Extensive intramural hematoma as the cause of failed coronary angioplasty: diagnosis by intravascular ultrasound and treatment by stent implantation

Dissections after coronary angioplasty are the major cause of ischemic events following percutaneous transluminal coronary angioplasty (PTCA) and may require additional measures such as intravascular stent deployment to relieve or prevent acute vessel closure. We describe a rare type of dissection after PTCA which caused a severe obstruction of the vessel segment proximal to the dilatation site without a visible dissection flap. Intravascular ultrasound was used to elucidate the morphology of the proximal vessel obstruction, which revealed an intramural hematoma extending into the proximal vessel segment as underlying mechanism. A Palmaz-Schatz stent was placed at the entry site of this hematoma, which led to the relief of the proximal vessel obstruction. After 3 months of anticoagulation therapy the repeat coronary angiography showed no significant restenosis. This demonstrates the unique insight into the underlying morphology of failed PTCA by intravascular ultrasound, which can help to manage even rare and unusual complications.

Indium-111-antimyosin Fab imaging to demonstrate myocardial involvement in systemic lupus erythematosus

Indium-111-antimyosin Fab imaging has been used to indicate myocardial injury. This report describes antimyosin accumulation in two patients with myocardial involvement in systemic lupus erythematosus. Both patients complained of chest pain, and significant stenoses of extramural coronary arteries were ruled out by angiography. The first patient, a 64-yr-old woman, had immunopathologic findings suggestive of systemic lupus. Indium-111-antimyosin Fab imaging showed myocardial tracer uptake. This prompted endomyocardial biopsy providing evidence of systemic lupus. The patient improved under immunosuppressive therapy. The second patient, a 47-yr-old man, had systemic lupus diagnosed by immunopathologic findings and skin biopsy. He had evidence of pericarditis on electrocardiography and echocardiography. Indium-111-antimyosin Fab imaging demonstrated additional myocardial involvement, which supported the initiation of immunosuppressive therapy. Our results suggest that 111In-antimyosin Fab imaging may provide valuable diagnostic information and influence patient management in systemic lupus erythematosus with suspected myocardial involvement.

Pulmonary and left ventricular decompression by artificial pulmonary valve incompetence during percutaneous cardiopulmonary bypass support in cardiac arrest

BACKGROUND

In cardiac arrest, use of percutaneous cardiopulmonary bypass support (PCPS) may lead to left ventricular loading, with deleterious effects on the myocardium, and is often accompanied by an increase in pulmonary artery pressure. The present study was designed to assess the potential of artificially induced pulmonary valve incompetency to retrogradely decompress the left ventricle during PCPS in ventricular fibrillation.

METHODS AND RESULTS

Studies were performed using a standardized experimental animal model in sheep (n = 12; body weight, 77 to 112 kg). When PCPS was used during fibrillation, an increase in left ventricular pressure (from 21.4 +/- 5.0 mm Hg after 1 minute to 28.4 +/- 9.5 mm Hg after 10 minutes of fibrillation) was observed in all animals, with a simultaneous increase in pulmonary artery pressure in 6 animals, from 15.5 +/- 3.8 to 24.3 +/- 5.4 mm Hg (group A). In these animals, artificial pulmonary valve incompetency, which was induced by a special "pulmonary valve spreading catheter," led to effective decompression of both the pulmonary circulation (decrease in pulmonary artery pressure from 24.3 to 11.3 mm Hg) and the left ventricle (decrease in left ventricular pressure from 30.5 to 17.7 mm Hg). We simultaneously measured a decrease in the myocardial release of lactate (increase in arterial coronaryvenous difference in lactate content from -0.01 to 0.14 mmol/L), demonstrating the myocardial protective effect of the procedure. In contrast, in 6 animals without an increase in pulmonary artery pressure during PCPS (group B), artificial pulmonary valve incompetency did not reduce left ventricular loading, which was probably because of competent mitral valves in these animals.

CONCLUSIONS

In case of increasing pulmonary artery pressure during PCPS in cardiac arrest, artificial pulmonary valve incompetency might be a useful tool for effective pulmonary and retrograde left ventricular decompression.

Myocardial enterovirus infection with left ventricular dysfunction: a benign disease compared with idiopathic dilated cardiomyopathy

OBJECTIVES

Endomyocardial biopsy samples from patients with idiopathic dilated cardiomyopathy were screened for the presence of enterovirus genome. Patients with enterovirus-positive samples were further studied with regard to disease course, histologic variables and response to interferon-alpha treatment.

