Early Elective Conversion for Failing Evar

Background:

The aim of the study was to assess the long term results of endovascular aneurysm repair (EVAR) of abdominal aortic aneurysms at the Helsinki University Central Hospital 1996–2004 with a special emphasis on elective conversion procedures and their outcome.

Methods:

Treatment results and follow-up data of all 110 elective EVAR procedures performed in our institution were gathered prospectively and evaluated.

Results:

Conversion to open surgery was performed in 23 (21%) of 110 EVAR patients. 30-day mortality after elective stent-graft deployment was 0% as it was also on elective conversions (n = 20). Secondary elective conversions were performed due to infection in two and after failing stent-graft treatment in 12 patients. Six of the conversions were performed primarily. Three urgent conversions (3% overall) were performed: two of these patients died, corresponding to an overall mortality of 9% (2/23) in all conversions. Five-year aneurysm-related mortality after EVAR among patients with elective conversion was 0% and 19% in patients with secondary procedures other than elective conversions.

Conclusions:

As conversions seem to be hazardous only when performed in urgent situations, elective conversion could be an alternative treatment method in complex failing first-generation stent-grafts as it may reduce mortality associated with urgent conversions or repeated attempts to maintain graft integrity with endovascular procedures.

Statin-treated familial hypercholesterolemia patients with coronary heart disease and pronounced atherosclerosis do not have more brain lesions than healthy controls in later middle age

BACKGROUND

Clinically silent brain lesions detected with magnetic resonance imaging (MRI) are associated with increased risk for stroke, while stroke risk is controversial in familial hypercholesterolemia (FH).

PURPOSE

To determine whether the occurrence and size of clinically silent brain lesions in FH patients with coronary heart disease (CHD) is higher than in neurologically healthy controls without CHD.

MATERIAL AND METHODS

Brain MRI (1.5T) was performed on 19 DNA-test-verified FH patients with CHD and on 29 cardiovascularly and neurologically healthy controls, all aged 48 to 64 years. All patients were on cardiovascular medication. Intracranial arteries were evaluated by MR angiography. Infarcts, including lacunas, and white matter T2 hyperintensities (WMHI), considered as signs of small vessel disease, were recorded. A venous blood sample was obtained for assessment of risk factors. Carotid and femoral intima-media thicknesses (IMT), assessed with ultrasound, were indicators of overall atherosclerosis.

RESULTS

On intracranial MR angiography, three patients showed irregular walls or narrowed lumens in intracranial carotid arteries. No silent infarcts appeared, and no differences in numbers or sizes of WMHIs between groups were recorded. Patients had greater carotid and femoral IMTs, and a greater number of carotid and femoral plaques. Cholesterol-years score, level of low-density lipoprotein (LDL) cholesterol, and level of high-sensitivity C-reactive protein (hsCRP) of the FH-North Karelia patients were higher than those of the controls, while the level of high-density lipoprotein (HDL) cholesterol in controls was higher.

CONCLUSION

FH patients with CHD and adequate cardiovascular risk-factor treatment showed no difference in the amount or size of clinically silent brain lesions compared to controls, despite patients' more severe atherosclerosis.

Infra-inguinal percutaneous transluminal angioplasty for limb salvage: a retrospective analysis in a single center

PURPOSE

To review the feasibility of infra-inguinal angioplasty in the management of critical limb ischemia (CLI).

MATERIAL AND METHODS

Data on 221 patients with 230 critically ischemic limbs, treated with consecutive percutaneous transluminal angioplasty (PTA) at Helsinki University Central Hospital between January 2000 and December 2002 were collected and analyzed retrospectively. Patency, limb salvage, and survival rates were calculated on an intention-to-treat basis. Comparisons were done with univariate (Kaplan-Meier) and multivariate analysis (Cox regression).

RESULTS

Overall primary patency, secondary patency, limb salvage, and survival rates were 47%, 59%, 92%, and 76%, respectively, at 12 months. In the multivariate analysis, low toe pressure (< or =30 mmHg) was a significant risk factor for poor patency. Uremia with hemodialysis, low toe pressure (< or =30 mmHg), and hemodynamic failure of the endovascular procedure were found to increase significantly the risk of amputation. Uremia with hemodialysis, coronary artery disease, tissue loss as indication for PTA (Fontaine stage IV), and age over 70 years were all found to increase significantly the risk of death.

CONCLUSION

Infra-inguinal PTA is feasible in patients with CLI and resulted in good limb salvage.

Endovascular treatment of aortic aneurysms in Finland: the first four years' experience

BACKGROUND AND AIMS

In this study the results of endovascular treatment of aortic aneurysms in Finland are presented and compared to the results of the Eurostar registry.

MATERIAL AND METHODS

A total of 229 patients with aortic aneurysm were treated in five different Finnish centres during 1996-2000. The data of these patients were collected prospectively by surgeon or interventional radiologist involved. During the same period of time 2464 patients were registered in the Eurostar registry.

RESULTS

The procedure was performed successfully in 97% of patients in Finland, and the 30-day mortality was 0,9%. A graft limb thrombosis was detected in 9% of the patients in Finland. A permanent primary endoleak at the first 30-day control was seen in 23 patients (10%). During the follow-up 17 secondary endoleaks (7%) were detected. A secondary intervention was necessary in 26% of the patients. Three patients (1.3%) had late rupture of the abdominal aortic aneurysm.

