Search

Application of large amounts of iodine in the form of amidotricoic acid (Urografin) in 20 patients undergoing coronary angiography led to an increase in serum thyroxine (T4, p less than 0.005), triiodothyronine (T3, p less than 0.005) and plasma thyrotropin (TSH) in the basal state (p less than 0.05) as well as after TRH-stimulation (p less than 0.05), but not of serum 3,3',5'-triiodothyronine (reverse-T3, rT3) three weeks after contrast medium administration. Although TRH induced TSH stimulation had been subnormal prior to contrast medium application in five patients, T4 as well as T3 remained within the normal range in all patients. Neither preexisting iodine excretion nor the amount of contrast medium applied were related with the observed hormonal changes. We conclude, that application of relatively small as well as large amounts of amidotricoic acid leads to an increase of peripheral thyroid hormone concentrations, paralleled by a rise in basal and stimulated TSH secretion. These changes may be interpreted as physiological adaptation to augmented iodine supply in an area of moderate iodine deficiency.

The diagnostic efficacy of M-Mode and 2-d echocardiography for the detection of malfunctioning prosthetic valves was studied in twenty-nine patients with prosthetic valves and clinical deterioration. Echocaradiographic abnormalities were found in 8 of 12 patients with confirmed valve dysfunction; 30.8% of the cases had false negative echo tracings. In 17 patients with normal echocardiographic pictures of the valves another cause of clinical deterioration was found (congestive heart failure, pericardial effusion, aneurysm of aortic root). In this study M-Mode and 2-d echocardiography had an excellent diagnostic accuracy rate in distinguishing congestive heart failure from valve dysfunction. Comparing the data of M-Mode and 2-d registration, both methods are found to be complementary. A major advantage of the 2-d echocardiography is its enhanced spatial orientation, whereas M-Mode echocardiography enables better evaluation of valve movements and corresponding time intervals and recognition of quick movements and fibrillations.

In two patients with severe aortic stenosis successful resuscitation from ventricular fibrillation was documented by Holter recording/ECG monitoring. After aortic valve replacement programmed ventricular stimulation was performed in both patients, but ventricular tachycardia/ventricular fibrillation was not inducible. The patients were left without antiarrhythmic therapy and have been free from cardiac events for 18 and 20 months, respectively. The prognostic value of postoperative electrophysiologic testing after aortic valve replacement in patients with severe aortic stenosis and preoperative resuscitation is discussed.

Severe heart failure developed in a 49-year-old patient 18 months after orthotopic cardiac transplantation. Acute rejection as well as other overt causes of graft failure were excluded. Haemodynamic measurements suggested severe diastolic myocardial dysfunction. Since no other causes of diastolic heart failure were identified, a potential side effect from cyclosporine was considered. Cyclosporine was therefore withdrawn and immunosuppressive treatment was switched to conventional therapy consisting of azathioprine and prednisolone. Withdrawal of cyclosporine was followed by an impressive clinical improvement and by complete haemodynamic normalization. Therefore, in cases of otherwise unexplained graft failure, a potentially reversible side effect from cyclosporine should be taken into consideration.

The risk factors of ischemic cerebrovascular disorders in 77 young patients (⩽/ 40 years) were compared to those in 138 older patients (>40 years). The risk factor profile of patients with juvenile stroke was considerably different from that of older patients. Migrainous headache and mitral valve prolapse occurred more frequently in the younger age group, whereas hypertension, diabetes mellitus, high levels of cholesterol and triglycerides were found more often in older patients with stroke. 65% of the women under the age of 40 took oral contraceptives which compares to the baseline community value of 28% of women in childbearing age in this country. Cardiac disorders such as atrial fibrillation, left ventricular hypertrophy, coronary heart disease including a history of myocardial infarction, as well as mitral valve disease were demonstrated more often in the group of elderly patients. 7 out of 77 younger patients (9.1%), and 59 out of 138 older patients (42.8%) were considered to belong to a group with “high cardiac risk for stroke”. The results of this study indicate that electrocardiographic screening is of prime importance for detecting cardiac risk factors. However, echocardiographic examination often yields additional diagnostic information, particularly in younger patients. The conflicting opinions concerning the relevance of certain risk factors for ischemic stroke could partly be explained by the fact that these risk factors are distributed unevenly depending on age.