BACKGROUND

Studies of patients with idiopathic dilated cardiomyopathy have reported widely divergent clinical outcomes, suggesting that there is no unique underlying pathogenetic mechanism.

METHODS

Five left ventricular endomyocardial biopsy samples were screened for the presence of the enterovirus genome by an established in situ hybridization technique in combination with a histologic, histomorphometric and immunohistologic workup. The course of the disease was then prospectively followed for up to 50 months. Virus-positive patients whose condition deteriorated were treated with interferon-alpha.

RESULTS

Of 77 patients, 20 (26%) had enterovirus-positive and 57 (74%) enterovirus-negative biopsy samples. During a mean follow-up period of 25.8 +/- 13.7 months, 1 patient in the enterovirus-positive group and 11 in the enterovirus-negative group died. Four patients in the enterovirus-negative group underwent heart transplantation (p < 0.05). The surviving 19 enterovirus-positive patients had a decrease in mean left ventricular end-diastolic diameter from 66 to 61 mm (p < 0.05) and a mean increase in left ventricular ejection fraction from 0.35 to 0.43 (p < 0.05). In contrast, enterovirus-negative patients had no significant change in end-diastolic diameter or left ventricular ejection fraction. Four patients in the enterovirus-positive group whose condition deteriorated were treated with a 6-month course of subcutaneous interferon-alpha (3 x 10(6) U every second day). This treatment induced hemodynamic improvement in all four patients and eliminated the persistent enteroviral infection in two.

CONCLUSIONS

Enterovirus-positive patients have a better heart transplantation-free survival rate and hemodynamic course, with fewer histologic changes, than do enterovirus-negative patients. In addition, enterovirus-positive patients respond favorably to interferon-alpha treatment. These observations indicate that myocardial enteroviral infection with associated left ventricular dysfunction is a distinct disease entity with a benign course.

Enterovirus-induced myocarditis: hemodynamic deterioration with immunosuppressive therapy and successful application of interferon-alpha

In 1985, myocarditis was diagnosed by endomyocardial biopsy in a 53-year-old woman who was free of symptoms of heart insufficiency. Immunosuppressive therapy with azathioprine and prednisolone was prescribed as the patient had deteriorated to NYHA II heart insufficiency in March 1986. When application of immunosuppressive agents was terminated in 1987, serial endomyocardial biopsies revealed no signs of myocarditis, thus indicating effectiveness of immunosuppression. Nevertheless, the patient had worsened clinically and hemodynamically. At follow-up in 1991, the patient had progressed to dilated cardiomyopathy resulting in NYHA III heart insufficiency. Enterovirus infection of the heart was detected by in situ nucleic acid hybridization. In addition, retrospective serology indicated a significant increase of coxsackievirus B2 antibodies between 1985 and 1991. Investigational antiviral therapy with recombinant interferon alpha-2a was tolerated well and a favorable clinical, hemodynamic, and virologic response was observed. Thus, progression of biopsy-proven myocarditis to dilated cardiomyopathy may have been facilitated by immunosuppressive therapy in enterovirus infection. Antiviral therapy might be advantageous in patients with enterovirus myocarditis and dilated cardiomyopathy.

Comparison of hemodynamic and Doppler echocardiographic effects of a new low osmolar nonionic and a standard ionic contrast agent after left ventriculography

The hemodynamic effects of a new nonionic low osmolar contrast agent (iomeprol) during left ventriculography (LC) was compared with a standard ionic contrast agent (meglumine diatrizoate) in a randomized double blind study in 30 patients with suspected coronary artery disease and normal systolic ventricular function. LV diastolic function was assessed by Doppler echocardiographic recording of the transmittal filling curve and by intraventricular tip-manometry before and within 30 sec of the LC. In the group receiving the ionic contrast agent the systolic pressure fell from 126 +/- 23 to 111 +/- 18 mmHg (P < 0.05), and heart rate increased from 64 +/- 9 to 71 +/- 11 min-1 (P < 0.05), while no such effects were observed with the nonionic contrast agent, indicating differences in the vasodilator properties. The latter caused an increase of the peak early Doppler velocity (52 +/- 11 to 62 +/- 14 cm/sec; P < 0.05). After the ionic contrast agent, the effect on the peak early Doppler velocity was less pronounced, probably due to an interaction with the known depressant effect of the increase in heart rate on the early Doppler velocity. In both groups the left ventricular end diastolic pressure was increased from 7 +/- 3 to 10 +/- 4 mmHg. No significant effects on peak-dp/dt and dp/dt were observed in either group. The nonionic contrast agent iomeprol had no significant effect on systolic arterial pressure and heart rate in contrast to the ionic contrast agent, probably due to a less pronounced vasodilator effect. Despite these differences of the global hemodynamic response, there were similar effects of both contrast agents on LV diastolic filling.

