Endocardial metastases as the only site of relapse in a patient with bladder carcinoma: a case report and review of the literature.

Tumors metastatic to the heart (cardiac metastases) are infrequent and few systematic studies on this topic have been published. Urothelial carcinomas are among the rarest associated with heart metastases and all cases reported to date concern autopsy examinations. We present the first report of urothelial carcinoma metastatic to the endocardium diagnosed antemortem. Notably, the endocardiac infiltration was the only site of recurrence and occurred 6 years after original diagnosis of bladder carcinoma. Although rare enough, the possibility of heart metastases without any other signs of recurrence should be included in the differential diagnosis in cases of urothelial cancer with increasing fatigue and dyspnea.

Heart rate effect on hemodynamics during mechanical assistance by the intra-aortic balloon pump.

UNLABELLED: Heart rate (HR) has been characterized as an important cardiovascular parameter that affects acute hemodynamic performance of intra-aortic balloon counterpulsation (IABC). However, the effect of HR on hemodynamics during mechanical assistance by the IABC has neither been clarified nor quantified. We sought to evaluate the relationship between IABC and HR and also to examine whether there is a range of HR with optimum hemodynamic response to IABC. METHODS: 20 patients (14 males--6 females, mean age 64.4 +/- 11.4 years) with post-infarction cardiogenic shock undergoing IABC treatment were evaluated. Hemodynamics were recorded for each patient once per day during the assistance period; 131 measurements were taken and thus a wide range of heart rates was obtained (64-141 bpm). The following changes in aortic pressures were used to evaluate acute IABC performance on: a) the maximal increase of diastolic aortic pressure induced by IABC and b) the reduction in systolic and end-diastolic aortic pressure. RESULTS: Non-linear regression analysis and analysis of variance revealed that a significant correlation exists between IABC performance indices and heart rate. At HR<80 bpm, IABC performance tended to be reduced, whereas the increase in HR above 110 bpm resulted in a significant reduction of all IABC performance indices. In contrast, IABC operating at 80-110 bpm resulted in optimum hemodynamic performance. In conclusion, the effect of heart rate on IABC performance is non-linear indicating that IABC may be more effective when operating within 80-110 bpm.

Pneumonia due to Candida krusei.

A case of post-transplantation pneumonia due to Candida krusei is reported. A 42-year-old man was admitted 28 days after heart transplantation with cough, pleuritic pain and fever. A chest computed tomograph showed multiple alveolar infiltrates bilaterally. He received broad-spectrum antibiotics, fluconazole for oral candidiasis, and cotrimoxazole for possible Pneumocystis carinii. A short-lived period of improvement was followed by respiratory failure. Cultures of bronchial washings grew C. krusei and C. albicans. The infection was documented by histology and culture obtained by transthoracic aspiration. Treatment with amphotericin B was initiated, but the patient died. Histology and culture of a pulmonary specimen, obtained immediately post mortem, further documented the infection with C. krusei.

Early recovery of oxygen kinetics after submaximal exercise test predicts functional capacity in patients with chronic heart failure.

