Placental 11 beta-hydroxysteroid dehydrogenase activity in normotensive and pre-eclamptic pregnancies

Apparent mineralocorticoid excess and licorice induced hypertension, both hypertensive disorders, have been attributed to a defect in the enzyme 11 beta-hydroxysteroid dehydrogenase (11 beta-HSD), which interconverts cortisol to cortisone. Therefore, we undertook this study to determine the role of human placental 11 beta-HSD activity in preeclampsia, which is a hypertensive disorder in pregnancy. 11 beta-HSD activities were determined in placentas of 17 normotensive and 11 preeclamptic patients matched for gestational age at 34-42 weeks. Cortisol levels in umbilical venous and arterial sera were also determined for both groups. Statistical analysis was performed using Student's t-test, significance at p < 0.05. 11 beta-dehydrogenase (oxidation activity of 11 beta-HSD) activity was significantly lower in placentas of preeclamptic compared to normotensive patients (0.19 +/- 0.09 vs. 0.26 +/- 0.08 mmoles/min/placenta, p = 0.02). Cortisol level in umbilical cord blood was significantly higher in the preeclamptic group (14.99 +/- 14.08 vs. 6.71 +/- 3.69 g/dL, p = 0.02). The decreased 11 beta-HSD activity is accompanied by an expected increase in umbilical cord blood cortisol level and decrease in fetal weight. This enzyme may play an important role in influencing fetal growth.     

Premenstrual dysphoric disorder: controversies surrounding the diagnosis

OBJECTIVE: To evaluate the umbilical and uterine arterial Doppler flow velocity waveform systolic to diastolic (S/D) ratios performed at 24-30 weeks gestation for predicting fetal growth retardation (IUGR). METHODS: A prospective double blind study was conducted in 118 cases of high risk singleton pregnant women. The umbilical and uterine arterial S/D ratios were measured at 24-30 gestational weeks and the pregnancy outcomes were followed up. RESULTS: The prevalence of IUGR in our study population was 16.9%. At 24-30 weeks gestation, the S/D ratio of both umbilical artery and uterine artery in IUGR pregnant women were significantly higher than those in normal pregnant women, while the fetal biometric measurements were normal in all the 118 cases. The sensitivity, specificity and positive predictive value of umbilical arterial S/D ratio to predict IUGR were 80.0%, 83.7% and 50.0% with a Kappa index of 0.51 at 24-30 weeks gestation. With lower sensitivity, specificity, positive predictive value and Kappa index (40.0%, 84.5%, 34.8% and 0.23 respectively), the uterine arterial S/D ratio had less predictive value. CONCLUSIONS: The umbilical arterial Doppler flow velocity waveform S/D ratio may be an earlier predictor for screening of IUGR at 24-30 weeks gestation in high risk pregnant women with normal fetal biometric measurements.     

The role of reflection in single and double loop learning

OBJECTIVE: The purpose of this study was to determine whether there are demonstrable alterations in uterine artery blood flow in pregnant women with müllerian duct anomaly. STUDY DESIGN: Flow velocity waveforms obtained from the placental and nonplacental uterine arteries were studied at 18 to 24 weeks' gestational age in 15 pregnant women with müllerian duct anomaly and in 30 controls. The systolic/diastolic ratios were compared and correlated with the degree of placental laterality and perinatal outcome. RESULTS: Systolic/diastolic ratio in the uterine artery was abnormal in 80% of the cases and in 10% of controls (p < 0.0001). A completely lateral placenta was found in 10 of 15 women of the study group and only in 1 of the 30 controls (p < 0.0001). Women with müllerian duct anomaly had higher systolic/diastolic ratios in the nonplacental uterine artery than those with a normal uterus (median 4.3, range 2.0 to 7.4 vs median 2.8, range 2.0 to 4.0; p < 0.001). Twelve of 15 women of the study group had poor perinatal outcome compared with 4 of the 30 controls (p < 0.001). Among those women with poor perinatal outcome, 11 of 12 (92%) in the study group and only 1 of the 4 (25%) in the control group had an abnormal systolic/diastolic ratio in the uterine arteries (p < 0.05). CONCLUSION: There is a clear association between placental laterality and high systolic/diastolic ratio in the nonplacental uterine artery in pregnant women with müllerian duct anomaly who had poor perinatal outcome. This finding suggests that unilateral placental implantation could lead to functional exclusion of one uterine artery from the uteroplacental circulation and could explain pregnancy complications in women with developmental fusion defects of the uterus.     

