Effect of Wound Position, Auxin, and Agrobacterium vitis Strain F2/5 on Wound Healing and Crown Gall in Grapevine

ABSTRACT Agrobacterium vitis is the causal agent of crown gall disease in grapevine, which can be severe in many regions worldwide. Vitis vinifera cultivars are highly susceptible to freeze injury, providing the wounds necessary for infection by A. vitis. Wound position in relation to the uppermost bud of cuttings was determined to be important in tumor development. Inoculated wounds below buds developed tumors, whereas wounds opposite the bud did not, implying that indole-3-aectic acid flow contributes to tumor formation. If auxin was applied to wounds prior to inoculation with a tumorigenic A. vitis strain, all sites of inoculation developed tumors, accompanied by an increased amount of callus in the cambium. Wounds inoculated with an A. vitis biological control strain F2/5 prior to application of the pathogen did not develop galls. A closer examination of these wounds determined that callus cells formed in the cambium during wound healing are susceptible to transformation by the pathogen. Although the mechanism by which F2/5 prevents transformation is unknown, our observations suggest that F2/5 inhibits normal wound healing by inducing necrosis in the cambium.

Characterization of Agrobacterium vitis Strains Isolated from Turkish Grape Cultivars in the Central Anatolia Region

Crown gall was detected in several vineyards in the Central Anatolia region of Turkey. Vineyards were planted to cultivars of grape that originated in Turkey and that were not grafted. The predominant species isolated from galls consisted of tumorigenic strains of Agrobacterium vitis. They were identified based on reactions to standard biochemical and physiological tests, by polymerase chain reaction amplification of specific Ti plasmid and chromosomal sequences, and by reaction to a species-specific monoclonal antibody. All strains utilized octopine, suggesting that they may carry similar types of Ti plasmids. Some of the strains exhibited a differential host range compared with others and were less virulent based on the numbers of galls that they induced on grape. When grapevines were treated with nontumorigenic A. vitis strain F2/5 prior to inoculation with the Turkish A. vitis strains, crown gall was effectively controlled. The genetic diversity of strains was evaluated by comparing DNA fingerprints that were generated by restriction enzyme digestion of the intergenic spacer region that lies between 16S and 23S rRNA genes. They segregated into two main groups, one that is similar to previously identified A. vitis strains carrying octopine type Ti plasmids and one that was more similar to strains carrying nopaline and vitopine Ti plasmids. The strains of A. vitis from Turkey may represent ancestral forms of the pathogen that will provide insight into the evolution of the bacterium.

Clinical and echocardiographic follow-up of patients previously treated with dexfenfluramine or phentermine/fenfluramine

CONTEXT

Use of anorexigen therapy is associated with valvular abnormalities, although there is limited information on long-term changes in valvular regurgitation following discontinuation of these agents.

OBJECTIVE

To evaluate changes in valvular regurgitation, valve morphology, and clinical parameters 1 year after an initial echocardiogram in patients previously treated with dexfenfluramine or phentermine/fenfluramine and in untreated controls.

DESIGN AND SETTING

A reader-blinded, multicenter, echocardiographic and clinical 1-year follow-up study at 25 outpatient clinical sites.

PATIENTS

A total of 1142 obese patients (1466 participated in the initial study) who had follow-up echocardiogram; all but 4 had a follow-up medical history and physical examination. Follow-up time from discontinuation of drug to follow-up echocardiogram for 371 dexfenfluramine patients was 17.5 months (range, 13-26 months) and for 340 phentermine/fenfluramine patients was 18.7 months (range, 13-26 months) after discontinuation of drug therapy.

MAIN OUTCOME MEASURE

Change in grade of valvular regurgitation and valve morphology and mobility.

RESULTS

Echocardiographic changes in aortic regurgitation were observed in 8 controls (7 [1.7%] had decreases; 1 [0.2%] had an increase); 29 dexfenfluramine patients (23 [6.4%] had decreases; 6 [1.7%] had increases; P<.001 vs controls); and 15 phentermine/fenfluramine patients (4.5% all decreases; P =.03 vs controls). No statistically significant differences were observed when treated patients were compared with controls for changes in medical history, physical findings, mitral regurgitation, aortic or mitral leaflet mobility or thickness, pulmonary artery systolic pressure, ejection fraction, valve surgery, or cardiovascular events.

CONCLUSION

Progression of valvular abnormalities is unlikely in patients 1 year after an initial echocardiogram and 13 to 26 months after discontinuation of dexfenfluramine and phentermine/fenfluramine.

A cross marks the spot: a study of roadside death memorials in Texas and Oklahoma

Motor vehicle collisions (MVCs) resulting in death have been a serious concern for many years. However, the placement of roadside death memorials (RDMs) at collision sites has become increasingly common in the United States, in the memorialization of those deceased because of MVCs. This practice has been used in numerous countries for hundreds of years. Of the 78 sites observed, most were for males whose deaths had occurred in the past year and were placed by both family members and friends. The sites include the use of a cross and flowers whose meaning is obvious; however numerous other artifacts are found, the meaning of which is less obvious. Some of the functions served by these memorials are to prolong the memory of the deceased in a public place and to communicate with the deceased and to society. RDMs are used by mourners as a way of coping with the sudden and tragic nature of deaths from MVCs.

Simple method for estimating regurgitant volume with use of a single radius for measuring proximal isovelocity surface area: an in vitro study of simulated mitral regurgitation

The proximal isovelocity surface area (PISA) color Doppler method with use of a hemielliptic formula is reported to be accurate for quantitating regurgitant volume (RV). However, this formula ideally requires the measurement of 2 or 3 radii and therefore is not widely used clinically. The purpose of this in vitro study was to derive a simple PISA formula for estimating RV with use of a single radius axial to the valve orifice and to compare it with the clinically used single-radius hemispherical formula (2 x pi R(2) x AV x TVI/Vp), where AV is the apparent color Doppler aliasing velocity, R is the PISA color Doppler aliasing radius, TVI is time-velocity integral of the jet by continuous wave Doppler, and Vp is the peak velocity of the jet by continuous wave Doppler. Pulsatile flow studies were performed across a convex curvilinear surface, which more closely approximates the shape of the mitral valve than does a planar surface. Pulse rates (60 to 80 bpm), peak flow velocities (4.0 to 6.0 m/s), and regurgitant orifice areas (0.2 to 1.0 cm(2)) were varied to simulate mitral regurgitation. The AVs were varied from 11 to 39 cm/s, and a single PISA aliasing radius was measured at each AV. Excellent linear correlations were obtained between the PISA radius and the actual RV measured with use of a beaker (r = 0.94 to 0.97, P <.0001). A series of simplified formulas was derived from the regression line of the PISA radius versus the RV. For example, with an AV of 21 cm/s, RV was estimated by a simplified PISA formula (where RV[mL] = 10 x R [mm] - 30) with an accuracy of 3.3 +/- 6.3 mL versus -20.3 +/- 8.7 mL for the standard single-radius PISA method (P <.0001). By using the standard single-radius hemispherical PISA formula, RV was underestimated if the radius was <20 mm. By using simplified regression equations, the PISA radius accurately estimated RV at a PISA radius <20 mm. Clinical studies are necessary to validate this concept.

