Short-term evaluation of captopril in patients with chronic left sided valvular regurgitations.

OBJECTIVE: To evaluate the clinical effects and the changes in cardiac performance of high- and low-dose captopril compared to placebo in patients with chronic symptomatic aortic regurgitation (AR), and/or mitral regurgitation (MR). PATIENTS AND METHODS: We randomized patients into three groups, placebo (Group 1), incremental daily doses of 50 mg (Group 2), and 100 mg captopril (Group 3). We compared exercise capacity before and after four-week of treatment. RESULTS: Treatment was well tolerated with no serious side effects including blood chemistry. There were no significant effects of treatment on left ventricular dimensions nor calculated left ventricular ejection fraction (LVEF) between groups (LVEF change -0.6%, -2.6%, 2.4%, in group 1, 2 and 3 respectively; p > 0.05). No difference of exercise duration between treatment and placebo arms (change by 13%, 12.8%, 16.4%, respectively; p > 0.05). However, there were trends in the number of the patients who improved in left ventricular performance (absolute LVEF change > 5% unit = 15%, 16%, and 42% respectively; p > 0.05) and exercise performance (exercise time improvement > 75 sec = 50%, 47%, and 68% respectively; p > 0.05) in high dose captopril treatment group. CONCLUSION: There was no significant improvement of left ventricular performance and exercise capacity after four-weeks' treatment of low and high dose captopril. Further study with a larger sample size, and longer follow-up period may be required.

Perforation of interventricular septum in acute myocardial infarction.

Eight cases of ruptured interventricular septum associated with myocardial infarction were diagnosed at Siriraj Hospital between 1985-1995. Clinical congestive heart failure and holosystolic murmur were found in all. Diagnosis was confirmed by echocardiogram and right heart catheterization in all patients. Two patients died from congestive heart failure preoperatively and the third case died from organ failure and sepsis postoperatively. Another five cases underwent successful ventricular septal defect closure and coronary artery bypass with good results.

Non-invasive diagnostic approaches of the dissection of the aorta: transesophageal echocardiography vs computed tomography.

The accuracy of non-invasive diagnosis of aortic dissection between transesophageal echocardiography (TEE) and computed tomography (CT) was studied in 21 patients. All patients had both diagnostic procedures. With TEE examination, De Bakey's type I was found in 9 patients, type II in 1 and type III in 10 while CT imaging revealed aortic dissection in 19 out of 21 patients. If the dissection found by both diagnostic procedures was considered definitive then both examinations were similarly sensitive. TEE is a preferred choice of non invasive work up for aortic dissection. Medical and surgical therapy in appropriate cases evaluated by TEE give rise to good results in the majority of patients.

Relationship between exercise capacity and left ventricular function in aortic and mitral regurgitation.

The exercise capacity as assessed by treadmill exercise or functional class from clinical history cannot predict standard echocardiographic findings in patients with AR/MR, in terms of EF, LVDs, ESVI. Therefore, exercise capacity cannot be used to predict the timing for surgery in those patients. However, symptomatic patients with dilated LV usually have low LVEF such as in our group.

Left ventricular hypertrophy: relationship of echocardiographic and electrocardiographic findings in idiopathic dilated cardiomyopathy.

Diagnosis of left ventricular hypertrophy is important in patients with cardiac disease. To test the correlation of echocardiographic and electrocardiographic findings for diagnosis of left ventricular hypertrophy in Idiopathic Dilated Cardiomyopathy (IDC), 18 patients with proven IDC were examined. There were 15 males and 3 females, ages ranged from 22-60 years (mean 43 +/- 10.7). LV mass index ranged from 134.4-421.2 g/m2 (mean 187.8 +/- 68.6). All 18 patients had LVH by echocardiography but only 10 patients (55.6%) had LVH by using ECG Romhilt-Estes scoring system. The correlation between echocardiographic and electrocardiographic findings for diagnosis LVH was not significant (r = 0.026; p = 0.935) and echocardiography was better than electrocardiography for diagnosis of LVH in IDC.

Prevalence of myocarditis in idiopathic dysrhythmias: role of endomyocardial biopsy and efficacy of steroid therapy.

In order to study the prevalence of myocarditis, EMB was carried out prospectively in 53 consecutive patients with various idiopathic dysrhythmias and efficacy of steroid therapy was evaluated. The patients consisted of 24 males and 29 females with ages ranging between 12 to 80 yrs. Histologic studies revealed myocarditis in 36 per cent. Steroid therapy resulted in good response in 14 of 18 patients (77.8%) with biopsy-proven myocarditis and in 5 of 17 patients (29.4%) with biopsy-negative but with clinically suspected myocarditis. The remaining patients did not have good response to steroid and there was 1 sudden death in each group.

Endomyocardial biopsy: its diagnostic usefulness.

In order to assess the diagnostic usefulness of EMB in patients with clinically suspected myocardial diseases, with and without heart failure or dysrhythmias, a prospective study was carried out in 84 consecutive patients. With EMB, the histological diagnosis was considered specific in 33 patients (39.3%), confirmative in 12 patients (14.3%) and negative in 39 patients (46.4%). It was found particularly useful in patients with unexplained heart failure and idiopathic dysrhythmias and in the differentiation between restrictive cardiomyopathy and constrictive pericarditis. The procedure can be safely performed with minimal morbidity and there was no mortality in the present study.

