Spontaneous rupture of gastroduodenal artery aneurysm.

Gastroduodenal artery (GDA) aneurysm is a rare entity, comprising only 1.5% of all 3000 cases of visceral artery aneurysms that have been reported in literature. We report a case of a 55-year-old Caucasian man, diagnosed with right inguinal hernia. He was admitted to our department for surgical treatment. His medical history was remarkable for hypertension, and angina. He was operated the next day. A external oblique right inguinal hernia was diagnosed intraoperative. The Halsted technique was used for primary inguinal hernia. Immediate postoperative evolution was favorable, systolic blood pressure of 120 mmHg, pulse of 68 beats/minute. 16 h postoperative there was a sudden alteration of the general condition with signs of hemodynamic shock, with a systolic blood pressure of 60 mmHg, tachycardia of 110 beats/min. Physical examination revealed a pale, cold, and clammy patient. His hemoglobin had dropped from 14 g/dL on admission to 6 g/dL. A bedside ultrasound identified pelvic free fluid. An exploratory laparotomy revealed hemoperitoneum, and over 2 500 ml of blood and clot, a large hematoma was identified that was occupying the transvers colon mesentery and retroperitoneum. A clot was removed, revealing ruptured gastroduodenal artery aneurysm with active hemorrhage. The opening was isolated and closed. The contents were returned to the abdomen, which was irrigated and closed. Postoperative laboratory evaluation revealed hyperamylasemia (1543 IU/L, Normal Value (NV) = 15-95 IU/L). He remained normotensive throughout his 8-day hospitalization and was discharged home in good condition. In conclusion, gastroduodenal artery aneurysm rupture is a rare and patients can present with nonspecific symptoms. Rapid diagnosis, localization, and surgical or endovascular intervention are necessary to avoid devastating consequences.

Glomectomy in carotid sinus syncope and associated arrythmias: symptomatic bradycardia, atrial flutter and atrial fibrillation.

UNLABELLED: The main causes of neurally mediated syncope (NMS) are carotid sinus syndrome (CSS) and vasovagal syncope. Long before, carotid sinus denervation was performed for different diseases, but for the first time we consider glomectomy (G) as a surgical treatment for NMS and related arrhythmias, alone or associated with cardiac pacing (PM). METHODS: We used Nakayama's technique for bronchial asthma, modified by us: removal of hypersensitive carotid glomus and presinusal lymphadenectomy. Forty five patients (pts) with recurrent NMS (cardioinhibitory 14 pts, mixed 31 pts) were included: 41 males, 4 females, aged 23-84 (mean 60 yrs). The diagnosis was documented clinically by carotid sinus massage, ECG-Holter, electrophysiologic studies, head-up tilt test. Malignant orthostatic syndrome was present in 4 pts, tussive syncope in one, sick sinus syndrome (SSS) in 6 pts, atrial fibrillation and flutter in 6 pts, AV block in 2 pts. Thirty four pts underwent G alone; 6 pts-G and PM; 5 pts-PM alone, 3 pts-G plus carotid endarterectomy. RESULTS: of G were excellent. All pts became free of syncope (max. follow-up 10 yrs). In addition, stable sinus rhythm was obtained in two pts (one with severe atrial fibrillation, another with persistent atrial fibrillation). In pts with SSS, A-V block or atrial fibrillation with bradycardia, PM was inserted (DDDR or VVIR). However, in pts with vasodepressor component of NMS, symptoms persist until G was performed. CONCLUSIONS: We conclude that our data support the efficiency of G in pts with NMS (either cardioinhibitor or vasodepressor), as well as in related arrhythmias. PM is indicated in pts with associated diseases: intrinsic SSS, AV block, atrial fibrillation with bradycardia.

Complete atrioventricular block in patients with acute inferior myocardial infarction. Clinical spectrum and prognostic significance.

Patients with acute inferior myocardial infarction (IMI) and complete atrioventricular block (CAVB) have a wide range of mortality rate. This raises the question whether there is no other risk factor that interferes in this particular situation. In our study, mortality rate in patients with acute IMI and CAVB was significantly greater than in patients without conduction disturbance, but the occurrence of right ventricle myocardial infarction (RVMI) enhanced the mortality rate regardless of the presence or absence of CAVB.

Mitral regurgitation and left ventricular outflow tract obstruction in hypertrophic cardiomyopathy. Analysis by Doppler echocardiography.

