Remifentanil does not impair left ventricular systolic and diastolic function in young healthy patients.

BACKGROUND: Experimental studies and investigations in patients with cardiac diseases suggest that opioids at clinical concentrations have no important direct effect on myocardial relaxation and contractility. In vivo data on the effect of remifentanil on myocardial function in humans are scarce. This study aimed to investigate the effects of remifentanil on left ventricular (LV) function in young healthy humans by transthoracic echocardiography (TTE). We hypothesized that remifentanil does not impair systolic, diastolic LV function, or both. METHODS: Twelve individuals (aged 18-48 yr) without any history or signs of cardiovascular disease and undergoing minor surgical procedures under general anaesthesia were studied. Echocardiographic examinations were performed in the spontaneously breathing subjects before (baseline) and during administration of remifentanil at a target effect-site concentration of 2 ng ml(-1) by target-controlled infusion. Analysis of systolic function focused on fractional area change (FAC). Analysis of diastolic function focused on peak early diastolic velocity of the mitral annulus (e') and on transmitral peak flow velocity (E). RESULTS: Remifentanil infusion at a target concentration of 2 ng ml(-1) did not affect heart rate or arterial pressure. There was no evidence of systolic or diastolic dysfunction during remifentanil infusion, as the echocardiographic measure of systolic function (FAC) was similar to baseline, and measures of diastolic function remained unchanged (e') or improved slightly (E). CONCLUSION: Continuous infusion of remifentanil in a clinically relevant concentration did not affect systolic and diastolic LV function in young healthy subjects during spontaneous breathing as indicated by TTE.

Different effects of sevoflurane, desflurane, and isoflurane on early and late left ventricular diastolic function in young healthy adults.

BACKGROUND: Knowledge on the effects of volatile anaesthetics on left ventricular (LV) diastolic function in humans in vivo is limited. We tested the hypothesis that sevoflurane, desflurane, and isoflurane do not impair LV diastolic function in young healthy humans. METHODS: Sixty otherwise healthy subjects (aged 18-48 yr) undergoing minor procedures under general anaesthesia were studied. After randomization for the anaesthetic, transthoracic echocardiographic examinations were performed at baseline and under anaesthesia with 1 minimum alveolar concentration (MAC) of the volatile anaesthetics during spontaneous breathing and intermittent positive pressure ventilation (IPPV). Peak early (E') and late (A') diastolic velocities of the mitral annulus were studied as the main echocardiographic indicators of diastolic function. RESULTS: During anaesthesia with 1 MAC under spontaneous breathing, E' increased with desflurane (P<0.001), was not significantly different with isoflurane (P=0.030), and decreased with sevoflurane (P=0.006). During IPPV, E' was similar to baseline with desflurane (P=0.550), insignificantly decreased with isoflurane (P=0.029), and decreased with the sevoflurane group (P<0.001). In contrast, A' was similarly reduced in all groups during spontaneous breathing without further changes during IPPV. Haemodynamic changes were comparable in all study groups. CONCLUSIONS: The findings of this in vivo study indicate that desflurane and isoflurane, and most likely sevoflurane, have no relevant direct negative effect on early diastolic relaxation in young healthy humans. In contrast, all three volatile anaesthetics appear to impair late diastolic LV filling during atrial contraction.

Diffusion-weighted imaging findings differ between stroke attributable to spontaneous cervical artery dissection and patent foramen ovale.

