Edvardas Varnauskas

Right atrial myxoma. Report of a case and review of the literature

Abstract Two cases of right atrial myxoma are presented, together with a review of 16 other published cases. The clinical course of these patients is characterized by progressive right heart failure, usually refractory to medical therapy, without evidence of underlying pulmonary disease or left heart failure. A low-pitched diastolic murmur along the lower left sternal border is the most characteristic ausculatory finding. Right atrial hypertension and a diastolic gradient across the tricuspid valve are consistent findings at cardiac catheterization. Angiocardiography is the definitive diagnostic method for establishing the diagnosis of right atrial myxoma, and a characteristic filling defect is noted in every reported case. Since cure may be obtained by utilizing open-heart surgery with cardiopulmonary bypass, an early and accurate preoperative diagnosis is of great importance.

Coronary blood flow in man and its relation to the coronary arteriogram.

Abstract Coronary flow was measured by injection of radioactive xenon into the aortic root and registration of the clearance curve in coronary sinus blood. Double determinations at rest were performed in 17 patients and showed good reproducibility. The values were in good agreement with those published earlier. Values for coronary blood flow were related to the degree of coronary heart disease established by coronary arteriogram. No difference in coronary flow was found between patients without detectable disease and patients with advanced coronary heart disease.

Obscure cardiomyopathies with coronary artery changes

Abstract A series of patients with suspected cardiomyopathy were investigated by coronary angiography. Thirteen of them had coronary arteriograms suggesting more or less extensive coronary involvement of the type demonstrated by markedly straight and narrow branches of both main coronary arteries. One of these patients had established Friedreichs disease and another had three sisters affected by this neurologic disease. The coronary angiographie findings in these 2 patients were indistinguishable from those of the remaining 11. A special histopathologic examination in 1 of the 5 deceased patients (all from the group of 11) disclosed widely distributed medial changes in the medium-sized and small coronary arteries and fibrotic involvement of the myocardium of the same appearance as described in cases of Friedreichs disease or other heritable diseases. Thus a possibility exists that a similar coronary arteriopathy is responsible for the angiographie pattern of all patients in the present series. Various types of cardiac arrhythmias, occurring paroxysmally or persistently, conduction disturbances, and in a few cases cardiac failure as well as chest pain, were the main causes of symptoms, except in 3 patients who were free of symptoms. No conclusive correlation could be established between electrocardiographic abnormalities (including ST-T changes in a few patients) and the extent and distribution of the coronary involvement on the arteriograms. The arrhythmias were, with one exception, resistant to the usual therapy. Hemodynamic (in 4 patients) and other laboratory investigations were unrewarding concerning the pathogenesis. Five of the 13 patients died (4 in ventricular fibrillation and 1 in congestive heart failure) during a relatively short follow-up period.

Pulmonary extravascular and intravascular fluid volumes in resting patients

Abstract Pulmonary extravascular and intravascular fluid volumes were measured in 29 patients at rest during cardiac catheterization. Increased extravascular fluid volume was clearly related to increased left atrial and pulmonary arterial pressures. It was not related to flow, resistance or intravascular volume. Extravascular water volumes 3 times “normal” were observed without clinical signs of alveolar pulmonary edema. This probably represents increased interstitial volume or edema. Pulmonary intravascular volume (pulmonary blood volume) was observed to act as a rigid compartment, changing little with intravascular pressure, whereas the extravascular volume was very compliant or distensible. A possible feedback relationship between the pulmonary extravascular and intravascular volumes is discussed. Increases in pulmonary extravascular volume described here correlated well with functional capacity and dyspnea as evaluated by the New York Heart Association classification. Individuals with the greatest extravascular volume were most incapacitated. Chest roentgenograms showing pulmonary congestion and interstitial edema were also related to increased pulmonary extravascular volumes.

