Long-term intravenous infusion of antiarrhythmic drugs using a totally implanted drug delivery system.

In vitro and in vivo testing was performed to establish the feasibility of a totally implantable pump system to deliver antiarrhythmic agents. In vitro flow characteristics suggested predictable day to day delivery with acceptably small variations in flow with changes in reservoir volume or temperature. During 3 months of in vitro testing, procainamide and bretylium were found suitable for long-term delivery. Delivery of lidocaine was limited by high viscosity and corrosion of steel elements within the pump. The pump was implanted in a subcutaneous pocket in four dogs. Procainamide (0.5 g/ml), delivered at 4 ml/day (70 mg/kg body weight per day), provided a mean steady state drug concentration of 5.3 micrograms/ml. Bretylium (50 mg/ml), delivered at 8 ml/day (13 mg/kg per day), provided a steady state concentration of 0.8 micrograms/ml (range 0.4 to 1.4). Long-term intravenous administration of therapeutic doses of bretylium and procainamide with this delivery system has been demonstrated in dogs and appears to be feasible in human subjects.

Noninvasive quantification of jeopardized myocardial mass in dogs using 2-dimensional echocardiography and thallium-201 tomography.

The evaluation of jeopardized myocardial mass is important in defining the effect of interventions during myocardial infarction. To quantitate the in vivo mass at risk, 2-dimensional echocardiography (2-D echo) and thallium-201 single-photon emission computed tomography (SPECT) was performed in 10 closed-chest dogs after circumflex coronary artery occlusion. The 2-D images were manually digitized to compute left ventricular (LV) mass using a modified Simpson's rule algorithm. This measure of LV mass correlated well with the actual LV mass (r = 0.97). Perfused myocardial mass was estimated from thallium SPECT images 4 hours after occlusion using a region-growing algorithm. After the dogs were killed, the jeopardized mass was outlined using a dual perfusion staining technique using triphenyltetrazolium chloride and Evans blue dye. The actual perfused mass was well estimated by the thallium images (r = 0.96). The noninvasively determined mass at risk was calculated as: 2-D mass--thallium SPECT mass, and correlated well with the pathologically determined mass at risk (r = 0.91). Thus, the jeopardized mass may be determined noninvasively by using 2-D echo and thallium-201 tomography. This approach may provide further information regarding the effect of intervention therapy on jeopardized myocardium.

Atrial natriuretic peptide secretion in heart transplant patients.

Plasma atrial natriuretic peptide (ANP), plasma renin activity (PRA), aldosterone (ALD) and vasopressin (VP) were assessed in six heart transplant patients (HTP) and ten healthy subjects under bed rest conditions and 60 and 120 minutes after head-out water immersion (WI). Bed rest had no significant influence on these parameters. WI raised plasma volume (PV) to the same extent in both groups. This increase of PV was accompanied by significant suppression of PRA, ALD and VP and an increase of plasma ANP. In HTP basal plasma ANP was significantly elevated and the ANP response to central hypervolemia reduced. Significantly elevated VP plasma levels were also found in HTP. These endocrine abnormalities in HTP seem to be caused by latent failure of the transplanted heart. No direct correlation was found between plasma ANP and PRA, ALD and VP under basal conditions and after WI in either HTP or normals.

[Angioplasty of several stenoses including the left main coronary artery in a patient with acute circulatory insufficiency after myocardial infarction]. / Angioplastyka kilku zwezen, w tym pnia lewej tetnicy wiencowej, u chorego z ostra niewydolnoscia krazenia po zawale serca.

A 74 year old man with diabetes and multivessel coronary heart disease involving also left main coronary artery is presented. The patient was admitted to the hospital because of acute myocardial infarction. PTCA of left main coronary artery and other four severe stenoses was attempted. The clinical status after procedure, short-term (after eight months) and long-term (after five years) was much improved.

[A case of paroxysmal ventricular tachycardia surgically treated based on electrophysiological diagnosis]. / Przypadek napadowego czestoskurczu komorowego leczonego chirurgicznie w oparciu o diagnostyke elektrofizjologiczna.

