Reproducibility of Doppler echocardiographic quantification of aortic and mitral valve stenoses: comparison between two echocardiography centers.

Doppler echocardiography has been widely used as a noninvasive method to quantify valvular heart diseases. This study assessed the variability between 2 echocardiography centers concerning 2-dimensional and Doppler echocardiographic results in the quantification of mitral and aortic valve stenoses. Forty-two patients were studied by 2 different echocardiography centers in a blinded, independent fashion. In patients with aortic and mitral valve stenosis, mean and maximal flow velocities were measured. The aortic valve orifice area was calculated according to the continuity equation. Mitral valve orifice area was determined by direct planimetry and by pressure half-time. In patients with an aortic valve stenosis, a close relation between the 2 centers was found for the maximal and mean flow velocities (coefficient of correlation, r = 0.72 to 0.92; coefficient of variation, 3.7 to 7.7%). A close correlation and a small observer variability was found for the flow velocity ratio determined by flow velocities measured in the left ventricular outflow tract and over the stenotic valve (r = 0.88; coefficient of variation, 0.01 +/- 0.009). In contrast, there was a poor correlation between the diameter of the left ventricular outflow tract and the aortic orifice area (r = 0.36 and 0.59, respectively). In patients with a mitral valve stenosis, mean and maximal velocities were closely correlated (r = 0.85 and 0.77, respectively). Velocities were not found to be significantly different between the 2 centers. Variability between the 2 centers for the mitral valve orifice area was 9.8% (2-dimensional echocardiography) and 5.7% (pressure half-time).(ABSTRACT TRUNCATED AT 250 WORDS)

[Primary atrial heart tumors--a review of 21 cases]. / Primäre atriale Herztumoren--eine Ubersicht über 21 Fälle.

Between 1978 and 1986, atrial heart tumors were found in 21 of our patients, all of them subsequently underwent surgery. Pathological-histological examination in 20 patients confirmed the diagnosis of a myxoma; the one remaining case was a female patient with primary cardiogenic osteosarcoma. Of the 20 patients, 15 (75%) were females; in four female patients (20%) the tumor was localized in the right atrium. The main symptoms and findings were elevated erythrocyte sedimentation rates (80%), stress-induced dyspnea or paroxysmal dyspnea (71% resp.), and diastolic mitral or tricuspid murmurs (62%). The patient with osteosarcoma died of cachexia on the basis of generalized diffuse metastases. One female patient with a preoperative history of severe left ventricular impairment on the basis of dilative cardiomyopathy died 5 weeks after surgery. Relapse of atrial myxoma has not yet occurred during follow-up since 1978.

Long-term treatment of hypertrophic cardiomyopathy with verapamil or propranolol in matched pairs of patients: results of a multicenter study.

The effects of a 2-year treatment with high-dose propranolol (mean, 340 +/- 135 mg/day) and verapamil (mean, 493 +/- 136 mg/day) were compared in two groups of patients with hypertrophic cardiomyopathy. Both groups were broadly identical at the beginning of the trial and were formed of matched pairs. Out of 137 patients entering the study, 37 pairs completed the 2 year follow-up. The mean group symptomatology (NYHA-classification) improved significantly only following verapamil treatment. Individual improvement was seen more often following verapamil (V), but deterioration was almost exclusively seen during propranolol (P) treatment. Reduction of the Sokolow-index was significant in the V group only. Reduction in the resting heart rate and maximum gradient was more pronounced following P. No correlation could be found between the change in clinical symptoms and electrocardiographic, echocardiographic or hemodynamic data, nor to the dosage of V or P administered. From clinical and echocardiographic findings and in respect of side effects, V is advantageous over P in the treatment of hypertrophic cardiomyopathy, although a considerable number of patients improve after P. Objective data do not allow one to anticipate responders or non-responders to either treatment.

[Cardiogenic embolisms following silent anterior wall infarct]. / Kardiogene Embolien nach stummem Vorderwandinfarkt.

