Typical chest pain and precordial leads ST-elevation in patients with pacemakers--are we always looking at an acute myocardial infarction?

INTRODUCTION: Electrocardiographic (ECG) diagnosis of acute myocardial infarction (AMI) in patients with paced rhythm is difficult. Sgarbossa's criteria represent helpful diagnostic ECG tool. CASE REPORT: A 57-year-old female patient with paroxysmal atrial fibrillation and a permanent pacemaker presented in the Emergency Department with prolonged typical chest pain and ECG recording suggestive for AMI. Documented ECG changes correspond to the first Sgarbossa's criterion for AMI in patients with dual pacemakers (ST-segment elevation of 5 mn in the presence of the negative QRS complex). The patient was sent to catheterization lab where coronary angiogram reveled normal findings. ECG changes occurred due to pericardial reaction following two interventions: pacemaker implantation a month before and radiofrequency catheter ablation of AV junction two weeks before presentation in Emergency Department. CONCLUSION: This case report points out to the limitations of proposed criteria that aid in the recognition of AMI in patients with underlying paced rhythm and possible cause(s) of transient electrocardiographic abnormalities.

Clopidogrel cessation triggers aspirin rebound in patients with coronary stent.

WHAT IS KNOWN AND OBJECTIVE: Premature discontinuation of clopidogrel in patients undergoing percutaneous coronary intervention is a significant risk factor for thrombotic adverse outcomes. However, recent studies indicate that even discontinuation of long-term use of clopidogrel may be associated with multiple adverse outcomes, that is, rebound phenomenon whose mechanism is not definitely clear. The aim of the study was to examine the effect of clopidogrel withdrawal in those on combined aspirin and clopidogrel therapy. METHODS: This prospective, multicenter study enrolled 200 patients who underwent coronary stent implantation and were on dual antiplatelet therapy (100 mg aspirin + 75 mg clopidogrel) 1 year after the stent placement. In all patients, we measured the platelet aggregation, by multiplate electrode aggregometry, using two agonists [adenosine diphosphate with PGE1 (ADPHS) and arachidonic acid (ASPI)] two times: on the day of cessation of clopidogrel and 90 days after clopidogrel was stopped. RESULTS AND DISCUSSION: Following clopidogrel discontinuation, we registered an increase in ASPI values (P < 0·001), linear correlation between changes in ASPI and ADPHS values (P = 0·009) and significant difference in the values of ASPI first quartile of ADPHS compared with the other three (P < 0·001, P = 0·016, P < 0·001, I vs. II, I vs. III and I vs. IV quartile of ADPHS, respectively). WHAT IS NEW AND CONCLUSION: Our findings show that cessation of clopidogrel causes loss of antiplatelet synergism with aspirin, leading to a weakening of the response to aspirin, which may be one explanation for the rebound after the clopidogrel cessation.

Cerebrospinal fluid biomarkers of neurodegeneration in patients with juvenile and classic myotonic dystrophy type 1.

BACKGROUND AND PURPOSE: The aim of the present study was to analyze cerebrospinal fluid (CSF) levels of total tau (T-tau), phosphorylated tau (P-tau) and the 42-amino-acid form of ß-amyloid (Aß42 ) in patients with myotonic dystrophy type 1 (DM1), and their possible correlations with cognitive and behavioral manifestations in these patients. METHODS: Lumbar puncture was performed in 74 patients with DM1 [27 with the childhood/juvenile form (jDM1) and 47 with the adult form (aDM1) of the disease] and 26 control subjects who were subjected to orthopedic surgery. Sandwich ELISA was used for measuring the levels of T-tau, P-tau and Aß42. RESULTS: The CSF level of Aß42 was at its lowest in patients with jDM1 and at its highest in controls (P < 0.05). A tendency of T-tau and P-tau to increase was greater in aDM1 patients than in jDM1 patients and controls (P > 0.05). In both jDM1 and aDM1 patients, significant correlations were found between Aß42 and T-tau (rho = 0.81 and rho = 0.67, respectively, P < 0.01), as well as between Aß42 and P-tau (rho = 0.87 and rho = 0.67, respectively, P < 0.01). The Aß42/P-tau ratio decreased with age in aDM1 patients (rho = -0.30, P < 0.05). Only the level of Aß42 in the CSF of jDM1 patients was correlated with the size of the CTG expansion (rho = -0.53, P < 0.05). Only a few correlations were observed between levels of biomarkers and neuropsychological testing. CONCLUSION: The CSF level of Aß42 was decreased in patients with jDM1, whilst the Aß42/P-tau ratio was decreased in aDM1 patients. Positive correlations between Aß42 , T-tau and P-tau were observed in both forms of disease. Further studies with larger cohorts of DM1 patients are necessary.

