bluuebunny/crossref_metadata_2025 huggingface dataset:
Features of the hemodynamic response to amyl nitrite inhalation: Ew aspects of an old tool
Authors: Moody M. , Rubal Bernard J. , Balley Steven R.
Published: August 2009

Although amyl nitrite inhalation (ANI) antedates current short acting vasodilators as a clinically useful pharcologic stressor, few clinicians are aware of the subtle hemonamic actions of this agent. This study examined transients left and right heart hemodynamics after ANI in seven men ages 44 ± 7 years) undergoing elective cardiac catheterization. ‐fidelity central aortic (AoP), left ventricular (LVP), pulonary artery (PAP), right ventricular (RVP), and right atrial (PAP) pressures were simultaneously recorded from left and right heart multisensor catheters. As expected, ANI caused an fall in Ao pressure (27%; p<0.01) and reflex (p<0.001). Little change was noted in PAP, RVP, RAP, or end‐diastolic pressures or the time constant of LV isovolnetric relaxation (tau). LV ejection time decreased 23 ± 10 (p<0.05) and RV ejection time did not change. Baroreflex was similar during pressure fall and recovery (6.4 ± vs. 6.1 ± 3.6 ms/mmHg), however hysteresis (p<0.05) was. Aortic pressure waveforms also changed following ANI. Changes were determined to be in part a consequence of the atanuation and delay in arterial wave reflections. This study the understanding of the complex nature of the hemodynamic response associated with ANI.
AAI pacing mode: When is it indicated and how should it be achieved?
Authors: Katritsis Demosthenes , Camm A. John
Published: August 2009

AAI pacing offers better hemodynamic characterstics than dual‐chamber pacing and is the optimal mode for patents with sick sinus syndrome without AV conduction disorders. AAI pacing may be achieved by single‐chamber atrial, by programming a dual‐chamber pacemaker to the AAI mode, or by programming a dual‐chamber pacemaker to DDD mode with a long AV delay. The annual incidence of AV block development in patients with sick sinus syndrome is low, probably 1‐5%, but there is no method of detecting patients immune to future development of AV block. Chronotropic is often present in patients with sick sinus but the value of additional rate response is not yet established. Our recommendations for the choice of the method of pacing are discussed.
Anatomy, histology, and pathology of the cardiac conduction system: Part II
Authors: Waller Bruce F. , Gering Lawrence E. , Branyas Nancy A. , Slack John D.
Published: August 2009

Normal anatomic and histologic features of the atrioventricular junction (transitional cell zone, atrioventricular node, penetrating portion of bundle) and the bifurcation of the penetrating portion into bundle branches are reviewed. Terminal ventricular Purkinje fibers are also discussed.
The postcardiac injury syndrome following percutaneous transluminal coronary angioplasty
Authors: Velander M. , Grip L. , Mogensen L.
Published: August 2009

A 57‐year‐old man, who had suffered an anterior Q‐wave myocardial infarction complicated with typical postcardiac injury syndrome (PCIS) 9 years earlier, underwent percutaneous transluminal coronary angioplasty (PTCA) without any immediate clinical, laboratory, or radiological signs of complications. After 4 days he recognized the recurrence of the earlier symptoms of PCIS. The diagnosis was supported by slight fever, elevated inflammatory parameters, and improvement when oral corticosteroids were given. The observations suggest that milder cardiac injury than previously considered, that is, without demonstrated structural damage to pericardium or myocardium, may precipitate PCIS in predisposed individuals. The case adds a differential diagnosis to chest pain and malaise following PTCA.
Coronary artery rupture during transluminal coronary recanalization and angioplasty in a case of acute myocardial infarction and shock
Authors: Eeckhout E. , Beuret P. , Goy J. J. , Lobrinus A. , Genton C. Y.
Published: August 2009

Percutaneous transluminal coronary angioplasty (PTCA) is a widely performed and effective therapy for coronary artery disease. Evolution of the dilatation instruments during the last decade has led to an increased success rate of PTCA and to the development of newer techniques such as recanalization of totally occluded coronary arteries. We report a case of coronary artery recanalization complicated by fatal coronary artery rupture.
Giant dissecting aortic aneurysm with concealed perforation in an 81‐year‐old female
Authors: Eber Bernd , Sarlay Holger , Dusleag Johann , Kullnig Peter , Ebner Franz
Published: August 2009

This paper describes the history of an 81‐year‐old female suffering from a giant dissecting aortic aneurysm with concealed perforation within the thorax. The patient had suffered from arterial hypertension for about 10 years and had been treated with thiazide. Nine months prior to admission the patient was in a state of collapse, and ultrasound examination revealed an intra‐abdominal aortic aneurysm. At this time thoracic x‐ray showed aortic sclerosis and elongation of the aorta but no signs of aneurysm formation. After this episode the patient was symptom‐free for the next 9 months. Following a further syncopal attack with severe thoracic pain, the patient was hospitalized at the intensive care unit. Both in thoracic x‐ray and computed tomography of the thorax, a pronounced dissecting aortic aneurysm with perforation of the thoracic aorta into the mediastinum could be established. Because of the patient's poor general condition and advanced age, as well as far reaching pathological findings, surgery was not advised by either the heart and vascular surgeon or the anesthetist. Following 1 week's intensive therapy, the patient's general condition improved greatly, with stabilization of thoracic pain, blood pressure, and respiratory action. On the other hand, thoracic x‐ray, computed tomography, and magnetic resonance imaging produced a distinct progression of the aneurysm with consequent mild displacement of mediastinum and left lung. Laboratory examinations for syphilis showed no evidence of that disease. After further improvement the patient was discharged 4 weeks after admission and has been symptom‐free for 6 months in spite of the extensive pathological findings described herein. This case demonstrates the efficacy of conventional therapy when surgery is not recommended.
Balloon dilatation of inferior vena cava obstruction in budd‐chiari syndrome
Authors: Short Sydney G. , Jian Liu , Ruijie Li
Published: August 2009

