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Although colorectal carcinoma (CRC) is the third most common type of cancer in adults, only 1-4 % of cases are reported in individuals younger than 25-30 years. Its presentation is usually confused with other diseases, leading to significant delays in diagnosis. Given its low incidence, few pediatricians will see a case throughout their practice. However, multiple hereditary syndromes during childhood predispose to CRC. The objective of this review is to provide an update on syndromes predisposing to CRC. Screening indications will be reviewed because an early diagnosis during localized stages is the main prognostic factor. In addition, patient and family genetic counseling tools will be enhanced. In turn, the clinical and histological manifestations and prognostic factors typical of CRC in the pediatric population will be discussed. Although treatment guidelines are extrapolated from the adult experience, therapy guidelines will be summarized here.Si bien el carcinoma colorrectal (CCR) es la tercera enfermedad oncológica más frecuente en adultos, solo el 1-4 % ocurre en menores de 25-30 años. Su presentación suele confundirse con otras patologías, lo cual lleva a significativas demoras diagnósticas. Dada su baja incidencia, pocos pediatras se enfrentarán con algún caso a lo largo de su carrera. Sin embargo, existen en la niñez múltiples síndromes hereditarios que predisponen al CCR. El objetivo de esta revisión es brindar una actualización sobre los síndromes predisponentes al CCR. Se revisarán las indicaciones de tamizaje, dado que el diagnóstico precoz en estadios localizados es el principal factor pronóstico. Además, se fortalecerán las herramientas de consejería genética para el paciente y su familia. A su vez, se discutirán las manifestaciones clínicas e histológicas y los factores pronósticos propios del CCR en la población pediátrica. Si bien las guías de tratamiento se extrapolan de la experiencia en adultos, se resumirán los lineamientos terapéuticos.

Acute lymphoblastic leukemia (ALL) is the most common malignancy in childhood, corresponding to 23 % of cancer in children younger than 15 years old. About 20 % of ALL cases will relapse, commonly in the bone marrow. Extramedullar relapses are unusual, and the two most frequent locations are CNS and testicles. ALL relapses, when diagnosed in the CNS, frequently present with clinical features of a meningeal syndrome. The hypothalamic syndrome, consisting of hyperphagia, obesity and / or behavior disturbances, corresponds to an unusual presentation of relapses in this location and should alert pediatricians to suspect it. We describe 4 ALL cases of hypothalamic syndrome at the time of CNS relapse.

Infantile fibrosarcoma is a rare tumor, belonging to the nonrhabdomyosarcoma, soft tissue sarcoma. It is mostly presented in infants, most commonly involving the extremities. We report a 5-month-old boy, presenting with digestive bleeding since the age of 3 months, initially diagnosed as cow's milk allergy, with a torpid evolution and anemia. He underwent laparoscopic exploration, with evidence of a mass in the small bowel. Resection and end-to-end anastomosis were performed. Because of inadequate microscopic margins (< 1 cm), a new surgery was performed to achieve tumor free margins. Histological examination consisted of spindle cells that mainly expressed vimentin, and reverse transcriptasepolymerase chain reaction was positive for the ETV6-NTRK3 transcript, confirming the diagnosis of infantile fibrosarcoma. The patient did well after 24 months of follow-up. Although infantile intestinal fibrosarcoma is extremely uncommon in children, it should be considered as differential diagnosis for digestive bleeding in infants.

