Relevance of hemostasis on restenosis in clinically stable patients undergoing elective PTCA.

BACKGROUND: Secondary coronary thrombus formation is considered to be co-factor in the pathogenesis of restenosis after percutaneous transluminal coronary angioplasty (PTCA). Therefore systemic factors indicating a hypercoagulable disease state may be relevant for the process of coronary renarrowing. Even though experimental data suggest that in particular thrombin may be of major relevance for restenosis induced by mechanical injury, only little clinical data has been presented so far. METHODS AND RESULTS: In 60 consecutive patients, who had been clinical stable for at least 2 months, and who underwent elective and primarily successful PTCA, follow-up films were evaluated by means of quantitative coronary angiography in respect to a categorical and a continuous definition of restenosis, luminal narrowing >50% and late luminal loss respectively. Of the chosen laboratory variables prothrombin fragment 1+2 (1.3+/-0.5 vs. 0.9+/-0.4 mmol/l, p<0.001) red blood cell aggregation at low shear stress (13.5+/-2.9 vs. 11.6+/-2.8 units, p<0.05), and plasminogen-activator inhibitor (3.7+/-1.8 vs. 5.3+/-3.2 U/ml p<0.05) differentiated between patients with (n=18) and without restenosis (n=42). Late luminal loss correlated positively with prothrombin fragment 1+2 (r=0.41, p<0.001), plasminogen-activator inhibitor (r= -0.28, p<0.05) and plasmin-alpha2-antiplasmin complex (r=0.39, p<0.01). CONCLUSIONS: A hypercoagulable disease state and in particular thrombin generation characterize a high-risk group prone for restenosis in clinically stable coronary artery disease.

"One-stop-shop" ultrasound diagnosis of functional, structural and physicomechanical properties of the brachial artery.

BACKGROUND: The pathogenesis of atherosclerosis comprises endothelial dysfunction, thickening as well as impaired compliance of the arterial vessel wall. Early assessment of these alterations of the vessel wall at the same site of the vascular tree has yet been hampered by the lack of highly sensitive diagnostic approaches suitable for clinical routine. We therefore aimed to develop and validate a single non-invasive examination of the brachial artery for simultaneous and highly accurate measurement of functional, structural and physicomechanical parameters of the brachial artery. PATIENTS AND METHODS: 20 healthy individuals were investigated using high resolution ultrasound. Flow-mediated dilation (FMD), fractional diameter changes (FDC) and intima-media-thickness (IMT) were measured in the same segment of the brachial artery. Coefficients of variation, day-to-day-variability, between- and within-observer-variability were investigated in 5 individuals. All measurements were performed manually and by an automated PC-based analyzing system. RESULTS: Mean values for all measured parameters were 7.65 +/- 0.8% for FMD, 0.02 +/- 0.002 for FDC, 0.351 +/- 0.007 mm for IMT and followed an even distribution throughout the study population. Automated analysis of coefficient of variation, day-to-day-, between- and within-observer variabilities were: 0. 78%, 1.3%, 0.8%, 0.8% (FMD); 4.7%, 2.8%, 4.2%, 2.7% (FDC); 1.8%, 1.1%, 1.9%, 1.1% (IMT). Coefficient of variation, day-to-day-, between- and within-observer variabilities for the manual readings were significantly higher. CONCLUSIONS: Functional, structural and physicomechanical parameters of the brachial artery can be quantified consecutively, time-saving and highly reproducibly as an "one-stop-shop" in a single session using high resolution ultrasound with digitized post-processing. This highlights the future possibility of early, sensitive and non-invasive diagnostic testing of vascular function in patients prone to vascular disease.

[Cyanosis and dyspnoea in orthostasis]. / Zyanose und Luftnot in Orthostase.

