Impacts of leaks and gas accumulation on closed chamber methods for measuring methane and carbon dioxide fluxes from tree stems

Accurate measurements of methane (CH4) and carbon dioxide (CO2) fluxes from tree stems are important for understanding greenhouse gas emissions. Closed chamber methods are commonly employed for this purpose; however, leaks between the chamber and the atmosphere as well as gas accumulation, known as the concentration buildup effect, can impact flux measurements significantly. In this study, we investigated the impacts of concentration buildup and leaks on semi-rigid closed chamber methods. Field measurements were conducted on six tree species, including three species from a Mexican mangrove ecosystem and three species from a Magellanic sub-Antarctic forest. Systematic observations revealed significant leak flow rates, ranging from 0.00 to 465 L h-1, with a median value of 1.25 ± 75.67 L h-1. We tested the efficacy of using cement to reduce leaks, achieving a leak flow rate reduction of 46-98 % without complete elimination. Our study also demonstrates a clear and substantial impact of concentration buildup on CH4 flux measurements, while CO2 flux measurements were relatively less affected across all tree species studied. Our results show that the combined effects of leaks and concentration buildup can lead to an underestimation of CH4 emissions by an average of 40 ± 20 % and CO2 emissions by 22 ± 22 %, depending on the bark roughness. Based on these findings, we recall a straightforward yet effective method to minimize experimental errors associated with these phenomena, previously established, and reiterated in the current context, for calculating emissions that considers effects of leaks and concentration buildup, while eliminating the need for separate determinations of these phenomena. Overall, the results, combined with a literature review, suggest that our current estimates of GHG flux from tree stems are currently underestimated.

CAM plants: their importance in epiphyte communities and prospects with global change

BACKGROUND AND SCOPE

The epiphytic life form characterizes almost 10 % of all vascular plants. Defined by structural dependence throughout their life and their non-parasitic relationship with the host, the term epiphyte describes a heterogeneous and taxonomically diverse group of plants. This article reviews the importance of crassulacean acid metabolism (CAM) among epiphytes in current climatic conditions and explores the prospects under global change.

RESULTS AND CONCLUSIONS

We question the view of a disproportionate importance of CAM among epiphytes and its role as a 'key innovation' for epiphytism but do identify ecological conditions in which epiphytic existence seems to be contingent on the presence of this photosynthetic pathway. Possibly divergent responses of CAM and C3 epiphytes to future changes in climate and land use are discussed with the help of experimental evidence, current distributional patterns and the results of several long-term descriptive community studies. The results and their interpretation aim to stimulate a fruitful discussion on the role of CAM in epiphytes in current climatic conditions and in altered climatic conditions in the future.

Lead tolerance of Laguncularia racemosa is associated to high proline accumulation and high antioxidant capacities

Mangrove forests are threatened by the continuous discharge of inorganic pollutants and studies show that coasts receive high levels of heavy metals, from which lead (Pb) is one of the most persistent and toxic. In the present study, lead accumulation capacity, as well as its toxicological effects and tolerance mechanisms, such as proline accumulation and increased antioxidant capacity were evaluated in two contrasting mangrove species: Avicennia germinans and Laguncularia racemosa. Six-month-old plants were exposed to different concentrations of lead nitrate (0, 75, 150, and 300 µM) and samples of roots and leaves were taken from all treatments at different times during a 30d exposure period. Both species accumulated Pb in their tissues mainly in the roots, but L. racemosa had a greater capacity to accumulate Pb than A. germinans. Nevertheless, lead exposure caused less leaf chlorosis, lower reduction in the efficiency of photosystem II, lower reduction of daily photosynthetic rates, and lower electrolyte leakage in L. racemosa than in A. germinans. In line with those results, L. racemosa, in response to Pb exposure, accumulated more proline and showed higher antioxidant capacity than A. germinans, in both roots and leaves. Altogether, L. racemosa might be more suitable for restoration purposes, as it is not only capable of accumulating more Pb in its tissues but also shows greater tolerance to the stress caused by lead.

New Proposal of Epiphytic Bromeliaceae Functional Groups to Include Nebulophytes and Shallow Tanks

The Bromeliaceae family has been used as a model to study adaptive radiation due to its terrestrial, epilithic, and epiphytic habits with wide morpho-physiological variation. Functional groups described by Pittendrigh in 1948 have been an integral part of ecophysiological studies. In the current study, we revisited the functional groups of epiphytic bromeliads using a 204 species trait database sampled throughout the Americas. Our objective was to define epiphytic functional groups within bromeliads based on unsupervised classification, including species from the dry to the wet end of the Neotropics. We performed a hierarchical cluster analysis with 16 functional traits and a discriminant analysis, to test for the separation between these groups. Herbarium records were used to map species distributions and to analyze the climate and ecosystems inhabited. The clustering supported five groups, C₃ tank and CAM tank bromeliads with deep tanks, while the atmospheric group (according to Pittendrigh) was divided into nebulophytes, bromeliads with shallow tanks, and bromeliads with pseudobulbs. The two former groups showed distinct traits related to resource (water) acquisition, such as fog (nebulophytes) and dew (shallow tanks). We discuss how the functional traits relate to the ecosystems inhabited and the relevance of acknowledging the new functional groups.

Multidimensional tropical forest recovery

[Figure: see text].

El Niño-Southern Oscillation affects the water relations of tree species in the Yucatan Peninsula, Mexico

We evaluated the effect of ENSO 2015/16 on the water relations of eight tree species in seasonally dry tropical forests of the Yucatan Peninsula, Mexico. The functional traits: wood density, relative water content in wood, xylem water potential and specific leaf area were recorded during the rainy season and compared in three consecutive years: 2015 (pre-ENSO conditions), 2016 (ENSO conditions) and 2017 (post-ENSO conditions). We analyzed tree size on the capacity to respond to water deficit, considering young and mature trees, and if this response is distinctive in species with different leaf patterns in seasonally dry tropical forests distributed along a precipitation gradient (700–1200 mm year⁻¹). These traits showed a strong decrease in all species in response to water stress in 2016, mainly in the driest site. Deciduous species had lower wood density, higher predawn water potential and higher specific leaf area than evergreen species. In all cases, mature trees were more tolerant to drought. In the driest site, there was a significant reduction in water status, regardless of their leaf phenology, indicating that seasonally dry tropical forests are highly vulnerable to ENSO. Vulnerability of deciduous species is intensified in the driest areas and in the youngest trees.

