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Objectives: To report the elevation of the 14-3-3 protein and the complete denervation of hand muscles in idiopathic acute transverse myelitis (IATM) of the cervical cord. Case description: In a 29-year-old woman with a 2-week history of neck pain and repeated attenuated flus, subacute quadriplegia, hypaesthesia of both arms, a T3 sensory level, and urinary dysfunction occurred. Based upon the clinical findings, the cervical MRIs, and an elevated 14-3-3 protein in the CSF, IATM C4–C7 was diagnosed. Ten, 17, 28 and 61 days after onset, nerve conduction studies revealed complete denervation of the right abductor pollicis brevis and abductor digiti minimi muscles but gradual improvement of the compound muscle action potential of the left abductor pollicis brevis muscle. F-waves of the right median nerve were absent. Tibial somatosensory evoked potentials showed a prolonged central conduction time. Transcranial magnetic stimulation evoked a response in the left but not the right abductor digiti minimi muscle. Conclusion: IATM may cause elevation of the 14-3-3 protein and loss of motor axons originating from affected anterior horn cells.

We report on a 25-year-old female patient who presented with recurrent cholestasis following liver transplantation due to primary sclerosing cholangitis. Abdominal ultrasound and computed tomography showed intrahepatic bile duct dilatation and stenosis of the common hepatic artery with flow acceleration and decreased resistance index. The patient developed a severe secondary sclerosing cholangitis (SSC) with biliary casts - despite interventional stent placement of the common hepatic artery - thus requiring retransplantation. After prolonged intensive care unit treatment the patient was discharged in a good general condition. This case report describes SSC as a rare cause for graft failure. In unclear cholestasis after liver transplantation SSC has to be considered as the underlying cause.

Anderson-Fabry disease is a glycosphingolipid storage disorder with an X-linked recessive inheritance. The alpha-galactosidase A deficiency leads to a progressive accumulation of globotriaosylceramide in the endothelium and tissue cells of various organs. The kidney, heart and brain are predominantly affected. Reports on endocrine function and fertility rates in patients with Anderson-Fabry disease are sparse. In the present study, we assessed ovarian, testicular and adrenal function in a cohort of patients with Anderson-Fabry disease. Plasma follicle-stimulating hormone, luteinizing hormone, prolactin, estradiol, testosterone, sex hormone-binding globulin, somatotropin, insulin-like growth factor-I and serum cortisol were measured in 13 patients (six female and seven male), currently observed in an outpatient clinic. The profile revealed an undisturbed hormonal function and a normal fertility rate in both male and female Anderson-Fabry patients when compared with the corresponding Austrian population.

The aim was the study was to evaluate the patency of coronary artery bypass grafts with the 3D Navigator and the Haste magnetic resonance imaging techniques.Thirty-four patients with 82 grafts (18 internal mammarian artery and 64 saphenous venous grafts) were examined at 1.5 T using a phased arrray body coil. A 2D T-2 weighted turbo spin echo sequence (Haste) and a 3D-angiography sequence in navigator technique were used. Reference method was the conventional coronary angiography that was performed within 7 days.With the HASTE sequence 54 of 56 patent and 12 of the 16 occluded grafts were recognized, the sensitivity and specificity was 96 and 75%. The distal anastomosis could be assessed in 28 of 76 cases. With the Haste sequence 54 of the 56 patent and 12 of the 14 occluded grafts were detected correctly. Eight patent and two occluded grafts were judged as not assessable. The sensitivity and specificity was 96 and 85%. Sixty-six percent (50/76) of the distal anastomosis were identified correctly. With both sequences none of the bypass stenosis could be detected.The patency of coronary bypass grafts can be evaluated noninvasively with a sensitivity of 96% and a specificity of 76%. No inference can be made with respect to the nature of bypass graft stenosis. Better results can be expected with the development of a blood pool contrast medium, an improvement of the spatial resolution and in the combination of flow measurements.

MR investigations using a breath-hold sequence at an open low-field MR had to be compared to chest X-rays in patients with a wide spectrum of cardio-thoracic pathologies.114 patients and three volunteers who actually received a chest X-ray due to different indications underwent triplanar breath-hold (17 - 20 s) True-FISP sequence using a 0.2 T low-field MR (Siemens Magnetom Open, TR/TE/alpha: 7.3/3.5/80 degrees, SD: 10 mm, Pixel: 2.81 x 1.41 mm) a mean of 5.1 (+/- 8.2) days later.Signal-to-noise ratio as basics for pattern recognition was 3.2 in nodule, 5.0 in infiltration, and 12.0 in effusion, and therefore True-FISP is usable for the detection of these findings. MRI demonstrated nodules (89 % vs. 57 %), infiltration (81 % vs. 71 %), pleural effusions (86 % vs. 75 %), pericardial effusions (100 % vs. 21 %) and pulmonary congestion (90 % vs. 80 %) clearly more frequently compared to chest X-ray.MRI of the lung has been implemented successfully at an open low-field MR system. Diagnostic safety and accuracy are at least comparable to those of chest X-ray. The lack of superimposition led to a major improvement in the detection of pericardial effusions and nodules, and an increase in identification of infiltration, pleural effusion, and pulmonary congestion.

