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Families of asteroids generated by the collisional fragmentation of a common parent body have been identified using clustering methods of asteroids in their proper orbital element space. An alternative method has been developed in order to identify collisional families from the correlation between the asteroid fragment sizes and their proper semi-major axis distance from the family centre (V-shape). This method has been shown to be effective in the cases of the very diffuse families that formed billions of years ago. We obtained photometric observations of asteroids in order to construct their rotational light curves; we combine them with the literature light curves and sparse-in-time photometry; we input these data in the light curve inversion methods to determine the shape and the spin pole of the asteroids in order to assess whether an object is prograde or retrograde. The ultimate goal is to assess whether we find an excess of retrograde asteroids on the inward side of the V-shape of a 4 Gyr asteroid family identified via the V-shape method. This excess of retrograde rotators is predicted by the theory of asteroid family evolution. We obtained the spin poles for 55 asteroids claimed to belong to a 4 Gyr collisional family of the inner main belt that consists of low-albedo asteroids. After re-evaluating the albedo and spectroscopic information, we found that nine of these asteroids are interlopers in the 4 Gyr family. Of the 46 remaining asteroids, 31 are found to be retrograde and 15 prograde. We also found that these retrograde rotators have a very low probability (1.29%) of being due to random sampling from an underlying uniform distribution of spin poles. Our results constitute corroborating evidence that the asteroids identified as members of a 4 Gyr collisional family have a common origin, thus strengthening their family membership., 20 pages, 7 figures. A&A (2022)

From October, 1977 to April, 1983, a total of 500 transluminal coronary angioplasties (TCA) were performed. The acute success rate averaged 71%, in stenoses of the anterior interventricular branch it was 75%. Long-term results were assessed on the basis of clinical findings, functional studies including ergometry, radionuclide ventriculography and thallium scan, revealing a recurrence rate of 13%. Repeat angiography of 213 patients with successful angioplasty indicated a recurrence of 15% (lasting widening of the stenosis less than 20%). All recurrences occurred within the first three months. A second angiogram was performed 12 months after successful angioplasty in 66 patients who three months after the origin TCA had shown no recurrence. In no case was there a reduction in the widened stenosis. The reported recurrence rate is lower than comparable figures in published reports. Possible reasons for this may be the selection of patients, the technique of angioplasty and long-term treatment with acetylsalicylic acid, nitrates and calcium antagonists.

Sixteen pseudoaneurysms occurred after 1796 femoral arterial punctures for diagnostic coronary angiography and/or angioplasty, performed between 1. 1. 1993 and 25. 3. 1994. One additional patient with pseudoaneurysm had undergone a femoral arterial puncture at another hospital. Primary colour Doppler-directed compression of the pseudoaneurysm (15-minute compression followed by 10-minute compressions, as needed) was successful in 16 patients. There was one recurrence, after five days, which was successfully and lastingly treated by another compression. Primary thrombosing by compression of the pseudoaneurysm failed in only one patient, but after spontaneous thrombosis achieved by a compression bandage no flow was demonstrable on the following day. Clinical examination and/or colour Doppler sonography was performed on all patients a mean of 84 days (5 days to 6 months) after successful treatment: no recurrence was recorded. There were no significant early or late complications. These data indicate that colour Doppler-monitored compression of femoral-artery pseudoaneurysm can be considered the treatment of choice, with few exceptions, for this not rare complication of arterial catheterization.

Photometric data on 17 binary near-Earth asteroids (15 of them are certain detections, two are probables) were analysed and characteristic properties of the near-Earth asteroid (NEA) binary population were inferred. We have found that binary systems with a secondary-to-primary mean diameter ratio D s / D p ⩾ 0.18 concentrate among NEAs smaller than 2 km in diameter; the abundance of such binaries decreases significantly among larger NEAs. Secondaries show an upper size limit of D s = 0.5 – 1 km . Systems with D s / D p ⩽ 0.5 are abundant but larger satellites are significantly less common. Primaries have spheroidal shapes and they rotate rapidly, with periods concentrating between 2.2 to 2.8 h and with a tail of the distribution up to ∼4 h. The fast rotators are close to the critical spin for rubble piles with bulk densities about 2 g/cm3. Orbital periods show an apparent cut-off at P orb ∼ 11 h ; closer systems with shorter orbital periods have not been discovered, which is consistent with the Roche limit for strengthless bodies. Secondaries are more elongated on average than primaries. Most, but not all, of their rotations appear to be synchronized with the orbital motion; nonsynchronous secondary rotations may occur especially among wider systems with P orb > 20 h. The specific total angular momentum of most of the binary systems is similar to within ±20% and close to the angular momentum of a sphere with the same total mass and density, rotating at the disruption limit; this suggests that the binaries were created by mechanism(s) related to rotation near the critical limit and that they neither gained nor lost significant amounts of angular momentum during or since formation. A comparison with six small asynchronous binaries detected in the main belt of asteroids suggests that the population extends beyond the region of terrestrial planets, but with characteristics shifted to larger sizes and longer periods. The estimated mean proportion of binaries with D s / D p ⩾ 0.18 among NEAs larger than 0.3 km is 15 ± 4 % . Among fastest rotating NEAs larger than 0.3 km with periods between 2.2 and 2.8 h, the mean proportion of such binaries is (66+10−12)%.

