Spinal and cortical activity-dependent plasticity following learning of complex arm movements in humans.

Activity-dependent plasticity is a fundamental requirement for human motor learning, which takes place at several stages of the motor system and involves various mechanisms in neuronal circuitry. Here, we investigate parameters of cortical and spinal excitability before and immediately after a single session of locomotion-like arm training (LMT) or sequential visuo-motor learning (VMT). Both training paradigms focused especially on mainly activating the flexor carpi radialis muscle (FCR). The activity-dependent change in the excitability of FCR-associated neurons was investigated using standard transcranial magnetic stimulation, including analysis of motor-evoked potentials (MEP) amplitude, short-interval intracortical inhibition and intracortical facilitation (ICF). Furthermore, spinal plasticity was also assessed by means of homosynaptic FCR H-reflex depression (HD). LMT decreased HD and ICF. In contrast, VMT had no significant effect on cortical and spinal parameters. There was a nonsignificant tendency of an increase in MEP amplitudes after both interventions. This implies that human locomotor-related learning involves spinal mechanisms. Despite the decreasing importance of quadrupedal coordination in the course of evolution, these changes in transsynaptic plasticity may reflect a persisting locomotor memory-encoding function in the spinal circuitry of the human upper extremities. Evaluating FCR HD might be helpful for the evaluation and development of locomotor rehabilitation strategies.

[Functional magnetic stimulation as a supposedly 'painless' option for movement induction in plegics]. / Funktionelle Magnetstimulation als "schmerzlose" Variante der künstlichen Bewegungsinduktion bei Lähmungen.

BACKGROUND: It is known in the rehabilitation of central pareses that functional electrical stimulation (FES) of the muscles can induce movement and accomplish training in patients. The main limitations of this method are that patients with preserved sensation experience pain and the reflexes triggered by FES. Therefore the application of the largely "painless" magnetic stimulation (FMS) of the muscles would be a potential alternative in the rehabilitation of patients with partially preserved sensation. As the generation of high force and power levels is considered to be an essential requirement of effective rehabilitation strategies, we have shown in previous work that FMS with large surface magnetic coils fitted to the thigh can generate about 2.5 times higher isometric forces in patients with preserved sensation, than can FES. OBJECTIVES: The goal of the present pilot study was to prove that the mechanical power generated by functional magnetic stimulation is superior to that produced by electrical stimulation too. METHODS: We have measured the mechanical torque, the power, the accomplished work and the kinematics in 4 healthy control subjects, who performed pedalling propelled by FMS and FES until complete muscular exhaustion, using a cycling test-bed under isotonic conditions (constant resistance). RESULTS: We have proved that the generated work, mean power, cadence and smoothness of pedalling essentially depend on peak torque and power. Furthermore, we found evidence that smoother pedalling could be achieved using magnetic, compared to electrical stimulation because of the higher peak torques that were generated by FMS. CONCLUSION: This study supports the concept that peripheral magnetic stimulation is an appropriate rehabilitation method for patients with central pareses and preserved sensory apparatus because FMS is less painful than electrical stimulation.

FES-propelled cycling of SCI subjects with highly spastic leg musculature.

BACKGROUND: The presence of spasms precludes the use of artificial electrical activation of the muscles to restore mobility. The prospect of using an electrical stimulus that produces motor activation without causing unwanted reflex activation in patients with high levels of spasticity is an appealing one. OBJECTIVE: The purpose of the study was to determine the efficacy of modulated middle frequency alternating current (MFAC) muscle stimulation compared to the conventional method of standard low frequency rectangular pulse (LFRP) stimulation used in cycling of persons with spinal cord injury (SCI) and pronounced spasticity. METHODS: To evaluate cycling-relevant differences between stimulation modes, 13 subjects with SCI (ASIA-A), 11 of them with strong spasticity, underwent isometric and cycling measurements using both 20 Hz LFRP and 4 KHz modulated with 50 Hz MFAC. The isometric long-lasting reflex torque response in the quadriceps and hamstrings muscles, and the dynamic work during 1000 sec of ergometric cycling as well as the number of involuntary stops caused by hyperreflexia were recorded. RESULTS: The long-lasting reflex torque response was significantly lower when using MFAC than with LFRP stimulation. During MFAC stimulation work generated was on average 374% higher (p = 0.002) and the number of involuntary stops was on average 32% lower (p < 0.001) than during standard LFRP stimulation-propelled cycling. CONCLUSION: These findings suggest that MFAC-stimulated cycling of strongly spastic SCI subjects is more effective in terms of generated isometric torque and power than stimulation with LFRP. Thus, more health benefits, e.g., cardiovascular and muscular training and spasticity-decreasing effects, can be expected faster using MFAC instead of LFRP in stimulation-propelled cycling.

