bluuebunny/crossref_metadata_2025 huggingface dataset:
Diagnostic value of atrial pacing and thallium‐201 scintigraphy for the assessment of patients with chest pain
Authors: Stratmann H. G. , Mark A. L. , Walter K. E. , Williams G. A.
Published: August 2009

Atrial pacing was performed either alone (n = 23) or in combination with thallium‐201 scintigraphy (n = 113) in 136 patients referred for evaluation of chest pain. The presence of coronary artery disease (CAD) was excluded by cardiac catheterization in 12 patients and confirmed in 124. Both pacing‐induced ST depression and angina had sensitivities of 48% for CAD; specificities were 75% and 83%, respectively. An abnormal thallium‐201 scan (one or more reversible and/or fixed perfusion defects) was seen in 72% of patients with CAD (specificity 83%), and fixed defects in 36% (specificity 100%). Pacing was associated with either ST depression or an abnormal perfusion scan in 81% of patients (specificity 67%). There were no significant differences in the results of atria pacing or thallium‐201 scintigraphy in patients with or without a history of myocardial infarction, or in those with or without previous coronary artery bypass surgery. Pacing‐induced ST depression, or both ST depression and a reversible perfusion defect occurred significantly less frequently in patients with peripheral vascular disease than in those without this diagnosis (p <.05). With only one exception, there were no significant differences in the sensitivities of any indicators of ischemia (ST depression, angina, or perfusion scans), either individually or in combination, as the peak pacing rate or double product achieved increased. Patients paced to maximum double products in excess of 26,000 beats‐mmHg/min had a significantly increased incidence of ischemic ST depression compared to those paced to lower double products (p <.05). We conclude that atrial pacing and thallium‐201 scintigraphy, when used together, are useful for evaluating selected patients with chest pain for the presence of CAD.
Sudden cardiac death after aortic valve surgery: Incidence and concomitant factors
Authors: Föppl M. , Hoffmann A. , Amann F. W. , Roth J. , Stulz P. , Hasse J. , Grádel E. , Burckhardt D.
Published: August 2009

A retrospective analysis of 599 consecutive patients after aortic valve surgery aged 7‐82 years (mean 56) was performed. During a follow‐up of 1‐14 years (mean 4.7 years) a 4‐week perioperative mortality of 6.9% and a late annual mortality of 3.6% were observed. Sudden cardiac death was the most frequent single cause of death, accounting for 24% of all deaths. Patients dying suddenly were younger than patients dying from other causes (51 ± 17 vs. 59 ± 14 years, p<0.05) and showed more left ventricular hypertrophy by electrocardiographic criteria when compared with matched survivors (mean Estes score 5.2 ± 2.4 vs. 2.8 ± 1.9; p<0.01) and with patients dying nonsuddenly (mean Estes score 5.2 ± 2.4 vs. 1.8 ± 1.8; p<0.01). Ventricular premature beats in the resting electrocardiogram were more prevalent in patients dying suddenly than in matched survivors (55 vs. 20%; p<0.025) as well as in patients dying from other causes (55 vs. 25%; p<0.05). In addition, there were more intracardiac conduction disturbances and more ungrafted coronary vessels with insignificant stenoses at the time of surgery in sudden death patients. Our findings suggest that after aortic valve replacement patients with left ventricular hypertrophy, bundle‐branch block, and ventricular premature beats in the resting electrocardiogram are at increased risk for sudden cardiac death. A possible etiological role of concomitant coronary artery disease must be considered.
Exercise‐induced pulmonary blood volume changes and diastolic dysfunction of the aged heart
Authors: Alexopoulos D. , Machac J. , Arora R. R. , Horowitz S. F.
Published: August 2009

Impaired diastolic function has been described in healthy elderly subjects. Pulmonary blood volume (PBV) changes with exercise have been associated with left ventricular dysfunction, but not directly related to diastolic abnormalities. Exercise‐induced relative changes in PBV were measured using gated blood pool imaging with count density comparisons over the lung in 20 healthy volunteers: 13 elderly, age 76 ± 5 years and seven young, age 27 ± 4 years. Serial (first exercise stage, peak exercise, and post exercise) PBV ratios were measured and correlated to peak early filling rate, peak late filling rate, and percent atrial filling obtained from the resting left ventricular timeactivity curve analysis. PBV ratios tended to be higher in elderly subjects, but reached significance only at the first stage of exercise (1.04 ± 0.07 vs. 0.93 ± 0.10, p<0.01). Significant correlations were found between PBV rations at first exercise stage and peak early filling rate (r= −0.64), peak late filling rate (r = 0.47), and percent atrial filling (r = 0.48). A significant correlation was found between PBV changes at peak exercise and resting diastolic parameters. Exercise‐induced PBV changes are associated with left ventricular diastolic dysfunction at rest. Diastolic abnormalities of the aged heart may explain the differential PBV response early into exercise between young and elderly healthy subjects.
Hemodynamic effects of continuous infusion of AR‐C 239 in left ventricular failure
Authors: Colle J. P. , Besse P.
Published: August 2009

