Combined first pass and equilibrium radionuclide cardiographic determination of stroke volume for quantitation of valvular regurgitation.

A new noninvasive procedure for quantitation of cardiac valve regurgitation was evaluated using a combination of first pass and gated equilibrium radionuclide cardiography in 38 subjects with and without cardiac valve disease. Left-sided cardiac catheterization was performed to determine the severity of mitral incompetence and aortic regurgitation semiquantitatively. In healthy subjects and in patients without valve disease, stroke volumes were nearly identical with the two methods and the correlation was high (r = 0.98 [p less than 0.001]). The mean regurgitation fraction was 13% in patients with mild mitral incompetence and 2+ aortic regurgitation, 37% in patients with moderate mitral incompetence and 3+ aortic regurgitation and 57% in patients with severe mitral incompetence and 4+ aortic regurgitation. These findings suggest that combined first pass and gated equilibrium radionuclide cardiography, being insensitive to intracardiac shunts and right-sided valve disorders, constitutes a valid noninvasive technique for quantitation of left-sided cardiac valve regurgitation.

Endoscopic ultrasonography and real-time guided fine-needle aspiration biopsy of solid lesions of the mediastinum suspected of malignancy.

STUDY OBJECTIVE: The study details our preliminary experience with endoscopic ultrasonography (EUS) guided fine-needle aspiration biopsy (FNAB) of mediastinal masses suspected of malignancy. DESIGN: Prospective uncontrolled study. PATIENTS: Nine patients had lesions suspected of malignancy ranging from 1 to 9 cm in diameter in various locations of the mediastinum. INTERVENTIONS: The EUS examination was performed with a gastroscope (Hitachi/Pentax FG-32 UA) equipped with an adjustable 5- or 7.5-MHz curved array ultrasonic transducer. The scanning plane is in the long axis of the endoscope allowing endosonographically guided biopsy to be performed. A 21-gauge (0.8 mm), full-length steel needle housed in a biopsy handle (type: Hancke/Vilmann; GIP-Medizin Technik; Grassau, Germany) was used for the biopsies. RESULTS: Nine patients had biopsy specimens taken from 13 lesions. The total number of needle passes was 18 (range, 1 to 3; median, 1.4). The cytologic diagnosis was conclusive for cancer in ten lesions and consistent with a benign lesion in three lesions. All ten malignant diagnoses and two benign diagnoses were confirmed either by operation or follow-up. In the last patient with lung cancer, a final diagnosis of the EUS-guided biopsy of an enlarged lymph node could not be obtained. No false-positive or negative biopsy diagnoses were recorded. The biopsy procedure was well tolerated by all patients, and there were no complications. CONCLUSIONS: EUS-guided aspiration biopsy is a significant advance in the differentiation between malignant and benign lesions of the mediastinum carrying a high diagnostic potential.

Omnipaque and Urografin in left ventriculography and coronary arteriography. A randomised, double blind study.

In order to compare tolerability and radiographic properties of Omnipaque (iohexol) 350 mg I/ml and Urografin (sodium meglumine diatrizoate) 76% (370 mg I/ml) in left ventriculography and coronary arteriography, a randomised, double-blind parallel study was conducted. ECG, heart rate, blood pressure, cardiac output, oxygen saturation, CK-MB, adverse reactions and opacification were recorded. Twenty-five patients received Omnipaque and 24 Urografin and all patients were included in the final material. Omnipaque was found to have less influence on haemodynamics than Urografin. Few adverse reactions were encountered in the entire study, but fewer after injections of Omnipaque than after Urografin. Equally good opacification was demonstrated for both media. Omnipaque was found well suited for cardioangiography and superior to standard ionic media.

[Lymphangioleiomyomatosis]. / Lymphangioleiomyomatosis.

