[Brain natriuretic peptide for postoperative monitoring of the fluid balance in a cardiac surgery patient]. / Brain-natriuretisches Peptid für die postoperative Uberwachung der Flüssigkeitsbelastung bei einem herzchirurgischen Patienten.

Brain natriuretic peptide is a neurohormone used for estimation of left ventricular wall tension and volume overload. We describe the use of this parameter in a postoperative cardiac surgery patient for detection and monitoring of left ventricular failure in a postoperative intensive care unit at a tertiary care center. Left ventricular failure was detected by brain natriuretic peptide levels, while x-ray and values obtained by the pulmonary artery catheter were inconclusive.

[Secondary prevention following coronary intervention. Survey of 13 intervention centers in Austria]. / Sekundärprävention nach Koronarintervention. Vorgangsweise an 13 Interventionellen Zentren in Osterreich.

Risk factor control has been shown to reduce the incidence of coronary events in patients with or without preceding infarction. Secondary prevention should therefore be borne in mind by every cardiologist. In order to test this concept and/or to promote secondary prevention in our country, the following survey was conducted by our working group for epidemiology and prevention. All interventional centres of the country (7 million inhabitants) were asked to report relevant data of 50 consecutive patients with PTCA in a structured questionnaire. Thirteen centres responded and we report the data of 650 patients. The mean proportion of women was 28%, the mean age 61.1 years and the mean stent rate 49.8%. The indications for PTCA varied widely: stable angina 10-74%, unstable angina 10-86%, primary PTCA 0-22%. The risk factor history was distributed as follows: diabetes 12-46% (mean 22.3%), hypertension 32-68% (mean 54.2%), current smoking 6-56% (mean 21.9%), and total cholesterol (TChol) > 200 mg/dl: 30-78% (mean 60.3%). Current lipid values were available for T chol. in 44-100% (mean 84.5%) and for LDL in 4-100% (mean 67.1%). Dietary counselling by a dietician was done in 4-100% of patients (mean 35.6%) Information concerning the hazards of smoking was given to 25-100% (mean 83.6%) of current smokers. Drug treatment at hospital discharge was as follows: 84-100% (mean 93.1%) received ASA, 24-74% (mean 49.8%) ticlopidine, 6-84% (mean 53.3%) nitrates, 34-82% (mean 60.2%) beta blockers, 10-70% (mean 39.5%) ACE inhibitors, 4-74% (mean 4 7.2%) lipid lowering drugs, 7-48% (mean 17.8%) calcium antagonists, 0-12% (mean 6.1%) digitalis and 0-28% (mean 13.6%) diuretics. Follow-up data were collected in 4 centres at 6 months post discharge and were available for 174 patients. Here we found an increase in the prescription of calcium antagonists, digitalis and statins. The following conclusions were drawn at a conference in which all centres participated: lipid values should be available for each patient at PTCA, dietary counselling should be initiated for every patient during hospitalisation (and continued by the family physician) and the national cardiac society should promote guidelines for the use of drugs in which the variation in use is too wide at present. It should be ensured that these guidelines are implemented not only in patients after AMI but also in those after PTCA.

Single-bolus tenecteplase compared with front-loaded alteplase in acute myocardial infarction: the ASSENT-2 double-blind randomised trial.

