The course of pregnancy in patients with artificial heart valves.

Twenty-five women with prosthetic heart valves (PHV) became pregnant 28 times. Twenty-six of the pregnancies occurred while the patients were receiving oral anticoagulants and these were continued throughout in 25 pregnancies. Dipyridamole or dipyridamole and acetylsalicyclic acid were used in 22 pregnancies. Eighteen infants were delivered, one with a congenital corneal leukoma; none had hemorrhagic complications; their psychomotor development was normal. Nine women aborted 10 times, including patients with two PHV, pelvic trauma and self-induced abortion. We could not detect excess anticoagulation in eight of the nine who had spontaneous losses; excess anticoagulation occurred five weeks before an abortion. There were no maternal deaths despite numerous complications; in two women, brain embolism was related to short interruptions of anticoagulation. The details of management are mentioned. We lack enough evidence to suggest routine sterilization, routine interruption of coumarin therapy during pregnancy or routine interruption of pregnancy in women with certain types and models of PHV; however, pregnancy under such conditions, plus antithrombotic therapy, carries a high risk for the product and a potential teratogenic effect. Women with one or two PHV can have children if their management is closely supervised and if extreme care is taken with the use of oral anticoagulants.

The Dressler syndrome after pulmonary embolism.

A study was conducted in 14 patients with pericardial syndrome after pulmonary embolism. The role of right ventricular myocardial injury and noncardiogenic pulmonary edema in this syndrome is considered and its existence is established.

Thoracic complications of amebic abscess of the liver: report of 501 cases.

During an 18-year period, 501 cases of thoracic complications of amebic abscess of the liver were studied; 175 had inflammatory reactions of thoracic structures (165 with pleural effusions and pneumonitis, ten with pericarditis) and 326 ruptured through the diaphragm (175 into the airways, 106 into the pleural cavity, 5 into the pericardium, 39 into the airways and pleura, and 1 into the pleura and pericardium). The thoracic complication was preceded by a picture suggesting an acute inflammatory process or a chronic wasting disease. Depending on type, the complication itself was signaled by increase or change in character of right upper abdominal or lower thoracic pain, dyspnea, or overt respiratory insufficiency, hemoptysis, and expectoration of necrotic material, sepsis, tamponade, and shock. Chest roentgenograms showed small to massive pleural effusions, basal pneumonitis, and cardiomegaly; serology, liver scans, and induced pneumoperitoneum were diagnostic. Treatment included metronidazole and emetine, drainage of pleural or pericardial contents or promotion of bronchial drainage, and meticulous care of associated respiratory, circulatory, and systemic derangements. Mortality for cases with rupture was 11.4 percent, due mainly to sepsis, shock, respiratory insufficiency, and tamponade. The rest of the patients were discharged in cured or improved condition.

Dressler-like syndrome after pulmonary embolism and infarction.

Among 195 patients with pulmonary embolism admitted to our hospital, three men and three women, 16 to 65 years old, developed a pericardial syndrome five to 15 days after the onset of pulmonary embolism and infarction. Other known causes of pericarditis were ruled out by clinical history and ancillary methods. The six patients had a pericardial rub, fever, anemia, leukocytosis, and increasing sedimentation rate; four had a pericardial effusion; two had a pleural effusion. One patient, with coexisting heart disease, died after another episode of pulmonary embolism; in the other five, oral corticosteroids induced complete remission of the pericardial syndrome. This type of pericarditis deserves wider recognition.

Intrapleural fibrinolysis with streptokinase as an adjunctive treatment in hemothorax and empyema: a multicenter trial.

To test the efficacy of intrapleural fibrinolytic therapy in patients with loculated pleural effusions, we conducted an open, prospective, and multicenter trial among five hospitals in Mexico. We enrolled patients with hemothorax or empyema, clotted and/or loculated, that was not resolved through conventional pleural drainage with chest tube and antibiotics in patients with empyema. All patients received repeated doses of 250,000 IU of streptokinase through chest tube. Effectiveness criteria were before and after intrapleural streptokinase (IPSK) drainage, and poststreptokinase radiographic and respiratory function test improvement. Forty-eight patients were studied; there were 30 patients with empyemas, 14 with hemothorax, and 4 patients with malignant pleural effusions without lung trapping. Successful fibrinolysis was obtained in 44 patients, with complete resolution of the pleural collection and adequate radiologic and spirometric improvement. In three of four patients with multiloculated malignant hemothorax with high-yielding pleural drainage, IPSK allowed successful lysis of loci and an adequate pleurodesis was achieved. Only four patients required surgical treatment. The overall success rate in our series was 92%, similar to previous reports. The results in this first prospective and multicentric trial suggest that intrapleural fibrinolysis is an effective and safe adjunctive treatment in patients with heterogeneous pleural coagulated and loculated collections to restore the pulmonary function assessed by respiratory function tests and can obviate surgery in most cases.

Iodopovidone and bleomycin pleurodesis for effusions due to malignant epithelial neoplasms.

The search for the ideal agent to achieve pleurodesis for malignant pleural effusions is still on. Twenty-two patients with dyspnea-producing, recurrent pleural effusions secondary to epithelial neoplasms were subjected to instillation into the pleural cavity of either iodopovidone (14 patients) or bleomycin (8 patients) through a large bore chest tube. The results showed that in 9 of the 14 patients receiving iodopovidone (64.2%) and in 7 of the 8 patients in the bleomycin group (87.5%) there was no further need for drainage of the pleural space. Local or systematic complications occurred in 8 patients; no complication was severe. In conclusion in this preliminary study, iodopovidone has shown promise as an effective, readily available and inexpensive alternative to achieve chemical pleurodesis in cases of recurrent, incapacitating effusions secondary to malignant epithelial neoplasms; further studies are needed to confirm these initial results.

