Paul C. Kahn

Diagnosis and localization of aldosterone-producing adenomas by adrenal-vein cateterization.

EVEN when the diagnosis of primary aldosteronism is obvious before operation, there is no way to localize the adenoma. Preoperative demonstration of the tumor radiographically, as by retroperitonea...

Comparison of left and right ventricular end-systolic pressure-volume relations in congestive heart failure.

A hemodynamic-radionuclide study was performed to compare the relations between end-systolic pressure and volume in the left and right ventricles in 10 patients with biventricular failure, and to correlate the end-systolic pressure-volume slope with baseline variables of systolic function. During nitroprusside or nitroglycerin infusion, or a combination of both, linear relations were found between end-systolic pressure and volume for both ventricles. In 9 of 10 patients, the end-systolic pressure-volume slope was greater for the left ventricle (mean +/- SD 1.12 +/- 0.36 mm Hg X m2/ml) than for the right ventricle (0.46 +/- 0.27 mm Hg X m2/ml) (p less than 0.001). In all 10 patients, the volume-axis intercept of the pressure-volume relation was greater for the left ventricle (82 +/- 66 ml/m2) than for the right ventricle (2 +/- 30 ml/m2) (p less than 0.005). Right ventricular pressure-volume slope correlated weakly with baseline right ventricular ejection fraction (r = 0.69, p less than 0.05), strongly with the baseline right ventricular end-systolic pressure-volume ratio (r = 0.89) and inversely with baseline right ventricular end-systolic volume (r = -0.86). In conclusion, 1) in patients with severe biventricular failure, changes in systolic pressure influence end-systolic volume more strongly in the right than in the left ventricle. 2) For the right ventricle, the slope of the end-systolic pressure-volume relation is directly related to rest indexes of systolic function. 3) The greater the end-systolic volume at rest, the greater the predicted improvement in right ventricular emptying for any vasodilator-induced reduction in pulmonary artery end-systolic pressure.

Selective Angiography of the Inferior Phrenic Arteries

The inferior phrenic arteries are a major source of blood for the diaphragm and the adrenal glands and often give important branches to the esophagus, stomach, liver, inferior vena cava, and retroperitoneum. The development of selective catheterization technics of other small vessels, such as the bronchial arteries (2), has prompted this investigation of the feasibility and usefulness of selective angiography of the inferior phrenic arteries. Anatomic Considerations The inferior phrenic arteries develop in the meshwork of ventrolateral vessels supplying the mesonephros of the embryo (3), and, because of the early growth of the adrenal glands, they are initially primarily superior suprarenal arteries. With the relatively greater development of the diaphragm in late fetal and early extrauterine life, however, the phrenic branches become predominant (9). The arteries originate with almost equal frequency from the aorta and celiac axis, with an aortic origin slightly more frequent on the right side (46 per ce...

Adrenal Arteriography and Venography in Primary Aldosteronism

Twenty patients with primary aldosteronism were studied by adrenal arteriography, venography, and adrenal vein aldosterone assay. Selective arteriography was successfully performed in 78% of the patients, correctly diagnosing the lesion in 60%. Selective venography was accomplished bilaterally in all but one patient; however, 3 adrenal ruptures occurred during the procedure. Adrenal vein assay, the best single method, was 85% accurate, but 2 tumors easily visible at angiography were missed by this routine. The authors recommend the use of a combination of these 3 techniques, which gave 95% accuracy in localizing aldosteronomas.

Vasodilator effect on right ventricular function in congestive heart failure and pulmonary hypertension: End-systolic pressure-volume relation

The right ventricular (RV) end-systolic pressure-volume relation during vasodilator administration was studied in 10 patients with pulmonary arterial (PA) hypertension, most of whom had biventricular failure. RV end-systolic volumes were estimated from equilibrium radionuclide RV counts and forward cardiac output. Simultaneous radionuclide and hemodynamic values were measured at rest and during nitroglycerin and nitroprusside infusion. Vasodilator administration resulted in decreases in PA mean and systolic pressures in all 10 patients, with an average decrease in end-systolic pressure (p less than 0.001) from 48 +/- 11 to 38 +/- 9 and 35 +/- 10 mm Hg during nitroglycerin and nitroprusside administration, respectively. In each patient, a direct linear relation was observed between the vasodilator-induced decrease in PA end-systolic pressure and in RV end-systolic volume. Average RV end-systolic volume decreased (p less than 0.001), from 130 +/- 69 ml/m2 at baseline to 108 +/- 62 and 102 +/- 55 ml/m2 during nitroglycerin and nitroprusside infusion, respectively. The slope of the RV end-systolic pressure-volume relation was directly related to RV ejection fraction. Thus, the vasodilator-induced decrease in PA systolic pressure is accompanied by a linear decrease in RV end-systolic volume, with a slope which is dependent on RV systolic function. This linear relation is analogous to the left ventricular end-systolic pressure-volume relation.