Left ventricular diastolic function in the elderly

Previous studies using pulsed Doppler echocardiography have demonstrated a pattern of abnormal left ventricular relaxation associated with increasing age. Specifically, aging is associated with decreased peak velocity of early diastolic mitral inflow, increased peak velocity of late diastolic inflow, increased isovolumic relaxation time, and early diastolic deceleration time. Abnormal relaxation can progress to significantly elevated left atrial pressure--characterized by increased early peak velocity and shortened isovolumic relaxation time and deceleration time--as part of the disease processes. Left ventricular diastolic dysfunction is highly prevalent, occurring in one half to two thirds of elderly patients with congestive heart failure, in association with normal systolic function. Left ventricular hypertrophy, which is commonly related to systemic arterial hypertension, and ischemic heart disease are the two major causes of abnormal left ventricular diastolic function in the elderly. Recently, newer echocardiographic techniques have been described that allow more accurate evaluation of left ventricular diastolic function. Treatments for left ventricular diastolic dysfunction should focus on the underlying disease etiology as well as on the derangement in left ventricular diastolic function. Although calcium channel blockers and angiotensin-converting enzyme inhibitors have been used clinically to treat diastolic dysfunction, their effects on prognosis remain unproven.

Valvular abnormalities and cardiovascular status following exposure to dexfenfluramine or phentermine/fenfluramine

CONTEXT

Fenfluramine and dexfenfluramine were voluntarily withdrawn from the market in September 1997 because of reports of an association with heart valve abnormalities. Studies have been limited by lack of comparison with untreated controls.

OBJECTIVE

To evaluate cardiovascular status and the prevalence of valvular abnormalities, as assessed by clinical cardiovascular parameters and echocardiography, in patients treated for obesity with dexfenfluramine or phentermine/fenfluramine.

DESIGN

Reader-blinded controlled study completed in February 1998.

SETTING AND PARTICIPANTS

Twenty-five clinical centers in the United States. Of 1640 enrolled subjects, 1473 were eligible (479 and 455 had taken dexfenfluramine and phentermine/fenfluramine, respectively, continuously for 30 days or more in the previous 14 months, and 539 were untreated matched controls) and provided clinical and echocardiographic data. Mean (SD) age was 47.4 (11.4) years, mean body mass index was 35.0 (7.4) kg/m2, and 74% were women. Mean (SD) duration of therapy was 6.0 (3.3) months (range, 1-18.4 months) in the dexfenfluramine group, and 11.9 (10.4) months (range, 1.4-63 months) in the phentermine/fenfluramine group, while the untreated group had no anorexigen use during the previous 5 years.

MAIN OUTCOME MEASURES

Cardiovascular signs and symptoms; echocardiographic evidence of aortic (AR) or mitral (MR) regurgitation according to US Food and Drug Administration (FDA) criteria (AR > or = mild or MR > or = moderate) and by grade; tricuspid and pulmonic valve regurgitation; and aortic, mitral, and tricuspid valve leaflet mobility and thickness, for treated vs untreated subjects.

RESULTS

Cardiovascular signs and symptoms were similar among anorexigen-treated and untreated subjects. Prevalence rates and relative risk (RR) of AR were significantly increased in anorexigen-treated patients and were 8.9% in the dexfenfluramine group (RR, 2.18; 95% confidence interval [CI], 1.32-3.59), 13.7% in the phentermine/fenfluramine group (RR, 3.34; 95% CI, 2.09-5.35), and 4.1% in the untreated group (P<.001). No statistically significant differences in prevalence were observed for MR, thickening or decreased mobility of any valve leaflet, calculated pulmonary artery systolic pressure, or left ventricular ejection fraction. Serious cardiac events (including myocardial infarction, congestive heart failure, or ventricular arrhythmia) occurring at any time were not statistically different in treated and untreated subjects (dexfenfluramine, 9.0%; phentermine/fenfluramine, 4.0%; and untreated, 8.4%); and following anorexigen treatment were uncommon (dexfenfluramine, 2.3%; phentermine/fenfluramine, 2.4%, and untreated, 3.3%, when adjusted for the median start date of anorexigen use).

CONCLUSIONS

Our data indicate that use of dexfenfluramine and phentermine/fenfluramine is associated with an increase in the prevalence of AR using FDA echocardiographic criteria, but was not associated with an increase in the prevalence of MR using FDA criteria or with serious cardiac events.

Care giving as an occupational role in the dying process

Being involved in the death and dying process as a professional, family member, friend, or patient means taking on an occupational role that will impact one's life. Types of occupational roles associated with death and dying, and how these roles influence the participants, are explored in relation to concepts presented in the Model of Human Occupation. Also addressed is the potential for a care-giving role to bring on distress in the form of role imbalance or role changes, or because of inability to adequately fulfill the role. Suggestions for seeking relative balance within and among roles are presented.

Characterization of Agrobacterium vitis Strains Isolated from Feral Vitis riparia

Agrobacterium vitis was isolated from roots of 41 of 66 feral Vitis riparia vines collected in three different regions of New York State. Two of the regions were more than 150 km from commercial vineyards. The strains were highly diverse as determined by DNA fingerprinting of the chromosomal region lying between the 16S and 23S rRNA genes. Of 24 strains examined, 15 different fingerprints were generated, and none was identical to fingerprints generated by previously identified groups of tumorigenic A. vitis strains. Results of physiological tests that were done to characterize strains from V. riparia conformed closely to those expected for A. vitis, except that 23 of 26 strains did not utilize tartrate. All strains were nontumorigenic, did not hybridize with a probe consisting of T-DNA genes, did not utilize octopine or nopaline, and carried zero to three plasmids. Of 26 strains, 7 inhibited A. vitis strain K306 from causing galls at wound sites on grape as well as or better than a previously studied nontumorigenic A. vitis strain, F2/5, that is known to have biological control activity.

