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δ-Protocadherins partition the zebrafish optic tectum into radial columns of neurons, and the neurons within a column are siblings derived from common neuronal progenitors., Cell–cell recognition guides the assembly of the vertebrate brain during development. δ-Protocadherins comprise a family of neural adhesion molecules that are differentially expressed and have been implicated in a range of neurodevelopmental disorders. Here we show that the expression of δ-protocadherins partitions the zebrafish optic tectum into radial columns of neurons. Using in vivo two-photon imaging of bacterial artificial chromosome transgenic zebrafish, we show that pcdh19 is expressed in discrete columns of neurons, and that these columnar modules are derived from proliferative pcdh19+ neuroepithelial precursors. Elimination of pcdh19 results in both a disruption of columnar organization and defects in visually guided behaviors. These results reveal a fundamental mechanism for organizing the developing nervous system: subdivision of the early neuroepithelium into precursors with distinct molecular identities guides the autonomous development of parallel neuronal units, organizing neural circuit formation and behavior.

The present study investigated the distribution of HLA-antigens and Bf alleles in a group of 21 patients suffering from biopsy proven Idiopathic Membranous Nephropathy (IMN). A statistically significant increase of HLA-DR3 (76.2%) was detected in the patient group as well as an increase of MT-2 (86%), which is a new supertypic specificity defined within the 8th International Histocompatibility Workshop 1980. No association between BfF1 and IMN can be deduced from this study. Only the common Bf alleles (BfFF, BfFS, BfSS) were found in the patient group presented here. Also the previously reported association between HLA-B18 and IMN was not corroborated by this study. Not a single IMN-patient typed positive for HLA-B 18. Thus the presence of two different HLA-DR-Bf-B linkage groups (HLA-DR3/BfF1/HLA-B18 and HLA-DR3/Bf; all alleles/HLA-B8) may point to at least two different immunological mechanisms underlying IMN.

Das Verfahren der subcutanen Fettabsaugung (Liposuction) in Tumeszenz-Technik wird haufig insbesondere in asthetisch-chirurgischen Kliniken und Praxen durchgefuhrt und als Wohlfuhlchirurgie beworben. Wir berichten uber zwei schwere Komplikationen im Rahmen dieses Eingriffs, einmal mit letalem Ausgang. Es handelt sich auch in erfahrenen plastisch-chirurgischen Kliniken mit qualifizierter anasthesiologischer Betreuung nicht um eine harmlose Prozedur, sondern um einen Eingriff mit samtlichen allgemeinen Operationsrisiken und moglicherweise verfahrenstypischen zusatzlichen Komplikationsmoglichkeiten.

We describe a 30-year-old patient (gravida 4, para 1) who presented at 22 weeks' gestation with signs of acute heart failure due to cardiomyopathy of pregnancy. Other causes of dilatative cardiomyopathy were ruled out. Cardiac function did not improve with medical therapy and in the 25th gestational week the decision was made to terminate the pregnancy. Symptoms improved markedly after termination. Echocardiographic follow-up before discharge from hospital showed persistent left ventricular dysfunction and at 6 months cardiac catheterization showed no improvement of left ventricular function. Endomyocardial biopsy showed features of dilatative cardiomyopathy without signs of myocarditis.

An anterior mitral leaflet aneurysm was detected by two-dimensional echocardiography using the transesophageal approach in a 53-year-old patient with cerebral ischemic event. The transesophageal examination allowed a clear description of the aneurysm which was confirmed during surgery. This case demonstrates that transesophageal echocardiography is the method of choice in evaluation of distinct valvular lesions. The importance of TEE examination in patients with a neurological history is evident.

Though rare, cardiac echinococcosis should be included in the differential diagnosis of cardiac tumors, particularly in patients originating from endemic areas or with manifestation of hydatid disease in other organs. Diagnosis and localisation of the cysts is best accomplished with non-invasive methods such as 2-D transthoracic and transesophageal echocardiography, computed tomography and NMR. Excision of the cardiac cyst from the interventricular septum in a 21 year old patient with polyvisceral echinococcosis was performed with cardiopulmonary bypass. Adjunctive medical therapy with mebendazol is being continued for 24 months postoperatively. Twelve months after surgery the patient is asymptomatic without echocardiographic signs of recurrence.

