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Biomedical subjects

B F Uretsky

Publications and source records attributed to B F Uretsky.

At least 55 records · Page 3Linked to original sources
PubMed1994

Angioscopic evaluation of incompletely obstructing coronary intraluminal filling defects: comparison to angiography.

At 66 sites in 40 patients, we evaluated the sensitivity and specificity of coronary angiography in detecting intraluminal filling defects of varying sizes and in characterizing the contents (thrombus, intimal flap, both) of such defects using coronary angioscopy as "the gold standard." Overall angiographic sensitivity for thrombus was 37% and for intimal flap 45%. Specificity for thrombus was 100% and intimal flaps 96%. Angioscopically small flaps were less frequently seen angiographically (28%) than larger sizes (65%, p = 0.03). Angioscopically small thrombi were seen less often angiographically (30%) than larger ones (75%, p = 0.13). Filling defects (intimal flaps, thrombus, both) were characterized correctly in only 37% of sites. Angiography is relatively insensitivity in detecting intraluminal filling defects. Angioscopy may be preferred to or adjunctive with angiography in detecting these lesions.

Angioplasty, Balloon, Coronary↗
PubMed1994

Increased plasma atrial natriuretic peptide levels after heart transplant: relation to ventricular expression and severity of rejection.

To determine whether elevated plasma atrial natriuretic peptide (ANP) levels observed after cardiac transplant are related to ventricular ANP expression and/or the severity of rejection, 59 ambulatory patients with cardiac transplant underwent hemodynamic evaluation, endomyocardial biopsy, and plasma ANP sampling. Forty-two of the 59 patients had right ventricular (RV) biopsy specimens immunohistochemically stained for the presence of ANP. Plasma ANP levels were elevated (p < 0.0001) in transplant patients (172 +/- 12 pg/ml) compared to normal subjects (36 +/- 4 pg/ml). Sixty-four percent of transplant patients showed stainable RV ANP on endomyocardial biopsy. There was no significant difference in plasma ANP levels between patients with or without RV ANP. The degree of RV staining did not correlate with plasma ANP levels, degree of rejection, mean atrial or systemic pressures, or specific immunosuppressive regimen. Plasma ANP levels were higher in patients with moderate or severe rejection (237 +/- 17 pg/ml) compared to patients with mild or no rejection (163 +/- 12 pg/ml; p 0.03), but there was significant overlap of values. These data suggest that ventricular ANP secretion may account for some of the increase in plasma ANP levels in cardiac transplant patients. However, increased plasma ANP levels in some transplant patients who have no RV ANP and the lack of correlation between the amount of stainable RV ANP and plasma ANP levels suggest that other mechanisms are also likely responsible for plasma ANP elevations in this setting.

Adult↗
PubMed1994

Intra-aortic balloon counterpulsation as a 'bridge' to cardiac transplantation. Effects in nonischemic and ischemic cardiomyopathy.

Intra-aortic balloon (IAB) counterpulsation has been utilized as an effective "bridge" to transplantation in patients with end-stage heart failure. To determine if patients with heart failure with nonischemic cardiomyopathy (NICM) derive the same benefit from IAB support as those with ischemic cardiomyopathy (ISCM), we evaluated 27 patients with NICM and 16 patients with ISCM who required IAB support while awaiting transplantation. Hemodynamic changes, effects on organ function (renal and hepatic), frequency of complications, and clinical outcomes were analyzed. Baseline demographics and hemodynamics were comparable in both groups (p = NS). Hemodynamics improved in both groups, immediately (15 to 30 min) following IAB insertion, with greater improvement (p < 0.05) in cardiac index and a trend toward greater reduction in filling pressures in the NICM group. Systemic vascular resistance fell to a similar degree in both groups. During continued IAB support (0.13 to 38 days in NICM, 1 to 54 days in ISCM), all hemodynamic changes persisted in both groups, with larger decrease (p < 0.05) in systemic vascular resistance and greater increase (p < 0.05) in cardiac index in the patients with NICM. The reduction in filling pressures, however, tended to be greater in patients with ISCM. Renal and hepatic function parameters improved to a similar extent in both groups. The frequency of complications and clinical outcome during IAB support were also similar in the two groups. These data confirm that IAB counterpulsation is a safe and effective "bridge" in patients with both NICM and ISCM with end-stage heart failure. The mechanism of sustained benefit in the two groups, however, may be different; afterload reduction appears to be more important in patients with NICM whereas reduction in filling pressures (increased coronary perfusion pressure) may be the main mechanism in patients with ISCM.