Functional electrical stimulation assisted cycling of patients with subacute stroke: kinetic and kinematic analysis.

BACKGROUND: Cycling is a safe and functionally effective exercise for patients with early post-stroke and poor balance. Such exercise is considered even more effective when functional electrical stimulation is added. Our principal aim was to determine the biomechanically quantifiable parameters of cycling that can be improved in patients with subacute hemiparesis by incorporating functional electrical stimulation. These parameters were defined as objective goals that can be achieved in clinical applications. A secondary aim was to determine whether they could be used to identify subjects who would benefit from such therapy. METHODS: Using a tricycle testbed, we tested 39 subacute (mean 10.9 weeks post-stroke (SD 5.9)), hemiplegic subjects. During isometric measurements we recorded volitional and electrically evoked crank torques, the latter at maximal tolerable intensity. During ergometric measurements, volitional pedaling was alternated with combined pedaling (volitional supported by stimulation), performed at 30-s intervals. Power, smoothness, and symmetry of cycling were evaluated. FINDINGS: Twenty-six percent of the subjects significantly improved the smoothness of their cycling with functional electrical stimulation. Only 8% and 10% significantly increased their power and symmetry, respectively. The improvement in smoothness significantly correlated with the capability of the individual to generate electrical torque (Spearman's rank correlation coefficient=0.66 at P=0.001). INTERPRETATION: The smoothness of cycling was the most sensitive parameter improved by functional electrical stimulation. This improvement depended on the amount of torque evoked, and the torque achieved, in turn, correlated with the tolerated intensity of stimulation.

Delayed rectifier potassium current in undiseased human ventricular myocytes.

OBJECTIVE: The purpose of the study was to investigate the properties of the delayed rectifier potassium current (IK) in myocytes isolated from undiseased human left ventricles. METHODS: The whole-cell configuration of the patch-clamp technique was applied in 28 left ventricular myocytes from 13 hearts at 35 degrees C. RESULTS: An E-4031 sensitive tail current identified the rapid component of IK (IKr) in the myocytes, but there was no evidence for an E-4031 insensitive slow component of IK (IKs). When nifedipine (5 microM) was used to block the inward calcium current (ICa), IKr activation was fast (tau = 31.0 +/- 7.4 ms, at +30 mV, n = 5) and deactivation kinetics were biexponential and relatively slow (tau 1 = 600.0 +/- 53.9 ms and tau 2 = 6792.2 +/- 875.7 ms, at -40 mV, n = 7). Application of CdCl2 (250 microM) to block ICa altered the voltage dependence of the IKr considerably, slowing its activation (tau = 657.1 +/- 109.1 ms, at +30 mV, n = 5) and accelerating its deactivation (tau = 104.0 +/- 18.5 ms, at -40 mV, n = 8). CONCLUSIONS: In undiseased human ventricle at 35 degrees C IKr exists having fast activation and slow deactivation kinetics; however, there was no evidence found for an expressed IKs. IKr probably plays an important role in the frequency dependent modulation of repolarization in undiseased human ventricle, and is a target for many Class III antiarrhythmic drugs.

The slow component of the delayed rectifier potassium current in undiseased human ventricular myocytes.

OBJECTIVE: The purpose of this study was to investigate the properties of the slow component of the delayed rectifier potassium current (I(Ks)) in myocytes isolated from undiseased human left ventricles. METHODS: The whole-cell configuration of the patch-clamp technique was applied in 58 left ventricular myocytes from 15 hearts at 37 degrees C. Nisoldipine (1 microM) was used to block inward calcium current (I(Ca)) and E-4031 (1-5 microM) was applied to inhibit the rapid component of the delayed rectifier potassium current (I(Kr)). RESULTS: In 31 myocytes, an E-4031 insensitive, but L-735,821 and chromanol 293B sensitive, tail current was identified which was attributed to the slow component of I(K) (I(Ks)). Activation of I(Ks) was slow (tau=903+/-101 ms at 50 mV, n=14), but deactivation of the current was relatively rapid (tau=122.4+/-11.7 ms at -40 mV, n=19). The activation of I(Ks) was voltage independent but its deactivation showed clear voltage dependence. The deactivation was faster at negative voltages (about 100 ms at -50 mV) and slower at depolarized potentials (about 300 ms at 0 mV). In six cells, the reversal potential was -81.6+/-2.8 mV on an average which is close to the K(+) equilibrium potential suggesting K(+) as the main charge carrier. CONCLUSION: In undiseased human ventricular myocytes, I(Ks) exhibits slow activation and fast deactivation kinetics. Therefore, in humans I(Ks) differs from that reported in guinea pig, and it best resembles I(Ks) described in dog and rabbit ventricular myocytes.

