bluuebunny/crossref_metadata_2025 huggingface dataset:
Heart rate variability in patients with orthotopic heart transplantation: Long‐term follow‐up
Authors: Folino Antonio Franco , Buja Gianfranco , Miorelli Manuela , Livi Ugolino , Nava Andrea , Thiene Gaetano , Dalla Volta Sergio
Published: February 2009

To evaluate heart rate variability (expressed as the standard deviation of RR intervals) within 5 years of follow‐up, we studied 20 patients (14 males, 6 females, mean age 44 ± 12 years) who underwent orthotopic heart transplantation. Six measurements were taken: one in the first 3 weeks after transplantation, and the others once annually, for 5 years. Twenty healthy subjects (mean age 44 ± 7 years) constituted the control group. Heart rate variability increased significantly in the first 3 years of follow‐up (7.2 ± 1 vs. 11.1 ± 4, p < 0.001; 11.1 ±4vs. 15.2±4, p<0.01; 15.2±4vs. 18.9±5, p< 0.05); in the following years this trend slackened and values did not reach a statistically significant difference (18.9 ± 5 vs. 21.4 ± 5; 21.4 ± 5 vs. 22.5 ± 5). The mean standard deviation was invariably greater in the control group (63.6 ± 12). These findings show that sinus rhythm variability in the denervated heart progressively increased over 5 years of follow‐up. The absence of presynaptic uptake, which is responsible for adrenergic hypersensitivity to circulating catecholamines and intrinsic cardiac reflexes, does not appear to cause this phenomenon, since these mechanisms are not able to evolve in time after cardiac transplantation. Therefore, an enhanced beta‐adrenergic receptors density or affinity to circulating catecholamines or a limited sympathetic reinnervation may be the more probable underlying mechanism.
Comparison between diurnal distribution of onset of infarction in patients with acute myocardial infarction and circadian variation of blood pressure in patients with coronary artery disease
Authors: Tsuda Makoto , Hayashi Hlroshi , Hayashi Hlroshi , Yoshikan Mari , Saito Hldehiko
Published: February 2009

We analyzed the diurnal distribution of the onset of infarction in 636 patients with acute myocardial infarction (MI) and compared it with the circadian variation of blood pressure in 57 patients with coronary artery disease (CAD). In addition, we studied the modification of the circadian blood pressure variation during treatment with antianginal medications in 20 patients with CAD. A marked diurnal periodicity (p < 0.05) was observed for the onset of MI, with peaks seen in the late morning, late evening, and very early morning. The blood pressure in the patients with CAD was elevated in the morning, reduced in the late evening, and was the lowest in the very early morning. The peaks of onset of infarction temporally corresponded to the characteristic feature of blood pressure profile observed in the patients with CAD, that is, the morning rise, the late evening decline, and the very early morning reduction. Antianginal medications significantly reduced the blood pressure, not only during the day (p < 0.02) but also at night (p < 0.05). These observations suggest that the decline in blood pressure, as well as the morning surge in blood pressure, may be closely related to the onset of MI. Therefore, when treating patients with CAD with antianginal medications which can potentially reduce blood pressure, the effects on the circadian variation of blood pressure should be considered.
Changes in pulmonary hemodynamics predict benefits in exercise capacity after ACE inhibition in patients with mild to moderate congestive heart failure
Authors: Pelliccia Francesco , Borghi Alberico , Ruggeri Augusto , Cianfrocca Cinzia , Morgagni Gian L. , Bugiardini Raffaele
Published: February 2009

Several causes may affect the efficacy of angiotensin‐converting enzyme (ACE) inhibitors in congestive heart failure (CHF). The present study was undertaken to identify what factors might predict benefits in exercise capacity after ACE inhibition in 22 patients with mild to moderate CHF. All patients underwent hemodynamic evaluation before and following an oral dose of quinapril (20 mg). They were then treated daily with 20 mg of quinapril and underwent exercise stress test off‐drugs 1 day and 6 months later. Patients were grouped according to their relative changes in vascular resistances after quinapril: Group A (n=15) showed a greater decrease in pulmonary vascular resistance (PVR) than in systemic vascular resistance (SVR) (%ΔPVR/%ΔSVR>1). The opposite occurred in Group B (n = 7). Comparison of pretreatment baseline features revealed that the two groups had similar biochemical and hormonal variables, cardiac index, and SVR. Conversely, Group A patients had higher (p<0.05) pulmonary artery pressure and PVR compared with Group B patients. Following quinapril, Group A patients showed a greater (p<0.05) increase in cardiac index than Group B patients, despite a similar reduction in SVR. Accordingly, 1‐day drug treatment significantly (p<0.001) increased exercise duration in Group A (+29%), but not in Group B patients (+7%). Benefits in exercise capacity were still significant (p<0.001) 6 months later. It is concluded that (1) ACE inhibitors may significantly increase exercise capacity in most but not all CHF patients; (2) these salutary effects occur predominantly in patients with abnormal pulmonary hemodynamics; (3) although there are many possible mechanisms by which these drugs may benefit CHF, these data favor the effects on veins and/or pulmonary vasculature as being the most clinically important factor.
Structural and dynamic changes in the elastic arteries due to arterial hypertension and hypercholesterolemia
Authors: Alva Felix , Samaniego Virginia , Gonzalez Vidal , Moguel Rafael , Meaney Eduardo
Published: February 2009

