Cryptogenic ischemic stroke and paradoxical embolism: should a patent foramen ovale be closed? Case report and literature review

Paradoxical embolism is a well-recognized cause of stroke. While the diagnosis in the majority of the cases with a patent foramen ovale is presumptive, numerous treatment strategies have been described. However, there is no single approach that has been overwhelmingly recommended for these patients. A patient is described who presented with ischemic stroke. Transesophageal echocardiography revealed a thrombus that straddled a patent foramen ovale. Anticoagulation with intravenous heparin resulted in resolution of thrombus and neurologic deficit. The literature regarding diagnosis and treatment of paradoxical embolism in the presence of patent foramen ovale is reviewed.

Exercise update 2001

Recent studies addressing the role of exercise in the detection, prevention, and treatment of coronary heart disease have significantly expanded our knowledge base in this area. This therapeutic review is focused on physiologic parameters in exercise, electrocardiogram testing, and the preventive impact of low-intensity regular exercise and the role of exercise training in selected patient populations.

Multi-morphology wide QRS tachycardias in a patient without structural heart disease: an unusual presentation of ventricular tachycardia

Ventricular tachycardia occurs infrequently in patients without structural heart disease. These tachycardias commonly originate from the right ventricular outflow tract. However, the presence of more than one arrhythmogenic substrate in a patient without structural heart disease is rare. We report such a 48-year old patient with no structural heart disease who presented with three morphology wide QRS tachycardia. A brief review of the pathophysiology and management is discussed.

Real-time kinetics of ligand/cell surface receptor interactions in living cells: binding of epidermal growth factor to the epidermal growth factor receptor

We describe a system for extending stopped-flow analysis to the kinetics of ligand capture and release by cell surface receptors in living cells. While most mammalian cell lines cannot survive the shear forces associated with turbulent stopped-flow mixing, we determined that a murine hematopoietic precursor cell line, 32D, is capable of surviving rapid mixing using flow rates as great as 4.0 mL/s, allowing rapid processes to be quantitated with dead times as short as 10 ms. 32D cells do not express any endogenous epidermal growth factor (EGF) receptor or other ErbB family members and were used to establish monoclonal cell lines stably expressing the EGF receptor. Association of fluorescein-labeled H22Y-murine EGF (F-EGF) to receptor-expressing 32D cells was observed by measuring time-dependent changes in fluorescence anisotropy following rapid mixing. Dissociation of F-EGF from EGF-receptor-expressing 32D cells was measured both by chase experiments using unlabeled mEGF and by experiments in which equilibrium was perturbed by dilution. Comparison of these dissociation experiments showed that little, if any, ligand-induced dissociation occurs in the chase dissociation experiments. Data from a series of association and dissociation experiments, performed at various concentrations of F-EGF in the nanomolar range and at multiple cell densities, were simultaneously analyzed using global analysis techniques and fit to a two independent receptor-class model. Our analysis is consistent with the presence of two distinct receptor populations having association rate constants of k(on1) = 8.6 x 10(6) M(-1) s(-1) and k(on2) = 2.4 x 10(6) M(-1) s(-1) and dissociation rate constants of k(off1) = 0.17 x 10(-2) s(-1) and k(off2) = 0.21 x 10(-2) s(-1). The magnitudes of these parameters suggest that under physiological conditions, in which cells are transiently exposed to nanomolar concentrations of ligand, ligand capture and release may function as the first line of regulation of the EGF receptor-induced signal transduction cascade.

Dipyridamole-induced ST-segment elevation indicative of transmural myocardial ischemia--a case report

Dipyridamole nuclear myocardial perfusion test is a safe and effective alternative to exercise nuclear perfusion testing for detecting myocardial ischemia. It is the procedure of choice in selected patients who are unable to exercise adequately. Intravenous dipyridamole causes coronary vasodilation with resultant maldistribution and heterogeneity of coronary flow in the presence of significant coronary artery disease. True ischemia, causing symptoms or ST-segment depression, is uncommon, in part because there is no increase in myocardial oxygen demand. A patient in whom myocardial ischemia developed, manifested by ST-segment elevation, during dipyridamole stress testing is described. Scintigraphic images illustrated a myocardial perfusion defect, which was consistent with coronary angiographic findings. This case report addresses the importance of dipyridamole-induced ST-segment elevation, its correlation with angiographic findings, and the need for continued hemodynamic and electrocardiographic monitoring in patients following dipyridamole infusion.

Cardiovascular risks of sexual activity

The risks associated with sexual activity relate in part to the pathophysiology of the cardiovascular response to sexual activity. This review addresses this subject and reviews studies that directly address the cardiovascular risk associated with sexual activity.

Anterior mitral valve aneurysm: a subaortic complication of aortic valve endocarditis: a case report and review of literature

Mitral valve aneurysm is a rare cause of mitral regurgitation, and is usually associated with aortic valve endocarditis. Prompt diagnosis and early surgical treatment can prevent complications such as embolization and rupture of the aneurysm. The authors report a case of aortic valve endocarditis and mitral valve aneurysm in a patient who initially presented with urinary tract infection.

Adverse effects of herbal treatment of cardiovascular disease: what the physician must know

The increasing use of herbal products by patients with cardiovascular disease represents a clinical challenge to physicians. The use of herbal products is increasing in our society, and less than 50% of patients using herbal products report this information to their physicians. In addition, physicians often lack the knowledge base for herbal medications to effectively counsel patients regarding adverse effects and potential herb-drug interactions. This article reviews Western and traditional Chinese herbs that are commonly used by patients with cardiovascular diseases, herbs noted to have adverse cardiovascular effects, and herbs that may potentially interact with commonly prescribed cardiovascular medications.

