Use of B-type natriuretic peptide to predict blood pressure improvement after percutaneous revascularisation for renal artery stenosis.

OBJECTIVES: The purpose of this study was to evaluate the utility of B-type natriuretic peptide (BNP) to predict blood pressure (BP) response in patients with renal artery stenosis (RAS) after renal angioplasty and stenting (PTRA). METHODS: In 120 patients with RAS and hypertension referred for PTRA, 24-h ambulatory BP recordings were obtained before and 6 months after intervention. BNP was measured before, 1 day and 6 months after PTRA. RESULTS: BP improved in 54% of patients. Median BNP levels pre-intervention were 97 pg ml(-1) (interquartile range (IQR) 35-250) and decreased significantly within 1 day of PTRA to 62 pg ml(-1) (IQR 24-182) (p < 0.001), remaining at 75 pg ml(-1) (IQR 31-190) at 6 months. The area under the receiver operating curve for pre-intervention BNP to predict BP improvement was 0.57 (95% confidence interval (CI) 0.46-0.67). Pre-intervention BNP >50 pg ml(-1) was seen in 79% of patients with BP improvement compared with 56% in patients without improvement (p = 0.01). In a multivariate logistic regression analysis, BNP >50 pg ml(-1) was significantly associated with BP improvement (odds ratio (OR) 4.0, 95% CI 1.2-13.2). CONCLUSIONS: BNP levels are elevated in patients with RAS and decrease after revascularisation. Although BNP does not seem useful as a continuous variable, pre-interventional BNP >50 pg ml(-1) may be helpful to identify patients in whom PTRA will improve BP.

B-type natriuretic peptide and C-terminal-pro-endothelin-1 for the prediction of severely impaired peak oxygen consumption.

OBJECTIVE: To assess the utility of B-type natriuretic peptide (BNP) and C-terminal-pro-endothelin-1 (CT-proET-1) to predict a severely impaired peak oxygen consumption (peak VO(2), < 14 mL kg(-1) min(-1)) in patients referred for cardiopulmonary exercise testing. DESIGN: Cross-sectional study. SETTING: Tertiary care center. METHODS: Peak VO(2), BNP and CT-proET-1 were assessed in 141 consecutive patients referred for cardiopulmonary exercise testing. RESULTS: B-type natriuretic peptide [median (interquartile range) 48 (38-319) vs. 33 (15-86) pg mL(-1); P = 0.002] and CT-proET-1 [87 (76-95) vs. 60 (52-74) pmol L(-1); P < 0.001] were higher in patients with a peak VO(2) < 14 mL kg(-1) min(-1) (n = 30) than in those with a peak VO(2) > or = 14 mL kg(-1) min(-1) (n = 111). CT-pro-ET-1 had a higher area under the receiver-operator-characteristics curve (AUC) to predict a peak VO(2) < 14 mL kg(-1) min(-1) than BNP (0.79 vs. 0.68; P = 0.04). The optimal BNP cut-off of 37.2 pg mL(-1) had a sensitivity of 80% and a specificity of 56%. The optimal CT-proET-1 cut-off of 74.4 pmol L(-1) had a sensitivity of 80% and specificity of 76%. A five-item score composed of body mass index, diabetes, forced expiratory volume within the first second, alveolo-arterial oxygen pressure difference, and BNP had an AUC of 0.88 to predict a peak VO(2) < 14 mL kg(-1) min(-1). Adding CT-proET-1 to the score resulted in an AUC of 0.92. CONCLUSIONS: C-terminal-pro-endothelin-1 is superior to BNP for the prediction of a peak VO(2) < 14 mL kg(-1) min(-1) in patients referred for CPET. A score incorporating body mass index, diabetes status, spirometry, blood gases, BNP and CT-proET-1 improves the prediction of a peak VO(2) < 14 mL kg(-1) min(-1) based on single biomarkers.

Two-dimensional echocardiographic assessment of complications involving the Ionescu-Shiley pericardial valve in the mitral position.

The function of the Ionescu-Shiley bovine pericardial xenograft in the mitral position was investigated in 70 patients by two-dimensional echocardiography. Echocardiographic data from 21 patients with suspected bioprosthetic dysfunction and 49 patients with normal clinical findings were analyzed in a double-blind fashion. Confirmation of cardiovascular status was obtained by means of cardiac catheterization, surgery, autopsy or other techniques in 19 of the 21 symptomatic patients. Two-dimensional echocardiography correctly evaluated bioprosthetic function in 98% of the patients. Six of the seven patients with proven xenograft dysfunction demonstrated echocardiographic evidence of malfunction. There was one false negative evaluation but no false positive results. Valve dysfunction included endocarditic mass lesions, mitral regurgitation resulting from dehiscence of a leaflet or the sewing ring or mitral stenosis due to calcification or malposition of the valve. This experience indicates that two-dimensional echocardiography is useful for assessing the Ionescu-Shiley mitral bioprosthesis, particularly in those patients who develop nonspecific symptoms.