The cellular electrophysiologic effect of a new amiodarone like antiarrhythmic drug GYKI 16638 in undiseased human ventricular muscle: comparison with sotalol and mexiletine.

The cellular electrophysiologic effect of GYKI 16638, a new antiarrhythmic compound was studied and compared with that of sotalol and mexiletine in undiseased human right ventricular muscle preparation by applying the conventional microelectrode technique. GYKI 16638 (5 microM), at stimulation cycle length of 1000 ms, lengthened action potential duration (APD(90)) from 338.9 +/- 28.6 ms to 385.4 +/- 24 ms (n = 9, p > 0.05). This APD lengthening effect, unlike that of sotalol (30 microM), was rate-independent. GYKI 16638, contrary to sotalol and like mexiletine (10 microM), exerted a use-dependent depression of the maximal rate of depolarization (V(max)) which amounted to 36.4 +/- 11.7% at cycle length of 400 ms (n = 5, p < 0.05) and was characterised with an offset kinetical time constant of 298.6 +/- 70.2 ms. It was concluded that GYKI 16638 in human ventricular muscle shows combined Class IB and Class III antiarrhythmic properties, resembling the electrophysiological manifestation seen after chronic amiodarone treatment.

18F-FDG PET studies in patients with extratemporal and temporal epilepsy: evaluation of an observer-independent analysis.

UNLABELLED: The aim of this study was to evaluate an observer-independent analysis of 18F-fluorodeoxyglucose (FDG) PET studies in patients with temporal or extratemporal epilepsy. METHODS: Twenty-seven patients with temporal epilepsy and 22 patients with extratemporal epilepsy were included in the study. All patients with temporal epilepsy and 7 patients with extratemporal epilepsy underwent surgical treatment. In patients who showed significant postoperative improvement (temporal, n = 23; extratemporal, n = 6), the epileptogenic focus was assumed to be located in the area of surgical resection. In extratemporal epilepsy patients who did not undergo surgery, the focus localization was determined using a combination of semiology, ictal and interictal electroencephalography, [99mTc]ethyl cysteinate dimer SPECT, MRI and [11C]flumazenil PET. Visual analysis was performed by two experienced and two less experienced blinded observers using sagittal, axial and coronal images. In the automated analysis after anatomic standardization and generation of three-dimensional stereotactic surface projections (SSPs), a pixelwise comparison of 18F-FDG uptake with an age-matched reference database (n = 20) was performed, resulting in z score images. Pixels with the maximum deviation were detected, summarized and attached to one of 20 predefined surface regions of interest. For comparison with 18F-FDG PET and MR images, three-dimensional overlay images were generated. RESULTS: In patients with temporal epilepsy, the sensitivity was comparable for visual and observer-independent analysis (three-dimensional SSP 86%, experienced observers 86%-90%, less experienced observers 77%-86%). In patients with extratemporal epilepsy, three-dimensional SSP showed a significantly higher sensitivity in detecting the epileptogenic focus (67%) than did visual analysis (experienced 33%-38%, each less experienced 19%). In temporal lobe epilepsy, there was moderate to good agreement between the localization found with three-dimensional SSP and the different observers. In patients with extratemporal epilepsy, there was a high interobserver variability and only a weak agreement between the localization found with three-dimensional SSP and the different observers. Although three-dimensional SSP detected multiple lesions more often than visual analysis, the determination of the highest deviation from the reference database allowed the identification of the epileptogenic focus with a higher accuracy than subjective criteria, especially in extratemporal epilepsy. CONCLUSION: Three-dimensional SSP increases sensitivity and reduces observer variability of the analysis of 18F-FDG PET images in patients with extratemporal epilepsy and is, therefore, a useful tool in the evaluation of this patient group. The benefit of this analytical approach in patients with temporal epilepsy is less apparent.

