Objective: Conventional hemodynamic indexes (cardiac index (CI), and pulmonary capillary wedge pressure) are of limited value in the diagnosis and treatment of patients with acute congestive heart failure (CHF). Patients and methods: We measured CI, wedge pressure, right atrial pressure (RAP) and mean arterial blood pressure (MAP) in 89 consecutive patients admitted due to acute CHF (exacerbated systolic CHF, ns56; hypertensive crisis, ns5; pulmonary edema, ns11; and cardiogenic shock, ns 17) and in two control groups. The two control groups were 11 patients with septic shock and 20 healthy volunteers. Systemic vascular resistance index (SVRi) was calculated as SVRis(MAPyRAP)yCI. Cardiac contractility was estimated by the cardiac power index (Cpi), calculated as CI=MAP. Results and discussion: We found that CI-2.7 lyminym and wedge pressure )12 2 mmHg are found consistently in patients with acute CHF. However, these measures often overlapped in patients with different acute CHF syndromes, while Cpi and SVRi permitted more accurate differentiation. Cpi was low in patients with exacerbated systolic CHF and extremely low in patients with cardiogenic shock, while SVRi was increased in patients with exacerbated systolic CHF and extremely high in patients with pulmonary edema. By using a two-dimensional presentation of Cpi vs. SVRi we found that these clinical syndromes can be accurately characterized hemodynamically. The paired measurements of each clinical group segregated into a specific region on the CpiySVRi diagnostic graph, that could be mathematically defined by a statistically significant line (Lambdas0.95). Therefore, measurement of SVRi and Cpi and their two-dimensional graphic representation enables accurate hemodynamic diagnosis and follow-up of individual patients with acute CHF.

We found that CI<2.7 l/min/m(2) and wedge pressure >12 mmHg are found consistently in patients with acute CHF. However, these measures often overlapped in patients with different acute CHF syndromes, while Cpi and SVRi permitted more accurate differentiation. Cpi was low in patients with exacerbated systolic CHF and extremely low in patients with cardiogenic shock, while SVRi was increased in patients with exacerbated systolic CHF and extremely high in patients with pulmonary edema. By using a two-dimensional presentation of Cpi vs. SVRi we found that these clinical syndromes can be accurately characterized hemodynamically. The paired measurements of each clinical group segregated into a specific region on the Cpi/SVRi diagnostic graph, that could be mathematically defined by a statistically significant line (Lambda=0.95). Therefore, measurement of SVRi and Cpi and their two-dimensional graphic representation enables accurate hemodynamic diagnosis and follow-up of individual patients with acute CHF.

Contractile reserve measured noninvasively during dobutamine infusion is a valuable prognostic indicator in patients with severe heart failure, with added value to ejection fraction.

SUMMARY We report 21 patients with discrete subaortic stenosis (DSS) causing mild obstruction with a peak systolic left ventricular outflow pressure gradients less than 50 mm Hg. They were followed 1-17 years (mean 6.5 years), and eight were recatheterized before surgery, 2-17 years after the first cardiac catheterization.Three patients (14%) had subacute bacterial endocarditis. Ten (48%) had aortic insufficiency, one of whom had no pressure gradient across the left ventricular outflow tract. In three of the 10 patients, aortic insufficiency was found only at the second catheterization. Nine patients (43%) had hyperactive, asymmetric left ventricular contraction; in three, this finding was present only at the second catheterization. Seven of the eight patients who were recatheterized (33% of the entire group) showed an increase in gradient. The increase was from a mean gradient of 35.2 mm Hg to 76.7 mm Hg. Seventeen patients (81 %) had at least one of these four features.In view of these data, we suggest that surgical indications for DSS might be expanded, although definitive recommendations are not possible. All cases of DSS should be carefully followed. Surgery should be performed if signs of progressive complications develop.DISCRETE subaortic stenosis (DSS) is an uncommon congenital cardiac lesion in which the left ventricular outflow tract is narrowed by a fibrous ring, a muscular ridge or a fibromuscular tunnel, either singly or in various combinations.' It is hazardous not only because of obstruction and hemodynamic impairment, but also because of its complications'-'": subacute bacterial endocarditis, aortic insufficiency, and possible development of an inherently associated muscular obstruction.DSS has been studied by many investigators.'-19 Most series, however, include mainly cases with moderate-to-severe obstruction, as these are naturally more likely to be studied. We report our experience with 21 patients with DSS and mild obstruction causing a peak systolic left ventricular outflow pressure gradient of less than 50 mm Hg or no gradient at all. Between 1963 and1980, 80 patients with DSS were studied. In all patients, the diagnosis was established by cardiac catheterization and angiocardiography, and in 56 who were operated upon, also by direct observation at surgery. Only patients with resting systolic pressure gradients across the obstruction of 50 mm Hg or less at first catheterization (measured by pullback of the catheter from the left ventricle to the aorta) were included in this study. Materials and Methods

The effect of sotalol on exercise tolerance and incidence of arrhythmias was studied in 30 patients with hypertrophic cardiomyopathy (HCM). In this short-term, double-blind, crossover study, exercise time on sotalol (320 mg/day) was significantly longer than on placebo (10.6 ± 4.0 vs. 9.4 ± 3.6 min; p < 0.01). Sotalol eliminated supraventricular arrhythmias in 6 of 7 patients (p < 0.03) and suppressed ventricular arrhythmias in 7 of 13 patients in whom they were present on placebo (p < 0.05). Ventricular tachycardia was abolished in 4 of 8 patients, but appeared during sotalol treatment in 1 patient who was free of repetitive arrhythmias on placebo. Twenty-five patients who had better exercise tolerance on sotalol than on placebo and did not experience aggravation of arrhythmia entered a 6-month prospective, open-label treatment with sotalol (160-480 mg/day, mean ± SD377 ± 94). One patient was withdrawn after 1 month because of bronchospasm. Mean exercise time improved from 9.8 ± 3.6 min on placebo to 12.7 ± 3.2 min (p < 0.01) after 6 months of treatment with sotalol. During the prospective follow-up, sotalol abolished ventricular tachycardia in all 6 patients after 1 month (p = 0.022), and in 4 of 6 patients (p > 0.2) after 6 months of treatment. It is concluded that sotalol significantly improves exercise tolerance and is effective in suppressing both supraventricular and ventricular arrhythmias in patients with HCM.