A Multicenter Study of Stellate Ganglion Block as a Temporizing Treatment for Refractory Ventricular Arrhythmias

BACKGROUND

Ventricular tachycardia (VT) and ventricular fibrillation (VF) are life-threatening conditions and can be refractory to conventional drug and device interventions. Stellate ganglion blockade (SGB) has been described as an adjunct, temporizing intervention in patients with refractory ventricular arrhythmia. We examined the association of SGB with VT/VF in a multicenter registry.

OBJECTIVES

This study examined the efficacy of SGB for treatment/temporization of refractory VT/VF.

METHODS

The authors present the first analysis from a multicenter registry of patients treated for refractory ventricular arrhythmia at a clinical site in the Czech Republic and the United States. Data were collected between 2016 and 2022. SGB was performed at the bedside by anesthesiologists and/or cardiologists. Outcomes of interest were VT/VF burden and defibrillations at 24 hours before and after SGB.

RESULTS

In total, there were 117 patients with refractory ventricular arrhythmias treated with SGB at Duke (n = 49) and the Institute for Clinical and Experimental Medicine (n = 68). The majority of patients were male (94.0%), were White (87.2%), and had an implantable cardioverter-defibrillator (70.1%). The most common etiology of heart disease was ischemic cardiomyopathy (52.1%), and monomorphic VT was the most common morphology (70.1%). Within 24 hours before SGB (0-24 hours), the median episodes of VT/VF were 7.5 (Q1-Q3: 3.0-27.0), and 24 hours after SGB, the median decreased to 1.0 (Q1-Q3: 0.0-4.5; P < 0.001). At 24 hours before SGB, the median defibrillation events were 2.0 (Q1-Q3: 0.0-8.0), and 24 hours after SGB, the median decreased to 0.0 (Q1-Q3: 0.0-1.0; P < 0.001).

CONCLUSIONS

In the largest cohort of patients with treatment-refractory ventricular arrhythmia, we demonstrate that SGB use was associated with a reduction in the ventricular arrhythmia burden and need for defibrillation therapy.

Hazard characterisation for significant mycotoxins in food

This review updates the current status of activities related to hazard characterisation for mycotoxins, with special reference to regulatory work accomplished within the European Union. Because the relevant information on these topics is widely scattered in the scientific literature, this review intends to provide a condensed overview on the most pertinent aspects. Human health risk assessment is a procedure to estimate the nature and potential for harmful effects of mycotoxins on human health due to exposure to them via contaminated food. This assessment involves hazard identification, hazard characterisation, exposure assessment, and risk characterisation. Mycotoxins covered in this review are aflatoxins, ochratoxin A, cyclopiazonic acid, citrinin, trichothecenes (deoxynivalenol, nivalenol, T-2, and HT-2 toxins), fumonisins, zearalenone, patulin, and ergot alkaloids. For mycotoxins with clear genotoxic/carcinogenic properties, the focus is on the margin of exposure approach. One of its goals is to document predictive characterisation of the human hazard, based on studies in animals using conditions of low exposure. For the other, non-genotoxic toxins, individual 'no adverse effect levels' have been established, but structural analogues or modified forms may still complicate assessment. During the process of hazard characterisation, each identified effect is assessed for human relevance. The estimation of a 'safe dose' is the hazard characterisation endpoint. The final aim of all of these activities is to establish a system, which is able to minimise and control the risk for the consumer from mycotoxins in food. Ongoing research on mycotoxins constantly comes up with new findings, which may have to be implemented into this system.

Investigation of ochratoxin a in blood sausages in the Czech Republic: Comparison with data over Europe

Blood sausages consisting of groats, pork, porcine offal, fat, blood, and spices are very popular in the Czech Republic. All these ingredients are potential sources of dietary exposure to ochratoxin A (OTA). OTA has a strong affinity to serum proteins in porcine blood. Thus, the contamination of blood sausages with OTA can be expected. This study aims to evaluate OTA in 200 samples of porcine blood sausages purchased at the Czech market during 2020-2021. The analytical method high-performance liquid chromatography coupled with fluorescence detection with pre-treatment using immunoaffinity columns was employed to determine OTA. The limit of detection was 0.03 ng/g and the limit of quantification 0.10 ng/g. Recovery was 71.6 %. All samples were positive at contents ranging from 0.15 to 5.68 ng/g with a mean of 1.47 ng/g, and a median of 1.26 ng/g. A total of 66% of these samples contained OTA content exceeding the maximum limit of 1 ng/g set in Italy. This study demonstrates that the Czech population is exposed to OTA from blood sausages. The proposed preliminary action limit for OTA in blood sausages should be set at 1 ng/g. No regulatory limits for OTA in blood sausages have been established yet in the European Union legislation. To protect human health, further monitoring of OTA in these products is necessary.

Natural Occurrence of Ochratoxin A in Spices Marketed in the Czech Republic during 2019-2020

Spices are a popular ingredient in cuisine worldwide but can pose a health risk as they are prone to fungal infestation and mycotoxin contamination. The purpose of this study was to evaluate ochratoxin A (OTA) in 54 single-kind traditional and less traditional spices, each of which was purchased in six samples of different batches (324 samples in total) at the Czech market during 2019-2020. The HPLC-FLD method with pre-treatment by immunoaffinity columns was employed to determine OTA. The limits of detection and quantification were 0.03 ng g^-1 and 0.10 ng g^-1, respectively. A total of 101 (31%) samples of 19 spice kinds were positive at concentrations ranging from 0.11-38.46 ng g^-1. Only turmeric was contaminated with an OTA level exceeding the European Union limits. However, most spices have no regulation, thus further extensive monitoring of various mycotoxins in various kinds of spices is necessary. Chilli and black pepper are the most studied spices for OTA contamination, however, many other kinds of spice can also be highly contaminated, but studies on them are less common, rare, or have not yet been performed. The uniqueness of this study lies in the wide range of spice types studied for the presence of OTA on the Czech market.

Investigation of ochratoxin A biomarkers in biological materials obtained from patients suffering from renal cell carcinoma

Ochratoxin A (OTA) exposure can result in chronic renal diseases and cancer. The incidence of kidney, renal pelvis, and ureter malignant neoplasms in the Czech Republic is approximately 29.5 renal tumours per 100,000 inhabitants. The question arises whether mycotoxins are also involved in kidney disease and cancer. A sensitive validated analytical methodology, based on an immunoaffinity clean-up followed by HPLC with fluorescence detection, was developed to explore whether OTA accumulates in clear renal cell carcinoma-adenocarcinoma in Czech patients. Simultaneously, DNA-adducts and OTA metabolites were qualitatively analysed in tissues and urine. OTA was analysed in 33 kidney and tumour samples from 26 men and 7 women collected during nephrectomy from patients of the East Bohemian region from 2015 to 2017. OTA was found in 76% of the analysed samples. Its concentrations ranged from not detectable to 390 ng/kg with a median of 167 ng/kg in kidney samples and from not detectable to 430 ng/kg with a median of 122 ng/kg in tumour samples. Urinary OTA metabolites and DNA adducts were qualitatively analysed for the corresponding 20 patients. The presence of some OTA metabolites such as ochratoxin A hydroquinone and/or decarboxylated ochratoxin A hydroquinone correlate with the presence of OTA-DNA adducts.