BACKGROUND: Bolus fibrinolytic therapy facilitates early efficient institution of reperfusion therapy. Tenecteplase is a genetically engineered variant of alteplase with slower plasma clearance, better fibrin specificity, and high resistance to plasminogen-activator inhibitor-1. We did a double-blind, randomised, controlled trial to assess the efficacy and safety of tenecteplase compared with alteplase. METHODS: In 1021 hospitals, we randomly assigned 16,949 patients with acute myocardial infarction of less than 6 h duration rapid infusion of alteplase (< or = 100 mg) or single-bolus injection of tenecteplase (30-50 mg according to bodyweight). All patients received aspirin and heparin (target activated partial thromboplastin time 50-75 s). The primary outcome was equivalence in all-cause mortality at 30 days. FINDINGS: Covariate-adjusted 30-day mortality rates were almost identical for the two groups--6.18% for tenecteplase and 6.15% for alteplase. The 95% one-sided upper boundaries of the absolute and relative differences in 30-day mortality were 0.61% and 10.00%, respectively, which met the prespecified criteria of equivalence (1% absolute or 14% relative difference in 30-day mortality, whichever difference proved smaller). Rates of intracranial haemorrhage were similar (0.93% for tenecteplase and 0.94% for alteplase), but fewer non-cerebral bleeding complications (26.43 vs 28.95%, p=0.0003) and less need for blood transfusion (4.25 vs 5.49%, p=0.0002) were seen with tenecteplase. The rate of death or non-fatal stroke at 30 days was 7.11% with tenecteplase and 7.04% with alteplase (relative risk 1.01 [95% CI 0.91-1.13]). INTERPRETATION: Tenecteplase and alteplase were equivalent for 30-day mortality. The ease of administration of tenecteplase may facilitate more rapid treatment in and out of hospital.

Randomized, double-blind study comparing saruplase with streptokinase therapy in acute myocardial infarction: the COMPASS Equivalence Trial. Comparison Trial of Saruplase and Streptokinase (COMASS) Investigators.

OBJECTIVES: This study sought to demonstrate the equivalence of saruplase and streptokinase in terms of 30-day mortality. BACKGROUND: The use of thrombolytic agents in the treatment of acute myocardial infarction is well established and has been shown to substantially reduce post-myocardial infarction mortality. METHODS: Three thousand eighty-nine patients with symptoms compatible with those of acute myocardial infarction for < 6 h entered the study at a total of 104 centers and were randomized to receive streptokinase (1.5-MU infusion over 60 min) or saruplase (20-mg bolus and 60-mg infusion over 60 min). In the saruplase group, a bolus of heparin (5,000 IU) was administered before saruplase, and a corresponding blinded double-dummy placebo bolus was administered before streptokinase. All patients received intravenous heparin infusions for > or = 24 h starting 30 min after the end of the thrombolytic infusions; the infusions were titrated to maintain an activated partial thromboplastin time at 1.5 to 2.5 times that of normal. RESULTS: Death of any cause up to 30 days after randomization occurred in 88 (5.7%) of 1,542 patients randomized to receive saruplase and 104 (6.7%) of 1,547 patients randomized to receive streptokinase (odds ratio 0.84, p < 0.01 for equivalence). Hemorrhagic strokes occurred more often in patients receiving saruplase (0.9% vs. 0.3%), whereas thromboembolic strokes were more prevalent in the streptokinase-treated patients (0.5% vs. 1.0%). The rate of bleeding was similar in the two treatment groups (10.4% vs. 10.9%). Hypotension and cardiogenic shock occurred less frequently in the saruplase group. Reinfarction rates were similar. CONCLUSIONS: Saruplase is a clinically safe and effective thrombolytic medication. This profile ranks saruplase favorably among the currently available thrombolytic agents.

The effect of anticoagulant therapy in primary and anorectic drug-induced pulmonary hypertension.

