bluuebunny/crossref_metadata_2025 huggingface dataset:
Familial homozygous hypercholesterolemia: Clinical and cardiovascular features in 18 patients
Authors: Brook G. J. , Keidar S. , Boulos M. , Grenadier E. , Wiener A. , Shehada N. , Markiewicz W. , Benderli A. , Aviram M.
Published: February 2009

Homozygous familial hypercholesterolemia (HFH) is a very rare autosomal dominant disease characterized by accelerated severe atherosclerosis. We examined 18 patients from 9 families with HFH. The age range was 6–30 years (mean == 16 years). Male to female ratio was equal. All patients had huge, multiple tuberous xanthomas on the skin and tendons. Mean ± standard deviation of plasma cholesterol, triglycerides, low‐density lipoproteins (LDL), and high‐density lipoproteins (HDL) cholesterol levels were 608±89, 122±39, 550±88, and 26±8 mg/dl, respectively. Five patients (28%) had angina pectoris, two sustained a myocardial infarction, and one died at the age of 15 years. Two‐dimensional echocardiography demonstrated supravalvular aortic stenosis in 3 of the 13 patients (23%). Coronary arteriography performed in 11 patients demonstrated significant obstruction in 6 patients, 2 each with single‐, double‐, and triple‐vessel disease. Left main stenosis was present in 3 patients (27%). Supravalvular aortic narrowing was demonstrated in 6 patients (54%) and was associated with a gradient in 2 (25 and 35 mmHg, respectively). Segmental contraction abnormalities were detected in 2 of the 11 patients (18%). It is concluded that coronary artery disease is prevalent in patients with HFH and, based on the data presented, we recommend the performance of noninvasive technique, coronary arteriography and supravalvular aortography at an early age to detect and to follow the progression of the disease.
Delay time in suspected acute myocardial infarction and the importance of its modification
Authors: Herlitz J. , Blohm M. , Hartford M. , Hjalmarsson Å. , Holmberg S. , Karlson B. W.
Published: February 2009

This paper summarizes the present knowledge of delay time in suspected acute myocardial infarction. More than 50% of deaths in acute myocardial infarction occur outside of the hospital setting. Recent experiences indicate that early and even late mortality can be dramatically reduced by intervention in the early phase. This points up the importance of bringing patients with suspected acute myocardial infarction to the hospital as early in the course of MI as possible. The predominating cause of delay is the time it takes for the patient to decide to go to hospital regardless of a previous history of cardiovascular disease. Patients arriving in hospital in later stages of MI are at a very high risk of mortality. Therefore one of the most important problems to be resolved is how to reduce delay time in suspected acute myocardial infarction. Such efforts have been surprisingly few. Limited experiences indicate that public education can reduce delay time dramatically.
Chronobiologic vs. sphygmomanometric assessment of hypertension in a hospital setting
Authors: Portaluppi F. , Montanari L. , Capanna M. , Ferlini M.
Published: February 2009

The aim of this study was to assess the possible correlations between casual measurements and automatic monitoring analyzed with the chronobiologic technique in hospitalized hypertensive patients. Forty‐three patients (24 men and 19 women) with mild to moderate essential hypertension were studied in an open hospital ward 5 to 7 days after admission. Meal times, sleep times, and visiting hours were standardized. A clinical value of blood pressure was calculated as the arithmetic mean of three sphygmomanometric measurements taken in the morning (patient seated; 5‐min interval between measurements). Then, a basal value of blood pressure was considered as the lowest systolic and the lowest diastolic blood pressure among six sphygmomanometric measurements obtained every 5 min (patient supine). Noninvasive, automatic recording of blood pressure was also obtained every 15 min for 24 hours by a quasiportable oscillometric instrument. Blood pressure recordings were analyzed according to the “cosinor” method of Halberg. On average, clinical blood pressure was 160/96±14/10 mmHg, significantly higher (p<0.005) than either basal blood pressure (150/91±12/8 mmHg) or 24‐h recorded blood pressure mesor (144/88±13/9 mmHg). The differences were not entirely due to diurnal variations, since morning casual measurements were significantly higher than daytime average blood pressure. A chronobiologic assessment of hypertension in hospitalized patients is more representative of true blood pressure behavior, not only because of the multiple recordings but also because of the absence of an alarm reaction that may trigger a pressor response.
Determinants of end‐stage idiopathic dilated cardiomyopathy: A multivariate analysis of 104 patients
Authors: Romeo F. , Pelliccia F. , Cianfrocca C. , Barilla F. , Reale A. , Gallo P. , Cristofani R.
Published: February 2009