Aflatoxins: History, Significant Milestones, Recent Data on Their Toxicity and Ways to Mitigation

In the early 1960s the discovery of aflatoxins began when a total of 100,000 turkey poults died by hitherto unknown turkey "X" disease in England. The disease was associated with Brazilian groundnut meal affected by Aspergillus flavus. The toxin was named Aspergillus flavus toxin-aflatoxin. From the point of view of agriculture, aflatoxins show the utmost importance. Until now, a total of 20 aflatoxins have been described, with B1, B2, G1, and G2 aflatoxins being the most significant. Contamination by aflatoxins is a global health problem. Aflatoxins pose acutely toxic, teratogenic, immunosuppressive, carcinogenic, and teratogenic effects. Besides food insecurity and human health, aflatoxins affect humanity at different levels, such as social, economical, and political. Great emphasis is placed on aflatoxin mitigation using biocontrol methods. Thus, this review is focused on aflatoxins in terms of historical development, the principal milestones of aflatoxin research, and recent data on their toxicity and different ways of mitigation.

A Review on Mycotoxins and Microfungi in Spices in the Light of the Last Five Years

Spices are imported worldwide mainly from developing countries with tropical and/or subtropical climate. Local conditions, such as high temperature, heavy rainfall, and humidity, promote fungal growth leading to increased occurrence of mycotoxins in spices. Moreover, the lack of good agricultural practice (GAP), good manufacturing practice (GMP), and good hygienic practice (GHP) in developing countries are of great concern. This review summarizes recent data from a total of 56 original papers dealing with mycotoxins and microfungi in various spices in the last five years. A total of 38 kinds of spices, 17 mycotoxins, and 14 microfungi are discussed in the review. Worldwide, spices are rather overlooked in terms of mycotoxin regulations, which usually only cover aflatoxins (AFs) and ochratoxin A (OTA). In this paper, an extensive attention is devoted to the limits on mycotoxins in spices in the context of the European Union (EU) as well as other countries. As proven in this review, the incidence of AFs and OTA, as well as other mycotoxins, is relatively high in many spices; thus, the preparation of new regulation limits is advisable.

Presence of Mycotoxins in Milk Thistle (Silybum marianum) Food Supplements: A Review

The consumption of herbal-based supplements, which are believed to have beneficial effects on human health with no side effects, has become popular around the world and this trend is still increasing. Silybum marianum (L.) Gaertn, commonly known as milk thistle (MT), is the most commonly studied herb associated with the treatment of liver diseases. The hepatoprotective effects of active substances in silymarin, with silybin being the main compound, have been demonstrated in many studies. However, MT can be affected by toxigenic micro-fungi and contaminated by mycotoxins with adverse effects. The beneficial effect of silymarin can thus be reduced or totally antagonized by mycotoxins. MT has proven to be affected by micro-fungi of the Fusarium and Alternaria genera, in particular, and their mycotoxins. Alternariol-methyl-ether (AME), alternariol (AOH), beauvericin (BEA), deoxynivalenol (DON), enniatin A (ENNA), enniatin A1 (ENNA1), enniatin B (ENNB), enniatin B1 (ENNB1), HT-2 toxin (HT-2), T-2 toxin (T-2), tentoxin (TEN), and zearalenone (ZEA) seem to be most significant in MT-based dietary supplements. This review focuses on summarizing cases of mycotoxins in MT to emphasize the need for strict monitoring and regulation, as mycotoxins in relation with MT-based dietary supplements are not covered by European Union legislation.

Analyses of biomarkers of exposure to nephrotoxic mycotoxins in a cohort of patients with renal tumours

The Czech Republic occupies the first place in the world in the frequency of renal and other urinary tract tumours, but their aetiology is unknown. To explore whether carcinogenic and nephrotoxic mycotoxins may contribute to kidney diseases in the Czech population, biomarkers of ochratoxin A (OTA) and citrinin (CIT) exposure were determined in biological specimens from a cohort of 50 patients with malignant renal tumours. Biomarker analyses in blood and urine samples used validated targeted methods for measuring OTA and CIT plus dihydrocitrinone (DH-CIT) after enrichment of analytes by specific immunoaffinity clean-up. OTA and CIT plus its metabolite DH-CIT were frequently detected in patient urine samples (OTA 62%; CIT 91%; DH-CIT 100%). The concentration ranges in urine were 1-27.8 ng/L for OTA, 2-87 ng/L for CIT and 2-160 ng/L for DH-CIT. The analyses of blood samples revealed also a frequent co-occurrence of OTA and CIT, in the ranges of 40-870 ng/L serum for OTA and 21-182 ng/L plasma for CIT. This first analysis of biomarkers in blood and urine samples of Czech patients revealed no major differences in comparison with published data for the general healthy Czech and European populations. Nonetheless, a frequent co-occurrence of CIT and OTA biomarkers in patient samples may be of interest with regard to potential interactions with other risk factors for renal disease.

Investigation of patulin and citrinin in grape must and wine from grapes naturally contaminated by strains of Penicillium expansum

Twenty three strains of Penicillium expansum, as a predominant species, were isolated from 23 (92%) out of 25 grape samples of 17 different grape varieties. The results of the identification of P. expansum strains were confirmed by a PCR method. Most of the isolates of P. expansum (21/23, 91%), when tested for toxigenicity, were bi-toxigenic: they produced citrinin (CIT) and particularly high amounts of patulin (PAT). A validated UPLC-MS/MS method for the determination of PAT and CIT was applied. The limits of quantification (LOQ) for PAT and CIT in grape must and toxigenicity testing samples were 100 and 2 ng/g, respectively. The results of PAT and CIT quantification in 23 grape must samples demonstrated the occurrence of PAT in 10 (43%) grape must samples (mean: 171 ng/g; median: 50 ng/g; and range: 143-644 ng/g) and the occurrence of CIT in two (9%) grape must samples (mean: 1 ng/g; median: 1 ng/g; and range: 2.5-3.5 ng/g). This is the first report on the natural occurrence of CIT in grape must. A validated HPLC-UV-VIS method for the determination of PAT in wine samples was applied, and concentrations in all 23 wine samples were below the LOQ (<10 ng/g).

Occurrence of ochratoxin A in Astragalus propinquus root and its transfer to decoction

The aim of this study was to conduct a survey assessing (a) the ochratoxin A (OTA) content in different samples of Astragalus propinquus root (AR), one of the fundamental herbs in traditional Chinese medicine, and (b) the rate of OTA transfer to AR decoctions that are traditionally used to reduce general weakness and increase overall vitality. A validated method of high-performance liquid chromatography with fluorescence detection (HPLC-FLD) was used to determine OTA concentrations in AR samples and AR decoctions. The limit of quantification was 0.35 ng/g; the recovery of the HPLC method for AR samples was 82%; and the relative standard deviation (SD) of repeatability was 2.6%. All 40 tested AR samples were positive, with a mean value of 451.0 ng/g (range, 28.8-1700.0 ng/g). The transfer rate of OTA to decoctions, from a naturally contaminated and homogenized AR sample (internal reference material) with a concentration of OTA of 288.9 ng/g ± 12.3 (SD), was 83.4% ± 8.5 (SD). We believe it is necessary to continue OTA monitoring in AR and other herbal products, estimate the actual human usual intake, and perform health risk assessment.

Cyclopiazonic acid: 50th anniversary of its discovery

In 1968, the mycotoxin cyclopiazonic acid (CPA) was first discovered and characterised as a chemical substance. Within the following five decades, much has been learned from the results of CPA research. CPA is produced by several Penicillium species (P. griseofulvum, P. camemberti, P. commune, P. dipodomyicola) and Aspergillus species (A. flavus, A. oryzae and A. tamarii). It is widespread on naturally contaminated agricultural raw materials. CPA has been reported to occur in food commodities (e.g. oilseeds, nuts, cereals, dried figs, milk, cheese and meat products) and to possess toxicological significance. CPA is also frequently detected in peanuts and maize; the presence of CPA and aflatoxins in maize and peanuts contaminated with A. flavus suggests that synergism may occur. CPA is toxic to several animal species, such as rats, pigs, guinea pigs, poultry and dogs. After ingesting CPA-contaminated feeds, test animals display severe gastrointestinal upsets and neurological disorders. Organs affected include the liver, kidney, heart, and digestive tract, which show degenerative changes and necrosis. Biologically, CPA is a specific inhibitor of sarco(endo)plasmic reticulum Ca2+-ATPase. Data from toxicological evaluation of aflatoxins and CPA in broiler chickens demonstrate that both aflatoxins and CPA alone and the aflatoxin-CPA combination can adversely affect broiler health. The effects of aflatoxins and CPA combination were additive in most cases.