Coronary angiography in the clinical analysis of suspected coronary disease

Of 420 patients studied with coronary arteriography, 10 were selected and described in detail, the aim being to illustrate diagnostic possibilities of the method. Current pathophysiologic and etiologic concepts are discussed against the background of findings in the 10 patents and in the whole series. The coronary arteriograms were performed according to Paulins33 method, including contrast injection through a loop-end catheter placed immediately above the aortic valves, without any general anesthesia or pharmacologic interference with heart action. The validity of the method was shown by good agreement between the angiographic and postmortem findings in 39 patients who died at different times after the investigation and had normal to severely diseased coronary arteries. Even if there is generally a good correlation between the electrocardiographic changes and the arteriographic picture, there are also many exceptions. These can be explained by basic differences in methods. Arteriography pictures the patency of only part of the hearts vascular system. The electrocardiogram depicts a sort of integrated electrical function of the cellular activity of the heart. Extensive investigations have been made to establish some risk factors that may have value in predicting coronary heart disease. However, it cannot be emphasized enough that these risk factors are too loose to be of any great importance in the evaluation of the single patient. Our results show that a carefully taken history of pain and use of the symptom “angina pectoris” based on strict criteria is a diagnostic method with a value at least equal to that of the electrocardiogram. Our experience does not support the view that coronary arterial disease is a continuous process but indicates that it may instead have a more episodic character. Even if coronary arteriography is often of great value in diagnosis and in the management of patients, we believe that it is still not a method to be used routinely. It should be used by those with a scientific interest in coronary heart disease. As a tool in present and future clinical research, it has an important place in solving specific problems.

The syndrome of anomalous pulmonary venous drainage with enlarged left atrium reflecting mitral stenosis

Abstract The syndrome of enlarged left atrium in the presence of partial anomalous pulmonary venous return is presented in two forty year old female patients. The cause of the left a trial enlargement was found to be clinically silent mitral valvular stenosis. The hemodynamic features of this syndrome were studied with right heart catheterization and transseptal left atrial catheterization. The anatomy of the left atrium, including the restricted function of the mitral valves, was demonstrated by selective transseptal angiocardiography. In one patient the right main pulmonary arterial branch was occluded by a latex balloon, thus restricting the anomalous pulmonary venous drainage and diverting the total pulmonary blood flow to the left atrium. This caused an instantaneous increase in left atrial pressure and systolic right ventricular pressure These pressures returned to the preocclusion level when the balloon was deflated. The significance of the hemodynamic findings are discussed with respect to the clinical picture.

Left atrial pressure during exercise in hemodynamic normals

Abstract Mean left atrial pressure during supine submaximal exercise was studied in seven hemodynamic normal individuals. A rapid increase in pressure to a maximum at the second to fourth minute of exercise followed by a slow decline to levels near or below those of rest conditions was noted in all individuals. A possible mechanism relating left ventricular exercise response to left atrial pressure is discussed.

A Computerized System for Optimal Filtering of Left Ventricular Pressure Data

On account of noise, considerable errors appear in standard pressure-record estimates of left ventricular performance. These errors can be reduced by adequate data processing. A clinically useful criterion of such processing of left ventricular pressure is presented. The reproducibility and clinical usefulness of the method are demonstrated by application to a number of experimental records as well as to a series of simulated pressure waves.

Five-year mortality for stable angina in a medical practice study and a randomised trial.

Objective : Evolution of revascularization and medical therapy has increased the probability of improved survival in patients with stable angina. The present investigation tests the hypothesis that medical practice will generate lower mortality than randomly assigned bypass surgery in the European Coronary Surgery Study (ECSS) two decades earlier. Method : Using eligibility criteria of ECSS, a clinical decision strategy (CDS) cohort of 362 patients was selected from a nationwide study of medical practice in Sweden. Access to the individual data allowed common protocol design to compare 5-year mortality between CDS and surgical strategy of ECSS. Results and interpretation : CDS advised bypass surgery (BS) or percutaneous transluminal coronary angioplasty (PTCA) in 93% and medical treatment alone in 7%, while 94% of 394 patients randomized to surgery (Euro-S) in ECSS obtained BS. Operative mortality was 3.2% for Euro-S while no operative deaths occurred in CDS reflecting medical progress during two decades. However, the 5-year mortality for CDS decreased first when the risk ratio was adjusted for age, diabetes mellitus and hypertension (RR = 0.49 with 95% CI 0.26-0.93) p = 0.03 suggesting a need for improved comprehensive medical care.