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Myocardial infarction and coronary artery ventricular fistulas due to blunt chest trauma. HISTORY AND CLINICAL FINDINGS: An 18-year-old previously healthy, cigarette smoking man with no other risk factors for ischaemic heart disease, was admitted to hospital after being kicked in the chest by a horse. On arrival he complained about pain in the lower mediastinum. INVESTIGATIONS: The ECG showed sinus rhythm, right bundle branch block and convex bowed ST elevation in leads V1-V3. Sixty minutes after the incident the cardiac enzymes (creatinekinase-MB fraction, troponin I) were significantly raised. Despite an only slightly reduced left ventricular function documented by transthoracic echocardiography, SPECT-thallium scan showed large scintigraphic defects. Coronary heart disease was excluded by coronary angiography. Four small coronary-ventricular fistulas were identified. Laevocardiography showed a hypokinesia in the antero-septal region. DIAGNOSIS, TREATMENT AND COURSE: We assumed traumatic myocardial infarction of the anterior wall and rupture of multiple small coronary vessels, leading to coronary-ventricular fistulas. No interventional or surgical therapy was performed. Later on the left ventricular function became normal. Echocardiography merely outlined an akinetic scar in the middle of the septum. At exercise ECG test sixteen months later, the patient remained asymptomatic and was able to exercise without any signs of ischaemia up to a work load of 175 W. Furthermore, the fistulas could be seen by echocardiography. CONCLUSION: Cardiac involvement should be considered in all cases of blunt chest trauma. In addition to a traumatic myocardial infarction fistulas may also, though rarely, occur. Myocardial scintigraphy after cardiac contusion is not suitable for diagnosing myocardial ischaemia or vitability.

Case Report: A 30-year-old male was admitted to hospital because of chest pain and raised cardiac enzymes. Coronary heart disease was excluded by coronary angiography. Assuming myocarditis serological testing was performed and showed markedly raised antibody titers against Coxiella Burnetii. We treated the patient with doxycycline, 2 times 100 mg daily for 5 months., Conclusion: Acute Q-fever should be considered as a possible cause of myocarditis, especially in rural areas.

History and Admission Findings: A few days after uneventful surgical reconstruction of the mitral valve a 43-year-old man was found to have a systolic murmur due to prolapse of the posterior leaflet, suggesting renewed mitral regurgitation., Investigations: Echocardiography revealed haemodynamically significant left ventricular outflow tract obstruction (LVOT) with a left ventricle to aorta systolic gradient of 83 mm Hg. In addition there was moderately severe mitral regurgitation as well as a pericardial effusion but no signs of tamponade., Treatment and Course: The obstruction was at first treated with verapamil, later with sotalol. The pericardial effusion was interpreted as part of a postcardiotomy syndrome. The effusion regressed under steroid administration, and the LVOT and mitral regurgitation also decreased. A provocation test five months postoperatively no longer brought about an outflow gradient. The good results were still present 12 months postoperatively., Conclusion: The described, rarely seen form of LVOT was probably caused by a combination of a very large anterior mitral leaflet, postoperative pericardial effusion and pharmacological effects. If the obstruction first occurs postoperatively, appropriate medication may improve the cardiac status and reoperation may be avoided. Echocardiography is an important method of diagnosis and serial monitoring.

History and Clinical Findings: A 53-year-old patient had a prosthetic valve (St. Jude Medical 25) 9 years ago because of a Staphylococcus aureus endocarditis with severe aortic regurgitation. An initially mild, progressively more severe, aortic regurgitation then developed as a result of an empty paravalvular abscess cavity, requiring another valve replacement. Fever started on the 3rd postoperative day and persisted despite combined treatment with beta-lactam antibiotics and aminoglycoside., Investigations: At first no infectious focus could be identified radiologically or by echocardiography. But transoesophageal echocardiography revealed vegetations in the old abscess cavity. Several blood cultures were negative, while serological tests gave markedly raised antibody titers against Coxiella burnetii., Diagnosis, Treatment and Course: Assuming Coxiella burnetii endocarditis the patient was given doxycycline, 2 x 100 mg daily and cotrimoxazole, 1 x 960 mg daily. The fever subsided and the vegetations had disappeared after four weeks. Because of the high risk of recurrence the antibiotic treatment was to be continued for two years., Conclusion: Coxiella burnetii should be considered as a possible cause of fever of unknown origin, especially in patients with existing or operated cardiac valvar defects, when endocarditic vegetations have been demonstrated and several blood cultures have been negative.

