digoxin and Aortic-Valve-Insufficiency

The use of vasodilator therapy in chronic AR and MR may be beneficial in selected patients and harmful in others. The hemodynamics of the two conditions are different and must be taken into account. In AR, vasodilators reduce afterload mismatch and can preserve LV function and delay the need for surgery. However, if the patient has severely reduced diastolic blood pressure, vasodilators could potentially impair coronary perfusion. In MR, vasodilators may reduce regurgitant volume and LV preload depending on the mechanism of MR. In patients with MR caused by dilated cardiomyopathy, vasodilators reduce symptoms, and improve functional class. However, in mitral valve prolapse or hypertrophic cardiomyopathy, vasodilators may worsen the MR and should be avoided. In other primary causes of MR, vasodilators could potentially mask the development of LV dysfunction and lead to unnecessary and harmful delays in surgery.

Topics: Aortic Valve Insufficiency; Chronic Disease; Digoxin; Heart Ventricles; Hemodynamics; Humans; Mitral Valve Insufficiency; Nifedipine; Survival Rate; Vasodilator Agents

Vasodilator therapy with nifedipine reduces left ventricular volume and mass and increases the ejection fraction in asymptomatic patients with severe aortic regurgitation.. To assess whether vasodilator therapy reduces or delays the need for valve replacement, we randomly assigned 143 asymptomatic patients with isolated, severe aortic regurgitation and normal left ventricular systolic function to receive either nifedipine (20 mg twice daily, 69 patients) or digoxin (0.25 mg daily, 74 patients).. By actuarial analysis, we determined that after six years a mean (+/- SD) of 34 +/- 6 percent of the patients in the digoxin group had undergone valve replacement, as compared with only 15 +/- 3 percent of those in the nifedipine group (P < 0.001). In the digoxin group, valve replacement (in a total of 20 patients) was performed because of left ventricular dysfunction (ejection fraction < 50 percent) in 75 percent, left ventricular dysfunction plus symptoms in 10 percent, and symptoms alone in 15 percent. In the nifedipine group, all six patients who underwent valve replacement did so because of the development of left ventricular dysfunction. In addition, all the patients in both groups who underwent aortic-valve replacement had an increase of 15 percent or more in the left ventricular end-diastolic volume index. After aortic-valve replacement, 12 of the 16 patients (75 percent) in the digoxin group and all six patients in the nifedipine group who had had an abnormal left ventricular ejection fraction before surgery had a normal ejection fraction.. Long-term vasodilator therapy with nifedipine reduces or delays the need for aortic-valve replacement in asymptomatic patients with severe aortic regurgitation and normal left ventricular systolic function.

Topics: Adult; Aortic Valve Insufficiency; Chronic Disease; Digoxin; Female; Follow-Up Studies; Heart Valve Prosthesis; Humans; Male; Nifedipine; Stroke Volume; Ventricular Function, Left

In order to assess the relative value of digoxin, nifedipine and hydralazine on left ventricular performance at rest and during exercise, we studied 10 men with moderately severe chronic aortic regurgitation using two-dimensional echocardiography. Digoxin after one month at therapeutic serum levels increased resting ejection fraction as compared to control [0.54 +/- 0.08 (SD) vs 0.47 +/- 0.08, respectively, P less than 0.03]. Ejection fraction decreased during exercise but the difference between digoxin and control was maintained. Stroke volume also was higher on digoxin than control at rest (93 +/- 15 vs 83 +/- 17 ml, P less than 0.02) and the larger stroke volume on digoxin was maintained during exercise. By contrast, stroke volume was reduced by one month of therapy with maximally tolerated nifedipine doses compared to control (74 +/- 8 vs 83 +/- 17 ml, P = 0.03) and this difference was maintained during exercise. Hydralazine in doses up to 225 mg/day for one month produced no significant changes in left ventricular performance compared to control at rest or during exercise. However, compared to digoxin ejection fraction at peak exercise was significantly less on hydralazine (0.39 +/- 0.9 vs 0.52 +/- 10, P less than 0.02). These data suggest that digoxin improved left ventricular performance and may be of benefit in the treatment of patients with chronic aortic regurgitation.