A rare case of a cardiac tumor located between the right coronary ostium and cusp of the aortic valve is reported. Diagnosis was confirmed by two-dimensional echocardiography. Histologic evaluation revealed a papillary fibroelastoma.

Zur Differenzierung zwischen essentieller und renininduzierter Hypertonie wurde bei 34 Patienten nach unterschiedlicher Kochsalzverarmung Saralasin infundiert. Nach kurzdauernder Kochsalzverarmung kam es bei 9 von 25 Patienten mit essentieller und bei 7 von 9 Patienten mit renininduzierter Hypertonie zu einem Abfall des arteriellen Mitteldruckes von mehr als 10 mm Hg. Nach langdauernder Kochsalzverarmung fiel der arterielle Mitteldruck unter Saralsin bei 11 von 16 Patienten mit essentieller und bei 8 von 9 Patienten mit renininduzierter Hypertonie um mehr als 10 mm Hg. Der Saralasin-Test erlaubte somit keine sichere Differenzierung zwischen beiden Hochdruckformen. Ebenso war durch die Plasma-Renin-Werte vor und nach Saralsin diese Differenzierung nicht moglich. Die Reninwerte unter Saralasin waren zur Blutdruckanderung negativ korreliert. Der Quotient der Reninkonzentration im Nierenvenenblut bei Patienten mit einseitiger Nierenarterienstenose wurde durch Saralasin nicht verandert. Plasmarenin und Plasmaaldosteron wurden durch Saralasin gegensinnig beeinflust.

Captopril (Lopirin Squibb, von Heyden) ein Hemmer des Angiotensin-Converting-Enzyms blockiert bei herzinsuffizienten Patienten, die durch Angiotensin II vermittelte Vasokonstriktion und Aldosteron-Stimulation. Daraus resultiert eine hochsignifikante Reduktion des kardialen Preloads und des Afterloads. Dieser Effekt fuhrt zu einem Anstieg des Herzzeitvolumens und zum Druckabfall im Lungenkreislauf. Captopril vereinigt damit die Wirkung von arteriellen und venosen Gefaserweiterern und entspricht in seinem vasodilatierenden Effekt etwa dem des Nitroprussid Natrium.

Thirtheen male patients with chronic renal failure undergoing regular dialysis treatment (2 X 8-10 hours/week) were treated with gonadotropins (HCG, Primogonyl) primarily 2 X 2,000 IU/week and later 2,000 IU/week. Before HCG administration and during 4-months HCG-therapy testosterone, dihydrotestosterone, Androstandiol, LH and FSH levels were determined by RIA-methods in 7-14 days intervals. Before HCG-application plasma testosterone levels were low and did not increase in the course of regular dialysis treatment. Derivates from testosterone like dihydrotestosterone and Androstandiol were elevated in plasma, presumbably because of accumulation in renal failure. LH-levels were slightly elevated on the average. FSH-levels showed a high individual variation but also seemed to be elevated on the average. HCG stimulation by exogenous HCG administration for short time resulted in a insufficient rise of testosterone levels as compared to normals. During prolonged HCG administration plasma testosterone levels increased to normal but dropped immediatly after cessation of therapy or reduction to less than 2,000 IU HCG twice/week. Body weight, plasma proteins, haematocrite and fertility did not improve significantly. These results indicate that in chronic renal failure androgen synthesis by testicular tissue is seriously impaired and does not improve under usual dialysis treatment. Feedback regulation of testosterone levels by increase of LH levels seems not to be sufficient although pituitary response is found to be normal. This may be explained by elevated levels of testosterone derivates which exert negative feedback effects.

Infusion des Angiotensin II Inhibitors Saralasin bei 10 Hypertonikern fuhrte nach Kochsalzverarmung zur Blutdrucksenkung, wobei eine reflektorische Steigerung von Herzfrequenz und Herzzeitvolumen ausblieben. Aus der fehlenden Kreislaufregulation nach Angiotensin II Hemmung wird auf einen unmittelbaren Einflus von Angiotensin II auf die Barorezeptoren und/oder Katecholamine geschlossen. Das Ausbleiben der blutdrucksenkenden Wirkung von Saralasin nach vorheriger Gabe von Beta-Blockern stutzt diese Hypothese.