In a group of five patients with asymmetric septal hypertrophy, the presence of the mitral regurgitation and the left ventricular outflow tract gradient were studied by the Doppler echocardiographic technique. By means of Bernoulli's formula 4V2 = P1-P2, left ventricular maximal systolic pressure was assessed using mitral regurgitant and left ventricular outflow tract jets. Aortic systolic and diastolic blood pressures were measured by cuff sphygmomanometry, and simultaneous carotid pulse tracings were recorded. All patients had outflow tract pressure gradients (peak 84 +/- 11.7 mmHg) and mild mitral regurgitation. Continuous wave Doppler study recorded peak flow velocities in the outflow tract (4.6 +/- 0.26 m/sec) and mitral regurgitant (6.5 +/- 0.51 m/sec) jets. The values for ventricular systolic pressures by both methods were similar (180 +/- 24.2 vs 186 +/- 13.5 mmHg). This study confirms the presence of mitral regurgitation and actual obstruction in hypertrophic cardiomyopathy with asymmetric septal hypertrophy.

Prevalence of arrhythmias during exercise stress testing in patients with hypertrophic cardiomyopathy.

To identify the patients with hypertrophic cardiomyopathy at high risk of morbid events we investigated 25 patients with echocardiographic evidence of hypertrophic cardiomyopathy. All the patients were subjected to submaximal exercise test under electrocardiographic monitoring. More than 50% of the patients developed ventricular arrhythmias, about half of them presenting multiform or repetitive premature ventricular depolarizations; two patients presented ventricular tachycardia. Our results suggest the value of exercise test in identifying the patients at high risk of developing severe arrhythmias.

[Doppler echocardiography in mitral insufficiency]. / Eco Doppler în insuficienta mitrala.

The Doppler method (pulsatile and continuous) was used for finding out and semiquantitatively evaluating the mitral insufficiency of various etiologies: inflammatory (rheumatic); prolapse of mitral valve; obstructive hypertrophic cardiomyopathy; dilatative cardiomyopathy; calcification of valvular ring. The Doppler parameters obtained after automatic processing of the image (speed transvalvular pressure gradient, flow period and acceleration) offer data on the diastolic performance of the left ventricle. Registration of the aortic flow makes possible the calculation of the cardiac flow (the diameter of the aorta is measured in echo-B), and of the aortic flow permits the noninvasive evaluation of the lung arterial pressure. The method offers a large vista in the noninvasive evaluation of the patients suffering from mitral insufficiency.

[Hypertensive cardiopathy--an adaptive or a pathologic phenomenon?]. / Cardiopatia hipertensiva--fenomen adaptativ sau patologic?

The hypertensive cardiopathy is a controversial entity as regards the physiopathological mechanisms and clinical aspects. Defined as the hypertrophy of the left ventricle, secondary to the permanent tension increases, it accompanies not only the severe forms of arterial hypertension but also the medium and mild ones. In the authors' opinion, based on numerous experimental and clinical studies, the main factor that initiates the myocardial hypertrophy is the increased parietal tension (hemodynamic hypertrophy). The natural evolution is progressive, the myocardial hypertrophy initially adaptive becomes pathological and the cardiac performance is affected gradually, first in its diastolic and then in its systolic component, up to the final stage of congestive cardiac insufficiency. The structural changes of the myocardial fibre also document the adaptive and pathological hypertrophy, the alteration of the myocardial contractility consisting in the difficulty of transforming the chemical energy into mechanical work. The clinical aspects show an incipient myocardial hypertrophy, considered adaptive, since the cardiac performance is normal; an important hypertrophy affecting the diastolic component and the hypertrophy with dilatation that affects the overall performance. Of the evaluation methods, the echocardiography is the most accurate one in quantifying hypertrophy, evaluation of the cardiac performance and possibility of detecting several characteristic aspects of the hypertensive cardiopathy. The transition moment from the adaptive hypertrophy to the pathological hypertrophy cannot be exactly established but it is documented that the hemodynamic and nonhemodynamic hypertrophy is a supplementary cardiovascular risk factor.

The effects of captopril in severe congestive heart failure. An echocardiographic study.

