) for mitral stenosis, two-dimensional echocardiography was performed before BMV in 53 patients and in 25 normal controls. The two-dimensional echocardiographic features of MV leaflets: thickness, length and motion, diastolic MV excursion, chordal length, MV annular diameter (MVAnD), subvalvular distance ratio (SDR), and effective balloon dilating area (EBDA) and diameter (EBDD) were then correlated to the immediate post-BMV mitral valve area (MVA). For the total patient population, post-BMV MVA increased from 0.76 +/- 0.24 to 1.91 +/- 0.59 cm2 (p < 0.0001) and mean diastolic transmitral gradient decreased from 20.1 +/- 6.15 to 5.8 +/- 3.29 mm (p < 0.0001). The patients were divided into two groups on the basis of post-BMV MVA. Group I had post-BMV MVA < 2.0 cm2 and group II had post-BMV MVA > or = 2.0 cm2. A statistically significant difference was noted in SDR (0.33 +/- 0.057 vs 0.45 +/- 0.042, p < 0.0001); mid-MV anulus to tip of papillary muscle (PM) distance (20.0 +/- 3.8 vs 27.9 +/- 4.54 mm, p < 0.0001); chordal length (4.3 +/- 3.6 vs 9.8 +/- 3.9 mm, p < 0.0001); diastolic MV excursion (15.5 +/- 2.6 vs 18.2 +/- 4.2 mm, p < 0.01); leaflet mobility (p < 0.05); and EBDA (4.4 +/- 0.6 vs 4.9 +/- 0.5 cm2, p < 0.01).(ABSTRACT TRUNCATED AT 250 WORDS)

Echocardiographic diagnosis of aneurysm of the sinus of Valsalva

Echocardiographic and Doppler data of 62 patients with ASOV are presented. Catheterization and angiography were performed in 38 cases and surgery in 25 of the 38. The origin of these aneurysms was the RCS in 56 cases, NCS in 5, and LCS in 1 case. Seven had unruptured aneurysms, 6 rising from RCS dissected into the ventricular septum, producing heart block in 4, AR in 5, mitral regurgitation in 1; 1 aneurysm rising from the LCS was asymptomatic. In other cases (n = 55) the aneurysm had ruptured into one of the cardiac chambers. Thirty-two of the 50 RCS aneurysms ruptured into the RVOT, 13 into the RV cavity, 2 into the RA, and 3 into the LV. Of the 5 NCS aneurysms, (3 ruptured into the RA, 1 into the RV, and 1 into both the RA and RV. Associated VSD was identified in 16 (25.8%) of 62 cases. All of these patients had RCS aneurysms that ruptured into the RVOT. Echocardiography missed VSD in three cases that at surgery were found to have VSD. AR was found in 34 of 62 cases. Echocardiography picked up discrete subaortic stenosis in two cases but missed subvalvar PS in 2 of the 3 cases. A detailed echocardiographic study (two-dimensional, Doppler, and color flow imaging) is accurate in the diagnosis of ASOV, in the identification of its site of origin and rupture, and in the evaluation of the associated defects; in the vast majority of cases, it can totally supplant the need for angiography.

Clinical profile of biopsy proven idiopathic myocarditis

We studied 20 patients in detail (age: 27 months to 45 years, mean 22 years; 15 males, 5 females) of idiopathic myocarditis histologically confirmed by endomyocardial biopsy. None of these patients had evidence of active or previous rheumatic fever. The commonest mode of presentation was congestive heart failure (16 patients) followed by arrhythmias (seven patients--five of whom had associated congestive heart failure) and chest pain resembling myocardial infarction (two patients). Ten patients had a history of preceding upper respiratory infection. Only one of these patients had a significant rising serum titre for Coxsackie B3 virus. Throat and rectal swabs for virus culture were negative in all patients. The electrocardiogram was abnormal in all patients, with a prolonged corrected QT-interval being the commonest abnormality (14 patients). Serial electrocardiographic patterns of evolving myocardial infarction occurred in three patients. Echocardiographic left ventricular end diastolic dimension (4.15 +/- 1.01 cm/m2) and end systolic dimension (3.37 +/- 1.03 cm/m2) were increased in 15 of the 18 patients studied. Pericardial involvement occurred in only one patient. Radionuclide ventriculography showed a reduced left ventricular ejection fraction (< 50%) in 17 patients, global hypokinesia in 12 patients and regional wall motion abnormalities in five patients. Left ventricular and right ventricular end diastolic pressures were elevated in 15 and 11 patients, respectively.