In a retrospective study, we tested the hypothesis that anticoagulant therapy with warfarin sodium (Coumadin) has a beneficial influence on the long-term prognosis in patients with primary pulmonary hypertension (PPH) and aminorex-induced plexogenic pulmonary hypertension. The study included a total of 173 patients from two European cities. One hundred four of these patients took the anorectic drug aminorex (Menocil), which was available in some European countries almost 30 years ago; 69 patients had pulmonary hypertension of unexplained etiology, ie, PPH. Fifty-six of the 104 aminorex-treated patients and 24 patients in the PPH group received warfarin after diagnosis was established. For analysis, patients were divided into four groups according to their history of aminorex intake and anticoagulant therapy. Survival time, changes in hemodynamics (pulmonary arterial pressure), and improvement in quality of life (scored by the New York Heart Association [NYHA] classification) were compared and analyzed. We found that aminorex-treated patients had a better long-term prognosis than those with PPH (7.5 vs 3.9 years; p < or = 0.001). The best mean survival time of 8.3 years was found in anticoagulated aminorex-treated patients, compared to 6.1 years in nonanticoagulated aminorex-treated patients. Moreover, aminorex-treated patients who received anticoagulant therapy soon after the onset of symptoms showed significantly better prognosis (10.9 years) than those who commenced treatment 2 years thereafter (5.9 years) (p < or = 0.05). In patients with PPH, systolic pulmonary pressure was shown to influence survival time significantly (p < or = 0.0005); however, this correlation was not found in aminorex-treated patients. An improvement of symptoms like dyspnea on exertion was seen in 44.8% of the anticoagulated aminorex-treated patients, while deterioration was evident in 72.2% of the nonanticoagulated aminorex-treated patients. In conclusion, our study has shown that anticoagulant therapy had a positive influence on long-term survival and a significant improvement in quality of life in patients with PPH, in particular in patients with a history of anorectic drug intake.

[Quality assurance in invasive and interventional cardiology in Austria for the 1995 calendar year]. / Qualitätssicherung in der invasiven einschliesslich interventionellen Kardiologie Osterreichs für das Kalenderjahr 1995.

A complete national database is the prerequisite for quality control, quality management and improvement. In Austria, we are reaching for this goal since more than 3 years. 23969 diagnostic coronary angiographies (CA) and 5898 PTCA were performed in all 25 adult-centers (out of which 18 perform PTCA) in Austria during the year 1995. This is an increase of 13.6% concerning CA and a 19.5% increase in PTCA compared to 1994. 50% of all PTCA were done during the diagnostic study (CA), direct PTCA for ongoing infarction in 2.8%. Concerning "new devices", 1572 stents (27% of the PTCA cases) were implanted in 1995. Hospital mortality after PTCA was 0.5% (unchanged to the years 1992 and 1993), emergency bypass surgery rate after PTCA was 0.8% (0.7% during the year 1993), and 1.3% of the patients suffered a myocardial infarction due to PTCA in the cath-lab (1.4% during 1994). International comparison shows Austria under the top nations with 2996 CA and 737 PTCA per million inhabitants, corresponding to a ratio of 41% PTCA and CABG per 100 CA. Out of 18 centers with PTCA-activity ischemia was proven to be present before PTCA in 2729 patients within 11 centers, primary-success-rate was documented in 14 centers concerning 3703 patients and a controlling exercise stress test within 3 months after PTCA was reported by 8 centers for 1555 patients. Local logbooks with continuous readings of complications, guidelines and monitor visits (audits) within all cath-labs in Austria turned out to be a better tool for quality control than computer-databases. But additional electronic databases will be necessary in the future. Austria is the only nation worldwide to support a complete national database with controlled numbers and parameters since more than three years, including complete yearly monitor visits and feedback reports. We experienced no single negative reaction to our activities, but find them necessary for further quality management targets.

[Incidence and management of acute left main coronary artery dissection as a complication of acute transluminal coronary angioplasty]. / Häufigkeit und Management der akuten Links-Hauptstammdissektion als Komplikation der perkutanen transluminalen Koronarangioplastie.

Out of 1730 consecutive patients undergoing percutaneous transluminal coronary angioplasty (PTCA) of left descending coronary artery (LAD) or circumflex artery (CX) five patients (0.3%) suffered an acute dissection of left main coronary artery. In three patients dissection developed because of manipulation of the guiding catheter. In one patient retrograde dissection of the left main stem occurred because of balloon angioplasty of ostial LAD stenosis and in a second patient because of balloon rupture in the setting of stent deployment in the proximal part of the LAD. Four patients were selected for emergency operation, but one patient died before reacting the operation theatre. Out of the three remaining patients one patient died postoperatively and another patient suffered a transmural myocardial infarction. In the fifth patient three AVE Micro stents were implanted; one just at the origin of the LAD, one at the origin of the CX and the third in the left main stem. This patient was not sent for operation and was discharged without symptoms.

