[Echocardiographic detection of wedged emboli in the right heart in patients with pulmonary embolisms]. / Echokardiografický prukaz zaklínených embolu v pravém srdci u nemocných s plicní embolií.

The authors describe two case-histories of patients with the clinical picture of pulmonary embolism where on echocardiography a mobile formation in the right atrium was detected. In both patients the embolus of peripheral origin wedged in the right atrium was removed by surgery.

[Contralateral asynergy after myocardial infarct]. / Protilehlá asynergie po infarktu myokardu.

The purpose of the work was to assess whether during several years of echocardiographic follow-up of patients after myocardial infarction later contralateral asynergy develops (i.e. asynergy of another coronary vessel than that which supplies the area of the infarction) and what are the clinical symptoms associated with its development. In a group of 208 patients followed-up for 1-5 years contralateral asynergy was found in 19 patients (i.e. 9.1%). In 12 patients the development of contralateral asynergy was asymptomatic, in 18 patients significant stenosis or occlusion of the coronary artery which supplied the area of the contralateral asynergy was present. It can thus be concluded from the results that contralateral asynergy develops after myocardial infarction in cca 9% patients and usually its development is asymptomatic. The finding of contralateral asynergy on echocardiographic examination indicates multiple affection of the coronary circulation.

[Are there abnormalities of parathormone, calcium and phosphorus metabolism in hypertrophic cardiomyopathy?]. / Lze nalézt u hypertrofických kardiomyopatií abnormality parathormonu, metabolismu vápníku a fosforu?

The importance of calcium and phosphorus metabolism for the development of hypertrophic cardiomyopathies is still obscure. Therefore 52 patients with hypertrophic cardiomyopathy were subjected to detailed cardiological and laboratory examinations. Twenty-five age matched healthy subjects served as controls. The following indicators were assessed: calcium and its ionized fraction, phosphorus, chlorides and magnesium in serum and 24 h urine, as well as AST, ALT, ALP, ACP, urea, creatinine, protein electrophoresis (to check calcium values with regard to serum albumins), endogenous creatinine clearance, Palmer's chloride phosphate index and Nordin's index. In addition to tubular phosphate reabsorption, the renal phosphate threshold was assessed and finally the parathormone blood level by the RIA method. In patients with hypertrophic cardiomyopathy a significant increase of the parathormone level was found--in a total of seven patients with advanced myocardial hypertrophy (more than 30 mm). There were no significant differences in the remaining parameters. It may thus be admitted that in some instances the increased parathormone level may cause an increase of the already existing myocardial hypertrophy. However, in the broad spectrum of patients with hypertrophic cardiomyopathy it is not suited for explaining morphological findings.

[Myocardial infarct. Results and tactics in reperfusion therapy]. / Infarkt myokardu. Výsledky a taktika reperfúzní lécby.

In a group comprising a total of 217 patients with a recent myocardial infarction, who were treated with streptokinase the authors provided evidence that early recanalization of the coronary occlusion occurred after superselective intracoronary administration in 81 and 83% of the patients. After intravenous streptokinase administration they recorded early recanalization in 62%. They found a significant diminution of the infarction focus and improved left ventricular function, as compared with patients treated in the "classical" way by antiarrhythmic drugs, beta-blockers and vasodilatating drugs. The follow up of some other indicators is also in favour of significant improvement after thrombolytic treatment--thrombi in the left ventricle, cardiac decompensation, development of an aneurysm, myocardial rupture. Conversely an argument against thrombolytic treatment are more frequent haemorrhagic complications--16%. However, in these complications no deaths were recorded nor the need of an operation or discontinuation of maintenance anticoagulant treatment. In reperfused patients no hospitalization mortality was recorded. Reocclusions occurred most frequently during the first four weeks after treatment and only after intracoronary administration--10%. According to the authors this is due to residual stenoses more serious ones, 75% of the lumen--the higher incidence of reocclusions in significant stenoses is statistically evident. The only prevention of reocclusions is immediate follow up of PTCA after intracoronary thrombolysis. The intravenous administration of streptokinase in myocardial infarctions is according to the authors a safe method and they recommend its use in all coronary units in the CSSR.