Bridge Graft to a Small Distal Artery after Fistula Ligation for Angioaccess-Induced Ischemia: Report of Two Cases

Angioaccess-induced ischemia is an infrequent but cumbersome problem, because both limb ischemia correction and access salvage should be undertaken during the same procedure. This paper reports two cases that we successfully managed with a bridge graft to a small distal artery after fistula ligation.

Epicardial fat thickness correlates with P-wave duration, left atrial size and decreased left ventricular systolic function in morbid obesity

BACKGROUND AND AIM

Epicardial fat (EF) is increased in obesity and has important interactions with atrial and ventricular myocardium. Most of the evidence in this scenario can be confused by the presence of comorbidities such as hypertension, diabetes and dyslipidemia, which are very common in this population. The influence of EF on atrial remodeling and cardiac function demands further investigation on morbidly obese without these comorbidities.

METHODS AND RESULTS

We prospectively recruited 20 metabolically healthy morbidly obese and 20 normo-weights controls. The maximum P-wave duration (PWD) was analyzed by 12-lead electrocardiogram. Left atrial diameter (LAD), left ventricular ejection fraction (LVEF) and EF thickness (EFT) were evaluated by two-dimensional echocardiography. The mean of maximum PWD and LAD were significantly larger in the obese group as compared to the control group: 109.55 ± 11.52 ms × 89.38 ± 11.19 ms and 36.12 ± 3.46 mm × 31.45 ± 2.64 mm, (p < 0.0001). The mean LVEF was lower in the obese group: 63.15 ± 4.25% × 66.17 ± 3.37% (p < 0.017). The mean EFT was higher in the obese group: 7.72 ± 1.60 mm × 3.10 ± 0.85 mm (p < 0.0001). A positive correlation was found between EFT and PWD (r = 0.70; p = 0.001) and LAD (r = 0.667; p = 0.001). An inverse correlation was found between EFT and LVEF (r = -0.523; p = 0.001). In a multiple multivariate regression analysis the EFT remains correlated with LAD and LVEF.

CONCLUSIONS

In a select group of morbidly obese, the excess of EF had a significant impact on atrial remodeling and cardiac function.

Photoprotection related to xanthophyll cycle pigments in epiphytic orchids acclimated at different light microenvironments in two tropical dry forests of the Yucatan Peninsula, Mexico

Epiphytic orchids from dry forests of Yucatán show considerable photoprotective plasticity during the dry season, which depends on leaf morphology and host tree deciduousness. Nocturnal retention of antheraxanthin and zeaxanthin was detected for the first time in epiphytic orchids. In tropical dry forests, epiphytes experience dramatic changes in light intensity: photosynthetic photon flux density may be up to an order of magnitude higher in the dry season compared to the wet season. To address the seasonal changes of xanthophyll cycle (XC) pigments and photosynthesis that occur throughout the year, leaves of five epiphytic orchid species were studied during the early dry, dry and wet seasons in a deciduous and a semi-deciduous tropical forests at two vertical strata on the host trees (3.5 and 1.5 m height). Differences in XC pigment concentrations and photosynthesis (maximum quantum efficiency of photosystem II; F v/F m) were larger among seasons than between vertical strata in both forests. Antheraxanthin and zeaxanthin retention reflected the stressful conditions of the epiphytic microhabitat, and it is described here in epiphytes for the first time. During the dry season, both XC pigment concentrations and photosystem II heat dissipation of absorbed energy increased in orchids in the deciduous forest, while F v/F m and nocturnal acidification (ΔH(+)) decreased, clearly as a response to excessive light and drought. Concentrations of XC pigments were higher than those in orchids with similar leaf shape in semi-deciduous forest. There, only Encyclia nematocaulon and Lophiaris oerstedii showed somewhat reduced F v/F m. No changes in ΔH(+) and F v/F m were detected in Cohniella ascendens throughout the year. This species, which commonly grows in forests with less open canopies, showed leaf tilting that diminished light interception. Light conditions in the uppermost parts of the canopy probably limit the distribution of epiphytic orchids and the retention of zeaxanthin can help to cope with light and drought stress in these forests during the dry season.

A roadmap for research on crassulacean acid metabolism (CAM) to enhance sustainable food and bioenergy production in a hotter, drier world

Crassulacean acid metabolism (CAM) is a specialized mode of photosynthesis that features nocturnal CO2 uptake, facilitates increased water-use efficiency (WUE), and enables CAM plants to inhabit water-limited environments such as semi-arid deserts or seasonally dry forests. Human population growth and global climate change now present challenges for agricultural production systems to increase food, feed, forage, fiber, and fuel production. One approach to meet these challenges is to increase reliance on CAM crops, such as Agave and Opuntia, for biomass production on semi-arid, abandoned, marginal, or degraded agricultural lands. Major research efforts are now underway to assess the productivity of CAM crop species and to harness the WUE of CAM by engineering this pathway into existing food, feed, and bioenergy crops. An improved understanding of CAM has potential for high returns on research investment. To exploit the potential of CAM crops and CAM bioengineering, it will be necessary to elucidate the evolution, genomic features, and regulatory mechanisms of CAM. Field trials and predictive models will be required to assess the productivity of CAM crops, while new synthetic biology approaches need to be developed for CAM engineering. Infrastructure will be needed for CAM model systems, field trials, mutant collections, and data management.

Subclinical right ventricle systolic dysfunction in childhood-onset systemic lupus erythematosus: insights from two-dimensional speckle-tracking echocardiography

Objective

The objective of this article is to evaluate right ventricle strain imaging by two-dimensional speckle-tracking (2DST) in childhood-onset systemic lupus erythematosus (c-SLE).

Methods

Thirty-five c-SLE patients with no signs or symptoms of heart failure and 33 healthy volunteers were evaluated by standard echocardiogram and 2DST. Conventional parameters included tricuspid annular plane systolic excursion (TAPSE), RV tissue-Doppler-derived Tei index and systolic pulmonary artery pressure. Global peak longitudinal systolic strain (PLSS) and strain rate (PLSSR) of RV were obtained by 2DST. Demographic/clinical features, SLEDAI-2K/SLICC/ACR-DI and treatment were also assessed.