Indirect calorimetry--a review of recent clinical applications

There has been a resurgence of interest in the information provided by indirect calorimetry. In the past calorimetry was considered a research technique, but technological advances have made it applicable in many clinical situations. Recent clinical applications of this technique have been examined in this review.

High school graduation requirements for students with disabilities

Although increasing the high school graduation rate is now a national goal, requirements for graduation are not set at the national level. And, although the goal is said to include students in special education programs, what high school graduation means for these students is not clear. We collected documentation from state departments of education to examine high school graduation requirements for students in general, and for students with disabilities. Forty-four states use Carnegie course unit requirements ranging from 10.35 to 24.00 credits. Seventeen states currently have requirements for either a minimum competency test or an exit exam. Local education agencies in several states have the option of establishing more stringent requirements than called for in state guidelines. Exit documents that are awarded to students with disabilities (e.g., standard diplomas, modified diplomas, certificates of attendance) also vary from state to state, with similar requirements sometimes earning different types of exit documents in different states. These inconsistencies in graduation requirements and their implications for students with learning disabilities are discussed.

Safety and results of dobutamine stress echocardiography in women versus men and in patients older and younger than 75 years of age

The purpose of this retrospective study was to examine 732 consecutive patients who underwent dobutamine stress echocardiography (DSE) in order to compare the safety and result profiles of this test between women versus men and in patients > or = 75 and < 75 years of age. Our study included 416 women (57%) and 316 men (43%; mean age 62 +/- 12 years [range 16 to 93]). Patients were divided into 3 age groups: (1) group I (n = 179): < 55 years (mean 47 +/- 6), (2) group II (n = 447): 55 to 74 years (mean 64 +/- 5), and (3) group III (n = 106): > or = 75 years (mean 80 +/- 4). DSE was more likely to have negative results in women than in men (prevalence of positivity = 20% vs 31%, p = 0.001), but DSE had a similar safety profile in both genders. Women required lower doses of dobutamine and atropine to reach an end point. There was a similar incidence of test positivity in older and younger patients (23% in group I, 24% in group II, and 30% in group III, p = NS). DSE was generally a safe test in patients > or = 75 years, but there was a different safety profile in the elderly group compared with younger patients--specifically, more frequent asymptomatic hypotension (7% in group I, 13% in group II, and 25% in group III, p = 0.0002) and ventricular arrhythmias (26% in group I, 30% in group II, and 41% in group III, p = 0.04), but less frequent chest pain (32% in group I, 23% in group II, and 17% in group III, p = 0.009). Multivariate analysis suggested that the baseline usage of beta blockers was also a major determinant of the safety and ischemia profile during DSE. In conclusion, there were significant gender- and/or age-specific differences in the safety and test result profile of DSE. These differences should be considered when performing or interpreting DSE, particularly in women and in patients aged > or = 75 years.

Biological control of grape crown gall by strain f2/5 is not associated with agrocin production or competition for attachment sites on grape cells

ABSTRACT Agrocin-minus mutants of nontumorigenic Agrobacterium vitis strain F2/5 controlled grape crown gall as well as the wild-type strain, indicating that agrocin is not a major factor in the mechanism of biological control. Relative levels of attachment to grape cells by tumorigenic and biocontrol strains were also measured. Attachment of tumorigenic strains (CG49 and K306) and biological control strains (F2/5 and agrocin-minus mutant 1077) was often reduced when mixtures of the strains were applied. However, high populations (10(3) to 10(5) CFU/ml) of all strains attached following mixed inoculations, suggesting that competition for attachment sites is also not a factor in the mechanism of biological control. Transfer of T-DNA to grape by CG49 was prevented or greatly inhibited in the presence of F2/5 or 1077 as measured by expression of the GUS reporter gene. The Ti plasmid virulence genes, however, were induced by exudates from grape shoots that had been inoculated with F2/5. Sonicated and autoclaved preparations of F2/5 and 1077 did not control crown gall or inhibit T-DNA transfer. Control by F2/5 is specific to grape, since gall formation on tomato, sunflower, and Kalanchoe daigremontiana were not inhibited.

Phase IB clinical trial of the oligosaccharide processing inhibitor swainsonine in patients with advanced malignancies

The indolizidine alkaloid swainsonine, a potent inhibitor of Golgi alpha-mannosidase II, has been shown to reduce tumor cell metastasis, enhance cellular immune responses, and reduce solid tumor growth in mice. In our previous Phase I study, swainsonine administered by 5-day continuous infusion inhibited L-phytohemagglutinin-reactive N-linked oligosaccharide expression on peripheral blood lymphocytes. Significant toxicities included edema and elevated serum aspartate aminotransferase (AST). One patient with head and neck cancer had objective (>50%) tumor remission. Two patients showed symptomatic improvement. The objectives of this Phase IB trial were to examine the pharmacokinetics, toxicities, and biochemical effects of bi-weekly oral swainsonine at escalating dose levels (50-600 microgram/kg) in 16 patients with advanced malignancies and 2 HIV-positive patients unsuitable for conventional therapy. Eastern Cooperative Oncology Group performance status was </=2. The maximum tolerated dose was defined as 300 microgram/kg/day due primarily to serum AST abnormalities and dyspnea. Other adverse events present in >20% of patients included increase in serum AST (all patients), fatigue (n = 9), anorexia (n = 6), dyspnea (n = 6), and abdominal pain (n = 4). Inhibition of Golgi alpha-mannosidase II occurred in a dose-dependent manner. Examination of immunological parameters revealed a transient decrease in CD25(+) peripheral blood lymphocytes and, in seven of eight patients, an increase in CD4(+):CD8(+) ratios at 2 weeks. Serum drug levels peaked 3-4 h following a single oral dose in most patients and were proportional to dose at levels >/=150 microgram/kg. We conclude that oral swainsonine is tolerated by chronic intermittent administration at doses up to 150 microgram/kg/day. Adverse events considered drug related were similar to those observed in the infusional study but with fatigue and neurological effects also noted. Investigations of alternative dosing schedules with low starting doses are suggested for further clinical testing.