AR‐C 239 is a new specific alpha1 antagonist drug with an action similar to that of prazosin. In dogs it appears to be specific for the alpha1 adrenoreceptor. AR‐C 239 was tested in 11 patients (49 ± 11 years old) with left heart failure, who had not received any previous treatment. The drug was infused intravenously with a stepwise increase in dose, producing three stable plasma concentration plateaus: 10 ± 2, 51 ± 3, and 138 ± 55 ng/ml. Hemodynamic data were collected at time T0 before drug infusion, and half‐way through each infusion. Blood pressures and cardiac output were recorded using a Millar microtip manometer (left ventricle), a Swan‐Ganz catheter (pulmonary artery), and a femoral catheter, connected to a Syscomoram computer system which calculated the following parameters: work, resistances, tension—time index and contractility indices. Left ventricular ejection fraction and volumes were obtained from cineangiograms performed 30 min before drug infusion and at the end of the third infusion plateau. AR‐C 239 produces a dose‐dependent fall in systemic blood pressure (r=0.539, n=33, p<.001). Maximal beneficial effects are reached with the second infusion dose with a dramatic fall in systemic (peripheral) resistance (−30±21%, p±0.01), accompained by a decrease in pulmonary resistance (−22±24%, p<.05), leading to a drop in the tension‐time index (−22±16%, p<.01), a fall in LV filling pressure (−17±8%, p<.001), and an improvement in cardiac index (+20±18%, p<.02). Apart from a reflex‐related increase in heart rate (14±10%, p<.01), the drug does not affect contractility indices such as extrapolated Vmax. No adverse reactions were noted during the experiment. AR‐C 239 appears to be a powerful vasodilator via selective alpha1‐adrenoreceptor blockade. Its good tolerance together with the large range of available dose concentrations indicate that this drug could be useful in the acute management of left heart failure.
Long QT syndrome associated with inflammatory degeneration of the stel ganglia
Authors: Pfeiffer D. , Fiehring H. , Rostock K. J. , Rathgen K. , Henkel H. G.
Published: August 2009

A well‐studied case of intermittent long QT syndrome in a 21‐year‐old female is presented. Electrophysiologic investigation repeated three times revealed changing sinoatrial and atrioventricular dysfunction and nonsustained ventricular tachycardia. The patient died 29 months after first hospitalization in a stage of electromechanical dissociation after runs of torsade de pointes although she had been treated with repeated anti‐inflammatory therapy as well as high doeses of propranolol. Postmortem examination demonstrated active inflammation of stellate ganglia. Myocardium appeared normal.
Lower than conventional doses of captopril in the initiation of converting enzyme inhibition in patients with severe congestive heart failure
Authors: Scott R. A. , Barnett D. B.
Published: August 2009

Angiotensin converting enzyme (ACE) inhibitors are effective long‐term therapy for congestive heart failure, improving symptoms, exercise tolerance, biochemical anomalies, and mortality. Captopril, in doses of up to 150 mg daily is relatively free of serious adverse effects. A test dose of 6.25 mg normally precedes regular therapy in an attempt to avoid first‐dose hypotension which may also be prevented by reduction in diuretic dosage and by the avoidance of overdiuresis leading to volume depletion. We report two patients who, despite the above precautions developed symptomatic first‐dose hypotension with 6.25 mg, but were subsequently able to recommence captopril therapy by the initial oral administration of doses as low as 1 mg.
The cardiovascular abnormalities associated with duplicated segments of chromosome 7
Authors: Talley J. D. , Click L. A. , Dooley K. J. , Tuboku‐Metzger A. , Burgess G. H. , Wilcox W. D. , Blackston R. D.
Published: August 2009

congenital heart disease is an integral part of many genetic syndromes such as the major trisomies 13, 18, and 21. Little information, however, is available with reference to the incidence of cardiac anomalies in the trisomy 7 syndromes. Two patients with partial trisomy 7q, one of whom had congenital heart disease, are presented. A reviews of the literature reveals incomplete description of the cardiovascular abnormalities in the majority of case reports of patients with this syndrome, however, when described it appears that there are no specific defects associated with trisomy 7p and 7q, but only an increased frequency of occurrence. Further clinical and postmortem data regarding details of the congenital heart defects associated with trisomy 7 is requried to confirm this preliminary observation.
Dynamic cardiomyoplasty for treatment of heart failure
Authors: Hill A. B. , Chiu R. C‐J.
Published: August 2009

Dynamic cardiomyoplasty is a new surgical procedure proposed for treatment of the failing heart. Clinically, the latissimus dorsi muscle is raised as a pedicled flap and wrapped around the heart. The skeletal muscle is transformed to produce a myocardium‐like fatigueresistant muscle. It is stimulated to contract in synchrony with the heart in hope of assisting the myocardial contraction. An R‐wave synchronous pacemaker provides a pulse‐train form of stimulation to simulate, for the skeletal muscle, the contractile characteristics of the myocardial syncytium. We have undertaken a critical review of the clinical results of dynamic cardiomyoplasty reported to date. Objective evidence of clinical improvement after dynamic cardiomyoplasty resulting from the contractile assistance of the myoplasty has been modest. Many of the beneficial results reported could be explained by concomitant procedures done, such as aneurysmectomy or coronary artery bypass grafting. Hemodynamic studies have failed to demonstrate consistent and convincing improvement as a result of the cardiomyoplasty stimulation. We have, however, identified an interesting subgroup of patients, in whom a striking hemodynamic response to cardiomyoplasty stimulation has been reported. These patients all possess large resting heart volumes characteristic of dilated cardiomyopathy. Thus, case selection may ultimately be one of the most important factors in determining the success of dynamic cardiomyoplasty for the treatment of heart failure.
A multicenter randomized trial of ionic (ioxaglate) and nonionic (iopamidol) low‐osmolality contrast agents in cardiac angiography
Authors: Klinke W. P. , Grace M. , Miller R. , Naqvi S. Z. , Roth D. , Roy L.
Published: August 2009