[Initial experience with liposuction]. / Prvé zkusenosti s liposukcí.

The principle of the method of liposuction is based on the reduction of circumscribed excessive subcutaneous adipose tissue by means of highly efficient pumps and special cannulas by means of which the tissue is dilacerated and sucked up. Administration of hyaluronidase facilitates the operation. The very good final effect depends above all on the selection of patients for the operation, its precise implementation and several weeks' bandaging of the operated area.

[The importance of the determination of primary bile acids in diseases of the digestive tract]. / Význam stanovení primárních zlucových kyselin u chorob zazívacího traktu.

The authors assessed the concentration of primary bile acids in patients with liver diseases, diseases of the gallbladder and biliary pathways, with affections of the pancreas and in a control group. Primary bile acids and their conjugated derivatives were assessed by radioimmunoanalysis from the patients' serum, using radiodiagnostic sets of Farmos Co. Finland. The range of the assessed concentrations was 0.15-15 mumol/l. The total number of examined subjects was 56, blood specimens for estimation of bile acids were collected in the morning after 12 hours fasting. From the investigation ensues that primary bile acids were elevated in diseases of the hepatobiliary tract; in diseases of the gallbladder and biliary pathways an increased ratio of glycocholic to glycochenodeoxycholic acid was found. Elevated concentrations of the two investigated primary bile acids were also found in subjects with tumorous diseases. Consistent with the result of other authors, it is obvious that estimation of bile acids is a sensitive liver function test.

[Unstable angina pectoris--pathogenesis and therapy]. / Nestabilní angina pectoris--príspevek k patogenezi a terapii.

Unstable angina pectoris is a clinical syndrome characterized as a rule as rapid deterioration of angina or newly developed angina pectoris. The authors examined 30 patients with unstable angina pectoris who were admitted to hospital within 24 hours after the attack. Coronarography was performed on average after 14.6 hours. In all patients significant coronary stenoses were found. Streptokinase was administered into the coronary artery exhibiting the maximum narrowing in a total dose of 500,000 u. at a rate of 10,000 u/min. After streptokinase administration improvement of the coronarographic finding was recorded in 53% of the group, subjective improvement in 77%. Newly developed angina pectoris exhibited coronarographic improvement in 100%. Deteriorated angina improved coronarographically in 36%, subjective improvement was recorded in 68%. The authors found a significant difference (p less than 0.01) between the group of new anginas and deteriorated anginas following treatment, the coronarographic improvement being in favour of the group of fresh anginas (100% vs. 36%). The authors did not detect a significant difference between the groups when evaluating subjective improvement. In the group of deteriorated anginas more frequently subjective improvement was observed (68%) without detectable coronarographic improvement (36%). The authors verified on their own material that in more than 50% of the patients with sudden deterioration or the development of angina pectoris classified as unstable angina pectoris thrombotic narrowing can be found or even occlusion of the coronary arteries. The authors recommend therefore intravenous streptokinase administration in newly developed angina pectoris. In deterioration of angina pectoris they recommend heparin or possibly streptokinase as the drug of choice.

[Disorders of heart rhythm in hypertrophic cardiomyopathy]. / Poruchy srdecního rytmu u hypertrofických kardiomyopatií.

In 64 patients with hypertrophic cardiomyopathy 24-hour Holter monitoring of the ECG was made in order to detect the incidence of individual disorders of the cardiac rhythm. The examination revealed a large number of potentially malignant ventricular arrhythmias (47% of the patients). Most frequently polytopic ventricular extrasystoles were involved (31.3%), attacks of ventricular tachycardia (20.3%), less frequently bigeminy was recorded (10.9%) and early extrasystoles type R on T (3.1%). As to other disorders of the cardiac rhythm, paroxysmal supraventricular tachycardia was frequent (34.4%), atrial fibrillation or flutter (9.4%) and more numerous supraventricular extrasystoles (7.8%). Sinoatrial (4.7%) and atrioventricular blocks (7.8%) were relatively rare. Examination of patients with hypertrophic cardiomyopathy is an essential prerequisite for the initiation of early and effective treatment which can exert a favourable effect on the subsequent fate of the patients.