Aims Glimepiride is a new sulfonylurea for diabetes treatment which is supposed to impact less on extra-pancreatic ATP-dependent K+channels than the conventional drug glibenclamide. This study was performed to evaluate whether this results in a better maintenance of ATP-dependent K+channel mediated ischaemic myocardial preconditioning. Methods and Results In a double-blind placebo-controlled study the period of total coronary occlusion during balloon angioplasty of high grade coronary artery stenoses was used as a model to compare the effects of both drugs. Quantification of myocardial ischaemia was achieved by recording the intracoronary ECG and the time to the occurrence of angina during vessel occlusion. All patients underwent three dilatations. The first dilatation (dilatation 1) served to determine the severity of ischaemia during vessel occlusion. During dilatation 2, baseline values were recorded. Thereafter, glimepiride (15 patients: 1·162mg), glibenclamide (15 patients: 2·54mg) or placebo (15 patients) were intravenously administered over 12min. Dilatation 3 started 10min after the beginning of the drug administration. Mean ST segment shifts in the placebo group decreased by 35% (dilatation 2: 0·23; dilatation 3: 0·15mV; CI −0·55 to 0·00mV; P =0·049). A similar reduction also occurred in the glimepiride group, in which repetitive balloon occlusion led to a 34% reduction (dilatation 2: 0·35; dilatation 3: 0·23mV; CI −0·21 to −0·02mV; P =0·01). There was little influence however, on mean ST segment shifts in the glibenclamide group (dilatation 2 and dilatation 3: 0·24mV; CI −0·10 to 0·25mV; P =0·34). Accordingly, time to angina during balloon occlusion slightly increased (by 30%) in the placebo group (dilatation 2: 37s; dilatation 3: 48s; CI 0·0 to 15·0s; P =0·16); increased by 13% in the glimepiride group (dilatation 2: 40s; dilatation 3: 45s; CI 0·0 to 14·0s; P =0·023); and remained unchanged in the glibenclamide group (dilatation 2 and dilatation 3: 30s; CI −7·5 to 7·5s; P =0·67). Conclusion These results show that glimepiride maintains myocardial preconditioning, while glibenclamide might be able to prevent it.

Der positive Einflus der PTCA auf die Symptomatik ist fur alle Schweregrade der koronaren Herzerkrankung sicher belegt. Weit schwerer fallt der Nachweis einer prognostischen Wirkung. Dies trifft bzw. traf auch fur andere Behandlungsformen zu, wie die medikamentose Therapie und die Bypasschirurgie. Generell lies sich unter den verschiedenen Therapien eine Prognoseverbesserung fur Patientenkollektive mit geringem Spontanrisiko statistisch nur sehr schwer, fur Patienten mit hohem Spontanrisiko dagegen einfach belegen. Dafur sind randomisierte Studien bei letzteren Patienten aus ethischen Grunden weit schwerer durchfuhrbar.

The cardiodepressant and vasodilator effects of an intravenous (i.v.) infusion of 0.5 mg isradipine or 2 mg nifedipine were interindividually (10 vs. 10 patients) compared in a double-blind study in patients with stable coronary heart disease. To minimize vasodilation-induced autonomic reflex mechanisms, which may counterbalance negative inotropic effects after acute administration of calcium antagonists, i.v. autonomic blockade was produced by 0.2 mg/kg propranolol and 0.04 mg/kg atropine. Systemic hemodynamics were measured before and 15 min after the end of the 15-min calcium antagonist infusion. After administration of both drugs, heart rate (HR) decreased similarly during the observation period (isradipine from 93 +/- 10 to 88 +/- 9 beats/min and nifedipine from 84 +/- 9 to 79 +/- 6 beats/min, both p less than or equal to 0.01). The reduction in total peripheral resistance (TPR) was significantly (p less than or equal to 0.01) greater after isradipine (from 1,376 +/- 285 to 1,002 +/- 224 dynes s cm-5) than after nifedipine (1,258 +/- 262 to 1,112 +/- 225 dynes s cm-5). Between the two drugs, the difference in the reduction of afterload independent dP/dt40, determined by tip-manometry, reached borderline significance (p = 0.08) (isradipine from 1,197 +/- 258 to 1,157 +/- 225 mm Hg/s, NS and nifedipine 1,228 +/- 226 to 1,109 +/- 227 mm Hg/s, p less than or equal to 0.01).(ABSTRACT TRUNCATED AT 250 WORDS)

Trimetazidine (TMZ) has recently been shown to improve anginal symptoms without altering haemodynamic variables. A randomized, double-blind, placebo-controlled study was conducted in 20 patients to study the effects of TMZ on the severity of myocardial ischaemia during PTCA of the left anterior descending coronary artery. Five minutes after a first successful dilatation (D0), a control balloon inflation (D1) was performed until onset of ischaemic signs on both the intracoronary (i.c.) and precordial ECG. Two minutes later, patients received either TMZ 6 mg or placebo i.c. Another inflation (D2) was performed 5 min after D1. No differences were found between the two groups regarding responses in heart rate, systemic and i.c. pressures during the study. TMZ decreased the maximum ST-segment shift at D2 compared with D1 (0.8 +/- 0.1 vs 1.4 +/- 0.3 mV, P = 0.023) and delayed its onset (46 +/- 4 vs 36 +/- 5 s, P = 0.024). TMZ also decreased maximum T-wave changes (1.06 +/- 0.24 vs 2.19 +/- 0.3 mV, P = 0.001), and significantly reduced the area under the curve (mv s-1) of the i.c. ST-segment and T-wave changes during balloon inflation (P = 0.042 and P = 0.009 respectively). The placebo had no effect on these parameters. These results support the hypothesis that trimetazidine has a direct anti-ischaemic effect on human myocardial cells.