An Analytical Approach to the Measurement of Equilibrium Binding Constants: Application to EGF Binding to EGF Receptors in Intact Cells Measured by Flow Cytometry

In ligand binding studies, ligand depletion often limits the accuracy of the results obtained. This problem is approached by employing the simple observation that as the concentration of receptor in the assay is reduced, ligand depletion is also reduced. Measuring apparent K(D)'s of a ligand at multiple concentrations of receptor with extrapolation to infinitely low receptor concentration takes ligand depletion into account and, depending on the binding model employed, yields a K(D) within the defined limits of accuracy. We apply this analysis to the binding of epidermal growth factor (EGF) to the EGF receptor expressed in intact 32D cells, using a homogeneous fluorescein-labeled preparation of EGF and measuring binding by flow cytometry. Binding isotherms were carried out at varying cell densities with each isotherm fit to the generally applied model with two independent binding sites. Examination of the variation in the K(D)'s versus cell density yields a high-affinity site that accounts for 18% of the sites and a lower affinity site that accounts for the remainder. However, further examination of these data suggests that while consistent with each individual isotherm, the simple model of two independent binding sites that is generally applied to EGF binding to the EGF receptor is inconsistent with the changes in the apparent K(D)'s seen across varying cell densities.

Use of intracoronary electrocardiography for detecting ST-T, QTc, and U wave changes during coronary balloon angioplasty

Intracoronary electrocardiography (IC-ECG) is a more sensitive method than surface ECG to detect electrical changes during percutaneous transluminal coronary angioplasty (PTCA). It also provides direct monitoring of ST-T segment, QTc intervals, and U-wave genesis during balloon inflation. These changes are reflective of myocardial ischemia. The authors studied the effect of transient myocardial ischemia on ST-T segment, QTc intervals, and U-wave appearance by comparing standard and perfusion balloon angioplasty. PTCA of left anterior descending artery was performed in 14 patients using the standard balloons and in 11 patients using the perfusion balloons. Patients with perfusion balloon angioplasty had less ST-T elevation (0.15 +/- 0.05 mV versus 1.04 +/- 0.19 mV, P < 0.001), less QTc-shortening intervals (0.01 +/- 0.02 seconds versus -0.05 +/- 0.04 seconds, P < 0.001), and less positive U waves (two versus nine). The authors concluded that balloon angioplasty with perfusion balloons is associated with less ischemia as reflected by ST-T, QTc-shortening intervals, and U-wave changes. There was more positive U-wave appearance with the standard balloon angioplasty, which implies more ischemia. In addition, QTc-shortening intervals are associated with the development of U waves during standard balloon angioplasty. These findings suggest that IC-ECG is a sensitive tool in detecting myocardial ischemia. IC-ECG may also help to clarify the nature of chest pain during PTCA in some patients. Like QT dispersion (QTd), QTc-shortening intervals and new U waves can have prognostic implications and additional studies are needed to define this role.

Structural characterization of penicillin-binding protein-related factor A (PrfA) from Bacillus species

The prfA genes of Bacillus stearothermophilus and Bacillus subtilis are in an operon downstream of the ponA gene encoding penicillin-binding protein 1 (PBP1), a major enzyme involved in peptidoglycan synthesis. The specific function of the 23- to 24-kDa PrfA protein is unknown but this protein plays some role in nucleoid segregation and the functions of PrfA and PBP1 are interrelated. We overexpressed B. stearothermophilus and B. subtilis PrfA in Escherichia coli and purified the proteins to homogeneity by cation exchange and gel filtration chromatography. The protein is a monomer in solution, and circular dichroism spectroscopy revealed an abundance of beta-sheet secondary structure. Crystals of B. stearothermophilus PrfA were also obtained and diffracted X-rays to 1.8 A resolution.

Management of sexual dysfunction in patients with cardiovascular disease: recommendations of the Princeton Consensus Panel

Sexual dysfunction is highly prevalent in both sexes and adversely affects patients' quality of life and well being. Given the frequent association between sexual dysfunction and cardiovascular disease, in addition to the potential cardiac risk of sexual activity itself, a consensus panel was convened to develop recommendations for clinical management of sexual dysfunction in patients with cardiovascular disease. Based upon a review of the research and presentations by invited experts, a classification system was developed for stratification of patients into high, low, and intermediate categories of cardiac risk. The large majority of patients are in the low-risk category, which includes patients with (1) controlled hypertension; (2) mild, stable angina; (3) successful coronary revascularization; (4) a history of uncomplicated myocardial infarction (MI); (5) mild valvular disease; and (6) no symptoms and <3 cardiovascular risk factors. These patients can be safely encouraged to initiate or resume sexual activity or to receive treatment for sexual dysfunction. An important exception is the use of sildenafil in patients taking nitrates in any form. Patients in the intermediate-risk category include those with (1) moderate angina; (2) a recent MI (<6 weeks); (3) left ventricular dysfunction and/or class II congestive heart failure; (4) nonsustained low-risk arrhythmias; and (5) >/=3 risk factors for coronary artery disease. These patients should receive further cardiologic evaluation before restratification into the low- or high-risk category. Finally, patients in the high-risk category include those with (1) unstable or refractory angina; (2) uncontrolled hypertension; (3) congestive heart failure (class III or IV); (4) very recent MI (<2 weeks); (5) high-risk arrhythmias; (6) obstructive cardiomyopathies; and (7) moderate-to-severe valvular disease. These patients should be stabilized by specific treatment for their cardiac condition before resuming sexual activity or being treated for sexual dysfunction. A simple algorithm is provided for guiding physicians in the management of sexual dysfunction in patients with varying degrees of cardiac risk.

