Value of transthoracic echocardiography for the detection of high-grade coronary artery stenosis: prospective evaluation in 50 consecutive patients scheduled for coronary angiography.

We prospectively evaluated the feasibility of direct, transthoracic evaluation of coronary arteries to diagnose flow-limiting lesions. Second harmonic mode in B-mode and fundamental mode for Doppler examinations was used. A stenosis was diagnosed when maximal flow velocity at least doubled in comparison with that of the adjacent segment or when local velocity was at least 2 m/s. Of the left anterior descending coronary artery segments assessed, 34 were proximal, 35 middle, and 34 distal segments. The corresponding figures for circumflex coronary artery segments were 17 proximal and 11 middle segments and for the right coronary artery, 14 proximal and 15 distal segments. No distal circumflex and only 1 mid right coronary artery segment was visualized. Twenty-eight stenoses were diagnosed. Specificity for stenosis detection was 96% to 100% and sensitivity was 62% to 66%. Echo-cardiography was unable to document occlusions. Transthoracic echocardiography allows for coronary artery assessment in a significant portion of patients scheduled for coronary angiography. It may be used to document the presence of coronary artery stenosis. With further technologic improvements, transthoracic echocardiography could enable the monitoring of the restenosis process after percutaneous transluminal coronary angioplasty/stent intervention and coronary artery luminal narrowing after heart transplantation.

[Balloon angioplasty of branches of the aortic arch]. / Angioplastyka balonowa duzych galezi luku aorty.

Balloon angioplasty has become a first-line therapy of symptomatic brachiocephalic occlusive disease. We review our own results of treatment of these lesions for the last two years. 16 patients (18 vessels--6 occlusions) with chronic limb ischaemia (9 cases), vertebrobasilar insufficiency (4 cases), ischemic stroke (2 cases); in one case angioplasty was performed as prevention before major abdominal surgery. Femoral approach was predominantly used; in 3 occlusions brachial approach was chosen. Stents were implanted in 4 cases of poor angioplasty result with severe limb ischaemia. Lesions were crossed in all stenoses and in 4 of 6 occlusions. Residual stenosis < 30% was attained in 10 pts. In 11 cases transstenotic gradient was relieved and a normal flow in vertebral artery was reestablished. There were two cases of acute upper limb ischaemia, one needed surgery. Reversible ulnar nerve paresis was noted in one patient, transient symptoms of postreperfusion syndrome in two. At follow up (mean 12 mo, range 1-30 mo) 1 restenosis was recorded. Balloon angioplasty is easy, safe and effective for treating brachio-cephalic stenoses. Recanalisation of occlusions is more difficult and risky. Treatment of stenoses should not be undully postponed; recanalisation should be reserved for patients with more advanced symptoms of the disease.

[Comparison of the clinical course of pneumonia and concentration of immunoglobulin in patients treated with a standard method and with the addition of gmma-venin P]. / Porównanie przebiegu klinicznego zapalenia pluc oraz stezenia immunoglobulin w surowicy krwi u chorych leczonych metoda standardowa i w polaczeniu z Gamma-Venin P.

The therapy with immunoglobulin have been used since many years, although its clinical efficacy still is uncertain. The aim of this study was to compare the clinical course of severe pneumonia and concentration of immunoglobulin in patients admitted to the intensive care units (ICU). The patients were treated either with antibiotics only or with antibiotics and Gamma-Venin P. Investigates group consisted of 30 patients with severe pneumonia. 15 of them (group A) were treated with antibiotics only, and another 15 (group B) with antibiotics and Gamma-Venin P. Immunoglobulins were administrated intravenously in the maximum single dose 3.0 g/kg. The serum concentration of immunoglobulin were measured before and every second day after beginning of the treatment. 27 patients completed the study due to protocol (14 patients in group A and 13 patients in group B). Only two patients revealed sings of intolerance of Gamma-Venin P during the first infusion of immunoglobulin. The clinical course of pneumonia and duration of treatment in ICU were similar in both groups. Statistically significant differences in concentration of immunoglobulins in patients treated without immunoglobulin infusion in comparison with patients with Gamma-Venin P were not found. We conclude, that infusion of immunoglobulins did not improve the clinical course of the severe pneumonia.

Coronary flow reserve and exercise capacity in hypertrophic cardiomyopathy.

The aim of this study was to evaluate the relation of coronary flow velocity (CFV) and coronary flow reserve (CFR) to exercise capacity in ten verapamil-treated patients with hypertrophic cardiomyopathy (HC). Using Doppler transesophageal echocardiography, we assessed diastolic CFV in the proximal left anterior descending coronary artery at baseline and after administering 0.56 mg/kg intravenous dipyridamole. The CFR was calculated as the post-dipyridamole/baseline diastolic CFV ratio. A maximal symptom-limited exercise treadmill test was performed according to a modified Bruce protocol and the exercise capacity was expressed as metabolic equivalents. The mean value for baseline diastolic CFV was 59 +/- 27 cm/s; this increased after dipyridamole to 134 +/- 57 cm/s. The CFR was 2.37 +/- 0.67. Baseline diastolic CFV correlated negatively with both exercise duration (r = -0.69; P < 0.05) and value for metabolic equivalents (r = -0.70; P < 0.05). CFR was weakly and non-significantly related to exercise duration (r = 0.40; P > 0.05) and to the value for metabolic equivalents (r = 0.32; P > 0.05). Shortening of exercise time and decreasing metabolic equivalents were correlated with increased baseline diastolic CFV. Dipyridamole-assessed CFR, was weakly related to parameters of exercise capacity.

Thrombinogenesis and its pharmacological modulation in atherosclerosis.

Appearance of thrombin in circulating blood can be monitored in the clinical setting by measuring specific thrombin markers, such as fibrinopeptide A, thrombin-antithrombin III or prothrombin fragment 1 + 2. In myocardial infarction monitoring of thrombin activity is of growing clinical interest. High levels of thrombin markers indicate an increased risk to a patient with myocardial infarction. Persistent, high thrombin marker levels, despite heparin anticoagulation, point to ongoing thrombin generation that may necessitate more anticoagulation, increased antiplatelet treatment, angioplasty or, in the future, use of new antithrombotic drugs. Recently, new sensitive methods have been developed to study the reaction of thrombin generation in clotting blood. These methods permitted to demonstrate that, aspirin, contrary to several other antiplatelet drugs, delay the process of thrombin formation. Continuous dampening of thrombin formation by aspirin might be one of the mechanisms responsible for its prophylactic and therapeutic efficacy. Hypercholesterolemic subjects might profit less than others from this type of treatment, since aspirin dampening effects are not so evident in hypercholesterolemia.