Echocardiographic changes and alterations in lipid profile in cases of subclinical and overt hypothyroidism

Forty four patients (22 of overt hypothyroidism and 22 of subclinical hypothyroidism) and 11 controls underwent lipid profile evaluation and two dimensional echocardiography. Amongst the various parameters evaluated, mean Interventricular Septal (IVS) dimensions were significantly (p < 0.005) raised in overt hypothyroidism [IVS: end diastolic (ED) = 0.973 +/- 0.223 cm.; end systolic (ES) = 1.300 +/- 0.240 cm.] with respect to control group [IVS : ED = 0.747 +/- 0.118 cm.; ES = 1.073 +/- 0.173 cm.]. Mean Left Ventricular Posterior Wall (LVPW) thickness was also significantly (p < 0.005) raised in overt hypothyroidism [LVPW : ED = 0.944 +/- 0.200 cm.; ES = 1.350 +/- 0.243 cm.] in comparison with control group [LVPW : ED = 0.779 +/- 0.091 cm.; ES = 1.176 +/- 0.128 cm.]. Evidence of diastolic dysfunction was present in both subclinical (n = 2) and overt hypothyroidism (n = 6) while pericardial effusion was seen only in overt hypothyroidism (n = 10). Mean Serum cholesterol was significantly raised in both subclinical (192.13 +/- 47.40 mg%) (p < 0.05) and overt hypothyroidism (231.27 +/- 68.30 mg%) (p < 0.005) with respect to control group (157.63 +/- 37.69 mg%). In overt hypothyroid patients mean serum Triglyceride (235.59 +/- 137.53 mg%) (p < 0.05), LDL (126.09 +/- 54.99 mg%) (p < 0.05) and Apo-B (0.698 +/- 0.354 g/L) (p < 0.05) levels were significantly higher as compared to control group (serum triglyceride 165.45 +/- 49.15 mg%, LDL 88.72 +/- 38.75 mg%, Apo-B 0.474 +/- 0.176 g/L.     

Doppler flow velocity waveforms of the umbilical arteries correlate with intravillous blood volume

OBJECTIVE: My purpose was to measure the volume of the fetoplacental vessel tree and to relate findings to Doppler flow patterns of the umbilical arteries. STUDY DESIGN: One hundred sixty placentas were examined by means of standardized random block placental histomorphometry after delivery and the results were compared with antenatal Doppler findings. RESULTS: There was a high correlation (r = -0.703) between the intravillous blood volume obtained from measurements of intermediate and terminal villi and the Doppler flow velocity waveforms detected within the last week before delivery. Moreover, the reduced size of a vessel tree less than 85 mL is highly predictive of perinatal complications, such as fetal growth restriction, low umbilical artery pH values after birth, reduced Apgar scores, and cesarean section for fetal distress. CONCLUSION: These data suggest that reduced end-diastolic flow velocities in the umbilical arteries are associated with elevated fetoplacental impedance owing to reduced vascularization of intermediate and terminal villi.     

Simultaneous determination of nerisopam, a novel anxiolytic agent showing polymorphic metabolism, and its N-acetyl metabolite from human plasma by a validated high performance liquid chromatographic method

OBJECTIVE: Our goal was to determine the effect of chronic and acute umbilical-placental embolization on placental hemodynamic and fetal heart rate patterns in relation to fetal oxygenation in the near-term ovine fetus. STUDY DESIGN: Daily fetal placental embolization was performed during 10 days in 9 sheep fetuses until fetal arterial oxygen content decreased by approximately 30%. Nine control fetuses received saline solution. Mean and pulsatile umbilical blood flow, perfusion pressure, placental vascular resistance, fundamental impedance, pressure pulsatility index, and umbilical artery resistance index corrected to a fetal heart rate of 160 beats/min were measured. On day 10 both groups were acutely embolized until fetal arterial pH decreased to approximately 7.00. Fetal heart rate was measured with the Sonicaid System 8000 (Oxford Sonicaid, Oxford, United Kingdom). RESULTS: Chronic fetal placental embolization was associated with a progressive reduction in umbilical blood flow (p < 0.00001) and fetal arterial oxygen content (p < 0.001) whereas fetal heart rate patterns remained unaltered. A chronic increase in umbilical artery resistance index corrected to a fetal heart rate of 160 beats/min could be entirely explained only if the changes in umbilical artery pressure pulsatility index and the fundamental impedance were taken into account, in addition to the changes observed in placental vascular resistance. During acute embolization leading to a 50% reduction in umbilical blood flow (p < 0.0002) and a three times increase in placental vascular resistance (p < 0.0001), the most consistent change in fetal heart rate patterns related to progressive metabolic acidosis was an 84% decrease in absolute acceleration frequency (p < 0.0001) whereas short-term fetal heart rate variability remained unaltered. CONCLUSION: Changes in umbilical artery resistance index induced by chronic umbilical-placental embolization resulting in fetal hypoxemia occurred before any changes in fetal heart rate patterns were detectable. A decrease in the absolute acceleration frequency was the only component of fetal heart rate patterns related to progressive metabolic acidosis in the near-term ovine fetus.     