Infantile fibrosarcoma is a rare tumor, belonging to the nonrhabdomyosarcoma, soft tissue sarcoma. It is mostly presented in infants, most commonly involving the extremities. We report a 5-month-old boy, presenting with digestive bleeding since the age of 3 months, initially diagnosed as cow's milk allergy, with a torpid evolution and anemia. He underwent laparoscopic exploration, with evidence of a mass in the small bowel. Resection and end-to-end anastomosis were performed. Because of inadequate microscopic margins (1 cm), a new surgery was performed to achieve tumor free margins. Histological examination consisted of spindle cells that mainly expressed vimentin, and reverse transcriptasepolymerase chain reaction was positive for the ETV6-NTRK3 transcript, confirming the diagnosis of infantile fibrosarcoma. The patient did well after 24 months of follow-up. Although infantile intestinal fibrosarcoma is extremely uncommon in children, it should be considered as differential diagnosis for digestive bleeding in infants.El fibrosarcoma infantil es un tumor raro, perteneciente al grupo de sarcomas no rabdomiosarcoma; se presenta, preferentemente, en infantes, con localización más frecuente en extremidades. Se reporta un varón de 5 meses, con historia de sangrado digestivo desde los 3 meses, interpretados, al principio, como alergia a la proteína de leche de vaca, con evolución tórpida y anemia. Por laparoscopía exploradora, se evidenció un tumor en el intestino medio; se realizó resección y anastomosis términoterminal. Luego, se ampliaron los márgenes de resección por ser0,1 cm. Microscópicamente, se observó una proliferación neoplásica fusocelular con positividad difusa para vimentina, y reacción en cadena de la polimerasa con transcriptasa reversa positiva para ETV6-NTRK3. Se diagnosticó fibrosarcoma infantil intestinal. Presentó buena evolución a 24 meses del diagnóstico. Si bien es infrecuente en pediatría, se debe considerar como diagnóstico diferencial en lactantes con sangrado digestivo sin causa clara.

Acute leukemia is the most frequent malignant disease in childhood. Acute lymphoblastic leukemia represents 75% and acute myeloblastic leukemia 25% of them. Erythroleukemia is a rare entity, corresponding to less than 5% of acute myeloblastic leukemia. Its definition has changed over the time. WHO in 2017 defines erythroleukemia when the percentage of erythroblasts represent 80% of the total cellularity of the bone marrow aspirate. This analytical and retrospective study was performed with the aim of reviewing morphology, flow cytometry and cytogenetic features, response to treatment and outcome of cases previously defined as erythroleukemia in our center during the last 25 years and, in addition to reclassify those cases which do not meet the new WHO 2017 criteria. From January 1990 to December 2015, 576 patients were diagnosed as acute myeloblastic leukemia and 11 (1.9%) of them were classified as erythroleukemia. Ten cases were evaluable. Sex distribution was 1:1 and the median age at diagnosis was 5 (range: 0.9-14) years. Six of them had presented with previous myelodysplastic syndrome. None of the analyzed cases can be currently defined as erythroleukemia, according to the new criteria. When reclassified, the cases were defined as leukemias of subsets with poor prognosis such as acute undifferentiated leukemia, without differentiation and megakaryoblastic leukemia. Only 2 patients remain leukemia-free and this could be explained both by the unfavorable prognosis of these leukemia subtypes, and the antecedent of myelodysplastic syndrome in most of the cases

For evaluation of coronary artery spasm 201thallium sequential scintigraphy of the myocardium after ergotamine provocation was performed in 10 patients with recurrent angina pectoris at rest and normal exercise ECG. In 9 out of the 10 patients ergotamine administration in the same dosage was repeated during the coronary angiography. A reversible defect in the 201thallium scintigram representative of regional myocardial ischaemia developed in 9 patients after ergotamine. Only in 4 out of the 9 patients angina pectoris and ST elevation were present at the same time. In all cases coronary spasm after ergotamine was demonstrable in the coronary angiogram; in the 4 patients with ergotamine-induced Prinzmetal angina pectoris it consisted of complete vascular occlusion, in the asymptomatic patients of incomplete vascular narrowing of a higher degree. In all cases the spasm could be relieved by ergotamine antidotes within a few minutes.

In addition to digitalis and diuretics, 10 patients with chronic cardiac failure were treated with prazosin (15 mg/d) over a period of 6 months. It was shown that the mean pulmonary artery pressure decreased significantly, on average by 30%, during both rest and exercise. Despite significant decrease of arterio-central venous oxygen difference no improvement of cardiac output was measured after 6 months on prazosin. Cardiac output increased clearly in only 4 patients, particularly during exercise. Heart rate and arterial blood pressure remained statistically unchanged. Eight patients reported subjective improvement of dyspnoea after 6 months. Prazosin plasma levels were between 9.4 and 58.6 ng/ml. Side effects such as orthostatic hypotension, urinary incontinence and disturbances of potency occurred in 4 patients. Antinuclear factors could not be demonstrated after 6 months. These data show that after 6 months of prazosin therapy haemodynamically significant improvement of pulmonary congestion can be demonstrated without concurrent increase of cardiac output. Prazosin is indicated in treatment of chronic cardiac insufficiency with predominant pulmonary congestion an an adjunct to digitalis and diuretic baseline treatment.

