Contrast-echocardiography: confirmation of patency of laser channels after transmyocardial laser revascularization.

AIMS: Apart from casuistic autopsy results there is no long-term evidence for channel perfusion after transmyocardial laser revascularization in humans. METHODS AND RESULTS: Fifteen consecutive patients aged 63+/-17 years were investigated 71+/-15 days after coronary artery bypass surgery and/or transmyocardial revascularization with 13-37 (20+/-5) channels (CO(2) laser, 40 J/pulse). Echocardiography was performed after injection of 6 ml echo contrast medium into left ventricular cavity and after injection of 3 ml contrast medium into the left main coronary artery. In five patients with additional bypass surgery to the same region, we also injected 3 ml contrast medium into bypass graft. We could prove in 10 of 15 patients (67%) one or two laser channels in the apical left ventricular myocardium. Channels were perfused exclusively during systole. During following heart cycles myocardium was opacified up to a mean width of 1.4+/-0.4 cm, a mean depth of 0.71+/-0.1cm, and a mean area of 1.0+/-0.6 cm(2). Contrast medium was washed out via coronary venous system in 9+/-8 systoles. CONCLUSION: This is the first clinical evidence of long-term laser-channel patency in humans showing perfused myocardium via left ventricular cavity.

[Secondary immunologically-caused myocarditis, pericarditis and exudative pleuritis due to meningococcal meningitis]. / Sekundär immunologisch bedingte Myokarditis, Perikarditis und Pleuritis exsudativa infolge einer Meningokokken-Meningitis.

Myocarditis, pericarditis and pleural effusion as secondary immunological reactions due to meningococcal meningitis are rare. Meningococcal meningitis is itself uncommon, with a morbidity of approximately 1.25 cases per 100,000 inhabitants per year in Germany. Cardial participation could be observed either primary infectious-toxic in the first week or secondary immunologic in the second week after disease onset. In our patient, six days after the onset of meningococcal meningitis (serogroup B) a distinct swelling of the myocardium appeared together with pericardial effusion in the absence of Waterhouse-Friderichsen syndrome. This case is proving difficult to tackle therapeutically due to repeated relapses.

[Acute effects of enoximone after intracoronary administration on hemodynamics, myocardial perfusion and regional wall motion]. / Akutauswirkungen von Enoximon nach intrakoronarer Applikation auf die Hämodynamik, Myokardperfusion und die regionale Wandbewegung.

The influence of intracoronary enoximone at a dose of 0.075 mg/ kg/10 min on global and regional wall motion and myocardial perfusion (Group I, n = 10) as well as on diastolic LV function (Group II, n = 8) during pacing-induced ischemia was investigated in 18 patients with significant LAD stenoses. The hemodynamic parameters were determined by left heart catheterization, the systolic and diastolic left ventricular function by echocardiography including Doppler technique, and myocardial perfusion analysis was done after intracoronary application of contrast medium. Enoximone did not change either heart rate (79 +/- 9 vs 80 +/- 9 min-1) or blood pressure (LVSP: 159 +/- 7 vs 162 +/- 5 mm Hg) at rest. In the postpacing ischemic period after enoximone, LVEDP fell from a mean of 28.9 to 18.4 mm Hg (p < 0.001), dp/dtmax increased from 1050 to 1369 mm Hg/s (p < 0.001) and regional EF from 47% to 58% (p < 0.01), while global EF remained unchanged (45% vs 47%). ST-segment depression was reduced significantly from 2.3 to 1.5 mm (p < 0.01). Enoximone induced an increase in myocardial perfusion by 129% (p < 0.001) in the stenosis-dependent myocardial areas with shortening of the wash-out half-life time of the echo contrast medium from a mean of 14 s to 5 s (p < 0.001). The isovolumetric relaxation was shortened by 13% (p < 0.05), the E wave by 5%, and dp/dtmin increased by 17% (p < 0.01). In summary, intracoronary application of enoximone led to an improvement in both systolic and diastolic LV function without concomitant peripheral effect due to regression of myocardial ischemia.

Effects of nicorandil on regional perfusion and left ventricular function.