Transfer of ochratoxin A from raw black tea to tea infusions prepared according to the Turkish tradition

BACKGROUND

Ochratoxin A (OTA) is a natural contaminant of food including tea with multiple toxic effects, which poses a threat to human health. In terms of lifestyle, the Turkish population is a frequent visitor of tearooms, and the traditional Turkish tea preparation is one of the most popular ways of preparing tea infusion.

RESULTS

The aim of this study was to investigate OTA transfer from raw black tea to the tea infusion prepared according to the Turkish tradition. A high-performance liquid chromatography method with a limit of quantification of 0.35 ng g-1 was used for OTA determination. The OTA amount in raw black teas from Turkey ranged from ≤0.35 ng g-1 up to 56.7 ng g-1 . An homogenised sample of black tea naturally contaminated with 55.0 ng g-1 was used to prepare infusions. The OTA transfer from the black tea to the infusion was found to be 41.5% ± 7%.

CONCLUSION

These data are important for the realisation of a 'Total Diet study' (TDS). The TDS can be a complementary tool to estimate the population dietary exposure to OTA across the entire diet by analysing main foods prepared 'as consumed' (tea infusions) and not 'as purchased' (raw tea). © 2017 Society of Chemical Industry.

Mycotoxins as human carcinogens-the IARC Monographs classification

Humans are constantly exposed to mycotoxins (e.g. aflatoxins, ochratoxins), mainly via food intake of plant and animal origin. The health risks stemming from mycotoxins may result from their toxicity, in particular their carcinogenicity. In order to prevent these risks, the International Agency for Research on Cancer (IARC) in Lyon (France)-through its IARC Monographs programme-has performed the carcinogenic hazard assessment of some mycotoxins in humans, on the basis of epidemiological data, studies of cancer in experimental animals and mechanistic studies. The present article summarizes the carcinogenic hazard assessments of those mycotoxins, especially aflatoxins (aflatoxin B1, B2, G1, G2 and M1), fumonisins (fumonisin B1 and B2) and ochratoxin A (OTA). New information regarding the genotoxicity of OTA (formation of OTA-DNA adducts), the role of OTA in oxidative stress and the identification of epigenetic factors involved in OTA carcinogenesis-should they indeed provide strong evidence that OTA carcinogenicity is mediated by a mechanism that also operates in humans-could lead to the reclassification of OTA.

Ochratoxin A: 50 Years of Research

Since ochratoxin A (OTA) was discovered, it has been ubiquitous as a natural contaminant of moldy food and feed. The multiple toxic effects of OTA are a real threat for human beings and animal health. For example, OTA can cause porcine nephropathy but can also damage poultries. Humans exposed to OTA can develop (notably by inhalation in the development of acute renal failure within 24 h) a range of chronic disorders such as upper urothelial carcinoma. OTA plays the main role in the pathogenesis of some renal diseases including Balkan endemic nephropathy, kidney tumors occurring in certain endemic regions of the Balkan Peninsula, and chronic interstitial nephropathy occurring in Northern African countries and likely in other parts of the world. OTA leads to DNA adduct formation, which is known for its genotoxicity and carcinogenicity. The present article discusses how renal carcinogenicity and nephrotoxicity cause both oxidative stress and direct genotoxicity. Careful analyses of the data show that OTA carcinogenic effects are due to combined direct and indirect mechanisms (e.g., genotoxicity, oxidative stress, epigenetic factors). Altogether this provides strong evidence that OTA carcinogenicity can also occur in humans.

Transfer of ochratoxin A into tea and coffee beverages

Ochratoxin A (OTA) is nephrotoxic, hepatotoxic, immunotoxic, neurotoxic, reprotoxic, teratogenic, and carcinogenic (group 2B), being characterized by species and sex differences in sensitivity. Despite the fact that OTA is in some aspects a controversial topic, OTA is the most powerful renal carcinogen. The aim of this study was to make a small survey concerning OTA content in black tea, fruit tea, and ground roasted coffee, and to assess OTA transfer into beverages. OTA content was measured using a validated and accredited HPLC-FLD method with a limit of quantification (LOQ) of 0.35 ng/g. The OTA amount ranged from LOQ up to 250 ng/g in black tea and up to 104 ng/g in fruit tea. Black tea and fruit tea, naturally contaminated, were used to prepare tea infusions. The transfer from black tea to the infusion was 34.8% ± 1.3% and from fruit tea 4.1% ± 0.2%. Ground roasted coffee naturally contaminated at 0.92 ng/g was used to prepare seven kinds of coffee beverages. Depending on the type of process used, OTA transfer into coffee ranged from 22.3% to 66.1%. OTA intakes from fruit and black tea or coffee represent a non-negligible human source.

WITHDRAWN: Prognostic Importance of the Right Ventricular Function Assessed by Doppler Tissue Imaging

The publisher regrets that this was an accidental duplication of an article that has already been published in Eur. J. Echocardiogr., 4 (2003) 262-271, . The duplicate article has therefore been withdrawn.

Treatment of gastrointestinal hemorrhage

BACKGROUND

We assessed the value of selective arteriography in the diagnosis and management of acute gastrointestinal hemorrhage.

METHODS

We reviewed the records of 107 consecutive patients who had gastrointestinal hemorrhage and underwent selective arteriography between January 1992 and October 2003: 10 had upper gastrointestinal bleeding, 79 had lower gastrointestinal bleeding, and 18 had varicose bleeding with portal hypertension. Selective embolization was attempted in 15 patients to obtain hemostasis. Angiographic findings were reviewed and prospective reports were compared with the final diagnosis and outcome.

RESULTS

Of 129 angiographic studies, 36 correctly revealed the bleeding site and 93 were negative. Extravasation was seen in 24 cases at the level of stomach (n = 2), duodenum (n = 1), small bowel (n = 5), or colon (n = 16). Indirect signs of bleeding sources were identified in 12 patients (stomach in one, small bowel in four, large bowel in four, liver in three). Transcatheter embolization induced definitive hemostasis in 11 of 15 patients (73%), namely in the stomach (n = 2), small bowel (n = 3), colon (n = 7), and liver (n = 3). Three patients required surgery after embolization.

CONCLUSION

Abdominal arteriography may localize gastrointestinal bleeding sources in approximately one-third of cases. Selective embolization may provide definitive hemostasis in most instances.

Nuclear imaging of an extraskeletal retroperitoneal osteosarcoma: respective contribution of 18FDG-PET and (99m)Tc oxidronate (2005:1b)

Extraskeletal osteosarcoma (ExOs) is a rare, usually highly aggressive malignancy, which affects individuals beyond the fifth decade of life. ExOs prinicipally occurs as a soft tissue mass in a limb or retroperitoneum. We present the case of a 58-year-old man with a huge abdominal mass who underwent a complete range of clinical imaging investigations including computed tomography (CT), skeletal scintigraphy (BS) and positron emission tomography (PET). These exams showed a central calcified and ossified, strongly metabolic retroperitoneal tumour suggestive of an ExOs. This diagnosis was later confirmed by histopathology. To our knowledge, such a case has not previously been documented fully using radiological imaging correlated to modern nuclear medicine techniques such as PET.