Results

The median current age was similar in patients and controls (14.75 vs. 14.88 years, p = 0.62). RV PLSS was significantly reduced in c-SLE (−24.5 ± 5.09 vs. −27.62 ± 3.02%, p = 0.003). Similar findings were observed after excluding patients with pulmonary hypertension (−24.62 ± 4.87% vs. −27.62 ± 3.02%, p = 0.0041). RV PLSS was positively correlated with TAPSE ( r = +0.49, p = 0.0027) and negatively correlated with Tei index ( r = −0.34, p = 0.04) in c-SLE. RV PLSSR was not different comparing patients and controls (−0.65 s−1 ± 0.47 vs. −1.87 ± 0.49 s−1, p = 0.07). Further analysis of c-SLE patients revealed higher frequencies of neuropsychiatric manifestations (39% vs. 0%, p = 0.007) and antiphospholipid antibodies (55% vs. 18%, p = 0.035) in those with RV PLSS ≤ −23.7% vs >−23.7%. No differences were evidenced in demographic data, disease activity/damage or treatments ( p > 0.05).

Conclusions

The present study, using a new and more sensitive technique, revealed subclinical RV systolic dysfunction in c-SLE patients that may have future prognostic implications. The novel association of asymptomatic RV dysfunction with neuropsychiatric manifestations and antiphospholipid antibodies may suggest common physiopathological pathways.

Environmental regulation of carbon isotope composition and crassulacean acid metabolism in three plant communities along a water availability gradient

Expression of crassulacean acid metabolism (CAM) is characterized by extreme variability within and between taxa and its sensitivity to environmental variation. In this study, we determined seasonal fluctuations in CAM photosynthesis with measurements of nocturnal tissue acidification and carbon isotopic composition (δ(13)C) of bulk tissue and extracted sugars in three plant communities along a precipitation gradient (500, 700, and 1,000 mm year(-1)) on the Yucatan Peninsula. We also related the degree of CAM to light habitat and relative abundance of species in the three sites. For all species, the greatest tissue acid accumulation occurred during the rainy season. In the 500 mm site, tissue acidification was greater for the species growing at 30% of daily total photon flux density (PFD) than species growing at 80% PFD. Whereas in the two wetter sites, the species growing at 80% total PFD had greater tissue acidification. All species had values of bulk tissue δ(13)C less negative than -20‰, indicating strong CAM activity. The bulk tissue δ(13)C values in plants from the 500 mm site were 2‰ less negative than in plants from the wetter sites, and the only species growing in the three communities, Acanthocereus tetragonus (Cactaceae), showed a significant negative relationship between both bulk tissue and sugar δ(13)C values and annual rainfall, consistent with greater CO(2) assimilation through the CAM pathway with decreasing water availability. Overall, variation in the use of CAM photosynthesis was related to water and light availability and CAM appeared to be more ecologically important in the tropical dry forests than in the coastal dune.

Antioxidant content in two CAM bromeliad species as a response to seasonal light changes in a tropical dry deciduous forest

Plants have evolved photoprotective mechanisms to limit photodamage; one of these mechanisms involves the biosynthesis of antioxidant metabolites to neutralize reactive oxygen species generated when plants are exposed to excess light. However, it is known that exposure of plants to conditions of extreme water stress and high light intensity results in their enhanced susceptibility to over-excitation of photosystem II and to photooxidative stress. In this investigation we used the 2,2-diphenyl-1-picrylhydrazyl reduction assay to conduct a broad survey of the effect of water availability and light exposure conditions on the antioxidant activity of the leaf extracts of two bromeliad species showing crassulacean acid metabolism. One of these was an epiphyte, Tillandsia brachycaulos, and the other a terrestrial species, Bromelia karatas. Both species were found growing wild in the tropical dry deciduous forest of Dzibilchaltún National Park, México. The microenvironment of T. brachycaulos and B. karatas experiences significant diurnal and seasonal light variations as well as changes in temperature and water availability. The results obtained showed that, for both bromeliads, increases in antioxidant activity occurred during the dry season, as a consequence of water stress and higher light conditions. Additionally, in T. brachycaulos there was a clear correlation between high light intensity conditions and the content of anthocyanins which accumulated below the leaf epidermis. This result suggests that the role of these pigments is as photoprotective screens in the leaves. The red coloration below the leaf epidermis of B. karatas was not due to anthocyanins but to other unidentified pigments.

Repeated echocardiographic examinations of patients with suspected infective endocarditis

OBJECTIVE

To study the diagnostic contribution of repeated transthoracic (TTE) and transoesophageal echocardiography (TOE) among patients with suspected infective endocarditis.

METHODS

262 patients with 266 episodes of suspected infective endocarditis were referred for TTE and TOE over three years in a 423 bed university cardiology hospital. Patients were a mean (SD) of 47.6 (17.9) years old. 139 (52.3%) episodes occurred in men and 127 (47.7%) in women. The diagnostic information obtained from repeated TTE and TOE examinations was evaluated relative to the diagnosis of endocarditis.

RESULTS

TTE examinations were repeated in 192 (72.2%) and TOE examinations were repeated in 49 (18.4%) of 266 episodes. A mean of 2.4 TTE and 1.2 TOE examinations were performed for each episode of suspected endocarditis. The second and third TTEs added diagnostic information in 34 (26.7%) and the second and third TOEs added diagnostic information in 25 (19.7%) of 127 episodes with definite endocarditis. After the third TTE or TOE no additional diagnostic information was obtained.

CONCLUSIONS

The diagnostic contribution of repeated TTE or TOE for the diagnosis of endocarditis decreased as the number of repetitions increased. In this setting, the data do not substantiate more than three TTE or TOE examinations as an efficient strategy to increase the diagnostic yield for all but selected patients with suspected endocarditis.

Maintenance of midgut epithelial cells from Dendroctonus valens (Coleoptera: Scolytidae) in vitro

This article describes the culture of epithelial cells from anterior and posterior midgut regions of adult Dendroctonus valens. Culture conditions were established, and cell adherence was improved by means of a new technique that allowed the cells to grow between two glass coverslips. Cytoplasmic projections occur as anterior midgut cells grow to confluence; these projections were not observed in cells of the posterior midgut. The optimal culture medium for the maintenance of these epithelial cells was Roswell Park Memorial Institute 1640 medium at 25 degrees C. Cells in Grace's medium died in 24 h. Cultures did not require CO(2) atmosphere, but culture development was favored by the microaerophilic environment and the dark conditions in which the cells were grown, between the coverslips.

Prevalence of lower limb occlusive vascular disease in outclinic diabetic patients

AIM

The aim of this study was to determine the prevalence and risk factors for peripheral occlusive vascular disease (POVD) in subjects with diabetes mellitus (DM) in Brazil.

METHODS

We evaluated 236 diabetic individuals, in spontaneous demand, representing 471 legs. POVD was assessed by the ankle brachial index (ABI).