Cell culture experiments and various animal models have shown that calcium antagonists can inhibit atheroma development. A number of antiatherosclerotic mechanisms have been proposed and the promising results of these in vitro and animal experiments prompted clinical trials. Retrospective analyses indicated that verapamil might retard disease progression and the development of new stenoses. Prospective clinical studies, however, have revealed no effect by calcium antagonists on pre-existing coronary stenoses (> or = 20%) and it is suggested that the study duration (2 to 3 years) may have been too short and that advanced stages of atheromatous disease are not influenced by calcium antagonists. Current data suggest that only early stages of coronary atheromatosis may be affected by treatment with calcium antagonists; however, optimum drug, dosage and suitable patients are yet to be defined.

One hundred and three patients with a history of ventricular arrhythmia were screened by baseline 24-h Holter monitoring for a minimal mean number of 30 premature ventricular beats (PVB) per hour. One hundred and one patients were subsequently enrolled in a double-blind, cross-over trial, including four 4-day periods with administration of placebo (PL) or nicainoprol (N.) in doses of 200, 400, 600 mg three times daily in randomized order. Antiarrhythmic efficacy could be evaluated in 61 patients who met all requirements of the protocol, including a complete sequence of valid Holter recordings (> 18 h each). Total PVBs were significantly reduced by the 400-mg dose (65%) and the 600-mg dose (71%) as compared to baseline. Two hundred mg N. and PL led to a non-significant reduction of PVBs by 41% and 24%, respectively. An individual response, assumed where there was simultaneous reduction of total PVBs > 75%, of ventricular pairs > 90% and elimination of ventricular runs, wasfoundin6 (10%), 10 (16%),21 (34%),and 22 (36% ) patients with PL, 200 mg N., 400 mg N. and 600 mg N., respectively. Four hundred and 600 mg N. significantly prolonged the PR interval (0·17 s and 0·18 s; median values) as compared with baseline (0·16 s), while the QRS duration was significantly increased only by the 600-mg dose (from 0·10 to 0·11 s). Heart rate, mean blood pressure, QT and JTc intervals were not significantly influenced by any dose of N. Plasma concentrations of nicainoprol were dose related in a linear fashion (200 mg: 1·0 µg /ml, 400 mg: 20 µg/ml, 600 mg: 3·0 µg/ml). The extent of PR interval prolongation, correlated with mean plasma concentrations; PVB suppression did not. Seven patients complained of extracardiac side effects most frequently after 600 mg N. t.i.d. (nausea, dizziness, gastrointestinal discomfort, exanthema). In one patient fatal ventricular fibrillation occurred during the first treatment period (600 mg t.i.d.). It is concluded that nicainoprol leads to a dose-related suppression of PVBs in patients with frequent ventricular arrhythmias due to various cardiac disorders. With regard to both antiarrhythmic efficacy and tolerance, a dose of 400 mg t.i.d. appears re commendable. This dose covered more than 90% of the responding patients with virtually no side effects.

Left ventricular systolic and diastolic performance was evaluated by radionuclide angiography in 17 patients following cardiac transplantation and compared with normal persons. Both groups performed supine bicycle exercise during the investigation, the control group at 102 ± 73 W and the transplanted patients at 61.2 ± 15 W. The ejection fraction increased in the normal persons from 61 ± 8 to 69 ± 10% whereas in the transplanted patients it did not increase significantly. There were no relevant changes in systolic parameters during exercise in the transplant recipients. The changes in diastolic parameters were significantly smaller in transplant patients than in normals. After correction for heart rate-induced changes a significantly different time course of the systolic-diastolic sequence during the cardiac cycle became evident in the transplanted group at rest. During exercise the systolic-diastolic sequence during the cardiac cycle became similar in both groups. It is concluded that the reduced exercise capacity of patients in the late phase after cardiac transplantation is partially due to the absence of an EF increase and a limitation of diastolic reserve during exercise.