CONCLUSIONS

According to the Finnish short-time results, endovascular treatment of aortic aneurysms is safe and associated with relatively low morbidity and mortality. The mid-term results are more disappointing with relatively many graft thromboses and endoleaks, and a frequent need of secondary interventions.

Safety and effectiveness of single- versus triple-dose gadodiamide injection- enhanced MR angiography of the abdomen: a phase III double-blind multicenter study

PURPOSE

To evaluate the safety and effectiveness of gadodiamide-enhanced magnetic resonance (MR) angiography with single and triple doses in the assessment of abdominal arterial stenoses.

MATERIALS AND METHODS

One hundred five patients were included in the randomized, double-blind, phase III multicenter trial. Results of MR angiography with 0.1 mmol/kg and 0.3 mmol/kg doses of gadodiamide were compared with those of digital subtraction angiography (DSA) and according to dose.

RESULTS

No serious adverse events were observed. The mean contrast index at the region proximal to the primary stenosis was significantly higher in the triple-dose group (P =.03). Mean 95% CI values for the difference in depicted degree of stenosis between DSA and postcontrast MR angiography improved from -3.4% +/- 4.7 (SD) in the single-dose group to -1.2% +/- 4.7 in the triple-dose group. Mean values for overall image quality on the visual analogue scale improved with the triple dose (P =.02). Confidence in diagnosis was high at postcontrast MR angiography in 88% and 96% of cases in the single- and triple-dose groups, respectively.

CONCLUSION

Gadodiamide-enhanced MR angiography performed with single and triple doses is safe and effective for assessing major abdominal arterial stenoses. Although high agreement between MR angiography and DSA was achieved with both doses, triple-dose MR angiography was superior in the evaluations of image quality, degree of arterial stenoses, and confidence in diagnosis.

Arrhythmic disorder mapped to chromosome 1q42-q43 causes malignant polymorphic ventricular tachycardia in structurally normal hearts

OBJECTIVES

The purpose of this study was to provide clinical and anatomical characteristics as well as genetic background of a malignant arrhythmogenic disorder.

BACKGROUND

An inherited autosomally dominant cardiac syndrome causing stress-induced polymorphic ventricular tachycardia and syncope in the absence of structural myocardial changes was detected in two families.

METHODS

Two unrelated families with six victims of sudden death and 51 living members were evaluated. Resting and exercise electrocardiograms (ECG), echocardiography, magnetic resonance imaging (MRI), cineangiography, microscopic examination of endomyocardial biopsies and a drug testing with a class IC antiarrhythmic agent flecainide were performed. A genetic linkage analysis was carried out to map the gene locus.

RESULTS

Of the 24 affected individuals, 10 had succumbed with six cases of sudden death, and 14 survivors showed evidence of disease. Exercise stress test induced ventricular bigeminy or polymorphic ventricular tachycardia in affected individuals. Three children initially examined before 10 years of age developed arrhythmias during a four-year follow-up. Resting ECGs were normal in affected subjects except a slight prolongation of the QT intervals adjusted for heart rate (QTc) (430 +/- 18 vs. 409 +/- 19 ms, affected vs. nonaffected, p < 0.01). Administration of flecainide did not induce ECG abnormalities encountered in familial idiopathic ventricular fibrillation. Ventricular volumes, contractility and wall measurements were normal by echocardiography, right ventricular cineangiography and MRI. Histopathological examination showed no fibrosis or fatty infiltration. The cumulative cardiac mortality by the age of 30 years was 31%. The disease locus was assigned to chromosome 1q42-q43, with a maximal pairwise lod score of 4.74 in the two families combined. Only one heterozygous carrier was clinically unaffected suggesting high disease penetrance in adulthood.

CONCLUSIONS

A distinct cardiac disorder linked to chromosome 1q42-q43 causes exercise-induced polymorphic ventricular tachycardia in structurally normal hearts and is highly malignant. Delayed clinical manifestation necessitates repeated exercise electrocardiography to assure diagnosis in young individuals of the families.

Nonfluoroscopic localization of an amagnetic stimulation catheter by multichannel magnetocardiography

This study was performed to: (1) evaluate the accuracy of noninvasive magnetocardiographic (MCG) localization of an amagnetic stimulation catheter; (2) validate the feasibility of this multipurpose catheter; and (3) study the characteristics of cardiac evoked fields. A stimulation catheter specially designed to produce no magnetic disturbances was inserted into the heart of five patients after routine electrophysiological studies. The catheter position was documented on biplane cine x-ray images. MCG signals were then recorded in a magnetically shielded room during cardiac pacing. Noninvasive localization of the catheter's tip and stimulated depolarization was computed from measured MCG data using a moving equivalent current-dipole source in patient-specific boundary element torso models. In all five patients, the MCG localizations were anatomically in good agreement with the catheter positions defined from the x-ray images. The mean distance between the position of the tip of the catheter defined from x-ray fluoroscopy and the MCG localization was 11 +/- 4 mm. The mean three-dimensional difference between the MCG localization at the peak stimulus and the MCG localization, during the ventricular evoked response about 3 ms later, was 4 +/- 1 mm calculated from signal-averaged data. The 95% confidence interval of beat-to-beat localization of the tip of the stimulation catheter from ten consecutive beats in the patients was 4 +/- 2 mm. The propagation velocity of the equivalent current dipole between 5 and 10 ms after the peak stimulus was 0.9 +/- 0.2 m/s. The results show that the use of the amagnetic catheter is technically feasible and reliable in clinical studies. The accurate three-dimensional localization of this multipurpose catheter by multichannel MCG suggests that the method could be developed toward a useful clinical tool during electrophysiological studies.