Transthoracic and transesophageal echocardiographic diagnosis of cor triatriatum: operation without catheterization in an adult patient.

Cor triatriatum presenting in adulthood is extremely rare. An 18-year-old female patient presented with a clinical picture masquerading mitral valvular heart disease. Both transthoracic and transesophageal echocardiography demonstrated a membrane in the left atrium with no other cardiac anomaly. The patient was successfully operated on without the need for catheterization.

Native valve infective endocarditis at Siriraj Hospital, 1982-1989.

During January 1982 to June 1989, there were 105 evaluable adult cases of native valve infective endocarditis admitted to Department of Medicine, Siriraj Hospital. The incidence was approximately 2.6 per 1,000 admissions. The male to female ratio was 1.4 and the mean age was 31.6 years. Thirty (28.5%) were cases associated with intravenous drug abuse. All non-addicts had pre-existing cardiac lesions susceptible to endocarditis especially rheumatic mitral regurgitation, aortic regurgitation, VSD and PDA. The clinical features of cases without intravenous drug abuse were low grade fever for few weeks, malaise, dyspnea and heart murmur. The addicts with endocarditis presented with acute febrile illness and pulmonary symptoms. Mucocutaneous embolic lesions were detected in one third of the patients. Echocardiography detected vegetations in 50 per cent of the patients. Streptococci were the most common causative agent in 93 per cent of non-addicts whereas the same percentage in addicts were caused by S. aureus. Most of the patients were treated with beta lactams (pen G, ampicillin or cloxacillin) alone or combined with aminoglycosides (streptomycin or gentamicin) for a duration from 10 days to 16 week. Six cases had valve replacement operation due to intractable heart failure and valve ring abscess, 2 had embolectomy of major arteries and 2 had craniotomy due to intracerebral hemorrhage. The overall case fatality rate was 14 per cent. The causes of death were heart failure, cerebral complications and severe pulmonary infections. Clinical response was observed sooner in non-addict patients.

Multivariate analysis in the prediction of death in hospital after acute myocardial infarction.

Prognostic factors in patients with acute myocardial infarction based on clinical and investigative data on admission were evaluated prospectively in 111 consecutive patients. Seventeen patients (15.3%) died during hospital stay. Age, a previous infarct, high Killip class, cardiomegaly, high serum concentrations of cardiac enzymes, a low ejection fraction, and a high wall motion score index correlated significantly with in-hospital mortality; whereas sex, risk factors, and pericardial effusion did not. Multivariate analysis showed that age and the wall motion score index were the best predictors of death in hospital. Wall motion detected by cross sectional echocardiography may reflect the extent of myocardial involvement. Age and wall motion score index predicted in-hospital mortality with a sensitivity of 76.5%, a specificity of 91.5%, and a predictive accuracy of 89.2%. Age and the wall motion score index can be determined on admission and are useful for identifying patients at high risk of cardiac death who might benefit from early intervention.

Cardiac involvement in beta-thalassemia/hemoglobin E disease: clinical and hemodynamic findings.

Clinical and hemodynamic studies were conducted in 6 women and 2 men with beta-thalassemia/hemoglobin E disease. All except one had splenectomy. The patients were hospitalized in the state of congestive heart failure. The systemic blood pressure was low or normal. The electrocardiograms revealed normal sinus rhythm in all, right axis deviation in some, right atrial enlargement in the majority and repolarization abnormalities in some. The echocardiograms were sensitive to detect the right heart abnormalities and pericardial effusion. Cardiac catheterization disclosed moderate to marked hypoxemia. All patients except one had pulmonary hypertension. Some had left ventricular dysfunction. From this study. It is concluded that right heart involvement secondary to diffuse pulmonary thromboembolic disease is a major complication of beta-thalassemia/hemoglobin E disease.

Short and long term mortality after acute myocardial infarction as predicted by two-dimensional echocardiography.

We have non-invasively determined the extent of the acute myocardial insult shortly after admission in a large group of patients with acute myocardial infarction. There appeared a fairly sharp distinction between patients with low and high likelihood of in-hospital death and one year mortality on the basis of echocardiographic findings. The use of wall motion score index and ejection fraction in the prediction of short term mortality (in-hospital death) is good, but the prediction of long term mortality is not that good, since several patients survived up to one year even with high wall motion score index (greater than 2.2) or low ejection fraction (less than or equal to 35%) on admission. One-year survival is high up to 90 per cent in patients with low wall motion score index or high ejection fraction on admission.

Two-dimensional echocardiographic detection of in-hospital complications in acute myocardial infarction.

The two-dimensional echocardiogram is an ideal noninvasive method for evaluation of the global and regional wall function of left ventricle particularly the apical part in the early phase of acute myocardial infarction. Apical dysfunction, right ventricular infarction, left ventricular thrombi can be detected by 2D-Echo. It is especially useful in the identification of a high risk group of patients with acute myocardial infarction, as a guideline for attempting different therapeutic modalities in these patients.