Topics: Adult; Analysis of Variance; Aortic Valve Insufficiency; Digoxin; Echocardiography; Exercise Test; Heart Ventricles; Humans; Hydralazine; Male; Middle Aged; Nifedipine; Stroke Volume

The haemodynamic effects of N, N-bis(phenyl-carbamoylmethyl) dimethylammonium chloride (QX-572) in man were studied. A controlled study was performed to rule out a possible influence of the catheterization procedure as such on the results. Ten patients with mild to moderate aortic regurgitation were studied: based on clinical data the patients were divided into 2 groups of 5. Randomly it was decided that one group should constitute a control group receiving saline while the second group received QX-572 , MG/KG BODY WEIGHT. In both groups the administration was performed as a slow intravenous infusion during 30 minutes. Heart rate, pressures in brachial artery and right atrium, cardiac output, stroke volume, and systemic vascular resistance were determined before, during, and up to 30 minutes after completion of placebo or QX-572. These variable remained stable in the control group while QX-572 produced an increase in heart rate most pronounced at the end of the infusion period. A transient decrease in systolic and mean brachial artery pressure during the infusion, and during the same period a decrease in right atrial pressure. Cardiac output and systemic vascular resistance were unchanged by QX-572 but they were not measured during the infusion when the changes in pressures were most pronounced. QX-572 was thought to act as a peripheral vasodilator during the infusion. Left ventricular contractility was studied by means of pressure curves obtained from a catheter tip manometer placed in the left ventricle. The first derivative of the isovolumic left ventricular pressure at the highest level (45mmHg) common to all patients was used (dp/dt-45). No significant difference could be observed when comparing mean changes of dp/dt-45 for the two groups. In the control group there was a slight but significant increase in dp/dt-45 during the time of observation. In the QX-572 group the results varied between individuals. Two of the patients differed from all other patients in the control and QX-572 groups showing a decrease in dp/dt-45 which, when most pronounced at the end of the infusion period, was -31 and -28 per cent of the preinfusion levels, respectively. This decrease probably reflects reduction of contractility. It was concluded that QX-572 in a dose of 8 mg/kg body weight did not have any major haemodynamic drawbacks.

Topics: Adult; Anti-Arrhythmia Agents; Aortic Valve Insufficiency; Arrhythmias, Cardiac; Blood Pressure; Brachial Artery; Carbamates; Cardiac Output; Clinical Trials as Topic; Digitoxin; Digoxin; Female; Heart Atria; Heart Rate; Heart Ventricles; Hemodynamics; Humans; Infusions, Parenteral; Male; Middle Aged; Placebos; Quaternary Ammonium Compounds; Vascular Resistance

To determine the prognosis of Takayasu arteritis (TA) patients with moderate-to-severe aortic regurgitation treated with surgical vs conservative treatment and to identify independent prognostic factors of long-term outcomes.. Between January 2002 and January 2017, 101 consecutive TA patients with moderate-to-severe aortic regurgitation treated with either surgical (n = 38) or conservative (n = 63) treatments were investigated in this retrospective observational case-control study. The primary end point was all-cause mortality, and the secondary end point comprised the combined end points of death, non-fatal stroke and cardiac events (non-fatal myocardial infarction and congestive heart failure). Propensity score matching was used to reduce the bias of baseline risk factors.. The unadjusted all-cause 10-year mortality in the conservative group was increased compared with the surgical group (28.2% vs 7.4%; log-rank P = 0.036), and the combined end points showed the same trend (52.1% vs 25.3%; log-rank P = 0.005). After an adjustment of baseline risk factors, the conservative treatment was associated with reduced survival rates of both all-cause mortality [hazard ratio (HR): 8.243; 95% CI: 1.069, 63.552; P = 0.007] and combined end points (HR: 6.341; 95% CI: 1.469, 27.375; P = 0.002). Conservative treatment (HR: 3.838, 95% CI: 1.333, 11.053; P = 0.013) and left ventricular end-diastolic diameter (HR: 1.036, 95% CI: 1.001, 1.071; P = 0.042) were risk factors for increased combined end points.. Surgical treatment improves the outcomes of patients with moderate-to-severe aortic regurgitation due to TA. The dilated left ventricle indicated a worse prognosis.

