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PubMed1977

Cardiac size and function in acromegaly.

Sixteen acromegalic patients underwent echocardiography, phonocardiography, stress electrocardiography with Thallium perfusion scanning and gated radioisotope left ventricular angiocardiograms. Abnormalities consisting of increased echo left ventricular mass index, low velocity of circumferential fiber shortening or elevated pre-ejection period to left ventricular ejection time ratio were found in six patients with coexistent hypertension or coronary disease. Concentric left ventricular hypertrophy was also found in three patients with no known etiology other than acromegaly of greater than thirteen years' duration or with fasting growth hormone concentrations greater than 100 ng/ml. One of these three also had left ventricular dysfunction. Neither hypertrophy nor ventricular dysfunction was found in other acromegalics with shorter duration of disease or lower growth hormone concentrations or with normal growth hormone concentrations after therapy. A high prevalence of coronary artery and hypertensive heart disease is associated with acromegaly. A few patients with acromegaly have a specific, potentially reversible cardiomyopathy probably related to prolonged acromegaly or very high growth hormone concentrations.

Acromegaly↗

PubMed1976

Effects of varying pacemaker sites on left ventricular performance.

The hemodynamic effects of the site of the artificial cardiac stimulation were studied in 17 open chest dogs. The right atrium and five ventricular sites (the inflow and outflow tracts and apex of the right ventricle, apex and lateral wall of the left ventricle) were stimulated electronically at a given rate, ranging from 130 to 190 per min. When cardiac performance during ventricular pacing was compared with those during right atrial pacing, the former uniformly caused a diminution of cardiac output and systemic blood pressure, without reduction of left ventricular end-diastolic pressure. Ventricular function curves, in which left ventricular stroke work was related to left ventricular end-diastolic pressure, shifted downwards and to the right during ventricular pacing. Stimulation frequency did not alter these variables. It was considered that the left ventricular dysfunction in ventricular pacing resulted from the absence of atrial contribution to ventricular filling, mitral regurgitation present and asynchronous ventricular contraction. No significant difference of cardiac performance was demonstrated by changing the site of ventricular pacing, suggesting that the mode of ventricular depolarization itself was not relevant to a decrease in cardiac performance.

Animals↗

PubMed1979

Noninvasive screening criteria for enhanced 4-year survival after aortocoronary bypass surgery.

Two thousand one men with coronary heart disease (CHD) who were enrolled in the Exercise Testing Registry of the Seattle Heart Watch had symptom-limited maximal exercise tests at the initial clinical examination and follow-up surveillance of subsequent mortality for 4.1 +/- 1.6 years. When subdivided into three mutually exclusive subgroups, 636 patients did not have exertional myocardial ischemia, left ventricular dysfunction or cardiomegaly; 885 without cardiomegaly had only exertional ischemia; 480 had left ventricular dysfunction by either cardiomegaly and/or two noninvasive exertional criteria, with or without exertional myocardial ischemia. Three hundred thirty-one men had aortocoronary bypass surgery, while 1670 remained unopened for at least 4 years. Only 34% of the operated patients who had left ventricular dysfunction, as defined, showed a marked improvement in 4-year survival rates (p less than 0.01). Differences in the annual CHD mortality rates in relation to surgical treatment in the other two groups were not statistically significant. Restricting the analysis to a subset of patients who had invasive studies did not alter the conclusion. Accordingly, we suggest the use of noninvasive criteria to aid preliminary screening of patients for invasive studies and surgical treatment.

Adult↗

PubMed1976

Serial measurements of left ventricular ejection fraction by radionuclide angiography early and late after myocardial infarction.