Five groups of 20 patients each were studied to analyze the vascular dynamics and structure of the elastic arteries. Group I consisted of healthy young individuals (27±4 years); Group II of healthy adults (46±9 years); Group III of normotensive hypercholesterolemic adults (45±12 years and serum cholesterol >239 mg/dl); Group IV of hypertensive normocholesterolemic adults (56±13 years); and Group V of hypertensive hypercholesterolemic adults (56±9 years). The differential arterial pressure was estimated and divided by the volume change (delta P/delta V) of the aorta and the carotid and brachial arteries. The volume change was calculated using the “cylinder formula,” measuring the radius from the ultrasonographic vessel image and assigning the cylinder a height of 1 cm. The A/E index of the Doppler transmitral spectrum and the maximum velocity flow using Doppler in the above arteries were calculated. The presence of carotid atherosclerosis was observed and given an arbitrary scoring grade of 0, 1, or 2. A higher arterial and ventricular stiffness was found in the hypertensive patients regardless of the presence of hypercholesterolemia. A higher fall in Doppler velocity and an increase in atherosclerosis lesions were found in Group V. Based on the results of this study, it was concluded that vascular and left ventricular stiffness have a close relationship with arterial hypertension but not with hypercholesterolemia. The hypercholesterolemic patients had a higher prevalence of carotid atherosclerosis and a higher scoring grade of severity.
Concomitant occurrence of a left atrial myxoma and an adenocarcinoma of the lung
Authors: Canver Charles C. , Plehn Jonathan F.
Published: February 2009

A 72‐year‐old previously healthy woman was found to have both a left atrial myxoma and a left lung mass during the evaluation for two cerebrovascular events. Resection of the atrial myxoma and a biopsy of the left lung mass were performed. Six weeks later she underwent a left upper lobectomy for adenocarcinoma of the lung. This case illustrates the concomitant occurrence of a left atrial myxoma and a primary lung cancer in a patient who underwent a successful staged treatment for both diseases.
Patterns of radiofrequency catheter ablation of left free‐wall accessory pathways: Implications for accessory pathway anatomy
Authors: Tai Yau‐Ting , Lau Chu‐Pak
Published: February 2009

Despite the abundance of literature on the electrophysiology of accessory pathways, clinical data on their anatomic properties remain infrequent. The small and discrete nature of lesions generated by radiofrequency (RF) energy may allow better characterization of accessory pathway anatomy in the intact heart. RF catheter ablation was performed on 40 left free‐wall accessory pathways in 39 consecutive patients with a unipolar endocardial approach. The patterns of accessory pathway ablation were identified. Spatial‐electrophysiologic information provided by the ablation catheter at individual sites of RF application and corresponding data from the coronary sinus catheter were correlated with the effects of RF energy on accessory pathway conduction. Of 39 accessory pathways permanently (n = 37) or transiently (n = 2) ablated, 24 had “simple” ablation, with abolition of conduction by one individual RF application. In 15 of 24 pathways that could be crossed by the coronary sinus catheter, the concordance in anatomic and electrophysiologic information between the site of earliest retrograde atrial activation and the effective ablation position (ventricular approach) suggested a perpendicular fiber course. Fifteen pathways had “complex” ablations; of these, eight had spatial‐electrophysiologic discordance between the atrial and ventricular insertions, suggesting an oblique fiber orientation. Seven pathways had modification or transient suppression of conduction, with or without subsequent abolition of conduction at identical or physically disparate (1 cm apart) sites; four pathways had sequential ablation of antegrade and retrograde conduction. These raised possibilities of broad fiber span and functional longitudinal dissociation of accessory pathway conduction. Accessory pathways with simple and complex ablations did not differ in clinical and electrophysiologic parameters. Complex ablations demanded more lengthy and difficult procedures. In conclusion, 38% of left free‐wall accessory pathways in this series had complex patterns of RF ablation. The results of this study raised interesting implications in regard to accessory pathway anatomy and provided information that might facilitate electrophysiologic guidance of RF accessory pathway ablation.
Diagnosis of papillary muscle rupture after acute myocardial infarction by transthoracic and transesophageal echocardiography
Authors: Zotz Rainer J. , Genth Sabine , Erbel Raimund , Meyer Jorgen , Dohmen Guido
Published: February 2009

The sensitivity of transthoracic echocardiography to visualize the structural abnormality of papillary muscle rupture (PMR) after acute myocardial infarction can be anticipated to average about 50%; therefore, we evaluated five patients exhibiting the condition with both transthoracic and transesophageal echocardiography. The use of the two imaging techniques resulted in the fact that no instance of PMR was missed. Using transthoracic echocardiography in two patients and transesophageal echocardiography in four, the ruptured papillary muscle was visualized directly. Mitral insufficiency as an indirect sign was observed in all patients. In one patient the papillary muscle rupture developed in a mitral valve previously affected by endocarditis. All patients underwent mitral valve replacement and coronary artery bypass grafting. The diagnosis was confirmed at surgery in all patients. Four patients died in hospital, the fifth 5 months later. We recommend that transesophageal echocardiography be performed in patients with suspected PMR if transthoracic echocardiography does not provide an unequivocal diagnosis.
Torsade de pointes
Authors: Roden Dan M.
Published: February 2009