History and Admission Findings: An 85-year-old woman was admitted because of frequent syncopes. She also reported slight weight loss, cough and dyspnoea. Chest auscultation revealed slight stridor and a cardiac arrhythmia, with an irregular ventricular rate between 120 and 140 beats/min., Investigations: She had a thrombocytopenia (96 platelets/nl), and the ECG and long-term monitoring showed a tachyarrhythmia with atrial fibrillation, a bifascicular block (left anterior hemiblock and right bundle branch block), as well typical signs of sick-sinus syndrome with short periods of bradycardic sinus rhythm and pauses of up to 6 s on rhythm change. Echocardiography indicated moderately reduced left ventricular function. Chest radiogram revealed tracheal narrowing by a retrosternal goitre. No evidence of tumour was found on bronchoscopy., Diagnosis, Treatment and Course: A VVI pacemaker was implanted. When the platelet count dropped to 30/nl idiopathic thrombocytopenic purpura was suspected, but administration of high doses of corticoids and immunoglobulin was without effect. Another echocardiogram, performed because of chest pain suspicious of pulmonary embolism, revealed a large bowl-shaped right ventricular thrombus with floating parts. Demonstration of anticardiolipin antibodies established the diagnosis of antiphospholipid syndrome (APLS), thought to be secondary to thyroid cancer suspected from the computed tomography. The patient died 2 months later from recurrent pulmonary embolism and progressive liver failure. Autopsy revealed a not previously diagnosed tracheal carcinoma with metastases to the thyroid, as well as haematogenous metastatic foci within the right ventricular thrombus., Interpretation: In case of thrombocytopenia of uncertain aetiology APLS should be included in the differential diagnosis, even in the absence of any early or acute thrombosis. If anticardiolipin antibodies and/or lupus anticoagulant are demonstrated, malignant neoplasm should be considered in addition to autoimmune disease.

Objective: To investigate prospectively the extent of potentially harmful interference of cardiac pacemakers by mobile phones in the C (analog) and D (digital) networks in use in Germany., Patients and Methods: 104 patients (54 men, 50 women; mean age 75.8 [40-100] years) with 58 different implanted pacemaker models (43 one-chamber and 15 two-chamber systems) underwent uniform tests at various functional states with three different telephones (D1 portable 8 Watt, D1 Handy model 2 Watt, C Handy model 0.5 Watt). The distances between telephone aerial and pacemaker, as well as reception sensitivity and polarity of the pacemaker were varied. All tests were done during continuous ECG monitoring., Results: 28 different pacemaker types (48.3%) in 43 patients (41.3%) showed interference in the form of pacemaker inhibition and switching to interference frequencies as well as triggering of pacemaker-mediated tachycardias in the DDD mode, as well as in the temperature-regulated frequency-adaptive function. D portables influenced pacemaker function more often and at greater distance than the D Handy model, which was little different from the c network hand phone. Reduction in pacemaker sensitivity as well as switching to bipolar reception only partly eliminated the interference., Conclusions: Patients with implanted pacemakers should if possible not use mobile phones in the C and D networks. Individual testing with suitable programming of pacemaker sensitivity and polarity can reduce the risk of interference.

