Corporeal veno-occlusive dysfunction: predominantly intracavernous muscular pathology

PURPOSE: We investigated whether a relationship exists between the flow to maintain an erection obtained at cavernosometry and the alteration of intracavernous structures in impotent patients with corporeal veno-occlusive dysfunction and normal arterial inflow. MATERIALS AND METHODS: Computerized histomorphometric analysis of smooth muscle and elastic fibers, and endothelial cells was compared to the flow necessary to maintain erection after intracavernous vasoactive drug injection in 18 patients with corporeal veno-occlusive dysfunction. RESULTS: A significant correlation between percentage of smooth muscle fibers and flow to maintain erection was observed, while no correlation was noted with elastic fibers and endothelial cells. CONCLUSIONS: Corporeal veno-occlusive dysfunction seems to be due mainly to smooth muscular alterations. According to this observation treatment of impotent patients with this abnormality should not be restricted to the penile veins but should also include the intracavernous structures, predominantly the muscular component.     

Determinants of the pulmonary artery pressure rise in left ventricular dysfunction

Pulmonary artery hypertension in patients with left ventricular dysfunction is related to poor outcome but the role of cardiac functional abnormalities in the genesis of pulmonary hypertension remains unknown. The aim of this prospective study was to identify the determinants of pulmonary hypertension in 102 consecutive patients with primary left ventricular dysfunction (ejection fraction < 50%). Systolic pulmonary artery pressure was measured by continuous wave Doppler. Left ventricular systolic and diastolic function, severity of functional mitral regurgitation, cardiac output, and left atrial volume were assessed using Doppler echocardiography. In patients with left ventricular dysfunction, systolic pulmonary artery pressure was increased (51 +/- 14 mmHg, range 23 to 87 mmHg). Mitral deceleration time (r = -0.61; p = 0.0001) and mitral effective regurgitant orifice (r = 0.50; p = 0.0001) were the strongest parameters related to systolic pulmonary artery pressure. Multivariate analysis identified these two variables as the strongest predictors of systolic pulmonary artery pressure in association with the mitral E/A ratio (p = 0.006) and age (p = 0.005). In conclusion, pulmonary hypertension is common and variable in patients with left ventricular dysfunction. It is closely related to diastolic dysfunction and severity of functional mitral regurgitation but not independently to the degree of left ventricular systolic dysfunction. These findings underline the importance of assessing diastolic function and quantifying mitral regurgitation in patients with left ventricular dysfunction.     

Simultaneous operation of intra-descending aorta bypass grafting and brachiocephalic artery reconstruction in a patient of aortitis syndrome

OBJECTIVE: To determine the intracavernous partial oxygen pressure in different etiological groups of erectile dysfunction: psychogenic (control group), arterial and veno-occlusive and the value of intracavernous gasometry as an indicator of the degree of severity of impotence. METHODS: A total of 16 patients were evaluated according to the diagnostic protocol utilized to determine the etiology of erectile dysfunction. Intracavernous blood samples were obtained during the initial phase of gasometry and PO2 was determined by standard gasometric methods. RESULTS: After injection of the vasoactive drug, the mean intracavernous PO2 was 92.4 +/- 1.27 for the control group, 62.2 +/- 0.85 for the group with arterial impotence, and 76.8 +/- 1.45 for the group with venous impotence, demonstrating a statistically significant difference (p < 0.01). CONCLUSIONS: Intracavernous gasometry, in combination with other diagnostic tests, is useful for evaluating the degree of severity of erectile dysfunction. The reduction in cavernous oxygen tension, which induces cavernous tissue fibrosis, can be considered to be a common mechanism in arterial and venous impotence.     

A primary intervention program (pilot study) for Mexican American children at risk for type 2 diabetes