Our purpose in this study was to investigate the correlation of clinical, electrocardiographic, hemodynamic, and histopathologic features at diagnosis with the long‐term prognosis in 104 patients with idiopathic dilated cardiomyopathy to determine which factors are the independent determinants of the end‐stage disease. During a mean follow‐up of 3.8±3.5 years, 35 patients (33%) died, 14 (13%) suddenly and 21 (20%) from congestive heart failure. Univariate analysis of survival curves disclosed that clinical and electrocardiographic variables at diagnosis were similar in survivors and non‐survivors. On the contrary, patients who subsequently died had higher mean right atrial pressure (p=0.0001), right ventricular end‐diastolic pressure (p=0.0061), mean pulmonary artery pressure (p=0.0001), and left ventricular systolic (p=0.0049) and end‐diastolic (p=0.0021) pressure than survivors. They also exhibited larger left ventricular end‐diastolic (p=0.0046) and end‐systolic (p=0.0027) volumes, lower ejection fraction (p=0.0001), and a greater proportion had severe mitral regurgitation (p=0.0095). Univariate analysis of histologic findings collected in a subgroup of patients referred since 1984 revealed a mild degree of myocellular hypertrophy to be associated with a poor prognosis (p=0.0217). Multivariate analysis selected only mean right atrial pressure (p=0.0022), ejection fraction (p=0.0089), and endsystolic volume (p=0.0265) as independent determinants of cardiac death. Our results suggest that cardiac catheterization is mandatory for risk stratification of patients with idiopathic dilated cardiomyopathy, since it allows the assessment of hemodynamic, angiographic, and histopathologic features helpful in identifying patients with a poor prognosis.
Hemodynamic and antianginal effects during rest and exercise of intravenous isradipine, a new dihydropyridine calcium antagonist
Authors: Burger W. , Neidel S. , Kober G.
Published: February 2009

In an open randomized study, hemodynamic and antianginal effects of nifedipine and the new dihydropyridine derivative isradipine were compared in patients with stable, angiographically confirmed coronary heart disease. Right heart hemodynamics, systemic arterial blood pressure, ECG, and drug plasma concentrations were measured before medication at rest and exercise, after infusions of increasing doses at rest, and again after treatment at rest and exercise. A linear relationship between serum concentrations and cumulated dosages was obtained for both drugs. At rest, both drugs significantly increased cardiac output and heart rate. The reduction of arterial blood pressure was significantly greater after isradipine (systolic from 148±3 to 104±3 mmHg; diastolic from 90±4 to 58±2 mmHg) than after nifedipine (systolic 149±6 to 125±4 mmHg; diastolic 92±4 to 76±3 mmHg). The minimal effective plasma level of isradipine regarding blood pressure reduction was estimated at 5 ng/ml (nifedipine: 10–25 ng/ml). During exercise both medications significantly reduced mean pulmonary artery pressure (isradipine: 40±3 to 20±1 mmHg, nifedipine: 37±4 to 22±1 mmHg), pulmonary artery wedge pressure (isradipine: 23±3 to 10±1 mmHg, nifedipine 24±3 to 14±1 mmHg), and diastolic arterial pressure (isradipine: 103±3 to 73±4 mmHg, nifedipine: 99±3 to 91±2 mmHg), whereas systolic pressure was reduced by only isradipine (189±4 to 147±5 mmHg). Neither medication significantly changed electrocardiographic ST depression during exercise. There was a high rate of painless ST depression (nifedipine 1/8, isradipine 4/8) during the drug dosing and increased ST depression during exercise. This phenomenon can be explained by either coronary steal or by ST depression of unknown origin after dihydropyridine treatment.
Combination of sensors to provide optimal pacing rate response
Authors: Paul V. , Garratt C. , Camm A. J.
Published: February 2009

Previously, single‐chambered rate‐adaptive and dual‐chamber pacemakers have been considered as alternative methods of providing rate response. Neither can adapt to changing circumstances and each has its own benefits and limitations. The development of units combining both facilities expands the range of conditions for which atrioventricular sequential pacing is possible and will ensure appropriate and adequate rate response at all times. At present, change in pacing mode is dependent on physician programming, but future generations will have the ability to diagnose the intrinsic rhythm and then prescribe automatically the pacing modality of choice.
Does nitroglycerin induce heparin resistance?
Authors: Lepor N. E. , Amin D. K. , Berberian L. , Shah P. K.
Published: February 2009

We studied the possibility that intravenous nitroglycerin may produce heparin resistance both in vitro and prospectively in a group of 10 patients following coronary angioplasty. Nitroglycerin in physiologic to pharmacologic concentrations (41‐250 μg/ml) did not produce heparin resistance in vitro as measured by activated partial thromboplastin time and thrombin time. The maximum reduction in activated partial thromboplastin time was 7%. In patient studies, the activated partial thromboplastin time at baseline on heparin alone (93±22 s) was not significantly different (p=0.61) from activated partial thromboplastin measured upon addition of nitroglycerin (94±27 s) or 30 min following cessation of the nitroglycerin infusion while continuing the same dose of heparin (91±24 s). We conclude that intravenous nitroglycerin does not induce heparin resistance in vitro or in patients during short‐term administration.
Assessment of the intracardiac left to right shunts with a single scintillation probe
Authors: Tendera M. , Bartoszewski A. , Foremny J. , Salamon A. , Wodniecki J. , Malecka‐Tendera E.
Published: February 2009

In order to assess the accuracy of pulmonary time‐activity curves obtained at bedside with a single scintillation probe and Technetium‐99m‐labelled erythrocytes, pulmonary to systemic flow ratio (Qp:Qs) was calculated for radionuclide and hemodynamic investigations in 104 patients with suspected intracardiac left to right shunts. Cardiac catheterization confirmed the presence of shunts in 76 patients. Pulmonary time‐activity curve was 100% sensitive, 88% specific, and 96% accurate in detecting the shunt. Correlation between the radionuclide and hemodynamic Qp:Qs was excellent (r=0.93). Results were classified in four quantitative categories according to the Qp:Qs values. In 76 patients (73%) radionuclide and hemodynamic data fell in the same category. We conclude that radionuclide pulmonary time‐activity curves generated with a scintillation probe is a reliable method in quantitative assessment of intracardiac left to right shunts.
Increased Ca2+ influx into platelets induced by thromboxane A2 analog in patients with ischemic heart disease
Authors: Kobayashi N. , Okumura K. , Hashimoto H. , Ito T. , Satake T.
Published: February 2009

