Echocardiographic morphometry of the right chambers of the heart in permanent cardiac pacing.

Permanent cardiac pacing is a method of choice in the treatment of specific arrhythmias and conduction disturbances. Clinical studies show that cardiac performance diminished at the site of impulse spreading. It determines local hypotrophy below the position of the pacing lead (early electric activation) with hypertrophic changes in the opposite lying myocardium (late electric activation). It seems that morphological changes, especially research by intravital methods, so relevant in permanent pacing to today's invasive cardiologist, are not understood in full. In connection with this we decided, on the basis on the echocardiographic examination, to evaluate in detail the morphology of the right ventricle and atrium in patients with permanent pacing. Research was carried out on a group of 124 patients (68 males, 56 females) from 40-93 years of age (avg. 68 +/- 14 yrs): 86 patients had implanted pacemakers or AICD (group I), the control group consisted of 38 patients with other cardiac diseases without any pacemaker devices (group II). We measured echocardiographically the following diameters: end-diastolic and systolic diameters of the right ventricle/atrium in short and long axis, diameter of the tricuspid orifice valve and calculated area of the tricuspid orifice based on a special formula. Regarding the morphometric parameters of the right ventricle and right atrium, we confirmed that all diameters of group I were overshooting in correlation to group II. Those differences, such as RVd-short and -long, RVs-long, RVinflow, RA-long and -short, TRId, were statistically significant. Regarding the area of the tricuspid orifice (TRIa), we did not observe any changes in the two examined groups. We concluded that patients with implanted devices have changes in the morphometric parameters of the right ventricle, atrium and orifice, but they do not depend on the duration of pacemaker implantation.

Permanent cardiac pacing and its influence on tricuspid valve function.

Implantation of transvenous devices is a widespread procedure in clinical cardiology. It is well known that the presence of the electrodes in the cardiovascular system can induce fibrosis or fibrous adhesions between them and cause tricuspid regurgitation. Moreover there are suggestions that the placement of the electrode in the tricuspid orifice may also play a role in the development of tricuspid insufficiency because of the thickening of reactive leaflets and the impairment of their mobility in morphological studies. There are no papers regarding the topography of the electrode in the right ventricle judged by means of transthoracic echocardiography. Moreover in literature we did not meet reports comparing the localisation of the lead on the tricuspid valve function. Therefore we decided to describe the detailed topographic relations between the lead and the structures of the right ventricle in a larger population and we compared the influence of the lead location for tricuspid valve function. Research was carried out on a group of 86 patients (52 M, 34 F), with a mean age of 64.7 +/- 14.9 years with permanent cardiac pacemaker or implantable cardioverter-defibrillator (ICD). On the basis of echocardiograms performed we assessed the position of the lead regarding the tricuspid valve leaflets or commissure, and judged the course of the lead beneath the tricuspid valve level. Moreover special attention was focused on the placement of the tip of the electrode. We qualified its position into three categories: apex of the right ventricle, right ventricle outflow tract, and "para-apex" position. The degree of the tricuspid valve insufficiency was assessed by means of semiquantitative method based on the Color-flow Doppler echocardiography. We measured the extension and the area of the tricuspid regurgitant jet using four-gradual scale. We compared the topography of the lead at the level of the valve with its function by means of the presence and degree of its regurgitation. We stated that in 35% of cases the pacing lead was located at the level of the anterior leaflet of the tricuspid valve, in 23% at the level of the septal leaflet and in 12% at the posterior one. Besides in 10% the electrode was placed between the leaflets just over the commissures. On the other hand in the remaining 20% the lead was positioned centrally in the right atrioventricular orifice without adherence to any leaflet. Next we assessed the course of the lead beneath the tricuspid valve level and stated that most frequently (45%) it run just across the centre of the right ventricle, and in other cases was lying along the interventricular septum (in 39% of cases) or along the anterior wall of the right ventricle (in 16%). The tip of the lead was positioned exactly in the apex of the right ventricle in 74%, in the right ventricular outflow tract in 9% and in 17% its position was "para-apical". We did not see any statistically significant differences between the presence and intensification of valve regurgitation and topography of the lead. We concluded that at the level of the tricuspid valve the lead was positioned in the anteroseptal part of tricuspid annulus and the proper apical position of the electrode's tip occurred in approximately 75% of cases. Localisation of the electrode at the level of the tricuspid orifice does not influence its insufficiency as detected by Doppler echocardiography.

