[Mastery of conflictual relationship patterns in the course of a psychodynamic focal therapy]. / Meisterung konflikthafter Beziehungsmuster im Verlaufe einer psychodynamischen Fokaltherapie.

Mastery is a psychological construct rooted in the psychodynamic psychotherapy research. The Mastery Scale provides a reliable content analytic method to measure the mastery of maladaptive interpersonal conflicts. With the help of model-sentences verbatim transcripts of relationship episodes are assessed regarding to six hierarchical so-called levels: lack of impulse-control, introjection and projection of negative emotions, difficulties in understanding and cognitive control, interpersonal consciousness, understanding of the self and self control. Further, mastery capabilities can be quantified by a mastery score. For the first time, the instrument is introduced in German by a study of a rather well known successful psychodynamic short-term psychotherapy which previously has been investigated with several empirical methods. The results verify the possibilities of the Mastery Scale in subtly describing changes in the course of a psychotherapy.

Quantitative assessment of the operative results after extended myectomy and surgical reconstruction of the subvalvular mitral apparatus in hypertrophic obstructive cardiomyopathy using dynamic three-dimensional transesophageal echocardiography.

OBJECTIVES: The aim of this study was to examine the value of dynamic three-dimensional (3D) transesophageal echocardiography (TEE) for the postoperative evaluation after extended myectomy and surgical reconstruction of the subvalvular mitral valve apparatus in patients with hypertrophic obstructive cardiomyopathy (HOCM). BACKGROUND: Two-dimensional imaging techniques such as echocardiography, computed tomography and magnetic resonance imaging have not been able to precisely quantify the effects of surgical therapy on the morphology of the left ventricular outflow tract (LVOT). METHODS: Multiplane TEE with 3D reconstruction was performed in 11 patients before and after the operation and in 16 normal control subjects for comparison. The preoperative maximal systolic pressure gradient in the LVOT was 69 +/- 59 mm Hg. The following variables were measured within the dynamic 3D data set: depth, width, length and cross-sectional area (CSA) gain caused by the myectomy trough, minimal CSA of the LVOT at each time point and its cyclic changes and maximal mitral leaflet deviation during systole. RESULTS: Functional class improved from 3.0 +/- 0.2 before the operation to 1.5 +/- 0.6 after it. The maximal systolic pressure gradient in the outflow tract decreased to 26 +/- 21 mm Hg postoperatively (p < 0.001). Minimal CSA of the outflow tract increased from 1.1 +/- 1.2 to 3.8 +/- 1.9 cm2 postoperatively (p < 0.001), similar to the value of the control group (4.2 +/- 1.5 cm2, p = NS). The area gain due to the myectomy trough was 1.3 +/- 1.0 cm2, corresponding to 48 +/- 12% of the total operative area difference. Maximal systolic depth of the myectomy was 7 +/- 2 mm, maximal width was 20 +/- 8 mm and length was 28 +/- 7 mm. Maximal deviation of the mitral leaflets fell from 15 +/- 7 to 6 +/- 7 mm postoperatively (p < 0.01). In five patients mass measurements of the intracavitary portion of the papillary muscle (PM) revealed an increase from 7.3 +/- 1.0 to 12.1 +/- 2.5 g due to surgical mobilization of PMs (p < 0.01). CONCLUSIONS: 3D TEE quantifies the differences in outflow tract morphology before and after surgery for HOCM. This technique may have an impact on the planning of operative interventions and allow for the evaluation of its results.

Quantitative analysis of the morphology of secundum-type atrial septal defects and their dynamic change using transesophageal three-dimensional echocardiography.

BACKGROUND: A noninvasive method for the determination of size and spatial relationships of atrial septal defects to adjacent cardiac structures, which would be advantageous to those contemplating device closure, is described. The aim of the study was to examine the value of transesophageal three-dimensional echocardiography for this purpose. METHODS AND RESULTS: Three-dimensional reconstruction of transesophageal two-dimensional echocardiography was performed in 17 patients. Left-to-right shunt (by oximetry in 16 of 17 patients) was 2.4 to 16.2 L/min, and the Qp/QS ratio was 1.4 to 4.7. The defect area of the atrial septal defect was measured throughout the whole cardiac cycle each 40 ms from the three-dimensional data set. Results were compared with shunt parameters by oximetry and with intraoperative measurements. Distances between atrial septal defect and mitral and tricuspid annulus and the orifices of the caval and pulmonary veins were also measured. The atrial septal defect area ranged from 0.2 to 2.4 cm2 (diastole) to 0.5 to 5.6 cm2 (systole). The maximal area at end-systole was 108% of the area at beginning of systole, and the minimal area at end-diastole was 43%. The defect area correlated significantly with the Qp/QS ratio (r=.70), and the maximal atrial septal defect diameters as measured by using three-dimensional echocardiography correlated well with intraoperative measurements (r=.87). Distances to mitral and tricuspid annulus and to the superior caval vein were determined in all patients. Distances to orifice of the inferior caval vein were measured in 12 patients, and orifices of right pulmonary veins were visible in 5 patients. CONCLUSIONS: Transesophageal three-dimensional echocardiography of atrial septal defects allows the determination of the instantaneous defect area and its dynamic changes and thus provides valuable information about the distances to adjacent cardiac structures. This may have clinical implications for the selection of patients suitable for interventional closure and for the assessment of procedural success.

[Quadricuspid aortic valve: diagnosis by multiple transesophageal echocardiography]. / Quadrikuspide Aortenklappe: Diagnose durch multiplane transösophageale Echokardiographie.

The case of a quadricuspid aortic valve diagnosed in adult age is reported. A 67-year-old patient, who had no previous diseases or cardiovascular complaints, presented in the clinic for an embolic occlusion of the left retinal artery. Isolated moderate aortic regurgitation was diagnosed clinically and echocardiographically. For its further evaluation and for seeking embolic sources, multiplane transesophageal echocardiography was performed, which discovered a quadricuspid aortic valve as the cause of aortic regurgitation and major atherosclerotic lesions in the ascending aorta and the aortic arch as possible cause of the embolic event. The fourth, accessory cusp, smaller than the other three, was localized between the non-coronary and left coronary cusp. In the short axis view the quadricuspid aortic valve showed in diastole a "X"-configuration, with a persistent central orifice between the commissures, which was the cause of the regurgitation jet in color Doppler examination, and in the systole a trapezoid opening pattern. In the long-axis view the valve showed a tricuspid closing pattern. The quadricuspid aortic valve can be exactly diagnosed by multiplane transesophageal echocardiography.