studies the renal circulation and the renal function...

Studies on the Renal Circulation and theRenal Function in Mitral Valvular

Disease

III. Effect of ValvulotomyBy LARS WERK6, M.D., JONAS BERGSTR6M, M.K., HARJE BUCHT, MI.D., JAN EK, M.D.,

HARALD ELIASCH, M.D., KERSTIN ERIKSSON, M.K., BENGT THOMLASSON, M.D.,AND EDVARDAS VARNAUSKAS, M.D.

Renal circulation and function were studied simultaneously with pulmonary and systemic hemo-dynamics in 25 patients with mitral stenosis before and six weeks after valvulotomy. Postopera-tively no essential change in renal circulation or function could be demonstrated whethersignificant relief of pulmonary hypertension had occurred or not. However, results from follow up

studies made on 21 patients up to more than three years after operation showed that renal plasmaflow could be increased in patients that were hemodynamically improved at the postoperativestudy. The effect of exercise was investigated in eight patients before and after valvulotomy. Inseven the response pattern of renal circulation and function was essentially unchanged regardlessof whether improvement in pulmonary pressures and cardiac output did or did not occur. In theeighth patient, the only one with elevated right atrial pressure before operation, the response

to exercise improved markedly. Preoperative results obtained on seven patients who died in con-

nection with operation showed that a fatal outcome was not necessarily related to the degree ofimpairment in renal circulation or function.

T HE direct surgical attack on narrowedmitral valves has established itself in thepast six years.7 The application of the

cardiac catheterization technic' has made pos-sible the evaluation of circulatory changesfollowing surgical treatment. The vast major-ity of reports published so far are concernedwith changes in clinical findings and altera-tions in cardiopulmonary hemodynamics.7' 14,15, 17

Impairment of the renal circulation and therenal function in mitral valvular disease hasbeen demonstrated.1' 11 18, 19 Recent studieshave disclosed that these features roughlyparallel the severity of disease and may evenprecede the onset of major hemodynamic al-terations in the cardiopulmonary circulation.'9The purpose of this study is to report the ef-fects of mitral valvulotomy on the renal cir-culation and function and to compare these

From the JVth Medical Service and the CentralLaboratory, St. Erik's Hospital, Stockholm, Sweden.

The work described in this papel wsas aided bygrants from the Swedish Medical Research Counciland the Knut and Alice Wallenberg Foundation.

187

findings with observed alterations in cardio-pulmonary hemodynamics.

MATERIALThe present study is mainly concerned with

investigations performed on 25 patients before andafter mitral valvulotomy. On clinical and radio-logic evidence, each patient was considered to havemitral valvular disease, predominantly stenosis.Diagnosis was confirmed at operation. Patients wvithother complicating valvular involvement wereexcluded. No patient had any record of renaldisease, nor any clinical signs thereof. All patientsexcept one, case 565, had a normal right atrialpressure.No attempt to report the clinical effects of oper-

ation was ma(le in this study. Classification ofpatients was made only on the basis of alterations incardiopulmonary hemodynamics, following oper-ation. All patients were operated upon by ClarenceCrafoord, M.D., at the Surgical Clinic of Sabbats-berg's Hospital, Stockholm, Sweden. Included alsoare reported results from preoperative studies onseven patients who (lied in connection with oper-ation. The causes of death are shown in table 4.The studies on tile 32 patients, which are the

basis of this paperl were performed during the years1951 to 1954. Studies made on some other operatedpatients during this period are not reported here

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188RANAL FUNCTION IN MITRAL VALVULAR, DISE&ASE$

because ienal investigations were not lone, due totechnical reasons.

METHODSAll patients were studied in the morning, recum-

bent, and in the postabsorptive state. An indwellingcatheter was placed in the urinary l)ladder. Therenal clearance for par.a-atmiiiohil)l)tPrate (PAH)wvas determined after a single, intramuscular in-jection according to the method of Bucht.4 5The renal clearance for inulin wals determined aftera single, intravenous injection. Iin pltients 630/766,666/726 and 685/755 l~ara-alainohiplurate andinulin were administered intravenously after apriming injection with a continuous injectionsyringe. Clearances were determine(l simultaneously.Urine was collected at 10 to)15 minute intervals, thebladder being rinsed twice with distilled water. Theurinary content of sodium was (letermined byflame photometry. Resting clearance values wereobtained from the mean of two or three periods.The pulmonary artery was (atheterized according

to the method of Cournand and Ranges6 as modifiedby Lagerl6f and Werkii.12 11 An in(lwelling arterialneedle was placed in the l)rachial artery. Thecardiac output was determinedl)y the direct Fickmethod. Blood gases were determine(l according tovan Slyke and the air gases on a Haldatne apparatus.Pressures were recorded by the Tv bj airg-Hansenand Warburg electric capacitance manometer.16