Usefulness of color Doppler proximal isovelocity surface area method in quantitating valvular regurgitation

To define the clinical utility of the color Doppler proximal isovelocity surface area (PISA) method for estimating regurgitant stroke volume (SV), 160 regurgitant lesions were evaluated in 104 patients with mitral (MR), aortic (AR), and tricuspid (TR) regurgitation. Regurgitant SV by PISA was calculated as 2 pi R2 x V x (time-velocity integral/peak flow velocity), where R is the radius corresponding to the first blue-red interface velocity of the maximal PISA during the cardiac cycle. The time-velocity integral and peak flow velocity from the continuous-wave Doppler recording of the regurgitant jet were used to correct PISA for phasic variations in regurgitant flow. Fifteen lesions were excluded because of difficulty in tracing the continuous-wave Doppler regurgitant curve. Among 145 remaining regurgitant lesions, PISA was measurable in 50 (78%) of 64 cases of MR and 24 (69%) of 35 cases of TR but in only 12 (26%) of 46 cases of AR (p < 0.001). Regurgitant SV by PISA correlated modestly well with jet area/atrial area in all atrioventricular valve lesions (MR: r = 0.55; TR: r = 0.65; p < 0.001). However, the correlation improved if only central jets were considered (MR: r = 0.70; TR; r = 0.75; p < 0.001). These findings are not unexpected because jet area/atrial area underestimates the true severity of regurgitation in cases of eccentric (wall-impinging) jets. PISA was detected in all severe cases of regurgitation but in only 64% of cases of mild MR, 45% of cases of mild TR, and 6% of cases of mild AR (p < 0.01). The color Doppler PISA method is clinically useful in estimating regurgitant SV in MR and TR, including mild cases, but is less useful in AR.

Left ventricular cavitary geometry and dynamic intracavitary left ventricular obstruction during dobutamine stress echocardiography

To investigate the relationship between left ventricular cavity geometry and dynamic intracavitary left ventricular obstruction occurring during dobutamine stress echocardiography, we evaluated 44 patients who underwent dobutamine stress echocardiography. Dynamic intracavitary left ventricular obstruction appeared in 10 (23%) patients (Group 1), and was absent in the remaining 34 patients (Group 2), during dobutamine stress echocardiography. The ratio of the apicalto-narrowest mid-left ventricular minor-axis dimension (D1/D2), as an index of the left ventricular cavitary geometry, was measured in the baseline two dimensional apical long-axis view. The left ventricular out-flow blood Doppler velocity was measured in the apical long-axis or five-chamber view at each stage during dobutamine infusion. Left ventricular end-systolic dimension was smaller (21 +/- 4 mm v 29 +/- 6 mm; p< .01), percent fractional shortening of the left ventricle was greater (51 +/- 4% v 39 +/- 8%, P>.01), and D1/D2 was greater (1.13 +/- 0.08 v.0.96 +/- 0.09; p < .0001) in Group 1 than in Group 2 in the baseline echocardiogram. Maximal out flow blood Doppler velocity during dobutamine infusion correlated moderately with percent fractional shortening of the left ventricle (r = .53; P < .01) and D1/D2 (r = .60; P < .0001). Dynamic intracavitary left ventricular obstruction, defined as an elevated intracavitary Doppler flow velocity with late-systolic peaking, was not related to the presence of left ventricular hypertrophy or the development of hypotension during dobutamine infusion. We conclude that dynamic left ventricular intracavitary obstruction during dobutamine infusion is associated with a characteristic (narrower-waisted) left ventricular cavitary geometry and increased contractility.

Gender differences in left ventricle geometry and function in patients undergoing balloon dilatation of the aortic valve for isolated aortic stenosis. NHLBI Balloon Valvuloplasty Registry

BACKGROUND

Gender differences in cardiac size have been described in normal humans and animals and in response to pressure overload. To examine the influence of gender on the left ventricular response to pressure overload, clinical, haemodynamic, and echocardiographic data were analysed in the 232 adults with isolated aortic stenosis enrolled in the Balloon Valvuloplasty Registry.

METHODS AND RESULTS

There were 92 men (mean (SD) age 75 (11) years) and 140 women (79 (9) years; P = 0.002). Women had similar symptoms (New York Heart Association class) but lower overall functional status than men (P = 0.008). Catheterisation data showed similar valve area indices (mean (SD) (0.30 (0.09) in men and 0.31 (0.13) cm/m2 in women) but higher peak and mean gradients in women (peak 74 (30) v 63 (22) mm Hg; mean 61 (21) v 54 (18) mm Hg; both P < or = 0.01). On M mode echocardiography women had greater septal and posterior wall thickness but similar cavity diameter, after normalising dimensions to body surface area, resulting in higher relative wall thickness (0.60 (0.20) v 0.50 (0.15); P = 0.0002). Left ventricular mass index was similar in women and men (166 (59) v 159 (50) gm/m2 respectively), however, the prevalence of left ventricular hypertrophy according to sex specific criteria was 54% in men and 81% in women (P = 0.0001). Multiple logistic regression models that adjusted for age, functional status, fractional shortening, and left ventricular systolic pressure found the presence or absence of hypertrophy to be independently associated with gender (P < or = 0.002). Left ventricular systolic function tended to be better in women, who had a higher cardiac index (2.5 (0.8) v 2.3 (0.6) 1/min/m2; P = 0.01), left ventricular peak systolic pressure (211 (36) v 192 (35) mm Hg; P = 0.0001), and echo fractional shortening (32 (13) v 28 (12)%; P = 0.05); however, these differences were reduced when patients with regional wall motion abnormalities were excluded.

CONCLUSIONS

In this population of elderly patients undergoing balloon dilatation of isolated aortic stenosis, left ventricular chamber geometry was different in men and women. Because this was a selected population, gender should be further evaluated as a possible determinant of the cardiac adaptation to chronic pressure overload.

