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PubMed1996

Right atrial thrombi in children with cancer and indwelling catheters.

OBJECTIVE: To determine the prevalence of right atrial thrombi in children with cancer and indwelling catheters. STUDY DESIGN: We systematically examined 156 children with cancer and indwelling catheters for the presence of a right atrial thrombus when they underwent routine screening of cardiac function by two-dimensional echocardiography. RESULTS: Thirteen children (8.8%) had right atrial thrombi. Of the 13 children, 6 had thrombi adherent to the right atrial wall, and in 5 of these 6 children the clots were considered large enough to require intervention: 2 children with obstruction of venous or tricuspid valve inflow underwent right atriotomy and thrombus removal; they recovered and remained well. The other 3 children had moderate-sized thrombi and were treated with oral anticoagulants; their clots stabilized (2 children) or regressed (1 child). The remaining 7 children had thrombus on the tip of the catheter: 5 of these children were observed; the thrombi spontaneously resolved in 2 of them and did not change in size in the other 3. In the sixth child, the catheter malfunctioned 2 weeks after discovery of the clot and the catheter was removed. The seventh child was treated with warfarin and the clot decreased in size. Thrombi were detected in a greater proportion of children with catheter tips in the right atrium versus the superior vena cava, and in a greater proportion of children with acute lymphoblastic leukemia versus other diagnoses. There was no association between the presence of a clot and duration of time the catheter was in place, the number of catheters placed, treatment with asparaginase, or treatment with total parenteral nutrition. CONCLUSION: The incidence of right atrial thrombi in children with indwelling catheters may be higher than was previously appreciated.

Adolescent↗
PubMed1986

Radionuclide left ventricular function curve during atrial pacing in normal subjects and in patients with coronary artery disease.

We used radionuclide angiography during right atrial pacing to assess left ventricular function in 7 normal subjects and 20 patients with coronary artery disease. A left ventricular function curve relating stroke volume to end-diastolic volume was plotted for each patient. The normal pacing ventricular function curve was a straight line passing through the origin of axes. The pacing ventricular function curve was abnormal in 18 of the 20 patients with coronary artery disease, and three different shaped curves were obtained, reflecting decreased contractile force for the same end-diastolic volume during ischemia. Cardiac output and blood pressure do not change during atrial pacing, thus the Frank-Starling relationship is evaluated by this method during almost experimentally controlled conditions. Relating stroke volume to end-diastolic volume, and not end-diastolic pressure, distinguishes between overall left ventricular systolic function and left ventricular compliance.

Adult↗
PubMed2006

Chiari anomalies in the human right atrium.

Chiari anomalies in the human right atrium ostensibly are encountered rarely. There is only sporadic mention in the literature of these fenestrated, net-like valves of the inferior vena cava, coronary sinus, or various strands connecting these with other right atrial structures. The effects of such structural anomalies on heart function are unknown. We report here gross observations of the right atrial net from among 213 cadavers, 38 autopsied, and 11 fetal hearts. Histological and ultrastructural examination of inferior vena cava and coronary sinus valves demonstrated that only the anomalous coronary sinus valves contained cardiac muscle. Chiari anomalies typically have referred to perforations or tissue strands related to the inferior vena cava valve and possibly the coronary sinus valve. The anomaly commonly is cited as occurring in 2% of individuals, although there has been no study to support this. We observed Chiari malformations in 13.6% of the 213 cadaver hearts, and 10.5% of the autopsied hearts examined. Of these malformations, the coronary sinus valve was fenestrated most frequently. We propose the term "right atrial net" for "Chiari net," for anomalies involving valves of the inferior vena cava and coronary sinus, and strands within the right atrium connecting these valves with the crista terminalis, right atrial wall, or interatrial septum.

Adult↗
PubMed1976

Abolition of ischemic response to atrial pacing following aortocoronary bypass surgery.