Fatty acid peptide derivatives as model compounds to protect elastin against degradation by elastases.

Peptide sequences which fit the extended binding sites of porcine pancreatic elastase and human leukocyte elastase were covalently coupled to oleic acid. These compounds behave as competitive inhibitors towards both elastases. The coupling of fatty acid moiety to the peptide greatly decreases its inhibitor constant (Ki) vs human leukocyte elastase (Ki for Oleoyl(Ala)2ProValine: 3.0 (10(-6)M). It is less active on porcine pancreatic elastase (Ki for Oleoyl(Ala)2ProAlanine: 3.8 10(-4)M). The modifications of the carboxylic end group of the peptide to an aldehyde further greatly enhanced the inhibition capacity of the compound towards leukocyte elastase (Ki for Oleoyl(Ala)2ProAlaninal: 0.7 microM). Oleoyl peptide derivatives were seen to bind in a saturable fashion to purified insoluble elastin, and decreased the susceptibility of the macromolecule to hydrolysis by both pancreatic and leukocyte elastases. As stoichiometric quantities of elastase (vs inhibitor) could not desorb 3H-oleoyl(Ala)2Pro-Val bound to insoluble elastin, it is postulated that oleoyl peptide derivatives may act as bifunctional agents. This contention was further strengthened by the comparison of the adsorption curves of elastase to untreated insoluble elastin and elastin saturated with oleoyl peptide derivatives respectively. It was shown finally that Oleoyl(Ala)2Pro-Valine was also capable of inhibiting elastases in their adsorbed form to insoluble elastin.

Nucleoside transport inhibition mediates lidoflazine-induced cardioprotection during intermittent aortic crossclamping.

The effects of pretreatment with the nucleoside transport inhibitor lidoflazine on repeated ischemia-reperfusion injury induced by normothermic intermittent aortic crossclamping were studied in canine hearts. Eighteen mongrel dogs were allocated to three groups: placebo (n = 6), lidoflazine (1 mg/kg) (n = 6), and lidoflazine (1 mg/kg) plus the adenosine receptor blocker aminophylline (7 mg/kg) (n = 6). Pretreatment was performed intravenously during 15 minutes before extracorporeal circulation. All hearts were subjected to four intervals of 15 minutes of global ischemia each followed by 10 minutes of reperfusion. After weaning from extracorporeal circulation, functional recovery was followed for 1 hour. In the lidoflazine group, myocardial adenosine content (0.25 +/- 0.06 mumol/gm dry weight) was 3.5 times higher than that in the control group (0.07 +/- 0.03 mumol/gm dry weight; p < 0.05) at the end of the last aortic crossclamping. The release of adenosine from the myocardium during each reperfusion period was significantly higher than that in the control group (p < 0.05). Myocardial extraction of lactate was normalized at every reperfusion interval in the lidoflazine group but not in the control group (p < 0.05). In the lidoflazine group functional recovery was significantly better than that in the control group. Positive rate of rise of pressure, negative rate of rise of pressure, and cardiac output recovered to, respectively, 150% +/- 19%, 82% +/- 8%, and 131% +/- 15% in the lidoflazine group versus, respectively, 37% +/- 9%, 23% +/- 7%, and 29% +/- 8% in the control group (p < 0.001) at 1 hour after extracorporeal circulation. When the adenosine receptor blocker aminophylline was administered in association with lidoflazine, protection dropped significantly: positive and negative rate of rise of pressure and cardiac output were, respectively, 58% +/- 8%, 46% +/- 9%, and 67% +/- 16% at 1 hour after extracorporeal circulation (p < 0.05 versus lidoflazine alone). These results suggest that the cardioprotective effects of lidoflazine are at least in part mediated by adenosine receptor stimulation via nucleoside transport inhibition-induced accumulation of endogenous adenosine in the myocardium.

Determinants of early and late results of combined valve operations and coronary artery bypass grafting.

