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Intraluminal pulsed Doppler evaluation of the pulmonary artery velocity time curve in a canine model of acute pulmonary hypertension.

The velocity pattern of the blood flow in the pulmonary artery was investigated in an animal model of acute pulmonary hypertension. Nine anesthetized, open-chest dogs were embolized with polystyrene microspheres, and the velocity pattern of the blood flow in the pulmonary artery was studied with use of an invasive pulsed Doppler technique. Phasic intraluminal velocity was recorded with use of a miniature piezoelectric crystal activated by 20-MHz Doppler pulses and mounted on the tip of a needle probe introduced into the pulmonary artery. The recorded Doppler quadrature signals were processed by spectral analysis. Significant increases occurred in mean, systolic, and diastolic pulmonary arterial pressures (p less than 0.0002), in pulmonary vascular resistance (p less than 0.005), and in negative velocity time (duration in milliseconds that the mean velocity was directed toward the pulmonic valve) (p less than 0.002). Significant decreases occurred in right ventricular ejection time (p less than 0.006) and in positive velocity time (duration in milliseconds that the mean velocity was directed away from the pulmonic valve) (p less than 0.005). A significant shortening in the time to peak velocity (acceleration time) was found (p less than 0.005). Second-order regression analyses demonstrated an inverse correlation between the ratio of positive velocity time to negative velocity time and the mean pulmonary artery pressure in all animals (r = 0.71). These findings should be compared with the velocity patterns of the blood flow in the pulmonary artery obtained under pulmonary hypertensive conditions due to various causes to facilitate interpretation and understanding of clinical investigations.

Animals↗

Adenosine is a selective pulmonary vasodilator in cardiac surgical patients.

OBJECTIVE: The purpose of this study was to examine and compare the systemic and pulmonary hemodynamic effects of a central venous infusion of adenosine in cardiac surgical patients. DESIGN: Prospective; each subject served as his/her own control. SETTING: University Hospital and Veteran's Affairs Medical Center. PATIENTS: Ten cardiac surgical patients (age 56 +/- 6 years) were studied in the operating room under general anesthesia after weaning from cardiopulmonary bypass. Pulmonary vascular resistance (PVR), systemic vascular resistance (SVR), mean pulmonary arterial pressure (MPAP), and mean systemic arterial pressure (MAP) were determined before, during, and after central venous infusion of adenosine (50 micrograms/kg/min) for 15 min. Statistical analysis was by analysis of variance; significance was accepted at p < 0.05. RESULTS: Adenosine produced selective vasodilation of the pulmonary vascular bed: both PVR and MPAP were significantly reduced during adenosine infusion without changes in either SVR or MAP. PVR and MPAP returned to preinfusion levels after cessation of the infusion. Adenosine effectively reduced PVR and pulmonary arterial pressure without decreasing SVR or systemic arterial pressure. CONCLUSIONS: Adenosine may be used clinically as a selective pulmonary vasodilator to optimize pulmonary hemodynamics without adverse systemic hemodynamic effects in cardiac surgical patients. It may be particularly valuable in patients with right heart dysfunction by selectively lowering right ventricular afterload.

Adenosine↗

[Spontaneous reversion to sinus rhythm in a case of lone atrial fibrillation of fifteen years duration].

A 69-year-old male visited our clinic in 1973 because of atrial fibrillation noted during an annual check-up for the aged. Blood pressure, heart rate and CTR in chest X-ray films showed 110/80 mmHg, 150/min and 55%, respectively. There were no signs of valvular heart diseases, and a diagnosis of lone atrial fibrillation was convincing. Since then, repeated ECGs recorded twice or more a year had shown atrial fibrillation until 1988, when sinus rhythm with both first degree AV block and low P-wave amplitude appeared. The motion pattern of the anterior mitral leaflet on M mode echocardiography was abnormal with almost complete disappearance of the A-wave, whereas the motion pattern of the tricuspid valve was normal.

Aged↗

[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↗

Transesophageal echocardiography in atrial fibrillation. A new paradigm.

Transesophageal echocardiography (TEE) has contributed to our understanding of the patho-physiology of the thromboembolic sequelae of atrial fibrillation. This imaging modality has demonstrated thrombus formation within the left atrial appendage, as well as allowing for assessment of dynamic indices of left atrial appendage function. Studies using TEE have introduced the concept of post conversion "stunning", suggesting an increased milieu for thrombus formation after restoration of sinus rhythm. The detailed assessment of the atrium allowed for by TEE gave rise to the concept of TEE guided cardioversion, bypassing the traditional practice of prolonged anticoagulation prior to cardioversion. The only randomized trial of this practice, the multicenter ACUTE trial, has demonstrated that this strategy is a safe one with less bleeding, and appears to be a strong alternative to the conventional approach. There is some suggestion that TEE may play a role in further risk stratification of patients with chronic atrial fibrillation, but more data is needed on this potential utility of TEE. Treatment strategies for atrial fibrillation are continuing to evolve, and TEE has played a role and will likely continue to play a role in this development.

