SUN-039 Characterization of Human Adrenal Steroidogenesis during Fetal Development

Context: The endocrine function of human fetal adrenals (HFA) is activated already during first trimester, but changes in adrenal steroidogenesis during fetal life are not well characterized. Objective: This study aimed to investigate HFA steroidogenesis by analyzing adrenal glands from 1^st and 2^nd trimester. Design and Setting: Male and female HFA samples from gestational week (GW) 8-19 were examined, including a total of 101 samples from 83 fetuses. Main Outcome Measure(s): Expression level of steroidogenic genes and protein expression/localization were determined by quantitative PCR and immunohistochemistry, respectively, and intra-adrenal steroid levels were quantified by LC-MS/MS. Results: Transcriptional levels of StAR, CYP11A1, CYP17A1, CYP21A2, CYP11B1/2 and SULT2A1 was significantly higher in 2^nd trimester compared with 1^st trimester (P<0.05), while expression levels of 3β-HSD2 and ARK1C3 were unaltered between GW 8-19. All investigated steroidogenic proteins were expressed in a distinct pattern throughout GW 8-19 with most enzymes expressed primarily in the fetal zone, except 3β-HSD1/2 which was mainly expressed in the definitive zone. The abundant steroidogenic enzyme expression was reflected in overall high intra-adrenal tissue concentrations of mineralocorticoids, glucocorticoids, and androgens; cortisol was the most abundant (1,071-2,723 ng/g tissue, in average) and testosterone levels the lowest (2-14 ng/g tissue, in average). Conclusions: The expression profiles of HFA steroidogenic enzymes are distinct from 1^st to 2^nd trimester, with no major differences between male and female samples. The intra-adrenal steroid hormone concentrations confirms that cortisol is produced throughout 1^st and 2^nd trimester, suggesting continued regulation of the HPA axis during this entire period.

Late coronary stent thrombosis

Coronary stent thromboses are characterized as early, if they occur within one month of the index PCI. Late stent thromboses (LST) have an occurrence after one month. Both early and late stent thromboses are a major concern in PCI, because of their clinical presentation as acute myocardial infarction and sudden cardiac death. Early stent thromboses are seen following implantation with bare metal (BMS) and drug eluting (DES) stents. Late occurring stent thromboses (LST) are rare but usually severe events and primarily seen after DES implantation. A number of pathogenetic mechanisms seem to be operating and there will probably be major differences between different types DES and the risk of LST. While early stent thrombosis is primarily related to stent implantation techniques, lesion characteristics and the effect of double platelet therapy, there is emerging evidence that very late stent thrombosis, occurring more than one year after the implantation may be caused by local tissue reaction to the polymers of sirolimus and paclitaxel eluting stents. It is likely that the use of new generations DES with tissue friendly polymers or bioabsorbable polymers will reduce the risk of late stent thrombosis.

Spontaneous coronary artery dissection: a Western Denmark Heart Registry study

BACKGROUND

Spontaneous coronary artery dissection (SCAD) is a rare cause of acute coronary syndrome (ACS) that associates with a high acute-phase mortality rate, whereas long-term outcome is less well described.

OBJECTIVE

To describe the incidence, predictors, and prognosis of SCAD.

DESIGN

Retrospective case-identification study from the Western Denmark Heart Registry and the database of the Forensic Institute at Aarhus University from 1999 through 2007.

RESULTS

SCAD was documented in 22 of 32,869 (0.7 per thousand) angiograms in the angiographic registry. The SCAD incidence among cases of ACS was 22 of 11,175 (2.0 per thousand). None was seen in the forensic database. The mean age was 48.7 +/- 8.9 years (range: 37-71 years). Females constituted 17 of 22 (77%) patients and all had undergone one or more pregnancies; two cases occurred in the postpartum period. The left descending artery (LAD) was the predominant site of entry. The age distribution, prevalence of the cardiovascular risk factors, presence of coronary atherosclerosis, and entry of the dissection were comparable among genders. Treatment was percutaneous coronary intervention in 13 of 22 (59%), coronary artery bypass operation in 2 of 22 (9%), and medical treatment in 7 of 22 (32%) patients. The mean follow-up period was 3.6 +/- 2.9 years. One patient suffered from recurrent SCAD; another patient died suddenly. The MACE- (cardiac death, nonfatal myocardial infarction, and new revascularization) free survival was 81% after 24 months.

CONCLUSION

SCAD is a rare disease that mainly affects younger women. Compared with earlier reports, the prognosis seems to be improved by early diagnosis and interventional treatment.

Echocardiographic-determined left ventricular wall characteristics in insulin-dependent diabetic patients

Left ventricular wall mass, thickness and movement were investigated by echocardiography in 80 insulin-dependent diabetic patients with no signs of ischaemic heart disease and in 40 healthy controls. In diabetics with a disease duration of greater than 30 yr, urinary albumin excretion rate greater than 200 micrograms/min (clinical nephropathy), proliferative retinopathy or autonomic neuropathy, both the posterior wall thickness and the septal thickness were increased compared to controls. The posterior wall thickness and the septal thickness were positively correlated to blood pressure (p less than 0.001), disease duration (p less than 0.001), urinary albumin excretion rate (p less than 0.001), and negatively correlated to the heart variation during deep respiration (p less than 0.01). The left ventricular wall mass was correlated to both blood pressure (p less than 0.01) and urinary albumin excretion rate (p less than 0.01). By multiple regression analysis urinary albumin excretion rate, disease duration and heart rate variation during deep respiration did not add significantly to the correlation between left ventricular wall mass/wall thickness and blood pressure. The septal movement was reduced in diabetics with proliferative retinopathy or clinical nephropathy. In conclusion, left ventricular wall thickness and wall mass were closely related to blood pressure in insulin-dependent diabetics. Signs of impaired cardiac function, such as reduced septal movement, were seen only in patients with severe microvascular disease.