HISTORY AND CLINICAL FINDINGS: A 69-year-old female patient was admitted to a hospital for severe dyspnoea. It was conspicuous that shortness of breath and cyanosis only occurred in upright and completely disappeared in the supine position. This finding was objectified by pulse oximetry which demonstrated a decrease of arterial oyxgen saturation from 96 % in the supine to 86 % in the upright position. INVESTIGATIONS: After exclusion of other diseases the diagnosis of platypnoe- orthodeoxia syndrome as a result of a patent foramen ovale (PFO) was established. TREATMENT AND COURSE: Cardiac catheterization in the upright and the supine position documented a high-grade right-to-left shunt of 31 % proportionally to systemic circulatory volume in the upright position with subsequent critical reduction of pulmonary perfusion to 1.4 l/min/m (2) (reference value > 2.2 l/min/m (2)) as the cause of dyspnoea. Catheter-based occlusion of the PFO was chosen as causal treatment modality. After that arterial oxygen saturation remained constant at 95 % in the supine and upright position and symptoms improved. CONCLUSIONS: Platypnoe-othodeoxia syndrome is a very rare syndrome but it can be substantiated by pathognomonic case history, clinical examination and simple machine-aided examinations. With a causative PFO a causal and save therapy is available.

Coronary artery angioplasty for treatment of peri-operative myocardial ischaemia.

Increasing numbers of elderly patients with severe co-existing medical diseases undergo major surgery. With these patients there is also an accompanying risk of age-related cardiovascular complications such as life-threatening myocardial ischaemia. We present a patient who suffered a myocardial infarction after a hemicolectomy and suffered a cardiac arrest in the recovery room. The therapeutic options available (e.g. coronary artery bypass grafting, acute percutaneous coronary angioplasty and peri-operative thrombolysis) are discussed and the successful management of the case by coronary angioplasty and stent implantation is described.

[Left ventricular diastolic function parameters after PTCA and stent implantation]. / Linksventrikuläre diastolische Funktionsparameter nach PTCA und Stentimplantation.

UNLABELLED: This study was designed to determine the effect of successful coronary revascularisation on left ventricular diastolic function. METHODS: We consecutively studied the time course of diastolic function by Doppler echocardiography in 100 patients with one-vessel disease before and 48 hours after elective coronary angioplasty. Three abrupt vessel closures occurred within 24 hours after intervention. These three patients were excluded from the study. 58 patients were initially successful treated with coronary angioplasty (residual stenosis < 40%). In 39 patients stents were used to improve an inadequate result after coronary angioplasty. The following parameters of left ventricular diastolic function were evaluated before and 48 hours after coronary intervention: peak early (VE, m/s) and peak late diastolic (VA, m/s) flow velocity, E/A ratio, acceleration time (AT, ms), deceleration time (DT, ms) and isovolumetric relaxation time (IVRT, ms). Ejection fraction (EF; %) was determined and used to characterise systolic left ventricular function. RESULTS: Both patient groups (58 patients with coronary angioplasty and 39 patients with combined coronary angioplasty and stent implantation) showed no relevant differences concerning sex, age, atherosclerotic risk factors, exercise capacity and results of exercise electrocardiography. All patients who underwent stent implantation showed an early improvement of left ventricular diastolic function 48 hours after revascularisation. Surprisingly there was no significant short-term improvement (48 hours) of diastolic function in patients with initially successful angioplasty. CONCLUSION: We suppose that stent implantation faster normalises coronary blood flow than coronary angioplasty.

[Left ventricular diastolic function in pregnancy in patients with arterial hypertension. A prospective study with M-mode echocardiography and Doppler echocardiography]. / Linksventrikuläre diastolische Funktion in der Schwangerschaft bei Patientinnen mit arterieller Hypertonie. Eine prospektive Untersuchung mittels M-mode-Echokardiographie und Doppler-Echokardiographie.