A multicentered double‐blind randomized study was performed comparing the electrocardiographic and hemodynamic changes induced by two new low osmolar contrast agents used for cardiac angiography. The low osmolar ionic (ioxaglate) contrast agent was compared with a low osmolar nonionic (iopamidol) contrast agent in 150 patients with angina pectoris undergoing angiography. Systolic blood pressure, left ventricular enddiastolic pressure, heart rate, and QT interval were measured just before and for 90s following the left ventricular angiography and selective coronary angiography. Each group was also evaluated for adverse events and quality of radiographic images. Following left ventricular angiography, the systolic blood pressure dropped slightly in both groups with a greater decrease seen in the iopamidol group at 5 s (p<0.05). After selective right and left coronary angiography, systolic blood pressure decreased transiently and equally in both treatment groups. The left ventricular end‐diastolic pressure increased after the ventriculogram in both groups (15.9±6.3 to 18.9±8.6 mmHg in the ioxaglate group and 16.1±6.7 to 20.1±7.8 mmHg in the iopamidol group), the change being significant only in the iopamidol group (p<0.05). Heart rate increased slightly but significantly in the ioxaglate‐treated patients following left ventricular angiography (71.4±15.2 to 74.4±13.7 beats/min) (p<0.01). QT interval transiently increased following left ventriculography with ioxaglate (407±59.5 to 420±58.3 ms) (p<0.05) compared with iopamidol. Following coronary angiography the QT interval increased transiently but significantly in the ioxaglate group compared to iopamidol (p<0.05) for right coronary artery, p<0.01 for left coronary artery). However, no significant change from baseline was observed at 90 s. No significant change in QT interval or heart rate was seen with iopamidol‐treated patients. Side effects were infrequent in both groups. Nausea was more frequent with ioxaglate injection than with iopamidol (10 patients versus 1 patient) (p<0.01) as was hives (8 patients versus 1 patient) (p<0.05). No severe life‐threatening adverse effects occurred. There was no difference in the quality of radiographic images obtained with either contrast agent. Electrocardiographic and hemodynamic changes are minimal with both contrast agents and no clinically important changes were seen with either group. In conclusion, both low osmolar contrast agents are safe for use in cardiac angiography although the incidence of nausea and hives occurs more frequently with the use of ioxaglate.
Systolic tricuspid leaflet prolapse in asymptomatic young men
Authors: Froom P. , Ribak J. , Shochat I. , Tamir A. , Krivisky M. , Lewis B. S.
Published: August 2009

The degree of systolic movement of the tricuspid valve (TV) leaflets was measureds in 100 consecutive apparently healthy men 18‐20 years old at the time of maximum posterosuperior motion toward or into the right atrium. Backward bowing of >0.20 mm2 of the anterior leaflet, and >0.15 mm2 of either the posterior or septal leaflets beyond the plane of the tricuspid annulus was found in 5% or less of the cohort irrespective of the echocardiographic view in which it was recorded. The upper 5% of these young men had >0.80 mm2 of backward bowing when the leaflet motion was summed from all three views. The anterior leaflet demonstrated more bowing than either the septal or posterior leaflets. The systolic TV prolapse area correlated highly with the degree of mitral leaflet prolapse (r=0.654, p<0.001). We conclude that there is a wide continuous spectrum of tricuspid valve leaflet prolapse area in healthy young men. This quantitative approach may help standardize the echocardiographic evaluation of tricuspid leaflet motion.
Sudden coronary death
Authors: Warnes C. A.
Published: August 2009

Many reports have described the amounts of atherosclerotic plaque in victims of sudden coronary death, defining the number of coronary arteries narrowed at some point > 75% in cross‐sectional area (XSA). In order to quantitate more precisely the amount and distribution of plaque, 70 victims of sudden coronary death aged 22‐81 years (mean 50) were studied. The four major epicardial coronary arteries (left main, left anterior descending, left circumflex, and right) from each of 70 victims were cut into 5‐mm segments (average 50 per patient) and a histologic section prepared from each segment. The amount of lumnial narrowing by plaque was categorized into five groups (0‐25%, 26‐50%, 51‐75%, 76‐95%, 96‐100%). Of 3,484 five‐mm segments, 950 (27%) were narrowed 76‐100% in XSA. Comparison of 31 previously symptomatic victims (angina pectoris and/or myocardial infarction) to 39 victims who had been asymptomatic disclosed a higher mean percent of severely narrowed segments (30% vs. 25%, p = <0.005) and a lower mean percent of minimally narrowed segments in the symptomatic group. Comparison of the 31 patients with a healed myocardial infarction at necropsy with 39 patients with no left ventricular scar disclosed a higher mean percent of segments severely narrowed (33% vs. 24%, p = <0.001) and a lower mean percent of segments narrowed minimally in those with a left ventricular scar (13% vs. 26%, p= <0.001). Those patients with higher heart weights (>450 grams) compared with those with lower heart weights had a higher mean percent of segments severely narrowed (23% vs. 19%, p = <0.01) and a lower percent of minimally narrowed segments (24% vs. 29%, p = <0.005) in the large heart group. Patients in each decade had similar mean percents of severely narrowed segments. Thirteen patients had a coronary artery thrombus, and in each the thrombus occurred at a site narrowed >50% by plaque. Seven patients had disrupted fibrocellular caps at the site of thrombus, and the role of “plaque fissuring” is examined.
Multiple coronary thrombosis in a patient with thrombocytosis
Authors: Hamada Y. , Matsuda Y. , Fujil B. , Ohno H. , Takashiba K. , Ebihara H. , Hyakuna E.
Published: August 2009