A 33-year-old man had suffered recurrent arterial embolisms. Echocardiography identified as the most likely cause a large mobile mass in the left ventricle. Initially a primary heart tumor was discussed, but the ECG finding of an anterolateral scar and an angiographically proven LAD-stenosis were suspicious of an organized thrombus of the left ventricle. After surgical excision, histological analysis classified the mass as an organized thrombus.

[Ventricular thrombi in the chronic infarct stage]. / Ventrikelthromben im chronischen Infarktstadium.

Left ventricular thrombi were detected in 98 (11%) of 864 consecutive patients examined by 2-D-echocardiography in the chronic phase of myocardial infarction. Using unequivocal criteria in identifying intracavitary masses as thrombus, the sensitivity and specificity of the echocardiographic diagnosis reached 90% compared to intraoperative findings (n = 23). To avoid false positive diagnoses, normal apical structures like muscular trabeculae must be ruled out, preferably by applying high-frequency transducers. All thrombi were located on akinetic or dyskinetic segments near the ventricular apex. Accordingly they were best visualised in the apical 4-chamber (92%) and 2-chamber (96%) views as well as in apical short-axis cross-sections (49%). Thrombus size ranged from 0.5 to 32 cm2. Two-thirds of the thrombi appeared as flat, one-third as protruding masses. Thrombi were found mainly with anterior wall infarctions (14.5%) and with aneurysms (28.5%), but rarely with posterior wall infarctions (.6%). 95% of the thrombus patients had suffered large infarctions. The rate of embolic events prior to the thrombus diagnosis was 7% in patients with thrombi but only 0.6% in patients without thrombi.

[Ventricular thrombi in the chronic infarct stage: echocardiographic findings, clinical aspects, relations to anticoagulation]. / Ventrikelthromben im chronischen Infarktstadium: echokardiographische Befunde, Klinik, Beziehung zur Antikoagulation.

In 10% (n = 139) of 1,383 patients in the chronic phase of myocardial infarction left ventricular mural thrombi on a-/dyskinetic segments were present in the 2D-echocardiogram. Thrombi were more often seen in patients with anterior wall infarct (14% of 734) or combined anterior-posterior infarcts (11% of 337) than in those with posterior wall infarct (0.6% of 312). Thrombi were most frequent in patients with left ventricular aneurysm (26% of 362). Generally, our patients with left ventricular thrombi had suffered large infarctions, involving on average 42% of the wall segments. Accordingly, signs of severe left ventricular damage were found in most of these patients: in 69% global ventricular dilation was present in the echocardiogram, in 64% the global heart size, determined by chest-ray was enlarged, in 42% the exercise tolerance on the bicycle ergometer was limited to 25 watts or less, 29% had congestive heart failure, and 17% severe ventricular arrhythmias. Systemic embolization had occurred in 7.9% of the 132 thrombus patients, but in only 0.7% of the 1,244 patients without thrombi. At the time of the thrombus diagnosis by means of 2D-echocardiography, 90% of the thrombus patients had not received effective anticoagulant therapy. Follow-up was possible in 65 of these patients and showed thrombus regression in 45 patients, 93% of whom were effectively anticoagulated. Of the 20 patients with persisting thrombi only 20% were under an effective anticoagulant drug management. If anticoagulant therapy has to be stopped, a former thrombus patient runs a high risk of developing thrombi also in the chronic phase of myocardial infarction.

[Constrictive pericarditis as a late complication of heart operations]. / Pericarditis constrictiva als Spätkomplikation von Herzoperationen.