To compare the shaping ability of four different nickel-titanium rotary instruments during the preparation of curved root canals in extracted teeth.A total of 80 root canals with curvatures ranging between 25° and 39° were divided into four groups of 20 canals. Based on radiographs taken prior to instrumentation, the groups were balanced with respect to the angle and the radius of canal curvature. Canals were prepared to a final apical size of 40 using Mtwo, ProTaper Universal, ProTaper NEXT and BT-RaCe. Using pre- and post-instrumentation radiographs, straightening of the canal curvatures and canal transportation were determined with a computer image analysis programme. Preparation time and instrument failures were also recorded. The data were analysed statistically using anova and Student-Newman-Keuls test.The use of BT-RaCe files resulted in significantly more straightening during instrumentation compared to Mtwo (P 0.05), whilst the differences between all other instruments were not significant (P 0.05). No significant differences were obtained between all four instruments regarding canal transportation (P = 0.429). Instrumentation with ProTaper NEXT files was significantly faster than with all other instruments (P 0.05). During the preparation of the curved canals, one BT2 instrument fractured, whilst no fracture occurred when using the other instruments (P 0.05).Within the parameters of this study, all instruments maintained root canal curvature well and were safe. However, care should be taken when using the BT2 instrument due to its unique cylindrical design.

Obwohl ein qualitatsmanagement im Herzkatheterlabor Sinn macht und auch gesetzlich vorgeschrieben ist, gibt es in Deutschland hierzu bislang keine allgemein gultigen Strukturen. Daher hat der Bundesverband Niedergelassener Kardiologen (BNK) die Initiative ergriffen und 1994 in Zusammenarbeit mit der Arbeitsgruppe interventionelle Kardiologie (AGIK) der Deutschen Gesellschaft fur Kardiologie — Herzund Kreislaufforschung ein Computerprogramm zur papierlosen Dokumentation fur diagnostische Linksherzkatheter und Koronarinterventionen (PTCA) entwickelt, 1996 nahmen acht Katheterpraxen an der Datenerfassung teil. Die Analyse der 10 316 Linksherzkatheter und 2597 PTCA fuhrte zu folgenden Ergebnissen: Linksherzkatheter: Bei 95% der Patienten erfolgte die Katheterisierung uber die Arteria femoralis, bei 5% uber Armarterien. Die mittlere applizierte Kontrastmittelmenge betrug 164±138 ml pro Untersuchung. Die linksventrikulare Auswurffraktion (EF) lag bei 58,4% der Patienten uber 50% und bei 10,1% zwischen 30% und 50%. 69,6% der Patienten hatten eine koronare Herzerkrankung, 8,5% Vitien, und bei 18,4% war keine organische Herzerkrankung nachweisbar. Die Mortalitat im Katheterlabor sowie die Rate zerebraler Insulte betrug jeweils 0,05%. Die Indikation zur PTCA wurde bei 22,9%, zur Herzoperation bei 19% gestellt. Bei den PTCA-Patienten bestand eine stabile Angina pectoris in 74,4%, eine instabile in 13,1%. 5,8% wurden wegen eines akuten Myokardinfarkts dilatiert. Erfolgreich dilatiert werden konnten 96% der Stenosen. Der visuell geschatzte mittlere Stenosegrad betrug vor Intervention 81% und nach der Intervention 6%. Die Mortalitat (einschlieslich vier Wochen nach der PTCA) betrug 0,4%, die Myokardinfarktrate 1,0%. In 1,3% kam es zu einem akuten Koronargefasverschlus, 0,6% musten einer notfallmasigen Bypassoperation zugefuhrt werden. Unsere Ergebnisse lassen im Vergleich mit anderen Datenbanken viele Gemeinsamkeiten, aber auch unterschiedliche Trends erkennen. Somit hat sich der AGIK-Datensatz zur Qualitatserfassung fur Linksherzkatheter und PTCA bewahrt. Bei geringem Zeitaufwand und hoher Akzeptanz ermoglicht er die rasche Standortbestimmung einer individuellen Praxis im Vergleich zu den Mittelwerten der Gesamtgruppe und konnte flachendeckend eingesetzt werden.