Zur Prufung der Frage, ob eine Verbesserung der Digitalistoleranz unter Spirolactone durch eine gegensinnige Beeinflussung der myokardialen Kaliumbilanz mitbedingt wird, erhitelen 6 klinisch nicht kardial dekompensierte Patienten 5–7 Tage hindurch taglich 400 mg, 3 Patienten 200 bzw. 300 mg Spirolactone oral und 6 Patienten Placebo. Im Rahmen eines diagnostischen Herzkatheterismus wurden hamodynamische Messungen und multiple Serumkaliumbestimmungen vor und nach Gabe von 0,375–0,625 mg Strophanthin intravenos durchgefuhrt. Nach Strophanthin kam es zu einem signifikanten Abfall des enddiastolischen Drucks und zu einem Anstieg desdp/dt max im linken Ventrikel. In der Kontrollgruppe war ein signifikanter Anstieg der Kaliumspiegel im arteriellen und Koronarsinusblut zu beobachten, es bestand eine negative myokardiale Kaliumbilanz von der 3. bis zur 8. min nach Strophanthin. Die entsprechenden Werte nach Spirolactonevorbehandlung unterschieden sich von jenen der Kontrollgruppe nicht signifikant. Es wird geschlossen, das nicht toxische Dosen von Strophanthin beim Menschen durch Hemmung der Natrium-Kalium-Membran ATPase zu einem myokardialen Kaliumverlust fuhren, der durch orale Vorbehandlung mit Spirolactone nicht sicher verandert wird.

Um die Moglichkeiten und Grenzen der Schnittbildechokardiographie bei der Diagnose der bakteriellen Endocarditis zu untersuchen wurden M-mode und Schnittbildechokardiogramme von 39 Patienten mit gesicherter Endocarditis und/oder endocarditisverdachtigem Schnittbildechokardiogramm analysiert. Das Echokardiogramm galt als Endocarditis-verdachtig wenn Zeichen fur valvulare oder murale Vegetationen und/oder Hinweise fur eine Klappendestruktion nachgewiesen werden konnten.

The results of biphasic 201thallium scintigraphy after dipyridamole i.v. could neither prove nor exclude the presence of small focal lesions in the myocardium of 17 patients with mitral valve diseases. The frequent finding of a decrease in activity in the anterolateral myocardium is probably due to a relative increase in activity in the region of the inferior wall with superimposed areas of the papillary muscle and right ventricular myocardium. If the right ventricle is visualized in stress- or redistribution images, an increase in mean pulmonary artery pressure can be accepted. According to Cohen's criteria, a grade 2 or 3 virtually proves the existence of pulmonary hypertension, a grade 1 makes this finding rather probable. The possibility of pulmonary hypertension can not be excluded if the right ventricular myocardium is not visualized.

The report deals with 2 cases of heart tumors in which a commercial ultrasonic diagnostic equipment was used for tomography. In both cases we were successful in demonstrating the lesions. The visualization of subtle diagnostic details is ruled out by the rhythmical movements of the heart which cause blurring and superposition of signals.

The authors have seen 14 cases of idiopathic, hypertrophic, subaortic stenosis and they describe the pathology, the clinical and radiological diagnosis and the differential diagnosis of this condition. Their own findings are compared with those in the literature and substantial agreement is found. Some uncharacteristic clinical and radiological findings are associated with typical pressure curves in the left ventricle and marked abnormalities in the laevocardiogram. Variations in ventricular filling due to the difference in severity of the disease are discussed. The importance of a correct diagnosis is stressed, since the use of inotropic substance is this condition is contra-indicated.

Ischaemic heart disease is the main cause of death. Most of these deaths are sudden and occur within the first few hours of onset of symptoms and before the patient reaches the hospital. It is generally accepted, that sudden death is due to ventricular fibrillation. The aim of this presentation is to review the studies of long-term antiarrhythmic therapy and beta-blockade in the prevention of sudden cardiac death. Studies, in which a given antiarrhythmic drug was routinely applied, have universally failed to show any protective effect. However, when effective patient specific drugs are selected during programmed ventricular stimulation, long-term treatment in high risk patients may be beneficial. Recently suggestive evidence has been presented, that long-term beta-blockade is beneficial in preventing sudden death and reducing overall mortality in ischaemic heart diseases although the antiarrhythmic properties of beta-blockers are relatively weak.

