Itraconazole-related amaurosis and vomiting due to digoxin toxicity.
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Aged↗
Biomedical subjects
R B Himelman
Publications and source records attributed to R B Himelman.
Exercise Doppler: functional evaluation of right heart dynamics.
Exercise echocardiography is a versatile technique that includes not only two-dimensional imaging, but also Doppler of aortic, mitral, and tricuspid valves. Doppler echocardiography can be useful in the evaluation of global left ventricular systolic and diastolic function, valvular function, transvalvular gradients, and pulmonary artery pressure. The technique lends itself to the study of the cardiac response to exercise in a variety of disease states, including pulmonary, coronary artery, valvular, and congenital heart disease. We review our experience using agitated saline-enhanced Doppler of tricuspid insufficiency to determine pulmonary artery pressure throughout exercise in chronic lung disease.
Adult↗
Oxygen may improve dyspnea and endurance in patients with chronic obstructive pulmonary disease and only mild hypoxemia.
Oxygen (O2) has been reported to improve exercise tolerance in some patients with chronic obstructive pulmonary disease (COPD) despite only mild resting hypoxemia (PaO2 greater than 60 mm Hg). To confirm these prior studies and evaluate potential mechanisms of benefit, we measured dyspnea scores by numeric rating scale during cycle ergometry endurance testing and correlated the severity of dyspnea with right ventricular systolic pressure (RVSP) measured by Doppler echocardiography during a separate supine incremental exercise test. Both sets of exercise were performed according to a randomized double-blind crossover protocol in which patients breathed compressed air or 40% O2. We studied 12 patients with severe COPD (FEV1 0.89 +/- 0.09 L [mean +/- SEM], FEV1/FVC 37 +/- 2%, DLCO 9.8 +/- 1.5 ml/min/mm Hg[47% of predicted], PaO2 71 +/- 2.6 mm Hg). With endurance testing on compressed air, PaO2 did not change significantly in the group as whole (postexercise PaO2 63 +/- 5.1 mm Hg, p = NS), but did fall to less than 55 mm Hg in four patients from this group. Duration of exercise increased on 40% O2 from 10.3 +/- 1.6 to 14.2 +/- 1.5 min (p = 0.005), and the rise in dyspnea scores was delayed. Oxygen delayed the rise in RVSP with incremental exercise in all patients and lowered the mean RVSP at maximum exercise from 71 +/- 8 to 64 +/- 7 mm Hg (p less than 0.03). Improvement in duration of exercise correlated with decrease in dyspnea (r2 = 0.66, p = 0.001) but not with decreases in heart rate, minute ventilation, or RVSP.(ABSTRACT TRUNCATED AT 250 WORDS)
Double-Blind Method↗
Left atrial volume determination by biplane two-dimensional echocardiography: validation by cine computed tomography.
Left atrial (LA) volume measurements have been made by the application of the method of discs (modified Simpson's rule) to orthogonal biplane atrial echocardiographic images. Validation of the technique has been suboptimal due to deficiencies of the reference standard, levophase angiography. To define the accuracy of echocardiography, we compared LA end-systolic volume by echocardiography in 27 patients with volumes by cine computed tomography (Cine CT), a highly accurate and validated method of measuring cardiac chambers. Echocardiographic tracings were made in the apical long-axis two- and four-chamber views. In patients with atria less than 300 ml, 14 had echoes performed prospectively, with optimization of LA size, while the remaining 10 were analyzed retrospectively. The volume of each slice was calculated and was then summated to obtain total volume. The correlation coefficient between two-dimensional echocardiography and Cine CT was r = 0.98, and it was r = 0.82 when patients with atria greater than 300 ml (n = 3) were excluded. Echocardiography underestimated Cine CT measurements by 23%. The slope of the prospective group was closer to unity than the slope of the retrospective group (p less than 0.001), and the correlation with Cine CT was slightly better for the prospective group (r = 0.88 versus r = 0.77). LA volume by two-dimensional echocardiography correlates closely with Cine CT, a more accurate method of volume determination, and gives valid measurements of LA volume. Efforts to maximize LA size during scanning limit inaccuracies of echocardiographic measurements of the left atrium.
Echocardiography↗
The flail mitral valve: echocardiographic findings by precordial and transesophageal imaging and Doppler color flow mapping.