Cardiovascular response to sexual activity

The cardiovascular response to coitus and the risk of an acute cardiac event related to sexual activity is of clinical importance, especially now that effective pharmacologic treatment of male erectile dysfunction permits older men to resume active sex lives. Early studies by Masters and Johnson of young subjects engaging in coitus in laboratory settings reported that heart rates and systolic blood pressures were at near maximum exercise levels. Subsequent data from studies by Hellerstein and Friedman and by Stein in men with coronary artery disease, using ambulatory electrocardiographic recordings during coitus at home, demonstrated significantly lower heart rate and blood pressure responses to coitus. The associated myocardial oxygen demand of coitus in these men was found to in the range of moderate activities, often achieved or exceeded during their workday. The cardiovascular risk of coitus was addressed in the recent ONSET study in which myocardial infarction (MI) patients were interviewed shortly after their MI about potential triggering activities or events. Coitus was noted to represent a very low absolute risk of being a trigger for MI, but had an increased relative risk of 2.5 for the subjects in their study. Sexual intercourse will, in most men, represent only a moderate "stress" on the heart in terms of the responses that impact on myocardial oxygen requirement (heart rates, and systolic blood pressure). In patients with coronary artery atherosclerosis, coitus, compared with vigorous physical activity and intense emotional responses, represents a small risk of triggering an acute MI.

Management of sexual dysfunction in patients with cardiovascular disease: recommendations of The Princeton Consensus Panel

Sexual dysfunction is highly prevalent in both sexes and adversely affects patients' quality of life and well being. Given the frequent association between sexual dysfunction and cardiovascular disease, in addition to the potential cardiac risk of sexual activity itself, a consensus panel was convened to develop recommendations for clinical management of sexual dysfunction in patients with cardiovascular disease. Based upon a review of the research and presentations by invited experts, a classification system was developed for stratification of patients into high, low, and intermediate categories of cardiac risk. The large majority of patients are in the low-risk category, which includes patients with (1) controlled hypertension; (2) mild, stable angina; (3) successful coronary revascularization; (4) a history of uncomplicated myocardial infarction (MI); (5) mild valvular disease; and (6) no symptoms and <3 cardiovascular risk factors. These patients can be safely encouraged to initiate or resume sexual activity or to receive treatment for sexual dysfunction. An important exception is the use of sildenafil in patients taking nitrates in any form. Patients in the intermediate-risk category include those with (1) moderate angina; (2) a recent MI (<6 weeks); (3) left ventricular dysfunction and/or class II congestive heart failure; (4) nonsustained low-risk arrhythmias; and (5) >/=3 risk factors for coronary artery disease. These patients should receive further cardiologic evaluation before restratification into the low- or high-risk category. Finally, patients in the high-risk category include those with (1) unstable or refractory angina; (2) uncontrolled hypertension; (3) congestive heart failure (class III or IV); (4) very recent MI (<2 weeks); (5) high-risk arrhythmias; (6) obstructive cardiomyopathies; and (7) moderate-to-severe valvular disease. These patients should be stabilized by specific treatment for their cardiac condition before resuming sexual activity or being treated for sexual dysfunction. A simple algorithm is provided for guiding physicians in the management of sexual dysfunction in patients with varying degrees of cardiac risk.

Evolutionary analysis of the ErbB receptor and ligand families

We have compared all available deduced protein sequences of the ErbB family of receptors and their ligands. Analysis of the aligned sequences of the receptors indicates that there are some differences in the receptors that are specific to invertebrates. In addition, comparison of the vertebrate ErbB receptors suggest that a gene duplication event generated two ancestral receptors, the ErbB3/ErbB4 precursor and the ErbB1/ErbB2 precursor. Subsequent gene duplications of these precursors generated the four receptors present in mammals. Analysis of the sequences for the known ligands of the ErbB receptors suggests that the vertebrate ligands segregate into the ErbB1 ligands and the ErbB3/ErbB4 ligands, paralleling the evolution of the receptors; however, it is difficult to ascertain any correlation between the invertebrate and the vertebrate ligands. Even though ErbB3 is kinase-impaired, there is significant conservation of the kinase domain within the vertebrate lineage (human, rat, and F. rubripes), suggesting some function for this domain other than kinase activity, such as mediating protein-protein interactions that are involved in receptor dimerization and/or activation of the kinase domain of the heterodimerization partner. To date, no ligand for ErbB2 has been identified, and comparison of the extracellular domains of ErbB2 reveals two regions that are not conserved across the mammalian species. These two regions of divergence align with sequences in ErbB1 that have been shown to be proximal to the amino-terminus and to the carboxyl-terminal region, respectively, of bound EGF. Further, one of these regions contains an insertion, relative to the other members of the mammalian ErbB family, which might affect the ligand binding site and provide a structural basis for this receptor's apparent inability to bind ligand independently.

Recurrent right atrial thrombus after repair of ruptured sinus of valsalva aneurysm

Ruptured sinus of Valsalva aneurysm is a rare cardiac abnormality. Early surgical repair is indicated to prevent complications such as heart failure, infective endocarditis, arrhythmias, and thromboembolic events. The authors report an unusual case of recurrent right atrial thrombus after the surgical repair and closure of ruptured sinus of Valsalva aneurysm.

Update on exercise cardiology

This review focuses on innovative directions and recent studies in cardiovascular exercise science. Studies that address the enhancement of the diagnostic and prognostic value of exercise testing, by virtue of electrocardiographic analysis and the integration of exercise tolerance and clinical findings, are reviewed. The roles of exercise electrocardiographic testing in chest pain centers and the epidemiologic and physiologic effects of exercise training are discussed. The impact of exercise training on the angiographic and clinical regression of coronary artery disease and gender differences in exercise testing and training are among the concluding topics.