Objective: The factors that influence long-term survival after out-of-hospital resuscitations were investigated., Patients and Methods: Between 1985 and 1989, out of a total of 8403 responded emergency calls, 505 resuscitations were undertaken out of hospital by the emergency medical service in Göppingen. All emergency calls were recorded uniformly. Of the 505 resuscitations, 154 were primarily successful (30.5%), and 58 were secondarily successful, i.e. the patients were ultimately discharged from hospital. In 56 of them the further course could be followed at least 5 years after the resuscitation (45 males, 11 females; mean age 57 [10-83] years). The patients' charts were analysed; in 51 cases data could be obtained from the family doctor, from ambulant care or from home visits., Results: 34 patients (60.4%) were still alive 5 years after the resuscitation. The highest death rate (16%) was in the first post-resuscitation year. Prognostically unfavourable factors were: advanced age (P < 0.01), underlying cardiac disease (n = 49; P < 0.025), especially coronary heart disease (n = 34; P < 0.01). Patients with primary ventricular fibrillation and previous myocardial infarction (n = 10) had a poorer prognosis than those with acute infarction (n = 24; P < 0.05). Reduced survival chances occurred in those with impaired left ventricular function, as measured echocardiographically (P < 0.05), or with cardiac arrhythmias, Lown classes III and IV (P < 0.05), as well as in those with severe neurological sequelae (n = 8; P < 0.08)., Conclusion: Long-term prognosis depends, in the first instance, on the resuscitated patient's basic condition and not so much on the circumstances of the resuscitation.

A 32-year-old woman without preceding illness or significant cardiovascular risk factors was admitted to hospital because of a syncope after physical exertion. Transoesophageal echocardiography, performed to exclude aortic dissection, showed as an incidental finding a cystic space-occupying mass, 5 x 6 cm in diameter, dorsal to the aortic root and main pulmonary artery. Exercise ECG had S-T segment depressions of about 0.3 mV, associated with anginal symptoms, so that inadequate coronary artery flow on exertion was suspected. Subsequent coronary angiography demonstrated a funnel-shaped 80% stenosis at the origin of the main left coronary artery, while all other coronary arteries were normal and smooth-walled. A causal connection between the two findings was assumed and quickly undertaken surgical intervention revealed an intrapericardial bronchogenic cyst which, presumably as a result of its size and location, had pressed on the main stem of the left coronary artery and caused the stenosis of its ostium. The cyst was completely resected and angioplasty of the coronary artery ostium was performed to ensure its patency. 3 months postoperatively the patient underwent an exercise test of up to 125 Watt without signs of ischaemia. This case presents a previously unreported complication of a bronchogenic cyst.

Between 1986 and 1992, pacemakers were implanted in 307 patients with symptoms caused by the sick sinus syndrome (SSS). 301 patients were regularly followed up (161 men, 146 women, mean age 72.9 [27-91] years) of whom 180 had a VVI, 65 and AAI and 58 a DDD/DDI pacemaker. Mean follow-up period was 58.3 months for VVI-stimulated patients and 35.6 months for atrial paced patients. The data were analysed retrospectively to ascertain whether a change in pacemaker treatment to a more physiological system produced any lowering in the mortality rate, incidence of permanent atrial fibrillation (AF), and thromboembolic phenomena. The annual mortality rate of the VVI-stimulated patients was 6.9%, that of atrial paced patients 2.8%. Age, abnormal ventricular function, survived resuscitation and diabetes mellitus each correlated with a shortened life expectancy already at the time of implantation, regardless of the pacemaker mode. Permanent AF was more frequent during VVI stimulation (16% vs 7%), especially if it had been preceded by intermittent AF (26% vs 13%). But there was no significant difference with regard to transitory cerebral ischaemic episodes and peripheral arterial emboli (15% vs 10%). Fewer patients with atrial pacing went into heart failure (20% vs 30%). Four patients developed a high-grade atrioventricular (a-v) block on AAI stimulation (annual incidence 2.4%). - These observations suggest that patients with SSS should always have atrial paced pacemaker systems. If a-v conduction is disturbed, a bifocal pacemaker is the system of choice.