Eye lens dosimetry in interventional cardiology: results of staff dose measurements and link to patient dose levels.

Workers involved in interventional cardiology procedures receive high eye lens dose if protection is not used. Currently, there is no suitable method for routine use for the measurement of eye dose. Since most angiography machines are equipped with suitable patient dosemeters, deriving factors linking staff eye doses to the patient doses can be helpful. In this study the patient kerma-area product, cumulative dose at an interventional reference point and eye dose in terms of Hp(3) of the cardiologists, nurses and radiographers for interventional cardiology procedures have been measured. Correlations between the patient dose and the staff eye dose were obtained. The mean eye dose was 121 µSv for the first operator, 33 µSv for the second operator/nurse and 12 µSv for radiographer. Normalised eye lens doses per unit kerma-area product were 0.94 µSv Gy⁻¹ cm⁻² for the first operator, 0.33 µSv Gy⁻¹ cm⁻² for the second operator/nurse and 0.16 µSv Gy⁻¹ cm⁻² for radiographers. Statistical analysis indicated that there is a weak but significant (p < 0.01) correlation between the eye dose and the kerma-area product for all three staff categories. These values are based on a local practice and may provide useful reference for other studies for validation and for wider utilisation in assessing the eye dose using patient dose values.

Nobori™ drug eluting stent system: clinical evidence update.

Drug eluting stents (DES) have changed the landscape of interventional cardiology with their high efficacy in preventing restenosis. Several DES are available for clinical use with different drugs, polymers and platforms. The Nobori™ is a novel generation drug eluting stent. The drug, Biolimus A9™, a sirolimus analogue, is immersed in a biodegradable polymer which is applied solely to the abluminal surface of a flexible stainless steel stent platform. The drug-polymer matrix is designed to release the drug simultaneously with the polymer degradation in a process lasting between 6-9 months. The coating design along with the lipophilicity of the drug is expected to optimize drug distribution and to reduce its release into the peripheral circulation. The drug free luminal surface might reduce negative impact on endothelization observed with DES with circumferential coating and durable polymers. Nobori™ stent is extensively studied in the comprehensive NOBORI clinical program. This stent showed superiority versus Taxus Liberte stent for in-stent late loss at 9 months in NOBORI 1 study, similarity to Cypher stent in NOBORI CORE study and superior performance versus both Taxus and Cypher stent in the study indirectly assessing endothelial function at 6-9 months after stent implantation. The landmark of NOBORI trials is very low rate of late and very late stent thrombosis along with exceptionally low target lesion revascularization rate.

Main branch stent deformation following difficult side branch rewiring and balloon dilatation. Rare complication of provisional T stenting.

Coronary artery bifurcations are one of the largest challenges in interventional cardiology. Presented is the case of a patient in whom restenosis of a drug-eluting stent (DES) occurred as a consequence of guide wire re-crossing between the main vessel stent struts and the vessel wall in the proximal part of DES, and consequential balloon crushing of the proximal portion of the DES. Initially, the complication was not recognized because of a good angiographic result and absence of intravascular ultrasound (IVUS) guidance during the procedure. During the second procedure, IVUS analysis explained the mechanism of the DES failure. The problem was solved with the implantation of a new DES.

[Current opinion in epidural analgesia influence on incidence of complications after major abdominal surgery].

Review article summarizes current knowledge of general and epidural anaesthesia combination for major abdominal surgery and incidence of postoperative complications. Continuous epidural local anaesthetics especially through thoracic placed epidural catheter decrease opioids use and as part of "acute rehabilitation" plays important role in postoperative recovery. Most of the studies showed tion is not dependent on kind of anaesthesia and analgesia. Successfully treated postoperative pain prevents chronic postoperative pain, which is best achieved in abdominal surgery with thoracic epidural use.