INTRODUCTION: During pregnancy eminent cardiovascular changes occur. The aim of the following study was to investigate the course of hemodynamic parameters under increased volume load during pregnancy in women suffering from mild arterial hypertension. METHODS: Altogether 47 women (age: 25 +/- 4 years) with mild arterial hypertension detected during pregnancy underwent echocardiography at the 9th, 24th and 33rd week of gestation. Furthermore echocardiography was performed postpartum at weeks 1 and 8. The control group comprised 45 healthy pregnant women. In all patients left ventricular muscle mass index and systolic shortening fraction were measured. The following Doppler echocardiographic parameters were ascertained: peak early diastolic and peak late diastolic flow, VE/VA ratio, acceleration time, deceleration time and isovolumetric relaxation time. RESULTS: During pregnancy all patients had an increase of left ventricular muscle mass index and a decrease of fractional shortening. All patients developed a relevant diastolic dysfunction. While the control group developed signs of disturbed relaxation as reduction of peak early diastolic flow (0.89 +/- 0.07 versus 0.82 +/- 0.08 m/s*), VE/VA ratio and an increase of isovolumetric relaxation time (72 +/- 12 versus 123 +/- 7*) at the 33rd week of gestation (* p < 0.01), all pregnant women with mild arterial hypertension developed a diastolic dysfunction with signs of delayed relaxation already at the beginning of gestation. 26 pregnant women with arterial hypertension developed a restrictive diastolic filling pattern at 24 weeks of gestation. The other 21 pregnant women only showed restriction for a short time at the end of gestation. In healthy pregnant women, volume load results in a reversible physiologic left ventricular hypertrophia, a significant alteration of diastolic left ventricular function in terms of a disturbed relaxation pattern and a temporary decrease of systolic function. In comparison hypertensive pregnant women show a delayed relaxation at the beginning of pregnancy and 50% developed early signs of restrictive cardiomyopathy. These changes may predispose to critical complications during pregnancy.

Angiographic progression of coronary artery disease in patients with end-stage renal disease.

BACKGROUND: Patients with end-stage renal disease have an increased risk of developing coronary artery disease (CAD). The cardiovascular mortality of dialysis patients is 10-15 times higher compared with the general population. The aim of our study was to evaluate the morphological progression of coronary arteriosclerosis in this cardiovascular high-risk group by visual assessment and quantitative coronary angiography. Methods and results. In 26 patients with chronic renal failure (age, 47+/-11 years; 15 male; duration of dialysis, 23+/-25 months) the severity of CAD and degree of coronary stenoses were assessed in two coronary angiograms after a mean follow-up interval of 30+/-15 months (12-60). Baseline angiography revealed CAD in 13/22 patients (59%). The second angiography was performed as screening procedure prior to renal transplantation (n=20) and/or as follow-up angiography after coronary angioplasty (n=10). Visual assessment showed a progression defined by the development of haemodynamically relevant stenosis of >50% luminal diameter in 13 patients. Quantitative angiographic evaluation was performed in a total of 45 segments showing >25% narrowing at the second angiogram. A progression (>15% luminal reduction) was found in 17 of 45 segments, a new lesion (initial luminal diameter <20%) was detected in nine segments, resulting in progression or new lesion in 16 patients (62%). Patients with or without progression did not differ in age, duration of dialysis treatment, number of cardiovascular risk factors, or serum total cholesterol and fibrinogen levels. After percutaneous transluminal coronary angioplasty (PTCA) a restenosis was seen in seven of 16 primarily successfully dilated segments. After the second angiography, myocardial revascularization was performed in eight patients (1 PTCA, 7 coronary artery bypass graft). CONCLUSIONS: Patients with end-stage renal disease have a high prevalence of CAD. In line with the clinical course, CAD patients on maintenance dialysis undergo rapid angiographic progression of CAD, which results in a high rate of subsequent myocardial revascularizations.

[Prognostic relevance of left ventricular diastolic function parameters in dilated cardiomyopathy]. / Prognostische Relevanz linksventrikulärer diastolischer Funktionsparameter bei dilatativer Kardiomyopathie.