Vasospastic angina assessed by hyperventilation-thallium-201 myocardial scintigraphy

The response to prolonged hyperventilation (HVT) was evaluated by electrocardiography (HVT-ECG) and thallium-201 myocardial scintigraphy (HVT-Tl-Sc) in 40 patients suspected of vasospastic angina. Both tests showed ischaemic changes in 16 patients and no changes in 20 patients. Two patients had abnormal HVT-ECG and normal HVT-Tl-Sc, and the reverse combination was found in two patients. Prolonged HVT was performed in 14 patients during coronary angiography (CAG). Nine developed transient total or subtotal occlusion in one of the major coronary arteries, all of whom had ischaemic HVT-ECG and eight had abnormal HVT-Tl-Sc. In the five patients without spasm at CAG four had normal HVT-ECG and all five normal HVT-Tl-Sc. Our data suggest that HVT-ECG and HVT-Tl-Sc have essentially the same sensitivity and specificity in detecting vasospastic angina.

A hyperkinetic heart in uncomplicated active acromegaly. Explanation of hypertension in acromegalic patients?

Cardiac function was studied by echocardiography in 12 patients with active acromegaly and in 12 age- and sex-matched healthy control subjects. None of the patients had cardiovascular diseases or other endocrine diseases than acromegaly. The patients had a mean age of 39 +/- 5 years and were short-term acromegalic with a mean duration of disease of 6 +/- 3 years. Mean left ventricular mass was 163 +/- 43 g/m2 in the acromegalic group versus 120 +/- 24 g/m2 in the control group. Preload (the diastolic diameter of the left ventricle) was within normal limits, while afterload (end-systolic meridional wall stress) was significantly decreased in the acromegalic group. Myocardial contractility assessed as fractional shortening of the left ventricle was 39.9 +/- 3.6% in the acromegalic group versus 32.9 +/- 5.1% in the control group, and cardiac output was increased by 52% in the acromegalic group because of increased heart rate and stroke volume. We suggest that augmented peripheral blood flow is responsible for the condition of cardiac hyperkinesia in short-term acromegaly and involved in the development of hypertension, which is a frequent complication of long-term acromegaly.

Myocardial infarction centres: the way forward

In the era of primary PCI, a strategy of admitting patients to the nearest hospital should be obsolete. Instead, a prehospital diagnostic strategy should be implemented in order to: (1) refer patients directly to interventional centres, thereby eliminating delay at local hospitals; (2) alert the interventional centre, thereby reducing door to balloon times; (3) initiate adjunctive medication in the prehospital phase.

Magnetic resonance imaging seems safe in patients with intracoronary stents

We elucidated whether exposure to cardiac magnetic resonance imaging (MRI) of patients with implanted intracoronary stents is associated with increased risk of stent-thrombosis, stent-restenosis, or other cardiovascular complications. Forty-seven patients admitted with acute myocardial infarction (AMI) were studied. Twenty-three were included in a serial cardiac MRI study, using 1.5-T scanners with standard gradient systems. The remaining patients were control subjects who were matched for age and gender with the MRI group. All patient had intracoronary stents implanted in connection with primary angioplastic treatment (PTCA) of AMI (n = 21), secondary PTCA procedures due to recurrent angina (n = 22), or both (n = 4). In the MRI group (n = 23, aged 58 +/- 10 yr), MRI was carried out one to five times in each patient a median of 166 days (range, 1-501) after stent implantation. The control group comprised 24 patients, ages 59 +/- 11 yr. The incidences of stent-thrombosis, stent-restenosis, and other cardiovascular complications did not differ statistically significantly between the two groups. In the MRI group, stent-related thrombosis (n = 1) or restenosis (n = 7) was observed in eight cases a median of 102 days (range, 7-547) after MR examination and a median of 318 days (range, 138-713) after stent implantation, compared with nine cases in the control group (thrombosis, n = 1; restenosis, n = 8) observed a median of 147 days (range, 1-267) after stent implantation. No acute thromboembolic or other complication occurred in immediate connection with MRI. The follow-up time was 21.3 +/- 4.5 months. This small study shows no evidence of an MRI-related risk of stent-restenosis or other cardiovascular complications, not even if cardiac MRI is performed early after stent implantation.

Electromechanical mapping for detection of myocardial viability in patients with ischemic cardiomyopathy

BACKGROUND

We evaluated the ability of electromechanical mapping of the left ventricle to distinguish between nonviable and viable myocardium in patients with ischemic cardiomyopathy.