Budd‐Chiari syndrome is a well described entity which can easily be confused with congestive hepatomegaly. The syndrome usually is caused by thrombosis of the hepatic veins, however it also can be caused by congenital fibrous webs that occlude hepatic vessels in the inferior vena cava. It leads to an enlarged liver with ascites, peripheral edema, and portal hypertension.
The toxic oil syndrome
Authors: James Thomas N.
Published: August 2009

Hundreds died and thousands were poisoned by rapeseed oil adulterated with aniline and sold illegally in Spain in 1981. The clinical manifestations, now known as the toxic oil syndrome, include pulmonary hypertension and right ventricular hypertrophy plus widespread vascular and neural lesions in other organs. Many of the late deaths ended with a scleroderma‐like illness. Because scleroderma involves the heart, an examination was made of the small and large coronary arteries, the neural structures, and the conduction system from 11 victims dying with the toxic oil syndrome. Dense fibrosis, atrionodal junctional hemorrhages, and cystic degeneration of the sinus nodes were present. Small and large coronary arteries exhibited focal fibromuscular dysplasia and a proliferative cystic myointimal degeneration. This latter abnormality was associated with sloughing of the inner wall and embolization of the detached fragment downstream in the same coronary artery. Every heart had many degenerative lesions within nerves, ganglia, and the coronary chemoreceptor. Based upon observations by others with experimental feeding of rapeseed oil containing either high or low erucic acid, it is suggested that this oil must remain a major suspected cause of the toxic oil syndrome, particularly in conjunction with some as yet unexplained facilitative influence by oleoanilids. If this is so, it is important to reexamine the widely recommended use of any rapeseed oil product as a suitable food for humans or animals.
The effect of successful angioplasty on variables of signal‐averaged electrocardiogram and ventricular wall motion in patients with a first myocardial infarction
Authors: Masui Akira , Tsuji Hisako , Tamura Koji , Kamihata Hiroshi , Karakawa Masahiro , Sugiura Tetsuro , Iwasaka Toshiji , Inada Mitsuo
Published: August 2009

The correlation among three variables of late potentials (LPs) obtained by signal‐averaged electrocardiography (SAECG) and improvement of ventricular wall motion estimated by echocardiography were studied in 66 patients with a first acute myocardial infarction (MI). Patients with bundle‐branch block, intraventricular conduction delay, multi‐vessel disease, previous MI, repeat percutaneous transluminal coronary angioplasty (PTCA), or evidence of reinfarction during a 6‐month follow‐up were excluded. A total of 66 patients was divided into two groups, with (Group 1: n = 27, age 56 ± 11) or without (Group 2: n = 39, age 61 ± 10) improvement of ventricular wall motion. Three variables of LPs and ventricular wall motion index (WMI) estimated and scored by echocardiography at admission (WMI 1) and at 6 months after MI (WMI 2) were compared in each group. In Group 1 (WMI 1 vs. WMI 2, p < 0.002), 20 of 27 patients underwent successful angioplasty; in Group 2 (WMI 1 vs. WMI 2, p = NS), 7 of 39 patients had successful emergency angioplasty. There were significant differences in three variables of LPs between the time of admission and at 6 months after MI in Group 1 but not in Group 2. Higher incidence of LPs and greater frequency of successful emergency PTCA were found in Group 1 compared with Group 2. These results suggest that because myocardial ischemia is reversed by successful angioplasty, ventricular wall motion is improved and the arrythmogenic substrate that generates LPs is stabilized electrically. Stunned or hibernating myocardium may be the arrhythmogenic substrate that generates LPs.
Conversion from immediate‐release to extended‐relase diltiazem in angina pectoris
Authors: Pool Peter E. , Thadani Udho , Miller Alan B. , Fromell Gregg J. , Eff Jack
Published: August 2009

This multicenter, open‐label, single crossover study examined 195 patients taking an immediate‐release diltiazem tablet as chronic stable angina therapy to determine if apparently logical methods of converting them to an extended‐release, once‐daily formulation were effective. Patients were converted from the immediate‐release (Phase I) to an extendedrelease (Phases II) formulation of diltiazem on a mg‐for‐mg basis or, when a similar dose was not available, to the next higher 120mg dose. Weekly angina occurrences and nitroglycerin use, exercise testing at the end of each phase, and ambulatory electrocardiographic monitoring (AEM) during the week prior to the exercise study were evaluated. There was a statistically significant decrease in angina frequency and nitroglycerin consumption during Phase II. In the exercise studies, there was an insignificant increase in time to 1 mm ST‐segment depression and total exercise time associated with a statistically significantly lower end‐exercise blood pressure and heart rate in Phase II. In those patients who had ischemia during either phase on AEM, total ischemic duration and ischemic episodes were insignificantly lower in Phase II. All observations were similar in the subgroup of patients who were converted mg‐for‐mg. Adverse reactions were equal. Thus, in converting patients from an immediate‐to an extended‐release diltiazem formulation for the treatment of symptomatic coronary artery disease, it is reasonable to convert directly to the same or, if not available, the next higher available dose of the extended‐release preparation.
Factors associated with the development of persistently depressed cardiac output during the first year after cardiac transplantation
Authors: Glazier James J. , Mullen G. Martin , Johnson Maryl R. , Ching‐Tung  , Heroux Alain L. , Kao Walter G. , Koch Dorothea , Khatib Yazan , Fisher Susan G. , Costanzo Maria Rosa
Published: August 2009