In 45 patients (pts.) with mitral stenosis (MS) multiple echocardiographic recordings of the posterior mitral leaflet (PML) were obtained and its motion pattern was carefully analyzed. 25 pts. showed only parallel motion (PM), one patient only opposite motion (OM) of the leaflets during diastole. In 19 pts. PM as well as OM (defined as backward movement of the PML immediately after the D-point and as forward motion during mitral closure, respectively) could be recorded at least two times. In most of these cases PM was impressive while OM could be demonstrated only by careful analysis of numerous recordings. In 4 of the 19 cases with PM and OM, however, the reverse was true. We conclude that OM should only be taken as evidence against MS when multiple recordings of the mitral leaflets have failed to reveal PM and when other echocardiographic signs of MS are missing. Possible explanations of the PM-OM combination are discussed.

The diagnostic accuracy of the dipyridamole test in provoking coronary insufficiency was investigated in 79 patients with chest pain and the results were compared with the findings on angiography and exercise electrocardiogram. 58 patients had documented severe coronary artery stenosis, 21 had patent coronary vessels (cardiomyopathy 8, aortic stenosis 1, ectopic origin of coronary artery 1, normal 11). Anginal pain after dipyridamole was a non-specific finding. Approximately half the subjects in whom coronary insufficiency would be expected according to the coronary angiographic and ventriculographic findings evidenced ischaemic ST-segment depression after dipyridamole, which was comparable to the number of positive exercise electrocardiograms. In 23 patients, most of whom had shown an inadequate frequency response during the initial exercise test, ergometry was repeated after the administration of dipyridamole. This resulted in an increase in ischaemic ECG response from 26 to 70%. It is concluded that a stress test combining dipyridamole and submaximum exercise increases the incidence of ischaemic ST-segment depression in comparison with ergometry alone. Anginal pain without ST-segment depression proved to be without diagnostic value.

The principle of the ultrasound examination of the heart is explained and the possible applications of this method are discussed. Three case histories are presented to exemplify the usefulness of echocardiography in clinical cardiology.

The authors have seen 14 cases of idiopathic, hypertrophic, subaortic stenosis and they describe the pathology, the clinical and radiological diagnosis and the differential diagnosis of this condition. Their own findings are compared with those in the literature and substantial agreement is found. Some uncharacteristic clinical and radiological findings are associated with typical pressure curves in the left ventricle and marked abnormalities in the laevocardiogram. Variations in ventricular filling due to the difference in severity of the disease are discussed. The importance of a correct diagnosis is stressed, since the use of inotropic substance is this condition is contra-indicated.

Doppler-echocardiography is the most important non invasive method for the assessment of the severity of aortic stenosis. After measuring the maximal transstenotic flow velocity (= Vmax) the maximal pressure drop between left ventricle and aorta (= maximal instantaneous gradient) can bei calculated according to a simple formula. The accurate determination of Vmax may be difficult and time consuming, however, and when interpreting the Doppler-data it is important to realize that there is always a systematic numerical difference between the instantaneous gradient and those gradients which one usually measures at catheterization (peak to peak and mean gradient respectively). In mixed aortic valve disease the aortic insufficiency will distort the relationship between the various gradients still further. Despite these problems Doppler-echocardiography is extraordinarily useful in quantitating aortic stenosis and obviates the need for catheterization in most patients.

Indications, results, and complications in 400 transfemoral selective coronary arteriograms are reported. After the first 100 examinations a sharp decline in serious complications and an increase in complete studies with opacifications of both coronary arteries and left ventricle was achieved. This was thought to be due not only to mounting experience but also to total body heparinization and transfemoral use of Sones catheters with torque control. According to our results transfemoral selective coronary arteriography is considered to be an indispensable examination which may be performed by experienced investigators without hesitation when indicated.

