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Percutaneous high frequency coronary rotational ablation (PTCR) was used in 10 patients with significant coronary artery disease. PTCR removes arteriosclerotic material from the vessel wall. A diamond-coated (60-80 micron) brass burr-drill, fastened to a flexible drive shaft rotating and tracking along a central coaxial guide wire, was used. The turbine rotates the drive shaft in excess of 150,000-190,000 revolutions per minute. PTCR was successful in all patients, but in three additional percutaneous transluminal coronary angioplasty (PTCA) was then successfully performed. Coronary dissection occurred only once, requiring surgery which was successful. No vessel perforation was observed. All vessels were open on the coronary angiograms performed after 24 hours. The main indication for PTCR seems to be a rigid and longer lesion which can not be dilated with the balloon catheter.

UNLABELLED Dobutamine stress echocardiography having established itself as a sensitive method for diagnosing coronary heart disease, even in the absence of normative values, the physiological haemodynamics as well as the physiological values for global and regional left ventricular myocardial function were measured. TEST PERSONS AND METHODS 14 healthy subjects (ten men, four women; median age 25 [range 21-32] years) underwent dobutamine stress echocardiography according to an internationally practised dosage steps protocol (5-40 micrograms/kg/min with additional 0.5 mg atropine at 40 micrograms). RESULTS Maximal infusion rate achieved a serum dobutamine level of 1.67 micrograms/ml with minimal quartiles; it did not influence serum electrolytes (especially potassium). Heart rate increased from 64 to 150/min (P < 0.0001), blood pressure from 111/66 to 158/88 mmHg (systolic: P < 0.0001; diastolic P < 0.001) and the double product of systolic pressure and heart rate from 6714 to 24571 (P < 0.001). While the end-diastolic volume index decreased from 50 to 37 ml/m2 (P < 0.05), the end-systolic volume index fell from 20 to 7 ml/m2 (P < 0.0001). Regional wall motion analysis indicated an increase in left ventricular circumferential contractility with little scatter. CONCLUSIONS The usual protocol for dobutamine stress echocardiography is a sensible one, because the haemodynamic effect occurs already at low dosage and can then be increased significantly with further dosage steps. High serum dobutamine concentrations can be achieved without arrhythmogenic hypokalaemia. Volume index and ejection fraction are especially discriminatory variables. Quantitative analysis of wall motion is justified because of the low scatter of values.

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Qualitatively, dobutamine stress echocardiography has become an established procedure. Quantitative results are in great demand but this is still difficult due to limited endo- and epicardial border definition. Transmitral Doppler variables are strictly quantitative and less subjective. Furthermore, ischemic alterations precede systolic ones (ischemic cascade). There are preliminary reports of the utility of dobutamine stress Doppler echocardiography, but proof of reproducibility and left ventricular filling patterns are still lacking. Fourteen healthy volunteers (10 men, 4 women, median age 25.9 years, range 21-32 years) were investigated according to the usual dobutamine stress echocardiographic protocol (5, 10, 15, 20, 30, 40 and 40 micrograms/kg/min + 0.5 mg atropine). At each titration step a standardized transmitral PW-Doppler recording with the sample volume positioned at the opened mitral leaflet tips was analyzed three times by two independent, experienced investigators. Of the early, late, and mean velocities (VmaxE, VmaxA, Vmean), time integrals (VTI-E, VTI-A, VTI), their ratios (E/A, E/A VTI), and various time intervals (Tacc, Tdec, E- and A-duration, FillT), VmaxE (0.82 to 1.09 m/s; P0.0001), VTI-E (16.17 to 17.19 cm; P0.0001) and Vmean (0.29 to 0.82 m/s; P0.0001) were found to have the greatest discriminatory power, commencing already at a dose of 10-15 micrograms/kg/min dobutamine. VmaxE and VTI-E demonstrated the smallest intra- and interobserver variation without any increase in variability during incremental dose titration. Assessment of the early diastolic filling pattern by Doppler echocardiography is a valuable quantitative and reproducible adjunct to conventional dobutamine stress echocardiography. Further controlled studies in coronary artery disease patients have to confirm, whether lower dobutamine doses could be used in the test and sensitivity increased due to better data acquisition in cases of limited echogenicity, less subjectivity, and earlier onset of ischemic alterations.