The screening for X-linked Emery-Dreifuss muscular dystrophy amongst young patients with idiopathic heart conduction system disease treated by a pacemaker implant

The X-linked Emery-Dreifuss muscular dystrophy (X-EDMD) is a hereditary muscle disorder associated with cardiac involvement. Sinus node dysfunction and atrioventricular conduction defects, typical of X-EDMD, occur in both males and females and may result in sudden cardiac death unless treated by permanent pacing. The objective of the study was to determine the frequency and relevance of X-EDMD in heart conduction system disease in young individuals treated with a pacemaker implant. The medical history of 3450 paced individuals in the region of South Moravia, Czech republic, was reviewed. Thirty-five patients, 20 males and 15 females, with idiopathic heart conduction disease of onset before age 40 were identified and screened for X-EDMD. Within these 35 individuals, only one male was found to carry a mutation in X-EDMD gene. We conclude that the clinical relevance of X-EDMD in heart conduction system disease is very low. It should, however, be included into the diagnostic work-up of young male individuals with idiopathic cardiac conduction disturbances.

Big endothelin in chronic heart failure: marker of disease severity or genetic determination?

The first objective of the study was to compare the levels of big endothelin and endothelin-1 and other noninvasive parameters used for evaluation of disease severity in patients with stable chronic heart failure (CHF). Endothelin-1 and big endothelin plasma concentrations were measured in 124 chronic heart failure patients. The second objective of the study was to prove an association between endothelin-1 and big endothelin plasma levels and two frequent polymorphisms in the endothelin-1 coding gene (6p21-23) -3A/-4A and G (8002) A in patients with chronic heart failure. Thirdly, we tried to associate other noninvasive parameters of CHF, especially cardiothoracic index (CTI), NYHA classification, signs of pulmonary congestion (PC) and ejection fraction (EF) with determined genotypes of the two ET-1 polymorphic variants. There were significant differences between big endothelin levels in NYHA II versus IV (P<0.001) and NYHA III versus IV (P<0.001) and endothelin-1 in NYHA II versus IV (P<0.001) and NYHA III versus IV (P<0.001). No associations between plasma levels of endothelin-1 and big endothelin and polymorphisms G (8002) A and -3A/-4A in gene coding endothelin-1 were found. In patients with CHF with CTI above 60% the number of carriers of genotypes with ET-1 8002A (AA and AG genotypes) increases. Concerning on the -3A/-4A ET-1 polymorphism, we observed a significant difference in genotype distribution as well as in allelic frequency in the group of patients with CTI above 60% between patients without and with pulmonary congestion. The allelic frequency of 3A allele is twice elevated in the patients with pulmonary congestion (37.8 vs. 78.1%, respectively).

Prognostic Importance of the Right Ventricular Function Assessed by Doppler Tissue Imaging

AIMS

We sought to assess whether the peak systolic and diastolic tricuspid annular velocities as indicators of the right ventricular systolic and diastolic function are of prognostic importance in patients with symptomatic heart failure.

METHODS AND RESULTS

The study included 139 consecutive patients with symptomatic heart failure. Their mean left ventricular ejection fraction was 24% (range, 10-39%); 107 patients (77%) were in functional class III according to the New York Heart Association. All patients underwent clinical and laboratory examination, standard echocardiography completed by the Doppler tissue imaging of the tricuspid annular motion, and the right-sided heart catheterization. They were followed up for cardiac-related death and non-fatal cardiac events including the need for implantation of a cardioverter-defibrillator and hospitalization for heart failure. The median follow-up was 11 months (range, 1-48 months). There were 17 cardiac-related deaths and 23 non-fatal cardiac events. The multivariate stepwise Cox regression modelling revealed three effective predictors for both survival and event-free survival: aetiology of heart failure, left ventricular end-diastolic diameter, and the peak systolic tricuspid annular velocity (Sa). Patients with Sa<10.8cms(-1) exhibited worse survival (P=0.048) and event-free survival (P<0.001) compared with those having Sa>/=10.8cms(-1). Risk values of Sa (<10.8cms(-1)) and the left ventricular end-diastolic diameter (>70mm) were found to be of additive simultaneous influence leading to a very poor prognosis, mainly if aetiology of heart failure was idiopathic dilated cardiomyopathy (P<0.001).

CONCLUSION

The Sa represents a significant independent predictor of survival and event-free survival in patients with symptomatic heart failure. Its combination with the left ventricular end-diastolic diameter provides a very powerful tool for patient risk stratification.

Heart rate and increased intravascular volume

The objective was to establish whether an intravascular volume increase leads to a heart rate (HR) increase without increased sympathetic tonus. HR changes at rest and at deep breathing (6/min - simulated increase of atrial filling pressure) were measured in patients after heart transplantation. Evaluation of dependency of HR changes on breathing depth was done through a new time series methodology. The data was evaluated through graphs displaying a significant increase in the graph area at deep breathing, when compared with breathing at rest (p<0.01). We presume that an increase in HR corresponds to increased intravascular volume and malfunctioning kidneys.

[Disorders of laminins in diseases of myocardial and skeletal muscles]

The Emery-Dreifuss muscular dystrophy is caused by muscular lesions and disorders of cardial rhythm and/or by cardiomyopathy. An autosomal dominant form is related to mutations of genes, which are coding for lamins A/C.

GROUP AND METHODS

In the group A the authors examined 37 patients with the diagnosis of dilatation cardiomyopathy (DKMP) and the mean ejection fraction 28.4; 8.8%. In the group B of 13 patients a cardiac stimulator was implanted for a rhythm disorder. Both groups were subjected to cardiological, neurological, clinical and electromyographic (EMG) examinations. A muscle biopsy from m. vastus lateralis was made and the sample was evaluated by histology, histochemistry and immunohistochemistry. The coding sequences of genes for lamins were amplified by polymerase chain reaction and the products were analyzed by the DHPLC method (denaturing higher performance liquid chromatography).

RESULTS

In the group A there was a clinically myopathic picture in three patients, while EMG examination revealed a myogenic finding in 12 patients and a marginally myogenic one in five patients. The histological finding in 12 patients was evaluated as myogenic and marginally myogenic in six. In one patient the mutation analysis revealed mutation in the gene for lamin A/C. A myogenic finding in this patient was determined by EMG as well as by histological examination and the autosomal dominant form of the Emery-Dreifuss muscular dystrophy was therefore diagnosed. In the group B one patient displayed a myopathic neurological finding and a myogenic finding during EMG. A subsequent mutation analysis revealed a mutation in the gene for lamin A/C. The case was therefore the autosomal dominant form of the Emery-Dreifuss muscular dystrophy. In the other patients the clinically marginal myopathic finding was observed once, a marginally myogenic finding during EMG was seen five times, histology and immunochemistry revealed a myogenic finding once and a marginally myogenic finding also once. The other findings were within normal range.

CONCLUSIONS

A careful neurological examination including EMG determined symptoms of skeletal muscle myopathies in a surprisingly high percentage of our cardiological patients. This observation draws attention to the need of neurological examination in patients with DKMP in order to discovered disorder in this area in time. In two patients mutations in genes coding lamins A/C were detected. It would be useful to analyze also genes coding for other cytoskeletal proteins in the future.

The double heterozygote of two endothelin-1 gene polymorphisms (G8002A and -3A/-4A) is related to big endothelin levels in chronic heart failure

The aim of this study was to focus on the relationship among the associated genotypes of G (8002) A and -3A/-4A endothelin-1 (ET-1) gene polymorphisms and some clinical and/or biochemical parameters in Czech (Caucasian) patients with chronic heart failure. Included in the study were 103 patients with chronic heart failure (functional classes NYHA II-IV, ejection fraction < 40%). The ET-1 gene polymorphisms were detected by polymerase chain reaction (PCR) and restriction fragment length polymorphism methods. A significant decrease in the ET-1-associated genotype AG3A4A number (double heterozygote) was observed in CHF patients with plasma big endothelin levels above 0.7 pmol/L compared to those with levels below 0.7 pmol/L (OR = 0.19; 95% confidence interval = 0.06-0.57; P = 0.005; Pcorr = 0.03). We found a significant decrease in the AG3A4A genotype number in the other groups compared to the group of patients with both big endothelin and endothelin-1 levels under 0.7 pmol/L (OR = 0.22; 95% confidence interval = 0.07-0.79; P = 0.02). The double heterozygote variants of two ET-1 gene polymorphisms were associated with significantly less risk for chronic heart failure with higher levels of big endothelin.