Minimally invasive coronary artery bypass grafting: one-year follow-up

BACKGROUND

Use of the minimally invasive direct coronary artery bypass grafting (MIDCAB) technique has been associated with excellent primary results, and sparing of resources has been assumed. There is, however, a limited amount of information available concerning the results of mid-term follow-up. The purpose of this study was to present 1-year follow-up results of our first 130 consecutive MIDCAB patients.

METHODS

MIDCAB operations, defined as no sternotomy, no cardiopulmonary bypass, and no aortic manipulation were started in our clinic in February 1996. One hundred thirty patients requiring invasive treatment of coronary artery disease who were not suitable for percutaneous transluminal angioplasty were included in this series. The main outcome measures were mortality, the need for subsequent invasive treatment, and 1-year NYHA classification.

RESULTS

There was one hospital death, but during the first-year follow-up, four additional deaths occurred and three patients were reoperated on with conventional techniques. Five percutaneous transluminal coronary angioplasties (PTCAs) had to be performed, two because of anastomosic stenosis. Additionally, cardiac- or operation-related symptoms caused a total of 27 hospital visits among 23 patients during the first-year follow-up. Angiographic left internal thoracic artery (LITA)-left anterior descending artery (LAD) patency was 97.4% (37/38) (confidence interval [CI] ranged from 86.2% to 99.9%) at 3 months. After 1 year, 86.9% (113/130) of the patients were without symptoms. A clear improvement of the follow-up results was observed to be associated with increased experience during the study period.

CONCLUSIONS

MIDCAB operations, after some experience, can be performed with relatively good outcome. However, special attention should be directed to determination of correct anastomosic site and to avoiding anastomosic stenosis. We also recommend extended mobilization of the ITA and use of specific stabilizers.

A prospective study of bone loss and turnover after allogeneic bone marrow transplantation: effect of calcium supplementation with or without calcitonin

Transplantation of solid organs including heart, kidney, and liver is associated with rapid bone loss and increased rate of fracture; data on bone marrow transplantation recipients (BMT) are scarce. The purpose of the present study was to examine the magnitude, timing, and mechanism of bone loss following allogeneic BMT, and to study whether bone loss can be prevented by calcium with or without calcitonin. Sixty-nine patients undergoing allogeneic BMT for malignant blood diseases were enrolled into the study. Forty-four (22 women, 22 men) completed 6 months, and 36 patients 1 year follow-up. They were randomized to receive either no additional treatment (n = 22), or oral calcium 1 g twice daily for 12 months (n = 12) or the same dose of calcium plus intranasal calcitonin 400 IU/day for the first month and then 200 IU/day for 11 months (n = 10). Bone mineral density (BMD) at the lumbar spine and three femoral sites (femoral neck, trochanter, Ward's triangle) was measured by dual-energy X-ray absorptiometry (DXA). Bone turnover rate was followed with markers of bone formation and resorption (serum bone-specific alkaline phosphatase (B-ALP), type I procollagen carboxyterminal (PICP) and aminoterminal propeptide (PINP), serum type I collagen carboxyterminal telopeptide (ICTP)). Serum testosterone was assayed in men. Calcium with or without calcitonin had no effect on bone loss or bone markers; consequently the three study groups were combined. During the first 6 post-transplant months BMD decreased by 5.7% in the lumbar spine and by 6.9% to 8.7% in the three femoral sites (P < 0.0001 for all); no significant further decline occured between 6 and 12 months. Four out of 25 assessable patients experienced vertebral compression fractures. Markers of bone formation reduced: B-ALP by 20% at 3 weeks (P = 0.027), PICP by 40% (P < 0.0001) and PINP by 63% at 6 weeks (P < 0.0001), with a return to baseline by 6 months. The marker of bone resorption, serum ICTP was above normal throughout the whole observation period, with a peak at 6 weeks (77% above baseline, P < 0.0001). In male patients serum testosterone decreased reaching a nadir (57% below baseline) at 6 weeks (P = 0.0003). In conclusion, significant bone loss occurs after BMT. It results from imbalance between reduced bone formation and increased bone resorption; hypogonadism may be a contributing factor in men. Bone loss can not be prevented by calcium with or without calcitonin.