METHODS AND RESULTS

Unipolar voltage amplitudes and local endocardial shortening were measured in 31 patients (mean+/-SD age, 62+/-8 years) with ischemic cardiomyopathy (ejection fraction, 30+/-9%). Dysfunctional regions, identified by 3D echocardiography, were characterized as nonviable when PET revealed matched reduction of perfusion and metabolism and as viable when perfusion was reduced or normal and metabolism was preserved. Mean unipolar voltage amplitudes and local shortening differed among normal, nonviable, and viable dysfunctional segments. Coefficient of variation for local shortening exceeded differences between groups and did not allow distinction between normal and dysfunctional myocardium. Optimum nominal discriminatory unipolar voltage amplitude between nonviable and viable dysfunctional myocardium was 6.5 mV, but we observed a great overlap between groups. Individual cutoff levels calculated as a percentage of electrical activity in normal segments were more accurate in the detection of viable dysfunctional myocardium than a general nominal cutoff level. The optimum normalized discriminatory value was 68%. Sensitivity and specificity were 78% for the normalized discriminatory value compared with 69% for the nominal value (P:<0.02).

CONCLUSIONS

Endocardial ECG amplitudes in patients with ischemic cardiomyopathy display a wide scatter, complicating the establishment of exact nominal values that allow distinction between viable and nonviable areas. Individual normalization of unipolar voltage amplitudes improves diagnostic accuracy. Electroanatomic mapping may enable identification of myocardial viability.

Six months' clinical and angiographic follow-up of a flexible, coiled stainless steel stent in long, native coronary artery lesions

This study was conducted to evaluate the short- and long-term clinical and angiographic results of implantation of a flexible, coiled stainless steel stent, the Freedom Coronary Stent. During the study period this stent was used as an alternative to the Palmaz-Schatz PS153 coronary stent in long or tortuous lesions. The study was designed as a prospectively planned outcome analysis. Implantation of Freedom stents was attempted in 62 consecutive patients (56% males, mean age 63+/-10 years) with a total of 65 coronary lesions. Indications for stent implantation were: restenosis, 8%; recoil, 26%; visible dissection, 32%; threatening occlusion, 15%; chronic total occlusion, 18%. The average stent length was 30+/-16 mm and 67% of the lesions were type C. Rate of successful stent implantation, acute complications, angiographic restenosis after 6 months and major cardiac events (death, myocardial infarction, target vessel revascularization) during follow-up were assessed. The success rate of stent implantation was 94%. One patient died after an emergency bypass operation and one patient suffered a subacute stent thrombosis, which was successfully treated with re-percutaneous transluminal coronary angioplasty (PTCA). There were no Q- or non-Q myocardial infarctions. Clinical follow-up was carried out in 56 patients (97%) and 57 vessels were assessed by angiography (93%). Mean length of the follow-up period was 6.8+/-2.3 months. During the 6 months' follow-up period, one patient died, two patients suffered an acute non-Q myocardial infarction and eight patients had revascularization of the target vessel. Major cardiac event rate for all patients where stent implantation was intended was 23%. Angina CCS class declined from 3.0+/-0.9 to 1.1+/-0.8 (p < 0.01) before PTCA to follow-up. Overall restenosis rate was 28%. In 14 lesions with a stented segment length of <20 mm, the restenosis rate was 21%; in 31 lesions with a stented segment length > or =20 and <30 mm, the restenosis rate was 26%; and in 13 lesions with a stented segment length of > or =30 mm, the restenosis rate was 42%. Although there was a high procedural success rate after implantation of the Freedom stent in long or tortuous lesions, problems with high restenosis rates in long lesions remain unresolved.

Percutaneous transluminal coronary angioplasty versus thrombolysis in acute myocardial infarction

The aim of this study was to evaluate the outcome of primary percutaneous transluminal coronary angiography (PTCA) in the treatment of acute myocardial infarction (AMI) The study included patients with electrocardiographic signs of transmural AMI, symptom duration of less than 12 h, and with no contraindications to thrombolytic therapy. Patients who had undergone primary PTCA were matched consecutively, for age, gender, infarct localization and duration of symptoms, to patients who had received thrombolytic therapy (82 patients to each group). Patients who were admitted to hospital during daytime had a primary PTCA, whereas those admitted outside daytime were given thrombolytic therapy. In the primary PTCA group, 9 patients had a combined endpoint compared with 22 patients in the thrombolysis group (p < 0.02 ). In-hospital mortality was 3.7% in the PTCA group and 4.9% in the thrombolysis group (ns). At six months, a combined endpoint occurred in 23 patients in the primary PTCA group and in 50 patients in the thrombolysis group (p < 0.00005). Six months' mortality was 4.9% in the PTCA group and 7.3% in the thrombolysis group (ns). Among patients in the PTCA group, left ventricular ejection fraction was significantly higher, stay in hospital was shorter and there were significantly fewer incidences of heart failure and severe arrhythmias than among patients in the thrombolysis group. The results of primary PTCA implemented in our departments are comparable with those reported in randomized trials from experienced centres. Our study indicates that patients treated with primary PTCA have fewer complications, a better left ventricular systolic function and a shorter hospital stay compared with patients treated with thrombolysis.

[Percutaneous transluminal septal myocardial ablation in hypertrophic obstructive cardiomyopathy. A new therapeutic option]

We here report on the PTSMA results in four HOCM patients having severe symptoms despite medical treatment and dual chamber pacing. Between two and five ml of ethanol was injected in one or two septal branches from the left coronary artery. Six months after treatment the pressure gradient across the left ventricular outflow tract was reduced between 25-80 mmHg at rest and between 55-180 mmHg at exercise. There was an increase in functional capacity of about two NYHA-classes. Two patients developed permanent right bundle branch block, and one patient with pre-existing left bundle branch block developed persistent total atrioventricular block after the treatment. Serum creatine phosphokinase MB increased on average to 146 U/l. No other complications were seen. In conclusion, our initial PTSMA results seems promising.