Topics: Adrenergic beta-Antagonists; Adult; Angiotensin Receptor Antagonists; Angiotensin-Converting Enzyme Inhibitors; Aorta; Aortic Valve Insufficiency; Calcium Channel Blockers; Cardiotonic Agents; Case-Control Studies; Cause of Death; Conservative Treatment; Digoxin; Female; Glucocorticoids; Heart Failure; Heart Valve Prosthesis Implantation; Humans; Immunosuppressive Agents; Male; Middle Aged; Mortality; Myocardial Infarction; Platelet Aggregation Inhibitors; Prednisone; Propensity Score; Retrospective Studies; Severity of Illness Index; Stroke; Takayasu Arteritis; Treatment Outcome

This study investigated the effect of chronic digitalis glycoside use on beta-adrenergic sympathetic activities in heart failure. Twenty-two Japanese white rabbits were anesthetized by intravenous injection of chloral hydrate. Aortic regurgitation (AR) was produced by perforating aortic valves in 14 rabbits. Digoxin was given for 1 week to 7 rabbits with AR (AR + Dig) and saline to 7 rabbits with AR (AR + C). Sham operation was performed in the remaining 8 rabbits (S). The left ventricular end-diastolic pressure was higher in AR + C than S (p < 0.05). It was lower in AR + Dig than AR + C (p < 0.05). Cardiac output was lower in AR + C than S (p < 0.05). There was no difference between AR + Dig and S. Both the left ventricular end-diastolic and end-systolic diameters were larger in AR + C (p < 0.05) than S, but they were similar between AR + Dig and S. Plasma norepinephrine level was lower in AR + Dig than AR + C. Myocardial beta-adrenergic receptors number determined by radioligand binding assay using 30-800 pM 125I-iodocyanopindolol was lower in AR + C than S (28.8 +/- 7.9 vs. 69.9 +/- 12.3 fmol/mg protein, p < 0.05). It was higher in AR + Dig (39.9 +/- 9.8) than AR + C (p < 0.05). Myocardial norepinephrine content was lower in both AR + C (p < 0.05) and AR + Dig than S (p < 0.05). Thus, digitalis glycosides exert favorable effects on beta-adrenergic sympathetic activities in addition to the effects on hemodynamic variables in this animal model of heart failure.

Topics: Animals; Aortic Valve Insufficiency; Cardiac Output; Cardiotonic Agents; Digitalis Glycosides; Digoxin; Heart Failure; Hemodynamics; Norepinephrine; Rabbits; Receptors, Adrenergic, beta; Ventricular Pressure

The authors report on a 47-years old woman with bacterial endocarditis involving both the mitral and aortic valves. At first echocardiographic examination, the mitral vegetation was small, while the aortic one was large highly mobile. Despite adequate antibiotic therapy, the aortic vegetation had become bigger and the valve regurgitation, initially mild to moderate, resulted severe and was associated with left heart failure. While awaiting surgery, the patient sustained an acute non Q wave myocardial infarction with ST segment elevation in inferior and anterolateral leads, complicated by ventricular arrhythmias. Thirty-six hours later, the patient received mitral and aortic valve replacement: at surgical view, the aortic vegetations was found to be very close to the right coronary orifice. After a period of further antibiotic therapy, the woman discharged and at a six months follow-up, she was fairly well. The authors review the mechanisms of acute coronary insufficiency in infective endocarditis and suggest an embolic pathogenesis in the case reported. Taking into account the possible life threatening embolic complications, it seems reasonable not to delay surgery when antibiotic therapy fails to reduce the size and mobility of valve vegetations.