Preliminary characterization of lactic acid bacteria isolated from Zlatar cheese.

AIMS: Isolation, characterization and identification of lactic acid bacteria (LAB) from artisanal Zlatar cheese during the ripening process and selection of strains with good technological characteristics. METHODS AND RESULTS: Characterization of LAB was performed based on morphological, physiological and biochemical assays, as well as, by determining proteolytic activity and plasmid profile. rep-polymerase chain reaction (PCR) analysis and 16S rDNA sequencing were used for the identification of LAB. PCR analysis was performed with specific primers for detection of the gene encoding nisin production. Strains Lactobacillus paracasei subsp. paracasei, Lactobacillus plantarum, Lactobacillus brevis, Lactococcus lactis subsp. lactis, Enterococcus faecium and Enterococcus faecalis were the main groups present in the Zlatar cheese during ripening. CONCLUSIONS: Temporal changes in the species were observed during the Zlatar cheese ripening. Mesophilic lactobacilli are predominant microflora in Zlatar cheese. SIGNIFICANCE AND IMPACT OF THE STUDY: In this study we determined that Zlatar cheese up to 30 days old could be used as a source of strains for the preparation of potential starter cultures in the process of industrial cheese production. As the Serbian food market is adjusting to European Union regulations, the standardization of Zlatar cheese production by using starter culture(s) based on autochtonous well-characterized LAB will enable the industrial production of this popular cheese in the future.

[Methods for the quantification of left ventricular volumes assessed by radionuclide ventriculography (first part)].

The purpose of this study was to point out the existing methods and to describe and evaluate the accuracy of new, original, "Geometric-count-based" (GCB) method, based on radionuclide ventriculography, for the measurement of left ventricular volumes compaired to the contrast ventriculography. By having done this, the aim was to compare the accuracy of GCB method and other two radionuclide methods available for left ventricular volume measurements: Count-bases Massardo method and gated blood pool SPECT method. In GCB method count based data from radionuclide ventriculography were combined with geometric ones assuming a prolate ellipsoid left ventricular's shape with identical short axes. The following equation for computing left ventricular end-diastolic volume was developed: EDV = 2 x c x M x C(tot)/C(max), (1) where: 2c--manually drown short axis of prolate ellipsoid (left ventricle) at end-diastolic frame, M-calibrated pixel size, C(tot)--total counts in left ventricular's region of interest at end-diastolic frame, C(max)--maximum pixel counts in left ventricular's region of interest. Physical experiments with two different heart shaped phantoms were used to compare volumes assessed by all three radionuclide methods with the true volumes. The true volumes of cylindrical and ellipsoid phantoms of 112.5 ml and 190.5 ml, were computed to be 114 ml and 196 ml by our GCB method, 168 ml and 180 ml by Massardo method and 142 ml and 222 ml by gated blood pool SPECT methods, respectively. In clinical study, in 65 patients volumes assessed by radionuclide methods were compared to volumes measured using single plane contrast ventriculography as a gold standard. A good correlation of our original method was obtained with a contrast ventriculography for both EDV/m2 and ESV/m2 (r = 0.94, r = 0.92), slightly lower for Massardo method (EDV/m2: r = 0.90, ESV/m2 : r = 0.89) and significantly lower for gated blood pool SPECT (EDV/m2: r = 0.85, ESV/m2: r = 0.81, p < 0.01). In conclusion, both, phantom and clinical studies indicate that GCB radionuclide method is accurate, noninvasive for left ventricular volumes' measurement and should be widely used in everyday clinical practice.

Prognostic value of myocardial viability determined by a 201Tl SPECT study in patients with previous myocardial infarction and mild-to-moderate myocardial dysfunction.

