Prevalence of pulmonary hypertension and its association with respiratory disturbances in obese patients living at moderately high altitude

OBJECTIVE

To determine the point prevalence of pulmonary hypertension (PH) and its relationship with respiratory disturbances in obese patients living at moderate altitude.

SUBJECTS

A total of 57 obese patients comprised the final sample and consisted of 34 women and 23 men, with a mean age of 42.7+/-12.1 ys and a mean body mass index (BMI) 47.1+/-10.6 kg/m(2) (range from 30.1 to 76.1). The mean living altitude was 2248.7 m, range 2100-2400 m above sea level.

MEASUREMENTS

Doppler echocardiography, pulmonary function tests, arterial blood gas analysis, and polysomnography were performed.

RESULTS

Data showed that 96.5% of the studied sample had daytime PH defined as calculated systolic pulmonary artery pressure (PSAP) >30 mmHg (mean PSAP=50, s.d.=13 mmHg). The severity of diurnal PH was found to be related to the presence of alveolar hypoventilation and BMI. The main risk factor for severity of diurnal PH was hypoventilation with a significant odds ratio (OR) 7.96, 95% CI 1.35-46.84, BMI was (OR 1.12, 95% CI 1.02-1.25) and apnea/hypopnea index was not a predictor of pulmonary hypertension severity (OR 0.99, 95% CI 0.97-1.02).

CONCLUSION

We concluded that prevalence of diurnal PH is high in obese patients living at moderate altitude, and that hypoventilation is the main risk factor associated with the severity of pulmonary hypertension.

Ebstein's anomaly, atrial paralysis and atrio-ventricular block: an uncommon association

We report here the case of a 22-year-old female patient with an incomplete Ebstein's anomaly, complete heart block and atrial standstill. Atrial paralysis associated with Ebstein's anomaly is the most important feature, since there is a report of familial Ebstein's anomaly associated with atrial standstill but isolated cases have not been described. The patient presented with atypical chest pain and a symptomatic bradycardia of 37 beats per minute. A VVIR pacemaker was implanted. She has subsequently been symptom free.

[Carcinoid syndrome: report of a case with heart involvement and primary ovarian tumor]

A patient with a primary ovarian carcinoid tumor with extensive carcinoid heart disease, without hepatic metastases is presents. Literature was revisited, emphasizing that carcinoid heart disease secondary to an ovarian tumor is quite rare. Surgical indications relative to this patient are discussed.

[Myxoma of the mitral valve with embolization of the posterior circulation. A case report and review of the literature]

INTRODUCTION

Although cardiac tumours are infrequent, over half are myxomas. Most are situated in the cavities of the heart and exceptionally on the valves. Embolism towards the arteries of the anterior circulation of the central nervous system is the commonest neurological finding, but rarely involves the posterior circulation.

CLINICAL CASE

A 79 year old woman who one year before admission had had a right hemiparesia of the face and body, from which she had made a complete recovery. Three months later she had a sudden onset of unsteady gait which was deviated towards the right and vertigo. She attended our institution where magnetic resonance (MR) studies showed that there were infarcts in the territory of the right anterior and posterior inferior cerebellar arteries. Four months later she had a further episode of unsteady gait, vertigo and right hemiparesia of face and body for which she was admitted to hospital. On physical examination there was dysmetry, dysdiadokokinesia and involvement of the third cranial nerve. Further MR studies showed the previous lesions and also a new ischaemic lesion of the mesencephalum. A transoesophagic echocardiogram showed a tumour of approximately 18 x 20 mm, implanted in the mitral valve. Study of the resected tumour showed it to be a myxoma. Six months later the patient was asymptomatic and had not relapsed.

CONCLUSION

Although the association of vascular events of the posterior circulation with myxomas of the mitral valve is rare, its clinical importance cannot be overlooked.

Prevalence of sleep apnea and electrocardiographic disturbances in morbidly obese patients

OBJECTIVE

To determine the prevalence of sleep apnea in morbidly obese patients and its relationship with cardiac arrhythmias.

RESEARCH METHODS AND PROCEDURES

Fifty-two consecutive morbidly obese (body mass index > or = 40 kg/m2) outpatients from the Obesity Clinic of the National Institute of Nutrition Salvador Zubirán underwent two nights of polysomnography with standard laboratory techniques. Electrocardiographic polysomnography signals (Lead II) were evaluated by two experienced cardiologists, and sleep complaints were measured with a standard sleep questionnaire (Sleep Disorders Questionnaire). In order to make comparisons between groups with different severities of sleep-disordered breathing, we classified the patients in four groups using the apnea-hypopnea index (AHI): Group 1, AHI 5 < 15 (n = 10); Group 2, AHI 15 < 30 (n = 10); Group 3, AHI 30 < 65 (n = 14); Group 4, AHI > or = 65 (n = 17).

RESULTS

A wide range of sleep-disordered breathing, ranging from AHI of 2.5 to 128.9 was found. Ninety-eight percent of the sample (n = 51) had an AHI > or = 5 (mean = 51 +/- 37), and 33% had severe sleep apnea with AHI > or = 65 with a mean nocturnal desaturation time of <65% over 135 minutes. Electrocardiographic abnormalities were present in 31% of the patients. Cardiac rhythm alterations showed an association with the level of sleep-disordered breathing and oxygen desaturation.

DISCUSSION

We conclude that there is a high prevalence of sleep apnea in morbidly obese patients and that the risk for cardiac arrhythmias increases in this population in the presence of a severe sleep apnea (AHI > or = 65) with severe oxygen desaturation (SaO2 < or = 65%).

Multiple recurring paragangliomas: a problem of diagnosis and location. Case report and review of the literature

RATIONALE

Paragangliomas constitute a particular diagnostic challenge because of the difficulties involved in identifying new lesions.

CASE REPORT

The findings in the case of a young woman with multiple recurring paragangliomas which reappeared eleven years after successful surgical treatment are presented.

DISCUSSION

This case illustrates the diagnostic difficulties of this pathologic entity and the lack of a technique of sufficient sensitivity to reveal the existence of one or more tumors with or without hormonal secretion, their location and rate of growth and the number of neoplasias to avoid as many surgical interventions as possible. Inasmuch as an ideal technique for diagnosis and localization of this type of tumor remains to be developed, non-invasive methods, particularly 131I MIBG scintigraphy, play a significant role in evaluation because of their high sensitivity for detecting chromaffin tissue, especially in extra-adrenal locations.

CONCLUSION

Periodic long-term radionuclide scanning should be recommended for all asymptomatic patients given the risk of residual and/or reactivating tumoral tissue with benign or metastatic behavior.