The polymorphic ventricular tachycardia torsade de pointes can occur in the congenital long QT syndromes or as a consequence of therapy with QT‐prolonging drugs. The latter can include not only antiarrhythmic drugs such as quinidine, but also a number of drugs which are not usually considered to have major cardiovascular effects: these include nonsedating antihistamines, such as terfenadine; antibiotics such as erythromycin; and neuroleptics such as thioridazine. The electrocardiographic hallmark of both the congenital and acquired forms of the long QT syndrome is marked QT(U) lability, particularly as a function of heart rate. The underlying mechanism is thought to be triggered activity arising as a consequence of early afterdepolarizations. An understanding of the basic mechanism has led to an understanding of the effective forms of therapy, which include maneuvers to include the heart rate (pacing, isoproterenol) as well as maneuvers which may not necessarily alter the QT interval but may prevent the arrhythmia (magnesium, beta blockers). Intensive study of the clinical features and basic mechanisms underlying torsade de pointes has led to the definition of a new mechanism for cardiac arrhythmias; understanding such mechanisms may ultimately lead to the development of safer antiarrhythmic therapy.
Coronary artery bypass grafting for left main trunk coronary artery lesion associated with essential thrombocythemia
Authors: Momiyama Takuya , Hiranaka Toshiyuki , Nomura Fumikazu , Tominaga Harumi , Nishioka Takehiko
Published: February 2009

Effort angina due to left main trunk (LMT) lesion was diagnosed in a 58‐year‐old man. Platelet count was markedly increased and essential thrombocythemia was also diagnosed. Because of LMT disease, coronary artery bypass grafting (CABG) was performed prior to medication for essential thrombocythemia. There were no complications during the operation or in the early postoperative period. Melphalan was administered postoperatively resulting in the decrease of platelet count. Postoperative coronary angiography demonstrated that both grafts were patent; however, immediately after coronary angiography, the patient suffered from a sudden onset of myocardial infarction and cerebral infarction. The therapeutic problems associated with hematological disorder in such patients are discussed in this report.
Coronary anomalies: Incidence and importance
Authors: Ciesunski G. , Rapprich B. , Kober G.
Published: February 2009

Most patients with coronary anomalies are asymptomatic. The knowledge of those variations could be important in regard to invasive catheter treatment or bypass surgery. In a retrospective study, the angiographic findings based on 4, 016 patients (1985‐1989) were analyzed concerning coronary anomalies and malformations. Of the patients studied, 39 (0.97%) had coronary anomalies, and in 26 of these patients it was an anomalous circumflex branch. In 14 cases, the circumflex branch arose from a separate origin in the left aortic sinus. In 11 patients the origin was from the proximal segment of the right coronary artery. A singular coronary artery was found in five patients, originating from the right aortic sinus in two patients and from the left aortic sinus in three patients. An origin of the left coronary artery from the pulmonary artery, a coronary fistula, or an origin of the left anterior descending coronary artery from the RCA could be found in only one patient. Unexpected findings during invasive procedures would suggest a possibly existing coronary anomaly, especially when main branches cannot be opacified by selective contrast medium injection.
SIN‐1 has no direct myocardial anti‐ischemic action
Authors: Kober G. , Bender M. , Vallbracht C. , Sievert H. , Klepzig H.
Published: February 2009

Anti‐ischemic drugs may develop their cardiac activity via peripheral (reduction in preload and/or afterload) or cardiac (coronary vasculature, myocardial cell metabolism) effects. The aim of the study was to investigate whether SIN‐1, the active metabolite of molsidomine, develops a direct myocardial anti‐ischemic property. Three groups of seven patients each were treated with 0.4 mg SIN‐1 administered via either the intracoronary (IC) or intravenous (IV) route, or with placebo in a double‐blind randomized investigation. SIN‐1 had no influence on either the ischemic parameters in the surface electrocardiogram (ECG) or the intracoronary ECG. There was also no change in peripheral or central hemodynamics or in the severity of angina following this low IC or IV dosage. There is no evidence of a direct myocardial anti‐ischemic response of SIN‐1. The well known anti‐ischemic activity of SIN‐1 or molsidomine has to be attributed to the proven peripheral and cardiac vascular responses.
Echocardiographic study of left atrial thrombi in mitral stenosis
Authors: Conradie C. , Marx J. D. , Schall R.
Published: February 2009

Sixty‐nine patients with predominant mitral stenosis were examined by echocardiographic means to detect the presence of left atrial thrombi. Forty‐nine of these patients were in sinus rhythm and twenty in atrial fibrillation. Four percent of patients in the sinus rhythm group and 45% of those in the atrial fibrillation group had left atrial thrombi. The two risk factors identified for left atrial thrombi in mitral stenosis were atrial fibrillation and left atrial enlargement.
An integrated software system for quality assurance‐related kappa coefficient analysis of intraoperative transesophageal echocardiography interpretive skills
Authors: Rafferty T. , Edwards B. , Judd J. , Swamy V. , Workman R. , Lippmann H. , Harris S. , Cohen I. , Prokop E. , Ezekowitz M.
Published: February 2009

This report describes the development of a quality assurance‐oriented integrated software system designed for an anesthesiology‐based intraoperative transesophageal echocardiography service. Entry data include patient and operation demographics, two‐dimensional echocardiographic, saline‐contrast, and color flow/pulsed Doppler assessments of the heart and great vessels, presented in a defined sequence. A statistical analysis component (kappa coefficient analysis) allows for comparison of intraoperative real‐time interpretations with laboratory interpretations made by experienced full‐time echocardiographers on a field‐by‐field basis. This provides a means of quantifying expertise in each individual aspect of the patient examination sequence. We believe that such self‐appraisal data are essential for delineating the status and tracking the progress of service being provided.
Quality of life and circadian variation of heart rate and heart rate variability in short‐term survivors and nonsurvivors after acute myocardial infarction
Authors: Kümmell Hans Christoph , Van Leeuwen Peter , Heckmann Christian , Engelke Peter , Resting Gisela , Kremer Heidemarie , Becher Andreas
Published: February 2009