BACKGROUND: Factors determining the outcome of operative correction of valvular abnormalities combined with coronary artery bypass grafting are still incompletely defined. METHODS: Determinants of early and late (more than 90 days) deaths and event-free survival were studied for combined valve operations and coronary artery bypass grafting in 741 patients using multivariate analysis. RESULTS: Ninety-day survival probability was 89% (95% confidence interval, 87% to 92%). Preoperative risk factors for early death were age, female sex, renal failure, New York Heart Association class IV or V, and mitral insufficiency. The operative risk factor was the duration of aortic cross-clamping. Five- and 10-year survival probabilities were 74% (95% confidence interval, 71% to 78%) and 43% (95% confidence interval, 36% to 50%), respectively. Preoperative risk factors for late death were age, preoperative renal failure, New York Heart Association class IV or V, vessel disease, and nonsinus rhythm. Five- and 10-year event-free survival probabilities were 57% (95% confidence interval, 53% to 61%) and 23% (95% confidence interval, 17% to 28%), respectively. Preoperative risk factors for non-event-free survival were age, female sex, reduced left ventricular function, mitral regurgitation, and pacemaker rhythm. CONCLUSION: The demographic factors of age and female sex; the comorbid condition of renal failure; the cardiac conditions of advanced New York Heart Association class, left ventricular function, mitral regurgitation, vessel disease, and cardiac rhythm; and the operative condition of ischemia time are the most important predictors of clinical outcome after combined valve operations and coronary artery bypass grafting.

Binding characteristics and analgesic activity of D-ALA2-Leu5-enkephalin chloromethyl ketone.

The chloromethyl ketone derivative of D-Ala2-Leu5-enkephalin (DALECK) was synthesized and its potency was tested in competing for 3H-naloxone binding sites and inducing analgesia. It was established that the compound is a potent affinity reagent at alkaline pH, blocking selectively and irreversibly the high-affinity (KD less than 1 nM) binding site. Intracisternally given DALECK showed a long-lasting, dose-dependent antinociceptive effect in the rat tail-withdrawal test. This could be completely antagonized by naloxone administration showing the reversible nature of DALECK in this in vivo assay. It is suggested that DALECK binds reversibly to the morphine receptor which mediates analgesia but irreversibly to the enkephalin receptor, the function of which remains to be elucidated.

Aortic and mitral valve replacement with the Carpentier-Edwards pericardial bioprosthesis: mid-term clinical results.

Between May 1st 1985 and December 31st 1992, 283 Carpentier-Edwards pericardial valves were implanted in 260 patients in the aortic (n = 196), mitral (n = 41) and both aortic and mitral (n = 23) positions at the Gasthuisberg University Hospital in Leuven, Belgium. Patients undergoing tricuspid valve replacement or mixed replacement with another type of prosthesis were excluded from this study. The mean age was 70 +/- 7 years, there were 121 males and 139 females. The mean follow up was 40.55 months, the total follow up experience 10543 months (878.6 patients years). Hospital mortality was 10.4%, and was not significantly related to the position of the valve: 17.3% +/- 7.88% (n = 23) for double valve replacement, 10.2% +/- 2.16% (n = 196) for aortic valve replacement and 7.3% +/- 4.06% (n = 41) for mitral valve replacement. Hospital mortality was 14.1% +/- 3.27% for those with and 7.48% +/- 2.5% for those without concomitant coronary surgery (p = NS). Survival at 92 months was 63% +/- 6% and was not significantly related to the position of the valve. Not a single patient needed to be reoperated because of primary tissue failure. We conclude that the mid-term durability of this valve is excellent and consider the Carpentier-Edwards pericardial valve as the stented bioprosthesis of choice both in the aortic and mitral positions for the elderly. Because of the older age of our study population and the medium term length of follow up, we were unable to draw any conclusions concerning the incidence of calcific degeneration of this valve.

Mitral valve surgery combined with coronary bypass grafting: multivariate analysis of factors predicting early and late results.

Total of 123 patients (mean age: 63.8 +/- 7.3 years, (male/female 65/35 percent) underwent mitral valve surgery combined with coronary artery bypass grafting during a seven year period. Preoperatively 12% of them belonged to NYHA functional class II, 54% to class III, 29% to class IV and 3% was operated under emergency conditions. The mitral valve lesion was most frequently either ischaemic (45%) or rheumatic (33%) in origin. Left ventricle function was moderately decreased in 18% and severely damaged in 3% of the patients as documented by preoperative ventriculography. Coronary surgery was performed in all cases with an average number of distal anastomosis of 2.2 +/- 1.1 per patient. The hospital mortality was 13%. Risk factors for early and late mortality were determined by univariate and multivariate analysis. Advanced preoperative functional class and decreased left ventricular function or ischaemic etiology were identified as significant risk factors for early mortality. The patients were followed for an average of 33 +/- 25 months. The majority of them experienced significant functional improvement postoperatively with 69% belonging to NYHA class I or II. The late survival for the 107 hospital survivors was 94.7% at one year, and 84.7% at five years, respectively. Late survival was independently determined by preoperative functional class or previous myocardial infarction. Freedom from ischemic and valve related complications at five years was 95% and 71.2% respectively. 58.2% of the hospital survivors were in functional class I or II and free of any valve related or ischemic complications at the end of the fifth follow up year.(ABSTRACT TRUNCATED AT 250 WORDS)

