[Prevalence of dangerous arrhythmia during pharmacological stress echocardiography]. / Czestosc wystepowania groznych zaburzen rytmu podczas farmakologicznej echokardiografii obciazeniowej.

UNLABELLED: Pharmacological stress echocardiography (SE) has become a routine diagnostic and prognostic method in patients with ischemic heart disease. However, all stress tests can provoke undesirable adverse effects including dangerous arrhythmia. The aim of the study was to access the prevalence and types of arrhythmia that can appear during SE. MATERIALS AND METHODS: A retrospective study included the cohort of patients studied using SE in our Department of Cardiology between 1995 and 2002. We followed the data of 836 patients (pts) (615 men, aged 52 +/- 5 yrs). Dobutamine SE was performed in 695 pts (83.2%) and dipyridamole SE in a group of 141 pts (16.8%). Additionally, atropine was administrated to achieve submaximal heart rate in a group of 694 pts (83%). 519 pts (62%) underwent SE was performed according to high dose protocol and in 317 pts (35%)--low dose protocol. RESULTS: During SE the following arrhythmia events were observed: one persistent ventricular tachycardia (0.12%) and two paroxysmal atrial fibrillation (0.24%) in dobutamine test. The set of unsustained ventricular tachycardia in six patients (0.72%) 5 patients from dobutamine group and 1 from dipyridamole group). Complex forms of ventricular extrasystoles (as bigeminy and trigeminy) in 46 pts (5.5%) 43 in dobutamine SE and 3 in dipyridamole SE. All arrhythmias were mild and withdrew spontaneously or after beta-blockers administration. CONCLUSIONS: The risk of dangerous arrhythmia during either dobutamine SE or dipyridamole SE is small and similar in both groups. Dobutamine SE tends to provoke of mild arrhythmia (p = 0.075) more often.

Effect of amiodarone on mortality after myocardial infarction: a double-blind, placebo-controlled, pilot study.

OBJECTIVES: The goal of this study was to evaluate the effect of amiodarone on mortality, ventricular arrhythmias and clinical complications in high risk postinfarction patients. BACKGROUND: No therapy has been shown to reduce sudden death in patients ineligible to receive beta-adrenergic blocking agents after myocardial infarction. METHODS: Patients who were not eligible to receive beta-blockers were randomized to receive amiodarone (n = 305) or placebo (n = 308) for 1 year. RESULTS: There were 21 deaths in the amiodarone group compared with 33 in the placebo group (odds ratio 0.62, 95% confidence interval [CI] 0.35 to 1.08, p = 0.095). There were two noncardiac deaths in the amiodarone group and none in the placebo group; thus, the difference in cardiac mortality (19 vs. 33, respectively) was statistically significant (odds ratio 0.55, 95% CI 0.32 to 0.99, p = 0.048). There was a significant decrease in Lown class 4 ventricular arrhythmias (7.5% vs. 19.7%, respectively, p < 0.001). Adverse effects developed in 30% of amiodarone-treated patients and 10% of placebo-treated patients. Pulmonary toxicity, which was mild and reversible, occurred in only one patient in the amiodarone group but in no patient in the placebo group. CONCLUSIONS: This trial demonstrated a significant reduction in cardiac mortality and ventricular arrhythmias with amiodarone treatment. However, given the wide confidence intervals and borderline statistical significance of our trial, larger trials are needed to confirm or refute this view.

Right ventricular outflow tract obstruction by cardiac metastasis as the first manifestation of follicular thyroid carcinoma.

A 40-year-old man was sent to the echocardiographic laboratory because of a heart murmur. An intracardiac mass, causing obstruction of flow within right ventricle, was diagnosed and the patient was referred to surgery. Histologic examination classified the mass as a metastasis of highly differentiated follicular carcinoma of the thyroid gland. Thyroidectomy was performed and radioiodine treatment instituted. Thus echocardiographic identification of right ventricular outflow obstructing mass was the initial presentation of follicular carcinoma of the thyroid gland. Early detection of this moderately disseminated malignancy allowed for surgical excision and systemic radioactive iodine treatment.