The purpose of this study was the simultaneous examination of the quality of life and changes in heart rate (HR) variables of patients immediately following acute myocardial infarction (AMI). Quality of life, estimated on a rating scale assessing the patients' well‐being, as well as the circadian rhythm of their HR and HR variability, were determined within the first 3 days and at approximately 3 weeks after admission and the results were related to survival. The quality of life within the first 3 days post AMI was low in both the surviving (n = 42) and the nonsurviving (n = 5) patients but only the scores of the survivors increased significantly over the following three weeks. The HR of the survivors, initially lower than that of the nonsurvivors, decreased significantly at 3 weeks and a normal circadian pattern had developed. The HR variability of the survivors within the first 3 days was significantly higher than that of the nonsurvivors and had developed a clear circadian pattern after 3 weeks. It is concluded that in patients with AMI such diverse clinical aspects as quality of life and circadian patterns of HR and HR variability can be assessed meaningfully immediately post AMI and may find common expression in changes in sympathovagal balance.
Evolution of cardiac changes in young insulin‐dependent (type 1) diabetic patients—one more piece of the puzzle of diabetic cardiopathy
Authors: Raev Dlmitar Christov
Published: February 2009

Based on our recent reports that increased myocardial contractility has been found in newly diagnosed diabetic patients, and that diastolic (D) dysfunction precedes systolic (S) dysfunction, we suggested that the development of diabetic cardiopathy passes through the following stages: (I) increased myocardial contractility, (II) intact S and D function, (III) intact S function and D dysfunction, and (IV) S and D dysfunction. The aim of this pilot study was to test this hypothesis. One hundred fifty‐seven young (26.2 ± 7.4 years) cardiac‐asymptomatic patients with type 1 diabetes and 54 healthy subjects were studied using M‐mode echocardiography. The presence of at least one of the variables for systolic function (ejection fraction, mean velocity of circumference, fiber shortening, and stroke index) or diastolic function [left atrium emptying index (LAEI), EFo slope of anterior mitral leaflet, and isovolu‐metric relaxation time (IRT)] outside the control mean ± 2 SD was interpreted as an increased or depressed myocardial contractility, and diastolic dysfunction, respectively. The severity of diabetic complications (retinopathy, nephropathy, and cardiac autonomic neuropathy) was evaluated by the diabetic complication index (DCI=0 + 6 scores). Our hypothesis was confirmed significantly (p< 0.001) in 148 (94%) patients with diabetes. Duration of diabetes and DCI progressed significantly (ANOVA: F = 36.6, p<0.001; F=70.8, p<0.001) with hypothetical stages. Diastolic dysfunction was more pronounced in stage IV than in stage HI: IRT (80.5 ± 18.6 ms vs. 62.5 ± 16.4, p<0.001), EFo (63 ± 15 mm/s vs. 72 ± 21, p<0.05), LAEI (0.58 ± 0.13 vs. 0.8 ± 0.15, p < 0.001). End‐diastolic volume/LV muscle mass ratio was reduced in stage III (0.73 ±0.16 ml/g) compared with the control value (0.83 ± 0.17, p < 0.01), but was higher than that in stage IV (0.65 ± 0.16, p < 0.05). The left atrium in stage HI (18.2 ± 3.7 mm/m2) was dilated compared with the control value (16.2 ± 3.3, p < 0.01) and more dilated in stage IV (19.6 ± 3.1, p<0.001).

The present study demonstrates the following stage development of specific diabetic cardiac changes: (I) increased myocardial contractility; (II) intact S and D function; (III) initial D dysfunction, LV restriction and LA dilation with normal S function; and (IV) progression of the previous changes and appearance of S dysfunction.
Cor pulmonale caused by recurrent pulmonary emboli
Authors: Hackel Donald B. , Peter Robert H. , Wagner Galen S.
Published: February 2009

A 53‐year‐old black man developed femoral thrombophlebitis in 1983 following a Harrington nail implantation in his first lumbar vertebral region. There was evidence of pulmonary embolization at that time and recurrently until he developed ventricular fibrillation and died in 1987. The terminal event followed a hypotensive episode during the course of a right ventricular catheterization. Autopsy confirmed the clinical impression that he had multiple recurrent thromboemboli to his lungs. After several years of embolization, the pulmonary arterial circulation was sufficiently occluded to result in pulmonary hypertension. Cor pulmonale was produced, with congestive heart failure leading to a progressively downhill course in the 4 months before his death.
Thrombolytic retreatment with tissue plasminogen activator for threatened reinfarction and thrombotic coronary reocclusion
Authors: Becker Richard C.
Published: February 2009

Following successful coronary arterial thrombolysis, thrombogenic substrate persists, increasing the risk of recurrent thrombosis, reocclusion, and reinfarction. The preferred treatment in this setting has not been established. Although many patients receive mechanical revascularization, it is conceivable that repeat thrombolysis. primarily with tissue plasminogen activator, represents the most readily available and effective alternative.
Activation of leukocytes and of the kallikrein‐kinin system in patients with unstable angina pectoris
Authors: Hoffmeister Hans Martin , Beyer Martin E. , Engel Zwetana , Heller Wolfgang
Published: February 2009