Left ventricular function and regional perfusion were evaluated by two study designs in patient groups with stable ischemic coronary artery disease (CAD): (1) using conventional left ventricular angiographies and (2) applying myocardial contrast echocardiography. The aim of the studies was to establish the effects of sublingually or orally applied nicorandil (N) on pacing-induced myocardial ischemia (MIS). In the first angiographic study, in nine patients with ischemic CAD and with pacing-inducible MIS, the effect of N, 20 mg sublingually, on hemodynamics and regional wall motion (RWM) were studied. There were no parameter changes without MIS being induced when comparing measurements at the 7th and 14th minute after N application to control values (p > 0.05). In the 15th and 16th minutes after N, pacing-induced MIS could no longer be elicited but left ventricular pump function improved; comparing MIS with N versus MIS without N: ejection fraction improved by 21%, cardiac index by 37%, and RWM by 21%, while filling pressure fell by 41% and systemic vascular resistance fell by 29%. Thus, N-mediated "protection from ischemia" with rather improved hemodynamics and RWM corresponds with alterations that theoretically could have been expected after nitroglycerin given under the above conditions. In the second echocardiographic study, regional perfusion was assessed in 10 patients by intracoronary injection of a newly developed echo contrast medium (ECM) and measurement of ECM washout halftime (t1/2) over opacified myocardial regions of interest, which displayed wall motion abnormalities already at rest.(ABSTRACT TRUNCATED AT 250 WORDS)

[Doppler and echocardiography parameters in detection of acute graft rejection after heart transplantation]. / Doppler- und echokardiographische Parameter zum Nachweis akuter Abstossungen nach Herztransplantation.

Due to the invasive nature of myocardial biopsies, a complication rate of up to 2.5%, and the limitations, e.g., at focal distribution of rejection, there is a continuous need for reliable, non-invasive parameters in recognizing moderate (grade 2) and severe (grade 3) acute cardiac allograft rejections in patients treated with cyclosporine A. 64 biopsies of 20 patients with previous heart transplantations in the past 3 weeks to 36 months (mean 11 months) were compared prospectively to Doppler and echocardiographic results. Parameters of systolic function such as percent fractional shortening (FS) and systolic wall thickness of the posterior wall (SWT) remained without significant changes at grade 2 and grade 3 rejections. The same is valid for relaxation parameters such as maximum velocity of posterior wall reduction (PTR), the time interval of endsystole to maximum velocity of posterior wall reduction (tES-PTR), and the isovolumic relaxation time (IVRT). Left-ventricular filling parameters such as maximum early diastolic flow velocity (VEmax) increased significantly from 73.3 +/- 15.2 cm/s in the rejection-free interval (grade 0) to 103.9 +/- 15.0 cm/s at grade 2 rejection and 101.1 +/- 9.2 cm/s at grade 3 rejection (both p < 0.001). A sensitivity of 50% and a negative predictive value of 77% are, however, too low to diagnose or exclude a moderate or severe acute rejection in the individual case.(ABSTRACT TRUNCATED AT 250 WORDS)

[The assessment of myocardial perfusion using contrast echocardiography]. / Beurteilung der Myokardperfusion mit der Kontrastechokardiographie.

A brief survey is given on the state of the art of qualitative and quantitative myocardial contrast echocardiography as well as on the contrast agents used. Exact qualitative assessment of coronary perfusion areas is possible. In addition, myocardial areas of collaterals of less than 100 microns in diameter can be visualized and measured that were not seen by routine coronary angiography. Quantitative analysis was done in 5 normal subjects and 16 patients with coronary artery disease before and after right ventricular stimulation (170 bpm over 75 s). While decay half time (T1/2) remained unchanged in normal subjects before and after pacing (7 +/- 4 s vs 7 +/- 5 s), it increased significantly from 5 +/- 1 to 16 +/- 1 s in patients with coronary stenoses between 50% and 75%. Stenotic area reduction greater than 75% had significant prolongations of T 1/2 = 12 +/- 7 s already at rest with further prolongation to 36 +/- 17 s (p less than 0.05) after pacing. Regional wall motion in these areas, however, was not significantly altered either in the fixed axis or floating axis system. Following dipyridamole hyperaemia (0.56 mg/kg i.v.), normal subjects showed a significant shortening of T 1/2 (6 +/- 2 vs 1.6 +/- 1; p less than 0.01; n = 5), while T 1/2 of patients with multiple vessel disease was prolonged from 9 +/- 6 to 15 +/- 6 s (p less than 0.01; n = 7). This prolongation was not uniform, since some myocardial areas were found to be hyperaemic after dipyridamole. One patient showed an opening of antegrade collaterals following dipyridamole. In first results myocardial contrast echocardiography proved capable of recognizing ischaemic and hyperaemic myocardium.(ABSTRACT TRUNCATED AT 250 WORDS)

Echocardiographic imaging of the left ventricle by peripheral intravenous injection of echo contrast agent.