Echocardiographic diagnosis of total anomalous pulmonary venous connection

Over a 7-year period, 110 of 35,000 echocardiographic cases were diagnosed to have total anomalous pulmonary venous connection (TAPVC). Ages ranged from 7 days to 38 years (male 62, female, 48). In 60 cases the diagnosis was confirmed by angiography (n = 47) and/or surgery (n = 50). In 13 cases angiography was not performed; surgery was performed on the basis of echocardiographic diagnosis. Diagnosis of TAPVC was correctly made in all of the 60 confirmed cases. Drainage sites were correctly identified by echocardiography in 58 (96.7%) of these 60 cases. Of the five cases of mixed TAPVC, the second drainage site was missed by echocardiography in two cases. Of the 110 cases the drainage sites were as follows: supracardiac 70, cardiac 30, infracardiac 5, and mixed variety 5. Seventeen cases had Doppler echocardiographic evidence of obstruction along the course of the anomalous vein. The continuous wave Doppler signal for tricuspid regurgitation was present in 14 of 47 catheterized patients, and catheterization-measured peak pulmonary artery systolic pressure correlated well with that derived by Doppler study (r = 0.96, p = 0.001). Additionally, 17 patients had other cardiac anomalies that were correctly diagnosed by echocardiography. Combined two-dimensional and Doppler echocardiography is accurate in the diagnosis of TAPVC, identification of the site of drainage, presence of obstruction, and assessment of pulmonary arterial hypertension and other associated anomalies.

Pattern of cancer in Jammu region (hospital based study 1978-'87)

2681 histologically confirmed cases of cancer (1402 males and 1279 females) were seen during the ten year period 1978 to 1987 in Pathology Department, Government Medical College, Jammu. The relative frequencies of cancer at various primary sites have been determined with respect to age, sex and religion. The majority of cancers were seen between 31-60 years (67.7%) with a peak in 41-50 years age group. Out of the total cancer patients 2,437 were Hindus (90.8%) and 244 were Muslims (9.2%). The most common cancer sites among males were lung, skin, larynx, prostate and lymphnodes. Cancer cervix was the most common tumor in females, followed by cancer breast, gall bladder and uterus. Among Muslims, cancer cervix and penis were infrequent. Cancer lung and larynx were also relatively less frequent in Muslims.

Concurrent percutaneous balloon valvotomy for combined rheumatic tricuspid and aortic stenosis

Concurrent percutaneous balloon valvotomy of aortic and tricuspid valve was successfully performed in a 20-year-old male with severe rheumatic aortic and tricuspid stenosis. Balloon valvotomy was done using a 18-mm single balloon for aortic and 20 + 20-mm double balloon for the tricuspid valve. Immediately after valvotomy the peak transaortic systolic gradient decreased from 120 to 32 mmHg and the aortic valve area increased from 0.27 to 1.1 cm2, the mean and end-diastolic trans-tricuspid gradient decreased from 14 and 18 to 1.5 and 2 mmHg, respectively, the tricuspid valve area increased from 0.8 to 3.6 cm2 and the cardiac-index increased from 2 to 2.9 l/mt/m2. At 1 year of follow-up the clinical (NYHA class 1) and hemodynamic improvement was maintained.

Rheumatic mitral stenosis associated with hypertrophic cardiomyopathy and anomalous muscle bundle in the right ventricle

Clinical, echocardiographic, haemodynamic and angiographic features of a patient with rheumatic mitral stenosis, hypertrophic cardiomyopathy and anomalous muscle bundle in the right ventricle are presented. At the bedside, the presence of left ventricle type apex beat, left ventricle S4 gallop, ejection systolic murmur at the left mid sternal border and electrocardiographic evidence of left ventricular hypertrophy in a patient with classical findings of mitral stenosis in the absence of significant mitral regurgitation and aortic valve disease should suggest this extremely rare association of mitral stenosis with hypertrophic cardiomyopathy.

Noninvasive assessment of systolic and diastolic left ventricular function in patients with chronic severe anemia: a combined M-mode, two-dimensional, and Doppler echocardiographic study

Thirty-one patients with chronic severe anemia of more than 3 months' duration (hemoglobin less than 7 gm/dl) and no underlying heart disease were studied by means of M-mode, two-dimensional, and Doppler echocardiography; an equal number of normal control subjects was also studied. There are conflicting reports regarding the influence of chronic severe anemia on systolic myocardial function, but diastolic function has not been systematically assessed. It is also uncertain whether anemia alone can cause heart failure in a structurally normal heart. We therefore performed a detailed study of echocardiographic indexes of systolic and diastolic left ventricular function in these patients. We found that patients with anemia have significantly faster heart rates and lower diastolic and mean blood pressures than normal subjects. They also have a significantly elevated cardiac output and stroke volume and larger left ventricles. Left ventricular contractility, assessed by the end-systolic stress-dimension relationship, was enhanced. There was no systematic evidence of diastolic dysfunction by Doppler assessment of mitral inflow. There was also no clinical evidence of congestive heart failure. We conclude that chronic severe anemia leads to a hyperdynamic state with systolic hyperfunction and no impairment of diastolic function. Anemia does not lead to congestive heart failure in the absence of underlying heart disease.

