[Short and long-term results of balloon mitral valvotomy]

BACKGROUND

Since its introduction in the eighties by Inoue, percutaneous balloon valvotomy has been established as treatment of choice for symptomatic degenerative mitral stenosis. Especially young patients with rheumatic fusion of the mitral commissures and no calcification of the still pliable valve leaflets are candidates for this procedure. In these patients balloon valvotomy is expected to give results comparable or even superior to operative commissurotomy.

PATIENTS AND METHODS

This report presents the short and long-term results of 33 patients (24 females, 9 males; median age: 53 years) that underwent percutaneous mitral valvotomy (PMV) at the cardiac unit of the university hospital in Cologne during the last three years.

RESULTS

The intervention was immediately successful in 31 patients (94%). The median mitral valve area was increased after PMV to 2.0 +/- 0.5 cm(2) an increase of mean opening area of 82% and a decrease of mean pressure gradient by about 50%. Follow-up date at 12 and 24 months were available for 21 and 12 patients, respectively. During the first 12 months after intervention four patients subsequently had to have surgical mitral valve replacement, one of them together with a coronary artery bypass graft. One patient, who had undergone PMV in cardiogenic shock died after the intervention. A 12-month follow-up demonstrated a mean mitral valve area of 1.7 +/- 0.4 cm(2) as assessed by echocardiography. After 24 months comparable mean valve area was 1.7 +/- 0.4 cm(2). One other patient required operative valve replacement, but there were no further deaths.

CONCLUSION

The data collected from this very heterogeneous group of patients at the cardiac unit of the university hospital in Cologne confirms the observation that PMV is beneficial in young patients with favorable valve morphology and shows that it is indicated not only as a palliative measure but also as treatment option in older patients with more complex alterations of the mitral valve.

[Chlamydial and human heat shock protein 60 homologues in acute coronary syndromes. (Auto-)immune reactions as a link between infection and atherosclerosis]

Recent studies provide evidence that infectious agents play a causal role in the pathogenesis of atherosclerosis. In this respect, a chronic persistent Chlamydia pneumoniae infection, indicated by the presence of chlamydial heat shock protein 60 (cHSP 60), is of central interest. Both cHSP60 and endogenous human (h) HSP60 are upregulated under stress conditions in intimal cells and serve as a target for cross-reactive cytotoxic HSP-serum-antibodies. Therefore, the present study evaluates the expressions of both HSP60 homologues in advanced human coronary lesions and a correlation between intimal tissuebound protein and serum antibodies (Ab) to HSP65. Coronary atherectomy specimens retrieved from 114 primary target lesions of patients with acute coronary syndrome (ACS; n=46) or stable angina (SA; n=68) were assessed immunohistochemically for the presence of cHSP60 and hHSP60. Chronic persistency of Chlamydia pneumoniae was additionally examined by transmission electron microscopy. Blood samples from30 patients were tested for anti-Chlamydia pneumoniae-IgG/IgA- and anti-HSP65-Ab titers and for serum CRP levels. Coronary plaques revealed immunoreactive cHSP60 in 47% and hHSP60 in 57% of the lesions colocalized within macrophages/foam cells. Chlamydia in foam cells most often presented ultrastructural patterns that pointed to the persistency of the pathogen. Intact, non-atherosclerotic vessels showed no signals. Mean expressions were 3.1% for cHSP60 and 3.3% for hHSP60. As a central finding, the expression of both HSP homologues was significantly (each p<0.001) higher in ACS lesions compared to SA lesions (cHSP60: 6.2 vs 1.0%, and hHSP60: 7.2 vs 0.7%). Moreover, we found positive correlations between both determinants in ACS and SA lesions (r=0.41, r=0.37; p<0.01). Most interestingly, cHSP60 revealed no relationship with anti-Chlamydia pneumoniae-IgG/IgA titers, whereas expression of cHSP60 as well as that of hHSP60 correlated with anti-HSP65-Ab titers (r=0.50, p<0.01, and r=0.42, p<0.05, respectively).cHSP60 and hHSP60 colocalize within coronary primary atheroma, most prevalent in lesions associated with ACS. For the first time, our data demonstrate a significant correlation between the intimal expression of these HSP60 homologues and serum HSP65 antibodies, thereby suggesting that humoral immune reactions to bacterial and human HSPs may play an important role in coronary atherosclerosis and plaque instability.

Effects of beta-blockers on sexual performance in men with coronary heart disease. A prospective, randomized and double blinded study

In a prospective trial assessing the effects of beta-blockers on sexual function men with coronary heart disease were randomized to a 4 month treatment with sustained release metoprolol 95 mg or placebo. A standardized and validated self-report questionnaire (KEED = Kölner Erhebungsbogen der Erektilen Dysfunktion) dealing with several aspects of sexual performance in men had to be answered at the beginning and at the end of the study. Based on 65 patients completing the study, sex life seemed unaffected by metoprolol treatment.

Acute anterior myocardial infarction as first manifestation of acute myeloid leukemia

A 42-year-old man was admitted with heavy retrosternal pain lasting 30 min. Electrocardiography showed typical signs of acute anterior myocardial infarction. The patient reported only attacks of coughing for a couple of days, and no serious diseases. The physical examination was normal. Laboratory tests showed a white blood cell count of 45/nl, platelet count of 58/nl, and hemoglobin of 14.4 g/dl. Blood chemistry showed elevated lactic dehydrogenase (413 U/l) but no elevation in creatine phosphokinase or glutamic-oxaloacetic transaminase. Therefore no thrombolysis was administered, but coronary angiography was performed. This showed a long-distance, subtotal thrombotic occlusion of the left anterior descending artery. After percutaneous transluminal coronary angioplasty and implantation of serial stents a normal perfusion of the artery was observed. The patient's blood and bone marrow films revealed acute myeloid leukemia FAB M2. Various conditions can cause a myocardial infarction in leukemias. We discuss the clinical management and the possible reasons for a subtotal thrombotic occlusion of the coronary artery.

Hypertension guidelines and their limitations--the impact of physicians' compliance as evaluated by guideline awareness

OBJECTIVE

The initial step of an optimal therapeutic strategy for patients with arterial hypertension is the recognition and acceptance of new recommendations by the physicians themselves. This guideline awareness of the physicians has never been evaluated in detail.

DESIGN

The awareness of content of current recommendations in hypertension diagnosis, treatment and treatment control was therefore assessed in primary care physicians using a questionnaire. The guidelines of the German Hypertension Society were used as the reference standard.

PARTICIPANTS

A total of 24 899 German physicians, including all internists, all cardiologists and 22% of general practitioners were contacted in a nationwide survey.

MAIN OUTCOME MEASURES

The number of answers in agreement with the guideline was used as a measure of guideline awareness. Adequate awareness of content of guideline recommendations was defined as the correct answer to five out of eight questions; the correct answers had to include the appropriate definition of hypertension.

RESULTS

The analysis was based on 11 547 returned questionnaires (47.1%). An adequate guideline awareness was found in 23.7% of the total study population, especially in 37.1% of cardiologists, in 25.6% of internists and in 18.8% of general practitioners. While the guideline awareness was significantly influenced by the duration of private practice, regional and municipal factors had only minor influence on the results.

CONCLUSION

The impact of hypertension guidelines on actual medical knowledge is modest. Thus, the information strategies about current treatment guidelines must be improved and tailored to the needs of physicians in clinical practice to ultimately improve patient care.

