Angiotensin II levels, hemodynamics, and sympathoadrenal function after low-dose captopril in heart failure

The angiotensin converting enzyme inhibitor captopril improves the altered hemodynamics in many patients with chronic heart failure, but the first dose may precipitate hypotension. Ten patients with chronic heart failure were studied, nine with high plasma concentrations of renin and one with a low concentration. Frequent measurements of plasma concentrations of angiotensin II, renin, and catecholamines were made over 60 minutes after a small dose (6.25 mg) of captopril and related to concurrently measured hemodynamic variables. Captopril caused a decrease in systemic and pulmonary artery pressure and an increase in cardiac index, and these changes coincided with reductions in the plasma concentrations of angiotensin II and increases in plasma concentrations of renin. The hemodynamic changes were accompanied by reductions in the plasma concentrations of norepinephrine but transient increases in plasma concentrations of epinephrine in patients in whom vasomotor syncope developed. The patient with a low plasma renin concentration showed little hemodynamic response to the drug. It is concluded that vasomotor syncope occurs quite frequently in patients with severe chronic heart failure after captopril in a small dose and is associated with a selective increase in epinephrine secretion from the adrenal medulla.

Aortobronchial fistula: a late complication of division of the persistent ductus arteriosus

An 11-year-old girl had nearly fatal hemoptysis due to false aneurysm and aortobronchial fistula following ductus division 9 years previously. Silk suture material was implicated as a causative agent in association with dilation of the aortic isthmus. To our knowledge, no previous report of this complication exists in the literature. Twenty-two cases of false aneurysm have been described, 86.3% following ligation. The use of elective hypotension during ligation and monofilament suture during division may prevent this serious late complication in the future.

The individuality of teenage mothers and its implication for intervention strategies

An exploratory longitudinal research project of teenage mothers and their infants was carried out, involving intensive study of a small number of cases. Four case studies from the research are presented which illustrate the tremendous differences between teenage mothers, their support systems and the need for and success of intervention. The cases also show the need to individualize support to teenage mothers and suggest that routine structured classes on child development and parenting skills are not always necessary or sufficient. The cases also suggest that there are at least three types of teenage mother-infant pairs each of which will require a different level of intervention, ranging from Level I to Level IV. A plea is made for the individualization of services to teenage mothers depending on the strengths, emotional capacities and needs of the mother and her infant.

Echocardiographic features in spontaneous disruption of implanted tissue aortic valves

The echocardiographic features were recorded in three patients with spontaneous disruption of implanted tissue aortic valves. Two of the patients had xenografts, and one had a homograft. Aortic regurgitation had developed in all three spontaneously in the absence of active infective endocarditis. In each case there was severe disruption of the valve. Similar echocardiographic features have been found, usually in association with infective endocarditis or with myxomatous degeneration of the aortic valve. They have not previously been reported in association with implanted tissue aortic valves.

Clinical, echocardiographic, and operative findings in active infective endocarditis

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Mitral annuloplasty in endomyocardial fibrosis: an alternative to valve replacement

The case of a patient with left ventricular endomyocardial fibrosis (EMF) causing severe mitral regurgitation is presented. Excision of the fibrotic tissue through the left atrium and mitral annuloplasty resulted in symptomatic relief and uncomplicated pregnancy. An X-linked congenital dermatological condition, Bloch-Sulzberger syndrome (incontinentia pigmenti), associated with chronic eosinophilia, was also present. This occurrence with EMF has not previously been reported. Atrioventricular valve reconstruction is a feasible alternative to valve replacement in EMF.

Discrete subaortic stenosis

Data concerning 17 consecutive patients with discrete subaortic stenosis are recorded. Twelve patients underwent operative resection of the obstructing lesion. Of these all except one were symptomatic and all had electrocardiographic evidence of left ventricular hypertrophy or left ventricular hypertrophy with strain. They had a peak resting systolic left ventricular outflow tract gradient of greater than 50 mmHg as predicted from the combined cuff measurement of systolic blood pressure and the echocardiographically estimated left ventricular systolic pressure and/or as determined by cardiac catheterisation. The outflow tract gradient as predicted from M-mode echocardiography and peak systolic pressure showed close correlation with that measured at cardiac catheterisation or operation. During the postoperative follow-up from one month to 11 years, of 11 patients, one patient required a further operation for recurrence of the obstruction four years after the initial operation. All patients are now asymptomatic. Five patients have not had an operation. The left ventricular outflow tract gradient as assessed at the time of cardiac catheterisation was greater than 50 mmHg. One patient has been lost to follow-up. The remaining four have been followed from four to eight years and have remained asymptomatic and the electrocardiograms have remained unchanged. Careful follow-up of all patients is essential with continuing clinical assessment, electrocardiograms, M-mode and two-dimensional echocardiograms, and if necessary cardiac catheterisation. Prophylaxis against bacterial endocarditis is also essential.

Aortic valve replacement for severe aortic regurgitation caused by idiopathic giant cell aortitis

Giant cell aoritis occurred in a 25-year-old woman, with absent pulses in the left arm and severe aortic regurgitation from dilatation of the valvar annulus. The aortic valve was replaced by a Starr-Edwards prosthesis, and the patient was treated with steroids. Five years later, she continues asymptomatic and haemodynamically stable. The left brachial and radial pulses have returned.