Hundenieren, die bis zu 48 Std unter 2 atm Xenon-Uberdruck hypotherm gelagert wurden, erwiesen sich anhand ihrer Transplantatfunktion (Halsniere) als vital. Es wurden allerdings wie in der Kontrollserie (2 atm hyperbarer Sauerstoff) konservierungsbedingte Schadigungen nachgewiesen. Diese Methode eignet sich nicht zur Langzeitkonservierung, wie die vollige Funktionslosigkeit der uber 5 Tage konservierten Hundenieren zeigt.

Thirtheen male patients with chronic renal failure undergoing regular dialysis treatment (2 X 8-10 hours/week) were treated with gonadotropins (HCG, Primogonyl) primarily 2 X 2,000 IU/week and later 2,000 IU/week. Before HCG administration and during 4-months HCG-therapy testosterone, dihydrotestosterone, Androstandiol, LH and FSH levels were determined by RIA-methods in 7-14 days intervals. Before HCG-application plasma testosterone levels were low and did not increase in the course of regular dialysis treatment. Derivates from testosterone like dihydrotestosterone and Androstandiol were elevated in plasma, presumbably because of accumulation in renal failure. LH-levels were slightly elevated on the average. FSH-levels showed a high individual variation but also seemed to be elevated on the average. HCG stimulation by exogenous HCG administration for short time resulted in a insufficient rise of testosterone levels as compared to normals. During prolonged HCG administration plasma testosterone levels increased to normal but dropped immediatly after cessation of therapy or reduction to less than 2,000 IU HCG twice/week. Body weight, plasma proteins, haematocrite and fertility did not improve significantly. These results indicate that in chronic renal failure androgen synthesis by testicular tissue is seriously impaired and does not improve under usual dialysis treatment. Feedback regulation of testosterone levels by increase of LH levels seems not to be sufficient although pituitary response is found to be normal. This may be explained by elevated levels of testosterone derivates which exert negative feedback effects.

The effect of 2.5 mg prazosin orally was monitored for one hour by cardiac catheterisation in 11 patients with cardiac insufficiency as a result of primary cardiomyopathy. Mean pressures of the pulmonary capillary bed and pulmonary artery decreased on average by 9 mm Hg, of the right atrium by 2.5 mm Hg and systemically by 8 mm Hg. Judging by the increase of cardiac index patients were divided into a group of 7 "responders", all showing congestive cardiomyopathy, and a group of 4 "nonresponders" with various cardiomyopathies. During prazosin treatment cardiac index increased by 23% and pulmonary arteriole resistance decreased by 4% and pulmonary arteriole resistance increased by 41%. It is concluded that not all forms of left ventricular failure respond favourably to prazosin. Divergent effects of prazosin may possibly be caused by unequal effects on pre- and after-load of both ventricles and on variable behaviour of lung arteriole resistance.

Die kontinuierliche Periduralanalgesie zur postoperativen Schmerzbekampfung bietet gegenuber den herkommlichen Verfahren folgende Vorzuge: 1. Drastische Reduktion des Verbrauchs an Analgetika (insbesondere Opiate) und Sedativa [2]. 2. Senkung der pulmonalen Komplikationsrate durch Vermeidung der postoperativen Hypoventilation (zentrale Atemdepression, Schon-Atmung) [1, 5]. 3. Senkung der Nachbelastung des Herzens durch Sympathikolyse [4]. 4. Steigerung des Blutflusses im Bereich von Gefasanastomosen nach Operationen wegen peripherer Durchblutungsstorungen [3]. 5. Gunstige Beeinflussung der Darmmotilitat (Atonie-Prophylaxe).

The intracoronary administration of calcium channel blocking agents may potentially be useful during interventional procedures. During reperfusion of acute myocardial infarction it may allow to rule out coronary arterial spasm as the major cause of myocardial ischemia. During PTCA it may facilitate easier passage of the ballon catheter through a tight stenosis and may additionally exert regional cardioplegia with increased tolerance to myocardial ischemia. Consequently, the coronary hemodynamic and metabolic effects of Diltiazem (2mg intracoronarily) were evaluated in 13 patients with angina pectoris.