Influence of mitral valve morphology on mitral balloon commissurotomy: immediate and six-month results from the NHLBI Balloon Valvuloplasty Registry

Echocardiographic data were analyzed in 555 patients undergoing mitral balloon commissurotomy (MBC). Patients were enrolled in the National Heart, Lung, and Blood Institute Balloon Valvuloplasty Registry from 24 centers. There were 456 women and 99 men with a mean age of 54 years. Before MBC the two-dimensional echocardiographic variables of mitral valve thickness, mobility, calcification, and subvalvular disease were evaluated and assigned scores of 1 to 4. The mitral valve morphology score was related to mitral valve area (MVA) measured after MBC by cardiac catheterization. The leaflet mobility score was related to the immediate post-MBC MVA: 2.2 +/- 0.8 cm2 for grade 1, 1.9 +/- 0.7 cm2 for grade 2, 1.7 +/- 0.7 cm2 for grade 3, and 1.9 +/- 0.9 cm2 for grade 4 (p less than 0.001). Results of the MVA after MBC showed a similar relationship for each echocardiographic variable. The total morphology score (sum of the four variables) showed a weak relationship to MVA immediately after MBC (r = 0.24), which was persistent at 6 months after MBC (r = -0.25). Multiple regression analysis showed that the MVA after MBC is predicted by pre-MBC MVA (p less than 0.001), left atrial size (p = 0.01), balloon diameter (p = 0.02), cardiac output (p = 0.004), and leaflet mobility (p = 0.01). The R2 of the model was 0.31 (p less than 0.001). Total morphology score, leaflet thickness, calcification, and subvalvular disease were not important univariate or multivariate predictors of the results of MBC.(ABSTRACT TRUNCATED AT 250 WORDS)

Response of angina and ischemia to long-term treatment in patients with chronic stable angina: a double-blind randomized individualized dosing trial of nifedipine, propranolol and their combination

Seventy-four patients with chronic stable mild angina, mild coronary artery disease (83% had one- or two-vessel disease) and normal left ventricular function were studied to measure the response of treadmill exercise performance and painful and silent ischemia in the ambulatory setting to randomly assigned treatment with nifedipine or propranolol and their combination; titration to maximal tolerated dosages was performed in double-blind manner. At 3 months both nifedipine and propranolol reduced the weekly angina rate (p less than 0.05); during treadmill exercise testing, increases (p less than 0.05) were noted in time to angina and total exercise time and decreases in maximal ST depression at the end of exercise. There were no differences between the responses to nifedipine and propranolol and no significant additional changes were seen after another 3 months of therapy. The combination of nifedipine and propranolol reduced the number of patients with angina on exercise treadmill testing from 64% to 38% (p less than 0.05). During ambulatory electrocardiographic monitoring before treatment, there were 1.4 +/- 2.4 (mean +/- SD) episodes/24 h of painful ischemia and a very low silent ischemia frequency: mean 1.1 +/- 2.7 episodes/24 h, mean duration 16 +/- 25 min/24 h. Treatment with propranolol and nifedipine resulted in reduction of episodes and duration of painful and painless ischemia; approximately 77% of patients were free of all ischemic episodes. It is concluded that patients with chronic stable mild angina have a low incidence of silent ischemia. Nifedipine or propranolol alone, titrated to individualized maximally tolerated dosages, are equally effective in long-term control of painful and painless ischemia, anginal episodes and exercise-induced ischemia.(ABSTRACT TRUNCATED AT 250 WORDS)

The role of echocardiography/Doppler in catheter balloon treatment of adults with aortic and mitral stenosis

Doppler and two-dimensional echocardiography (2DE) have played a major role in the evaluation of patients undergoing catheter balloon treatment of aortic and mitral stenosis. Doppler/2DE has made possible an understanding of the mechanism of increase in valve area. Before the procedure, Doppler/2DE provides a reasonable estimate of the severity of the valvular stenosis and associated cardiac abnormalities. The evaluation of mitral valve morphology by 2DE before catheter balloon treatment has shown that patients with excellent leaflet motion and minimal increase in valve thickness have the greatest increase in mitral valve area. During the procedure, Doppler/2DE can aid in the transseptal puncture, in positioning the balloons across the stenotic orifice, and in the immediate assessment of changes in valve function and complications. The estimate of the aortic and mitral valve gradients and areas by Doppler/2DE before catheter balloon treatment shows a reasonable correlation with hemodynamic measurements. Immediately after the procedure, the Doppler/2DE estimates of aortic valve gradient and area show a fair correlation with data from cardiac catheterization, provided care is taken to avoid technical problems. Doppler/2DE assessment of mitral valve area immediately after catheter balloon commissurotomy (CBC) shows a poor correlation with catheterization data, which has been attributed to rapid changes in left atrial compliance and gradient. However, the correlation of Doppler estimates of mitral valve area with catheterization data improves at 3 months after CBC. Serial evaluations of patients after aortic or mitral catheter balloon dilatation should permit detection of restenosis and valve regurgitation and assessment of ventricular function and may provide valuable insights into the mechanisms of restenosis and changing clinical status.

Response of blood pressure, cardiac output, peripheral resistance, and exercise performance to substitution of calcium blocker for beta-blocker plus thiazide diuretic therapy in patients with both systemic hypertension and mild stable angina

We studied 14 patients to determine whether sustained-release diltiazem is a satisfactory long-term substitute for the combination of propranolol plus hydrochlorothiazide (HCTZ), control phase, in the treatment of systemic hypertension with coexisting chronic stable angina pectoris. All patients had either one- or two-vessel coronary disease and normal left ventricular systolic function. Measurements were made during the control phase and 4 and 8 weeks after substitution of sustained-release diltiazem. Only the sitting blood pressure was available before the control phase (pretreatment). Blood pressure and heart rate were measured with patients supine, sitting, and 5 minutes after standing. Cardiac output was measured in the supine position using a computerized Doppler system, and stroke volume, mean arterial pressure, and total systemic resistance were calculated. Symptom-limited modified Bruce protocol treadmill tests were performed to determine time to onset of 1 mm ST segment depression, time to termination of exercise, reason for cessation of exercise, and maximum rate-pressure product. The patients were initially receiving 160-240 mg/day of propranolol (40-60 mg q.i.d.) plus 25-50 mg/day of HCTZ and, subsequently, 12 of 14 had substitution with 240 mg/day (120 mg b.i.d.) of sustained-release diltiazem, and two received 360 mg/day with one of these patients also receiving 50 mg/day of HCTZ. These patients are a subset of a larger group of patients in whom the response of blood pressure alone has been previously reported. Diltiazem resulted in reduction of blood pressure equivalent to that with the propranolol plus HCTZ combination.(ABSTRACT TRUNCATED AT 250 WORDS)