A review of the neuropsychological effects of commonly used prescription medications

The practice of clinical neuropsychology has traditionally accorded limited attention to the impact of prescription medications on cognitive functioning. Though neuropsychologists see a wide array of patients with cerebropathologic and other organ system disease that are under pharmacotherapy, systematic attention to how these compounds potentially affect neuropsychological functioning has lagged. Psychomotor functioning, concentration, and memory are the most common cognitive domains negatively affected by such medications. In general sedative, psychomotor, and, to a lesser extent, attention/concentration effects covary and typically show tolerance with sustained drug administration. Memory effects are more resistant probably due to ongoing anticholinergic effects and the established link between the cholinergic system and memory functioning. This review covers the basic science and clinical literature addressing neuropsychological functioning both in healthy nonpatients and in patients treated with antidepressants, anxiolytics, stimulants, antihypertensives, antiepileptics and antihistamines. Critical to the understanding of the effects of these agents is the integration of multiple factors that modulate medication-induced neurocognitive effects, such as chronicity of treatment, tolerance, age, ethnicity, metabolic capacity, psychological, and neurological disorders in the patient, and the benefits of successful treatment of these disorders.

Cardiovascular response to sudden strenuous exercise: an exercise echocardiographic study

We studied the response in left ventricular (LV) internal dimensions and posterior wall thickness during the performance of sudden strenuous exercise without warm-up (SSE) and sudden strenuous exercise with warm-up (SSEw) in 15 healthy, untrained college-aged males (26 +/- 5.0 yr). Measurements of left ventricular end-diastolic dimension (LVEDD), left ventricular end-systolic dimension (LVESD), stroke dimension (SD = LVEDD-LVESD), fractional shortening (FS = SD/EDD) and posterior wall thickness (PWT) were obtained from continuous 2-D targeted on M-mode echocardiography. Continuous EKG and blood pressure were obtained at rest and during the final 10 s of SSE (30 s of upright leg cycle ergometry of 400 W at 80 rpm). SSEw was preceded by warm-up exercise (6 min of graded leg cycle exercise of 2-min stages initial load 30 W, increasing in 30-W increments at 60 rpm, followed immediately by SSE). Our findings revealed that there were no significant differences in the LV internal dimensions (LVEDD, LVESD, FS, PWT), HR max, RPP max, ECG, and MAP max between SSE and SSEw. Sudden strenuous exercise without warm-up is not associated with a reduced LV function. The results of this study are contradictory to previous findings that have suggested that SSE is associated with transient global left ventricular (LV) dysfunction.

Activation of creatine kinase-B and phospholamban gene expression in transformed latissimus dorsi muscle: evaluation of mRNA by polymerase chain reaction

Latissimus dorsi muscle (LDM) transformation following chronic stimulation is the critical requirement for its use in cardiac assist procedures. In order to identify one or two molecular markers that can be used to effectively monitor the LDM transformation, the modulation in the expression of creatine kinase (CK) and phospholamban (PLB) genes by semi-quantitative reverse transcriptase polymerase chain reaction (RT-PCR) was examined. Continuous in situ stimulation of left LDM was performed in four dogs for a period of 10 weeks after a vascular delay period of 2 weeks following surgery. For RT-PCR, gene-specific radiolabeled primers and equal amounts of cDNA synthesized from total RNA extracted from the LDM biopsies obtained at 4, 7, and 10 weeks of stimulation were used. A 2.6-fold increase in creatine kinase (brain type) (CK-B) mRNA was observed at transformed LDM compared to the control (P = 0.004) following 10 weeks of stimulation. On the contrary, a 30% decline was observed in creatine kinase (muscle type) (CK-M) mRNA level. An increase up to eight-fold was also observed in PLB mRNA in stimulated LDM compared to the contralateral muscle (P = 0.002). The PLB mRNA level in transformed LDM reached plateau and became comparable to that of normal heart after 7 weeks of stimulation. However, a sustained increase in CK-B mRNA level was observed until 10 weeks of stimulation. The level of beta-actin mRNA used as control remained the same in both stimulated and control samples. Thus the increase in CK-B and PLB mRNA and downregulation of CK-M mRNA in transformed LDM, demonstrated here by RT-PCR, indicate a switch from anaerobic to aerobic potential of transformed LDM along with a change towards slow-twitch phenotype and provide valuable markers to monitor the effectiveness of muscle transformation in cardiomyoplasty.

5'-(p-fluorosulfonylbenzoyl)-2'(or 3')-(methylanthraniloyl)adenosine, fluorescent affinity labels for adenine nucleotide binding sites: interaction with the kinase active site of the receptor for epidermal growth factor