Atrial Fibrillation↗

Factors predicting recurrence of atrial fibrillation after cardioversion.

BACKGROUND: Factors predicting the maintenance of sinus rhythm (SR) after cardioversion of atrial fibrillation (AF) have not been well defined. Little is known about the impact of the recovery of the left atrial mechanical function (RLAMF) on AF recurrences. AIM: To identify the clinical and echocardiographic predictors of AF recurrences after cardioversion. METHODS: Of 112 consecutive patients (39 females, 73 males, mean age 62.1+/-10.6 years) with AF who underwent successful electrical or pharmacological cardioversion, 50 maintained SR during 6 month follow-up whereas the remaining 62 had a recurrence of AF. Clinical examination and 2D Doppler echocardiography were performed. From the Doppler mitral flow, RLAMF was evaluated 1, 7, and 21 days after cardioversion. RESULTS: Patients with or without AF recurrence did not differ with respect to age, gender, aetiology, duration of AF, LA size and ejection fraction. In the univariate analysis the lack of RLAMF detected 1 day after cardioversion (relative risk - RR=1.15, p<0.01), functional NYHA class II or III (RR=1.86, p<0.005) and a history of AF episodes (RR=2.02, p</=0.0005) were identified as the predictors of a recurrence of AF. In the multivariate analysis using Cox proportional hazard model the latter two factors remained the independent predictors of AF recurrences during a six-month follow-up period. The Kaplan-Meier analysis showed that out of all analysed risk factors, the most significant were functional NYHA class, history of AF and lack of RLAMF one day after cardioversion. CONCLUSIONS: A history of AF, functional NYHA class II or III, and the lack of RLAMF were the independent predictors of a recurrence of AF. The presence of more than one risk factor strongly identified those who failed to maintain SR during six-month follow-up.

Journal Article↗

Esophageal and gastric pressure measurements.

The measurement of esophageal and gastric pressures with balloon-tipped catheters has been used with great success over the past half century to delineate the physiology of the mechanical respiratory system. Pleural pressure and abdominal pressure values estimated from esophageal and gastric pressure measurements allow analysis of lung and chest wall compliance, as well as work of breathing, respiratory muscle function, and the presence of diaphragm paralysis. Although much of the use of these measurement techniques has been in the clinical laboratory, to improve the understanding of basic physiologic mechanisms, the techniques have also been used in clinical situations to diagnose diaphragm paralysis, assess the work of breathing during mechanical ventilation, and estimate pulmonary compliance. In this article I review the historical background, physiology, placement techniques, and potential clinical applications of esophageal and gastric pressure measurements. In addition, I will briefly review the measurement of bladder pressure, which is a related topic.

Atrial Function, Left↗

Binding profiles of class I antiarrhythmic agents to cardiac muscarinic receptors: competitive and allosteric interactions with the receptors and their pharmacological significance.

The binding profiles of the class I antiarrhythmic agents disopyramide, pirmenol and pentisomide (CM7857) to cardiac muscarinic receptors were characterized by the binding assay using [3H]-N-methyl scopolamine ([3H]NMS) as a ligand and their anti-muscarinic actions were investigated functionally in left atrial preparations. All the agents displaced the specific binding of 200 pM [3H]NMS from guinea pig left atrial membranes. Computer-assisted analysis indicated that pirmenol interacted with a single class of binding sites, but the displacement curves of disopyramide and pentisomide were shallow and best fitted to a two-site model. When the concentration of [3H]NMS was increased to 1 nM, the displacement curve of pirmenol was best fitted to a two-site model. In higher concentrations, these agents inhibited the dissociation of [3H]NMS initiated by 1 microM atropine in a concentration-dependent manner, thus revealing allosteric interactions. Two enantiomers of pirmenol possessed qualitatively the same binding properties as the racemate. In guinea pig left atria, disopyramide, pirmenol and pentisomide shifted the concentration-response curves for the negative inotropic effect of carbachol in a parallel manner. The slopes of Schild plot were not significantly different from unity, indicating that they act as a competitive antagonist of cardiac muscarinic receptors. Excellent correlation between the high affinity pKi values and the pA2 values was established for the antiarrhythmic agents. These findings suggest that disopyramide, pirmenol and pentisomide all interact with cardiac muscarinic receptors in both a competitive fashion and an allosteric one. The dual mode of the interaction with cardiac muscarinic receptors seems to be independent of their chiralities.(ABSTRACT TRUNCATED AT 250 WORDS)

Animals↗

[Tissue Doppler echocardiography: a new stage in the study of myocardial function].

Tissue Doppler echocardiography is a new technique that allows selective visualization and measurement of myocardial velocities, affording a new perspective on cardiac function. It has been showing promising and exciting preliminary results on coronary artery disease, hemodynamics, cardiomyopathies, right ventricular and aortic diseases and arrhythmias, opening a new era in the analysis of regional myocardial function.

Aorta↗