Sean Blake

Pregnancy complicated by maternal heart disease at the National Maternity Hospital, Dublin, Ireland, 1969 to 1978

Three hundred eighty-seven pregnancies (295 patients) complicated by maternal heart disease, managed at the National Maternity Hospital, Dublin, Ireland, during the years 1969 to 1978, were reviewed. The incidence was 0.5%. Three hundred twenty-three (83.5%) were of rheumatic origin, 52 (13.4%) were congenital, and the remaining 12 (3.1%) were a miscellaneous group and included cases of cor pulmonale and coronary artery disease. There were two maternal deaths--one from congenital heart disease and one from postpartum suicide, unrelated to mild rheumatic heart disease. The perinatal mortality rate was 3.3%. Five pregnancies (three patients) were complicated by surgically uncorrected cyanotic congenital heart disease. One of the maternal deaths and three of the perinatal deaths occurred in this group. There were 38 episodes of cardiac failure (38 patients) in cases of rheumatic heart disease. The New York Heart Association grading was grade 1 in 15 (39%) of these before the onset of failure. Prophylactic antibiotics were not used and infective endocarditis did not occur. Therapeutic abortion was not practiced and a conservative approach was adopted in obstetric intervention and in all drug therapy.

Serial changes in cardiac output during normal pregnancy: a Doppler ultrasound study

OBJECTIVES To determine the direction and magnitude of change in cardiac output (CO) during pregnancy. STUDY DESIGN We performed serial measurements of CO on five occasions from 24 weeks gestation to term and once during the puerperium in 26 normal pregnancies (156 measurements) using Doppler ultrasound measurement of flow velocity profiles and aortic root cross sectional area. RESULTS CO increased to 7.0 l/min by 32 weeks gestation, 49% above baseline values. It fell to 5.7 l/min by term, 21% above baseline. The peak in CO corresponded with an increase in heart rate to 91 beats/min, 32% above baseline. Stroke volume peaked at 36 weeks gestation, by which time CO had already begun to decline. CONCLUSIONS CO increased in a linear fashion until 32 weeks gestation and then declined to term, but to a value still greater than the postpartum baseline. These findings have obvious management implications for patients with serious heart disease complicating pregnancy.

The effect of a peripheral vasconstrictor drug on the systemic arterial oxygen saturation in eisenmenger’s syndrome

SummaryEisenmenger’s syndrome is associated with a high mortality rate. Pregnancy is particularly hazardous, carrying a death rate of at least 30%. Death is usually attributed to anoxaemia due either to a fall in the systemic vascular resistance or a rise in the pulmonary resistance. On this basis a peripheral vasoconstrictor drug has frequently been recommended as an appropriate form of treatment. To assess this recommendation a patient with Eisenmenger’s syndrome was administered the vasoconstrictor drug phenylephrine during diagnostic cardiac catheterisation. This resulted in. a fall rather than a rise in the systemic arterial oxygen saturation. The result provides a caution about the advisability of administering a vasoconstrictor drug to an Eisenmenger patient.

Cardiac constriction due to malignant disease of the pericardium

SummaryTwo patients with pericardial constriction due to tumour are described. The tumour consisted of a lymphoma in both cases. Tumour is not an uncommon cause of pericardial constriction; it was responsible for 6% of a consecutive series of 34 cases seen at the Mater Misericordiae Hospital. Treatment may provide satisfactory relief of symptoms, at least in the short-term.