The left ventricular ejection fraction was determined serially with radioisotope angiography in 63 patients with acute myocardial infarction. After the peripheral injection of a bolus of technetium-99m, precordial radioactivity was recorded with a gamma scintillation camera and the ejection fraction calculated from the high frequency left ventricular time-activity curve. Since this technique requires no assumptions with respect to left ventricular geometry, it is particularly useful in patients with segmental left ventricular dysfunction. Serial measurements during the first 5 days after hospital admission were made in 50 patients, 30 of whom were studied during the subsequent 2 to 39 months (mean 19.9 months). Late follow-up serial studies were also performed in an additional 13 patients who had only one measurement of the left ventricular ejection fraction during the early postinfarction period. Early after infarction, the left ventricular ejection fraction was normal (more than 0.52) in only 15 of the 63 patients, and averaged 0.52 +/- 0.05 (standard deviation) in the 27 patients with an uncomplicated infarct. The ejection fraction was reduced in 24 patients with mild to moderate left ventricular failure (0.40 +/- 0.05, P less than 0.0001) and in the 12 patients with overt pulmonary edema (0.33 +/- 0.07, P less than 0.0001). In 35 patients the ejection fraction correlated with the mean pulmonary arterial wedge pressure (r = 0.72). In 15 patients with normal left ventricular wall motion by heart motion videotracking, the ejection fraction was significantly higher (0.53 +/- 0.08) than in the 26 patients with regional left ventricular dysfunction (0.41 +/- 0.10, P less than 0.0001). During the early postinfarction period, the left ventricular ejection fraction improved in 55 percent of patients and remained unchanged or decreased in 45 percent. A further increase in the ejection fraction was noted in 61 percent of patients during the late follow-up period. Patients with an initially low or decreasing ejection fraction had a significantly greater incidence of early mortality and left ventricular dysfunction (P less than 0.02) than those whose ejection fraction was normal or improved to normal early after infarction. These data indicate that the ejection fraction is a sensitive indicator of left ventricular function after acute myocardial infarction and that serial measurements are helpful in predicting early mortality and morbidity.

Acute Disease↗

PubMed1977

Noninvasive assessment of left ventricular performance in patients with chronic obstructive pulmonary disease.

In patients with chronic obstructive pulmonary disease (COPD), the clinical differentiation between dyspnea due to left ventricular dysfunction and that due to pulmonary events is difficult. Invasive techniques have been the only reliable diagnostic approach. To assess the potential value of noninvasive techniques in this context, 27 patients with COPD and with clinically suspected left ventricular dysfunction were studied by echocardiography, radionuclide angiography, and right cardiac catheterization. In 20 (74%), adequate echocardiogram were obtained. Of these 20 patients, 17 had normal pulmonary arterial wedge pressures at rest and during submaximal handgrip exercise. Sixteen of these 17 had normal left ventricular performance by all three echocardiographic criteria used; in one patient, two criteria were not interpretable, but the third was normal. Results of radionuclide studies were normal in 15 patients, borderline in one, and not measurable in one. Of the three patients with abnormal wedge pressures, at least one echocardiographic criterion was abnormal in all. Radionuclide data were abnormal in two and not measurable in one. We conclude that left ventricular dysfunction is infrequently present in patients with COPD in whom such dysfunction is clinically suspected, that the two noninvasive techniques described here can be applied successfully to a high percentage of patients with COPD, and that the agreement among echocardiographic, radionuclide, and wedge pressure data is excellent.

Aged↗

PubMed2026

Cine-derived mitral annular relaxation velocity for detection of preclinical left ventricular diastolic dysfunction.

OBJECTIVES: Imaging diastolic dysfunction in pre-clinical heart failure (HF) is challenging. We evaluated a novel cardiac MRI (CMR) biomarker, CMR e-prime (CMR-MARV), in patients at risk of HF. METHODS: In this substudy of the PARABLE trial (NCT04687111), 236 patients (71.6 ± 7.7 years, 61.6% male) fulfilling trial-defined ALVDD citeria underwent CMR with measurement of mitral annular relaxation velocity (CMR-MARV) at four mitral annular anchor points. Diastolic strain rates from FT were also assessed. Twenty-five age- and sex-matched controls were included (73.8 ± 3.1 years, 52% male). Group differences were tested with t-tests, diagnostic accuracy with ROC analysis, and predictors of diastolic dysfunction with adjusted logistic regression. RESULTS: Compared with controls, patients had significantly higher indexed maximal left atrial volume (LAVimax), LV end-diastolic and end-systolic volumes, and LV mass (all p < 0.001). Of FT variables, only peak diastolic longitudinal velocity differed between groups (p < 0.001). In multivariate models, CMR-MARV correlated with radial, circumferential, and longitudinal diastolic strain rates, radial and longitudinal diastolic velocities (all p < 0.001), echocardiographic e' (r = 0.20, p = 0.007), LV mass (r = -0.18, p = 0.008), LAVimax (r = -0.18, p = 0.008), and NT-proBNP (r = -0.30, p < 0.0001). LAVimax and CMR-MARV were strongly independently associated with ALVDD (AUC 0.89 and 0.76, respectively; p < 0.0001). A combined model (LAVimax + CMR-MARV) achieved excellent discrimination (AUC 0.91, 95% CI 0.86-0.97, p < 0.0001). Independent predictors included LAVimax, CMR-MARV, and peak diastolic longitudinal velocity (all p < 0.001). CONCLUSION: CMR-MARV provides a simple cine-derived measure of longitudinal relaxation that correlates with established structural and biochemical markers of diastolic burden. Within an at-risk population, it offers incremental functional information beyond conventional parameters and may support multiparametric CMR phenotyping of preclinical diastolic dysfunction.

