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Davidoff R, McTiernan A, Constantine G, Davis KD, Balady GJ, Mendes LA, Rudolph RE, Bowen DJ. Echocardiographic examination of women previously treated with fenfluramine: long-term follow-up of a randomized, double-blind, placebo-controlled trial. Arch Intern Med 2001; 161:1429-36. [PMID: 11386892 DOI: 10.1001/archinte.161.11.1429] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
BACKGROUND Fenfluramine hydrochloride was withdrawn from the market in September 1997 after reports of heart valve abnormalities in patients who used it. The prevalence of echocardiographic abnormalities and the clinical cardiovascular status of patients who received fenfluramine monotherapy remains uncertain. METHODS A long-term, follow-up evaluation was undertaken in subjects who were randomly assigned to receive either fenfluramine hydrochloride (60 mg daily) or placebo as part of a double-blind smoking cessation therapy study. Cardiovascular status was evaluated by echocardiography, medical history, and physical examination. RESULTS From the group of 720 smokers who had originally participated in the smoking cessation therapy trial, 619 women were enrolled; data from 530 (276 in the fenfluramine group and 254 in the placebo group) were evaluable. No statistically significant differences were identified in the prevalence of aortic or mitral regurgitation by Food and Drug Administration criteria or by grade, aortic or mitral valve leaflet mobility restriction or thickening, elevated pulmonary artery systolic pressure, or abnormal left ventricular ejection fraction. No significant differences were demonstrated in cardiovascular status by physical examination, and no serious cardiac events were noted among fenfluramine-treated subjects. CONCLUSION There was no evidence of drug-related heart disease up to 4.9 years after anorexigen therapy in subjects who were randomly assigned to receive fenfluramine at the recommended dose for up to 3 months.
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Affiliation(s)
- R Davidoff
- Section of Cardiology C8, Boston University Medical Center, 88 E Newton St, Boston, MA 02118-2393, USA.
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2
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Klein AL, Grimm RA, Murray RD, Apperson-Hansen C, Asinger RW, Black IW, Davidoff R, Erbel R, Halperin JL, Orsinelli DA, Porter TR, Stoddard MF. Use of transesophageal echocardiography to guide cardioversion in patients with atrial fibrillation. N Engl J Med 2001; 344:1411-20. [PMID: 11346805 DOI: 10.1056/nejm200105103441901] [Citation(s) in RCA: 602] [Impact Index Per Article: 26.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
BACKGROUND The conventional treatment strategy for patients with atrial fibrillation who are to undergo electrical cardioversion is to prescribe warfarin for anticoagulation for three weeks before cardioversion. It has been proposed that if transesophageal echocardiography reveals no atrial thrombus, cardioversion may be performed safely after only a short period of anticoagulant therapy. METHODS In a multicenter, randomized, prospective clinical trial, we enrolled 1222 patients with atrial fibrillation of more than two days' duration and assigned them to either treatment guided by the findings on transesophageal echocardiography or conventional treatment. The composite primary end point was cerebrovascular accident, transient ischemic attack, and peripheral embolism within eight weeks. Secondary end points were functional status, successful restoration and maintenance of sinus rhythm, hemorrhage, and death. RESULTS There was no significant difference between the two treatment groups in the rate of embolic events (five embolic events among 619 patients in the transesophageal-echocardiography group [0.8 percent]) vs. three among 603 patients in the conventional-treatment group [0.5 percent], P=0.50). However, the rate of hemorrhagic events was significantly lower in the transesophageal-echocardiography group (18 events [2.9 percent] vs. 33 events [5.5 percent], P=0.03). Patients in the transesophageal-echocardiography group also had a shorter time to cardioversion (mean [+/-SD], 3.0+/-5.6 vs. 30.6+/-10.6 days, P<0.001) and a greater rate of successful restoration of sinus rhythm (440 patients [71.1 percent] vs. 393 patients [65.2 percent], P=0.03). At eight weeks, there were no significant differences between the two groups in the rates of death or maintenance of sinus rhythm or in functional status. CONCLUSIONS The use of transesophageal echocardiography to guide the management of atrial fibrillation may be considered a clinically effective alternative strategy to conventional therapy for patients in whom elective cardioversion is planned.
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Affiliation(s)
- A L Klein
- Cleveland Clinic Foundation, Department of Cardiology, OH 44195, USA.
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3
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Abstract
The effect of long-term arm exercise on cardiac morphology and function is unknown. To study these effects, highly trained wheelchair athletes were compared with long-distance runners and controls. In addition, the wheelchair athletes were compared with the long-distance runners to determine if long-term leg exercise confers a training effect during the performance of dynamic arm exercise. The study included 31 male subjects (mean age of 33+/-5 years), who comprised 3 groups matched for age and weight: wheelchair athletes (n = 9), long-distance runners (n = 12), and healthy controls (n = 10). All underwent echocardiography at rest and arm ergometry exercise testing with expiratory gas analysis. The peak work rate during arm exercise was highest among the wheelchair athletes, and was significantly higher in both groups of trained athletes compared with the control group (p<0.001). Runners demonstrated a significantly lower submaximal heart rate response to arm exercise compared with wheelchair and control subjects. Wheelchair athletes had increased left ventricular (LV) volume and mass by echocardiography compared with controls, but not to the same degree as that of runners. Although chamber dimensions and wall thickness did not differ among the groups, the LV volume index tended to be largest in the runners. Doppler indexes of diastolic LV filling were similar between the trained and untrained subjects. These data demonstrate that both long-term arm and leg exercise yield increases in LV volume and mass compared with untrained control subjects, although to a lesser degree in arm-trained athletes. Runners demonstrated a transfer of training effect in the performance of dynamic arm exercise, as demonstrated by their ability to achieve a higher peak work rate than controls, and showed a lower heart rate response to submaximal exercise than the wheelchair athletes and control subjects.
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Affiliation(s)
- D T Price
- Section of Cardiology, Evans Department of Medicine, Boston University Medical Center, Boston, Massachusetts 02118, USA
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4
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Abstract
Quantification of aortic regurgitation (AR) is a common and difficult clinical problem. The severity of regurgitation has traditionally been estimated with the use of contrast aortography, which is impractical as a screening tool or for serial examinations. In the past two decades, Doppler echocardiography has emerged as an important tool in the quantification of AR. Pulsed Doppler mapping of the depth of the regurgitant jet into the left ventricle was one of the initial echocardiographic methods used for this purpose. The slope and pressure (or velocity) half-time of continuous-wave Doppler profiles of regurgitant jets are also useful. These Doppler techniques may be used to determine the regurgitant volume or regurgitant fraction in patients with AR. The use of color Doppler to measure the height (or cross-sectional area) of the regurgitant jet relative to the height (cross-sectional area) of the left ventricular outflow tract is both sensitive and specific in the quantification of AR. More recently, the continuity principle has been used to determine the effective aortic regurgitant orifice area, which increases as AR becomes more severe. Although this is a promising tool, calculation of this value is not yet common practice in most echocardiography laboratories. Although no single echocardiographic technique is without limitations, all have some validity, and it is reasonable to use a combination of them to obtain a composite estimate of the severity of AR.
