Biomedical subjects
J Skoularigis
Publications and source records attributed to J Skoularigis.
Submitral left ventricular aneurysm compressing the left main coronary artery.
This report describes a 43-yr-old black women who was referred for evaluation of severe mitral regurgitation. Conventional echocardiography revealed a large submitral left ventricular aneurysm. A selective coronary angiography demonstrated compression of the left main coronary artery by submitral aneurysm. Successful surgical repair was performed.
Once-daily fixed dose combinations of verapamil and trandolapril in black patients with mild to moderate hypertension: a new choice for first line treatment.
Using ambulatory blood pressure (BP) monitoring, a potent ACE-inhibitor/calcium channel blocker combination was tested in 21 Black patients (age 52 +/- 10 years; 10 males, 11 females) with mild to moderate hypertension (mean 12-hour daytime diastolic BP > or = 90 mmHg and < or = 114 mmHg). After a 14-day wash-out and a 14-day placebo run-in period, therapy was initiated with verapamil 180 mg plus trandolapril 2 mg. At monthly visits, if mean daytime diastolic BP remained > or = 90 mmHg, the dose combination was uptitrated stepwise to verapamil 240 mg plus trandolapril 4 mg, verapamil 360 mg plus trandolapril 4 mg, and finally hydrochlorothiazide 12.5 mg were added. Mean 24-hour BP dropped from 150 +/- 14/96 +/- 7 mmHg at baseline to 131 +/- 13/82 +/- 8 mmHg after 4 months treatment (p < 0.001). In 16 (76%) patients mean 24-hour diastolic BP was < 90 mmHg at the end of the trial and 15 (71%) patients achieved a reduction of > 10 mmHg. Five out of 5 patients finishing on dose I were controlled, 5/6 patients on dose II, 5/8 patients on dose III, and 1/2 patients who received additional hydrochlorothiazide. The 24-hour BP load fell from 72 +/- 8% at baseline to 35 +/- 25% in 4 months (p < 0.001). Mean diastolic BP drop for the 2 peak hours during daytime was 20 mmHg and for the last 2 hours of monitoring was 13 mmHg, resulting in a trough to peak ratio of 65%. There were no significant adverse events or biochemical abnormalities. It is concluded that the combination doses tested showed a sustained and marked antihypertensive effect throughout the 24-hour dosing interval, and the starting dose (verapamil 180 mg plus trandolapril 2 mg) seems appropriate in this group of patients.
Long-term changes in left ventricular performance following mitral valve replacement for pure rheumatic mitral regurgitation.
Our data indicate that MVR, with or without chordal preservation, for pure severe MR in symptomatic younger rheumatic patients with a good preoperative ejection fraction results in normalization of LV size and performance by 1 year. Normalization of LV performance was only achieved at 1 year after surgery, and it is therefore essential to extend the assessment of LV function to at least 1 year postoperatively.
Pheochromocytoma associated with clinical and echocardiographic features simulating hypertrophic obstructive cardiomyopathy.
Left ventricular hypertrophy simulating hypertrophic obstructive cardiomyopathy is a rare complication of pheochromocytoma. In this report, two cases of pheochromocytoma with this complication are described. Successful tumor removal in both cases led to relief of symptoms, normalization of BP, regression of abnormal clinical features, normalization of the ECGs, but only partial regression of the echocardiographic features despite prolonged follow-up of 24 and 32 months, respectively.
Comparison of captopril-thiazide and enalapril-thiazide combinations in the management of mild to moderate black hypertensive patients: how important is diuretic dose and duration of action of the ACE-inhibitor?