A prospective study of bone loss and turnover after cardiac transplantation: effect of calcium supplementation with or without calcitonin

Cardiac transplantation exposes recipients to osteoporosis and increased risk of consequent fractures. The purpose of the present study was to examine the magnitude, timing and mechanism of bone loss following cardiac transplantation, and to establish whether bone loss can be prevented by calcium with or without calcitonin. Thirty patients (29 men, 1 woman), aged 26-68 years (mean 48 years), were randomized into three groups of 10 to receive either no additional treatment, oral calcium 1 g twice daily for 12 months or the same dose of calcium plus intranasal calcitonin 400 IU/day for the first month and then 200 IU/day for 11 months. Bone mineral density (BMD) at the lumbar spine and three femoral sites (femoral neck, trochanter, Ward's triangle) was measured by dual-energy X-ray absorptiometry (DXA) at the time of transplantation and 6 and 12 months later. Markers of bone formation [serum bone-specific alkaline phosphatase (B-ALP), type I procollagen carboxyterminal propeptide (PICP) and aminoterminal propeptide (PINP)] and resorption [serum type I collagen carboxyterminal telopeptide (ICTP)], as well as serum testosterone in men, were assayed before transplantation and at 1 week and 1, 3, 6 and 12 months after transplantation. During the first 6 post-transplant months BMD calculated as a percent change from baseline decreased in the control group by 6.4% (p = 0.014) in the lumbar spine, by 6.0% (p = 0.003) in the femoral neck, by 5.0% (p = 0.003) in the trochanter and by 5.5% (p = 0.130) in Ward's triangle. Between 6 and 12 months a further decline in BMD occurred only at the three femoral sites, ranging from 2.2% to 9.8% (p = 0.004-0.079). In comparison with the control group, the group receiving calcium alone lost less bone in the trochanter between 0 and 6 months (p = 0.019), and the group receiving calcium together with calcitonin lost less bone in the femoral neck (p = 0.068) and Ward's triangle (p = 0.076) between 0 and 12 months. Seven (28%) of 25 assessable patients experienced vertebral compression fractures. Calcium with or without calcitonin had no effect on changes in biochemical parameters; consequently, the three study groups were combined. The markers of bone formation increased, the elevations in mean values being 59% for B-ALP at 1 month (p = 0.009), 152% for PICP at 1 week (p < 0. 0001) and 27% for PINP at 1 week (p = 0.021). After a temporary decline at 3 months B-ALP (p = 0.0002) and PINP (p < 0.0001) at 1 year were nearly doubled compared with baseline values. Throughout the study the marker of bone resorption, serum ICTP, was above normal, with a peak (mean values 67-69% above baseline) at 1 week (p = 0.0002) to 1 month (p < 0.0001). The mean concentration of total testosterone was decreased by 48% (p < 0.0001) 1 week and by 28% (p = 0.0005) 1 month after transplantation, but this was mainly explained by the concomitant drop in serum albumin. High bone turnover underlies bone loss after cardiac transplantation. Bone loss is most rapid during the first 6 post-transplant months. In the upper femur this bone loss may be reduced by treatment with calcium and calcitonin.

Minimally invasive coronary artery bypass grafting using the right gastroepiploic artery

BACKGROUND

Anastomosis of the left internal thoracic artery to the left anterior descending artery without sternotomy and without cardiopulmonary bypass is a standard approach in minimally invasive coronary artery bypass grafting. To expand the indications for minimally invasive coronary artery bypass grafting from one-vessel disease to two-vessel disease, we began to perform anastomosis of the right gastroepiploic artery (RGEA) to the right coronary artery (RCA).

METHODS

From February to November 1996, an RGEA graft was used in 25 of the 100 patients who underwent minimally invasive coronary artery bypass grafting at our clinic. Eleven of the patients had only RCA disease and 14 had both RCA and left anterior descending artery disease. One of the operations was a redo coronary artery bypass grafting. The RGEA was anastomosed to the RCA through a laparotomy incision and the left internal thoracic artery was anastomosed to the left anterior descending artery through a left anterior thoracotomy. In 5 patients, the RGEA was lengthened by venous grafting.

RESULTS

All patients underwent angiography after operation; 82.6% of the RGEA grafts and all the left internal thoracic artery grafts were functioning well. In three of the four nonvisualized RGEA grafts, the percentage of proximal stenosis of the RCA seen on postoperative angiography was not critical (40%, 50%, and 50%, respectively), allowing significant competitive flow through the native bypassed RCA. The patency of all the RGEA grafts without competitive flow was 95%, with a 95% confidence interval of 75.1% to 99.9%.

CONCLUSIONS

The indications for minimally invasive coronary artery bypass grafting could be extended to primary operations in patients with left anterior descending artery and RCA lesions by using both the left internal thoracic artery and the RGEA.

Angiographic 5-year follow-up study of right gastroepiploic artery grafts

BACKGROUND

The right gastroepiploic artery (RGEA) has been used from 1987 in coronary artery bypass grafting in several clinical studies. However, the published 1- to 5-year patency rates have been dependent on the selection of patients for angiography.

METHODS

In our study, the RGEA was used from March 1987 to May 1990 for coronary artery bypass grafting in 31 consecutive patients, 25 male and 6 female. All but 1 patient had triple-vessel disease, and the mean number of distal anastomoses was 3.9 (range, 2 to 5). Internal thoracic artery grafts were used concomitantly in all patients.