Diastolic dysfunction is common in hypertrophic cardiomyopathy (HC). Previous studies suggest that Doppler transmitral flow velocity profiles, and the left atrial (LA) M-mode echogram can be used noninvasively to evaluate left ventricular (LV) diastolic function. However, this has not been proved in HC. In this study we determined the relation of Doppler transmitral flow velocity profiles and the LA M-mode echograms to invasive indexes of LV diastolic function in patients with HC. We studied 25 patients with HC, while off drugs, and calculated LA global and active fractional shortening and the slope of both early and late displacement of the posterior aortic wall during LA emptying by M-mode echocardiography. We calculated peak velocity of early (E) and atrial (A) filling, E to A ratio, and E-wave deceleration time by pulsed Doppler echocardiography, and simultaneous radionuclide angiography, LV pressures, time constant of isovolumic relaxation tau, and the constant of chamber stiffness k by cardiac catheterization. The time constant of isovolumic relaxation tau correlated with the slope of early posterior aortic wall displacement (r = 0.59; p <0.01). LV end-diastolic pressure correlated with global LA fractional shortening (r = -0.75; p <0.001); the constant of chamber stiffness k correlated with active LA fractional shortening (r = -0.53; p <0.02). In a subset of 13 patients, in whom echocardiography and cardiac catheterization were performed simultaneously, similar results were found. LA M-mode recordings provide a more reliable noninvasive assessment of diastolic function in HC than mitral Doppler indexes.     

Noninvasive assessment of collateral blood flow of the cerebral hemisphere by Doppler ultrasound

Directional flow in the frontal artery, a terminal branch of the ophthalmic artery, was assessed nonivasively by Doppler ultrasound druing brief digital compression of the ipsilateral common carotid artery in 62 patients. Directional frontal artery flow during carotid compression was compared with mean distal internal carotid back pressure measured at subsequent carotid endarterectomy. Mean carotid back pressure in 28 patients with normal frontal artery flow direction during carotid compression, 68 +/- 14 millimeters of mercury, was significantly higher than that observed in 24 patients in whom frontal artery flow was completely obliterated and ten in whom frontal artery flow was reversed. Distal internal carotid back pressure exceeded 48 millimeters of mercury in all patients with normal frontal artery flow direction during carotid compression. Conversely, carotid back pressure was below 41 millimeters of mercury in all but one patient in whom frontal artery flow was obliterated or bliterated or reversed during carotid compression. The results of this study indicate that Doppler ultrasound assessment of frontal artery flow direction during simultaneous carotid compression provides a rapid, sale noninvasive estimate of the adequacy of collateral hemispheric circulation.     

Antithrombin-III for the treatment of chemotherapy-induced organ dysfunction following bone marrow transplantation

A hypercoaguable state has been shown to follow high-dose chemotherapy for bone marrow transplantation (BMT). Deficiency of the natural anticoagulants, antithrombin III (AT-III), protein C and protein S correlate with organ dysfunction following BMT. We treated 10 patients with severe post-BMT organ dysfunction with AT-III concentrate. Indications for treatment included AT-III anticoagulant level less than 88% and life-threatening single or multiorgan dysfunction. All patients were loaded with 50 units/kg AT-III every 8 h for three doses followed by 50 units/kg/day each day for 3-12 days. Clinical improvement was seen within 1-5 days of start of therapy in all patients. Patients with veno-occlusive disease (VOD) showed a decrease in platelet consumption in nine of nine patients, resolution of hepatic tenderness in six of eight patients, and reduction of severe ascites and weight gain in four of five patients. The probability of death due to VOD and life-threatening organ dysfunction was significantly less in the AT-III-treated group when compared to a historical control group receiving the same preparative regimen (P = 0.047 and P = 0.034, respectively). Significant improvements in organ dysfunction following AT-III treatment in this small study supports a causal relationship between AT-III deficiency and post-BMT chemotherapy-induced organ dysfunction.     

Doppler color echography in the diagnosis of impotence

This study reports the experience achieved with duplex and color Doppler ultrasonography in 120 impotent patients. The following morphodynamic parameters of the cavernosal arteries were studies before and after intracorporal injection of a mixture of vasoactive drugs: arterial diameter, wall pulsatility, morphology of the spectral waveform, peak systolic velocity, end diastolic velocity and flow volume. The veno-occlusive mechanism of the corpora cavernosa was studied directly by determination of flow along the deep dorsal vein of the penis and indirectly by serial evaluation of the diastolic flow of the cavernous arteries.     

