Outcome predictors of ultrafiltration in patients with refractory congestive heart failure and renal failure.

This study is an attempt to identify predictors of outcome from the use of ultrafiltration (UF) in patients with refractory congestive heart failure (CHF) and renal failure. The authors studied 30 patients in NYHA functional class IV in whom UF was utilized in the management of refractory CHF. Patients were retrospectively divided into two groups according to their outcome. Group A included 12 patients who improved and survived hospital admission, and group B included 18 patients who did not respond and died shortly after UF. Clinical, hemodynamic, and laboratory data before UF were fairly comparable between both groups. Renal function and hemodynamic parameters were compared and analyzed within the same group and between both groups before and after UF. The mean age in group A was sixty-three +/- thirteen years while in group B it was seventy +/- eleven years (P < 0.005). A mean of 9.6 liters of fluid were removed from group A and 3.2 liters from group B (P < 0.001). Group A showed greater reduction in the mean values of right atrial pressure (P < 0.005) and pulmonary capillary wedge pressure (P < 0.05) after UF. Additionally, group A showed a significant decrease in their blood urea nitrogen (P < 0.05) and serum creatinine values (P < 0.05), in contradistinction to group B patients who showed a major increase in those values after UF. There was no significant change in the mean values of cardiac index, systemic vascular resistance, and pulmonary vascular resistance after UF. These findings suggest that younger age groups, greater fluid removal, as well as significant decreases in blood urea nitrogen, serum creatinine, and right atrial and pulmonary wedge pressures after UF, are associated with favorable outcome. Conversely, older age groups, less fluid removal, and rising blood urea nitrogen and serum creatinine levels after UF were associated with poor outcome.

Critical role of pulmonary angiography in the diagnosis of pulmonary emboli following cardiac surgery.

This study was conducted to identify patients at high risk of the development of Pulmonary Embolism (PE) after open heart surgery, to evaluate pertinent diagnostic methods, and to assess the mortality associated with this complication. We evaluated the records of 2,551 consecutive patients who underwent open heart surgery over a 10-year period to identify those patients in whom PE developed. All surgical reports, ventilation/perfusion scans, pulmonary angiograms, and autopsies from the same period were also reviewed. Preoperative and postoperative risk factors for pulmonary embolism were also analyzed, as well as the outcome of this complication in each type of surgical procedure. Pulmonary embolism was identified in 69 (2.7%) patients after open heart surgery, in 43 (62.3%) of whom the diagnosis was established within the first week of surgery. Factors associated with high incidence for PE were hyperlipidemia, congestive heart failure and heparin-induced thrombocytopenia (P < 0.001); obesity and prolonged mechanical ventilation (P < 0.005); and prior right heart catheterization by the femoral approach and prior PE and/or deep vein thrombosis (P < 0.05). The diagnosis of PE was established by a high-probability ventilation/perfusion scan in 25 patients, by pulmonary angiography in 42 (29 of whom had prior V/Q scan read as intermediate or low probability for PE) and by autopsy in two patients. The mortality rate in patients who had PE was 7.2%, while in those without this complication it was 3.2%. These findings suggest that aggressive approach for the diagnosis of PE by pulmonary angiography whenever the V/Q scan is not read as high probability is crucial in patients with recent open heart surgery; such approach may identify patients with PE at an early stage and may have an impact in reducing mortality incurred by this complication. This diagnostic assessment should be emphasized in the perioperative period, especially in patients with multiple significant and identifiable risk factors for PE.

Recanalization characteristics of intracoronary streptokinase compared to intravenous tissue plasminogen activator following acute myocardial infarction: a community hospital experience.