Diagnosis and treatment of amebic "empyema": report of eighty-eight cases.

To prevent pleural soilage, early diagnosis and adequate treatment of amebic abscess of the liver are mandatory. Therapy includes administration of amebicidal drugs, drainage of the chest cavity, and treatment of associated respiratory, circulatory, and systemic derangements.

Diagnosis and treatment of pericarditis by the subxiphoid approach.

The subxiphoid approach for the diagnosis and treatment of pericarditis was used in 49 patients. Various diagnoses were established in 43 cases, and drainage was accomplished in 46. One patient died as a direct consequence of the procedure. Accidental right pneumothorax occurred in three cases. Total evacuation of the pericardial contents, direct inspection and palpation of structures, correction of unsuspected pathology and simultaneous biopsy of the pericardium and other tissues can be achieved, while avoiding the need for repeated pericardiocentesis. The procedure can be done safely under local anesthesia, providing prompt relief of abnormal hemodynamics and a sample for tissue diagnosis.

Single-dose sublingual nifedipine as the only treatment in hypertensive urgencies and emergencies.

One hundred and eighteen patients with hypertensive urgencies and emergencies and diastolic blood pressure (DBP) at least 120 mm Hg by the cuff method were seen at the Emergency Care Department; none had received calcium channel blockers during the previous twelve hours. Patients with DBP of 120 to 139 mm Hg received 10 mg of sublingual nifedipine; patients with left ventricular hypertrophy or failure, renal disease, hypertensive encephalopathy, angina, papilledema, or a DBP over 140 mm Hg received 20 mg of the drug. The criterion for control was the achievement of a DBP of 100 mm Hg or less within sixty minutes of receiving sublingual nifedipine and maintenance of the effect until discharge. Control was achieved in all patients; a sixty-three-year-old man died of a brain hemorrhage after pulmonary edema and a DBP of 210 had been controlled; the other 117 were discharged to their attending physicians, either as outpatients or to a hospital ward. No patient developed hypotension, clinical or electrocardiographic signs of myocardial ischemia, or clinical signs of neurologic dysfunction. Practical, fast, safe, and dependable control of hypertensive urgencies and emergencies has made sublingual nifedipine the treatment of choice of such patients in the Emergency Care Department.

Prevalence and prevention of deep venous thrombosis of the lower extremities in high-risk pulmonary patients.

Information is lacking about the prevalence of, and the best method of preventing deep venous thrombosis (DVT) of the lower extremities in patients forty years or older with pulmonary disease that keeps them in bed for three consecutive days or more and who are thus at high risk of developing DVT or pulmonary embolism (PE). In this study, 192 high-risk patients, aged forty to ninety-two, received 125I fibrinogen and had daily radioactive scans, venous Doppler, and strain gauge plethysmography. Four preventive methods were used until patients became ambulatory: graded compression stockings (GCS) in 39, elastic bandages (EB) in 33, subcutaneous administration of 5,000 USP units of heparin (HEP) bid in 39, and oral administration of 0.5 g of acetylsalicyclic acid (ASA) bid in 35. Results were compared with those in 46 patients in a control group (CG). Twelve patients in CG, none in GCS, 4 in EB, 1 in HEP, and 2 in ASA developed DVT proved by contrast venography. There was a statistically significant difference between GCS and CG (P less than 0.0003), HEP and CG (P less than 0.0022), and ASA and CG (P less than 0.0148) but not between EB and CG (P greater than 0.10); no significant differences were found between any pair of prophylaxis groups. The significant differences could not be attributed to differences in age, sex, or length of stay in bed. PE occurred in 3 patients in CG and 1 in EB. Hemorrhagic complications occurred in 7 patients in HEP and 4 in ASA, requiring exclusion of 2 patients and 1 patient, respectively, from the study.(ABSTRACT TRUNCATED AT 250 WORDS)

Valve surgery at the Hospital de Cardiología y Neumología del Centro Médico Nacional IMSS.

From January 1964 until February 1985, we performed 8,370 prosthetic valve procedures; this represents 54.32% of our total surgical load. Approximately 93% of the replacements were for rheumatic valve disease; the rest were for ischemic, myxomatous, degenerative, congenital, and traumatic heart disease. All cases were between New York Heart Association (NYHA) Classes II and IV; almost all patients had heart catheterizations before surgery. During the last 6 years, all patients had echocardiograms before undergoing heart catheterization.

[Lung perforation by a small-bore enteral feeding tube]. / Perforación pulmonar por sonda de pequeño calibre para alimentación enteral.

A 68 year old male with multisystemic disease, mainly lungs and heart, was treated with a cuffed endotracheal tube, mechanical ventilation and a 16 Fr Levin nasogastric tube for feeding; it was substituted 13 days later by a 2.3 mm, 8 Fr O'Brien KMI polyurethane small bore enteral feeding tube introduced with a guide wire. The feeding tube perforated his right lung and passed into the pleural cavity, either through the larynx or through a nonconfirmed tracheoesophageal fistula; signs for the supposedly correct position of the tube were positive. In patients with depressed sensoria, abnormalities of gag or cough reflexes, esophageal strictures, significant cardiomegaly or tracheoesophageal fistula, small bore enteral feeding tubes should be passed under direct vision by laryngoscopy or preferably by flexible endoscopy; adequate confirmation of the correct position requires a chest and an upper abdominal roentgenogram.