We investigated the leucocyte‐elastase and the activity of the kallikrein system including kinin precursors and plasma inhibition levels in 14 patients with unstable angina pectoris (normal or only slightly elevated creatine kinase levels; no transmural myocardial infarction) and compared them with 10 controls. Leucocyte‐elastase levels and activity of the kallikrein system were significantly elevated in unstable angina pectoris. The bradykinin precursor high‐molecular‐weight kininogen was markedly decreased to 79 ± 16% indicating kinin generation. Except for a slight decrease in the beta factor Xlla inhibition, we observed no abnormalities in the plasma kallikrein inhibition or in the antithrombin III levels in patients with unstable angina pectoris. The findings indicate a significant activation of the plasma kallikrein‐kinin system, which is not associated with a considerable reduction in the plasma inhibitor levels. Kinin generation might influence vascular tone and leucocyte function and thus be involved in the pathophysiologic alterations occurring in patients with recurrent angina at rest.
A new approach to the management of infected pacemakers
Authors: Antinori Charles H. , Villanueva Dioscoro T. , Pierucci Louis , Manuel Victor J. , Kuchler Joseph A.
Published: February 2009

Management of infected pacemakers always presents a problem. This report describes a method of managing infected pacemakers, using the infected unit as a temporary pacer. This method has worked well in four patients.
General concepts in the morphologic assessment of operatively excised cardiac valves—part I
Authors: Waller Bruce , Howard Jane , Fess Stephen
Published: February 2009

This two‐part article discusses the general morphologic assessment of operatively excised cardiac valves and applies these principles to functional classifications. All cardiac valves are categorized into stenotic and purely regurgitant (no element of stenosis) groups based upon structural features: presence or absence of commissural fusion, calcific deposits, and degree and location of fibrosis. Of 2980 operatively excised cardiac valves reviewed between 1962 and 1992, the most common lesion was aortic stenosis, followed by mitral stenosis and the combination of aortic and mitral stenosis.
New evidence for improved survival in chronic heart failure
Authors: Clark Andrew L. , Coats Andrew J. S.
Published: February 2009

Chronic heart failure is a common clinical syndrome with high associated mortality and morbidity. Recent advances in therapy for the condition with vasodilators and, in particular, angiotensin‐converting enzyme inhibitors, have led to hopes for improvement in survival. Several large scale studies examining the role of vasodilators have reported over the last few years, and the role of vasodilators in the treatment and prevention of chronic heart failure is being delineated. There is new hope for patients with symptomatic heart failure; symptoms can be alleviated and prognosis improved. Increasingly, it appears as if there is a role for drug therapy in preventing the onset of chronic heart failure. In this paper, we examine the results of these studies and of some smaller studies in order to discuss the implications for current therapy and future research.
The optimal technique for electrical cardioversion of atrial fibrillation
Authors: Ewy Gordon A.
Published: February 2009

The optimal approach to electrical cardioversion of atrial fibrillation includes appropriate patient selection, anticoagulation, careful selection and monitoring of antiarrhythmic therapy, and proper electrical cardioversion technique. The optimal technique requires the use of metal electrodes, with one electrode of at least 8 cm in diameter placed in the anterior position, and the second of 12–13 cm diameter placed posteriorly just below the left scapulae, with generous amounts of the appropriate gel (such as Hewlett‐Packard Redux Paste) as the electrode‐skin interface and firm pressure to the paddle electrode with the patient in expiration. Thus the anterior‐posterior chest diameter is decreased and less air between the electrodes is assured. The initial shock strength should be 200 J. The shock is synchronized with the electrocardiographic QRS complex. This report reviews the justification for these recommendations.
The plasma concentration of N‐terminal proatrial natriuretic factor anf (1‐98) is related to prognosis in severe heart failure
Authors: Hall Christian , Kjekshus John , Eneroth Peter , Snapinn Steven
Published: February 2009

Due to its longer halflife, the N‐terminal of ANF prohormone, ANF( 1‐98), has plasma concentrations that exceed those of ANF itself by a factor of 10 or more. It is also less prone to rapid changes secondary to hemodynamic alterations. To evaluate the prognostic significance of ANF(1‐98) plasma levels in severe heart failure (NYHA IV), the peptide was measured by radioimmunoassay in plasma samples from patients randomized to additional treatment with enalapril (n = 78) or placebo (n = 61) (CONSENSUS study). In the placebo group there was a positive relation between mortality after 6 months and baseline ANF(1‐98) level. Because of a reduced mortality, especially among patients with high ANF(l‐98) levels, there was no such relation in the patients treated with enalapril. For both groups there was a positive relationship between increase in ANF(1‐98) after 6 weeks of treatment and mortality, while a decrease signaled a favorable prognosis. It is concluded that the magnitude and changes of plasma ANF(1‐98) provide information on prognosis and therapeutic effects with respect to mortality in patients with severe heart failure. Plasma ANF(1‐98) may serve as a useful clinical biochemical parameter in the treatment of heart failure.
General concepts in the morphologic assessment of operatively excised cardiac valves—Part II
Authors: Waller Bruce , Howard Jane , Fess Stephen
Published: February 2009

This 2‐part article discusses general morphologic assessment of operatively excised cardiac valves and applies these principles to functional classifications. All cardiac valves are categorized into stenotic and purely regurgitant (no element of stenosis) groups based upon structural features: presence or absence of commissural fusion, calcific deposits, and degree and location of fibrosis. Of 2,980 operatively excised cardiac valves reviewed between 1962 and 1992, the most common lesion was aortic stenosis, followed by mitral stenosis and the combination of aortic and mitral stenosis.
Efficacy of rapid atrial pacing for conversion of atrial flutter in medically treated patients
Authors: Baeriswyl Gérard , Zimmermann Marc , Adamec Richard
Published: February 2009