To determine the effect of successful aortocoronary bypass surgery (ACBS) on left ventricular (LV) function, the ischemic response to right atrial pacing (RAP) was studied in 22 angina patients before and 3.8 +/- 1.1 months after surgery. All patients were free of angina after ACBS and had at least one patent graft. Before ACBS, RAP induced angina in 15 patients (Group 1) but not in 7 patients (Group 2). After ACBS, no patient had angina with RAP despite the increased maximum rate of pacing. Post-pacing LV end-diastolic pressure (LVEDP) after ACBS decreased in Group 1 from 25 +/- 6 to 15 +/- 6 mm Hg (P less than 0.01), but not in Group 2. Changes in ejection fraction, cardiac output, resting LVEDP, or LVEDP after LV angiography were not significant in either group and were therefore not useful in evaluating the result of ACBS. However the ischemic response to right atrial pacing was abolished by successful aortocoronary bypass surgery, suggesting improved myocardial perfusion during stress.

Angina Pectoris↗
PubMed1981

[Right ventricular function in patients with transposition of the great arteries after atrial inversion (Mustard procedure) (author's transl)].

Twenty-nine patients with transposition of the great arteries (TGA) and intact ventricular septum underwent hemodynamic and angiocardiographic investigation 18,8 +/- 5,8 months after inflow correction (Mustard). The mean age at operation was 14,6 +/- 7,5 months and in all, a good anatomical result was achieved. The hemodynamic parameters such as cardiac index, pressures in all heart chambers as well as in the venous channels and arterial vessels were found within normal limits. The end-diastolic volume of the right ventricle (RVEDV) was closely correlated to body surface area (r = 0,697). It increased, however, more rapidly than in children with normal hearts. Mean RVEDV/m2 was 86 +/- 8 ml which is 123 +/- 10% of the normal values for children (70 +/- 13 ml) according to Graham et al. The mean ejection fraction (EF) of the right ventricle (58 +/- 7%) was only slightly below the normal range (65 +/- 7%). Thus, a good hemodynamic function of the RV can be assumed at least for the early postoperative years after a Mustard operation. It remains open, however, if the more rapid increase of RVEDV/m2 expresses the RV adjustment to the afterload of the systemic circulation or if this should be interpreted as an early sign of RV functional impairment.

Angiocardiography↗
PubMed1993

Ebstein's anomaly: a long-term study of survival.

This study examines data regarding the survival of patients with Ebstein's malformation. Of 61 patients studied at the University of Minnesota, 31 are currently alive, with the average survival being 15 years. Several factors adversely affected survival: NYHA functional classification, hemoglobin level, right atrial pressure, symptoms during the neonatal period, and cardiac surgery. Data from a multi-institutional study collected during the past decade adds information regarding survival. Of 18,281 patients in the study, 71 (0.4%) had Ebstein's malformation. Sixteen of these were among 7235 infants, and of these seven died during the first year of life. In contrast, among 55 patients over the age of 1 year, four died, each after cardiac surgery. The data help our understanding of the course of patients with Ebstein's malformation and decisions regarding surgical treatment.

Adolescent↗
PubMed2005

Map-guided surgery for atrial fibrillation.

BACKGROUND: Although current surgical procedures result in a high success rate for atrial fibrillation, they are not guided by electrophysiologic findings in individual patients and thus might include unnecessary incisions in some patients or be inappropriate for other patients. We sought to determine whether intraoperative mapping is beneficial for the surgical treatment of atrial fibrillation. METHODS: A 256-channel 3-dimensional dynamic mapping system with custom-made epicardial patch electrodes was used to examine the atrial activation during atrial fibrillation and to determine the optimal procedure in 37 patients with continuous and 9 patients with intermittent atrial fibrillation intraoperatively. RESULTS: Surgical intervention for atrial fibrillation was not indicated in 3 patients in whom the atrial electrograms had a low voltage over a broad area. Concurrent, multiple, and repetitive activations arising from the pulmonary veins or left atrial appendage were observed in all patients. A simple left atrial procedure consisting of pulmonary vein isolation and left atrial incisions without any right atrial incisions was performed in 8 patients in whom the right atrial activation was passive, and all (100%) were cured of atrial fibrillation. The radial procedure was performed in the remaining 35 patients, and 31 (89%) of the patients were cured of atrial fibrillation. In this subset of patients, 10 exhibited reentrant or focal activation in the posterior left atrium between the right and left pulmonary veins and required an additional linear ablation on the posterior left atrium. The total amount of postoperative bleeding after the simple left atrial procedure was significantly less than after the radial procedure (378 +/- 135 vs 711 +/- 364 mL, P = .03). The right and left atrial transport functions were well preserved after both the radial and simple left atrial procedures. CONCLUSION: Intraoperative mapping facilitates determining the optimal procedure for atrial fibrillation in each patient.

