[Atresia of the aortic arch. A rare cause of asymmetrical arterial hypertension in adulthood]. / Atresie des Aortenbogens. Seltene Ursache der asymmetrischen arteriellen Hypertonie im Erwachsenenalter.

HISTORY AND CLINICAL FINDINGS: A 58-year-old man, previously resident in Russia, was known since the age of 18 years to have arterial hypertension of unknown cause in only the right arm. A single syncope was the only previous symptom. On examination the pressure was 230/110 mmHg in the right arm, 150/100 mmHg in the left one. The pulse in the right arm and neck was strong and heaving, that in the left arm and the legs much more weakly palpable. INVESTIGATIONS: Electrocardiogram and echocardiogram showed left ventricular hypertrophy. The chest radiogram demonstrated rib notching. Digital subtraction angiography revealed aortic arch atresia just distal to the common carotid artery. No other cardiovascular abnormalities were found. TREATMENT: The patient declined operative treatment. Cautious antihypertensive drug treatment with Atenolol (25 mg daily) reduced the pressure in the right arm to 180/90 mmHg. CONCLUSION: This rare malformation of aortic arch atresia should be considered in the differential diagnosis of asymmetrical arterial hypertension in an adult.

[Coronary angiography with a 5F catheter after percutaneous puncture of the right brachial artery. Technique and experience in 70 patients]. / Koronarangiographie mit 5-F-Kathetern nach perkutaner Punktion der rechten Arteria brachialis. Technik und Erfahrung bei 70 Patienten.

Out of a total of 1640 consecutive left heart catheterizations, 70 (58 males and 12 females; mean age 56 +/- 8 years) were performed via the right brachial artery, in most instances because of occlusive disease of the arteries in the pelvic region. 5F catheters were then successfully used for both the coronary and left-ventricular angiographies. Noninvasive examinations after two days (Doppler ultrasound, oscillography at rest and on exercise, acral plethysmography and colour-coded duplex sonography) revealed small haematomas in the region of the arterial puncture in four and a haemodynamically insignificant fistula between brachial artery and vein in one patient but no aneurysm, stenosis or thrombosis at the puncture site. This procedure is thus a valuable addition to invasive cardiological diagnosis.

Acute and long-term haemodynamic and neurohumoral response to nisoldipine vs captopril in patients with heart failure: a randomized double-blind study.

To study the haemodynamic and neurohumoral effects of nisoldipine (2 X 10 mg) vs captopril (3 X 25 mg), 24 patients with heart failure (New York Heart Association class II and III) due to coronary artery disease were treated in a randomized double-blind trial over 3 months. Both drugs were well tolerated. Clinical status was similarly improved in both groups, nisoldipine exerted an additional antiischaemic effect. Nisoldipine lowered the mean arterial pressure and capillary wedge pressure acutely and also after long-term treatment. The increase in cardiac index and stroke volume index, however, which was pronounced after acute administration, was no longer present after 3 months of therapy at rest and was abolished during exercise. Norepinephrine plasma concentration increased after the first dose, plasma renin activity did not change, and aldosterone plasma concentration showed a small insignificant decrease. Urine concentrations of norepinephrine and vasopressin were slightly elevated after the 3-month therapy. After captopril, mean arterial pressure and pulmonary capillary wedge pressure decreased acutely and at follow up. Cardiac index and stroke volume index increased significantly only during exercise at follow-up. Plasma renin activity was significantly elevated and aldosterone plasma concentration only slightly lowered. In contrast to what was seen with nisoldipine, plasma norepinephrine concentration and urine catecholamine and vasopressin concentrations remained unchanged. In conclusion, the pronounced haemodynamic effects seen after the first dose of nisoldipine are mostly abolished after long-term treatment, probably due to neurohumoral counterregulation. The haemodynamic response to captopril is complete only after long-term treatment, without evidence of activation of the neurohumoral systems.

Role of transmitral blood flow velocity by Doppler echocardiography in the evaluation of coronary artery disease.

To determine the relation between presence and severity of coronary artery disease and diastolic filling abnormalities by Doppler echocardiography, recordings of transmitral inflow velocity were made at rest in 90 patients with coronary artery disease and 28 normals. At the time of the Doppler examination, 81 patients with coronary artery disease (90%) and 10 normals (36%) were treated with antianginal medications. No difference was found in the ratio between early (E) and late (A) diastolic filling velocity (E/A ratio) when comparing patients with greater than 70% obstruction of at least one coronary artery to age-matched normals, regardless of the presence or absence of wall motion abnormalities. The E/A ratio was 1.3 +/- 0.46 in coronary patients with normal wall motion, 1.2 +/- 0.47 in coronary patients with abnormal wall motion, and 1.3 +/- 0.53 in both samples of age-matched normals. Multivariate analysis of the relation between E/A ratio and other variables showed that heart rate (F = 24.46, p less than 0.00001) and age (F = 19.51, p less than 0.00001) were significant independent determinants of the E/A ratio, while the presence or severity of coronary artery disease, the presence of hypertension, the magnitude of wall motion abnormalities, and end-diastolic dimension by echocardiography were not. These data suggest that transmitral inflow velocity recordings by Doppler have limited value for the recognition of coronary artery disease, since the E/A ratio is profoundly influenced by other factors, such as heart rate and age.