Long-term follow-up after treatment with primary angioplasty compared to treatment with thrombolysis in patients with acute myocardial infarction (AMI) remains still to be determined. We therefore analyzed the data of the "Maximal Individual Therapy" in Acute Myocardial Infarction (MITRA-1) Registry. Follow-up data for a median of 17 months after discharge were available in 2090 out of 2195 (95%) AMI patients treated with thrombolysis, as well as 293 out of 312 patients (94%) treated with primary angioplasty. There were only small differences in patient characteristics between the two treatment groups. Compared to patients treated with thrombolysis, those treated with primary angioplasty had a higher prevalence of prior myocardial infarction (16.4% versus 12.2%, p = 0.04), longer prehospital delay: 10 minutes (130 minutes versus 120 minutes, p = 0.002), and a longer door-to-treatment time: 45 minutes (p0.001). Primary angioplasty patients were more likely to be treated with beta-blockers (primary angioplasty 79.8% versus thrombolysis 66.2%, p0.001) or statins (24.5% versus 16.5%, p0.001). There was no difference between the treatment groups for total mortality (p = 0.90) nor for the combined endpoint of death or re-infarction (p = 0.85). However, the combined endpoint of death, re-infarction or percutaneous coronary intervention or coronary bypass surgery was significantly lower in the primary angioplasty group (primary angioplasty 25.6% versus thrombolysis 32.3%, univariate odds ratio 0.72, 95% CI: 0.55-0.95, p = 0.02). This result was confirmed by multivariate analysis after adjusting for confounding parameters (multivariate odds ratio: 0.62, 95% CI: 0.42-0.91). The beneficial effect of primary angioplasty compared to thrombolysis achieved during the hospital stay after an AMI is maintained during a 17 month follow-up. AMI patients treated with thrombolysis were more likely to be treated with either percutaneous coronary intervention or coronary bypass surgery after discharge.

To evaluate breath-hold MR techniques for morphologic and functional assessment of vascular abnormalities of the pulmonary vasculature.13 patients aged 11 to 60 years with different vascular abnormalities of the pulmonary vasculature (5 patients with 16 arteriovenous malformations, 8 patients with partial anomalous pulmonary venous return) underwent MR imaging at 1.5 T. For morphological assessment, a contrast-enhanced 3D MR angiography (ce-MRA) was performed after a timing run. Segmented cine- and velocity-encoded GRE sequences were used for delineation of associated cardiac septal defects and for determination of systemic left-to-right or intrapulmonary shunt volumes. Selective intra arterial digital subtraction angiography, cardiac catheterization, and the intraoperative situs served as reference standards.Ce-MRA allowed for detection of all vascular abnormalities and for anatomic characterization of 14/16 arteriovenous malformations. Flow measurements in the feeding arteries allowed for determination of intrapulmonary shunt volumes in 4/5 patients. Flow measurements performed in the pulmonary arteries and the ascending aorta enabled determination of systemic left-to-right shunting in patients with anomalous pulmonary venous return. Cine-sequences clearly depicted associated cardiac septal defects.Breath-hold MR techniques allow for morphological and functional characterization of vascular anomalies of the pulmonary vasculature. Therefore, they are the non-invasive method of choice for planning further treatment.

Comparison between two semiquantitative methods and a quantitative evaluation of myocardial blood flow (MBF) for assessment of myocardial perfusion reserve (MPR) in patients with CAD.9 patients with coronary stenoses50 % were examined with an ECG-gated Saturation Recovery Turbo FLASH sequence by using Gd-DTPA as contrast agent (CA). The entive measurements were performed both during rest and hyperemia induced by adenosine. The up-slopes of the signal-time S(t) curves in the myocardium and left ventricular (LV) cavity were evaluated by a linear fit. MPR was calculated from the original up-slopes of the myocardial S(t) curves and from the up-slopes, which were normalized to the up-slopes of the LV S(t) curves, respectively. For quantification of MBF values, the mathematical model MMID 4 was used and MPR was evaluated from the MBF values.With all tested methods, MPR was reduced in myocardial regions subtended by arteries with stenoses/= 70 % compared with remote regions. With MMID 4 and the normalized up-slope method, differences between severe ischemic and remote regions were statistically significant.The up-slope method with normalization and quantification with MMID 4 are more sensitive methods to differentiate between remote and ischemic myocardium than the up-slope method without normalization.

We sought to determine the effectiveness of primary angioplasty compared with thrombolysis in clinical practice.In clinical practice, primary angioplasty for the treatment of acute myocardial infarction (AMI) has not yet been proven more effective than intravenous thrombolysis, nor have subgroups of patients been identified who would perhaps benefit from primary angioplasty.The pooled data of two AMI registries--the Maximal Individual TheRapy in Acute myocardial infarction (MITRA) study and the Myocardial Infarction Registry (MIR)--were analyzed. A total of 9,906 lytic-eligible patients with AMI, with a pre-hospital delay ofor =12 h, were treated with either primary angioplasty (n = 1,327) or thrombolysis (n = 8,579).Despite differences in the patients' characteristics and concomitant diseases between the two groups, the prevalence of adverse risk factors was balanced. Univariate analysis of hospital mortality showed a more favorable course for patients treated with primary angioplasty: 6.4% versus 11.3% (odds ratio [OR] 0.54, 95% confidence interval [CI] 0.43 to 0.67). This was confirmed by logistic regression analysis (multivariate OR 0.58, 95% CI 0.44 to 0.77). Primary angioplasty was associated with a lower mortality in all subgroups analyzed. We observed a significant correlation between mortality and absolute risk reduction (r = 0.82, p0.0001) in the different subgroups: as mortality increased, there was an increase in absolute benefit of primary angioplasty compared with thrombolysis.These large registry data showed the effect of primary angioplasty to be more favorable than thrombolysis for the treatment of patients with AMI in clinical practice. This effect was not restricted to special subgroups of patients. As mortality increased, the absolute benefit of primary angioplasty also increased.