Supravalvular mitral stenosis associated with tetralogy of Fallot.

The association of tetralogy of Fallot with supravalvular mitral stenosis is a rare anomaly that has been reported only once previously. The difficulty of preoperative diagnosis is emphasized. Although left-sided obstructive lesions in association with tetralogy of Fallot are rare, their recognition is imperative since these are surgically correctable anomalies and potentially lethal, as proved in this case and the one previously reported.

The morphology of ascending aortic aneurysms.

To determine the frequency of morphologic abnormalities of the aorta, especially of the media, in patients with aneurysms of the ascending aorta, tissue specimens from surgically resected ascending aortic aneurysms of 339 patients were studied. Included were 232 men and 107 women; 53 (29 men, 23 women) had clinical signs of Marfan's disease. Features evaluated and graded included fragmentation of elastic fibers, cystic medial change, medial fibrosis, medial necrosis, atherosclerosis, periaortic fibrosis, and thickening of the vasa vasorum. Both elastic fragmentation and cystic medial change were present in a high percentage of patients. Cystic medial change was inversely correlated with increasing age of patients, especially in the group of patients without clinical evidence of Marfan's syndrome. Marked changes of these types in many younger patients without Marfan's syndrome could reflect a "tissue insufficiency" in early life that causes the aortic wall to weaken and dilate. Medial necrosis, fibrosis, and atherosclerosis were directly correlated with age. Hemodynamic events are considered to initiate injury and repair within the aortic wall. Dissection was more frequently seen with medial abnormalities than with atherosclerosis.

Transmyocardial laser revascularization: histopathological findings.

Transmyocardial laser revascularization (TMLR) is a new surgical technique clinically tested in patients with advanced severe coronary arteriosclerosis when classic routine treatment by medicaments, percutaneous transluminal coronary angioplasty (PTCA), or aorto-coronary bypass surgery does not improve symptoms of ischemic heart disease. During the procedure high-energy CO 2 laser performs 35-40 transmyocardial channels via left-sided thoracotomy. Channels are drilled from the epicardial side of the heart through the myocardium into the left ventricle cavity. Impulses are synchronized with EKG (diastole), the channel diameter is about 1 mm. Transmural laser penetration is confirmed by intraoperative transesophageal echocardiography (TEE). This technique is based on a theory that channels allow blood supply from left ventricle directly into the intramyocardial vessels (possibly capillaries) and so improve oxygenation of ischemic myocardium. Presented are gross and microscopic findings in a 75-year-old woman who suffered from classic class IV angina with shortness of breath. She had a history of an inferior myocardial infarct, ventricular tachyarrhythmia, aorto-coronary bypass, and mitral valvuloplasty. Her ejection fraction by echocardiography was 25%. Angiographically, she had multiple occlusions of native coronary arteries and diffuse distal stenosis in the graft of the left internal mammary artery (LIMA) to the left anterior descending coronary artery (LAD). Thirty six of forty laser pulses were confirmed by TEE as transmural. The patient died suddenly of ventricular fibrillation 5 days after TMLR surgery. The autopsy was performed 6 hours after death. After cross-sectioning of the heart all the laser-bored channels were found partially or completely filled by fibrin and cell infiltrate composed mainly of polymorphonuclear leukocytes. Patent channels were found within myocardial scars, channels performed through viable myocardium appeared to be partially collapsed and occluded.

True aneurysm of the saphenous vein graft stump associated with CABG in a cardiac transplant patient.

Aneurysm of a saphenous vein graft after coronary artery bypass requires surgical resection because of its potential for rupture. This report describes a case of aneurysm formation in a 55-year-old man who underwent coronary artery bypass operation in 1977 and orthotopic heart transplantation 7 years later. A proximal vein graft remnant that had been ligated at the time of transplantation developed into a 5-cm aneurysm. In patients who have undergone previous coronary artery bypass operation, we recommend that the entire vein graft stump be excised and oversewn at the aortosaphenous anastomosis at the time of transplantation.

Maternal malignancy metastatic to the products of conception: a review.

Documented reports of maternal malignancy metastatic to the placenta and fetus are rare. From 1866 until the present there have been 52 cases reported in the Western literature. We report a case of maternal large-cell carcinoma of the lung metastatic to the maternal brain and the placenta without fetal involvement.