BACKGROUND AND PURPOSE: Spontaneous cervical arterial dissection and patent foramen ovale (PFO) are important causes of stroke in younger patients. We tested whether characteristics of cerebral ischaemia visible on diffusion-weighted imaging (DWI) aid in differentiating between these two aetiologies. METHODS: Diffusion-weighted imaging was performed after a median of 2 days [interquartile range (IQR) 1-3 days] in 94 consecutive patients with an acute ischaemic stroke caused either by carotid or vertebral artery dissection (n = 33) or PFO (n = 61). We compared number, size, location and predefined patterns of DWI lesions between both aetiologies. RESULTS: Ninety-three out of 94 patients had acute DWI lesions and were included in the analysis. Multiple DWI lesions occurred more frequently in patients with dissection (23/33, 70%) than in those with PFO (26/60, 43%, P = 0.02). Lesions were larger in the dissection group [median diameter of largest lesion, 50 mm (IQR 19-68 mm)] than in the PFO group [23 (9-48) mm; P = 0.02]. The distribution of lesion patterns differed between the two aetiologies (P < 0.001): single, non-territorial infarcts were more frequent in PFO (25/60, 42%) than in dissection (2/33, 6%); large territorial infarcts with or without additional smaller lesions in the same territory occurred in 20/33 (61%) patients with dissection and in 16/60 (27%) patients with PFO. CONCLUSIONS: Diffusion-weighted imaging characteristics differ between PFO and dissection, suggesting differences in the pathogenesis of brain infarction between these aetiologies. A single non-territorial infarct seems to favour PFO as stroke aetiology. Whether this or other features are distinctive enough to diagnose PFO or dissection in individual patients requires further testing.

Comparing ERP concomitant with stimulus-induced and self-paced movements: intracerebral recordings at various cortical sites.

OBJECTIVES: To compare the shape, amplitude, and topographical distribution over sensorimotor and centroparietal cortex of two sets of ERP concomitant with the same type of movement (MCP), either visually-triggered (VT-MCP) or self-paced (SP-MCP). METHODS: MCP were recorded in 21 patients with intractable partial seizures, undergoing presurgical evaluation using stereotaxically implanted multilead intracerebral electrodes. Each patient was tested during a single session with three successive experimental paradigms, each comprised of thirty trials: (1) a tone announcing a visual pattern, with no instruction to move; (2) same tone, and instruction to squeeze abruptly a joystick at a visual signal; (3) instruction to perform the same movement paced at will, without any "go" signal. Averaged ERP recorded during task (1) were subtracted from those recorded during task (2) giving the VT-MCP. All records were taken from various cortical sites devoid of overt pathological activity. RESULTS: MCP recorded from two main sites, perirolandic and centroparietal, were compared. Between all sites, VT-MCP and SP-MCP morphology differed only slightly. Ipsilateral and contralateral MCP were also very similar. By contrast, perirolandic MCP were mainly monophasic negative (N component 400 ms after visual stimulus), whereas centroparietal MCP tended to be biphasic, the late negativity being preceded by a positive P component, at 125 ms. CONCLUSIONS: MCP patterns were quasi-identical regardless of how they were elicited (visually-triggered or self-paced). On the other hand, perirolandic and centroparietal MCP had distinct shapes, suggesting that the mode of functioning of the generators at the two sites is different.

Optimization of imaging before pulmonary vein isolation by radiofrequency ablation: breath-held ungated versus ECG/breath-gated MRA.

Isolation of the pulmonary veins has emerged as a new therapy for atrial fibrillation. Pre-procedural magnetic resonance (MR) imaging enhances safety and efficacy; moreover, it reduces radiation exposure of the patients and interventional team. The purpose of this study was to optimize the MR protocol with respect to image quality and acquisition time. In 31 patients (23-73 years), the anatomy of the pulmonary veins, left atrium and oesophagus was assessed on a 1.5-Tesla scanner with four different sequences: (1) ungated two-dimensional true fast imaging with steady precession (2D-TrueFISP), (2) ECG/breath-gated 3D-TrueFISP, (3) ungated breath-held contrast-enhanced three-dimensional turbo fast low-angle shot (CE-3D-tFLASH), and (4) ECG/breath-gated CE-3D-TrueFISP. Image quality was scored from 1 (structure not visible) to 5 (excellent visibility), and the acquisition time was monitored. The pulmonary veins and left atrium were best visualized with CE-3D-tFLASH (scores 4.50 +/- 0.52 and 4.59 +/- 0.43) and ECG/breath-gated CE-3D-TrueFISP (4.47 +/- 0.49 and 4.63 +/- 0.39). Conspicuity of the oesophagus was optimal with CE-3D-TrueFISP and 2D-TrueFISP (4.59 +/- 0.35 and 4.19 +/- 0.46) but poor with CE-3D-tFLASH (1.03 +/- 0.13) (p < 0.05). Acquisition times were shorter for 2D-TrueFISP (44 +/- 1 s) and CE-3D-tFLASH (345 +/- 113 s) compared with ECG/breath-gated 3D-TrueFISP (634 +/- 197 s) and ECG/breath-gated CE-3D-TrueFISP (636 +/- 230 s) (p < 0.05). In conclusion, an MR imaging protocol comprising CE-3D-tFLASH and 2D-TrueFISP allows assessment of the pulmonary veins, left atrium and oesophagus in less than 7 min and can be recommended for pre-procedural imaging before electric isolation of pulmonary veins.