Aged↗

PubMedDate not supplied

[Hospital mortality of acute myocardial infarct].

Hospital mortality was studied in 541 consecutive patients with acute myocardial infarction (AMI) admitted during a three year period to the Coronary Care Unit (CCU) of the Instituto Nacional de Cardiología de México. Total mortality was 15.3%. Two thirds of the deaths occurred in the CCU. In the remaining fatal cases, the patients had been transferred to regular hospital wards at the time of their death. The largest number of deaths (68.7%) were due to pump failure. A smaller number of patients (14.5%) died as a result of cardiac ruptures. Deaths due to primary arrhythmias have practically disappeared at the CCU's. Hospital mortality due to AMI correlates well with the degree of left ventricular dysfunction. In the cardiogenic shock group and in the acute pulmonary edema group mortality was 93.4 and 50.0% respectively. Patients with moderate degrees of heart failure had a lower mortality rate (18.4%) while in those who did not develop clinical or radiological evidence of left ventricle failure mortality was minimal. In patients with AMI there is a direct relationship between the mass of destroyed myocardium and the degree of left ventricular dysfunction. Thus, mortality is greater in patients with previous infarction, with important enzyme elevation, intraventricular conduction defects, larger cardiac size, etc. Four fifths of the cases studied at post-mortem had a left ventricular mass destruction of at least 40% and most of the cases had significant atheromatous lesions of two or of all three coronary vessels. Further reduction in mortality due to AMI would require an early and effective treatment of the syndromes of left ventricular dysfunction.

Adolescent↗

PubMed1977

Familial atrial tachyarrhythmia with short PR interval.

A family had an unusual and perhaps unique familial dysrhythmia. The proband had a short PR interval with normal QRS and chronic recurrent paroxysmal atrial tachycardia (Lown-Ganong-Levine syndrome). The arrhythmia produced left ventricular dysfunction. Both paroxysmal atrial tachycardia (PAT) and left ventricular dysfunction were reversed with administration of digoxin and propranolol hydrochloride. Three family members had paroxysmal or chronic atrial fibrillation, first diagnosed at a relatively young age (23 years, 38 years, and early 40s, respectively). Five additional family members had short PR intervals with normal QRS, and eight other family members had borderline short PR intervals. The mode of inheritance appeared to be autosomal dominant with varying expressivity. We have described a familial syndrome characterized by PAT or atrial fibrillation in its advanced form with short PR interval as a possible identifying trait. The future course of members with isolated short PR is unknown.

Adult↗

PubMed1976

Clinical and hemodynamic criteria for use of the intra-aortic balloon pump in patients requiring cardiac surgery.

