Harald Eliasch

THE EFFECT OF EXPERIMENTALLY INDUCED HYPERVOLEMIA ON CARDIAC FUNCTION IN NORMAL SUBJECTS AND PATIENTS WITH MITRAL STENOSIS

The physiologic differences between various types of laboratory preparations and unanesthetized man have been in part responsible for a wide diversion of opinion concerning the control of cardiac function in man (1). While numerous studies of the regulation of cardiac performance have been carried out in animals, relatively few studies have been done in man(2). The present work was undertaken in an attempt to clarify some of the mechanisms concerned with the control of cardiac function in man and has included studies in normal subjects and patients with mitral stenosis. During a study of the relation existing between renal and cardiac function, rapid intravenous infusions were given to normal individuals and patients with various types of cardiac disorders (3). When the infusions consisted of isotonic solutions of dextran 1 it was possible to analyze the relation of right heart filling pressure to cardiac output or right ventricular work, in a manner which closely simulated that used by Sarnoff and Berglund in the anesthetized dog (4), or Warren, Brannon, Weens and Stead in man (5). The present report is concerned with the effects on cardiac performance of varied degrees of expansion of the blood volume during 32 studies in 31 normal subjects and 16 studies in 15 patients with mitral stenosis.

Pulmonary circulatory dynamics in mitral stenosis before and after commissurotomy

Abstract 1.1. Forty-six cases of mitral stenosis were operated upon by digital commissurotomy. No case was in right heart failure. No other valvular lesions of important degree were demonstrated. Seven cases died in direct connection with the operation. 2.2. All cases were studied with the heart catheterization technique before and about six weeks after operation. The response to slight, graded work was also studied before and after valvulotomy in eleven cases. 3.3. The best objective results from operation were obtained in cases below the age of 45 years, with sinus rhythm and heart size less than 600 ml/m 2 B.S.A. and symptoms corresponding to Group III or IV. 4.4. Commissurotomy has afforded beneficial results to many cases of mitral stenosis, suggesting further operative treatment of this disease: Thorough hemodynamic studies are still needed to form proper indications and contraindications.

Studies on the renal circulation and renal function in mitral valvular disease. I. Effect of exercise.

In 31 patients with mitral stenosis of varying severity the effect of light, steady exercise during 15 to 17 minutes on renal function and renal circulation has been studied during heart catheterization. The results have been compared with the values obtained at rest in 72 patients with mitral stenosis. Exercise produced a decrease in clearance of para-aminohippurate and sodium excretion and an increase in renal resistance, changes not produced in normal individuals. Cardiac output and pulmonary pressures increased. In patients with right heart failure exercise produced increased pressures but no increase in cardiac output, and only slight changes in clearance but increase in renal resistance and renal venous pressure.

Studies on the Renal Circulation and the Renal Function in Mitral Valvular Disease III. Effect of Valvulotomy

Renal circulation and function were studied simultaneously with pulmonary and systemic hemodynamics in 25 patients with mitral stenosis before and six weeks after valvulotomy. Postoperatively no essential change in renal circulation or function could be demonstrated whether significant relief of pulmonary hypertension had occurred or not. However, results from follow up studies made on 21 patients up to more than three years after operation showed that renal plasma flow could be increased in patients that were hemodynamically improved at the postoperative study. The effect of exercise was investigated in eight patients before and after valvulotomy. In seven the response pattern of renal circulation and function was essentially unchanged regardless of whether improvement in pulmonary pressures and cardiac output did or did not occur. In the eighth patient, the only one with elevated right atrial pressure before operation, the response to exercise improved markedly. Preoperative results obtained on seven patients who died in connection with operation showed that a fatal outcome was not necessarily related to the degree of impairment in renal circulation or function.

Studies on the Renal Circulation and Renal Function in Mitral Valvular Disease II. Effect of Apresoline

In a study of the nature of the renal changes in patients with mitral stenosis, lowered renal function and reduced renal circulation the effect of Apresoline, given during heart catheterization to 12 patients with mitral stenosis of varying severity, was studied. The drug was found to increase renal blood flow (and decrease arterial blood pressure), showing that the renal changes in mitral stenosis are reversible. The two effects of Apresoline were shown to be independent of each other.

Pulmonary and renal circulatory adjustments to the upright posture in patients with mitral valvular disease

Abstract 1.1. Ten patients with mitral valvular disease were investigated in the recumbent and in the erect posture (tilted 60 degrees head up). The cardiac output, pulmonary and systemic pressures, cardiopulmonary and total blood volumes, and renal clearances of inulin and para-aminohippurate, as well as the excretion of sodium, were determined. 2.2. In 7 patients without symptoms and signs of right heart failure the cardiac and stroke outputs decreased, as well as the pulmonary capillary and the right atrial pressures. In 2 patients with clinical signs of right heart failure the cardiac and stroke outputs remained unaltered. 3.3. The pulmonary arterial pressure fell moderately when the patients took the erect posture. The pulmonary arterial and the systemic arterial pulse pressures were generally diminished. 4.4. The cardiopulmonary blood volume fell in 3 instances. This was reflected by a concomitant decrease in pulmonary capillary venous pressure. 5.5. The renal clearance of inulin and paraaminohippurate as well as the excretion of sodium generally decreased. 6.6. One patient was tilted 30 degrees head down. No symptoms appeared, and no major hemodynamic change was recorded. 7.7. The results are discussed in view of possible hemodynamic factors that may cause orthopnea in heart disease.

Contribution of the coronary arteriogram to diagnosis of coronary heart disease

Abstract Sixty-five patients were studied by coronary arteriography over a period of three years in order to analyze the relation between the roentgenologic findings and the presence or absence of “typical” anginal pain and ischemie electrocardiographie change. Complications caused by the examination were rare and nonfatal. In 34 of 35 patients with typical anginal pain together with an ischemie electrocardiographic pattern, the coronary arteriogram showed structural change. In 13 of 14 patients without the aforementioned clinical and electrocardiographic features, no arterial change was visible. In 16 patients whose clinical history and electrocardiographic patterns were dissociated, arterial change was present in 9. The results suggest that coronary arteriography can provide an important clue to the diagnosis of coronary heart disease. Appraisal of the prognostic value of coronary arteriography is important and must await follow-up examinations.

The effect of a single intravenous dose of scillaren B on the pulmonary circulation and renal function in patients with rheumatic heart disease.

Abstract 1. 1. The effect of a single intravenous dose of Scillaren B on the blood pressures in the lesser circulation, and the clearance values for inulin and para-aminohippurate as well as sodium excretion were studied in six patients with rheumatic heart disease. 2. 2. Heart rate rapidly decreased, in some cases during the first minute after administration. 3. 3. Pulmonary blood pressures fell rapidly, while cardiac output remained unchanged. Stroke index rose considerably. 4. 4. No effect on clearance values or sodium excretion was noticed. 5. 5. Compared with lanatoside C, Scillaren B acts with shorter latency on pulmonary pressures in patients with mitral stenosis, but does not show any of the prompt, direct renal effects of the digitalis drug. 6. 6. Scillaren B is a swift and potent cardiac drug. The renal action which has been described earlier is secondary to its effect on the heart.