Improvements in physical and mental domains of quality of life by anti-ischaemic drug and revascularisation treatment in elderly men and women with chronic angina.

BACKGROUND: The severity of angina is related to a reduction in global quality of life (QoL), which may be improved by anti-ischaemic treatment. It is not known, however, whether improvements relate only to physical or also to mental and social domains of QoL and whether women benefit in a similar way to men. OBJECTIVES: To relate improvements in angina severity through anti-ischaemic treatment to physical and mental domains of QoL in elderly men and women and to assess differences in this relation between the sexes. METHODS: Angina severity and full assessment of QoL by structured, self-administered and validated questionnaires were measured prospectively at baseline and after 6 months' optimal drug or revascularisation treatment in all 301 patients of the Trial of Invasive versus Medical therapy in Elderly (TIME) patients with chronic angina. RESULTS: At baseline, angina severity correlated significantly with physical domains of QoL (trend test at least p<0.02) and daily activities (p = 0.05). At similar angina levels, women had significantly lower QoL scores than men. With anti-ischaemic treatment, physical as well as mental and social QoL domains and daily activities improved, together with a relief in angina (trend tests at least p<0.02). This was true for women and men and was more pronounced after revascularisation than with medical treatment. CONCLUSIONS: These findings confirm the relation between angina severity and physical limitation. In addition, they show that anti-ischaemic treatment not only relieves angina and improves physical components of QoL but also improves mental and social domains. This is true for women as well as for men despite the lower overall scores for women.

[28-year old patient with successfully treated dilatative cardiomyopathy]. / 28-jähriger Patient mit erfolgreich behandelter dilatativer Kardiomyopathie.

A 28-year was admitted with heart failure. His medical history included treatment for hypogonadotropic hypogonadism. Echocardiography showed dilatation of all chambers. Elevated serum ferritin levels and liver biopsy indicated hereditary hemochromatosis. Cardiac iron overload was seen on magnetic resonance imaging. Genetic testing revealed homozygosis for G320 V mutation, confirming the diagnosis of juvenile hemochromatosis. Phlebotomy on a biweekly regimen was started and after twelve months of therapy the patient had normal ferritin values as well as normal ejection fraction on echocardiography.

Intra-operative myocardial ischaemia cannot be detected by analysis of transmitral inflow patterns in patients undergoing off-pump coronary surgery.

BACKGROUND AND OBJECTIVE: Transmitral inflow patterns have been used for detection of myocardial ischaemia. However, its diagnostic value has not been tested in anaesthetized and mechanically ventilated patients undergoing coronary artery bypass graft surgery. METHODS: Transmitral inflow patterns were studied by transoesophageal Doppler echocardiography in 43 patients undergoing coronary artery bypass graft surgery without cardiopulmonary bypass after opening of the sternum (baseline) and during grafting of the left anterior descending artery. Peak early (E) and peak late (A) transmitral velocities and their ratio (E/A) were recorded. Myocardial ischaemia was defined by standard criteria using two-dimensional echocardiography and seven-lead electrocardiogram. RESULTS: Thirty-one patients (64 +/- 8 yr, 9 women) fulfilled the predefined inclusion criteria for analysis. During distal revascularization, 16 patients showed myocardial ischaemia and 15 did not. The use of vasoactive drugs, haemodynamic findings and transmitral inflow patterns were similar in both groups at baseline and during grafting. In the ischaemic group, E was 67.1 +/- 13.9 cm s-1 at baseline and 69.5 +/- 23.2 cm s-1 during grafting, and the E/A ratios were 1.3 +/- 0.3 and 1.4 +/- 0.9, respectively. In the non-ischaemic group, E was 64.0 +/- 17.1 cm s-1 at baseline and 60.9 +/- 14.8 cm s-1 during grafting, and the E/A ratios were 1.4 +/- 0.7 and 1.2 +/- 0.3, respectively. CONCLUSIONS: Analysis of Doppler findings of transmitral inflow patterns did not allow for detection of myocardial ischaemia during surgical revascularization of the myocardium.

