The value of magnetic resonance imaging of the left ventricular outflow tract in patients with hypertrophic obstructive cardiomyopathy after septal artery embolization.

BACKGROUND: We tested the value of magnetic resonance imaging (MRI) in the follow-up of patients with hypertrophic obstructive cardiomyopathy after septal artery embolization. MRI provides a noninvasive visualization of transplanar turbulent flow in order to quantify left ventricular outflow tract obstruction. METHODS AND RESULTS: We followed 10 patients who were treated with septal artery embolization for 12 months. We used gradient echo sequences to document continuous improvement of the outflow tract area and T1- and T2-weighted spin echo sequences to visualize myocardial infarction. A continuous, but not linear, improvement of the outflow tract area occurred after septal artery embolization during the 12-month follow-up period. The improvement of the outflow tract area correlated well with the amelioration of symptoms (r(2)=0.86). CONCLUSIONS: We conclude that MRI reliably detects the degree of obstruction in patients with hypertrophic obstructive cardiomyopathy. This modality may be especially useful for follow-up after septal artery embolization.

Balloon-protected carotid artery stenting: relationship of periprocedural neurological complications with the size of particulate debris.

BACKGROUND: Carotid artery stenting (CAS) has been advocated as an alternative to endarterectomy. To prevent cerebral atheroembolism during CAS, distal balloon occlusion of the target artery increasingly is employed during the procedure. A correlation of the size of captured particles with the incidence of periprocedural neurological complications (PNCs) has not been attempted. METHODS AND RESULTS: In a 4-center, phase-1 trial, 54 patients (46 men; age, 69+/-8 years) underwent 58 CAS procedures using the PercuSurge GuardWire system for distal protection. Aspirated debris was sent for histological/cytological analysis. Stent placement was successful in all cases. Mean balloon occlusion time was 10.4+/-4.0 minutes (range, 3.0 to 22.0 minutes). Three patients (5.2%) experienced PNCs: 1 prolonged reversible ischemic neurological deficit that resolved in /=10 000 micrometer(2)) were found in 48 aspirates (83%). The median number of particles, their maximum diameter, and their maximum area were all significantly higher in the aspirates obtained during procedures associated with PNCs than in aspirates obtained during procedures not associated with PNCs. However, pronounced overlap in the distributions (PNCs versus no PNCs) of the number and maximum diameter of particles precluded any predictive inferences. In contrast, a maximum particle area >800 000 micrometer(2) (>0.8 mm(2)) was associated with a 60% chance of having a PNC. CONCLUSIONS: Despite balloon protection, PNCs occurred in 5.2% of patients who underwent CAS procedures. The maximum area of aspirated particles seems to be an indicator of increased risk for PNCs.

Sixty-minute alteplase protocol: a new accelerated recombinant tissue-type plasminogen activator regimen for thrombolysis in acute myocardial infarction.

OBJECTIVES: Our aim was to design and evaluate a new and easily administered recombinant tissue-type plasminogen activator (rt-PA) regimen for thrombolysis in acute myocardial infarction (AMI) based on established pharmacokinetic data that improve the reperfusion success rate. BACKGROUND: Rapid restoration of Thrombolysis in Myocardial Infarction (TIMI) grade 3 flow is a primary predictor of mortality after thrombolysis in AMI. However, TIMI grade 3 patency rates 90 min into thrombolysis of only 50% to 60% indicate an obvious need for improved thrombolytic regimens. METHODS: Pharmacokinetic simulations were performed to design a new rt-PA regimen. We aimed for a plateau tissue-type plasminogen activator (t-PA) plasma level similar to that of the first plateau of the Neuhaus regimen. These aims were achieved with a 20-mg rt-PA intravenous (i.v.) bolus followed by an 80-mg i.v. infusion over 60 min (regimen A). This regimen was tested in a consecutive comparative trial in 80 patients versus 2.25 10(6) IU of streptokinase/60 min (B), and 70 mg (C) or 100 mg (D) of rt-PA over 90 min. Subsequently, a confirmation trial of regimen A in 254 consecutive patients was performed with angiographic assessment by independent investigators of patency at 90 min. RESULTS: The comparative phase of the trial yielded, respectively, TIMI grade 3 and total patency (TIMI grades 2 and 3) of 80% and 85% (regimen A), 35% and 50% (B), 50% and 55% (C) and 60% and 70% (D). In the confirmation phase of the trial, regimen A yielded 81.1% TIMI grade 3 and 87.0% total patency. At follow-up angiography 7 (4.1%) of 169 vessels had reoccluded. In-hospital mortality rate was 1.2%. Nadir levels of fibrinogen, plasminogen and alpha2-antiplasmin were 3.6 +/- 0.8 mg/ml, 60 +/- 21% and 42 +/- 16%, respectively (mean +/- SD). Fifty-seven patients (22.4%) suffered from bleeding; 3.5% needed blood transfusions. CONCLUSIONS: The 60-min alteplase thrombolysis in AMI protocol achieved a TIMI grade 3 patency rate of 81.1% at 90 min with no indication of an increased bleeding hazard; it was associated with a 1.2% overall mortality rate. These results are substantially better than those reported from all currently utilized regimens. Head to head comparison with established thrombolytic regimens in a large-scale randomized trial is warranted.