The purpose of this study was to determine factors associated with the development of a persistently depressed cardiac output during the first year after cardiac transplantation. With this aim in mind, the records of 133 consecutive patients undergoing orthotopic cardiac transplantation and surviving for ≥1 year after transplantation were reviewed. For each patient, the mean cardiac index for each of the 3‐month periods, 0‐3, 4‐6, 7‐9, and 10‐12 months after transplantation was calculated. of the 133 patients, 19 (14%) had a mean cardiac index < 2.41/min/m2 during ≥3 of these 3‐month periods. The pre‐ and post‐transplantation clinical, immunologic, and hemodynamic data of these 19 patients (study group) were compared with the remaining 114 patients (control group). Compared with the control group, the patients in the study group were older (56±5 vs. 46±15 years; p = 0.0001), more frequently had ischemic heart disease as the original diagnosis (58 vs. 37%; p < 0.05), had a lower preoperative cardiac index (1.91 ± 0.53 vs. 2.71 ± 1.0 1/min/m2; p = 0.0001), more frequently did not receive perioperative anti‐T cell therapy (47 vs. 25%; p=0.046), and had a greater median number of infections during the first year after transplantation (5 vs. 3; p = 0.027). However, only one factor—a low preoperative cardiac index—emerged as an independent predictor of the development of a persistently depressed cardiac index during the first year after transplantation. Of note, mean systemic vascular resistance was higher in the study group than in the control group at every 3‐month period following cardiac transplantation. One possible although largely speculative explanation of the latter observation is that heart transplantation does not entirely reverse the neurohumoral abnormalities of chronic heart failure. Furthermore, this persistently elevated systemic vascular resistance may impact negatively on long‐term allograft function.
Pacing for sinus node disease: A therapeutic rationale
Authors: Brandt Johan , Schüller Hans
Published: August 2009

Symptomatic sinus node disease is a common indication for permanent pacemaker implantation. Single‐chamber ventricular (VVI) pacing, single‐chamber atrial (AAI) stimulation, and dual‐chamber (DDD or DDI) systems are used to a varying extent at different implanting centers. Hemodynamic and clinical studies relevant to the choice of pacing mode in these patients are reviewed. The data currently available strongly support the use of pacing systems providing atrial stimulation. The choice between single‐chamber atrial or dual‐chamber pacing can be based on the relative importance assigned to a number of factors: Hemodynamic aspects, the risk of ventricular lead problems, cost, and complexity aspects favor AAI pacing, whereas patients with a substantial risk of developing atrioventricular block should receive a DDD or DDI unit.
Reproducibility of the spectral turbulence analysis of the signal‐averaged electrocardiogram
Authors: Vado Antonello , Bruna Claudio , Rossetti Guido , Uslenghi Eugenio
Published: August 2009

Spectral turbulence analysis (STA) of the signal‐averaged electrocardiogram (SAECG) is a recently proposed technique to identify patients with ventricular tachycardia as well as patients at risk for arrhythmic events after acute myocardial infarction (MI). The short‐term reproducibility of this technique has been previously reported; our study evaluates the reproducibility of STA by shifting the reference points. Twenty patients with acute MI were recruited. SAECG was recorded 13 days after onset of the acute MI. Unfiltered data were transferred and analyzed by personal computer software for spectral turbulence analysis according to the standard condition; reference points of the segment of interest were shifted from QRS offset −10 ms and QRS onset −10 ms to QRS offset +10 ms and QRS onset +10 ms, step 2 ms. Thus, 10 analyses were computed. Reproducibility of the results was calculated using the coefficient of variation (CV) and the relative error (RE). The reproducibility of the classification (RC) was defined as the percentage of the identical classification compared with the standard segment. CV of the intersegment correlation standard deviation was statistically higher than the other parameters regardless of the lead considered. RE was not different in each parameter and in each lead. RC was > 90% in all parameters, except in spectral entropy which showed an RC > 80%. Reproducibility of the STA introducing a temporal shift in the analyzed segments was high in all considered parameters.
Echocardiographic diagnosis of congential absence of the pericardium in a patient with VATER association defects
Authors: Lu Charles , Ridker Paul M.
Published: August 2009

The VATER association denotes a nonrandom pattern of congential malformations which typically include vertebral defects, anal atresia, tracheo‐esophageal fistula, and radial and renal dysplasia. Vascular anomalies including ventricular septal defect and single umbilical artery have also been described, although the frequency of cardiovascular anomalies in this congenital association is unknown. In this report, we describe a 26‐year‐old patient with several VATER association defects who, in addition, was found to have congenital absence of the left pericardium and an aberrant right subclavian artery.
Electrocardiographic and segmental wall motion abnormalities in pancreatitis mimicking myocardial infarction
Authors: Patel Jayesh , Movahed Assad , Reeves William C.
Published: August 2009

Transient electrocardiographic changes in patients with acute cholecystitis, pancreatitis, and pneumonia have been reported in the past.1‐5These changes usually are in the form of T‐wave inversion, ST‐segment depression, and rarely ST‐segment elevation in the absence of coronary artery disease.1‐5To the authors' knowledge, this is the first report documenting both left ventricular segmental wall motion abnormality and electrocardiographic changes of myocardial injury in the presence of acute pancreatitis.
Newer doppler measures of left ventricular diastolic function
Authors: Pai Ramdas G. , Buech Geneen C. C.
Published: August 2009