Electrocardiograms and radionuclide ventriculograms were obtained at rest and on exercise in 23 patients (20 men and 3 women, mean age 53.4 years) with exercise-dependent myocardial ischaemia after infarction, as well as in 22 persons (17 men and 5 women, mean age 43 years) without clinical, electrocardiographic and biochemical evidence of coronary heart disease. Among the ischaemia patients exercise-dependent loss of motility, as measured by regional ejection fraction and Fourier amplitude, occurred in 95% (50% of controls) in one sector, in 78% (4.5% of controls) in the two sectors with the highest contractility at rest, and in 74% (0% of controls) in three sectors. On exercise, phase shifts occurred in 87% (27% of controls). When combining the exercise-ECG, global ejection fraction as well as regional motility loss in one sector, in the two sectors with the highest contractility at rest and in three sectors, at least two of the five criteria of abnormality were present in 91.3% of the ischaemia patients, compared with at most one criterion in 90.9% of controls. The results indicate the greater diagnostic value of regional than global measures of ventricular function and emphasize the importance of radionuclide ventriculography as an addition to exercise electrocardiography in the pre-invasive diagnosis of coronary heart disease.

In 17 patients without evidence of regional wall motion abnormality a determination of the variation of global and regional parameters of two contour delineations was attempted by the same (intraobserver) and by an independent observer (interobserver). In the intraobserver comparison all computed comparison all computed parameters showed excellent correlation coefficients: enddiastolic volume (EDV) r = 0.97, endsystolic volume (ESV) r = 0.94, ejection fraction (EF) r = 0.93. In the interobserver comparison, the correlations were slightly lower (EDV: r = 0.94, ESV: r = 0.93, EF: r = 0.85). Absolute differences in volumes and ejection fractions were for the EDV 3.0 +/- 11.8 ml (+/- 1 SD), for the ESV 2.6 +/- 4.9 ml, and for EF 1.9 +/- 4.1%. Additionally, the three contour tracings were subjected to an analysis of regional wall motion using nine different methods. With most of the methods applied, the analysis showed areas near valves and the cardiac apex, where small changes in contour tracings resulted in statistically significant differences in wall motion (p less than 0.05). Therefore, using each method described, it was possible to determine, which regions demonstrated the greatest variation in interpretation of quantitative regional wall motion. Finally we conclude, that enddiastolic and endsystolic volumes and ejection fraction can be subjected to repeated estimation by the same or an independent observer with sufficient accuracy.

Camera-Kinematography is a nearly noninvasive method to investigate regional motion of the myocard, and allows evaluation of the function of the heart. About 20 min after injection of 15-20 mCi of 99mTC-Human-Serum-Albumin, when the tracer is distributed homogenously within the bloodpool, data acquisition starts. Myocardial wall motion is represented in an appropriate quasi three-dimensional form. In this representation scars can be revealed as "silent" (akinetic) regions, aneurysms by asynchronic motion. Time activity curves for arbitrarily chosen regions can be calculated and give an equivalent for regional volume changes. 16 patients with an old infarction have been investigated. In fourteen cases the location and extent of regions with abnormal motion could be evaluated. Only two cases of a small posterior wall infarction did not show deviations from normal contraction pattern.

A 60-year-old woman swallowed 2.4 g verapamil in a retard form (Isoptin retard). Depsite intensive efforts she died 44 hours later in a coma due to circulatory collapse. In contrast to other reported cases of poisoning, the verapamil concentration in plasma continued to rise. This atypical course with continuing absorption of verapamil was due to small-intestinal deposits of the drug, found at autopsy.

Radionuclide ventriculography and cineangiography were performed in 62 patients with suspected coronary artery disease. Regional wall motility irregularities could be demonstrated in 97% of those patients who revealed an irregularity in the cineangiogram. Two small scars of the posterior myocardial wall escaped detection. The sensitivity of the radionuclide ventriculography was 97%, the specificity was 80%, 4 patients with normal cineangiography showed small irregularities in the radionuclide ventriculogram. 70 patients with infarction revealed wall motility irregularities in 90%, whereas perfusion defects could be detected by thallium scintigraphy in 66% (young and old infarctions).