Aged↗
PubMed1997

Right-sided cardiac tumors detected by transesophageal echocardiography and its usefulness in differentiating the benign from the malignant ones.

Eighteen patients (3 men and 15 women; mean age 63 years) with right-sided tumors were evaluated by both transthoracic and transesophageal echocardiography from 1989 to 1996. The indications for echocardiographic studies included evaluation for a presumed mass and further evaluation of ventricular function and valvular function. Fifteen patients had right atrial tumors. These included 5 hypernephromas, 4 myxomas, 2 angiosarcomas, 1 lipoma, 1 cavernous hemangioma, 1 hepatoma, and 1 chondrosarcoma. Three patients had right ventricular (RV) tumors: 1 metastatic olfactory neuroblastoma, a leiomyosarcoma, a chondrosarcoma, and a fourth patient had infiltration of the RV free wall of unknown etiology. Biopsy of either right atrial or RV masses was performed with transesophageal echocardiographic guidance in 2 patients, and allowed histologic diagnosis before surgical resection. These findings indicate that tumors are more often found in the right atrium than in the right ventricle, and females predominate. Most tumors arising within the right atrium are benign, whereas those extending into the right atrium from outside are malignant. RV tumors are rarely encountered; when present, they are likely to be malignant.

Adult↗
PubMed2001

Differential atrial stunning after electrical cardioversion: an echo tissue Doppler case study.

Left atrial stunning after cardioversion is a well-known phenomenon. It has been associated with higher risk of postcardioversion thromboemboli and increased risk of recurrence of atrial fibrillation. We present a case of differential atrial stunning after electrical cardioversion for atrial fibrillation. Diagnosis was made by pulsed wave Doppler of mitral, tricuspid, and pulmonary vein inflow and mitral and tricuspid annuli. Differential mechanical atrial stunning may be a common phenomenon after cardioversion and may suggest difference in right and left atrial transport function. Its prevalence needs to be determined by a large study. Doppler tissue imaging might be routinely used in patients after cardioversion for atrial fibrillation to detect atrial stunning.

Aged↗
PubMedDate not supplied

The Maze procedure for the treatment of atrial fibrillation: a minimally invasive approach.

OBJECTIVES: The standard Maze procedure has proven to be extremely effective in curing atrial fibrillation in thousands of patients worldwide. Until now it has required a median sternotomy and cardiopulmonary bypass. In order to simplify the standard approach, a minimally invasive technique was developed. We have recently applied this minimally invasive Maze procedure in 72 patients. METHODS: The technique is dependent on the use of cryosurgery and the total number of atriotomies has been decreased from twelve to four. In addition to performing the Maze procedure, 32% of patients have had concomitant surgery via the minimally invasive approach including mitral valve repair/replacement and tricuspid valve repair. RESULTS: Perioperative morbidity is improved following the minimally invasive approach in comparison to the standard approach with the incidence of temporary perioperative arrhythmias being decreased by 50%. The long-term recurrence of atrial fibrillation is 2.4% following the minimally invasive Maze procedure and 2.2% following the standard Maze procedure. The incidence of pacemaker requirements following the standard Maze procedure is 20% but only 6% following the minimally invasive Maze procedure. Both right atrial and left atrial transport function have been documented in 100% of patients following the minimally invasive Maze procedure. CONCLUSIONS: We believe that the minimally invasive Maze procedure is a substantial improvement over the standard approach in terms of patient morbidity while preserving the effectiveness of the Maze procedure in curing atrial fibrillation.