Laser angioplasty of restenosed coronary stents: results of a multicenter surveillance trial. The Laser Angioplasty of Restenosed Stents (LARS) Investigators.

OBJECTIVES: This study evaluated safety and efficacy of excimer laser angioplasty for treatment of restenosed or occluded coronary stents. BACKGROUND: Balloon angioplasty of in-stent restenosis is limited by a high recurrence rate. Debulking by laser angioplasty is a novel concept to treat in-stent restenosis. METHODS: A total of 440 patients with restenoses or occlusions in 527 stents were enrolled for treatment with concentric or eccentric laser catheters and adjunctive balloon angioplasty. RESULTS: Laser angioplasty success (< or =50% diameter stenosis after laser treatment or successful passage with a 2.0-mm or 1.7-mm eccentric laser catheter) was achieved in 92% of patients. Adjunctive balloon angioplasty was performed in 99%. Procedural success (laser angioplasty success followed by < or =30% stenosis with or without balloon angioplasty) was 91%. There was neither a significant difference in success with respect to lesion length, nor were there differences between small and large vessels or native vessels and vein grafts. Success was higher and residual stenosis lower using large or eccentric catheters. Serious adverse events included death (1.6%, not directly laser catheter related), Q-wave myocardial infarction (0.5%), non-Q-wave infarction (2.7%), cardiac tamponade (0.5%) and stent damage (0.5%). Perforations after laser treatment occurred in 0.9% of patients and after balloon angioplasty in 0.2%. Dissections were visible in 4.8% of patients after laser treatment and in 9.3% after balloon angioplasty. Reinterventions during hospitalization were necessary in 0.9% of patients; bypass surgery was performed in 0.2%. CONCLUSIONS: Excimer laser angioplasty with adjunctive balloon angioplasty is a safe and efficient technology to treat in-stent restenoses. These data justify a randomized comparison with balloon angioplasty.

Treatment of carotid artery stenosis by elective stent placement instead of carotid endarterectomy in patients with severe coronary artery disease.

Patients with concomitant cardiac and cerebrovascular disease undergoing revascularization procedures are at high risk of both, cardiac and cerebrovascular complications. The purpose of our study was to evaluate the feasibility of prior elective carotid artery stenting as an alternative treatment procedure to carotid endarterectomy (CEA) in patients with concomitant coronary artery disease (CAD), who clearly needed coronary revascularization. We offered extracranial internal carotid stenting to 85 patients with 89 significant carotid stenoses. Out of these, 19 patients were symptomatic. The quantitative mean reduction in diameter was 77 +/- 11%. Stent implantation was successful in 88 lesions. Two disabling major and 3 reversible minor strokes occurred periprocedurally. Three patients showed asymptomatic restenosis and stent deformation was detected in 2 patients. Based on this experience, carotid stenting in high risk patients with severe coronary artery disease is feasible and safe and might be indicated as an alternative procedure for combined surgery.

Relation between arteriosclerosis in the coronary and renal arteries.

This study analyzes the severity of coronary artery disease in terms of the severity of renal artery disease in 609 patients undergoing coronary and renal angiography. The presence of renal artery disease of any severity is strongly suggestive of advanced coronary artery disease.