The prognostic meaning of myocardial viability is most important in patients with severe left ventricular dysfunction and ischaemic heart disease, but its prognostic significance in patients with previous myocardial infarction and mild-to-moderate myocardial dysfunction is uncertain. The aim of this study was to assess the prognostic value of a 201Tl single photon emission computed tomography (SPECT) rest-redistribution study in patients with previous myocardial infarction, ischaemic heart disease and mild-to-moderate myocardial dysfunction. Myocardial viability was assessed in 55 patients (50 male; mean age 58+/-9 years) by 201Tl SPECT rest-redistribution (after 4 h) scintigraphy. All patients had previous myocardial infarction (>3 months) and angiographically documented coronary artery disease, with the mean ejection fraction of 43+/-10%. Out of 55 patients, 20 were medically treated and 35 were revascularized. The follow-up period for adverse cardiac events, including death and non-fatal myocardial infarction, was 12 months. 201Tl SPECT study was positive for myocardial viability in 36 patients (65%) and negative in 19 patients (35%). Sensitivity, specificity, positive and negative predictive values for functional improvement in the follow-up period were 85%, 75%, 92% and 60%. Out of seven (13%) cardiac events in the follow-up period (four cardiac deaths and three reinfarctions), five occurred in 20 medically treated patients and two in 35 revascularized patients (25% vs 6%, P <0.05). Absence of myocardial viability was the only variable associated with adverse cardiac events (P =0.02). Survival at 12 months, as determined by using Kaplan-Meier analysis, was 56% for medically treated and non-viable patients, 80% for revascularized and non-viable patients, 91% for medically treated and viable patients, and 100% for revascularized and viable patients (P =0.0034). These findings suggest that in patients with previous myocardial infarction and mild-to-moderate myocardial dysfunction, the absence of myocardial viability as determined by the 201Tl SPECT study was the only variable associated with adverse cardiac events. The best 12 month survival was observed in revascularized viable patients, whereas the worse prognosis was found in non-viable, medically treated patients.

[Total intravenous anesthesia using remifentanil and propofol with midazolam co-induction in laparoscopic surgery of the gallbladder]. / TIVA remifentanilom i propofolom uz koindukciju midazolamom za laparoskopske operacije zucne kese.

We investigated effects of total intravenous anesthesia (TIVA) with propofol and remifentanil (in two parallel continuous infusions), on 28 ASA I-II patients undergoing laparoscopic cholecystectomy. All patients received midazolame (0.05 mg/kg b.w.), and 90 sec thereafter, remifentanil (0.5 g/kg b.w.). Computer controlled intravenous infusion of propofol started at dose of 6 mg/kg/h (by Graseby 3400 Syringe Pump). Muscle relaxation was achieved by rocuronium (0.6 mg/kg b.w.). After endotracheal intubation, rate of propofol was decreased on 3 mg/kg/h and started with another infusion of remifentanil (0.5 ug/kg/min). Before (T0) and after induction (T1), after start of surgery (T2), and at the end of surgery (T3), we evaluated: systolic, diastolic, and medial arterial blood pressure (SAP, DAP, MAP), heart rate (HR), peripheral saturation of O2 (O2Sat), and capnometry (ETCO2), by Datex-Engstrome AS/3 Monitore. It was followed side effects of anaesthesia, early and complete recovery rate, and frequency of nausea and vomiting in postoperative period. Results showed haemodynamic stability of patients after induction in anaesthesia (defined as decreasing of MAP 20%, compared with preinduction values). During investigation (T0-T3), results of 0.2Sat and ETCO2 were excellent (0.60 +/- 2 and 5.1 +/- 2.4 min). There wasonly one case of postoperative nausea and vomiting, and no significant side effects of anaesthesia. TIVA remifentanil-propofol and co-induction with midazolame makes possible haemodynamic stability of patients after induction in anaesthesia, good oxygenation during surgery, fast early and complete recovery, and avoiding of side effects of anaesthesia and postoperative nausea and vomiting. We concluded that it is a good choice of anaesthesia for laparoscopic cholecystectomy.

The prognostic value of myocardial viability recognized by low dose dipyridamole echocardiography in patients with chronic ischaemic left ventricular dysfunction.