To determine the echocardiographic and Doppler characteristics of mitral regurgitation associated with a flail mitral valve, precordial and transesophageal echocardiography with pulsed wave and Doppler color flow mapping was performed in 17 patients with a flail mitral valve leaflet due to ruptured chordae tendineae (Group I) and 22 patients with moderate or severe mitral regurgitation due to other causes (Group II). Echocardiograms were performed before or during cardiac surgery; cardiac catheterization was also performed in 28 patients (72%). Mitral valve disease was confirmed at cardiac surgery in all patients. By echocardiography, the presence of a flail mitral valve leaflet was defined by the presence of abnormal mitral leaflet coaptation or ruptured chordae. Using these criteria, transesophageal imaging showed a trend toward greater sensitivity and specificity than precordial imaging in the diagnosis of flail mitral valve leaflet. By Doppler color flow mapping, a flail mitral valve leaflet was also characterized by an eccentric, peripheral, circular mitral regurgitant jet that closely adhered to the walls of the left atrium. The direction of flow of the eccentric jet in the left atrium distinguished a flail anterior from a flail posterior leaflet. By transesophageal echocardiography with Doppler color flow mapping, the ratio of mitral regurgitant jet arc length to radius of curvature was significantly higher in Group I than Group II patients (5.0 +/- 2.3 versus 0.7 +/- 0.6, p less than 0.001); all of the Group I patients and none of the Group II patients had a ratio greater than 2.5.(ABSTRACT TRUNCATED AT 250 WORDS)
Chordae Tendineae↗
Noninvasive estimation of right atrial pressure from the inspiratory collapse of the inferior vena cava.
To evaluate a simple noninvasive means of estimating right atrial (RA) pressure, the respiratory motion of the inferior vena cava (IVC) was analyzed by 2-dimensional echocardiography in 83 patients. Expiratory and inspiratory IVC diameters and percent collapse (caval index) were measured in subcostal views within 2 cm of the right atrium. Parameters were correlated with RA pressure by flotation catheter within 24 hours of the echocardiogram (38 were simultaneous). Correlations between RA pressure (range 0 to 28 mm Hg), expiratory and inspiratory diameters and caval index were 0.48, 0.71 and 0.75, respectively. Of 48 patients with caval indexes less than 50%, 41 (89%) had RA pressure greater than or equal to 10 mm Hg (mean +/- standard deviation, 15 +/- 6), while 30 of 35 patients (86%) with caval indexes greater than or equal to 50% had RA pressure less than 10 mm Hg (mean 6 +/- 5). Sensitivity and specificity for discrimination of RA pressure greater than or equal to or less than 10 mm Hg were maximized at the 50% level of collapse. Thus, IVC respiratory collapse on echocardiography is easily imaged and can be used to estimate RA pressure. A caval index greater than or equal to 50% indicates RA pressure less than 10 mm Hg, and caval indexes less than 50% indicate RA pressure greater than or equal to 10 Hg.
Adult↗
Benefits of physiologic atrioventricular synchronization for pacing with an exercise rate response.
Although the loss of atrioventricular (AV) synchronization may diminish resting cardiac output, previous studies have not shown any impact on exercise capacity as long as an exercise rate response is present. To test the impact of suboptimal atrial activation during treadmill exercise, 12 patients with normal sinoatrial node function and dual chamber pacemakers were evaluated in pacemaker modes with normal AV intervals allowing maximal atrial contribution to ventricular filling and with the shortest programmable nonphysiologic AV delay. During a double-blinded randomized crossover protocol, exercise performance was improved with physiologic AV filling in comparison with nonphysiologic AV filling: (1) mean increase in exercise time was 16 +/- 16% (mean +/- standard deviation) (p less than 0.05); (2) time to anaerobic threshold was increased by 23 +/- 28% (p less than 0.05); and (3) the level of perceived exertion during comparable stages of exercise was decreased. In 3 patients, exercise time was greater by greater than 35% in the physiologic AV filling mode. Resting echo-Doppler parameters of left atrial and ventricular function did not predict benefit from AV synchronization during exercise. During exercise with rate-responsive pacing an appropriate AV relation is beneficial, and in a subset of patients this benefit may be striking.
Adult↗
Noninvasive evaluation of pulmonary artery systolic pressures during dynamic exercise by saline-enhanced Doppler echocardiography.
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Adult↗
Severe pulmonary hypertension and cor pulmonale in the acquired immunodeficiency syndrome.
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Acquired Immunodeficiency Syndrome↗
Doppler echocardiography and ultrafast cine computed tomography during dynamic exercise in chronic parenchymal pulmonary disease.
