Alf Wennevold

The supra-additive natriuretic effect addition of bendroflumethiazide and bumetanide in congestive heart failure: Permutation trial tests in patients in long-term treatment with bumetanide

The additive natriuretic effect of a single dose of bendroflumethiazide, 5 mg., has been studied in patients with advanced congestive heart failure in long-term treatment with bumetanide, 4 mg., daily. Three permutation trial tests were performed including six patients each. In the first trial, the response to supplementary bendroflumethiazide, 5 mg., was definitely superior to that of additional bumetanide, 4 mg., in terms of renal output of sodium, chloride, potassium, water, and osmolar clearance. In the second trial, a similar pattern was found in patients receiving a combination of bumetanide, 4 mg., and spironolactone, 100 mg., daily. The third trial compared the effects of bendroflumethiazide, 5 mg., plus bumetanide, 4 mg.; of bendroflumethiazide, 5 mg.; and of bumetanide, 4 mg. In terms of natriuresis and chloruresis, the response to the combination of two drugs was significantly larger than the sum of the effects of other treatments. It is concluded that the combined effects of the drugs represent a supra-additive effect addition for sodium and chloride. A tentative explanation of the mechanism of interaction in terms of inhibition of renal tubular supplementary spironolactone, involve a tendency to development of hypokalemia, hypochloremia, and alkalosis, it is recommended that supplementary use of bendroflumethiazide in this setting is combined with the administration of potassium chloride or potassium-saving diuretics.

Complications in 4,413 catheterizations of the right side of the heart

Abstract The frequency of complications in a material consisting of 4,413 catheterizations of the right side of the heart performed in the same laboratory over 16 years is reported. The patient material consisted mainly of adults and older children. Two thirds of the patients had a congenital heart disease, and one third had an acquired heart disease. Two deaths occurred in direct connection with the examination (0.045 per cent). During the days which followed the examination, 3 severely ill patients died, but there was no reason to assume that these deaths were caused by the examination. Apart from single extrasystoles, arrhythmia occurred in 135 cases (3 per cent). The arrhythmia was considered to be perilous in 4 cases (0.09 per cent): 2 cases of severe arrhythmia were ventricular tachycardia, one of which had a fatal outcome. The other 2 cases were ventricular fibrillation; both patients survived after cardiac massage and A.C. defibrillation, but one of them died 10 days later. Lesions of the heart produced by the catheter occurred twice; in both cases the heart wall was perforated and the course was benign. The risk of death or late sequelae in connection with heart catheterization is slight. Dangerous complications may arise, however, and heart catheterization should, therefore, be performed only when there is access to treatment with electrical stimulation of the heart and to assistance from chest surgeons.

The natural history of small atrial septal defects: Long-term follow-up with serial heart catheterizations

Thirty-nine patients with a small ASD of the secundum type were followed clinically for 5 to 21 years (mean 11.6 years); no evidence of deterioration was found. In 26 of these cases recatheterization was carried out with a mean follow-up period of 9.8 years. No significant changes were found in most patients; in four patients, however, the left-to-right shunt had increased significantly. Our recommendations are that we will continue to advise surgery in patients with large ASDs, whereas we still do not recommend surgery in patients with small ASDs; the latter patients should be followed for longer periods to ensure that no deterioration occurs. The decision as to whether an ASD should be regarded as large or small in our opinion not only should be based on a chosen limit of pulmonary-to-systemic flow ratio, but clinical factors such as diastolic flow murmurs, ECG changes, the heart size, and the pulmonary vascular markings should also be taken into consideration.

Long-term follow-up of right ventricular function after mustard operation for transposition of the great arteries

As development of right ventricular (RV) failure is a potential risk after Mustard operation for transposition of the great arteries, 17 patients were reexamined 5-13 years postoperatively. Comparisons were made with healthy controls. There were no clinical signs of heart failure. Echocardiographically determined RV end-diastolic diameter was increased to 2.5 +/- 0.8 cm (controls: 1.5 +/- 0.4 cm, p less than 0.001). Comparison of RV systolic time intervals (STI) in patients with normal left ventricular (LV) STI revealed decreased RV function, with RPEPI 165 +/- 19 msec (controls 126 +/- 12, p less than 0.001) and RPEP/RVET 0.484 +/- 0.096 (controls 0.284 +/- 0.045, p less than 0.001). Nuclear angiography demonstrated decreased RV ejection fraction (EF), viz. 42.8 +/- 6.6% (normal RV 53 +/- 6%, LV 68 +/- 9%, p less than 0.001). Only two patients showed normal (5%) rise in RV-EF during exercise. There was no evidence of deterioration with passage of time. The results do not justify use of anatomic repair at our center, since the perioperative mortality might then be higher than in the Mustard or Senning procedures.