RESULTS

One early and two late deaths occurred. All but 1 of the 28 surviving patients underwent clinical and angiographic follow-up examinations 3 months and 5 years after the operation. The 5-year patency of RGEA grafts was 82.1%, with a 95% confidence interval of 63.1% to 93.9%. In 4 of the 5 nonvisualized cases, the recipient coronary artery showed proximal stenosis of up to 70%, allowing substantial competitive flow. The 5-year patency of the RGEA graft was near that of the left internal thoracic artery, at 90.3%, and the right internal thoracic artery, at 94.4%; and superior to the 66.7% patency of venous grafts.

CONCLUSIONS

At 5-year follow-up, angiography of RGEA grafts showed good function and a smooth lumen, especially if the proximal stenosis was more than 70%.

Assessment of right and left atrial function in patients with transplanted hearts with the use of magnetic resonance imaging

BACKGROUND

The purpose of this study was to determine the volumes and cyclic volume changes of the cardiac atria after heart transplantation in physically healthy recipients.

METHODS

Ten heart transplant recipients (New York Heart Association grade I) entered the protocol. All operations had been made with classic biatrial anastomoses. Eight healthy volunteers were studied as controls. To measure the volumes of both atria and left ventricular cavity, we used a gradient-echo cine sequence. The 10 mm slices covered both atria over the total cardiac cycle. Images were planimetered, and simultaneous volumes were totalled to give the cavity volume at each time phase.

RESULTS

The heart rate of the heart transplant recipients was faster than in controls, which resulted in higher cardiac output. The atrial minimum volumes were significantly larger, and fractional emptying was smaller in transplanted hearts when compared with controls. Reservoir and stroke volumes were smaller and conduit volumes were larger in transplanted hearts than in controls. The atrial filling and emptying rates were lower in heart transplant recipients than in controls.

CONCLUSIONS

The classic surgical technique used in heart transplantation results in large atria with decreased volume changes and filling rates even in physically healthy transplant recipients. Magnetic resonance imaging is a reliable tool in assessment of atrial volumes and cyclic function after heart transplantation.

Effects of angiotensin-converting enzyme inhibition versus beta-adrenergic blockade on aortic stiffness in essential hypertension

We assessed the effects of 6 months of treatment with an angiotensin-converting enzyme (ACE) inhibitor (cilazapril) or a beta 1-adrenergic blocker (atenolol) on aortic stiffness in essential hypertension. Forty patients (16 women) aged 47 +/- 9 years (mean +/- SD) with baseline systolic and diastolic blood pressures of 162 +/- 15 and 105 +/- 5 mm Hg, respectively, were entered into a double-blind, parallel-group study with cilazapril, 5 mg once daily, or atenolol, 100 mg once daily. The treatment period was preceded by a 4-week placebo washout phase. Aortic elastic modulus (Ep) was determined by cine magnetic resonance imaging (MRI) and indirect brachial artery blood pressure measurements prior to and after 3 weeks and 6 months of therapy. The reductions in systolic and diastolic blood pressures from baseline to 6 months averaged -17 +/- 13 and -10 +/- 6 mm Hg, respectively, with cilazapril and -23 +/- 16 and -14 +/- 6 mm Hg with atenolol. Concomitantly, Ep of the ascending aorta decreased with cilazapril from a median of 2,234 10(3)dyn/cm2 (interquartile range, 866-3,740) to 868 10(3)dyn/cm2 (515-1,486) and with atenolol from a median of 1,611 10(3)dyn/cm2 (895-2,790) to 1,054 10(3)dyn/cm2 (616-1,860). In repeated-measurements analysis of variance, the change in Ep with time was statistically significant (p < 0.001) but the group x time interaction was not. We conclude that 6 months of treatment with either cilazapril or atenolol reduces the stiffness of the ascending aorta in essential hypertension. No statistically significant differences between the effects of the two drugs were observed. The mechanisms and clinical significance of improved aortic distensibility with antihypertensive therapy deserve further study.

Left ventricular function in children with the Marfan syndrome

Aortic dilatation and heart valve lesions are common in the Marfan syndrome but whether primary alterations occur in left ventricular (LV) function has not been studied hitherto. LV size, mass and systolic as well as diastolic function were studied by M-mode and Doppler echocardiography and cine magnetic resonance imaging in 22 Marfan children aged 3.0-15.4 years and in 22 age-matched healthy children. No child had significant valve disease. Heart rate and systolic blood pressure were comparable in the groups but diastolic blood pressure was higher in the controls (67 +/- 7 mmHg vs 62 +/- 8 mmHg, P = 0.030). No statistically significant differences were found in LV size, mass or systolic function. The Marfan children had slower LV peak diameter lengthening rates (106 +/- 27 mm.s-1 vs 132 +/- 29 mm.s-1, P = 0.004), prolonged relaxation times (155 +/- 22 ms vs 140 +/- 19 ms, P = 0.023), slower deceleration of the early transmitral velocity (580 +/- 144 cm.s-1 vs 720 +/- 160 cm.s-2, P = 0.006), and smaller early-to-late peak velocity ratios (1.99 +/- 0.40 vs 2.29 +/- 0.46, P = 0.031). These data indicate that LV early diastolic function (relaxation) is impaired in the Marfan syndrome. Weakened elastic recoil due to the underlying connective tissue abnormality may best explain this novel observation.