[Quality assurance in invasive and interventional cardiology in Austria in 1994. Commissioned by the Interventional Cardiology Working Group of the Austrian Cardiology Society]. / Qualitätssicherung invasiver und interventioneller Kardiologie in Osterreich im Jahr 1994. Auftrag der Arbeitsgruppe Interventionelle Kardiologie der Osterreichischen Kardiologischen Gesellschaft.

A complete National Database is the prerequisite for quality control, quality management and improvement. In Austria, we have been reaching for this goal since more than three years. 21 094 diagnostic coronary angiographies (CA) and 4934 PTCAs were performed in all 27 centers (out of which 17 perform PTCA) in Austria during the year 1994. This is a reduction of 3.2% concerning CA and an 8.6% increase in PTCA compared to 1993. 48% of all PTCAs were done during the diagnostic study (CA), multivessel PTCA in 11%, direct PTCA for ongoing infarction in 2.3%. Concerning "new devices", 437 stents (182 during the year 1993) were implanted in 1994; also all 73 cases with rotablator, 105 with intracoronary ultrasound, and 26 directional coronary atherectomies (DCA) are documented. Hospital mortality after PTCA was 0.5% (unchanged from the years 1992 and 1993), emergency bypass surgery rate after PTCA was 1.2% (0.7% during the year 1993), and 1.4% of the patients suffered a myocardial infarction in the cathlab (1.2% during 1993). International comparison shows Austria among the top nations with 2637 CA and 617 PTCA per million inhabitants, corresponding to a ratio of 23% PTCA per 100 CA. Risk adjustment (exercise stress test pre PTCA documented in six cath-labs in 1993, compared to 11 in 1994. Type of stenosis (A, B, C) in five labs in 1993 and in 12 labs in 1994) and outcome control (exercise stress test 3 months after PTCA documented in five cath-labs in 1993, compared to 10 in 1994) are subject to constant improvement of our yearly monitor visits and feedback reaction. Austria is the only nation worldwide to support a complete national database with controlled numbers and parameters since more than 3 years, including yearly monitor visits (Internet address for the 1995 data: http@info.uibk.ac.at/gin/org/i_iik.stu/i_iik+ ++.htm) and feedback reports. We experienced no single negative reaction to our activities, but find them necessary for further quality management targets.

[Thallium scintigraphy of the myocardium. Uniform research protocols of the Austrian Society for Nuclear Medicine]. / Die Thalliumszintigraphie des Myokards. Einheitliches Untersuchungsprotokoll der Osterreichischen Gesellschaft für Nuklearmedizin.

A uniform protocol for thallium scintigraphy of the myocardium has been issued in Austria to avoid difficulties in interpreting results and to avoid repeated examinations to save expenses and radiation burden. From the beginning of 1995 this protocol will be used in the Austrian departments of Nuclear Medicine, differences from this protocol have to be mentioned separately. In this protocol the procedure of examination, bicycle and pharmacological stress testing and vasodilatation, acquisition techniques for planar and SPECT imaging, data processing and quality control of devices are defined.

[Changes in antithrombin III, prothrombin fragment 1 + 2 and thrombin-antithrombin III complex following implantation of a coronary Palmaz-Schatz stent]. / Veränderungen von Antithrombin III, Prothrombinfragment 1 + 2 und Thrombin-Antithrombin-III-Komplex nach Implantation von koronaren Palmaz-Schatz-Stents.