Cardiomyopathies↗
PubMed1994

Maximal exercise tolerance in chronic congestive heart failure. Relationship to resting left ventricular function.

The relationship between maximal exercise tolerance and resting radionuclide indexes of left ventricular systolic and diastolic function were evaluated in 20 ischemic and 44 idiopathic cardiomyopathy patients with New York Heart Association class 2-4 chronic congestive heart failure. Left ventricular ejection fraction, peak systolic ejection rate, peak diastolic filling rate, time to peak filling from end-systolic volume, and fractional filling in early diastole were measured from the radionuclide ventriculogram. All patients underwent symptom-limited exercise testing with on-line measurement of oxygen consumption. In the ischemic group, all of the radionuclide indexes correlated poorly with maximal exercise oxygen consumption (VO2max) except the peak systolic ejection rate which correlated modestly (r = 0.58, p < 0.05). Peak systolic ejection rate was significantly lower (p < 0.01) as were the peak diastolic filling rate and fractional filling in the first third of diastole (p < 0.05) in ischemic patients with marked exercise intolerance (VO2max < or = 14 mL/kg/min) compared with those with preserved exercise tolerance (VO2max > 14 mL/kg/min). In the idiopathic group, none of the radionuclide indexes correlated well with VO2max; and all indexes were similar in patients with and without marked exercise intolerance. These data suggest that (1) resting left ventricular ejection fraction poorly predicts maximal exercise capacity in both ischemic and idiopathic cardiomyopathy and (2) resting peak systolic ejection rate, peak diastolic filling rate, and fractional filling in early diastole may predict exercise tolerance in ischemic but not idiopathic cardiomyopathy.

Adult↗
PubMed1993

Diastolic dysfunction in cardiac transplant recipients: an important role in the response to increased afterload.

We evaluated the hemodynamic and functional response to acute elevations in left ventricular (LV) afterload in 22 recent recipients of cardiac transplants to determine whether abnormalities in LV diastolic function influence the response to this intervention. In seven patients (group 1) LV ejection fraction decreased significantly from baseline values (> or = 5%) during methoxamine infusion, whereas in 15 patients (group 2) LV ejection fraction was maintained. Peak filling rate was lower in group 1 versus group 2 (3.36 +/- 0.46 vs 4.23 +/- 0.68 end-diastolic volumes/sec, p < 0.01). In addition, patients in group 1 did not have LV dilatation during methoxamine (percentage change in end-diastolic counts, -3.4 +/- 6.9%) and had a large increase in pulmonary artery wedge pressure. In contrast, patients in group 2 had LV dilatation (percentage change in end-diastolic counts, +10.7 +/- 14.7%) and a smaller increase in pulmonary artery wedge pressure. There was a relationship between the baseline peak filling rate and the change in LV ejection fraction during methoxamine (r = 0.65, p = 0.001). Therefore in a subset of cardiac transplant patients, abnormalities in LV filling can have an impact on the response to increased afterload.

Adult↗
PubMed1993

Preoperative pulmonary hemodynamics and early mortality after orthotopic cardiac transplantation: the Pittsburgh experience.