Functional significance of recruitable collaterals during temporary coronary occlusion evaluated by 99mTc-sestamibi single-photon emission computerized tomography

OBJECTIVES

The present study evaluated the impact of recruitable collaterals on regional myocardial perfusion measured by 99mtechnetium (Tc)-sestamibi single-photon emission computerized tomography (SPECT) during temporary coronary occlusion and related these estimates to the coronary wedge pressure and electrocardiographic (ECG) ST-segment changes.

BACKGROUND

Clinical variables (angina and ECG changes) and intracoronary flow and pressure recordings have indicated a protective role of recruitable collaterals on myocardial perfusion during percutaneous transluminal coronary angioplasty (PTCA).

METHODS

Thirty patients (mean age 55 years, SD 9; 20 men) with stable angina pectoris and proximal nonocluding single-vessel left anterior descending coronary artery (LAD)-stenosis scheduled for PTCA were included. Visualization of recruitable collaterals by ipsilateral and contralateral contrast injection, registration of coronary wedge pressure and injection of 99mTc-sestamibi during 90-s LAD occlusions were undertaken. A rest perfusion study was performed within four days before PTCA. As an estimate of the severity of regional hypoperfusion during occlusion, an occlusion/rest count ratio was calculated (mean defect pixel count during occlusion divided by mean pixel count in identical regions at rest).

RESULTS

The scintigraphic occlusion/rest count ratio was higher in patients with recruitable collaterals (n = 16), 67 +/- 11%, compared to patients without collaterals (n = 14), 60 +/- 6% (p < 0.05). The occlusion/rest count ratio correlated with the coronary wedge pressure (R2 = 0.34; p < 0.001). The occlusion/rest count ratio was lower, 61 +/- 6%, in patients with ST-segment elevation (n = 23) versus 74 +/- 9% in patients without ST-segment elevation (n = 7) (p < 0.0001).

CONCLUSIONS

Using 99mTc-sestamibi SPECT imaging during brief episodes of coronary occlusion, the severity of regional myocardial hypoperfusion was reduced by the presence of recruitable collaterals in a selected patient population with proximal LAD stenoses. Our results demonstrate a protective effect of recruitable collaterals on myocardial perfusion during temporary coronary occlusion.

Arterial thromboembolism in patients with sick sinus syndrome: prediction from pacing mode, atrial fibrillation, and echocardiographic findings

OBJECTIVE

To evaluate whether thromboembolism in sick sinus syndrome can be predicted by pacing mode, atrial fibrillation, or echocardiographic findings.

METHODS

Patients were randomised to single chamber atrial (n = 110) or ventricular (n = 115) pacing. They were divided into subgroups with and without brady-tachy syndrome at time of randomisation. The occurrence of atrial fibrillation and thromboembolism during follow up were investigated and compared with echocardiographic findings.

RESULTS

The annual risk of thromboembolism was 5.8% in patients with brady-tachy syndrome randomised to ventricular pacing, 3.2% in patients without brady-tachy syndrome randomised to ventricular pacing, 3% in patients with brady-tachy syndrome randomised to atrial pacing, and 1.5% in patients without brady-tachy syndrome randomised to atrial pacing. In atrial paced patients without brady-tachy syndrome at randomisation and without atrial fibrillation during follow up, the annual risk of thromboembolism was 1.4%. Left atrial size measured by M mode echocardiography was of no value in predicting thromboembolism.

CONCLUSIONS

Arterial thromboembolism in patients with sick sinus syndrome is very common and is associated primarily with brady-tachy syndrome at randomisation and with ventricular pacing. The risk of thromboembolism is small in atrial paced patients in whom atrial fibrillation has never been documented.

[Single-chamber atrial pacing is better than single chamber ventricular pacing in patients with sick sinus syndrome. Results of long-term follow up in a prospective randomized study]

In a study of 225 patients with sick sinus syndrome randomized to single chamber atrial pacing (n = 110) or ventricular pacing (n = 115), atrial pacing was associated with less atrial fibrillation and thromboembolism after 3.3 years follow-up. To determine whether this beneficial effect of atrial pacing is maintained at long-term, follow-up was extended. Follow-up visits were at 3 months, 12 months, and then once every year, and included physical examination, ECG, and pacemaker check-up. After 5.5 years follow-up, all-cause mortality, cardiovascular deaths, atrial fibrillation, thromboembolism, and heart failure were significantly less in the atrial group. AV block occurred in four patients in the atrial group. The beneficial effect of atrial pacing observed previously is enhanced substantially after extended follow-up. Patients with sick sinus syndrome should be treated with an atrial pacing system.

Atrioventricular conduction during long-term follow-up of patients with sick sinus syndrome

BACKGROUND

It has been claimed that patients with sick sinus syndrome have an increased risk of developing AV block, but this has never been assessed prospectively. The aim of the present study was to evaluate in a prospective trial AV conduction during the long-term follow-up of patients with sick sinus syndrome.

