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Chronic renal failure has been suggested as a risk factor for mitral annular calcification (MAC), a degenerative process of the mitral annulus. The objective of the present study was to define MAC risk factors at the start of dialysis and 'de-novo' appearance after medium- or long-term CAPD, in a non-selected population (135 patients) with a low degree of secondary hyperparathyroidism. Echocardiographic studies were performed at the beginning of CAPD and every 1-1.5 years thereafter. Diagnosis of MAC was established by M mode and 2-D study. Seventeen of 135 patients studied at the start of dialysis showed MAC. Patients who showed MAC were older and presented a higher mean systolic blood pressure. The other anthropometric/demographic parameters did not show statistically significant differences. MAC thickness: mean 6.21 +/- 3.65 mm (range 3-17.2 mm). The posterior annulus was universally affected and in four patients the anterior annulus was involved. Seventeen of 76 patients included in the follow-up study developed MAC. No significant differences for demography, except age, with MAC patients being older, were found. Mean time on CAPD until de-novo MAC diagnosis was 49.7 +/- 26.9 months. MAC thickness: mean 4.97 +/- 1.6 mm (range 3-8.42 mm). The posterior annulus was affected in all patients except for one and in four patients the anterior annulus was involved. The most remarkable echocardiographic feature is the almost constant association of MAC with left atrial dilatation (LAD). The last one does not seem a consequence of mitral insufficiency, or systolic dysfunction. Left ventricular hypertrophy was universally found, with no different intensities for patients with or without MAC. In conclusion, a high incidence of mitral annular calcification has been found in CAPD patients. Our data do not confirm the role of classical invoked risk factors. Blood CaP product under 75, a moderate to mild degree of hyperparathyroidism and/or hypertension with left ventricular hypertrophy do not seem to be isolated risk factors during the CAPD period. Length of time on CAPD, for unknown reasons, seems to favour the appearance of MAC. At starting dialysis, high systolic blood pressure and left ventricular hypertrophy seem to be related to MAC. Diabetes appears to represent an additional risk factor. Further research on mitral annular calcification pathogenesis and its consequences is urgently required.
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PMID:Mitral annular calcification in CAPD patients with a low degree of hyperparathyroidism. An analysis of other possible risk factors. 864 73

This type of disease has benefited considerably, over recent decades, from progress in ultrasound technique and new methods of medical and surgical treatment. The aetiologies of mitral incompetence can be classified into 4 categories according to their mechanism: 1. Mutilating valve lesions, usually secondary to bacterial endocarditis, but sometimes secondary to trauma (percutaneous valvuloplasty). 2. Rupture of chordae tendineae, either spontaneous or bacterial, in a context of pre-existing valvular heart disease, usually degenerative. 3. Papillary muscle lesions, usually corresponding to rupture of a papillary muscle or the head of a papillary muscle, associated with myocardial infarction. 4. Biological or mechanical valve prosthesis dysfunction. The consequences of acute mitral incompetence depend on its aetiology and the presence or absence of previous mitral valve disease. Three factors determine the clinical presentation and prognosis: the volume of regurgitation, left ventricular function and left atrial compliance. In pure forms, such as those occurring after rupture of chordae tendineae, the haemodynamic profile consists of a marked elevation of left ventricular filling pressures, left atrial mean and systolic pressures (large V wave), and a reduction of the cardiac output. The left ventricular end-diastolic volume is moderately increased, while the end-systolic volume is normal or decreased and the ejection fraction is increased. The clinical picture is that of acute left ventricular failure with a systolic murmur of mitral regurgitation and a pulmonary hypertension syndrome. The absence of left ventricular hypertrophy on the electrocardiogram and the absence of left-sided dilatation on radiological examination indicate the recent nature of the haemodynamic disturbances. The diagnosis of acute IM is confirmed by Doppler ultrasound, which defines the mechanism and sometimes eliminates the need for an invasive investigation. The clinical course depends on the aetiology, the volume of regurgitation, left ventricular function and the treatment implemented. First-line treatment must include vasodilators. Sodium nitroprussate infusion decreases the left ventricular end-diastolic volume and the volume of regurgitation and increases the cardiac output. It allows a rapid reduction of pulmonary artery and capillary hypertension. When this treatment is not sufficient, intra-aortic counterpulsation may be useful. Emergency surgery is sometimes necessary, but usually after improvement of the haemodynamic state by vasodilators. Depending on the aetiology, surgery may consist of valve replacement or surgical repair, which can give excellent results even in the presence of active bacterial endocarditis. In other cases, following control of the acute phase by medical treatment, mitral incompetence will become chronic.
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PMID:[Acute mitral valve insufficiency]. 878 32

