RESUMEN
OBJECTIVES: Recently, valvular regurgitation has been observed in patients who have taken fenfluramine or dexfenfluramine with or without phentermine. This study describes the clinical, echocardiographic, and pathologic findings of anorexigen-associated valvular heart disease and the surgical interventions required to treat it. METHODS: We reviewed clinical information on 14 patients with severe anorexigen-associated valvular disease who underwent cardiac operations. RESULTS: Thirteen women (mean age 44.2 +/- 5.3 years) received fenfluramine, 58.5 +/- 22.3 mg/day, and phentermine, 32.1 +/- 11.4 mg/day, for an average of 12.1 +/- 7.3 months before presentation. One woman received dexfenfluramine, 30 mg/day for 13 months, and phentermine, 60 mg/day, concomitantly for 6 months. Presenting symptoms included dyspnea (12 cases), palpitations (3), and atypical chest pain (3). Six patients had heart failure, and 4 had a new murmur. Echocardiography demonstrated severe mitral valve regurgitation in all patients. Seven also had aortic regurgitation, and 4 had significant tricuspid regurgitation. Four patients had successful mitral valve repair, 1 with concomitant aortic valve repair. Ten additional patients eventually required mitral valve replacement, 5 with concomitant aortic valve replacement. Excised valves demonstrated a glistening white appearance with plaque-like encasement of leaflets and chordae. Focal surface proliferation and fibrosis with a "stuck-on" appearance was consistently found. CONCLUSIONS: Anorexigen use may lead to severe multivalvular regurgitation with characteristic echocardiographic and pathologic findings. Recognition of drug-induced valvulopathy is important because of widespread use of these medications and the uncertain natural history of the disease. Early surgical experience suggests that valve repair is possible in these young patients.
Asunto(s)
Depresores del Apetito/efectos adversos , Dexfenfluramina/efectos adversos , Fenfluramina/efectos adversos , Enfermedades de las Válvulas Cardíacas/inducido químicamente , Enfermedades de las Válvulas Cardíacas/cirugía , Fentermina/efectos adversos , Serotoninérgicos/efectos adversos , Agonistas de Receptores de Serotonina/efectos adversos , Adulto , Femenino , Enfermedades de las Válvulas Cardíacas/diagnóstico por imagen , Humanos , Persona de Mediana Edad , UltrasonografíaRESUMEN
Papillary fibroelastomas are rare, benign, primary cardiac tumors. They are, however, the most common primary tumor of the cardiac valves and may cause great morbidity risk from embolization. This paper reports the case of a healthy 34-year-old man who presented with symptoms of a right occipital embolic stroke. Transesophageal echocardiography revealed a papillary fibroelastoma on the anterior leaflet of the mitral valve. The papillary fibroelastoma was surgically excised and he has had no recurrent symptoms. This case illustrates the importance of obtaining a transesophageal echocardiogram to investigate a possible embolic source in patients with ischemic stroke.
Asunto(s)
Fibroma/diagnóstico por imagen , Fibroma/patología , Neoplasias Cardíacas/diagnóstico por imagen , Neoplasias Cardíacas/patología , Embolia Intracraneal/patología , Lóbulo Occipital/patología , Accidente Cerebrovascular/diagnóstico por imagen , Accidente Cerebrovascular/patología , Adulto , Isquemia Encefálica/patología , Ecocardiografía Transesofágica , Humanos , MasculinoAsunto(s)
Ecocardiografía Transesofágica , Insuficiencia de la Válvula Mitral/diagnóstico por imagen , Prolapso de la Válvula Mitral/diagnóstico por imagen , Válvula Mitral/diagnóstico por imagen , Anciano , Humanos , Masculino , Persona de Mediana Edad , Válvula Mitral/anatomía & histología , Insuficiencia de la Válvula Mitral/patología , Prolapso de la Válvula Mitral/patología , Músculos Papilares/diagnóstico por imagenRESUMEN
This study was designed to determine the safety and efficacy of extended, continuous infusion of urokinase plus stent deployment to treat older saphenous vein bypass grafts obstructed by both thrombus and atheromatous material. Thirty patients with angiographic evidence of thrombus and atheromatous material obstructing older vein grafts (mean age 8.3 years) underwent the combined interventions of urokinase infusion and stent deployment. The continuous infusion of urokinase was administered directly into each obstructed vein graft over a mean of 20.5 +/- 8.1 hours (median dose 2.2 +/- 0.7 million units). Stents were deployed at the sites of atheromatous obstruction either before (5 patients) or after (25 patients) infusion of urokinase. Twenty-eight