Influence of mitral valve morphology on double-balloon catheter balloon valvuloplasty in patients with mitral stenosis. Analysis of factors predicting immediate and 3-month results

To determine if mitral valve morphology influences the results of double-balloon catheter balloon valvuloplasty (CBV) for mitral stenosis, two-dimensional echocardiography was performed in 33 patients before CBV. The two-dimensional echocardiographic features of leaflet motion, leaflet thickness, subvalvular disease, and commissural calcium and 14 pre-CBV clinical and hemodynamic variables were then correlated to the immediately post-CBV mitral valve area (MVA). At 3 months after CBV, the two-dimensional echocardiographic features of patients with a 25% or greater decrease in MVA were analyzed to determine whether mitral valve morphology had influenced early results. Leaflet motion had a significant relation with the immediately post-CBV MVA (r = 0.67, y = 4.5x + 0.29, and SEE = 0.45). Leaflet thickness had a weak and negative relation (r = -0.48, y = -0.17x + 2.6, and SEE = 0.53) with the immediately post-CBV MVA. Subvalvular disease and commissural calcium had no significant relation to the immediately post-CBV MVA. When leaflet motion and leaflet thickness were considered as grades of mild, moderate, and severe and assigned a score of 0-2, patients with more severe disease (total score, 3 or 4) had a significant lower MVA immediately after CBV (1.4 +/- 0.4 cm2) than patients with moderate disease (score, 1-2; MVA, 2.0 +/- 0.5 cm2; p less than 0.05) or mild disease (score, 0; MVA, 2.6 +/- 0.6 cm2; p less than 0.05). In 96% of patients with a total score of 0-2, the immediately post-CBV MVA was more than 1.4 cm2, whereas only 29% of patients with a total score of 3-4 had an immediately post-CBV MVA of more than 1.4 cm2. Analysis of all two-dimensional echocardiographic features showed that leaflet motion score had the strongest influence on the post-CBV MVA (p less than 0.001). When all two-dimensional echocardiographic, clinical, and hemodynamic variables were included, leaflet motion, effective balloon dilating area, and cardiac output were the strongest predictors of the immediate post-CB MVA.(ABSTRACT TRUNCATED AT 400 WORDS)

Improvement in exercise capacity and exercise hemodynamics 3 months after double-balloon, catheter balloon valvuloplasty treatment of patients with symptomatic mitral stenosis

Clinical status, exercise treadmill performance, and hemodynamics were determined in 24 patients with symptomatic mitral stenosis before catheter balloon valvuloplasty (CBV) and at 3 months follow-up. Hemodynamic determinations at rest showed that mitral CBV performed by the double-balloon technique resulted in significant immediate decreases in mean pulmonary arterial wedge pressure (28 +/- 7 to 16 +/- 5 mm Hg, p less than .01), mean pulmonary arterial pressure (41 +/- 11 to 33 +/- 10 mm Hg, p less than .05), and mitral valve gradient (16 +/- 7 to 6 +/- 3 mm Hg, p less than .01), and significant increases in cardiac output (4.3 +/- 1.1 to 5.0 +/- 1.4 liters/min, p less than .01). Mitral valve area increased from 1.0 +/- 0.3 to 2.2 +/- 0.7 cm2 (p less than .01). The mitral valve area was unchanged (2.0 +/- 0.7 cm2, p = NS) at 3 months. The lower pulmonary arterial wedge pressure, pulmonary arterial pressure, and mitral valve gradient persisted at 3 month follow-up catheterization. Clinical examinations showed that before CBV, 21 of 24 patients were in New York Heart Association functional class III or IV; 3 months after CBV, 22 patients were in class I or II. Before CBV, the mean exercise treadmill time was 5.9 +/- 3.2 min and it had increased to 9.8 +/- 2.9 min (p less than .01) by the 3 month follow-up.(ABSTRACT TRUNCATED AT 250 WORDS)

Effect of pharmacologic therapy on angina frequency, ST segment depression during ambulatory ECG monitoring, and treadmill performance in patients with chronic stable mild angina

Fifteen patients aged 55 +/- 6 years (mean +/- SD) with mild, chronic stable angina were evaluated after 2 weeks of sublingual nitroglycerin therapy (control) and also after 12 weeks of treatment with either propranolol, up to 320 mg per day, or nifedipine, up to 120 mg per day, in order to measure signs of ischemia and the response of symptoms to therapy. Compared with the control period, there was a decrease in average daily episodes of angina from 1.0 +/- 0.8 to 0.5 +/- 0.4 with treatment (p = 0.10). There was a significant decrease of greater than or equal to 1.0 mm ST segment depression (both symptomatic and asymptomatic), from 6.1 +/- 6.5 to 1.5 +/- 2.4 episodes per 24 hours, p less than 0.001, and of asymptomatic episodes of ST segment depression, from 3.5 +/- 3.9 to 1.0 +/- 2.1 episodes per 24 hours, p = 0.03. The number of patients who had any episodes of greater than or equal to 1.0 mm ST segment depression on their 24-hour ECG decreased from 14 to 6 (93% to 40% of patients, p = 0.005) with treatment, and the number of patients with any episodes of ST segment depression without symptoms decreased from 11 to 5 (73% to 33% of patients, p = 0.07). There was an insignificant increase in treadmill time from 333 +/- 134 to 380 +/- 156 seconds, and an insignificant decrease in maximum double-product from 16,631 +/- 3,599 to 14,922 +/- 4,086; the number of patients with angina at maximum exercise decreased from 13 to 10 (87% to 67%).(ABSTRACT TRUNCATED AT 250 WORDS)

Mechanisms of increase in mitral valve area and influence of anatomic features in double-balloon, catheter balloon valvuloplasty in adults with rheumatic mitral stenosis: a Doppler and two-dimensional echocardiographic study