We compared platelet aggregation and intracellular free calcium concentrations ([Ca2+]i) following stimulation with STA2, an analog of thromboxane A2 between patients with ischemic heart disease (IHD) showing significant stenosis in coronary angiograms and controls. In the presence of extracellular calcium, platelet aggregation and intracellular Ca2+ increase were enhanced by STA2 stimulation in a dose‐dependent fashion and were higher in the IHD patients than in the controls. However, in the absence of extracellular calcium, no difference in intracellular Ca2+ increase was observed due to its total dependence on release from intracellular stores. These results suggest that thromboxane A2 increases platelet intracellular Ca2+‐inducing aggregation, and this increase and aggregation, which is enhanced by thromboxane A2 in IHD patients, is due to promotion of Ca2+ influx by thromboxane A 2. IHD patients appear to have an abnormality in the platelet membrane which may explain such thromboxane A2‐dependent increased permeability to Ca2+.
Mesothelioma of the atrioventricular node and congenital complete heart block
Authors: Subramanian R. , Flygenring B.
Published: February 2009

Congenital complete heart block (CCHB) has heterogeneous etiologies. It may occur as an isolated entity with no associated congenital cardiac malformations and is difficult to diagnose even with modern technology. Mesothelioma of the atrioventricular (AV) node is a benign tumor that causes CCHB. The occurrence of this tumor is rare, and a definitive diagnosis of the entity is made only at autopsy. The conduction disturbance caused by the mesothelioma is potentially treatable and should be considered in the differential diagnosis of CCHB. We present a case report of a 38‐year‐old female with CCHB caused by such a tumor. Clinical diagnosis and treatment of CCHB are reviewed.
Doppler echocardiographic assessment of transmitral gradients and mitral valve area before and after mitral valve balloon dilatation
Authors: Dev V. , Singh L. S. K. , Radhakrishnan S. , Saxena A. , Shrivastava S.
Published: February 2009

This is a comparative study of 60 sets of observations of mitral valve end‐diastolic gradient, mean diastolic gradient, and mitral valve area obtained by Doppler echocardiography and cardiac catheterization. The studies were performed in 28 patients, 16 of whom underwent mitral valve balloon valvuloplasty. These 16 patients had studies performed before, immediately after valvuloplasty, and one week later. Thus 28 studies were performed before or without valvuloplasty (Group I) and 32 after valvuloplasty (Group II). The time interval between Doppler echocardiography and cardiac catheterization was less than 24 hours in 44 studies and 24 to 72 hours in 16 studies. In Doppler echocardiography the gradients were obtained by simplified Bernoulli's equation and the mitral valve area by pressure half‐time method. There was excellent correlation between end‐diastolic gradients (r=0.96, p<0.001) and mean diastolic gradients (r=0.92, p<0.001) measured by the two techniques. A statistically significant correlation also existed in the mitral valve area values (r=0.53, p<0.005). On separate analysis Group I showed excellent correlation for all three variables (r values of 0.90, 0.87, and 0.82 for end‐diastolic gradients, mean‐diastolic gradients, and mitral valve area, respectively). Group II also showed excellent correlation of end‐diastolic gradients (r=0.80) and mean diastolic gradients (r=0.87), but poor correlation of the mitral valve areas (r=0.17; p=NS) by the two techniques. Doppler echocardiography can accurately measure transmitral gradients both before and after valvuloplasty. The mitral valve area derived by Doppler echocardiography using the pressure half‐time method was unreliable 1 to 7 days after mitral valvuloplasty in our experience. The presence of atrial fibrillation (n=8), mild aortic regurgitation (n=6), and mitral valve calcification (n=5) did not seem to alter the accuracy of Doppler echocardiography in assessing the severity of mitral stenosis.
Prognostic significance of postinfarction arrhythmias and biventricular dysfunction under stress
Authors: Fridrich L.
Published: February 2009

The prognostic relevance on mortality of right ventricular dysfunction in comparison with left ventricular function during stress, complex arrhythmias detected by Holter monitoring, and variables of exercise performance, was evaluated via a retrospective follow‐up of more than four years for cardiac mortality of all patients in the chronic stage after myocardial infarction who were referred serially during a one‐year period to stress radionuclide‐ventriculography and 24‐h Holter monitoring. A sample of 47% (213) of all patients admitted after myocardial infarction to the rehabilitation center during 1983 was investigated by scintigraphic stress testing and Holter monitoring and were followed up. Subsequent medication and invasive therapeutic interventions were documented. The mortality during a mean follow‐up period of 3.9 years in 213 patients (mean age, 56 years) was 14.6%. Significantly decreased values of left and right ventricular ejection fractions during stress scintigraphy (38±14 versus 50±15%, p=0.000 and 45±13 versus 54±11%, p=0.001, respectively) were revealed in the cardiac deceased patient cohort compared with the remainder. Complex arrhythmias during Holter monitoring occurred twice as often (62 vs. 34%, p=0.0059) in later deceased patients. Lifetable analysis demonstrated that patients with biventricular stress dysfunction had a significantly worse survival prognosis than those with monoventricular dysfunction. Multivariate nonlinear Cox survival analysis revealed that left and right ventricular ejection fraction during stress and arrhythmias were of independent prognostic significance compared with multiple clinical variables including those of exercise performance. Thus, apart from left ventricular dysfunction and arrhythmias, scintigraphically assessed right ventricular stress dysfunction is a further marker of poor prognosis after myocardial infarction. This reflects the previously neglected pathophysiologic significance of right ventricular performance in patients after myocardial infarction.
Structure and function of contractile proteins in human dilated cardiomyopathy
Authors: Wiegand V. , Ebecke M. , Figulla H. , Schüler S. , Kreuzer H.
Published: February 2009