of the 30 patients were successfully treated with the combined interventions (success rate 93.3%). In these 28 patients, percent diameter stenosis at the site of obstruction decreased from 86.0% to -0.2% and Thrombolysis in Myocardial Infarction trial flow increased from 1.0 to 2.5. Two patients (6.7%) developed stent thrombosis followed by myocardial infarction (1 with Q-wave infarction, 3.3%) and congestive heart failure. Minor complications included non-Q-wave myocardial infarction (5 patients, 16.7%) and access-site hemorrhage (5 patients, 16.7%). At 2-week follow-up, anginal symptoms were decreased in all 28 successfully treated patients. At 7.2 +/- 3.7-month follow-up, 5 of the 28 successfully treated patients (17.9%) had reacceleration of angina and angiographically documented restenosis at the site of stent deployment.(ABSTRACT TRUNCATED AT 250 WORDS)
Asunto(s)
Puente de Arteria Coronaria , Enfermedad de la Arteria Coronaria/terapia , Trombosis Coronaria/terapia , Oclusión de Injerto Vascular/terapia , Activadores Plasminogénicos/uso terapéutico , Vena Safena/trasplante , Stents , Terapia Trombolítica , Activador de Plasminógeno de Tipo Uroquinasa/uso terapéutico , Anciano , Distribución de Chi-Cuadrado , Terapia Combinada , Angiografía Coronaria , Enfermedad de la Arteria Coronaria/diagnóstico por imagen , Enfermedad de la Arteria Coronaria/tratamiento farmacológico , Enfermedad Coronaria/etiología , Trombosis Coronaria/diagnóstico por imagen , Trombosis Coronaria/tratamiento farmacológico , Femenino , Estudios de Seguimiento , Oclusión de Injerto Vascular/diagnóstico por imagen , Oclusión de Injerto Vascular/tratamiento farmacológico , Hemorragia/etiología , Humanos , Infusiones Intravenosas , Masculino , Persona de Mediana Edad , Infarto del Miocardio/etiología , Activadores Plasminogénicos/administración & dosificación , Activadores Plasminogénicos/efectos adversos , Pronóstico , Estudios Prospectivos , Stents/efectos adversos , Activador de Plasminógeno de Tipo Uroquinasa/administración & dosificación , Activador de Plasminógeno de Tipo Uroquinasa/efectos adversosRESUMEN
Procainamide-induced lupus is a well-recognized syndrome, but the events leading up to clinical symptoms are obscure. In the present study, serologic changes in a 69-year-old man were monitored during his treatment with procainamide and after discontinuation of procainamide because of symptoms of drug-induced lupus. Antihistone antibodies of unique specificity and in vivo complement activation were detected after one year of procainamide therapy during a period prior to development of significant clinical symptoms. Antihistone antibodies and complement activation substantially increased during a full-blown episode of lupus-like symptoms. Progressive return to normal laboratory findings occurred after procainamide was discontinued. The antihistone/complement profile may be useful in the diagnosis of drug-induced lupus and warn of impending clinical deterioration in patients with minimal symptoms.
Asunto(s)
Lupus Eritematoso Sistémico/inducido químicamente , Procainamida/efectos adversos , Anciano , Anticuerpos/análisis , Activación de Complemento/efectos de los fármacos , Histonas/inmunología , Humanos , Lupus Eritematoso Sistémico/diagnóstico , Masculino , Pancitopenia/inducido químicamente , Pancitopenia/diagnóstico , Pronóstico , Estudios Prospectivos , Factores de TiempoRESUMEN
Interactions between an ultrasonic signal and cardiac tissue have been used to characterize the histologic state of myocardium in vitro. To assess the utility of in vivo ultrasonic tissue characterization, stochastic analysis was applied to the digitized echocardiographic signals from 15 patients with 2-dimensional echocardiograms suggesting intracardiac masses. Ten subjects with echocardiograms suggesting mural thrombi underwent subsequent surgery or necropsy, which confirmed thrombi in 6 and revealed no thrombi (designated artifact) in 4. Five other patients had intracardiac tumors. The amplitudes within the digitized ultrasonic signals were displayed as histograms, which were described by a parameter k that represented the degree to which each histogram departed from a totally random probability density function. In 5 of 6 thrombi, k = 0, but in all 4 artifacts, k greater than 0. The sixth thrombus had k = 0.5 due to the specular effect of the interface between the thrombus' 2 lobes. All 5 tumors had k greater than 0. Ultrasonic tissue characterization using a stochastic analysis of backscatter can be performed in vivo and helps differentiate thrombus from artifact and tumor in the heart.