Topics: Aortic Valve; Aortic Valve Insufficiency; Cardiotonic Agents; Digoxin; Diuretics; Echocardiography, Doppler, Color; Echocardiography, Transesophageal; Electrocardiography; Embolism; Endocarditis, Bacterial; Female; Follow-Up Studies; Furosemide; Heart Valve Prosthesis; Humans; Middle Aged; Mitral Valve; Mitral Valve Insufficiency; Myocardial Infarction; Penicillin G; Penicillins; Streptococcal Infections; Time Factors

Topics: Aortic Valve Insufficiency; Digoxin; Humans; Nifedipine; Research Design

Topics: Aortic Valve Insufficiency; Digoxin; Humans; Nifedipine; Placebos

Topics: Aortic Valve Insufficiency; Digoxin; Humans; Nifedipine; Ventricular Function, Left

Topics: Aortic Valve Insufficiency; Chronic Disease; Digoxin; Heart Valve Prosthesis; Humans; Nifedipine; Stroke Volume; Ventricular Function, Left

The effect of an unloading (nifedipine, 20 mg sublingually) and of a combined unloading and positive inotropic intervention (nifedipine plus digoxin, 0.5 mg intravenously) on left ventricular performance was assessed in 48 patients with chronic severe aortic insufficiency. The left ventricular pump function-myocardial contractility relation (ejection fraction, EF vs. peak arterial pressure to end-systolic volume ratio, PAP/ESV), and the pump function-afterload relation (EF vs. mean systolic wall stress, MWS) were constructed by means of quantitative M-mode and two-dimensional echocardiography. In patients with normal control pump function (n = 14), nifedipine markedly decreased MWS, moving the patients to a new, more advantageous EF-MWS relation. In the 34 patients with abnormal pump function, the myocardial contractility level was the mean factor conditioning the response to pharmacological intervention. Patients with a value of PAP/ESV greater than 2.5 (n = 22) had normalization of EF after nifedipine and were upgraded to a more advantageous outlook for left ventricular mechanics EF-MWS and EF-PAP/ESV relations. Of the 12 patients without normalization of EF after nifedipine, only the 4 patients with PAP/ESV greater than 2 had normalization of pump function indices after combined administration of nifedipine and digoxin.

Topics: Adult; Aortic Valve Insufficiency; Digoxin; Drug Therapy, Combination; Echocardiography; Female; Heart Ventricles; Humans; Male; Middle Aged; Myocardial Contraction; Nifedipine

Topics: Aortic Valve; Aortic Valve Insufficiency; Combined Modality Therapy; Digoxin; Drug Therapy, Combination; Heart Failure; Heart Valve Prosthesis; Hemodynamics; Humans; Hydralazine; Mitral Valve; Mitral Valve Insufficiency; Nitroprusside; Vasodilator Agents

Intravenous administration of the vasodilator sodium nitroprusside has beneficial haemodynamic effects in subjects with severe aortic regurgitation while acute digitalisation can produce unwanted effects associated with an increase in systemic vascular resistance. This study compares the haemodynamic effects of the vasodilator prazosin and digoxin in eight patients with isolated severe aortic regurgitation. Prazosin 5 mg orally resulted in a 12 +/- 3 (SE) per cent increase in cardiac index (thermodilution), maintained over four to six hours, while digoxin 0.75 mg intravenously did not change the cardiac index. Prazosin reduced mean arterial pressure by 9 +/- 3 mmHg and systemic vascular resistance by 18 +/- 4 per cent while digoxin resulted in a 6 +/- 2 per cent increase in the latter. Mean pulmonary capillary wedge pressure fell 3 mmHg with prazosin. In this group of patients with severe aortic regurgitation but without severe cardiac failure, the changes with either drug, studied in doses conventionally used, were small but those with prazosin were directionally more desirable than those resulting from digoxin.