Three cases of cardiac tamponade resulting from perforation of central venous catheters are presented. Purpose of the case reports and of the brief literature review is to derive criterions for X-ray examination of the catheter position since only routine roentgenographic control can prevent the occurrence of catheterization -- induced complications significantly. The catheter tip should not exceed the right sternoclavicular border by more than two centimeters. Roentgenograms of catheters inserted via the brachial venous route have to be obtained with the arm abducted 90 degrees. On adequately exposed Roentgen films the vertebral column should be clearly discernible within the cardiac shadow. Injection of radiopaque dye through the catheter helps to locate its tip and, in addition, confirms the diagnosis of catheter perforation and concomitant pericardial tamponade.

Extensive analysis of heart function by scintigraphy yields global parameters of ventricular volumes and their changes during the heart cycle (ejection fraction, enddiastolic and endsystolic volumes, velocity of contraction and relaxation). Additionally, information regarding localized disorders of wall motion may be obtained in a qualitative and quantitative manner by the parameters "phase" and "amplitude". These parameters can be computed from regional time-activity curves by Fourier analysis. The radionuclide ventriculogram at rest is suitable for the detection and follow-up of asynergies caused by acute and chronic infarction. In can also be used as a method of distinguishing between reversible and irreversible asynergy by therapeutical intervention (intervention ventriculography). Abnormalities of regional wall motion which develop during exercise may indicate hemodynamically relevant coronary artery stenoses.

In 17 patients with no demonstrable cardiac disease, analysis of the ventriculogram with respect to regional wall motion was performed. These normal patients formed the basis for establishing the normal ranges for 6 different methods of regional wall motion analysis (3 chord, 2 radial, 1 area). In each method, analysis of regional shortening showed a Gaussian distribution. The normal range of a segment was defined as the mean +/- 2 standard deviations, hence comprising 95% of normals. Comparing our 6 normal ranges with the ranges as initially described by their respective authors, the general shape of our curves was largely in agreement with the original curves. In detail, the amount of regional shortening showed some discrepancies, and only our normal range curve, calculated according to the method of Leighton, was highly comparable to the original range of the author, as well as to the one of Brower. Reasons for the discrepancies using other methods may be accounted for by different catheter conditions, different patient material and a subjective variation in delineating the contours of diastole and particularly of systole. It is concluded that normal ranges of a method for wall motion analysis cannot be applied directly from the literature without their prior verification under the special conditions of the angiographic technique and evaluation used.

Cyclic precordial variations of radiation after i.v. administration of 15 mCi 99mTc-HSA correspond to cyclic volume changes of ventricular volumes of the heart. The "gated blood pool procedure" yields reliable data. Extensive analysis of these data results in subsequent information concerning left ventricular myocardial behaviour: 1. extent of the regional myocardial contraction 2. homogeneity of the contraction 3. regional contraction velocity 4. regional relaxation velocity. Four parametric scans present the distribution of each one of those parameters within the heart. Gated blood pool data have been compared with angiographic data. Reliability of those parameters obtained by extensive analysis of the gated blood pool data could be proven.

In order to evaluate the usefulness of various quantitative methods for the assessment of regional left ventricular function, a total of 9 methods (3 hemiaxial models, 1 area model and 5 radial-axes models) were applied to the radiopaque ventriculograms of 16 patients with anterior wall infarction and 13 patients with posterior wall infarction. A series of 17 patients without clinical or angiographic evidence of heart disease were used as control group. While the hemiaxial methods were consistently found to be useful and reproducible, the area method did not provide significant additional information. The diagnostic accuracy was highest with the use of 2 radial-axes methods. The sensitivity and specificity data were 90% to 100% and 70% to 100%, respectively. The remaining 3 radial-axes methods were found to be of limited value since regional wall motion abnormalities were projected to the contralateral wall. Because of this methodological shortcoming these techniques may falsely indicate asynergy in areas with normal contraction patterns. This was reflected by high sensitivity but low specificity values. A feature of the latter 3 methods was the use of the gravity center of the end-systolic frame as the reference point. The position of this reference point is decisively influenced by the extent and localization of asynergy. These findings suggest that methods using the gravity center of the end-systolic frame should not be employed in the evaluation of regional left ventricular function. In general, some quantitative methods for assessing regional left ventricular function require a considerable expense for technical apparatus which is not always justified by the extent to which additional information is gained.