Prevalence and predictors of audible physiological third heart sound in a population sample aged 36 to 37 years

BACKGROUND

A physiological third heart sound (S3) is common in youth but allegedly very rare after the age of 40 years. The mechanism of its disappearance is not known. The aim of this work was to study the prevalence and predictors of physiological S3 in a population-based sample of persons approaching 40 years of age.

METHODS AND RESULTS

A random sample of 120 persons born in 1954 was invited; 93 (42 men) entered the study. Their physical activity, alcohol and tobacco consumption, and salt intake were quantified by diary follow-up. The presence of an S3 was determined by auscultation and confirmed by phonocardiography. Left ventricular (LV) size, mass, and systolic function were assessed by M-mode echocardiography and LV filling by Doppler velocimetry of transmitral flow. An audible S3 was detected in 22 subjects, 1 of whom had heart disease. The prevalence of physiological S3 was 23.1%. Subjects with physiological S3 had a lower body mass index (22.3 +/- 2.8 versus 24.6 +/- 4.1 kg/m2 [mean +/- SD], P = .005), lower heart rate (63 +/- 7 versus 68 +/- 10 beats per minute, P = .015), higher peak early diastolic transmitral velocity (67 +/- 10 versus 58 +/- 8 cm/s, P = .002), and higher acceleration of early diastolic velocity (717 +/- 148 versus 622 +/- 122 cm/s2, P = .012) than those without S3. No differences were noted in the lifestyle characteristics, blood pressure, or LV mass and systolic function. Body mass index and peak early diastolic transmitral velocity were independent predictors of physiological S3 in logistic regression analysis.

CONCLUSIONS

Nearly one fourth of persons approaching their forties still have an audible physiological S3. The presence of S3 is predicted by leanness and a high early diastolic LV inflow velocity; the disappearance of S3 is unlikely to be secondary to increasing blood pressure and relative LV hypertrophy, as is widely presented, but reflects a more primary age-related alteration of LV early diastolic function.

Relation of aortic stiffness to factors modifying the risk of atherosclerosis in healthy people

To identify factors predicting aortic stiffness, we studied the modulus of elasticity of the thoracic aorta in relation to sex, obesity, blood pressure, physical activity, smoking, ethanol consumption, salt intake, and serum lipid and insulin levels in 55 healthy people born in 1954. A transverse cine magnetic resonance image of the thoracic aorta was made, and the modulus of elasticity was determined as brachial artery cuff pulse pressure/aortic strain, where strain was determined as the ratio of pulsatile aortic luminal area change to the diastolic luminal area. The average of measurements made in the ascending and descending aorta was used as the elastic modulus of the thoracic aorta. Habitual physical activity, smoking, and alcohol use were quantified by 2-month prospective daily recording and salt intake by 7-day food records. The aortic elastic modulus ranged from 100 to 2091 10(3) dyne/cm2 (median, 390 10(3) dyne/cm2). In multiple regression analyses, log10 aortic elastic modulus was related directly to mean blood pressure (standardized coefficient [beta] = .37, P = .002), serum high-density lipoprotein cholesterol (beta = .36, P = .012), square root of daily energy expenditure in physical activity (beta = .33, P = .005), and log10 serum insulin (beta = .27, P = .047) and inversely to serum low-density lipoprotein cholesterol (beta = -.26, P = .035). A relation to salt intake was also observed, but the regression slope was dependent on mean blood pressure (P = .005 for interaction). These data suggest that many modifiable constitutional and lifestyle characteristics may contribute to the stiffness of the thoracic aorta.

The integrity of intervertebral disks after operative treatment of thoracolumbar fractures

This study presents the results of magnetic resonance imaging (MRI) follow-up studies on 14 patients with unstable fractures of T12 or L1. Internal fixation was performed with Harrington rods in eight patients and with transpedicular fixation in six patients. Sixteen intervertebral disks adjacent to the fractured vertebral body in 11 patients showed decreased signal intensity in T2-weighted images. None of the uninjured intervertebral disks showed any detectable signal decrease in T2-weighted images. Temporary fixation of several healthy motion segments of thoracolumbar spine, as is necessary with Harrington instrumentation for 11 months, on average, does not seem to result in an intervertebral disk degeneration detectable on MRI in the patients within a follow-up period of two years.

Cerebrospinal fluid and MRI findings in three patients with multiple sclerosis and systemic lupus erythematosus

Three patients fulfilling the diagnostic criteria of both multiple sclerosis (MS) and systemic lupus erythematosus (SLE) were examined clinically, immunologically and by magnetic resonance imaging (MRI). In all three patients MRI showed several high-signal lesions compatible with MS and, additionally, non-specific small white matter lesions suggesting small vessel occlusion were seen. In CSF the cytoimmunological abnormalities were variable and showed only slight to moderate immunoactivation within the CNS at the time of sampling.

