[Bedside cardiac catheterization. Advantages and disadvantages]

Three hundred patients submitted to bedside heart catheterization (BHC) from 1973 to 1985 were studied, in order to assess advantages and risks of the procedure. Two-hundred and sixty seven patients (89%) suffered a myocardial infarction (MI) and 146 of them were in functional class (Killip) II, 36 in FC III and 71 in FC IV. Thirty cases were submitted to BHC due to congestive heart failure. BHC was successful in 288 patients (96%) and the wedge pressure (WP) could be measured in 236 cases (78.7%). The WP was less than 18 mmHg in 47.2% of the patients in FC II, in 44.9% of the patients in FC III and in 35.3% of those in FC IV. Minor complications occurred in 33 cases (11.0%); balloon rupture in 12 (4.0%), transient arrhythmias in 11 (3.7%) and lumen obstruction in another 10 cases (3.3%). Forty five patients (15.0%) presented major complications related to the procedure: pulmonary infarction (PI) in 18 cases (6%), phlebitis in 15 cases (5%), sustained arrhythmias in 10 cases (3.3%), pulmonary artery rupture and endocarditis each in 1 case. The mean age between the group of patients with and without complications was similar the maintenance time as greater in the group of patients with complications: 3.4 +/- 0.2 vs 2.7 +/- 0.1 days (p less than 0.05). We concluded that many patients with clinical evidence of heart failure had WP smaller than 18 mmHg, emphasizing the value of the procedure in patients with complicated MI. The maintenance time was associated with the occurrence of complications, mainly PI and phlebitis.

Acute obstructive pancreatitis secondary to a duodenal hematoma

An 18-year-old male with hemophilia presented with symptoms and signs of upper intestinal obstruction. Evaluation was consistent with an intramural duodenal hematoma and obstructive pancreatitis. As it is not possible to distinguish between these two disorders on a clinical basis, it is important to realize that pancreatitis may occur in such patients more often than is recognized.

Subaortic fibrous ridge and ventricular septal defect: role of septal malalignment

The purpose of this study was to test the hypothesis that the presence of a subaortic ridge associated with a ventricular septal defect (VSD) is related to a malaligned ventricular septum caused by anterior or posterior deviation of the infundibular septum with or without obstructive lesions of the aortic arch. Thirty-two of 295 patients in whom a diagnosis of VSD was made by two-dimensional echocardiography and who were studied from June 1983 to April 1985 presented with a subaortic shelf. Every patient (p less than .00001) had a malalignment type of defect; the defect was produced by anterior deviation of the outlet septum (without compromise of the right ventricular outflow tract) in 28 and by posterior deviation of the infundibular septum in four. The prevalence of a subaortic shelf in the malalignment VSD group was 82% (32/39). Among the 28 patients with a subaortic ridge and anterior deviation of the outlet septum only three had aortic coarctation, but all four patients with subaortic stenosis and posterior infundibular malalignment had obstructive lesions of the aortic arch--coarctation in three and interruption of the aortic arch in one (p less than .001). We conclude that a malalignment type of VSD may be a consistent feature in patients with VSD and associated discrete subaortic stenosis. We also noted a high prevalence of subaortic ridge in the presence of a malalignment VSD and therefore speculate that there may be a common morphogenesis for malalignment VSD, subaortic shelf, and obstructive lesions of the aortic arch.

Constriction of human umbilical artery induced by local anesthetics

In order to study the direct effects of local anesthetics on the umbilical artery, an in vitro perfusion technique, utilizing 3-cm segments of human umbilical artery obtained within 15 min of delivery, has been developed. Basal perfusion pressure (tonus) and the frequency of phasic contractions were determined in 37 arterial segments perfused for 240-min periods with Tyrode's solution containing lidocaine in concentrations of 2.0, 8.0 or 16 microgram/ml of bupivacaine in concentrations of 0.25 or 9.8 microgram/ml. A control group consisting of 11 arterial segments was perfused only with Tyrode's solution. The lowest concentration of each anesthetic approximated that reportedly present in the umbilical arteries following administration of epidural anesthesia during labor. Both lidocaine and bupivacaine induced dose-related increases of up to 100% in tonus above the control levels of approximately 60 mm Hg, statistically significant (p less than 0.05) except for 2 microgram/ml lidocaine. At the same molar concentration, bupivacaine was more effective than lidocaine (p less than 0.05). Both anesthetics also increased the frequency of phasic contractions. These data suggest that these agents may exert their effects on the fetus, at least in part, through a direct constricting action on the umbilical artery.