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Affiliation(s)
- D L Ekery
- Section of Cardiology, Boston University Medical Center, 88 East Newton Street, Boston, MA 02118, USA
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5
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Mendes LA, Jacobs AK, Davidoff R, Ryan TJ. The gender paradox. Rev Port Cardiol 1999; 18 Suppl 3:III21-4. [PMID: 10574019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/14/2023] Open
Affiliation(s)
- L A Mendes
- Department of Medicine, Boston Medical Center, MA, USA
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Cannistra LB, Davidoff R, Picard MH, Balady GJ. Moderate-high intensity exercise training after myocardial infarction: effect on left ventricular remodeling. J Cardiopulm Rehabil 1999; 19:373-80. [PMID: 10609188 DOI: 10.1097/00008483-199911000-00009] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Regular exercise increases exercise capacity and physical fitness, but questions remain about the effects of exercise on left ventricle (LV) remodeling after myocardial infarction. This study investigated the effects of moderate to high intensity exercise training on LV remodeling after a first myocardial infarction. METHODS An exercise group of 68 patients in cardiac rehabilitation after a first myocardial infarction had an initial echocardiogram and exercise stress test. Thirty patients completed the 12 weeks of training and had echocardiograms suitable for quantitative analysis. Follow-up echocardiograms and exercise tests were performed. A carefully matched control group of 30 patients with echocardiograms at fixed intervals after myocardial infarction and no formal exercise training were also studied. LV size was expressed as the endocardial surface area-to-body surface area (ESAi), whereas infarct size was characterized by the percent abnormal wall motion (%AWM) by echocardiography using an endocardial surface area mapping technique. Indices of LV shape (sphericity) were also assessed. RESULTS In the exercise group, no significant changes were seen in ESAi (57.95 +/- 13.1 vs 57.80 +/- 12.04 cm2/m2) or in %AWM (19.33 +/- 15.27 vs 20.11 +/- 15.95) from the initial to the final echo. The indices of sphericity were also unchanged. None of these parameters changed in the control group. Within each group was found heterogeneity in LV remodeling. Multivariate regression analysis revealed initial ESAi and initial %AWM to predict change in ESAi over time. CONCLUSIONS In this study of patients with predominately small infarcts, exercise training did not adversely affect LV remodeling after myocardial infarction. Remodeling is heterogeneous and appears related to infarct and LV size.
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Affiliation(s)
- L B Cannistra
- Department of Medicine, Boston University Medical Center, Massachusetts, USA.
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7
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Abstract
Papillary fibroelastomas are uncommon benign tumors usually involving the heart valves, which historically have been diagnosed at autopsy. With the advent of echocardiography, however, the number of patients diagnosed in life has increased. Papillary fibroelastomas represent a surgically treatable cause of cerebrovascular and cardiovascular ischemia and infarction making their identification clinically important. We report three unusual cases of papillary fibroelastoma; two patients presenting with symptoms of cerebrovascular ischemia and one presenting with myocardial infarction. We also present a comprehensive review of the literature and provide a compilation of all case reports to date.
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Affiliation(s)
- R A Howard
- Department of Medicine, Boston Medical Center, Massachusetts 02118, USA
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8
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McKenney PA, Apstein CS, Mendes LA, Connelly GP, Aldea GS, Shemin RJ, Davidoff R. Immediate effect of aortic valve replacement for aortic stenosis on left ventricular diastolic chamber stiffness. Am J Cardiol 1999; 84:914-8. [PMID: 10532510 DOI: 10.1016/s0002-9149(99)00465-8] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Diastolic dysfunction is common after coronary artery bypass surgery, and we hypothesized that left ventricular (LV) hypertrophy associated with aortic stenosis may lead to worsening LV diastolic function after aortic valve replacement for aortic stenosis. Transesophageal echocardiographic LV images and simultaneous pulmonary arterial wedge pressures were used to define the LV diastolic pressure cross-sectional area relation before and immediately after aortic valve replacement for aortic stenosis in 14 patients. In all patients, LV diastolic chamber stiffness increased, as evidenced by a leftward shift in the LV diastolic pressure cross-sectional area relation. At comparable LV filling (pulmonary arterial wedge) pressures the mean LV end-diastolic cross-sectional area preoperatively was 17.9 +/- 1.7 cm2, but decreased by 32% after aortic valve replacement to 12.1 +/- 1.2 cm2 (p = 0.0001). In conclusion, after aortic valve replacement, diastolic chamber stiffness increased in all patients.
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Affiliation(s)
- P A McKenney
- Department of Medicine, Boston Medical Center and Boston University School of Medicine, Massachusetts 02118, USA
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9
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Eagle KA, Guyton RA, Davidoff R, Ewy GA, Fonger J, Gardner TJ, Gott JP, Herrmann HC, Marlow RA, Nugent WC, O'Connor GT, Orszulak TA, Rieselbach RE, Winters WL, Yusuf S, Gibbons RJ, Alpert JS, Eagle KA, Garson A, Gregoratos G, Russell RO, Smith SC. ACC/AHA Guidelines for Coronary Artery Bypass Graft Surgery: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee to Revise the 1991 Guidelines for Coronary Artery Bypass Graft Surgery). American College of Cardiology/American Heart Association. J Am Coll Cardiol 1999; 34:1262-347. [PMID: 10520819 DOI: 10.1016/s0735-1097(99)00389-7] [Citation(s) in RCA: 329] [Impact Index Per Article: 13.2] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
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10
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Eagle KA, Guyton RA, Davidoff R, Ewy GA, Fonger J, Gardner TJ, Gott JP, Herrmann HC, Marlow RA, Nugent W, O'Connor GT, Orszulak TA, Rieselbach RE, Winters WL, Yusuf S, Gibbons RJ, Alpert JS, Garson A, Gregoratos G, Russell RO, Ryan TJ, Smith SC. ACC/AHA guidelines for coronary artery bypass graft surgery: executive summary and recommendations : A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee to revise the 1991 guidelines for coronary artery bypass graft surgery). Circulation 1999; 100:1464-80. [PMID: 10500052 DOI: 10.1161/01.cir.100.13.1464] [Citation(s) in RCA: 237] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Abstract
Because of constraints on the costs of providing medical care, cardiologists in the future will find themselves challenged to provide care for their patients in the most cost-effective manner possible. Although stress-echocardiography has been shown to compare favorably with other tests in diagnostic accuracy, data on cost-effectiveness are scarce. In this article, general concepts of cost-effectiveness as they relate to stress-echocardiography are reviewed and the available literature is summarized. Although definitive data are lacking, there is evidence to suggest that stress-echocardiography may prove to be cost-effective in several clinical situations.
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Affiliation(s)
- J E Marine
- Section of Cardiology, Boston University School of Medicine, MA, USA
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12
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Abstract
BACKGROUND Remodeling of the left ventricle with the development of a spherical cavity occurs in dilated cardiomyopathy and is associated with a poor long-term prognosis. The early effects of myocarditis on left ventricular geometry have not been previously described or correlated with clinical outcome. METHODS The baseline echocardiograms of 35 patients with biopsy-confirmed myocarditis were compared with 20 normal controls. Left ventricular end-diastolic volume, long axis length, and mid-cavity diameter were measured. The degree of sphericity was expressed as the ratio of the mid-cavity diameter to the long axis length. Left ventricular ejection fraction was assessed by radionuclide angiography. RESULTS In patients with myocarditis, mean left ventricular volume of 81 +/- 29 mL/m(2) was significantly greater than 50 +/- 8 mL/m(2) in controls (P =.001). Chamber dilatation occurred primarily along the mid-cavity diameter, which measured 5.3 +/- 0.8 cm in patients with myocarditis versus 4.2 +/- 0.4 cm in controls (P =.001). The degree of left ventricular sphericity in patients with myocarditis, 0.64 +/- 0.08, was significantly greater than that of controls, 0.54 +/- 0.04 (P =.001). When patients were stratified according to left ventricular volume, patients with increased left ventricular volume (>75 mL/m(2)) were associated with a more spherical chamber and lower left ventricular ejection fraction than patients with a more normal left ventricular volume (</=75 mL/m(2)). CONCLUSIONS Active myocarditis is associated with early left ventricular remodeling and the development of a spherical chamber. These changes correlate with ventricular dilatation and reduced left ventricular ejection fraction.