[Comparison of the acute hemodynamic effect of nisoldipine (Bay k 5552) and nifedipine in patients with ischemia-induced left ventricular impaired function]. / Vergleich der akuten hämodynamischen Wirkung von Nisoldipin (Bay k 5552) und Nifedipin bei Patienten mit ischämisch bedingter linksventrikulärer Funktionsstörung.

Calcium channel blockers of the dihydropyridine type have different sites of action that may cause negative inotropic effects in some patients; therefore, their use as systemic vasodilators in left heart failure may be limited. In 10 patients with coronary heart disease we compared the acute peripheral and central hemodynamic effects of i.v. nisoldipine vs. i.v. nifedipine intraindividually, using a sequential crossover protocol. All patients were subjected to right heart catheterization, arterial pressure monitoring, and simultaneous radionuclide angiography. The infusion of either calcium channel blocker was titrated to a similar steady-state reduction of mean arterial pressure by 15 +/- 3% and 15 +/- 2%, respectively, which reduced systemic vascular resistance by 25 +/- 5% and 17 +/- 2%, respectively. The required equally effective dosage was 0.17 +/- 0.06 micrograms/min/kg for nisoldipine and 0.58 +/- 0.1 micrograms/min/kg for nifedipine. In contrast to nifedipine, the administration of nisoldipine was associated with an increase in cardiac index by 0.45 +/- 0.33 l/min/m2 (p less than 0.05), stroke volume index by 3.91 +/- 3.0 ml/m2 (p less than 0.05), and left ventricular ejection fraction by 4.6 +/- 2.8% (p less than 0.05). Mean pulmonary capillary wedge pressure decreased with nisoldipine from 11.8 +/- 3.4 to 8.0 +/- 3.4 mm Hg (p less than 0.005) and mean pulmonary artery pressure decreased from 20.4 +/- 4.06 to 16.1 +/- 3.2 mm Hg (p less than 0.005), but was unaffected by nifedipine. Left and right ventricular endsystolic and enddiastolic volumes were not significantly altered by either drug.(ABSTRACT TRUNCATED AT 250 WORDS)

Comparison of the acute hemodynamic response to intravenous nisoldipine (Bay k 5552) and intravenous nifedipine for left ventricular dysfunction secondary to myocardial infarction.

Dihydropyridine calcium blocking drugs exert potentially dangerous negative inotropic action in selected patients with severe left ventricular dysfunction. In 10 patients peripheral and central hemodynamic effects of nisoldipine were intraindividually compared with nifedipine using a sequential crossover protocol. The drugs were titrated to a similar steady-state reduction of mean arterial pressure by 15 +/- 3% and 15 +/- 2% and systemic vascular resistance by 25 +/- 5% and 17 +/- 2%, respectively. The equi-effective dosage was 0.17 +/- 0.06 microgram/min/kg for nisoldipine and 0.58 +/- 0.1 microgram/min/kg for nifedipine. In contrast to nifedipine, administration of nisoldipine was associated with increases in cardiac index of 0.45 +/- 0.33 liters/min/m2 (p less than 0.05), stroke volume index of 3.91 +/- 3.0 ml/m2 (p less than 0.05) and left ventricular ejection fraction of 4.6 +/- 2.8% (p less than 0.05). Mean pulmonary capillary wedge pressure decreased with nisoldipine from 11.8 +/- 3.4 to 8.0 +/- 3.4 mm Hg (p less than 0.005) and mean pulmonary arterial pressure from 20.4 +/- 4.06 to 16.1 +/- 3.2 mm Hg (p less than 0.005); these variables were unaffected by nifedipine. Thus, intraindividual comparison revealed no cardiodepressive action of nisoldipine, whereas with nifedipine the conceptually beneficial effect of afterload reduction appears to be offset by intrinsic negative inotropic action. Due to higher vasospecificity and more effective unloading, nisoldipine appears to be superior to nifedipine in patients with left ventricular dysfunction secondary to ischemic heart disease.

[Thrombi in the left atrial appendage in mitral defects despite adequate anticoagulation. The advantages of transesophageal echocardiography]. / Thromben im linken Herzohr bei Mitralvitien trotz adäquater Antikoagulation. Vorteile der transösophagealen Echokardiographie.

Thrombi in the left atrium are a frequent complication of mitral valve disease accompanied by left atrial enlargement. It is often difficult to recognize abnormal structures in this area with sufficient reliability by conventional transthoracic cross-sectional (2-D) echocardiography. Diagnosis is almost impossible with thrombi in the left atrial appendage. Transesophageal echocardiography presents a useful alternative. By this means thrombi in the left atrial appendage were diagnosed in seven of 24 patients with mitral stenosis on adequate anticoagulation, transthoracic 2-D echocardiography having given negative results. At subsequent valve replacement the results of transthoracic echocardiography were confirmed in all cases.

Transesophageal two-dimensional echocardiography for the detection of left atrial appendage thrombus.

Thrombi located in the left atrial appendage are frequently not detected with conventional two-dimensional echocardiography. The transesophageal echocardiographic approach readily visualizes left atrial morphology and may be used as an alternative. In 6 of 21 patients with mitral valve stenosis, a left atrial appendage thrombus was diagnosed by transesophageal two-dimensional echocardiography when transthoracic echocardiography had failed. The transesophageal echocardiographic findings were confirmed at surgery for mitral valve replacement in all cases.