There was presented a case of recurrent ventricular tachycardia in the patient after myocardial infarction. Considering uneffective pharmacotherapy and several cardiac arrests, the patient underwent guided endo-cardiotomy based on complex electrophysiological diagnostics (including intraoperative examination). Postoperative period was uncomplicated. There were no recurrences of ventricular tachycardia during 18-month follow-up.

[Cardiomyopathy in diabetes. Ultrastructural examinations]. / Uszkodzenie serca w cukrzycy. Badania ultrastrukturalne.

The functional and morphological changes in myocardium of diabetic patients is caused by diabetic macroangiopathy, diabetic microangiopathy, autonomic neuropathy and metabolic disorders. Mechanism of these changes in the course of diabetes is not fully known. To determine whether there are myocardial ultrastructure differences between patients with diabetic cardiomyopathy (normal coronary angiograms) and diabetic patients with coronary artery disease, electron microscopy examination were performed of 70 sections received from seven biopsied patients (1F, 6M), average age 53 years (range: 42-60) with diabetes type II WHO (group A) without clinical evidence of prior coronary artery disease and hypertension, and 100 sections from 10 patients (2F, 8M), average age 54 years (range: 42-65) with diabetes and coronary atherosclerosis. These patients had clinical evidence of heart failure and were submitted to bypass-graft operations (group B). Endomyocardial biopsy tissues were obtained from the right ventricle without complications either during or after the procedure. Obtained biopsy specimens were fixed in 3% glutaraldehyde stabilized with 1M cacodylate buffer at pH 7.4, postfixed in 1% OsO4 on cacodylate buffer. The materials were then dehydrated and embedded in epon. The Irvin-Fischer test for statistical analysis was used. A p value < 0.05 was considered significant. The presence of focal mild loss of myofibrils (+) was statistically more frequent in the patients in A group (p < 0.05). It was found in 86% (6/7) of cases in A group, while in the B group was observed in 20% of (2/10) cases.(ABSTRACT TRUNCATED AT 250 WORDS)

[Invasive treatment of recent myocardial infarction. Evaluation of left ventricular function]. / Leczenie inwazyjne swiezego zawalu serca. Ocena funkcji lewej komory.

Hemodynamic parameters of left ventricular function were assessed in 179 patients with acute myocardial infarction, who were treated with intracoronary thrombolysis during first six hours after the onset of chest pain. Some of them were subjected to coronary angioplasty. Patency of the infarct related artery was controlled between the 2nd and 3rd week after acute myocardial infarction concomitant with evaluation of EF and LVEDP. Reperfusion of the infarct related artery was obtained in 121 patients (67.6%) and also significant increase of EF was observed in those patients. EF rose in patients with a patent coronary artery after 2-3 weeks (not significant) in contrast to patients with obstructed coronary artery in whom there was a fall in EF. The rise of EF was more pronounced in patients with reperfusion reached in 3 hours after the onset of infarct pain and without coronary angioplasty. It was shown that LVEDP is not usefull in estimation of left ventricular function.

[Cardiogenic shock. Coronary angioplasty after failed intravenous thrombolysis]. / Wstrzas kardiogenny. Koronaroplastyka przy niepowodzeniu trombolizy dowiencowej.

Rescue coronary angioplasty (PTCA) was employed as reperfusion strategy after unsuccessful intracoronary infusion of streptokinase in 13 patients with AMI complicated by cardiogenic shock (CS). Reperfusion defined as reestablishment of TIMI 3 degree flow in the infarct related artery and reduction in luminal narrowing to less than 50% was achieved in 8 patients (61.5%). The failure of PTCA was caused by: inability to cross occlusion in 2 patients and recurrent thrombosis despite repeated dilatations resulting in hemodynamic instability requiring cardiopulmonary resuscitations during the procedure in 3 patients. There was no significant differences in mean age, sex, time from onset of symptoms, LVEF, artery involved, extent of coronary disease and incidence of cardiopulmonary resuscitations during the procedures. There where 4 in-hospital deaths among patients with failed PTCA (80%) compared to 25% mortality in reperfused group. We conclude that PTCA is an effective method of achieving reperfusion in patients with CS complicating AMI after failed thrombolysis with intracoronary streptokinase and that it improves in-hospital survival.