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Affiliation(s)
- L A Mendes
- Evans Memorial Department of Clinical Research, Boston Medical Center, Boston, MA, USA
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13
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Davidoff R, Bellman G. RE: INFLUENCE OF TECHNIQUE OF PERCUTANEOUS TRACT CREATION ON INCIDENCE OF RENAL HEMORRHAGE. J Urol 1998. [DOI: 10.1016/s0022-5347(01)62568-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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14
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Candela JV, Park E, Gerspach JM, Davidoff R, Stout L, Levy SM, Leach GE, Bellman GC, Lad PM. Evaluation of urinary IL-1alpha and IL-1beta in gravid females and patients with bacterial cystitis and microscopic hematuria. Urol Res 1998; 26:175-80. [PMID: 9694599 DOI: 10.1007/s002400050043] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
OBJECTIVES to determine IL-1alpha and IL-1beta levels in patients with bacterial cystitis, microscopic hematuria, and gravid females relative to a control group of normal subjects. METHODS enzyme immunoassays were used to measure concomitantly urinary IL-1alpha and IL-1beta in clean catch urine samples from normal subjects (n = 31) and study patients (n = 46). All normal subjects and patients underwent urinalysis, urine culture, and urine creatinine level determination. Since the IL-1alpha assay was developed for serum, the utility of the assay for urine specimens was unknown. The key parameters of urine collection, processing and sample storage for IL-1alpha were evaluated in detail. RESULTS mean values +/- SEM (pg/mg) for IL-1alpha/ Cr and IL-1beta/Cr were control group (0.25 +/- 0.10 and 0.17 +/- 0.06), bacterial cystitis (9.97 +/- 1.15 and 42.45 +/- 1.86), and microscopic hematuria (2.81 +/- 0.65 and 2.82 +/- 0.70). Differences in cytokine levels between the control group and patients with either bacterial cystitis or microscopic hematuria were statistically significant for both IL-1alpha/Cr (P < 0.026; P < 0.007, respectively) and IL-1beta /Cr (P < 0.0004; P < 0.014, respectively). IL-1beta/Cr correlates better with pyuria than IL-1alpha/ Cr (P = 0.02 vs P = 0.44). In gravid females, only IL-1alpha was significantly elevated relative to non-pregnant females (IL-1beta elevation approached statistical significance). Gravid females with positive urine cultures could not be distinguished from those with negative cultures based on either interleukin (P > 0.05). CONCLUSIONS Significant elevations of IL-1alpha and IL-1beta occur in patients with bacterial cystitis and microscopic hematuria. Correlation between pyuria and cytokine elevation was stronger for IL-1beta than for IL-1alpha. Changes in IL-1alpha may reflect changes in the bladder epithelium rather than in the inflammatory leukocytes. The ability of IL-1alpha and IL-1beta to serve as markers for bacterial cystitis in gravid females is diminished due to high basal levels during pregnancy.
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Affiliation(s)
- J V Candela
- Department of Urology, Kaiser Permanente Medical Center, Los Angeles, CA 90027, USA
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15
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Affiliation(s)
- O M Shapira
- Department of Cardiothoracic Surgery, Boston Medical Center, Mass 02118, USA.
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Orlandi Q, Davidoff R, Aldea G, Apstein C, Pimental D, Hesselvik J, Shemin R, Shapira O. Diastolic dysfunction post coronary artery bypass grafting: a consistent finding of clinical relevance. J Am Coll Cardiol 1998. [DOI: 10.1016/s0735-1097(98)80198-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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17
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Abstract
This study was designed to characterize the geometry and function of the right ventricle and its prognostic significance in patients with primary (AL) cardiac amyloidosis. AL amyloidosis is an infiltrative systemic disease that can result in thickening of heart structures and rapidly progressive congestive heart failure due to restrictive ventricular physiology and eventual systolic dysfunction. Thirty-seven patients with AL amyloid heart involvement and 20 normal control subjects were evaluated using 2-dimensional and Doppler echocardiography. Based on the ratio of left-to-right end-diastolic ventricular chamber areas, patients were classified into 2 groups: 25 patients with disproportionate right ventricular (RV) dilation (left ventricular to RV ratio < or = 2) and 12 with a ventricular area ratio > 2. Patients with a relatively dilated right ventricle (ratio < or = 2) had a shorter median survival (4 months) compared with patients with an area ratio > 2 (10 months, p <0.003). Of multiple clinical, echocardiographic, and Doppler features entered into a multifactorial model, a ventricular area ratio < or = 2 remained the only independent predictor of survival. Patients with AL amyloid heart disease represent a heterogeneous population with regard to both prognosis and the relative degree of right to left ventricular dilation. RV dilation in patients with amyloid heart disease appears to be associated with more severe involvement and is associated with a very poor prognosis with a median survival of only 4 months.
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Affiliation(s)
- A R Patel
- Evans Memorial Department of Clinical Research, Arthritis Research Center, Boston University Medical Center, Massachusetts 02118, USA
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18
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Abstract
To determine whether the increased prevalence of congestive heart failure in women compared with men undergoing diagnostic cardiac catheterization is the result of a difference in the left ventricular pressure/volume relation, we retrospectively compared the clinical characteristics, left ventricular ejection fraction, and end-diastolic pressure and volume in 586 women and 1081 men undergoing diagnostic coronary angiography and left ventriculography. In comparison with men, women were older (63 vs 60 years; p = 0.0001) and had more hypertension (41% vs 31%; p = 0.0001), diabetes (18% vs 12%; p = 0.003), and symptoms of congestive heart failure (13% vs 10%; p = 0.05). In spite of this, women had a better mean left ventricular ejection fraction (61% vs 56%; p = 0.0001) and less prevalent three-vessel disease (23% vs 34%; p = 0.0001). Left ventricular end-diastolic volume index was smaller in women compared with men (73 vs 79 ml/m2; p = 0.0001) in spite of having similar left ventricular end-diastolic pressure. When patients were stratified according to left ventricular end-diastolic pressure, women had a significantly smaller end-diastolic volume than men did when left ventricular end-diastolic pressure was > or = 18 mm Hg (74 vs 86 ml/m2; p = 0.0001). In a multivariate analysis, female sex remained an independent predictor of congestive heart failure (odds ratio 1.72, 95% confidence interval 1.11 to 2.66, p = 0.02). This study suggests that diastolic dysfunction is one mechanism for the paradox of more frequent heart failure symptoms in spite of better preserved left ventricular systolic function in women. Sex appears to influence the pattern of myocardial dysfunction in patients with known or suspected coronary artery disease, but the basis for this observation remains speculative.
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Affiliation(s)
- L A Mendes
- Evans Memorial Department of Clinical Research, Boston Medical Center, MA 02118-2393, USA
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19
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Dubrey SW, Davidoff R, Skinner M, Bergethon P, Lewis D, Falk RH. Progression of ventricular wall thickening after liver transplantation for familial amyloidosis. Transplantation 1997; 64:74-80. [PMID: 9233704 DOI: 10.1097/00007890-199707150-00014] [Citation(s) in RCA: 145] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND Familial amyloidosis (FAP) is characterized by the progression of neurologic and cardiac impairment ultimately leading to death within 7 to 15 years after the onset of the disease. Liver transplantation represents the only definitive therapy for this disease and has been performed since 1990. METHODS To determine the effect of liver transplantation on disease progression, electrocardiography and Doppler echocardiography were performed and blindly analyzed on 11 patients with FAP who were followed 0.8 to 8.6 years before liver transplantation and 0.8 to 4.1 years after liver transplantation. RESULTS; After liver transplantation, five patients showed progression of left ventricular wall thickening with increased left ventricular mass, and three of these five showed a reduction in electrocardiographic voltage despite abolition of the mutant protein from the serum. Of the five patients showing progressive wall thickening, four had the transthyretin variant Glu 42 Gly and one patient had the Ala 36 Pro variant; none of the remaining six patients, all of whom possessed the Val 30 Met variant, showed echocardiographic changes. Although 9 of the 11 patients have shown symptomatic improvement in neurologic symptoms, 1 patient has developed heart failure and a second patient has suffered a sudden cardiac death. CONCLUSIONS After liver transplantation, patients with FAP should have regular clinical evaluations including electrocardiographic and echocardiographic examinations to look for continued deterioration in heart structure or function.