In an effort to better understand the cardiac contribution to exercise limitation in chronic lung disease, 21 patients with advanced chronic pulmonary parenchymal disease and 10 normal control subjects were evaluated for changes in right ventricular (RV) pressure, volume and function during incremental, symptom-limited supine bicycle exercise. Patients underwent sequential exercise tests with Doppler echocardiography and ultrafast cine computed tomography (CT). RV systolic pressure during exercise was determined by saline-enhanced Doppler of tricuspid regurgitation. RV ejection fraction, end-diastolic volume, stroke volume and cardiac index were obtained by CT at rest and peak exercise. Sixteen of the 21 study patients also exercised on high-flow oxygen. In the control subjects RV systolic pressure increased from 21 +/- 6 mm Hg (mean +/- standard deviation) at rest to 32 +/- 8 mm Hg at peak exercise, whereas in patients with lung disease, RV systolic pressure increased from 42 +/- 17 to 81 +/- 26 mm Hg (both p less than 0.01). Compared with the control subjects, the patients with lung disease had significantly lower mean values for RV ejection fraction at rest (47 +/- 7 vs 55 +/- 7%) and at peak exercise (47 +/- 9 vs 57 +/- 3%, respectively, both p less than 0.05). The patients who demonstrated oxyhemoglobin desaturation during exercise showed the most abnormal cardiac responses, with marked increases in mean RV systolic pressure, decreases in mean RV ejection fraction and blunted increases in cardiac index and RV stroke volume. Although acute oxygen supplementation was associated with a slight decrease in RV systolic pressure at peak exercise and a longer duration of exercise, there was no significant improvement in RV function. Doppler echocardiography and CT provide complementary and potentially useful information about right-sided heart pressures and RV ejection fraction during exercise in patients with advanced chronic lung disease. Oxyhemoglobin desaturation during exercise is a marker for the most abnormal pulmonary vascular reserve, as indicated by RV contractile dysfunction and limited ability to increase cardiac index.
Aged↗
Clinical and echocardiographic comparison of patients with the carcinoid syndrome with and without carcinoid heart disease.
To correlate clinical and laboratory variables in carcinoid heart disease, clinical data, echocardiograms, 24-hour urinary 5-hydroxyindoleacetic acid levels and liver function tests were evaluated in 30 patients with the carcinoid syndrome. The dominant cardiac lesion of carcinoid heart disease by echocardiography and Doppler was severe tricuspid regurgitation with right ventricular volume overload. A characteristic finding was thickened, retracted tricuspid valve leaflets that were fixed in a partially open position. Carcinoid heart disease was progressive and often fatal. The 17 patients with echocardiographic evidence of carcinoid heart disease had higher peak levels of urinary 5-hydroxyindoleacetic acid (331 +/- 231 vs 58 +/- 78 mg, p less than 0.001) and more severe hepatic dysfunction than the 13 patients without carcinoid heart disease. Although duration of symptoms of the carcinoid syndrome before echocardiography was similar for patients with and without carcinoid heart disease (5.4 +/- 6.4 vs 6.2 +/- 5.9 years, respectively, p greater than 0.1), survival after echocardiography was shorter for those with carcinoid heart disease (1.9 +/- 1.4 vs 3.8 +/- 2.9 years, p = 0.05). The findings support the concept that long-term exposure of the endocardium to serotonin in the right side of the heart leads to the development of heart lesions; in addition, progressive hepatic dysfunction may allow more serotonin to bypass liver enzymes and reach the right side of the heart.
Adult↗
Cardiac manifestations of human immunodeficiency virus infection: a two-dimensional echocardiographic study.
To determine the prevalence of cardiac abnormalities in patients with human immunodeficiency virus (HIV) infection, two-dimensional Doppler echocardiography was performed on 70 consecutive patients with HIV infection, including 51 with acquired immunodeficiency syndrome (AIDS), 13 with AIDS-related complex and 6 with asymptomatic HIV infection. Of the 70 patients, 36% were hospitalized and 64% were ambulatory at the time of evaluation. The average age was 37 years; 93% were homosexual men. Echocardiographic findings included dilated cardiomyopathy in eight patients (11%), pericardial effusions in seven patients (10%) (one with impending tamponade), pleural effusion in four patients (6%) and mediastinal mass in one patient (1%). Among the 25 hospitalized patients, echocardiographic abnormalities were noted in 16 (64%), whereas among the 45 ambulatory patients, the only abnormality noted was mitral valve prolapse in 3 patients (7%) (p less than 0.0001). Dilated cardiomyopathy was the only echocardiographic lesion more common in the 25 hospitalized patients than in 20 hospitalized control patients with acute leukemia. Symptoms of congestive heart failure responded to conventional therapy. Cardiac lesions were associated with active Pneumocystis carinii pneumonia and low T helper lymphocyte counts. Dilated cardiomyopathy of unknown origin may be more common than was previously recognized in hospitalized, acutely ill patients with AIDS, but is uncommon in ambulatory patients with HIV infection. Echocardiography should be considered in the evaluation of dyspnea in hospitalized patients with HIV infection, especially those with dyspnea that is out of proportion to the degree of pulmonary disease.