[Difficulties in the transfer of drug therapy from inpatient to ambulatory treatment]

The prospective study compares prescribed drugs of 192 primarily cardiological patients at discharge and 7 weeks later in ambulatory care. The data were determined by discharge summaries and by standardized patient-questionnaires. The drug division was made with the ATC-classification according to the recommendations of the World Health Organisation for Drug Utilisation Studies. The intraindividual cost comparison was calculated by current pharmacy sale prices. The findings were changes in hospital discharge medications in ambulatory care in over 2/3 of the cases. The most frequent change was the additional prescribing of drug groups. The average daily tablet number increased in patients with the same or worsened subjective feeling after discharge. Additionally we found in a number of patients a change of drug therapy within the ATC-groups, or in fact, withdrawal of drug therapy all together. The frequency of changes increased with the number of patient/doctor contacts. The observation that the average daily therapeutical cost decreased just slightly could give an indication that cost saving was a minor part of the doctors decision for drug changing. However, the frequency of changes has shown to be dependent upon the specialities of the physician or pharmaceutical group.

[Transcatheter closure of atrial septal defects in adults. Practicality and safety of four different closure systems used in 102 patients]

BACKGROUND AND OBJECTIVE

Surgical closure of secundum atrial septal defect (ASD) or patent foramen ovale (PFO) is a procedure with few complications. But this surgical intervention can nowadays be avoided by transcatheter insertion of occluding devices. Such interventional methods must be judged against the results of surgical procedures. This report from one center presents the practicability and safety of different transcatheter occluder systems.

PATIENTS AND METHODS

Transcatheter occlusion was undertaken in 102 patients (40 females, 62 males, aged between 17 and 76 years [median age 45]) with either an ASD (41pts.) or a PFO (60 pts.) or with both, in one patient. Four different systems were used: ASDOS (for ASD and PFO), PFO-STAR (for PFO), Amplatzer Septal Occluder (for ASD) or Amplatzer PFO Occluder (for PFO). Follow-up, including transoesophageal echocardiography took place 48 hours, 4 weeks, 6 months and 1 year after the interventional occluder placement.

RESULTS

An occluder was successfully placed in the ASD or PFO in 99 of the 102 patients. In three patients the occluder ( ASDOS ASD) could not be correctly ancchored in the defect. In two other patients the same device was subsequently removed surgically because of mispositioning or a large resiudal shunt. Occluder-associated problems were: mild (41%) or extensive (11%) thrombus formation on the occluder without early embolization, residual shunt at one year (ASD 16%, PFO 29%); minor displacement (10%) or broken umbrella strut (6%) of no clinical relevance. One patient required emergency surgical intervention on the day of the transcatheter placement (PFO-STAR) because of pricardial tamponade. Primary complete occlusion was achieved in 71%. There was no case of cerebral emboli.

CONCLUSION

Transcatheter occlusion of ASD and/or PFO is a reliable and safe procedure. Regarding peri- and/or postinterventional complications, primary results and practicability, the Amplatzer septal occluder and Amplatzer PFO occluder are particularly advantageous.

[Coronary intervention and occupational rehabilitation--a prospective, randomized intervention study]

Coronary catheter revascularisation is less costly than bypass surgery due to lower direct (medical) and indirect costs (loss of work). Many studies show that the time patients stay out of work following coronary intervention is much longer than necessary. This leads to a considerable increase of indirect costs, which can far exceed the medical costs of the treatment. This prospective randomised study was done to determine whether specific information to patient and family doctor results in an earlier return to work. After catheter revascularisation 100 working patients (mean age 52.4 years) were randomised either to the intervention group (information to patient and family doctor) or to the control group (no specific information about return to work). Four months later 81 patients had returned to their previous jobs (mean sick leave 18.9 +/- 24.8 days) while 19 were still out of work. In the control group, the rate was 79% and the mean sick leave was 16.4 +/- 22.0 days (median 7); in the intervention group 83% had returned to work after a mean of 21.5 +/- 27.4 days (median 10). There was no significant difference between the two groups, neither according to the rate of returned workers nor to the duration of sick leave. In the subgroup of patients with a private insurance (23% of all) 96% started to work again (mean sick leave 5.7 +/- 5.1 days median 3.5), while the rate was 77% in the group of panel patients (mean sick leave 23.7 +/- 27.4 days, median 11). The difference in sick leave between these two groups was highly significant (p = 0.0003). Specific information to the patient and family doctor has no effect on the time patients stay out of work following catheter revascularisation. It seems that the observed delay depends on social and psychological factors that cannot be influenced directly.

[Guideline-adequate knowledge in internists and general practitioners about the diagnosis and treatment of arterial hypertension]

Only a small proportion of patients with arterial hypertension are adequately treated. Although a possible cause for this fact may be the deficient knowledge of physicians about diagnosis and treatment of arterial hypertension, to date no studies have addressed this important problem in Germany. Therefore, we have reviewed the knowledge of internists and general practitioners about diagnosis and treatment of arterial hypertension using a questionnaire. The guidelines of the German Hypertension Society were used as the reference standard. The questionnaire was sent out in December 1999 to all internists (n = 15,952) and to a random sample of general practitioners (n = 8947) who work as statutory health insurance physicians. A total of 11,547 questionnaires were sent back and could be analysed. Adequate guideline knowledge was assumed if five out of eight questions were correctly answered; the correct answers had to include the correct definition of arterial hypertension (> 140/90 mmHg). The correct definition of arterial hypertension was known by 4103/11,547 participants (36%). An adequate guideline knowledge was found in 18.8% of the general practitioners and in 26.6% of the internists. There were no relevant regional differences. The level of awareness about diagnosis and treatment of arterial hypertension is insufficient among internists and general practitioners. This insufficient knowledge may in part explain the inadequate care for patients with arterial hypertension. Thus, the implementation and evaluation of new information and training strategies are mandatory to improve the care for patients with arterial hypertension.

[Angiographically unexplained myocardial ischemia in high grade coronary stenosis with main stem involvement in intravascular ultrasound]

HISTORY AND ADMISSION FINDINGS

For seven weeks a 57-year-old man had been complaining of recurrent non-radiating retrosternal pain and pressure on slightest exertion. Admission physical examination was unremarkable except for evidence of peripheral vascular disease. Cardiovascular risk factors were hypertension, hyperlipoproteinaemia and obesity.

INVESTIGATIONS

The resting ECG was unremarkable. Objective signs of myocardial ischaemia were produced in the exercise ECG (angina at 100 Watt, negative T waves in V2 to V6 and borderline S-T depression in V4). Myocardial scintigraphy showed reversible reduced perfusion of the anterior wall near the apex and also of the apex and septum. Left ventricular (LV) angiography demonstrated a normally contracting LV, while selective coronary angiogram revealed a 20% reduction in caliber of the proximal branch of the anterior interventricular branch (AIVB), with otherwise normal coronary arteries. Subsequent intravascular ultrasound (IVUS) showed a circular echo-poor 80% stenosis at the origin of the AIVB with extension to the main stem.

TREATMENT AND COURSE

A bypass from the internal mammary artery to the AIVB and an aortocoronary venous bypass to the intermediate branch were performed. The patient was free of symptoms postoperatively.