[Acute myocardial infarction with shock. Intracoronary thrombolysis]. / Ostry zawal serca ze wstrzasem. Tromboliza dowiencowa.

UNLABELLED: Of 932 pts with acute myocardial infarction (AMI) who underwent reperfusion therapy (RT) by intracoronary streptokinase (IC.STK), 32 pts had cardiogenic shock (CS). Shock was defined as systolic blood pressure (BP) < or = 80 mmHg without inotropic support or BP < or = 90 mmHg with inotropic or balloon counterpulsation support and left ventricular end diastolic pressure < 18 mmHg and clinical symptoms of hypoperfusion. Time from onset of symptoms to initiation of therapy was less than 6 hours. Reperfusion was defined as reestablishment of antegrade TIMI-2 or 3 flow in occluded artery. Comparison revealed no significant differences in sex, age, time after onset of symptoms, artery involved, history of previous AMI, left ventricular ejection fraction and in extent of coronary disease between pts with successful and failed thrombolysis. IC.STK was successful in 12 pts with CS (37.5%) and in 67.2% of pts without CS (p < or = 0.001). Mortality rate in pts with CS was 25% in reperfused and 81.8% among nonreperfused (p = 0.0095). CONCLUSIONS: 1. IC.STK gives a considerably lower rate of reperfusion in pts with AMI complicated by CS. 2. No influence on the frequency of effective reperfusion with respect to the analyzed clinical and angiographical data was found. 3. The high mortality in the group with unsuccessful reperfusion as well as the low effectiveness of the IC STK indicates the necessity to apply more effective methods of reperfusion in pts with AMI complicated by CS.

[Effect of water immersion on the cortisol, glucose, growth hormone and prolactin levels in patients with transplanted heart]. / Kortyzol, glukoza, hormon wzrostu i prolaktyna u chorych z przeszczepionym sercem w warunkach immersji wodnej.

In 6 heart transplant patients (HTP) and in ten healthy subjects the influence of head out water immersion (WI) on blood levels of glucose, cortisol, somatotropic hormone (HGH) and prolactin was examined. Under baseline conditions. HTP showed similar blood levels of the above mentioned parameters as normals. After WI a significant increase of blood HGH but decrease of blood cortisol and prolactin were found in both examined groups. HTP differed from healthy subjects only by a less marked decline of blood cortisol induced by WI. Data obtained in this study suggest presence of a preserved physiological endocrine response of HTP to WI.

[Effect of water immersion on glucose, insulin and atrial natriuretic factor levels in patients with transplanted heart]. / Glukoza, insulina i przedsionkowy czynnik natriuretyczny u chorych z przeszczepionym sercem w warunkach immersji wodnej.

In 6 heart transplant patients [HTP] and in 10 healthy subjects the influence of water immersion [WI] on blood levels of glucose, insulin and atrial natriuretic peptide [ANP] were studied. HTP showed significantly higher baseline ANP levels and a reduced response of ANP to water immersion as compared with normals. HTP did not differ from normals by baseline plasma levels of glucose and insulin. WI induced significant decline of blood glucose and increase of insulin in both examined groups. A significant correlation was found between WI induced increase of blood insulin and ANP and between the increase of ANP and decline of blood glucose both in HTP and in healthy subjects. Data presented in this paper suggest existence of a significant relationship between ANP and insulin secretion and participation of ANP in the carbohydrate metabolism both in normals and HTP.

[Late right and left ventricular potentials using inter-cardiac recording in patients with ischemic heart disease--methodologic and clinical problems]. / Opóznione potencjaly prawo- i lewokomorowe rejestrowane z wnetrza serca u chorych z choroba niedokrwienna serca--problemy metodologiczne i kliniczne.