To detect changes in the clotting parameters antithrombin III (AT III), prothrombin-fragment 1 + 2 (F 1 + 2) and thrombin-antithrombin-III-complex (TAT) after implantation of Palmaz Schatz stents, coagulation was monitored at standardized time points in 35 patients for 10 days. All patients were anticoagulated using a combination of heparin, phenprocoumon, and acetyl salicylic acid. Heparin therapy was guided by APTT levels (normal range 25-35 s), which were still within the therapeutic range (median 49.6 s (25%/75% percentiles 41.6/54.4) on day 10. Simultaneous oral anticoagulation was found to be effective on day 8 on average (INR median 2.24 (1.93/2.50)). The AT III activity dropped significantly (p < 0.0001) after a heparin loading dose of 15,000 IU during stenting. As the heparin dose was reduced on the following days, AT III levels increased significantly (p < 0.0001) during the observation time. There was a highly significant (p < 0.001) negative correlation between AT III and heparin levels. On days 4 and 5 F 1 + 2 values were significantly (p < 0.001 and p < 0.05) higher than on the day of stenting (median 1.07 (0.90/1.31) 1.13 nmol/l and 1.06 (0.85/1.23) nmol/l vs. 0.97 (0.69/1.15) nmol/l) and dropped during anticoagulation. F 1 + 2 levels showed a significant negative correlation (p < 0.0005) with APTT values. TAT values showed no significant changes during the observation period.(ABSTRACT TRUNCATED AT 250 WORDS)

Fibrinogen, t-PA, and PAI-1 plasma levels in patients with pulmonary hypertension.

We measured fibrinogen levels as well as the fibrinolytic parameters tissue-type plasminogen activator (t-PA) and plasminogen activator inhibitor 1 (PAI-1) in plasma samples obtained at basal conditions and after stimulating the fibrinolytic system by venous occlusion (VO). Samples were taken from patients with primary pulmonary hypertension (PPH), with secondary thromboembolic pulmonary hypertension (SPHTH), with secondary pulmonary hypertension due to congenital heart disease with Eisenmenger's reaction (SPHCD), and from healthy control individuals (CON). Fibrinogen levels were not significantly different between the groups with PPH and SPHTH or between SPHCD and CON. The latter groups, however, exhibited significantly lower fibrinogen plasma levels compared with PPH or SPHTH (p < 0.01). Basal plasma levels of t-PA antigen, t-PA activity, and PAI-1 activity, respectively, did not differ significantly between the study groups. After VO, mean t-PA activity levels increased to a higher extent in control subjects compared with patients with PPH, or SPHTH, or SPHCD, with significant differences only between CON and SPHTH or CON and PPH (p < 0.03). Patients with PPH and SPHTH exhibit both increased fibrinogen plasma levels and a diminished fibrinolytic response compared with healthy subjects. Moreover, the fibrinogen plasma levels in patients with SPHCD are in normal range, and the fibrinolytic response is similar to CON compared with PPH and SPHTH, thus indicating the existence of a comparable prothrombotic situation in patients with PPH and SPHTH.

Course of thrombin activation markers in patients implanted with Palmaz-Schatz stents: first experiences with a post-interventional anticoagulation regimen.

