Mark M. Applefeld

The Late Appearance of Chronic Pericardial Disease in Patients Treated by Radiotherapy for Hodgkin's Disease

Radiation-induced chronic pericardial disease was recognized in nine patients 53 to 124 months (mean, 88 months) after radiotherapy for Hodgkins disease. Depending on whether abnormal cardiac hemodynamics occurred before or after a fluid challenge, patients were considered to have either constrictive pericarditis (Group I) or occult constrictive pericarditis (Group II). There were no differences between these groups in various radiotherapy data, the use of chemotherapy, or the interval after treatment when the diagnosis of chronic pericardial disease was made. There were no consistent noninvasive variables to support the diagnosis of radiation-induced chronic pericardial disease before cardiac catheterization. Four patients underwent pericardiectomy. Two of the four operated patients had an excellent surgical result; a third patient died 4 months postoperatively of drug-induced granulocytopenia; the fourth patient has persistent visceral constrictive pericarditis 18 months after surgery. Speculation over the causes of radiation-induced chronic pericardial disease is made and our recommendations for its treatment given.

Outpatient dobutamine and dopamine infusions in the management of chronic heart failure: Clinical experience in 21 patients

Dobutamine (and dopamine) are potent positive inotropic drugs which are frequently given to treat decompensated congestive heart failure. This study reports on the use of ambulatory dobutamine (and dopamine) infusions in 21 outpatients with advanced congestive heart failure. Each patient was initially hospitalized, and hemodynamic and clinical efficacy to dobutamine (and dopamine) was assessed. These 21 patients were carefully selected from a larger population of approximately 40 patients referred for this therapy. Chronic venous access was established and a drug infusion pump was supplied. Patients and family members were trained in the use of these devices. Eleven patients were treated with intermittent dobutamine infusions for 48 consecutive hours weekly, six patients with continuous (i.e., 24 hours daily) dobutamine infusions, and four patients with continuous, daily dobutamine and dopamine infusions. Significant (p less than 0.001) increases in cardiac index (1.8 +/- 0.6 to 2.7 +/- 0.7 L/min/m2) occurred during the initial dobutamine titrations. Functional classification (3.8 +/- 0.4 to 2.8 +/- 0.7) also improved significantly (p less than 0.01) during the 1.8 to 24 (mean 7.8) months of outpatient infusion therapy with dobutamine (and dopamine). Complications during outpatient therapy included drug tolerance (two instances), infection (two with bacteremias, eight with exit site infections), drug extravasation (three instances), and pump malfunction (two instances). Twenty patients have died: eleven from heart failure, four suddenly (one of them 9 months after dobutamine was stopped), and five from noncardiac causes. Our data suggest that outpatient dobutamine (and dopamine) infusions may be an effective form of therapy for selected patients with severe congestive failure who are refractory to more conventional treatment or who are awaiting cardiac transplantation.

Drug Extravasation as a Complication of Venous Access Ports

Excerpt Although Hickman catheters provide safe and reliable venous access for chemotherapy over many months (1, 2), infectious complications (3, 4) and the need for sophisticated and attentive car...

Delayed pericardial disease after radiotherapy

Delayed chronic constrictive pericarditis developed in seven patients 51 to 268 (mean 116) months after radiotherapy. Six of the seven complained of exertional dyspnea that was initially believed to be caused by mediastinal fibrosis. All patients had raised jugular venous pressure, although in two patients this finding was not appreciated by the primary physician. There were no consistent noninvasively identifiable features to allow prediction of constrictive pericarditis other than consideration of its existence and careful examination of the cardiovascular system. All patients had constrictive pericarditis proved at cardiac catheterization. Of the five patients who underwent pericardiectomy, two had an excellent functional result, one has residual pericardial constriction and two died of unrelated causes. Recommendations for the treatment of radiation-induced pericardial disease are given.

Isolated left main coronary artery stenosis and mediastinal radiotherapy as an etiologic factor

Abstract The finding of isolated stenosis of the left main (LM) coronary artery in the absence of narrowing of other coronary arteries is rare. 1–3 Syphilitic aortitis, Takayasus aortitis, familial hypercholesterolemia, aortic valve disease or replacement and idiopathic ostial stenosis in women have been reported as causes of isolated LM coronary artery stenosis. To assess the incidence, clinical significance and other potential etiologic factors associated with isolated LM coronary artery stenosis, we undertook the following study.

Digitalis and other positive catecholamine-like inotropic agents in the management of congestive heart failure

Positive inotropic agents are used to improve the impaired cardiac contractility that characterizes chronic heart failure. Digitalis is the traditional drug given for this purpose. However, there is controversy about the effectiveness of digitalis in chronic heart failure. Analysis of the available data indicates the efficacy of digoxin in mild heart failure (i.e., New York Heart Association functional classes I and II) and the relative lack of efficacy in advanced heart failure (i.e., NYHA functional class IV). Further, digoxin can be stopped in a substantial number of patients without recurrence of congestive heart failure. In selected patients whose condition no longer responds to digoxin, the long-term administration of dobutamine may be an effective alternative approach.

Digoxin pharmacokinetics in congestive heart failure.

Abstract: The steady‐state pharmacokinetics of oral digoxin in eight hospitalized patients was compared upon their admission with marked right‐sided congestive heart failure and later when they were compensated. Large intersubject variations in the serum digoxin concentration profiles were observed. However, over a 24‐hour dosing interval, digoxin concentrations in each patient studied during heart failure were either similar or higher than those observed when the patient became compensated. There were no significant differences in digoxin half‐life of elimination between the two states. In contrast, the mean ratio of the fraction of digoxin dose absorbed to its apparent volume of distribution was increased by 37 per cent (P < 0.05) in heart failure. Contrary to the prevailing notion, we found that the oral administration of supplemental doses of digoxin only on the basis of its reduced serum concentration in patients with congestive heart failure is unwarranted.