Comparative analysis of isolated aortic valve replacement with fascia lata and homograft valves

Thirty-eight consecutive patients who underwent isolated replacement of the aortic valve with fascia lata in 1970 were compared with a similar series of patients undergoing homograft replacement of the aortic valve. These series were well matched in number, age sex of patients, symptomatology, valvular disease, electrocardiographic and roentegenographic changes, and preoperative cardiac catheterization data. The mean follow-up time was 73 months in the fascia lata series and 69.1 months in the homograft series, and all the post-operative survivors were reviewed. The early and long-term results were similar of the two series, and there was no statistical difference in the operative and late mortality, the incidence of early and late diastolic murmurs, valve failure necessitating valve replacement, infective endocarditis, thromboembolism, over-all survival, and survival with an intact valve. It is concluded that the long-term results of valve replacement using these two tissues, in the aortic position, are similar and there is little to choose between the two types of valves. If fascia lata, as we believe, is no longer acceptable as a satisafactory valve substitute, then homograft valves are not acceptable either.

Delayed non-mycotic false aneurysm of ascending aortic cannulation site

Two cases of delayed non-mycotic false aneurysm arising from ascending aortic cannulation site, presenting one-and-a-hald years and seven years after cardiopulmonary bypass, are described. These two cases represent an incidence of 0.12% of this complication. Repair using profound hypothermia and circulatory arrest with femoral artery and femoral vein cannulation for cardiopulmonary bypass is recommended. The advantages and complications of aortic cannulation are discussed and recommendations to minimise the complications of cannulation are made. The clinical presentation and diagnosis of non-mycotic false aneurysms arising from the aortic cannulation site are described. In addition one delayed and two early cases of non-mycotic cannulation site false aneurysms previously published are analysed. Surgeons should be alert to the possibility of this complication in all patients who have had aortic cannulation for cardiopulmonary bypass even in the distant past. Unexpected symptoms such as constant anterior chest pain, dysphagia, hoarseness, and increasing widening of the superior mediastinum on the chest radiograph warrant prompt investigation.

The diagnosis of organic tricuspid valve disease

Diagnostic features of organic tricuspid valve disease are discussed with emphasis on clinical features. Cardiac catheter data show considerable differences in assessment as do the chest radiographs. Measurement of the right atrial border from the vertebral edge is a reliable guide to diagnosis.

A universally applicable continuous suture technique for insertion of aortic valve prostheses

In a series of 55 consecutive patients with both single- and multiple-valve disease and aortic aneurysm, the aortic valve was replaced using a continuous suture technique. The technique is applicable for both ball- and disc-valve prostheses. This method resulted in a marked reduction in cardiopulmonary bypass time with a very low incidence of perivalvular leak. It has major advantages over other continuous and interrupted suture techniques.

Plasma and tissue digoxin concentrations in patients undergoing cardiopulmonary bypass

Plasma myocardial, and skeletal muscle digoxin concentrations were measured in 32 patients undergoing cardiopulmonary bypass who were on long-term treatment with digoxin. The patients were divided into 4 groups according to the daily digoxin dose and the interval between discontinuation of the drug and operation. Before bypass, the mean digoxin concentrations were 1.58 nmol/l (1.24 ng/ml) in plasma 65.2 nmol/kg (50.9 ng/g) in the atria, 121.4 nmol/kg (94.98 ng/g) in 11 papillary muscles, and 16.6 nmol/kg (13.0 ng/g) in skeletal muscle. Mean atrial digoxin concentrations were significantly lower tham mean papillary muscle concentrations in 11 patients. Ratios of plasma of myocardial or skeletal muscle digoxin concentrations were very variable. Generally digoxin concentrations were higher in patients on the larger digoxin dose and with the shorter discontinuation time before surgery. These differences attained significance only with plasma digoxin concentrations. There was a slight fall in plasma digoxin concentration during cardiopulmonary bypass but no significant differences were observed between plasma, atrial, or skeletal muscle digoxin concentrations before and at the end of bypass. No clear relation was seen between plasma or atrial digoxin concentrations and postoperative cardiotoxicity. Stopping digoxin 48 hours before operation appeared to account for pre- or post-bypass plasma digoxin concentrations of less than 1.0 nmol/l (0.8 ng/ml) in most of the instances encountered, whereas the 3 patients who developed pulsus bigeminus postoperatively had received 0.5 mg digoxin only 24 hours before operation.

Thrombo-embolic complications of the cloth-covered Starr-Edwards prostheses No. 2300 aortic and No. 6300 mitral

The thrombo-embolic complications of the cloth-covered Starr-Edwards prostheses No. 2300 aortic and No. 6300 mitral followed for an average of 14 months in 155 patients are reviewed. There was a high incidence of early fatal and disabling thrombo-embolus in patients having mitral valve replacement. Late emboli were more common after aortic valve replacement. Anticoagulant control was unsatisfactory and not without hazards.