In a double-blind cross-over study, 10 patients with stable angina pectoris owing to coronary heart disease were investigated in supine position during rest and bicycle exercise for the effect of 0.4 mg of intravenous (i.v.) isradipine in comparison to 2 mg i.v. nifedipine on cardiac hemodynamics and myocardial ischemia. At rest, both drugs significantly decreased total peripheral resistance (TPR) and mean arterial blood pressure (MAP), whereas heart rate (HR) increased. The pressures and resistance of the pulmonary circulation remained uninfluenced at rest. During symptom limited-exercise, both medications reduced TPR despite an unchanged MAP. Mean pulmonary artery pressure decreased significantly after both medications, whereas right atrial pressure (RAP), pulmonary capillary wedge pressure (PCWP), and pulmonary vascular resistance (PVR) decreased significantly only after nifedipine. The improvement of mean ischemic ST-segment depression averaged 44 +/- 6% (mean +/- SEM, p less than or equal to 0.01) after nifedipine and 45 +/- 7% (p less than or equal to 0.01) after isradipine. The time until angina appeared increased after isradipine by 89 +/- 28% (p less than or equal to 0.05) and after nifedipine by 105 +/- 42% (p less than or equal to 0.01). Significant differences between the two medications appeared only for cardiac output (CO) at rest (p less than or equal to 0.05), during which state the increase after isradipine was higher than after nifedipine, and for exercise HR (p less than or equal to 0.01), during which state only nifedipine induced a significant increase in frequency. We conclude that at the chosen dosages the hemodynamic and antiischemic effects of isradipine are similar to the effects that occur after nifedipine.

Immunological events are involved in the pathophysiology of chronic active hepatitis as indicated from the accumulation of T lymphocytes at the site of tissue damage. We generated T cell clones from liver biopsies of 3 patients with chronic active hepatitis B and 2 patients with primary biliary cirrhosis. These T cell clones (n = 84) were analyzed by means of T cell receptor (TcR) beta gene rearrangements to determine whether the infiltrate consists of a polyclonal or oligoclonal T cell population. The vast majority (62 of 64) of T cell clones from three different patients with chronic active hepatitis B showed no identical rearrangements of the TcR beta chain genes. In marked contrast, in both patients with primary biliary cirrhosis, T cell clones established were of limited diversity. Thus 5 out of 10 and 2 out of 10 T cell clones from one patient and 3 out of 9 and 2 out of 9 T cell clones from the second patient, respectively, showed identical TcR beta gene rearrangements. These data suggest that a clonal dominance is characteristic for local T cell responses in autoimmune liver disease such as primary biliary cirrhosis whereas in virus-induced chronic active hepatitis T cell activation occurs polyclonally.

When right ventricular (RV) afterload is abnormally increased, it correlates inversely with right ventricular ejection fraction (RVEF). We tested, whether this would be different with normal afterload. Additionally, we investigated whether previous studies on the slope of RV preload recruitable stroke work (SW) relation, which used rather non-physiological measures to change RV preload, could be transferred to more physiological loading conditions. RV volumes were determined by thermodilution in 16 patients with stable coronary artery disease and normal pulmonary artery pressure (PAP) at rest. Pre- and afterload were varied by body posture, nitroglycerin (NTG) application and by exercise at different body positions. At rest, the change from recumbent to sitting position decreased PAP, cardiac index (Ci), RV diastolic and systolic volumes, and RVEF. Additionally, mean pulmonary artery pressure (MPAP) correlated positively with both RVEF and cardiac index. After correction for mathematical coupling, the RV preload recruitable SW relation was: right ventricular stroke work index (RVSWi) (103 erg m-2)= 8.1 x (RV end-diastolic volume index -4.9), with n=96, r=0.57, Por =0.001. Exercise abolished this correlation and led to an inverse correlation between RV end-systolic volume (ESV) and RVSW. In conclusion, (i) RVEF correlates positively with RV afterload when afterload varies within normal range; (ii) the slope of the RV preload recruitable SW relation, which is obtained at steady state under normal loading conditions, is substantially flatter than previously described for dynamic changes of RV preload. With increasing afterload, preload loses its determining effect on RV performance, while afterload becomes more important. This puts earlier assumptions of an afterload independent RV preload recruitable SW relation into question.

Serum magnesium analysis does not reflect body content of magnesium. So substitution is based on empirical maneuvers.In a study on 44 patients urinary magnesium excretion was analyzed before and after oral magnesium substitution (40 mval). The provable hypothesis was the estimation that patients in magnesium deficiency under chronical diuretic treatment (n = 11) would have a lower magnesium excretion than patients of the control group (n = 10). Further analysis was done with patients after orthotopic cardiac transplantation (n = 12) and those suffering from coronary heart disease (n = 11).After oral administration of magnesium in all 4 groups there was a rise in blood levels, only significant in the patient group under chronic diuretic treatment. Urinary magnesium excretion, however, showed no significant differences. Patients after cardiac transplantation had the lowest rise in urinary magnesium excretion.There was no clear differentiation by means of this oral magnesium substitution test. Magnesium excretion even after oral substitution is of no value to analyze magnesium deficiency.

A 56-year-old man in marked right heart failure (stage III-IV of the New York Heart Association classification) and severe pulmonary hypertension was admitted to a rehabilitation clinic for therapeutic and social-medical assessment. On physical examination the important features were markedly distended neck veins, tachycardia at rest (90/min), a loud 2nd pulmonary sound and dyspnea.Non-invasive tests (ECG, echocardiography, abdominal ultrasound and lung functions) confirmed right heart failure; invasively obtained haemodynamic data indicated its severity. Selective pulmonary angiography defined the embolisation to be central and bilateral.As intensive drug treatment and physiotherapy had failed to achieve significant improvement, operative removal of the bilateral central and some segmental pulmonary thrombi was performed and an inferior vena caval filter inserted. Immediately after operation the markedly elevated right-heart and pulmonary artery pressures fell markedly and there was dramatic improvement in the patient's general condition and in his physical capacity. Angiography demonstrated largely normal pulmonary perfusion. Instead of the anticipated retirement, the patient was discharged on anticoagulants, in the expectation of a return to full-time work.With pulmonary thrombendarterectomy severe chronic thromboembolic pulmonary hypertension may well be treated.