Asunto(s)
Coagulación Sanguínea , Ecocardiografía , Neoplasias Cardíacas/diagnóstico , Cardiomiopatías/complicaciones , Cardiomiopatías/cirugía , Aneurisma Cardíaco/complicaciones , Aneurisma Cardíaco/cirugía , Neoplasias Cardíacas/cirugía , Humanos , Mixoma/diagnóstico , Mixoma/cirugíaRESUMEN
Twenty patients with coronary artery disease were studied with two-dimensional echocardiography the day before saphenous vein bypass graft surgery. Serial studies were obtained 7.4 +/- 2.5 (+/- SD) and 43.4 +/- 13.1 days postoperatively to qualitatively assess the effect of bypass surgery on regional wall motion. Changes in segmental wall motion were assessed semiquantitatively by assigning a segmental wall motion score to each of nine echocardiographically defined segments. Preoperatively, 18% of the segments moved abnormally. The mean overall segmental wall motion score did not change significantly, as shown by comparing the postoperative studies with the preoperative study. However, there was a significant worsening in the septal motion (apical and basal) and a significant improvement in posterior wall motion (apical and basal) after bypass surgery. Anterior and lateral wall motion were not significantly changed. Nonseptal segments that were normal preoperatively usually remained normal; abnormal nonseptal segments usually improved or were unchanged by surgery. The motion of septal segments, however, generally worsened postoperatively whether they were normal or abnormal preoperatively. We conclude that segmental wall motion assessed by two-dimensional echocardiography may improve after revascularization surgery, but the interventricular septum shows impaired motion. This effect of coronary artery bypass on wall motion is better demonstrated relatively late after operation than early in the postoperative course, as has been done in some previous studies.
Asunto(s)
Puente de Arteria Coronaria , Enfermedad Coronaria/cirugía , Ecocardiografía , Anciano , Enfermedad Coronaria/diagnóstico , Femenino , Ventrículos Cardíacos , Humanos , Masculino , Persona de Mediana Edad , Contracción Miocárdica , Periodo Posoperatorio , Factores de TiempoRESUMEN
In two patients with acute dissection of the ascending aorta, the diagnosis was made with two-dimensional echocardiography and confirmed by aortography. The echocardiograms localized the intimal flap and false channel in both cases. Although clinical evaluation and indicated radiologic studies remain the primary modalities of diagnosis in acute aortic dissection, two-dimensional echocardiography may be a useful additional diagnostic technique.
Asunto(s)
Enfermedades de la Aorta/diagnóstico , Disección Aórtica/diagnóstico , Ecocardiografía , Adulto , Anciano , Humanos , Masculino , Rotura EspontáneaRESUMEN
We reviewed M-mode and two-dimensional echocardiographic findings in 11 patients with abacteremic endocarditis to study the application of echocardiography in this setting. All patients had negative blood cultures but underwent surgery that confirmed the presence of active infective endocarditis. The infection involved native valves in five patients and prosthetic valves in six patients. Valvular masses were identified in eight patients. The other three patients, who had prosthetic aortic valves, had diastolic mitral valve vibration characteristic of aortic regurgitation. One of these also showed dehiscence of the prosthesis. Three patients had poorly defined clinical illnesses and echocardiography was a prime element in the diagnosis because valvular masses were identified. The operation was facilitated by knowledge of the mass indicated by echocardiography in these eight cases. Also, the surgical approach was affected by knowledge of dehiscence and perivalvular abscess formation in two cases each.
Asunto(s)
Ecocardiografía/métodos , Endocarditis Bacteriana/diagnóstico , Absceso/complicaciones , Adulto , Anciano , Válvula Aórtica/trasplante , Insuficiencia de la Válvula Aórtica/etiología , Técnicas Bacteriológicas , Bioprótesis , Diástole , Endocarditis Bacteriana/cirugía , Femenino , Prótesis Valvulares Cardíacas , Humanos , Masculino , Persona de Mediana Edad , Válvula Mitral/trasplanteRESUMEN
We review the basic similarities and differences of currently used M-mode and two-dimensional (2D) echocardiography. Discrete categories of disease are used to show the relative strengths of M-mode and 2D methods. The format of 2D echocardiography is well suited to analyze congenital heart disease, consequences of coronary artery disease, and distortions of anatomy due to acquired heart disease. Rapid structure movement is preserved with M-mode recording, facilitating detailed analysis of motion. The vast clinical experience with M-mode echocardiography can now be augmented by 2D echocardiography, but combination of 2D and M-mode methods is optimal for understanding each type of ultrasound recording and for best serving the patient.