The aim of the study was to compare detection frequency of late inter-cardiac potentials recorded from the right and left ventricle. There was also estimated relationship between their incidence and ventricular tachycardia or fibrillation occurrence. 41 patients with ischemic heart disease underwent the study. Electrophysiologic examination were performed because of ventricular tachycardia and/or fibrillation attacks or complex ventricular arrhythmias recorded in ECG Holter monitoring. In 11 patients intracardiac electrocardiograms were recorded from both ventricles, in 29 only from the right and in 1 from the left one. All patients underwent programmed right and/or left ventricular stimulation. Left ventricular end-diastolic diameter, segmental contractility and ejection fraction were echocardiographically estimated. Study results were statistically analyzed by means of CHI2 and t-Student tests for unpaired variables. Late potentials were more frequently observed in patients with left ventricular dyskinesis (p less than 0.01) and decreased ejection fraction. Late potentials recorded in patients with a history of ventricular tachycardia or fibrillation were more delayed to proceeded QRS complex and had a greater amplitude. This prolongation of ventricular activation can make an anatomic substrate for dangerous ventricular arrhythmias occurrence. Since the presence of late potentials in patients with contractility disorders is connected with more frequent incidence of spontaneous and provoked ventricular arrhythmias, endocardial late potentials recording may be of a prognostic value, if it is performed from both ventricles.

[Effect of beta adrenergic blocking drugs on the prognostic value of ST-segment depression during exercise electrocardiogram testing]. / Wplyw leków beta adrenolitycznych na wartosc prognostyczna obnizonego odcinka ST w elektrokardiogramie wysilkowym.

Exercise testing has been shown to be predictive for future cardiac events in patients with established diagnosis of coronary heart disease. Exercise test parameters associated with poor prognosis may be unreliable if patient is receiving beta adrenergic agents. The purpose of this study was: 1) to compare the results of exercise testing performed before and during beta blocking therapy, and 2) to determine the role of beta blockers in the prognostic significance of the ST-segment response recorded during exercise testing. The study population consisted of 518 patients (mean age 52 +/- 7 years) with coronary heart disease. The diagnosis was based on the presence of one of the following three criteria: 1) typical history and significant ST-segment depression on resting or exercise electrocardiogram, 2) history of myocardial infarction, 3) significant coronary angiographic abnormalities. In all patients symptom-limited exercise test was performed before and two weeks after the onset of beta blocker therapy. The data from the first and second tests were estimated for significance of differences between the mean values with following results: maximal heart rate--135 +/- 21 and 123 +/- 19 bpm (p less than 0.001), maximal work load achieved--98 +/- 43 and 109 +/- 44 W (p less than 0.001), maximal systolic blood pressure--171 +/- 28 and 163 +/- 26 mmHg (p less than 0.001). Occurrence of characteristic ST-segment depression was more frequent during the first than during the second test (p less than 0.001).(ABSTRACT TRUNCATED AT 250 WORDS)

[Surgical treatment of paroxysmal ventricular tachycardia (personal observations)]. / Chirurgiczne leczenie napadowego czestoskurczu komorowego (doswiadczenia wlasne).

Five patients with recurrent VT/VF resistant to medical treatment were successfully treated surgically. In 3 patients excision of the altered endocardium by Harken's method (endocardial peeling) was done; in 2 of the patients it was preceded by intraoperative electrophysiological study. Two other patients were treated alternatively: a 45-year old patients with post-MI cardiomyopathy had a cardiac transplantation and a 57-year old patient with good left ventricular function an implantation of a automatic cardioverter-defibrillator (AICD). No patient had VT and/or VF during the 14-35 month follow-up. Exercise tolerance improved in all patients. Good short- and longterm results of surgical treatment show that these methods can be effective in treating patients with life-threatening arrhythmias resistant to pharmacological therapy.

[Programmed electrical stimulation of the heart in relation to left ventricular contractility in ischemic heart disease]. / Programowana stymulacja elektryczna serca a kurczliwosc lewej komory w chorobie niedokrwiennej.