DC-Conversion of Atrial Fibrillation after Mitral Valve Operation. An Analysis of the Long-term Results

In a prospective study comprising 43 patients with atrial fibrillation after mitral valve surgery, an evaluation was made of the prognostic significance of clinical, radiological, haemodynamic and operative factors for the maintenance of sinus rhythm after DC-conversion. Atrial fibrillation with a duration of less than 12 months proved to be the only single factor of significance for sustained sinus rhythm after 12 months and it is suggested as a simple clinical criterion for selection of patients for DC-conversion after mitral valve operation.

Complications in 1,056 investigations of the left side of the heart

Abstract The frequency and type of complications in a material consisting of 832 suprasternal and/or percutaneous left ventricular punctures, 72 retrograde left ventricular catheterizations, and 152 transseptal left heart catheterizations performed in this laboratory are reported. The patient material consisted of 726 persons, mainly adults and older children. Two deaths occurred during the 1,056 investigations (0.19 per cent), one after a combined suprasternal and left ventricular puncture, and the other after a transseptal left heart catheterization. Serious complications were seen a total of 19 times (1.7 per cent), as shown in Table VIII.

The Natural History of Pulmonary Stenosis

A follow-up study was performed in 82 patients in whom a diagnosis of isolated pulmonary stenosis was established by cardiac catheterization in this laboratory between 1947 and 1961. Only patients who

Fourteen- to nineteen-year follow-up after corrective repair for tetralogy of Fallot.

A long-term follow-up was made of the first 28 patients who survived corrective repair for tetralogy of Fallot at the Department of Thoracic Surgery R, Rigshospitalet. Copenhagen. They were discharged in the years 1960–1964. There were 20 males and 8 females. The age at operation was 6–41 years (median 12 years). Nineteen patients had previous palliative operations. All of them had one or more postoperative clinical examinations at the hospital and 18 had postoperative heart catheterizations. Six patients had died, five within 10 years after operation (21.4%: 95% confidence limits 8.3–41.0%). Four late deaths were clearly related to residual cardiovascular abnormalities, insufficient VSD closure being the main problem. One further death was due to a malignant arrhythmia provoked at the routine postoperative heart catheterization. Two deaths were sudden, one in a patient with a ruptured VSD. The only patient with transient a-v block postoperatively, who later died, did so from pump failure after the second...

INTERRUPTED AORTIC ARCH IN TWO SIBLINGS

Abstract. Buch, J., Wennevold, A., Efsen, F. and Andersen, G. E. (Cardiovascular Laboratory of Medical Department B, Cardiovascular Section of Department of Diagnostic Radiology X and Department of Neonatology, Rigshospitalet, Copenhagen, Denmark). Interrupted aortic arch in two siblings. Acta Paediatr Scand, 69: 783, 1980.—Two siblings with identical malformations consisting of complete interruption of the aortic arch, type B, ventricular septa) defect, patent ductus arteriosus and anomalous origin of the right subclavian artery are described. Five other unrelated patients with interrupted aortic arch have been investigated in the years 1971–79. Of their 6 siblings, one had a coarctation of the aorta, while 5 were normal. Together with future reports this may help us to elucidate the genetics of this entity and may improve genetic counselling.

Different Patterns of Hemodynamic Abnormalities in Patients with Ischemic Heart Disease Compared with Patients with Congestive Cardiomyopathy

48 patients with chest pain or unexplained heart failure were examined with exercise test, systolic time intervals, apexcardiogram and left- and right-sided heart catheterization including coronary arteriography. The 23 patients with ischemic heart disease (IHD) and 19 patients with congestive cardiomyopathy (COCM) could as groups be separated by several of the parameters. Two major patterns of change were present when using the whole range of parameters, probably reflecting that the heart and circulation had compensated for left ventricular dysfunction in different ways in IHD and COCM. Comparing patients with the same ejection fraction (EF), preejection-period index (PEPI) pre-ejection-period/left ventricular ejection time (PEP/LVET) and systolic blood pressure/left ventricular end systolic volume index (SBP/LVESVI), were all more abnormal in patients with COCM than with IHD at most EF levels. The best separation between the diseases was obtained using exercise capacity in combination with PEP/LVET. The correlations between invasive and noninvasive parameters underlined that no single parameter can satisfactorily characterize the circulatory function in patients with individual differences in preload, afterload, pulse rate, cardiac volumes, compliance and contractility. No or poor correlations were found between exercise capacity and the different function parameters used.