Abdel-Mohsen Nomeir

THE PATHOGENESIS OF ACUTE PULMONARY EDEMA ASSOCIATED WITH HYPERTENSION

BACKGROUND Patients with acute pulmonary edema often have marked hypertension but, after reduction of the blood pressure, have a normal left ventricular ejection fraction (> or =0.50). However, the pulmonary edema may not have resulted from isolated diastolic dysfunction but, instead, may be due to transient systolic dysfunction, acute mitral regurgitation, or both. METHODS We studied 38 patients (14 men and 24 women; mean [+/-SD] age, 67+/-13 years) with acute pulmonary edema and systolic blood pressure greater than 160 mm Hg. We evaluated the ejection fraction and regional function by two-dimensional Doppler echocardiography, both during the acute episode and one to three days after treatment. RESULTS The mean systolic blood pressure was 200+/-26 mm Hg during the initial echocardiographic examination and was reduced to 139+/-17 mm Hg (P< 0.01) at the time of the follow-up examination. Despite the marked difference in blood pressure, the ejection fraction was similar during the acute episode (0.50+/-0.15) and after treatment (0.50+/-0.13). The left ventricular regional wall-motion index (the mean value for 16 segments) was also the same during the acute episode (1.6+/-0.6) and after treatment (1.6+/-0.6). No patient had severe mitral regurgitation during the acute episode. Eighteen patients had a normal ejection fraction (at least 0.50) after treatment. In 16 of these 18 patients, the ejection fraction was at least 0.50 during the acute episode. CONCLUSIONS In patients with hypertensive pulmonary edema, a normal ejection fraction after treatment suggests that the edema was due to the exacerbation of diastolic dysfunction by hypertension--not to transient systolic dysfunction or mitral regurgitation.

Cardiac Involvement in Rheumatoid Arthritis.

Abstract The nature and extent of cardiac involvement in 30 patients with classic rheumatoid arthritis were studied. Physical examination showed no significant cardiac abnormalities in these patien...

Mechanism of altered pattern of left ventricular filling with aging in subjects without cardiac disease

The mechanism whereby aging, in the absence of cardiac disease, may alter the pattern of left ventricular (LV) diastolic filling is unknown. Accordingly, this study was designed to examine the factors that may be in part responsible for agings effect on the pattern of LV diastolic filling. The LV end-diastolic pressure-volume relation was analyzed in 11 elderly subjects (68 +/- 5 years, mean +/- standard deviation) and 15 normal young adults (31 +/- 7 years) without coronary artery disease, systemic hypertension, LV hypertrophy or abnormality of LV systolic function. After catheterization, the subjects underwent pulsed Doppler analysis of mitral flow. All had normal 2-dimensional echocardiograms without LV or valvular dysfunction. Peak early filling velocity in the elderly subjects was decreased in comparison with that in young adults (61 +/- 14 vs 83 +/- 8 cm/s, p less than 0.001) and the ratio of early and late diastolic filling velocity was reduced (0.81 +/- 0.26 vs 1.88 +/- 0.40, p less than 0.001). The isovolumic relaxation time did not differ between the elderly and young subjects (158 +/- 20 vs 146 +/- 22 ms, difference not significant). In the elderly, LV end-diastolic pressure was increased (15 +/- 7 vs 11 +/- 4 mm Hg, p less than 0.05) despite a smaller end-diastolic volume index (60 +/- 16 vs 74 +/- 18 ml/m2, p less than 0.05), indicating a shift of the passive diastolic pressure-volume relation. It was concluded that early diastolic filling is reduced in normal aged subjects, even in the absence of coronary artery disease and systolic dysfunction. This altered pattern of diastolic filling may result from a shift of the passive LV diastolic pressure-volume relation.

Diastolic mitral regurgitation in acute but not chronic aortic regurgitation: Implications regarding the mechanism of mitral closure

In acute aortic regurgitation, left ventricular pressure rises rapidly during diastole, which produces presystolic mitral valve closure. This does not occur in chronic aortic regurgitation. Since normal, nonregurgitant mitral valve closure may depend on properly coordinated atrial and ventricular contractions, we hypothesized that abnormal mitral valve closure occurring before systole in acute aortic regurgitation may produce diastolic mitral regurgitation detectable by Doppler echocardiography. Accordingly, we performed ultrasonic Doppler examination of seven patients with acute aortic regurgitation and 12 patients with chronic aortic regurgitation. Regurgitant aortic flow was severe in all cases. Doppler sampling within the left atrium demonstrated regurgitant mitral flow in late diastole in all patients with acute aortic regurgitation. The onset of diastolic mitral regurgitation coincided with mitral valve preclosure in patients with acute aortic regurgitation and occurred regardless of the position of the mitral leaflets at the initiation of closure. In contrast, none of the 12 patients with chronic aortic regurgitation had mitral valve preclosure or diastolic mitral regurgitation (p less than 0.05 versus acute aortic regurgitation). We conclude that diastolic mitral regurgitation accompanies mitral valve preclosure, which occurs in acute but not chronic aortic regurgitation. Thus diastolic mitral regurgitation may be a Doppler sign of acute aortic regurgitation, in the absence of a markedly prolonged PR interval. Furthermore, this observation suggests that normal, nonregurgitant mitral closure requires more than an increase in left ventricular pressure above left atrial pressure, regardless of the position of the mitral leaflets before closure.