We describe the baseline characteristics and clinical course of patients who had an acute myocardial infarction (AMI) during their hospital stay.In comparison with patients who had an AMI outside of the hospital (prehospital AMI), the data on patients who had an AMI in the hospital are poorly described.Patients with an in-hospital AMI were prospectively registered in the Southwest German Maximal Individual TheRapy in Acute myocardial infarction (MITRA) study and compared with patients with prehospital AMI.Of 5,888 patients with AMI, 403 patients (6.8%) had an in-hospital AMI. These patients were older, more often male and sicker as compared with the patients with a prehospital AMI. They also showed a higher prevalence of concomitant diseases, such as arterial hypertension, diabetes mellitus, renal insufficiency and contraindications for thrombolysis. There was no significant difference regarding the use of reperfusion therapy, either thrombolysis (in-hospital AMI 44.2% vs. prehospital AMI 49.1%; odds ratio [OR] 0.86, 95% confidence interval [CI] 0.70 to 1.05) or primary angioplasty (9.9% vs. 8.2%; OR 1.23, 95% CI 0.88 to 1.73), or a combination of both, between the two groups. The interval from symptom onset to the start of treatment in patients receiving reperfusion therapy was 55 min for patients with an in-hospital AMI versus 180 min for patients with a prehospital AMI (p = 0.001). In-hospital death occurred in 110 (27.3%) of 403 patients with an in-hospital versus 762 (13.9%) of 5,485 patients with a prehospital AMI (OR 2.33, 95% CI 1.85 to 2.94). This was confirmed by logistic regression analysis after adjusting for other confounding variables (OR 1.67, 95% CI 1.23 to 2.24).In-hospital AMI occurred in 6.8% of patients. Time to intervention was shorter; however, the use of reperfusion therapy for in-hospital AMI was not different from that for prehospital AMI. In particular, primary angioplasty seems to be underused in these patients. This, as well as the selection of patients, may result in the high hospital mortality rate of 27.3%.

To evaluate accuracy of velocity encoded cine MR imaging for determination of blood flow in coronary arteries and coronary bypass grafts.12 patients with 22 coronary bypass grafts underwent intraoperative flow quantification using the transit time ultrasound method. These values were compared to postoperative MR phase shift measurements. Flow measurements were performed preoperatively in 28 coronary arteries of 20 patients. For flow measurement, we used a velocity-encoded k-space segmented gradient echo sequence with a temporal resolution of 110 or 125 ms, respectively. 6-8 pase shift images could be acquired during one cardiac cycle.There was a significant correlation between intraoperative and flow measurements using velocity-encoded MR imaging (r = 0.74, p0.0001, t-test). Flow volumes determined by MR imaging were systematically larger than those determined by the transit time ultrasound method. Mean flow in coronary arteries was reduced in severely stenosed vessels (70%) compared to normal vessels. Intra- and interobserver variability were 10.5 and 15% (coronary bypass grafts), and 12.3 and 15.8% (coronary arteries), respectively.Velocity-encoded MR imaging enables determination of flow in coronary artery bypass grafts and coronary arteries. Future developments should aim at the improvement of spatial and temporal resolution of the method.

The aim of the study was to evaluate the patency of coronary artery bypass grafts (CABG) with the 2D and 3D magnetic resonance (MR) imaging techniques. 29 patients with 74 bypass grafts and a total of 91 distal anastomoses were studied on a 1.5 Tesla scanner using a phased array body coil. A 2D T-2 weighted breathhold turbo spin echo sequence (Haste) and a 3D breath hold contrast enhanced MR angiography sequence (Fisp-3-D) were performed. With the Haste and Fisp-3-D sequences 55 of the 58 patent and 15 of the 16 occluded grafts were recognized; the sensitivity and specificity were 95% and 94%, respectively. With the Haste sequence 74% (47/63) and with the Fisp-3-D sequence 64% (40/63) of the distal anastomoses were seen in good image quality. Only 3 of 8 significant grafts stenoses were detected. The patency of CABGs can be evaluated non-invasively with the Haste and the Fisp-3-D angiography sequences. Better results can be expected with the development of a blood-pool contrast medium and the combination of MR flow measurements with imaging techniques.