[Proliferating mole in menopause imitating choriocarcinoma recurrence--case report]

OBJECTIVE

To show the possibility of new invasive mole arising after 2 years of menopause, after choriocarcinoma cured by chemotherapy 5 years ago.

SETTING

Trofoblastic disease center (TDC), Prague, Institution for care of mother and child, Prague.

CASE REPORT

Patient 50-years-old with choriocarcinoma, in consequence to invasive mole, was cured by chemotheraphy. After 5 years of clinical and laboratory remission and after two years of menopause new pregnancy with invasive mole arised imitating relapse of choriocarcinoma.

[Echocardiography after orthotopic heart transplantation]

One of the most serious complications after orthotopic transplantation of the heart (OTH) is graft rejection. Its early detection can help successful control. The diagnostic gold standard is myocardial biopsy, it is however not always supreme. We tried to find out whether some modern echocardiographic methods can provide further valuable information. At the same time we were concerned with the follow up of basic variables of the circulation and echocardiographic indicators of left ventricular function.

MATERIAL AND METHODS

The authors examined repeatedly 22 patients where in 1998-2000 OTH was performed, who did not have an acute severe rejection, who had at least one myocardial biopsy between the first and second month after OTH without signs of rejection and who were easily examined by echocardiography. In addition to the standard follow up according to a routine pattern they were subjected to clinical and echocardiographic examination during the 1st-2nd month after OTH, 6 months after the first examination and one year after the second examination. Classical echocardiography, acoustic densitometry and Doppler tissue examination of the movement of the mitral ring were used.

RESULTS

The patients had throughout the investigation period clinical cardiological complications. Between the first and second examination the systolic pressure rose from 125.4 +/- 9.5 to 135.4 +/- 13.5 mm Hg (p < 0.05), the diastolic pressure from 79.6 +/- 8.2 to 86.4 +/- 9.5 mm (p < 0.05), during the third examination it dropped again to original values. During the follow up no significant differences developed in indicators of classical echocardiography, acoustic densitometry and Doppler tissue echocardiography. Of 22 patients however myocardial biopsy of the right ventricle proved rejection only in two. In those the authors did not observe any echocardiographic changes during rejection. In one patient who died echocardiography revealed a decline of left ventricular function and a non-specific bioptic finding, and on necropsy severe cellular vascular rejection.

CONCLUSIONS

Blood pressure rises early in some patients after OTH, it is therefore important to monitor it carefully and to administer early and systematic treatment of hypertension. In non-complicated patients the echocardiographic findings did not change. Because of the low number of rejections the authors were not able to prove the importance of some new echocardiographic methods. In view of discrepancies between methods in some patients with rejection a comprehensive diagnostic approach is still necessary: myocardial biopsy supplemented by further examinations, in particular echocardiographic ones.

[A safe site for transposition of ovaries in radical hysterectomy for cervical carcinoma]

OBJECTIVE

To know the influence of twilight by using the radiotherapeutical technique box on hormonal function of ovaries. The aim of transposition of ovaries by radical hysterectomy of the cervical cancer is to move the ovaries out of radiotherapeutical target volume, and thus to protect their hormonal function.

SETTING

Institute for the Care of Mother and Child, Prague, Czech Republic.

METHODS

Computer simulation of radiation isodoses of linear accelerator on the transferred pictures of CT and calculation on the total dose, and radiobiological equivalent outside the target volume of radiation regarding the total dose of 46 Gy.

RESULTS

In the pelvis region the minimal dose succeeded in acting as a castrating dose. The safe area is 2.5 cm above the margin of the radiation beam.

CONCLUSION

It can be recommended to tuck the ovaries 3.5 cm above the margin of the pelvis.

Pulsed Doppler tissue imaging of the velocity of tricuspid annular systolic motion; a new, rapid, and non-invasive method of evaluating right ventricular systolic function

AIMS

Rapid, accurate, and widely available non-invasive evaluation of right ventricular function still presents a problem. The purpose of the study was to determine whether the parameters derived from Doppler tissue imaging of tricuspid annular motion could be used as indexes of right ventricular function in patients with heart failure.

METHODS

Standard and pulsed Doppler tissue echocardiography were obtained in 44 patients with heart failure (mean left ventricular ejection fraction 24 +/- 7%) and in 30 age- and sex-matched healthy volunteers. The tricuspid annular systolic and diastolic velocities were acquired in apical four-chamber views at the junction of the right ventricular free wall and the anterior leaflet of the tricuspid valve using Doppler tissue imaging. Within 2 h of Doppler tissue imaging, the first-pass radionuclide ventriculogram, determining right ventricular ejection fraction and equilibrium gated radionuclide ventriculography single photon emission computed tomography, were performed in all patients.

RESULTS

In patients with heart failure, the peak systolic annular velocity was significantly lower and the time from the onset of the electrocardiographic QRS complex to the peak of systolic annular velocity was significantly greater than the corresponding values in healthy subjects (10.3 +/- 2.6 cm. s(-1) vs 15.5 +/- 2.6 cm.s(-1), P < 0.001, and 198 +/- 34ms vs 171 +/- 29 ms, P < 0.01, respectively). There was a good correlation between systolic annular velocity and right ventricular ejection fraction (r = 0.648, P <0.001). A systolic annular velocity < 11.5 cm.s(-1)predicted right ventricular dysfunction (ejection fraction < 45%) with a sensitivity of 90% and a specificity of 85%.

CONCLUSION

We conclude that the evaluation of peak systolic tricuspid annular velocity using Doppler tissue imaging provides a simple, rapid, and non-invasive tool for assessing right ventricular systolic function in patients with heart failure.

[Physical training in patients with chronic heart failure: functional fitness and the role of the periphery]

In recent years evidence is increasing on the usefulness of physical loads and controlled physical training in patients with chronic heart failure (CHSS). In the presented work the authors assessed changes of the functional capacity and muscular strength after training on a bicycle ergometer. The group comprised 38 patients with CHSS due to IHD or dilatation cardiomyopathy NYHA II-III, EF lower than 40%, with a peak oxygen consumption (pVO2) lower than 20 ml/kg/min. The group was subdivided in a random fashion to subjects participating in training (T) and the control group (K). The patients were subjected to clinical examination, examination by common laboratory methods, spiroergometry, dynamometry. By the puncture technique a specimen of the m. vastus lateralis was taken for histological and histochemical examination of the muscle. The patients trained on the bicycle ergometer three times per week for a period of eight weeks, one exercise session lasted 30 minutes and was at the level of the anaerobic threshold. After completion of the training period the examinations were repeated.