The influence of preoperative transpulmonary pressure gradient (TPG) and pulmonary vascular resistance (PVR) on early post-transplant mortality was evaluated in 425 orthotopic transplant recipients. The overall 30-day post-transplant mortality rate was 12.5%; the majority of the deaths (52.8%) were due to primary allograft failure. The 0- to 2-day mortality rate was threefold higher in patients with severe preoperative pulmonary hypertension (TPG > or = 15 mm Hg or PVR > or = 5 Wood units), whereas the 3- to 7-day and 8- to 30-day mortality rates were similar. Early post-transplant mortality (0 to 2 days and 8 to 30 days) was also significantly higher (15.9% vs 3.9% and 9.9% vs 2.8%, respectively; p < 0.05) in women compared with men. Women with severe preoperative pulmonary hypertension had higher (p < 0.05) 0- to 2-day post-transplant mortality than comparable men. According to univariate analysis, recipients with preoperative TPG > or = 15 mm Hg had a significantly higher 30-day postoperative mortality rate, irrespective of their level of PVR. Furthermore, patients with severe preoperative pulmonary hypertension who underwent transplantation between 1980 and 1987 had a higher 0- to 2-day post-transplant mortality rate compared with patients operated on after that time. Multiple logistic regression analysis identified female recipient sex and preoperative TPG but not preoperative PVR, era of transplantation, or recipient age as significant (p < 0.001 and p < 0.01, respectively) independent predictors of early post-transplant mortality.

Adolescent↗
PubMed1993

Randomized study assessing the effect of digoxin withdrawal in patients with mild to moderate chronic congestive heart failure: results of the PROVED trial. PROVED Investigative Group.

OBJECTIVES: The purpose of this study was to determine whether digoxin is effective in patients with chronic, stable mild to moderate heart failure. BACKGROUND: Digoxin has been a traditional therapy in heart failure, but methodologic limitations in earlier studies have prevented definitive conclusions regarding its efficacy. METHODS: Withdrawal of digoxin (placebo group, n = 46) or its continuation (digoxin group, n = 42) was performed in a prospective, randomized, double-blind, placebo-controlled multicenter trial of patients with chronic, stable mild to moderate heart failure secondary to left ventricular systolic dysfunction who had normal sinus rhythm and were receiving long-term treatment with diuretic drugs and digoxin. RESULTS: Patients withdrawn from digoxin therapy showed worsened maximal exercise capacity (median change in exercise time -96 s) compared with that of patients who continued to receive digoxin (change in exercise time +4.5 s) (p = 0.003). Patients withdrawn from digoxin therapy showed an increased incidence of treatment failures (p = 0.039) (39%, digoxin withdrawal group vs. 19%, digoxin maintenance group) and a decreased time to treatment failure (p = 0.037). In addition, patients who continued to receive digoxin had a lower body weight (p = 0.044) and heart rate (p = 0.003) and a higher left ventricular ejection fraction (p = 0.016). CONCLUSIONS: These data provide strong evidence of the clinical efficacy of digoxin in patients with normal sinus rhythm and mild to moderate chronic heart failure secondary to systolic dysfunction who are treated with diuretics.

Body Weight↗
PubMed1993

Effect on verapamil on ventricular function: studies in denervated human heart.

Verapamil has complex influences on ventricular function owing to its direct myocardial effects, vasodilation, and reflex activation of the sympathetic nervous system. To investigate the direct myocardial effects of verapamil in humans independent of reflex sympathetic stimulation, we administered the drug to 13 recent heart transplant recipients with denervated ventricles. Hemodynamics and radionuclide angiograms were recorded at baseline, with altered loading conditions, and after intravenous (i.v.) verapamil (median dose 4 mg). Left ventricular (LV) systolic and diastolic function was analyzed by systolic pressure-volume relations (SPVR) and peak filling rate (PFR), respectively. Verapamil caused a decrease in blood pressure (BP) and heart rate (HR) with increases in right atrial pressure (RAP 6 +/- 3-8 +/- 3, p < 0.01) and pulmonary artery wedge pressure (PAWP, 9 +/- 3-11 +/- 3 mm Hg, p < 0.01) pressures. LV ejection fraction (EF) decreased (69 +/- 7-66 +/- 8%, p < 0.02) in association with an increase in LV end-systolic counts (3.45 +/- 1.27 to 4.72 +/- 1.78 kcts, p < 0.001). In 11 of 13 patients, the SPV point after verapamil administration was decreased from the line established during altered loading conditions. PFR (4.05 +/- 0.81 to 4.11 +/- 0.76 EDV/s) was unchanged. In the denervated ventricle, verapamil has negative chronotropic and inotropic effects with minimal effects on PFR.