Significant bleeding at the puncture site is one of the most important problems in the care of patients undergoing interventional coronary procedures like PTCA, rotablation, laser angioplasty or stent implantation. This is due to systemic application of heparin, acetylic salicic acid and, in stent patients, even additional coumadine. Furthermore, the interventional systems implement catheter systems with a large inner and outer lumen leading to increased vessel trauma. To decrease the risk of bleeding and to reduce the time of pressure dressing and bed rest, a bovine collagen plug (VasoSeal) was used in 600 consecutive patients undergoing one of the above-mentioned interventional procedures. In the majority of patients (pts.) (474/600 = 79%) either no (404 pts.) or minimal (70 pts.) bleeding occurred. Bed rest could be reduced from more than 24 h to 6-12 h. In 65/600 pts. (11%) significant bleeding developed which could be controlled by compression. Bed rest in these patients was 13-20 h. Larger bleedings or complications occurred in 61/600 pts. (10.2%) and could be controlled conservatively in all but eight patients. One patient (0.2%) had a narrowing of the artery at the puncture site after the procedure, probably due to intraarterial plug application. In another patient (0.2%) embolization of the plug into the popliteal artery occurred which could be treated by embolectomy using a Fogarty-catheter. Arteriovenous fistulae or aneurysms developed in 8/600 pts. (1.3%) but these are no specific complications of the hemostatic device. The plug could not be placed in 13/600 pts. (2%), mainly in the beginning of the study.(ABSTRACT TRUNCATED AT 250 WORDS)

Isovolumetric relaxation and diastolic stiffness of the left ventricle were studied in seven open-chest dogs following serial ligation of coronary arteries. After experimental infarction, diastolic stiffness increased by 221% (p

Poly- and monoclonal antibodies to neoantigens of the human C5b-9 complement complex, as well as polyclonal antibodies to C5, C8, and C9, were used to detect and identify C5b-9 deposits in human myocardial tissue. Immunocytochemical studies were performed on fresh-frozen autopsy material derived from patients with myocardial infarctions; in addition, in 17 of these patients, paraffin sections of formalin-fixed tissue were investigated. Sixteen autopsies from patients with noncardiac diseases were analyzed as controls. Without exception, C5b-9 positivity was registered selectively and exclusively on and in myocardial cells located within the zones of infarction. The selectivity of staining was confirmed by control reactions for succinic dehydrogenase activity performed in adjacent, respective double-stained sections. Most intensive staining with anti-neoantigen antibodies was observed in the peripheral areas of the infarctions. Weak staining for C3d, rather strong staining for C5 and C9, and intermediate staining with anti-C8 antibodies were observed in the same localizations. Stainings for C4 and IgA were negative, whereas immunocytochemical reactions for IgG and IgM revealed an irregular and very weak staining. Only very weak staining was also observed with a monoclonal antibody to complement S-protein, indicating that the terminal complement components were deposited mainly in the form of membrane-damaging C5b-9 complexes. Immunocytochemical staining for C5b-9 was found to represent a most sensitive tool for detection of ischemic myocardial lesions, permitting easy detection even of single cell necroses. As a working hypothesis, we suggest that initial ischemia may cause loss of the ability of the heart muscle cells to regulate complement turnover at the membrane level. The resulting deposition of C5b-9 on the cell membranes may contribute to functional disturbance and irreversible damage of myocardial cells during the infarction process.

Dringliche Coronarchirurgie soll einen Herzinfarkt verhindern bzw. dessen Komplikationen beheben. Die Methoden sind: aortocoronarer Venenbypass bei drohendem Infarkt nach erfolgreicher intracoronarer Lyse, Verschlus von Septumperforationen, Korrektur einer Mitralklappeninsuffizienz durch Infarkt und Resektion von Ventrikelaneurysmen. 1975–1982 wurden in Hamburg 1108 Patienten wegen Coronarinsuffizienz elektiv operiert, die Letalitat lag bei 2,4%. Noteingriffe in dieser Zeit fanden bei 105 Patienten statt, die Sterblichkeit betrug 15,2% (n = 16). Die Indikationen waren: drohender Infarkt (48 Zustand nach Thrombolyse (24%), Herzinsuffizienz (10%) u. a. (8%).