Die medikamentose Behandlung des renovaskularen Hochdrucks ist haufig unbefriedi-gend, da eine Blutdrucknormalisierung meist nicht gelingt. Die Moglichkeit eines rekon-struktiven Eingriffs bei Nierenarterienstenose (NAS) oder der Nephrektomie bei Schrumpfniere (SN) sollte deshalb bei alien renal bedingten Hochdruckformen unbedingt erwogen werden. Es stellt sich deshalb die Frage nach diagnostischen Masnahmen, die es praeoperativ erlauben, die Erfolgsaussichten durch die Operation abzuschatzen.

The effect of nifedipine and nitroglycerin on the diameter of epicardial coronary arteries, the stenosis diameter, as well as arterial blood pressure and heart rate were recorded in 20 patients with coronary-heart disease. Nifedipine (20 mg sublingually) caused a significant fall in arterial pressure and a significant rise in heart rate. Additional administration of nitroglycerin (0.8 mg sublingually) caused a further fall in arterial pressure while heart rate remained constant. A definite relaxation (vasodilatation) of the epicardial vessels was demonstrated after nifedipine and a further increase after nitroglycerin. While nifedipine on average led to a significant increase in the diameter at the site of stenosis, response of individual stenoses was highly variable. In one patient with subtotal stenosis of the anterior interventricular branch a complete, transitory occlusion at the site of the stenosis occurred during nifedipine medication. This paradoxical reaction was not noted after nitroglycerin. Relaxation of the epicardial coronary arteries by nifedipine with suppression of phasic tone thus seems to be the major part of its anti-anginal effect. This effect is potentiated by nitroglycerin so that the combination of nitrate and calcium-antagonist appears to be therapeutically reasonable. In individual patients, however, there may be a paradoxical reaction to nifedipine.

Die Belastungsuntersuchung wird fur die genauere Beurteilung vieler kardiovaskularer Erkrankungen haufig durchgefuhrt. Ziel der Belastung ist es, eine lokale oder globale Steigerung des Sauerstoffverbrauchs zu induzieren. Die sich daraus haufig krankheitsspezifisch entwickelnden klinischen Symptome und hamodynamischen Veranderungen liefern Hinweise fur Art und Schweregrad der zu diagnostizierenden Krankheiten.

Die perimembranose Glomerulonephritis reprasentiert weniger als 20% aller primaren glomerularen Erkrankungen [1]. Im Erwachsenenalter ist sie haufig Ursache eines nephrotischen Syndroms, fur das sie jenseits des 60. Lebensjahres sogar in 50% verantwortlich ist [1]. Die Prognose ist bei jungeren Patienten im allgemeinen besser, denn nach einer Laufzeit von 5 Jahren werden etwa 4% der Kinder, aber 10% der Erwachsenen chronisch hamodialysiert oder sind verstorben [2]. Die glomerularen Veranderungen sind histologisch gut definiert [3]. Charakteristisch sind diffuse abnorme Ablagerungen auf der epithelialen Seite der glomerularen Kapillarwand sowie deren allgemeine Verdickung. Vor allem im Stadium II der Erkrankung werden typische „Spikes“ bei Silberfarbung gefunden. Mit Hilfe der Immunfluoreszenztechnik lassen sich Ablagerungen von IgG und C3 in der Niere nachweisen. Bei den meisten Patienten werden keine zirkulierenden Immunkomplexe nachgewiesen, weil die Antigenantikorperreaktion moglicherweise im Glomerulum ablauft [4]. Die Bildung derartiger Komplexe, die durch ihre Ablagerung in der Niere diese schadigen, kann durch innere und ausere Antigene stimuliert werden, dennoch ist uber die atiologie und die Pathogenese dieser Erkrankung wenig bekannt. Zahlreiche Erkrankungen mit immunologischen Storungen konnten mit verschiedenen HLA-Antigenen assoziiert werden (Human Leukocyte Antigen). So ist das Goodpasture-Syndrom (Antikorper gegen korpereigene glomerulare Basalmembran) mit HLA-DR 2 [5] und der systemische Lupus erythematodes (DNS-Antikorper) mit HLA-DR 2 und HLA-DR 3 [6] assoziiert. Inwieweit das Haupthistokompatibilitatssystem, dem die Kontrolle und Steuerung der Immunabwehrmechanismen zu obliegen scheint (HLA-Antigene, Immunantwortrezeptoren, Mediatoren), bei der Pathogenese dieser Erkrankung mitwirkt, ist derzeit nicht geklart.