Left ventricular function and exercise tolerance in patients with type II diabetes mellitus

BACKGROUND: Left ventricular (LV) preload changes may alter exercise tolerance (ET), probably lessening activation of the Maestrini-Starling mechanism. Reduced LV filling (pre-load) during the diastolic phase, usually impaired in diabetic patients, could affect ventricular function. HYPOTHESIS: To evaluate the relationship between some echocardiographic LV function indices and ET, 24 patients (age 43-75 years, mean 54 +/- 13 years, Group A) with type II diabetes mellitus (DM), not suffering from other pathologies, and for whom the ergometric stress test (EST) resulted in an early interruption because of muscular fatigue and/or dyspnea, and 14 patients (age 38-70 years, mean 53 +/- 12 years, Group B) with type II DM and maximal ergometric stress test, used as control group, were studied. METHODS: The EST was performed by increasing the load by 25 W every 2 min; its duration was used as an ET index and correlated with clinical parameters of LV function obtained with M-mode, two-dimensional, and Doppler echocardiography. RESULTS: No patients in either Group A or Group B showed a high systolic blood pressure value at rest and/or an LV hypertrophy and/or an alteration of systolic functional indices. In neither group was there significant correlation between ET and duration of DM, basal heart rate, basal and max systolic blood pressure, and EF values. Linear regression analysis showed a significant correlation between Doppler parameters of the diastolic function and ET index in Group A, while there was no significant correlation in Group B. CONCLUSION: From these data we can deduce that in absence of left systolic ventricular dysfunction the impairment of LV relaxation in DM can influence exercise tolerance, probably by limiting activation of the contractile reserve.     

Doppler estimation of left ventricular filling pressure in sinus tachycardia. A new application of tissue doppler imaging

BACKGROUND: Doppler echocardiography is frequently used to predict filling pressures in normal sinus rhythm, but it is unknown whether it can be applied in sinus tachycardia, with merging of E and A velocities. Tissue Doppler imaging (TDI) can record the mitral annular velocity. The early diastolic velocity (Ea) behaves as a relative load-independent index of left ventricular relaxation, which corrects the influence of relaxation on the transmitral E velocity. METHODS AND RESULTS: We evaluated 100 patients 64+/-12 years old with simultaneous Doppler and invasive hemodynamics. Mitral inflow was classified into 3 patterns: complete merging of E and A velocities (pattern A), discernible velocities with A dominance (B), or E dominance (C). The Doppler data were analyzed at the mitral valve tips for E, acceleration and deceleration times of E, and isovolumic relaxation time. In patterns B and C, the A velocity, E/A ratio, and atrial filling fraction were derived. Pulmonary venous flow velocities were also measured, and TDI was used to acquire Ea and Aa. Weak significant relations were observed between pulmonary capillary wedge pressure (PCWP) and sole parameters of mitral flow, pulmonary venous flow, and annular measurements. These were better for patterns A and C. E/Ea ratio had the strongest relation to PCWP [r=0.86, PCWP=1.55+1.47(E/Ea)], irrespective of the pattern and ejection fraction. This equation was tested prospectively in 20 patients with sinus tachycardia. A strong relation was observed between catheter and Doppler PCWP (r=0.91), with a mean difference of 0.4+/-2.8 mm Hg. CONCLUSIONS: The ratio of transmitral E velocity to Ea can be used to estimate PCWP with reasonable accuracy in sinus tachycardia, even with complete merging of E and A velocities.     

Fattiviracin A1, a novel antiherpetic agent produced by Streptomyces microflavus Strain No. 2445. I. Taxonomy, fermentation, isolation, physico-chemical properties and structure elucidation

A 67-old man was referred to our hospital because of dyspnea on exertion and severe hypoxia. He had been given, tegafur and OK 432 for seven years following an operation for gastric cancer. Pulmonary hypertension was noted by right heart catheterization. The findings of a transbronchial lung biopsy resulted in a diagnosis of pulmonary veno-occlusive disease. Pulmonary hemodynamic studies were performed for five different agents: nifedipine, beroprast sodium (PGI2), nitroglycerin, theophylline, and isosorbide dinitrate. However, none of these agents showed significant effects on pulmonary arterial pressure or pulmonary vascular resistance. Treatment with glucocorticoid relieved the patient's symptoms without any apparent effect on pulmonary hemodynamics. The long-term administration of anticancerous agents (tegafur) were thought to have caused pulmonary veno-occlusive disease to develop in this patient.     