[Involvement of the pericardium in Churg-Strauss syndrome]

In two patients (24 and 26 years old) with chronic bronchial asthma, allergic rhinitis, peripheral blood eosinophilia of 48% and 51%, respectively, mononeuritis multiplex and abnormal erythrocyte sedimentation rate, Churg-Strauss syndrome was diagnosed. Acute pericarditis with abnormal ECGs and compensatory sinus tachycardia was documented in both cases as a sign of systemic vasculitis. Echocardiography revealed hemodynamically relevant pericardial effusions of 1.3 cm and 2.7-3.2 cm leading in one case to slightly diastolic compression of the right ventricle. The pericardial lesions showed good response to diuretic therapy with furosemide and administration of immunosuppressive agents like cyclophosphamide and azathioprine in combination with corticosteroids. The two presented cases underline that pericardial effusions of hemodynamic significance can be prominent clinical features of Churg-Strauss syndrome.

Prognostic value of Doppler echocardiographic assessment of left ventricular filling in idiopathic dilated cardiomyopathy

The relation of left ventricular (LV) diastolic filling with the clinical outcome in patients with idiopathic dilated cardiomyopathy (IDC) was examined. LV diastolic filling was assessed by Doppler echocardiography in 57 patients with IDC at the time that the diagnosis was established by angiocardiography. Patients were followed for 29 +/- 16 months. Fifteen patients died: 12 due to progressive congestive heart failure and 3 suddenly. Four other patients underwent cardiac transplantation because of progressive heart failure (1-year survival 86%). Patients who died of congestive heart failure or underwent cardiac transplantation had a steep increase and decrease in the early filling phase as compared with survivors; the peak early Doppler velocity was higher (0.84 +/- 0.16 vs 0.65 +/- 0.21 m/s; p < 0.005), and the deceleration time of the early velocity peak was shorter (117 +/- 26 vs 188 +/- 62 ms; p < 0.001) than in survivors. Surviving patients and those who died suddenly showed similar patterns of LV filling. Deceleration time and peak early Doppler velocity were the strongest predictors of survival as compared with systolic function and clinical status in a Cox proportional-hazards analysis. Patients with a shortened deceleration time (< or = 140 ms) had a significantly reduced 2-year survival rate of 52% (confidence interval 34 to 71%) as compared with those with a longer deceleration time (94%; confidence interval 89 to 98%) (p < 0.001). Evidence was presented for a relation between LV filling and survival in patients with IDC.

[Dynamic blood volume determination using the body transport function]

This paper describes a dynamic blood volume determination which is faster and more accurate than the classic method. The new method determines blood volume by means of the product of the mean transit time of the circulation and the cardiac output. The mean transit time is calculated from the body transport function. To examine the precision of the dynamic method the blood volume of 24 patients was determined in both the dynamic and the classical way, using radioactively labelled erythrocytes. The comparison of the two methods resulted in a correlation coefficient of r = 0.77. The dynamic method of blood volume determination will be helpful especially in risk patients to accurately determine the quantities of fluids to be administered.

Need for active left-ventricular decompression during percutaneous cardiopulmonary support in cardiac arrest

During ventricular fibrillation, myocardial hemodynamic and metabolic effects of percutaneous cardiopulmonary support (PCPS) were analyzed in 11 adult sheep (body weight 77-112 kg). During supported fibrillation, an abrupt increase in left-ventricular pressures with alignment to aortic pressures was observed in 2 animals, which was probably due to spontaneous aortic regurgitation, and resulted in deterioration of coronary perfusion. In 9 animals, left-ventricular pressures rose from 22.9 +/- 4.9 to 31.2 +/- 7.9 mm Hg elevating left ventricular wall stress from 16,750 +/- 8,745 to 28,835 +/- 8,892 dyn/cm2 after 10 min of PCPS-supported fibrillation (mean flow rate 4.5 +/- 0.7 liters/min). Simultaneously, myocardial perfusion pressures decreased from an average of 32.4 +/- 11.7 to 22.3 +/- 9.4 mm Hg and myocardial lactate release was observed. Additional transapical LV venting using a 9-Fr catheter led to a decrease in both LV pressure (to 25.7 +/- 5.3 mm Hg) and wall stress (to 20,612 +/- 7,499 dyn/cm2). Left-ventricular decompression decreased myocardial oxygen consumption (from 5.3 +/- 1.4 to 4.8 +/- 0.9 ml/min.100 g), and reduced myocardial lactate release, which indicates myocardial protection. Protective effects were most pronounced using 12-Fr-, and 21-Fr-venting cannulas (with 21 Fr: decrease in myocardial oxygen consumption to 2.7 +/- 0.6 ml/min.100 g, and reversal of myocardial lactate release to lactate uptake during fibrillation). Conclusions. Hemodynamic and metabolic data clearly demonstrate the deleterious effects of PCPS to the unvented left ventricle during cardiac arrest. The results emphasize the need for active left-ventricular decompression during PCPS in ventricular fibrillation.

