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In diesem Fallbericht uber eine 48-jahrige Patientin wird der seltene Befund eines kardialen Myxoms bei systemischem Lupus erythematodes (SLE) und Antiphospholipid-Syndrom (APS) dargestellt. Wir ubernahmen die Patientin zur transosophagealen Kontrolle einer seit 5 Jahren bekannten rechtsatrialen Raumforderung. Anhand der echokardiographischen Kriterien bestand der Verdacht auf ein Myxom. Aufgrund des erhohten Risikos fur systemische thromboembolische Ereignisse war die chirurgische Resektion der Raumforderung und der Verschluss eines persistierenden Foramen ovale indiziert. Nach unkompliziertem perioperativen Verlauf machte sich eine erneute Hospitalisierung bei verzogerter Rekonvaleszenz und persistierenden bilateralen Pleuraergussen erforderlich. Weiterfuhrend ist die kurzfristige echokardiographische Kontrolle und orale Antikoagulation unter dem Verdacht eines Thrombus bei persistierender rechtsatrialer Raumforderung angezeigt. Kardiale Tumoren sollten mittels transosophagealer Echokardiographie evaluiert werden. Kardiale Myxome erfordern die chirurgische Resektion. Patienten mit systemischen Kollagenosen bedurfen einer individuellen perioperativen Risikostratifizierung und intensiver kardiologischer und rheumatologischer Kontrolle bis zum Erreichen der postoperativen Rekonvaleszenz. Aufgrund eines erhohten Risikos fur Thrombenbildung sollte die effektive orale Antikoagulation bei Patienten mit APS im Einzelfall uberdacht werden.

Die kalzifizierende Aortenklappenstenose (AST) stellt das haufigste erworbene Klappenvitium bei uber 65-Jahrigen dar. Die bewahrten Parameter der Schweregradbestimmung werden besprochen. Die Echokardiographie ist zurzeit das diagnostische Verfahren der Wahl. Die invasive Schweregradbestimmung ist nur noch in wenigen Fallen erforderlich. Auf die besondere Bedeutung von Belastungstests bei asymptomatischer AST und bei Patienten mit AST und reduzierter LVPumpfunktion (Low-Dose-Dobutamin-Stressecho) wird hingewiesen. Die Bedeutung regelmasiger kardiologischer Follow-ups bei Patienten mit AST wird differenziert nach dem Schweregrad der Erkrankung erlautert. Bei ubereinstimmenden klinischen und echokardiographischen Befunden ist eine retrograde Sondierung des LV nicht erforderlich. Entsprechend koronarem Risiko, geplantem OP-Procedere und Begleiterkrankungen des Patienten mussen praoperativ lediglich eine Koronarographie und eine Aortographie durchgefuhrt werden.

BACKGROUND: Metoprolol can improve haemodynamics in chronic heart failure, but survival benefit has not been proven. We investigated whether metoprolol controlled release/extended release (CR/XL) once daily, in addition to standard therapy, would lower mortality in patients with decreased ejection fraction and symptoms of heart failure. METHODS: We enrolled 3991 patients with chronic heart failure in New York Heart Association (NYHA) functional class II-IV and with ejection fraction of 0.40 or less, stabilised with optimum standard therapy, in a double-blind randomised controlled study. Randomisation was preceded by a 2-week single-blind placebo run-in period. 1990 patients were randomly assigned metoprolol CR/XL 12.5 mg (NYHA III-IV) or 25.0 mg once daily (NYHA II) and 2001 were assigned placebo. The target dose was 200 mg once daily and doses were up-titrated over 8 weeks. Our primary endpoint was all-cause mortality, analysed by intention to treat. FINDINGS: The study was stopped early on the recommendation of the independent safety committee. Mean follow-up time was 1 year. All-cause mortality was lower in the metoprolol CR/XL group than in the placebo group (145 [7.2%, per patient-year of follow-up]) vs 217 deaths [11.0%], relative risk 0.66 [95% CI 0.53-0.81]; p=0.00009 or adjusted for interim analyses p=0.0062). There were fewer sudden deaths in the metoprolol CR/XL group than in the placebo group (79 vs 132, 0.59 [0.45-0.78]; p=0.0002) and deaths from worsening heart failure (30 vs 58, 0.51 [0.33-0.79]; p=0.0023). INTERPRETATION: Metoprolol CR/XL once daily in addition to optimum standard therapy improved survival. The drug was well tolerated.