To determine factors affecting the success rate of rapid atrial pacing in converting atrial flutter to sinus rhythm in medically treated patients, we prospectively used this technique for 120 consecutive episodes in a total of 110 patients (94 male, 16 female, mean age 63 ± 14 years). Structural heart disease was present in 77%, and all patients were receiving antiarrhythmic drugs at the time of the procedure. Atrial flutter type I was present in 92 of 110 patients (84%), and atrial flutter type II in 18 of 110 (16%). Primary success rate (return to sinus rhythm either immediately or after < 10 min of atrial fibrillation) was 70% (71/102) for flutter type I, and 6% ( 1/18) for flutter type II (p < 0.001). Delayed success (conversion to sinus rhythm in > 10 min but < 24 h) was observed in 15 additional episodes of flutter type I (15%) and in 1 additional episode of flutter type II (6%). The only clinical factors predicting primary success were (a) characteristics of flutter waves on the 12‐lead surface electrocardiogram, (b) duration of flutter (primary success rate of 81 % if flutter < 1 month vs. 57% if > 1 month, p< 0.05), and (c) flutter rate (primary success rate of 78% if < 260/min vs. 56% if > 260/min, p< 0.05). In 6/71 episodes of flutter type I (8%), prolonged sinus pauses or severe bradyarrhythmias occurred after conversion to sinus rhythm. It was concluded that overdrive atrial pacing is an effective procedure to convert atrial flutter type I in sinus rhythm in medically treated patients; the primary success rate of the procedure depends on flutter type, duration, and rate. Because severe bradyarrhythmias are not uncommon at the time of conversion and because it does not require general anesthesia, this technique can be considered as a first‐step therapy in this particular population.
Double‐blind comparison of amlodipine and hydrochlorothiazide in patients with mild to moderate hypertension
Authors: S. Ram C. Venkata , Ames Richard P. , Applegate William B. , Burris James F. , Davidov Michael E. , Mroczek William J.
Published: February 2009

In the final analysis of this study at Week 26,26% of the patients randomized to receive amlodipine attained blood pressure control with amlodipine alone compared with 33% of the patients allocated to hydrochlorothiazide (HCTZ). Neither amlodipine nor HCTZ produced clinically significant changes in pulse rate or in the electrocardiogram. Amlodipine treatment did not appear to produce clinically significant changes in blood lipids; HCTZ, however, produced an increase in total plasma cholesterol (Δ22.9 ± 8.6 mg/dl). The incidence of side effects and the rate of patient withdrawal in the amlodipine and HCTZ groups were comparable. As expected, HCTZ therapy caused well‐recognized biochemical alterations in cholesterol and potassium levels, whereas amlodipine was metabolically neutral.
Effect of left ventricular contractile performance on passive left atrial filling—Clinical study using radionuclide angiography
Authors: Fujii Kaoru , Ozaki Masaharu , Yamagishi Takashi , Ishine Kenji , Furutani Yuhji , Nagano Hiroyuki , Yamamoto Kouzo , Saiki Atsusi , Matsuzaki Masunori
Published: February 2009

Many invasive and noninvasive methods have been used to study the cardiac atria; however, few allow quantitative measurement of atrial function. To determine the interaction between left ventricular (LV) contraction and left atrial (LA) filling, gated radionuclide angiography was conducted in 30 normal subjects (24 men and 6 women, mean age 58 ± 10 years, range 26‐68). LV and LA time‐activity curves and their firstderivative curves were obtained simultaneously by using the method of Bough et al. The LV ejection fraction (64 ± 18%) and LV peak ejection rate (LVPER; 3.42 ± 0.27 EDV/s) were computed from these curves. As indices of LA filling, LA fractional emptying (38 ± 12%) and LA peak filling rate (LAPFR; 2.86 ± 0.17 LAVmax/s)—the latter being defined as the peak rate of LA filling during the LA filling phase—were also computed from these curves. In all subjects, the timing of the LVPER coincided with the occurrence of LAPFR, and there was a significant positive correlation between the LVPER and LAPFR (r= 0.81, p < 0.001 ), indicating that the LAPFR was strongly affected by the degree of LVPER. Thus, these results indicate that LV contractile performance plays an important role in determining LA passive filling during ventricular systole.
Familial cardiac and skeletal myopathy associated with desmin accumulation
Authors: Porcu Maurizio , Mereu Dionigi , Muntoni Francesco , Catani Gualtiero
Published: February 2009

We describe the case of a mentally retarded young man with marked biventricular hypertrophy, skeletal myopa thy, and bilateral pes cavus, in whom desmin accumulation was documented in cardiac and skeletal muscle biopsies. Hemodynamic assessment showed a restrictive profile. A brother of the proband was similarly affected and died at the age of 24 of cardiac failure. Sudden death occurred in other six members of this family. Pedigree analysis suggested an X‐linked inheritance. This observation and previous reports suggest that desmin accumulation is probably less rare than was thought in patients with unexplained hypertrophic or restrictive cardiomyopathies.Desmin accumulation should be systematically searched for in these types of cardiomyopathies, although its specificity needs to be investigated in further studies.
Transplantation and the problems afterward including coronary vasculopathy
Authors: Mills Roger M.
Published: February 2009