Patients with dilated cardiomyopathy (DCM) generally have an impaired functional capacity and poor long-term out-comes. A mortality of 5-15% per year has been described actually. Aim of this study was to verify the prognostic relevance of invasive and non-invasive parameters of diastolic function in patients with DCM. In 33 patients with DCM, cardiac catheterization was performed and left ventricular systolic (ejection fraction (EF; %)); left ventricular enddiastolic pressure (LVEDP; mmHg) and diastolic function (time constant of relaxation (T, ms); the constant of myocardial stiffness (b) were derived from biplane laevocardiography and simultaneous micromanometric registration of pressure-volume curves. For evaluation of clinical out-come, the follow-up period was defined as beginning on the day after cardiac catheterization and ending on the most recent date or with a cardiac event (death or cardiac transplantation). All patients were reevaluated for NYHA functional class and completed a standard questionnaire. The following hemodynamic parameters were evaluated: invasive parameters of left ventricular diastolic function (constant of relaxation: tau (ms), constant of myocardial stiffness: b)), as well as parameters of systolic function (ejection fraction (EF; %)), left ventricular pressure (LVEDP; mmHg), left ventricular muscle mass index (LVMMI; g/m2), left ventricular enddiastolic volume index (LVEDVI; ml/m2) and non-invasive parameters of morphological data, left ventricular systolic (fractional shortening (FS, %) and ejection fraction) and diastolic parameters with echocardiography. During the follow-up period of 36 months, 11 of 33 patients experienced a major cardiac event (cardiac death n = 8, heart transplantation n = 3). The major cause of death was progressive pump failure. The remaining 22 patients were further classified with respect to changes in functional status. While clinical symptoms could be improved medically in patients with moderate increase of myocardial stiffness, patients with severe increase of myocardial stiffness (b: 76.1 +/- 12.1 vs 17.9 +/- +8.1, p < 0.001) could not be improved and suffered more cardiac events. Doppler echocardiographic measurements in these patients showed a restrictive filling pattern (VE 0.91 +/- 0.21 vs 0.64 +/- 0.18 m/s; p < 0.01; VA 0.52 +/- 0.23 vs 0.57 +/- 0.24 m/s; p < 0.01, deceleration time 129 +/- 17 vs 211 +/- 14 ms; p < 0.01). The medical heart failure therapy was comparable in both groups. In patients with cardiac events, the diastolic left ventricular variables did not significantly differ between patients who underwent heart transplantation and those who died. Patients who demonstrated a sole impairment of relaxation (tau: > 50 ms) suffered no cardiac events. Impaired diastolic function contributes to the clinical picture of congestive heart failure. Parameters of left ventricular diastolic function are powerful and important predictors of major cardiac events in patients with DCM, like heart transplantation and non-sudden death, and may indicate future clinical success of medical treatment. Invasive and non-invasive parameters of diastolic function reveal comparable information for the estimation of prognosis of patients with DCM in order to initiate early therapy.

Vineberg graft: flow reserve of bilateral implantation after 27 years.

We report a patient who underwent bilateral internal thoracic artery implantation into the myocardium known as a Vineberg procedure 27 years ago. Coronary angiography and Doppler echocardiography revealed patent grafts with total occlusion of all native coronary arteries. We measured flow velocities at rest and under stress conditions with noninvasive ultrasonic Doppler echocardiography. The flow patterns in both grafts were biphasic as in native coronary arteries. Under stress conditions no increase in flow was detectable as a marker of end-stage coronary artery disease with refractory angina pectoris.

In vitro bleeding test with PFA-100-aspects of controlling individual acetylsalicylic acid induced platelet inhibition in patients with cardiovascular disease.