Constrictive pericarditis is a rare complication of previous cardiac surgery, the rate of incidence being approximately 0.1 to 0.3%. Until now about 60 cases have been documented. With increasing frequency of surgical procedures, especially bypass operations, cardiac surgery plays a major role in the etiology of pericardial constriction. In our own series of 12 consecutive pericardiectomies previous cardiac surgery was in 4 cases responsible for the constriction. These cases are presented in detail. A correct diagnosis is difficult and - as in our own cases - often not noticed for a long period of time because the symptoms are obliterated by the primary heart disease and the previous operation. In our own patients the diagnosis was eventually established by echocardiography and then confirmed by right sided heart catheterization. Due to the late diagnosis the results of pericardiectomy - considered the method of choice - were only poor. Two patients, both in a very bad overall condition, died soon after surgery. The remaining 2 patients recovered satisfactorily. Regarding the pathogenesis, hematomas seem to play a leading role in the development of subsequent pericardial fibrosis. Typically the patients present symptoms of a prolonged pericarditis soon after the original surgical intervention. The time between cardiac surgery and the development of constrictive features varies between weeks and years. The postoperative course of patients with excessive postoperative bleeding or larger pericardial effusions should be watched carefully, keeping the possibility of later pericardial constriction in mind.

[Echocardiography diagnosis of infarct complications]. / Echokardiographische Diagnostik von Infarktkomplikationen.

Congestive heart failure, shock or severe arrythmias after myocardial infarction can be caused by mechanical complications suitable for surgical correction. These complications - such as aneurysms, rupture of the ventricular wall, septum or papillary muscle, pericardial tamponade - are reliably detected or excluded by echocardiography. Additional aspects related to the surgical techniques can be evaluated, moinly the resectability of left ventricular aneurysms. From these, pseudoaneurysms bearing a high risk of rupture can be differentiated. The causes of systolic murmurs after myocardial infarction - septal rupture, papillary muscle rupture or dysfunction - can be classified definitely. The diagnosis of Dressler's syndrome is facilitated by echocardiographic demonstration of pericardial effusion.

[Echocardiography in coronary heart disease]. / Echokardiographie bei koronarer Herzerkrankung.

Coronary heart disease can be detected via echocardiography, if myocardial ischemia or infarction are present leading to segmental abnormalities of left ventricular function. The capability to demonstrate these regional changes is limited as far as TM echocardiography is concerned, whereas 2D echocardiography is more reliable. For this purpose, cross-sectional imaging of all segments in several planes is necessary. The complex mosaic of findings obtained in this way is best documented by means of a segmental scheme of representative sections. Infarct size then can be estimated by a segmental score. Depressed wall motion and systolic wall thickening are used as criteria for ischaemia and infarction. In the chronic phase, morphological changes can be identified additionally: Thinning, expansion and increased reflectivity of the infarcted areas. In acute myocardial infarction, echocardiography is mainly used if the course is complicated, in the chronic phase, if ECG-changes are questionable, or to evaluate residual ventricular function after large infarcts. Even the TM echocardiogram reliably estimates the ventricular damage caused by the infarct in the chronic phase.

[Treatment of congestive cardiac failure with vasodilators (author's transl)]. / Behandlung der Stauungsherzinsuffizienz mit Vasodilatatoren. Vergleich der Akut- und Langzeiteffekte unter Berücksichtigung verschiedener Substanzgruppen.

The possibility of development of tolerance of treatment with vasodilators was investigated in 16 patients with severe chronic congestive cardiac failure. Independent of the primary site of action, the first application of a vasodilator resulted in lowering of pulmonary artery pressure by about 30% (isosorbide dinitrate 40 mg orally in delay-action form and 5 mg sublingually, prazosin 2 mg, dihydralazine 75 mg). Only dihydralazine reduced systemic resistance acutely by 42% and increased cardiac minute volume by 66%. After treatment for 12 days with isosorbide dinitrate delay-action (three times 20 mg), prazosin (three times 2 mg) or dihydralazine (three times 75 mg), there was persistent lowering of the pulmonary artery pressure 16 hours after cessation of treatment only after isosorbide dinitrate (-29%) and dihydralazine (-27%). A decrease of systemic resistance by 11% and an increase of cardiac minute volume by 20% were seen only after dihydralazine. An additional acute application of isosorbide dinitrate or dihydralazine resulted in a further decrease of pulmonary artery pressure (-25% and -11%, respectively). An additional decrease of systemic resistance (-23%) and increase of cardiac minute volume (+18%) were again only seen with dihydralazine. In contrast to the first medication there was no significant change of the pulmonary artery pressure after treatment with prazosin for 12 days.

