Heart transplantation for restrictive cardiomyopathy: development of cardiac amyloidosis in preexisting monoclonal gammopathy.

A 54-year-old woman died 6 months after heart transplantation for treatment of restrictive cardiomyopathy. A monoclonal gammopathy without other signs of malignant disease was present preoperatively, and up to 6 weeks before transplantation no evidence of amyloidosis was established in the rectal, bone marrow, and cardiac specimens. At autopsy there was amyloidosis type AL in the kidneys, bone marrow, liver, spleen, recipient atrium, and donor heart. Retrospectively, the explanted heart also revealed amyloidosis. We conclude that in patients undergoing heart transplantation for treatment of restrictive cardiomyopathy with a preexisting monoclonal gammopathy, a thorough evaluation, including multiorgan biopsy for amyloidosis with electron microscopic workup, should be performed.

Ischemia: reperfusion injury and restenosis after coronary angioplasty.

Percutaneous transluminal coronary angioplasty (PTCA) is a very effective technology that allows, without surgery, successful mechanical revascularization of acutely or chronically obstructed coronary arteries. The success of PTCA in patients with acute myocardial infarction or unstable angina is questioned by early coronary reocclusion and by so-called reperfusion injury. In a biochemical context, reperfusion injury occurs as a very complex interaction between the different tissues that build heart muscle. Free radicals play a pivotal role and initiate a deleterious cascade of events after reperfusion. Protective mechanisms such as superoxide dismutase, glutathione peroxidase, and catalase are normally present in the cell to prevent damage by free radicals. Endothelial cells have a greater number of specific physiologic and metabolic functions and influence the microcirculatory flow. In the presence of exogenous glucose, coronary endothelial cells show a pronounced lactate production under well-oxygenated conditions. Low energy demand and high glycolytic activity may be the cause of why the coronary endothelium is less severely injured than the cardiomyocytes in the ischemic and anoxic heart. The success of PTCA in patients with chronically obstructed coronary arteries (stable angina) is questioned by vessel occlusion and restenosis. Restenosis is a very complex process involving clinical, morphological, procedural, regional flow-dependent, and biological determinants. Early platelet deposition, formation of mural thrombus, coronary vasospasm, and elastic recoil forces of stretched vessel wall may contribute to early restenosis in the first days after PTCA, but the peak incidence of restenosis occurs between two and three months after PTCA. Intimal hyperplasia or proliferation of smooth muscle cells is believed to be the fundamental process of restenosis. To solve the problem of restenosis, much effort has been expended, which includes several technical and pharmacological approaches. Pharmacological strategies, systemically or locally administered, aim at increased vasomotor tone, platelet function, smooth muscle cell proliferation/migration, and fibrocollagenous healing. Up to now none of the proposed drugs has been able to reduce the restenosis rate. There is experimental evidence for a claim that the antioxidant functions of vitamins (E, C, and beta-carotene) may prevent restenosis post-PTCA. Until recently, in most post-PTCA restenosis trials the angiographic analyses were not performed using computerized measurement methods. In order to assess the efficacy of acute or long-term interventions on the natural course or acute complications of coronary artery disease, quantitative measures have been introduced and validated that make use of digital coronary angiography and computerized image processing techniques.(ABSTRACT TRUNCATED AT 400 WORDS)

Anomalous origin of the left coronary artery from the pulmonary trunk with multiple valvar incompetence.

A 63-year-old woman, operated upon for anomalous origin of the left coronary artery from the pulmonary trunk, developed complaints of dyspnea several years later. Echocardiography and angiography showed incompetence of all four cardiac valves. Possible causes of the multiple valvar incompetence are discussed.

Doppler sonographic examination of the internal mammary artery graft: influence of exercise.

With the frequent use and excellent longevity of the internal mammary artery graft, knowledge about the behaviour of this graft under different conditions is becoming relevant. We studied 20 patients with combined two-dimensional and pulsed Doppler sonography before and after exercise testing and established values for peak velocities and flow duration. During exercise flow duration shortened in systole and diastole by the same order of magnitude, while peak diastolic velocity especially increased during exercise.

Grafting with the internal mammary artery: correlation between preoperative angiography and intraoperative findings.

No data exist on the relation between angiography of the internal mammary artery and intraoperative findings during bypass surgery. We studied 47 consecutive patients and found no atherosclerotic changes. Intraoperatively, however, 4 left internal mammary arteries were judged unsuitable for grafting. No relation could be found to the diameter of the vessel as judged angiographically. Possible causes of unsuitability are discussed.

Combined two-dimensional and Doppler echographic examination of internal mammary artery grafts from the supraclavicular fossa.