In most randomized controlled trials on revascularization therapy for patients with ischemic coronary artery disease (CAD), the diabetes prevalence ranges between 15% and 35%. However, the true prevalence of diabetes is probably considerably underestimated in these trials. The European heart survey diabetes and the heart published in 2004 supplied strong evidence that there are many additional cases of undetected prediabetics and diabetics in any cardiology patient cohort. The long-term outcome of newly detected diabetics was found to be comparable to patients with already known diabetes mellitus. With this in mind, the Dresden silent diabetes study investigated the prevalence of undetected diabetes mellitus by oral glucose tolerance testing (OGTT) and comparative HbA1c sampling in 1,015 patients admitted for coronary angiography. Patients with known diabetes were excluded from the study.According to the OGTT only 513 patients (51%) were classified with normal glucose tolerance (NGT), 10 (1%) with isolated impaired fasting glucose (IFG), 349 (34%) with impaired glucose tolerance (IGT) and 143 (14%) were diagnosed with newly detected diabetes mellitus (DM). According to the HbA1c measurements 588 patients (58%) were classified as normal, 385 (38%) as borderline and only 42 (4%) were diagnosed with diabetes (DM). There was a significant correlation between the extent of CAD and glycemic status as defined by the OGTT. The number of patients with IGT and diabetes increased with the extent of CAD (IGT group p0.001, diabetes group p=0.01). However, no such correlation was observed when glycemic status was defined by HbA1c testing.Based on these results an OGTT should be routinely performed in patients with known or suspected coronary artery disease undergoing coronary angiography for diagnosis of diabetes, as HbA1c measurements alone appear to miss a substantial proportion of patients. These findings are of high clinical relevance with regard to optimal coronary revascularization procedure chosen in catheterization laboratories, preferably drug-eluting stents in cases of diabetes mellitus or newly detected diabetes mellitus and preferably coronary bypass surgery in diabetics with multi-vessel disease and high SYNTAX scores.

An intrapericardial aneurysm of the left atrial wall in a 28-year-old man is reported. This is a rare congenital anomaly. The patients are usually identified by clinical signs, when complications such as cardiac arrhythmias and systemic embolism occur. Clinical findings including the ECG are non-specific. Cardiomegaly and unusual configuration of the heart are consistantly found, but are not pathognomonic. The diagnosis is usually confirmed by angiocardiography. Echocardiography, computed tomography and/or MRI can contribute to the diagnosis. Operation seems to be indicated if complications are to be avoided.

In 10 cases of dilated cardiomyopathy the HLA-loci (A, B, C, DR) and marker expression on lymphocytes were studied. In this group the T4/T8-ratio was decreased and interleukin-2-expression was increased in relation to normals or patients with chronic coronary heart disease, respectively. 9 patients had the HLA-A1 or HLA-A2-locus in their siblings. In correlation analysis between immunological and hemodynamic parameters a good correlation of the number of NK-cells to the ejection fraction (r = 0.79) and negative correlation of helpercells (CD4) to the cardiac output were found (r = -0.80). The results of this attempt suggest an immunological pathogenesis of the dilated cardiomyopathy.

Today, with the help of modern echocardiographic techniques we are able not only to describe the characteristic changes when a HOCM is present and to determine the intracavitary pressure gradient, but also recognize the functional irregularities typical for the HOCM. Thus, the methodical progress of the echocardiography has essentially enlarged our knowledge about the pathophysiology of this clinical picture. Today, the echocardiography is the method of choice for the diagnostics of the HOCM and for the judgment of the functional consequences of therapeutic interventions.

Despite the small cohort of patients with HOCM could be shown that the routine application of the conventional and colour Doppler echocardiography after myectomy is indicated and reasonable. The modern echocardiography is able to assess with high individual reliability the therapeutic aim of myectomy--drastic reduction of the intracavitary pressure gradient. Significant changes were also the results in the systolic acceleration time (TPVS/LVET standardized on the LVET and the diastolic measuring parameters VmaxE, ATE and TVIE/TVIA), the importance of which is partly still fully open.