Ischaemic episodes detected by early exercise test and Holter monitoring after myocardial infarction: which are of most prognostic value?

BACKGROUND: The aim of this study was to assess the significance of ST-segment depressions (ST-SD) detected during exercise test or Holter monitoring and to determine which parameters of ST-SD are the most important prognostic factors in patients after myocardial infarction. METHODS: The study group consisted of 164 patients (126 men and 38 women) who survived their first uncomplicated myocardial infarction. Twenty-four-hour Holter monitoring on day 10 (+/- 2) after infarction and a treadmill exercise test 1 or 2 days later were performed. The following parameters of ST-SD were taken into consideration: amplitude, localization according to the area of infarction and presence or absence of concomitant angina. Patients were observed for 24 months to assess the occurrence of new cardiac events. RESULTS: In 78 patients (group I) ST-SD were detected in both Holter monitoring and the exercise test, and in 32 patients (group II) in the exercise test only. Fifty-four patients (group III) were without ST-SD. During follow-up there were 83 cardiac events in group I, 24 in group II and 16 in group III (P < 0.01, group I versus II; P < 0.0001, group I versus III; P < 0.05, group II versus III). In multivariate analysis the presence of ST-SD during Holter monitoring or the exercise test, or both, appeared to be of most prognostic significance (P < 0.0001). The number of new cardiac events was significantly higher in patients with painful ST-SD greater than 3 mm, detected outside the area of infarction (distant ischaemia). CONCLUSIONS: This study shows a significant prognostic value of early post-infarction ischaemia detected by Holter monitoring and an exercise test. Distant, painful ST-SD greater than 3 mm were more powerful determinants of poor prognosis than others. Electrode placement during Holter monitoring appears to be very important, particularly in post-infarction patients.

Regression of left ventricular dilatation and hypertrophy after aortic valve replacement.

The aim of the study was to assess the influence of aortic valve replacement on left ventricular size and muscle hypertrophy according to the type of preexisting valve disease (aortic stenosis, insufficiency or combined disease). The study group consisted of 143 consecutive patients (pts) after aortic valve replacement (109 men, 34 women, mean age 48.1 +/- 10.9 years). Reason for the operation was aortic stenosis in 35 pts, aortic insufficiency in 64 pts and combined disease in 44 pts. Echocardiography was performed before surgery, 1 month and 1 year after operation, and yearly during 5-year follow-up. Transvalvular aortic pressure gradients decreased significantly after valve replacement in all subsets without further changes during follow-up (Pmax (mmHg): from 54.2 +/- 20.7 to 17.9 +/- 9.6 in combined disease pts, from 72.3 +/- 19.9 to 21.6 +/- 14.6 in aortic stenosis and from 34.5 +/- 24.2 to 15.6 +/- 11.3 in aortic insufficiency pts, respectively, P < 0.0005). One year after surgery the diastolic dimension of the left ventricle decreased significantly in all subjects, whereas the systolic dimension only in aortic insufficiency and combined disease pts (from 44 +/- 11.8 to 31.6 +/- 5.4 mm, P < 0.001 and from 41.9 +/- 11.5 to 33 +/- 6.7 mm, P < 0.05, respectively). Further decrease of both diastolic and systolic dimensions was observed only in the aortic insufficiency group. Ejection fraction of left ventricle increased only in combined disease pts (from 51.6 +/- 10% to 56.8 +/- 8.2%, P < 0.05). Wall thickness of the left ventricle decreased 1 year after valve replacement only in the aortic stenosis group and in further follow-up in the aortic stenosis and combined disease group. Normalization of left ventricular size is observed in more than 90% of patients during 5-year follow-up as opposed to left ventricular muscle hypertrophy, regressed only in less than a half of the study population. In patients with aortic valve disease the greatest hemodynamic improvement is observed 1 year after valve replacement. This is expressed by marked reduction of the left ventricular dimensions and wall thickness, without significant improvement of the ejection fraction. Further regression of left ventricle dimensions occurs in patients operated on due to predominant valve insufficiency, whereas regression of left ventricular hypertrophy is observed in patients with preexisting valvular stenosis.