Role of QT interval at onset of acute myocardial infarction in predicting early phase ventricular arrhythmia

In this study, the QTc interval was determined in 51 patients of acute myocardial infarction and the incidence of ventricular arrhythmias in them was noted. It was found that the QTc interval was prolonged (more than 0.44 sec) in all the 33 patients who developed ventricular arrhythmias, while it was below 0.44 sec in all the 18 patients who did not develop ventricular arrhythmia.

Immunosuppressive therapy in inflammatory myocarditis: long-term follow-up

Sixteen patients (12 male and 4 female, age 2-46 years) with endomyocardial biopsy-proven myocarditis were prospectively evaluated with immunosuppressive therapy including azathioprine and prednisolone in addition to other standard measures. Patients were either in NYHA class IV (n = 12) or class III (n = 4). Twelve patients showed improvement and the remaining 4 continued to deteriorate: 2 died at 1 and 2 months after therapy and the other 2 were lost to follow-up after 4-6 weeks of therapy. Three of the 12 patients who showed significant improvement, after sudden omission of therapy (at 8 weeks, 6 and 8 months) worsened and died. One patient who showed significant improvement died suddenly after 9 months of therapy while playing football. The remaining patients have shown significant clinical and haemodynamic improvement with normalization of myocardial morphology. Serial haemodynamic studies revealed a significant fall in cardiothoracic ratio (before: 62.3 +/- 4.7%; 3 months: 55.1 +/- 3.1%, P less than 0.0001; 6-12 months: 50.6 +/- 1.5%, P less than 0.0001), mean pulmonary artery pressure (before: 34.3 +/- 13.05 mm; 3 months: 20.4 +/- 8.71 mm, P less than 0.01; 6-12 months: 20.0 +/- 2.75 mm, P less than 0.01) and mean pulmonary artery wedge pressure (before: 26.0 +/- 9.07 mm; 3 months 14.0 +/- 5.63 mm, P less than 0.001; 6-12 months: 13.2 +/- 4.57 mm, P less than 0.001). The left ventricular ejection fraction improved from 24.3 +/- 8.36% to 35.8 +/- 9.72% (P less than 0.001) at 3 months and 49.8 +/- 18.2% (P less than 0.0001) at 6-12 months of therapy. Two patients have been subsequently lost to follow-up whereas the remaining 6 patients are on follow-up for 1-4 years after therapy and are doing fine. Our uncontrolled observations suggest that immunosuppressive therapy may be useful in patients with inflammatory myocarditis.

Value of exercise vectorcardiography and exercise radionuclide ventriculography in identification of coronary arterial disease in patients with left bundle branch block

Twelve patients (8 male and 4 female, age ranged 39-60 years) with suspected coronary arterial disease with left bundle branch block were evaluated for ischemia by simultaneous exercise vectorcardiography and radionuclide-ventriculography. Selective coronary angiography revealed normal coronary arteries in 5 and significant coronary arterial disease in 7 patients. Radionuclide ventriculography revealed no significant difference in resting left ventricular ejection fraction in patients with normal coronary arteries (44.0 +/- 13.9%) and coronary arterial disease (45.7 +/- 11.9%). Exercise radionuclide ventriculography showed positive response suggestive of ischemia in 11 patients (11/12), including all 5 with normal coronary arteries and 6/7 with coronary arterial disease. The magnitude of spatial 'R' maximum cardiac vector in both groups at rest (normal coronary arteries: 1.61 +/- 0.22 mV, coronary arterial disease: 1.63 +/- 0.35 mV) did not show any significant difference. On exercise, the magnitude of spatial 'R' maximum cardiac vector uniformly increased in patients with normal coronary arteries (1.61 +/- 0.22 to 1.75 +/- 0.25 mV, P less than 0.01) and decreased in 6 and remained unchanged in 1 patient with coronary arterial disease (1.63 +/- 0.35 to 1.34 +/- 0.46 mV, P less than 0.01). There was no change in rotational characteristics of QRS and T loops at end exercise in either group. Our preliminary observations indicate that exercise induced alteration of the magnitude of the maximal spatial 'R' cardiac vector appears to be an useful parameter to diagnose underlying coronary arterial disease in patients with left bundle branch block. Having a high false positive response, exercise radionuclide ventriculography appears to be of limited value in these patients.