The pathogenesis of reduced systolic left ventricular function in dilated cardiomyopathy is yet unclear. To analyze a possible involvement of contractile protein, function and structure of left ventricular myofibrils were examined in hearts of patients with advanced cardiomyopathy undergoing heart transplantation and in normal control hearts (from renal transplant donors). Myosin and actin content of the left ventricular myocardium was slightly reduced in cardiomyopathic hearts. Myofibrillar polypeptide composition was determined using two‐dimensional electrophoresis and immunoblotting. No differences in constituting polypeptides were apparent, including Z‐line proteins and proteins of the endosarcomeric lattice. M‐line‐bound creatine kinase was identical in both groups. Further, basal and maximal myofibrillar adenosine triphosphatase (ATPase) activities were unaltered in dilated cardiomyopathy. The structure of purified myosin was identical in both groups by the following criteria: electrophoretic mobility of native myosin, identical pattern of light chains after isoelectric focusing, identical cleavage peptides of myosin's heavy chain, and identical patterns after immunoblotting of heavy chain cleavage peptides using polyclonal antibodies generated against myosin from normal and cardiomyopathic ventricles. Ca2+‐activated, K+‐EDTA‐activated and actin‐activated myosin ATPase activities were identical in control and cardiomyopathic hearts. A structural alteration or functional defect of myofibrils does not seem to be primarily involved in the pathogenesis of reduced myocardial contractility in dilated cardiomyopathy.
Some aspects of the wideband recording of the electrocardiogram
Authors: Mor‐Avi V. , Akselrod S.
Published: February 2009

The physiological mechanisms responsible for the high frequency components of the electrocardiographic signals in different frequency ranges are still unknown. These components have been studied in the frequency domain as well as in the time domain. Numerous clinical and experimental studies have focused upon the incidence and interpretation of high frequency notches and slurs under different conditions in the myocardium. However, the analysis of the high frequency components appeared to be tedious and imprecise, and the interpretation of its results difficult and controversial, and strongly dependent upon empirically determined standards which still require thorough evaluation. Digital methods for processing electrocardiographic signals developed during the last decade have given rise to a variety of fast and reliable approaches for analyzing the information carried by the electrocardiogram. Many researchers have applied such methods to various clinical situations in human studies and to different kinds of interventions in animal studies. These developments prompted us to review research in the field of wideband recording of the electrocardiogram and to briefly discuss some of the aspects that still require elucidation.
Catheter ablation using radiofrequency energy
Authors: Borggrefe M. , Hindricks G. , Haverkamp W. , Breithardt G.
Published: February 2009

Recently, transvenous catheter ablation using radiofrequency impulses has been applied in experimental animals as well as in humans. This review describes the biophysics, mechanisms, and tissue effects of radio‐frequency alternating current. Ablation of the AV‐junction has been performed in experimental studies as well as in a growing number of patients. Complete AV‐block or modification of the AV conduction by RF‐current application can be achieved in about 45‐65% of patients. Presently about 50% of patients with rightsided accessory pathways can be successfully managed using radiofrequency impulses. Certain limitations exist using a biopolar “epi‐endocardial” electrode configuration forleftsided accessory pathways. Only few studies are available concerning the use of RF ablation of ventricular tachycardia foci. As most experimental investigations were carried out in structurally nondiseased myocardium, the use of this new technique in fibrotic or scarred tissue warrants further studies. Radiofrequency catheter ablation seems to be feasible and relatively safe for the treatment of otherwise drug‐refractory supraventricular arrhythmias; further studies are needed to assess the safety and efficacy in patients with drug‐refractory ventricular tachyarrhythmias.
Two unusual manifestations of aortic aneurysms
Authors: Tejada E. , Becker G. J. , Waller B. F.
Published: February 2009

Pain and pulsation are common presenting features of aortic aneurysms. Massive hematemasis and ureteral obstruction represent rare clinical presentations. This report describes a patient with massive hematemesis in whom a thoracic aneurysm ruptured into the esophagus, and a second patient in whom a large abdominal aortic aneurysm caused bilateral ureteral obstruction.
Fatal massive pulmonary hemorrhage complicating mitral stenosis
Authors: Leung W.‐H. , Lau C.‐P. , Wong C.‐K. , Cheng C.‐H.
Published: February 2009

Mitral stenosis is a well known cause of hemoptysis; however, sudden death due to fatal massive pulmonary hemorrhage is an extremely rare complication. In this report, we describe a 28‐year‐old female with severe mitral stenosis who died suddenly due to such complication. A review of the literature shows such complication is extremely rare and unpredictable. We recommend that patients with severe mitral stenosis and history of hemoptysis be considered as candidates for early surgical intervention.
Hereditary long qt syndrome in the postoperative cardiac patient
Authors: Klitzner T.
Published: February 2009