Exercise ECG is an established method of evaluating the anti-ischemic properties of drugs. However, there are considerable methodologic limitations to this procedure and its use is restricted to patients with exercise-provoked ECG alterations which can be interpreted as ischemia. The principal, earlier onset of wall motion abnormalities according to the ischemic cascade can be detected by stress echocardiography and might be utilized as a pharmacological stress testing modality. Sixteen consecutive patients (15 men, one woman; 53 +/- 9 years old) with angiographically proven coronary artery disease (8 with one-, 5 with two-, and 3 with three-vessel disease) and exercise-induced wall motion abnormalities were examined by dynamic stress echocardiography (50 watt followed by 20-watt increases/min). Anti-ischemic drugs were withdrawn prior to and on day 1; on the following day 2, 0.2 microgram/kg/min nisoldipine was infused intravenously during the test after a 3 micrograms/kg bolus was given. At maximum comparable workload 15/16 patients showed an improved wall motion score on treatment (day 1: 22.9 +/- 4.9 vs day 2: 20.0 +/- 3.9; normal score: 12; one-sided binomial test: p = 0.0003). Eight of 16 patients demonstrated ST-segment deviations on day 1 and day 2. The double product did not differ at any workload stage until the maximum of 130 watt (day 1: 14,101 +/- 3140 vs day 2: 13,365 +/- 2865; n.s.). Dynamic stress echocardiography seems to be a valuable tool in pharmacologic stress testing and in terms of accuracy is supposed to be superior to conventional exercise ECG. Nisoldipine reduces exercise-induced wall motion abnormalities in patients with and without exercise-induced ECG alterations. The data result from a controlled pilot study, and further studies are required to confirm these promising methodological and therapeutic findings.

The increasing demand for insight into the relationship between coronary perfusion and myocardial function stimulated the development of tissue Doppler echocardiography. This new technique was applied simultaneously with PTCA of a subtotal LAD lesion (single vessel disease, no collaterals) in a 68-year-old patient suffering from unstable angina pectoris. Prior to the conventional signs of ischaemia a decrease in myocardial tissue velocities and a loss of color-coded heart cycle intervals was observed. A myocardial velocity gradient calculated from the higher subendocardial and lower subepicardial velocity decreased from 3.3 to 1.3. This decrease was prevented by an active autohaemoperfusion device which supplied blood distally to an insufflated balloon (60 ml/min). Thus, contractility and viability might be maintained by preserving myocardial velocity gradients.

Infective endocarditis is associated with significant morbidity and mortality, with valvular destruction and congestive heart failure being more common in patients with echocardiographically discernible vegetations. The transoesophageal approach affords consistently high quality images with excellent structural resolution. Two-hundred and eighty-one patients with clinically suspected infective endocarditis were studied, to evaluate the prognostic value of ascertaining the site of vegetations. Among them were 118 patients with vegetations attached to the aortic or mitral valve. These patients were followed for a mean period of 14 months. Mitral valve vegetations were associated with a significantly higher incidence of embolic events than vegetations on aortic valves (25% vs 9.7%). The incidence of abscess formation was higher in aortic than in mitral valve endocarditis (6% vs 0%), as were the need for surgical intervention (11% vs 5.5%) and mortality (1.6% vs 0%) respectively). Bivalvular endocarditis was associated with an increased rate of complications: embolism (50%), abscess formation (15%), surgery (35%) and mortality (10%). By multivariate analysis, echocardiographically accessible risk factors for subsequent embolism were a vegetation size of more than 10 mm and mitral valve involvement. Risk factors associated with in-hospital fatality were embolism, a vegetation size of more than 10 mm, and Staphylococcus aureus infection. Our data suggest that the site influences both the rate and the type of complications. Precise echocardiographic visualization of vegetations helps to stratify patients into a high-risk sub-group, perhaps warranting early prophylactic surgical intervention. Transoesophageal echocardiography may play an important role in assessing the clinical outcome for these patients.

The genetic mucopolysaccharidosis syndromes (MPS) are autosomal recessive inborn errors of metabolism. Heart valve involvement in MPS is not uncommon but only a few case reports of successful cardiac surgery are available. In particular, reports of combined aortic and mitral stenosis associated with MPS type I-S are very rare. Both type I and type VI MPS are associated with significant left sided valvar heart disease that requires surgical valve replacement because of irregular valve thickening, fibrosis, and calcification. A 35 year old man had severe mitral valve stenosis after successful surgical replacement of a stenotic aortic valve. Valvar heart disease was investigated by cardiac ultrasound and left heart catheterisation. Histomorphological characterisation of the affected mitral valve was performed. The case illustrates typically associated clinical features of cardiac and extracardiac abnormalities found in MPS type I-S. Keywords: valvar disease; mucopolysaccharidosis; mitral valve stenosis; aortic valve stenosis

We report a case of a 22 year old pregnant women seen after uterine curettage resulting from “missed abortion”. The patient's condition deteriorated because of dyspnoea and leg oedema. We observed raised C-reactive protein, leucocytosis, low platelet count, and signs of disseminated intravasal coagulation. Extensive microbiological analysis did not disclose any …