Conventional echocardiographic methods of measuring left ventricular mass (LVM) are limited by assumptions of ventricular geometry and image plane positioning. Three-dimensional (3D) echocardiography offers a promising new approach for more accurate determination of LVM. This study was performed to compare LVM measurement by one- (1D), two- (2D), and 3D echocardiography with magnetic resonance imaging (MRI) in patients (pts) with dilated cardiomyopathy (DCM). 36 pts (age 18-74) with DCM underwent imaging by conventional 1D and 2D echocardiography as well as transthoracic 3D echocardiographic data acquisition. Also, pts were imaged with cardiac MRI. Due to echocardiographic and MRI quality and because of exclusion criteria's for MRI, it was not possible to accomplish each LVM determination method for each patient. LVM was determined by Devereux and area-length algorithm for the conventional echocardiography. 3D echocardiographic data was calculated after manual delineation of endo- and epicardial boundaries--slice by slice (5 mm)--in 3 perpendicular cut planes. LVM was determined by multiplying the myocardial volume by the specific density of the myocardium. To determine LVM in MRI, the even summation of slices method for myocardial volume measurement was used defined by the endo- and epicardium in short axis images. There was no significant correlation (r = 0.42) for measuring LVM between 1D echocardiography and MRI in pts with DCM. A significant correlation was obtained between 2D (r = 0.64, p0.01) echocardiography and MRI as well between 3D (r = 0.78, p0.01) and MRI in determination of LVM. Compared with 1D and 2D echocardiography, the 3D analysis achieved a significantly higher agreement with the results of the MRI (1D: 399.2 g, 2D: 285.9 g, 3D: 172.6 g versus MRI: 199.1 g). Interobserver variability was 5.1% for measuring LVM by 3D echocardiography (1D: 11.2%, 2D: 9.1%). In conclusion, in pts with DCM the determination of LVM was incompletely characterized by 1D and 2D echocardiography compared with results of MRI. The best correlation and high agreement for determination of LVM was obtained with 3D echocardiography compared with MRI.

Concern exists regarding the results of primary angioplasty for acute myocardial infarction when the procedure is performed during night hours.Between June 1994 and January 1997, 491 patients with acute myocardial infarction who underwent primary angioplasty procedures were consecutive registered in the Maximal Individual Therapy in Acute Myocardial Infarction (MITRA) study. Three hundred seventy-eight patients (77%) were treated during the day and 113 (23%) at night. Baseline characteristics showed no major differences between the 2 groups. Prehospital delay time was 60 minutes shorter during the night (median value 180 minutes for day, 120 minutes for night, P =.005), and in-hospital time to treatment was 9 minutes longer (median value 85 minutes day, 94 minutes night, P =.037). Patients treated during the night more often received angiotensin-converting enzyme blockers (61.4% day, 76.1% night, P =.004) and the so-called optimal adjunctive therapy (54% day, 64.6% night, P =.045). There were no differences concerning clinical events between the 2 groups. Hospital mortality was 8.7% during the day and 5.3% during the night (univariate analysis P =.238; logistic regression P =.653).In a clinical setting, primary angioplasty for acute myocardial infarction can be performed safely during the night with a clinically insignificant prolongation of in-hospital time to reperfusion compared with practice during the day.

The aim of the study was to compare the mean and maximum flow and the flow pattern of coronary vein grafts (SVG) supplying target vessels of the inferior and lateral wall with internal mammary (IMA) grafts to the left anterior descending artery (LAD). In 21 patients 25 bypass grafts (13/25 SVG, 12/25 IMA) were investigated. Using the transit time ultrasound method, flow was measured every 5 ms and the flow data of 60 s were acquired. The flow pattern showed significant differences between both graft types during their cycle. IMA grafts showed only one peak occurring after 22.1+/-12.3% and the second after 63.4+/-15.5% of their cycle. The mean flow was not different in both graft types (IMA: 45.3+/-27.0 ml/min and SVG: 41.8+/-26.7 ml/min, p = n. s.) as it was the case for the maximum flow (IMS: 98. 4+/-45.2 ml/min and SVG: 75.7+/-55.4 ml/min, p = n. s.). In conclusion, there is a different flow pattern for both graft types concerning the number and the occurrence of flow-peaks in the bypass cycle. The mean and peak flow showed no significant difference.

Two third of patients with acute myocardial infarction are admitted to hospitals without cardiac catheterization facilities. Whether a postinfarction patient will undergo cardiac catheterization or not is more often decided by general physicians than by cardiologists. The purpose of this presentation is to investigate the determinants for decision making to use cardiac catheterization in patients after myocardial infarction.MITRA is a prospective, multicenter registry, which enrolls all consecutive patients with acute Q wave infarction admitted to 54 hospitals in Southwestern Germany. During the pilot phase 949 consecutive survivors of acute myocardial infarction were included, and inhospital outcome as well as therapeutic strategies were registered.Only half of the patients underwent cardiac catheterization regardless of whether a catheterization facility was available or not. In 63% of the patients under 65 years of age coronary angiography was performed; however, every fourth patient with age above 70 years was transferred to an invasive therapeutic strategy. The percentage of male patients was twice a high in the invasive group, whereas patients with prior infarction, clinical signs of congestive heart failure, patients with moderately or severely impaired left ventricular function, and finally patients with a prehospital delay of more than 4 hours were more frequent in the conservative group. The following three parameters were calculated to be independent determinants of an invasive strategy: pathological stress ECG (OR: 2.8; CI: 1.80-4.60), patients70 years without stress ECG (OR: 2.18; CI: 1.5-3.18), and male gender (OR: 1.45: CI: 1.10-2.00). Independent factors of a conservative strategy were primary PTCA (OR: 0.2; CI: 0.09-0.46), prehospital delay4 hours (OR: 0.71; CI: 0.51-0.97), and the combination of age70 years and the absence of a stress ECG (OR: 0.78; CI: 0.55-1.11).In Germany, patients with acute myocardial infarction are less likely to undergo cardiac catheterization compared to patients in other Western countries (e.g. , the United States). Despite recommended guidelines, invasive strategies are more frequent in low risk groups (younger patients, male gender) than in postinfarction patients at high risk (severely impaired left ventricular function, clinical signs of congestive heart failure, the elderly).