BACKGROUND: Oxygen (O2) uptake at peak exercise (VO2 peak) is an objective measurement of functional capacity in patients with chronic heart failure (CHF). The significance of recovery O2 kinetics parameters in predicting exercise capacity, and the parameters of submaximal exercise testing have not been thoroughly examined. METHODS AND RESULTS: Thirty-six patients (mean age = 48+/-14 years) with CHF and New York Heart Association functional class I, II, or III, and eight healthy volunteers (mean age = 39+/-13 years) were studied with maximal and submaximal cardiopulmonary exercise testing (CPET). The first degree slope of O2 uptake decay during early recovery from maximal (VO2/t-slope), and submaximal exercise (VO2/t-slope)(sub), were calculated, along with VO2 half-time (T(1/2)VO2). Patients with CHF had a longer recovery of O2 uptake after exercise than healthy volunteers, expressed by a lower VO2/t-slope (0.616+/-0.317 vs. 0.956+/-0.347 l min(-1) min(-1), P=0.029) and greater T(1/2)VO2 (1.28+/-0.30 vs. 1.05+/-0.15 min, P = 0.005). VO2/t-slope correlated with the VO2 peak (r = 0.84, P<0.001), anaerobic threshold (r = 0.79, P<0.001), and T(1/2)VO2, a previously established estimate of recovery O2 kinetics (r = -0.59, P<0.001). (VO2/t-slope)(sub) was highly correlated with VO2/t-slope after maximal exercise (r=0.87, P<0.001), with the VO2 peak (r=0.87, P<0.001) and with T(1/2)VO2 after maximal exercise (r=-0.62, P<0.001). VO2/t-slope after maximal and submaximal exercise was reduced in patients with severe exercise intolerance (F=9.3, P<0.001 and F=12.8, P<0.001, respectively). CONCLUSIONS: Early recovery O2 kinetics parameters after maximal and submaximal exercise correlate closely with established indices of exercise capacity in patients with CHF and in healthy volunteers. These findings support the use of early recovery O2 kinetics after submaximal exercise testing as an index of functional capacity in patients with CHF.

Intravenous amiodarone decreases the duration of atrial fibrillation associated with acute myocardial infarction.

PURPOSE: Atrial fibrillation (AF) is a fairly common complication of acute myocardial infarction (AMI). The aim of this study was to examine the safety and efficacy of intravenous amiodarone in converting AF associated with AMI. METHODS: Seventy patients with AMI complicated with AF were prospectively divided into 3 groups: a) In group D (n = 26), 0.75 mg digoxin was administered intravenously and thereafter as needed, b) In group AM (n = 16), 300 mg of amiodarone was infused over 2 hours followed by 44 mg/hour for up to 60 hours or until sinus rhythm was restored, c) In group D + AM (n = 28), 0.75 mg of digoxin was administered (as in group D) for the initial 2 hours followed by amiodarone infusion as in group AM. RESULTS: Sinus rhythm was restored: a) by the end of the 2nd hour in 9/26 patients from group D, 4/16 from group AM, and 10/28 from group D + AM (p = NS), b) by the end of the 96th hour, in 18/26 patients from group D, and in all patients from group AM and groupd D + AM. The corresponding duration of AF was 51 +/- 34 hours, 17 +/- 15 hours and 9 +/- 13 hours, respectively (F = 15.4, p < 0.001). AF recurred in 9/26, 5/16 and 1/28 patients of groups D, AM and D + AM, respectively (p = 0.026). The required dosage of amiodarone was lower in the D + AM group than in the AM group (603 +/- 563 mg versus 1058 +/- 680 mg, p = 0.037). CONCLUSIONS: Intravenous amiodarone was well tolerated in patients with AMI complicated by AF and was effective in decreasing the duration of AF. However, the combination of amiodarone and digoxin was superior to amiodarone alone in restoring sinus rhythm faster, maintaining sinus rhythm longer, and allowing the use of a lower cumulative amount of amiodarone.

Arterial compliance is an independent factor predicting acute hemodynamic performance of intra-aortic balloon counterpulsation.

Data concerning the effect of arterial compliance (AC) on hemodynamics during intraaortic balloon counterpulsation (IABC) are lacking. This study examines the effect of AC on acute hemodynamics induced by IABC in 15 patients with post-infarction cardiogenic shock. AC was estimated by aortic pulse wave analysis using the reflection time index (RTI). Measurements were obtained once per day during IABC. The % reduction in systolic aortic pressure (ASAP), end-diastolic aortic pressure (AEDAP) and the peak aortic diastolic augmentation (PADA) were used as performance indices of IABC; 107 sets of measurements were obtained. Multivariate analysis indicated an independent association of each IABC performance index with AC (p<0.05). A high AC group (RTI< or =20.6%, n=40) and a low AC group (RTI>20.6%, n=67) were obtained. DeltaSAP deltaEDAP and PADA were significantly higher in the low AC group by almost 75%, 54.6% and 11.3% (p<0.03), while arterial blood pressure did not significantly differ. Arterial compliance is an independent factor affecting hemodynamics during IABC. RTI values higher than 20.6% may predict a better acute hemodynamic response to IABC.