Asunto(s)
Ecocardiografía/métodos , Cardiomiopatías/diagnóstico , Enfermedad Coronaria/diagnóstico , Enfermedades de las Válvulas Cardíacas/diagnóstico , Prótesis Valvulares Cardíacas , Humanos , Insuficiencia de la Válvula Mitral/diagnóstico , Derrame Pericárdico/diagnóstico , Pericarditis Constrictiva/diagnósticoRESUMEN
N-Acetylprocainamide (NAPA) disposition kinetics was studied in eight patients with coronary artery disease. NAPA was given over a 45-min period by intravenous infusion, and blood samples were drawn at specified times for 24 hr. NAPA plasma levels were determined by a specific high-pressure liquid chromatography (HPLC) procedure and the concentration-time data were fit to a three-compartment model. Mean (+/- SD) values for the elimination half-life, the total body clearance, and the steady-state volume of distribution were 9.53 +/- 3.22 hr, 1.98 +/- 0.40 ml/min/kg, and 1.30 +/- 0.18 1/kg. There was moderate intersubject variability in disposition. The data reported here differ from those reported for normal subjects.
Asunto(s)
Acecainida/sangre , Enfermedad Coronaria/sangre , Procainamida/análogos & derivados , Acecainida/administración & dosificación , Adulto , Anciano , Creatinina/sangre , Femenino , Semivida , Humanos , Infusiones Parenterales , Cinética , Masculino , Tasa de Depuración Metabólica , Persona de Mediana EdadRESUMEN
In a patient with the Wolff-Parkinson-White Syndrome we observed atrial fibrillation and three distinct paroxysmal re-entrant tachycardias. Intracardiac electrograms obtained during the tachycardias showed the mechanisms to be A-V nodal, accessory pathway and sinus node re-entry. When P wave morphology, R-P relationship and QRS configuration are considered, it is illustrated how these four tachyarrhythmias may be successfully diagnosed on the surface electrocardiogram. The therapeutic implications of multiple arrhythmias with different mechanisms in the Wolff-Parkinson-White Syndrome are discussed.
Asunto(s)
Fibrilación Atrial/etiología , Electrocardiografía , Taquicardia Paroxística/etiología , Síndrome de Wolff-Parkinson-White/complicaciones , Antiarrítmicos/uso terapéutico , Fibrilación Atrial/diagnóstico , Nodo Atrioventricular , Sistema de Conducción Cardíaco/fisiopatología , Taquicardia Paroxística/diagnóstico , Taquicardia Paroxística/tratamiento farmacológico , Síndrome de Wolff-Parkinson-White/diagnóstico , Síndrome de Wolff-Parkinson-White/fisiopatologíaRESUMEN
The effects of digitalis on retrograde conduction and refractoriness of the His-Purkinje system, ventricular myocardium and reentry within the His-Purkinje system were studied in 17 patients using the ventricular extrastimulus (V2) technique. Studies were performed, before and 30 minutes after intravenous administration of ouabain, 0.01 mg/kg. After treatment with ouabain, there was a significant decrease in the functional refractory period (266 +/- 19 to 254 +/- 18 msec, P less than 0.001), relative refractory period (253 +/- 17 to 240 +/- 16 msec, P less than 0.001) and effective refractory period (242 +/- 23 to 231 +/- 24 msec, P less than 0.005) of the ventricular muscle. In contrast, there was no significant change in retrograde His-Purkinje conduction and refractoriness. The phenomenon of reentry within the His-Purkinje system characterized by the reentrant beat (V3) at critical retrograde conduction delays in the His-Purkinje system (V2-H2) within a narrow range of V1-V2 intervals was seen in 10 of 17 patients. Ouabain increased and shifted to the left the zone of reentry within the His-Purkinje system in 7 of 10 patients (36 +/- 23 to 55 +/- 23 msec, P less than 0.001) and decreased it by 10 to 30 msec in the remaining 3 patients. The critical V2-H2 (186 +/- 29 to 193 +/- 27 msec, difference not significant [NS]) and V1-V2 (299 +/- 30 to 294 +/- 36 msec, NS) intervals for reentry did not significantly change after ouabain. However, the minimal V1-V2 intervals (266 +/- 26 to 253 +/- 25 msec, P less than 0.025) decreased significantly, whereas the maximal V2-H2 intervals (266 +/- 40 to 239 +/- 37 msec, P less than 0.01) increased significantly. Thus, in the intact human heart, digitalis (1) significantly decreased all measures of ventricular myocardial refractoriness, (2) had no significant effect on retrograde conduction and refractoriness of the His-Purkinje system, and (3) widened the zone of reentry within the His-Purkinje system due to shortening of the functional refractory period of the ventricular muscle with attainment of longer V2-H2 delays.