The head-to-abdomen circumference ratio: a reappraisal

Our objective was to assess the clinical significance of the sonographically derived head-to-abdomen circumference ratio in small-for-gestational-age (SGA) fetuses. The head-to-abdomen ratio was determined in 134 singleton SGA fetuses without ultrasound evidence of malformations at 26-40 weeks' gestation. Data were collected regarding antenatal surveillance, umbilical artery Doppler velocimetry and neonatal outcome. In SGA fetuses, the head-to-abdomen ratio, adjusted for gestational age, had a normal frequency distribution, positively skewed with regard to fetuses with normal birth weight. An elevated head-to-abdomen ratio was found in 56 SGA fetuses (42%), and was associated with increased perinatal mortality (odds ratio 3.27; 95% confidence internal 1.04-9.34), lower birth weight (1533 +/- 635 g vs. 2022 +/- 655 g, p < 0.0001) and lower gestational age at delivery (34 +/- 3.6 weeks vs. 36.3 +/- 3.6 weeks, p < 0.005). However, logistic regression revealed that the most powerful antenatal determinants of pregnancy outcome were Doppler velocimetry of the umbilical artery, followed by biophysical profile, while no independent correlation was found with the head-to-abdomen ratio. The existence of two distinct categories of SGA fetuses, 'symmetric' and 'asymmetric', remains uncertain. An elevated head-to-abdomen ratio is an adverse risk factor for pregnancy outcome. However, this parameter has no clearcut clinical value when umbilical artery Doppler velocimetry and biophysical antenatal testing are available.     

The impact of ibuprofen on the efficacy of antihypertensive treatment with hydrochlorothiazide in elderly persons

BACKGROUND: Nonsteroidal antiinflammatory drugs (NSAIDs) may alter blood pressure through their inhibitory effects on prostaglandin biosynthesis. Such potential hypertensive effects of NSAIDs have not been adequately examined in the elderly, who are the largest group of NSAID users. METHODS: We performed a randomized, double-blind, two-period crossover trial of ibuprofen (1800 mg per day) vs placebo treatment in patients older than 60 years of age with hypertension controlled with hydrochlorothiazide. While continuing their usual thiazide dosage, subjects were randomized to a 4-week treatment period (ibuprofen or placebo) followed by a 2-week placebo wash-out period and a second 4-week treatment period with the alternative therapy. Supine and standing systolic and diastolic blood pressures were measured weekly. RESULTS: Of 25 randomized subjects, 22 completed the study protocol (mean age = 73 +/- 6.7 years). Supine systolic blood pressure and standing systolic blood pressure were increased significantly with ibuprofen treatment, compared with placebo. Mean supine systolic blood pressures were 143.8 +/- 21.0 and 139.6 +/- 15.9 mmHg on ibuprofen and placebo, respectively (p = .004). Mean standing systolic blood pressures were 148.1 +/- 19.9 and 143.4 +/- 17.9 mmHg on ibuprofen and placebo, respectively (p = .002). CONCLUSION: We conclude that 1800 mg per day of ibuprofen does induce a significant increase in systolic blood pressure in older hypertensive patients treated with hydrochlorothiazide. NSAID therapy may negatively impact the control of hypertension in elderly patients.     