Correlation and stability of heart rate and ventricular ectopy variability in patients with congestive heart failure.

The stability of indexes of heart rate variability and their possible association with spontaneous variability of ventricular ectopy was examined in 13 patients with advanced congestive heart failure over 14 consecutive days of 24-hour ambulatory electrocardiographic recording. It was found that time and frequency domain measures of heart rate variability are stable over time and are inversely correlated with spontaneous variability of ventricular ectopy.

Limitation of infarct size by fixed coronary arterial stenosis maintained during reperfusion.

BACKGROUND: The effect on infarct size of a pre-infarction high-grade, fixed coronary arterial stenosis maintained during reperfusion, was evaluated. METHODS: This experimental study was carried out in the research laboratory of a University Hospital. A canine occlusion-reperfusion model was used. Twenty-eight dogs underwent proximal left anterior descending (LAD) coronary artery occlusion (O). In Group 1 (n=6) the O lasted for 6 hours. In Group 2 (n=6) the O lasted for 2 hours followed by 4 hours of reperfusion (R). In Group 3 (n=3), LAD was stenosed for 30 minutes followed by O for 6 hours. In Group 4 (n=7) LAD was stenosed for 30 minutes followed by O for 2 hours and then 4 hours of R during which the artery was kept stenosed at the same degree (fixed) as the initial one. In Group 5 (n=6) the protocol was identical to Group 4 with the additional use of the intra-aortic balloon pump during R. RESULTS: The infarcted myocardium was almost the same in Groups 1 and 3 (80.0+/-10.6% vs 77.3+/-3.8%, respectively, p=NS), but less in Group 2 (59.0+/-19.9%, p=0.046 vs Group 1). There were no hemodynamic differences between Groups 4 and 5 and the infarcted myocardium was almost identical in both groups (37.7+/-18.8% and 38.7+/-19.1%, respectively, p=NS). The combined results of Groups 4 and 5, regarding the infarcted myocardium, was 38.1+/-18% (p=0.037 vs Group 2). CONCLUSIONS: In this acute coronary occlusion model, a pre-existing high-grade stenosis that maintained during reperfusion increased the amount of salvaged ischemic myocardium.

Long-term intermittent dobutamine infusion combined with oral amiodarone improves the survival of patients with severe congestive heart failure.

STUDY OBJECTIVE: To evaluate the effects of long-term intermittent dobutamine infusion (IDI) with concomitant administration of low-dose amiodarone in patients with congestive heart failure (CHF) refractory to standard medical treatment. DESIGN: Prospective, interventional clinical trial. SETTING: Inpatient and outpatient heart failure clinic in a university teaching hospital. PATIENTS AND INTERVENTIONS: Twenty-two patients with CHF refractory to standard treatment who could be weaned from dobutamine therapy after an initial 72-h infusion were included in this study. The first 11 patients (group 1) were treated with IDI, 10 micromin, as needed (mean, once every 16 days, lasting for 12 to 48 h); the next 11 patients (group 2) received oral amiodarone, 400 mg/d, and IDI, 10 microg/kg/min, for 8 h every 7 days. MEASUREMENT AND RESULTS: There were no differences in baseline clinical, hemodynamic, and five biochemical characteristics between the two groups. The left ventricular ejection fraction was 13.5 +/- 4.5% in group 1 vs 15.5 +/- 4.9% in group 2 (mean +/- SD; p = 0.451); mean pulmonary capillary wedge pressure was 31.3 +/- 4.4 mm Hg vs 29.4 +/- 3.3 mm Hg (p = 0.316); serum creatinine was 1.9 +/- 0.4 mg/dL vs 1.6 +/- 0.5 mg/dL (p = 0.19); and serum Na was 139.6 +/- 6.2 mEq/L vs 138.4 +/- 3.1 mEq/L (p = 0.569). At 12 months of follow-up, 1 of 11 patients (9%) was alive in group 1 vs 6 of 11 patients (55%) in group 2 (p = 0.011). Furthermore, in group 2, the functional status improved significantly within the first 3 months of treatment, from New York Heart Association functional class IV to 2.63 +/- 0.5 (p = 0.0001). CONCLUSION: Long-term IDI in conjunction with amiodarone, added to conventional drugs, improved clinical status and survival of patients with severe CHF.