Percutaneous transluminal coronary recanalization, a new therapeutic procedure used in acute myocardial infarction, offers significant reduction in mortality, as well as more effective limitation of the zone of infarction than has been possible with other pharmacologic treatment employed in the past. The risk of coronary angiography during acute myocardial infarction was surprisingly low, as was the risk of hemorrhagic complications following the intracoronary administration of relatively low doses of thrombolytic substances such as streptokinase. Mechanical recanalization was possible in about one fifth of patients and successful in approximately half of all such attempts, but complications occurred in a small percentage of attempts at this step. Coronary artery spasm was excluded as a possible cause of occlusion in almost all cases. Selective intracoronary infusion of streptokinase produced the highest degree of myocardial reperfusion, and best results were achieved when therapy was initiated shortly after thrombotic occlusion occurred. Residual stenosis of more than 75% luminal diameter narrowing was present in approximately three fourths of cases after complete thrombolysis, and the majority of patients remained appropriate candidates for coronary bypass surgery or for percutaneous transluminal coronary angioplasty (Grüntzig procedure). Although complete analysis of the efficacy of selective recanalization was difficult because it was not possible to establish a suitable control group for purposes of comparison, the mortality of less than 1% in the present group of 232 patients within the first 6 hours following myocardial reperfusion provides an encouraging result.

Creatine kinase (CK) release curves were analysed in 40 patients with acute myocardial infarction. Three groups could be identified. Group A (duration of CK release less than 30 hours) comprised 15 patients whose CK release was completed within 22.8 hours. In these patients chest pain was noted on the first hospital day and necropsy in three showed a homogeneous myocardial infarction. Group B (duration of CK release greater then 30 hours) comprised 16 patients who had a significantly longer CK release time of 42.2 hours (P less than or equal to 0.05). Their chest pain persisted for two to three days and pathological examination in five patients showed a heterogeneous composition of the infarcted myocardium. Group C comprised nine patients who had a second rise of serum CK. This was always associated with chest pain. It reflected an extension of the infarct which accounted on average for 24 per cent of the size of the final infarct. We concluded that a CK release of short duration indicated infarction without extension, CK release of longer duration indicated a gradual extension of infarction, and a repeated CK release resulted from a sudden extension of an infarct. According to these criteria an extension of the infarct occurred in 62 per cent of our patients.

A multicenter study evaluated the early management and subsequent hospital course of 204 patients with acute myocardial infarction who were receiving intracoronary infusions of streptokinase (STK). The in-hospital mortality in 37 patients with thrombotic occlusion of the infarct-related vessel, in whom recanalization could not be achieved, was 24%. However, the cardiac mortality in 129 patients who were successfully treated by percutaneous transluminal coronary recanalization (PTCR) was only 5.4%. Cardiac deaths (five patients) and nonfatal reinfarctions (20 patients) occurred in the early period in the cardiac care unit (CCU) in 21% of the latter group and, despite anticoagulation measures, could not be consistently prevented. Hemorrhagic complications, necessitating blood transfusion, occurred in 15 (7.4%) of the total 204 patients in the group, usually in the acute CCU stage, and were positively related to decline of fibrinogen serum concentrations below 100 mg/dl and to use of the Judkins technique. The later course of most of the patients on the general ward was uneventful until hospital discharge. Thus there were only two more cardiac deaths, and of 64 successfully treated STK-PTCR patients who left the CCU without clinical indications of reinfarction and agreed to repeat coronary angiography before hospital discharge, the infarct-related vessel was patent in 59 patients and reoccluded in only five (7.8%).

The results of biphasic 201thallium (201Tl) scanning were compared with those of coronary arteriography, left ventricular angiogarphy and stress ECG in 56 patients with coronary artery disease and six with no evidence of heart disease. There were 104 201Tl defects, 50 of them reversible. The defects were always located in the area supplied by a critically stenotic coronary artery. Correlation of regional wall motion with 201Tl activity demonstrated that in all forms of abnormal wall motion there was either ischaemia or fibrosis. The resting LV angiogram thus does not make it possible to distinguish between myocardial ischaemia and fibrosis. Taking the LV angiogram as a standard, the rate of false-positive 201Tl scintigrams was 5%, that of false-negative ones 23%. The biphasic 201Tl scintigram was more sensitive than the stress ECG in detecting myocardial ischaemia. It furthermore made it possible to localize the ischaemic (or fibrotic) region within the LV and to estimate its size.