The purpose of the present article is to evaluate the diagnostic implications of the long QT syndrome presenting in postoperative cardiac patients. Diagnosis of long QT syndromes may be complicated by an inability to measure the QT interval correctly due to postoperative electrocardiographic changes such as right bundle‐branch block. For this reason, a study of the effect of right bundle‐branch block on the QT interval was undertaken. Electrocardiograms of 17 randomly selected patients undergoing a right ventriculotomy for repair of tetralogy of Fallot were evaluated for QT prolongation pre‐ and postoperatively. Preoperatively, no patient demonstrated QT interval prolongation. After surgery, however, right bundle‐branch block created an apparent prolongation of the QT interval in 9 of the 17 patients (53%). These results suggest that in postoperative cardiac patients QT prolongation and familial long QT syndromes may be difficult to diagnose. It is, therefore, important to exclude the long QT syndrome in patients with ventricular tachycardia even if a more obvious explanation such as previous cardiac surgery is present. Usually a careful family history and preoperative electrocardiogram are all that is required.
Hypertension and sports activities: Institutional experience
Authors: Lehmann M. , Dürr H. , Merkelbach H. , Schmid A.
Published: February 2009

Findings of 185 patients and 271 control subjects are presented for the assessment of work capacity in hypertensive individuals (primary hypertension); an attempt at classification by hypertensive stage is seen as an essential presupposition. The subdivision into three stages recommended by the Experts' Commission of the WHO places the effects of hypertension on the organism, especially on the heart, in the focal point. This appears justified from a prognostic, pathophysiological, and therapeutic point of view. Hemodynamics in the examined patients undergo increasing impairment in relation to the stage of hypertension with a decrease in maximum cardiac index and work capacity and an increase in myocardial oxygen requirement. Initially, only the diastolic cardiac function is impaired; however, in advanced stages, the systolic function of the heart is impaired as well. Evaluation of work capacity is usually possible from a cardiac point of view by means of noninvasive echocardiographic and spiroergometric methods. The mass/volume ratio of the left cardiac ventricle and the relationship between left ventricular muscle mass (or volume) and work capacity are especially important. Both experience characteristic changes depending on the stage of hypertension and thus permit precise determination of work capacity, progress controls, and delineation from physiological cardiac hypertrophy (athletic heart).
Coronary arterial morphology 10 years after “Endarterectomy”
Authors: Kragel A. H. , Mcintosh C. L. , Roberts W. C.
Published: February 2009

Little information is available regarding coronary artery morphology after endarterectomy. In this report, we describe coronary artery morphology seen at necropsy 10 years after coronary artery endarterectomy and compare it with the morphology of the original endarterectomy specimen. Surprisingly, in some areas, all of the internal elastic membrane and most of the media were observed in the “endarterectomy” specimen.
Acute myocardial infarction associated with intravenous dipyridamole for rubidium‐82 pet imaging
Authors: Marwick T. H. , Hollman J.
Published: February 2009

This report describes the occurrence of chest pain and electrocardiographic features of acute myocardial infarction following intravenous dipyridamole‐handgrip stress. Myocardial perfusion imaging (Rb‐82 PET) demonstrated a stress‐induced perfusion defect. Following failure to respond to medical therapy, urgent cardiac catheterization demonstrated total occlusion of the left anterior descending coronary artery. The vessel was revas‐cularized, with limitation of myocardial damage evidenced by failure to develop anterior Q waves and only modest elevation of cardiac enzyme levels. Complications of intravenous dipyridamole stress are rare, this case constituting the first major problem in over 500 such procedures at this institution. However, this experience demonstrates the importance of vigilant observation during the performance of this technique.
Prognosis during one year for patients with myocardial infarction in relation to the development of q waves: Experiences from the miami trial
Authors: Herlitz J. , Hjalmarson Å. , Karlson B. W.
Published: February 2009

From a randomized multicenter trial with metoprolol in suspected acute myocardial infarction (n = 5778) we report on the outcome during a one‐year follow‐up in patients with confirmed infarction (n = 4106) in relation to whether or not they developed Q waves. Patients with Q waves had another pattern of risk factors, including lower age and a lower occurrence of previous infarction, angina pectoris, and congestive heart failure. After one year follow‐up, 14.3% of the patients with Q waves had died versus 9.0% of those without Q waves (p < 0.001). Reinfarction during the first year occurred in 8.2% of patients with Q waves and 12.5% of patients without Q waves (p < 0.001). After one year, other morbidity aspects appeared relatively independent of the original presence of Q waves. In conclusion, during the first year after development of acute myocardial infarction the appearance of Q waves during the first three days is associated with a higher mortality and a lower reinfarction rate, whereas other morbidity aspects appear to be relatively independent of its presence.
Cardiac surgery in patients over the age of 80 years
Authors: Bashour T. T. , Hanna E. S. , Myler R. K. , Mason D. T. , Ryan C. , Feeney J. , Iskikian J. , Wald S. H. , Antonini C. , Malabed L. L.
Published: February 2009