CONCLUSION

If cases where there is a discrepancy between clinical and coronary angiographic findings--the latter being unclear or inconsistent, especially in the area of the left main stem, bifurcations or vessel origin--IVUS may contribute decisively to demonstrating coronary anatomy or pathology, and to indicating the type of revascularizing measures.

Vascular remodeling in atherosclerotic coronary arteries is affected by plaque composition

BACKGROUND

Narrowing of lumen in atherosclerotic lesions is determined not solely by accumulation of plaque but also by constrictive or expansive vascular remodeling. Underlying mechanisms and determinants of these bidirectional processes are not known.

OBJECTIVES

To elucidate the response of vascular remodeling to progressive atherosclerosis by analyzing its potential association with composition of plaque.

METHODS

Seventy patients with 77 de-novo coronary artery lesions underwent intravascular ultrasound imaging before coronary intervention. Target lesions were defined as soft, fibrous/mixed, and calcified plaques. Quantitative measurements of area of lumen (A(L)), total area of vessel (A(TV)) and area of plaque (A(P) = A(TV)-A(L)) were performed at the lesion site and at the proximal and distal reference sites. Remodeling was determined by using a remodeling index [I(R) = (stenosis of A(TV)/mean reference A(TV)) x 100].

RESULTS

Overall vascular remodeling was balanced with a mean remodeling index of 100.2+/-19.3% and a high interlesion range (60.2-152.4%). The remodeling index for soft lesions was significantly higher than those for fibrous/mixed and calcified lesions (110+/-18.8 versus 96.2+/-14.4 and 85.9+/-15.1%, P < 0.01). Calcified lesions exhibited lower remodeling indexes than did uncalcified lesions (85.9+/-15.1 versus 104.6+/-18.4%, P < 0.01).

CONCLUSIONS

Processes involved in vascular remodeling are affected by composition of plaque insofar as there is a higher prevalence of constrictive remodeling among calcified plaques and a higher prevalence of expansive remodeling among soft lesions. These findings indicate that constrictive remodeling is a late manifestation in atherogenesis. Future studies are warranted in order to enhance the understanding of progression of atherosclerosis, and of mechanisms of vascular remodeling and their impacts on interventional therapy.

A synergistic approach to optimal stenting: directional coronary atherectomy prior to coronary artery stent implantation--the AtheroLink Registry. AtheroLink Study Group

OBJECTIVES

The AtheroLink registry sought to observe the effect of plaque burden reduction by directional coronary atherectomy (DCA) prior to stenting on acute lesion success rate, on the clinical success rate and on the incidence of in-stent restenosis six months after intervention.

BACKGROUND

Although coronary stenting has reduced restenosis, its effect has been less favorable in complex lesions with a high plaque burden that results from suboptimal stent expansion. Therefore, plaque removal by DCA may improve the results of coronary stenting.

METHODS

A total of 167 patients with >60% stenosis in a native coronary artery of 2.8 to 4.0 mm in diameter were enrolled in 10 study centers on an intention-to-treat basis. All patients underwent DCA aimed at an optimal result (residual diameter stenosis <20%) followed by stenting. Angiographic follow-up was performed in 120 (71.8%) patients at 5.3+/-2.8 months.

RESULTS

Lesion success was achieved in 164/167 (98.2%) patients, and the clinical success rate was 95.2% (159/167 patients). The overall restenosis rate in the 120 patients with angiographic follow-up was 10.8% (13/120). Incidence of restenosis was lower (8.4%) in patients with optimal stent deployment following DCA compared to patients with a persisting caliber reduction >15% (restenosis rate 15.3.%) and restenosis occurred with a significantly higher frequency (p<0.04) in distal lesions (37.5%) compared to proximal stenoses (9.0%).

CONCLUSIONS

This observational multicenter registry points to a potential reduction in restenosis by a synergistic approach of DCA and stenting performed under routinely accessible angiographic guidance. Therefore, multicenter-based randomized clinical trials are clearly warranted to finally clarify the validity of this complex approach versus conventional angioplasty plus stenting.

In vivo uptake of azithromycin in human coronary plaques

Ten patients with symptomatic coronary artery disease received oral azithromycin for 3 days and underwent directional atherectomy on the third day. Azithromycin was found in all plaque samples with a median concentration of 284 ng/ml (95% confidence interval 163 to 517 ng/ml).

[Stent implantation as initial coronary interventional therapy? A theoretical model on clinical and economical consequences of in-stent restenosis]

The reduction of acute complications and late restenosis compared to conventional PTCA has led to a rapid increase in stent implantation as initial treatment for coronary stenosis. As a result, in-stent restenosis has become an important clinical and economical problem, especially the diffuse form, which is much more likely to reappear. In order to compare the consequences of initial stenting and initial angioplasty, we developed an analytic model, considering the differences between diffuse and focal in-stent restenosis. The simulation based on the optimized therapeutic proceeding following an elective 1-vessel revascularization of a 60-year-old patient, dealing with probabilities for acute complications and late restenosis taken from the literature and in-hospital costs obtained from 200 elective interventions. In the stent group 71.0% of patients were free of any target lesion-related event, compared to 60.2% in the PTCA group. Catheter reintervention was necessary for 32.1% of the patients initially treated with angioplasty and for 17.6% of the initially stented patients, whereas 7.7% of the stent patients had to undergo elective bypass surgery as final treatment compared to 2.8% in the PTCA arm. Long-term medical costs for initial stenting (6,237 Euros) were 14% higher than for conventional PTCA (5,345 Euros). Taking also into consideration the indirect costs (loss of productivity) for a collective with an employment rate of 50%, the difference between stent implantation (9,067 Euros) and angioplasty (8,581 Euros) is smaller. Initial treatment of coronary stenosis by stent implantation decreases the rate of repeat revascularization compared to initial PTCA, but there is a greater likelihood that elective bypass surgery will become necessary. This difference in following treatment is related to the occurrence of diffuse in-stent restenosis. When calculating the long-term costs stenting still appeared to be more expensive than PTCAA because the savings in following costs can not compensate for the higher primary in-hospital costs. An empirical study which collects cost data in different hospitals as well as in the outpatient setting over 1 year is necessary to confirm this preliminary result.

Patients with dilated cardiomyopathy and less than 20% ejection fraction increase exercise capacity and have less severe arrhythmia after controlled exercise training

The results of this pilot study suggest that patients with a diminished ejection fraction as low as 16% can safely perform an exercise program. A significant improvement in peak VO2 and maximal work rate was achieved. Moreover, this study suggests that exercise training might diminish the severity of asymptomatic ventricular arrhythmia; however a larger controlled study is needed to confirm these findings.