Alternative coronary angioplasty techniques have not been applied as often as initially supposed. Due to the favorable success rates, complication rates and costs, balloon angioplasty is still the gold standard and primary intervention procedure. Beyond that, in randomized studies recurrence rates were shown mostly higher with newer techniques. Thus alternative techniques are recommendable only when balloon angioplasty is unsuccessfull or when a failure is to be expected. Today, some niches for alternative techniques can be defined, although they have to be confirmed in further randomized studies, particularly since these techniques usually require a final balloon dilatation and can give rise to new complications.

Swimming differs from other forms of exercise due to its additional hydrostatic and thermal burden. It was investigated whether additional pathologic findings in comparison to history and standard exercise tests can be obtained by holter monitoring during swimming. Symptoms and exercise electrocardiogram were compared with the holter ECG during swimming in 125 patients divided into 3 groups with different diagnoses and severity of cardiac diseases. In a considerable percentage of patients ischemic changes and severe rhythm disturbances were found only during swimming with further diagnostic and therapeutic consequences, though patients with moderate and severe angina and with significant ischemic signs in the exercise test were excluded and mainly patients with slight or absent symptoms were evaluated predominantly. Thus, since swimming is a favorite leisure-time occupation also in patients with diseases of heart and circulation, holter monitoring during swimming is of diagnostic importance in the rehabilitation of these patients.

The long-term antihypertensive efficacy of molsidomine 8 mg bid was studied in 24 patients with coronary artery disease in a double-blind, placebo-controlled trial of 3 weeks duration. Ambulatory 24-h blood pressure measurements were performed at days 1, 2, 7, 14, and 21. Sphygmomanometric measurements of blood pressure heart rate and a protocol for number and time of angina pectoris attacks were also taken. Following the application of molsidomine a reduction of mean 24-h systolic blood pressure of 14% and of mean diastolic blood pressure of 11% was observed. The duration of the blood-pressure-lowering action was 7 h. After 3 weeks of treatment with 8 mg molsidomine sr bid a persistent and significant reduction of systolic and diastolic blood pressure was found. A similar acute and long-term effect was found by manually measured blood pressures. Heart rate was unchanged under molsidomine while the frequency of angina pectoris was diminished. In conclusion, a long-lasting antihypertensive efficacy (without signs of tolerance) was found over a 3-week period of treatment with 8 mg molsidomine in a slow-release formulation given twice a day.

Today indication for percutaneous transluminal coronary angioplasty is based on typical chest pain and objective signs of myocardial ischemia during exercise. Especially in chronic coronary occlusions, however, prognostic implications may play an increasing role in the future. The case report describes long-term follow-up of a patient in whom a chronic complete occlusion of the right coronary artery could be reopened successfully back in September 1988. At this time, the peripheral part of the occluded RCA was filled retrogradely by septal collaterals from the LAD. After reopening the patient remained symptom-free for more than two years. In January 1991 again severe angina recurred and ECG showed a non-transmural anterior myocardial infarction. The LAD was occluded proximal and the peripheral part was filled retrogradely by septal collaterals coming from the right coronary artery which was still open (flow reversal). Left ventricular function was only slightly impaired and the LAD occlusion could be reopened successfully too. The case suggests that prognostic implications should be taken into consideration in addition to symptoms especially in complete coronary occlusions.

Central venous puncture is required for endomyocardial biopsy to identify rejection after cardiac transplantation. We evaluated our use of the Seldinger technique to determine the safety of this invasive method.In 42 immunosuppressed patients central venous puncture was performed after cardiac transplantation using the Seldinger technique for right heart biopsy. Together with physical examinations, chest X-ray and cardiac ultrasonography were performed during the inhospital follow-up. Outpatient follow-up continues and all reported adverse effects were evaluated by the attending cardiologist.There were a total of 620 central venous punctures, most via the right internal jugular vein (77.9%). The planned puncture could not be performed in 3.2% of the cases and an alternative site was used. The femoral approach was associated with the longest radiation time. No severe adverse effects were observed and no complications (infection, large haematoma, pneumothorax, severe rhythm disorders) were recorded.Even in immunosuppressed patients frequently requiring central venous puncture, right heart endomyocardial biopsy can be safely performed to evaluate rejection.