Early and long-term outcome of aortic valve replacement with homograft versus mechanical prosthesis--8-year follow-up study.

BACKGROUND: Aortic valve disease is an important and frequent clinical problem with a mortality rate as high as 50-80% in a 5-year natural history of patients with severe aortic valve disease. Biological or mechanical prosthesis implantation is the only way to improve prognosis. HYPOTHESIS: The aim of our study was to assess the clinical outcome of aortic valve replacement according to the underlying valve pathology and the type of replacement device, that is, aortic homografts versus mechanical prostheses. METHODS: The study group consisted of 143 patients with a mean follow-up period of 4.1 +/- 2.7 years. All patients had annual clinical and Doppler echocardiographic evaluation. RESULTS: Total 8-year mortality was 4.9% (7/143) including early mortality of 1.4%. Eight-year survival probability was not significantly higher in the homograft than in the mechanical prosthesis recipients. No differences were found among subgroups with aortic stenosis, insufficiency, and combined disease. Overall early and late complication rate (13.3 and 24.8%, respectively) was similar in homograft and mechanical valve recipients. The most common late complications were ventricular arrhythmia (10%) (Lown class I-III), predominantly in the homograft recipients (17.7 vs. 3.7%), and heart failure (9.2%), more frequent in mechanical valve recipients (14.8 vs. 1.6%). Thromboembolic events occurred in 6.3%, infective endocarditis in 4.2% (more common in mechanical valve recipients), serious bleeding in 3.7% (only in mechanical valve recipients). There was no significant difference in early and late complication rate among subgroups (aortic stenosis, insufficiency, and combined disease). Of the patients studied, 91.6% improved in functional status after surgery, with significantly better outcome in homograft recipients. The type of preexisting valve disease did not influence clinical improvement. CONCLUSION: Early and late mortality as well as estimated probability of survival and hemodynamic improvement at 8-year follow-up after aortic valve replacement are independent of the type of implanted valve. Complication rate does not depend upon the type of preexisting valve pathology, but severe late complications are more common after mechanical valve implantation than after homograft implantation.

[Non-Q wave myocardial infarction. Recurrent myocardial infarction, unstable angina and arrhythmia in 8-year observation]. / Zawal serca bez zalamka Q. Czesciej ponowny zawal serca, niestabilna angina pectoris i zaburzenia rytmu w 8 letniej obserwacji.

UNLABELLED: The contradictory views on long term clinical course of patients after non-Q wave myocardial infarction (NQMI) as compared with those after Q wave myocardial infarction (QMI)--induced us to undertake a comparative study of both types of myocardial infarction during a 8 year follow-up. The study was carried out in 400 patients (pts) with NQMI (mean age 51) and 485 pts with QMI (mean age 53). Both groups were compared. We have analysed the following parameters: the dynamics of ischaemic heart disease (unstable angina, reinfarction, arrhythmias, mortality) and coronary arteriography. During 8 year observation unstable angina and arrhythmias, were statistically more frequent in pts after NQMI. Recurrent myocardial infarction occurred in 196 (49%) of pts after NQMI and only in 87 pts (18%) after QMI (p less than 0.001). However, the difference in mortality between both groups was not significant (37% vs 39% respectively). Coronary angiography was performed at 1-6 months after myocardial infarction. In 65% of pts after NQMI detected lesions were limited to proximal part of one or two coronary arteries. CONCLUSION: NQMI is characterized by unstable long-term clinical course, and that is why pts with NQMI should be recommended for early coronary angiography and revascularization.