Congestive heart failure in patients with valvular aortic stenosis. A clinical and echocardiographic Doppler study

The aim of this study was to evaluate echographically anatomic and functional features of the left ventricle in adult patients with valvular aortic stenosis according to the presence or absence of congestive heart failure and the level of ventricular performance. Fifty-six adult patients with moderate-to-severe aortic stenosis underwent echocardiographic Doppler examination in order to evaluate left ventricular mass and dimensions, systolic function and filling dynamics. Twenty-seven patients had no heart failure and were symptomatic for angina (5), syncope (4) or were symptom-free (group I); the other 29 had heart failure (group II): 16 with normal left ventricular systolic performance (fractional shortening > 25%, group IIa) and 13 with systolic dysfunction (fractional shortening < or = 25%, group IIb). Despite a similar left ventricular mass, compared to group IIa, group IIb showed a significant left ventricular dilatation (end-diastolic diameter: 61 +/- 6.5 vs. 45.5 +/- 6.1 mm, p < 0.001) and mild or no increase in wall thickness (11.5 +/- 1.6 vs. 14.9 +/- 2 mm, p < 0.001). Indices of left ventricular filling on Doppler transmitral flow were also significantly different between the two groups, with a higher early-to-late filling ratio and a shorter deceleration time of early filling in group IIb (2.8 +/- 1.9 vs. 1.2 +/- 0.85, p < 0.01, and 122 +/- 66 vs. 190 +/- 87 ms, p < 0.05, respectively), both indirectly indicating higher left atrial pressure. Finally, heart failure was generally more severe in group IIb patients. In some patients with aortic stenosis, symptoms of heart failure may be present despite a normal left ventricular systolic function and seem to depend on abnormalities of diastolic function. The presence of systolic or isolated diastolic dysfunction appears to be related to a different geometric adaptation of the left ventricle to chronic pressure overload.     

Fetal endocrine responses to chronic placental embolization in the late-gestation ovine fetus

OBJECTIVE: The purpose of this study was to examine the effect of chronic fetal placental embolization on the fetal corticotropin, cortisol, and catecholamines concentrations and on myometrial contractility pattern. STUDY DESIGN: Fourteen fetal sheep were studied (seven embolized, seven controls) for 10 days between 0.84 and 0.91 of gestation. Daily injections of nonradioactive microspheres were performed to decrease fetal arterial oxygen content by 30% to 35% of the preembolization value. Umbilical artery Doppler flow velocity waveforms were measured daily. RESULTS: Chronic fetal placental embolization produced progressive fetal hypoxemia (p < 0.001) with changes in umbilical artery Doppler flow velocity waveforms indicative of a 25% increase in placental vascular resistance (p < 0.01). In response to chronic fetal hypoxemia there was a progressive increase in baseline fetal plasma norepinephrine concentration (p < 0.001). There was a transient fourfold to fivefold increase in baseline fetal plasma cortisol levels concomitant with a significant decrease in baseline immunoreactive corticotropin between days 7 and 9 of embolization (both p < 0.05), with a return to control values by day 10. There was a 57% increase in myometrial contracture frequency in the embolized group when compared with controls (p = 0.001). CONCLUSIONS: During repetitive chronic placental damage that led to fetal hypoxemia, the fetal endocrine environment changed with time in a direction that would prevent the onset of premature activation of the hypothalamic-pituitary-adrenal axis and premature delivery.     

Doppler analysis of pulmonary venous flow profiles in orthotopic heart transplant recipients: a comparison with mitral flow profiles and atrial function