A 59‐year‐old woman was admitted with acute inferior myocardial infarction. Cardiac catheterization revealed total occlusion in the right coronary artery and thrombus‐like filling defect in the left anterior descending coronary artery. With simultaneous intracoronary urokinase infusion to the right and left coronary arteries, the right coronary artery became patent and the thrombus in the left anterior descending coronary artery was released to the distal coronary artery. Thrombocytosis was disclosed by laboratory examination. The relationship between myocardial infarction and thrombocytosis is discussed.
Reversible dilated cardiomyopathy induced by methamphetamine
Authors: Jacobs L. J.
Published: August 2009

This brief report details the case of a woman who was thought, after extensive evaluation, to have idiopathic congestive cardiomyopathy. It was subsequently found that systolic ventricular dysfunction was due to amphetamine abuse, and that ventricular function normalized after discontinuation of this drug.
Umbilical catheter masquerading at echocardiography as a left atrial
Authors: Crie J. S. , Hajar R. , Folger G.
Published: August 2009

The case of a newborn who had an umbilical catheter inserted in the intensive care unit is discussed. This catheter was meant to be inserted into the umbilical artery, but was instead inadvertently inserted into the umbilical vein. It crossed a patent foramen ovale into the left atrium. This fact was not known at the time of echocardiographic evlaluation. At echocardiography, abnormal echoes within the left atrium were seen. Findings were typical for a catheter within the heart, and the umbilical catheter was subsequently withdrawn. There is a potential for mistaking the echocardiographic findings for a left atrial abnormality and echocardiographers should be alert to this possibility.
Update on intravenous dipyridamole cardiac imaging in the assessment of ischemic heart disease
Authors: Younis L. T. , Chaitman B. R.
Published: August 2009

Intravenous dipyridamole is a relative selective coronary vasodilator which, when combined with thallium–201, provides a useful technique to assess myocardial perfusion. The intravenous dipyridamole is administered as an infusion at a rate of 0.14 mg/kg/min for 4 minutes. In the presence of significant coronary artery disease the increase of coronary blood flow is disproportionate between vessels with and without significant coronary lesions, providing the basis for detecting regional differences in flow using thallium–201. The test can be used alone or combined with low level exercise to increase test sensitivity. The test is safe when performed under medical supervision and when patient selection is done appropriately. Most of the side effects induced by dipyridamole infusion are well tolerated by patients and readily reversed with intravenous aminophylline and sublingual nitroglycerin. The average sensitivity and specificity of the dipyridamole thallium scintigraphy test from the major studies are 76% and 70%, respectively. The test is very useful in providing prognostic information in patients who are unable to exercise. A reversible thallium defect after dipyridamole infusion has been shown to be associated with signficant mortality and morbidity in patients with documented or suspected coronary artery disease. The use of intravenous dipyridamole has been extended into other modalities of imaging, including 2–dimensional and Doppler echocardiography, to study functional changes in the left ventricular induced by the infusion of intravenous dipyridamole. Like other noninvasive tests, intravenous dipyridamole thallium scintigraphy has its own limitations, including the absence of standard physiologic data which are acquired during exercise testing, the need to stop theophylline or its derivatives 48 hours prior to testing, and a relatively low yield of ischemic electrocardiographic changes. It is anticipated that intravenous dipyridamole will soon be commercially available.
Coronary revascularization: Influence on ventricular arrhythmias
Authors: Rotman B. , Eber B. , Dusleag J. , Klein W. , Rigler B.
Published: August 2009

Myocardial ischemia may cause severe cardiac arrhythmias. In the present study, the influence of revascularization on ventricular arrhythmias was investigated. A total of 68 patients (61 male, 7 female; mean age 53 years) with coronary artery disease was divided into three groups: Group A (21 patients) underwent percutaneous transluminal coronary angioplasty (PTCA); Group B (37 patients) had coronary artery bypass grafting (CABG); and Group C were 10 patients who served as controls, who had simple coronary angiography. All patients had a Holter ECG on the day before angiography. PTCA patients and controls were restudied on the day after the procedure, while in Group B, Holter ECG was repeated three weeks after surgery. Groups A and B were again studied 18 months after the first Holter ECG. The PTCA group showed a slight reduction in complex arrhythmias immediately following PTCA, which increased again after 18 months; the CABG group, however, revealed a significant increase in complex arrhythmias three weeks after bypass surgery, but a decrease after 18 months. There was no significant change in the control group before or after ngiography. Thus, successful revascularization has no influence on ventricular arrhythmias after 18 months.
Dipyridamole thallium imaging may not be a reliable screening test for coronary artery disease in patients undergoing vascular surgery
Authors: Marwick T. H. , Underwood D. A.
Published: August 2009