Combined valve and coronary artery bypass surgery: early and late results.

Determinants of early, late and event-free survival of combined valve and coronary artery bypass graft (CABG) surgery were studied in 420 patients using multivariate analysis. It was found that the risk of hospital death increases 5 times when the preoperative NYHA class was > or = IV, 3 times when left ventricular (LV) function is significantly impaired and is double when mitral regurgitation is present. The survival probability of hospital survivors was 91% (87.3-94.5%) at 5 years. Late mortality was determined by advanced preoperative NYHA class ( > or = IV) and the presence of mitral regurgitation. The event-free survival probability of hospital survivors, i.e. total events including death, valve-related complications, ischemic complications and recurrent NYHA class > or = IV, was 73.0% (66.7-79.5%) at 5 years. Postoperative events were determined by the presence of preoperative NYHA class > or = IV, impaired ventricular function, mitral regurgitation and non-sinus rhythm. It is concluded that these parameters can be considered as the most important predictors of clinical outcome after combined valve and CABG surgery.

Time course of serum Lp(a) in men after coronary artery bypass grafting.

The serum Lp(a) time course was studied in 100 male patients who underwent coronary artery bypass grafting (CABG). The patients were randomized in a placebo (N = 50) and pravastatin treated (N = 50) group. The pravastatin regimen was 10 mg daily from the third postoperative day on and 20 mg daily after 1 week during 11 weeks. Lp(a) levels and serum lipids were analyzed at baseline, at 3 and 10 days, and at 4 and 12 weeks post-CABG. A decrease of serum Lp(a) levels at the third postoperative day was seen which parallels the changes noted with the other serum lipids when using extracorporeal circulation. In contrast with the other serum lipids, a slight but significant Lp(a) overshooting was noticed at day 10 followed by a decrease of the serum Lp(a) levels to preoperative levels 1 month after the acute event. The study clearly depicts that there is a significant time-dependent effect on the serum Lp(a) levels post-CABG and that there is no effect of treatment (pravastatin). The data also reveal that reliable postoperative Lp(a) measurements can be made at earliest 1 month post-CABG.

Time course of serum lipid and lipoprotein levels after coronary bypass surgery: modification by pravastatin.

The time course of the changes in serum lipid and lipoprotein levels have been studied in 100 patients undergoing coronary artery bypass surgery. Marked decreases occur in the levels of cholesterol (-45%), HDL-cholesterol (-35%), LDL-cholesterol (-53%), Apo A1 (-43%) and Apo B (-43%) on the third day after the operation. In the control group the values gradually returned to preoperative levels which are reached after three months. Three months after the intervention, in the pravastatin-treated group (20 mg/day) the values of total cholesterol (-20%), LDL-cholesterol (-28%) and Apo B (-22%), remained significantly lower than in the control group (p 0.0001) and were lower over the whole duration of the study. The postoperative time course of HDL-cholesterol and Apo A1, however, was not significantly influenced by the administration of pravastatin.

[Direct revascularization of the myocardium using the internal mammary artery]. / A szívizom direkt revascularisatiója az arteria mammaria interna felhasználásával.