[Type and extent of vascular remodeling in significant coronary lesions: An intravascular ultrasound study]

The purpose of this study was to assess the dimension of regional vascular remodeling and its influence on lumen narrowing in vivo. Sixty-three patients with 68 coronary lesions were imaged by intravascular ultrasound before transcatheter therapy. Quantitative measurements of lumen area, vessel area, and plaque area were performed at the lesion site and at the proximal and distal reference site. Area stenosis was calculated as plaque area/vessel area. 100. The extent of remodeling was quantified by a remodeling index (RI = stenosis vessel area - mean reference vessel area/mean reference vessel area. 100). Additionally, three different groups of vascular remodeling were defined: 1) positive remodeling = stenosis vessel area > maximal reference vessel area; 2) intermediate remodeling = maximal reference vessel area >/= stenosis vessel area >/= minimal reference vessel area; 3) negative remodeling = stenosis vessel area < minimal reference vessel area. In 57% of lesions stenosis vessel area was not in between the proximal and distal reference area: 29% of lesions (20/68) had positive, 28% (19/68) negative, and 43% (29/68) intermediate remodeling. Overall remodeling index averaged -0.8+/-19.7%. In the negative remodeling group, reduction of vessel area contributed to 40+/-21% of lumen narrowing, in the positive remodeling group, stenosis vessel area was 21+/-12% enlarged (p<0.001). Lesions with negative remodeling exhibit a lesser plaque area, lesions with positive remodeling a larger than other vessels (8.2+/-2.4 mm(2), 13.8+/-3.7 mm(2), 10. 8+/-3.7 mm(2); p <0.001). Distinct vascular remodeling occurred in the majority of atherosclerotic lesions and is a bidirectional process. Overall, the extent and the frequency of positive and negative remodeling was almost balanced. In lesions with negative remodeling the plaque area was significantly lesser than in other lesions.

Thrombus formation after transcatheter closure of atrial septal defect

Thrombotic layers and/or atrial thrombi were detected by transesophageal echocardiography as a usual finding after transcatheter closure of atrial septal defects with the ASDOS device. The size of the thrombotic structures regularly decreased within 6 months without any clinical signs of embolization.

[Percutaneous transvenous mitral valvuloplasty in a pregnant patient. Successful treatment of severe mitral stenosis]

HISTORY AND CLINICAL FINDINGS

A 31-year-old woman presented in the 25th week of pregnancy with ankle and pretibial oedema and increasing dyspnoea, ultimately in class IV (New York Heart Association classification). There were fine rales on auscultation and dullness on palpation over both lung bases. The heart rate was regular at 110/min. The first heart sound was very loud, and there was a mitral opening snap and a loud diastolic murmur maximal, over the cardiac apex.

INVESTIGATIONS

The ECG showed sinus rhythm at a rate of 110/min, left axis deviation, incomplete right bundle branch block and P biatriale, but no other abnormalities. Echocardiography revealed biatrial enlargement and an enlarged right ventricle as well as pulmonary systolic hypertension of 100 mm Hg. Doppler sonography demonstrated severe mitral stenosis with a calculated mitral opening area of 0.9 cm2.

DIAGNOSIS, TREATMENT AND COURSE

The symptoms improved only slightly under conservative drug treatment. The mitral valve changes, as noted sonographically, met the criteria for percutaneous transluminal balloon mitral valvoplasty (PTBMV), which was successfully performed. Afterwards the mitral opening area was 2.6 cm2 and pulmonary artery pressure gradually became normal. She was delivered without complication of a healthy child in the 39th week of pregnancy.

CONCLUSION

PTBLMV is a relatively low-risk treatment in pregnant women with symptomatic mitral stenosis.

A prognostic computer model to individually predict post-procedural complications in interventional cardiology: the INTERVENT Project

AIMS

The purpose of this part of the INTERVENT project was (1) to redefine and individually predict post-procedural complications associated with coronary interventions, including alternative/adjunctive techniques to PTCA and (2) to employ the prognostic INTERVENT computer model to clarify the structural relationship between (pre)-procedural risk factors and post-procedural outcome.

METHODS AND RESULTS

In a multicentre study, 2500 data items of 455 consecutive patients (mean age: 61.1+/-8.3 years: 33-84 years) undergoing coronary interventions at three university centres were analysed. 80.4% of the patients were male, 16.7% had unstable angina, and 5.1%/10.1% acute/subacute myocardial infarction. There were multiple or multivessel stenoses in 16.0%, vessel bending >90 degrees in 14.5%, irregular vessel contours in 65.0%, moderate calcifications in 20.9%, moderate/severe vessel tortuosity in 53.2% and a diameter stenosis of 90%-99% in 44.4% of cases. The in-lab (out-of-lab) complications were: 0.4% (0.9%) death, 1.8% (0.2%) abrupt vessel closure with myocardial infarction and 5.5% (4.0) haemodynamic disorders.

CONCLUSION

Computer algorithms derived from artificial intelligence were able to predict the individual risk of these post-procedural complications with an accuracy of >95% and to explain the structural relationship between risk factors and post-procedural complications. The most important prognostic factors were: heart failure (NYHA class), use of adjunctive/alternative techniques (rotablation, atherectomy, laser), acute coronary ischaemia, pre-existent cardiac medication, stenosis length, stenosis morphology (calcification), gender, age, amount of contrast agent and smoker status. Pre-medication with aspirin or other cardiac medication had a beneficial effect. Techniques, such as laser angioplasty or atherectomy were predictors for post-procedural complications. Single predictors alone were not able to describe the individual outcome completely.

Coronary-artery stenting compared with balloon angioplasty for restenosis after initial balloon angioplasty. Restenosis Stent Study Group

BACKGROUND

Intracoronary stenting reduces the rate of restenosis after angioplasty in patients with new coronary lesions. We conducted a prospective, randomized, multicenter study to determine whether intracoronary stenting, as compared with standard balloon angioplasty, reduces the recurrence of luminal narrowing in restenotic lesions.

METHODS

A total of 383 patients who had undergone at least one balloon angioplasty and who had clinical and angiographic evidence of restenosis after the procedure were randomly assigned to undergo standard balloon angioplasty (192 patients) or intracoronary stenting with a Palmaz-Schatz stent (191 patients). The primary end point was angiographic evidence of restenosis (defined as stenosis of more than 50 percent of the luminal diameter) at six months. The secondary end points were death, Q-wave myocardial infarction, bypass surgery, and revascularization of the target vessel.

RESULTS

The rate of restenosis was significantly higher in the angioplasty group than in the stent group (32 percent as compared with 18 percent, P= 0.03). Revascularization of the target vessel at six months was required in 27 percent of the angioplasty group but in only 10 percent of the stent group (P=0.001). This difference resulted from a smaller mean (+/-SD) minimal luminal diameter in the angioplasty group (1.85+/-0.56 mm) than in the stent group (2.04+/-0.66 mm), with a mean difference of 0.19 mm (P=0.01) at follow-up. Subacute thrombosis occurred in 0.6 percent of the angioplasty group and in 3.9 percent of the stent group. The rate of event-free survival at 250 days was 72 percent in the angioplasty group and 84 percent in the stent group (P=0.04).

CONCLUSIONS

Elective coronary stenting was effective in the treatment of restenosis after balloon angioplasty. Stenting resulted in a lower rate of recurrent stenosis despite a higher incidence of subacute thrombosis.