Left ventricular (LV) diastolic dysfunction is an important cause of heart failure, and recent advances in the application of Doppler techniques allow a semiquantitative assessment of LV diastolic performance. This review discusses the use of Doppler echocardiography in the comprehensive assessment of LV diastolic function and performance in terms of the normal mitral and pulmonary venous flow profiles, their physiologic basis, and alteration in diseased states. There is also a discussion on the newer aspects of mitral flows such as relative durations of mitral A and pulmonary vein AR waves, E‐ and A‐wave propagation inside the LV with their hemodynamic correlates, and derivation of ventricular dP/dt and Tau from the mitral regurgitation velocity profile. Analysis of these flow profiles and the other Doppler measures alluded to above allow one to make a fairly precise hemodynamic assessment of a patient in terms of left atrial pressure, LV relaxation and stiffness and the profile of LV diastolic pressure in terms of pre‐‘a’ wave and ‘a’ wave pressures and ventricular end‐diastolic pressure.
Evidence for a relation between inspired gas mixture and the left ventricular contrast achieved with albunex® in a Canine Model
Authors: Geiser Edward A. , Cunningham Michael S. , Wilson David C. , Buss Daryl D. , Wible James H. , Webb Alistair I. , Yang Mark
Published: August 2009

Background: In a previous experiment, a marked reduction in the right‐and left‐sided contrast effect of Albunex was noted in an intubated animal spontaneously breathing isoflurane in 100% oxygen. The theory suggests that the time course of echogenicity of microbubbles in a liquid is dependent on the pressure and the gradients of dissolved gases. The present set of experiments tested whether the loss of contrast occurs at commonly used therapeutic concentrations of inspired oxygen.

Hypothesis: This research tested the hypothesis that the left ventricular (LV) contrast effect achieved with intravenous injection of the ultrasound contrast agent Albunexr̀ is related to the inspired oxygen content.

Methods: Intubated dogs were maintained in a spontaneously respiring anesthetic state on isoflurane and mixtures of oxygen (12‐50%) in nitrogen. FIo2 was held steady for 15 min prior to injection of 0.08 ml/kg of Albunex. The contrast effects were recorded from a transthoracic short‐axis view. Left and right ventricular brightness curves were generated from digitized sequences of end‐diastolic frames. The minimum and maximum brightness and area under the time‐brightness curves were determined.

Results: The LV maximum brightness and area under the curve showed significant negative correlations (p = <0.004) with the FIo2, while the minimum brightness showed a significant positive correlation (p = < 0.002). No significant correlations were found for the right ventricular brightness parameters.

Conclusions: These findings show an important relationship between the FIo2 and loss of the contrast effect of Albunex. This loss occurs at oxygen concentrations in the therapeutic range, but could be overcome by increasing the dose of Albunex. The mechanism is likely related to an outward nitrogen gradient causing a loss of echogenicity. The clinical implication is that patients on supplemental oxygen may require higher doses of Albunex to achieve optimal opacification.
Effects of heart rate on flow velocity of the left atrial appendage in patients with nonvalvular atrial fibrillation
Authors: Noda Toshiyuki , Arakawa Michio , Mrwa Hiroshi , Ito Yoshimi , Kagawa Kensaku , Nishigaki Kazuhiki , Hirakawa Senri , Fujiwara Hisayoshi
Published: August 2009

Background and hypothesis: Flow velocity of the left atrial appendage (LAA) is thought to be important in thrombus formation in association with blood stasis and the development of spontaneous echo contrast. The effects of heart rate on peak flow velocity of the LAA have not been studied in patients with nonvalvular atrial fibrillaton.

Methods: Using transesophageal Doppler echocardiography, peak flow velocity of the LAA was measured at the junction between the left atrium and the LAA during left ventricular (LV) systole and diastole in 21 patients with nonvalvular atrial fibrillation. In six cases, the average peak flow velocity of the LAA for 10 consecutive beats with moderately long R‐R intervals (LI beats) was compared with those for 3‐5 consecutive beats with extremely short R‐R intervals (SI bets).

Results: Average peak flow velocity of the LAA during LV diastole was significantly higher than that during LV systole (26.5 ± 15.7 vs. 19.3 ± 10.4 cm/s, p<0.01). In SI beats, average peak flow velocity of the LAA was significantly lower than that in LI beats (17.1 ± 12.1 vs. 21.2 ± 12.9 cm/s, p<0.01).

Conclusion: An increased heart rate reduced the peak flow velocity of the LAA in patients with nonvalvular atrial fibrillation, which would promote blood stasis in the LAA.
Association of Conventional and Exertional Coronary Heart Disease Risk Factors in 5,000 Apparently Healthy Men
Authors: Davies Bruce , Ashton William D. , Rowlands Derek J. , El‐Sayed Mahmoud , Wallace Philip C. , Duckett Ken , Coley John , Daggett Anne M.
Published: August 2009

Background and hypothesis: The aim of this study was to define the prevalence of previously undetected coronary heart disease among asmptomatic males, aged 30‐65 years, by means of resting and exercise electrocardiography in conjunction with an analysis of conventional and exertional coronary risk factors.

Methods: Between January 1985 and December 1989 we examined 5,000 clinically asymptomatic subjects. A detailed case history was obtained for each individual, followed by a complete physical examination, comprehensive blood (including lipid) profile, lung function tests, chest x‐ray, a resting 12‐lead electrocardiogram (ECG), and a maximal treadmill exercise ECG. Whenever possible, on‐line computerized respiratory analysis (Beckman Metabolic Measurement Cart) was carried out during the exercise tests. Conventional and exertional coronary heart disease risk factors were also recorded.