[HLA histocompatibility antigens in patients with aortic valve defects]. / Antygeny zgodnosci tkankowej HLA u chorych z wadami zastawki aortalnej.

HLA antigens A, B, C were determined in 61 patients with aortic valve disease and in 263 healthy controls. The patients were divided into two subgroups--with rheumatic fever in anamnesis (N = 24) and without (N = 37). In the whole group of patients with aortic valve disease there was a lower frequency of incidence of HLA A3 in comparison to the control group. In the subgroup with rheumatic fever in anamnesis there was a deficit of HLA A3 and a much more frequent incidence of HLA B17, in the subgroup without rheumatic fever a more frequent incidence of HLA A2, A9, A28, B15 was noted in comparison to the control group. This study shows that in 60% of patients with aortic valve disease the etiology is linked not to rheumatic fever but probably to a connective tissue disorder. A deficit of HLA A3 and presence of B17 can be a risk factor for rheumatic fever.

[Transesophageal echocardiograph in the evaluation of proximal segments of coronary arteries]. / Echokardiografia przezprzelykowa w ocenie proksymalnych odcinków naczyn wiencowych.

The study was undertaken to assess the usefulness of TEE for evaluation of morphology and flow in coronary arteries. TEE (2D, spectral and color Doppler imaging) and coronary angiography were performed in 75 patients (pts)-41 with valvular heart disease and 34 with ischemic heart disease. Proximal coronary artery stenosis was detected by coronarography in 11 pts (9--left main coronary artery, 2--right coronary artery). TEE visualization of proximal coronary arteries was possible in all pts. Echocardiographic features of artery stenosis were: the narrowing of the vessel in 2D image (9 pts), high flow velocity spectral Doppler (4 pts, mean 135 cm/s vs 55 cm/s in normal arteries) and mosaic, turbulent flow in color Doppler (10 pts). Sensitivity and specificity of TEE for coronary artery stenosis detection was respectively 81%/98% for 2D imaging and 90%/100% for color Doppler. TEE is a new, noninvasive and safe method for the evaluation of proximal coronary arteries. Detection of LMCA stenosis prior to catheterization may enhance the safety of coronary angiography.

[Immunologic aspects of allogenic valve implantation]. / Immunologiczne aspekty wszczepienia zastawki allogennej.

Immunological response against myocardial antigens was assessed in 12 patients (pts) (9 males, 3 females, aged 24-62 years) with aortic homografts (AH) and 36 pts (29 males, 7 females, aged 26-61 years) with aortic valve prostheses (AVP). In all pts a titre of anti-myocardial antibodies, a concentration of free-circulating immune complexes and leucocytes migration inhibition test with myocardial antigen were assessed before operation and 1, 12, 24 months after operation. In 20 pts with AH immunological humoral response against HLA antigens was evaluated. After the operation pathological indexes of immunological response against myocardial antigens were observed both in pts with AH as in pts with AVP. The mean titre of anti-myocardial antibodies before operation was in both groups between 1:4 and 1:8, and 1 month after operation between 1:32 and 1:64. In 12 and 24 months after operation the mean titre in AH and AVP group was respectively 1:8 and 1:4. Before operation pathological concentration of immune complexes (> 0.084 mg/ml) was observed in 17% AH and 11% AVP pts. Pathological elevation of immune complexes 1, 12 and 24 months after operation was observed respectively in AH and AVP group in 58%, 42%, 33% and 67%, 50%, 42%. Leucocyte migration inhibition index was pathological (< 0.8) before operation in 58% in both groups, and 1, 12, 24 months after operation was pathological in AH and AVP group respectively in 67%, 17%, 17% and 61%, 33%, 31%. In most pts of both groups immunological response against myocardial antigens was transient and was terminated up to 12-24 months after operation.(ABSTRACT TRUNCATED AT 250 WORDS)