We have found that the epidermal growth factor (EGF) receptor kinase can utilize the fluorescent ATP derivative, methylanthraniloyl ATP, as a substrate. On the basis of this observation, together with our previous studies that showed that 5'-(p-fluorosulfonylbenzoyl)adenosine (5'-FSBAdo) is a highly specific affinity label for the ATP site of the kinase domain of the EGF receptor, we prepared new derivatives of 5'-FSBAdo, 5'-(p-fluorosulfonyl)-2'(or 3')-(methylanthraniloyl)adenosine (FSBMantAdo), as fluorescent affinity labels for adenine nucleotide binding sites, and in particular for the ATP site of the EGF receptor. The two products were purified by HPLC and were characterized by UV-Vis absorbance spectroscopy, mass spectrometry, nuclear magnetic resonance spectroscopy, and fluorescence spectroscopy. Incubation of membrane vesicles containing the EGF receptor with either the 2' or 3' derivative resulted in irreversible inhibition of the receptor kinase activity, as assessed by autophosphorylation assays. Preincubation of vesicles with AMP imidodiphosphate (AMPPNP), a hydrolysis-resistant ATP analog, prior to treatment with FSBMantAdo resulted in the protection of the receptor kinase activity' from FSBMantAdo inactivation. Steady state fluorescence spectra (with excitation at 360 nm) revealed a blue shift in the emission maximum of partially purified FSBMantAdo-labeled receptor (426 nm), as compared with the emission maximum of free FSBMantAdo (441 nm) in aqueous solution, suggesting that the receptor-bound label is in a relatively low polarity environment. These studies show that FSBMantAdo is a specific affinity label for the ATP site of the EGF receptor. FSBMantAdo may also prove useful as a fluorescent affinity label for other ATP binding sites.

Cardiac catheterization and selective coronary angiography with tortuous aorta and anomalous coronary artery

The authors report a case of selective coronary angiography by use of a modified technique in a patient with tortuous iliac artery, distorted thoracic descending aorta, and anomalous left coronary artery. This approach to such anatomy can decrease the fluoroscopy time and reduce the likelihood of complications.

Thermal inactivation of the protein tyrosine kinase of the epidermal growth factor receptor

It has been shown previously that the EGF-stimulable protein tyrosine kinase in a membrane preparation from A431 cells was inactivated by heat shock (45 degrees C), under conditions where EGF binding was unaffected [Carpenter et al. (1979) J. Biol. Chem. 254, 4884-4891]. A later study found that in intact cells, the protein tyrosine kinase of the EGF receptor was insensitive to heat shock [Liu & Carpenter (1992) Biochem. J. 286, 541-547]. We have extended these previous studies to better understand the thermal stability of the protein tyrosine kinase of the EGF receptor. We have measured the rate of inactivation of the kinase in membrane vesicles in the physiological to heat shock temperature range (37-45 degrees C). At 45 degrees C, the protein tyrosine kinase is rapidly inactivated with a rate of approximately 0.14 min-1. There is, however, protection against inactivation by incubation of the EGF receptor with AMPPNP, a hydrolysis-resistant ATP analog. At 45 degrees C, the rate of inactivation of nucleotide-bound receptor is an order of magnitude lower than the rate of inactivation of unoccupied receptor. Analysis of the temperature dependence of inactivation between 37 and 45 degrees C yields an activation energy, E(a), of 42 kcal/mol, an activation Gibbs free energy, delta G(++), between 23 and 22 kcal/mol, an activation enthalpy, delta H(++), of 42 kcal/mol, and an activation entropy, delta S(++), of 60 cal/(K.mol). The signs and magnitudes of the thermodynamic parameters suggest that inactivation is more likely due to some local reorganization within the kinase domain than to a simple chemical process. Further, the kinetic data show that the receptor is stabilized against inactivation by binding adenine nucleotide.

Double Orifice Mitral and Tricuspid Valves

Atrioventricular valve duplication is a rare congenital cardiac anomaly. The anomaly is usually recognized as an incidental finding at autopsy, open heart surgery, or two-dimensional echocardiography. In this article we present the transthoracic and transesophageal presentation of a case of mitral and a case of tricuspid valve duplication. The hemodynamic consideration of the lesions is discussed with a review of the literature. (ECHOCARDIOGRAPHY, Volume 13, January 1996)

Combined dissection of the right coronary artery and right coronary cusp during coronary angiography

Dissection of coronary arteries during diagnostic coronary angiography is infrequent; dissection of the coronary cusp is extremely rare. The combination of coronary artery and coronary cusp dissection has not been reported previously. A case of right coronary artery dissection and right coronary cusp dissection during diagnostic coronary angiography is described.

Intracoronary ST-T alternans during coronary balloon angioplasty

To evaluate the presence and clinical significance of electrical alternans during PTCA, intracoronary electrocardiography (ic-ECG) was performed in 65 consecutive lesions. ST-T alternans, defined as a beat-to-beat difference in the ST elevation > or = 1 mm, was present in five lesions (7.7%), all in the proximal left anterior descending (LAD) coronary artery. The phenomenon was seen only after 130 sec (mean 174 +/- 57) of balloon inflation. Only two of the five showed ST-T alternans simultaneously on both surface and ic-ECG. One of five patients had premature ventricular contractions following ST-T alternans. Three of these five lesions required a second balloon inflation with duration of > or = 300 sec; there was no ST-T alternans on the second inflation in any of these lesions. We conclude: (1) the detection of ST-T alternans during PTCA is enhanced by use of ic-ECG, (2) electrical alternans during PTCA was seen only in proximal LAD lesions, implicating a large amount of ischemic myocardium as a requisite for the phenomenon, (3) electrical alternans is not immediate, requiring a certain duration of balloon occlusion and hence ischemia to occur, and (4) the absence of ST-T alternans during second balloon inflations suggests ischemic preconditioning may abolish this phenomenon.

Light distribution of ocular endophotocoagulator probes and its surgical implications

Ophthalmic endophotocoagulator probe cone angle affects the spot size, working distance, laser output power requirement, tissue exposure time, and uniformity of tissue irradiance, which all affect ease and safety of clinical use. The cone angle and irradiance distribution of several ophthalmic endophotocoagulator delivery systems were studied by directing the laser energy emitted by them on a CCD video sensor at several angles of incidence. The irradiances followed a Gaussian distribution. The measured irradiances were compared to a mathematical model of tissue irradiance that adjusted for the cone angle, probe-tissue distance, and angle of incidence. Using this model, laser irradiances produced by endophotocoagulator probes can be estimated under a wide variety of conditions. At highly oblique angles of incidence, wide-angle probes produce unexpectedly higher and uneven tissue irradiance. When numerous characteristics are considered, probes with a cone angle in the range of 10 degrees have many advantages over narrower or wider angle probes.