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Affiliation(s)
- S W Dubrey
- Department of Medicine, Boston University School of Medicine, Massachusetts 02118, USA
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20
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Bellman GC, Davidoff R, Candela J, Gerspach J, Kurtz S, Stout L. Tubeless percutaneous renal surgery. J Urol 1997; 157:1578-82. [PMID: 9112480] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
PURPOSE We challenge the requirement for routine placement of a nephrostomy tube following percutaneous renal surgery. MATERIALS AND METHODS A total of 50 patients underwent tubeless percutaneous renal procedures consisting of nephrolithotripsy, endopyelotomy, and stone extraction plus endopyelotomy performed during the same setting. In the initial 30 patients a Double-J* stent and a Councill nephrostomy tube were placed at the end of the procedure. The Councill catheter was removed 2 to 3 hours postoperatively. The subsequent 20 patients received only a Double-J stent with no Councill catheter. This study group was compared to a control group of 50 age, sex and procedure matched patients who had previously undergone standard percutaneous renal procedures with routine placement of postoperative nephrostomy tubes. The incidence of complications, analgesia requirements, length of hospitalization, interval to return to normal activities and cost of treatment were compared between the 2 groups. RESULTS All 50 tubeless percutaneous procedures were performed successfully without significant complications. In the initial 15 patients postoperative renal ultrasound demonstrated no urinoma. Hospitalization was 0.6 days for the study group and 4.6 days for the controls (p = 0.0001). Average parenteral or intramuscular analgesia requirements were 11.58 and 36.06 mg. morphine sulfate, respectively (p = 0.0001), with patients requiring oral analgesia for 5.9 and 11.7 days, respectively (p = 0.0001). Patients in the study group returned to normal activities within 17.85 days versus 26.6 days for the controls (p = 0.0004). The costs of the procedures were $1,638 and $3,750 (129% greater), respectively, for a cost saving of $2,112 per case. CONCLUSIONS Tubeless percutaneous renal surgery is a safe procedure and offers numerous advantages over routine placement of a nephrostomy tube. The hospitalization, analgesia requirements, return to normal activities as well as cost are significantly less with this new technique.
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Affiliation(s)
- G C Bellman
- Department of Urology, Kaiser Permanente, Los Angeles, California, USA
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21
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Davidoff R, Yamaguchi R, Leach GE, Park E, Lad PM. Multiple urinary cytokine levels of bacterial cystitis. J Urol 1997; 157:1980-5. [PMID: 9112576] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
PURPOSE We have examined urinary cytokine levels to define the inflammatory response in patients with bacterial cystitis or microhematuria relative to normal subjects. Cytokines examined include interleukin-1beta (IL-1beta), IL-1alpha, tumor necrosis factor (TNF alpha), IL-6 and IL-4. Unique features of this study include a) a simultaneous study of several relevant cytokines b) a study of the inflammatory response at both low and high counts of bacterial infection and c) an assessment of whether microhematuria without bacterial cystitis or pyuria is associated with cytokine elevation compared to normals. MATERIALS AND METHODS Enzyme immunoassays were utilized for each cytokine. Patients studied include those with bacterial cystitis (n = 49), patients with microhematuria (n = 11), and normal subjects (n = 36). Cytokine levels were also determined for patients with low count bacterial cystitis (1,000-50,000 organisms; n = 15) and compared to high count bacterial cystitis (>100,000 organisms; n = 34) and normal subjects. Statistical analysis was carried out using the Kruskal-Wallis test followed by pairwise testing with Newman-Keuls test. RESULTS a) The means for normal, microhematuria and bacterial cystitis groups were significantly different (p <0.05) for IL-1beta, IL-1alpha, TNF alpha and IL-6, but not for IL-4. b) Except for IL-4, all cytokines were found to be significantly elevated in low count bacterial cystitis compared to normals. No statistically significant difference was observed between low and high count bacterial cystitis groups for any of the cytokines tested. CONCLUSIONS a) Significant and similar inflammatory responses are present in both low and high count bacterial cystitis groups as compared with the normal group. b) IL-6 and TNF alpha are significantly elevated in patients with microhematuria compared to normals. c) The potential clinical utility of the assays lies in identifying the specific cytokines elevated, understanding the pathways that give rise to their production, and in defining potential virulence factors that may produce significant inflammation at low count bacterial infections.
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Affiliation(s)
- R Davidoff
- Department of Urology, Kaiser Foundation Hospitals, Los Angeles, California 90027, USA
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Abstract
PURPOSE Renal hemorrhage is one of the most common and worrisome complications of percutaneous renal surgery. We studied the incidence of renal hemorrhage and transfusion rates in patients undergoing balloon or Amplatz fascial dilation of the nephrostomy tract. MATERIALS AND METHODS Medical records of 143 patients who underwent 150 percutaneous renal procedures, including percutaneous nephrolithotomy, antegrade endopyelotomy and percutaneous treatment of stones in caliceal diverticula, were reviewed. The nephrostomy tract was dilated with balloon (50 patients) or Amplatz sequential (100) dilators. Perioperative decreases in hemoglobin level and blood transfusion rates were compared between the 2 groups. RESULTS Of the 100 patients undergoing percutaneous renal Amplatz dilation 25 (25%) required a blood transfusion, compared to only 5 of 50 (10%) undergoing balloon dilation. The difference in the transfusion rates between the 2 groups was statistically significant (p = 0.048). CONCLUSIONS Improvements in the technique of percutaneous renal surgery have decreased the morbidity associated with these procedures. In our study use of balloon tract dilators led to less renal hemorrhage and lower transfusion rates compared to Amplatz dilation. Additionally, balloon dilation appears to be more rapid and avoids renal movement away from the surgeon, which occasionally occurs during Amplatz dilation.
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Affiliation(s)
- R Davidoff
- Department of Urology, Kaiser Permanente Medical Center, Los Angeles, California, USA
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Davidoff R, Bellman GC. Influence of technique of percutaneous tract creation on incidence of renal hemorrhage. J Urol 1997; 157:1229-31. [PMID: 9120908] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
PURPOSE Renal hemorrhage is one of the most common and worrisome complications of percutaneous renal surgery. We studied the incidence of renal hemorrhage and transfusion rates in patients undergoing balloon or Amplatz fascial dilation of the nephrostomy tract. MATERIALS AND METHODS Medical records of 143 patients who underwent 150 percutaneous renal procedures, including percutaneous nephrolithotomy, antegrade endopyelotomy and percutaneous treatment of stones in caliceal diverticula, were reviewed. The nephrostomy tract was dilated with balloon (50 patients) or Amplatz sequential (100) dilators. Perioperative decreases in hemoglobin level and blood transfusion rates were compared between the 2 groups. RESULTS Of the 100 patients undergoing percutaneous renal Amplatz dilation 25 (25%) required a blood transfusion, compared to only 5 of 50 (10%) undergoing balloon dilation. The difference in the transfusion rates between the 2 groups was statistically significant (p = 0.048). CONCLUSIONS Improvements in the technique of percutaneous renal surgery have decreased the morbidity associated with these procedures. In our study use of balloon tract dilators led to less renal hemorrhage and lower transfusion rates compared to Amplatz dilation. Additionally, balloon dilation appears to be more rapid and avoids renal movement away from the surgeon, which occasionally occurs during Amplatz dilation.
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Affiliation(s)
- R Davidoff
- Department of Urology, Kaiser Permanente Medical Center, Los Angeles, California, USA
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24
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Candela J, Davidoff R, Gerspach J, Bellman GC. "Tubeless" percutaneous surgery: a new advance in the technique of percutaneous renal surgery. Tech Urol 1997; 3:6-11. [PMID: 9170218] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
We describe our modification of the technique of traditional percutaneous renal surgery called "tubeless" percutaneous renal surgery. Fifty patients have now undergone percutaneous renal procedures without the use of a postoperative nephrostomy tube consisting of percutaneous nephrolithotripsy, percutaneous endopyelotomy, and both percutaneous stone extraction and endopyelotomy in the same setting. Our current modification of standard percutaneous surgical technique includes the placement of an internal ureteral catheter with primary closure of the access site using hemostatic skin sutures. The study group was compared to a control group of 50 patients who were age, sex and procedure matched who had undergone standard percutaneous renal procedures previously with routine placement of postoperative nephrostomy tubes. The incidence of complications, analgesia requirements, length of hospitalization, time of return to normal activities, and cost of treatment were compared between the two groups. All tubeless percutaneous procedures were successfully performed without significant complications. The initial 15 patients had postoperative renal ultrasounds demonstrating no urinoma. Hospital stay, analgesia requirements, and the patient's ability to return to normal activities were statistically significantly decreased in the patient group studied. The cost of a "tubeless" procedure was $1,638 compared with $3,750 (129% greater) for traditional percutaneous surgery (cost saving of $2,112/case). Tubeless percutaneous renal surgery is a safe procedure and offers advantages over the routine placement of a nephrostomy tube. The hospitalization period, analgesia requirements, return to normal activities, and cost are significantly less with this new technique.