[Rare vascular findings in CT of the upper mediastinum]. / Seltene Gefässbefunde im CT des oberen Mediastinums.

The CT findings of malformation of major veins near the heart are described (one case of persistent left superior vena cava and two cases of partial anomalous pulmonary veins) as well as one malformation of the pulmonary artery (vascular sling). These findings demonstrate the vascular character of the lesion and the procedure permits detailed clarification of the abnormality.

[The current value of angiography within the scope of complex tumor diagnosis]. / Gegenwärtiger Stellenwert der Angiographie im Rahmen der komplexen Tumordiagnostik.

The development of noninvasive imaging methods with high diagnostic accuracy in the last decade has led to a new determination of the role of angiographic techniques in oncologic diagnosis. The disadvantages of angiography are discussed and the major indications in tumor diagnosis are delineated: preoperative vascular mapping, vascular involvement of the great vessels, CT and ultrasound equivocal, selective blood sampling and interventional procedures. The increasing importance of interventional radiology in oncology is emphasized.

[Complex angiographic diagnosis of space-demanding processes in the kidney including renocystography]. / Komplexe angiographische Diagnostik raumfordernder Prozesse der Nieren einschliesslich der Renozystographie.

Issuing from the experiences of the complex angiorgraphic diagnostics of space-demanding processes of the kidneys in 400 patients value and sequence of different angiographic methods including renocystography are discussed. The diagnostic certainty in hypo- and avascular tumours by the renal phlebography and in cystic processes is essentially increased by percutaneous puncture. In malignant tumours before operation the judgement of the endovenous extension is always to be demanded, which is most certainly achieved by direct venography. A diagnostic step programme is proposed, to make possible the rational use of the methods.

[Leiomyoblastoma of the stomach]. / Das Leiomyoblastom des Magens.

The leiomyoblastoma of the gastrointestinal tract is a tumour which arises from the smooth musculature. With regard to its malignancy it is between leiomyoma on the one hand and leiomyosarcoma on the other. In 12% of the patients the leiomyoblastoma shows a malignant course. Males somewhat more frequently fall ill with leiomyoblastoma than females (ratio 1.3:1). The average age of the patients is 56.6 years. The most impressive clinical symptom is the gastrointestinal haemorrhage. In an own case problems of therapy are discussed. The mere enucleation of the tumour is not enough for cure. The resection of the stomach, at least of the involved part of the stomach, seems to be necessary.

[Late results following palliative vascular embolization in inoperable kidney tumors. (Preliminary report)]. / Spätergebnisse nach palliativer Gefässembolisierung bei inoperablen Nierentumoren (Vorläufige Mitteilung).

During 18 months in 15 patients with inoperable renal tumours palliative therapeutic vascular embolisations were carried out with the help of an own catheter technique. In contrast to preoperative embolisation (16 patients) in the inoperable cases a non-absorpable polyvinyl alcohol foam substance ("Ivalon") was used, which leads to a secure permanent vascular occlusion. The haematuria occurring in all patients which many times threateningly increased was removed in all cases. There did not appear any essential complications. However, on account of the formation of a symptomatology of renal infarction a clinical after-treatment is necessary. In 12 patients regulary clinical and paraclinical control examinations during an observation period of on an average 11 months were carried out (minimum 6 months, maximum 18 months). 11 of these patients were still alive at the end of the report and had a tolerable or even improved general condition. In angiographical after-controls of 4 patients, and in one case by autopsy, permanent vascular occlusions with formation of necroses of a large area and partly considerable restriction of the tumour kidneys were found. In these cases the therapeutic embolisation led to a provable damage of the tumorous process. An influence of metastases distant from the primary tumour was not observed.