The future of cardiovascular imaging and non-invasive diagnosis: a joint statement from the European Association of Echocardiography, the Working Groups on Cardiovascular Magnetic Resonance, Computers in Cardiology, and Nuclear Cardiology, of the European Society of Cardiology, the European Association of Nuclear Medicine, and the Association for European Paediatric Cardiology.

Advances in medical imaging now make it possible to investigate any patient with cardiovascular disease using multiple methods which vary widely in their technical requirements, benefits, limitations, and costs. The appropriate use of alternative tests requires their integration into joint clinical diagnostic services where experts in all methods collaborate. This statement summarises the principles that should guide developments in cardiovascular diagnostic services.

Selection bias of elderly patients with chronic angina referred for catheterization.

BACKGROUND: Registry patients are generally older and more sick than patients enrolled in trials questioning the generalizability of trial results. We assessed whether such a selection bias also exists in elderly patients with chronic angina referred for catheterization. METHODS AND RESULTS: All 119 patients age>or=75 years with Trial of Invasive versus Medical Therapy in the Elderly (TIME) inclusion but no major exclusion criteria referred for catheterization during the TIME trial inclusion period in four TIME centers were registered and followed-up for one year. Registry patients differed from the 188 trial patients in the same hospitals in that they were younger, somewhat more frequently male, with less antianginal drugs and studied more often after acute chest pain at rest but with more comorbidities than study patients. Left ventricular ejection fraction and vessel disease were similar. One year mortality was 11.4% in registry and 9.6% in invasive TIME patients but differences disappeared after adjustment for baseline differences. Symptomatic status after one year was similar too. CONCLUSIONS: In elderly patients with chronic angina, a bias in the selection for invasive management exists which seems different from that reported in younger patient settings. After adjustment for these selection factors, however, one-year outcome was remarkably similar in registry and trial patients.

Unilateral paralytic strabismus in the adult cat induces plastic changes in interocular disparity along the visual midline: contribution of the corpus callosum.

Neurones activated through the corpus callosum (CC) in the cat visual cortex are known to be almost entirely located at the 17/18 border. They are orientation selective and display receptive fields (RFs) distributed along the central vertical meridian of the visual field ("visual midline"). Most of these cells are binocular, and many of them are activated both from the contralateral eye through the CC, and from the ipsilateral eye via the direct retino-geniculo-cortical (GC) pathway. These two pathways do not carry exactly the same information, leading to interocular disparity between pairs of RFs along the visual midline. Recently, we have demonstrated that a few weeks of unilateral paralytic strabismus surgically induced at adulthood does not alter the cortical distribution of these units but leads to a loss of their orientation selectivity and an increase of their RF size, mainly toward the ipsilateral hemifield when transcallosally activated (Watroba et al., 2001). To investigate interocular disparity, here we compared these RF changes to those occurring in the same neurones when activated through the ipsilateral direct GC route. The 17/18 transition zone and the bordering medial region within A17 were distinguished, as they display different interhemispheric connectivity. In these strabismics, some changes were noticed, but were basically identical in both recording zones. Ocular dominance was not altered, nor was the spatial distribution of the RFs with respect to the visual midline, nor the amplitude of position disparity between pairs of RFs. On the other hand, strabismus induced a loss of orientation selectivity regardless of whether neurones were activated directly or through the CC. Both types of RFs also widened, but in opposite directions with respect to the visual midline. This led to changes in incidences of the different types of position disparity. The overlap between pairs of RFs also increased. Based on these differences, we suggest that the contribution of the CC to binocular vision along the midline in the adult might be modulated through several intrinsic cortical mechanisms.