Radionuclide ventriculography (RNV) is now a well-established procedure for the noninvasive evaluation of cardiac hemodynamics, including the detection and quantification of valvular regurgitation. 46 patients undergoing aortic or mitral valve replacement were examined by RNV pre- and postoperatively. The specificity of RNV in the diagnosis of aortic or mitral incompetence was high. All cases of moderate to severe aortic regurgitation were identified. This, however, was not true for mitral incompetence. A significant overlap between the left atrium and the left ventricle in the LAO view is held responsible for this decrease in sensitivity. The quantification of aortic regurgitation and the assessment of left ventricular function by RNV appears to hold promise in the preoperative workup. This diagnostic approach yields important additional information, which may be essential in the appropriate timing of surgical intervention. Aortic valve replacement for incompetence as well as for stenosis was accompanied by a significant improvement in global left ventricular ejection fraction. No postoperative change in ejection fraction was found in cases of mitral incompetence, while a slight increase was observed following operative therapy for mitral stenosis. The radioisotope findings were correlated to the results obtained by cardiac catheterization and noninvasive techniques such as echocardiography. The place of RNV in the pre- and postoperative management of valvular heart disease is delineated in this paper. It is of special value in the evaluation of aortic incompetence and may be an important diagnostic adjunct in the approach to the patient with mitral valve disease or aortic stenosis.

The ejection fraction as determined by gated blood pool studies was compared with the ejection fraction as evaluated by the following conventional methods: 1) biplane cineangiography employing the Simpson rule. Correlation was r = 0.805 (n = 25); 2) the same patients using the area-length method (r = 0.88, n = 25); 3) monoplane cineangiography using the method of Greene et al. (5) (r = 0.86, n = 35). In 20 patients the maximal contraction velocity as evaluated by radionuclide ventriculography was compared with the mean systolic ejection rate. The observed correlation was weak (r = 0.62, n = 20); however, it should be noted that the radionuclide method determines the maximum contraction velocity whereas cinceangiography measures an average value over the whole systole.

Using local time activity curves parameters are calculated which depend on the local wall motion of the heart cavities. These functional parameters allow the determination of the contours of the heart cavities and the assessment of segmental wall motion disorders. The left ventricular ejection fraction has been calculated by enddiastolic and endsystolic counts using a method which takes into account background inhomogeneity.

Ejection fraction and end-diastolic volume (EDV) are valuable parameters of left ventricular function. They can be measured by radionuclide ventriculography. This study examines EDV in comparison to two other methods. A comparison was made between EDV derived from radionuclide ventriculography (RNV), standard contrast ventriculography and a 'hybrid' method, which calculates EDV from ejection fraction, heart rate and thermodilution cardiac output. Two groups of patients were examined: 54 patients with various cardiac diseases by contrast and radionuclide ventriculography (RNV); and 18 patients with typical angina were examined by RNV at rest and during exercise three times: Control without medication, 20 minutes after 10 mg metoprolol i.v. and again 10 minutes after the second exercise and 10 mg isosorbide dinitrate sublingually. In comparison to contrast ventriculography RNV overestimated EDV by 27%, and in comparison to the hybrid method by 11% with satisfactory linearity. The extent of error increases with decrease of ventricular volume. The assumption that the two short axes of the left ventricle are equally long causes one quarter of total error. Errors caused by the algorithm delineating the borders of the left ventricle cannot be measured. For clinical purposes radionuclide ventricular EDV seems to yield satisfactory results.

The clinical diagnosis of mitral-valve prolapse was made in ten patients on the basis of a late systolic murmur with or without a click. In each case the echocardiogram confirmed the diagnosis. In five it was further confirmed by angiocardiography. The late systolic murmur, with or without click, accentuated after nitroglycerin, is characteristic for mitral-valve prolapse.