RESULTS

The mean age was 62.1 years (range 22-89 years), 52% were male, 93.2% type II DM and the mean time to diagnosis was 7.9 years (range 0-37 years). Sixty percent were hypertensives. In 61% at least one pulse was diminished or absent. The prevalence of ischemia was 18% (ABI<0.9) while 22% had an ABI compatible with high grade arterial calcification (ABI>1.3). Overall less than 1/3 of the cases had the vascular exam that could be considered normal. The ABI was lower in subjects with pulse deficit (p<0.001), and a normal pulse had a negative predictive value for ischemia of more than 90%. Subjects with normal pulses were younger and had a decreased diabetes duration (p<0.001 and p<0.05, respectively). An increase in the duration of the diabetes was associated with a progressive decrease in the ABI (p<0.01). Female gender and hypertension were associated with a reduced ABI (p<0.01 and p<0.05, respectively).

CONCLUSION

There is a high prevalence of POVD in diabetic individuals. The disease is associated with hypertension and female gender and gets worse with increasing duration of the diabetes.

Evaluation of stunned and infarcted canine myocardium by real time myocardial contrast echocardiography

Differentiation between stunned and infarcted myocardium in the setting of acute ischemia is challenging. Real time myocardial contrast echocardiography allows the simultaneous assessment of myocardial perfusion and function. In the present study we evaluated infarcted and stunned myocardium in an experimental model using real time myocardial contrast echocardiography. Sixteen dogs underwent 180 min of coronary occlusion followed by reperfusion (infarct model) and seven other dogs were submitted to 20 min of coronary occlusion followed by reperfusion (stunned model). Wall motion abnormality and perfusional myocardial defect areas were measured by planimetry. Risk and infarct areas were determined by tissue staining. In the infarct model, the wall motion abnormality area during coronary occlusion (5.52 1.14 cm(2) ) was larger than the perfusional myocardial defect area (3.71 1.45 cm (2); P < 0.001). Reperfusion resulted in maintenance of wall motion abnormality (5.45 1.41 cm (2); P = 0.43 versus occlusion) and reduction of perfusional myocardial defect (1.51 1.29 cm (2); P = 0.004 versus occlusion). Infarct size determined by contrast echocardiography correlated with tissue staining (r = 0.71; P = 0.002). In the stunned model, the wall motion abnormality area was 5.49 0.68 cm (2) during occlusion and remained 5.1 0.63 cm (2) after reperfusion (P = 0.07). Perfusional defect area was 2.43 0.79 cm (2) during occlusion and was reduced to 0.2 0.53 cm(2) after reperfusion (P = 0.04). 2,3,5-Triphenyl tetrazolium chloride staining confirmed the absence of necrotic myocardium in all dogs in the stunned model. Real time myocardial contrast echocardiography is a noninvasive technique capable of distinguishing between stunned and infarcted myocardium after acute ischemia.

Regulation of water flux through tropical forest canopy trees: do universal rules apply?

Tropical moist forests are notable for their richness in tree species. The presence of such a diverse tree flora presents potential problems for scaling up estimates of water use from individual trees to entire stands and for drawing generalizations about physiological regulation of water use in tropical trees. We measured sapwood area or sap flow, or both, in 27 co-occurring canopy species in a Panamanian forest to determine the extent to which relationships between tree size, sapwood area and sap flow were species-specific, or whether they were constrained by universal functional relationships between tree size, conducting xylem area, and water use. For the 24 species in which active xylem area was estimated over a range of size classes, diameter at breast height (DBH) accounted for 98% of the variation in sapwood area and 67% of the variation in sapwood depth when data for all species were combined. The DBH alone also accounted for > or = 90% of the variation in both maximum and total daily sap flux density in the outermost 2 cm of sapwood for all species taken together. Maximum sap flux density measured near the base of the tree occurred at about 1,400 h in the largest trees and 1,130 h in the smallest trees studied, and DBH accounted for 93% of the variation in the time of day at which maximum sap flow occurred. The shared relationship between tree size and time of maximum sap flow at the base of the tree suggests that a common relationship between diurnal stem water storage capacity and tree size existed. These results are consistent with a recent hypothesis that allometric scaling of plant vascular systems, and therefore water use, is universal.

Structural and functional characteristics of rat hearts with and without myocardial infarct. Initial experience with Doppler echocardiography

OBJECTIVE

To assess by Doppler echocardiography the structural and functional alterations of rat heart with surgical induced extensive myocardial infarction.

METHODS

Five weeks after surgical ligature of the left coronary artery, 38 Wistar-EPM rats of both sexes, 10 of them with extensive infarction, undergone anatomical and functional evaluation by Doppler echocardiography and then euthanized for anatomopathological analysis.

RESULTS

Echocardiography was 100% sensible and specific to anatomopathological confirmed extensive miocardial infarction. Extensive infarction lead to dilatation of left ventricle (diastolic diameter: 0.89 cm vs.0.64 cm; systolic: 0. 72 cm vs. 0.33 cm) and left atrium (0.55 cm vs. 0.33 cm); thinning of left ventricular anterior wall (systolic: 0.14 cm vs. 0.23 cm, diastolic: 0.11 cm vs. 0.14 cm); increased mitral E/ A wave relation (6.45 vs. 1.95). Signals of increased end diastolic ventricle pressure, B point in mitral valve tracing in 62.5% and signs of pulmonary hypertension straightening of pulmonary valve (90%) and notching of pulmonary systolic flow (60%) were observed in animals with extensive infarction.

CONCLUSION

Doppler echocardiography has a high sensitivity and specificity for detection of chronic extensive infarction. Extensive infarction caused dilatation of left cardiac chambers and showed in Doppler signals of increased end diastolic left ventricular pressure and pulmonary artery pressure.

Multiple arterial anomalies in the newborn infant. Echocardiographic and angiographic diagnosis

Multiple arterial anomalies characterized by tortuosity and rolling of the pulmonary arteries and aorta were diagnosed on echocardiography in an asymptomatic newborn infant with a phenotype suggesting Ehlers-Danlos syndrome. These changes were later confirmed on angiography, which also showed peripheral vascular abnormalities. The electrocardiogram showed a probable hemiblock of the left anterosuperior branch, and the chest x-ray showed an excavated pulmonary trunk with normal pulmonary flow.

Association of pulmonary atresia with intact ventricular septum and aortic valve stenosis. Prenatal diagnosis

A rare association of pulmonary atresia with an intact septum was diagnosed through echocardiography in a fetus 32 weeks of gestational age. The diagnosis was later confirmed by echocardiography of the newborn infant and further on autopsy. The aortic valve was bicuspid with a pressure gradient of 81 mmHg, and the right ventricle was hypoplastic, as were the pulmonary trunk and arteries, and the blood flow was totally dependent on the ductus arteriosus.