Between January 1979 and October 1991, percutaneous transluminal angioplasty of stenosed or occluded coronary bypass grafts was attempted 180 times in 146 patients (180 lesions in 157 bypass grafts); 6/157 grafts were internal mammary grafts. The procedure was successful in 129/157 grafts (82%) and in 151/180 lesions (84%). Failures occurred almost exclusively in recanalization attempts. Cardiac complications occurred in 4/146 patients (2.7%). Three patients developed an acute myocardial infarction, another patient died after acute occlusion of a native vessel dilated during the same procedure. In successful attempts the severity of stenosis was reduced from 87 +/- 10% to 33 +/- 15%. 113/129 successfully dilated grafts had at least one (mean 2.7) control angiogram. 54/113 (48%) showed recurrence after a mean follow up of 6 months. An additional 15 grafts showed late restenosis in a second control angiogram (mean follow-up 23 months). The total restenosis rate was 61%. Restenoses were dilated again one to six times (mean 1.9) with comparable success and recurrence rate. Two patients died during the sixth angioplasty. Finally, 32/129 (25%) grafts were occluded or presumably occluded, and 97/129 (75%) were angiographically confirmed open without restenosis. Thus, angioplasty of bypass grafts is an alternative to a repeat revascularization surgery. The acute results are comparable to the results of angioplasty in native coronary arteries. The restenosis rate is high. One has to be aware of late restenosis. Restenosis can be dilated repeatedly with a comparable success rate and with no significant increase in restenosis rate.

In a series of 8500 consecutive coronary angiographies, we found three times an "anatomic single coronary artery" with origin of the right coronary artery from the AV-branch of the dominant circumflex artery (incidence 0.035%). In all three patients the investigation was made because of the suspicion of coronary heart disease. All 59 previously published cases (44 found at coronary angiography, 15 at necropsy) and our own three cases were not associated with other cardiovascular anomalies. A pathophysiological significance of this anomaly alone with regard to inducing myocardial ischemia can almost be excluded. The knowledge of this anomaly however is important to avoid errors in diagnosis and to evaluate the exact degree of severity of coronary heart disease.

Most patients with coronary anomalies are asymptomatic. The knowledge of those variations could be important in regard to invasive catheter treatment or bypass surgery. In a retrospective study, the angiographic findings based on 4, 016 patients (1985-1989) were analyzed concerning coronary anomalies and malformations. Of the patients studied, 39 (0.97%) had coronary anomalies, and in 26 of these patients it was an anomalous circumflex branch. In 14 cases, the circumflex branch arose from a separate origin in the left aortic sinus. In 11 patients the origin was from the proximal segment of the right coronary artery. A singular coronary artery was found in five patients, originating from the right aortic sinus in two patients and from the left aortic sinus in three patients. An origin of the left coronary artery from the pulmonary artery, a coronary fistula, or an origin of the left anterior descending coronary artery from the RCA could be found in only one patient. Unexpected findings during invasive procedures would suggest a possibly existing coronary anomaly, especially when main branches cannot be opacified by selective contrast medium injection.

Postrheumatic mitral stenosis might cause impairment of right ventricular (RV) function due to both an increase in RV afterload and rheumatic myocardial disease. Therefore, we investigated in 19 patients with postrheumatic mitral stenosis and sinus rhythm right ventricular volumes and hemodynamics by a computerized thermodilution catheter during rest and supine bicycle exercise. In 14 patients the investigation was repeated within 2 days after balloon mitral valvuloplasty. Resting RV ejection fraction was decreased (43 (15-53)%, median (range)) and correlated significantly with RV end-systolic volume index (r = -0.90), stroke volume index (r = 0.77), RV end-diastolic volume index (r = -0.76), heart rate (r = -0.69), pulmonary artery resistance (r = -0.69), and mean pulmonary artery pressure (r = -0.68). RV end-diastolic volume index was 107 (81-200) ml/m2. Exercise induced a decrease of RV ejection fraction to 36 (13-48)% at 50 Watt (p0.001), while it increased RV end-diastolic volume index to 131 (78-231) ml/m2 (p0.001). Balloon mitral valvuloplasty improved RV ejection fraction at rest from 41 (15-47)% to 48 (39-55)% (p0.005) and from 30 (13-46)% to 43 (27-56)% during exercise (p0.005). The increase of RV ejection fraction after valvuloplasty was caused by an increase in stroke volume, but not by a reduction in RV end-diastolic volume.Depending on the increased RV afterload, RV function is markedly depressed in mitral stenosis. An immediate and almost complete improvement of RV function occurs with the reduction of RV afterload after balloon mitral valvuloplasty.(ABSTRACT TRUNCATED AT 250 WORDS)

Endomyocardial biopsy in cardiac transplantation is still the most exact test (gold standard) to confirm or exclude a suspected rejection. Up to now, all available noninvasive tests suffer from a low sensitivity and specificity. For a further reduction of biopsies early available noninvasive methods are desirable. In the data presented a comparison between histological findings and heart volume measurements is shown in 40 patients (112 histological findings) after orthotopic cardiac transplantation. In 46 cases with no evidence of histological rejection the echocardiographically or radiologically determined heart volume was 869 +/- 142 ml/1.73 m2 body surface area, compared to 1026 +/- 178 ml/1.73 m2 in 29 cases with mild cardiac rejection. In 37 cases with a moderate or severe rejection heart volume as 1094 +/- 181 ml/1.73 m2. The diagnosis of a moderate or severe rejection by biopsy is combined with a heart volume above 950 ml/1.73 m2 with a sensitivity of 78% and a specificity of 73%. Intramyocardial edema as well as an increase in right and left ventricular volumes due to heart failure may be the causes for heart volume increase in rejection. Thus, heart volume measurement which can be performed easily during routine echocardiography gives additional information about whether a rejection has to be assumed or can be excluded. Today, sensitivity and specificity of the test does not allow a reduction of biopsy frequency. Further investigations are necessary to analyze the course of heart volume changes during an episode of rejection.