Transcatheter closure of atrial septal defect and patent foramen ovale with ASDOS device (a multi-institutional European trial)

A clinical trial was conducted to assess the feasibility, safety, and efficacy of the atrial septal defect (ASD) occlusion system for transcatheter closure of secundum ASD and patent foramen ovale (PFO) after episodes of cerebral embolism. Occlusion was attempted in 200 patients aged 1 to 74 years (mean 32). The procedure failed in 26 patients (13%); the device was retrieved through a catheter in 20 and through surgery in 6 patients. Procedure-related complications necessitating surgical removal of the device included device embolization in 2, device entrapment within the Chiari network in 1, frame fracture in 1, and perforation of atrial wall in 2. All 6 patients experienced an uneventful postoperative course. An additional 11 patients (6%) underwent surgical removal of the device during follow-up. There were 163 patients (81%) with an implanted ASD occlusion system at follow-up of from 6 to 36 months (mean 17). Thrombus formation around the device was detected by transesophageal echocardiography in 9 patients 1 to 4 weeks after implantation. One of these patients (who had a coagulation factor XII deficiency) suffered a cerebral thromboembolism. Late atrial wall perforation (5, 6, and 8 months after implantation) occurred in 3 adult patients. Infectious endocarditis developed in 2 adult patients (1%). No late device embolization and no atrioventricular valve injury occurred. An asymptomatic device frame fracture was found in 14% and frame deformity in 4% of all patients during the follow-up period of >230 patient-years. Immediately after closure, a moderate/large residual shunt remained in 8% and a small shunt in 29% of patients. After 1 year, a moderate/large shunt was present in 2% and a small one in 26% of patients. During a total follow-up of 49 patient-years, only 1 of 46 patients with PFO had a transient neurologic event after the closure. The study indicates that patients with centrally situated secundum ASD and those with PFO after cerebral embolism can be treated with this system with a high success rate and an acceptable morbidity.

Comparison of angioscopic, intravascular ultrasonic, and angiographic detection of thrombus in coronary stenosis

Coronary angioscopy, intravascular ultrasound, and angiography were compared in 20 patients regarding their sensitivity and specificity in the detection of thrombus. Although all imaging procedures demonstrate a high specificity, only coronary angioscopy has a sensitivity high enough to provide sufficient evidence of thrombus, even in patients with stable angina.

A prognostic computer model to predict individual outcome in interventional cardiology. The INTERVENT Project

It is not yet possible to predict an individual's outcome from percutaneous transluminal coronary angioplasty or alternative/adjunctive coronary interventional techniques. The purpose of the INTERVENT project is to redefine complications associated with coronary interventions, to set up a prognostic computer model to predict individual outcome and to compare the results to those of conventional statistical techniques. 2500 data items were analysed in 455 consecutive patients (mean age: 61.1 +/- 8.3 years; range 33-84 years; 80.4% male, 16.7% unstable angina, 5.1%/10.1% acute/subacute myocardial infarction) undergoing coronary interventions at three university centres. In-lab/out-of-lab complication rates were 0.4%/0.9% (death), 1.8%/0.2% (abrupt vessel closure with myocardial infarction) and 5.5%/4.0% (haemodynamic complications). Computer algorithms derived by applying techniques from artificial intelligence were able (1) to reduce the set of possible relevant risk factors from 2500 to about 40, (2) to predict individual risk with an accuracy of > 95% and (3) to explain the structural relationship between outcome and risk factors. Patient data from two centres were used to construct and test the algorithm. Data from a third centre were used to evaluate the algorithm. The most important predictors-were acute myocardial infarction, heart failure (NYHA class > II), unstable angina, complex lesions, high low density lipoprotein cholesterol and duration of coronary heart disease. Neither age nor gender impaired the percutaneous transluminal coronary angioplasty results in acute ischaemic syndromes; however, for stable angina, procedural risk increased with age. There was little risk from primary percutaneous transluminal coronary angioplasty in acute myocardial infarction in patients with NYHA heart failure classes I-II; however, the risk was high for patients in NYHA classes > II, either with or without additional thrombolysis. Alternative/adjunctive intervention techniques were no predictors for in-lab-, but were predictors for post-procedural complications.

Dipyridamole scintigraphy and intravascular ultrasound after successful coronary intervention

Despite angiographically successful interventions, perfusion defects are not uncommonly observed in postinterventional perfusion scintigrams. The aim of this study was to test the hypothesis that perfusion defects after coronary intervention are associated with a significant residual stenosis in the treated vessel segment detectable by intravascular ultrasound but not by angiography.

METHODS

Forty consecutive patients with angiographically successful coronary interventions were prospectively studied by intravascular ultrasound immediately after the intervention. Within 48 hr after the intervention all patients had myocardial scintigraphy using 99mTc-methoxyisobutyl-isonitrile SPECT after dipyridamole stress. Myocardial perfusion defects in the scintigram were assigned to a segmental left ventricular model and compared to the perfusion territory of the treated vessel estimated from the coronary angiogram.

RESULTS

Twenty of 40 patients had reversible myocardial perfusion defects. Mean ultrasound area stenosis was 50% in these patients and 33% in patients without perfusion defects (p < 0.002); ultrasound percent plaque area was 75% versus 63% (p < 0.0001), respectively. The best concordance between residual area stenosis and perfusion defects was found for an ultrasound area stenosis > or = 40%.

CONCLUSION

Patients with stress-induced myocardial perfusion defects immediately after successful coronary intervention show high-grade residual stenoses that are more pronounced in patients with perfusion defects than in patients with normal postinterventional scintigrams. In addition, vessels serving myocardial regions with perfusion defects showed a significantly higher plaque burden indicating diffuse atherosclerotic changes in the vessel. The evaluation of the postprocedural result by intravascular ultrasound contributes to a better understanding of the discrepancy between the angiographic finding of a widely patent vessel but scintigraphic evidence of impaired perfusion.

[Prescribing practice for beta blockers at patient discharge to ambulatory care. A health care economic evaluation in a cardiology patient sample with special reference to drug budgeting]

Beta blockers are known to reduce mortality from hypertension and coronary heart disease after myocardial infarction. Recent health care laws in Germany did impose a medication budget for ambulatory patients only. To evaluate the effects of this administrative instrument we studied prescribing practices of beta blockers in patients transferred from inpatient to ambulatory care. Specifically, we aimed of assessing the quality and cost effectiveness of beta blocker prescriptions. In a prospective cohort study of 142 patients discharged from a tertiary care center, the beta blocker medication was continued in 130 patients (91%). Adequate quality of the medication, defined as continuation of a beta blocker in sufficient dosage, was found in 77% of patients. Cost effective prescribing practices, defined as adequate quality at a lower cost than at discharge, were documented in 10% of the patients. However, inadequate dosage or even omitting of a beta blocker was found in 23% of patients. Overall, we found high-quality prescribing practices in more than two-thirds of our patients, but documented inadequate care in more than 20%. Our study did not document any consistent pattern between medication changes and cost-effective prescribing practices attributable to medication budgeting in Germany.

[Intracoronary ultrasound changes the therapeutic approach in ambivalent angiography findings]

Despite careful evaluation of multiple projections, coronary angiography may give ambiguous results of lesion severity. The purpose of this study was to analyze the impact of ultrasound imaging on revascularization treatment strategy in angiographically ambiguous findings. We reviewed our experience with such equivocal angiographic findings before intervention in 31 patients (34 lesions) who had additional intravascular ultrasound (IVUS) to clarify coronary anatomy. Intervention was felt to be indicated if area stenosis by IVUS exceeded 50% in the left main or 75% in other major coronary arteries. To evaluate the clinical efficacy of IVUS based management strategies, all patients had clinical follow-up after 1 year. Seven of nine ostial lesions were overestimated by angiography, but two of three left main lesions were found to be significant. Seven lesions in one of the proximal coronary arteries whose significance was difficult to judge by angiography were found not to be significant by IVUS, whereas in the other four severe obstruction was confirmed. Membranes by angiography corresponded to remnants of ruptured plaques by IVUS in all five patients. However, significant narrowing was found in only two patients. Side branch ostial lesions were ruled out by IVUS in all four instances. Two patients with unstable angina but normal angiograms showed complex atherosclerotic plaques in the left coronary artery. IVUS led to a change of therapy in 21 patients (revascularization instead of conservative treatment in two and cancellation of initially intended intervention in 19). At follow-up examination, 17 of these 21 patients were free of cardiac symptoms. Interventions at the site thought not severely diseased by IVUS had to be performed in two patients with persistent angina who were afterwards free of symptoms. One patient with persistent chest pain had a second coronary angiogram during the follow-up period, but conservative therapy was continued. Evaluation was impossible in one patient because of bypass surgery due to another coronary lesion. In conclusion, IVUS was clinically useful in patients with angiographically ambiguous findings and resulted in a change of therapy in 21/31 patients obviating interventions in 19 patients with excellent clinical results.