This study compares the recanalization characteristics of intracoronary streptokinase (IC-SK) with those of intravenous tissue plasminogen activator (t-PA) in patients with acute myocardial infarction (AMI) treated in the first 6 hours after onset of symptoms. We studied 263 patients with AMI. Among these, 160 were treated with IC-SK; in 59 the drug was given within the first 3 hours and in 101 from 3 to 6 hours. Another 103 patients were treated with IV t-PA; in 64 the drug was given in the first 3 hours and in 39 within 3 to 6 hours. The recanalization rate in the IC-SK group at 0 to 3 hours was 73% and at 3 to 6 hours was 71%, with an overall recanalization rate of 72% from 0 to 6 hours. In the t-PA group, the recanalization rate at 0 to 3 hours was 72% and at 3 to 6 hours was 46%, with an overall recanalization rate of 62%. We conclude that during the first 6 hours of AMI, IC-SK treatment resulted in a rather steady thrombolysis rate, while t-PA treatment with the standard regimen produced a significant decline in recanalization when administered after 3 hours from the onset of AMI symptoms.

The potential impact of the thrombolytic era on cardiac rupture complicating acute myocardial infarction.

Cardiac rupture complicating acute myocardial infarction (AMI) remains a serious diagnostic and therapeutic challenge. The authors present 27 consecutive patients who died from cardiac rupture following AMI. These included 22 patients from 1975 through 1983 (prethrombolytic era) and 5 patients from 1984 through 1992 (postthrombolytic era) and all had postmortem examination. There were 16 men and 11 women with a mean age of seventy-two years. Myocardial infarction was anterior/anterolateral in 10 and inferior/inferoposterior in 17. Cardiac rupture followed AMI within one day in 14 (52%), two to five days in 8 (30%), and six to fourteen days in 5 (18%). Chest pain followed by sudden hypotension leading to electromechanical dissociation was the common terminal event. Cardiopulmonary resuscitation was unsuccessful in all patients. Postmortem findings showed three-vessel coronary disease in 21 (78%) and two-vessel disease in 6 (22%). Isolated free left ventricular wall rupture was found in 22 (81%), was anterior/anterolateral in 13 (48%), posterior in 9 (33%), and in conjunction with interventricular septum or papillary muscle in 5 (18%). Patients encountered in this series were mostly elderly hypertensives with multivessel coronary disease and postinfarction angina. Furthermore, cardiac rupture commonly occurred within the first five days of AMI and cardiopulmonary resuscitation was uniformly unsuccessful. During the thrombolytic era at their institution, this complication is now being seen much less often. These observations suggest that such interventions are expected to have a favorable impact on reducing the incidence of this catastrophic event.

Sustained supraventricular tachyarrhythmias following coronary artery bypass surgery comparing mammary versus saphenous vein grafts.

This retrospective study was designed to determine the incidence of sustained supraventricular tachyarrhythmias (SVTs) in patients undergoing coronary artery bypass grafting (CABG) with internal mammary artery (IMA) grafts, Group A, compared with those with saphenous vein grafts (SVG), Group B. Among 569 consecutive patients who underwent CABG surgery in the same institution, a total of 80 cases from Group A and 80 cases from Group B were selected for this study after application of exclusion criteria. Excluded from this study were the following: patients with preexisting or prior history of SVTs, significant left ventricular dysfunction (ejection fraction less than 40%), postoperative myocardial infarction, drug toxicity or electrolyte imbalance, and advanced chronic obstructive lung disease. Group A consisted of 63 men and 17 women and Group B consisted of 52 men and 28 women. All patients were monitored either in ICU or by telemetry for a period of three to six days after surgery and all had a predischarge 12-lead electrocardiogram. Both groups were fairly comparable in most of their clinical profile and number of grafts. The incidence of SVTs in Group A was 31% (25 of 80 patients) and in Group B was 24% (19 of 80 patients). Furthermore, the incidence of postoperative pericarditis was noted in 35% (28 of 80 patients) of Group A and in 19% (15 of 80 patients) in Group B. The authors conclude that male tobacco smokers of Group A tended to have a significantly higher incidence of postoperative pericarditis with a higher trend for postoperative SVTs than patients from Group B.

Acute dissecting aortic aneurysm: community hospital experience in 20 cases.

Of 20 patients with dissecting aortic aneurysm managed at our community hospital, 16 had type A (ascending) dissection and four had type B (descending) dissection. Twelve of the patients with type A dissection were operated on; six of them survived and six died postoperatively. The remaining four patients with type A dissection had cardiopulmonary arrest and died before surgical intervention was attempted. All four patients with type B dissection were treated medically and all survived. Although acute aortic dissection is not commonly seen at community hospitals, expedient management of such patients can have a major impact on their survival. Patients at extreme risk are those with type A dissection, particularly those with cardiopulmonary arrest.