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Affiliation(s)
- J Candela
- Department of Urology, Kaiser Permanente Medical Center, Los Angeles, California 90027, USA
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25
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Shapira OM, Davidoff R, Hilkert RJ, Aldea GS, Fitzgerald CA, Shemin RJ. Repair of left ventricular aneurysm: long-term results of linear repair versus endoaneurysmorrhaphy. Ann Thorac Surg 1997; 63:701-5. [PMID: 9066387 DOI: 10.1016/s0003-4975(96)01112-5] [Citation(s) in RCA: 42] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
BACKGROUND Recently, endoaneurysomorrhaphy has been proposed as a more physiologic repair of postinfarction left ventricular aneurysm than is linear repair. There are only a few studies comparing the short-term and long-term results of the two techniques. METHODS Clinical outcomes and echocardiographic measurements of left ventricular volume and sphericity in 27 patients who underwent endoaneurysmorrhaphy were compared with those in 20 patients who had linear repair. RESULTS The two groups were matched with respect to age, gender, comorbid risk factors, functional class, urgency of the operation, and concomitant procedures. Preoperatively, left ventricular ejection fraction was lower in the endoaneurysmorrhaphy group (0.25 +/- 0.08 versus 0.30 +/- 0.09; p = 0.03). Follow-up was available in 44 patients (94%) and ranged from 2 to 86 months (mean, 41.0 +/- 26.5 months). Thirty-day operative mortality, perioperative complications, 5-year survival, and freedom from cardiac death were similar. Early postoperative percentage increase in left ventricular ejection fraction was greater after endoaneurysmorrhaphy (0.51 +/- 0.64 versus 0.18 +/- 0.48; p = 0.036). Long-term functional improvement was significantly better in the endoaneurysmorrhaphy group: At the time of last follow-up, 88% of patients were in New York Heart Association class I/II, compared with 53% after linear repair (p = 0.01). There were no measurable differences between the groups with respect to left ventricular ejection fraction (0.28 +/- 0.11 versus 0.27 +/- 0.11; p = 0.90), left ventricular volume (171.6 +/- 59.1 versus 169.9 +/- 54.4 mL; p = 0.94), and sphericity index (0.61 +/- 0.09 versus 0.61 +/- 0.12; p = 1.0). CONCLUSIONS Despite having a similar effect on left ventricular geometry, endoaneurysmorrhaphy resulted in a greater increase in postoperative left ventricular ejection fraction and a substantially improved long-term clinical outcome.
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Affiliation(s)
- O M Shapira
- Department of Cardiothoracic Surgery, Boston University Medical Center, Massachusetts 02118, USA.
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26
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Abascal VM, Moreno PR, Rodriguez L, Monterroso VM, Palacios IF, Weyman AE, Davidoff R. Comparison of the usefulness of Doppler pressure half-time in mitral stenosis in patients < 65 and > or = 65 years of age. Am J Cardiol 1996; 78:1390-3. [PMID: 8970412] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Doppler pressure half-time is a reliable method for estimating mitral valve area when net left atrial and ventricular compliance remain stable. The accuracy of Doppler pressure half-time in estimating mitral valve area in older patients is unknown. We studied 80 patients (65 women and 15 men, aged 56 +/- 14 years) with cardiac catheterization and echocardiography. Mitral valve area was calculated using the Gorlin formula and by the Doppler pressure half-time method. Patients were stratified into those aged < 65 years (n = 57), and those aged > or = 65 years (n = 23). The discordance between pressure half-time and Gorlin-derived mitral valve area was assessed and related to multiple clinical, echocardiographic, and hemodynamic variables. The difference between pressure half-time and Gorlin-derived mitral valve area was greater in the older than in the younger patient (0.34 +/- 0.30 vs 0.15 +/- 0.27 cm2, p = 0.009) but the older group had smaller mitral valve areas by the Gorlin method (0.72 +/- 0.18 vs 0.89 +/- 0.32 cm2, p = 0.02) and lower cardiac output. The difference between pressure half-time and Gorlin remained greater in the group of older patients (0.32 +/- 0.30 vs 0.19 +/- 0.22 cm2, p = 0.04), even when the analysis was restricted to patients with similar mitral valve area (< 1 cm2 by the Gorlin method). Using multivariate analysis, age > or = 65 years remained the only significant predictor of the discrepancy between pressure half-time and Gorlin mitral valve area. Thus, when compared with Gorlin-derived mitral valve area, pressure half-time overestimated valve area in older patients, and this technique for estimating mitral valve area should be used with caution in patients > or = 65 years of age.
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Affiliation(s)
- V M Abascal
- Evans Memorial Department of Clinical Research, Boston University Medical Center Hospital, Massachusetts, USA
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27
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Abstract
Systemic embolization is a common complication of left atrial myxoma; however, coronary embolism leading to acute myocardial infarction is rare. The use of echocardiography has increased the detection of intracardiac tumors when signs and symptoms are not evident. Echocardiography is the diagnostic procedure of choice in the initial evaluation of patients with suspected left atrial myxoma.
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Affiliation(s)
- V M Abascal
- Evans Memorial Department of Clinical Research, Boston University School of Medicine, MA, USA
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28
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Kinch JW, Davidoff R. Prevention of embolic events after cardioversion of atrial fibrillation. Current and evolving strategies. Arch Intern Med 1995; 155:1353-60. [PMID: 7794083] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
We review the incidence of embolic events following cardioversion of atrial fibrillation, as well as the literature that forms the basis for the current strategy of anticoagulation before, and following, cardioversion to reduce the risk of post-cardioversion embolism. We evaluate a new strategy that uses transesophageal echocardiography to identify patients in atrial fibrillation without atrial thrombi who may be safely cardioverted without preceding anticoagulation and we also address the embolic event and anticoagulation issues in patients with atrial flutter. Cardioversion of atrial fibrillation to sinus rhythm is associated with a small but significant risk of thromboembolic events (average incidence, 1.5%; range, 0% to 7%). Anticoagulating these patients before cardioversion appears to significantly reduce this risk, and because of the delay in return of atrial contraction, anticoagulation should be continued for several weeks following cardioversion. The current guidelines for anticoagulating patients in atrial fibrillation who are to be cardioverted is based primarily on clinical observations, numerous uncontrolled case series, two retrospective trials, and one prospective nonrandomized controlled trial. Anticoagulation for 3 weeks before cardioversion followed by 4 weeks of anticoagulation after cardioversion is a theoretically sound and effective approach to reduce the risk of thromboembolic events. The use of transesophageal echocardiography to rule out thrombus and thus identify low-risk patients who may undergo cardioversion without preceding anticoagulation has been supported by several small studies that successfully used this strategy. However, the demonstration of a postcardioversion atrial and atrial appendage "stunning" suggests that anticoagulation needs to be given at the time of, and following, cardioversion. While promising, this transesophageal echocardiography--guided strategy for cardioversion of patients in atrial fibrillation requires more rigorous study before its routine use can be recommended. The current management of pure atrial flutter requires no anticoagulation before cardioversion; however, several clinical observation suggest theoretical risks for embolic events in these patients, thus further investigation of this strategy may be warranted.
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Affiliation(s)
- J W Kinch
- Evans Memorial Department of Clinical Research, Boston (Mass) University Medical Center Hospital, USA
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29
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Abstract
Three cases of rapidly reversible severe myocardial depression are described in patients with status asthmaticus. Initial echocardiograms obtained within 1 day of hospital admission revealed global left ventricular hypokinesis with ejection fractions of 11 to 34%. Follow-up echocardiograms obtained only 3 to 8 days later revealed marked improvement of left ventricular function. Possible mechanisms responsible for the observed rapidly reversible myocardial depression and the clinical implications of this finding are discussed.