The risk‐benefit relationship of open heart surgery in octogenarians is not well established. Eighty consecutive patients over the age of 80 who underwent cardiac operations under cardiopulmonary bypass were evaluated. Twenty‐five patients were in functional class IV, 42 in class III, and 13 in class II. Forty‐four patients had only coronary artery bypass grafts (CABG), 12 only aortic valve replacement (AVR), 6 only mitral valve replacement (MVR), 12 CABG and AVR, 4 CABG and MVR, 1 CABG and aneurysmectomy, and 1 had resection of left atrial myxoma. Operative mortality (within 30 days) was 12.5% for the group. Mortality was related to bleeding, left ventricular failure, primary ventricular fibrillation, pulmonary failure, and renal failure. Mortality was higher in patients with (1) advanced functional class, (2) mitral valve replacement, (3) postoperative hemorrhage, and (4) associated pulmonary disease. While a generally conservative approach is recommended for octogenarian patients, many with life‐threatening cardiac disease, especially those free of major multisystem illnesses, should not be denied the benefit of surgical treatment.
Calcific deposits in the heart
Authors: Catellier M. J. , Chua G. T. , Youmans G. , Waller B. F.
Published: February 2009

Four case reports are presented which illustrate various patterns of calcific deposits in the heart. Valvular, myocardial, intracavitary, and coronary calcific deposits are illustrated, with emphasis on pathology and clinicopathologic‐radiologic correlation. “Dystrophic” and “metastatic” calcification are terms used to describe calcific deposits in abnormal and normal soft tissues, respectively. These terms are somewhat confusing in relation to the myocardium, however, as the chronologic sequence of cardiac injury is often uncertain. We suggest that these terms be avoided in relation to the heart, in favor of simple descriptive terms such as “myocardial calcific deposits.” Many conditions, such as renal failure and hypercalcemia may contribute to the likelihood of soft tissue calcification, although a definite common etiology has not been identified. Likewise, soft tissue calcification has been difficult to diagnose premortem. The advent of ultrafast (cine) computed tomography may provide a quick, noninvasive, highly sensitive and specific method for diagnosis of soft tissue calcific deposits in the future.
Huge, unattached left atrial thrombus in mitral stenosis
Authors: ROBERTS C. S. , ROBERTS W. C.
Published: February 2009

We describe certain clinical and morphologic findings in a 75‐year‐old woman in whom a large, spherical, nonadherent, clinically undetected thrombus developed in the left atrium in association with mitral stenosis.
Aortic and large artery stiffness: Current methodology and clinical correlations
Authors: Hickler R. B.
Published: February 2009

Current methodology for the in vitro determination of aortic and large artery stiffness is reviewed and involves three approaches: (1) the estimation of distensibility by pulse wave velocity measurement; (2) the estimation of distensibility from the fractional diameter change of a given arterial segment by imaging techniques (e. g., angiography, Doppler ultrasound) against pressure change; (3) the estimation of compliance by determining volume change against pressure change in the arterial system during diastolic runoff from the Windkessel model of the circulation. Clinical correlations may be summarized as follows: (1) age: a progressive stiffening on aging due to structural changes up to the seventh decade; (2) sex: a lower degree of stiffness in women until menopause, after which they show an accelerated stiffening, catching up with men by the seventh decade; (3) atherosclerosis: a dissociation between degree of stiffness and extent of atherosclerosis, with a suggestion that in advanced atherosclerosis the extensive calcification may lead to increased stiffness; (4) coronary disease: an inconsistent correlation by pulse wave velocity studies, but a strongly positive correlation by angiographic study of the aortic root; (5) diabetes mellitus: a significant correlation by pulse wave velocity study, particularly in the presence of advanced peripheral vascular disease; (6) hypertension (both essential and elderly patients with systolic): positive correlation but only referable to the stiffening effect of a higher mean arterial pressure (i. e., unrelated to structural changes), although an experimental study did show a loss of compliance unrelated to the mean arterial pressure level in baboons with chronic renovascular hypertension.
The relationship between new cardiac conduction defects and extension of valve infection in native valve endocarditis
Authors: Weisse A. B. , Khan M. Y.
Published: February 2009

New conduction defects in the setting of native valve infective endocarditis (IE) are commonly believed to be associated with direct extension beyond the free valve area. At University Hospital in Newark, among 100 cases of IE, in none of five instances of associated conduction defects (excluding first‐degree heart block) was this the case. in neither of two instances of direct extension of valve infection was this accompanied by a new conduction defect. To explore this relationship, autopsy, surgical, and echocardiographic findings from other institutions were combined with these data. Among 47 instances of new conduction defects in IE, only 60% could be related to direct extension of valve infection. The cause was coronary embolization in 4% and unknown in 36%. Among 119 cases of complicated valve lesions, significant conduction defects were documented by ECG in only 15%. in IE the appearance of new conduction abnormalities may often result from causes other than extension of valve infection. Furthermore, complicated valve lesions may often be present without electrocardiographic evidence, indicating interruption of normal conduction pathways.
Limb leads of the electrocardiogram: Sequencing revisited
Authors: Dower G. E. , Nazzal S. B. , Bullington D. , Pahlm O. , Haistey W. K. , Marriott H. L. , Bullington R. H.
Published: February 2009