Lymphangioleiomyomatosis (LAM) is a rare disease, which only affects women of childbearing age. A case of LAM in a 36-year-old woman is presented. Patho-anatomical findings are smooth muscle hyperplasia leading to obstruction of lymphatics (possibly resulting in chylothorax), blood vessels (possibly resulting in haemoptysis) and bronchi (possibly resulting in emphysema and pneumothorax). High resolution computed tomography (HRCT) of the chest can show the typical multiple small cysts and bullous emphysema distributed diffusely throughout both lungs together with interstitial fibrosis. Treatment of the disease aims at an inhibition of the presumed growth-promoting effect of oestrogen on the smooth muscle cells. However, progression is often seen in spite of treatment.

[201-thallium myocardial scintigraphy before and after percutaneous transluminal coronary angioplasty]. / 201thallium myokardieskintigrafi før og efter perkutan transluminal koronar angioplastik.

We describe our experience from the first 30 patients treated with percutaneous transluminal coronary angioplasty (PTCA) in the Cardiologic Department P, Gentofte Hospital. The main purpose was to evaluate the value of thallium scintigraphy performed before and three months after PTCA. After PTCA, 23 (77%) had no angina and 22 (73%) had normal exercise-ECG. On the basis of the scintigraphies before PTCA, the patients were divided into two groups: In group 1, five had normal scintigraphy and 14 reversible perfusion defects only. In group 2, all 11 patients had both persistent and reversible defects. In patients without persistent defects, significantly more were free from angina. No difference was observed between group 1 and 2 in percentage stenosis of the vessel or in reduction of the diameter. Significant reduction in the extent of reversible perfusion defects after PTCA was observed in both groups and also in the extent of persistent defects in group 2. In about 1/3 of the patients, the changes in percentage stenosis after PTCA and in the perfusion as judged by the scintigraphies differed. Therefore, as the two methods supplement each other, the main conclusions are: 1) Evaluation of the revascularization procedure is more reliable if a scintigraphy is obtained both before and after PTCA than if only coronary arteriography is performed. 2) Scintigraphy alone suffices for the three-month follow-up examination, partly because it gives better information about the myocardial perfusion than does the arteriography, partly because scintigraphy is a noninvasive procedure.

[A 20-year follow-up of Danish coronary artery bypass patients]. / Tyve års opfølgning af danske koronararteriebypass-patienter.

This study describes the influence of complete revascularization on the long term survival of patients following coronary artery bypass surgery. The patient population consists of 100 consecutive patients discharged from our department after undergoing a coronary bypass operation between November 1973 and July 1978. Patients who survived less than 30 days postoperatively are excluded from the study. The patient population consists of 87 males and 13 females. Mean age was 52.2 years at time of surgery. The rate of revascularization was estimated by coronary angiography, performed between one and 34 months postoperatively, in contrast to other similar studies found in the literature, where such estimation was performed peroperatively. Twenty-five of 86 patients were completely revascularized at postoperative angiographic estimation. Long term survival for the patient population and for the group of completely revascularized patients were compared to the expected survival of the Danish background population (comparable age and sex). Long term survival for the patient population as a whole was similar to that found in similar studies. There was an expected increased mortality compared to the Danish background population.

Development of apical hypertrophic cardiomyopathy.

A 40-year old male patient with a mild, rather diffuse hypertrophic cardiomyopathy (HCM) developed a marked apical hypertrophy of the left ventricle during nine years of observation. The apical HCM showed a characteristic "ace of spades" diastolic configuration on the left ventriculogram. There was no change in the patient's symptoms or haemodynamics. The ECG showed constantly inverted T-waves whereas the precordial QRS amplitude and the corrected QT-interval increased during the observation period. Previous studies have proposed that abortive forms of the apical HCM exist that might become complete later. The present case demonstrates that such a morphological change can take place and that the clinical and haemodynamic picture can be unaffected by the progression of the left ventricular hypertrophy.

Surgery of complex coronary arteriovenous fistula.

A rare type of coronary arteriovenous fistula with multiple supplying vessels from both coronary arteries and draining into the pulmonary artery was found in a 52-year-old woman with angina pectoris. The fistula was successfully closed by division of the vessels draining into the pulmonary artery.

Ruptured arteriosclerotic aneurysm of the splenic artery.