With the use of a new echo contrast agent (ECA) that consists of a suspension with microbubbles (100% less than 3.9 micron in a moving system), we were able to opacify the left ventricle by peripheral intravenous injection in 124 of 130 patients (95%) without shunt connection. In 12 patients with aortic valve disease we measured the opacification of the right and left ventricles videodensitometrically by means of increasing doses. Dose 1 (8.7 ml ECA) and dose 4 (50 ml ECA) led to no significant difference in intensity in the right ventricle (168 +/- 32 vs 184 +/- 16 units, respectively; p greater than 0.05); however, opacification of the left ventricle was significantly more evident after dose 4 (60 +/- 60 vs 88 +/- 62 units, respectively; p less than 0.05). On the basis of the farthest distance reached by the regurgitant microbubbles from the aortic valve, the severity of regurgitation was graded on a four-point scale; the results were compared with those of aortography. A significant correlation (r = 0.98, n = 9) was found between ECA grading and aortography in the evaluation of the severity of aortic insufficiency. In addition, flow characteristics in patients with mitral stenosis, aortic insufficiency, and the regurgitation jet in incompetent aortic prosthesis in connection with diastolic inflow over the mitral valve were described. Moreover, it was possible to differentiate between inflow of ECA into the left atrium via an atrial septal defect and across the pulmonary vascular bed. No adverse effects were reported by the patients. Left ventricular end-diastolic volume index, end-systolic volume index, stroke volume index, and ejection fraction were determined before and after intravenous injection of increasing doses of ECA by means of the area-length method of Sandler and Dodge. Even after dose 4 we observed no significant changes in left ventricular function. The values before and after injection were in the range of intra- and interobserver reproducibility. Only three patients reported a slight taste sensation. In nine patients with a history of allergies there were no side effects.

[Comparative echocardiographic volume determinations using a dynamic heart model]. / Vergleichende echokardiographische Volumenbestimmungen mittels eines dynamischen Herzmodells.

Using a dynamic and symmetrical cardiac phantom different echocardiographic mathematical models (Simpson 7 slices, area-length method, Simpson 2 slices and method according to Teichholz) were compared. 9 different end-diastolic (EDV) and end-systolic (ESV) volumes, 9 different stroke volumes (SV) and ejection fractions (EF) were used. EDV and ESV varied between 39-298 ml; SV between 29-100 ml and EF between 14-46%. In addition 10 fixed volumes of the same shape were evaluated using the same echocardiographic mathematical models. While symmetrical fixed volumes can be assessed correctly (r = 0.97-0.98), apart from the formula according to Teichholz (r = 0.89, significant underestimation of volumes), the correlation coefficients decrease using a dynamic cardiac phantom. In the modification of Simpson with 7 slices the best correlation was found for all parameters (EDV: r = 0.93; ESV: r = 0.94; EF: r = 0.87; SV: r = 0.81). The biplane area-length method has no advantages over Simpson's rule with 2 slices in the short axis; for symmetrical models both methods are comparable, both having high correlation coefficients (for volumes r = 0.85 and r = 0.88; for EF 0.78 and 0.84). Using the method according to Teichholz symmetrical volumes can be well assessed (r = 0.90), for the determination of EF the correlation coefficient decreases to r = 0.65 and for stroke volume to 0.33, reflecting no significant correlation to the actual SV. Possible causes for a poorer correlation are discussed for moving objects as opposed to the fixed volumes.

On the problem of optimum digitlaization in man.

The low therapeutic index of cardiac glycoside requires an optimum individual digitalization. This is also a difficulty in the case of known serum glycoside concentrations because individual differences of biochemical and physiological factors (which influence both therapeutic and side effects) are important. As a rule the physician's criterion for an optimum digitalization is that side effects are avoided. This investigation attempted to find a measure for the effect of glycosides by noninvasive recording of parameters of myocardial contractility (systolic time intervals, STI). The measurements were made under oral digitalization with digoxin (Dilanacin). The serum glycoside concentration was determined by the radioimmunoassay method. The changes in STI were investigated in the rage of 1 to 3 ng digoxin per ml serum. In this concentration a significant correlation was demonstrated between STI shortening and glycoside level. It was found that the shortening of STI was maximum at the lowest concentration (1 ng/ml). It appears that the control of STI is for the physician a useful aid for an optimum digitalization in man.