AIMS: The aim of this study was to assess the prognostic value of myocardial viability recognized as a contractile response to vasodilator stimulation in patients with left ventricular dysfunction in a large scale, prospective, multicentre, observational study. METHODS AND RESULTS: Three hundred and seven patients (mean age 60 +/- 10 years) with angiographically proven coronary artery disease, previous (>3 months) myocardial infarction and severe left ventricular dysfunction (ejection fraction <35%; mean ejection fraction: 28 +/- 7%) were enrolled in the study. Each patient underwent low dose dipyridamole echo (0.28 mg x kg(-1) in 4 min). Myocardial viability was identified as an improvement of >0.20 in the wall motion score index. By selection, all patients were followed up for a median of 36 months. One-hundred and twenty-four were revascularized either by coronary artery bypass grafting (n=83) or coronary angioplasty (n=41). The only end-point analysed was cardiac death. In the revascularized group, cardiac death occurred in one of the 41 patients with and in 16 of the 83 patients without a viable myocardium (2.4% vs 19.3%, P<0.01). Outcome, as estimated by Kaplan-Meier survival, was better for patients with, compared to patients without, a viable myocardium, who underwent coronary revascularization (97.6 vs 77.4%, P=0.01). Using a Cox proportional hazards model, the presence of myocardial viability was shown to exert a protective effect on survival (chi-square 4.6, hazard ratio 0.1, 95% CI 0.01-0.8, P<0.03). The survival rate in medically treated patients was lower than in revascularized patients irrespective of the presence of a viable myocardium (79.7% vs 86.2, P=ns). CONCLUSION: In severe left ventricular ischaemic dysfunction, myocardial viability, as assessed by low dose dipyridamole echo, is associated with improved survival in revascularized patients.

[The yentl syndrome in women with arterial hypertension and positive findings on the echocardiography dipyridamole stress test]. / Sindrom jentl kod zena s arterijskom hipertenzijom i positivnim nalazom ehokardiografskog testa stres-dipiridamol.

UNLABELLED: The aim of this study was to assess the possible gender differences between positive (new wall motion abnormality) combined dipyridamole stress echocardiography and coronary angiography or myocardial revascularization procedures. We evaluated 127 consecutive patients (82 males, 53.5 years old and 45 females, 56.1 years old) with systemic hypertension and chest pain (angina or atypical chest pain) who underwent pharmacological stress echocardiography (dipyridamole-atropine or dipyridamole-dobutamine) for detection of myocardial ischaemia. Coronary angiography was carried out in 84 patients (58 males and 26 females). Diagnostic accuracy of the test was the same in women as in men (92.3 vs 89.1%, females vs males, respectively). Coronary angiography was done in 73.6% of male and 66.7% of female patients with positive test; the difference was not significant. Over a two-year follow-up there were 31 myocardial revascularization procedures (20 coronary surgery and 11 angioplasty), 25 in men and 6 in women (p = 0.028). There was a trend in women with positive test to have less surgery or angioplasty (28.6%) than in men (45.3%), but the difference was not significant. Cox multivariate regression analysis revealed that women were less likely to receive revascularization (relative risk for females RR = 0.1457, 95% CI 0.0416-0.5101). CONCLUSION: Although diagnostic accuracy of third generation dipyridamole stress echocardiography was not different between men and women, in patients with positive test there was a trend in women to undergo coronary angiography and coronary surgery or angioplasty in lesser degree than in men. Cox multivariate model showed low relative risk of females for revascularization procedures and possible Yentl's syndrome in studied population.

Dipyridamole-atropine-induced myocardial infarction in a patient with patent epicardial coronary arteries.

BACKGROUND: The diagnostic accuracy of the physical and pharmacological stress echocardiography tests is higher than routine exercise electrocardiography. They have an acceptable safety profile and have been rarely associated with severe adverse effects. CASE REPORT: We present a case of acute anterior myocardial reinfarction immediately after exercise and pharmacological (dipyridamole-atropine) stress echocardiography testing 1 month after successful stent implantation in LAD. Our patient was a 43-year-old man with a history of heavy smoking and hypertension. Remarkably, the stress echocardiogram was non-diagnostic few hours before the infarction occurred. Angiography performed 4 months after the reinfarction revealed neither a culprit lesion nor stent thrombosis. CONCLUSION: Aggressive "last generation" pharmacological stress testing may provide optimal diagnostic accuracy, but as in our case, complications may occur, even after negative stress testing. To our knowledge, this is the first reported case of an acute myocardial infarction as a severe complication of stress testing, which developed in a patient after stent implantation.