The value of echocardiography in the diagnosis and followup of rheumatic carditis in children and adolescents: a 2 year prospective study

OBJECTIVE

To evaluate echocardiographic/Doppler findings in patients with rheumatic fever whether or not clinical manifestations of carditis were present, and the followup of these findings 24 months after the acute phase.

METHODS

Twenty-two patients with rheumatic fever (13 boys, 9 girls, mean age 11.0 years) were evaluated at baseline (at diagnosis) and after 3 and 6 mo of disease. Eighteen patients were reevaluated 24 mo later. The assessment included physical and cardiac examination, electrocardiogram, chest radiography, and color ECHO/Doppler performed blindly by different investigators. The control group included 15 healthy children.

RESULTS

We observed clinical carditis in 8 patients (36.4%): Group 1, all with ECHO abnormalities. We observed no clinical cardiac manifestations in 14 patients (Group 2), but 5 (35.7%) had positive ECHO/Doppler abnormalities that persisted at least 6 mo in followup assessments. Mitral and aortic were the most frequently involved valves. In Group 1 we observed normalization of the ECHO/Doppler in 3 patients, improvement in 2, no change in 2, and worsening in one. Twelve of 14 patients without clinical carditis were reevaluated, including the 5 patients with ECHO/Doppler abnormalities during the initial evaluations; normalization or improvement was observed in 2 patients, no change in 2, and worsening in one. We observed no ECHO/Doppler abnormalities in the control group.

CONCLUSION

This blind prospective study suggests the existence of asymptomatic carditis in some patients with rheumatic fever and the role ECHO/Doppler investigation could play in diagnosis and followup.

Right coronary artery fistula with congestive heart failure in the neonate. Doppler echocardiographic diagnosis and closure with detachable balloon

We report here a case of coronary artery fistula in a neonate with clinical signs of heart failure. The electrocardiogram showed signs of left ventricular hypertrophy and diffuse alterations in ventricular repolarization. Chest X-ray showed an enlargement of the cardiac silhouette with an increase in pulmonary flow. After echocardiographic diagnosis and angiographic confirmation, closure of the fistulous trajectory was performed with a detachable balloon with an early and late successful outcome.

Safety of dobutamine-atropine stress echocardiography: A prospective experience of 4,033 consecutive studies

Dobutamine-atropine stress echocardiography (DASE) is an established method and has been shown to be accurate for the detection of coronary artery disease. Still, there are few large clinical studies that analyze the safety of DASE in general or the safety of performing it on an ambulatory basis. Most studies use a target heart rate as the primary end point regardless of whether asymptomatic ischemia occurs. Such studies have shown a serious cardiac event rate of approximately 0.3%. We prospectively studied 4,033 consecutive patients on an ambulatory basis and in the hospital with the use of DASE from July 1991 to December 1998. All tests were performed by an experienced physician, and all clinical and DASE data were stored in a large database organized at the beginning of the study. Dobutamine was infused in scalar doses of 5, 10, 20, 30, and 40 microg/kg per minute in 3-minute stages. Development of a new wall motion abnormality, achievement of 85% of target heart, and end of the DASE infusion protocol were used as an end point. If 85% of the target heart rate was not achieved, atropine was infused up to 1 mg in the absence of myocardial ischemia, which was used in 1,280 studies. There were 3,645 diagnostic tests, and 388 (10%) were found to be nondiagnostic. This result was due to poor image quality in 115 (3%), end of protocol in negative-submaximal examinations in 124 (3%), and limiting side effects in 149 (4%). Thirty-seven percent of the tests showed positive results for myocardial ischemia. Major test-related cardiac complications occurred in 10 (0.25%) patients and included 1 ventricular fibrillation, 1 case of myocardial infarction, and 8 cases of sustained ventricular tachycardia. Atropine poisoning was observed in 5 (0.12%) patients. No deaths occurred as a direct or indirect consequence of DASE. We conclude that dobutamine-atropine stress echocardiography is a reasonably safe method for detection of coronary artery disease in the hospital or in an ambulatory basis. The use of new wall motion abnormality as 1 of the end points may prevent further ischemia-related complications.

Potential errors in measurement of nonuniform sap flow using heat dissipation probes

The empirical calibration of Granier-type heat dissipation sap flow probes that relate temperature difference (DeltaT) to sap velocity (v) was reevaluated in stems of three tropical tree species. The original calibration was confirmed when the entire heated probe was in contact with conducting xylem, but mean v was underestimated when part of the probe was in contact with nonconducting xylem or bark. Analysis of the effects of nonuniform sap velocity profiles on heat dissipation estimates showed that errors increased as v and the proportion of the probe in nonconducting wood increased. If half of a 20-mm probe is in sapwood with a v of 0.15 mm s(-1) and the other half is in nonconducting wood, then mean v for the whole probe can be underestimated by as much as 50%. A correction was developed that can be used if the proportion of the probe in nonconducting wood is known. Even with the entire heated probe in contact with conducting xylem, v would be underestimated when radial velocity gradients are present. In this case, the error would be smaller except when velocity gradients are very steep, as can occur in species with ring-porous wood anatomy. Errors occur because the relationship between DeltaT and v is nonlinear. Mean DeltaT along the probe is therefore not a measure of mean v, and users of heat dissipation probes should not assume that v is integrated along the length of the probe. The same type of error can occur when DeltaT is averaged through time while v is changing, but the error is small unless there are sudden, step changes between zero and high sap velocity. It is recommended that relatively short probes (20 mm or less) be used and that probes longer than the depth of conducting sapwood be avoided. Multiple probes inserted to a range of depths should be used in situations where steep gradients in v are expected. If these conditions are met, heat dissipation probes remain useful and widely applicable for measuring sap flow in woody stems.

Lectin-induced nitric oxide production

Considering that nitric oxide (NO) may be involved in anti-tumoral and anti-parasite lectin effects, in this report we investigated whether lectin induces NO production. Lectins from Canavalia brasiliensis, Dioclea grandiflora, Pisum arvense (PAA), and concanavalin A induced murine peritoneal cells to produce NO in vitro. PAA induced similar levels to that obtained with lipopolysaccharide plus interferon-gamma. NO production by adherent cells was significantly lower than that of unfractionated cells, suggesting a combination of lectin stimuli directly on macrophages and via lymphocyte stimulation. Ex vivo experiments showed that cells stimulated in vivo could maintain NO production in vitro without further stimuli. NO synthesis blockage in vivo can significantly increase cell numbers in draining lymph nodes after lectin injection compared to unblocked controls, suggesting an in vivo association of lectin stimuli and NO production. Taken together these data show that lectins can induce NO production both in vitro and in vivo.