OBJECTIVES: This study investigated the usefulness and practicability of a platelet function analyzer (PFA-100(TM), DADE-Behring, Germany) to determine individual platelet inhibition in patients treated with acetylsalicylic acid (ASA). BACKGROUND: Patients with coronary artery disease (CAD) routinely and during angioplasty (PTCA) receive standard doses of ASA to avoid acute coronary syndromes and abrupt vessel closures without information of the individual efficacy of platelet inhibition. METHODS: With the PFA-100(TM) a standardized bleeding time is measured. Whole-blood anticoagulated with 3.2% sodium citrate is aspirated through a capillary ( solidus in circle 200 microm) and through an aperture ( solidus in circle 147 microm). The time until occlusion of the aperture (closure time, CT) by a stable platelet plug induced by shear stress, collagen and epinephrine (COLL/EPI-CT) or shear stress, collagen and adenosine 5'-diphosphate (COLL/ADP-CT) is determined. To examine the usefulness of the PFA-100(TM) as a rapid bedside test and the individual effect of ASA, closure time was measured in healthy individuals (n=17), in patients with stable CAD (n=19) and in patients undergoing PTCA (n=8). RESULTS: Patients with stable CAD and regular medication with 100 mg ASA per day for at least 3 month showed shorter COLL/ADP-CT in comparison to healthy individuals who took only one single dose of 100 mg ASA. Of the patients with CAD 63% had a COLL/EPI-CT within normal range suggesting a low or no response to ASA. Also only 50% of the patients undergoing PTCA reached the expected COLL/EPI-CT>300 s after an additive single dose of 500 mg ASA intravenously. Neither heparin, phenprocoumon, sex nor different blood sampling methods seem to influence the measurements relevantly. CONCLUSIONS: This pilot study indicates that with the PFA-100(TM) test device a simple and quick measurement of an in vitro bleeding time is possible. It is able to detect an increase in the bleeding time after a single dose of ASA 100 mg in healthy subjects, reflecting a sensitive detection of ASA induced changes in platelet inhibition respective activation. Differences in the individual response to ASA could be observed in healthy subjects, patients with stable CAD and patients undergoing PTCA. Further studies should validate the PFA-100(TM) with standard methods to determine ASA response in patients with cardiovascular disease and investigate implications for treatment and outcome in this patient group.

Myocardial revascularization in patients with end-stage renal disease: comparison of percutaneous transluminal coronary angioplasty and coronary artery bypass grafting.

BACKGROUND: Ischemic heart disease is the major cause of death in patients with end-stage renal disease. The high prevalence of coronary artery disease results in a rising number of dialysis patients requiring myocardial revascularisation. OBJECTIVE: The objective of this study was to compare the outcomes of recurrent angina, myocardial infarction, rate of reinterventions and cardiovascular death following percutaneous coronary angioplasty (PTCA) or coronary artery bypass grafting (CABG) in patients with end-stage renal disease. PATIENTS AND METHODS: In a retrospective investigation 40 patients with chronic renal failure undergoing primarily PTCA and 65 patients undergoing CABG were included. Both groups were comparable for gender, duration on dialysis and the number of cardiovascular risk factors per patient. Patients undergoing PTCA were younger (53 +/- 12 years vs. 57 + 8 years; p < 0.05) and more often diabetics (30% vs. 14%; p < 0.05). RESULTS: Most patients in both groups had a multi-vessel disease (95% in the CABG group vs. 74% in the PTCA group), in the CABG group there were significantly more patients with a triple-vessel disease (62% with vs. 40% in the PTCA group; p < 0.01), PTCA was primarily successful in 95% of the patients while complete revascularization was achieved in 88% of patients undergoing CABG. The perioperative mortality after CABG was 4.8% as compared to none after interventional revascularisation. The cumulative freedom of angina after 6, 12 and 24 months after intervention was significantly lower after PTCA (54%, 40%, 29%) than after bypass grafting (97%, 94%, 90%, p < 0.001). The frequency of reinterventions following PTCA was significantly higher compared to patients following CABG (p < 0.001). After PTCA 15 patients needed further revascularisations, 8 of them underwent CABG, whereas after CABG only two patients required additional myocardial revascularisation. There was no significant difference in the overall mortality between both groups; the survival rate after 12 and 24 months was 95% and 82% after PTCA and 93% and 86% after CABG, respectively. CONDITION: Although patients receiving CABG had a more severe coronary artery disease the overall mortality was comparable and clinical and functional outcome was improved compared to patients after coronary angioplasty.