Adult↗
PubMed1985

The pericardial hypothesis: a mechanism of acute shifts of the left ventricular diastolic pressure-volume relation.

Changes in LV diastolic P-V relations may be caused by changes in myocardial distensibility and by changes in extraventricular constraint. Experimental studies suggest that the upward shift of the LV diastolic P-V relation associated with pacing tachycardia, in patients with angina pectoris, is due to decreased myocardial distensibility which possibly represents incomplete relaxation. However, shifts in the LV diastolic P-V relation with vasodilator and vasoconstrictor agents seem to be caused by changes in extraventricular constraint. Experimental and clinical data show that such interventions do not significantly change the LV transmural P-V relation. This supports the hypothesis that these shifts are due to changes in pericardial pressure. Our data suggest that such vasoactive agents act by shifting blood between the (splanchnic) venous compartment and the heart, thereby changing heart size and in turn pericardial pressure. These concepts have significantly improved our understanding of the mechanisms of action of vasoactive agents. It seemed a paradox that vasodilators (e.g., nitroglycerine) could substantially lower filling pressure of the failing left ventricle without reducing cardiac output. Because of the downward-shift in the P-V relation with nitroglycerine, preload is virtually unchanged and therefore stroke volume is maintained. Appreciation of these phenomena has considerable impact on how haemodynamic measurements are interpreted. It is obvious that the use of LV end-diastolic pressure as an index of end-diastolic volume may lead to serious misinterpretations of ventricular function. Our demonstration that right atrial pressure might be used to assess pericardial pressure provides a potentially useful way to estimate LV transmural pressure, and therefore an accurate measure of preload.

Animals↗
PubMed1997

[Maze procedure for chronic atrial fibrillation associated with mitral valve disease].

From May 1995 to October 1996, 20 patients with mitral valve disease underwent the maze procedure for chronic atrial fibrillation and mitral valve replacement or mitral valvuloplasty. Epicardial mapping data demonstrated that the large macrorecurre flutter circuit was located in left atrium (14/20) and complex fibrillation in right atrium (18/20) of the majority of patients. No early death occurred. 20 patients were followed up for at least 3 months (range 3-20 months) and 14 patients for at least 1 year after operation, sinus rhythm and atrioventricular synchrony were restored (100%), atrial fibrillation was not induced by electrophysiologic study. The right and left atrial transport function was preserved (100%) by Doppler echocardiogram tracings. One patient died from acute necrotic hepatitis, 4 and half months after operation. Cox maze procedure was modified, atrial flutter and atrial fibrillation never occurred. In this study, the electrophysiologic mechanism of chronic atrial fibrillation associated with mitral valve disease, indications of operation and clinical results are discussed.

Adult↗
PubMed2003

[Functional status of the circulatory system in during dynamics of treating arterial hypertension in patients with vibration disease].

AIM: To develop medicinal approaches to correction of hemodynamic disturbances in vibration disease (VD) associated with arterial hypertension. MATERIAL AND METHODS: The study compared hypotensive and hypodynamic efficiency of amlodipin, diltiazem, enalapril, perindopril and indapamide in 74 VD patients with arterial hypertension (SAP 140-179 mm Hg, DAP 90-109 mm Hg; mean age 54.8 years, mean exposure to vibration 26.8 years). Before and after the treatment course the patients were examined with ultrasound by the following parameters: left ventricular contractility, left and right ventricular diastolic function, left atrial function. RESULTS: Amlodipin reduced left ventricular volume both in systole and diastole as well as maximal intramyocardial tension without significant change in contractility, raised a contraction reserve of the left atrium, improved ventricular relaxation. Diltiazem potentiates contractility of the left ventricle and atrium without marked impact on relaxation and tension of the myocardium. Enalapril and perindopril cause positive hemodynamic shifts. Perindopril vs enalapril was more effective in easing intramyocardial systolic tension of the left ventricular wall and in improving the diastolic function. Indapamid vs calcium antagonists and ACE inhibitors had a weaker effect on arterial pressure, no significant effect on left ventricular contraction, peripheral hemodynamics. Left atrial function was hyperactive. This was observed also in response to the other drugs. CONCLUSION: Amlodipin produced in patients with VD and AH more positive hemodynamic effects, reduced isotonic hyperfunction of the left ventricle, improves diastolic function of the ventricles. Amlodipin and perindopril are more promising prognostically in relation to reduction of left ventricular myocardial mass.

