Treatment of left ventricular hypertrophy in hypertensive patients with a combination of verapamil and captopril--a multicenter study.

UNLABELLED: The regression of left ventricular hypertrophy in hypertensive patients was evaluated in a multicenter study with a combination therapy of verapamil 120 mg and captopril 25 mg given once or twice daily. The degree of left ventricular hypertrophy was assessed using echocardiography, while hypertension was evaluated by means of twice daily blood pressure self-measurements and ambulatory blood pressure monitoring. RESULTS: An overall of 61 patients was evaluated. Left ventricular mass had decreased by 13.5% during the 6-month treatment period. This reduction neither correlated with the baseline left ventricular mass nor with the extent of blood pressure decrease. CONCLUSION: The combination therapy-verapamil 120 mg plus captopril 25 mg--is well tolerated by hypertensive patients with left ventricular hypertrophy and produced a decrease of left ventricular mass that is independent of the extent of blood pressure decrease.

Transjugular intrahepatic portosystemic shunt: angiographic follow-up and secondary interventions.

PURPOSE: To evaluate transjugular intrahepatic portosystemic shunt (TIPS) placements and secondary interventions. MATERIALS AND METHODS: Thirty shunt venograms were obtained in 21 patients with TIPS placement at 6-month intervals or if Doppler ultrasound showed an abnormality. RESULTS: Abnormalities in the shunt were shown in 24 venograms (80%). Eight occlusions (two early, five late, one repeat) and 16 stenoses (nine hepatic vein, six hepatic vein and stent, one stent only) were seen. Two patients with shunt abnormalities experienced recurrent bleeding. All others had no signs of recurrent portal hypertension. Occluded TIPS were recanalized (n = 5) or a new TIPS was placed parallel to the occluded one (n = 2). One repeat occlusion was not revised. Fifteen of 16 stenoses were treated successfully with balloon catheter dilation (n = 8) or additional stent placement (n = 7). The mean portal pressure gradient before revision was 21 mm Hg +/- 3.8 (standard deviation) and 13 mm Hg +/- 3.6 after revision. CONCLUSION: Stenosis and occlusion of TIPS may be common during long-term follow-up. Regular examinations may demonstrate abnormalities early. An abnormality seen on the shunt venogram usually can be revised during the same procedure.

[Management of acute intrathoracic aortic dissection]. / Management der akuten intrathorakalen Aortendissektion.

At the intensive care station of the Internal Medicine Department, University Clinic Graz, all patients admitted were promptly and carefully examined in case of suspected acute intrathoracic aortic dissection and immediately treated. In 1987 a total of 4446 patients were referred to this CCU, 893 suffered from acute thoracic pain. In 21 patients of the latter a clinical suspicion of aortic dissection was observed. In 9 patients of these, diagnosis could be established within 5 hours by echocardiography, CT and angiography. 11 patients had no dissection while one positive finding could only be determined by postmortem exam. Retrospectively, these figures for 1982 were 3908 admitted patients, 790 suffering from acute thoracic pain of which only 5 showed suspected dissection. In 3 cases dissection could be confirmed using the same diagnostic procedures, but 2 were without finding. Further 3 patients out of the total series were affected with dissection which could only be determined postmortem. Out of the 9 patients with positive diagnosis, 6 showed Typ I, 1 Typ II and 2 Typ III dissection according to DeBakey (8m, 1f, range 46-78 years). 2 patients underwent surgery immediately after diagnosis, 1 after 12 hours, while 4 cases were conservatively treated. These 7 patients have survived by controlled hypotension up to now (10 to 22 months). Two patients died 2 and 10 hours, respectively, after admission with positive diagnosis. In spite of the severity of this disease prompt and efficient diagnosis and rapid therapeutic management are the key to survival.

Semiquantitative grading of mitral regurgitation by color-coded Doppler echocardiography.

We evaluated patients with mitral regurgitation by color-coded Doppler echocardiography using a semiquantitative score system, which is useful in the clinical setting, by providing rapid discrimination between mild, moderate and severe regurgitation. The study was performed in 42 patients (19 female, 23 male) mean age 58 years, range 23-75 years with mitral regurgitation of different etiology. Color-coded Doppler measurements were compared to angiographic findings using a three point score system. In addition to such parameters as maximal jet length, area and the ratio jet area/left atrial area, we also considered the duration of regurgitant flow. The best correlation was obtained for the maximal area of the jet multiplied by the duration of regurgitant flow/cycle length (r = 0.88), determined in the apical plane where the jet was best visualized. For the parameter area of jet alone, the correlation coefficient was 0.81, for the length of the jet the value was r = 0.65 and comparison of the areas of jet and left atrium gave a coefficient of 0.77. A clear separation between mild and severe regurgitation was observed only for the parameter calculated by multiplying the area of the jet by the duration of mitral regurgitation. In only 7% of the patients with moderate and severe regurgitation could we observe an overlap. This parameter, therefore, represents a useful method for estimating in a semiquantitative manner the severity of mitral regurgitation by color-coded Doppler echocardiography.