In 12 patients with severe congestive heart failure (CHF), captopril in doses of 25 to 150 mg, every 8 hours, was given for a period of 2 months, in addition to cardiac glycoside and diuretic drugs. After this treatment left ventricular end-diastolic diameter (EDD) decreased from 6.4 +/- 0.5 to 6.2 +/- 0.6 cm (p less than 0.05), left-ventricular end-systolic diameter (ESD) decreased from 5.7 +/- 0.5 to 5.4 +/- 0.6 cm (p less than 0.001), the ejection fraction increased from 30.8 +/- 7.0 to 36.2 +/- 6.9% (p less than 0.005) and mean velocity of circumferential fiber shortening (Vcf) increased from 0.51 +/- 0.12 to 0.62 +/- 0.13 circ/sec (p less than 0.001). Captopril markedly relieved dyspnea and fatigue. Three patients improved from class IV to class III, 4 patients from class IV to class II and 3 patients from class III to class II. These data suggest that captopril may be effective in the treatment of severe chronic CHF.

[Echocardiographic parameters in the follow-up of left ventricular performance before and after the surgical correction of mitral and aortic regurgitation]. / Parametrii ecocardiografici de urmarire a performantei ventriculare stîngi, înainte si dupa corectia chirurgicala a regurgitarii mitrale si aortice.

The present study investigates 16 patients with aortic regurgitation (AR), and 10 patients with mitral regurgitation (MR). Before operation, all the 26 patients had increased telediastolic and telesystolic diameters. The patients were divided into two groups, as a function of the postoperative values of the telediastolic diameter: group A--with the telediastolic diameter within normal limits; group B--with the persistence of the increased values of the telediastolic diameter. In the case of the patients with AR, the following postoperative situation was noticed: in group A: the peak systolic stress (PSS) was increased, the shortening fraction (SF) in the telesystolic stress (TSS) within normal limits; in group B: PSS and TSS were increased, and ST depressed. 8 months after the valvular correction, in group A: PSS, TSS and SF were normal; in group B: the changes in PSS and TSS continued and was lowered. In the case of the patients with MR, before operation, in group A: PSS was slightly increased while TSS and SF were normal; in group B: PSS was slightly increased, TSS, increased and SF depressed. 8 months after the surgical correction: in group A: PSS and SF decreased; in group B: echocardiographic changes continued. Therefore, in the group B patients with MR and AR, the persistence of the increased values of PSS, TSS leads to the postoperative decrease of SF (post-charge in excess).

Left ventricular relaxation time index and left atrial emptying index as early echocardiographic indicators in predicting hypertensive heart disease.

To study the earliest changes in left ventricular structure and function appearing in response to hypertensive heart disease the study was started with an initial group of subjects detected for the first time in their lives with elevated levels of systemic blood pressures. A careful follow up of these subjects during the next year allowed the division of these subjects into a group of healthy not hypertensive subjects and a group of subjects with mild essential systemic hypertension detected in an early phase. The next six years of repeated controls (arterial blood pressure measurement, clinical examination, routine chest X-ray pictures, standard 12 leads ECG and M-mode echocardiography) allowed a further division of the hypertensive subjects into two groups of patients: one correctly treated and the other treated incorrectly or not at all. It was found that left ventricular diastolic functions expressed by left ventricular relaxation time index (LVRTI) and left atrial emptying index (LAEI) are the earliest indicators of hypertensive heart disease due to mild essential systemic hypertension.

Glomectomy in carotid sinus syncope.

Carotid sinus hypersensitivity (CSH) is a common cause of syncope, and permanent pacemarker is unequivocally indicated in such patients. From 37 patients with spontaneous syncope, in 10 (mean age 60 years), CSH was confirmed by carotid sinus massage: cardioinhibitor CSH, 6 patients (asystole greater than 3 sec), cardioinhibitor and vasodepressor CSH, 4 patients (asystole greater than 3 sec, and decrease of systolic blood pressure by more than 30 mmHg). The sick sinus syndrome was excluded by electrophysiologic studies performed after autonomic blockade (atropine, 0.04 mg/kg, and propranolol 0.2 mg/kg): heart rate at rest (60.1 +/- 3.1 bpm); corrected intrinsic sinus node recovery time (29.5 +/- 92.8 ms); intrinsic sinoatrial conduction time (96.2 +/- 30.7 ms). No atrioventricular conduction disturbances occurred during atrial pacing up to 160 beats/min. Surgical removal of carotid glomus (glomectomy) was performed according to Nakayama's technique for bronchial asthma: right side 7 patients, left side 2 patients, both sides one patient. Postoperative follow-up from fourteen to forty-four months (mean 28 months), demonstrated excellent results. All but one patient remained asymptomatic. The heart rate at rest, autonomic chronotropy, and exercise tolerance improved significantly (p less than 0.001). Thus glomectomy appears to be the treatment of choice in selected patients with CSH and syncope.

Evaluation of pulmonary hypertension by echocardiographic right ventricular systolic time intervals.