A double-blind, randomized, parallel-group study was performed to compare the efficacy and tolerability of captopril-thiazide and enalapril-thiazide combinations. After a 3-week placebo run-in period, 47 Black patients with mild to moderate essential hypertension (mean 24-hour diastolic blood pressure (BP) > 90 mmHg and < 115 mmHg) were randomized to receive 1 of 2 combination tablets: captopril 50 mg plus hydrochlorothiazide 25 mg (CAP, n = 24) or enalapril 20 mg plus hydrochlorothiazide 12.5 mg (COR, n = 23) once daily. After 12 weeks of active treatment the mean 24-hour ambulatory BP was reduced from 152 +/- 11/99 +/- 6 to 133 +/- 13/86 +/- 7 mmHg (p < 0.005) in the CAP group and 157 +/- 15/100 +/- 6 to 141 +/- 18/90 +/- 12 in the COR group (p < 0.005). Target BP (24-hour diastolic BP < 90 mmHg) was achieved in 75% (18/24) of patients on CAP and 48% (11/23) on COR (p = n.s.). 24-hour BP load fell significantly with both CAP (from 69% to 34%, p < 0.001) and COR (from 67% to 37%, p < 0.001). Left ventricular mass index decreased by 7% with CAP and 11% with COR. Cardiac index and fractional shortening remained essentially unchanged in both groups. Both treatments were well tolerated and overall incidence of side effects was very low. It is concluded that both CAP and COR are effective, safe first-line antihypertensive choices in Black patients with mild to moderate hypertension with the former showing a trend towards greater efficacy than the latter.
Effects of amlodipine on 24-hour ambulatory blood pressure profiles, electrocardiographic monitoring, and left ventricular mass and function in black patients with very severe hypertension.
In a 3-month, open-label study, 54 consecutive black patients with very severe hypertension were treated with amlodipine. Very severe hypertension was defined as an average sitting diastolic blood pressure (BP) > or = 115 mmHg and < or = 140 mmHg as a mean of 10 readings over a 30-minute period using an automatic BP measuring device and a mean 24-hour diastolic ambulatory blood pressure (ABP) > or = 110 mmHg and < or = 140 mmHg). Serial changes in 24-hour ABP and electrocardiographic monitoring, left ventricular (LV) mass index, and LV systolic function were evaluated. Mean 24-hour ABP was reduced from 181 +/- 14/119 +/- 6 to 140 +/- 15/92 +/- 9 mmHg at 3 months (P < 0.0001). Target BP (mean 24-hour diastolic ABP < 90 mmHg) was achieved in 35% of the patients. The reduction in BP was sustained for 24 hours after drug administration. Simultaneous BP measurements using the automatic BP measuring device were significantly different from the ABP measurements before and after treatment, suggesting a marked "white coat" pressor effect. At baseline, frequent or complex ventricular arrhythmias (> 30 ventricular extrasystoles per hour, ventricular couplets) were present in 2 (4%) patients, with no significant change after treatment. Left ventricular mass index regressed from 140 +/- 50 to 111 +/- 30 g/m2 at 3 months (P < 0.03); LV performance was not adversely affected. Adverse effects were few and tended to disappear during the treatment period. All of the clinical laboratory parameters tested remained unchanged. In this group of patients, treatment with amlodipine showed a marked and sustained antihypertensive action as demonstrated by 24-hour ABP monitoring, and was well tolerated and associated with LV mass regression without adverse effect on systolic cardiac function. Further, a low rate of complex ventricular arrhythmias was documented.
Low dose hydrochlorothiazide (12.5 to 25 mg daily) as monotherapy in black patients with mild to moderate hypertension. Assessment by ambulatory blood pressure monitoring.
The efficacy of low dose (12.5 to 25 mg daily) hydrochlorothiazide (HCTZ) was evaluated by ambulatory blood pressure monitoring (ABPM) in 19 mild to moderate hypertensive (mean daytime 12-h diastolic BP > or = 90 mm Hg and < 115 mm Hg) South African black patients. After a 3-week placebo run-in period, HCTZ was administered for 8 weeks as monotherapy. The mean daytime ABPM was reduced from 159 +/- 13/105 +/- 6 to 145 +/- 11/97 +/- 10 mm Hg (P < .005). Only 6/19 (32%) patients achieved BP control. The 24-h BP load fell from 69% at baseline, to 53% with 12.5 mg HCTZ and to 47% with 25 mg HCTZ daily. There were no side effects but the increase of HCTZ to 25 mg daily was followed by adverse changes (P < .05) in serum potassium levels. It is concluded that low dose of HCTZ monotherapy has only a moderate effect on the BP control and 24-h BP load while the higher 25 mg dose is associated with significant decrease in serum potassium level.