In order to establish criteria for elective use of the intra-aortic balloon pump (IABP) in patients having cardiac surgery, we conducted a retrospective study of 43 patients who required counterpulsation, because of inability to be weaned from cardiopulmonary bypass, between May, 1972, and June, 1974. Patients in cardiogenic shock preoperatively were excluded. The 43 patients included 23 (Group A) who had severe preoperative left ventricular dysfunction with a mean cardiac index less than 1.8 L. per minute per square meter, ejection fraction less than 30 per cent, and end-diastolic pressure greater than 22 mm. Hg; 20 patients (Group B) had a combination of moderate cardiac dysfunction (cardiac index less than 2.2, ejection fraction less than 40, end-diastolic pressure less than 18) in the presence of acute infarction or severe aortic stenosis (gradient greater than 80 mm. Hg) with or without coronary disease. An inverse relationship was noted between survival and delay from completion of operation to the use of 1ABP. Thirty-two of 43 patients were weaned off bypass and were balloon assisted for 12 to 96 hours postoperatively; 25 patients were discharged (58 per cent). In Subgroup A, 14 of 23 (60 per cent) and, in Subgroup B, 9 of 20 (45 per cent) were long-term survivors. Based on these findings, 45 patients were operated upon between June, 1974, and December, 1975, with elective use of 1ABP and were assessed by serial hemodynamic studies. Sixteen had severe preoperative left ventricular dysfunction similar to Subgroup A and 29 had moderate dysfunction in combination with pathology similar to Subgroup B. Fifteen of these patients were hemodynamically unstable at time of arrival in the operating room; 1ABP was inserted under local anesthesia. Thirty-nine patients (87 per cent) were weaned off bypass and were hospital survivors. In Subgroup A, 13 of 16 (81 per cent) and, in Group B, 21 of 29 (72 per cent) were long-term survivors. Criteria for elective use of 1ABP in cardiac surgery should include severe preoperative left ventricular dysfunction or a combination of moderate dysfunction with coronary or valvular pathology. Elective 1ABP improves the survival with trivial iatrogenic morbidity.

Assisted Circulation↗

PubMed1978

Sequential radionuclide assessment of left and right ventricular performance after acute transmural myocardial infarction.

Ventricular performance was evaluated sequentially in 31 patients with uncomplicated acute transmural myocardial infarction (13 anterior and 18 inferior). Left ventricular ejection fraction, ejection rate, regional wall motion, and right ventricular ejection fraction were ascertained using first-pass radionuclide angiocardiography on four occasions during hospitalization. Inferior infarction resulted in a greater reduction in right ventricular ejection fraction than anterior infarction (mean +/- SEM; 48 +/- 2 versus 56 +/- 2%, P less than 0.01). In contrast, in anterior infarction there was greater depression of left ventricular ejection fraction than in inferior infarction (34 +/- 3 versus 50 +/- 3%, P less than 0.01). From initial to discharge studies, there was no significant change in global performance or regional wall motion in either group. These data show that the location of transmural infarction has a profound effect upon the magnitude of right and left ventricular dysfunction. In addition, ventricular systolic performance remains relatively stable during the hospital phase of uncomplicated transmural myocardial infarction.

Acute Disease↗

PubMed1979

[Short- and mean results of mitral and aortic valve replacement with a Björk-Shiley disc prosthesis. Thromboembolic and hemorrhagic complications].

96 patients with a Björk aortic valve and 112 patients with a Björk mitral valve were followed up for four and a half years and five years after operation respectively. The actuarial survival rate was 82.5% in the aortic and 73% in the mitral patients. Late death was observed in 7.3% of mitral patients with thromboembolic complications and 4.2% of mitral patients with left ventricular dysfunction, compared to 2.6% of aortic patients with thromboembolism and 3.6% with left ventricular dysfunction. The incidence of thrombolic complications was three times as great with the prosthesis in the mitral position. The probability of absence of thromboembolic complications, studied by actuarial methods, was 93% at 4 1/2 years in aortic prostheses compared to 82% at 5 years in the mitral prostheses. 12 haemorrhagic complications (5.7%), with one fatality, were observed. Aortic valve replacement with a Björk prosthesis is a very satisfactory operation and the results compare favourably with other prostheses. However, the risk of thromboembolic complications should be seriously considered in the surgical indications when this prosthesis is to be used for mitral valve replacement.

Adolescent↗

PubMed1978

[Exercise haemodynamics and ECG in the evaluation of the severity of coronary heart disease (author's transl)].