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Affiliation(s)
- G N Levine
- Department of Medicine, Evans Memorial Department of Clinical Research, Boston University Medical Center Hospital, Boston City Hospital 02118, USA
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30
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Libonati JR, Apstein CS, Ngoy S, Sesselberg H, Herrick B, Balady G, Dempsey A, Davidoff R, Eberli FR. EXERCISE TRAINING FOLLOWING MYOCARDIAL INFARCTION DOES NOT ADVERSELY AFFECT LEFT VENTRICULAR GEOMETRY OR FUNCTION. Med Sci Sports Exerc 1995. [DOI: 10.1249/00005768-199505001-00885] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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31
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Mendes LA, Connelly GP, McKenney PA, Podrid PJ, Cupples LA, Shemin RJ, Ryan TJ, Davidoff R. Right coronary artery stenosis: an independent predictor of atrial fibrillation after coronary artery bypass surgery. J Am Coll Cardiol 1995; 25:198-202. [PMID: 7798502 DOI: 10.1016/0735-1097(94)00329-o] [Citation(s) in RCA: 93] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
OBJECTIVES This study attempted to determine the importance of severe proximal right coronary artery disease as a predictor of atrial fibrillation in patients after coronary artery bypass surgery. BACKGROUND Studies in patients undergoing noncardiac surgery have suggested that ischemia in the right coronary artery distribution is associated with a high incidence of atrial fibrillation. However, the importance of right coronary artery disease as a predictor of atrial fibrillation after bypass surgery is unknown. METHODS The occurrence of sustained postoperative atrial fibrillation was studied prospectively in 168 consecutive patients undergoing coronary artery bypass grafting. Patients were followed up postoperatively until discharge. Severe right coronary artery stenosis was defined as > or = 70% lumen narrowing. RESULTS Of 104 patients with proximal or mid right coronary artery stenosis, 45 (43%) had atrial fibrillation postoperatively compared with 12 (19%) of the 64 patients without significant right coronary disease (p = 0.001). Univariate predictors of atrial fibrillation included right coronary artery stenosis (p = 0.001), advancing age (p = 0.0001) and lack of beta-adrenergic blocking agent therapy after bypass surgery (p = 0.0004). Multivariate adjusted risk of developing atrial fibrillation after bypass surgery increased with the presence of severe right coronary artery disease (odds ratio 3.69, 95% confidence interval [CI] 1.61 to 8.48), advancing age (odds ratio 2.24/10 years, CI 1.48 to 3.41) and male gender (odds ratio 2.36, CI 1.01 to 5.49). The use of beta-blockers postoperatively was associated with a protective effect (odds ratio 0.4, CI 0.17 to 0.80). CONCLUSIONS The presence of severe right coronary artery stenosis is an independent and powerful predictor of atrial fibrillation after coronary artery bypass surgery. In association with age, gender and postoperative beta-blocker therapy, these variables can be used to identify patients at increased risk for developing this arrhythmia.
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Affiliation(s)
- L A Mendes
- Department of Medicine, Evans Memorial Department of Clinical Research, Boston University Medical Center Hospital, Massachusetts 02118
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McKenney PA, Apstein CS, Mendes LA, Connelly GP, Aldea GS, Shemin RJ, Davidoff R. Increased left ventricular diastolic chamber stiffness immediately after coronary artery bypass surgery. J Am Coll Cardiol 1994; 24:1189-94. [PMID: 7930238 DOI: 10.1016/0735-1097(94)90097-3] [Citation(s) in RCA: 62] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
OBJECTIVES The aim of this study was to assess the incidence and severity of left ventricular diastolic dysfunction immediately after coronary artery bypass surgery by utilizing simultaneous transesophageal echocardiographic and hemodynamic monitoring. BACKGROUND Left ventricular diastolic dysfunction has been documented after coronary bypass surgery, but its measurement has been technically difficult to acquire and limited by dependence on loading conditions. METHODS End-diastolic pressure-area curves were constructed before and immediately after coronary bypass surgery in 20 patients. Transesophageal echocardiographic images at the midpapillary level of the left ventricle and hemodynamic data were recorded. Volume status was manipulated to alter loading conditions, and multiple measurements were taken at each loading condition. RESULTS Diastolic function worsened in all patients, as manifested by a postoperative leftward shift of the end-diastolic pressure-area curve. At a comparable preload, mean end-diastolic area +/- SEM decreased by 15% from 17.6 +/- 0.8 to 14.9 +/- 0.8 cm2 postoperatively (p = 0.0001). CONCLUSIONS Left ventricular diastolic chamber stiffness frequently increases immediately after coronary artery bypass surgery. Simultaneous hemodynamic and transesophageal echocardiographic monitoring, through the construction of end-diastolic pressure-area curves, is a useful method to evaluate diastolic function and guide management after cardiac surgery.
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Affiliation(s)
- P A McKenney
- Department of Medicine, Evans Memorial Department of Clinical Research, Boston University Medical Center Hospital, Massachusetts
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33
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Connelly G, Arkoff H, Davidoff R, Shapira O, Aldea G, Shemin R. Intraoperative Transesophageal Echocardiography for Aortic Annular Measurement and the Selection and Preparation of Aortic Valve Homografts. Anesthesiology 1994. [DOI: 10.1097/00000542-199409001-00113] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Connelly GP, Arkoff H, Davidoff R, McKenney P, Mendes L, Aldea G. Pulmonary Vein Pulse Doppler. Anesthesiology 1994. [DOI: 10.1097/00000542-199409001-00121] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Abstract
To assess the predictive value of right ventricular systolic function in patients with active myocarditis, the echocardiograms of 23 patients with biopsy-confirmed myocarditis were reviewed. Right ventricular systolic function was evaluated qualitatively and quantitatively by descent of the right ventricular base. Patients were divided into those with normal right ventricular function, in whom right ventricular descent was 1.9 +/- 0.1 cm, and those with abnormal right ventricular function, in whom right ventricular descent was 0.8 +/- 0.1 cm (p < 0.001). There were no differences between the two groups in age, duration of symptoms, baseline hemodynamics, or histologic assessment. Initial left ventricular ejection fraction was significantly lower in patients with depressed right ventricular function (27.5 +/- 4.9%) compared with that in patients with normal right ventricular function (47.5 +/- 6.3%) (p = 0.01). The likelihood of an adverse outcome, defined as death or need for cardiac transplantation, was greater in patients with abnormal right ventricular function (right ventricular descent < or = 1.7 cm) than in patients with normal right ventricular function (right ventricular descent > 1.7 cm) (p < 0.03). Multivariate analysis revealed that right ventricular dysfunction as quantified by right ventricular descent was the most powerful predictor of adverse outcome.
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Affiliation(s)
- L A Mendes
- Evans Memorial Department of Clinical Research, Boston University Medical Center Hospital, MA 02118
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36
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Abstract
Behcet's disease is a chronic multisystem illness in which cardiac involvement is a rare manifestation. In this unusual case a young man had symptoms that primarily related to recurrent right ventricular thrombi and pulmonary thromboemboli. Transesophageal echocardiography was useful in documenting the presence of intracardiac thrombus and establishing the diagnosis.
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Affiliation(s)
- L A Mendes
- Evans Memorial Department of Clinical Research, Boston University Medical Center, University Hospital, MA 02118
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37
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Davidoff R, Picard MH, Force T, Thomas JD, Guerrero JL, McGlew S, Weyman AE. Spatial and temporal variability in the pattern of recovery of ventricular geometry and function after acute occlusion and reperfusion. Am Heart J 1994; 127:1231-41. [PMID: 8172051 DOI: 10.1016/0002-8703(94)90041-8] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
Myocardial ischemia and infarction are known to cause changes in both ventricular shape and function. Little is known about the recovery of ventricular geometry after transient myocardial ischemia and its relationship to recovery of function. To examine the pattern of recovery of ventricular geometry following transient coronary artery occlusion and to assess the relationship of this to the return of systolic function, we used echocardiography to study 13 dogs following 15-minute occlusion of the left anterior descending coronary artery. During ischemia, total endocardial surface area (ESA) increased from 32.55 +/- 1.77 to 45.36 +/- 3.18 cm2 (p = 0.001). The most striking increase was at the apex, where circumference increased from 5.04 +/- 0.24 at baseline to 7.86 +/- 0.43 cm at the end of occlusion (p = 0.0001), an increase of 58%. During reperfusion, ventricular geometry rapidly returned toward normal (baseline), with recovery of 80% of the increase in ESA evident by 15 minutes of reperfusion. Recovery of systolic function was substantially slower (p < 0.005 for all periods of observation during the 2 hours of reperfusion). During reperfusion, recovery of ventricular geometry and function was not uniform throughout the ischemic bed. The apex recovered most slowly, with the centroid of the area of abnormal contraction progressively moving along the long axis of the left ventricle toward the apex. There was also a progressive decrease in the radius of the area of dysfunction, from 2.0 +/- 0.15 at end occlusion to 0.13 +/- 0.07 cm at 120 minutes of reperfusion (p = 0.0001). There was no difference in blood flow between the apical and anterior segments during ischemia or reperfusion. Reperfusion favorably reduced the ischemic zone dilation before recovery of active systolic function and geometric recovery thus may be important in determining ultimate functional recovery. In addition, recovery of function proceeded inward towards the center of the ischemic territory and in a wavefront from the base to apex. This heterogeneous and asymmetric recovery suggests that sampling at one point within the ischemic zone may not reflect the true temporal pattern of recovery.