Non-cryopreserved peripheral blood progenitor cells collected by a single very large-volume leukapheresis: a simplified and effective procedure for support of high-dose chemotherapy.

High-dose chemotherapy with autologous peripheral blood progenitor cell (PBPC) support has become a widely used treatment strategy. In order to simplify the procedure, a single very large-volume leukapheresis programme combined with short-term refrigerated storage of the PBPC was developed. Seventy-two patients suffering from various relatively chemosensitive malignancies received high-dose chemotherapy, consisting of agents with short in vivo half-lives and 24 to 48 hours later, the refrigerated PBPC were reinfused. A single very large-volume apheresis was sufficient to obtain at least 2 x 10(6)/kg CD34+ cells in 58 patients (81%), and 63% had at least 2.5 x 10(6) CD34+ cells/kg. Only two patients (3%) were transplanted with less than 1 x 10(6) CD34+ cells/kg. In three patients (4%) leukapheresis was repeated because of insufficient number of PBPC. The median CD34+ cell count was 3 x 10(6)/kg. A median of 38.5 L blood (range, 21 to 59) was processed, which accounted for a median of 9 x patient's total blood volume. Very large-volume leukapharesis was well tolerated with symptomatic hypocalcemia being the most common (18%) side-effect. The median time to neutrophils >1.5 x 10(9)/L, and to self-supporting platelet count >25 x 10(9)/L, was 10 and 12 days after reinfusion of PBPC graft, respectively. There were no treatment-related deaths. Our results indicate that this simplified approach of PBPC transplantation can be associated with prompt hematologic recovery in most patients and that it can be useful in settings where facilities are limited or for certain diseases where conditioning regimens with short half-life are appropriate. J. Clin. Apheresis, 15:236-241, 2000.

Outcome of patients with congestive heart failure treated with standard versus high doses of enalapril: a multicenter study. High Enalapril Dose Study Group.

OBJECTIVES: We sought to prospectively and randomly compare survival with clinical and hemodynamic variables in patients with congestive heart failure (CHF) treated with standard versus high doses of enalapril. BACKGROUND: Angiotensin-converting enzyme (ACE) inhibitors produce hemodynamic and symptomatic benefits in patients with CHF, but there is still controversy about the optimal dose in this clinical setting. METHODS: Two hundred and forty-eight patients with advanced CHF (age 56.3+/-12 years) were randomized to receive a maximal tolerated dose of enalapril, up to 20 mg/day in group 1 (mean dose achieved 17.9+/-4.3 mg/day, n = 122) and 60 mg/day in group 2 (mean dose achieved 42+/-19.3 mg/day, n = 126). RESULTS: At enrollment, patients in group 1 were in New York Heart Association (NYHA) functional class 2.6+/-0.7 and had a mean systolic blood pressure (SBP) of 117+/-18 mm Hg, a mean heart rate (HR) of 85+/-16 beats/min and a left ventricular ejection fraction (LVEF) of 20.0+/-9.8%. In group 2, patients were in NYHA class 2.6+/-0.7; their SBP was 118+/-17 mm Hg, HR 83+/-15 beats/min and LVEF 18.8+/-8.1%. There were no significant differences in these characteristics between the two groups of patients at enrollment. After 12 months of follow-up, 22 (18%) of 122 patients in group 1 and 23 (18%) of 126 patients in group 2 had died (p = 0.995, with 80% power of the study to detect a delta difference of 13%). The NYHA class was the same (1.9+/-0.7) in both groups; SBP was 111+/-16 and 111+/-17 mm Hg, HR 77+/-12 and 79+/-13 beats/min and LVEF 31+/-19% and 30+/-12% in groups 1 and 2, respectively. These differences were not statistically significant. The study had a power of 80% to detect (p = 0.05) the following changes: 13% in death rate, 0.25 units in NYHA class, 6 mm Hg in SBP, 5 beats/min in HR and 6% in LVEF. CONCLUSIONS: No significant differences were found in survival and clinical and hemodynamic variables between patients receiving standard and those receiving high doses of enalapril.