The authors present three cases of pregnant women with symptomatic severe mitral stenosis with a mean age of 28.6 +/- 2.3 years, and during 27.6 +/- 1.52 weeks of pregnancy. Two patients were in class III and one in class IV of the New York Heart Association (NYHA). All patients had a mitral valvular area equal or less than 1 cm2, with a Wilkins score of 7 to 9 and mitral insufficiency grade I in two cases; two, had severe pulmonary arterial hypertension (mean > 50 mm Hg). After Percutaneous Mitral Valvuloplasty (PMV) the mitral valve measured by 2D echocardiography increased form 0.83 +/- 0.2 cm2 to 1.8 +/- 0.15 cm2; the mean transmitral gradient diminished from 13 +/- 3.4 mm Hg to 3.6 +/- 1.15 mm Hg; the degree of mitral insufficiency was no modified in neither case. Hemodynamic results revealed increasing of the mitral valve from 0.83 +/- 0.18 cm2 to 2.23 +/- 0.3 cm2; the mean mitral gradient decreased from 21.6 +/- 9 to 4.3 +/- 0.5 mm Hg; the mean left atrial pressure from 30 +/- 12 to 12.3 +/- 4 mm Hg; the mean pressure of the pulmonary artery diminished suddenly from 44.3 +/- 16 to 25.6 +/- 11 mm Hg. The average fluoroscopic time was 15.3 +/- 3 minutes. There were no complications. The patients were discharged 48 hours after the procedure and continued their pregnancies in class I NYHA, which resolved in a non complicated vaginal delivery with normal products. We conclude that PMV is a safe and useful therapy in pregnant patient with severe mitral stenosis refractory to medical treatment.
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PMID:[Percutaneous mitral commissurotomy using Inoue's balloon during pregnancy]. 898 57

Correlations between endocrine and cardiological findings were investigated in 106 patients with catecholamine-secreting tumours during the florid phase of their illness. Endocrine data showed an elevation of urinary catecholamine or vanillylmandelic acid excretion in all but one subject. Hypertension was found in 78%, symptoms of coronary heart disease in 26% and arrhythmias in 20% of the patients. Twelve per cent of the patients came to the hospital with heart attacks, 7% with acute left heart failure and 6% with myocardial infarction. At admission electrocardiograph (ECG) analysis showed a sinus rhythm in 98%, tachycardia > 100 min-1 in 14% and bradycardia < 60 min-1 in 10%. In 16% of the ECGs cQT was increased, in 17% the ST segment was lowered and in 37% abnormal T waves occurred. Indices of myocardial hypertrophy such as the Sokolow index, the modified Romhilt-Estes score and the Murphy score were raised in 29%, 19% and 38% respectively. In 23 of 51 (45%) patients echocardiography showed left ventricular hypertrophy, in 16% mitral valve insufficiency and in 24% disturbances of contractility. Comparison of cardiac and endocrine parameters confirm in vitro and animal studies indicating that, in particular, the alpha-mimetic noradrenaline (NA) has deleterious effects on the cardiovascular system. Urinary NA, but not adrenaline or dopamine, excretion was significantly higher in constantly hypertensive than in normotensive patients and associated with an elevation of the Sokolow index and the Romhilt-Estes score. Both indices and plasma NA were higher in patients with myocardial hypertrophy and we found a significant correlation between the Romhilt-Estes score and NA excretion.
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PMID:Cardiological effects of catecholamine-secreting tumours. 908 53

Cardiac involvement, evaluated by echo-doppler-cardiography, occurred in 41 of 50 (82%) patients with systemic lupus erythematosus (SLE). Valvular pathology with aortic cusp sclerosis was the most prevalent finding irrespective of age. This finding, suggestive of atherosclerotic heart disease, was supported by increased levels of cholesterol and triglycerides in these patients. There was no significant increase in Lp(a) in the whole patient group, but Lp(a) was raised in patients with proteinuria. Forty percent of the SLE patients had pericarditis. Twelve patients with hypertension and/or mitral regurgitation had increased dimensions of left ventricle, left atrium or interventricular septum while 15 of 50 patients had isolated increase of these parameters. Localized hypokinesia was found in nine patients. Reduced cardiac index was found in five patients with SLE. There was no association between valvular disease, increased pulmonary artery pressure, and anticardiolipin antibodies.
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PMID:Echocardiographic findings, lipids and lipoprotein(a) in patients with systemic lupus erythematosus. 909 95