To determine the relation between left ventricular contractility disorders and the inducibility of serious ventricular arrhythmias, 83 patients (pts) with ischaemic heart disease and ventricular tachycardia (VT) or fibrillation (VF) in history and/or Lown's class IVb arrhythmia in 24-hour Holter ECG monitoring were evaluated by means of echocardiography and programmed electrical stimulation (PES) of the heart. Inducible VT or VF were observed in 66% of pts: sustained monomorphic VT (SMVT) in 33%, nonsustained VT (NSVT) in 28% and VF in 6%. VT or VF were significantly more frequent in patients with VT/VF in history (91% vs 42%, p less than 0.001), SMVT (48% vs 17%, p less than 0.01) as well as NSVT (38% vs 17%, p less than 0.01). Low ejection fraction (EF less than 40%) was observed in 18 pts (22%), VT/VF was inducible in 94% of them, while only in 57% with EF greater than or equal to 40%, p less than 0.01, SMVT in 39% vs 30%, NSVT in 33% vs 25%. Among 21 pts (21%) with left ventricular (LV) dyskinesis in 91% of pts while only in 55% without it, p less than 0.01, SMVT in 53% vs 26%, p less than 0.05. We concluded that in patients with previous myocardial infarction, VT/VF in history and abnormal LV contractility full haemodynamic, angiographic and electrophysiologic examination should be performed to determine their risk of sudden death due to serious ventricular arrhythmia before final decision about the mode of treatment.

[Right ventricular infarction]. / Zawal prawej komory serca.

Right ventricle infarction (RVI) is not a rare clinical entity. It complicates approximately half of inferolateral myocardial infarctions. Under the term RVI we can find mild, asymptomatic dysfunction of right ventricle and cardiogenic shock as well. RVI is associated with increased mortality and its presence obliged us to qualify patient to a high risk group. Diagnosis is based on clinical signs, electrocardiographic findings, hemodynamic measurements and echographic evaluations. The proper treatment of RVI requires support of right ventricle preload with fluid administration, maintainance of atrio-ventricular synchrony, reduction of right ventricle afterload. Early reperfusion with fibrinolytic therapy and coronary angioplasty should be regarded as the prior methods of treatment RVI. Patients who survive RVI have complete resolution of hemodynamic abnormalities with restoration of proper right ventricle function.

[Measurement dispersion of the QT interval and its significance in different diseases]. / Pomiar dyspersji odstepu QT i jej znaczenie w róznych schorzeniach.

QT dispersion reflects in homogenecity of ventricular repolarization. It is calculated using 12-leads standard synchronized ECG or 24-hours Holter monitoring. The most common used indicators are: QT dispersion (QTd), based on Bazett's formula corrected for heart rate QT dispersion (QTcd) and QT dispersion ratio (QTdR). QT apex and QTd corrected for total number of leads ECG in which QT interval was counted are rare used. Increased QT dispersion is observed among others: following myocardial infarction (MI), coronary heart disease (CAD), hypertension, chronic heart failure (CHF), long QT syndrome, as well as diabetes. Following mentioned diseases increased QT dispersion has prognostic value for sustained ventricular tachycardia. Dispersion of repolarization > or = 80 ms after MI is a risk factor for sudden cardiac death. Following acute MI decrease of QT dispersion after successful thrombolytic therapy is observed and its value > or = 100 ms is regarded as a marker of reperfusion insufficiency. QT dispersion in patients with CAD correlates with extent of ischemia and decreases after coronary angioplasty (PTCA). In recent years beneficial effect of angiotensin-converting enzyme inhibitors and beta-adrenolytic therapy on QT dispersion was described. Actually the improvement of computerised methods in assessment of QT dispersion is observed, but it require further investigations.

[The assessment and clinical significance of heart rate variability]. / Metody oceny i znaczenie kliniczne zmiennosci rytmu zatokowego.