Results: A total of 162 persons (3.2%) showed abnormal S‐T segment responses during the exercise or recovery period. Of these, 92 subjects underwent further investigations: coronary angiography (79), 201thallium scanning (13), 201thallium scanning followed by coronary angiography(7). Of the 86 patients who proceeded to cornoary angiography, 19 (22%) had either normal coronary artery anatomy or only insignificant disease. Among the 67 (78%) of patients with significant angiographically demonstrable disease, 26 received coronary artery bypass grafting, 7 underwent coronary angioplasty, and the remainder continued on medical management.

Conclusions: These results are discussed in relation to a variety of conventional and exertional coronary risk factors.
F‐Amplitude, left atrial appendage velocity, and thromboembolic risk in nonrheumatic atrial fibrillation
Authors: Blackshear Joseph L. , Safford Robert E. , Pearce Lesly A. ,   On Behalf of the Stroke Prevention in Atrial Fibrillation Investigators
Published: August 2009

Background: Reduced left atrial appendage velocity (LAAV) has been identified as a marker for thromboembolism in patients with atrial fibrillation.

Hypothesis: It was postulated that electrocardiographic (ECG) F‐wave amplitude would correlate with LAAV, and inversely with the risk of thromboembolism in patients with atrial fibrillation.

Methods: In all, 53 patients with nonrheumatic (NRAF) and 7 patients with rheumatic (RAF) atrial fibrillation underwent assessment of maximum LAAV, which was correlated to the maximum ECG F‐wave voltage from lead V1 (Fmax). In 450 NRAF patients on neither aspirin nor warfarin, the relationship between Fmax and thromboembolic risk was assessed over an average follow‐up of 1.3 years.

Results: Fmax did not correlate with LAAV (r = 0.2, p = 0.07). Patients with intermittent atrial fibrillation (n = 123) had smaller Fmax amplitude than patients with constant atrial fibrillation (n = 327) (mean 0.73 vs. 0.88 mV−1, p = 0.001). Fmax amplitude was not related to a history of hypertension, systolic blood pressure, duration of NRAF, abnormal transthoracic echocardiographic left ventricular (LV) systolic function or left atrial (LA) diameter. There was a strong trend for increased LV mass being related to smaller Fmax amplitude after adjusting for body surface area (p = 0.06). Fmax amplitude was not correlated with risk of embolic events, including only those events presumed by a panel of case‐blinded neurologists to be cardioembolic.

Conclusion: Fmax amplitude in NRAF is smaller in patients with intermittent versus constant AF. It does not correlate with LAAV, LA size, increased LV mass, or systolic dysfunction, hypertension, or risk of embolism. Therefore, Fmax amplitude may not be used as a surrogate for LAAV, or as a measure of thromboembolic risk in NRAF.
Holmium laser‐assisted coronary angioplasty in acute ischemic syndromes
Authors: De Marchena Eduardo , Larrain German , Posada Juan D. , Tang Sherman , Mcghee Vivian , Mallon Stephen
Published: August 2009

Background and hypothesis: Initial studies have shown holmium laser to be effective in ablation of coronary atheromam, and small studies suggest that it may be helpful in ablation of thrombotic stenoses. Therefore, holmium laser‐assisted coronary angioplasty was studied in 85 consecutive patients with acute ischemia syndromes.

Methods: Indications for therapy were acute myocardial infarction (MI) in 7 patients (8%), post‐MI ischemic in 32 patients (38%), and crescendo angina pectoris in 46 patients (54%). Coronary morphology characteristics by multivessel angioplasty prognosis group criteria were Type A in 9 (10%), Type B1 in 15 (18%), Type B2 in 44 (52%), Type C in 17 patients (20%).

Results: Angiographic evidence of thrombus was seen in 37 (44%) of patients. The laser successfully crossed the total length of the coronary narrowing in 76 patients (89%). Procedure/clinical success was 92% for the total study population, 100% for patients with acute MI, 94% for post‐MI ischemia patients, and 89% for patients with crescendo angina. Lesions with and without thrombus had identical procedure succes rates. Major complication rate was 3.5%, (deaths 0%, Q‐wave MI 0%, and emergent bypass surgery 3.5%). Six‐month angiographic restenosis rate (>50% stenosis) was 45%.

Conclusion: Holmium laser‐assisted balloon angioplasty appears promising in the treatment of acute ischemic syndromes and thrombotic coronary lesions.
Prognosis of patients with frequent premature ventricular complexes and nonsustained ventricular tachycardia after coronary artery bypass graft surgery
Authors: Pinto Rodger P. , Romerill David B. , Nasser William K. , Schier John J. , Surawicz Borys
Published: August 2009

Background: Previous studies in small groups of predominantly nongeriatic patients showed that complè ventricular arrhythmias occurring after coronary artery graft (CABG) surgery are of no prognostic significance. The purpose of this study was to compare the prognosis of patients with and without advanced grade ventricular arrhythmias (AGVA) after CABG in a large group of patients. [In this paper, AGVA is used as an abridged definition of frequent premature ventricular complexes (PVCs) and nonsustained ventricular tachycardia (NSVT) which represent advanced grade ventricular arrhythmias.]

Methods: Twenty‐four hour ambulatory electrocardiographic (ECG) monitoring was performed 3 days after CABG in 185 consecutive patients with and 185 closely matched control patients without AGVA. Of 185 patients with AGVA, 77 had frequent PVCs, 45 had NSVT, and 63 patients had both. The average age of both groups was 65 ± 9.7 years. Patients were followed for 34 ± 10 months, and in 30 patients ambulatory monitoring was repeated at the end of the follow‐up.