Ras oncogenes and p53 tumor suppressor gene analysis in cardiac myxomas.

Although ras oncogenes and p53 tumor suppressor gene mutations are implicated in the development of several human tumors, little is known about their role in the pathogenesis of primary cardiac tumors. Paraffin-embedded tissue from 19 cardiac myxomas were investigated for the presence of ras oncogenes and p53 tumor suppressor gene abnormalities. Immunohistochemical analysis was used to identify the accumulation of p21-ras and p53 proteins. A polymerase chain reaction was used to amplify exons 1 and 2 of the ras genes and exons 5 to 8 of the p53 gene. The PCR products were analyzed by single strand conformation polymorphism analysis and by direct DNA sequencing. Three of 19 myxomas showed strong positive staining for the ras p21 protein. In contrast, nuclear p53 was not detectable in any of the myxomas. Among the ras p21 immunopositive myxomas, 2 were heterozygous for a missense point mutation of the K-ras, Gly 12Asp. Further screening of the remaining myxomas showed no mutation or even silent polymorphism in any exon of the ras and p53. The results suggest that although genetic alterations of ras oncogenes and p53 are uncommon events in cardiac myxomas, ras mutations may be involved in the pathogenesis of a subgroup of this type of tumor.

Histological assessment of apoptotic cell death in cardiomyopathies.

Apoptosis in the myocardium is complex and often difficult to recognise. Myocyte apoptosis is scattered across the myocardial wall and is restricted to individual cells. In the present study, we describe the amount of apoptosis in 50 endomyocardial biopsies taken from 50 patients with dilated cardiomyopathy, in 14 hearts with hypertrophic cardiomyopathy and in five hearts with arrhythmogenic dysplasia of the right ventricle. As a control group, 15 endomyocardial biopsies from 15 transplanted hearts (of live patients) were used. Apoptosis was immunohistochemically determined in paraffin sections with the TUNEL method. In each specimen the TUNEL index was calculated as the percentage of TUNEL-positive nuclei among a total number of 200 counted nuclei. Cellular morphology was assessed in conjunction with TUNEL staining. The mean percentage of TUNEL-positive myocardial cells varied from 4% for dilated cardiomyopathy to 17.5% for arrhythmogenic right ventricle dysplasia and 18.5% for hypertrophic cardiomyopathy, whereas no signs of apoptotic myocardial cell death were found in normal subjects. The numbers of apoptotic cells in dilated cardiomyopathy specimens were significantly lower by comparison with both those of hypertrophic cardiomyopathy and those of arrhythmogenic right ventricular dysplasia specimens. It is evident that apoptosis constitutes a major biological phenomenon in the development of at least some heart diseases, but its role in their pathophysiology has yet to be delineated.

Indium-111 monoclonal antimyosin cardiac scintigraphy in men with idiopathic dilated cardiomyopathy.

This study examined the prognostic value and the evolution of the heart-to-lung ratio of monoclonal antimyosin antibody (MAA) uptake in patients with a diagnosis of idiopathic dilated cardiomyopathy (IDC). Uptake of indium-111-labeled MAA occurs when the myocytes become irreversibly damaged. The study included 29 men with IDC followed up for 3 years. The diagnosis was verified by endomyocardial biopsy in all patients. Patients who survived beyond 1 year were restudied. Baseline heart-to-lung ratio of MAA was 1.74+/-0.22. Multivariate Cox regression analysis revealed that MAA and New York Heart Association class were independent predictors of late mortality, with a hazard ratio of 4.4 (95% confidence interval 1.1 to 17.9, p = 0.036) and 7.5 (95% confidence interval 2.0 to 28.4, p = 0.003), respectively, when heart-to-lung ratio of MAA uptake was > 1.74 and New York Heart Association class was >11. When these patients were divided into those with chronic IDC (group I [n = 19]) and those with subacute IDC (group II [n = 10]), baseline heart-to-lung ratio was 1.7+/-0.2 and 1.86+/-0.25, respectively (p = NS). In the surviving patients, on restudy, the heart-to-lung ratio of MAA uptake was unchanged in group I (1.64+/-0.20, p = NS), but had decreased to the level of group I (1.66+/-0.21 [p = 0.008]) in group II. Thus, men with IDC and a high heart-to-lung ratio of MAA uptake have a worse long-term prognosis than patients with a lower ratio. The heart-to-lung ratio of MAA decreases comparably over time in subacute IDC and remains stable in chronic IDC.