Resting observations on iuressures and flow wereobtained after the patient lhad been ait complete restfor at least half an hour. The details; of technicsused were reported earlier.19The response to graded exer ise was investigated

in some patients by studies oin pressures, flow, renalclearances and urinary sodium excretion. i\[easure-ments were made during 10 to 15 minutes of exer-cise?, 10, 19 XWork was (ontiinue(l (luring.all thesedeterminations.

As a rule patients were reinvxestigated in the samemanner after a period of six weeks following theoperation. In 21 patients, renial clearances weredetermined again at different time intervals, up tomore than three years after operation.

RESULTS

The criterion of hemodyi amic improvementwas a decrease after operation of the pul-monary arterial pressure-cardiac index quotientby at least one-third. Accordingly, 16 patientsout of 25 were considered to have been im-proved. Table 1 shows the mesults of studiesmade on improved patients.The pulmonary arterial and capillary venous

pressure decreased markedly on the averageand the cardiac output rose. The pulmonary

capillary venous pressure fell to within normallimits in nine patients, while in only one didthis pressure exceed a level of 16 mm. Hg afteroperation. In contrast to this the pulmonaryarterial pressure returned to normal limits infive patients only; in two of the remaining thepressure was still as high as 38 and 52 mm. Hg,respectively.

In the one patient, 565/606, with elevatedright atrial pressure before operation, a nor-mal value wvas recorded after. There was on anaverage no significant change in pulse rate or inbrachial arterial pressure.The renal clearance of para-aminohippurate

(PAH) was mainly unchanged after operation.A substantial increase was, however, observedin three patients, 565/606, 601/632 and 685/755. In one patient, case 666/726, there was adecrease. The para-aminohippurate clearancewas over 400 ml per minute in six patients be-fore and in seven after operation.

Greater differences were observed in therenal clearance of inulin. There was a sub-stantial increase in five patients, Cases 436/488, 554/592, 565/606, 601/632 and 685/755.On the average the inulin clearance increasedby 15 per cent.

Table 2 lists results in nine patients who wereconsidered hemodynamically unimproved ac-cording to the criterion mentioned above.There was thus on the average no change inpulmonary pressures or flow in these nine pa-tients.The mean preoperative value for para-amino-

hippurate clearance was of the same order as inthe former category. A marked increase wasrecorded in patients 424/479, 630/766 and695/728. A considerable fall was noted inpatients 392/418 and 403/499. The para-amino-hippurate clearance was over 400 ml. per min-ute in three patients before and in four afteroperation.The renal clearance of inulin was on an aver-

age of the same order in the patients listedin table 1 as in this set of patients. In the lattergroup, a marked increase was observed in pa-tients 388/452, 424/479, 630/766 and 695/728.There was a considerable fall in patient 392/418, but the postoperative value was still withinnormal limits.

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WElRK0 AND CO-WORKERS1

TABLE 1.-Clinical Data, Arterial Oxygen Saturation, Mean Pulmonary (ind Systemic Blood Pressures, CardiacIndex and Renal Clearance of Inulin and Para-aminohippurate in Sixteen Patients with Mitral Stenosis