Results: Fifteen AGVA and nine control patients died. In each group seven deaths were noncardiac. Six nonsudden and two sudden cardiac deaths (SCD) occurred in the AGVA group at 2‐36 months after CABG and two nonsudden cardiac deaths in the control group at 3 and 35 months after CABG (p = 0.053). Both SCDs occurred 33 months after CABG after new events known to predispose to SCD. In 18 of 30 patients AGVÀ was no longer present when ambulatory ECG monitoring was repeated 36 ± 11 months after CABG.

Conclusions: AGVA after CABG was not a marker of an early sudden cardiac death. In 60% of patients not treated with antiarrhythmic drugs, AGVA was no longer present late after operation.
Ionic mechanisms of ischemia‐related ventricular arrhythmias
Authors: Ducceschi Valentino , Di Micco Gianluca , Sarubbi Berardo , Russo Biancamaria , Santangelo Lucio , Iacono Aldo
Published: August 2009

The aim of this review is the utmost simplification of the cellular electrophysiologic background of ischemia‐related arrhythmias. In the acute and subacute phase of myocardial infarction, arrhythmias can be caused by an abnormal impulse generation, abnormal automaticity or triggered activity caused by early or delayed afterdepolarizations (EAD and DAD), or by abnormalities of impulse conduction (i.e., reentry). This paper addresses therapeutic intervention aimed at preventing the depolarization of “pathologic” slow fibers, counteracting the inward calcium (Ca) influx that takes place through the L‐type channels (Ca antagonists), or hyperpolarizing the diastolic membrane action potential, increasing potassium (K) efflux (K‐channel openers) in arrhythmias generated by an abnormal automaticity (ectopic tachycardias or accelerated idioventricular rhythms). If the cause of enhanced impulse generation is related to triggered activity, and since both EAD and DAD are dependent on calcium currents that can appear during a delayed repolarization, the therapeutic options are to shorten the repolarization phase through K‐channel openers or Ca antagonists, or to suppress the inward currents directly responsible for the afterdepolarization with Ca blockers. Magnesium seems to represent a reasonable choice, as it is able to shorten the action potential duration and to function as a Ca antagonist. Abnormalities of impulse conduction (reentry) account for the remainder of arrhythmias that occur in the acute and subacute phase of ischemia and for most dysrhythmias that develop during the chronic phase. Reentrant circuits due to ischemia are usually Na channel‐dependent. Drug choice will depend on the length of the excitable gap: in case of a short gap (ventricular fibrillation, polymorphic ventricular tachycardia, etc.), the refractory period has been identified as the most vulnerable parameter, and therefore a correct therapeutic approach will be based on drugs able to prolong the effective refractory period (K‐channel blockers, such as class III antiarrhythmic drugs); on the other hand, for those arrhythmias characterized by a long excitable gap (most of the monomorphic ventricular tachycardias), the most appropriate therapeutic intervention consists of depressing ventricular excit‐ability and conduction by use of sodium‐channel blockers such as mexiletine and lidocaine. Compared with other class I antiarrhythmic agents, these drugs minimally affect refractoriness and exhibit a use‐dependent effect and a voltage‐dependent action (i.e., more pronounced on the ischemic tissue because of its partial depolarization).
Regional cardiac compression due to a large anaerobic bacterial empyema
Authors: Colleran John A. , Papademetriou Vasilios , Lu David , Fletcher Ross D. , Ballo Michael S.
Published: August 2009

Compression of the heart outside the pericardial sac is a rare cause of hemodynamic compromise and cardiac tamponade. We report an atypical case of regional cardiac compression caused by a large loculated anaerobic bacterial empyema.
Malposition of transvenous pacing lead in the left ventricle
Authors: Raghavan Chakravarthy , Cashion W. Richard , Spencer William H.
Published: August 2009

Transvenous pacemaker lead malposition in the left ventricle occurs rarely and requires a high index of suspicion for proper diagnosis. The case of a woman with unintentional lead placement in the left ventricle is presented. She had two episodes of transient neurologic deficits, possibly secondary to embolic events, and was started on oral anticoagulants. Chest x‐ray and electrocardiogram (ECG) suggested pacemaker lead malposition and transesophageal echocardiography revealed sinus, venosus atrial septal defect. The lead was shown to cross the atrial septum and the mitral valve to the left ventricle. The malpositioned lead was successfully removed from the left ventricle at the time of surgical repair of the atrial septal defect. The potential value of 12‐lead ECG, chest x‐ray, posteroanterior and lateral views, and echocardiography in the diagnosis of pacemaker lead malposition are discussed and recommendations to avoid this complication at the time of pacemaker implant are outlined.
Wound healing following myocardial infarction
Authors: Weber Karl. T. , Sun Yao , Katwa Laxmansa C.
Published: August 2009

A wound‐healing response that eventuates in fibrous tissue formation appears at the site of myocardial infarction (MI) in the affected ventricle. Fibrosis can likewise appear remote to the MI and cause an extensive structural remodeling of the myocardium of infarcted and noninfarcted ventricles. Substances involved in promoting healing at and remote to MI are of considerable interest and an important clinical issue, given that the healing response is subject to pharmacologic intervention. Angiotensin‐converting enzyme (ACE) is expressed by wound‐healing fibroblast‐like cells; it likely serves to regulate local concentrations of angiotensin II and bradykinin involved in healing and matrix remodeling. Wound healing following MI and its regulation are addressed in this review.
Evaluation of heart failure patients: Objective parameters to assess functional capacity
Authors: Mills Roger M. , Haught W. Herbert
Published: August 2009

Measures of disease severity used in the evaluation of patients with heart failure include survival data, the New York Heart Association classification, ejection fraction, functional assessments, exercise protocols, rest and exercise hemodynamic data, and biochemical parameters including catecholamine levels and serum sodium. Clinicians must integrate these multiple variables into an overall assessment. An overview of the clinical application of these techniques in the evaluation and treatment of patients with heart failure is presented.
Effects of intracoronary carbon dioxide on left ventricular function in swine
Authors: Lambert Charles R. , Bikkina Mahesh , Arcement Brian K. , De Marchena Eduardo J.
Published: August 2009

Background and hypothesis: Carbon dioxide is currently used as an arterial and venous contrast agent; however, little is known of its effects on left ventricular function. This study was undertaken to investigate those effects.