[Relation between disorders of cardiac rhythm to the symptomatology and extent of hypertrophic cardiomyopathy]. / Vztah poruch srdecního rytmu k symptomatologii a rozsahu postizení u hypertrofických kardiomyopatií.

The aim of the work was a more detailed characteristic of patients with hypertrophic cardiomyopathy who are threatened by an increased risk of serious disorders of the cardiac rhythm and thus probably also by sudden death. The authors analyzed a group of 64 patients subjected to 24-hour monitoring of the ECG by the Holter system. The patients were subjected to echocardiographic examination and the distribution of the myocardial hypertrophy was described in detail, incl. its extent in per cent of the affected myocardium, the mean thickness of the myocardium (arithmetic mean of the thickness of the left ventricular musculature and septum divided into 10 areas) and the maximum thickness of the heart muscle. The authors found a significantly higher incidence of serious ventricular arrhythmias in patients with an extensive area of the hypertrophy and a greater thickness of the hypertrophic myocardium. In subjects with a positive history of syncopes there was a high incidence of serious supraventricular and ventricular disorders as well as ventricular disorders of the cardiac rhythm. No relationship was found between the incidence of arrhythmias and the presence or size of obstruction. Patients with extensive hypertrophy (i.e. an extensive area of hypertrophy and thickness of the myocardium) and patients with a history of syncopes form thus as regards life-threatening arrhythmias a risk group which after diagnosis should be without delay examined by the Holter system and then treated by medicamentous therapy.

Electrocardiographic changes can precede the development of myocardial hypertrophy in the setting of hypertrophic cardiomyopathy.

A comparison was made of electrocardiographic findings in 107 first-degree relatives of patients with hypertrophic cardiomyopathy without any clinical and echocardiographic signs of the disease and 188 healthy persons with a negative family history. A significantly larger number of electrocardiographic signs of left ventricular hypertrophy (P less than 0.05) and abnormal Q wave (P less than 0.005) was shown in the group of the relatives. Abnormalities of the R wave in V1-3 and of the ST-T segment were also more frequent in this group, but the difference is not statistically significant. In all, electrocardiographic abnormalities were found in 13 of 107 asymptomatic relatives of the patients with hypertrophic cardiomyopathy. These relatives had normal clinical and echocardiographic findings. These 13 patients underwent long-term follow-up (4.5-8 years). Typical hypertrophic cardiomyopathy developed in two patients (an increase in the myocardial thickness from 6 to 15 m in six years and from 8 to 13 mm in 4.5 years, respectively) which was accompanied by progression of the electrocardiographic findings. Electrocardiography is the only commonly available method which may reveal the latent forms of hypertrophic cardiomyopathy at the stage when neither myocardial hypertrophy nor other signs of the disease are expressed. Longitudinal follow-up is necessary for all the relatives of the patients with hypertrophic cardiomyopathy who have abnormal or borderline electrocardiographic findings. A normal echocardiogram cannot exclude the disease at this stage.

Cardiac rhythm disorders in various types of hypertrophic cardiomyopathies.

The aim of the study was to provide a detailed characterization of patients with hypertrophic cardiomyopathy who are at increased risk of severe cardiac rhythm disorders and, thus, also sudden death. The group, made up of 64 patients, was subjected to 24-hour ECG Holter monitoring. The patients were examined by echocardiography and myocardial hypertrophy distribution was studied in detail. A significantly higher incidence of severe ventricular arrhythmias was found in patients with hypertrophy involving large areas of the myocardium and with increased myocardial wall thickness. Patients with a positive history of syncopes were found to have a high incidence of severe supraventricular and ventricular cardiac rhythm disorders. No relationship was established between the incidence of arrhythmias and the presence or extent of obstruction. Patients with extensive hypertrophy (both in terms of the area involved and myocardial thickness) as well as those with a history of syncopes represent a risk group as regards the development of potentially lethal arrhythmias.

