[Transmyocardial laser revascularization of the myocardium and coronary reconstruction without extracorporeal circulation]. / Transmyokardiální laserová revaskularizace myokardu a koronární rekonstrukce bez pouzití mimotelního obehu.

The authors report their experience with myocardial revacularization using transmyocardial laser revascularization combined with aortocoronary reconstruction without the use of extracorporeal circulation. The discussion section addresses indications for the procedure, operative tactics, the benefits and limitations of the above technique.

[A system for monitoring hemodynamic data and treatment of arterial hypertension (Part I. Evaluation of long-term results of classical therapy)]. / Systém sledování hemodynamických dat a lécba arteriální hypertenze (cást I.--hodnocení dlouhodobých výsledku klasické lécby).

In 383 hypertonic patients treated for prolonged periods in the classical way (stopped-care-approach) for an average of 12.5 years, all with more than three drugs, the authors used during comprehensive evaluation thoracic electric bioimpedance. In group (0) are 15.9% normotensive subjects, while 84.1% (189 men and 133 women) are divided into groups (III and IV) with 15.4% where treatment failed, into group (II) with controversial therapeutic effect, 32.4%, and group (I) 36.3% where a certain therapeutic effect was achieved. With regard to the reduction of systemic pressure (groups 0 and I), the success of classical treatment could be expressed as 52.2%. Normotensive subjects (41 men and 20 women) were evaluated according to age, pulse index and the index of vascular resistance. Only 40 (10.4%) are normotensive and normodynamic. There are 24 (6.2%) normotensive subjects with a normal index of vascular resistance. In women, contrary to men, independent on the age bracket (under 30 years, 30-60, over 60 years) hyperdynamic conditions predominate 2.9 x. In treated patients with persisting hypertension in groups II to IV the ratio of hypodynamia is increasing. In men there is a relatively greater increase of systemic vascular resistance, however, even in group IV there is a reduced (supernormal) index of systemic vascular resistance. The hyperdynamic syndrome is not a privilege of the young. It can be found also in men and women over 60 years of age.

[A system of monitoring hemodynamic data and treatment of arterial hypertension. (Part II: Evaluation of short-term results of directed therapy)]. / Systém sledování hemodynamických dat a lécba arteriální hypertenze (cást II: zhodnocení krátkodobých výsledku cílené lécby).

Short-term results of aimed treatment (4-6 weeks) in 100 consecutive controls (65 men and 35 women) comprise reduction of systemic hypertension in 80% (as compared with 52.5% in those treated by the classical approach). Normodynamic normotension was achieved in 35% (as compared with 10.5%). Aimed treatment uses available antihypertensive drugs of the main classes, based on clinical examination supplemented by analysis of haemodynamic parameters in the CDDP system.

[Immunogenetic study in hypertrophic cardiomyopathy]. / Imunogenetická studie u hypertrofických kardiomyopatié.

Results of assessment of HLA antigens in hypertrophic cardiomyopathies in the world literature are very controversial. Work dealing with this problem in sufficiently large groups of patients is lacking, i.e. work which takes into account different functional and morphological forms of the disease. The authors made therefore a detailed investigation of 60 class 1 and 2 antigens in 117 patients with this disease. Values of the relative risk and chi 2 test revealed a number of possible associations. After correction for the number of examined antigens a significantly higher prevalence was proved only in HLA-B21 in patients with the obstructive form and in patients with advanced myocardial hypertrophy (thickness of more than 30 mm). Examination of HLA antigens can have in the mentioned cases a certain importance during comprehensive examinations of not quite typical forms of the disease. Carriership of antigen B21 is associated with an increased risk of serious cardiological disease, manifested already in young age.

[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.

An immunogenetic study in hypertrophic cardiomyopathy.

Research of the relevant international literature on HLA studies in patients with hypertrophic cardiomyopathy yielded controversial results. There are no studies, conducted in sufficiently large groups of patients, that would consider the different functional and morphological forms of the disease. Therefore, the authors carried out detailed typing of 60 Class I and II antigens in 117 patients known to suffer from hypertrophic cardiomyopathy. Values of the relative risk and chi-square test showed a number of possible associations. However, after correction for the number of antigens tested, only HLA-B21 was shown to have a significantly high frequency (in patients with the obstructive form and in those with advanced myocardial hypertrophy, defined as a wall thickness greater than 30 mm). An association with this antigen has previously been demonstrated in a number of cases of ischaemic heart disease, myocardial infarction of young people, and in hypertensive subjects. HLA typing may be helpful in recognizing forms which are not fully typical. In Czechoslovakia, HLA-B21 carriers are at increased risk of developing a serious heart disease manifesting already in young age.

[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.

[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.

[The dipyridamole echocardiography test combined with isometric loading in the diagnosis of ischemic heart disease]. / Dipyridamolový echokardiografický test kombinovaný s izometrickou zátezí v diagnostice ischemické choroby srdecní.

The authors compared the sensitivity of the simple dipyridamole test (DP test) and the dipyridamole test combined with an isometric load (DP + HG test). Evaluation by means of two-dimensional echocardiography was used. The sensitivity and specificity of the DP test, in case of a 50% or greater stenosis of one or several coronary arteries, as a criterion of classification of the group was 45% and 100%, as compared with 72% and 100% in the combined DP + HG test. The correct diagnosis was confirmed by a selective reference coronarographic findings in all patients. The electrocardiographic changes alone in both tests were positive for IHD only in 9 and 17% resp. Ergometry was more sensitive (44%) than electrocardiographically evaluated changes, using the mentioned intervention tests, but it did not attain the sensitivity of the echocardiographic evaluation. The work indicates that temporary changes of the regional kinetics evaluated by two-dimensional echocardiography are a highly specific manifestation of myocardial ischaemia which developed during a load, and these changes are detected sooner and more frequently than associated electrocardiographic changes.

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.