Frank E. Kloster

The Role of Left Atrial Transport in Aortic and Mitral Stenosis

The relationship of left atrial contraction to ventricular filling was studied in 24 patients. Eight patients had aortic stenosis, eight had mitral stenosis, and eight others served as a control group. All had normal sinus rhythm. Cineangiocardiographic volumetric determinations of the left ventricle were done throughout the cardiac cycle, and the rate of left ventricular filling before and during left atrial contraction was calculated.In the group with aortic stenosis 39% of the left ventricular stroke volume entered the ventricle during left atrial contraction; in the group with mitral stenosis 24% was contributed during left atrial contraction, and in the control patients, 26%.The rate of left ventricular filling more than doubled during left atrial contraction in aortic stenosis, while no consistent change in the rate of filling occurred during left atrial contraction in mitral stenosis and in the control group.The character of the resistance to left ventricular filling in aortic stenosis and mitral stenosis is discussed. An important contribution by left atrial contraction to left ventricular performance in aortic stenosis is suggested.

Natural history of asymptomatic coronary arteriographic lesions in diabetic patients with end-stage renal disease

Arteriosclerotic heart disease is a major cause of death in insulin-requiring juvenile diabetic patients treated for end-stage renal disease. Eleven consecutive diabetic patients without clinical evidence of coronary artery disease underwent complete cardiac evaluations, including coronary arteriography, as part of transplant recipient work-ups. Seven were women and four were men; their mean age was 32 (21 to 50 years). Angiographically, every patient had multifocal atherosclerotic coronary disease. Four of seven patients tested had positive-stress electrocardiograms. In this group of patients followed for a mean of 19.8 months, eight died. Of these deaths, six were due to coronary heart disease and another due to a stroke. In two patients who became clinically symptomatic, serial angiograms revealed progressive disease of the coronary circulation; in one case, despite normal renal allograft function and serum lipid levels. The mode of end-stage renal disease treatment, serum lipids or blood pressure control could not be linked to mortality. It is concluded that arteriosclerotic heart disease is common in diabetic patients with end-stage renal disease even when angina is absent. The natural history in this high risk population is an important consideration in the selection of patients for end-stage renal disease treatment.

Improvement in left ventricular wall motion following nitroglycerin.

Coronary artery disease patients frequently have left ventricular wall motion abnormalities. Though nitroglycerin is commonly used in ischemic heart disease, its effects on wall motion abnormalities is unknown. In this study we have evaluated the effects of nitroglycerin on wall motion abnormalities and on ejection fraction in 25 patients. Sixteen had coronary artery disease (>70% luminal narrowing). Six had no evidence of heart disease and three had congestive cardiomyopathies with normal coronary arteries. Left ventricular angiography was performed prior to and six minutes after administration of 0.4 mg of sublingual nitroglycerin. Twelve of the 16 coronary artery disease patients had wall motion abnormalities, and in seven of these, segmental wall motion improved after nitroglycerin. In five, wall motion did not change. The initial heart rate, left ventricular systolic and end-diastolic pressure, and left ventricular end-diastolic volumes were not different for those whose wall motion improved versus those whose did not. The increase in the former and fall in the latter three hemodynamic parameters were significant (P < 0.01) and similar for the two groups. In those whose wall motion abnormalities improved after nitroglycerin, ejection fraction (mean ± se) increased significantly (P < 0.05), from 0.47 ± 0.025 to 0.62 ± 0.046. In those without improvement, the ejection fraction went from 0.55 ± 0.056 to 0.58 ± 0.051 (NS). Three patients with congestive cardiomyopathy showed no improvement in ventricular wall motion or ejection fraction after nitroglycerin. Left ventricular wall motion abnormalities and ejection fraction improved in some coronary artery disease patients following nitroglycerin. The mechanism for this is unknown; however, ventriculography before and after nitroglycerin may be of potential usefulness for identifying areas of reversible wall motion abnormalities.

Diagnosis and management of complications of prosthetic heart valves

Complications after heart valve replacement remain a substantial source of morbidity and mortality despite continuing advances in surgical care and prosthetic design. Infectious endocarditis occurs in about 4 percent of patients and may appear early (within 60 days) or late after operation. Endocarditis of early onset is commonly due to staphylococcal, fungal or gram-negative organisms and is fatal in 70 percent or more of cases. Infection of late onset is more often of streptococcal origin and the mortality rate is lower, about 35 percent. With either type, prompt recognition, vigorous and appropriate antimicrobial therapy and early consideration of surgical intervention are crucial. The postperfusion and postpericardiotomy syndromes are relatively common and relatively benign syndromes associated with postoperative fever. Their recognition is important to prevent confusion with endocarditis or sepsis and thus to reassure the patient and physician. Treatment is primarily symptomatic. Intravascular hemolysis occurs with most prosthetic heart valves but is more common with certain prostheses and with paraprosthetic valve regurgitation, with significant hemolytic anemia in 5 to 15 percent. Oral iron replacement therapy is effective in the majority of patients, but occasionally blood transfusion or reoperation for leak around the prosthesis is necessary. Prosthesis dysfunction due to thrombus may be recognized clinically by recurrence of heart failure, syncope, cardiomegaly and altered prosthetic valve sounds or new murmurs. Hemodynamic studies verify the diagnosis, and prompt reoperation is indicated for this potentially lethal problem. Systemic embolization has decreased markedly with the introduction of cloth-covered prostheses and is frequently related to erratic or ineffective anticoagulant therapy. We continue to recommend anticoagulant therapy for all patients with prosthetic heart valves unless there is a major contraindication.