The effect of corneal thickness on applanation tonometry

Simultaneous manometry and Perkins tonometry were performed at 10.0, 20.0, and 30.0 mm Hg on 15 eyes on which intraocular procedures were performed. There was a statistically significant relationship between corneal thickness and the error of Perkins tonometry. Thin corneas produced underestimations of the intraocular pressure by as much as 4.9 mm Hg, whereas thick corneas produced overestimations by as much as 6.8 mm Hg. Measuring the corneal thickness is necessary to interpret properly the results of Goldmann applanation tonometry, particularly in eyes with thin corneas.

Foreign bodies in the foot

A symptomatic foreign object lodged in the foot can be a difficult problem. The object's location and shape are the most important factors to identify before removal of the object is attempted. Many different imaging modalities have been used to locate the foreign objects in the foot. The authors briefly reviewed several common imaging modalities. Computed tomography appears to be superior to the other imaging modalities discussed in visualizing and localizing foreign objects in the foot. Magnetic resonance scanning is probably equal to computed tomography but is less readily available and more expensive and is contraindicated with ferrous metal foreign bodies.

Changes in left ventricular size, wall thickness, and function in anemic patients treated with recombinant human erythropoietin

Left ventricular size and function were evaluated in 15 anemic chronic hemodialysis patients before and after the administration of recombinant human erythropoietin (rHuEPO). All patients were studied with two-dimensional and M-mode echocardiographic examinations before the initiation of rHuEPO (T1) and at 28 +/- 7 weeks of rHuEPO therapy (T2). The two-dimensional targeted M-mode echocardiographic measurements obtained were: end-diastolic dimension (EDD); end-systolic dimension (ESD); stroke dimension (SD); dimensional shortening (SD/EDD); systolic posterior wall thickness (PWs); diastolic posterior and interventricular septal thickness; end-systolic wall stress (ESWS); and left ventricular mass. Mean hematocrit in these patients increased almost 50%. The EDD decreased from a mean value (+/- SEM) of 6.41 +/- 0.33 to 4.93 +/- 0.21 cm (p less than 0.05). ESD decreased from a mean value of 4.16 +/- 1.2 to 2.77 +/- 0.06 cm (p less than 0.05). The calculated mean SD decreased slightly but not significantly from 2.21 +/- 0.69 to 2.19 +/- 0.60 cm. The calculated SD/EDD increased from a mean 0.35 +/- 0.09 to 0.44 +/- 0.07 (p less than 0.05). ESWS fell from 59.2 +/- 12.2 to 37.6 +/- 9.3 gm/cm2 (p less than 0.01), and left ventricular mass fell (p less than 0.05) from 347 +/- 15.2 to 227 +/- 59 gm. There was no significant difference in resting heart rate or systolic blood pressure between T1 and T2. The increase in dimension shortening reflects afterload reduction, as indicated by the fall in end-systolic wall stress.(ABSTRACT TRUNCATED AT 250 WORDS)

Lipid and lipoprotein profiles relate to peak aerobic power in spinal cord injured men

The relationship between peak VO2 and serum lipids, lipoproteins, and apolipoproteins was assessed in nine traumatic spinal cord injured (SCI), active, male volunteers. Mean (SD) age, height, and weight were 30.6 (11.6) yr, 171.1 (11.3) cm, and 74.2 (12.5) kg, respectively. Peak VO2 (X = 2.13 l.min-1) was assessed by a graded arm-crank test to maximum, percent body fat (X = 28.7%) by densitometry, and lipid profile by measures of serum triglycerides, total cholesterol (TC), high and low density lipoprotein cholesterol (HDL-C and LDL-C, respectively), apolipoproteins (apoA-1, apoB), and various ratios of lipids, lipoproteins, and apolipoproteins. Significant inverse relationships emerged between peak VO2 and TC/HDL-C (r = -0.86; P less than 0.01), apoB/apoA-1 (r = -0.75; P less than 0.05), triglycerides (r = -0.73; P less than 0.05), and LDL-C/HDL-C (r = -0.72; P less than 0.05). Direct correlations (P less than 0.05) were demonstrated between peak VO2 and apoA-1/apoB (r = 0.71) and HDL-C/apoA-1 (r = 0.64). The present results indicate that, for active, mid-to-lower thoracic SCI men, the putative atherogenic and antiatherogenic lipid, lipoprotein, and apolipoprotein indices are significantly related to peak VO2 in a manner similar to that described for the able-bodied. These findings indicate the relevance of aerobic fitness assessment in planning CHD prevention strategies for the SCI.

Exercise in hemodialysis patients after treatment with recombinant human erythropoietin

To assess the effect of substantial increases in blood hemoglobin (Hb) caused by treatment with recombinant human erythropoietin (rhEPO) on exercise capacity in maintenance hemodialysis patients, we evaluated 10 patients (7 men and 3 women) at a mean age of 44.3 +/- 8.4 years on maintenance hemodialysis for a mean of 29.7 +/- 30.2 months by treadmill exercise to exhaustion. The patients were tested before administration of rhEPO and after a minimum 1 g/dl rise in Hb. With a change in Hb from 7.1 +/- 1.4 to 9.8 +/- 2.1 g/dl, peak oxygen consumption (VO2 peak) with exercise increased 50.3 +/- 9% (T1 = 15.1 +/- 5.3, T2 = 22.7 +/- 4.6 ml O2/kg/min, p less than 0.05). Respiratory exchange ratio (RER) at a given submaximal exercise level (3 mph, 6% of elevation) decreased significantly (T1 = 1.13 +/- 0.24, T2 = 0.92 +/- 0.08, p less than 0.05). The rhEPO-mediated increase in Hb was associated with an increased VO2 peak--an improvement of the peak exercise capacity and a reduced submaximal RER--reflecting a reduction in anaerobic metabolism at activities of daily living.