Methods: Ascending doses of 5, 10, and 20 ml of carbon dioxide were administered into the left main coronary artery of domestic swine with and without a continuous infusion of intravenous nitroglycerin (50 μg/min).

Results: Carbon dioxide had an immediate and profound depressant effect on both systolic and diastolic left ventricular function associated with ischemic electrocardiographic changes. Compared with controls (% change), ascending doses of carbon dioxide decreased systolic pressure by −35 ± 7, −48 ± 8, and −53 ± 4 in the absence of nitroglycerin, and by −32 ± 9, −50 ± 9, and −60 ± 9 in the presence of nitroglycerin. Peak +dP/dt decreased by −54 ± 7, −61 ± 11, and −64 ± 3 in the absence of nitroglycerin, and by −36 ± 13, −55 ± 11, and −65 ± 11 in the presence of nitroglycerin. Minimum ‐dP/dt increased by 65 ± 8, 71 ± 8, and 77 ± 3 in the absence of nitroglycerin, and by 63 ± 7, 71 ± 8, and 78 ± 7 in the presence of nitroglycerin. No significant changes in heart rate were observed; however, widespread ST‐segment elevation was observed in all animals. Coronary angiography following carbon dioxide injection revealed a marked decrease in coronary flow velocity until the gas was cleared from the microcirculation. This was also documented by direct measurement of flow velocity using a Doppler catheter in an additional animal. Left ventriculography demonstrated immediate global dilation and depression of systolic function.

Conclusions: In the swine model, relatively small doses of intracoronary carbon dioxide cause profound yet reversible global left ventricular dysfunction which appears to be ischemic in origin.
Diagnosis of silent myocardial ischemia using ambulatory electrocardiographic monitoring with pedometer, analysis of heart rate, and ST loop in ambulatory electrocardiogram
Authors: Ino‐Oka Eui , Takahashi Takashi , Sagawa Kouichi , Inooka Hikaru
Published: August 2009

Background: It has been suggested that episodes of silent myocardial ischemia (SMI) might influence the prognosis of patients with ischemic heart disease, as its consequences are similar to those of myocardial ischemia accompanied by pain. Ambulatory electrocardiogram (ECG) is generally employed in diagnosis as well as in evaluation of clinical efficacy in patients with SMI, but problems related to its application remain because of the difficulty in differentiating between nonischemic and ischemic ST‐segment depressions and because of the absence of data concerning body movement.

Methods and results: We developed a method for simultaneously recording onto magnetic tape both the ECG chart and pedometer count, as well as a program which enables semi‐automatic analysis of the heart rate (HR)‐ST relationship. This new method was employed to record ambulatory ECG along with pedometer count for a total of 70 patients, consisting of 53 with coronary heart disease who were shown to have ischemic heart disease, and 17 with various heart diseases in whom coronary angiography revealed no coronary stenosis. The HR‐ST relationship was assessed for periods during which steps were recorded by the pedometer, that is, when patients were confirmed to have been under exertion effort. Patients demonstrating the following findings were diagnosed as true positive for SMI: the ST segment level did not decline until HR increased to a certain threshold, and the rate of change in the ST‐segment level noted thereafter was −0.025 mm/beats/min or lower; or the ST‐segment depression induced by effort continued even after discontinuation of exercise, after which time HR began to decrease, and the HR‐ST loop consequently described a counterclockwise rotation. Evaluation of the HR‐ST relationship based on these criteria revealed excellent results, as demonstrated by values of 79.2% for sensitivity and 94% for specificity.

Conclusion: Our newly developed method of assessment of the HR‐ST relationship via analysis of simultaneous data from an ambulatory ECG and a pedometer appears to be time saving, highly objective, and useful with regard to the diagnosis of SMI and evaluation of the therapeutic effect of drugs in patients with ischemic heart disease.
Increased serotonin release across the coronary bed during a nonischemic interval in patients with vasospastic angina
Authors: Murakami Yo , Ishinaga Yuji , Sano Kazuya , Murakami Rinji , Kinoshita Yoshihisa , Kitamura Jun , Kobayashi Kanako , Okada Seiji , Shimada Toshio , Morioka Shigefumi , Matsubara Kazuo
Published: August 2009

Background: Platelet activation and coagulation abnormality have been observed during coronary spasm. It is crucial whether platelet activation occurs even during a nonischemic period.

Hypothesis: This study was designed to determine whether platelets might be activated across the coronary bed during a nonischemic interval in patients with vasospastic angina.

Methods: Plasma levels of serotonin, 6‐keto‐prostaglandin F1 α, and catecholamines in the aorta and the coronary sinus were simultaneously measured in 16 patients with vasospastic angina and 13 control patients with nonischemic heart disease.