Heart Art. 02Ae Vol. Rhytm StBS.A,2 Per Cent

31 680680

39 575500

38 620640

39 480530

44 470470

43 520520

41 400500

33 510510

23 410530

43 430360

40 480480

42 465465

44 600600

44 500500

47 650505

26 950950

16

38.6

16

546

0

SSSSSSSSSSAFSSSSSSSSSAFSSSSSSSSS

SS

91.7

93.795.5

94.690.793.692.9

87.5

94.087.2

91.5

87.7

86.4

90.093.796.2

86.490.992.992.387.9

95.4

93.1

94.296.1

90.5

95.0

93.3

93.688.8

90.7

15

91.4

0.9

PulseRate

7678100987868728276928676120125107

111266

6612011895867173627111510274838180

16

87.4

Mean Pressuremm Hg

PCV

2414222125112116191021104015221427112313238

215

3210261114

5

1515

16

23.4

0.7 -11.6

PA

4724282941

233223

21

172519

1095242

2831

1935

2847

30

23

1074

38

55

2625193527

16

RA BA1

33

12

3

1

1

44

0

21

3

-1-1

10

10

4

-223

9

3

0

11

!-1!-2

3

80

979811510811510499100987470849385899075100

8910062697775788983111

12875

15

A-V 02 Card.Dmff. ind.ml.L./min./mj.M.2 BSA

5746523851445028464243405632363242323736473952506641453544

305037

16

41.9 2.0 91.1 48.4

-16.11-0.7 0.1 -10.8

2.73.03.4

6.32.83.62.5

4.92.83.7

3.23.92.3

4.24.24.4

3.6

3.93.84.92.4

3.2

3.3

2.62.1

3.1

4.2

4.72.64.4

2.64.7

16

3.0

1.1

Investigation was made before valvulotomy (upper case number) and six weeks after (lower case number).Thiseset of patients was considered hemodynamically improved on the grounds that the quotient pulmonaryarterial pressure/cardiac index had decreased by at least one third after operatiois.PCV = pulmonary capillary venous pressure; PA = pulmonary arterial pressure; RA = right atrial pressure;

BA = Brachial arterial pressure; A-V 02 diff. = arteriovenous oxygen difference; 1'AH = para-aminohippurate;n = number of cases; BSA = body surface area.

Differences between pre- and postoperativevalues for renal clearances and hemodynamicdata were compared. No correlation was found.This was true for both sets of patients and forthe total material.The effects of a slight, graded, exercise test was

studied in eight patients, four from each group.

Figure 1 illustrates the results obtained in twopatients. In patient 438/520 (table 1) the re-

sponse to exercise after operation showed a

marked improvTemenit in the pulmonary hy-pertension present before operation. The

Sex

F

F

M

F

F

F

F

F

M

F

F

F

F

F

F

M

Case No.

292321315340316350334490337369397456408481436488438520462497464496554592565606601632666726685755

n............

Mean (beforeop.) ........

Diff. (pre-postop.) ....

Clearanceml.min./ .73

M.2 BSA

Inulin PAH

105 311109 325113 543127 61168 23270 181127 473153 445129 479134 48898 361114 42095 25797 325116 432150 45472 26781 321134 410145 459137 341117 280102 301135 31977 116120 28491 299126 38487 38372 29195 408137 546

16 16

102.9 350.8

15.0 32.4

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190 RNAL FUNCTION IN MITRAL VALVULAR DISEASE

TABLE 2.-Clinical Data, Arterial Oxygen Saturation, Mean Pulmonary and Systemic Blood Pressures, CardiacIndex and Renal Clearance of Inulin and Para-aniinohippurate in Nine Patients with Mitral Stenosis

HeartVol.Case No. Sex Age ml /l\1.2BSA

Rhythm Art. 02Sat. c

354 F 45 390 S376 480 S360 F 40 630 AF379 630 AF380 M 46 590 AF415 430 AF388 F 30 560 S452 560 S392 F 26 410 S418 410 S403 M 45 420 S499 420 S424 M 34 500 S479 500 S630 1\I 38 500 S766 a10 S695 F 39 690 AF728 580 AF

n. 9 9Mean (before

op.) .38.1 521Diff. (pre-

postop.) .... -19

92.692.091.090.095.996.093.882.193.090.592.592.492.697.194.3

91.792.0

PulseRate

65678084667682751201086377717959757079

__-i-8 9

92.9 75.1

-1.4 4.9

Mean Pressuremm. Hg

PCV

16172924121325141413282318141810161n

PA RA

19273934202336282820323822152727221R

3

150204112203005

BA

94103155

108

8881929590751029574766170

9 8 7

ClearanceA-V 02 Card. Ind. ml./min.1.73Diff. L./min./M.2 M2 BSAml. /L. BSA

Inulin PAH

40 2.6 102 40044 2.8 95 37349 2.7 105 28758 2.4 105 29054 2.1 76 26052 2.3 77 20932 4.9 89 39428 5.1 133 40329 5.1 198 64641 4.3 132 45647 2.9 111 41237 4.6 87 22750 3.4 84 34963 2.1 125 55252 2.6 50 19750 2.8 87 38049 3.9 109 32449 2.5 140 426