The study was performed to determine the morphological characteristics of normal and diseased pulmonary arteries by ultrasound (intravascular ultrasound, IVUS) and histology. Forty-nine cadaver segments of pulmonary arteries from 16 postmortem patients were imaged in vitro by IVUS and compared to matched histological sections. The pulmonary vasculature of 11 patients with pulmonary hypertension was investigated in vivo by IVUS. In the in vitro study, 34 of a total of 143 histological sections of the segmental pulmonary arteries showed fibrotic wall components; the remaining 109 sections had regular components. Imaged by IVUS, the wall of the regular and fibrotic arteries revealed a single layer histologically, representing the intima, media, adventitia and connective tissue. Adjacent lung tissue could be detected by IVUS and was confirmed by the histological section. In three patients with a history of chronic embolic pulmonary hypertension, IVUS revealed thrombi or a double vessel wall layer. Histologically, the material extracted after pulmonary thromboendarterectomy in two patients showed wall-adherent thrombus features of early organization. In all other patients only a single wall layer was seen. The vessel walls (intima, media, adventitia and connective tissue) of regular and slightly fibrosed pulmonary arteries show only a single layer. Wall-adherent organized thrombi in chronic embolic pulmonary hypertension can be detected by IVUS as a second inner vessel layer. Thus IVUS may represent an additional tool for detecting chronic embolic pulmonary hypertension when the results of pulmonary angiography or computed tomography are not definite.

There have been some prospective randomized studies which compared primary angioplasty with intravenous thrombolysis in patients with an acute myocardial infarction (AMI). However, a substantial number of patients with AMI who would not have been included in those trials are treated with one of these two therapeutic options. To describe the proportions, characteristics, and outcome of these patients treated with primary angioplasty or thrombolysis we analyzed the data of the prospective "Maximal Individual Optimized Therapy for Acute Myocardial Infarction" (MITRA) trial. Out of 3308 patients treated with primary angioplasty or thrombolysis, 737 (22.3%) belonged to one of the following groups, not included in current randomized trials: Left bundle branch block, non-diagnostic first ECG, pre-hospital delay12 hours or unknown pre-hospital delay. Primary angioplasty was performed in 158/737 (21.4%) and thrombolysis received 579/737 (78.6%) of the patients. There were only minor differences regarding patients' characteristics and concomitant diseases between the two groups. Patients treated with primary angioplasty were 3 years younger (62 years median versus 65 years median (p0.036). They also more often showed overt heart failure at admission compared to patients treated with thrombolysis (primary angioplasty: 3.2% versus thrombolysis: 8.9%, OR = 0.34, 95% CI: 0.13-0.86). In-hospital time to intervention was 1 1/2 hours longer in patients treated with primary angioplasty (156 minutes median versus 47 minutes median, p = 0.001). beta-blockers were more often used with primary angioplasty compared to thrombolysis (70.31% versus 55.9%; OR = 1.87, 95% CI: 1.28-2.72), as well as ACE inhibitors (62% versus 49.9%; OR = 1.64, 95% CI: 1.14-2.35). Hospital mortality (8.2% versus 16.4%; OR = 0.46, 95% CI: 0.25-0.84), as well as a combined endpoint of death, reinfarction, postinfarction angina, advanced heart failure, and stroke (24.1% versus 42.3%, OR = 0.43, 95% CI: 0.29-0.64) were lower in patients treated with primary angioplasty compared to those treated with thrombolysis. Logistic regression analysis showed primary angioplasty to be independently associated with a lower rate of the combined endpoint (OR = 0.73, 95% CI: 0.59-0.91), after adjusting for confounding parameters. All subgroups showed a more favorable outcome in patients treated with primary angioplasty. In clinical practice, patients with AMI, not included in current randomized trials comparing primary angioplasty with thrombolysis, account for 22% of all patients with AMI treated with one of those two therapies. Primary angioplasty seems to be associated with a lower event rate compared to thrombolysis in these patients. This has to be confirmed by a prospective randomized trial.

To evaluate the patency of coronary artery bypass grafts with a 2D T2-weighted breath-hold turbo-spin-echo sequence.38 patients with 97 grafts (19 internal mammary artery and 78 saphenous vein grafts) and a total of 120 distal anastomoses were studied at 1.5 Tesla in supine position using a phased array body coil. An ECG gated 2D T2-weighted breath-hold turbo-spin-echo sequence (HASTE) was performed. Reference method was selective coronary angiography. The image material was evaluated independently by two radiologists (observer one, a radiological fellow and the second a staff radiologist).Observer 1 reached a sensitivity of 96% (72/75) and a specificity of 91% (20/22), positive predictive value was 97%, negative predictive value 87%. 79 of the 97 (81%) patent distal anastomoses were correctly identified. Observer 2 achieved a sensitivity of 92% (69/75) and a specificity of 82% (18/22), positive and negative predictive values were 95% and 75% respectively. From 97 patent distal anastomoses 59 (61%) were recognized. The interobserver agreement was good (Cohen's kappa = 68%, p-value [McNemar] = 58%).Using the HASTE sequence a reliable assessment of graft patency is possible. This sequence is a helpful tool for planning flow measurements and 3D MR angiography.