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Affiliation(s)
- R Davidoff
- Evans Memorial Department of Clinical Research, Boston University Medical Center, MA 02118
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Davidoff R. Sensory Neurons: Diversity, Development, and Plasticity. Neurology 1993. [DOI: 10.1212/wnl.43.8.1633-d] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
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Affiliation(s)
- L A Mendes
- Evans Memorial Department of Clinical Research, Boston University Medical Center, MA
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Casale PN, Palacios IF, Abascal VM, Harrell L, Davidoff R, Weyman AE, Fifer MA. Effects of dobutamine on Gorlin and continuity equation valve areas and valve resistance in valvular aortic stenosis. Am J Cardiol 1992; 70:1175-9. [PMID: 1414942 DOI: 10.1016/0002-9149(92)90051-y] [Citation(s) in RCA: 64] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Previous studies demonstrated changes in aortic valve area calculated by the Gorlin equation under conditions of varying transvalvular flow in patients with valvular aortic stenosis (AS). To distinguish between flow-dependence of the Gorlin formula and changes in actual orifice area, the Gorlin valve area and 2 other measures of severity of AS, continuity equation valve area and valve resistance, were calculated under 2 flow conditions in 12 patients with AS. Transvalvular flow rate was varied by administration of dobutamine. During dobutamine infusion, right atrial and left ventricular end-diastolic pressures decreased, left ventricular peak systolic pressure and stroke volume increased, and systolic arterial pressure did not change. Heart rate increased by 19%, cardiac output by 38% and mean aortic valve gradient by 25%. The Gorlin valve area increased in all 12 patients by 0.03 to 0.30 cm2. The average Gorlin valve area increased from 0.67 +/- 0.05 to 0.79 +/- 0.06 cm2 (p < 0.001). In contrast, the continuity equation valve area (calculated in a subset of 6 patients) and valve resistance did not change with dobutamine. The data support the conclusion that flow-dependence of the Gorlin aortic valve area, rather than an increase in actual orifice area, is responsible for the finding that greater valve areas are calculated at greater transvalvular flow rates. Valve resistance is a less flow-dependent means of assessing severity of AS.
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Affiliation(s)
- P N Casale
- Department of Medicine, Harvard Medical School, Boston, Massachusetts
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41
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Affiliation(s)
- P A McKenney
- Evans Memorial Department of Clinical Research, Boston University Medical Center, MA
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42
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Sanfilippo AJ, Picard MH, Newell JB, Rosas E, Davidoff R, Thomas JD, Weyman AE. Echocardiographic assessment of patients with infectious endocarditis: prediction of risk for complications. J Am Coll Cardiol 1991; 18:1191-9. [PMID: 1918695 DOI: 10.1016/0735-1097(91)90535-h] [Citation(s) in RCA: 228] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
To enhance the echocardiographic identification of high risk lesions in patients with infectious endocarditis, the medical records and two-dimensional echocardiograms of 204 patients with this condition were analyzed. The occurrence of specific clinical complications was recorded and vegetations were assessed with respect to predetermined morphologic characteristics. The overall complication rates were roughly equivalent for patients with mitral (53%), aortic (62%), tricuspid (77%) and prosthetic valve (61%) vegetations, as well as for those with nonspecific valvular changes but no discrete vegetations (57%), although the distribution of specific complications varied considerably among these groups. There were significantly fewer complications in patients without discernible valvular abnormalities (27%). In native left-sided valve endocarditis, vegetation size, extent, mobility and consistency were all found to be significant univariate predictors of complications. In multivariate analysis, vegetation size, extent and mobility emerged as optimal predictors and an echocardiographic score based on these factors predicted the occurrence of complications with 70% sensitivity and 92% specificity in mitral valve endocarditis and with 76% sensitivity and 62% specificity in aortic valve endocarditis.
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Bilazarian SD, Davidoff R. Mitral regurgitation improves when aortic valve area increases significantly. Am J Cardiol 1991; 68:567-8. [PMID: 1872298 DOI: 10.1016/0002-9149(91)90810-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
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Davidoff R, Palacios I, Southern J, Fallon JT, Newell J, Dec GW. Giant cell versus lymphocytic myocarditis. A comparison of their clinical features and long-term outcomes. Circulation 1991; 83:953-61. [PMID: 1999043 DOI: 10.1161/01.cir.83.3.953] [Citation(s) in RCA: 94] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
BACKGROUND Giant cell myocarditis has rarely been diagnosed premortem, and little is known about its natural history. In addition, no comparative studies with lymphocytic myocarditis exist. METHODS AND RESULTS The clinical features, serial change in left ventricular fraction (LVEF), and outcomes of all patients with histologically verified myocarditis were retrospectively evaluated. Ten patients (22%) were found to have giant cell myocarditis (group 1), whereas the remaining 36 (78%) had lymphocytic myocarditis (group 2). Age at presentation, gender distribution, duration of symptoms, initial LVEF, and resting hemodynamics did not differ between groups. Ventricular tachycardia was detected in 90% of group 1 patients compared with only 25% of group 2 (p = 0.0007). Atrioventricular block that required pacemaker insertion was also more common in group 1 (60%) than in group 2 (8.3%) (p = 0.001). Left ventricular systolic function declined during follow-up in group 1 patients (LVEF, 0.43 +/- 0.07-0.26 +/- 0.05, p = 0.11) but increased in group 2 patients (LVEF, 0.33 +/- 0.03-0.41 +/- 0.03, p = 0.02). When the net change between initial and final LVEF was assessed, a significant difference was evident (giant cell group, -0.17 +/- 0.06; lymphocytic group, +0.07 +/- 0.03; p = 0.0008). Although a greater proportion of patients in group 1 died or required transplantation (seven of 10 versus 11 of 36, p = 0.03), actuarial survival over 4 years was not different for the giant cell group (50%) than for the lymphocytic group (62%). CONCLUSION Giant cell myocarditis was more prevalent than previously recognized and highly associated with both ventricular tachycardia and pacemaker requirement. The likelihood of an adverse event, either cardiovascular mortality or cardiac transplantation, was significantly greater for patients with giant cell myocarditis than for those with lymphocytic myocarditis, perhaps because of the progressive decline in left ventricular systolic function that was observed in those with giant cell myocarditis.
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Affiliation(s)
- R Davidoff
- Evans Memorial Department of Clinical Research, Boston University Medical Center, Mass
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Abstract
The article reports on a 1-year descriptive study of aggressive incidents and staff counteraggressive strategies within a child psychiatry inpatient unit. Ninety-nine child/adolescent patients produced a total of 887 reportable aggressive incidents during the 12-month study period. Seclusion, activity restriction, physical restraint, and administration of p.r.n. medication were studied in relation to patient aggression. Results of the study confirm the hypotheses that (1) much patient aggression within defined clinical contexts conforms to patterns of prediction directly related to person and environmental variables, and (2) the primary value of counteraggression strategies such as seclusion and restraint resides in the acute management of aggressive children and not in long-term therapeutic functions. The article offers some recommendations for new research in this general area as well as suggestions for clinical applications of these methods.