Relation of dispersion of QRS and QT in patients with advanced congestive heart failure to cardiac and sudden death mortality.

This study examined the usefulness of 01 and QRS dispersion in the prognosis of patients with advanced congestive heart failure (CHF). One hundred four patients in New York Heart Association functional classes II to IV, with a left ventricular ejection fraction of <35%, and untreated with antiarrhythmic drugs, were followed prospectively. QRS and QT dispersion were defined as the maximum difference in QRS and QT interval duration, respectively, measured on all leads of standard 12-lead electrocardiograms. The end points of the study were non-sudden and sudden cardiac mortality. During an average follow-up of 20 months, there were 13 non-sudden and 10 sudden deaths. The average QRS duration was significantly longer in nonsurvivors than in survivors (125 ¿ 34 vs 113 ¿ 34 ms, respectively, p <0.04). Similar results were obtained with 01 dispersion (95 ¿ 48 ms vs 78 ¿ 31 ms, respectively, p <0.03) and QRS dispersion (54 ¿ 17 ms vs 46 16 ms, respectively, p <0.02). Furthermore, patients who died suddenly had significantly greater QRS dispersion than patients who survived (56 ¿ 13 vs 46 ¿ 16 ms, respectively, p <0.02). In a multivariate analysis, QT and QRS dispersion were both independent predictors of non-sudden cardiac death (p = 0.01 and p = 0.001, respectively), and QRS dispersion was also an independent predictor of sudden cardiac death (p = 0.04). Death rate in patients with 01 dispersion >90 ms was 2.8-fold higher than those with 01 dispersion 90 ms (95% confidence intervals [CI] 1.2 to 6.4). Similarly, the death rate in patients with QRS dispersion >46 ms was 3.9-fold higher than in those with QRS dispersion 46 ms (95% Cl 1.6 to 9.5). These findings suggest that QT and QRS dispersion are useful predictors of mortality in patients with advanced CHF. ¿2000 by Excerpta Medica, Inc.

Postpericardiotomy syndrome during intensive immunosuppression after cardiac transplantation.

A 15-year-old man with end-stage heart failure due to dilated cardiomyopathy, underwent heart transplantation. In the second postoperative week, while being treated with monoclonal antibodies (OKT3), cyclosporine and azathioprine, he developed a postpericardiotomy syndrome and cardiac tamponade, which necessitated emergency pericardiocentesis. Corticosteroids, administered according to the immunosuppression protocol, resulted in the prompt subsidence of the syndrome. This is the first report of a large pericardial effusion and cardiac tamponade due to a postpericardiotomy syndrome in an adult cardiac recipient.

Congestive heart failure treated by the upgrade from VVI to DDD pacing.

The case is presented of an elderly woman with normal left ventricular (LV) systolic function and VVI pacing complicated by severe congestive heart failure. The symptoms and findings of congestive heart failure became refractory to medical treatment and resolved with the upgrade of the VVI to a DDD system. Right heart catheterization during VVI pacing showed increased mean pulmonary capillary wedge and right atrial pressures both being normalized under DDD pacing. This case report illustrates the need to consider permanent physiological pacing in elderly patients, even in presence of normal LV systolic function, to ensure AV synchrony when the atrium can be paced, since diastolic LV dysfunction is quite common in these subjects.