The noninvasive examination of internal mammary artery grafts is gaining importance with the increasing use of this vessel in the surgical treatment of coronary atherosclerosis of the left anterior descending artery. We studied 36 patients (37 internal mammary artery grafts) with combined two-dimensional and pulsed Doppler echography from the supraclavicular fossa. Adequate visualization and Doppler signals were obtained in 95% of arterial grafts. Twenty-four grafts leading to an area without evidence of old myocardial infarction or ischemia and 10 grafts leading to an area of old myocardial infarction but without evidence of ischemia on exercise showed a significant decrease of the peak systolic velocity and of the peak systolic velocity/peak diastolic velocity ratio as compared to the controls, which consisted of the contralateral internal mammary arteries in situ. One patient with a distally subtotally occluded mammary artery graft had a flow pattern different from the other bypassed mammary arteries. It seems that combined two-dimensional and pulsed Doppler echography is a useful method to evaluate the functional status of internal mammary artery grafts.

Early diastolic left ventricular function as a marker of acute cardiac rejection: a prospective serial echocardiographic study.

Changes in left ventricular early diastolic time intervals are sensitive indicators of incipient left ventricular dysfunction. We tested the hypothesis that acute rejection in cardiac transplant recipients is associated with alteration of early diastolic myocardial function, as expressed by the time interval Te, a parameter derived from digitized M-mode echocardiograms. Te is defined as the time interval between maximal posterior wall contraction and the point of peak posterior wall endocardium retraction velocity, as determined by the nadir of the computed first derivative curve. In transplant patients without rejection (group A, n = 48), Te was prolonged compared to healthy individuals (group C, n = 35) (79.0 +/- 12.5 ms vs 64.0 +/- 7.9 ms; p < 0.0001). During acute rejection (group B, n = 18) transplant patients had significantly longer mean Te values compared to transplant patients without rejection (group A) (97.8 +/- 17.9 ms vs 79.0 +/- 12.5 ms; p < 0.0001). Longitudinal studies in individual patients (group D, n = 18) demonstrated that rejection is associated with prolongation of Te (94.5 +/- 16.0 ms during rejection vs 79.0 +/- 10.3 ms before rejection; p < 0.0002) and that Te returns to individual baseline values in response to treatment (79.2 +/- 9.4 ms after therapy vs 79.0 +/- 10.3 ms before rejection; NS). In a prospective study, Te changes in transplant patients (group E, n = 96) were correlated with myocardial biopsy results. Sixty-one biopsies showed acute rejection, and 115 biopsies were negative.(ABSTRACT TRUNCATED AT 250 WORDS)

Enoximone therapy as pharmacological bridging to cardiac transplantation.

Keeping pre-transplant patients alive while waiting for a suitable donor is still a major challenge. New pharmacological agents which can provide improved hemodynamics are urgently needed in patients with severe heart failure who are on the waiting list for cardiac transplantation. Intravenous enoximone therapy (an initial 0.5 mg/kg bolus, then 1.25-5.0 mcg/kg/min infusion) was administered to 35 transplant candidates with progressive heart failure despite optimal drug regimen including digoxin, diuretics, and ACE-inhibitors. In 18 out of 35 patients complete hemodynamic, echocardiographic, neurohumoral, and Holter-ECG studies were performed before and 24 hours after intravenous enoximone infusion. Patients were then continued on chronic oral therapy of 100 mg twice a day. Enoximone infusion increased the cardiac index (CI) (1.78 +/- 0.45 l/min/m2 vs 3.04 +/- 0.83 l/min/m2; p < 0.001) and stroke volume index (SVI)(22.33 +/- 9.45 ml/m2 vs 32.28 +/- 7.29 ml/m2; p < 0.05) and decreased wedge pressure (PCP)(24.1 +/- 11.98 mmHg vs 17.78 +/- 8.76 mmHg; p < 0.05) while mean arterial pressure (MAP) was unchanged. Left ventricular ejection time (LVET)(225.1 +/- 26.9 ms vs 242.2 +/- 25.8 ms; p < 0.05) was increased whereas other echocardiographic parameters were unchanged (Left ventricular end-diastolic dimension LVEDD, left ventricular end-systolic dimension LVESD, fractional shortening FS, early diastolic relaxation parameter Te). Plasma neurohumoral parameters did not change (Aldosterone, epinephrine, renin, atrial natriuretic factor) except for a significant drop in norepinephrine (936.7 +/- 443.2 pg/ml vs 522.4 +/- 287.6 pg/ml; p < 0.05). Holter-ECG parameters (ventricular premature beats VPB, couplets, ventricular tachycardia VT) were not influenced by enoximone infusion.(ABSTRACT TRUNCATED AT 250 WORDS)

[Transient loss of preexcitation by acute coronary ischemia--a case report]. / Passagerer Präexzitationsverlust durch akute koronare Ischämie--eine Kasuistik.

We present a case of WPW syndrome with an accessory pathway in the right free wall. Two prolonged and failed attempts at radiofrequency catheter ablation of this accessory pathway in other institutions led to a third attempt in our hospital. With a 7F catheter in the right coronary artery, transient ischemia in the right ventricular myocardium developed with consecutive loss of bidirectional preexcitation within 45 seconds prior to catheter ablation. Removal of the guiding catheter, while the mapping catheter in the coronary artery was still in place, was reproducibly followed by the reoccurrence of the preexcitation pattern. Successful outcome of accessory pathway ablation was achieved by mapping the right free wall using an intracoronary catheter in the right coronary artery and ablating the accessory pathway using a modified long vascular sheet.