Mechanical left ventricular unloading during high risk coronary angioplasty: first use of a new percutaneous transvalvular left ventricular assist device

A new catheter mounted, transvalvular left ventricular assist device has been designed for percutaneous transfemoral access. The device, the Hemopump [14 French (Fr.) outer diameter], is based on a mixed flow rotary pump and is capable of flow rates of 1.5-2.2 l/min. The pump is inserted using a specialized 16 Fr. femoral introducer sheath. The first application of the percutaneous Hemopump in man was performed in two patients with hemodynamic compromise during high risk coronary angioplasty. In these patients, Hemopump support resulted in hemodynamic stabilization (increase in aortic pressure from 60/42 to 87/61 and from 80/60 to 100/70 mm Hg, respectively) and marked left ventricular unloading (decrease in pulmonary capillary wedge pressure from 25 to 10 and from 14 to 10 mm Hg) during balloon inflation. In both patients, percutaneous transluminal coronary angioplasty (PTCA) could be accomplished successfully. Using the system for periods of about 2 hr in each patient, we observed no vascular, hemorrhagic, or embolic complications. In both patients, only a minor increase in both plasma free hemoglobin and lactate dehydrogenase levels was noted. Our preliminary experiences suggest that the percutaneous Hemopump is safe and effective and may be a powerful alternative to other devices used for supported angioplasty.

Circulatory support devices in clinical cardiology. Current concepts

Percutaneous transluminal coronary angioplasty (PTCA) has extended its indications to multivessel disease and impaired left-ventricular function. In these patients, failed PTCA may induce cardiogenic shock or arrest. Coronary and circulatory support devices such as antegrade perfusion catheters, coronary sinus retrograde perfusion, intraaortic balloon pumping, left-ventricular pumping (Hemopump) and percutaneously applicable cardiopulmonary support are the tools necessary for high-risk PTCAs. The devices are a prerequisite for developing a minimally invasive cardiac surgery.

Doppler echocardiographic assessment of left ventricular filling in idiopathic dilated cardiomyopathy during a one-year follow-up: relation to the clinical course of disease

In idiopathic dilated cardiomyopathy (IDC), an impaired left ventricular filling as assessed by the Doppler echocardiographic mitral flow pattern is closely related to the severity of congestive heart failure. This study examined the relation of left ventricular filling and the clinical course of the disease in patients with a recent diagnostic procedure and initiation of medical therapy (group 1, n = 15) as compared with patients in a chronic stage of the disease (group 2, n = 24) with the diagnosis established > 1 year before. All patients had to be in sinus rhythm to facilitate the Doppler echocardiographic evaluation of left ventricular filling. The clinical status was assessed by the New York Heart Association classification and a heart failure score at baseline and after a period of 12 +/- 7 months. At baseline the ratio of the peak early/atrial Doppler velocities (VE/VA) was shifted toward the early diastole in group 1 as compared to group 2 (1.84 +/- 1.02 vs 1.12 +/- 0.55; p < 0.05). Symptoms of heart failure were more severe in group 1. During follow-up, VE/VA tended to decrease in group 1 from 1.84 +/- 1.02 to 1.35 +/- 1.03 (p = 0.07) and remained unchanged in group 2 (1.12 +/- 0.55 and 1.34 +/- 1.23; not significant). In a subgroup of 10 patients who underwent repeat right heart catheterization, the decrease of VE/VA coincided with a decrease of the pulmonary capillary wedge pressure.(ABSTRACT TRUNCATED AT 250 WORDS)