Following implantation of coronary Palmaz-Schatz stents, 29 patients were anticoagulated with a combination of heparin, phenprocoumon and aspirin following a standard protocol. After removing the arterial and venous lines, post-interventional intravenous (i.v.) heparin treatment started with 1500 IU/h for patients > 80 kg and 1250 IU/h for patients < 80 kg. Heparin was monitored by the activated partial thromboplastin time (aPTT) and adjusted by increasing or reducing i.v. heparin by 250 IU/h to maintain the aPTT within the therapeutic range. Phenprocoumon therapy began the day after stent implantation (day 2) and lasted for 3 months. aPTT, Heptest, prothrombin fragment F1 and 2 (F1.2) and thrombin-antithrombin III complexes (TAT) were monitored at standard intervals for 10 days (mean monitoring time: 9.7 +/- 2.3 days). Anticoagulation was efficient with aPTT levels remaining within the therapeutic range on day 9 and the simultaneous, moderate-onset oral anticoagulation within the therapeutic range of the International Normalized Ratio (INR; 2.15-4.80) on day 8 on average, the mean INR being 2.43 +/- 0.76. On day 4, F1.2 levels were significantly higher than on the day of stenting (1.16 +/- 0.30 nmol/l vs 1.04 +/- 0.53 nmol/l; P < 0.005). F1.2 levels fell after day 5, the difference becoming significant from day 8 on (P < 0.05). F1.2 was negatively correlated with the Heptest (P < 0.05) and fell significantly as a function of the INR during phenprocoumon administration (P < 0.001). After phenprocoumon therapy was discontinued over 3 weeks, 25 patients were followed up by angiography. Despite adequate anticoagulation, mean F1.2 levels in patients showing restenosis at follow-up angiography were significantly higher (P < 0.005) than in those without restenosis. In one patient who developed subacute stent thrombosis, clotting factors were determined 20 min before stent occlusion. The levels of F1.2 and TAT were less than all other patients on this day (F1.2: 0.98 nmol/l vs 1.11 +/- 0.40 nmol/l; TAT: 2.7 micrograms/l vs 3.21 +/- 3.38 micrograms/l). Thus, neither F1.2 nor TAT predicted the occurrence of thrombotic stent failure in individuals. Efficient anticoagulation by a combination of anticoagulants is imperative for stent implantation. Using only current routine methods, this way of monitoring anticoagulation is effective for managing combined anticoagulation therapy.

Effect of nitrates on the frequency of left ventricular free wall rupture complicating acute myocardial infarction: a case-controlled study.

Although up to 33% of all deaths from acute myocardial infarction are attributable to left ventricular free wall rupture, data showing a beneficial effect of drugs on this complication are scarce and contradictory. The aim of our study was to investigate the effect of nitrate therapy (intravenous or oral) during the first days after acute myocardial infarction on the frequency of free wall rupture in human beings. In a retrospective case-controlled study, 91 patients with free wall rupture complicating acute myocardial infarction demonstrated on autopsy or operation were compared with 182 control patients with acute myocardial infarction without rupture. The risk of sustaining free wall rupture was approximately 30% lower in patients receiving nitrates: (crude odds ratio 0.62; adjusted odds ratio 0.73 p 0.038). The data analysis demonstrates a possible association between nitrate use and frequency of left ventricular free wall rupture in patients with acute myocardial infarction. Nitrates seem to reduce the risk of rupture by approximately 30%.

[Dissection of the left coronary main branch by balloon rupture during stent implantation. A case report]. / Dissektion des links-koronaren Hauptstammes durch Ballonruptur während Stentimplantation. Ein kasuistischer Bericht.

A 68-year-old female patient was admitted at our hospital because of unstable angina pectoris. Coronary angiography revealed an 85% diameter stenosis in the proximal segment of the left anterior descending coronary artery (LAD) and a 70% diameter stenosis in the mid segment of the right coronary artery (RCA). Elective implantation of a Palmaz-Schatz stent in the LAD stenosis and conventional angioplasty of the RCA stenosis was decided for. Positioning of the Palmaz-Schatz stent was uneventful, whereas deployment of the stent, using a pressure of 10 atmospheres was complicated by balloon rupture, causing an extensive retrograde dissection of the LAD, involving the left main stem, the adjacent coronary sinus, and the proximal segment of the circumflex artery (CX). Coronary flow was stabilized by two guide wires inserted in the LAD and CX and the patient was sent to emergency operation. The postoperative course was uneventful and there were no signs of myocardial infarction.

[Aminorex-induced, plexogenic pulmonary arteriopathy: 25 years later!]. / Aminorex-induzierte, plexogene pulmonale Arteriopathie: 25 Jahre danach!