Problems in the hemodynamic diagnosis of tricuspid insufficiency

Abstract The dependability of RVA in the evaluation of TI was studied in 141 patients with congenital or rheumatic disease. In patients over age 10, angiocardiography revealed TI in 13 and was negative in 27. Eight with positive RVA had cardiac operation and TI was confirmed in seven; three not having been operated upon were probably false positives. Six with negative RVA had an operation and no TI was detected. In 20 per cent of 95 younger patients, RVA revealed TI, often believed catheter induced. RA pressure criteria commonly employed in the hemodynamic diagnosis of TI were tested. RA pressure level and contour were analyzed in 27 cases proved negative for TI by RVA and in seven proved positive by operation. An X descent shallower than Y correlated better with atrial fibrillation than with TI; X deeper than Y correlated better with sinus rhythm than with tricuspid competence. RVA can exclude TI but yields false positive studies. RA pressure contour is believed not to have the usually accepted significance.

Echocardiographic criteria for aortic root dissection

Echocardiographic findings from 10 patients without clinical indications of aortic root dissection or aortic valve disease from 1 patient with angiographic confirmation of aortic root dissection are reported and compared. Previously reported echocardiographic findings were confirmed in the patient with aortic root dissection. These include (1) a widened posterior or anterior aortic wall, or both; (2) parallel motion of the separated margins of the aortic walls; and (3) aortic root dilatation (42 mm or more at end-systole). However, all three findings were also noted in 5 of the 10 patients without clinical indications of aortic root dissection or aortic valve disease, and at least two of the three findings were noted in the remaining 5 patients. Echocardiographic detection of aortic root dissection appears to be most reliable when clinical indications of the anomaly are present.

Clinically suspect ischemic heart disease not corroborated by demonstrable coronary artery disease. Physiologic investigations and clinical course.

Abstract In 11 patients with angina pectoris and abnormal stress electrocardiograms, no narrowing or obstruction of coronary vessels was visible by selective cut film and coronary cinearteriography. One patient showed chemical evidence of myocardial hypoxia despite normal arteriograms. Similar evidence of impaired myocardial oxygen supply was absent in the remaining 10 patients. We found no abnormality in hemoglobin O 2 affinity which might jeopardize myocardial O 2 supply. The clinical course of these patients, including that during a 1 to 2 year followup period, has not been complicated by myocardial infarction or cardiac failure. In 5 symptoms have decreased.

Phonocardiographic Diagnosis of Aortic Ball Variance

Fatty infiltration causing changes in the silastic poppet of the Model 1000 series Starr-Edwards aortic valve prostheses (ball variance) has been detected with increasing frequency and can result in sudden death. Phonocardiograms were recorded on 12 patients with ball variance confirmed by operation and of 31 controls. Ten of the 12 patients with ball variance were distinguished from the controls by an aortic opening sound (AO) less than half as intense as the aortic closure sound (AC) at the second right intercostal space (AO/AC ratio less than 0.5). Both AO and AC were decreased in two patients with ball variance, with the loss of the characteristic high frequency and amplitude of these sounds. The only patient having a diminished AO/AC ratio (0.42) without ball variance at reoperation had a clot extending over the aortic valve struts. The phonocardiographic findings have been the most reliable objective evidence of ball variance in patients with Starr-Edwards aortic prosthesis of the Model 1000 series.

Response of coronary circulation to cutaneous cold

Abstract The coronary and systemic hemodynamic responses to cutaneous cold stimulation were investigated in 25 patients. Nineteen had coronary heart disease and six had no evidence of coronary heart disease. Cutaneous cold increased systemic arterial and left ventricular end-diastolic blood pressures. Coronary blood flow increased in proportion to the increase in myocardial oxygen consumption, and there was no significant change in coronary blood arteriovenous oxygen difference. Cold provoked angina pectoris in five patients and chemical evidence of myocardial hypoxia in seven patients. We detected no difference in systemic or coronary circulatory responses in patients with a history of cold intolerance, and myocardial hypoxia appeared to be related to restricted coronary reserve rather than to a special effect of cold on myocardial metabolism or coronary vasomotion.

Clinical and hemodynamic results of peritoneal dialysis for severe cardiac failure

Abstract A total of 16 patients with heart disease of various types underwent peritoneal dialysis for severe and often intractable, cardiac failure. The average amount of fluid removed was 6 liters. Most patients had immediate improvement of symptoms and signs of fluid overload, 12 entered periods of remission, and four were improved enough to undergo corrective surgery, with survival of three. An average weight loss of 6 kilograms occurred during dialysis and 4 kilograms more in the next 2 weeks. Serum sodium and chloride levels were depressed initially and returned toward normal in most patients. The average predialysis sodium and chloride levels were 126 and 86 mEq. per liter, increasing to 136 and 97, respectively. Total blood volume (TBV) was greatly expanded beforehand and decreased with therapy in all 9 patients so studied. The average decrease was from 139 to 109 ml. per kilogram. Cardiac index (CI) was low in all and increased significantly in 6 of 8 patients so studied, the average changing from 1.4 to 1.9 L. per minute per square meter. The decrease in TBV, increase in CI, and sustained clinical improvement were closely associated. There were no definite complications, although in one instance, excessive vascular volume depletion may have contributed to hypotension, oliguria, and death. It is concluded that hypertonic peritoneal dialysis is an effective method for the treatment of severe heart failure with sodium dilution.