The clinical success of cardiac transplantation requires clinical cardiologists to become familiar with care of the post‐transplant patient. This review emphasizes five major post‐transplant problems: (1) infection/immunosuppression, (2) metabolic problems, (3) post‐transplant hypertension, (4) exercise intolerance, and (5) graft coronary disease. The evolution of these problems after transplantation is emphasized, so that clinical cardiologists and internists sharing the management of these patients can develop a context in which to work.
Efficacy and safety of amlodipine in hypertensive patients with renal dysfunction
Authors: Saruta Takao , Ishii Masao , Abe Keishi , Iimura Isamo
Published: February 2009

Amlodipine, a dihydropyridine calcium antagonist, was administered at 2.5‐5.0 mg/day for 8 weeks to 35 hypertensive patients with renal dysfunction, and its efficacy and safety were evaluated. The target reduction in blood pressure was achieved in 28 of the 35 patients (80%), while blood pressure was decreased in 4 patients (11.4%) and unchanged in 3 patients (8.6%). A side effect of mild headache was reported by one patient (2.9%). In addition, abnormal changes in laboratory values were observed in five patients, but all of the changes were mild. Blood urea nitrogen and serum creatinine levels both increased in two of these five patients, and serum creatinine levels increased in another two patients. Serum amlodipine concentration was 4.86 ± 2.57 ng/ml (n = 8) and 3.01 ± 1.02 ng/ml (n = 8) in patients receiving a daily dose of 2.5 mg for 2‐5 weeks and 8‐10 weeks, respectively. Serum concentration in patients receiving 5 mg from Weeks 2‐6 was 9.72 ± 6.89 ng/ml (n = 6) after 7‐9 weeks, suggesting no tendency for the accumulation of this drug. The drug was rated as of clinical benefit in 27 of the 35 patients (77.1%), and as slightly beneficial in another 5 patients (14.3%). Thus, amlodipine significantly decreased the blood pressure while causing little or no aggravation of renal dysfunction in hypertensive patients with renal impairment.
Signal‐averaged electrocardiographic late potentials in children with complete heart block
Authors: Hayabuchi Yasunobu , Matsuoka Suguru , Kubo Masahiro , Aktta Hiroshi , Kuroda Yasuhiro
Published: February 2009

The purpose of this study was to examine signalaveraged electrocardiographic (SA‐ECG) late potentials to predict ventricular arrhythmias during intrinsic cardiac rhythm and during ventricular pacing in children with complete heart block (CHB). Recordings of SA‐ECG were obtained from eight patients (aged 3‐18 years) with documented CHB. The etiology of CHB was congenital in four cases and acquired in four cases. Six of these patients underwent permanent pacemaker implantation. Comparisons of the SA‐ECG were made before and during ventricular pacing. Abnormalities of SA‐ECG during intrinsic cardiac rhythm were noted in four patients, all of whom were older than 14 years. Although there was no significant difference in SA‐ECG parameters between patients with congenital CHB and acquired CHB, abnormal SA‐ECG was noted in one of four patients with congenital CHB and in three of four patients with acquired CHB. Two patients without permanent pacemaker implantation had normal SA‐ECG, but four of six patients with permanent pacemaker implantation had abnormal SA‐ECG. Three of the four patients had abnormal SA‐ECG during ventricular pacing, but the abnormal SA‐ECG in one patient had normalized during ventricular pacing. It is important to record SA‐ECG before and during ventricular pacing to detect late potentials in patients with CHB. It may be useful to record SA‐ECG while changing the pacing site to find ideal sites for electrode implantation for the potential prevention of ventricular arrhythmias.
Pathology of mitral valve stenosis and pure mitral regurgitation—Part I
Authors: Waller Bruce F. , Howard Jane , Fess Stephen
Published: February 2009

This two‐part article examines the histologic and morphologic basis for stenotic and purely regurgitant mitral valves. In Part I, conditions producing mitral valve stenosis are reviewed. In over 99% of stenotic mitral valves, the etiology is rheumatic disease. Other rare causes of mitral stenosis include congenitally malformed valves, active infective endocarditis, massive annular calcium, and metabolic or enzymatic abnormalities. In Part II, conditions producing pure mitral regurgitation will be discussed. In contrast to the few causes of mitral stenosis, the causes of pure (no element of stenosis) mitral regurgitation are multiple. Some of the conditions producing pure regurgitation include floppy mitral valves, infective endocarditis, papillary muscle dysfunction, rheumatic disease, and ruptured chordae tendineae.
Radiofrequency catheter ablation of both atrial ventricular nodal reentrant and atrial ventricular reentrant tachycardia in a single session
Authors: Schläpfer Jürg , Goy Jean‐Jacques
Published: February 2009

Radiofrequency catheter ablation is a new therapeutic approach to treat patients with symptomatic drug‐resistant paroxysmal supraventricular tachycardia. Ablation of two accessory atrioventricular pathways in a single session has been frequently described previously. However, ablation in a single session of both the fast pathway, involved in atrial ventricular nodal reentrant tachycardia, and a concealed atrioventricular accessory pathway involved in a circus movement tachycardia has rarely been reported. A 57‐year‐old man with a grade III aortic incompetence had the infrequent association of atrial ventricular nodal reentrant tachycardia and orthodromic circus movement tachycardia due to a concealed accessory pathway. He presented with drug‐resistant reentrant supraventricular tachycardia and, in a single session, underwent a successful radiofrequency catheter ablation of the fast atrial ventricular nodal pathway and a concealed posteroseptal accessory pathway. During a 10‐month follow‐up he was free of palpitations without any antiarrhythmic therapy and underwent elective aortic valve replacement.
Activated clotting‐time variability in patients undergoing coronary angioplasty
Authors: Warner Mark F. , Shahbaz MIAN M. , Missri Jose C.
Published: February 2009