To study the mechanism of increase in the mitral valve area (MVA) and the anatomic features of the mitral valve that may affect the results of catheter double-balloon valvuloplasty (CBV) in adult patients with mitral stenosis, Doppler and two-dimensional echocardiography was performed in 12 patients before and immediately after CBV. Immediately after CBV, there was an increase in the transverse diameter of the mitral valve orifice from 18 +/- 1.6 to 25 +/- 2.8 mm (mean +/- SD, p less than .001). The anterior angles at the commissure increased from 33 +/- 6 to 57 +/- 20 degrees (p less than .05) and the posterior angles from 36 +/- 9 to 54 +/- 14 degrees (p less than .05). The MVA was greater after CBV in patients with pliable mitral valves (2.6 +/- 0.7 cm2) compared with those with rigid mitral valves (1.9 +/- 0.8 cm2; p = .08). After CBV, MVA was smaller in patients with calcification (2.1 +/- 0.2 cm2) compared with those without (2.7 +/- 0.5 cm2; p = .10) and in those with subvalvular disease (2.0 +/- 0.6 cm2) compared with those without (2.9 +/- 0.9 cm2;p = .03). The MVA by Doppler ultrasound before CBV (1.0 +/- 0.2 cm2) correlated well with MVA by cardiac catheterization (1.0 +/- 0.3 cm2; r = .8, SEE = 0.2 cm2). After CBV, the correlation of MVA by Doppler ultrasound (2.0 +/- 0.5 cm2) with MVA by cardiac catheterization (2.4 +/- 0.8 cm2) was poor (r = .3, SEE = 0.44 cm2).(ABSTRACT TRUNCATED AT 250 WORDS)

Changes in blood rheology in patients with stable angina pectoris as a result of coronary artery disease

We investigated several rheologic variables in 17 patients (11 men, six women, mean age = 52.1 +/- 9.8 years) with chronic stable angina. None took any medication except for sublingual nitroglycerin for 2 weeks before the study, and all had angiographically proven coronary artery disease with no history of myocardial infarction. Rheologic measurements included hematocrit, whole blood and plasma viscosity (750 and 1500 sec-1), degree of red cell aggregation via the zeta sedimentation ratio, and the extent and rate of red cell aggregation after stasis (Myrenne aggregometer). Compared with normal control donors, salient observations in the patients as a group included: a small (6%) but significant increase in hematocrit, a significant elevation in plasma viscosity (9%), significant increases in whole blood viscosity at both shear rates (14% and 16%), significant increases in the degree (12%), the extent (41%), and the rate (28% faster time constant) of red cell aggregation, an elevated alpha 2 level (15% increase) and a significantly increased fibrinogen concentration (25% increase), both of which correlated with the enhanced red cell aggregation. Rheologic abnormalities were evident when patients with disease in either one vessel or two to three vessels were compared with controls, but differences between these subgroups of patients were not significant. We conclude that patients with angina have rheologic abnormalities that are compatible with disturbed blood flow and an enhanced tendency for coronary arterial thrombosis.

Diffuse hepatocellular dysplasia and carcinoma associated with the Mmalton variant of alpha 1-antitrypsin

The cirrhosis and hepatocellular carcinoma associated with alpha 1-antitrypsin deficiency has been exclusively reported with the PI Z allele. We present a 63-yr-old white man with emphysema, cirrhosis, and hepatocellular carcinoma. The latter occurred on a background of diffusely distributed hepatocellular dysplasia. Serum protein electrophoresis suggested a deficiency of alpha 1-antitrypsin quantitated at 13% of normal. PI phenotyping showed that he had only the rare PI Mmalton allele, previously associated only with severe lung disease. Family studies demonstrated the distribution of this rare allele. The liver at autopsy displayed well-differentiated hepatocellular carcinoma in addition to alpha 1-antitrypsin deposits in normal, dysplastic, and malignant cells.

Chest trauma: evaluation by two-dimensional echocardiography

Patients with either blunt or penetrating chest injuries may develop a variety of cardiac complications. The studies of 76 patients with suspected cardiac injury obtained over a 30-month period were reviewed in order to determine how frequently and in what manner two-dimensional echocardiography (2DE) is of value in the assessment of such patients. Thirty-nine patients had blunt trauma (group I), and 37 had penetrating trauma (group II). The 2DE findings in group I were: no visible abnormality in 19, pericardial effusions in six, and wall motion abnormalities in two; the studies were technically inadequate in six. In group II patients, the 2DE findings were: no visible abnormality in 14, pericardial effusions in 12, wall motion abnormalities in three, and unusual abnormalities such as foreign body or intrathoracic air in three; the studies were technically inadequate in four. This study shows that satisfactory 2DE can be performed in up to 87% of unselected patients who sustain chest injuries and does provide clinically valuable information that cannot be easily obtained by other noninvasive tests. In this series, 2DE was of greatest value in the detection of pericardial effusions that were present in 27% and of unusual abnormalities including intrathoracic air and foreign bodies such as a bullet.

Cardiovascular response to dynamic exercise in patients with chronic symptomatic mild-to-moderate and severe aortic regurgitation

Fifteen patients with symptomatic mild-to-moderate and severe chronic aortic regurgitation (AR) performed supine bicycle exercise while measurements of rest and exercise hemodynamics and left ventricular function were obtained. A continuous Doppler method was used to determine the change in distribution of total left ventricular stroke volume between forward stroke volume and regurgitant volume (RgV) with exercise. The pulmonary arterial wedge pressure (PAWP) was lower in the mild-to-moderate AR group than in the severe AR group at rest (8 +/- 1.2 vs 19 +/- 3.6 mm Hg, p = 0.01) and during exercise (15 +/- 3.9 vs 30 +/- 4.3 mm Hg, p = .02). In all patients there were increases in heart rate (78 +/- 4 to 96 +/- 5 beats/min, p less than .001), forward stroke volume (41 +/- 2 to 46 +/- 2 ml/m2), and the cardiac index (3.1 +/- 0.2 to 4.4 +/- 0.3 liters/min-m2, p less than .001), despite a fall in total left ventricular stroke volume index from 84 +/- 5 to 76 +/- 5 ml/m2 (p = .03). The systemic vascular resistance (SVR) decreased with exercise from 1277 +/- 72 to 1031 +/- 64 dynes-sec/cm5 (p less than .001), and the RgV and regurgitant fraction (RgF) both decreased with exercise from 43 +/- 5 ml/m2 to 30 +/- 4 ml/m2 (p = .002) and 0.50 +/- 0.03 to 0.37 +/- 0.03 (p less than .001), respectively. Left ventricular ejection fraction increased on exercise from 0.51 +/- 0.03 to 0.55 +/- 0.03 (p = .02) for the group, but it either decreased or failed to increase by at least 0.05 in seven of 13 patients. The change in ejection fraction on exercise was directly related to the change in SVR (r = .80, p less than .001). We conclude that: in patients with mild-to-moderate AR, the PAWP is generally normal at rest and exercise, in most of those with severe AR, the PAWP is elevated at rest and increases significantly with exercise, which is the likely mechanism for dyspnea on exertion in these patients, the cardiac index in both groups is normal at rest and increases on exercise, the increase in cardiac output results from both an increased heart rate and forward stroke volume, the increase in forward stroke volume results from reductions of RgV and RgF, the RgV and RgF are decreased due to a decreased SVR, and the ejection fraction response to exercise is variable and correlates best with changes in SVR with exercise.