Dipyridamole thallium imaging has been proposed for cardiac risk stratification in patients undergoing peripheral vascular surgery. The purpose of this study was to define the benefit of this investigation in routine preoperative evaluation of these patients. The outcome of 86 patients undergoing vascular surgery procedures was examined in light of preoperative clinical assessment and dipyridamole SPECT thallium imaging (DST). Fifty–one patients (59%) were considered at high risk on clinical grounds, and 22 patients (26%) had perfusion defects. Ten patients suffered a perioperative coronary event, including unstable angina, myocardial infarction, or cardiac death. Seven of the patients with such events were among the 51 clinically high–risk subjects (14%). Three perioperative events occured in the group of 19 patients with positive DST images who underwent surgery (16%), but the DST test failed to identify 7 patients who suffered coronary events. The frequency of abnormal thallium imaging was similar to the prevalence of angiographically significant coronary disease reported previously at this center, but considerably less than the rate of abnormal thallium imaging in past studies of vascular surgery patients. The application of the test to a low to moderate risk population is probably responsible for its lower predictive accuracy for coronary events. DST is not an ideal routine noninvasive technique for risk stratification in patients undergoing vascular surgery.
The slope of the end–systolic pressure–volume relationship compared with the global end–systolic pressure–volume ratio in humans
Authors: Abboud L. , Sideman S. , Battler A. , Rath S. , Beyar R.
Published: August 2009

The slope of the end–systolic pressure–volume relationship (Emax), which is generated clinically by load manipulation, as well as the “absolute” peak systolic pressure end–systolic volume ratio (denoted as pressure–volume ratio), have been suggested as indices defining left ventricular function. This study represents an attempt to determine the relationship between these two indices by studying 20 patients (16 with coronary artery disease and 4 with normal coronary arteries) undergoing cardiac catheterization. Left ventriculography was performed three times in each patient: (1) in the control baseline state, (2) after rapid intravenous infusion of 250–300 cc of saline, and (3) after sublingual administration of 5 mg isosorbide dinitrate. Emax was approximated by linear regression using the peak left ventricular pressure (replacing endsystolic pressure) and the smallest left ventricular (endsystolic) volume for these three different loads. Actue ischemia with typical chest pain and ECG changes developed in 4 patients during saline loading. The pressure–volume ratio showed no change with load manipulation in patients who developed acute ischemia, the pressure–volume ratio dropped from 4.4±1.3 to 2.9±0.9 mmHg/ml (p < 0.001). In all of the patients, the pressure–volume ratio, but not the Emax, correlated with the ejection fraction (r = 0.6; p<0.05). In addition, the Emax line demonstrated a markedly nonphysiological Vo. There was no correlation between Emax and pressure–volume ratio. Generally, there was a significant disparity between Emax and the peak systolic pressure–volume ratio, with the latter having the advantage of simplicity, sensitivity to acute ischemia, and a correlation with the well–established EF index.
Identification of patients prone to infarct expansion by the degree of regional shape distortion on an early two–dimensional echocardiogram after myocardial infarction
Authors: Jugdutt B. J.
Published: August 2009

Early detection of potential expanders (patients who develop clinically significant infarct expansion with acute left ventricular (LV) dilation and failure but no necrosis) after acute myocardial infarction (AMI) is necessary in order to apply preventive therapy. To determine whether the degree of regional shape distortion (RSD), or dilatation, on early two–dimensional echocardiogram (2–D echo) after AMI can identify potential expanders, serial clinical and echocardiographic data were studied prospectively in 244 consecutive patients with a first Q–wave AMI. Initial (mean 2 days) and final (mean 10 days) two–dimensional echocardiograms were compared for regional LV asynergy, RSD, and conventional indices of expansion measured on endocardial diastolic outlines of mid–LV short–axis sections. Analysis of clinical and 2–D echo data revealed 51 expanders and 193 nonexpanders. Expanders showed greater LV dysfunction and more inhospital deaths (27% vs. 8%, p<0.001) compared with nonexpanders; conventional indices of expansion showed more marked increase between initial and final two–dimensional echo in expanders, but initial indices were not predictive. In contrast, the new RSD index Pk, a measure of the outward bulge, was markedly greater in expanders than nonexpanders on both initial (16.5 vs. 2.4 mm, p<0.001) and final echo. Furthermore, expanders with ≥ 30% increase in Pk (to 21 mm) developed rupture of the ventricular septum (n=10) or free wall (n=2). Also 50 of 51 expanders compared with 3 of 193 nonexpanders had a Pk ≥ 10 mm on the initial echo. A simpler index, the depth of RSD (rd), provided similar discrimination as Pk. Thus, the degree of diastolic RSD on an early 2–D echo after AMI can identify potential expanders.
Atrial pacing for sick sinus syndrome
Authors: Rosenqvist M.
Published: August 2009

