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Left ventricular inferoseptal clefts are a localized variant of myocardial structure, easily overlooked but potentially raising concern when identified through imaging. Here we illustrate and describe inferoseptal clefts by means of multimodality imaging and consider them in relation to possible differential diagnoses. A 49-year-old male patient was investigated for chest pain and found to have multiple inferoseptal clefts. The pain subsequently resolved and was thought to have been pleuritic. There was no evidence or family history of hypertrophic cardiomyopathy. The diagnosis of clefts was arrived at after consultation with several cardiac imaging specialists and the few available relevant published reports. Echocardiography, cardiovascular magnetic resonance, invasive ventriculography and computed tomography each showed the clefts in relation to surrounding compact and contractile myocardium of the inferoseptal region, which occluded the clefts in systole. In terms of location, orientation and systolic occlusion the inferoseptal clefts resembled the isolated clefts reported in healthy volunteers, and have features in common with crypts reported in carriers of a genetic mutation associated with hypertrophic cardiomyopathy (HCM). The incidence and implications of multiple inferoseptal clefts have yet to be determined. Multimodality imaging permits clear depiction of left ventricular inferoseptal clefts, which should be distinguished from different entities such as left ventricular noncompaction cardiomyopathy (LVNC), cardiac diverticula and cardiac aneurysms. Inferoseptal clefts have yet to be widely recognized as a distinct variant of regional left ventricular structure.

The indication for therapy of high degree carotid stenoses is discussed controversely in regard to new publications. Only symptomatic carotid stenoses are accepted as indication for operative therapy (arterectomy). The new method of carotid stenting was investigated in several studies and needs to be proved in controlled prospective randomized trials. The use of the self-expanding wall-stent has been established in most working groups; nevertheless some disadvantages should be considered (uncontrolled long segment stenting, covering the origin of ext. carotid artery, insufficient adaptation of struts in carotid communis). After development of a new flexible multicellular balloon-expanding stent (Jo-Carotisstent) with sufficient flexibility and compressibility and different stent lengths, the use of this stent in high degree carotid stenoses was investigated. The aim of this study was to analyze the acute and long-term quantitative stent results (angiography and duplex sonography) and clinical results periinterventionally and during follow-up (0.5-1 year).Selective approach from femoral, 8 Fr.-guiding catheter, canalization of stenosis with coronary guide wire (0.014 inch), primary PTA with coronary balloon.In 47 of 48 patients with 49 carotid stenoses, successful stent implantation was achieved (97.9%). In 2 patients TIA of short duration (4.2%) and in 1 patient (2.1%) a minor stroke occurred. All stents could be implanted with optimal reference diameter. During follow up after 0.5 year no significant proliferative restenosis was observed. The quantitative analysis showed excellent stent-diameter after 0.5 year with only minimal recoil (5%) and no clinical event.Using a new flexible and non-deforming multicellular balloon-expanded stent, selective stenting of high degree carotid artery stenoses can be realized with an excellent procedural success rate and a complication rate comparable with the results of other publicated studies. The results after 0.5 year follow-up seem to be promising.

The coincidence of aortic valve stenosis and cryptogenic gastrointestinal bleeding usually from angiodysplasia of the cecum and ascending colon has been called Heyde syndrome. The pathophysiologic link between both remains unclear and may be due to subtle changes in plasmatic coagulation. There are some statistic and numerous casuistic reports, and recently the existence of the syndrome has been questioned. We describe two cases of aortic valve stenosis and cryogenic gastrointestinal bleeding in which bleeding subsided after replacement with a bioprosthesis. We give an overview of the current literature.

Following coronary artery bypass grafting repeat ischemia mandatory for reintervention occurs in 2 to 30% of cases, depending mainly on graft age. Selection of a suitable strategy for revascularisation--transcatheter angioplasty or reoperation--depends on various parameters including coronary morphology, left ventricular performance, comorbidity and availability of graft material. Catheter-based interventions on saphenous vein bypass grafts are feasible, but lower primary success rates and a higher incidence of restenosis--compared with native coronary arteries--have to be expected. Repeat coronary artery bypass graft operations are associated with a significantly higher perioperative morbidity and mortality, patency rates are lower and late clinical outcome is worse than in primary surgery. We report on a patient who underwent coronary artery bypass grafting 4 years ago revealing a high grade ostial stenosis in a jump-graft supplying RCA, LAD and Cx sequentially, making reintervention necessary. As a prerequisite serial balloon angioplasty of two native vessels was performed prior to ostial intervention. Intravascular-ultrasound guided directional coronary atherectomy was performed with good primary and long-term result. Our case demonstrates that, if all relevant clinical parameters and different therapeutic options are taken into account, complex transcatheter angioplasty procedures are feasible and associated with a reasonable amount of risk, thus avoiding repeat coronary artery bypass graft operations.