Intracardiac Myxomas: Twenty-year Echocardiographic Experience With Review of the Literature

We reviewed the echocardiograms of 35 patients with intracardiac myxomas. Patient data were combined from two geographically distant laboratories. No significant variations in the patient profiles were encountered. Most patients were white (33 of 35) with a mean age of 45 years. The diagnosis was suspected on clinical grounds alone in only six of 35 patients before the echocardiogram was done. M-mode recordings were the primary echocardiographic modality available in the first 16 patients, whereas two-dimensional studies were also done in the others. Continuous and pulsed wave Doppler echocardiography were added in eight of the most recent studies. In one patient color flow imaging from both transthoracic and esophageal approaches was possible to better visualize a large left atrial tumor. Thirty-three patients had solitary tumors (29 left atrial, three right atrial, and one left ventricular), and two had multiple tumors. The most characteristic finding, as expected, was the demonstration of abnormal mass echoes produced by the myxoma tissue. Several interesting features not previously emphasized in the literature included abnormal notching of the interventricular septum and posterior left ventricular wall probably produced by displacement from the larger mobile left atrial tumors dropping into the mitral sleeve. This was best appreciated by the M-mode recordings. In one patient with an associated atrial septal defect, movement of the tumor into the defect appeared to alter the expected downward displacement into the mitral orifice. In the patients who were studied by two-dimensional, Doppler, or color flow imaging, tumor movement was evidenced by abnormal frequency shifts, and dispersion of flow around the tumor mass was readily appreciated. Surgical removal was performed in all patients. Follow-up echocardiograms were done postoperatively ranging up to 17 years. Recurrent tumors occurred in two patients, both of whom had congenital myxomas. Echocardiography is proving to be an unparalleled tool in the diagnosis of intracardiac tumors.

A prospective, randomized, blinded comparison of multiplane and biplane transesophageal echocardiographic techniques☆

Although multiplane transesophageal echocardiography has become an accepted diagnostic technique, there is a paucity of literature directly comparing the diagnostic yield of multiplane and biplane transesophageal examinations. This study was designed to compare the ability of multiplane and biplane transesophageal echocardiographic techniques to visualize intracardiac structures. Complete multiplane and biplane transesophageal studies were performed on each of 50 patients (100 total studies) referred to the echocardiography laboratory for elective transesophageal echocardiography. The biplane examinations were performed with a multiplane probe with angles only at 0 and 90 degrees. Images of 29 prospectively selected cardiac structures and valvular function parameters were scored as follows: 0 = not visualized, 1 = visualized well enough to identify structure, 2 = diagnostic quality, and 3 = exceptional quality. The scores for the individual structures were combined to identify total structure visualization quality scores for each of the imaging techniques. A separate subjective score was also determined to assess the overall adequacy of each study for addressing the clinical indication. The total structure visualization quality score was significantly higher for multiplane transesophageal echocardiography than for biplane transesophageal echocardiography (49 +/- 7 versus 45 +/- 7; p = 0.0001). Several individual structures were visualized significantly better (p < 0.05) by the multiplane technique, including the left upper pulmonary vein, fossa ovalis, left main coronary artery, and proximal ascending aorta. The subjective score of overall adequacy of the study for addressing the clinical indication showed a strong trend (p < 0.06) in favor of the multiplane technique, with higher scores in 11 of 50 multiplane studies versus three of 50 biplane studies when the two techniques were compared in individual patients. Therefore multiplane transesophageal echocardiography provides superior overall visualization of intracardiac structures compared with biplane studies, particularly for the left upper pulmonary vein, fossa ovalis, left main coronary artery, and ascending aorta.