A case of arteriosclerotic aneurysm of the splenic artery with rupture into the transverse colon resulting in secondary perforation of the cecum is presented. Symptomatology, diagnosis and treatment of aneurysms of the splenic artery are briefly illustrated. Aneurysm of the splenic artery must be suspected by the presence of uncharacteristic upper abdominal pain and the annular calcification in the left upper quadrant on roentgenogram. The diagnosis is verified by arteriography. Operation of all symptomatic splenic artery aneurysms is recommended. Asymptomatic aneurysms measuring more than 3 cm in diameter and aneurysms with radiographic evidence of enlargement, should be operated too.

Acute segmental gastro-intestinal gangrene probably of clostridial origin. Report of a case.

A 29-year-old female suffering from acute terminal ileitis was subjected to laparotomy undertaken on the tentative diagnosis of acute appendicitis. The appendix was found to be normal and was removed. The course was complicated with segmental gastro-intestinal gangrene with fatal outcome. The involvement of histotoxic clostridial infection as a causative factor is discussed.

Non-invasive measurement of stroke volume and left ventricular ejection fraction. Radionuclide cardiography compared with left ventricular cardioangiography.

The stroke volume (SV) was determined by first passage radionuclide cardiography and the left ventricular ejection fraction (LVEF) by multigated radionuclide cardiography in 20 patients with ischemic heart disease. The results were evaluated against those obtained by the invasive dye dilution or thermodilution and left ventricular cardioangiographic techniques. In a paired comparison the mean difference between the invasive and radionuclide SV was -1 ml (SED 3.1) with a correlation coefficient of 0.83 (p less than 0.01). Radionuclide LVEF values also correlated well with cardioangiographic measurements, r = 0.93 (p less than 0.001). LVEF determined by multigated radionuclide cardiography was, however, significantly lower than when measured by cardioangiography, the mean difference being 6 per cent (p less than 0.001). These findings suggest that radionuclide determinations of SV and LVEF are reliable. The discrepancy between the non-invasive and invasive LVEF values raises the question, whether LVEF is overestimated by cardioangiography or underestimated by radionuclide cardiography.

Influence of complete revascularization on long-term survival after coronary artery bypass surgery.

To evaluate the influence of complete coronary revascularization after coronary artery bypass grafting (CABG) on long-term survival, we reviewed the records, including reports of coronary angiography, of 198 patients (25 women). Coronary artery bypass grafting was performed in the period 1973-1982, when the patients' mean age was 52.5 years. No significant (p < 0.05) difference in survival in the first 15 postoperative years was found between the patients judged to have complete revascularization at coronary angiography 6 months after CABG and the general Danish population. Complete revascularization by extensive grafting should improve survival of patients treated for angina. If the revascularization remains complete at coronary angiography assessment 6 months postoperatively, the 15-year survival rate can be expected to equal that in the general population.

201-Thallium imaging as an indicator of graft patency after coronary artery bypass surgery.

In a prospective study, forty-one patients underwent myocardial imaging using 201-thallium (201 Tl) scintigraphy before and 6 months after coronary artery bypass grafting (CABG). The results were compared with the findings at coronary arteriography performed at the same time. 201 Tl was injected at peak exercise level performing an exercise scintigram. A thallium image equivalent to a redistribution scan was obtained at rest approximately 4 h after the injection of 201 Tl. The overall angiographic patency rate was 0.77. Postoperative myocardial perfusion was improved in 26 patients (88%) having 72 of 83 grafts patent (patency rate 0.87). New perfusion defects or unchanged ischaemic patterns were found in 5 patients, who had 2 of 13 grafts patent (graft patency 0.15). Estimation of the graft-status by 201Tl-scintigraphy showed a sensitivity, specificity, and predictive value of a positive and negative result of 0.71, 0.94, 0.79 and 0.91, respectively, using angiographic findings as a reference. It is concluded, that comparison between preoperative and postoperative 201Tl imaging of the myocardium at exercise and rest provides useful information on graft patency after CABG. The procedure is superior at exercise and rest provides useful information on graft patency after CABG. The procedure is superior to graft patency estimation based on resting--or postoperative scintigrams only.