Periodic respiration in patients with heart failure

Patients with heart failure are known to demonstrate periodic respiration (PR) during sleep. The factors causing PR are not well known. We therefore studied 20 patients (aged 18-66 years) with idiopathic dilated cardiomyopathy. Full-night polysomnography and evaluation of respiration and transcutaneous oxygen saturation were performed. Hypercapnic ventilatory response (HCVR) was evaluated during daytime. The patients showed PR for 25 +/- 26% (mean +/- standard deviation) of total sleep time. During PR, oxygen desaturated 7.1 +/- 4.6%. Sleep was impaired. HCVR was normal. Oxygen desaturation during PR was predicted by HCVR (r = 0.47, P < 0.05) and left atrial diameter (r = 0.60, P < 0.05). The time period of PR expressed as a fraction of total sleep time was correlated with HCVR (r = 0.45, P < 0.05) and left atrial diameter (r = 0.51, P < 0.05). In conclusion, PR with oxygen desaturation, arousals, and impaired sleep was observed in stable heart failure. HCVR and left heart dimensions were related to PR. These findings confirm the concept of a feedback loop describing respiratory control in PR.

Myocardial indium-111 antimyosin uptake in patients with idiopathic dilated cardiomyopathy: its relation to haemodynamics, histomorphometry, myocardial enteroviral infection, and clinical course

The myocardial uptake of indium-111 antimyosin indicates the presence of ongoing myocyte damage. To evaluate the role of this finding in patients with idiopathic dilated cardiomyopathy (IDC), 36 patients were studied by planar and SPECT antimyosin imaging. The diagnosis of IDC was based on coronary angiography and left ventricular endomyocardial biopsy. The antimyosin scan was evaluated qualitatively from SPECT images and assessed quantitatively by a count density index (CDI) which measured the tracer activity over the heart relative to the lung and sternal region (normal value less than 1.20). Group 1 consisted of 13 patients (36%) with an increased myocardial antimyosin uptake, while 23 patients had a normal antimyosin scan (group 2). Clinical data, pulmonary artery pressures, gated blood pool ejection fraction and histomorphometry of endomyocardial biopsies were similar in both groups. During a follow-up of 21 +/- 12 months there were two cardiac deaths in group 1 and 10 deaths in group 2 (P = 0.12). The 2-year survival rate was 81% and 59%, respectively. During follow-up, there was no significant change in haemodynamic parameters in either group, but there was a slight improvement in functional NYHA class in group 1 (P < 0.05). No association was found between the presence of myocardial enterovirus infection, determined in 17 patients by in situ hybridization and the antimyosin scan (P = 0.5 g). Myocardial antimyosin uptake was found in a high percentage of patients with IDC, indicating ongoing myocyte damage. This finding was not related to any clinical, haemodynamic, morphological parameter, or enterovirus infection. Myocyte damage is a distinct feature in a subgroup of patients with IDC unrelated to any known causes of myocellular destruction. This subgroup showed a trend towards a more favourable clinical outcome.

[Differences in the non-invasive assessment of left ventricular filling in patients with dilated cardiomyopathy using Doppler echocardiography and radionuclide angiography]

Doppler echocardiography and radionuclide angiography were shown to provide valuable tools with comparable functional parameters for the noninvasive assessment of left ventricular (LV) diastolic function in patients with coronary artery disease or LV hypertrophy. In order to examine the influence of an impaired systolic function on both methods, we studied LV filling simultaneously by Doppler echocardiography and radionuclide angiography in 47 patients with idiopathic dilated cardiomyopathy and stable sinus rhythm. The Doppler echocardiographic peak velocities (VE, VA) and radionuclide angiographic peak filling rates (PFRFF, PFRA) normalized to either left ventricular enddiastolic volume or stroke volume were measured and systolic function was assessed by obtaining the ejection fraction (EF) with the radionuclide angiography. Patients were divided into two groups with moderately (group 1: EF > or = 35%) or severely impaired (group 2: EF < 35%) systolic function. In group 2 the PFRFF (1.8 +/- 0.5 vs. 3.3 +/- 0.8 SV/s; p < 0.01) and PFRA (1.2 +/- 0.6 vs. 2.5 +/- 1.0 SV/s; p < 0.01) were both lower than in group 1, as was the Doppler echocardiographic VA (0.44 +/- 0.20 vs. 0.63 +/- 0.17 m/s; p < 0.01). However, VE was increased with reduced systolic function (0.75 +/- 0.20 vs. 0.53 +/- 0.16 m/s; p < 0.01). No relation was found between PFRFF and VE and only a weak relation between the atrial filling parameters of Doppler echocardiography and radionuclide angiography. The peak filling rates were closely correlated with the systolic function (PFRFF:r = 0.86; p < 0.001) and were reduced with an impaired systolic function.(ABSTRACT TRUNCATED AT 250 WORDS)