9 9 9 9

19.6 26.7 1.1 85.9 44.7 3.4 102.7 363.2

-4.3 -1.1 1.8 0.4 2.2 -0.2 6.3 5.2

Investigation was made before valvulotomy (upper case number) and six weeks after (lower case number).This set of patients was considered hemodynamically unimproved on the grounds that the quotient pulmonaryarterial pressure/cardiac index did not decrease by one-third after operation.PCV = pulmonary capillary venous pressure; PA = pulmonary arterial pressure; RA = right atrial pres-

sure; BA = brachial arterial pressure; AV 02 diff. = arteriovenous oxygen difference; PAH = para-amino-hippurate; n = number of cases; BSA = body surface area.

cardiac output was higher after operation.There was no change observed in either rightatrial or brachial arterial pressures. Therenal clearance of both para-aminohippurateand inulin showed the same response to exer-cise, both before and after operation. A mod-erate fall in sodium excretion was noted bothin the pre- and the postoperative study.

Essentially the same response to exercise wasobserved in seven out of these eight patients.The results in patient 565/606 (table 1) showa different pattern. This was the only patientwith elevated right atrial pressure presentbefore operation. Following surgery pulmonarypressures fell and cardiac output rose. Renalclearances increased markedly and the responseto exercise became normal. There weas no de-

crease in sodium excretion on the postopera-tive exercise test. The pathologically elevatedright atrial pressure decreased to a normallevel and stayed normal even on effort.

Table 3 (A and B) contains the results of allclearance determinations made before, im-mediately after and up to three years after theoperation. The material is divided into twogroups according to the same criterion alreadyused. Two patients were reinvestigated whenthey were admitted to the hospital because ofcomplicating disease (cases 315/340 and 334/490). In these the clearance values were mark-edly lower at the time of reinvestigation thanbefore.Some patients after successful operation had

a progressive increase in renal clearances over

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FIG. 1. Response to exercise of the renal clearanceof para-amino-hippurate and inulin, urinary sodiumexcretion, mean pressures in the pulmonary andsystemic circulation, cardiac output and arterialoxygen saturation in two patients with mitral steno-sis before and after valvulotomv (see text).PAH = para-aminohippurate; Na+ = urinary

sodium excretion; PCV = pulmonary capillaryvenous pressure; PA = plulmonary arterial pressure;

RA = right auricular pressure; BA = 1)rachial ar-

terial pressure; C.O. = cardiac output.

the years until normal values were reached(cases 601/632 and 462/497 table 3a). Othersalso showed increased values after the success-

ful valvulotomy although not to the same ex-

tent (cases 316/350, 408/481, 438/520, table3A). This was also observed in one patient, whowas classified as hemodynamically unimprovedat the first postoperative study (case 630/766,table 3B).

Of the patients in table 3A only one (case 337/369) had lower clearance at follow up thanbefore operation. She had atrial fibrillationat the time of study. The clearances did notimprove following reconversion to sinusrhythm. In another patient (case 464/496,table 3A), also fibrillating at the time of thethird study, conversion to sinus rhythm was

accompanied by a marked increase in renalclearances.

All other patients in the improved group hadvirtually unaltered clearances during the followup period. In the other group most patients

had unaltered or decreasing clearances (es-pecially the para-aminohippurate clearance)during the follow up period.

Table 4 shows the preoperative studies andautopsy findings in those seven patients whodied immediately after operation. Averagefigures show that the severity of disease wasgenerally more marked as compared with theseverity in those who lived after operation, asjudged from pulmonary pressures and cardiacoutput. The para-aminohippurate clearancewas over 400 ml. per minute in one patientonly, case 567. Moderately low figures wereobserved in the remaining studies, except forpatients 569 and 576, where a markedly lowvalue was recorded. In the latter patients the

TABLE 3A.-Renal Clearances of Inulin and Para-aminohippurate (PAH) in Fourteen Patients withMitral Stenosis

Clearance ml./min./1.73 M.2 BSA

[Case No.

292/321

315/340316/350334/490337/369x

397/456

408/481436/488

438/520462/497464/496x

554/592

601/632666/726

Mean...