Plasmaaustausch hat sich bei verschiedenen Nierenerkrankungen bewahrt. Das Prinzip des therapeutischen Effekts beruht wahrscheinlich auf der Elimination zirkulierender Immunkomplexe [1]. Auch die akute Abstosungsreaktion nach Nierentransplantation gehort in diesen Formenkreis von Krankheiten, wobei der therapeutische Wert von Plasmaaustausch bislang nicht erwiesen ist.

Die Behandlung niereninsuffizienter Patienten mit oralen Anticoagulantien ist mit einem erhohten Risiko belastet (Reidenberg, 1971; Fabre u. Ohr, 1974). Der Grund hierfur liegt nach bisherigen Beobachtungen nicht in einer abnormen Wirkung der Medikamente auf die Prothrombinzeit, sondern in der Blutungstendenz der uramischen Patienten (Cheny u. Bonnin, 1962). Diese Blutungstendenz uberlagert die Anticoagulantienwirkung und beeintrachtigt daher die Aussagekraft der Prothrombinzeit als Masstab der AnticoagulantienWirkung. Aus diesem Grund wird empfohlen, die Indikation zur Anwendung dieser Medikamente beim niereninsuffizienten Patienten streng zu stellen.

Es besteht heute kein Zweifel mehr, das eine Therapie mit Vasodilatanzien zu einer Verbesserung der Herzleistung bei Patienten mit kongestiver Herzinsuffizienz beitragt, meist als zusatzliche Therapie zu Digitalis und Diuretika. Im Gegensatz zu ino- tropen Pharmaka haben Vasodilatanzien keinen direkten Effekt auf die linksventrikulare Kontraktilitat, sondern beeinflussen die Herzfunktion durch Verminderung des systemischen Gefaswiderstandes (Nachlastsenkung) oder/und Verminderung der ventrikularen Fullung durch Venodilatation (Vorlastsenkung). Hieraus resultiert bei vielen Patienten ein Anstieg des Herzminutenvolumens sowie eine Verminderung des Drucks im Lungengefassystem. Der Angriffspunkt der verschiedenen Vasodilatanzien ist unterschiedlich, wobei Langzeittherapieerfolge hauptsachlich bei Substanzen, die in etwa gleichem Mase die Vor- und Nachlast senken oder die vorwiegend die Vorlast senken, beschrieben werden [1]. Da Mesdaten bei Patienten mit kongestiver Herzinsuffizienz, die in Ruhe erhoben werden, nur ungenugend Auskunft geben uber therapeutische Effekte, mussen im allgemeinen Belastungstests bei diesen Patienten durchgefuhrt werden [2]. Bei der Entwicklung einer Herzinsuffizienz spielt aber nicht nur die myokardiale Dysfunktion eine entscheidende Rolle, sondern auch neurohumorale gegenregulatorische Mechanismen wie die sympathische Aktivitat und das Renin-Angiotensin-Aldosteron-System [3, 4, 5]. Die beiden zur Zeit am meisten verwandten Dilatatoren sind der Alpha-1-Blocker Prazosin sowie der Converting-Enzyme-Inhibitor Captopril.

Saralasin, an angiotensin II inhibitor was infused in 10 hypertensive patients. A blood pressure reduction was achieved after stimulation of the renin-angiotensin-system by salt depletion. Heart rate and cardiac output failed to compensate for reduction of blood pressure. Thus circulatory reflex-mechanisms are inhibited by saralasin. A direct influence on baroreceptor mechanism and/or catecholamines is probable. Failure of the hypotensive effect of saralasin in salt-depleted patients after administration of beta-blockers supports this hypothesis.