Methods for coronary functional assessment

Functional evaluation of coronary vasomotion encompasses the assessment of dynamic changes in coronary lumen, vessel wall, blood flow, intracoronary pressure and myocardial perfusion in response to specific pharmacologic stimuli. These parameters are obtained to characterize mechanisms of physiologic regulation and to evaluate pathophysiologic processes and potential therapeutic strategies, especially with regard to the development of coronary atherosclerosis. To this end, a variety of direct (invasive) and indirect (non-invasive) diagnostic tools are employed. Among the invasive methods are registration of intracoronary Doppler flow, coronary pressure measurements, quantitative coronary angiography and intravascular ultrasound. The non-invasive modalities consist of coronary Doppler echocardiography, positron emission tomography, myocardial scintigraphy and magnetic resonance imaging. Because of the different technical and physiological principles involved, these methods are complementary by providing independent access to different aspects. The combined invasive functional testing as employed in the cardiac catheterization laboratory allows for a simultaneous synopsis of high-resolution coronary imaging and direct measurement of physiologic parameters during local application of defined pharmacologically active substances. However, the demands in terms of equipment, time and operator skills are high and limit this combined invasive approach to specialized centers. Besides these research purposes, a number of functional methods has entered the clinical arena. They are employed to evaluate the hemodynamic significance of coronary lesions and to assess functional outcome of therapeutic interventions in the catheterization laboratory. The underlying principles and applications of the different methods are described and an overview of selected results is presented.     

Two models of epileptic spike-and-wave rhythm in rats are differently influenced by ethosuximide

One hundred and thirty-seven consecutive patients who received bone marrow or peripheral blood stem cell transplantation were studied retrospectively to identify the risk factors for hepatic veno-occlusive disease (VOD). Of the 137 recipients, twenty (14.6%) patients were diagnosed with VOD using the McDonald's criteria. In these 20 patients with VOD, we analyzed various clinical parameters, including age, sex, HLA status, conditioning regimen, irradiation, immunosuppressive agents, mode of transplantation, history of hepatic dysfunction, pre-transplant hepatic and renal function, infectious episodes, antibiotics use, and serum viral titers. A history of hepatic dysfunction and low levels of pseudocholinesterase before transplantation were found to be statistically significant (P = 0.04 and 0.04). Low levels of pseudocholinesterase were significant by multivariate analysis using the logistic regression model (P = 0.02). These results suggest that pseudocholinesterase levels before transplant are important markers of VOD in patients receiving BMT.     

The role of colour Doppler imaging in the management of Peyronie's disease

OBJECTIVE: To determine the role of colour Doppler imaging (CDI) in the investigation of erectile dysfunction in patients with Peyronie's disease. PATIENTS AND METHODS: Fifty consecutive patients (age 35-75 years) with Peyronie's disease who were considered suitable for surgical treatment were investigated using CDI to determine the haemodynamic variables of penile vasculature after an intracorporeal injection of 20 microg of alprostadil (with manual self-stimulation). A clinician independently recorded the quality of erection and the deformity. RESULTS: Twenty of 50 patients (40%) considered they had normal erectile function despite their penile deformity and all had normal responses, although they tended to exaggerate the degree of penile deformity. Of the 30 remaining patients, 21 who considered themselves to have erectile dysfunction had normal clinical and CDI haemodynamic responses to alprostadil. The remaining nine patients had a variety of erectile problems and whilst CDI showed altered haemodynamic values, in no case did CDI alter the proposed treatment based on the clinically apparent features of those patients. CONCLUSION: Colour Doppler imaging of the penis after pharmacologically induced erection gives anatomical and functional information in patients with Peyronie's disease but does not provide useful additional information to aid the selection of surgical treatment for the disease.     

Use of ultrasound methods in vascular and circulatory diseases (author's transl)

The paper summarizes the principles, techniques and efficiency of ultrasound methods as indicator systems in the assessment of the peripheral and cerebral arteries; our studies predominantly refer to the use of these simple, non-invasive procedures in combination with sphygmo-oscillography and dynamographic circulation analysis, respectively. Ultrasound Doppler flowmetry (Pulse Doppler method), which permits relative measurements of the flow velocity in the peripheral haemodynamic regions, is of great importance in the rapid ascertainment of the patency of the major arterial trunks and the non-palpable vessels and also in the diagnosis, localization and follow-up control of stenoses and occlusions. Changes in the flow velocity due to organic or functional factors can be recorded by this method acoustically, oscilloscopically and graphically; measurements of the systolic blood pressure in the limb arteries by the Doppler technique provide semi-quantitative information in regard to the condition of the circulation. The registration of Doppler signals over the supra-orbital artery before and after compression of the superficial temporal artery and the common carotid artery has become established as a screening procedure for stenoses of the internal carotid artery. Ultrasound echography, which enables pulse registration and determination of vessel diameters, especially of the carotid siphon, can also be used for the detection of obstructions in the region of the internal carotid artery, as well as the vertebral artery.     