The large number of cardiovascular diseases affecting in particular the elderly represents a potential traffic hazard. MAJOR Points discussed: The significance of various cardiovascular diseases on a person's fitness to drive is presented with particular attention being paid to coronary heart disease. Our present knowledge about cardiovascular disease as a cause of accidents is extremely modest, and expert recommendations are often unrealistic and impractical. The risk of a disease leading to unfitness to drive decreases with increasing quality of medical management and treatment. The particular responsibility of the physician is, however, instruction and counselling, and especially the choice of proper treatment.In view of a deterioration in critical faculties and in the ability to compensate for loss of performance, due in particular to the multimorbidity commonly met with in old age, a general examination of the geriatric for fitness to drive is worth considering.

30-day-old polymyopathic hamsters (strain BIO 82.62) were orally treated with either magnesium pyridoxal 5-phosphate glutamate 100 mg/kg, equimolar amounts of magnesium alone (MgCl2 55 mg/kg), or water b.i.d. for 30 days, or sacrificed before treatment. 60-day-old healthy hamsters (strain CLAC) served as controls. Magnesium pyridoxal 5-phosphate glutamate lowered the myocardial calcium content (42.8 +/- 13.1 mmol/kg dry weight) as compared to MgCl2 (70.3 +/- 11.9 mmol/kg dry weight) and water (72.7 +/- 13.6 mmol/kg dry weight). The serum and tissue lipid pattern did not differ between BIO 82.62 and normal hamsters except high serum cholesterol and triglyceride levels in 30-day-old BIO 82.62 hamsters. Myocardial necroses were influenced by neither magnesium pyridoxal 5-phosphate glutamate nor MgCl2. Cytochemical investigation of the ultrastructural calcium localization in the aorta revealed less calcium precipitates with magenesium pyridoxal 5-phosphate glutamate in media myocytes. It is concluded that magnesium pyridoxal 5-phosphate glutamate exerts a calcium antagonistic effect in the cardiomyopathy of the Syrian hamster which is related neither to the magnesium content of magnesium pyridoxal 5-phosphate glutamate nor to its lipid lowering activity.

Changes in blood and plasma volumes were investigated in the course of diagnostic cardiac catheterizations, comparing the effect of a high and a low osmolar contrast medium in 30 patients (5 women and 25 men; mean age 53 [19-76] years) with coronary heart disease (n = 27) or valvular defect (n = 3). Using a randomized, double-blind protocol 15 patients received amidotrizoic acid (2.1 osmol/kg; mean dosage 166 +/- 68 or 2.2 +/- 1.1 ml/kg), while 15 patients received iopamidol (0.8 osmol/kg; mean dosage 154 +/- 78 ml or 2.1 +/- 1.0 ml/kg). The indocyanine-green method and the haematocrit were used to measure blood and plasma volumes immediately before and after the angiocardiography. Blood volume after amidotrizoic acid injection increased by a mean of 4.9% (228 +/- 242 ml) and by 0.4% (17 +/- 197 ml) after iopamidol (P less than 0.05). Plasma volume increased by a mean of 11.8% (331 +/- 150 ml) after amidotrizoic acid and 5.7% (157 +/- 97 ml) after iopamidol (P less than 0.01). The increase in plasma volume correlated with the dose of contrast medium: 2 ml per ml amidotrizoic acid (r = 0.93) and 1 ml per ml iopamidol (r = 0.82).--During angiocardiography blood and plasma volume may increase by up to 500 ml, an increase which depends not only on dosage but also on the osmolality of the injected contrast medium.

10,975 diagnostic left-heart catheterizations, performed between 1968 and 1987 in 8,436 men and 2,539 women, were analysed regarding indication, results and therapeutic implications. 6,974 patients (64%) had coronary heart disease, 2,573 (23%) a valvar defect and 849 a cardiomyopathy. The proportion of patients with coronary heart disease increased from 21% to 74% during the 20-year period, while that of patient with valvar defects fell from 52% to under 19%. Severe cardiac complications in relation to the procedure occurred in 0.88%, ending fatally in 8 patients (0.07%). 61% of patients with coronary heart disease and 31% of those with valvar defects were treated conservatively. Percutaneous transluminal coronary angioplasty (PTCA) gradually became more common after its introduction in 1977. In 1987, PTCA was indicated as often as a bypass operation.