Experiences with different computerprograms for the ECG-analysis.

As the use of computers for ECG-analysis has left the stage of laboratory investigation, and different systems are offered by industrial firms with high grade promises concerning their reliability, it seemed about time to perform an evaluation of the programs available. Each ECG of 252 adult patients was recorded in one session from adhesive electrodes within 10 minutes on the magnetic tapes of the data-acquisition-units of four different manufacturers. The computer-analysis of each of these ECGs was done by six programs of Pordy (Mt. Sinai-Hospital, New York), Caceres, Smith (Mayo Clinic, Rochester), Arvedson, Riedl with modified criteria of the USPHS and Riedl with criteria of the Minnesota-code. Besides this each ECG was also analysed in the conventional way by each of the three cardiologists involved in this study. The results of the computers' and the physicians' analysis concerning rhythm, extrasystoles, infarctions and ST-T-segment-variations are demonstrated and discussed.

Internal mammary artery bypass grafting in left main stenosis.

Internal mammary artery grafting to the left anterior descending artery gives higher long-term patency and improved survival as compared with venous grafts. Few data exist on the operative mortality and infarction rate in coronary artery bypass surgery when using this type of graft in high-risk groups, such as patients with left main stenosis. In 19 months, we studied 81 consecutive patients with left main stenosis who received a mammary artery graft to the left anterior descending artery as well as vein grafts to other vessels and found no excessive mortality or infarction rate. We suggest that patients with left main stenosis should be treated with an internal mammary artery graft.

Doppler sonographic examination of the internal mammary artery graft: comparison of supraclavicular and high intercostal signals.

In a group of 22 patients, Doppler signals from the proximal part of the internal mammary artery graft were studied from the supraclavicular fossa as well as from the high intercostal spaces. An adequate signal was found more often from the supraclavicular position. Both positions showed higher peak systolic than peak diastolic velocities. Transition of the flow to the typical coronary flow pattern with higher peak diastolic velocity seems to occur in lower parts of the graft.

[Prevalence of intimal pathogen burden in acute coronary syndromes]. / Prävalenz von intimalem Pathogen burden bei akutem Koronarsyndrom.

Increasing evidence supports a link between serological evidence of prior exposure to infectious pathogens, pathogen burden, and the risk for future myocardial infarction and death in patients with coronary artery disease. Based on this concept, we evaluated the intimal presence of four pathogens in human coronary atheroma, clinically associated with acute coronary syndromes (ACS) and stable angina (SA), and the effect of pathogen burden on the expression of human heatshock protein 60 (hHSP60), a key protein in (auto-)immune pathogenesis of atherosclerosis. Coronary atherectomy specimens retrieved from 53 primary target lesions of patients with ACS (n=33) or SA (n=20) were assessed immunohistochemically for the presence of Chlamydia pneumoniae (C. pn.), Helicobacter pylori (H.p.), Cytomegalovirus (CMV) and Epstein-Barr Virus (EBV), and for the expression of hHSP60. Chlamydia pneumoniae was present in 74%, Helicobacter pylori in 32%, CMV in 13% and EBV in 42%. Exclusively C.pn. revealed a prevalence in ACS (91%) vs SA (45%; p<0.001). Immunohistochemical analysis revealed 6 lesions without, 21 lesions with 1, 17 lesions with 2, 6 lesions with 3 and 3 lesions with 4 infectious agents. As an important finding, the mean value in ACS lesions was significantly increased compared to those in SA (1.9 vs 1.1; p<0.01). ACS-subgroup analysis revealed the highest mean value in patients with pain at rest within the last two days (Braunwald class III). In addition, expression of hHSP60 was significantly higher in ACS (8.7%) compared to SA (1.3%; p<0.001). Pathogen burden correlated highly significant (p<0.01) with the expression of hHSP60 (r=0.44).Our data demonstrate the impact of intimal pathogen burden in plaque instability, and suggest the presence of (auto-)immunoreactions against upregulated hHSP60 as an important pathomechanism that may contribute to acute coronary syndromes.

[Planimetric quantification of aortic valve stenoses using multiplanar transesophageal echocardiography]. / Planimetrische Quantifizierung von Aortenklappenstenosen mittels multiplaner transösophagealer Echokardiographie.

Standard techniques used in order to quantify the severity of aortic valve stenoses in clinical practice comprise: transthoracic echocardiography, namely, by determining maximum and mean transvalvular gradients and evaluating aortic valve areas, as well as invasive techniques which quantify aortic valve areas through hemodynamic pressure measurements and application of the Gorlin formula. Since the introduction of the multiplane TEE technique, it has become feasible to scan the aortic valve in a strictly horizontal plane and quantify the aortic valve orifice by planimetry. In this study, we investigated 23 patients with various degrees of aortic valve stenoses. We compared aortic valve areas, which had been planimetrically determined by multiplane TEE scans, and mean aortic valve gradients (standard TEE technique) with pressure gradients and valve areas derived from hemodynamic measurements obtained during cardiac catheterization, and have found that the valve areas as well as the mean pressure gradients correlate well.