Pulmonary valve echogram and right cardiac catheterization were simultaneously performed in 18 patients suffering from heart disease in whom pulmonary hypertension was suspected. Echocardiography was employed to measure right preejection period (RPEP), right ventricular ejection time (RVET) and RPEP/RVET ratio. Cardiac catheterization was used to determine pulmonary artery diastolic pressure (PADP), pulmonary artery systolic pressure (PASP), pulmonary artery mean pressure (PAMP) and right ventricular and diastolic pressure (RVDP). Each of these pressures was compared to each of the echo-date by means of regression analysis. The best correlation (r = 0.970; p less than 0.0005) was between PADP and RPEP/RVET ratio. We also found that RPEP/RVET ratio and RVET were each good predictors for the pulmonary artery pressures.

Exercise tests in labile hypertensive patients.

From a collectivity of 17,256 subjects below the age of 30 years, 80 subjects with labile hypertension (LH) were selected. The LH subjects were subjected to exercise test and the response of arterial blood pressure (BP) was followed up. The data obtained were compared with similar determinations carried out in a group of normotensive subjects. The mean value of systolic blood pressure (SBP) on exercise in the normal subjects was 171.0 +/- 2.9 mmHg and that of diastolic blood pressure (DBP) was 77.5 + 1.5 mmHg. The LH subjects presented, on exercise increases of both SBP and DBP in 35 cases (43.7%), increase of only SBP in 10 cases (12.5%) and "normal" type response in 35 cases (43.7%). In these subjects the mean value of SBP, on exercise, was 191.0 +/- 2.6 mmHg (p less than 0.001 as compared with the normal) and that of DBP was 90.0 +/- 1.9 mmHg (p less than 0.001 as compared with the normal). The above data proved that the LH subjects represented a group distinct from the normal subjects. The LH subjects presented a bimodal percent distribution of SBP and DBP on exercise, suggesting the existence of two subgroups one with "normal" type BP response the other with "hypertensive" type response. The BP response to exercise represents a simple test for the detection of abnormal BP increases. The authors consider as fully justified a longitudinal study of LH subjects. The exercise test might have a predictive value in detecting the early signs of essential hypertension.

Indication of cardiac surgery in infective endocarditis.

From the 33 patients with infective endocarditis (IE) hospitalized in the 1st Clinic of Internal Diseases, Timisoara between 1981 and 1984, in 5 (4 men and one woman) ranging in age from 21 to 52 years (mean 38) cardiac surgery was indicated and aortic (3) and mitral (2) valve replacements were performed. Valve replacement was performed for: 1) rapid/slow progressive hemodynamic deterioration with intractable congestive heart failure associated with ruptured chordae on posterior leaflet of mitral value (1 case); perforated aortic cusp (1 case); 2) prosthesis endocarditis (1 case); 3) precocious recurrence of IE (1 case); 4) uncontrollable infections (1 case). Echocardiography was helpful in all the cases by permitting recognition and evaluation of the preexistent lesions, and by the supplying of characteristic vegetations (all echocardiographic findings were confirmed by open heart surgery). Likewise it proved an accurate method in assessing pre- and post-operative left ventricular performance. In conclusion it is considered that early valve surgery in IE is indicated in hemodynamic deterioration, prosthetic endocarditis or impossibility to control septicemia. Echocardiography is the most useful noninvasive method for the pre- and postoperative evaluation of the patients investigated.

Correlations of electrocardiography and echocardiography in assessment of left ventricular wall thickness in hypertensive patients.

Posterior wall thickness (PW) and interventricular septal thickness (IVS), left ventricular end-diastolic diameter (LVEDD), left ventricular end-systolic diameter (LVESD), ejection fraction (EF) and left ventricular mass (LV mass) were determined by the echocardiogram. These were compared with the sum of the S wave in lead V1 plus the R wave in lead V6(SV1 + RV6) determined by electrocardiogram (ECG) in 21 hypertensive patients. A significant increase in PW (p less than 0,05), IVS (p less than 0.05) and LV mass (p less than 0.01) was found in all the 21 patients. PW was highly correlated with SV1 + RV6(r = 0,76; p less than 0.01) in 12 patients. LV mass was correlated with LVEDD (r = 0,60; p less than 0.05) and LVESD (r = = 0.66; p less than 0.05) in the same patients mentioned before. We conclude that LV mass increases early in hypertensive patients and can be better assessed by echocardiography than ECG. The PW has a greater influence on the SV1 + RV6 sum than the echocardiographically assessed IVS.