The benefit of primary angioplasty in patients with acute myocardial infarction (AMI) and contraindications for thrombolysis compared to a conservative regimen is still unclear. Out of 5,869 patients with AMI registered by the MITRA trial, 337 (5.7%) patients had at least one strong contraindication for thrombolytic therapy. Out of these 337 patients 46 (13.6%) were treated with primary angioplasty and 276 (86.4%) were treated conservatively. Patients treated conservatively were older (70 years vs. 60 years; P=0.001), had a higher rate of a history with chronic heart failure (14.8% vs. 4.4%; P=0.053), a higher heart rate at admission (86 beats/min vs. 74 beats/min; P=0.001), and a higher prevalence of diabetes mellitus (27.1% vs. 12.8%; P=0.056). Patients treated with primary angioplasty received more often aspirin (91.3% vs. 74.6%; P=0.012), beta-blockers (60.9% vs. 46.1%; P = 0.062), angiotensin converting enzyme (ACE) inhibitors (71.7% vs. 44%; P=0.001), and the so-called optimal adjunctive medication (54.4% vs. 32.3%; P=0.004). Hospital mortality was significantly lower in patients who received primary angioplasty (univariate: 2.2% vs. 24.7%; P=0.001; multivariate: OR=0.46; P=0.0230). In patients with AMI and contraindications for thrombolytic therapy, primary angioplasty was associated with a significantly lower mortality compared to conservative treatment. Therefore, hospitals without the facilities to perform primary angioplasty should try to refer such patients to centers with the facilities for such a service, if this is possible in an acceptable time.

Patients with acute myocardial infarction included in randomized trials comparing primary percutaneous transluminal coronary angioplasty (pPTCA) with thrombolysis represent a special subgroup of patients with a low event rate. Patients excluded from these trials represent a variety of different subgroups, with different patient characteristics and possibly different clinical event rates. Primary PTCA was performed in 491 consecutive patients with acute myocardial infarction in the prospective multicenter observational Maximal Individual Therapy in Acute Myocardial Infarction trial. They were divided into the following groups: group I, patients fulfilling the inclusion criteria of the randomized trials (284 of 491, 58%); group II, patients not included in these trials (207 of 491, 42%). Of group II the following subgroups were defined: group IIa, patients in cardiogenic shock (20 of 491, 4.1%); group IIb, patients with a left bundle branch block (12 of 491, 2,4%); group IIc, patients with contraindications for thrombolysis (42 of 491, 8.6%); group IId, patients with a nondiagnostic first electrocardiogram (95 of 491, 19.3%); group IIe, patients with a prehospital delay of12 hours (72 of 491, 14.7%); group IIf, patients with an unknown prehospital delay (30 of 491, 6.1%). A comparison of groups I and II showed similar baseline characteristics but a higher clinical event rate during hospitalization was seen in group II: combined end point of death, reinfarction, heart failure equal to or greater than NYHA class III, any stroke or postinfarction angina, 26.6% versus 18%; p = 0.022. Hospital deaths were nearly twice as high in these patients, without reaching statistical significance (10.6% vs 6%; p = 0.06). The subgroups of group II showed quite different rates of clinical events. In-hospital death rates were: IIa, 40% (8 of 20); IIb, 8% (1 of 12); IIc, 12% (5 of 42); IId, 5% (5 of 95); IIe, 6% (4 of 72); and IIf, 13% (4 of 30). The incidence of the combined end point was 60% (12 of 20) in IIa, 33% (4 of 12) in IIb, 29% (12 of 42) in IIc, 16% (15 of 95) in IId, 26% (19 of 72) in IIe, and 33% (10 of 30) in IIf. Thus, in clinical practice, about half of the patients treated with pPTCA would not have been included in randomized trials comparing pPTCA with thrombolysis. These patients represent a population at higher risk for in hospital clinical events. However, they do represent very different nonhomogenous subgroups with different clinical event rates.

Little is known about the differences in patients with acute myocardial infarction (AMI) treated with primary angioplasty or intravenous thrombolysis in clinical practice.In all, 5,906 patients with AMI were registered by the Maximal Individual Therapy in Acute Myocardial Infarction (MITRA) study. Of these, 491 (8.3%) patients were treated with primary angioplasty and 2,817 (47.7%) with intravenous thrombolysis.There were only minor differences in baseline characteristics between the two groups. Prehospital delay time (median) was longer in the angioplasty group than in the thrombolysis group (161 vs. 120, p = 0.001), as was door-to-treatment time (88 vs. 30 min; p = 0.001). Patients treated with primary angioplasty more often had contraindications for thrombolytic therapy (12.9 vs. 6%, p = 0.001) and received beta blockers (65 vs. 58.1%, p = 0.004), heparin (98.2 vs. 91.6%, p = 0.001), angiotensin-converting enzyme (ACE) inhibitors (64.8 vs. 50%, p = 0.001) and "optimal" concomitant medication (56.4 vs. 42.9%, p = 0.001) more often. Univariate analysis showed a significant lower incidence of heart failure (5.3 vs. 16.5%, p = 0.001), postinfarct angina (7.3 vs. 16.4%, p = 0.001), in-hospital death (7.9 vs. 11.7%, p = 0.015) and the combined end point (21.6 vs. 40.3%, p = 0.001) in these patients. Stepwise logistic regression analysis revealed optimal concomitant medication [odds ratio (OR) = 0.94, 95% confidence interval (CI): 0.89-0.98) and the type of revascularization (OR = 0.65, 95% CI: 0.58-0.73) to be associated with a significant reduction in the incidence of the combined end point. Similar results were obtained in all predefined subgroups.In clinical practice, patients treated with primary angioplasty are more often treated with beta blockers and ACE inhibitors than patients treated with intravenous thrombolysis. Thus, the selection of patients and the type of revascularization contributes to the reduction in mortality, overt heart failure, and postinfarct angina in these patients.