Flow patterns of mitral regurgitation due to different etiologies: analysis by color-coded Doppler echocardiography.

We have used cross-sectional real time color-coded Doppler echocardiography to characterize the patterns of the regurgitant jet seen in mitral valvar disease of different etiologies. We studied 118 patients with mitral regurgitation due to rheumatic valve disease (n = 26), hypertrophic obstructive cardiomyopathy (n = 22), dilated cardiomyopathy (n = 35) and prolapse of the leaflets of the mitral valve (n = 35). We analyzed the origin, spatial distribution, extent and duration of the regurgitant jet. A semiquantitative grading system was used to evaluate the extent of the jet by measuring its maximal area and the duration of regurgitant flow. Typical flow patterns could be observed in hypertrophic obstructive cardiomyopathy, (in which the crescent shaped jet was elongated in midsystole and directed posteriorly) in dilated cardiomyopathy (in which oval shaped jets were observed throughout systole) and in prolapse of the leaflets (in which early or late systolic regurgitant jets occurred with an eccentric "drop-like" pattern, being directed posteriorly in patients with a prolapse of the aortic leaflet and anteriorly in those with a prolapse of the mural leaflet of the valve). A large variety of patterns was found in rheumatic disease due to the individual deformation of the leaflets. A comparison of the measured area of the jet revealed no significant differences between regurgitation caused by rheumatic valve disease and dilated cardiomyopathy. The regurgitation in 80% of these patients was of moderate to severe degree. In contrast, regurgitation due to prolapse of the leaflets or hypertrophic obstructive cardiomyopathy appeared to be of mild to moderate degree in 90% of cases.

[Randomized comparison between gallopamil and diltiazem in angiography verified coronary heart disease]. / Randomisierter Vergleich zwischen Gallopamil und Diltiazem bei angiographisch gesicherter koronarer Herzkrankheit.

In a randomized study 30 patients (age 59 +/- 7) with angiographically confirmed coronary artery disease were treated with either gallopamil (15 patients) or diltiazem (15 patients). After a 48-h-run-in period of treatment with nitrates the gallopamil group was treated with 3 X 60 mg/day, and the diltiazem group was treated with 3 X 50 mg diltiazem/day. As criteria for the efficacy of therapy the anginal frequency, the nitroglycerin consumption, and exercise tolerance were monitored. During exercise the blood pressure in the 50-watt-level, the product of blood pressure, and pulse rate at 50 watts and at the maximal workload level, the ischemic index was calculated as the product of blood pressure, pulse rate, and ST-segment depression/Watt. Later the exercise tolerance and the difference of the exercise tolerance before and after the drug period was measured. The following parameters improved under gallopamil therapy: the gallopamil group showed a significant reduction of the anginal frequency/week (10 +/- 8 down to 3 +/- 2, p less than 0.001), the nitroglycerin consumption (1.4 +/- 1.4 down to 0.3 +/- 0.6, p less than 0.001), the ischemic index (from 63 +/- 24 down to 46 +/- 17, p less than 0.01), and the exercise tolerance (740 +/- 610 up to 1140 +/- 670, p less than 0.01).(ABSTRACT TRUNCATED AT 250 WORDS)

Transesophageal two-dimensional echocardiography in young patients with cerebral ischemic events.

Using transesophageal echocardiography, cardiac structures can be imaged with high resolution. The aim of our study was to evaluate whether transesophageal echocardiography is superior in detecting mitral valve prolapse and other cardiac abnormalities compared with transthoracic echocardiography in an age-matched control group and in young patients with cerebral ischemic events (patient group). Forty patients with cerebral ischemic events (mean age 35.2 years) and 29 controls (mean age 30.4 years) were examined using both methods. Transthoracic and transesophageal echocardiography showed a significantly higher incidence of mitral valve prolapse in the patient group compared with the control group (p less than 0.001). By means of transesophageal echocardiography, it was possible to measure highly significant bulging in both the anterior and the posterior mitral leaflet in the patient group compared with the control group (p less than 0.001), and the thickness of the mitral leaflets was significantly higher in the patient group. In 9 of 20 (45%) patients with normal transthoracic echocardiograms, transesophageal echocardiography showed pathologic findings. We found transesophageal echocardiography to be a sensitive method for detecting mitral valve prolapse as well as valve changes and other cardiac abnormalities not detectable by conventional echocardiography. Our study underlines the role of mitral valve prolapse in young stroke patients as a relevant risk factor and emphasizes the importance of changed mitral valve morphology.

[Clinical significance and expanded diagnostic possibilities by transesophageal echocardiography]. / Klinische Bedeutung und erweiterte diagnostische Möglichkeiten durch transösophageale Echokardiographie.