Electrophysiologic studies were performed in 51 patients with syncopes of unexplained origin. 25 patients (49%) had organic heart disease. Electrophysiologic testing included determination of corrected sinus node recovery time, AV-nodal effective refractory period, AH- and HV-intervals, and AV-nodal Wenckebach rate. During programmed right ventricular stimulation, 1-3 premature stimuli were used. 26 patients (53%) had an abnormal outcome that strongly suggested an arrhythmogenic cause of the reported syncopes. In ten patients (20%), corrected sinus node recovery time was prolonged; AV-nodal conduction disturbance was manifest in two patients (4%); reversibility with atropine was shown in one patient. Six patients (12%) had an infrahisian conduction delay with an HV-interval longer than 70 ms. Eight patients (15.6%) had either symptomatic ventricular tachycardias (n = 4), AV-nodal reentry tachycardias (n = 2), or inducible symptomatic rapid atrial fibrillation (n = 2). In one additional patient, ventricular tachycardias could not be reinitiated after ending tricyclic antidepressant drug medication. The diagnostic yield of the electrophysiologic study was not influenced by the presence of organic heart disease. Patients with prolonged corrected sinus node recovery time, prolonged HV-interval, and irreversible AV-conduction delay underwent pacemaker implantation (n = 17). Patients with rapid response to programmed stimulation received antiarrhythmic medication, the efficacy of which was assessed by serial electrophysiologic testing until non-inducibility was obtained. The mean follow-up period was 11 months (1-31 months). Overall 2-year mortality was 17%. In 4/5 patients, death was unrelated to the cause of syncope.(ABSTRACT TRUNCATED AT 250 WORDS)

Sudden cardiac death was documented on a Holter-monitor ECG in a 71-year-old man with known, but unoperated, calcific aortic stenosis (peak transvalvar gradient of 90 mm Hg). The tracing showed the development of a, presumably stress-induced, sinus tachycardia with broad QRSs and rapid transition to ventricular fibrillation. This rarely documented example of cardiac death in a patient with aortic stenosis during long-term ECG monitoring is of special interest because the patient had neither an inverse therapy effect nor impaired left-ventricular function.

Biphasic thallium-201-myocardial imaging was performed in 100 patients undergoing coronary angiography. The images were obtained in several views after the administration of dipyridamole (0.50 mg/kg body weight) and 4 hours later. 24 patients had normal coronary arteries or insignificant stenoses, in 74 patients a 70-percent or greater stenosis of one or more coronary arteries was present. 55 transmural myocardial scars were diagnosed by left ventriculography in 53 patients. The described method showed a sensitivity of 93 percent and a specificity of 96 percent in the detection of patients with significant coronary artery stenoses. Irreversible perfusion defects were found in 91 percent of myocardial scars, in additional 7 percent the scintigraphic defects were reversible. In patients with multivessel disease and transmural infarctions, only one third of non-infarction-related stenoses were recognized. The number of angiographically stenotic coronary arteries could be determined scintigraphically only in a minority of the cases. The regional sensitivity in the assessment of LAD and right coronary artery stenoses was higher than for the left circumflex artery (75%, 80%, and 48% resp.), the specificity was equally high for all three vessels (96%, 99%, 100%).

A 49-year-old man went blind in his left eye during coronary angiography. The following day an occlusion of the inferior temporal and inferior nasal branch of the central retinal artery was detected, associated with a moderate papilledema of the inferior part of the optic disk as well as retinal edema of the inferior fundus. Fluorescein angiography confirmed the clinical diagnosis, perimetry revealed loss of visual field in the superior half. Seven months after the initial examination the patient displayed a partial optic atrophy of the inferior portion of the disk associated with a moderate neovascularization in that area. The visual field loss remained unchanged.

The reproducibility of M-mode echocardiography, radionuclide ventriculography, and systolic time intervals (PEP/LVET) was studied in 16 patients with symmetrically contracting left ventricles and no signs of coronary heart disease. The values were determined four times in these 16 patients: twice each on day 1 and day 8 at an interval of 2-3 h. The mean EF and PEP/LVET values were nearly identical in all 4 repeat studies. There was a high correlation of echocardiographic and scintigraphic EF measurements (r between 0.90 and 0.96); the correlation between PEP/LVET and EF was considerably poorer (r ranging from -0.56 to -0.79). There was no difference in mean serial variabilities of EF for all repeated studies performed on the same day and on separate days for either echocardiography or radionuclide ventriculography. The mean variability of absolute EF for repeated studies was 2.9 +/- 2.4% for M-mode echocardiography and 3.4 +/- 2.4% for radionuclide ventriculography. To be attributed to nonrandom physiological alterations the absolute change in EF in an individual patient should be at least 8% for echocardiography and 9% for radionuclide ventriculography. The mean variabilities of PEP/LVET were different in studies performed on the same day and on separate days (0.03 +/- 0.02 vs 0.04 +/- 0.03, p less than 0.01). In 7 further patients the effect of dobutamine infusion was studied.(ABSTRACT TRUNCATED AT 250 WORDS)