Prediction of restenosis after coronary angioplasty by use of a new index: TIMI frame count/minimal luminal diameter ratio.

BACKGROUND: It has been shown recently that postangioplasty coronary flow reserve and the degree of residual stenosis have a modest predictive value for short- and long-term clinical outcomes after coronary angioplasty. Corrected TIMI frame count (CTFC) is a simple quantitative index of coronary blood flow. Its relationship with Doppler coronary flow velocity and clinical outcome after coronary angioplasty has not been fully clarified. The aim of this study was to identify clinical, angiographic, and functional predictors of clinical and angiographic restenosis after conventional coronary angioplasty. METHODS AND RESULTS: We studied 70 consecutive patients in whom intracoronary Doppler flow-velocity measurements were performed before and after angioplasty. Patients were evaluated for restenosis by clinical follow-up, exercise stress test/(201)Tl scintigraphy, and follow-up angiography, which was performed at 10. 5+/-10.3 months in 63 patients. According to the results of univariate analysis, a new index, postangioplasty CTFC/minimal luminal diameter (MLD) ratio, was created. Multivariate analysis revealed that CTFC/MLD ratio was the only independent predictor of angiographic (OR 2.02; 95% CI 1.37 to 2.97; P<0.0004) and clinical (OR 1.60; 95% CI 1.15 to 2.21; P<0.005) restenosis. The receiver operating characteristic curve area of this index was 79% for angiographic and 73% for clinical restenosis. The optimal CTFC/MLD ratio cutoff values were 7.88 for angiographic and 7.94 for clinical restenosis, respectively. CONCLUSIONS: Our data indicate that postangioplasty CTFC/MLD ratio, which incorporates both the angiographic and functional features of coronary lesions, is a reliable, objective, and inexpensive index for prediction of angiographic and clinical restenosis after conventional coronary angioplasty.

Arrhythmias in acute pericarditis. An endomyocardial biopsy study.

It is still controversial whether the arrhythmias in acute pericarditis are of myocardial or pericardial origin. The aim of the present study was to investigate the occurrence of arrhythmias and conduction disorders in patients with acute pericarditis with no endomyocardial biopsy evidence of myocarditis (group 1: 40 patients, 65% males, mean age 45.6 +/- 15.7 years, mean heart rate [HR] 98.7 +/- 22.2 beats per minute) in comparison to endomyocardial biopsy proven acute myocarditis/perimyocarditis (group 2: 10 patients, 3/10 with perimyocarditis, 70% males, mean age 46.1 +/- 15.8 years, mean heart rate 76.7 +/- 33.1 beats per minute). At the initial assessment all patients underwent comprehensive clinical work-up including echocardiography, cardiac catheterization, and endomyocardial biopsy. In all patients biventricular endomyocardial biopsy was performed using standard femoral approach and Schikumed 7 F or 8 F bioptomes. Tissue samples were stained by H & E, v. Gieson and independently reviewed by two cardiac pathologists. In addition immunohistochemistry and immunocytochemistry were performed, and only patients fulfilling Dallas and World Heart Federation criteria were selected for group 2. Comparative analysis of electrocardiograms and 24-hour Holter recordings at initial presentation revealed in group 1 vs group 2 significantly less frequent paroxysmal supraventricular tachyarrhythmias (5% vs 40%), and ventricular fibrillation (0 vs 20%), in contrast to atrial fibrillation that occurred more often (20% vs 0) (all p < 0.05). Furthermore, in the group 2 one patient died due to VF and two patients underwent ICD implantation. Low voltage (40% vs 30%) and ST/T wave changes (47.5% vs 30%), as well as the incidence of the II degree AV block (5% vs 0) and complete AV block (2.5% vs 10%) were not significantly different between the groups. In conclusion, patients with pericarditis and no endomyocardial biopsy indications of myocarditis had significantly less often life threatening rhythm disorders in contrast to patients with endomyocardial biopsy proven acute myocarditis/perimyocarditis. On the contrary, incidence of transitory atrial fibrillation was higher in acute pericarditis, than in myocarditis.

Flexible percutaneous pericardioscopy: inherent drawbacks and recent advances.