Coronary plaque morphology affects stent deployment: assessment by intracoronary ultrasound

The purpose of this study was to evaluate the changes in arterial wall morphology induced by coronary stent implantation and the influence of plaque morphology on stent expansion by intravascular ultrasound. Intravascular ultrasound imaging was performed in 25 lesions before and after Palmaz-Schatz stent implantation. In the 25 lesions with ultrasound images before and after stent deployment angiographic percent diameter stenosis decreased from 71% +/- 11% to 6% +/- 14%. By ultrasound there was a gain in luminal area from 2.0 mm2 +/- 1.5 mm2 to 6.6 mm2 +/- 2.1 mm2 owing to gain in external elastic membrane area of 2.5 mm2 +/- 1.7 mm2 and reduction of plaque area of 2.1 mm2 +/- 1.7 mm2. Calcified lesions (n = 8) showed significantly less relative luminal gain (218% +/- 128% vs. 421% +/- 276%, P = .01), and stent expansion was significantly less symmetric (minimal/maximal stent diameter 0.8 +/- 0.1 vs. 0.9 +/- 0.1, P = .002) as compared to non-calcified lesions (n = 17). The difference in lumen area within the stent between the previously stenotic area and the ends of the stent was significantly larger in calcified lesions as compared to non-calcified lesions (29 +/- 28% vs. 8 +/- 23%, P = .03). Both vessel stretch and plaque reduction contribute to the luminal gain after coronary stenting. Calcified lesions interfere with optimal stent expansion.

[Lumen enlargement in coronary angioplasty: qualitative and quantitative analysis of vascular mechanisms with intravascular ultrasound]

The purpose of this study was to determine the mechanisms by which balloon angioplasty increases luminal patency. Therefore serial examinations with intravascular ultrasound before and after coronary balloon angioplasty were performed. Forty consecutive patients (7 female, 33 male, aged 58 +/- 9 years) with 49 dilated lesions were examined with a 3.5 F, 20 MHz mechanical intravascular ultrasound imaging system before and immediately after coronary balloon angioplasty. Quantitative measurements of lumen area, total arterial area, plaque area and arterial stretch were performed in the dilated vessel segments. Plaque reduction accounted for 65% and vessel wall stretch for 35% of the total increase in luminal patency after angioplasty. In 34/49 (69%) lesions plaque reduction and in 15/49 (31%) arterial stretch contributed most (> 50%) of the overall increase in luminal area post angioplasty. in lesions with an ultrasound area stenosis before PTCA larger than the mean value of the group (> or = 87%) plaque reduction contributed a significantly higher percentage to luminal gain as compared to lesions with an area stenosis < 87% (76.5 +/- 25.0 vs 52.7 +/- 29.9, p < 0.05). Conversely, PTCA resulted in a significantly greater amount of vessel walls stretch in lesions with an area stenosis < 87% (47.3 +/- 29.9 vs. 24.4 +/- 24.2; p < 0.05). In lesions with localized dissections (32/49 (65%)) after PTCA as compared to lesions without dissection a significantly greater relative reduction of stenosis (24% +/- 13% vs. 19% +/- 7%, p < 0.05) was found. Plaque reduction and to a lesser extent vessel wall stretch constitute the principal mechanisms responsible for increased luminal patency after balloon angioplasty. The amount of plaque reduction and vessel wall stretch on the overall luminal gain after PTCA is dependent on the size of area stenosis. The presence of localized dissections after angioplasty correlates favorably with a better result.

[Occupational rehabilitation after percutaneous transluminal coronary angioplasty (PTCA)--correlation with subjective and objective parameters]

On the basis of medical criteria percutaneous transluminal coronary angioplasty (PTCA) is followed by only a short interval of work inability. This study evaluated the interval between PTCA and the return to work and the factors which may influence this interval. The study included 122 working patients with angiographically successful PTCA. Patients were followed up clinically and angiographically and completed a standardized questionnaire directly after PTCA and 4 months later. The study population comprised 87 patients (81 men, 6 women) who filled out both questionnaires appropriate for evaluation. Of these 48 (55%) had single-vessel, 27 (31%) two-vessel, and 12 (14%) three-vessel disease. Complete revascularization in terms of treatment of all lesions above 70% was achieved in 85 (98%) patients. In 30 (34%) patients restenosis developed during the observation period as evaluated by coronary angiography. At the time of the second evaluation 46 (53%) patients complained of persisting or new thoracic pain, which they understood as cardiac pain. After 4 months 68 (78%) patients returned to work, 12 (14%) were on sick leave, 3 (3%) were unemployed, and 4 (5%) were retired. The median of time on sick leave after PTCA was 14 days. The length of sick leave after PTCA was found to depend significantly on the previous intention to retire (25% vs. 75%, p < 0.01). Patients who did not return to work during study period reported more frequently of thoracic pain (55% vs. 45%, p = 0.01) and had less intention to return to work after PTCA (6% vs. 94%, p < 0.01).(ABSTRACT TRUNCATED AT 250 WORDS)

[Dissection following balloon angioplasty: predictive possibilities using pre-interventional intravascular ultrasonography]

The purpose of this study was to examine the association between qualitative and quantitative lesion characteristics before and the incidence of dissection after balloon angioplasty as assessed by intravascular ultrasound imaging. Thirty-seven patients (5 women, 32 men, aged 60 +/- 9 years) with 41 dilated lesions were examined with a 3.5 F, 20 MHz rotational tip intravascular ultrasound imaging system before and immediately after coronary balloon angioplasty. Images were assessed for plaque composition, topography and postinterventional effects on the plaque morphology. Quantitative measurements of lumen area, total arterial area and plaque area were performed in the dilated vessel segment. Plaque morphology was concentric in 18 lesions (44%) and eccentric in 23 lesions (56%). Fourteen lesions (34%) showed no calcification, 15 lesions (37%) were superficially and 12 lesions (29%) were deeply calcified. Four distinct changes of the plaque morphology were manifested by ultrasound imaging after balloon angioplasty. Dissection with detachment of the plaque from the underlaying wall was found in 10 lesions, plaque splitting in 9 lesions, superficial tears in 6 lesions, and smooth plaque contours in 16 lesions. The incidence of dissection detected by intravascular ultrasound was significantly greater in eccentric lesions (p = 0.03) and in stenoses with a small total arterial area (p = 0.006). The incidence of dissection was significantly increased in vessels in which balloon cross-sectional area exceeded 50% of the total cross-sectional vessel area as compared to those with a smaller balloon-to-vessel ratio. Preinterventional IVUS imaging provides information about the target stenosis which can be used to assess the risk of postinterventional dissections. In addition to the size of the balloon in relation to vessel cross-sectional area, the features small total vessel cross-sectional area and eccentric stenosis morphology in the preinterventional IVUS study predispose to an increased risk of dissection. Further studies have to elucidate the influence of dissections on late outcome after angioplasty.