METHODS

Two hundred twenty-five consecutive patients with sick sinus syndrome and intact AV conduction were randomized to undergo single-chamber atrial pacing (110 patients) or single-chamber ventricular pacing (115 patients). Follow-up after 3 months and then yearly included measurement of the PQ interval and, in patients with atrial pacemakers, determination of the atrial stimulus-Q intervals at pacing rates of 100 and 120 bpm. The occurrence of AV block in the atrial group was recorded. During follow-up (mean, 5.5+/-2.4 years), there was no change in PQ interval in either group and no change in atrial stimulus-Q intervals or Wenckebach block point in the atrial group. Four of 110 patients in the atrial group developed grade 2 to 3 AV block that required upgrading of the pacemaker (0.6% per year). Two of these 4 patients had right bundle-branch block at pacemaker implantation.

CONCLUSIONS

AV conduction, estimated as PQ interval and atrial stimulus-Q interval at atrial pacing rates of 100 and 120 bpm and the Wenckebach block point, remains stable during long-term follow-up. Thus, treatment with single-chamber atrial pacing is safe and can be recommended to patients with sick sinus syndrome without bundle-branch block.

[Percutaneous transluminal coronary angioplasty in acute myocardial infarction. A prospective controlled study]

In the present study we compared the outcome of primary percutaneous coronary angioplasty (PTCA) (PTCA without prior or concomitant administration of thrombolytic drugs) in 82 consecutive patients with acute myocardial infarction (AMI) with the outcome of 82 AMI patients, who were treated with intravenous thrombolysis. The thrombolysis patients were prospectively matched to the angioplasty patients regarding age, sex, duration of symptoms and infarct localisation. The in-hospital mortality was 3.7% in the PTCA group versus 4.9% in the thrombolysis group. Thrombolysis-treated patients had increased use of diuretics and ACE-inhibitors as compared to PTCA-treated patients. The mean ejection fraction was 52 +/- 11% in the PTCA group versus 47 +/- 10% (p = 0.01) in the thrombolysis group. We conclude that initial Danish experience with primary PTCA is promising, and that this treatment may favourably affect the outcome of acute myocardial infarction.

The Barath Cutting Balloon versus conventional angioplasty. A randomized study comparing acute success rate and frequency of late restenosis

In a randomized multicenter study initial success rate and 6 months' follow-up were compared between coronary angioplasty performed with the Barath Cutting Balloon (group A, n = 32) and conventional balloons (group B, n = 32) in patients with type A or B lesions in native coronary arteries. The culprit lesion was not reached in one patient in group A. Initial success rates were similar with and without additional stenting (8 in group A and 10 in group B). Angiographic follow-up data (in 95%) revealed a non-significant improvement in minimal lumen diameter, diameter stenosis in group A. Restenosis developed in 16.7% of group A vs 25.8% of group B, (p = 0.57). A separate analysis of stented patients showed no restenosis in group A and restenosis in 4 out of 10 patients in group B (p = 0.10). A possible beneficial effect of the Cutting Balloon with respect to in-stent restenosis requires further studies.

Heart failure and echocardiographic changes during long-term follow-up of patients with sick sinus syndrome randomized to single-chamber atrial or ventricular pacing

BACKGROUND

In patients with sick sinus syndrome, choice of pacing mode has been implicated in the development of congestive heart failure.

METHODS AND RESULTS

A total of 225 consecutive patients with sick sinus syndrome and intact atrioventricular conduction were randomized to either single-chamber atrial pacing (n = 110) or single-chamber ventricular pacing (n = 115). Clinical assessment included New York Heart Association classification, medication, and M-mode echocardiography before pacemaker implantation, after 3 months, and subsequently once every year. At long-term follow-up (mean, 5.5+/-2.4 years), NYHA class was higher in the ventricular group than in the atrial group (NYHA class I/II/III/IV: 65/44/4/0 versus 84/22/2/1 patients, P=.010). Increase in NYHA class during follow-up was observed in 35 of 113 patients in the ventricular group versus 10 of 109 in the atrial group (P<.0005). Increase in dose of diuretics from randomization to last follow-up was significantly higher in the ventricular group than in the atrial group (21+/-49 versus 8+/-42 mg furosemide/d, P=.033). The left ventricular fractional shortening decreased significantly in the ventricular group (from 0.36+/-0.12 to 0.31+/-0.08, P<.0005) but not in the atrial group (from 0.35+/-0.13 to 0.33+/-0.09, P=.087). The left atrial diameter increased significantly in both treatment groups (ventricular group: from 34+/-7 to 41+/-7 mm, P<.0005; atrial group: from 34+/-6 to 37+/-7 mm, P=.002), but the increase was significantly higher in the ventricular group than in the atrial group (P<.0005).

CONCLUSIONS

During long-term follow-up, ventricular pacing is associated with a higher incidence of congestive heart failure and consumption of diuretics than atrial pacing. This is accompanied by a decrease in left ventricular fractional shortening and an increased dilatation of the left atrium in the ventricular paced patients.

Long-term follow-up of patients from a randomised trial of atrial versus ventricular pacing for sick-sinus syndrome

BACKGROUND

In a previous study of 225 patients with sick-sinus syndrome randomised to either single-chamber atrial pacing (n=110) or single-chamber ventricular pacing (n=115), we found that after a mean follow-up of 3.3 years, atrial pacing was associated with significantly less atrial fibrillation and thromboembolism whereas there was no significant difference in mortality and heart failure between the two groups. We aimed to find out whether this beneficial effect of atrial pacing is maintained during extended follow-up of up to 8 years.

METHODS

Follow-up visits for all patients were at 3 months, 12 months, then once a year at which patients had a physical examination, ECG recording, and pacemaker check-up. Endpoints were mortality, cardiovascular death, atrial fibrillation, thromboembolic events, heart failure, and atrioventricular block. Data was analysed on Dec 31, 1996.