Antihypertensive Agents↗
PubMed2004

[Clinical features and diagnostic evaluation of heart failure in the elderly].

The diagnosis of heart failure in the elderly frequently represents a clinical challenge. Atypical symptoms and signs and confounding comorbid conditions are common situations in old patients with heart failure and may obscure the clinical picture, complicating the diagnostic evaluation. Furthermore in the elderly, especially in female gender with a long-lasting history of hypertension, heart failure commonly may ensue as a consequence of a predominating impairment of the diastolic function with normal or near-normal preserved systolic function. Echocardiography represents the gold standard for the confirmation of the clinical suspicion of heart failure and may provide detailed information about left and right ventricular dimensions and function, atrial dimensions, valvular function and pericardium. For this reason it is recommended as part of initial diagnostic evaluation in almost all cases of heart failure. However, the low diagnostic accuracy of the clinical picture in elderly patients with suspected heart failure, as suggested by the international guidelines, requires the corroboration of the clinical suspicion with the help of "first-line" traditional investigations like ECG and chest X-ray. Recently natriuretic peptides (B-type natriuretic peptide [BNP] and NT-proBNP) have emerged as an attracting "tool" to support the clinical signs in patients with suspected heart failure. In this review we discuss about the opportunity that BNP and NT-proBNP would be relevant in the diagnostic process of elderly patients with suspected heart failure.

Aged↗
PubMed2002

Atrial mechanical performance after internal and external cardioversion of atrial fibrillation: an echocardiographic study.

OBJECTIVES: To compare the time course of resumption of mechanical performance of the left and right atrium after the novel method of internal low-energy cardioversion (CV) and conventional external CV of atrial fibrillation (AF). BACKGROUND: Right atrial performance has been shown to normalize before the left atrium after external CV. However, no data on atrial function after internal CV are available. PATIENTS AND INTERVENTIONS: Sixty-three patients with chronic AF were randomized to participate in either external or internal CV. MEASUREMENTS: Echocardiographic examinations were carried out before as well as immediately after CV (day 0), and at days 1, 7, and 28 thereafter for the determination of cardiac dimensions, volumes, and transvalvular flow patterns. RESULTS: After randomized internal CV or external CV, stable sinus rhythm was restored in 59 patients. Irrespective of the mode of CV, the right atrium resumed its mechanical function immediately after CV, whereas the left atrium was stunned beyond day 7. The mode of CV, internal or external, had no influence on the recovery of atrial mechanical function. CONCLUSIONS: The right atrium resumes its normal function immediately after internal as well as external CV, whereas left atrium function is delayed. In contrast to the assumption that low-energy internal CV would impact less on atrial mechanical recovery, the type of method of CV used has no effect on such recovery.

Aged↗
PubMed1992

Pleuroperitoneal shunts for refractory chylothorax after operation for congenital heart disease.

Between 1980 and 1990, 10 of 12 children with a symptomatic chylothorax after operation for congenital heart disease failed to respond to traditional medical therapy (thoracentesis, tube thoracostomy, low-fat diet). All 10 patients underwent placement of a pleuroperitoneal shunt, with complete resolution of the chylothorax in 9 patients (90%). Cardiac catheterization, performed before placement of the pleuroperitoneal shunt in 5 patients, demonstrated elevated right atrial pressure in all patients (range, 10 to 25 mm Hg). The pleuroperitoneal shunt functioned effectively in 4 patients with moderately elevated right atrial pressures (range, 10 to 16 mm Hg; median, 13.5 mm Hg) but not in 1 patient with a right atrial pressure of 25 mm Hg. Pleuroperitoneal shunting as treatment for chylothorax after operation for congenital heart disease is safe and effective, even in the face of moderate elevations in right atrial pressure.

Chylothorax↗