Inulin

I II III

105 109 103

113 127 113

68 70 99127 153 129

129 '134 11397

98 114 104

95 97 120

116 150 129

72 81 83

134 145 163

137 117 108141

102 135 10891 126 11287 72 103

102.8 112.5 112.8_I

PAH

TV. v 1

92 311

-543

99 232- 473

479

361- 257- 432

- 267

410

341

301

299- 383

95.51339.4

III

325 326

611 382181 272

445 347

488 1382342

420 360

325 387454 445

321 .333

459 597

280 322

415319 315

384 625

291 415

IV

300

356

353.9 400.5 328.0

All patients were considered hemodynamicallyimproved by valvulotomy (for criterion see table 1or text). Determinations were made before val-vulotomy (I), approximately six weeks after opera-tion (II) and one and one half to two years after thepostoperative study (III). In two patients, deter-minations were repeated again after three years(IV) and in two (x), after conversion of atrial fibrilla-tion to normal sinus rhythm.

Cases 315/340 and 334/490 are not included in theaverages as they had complicating diseases at thetime of follow-tup study.

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RENAL FUNCTION IN MITRAL VALVULAR DISEASE

TABLE 3B.-Renal Clearances of Inulin and Para-aminohippurate (PAH) in Seven Patients with MitralStenosis

Clearance ml./min./1.73 M2 BSA

Case No. Inulin PAH

I II III I II III

354/376 102 95 105 400 373 326380/415 76 77 86 260 209 211388/452 89 133 125 394 403 298392/418 198 132 165 646 456 483424/479 84 125 95 349 552 373630/766 50 87 101 197 380 339695/728 109 140 107 324 426 318

Mean.. 101.1 112.7 112 .0 367.1 399.9 335.4

All patients were considered hemodynamicallyunimproved by valvulotomy (for criterion see table2 or text). Determinations were made before val-vulotomy (I), approximately six weeks after opera-tion (II) and one and one half to two years after thepostoperative study (III).

there were no renal emboli and the kidneysweighed 350, 260 and 400 Gm., respectively. Inthe remaining patients old renal infarcts werefound to a various extent and the kidney weightwas lower. In patient 569, who had the lowestrenal clearance, the left kidney was completelydestroyed and the right contained several in-farcts.

DISCUSSION

In patients with mitral valvular disease vary-ing degrees of impairment of the renal function,as measured by para-aminohippurate and inulinclearance, are present.'8' '9 The decrease inclearances and those alterations in the pul-monary or systemic circulation that are moredirectly caused by the heart lesion have, how-ever, generally correlated poorly. The closestrelationship has been established betweenelevation of pulmonary arterial pressure and

TABLE 4.-Clinical Data, Arterial Oxygen Saturation, Mean Pulmonary and Systemic Blood Pressures, CardiacIndex, Renal Clearance of Inulin and Para-aminohippurate and Autopsy Findings in Seven Patients with MitralStenosis Who Died Immediately after Operation

HeartVol.ml./M.2BSA

590

630

720

760

500

450

S

S

Art.02S

Sat.PerCent

87.5

76.61109

AFI 94.51 80

AF 89.2' 95

S 87.81 71

AFI 92.11 65

14001 AF1 85.01 97

7 740.7 721

PulseRate

Mean Pressure mm. Hg

PCV PA

90 22

25

27

19

19

29

32

7 7 787.5 86.7 24.7

59

88

47

44

26

46

89

757.0

RA BA

2

2

1

1

0

2

14

73.1

A-V 02Diff.ml./L.

112 47

110

87

119

73

80

124

7100.7

60

62

64

36

72

73

Card.Ind.L./

min./M.2BSA

3.3

Clearanceml./min./1.73M.2 BSA

Inulin

82

2.5 112

2.1 132

2.1 104

4.1 1115

1.9

1.7

7 759.1 2.5

41

66

7

PAH

313

285

369

301

432

119

153

793.11281.7

Cause of Death

Arterialembolism

Arterialembolism

Circulatoryfailure

Circulatoryfailure

Viruw pneu-monia

Arterialembolism

Circulatoryfailure

adCAZ,5

195

200

350

250

Remarks

Renal in-farcts

Renal in-farcts

Renal in-farcts

260 -

180 Extensiverenal in-farctions

400

PVC = pulmonary capillary venous pressure; PA = pulmonary arterial pressure; RA = right atrial pres-

sure; BA = brachial arterial pressure; A-V 02 diff. = arteriovenous oxygen difference; PAH = para-aminohip-purate; n = number of cases; BSA = body surface area.

inulin clearance was also very low. In the otherstudies the inulin clearance was over 100 in allexcept one patient, case 358.