Magnetic resonance imaging evaluation of recipient for cryopreserved aortic allograft

Aortic valve replacement with a cryopreserved aortic allograft is the procedure of choice for many patients with aortic valvular heart disease. We have used magnetic resonance imaging preoperatively to determine annular size and coronary artery orientation in the recipient, which not only has enabled us to select an allograft of appropriate size from a distant tissue bank, but also has helped us to identify preoperatively the recipient with a truly bicuspid valve in which the coronary arteries are oriented 180 degrees apart. Sixteen consecutive patients were evaluated preoperatively, the aortic annulus being measured with both magnetic resonance imaging and echocardiography. Cryopreserved aortic allografts were ordered on the basis of the magnetic resonance imaging measurement. Annular size was then measured intraoperatively with calibrated sizers. Magnetic resonance imaging annular measurements correlated highly with those found at operation (r = 0.92), whereas echocardiographic measurements correlated less well (r = 0.69). Coronary orientation was accurately predicted in every case (r = 1.0). Therefore, we have found magnetic resonance imaging to be useful in the preoperative evaluation of patients for aortic valve replacement with a cryopreserved aortic allograft.

Perforation of the Anterior Mitral Leaflet Caused by Aortic Valve Endocarditis: Diagnosis by Two-dimensional, Transesophageal Echocardiography and Color Flow Doppler

Perforation of the mitral valve as a result of aortic valve endocarditis is rare. Recognition of such abnormality is very important before surgical intervention. Diagnosis is very difficult by either invasive or noninvasive techniques. This report stresses the role of echocardiography in evaluating this rare abnormality. Perforation of the anterior mitral valve leaflet developed in our patient as a complication of aortic valve endocarditis. The perforation was suggested by the surface echocardiogram (as an interruption of the leaflet continuity) and by the color flow Doppler (which suggested turbulent flow at the area of suspected interruption). The perforation was confirmed during surgery by transesophageal echocardiography and alerted the surgeon to repair, rather than replace, the valve.

Diagnosis and management of acute hypoxemia after drainage of massive pericardial effusion

A 35-year-old, 99-kg female, with a history of hypertension, hypothyroidism, and asthma, complained of fatigue, weight loss, dyspnea, and pedal edema. Her medications included oral thyroxine, omeprazole, iron sulfate, and inhaled beclomethasone. Physical examination revealed clear lung fields, distant heart sounds, and pitting edema in both legs. The chest radiograph showed cardiomegaly and clear lung fields; the electrocardiogram showed sinus tachycardia and low QRS voltage. A transthoracic echocardiogram (Fig 1) showed a large pericardial effusion with diastolic collapse of the right ventricle and both atria. Thyroid function tests performed shortly after admission were normal. On arrival to the operating room for pericardial drainage, the patients blood pressure was 116/94 mmHg, her pulse rate was 107 beats/min, and her oxygen saturation by finger pulse oximeter (on 2 L/rain nasal oxygen) was 100%. After the operative field was prepared, intravenous ketamine and succinylcholine were administered, and a cuffed endotracheal tube inserted in the trachea. A subxyphoid incision was made, and 1.8 L of hemorrhagic pericardial fluid drained. Hemoglobin saturation remained 100% for 10 minutes before drainage of the pericardial effusion, whereupon saturation declined acutely to 85%. Normal breath sounds were heard over each lung field. An arterial blood gas revealed a PaO2 of 57 mmHg, PaCO2 of 53, and pH of 7.35, despite an FIO2 of 1.0, tidal volume of 800 mL, and ventilation rate of 8 breaths/min. Bronchoscopy revealed normal airways and the endotracheal tube tip in proper position. A pulmonary artery catheter was placed, revealing a central venous pressure of 10 mmHg, pulmonary artery pressure of 30/16 mmHg, pulmonary capillary wedge pressure of 13 mmHg, and a cardiac output (CO) of 7.0 L/rain (by thermodilution). A complete TEE examination was performed, revealing a 1.5-cm ostium secundum ASD (measured in the horizontal plane, four-chamber view) with a large right-to-left atrial shunt (by color-flow Doppler), mild global hypokinesis of the left ventricle, severe hypokinesis of the right ventricle, and moderate tricuspid regurgitation (by color-flow Doppler). The patient remained hypoxemic (arterial saturation 63% on FIO 2 of 1.0), despite infusions of norepinephrine (0.07 pg/kg/min) and dopamine (15 ~g/kg/min) to raise systemic vascular resistance and improve right ventricular function, and inhaled nitric oxide (60 ppm) to lower pulmonary vascular resistance. She was

Aortic Valve Thrombus Presenting as a Non-ST Elevation Myocardial Infarction

Thrombosis of prosthetic heart valves is well known; however it rarely occurs on native heart valves. To our knowledge there are no reports of native aortic valve thrombus in the absence of blood dyscrasia or prior valve pathology. We describe a patient who presented with a non-ST segment elevation myocardial infarction (NSTEMI) caused by a large aortic valve thrombus.