Non-invasive magnetocardiographic localization of ventricular pre-excitation in the Wolff-Parkinson-White syndrome using a realistic torso model

This study was performed to evaluate the accuracy of magnetocardiography in non-invasive localization of the ventricular pre-excitation site in patients suffering from the Wolff-Parkinson-White (WPW) syndrome. Twelve WPW patients were studied, in whom the pre-excitation caused serious supraventricular arrhythmias refractory to drug therapy. Magnetocardiographic measurements were performed in a magnetically shielded room, and non-invasive localization was computed from preprocessed magnetic signals using a current dipole source in a realistically shaped digital torso. All patients underwent intra-operative multicatheter mapping and subsequent dissection of the accessory atrioventricular connection. The intra-operative localization results were marked on magnetic resonance images of the heart, where magnetocardiographic results were also superimposed to allow comparison. The average of the three-dimensional differences between the magnetocardiographic and the invasive results was 2.1 +/- 0.9 cm. In all cases, the computed localization result was in the same or adjacent anatomical region as the intra-operative result. The present results show that the magnetocardiographic method using a realistic torso model is capable of localizing pre-excitation sites with sufficient accuracy to provide extra information so that non-pharmacological therapeutic interventions can be applied.

Left ventricular aneurysm associated with apical hypertrophic cardiomyopathy

A 47-year-old man with apical hypertrophic cardiomyopathy and an apical left ventricular aneurysm with palpitation as the initial manifestation is described. There was no intraventricular pressure gradient. The aneurysm is suggested to be a part of the myocardial disease or to be caused by myocardial bridging of the left anterior descending coronary artery demonstrated by angiography. The 24-hour ambulatory ECG recording showed only isolated ventricular ectopic beats and the clinical course has been favorable during 20 months without therapy.

Iohexol, ioxaglate and iopamidol in coronary angiography. A double-blind comparative study of 300 patients

A randomized, double-blind study was carried out in 300 consecutive coronary angiography examinations to investigate the clinical safety of three low osmolar contrast media, iohexol 300, ioxaglate 320 and iopamidol 300, and the electrocardiographic changes that occurred with them. The ECG from electrode V5/V6 or AVF and intra-arterial pressure were monitored continuously, and recorded before and after the first contrast injections into the left and right coronary arteries. Of the variables tested, no statistically significant changes occurred in systolic arterial pressure, PR interval or ventricular extrasystole. The QT interval increased in the ioxaglate group (p = 0.001). Heart rate decreased in all groups, but slightly less in the ioxaglate group than in the iopamidol group (p = 0.02). The ST segment depression (mean 0.67m) was more marked in the ioxaglate group than in the other treatment groups (p = 0.0001) during right coronary angiography. The same characteristics, but less marked, were observed during left coronary angiography, the ioxaglate group (mean 0.251mm) differing from the iopamidol group (mean 0.050mm) (p = 0.04). No significant difference in severe adverse reactions were detected between these groups (ioxaglate 1, iopamidol 1). Ioxaglate produced mild side effects (nausea, vomitus, urticaria) in 16% of the patients, the other two contrast agents producing side effects in 1%.

Bone mineral density measured by dual-energy X-ray absorptiometry in healthy Finnish women

A cross-sectional study of 351 healthy Finnish women aged 20-76 years was done to establish reference values of bone mineral density (BMD) using dual-energy X-ray absorptiometry (DEXA). The effects of age and of several physical and lifestyle factors on BMD of the lumbar spine and proximal femur (femoral neck, trochanter, and Ward's triangle area) were investigated. Altogether 58 women were excluded from the final analysis due to significant spinal osteoarthritis or other diseases or drugs known to influence calcium or bone metabolism. The precision of the method was 0.9, 1.2, 2.7, and 2.4% in the lumbar, femoral neck, Ward's triangle and trochanter area, respectively. Lumbar BMD was increased by 30% (P less than 0.001) in 15 patients with osteoarthritis (21% of women 50 years or older), but it was apparently unaffected in 5 cases with aortic calcification. Except for the trochanter area, BMD diminished along with age, and this was significant after the menopause. The peak of mean BMD was observed at the age of 31-35 years in the spine and at the age of 20-25 years in the femoral neck and Ward's triangle. BMD was in a positive relationship to weight both in premenopausal and postmenopausal women and to the use of oral contraceptives in premenopausal women and to that of estrogen replacement therapy in postmenopausal women. Labors and pregnancies had a weak positive effect on BMD in premenopausal women. As compared with nonusers premenopausal women who had used alcohol showed a slightly decreased BMD of Ward's triangle. In postmenopausal women there was a positive correlation between alcohol intake and BMD.

Indications for and risks in reoperation for coronary artery disease

Seventy-one coronary artery bypass grafting (CABG) reoperations were performed during a 17-year period, comprising 2.7% of all CABG operations. The main indication (in 87%) was vein graft failure alone or combined with other causes. Progression of disease in native coronary arteries was the sole indication in only 4 of the 71 cases. There were seven perioperative deaths, mainly due to myocardial infarction. Significant perioperative complications arose in 36 cases, including intraoperative lesion of a previous left internal mammary graft (16.2%) or of the right ventricle or anterior descending branch of the left coronary artery (2.8%). Postoperative low output syndrome appeared in 13 patients (18.3%), in seven of whom myocardial infarction was verified. Postoperative bleeding required resternotomy in six cases (9.1%). Because of the heightened operative mortality and morbidity risks, indications for redo CABG should be individualized. A well functioning internal mammary artery graft may be a relative contraindication. Accurate knowledge of the previous operation is essential and, especially in young patients, the possibility of reoperation should be taken into consideration at initial CABG.

