Diagnosis Of Structural Heart Disease Research Articles

Use of pharmaceuticals in noninvasive cardiovascular diagnosis.

A number of pharmaceuticals are employed as diagnostic agents for cardiovascular diseases. Four groups of agents are reviewed here: 1) vasoactive substances employed as adjuncts to physical maneuvers in diagnosis of structural heart disease; 2) vasodilators used to produce heterogeneity of coronary flow; 3) sympathomimetic agents simulating the effects of exercise on the heart for the purpose of detection of coronary artery stenosis; and 4) ultrasonic contrast agents used to enhance myocardial imaging for the assessment of segmental wall motion. In the first group are amyl nitrate, a vasodilator, and methoxamine and phenylephrine, both vasopressors. The vasodilators of the second group are dipyridamole and adenosine. When combined with scintigraphic perfusion imaging or with echocardiographic assessment of segmental wall motion, these agents can detect single- or multiple-vessel coronary artery disease with sensitivity and specificity comparable to submaximal exercise. They are especially useful for preoperative risk assessment before noncardiac surgery. The sympathomimetic agents of the third group, dobutamine and arbutamine, increase myocardial contractility and heart rate, and dilate the peripheral vasculature. As with the vasodilators, when combined with nuclear or echocardiographic techniques they are equivalent to exercise in detection of coronary disease. They are especially useful in patients with bronchospastic disease and for assessment of myocardial viability. Agents from groups 2 and 3 have acceptable side-effect and safety profiles. The last group reviewed includes echocardiographic contrast agents that, in this investigative setting, are employed to enhance detection of segmental wall motion when used with agents from groups 2 and 3.

New developments in fetal echocardiography.

Fetal echocardiography has assumed an increasingly important role in the diagnosis of structural heart disease. Recently, the usefulness of this technique as a tool with which to observe the prenatal natural history of congenital heart disease has been appreciated. The application of spectral and color Doppler ultrasonographic interrogation has added to our ability to assess the integrity of the fetal and placental circuit. Only when we can consistently and accurately diagnose congenital heart disease in utero will we be able to successfully apply prenatal treatment for this condition.

Prenatal Pediatrics: Traditional Specialty Definitions No Longer Apply

Prenatal Pediatrics: Traditional Specialty Definitions No Longer Apply

745-4 Sudden “Arrhythmic” Death in Young People with Apparently Normal Heart

The aim of the present study was to assess whether and how often the ultimate diagnosis of structural heart disease underlying sudden cardiac arrest depends on histologic examination of the myocardium and specialized conduction system. Among 186 cases of consecutive sudden cardiovascular death in young people (≤ 35 yrs) studied from 1979 to 1994, in 59 (32%) gross examination failed to show any cardiac cause of sudden death such as obstructive coronary atherosclerosis, congenital coronary anomaly, cardiomyopathy, valve disease and aortic dissection. The grossly normal heart group consisted of 40 males and 19 females, aged 4–35 yrs (mean 23.7); 27 patients experienced warning symptoms and signs consisting of syncope in 12, ECG abnormalities in 16, and arrhythmias in 11. None had been diagnosed while alive. Detailed histologic study, including examination of ordinary ventricular myocardium as well as serial sections of specialized conduction system, disclosed: 1)focal myocarditis in 17 patients; 2) conduction system abnormalities leading to heart block in 6 patients (sick sinus syndrome in 1, lipomatous discontinuity between the atrial myocardium and the atrioventricular node in 2, sclerotic interruption of His and bundle branches in 2, and longitudinal dissociation of the His bundle in 1). and to ventricular pre-excitation in 15 (atrioventricular by-pass fibers in 9, nodoventricular Mahaim fibers in 4, atriofascicular tract in 1, AV nodal hypoplasia in 1); 3) focal fibrousfatty replacement of the right anterior wall and infundibulum in 5 patients. Sudden death remained unexplained in 16 cases. In conclusion, gross heart features were normal in nearly one third of the young sudden cardiovascular death victims; in 73% of them, however, there was histopathologic evidence of concealed “arrhythmogenic” substrates mostly consisting of conduction system pathology and focal myocarditis.

Factors Influencing the Outcome of Congenital Heart Disease Detected Prenatally

The diagnosis of structural heart disease before birth is associated with a poor prognosis. Of 222 continuing pregnancies seen in a 10 year period, there has been a 79% mortality. This is inconsistent with published results and current concepts of the outcome for children with cardiac malformation. Of the 222, death occurred in intrauterine life in 57, 87 died as neonates, and 31 in infancy or childhood. There are 47 survivors of whom only five have survived beyond 4 years. Factors influencing the outcome in these cases were examined further. A high mortality was associated with the presence of extracardiac anomalies in 71 (32%) and prenatal cardiac failure in 28 (13%). As many patients were referred for these reasons, referral methods preferentially select patients with a different range of heart disease from that seen postnatally. In addition, some forms of heart disease progress in severity during fetal life. Those involved in the management and counselling after diagnosis of heart disease in early pregnancy must be aware of the additional prenatal factors influencing prognosis and allow for them in making predictions of outcome.

Factors influencing the outcome of congenital heart disease detected prenatally.

The diagnosis of structural heart disease before birth is associated with a poor prognosis. Of 222 continuing pregnancies seen in a 10 year period, there has been a 79% mortality. This is inconsistent with published results and current concepts of the outcome for children with cardiac malformation. Of the 222, death occurred in intrauterine life in 57, 87 died as neonates, and 31 in infancy or childhood. There are 47 survivors of whom only five have survived beyond 4 years. Factors influencing the outcome in these cases were examined further. A high mortality was associated with the presence of extracardiac anomalies in 71 (32%) and prenatal cardiac failure in 28 (13%). As many patients were referred for these reasons, referral methods preferentially select patients with a different range of heart disease from that seen postnatally. In addition, some forms of heart disease progress in severity during fetal life. Those involved in the management and counselling after diagnosis of heart disease in early pregnancy must be aware of the additional prenatal factors influencing prognosis and allow for them in making predictions of outcome.

The psychologic management of patients with cardiac disease

Dangerous disorders which threaten life, and serious disorders which threaten happiness are not the same. Death is inevitable; its occurrence before one's expected time is, at worst, only a quantitative tragedy. But misery of spirit lasting for decades is not inevitable; its occurrence at all is a qualitative tragedy. Sedatives and tranquilizers have their proper place as weapons against fear but are far inferior to the wise physician. He, by his words, actions, and feelings, can do much to banish this most common and most distressing of the symptoms related to disease of the heart. He must avoid the mistake of binding a vigorous Prometheus to the rock of Misery with chains of Fear forged either by a false diagnosis of structural heart disease or by an erroneous evaluation of its functional significance. Neither the electrocardiogram, the fluoroscope, nor the cardiac catheter can tell the physician what to say or how to say it. Science is no bubstitute for wisdom.