The purpose of this study was to examine the influence of treatment on long-term prognosis of patients with aminorex-induced plexogenic pulmonary hypertension. The study included 104 patients (13 males, 91 females) with an aminorex (menocil) intake between 1966 and 1968. All patients were treated with digitalis and diuretics, 52% received an anticoagulant medication with warfarin after pulmonary hypertension was diagnosed. During follow-up, a second right-heart catheterization was performed in 37 patients with a mean interval of 5 years. The longest mean survival time, 8.3 years, was found in patients treated with anticoagulant medication, compared to the 6.1 years found in the non-anticoagulated aminorex patients. Also, in the 5- and 10-years survival rate, patients with an anticoagulant therapy have shown better results (62.9 vs. 38% and 39 vs. 20%, respectively). Patients who received anticoagulant therapy soon after the onset of symptoms showed a better mean survival (10.9 years) than those who commenced treatment more than 1 year thereafter (mean survival 5.9 years). In 57% of the patients who had a second right-heart catheterization a decrease of pulmonary pressures could be diagnosed. Two-thirds of these patients with pulmonary pressure decrease were under anticoagulant therapy. An improvement in the NYHA-classification was seen in 44.8% of the patients treated with warfarin, in comparison to 22.2% of those who did not receive anticoagulant therapy. Although this study is retrospective, it shows a positive influence of anticoagulant therapy on survival in patients with a history of anorectic drug intake.

Detection and quantification of pulmonary artery hypertension with MR imaging: results in 23 patients.

OBJECTIVE: A study was performed to determine the value of MR imaging in detecting pulmonary artery hypertension and in determining pulmonary artery pressure semiquantitatively. SUBJECTS AND METHODS: MR studies were performed in 23 patients with pulmonary artery hypertension to measure right ventricular function (right ventricular ejection fraction, end-diastolic and end-systolic volumes, stroke volume), right ventricular wall thickness, and the diameters of the great vessels. The findings were compared with similar MR measurements made in eight control subjects. The cause of the pulmonary hypertension was primary pulmonary hypertension (eight patients), combined mitral valve disease (five patients), dilative cardiomyopathy (four patients), chronic pulmonary embolism (four patients), atrial septal defect (one patient), and pulmonary fibrosis (one patient). MR studies were done on a 0.5-T magnet using a double-angulation projection (equivalent to a four-chamber view) with a multislice-multiphase spin-echo technique and a blood flow-sensitive fast gradient-echo sequence. Pulmonary artery pressures were verified by catheterization of the pulmonary artery. RESULTS: In patients with pulmonary artery hypertension, MR imaging showed right ventricular enlargement with hypertrophy, right atrial enlargement, and abnormal septal motion. Fast gradient-echo images showed tricuspid regurgitation in all cases. In cases in which the mean pressures in the pulmonary artery were greater than 70 mm Hg, systolic slow-flow phenomena were detected. Linear correlations were seen between the mean pressure in the pulmonary artery and the end-diastolic thickness of the right ventricular wall (r = .83, p < or = .0001), the diameter of the inferior vena cava (r = .73, p < or = .0001), and the diameter of the main pulmonary artery (r = .48, p < or = .02). CONCLUSION: Our results show that MR imaging is a useful noninvasive technique for the detection of pulmonary artery hypertension and for the semiquantitative assessment of pulmonary artery pressure.

Early diagnosis of subacute free wall rupture complicating acute myocardial infarction.