Significance of coronary angiography, left heart catheterization, and endomyocardial biopsy for the diagnosis of idiopathic dilated cardiomyopathy

Many physicians assume that a reliable diagnosis of idiopathic dilated cardiomyopathy can be made by noninvasive methods, mainly echocardiography. On the other hand, use of endomyocardial biopsy in those patients who have undergone left heart catheterization and who demonstrate left ventricular dysfunction of unknown origin is increasing. Therefore the purpose of this study was to investigate the yield of that diagnostic strategy in patients with the tentative diagnosis of idiopathic dilated cardiomyopathy. Between 1980 and 1988, 3.2% of our 15,442 patients were diagnosed as having idiopathic dilated cardiomyopathy on the basis of left heart catheterizations and coronary angiograms. Idiopathic dilated cardiomyopathy was diagnosed in 444 patients on the basis of clinical data and results of noninvasive tests before catheterization, but in only 295 of these cases was the diagnosis confirmed by means of coronary angiography and left heart catheterization (predictive value of noninvasive tests is 66%). The remaining 34% of patients demonstrated extensive coronary artery disease (13%), significant valvular heart disease (11%), and other or no heart disease (10%). The diagnostic sensitivity of noninvasive tools (patient history, ECG, stress test, echocardiography) was only 59%. Left heart catheterization can easily be combined with endomyocardial biopsy. With the use of histologic techniques, specific heart muscle diseases were detectable in 3.5% of 209 patients, but in only 1% could therapeutic consequences be determined. Thus coronary angiography and left heart catheterization are mandatory for the correct diagnosis of idiopathic dilated cardiomyopathy.(ABSTRACT TRUNCATED AT 250 WORDS)

[The percutaneous implantable heart-lung machine in the coronary angioplasty of high-risk and emergency patients]

Using a recently developed, percutaneously introduced cardiopulmonary support system (PCPS) seven high-risk patients (four men, three women; mean age 61 [41-77] years) underwent percutaneous transluminal coronary angioplasty. In one patient, with unstable angina and in incipient cardiogenic shock, perfusion with PCPS was begun immediately before coronary angioplasty. In six patients it was undertaken with the PCPS on stand-by, but eventually not needed. Coronary angioplasty was successful in six patients, partially successful in one. Angina was considerably improved long-term in all patients, but one of them died 2.5 months afterwards at home. In two other patients (men, aged 41 and 71 years) with acute myocardial infarction, the PCPS was employed under circumstances of emergency resuscitation. In both cases recanalization of the occluded coronary artery was achieved mechanically during perfusion with PCPS; one patient survived. Availability of PCPS, also in an emergency, makes it possible to extend the indications for coronary angioplasty to include even high-risk patients.

Radioimmunoimaging of subacute infective endocarditis using a technetium-99m monoclonal granulocyte-specific antibody

Immunoscintigraphy with a technetium-99m murine monoclonal IgG1 antibody directed against non-specific cross-reacting antigen (NCA-95) and carcinoembryonic antigen was performed with 20 patients with suspected subacute infective endocarditis (SIE) and 6 controls with suspected inflammatory/infectious disease elsewhere in the body. Immunoscintigraphy and echocardiography localised SIE in 11 of 15 patients in whom the disease could be confirmed. In 4 patients with validated SIE, the immunoscan was abnormal, and the echocardiogram was normal. In another 4 patients, the result was exactly the opposite. These findings suggest that the combination of immunoscintigraphy and echocardiography improves diagnostic efficacy in patients with suspected SIE.

[Diagnosis by endomyocardial biopsy: angina pectoris as a manifestation of lupus erythematosus]

A 64-year-old female patient with a prosthetic mitral valve suffered from recurrent typical angina and dyspnea. Left heart catheterization excluded a dysfunction of the prosthesis and coronary artery disease (CAD). A stress thallium scan demonstrated an ischemic reaction. An antimyosin scintigram was positive, indicating myocytal membrane disruption. Serological tests were suspicious for systemic lupus erythematosus (SLE). Therefore, an endomyocardial biopsy (EMB) was performed and a severe alteration of an intramyocardial artery, comparable with chronic SLE, was diagnosed. EMB is a useful diagnostic tool in patients with typical chest pain, positive thallium and anti-myosin scintigrams, however exclusion of CAD.