Results: None of these patients showed myocardial ischemia during sampling. The difference in transcardiac plasma levels of serotonin in patients with vasospastic angina was significantly higher than that in controls (1.48 ± 1.08 ng/ml vs. 0.07 ± 0.12 ng/ml, respectively, p<0.001). Coronary sinus plasma norepinephrine levels in these two groups were almost the same (204.8 ± 110.8 pg/ml vs. 190.4 ± 131.6 pg/ml, respectively). The ratio of 6‐keto‐prostaglandin F1 α in the coronary sinus and the aorta was not different between the two groups (1.17 ± 0.96 in patients with vasospastic angina vs. 1.15 ± 0.68 in controls).

Conclusions: These data suggest that platelet activation across the coronary bed should be ascribed to endothelial dysfunction. Lack of compensatory enhancement of prostacyclin production might be concerned with dysfunction of coronary endothelial cells in these patients.
Effect of nipradilol on silent myocardial ischemia, plasma beta‐endorphin, and bradykinin in chronic stable angina
Authors: Takase Bonpei , Kurita Akira , Uehata Akimi , Hikita Hiroyuki , Nishioka Toshihiko , Mitani Hideki , Satomura Kimio , Mizuno Kyoichi , Nakamura Haruo
Published: August 2009

Hypothesis: This study was undertaken to investigate the effect of nipradilol on the total ischemic burden and on plasma levels of beta‐endorphin and bradykinin.

Methods: Sixteen patients with chronic stable angina were subjected to exercise treadmill testing and 24‐h ambulatory electrocardiogram (ECG).

Results: Nipradilol significantly decreased both mean heart rate and mean pressure rate product at submaximal and maximal exercise. It significantly improved exercise‐induced maximal ST‐segment depression from −2.7 ± 0.5 mm to −1.3 ± 0.6 mm (p<0.05) and reduced the number of leads with significant ST‐segment depression (4.0 ± 1.2 vs. 2.0 ± 1.8, p<0.05). Silent ischemic episodes recorded in 24‐h ambulatory ECG were significantly decreased by nipradilol administration, concomitantly with a decrement of mean heart rate and observed maximal heart rate. Patients with exercise‐induced silent myocardial ischemia showed significantly increased plasma levels of beta‐endorphin during both the placebo and nipradilol phases of the study. However, during the nipradilol phase, bradykinin did not change significantly at rest and at peak exercise.

Conclusion: Nipradilol effectively controls exercise‐induced myocardial ischemia and silent myocardial ischemic episodes, and does not influence the response of plasma levels of beta‐enduced silent myocardial ischemia.
Higher level of plasma cholesteryl ester transfer activity from high‐density lipoprotein to Apo B‐containing lipoproteins in subjects with angiographically detectable coronary artery disease
Authors: Hibino Takeshi , Sakuma Nagahiko , Sato Takaaki
Published: August 2009

Background and hypothesis: Plasma high‐density lipoprotein cholesterol (HDL‐C) levels correlate inversely with the incidence of coronary artery disease. In order to ascertain whether the transfer activity is related to coronary atherosclerosis, we studied plasma cholesteryl ester transfer activity (CETA) from HDL to apo B‐containing lipoproteins in a consecutive series of 64 Japanese men aged <60 years who had undergone diagnostic coronary angiography.

Methods: The subjects were divided into two groups: those who had ≥50% luminal stenosis in one or more coronary arteries (Group 1) and those who had <50% stenosis (Group 2).

Results: CETA was 20.8±6.0%/2h in 38 subjects in Group 1. significantly higher than 17.4±6.9%/2h in 26 subjects in Group 2(p<0.05). Plasma HDL‐C levels in Group 1 were significantly lower than those in Group 2(p<0.05). CETA correlated inversely with HDL‐C levels (r = −0.46, p<0.001). Plasma total cholesterol, low‐density lipoprotein cholesterol (LDL‐C), triglyceride (TG), and Lp(a) levels did not differ significantly between the two groups. There was no significant correlation between CETA and either LDL‐C or TG levels.

Conclusion: Results suggest that high CETA is realted to low plasma HDL‐C levels and may lead to the development of coronary atherosclerosis. Also, CETA was independent of plasma LDL‐C or TG levels.
Preoperative cardiac risk assessment with adenosine stress dual‐isotope myocardial single‐photon emission computed tomography
Authors: Maunoury Christophe , Stone David A. , Chen Charles C. , Plotnick Gary D. , Holder Lawrence E.
Published: August 2009

Background: Previous studies have demonstrated that pharmacologic stress thallium‐201(201Tl) myocardial scintigraphy is a useful tool to evaluate preoperative cardiac risk.

Hypothesis: The purpose of this study was to assess the utility of adenosine stress dual‐isotope [rest 201Tl/stress technetium‐99m (99mTc) sestamibi] myocardial single‐photon emission computed tomography (SPECT) in predicting the risk of perioperative cardiac events (unstable angina, myocardial infarction, cardiac death) in patients undergoing major noncardiac surgery.

Methods: We evaluated 43 consecutive patients (20 men, 23 women, mean age 64 years, range 30‐83 years) within 8 weeks prior to major noncardiac surgery requiring general anesthesia. SPECT imaging was performed with 111 MBq (3 mCi)201Tl at rest and 925 MBq (25 mCi)99mTc sestamibi during adenosine stress.

Results: Of the 43 patients, 15 (35%) had stress‐induced ischemia and 28 (65%) did not. Perioperative cardiac events occurred in 4 (27%) of the 15 patients with stress‐induced ischemia (2 unstable angina, 2 nonfatal myocardial infarctions) and in none of the 28 patients without inducible ischemia (p = 0.02).

Conclusion: Adenosine stress dual‐isotope myocardial SPECT is useful in determining the preoperative cardiac risk of patients undergoing major noncardiac surgery.