In 60 patients with angiographically documented 2- or 3-vessel disease (at least 70%) thallium-201 images after dipyridamole (0.50 mg/kg bodyweight i.v.) and 4 h later were obtained. In 95% of the patients stress perfusion defects were found. In 48% of the cases scintigraphy correctly diagnosed the presence of multivessel disease, but in only 30% of the patients were all angiographically narrowed vessels detected. The reliability of the method was much higher in the detection of 'infarct stenoses' (96%) than of 'noninfarct stenoses' (46%). The regional sensitivity to assess stenoses of the left anterior descending artery (75%) and right coronary artery (73%) was greater than in stenoses of the left circumflex artery (37%). Thallium-201 scintigraphy after dipyridamole is a sensitive method for diagnosing the presence of coronary artery disease. The diagnostic value is severely limited however by the fact that coronary vasodilation may provoke perfusion abnormalities only in the most ischemic regions, whereas perfusion defects in other areas may not be detectable. Therefore this method does not allow the precise quantitation of all coronary stenoses in the majority of patients.

In order to examine the question, whether improved digitalis tolerance by Spirolactone may be partially a result of antagonism on myocardial potassium balance, 6 patients without clinical signs of heart failure were given 400 mg, 3 were given 200 or 300 mg Spirolactone orally daily and 6 patients received placebo during a 5 to 7 days period. During cardiac catheterization hemodynamics and serum potassium concentrations were determined repeatedly prior to and following intravenous administration of 0,375 to 0,625 mg Strophanthin. Injection of Strophanthin resulted in a significant drop in left ventricular enddiastolic pressure and a rise in dp/dt max. In the control group a significant increase in arterial and coronary sinus potassium concentration was observed. Myocardial potassium balance was definitely negative from the third to the eighth minute. Values in the group receiving Spirolactone did not differ significantly from the placebo group. It is suggested that therapeutic doses of Strophanthin resllt in a loss of potassium from the myocardium by inhibition of the Na+, K+ membrane ATPase not influenced by pretreatment with Spirolactone.

The echocardiogram of a patient presenting with a systolic ejection murmur and ECG evidence of left ventricular hypertrophy revealed asymmetric septal hypertrophy but no abnormal systolic anterior motion of the mitral valve as in IHSS. Her pulmonary echo disclosed small A waves, partial valve closure in early systole and coarse systolic fluttering. This motion pattern--which is similar to that of patients with infundibular pulmonary stenosis and which resembles the aortic valve motion pattern in discrete subaortic stenosis--led us to the diagnosis of hypertrophic cardiomyopathy with subpulmonic obstruction, which was later confirmed by cardiac catheterization.

Peripheral M-mode contrast echocardiograms at rest and during the Valsalva manoeuvre were performed in 9 patients with haemodynamically insignificant interatrial communications. Contrast echoes appeared in the left heart in all 4 patients with elevated right ventricular pressure, but also in 3 out of the 5 patients with normal right-side pressures. Thus, a positive contrast echocardiogram, while definitely proving the presence of an intracardiac communication, does not necessarily mean that the defect is haemodynamically significant. The ability to detect a patent foramen ovale non-invasively by contrast echocardiography may be useful in patients with suspected paradoxical embolism.

In 33 patients 110 comparative measurements of stroke volume were performed by the thermodilution method and impedance cardiography during rest and various hemodynamic interventions. Agreement was moderate not allowing accurate estimation of the stroke volume in an individual patient. However, impedance cardiography proved useful in predicting acute changes in stroke volume or cardiac output exceeding 10% of control values.