Atrial pacing is the most physiological way to pace patients with sinus node disease, as it provides both AV synchrony and a normal ventricular activation pattern. Long–term studies comparing atrial and ventricular pacing imply that atrial pacing results in fewer cardiac complications and, possibly, reduced mortality. Ventricular pacing should thus, if possible, be avoided in patients with sinus node disease. The potential risk of impending high–grade AV block during atrial pacing is low, with an annual incidence around 1% if patients are selected appropriately. Approximately 40–50% of patients with sinus node disease show signs of chronotropic incompentence during physical exercise, and are thus candidates for atrial rate responsive pacing. A preoperative evaluation of candidates for atrial pacing should include longterm Holter/telemetry, exercise test, carotid sinus stimulation, and an electrophysiological study excluding significant AV conduction disturbances.
Coronary occlusion: Cause or consequence of acute myocardial infarction?
Authors: Baroldi G. , Marzilli M. , L'Abbate A. , Arbustini E.
Published: August 2009

A 45–year–old man with unstable angina developed persistent ECG changes of myocardial ischemia during coronary angiography. Occlusion of the left anterior descending branch (LAD) was documented 20 minutes after these changes. Intracoronary nitrate, Ca antagonist, urokinase, removal by percutaneous transluminal coronary angioplasty (PTCA) of atherosclerotic obstructions, and emergency bypass surgery failed to restore myocardial perfusion. Only short periods of reflow were obtained by urokinase and PTCA. The repeated coronary injections demonstrated a progressive disappearance of the left anterior descending artery (LAD) starting from the distal portion and progressing retrogradely up to the origin of the vessel. The patient developed a transmural anterolateral myocardial infarction and 12 months later underwent cardiac transplantation for untractable failure. His heart was examined and the infarct confirmed. Analysis of this case suggests that coronary occlusion in acute myocardial infarction can be an event secondary to increased intramyocardial resistance rather than the cause of reduced coronary blood flow in subepicardial coronary arteries.
Coronary artery spasm during cardiac angiography
Authors: Satoh A. , Matsuda Y. , Sakai H. , Nakatsuka M. , Ogawa H. , Katayama K. , Fujii T. , Moritani K. , Kusukawa R.
Published: August 2009

Unexpected occurrence of coronary artery spasm is sometimes observed during cardiac catheterization. We report here two cases of coronary artery spasm with hypotension and urticaria subsequent to administration of contrast material. The etiology of coronary artery spasm is discussed.
Future directions in plasminogen activator therapy
Authors: Bode  , Runge M. S. , Haber E.
Published: August 2009

Thrombotic disorders such as myocardial and stroke are the leading causes of death and dis in industrialized nations. Timely institution of therapy can achieve a reduction of infarct, a preservation of left ventricular function, and a in mortality. The administration of streptokinase, and acylated plasminogen‐streptokinase acti‐ complex (APSAC) can be associated with a complete breakdown of the hemostatic system. Tissue‐type activator (t‐PA) and single‐chain urokinase‐ plasmiogen activator (scu‐PA, prourokinase) are fibrin specific; however, at the large dosages of ac‐ needed for therapeutic efficacy, bleeding compli‐ are still a problem. New approaches to optimizing the risk/benefit ratio for the patient by improving without sacrificing specificity include the use of combinations of plasminogen activators, of t‐PA and scu‐PA, chimeric molecules, and ‐targeted thrombolytic agents. The last approach the possibility of targeting several different com‐ of the clot with either fibrinolytic or antiplatelet functions in one optimized molecule.
Primary pulmonary hypertension in adults
Authors: Hawkins J. W. , Dunn M. I.
Published: August 2009

Primary pulmonary hypertension is an enigmatic disease found predominantly in young women, but it also affects a significant number of middle‐aged and elderly males and females. Its onset, characterized by progressively worsening dyspnea, fatigue, and chest pain, is insidious. Three distinct histopathologic subtypes have been identified, and the natural history of the disease process has been well‐defined. Pharmacologic treatment options have, in general, been disappointing, and it appears that heart‐lung transplantation will be applied only to a small minority of young patients with primary pulmonary hypertension in the near future. We review the histopathology, evaluation, treatment, and prognosis of primary pulmonary hypertension.
Thrombolytic therapy for acute myocardial infarction: Evaluation of a selective approach to invasive diagnosis and therapy in a community hospital
Authors: Burks J. M. , Kirby J. C. , Keating E. C. , Calder J. R.
Published: August 2009

To investigate the effectiveness of selective catheterization and revascularization after thrombolytic therapy for myocardial infarction, we studied the early and late clinical course of 100 consecutive patients treated with streptokinase and an intensive medical regimen. Catheterization was performed because of recurrent angina or evidence for reperfusion and myocardial salvage. Fifty‐six patients were catheterized, and 37 underwent revascularization. Hospital mortality was 8%. Among the 92 hospital survivors, after 1 year follow‐up there was no significant difference between the revascularized and nonrevascularized groups in total survival (97% and 100%, respectively) or in infarct‐free survival (97% and 95%, respectively). During total follow‐up of 34 (±13) months, late clinical events (death, reinfarction, late revascularization, and severe angina) occurred in 16% of 37 revascularized patients and in 27% of 55 patients not revascularized (p=0.31). Cumulative hospital and late survival for the entire group was 91% at 1 year and 86% at final evaluation. Excellent long‐term survival and a low incidence of recurrent infarction may be achieved after thrombolytic therapy, using selective catheterization and revascularization based on widely available clinical estimates of further ischemic risk.
Malignant restenosis after primary successful excimer laser coronary angioplasty
Authors: Buchwald A. , Werner G. , Unterberg C. , Wiegand V. , Voth A.
Published: August 2009