Echocardiographic demonstration of pulmonary embolism as it evolves through the right heart chambers

In three patients with pulmonary embolism, two-dimensional echocardiography demonstrated thrombi within the right heart chambers. These thrombi, suspected of embolizing into the pulmonary circulation, showed varied morphology and mobility. Of the two patients undergoing embolectomy, only one survived. The third patient improved with anticoagulation therapy. Two-dimensional echocardiography is useful in evaluating patients suspected of having pulmonary thromboembolism because it may demonstrate evolution of the thrombus.

Differentiation between acute and healed myocardial infarction by signal averaging and color encoding two-dimensional echocardiography

To evaluate the ability of a system developed in our laboratory to differentiate between acute and healed myocardial infarction (MI), gated 2-dimensional echocardiography was performed in 10 patients with recent MI (within 48 hours) and 10 patients with healed MI (later than 4 weeks). The 2-dimensional echocardiographic images were digitized using a Datacube VG-120 videoframe digitizer and each digitized videoframe (320 X 240 matrix) was transmitted using a high-speed serial data link to a second computer and stored on floppy disc. Five gated video frames of each patient were time-averaged to give a smoothed digitized image. This image was displayed on high-resolution color monitor connected to a color graphic subsystem. Sixty-four colors indicated pixel intensity. The exact pixel value at any given location was determined using a high-resolution light pen. Color or pixel values were not significantly different between the area of acute MI (pixel intensity 23 +/- 3, mean +/- standard deviation) identified by a regional wall motion abnormality, and the adjacent normal muscle (23 +/- 4). In each patient with healed MI, an increase in color intensity and pixel value (43 +/- 6) was seen in the area of MI (i.e., area of regional wall motion abnormality) compared with adjacent normal muscle (23 +/- 2) (p less than 0.001). These preliminary data in selected patients indicate that this technique enables differentiation between acute and healed MI. It could be of value in management of patients with suspected MI.

Application of 2-dimensional contrast studies during pericardiocentesis

Two-dimensional echocardiographic contrast studies were performed in 16 patients with pericardial effusion. A 4-chamber view was obtained by positioning the transducer at the apex. The exploratory needle was visualized in 9 patients. Five milliliters of saline solution were injected through the exploring needle and a cloud of echoes indicated its position. Microbubbles were seen in all 16 patients. This technique enabled the operator to identify that the needle was inadvertently in the left ventricle in 2 patients and in the right ventricle in 1. Furthermore, in 2 patients, when fluid could not be aspirated, the contrast study confirmed that the needle was in the pericardial sac; in both cases, pericardial fluid could be aspirated with slight manipulation of the needle. In a patient with a stab wound a negative contrast effect indicated the probable site of laceration. Thus, 2-dimensional contrast echocardiography was useful in locating needle position, which facilitated pericardiocentesis.

Left ventricular asynergy in acute myocarditis. Simulation of acute myocardial infarction

Recent studies have demonstrated the usefulness of two-dimensional echocardiography in the detection of regional wall abnormalities in acute myocardial infarction. We describe two patients with acute myocarditis who had acute chest pain simulating acute myocardial infarction. Two-dimensional echocardiography initially demonstrated regional wall motion abnormalities that disappeared within a few days. These two cases illustrate that regional wall motion abnormalities are not specific for acute myocardial infarction and that acute myocarditis may simulate acute myocardial infarction.

Mitral valve aneurysm: clinical features, echocardiographic-pathologic correlations

Aneurysm of the mitral valve occurs most commonly in association with infective endocarditis of the aortic valve. The probable mechanism of its formation is destruction of the aortic valve which results in a regurgitant jet that strikes the anterior leaflet of the mitral valve, creating a secondary site of infection leading to the development of an aneurysm. Perforation of these aneurysms may occur, resulting in mitral regurgitation and pulmonary edema from a ventricle already volume overloaded from aortic regurgitation. This report describes the clinical and echocardiographic-pathologic findings in five patients with pathologically proven aneurysm of the mitral valve. There are no clinical features that appear specific for this abnormality. The two-dimensional echocardiographic feature that is helpful in the diagnosis is a bulge of the mitral valve leaflet toward the left atrium that persists throughout the cardiac cycle. Preoperative diagnosis is important because a mitral valve aneurysm may produce serious complications and is frequently overlooked during surgery. Repair of the aneurysm may be feasible; otherwise, valve replacement becomes necessary. Careful two-dimensional echocardiographic examination should be done in patients with left-sided infective endocarditis to detect an aneurysm of the mitral valve.

Echocardiographic detection of pneumomediastinum and pneumopericardium: the air gap sign

Six patients referred for echocardiographic evaluation in whom an unusual echocardiographic sign resulted from air within the mediastinum or pericardium are described. Three patients had a pneumomediastinum that occurred after chest trauma and three patients had a pneumopericardium induced during a therapeutic pericardiocentesis. Important features included a broad band of echoes (air) recorded during held respiration which obscured the normal cardiac structures and dropout (gap) of echoes posteriorly. Between the cyclic appearance of the "air gap" sign, intracardiac structures were normally visualized. Echocardiographic recording of the air gap sign was identical in the six cases; it disappeared after resolution of clinical signs and symptoms of the pneumopericardium or pneumomediastinum. The pattern most likely resulted from air within the anterior mediastinum or pericardium interfering with the echographic beam and resulted in a cyclic appearance from systole to early diastole as the air was displaced by the changing cardiac size. Recognition of the air gap sign can be helpful in evaluating patients for pneumomediastinum or pneumopericardium after thoracic trauma.