In 42 patients with coronary heart disease within a left heart catheterization by means of coronarography and conventional angiocardiography in each case before and after GTN digital subtraction angiographies of the left ventricle were performed with central venous injection of 20 ml visotrast with a flow of 16-18 ml/s. A DVI2-CV system of the firm Philips served as investigation device. In general between the angiocardiography and the digital subtraction angiographies the following results were obtained for EF 0.81, EDV 0.71, and ESV 0.88. When evaluating only the finally examined 22 patients the correlations improve for all parameters (EF: 0.89, EDV: 0.82, ESV: 0.90). Furthermore is was shown that the volumes are underestimated by 8-10%. The quantification of the regional movement of the wall according to the radial axis method did not results in any significant differences between the digital subtraction angiographies and the angiocardiography. The effects of GTN on the global and regional functional parameters appear somewhat more distinct in the digital subtraction angiographies than in the angiocardiography and are partly significant only in the first one. The influence of the experience of the investigator, the cardial state of the patient and other influential factors on the quality of the digital subtraction angiocardiographies are described and discussed. Therefore we regard the digital subtraction angiography as method of choice in indications to right heart catheterization without coronary angiography.

For the characterization of the left-ventricular thickness of the wall, of the diameter and of the functional parameters in obesity in a short-term investigation on 18 extremely adipose female normotonics and 17 normotonics with normal weight the echocardiographic investigation in the M-mode in the short parasternal axis was performed. The women with overweight had a by 28% (p less than 0.001) greater fractional shortening, a by 8% (p less than 0.01) greater ejection fraction, a by 23% (p less than 0.05) greater stroke volume and a by 34% (p less than 0.001) greater cardiac output as well as a by 13% smaller left-ventricular end-systolic volume than normotonic women with normal weight. Index of stroke volume and cardiac output did not differ. The women with overweight had a significantly larger left-ventricular end-diastolic diameter and a thicker interventricular septum as well as a larger thickness of the left-ventricular posterior wall in the systole. The results allowed the conclusion that changed left-ventricular parameters both with regard to the form and to the function in obesity per se might be the expression of the physiological adaptation to an increased requirement and the borderlines to the transition into a disturbed left-ventricular function and development of a left-ventricular hypertrophy were not fixed. Long-term studies should bring further explanation concerning these problems.

Systolic time intervals were measured with 55 middle aged healthy normal weight and 76 healthy overweight probands in two positions (standing and lying). In 39 adipose patients and 55 normal weight subjects an ergometric work was carried out. A significant difference between normal and extremely adipose subjects without cardiac diseases could not be noticed with regard to the preejection index. Preejection period and left ventricular ejection time showed significant differences in both positions between normal and overweight probands, independent of blood pressure. In overweight patients there was a significantly decreased heart work load. The preejection index of adipose patients with a work load below 76 watts amounted to a mean value of 1,04. A work load of 100 watts was reached by only half of the adipose patients. In 32 adipose subjects with a heart work load above 75 watts the regulation of heart-rate and blood-pressure was not different from that of normal weight persons. Muscle blood flow was measured by 133Xenon-Clearance after Lassen et al. The measurement of the 133Xenon-Clearance of the arm muscle at rest in 29 adipose patients resulted in significantly lower values compared with normal weight persons.

The theoretical and methodical base of computed tomography evaluation of the myocardial function are demonstrated. The possibilities and limits of this investigation method are discussed and compared with the results of numerous own examinations and the literature. Present indications for cardiacomputed tomography are deduced with consideration of other noninvasive imaging techniques in cardiology.

In 102 patients with typical symptoms of angina pectoris who underwent a coronary angiography a Dipyridamol test was performed. The result was a sensitivity of about 84% concerning the coronary heart disease and a specifity of about 93%. In the same test persons the ECG after work showed a sensitivity of about 84% and a specifity of about 57%. Dipyridamol test and bicycle ergometry are methods of the same value for the preinvasive diagnostics of the coronary heart disease which should supplement each other. The higher specifity of the ECG changes in the Dipyridamol test was evident in comparison to the bicycle ergometry. In 85 of our patients the Tl-201-scintigraphy was carried out under Dipyridamol and ergometer stress. For the Tl-201-scintigraphy under Dipyridamol a sensitivity of about 70% and a specifity of about 81,5% was the result. In the Tl-201-scintigraphy under ergometer load a sensitity ob about 84% and a specifity of about 57% was the result. The proportion of exactly positive findings increased with the number of the stenosed vessels under ergometer as well as Dipyridamol intervention. A negative load scintigraphy does not exclude a coronary heart disease, but renders a three-vessel-disease very improbable.