Partitioning of soil water among canopy trees in a seasonally dry tropical forest

Little is known about partitioning of soil water resources in species-rich, seasonally dry tropical forests. We assessed spatial and temporal patterns of soil water utilization in several canopy tree species on Barro Colorado Island, Panama, during the 1997 dry season. Stable hydrogen isotope composition (δD) of xylem and soil water, soil volumetric water content (θ_v), and sap flow were measured concurrently. Evaporative fractionation near the soil surface caused soil water δD to decrease from about -15‰ at 0.1 m to -50 to -55‰ at 1.2 m depth. Groundwater sampled at the sources of nearby springs during this period yielded an average δD value of -60‰. θ_v increased sharply and nearly linearly with depth to 0.7 m, then increased more slowly between 0.7 and 1.05 m. Based on xylem δD values, water uptake in some individual plants appeared to be restricted largely to the upper 20 cm of the soil profile where θ_v dropped below 20% during the dry season. In contrast, other individuals appeared to have access to water at depths greater than 1 m where θ_v remained above 45% throughout the dry season. The depths of water sources for trees with intermediate xylem δD values were less certain because variation in soil water δD between 20 and 70 cm was relatively small. Xylem water δD was also strongly dependent on tree size (diameter at breast height), with smaller trees appearing to preferentially tap deeper sources of soil water than larger trees. This relationship appeared to be species independent. Trees able to exploit progressively deeper sources of soil water during the dry season, as indicated by increasingly negative xylem δD values, were also able to maintain constant or even increase rates of water use. Seasonal courses of water use and soil water partitioning were associated with leaf phenology. Species with the smallest seasonal variability in leaf fall were also able to tap increasingly deep sources of soil water as the dry season progressed. Comparison of xylem, soil, and groundwater δD values thus pointed to spatial and temporal partitioning of water resources among several tropical forest canopy tree species during the dry season.

Importance of intraoperative transesophageal echocardiography during coronary artery surgery without cardiopulmonary bypass

The goal of this study was to assess left ventricular segmental wall motion (SWM) abnormalities during coronary artery bypass grafting (CABG) without cardiopulmonary bypass (CPB), and its impact on the immediate postoperative outcome. Transesophageal echocardiography was used intraoperatively in 27 patients (mean age 57 years) who had CABG without CPB. Images obtained with a 5-MHz biplane transesophageal echocardiographic probe in the transgastric and transesophageal planes were recorded before, during, and after 48 coronary artery clampings for saphenous vein or internal mammary artery anastomosis. Transthoracic echocardiography was performed 1 day before surgery and on the seventh postoperative day. During the 48 coronary artery clampings, 31 (64%) new SWM abnormalities were found. At the time of chest closure, complete recovery occurred in 16 (50%) segments, partial recovery in 10 (33%), and no recovery in 5 (17%). On the seventh postoperative day the new SWM abnormalities persisted in all 5 segments without recovery at the end of the surgery and in 2 of 10 (20%)segments with partial recovery (group 1). Group 1 had higher variation on the echocardiographic point score index between the beginning and end of surgery, higher enzymatic levels, more ST-T changes on the electrocardiogram, and more clinical problems than group 2 (patients without new SWM abnormalities on the seventh postoperative day) (P < .05). We concluded that new SWM abnormalities of the left ventricle occur during CABG without CPB as assessed by intraoperative transesophageal echocardiography. Persistence of these abnormalities at the end of surgery may be a predictor of SWM dysfunction and clinical problems in the immediate postoperative period.

[Right ventricle-dependent coronary circulation in pulmonary atresia with intact ventricular septum. Absence of origin of the coronary arteries from the aorta]

This report describes the clinical, echocardiographic and angiographic aspects of a five-day old boy with pulmonary atresia and intact ventricular septum. Both the echocardiogram and the aortography did not show any coronary arteries arising from the aorta. Two-dimensional echocardiography was able to identify the coronary arteries originating from the right ventricle and so did the right ventricular angiogram. No retrograde flow into the aorta or pulmonary trunk was identified after opacification of the coronary arteries. As far as we know this is the first case diagnosed by echocardiography, and is a vivid example of the necessity of identifying the coronary arteries in patients with pulmonary atresia and intact ventricular septum.

[Anomalous origin of the right pulmonary artery from the ascending aorta (Hemitruncus)]

The origin of the right pulmonary artery from the ascending aorta is a rare cogenital anomaly, with very few reports in the literature. We describe two cases of this rare malformation, one of them, associated with interruption of the aortic arch (type B). In both cases, the diagnosis was made by two-dimensional echocardiography, with angiographic confirmation in one of them. The origin of the right pulmonary artery was close to the aortic valve, anomaly pathogenetically distinct from the type that arises close to the innominate artery.

Dobutamine stress echocardiography in anomalous left coronary artery

The evaluation of left ventricular function with dobutamine stress echocardiography is described for the first time in a patient with anomalous left coronary artery from the pulmonary trunk during the preoperative and postoperative periods. This method demonstrated signs of myocardial ischemia that were not seen on the resting echocardiogram during the preoperative period and ventricular function recovery after surgical intervention.

[Athlete's heart in elite disabled athletes]

PURPOSE

To assess the prevalence of the athlete's, heart syndrome in elite disabled Brazilians athletes.

METHODS

Seventy-five athletes, age 27.8 +/- 6.7 years, 56 men, with various disabilities (47 physical, 12 visual and 16 cerebral paralysis) underwent clinical, electrocardiographic, vectorcardiographic, ergometric and echocardiographic evaluations.

RESULTS

Athlete's heart signs occurred in 33% of the clinical evaluations, in 55% of the electrocardiograms, in 15% of the vectorcardiograms, and in 5% of the echocardiograms. At least one of these signs was presented in 51% of the athletes. There were 2 or more abnormalities in 46% of the athletes and 4 or more signs in 12%. Exercise test was considered not ischemic in 77% of the subjects. There was right bundle branch block in 23% of the tests.

CONCLUSION

There were two or more athlete's heart syndrome signs in 46% of Brazilian disabled athletes.

[Assessment of left internal thoracic artery anastomosis with left anterior descending coronary artery by Doppler echocardiography]

PURPOSE

To study the value of Doppler echocardiography as a tool for the evaluation of left internal thoracic artery graft (LITAG) patency in patients who underwent coronary revascularization using minimally invasive bypass surgery without extracorporeal circulation.