Segmentation of high-frequency ultrasound images of atherosclerotic coronary arteries

High-frequency epicardial echocardiography (HFE) is an ultrasound imaging technique capable of visualizing coronary arteries in cross-section. Use of this imaging technique in the intra-operative setting can provide information about the structure of coronary arteries. As a result of time constraints imposed in this setting, there is a need for rapid, on-line analysis of HFE images. An algorithm for segmenting HFE images of coronary arteries into wall and luminal regions is described in this paper. The algorithm is more objective and time efficient than manual methods. A validation study with post-mortem human hearts demonstrated an excellent correlation (r = 0.99 for luminal areas, r = 0.99 for wall areas) between HFE images segmented with the algorithm and by manual methods, and a good correlation (r = 0.90 for luminal areas, r = 0.86 for wall areas) between HFE images segmented with the algorithm and manually segmented images of histological samples of the corresponding coronary arterial segments. Use of the algorithm for intra-operative HFE image segmentation may reduce the amount of time required for HFE image analysis and allow for an increased amount of data collection and analysis in the operating room.

Time-resolved rotational dynamics of phosphorescent-labeled myosin heads in contracting muscle fibers

We have measured the microsecond rotational motions of myosin heads in contracting rabbit psoas muscle fibers by detecting the transient phosphorescence anisotropy of eosin-5-maleimide attached specifically to the myosin head. Experiments were performed on small bundles (10-20 fibers) of glycerinated rabbit psoas muscle fibers at 4 degrees C. The isometric tension and physiological ATPase activity of activated fibers were unaffected by labeling 60-80% of the heads. Following excitation of the probes by a 10-ns laser pulse polarized parallel to the fiber axis, the time-resolved emission anisotropy of muscle fibers in rigor (no ATP) showed no decay from 1 microsecond to 1 ms (r infinity = 0.095), indicating that all heads are rigidly attached to actin on this time scale. In relaxation (5 mM MgATP but no Ca2+), the anisotropy decayed substantially over the microsecond time range, from an initial anisotropy (r0) of 0.066 to a final anisotropy (r infinity) of 0.034, indicating large-amplitude rotational motions with correlation times of about 10 and 150 microseconds and an overall angular range of 40-50 degrees. In isometric contraction (MgATP plus saturating Ca2+), the amplitude of the anisotropy decay (and thus the amplitude of the microsecond motion) is slightly less than in relaxation, and the rotational correlation times are about twice as long, indicating slower motions than those observed in relaxation. While the residual anisotropy (at 1 ms) in contraction is much closer to that in relaxation than in rigor, the initial anisotropy (at 1 microsecond) is approximately equidistant between those of rigor and relaxation.(ABSTRACT TRUNCATED AT 250 WORDS)

Effects of exercise on the signal-averaged electrocardiogram in coronary artery disease

The effects of exercise on the signal-averaged electrocardiogram (SAECG) were investigated in 52 patients with stable coronary artery disease. The SAECG was recorded before and immediately after the exercise test and analyzed at 25 to 250 Hz and 40 to 250 Hz. All patients had SAECG with noise level less than or equal 0.8 microV at 25 Hz and less than or equal to 0.6 microV at 40 Hz and with the difference in noise level between control SAECGs and SAECGs after exercise less than or equal to 0.2 to 0.3 microV. Twenty-eight patients developed ST changes consistent with transient subendocardial ischemia that persisted during the SAECG recording after exercise. There was no significant difference between control SAECGs and SAECGs after exercise in patients with or without a positive exercise test. The absence of significant change on the SAECG was not related to the presence or absence of prior myocardial infarction, site of infarction, development of exercise-induced ventricular arrhythmias or presence of an abnormal recording at baseline. These data suggest that exercise-induced electrophysiologic changes and ventricular arrhythmias may not be related to the anatomic-electrophysiologic substrate that underlies late potentials on the SAECG.

Effects of different exercise training intensities on lipoprotein cholesterol fractions in healthy middle-aged men

Exercise training has been associated with decreases in total cholesterol and increases in high-density lipoprotein (HDL) cholesterol. The effect of the intensity of the exercise on alterations in cholesterol and lipoprotein fractions has not been defined and is the subject of this study. We divided 49 healthy men (aged 44 +/- 8 years) into four groups and evaluated them before and after 12 weeks of cycle ergometer exercise training at (1) an intensity of 65% of maximal achieved heart rate, (2) 75% maximal heart rate, (3) 85% maximal heart rate, and (4) a 12-week nonexercise control period. Pre- and post-training evaluations included maximal ergometer exercise ECG examinations with measurement of maximal minute oxygen consumption and serum total cholesterol, HDL cholesterol, and triglyceride levels. Low-density (LDL) and very low-density lipoprotein (VLDL) cholesterol levels were calculated. Dietary histories were obtained before and after the training period, and body weight and percentage of body fat were measured. Post-training oxygen uptake was significantly increased (training effect) in the groups exercising to 65%, 75%, and 85% maximal heart rate. Results of within-group analysis showed significant increases in the HDL cholesterol fractions in the 75% and 85% groups but not in the 65% group or the control group. Significant decreases in calculated LDL fractions occurred only in the 75% exercise-trained group with maximal heart rate. Aerobic exercise training favorably alters plasma lipoprotein profiles. A minimum training intensity equal to 75% maximal heart rate is required to the increase HDL cholesterol level.