Emergency percutaneous balloon mitral valvotomy in a patient with septic shock.
We report an 18-year-old patient with severe mitral stenosis complicated by right lower lobe pneumonia, sepsis, and shock. Intractable low cardiac output led to an emergency percutaneous balloon mitral valvotomy in a patient, resulting in immediately improved hemodynamic parameters. We are unaware of another report of percutaneous balloon mitral valvotomy performed in a patient with sepsis and shock. This case supports previous isolated reports of the benefit from emergency percutaneous balloon mitral valvotomy in critical situations where thoracotomy is not possible due to coexisting medical problems.
Frequency of prosthetic valve-related complications with very low level warfarin anticoagulation combined with dipyridamole after valve replacement using St. Jude Medical prostheses.
The safety of a very low level of anticoagulation combined with dipyridamole in a rheumatic population (mean age 31 +/- 13 years) with the St. Jude Medical (SJM) prosthesis has not yet been tested. Furthermore, no data are available on the safety of relatively infrequent monitoring of anticoagulation levels and of the necessity for different therapeutic targets according to valve position, number of risk factors, and other baseline risk factors for thromboembolism. In this study, the performance of the SJM prosthesis was tested using a target international normalized ratio (INR) of 2.0 to 2.5 combined with dipyridamole 300 mg/day applied uniformly to all patients. Clinical, biochemical, and echocardiographic data were acquired prospectively in 200 consecutive patients at 3-month intervals. Follow-up (mean 27 +/- 13 months) was complete in 95% of patients. Thirteen patients died (2.9%/patient year). Severe left ventricular dysfunction was the cause of death in 10 of 13 patients. Probability of survival (Kaplan-Meier) was 0.92 at 36 months and of event-free survival 0.84 at 36 months. The median INR was 2.0 +/- 0.9. Valve obstruction did not occur, and there were 3 thromboembolic events (0.6%/patient year). Incidence of bleeding was 1.6%/patient year (n = 7) and was major (hemorrhagic stroke) in 1 (0.2%/patient year). Thus, the SJM prosthesis performs very well despite the use of very low level warfarin anticoagulation combined with dipyridamole. A 3-month assessment of the anticoagulation level is safe. Left ventricular dysfunction rather than valve-related complications is the leading cause of mortality in this population.
Usefulness of transesophageal echocardiography in the early diagnosis of penetrating stab wounds to the heart.
Explore the source record for details and available documents.
Effect of isradipine in black patients with very severe hypertension. 24-hour ambulatory blood pressure monitoring and echocardiographic evaluation.
Fifty consecutive black patients with very severe hypertension (sitting diastolic blood pressure > or = 120 mm Hg and systolic > or = 210 mm Hg by the conventional cuff method) were treated in an open-label study (without a placebo or active drug control group) for 3 months with a long-acting preparation of isradipine (Dynacirc SRO), during which time serial changes in 24-h ambulatory blood pressure monitoring (ABPM), left ventricular (LV) mass index, and LV systolic function were evaluated. Mean 24-h ABPM was reduced from 184 +/- 13/119 +/- 6 to 148 +/- 18/96 +/- 11 mm Hg at 3 months (P < .0001). The reduction in BP was sustained for 24 h after dosing. Simultaneous BP measurements using a conventional cuff method and Dinamap were significantly different from the ABPM pre- and posttherapy, suggesting a marked "white coat" pressor effect. LV mass index regressed from 143 +/- 36 to 122 +/- 32 g/m2 at 3 months (P < .02). Heart rate and mean body weight were unchanged. Left ventricular performance was not adversely affected. Cardiac index and fractional shortening changed insignificantly, from 2.6 +/- 0.6 to 2.7 +/- 0.5 L/min/m2, and from 28 +/- 6 to 31 +/- 7%, respectively. Adverse effects were few and tended to disappear during the treatment period. All of the clinical laboratory parameters tested remained unchanged. We conclude that in this group of patients long-acting isradipine 1) showed a marked and sustained antihypertensive action demonstrated by 24-h ABPM; and 2) was well tolerated and associated with LV mass regression without adverse effect on systolic cardiac function.(ABSTRACT TRUNCATED AT 250 WORDS)
Nifedipine versus captopril in the management of moderate hypertension in black patients.