Acute infarct size was estimated from serial determinations of creatine-kinase (CK) activity. In 15 patients the infarct size was obtained post-mortem, using nitro-blue-tetrazolium stain. There was good correlation between the two measurements (r = 0.98). The relationship between the calculated infarct size and haemodynamic values was obtained in 50 patients (end-diastolic pulmonary arterial pressure [PAEDP], cardiac output, stroke volume, stroke volume/filling pressure of left ventricle [SVI/PAEDP]). On average there was a tendency towards impaired left ventricular haemodynamics with increasing infarct size. Among the survivors the infarct size (51 g) was significantly less (P less than 0.05) than that of those who had died (83 g). PAEDP at 24 mm Hg was significantly higher in those who died than in the survivors (17 mm Hg), cardiac index was 2.95 l/min-m2 in the survivors compared with 2.14 l/min-m2, while SVI/PAEDP was 2.4 ml/m2-mm Hg in the former and 0.9 ml/m2-mm Hg in the latter. However, in individual cases the infarct size sometimes did not correlate with haemodynamic values. Taking into account infarct size and haemodynamics, four classes could be distinguished: (a) infarct size less than 65 g with good haemodynamics (PAEDP less than 18 mm Hg, normal cardiac index); (b) infarct size greater than 65 g with PAEDP greater than 18 mm Hg and markedly reduced cardiac index). Only 10% of those a to c had previously had infarcts, compared with 60% of those in class d (infarct less than 65 g, PAEDP above 18 mm Hg). Small infarcts with markedly impaired haemodynamics thus indicate that there has been previous damage to remaining myocardium.

The antiarrhythmic effect of tocainide, an amine analogue of lidocaine, was tested in the course of a double-blind trial on 12 patients with ventricular arrhythmias. Daily dose was 400 or 600 mg every eight hours. In all tested patients the frequency of ventricular extrasystoles, analysed by means of ambulatory 24-hour ECG monitoring, decreased by an average of 70%. In four of nine patients the severity of the ventricular extrasystoles (Lown's classification) was improved by at least one functional class. There was no correlation between the anti-arrhythmic effect and the plasma level of tocainide, which was between 4.1 and 9.7 micrograms/ml. Four patients had side effects in the form of CNS symptoms, but the drug did not have to be discontinued. Tocainide is an orally effective antiarrhythmic drug, an alternative in the treatment of ventricular arrhythmias.

In a single-blind randomised trial in patients with acute myocardial infarction of less than 6 h duration, the frequency of coronary patency was found to be higher after intravenous administration of recombinant human tissue-type plasminogen activator (rt-PA) than after intravenous streptokinase. 64 patients were allocated to 0.75 mg rt-PA/kg over 90 min, and the infarct-related coronary artery was patent in 70% of 61 assessable coronary angiograms taken 75-90 min after the start of infusion; 65 patients were allocated to 1,500,000 IU streptokinase over 60 min, and the infarct-related vessel was patent in 55% of 62 assessable angiograms. The 95% confidence interval of the difference ranges from +30 to -2% (p = 0.054). Bleeding episodes and other complications were less common in the rt-PA patients than in the streptokinase group. Hospital mortality was identical in the 2 treatment groups. At the end of the rt-PA infusion the circulating fibrinogen level was 61 +/- 35% of the starting value, as measured by a coagulation-rate assay, and 69 +/- 25% as measured by sodium sulphite precipitation. After streptokinase infusion, corresponding fibrinogen levels were 12 +/- 18% and 20 +/- 11%. In the rt-PA group only 4.5% of the fibrinogen was measured as incoagulable fibrinogen degradation products, compared with 30% in the streptokinase group. Activation of the systemic fibrinolytic system was far less pronounced with rt-PA than with streptokinase.