Anterior region of the atrioventricular perinodal area in relation to radiofrequency ablation procedures.

Atrioventricular nodal reentry tachycardia base on reentry circulation in nodal-perinodal area. The radical treatment of choice is radiofrequency ablation. Procedure approached from the anterior-superior (fast) region sufficient a few seconds of energy delivery for success, however this can result in A-V block. The possibility that arrhythmias substrate may lie very superficially (success of ablation) and damage the normal structures (complication) in the perinodal region must be considered. In order to confirm this hypothesis we examined the autopsy material of 100 normal hearts, both sexes from 18 to 105 years of age (control) and 50 hearts with A-V total block 45-95 years of age (block). We paid attention to the morphology of the nodal artery (NA), atrial inputs (AI) and transitional inputs (TI). It was observed that NA at the level of the central fibrous body was positioned in 94% in the central and in 6% in the inferior part of Koch's triangle. It was removed from the endocardium 3-6 mm in control and 2-5 mm in block group respectively (NS). In the perinodal area we distinguished AI that directly joined the A-V compact node: superficial (right part of the interatrial septum) or deep (left part). The former occurred in 100% of controls and in 80% of block groups (NS), and the latter in 80% of control group and in 34% in block respectively (p < 0.05). The real substrate of arrhythmia in anterior-superior region lies very superficially and far from the conduction tissue; NA in examined hearts was lying deep beneath the endocardium; ablation close to the node could result in A-V block.

The localisation of the electrode in permanently paced heart--an echocardiographical study.

UNLABELLED: Permanent cardiac pacing is a widely applied procedure in invasive cardiology. The aim of our study was the analysis of the localisation of the tip of the pacemaker lead and its course in the right ventricle. Research was carried out on a group of 12 patients (5F, 7M), from 40 to 93 years of age (average 70 +/- 15 yrs) with permanent cardiac pacing or implantable cardioverter-defibrillator (ICD). Subsequent echocardiographic views were applied: an apical four chamber view, a subcostal one and a parasternal right ventricular inflow tract view. At the level of the tricuspid annulus the electrode was positioned: the anterior leaflet--41.7% (5 pts), the anteroseptal commissure 25% (3 pts), the posterior leaflet 8.3% (1 pt) and the septal one--8.3% (1 pt). In 16.7% (2 patients) the lead was positioned centrally in the right atrioventricular orifice. Regarding the further positioning of the electrode in the ventricle, in 41.7% (5 pts) the leads were placed along the interventricular septum, in 16.7% (2 pts) along the anterior wall of right ventricle and in 41.7% (5 pts) across the centre of the right ventricle. The tip of the lead was positioned in the apex of the right ventricle in 83.4% (10 pts). In the remaining 16.7% (2 pts) the position was not apical--in 1 patient the anterior wall of the right ventricle and in 1 patient the interventricular septum. In the VVI pacing mode the electrode did not lie on the interventricular septum. In contrast to this in 80% of patients (4 pts) having the DDD pacing mode the lead was situated on the interventricular septum on its course downwards to the ventricle. CONCLUSIONS: 1) On the level of the leaflets of the tricuspid valve the lead most often was positioned at the level of the anterior leaflet and the anteroseptal commissure. 2) Most patients had an apical localisation of the tip of the lead. 3) Differences between morphological and echocardiographic studies are related to the intravital and the two-dimensional character of echocardiography, and probably to the small population of the group examined.

The morphological conditions of the permanent pacemaker lead extraction.