The treatment of dilated cardiomyopathy is primarily concerned with that of congestive heart failure. Digitalis is widely use in dilated cardiomyopathy but an improvement in the prognosis has not yet been demonstrated. Furthermore, the effects of digitalis in patients with sinus rhythm are debatable. If dilated cardiomyopathy induces atrial fibrillation and tachyarrhythmia, digitalis should be used. Diuretics are helpful in the treatment of congestive heart failure associated with dilated cardiomyopathy. By reducing hypervolemia and by venous dilatation, diuretics lower preload and afterload. This leads to relief of congestion and termination of the vicious cycle of congestive heart failure. Accordingly, the prognosis of dilated cardiomyopathy might be improved by diuretics. There are numerous diuretics acting differently on the renal tubules, the choice of which depends on the renal function and serum electrolyte concentrations. Reduction of preload and afterload improves congestive heart failure as has been demonstrated repeatedly. Many substances have therefore been used for arterial and venous dilation with differing results. At least for short-term periods, congestion is reduced and cardiac output increases. Especially inhibitors of angiotensin II converting enzyme are very effective since they act both in the arterial and venous systems. Additionally, inhibition of the action of angiotensin may be regarded as causal therapy since the renin-angiotensin system is the trigger for vasoconstriction and fluid retention in congestive heart failure. Unlike other substances, ACE inhibitors have been demonstrated to improve prognosis of patients with congestive heart failure. At present, combined diuretic therapy and angiotensin conversion enzyme inhibition would seem the most reasonable treatment for patients with dilated cardiomyopathy and sinus rhythm. If atrial fibrillation and tachyarrhythmia develop, additional digitalis therapy is effective.

The newly synthesized cardiotonic agent alifedrine (1-cyclohexyl-3-[(1S, 2R)-2-hydroxy-methyl-2-phenylethylamino]-propan-1-one) was shown to have vasodilating and positive inotropic effects in experimental animals. The effectiveness was tested in 8 patients with congestive heart failure already receiving digitalis and diuretics. After the intravenous administration of 40 mg alifedrine, cardiac output and stroke volume index increased and systemic vascular resistance and left ventricular filling pressure decreased. Left ventricular ejection fraction improved and there were no significant changes in heart rate and mean aortic pressure. Alifedrine, therefore, improves left ventricular performance in patients with congestive heart failure treated with digitalis and diuretic agents.

Reflex sympathetic nerve activation obscures the direct myocardial effect of Nifedipine after intravenous administration. Consequently, in 10 patients with coronary artery disease 0.1 mg of Nifedipine were injected into the left coronary artery to evaluate its specific effect on coronary sinus blood flow (CSF), coronary vascular resistance (CVR), and myocardial oxygen consumption (MVO2). One minute after Nifedipine, CSF increased from 115 +/- 15 to 193 +/- 47 ml/min (p less than 0.001), and CVR decreased from 0.92 +/- 0.16 to 0,54 +/- 0.12 mm Hg X min X ml-1 (p less than 0.001). Mean aortic pressure dropped from 107 +/- 5 to 99 +/- 3 mm Hg (p less than 0.01). MVO2 was reduced from 14.6 +/- 2.6 to 11.7 +/- 2.8 ml O2 X min-1 (p less than 0.05). After five minutes CSF (113 +/- 18) and MVO2 (14.9 +/- 3.1) had returned to their preinjection level. Additionally, CSF and MVO2 were measured during rapid atrial pacing (mean rate 118 +/- 6 min-1). Average CSF and MVO2 values were 172 +/- 63 and 19.8 +/- 5.0 before and 177 +/- 69 and 20.6 +/- 7.3 approximately 6 minutes after Nifedipine injection.Intracoronary Nifedipine results in coronary vasodilation and subsequently in an increase in coronary flow. The concomitant reduction in MVO2 provides evidence for an oxygen sparing, negative inotropic effect of Nifedipine, which, however, is of very limited duration. A sustained oxygen-saving effect during periods with increased oxygen demand could not be shown.