Total inferior vena cava thrombosis following coronary artery bypass surgery.

A 44-yr-old male presented with abdominal and back pain following coronary bypass surgery (CABG). Total inferior vena cava (IVC) thrombosis was then documented by computed tomography as well as IVC contrast cineangiography. Furthermore, the patient developed multiple pulmonary emboli. This presentation with severe abdominal and back pain with lack of early peripheral edema without apparent hepatic or renal dysfunction and with extreme elevation of erythrocyte sedimentation rate seems rather unusual. To our knowledge, such massive IVC thrombosis has not been reported following CABG. Thrombolytic and anticoagulant therapy was utilized with good recovery.

Early percutaneous transluminal coronary angioplasty or coronary bypass surgery following thrombolytic treatment of acute myocardial infarction.

Coronary reocclusion rates following intracoronary streptokinase (IC-SK) infusion remain significantly high despite anticoagulation. Early intervention by coronary angioplasty (PTCA) or coronary bypass surgery (CABG) was advocated to minimize such risk and/or maintain coronary reperfusion. Of 71 consecutive patients (60 men, 11 women; mean age, 54.9 years) who underwent IC-SK infusion for acute myocardial infarction (MI) 50 had early CABG, 18 had PTCA, and three had both procedures. Sixty-four of the 71 had successful thrombolysis. Thirty-six patients had either CABG or PTCA within three days, 22 patients within seven days, and 13 patients within two weeks. There was no immediate or in-hospital mortality, and all patients remained alive through the follow-up period of three to 36 months. Functional class (FC) 1 was achieved in 45 patients, FC 2 in 22 patients, FC 3 in three patients, and FC 4 in one patient. Sixty-seven patients (94 percent) were free of chest pain through the follow-up period. These data suggest that early intervention by CABG and/or PTCA in suitable candidates could be achieved with reduced risk and expected to yield favorable results. This favorable trend could be related to maintenance of myocardial perfusion by these procedures, initially induced by thrombolysis. Long-term, large-scale studies are needed to confirm the role of optimal timing of such procedures, but we believe that such results indicate that early revascularization yields promising results.

Observer variation in the echocardiographic diagnosis of mitral valve prolapse.

To assess inter- and intraobserver variation in the echocardiographic diagnosis of mitral valve prolapse, three independent observers analyzed M-mode echocardiograms (n = 80) and two-dimensional echocardiograms (n = 65) of patients with a mobile midsystolic click with or without a late or holosystolic murmur. In addition, a control group of 100 normal echocardiograms were interspersed among the echocardiograms of patients with mitral valve prolapse and were then interpreted. Each of the three observers analyzed all M-mode and two-dimensional echocardiograms initially and then 2 weeks later for the presence or absence of mitral valve prolapse. M-mode echocardiographic criteria for mitral valve prolapse consisted of late systolic posterior motion (greater than or equal to 3 mm) of one or both mitral leaflets or holosystolic hammocking (greater than or equal to 3 mm) of one or both mitral leaflets. Two-dimensional echocardiographic criteria for mitral valve prolapse consisted of: posterior systolic arching of one or both mitral leaflets in the parasternal long-axis view, and/or posterior systolic bowing of one or both mitral leaflets in the apical four-chamber view posterior to the plane of the mitral anulus, and/or excessive posterior coaptation of the mitral leaflets in either view flush with or posterior to the plane of the mitral anulus. There was insignificant observer variation both in the M-mode and two-dimensional echo groups, as determined using Cochran's Q test.(ABSTRACT TRUNCATED AT 250 WORDS)

Acute myocardial infarction with "normal" coronary arteries: clinical and angiographic profiles, with ergonovine testing.