RESULTS

Before the onset of training the groups did not differ in any indicators. After termination of training they increased in group T: pVO2 from 18.9 +/- 4.8 to 22.13 +/- 15.72 ml/kg/min. (p < 0.0004), the oxygen consumption at the level of the anaerobic threshold (VO2AT) from 13.4 +/- 3.4 to 15.96 < or = 3.75 ml/kg/min. (p < 0.0006), the respiratory quotient (RQ) from 0.93 +/- v0.09 to 0.97 +/- 0.006 (p < 0.05), the maximal tolerated load from 0.72 +/- 0.72 to 1.08 +/- 0.33 W/kg (p <0.002), the maximal voluntary contraction of the femoral quadriceps muscle (MVC START) from 291.2 +/- 70.1 to 328.1 +/- 66.0 N (p<0.01), the maximal voluntary contraction of this muscle after 20 mins. of repeated contractions (MVC END) from 157.6 +/- 109 to 290.1 +/- 64.9 N (p < 0.01), the decrease of the maximal contraction after 20 minutes of repeated contractions was from 52.8 +/- 32.1 to 12.4 +/- 5.0% (p < 0.01). After training there were statistically significant differences between groups in VO2AT (p < 0.01), in pVO2 (p < 0.03) and in the decrement of the maximal muscular contraction (p < 0.01). The authors found a trend towards normalization of the diameter of muscle fibres I and II and of their ratio. The ventilation equivalent for carbon dioxide VE/VCO2 during the maximal tolerated load correlated significantly with the systemic and pulmonary vascular resistance, with RQ, VO2AT, pVO2, with the maximal tolerated load and with the blood level of prostaglandin F.

CONCLUSION

Controlled physical training in patients with CHSS was safe, led to a significant improvement of spiroergometric indicators, load tolerance and muscular strength. After training there was a trend towards normalization of pathological changes in skeletal muscle. Based on the authors' experience and findings of other authors it is advisable to recommend training as part of treatment of patients with CHSS.

[Physical training in patients with chornic heart failure: haemodynamics, effects]

The objective of the investigation is to assess the safety and contribution of physical training in patients with chronic heart failure and to assess the effect of training on central haemodynamics, left ventricular function evaluated by echocardiography and humoral substances.

PATIENTS AND METHODS

Patients with cardiac failure NYHA II and III incl. 17 on t he background of IHD and 21 on the background of dilatation cardiomyopathy. All patients had the ejection fraction below 40% and pVO2 below 20 ml/kg/min. They were divided into groups enagaged in training (T) and controls (K). Before training and after its termination the patients were subjected to clinical examination, basic laboratory tests, echocardiography amd dextrolateral catheterization at rest and during ergometry and levels of humoral agents were assessed. The training was pursued three times per week for a period of two months on a bicycle ergometer.

RESULTS

Before training there were no statistically significant differences between the groups. After training the groups did not differ in echocardiographic and haemodynamic parameters. In the training group there was as compared with the onset of the experiment a decline of the maximal median pressure (123.6 +/- 11.9 vs. 113 +/- 10.2 mm Hg, p < 0.04) the maximal pulse rate (112.5 +/- 18.7 vs. 108.4 +/- 20.1 p <0.02). In the control group, on the other hand there was an increase of big endothelin (52.2 +/- 4 9.1 vs. 88.0 +/- 76.7 pg/ml, p < 0.04) and an increase of pulmonary vascular resistance (102.8 +/- 71.7 vs. 149.2 +/- 69.5 dyn.s/cm5, p < 0.002).

CONCLUSION

Physical training was well tolertaed by patients, it led to a subjective improvement of their conditionn, to a reduction of the chronotropic response to a load and thus to more economical cardiac activity.

Rupture of the coronary artery after blunt nonpenetrating chest wall trauma detected by color Doppler echocardiography: a case report

We report a rare case of a ruptured papillary muscle of the anterior leaflet of the tricuspid valve and the rupture of the septal branch of the left anterior descending coronary artery with drainage into the right ventricle after blunt nonpenetrating chest wall trauma. Both abnormalities were detected by transthoracic 2-dimensional and color Doppler echocardiography, and the septal branch rupture was confirmed by coronary angiography. The leading echocardiographic sign of the rupture of the coronary artery was intramyocardial mosaic-colored flow, representing the turbulent high-velocity flow in the ruptured coronary artery. Hypokinesis of the anteroseptal myocardial segments and the presence of Q waves in leads V1 through 4 on the electro-cardiogram were suggestive of anteroseptal myocardial infarction. We conclude that the history of chest trauma, the electrocardiographic changes, and wall motion abnormalities should be stimuli for a careful color Doppler flow "mapping" of the myocardium for possible identification of a coronary artery rupture.

[Transplantation of the heart--indications, complications, therapy--our experience from investigations of 100 patients after cardiac transplantation]

Transplantation of the heart has become an accepted method for the treatment of terminal cardiac failure. Despite obvious advances in the care of patients after trasplantation a number of problems exist. The authors summarize their experience with the long-term follow-up of 100 adult patients with transplantations made in the Brno Centre of Cardiovascular and Transplantation Surgery. One-year survival in the group of patients is 80%, three-year survival 69%. The authors discuss indications and contraindications of cardiac transplantations, necessary preoperative and postoperative examinations, they follow-up the most serious complications during the posttransplantation period. They mention therapeutic possibilities and outline briefly the perspectives of care of patients after cardiac transplantation. Despite the number of problems encountered transplantation of the heart is for indicated patients with cardiac failure a unique chance to improve the prognosis of survival and the quality of life.

First dose hypotension after angiotensin converting enzyme inhibitor captopril and angiotensin II blocker losartan in patients with acute myocardial infarction

BACKGROUND

First dose hypotension after the administration of an angiotensin-converting enzyme inhibitor in patients with acute myocardial infarction is one of the most important adverse events of this type of treatment. There is no information about first dose hypotension after angiotensin type 1-receptor blocker in this type of patient.

AIM

To compare the first dose responses to low dose captopril and losartan in patients with acute myocardial infarction.

METHODS

Single blind, randomised, multicentric, prospective study. Patients (n=320) with confirmed acute myocardial infarction, age >18 years, treated by direct percutaneous transluminal coronary angioplasty, thrombolysis and/or heparin, were randomised to receive a single dose of 6.25-12.5 mg captopril or 12.5-25 mg losartan within 24 h of hospital admission. Baseline laboratory and clinical examinations were performed before entering the study. Blood pressure monitoring started at hospital admission and continued for at least 8 h after the medication (second dose of captopril was given after 8 h).

RESULTS

The maximal blood pressure fall appeared about 1 h after the first dose of captopril and 3.5 h after the first dose of losartan. Patients in the captopril group had significantly higher incidence of asymptomatic hypotension (38%) than patients treated with losartan (24%) (P<0.001). No difference in hypotension requiring a change in medication was observed.

CONCLUSION

Low dose of losartan is safe for initiating therapy in patients with acute myocardial infarction within 24 h of hospital admission.

Oral glycoprotein IIb/IIIa inhibition with orbofiban in patients with unstable coronary syndromes (OPUS-TIMI 16) trial

BACKGROUND

Although intravenous glycoprotein IIb/IIIa inhibitors are beneficial in patients with acute coronary syndromes, prolonged oral IIb/IIIa inhibition might provide an additional reduction in recurrent events.

METHODS AND RESULTS

Investigators at 888 hospitals in 29 countries enrolled 10 288 patients with acute coronary syndromes, which was defined as ischemic pain at rest within 72 hours of randomization, associated with positive cardiac markers, electrocardiographic changes, or prior cardiovascular disease. Patients received aspirin and were randomized to receive, for the duration of the trial, (1) 50 mg of orbofiban twice daily (50/50 group), (2) 50 mg of orbofiban twice daily for 30 days followed by 30 mg of orbofiban twice daily (50/30 group), or (3) a placebo. The primary composite end point was death, myocardial infarction, recurrent ischemia requiring rehospitalization, urgent revascularization, or stroke. The trial was terminated prematurely because of an unexpected increase in 30-day mortality in the 50/30 orbofiban group. Mortality through 10 months was 3.7% for the placebo group versus 5.1% in the 50/30 group (P=0.008) and 4.5% in the 50/50 group (P=0.11). There were no differences in the primary end point (22.9%, 23.1%, and 22.8%, for the placebo, 50/30, and 50/50 groups, respectively). Major or severe bleeding (but not intracranial hemorrhage) was higher with orbofiban; it occurred in 2. 0%, 3.7% (P=0.0004), and 4.5% (P<0.0001) of patients, respectively. Exploratory subgroup analyses found that patients who underwent percutaneous coronary intervention had a lower mortality and a significant reduction in the composite end point (P=0.001) with orbofiban.