On 55 healthy test persons with normal weight and 76 healthy middle-aged obese test persons the measurement of systolic time intervals was performed standing and lying. In 39 obese patients and 55 test persons with normal weight a load ergometry was carried out. No significant difference between persons with normal weight and extreme overweight was recognized with regard to the index of tension. However, there were clear differences between persons with normal and overweight as to the time of tension and left-ventricular ejection time lying and standing, independent of the behaviour of blood pressure. In persons with overweight a significantly lower cardiac output was found. The index of tension of obese persons with a degree of efficacy below 75 Watt was on an average 1.04. Only half of the persons with overweight reached a degree of efficacy of 100 Watt. In 32 obese persons with a degree of efficacy of more than 75 Watt the regulation of frequency and blood pressure did not differ from that of persons with normal weight.

The development of new antiarrhythmic drugs allows to a certain extent the performance of a differential therapy and prophylaxis. This also concerns the lidocaine-like substance mexiletine, which according to Vaughan-Williams is to be classified into class I B of the antiarrhythmic drugs with direct membrane effect. It is effective in disturbances of the ventricular rhythm also in oral therapy, which in most cases are more life-endangering than the supraventricular ones. In own examination in 21 of 26 patients a complete or far-reaching suppression of accumulated extrasystoles and particularly of ventricular tachycardias could be achieved by an oral long-term therapy with 600--800 mg mexiletine. In the acute experiment short-term infusions were not effective in patients with ventricular tachycardias, since apparently no sufficient plasma level was obtained, wherefore also a following permanent drop infusion is recommended. The rate of side-effects was insignificant and in no case led to a withdrawal of the therapy.

Determining the systolic time intervals in a non-invasive method which is easy to apply and inexpensive, and it can be repeated as many times as necessary. The patient is subjected to low psychic stress so that even elderly and sick patients may undergo it. The STI method may be applied to case control and the observation of the development of a disease following pharmacological treatment. The method makes it possible to differentiate between healthy persons and patients suffering from cardiac insufficiency, and concealed insufficiencies of the cardiac circulation may be detected. The STI interpretation must take into account those factors which have an effect on the STI length. The results can be considerably upgraded through the use of certain indices, PI being the main one. The PI index is of particular value if the effect of the treatment by glycoside medication is to be observed.

36 normotensive obese and 23 hypertensive obese were treated with an isokaloric reduction diet of 800 kcal/a day under clinical conditions over a 4-week span. Blood pressure and cardiac performance were investigated by means of non-invasive techniques such as systolic time intervals (STI) and calculated indices. A significant decrease was established in systolic time intervals such as left ventricular ejection time and total electromechanical systole, systolic and diastolic blood pressure, myocardial oxygen consumption and cardiac output. Heart rate, preejection index and stroke volume were not diminished under dietary treatment. No decrease of all parameters was found in obese normotensives with a weight reduction greater than 5% after dietary treatment.

In individual cases the computed tomography renders possible the ascertainment of the coarctation of the aorta. Despite modified examination method (secondary section technique, continuous application of contrast medium) the reliability is insignificant. Therefore, the method cannot be recommended for the primary diagnostics of the coarctation of the aorta. The computed tomography is extraordinarily suited for the detection of aneurysms of anastomoses after operation of coarctations of the aorta. In 50 computed-tomographic examinations of 48 patients 11 times an aneurysm could be ascertained. This high proportion of late postoperative complications is above all to be traced back to the surgical suture material used in the sixties. There were only two falsely positive findings, in which cases also here relevant pathological changes were present. The computed tomography can more exactly than the aortography adopt a definite attitude to the question of the dissection of prostheses or to pseudoaneurysms.

A myopathy which sporadically appeared in a young male corresponds clinically, electromyographically, histologically and cardiologically to the rare picture of the X-chromosomally recessive benign myopathy with early contractures. The coordination to the clinical picture mentioned and the genetic advice, taking into consideration the X-chromosomally recessive heredity, are discussed and proved.

For the reduction of the functional obstruction of the left-ventricular outflow in hypertrophic obstructive cardiomyopathy since 1978 in selected cases conventional VAT cardiac pacemakers with shortened AV retardation time have been implanted. On the basis of 4 casuistics the insufficient adaptation of these systems to unexpectedly appearing disturbances of the cardiac rhythm is demonstrated. Thus already extreme sinus bradycardias lead to parasystole by the unchangeably given asynchronous basic frequency of the pacemakers. Furthermore, all tachycardiac supraventricular arrhythmias and retrograde atrium activations evoke haemodynamically unfavourable and partly even threatening ventricular tachycardies caused by the pacemakers. Control ECG made under these conditions are frequently inexactly interpreted by the continuing intact natural AV conduction and technical defects of the pacemakers are assumed. The individual diagnostic steps necessary for the assessment of the function of the devices and the inevitable immediate therapeutic measures are, therefore, explained. Finally the demands to more modern differentiated physiological pacemaker systems are derived which should be used in patients with hypertrophic obstructive cardiomyopathy.