Comparison of a breath-hold, velocity-encoded, phase-difference magnetic resonance (MR) sequence for intracardiac shunt flow measurement with the invasive shunt size determination by oximetry.10 patients with different cardiac shunts (6 ASD/3 VSD/1 PDA) and four healthy individuals were investigated using a 1.5 Tesla Siemens Vision system. For flow measurements a breath-hold, velocity-encoded, phase-difference magnetic resonance (MR) sequence was used ('through plane', FLASH 2D-sequence, TR/TE 110/5 ms, 'velocity encoding' 250 cm/s). Mean flow (ml/R-R interval) in the ascending aorta, the pulmonary trunk, and the right and left pulmonary arteries was determined. The ratio of the mean flow in the pulmonary circulation (Qp: sum of the mean flows in the right and left pulmonary arteries) and the systemic circulation (Qs: mean flow in the proximal aorta) was compared with the Qp/Qs ratios determined by the invasive oxymetric technique. Oximetry was performed within 24 hours after MR imaging.In the 4 healthy individuals MR flow measurement yielded a Qp/Qs ratio of 0.96 +/- 0.15. In the 10 patients with the various shunt defects, the non-invasive shunt determination by MR gave a Qp/Qs ratio of 2.09 +/- 0.67. The percentage of the calculated shunt sizes was 47.05 +/- 17.45%. In the comparison with the results determined by the invasive oxymetric technique, the MR data showed a strong correlation of r = 0.87.Breath-hold, velocity-encoded, phase-difference MR-technique enables a reliable quantification of cardiac shunts within a short acquisition time.

The aim of the study was to evaluate the effect of a conventional pressure dressing on arterial and venous blood flow of the legs after cardiac catheterization.Duplexsonographic measurements were performed of both legs in 100 consecutive patients before catheterization and with a pressure dressing after the procedure. The pressure dressing was applied by means of a pressure pad on the punctured leg, so that the ankle-arm-index (blood pressure at the leg/blood pressure at the arm) was not influenced. Arterial and venous blood flow of the superficial femoral artery and vein were registered. We evaluated both legs by means of duplex sonography to detect arterial or venous complications after cardiac catheterization. Statistical evaluation was performed using the 1-sample Wilcoxon test.There was a significant reduction of venous blood flow in the punctured leg from a mean of 119 ml/min before puncture to 84 ml/min during pressure dressing (29% flow reduction, p0.01), and a reduction of arterial blood flow from a mean of 132 ml/min before puncture to 84 ml/min during pressure dressing (36% flow reduction, p0.01). In the contralateral leg, venous blood flow was reduced from about 118 ml/min to 96 ml/min during pressure dressing (19% flow reduction, p0.01), and arterial blood flow was reduced from about 129 ml/min to 93 ml/min during pressure dressing (28% flow reduction, p0.01). There were no venous complications, 5 patients suffered false aneurysm (5%), and one patient had an arteriovenous fistula (1%).A conventional pressure dressing caused a significant reduction of arterial as well as venous blood flow of both the punctured leg and the contralateral leg. This is of clinical relevance especially in patients with known peripheral arterial disease or patients at risk for deep venous thrombosis.

Evaluation of clinical relevance of coronary calcifications detected by helical CT. Evaluation of congruence with fluoroscopy (FS) and coronary angiography. Comparison with studies reporting on application of ultrafast computed tomography.40 patients underwent helical CT (2 mm slice thickness, table-feed 3 mm/s). Coronary angiography and FS were performed in usual technique. Stenosis and calcifications were evaluated semiquantitatively.28 of 28 stenosesor = 75% were detected via helical CT by evaluation of calcification (FS: 19). One non-detected solitary stenosis was calculated as 40%. FS did not detect 4 cases with 2-vessel and 3-vessel disease each one case with 1-vessel disease, and one case with a main stem stenosis. Sensitivity of helical CT was 97% (FS: 66%). For the evaluation of stenosis III degree (or = 75%), sensitivity was 100% (FS: 58%), specificity was 77% (FS: 48%).Helical CT is more sensitive for haemodynamically relevant stenoses than FS. Helical CT is suitable as a substantial non-invasive diagnostic procedure in coronary heart disease. In certain cases, e.g. if the patient suffers from additional risks, helical CT should be done prior to coronary angiography. Coronary calcifications found incidentally in symptomatic patients at chest CT warrant further cardiological investigation.