Long-term outcome after surgical closure of atrial septal defect in childhood with extensive assessment including MRI measurement of the ventricles.

Surgical closure of the secundum type of atrial septal defect (ASD) in childhood leads to excellent survival. However, relevant morbidity has been reported. Transcatheter closure of these defects has now become an alternative approach. To compare the results of the two different interventions, reliable data are needed on the long-term morbidity after defect closure with both methods. Patients were evaluated after a minimum of 10 years after surgical closure of an ASD in childhood. Assessment included analysis of perioperative data, interview, clinical examination, electrocardiogram, (ECG), 24-hour ECG, ergometry, chest radiograph, echocardiography, and MRI. A total of 66 patients underwent operation between 1971 and 1986 at our institution. Forty-eight of them (73%) were interviewed and 38 (58%) participated fully in the study program. Eighteen (27%) either refused to participate or were lost to follow-up. There were no substantial residual disorders, such as arrhythmias, right-sided heart dilatation, pulmonary hypertension, or reduced work capacity. Surgical closure of an ASD in childhood has an excellent long-term outcome. Surgical closure is thus the standard against which transcatheter closure needs to be measured.

The use of B-type natriuretic peptide in the management of elderly patients with acute dyspnoea.

OBJECTIVES: The aim of this study was to define the impact of B-type natriuretic peptide (BNP) levels on the management of elderly patients presenting with acute dyspnoea. DESIGN: We performed a prospective randomized controlled study in 269 elderly patients at least 70 years of age included in the B-type natriuretic peptide for Acute Shortness of breath Evaluation (BASEL) study. Patients were randomly assigned to a diagnostic strategy with (n = 136, BNP group) or without (n = 133, control group) the use of BNP levels provided by a rapid bedside assay. The time to discharge and the total cost of treatment were the primary end-points. RESULTS: Amongst elderly patients, baseline characteristics were well matched between both groups. The use of BNP levels significantly reduced the time to discharge (median 9.0 in the BNP group versus 11.0 days in the control group; P = 0.029). Total treatment cost was $5381 (95% CI, 4482-6280) in the BNP group when compared with $7411 (95% CI, 6180-8642; P = 0.009) in the control group. In addition, a significant reduction in 30-day mortality was observed (9% in the BNP group versus 17% in the control group; P = 0.039). CONCLUSIONS: Used in conjunction with other clinical information, rapid measurement of BNP in the emergency department improved the management of elderly patients presenting with acute dyspnoea and thereby reduced the time to discharge and the total treatment cost. In addition, BNP testing seemed to reduce 30-day mortality.

Myocardial function and energy metabolism in carnitine-deficient rats.

Carnitine is essential for mitochondrial metabolism of long-chain fatty acids and thus for myocardial energy production. Accordingly, carnitine deficiency can be associated with cardiomyopathy. To better understand this disease, we determined myocardial function and energy metabolism in a rat model of carnitine deficiency. Carnitine deficiency was induced by a 3- or 6-week diet containing N-trimethyl-hydrazine-3-propionate, reducing cardiac and plasma carnitine by 70-85%. Myocardial function was investigated in isolated isovolumic heart preparations. Carnitine-deficient hearts showed left ventricular systolic dysfunction, reduced contractile reserve, and a blunted frequency-force relationship independently of the substrate used (glucose or palmitate). After glycogen depletion, palmitate could not sustain myocardial function. Histology and activities of carnitine palmitoyl transferase, citrate synthase, and cytochrome c oxidase were unaltered. Thus, as little as 3-6 weeks of systemic carnitine deficiency can lead to abnormalities in myocardial function. These abnormalities are masked by endogenous glycogen and are not accompanied by structural alterations of the myocardium or by altered activities of important mitochondrial enzymes.

Doppler indices of diastolic transmitral flow velocity are invalid indicators of myocardial ischaemia during high-dose dobutamine infusion in anaesthetized patients.