Echophonocardiographic studies of the contribution of the atrioventricular valves to the first heart sound

The movements of the mitral, tricuspid and aortic valves have been recorded echocardiographically and related to the first heart sound (S1) in patients with various hemodynamic and conduction abnormalities. Closure of the mitral and tricuspid valves has been studied with respect to the corresponding atrioventricular pressure crossover and it is clear that both valves finish closing about 50 msec after pressure crossover. In order to clarify the relative contribution of tricuspid valve closure and aortic root events to the second high frequency component of S1, a new simultaneous dual echophonocardiographic technique was employed. This permitted the simultaneous registration of tricuspid and aortic valve movements and demonstrated that in certain circumstances the second high frequency component of S1, could be attributed to tricuspid closure, aortic root events being excluded from the genesis of this sound. These observations suggest that the two high frequency components of S1 are related to closure of the mitral and tricuspid valves. The results do not however, exclude a contribution to S1 of aortic root events, which may be of lower frequency vibrations.     

Objectives of high blood pressure treatment: left ventricular hypertrophy, diastolic function, and coronary reserve

The authors report the cases of two patients admitted to hospital for investigation of haemolytic anaemia. Both had undergone, 10 and 12 years previously, mitral valve replacement with a Ionescu-Shiley bioprosthesis. In both cases, in the absence of signs of cardiac failure, Doppler echocardiography showed mitral regurgitation. The association of haemolytic anaemia and dysfunction of the bioprosthesis led to redux valve replacement and correction of the anaemia. Haemolytic anaemia was the presenting sign of bioprosthetic valve dysfunction requiring replacement of the prosthesis. This complication is common with mechanical valve prostheses but much more rare in bioprosthetic valves.     

Diastolic dysfunction in patients with chronic kidney failure on a hemodialysis program

OBJECTIVE: The aim of this study was to analyse different ultrasound parameters for the assessment of isolated left ventricular diastolic dysfunction (LVDD) in patients with chronic renal failure (CRF) on periodic hemodialysis (HD), comparing pulsed wave Doppler with pulsed tissue Doppler. MATERIALS AND METHODS: Forty-seven patients with CRF on HD (61% were male; mean age was 51.0 +/- 16.5 years, mean HD time--3.7 +/- 3.8 years, 38% had hypertension, 17% had diabetes) were studied by echocardiography (bidimensional, M-Mode, flow pulsed Doppler and tissue Doppler imaging). All patients had symptoms of left heart failure-class II NYHA, were in sinus rhythm and had no symptoms of ischemic heart disease. The presence of abnormal LV regional contractility was the exclusion criteria. According to their mitral inflow profile Doppler characteristics, patients were included in two groups: Group A (E/A > 1; n = 21) and B (E/A < 1; n = 26). We compared: LV dimensions and function, left atrial (LA) dimension. Gaasch index, LV mass index. E and A wave velocities (in flow pulsatile Doppler and tissue Doppler). E/N ratio in tissue Doppler, isovolumetric relaxation time (IVRT) and deceleration time (DT). RESULTS: There were no significant differences in the prevalence of age > or = 65 years male sex, hypertension or diabetes between group A and B patients, and almost all patients were on hemodialytic treatment for more than one year (81% vs 85%: NS). LV hypertrophy was present in almost all group A and B patients (A--95% vs B--85.5%; NS). Group A, compared with group B, had a difference in the Gaasch index (2.45 +/- 0.3 vs 2.08 +/- 0.4; p < 0.05), E wave velocity in flow pulsatile Doppler and tissue Doppler (cm/sec) (110 +/- 27 vs 62 +/- 20; p < 0.001 and 41 +/- 15 vs 28.5 +/- 16; p < 0.05), E/A ratio in tissue Doppler (1.3 +/- 0.4 vs 0.8 +/- 0.3; p < 0.001). IVRT (msec) (80.7 +/- 15.2 vs 113.5 +/- 28.3; p < 0.001) and DT (msec) (189.7 +/- 24 vs 278.2 +/- 17.9; p < 0.001). According to the E'/A' ratio in tissue Doppler, group A patients were divided in another two groups: E'/A' > 1 (13/21--62%) and < 1 (8/21--38%) and a significantly longer IVRT (75.8 +/- 9.3 vs 100.9 +/- 3.2; p < 0.001) and DT (178 +/- 15 vs 240 +/- 20; p < 0.001) and a greater LA dimension (37.6 +/- 6.9 vs 44.6 +/- 6.9; p < 0.05) were found. CONCLUSIONS: Pulsed wave Doppler is the most useful non invasive method for assessment of global diastolic dysfunction. In our study, 17% of the patients had E/A < 1 only in the tissue Doppler study. These patients probably had a pseudonormal mitral pattern.     