The six limb leads are normally presented in a format the logic of which is traditional rather than anatomical and does not allow visual interpolation such as is customary with the six chest leads. The sequence: aVL, I, ‐aVR, II, aVF, III was suggested years ago, and is used in some European countries, particularly Sweden. It provides a better impression of the extent of the changes of inferior infarction and makes the rather neglected lead aVR much more useful, though reversed in polarity. It also provides a more direct indication of the electrical axis, and simplifies comparisons with the frontal plane vectorcardiogram. Because modern digital electrocardiographs can provide the sequenced format, this seems a good time to review the advantages of adopting it.
Parkinson's disease and hypotension: 24‐hour blood pressure recording in ambulant patients
Authors: Brevetti G. , Bonaduce D. , Breglio R. , Perna S. , Simonelli P. , Marconi R. , Campanella G.
Published: February 2009

Continuous intra‐arterial blood pressure was recorded in 5 ambulatory patients with Parkinson's disease and in 5 control subjects. The 24‐h mean systolic blood pressure was 135±7.6 mmHg in controls and 123.8±8.1 mmHg (p<0.01) in the parkinsonian group. Similarly, diastolic blood pressure was 89±8.1 mmHg in the control group while in the parkinsonian patients it was lower, 69.4±5.8 (p<0.01). Averages were also calculated for 8‐h periods, the results of which indicate that both systolic and diastolic blood pressure were significantly lower in patients than in controls in all three 8‐h periods of the day. We normalized the blood pressure curve to mealtimes and arousal times and did not observe any difference between parkinsonian patients and controls. This first study reporting continuous intraarterial blood pressure measurements in ambulant parkinsonian patients demonstrates that blood pressure in such patients is lower than the mean for their age group. This finding may be of direct relevance in the management of idiopathic parkinsonism.
Improved diastolic LV filling after acute application of ajmaline in patients with coronary artery disease and normal systolic LV function
Authors: Hüiting J. , Thormann J. , Mitrovic V. , Schlepper M.
Published: February 2009

To determine whether ajmaline (A) can be safely applied in coronary artery disease (CAD), changes of left ventricular (LV) function after acute ajmaline application were analyzed by pulsed Doppler echocardiography in 10 CAD patients. LV pressures in systole and end‐diastole and LVEF remained normal and comparable. Doppler normalized peak filling rate (p < 0.02), peak early/atrial filling velocity (E/A) ratio (p < 0.01) and E‐deceleration (p<0.05) increased. The increase in E/A and in E‐deceleration relative to base values was directly correlated (p < 0.001). PEP increased, LVET remained unchanged. LV diastolic filling is improved after acute application of ajmaline in patients with CAD and normal systolic function; its application may be advised not only for therapy of arrhythmia but also to improve left ventricular diastolic mechanics in these patients.
Rare or unusual causes of chronic, isolated, pure aortic regurgitation
Authors: Waller B. F. , Taliercio C. P. , Dickos D. K. , Howard J. , Adlam J. H. , Jolly W.
Published: February 2009

Six patients undergoing aortic valve replacement had rare or unusual causes of isolated, pure aortic regurgitation. Two patients had congenitally bicuspid aortic valves with a false commissure (raphe) displaced to the aortic wall (“tethered bicuspid aortic valve”), two had floppy aortic valves, one had a congenital quadricuspid valve, and one had radiation‐induced valve damage.
Thallium‐201 perfusion imaging with atrial pacing or dipyridamole stress testing for evaluation of cardiac risk prior to nonvascular surgery
Authors: Stratmann H. G. , Mark A. L. , Williams G. A.
Published: February 2009

Preoperative assessment of cardiac risk using thallium‐201 scintigraphy and atrial pacing (n=42) or dipyridamole stress testing (n=35) was performed in 77 patients (mean age 65±7 years), who subsequently underwent elective nonvascular surgery. All patients were at low cardiac risk by clinical criteria; none could perform exercise stress testing due to physical limitations. ST depression consistent with ischemia occurred in 11 patients during atrial pacing and in 1 patient during dipyridamole stress testing (p<0.01). Nine patients had reversible perfusion defects with atrial pacing, and 10 patients with dipyridamole stress testing; fixed defects were present in 15 and 8 patients, respectively. Only one patient (fixed perfusion defect with atrial pacing, left main disease on coronary angiography) underwent preoperative coronary revascularization. Two patients subsequently had postoperative cardiac events. One patient (reversible perfusion defect with dipyridamole stress testing) experienced sudden death after a nonvascular procedure, while a second patient (normal thallium images with dipyridamole testing) had a nonfatal myocardial infarction. In patients having atrial pacing or dipyridamole stress testing, thallium‐201 scans that are normal or show only a fixed perfusion defect confirm a low risk of cardiac complications following nonvascular surgery. The presence of a reversible perfusion defect does not preclude a postoperative course free of cardiac complications in patients at low cardiac risk by clinical criteria.
T‐Lymphocyte subsets as noninvasive markers of cardiomyopathy
Authors: Kanda T. , Yokoyama T. , Suzuki T. , Murata K. , Ohshima S. , Yuasa K. , Watanabe T.
Published: February 2009