Linearity and contrast scale control in computed tomography

The aim of this paper is to present linearity studies and quality control charts for changes in the computed tomography (CT) number of water and contrast scales for two CT scanners over one year. Linear regression relates the attenuation coefficient to CT number. The CT number for water and the contrast scale values as obtained from the fit are: CT1 = (-0.13 +/- 1.3) Hounsfield units (HU), CT2 = (-1.8 +/- 1.6) HU and contrast scale (CS)1 = (1.80 +/- 0.03) 10(-4) cm-1 HU-1, CS2 = (1.82 +/- 0.02) 10(-4) cm-1 HU-1 for Picker International scanner models 600SE and 1200SX, respectively. Direct measurements of CT numbers are compared with fitted results, providing a necessary preliminary steps in the development of objective CT interpretation.

Small hydrocarbons formed by the peroxidation of squalene

Experiments were undertaken to determine whether peroxidized squalene forms isoprene in a manner such that peroxidation could be considered as a possible route for the formation of in vivo human breath isoprene. Small hydrocarbons derived from peroxidation of positions 1-6 of squalene were identified in the head space. The most unusual product, proposed to arise from peroxidation of carbon 1 and intramolecular cyclization, was a mixture of dimethylcyclopentadiene isomers. Sonication of an aqueous mixture or low O2 partial pressure favored isoprene formation.

Fatigue, acid-base and electrolyte changes with exhaustive treadmill exercise in hemodialysis patients

Aerobic conditioning exercises have been shown to be beneficial for maintenance hemodialysis patients, but biochemical changes during exhaustive exercise in these functionally anephric patients have been less thoroughly studied. We evaluated serum biochemical changes in 7 patients during and after treadmill exercise to patient exhaustion. Duration of exercise was limited by lower leg fatigue without claudication. At exhaustion, only mild changes from baseline rest values were noted in arterial pH (7.39 +/- 0.03-7.33 +/- 0.04) and lactate (0.94 +/- 0.3-5.73 +/- 2.68 mmol/l) despite normal exercise-induced intracellular fluid shifts as evidenced by albumin concentration increases (44.9 +/- 2.8-49.3 +/- 3.1 g/l). Increases in serum K+ concentrations are also modest (change in K from baseline = 0.87 +/- 0.22 mmol/l). An explanation for these minimal biochemical alterations at exhaustion is unclear, but could relate to exercise being limited well below estimated maximum cardiac output and muscle O2 extraction levels by early, unexplained muscle fatigue. Fatigue in hemodialysis patients does not appear to be due to muscle hypoxia.

Effect of background correction on left ventricular ejection fraction calculation through analysis of a simple cardiac model

The dependence of the left ventricular ejection fraction calculation on the background correction in gated cardiac blood pool studies is examined by analyzing a simple cardiac model. It is shown that the ejection fraction is relatively insensitive to the background correction when an accurately determined variable region of interest is used, but that with a fixed region of interest the background correction must be accurately estimated. A similar ejection fraction-background correction relationship is obtained in the analysis of clinical cardiac data. Based on the cardiac model, two methods are suggested which, with further investigation and refinement, may lead to a more accurate and consistent technique for determining ejection fraction and background.

A survey of diagnostic stress testing centers in New York City

Exercise electrocardiography (ECG) is widely employed for diagnosis of coronary heart disease (CHD) and for assessment of aerobic fitness prior to starting an exercise training program. This study surveyed stress testing centers in New York City (NYC) to determine practices currently used and to compare these practices with those suggested by the American Heart Association (AHA). A questionnaire was sent to 46 known centers in New York City and 18 responded. Of these, two did not list diagnosis of CHD as one of their purposes and were excluded from the sample, thus leaving 16 to be considered for this report. The most noteworthy findings were: most tests (56%) are conducted on asymptomatic adults, a population in whom the sensitivity and specificity of exercise ECG is relatively poor; only four centers employed qualified exercise physiologists, the profession specifically trained to perform fitness testing and exercise prescription for asymptomatic adults; over 50% of the centers terminate the test in the absence of symptoms when the client reaches a heart rate of 75%-95% of age-predicted maximal, even though maximal testing is suggested by the AHA; most centers did not include submaximal physiological responses in their test reports to clients and referring physicians; and most centers did not have a clearly established plan for handling emergencies. By bringing their practices into closer agreement with recommendations of appropriate professional organizations, testing centers can probably enhance the effectiveness and safety of their services to the public.

Toward quantitative characterization of the caudate nucleus through CT image enhancement

Dilated lateral cerebral ventricles have been reported in association with psychiatric disorders. The dilatation is likely secondary to changes in anatomically related centers in the brain. Our attention is focused on the caudate nucleus and the need to develop quantitative characterization of it in psychiatric research. A computer method is described for accurately detecting the edges of the caudate nuclei in CT scans. The method consists of a two-dimensional filtering step to reduce image noise, followed by gradient computation for edge enhancement, and then an edge detection step to identify and record the caudate nuclei cross sections. Results from both head scans and synthetic images indicate that the method is successful even for low-contrast edges where the standard deviation of image noise approaches the difference in mean HU across the edge. The availability of an automated method of delineating the caudate nucleus permits the cross-sectional area and shape to be determined, the density to be estimated, and, from a set of closely spaced slices, volume information to be obtained.