Myocardial scarring and coronary insufficiency give rise to regional changes in left ventricular function, often leading to generalized left ventricular dysfunction during physical activity only. The main purpose of this study was to evaluate the relations between left ventricular function determined by ECG and measurements of pulmonary artery pressure during exercise and the severity of coronary artery disease. Simultaneous measurements in the pulmonary artery and in the left ventricle in 76 patients revealed that the enddiastolic pulmonary pressure (PAEDP) was lower than the enddiastolic pressure in the left ventricle (LVEDP) by a mean value of 10.5 mm Hg in the presence of ventricular dysfunction. This difference was smaller in congestive heart failure than in cases of acute myocardial ischaemia. Correlation coefficients of mean pulmonary wedge pressure (PCm), PAEDP, mean pulmonary pressure (PAPm), and LVEDP were 0.90, 0.86, and 0.81, respectively, thus allowing only an approximate estimate of the left ventricular filling pressure. In 150 angiographically documented cases of coronary heart disease, haemodynamic measurements were performed during stepwise-increased, symptom-limited supine exercise on a bicycle ergometer. All patients limited at 25 watts had either triple vessel disease or stenosis of the trunk of the left coronary artery or of the proximal section of the left anterior descending artery (RIVA). In comparison with subjects with single vessel disease, patients with triple vessel involvement tolerated only a smaller exercise load and reached higher values of PAEDP (30.4 +/- 9.0 versus 24.0 +/- 7.7 mm Hg, p less than 0.001). Analysis of data of patients with a single coronary stenosis showed the exercise-PAEDP to be largely independent of the myocardial condition, but to depend upon the location of the stenosis, the highest pressure values being observed with stenoses of the main left coronary artery or the proximal segment of the RIVA. Based on these findings a simple coronary score system was delineated to determine the severity of the disease, taking into account the location of an obstruction, in particular, and, to a lesser amount, the degree of the stenosis and the type of coronary artery distribution. The score yielded essentially better correlations to work load and filling pressures during exercise than did the number of obstructed vessels. The regression line of the PAEDP versus the coronary score was flatter in patients with angiographically documented collaterals than in cases without, indicating the functional significance of these vessels. In patients with stenoses confined to the arteries supplying infarcted areas and, consequently, without signs of ischaemia during exercise a close relation was obtained between the left ventricular ejection fraction (EF) and the maximum PAEDP, best expressed by a third order regression equation (r = 0.79), p less than 0.001, SEE +/- 6.1). A PAEDP exceeding 25 mm Hg is, thus, a reliable sign of an EF of less than 40%...

Blood Pressure↗

PubMed1977

Postexercise systolic time intervals in the midsystolic click syndrome.

Postexercise systolic time intervals (STI) were measured in ten patients (PMV group) with auscultatory evidence of the midsystolic click syndrome (i.e. one or more systolic nonejection clicks alone or in association with the late systolic murmur), and compared to eight age-matched volunteers (control group) with no evidence of heart disease. Following measurement of supine STIs, the subjects pedalled an upright bicycle ergometer at progressive work loads until a target heart rate (HR) representing 85% of the age-adjusted maximum was attained, or an abnormal end point was noted. Immediately postexercise, a repeat measurement of STIs, was obtained. A shortened or unchanged postexercise left ventricular ejection time corrected for HR (deltaLVETc) and a marked shortening of total electromechanical systole after exercise (deltaQS2c) constituted a normal STI response to stress testing and was noted in all control subjects. All of the PMV group exhibited evidence of left ventricular dysfunction characterized by a prolonged deltaLVETc. It is concluded that an abnormal STI response to exercise consistent with left ventricular dysfunction can be demonstrated in patients with prolapse of the mitral valve by the response of the STI.

Adolescent↗

PubMed1979

[Non-invasive effects of cigarette smoking on left ventricular function at rest and with exercise in normal individuals (author's transl)].

The effect of cigarette smoking on systolic time intervals at rest, with volume overload and with dynamic exercise was studied in nine healthy cigarette smokers. For heart rate, PEP, LVET and blood pressure, reactions to smoking demonstrated considerable interindividual variations with comparable work loads and volume loads. More than half of the subjects developed significant left ventricular dysfunction by these parameters after smoking ten cigarettes. The negative inotropic effect was felt to be caused in these subjects by carbon monoxide. The remaining subjects did not show left ventricular dysfunction with smoking. In these subjects the stimulating effect of nicotine on the nervous system was covering the negative inotropic effect of carboxy hemoglobin.

Adult↗

PubMed1978

Clinical spectrum of anthracycline antibiotic cardiotoxicity.