Of 2608 consecutive patients with acute myocardial infarction, 24 developed subacute free wall rupture (= 0.92%; 95% C.I. = 0.6-1.4). Clinical manifestations varied widely (shock on admission; 25% of cases; severe arrhythmias followed by shock: 17%; shock during hospital stay: 42%; symptoms suggestive of infarct extension without shock: 17%). The electrocardiograms were confusing rather than revealing: 56% of patients showed new ST segment elevations of 0.2 to 1 mV in the infarct-related leads, while autopsy or creatinine phosphokinase evidence of infarct extension was missing. In the first 21 cases, therefore, no definitive diagnosis was made before autopsy. Using 197 infarct patients in cardiogenic shock or with infarct extension during the acute stage, i.e. a patient group with comparable clinical manifestations, as control group, a logistic regression model was generated in which the variables age, lateral wall involvement and history of hypertension were used for estimating the probability of subacute rupture. In fact, probability may rise to more than 40% in major subgroups. As death occurred after a median interval of 8 h (45 min-6.5 weeks) following the onset of rupture symptoms, echocardiography must be performed urgently in all cases presenting symptoms of shock or infarct extension. Pretest probability which can be roughly estimated from our model as well as sensitivity and specificity of individual echocardiographic or clinical parameters are indispensable for correct therapeutic decisions. The routine application of this algorithm in our department contributed to a timely diagnosis in the last three consecutive cases of whom one patient survived.

[Magnetic resonance tomography in pulmonary hypertension]. / Magnetresonanztomographie bei pulmonaler Hypertension.

We examined 23 patients with pulmonary hypertension of varying aetiology by MRI and compared the results with those of right heart catheterisation. The best correlation was obtained between right ventricular mural thickness and mean pulmonary pressure (R = 0.91, p = 0.001). There was significant correlation (R = 0.85, p = 0.001) for the diameter of the inferior vena cava, which was dilated in all patients with pulmonary hypertension. There was no significant correlation between mean pulmonary pressure and the diameters of the superior vena cava or the main pulmonary artery branches (R = 0.55 and 0.75 respectively, p less than 0.05). Amongst functional measurements there was a correlation between right ventricular ejection fraction and mean pulmonary artery pressure (R = 0.71, p = 0.001). There was no correlation between right ventricular end-systolic and end-diastolic volume. In all patients with pulmonary hypertension, dynamic flow sensitive gradient echo sequences showed the presence of tricuspid insufficiency. A further semiquantitative criterion for the presence of pulmonary hypertension in 4 patients (17%) was an abnormal signal from the main pulmonary artery in early to mid-systole shown on T1-weighted transverse sections.

Doppler sonographic evaluation of the CarboMedics bileaflet valve prosthesis: one-year experience.

Between April 1989 and March 1991, 237 CarboMedics bileaflet valve prosthesis carriers (165 aortic and 72 mitral valves, mean age 54.4 years) were studied prospectively with pulsed- and continuous-wave Doppler at a mean interval of 11.4 months following surgery in order to establish ranges of normal flow velocities and pressure gradients. Physical examination revealed no signs of prosthetic dysfunction or heart failure. Postoperative left ventricular function as measured by fractional shortening was 37% for aortic valve carriers and 30% for mitral valve carriers (p = NS). Mean peak velocity (+/- SD) across the aortic valve was 2.6 m/sec (+/- 0.4) and calculated instantaneous peak pressure gradient ranged from 11 to 58 mmHg (mean 28.1 +/- 10.3). It has to be emphasized that occasional patients with normally functioning valve prostheses can show unusual high gradients. Ring diameters between 21 and 27 mm showed no significant difference with regard to flow velocities and pressure gradients, whereas in 19-mm valves, significantly higher values could be demonstrated. The 123 aortic valve carriers with normal left ventricular function (fractional shortening greater than 25%) showed significantly higher pressure gradients than the 19 patients with reduced left ventricular function (28.6 +/- 11.6 mmHg vs 16.2 +/- 5.1 mmHg, p less than 0.05). In the mitral position, the mean of peak velocity (+/- SD) was 1.7 +/- 0.4 m/sec and pressure half-time was 108 +/- 26 msec, representing a calculated valve area between 1.4 to 3.1 cm2 (mean orifice size 2.1 +/- 0.5 cm2). No significant difference between valves of different sizes was found.(ABSTRACT TRUNCATED AT 250 WORDS)