Two-dimensional echocardiography is already a well-established diagnostic tool for evaluation of cardiac diseases. The introduction of two-dimensional transesophageal echocardiography (TEE) has widened the ultrasonic examination possibilities of the heart and great arteries. In 15% of patients where two-dimensional echocardiography gave false - negative results, TEE detected vegetations on the mitral and aortic valves. The sensitivity for detection of atrial septal defect in comparison with angiocardiography is 100%. TEE appears to be a useful noninvasive method for bedside diagnosis of acute aortic disease, particularly type III De Bakey dissections. In anaesthesiology, cardiac surgery and intensive care medicine TEE is used for simultaneous left ventricular function analysis and for detection of microair embolism. TEE is highly sensitive in the detection of mitral and aortic valvular disease, changes of the interatrial septum, left atrium and of the thoracic aorta.

[Color Doppler echocardiography: expanded noninvasive cardiologic diagnosis]. / Farb-Doppler-Echokardiographie: erweiterte nichtinvasive kardiologische Diagnostik.

Two-dimensional color Doppler flow mapping (CD) provides actual information concerning the spatial distribution of blood flow within the heart and the great vessels. CD enables the differentiation between physiological and pathological blood flow situations and provides additional information concerning turbulence, velocity and spatial relations. Thus rapid semiquantitative assessment of regurgitant lesions, detection of eccentric jets across stenotic valves and imaging of intracardiac shunts is possible. The development of CD represents an important improvement regarding noninvasive cardiology.

[Percutaneous transluminal valvuloplasty of a stenosed and calcified aortic valve in the aged]. / Perkutane transluminale Valvuloplastik einer stenosierten und verkalkten Aortenklappe im Alter.

In a 76-years old female patient with calcific aortic stenosis percutaneous balloon valvuloplasty reduced the aortic gradient from 80 mm Hg to 40 mm Hg. The preexisting aortic regurgitation did not increase after the procedure. Balloon valvuloplasty was performed without any complications and the patient was discharged one week after.

[Basedow's disease and mitral valve prolapse]. / Morbus Basedow und Mitralklappenprolaps.

The prevalence of mitral valve prolapse was investigated in 60 patients with Graves' disease (42 with ophthalmopathy) and in 20 patients with toxic nodular goitre. 2410 patients from the echocardiography laboratory served as controls. Standard M-mode, Doppler and two-dimensional echocardiography were performed. Mitral valve prolapse was defined as a systolic buckling greater than or equal to 3 mm. In patients with thyroid disease HLA antigens were determined. Patients with Graves' disease showed a significantly higher incidence of mitral valve prolapse (36/60, 60%) compared to the group with toxic nodular goitre (2/20, 10%) and to controls (238/2410, 9,9%) (P less than 0.0001). 16 of 36 patients had a prolapse of the anterior, in 3 of 36 the posterior leaflet was involved and 17 of 36 had both. Mean systolic buckling was 4.3 +/- 1.5 mm. 28 of 42 patients with ophthalmopathy (67%) showed a mitral valve prolapse. 20 of 60 patients (33.3%) with Graves' disease but none in the goitre group showed a thickened myxomatous valve (P less than 0.001). Thyroid function did not influence the incidence and intensity of the prolapse. The HLA phenotypes B8 were seen in 22 of 36 and DR3 in 24 of 36 patients with mitral valve prolapse. Since thyroid function was comparable in both groups an involvement of the mitral valve in an autoimmune process affecting several organs can be considered probable.

Lipoprotein(a) as a strong indicator for cerebrovascular disease.

To evaluate the role of lipoprotein(a) (Lp(a] in patients with cerebrovascular disease (CVD), lipid parameters were compared with a control group (CO). Additionally, the Lp(a) serum levels were investigated in a coronary artery disease (CAD) group. The CO was made up of 37 healthy persons (age: 54.5 +/- 7.7, 26 males and 11 females), the CVD group included 46 patients with sustained transient ischemic attack (TIA) prolonged reversible ischemic neurologic deficits (PRIND) and cerebral infarction (CI) (age: 53.6 +/- 9.7, 32 males and 14 females), and the CAD group was made up of 28 survivors of myocardial infarctions (age: 52.5 +/- 8.1, 18 males and 10 females). The median values of Lp(a) in CVD were significantly higher than in the CO (p less than 0.01) and did not differ significantly from the CAD. Total TC, HDL-C, TG, LDL-C and the ratio of LDL-C/HDL-C did not show any significant difference between the control and cerebrovascular disease group. For quantification of the vascular lesions of the carotid system, a Duplex Doppler score system was used. The score correlated with Lp(a) in patients between 40 to 65 years of age (r = 0.34, p less than 0.01). Thus, we conclude that Lp(a) is not only a risk factor for CAD but also for CVD.