In a series of 20 coronary excimer laser, two patients presented with a peculiar type malignant restenosis 6 and 8 weeks after a successful angioplasty procedure. One patient had a successful of an occluded left anterior descending (LAD) coronary artery and the second patient had a successful angioplasty of a subtotal proximal stenosis of the left anterior descending coronary artery. After the procedure, no ischemia could be demonstrated by exercise ECG and thallium scintigraphy. Both patients were free of angina until the sudden development of nocturnal anginaseveral hours before reangiography, which showed subtotal restenosis in both cases. One patient had a mammaria graft on the LAD and the second patient underwent a successful balloon angioplasty. This uncommon sudden and malignant development of restenosis seems to be related to the excimer laser angioplasty procedure and warrants some caution with the indiscriminative use of this new angioplasty procedure.
Percutaneous transluminal angioplasty in patients ≥ 5 years after their last coronary bypass graft surgery
Authors: Dorros G. , Lewin R. F. , Mathiak L.
Published: August 2009

Angioplasty (PTCA) was successfully performed in 257 of 304 patients (85%) ≥ 5 years after their last bypass surgery. A lesion was successfully dilated in 496 of 566 vessels attempted (88%): 332/386 coronary arteries (86%) and 164/180 vein grafts (91%). Significant complications included: 8 (2.6%) mortalities, 4 (1.3%) emergency surgeries, 13 (4.3%) Q‐wave myocardial infarctions, and 14 (4.6%) distal embolizations. Distal embolization occurred in 13/180 (7%) vein graft lesions dilated and usually resulted in a non‐Q‐wave infarction (4/13 distal embolizations). A second PTCA was performed on 89 (35%) patients: 44% of them had lesion recurrence; 20% a new lesion requiring dilatation; and 30% both recurrence and new lesion. Follow‐up (mean 3.7 years) revealed 78% of patients having an improved anginal status, and 58% no angina. The cumulative probability of survival at 60 months was 88± 3%. Angioplasty can be effectively employed in patients ≥ 5 years remote from their last bypass surgery in native arteries or saphenous vein grafts with good procedural and long‐term success. Vein graft age inherently does not appear to be a contraindication to angioplasty.
Energy‐conserving programming of vvi pacemakers: A telemetry‐supported, long‐term, follow‐up study
Authors: Klein H. H. , Knake W.
Published: August 2009

Thirty patients with VVI pacemakers (Quantum 253‐09, 253‐19, Intermedics Inc., Freeport, TX) were observed for a mean of 65 months. Within 12 months after implantation, optimized output programming was performed in 29 patients. This included a decrease in pulse amplitude (22 patients), pulse width (4 patients), and/or pacing rate (11 patients). After 65 months postimplantation, telemetered battery voltage and battery impedance were compared with the predicted values expected when the pulse generator constantly stimulates at nominal program conditions (heart rate 72.3 beats/min, pulse amplitude 5.4 V, pulse width 0.61 ms). Instead of an expected cell voltage of 2.6 V and a cell impedance of 10 kΩ mean telemetered values amounted to 2.78 V and 1.4 kΩ, respectively. These data correspond to a battery age of 12‐15 months at nominal program conditions. This longterm follow‐up study suggests that adequate programming will extend battery longevity and thus pulse generator survival in many patients.
Chronic vasodilator therapy with flosequinan in congestive heart failure
Authors: Hass G. J. , Binkley P. E. , Leier C. V.
Published: August 2009

This study was conducted to determine the long‐term effect of flosequinan, a new orally administered arterial and venous dilator, on the clinical course of patients with moderate to severe congestive heart failure. Seventeen patients on chronic digitalis and diuretic therapy were randomized to receive either flosequinan (n = 9) or placebo (n = 8) in a double‐blind fashion. Changes in symptomatology, exercise performance, and left ventricular function were assessed serially during the two‐month treatment period. During the course of therapy, a modest improvement in the symptom scores and functional classification of the flosequinan‐treated patients was observed. Flosequinan evoked a significant increase in maximal exercise capacity. While long‐term flosequinan administration also effected a progressive increase in resting heart rate, it did not consistently improve indices of left ventricular systolic function. The addition of chronic vasodilator therapy with flosequinan to standard digitalis—diuretic regimens is capable of inducing clinical improvement in patients with moderate to severe chronic heart failure. Trials involving larger patient populations will be necessary to confirm the results of this preliminary study and to determine the extent of clinical improvement, subpopulations benefited, role in heart failure therapeutics, and so forth.
Biophysical and anatomical considerations for safe and efficacious catheter ablation of arrhythmias
Authors: Bardy G. H. , Sawyer P. L.
Published: August 2009

The development of catheter ablation techniques for therapy of cardiac arrhythmias continues to evolve. Although many patients have benefited from catheter ablation procedures, failure to ablate the arrhythmogenic substrate and complications from the pulse used in these procedures remain too frequent occurrences. The purpose of this review is to focus on these problems of inefficacy and safety with attention directed to the role various direct current and radiofrequency pulses have had in the genesis of these difficulties.
Unstable angina pectoris
Authors: Wallace W. A. , Richeson J. F. , Yu P. N.
Published: August 2009