Acquired Immunodeficiency Syndrome↗
Noninvasive evaluation of pulmonary artery pressure during exercise by saline-enhanced Doppler echocardiography in chronic pulmonary disease.
To determine the feasibility of noninvasive determination of right ventricular systolic pressure (RVSP) during a graded-exercise protocol, saline contrast-enhanced Doppler echocardiography of tricuspid insufficiency was performed in 36 patients with chronic lung disease and 12 normal controls. In the patients with chronic pulmonary disease, symptom-limited, incremental supine bicycle exercise and pulse oximetry were performed on and off high-flow oxygen. Technically adequate Doppler studies were initially obtained in 20 patients (56%) at rest and 14 (39%) on exercise; these numbers increased to 33 (92%) and 32 (89%), respectively, after enhancement with agitated saline (both p less than 0.001). In 10 patients with chronic lung disease who had simultaneous hemodynamic monitoring during exercise, the correlation between Doppler and catheter measurements of pulmonary artery systolic pressure was close (r = 0.98). Among controls, RVSP increased from 22 +/- 4 at rest (mean +/- SD) to 31 +/- 7 mm Hg at peak exercise. In patients with chronic lung disease, RVSP increased from 46 +/- 20 to 83 +/- 30 mm Hg (both p less than 0.001 vs. controls). Despite normal resting values for RVSP in 28% of study patients, nearly all showed abnormal increases in RVSP during supine bicycle exercise. Increases in RVSP during exercise were greatest in patients who showed oxyhemoglobin desaturation. The short-term administration of oxygen significantly blunted the increase in RVSP during exercise. Saline contrast-enhanced Doppler evaluation of tricuspid insufficiency seems a potentially valuable noninvasive method of determining the exercise response of RVSP in patients with chronic pulmonary disease.
Adult↗
Reproducibility of quantitative two-dimensional echocardiography.
In order to assess reproducibility of quantitative planimetry, three physicians trained in two-dimensional echocardiography performed five successive studies on one another over 2 weeks (30 total studies). Then each physician traced each study (90 total tracings) for left ventricular and atrial volumes and ejection fraction by means of a modification of Simpson's rule, and left ventricular mass and average wall thickness by means of a truncated ellipsoid formula. Calculation of intertechnician variability, intertracer variability, and 95% confidence limits showed that measurements of volumes were less reproducible than measurements of ejection fraction, average wall thickness, and mass. Mean intertracer variability of 15% exceeded mean intertechnician variability of 11%; this disparity was magnified in the subject who was technically difficult to image. Ninety-five percent confidence limits were: ejection fraction +/- 7%, average wall thickness +/- 9%, left ventricular mass +/- 12%, left ventricular end-diastolic volume +/- 11%, stroke volume +/- 14%, left ventricular end-systolic volume +/- 15%, and left atrial volume +/- 19%. Reproducible planimetry data can be obtained in normal hearts with the use of a protocol for quantitative imaging and planimetry.
Echocardiography↗
Improved recognition of cor pulmonale in patients with severe chronic obstructive pulmonary disease.
To compare sensitivity of clinical methods (physical examination, electrocardiogram, and chest radiograph) to echocardiography in the detection of cor pulmonale, and to determine the role of nocturnal oxygen desaturation in its development, 33 non-hypoxemic patients who had severe chronic obstructive pulmonary disease (COPD) were evaluated by clinical methods, echocardiography, and overnight ear oximetry. Compared to 25 age-matched control subjects, COPD patients had higher peak pulmonary systolic pressures by contrast-enhanced Doppler (40 +/- 13 versus 22 +/- 5 mm Hg, or 5.3 +/- 1.7 versus 2.9 +/- 0.7 kPa) and ratios of right to left ventricular volume (1.1 +/- 0.6 versus 0.6 +/- 0.1, both p less than 0.05). Defining cor pulmonale as pulmonary hypertension, right ventricular enlargement, or right ventricular hypertrophy, 25 COPD patients (75 percent) had cor pulmonale by echocardiography and 13 (39 percent) by clinical methods (p less than 0.05). Nocturnal desaturation was present in only 21 percent of patients. Echocardiographic measurements were similar between patients with emphysema and patients with bronchitis, and between patients with and without sleep desaturation. In patients who have severe COPD without waking hypoxemia, cor pulmonale is detected nearly twice as often by echocardiography as by clinical methods, but is usually not associated with sleep desaturation.