Among 528 patients consecutively undergoing selective coronary angiography after acute myocardial infarction, ten cases (1.9%) with angiographically normal coronary arteries were identified. Eight of these ten patients were 45 years of age or younger and comprised 11% of those studied in this age group, with higher prevalence in females (five of 18 [28%]) versus males, (three of 57 [5%]). Common features besides the young age of patients included predominance of female sex, smoking as a risk factor, and the lack of preinfarction symptoms. An ergonovine test was carried out in seven of these patients, and all tested patients failed to show any evidence of focal coronary spasm. Three patients had recanalization of the infarct-related vessel by intracoronary streptokinase. The lack of a history of variant angina in nine patients, the negative response to ergonovine provocation in seven, and documented thrombolysis after intracoronary streptokinase in three seem to indicate that a thrombotic process is a leading factor in myocardial infarction in such cases. Angiographic studies of this young subset of patients would enhance their identification and might reveal the pathophysiologic mechanisms involved with potentially significant clinical implications. Long-term follow-up of such cases will be needed to determine their ultimate prognosis.

Ventricularization of right atrial wave form in amyloid restrictive cardiomyopathy.

Two patients with biopsy-proven amyloid restrictive cardiomyopathy were presented. Both cases showed ventricularization of an elevated right atrial pressure wave form in absence of tricuspid regurgitation. Possible explanations for this finding as well as its clinical implications are discussed. This observation indicates that ventricularization of right atrial pressure wave form could be a useful hemodynamic sign in amyloid restrictive cardiomyopathy in absence of tricuspid regurgitation. Furthermore, such a finding does not seem to be specific for tricuspid regurgitation.

Incidence of new focal pulmonary emboli after routine cardiac catheterization comparing the brachial to the femoral approach.

The incidence of pulmonary perfusion defects after routine cardiac catheterization was assessed in 56 patients by comparing ventilation-perfusion (V/Q) lung scans obtained before and 1 day after catheterization. Patients were prospectively randomized in two groups, one in which the brachial approach was performed using an antecubital cutdown procedure, and one in which the percutaneous femoral approach was used. None of the patients with the brachial approach had any ventilation-perfusion mismatch on the V/Q scan; however, three patients (8.3%) with the femoral approach did. These two groups did not differ significantly in clinical characteristics, duration of catheterization, and hemodynamic variables. The data suggest that pulmonary emboli postcardiac catheterization is more frequent in the femoral than the brachial approach. Furthermore, since those pulmonary emboli are mostly asymptomatic, their clinical recognition would be underestimated.

Increased left ventricular mass in idiopathic mitral valve prolapse.

We performed M-mode echocardiography on 100 subjects with idiopathic mitral valve prolapse (IMVP) and on 100 normal control subjects to determine if differences exist between the two groups in cardiac chamber size, left ventricular performance or left ventricular mass. Subjects with IMVP demonstrated significantly greater left ventricular mass than normal control subjects. There were no significant differences in fractional shortening of the left ventricle or left ventricular end-diastolic volume. There was no significant difference in left ventricular mass between asymptomatic subjects with IMVP and those with chest pain, palpitations, syncope or presyncope. Subjects with and without mitral regurgitation showed no significant difference in mass. The results indicate that subjects with IMVP demonstrate subtle left ventricular hypertrophy which does not appear to be caused by underlying organic heart disease, mitral regurgitation or sustained hypercontractility. This suggests that myocardial involvement is an integral part of the IMVP syndrome.

Sensitivity and specificity of M mode echocardiographic signs of mitral valve prolapse.

To assess the sensitivity and specificity of previously described M mode echocardiographic signs of mitral valve prolapse, 100 subjects with a mobile mid systolic click and 100 matched normal control subjects were prospectively studied. Late systolic posterior motion and holosystolic hammocking of the mitral leaflets were common, highly specific signs of mitral valve prolapse. When these signs were combined as a single criterion, sensitivity was 85 percent and specificity was 99 percent. Other signs, including systolic echoes in the mid left atrium, systolic anterior motion, early diastolic anterior motion of the posterior mitral leaflet and shaggy or heavy cascading linear diastolic echoes posterior to the mitral valve, were highly specific but uncommon. They occurred only in combination with late systolic posterior motion or holosystolic hammocking. The remaining signs tested did not differentiate subjects with mitral valve prolapse from normal persons.