The pathophysiology of unstable angina has been better elucidated in the past five years and has led to more rational therapy. Coronary arteries in patients with unstable angina have atherosclerotic plaques which are often complex and are the site of platelet activation and fibrin deposition. Nitrates, one of the oldest therapies, are efficacious and act not only by dilating coronary vessels but by reducing preload and afterload. Beta blockers have a salutary effect by decreasing myocardial oxygen demand. Calcium channel blockers attenuate smooth muscle contraction and thereby act to decrease coronary artery spasm. Beta blockers and calcium channel blockers are equally efficacious in unstable angina. The antiplatelet agent, aspirin, has been shown to reduce fatal or nonfatal myocardial infarction and probably overall mortality. The use of heparin acutely for unstable angina has been demonstrated to decrease refractory angina and myocardial infarction, and acutely is probably better than aspirin. For patients with reduced ejection fractions (0.30‐0.49), a prospective randomized trial has shown that coronary artery bypass graft surgery offers an improved three‐year survival compared with medical therapy; however, surgery does not prevent myocadial infarction. Percutaneous transluminal coronary angioplasty may be a reasonable therapeutic alternative for some patients with single‐vessel disease who are refractory to medical therapy but there are as yet no controlled trials of this question. To date a clinical benefit from thrombolytic therapy has not been demonstrated.
Does intensive medical therapy influence the outcome in unstable angina?
Authors: Mulcahy R. , Conroy R. , Katz R. , Fitzpatrick M.
Published: August 2009

Three hundred and forty‐six patients of all ages and both sexes were admitted to coronary care with documented unstable angina. Management was conservative, without the routine use of beta‐blockers or calcium antagonists. Mortality was 3.2%, and the nonfatal myocardial infarction rate was 10.1% during the first 28 days. After one year, coronary mortality was 10.5% with a non‐fatal infarction rate of 13.1%. Twenty‐six patients were subjected to coronary artery bypass surgery, eleven during the first 28 days and fifteen subsequently. No patient underwent coronary angioplasty. The factors influencing immediate and long‐term prognosis in these patients were studied. Persistence of pain in hospital, previous chronic angina, and age had an adverse effect on outcome.A total of 143 patients complained of persistent pain lasting for 24 hours or more. The use of beta blockers or calcium antagonists in patients with persistent pain exceeding five days did not appear to influence outcome. The current widespread adherence to “intensive medical treatment,” including the routine use of beta blockers and calcium antagonists, is questioned.
Temperature monitoring during peripheral thermo‐optical laser recanalization in humans
Authors: Barbeau G. R. , Abela G. S. , Friedl S. E. , Tomaru T. , Giacomino P. P. , Seeger J. M.
Published: August 2009

To determine probe temperature required to achieve laser thermal recanalization of human peripheral arteries, temperature was monitored at the probe tip using a K‐type thermocouple and displayed on a computer screen in real‐time in 21 procedures. Recanalization was performed using a Spectraprobe‐PLR delivering both laser light and heat in patients with prolonged ischemic limb symptoms. Laser recanalization of totally occluded peripheral arteries (occlusion length = 5.3 ± 3.8 cm) was done percutaneously (17 procedures) or intraoperatively (4 procedures), after unsuccessful attempts of recanalization using standard guide wire and balloon angioplasty techniques. Probes were activated using argon laser irradiation starting at 5 W and increased by 1‐W increments until successful recanalization, or up to a maximum of 12 W. Laser recanalization was achieved in 16/21 (76%) procedures at a mean temperature of 178±120° (range 64–503°) and a mean time of 12.4±14.1 s. Eleven of the 16 (69%) recanalizations occurred at probe temperature lower than 160°. Recanalization was achieved at a mean power of 7±2 W. Perforation occurred in 6 arteries at peak probe temperatures ranging from 73 to 502°. Perforations occurred in 4 of 6 densely calcific vessels which required high probe temperatures (>250°). An important feature of temperature monitoring was the immediate detection of probe dysfunction. Although recanalization temperature had a wide range, the majority of recanalizations occurred at probe temperature below 160°. Initial use of low laser power irradiation and low temperature with incremental rises seems to be a rational strategy when attempting recanalization of totally occluded peripheral arteries. Perhaps this strategy will prevent complications related to high probe temperature.
Late potentials recording with a precordial signal‐averaged electrocardiogram in 53 consecutive patients with a first acute myocardial infarction: Incidence and early natural history
Authors: Strasberg B. , Abboud S. , Kusniec J. , Sclarovsky S. , Agmon J.
Published: August 2009

Signal‐averaged electrocardiograms were obtained in 53 consecutive patients with a first acute myocardial infarction (AMI) who survived the first 10 days of hospitalization. The recording was performed twice, at Day 1 and at Day 10 of hospitalization, in patients without bundle‐branch block and who did not receive antiarrhythmic therapy. Signal‐averaged ECGs were obtained with an instrument which analyzes the presence of late potentials (LP) in each individual precordial lead. There were 41 men and 12 women, mean age of 67 years. On Day 1, three patients had L.P (5.6%). On Day 10, LP was recorded in 11 patients (21%). In only one patient was LP transient. Patients who developed LP by Day 10 (absent in Day 1) had statistically significant lower root mean square (rms) voltage and higher QRS duration than patients who did not develop LP on Day 10. In conclusion, in patients with a first AMI who survive the initial hospitalization period and are not in need of antiarrhythmic therapy have an incidence of LP of 21%. A predischarge recording is preferable since this will maximize the chances of detecting LP.