FINDINGS

At long-term follow-up, 39 patients from the atrial group had died versus 57 from the ventricular group (relative risk 0.66 [95% CI 0.44-0.99]; p=0.045). 19 patients from the atrial group and 39 patients from the ventricular group died from a cardiovascular cause (0.47 [0.27-0.82]; p=0.0065). The cumulative incidences of atrial fibrillation and chronic atrial fibrillation were also significantly lower in the atrial group than in the ventricular group (0.54 [0.33-0.89], p=0.012 and 0.35 [0.16-0.76], p=0.004, respectively). Thromboembolic events occurred in 13 patients in the atrial group and 26 in the ventricular group (0.47 [0.24-0.92], p=0.023). Heart failure was less severe in the atrial group than in the ventricular group (p<0.05). In multivariate analysis, atrial pacing was significantly associated with freedom from thromboembolic events (0.47 [0.24-0.92], p=0.028) and survival from cardiovascular death (0.52 [0.30-0.91], p=0.022), but no longer with overall survival (0.71 [0.46-1.08], p=0.11) or chronic atrial fibrillation (0.45 [0.20-1.05], p=0.063). Atrioventricular block occurred in four patients in the atrial group (0.6% annual risk).

INTERPRETATION

The beneficial effect of atrial pacing found in our previous study is enhanced substantially over time. Patients with sick-sinus syndrome should be treated with an atrial rather than ventricular-pacing system because after long-term follow-up, atrial pacing is associated with a significantly higher survival, less atrial fibrillation, fewer thromboembolic complications, less heart failure, and a low-risk of atrioventricular block.

[Stent implantation in genuine coronary vessels--with and without guidance of intracoronary ultrasound]

The purpose of the present study was to evaluate the clinical and angiographic results of implantation of stents in the native coronary circulation. In group A (n: 33) implantation was assessed by angiography, in group B (n: 17) also by ICUS. There were no procedure related deaths, transmural myocardial infarctions or acute coronary by-pass operations (CABG). The diameter of stenosis before treatment was 86% and 82% in group A and B, respectively. In both groups an overdilatation was seen following stent implantation, 5% in group A versus 22% in group B (p < 0.01). At four months follow-up 80% in group A and 81% in group B were symptom-free or improved (NS). Angiographic restenosis (> or = 50% reduction of vessel diameter) was found in 10.3% in group A versus 20.0% in group B (NS). Our results are in accordance with other coronary stent studies showing reduced acute coronary occlusion and CABG incidence and a low restenosis rate as compared to conventional balloon angioplasty. The role of ICUS in the implantation of intracoronary stents remains unsettled.

Growth hormone versus placebo treatment for one year in growth hormone deficient adults: increase in exercise capacity and normalization of body composition

OBJECTIVE

Studies with GH substitution in GH-deficient (GHD) adults lasting more than 6 months have so far been uncontrolled. End-points such as physical fitness and body composition may be subject to a considerable placebo effect which weakens the validity of open studies. We therefore tested GH (2 IU/m2 per day) versus placebo treatment for 12 months.

DESIGN

Twenty-nine patients (mean age 45.5 +/- 2.0 years) with adult-onset GHD were studied in a double-blind, parallel design. Measurements of body composition by means of conventional anthropometry, bioelectrical impedance (BIA), CT scan and DEXA scan, exercise capacity, and isometric muscle strength were performed at baseline and after 12 months treatment. For body composition measurements a control group of 39 healthy, age and sex-matched subjects was included.

RESULTS

Sum of skinfolds (SKF) at 4 sites decreased significantly after GH treatment. Total body fat (TBF) as assessed by DEXA and BIA was elevated at baseline but normalized after GH. TBF assessed by SKF revealed significantly higher levels compared to DEXA and BIA, although all estimates intercorrelated closely. Visceral and subcutaneous abdominal fat decreased by 25 and 17%, respectively after GH (P < 0.01) to levels no longer different from the control group. CT of the mid thigh revealed a significant reduction in fat tissue and a significant increase in muscle volume after GH treatment, both of which resulted in a normalization of the muscle: fat ratio (%) (placebo: 58:42 (baseline) vs 58:42 (12 months); GH: 66:34 (baseline) vs 72:28 (12 months) (P = 0.002); normal subjects: 67:33 (P < 0.05 when compared to 12 months placebo data)). Total body resistance and resistance relative to muscle volume decreased significantly after GH treatment suggesting over-hydration as compared to normal subjects. Exercise capacity (kJ) increased significantly after GH treatment (placebo: 54.7 +/- 9.8 (baseline) vs 51.6 +/- 8.2 (12 months); GH: 64.9 +/- 13.3 (baseline) vs 73.5 +/- 13.6 (12 months) (P < 0.05)). Isometric quadriceps strength increased after GH but no treatment effect could be detected owing to a small increase in the placebo group. Serum IGF-I levels (microgram/l) were low baseline and increased markedly after GH treatment to a level exceeding that of normal subjects (270 +/- 31 (12 months GH) vs 156 +/- 8 (normal subjects (P < 0.01)). The levels of serum electrolytes and HbA1c remained unchanged. The number of adverse effects were higher in the GH group after 3 months, but not after 6 and 12 months.