The acute effect of a new positive inotropic agent (AR-L 115 BS) on cardiac hemodynamics and contractility in patients with severe chronic congestive heart failure.

The hemodynamic effect of 2-[(2-methoxy-4-methylsulfinyl)phenyl]- 1H-imidazo[4,5-b]pyridine (AR-L 115 BS), a new positive-inotropic substance, was studied in 10 Patients with chronic congestive heart failure after i.v. infusion of increasing does of 1.8 mg/min, 2.7 mg/min and 3.6 mg/min over a period of 40 min each. Prior to each infusion an i.v. bolus of 16 mg was given. The hemodynamic changes were measured by means of a Swan Ganz balloon tipped catheter and by echocardiography. The heart rate remained unchanged whereas systolic, diastolic and mean arterial pressures fell slightly by about 5%. The mean and diastolic pulmonary pressures decreased by 30% with a concomitant increase in cardiac output of 15%. The total peripheral and pulmonary resistance was reduced by 20% and 40%, respectively. The echocardiographically measured fraction of systolic fiber shortening of the left ventricle was increased by 15%. In parallel the ratio of PEP/LVET decreased by 10%. While the increase of the infusion dose from 1.8 mg/min to 2.7 mg/min was followed by an increase in the hemodynamic changes, no further alterations were observed after the dose was increased from 2.7 mg/min to 3.6 mg/min despite a marked increase in the blood level of AR-L 115 BS. The effect was still present 75 min after the infusion had been stopped. The blood level at that time had returned to the level achieved with the dose of 2.7 mg/min. The results are consistent with findings in animals which have shown that AR-L 115 BS exerts not only a positive-inotropic action on the heart, but also exhibits a vasodilating effect, predominantly in the capacitance vessels. As the substance can also be administered orally it could prove to be a useful agent in the management of severe cases of heart failure.

[One- and two-dimensional echography for aneurysms and dissections of the aorta (author's transl)]. / Ein- und zweidimensionale Echographie bei Aneurysmen und dissektionen der Aorta.

Aneurysms and dissections of the aorta--depending on their location--are the cause for a variety of cardiovascular symptoms. In most cases they are the result of a generalised disease of the vessel wall. Consequently, echographic examinations should include the entire aorta from the root to the bifurcation, systematically utilising all accessibilities. This procedure often permits a complete evaluation of the aorta and its major branches thus enabling more selective use of catheterization. Morphologic and topographic information is gained mainly from two-dimensional images, whereas functional behaviour such as wall pulsation can best be analyzed from the T-M echogram. Today echography is the method of choice in the diagnosis of aneurysms and follow-up studies. Even if thrombosis is present aneurysms can be extensively assessed. If branches of the aorta are involved--especially in the thoracic region--the echographic examination must be complemented by aortography prior to surgery. In acute dissection of the aorta, echography permits an early bedside diagnosis and recognition of life-threatening complications, e.g. acute aortic regurgitation and pericardial tamponade. T-M echography has mainly been used in the analysis of aortic root dissections and dissections of the ascending artery. Here the classical phenomenon of a duplicated wall-echo together with an enlarged vessel diameter is sensitive, yet little specific, since many other diseases in the region of the aortic root and the ascending artery demonstrate similar findings. In our group of 14 patients with extensive dissections, the observation of a floating or pulsating intima flap was more specific. By systematically screening the entire aorta we could follow the dissection from the ascending aorta to the descending region and, by means of the modern sector-scanning technique, even as far as into the main branches of the aorta. The information obtained in this manner provides a rational basis for therapeutic measures in this life-threatening disease.