Earl N. Silber

Intermittent inotropic therapy in an outpatient setting: a cost-effective therapeutic modality in patients with refractory heart failure.

Patients with intractable heart failure (New York Heart Association [NYHA] class III and IV) who were receiving maximal conventional treatment were enrolled in an outpatient program that included inotropic infusions, intensive patient education, and close follow-up. The effects of this approach to therapy were evaluated on (1) the number of hospital admissions, (2) length of stay, and (3) number of emergency room visits during the ensuing year. These data were compared with similar data from the year before entry in the program for each patient. Thirty-six patients with stable NYHA class III and IV heart failure received milrinone or dobutamine to manage chronic heart failure in an outpatient setting. The cause of heart failure was ischemic heart disease in 12, idiopathic in 11, hypertension in 8, and pulmonary hypertension in 5. Four patients received dobutamine and 32 patients received milrinone. The mean period of observation was 294 days. For the period before entry in the program, patients had 21 emergency room visits, 75 admissions, and 528 days spent in the hospital. After enrollment, patients had 10 emergency room visits, 34 admissions, and 150 days spent in the hospital. In conclusion, this therapeutic regimen reduced the number of hospital admissions, days spent in the hospital, and emergency room visits. Our study supports the concept that the use of intermittent inotropic therapy in the outpatient setting plays an important role in managing this severely ill group of patients.

Effect of long-term β-blockade on aortic root compliance in patients with Marfan syndrome

Abstract Background This study was undertaken to assess the effect of long-term β-blockade on the aortic root stiffness index and distensibility in patients with Marfan syndrome. Methods Aortic root stiffness index and distensibility were calculated according to the formulas of Stefanadis and Hirai, respectively, with 2-dimensional guided M-mode echocardiogram before and after an average of 26 months of atenolol administration. Results Twenty-three asymptomatic patients were studied (11 men and 12 women, aged 31 ± 14.2 years). The follow-up was 4 ± 2.2 years. The dose of atenolol was individualized (mean 43.5 ± 21.6 mg/d). Heart rate decreased from 79 ± 9 beats/min to 64 ± 9 beats/min ( P = .01), and systolic blood pressure decreased from 124 ± 13 mm Hg to 114 ± 2 mm Hg ( P = .01). Distensibility increased from 1.85 ± 0.70 × 10 –6 cm 2 /dynes –1 to 2.21 ± 0.76 × 10-6 cm 2 /dynes –1 ( P = .02), and the stiffness index decreased from 9.68 ± 3.78 to 8.85 ± 3.15 ( P = .2). Two groups of responses to treatment were identified. Compared with baseline values 15 (65%) patients who responded to treatment had increased distensibility and decreased stiffness index of the aortic root ( P = .05). Eight patients (35%) who did not respond to treatment had no significant change. Body weight >91 kg and baseline end-diastolic aortic root diameter >40 mm were significantly associated with no response ( P = .05). Two patients in the nonresponding group had echocardiographic progression of aortic insufficiency. Conclusions There was a heterogeneous response in the aortic root elastic properties after long-term treatment with atenolol in asymptomatic patients with Marfan syndrome. Stiffness index and distensibility are more likely to respond when the baseline end-diastolic aortic root diameter is

Electrocardiographic patterns of patients with echocardiographically determined biventricular hypertrophy.

Abstract The numerous criteria proposed for the electrocardiographic (ECG) diagnosis of biventricular hypertrophy (BVH) suffer from inadequate correlative data. We used two-dimensional (2D) echocardiography to identify BVH and analyzed the ECG patterns in these patients. The study group had 69 such patients with BVH and the control group had 22 patients with isolated left ventricular hypertrophy (LVH) demonstrated by 2D echocardiography. The electrocardiograms were analyzed for the presence of established criteria used in the diagnosis of LVH and right ventricular hypertrophy (RVH). Of the 69 patients in the study group, 17 (25%) had EGG findings of BVH, 25 (36%) had LVH, and 14 (20%) had RVH. An S wave in V5/V6 of >7 mm was most the frequent finding in the 17 patients with BVH on the electrocardiogram. The sensitivity of ECG criteria for BVH was 24.6%, specificity was 86.4%, and positive predictive value was 85%. This study reemphasizes the difficulty of ECG diagnosis of BVH. The electrocardiogram has a low sensitivity but satisfactory specificity and positive predictive accuracy for BVH.

Observations on the Interatrial Pressure Gradients in Man

It was possible to calculate pressure gradients across the interatrial septum in several cases of congenital heart disease. Gradients in cases of interatrial septal defect are similar to those found in animals with artificially produced defects. The data are used to form a rounded picture of the hemodynamics of interatrial septal defect. In pulmonic stenosis with interatrial communication, reversal of the usual left-to-right gradient may occur only during atrial systole. Under these circumstances it is often possible to distinguish a patent foramen ovale with competent valve from an interatrial septal defect.

The Ventricular Electrokymogram

Over 200 left ventricular electrokymographic tracings were obtained in 32 normal adults, averaging more than six sites explored per individual. Records were analyzed with respect to the relationship of certain designated points to simultaneously recorded heart sounds. Considerable variability was demonstrated in these relationships both in tracings from different ventricular sites in the same individual and between comparable tracings from different individuals. The meaning of the ventricular electrokymogram and its clinical applicability are discussed in the light of these findings.

The Effect of Desiccated Thyroid on Plasma and Tissue Lipids and Atherogenesis in the Stilbestrol-Treated Chick

Repeated implantations of diethylstilbestrol pellets cause a sustained hyperlipemia in the chick, and atherosclerosis eventually supervenes. Desiccated thyroid significantly reduces the incidence and degree of the stilbestrol-induced atherosclerosis in the chick, although it is without sustained effect upon the plasma and tissue lipids.

Left ventricular constriction due to myocarditis in a child

Abstract A case (followed for six years) is reported of an 8 year old child with syncopal episodes presumed due to acute left ventricular failure. Electrocardiograms showed progressive left ventricular hypertrophy while radiographically there was evidence of left atrial and right ventricular enlargement. Hemodynamic data obtained at left heart catheterization revealed markedly elevated mean left atrial and left ventricular end-diastolic pressure. In the absence of gross left ventricular enlargement this suggested a constrictive phenomenon involving the left ventricle. The etiology of the latter was found at postmortem examination to be due to chronic myocarditis and coronary vasculitis.

Recurrent spontaneous mediastinal emphysema simulating myocardial infarction

Abstract 1. 1. A case of recurrent spontaneous mediastinal emphysema simulating myocardial infarction in a 23-year-old man is reported. 2. 2. The presence of signs of shock and hypotension, not previously reported in association with this syndrome, are described.

Ruth Pick, MD

I have three treasures. Guard and keep them: The first is deep love, The second is frugality, And the third is not to dare to be ahead of the world. Because of deep love, one is courageous. Because of frugality, one is generous. Because of not daring to be ahead of the world, one becomes the leader of the world. — –Lao-tzu,The Way of Lao-tzu Dr.Ruth Pick was born in Karlsbad, Czechoslovakia, on November 13, 1913, and died on July 19, 2003, in Chicago, Illinois. These years bound a life of scholarship, accomplishment, courage, commitment, and humility. With the passing of Dr Ruth Pick at the age of 89, we have lost someone who was not only a silent but powerful contributor to cardiovascular medicine but also a woman of heroic proportions to all who knew and loved her. Ruth Pick was known by many as the wife …