Adult↗
PubMed1993

Ultrasound-assisted cannulation of the internal jugular vein. A prospective comparison to the external landmark-guided technique.

BACKGROUND: Central venous access is an essential part of patient management in many clinical settings and is usually achieved with a blinded, external landmark-guided technique. The purpose of this study is to evaluate whether an ultrasound technique can improve on the traditional method. METHODS AND RESULTS: We prospectively evaluated an ultrasound-guided method in 302 patients undergoing internal jugular venous cannulation and compared the results with 302 patients in whom an external landmark-guided technique was used. Ultrasound was used exclusively in an additional 626 patients. Cannulation of the internal jugular vein was achieved in all patients (100%) using ultrasound and in 266 patients (88.1%) using the landmark-guided technique (p < 0.001). The vein was entered on the first attempt in 78% of patients using ultrasound and in 38% using the landmark technique (p < 0.001). Average access time (skin to vein) was 9.8 seconds (2-68 seconds) by the ultrasound approach and 44.5 seconds (2-1,000 seconds) by the landmark approach (p < 0.001). Using ultrasound, puncture of the carotid artery occurred in 1.7% of patients, brachial plexus irritation in 0.4%, and hematoma in 0.2%. In the external landmark group, puncture of the carotid artery occurred in 8.3% of patients (p < 0.001), brachial plexus irritation in 1.7% (p < 0.001), and hematoma in 3.3% (p < 0.001). CONCLUSIONS: Ultrasound-guided cannulation of the internal jugular vein significantly improves success rate, decreases access time, and reduces complication rate. These results suggest that this technique may be preferred in complicated cases or when access problems are anticipated.

Adult↗
PubMed1992

Prolonged intraaortic balloon support for septal rupture after myocardial infarction.

Timing of surgical repair of ventricular septal defect developing after acute myocardial infarction remains controversial. We report the case of a 75-year-old man in whom a ventricular septal defect developed 7 days after myocardial infarction. The patient was maintained on intraaortic balloon pump support for 33 days before successful surgical closure. In the present era of aggressive preoperative hemodynamic management, the strategy of prolonged support before definitive operation on patients with myocardial infarction in whom a ventricular septal defect develops must be reconsidered.

Aged↗
PubMed1992

Relationship of the renin-angiotensin system and systemic arterial pressure to sodium excretion during atrial natriuretic peptide infusion in men.

The goal of this study was to evaluate the relative contribution of the renin-angiotensin system and mean arterial pressure to sodium excretion and urine flow rate during an infusion of atrial natriuretic peptide (ANP) at physiologically relevant doses in humans. Eight normal volunteers were studied during five periods: (1) baseline in the supine position; (2) during an infusion of ANP at physiologic doses (0.01 micrograms/kg/min) in the supine position; (3) during ANP infusion and 60 degrees head-up tilt; (4) during ANP infusion, head-up tilt, and interruption of the renin-angiotensin axis with the angiotensin converting enzyme inhibitor (ACEI) enalaprilat; and (5) in the supine position during ANP infusion and ACEI. Infusion of ANP in the supine posture significantly increased urine flow rate and sodium excretion compared to baseline while mean arterial pressure and plasma renin activity were unchanged. During head-up tilt and ANP infusion, urine flow rate and sodium excretion were no longer significantly elevated over baseline while mean arterial pressure decreased and plasma angiotensin II levels increased. Addition of ACEI caused a marked diminution of urine flow rate and sodium excretion compared to baseline levels despite continued ANP infusion. Although mean arterial pressure after ACEI administration was lower than baseline, it was not significantly different from the non-ACEI head-up tilt state. Placing subjects in the supine position during ANP infusion and ACEI administration increased mean arterial pressure to levels that were no longer different from baseline, but urine flow rate and sodium excretion remained significantly depressed to the same degree as during head-up tilt with ACEI.(ABSTRACT TRUNCATED AT 250 WORDS)

Adult↗