METHODS

The first 12 consecutive patients were studied after coronary artery bypass surgery using a 5 MHz Doppler transducer. Doppler signals for the systolic and diastolic flow velocities were preferably obtained in the second intercostal space. All patients underwent coronary angiography while hospitalized.

RESULTS

The exam was feasible in 93% of patients. Doppler flow pattern was predominantly diastolic (pattern A) in patients with patent anastomoses (6/7). In patients with occluded anastomoses (4/4) Doppler flow pattern was predominantly systolic (pattern B) (p = 0.003).

CONCLUSION

Internal thoracic artery flow pattern as measured by Doppler echocardiography after minimally invasive coronary artery bypass graft surgery is an accurate method for identifying LITAG patency.

[Patent ductus arteriosus and pulmonary artery endarteritis]

We describe a seven year old girl with echocardiographic diagnosis of pulmonary artery endarteritis as a complication of a patent ductus arteriosus, confirmed at surgery. This case illustrates the necessity of complete surgical resection of the infectious source as a way to avoid other complications such as pulmonary embolism.

[Prognostic value of stress echocardiography by dobutamine combined with atropine]

PURPOSE

To determine the prognostic value of dobutamine-atropine stress echocardiography (DASE).

METHODS

We studied 452 consecutive patients at high risk for coronary artery disease, using DASE. They were followed during a mean period of 23 months.

RESULTS

There were 9 cardiac deaths and 2 acute myocardial infarctions in the group of patients with positive tests, and there were 2 myocardial infarctions and 1 cardiac death in patients with negative DASE.

CONCLUSION

We conclude that DASE reliably identifies patients at high risk for hard cardiac events.

[Prognostic value of stress echocardiography by dobutamine combined with atropine]

PURPOSE

To determine the prognostic value of dobutamine-atropine stress echocardiography (DASE).

METHODS

We studied 452 consecutive patients at high risk for coronary artery disease, using DASE. They were followed during a mean period of 23 months.

RESULTS

There were 9 cardiac deaths and 2 acute myocardial infarctions in the group of patients with positive tests, and there were 2 myocardial infarctions and 1 cardiac death in patients with negative DASE.

CONCLUSION

We conclude that DASE reliably identifies patients at high risk for hard cardiac events.

[Safety and feasibility of dobutamine-atropine stress echocardiography]

PURPOSE

To study the safety and feasibility of dobutamine-atropine stress echocardiography (DASE) in patients with known or suspected coronary artery disease.

METHODS

There were 3,000 DASE that were studied in a prospective fashion. All symptoms and side effects were stored in a data base format.

RESULTS

Major test-related complications observed included one case of myocardial infarction, four cases of sustained ventricular tachycardia and five cases of atropine intoxication. There was no death or ventricular fibrillation as a direct or indirect consequence of the test. The infusion protocol allowed to us to examine patients using beta blockers, and led to 95% feasibility.

CONCLUSION

DASE is a safe and feasible method for the study of patients with suspected or known coronary artery disease.

[Diagnostic accuracy of dobutamine-atropine stress echocardiography]

PURPOSE

To analyze the diagnostic accuracy of dobutamine-atropine stress echocardiography.

METHODS

We studied 304 consecutive patients using dobutamine-atropine stress echocardiography who underwent coronary angiography within a month of the exam. Patients received high dobutamine doses associated or not with atropine.

RESULTS

The global sensitivity was 92%, specificity was 72% and diagnostic accuracy was 87%. Analyzing 120 patients with normal LV function, we found sensitivity of 85%, specificity of 79% and accuracy of 82%.

CONCLUSION

Dobutamine-atropine stress echocardiography is an accurate method for the detection of coronary artery disease.

[Partial atrioventricular septal defect associated with right atrioventricular valve Ebstein's disease]

The association of Ebstein's disease and atrioventricular septal defect is extremely rare with only 13 cases described in the literature and none in our country. We described a 15 year-old girl with echo and angiographic diagnosis confirmed by surgery. The non-identification of one of the lesions could impair planning and surgical results.

Investigation of persistent colonization by Pseudomonas aeruginosa-like strains in a spring water bottling plant

Ninety-seven strains, producing a fluorescent pigment under UV light and/or a green diffusive pigment on cetrimide-naladixic acid agar, were isolated from a spring water bottling plant. These strains were presumptively identified as Pseudomonas aeruginosa, but they could not be confirmed as strains of this species nor identified by the API 20NE identification system. The isolates and reference strains were clustered by computer-assisted whole-cell protein sodium dodecyl sulfate-polyacrylamide gel electrophoresis. The numerical analysis of the protein electrophoregrams resulted in the formation of four clusters at a similarity level of 80% and two unclustered type strains. One cluster included strains isolated during a 4-month period and reference strains of several biotypes of P. fluorescens. The remaining isolates formed another cluster with a very high similarity of level, which included two groups of strains based on biochemical characterization by the API 20NE Test System. Strains were typed by random amplified polymorphic DNA (RAPD)-PCR and two different RAPD patterns were obtained, corresponding to each biochemical profile. This persistent colonization seems to be caused by a single species present in the bottling system, with two clonal origins, not related to P. aeruginosa or to any of the other type strains tested. Partial 16S rDNA sequence of a representative strain of one cluster of isolates had a level of similarity of 99.3% with P. alcaligenes. This study shows that characteristics similar to P. aeruginosa on cetrimide-naladixic acid agar can be exhibited by several groups of fluorescent pseudomonads that do not belong to this species, clearly showing that confirmation tests must be performed before a decision regarding the water quality is made.

[Clinical manifestation of aortopulmonary window as mitral regurgitation caused by secondary dilatation of the valvar anulus]

Two patients with huge aortopulmonary window, both ten months-old, that showed curiously up at a clinical viewpoint, including echocardiography, as a mitral valve regurgitation with a dilated mitral ring secondary to the accentuated blood volume through it, were reported. Early signs of heart failure, accentuated systolic murmur at mitral area and overload of left heart cavities, characterized clinical impression of a congenital mitral insufficiency, in both cases. The correct diagnosis was established at operation and at necropsy study, bringing it to us the need to a more accurate analysis of the different diagnostic elements, especially in anomalies which clinical manifestations show great similarities.