Phosphomannose isomerase (PMI) deficiency is the cause of a new type of carbohydrate-deficient glycoprotein syndrome (CDGS). The disorder is caused by mutations in the PMI1 gene. The clinical phenotype is characterized by protein-losing enteropathy, while neurological manifestations prevailing in other types of CDGS are absent. Using standard diagnostic procedures, the disorder is indistinguishable from CDGS type Ia (phosphomannomutase deficiency). Daily oral mannose administration is a successful therapy for this new type of CDG syndrome classified as CDGS type Ib.

A 62 year-old male patient developed malaise, unproductive cough and high temperature (39.5 degrees C) during immunosuppressive therapy with methylprednisolon and cyclosporin A six months after kidney transplantation for glomerulonephritis.Clinical examination revealed an endophthalmitis and chest X ray a left-sided lobar pulmonic infiltration. Computed tomography and magnetic resonance imaging examination performed because of recurrent petit-mal-convulsions demonstrated multiple intracranial infiltrations. Transoesophageal echocardiography revealed floating vegetations up to 8 mm in diameter predominantly attached to the aortic valve. A total of 39 consecutive blood cultures drawn during several days remained sterile. However, Nocardia asteroides (Biovar A1) was isolated from a small cutaneous tumor excised from the right thigh.After initiation of a specific antibiotic treatment with imipenem/cilastatin (each 1 g three times daily), and doxycyclin (100 mg twice daily), computed tomography and magnetic resonance imaging showed a reduction in size and number of the intracranial infiltrations. Neurological symptoms were progressive despite maximal anticonvulsant therapy. The patient died 83 days after hospital admission from an epileptic state resistant to therapy.Though nocardiosis is still rare, it should early be included in the differential diagnosis of infections in immunocompromised patients to allow timely diagnosis and therapy.

A prospective randomized trial in 324 patients (pts.) analyzed the early clinical course of stabile dissections (stabile perfusion, degree of residual stenosis50%70% and stabile early result after 24 h). The results of quantitative recoronary angiography after 6 weeks and 3-4 months with differentiated reintervention (long time-PTCA, atherectomy, stent, CABG) were analyzed to determine the early clinical course. 57% of pts. demonstrated a type-I dissection (excentric stabile dissection with quantifiable degree of residual stenosis). By early recoronary angiography after 6 weeks with differentiated reintervention 68% of pts. (125 pts.) showed a sufficient result after 3.8 months. In 51% of pts. an additional sufficient result could be achieved by a second reintervention after 1/4 year. Considerable complications (infarction, CABG, acute death) occurred in 2.7% of pts. with type-I dissections. 108 pts. (33%) could be classified with type-II dissection (diagonal flap). Sufficient result after 3.5 months could be achieved in 84% pts. In 20 of 22 pts. an additional successful reintervention could be performed. The complication-rate (infarction, CABG) was 5.5%. In pts. with type-IV dissection (complex dissection) the early clinical course was more unfavorable with higher restenosis rate and considerable complications of 10%. The rare type-III dissection (short spiral dissection) showed a high recurrence rate already after 6 weeks (33%) and sufficient results after 3.2 months only in 42% of pts. Complication rate was high with 50% (2 x deaths, 2 x CABG).

Previous studies, including our own prospective study (634 patients), on chronic coronary artery occlusion demonstrated the highest success rate in reopening by primary use of conventional guidewire technique. The present prospective randomized study in 124 patients investigates the role of high-speed rotational angioplasty after primary guidewire-recanalization in comparison to sequential PTCA. Early results were described by analyzing the residual degree of stenosis, early dissection, stabile dissection at the end of procedure, complicated dissection, necessity of stent implantation, acute re-occlusion, restenosis or reocclusion during recoronary angiography after 24 h, and infarction. Despite the advantage of rotablation with significant reduction of early and stabile dissections (p0.01) only slight difference in restenosis-rate and comparable results for the rest parameters were achieved.Results of this study demonstrate no advantage in using rotablation after recanalization of chronic coronary occlusion in comparison to sequential PTCA.