Bourneville''s tuberous sclerosis

In addition to demonstrating constrictive and restrictive cardiac physiology, simultaneous right and left ventricular pressure measurements can be helpful to identify various aspects of myocardial dysfunction. Intracardiac conduction defects will displace the right ventricular pressure under the left ventricular pressure upstroke and identify differences in the timing of ventricular contraction. Right ventricular dysfunction will also produce abnormal right ventricular pressure waveforms which may overlap left ventricular pressure and contribute to abnormalities in right atrial and ventricular pressure waveforms.     

Structuring a clinical learning environment for a hybrid-PBL dental curriculum

The standard noninvasive test to assess the severity of peripheral arterial occlusive disease (PAOD) is the ankle/brachial systolic blood pressure index (ABI). While ankle systolic blood pressure is obtained by the Doppler ultrasound technique, brachial systolic blood pressure can be obtained by the Doppler, auscultatory, or oscillometric (Dinamap 1846 SX) methods. The purpose was to determine whether the three methods yielded similar brachial systolic blood pressure values, and consequently similar ABI values, in PAOD patients with intermittent claudication. Fifty patients who had a history of intermittent claudication of 2.3 +/- 2.0 blocks for a duration of 5.7 +/- 5.8 years were recruited. Following 10 minutes of supine rest, brachial systolic blood pressure was measured in the right arm by the three techniques in a randomized order, and ankle systolic blood pressure (87.3 +/- 28.9 mmHg) was measured in the more symptomatic leg with the Doppler technique. Brachial systolic blood pressure was not significantly different (p=0.954) among the Doppler (128.5 +/- 18.4 mmHg), auscultatory (128.4 +/- 17.4 mmHg), and oscillometric (128.2 +/- 17.1 mmHg) methods. Corresponding ABI values also were similar (p=0.922) among the three respective methods (0.68 +/- 0.22, 0.68 +/- 0.22, and 0.68 +/- 0.21), indicating that ABI did not vary according to the technique used to obtain brachial systolic blood pressure. It is concluded that the accuracy of determining ABI in PAOD patients with intermittent claudication was minimally affected by the method chosen to obtain brachial systolic blood pressure.     

Clinical primary pulmonary hypertension: three pathologic types

Clinically, there is a group of patients with elevated pulmonary arterial pressure in whom the underlying cause is not apparent. The pulmonary arterial wedge pressure is not elevated. For such cases, the designation of primary pulmonary hypertension may be made clinically. From the clinical categorization of primary pulmonary hypertension, three distinct pathologic entities emerge, namely 1) plexogenic pulmonary arteriopathy, 2) recurrent pulmonary thromboembolism, and 3) pulmonary veno-occlusive disease. The plexogenic type is characterized initially by pulmonary arterial vasoconstriction with medial hypertrophy. Secondary proliferative intimal lesions, including the plexiform lesion, develop. Recurrent pulmonary thromboembolism is characterized by the presence of arterial thrombi of varying ages involving the microscopic-sized pulmonary arteries. Thrombi may be embolic in nature or may develop in situ. Pulmonary veno-occlusive disease is characterized by obstructive lesions of pulmonary veins and venules. The clinical presentation of the three pathologic types may be so similar that definitive diagnosis depends upon histologic examination of the lung from tissue obtained either by biopsy or at necropsy.