BACKGROUND AND OBJECTIVE: Doppler echocardiography of diastolic transmitral flow velocity is more sensitive for the detection of myocardial ischaemia in awake patients than echocardiographic analysis of systolic wall motion. However, its diagnostic value in anaesthetized patients is unknown. METHODS: Doppler indices of diastolic transmitral flow velocity previously found to be highly sensitive for detecting ischaemia in awake patients were studied in 72 anaesthetized patients with documented coronary artery disease undergoing dobutamine stress echocardiography. These Doppler indices were compared with standard echocardiographic and electrocardiographic criteria for ischaemia. RESULTS: Sixty-five patients showed evidence of ischaemia by standard echocardiographic and/or electrocardiographic criteria, and seven patients did not. Regardless of evidence of ischaemia by standard criteria, the Doppler indices changed similarly in both groups. Accordingly, only a minority of anaesthetized patients displayed the changes in Doppler indices of diastolic transmitral flow previously suggested to be sensitive for detecting ischaemia. CONCLUSIONS: The results do not confirm the diagnostic value of Doppler echocardiography of diastolic transmitral flow velocity for detecting ischaemia in anaesthetized patients undergoing dobutamine stress echocardiography during positive-pressure ventilation of the lungs.

[Are we treating coronary heart disease and heart failure appropriately in the clinic and ambulatory care? Secondary prevention and drug therapy 1998]. / Therapieren wir die koronare Herzkrankheit und die Herzinsuffizienz in der Klinik und ambulant konsequent? Sekundärprophylaxe und medikamentöse Therapie 1998.

We examined retrospectively 186 patients with acute coronary syndrome (ACS) and 163 patients with cardiac insufficiency (CHF) regarding secondary prevention in hospital or externally. Of the Inhospital-patients with ACS 99% had antithrombotic medicaments (AT), 73% betablockers and 73% a statin. CHF-patients had ACEH in 69%. Externally 120 patients with known coronary heart disease (CHD) received in 91% AT, 66% betablocker, 30% statins and 111 CHF-patients in 49% ACEH. Compared to other studies medical therapy ameliorated in CHD and CHF either stationary and ambulatory. The reasons for low prescription of statins may be due to short time since positive results occurred and to the expensive costs in the setting of pressure because of high cost in health system.

Parieto-temporal rhythms in the 6-9 Hz band recorded in epileptic patients with depth electrodes in a self-paced movement protocol.

OBJECTIVES: Description of 6-9 Hz rhythmic electrical activity observed on recordings from electrodes implanted in the cortex of epileptic patients undergoing presurgical evaluation. METHODS: Recordings were obtained from 74 patients with multilead electrodes in the frontal, parietal and temporal cortex. The motor task consisted of a self-paced fist clenching movement at approximately 10 s intervals. Events within a window extending from 4 s before to 1 s after movement EMG onset were analyzed. RESULTS: (i) Spindle-like rhythmic activity at 6-9 Hz was observed in 29 patients. (ii) This activity was located in the inferior parietal and superior temporal areas. (iii) Enhancement of rhythmic activity occurred when patients were asked to perform the motor task. (iv) A striking tendency to phase-locking of rhythmic oscillations on consecutive trials was noted during the 3-2 s epoch before movement EMG onset. CONCLUSION: Whether this intracerebrally recorded 6-9 Hz rhythmic activity belongs to the mu-alpha class or is a special type of theta, and if it is related to the epileptic process or to drug treatment remain open to discussion. Motor-task related enhancement and phase-locking suggest that this activity may be one more indicator of movement preparation.

Impairment of binocular vision in the adult cat induces plastic changes in the callosal cortical map.

In the primary visual cortex of normally reared adult cat, neurons activated through the corpus callosum are almost entirely located at the 17/18 border. They display small receptive fields distributed along the central vertical meridian of the visual field and are orientation selective. Here we demonstrate that a few weeks of monocular deprivation or unilateral convergent strabismus produced in adulthood does not modify the cortical distribution of these neurons, but leads to an increase of their receptive field size mainly toward the ipsilateral hemifield and to a loss of their orientation selectivity. We conclude that manipulation of binocular vision in the adult modifies neither the location of the primary callosal cortical map nor its retinotopy. In contrast, it induces functional plastic changes in this map which lead to a significant widening of the area of visual space signalled through the corpus callosum. These plastic changes are interpreted as the result of the strengthening of normally hidden subthreshold synaptic inputs.