Heart rate variability (HRV) is a phenomenon to generation through the sinus node consecutive impulses in the different succession. HRV is regarded as a marker of autonomic nervous system tone of the heart. To assess HRV following methods: time domain, frequency domain and non-linear analysis are known. Time domain parameters correlate with frequency domain parameters. Some parameters can be used substitution, particularly reflect parasympathetic activity: rMSSD, pNN50 and HF. In clinical practice the most useful is time domain analysis based on 24-hours ecg Holter monitoring. Among time domain parameters the most significant prognostic value has SDNN. Decreased HRV following many diseases has been described. Significant prognostic value of decreased HRV after myocardial infarction (MI) and in patients with chronic heart failure (CHF) has been proved. Decreased HRV after MI is independent as well as ejection fraction (EF) sudden cardiac death risk factor. In patients with SDNN value below 50 ms high risk of cardiac death is observed. SDNN should be estimated on 7th day of MI to evaluate patients with high risk of sudden cardiac death. In patients after MI with ventricular tachycardia (VT) before VT decreased HRV is described. During MI beneficial influence of infarct-related artery patency on HRV is observed. HRV correlates with EF and infarct site too. HRV in patients with CHF correlates with EF and functional severity of CHF. Correlation between decreased HRV and increased mortality in CHF has been shown. In diabetic patients decreased HRV is observed. Following diabetes examination of HRV is useful to estimate early phase of autonomic neuropathy. Increase HRV parameters is observed in the course of beta-adrenolytic and converting enzyme inhibition treatment. In other diseases, including heart transplantation prognostic value of HRV and its clinical significance are still investigated.

[Tachycardia-induced cardiomyopathy]. / Arytmogenna kardiomiopatia rozstrzeniowa.

Dilated cardiomyopathy induces circulatory insufficiency with poor prognosis. Persistent tachyarrhythmias may be the cause of this disease. At particular high risk for heart damage and insufficiency are young people and children. The group of most dangerous arrhythmias consist of: incessant tachycardia in patients with preexcitation syndrome and supraventricular tachyarrhythmias (atrial flutter and fibrillation, ectopic atrial tachycardia) with high rate of ventricles. The result of arrhythmias is dilatation of the heart and thinness of ventricular walls with hemodynamic disorders. The effective therapy of arrhythmias--ablation of the accessory pathway in patients with pre-excitation syndrome or reversion to sinus rhythm (pharmacological or electric cardioversion) in patients with atrial fibrillation and flutter, often leads to normalisation of heart ejection function and diameter. Therefore it exist important question: is dilated cardiomyopathy the cause or consequence of tachyarrhythmias? Causative antiarrhythmic therapy in these second cases gives a possibility to improve the prognosis in patients with such a disease.

[Atrial flutter: causes, electrophysiological characteristics, treatment with radiofrequency catheter ablation]. / Trzepotanie przedsionków--przyczyny, charakterystyka elektrofizjologiczna, leczenie za pomoca ablacji pradem o czestotliwosci radiowej.

Atrial flutter (TP) is one of the most common supraventricular tachyarrhythmias. Because of its influence on hemodynamics of the circulation, prolonged episode of paroxysmal TP can lead in as many as 1/3-1/2 patients to clinical signs of coronary insufficiency, decompensation of the circulatory system, or even such life-threatening states, like cardiac arrest. Patients with preexcitation syndrome, hyperthyroidism, as well as children, whose atrio-ventricular (AV) node can conduct in a 1:1 fashion, are in the group of particularly high risk of complications. Recurrent episodes of TP are also associated with frequent occurrence of thromboembolic events. Based on the electrocardiographic (ECG) pattern TP is divided into common type, with negative "sawtooth" in leads II, III, aVF, and uncommon type, which is characterised by other ECG morphologies. Experimental and clinical data have revealed, that common and some part of uncommon type are due to clockwise or counterclockwise reentry in the right atrium. These forms of TP can be treated with high success-rate with radiofrequency (CR) ablation. Because of difficulties in pharmacological conversion of the arrhythmia to the sinus rhythm and high frequency of recurrences, CR ablation seems to be a high effective method of treatment in patients with common and some forms of uncommon TP.