Rare primary sarcomas of the heart.

Three patients with primary malignant cardiac neoplasms are described. All tumors were intracavitary myxomatous masses of the left atrium. Preoperative clinical diagnostic techniques did not indicate malignancy, but suggested mitral stenosis, cor triatriatum, and cardiac myxoma. Grossly, the tumors were sessile rather than pedunculated, and they invaded the underlying structures. Microscopically, although the tumors resembled benign cardiac myxomas, they exhibited mitotic activity and areas of necroses. Ultrastructural examination revealed a spectrum of differentiated mesenchymal cells that lacked the maturation features of cardiac myxoma cells. These gross, microscopic, and ultrastructural features, which suggested the tumors' malignant potential, should help in the early recognition and management of similar tumors.

Malignant tumors arising in endometriosis: clinical-pathological study and flow cytometry analysis.

BACKGROUND: Malignant transformation to endometriosis is a well documented phenomenon that occurs most commonly in the ovaries with cancer arising in extra-ovarian endometriosis being a rare event. METHODS: A retrospective clinical-pathological evaluation of eleven cases with malignant tumors arising in endometriosis was performed to evaluate the prognostic impact of various factors. Nuclear DNA content (ploidy) was assessed through flow cytometric study. RESULTS: Ovarian origin was identified in eight cases and three were associated with extra-ovarian endometriosis. Histologic type was endometrioid carcinoma in ten patients. The eleventh case had high grade endometrial stromal sarcoma. All tumors were diploid with no relation to stage, grade, or clinical outcome. The S-phase fraction (SPF) was analyzed in nine patients and no correlation could be demonstrated with any histologic parameters or clinical outcome. CONCLUSIONS: The DNA content seems to have no association with the classical prognostic parameters in these cases.

Right ventricular thrombus: clinical and diagnostic features.

Because of clinical symptoms and findings at physical, echocardiographic, and angiographic examination, a patient was suspected of having a tumor in the right ventricle. Results of surgical and pathological examination, however, revealed a thrombus obliterating the right ventricle. The purpose of this article is to delineate the features of a patient with right ventricular thrombus.

Asymptomatic cavitary pneumonitis due to amiodarone pulmonary toxicity.

A 52-year-old woman presented with ventricular tachycardia after receiving amiodarone for the previous 18 months. The chest roentgenogram revealed evidence of multiple pleural-based cavitary nodules despite the absence of respiratory disease on clinical examination. The nodules were attributed to amiodarone because of histologic changes noted at open-lung biopsy. The cavitating nodules cleared with the discontinuation of amiodarone.

Experimental technique of laser coronary endarterectomy and its immediate effects on atherosclerotic plaques in cadaver hearts.

The immediate effects of carbon dioxide laser radiation were assessed in the normal canine aorta, the human atherosclerotic aorta, and 24 human coronary arteries from nine cadaver hearts. The parameters needed for precise control of laser energy were identified. Penetration of a 1-mm thick arterial wall required a minimum power (5 watts), power density (781 watts cm(2)), and radiant energy (1.5 joules). Use of an optimal pulse duration (30 msec or less) resulted in less thermal injury to the adjacent arterial wall. Laser radiation relieved stenosis and reopened totally occluded vessels in 21 of 24 coronary arteries. Coronary stenoses were not relieved in two heavily calcified arteries, and perforation occurred in another artery. In successfully treated arteries, laser coronary endarterectomy increased the luminal diameter from 25 to 100%.

Cardiac sarcoidosis: two cases with ventricular tachycardia and review of cardiac involvement in sarcoid.

Patients with significant cardiac sarcoidosis are at increased risk of sudden death from ventricular dysrhythmias or conduction disturbances. We report two patients whose initial manifestation of cardiac sarcoidosis was nonsustained ventricular tachycardia unresponsive to standard antiarrhythmic measures. Endomyocardial biopsy aided the diagnosis in each patient. This technique is helpful in establishing the diagnosis of cardiac sarcoidosis, which causes life-threatening ventricular dysrhythmias.

Iatrogenic stress fractures. / Iatrogenní zlomeniny z pretezování.

The author treated since 1982 85 fractures caused by overloading, incl. 19 which were associated with surgical, manipulation and medicamentous treatment. These iatrogenic influences altered statics and had a bearing on the locomotor stereotype causing deterioration of mechanical properties of osseous tissue and as a result of external rhythmic force during manipulation. Analysis of the causes makes it possible to draw preventive conclusions.