Previous Doppler studies of transmitral flow profiles in heart transplant recipients suggested left ventricular (LV) diastolic dysfunction. The influence of left atrial filling and emptying on mitral Doppler profiles in heart transplant recipients has not been studied systematically. In the present study, pulmonary venous flow profiles, mitral flow profiles, left atrial area change and mitral annulus motion were analyzed in 20 orthotopic heart transplant recipient and 20 control subjects by transthoracic and transesophageal echocardiography and Doppler. Mitral flow profiles revealed a "restrictive" pattern with a high early-to-late diastolic flow velocity ratio in transplant patients (2.16 +/- 0.52 vs. 1.30 +/- 0.25, p < 0.0001), which was mainly due to a reduced late diastolic maximum mitral flow velocity (32.6 +/- 8.3 vs. 51.6 +/- 12.4 cm/s, p < 0.0001). Left atrial area change (35.9 +/- 13.9 vs. 58.1 +/- 17.0%, p < 0.0006) and mitral annulus motion (9.2 +/- 3.3 vs. 12.2 +/- 2.0%, p < 0.05) were reduced in transplant recipients, compared to controls. Pulmonary venous flow parameters in transplant recipients were markedly altered during systole, when pulmonary venous flow parameters are influenced primarily by atrial function rather than by diastolic LV properties: peak systolic flow velocity (45.5 +/- 8.2 vs. 62.3 +/- 14.0 cm/s, p < 0.001), maximum flow velocity ratio (0.87 +/- 0.19 vs. 1.45 +/- 0.33), time velocity integral of pulmonary venous flow during systole (9.3 +/- 2.3 vs. 17.1 +/- 4.0 cm, p < 0.001) and the systolic fraction of the time velocity integral (52.6 +/- 10.8 vs. 68.5 +/- 6.8%, p < 0.001) were lower in heart transplant recipients than in controls. These findings are compatible with atrial dysfunction and reduced mitral annulus motion. The results of this study indicate that LV diastolic dysfunction is not the only possible cause of altered transmitral Doppler profiles in heart transplant recipients. Atrial abnormalities represent a major contributing factor to altered mitral and pulmonary venous flow patterns. Analysis of transmitral Doppler profiles alone are therefore not adequate for analysis of diastolic LV function in heart transplant recipients.     

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.     

Effects of antipyrine on umbilical and regional metabolism in late gestation in the fetal lamb

OBJECTIVE: Antipyrine has been used extensively in fetal metabolic studies and is now known to inhibit prostaglandin synthesis; therefore we wished to determine the effects of antipyrine on fetal umbilical and regional metabolism. STUDY DESIGN: Chronically catheterized fetal lambs were randomly assigned to antipyrine (n = 6) or control (n = 5) groups. Animals in the antipyrine group were infused with antipyrine (mean +/- SD 9.6 +/- 0.9 mg/min for 165 +/- 38 minutes), and control group animals were not infused. Measurements were made of fetal blood gases, oxygen content, glucose, lactate, lower-body blood flow, upper-body flow distribution, and substrate uptakes across the umbilical and hind limb circulations. The unpaired t test, correlation coefficient, and regression analysis were used for comparisons. RESULTS: There were no differences in antipyrine and control group animals with respect to blood gases, metabolite levels, umbilical blood flow, or umbilical uptakes. Hind limb blood flow (p < 0.10) and oxygen uptake (p < 0.05) were lower and lactate production was higher (p < 0.01) in antipyrine animals than in control group animals. Duration of antipyrine exposure correlated directly with hind limb lactate production (r = 0.85, p < 0.001) and inversely with hind limb oxygen uptake (r = -0.65, p < 0.05). The distribution of blood flow within the fetal upper body also differed between groups, with higher cardiac distribution in the antipyrine group (p < 0.025). CONCLUSIONS: Antipyrine does not affect umbilical metabolism but does affect carcass metabolism and fetal blood flow distribution.     

Modified ultrafiltration improves left ventricular systolic function in infants after cardiopulmonary bypass