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Affiliation(s)
- W T Garrison
- Department of Psychiatry, Baystate Medical Center, Springfield, Massachusetts
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Thomas JD, Liu CM, Flachskampf FA, O'Shea JP, Davidoff R, Weyman AE. Quantification of jet flow by momentum analysis. An in vitro color Doppler flow study. Circulation 1990; 81:247-59. [PMID: 2404625 DOI: 10.1161/01.cir.81.1.247] [Citation(s) in RCA: 126] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Previous investigations have shown that the size of a regurgitant jet as assessed by color Doppler flow mapping is independently affected by the flow rate and velocity (or driving pressure) of the jet. Fluid dynamics theory predicts that jet momentum (given by the orifice flow rate multiplied by velocity) should best predict the appearance of the jet in the receiving chamber and also that this momentum should remain constant throughout the jet. To test this hypothesis, we measured jet area versus driving pressure, flow rate, velocity, orifice area, and momentum and showed that momentum is the optimal jet parameter: jet area = 1.25 (momentum).28, r = 0.989, p less than 0.0001. However, the very curvilinear nature of this function indicated that chamber constraint strongly affected jet area, which limited the ability to predict jet momentum from observed jet area. To circumvent this limitation, we analyzed the velocities per se within the Doppler flow map. For jets formed by 1-81-mm Hg driving pressure through 0.005-0.5-cm2 orifices, the velocity distribution confirmed the fluid dynamic prediction: Gaussian (bell-shaped) profiles across the jet at each level with the centerline velocity decaying inversely with distance from the orifice. Furthermore, momentum was calculated directly from the flow maps, which was relatively constant within the jet and in good agreement with the known jet momentum at the orifice (r = 0.99). Finally, the measured momentum was divided by orifice velocity to yield an accurate estimate of the orifice flow rate (r = 0.99). Momentum was also divided by the square of velocity to yield effective orifice area (r = 0.84). We conclude that momentum is the single jet parameter that best predicts the color area displayed by Doppler flow mapping. Momentum can be measured directly from the velocities within the flow map, and when combined with orifice velocity, momentum provides an accurate estimate of flow rate and orifice area.
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Affiliation(s)
- J D Thomas
- Noninvasive Cardiac Laboratory, Massachusetts General Hospital, Boston 02114
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Carlson MD, Schoenfeld MH, Garan H, Choong CY, Davidoff R, Weyman AE, Ruskin JN, Fifer MA. Programmed ventricular stimulation in patients with left ventricular dysfunction and ventricular tachycardia: effects of acute hemodynamic improvement due to nitroprusside. J Am Coll Cardiol 1989; 14:1744-52. [PMID: 2584565 DOI: 10.1016/0735-1097(89)90026-0] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
To assess the electrophysiologic effects of acute hemodynamic improvement in patients with left ventricular systolic dysfunction, 12 patients with a left ventricular ejection fraction less than 0.40 and a history of sustained monomorphic ventricular tachycardia were studied. All patients had underlying coronary artery disease. Patients underwent programmed cardiac stimulation in random order during a baseline period and with nitroprusside infusion. Mean pulmonary capillary wedge pressure decreased from 20 +/- 8 mm Hg at baseline study to 8 +/- 3 mm Hg during nitroprusside infusion (p less than 0.0001). Pulmonary artery, right atrial and systemic arterial pressures also decreased with nitroprusside (p less than 0.01). Cardiac output did not change. Left ventricular dimensions, determined by two-dimensional echocardiography, decreased significantly during nitroprusside infusion. The right ventricular effective refractory period, measured during ventricular drive trains at cycle lengths of 400 and 600 ms, were similar during baseline and nitroprusside periods (271 +/- 30 versus 274 +/- 31 ms at 600 ms, and 249 +/- 25 versus 246 +/- 18 ms at 400 ms). In 2 patients no ventricular arrhythmias were induced during either study period; in the other 10, ventricular tachyarrhythmias were induced during both periods. The mean number of extrastimuli required to induce a ventricular tachyarrhythmia was similar during the baseline period (1.8 +/- 0.6) and during nitroprusside infusion (1.9 +/- 0.7). As well, the mean cycle length of ventricular tachycardia induced was similar during the baseline period (347 +/- 61 ms) and during nitroprusside infusion (342 +/- 70 ms).(ABSTRACT TRUNCATED AT 250 WORDS)
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Affiliation(s)
- M D Carlson
- Department of Medicine, Massachusetts General Hospital, Boston 02114
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Ascah KJ, Gillam LD, Davidoff R, Franklin TD, Newell JB, Hogan RD, Weyman AE. Evolution of the temporal contraction sequence after acute experimental myocardial infarction. J Am Coll Cardiol 1989; 13:730-6. [PMID: 2918178 DOI: 10.1016/0735-1097(89)90618-9] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
The effect of infarct maturation on the temporal sequence of contraction within infarct zones has not previously been described. Accordingly, the time-varying pattern of contraction within ischemic/infarct zones was studied with use of cross-sectional echocardiography in 17 dogs at 10 min to 6 weeks after acute experimental myocardial infarction. Left ventricular short-axis images were digitized from end-diastole to end-systole and endocardial fractional radial change along 36 evenly spaced rays was calculated. The circumferential extent of dyskinesia and the number of rays that exhibited maximal dyskinesia were determined for each decile of the normalized contraction sequence. Between 10 min and 1 week after infarction, the greatest circumferential extent of dyskinesia occurred between the 3rd and 4th deciles of the normalized contraction sequence. However, as the infarct matured, the greatest spatial expanse of dyskinesia was noted to occur progressively earlier in the contraction sequence (second decile at 6 weeks), and the extent of mid- to late-systolic dyskinesia decreased markedly. Whereas end-systolic dyskinesia was present in 30% to 50% of ischemic/infarct zone rays from 10 min to 48 h, end-systolic dyskinesia was no longer observed at 6 weeks. Similarly, the maximal amplitude of dyskinesia was most commonly observed during midsystole from 10 min to 48 h, but occurred progressively earlier as the infarct matured, falling during the first decile at 6 weeks after infarction. These data suggest that maximal circumferential extent and amplitude of dyskinesia occur progressively earlier in the systolic contraction sequence as the infarct matures.(ABSTRACT TRUNCATED AT 250 WORDS)
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Affiliation(s)
- K J Ascah
- Cardiac Ultrasound Laboratory, Massachusetts General Hospital, Boston 02114
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Abstract
Nineteen adolescent or adult patients with secundum atrial septal defect (ASD) underwent pulmonary arteriography to evaluate the presence of proximal pulmonary arterial (PA) thrombosis. This procedure demonstrated proximal PA thrombosis in 8 patients (group 2). These patients had a distinctive hemodynamic profile, consisting primarily of significant PA hypertension. None of the 11 patients with normal angiograms (group 1) had severe PA hypertension (p less than 0.0001). Proximal PA thrombosis appears to be the major factor in the development and progression of PA hypertension in adult patients with ostium secundum ASD. Pulmonary angiography should be undertaken in all adult patients with ostium secundum ASD who have at least moderate PA hypertension. Long-term anticoagulation is advocated for patients with PA thrombosis irrespective of a decision for surgical intervention.
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Diamond TH, Steingo L, Davidoff R, Smith RL, Goldman AP, Kawalsky D, Borowsky MH, Myburgh DP. Persistent ST-segment elevation in patients with anterior myocardial infarctions. Evaluation by exercise electrocardiography, echocardiography and Holter monitoring. S Afr Med J 1985; 68:94-7. [PMID: 4012509] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
One hundred and seventy patients who suffered an acute myocardial infarction (MI) were followed up at 3-monthly intervals by a full clinical evaluation, exercise electrocardiography and ambulatory Holter monitoring. Fifty-eight patients (34%) had anterior MIs, and of these 23 (40%) had persistent ST-segment elevation over the infarct zone, reflected by leads presenting with Q-S configuration. Fifteen (65,2%) of the latter demonstrated further ST-segment elevation during exercise. They were further investigated by cross-sectional echocardiography. Left ventricular (LV) dysfunction was diagnosed in 87% of patients with persistent ST-segment elevation, and in 93% of the patients with additional exercise-induced ST-segment elevation. Organized thrombi occurred in 2 patients (8,7%) and 1 experienced a transient ischaemic attack. Ventricular arrhythmias occurred frequently (ventricular ectopy--91,3%, ventricular tachycardia--17,4%, and couplets--47,8%). Death occurred in 3 patients (13,1%) and 1 patient (4,3%) had a second MI over a mean follow-up period of 83,6 months. This study suggests that persistent ST-segment elevation on the resting ECG of patients with anterior MIs is a reliable indicator of LV wall motion abnormalities, and that this correlation further increases if it is associated with exercise-induced ST-segment elevation. Furthermore, the role of echocardiography as a diagnostic tool in evaluating LV function is stressed. The prognosis of patients with post-infarction LV dysfunction is notably poor and may be the result of frequent complex ventricular arrhythmias.
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