The prognostic value of thrombolytics, aspirin, beta-blockers and ACE-inhibitors has been well documented in large clinical trials, but the application of these drugs in clinical practice is not known. MITRA is a multicenter study of 54 hospitals in a defined region in southwest Germany. The aim is to document actual clinical practice (pilot phase) and to establish an individually optimised prognostic therapy for acute myocardial infarction, considering only the absolute contraindications for each drug. In the pilot phase, 1303 consecutive patients with acute transmural myocardial infarction were enrolled. The median age was 66 years, the prehospital time was 2.7 hours. 47% had an anterior infarction. In the subgroup of patients without absolute contraindications, only 53.4% were treated with thrombolytics, 87.6% with aspirin, 37.1% with beta-blocker, and 17.4% with ACE-inhibitor. Out of these, patients were classified as "optimally treated" if they received thrombolysis, aspirin as well as beta-blocker. Patients were also included if any of these medications was withheld in the presence of absolute contraindications. Treatment was defined suboptimal, if the patients did not receive any of these three medications despite the absence of absolute contraindications. Only 29% (n = 383) received an optimal post-infarction therapy and 71% (n = 775) a suboptimal treatment. The univariate analysis revealed 10 variables influencing optimal therapy. In this subgroup patients were younger, they more often had clear ECG-findings or left bundle branch block, an anterior infarction, acute cardiac failure, AV-block, bradycardia, recent trauma or surgery (less then 2 weeks) and a severe chronic obstructive lung disease. The prehospital time was more often available. Early mortality after 2 days was 5.0% versus 9.3% in the suboptimal treated patients (OR: 0.5, CI: 0.30-0.86) the total inhospital mortality was 10.9% in the optimal versus 17.7% in the suboptimal group (OR: 0.6, CI: 0.38-0.84). In a multivariate analysis the parameter "optimal treatment" was found to be an independent predictor of the early (OR = 0.4; CI: 0.20-0.69) and the inhospital mortality (OR = 0.4; CI: 0.25-0.64). The following in-hospital events occurred: stroke 2.8%, reinfarction 12.9%, cardiac failure 21.5%, cardiogenic shock 10.4% and in-hospital mortality 18.1% (2-days mortality 9.5%). Pharmacological therapy for acute myocardial infarction is inconsistent with the recommendations suggested in recent clinical trials and needs to be individually optimised. Optimal treatment is an independent predictor of early and inhospital mortality.

VDD stimulation is an alternative to DDD pacing due to the possibility of p-wave synchronous ventricular pacing without the need of an atrial lead. Mainly, the reliability of the system depends on the atrial sensing. In 22 patients the intraoperative atrial amplitude and, postoperatively, the atrial sensing threshold were measured. Furthermore, the stability of the atrial sensing threshold during follow-up was proven. The mean atrial amplitude was intraoperative by 2.4 +/- 1.2 (1.0-6.8) mV. The measurement of the atrial sensing threshold in the first 5 postoperative days showed a mean value of 1.02 +/- 0.49 (0.3-1.6) mV. The measurements of the mean atrial sensing threshold after 30, 90, and 180 days showed no statistical differences. Intraindividual variance was shown in 17/20 patients (0.55 +/- 0,42; 0.15-1.05 mV). Seventeen of the 22 patients were programmed with an atrial sensing threshold of 0.3 mV. In five patients the atrial sensing threshold was programmed at less than 0.3 mV in order to reach a twofold atrial sensitivity. Despite a programmed atrial sensitivity of 0.1 mV and isometric conditions no atrial oversensing occurred. The postoperative atrial sensing thresholds of the VDD system investigated were significantly lower than the intraoperatively measured atrial amplitudes. The mean atrial sensing threshold did not change during the follow-up period. The variation which did occur was within individual variation at different return visits.

Preliminary clinical experience with early amniocentesis is reported. Fifty-two amniocenteses were performed before the end of the 14th week following the last menstrual period. Cytogenetic and biochemical analyses (AFP, AChE) were performed. Increasing experience with amniotic fluid samples containing small-cell populations and the use of combined culture media improved the poor initial results to a 100% level, thus enabling the use of this technique for diagnostic purposes. The sampling technique and the post-procedural evolution of twelve amniocenteses in pregnant women, whose pregnancy is to be continued, are presented. The possibility of performing amniocentesis in early pregnancy is discussed with reference to anatomical aspects (amniotic and chorionic cavity).

Elevated Alpha-Fetoprotein (AFP) values in the amniotic fluid are most frequently associated with neural occlusive disturbances or, in rare cases, with other external malformations of the foetus. In this article, the authors report on two cases where the elevated AFP had not been due to fetal malformations. In the first case, the cause was identified as foetal proteinuria, probably in the sense of an autosomal-recessive hereditary congenital nephrosis, whereas in the second case the phenomenon was possibly due to a "foetal distress" syndrome. Attention is drawn to the importance of elevated AFP levels. The possibilities of further prenatal differential diagnosis are discussed, such as ultrasound, determination of acetyl cholinesterase AChE) activity and assessment of the amniotic fluid cells.

The results of 1,000 transabdominal amniocenteses between 15 and 20 weeks gestation are reported. The method is described. The bio-chemical and cytogenetic results are reported. - Amniocentesis in the first trimester is not a routine investigation since fetal and maternal risks are associated with this procedure. The risk of abortion following amniocentesis was lowered from 6/1000 to 2/500 by improvement of the technique under ultra-sound control. The worst maternal complication observed was a septic abortion one day after amniocentesis. 96% of all cyto-genetic examinations showed normal karotypes. The largest group at risk were mothers over 35 years of age. In this group chromosome anomalies were found in 17 cases. All neural tube defects were found by determination of the alpha-fetoprotein in the amniotic fluid. 26 terminations of pregnancy for fetal indications were carried out. Two patients refused therapeutic abortions despite trisomy 21 for ethical reasons. One patient continues her pregnancy with a 47 XYZ pregnancy.