[The place of adrenal angiography (phlebography and arteriography) in the diagnostic stepwise program in arterial hypertension]. / Der Stellenwert der Nebennierenangiographie (Phlebographie und Arteriographie) im diagnostischen Stufenprogramm bei arterieller Hypertonie

Arteriographical and phlebographical methods are distinctly suited for the diagnostics of the adrenal glands in the stop program of the combat against hypertension. Hypervascular tumours of the adrenal medulla, especially phaeochromocytomata may be established arteriographically relatively certainly. Avascular processes of the adrenal cortex, however, are better to be diagnosed by the selective phlebography of the adrenal glands. The phlebography is also suited for the planimetric determination of the size. The following uncorrected normal values were established: on the left m1 = 10.58 +/- 1.17 cm2, on the right m2 = 6.95 +/- 1.39 cm2. The mean value of normal couples of adrenal glands is M = 18.17 +/- 1.96 cm2. The left adrenal gland is statistically significantly larger than the right one (p greater than 0.001). In 214 patients altogether 44 selective arteriographies and 276 selective phlebographies of the adrenal glands were performed. As angiographical basis examination of all patients was at first performed an abdominal aortography or an angiography of the kidneys. The phlebographical diagnostics was successful on the left in 98.7% and on the right in 90.4% of the cases. 72 patients had pathological processes of the adrenal glands, out of them 20 times a solitary adenoma of the adrenal glands was present. 38 patients had a one- or double-sided hyperplasia, and 4 patients had a phaeochromocytoma. In 10 other cases more infrequent changes were found.

[Submicroscopic indication of pathological cell growth in hypertrophic cardiomyopathy (HCM) in humans]. / Submikroskopische Hinweise auf pathologisches Zellwachstum bei hypertrophischer Kardiomyopathie (HCM) des Menschen.

The increasing application of transvascular endomyocardial biopsy for diagnostic verification of various heart diseases and elucidation of their etiology relies mainly on light microscopical methods. It is shown by hypertrophic cardiomyopathy as an example that also submicroscopical findings may be of value in diagnostic work, prognosis, and investigating research for etiological relationships. Specific morphological markers for idiopathic HCM were not demonstrable; nevertheless, some characteristic alterations such as fibrillary disorder, excessive folding of nuclear-, intercalated disc-, and sarcolemmal membranes, contraction bands, accumulation of mitochondria, glycogen, and lipid droplets, among others as well as sometimes the thickening of vascular walls with its unknown relations to the so-called "small vessel disease" may be helpful when endomyocardial biopsies are examined with the electron microscope too. Though many cytomorphologic findings are similar to those in dilatative cardiomyopathy, this disease probably is not a final state of HCM. In order to prove the actual cause of both heart failures, more intensive investigating research especially at the molecular biological level is required.

[Hypertrophic cardiomyopathy with midventricular and subvalvular obstruction in both heart ventricles]. / Hypertrophische Kardiomyopathie mit medioventrikulärer und subvalvulärer Obstruktion in beiden Herzkammern.

Typical (subaortic) and atypical (midventricular or apical) obstructions of both ventricles in HOCM are rare events. This combination could be demonstrated in a 21-year-old female patient by heart catheterization and angiocardiography. Simultaneous registration via 2 catheters in each ventricle showed pressure gradients with two steps in both ventricles: RV apical/RV midventricular 70-100 mm Hg, RV midventricular/subvalvular 25 mm Hg; LV apical/LV midventricular 70 mm Hg, LV midventricular/LV subvalvular 30 mm Hg; no valvular pressure gradients. Morphology of the obstructions is demonstrated by angiography: severe bilateral septal hypertrophy with midventricular systolic obstruction, systolic obstruction of right ventricular infundibulum by hypertrophy of the crista supraventricularis, systolic apical separation in the right ventricle; stenosis of the left ventricular outflow tract by SAM, systolic apical separation in the left ventricle by hypertrophy of papillary muscles.

[Vascular changes in experimental renal ischemia and after renal homotransplantation (experimental angiographic study on animals)]. / Gefässveränderungen bei experimenteller Nierenischämie und nach Nierenhomotransplantation (Eine tierexperimentelle angiographische Studie).

Which consequences result from these experimental results from practice? In the acute angiography in postoperative functional distrubance after transplantation of a human kidney is at first probably always to be reckoned with a rejection process, though this immunological process by no means must be in the foreground of the causal connection of several pathogenetic factors. Therefore, in our opinion it would then be assumed an ischaemia-conditioned cell damage of the tubulus by a longer lasting prefinal circulatory depression or due to a not optimal preservation, when there is in the angiogramme a clear discrepancy to the severity of the postoperative functional distrubance, i.e. when angiographically exists only a slight cortical ischaemia in an otherwise good arterial filling picture and a widely normal capillary filling phase.