In three patients, cases 402, 567 and 576,

decrease in renal plasma flow.'8 19 The presentstudy was undertaken to find out whether thedecrease in pulmonary arterial pressure and in-crease in cardiac output when caused by surgi-

Sex Age

F 142

F 46

M 145

M 140

CaseNo.

358

367

402

463

567

569

576

Mean

F 32

M 140

M 140

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WElIRK0 AND CO-WOIRKEIRS

cal therapy would influence the renal plasmaflo\V.The results have shown that the decreased

renal plasma flow in mitral stenosis may risemarkedly after successful valvulotomny andthat further increase may occur over a periodof some years. This was not the rule in all im-proeled patients, as in many, of them. only slightor no improvement in the renal circulationcould be demonstrated. In three patients, alsoclassified as improved at the immediate post-operative study, renal clearances had (lecreasedat the time of follow Up. Two of these patientshad had repeated attacks of carditis and thethird was studied during and after an attackof atrial fibrillation. It seems probable thatthese complications may have influenced boththe general and renal circulation ill an adversemanner. In the absence of such complicationssuccessful valvulotomvN was always followedby unaltered or improved renal circulation atthe late follow up.On the contrary, most of the patieilts who

were classified as unimproved at the postopera-tiv'e catheterization either demonstrated un-

altered or further (liminished renial plasmaflow at the follow up study.The criteria for hemodynamic imiprovemeent

used in this paper have been made rather ad-vanced. It is furthermore possible that, thecourse of the disease in each patient (luring thefollowving years may modify the immediateresponse to operation, in some patients causingfurther improvement, in others further de-crease of fuiiction. Several patients in thehemiiodynam-i(cally unimproved group showeda moderate to marked clinical improvemen-t atthe followtup and some patients in the im-proved group had experienced increasing symp-toms at this time. It is of interest to note that,notwithstanding these irregularities in the pa-tient material, the improved group as a wholehad imuch better renial circulation in thefollow up studies as compared with the unirm-proved group.The first postoperative study was (lone about

six weeks after operatioii when the patientsw-ere still hospitalized. In some of the inprovedpatients the increase in renal plasma flow oc-cuirred gradually as they resumned living anactive life, as a consequence of successful opera-

tion. This is in accordance with observationson the exercise tolerance after valvulotomiythat have shown that there may be a gradualimprovement up to about. nine months afteroperation.3 This finding is similar to the ob-servation that the decreased renal plasma flowoccurring ill anemia may remain low as long assix months after the correction of anemia andthen increase to normal.'The renal plasma flow may be decreased ill

patients with mitral valvular disease even ifthe pulmonary circulation is normal at rest.19In the present series surgical treatment causedmarked relief of pulmonary hypertension illseveral patients. Even in those who weremarkedly improved the pulmonary vascularpressures only partly returned to normal level.It was not likely that pathologically low renalclearances present before operation shouldreach normal levels after operation althoughsome improvement could be expected. Theimmediate postoperative values for the imll-proved group, however, were lower than ill 11011-operated patients with comparable pulmonarycirculation.18'19 At the follow up study thegroup as a whole had higher clearance values,which more closely corresponded to what wasexpected from studies on nonoperated pa-tients."' 19The unaltered level of renal clearance iii

many patients after operation once againbrings out the fact that surgical interventionldoes not cure patients with mitral stenosis butonly improves the circulation to a certain de-gree.7 This is substantiated by the results ob-tained on the exercise test. This fact is ofimportance when indications for surgical treat-ment are discussed. On the otfher hand thepresence of even markedly decreased renalclearances does not constitute any contra-indication to operation, which is amply demon-strated in patient 563/606 (table 1) with mark-edly elevated right atrial pressure beforeoperation. Afterwards the pulmonary pressureswere markedly decreased, and also the rightatrial pressure. The latter did not increaseduring exercise after operation in contrast tobefore operation. The renal plasma flow hadrisen, although not to a normal level, and, thedecrease ill ienal plasma flow and sodium ex-cretion during exercise wvas insignificant. Thus