The efficacy of nifedipine (20 to 40 mg twice daily) and captopril (25 to 50 mg twice daily) was assessed during a 12-week single-blind randomized trial in 41 moderately hypertensive black patients (mean 24-h diastolic blood pressure [BP] > or = 90 mm Hg and < 115 mm Hg). Nifedipine and captopril were administered as monotherapy in increasing dosage while a diuretic was added after 8 weeks in patients who failed to reach the target BP (24-h mean diastolic BP < 90 mm Hg) on monotherapy. After 8 weeks of monotherapy, the mean 24-h ambulatory BP was reduced from 156 +/- 12/101 +/- 5 to 128 +/- 11/84 +/- 7 mm Hg (P < .0001) in the nifedipine group while it remained essentially unchanged (156 +/- 15/101 +/- 7 to 158 +/- 17/102 +/- 9) in the captopril group. Left ventricular (LV) mass index was also reduced significantly (P < .05) in the nifedipine group, while cardiac index and fractional shortening changed marginally. The addition of diuretic in the captopril group (16/21 patients) resulted in a significant fall in BP to 123 +/- 11/81 +/- 7. Only 2/20 patients in the nifedipine group required the addition of diuretic. The overall incidence of side effects was similar with both treatments but the addition of diuretic in the captopril group was followed by adverse changes in serum sodium (P < .01), urea (P < .05), and creatinine (P < .01) levels.(ABSTRACT TRUNCATED AT 250 WORDS)
Evaluation of the long-term results of mitral valve repair in 254 young patients with rheumatic mitral regurgitation.
BACKGROUND: Surgical valve repair for mitral regurgitation has significant advantages over valve replacement, but the durability of the technique varies according to the cause of mitral valve disease. In this study, we examined the long-term performance of this procedure in a young rheumatic population and also attempted to identify factors predicting a poor outcome. METHODS AND RESULTS: Between January 1981 and 1989, 308 patients underwent primary mitral valve repair for rheumatic mitral regurgitation at our institution. Forty-nine patients who failed to report after surgery and another 5 with discordant data were excluded from the analysis. Mitral regurgitation was pure in 182 patients (72%) and associated with mild commissural fusion in 72 patients (28%). Patient ages ranged from 6 to 52 years (mean, 18 +/- 9 years). A total of 243 patients (96%) were in New York Heart Association class III or IV before surgery, and 66 (26%) had atrial fibrillation. Mean follow-up period was 60 +/- 35 months (range, 1 to 132 months). Rheumatic activity was present clinically in 30% and macroscopically during surgery in 32%. Surgical techniques included insertion of a Carpentier ring (99%), chordal shortening (88%), leaflet resection (14%), chordal transposition (7%), and commissurotomy (28%). Operative mortality was 2.6%, late mortality was 15%, and the reoperation rate was 27%. At 5 years, 96.8% of the patients were free from thromboembolism, 97.7% were free from endocarditis, 74.9% were free from reoperation, 66% were free from valve failure, and 66.2% were free from major events. Multivariate analysis identified active rheumatic carditis as a significant predictor of reoperation, valve failure, and future events, while sinus rhythm and shorter bypass time at initial surgery were the only predictors of long-term survival. Patients with pure mitral regurgitation, sinus rhythm, and no active carditis at initial operation had the best overall 5-year results. Among the 148 survivors without reoperation, 142 (96%) were in New York Heart Association class I and II, and 107 (72%) were in sinus rhythm. Doppler echocardiographic studies showed absence of mitral regurgitation in 34 patients (23%), severe regurgitation in 23 (16%), and severe mitral stenosis in 6 (4%). CONCLUSIONS: Mitral valve repair in this young rheumatic population is associated with a high long-term morbidity. Presence of active rheumatic carditis has a significantly adverse effect on the success of mitral valve repair.