Anthracycline derivatives may produce early or late cardiotoxic reactions in man. Early effects include: (a) pericarditis-myocarditis which can affect patients with no previous history of cardiac disease and which carries a high mortality rate ( approximately 20%); (b) left ventricular dysfunction which may lead to clinically significant heart failure in patients with limited cardiac reserve; and (c) arrhythmias, the most common of which is sinus tachycardia. Symptomatic supraventriclar tachycardia, heart block, and ventricular arrhythmias can occur, however, and may reflect primary effects on cardiac muscle or the conduction system. Late effects of anthracyclines are directly related to the degree of associated myocyte damage and include subclinical left ventricular dysfunction and overt heart failure. The implications for prognosis and further treatment are discussed for each of these entities and a common pathogenetic mechanism is proposed.

Adolescent↗

PubMed1978

The hemodynamic effects of intravenous tocainide in patients with heart disease.

In order to evaluate its hemodynamic actions, tocainide, a new orally effective antiarrhythmic drug, was given intravenously over a 15 minute period to 12 patients with compensated left ventricular dysfunction. Doses were 0.5 (4 patients) or 0.75 (8 patients) mg/kg/min. Hemodynamics and drug plasma concentrations were measured at the end and 15 minutes after the end of the infusion. Tocainide infusion produced small but statistically significant increases in the pulmonary and systemic vascular resistance, aortic and pulmonary arterial pressure, and left and right ventricular end-diastolic pressure. There was no significant change in left ventricular dp/dt, heart rate, or cardiac index. In patients with compensated left ventricular dysfunction, tocainide produces a small rise in vascular resistance and arterial pressure. Overall cardiac function is maintained with a small increase in left ventricular end-diastolic pressure.

Adult↗

PubMed1979

[Pulmonary stenosis with intact ventricular septum. Surgical experience in 200 cases, excluding the neonatal period].

Experience over 10 years, studying two groups of patients (group I: 79 cases aged between 2 months and 2 years, group II: 151 cases aged over 2 years) has shown that the operative prognosis of severe forms is now the same as in simple forms. Interest is now focused on the long term function of the right ventricle with regard to the surgical procedure. The main discussion in management is between isolated pulmonary commissurotomy, whatever the anatomical form, and operations such as we perform which associate ventricular resection with or without an infundibular patch in severe cases. The possible causes of late ventricular dysfunction are discussed, especially the muscular resection, the operative myocardial protection and the preoperative myocardial sclerosis. The good results observed in this series as opposed to the doubt as to the cause and variability of late ventricular dysfunction do not justify a change in our management at present.

Adolescent↗

PubMed1976

Mitral valve prolapse.

Mitral valve prolapse is a condition that is being recognized with increased frequency. It is not known whether its incidence is increasing, or whether we are better able to diagnose it today. In the idiopathic or familial variety, the mitral valve pathology is almost always that of myxomatous degeneration. Some authors have suggested the presence of a cardiomyopathy because of significant left ventricular dysfunction in many cases. Idiopathic prolapse occurs predominantly in females, often at a young age, and may be associated with chest pain, dyspnea, fatigue, presyncope, syncope, and/or sudden death. The clinical findings are variable and typically consist of a nonejection click and/or late systolic murmur, heard best at the cardiac apex. Diagnosis can be confirmed by echocardiography and/or ventricular cineangiography, the latter permitting accurate recognition of the anatomy of the prolapsed leaflets. The complications of infective endocarditis, severe mitral insufficiency, and life-threatening ventricular arrhythmias represent the major problems of management. It is important to distinguish the idiopathic form of mitral valve prolapse from that due to coronary artery disease and to realize that mitral valve prolapse may occur in Marfan's syndrome, Turner's syndrome, or in association with secundum atrial septal defect or ruptured chordae tendineae. Typical clicks and/or murmurs have also been described in patients with a history of rheumatic fever and in hypertrophic cardiomyopathy. Although much descriptive knowledge has accumulated over the past 15 years, many unanswered questions remain regarding the idiopathic type of prolapse. What is the nature and cause(s) of myxomatous degeneration? What is the relation of the valve pathology to the left ventricular dysfunction? What is the relation of both of these factors to disabling chest pain, electrocardiographic changes, and life-threatening arrhythmias? Hopefully, answers to these and other important questions regarding mitral valve prolapse will be forthcoming.

Electrocardiography↗