OBJECTIVE: Our objective was to test the hypothesis that use of modified ultrafiltration after cardiopulmonary bypass improves intrinsic left ventricular systolic function in children. METHODS: Twenty-one infants undergoing cardiopulmonary bypass were instrumented with ultrasonic dimension transducers, to measure the anteroposterior minor axis diameter, and a left ventricular micromanometer. Patients were randomized to modified ultrafiltration (n = 11, age 226 +/- 355 days, weight 6.7 +/- 3.1 kg) or control (n = 10, age 300 +/- 240 days, weight 7.0 +/- 2.5 kg) (all differences p > 0.05 between groups). Left ventricular systolic function was assessed by means of the slope of the preload-recruitable stroke work index. Myocardial cross-sectional area was measured by echocardiography. Data were acquired immediately after separation from bypass, at steady state, and during transient vena caval occlusion. Data acquisition was repeated after 13 +/- 5 minutes of modified ultrafiltration or after 12 +/- 5 minutes without modified ultrafiltration in the control group. Inotropic drug support was the same at both study points. RESULTS: In the modified ultrafiltration group, the filtrate volume was 363 +/- 262 ml. The hematocrit value increased from 26.0% +/- 2.7% to 36.7% +/- 9.5% (p = 0.018), myocardial cross-sectional area decreased from 3.72 +/- 0.35 cm2 to 3.63 +/- 0.36 cm2 (p = 0.04), end-diastolic length increased from 25.6 +/- 9.0 mm to 28.8 +/- 9.9 mm (p = 0.01), and end-diastolic pressure fell from 5.6 +/- 0.8 mm Hg to 4.2 +/- 0.8 mm Hg (p = 0.005), suggesting an improved diastolic compliance. In the control group, the hematocrit value, myocardial cross-sectional area, end-diastolic length, and pressure did not change (all p > 0.05). Mean ejection pressure increased in the ultrafiltration group (p = 0.001) but did not change in the control group (p = 0.22). The slope of the preload-recruitable stroke work index increased after ultrafiltration from 52.3 +/- 52.0 to 74.2 +/- 66.0 (10[3] erg/cm3) (p = 0.02) but did not change in the control group (p = 0.07). One patient from each group died in the postoperative period. Patients in the ultrafiltration group received less inotropic drug support in the first 24 hours after the operation (156.62 +/- 92.31 microg/kg in 24 hours) than patients in the control group (865.33 +/- 1772.26 microg/kg in 24 hours, p = 0.03). CONCLUSIONS: Use of modified ultrafiltration after cardiopulmonary bypass improves intrinsic left ventricular systolic function, improves diastolic compliance, increases blood pressure, and decreases inotropic drug use in the early postoperative period.     

Doppler echocardiographic assessment of fetal blood flow redistribution during maternal hyperoxygenation

In a retrospective analysis of the standard protocols for fetal echocardiographic examination, 27 fetuses (mean gestational age 29 +/- 5.4 weeks) with ascites were evaluated. Fetal cardiomegaly (increased heart area/chest area ratio), the presence or absence of atrioventricular valve regurgitation, inferior vena cava and ductus venosus Doppler flow velocity and umbilical vein pulsation were evaluated quantitatively in a group of survivors and non-survivors. A statistically significant difference between the two groups was found for the presence of atrioventricular valve regurgitation (p = 0.003), and for cardiomegaly (p = 0.009). There was no statistical difference for the presence of abnormal venous flow and umbilical pulsation (p > 0.05). Abnormal venous Doppler flow velocities in the inferior vena cava and ductus venosus were observed more frequently than umbilical vein pulsation. The mean heart area/chest area ratios in the group of survivors and in the group of non-survivors were 0.34 +/- 0.09 and 0.48 +/- 0.08, respectively (p < 0.001). The mean gestational ages at the time of diagnosis of ascites in the groups of survivors and non-survivors were 33 +/- 3.3 weeks and 28 +/- 5.1 weeks, respectively (p < 0.05); the mean gestational ages at the time of delivery were 35.6 +/- 2.3 weeks and 33.3 +/- 4.9 weeks, respectively (p = 0.33). In terms of different echocardiographic features as well as the gestational age of the unborn patient with ascites, there is apparently no single indicator of a poor prognosis. Our results suggest that the prognosis is usually poor in a fetus with ascites, when cardiomegaly is detected, as well as the presence of tricuspid and mitral valve regurgitation. This is regardless of the type of venous flow and regardless of the etiology of the ascites.     

Short-term effects of inhaled albuterol on maternal and fetal circulations

Short-term circulatory effects with the maximum recommended dose of inhaled albuterol (Proventil) were studied on 12 asthmatic patients between 33 and 39 weeks' gestation. The mean maternal blood pressures and heart rates, systolic/diastolic ratios of the uterine arcuate and umbilical arteries, and fetal heart rates and aortic velocities were unaffected during the first 2 hours after dosing.     

Phasic flow events at the aortic isthmus-ductus arteriosus junction and branch pulmonary artery evaluated by multimodal ultrasonography in fetal lambs