Fifty‐eight patients with symptomatic congestive heart failure were examined for T‐lymphocyte subsets in the peripheral blood using two‐color laser flow cytometry as a noninvasive diagnostic procedure. The final diagnoses established by catheterization and endomyocardial biopsy were dilated cardiomyopathy (DCM, n=24), myocarditis (MC) by the Dallas criteria (n=12), and coronary heart disease (CHD, n=16). The CD8+CD11‐ (cytotoxic T) subset was significantly low in patients with DCM (13.9±4.4 vs. controls, p<0.05) in comparison with MC (20.7 + 10.9) and CHD (22.3±5.9). Moreover, the CD4+2H4+ (suppressor/inducer T) subsets were higher in patients with DCM (27.3±6.9 vs. controls, p<0.01) than in those with MC (17.3±7.8) and CHD (15.6+7.9). The CD4/CD8 and CD4+2H4+/CD8+CD11‐ ratios were examined and compared with those of normal controls (NC n=16). The CD4+2H4+/CD8+CD11‐ ratio was clearly higher in patients with DCM (2.2+0.9 vs. controls, p<0.01) than in those with MC (1.1±0.6) CHD (0.9±0.7). A CD4+2H4+/CD8+CD11‐ ratio of > 1.6 was considered to facilitate diagnosis of dilated cardiomyopathy with 79% sensitivity and 70% specificity. There was no significant increase in the ratios between MC and CHD. However, the proportion of the CD8+Leu7+ (natural suppressor) subset of circulating T lymphocytes in patients with MC was statistically higher (19.1±6.3% vs. controls, p<0.05) than in DCM or CHD. An elevated ratio of CD4+2H4+/CD8+CD11‐ among peripheral blood lymphocytes may thus be a useful marker for differential diagnosis of dilated chronic cardiomyopathy from myocarditis and coronary heart disease.
Dynamic arm exercise during cardiac catheterization in the assessment of stenotic valvular disease
Authors: Balady G. J. , Jacobs A. K. , Faxon D. P. , Ryan T. J.
Published: February 2009

Assessment of hemodynamic responses during some form of exertion or stress during cardiac catheterization is useful among patients suspected of having valvular stenosis who demonstrate normal or borderline valve gradients at rest. Leg raising exercise and drug administration are commonly used for this purpose, but each has inherent limitations. To evaluate the usefulness of dynamic arm raising exercise as a means of altering hemodynamics during cardiac catheterization, 23 such patients were studied. Measurements obtained during arm raising exercise were compared with those at rest. Heart rate rose by 34±4 beats/min (p<0.001), while cardiac output increased by 1.4±0.2 1/min (p<0.001). Stroke volume decreased slightly, although left ventricular filling pressures and pulmonary capillary wedge pressures rose in nearly all subjects. The change in valvular gradients was variable. These data were compared with those obtained in 11 similar patients receiving either dopamine or isoproterenol as an intervention. The changes in heart rate and cardiac output from the resting state were similar between the groups, with fewer side effects occurring during arm exercise. Dynamic arm exercise is a safe and effective maneuver which can be performed during cardiac catheterization in patients undergoing diagnostic evaluation of stenotic valvular disease.
Variant angina due to deficiency of intracellular magnesium
Authors: Tanabe K. , Noda K. , Kamegai M. , Miyake F. , Mikawa T. , Murayama M. , Sugai J.
Published: February 2009

A 51‐year‐old man was diagnosed as having variant angina by documentation of typical ST elevation during anginal attack and also by showing coronary arterial spasm (#2 and #12) during hyperventilation on coronary arteriography. Large quantities of calcium blocking agents and nitrates could not improve his symptoms. Lack of intracellular magnesium was suspected from a daily excretion of urine magnesium (5.3 mEq) and magnesium tolerance test (56.7%). After hourly infusion of magnesium sulfate (80 mEq), coronary spasm could not be induced by ergonovine.
Clinical characteristics affecting success or failure of PTCA in patients with multiple vessel disease and poor candidates for surgery
Authors: Colle J. ‐P. , Delarche N. , Chague F. , Casteight F. , Choussat A. , Besse P.
Published: February 2009

A special form of complex coronary angioplasty is represented by the extension of indications for percutaneous transluminal coronary angioplasty (PTCA) to patients with multivessel disease (MVD) for whom surgery is not indicated, and thus for whom surgical standby is not available. Over a two‐year period, 254 consecutive coronary patients with multivessel disease underwent PTCA under such conditions. These patients could not benefit from surgery for various reasons. Of the 612 arteries involved, 155 were occluded, 47 had been previously bypassed. A distal nonbypassable lesion in one of the three major arteries was found in 244 patients, 61 had suffered from a previous infarct, 24 demonstrated an ejection fraction below 0.40, and in 19 a single patent vessel was found. Fifteen patients were in cardiogenic shock and 69 procedures were undertaken for unstable angina. Of this latter group, 25 emergency PTCA were attempted for refractory unstable angina, and 44 additional emergency procedures were directed to the treatment of acute infarct. A total of 40 intra‐aortic counterpulsations were needed. As far as possible the procedure aimed at full revascularization. Immediate outcome is strongly affected by the clinical context, and despite a rather constant initial success rate (88–95%), the procedural mortality (directly related or not) can change dramatically with clinical factors. Respective definitive success and mortality rates are: 93% and 0% when a complete revascularization is attempted, 89% and 0% in double‐vessel disease with stable angina, 80% and 2.8% with stable triple‐vessel disease, 85% and 3.2% in the overall elective procedures, 77% and 19% in emergency cases, 60% and 40% in cadiogenic shock, and 47% and 47% in cases of single patent vessel. In such nonsurgical MVD patients, some situations entail very high risks and clinical characteristics are powerful predictive factors. These clinical factors must be taken into account, isolated and associated, and included when weighing carefully the risks before any decision to treat.