Left ventricular (LV) mass, as estimated from M-mode echocardiography (echo), has previously been shown to be an independent predictor of incident cardiovascular disease morbidity and mortality. We evaluated the relationship at baseline of echo LV mass to relevant cardiovascular disease risk factors and other potential covariates in the Cardiovascular Health Study, multicenter study sponsored by the National Heart, Lung, and Blood Institute of 5201 men and women aged 65 years or older (mean, 73). Two-dimensionally directed M-mode echo LV mass measurements could be obtained in 1357 men and 2053 women (66% of this elderly cohort). Stepwise linear regression analyses of the relationship of echo LV mass to demographic and risk factor, physical activity, electrocardiographic, and prevalent disease variables resulted in a model that explained 37% of the variance for the entire cohort. In order of decreasing importance, factors positively associated with echo LV mass were body weight, male sex, systolic pressure, presence of congestive heart failure, present smoking, major and minor electrocardiographic abnormalities, treatment for hypertension, valvular heart disease, aortic regurgitation by color Doppler, and mitral regurgitation by color Doppler (in men) whereas diastolic pressure, bioresistance (a measure of adiposity), and high-density lipoprotein cholesterol were inversely related to echo LV mass. Although height and weight were both related to LV mass, height added nothing once weight was entered in multiple linear regression analyses. Furthermore, in the multiple regression models, diastolic pressure was inversely and systolic BP positively related to LV mass, with similar magnitudes for their coefficients. In consonance with these findings, pulse pressure was positively related to LV mass in bivariate analyses. Multiple linear regression analyses explained less of the variance for ventricular septal thickness (R2 = .13) and LV posterior wall thickness (R2 = .14) than for LV mass (R2 = .37) and LV diastolic dimension (R2 = .27). Intriguing findings in the elderly Cardiovascular Health Study cohort included the presence of pulse pressure as a positive correlate, and high-density lipoprotein cholesterol as an inverse correlate, of LV mass. Longitudinal studies in the Cardiovascular Health Study cohort will help to clarify the importance of demographic, risk factor, and other variables, and changes in these variables, in predicting changes in echo LV mass and its components as well as the prognostic significance of LV mass in the elderly.
Hypertension 1997 May
PMID:Left ventricular mass in the elderly. The Cardiovascular Health Study. 914 72

Doppler echocardiographic measurement of time-velocity integral of blood flow across the aortic annulus ("stroke distance") or of stroke volume (SV) have been proposed as noninvasive measures of cardiac pump performance that could elucidate the hemodynamics of hypertension. To evaluate the performance of these measures of hemodynamic volume load in a population with a wide range of body build and other characteristics, we obtained technically adequate imaging and Doppler echocardiograms in 1,935 of 2,212 (87%) American Indian Strong Heart Study participants, without mitral regurgitation or segmental left ventricular (LV) dysfunction, in Arizona, Oklahoma, and South/North Dakota. The subjects ranged widely in age (48 to 81 years) and body mass index (17.0 to 62.6 kg/m2); 65% were women; 1,161 were normotensive and 774 were hypertensive. As a reference standard, LV and stroke volumes were calculated from LV internal dimensions by the Teichholz method. Doppler SVs were moderately related to LV SVs (r = 0.63), but Doppler SV was slightly lower in both normotensive (mean = 69.8 and 72.9 mL, respectively) and hypertensive subjects (71.1 v 73.6 mL). Aortic stroke distance was less closely related than was aortic annular area to LV SV (r = 0.34 v 0.40, P < .001). Aortic annular area (r = 0.44) but not stroke distance (r = 0.04) was moderately correlated with body surface area. Stroke distance was inversely related to annular area (r = -0.29) and in subjects stratified by aortic annular diameter 1.6 to 1.9, 2.0 to 2.1, and 2.3 to 2.9 cm, mean LV SV increased from 67 to 74 to 80 mL, but average stroke distance fell from 22.8 to 21.6 to 20.1 cm. Stroke distance also failed to identify gender differences in LV SV but did identify that due to obesity. Thus Doppler SV closely parallels independently measured LV SV but slightly underestimates SV in both normotensive and hypertensive adults, whereas aortic stroke distance yields misleading comparisons between genders or individuals of different body sizes.
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PMID:Relations of Doppler stroke volume and its components to left ventricular stroke volume in normotensive and hypertensive American Indians: the Strong Heart Study. 919 7