Topics: Adult; Aortic Valve Insufficiency; Digoxin; Female; Hemodynamics; Humans; Male; Middle Aged; Prazosin; Quinazolines; Time Factors

Sudden withdrawal of oral therapy with hydralazine for reduction of afterload in a patient precipitated severe congestive heart failure. Signs of metabolic encephalopathy evolved due to low cardiac output. Reinstitution of therapy with hydralazine resulted in prompt improvement in cardiac and neurologic status. This case underscores the need for careful follow-up of such patients and argues against sudden withdrawal of vasodilator therapy.

Topics: Administration, Oral; Aged; Aortic Valve Insufficiency; Digoxin; Furosemide; Heart Failure; Hemodynamics; Humans; Hydralazine; Hypoxia, Brain; Injections, Intravenous; Male; Neurocognitive Disorders; Nitroprusside; Substance Withdrawal Syndrome; Vascular Resistance

The mechanism of atrial flutter is controversial. A 76-year-old woman with rheumatic heart disease was referred to our clinic with an unusual rhythm disturbance which initially appeared to be classic atrial flutter at a rate of 300 beats/min. Later tracings, however, demonstrated a rate exactly one-half that of the earlier ECGs, with an identical p-wave morphology and vector. This latter rhythm also behaved in a manner expected for a flutter mechanism in that both spontaneously and with carotid pressure high-degree atrioventricular block occurred without alteration of the underlying atrial mechanism. Finally, the two rates interchanged spontaneously over several days without any significant interval changes in medical therapy. These findings were initially explained as probable digoxin toxicity. The underlying mechanism, however, was more likely atrial flutter with exit block and in this patient may have represented another facet of her sick sinus syndrome. This unusual phenomenon is discussed in terms of previous reports and possible implications for the mechanism of atrial flutter.

Topics: Aged; Aortic Valve Insufficiency; Atrial Flutter; Digoxin; Female; Heart Block; Humans; Mitral Valve Stenosis

The findings in a patient with acute aortic insufficiency who was treated with sodium nitroferricyanide (sodium nitroprusside) prior to aortic valve replacement are presented. Administration of the drug resulted in clinical improvement, which was reflected in changes in systemic and pulmonary arterial pressures and in noninvasive measurements. Sodium nitroferricyanide is useful in the management of patients with severe acute aortic insufficiency, and its effect may be monitored by noninvasive means.

Topics: Aortic Valve Insufficiency; Digoxin; Ferricyanides; Furosemide; Heart Auscultation; Heart Valve Prosthesis; Humans; Male; Middle Aged; Nitroprusside

Topics: Abortion, Therapeutic; Adult; Aortic Valve Insufficiency; Chronic Disease; Digoxin; Drug Combinations; Female; Heart Diseases; Heart Failure; Heart Valve Diseases; Humans; Hypertension; Long-Term Care; Lynestrenol; Mestranol; Mitral Valve Insufficiency; Mitral Valve Stenosis; Pregnancy; Pregnancy Complications, Cardiovascular

Topics: Adult; Aortic Valve Insufficiency; Bundle-Branch Block; Carotid Arteries; Diagnosis, Differential; Digoxin; Electrocardiography; Female; Heart Block; Humans; Male; Massage; Middle Aged; Pacemaker, Artificial; Postoperative Complications; Prognosis; Transposition of Great Vessels

Topics: Aged; Aortic Valve Insufficiency; Digitoxin; Digoxin; Ethacrynic Acid; Female; Furosemide; Heart Failure; Humans; Male; Middle Aged; Mitral Valve Insufficiency; Oxygen Inhalation Therapy; Pulmonary Heart Disease; Spironolactone

Topics: Adolescent; Angiocardiography; Aortic Valve Insufficiency; Cardiac Catheterization; Cineangiography; Digoxin; Diuretics; Humans; Male; Mitral Valve Insufficiency; Prednisone; Rheumatic Heart Disease