Hypertrophic cardiomyopathy, ten years’ experience

SummaryA RETROSPECTIVE study was performed of patients who were diagnosed as having hypertrophic cardiomyopathy by left ventricular angiography in order to assess the incidence, the clinical and haemodynamic features and prognosis of this condition. The records of the cardiac catheter laboratory were reviewed for the ten year period from May 1975 to June 1985 to obtain haemodynamic and angiographic findings at diagnosis. Clinical features were obtained from the hospital records. To assess the prognosis, the clinical status of all patients, where possible, was reviewed in June 1985. During the ten year period 64 patients were diagnosed as having hypertrophic cardiomyopathy which was approximately 1% of all cardiac catheterizations. At diagnosis 22% of patients were asymptomatic and the commonest symptoms were chest pain or dyspnoea. Only 12% of patients had a family history of hypertrophic cardiomyopathy or sudden death. A systolic murmur was the most common abnormality on physical examination. Although evidence of left ventricular hypertrophy demonstrated by ECG was very common, only 13% of patients have evidence of an intraventricular pressure gradient. Of the 52 patients (81% of total) available for follow-up in June 1985, seven (13%) had died since diagnosis, all suddenly. The patients who died were significantly younger than the survivors and evidence of left ventricular hypertrophy was also more common in those who died. Our study confirms that although hypertrophie cardiomyopathy is uncommon, it carries a definite mortality. Thus definitive diagnosis of this condition is important especially as there is now evidence to suggest that the prognosis may be improved by treatment with amiodarone.

Pregnancy with constrictive pericarditis. Case reports

This patient had surgery for correction of a depressed sternum at 15 years. Five years later she developed massive oedema and was treated with diuretics. No diagnosis was made. One year later she became pregnant but aborted spontaneously at 8 weeks. In a second pregnancy after a further 1.5 years she became very oedematous and miscarried at 24 weeks. One year later she became pregnant for a third time. Oedema again became severe and she was treated with frusemide 40 mg daily. Her condition remained stable and at 34 weeks she was admitted to hospital. Blood pressure was then 120/80 mmHg and was at approximately this level during the remainder of her pregnancy. No observations were made on her jugular venous pressure. Her pulse rate was usually between 90 and 100 beats/min. There was no dyspnoea. No definite diagnosis was made. Spontaneous labour occurred at 38 weeks and after 6 h she was delivered by vacuum extraction of a normal baby weighing 2440 g. There were no complications. The maximum pulse rate during labour was 112 beatdmin and there was only slight dyspnoea. During the succeeding 48 h there was a negative fluid balance of 2.5 litres while still on frusemide 40 mg daily. Three months postpartum she was admitted electively to the Mater Misericordiae Hospital for medical investigation. A diagnosis of severe, noncalcified, constrictive pericarditis was established, a mean right atrial pressure of 20 mmHg reflecting the severity of the constriction. At thoracotomy the diagnosis was confirmed and a successful pericardiectomy performed.

The effect of amino acid administration on skeletal muscle blood flow

SummaryA protein meal increases renal and splanchnic blood flow and this study was undertaken to assess the effect of amino acids on skeletal muscle blood flow. In one group of ten subjects oral water was compared with oral amino acids and in a second group intravenous saline was compared with intravenous amino acids. Oral water produced no change in muscle blood flow while oral amino acids produced a significant increase. Neither intravenous saline nor intravenous amino acids had any significant effect.It is postulated that the increase in tissue blood flow is in all instances due to glomerulopressin, a substance produced in the liver during amino acid metabolism.

The usefulness of a rapid method of measuring creatine kinase isoenzymes in the diagnosis of myocardial infarction.

SummaryThe usefulness of creatine kinase isoenzymes, measured by a commercially available “kit” method, in the diagnosis of myocardial infarction, was assessed. Raised levels of the heart isoenzyme (MB) were found after exercise and in acute coronary insufficiency but the levels were lower than those found after myocardial infarction. Complete agreement between diagnosis based on creatine kinase isoenzyme measurements alone and diagnosis according to World Health Organization criteria was obtained.

Angiographic signs in isolated valvular pulmonary stenosis

SummaryThe angiocardiographic findings in a series of 50 cases of isolated pulmonary stenosis are described. The distinctive sign is systolic ballooning of the membrane formed by the fused valve cusps. Other helpful signs are jet formation, valve thickening, post-stenotic dilatation of the pulmonary artery and secondary stenosis in the region of the infundibulum. The place of angiocardiography in the diagnosis of pulmonary stenosis is discussed.