OBJECTIVES: We assessed the phasic flow and interaction between the pulmonary trunk and aortic isthmus flow at their junction in the lamb fetus in late gestation and also assessed the interaction of the left pulmonary artery branch. STUDY DESIGN: With echocardiographic and Doppler ultrasonographic and saline-contrast techniques, we studied 7 fetal lambs with arterial and venous catheters in place to assess direction, velocity, and timing of flow at the aortic isthmus, ductus arteriosus, and proximal left pulmonary artery. RESULTS: At the isthmus-ductus junction, ductus systolic flow occurred later (0.048 +/- 0.006 second, mean +/- SD) and accelerated more slowly than isthmus flow but with higher velocities (peak 70.7 +/- 7.1 vs 63.1 +/- 6.3 cm/s, velocity time integral 5.7 +/- 1.2 vs 4.5 +/- 1.3 cm, respectively; P <.001). There was a small degree of late systolic flow reversal and admixture from both sources. Signals from the left pulmonary arterial branch showed a sharp, brief systolic forward flow with a peak velocity of 48.8 +/- 9.1 cm/s, followed by late systolic and diastolic flow reversal with a peak velocity of 23.5 +/- 8.7 cm/s. CONCLUSION: The differences in the flow timing may be the result of different timing of ventricular contraction, resistances in the vascular beds, and ductus constriction, both anatomic and physiologic.     

Doppler ultrasonography of canine maternal and fetal arteries during normal gestation

Two-dimensional ultrasonography was used in combination with colour-flow imaging and pulsed wave Doppler ultrasonography to study the maternal circulation and the development of fetal vascularization in six Beagles during normal gestation. For the first time, the development of the circulation was demonstrated in the bitch and her fetuses intra vitam. The bloodstream was examined in small uteroplacental arteries, the umbilical artery, the fetal aorta and the common carotid artery. The duration of the study was from week 3 after insemination until birth. Relatively large vessels were detected by cross-sectional ultrasonography, and small vessels were detected by colour-flow imaging. In pulsed wave Doppler ultrasonography, the blood flow was measured and described using the parameters of systolic peak velocity, diastolic peak velocity, end-diastolic velocity, pulsatility index, resistance index, A:B ratio (systolic peak velocity:end-diastolic velocity) and S:D parameter (systolic peak velocity:diastolic peak velocity). The development of the measured parameters is typical and similar to that in humans. The systolic peak velocity of the canine maternal uteroplacental arteries shows important differences in comparison with humans. The pulsatility index, resistance index and A:B ratio decrease in nearly all vessels. Only the fetal common carotid artery has constant pulsatility and resistance indices during gestation. For the first time, the quality and quantity of the normal blood flow have been monitored during the whole of gestation. A normal circulation is fundamental for supplying the fetus adequately with oxygen and nutrients and thus for physiological development. These ultrasonographic results are the basis for further clinical studies.     

Left ventricular diastolic properties of hypertensive patients measured by pulsed tissue Doppler imaging

Examination of left ventricular (LV) diastolic dysfunction in hypertensive patients has been based on parameters obtained from the transmitral flow velocity during pulsed Doppler echocardiography. However, these parameters are affected by loading conditions. We evaluated LV diastolic function along the longitudinal and transverse axes by pulsed tissue Doppler imaging (TDI) in 50 hypertensive (HT) patients and 36 age-matched healthy volunteers (N). Transmitral flow velocity was recorded by pulsed Doppler echocardiography. LV posterior wall motion velocity along the longitudinal and transverse axes also was recorded by pulsed TDI. In both groups, peak early diastolic velocity of the LV posterior wall (Ew) along the transverse axis (N: 15.8+/-5.2 cm/s, HT: 12.2+/-4.4 cm/s) was higher than that along the longitudinal axis (N: 12.7+/-3.1 cm/s, HT: 9.5+/-3.3 cm/s). Peak atrial systolic velocity of the LV posterior wall (Aw) along the longitudinal axis (N: 9.1+/-1.8 cm/s, HT: 9.7 +/-2.6 cm/s) significantly exceeded that along the transverse axis (N: 8.0+/-2.2 cm/s, HT: 8.4+/-2.4 cm/s) in both groups. The Ews were lower and the Aws were higher along both axes in the patient group than in the control group. The time intervals from the aortic component of the second heart sound to the peak of the early diastolic wave (IIA-Ews) along both the transverse (N: 142+/-18 ms, HT: 154+/-19 ms) and longitudinal (N: 151 16 ms, HT: 162+/-20 ms) axes were longer in the patient group. In 29 patients, Ews along both axes correlated negatively (transverse: r = -0.80, P < .0001; longitudinal: r = -0.71, P < .0001) and IIA-Ews correlated positively (transverse: r = 0.81, P < .0001; longitudinal: r = 0.74, P < .001) with the time constant of the LV pressure decay during isovolumic diastole. The Aws along both axes in the 24 patients without pseudonormalization in transmitral flow velocity correlated positively (transverse: r = 0.60, P < .001; longitudinal: r = 0.74, P < .0001) with the LV end-diastolic pressure. In conclusion, LV relaxation and filling along the longitudinal and transverse axes were impaired in many patients with hypertension. Pulsed TDI was useful for evaluating LV diastolic dynamics in this disease.     