To determine the effects of beta-adrenergic stimulation on transmitral Doppler echocardiography flow characteristics of left ventricular diastolic filling, we studied 10 healthy volunteers aged 23-31 years (mean age, 26.6 years) during intravenous infusion of isoprenaline in consecutive steps of 0.1, 0.2, 0.4, 0.75, and 1.5 micrograms/min (each for 15 min). Saline control infusion was given in the same manner in a crossover and blinded protocol. Compared with the infusion of placebo, stepwise increasing doses of isoprenaline caused a dose-related increase in early and late diastolic filling velocities and velocity-time integrals, a lengthening of the acceleration time, and a shortening of the deceleration and filling time. The chosen method proved highly sensitive, as statistically significant changes were detectable at the lowest dose of 0.1 microgram/min for all variables except velocity-time integral of late filling and deceleration time (> or = 0.2 microgram/min). The effects related to dose in a log-linear fashion except for the lengthening of the acceleration time (early ceiling), the increase of peak early filling velocity (increased steepness at higher doses), and the shortening of the filling time. Inclusion of the associated increases in heart rate and systolic blood pressure and the decrease in diastolic blood pressure blunted all treatment contrasts except for the increase of peak early filling velocity. In addition, the hemodynamics with respect to heart rate and loading conditions were not altered at low dosages of drug (< 0.4 microgram/min). Effects of at least the peak early filling velocity must be interpreted as an active adrenergically mediated myocardial relaxation process. These findings have potentially important clinical implications for this noninvasive, readily available, and convenient technique in clinical pharmacology, stress testing, and possibly therapeutic interventions in diastolic dysfunction in humans.

OBJECTIVES To study the significance of serial quantitative regional wall motion analysis, volumes, and ejection fraction findings as well as their prognostic implications derived from cineventriculography in 30 degrees right anterior oblique (RAO) projection in comparison with 60 degrees left anterior oblique (LAO) projection in post-myocardial infarction patients. Ventriculographic left ventricular parameters are accepted surrogates of mortality in myocardial infarction. Nowadays, in contrast to a biplanar approach in most institutions and clinical trials, the investigation is reduced to monoplanar ventriculography. However, it is not known whether the relevance of the two established projections might differ in different infarct topographies. DESIGN AND METHODS Two hundred and six consecutive patients with acute myocardial infarction (infarct duration < 6 h) were treated with streptokinase (group I, n = 103) and allocated randomly additional percutaneous transluminal coronary angioplasty (group II, n = 103). Biplanar cineventriculography studies were performed at the acute stage, before discharge, and 6 months after discharge from hospital. RESULTS Regional wall motion analysis (using an algorithm of fixed radiants) documented larger hypokinetic areas and intensities on RAO than it did on LAO projections, whereby infarct size and its improvement (stunned myocardium) was displayed more comprehensively, and a higher predictive power for survival (P = 0.0002 versus NS) was shown in anterior and inferior infarcts. No advantage of the LAO projection could be detected for evaluation of lateral infarcts due to circumflex coronary artery thrombosis either. The predictive power of the global function (ejection fraction; the algorithm of disc summation method) established by RAO projection (P = 0.007) was superior to that of LAO projection (P = 0.03). Enlargement of volumes (left ventricular remodeling) could be documented significantly only by the RAO projection; the LAO projection failed to do so. Groups I and II did not differ in any respect. CONCLUSIONS The RAO projection has excellent diagnostic and predictive power at any infarct location. In contrast, additional LAO projection provides little information that cannot be obtained reliably from the RAO projection.

In summary, ST-segment elevations on the admission electrocardiogram not only diagnose acute myocardial infarction but also provide predictive information with respect to developing infarct size and left ventricular remodeling as well as survival.

Objectives. The purpose of this study was to demonstrate the accuracy of stress echocardiography for detecting the progression of coronary artery disease after nonsurgical revascularization. Background. The expanding role of nonsurgical coronary revascularization procedures mandates the development of sensitive noninvasive techniques for tbe detection of recurrent ischemia. Methods. Bicycle stress echocardiography was performed in a series of 86 patients 6.5 ±1.3 months after a revascularization procedure. Seven patients were excluded from analysis because of poor echocardiographic image quality. Results. Digital analysis achieved a sensitivity of 83% for the entire group and a specificity of 85% for stress echocardiographic detection of significant coronary artery disease. Sensitivity was greater in patients with (88%) than in those without (75%) prior myocardial infarction, but this difference did not reach statistical significance. Additional analysis using an increase in end-systolic volume index or a decrease in ejection fraction during stress as an additional marker for ischemia tended to enhance sensitivity (90% for the entire group and 93% for the subgroup with prior myocardial infarction). Conclusions. Stress echocardiography is a useful and sensitive method for the follow-up of patients undergoing nonsurgical revascularization procedures. The addition of volume determination to routine wall motion analysis may be helpfull in patients with prior infarction who have scar tissue that nay be difficult to distinguish from an adjacent exercise-induced wall motion abnormality.