Although the activated clotting time (ACT) is commonly used to assess adequacy of anticoagulation during percutaneous transluminal coronary angioplasty (PTCA), there is uncertainty whether measurements on samples from the arterial and venous circulations are directly comparable. We performed ACT determinations on 115 patients undergoing PTCA at our institution. Blood samples were drawn in a sequential fashion from the arterial and femoral venous sheaths at the conclusion of each case, and ACT determinations were performed in the catheterization laboratory immediately thereafter. The venous ACT exceeded the arterial value in 63 patients (55%), and was identical in only 2 instances. The arterial and venous ACT differed by more than 100 s in 10 patients. in 23 patients (20%) one ACT determination was ≥ 300 s, while the value from the other circulation was < 300 s. We conclude that there is substantial variability between arterial and venous ACT determinations in heparinized patients undergoing PTCA.
Left atrial thrombi despite anticoagulant and antiplatelet therapy
Authors: Zotz Rainer J. , Pinnau Uwe , Genth Sabine , Erbel Raimund , Meyer Jürgen
Published: February 2009

To investigate risk factors for embolization in patients with echocardiographically detected left atrial thrombi and to evaluate thrombus development, we examined 29 patients with transesophageal and transthoracic echocardiography at two points during a follow‐up of 18 months. We compared patients with a history of possible arterial embolization0 (n = 13) with those without (n = 16) in regard to age, gender, left atrial dilatation, localization of the thrombus in the left atrial cavity, spontaneous echo contrast, and atrial fibrillation. Eight patients were treated with aspirin, 20 with phenprocoumon. Only left atrial spontaneous contrast was associated with thrombembolism (10/15 patients with spontaneous contrast experienced arterial embolism; p = 0.038). in six patients arterial embolism occurred after thrombus detection (14% per patient per year). Four of these patients were treated with phenprocoumon, two with aspirin. At reexamination, one thrombus was detected in the patient without anticoagulant treatment and one thrombus was detected in the 8 patients treated with aspirin (13%), compared with ten thrombi detected in the 20 patients (50%) treated with phenprocoumon (p = NS). in 17 patients no thrombus was seen at reexamination. Since only 2 patients had undergone thrombectomy and 3 experienced arterial embolism during follow‐up, thrombi disappeared under medical therapy in 12 patients. Patients with left atrial thrombi have a high risk of arterial embolization despite proper anticoagulative or antiplatelet treatment. Embolization occurs significantly more often if spontaneous echo contrast can be visualized. Left atrial thrombi can be reduced in size by the administration of antiplatelet and anticoagulative agents. Detection of left atrial thrombi with transesophageal echocardiography identifies this patient population at an increased risk of embolization.
Electrophysiologic characteristics at initiation of ventricular tachycardia and ventricular fibrillation in a canine infarct model
Authors: Moroe Kazuo , Coelho Aldo , Sampsell Ronald N. , Chun Yeong‐Hwa , Mayrovitz Harvey N. , Gosselin Arthur J.
Published: February 2009

Local ventricular activation time and the conduction time during sinus rhythm at the induction of ventricular tachycardia (VT) and ventricular fibrillation (VF) were investigated using a canine model of chronic myocardial infarction. Of 26 dogs studied, 15 had inducible VT, 10 had inducible VF, and 1 had no inducible arrhythmias. Bipolar local ventricular electrograms were recorded during sinus rhythm from 136 sites in 10 dogs with VT and 164 sites in 11 dogs with VF. Mean activation time in dogs with inducible VT was significantly longer than in dogs with inducible VF. Furthermore, simultaneous local ventricular electrograms were recorded during the induction of VT (74 episodes) or VF (38 episodes) from the infarct border zone at the endocardium (B‐EN), the epicardium (B‐EP), and normal sites (N‐EN, N‐EP). During VT induction, the activation time at N‐EN and N‐EP was significantly longer than during VF induction (N‐EN: 94 ± 21, 70 ± 19 ms; N‐EP: 83 ± 21, 64 ± 10 ms; p < 0.05). Conduction time was measured at the initiation of VT or VF induced by orthodromic or antidromic pacing. The conduction times of the last paced beat between N‐EN and B‐EP (35 ± 11, 62 ± 24 ms), N‐EN and N‐EP (35 ± 12, 14 ± 13 ms), B‐EN and B‐EP (16 ± 10, 38 ± 25 ms), and B‐EP and N‐EP (77 ± 27, 44 ± 12 ms) were significantly different in dogs with inducible VT (p < 0.05), but not in dogs with VF. Dispersion of effective refractory period was also observed in dogs with VT. Percent infarct in inducible VT was larger than in inducible VF (VT: 16 ± 5%; VF: 10 ± 2%; p < 0.001). These studies suggest that dogs with inducible VT have prolonged ventricular activation time and significantly different bidirectional conduction time during VT induction. This may serve as a substrate for reentry.
Provocation of ventricular tachycardia by antimalarial drug halofantrine in congenital long QT syndrome
Authors: Toivonen Lauri , Viitasalo Matti , Pohjola‐Sintonen Sinikka , Siikamäki Heli , Raatikka Marja
Published: February 2009

This report deals with two patients who suffered sustained episodes of torsade de pointes ventricular tachycardia while using the novel antimalarial drug halofantrine. Both patients had congenital long QT syndrome, and their QT interval was further prolonged at the time of the event. This first electrocardiographic documentation of ventricular arrhythmias together with halofantrine's known prolonging effect on the QT interval demonstrates that the drug has the potential to induce life‐threatening arrhythmias.