To examine the time course of left ventricular filling, a computerized analysis of echocardiograms was performed in 16 normal subjects, 10 patients with coronary artery disease (CAD) but no cardiac enlargement and 7 patients with asymmetric septal hypertrophy (ASH). After hand-controlled digitization of the echocardiogram, a plot of the left ventricular diameter time-curve demonstrated separate phases of rapid filling, slow filling and atrial contribution. The left ventricular diameter at end-systole and at the end of the three diastolic phases was determined by pattern analysis of the diameter-time curve. On analysis of successive beats in the normals, the coefficient of variation for each of these four values of the left ventricular diameter was less than +/- 5%. Between CAD, ASH and normals there was no significant difference in left ventricular end-diastolic diameter, nor in the extent and percentage of diameter shortening during systole. In contrast, abnormalities of the filling pattern were found in CAD and ASH. The maximal rate of diameter lengthening was not different in CAD (13.0 vs 13.7 cm/sec in normals, N.S.) but decreased in ASH (9.3 cm/sec, p less than .01). The percentage of diameter lengthening occurring in the rapid filling phase was decreased in both patient groups (55% in CAD and ASH vs 73% in normals, p less than .001). The slow filling phase did not contribute to more diameter lengthening (13% in CAD and 17% in ASH vs 12% in normals, N.S.). In CAD and ASH, the atrial contribution was markedly increased (33% in CAD and 28% in ASH, vs 15% in normals, p less than .001), and there was a higher rate of diameter lengthening during the atrial contraction (7.6 cm/sec in CAD, p less than .001 and 5.7 cm/sec in ASH, p less than .01, vs 3.1 cm/sec in normals). In conclusion, after computer processing, noninvasive measurements of the left ventricular diameter allows to identify a typical filling pattern in patients with CAD and ASH, consistent with an abnormal compliance of the left ventricle and a compensatory increased atrial contribution.

Five patients with second degree intraatrial block are presented. The first three cases had a sick sinus syndrome with sinus bradycardia, broad P waves and episodes of atrial flutter or fibrillation. In these patients a Wenckebach phenomenon could bei elicited by atrial stimulation at a critical driving rate between the stimulated site and the recording electrode. In the first patient this conduction disturbance was obtained at several right atrial stimulation sites. The block could be elicited in the other two patients only in a limited area of the right atrium respectively only by left atrial pacing. In the remaining two patients an atrial tachycardia with block was observed. The intraatrial conduction disturbance was manifested as an exit block around the ectopic pacemaker. In one patient the tachycardia was induced by digitalis intoxication. In the other patient no etiologic factor of the tachycardia could be found. While the first three patients presented intraatrial conduction disturbances already in sinus rhythm, the last two cases showed after recovery from the atrial tachycardia P waves of normal duration and configuration.

Bei 11 Patienten (P) untersuchten wir den Einflus des neueren synthetischen Katecholamins Dobutamin (D) auf: 1. enddiastolischen Druck (LVEDP) und Druckanstiegsgeschwindigkeit (dp/dtmax) im linken Vetrikel. 2. Koronarvenen-sinusflus (KSF), gemessen mit dem Thermodilutionsverfahren. 3. myocardiale Laktatextraktion (LE) und myocardialen Sauerstoffverbrauch (MVO2). Alle P wiesen in Ruhe einen LVEDP > 15 mm Hg auf, ihre Ejektionsfraktion (EF) war im Mittel mit 41% ± 15% eingeschrankt. Die Messungen erfolgten in Ruhe (R) und am Ende einer 10-minutigen Infusionsperiode von 5 µg/kg/min D (A) und 10 µg/kg/ min D (B).

Standard electrocardiogram (ECG), His-bundle electrogram and biphasic thallium myocardial scanning was undertaken in 13 patients with histologically confirmed sarcoidosis (lung stages I--III). Changes in the standard ECG were present in five (sinus bradycardia, A-V nodal and intraventricular conduction disturbances, non-specific S-T--T changes). The His-bundle electrogram was abnormal in four of eleven patients in whom it was recorded (sick-sinus syndrome, supraventricular extrasystoles, damage to A-V node and supraventricular extrasystoles, damage to A-V node and intraventricular conduction disturbances). In seven of twelve patients who had thallium scans there was a definite irreversible defect, questionable abnormality in three others. Seven of ten patients who had all three tests had definite abnormalities in at least one of them. The electrophysiological findings and the abnormal scans point to cardiac involvement in sarcoidosis.

In 848 coronary arteriograms performed in a two-years period 21 patients (2.5%) showed a myocardial bridging of the left anterior descending artery. Resting- and/or stress-ECG were abnormal in half of the patients. Regional lactate-metabolism measured in the great cardiac vein at rest and during maximal atrial pacing was normal (29 +/- 12 resp. 24 +/- 9%). Thermodilution of great cardiac vein bloodflow at rest and during atrial pacing also demonstrated normal values (94 +/- 33 resp. 138 +/- 30 ml/min). Biphasic 201-Thallium myocardial imaging revealed no case of reversible perfusion defect, but surprisingly frequent (5 of 16 patients) clearly irreversible defects limited to the interventricular septum. We conclude that muscle bridges do not cause myocardial ischemia at rest or during exercise.