[Differences in the clinical performance and initial diagnosis in women with suspected coronary artery disease]. / Besonderheiten der koronaren Herzkrankheit in der klinischen Symptomatik und Erstdiagnostik bei Frauen.

BACKGROUND AND OBJECTIVE: Although coronary heart disease (CHD) is a major cause of morbidity and mortality, it is still being underestimated in women. This prospective study was undertaken to ascertain special features of the symptoms and in the initial diagnosis of CHD in women. PATIENTS AND METHODS: Between January 1996 and August 1998, a total of 5000 patients (2500 women, 2500 men; mean age 61 [39-83]) were admitted for their initial invasive investigation of suspected CHD. All data relating to history, laboratory tests, resting and exercise ECG, and coronary angiography were recorded and analysed. RESULTS: Typical angina pectoris as initial symptom was recorded in 40% of women, 57% of men, atypical symptoms in 48% vs. 24%. Typical angina pectoris in the presence of demonstrated CHD were found in 32% of women, compared with 69% in men. The interval from initial symptoms to established diagnosis was 68 months in women and 9 months in men, 71% of women but only 5% of men having consulted at least two specialists. Both women and men with CHD had comparable risk factors. Anginal symptoms prematurely ended an exercise ECG test in 49% of women and 44% of men. Significant S-T segment changes were noted in 19% of women, 30% of men with CHD. The positive predictive value of clinical symptoms and ergometric results with regard to CHD was much lower in women than in men: 33% vs 85%. CONCLUSIONS: Clinical symptoms and the exercise ECG are much less diagnostically reliable in women than in men and had a very low predictive value. Women often have typical anginal symptoms even in the absence of CHD. They, therefore, require more sensitive methods than the exercise ECG for the initial diagnosis of CHD, especially in the face of prolonged symptom-to-diagnosis intervals.

[Left ventricular diastolic function in normal pregnancy. A prospective study using M-mode echocardiography and Doppler echocardiography]. / Linksventrikuläre diastolische Funktion in der normalen Schwangerschaft. Eine prospektive Untersuchung mittels M-mode-Echokardiographie und Doppler-Echokardiographie.

BACKGROUND AND OBJECTIVE: During pregnancy many substantial changes occur in the cardiovascular system. Aim of this study was to examine how physiological preload alterations influence left ventricular haemodynamic parameters. PATIENTS AND METHODS: During the 9th, 24th and 33rd weeks of pregnancy and 8 weeks after childbirth 36 patients underwent echocardiographic studies. 36 young not pregnant women (25 +/- 7 years) served as controls. The following Doppler echocardiographic parameters were measured: peak early diastolic flow velocity (VE, ms); acceleration (AT; ms) and deceleration time (DT; ms) of flow velocity in early diastole; peak late diastolic flow velocity (VA; m/s) and isovolumetric relaxation time (IVRT; ms). In all women the left ventricular muscle mass index (LVMMI), fractional shorting (FS; %) and the ratio between septum and posterior ventricular wall were calculated. RESULTS: During pregnancy all women showed an elevation of the left ventricular muscle mass index (LVMMI: from 66 +/- 6 to 100 +/- 9 g/m2; p < 0.01) and a decrease of fractional shortening (FS: from 38 +/- 4 to 31 +/- 3%). All patients developed a relevant diastolic dysfunction: reduced early diastolic flow velocity (VE: from 0.89 +/- 0.11 to 0.83 +/- 0.19 m/s; P < 0.01), reduced E/A ratio (1.7 +/- 0.4 to 1.2 +/- 0.4; P < 0.01), prolonged IVRT (72 +/- 12 to 114 +/- 12 ms; P < 0.01) and deceleration time (DT: to 189 +/- 17 to 227 +/- 18 ms; P < 0.01). Eight weeks after childbirth all parameters of left ventricular systolic and diastolic functions were normal. CONCLUSION: Preload alterations during normal pregnancy lead to reversible physiological left ventricular hypertrophy. Furthermore, we found a short-time reduction of systolic function just before childbirth and a significant alteration of the left ventricular diastolic filling pattern (abnormal relaxation pattern). While left ventricular systolic function was normal in all patients one week after childbirth, left ventricular hypertrophy and left ventricular diastolic dysfunction persisted for nearly two months.