Atrial fibrillation (AF) is in most patients (approximately 70%) associated with organic heart disease including valvular heart disease, coronary artery disease, hypertension, hypertrophic cardiomyopathy, dilated cardiomyopathy, and congenital heart disease, mostly atrial septal defect in adults. In many chronic conditions, determining whether AF is the result or is unrelated to the underlying heart disease, remains unclear. The list of possible etiologies also include cardiac amyloidosis, hemochromatosis and endomyocardial fibrosis. Other heart diseases, such as mitral valve prolapse (without mitral regurgitation), calcifications of the mitral annulus, atrial myxoma, pheochomocytoma, and idiopathic dilated right atrium may present with AF. Atrial fibrillation may occur in the absence of detectable organic heart disease, the so-called "lone AF", in about 30% of cases. The term "idiopathic AF" implies the absence of any detectable etiology including hyperthyroidism, chronic obstructive lung disease, overt sinus node dysfunction, and overt or concealed preexcitation (Wolff-Parkinson-White syndrome), only to mention a few of other uncommon causes of AF. The autonomous nervous system may contribute to the occurrence of AF in some patients. AF occurs commonly. In patients with valvular heart disease, AF is common, particularly when the mitral valve is involved. The occurrence of AF is unrelated to the severity of mitral stenosis or mitral regurgitation but is more common in patients with enlarged left atrium and congestive heart failure. In patients with coronary artery disease, AF occurs predominantly in older patients, males, and patients with left ventricular dysfunction, Important predictive factors of AF include hypertension, left ventricular hypertrophy and diabetes. The risk of the development of AF, in an individual patient, is often difficult to assess. Increasing age, presence of valvular heart disease, and congestive heart failure increase the risk of atrial fibrillation.
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PMID:Factors predisposing to the development of atrial fibrillation. 935 13

The results of routine chest X-ray made in 250 males aged 22-69 years who had acute myocardial infarction were evaluated. The data were compared with the results of ECG, echocardiography, Judkins coronarography, and left ventriculography. The X-ray signs of pulmonary venous hypertension in acute myocardial infarction, even not followed by cardiomegalia suggest lower left ventricular myocardial contractility. In this connection, the significance of follow-up X-ray monitoring becomes higher. In 25% of the young patients (aged 22-40 years) with prior acute myocardial infarction, the dimensions of the heart may be in the normal ranges even in the presence of X-ray signs of venous congestion. If there are no signs of mitral regurgitation in patients with ischemic heart disease, the enlarged left atrium may be regarded as an indirect X-ray sign of reduced left ventricular contractility. The extent of necrosis in patients with myocardial infarction exerts an impact on hemodynamic changes in the lung.
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PMID:[X-ray characteristics of heart failure in patients with acute myocardial infarction]. 941 49

Primary hyperparathyroidism, characterized by hypersecretion of parathyroid hormone (PTH) leading to hypercalcemia and relative hypophosphatemia, is quite common in the elderly. Most patients with primary hyperparathyroidism have only mild hypercalcemia and are symptomless. But others experience various other organ diseases. Primary hyperparathyroidism is also associated with cardiovascular abnormalities, including QT interval shortening, heart block, cardiac arrhythmias, hypertension, myocardial hypertrophy, myocardial calcification and, though rarely, with valvular heart disease. We described a case of primary hyperparathyroidism associated with cardiac abnormalities. An 82-year-old male presented with the complaints of chest discomfort, fatigue, general weakness, nausea and vomiting over a period of months and was admitted in July 1996. Physical examination with heart auscultation showed a pansystolic murmur over the right sternal border and apex region, and a blowing diastolic murmur over the left sternal border. Biochemistry profiles revealed elevations of serum calcium (14.3 mg/dl) and chloride/phosphate ratio (> 33). Endocrinological studies showed elevations of serum PTH-C (4.8 ng/ml) and PTH-intact (705 pg/ml) concentrations. Kidney ultrasonography revealed a left renal stone. A spine X-ray revealed spondylosis and a compression fracture of the lumbar-spine with osteoporotic change. Thyroid ultrasonography and Thallium (Tl201)-technetium (Tc99m) subtraction scan showed parathyroid adenoma in the low pole of the right thyroid bed. Parathyroid aspiration cytology revealed few and discrete cells. Echocardiogram revealed moderate to severe aortic valvular calcification as well as stenosis with moderate aortic regurgitation, mitral regurgitation and myocardial calcification. The patient received parathyroidectomy one month later. During his postoperative days, he suffered from muscle twitching with positive Trousseau's sign and Chvostek's sign. The patient received calcium carbonate and vitamin D for hypocalcemia, diltiazem and capoten for his heart problems. A repeated echocardiogram two months after surgery showed no improvement of valvular calcification.
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PMID:Primary hyperparathyroidism with cardiac abnormalities: a case report. 950 84


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