CONCLUSIONS

(1) The reduction in excess visceral fat during GH substitution is pronounced and sustained; (2) beneficial effects on total body fat, muscle volume and physical fitness can be reproduced during prolonged placebo-controlled conditions; (3) uncontrolled data on muscle strength must be interpreted with caution; (4) a daily GH substitution dose of 2 IU/m2 seems too high in many adult patients.

[Sick sinus syndrome. Pacemaker with atrial versus ventricular stimulation]

In patients with sick sinus syndrome, single chamber atrial pacing has been reported in retrospective studies to be associated with lower frequencies of atrial fibrillation, thromboembolism, heart failure, and mortality than ventricular pacing. We did a prospective randomised trial in 225 consecutive patients (142 women, 83 men; mean age 76 years) with the sick sinus syndrome, randomised to atrial (n = 110) or ventricular (n = 115) pacing and followed for up to five years (mean 40 [SD 18] months). During follow-up, the frequency of atrial fibrillation was higher in the ventricular group. Thromboembolic events (stroke or peripheral arterial embolus) occurred in 20 patients in the ventricular group and in six patients in the atrial group (p = 0.008). Twenty five patients died in the ventricular group compared with 21 in the atrial group (p = 0.74). The number of cases of heart failure did not differ between the two groups. Atrioventricular block occurred in two patients in the atrial group. It is concluded that patients with sick sinus syndrome should be treated with atrial pacing rather than ventricular pacing because atrial pacing is associated with lower frequencies of atrial fibrillation, thromboembolic complications, and a low risk of atrioventricular block.

[Percutaneous removal of an in-situ embolised catheter fragment in a patient with Port-A-Cath]

The totally implantable catheter system has gained popularity as venous access when prolonged treatment is needed. It has several advantages over other methods of venous access, such as less discomfort for the patient, and a decreased rate of complications. A case with an uncommon but potentially serious complication, i.e. spontaneous intravascular fracture of the outlet catheter, is reported. The distal fragment of the catheter migrated into the right ventricle of the heart. The embolized fragment was removed percutaneously with a snare catheter. Causes of catheter fracture are discussed, and recommendations for implantation and radiological control are outlined.

[Intracoronary ultrasonography--a supplement to coronary arteriography]

Intracoronary ultrasound is a new technique, by means of which it is possible for the first time to visualise coronary artery wall structures in vivo. Compared to conventional coronary angiography the advances of this new modality appear to be: 1) Improved diagnosis of minimal and non-obstructive atherosclerosis; 2) Characterisation of plaque morphology, thereby being an aid in decision on interventional procedures (PTCA, atherectomy, stent placement); 3) Better delineation of coronary artery lumen area, which improves the accuracy of stenosis graduation both before and after interventional procedures. The examination can be performed in up to 95% of cases. The procedure appears to be safe with a reported complication rate of myocardial infarction and bypass surgery of 0.16% in 1837 cases; transient coronary artery spasms occurred in about 3%. Complications are predominantly associated with interventional procedures. Although intracoronary ultrasound has mainly been used for research purposes, results of ongoing trials assessing its clinical utility, as well as technological improvement providing more consistent image quality, suggest that the procedure will evolve into an important adjunct to coronary angiography.

[Ambulatory coronary arteriography]

Based upon hospital files and a questionnaire we assessed the patient safety of and the patient attitude towards outpatient coronary angiography (CAG). A total of 115 consecutive patients were included in the study. Thirty two of the patients (28%) were admitted following the angiography, while 83 (72%) were discharged to the home as planned. Of those de facto ambulatory patients one (1%) was readmitted because of a groin haematoma. Of those who returned the questionnaire, 93% of the patients admitted and 97% of the de facto ambulatory patients were satisfied with the level of information, and 76% and 99%, respectively, would prefer out-patient CAG to CAG during admission. We conclude that out-patient CAG can be performed with a very low risk and is well accepted by the patients.

Prospective randomised trial of atrial versus ventricular pacing in sick-sinus syndrome

In patients with sick-sinus syndrome, single-chamber atrial pacing has been reported, in retrospective studies, to be associated with lower frequencies of atrial fibrillation, thromboembolism, heart failure, and mortality than ventricular pacing; although single-chamber ventricular pacing is most commonly used. We did a prospective randomised trial in 225 consecutive patients (142 women, 83 men; mean age 76 years) with the sick-sinus syndrome, randomised to atrial (n = 110) or ventricular (n = 115) pacing and followed for up to 5 years (mean 40 [SD 18] months). During follow-up, the frequency of atrial fibrillation was higher in the ventricular group, except at the first follow-up at 3 months. Thromboembolic events (stroke or peripheral arterial embolus) occurred in 20 patients in the ventricular group and in 6 patients in the atrial group (p = 0.0083). 25 patients died in the ventricular group compared with 21 in the atrial group (p = 0.74). Heart failure estimated by the New York Heart Association classification and by the daily doses of diuretics did not differ between the two groups. Atrioventricular block occurred in 2 patients in the atrial group. Patients with sick-sinus syndrome should be treated with atrial pacing rather than ventricular pacing because atrial pacing is associated with lower frequencies of atrial fibrillation, thromboembolic complications, and a low risk of atrioventricular block.

Short and long-term cardiovascular effects of growth hormone therapy in growth hormone deficient adults

OBJECTIVE

Since GH substitution therapy is now available for adult GH deficient patients, information on the cardiovascular effects of GH substitution has assumed major clinical interest. We have therefore assessed cardiovascular effects of short and long-term growth hormone substitution therapy in these patients.