CONCLUSIONS

-Fixed-dose orbofiban failed to reduce major cardiovascular events and was associated with increased mortality in this broad population of patients with acute coronary syndromes; however, a benefit was observed among patients who underwent percutaneous coronary intervention.

A comparison of intervention with losartan or captopril in acute myocardial infarction

AIM OF STUDY

Angiotensin-converting enzyme (ACE) inhibitors prolong life, lower the progression of heart failure, and decrease the need for hospitalizations in patients after myocardial infarctions. It is still unclear whether these effects could also be achieved by blocking the angiotensin II (ATII) type 1 receptor.

METHODS AND RESULTS

We randomized 201 patients with acute myocardial infarction treated with either direct angioplasty, thrombolysis, or heparin alone to the ACE inhibitor captopril or the ATII antagonist losartan. The primary endpoints were safety, tolerability, and left ventricular parameters. The patients were followed for at least 15 days. The incidence of severe adverse events was similar in both groups, although cough presented less often in the losartan group. Captopril failed to prevent an increase in end-diastolic volume and did not influence left ventricular end-systolic volume. This effect led to an increase in the left ventricular ejection fraction (P<0. 001) without a change in wall-motion index. Losartan did not affect end-diastolic volume but decreased end-systolic volume (P<0.001), resulting in a significant increase in left ventricular ejection fraction (P<0.001) and a decrease in wall-motion index (P<0.001).

CONCLUSION

This study suggests that losartan is safe and well tolerated in patients after myocardial infarction. ATII antagonists seem to have a more pronounced effect on left ventricular remodeling than ACE inhibitors.

MTHFR (C677T) polymorphisms and stage III colon cancer: response to therapy

BACKGROUND

Leucovorin and 5-fluorouracil (5-FU) chemotherapeutics are often used as coinhibitors of the thymidylate synthase pathway to thwart the growth of cancer cells in certain types of neoplasms. The metabolism of leucovorin is mediated through the enzyme methylenetetrahydrofolate reductase (MTHFR). A common polymorphism in the MTHFR gene has been reported to be responsible for as much as a 70% reduction in activity of this enzyme when present in the homozygous form.

METHODS AND RESULTS

A total of 51 stage III colon cancer patients were identified through our tumor registry. Non-neoplastic, archived tissue was obtained for each patient and subjected to MTHFR C677T PCR-RFLP genotyping. The MTHFR C677T allele was present in 32 patients (28 heterozygotes and 4 homozygotes). The remaining 19 patients carried only the wild-type allele. Overall survival was 42.10% (8/19) for wild types and 43.757% (14/32) for those with at least one C677T allele. Of the four homozygotes identified, three have succumbed to their cancer and one is alive with cancer.

CONCLUSIONS

We were unable to demonstrate a survival difference between those stage III colon cancer patients receiving leucovorin therapy that carried the MTHFR C677T allele and those that were wild type for this allele. The results of this study suggest that certain subgroups (ie, homozygotes) of patients may benefit from genotypic analysis of the MTHFR gene.

[Ultrasonic tissue characterisation in cardiology]

Ultrasonic tissue characterization is a relatively new non-invasive examination method the application of which in cardiology is steadily increasing. It is therefore the objective of the present work to summarize hitherto assembled knowledge on the use of this method in clinical practice. Ultrasonic tissue characterization uses scattering of ultrasonic waves which penetrate into the heart muscle. This scatter is due to particles inside the heart muscle, their size being smaller than the wave length of the incident ultrasonic undulation. Evaluation of the intensity of the backscatter makes it possible to evaluate structural and functional changes of the examined cardiac tissue. Ultrasonic tissue characterization is so far used in cardiology for evidence of myocardial ischaemia, for evaluation of structural myocardial changes with hypertrophic cardiomyopathy, to detect rejection after transplantation of the heart and in the diagnosis of myocarditis. Other possibilities for application of this method is assessment of the viability of the heart muscle, quantification of the amount of fibrous tissue in the heart muscle and differentiation of acute from chronic vegetation in patients with infectious endocarditis. Due to some limitations ultrasonic tissue characterization is in the majority of the mentioned indications rather a subsidiary method which can supplement the diagnosis and make it more accurate. Its future position will obviously depend on further technical improvement and simplification.

Humoral response in patients with chronic heart failure

AIM

Correlation of five humoral markers with laboratory, echocardiographic and right heart catheterization parameters in patients with chronic heart failure.

STUDY POPULATION

29 patients, heart failure NYHA II and III, ejection fraction below 40% with coronary artery disease or dilated cardiomyopathy.

METHODS

evaluation of thromboxane, prostaglandin F (PGF), tumor necrosis factor (TNF) alpha, endothelin-1 and big endothelin rest levels and their correlation with: (1) laboratory parameters: Sodium, urea, creatinine, fibrinogen, (2) chest X-ray: cardiothoracic index (CTI), pulmonary congestion, (3) right heart catheterization parameters at rest, hand-grip and bicycle ergometry: mean pulmonary artery pressure (AP), wedge pressure (WP), systemic and pulmonary vascular resistance (SVR, PVR) and cardiac index (CI), (4) echocardiographic parameters at rest, hand-grip and bicycle ergometry: end-diastolic volume (EDV), end-systolic volume (ESV), ejection fraction (EF), mitral flow E/A, filling period of left ventricle and time of duration of mitral regurgitation.

RESULTS

No correlation was found between thromboxane, prostaglandin F and tumor necrosis factor alpha with the above mentioned parameters. Endothelin-1 level correlated with E/A, PVR and MPA at rest and at hand-grip. Big endothelin level correlated with EDV and ESV, AP, WP and SVR at rest and at both types of exercise. The highest correlation was between big endothelin and rest AP (r=0.79), rest WP (r=0.78) and CTI (r=0.58), all P<0.01.

CONCLUSIONS

Big endothelin and partly endothelin-1 levels showed a close correlation with some parameters used for the evaluation of chronic heart failure severity.

Relationship between kidney function, hemodynamic variables and circulating big endothelin levels in patients with severe refractory heart failure

Fluid retention is a major characteristic of symptomatic, progressive heart failure when a main factor implicated in the pathogenesis of renal dysfunction is renal hypoperfusion. This may be a consequence of forward cardiac failure, resulting in a low cardiac output integrating poor left ventricular function secondary to myocardial impairment and increased resistance in the regional renal vasculature secondary to locally released vasoconstrictors, e.g. endothelin. So far, the role of the pulmonary circulation in perpetuating renal dysfunction in heart failure is unclear.

METHODS

We investigated the relationship of hemodynamic variables obtained during right heart catheterization and plasma big endothelin levels to renal function variables in 18 male patients aged 52 +/- 3 years, with heart failure in the NYHA function class III-IV, based on idiopathic causes in 8 and ischemic causes in 10 patients. Renal plasma flow (RPF) was established by paraaminohippurate (PAH) clearance and the glomerular filtration rate (GFR) was measured by iothalamate clearance.