Aged↗
The echo-transponder electrode catheter: a new method for mapping the left ventricle.
The ability to locate catheter position in the left ventricle with respect to endocardial landmarks might enhance the accuracy of ventricular tachycardia mapping. An echo-transponder system (Telectronics, Inc.) was compared with biplane fluoroscopy for left ventricular endocardial mapping. A 6F electrode catheter was modified with the addition of a piezoelectric crystal 5 mm from the tip. This crystal was connected to a transponder that received and transmitted ultrasound, resulting in a discrete artifact on the two-dimensional echocardiographic image corresponding to the position of the catheter tip. Catheters were introduced percutaneously into the left ventricle of nine anesthetized dogs. Two-dimensional echo-transponder and biplane fluoroscopic images were recorded on videotape with the catheter at multiple endocardial sites. Catheter location was marked by delivering radiofrequency current to the distal electrode, creating a small endocardial lesion. Catheter location by echo-transponder and by fluoroscopy were compared with lesion location without knowledge of other data. Location by echo-transponder was 8.7 +/- 5.1 mm from the center of the radiofrequency lesion versus 14 + 7.8 mm by fluoroscopy (n = 15, p = 0.023). Echo-transponder localization is more precise than is biplane fluoroscopy and may enhance the accuracy of left ventricular electrophysiologic mapping.
Animals↗
Cardiac consequences of renal transplantation: changes in left ventricular morphology and function.
To characterize changes in left ventricular morphology and function associated with renal transplantation, noninvasive cardiac evaluations were performed in 41 adults at the time of surgery and at follow-up. At the time of transplantation, 36 patients had undergone hemodialysis through a fistula for 2.3 +/- 2.5 years (mean +/- SD); their hematocrit level was 26 +/- 6% and systolic blood pressure was 151 +/- 19 mm Hg. Perioperatively, left ventricular hypertrophy was present in 93% of patients by echocardiography, but in only 37% by electrocardiography. Abnormal left ventricular diastolic function was present in 67% of patients and indicated a high risk for perioperative pulmonary edema. At follow-up (1.5 +/- 1.4 years), mean hematocrit level increased to 39 +/- 7%, systolic blood pressure decreased to 132 +/- 14 mm Hg and spontaneous closure of the fistula occurred in 13 patients. Left ventricular mass by echocardiography decreased from 237 +/- 66 to 182 +/- 47 g (p less than 0.001), a decrease of 23%. Left ventricular volumes and cardiac index also decreased significantly, reflecting the rapid resolution of a pretransplant high output state. Despite proportionate regression of left ventricular hypertrophy within months of transplantation, diastolic function did not improve. The significant regression of left ventricular hypertrophy that occurs after renal transplantation may help explain the improved cardiovascular survival of patients with a renal transplant over that of patients on long-term dialysis.
Adult↗
Inferior vena cava plethora with blunted respiratory response: a sensitive echocardiographic sign of cardiac tamponade.
To assess the diagnostic and prognostic value of the respiratory behavior of the inferior vena cava in pericardial effusions, clinical and two-dimensional echocardiographic data of 115 consecutive patients with a moderate or large effusion, including 33 who had cardiac tamponade, were reviewed. Echocardiograms were reviewed for effusion size, inferior vena cava diameter before and after deep inspiration and presence of right atrial and ventricular collapse. For the 83 patients (72%) with less than 50% decrease in inferior vena cava diameter after deep inspiration ("plethora"), inferior vena cava diameter decreased from 2.0 +/- 0.3 to 1.6 +/- 0.4 cm after inspiration (mean +/- SD) (mean decrease 18%). For the 32 patients (28%) without plethora, the diameter decreased from 1.6 +/- 0.5 to 0.6 +/- 0.3 cm (mean decrease 63%). Patients with plethora had significantly higher values for heart rate (111 +/- 21 versus 98 +/- 20 beats/min), pulsus paradoxus (24 +/- 15 versus 12 +/- 4 mm Hg), jugular venous distension (14 +/- 5 versus 8 +/- 3 cm H2O) and right atrial pressure (17 +/- 6 versus 12 +/- 6 mm Hg) and lower values for systolic blood pressure (109 +/- 22 versus 132 +/- 27 mm Hg) (all p less than 0.05) than did patients without plethora. Plethora was present in 58 (92%) of 63 patients who underwent a pericardial drainage procedure, 14 (88%) of 16 who developed constrictive physiology and 11 (92%) of 12 of those whose hospital death was related to pericardial effusion.(ABSTRACT TRUNCATED AT 250 WORDS)
Cardiac Tamponade↗