PATIENTS AND MEASUREMENTS

Doppler echocardiography was performed in 21 GH deficient patients after 4 months placebo and 4 months GH therapy, in a double blind cross-over study. In an open design study, 13 patients were reinvestigated following 16 months and 9 patients following 38 months of GH therapy. Twenty-one age and sex-matched normal control subjects were also investigated.

RESULTS

Heart rate was increased in placebo treated patients as compared to controls. After 4 months of GH treatment, heart rate showed a further increase (10%, P < 0.01) and seemed to remain elevated after 16 months of GH therapy. Systolic and diastolic blood pressures were significantly lower in placebo treated patients than in controls, and did not change significantly after GH treatment. The left ventricular diastolic diameter was reduced in patients as compared to controls, but increased after 4 months GH therapy (P > 0.05) and seemed to increase further during prolonged GH treatment. Cardiac index was at the same level in controls and in placebo-treated patients, but increased by 20% following GH therapy and remained elevated after 16 and 38 months (P < 0.05) of GH substitution.

CONCLUSION

Following GH substitution in GH deficient adult patients, left ventricular diastolic dimensions increased and seemed to normalize, while heart rate and cardiac output were found to be increased to supranormal levels.

Short- and long-term survival after aortic balloon valvuloplasty for calcified aortic stenosis in 137 elderly patients

Percutaneous transluminal balloon aortic valvuloplasty was performed in 137 patients with symptomatic severe calcified aortic stenosis (50 men and 87 women, mean age 77 years) between December 1986 and September 1990. The purpose of the study was to evaluate short- and long-term survival after balloon aortic valvuloplasty, mean follow-up was 19 months. At the time of balloon aortic valvuloplasty congestive heart failure (NYHA III-IV) was present in 89%, angina pectoris in 47%, and syncope in 31% of the patients. Aortic balloon dilatation produced significant decreases in peak pressure gradient from 91 +/- 34 mmHg to 40 +/- 26 mmHg (p < 0.001). The procedure related mortality was 8% (11 pts) and the 30-days mortality 17% (23 pts). Severe complications occurred in 25% of the patients during the procedure and within the first 24 hours. Immediate clinical improvement was noted in 68% of the patients surviving the treatment. The overall survival rate was at one, two, three and four years follow-up 63%, 40%, 28%, and 21%, respectively. These survival rates were all statistically different from the survival rates in an age- and sex-matched background population (p < 0.001). A multivariate Cox analysis revealed that only female sex and angina before treatment seemed to improve survival.

CONCLUSION

The long-term outcome after aortic balloon valvuloplasty for severe aortic stenosis is so poor that we recommend aortic valve replacement as the initial treatment in these patients, if at all possible.

Three years of growth hormone treatment in growth hormone-deficient adults: near normalization of body composition and physical performance

Growth hormone (GH) replacement therapy in several controlled short-term trials have shown unanimous beneficial effects on body composition and other features. To evaluate more long-term effects we report data from 3 years of uninterrupted GH therapy in 10 GH-deficient adults who had all completed a previous double-blind placebo-controlled study and who also had been studied after 16 months of open GH therapy. No further increase in linear height was observed. The initial increase in thigh muscle volume was maintained after 3 years of GH therapy. A slight increase in body weight and thigh fat volume was recorded. Exercise capacity and isometric muscle strength were increased significantly compared to the initial placebo period. This was associated with stabilized levels of resting heart rate and blood pressure. Glycosylated hemoglobin levels were normal and did not change during the study. A standard oral glucose tolerance test performed at the end of the study revealed no evidence of glucose intolerance. No side-effects were reported. Compared to an age- and sex-matched group of healthy untreated subjects, thigh muscle volume, exercise capacity and isometric muscle strength had become normalized from subnormal levels after 3 years of GH therapy. We conclude that long-term GH replacement therapy in GH-deficient adults is associated with preserved beneficial effects on body composition and physical performance, resulting in a near normalization of several previously abnormal features and adding new merits to this treatment modality.

Cardiac function in patients with human immunodeficiency virus infection and with no other active infections

OBJECTIVE

to investigate cardiac function and prognostic significance of echocardiographic findings in patients with uncomplicated human immunodeficiency virus (HIV)-infection.

PATIENTS AND METHODS

Doppler echocardiography was performed in 60 male patients with HIV-infection and no signs of other active infections, and in 36 age and sex matched normal control subjects. The survival time of the patients was assessed 36 months after the echocardiographic examination.

RESULTS

None of the patients had significant pericardial effusions, intracardiac tumors, signs of valvular endocarditis or dilated cardiomyopathy. In none of the patients were the fractional shortening or the early and atrial mitral flow ration (E/A ratio) below the 95% confidence limit of the control group. The E/A ratio was slightly, but significantly, decreased in AIDS patients both as compared to asymptomatic HIV-infected patients and as compared to normal control subjects because of increased heart rated in the AIDS patients. Within the three-year observation period, 28 of the patients died from HIV-related disease. In the group of deceased patients, there was no significant correlation between blood pressure, heart rate, left ventricular diameters, fractional shortening, E/A ratio and the survival time.

CONCLUSION

In a population of HIV-infected patients with no other active infections, cardiac abnormalities seen to be uncommon, and the echocardiographic fractional shortening and E/A ratio were not related to the survival time of such patients. Thus, our data does not evidence that HIV is a direct cardiac pathogen.