The influence of hyperthyreosis on the cardiac function was investigated by means of non-invasive methods (radiocardiography, echocardiography, Tc-99m- und Tl-201-scintigraphy of the myocardium) and invasive methods (coronary angiography). Independent of age an increase of the frequency was always existing, a significant increase of the filling of the ventricle, of SI and HI was shown only by younger patients. With the help of the echocardiography local and global disturbances of kinetics, by means of the Tl-201-scintigraphy of the myocardium disturbances of the myocardial perfusion could be proved. For the circulating plasma catecholamines noradrenalin, adrenalin and dopamine values were established lying in the lower region of the normal. The effects of an increase of the thyroid hormone on the number and/or sensitivity of the membrane-bound beta-adrenoceptors of the heart as well as the independent of its effect of the SDH on the obtaining of myocardial energy are discussed.

The judgment of the function of the left ventricle is computer-tomographically possible using the ECG-regulated cardio-computer-tomography in a temporary resolution of about 0.1 sec. The qualitative and quantitative evaluation of the systolic and diastolic changes of the ventricle in patients with normal CT-findings, with idiopathic hypertrophic subaortic stenosis and with disturbances of motility in chronic ischaemic heart disease confirms the possible functional evidence known from literature. The quantitative parameters, in particular the systolic abbreviation of the axis, allow an estimation of the motility. The measurement of the thickness at the interventricular septum and at the lateral wall of the myocardium as well as the systolic abbreviation of the axis and the left-ventricular ejection fraction are essentially higher in the idiopathic hypertrophic subaortic stenosis than in the normal group. The values of the patients with disturbances of motility in the ischaemic heart disease were clearly below. The diagnosis of the idiopathic hypertrophic subaortic stenosis with response of the size of obstruction by the telesystolic and telediastolic pictures is possible in a high percentage. Sequelae of the chronic ischaemic heart disease, e.g. scars, become visible by a narrowing or an absence of the normal edge of the myocardium. Global and localized disturbances of motility are diagnosable by phase-referred systolic and diastolic ECG-regulated pictures.

It is reported on an at present 32-year-old male patient, in whom at the age of 30 years an excessive mediastinal lipoma was excised. For 12 years the cardiological diagnosis was not clear and could completely be clarified only with the help of the computed tomography of the heart.

Cardial and paracardial space occupations need a rapid, possibly non-invasive diagnosis. The echocardiography and the computer tomography are practically available. At the instance of 17 intracardial space occupations (4 solid tumours and 13 thrombi), which were found in a total number of 600 cardio-computer-tomographies, and several selected peri- und paracardial space occupations the high diagnostic significance of the computer tomography is demonstrated. With the computer tomography a standardized method independent of the investigator is available which in qualitative respect appears of the same value as to echocardiography in the diagnostics of the intracardial space occupations and in the peri- and paracardial space occupations the non-invasive method is the method of choice.

Left heart catheterisation, coronarography and conventional angiocardiography of the left ventricle (ACG) [30 degrees right anterior oblique; 45 ml contrast medium (Visotrast) with a flow of 12 ml per sec.] was performed in 86 patients with coronary heart disease. Additionally intraventricular digital subtraction angiography (DSA) was performed, using a Philips-device (DVI 2 CV). For DSA 15 ml contrast medium (Visotrast) was injected with a flow of 8 ml per sec. 73 examinations were selected for the study. The aim of the study was to compare the usefulness and applicability of ACG und DSA for ventriculography. There were no significant differences between enddiastolic (EDV) and endsystolic (ESV) volumes as well as ejection fractions (EF) determined by ACG and DSA. Results of the analysis of correlation were rEDV = 0.85;rESV = 0.93;rEF = 0.80. The increase of the end-diastolic pressure after ACG was determined with 7 Torr (mean), after DSA with less than 2 Torr (mean). According to these results we would prefer intraventricular DSA to conventional ACG, provided the technical equipment is available. This is concluded despite the fact that in single cases considerable differences were found between the volumes estimated by ACG and those determined by DSA. These differences were analysed in detail. The main advantages of the DSA are the by far smaller inconvenience for the patients, the rare occurrence of provoked extrasystoles and the fast and easy analysis of the ventriculographies by means of the implemented image processing programmes.