Pacemaker lead extraction is the treatment of choice in infectious complications regarding implantation procedure. The purpose of this study was to estimate the safety of the extraction in relation to the morphological changes of the pacing electrode. Research was carried out on materials consisting of 60 human hearts from 45 to 95 years of age (average 63 +/- 15 yrs), with VVI or DDD pacing (pacing duration 84 +/- 26 months) fixed in a formalin solution. Classical macroscopic anatomical methods were applied. In 44 hearts (73.3%) from the investigated group the posterior tricuspid leaflet was thickened only, and in 24 of these hearts the process regarded not only posterior leaflet but also the septal one and especially commissure between them. In 52 hearts (86.6%) inflammatory reaction spread also to the neighbouring part of the electrode. The length of the neointima-inflammatory tissue ranged from 4 to 8 mm (average 5 +/- 2 mm). On the tip of the electrode in the right ventricle cavity in 56 hearts (93.3%) we observed that endocardial leads were surrounded by fibrous thickening, and partially covered by endocardial tissue. We concluded that from the anatomical point of view the extraction of the pacing electrode seems to be questionable, especially in long-term permanent pacing. The experimental traction shows that only recently implanted electrodes were removed without any complications and in others with fraction of the tip, myocardial tissue avulsion or such removal was not successful at all.

[Ehrlichiosis: a tick-born infection]. / Erlichioza--choroba przenoszona przez kleszcze.

Ehrlichiosis is the potentially life-threating infection. It is caused by obligate intracellular bacteria. The clinical presentations are fever, headache, myalgia, malaise, nausea, vomiting and other nonspecyfic symptoms. Some patients develop neurologic symptoms and signs. The are two distinct forms of human ehrlichiosis: human monocytic ehrlichiosis /HME/--cased by Ehrlichia chaffeensis that infects mononuclear phagocytes and human granulocytic ehrlichiosis /HGE/--caused by E. species closely related to E. phagocytophyla and E. equi and infects granulocytes. Successful treatment of these infections may depend on proper diagnosis. Appropiate diagnostic tests are still not available. This diagnisis should be considered in febrile patients with tick bites.

[Tuberculous lymphadenitis--diagnostic difficulties]. / Gruzlicze zapalenie Wezlów chlonnych--trudnosci diagnostyczne.

Three cases of tuberculous lymphadenitis hospitalized in Department of Parasitology and Neuroinfection are presented. In all patients tuberculin test was positive. In 2 patients minimal lesions in lungs were present. In non patient BK in sputum was found. In microscopic picture of enlarged lymph nodes non specific inflammation granulomatosis was found but microbiological examinations were not done. In all patients the results of smears of lymph nodes pus were negative. In 2 patients culture was positive. Persistent enlarged peripheral lymphatic nodes, especially with fistula should be suspected of tuberculous etiology. Material obtained from node's biopsy should be taken to microbiological and histological examination.

[Albumin and immunoglobulin levels in cerebrospinal fluid and serum in tick borne meningoencephalitis]. / Stezenie albumin i immunoglobulin w plynie mózgowo-rdzeniowym i w surowicy w zapaleniach opon mózgowo-rdzeniowych o etiologii kleszczowej.

The levels of albumin and immunoglobulins G, A, M were determined by using nephelometry technique in the cerebrospinal fluid and serum in 14 adults with tick borne meningoencephalitis at the beginning and after four weeks of disease. Intra blood-brain synthesis of IgG, IgA, IgM was evaluated by indexes of synthesis (Tibbling formula). The blood-brain integrity was estimated by CSF/serum albumin ratio. Increased albumin and immunoglobulins G, A, M levels were demonstrated in first examination and only elevated levels of albumin and immunoglobulin M lasted after four weeks. Albumin level in cerebrospinal fluid and albumin ratio were elevated in both examinations. The serum levels of albumin and immunoglobulins were similar in first and second examination. On the basis these results we conclude that in tested patients blood-brain integrity was disturbed still after four weeks of disease.

[Diagnostic difficulties in tuberculous meningoencephalitis]. / Trudnosci w rozpoznaniu gruzliczego zapalenia opon mózgowo-rdzeniowych i mózgu.

Five cases of tuberculous meningoencephalitis with severe course treated in the period 1991-1994 at the Department of Parasitic Diseases and Neuroinfections, Medical Academy in Bialystok are reported. Diagnostic difficulties encountered in these cases, the clinical courses and the results of the treatment are discussed. The always lethal outcome of untreated tuberculous meningoencephalitis requires antituberculosis treatment to be tried in all cases of meningitis with severe and protracted course, with equivocal results of cerebrospinal fluid analysis, and lacking effect of non-specific therapy.