To discover what factors indicate spontaneous coronary artery spasms as a cause of myocardial ischaemia.In a retrospective analysis 15 of 1407 consecutive patients who had undergone coronary arteriography (six women and nine men; mean age 47 +/- 11 years) had acute ischaemia due to spontaneous coronary artery spasms. The clinical findings at the time of first investigation and during the follow-up period (mean of 29 [3-65] months) were evaluated.The most common risk factors were hypercholesterolaemia (or = 200 mg/dl) in ten patients (66%) and heavy nicotine consumptionor = 20 cigarettes per day) in eight patients (55%). Of the patients with angina at rest nine had reversible ST elevations, six had terminal T negativity in the ECG and an increased incidence of ventricular arrhythmias (n = 6). At time of hospitalization ten patients had acute myocardial ischaemia and five had signs of acute myocardial infarction (maximal creatine kinase concentration: 121-2980 U/l). Acute coronary angiography revealed circumscribed coronary artery constriction, reversible with nitroglycerin, with stenosis of70% in five patients and ofor = 70% in six, as well as intermittent vessel occlusion in four patients. Angiography showed smooth coronary artery walls in almost all instances. Angiographic evidence of circumscribed arteriosclerotic lesion with maximally 50% narrowing was present in six patients.Especially in younger, male patients with hypercholesterolaemia and heavy smoking recurrent anginal pectoris at rest, with reversible ECG signs of myocardial ischaemia but without advanced coronary sclerosis, speaks for spontaneous coronary artery spasms as the cause.

Forty-two consecutive patients received emergency treatment for acute mitral insufficiency causing pulmonary edema between 1984 and 1992. The underlying diagnoses were acute myocardial infarction (n = 21), acute bacterial endocarditis on the native mitral valve (n = 9), prosthetic endocarditis in the mitral position (n = 4), acute failure of a replacement valve (n = 5), blunt chest trauma (n = 1) and chordal rupture in Marfan's syndrome (n = 2). Dysfunction of the subvalvular apparatus was present in 24 patients, verified by transthoracic echocardiography in 18 (75%) and by transoesophageal echocardiography in all patients in whom this technique was used. There were four cases of outflow strut fracture of a Björk-Shiley mitral prosthesis; a reliable diagnosis was made by fluoroscopy in all patients. Bedside hemodynamic monitoring was found to be unreliable both for differential diagnosis and for the quantitative assessment of the degree of mitral insufficiency. The right ventricular filling pressure was normal in 32/39 patients (82%), and the pulmonary artery and pulmonary capillary pressures elevated in 37/39 (95%). Diagnostically important, high pulmonary capillary v-waves were documented in 13 patients (33%). The left ventricular impedance could be influenced with sodium nitroprussid combined in some cases with dobutamin, and the resultant decrease of the peripheral vascular resistance from 1480 +/- 222 to 702 +/- 86 dyn x sec x cm-5 was followed by a proportionate reduction in the transmitral regurgitant fraction. Three patients died prior to the intended emergency surgical intervention. Emergency surgery was completed in 21 patients with an early mortality of 23.8% (n = 5). Ten patients underwent elective surgery within, and another three later than one year from the onset of the acute symptoms with an early mortality of 7.7% (n = 1). Four patients are alive and clinically well with medical treatment alone.

A 33-year-old previously completely healthy man developed severe, at first colicky then persisting, pain in the left flank. The blood pressure was 190/110 mm Hg and he had pain over the left kidney on percussion. There was a mild leucocytosis (10,300/microliters), serum creatinine of 1.5 mg/dl and a rise in lactate dehydrogenase level to 395 U/l, while the urine was unremarkable. The pyelogram demonstrated on the left the upper calyceal system only and this very weakly. Colour Doppler ultrasound showed a massively reduced blood flow in the left renal vein while the artery was not visible. Digital subtraction angiography demonstrated eccentric narrowing of the left renal artery by an intravascular thrombus, providing the diagnosis of spontaneous renal artery dissection with thrombosis. Complete recanalization occurred after local thrombolysis with 500,000 IU urokinase over 7 hours, and subsequent administration of four times 40 mg tissue plasminogen activator over 4 hours. But the scintigram still demonstrated impaired renal function with decrease in clearance to 10% of total. The patient was still symptom-free on re-examination 16 months later, serum creatinine concentration was stable at 1.3 mg/dl and the blood pressure was normal.