Right gastroepiploic artery as a coronary bypass graft

Between November 1987 and April 1988, the right gastroepiploic artery (GEA) was used as a coronary artery bypass graft in 11 patients, 9 men and 2 women. In 1 of them, the GEA was used because no veins were available; in the others, the GEA was used to avoid the use of vein grafts. The GEA was anastomosed to the right coronary artery in all patients, and internal mammary artery grafts were used to bypass the left anterior descending and circumflex coronary arteries. All patients survived the operation. There were no early and, to date, there have been no late complications of the abdominal component of the operation. Postoperative coronary angiography showed a patent right GEA in 9 patients (82%). In 1 patient the GEA was occluded, probably because of an enlarged liver. If the long-term patency of right GEA grafts is similar to that of internal mammary artery grafts, wider use of this viable graft is indicated.

Heart transplantation in repaired transposition of the great arteries

Cardiac transplantation was carried out in a 40-year-old man with the diagnosis of repaired transposition of the great arteries and right-sided aortic arch who had end-stage cardiac failure due to myopathy of the ventricles. Because of several previous surgical repairs and the orientation of the great vessels, the operation presented some technical problems. Therefore, modifications of operative procedures were used, including recipient hypothermia, circulatory arrest, and changes in the donor heart implantation. The removal of the donor heart was modified in such a way that the graft included the aortic arch and both pulmonary arteries. With the extra length of ascending aorta and transverse arch, the innominate, left carotid, and left subclavian vessels were excised as a button, thereby leaving the distal orifice of the aorta in the superior portion of the transverse arch. For the recipient, the operation was performed using hypothermic total circulatory arrest to dissect free the huge pulmonary artery and the short right-sided aortic arch to place the clamp. Implantation of the donor heart was modified accordingly. The technical results were confirmed one and a half months later on a control digital angiogram. Thirty-five days postoperatively the patient was discharged. Six months after operation, the patient is doing better than ever before in his life. Our findings suggest that a complicated conotruncal development does not preclude cardiac transplantation.

Areae gastricae in gastritis: lack of correlation between size and histology

The area gastrica patterns of the stomach were studied using surgical specimens. From each of 15 patients, two specimens were obtained: one from the antrum and one from the corpus. These 30 specimens were photographed by stereomicroscope, and the areae gastricae were classified into three groups: none, 1-3 mm in diameter, and 4-6 mm in diameter. The same surgical specimens were studied histologically and the findings were compared with the area gastrica groups. Almost all specimens showed superficial and atrophic gastritis. No correlation between the different sizes of the areae gastricae and the histologic findings was found. The different area gastrica patterns have little value as indication of different types of gastritis.

Metoclopramide in double contrast barium meal

The effect of metoclopramide on gastric mucosal coating was studied in this randomized double blind study. One hundred and thirty consecutive patients underwent routine double contrast barium meal. The patients received 20 mg metoclopramide or a placebo before the examination. The visibility of the areae gastricae was used as an indicator of a good mucosal coating. The results indicate that metoclopramide does not have any statistically significant effect on mucosal coating in double contrast barium meal.

Observations on the behavior of barium sulfate contrast media in vitro

The double contrast method in the examination of the stomach has made possible the radiologic diagnosis of the surface lesions of the mucosa, eg, erosions and early gastric cancer. Changes in the patterns of areae gastricae can be visualized with a good contrast medium. We used a new, more physiologic in vitro method to compare contrast media and study the amounts of adsorption, the degrees of visualization of areae gastricae, and the effects of antifoam solution and blood on media adsorption. EZ-HD surpassed other contrast media on the Scandinavian market in total adsorption on the mucosa and the visualization of areae gastricae. Blood significantly reduces the adsorption of all media, while antifoaming agents have little or no effect.

Double contrast examination of the stomach compared with endoscopy

The results of the double examination of the stomach in a series of 102 patients were compared with the findings at endoscopy. Nasogastric intubation was used to introduce the air into the stomach. Hypotonia was achieved mainly with glucagon. The radiologic error rate was 10 per cent, consisting of 7 per cent false negative and 3 per cent false positive findings. The diagnostic advantages of the double contrast technique over those of the conventional barium examination are discussed.

Areae gastricae and gastritis in double contrast barium meal

The areae gastricae were studied in patients with different forms of gastritis and with normal gastric mucosa. The material consisted of 57 patients. First gastroscopy was done and biopsies were taken. The stomach was studied on the following day by the double contrast barium meal. The material was divided according to the gastroscopic and biopsy findings into the following groups: normal, superficial gastritis, mixed gastritis, and atrophic gastritis. In the analysis of the surface pattern, special attention was paid to the shape, size and defects of areae gastricae. Corpus and antrum were dealt with separately. In the normal material the areae gastricae were regular in shape, and the size was usually 1--3 mm. Irregular shape, bigger size and more frequent defect areas seemed to point to gastritis. Such changes were especially clear in atrophic gastritis. The significance of the areae gastricae in practice is discussed.

Radiologic demonstration of Meckel's diverticulum

A case of bleeding Meckel's diverticulum with a positive barium meal examination, selective mesenteric arteriography and 99mTc-pertechnetate scanning is presented. Complementary radiologic examinations are needed in the visualization of Meckel's diverticulum due to difficulties in making the correct diagnosis.