Die Rolle vasopressorischer Hormone als periphere Kreislaufregulationsmechanismen bei der schweren congestiven Herzinsuffizienz ist bis heute nicht eindeutig geklart. In der Literatur bestehen vollig kontrare Meinungen [1–6]. In letzter Zeit hat die therapeutische Anwendung von Gefasdilatantien bei der schweren Herzinsuffizienz das Augenmerk wieder mehr auf die Bedeutung der Zusammenhange zwischen verminderter Myokardfunktion und dem Verhalten des peripheren Gefassystems gelenkt. Die congestive Herzinsuffizienz last sich durch einen deutlich erhohten linksventrikularen enddiastolischen Druck bei vermindertem Herzminutenvolumen charakterisieren. Um bei der verminderten Herzforderleistung einen suffizienten Blutdruck aufrecht erhalten zu konnen, kommt es zu einer teilweise erheblichen Vasokonstriktion, was dann wieder zu einer vermehrten Belastung des linken Ventrikels fuhrt. Dieser Mechanismus bildet die Grundlage fur einen Circulus vitiosus, woraus eine fortschreitende Verschlechterung der Herzfunktion resultiert.

Die „klassische“ renovaskulare Hypertonie wird durch die Stenose einer oder beider Nierenarterien oder durch Einengung von Nierenarterienasten oder Polarterien verursacht. Renin ist hoher im Venenblut der minderdurchbluteten Nierenbezirke als im Venenblut anderer Nierenareale bzw. der gesunden kontralateralen Niere. Dem Renin-Angiotensin-System wird fur die Entwicklung und Aufrechterhaltung der Hypertonie bei Nierenarterieneinengung und bei den sehr seltenen reninproduzierenden Nierentumoren [Ubers, s. 2] die entscheidende Rolle zugeschrieben (Abb. 1 a, b).

Captopril (Lopirin, Squibb, von Heyden) is an inhibitor of the angiotensin-I converting enzyme. In congestive heart failure angiotensin mediated vasoconstriction and aldosterone secretion is reversed by captopril. Both effects of captopril induce reduction of cardiac preload and afterload. The clinical state of patients with congestive heart failure therefore improves since cardiac output increased and pulmonary pressures decrease. Captopril acts orally and the dosage used for the treatment of congestive heart failure ranges from 50 to 150 mg daily. After oral ingestion of a single dose the maximum haemodynamic effect is observed after 45-90 min. No tolerance induction or tachyphylaxis has been observed during maintenance therapy over a period of 18 months. There are some reversible adverse reactions like pruritus, skin rash and partial or complete taste loss which are dose related. Serious side effects include leucopenia, agranulocytosis, renal failure and membranous glomerulonephritis. Therefore regular urinary and blood analysis is necessary during captopril therapy.

1 Vasodilator therapy is used widely for the treatment of congestive heart failure irrespective of its origin. The acute and long-term effects of captopril were studied in 50 patients with congestive heart failure due to valvular incompetence, hypertension, cardiomyopathy, and ischaemic heart disease. Haemodynamic studies were performed in all patients. In those with valvular incompetence, regurgitation fractions were measured cineangiographically. In patients with ischaemic heart disease coronary sinus blood flow was assessed by a thermodilution technique. During clinical follow-up patients were studied by non-invasive techniques including electrocardiography, echocardiography and chest radiography. 2 In the short-term studies, left ventricular filling pressure, total peripheral resistance, and end-diastolic and end-systolic volumes decreased after captopril, while cardiac output, stroke volume, and ejection fraction increased. Valvular regurgitation fraction was assessed in 10 patients with aortic or mitral insufficiency. In every patient the regurgitation fraction decreased. Coronary blood flow was measured in eight patients with severe ischaemic heart disease. In three patients it remained constant and in the other five patients it decreased. At the same time a highly significant decrease of myocardial oxygen consumption was measured. 3 During long-term treatment clinical improvement occurred in most of the patients. This was documented by a reduction of ventricular diameters in hypertensive heart disease as well as in valvular incompetence. These values remained constant in congestive cardiomyopathy despite clinical improvement. Serious hypotensive episodes were observed in eight patients with valvular stenosis or complex congenital cardiac abnormalities. 4 Captopril is therefore an effective vasodilator for the treatment of congestive heart failure. In patients with intact left ventricular function captopril should not be given because severe hypotensive episodes may occur. Ischaemic heart disease with congestive heart failure is no contraindication for treatment with captopril because the reduction in myocardial blood flow is balanced by the reduced myocardial oxygen consumption.