Intraventricular obstructions in dobutamine stress echocardiography: determinants of their development and clinical sequelae

Dobutamine stress echocardiography (DSE) leads to strong hypercontraction, tachycardia, and peripheral vasodilatation. In previous studies systolic obstruction of the left ventricular outflow tract (LVOT) was observed as a result of these factors. To evaluate left ventricular function and morphology in patients (pts) with induced systolic LVOT obstruction, we used continuous wave (CW) doppler registrations in combination with quantitative 2-D-echocardiography in 100 pts during routinely performed DSE (5-40 micrograms/kg/min). In addition left ventricular wall thickness was measured. Symptoms were registered using a standardised questionnaire and cardiac arrhythmias were counted over a two minute interval at rest and during the maximal heart rate of each patient. During DSE dynamic flow acceleration with late systolic peak velocity above 2 m/second (s) was considered to represent LVOT obstruction in pts with normal flow profiles in the LVOT before infusion of dobutamine. For invasive studies pts were investigated with femoral catheterisation by the method of Judkins. A greater than 50% stenosis was judged to be significant. RESULTS: Examinations in 73 pts provided data of sufficient quality for echocardiographic and Doppler sonographic evaluations. 39 pts, 26 men, 13 women, mean age 64 +/- 8 years, developed late systolic flow velocities above 2 m/s and therefore formed the obstructive group (grp A). Grp B consisted of 34 pts, 26 men and 8 women, mean age 66 +/- 10 years, who showed normal time velocity integrals during DSE. In 41 pts invasive data provided information concerning the existence and severity of coronary artery disease. There were no significant differences in the increase of heart rate, the product of maximal systolic blood pressure and maximal heart rate or the percentage of pts, who reached their age corrected submaximal heart rate during DSE. Obstructive pts (group A) showed late systolic dynamic acceleration of systolic flow with a mean maximal speed of 315.4 +/- 139.8 cm/s, which peaked 0.12 +/- 0.04 s after the R-wave. From the velocities we calculated a mean pressure gradient of 47.5 +/- 39.7 mm Hg using the modified Bernoulli equation. Group B patients showed lower and earlier maximal speeds with a mean value of 158.2 +/- 37.6 cm/s, 0.09 +/- 0.04 s after the R-wave, corresponding to a pressure gradient of 10.6 +/- 4.9 mm Hg (p < 0.001). Ejection fractions were higher (p < 0.001) before the test in grp A: 68.2 +/- 8% compared to 55.7 +/- 10.4% in B. This difference increased during peak stress: 74.1 +/- 7.7% compared to 59.5 +/- 12.8%. End diastolic (EDVI) and end systolic volume indexes (ESVI) were lower in grp A (p < 0.001). During DSE, the decrease in ESVI was somewhat stronger for pts in grp A. Left ventricular hypertrophy was more often seen with obstruction. Septal thickness was increased in A: 1.45 +/- 0.34 cm compared to 1.13 +/- 0.27 cm in B (p < 0.001). Left ventricular posterior wall measured 1.03 +/- 0.28 cm in A and 0.83 +/- 0.23 cm in B (p < 0.01). 27 pts in grp B and only 9 in grp A had a history of previous myocardial infarction. Showing no difference at rest, wall motion score indexes raised under DSE in both groups and developed significantly higher scores in grp B at peak stress: 1.30 (1.0-1.90) compared to 1.18 (1.0-1.75) in A. We observed typical chest pain more often in grp B. Unspecific symptoms and arrhythmogenic complications were not statistically different, with the exception of ventricular bigeminy which was more often observed in grp B. A decline in the diastolic blood pressure was observed in pts with very severe obstruction (> 3.5 m/s, p < 0.05). Sensitivity of DSE was 84%, specificity 79%. No significant differences between pts with and without obstruction were observed. SUMMARY: Intraventricular obstructions during DSE are often observed in pts with normal systolic function at rest and during peak stress, especially in the case of left ventricular hypertrophy. (ABSTRACT TRU