Non-invasive assessment of graft patency using transcutaneous Doppler echocardiography for the validation of functional improvement after PTCA of the LAD via internal thoracic artery graft.

Percutaneous transluminal coronary angioplasty (PTCA) of a native coronary artery via internal thoracic artery (ITA) graft after bypass surgery is a relatively rare procedure. Our current study evaluates the flow velocity patterns of the graft before and after PTCA. After intervention the mean diastolic flow velocity increased under rest and stress conditions. In addition, the graft patency was proved not before control angiography after 6 months. It could be verified that the measurement of flow velocity patterns under rest and stress conditions is a useful non-invasive procedure for monitoring long-term patency and PTCA-results of this vessel.

Congestive heart failure as an indication for continuous renal replacement therapy.

Continuous venovenous hemofiltration (CVVH) is the most widely used renal replacement therapy for the treatment of critically ill patients with acute renal failure on the intensive care unit. Whether or not congestive heart failure is an indication for CVVH is controversial and needs to be discussed. Therefore, we present a patient with congestive heart failure who was treated successfully with CVVH.

Changes of hemostasis, endogenous fibrinolysis, platelet activation and endothelins after percutaneous transluminal coronary angioplasty in patients with stable angina.

OBJECTIVES: This study investigated parameters of endogenous fibrinolysis, activation of coagulation and platelets, and endothelin levels before and after elective percutaneous transluminal coronary angioplasty (PTCA) in patients with stable coronary artery disease (CAD). BACKGROUND: Abrupt vessel closure is a serious short-term complication after PTCA and is often unforeseeable. Detailed insight into the effect of PTCA on hemostasis, platelets and the release of vasoconstrictive substances, which are among the mainly discussed mechanisms of abrupt vessel closure, is needed to enhance the safety of coronary intervention. METHODS: Plasma levels of markers of platelet activity, coagulation, endogenous fibrinolysis and endothelins were determined in 20 patients with stable CAD undergoing elective PTCA. The blood specimens were drawn before, immediately after, 1 h after intervention and on the next morning. RESULTS: All patients showed an initially uncomplicated PTCA. Regarding the efficacy of anticoagulation after receiving 15.000 IU heparin during PTCA, two groups were compared. In eight patients with ineffective anticoagulation production of thrombin and platelet activation directly after and 1 h after PTCA was significantly higher compared with 12 patients with effective anticoagulation. Despite the strong activation of coagulation, only a low fibrinolytic response could be observed. Endothelins rose significantly after PTCA in both groups but stayed longer on higher levels in patients with distinct thrombin generation. Three of the eight patients without sufficient heparin treatment suffered abrupt vessel closure. CONCLUSIONS: Initially uncomplicated dilation of coronary arteries leads to systemically measurable activation of coagulation and platelets in patients with ineffective doses of heparin and release of endothelins in all patients. Therefore, individual adjustment of anticoagulation and platelet inhibition in combination with effective antivasospastic substances are needed in every patient before, during and after initially uncomplicated PTCA to prevent this serious complication.