Unusual Pelvic Masses: A Comparison of Computed Tomographic Scanning and Ultrasonography

Four unusual pelvic masses, studied by CT and gray scale ultrasonography, demonstrate the comparative values of these modalities for this area of the body. In each instance a significant contribution to the diagnosis was made by one or both techniques. The ultrasound study provides a somewhat better differentiation of solid from cystic lesions, but the CT scan denotes to best advantage the anatomy of the area, and provides a means of viewing bone as well as soft tissue detail.

Cholecystosonography: An Approach to the Nonvisualized Gallbladder

B-scan echography was employed in the evaluation of 12 patients whose gallbladders remained nonvisualized after double-dose oral cholecystography. The gallbladder was identified by ultrasound in all but 1 patient. Gallbladder size was assessed and specific diagnoses of chronic cholecystitis, empyema, obstruction or dilation, and gallstones were made by this technique. When a normal gallbladder is seen by ultrasound, it indicates a cause other than primary biliary disease for nonopacification. Cholecystosonography is considered a valuable supplementary study when adequate opacification of-the gallbladder cannot be achieved.

Activation of aldosterone secretion in primary aldosteronism

Angiotensin infusion evokes marked increases in aldosterone secretion in primary aldosteronism and little change in secondary aldosteronism. The low plasma renin activity of primary aldosteronism and the elevated plasma renin activity of secondary aldosteronism are thought to account for this differential response. The effect of angiotensin on aldosterone and 18-hydroxycorticosterone secretion was studied during adrenal vein catheterization in seven patients with primary aldosteronism (whose plasma renin activity had been elevated following spironolactone therapy), one hypertensive patient with normal plasma renin activity and normal aldosterone secretion, two patients with secondary aldosteronism who had elevated plasma renin activity, and one anephric patient whose plasma renin activity was 0. Adrenal venous aldosterone and 18-hydroxycorticosterone were measured before and after a ten min sub-pressor angiotensin infusion. The cells of the aldosterone-producing adenoma (APA) respond to small increases in plasma angiotensin with large increases in secretion of aldosterone and 18-hydroxycorticosterone. The dose of angiotensin capable of evoking this response from the aldosterone-producing adenoma produces little or no change in the secretion of the steroids from nontumorous glands. The augmentation of aldosterone secretion, induced by angiotensin, in primary aldosteronism is due solely to increased secretion by the adenoma and not by the contralateral zona glomerulosa. The increased sensitivity of the aldosterone-producing adenoma is characteristic of the tumor. This response is independent of fluctuations in endogenous plasma renin activity. This sensitivity is not blunted by high plasma renin activity, nor is it a function of tumor mass for the effect is observed in aldosterone-producing adenomas regardless of size. ACTH injection after angiotensin infusion resulted in a marked increase in aldosterone concentration in the effluent from the nontumorous adrenal, but was not capable of producing further increases in aldosterone concentration in the effluent from the APA. In view of this exquisite sensitivity to infused angiotensin, it may be that the small variations in endogenous plasma renin activity that have been observed in primary aldosteronism may be capable of evoking large changes in aldosterone secretion in patients with aldosterone-producing adenomas.

Clinical usefulness of 67gallium scanning in the malignant lymphomas

To determine the clinical usefulness of 67 gallium (Ga) scanning in the evaluation of patients with lymphomas, we reviewed 142 total body Ga scans performed on 44 patients with Hodgkins disease and 53 patients with non-Hodgkins lymphoma. Fifty-two per cent (123 of 236) of known disease sites were detected on scan. The false-positive rate was less than 5 per cent. The accuracy of detecting lymphoma varied in individual anatomic areas from 33 per cent in the axilla to 73 per cent in the thorax. In eight patients with bone involvement, all bone lesions were detected on scan. The size of the lesion appeared to influence accuracy, since tumors greater than 3 cm in diameter were more often positive.

INFERIOR MESENTERIC ARTERIAL PATTERNS; AN ANGIOGRAPHIC STUDY.

The importance of lesions of the segment of the gut supplied by the inferior mesenteric artery is hardly reflected by the volume of literature concerning this vascular bed. Over 75 per cent of all polyps and cancers of the colon occur in the area of distribution of this artery. Recent fragmentary studies suggest the possibility of identifying some of these lesions by arteriographie technics, and of differentiating them from inflammatory masses which simulate neoplasms (27). In the study of infarction of the bowel, emphasis traditionally has been on the superior mesenteric artery (29), which is a more common site of mesenteric thrombosis. Nevertheless, it is abundantly clear that the inferior mesenteric artery is also a frequent site of atheromatous change, and at times of occlusion. Perhaps a major factor in the persisting viability of the gut associated with significant disease of the inferior mesenteric artery is the richness of the collateral system. The inferior mesenteric artery itself serves as a co...