The effect of LDL apheresis on progression of coronary artery disease in patients with familial hypercholesterolemia. Results of a multicenter LDL apheresis study

This study investigated the effect of extracorporal lipid-lowering therapy by low-density lipoprotein (LDL) apheresis on coronary artery disease in a population characterized by early development and rapid progression of atherosclerosis. We treated 32 patients aged between 15 and 63 years with drug-refractory familial hypercholesterolemia, treated once a week by immuno-specific LDL apheresis for 3 years in a controlled prospective and non-randomized trial; 25 patients (14 females and 11 males) completed the study. Noninvasive data were obtained by physical examination, 12-lead ECG and exercise testing. Invasive cardiological data were obtained by cardiac catheterization according to a standardized protocol in four cardiological centers. Left ventricular ejection fraction was calculated using planimetry. Coronary stenoses were measured quantitatively in 23 defined coronary segments by a panel of four investigators with an electronic digital caliper. In addition, overall coronary atherosclerosis was visually qualified. Final decisions on a classification into one of three groups (regression, no change, progression) of coronary atherosclerosis were based on panel consensus. Six cardiac events occurred throughout the study: percutaneous transluminal coronary angioplasty in one patient, coronary bypass grafting in three and two deaths. Statistical analysis of exercise testing yielded no significant change for maximum power and work capacity during the study period. Hemodynamic data revealed no significant change; mean ejection fraction was calculated as 65.8 +/- 15.9% at study entry and 67.0 +/- 12.7% at completion. Quantitative measurement of 111 circumscribed coronary stenoses showed a mean stenosis degree of 45 +/- 26% at entry cineangio-film and 43 +/- 22% at final cineangio-film demonstrating no significant change.(ABSTRACT TRUNCATED AT 250 WORDS)

[Psychosocial problems of adolescents and adults with congenital heart defects]

Despite successful medical treatment and hemodynamic good results after surgical correction, relevant psychosocial problems occur in adult patients with congenital heart disease. 146 patients in Germany with simple but also with complex congenital heart defects were examined by means of a questionnaire to look into these problems. Although most of the patients belonged to Ability Index I or Ability Index II of J. Somerville, almost 60% felt not healthy and impaired. The level of education was above average. 98% had attended a regular school, 23% a secondary school, and 15% had attended university. The congenital heart disease negatively affected the choice of occupation for 25% of the patients, but only 8.6% had difficulties when they applied for a job. The majority of patients was employed and satisfied with their occupation. Most of them were working in physically less demanding jobs. Sporting activities were widespread, although half of the patients felt impaired by the congenital heart disease when performing sports. All patients had some kind of health insurance. Most of them were enrolled in the common public health insurance plan. The insurers paid for almost all expenses caused by the congenital heart disease. More than 30% were not accepted by life insurance companies. Only 1.4% were members of a self-help-group for congenital heart disease. The knowledge of these occurring problems may help to improve the treatment of adult patients with congenital heart disease and, moreover, infants and adolescent patients who still have to reach adulthood may later benefit from this information.

[Follow-up and characteristics of restenoses after coronary stent implantation in asymptomatic patients and patients with few symptoms]

Following coronary Palmaz-Schatz single stent implantation 50 patients had an angiographic follow-up after 4-6 and after 12 months. Quantitative angiography revealed that the restenosis process has finished 4-6 months after stent implantation in the majority of patients. In the present study, 6% had, however, developed symptomatic restenosis at 1-year follow-up. Detailed assessment of 15 patients revealed that the residual stenosis after stent implantation is most prominent at the stent edges, however, restenosis did occur in all segments in about the same amount. Analysis of several clinical and morphologic variables did not reveal any particular risk factor for the development of restenosis. The results of the present study do suggest that follow-up angiography should be performed 4-6 months after stent placement.

[Local vascular complications in heart catheter studies]

Over a period of 30 months (1. 1. 89-30. 6. 91) 3516 patients who had either a diagnostic (2718) or therapeutic (798) heart catheterization were followed for local vascular complications. 774 patients were investigated prospectively. The following complications were observed in declining frequency: 1. relevant haematoma, 2. pseudoaneurysm, 3. arteriovenous fistula, 4. arterial thrombosis/dissection, 5. venous thrombosis, 6. rupture of the vessel, 7. local infection. The total complication rate was 2.22%. With prospective investigation it was significantly higher (3.23%) than with retrospective investigation (1.93%). The complication rate was also significantly higher in therapeutical procedures (3.76%) than in diagnostic catheterizations (1.76%). Factors associated with a significantly higher incidence of local vascular complications were age (p < 0.01), female gender (p < 0.025), manifest arterial hypertension (p < 0.005), aortic regurgitation (p < 0.1), peri-interventional medication with acetylsalicylic acid and full dose heparin (p < 0.001), full dose heparin alone (p < 0.001) or fibrinolysis-therapy (p < 0.025). Relevant technical factors were: duration of the procedure, duration of the placement of the catheter-sheath, French size of the catheter, left femoral access, arterial and venous access at one extremity. In about half of the cases the treatment of the complications was conservative, in the other half it was surgical (51%). In relation to all surgically treated patients the percentage of emergency operations was 25%, the percentage of reoperations was 15%.

A unique scenario for coronary atherectomy

Despite several attempts, balloon angioplasty of a slightly eccentric stenotic lesion in the proximal right coronary artery failed to result in any increase of luminal diameter. Following disruption and partial removal of a fibrous atherosclerotic cap using directional atherectomy, subsequent balloon angioplasty was highly successful.

[Clinical experiences with four newly developed, surface modified stimulation electrodes]

Newly developed pacing electrodes with so-called porous surfaces promise a significantly improved post-operative pacing and sensing threshold. We therefore investigated four newly developed leads (ELA-PMCF-860 n = 10; Biotronik-60/4-DNP n = 10, CPI-4010 n = 10, Intermedics-421-03-Biopore n = 6) connected to two different pacing devices (Intermedics NOVA II, Medtronic PASYS) in 36 patients (18 men, 18 women, age: 69.7 +/- 9.8 years) suffering from symptomatic bradycardia. The individual electrode maturation process was investigated by means of repeated measurements of pacing threshold, electrode impedance in acute, subacute, and chronic phase, as well as energy consumption and sensing behavior in the chronic phase. However, with the exception of the 4010, the investigated leads showed largely varying values of the pacing threshold with individual peaks occurring from the second up to the 13th week. All leads had nearly similar chronic pacing thresholds (PMCF 0.13 +/- 0.07; DNP 0.25 +/- 0.18; Biopore 0.15 +/- 0.05; 4010 0.14 +/- 0.05 ms). Impedance measurements revealed higher, but not significantly different values for the DNP (PMCF 582 +/- 112, DNP 755 +/- 88, Biopore 650 +/- 15, 4010 718 +/- 104 Ohm). Despite differing values for pacing threshold and impedance, the energy consumption in the chronic phase during threshold-adapted, but secure stimulation (3 * impulse-width at pacing threshold) were comparable.