[Early decrease in diastolic function in young type I diabetic patients as an initial manifestation of diabetic cardiomyopathy]. / Frühzeitige Einschränkung der diastolischen Funktion bei jungen Typ-I-Diabetikern als Erstmanifestation einer diabetischen Herzmuskelerkrankung.

INTRODUCTION: The early determination of the myocardial manifestation is of considerable importance, since the prognosis of patients (P) with insulin dependent diabetes mellitus (IDDM) is generally masked by secondary cardiac complications. The aim of this study was to investigate whether young, asymptomatic P with IDDM and persisting normal systolic left ventricular (LV) function already show a diastolic LV dysfunction. METHODS: An echocardiographical examination of 92 IDDM patients (age: 25 +/- 4 years) without known cardiac disease and of 50 control persons (C) of similar ages was carried out. P with a cardiac disease or long-term diabetic syndrome were excluded. Using M-mode echocardiography, morphological parameters and systolic time-intervals (fractional shortening; ejection fraction) were determined. Doppler indices were then measured: maximal early and late diastolic flow velocity (VE; VA), E/A ratio, acceleration and deceleration time (DT), isovolumetric relaxation time (IVRT). RESULTS: Although the left atrial and left ventricular dimensions, as well as the systolic functional parameters of all P with IDDM were normal, they showed a diastolic dysfunction with a reduction of the early diastolic filling (VE; 0.54 +/- 0.07 m/s vs 0.72 +/- 0.04 m/s; p < 0.01) and the E/A ratio (0.9 +/- 0.15 vs 1.99 +/- 0.22; p < 0.01), an increase in the atrial filling (VA; 0.76 +/- 0.05 m/s vs 0.39 +/- 0.04 m/s, p < 0.01), an extension of the IVRT (129 +/- 23 ms vs 78 +/- 6 ms, p < 0.01), and an increased DT (248 +/- 27 ms vs 188 +/- 8 ms, p < 0.01). CONCLUSION: Even young P with IDDM, with a normal systolic ventricular function, suffer a diastolic dysfunction which serves as a marker of a diabetic cardiomyopathy. Therefore, echocardiography with measurements of systolic and diastolic functional parameters appears to be a sensible method for evaluating the course of diabetic cardiomyopathy.

[PTCA of the LAD via the internal thoracic artery graft with Doppler ultrasonic control of the results: a case report and review of the literature]. / RIVA-PTCA via Arteria-thoracica-interna-Bypass mit dopplersonographischer Erfolgskontrolle--Eine Kasuistik mit Literaturübersicht.

The report presents a transluminal angioplasty (PTCA) of a severe stenosis of the left anterior descending artery (LAD) behind the anastomosis; the internal thoracic artery (ITA) graft was used as a conduit. Before and after the PTCA the changing of velocity flow patterns under rest and stress conditions with a handgrip-maneuver were measured with a noninvasive transthoracic ultrasound Doppler system. The mean diastolic velocity, which represent coronary perfusion through the ITA graft, increased after successful PTCA at rest and under stress conditions. An additional increasing of the mean diastolic velocity at rest and under stress conditions was seen after six months before the catheterization proposing no signs of restenosis. For this reason the vessel could be classified prospectively patient. This could be confirmed during coronary angiography. We also present a review of the published reports concerning PTCA of ITA grafts and PTCA of the native vessel using the ITA as a conduit. In this review 286 cardiac interventions on 273 patients with a primary rate of success of 87% could be counted, the documented rate of restenosis was 30%, and the rate of complication was approximately 1%. The PTCA in ITA grafts or of the native vessel via ITA grafts, respectively, represent an alternative to reoperation. The ultrasound-duplex measurements are gaining an increasing significance for the noninvasive patency rate and post-interventional monitoring of the long-term PTCA result. With the augmentation of the ITA as a coronary bypass and expected increase of post-operative interventions, a noninvasive tool is necessary.