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renal function reacted to the burden of exer-cise almost in a normal fashion after surgery,in contrast to the marked pathologic reactionbefore.The remarkably stable level of renal plasma

flow during many years in some patients mayindicate the presence of pathologic lesions inthe kidneys, prohibiting any improvement ofits function. Patient 403/479 (table 2) hadmultiple emboli after operation, includingmesenteric and probably renal. This patienthad very marked decrease in para-amino-hippurate clearance. The postmortem studiesallow some comments on this matter. Patient569, who died at operation, had extensive renalinfarcts. He had the lowest renal plasma flow ofall of our patients. On the other hand, patient576 (table 4), who also had a similarly lowrenal plasma flow, had large congested kidneysat autopsy without any emboli. It has beenshown that the renal plasma flow in patientswith mitral stenosis may increase to normalvalues following the administration of Apreso-line,20 during a rapid infusion of isotonic glu-cose solution8 or during fever.21 One of thepatients in the present series, who was improvedafter surgery, had a lower renal plasma flowand filtration rate at the postoperative studythan before. When the patient was studiedduring the rapid infusion of isotonic glucosesolution, both renal plasma flow and filtrationrate increased to the same, normal value.8Similar findings have been recorded in otherpatients. Even though the renal plasma flowthus is low, the patient still has the ability toincrease the renal function. This reserve ca-pacity seems to be unaltered by the operativeprocedure.The preoperative studies on those patients

who did not survive operation show that renalclearances are not necessarily low in patientswhere the operative outcome is fatal.

SUMMARY

(1) Pressures in the pulmonary and systemiccirculation, cardiac output and renal clearancesof para-aminohippurate and inulin were de-termined simultaneously in 25 patients withmitral valvular disease. Patients were re-investigated in the same manner about six

weeks after valvulotomy. In eight patients theeffect of exercise was studied pre- and post-operatively.

(2) The renal clearance of para-aminohip-purate was essentially unaltered after operationwhether alleviation of pulmonary hypertensionhad occurred or not.

(3) Results from follow-up studies made on21 patients up to more than three years afteroperation showed that definite increase in renalplasma flow occurred in patients with improvedpulmonary circulation.

(4) One patient only had pathologicallyelevated right atrial pressure before opera-tion. After operation, this pressure becamenormal, both at rest and during exercise, and amarked improvement of both pulmonary cir-culation and renal function was observed.

(5) Preoperative results on seven patientswho died immediately after operation showedthat a fatal outcome was not related to thedegree of impairment in renal function.

SUMMARIO IN INTERLINGUA

Circulation e functiones renal esseva studiatesimultaneemente con le hemodynamica pulmo-nar e systemic in 25 patientes de stenosismitral ante e 6 septimanas post valvulotomia.Post le operation nulle alteration essential delcirculation o function renal esseva demonstra-bile, si o non un alleviamento significative delhypertension pulmonar habeva occurrite.Tamen, resultatos de studios posttractamentalexecutate pro 21 patientes durante periodos deusque a plus que tres annos post le operationmonstrava que le fluxo renal de plasma essevaaugmentabile in patientes qui se monstravahemodynamicamente meliorate al tempore delstudio postoperative. Le effecto de exercitioesseva investigate in octo patientes ante e postle valvulotomia. In septe casos le responsas delcirculation e function renal esseva plus o minusinalterate, sin reguardo a si o non un meliora-tion del pression pulmonar e del rendimentocardiac habeva occurrite. In le octave patiente,le sol con elevate pression dexteroauricular antele operation, le responsa a exercitio se melioravamarcatemente. Le resultatos de observationespre-operative in septe patientes qui moriva inconnexion con le operation monstrava que un

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termination mortal non esseva necessarimenteconnectite con le grado de disrangiamento in lecirculation e function renal.

REFERENCES1 AAS, K. AND BLEGEN, E.: The renal blood flow

and the glomerular filtration rate in congestiveheart failure and some other clinical conditions.Scandinav. J. Clin. & Lab. Invest. 1: 22, 1949.

BRADLEY, S. E. AND BRADLEY, G. P.: Renalfunction during chronic anemia in man. Blood2: 192, 1947.

BRUCE, R. AND RODGERS, D.: Quantitative effectsof medical and surgical treatment of mitralstenosis on exercise tolerance. Amn. J. Medl.15: 35, 1953.