Physiologic multivalvular regurgitation during pregnancy: a longitudinal Doppler echocardiographic study

Valvular function, assessed by Doppler technique, has not been extensively investigated during normal pregnancy. To prospectively study this feature, 18 normal pregnant women were followed during their pregnancies and puerperium, with serial clinical and pulsed-continuous Doppler echocardiographic examinations. In four gestational periods and the puerperium, we analysed: (a) ventricular and atrial dimensions, as well as valve annular diameters; (b) prevalence and characteristics of trivial valvular regurgitations. During pregnancy, slight but significant increases of the four cardiac chamber dimensions and valve annular diameters were observed, except for the aortic ring. The prevalence of physiologic valvular regurgitation in early pregnancy (mitral, 0%; tricuspid, 38.9%; pulmonary, 22.2%; aortic, 0%), was similar to a control group of 18 healthy non-pregnant women. As pregnancy evolved, there was a progressive and significant increase of multivalvular regurgitation, maximal at full-term (mitral, 27.8%; tricuspid, 94.4%; pulmonary, 94.4%, P < 0.05 vs. early pregnancy). Aortic regurgitation was not detected in any stage of pregnancy. In the puerperium, mitral regurgitation resolved, but tricuspid and pulmonary regurgitation were still significantly prevalent (83.3% and 66.7%, respectively, P < 0.05 vs. early pregnancy). It is concluded that physiologic multivalvular regurgitation is frequent in pregnancy, mainly involving right-sided valves in late gestational periods, occasionally persisting in the early puerperium. Chamber enlargement, valve annular dilatation, and increased prevalence of trivial valve regurgitation are time-related events during normal pregnancy, resulting from a reversible cardiac remodeling process induced by physiologic volume overload. These aspects should be considered for a correct interpretation of Doppler echocardiographic findings in pregnant women with suspected heart disease.

Contrast echocardiography during cardiac catheterization in patients with congenital heart diseases

Contrast echocardiography performed during cardiac catheterization has mostly been limited to a few published case reports. We studied 37 patients with congenital heart disease to assess the capability of the method to diagnose cardiac shunts and valve regurgitation. Injections of 5% dextrose in water through an angiographic catheter were made to evaluate septal integrity and valve competence compared with conventional contrast angiography. An overall sensitivity of 93% and specificity of 78% were found. In four cases of atrial septal defect and seven of mitral regurgitation, the sensitivity was 100%. It was slightly lower for eleven cases of ventricular septal defect (91%) and four of patent ductus arteriosus (75%). When assessing aortic, tricuspid and pulmonary valve competence, the method proved to be more sensitive than conventional angiography to detect mild regurgitation. Contrast echocardiography is a sensitive and safe technique that may be used in association with conventional angiography reducing the need for radiographic contrast and ionizing radiation time.

[Submitral left ventricular aneurysm in a Brazilian Indian]

Subvalvar left ventricular aneurysm is a rare disease of unknown etiology, that has been described most often in black Africans. A case of Brazilian indian with heart failure and a murmur of mitral regurgitation is reported. The chest x-ray showed a mild bulge in the left cardiac border and two-dimensional echocardiography demonstrated submitral left ventricular aneurysm, confirmed by left ventricular angiography. Surgical treatment consisted of resection of the aneurysm and mitral valvuloplasty. A perforation of the aneurysm, undetected neither by two-dimensional echocardiography nor by angiography was found at surgery.

[Assessment of pulmonary arterial pressure in adults with Doppler echocardiography]

PURPOSE

To assess the role of pulsed Doppler echocardiography (PDE) in the indirect assessment of pulmonary artery (PA) pressure (P), analysing the pulmonary velocity blood flow curves (PVBFC) profile.

PATIENTS AND METHODS

Sixty-one adults with several kinds of heart disease were submitted to heart catheterization to obtain PAP (systolic, diastolic, mean), and other hemodynamic variables. A PDE examination was performed in all to obtain the PVBFC at the level of the pulmonic annulus. Qualitative features of the curve were analysed (morphological pattern, presence of pulmonic regurgitation) as well as quantitative data (acceleration time = AT, right ventricle ejection time = RVET index, AT/RVET index AT corrected for heart rate = ATC), which were compared to the invasive measurements.

RESULTS

An abnormal rapid acceleration of the PVBFC, with triangular configuration, was noted in patient with pulmonary hypertension (PH), in contrast to the dome-like shape of the PVBFC in normal PAP. Pulmonary regurgitation was more frequent (p < 0.05) in patients with severe PH (mean PAP > or = 40 mmHg), comparing with patients with PAP < 40 mmHg. Inverse linear correlations were observed between AT and mean PAP, particularly when sinus rhythm was present (r = 0.89; p < 0.05) excluding patients with atrial fibrillation (19 cases).

CONCLUSION

PDE is an useful and noninvasive method for indirect evaluation of PAP in adults, especially during stable sinus rhythm, in heart rate range from 60 to 115 bpm.

Cardiopulmonary exercise testing early after catheter-balloon mitral valvuloplasty in patients with mitral stenosis

Seven female patients (age 27 to 53 yr) with significant mitral stenosis performed continuous, incremental, maximal treadmill exercise tests the day before and within 3-5 days after catheter-balloon valvuloplasty. Mitral valve area determined by the echo-Doppler method increased from 0.9 +/- 0.3 cm2 to 1.9 +/- 0.7 cm2 (p < 0.02). Mean left atrial pressure was reduced from 24 +/- 8 to 13 +/- 7 mmHg (p < 0.01) and mean pulmonary artery pressure from 36 +/- 13 to 28 +/- 10 mmHg (p < 0.02) with a non-significant increase in cardiac output from 3.6 +/- 1.2 to 4.0 +/- 1.7 l/min. After catheter-balloon valvuloplasty all patients reached a higher maximal workload during exercise, and mean value of oxygen consumption and pulmonary ventilation were significantly lower in submaximal workloads. The calculated ventilatory equivalent for oxygen was significantly reduced in submaximal and in maximal workloads after catheter-balloon valvuloplasty. Peak oxygen consumption and the ventilatory anaerobic threshold were not changed after catheter-balloon valvuloplasty (pre 15.59 +/- 2.72 vs post 16.90 +/- 3.44 and pre 12.10 +/- 2.55 vs post 12.62 +/- 2.71 ml/kg/min, respectively). We concluded that after catheter-balloon valvuloplasty the cost of breathing was reduced and the oxygen consumed was more effectively utilized during exercise. Increases in peak oxygen consumption and in ventilatory anaerobic threshold would require circulatory and metabolic adaptations in response to increased physical activity and were not observed when cardiopulmonary tests were performed early after catheter-balloon valvuloplasty.