A prospective, randomized, and double-blind trial on the effect of fish oil on the incidence of restenosis following PTCA

Restenosis after successful coronary angioplasty (PTCA) occurs in 25-35% of all procedures. To date, most pharmacologic strategies have failed to reduce the restenosis rate significantly. However, recent studies have suggested a potential benefit of dietary supplementation with omega-3 fatty acids (fish oil) on restenosis following PTCA. The benefit of omega-3 polyunsaturated fatty acids on the incidence of coronary artery restenosis following elective PTCA was assessed in 212 consecutive patients (41 female, 171 male). Following a successful angioplasty, 204 patients received a dietary supplementation with either nine capsules containing fish oil (3.15 g omega-3 fatty acids) or nine placebo capsules containing olive oil. Treatment was started immediately after PTCA and maintained over 4 mon. Compliance was assessed by analysis of lipid fatty acids prior to angioplasty and at 4 mon follow-up. The angiographically determined incidence of restenosis (stenosis diameter > 50%) was 31.2% per lesion in patients receiving fish oil and 33.7% in patients receiving olive oil. Gross progression of coronary artery disease in vessels not subjected to angioplasty was 17% and 16%, respectively. In conclusion, low dose fish oil supplementation begun on the day of a successful coronary angioplasty failed to demonstrate any effect on coronary artery restenosis.

[Long-term effects of low dosage fish oil on serum lipids and lipoproteins]

In a prospective and double-blind study, the long-term effects of low dose fish oil on serum lipids and lipoproteins was tested in patients with normal or moderately elevated serum lipids and compared to the effects of olive oil. The compliance to the study medication was evaluated by analysis of serum fatty acids and proved to be very good. Dietary supplementation with 9 g fish oil, respective 3.15 g n-3 fatty acids per day over one year resulted in a decrease of serum-triglycerides by 26% and increase of HDL-cholesterol by 26%. Treatment with 9 g olive oil resulted in an 18% increase of HDL-cholesterol. There was no effect on serum-triglyceride levels.

Functional health status in male patients without restenosis following successful PTCA

In a prospective pilot study, subjective and objective parameters of the health status were assessed in 148 male patients (mean age 56 +/- 8.4 years) before and 4 months after successful coronary angioplasty (PTCA). Restenosis was defined as residual diameter stenosis > 50%. Although 96 patients (65%) had not developed restenosis at 4 months' invasive follow-up, subjective assessment of general well-being was unchanged in 26% or worse in 71%; overall anginal status and exercise performance had however improved. Of 71 men younger than 60 years who had no restenosis at follow-up, 4 men retired and 13 remained on medical leave. The striking disparity between subjective and objective parameters was not related to significant differences of age, exercise capacity, and left ventricular ejection fraction, as well as to baseline characteristics (previous myocardial infarction, extent of coronary heart disease, comorbidity) compared with 52 patients with restenosis. Thus, despite documented sustained success after PTCA, the majority of patients failed to resume the status of subjective well-being.

Cardiac involvement during and after malaria

In 22 patients without a previous history of cardiac disease, we prospectively evaluated cardiac involvement during acute malaria and 9 +/- 5 months after recovery using non-invasive methods including resting electrocardiogram (ECG) and two-dimensional (2D) echocardiography. During the acute phase ECG abnormalities were common (5/22); pericardial effusion was found in 2 patients and global left ventricular hypokinesia in 1 patient infected with Plasmodium falciparum. At a follow-up of 19 patients, the resting ECG and echocardiography were normal or had normalized in all patients. The results of our study suggest that persistent cardiac damage following malarial infection seems to be rare; however, further trials in a larger patient population are needed to confirm our findings.

A prospective study on percutaneous coronary angioscopy with different guiding techniques in patients with coronary heart disease

The technical success of percutaneous coronary angioscopy using different guiding techniques was evaluated in 17 patients before (n = 17) and after (n = 8) coronary angioplasty. Steering the angioscope along or over a guidewire was successful in both groups; failures were predominantly due to insufficient alignment of the angioscope using along-the-wire guiding. Although over-the-wire angioscopy promises superior guiding and alignment capabilities, several technical problems remain unsolved.

New option for balloon recanalization of total coronary occlusions

In 9 out of 12 patients with a total coronary occlusion but definite signs of viable myocardium a new approach for the recanalization procedure was successfully employed: Following recanalization using an on-the-wire 2.0 or 2.5 mm angioplasty catheter, a standard coronary guidewire was placed along the angioplasty catheter. After withdrawal of the catheter, over-the-wire angioplasty with an appropriately sized balloon was performed for final dilatation. Pending further studies in a larger patient population, this new method may offer an alternative approach for revascularization of total coronary occlusions.

Failure of radiotherapy to resolve fatal lung damage due to paraquat poisoning

The most effective treatment of severe paraquat poisoning in man is uncertain. In order to prevent pulmonary fibrosis, we employed radiotherapy of both lungs in a 23-year-old patient with severe paraquat poisoning; however, it failed to prevent the fatal outcome.

Cardiopulmonary exercise testing (CPX) and transthoracic bioimpedance measurements: new tools for an "old disease" (congestive heart failure)

The purpose of the study was to examine the cardiovascular and cardiopulmonary exercise capacity in patients with symptomatic congestive heart failure more exactly than with conventional investigations, using the simultaneous non-invasive determination of the gas exchange parameters (ergospirometry, CPX) and of the hemodynamic (transthoracic bioimpedance). The reproducibility of the data were measured with each method with repeated tests under the same conditions in healthy subjects and patients with myocardial failure. Therefore we tested 15 patients with documented congestive heart failure repeatedly on a bicycle (semi-supine, +15 watts/min, symptom-limited). The ergospirometric (VO2, VCO2, RER = VCO2/VO2, max. VO2, VO2AT, VE, RR) and the bioimpedance-parameters (CI, SVI, HR) were measured simultaneously during rest and exercise. According to Wasserman et al. we used the VO2AT and the max. VO2 to assign the patients to the different Weber classes: Weber A: greater than 20 ml/min/kg max. VO2, greater than 14 ml/min/kg VO2AT; Weber B: 16 to 20 ml/min/kg max. VO2, 11 to 14 8 to 11 ml/min/kg VO2AT; Weber D: 6 to 10 ml/min/kg max. ml/min/kg VO2AT; Weber C: 10 to 16 ml/min/kg max. VO2, 8 to 11 ml/min/kg VO2AT; Weber D: 6 to 10 ml/min/kg max. VO2, 4 to 8 ml/min/kg VO2AT: Weber E: less than 6 ml/min/kg max. VO2, less than 4 ml/min/kg VO2AT. The V-slope-method according to Beaver et al. allowed for the determination of the anaerobic threshold in 13/15 patients. 2/15 patients didn't reach the anaerobic threshold. Oscillations of the gas exchange parameters due to Cheyne-Stokes-breathing were found in 9/15 patients.(ABSTRACT TRUNCATED AT 250 WORDS)

Left hemitruncus in adulthood: diagnostic role of magnetic resonance imaging

The diagnosis of left hemitruncus and large patent ductus arteriosus was made by magnetic resonance imaging in an adult patient with recurrent haemoptysis and dyspnoea on exertion. Previous cardiac catheterization and echocardiography failed to establish the complete diagnosis. Magnetic resonance imaging using spin-echo and gradient-echo pulse sequences is a useful imaging modality to evaluate anatomical and functional abnormalities in patients with complex congenital heart disease.