46 patients with coronary artery disease (at least 70% stenoses) were studied with thallium-201 imaging following dipyridamole (0.50 mg/kg bodyweight intravenously) with 4-hour control and by radionuclide ventriculography at rest and during symptom-limited bicycle exercise in supine position. 38 patients (83%) had positive thallium-201 findings with persistent defects in 18 and transient defects in 20 cases. Mean left ventricular ejection fraction (EF) fell during exercise from 56.1% +/- 13.3 to 50.2% +/- 14.5 (p less than 0.001). 43 patients (93%) showed an abnormal EF response to exercise (rise of less than 10% of the control EF during exercise). In 8 patients with false negative thallium-findings the EF did not change from rest to exercise (64.1% +/- 10.0 vs. 64.6% +/- 8.5), however, in the 20 patients with transient Tl-201 defects a significant fall of the EF was noted (60.8% +/- 9.1 vs. 49.8% +/- 10.9, p less than 0.001), in the 18 patients with persistent defects only a slight decrease of the EF was induced with exercise (47.3% +/- 14.0 vs. 44.2% +/- 16.1, p less than 0.02). Thus transient Tl-201 defects usually predict functional impairment of the left ventricle with exercise, persistent defects suggest impaired rest function with only minor further dysfunction during exercise. Compared with rest and exercise ECG in these patients, both radionuclide techniques showed a significantly higher sensitivity.

The value and limitations of phonocardiography, systolic time intervals, apex cardiography and kinetocardiography in the diagnosis of impaired cardiac function during rest and haemodynamic stress were critically reviewed on the basis of studies carried out in our laboratory, as well as reports in the literature. When compared with invasively-obtained measurements, none of the above-mentioned techniques allows the prediction of heart function quantitatively in a single given patient. However, when one considers the broad overlap of mechanocardiographic measurements in normal subjects and patients with heart disease and defines an abnormal mechanocardiogram accordingly, these methods may be used to diagnose abnormal cardiac function with adequate specificity though low sensitivity.

Cardiac performance was studied in 14 obese but otherwise healthy young subjects during rest and submaximal ergometric exercise by means of Swan Ganz catheters. Cardiac output and stroke volume determined by the thermal dilution method were normal or slightly increased during rest rising on exercise in the usual range. However, mean pulmonary artery and pulmonary wedge pressures were increased above normal values in 50% of the patients during exercise indicating depressed left ventricular function. Patients with normal and abnormal hemodynamic response to exercise could not be separated by clinical findings. Repetition of studies in 11 patients following therapeutic starvation of 2-3 weeks duration revealed a statistically significant fall of pressures in the right atrium, the pulmonary artery and in the pulmonary wedge position during rest and exercise. In the majority of patients a moderate reduction in cardiac output and stroke volume suggested a decrease in preload due to loss of intravascular volume, but in a few instances with unaltered or increased cardiac output improvement of cardiac function had to be considered.

Coronary anatomy and the results of treadmill exercise testing were compared in two partially overlapping groups of patients. In the first part of the study, treadmill tests of 29 patients with significant (greater than or equal to 50%) left main stenosis were compared to those of 40 patients each with proximal 1-, 2-, and 3-vessel disease, respectively. Two distinct subgroups were identified among the patients with greater than or equal to 50% left main stenosis: Of those with greater than or equal to 70% left main stenosis all had a positive (ST decreases greater than or equal to 0.1 mV) stress test, 79% had a markedly positive (ST decreases greater than or equal to 0.2 mV) test and this group had the lowest exercise capacity. In patients with only moderate left main stenosis (50-70%) ST-segment depression was significantly less and occurred significantly later than in patients with severe left main stenosis and 3-vessel disease. Patients with 1-, and 2-vessel disease could be clearly separated from patients with either severe left main stenosis or 3-vessel disease, but not from those with only moderate left main stenosis. In the second part of the study the coronary anatomy of 62 patients with a markedly positive stress test was analysed. In these patients left main stenosis, 3-, 2-, and 1-vessel disease was observed in 10%, 50%, 23% and 16%, respectively.(ABSTRACT TRUNCATED AT 250 WORDS)

A 22-year-old man with cardiac symptoms had been treated for myocarditis for two years. But the clinical course and special tests, including isoenzyme measurements, electromyography, peripheral muscle and myocardial biopsy, established the diagnosis of X chromosome-linked muscular dystrophy (type Becker-Kiener) with an associated cardiomyopathy (raised left-ventricular end-diastolic pressure). Light- and electron-microscopic studies of the (right ventricular) myocardial biopsy revealed degenerative changes like those seen in peripheral muscle.