Myocardial contrast echocardiography. A review of clinical studies.

A review is presented of to date published studies devoted to contrast echocardiography of the myocardium and covering a total of 169 patients. No complications occurred during investigations; slight transient ECG and haemodynamic changes of less than 30 s duration were not as pronounced as during coronary arteriography. Intracoronary administration of a 3-4 ml solution containing microbubles close to erythrocyte size leads to opacification of the perfused part of the myocardium in echocardiographic image, whereas the echogenity of nonperfused parts remains unchanged. With the use of this method it might be possible to evaluate the significance of coronary stenosis, to diagnose the "disease of small arteries", to assess the collateral circulation, myocardial infarction size, and to quantify the blood flow in various parts of the myocardium in real time. The method is promising for the assessment of myocardial microcirculation as a complement of coronary arteriography.

Severe diffuse hypokinesis of the remote myocardium--the main cause of cardiogenic shock? An echocardiographic study of 75 patients with extremely large myocardial infarctions.

Two-dimensional echocardiography was performed in 75 patients with extensive myocardial infarctions to prove why cardiogenic shock develops only in a minority of such patients. 23 patients with clinical signs of shock formed group A, and 52 patients without signs of shock group B. The extent of akinesis and/or dyskinesis was the same in both groups. The "Asynergy Index"--involving also hypokinesis--was more favourable in group B (126 +/- 28, compared with 158 +/- 23 in group A, p less than 0.05). The ejection fraction was significantly higher in group B (33 +/- 12%, compared with 17 +/- 6% in group A, p less than 0.01). The cause of these differences was severe diffuse hypokinesis of the remote myocardium, which was present in all 23 patients with cardiogenic shock and only in 2 patients without shock (p less than 0.001). All 23 patients with shock had multi-vessel disease, which was present only in 19% of patients without shock (p less than 0.01). The study shows that in addition to two known conditions necessary for the development of cardiogenic shock (multi-vessel disease and infarct size at least 40% of the left ventricle), there exists a third condition of equal importance: severe diffuse hypokinesis of the remote myocardium.

Myocardial contrast echocardiography: a new method for the evaluation of regional myocardial blood flow.

Myocardial contrast echocardiography is a new method enabling detailed evaluation of blood flow distribution within the myocardium. It is performed by means of intracoronary injection of small volumes of carrier solutions containing small microbubbles of a size similar to that of red blood cells. The perfused myocardium opacifies densely, while the ultrasonic backscatter of nonperfused areas does not change. This method enables evaluation of the physiologic impact of coronary stenosis, diagnosis of "small vessel disease", collateral blood flow assessment, infarct size measurement and, with the help of videomemory and a computer, also regional myocardial blood quantification. This paper reviews all hitherto published studies with myocardial contrast echocardiography in humans including some studies only recently submitted for publication. These studies examined a total of 169 patients. No complications of intracoronary injection of microbubbles were described. Transient ECG and haemodynamic changes of less than 30 seconds' duration are less pronounced than during routine coronary arteriography. This paper describes the methodology, safety, physiology and potential clinical usefulness of myocardial contrast echocardiography.

Clinical findings in hypertrophic cardiomyopathy and their relationship to the disease severity.

The clinical and electrocardiographic findings of 82 patients presenting with hypertrophic cardiomyopathy were compared with the distribution and extent of myocardial hypertrophy. The clinical and ECG signs did not depend on either the presence or the degree of the obstruction. Subjective complaints (with the exception of dypnoea) were not related to the value of myocardial thickness but they correlated with the square extent of the area affected by hypertrophy of the myocardium. It was distinct in the case of dyspnoea and especially syncope the occurrence of which was significantly higher in patients with a higher extent of hypertrophy. This extent of hypertrophy was reflected in our previously published classification of hypertrophic cardiomyopathies which is based on echocardiographic analyses of the individual parts of myocardial thickness.