Severe vascular complications are an inherent risk of percutaneous transluminal coronary angioplasty (PTCA). Data from 100 emergency aortocoronary bypass operations required after 2850 interventions (3.5%) were retrospectively analysed in order to identify factors that determine postoperative infarct size. Large infarctions were assumed if the patient died of cardiogenic shock (n = 12), if postoperative angiography demonstrated a decrease in left ventricular ejection fraction of more than 20% of if R-waves in the ECG decreased by more than 40% and a QRS-score increased by more than 5. According to these definitions, 29 patients experienced large infarctions, while 71 experienced no or only small infarctions. The following factors differentiated the two groups: age (58 vs 53 years, P = 0.008), pre-PTCA exercise work load (88 vs 118 Watts, P = 0.0001), exercise ischaemia score (2.7 vs 1.9, P = 0.045), degree of pre-PTCA stenosis (83 vs 86%, P = 0.03), coronary multivessel versus single vessel disease (60 vs 38%, P = 0.02), collaterals to the target vessel (10 vs 34%, P = 0.05), total vascular occlusion during PTCA (76 vs 56%, P = 0.035), and long duration of ischaemia after onset of the complication (253 vs 179 min, P = 0.012). Data from patients with large postoperative infarctions who survived ranged between those with no or small infarctions and those who died of cardiogenic shock. Higher age (P = 0.04), reduced exercise tolerance (P = 0.0004), absence of collaterals (P = 0.04), and duration of ischaemia until reperfusion (P = 0.001) were independent predictors of large postoperative myocardial infarctions.(ABSTRACT TRUNCATED AT 250 WORDS)

One hundred and three patients with a history of ventricular arrhythmia were screened by baseline 24-h Holter monitoring for a minimal mean number of 30 premature ventricular beats (PVB) per hour. One hundred and one patients were subsequently enrolled in a double-blind, cross-over trial, including four 4-day periods with administration of placebo (PL) or nicainoprol (N.) in doses of 200, 400, 600 mg three times daily in randomized order. Antiarrhythmic efficacy could be evaluated in 61 patients who met all requirements of the protocol, including a complete sequence of valid Holter recordings (greater than 18 h each). Total PVBs were significantly reduced by the 400-mg dose (65%) and the 600-mg dose (71%) as compared to baseline. Two hundred mg N. and PL led to a non-significant reduction of PVBs by 41% and 24%, respectively. An individual response, assumed where there was simultaneous reduction of total PVBs greater than 75%, of ventricular pairs greater than 90% and elimination of ventricular runs, was found in 6 (10%), 10 (16%), 21 (34%), and 22 (36%) patients with PL, 200 mg N., 400 mg N. and 600 mg N., respectively. Four hundred and 600 mg N, significantly prolonged the PR interval (0.17 s and 0.18 s; median values) as compared with baseline (0.16 s), while the QRS duration was significantly increased only by the 600-mg dose (from 0.10 to 0.11 s). Heart rate, mean blood pressure, QT and JTc intervals were not significantly influenced by any dose of N.(ABSTRACT TRUNCATED AT 250 WORDS)

Severe vascular complications are an inherent risk of per-cutaneous transluminal coronary angioplasty (PTCA). The data of the first 100 emergency aortocoronary bypass operations required in the first 2850 interventions (3.5%) were retrospectively analyzed in order to identify factors that determine postoperative infarct size. Large infarctions were assumed if the patient died of cardiogenic shock (n = 12), if postoperative angiography demonstrated a decrease in left ventricular ejection fraction by more than 20% or if R-waves in the ECG decreased by more than 40% and a QRS-score increased by more than 5.

31 patients with coronary artery disease (11 patients with diabetes mellitus and autonomic neuropathy. 10 patients with diabetes without neuropathy, and 10 patients with asymptomatic myocardial ischemia) participated in a study designed to investigate whether there is a difference in forearm skeletal muscle ischemia and pain threshold. The degree of ischemia was determined by plethysmographically measured reactive hyperemia. There was no difference in maximum reactive hyperemia after passive forearm ischemia of 5-min duration in the three groups. After symptom-limited ischemic work, there was significantly more reactive hyperemia in patients with silent myocardial ischemia as compared to diabetic patients. Exercise time was longer in patients with silent myocardial ischemia (153 +/- 51 s) than in patients with diabetic neuropathy (139 +/- 45 s) and diabetics without neuropathy (120 +/- 45 s). Pain as a cause of termination of symptom-limited ischemic forearm exercise occurred less frequently in patients with diabetic neuropathy (2/11) and patients with silent myocardial ischemia (3/10) as compared to patients with diabetes without neuropathy. Patients with silent myocardial ischemia had a higher ischemic tolerance in the ischemic working forearm than did diabetic patients with and without neuropathy. In patients with neuropathy, however, ischemic pain occurred less frequently at the same ischemic work level compared to diabetics without neuropathy. Therefore, diabetic neuropathy appears to facilitate the occurrence of silent myocardial ischemia. The data presented here suggest that there is a qualitative difference in ischemic tolerance between patients with silent myocardial ischemia and patients with diabetic neuropathy.

Coronary arteriography revealed severe stenoses of the proximal part of the anterior interventricular branch with normal ventricular function in two patients (aged 42 and 38 years) with stable angina and ischaemia reaction in the exercise ECG. In the first patient it was a short spur-like 80% narrowing. But percutaneous balloon angioplasty failed to change the angiographic appearance. In the other patient there was an eccentric, apparently elastic, 90% stenosis, about 10 mm long. Here, too, balloon angioplasty had failed. Subsequently directional coronary atherectomy in both patients achieved removal of the stenosis with lasting clinical improvement. Atherectomy should be considered in similar cases after failed balloon dilatation.