4 BUCHT, H.: Examination of the renal plasma flow'by means of para-amino-hippuric acid (PAH)using one intramuscular injection. Scandinav..J. Clin. & Lab. Invest. 1: 126, 1949.

5 -: Studies on renal function in man. Scandinav.J. Clin. & Lab. Invest. 3 (suppl. 3): 1, 1951.

{ COURNAND, A. AND RANGES, H. A.: Catheteriza-tion of right auricle in man. Proc. Soc. Exper.Biol. & Med. 46: 462, 1941.

7DEXTER, L., MCDONALD, L., RABINOWITZ, AI.,SAXTON, G. A., JR. AND HAYNES, F. W.: Medicalaspects of patients undergoing surgery formitral stenosis. Circulation 9: 758, 1954.

8 EK, J., VARNAUSKAS, E., THOMASSON, B., BUCHT,H., AND A\ERKO, L.: Studies on the renalcirculation and renal function in mitral valvulardisease. IV. Effect of rapid intravenous in-fusion of isotonic glucose solution. In prepa-

ration.9 ELIASCH, H.: The pulmonary- (irculation at rest

and on effort in mitral stenosis. Scandinav. .r.Clin. & Lab. Invest. 4: 1, suppl. 4, 1952.T.,WADE, G. AND AAERKO, L.: The effectsof work on the pulmonary circulation in mitralstenosis. Circulation 5: 271, 1952.

1 HELLER, B. I. AND JACOBSON, E. W.: Renal hemno-

dynamics in heart disease. Am. Heart J. 39:188, 1950.

12 LAGERL6F, H. AND WERKO, L.: Studies on thecirculation in man. I. Technique of venouscatheterization with determination of cardiacoutput and simultaneous recordings of the bloodpressures, the electrocardiogram, phonocardio-gram and lespiration. Acta med. scandinav.132: 495, 1947.

1:3_ AND : Studies on the circulation in man.VI. The pulmonary capillary venous pressurepulse. Scandinav. J. Clin. & Lab. Invest. 1:147, 1949.

14 SELLORS, T. H., BEDFORD, D. E. AND SOMERVILLE,W.: Valvulotomy in the treatment of mitralstenosis. Brit. MI. J. 2: 1059, 1953.

15 SOULIEJ, J., rI MATTEO, J., TRICOT, R. ANDMOREAU, L.: Commissurotomie pour retrecisse-ment mitral. Bull. et mem. Soc. m6d. d.hop.de Paris 24 & 25: 871, 1952.

16 TYBJXERG-HANSEN, A.: Pressure-M1easurement inthe Human Organism. Copenhagen, TekniskForlag, 1949.

17 VERK6, L., BI6RCK, G., CRAFOORD, C., W\ULFF,H., KROOK, H. AND ELIASCH, H.: Pulmonarycirculatory dynamics in mitral stenosis beforeand after commissurotomy. Am. Heart J. 45:477, 1953.

18 EK, J., BUCHT, H. AND ELIASCH, H.: Cor-relation between renal dynamics, cardiacoutput and right heart pressures in mitralvalvular disease, Scandinav. J. Clin. & Lab.Invest. 4: 15, 1952.

19 , VARNAUSKAS, E., ELIASCH, H., EK, J.,BUCHT, H., THOMASSON, B. AND BERGSTROM,J.: Studies on the renal circulation and renalfunction in mitral valvular disease. I. Effectof exercise. Circulation 9: 687, 1954.

20 , VARNAUSKAS, E., EK, J., BUCHT, H., THOM-ASSON, B. , BERGSTR6M, J. AND ELIASCH, H.:Studies on the circulation and renal functionin mitral valvular disease. II. Effect of Apres-oline. Circulation 9: 700, 1954.

21 WEESTON, R. E.: Personal communication.

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VARNAUSKASELIASCH, KERSTIN ERIKSSON, BENGT THOMASSON and EDVARDAS

LARS WERKÖ, JONAS BERGSTRÖM, HÄRJE BUCHT, JAN EK, HARALDDisease: III. Effect of Valvulotomy

Studies on the Renal Circulation and the Renal Function in Mitral Valvular

Print ISSN: 0009-7322. Online ISSN: 1524-4539 Copyright © 1956 American Heart Association, Inc. All rights reserved.

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