Search

Objective Doppler-derived flow velocity measured by transesophageal echocardiography (TEE) may overestimate pulmonary vein stenosis. We hypothesized that combining peak velocity with a stenotic flow pattern improves diagnosis compared with magnetic resonance imaging (MRI). Methods TEE and MRI were performed in 44 patients 19 ± 11 months after radiofrequency catheter ablation. Pulmonary vein stenosis was defined by a peak velocity of 110 cm/s or more plus a stenotic flow pattern (turbulence and reduced flow variation) on TEE and a lumen reduction of more than 50% on MRI. Results In all, 175 pulmonary veins were studied. MRI showed 7 cases of pulmonary vein stenosis that were correctly identified by TEE. In addition, TEE criteria for pulmonary vein stenosis were met in 4 pulmonary veins that did not show obstruction on MRI. In all, 5 pulmonary veins with normal appearance on MRI had peak velocity of 110 cm/s or more with normal flow pattern. Conclusions TEE Doppler measurements can be reliably used to detect or exclude significant pulmonary vein stenosis if the diagnosis is restricted to a combination of elevated peak velocity (≥ 110 cm/s) with turbulence and little flow variation.

Here, the case of a 48-year-old highly trained patient without classic myocardial risk factors is described who reported on frequent and recurrent angina pectoris. In a previous examination, the test for cardiac troponin T (cTnT) was slightly positive, however, cardiac examination including myocardial perfusion scintigraphy and coronary catheterization was without pathologic findings. Worth mentioning in the past medical history was a rheumatoid arthritis with persistent Raynaud's symptoms and hemoglobin as well as hematocrit levels in the upper normal range.The patient reported that symptoms would occur most likely during long-term endurance exercise. Therefore, a bicycle ergometry with 180 W and open ending was performed. After 1.55 h, the patient complained of severe angina pectoris. The ECG showed massive ST segment elevations in II, III, and aVF (Figure 2). However, coronary catheterization showed no major stenosis or occlusion. Nevertheless, cTnT increased to 0.979 ng/ml. (Therefore, the reason for the symptomatic ST elevation was believed to be a myocardial tissue damage due to coronary vasospasm and the patient received an antivasospastic medication (amlodipine, atorvastatin, and acetylsalicylic acid [ASS]). After 6 months, the patient had a relapse during moderate physical activity. The ECG showed an ST segment depression in V(4) and V(5) while markers for myocardial tissue damage including cTnT were negative. A coronary CT angiography was performed that revealed a subtotal stenosis of the proximal LAD (Fig ure 3), which was successfully treated by angioplasty with subsequent stenting. In the course of further examinations, a polycythemia vera (JAK2-V617 mutation) was diagnosed as the cause for the high hemoglobin and hematocrit levels. Since then, the patient was without further events under a medication consisting of ASS, atorvastatin, candesartan, and intermittent phlebotomy.Although a relative weighting is difficult, it can be assumed that the combined effects of a polycythemia- associated hypercoagulability, an increased reagibility of the coronary arteries (aggravated by physical stress) as well as a hemoconcentration following prolonged exercise, could account for symptomatic recurrent minor thrombotic coronary events as well as the subtotal occlusion of the LAD. Obviously, this could not be prevented by a healthy lifestyle, regular physical activity, and the absence of classic coronary risk factors.

Aims Pulmonary vein ablation offers the potential to cure patients with atrial fibrillation. In this study, we investigated the incidence of pulmonary vein stenosis after radiofrequency catheter ablation of refractory atrial fibrillation by systematic long-term follow-up. Methods and results Forty-seven patients with refractory and highly symptomatic atrial fibrillation underwent radiofrequency catheter ablation of arrhythmogenic triggers inside the pulmonary veins and/or ostial pulmonary vein isolation with conventional mapping and ablation technology. These patients had follow-up examinations at 2 years with transoesophageal doppler-echo and/or angio magnetic resonance imaging for the evaluation of the pulmonary veins. Seventy-seven percent of the patients were free from atrial fibrillation, 51% were without antiarrhythmic drugs, and 26% were on previously ineffective antiarrhythmic drug therapy. However, 13 of the 47 patients showed significant pulmonary vein stenosis or occlusion. Only three of these 13 patients complained of dyspnoea. Distal ablations inside the pulmonary vein were associated with a 5.6-fold higher risk of stenosis than ostial ablations. Conclusions At 2-year follow-up, the risk of significant pulmonary vein stenosis/ occlusion after radiofrequency catheter ablation of refractory atrial fibrillation with conventional mapping and ablation technology was 28%. Distal ablations inside smaller pulmonary veins should be avoided because of the higher risk of stenosis than ablation at the ostium.

MRT (magnetic resonance imaging) is a new method of producing pictures of internal organs; the main advantage compared to radiography is the ability to subtly differentiate soft tissues. 14 children suffering from juvenile chronic arthritis of different subgroups are described. MRT pictures of knee joints show clearly the structure and form of the articular cartilage, ligaments as well as the nature, density and thickness of the inflammatory tissue. MRT permits a very early diagnosis of a progression in the inflammatory articular process without accompanying ionising radiation, an advantage in childhood.

Subdural effusions in childhood are most often seen during the first year of life. In this age group two-dimensional echoencephalography gives excellent images of the brain due to the open fontanelle and the relatively low mineralisation of the cranium. The sonographic findings of two infants with postmeningeal subdural effusions are demonstrated and compared with CT-scan results. The sector-scan is much more useful than the linear-array. Computerized tomography remains necessary but it should be possible to reduce the number of examinations.

A semi-skeletted water-lodged corpse was supposed to be an 82-year-old missed man. Fifteen years ago this person had underwent an operation of a trimalleolar fracture of the left ankle joint. Conventional X-ray photograms of the left ankle joint of the water-lodged corpse showed no evidence of an operation. A T-1 weightened spin-echo sequence revealed the entire aspect of the osteosynthesis as documented in the previously performed post-operative X-ray photograms.

The article reports on a ward with 12 beds which has been set up for emergency cases in psychiatry or for immediate intervention in case of a crisis experienced by a patient. In the theoretical part of this article, it is explained that crisis situations are present in most of the psychiatric emergency patients. The article then goes briefly into the fundamentals of therapeutic strategy in such patients: A therapy which helps to uncover hidden conflicts, the pros and cons of therapy focussed on conflict and on supportive measures; as well as a therapy which supports and promotes the ego. This is followed by a comparison of the ward with corresponding facilities in Germany and abroad and a description of their structure, their patients and their function within a psychiatric care system. The concluding part of the article is devoted to a description of the authors' initial experiences and impressions gained during their work with the ward patients, quoting several examples.

In a premature twin boy (gestational age 34 weeks) two-dimensional echoencephalography, computed tomography, and NMR tomography revealed a brain tumor. The exact diagnosis was confirmed by stereotactic biopsy from the brain. Up to now the clinical course of the child has been surprisingly benign.