Die Folgen einer Arteriosklerose fuhren bei Tieren in freier Wildbahn kaum einmal zum Tode, wahrend sie beim Menschen heute in vielen Landern die haufigste Todesursache darstellen. Wir wissen nicht, wie das Gefassystem unserer Neandertaler Vorfahren ausgesehen hat, aber wir wissen, das die Arteriosklerose keine erst in jungster Zeit entstandene Zivilisationskrankheit ist. So sind z. B. deutliche arteriosklerotische Gefasveranderungen bei agyptischen Mumien nachgewiesen worden. Es ist moglich, das der Mensch nicht fur die Nahrung geschaffen ist, die er heutzutage zu sich nimmt, und auch nicht fur die soziologischen Strukturen, unter denen er lebt (Haust).

Der Frage, ob Patienten mit einer Hauptstammstenose der linken Koronararterie ≥ 70% uberwiegend durch das Auftreten maligner Arrhythmien (A) gefahrdet sind oder andere Mechanismen fur ihre hohe Mortalitatsrate verantwortlich sind, gingen wir bei 13 Patienten (P) nach. 9 der 13 P wiesen zusatzlich in allen 3 grosen Koronararterien signifikante Stenosen ≥ 70% auf. Untersucht wurde jeweils in Ruhe (R) und unter Vorhofstimulation (S, n = 8): 1. Der Blutflus in der grosen Herzvene (GCVF) mittels Thermodilution. 2. Der enddiastolische Druck im linken Ventrikel (LVEDP). 3. Die myocardialeLaktatextratkion(LE). 4. das 201Thallium-Myocardperfussionsszintigramm in Ruhe und unter Ergometerbelastung (-201Th). 5. Ein ambulantes 24-Stunden-Langzeit-Ekg (LZ-Ekg).

Left ventricular (LV) contrast cineventriculograms were obrained in 174 patients with evolving acute myocardial infarction (AMI) treated by intracoronary streptokinase (SK) infusion. Ejection fraction (EF) increased slightly, from 52% +/- 13% before admission SK intervention to 58% +/- 13% immediately after early recanalization of the completely obstructed coronary vessel (p less than 0.0005, n = 68), while local wall motion usually improved. Immediately improved LV function appears to be the result of early reperfusion and/or decreased LV afterload. In 55 chronic (long-term follow-up) post-AMI (2 to 4 weeks after successful early SK reperfusion) patients, repeat angiography revealed late reocclusion of the infarct vessel in nine patients. Chronic EF was not significantly different from pre-SK intervention EF in these nine patients with late reocclusion, whereas in the remaining 46 patients with persistent patency, EF increased mildly from 52% +/- 13% (before SK intervention) to 56% +/- 16% (in long-term recanalization) (p less than 0.025). Ventricular loading conditions were not different at pre-SK intervention angiography and chronic angiography. EF rose modestly from 51% +/- 14% to 57% +/- 18% in the 23 patients recanalized on follow-up, in whom pre-SK intervention angiography revealed collaterals to the infarcting area (p less than 0.025), whereas there was no EF change in the 23 chronically recanalized patients without pre-SK collaterals. In the eight patients recanalized at late follow-up, who had preadmission chest pain for less than 3 hours and successful SK reperfusion within 4 hours of symptom onset (group A), EF increased significantly from 51% +/- 12% to 65% +/- 6% (p less than 0.025). In the 25 chronically recanalized patients admitted 3 to 6 hours after onset of chest pain, in whom SK reperfusion was successful (group B), EF was unchanged at late study. In the 13 chronically recanalized patients with preadmission chest pain lasting longer than 6 hours, in whom SK reperfusion was successful (group C), EF increased from 52% +/- 13% before SK intervention to 56% +/- 16% at late study (p less than 0.025). Pre-SK intervention angiography revealed collateral vessels to the infarct area in 69% of group C patients but in only 42% of patients in groups A and B. These findings suggest that the critical interval for myocardial salvage, as well as for early and long-term improvement of LV function by SK reperfusion at admission, is 4 hours after onset of chest pain in the majority of AMI patients. This time interval may be longer in patients with well-developed collateral supply to the region of the acute infarct.