[Angiographic studies on regional contraction behavior of the left ventricle in the acute phase of myocardial infarction]. / Angiokardiographische Untersuchungen zum regionalen Kontraktionsverhalten des linken Ventrikels in der Akutphase des Myokardinfarktes.

Quantitative angiocardiographic examinations concerning the regional contraction of the left ventricle in 16 patients with acute myocardial infarction were performed. In comparison to a control group of 6 healthy male patients the determination of the speed of the medium regional shortening (MVRF) of 12 different ventricle segments resulted in typical findings deviating from the normal. On the second day after beginning of the infarction in the area of the myocardium affected by an acute infarction there existed as a rule severe hypokinetic and akinetic disturbances of the contraction (13 times), only in three cases slight paradoxical movements of the ventricular wall (dyskinesias) could be observed. The average speed of shortening of all segments together (MVRF) excellently represents the momentary global function of the ventricle. It comprises in the same way acutely and chronicly disturbed areas as well as also the function of regions of the myocardium which are not disturbed. MV/RF and systolic ejection fraction (SEF) show statistically a highly significant correlation of r = 0,797 (p less than 0.001). On the basis of the findings got considerations are performed concerning a proved differential therapy in the acute stage of the myocardial infarction.

[Stents: new studies--new trends]. / Stents: Neue Studien--neue Trends.

The increasing frequency of stent implantation into coronary arteries is based mainly on assumptions. One of these assumptions is that stents may prevent restenosis. Stents can prevent restenosis as has been shown in two randomized studies (Stress I and Benestent I), but only in large (> 3.0 mm) vessels with short denovo lesions. Despite the very tight selection of patients suitable for stent implantation in these two studies, the advantage for stents remained small (about 10% less restenosis) and appeared to decrease with time following intervention. There is increasing concern about the extension of stenting in an "unrestricted strategy". This concern was expressed in the ACC Expert Consensus Document which was published recently (JACC 28, No 3, September 1996: 782-794). Based on lack of data for most of the presently used stent indications the expert group recommended a more selective strategy for the implantation of stents into coronary arteries.

[Diagnostic contribution of endomyocardial biopsy in suspected latent cardiomyopathy]. / Diagnostischer Beitrag der Endomyokardbiopsie bei Verdacht auf latente Kardiomyopathie.

Twenty-eight patients with suspected diagnosis of latent cardiomyopathy are reported. In all patients left ventricular endomyocardial biopsy (five or more specimens) was performed after noninvasive and invasive investigations. The indication to investigate invasively arose from clinical symptoms in combination with uncertain ECG disturbances. Coronary heart disease, latent myocarditis and latent cardiomyopathy were to be excluded. Hemodynamic parameters proved to be normal or borderline at rest. Angiocardiography and coronary angiography revealed no pathological findings. But in all cases the histological results of endomyocardial biopsy were characterized by pathological criteria as follows: inflammatory myocardial process, narrowing or obliterating diseases of intramural small arteries, exogenous-toxic myocardial disturbances, idiopathic cardiomyopathy, endomyocardial fibrosis with endocardial thrombus and infiltrations of eosinophiles. Four cases are demonstrated as examples.

[Chemoembolization of the hepatic artery combined with intraportal cytostatic infusion--a new concept in the regional chemotherapy of liver metastases]. / Chemoembolisation der A. hepatica kombiniert mit intraportaler Zytostatikum-Infusion--ein neues Konzept für die regionale Chemotherapie von Lebermetastasen.

At present international the regional cytostatic chemotherapy for hepatic metastases is used by the intraarterial way. Newest methods are the technically very pretentious intraarterial perfusion with venous hemofiltration and the chemo-embolization of the hepatic artery requiring meanwhile an adjuvant systemic chemotherapy because the chemo-embolization influences only the arterially supplied part of the metastases. By the combination of the transumbilical intraportal chemotherapy formerly developed in the Central Institute for Cancer Research Berlin-Buch with the intraarterial chemo-embolization it is possible to reduce considerably the technical expenditure and to increase the regional concentration of cytostatics simultaneous avoiding the load of the whole organism. The bases of this new method and the technical procedure are discussed.