RESULTS

Plasma big endothelin (ET) levels were increased above the upper normal range (1.8 fmol/ml) in 16 out of 18 patients, averaging 5.0 +/- 0.8 fmol/ml (1.7-11.9 fmol/ml). Positive correlations to big ET plasma levels were detected with mean pulmonary pressure (r = 0.73, p < 0.001) pulmonary capillary wedge pressure (r = 0.56, p < 0.05) and pulmonary vascular resistance index (r = 0.69, p < 0.01). Glomerular filtration rate (70 +/- 7 ml/min) and renal plasma flow (358 +/- 36 ml/min) were considerably reduced and exhibited a tendency to correlate inversely with big ET levels (r = -0.46, p = 0.056 and r = -0.44, p = 0.069, respectively). Contrary to expectations, RPF did not correlate significantly with cardiac index, systemic vascular resistance index or arterial blood pressure. In contrast, significant correlations were detected of RPF with pulmonary capillary wedge pressure (r = -0.69, p < 0.01), mean pulmonary artery pressure (r = -0.65, p < 0.01), right atrial pressure (r = -0.47, p < 0.05) and right ventricular ejection fraction (r = 0.49, p < 0.05).

CONCLUSION

The findings suggest a role for endothelin in renal vasoconstriction and accord well with the concept that in severe heart failure renal hypoperfusion--by volume retention--as well as increased endothelin synthesis--by pulmonary vasoconstriction--play a part in the increased pulmonary filling pressures.

[Fluvastatin in patients after heart transplantation]

Hyperlipoproteinaemia is one of the frequent posttransplantation problems. Administration of statins is complicated in patients after transplantation by concurrent imunosuppressive treatment, in particular by possible undesirable interaction with cyclosporin. In the presented study 15 patients after transplantation of the heart with hyperlipoproteinaemia were examined who were on a standard triple combination of immunosuppressive drugs. Fluvastatin was administered, 20 mg in the evening, and in intervals of 6 weeks, 3 months and 6 months after the onset of treatment the levels of cholesterol, LDL and HDL-cholesterol, triglycerides, urea, creatinine, liver terts and cyclosporine were followed up. The mean cholesterol level declined from 7.66 mmol/l during the 6rd week (p < 0.002), to 6.01 mmol/l during 3rd month and to 5.83 mol/l after the 6rd month (p < 0.001), LDL-cholesterol declined from 4.82 mmol/l and then 3.46 mmol/l and 3.31 mmol/l (p < 0.001). In the other investigated parameters no change recorded, incl. the cyclosporin levels. No clinical signs of muscular damage were recorded Fluvastatin thus does not only reduce effectively the cholesterol and LDL-cholesterol level but is also safe combination with immunosuppressive treatment.

Can dobutamine echocardiography induce myocardial damage in patients with dysfunctional but viable myocardium supplied by a severely stenotic coronary artery?

In animal experiments, dobutamine infusion was found to impair the oxygen supply-demand balance in hypoperfused areas of hibernating myocardium which may induce myocardial damage. The aim of our study was to assess whether dobutamine echocardiography can induce myocardial damage detected by an increase in the cardiac troponin T level in blood. Twenty seven patients with coronary artery disease and severe stenosis of at least one major coronary artery (> or = 90% of luminal diameter narrowing) supplying dysfunctional myocardial segments underwent dobutamine echocardiography. Dobutamine was infused in 3 min dose increments of 5, 10, 20, 30, and 40 microg per kg body weight per minute with the addition of atropine up to 1 mg if ischemia or an 85% predicted maximal heart rate were not achieved. In 15 patients the protocol with prolonged application of 40 microg per kg per minute of dobutamine for 6 min and for the next 5 min with the addition of atropine was used. To exclude minor myocardial damage, an increase in the cardiac troponin T blood level was assessed qualitatively by the TROP T sensitive Rapid Test 20 h after dobutamine echocardiography. In 20 patients the dysfunctional segments were found to be viable with inducible ischemia exhibiting either continuous worsening in systolic thickening or "biphasic" response characterised by the improvement of their systolic thickening with a small dose and by a worsening of the thickening with a high dose of dobutamine. No patient exhibited positive TROP T sensitive Rapid Test result. In patients with coronary artery disease and severe stenosis of a major coronary artery supplying dysfunctional but viable myocardial segments, dobutamine echocardiography does not induce myocardial damage detectable by an increase in cardiac troponin T level.

Systolic and diastolic function in patients with chronic heart failure at rest and during exercise

In our study we tried to evaluate systolic and diastolic function in patients with chronic heart failure (CHF) by using some echocardiographic parameters and invasively measured pulmonary capillary wedge pressure (PCWP). We studied 19 patients with CHF NYHA II-III at rest, at the end of isometric exercise (handgrip) and during a bicycle stress test. Right heart catheterization and echocardiography were simultaneously performed. We measured exchange of blood gases, end diastolic volume (EDV), end systolic volume (ESV), ejection fraction (EF), peak E velocity, peak A velocity, E/A ratio, deceleration time of E wave (DT), time of mitral regurgitation (MR) and effective filling period of left ventricle (FP). We divided patients according to the median of PCWP at rest into two groups: group A with PCWP< or =11 mmHg (10 pts), group B with PCWP>11 mmHg (9 pts). In group A mean PCWP at rest was 6+/-2 mmHg, during handgrip 12+/-4 mmHg and during bicycle exercise 18+/-6 mmHg. In group B mean values of PCWP were 19+/-6 mmHg, 26+/-11 mmHg and 33+/-5 mmHg, respectively. All values were significantly higher in group B (P<0.01). There was a significant difference in pVO2: in group A 18.8+/-3.5 vs. 14.7+/-3.3 ml/kg per min in group B (P<0.03). No differences between the groups were noticed in EDV, ESV and EF. The E/A ratio in group A was less than 1, in group B greater than 1 with the restrictive pattern. No differences between the groups were observed in MR and FP at rest. During bicycle exercise, MR was significantly longer (284+/-98 vs. 164+/-79 ms; P<0.05) and FP shorter (322+/-99 vs. 421+/-74 ms; P<0.05) in group B than in group A. The functional capacity of patients with CHF is influenced not only by EF and other systolic variables, but also by filling conditions. The duration of effective diastole may be one of the most important of them.

[Acute and chronic heart failure]

Cardiac failure is a syndrome which comprises ventricular dysfunction (confirmed by echocardiography) and compensating mechanisms (immediate activation of the sympathetic nerve and functioning of Starling's mechanism, within hours or days activation of RAAS within days or weeks hypertrophy of the heart). Cardiac failure develops rapidly either in a previously healthy subject (first extensive IM, diffuse myocarditis, acute aortic or mitral regurgitation) or in a damaged heart (IHD, KMP, defect) as a result of sudden excessive burdening (ischaemia, arrythmia, infection, surgery etc.) or spontaneously (end-stage). It is manifested above all by "backward" failure (pulmonary oedema). The pulmonary pressure must be rapidly reduced: i.v. nitrovasodilators act immediately, i.v. furosemide acts within 10-15 min. (in can, however, reduce the circulating volume which has not increased during the first failure). Also O2, anodynes. In the subacute stage (without any precise time limits) which may develop in serious cases from acute failure, or develop as a result of deterioration of chronic failure, in addition to congestion, symptoms caused by "forward" failure are in the foreground. These are symptoms caused by a reduced minute output and hyperfusion of tissue. It is indicated to administer substances which improve work tolerance, i.e. positive inotropics (digitalis, beta-agonist or phosphodiesterase inhibitors). If the blood pressure drops, a combination of dopamine and dobutamine should be administered; if the respiratory volume drops, artificial pulmonary ventilation, in case of persisting oedema continuous arteriovenous haemofiltration, in severe failure intraaorrtic balloon contrapulsation etc. In an irreversible state urgent or elective orthoptic transplantation of the heart should be considered. In chronic heart failure an important component of comprehensive treatment is in addition to treatment of congestion and hypoperfusion, prevention of "cardiovascular remodelling" by means of angiotensin convertase inhibitors etc. Which improve the quality of life and survival. Arrhythmias are an independent prognostic factor.