Prevalence and clinical significance of mild paraprosthetic ring leaks and left atrial spontaneous echo contrast detected on transesophageal echocardiography three months after isolated mitral valve replacement with a mechanical prosthesis.
Explore the source record for details and available documents.
Effectiveness of amiodarone and electrical cardioversion for chronic rheumatic atrial fibrillation after mitral valve surgery.
Thirty consecutive patients with chronic rheumatic atrial fibrillation (AF) > or = 3 months after successful mitral valve surgery and left atrial diameter < or = 60 mm were treated with oral amiodarone. Protocol included high loading dosages of amiodarone for 4 weeks, and if conversion to sinus rhythm (SR) was not achieved then electrical cardioversion was performed. Patients converted to SR were maintained on low-dose amiodarone for another 4 weeks when treatment was discontinued. Overall, 23 patients (77%) converted to SR after 4 weeks of therapy: 12 (40%) taking amiodarone alone and 11 (37%) with the addition of electrical cardioversion. The duration of AF > 48 months was an adverse factor in the ability to restore SR. Sixteen patients (70%) remained in SR at a mean follow-up of 17 months. The duration of AF < or = 48 months alone or in combination with left atrial diameter < or = 45 mm were the best predictors for long-term maintenance of SR. Thus, short-term amiodarone with or without electrical cardioversion is effective and safe in the treatment of chronic rheumatic AF after mitral valve surgery. The duration of AF and left atrial size can be used to identify patients with successful outcome.
Transesophageal echocardiography in congenital submitral aneurysm.
Explore the source record for details and available documents.
Results of percutaneous balloon mitral valvotomy in young adults.
The results of percutaneous balloon mitral valvotomy (PBMV) were evaluated in 235 young patients (mean age 29 +/- 11 years) with symptomatic rheumatic mitral stenosis, and the single-balloon Inoue technique was compared with the double-balloon Mansfield technique. PBMV was associated with a significant increase in Gorlin mitral valve area (0.78 +/- 0.23 to 1.61 +/- 0.64 cm2; p < 0.001), and improvement in New York Heart Association functional class (2.78 +/- 0.59 to 1.28 +/- 0.58; p < 0.001). Mitral regurgitation increased significantly (0.4 +/- 0.6 to 1.3 +/- 1.0; p < 0.001), but was significant (> or = 3+) only in 19 patients (8%). Comparison of the Inoue and Mansfield techniques showed a significantly lower Gorlin mitral valve area after PBMV (1.55 +/- 0.56 vs 1.74 +/- 0.74 cm2; p < 0.05), but a lower incidence of mitral regurgitation by color Doppler echocardiography (1.1 +/- 0.7 vs 1.5 +/- 0.8; p < 0.05) in the Inoue group. Patients were divided into those with nonpliable (valve score > 8; group I) and pliable (score < or = 8; group II) valves. Although significant increases in mitral valve area were obtained in both groups, mitral valve area by planimetry was significantly lower in group I (1.49 +/- 0.46 vs 1.86 +/- 0.44 cm2; p < 0.05), whereas there was no difference in the amount of color Doppler mitral regurgitation (1.5 +/- 1.0 vs 1.2 +/- 0.7; p = NS).(ABSTRACT TRUNCATED AT 250 WORDS)