New morphologic aspects of explanted Hancock Extracorporeal pericardial bioprostheses.

Between 1981 and 1987 a total of 479 Hancock Extracorporeal bovine pericardial bioprostheses were implanted in 458 patients. During the time period from 1990 to 1993, 21 valves, 15 in the aortic and six in the mitral position, had to be removed 72 to 109 months after implantation. The mean age of these patients at the time of implantation was 49.7 +/- 10.5 years. All 21 removed as well as one unimplanted bioprosthesis were morphologically investigated. Visual examination, radiography, histology and ultrastructural observations were performed using scanning and transmission electron microscopy. In addition, clinical data were correlated to morphological findings. All valves failed due to cusp tears originating at the stent posts. Calcification was minimal in five valves, moderate in 10, and severe in five valves. Only one valve showed no mineralization at all. The late morphologic changes were associated with thickening of valve leaflets, tissue delamination, calcification, degeneration of collageneous network, and extensive insudation of plasma proteins and lipids. The present findings suggest that denatured collagen molecules may be capable of inducing immune response.

Integrity and viability of homograft valves.

Since it has been suggested that the leaflet tissue viability influences durability after homologous valve replacement, we compared different harvest and preservation techniques in order to examine the quality and smoothness of homograft conservation. We analyzed human aortic and pulmonary valve leaflets obtained from 'heart-beating donors' (HBD) during heart transplantation and from 'non-heart-beating donors' (NHBD) during coroner's autopsies. Valves were either cryopreserved in liquid nitrogen or stored at 4 degrees C in nutrient medium similar to the procedure reported in our protocols of the homograft bank system. All grafts from NHBD had been antibiotically sterilized for 3 days beforehand. Morphological observations were made using light and electron microscopy and, in order to characterize the endothelial cell viability, a non-radioactive cell proliferation assay was used. The PGI2 secretion of the remaining endothelium was defined as the 6-keto-prostaglandin F1 alpha metabolite by an enzyme immunoassay. Observations in the scanning electron microscope revealed that, after cryopreservation, homografts show an almost confluent endothelium when processed within 24 h after harvest from HBD, but lack endothelial cells when obtained from NHBD. Cryopreserved grafts from NHBD exhibited an altered tissue structure with edema and vacuolization within the spongiosa of the leaflets as well as irreversible cell damage when examined under the light and transmission electron microscope. That the metabolic activity of HBD homografts was maintained was confirmed by proven PGI2 secretion (6150 +/- 1200 pg/3 ml M199 after cryopreservation), whereas specimens from NHBD showed a reduced (1950 +/- 730 pg/3 ml M199) and, after cryopreservation, almost no release (P < 0.0001).(ABSTRACT TRUNCATED AT 250 WORDS)

Further studies on the effect of meals on electrocardiographic pattern in patients with chronic ischaemic heart disease (angima pectoris) and normal electrocardiogram at rest.

The study included 380 subjects divided into 3 groups. Group I comprised 148 patients with angina pectoris and normal resting ECG. Group II included 172 patients with angina pectoris and ECG changes (52 with changes of the ST-T at rest, 120 patients after myocardial infarction). Group III [control] comprised 60 young healthy volunteers aged 21--24 years. In all subjects the ECG was recorded in the morning before breakfast, and then 30 and 60 min. after breakfast. On the following day, Master's test I was performed in group I and III and when its result was negative, Master's test II was carried out. In patients of group I, ST-T changes developed after meals in 113 cases (76.4%) and after Master's tests in 118 cases [79.7%]. In group II, ST-T changes became more intense in 97 [56.3%]. In the control group, ECG changes developed after meals in one case [1.6%] and after Master's tests in two [3.2%]. It is concluded that ECG examination after meals may be a valuable diagnositc test of ischaemic heart disease in patients with normal resting ECG in the period without anginal attacks when contraindications to Master's tests are present.