The best graft in coronary bypass operations is the internal mammary artery (IMA) as its rate of staying open for long term is better than that of the vena saphena magna. The authors present the operative and postoperative results of their first 161 patients who were subjected to IMA grafting. 126 were men and 35 women of the patients and the average age was 50.2 years. Before the operation the majority of the patients belonged to NYHA III state (69.6%). 86 patients (53.4%) had myocardial infarction before the operation, 50.3% were operated on because of 3 blood vessel diseases and the stricture of the main trunk was confirmed in 12.4%. 128 patients underwent only coronary bypass operation, in the others thrombendarterectomy (17 patients), valvular operation (11 patients) and resection of the left ventricular aneurysma (5) were carried out simultaneously. The IMA graft was placed in the majority of the cases on the LAD (70.8%) or as a sequential anastomosis on the LAD-diagonal system (21.1%). The average number of peripheral anastomoses was 2.8 anastomoses patient. 2.5% was the rate of early mortality (4 patients), reoperation was performed in 10 cases because of bleeding or tamponade and perioperative infarction occurred in 8 cases. 3.1% was the rate of late mortality (5 patients). The average follow-up examination time was 12.7 months (3-39 months). At the postoperative examinations 88.8% of the patients were free of angina and 108 patients got into NYHA I state after the operation. Of the 43 control bicycle ergometric examinations 35 were negative and 8 positive.(ABSTRACT TRUNCATED AT 250 WORDS)

[Risk assessment and measuring the need for revascularization on the basis of residual ischemia by means of dobutamine stress echocardiography in the early phase of the first myocardial infarction]. / A kockázat meghatározása és a várható revascularisatiós igény felmérése residualis ischaemia kimutatása alapján az elsö acut myocardialis infarctus korai fázisában dobutamin stressz echocardiographia segítségével.

The aim of this study is to present a modern method which can be used in the early phase of myocardial infarction. Its results show that with the detection of residual ischaemia, valuable information can be gained concerning the progression of the disease and the claim to revascularisation. During the first week (2-7 days), the authors performed risk assessing dobutamine stress echocardiography in 52 nonselected acute patients with first myocardial infarction. Patients with negative results were regarded as low risk cases 35/52 (67.3%), while those with positive results were regarded as high risk cases 17/52 (32.7%). The number of the serious postinfarction hard events was 22/52 (42.3%) during the one-year following period. In the case of the positive group, during mainly the first three months the occurrence of such events was found to be extremely high: 16/17 (94.1%), while in the case of the negative group it was only 6/35 (17.1%). On the basis of the test results it can be stated that coronarography was performed in 14/17 (82.4%) vs. 3/35 (8.6%) of the cases, and revascularisation in 10/17 (58.8%) vs. 1/35 (2.9%) of the cases. In 2/17 (11.8%) vs. 3/35 (8.6%) of the cases, the patients suffered from acute coronary syndrome and the mortality rate was 2/17 (11.8%) vs. 1/35 (2.9%). The sensitivity value was 79.1%, the specificity value 90.6%, and the positive and negative predictive values 86.3% and 85.3%. There was no such significant complication detected which could be attributable to the examination. On the basis of the results and corresponding to the data in special literature, the authors found the dobutamine stress test a good and safe prognostical method even some days after the infarction. With the help of this method the high and low risk groups of patients can be separated early, and at the same time the claim to revascularisation in the first three months can be measured too.

[Effect of acute aprotinin (Gordox) therapy on hemostasis in heart surgery patients, with special reference to hyperfibrinolysis]. / Az akut aprotinin (Gordox) terápia hatása a haemostasisra szívsebészeti betegekben, különös tekintettel a hyperfibrinolysisre.

Authors have studied the effect of Gordox-therapy on haemostasis after open heart surgery in a prospective clinical trial. Thirty seven patients (pts) undergoing cardiac surgery due to their valve disease were randomly assigned either to control-group (20 pts) or to Gordox-group (17 pts). The patients in the Gordox group were given Gordox according the following scheme: 2 M IU within 20 min. after induction of anaesthesia followed by 0.5 M IU/hour infusion until the end of the operation. One M IU also was given into the oxygenator before starting the extracorporeal circulation. The postoperative chest tube drainage was less in Gordox-group (534 +/- 260 ml vs. 987 +/- 583 ml, p less than 0.005), and donor blood and fresh frozen plasma requirement was also lower in this group (534 +/- 633 ml vs. 935 +/- 718 ml p less than 0.05; 70 +/- 153 ml vs. 211 +/- 245 ml p less than 0.05, respectively). There was no significant difference between the two groups concerning the postoperative activated partial thromboplastin time, prothrombin time, thrombin time values. The authors could document significantly higher fibrinogen concentration and significantly lower fibrinolytic activity postoperatively in the Gordox-group (p less than 0.05). Gordox therapy has advantageous effect on haemostasis after open heart surgery which can be documented both by clinical and laboratory examination.