Pericardioscopy enables endoscopic inspection and aimed biopsy of the parietal and visceral pericardium. To elucidate possible technical modifications contributing to the feasibility, diagnostic value and safety of the procedure, pericardioscopy with an Olympus HYF-1T flexible endoscope was performed in 32 patients (53.1% males, mean age 46.2 +/- 13.1 years) with pericardial effusions. In all patients, the initial step of the procedure was subxiphoid fluoroscopically controlled pericardiocentesis and drainage of the pericardial effusion. An Olympus FB-41ST biopsy forceps was applied for endoscopically guided pericardial biopsies. Standard sampling was used in 22/32 patients (3 to 6 samples/patient) and extensive sampling in 10/32 patients (18 to 20 samples/patient). In additional 12 patients pericardial biopsy was performed without pericardioscopy, under fluoroscopic control. Endoscopic visualization was clearly superior when pericardial effusion was partially replaced with 100 to 300 ml of air (29/32 procedures) in comparison to 3/32 procedures in which the pericardial effusion was replaced with warm normal saline (37 degrees C). In patients with hemorrhagic effusion (12/32), we either repeatedly injected and removed 100 to 150 ml volumes of normal saline (37 degrees C), or postponed pericardioscopy for 2 to 3 days of active drainage. The specificity of endoscopic findings is low and not decisive for the diagnosis. However, pericardioscopy is significantly contributing to the diagnostic value of pericardial biopsy, especially regarding establishing the new diagnosis and etiology of the pericardial disease. Sampling efficiency was also significantly higher for procedures using aimed pericardial biopsy with standard and extensive sampling compared to procedures performed under fluoroscopy: 86.2%, 87.3%, and 43.7%, respectively. No major complications directly related to the procedure were encountered. Minor complications included: short-run ventricular tachycardia (6.3%), pain at the sheath entry site (75%) and transient fever (37.5%). In conclusion, pericardioscopy with Olympus HYF-1T, after air instillation, is a technically complex, but safe procedure that enables excellent visualization and extensive pericardial sampling with improved diagnostic value of pericardial biopsies.

Pharmacological radionuclide ventriculography for detection of myocardial contractile reserve in patients after myocardial infarction: head-to-head comparison of low dose dobutamine and low dose dipyridamole.

BACKGROUND: Low dose pharmacological stress echocardiography with either dobutamine or dipyridamole infusion has been proposed for recognition of myocardial viability. However, dependence on adequate acoustic window, observer experience, and the mild degree of wall motion changes make the viability assessment by stress echocardiography especially bothersome. The objective of the study was to evaluate the ability of low dose dobutamine and low dose dipyridamole radionuclide ventriculography to detect contractile reserve in patients after myocardial infarction and functional recovery after coronary angioplasty. METHODS: The study group consisted of 20 consecutive patients (52 +/- 10 years, 17 male, 3 female) with previous myocardial infarction and resting regional dyssynergy, in whom diagnostic cardiac catheterization revealed significant one-vessel coronary artery stenosis suitable for angioplasty. Each patient underwent equilibrium 99m-Tc radionuclide ventriculography which was performed at rest and during low dose dipyridamole (0.28 mg/kg over 2 minutes) and low dose dobutamine infusion (up to 10 mcg/kg/min). Left ventricular global and regional ejection fractions were determined. Increase of regional ejection fraction for > 5% (inferoapical and posterolateral regions) or > 10% (anteroseptal regions) during low dose dobutamine and dipyridamole in infarcted regions, as well as in the followup period, was considered as index of contractile reserve. After 8 weeks of successful angioplasty, resting radionuclide ventriculography was repeated in all patients in order to identify functional recovery of the infarct zone. RESULTS: Out of the 180 analyzed segments (20 x 9), 90 regional ejection fractions have shown depressed contractility. The mean of the regional ejection fractions showing depressed contractility increased from the resting value of 34 +/- 12% to 42 +/- 14% in the follow-up period (p = 0.06). Of the 90 with baseline dyssynergy, 46 were responders during low-dose dobutamine (51%), whereas 32 segments were responders (36%, p = 0.05 vs. dobutamine) during low dose dipyridamole. Positive predictive value of dobutamine and dipyridamole for predicting functional recovery was 72% and 75% (p = ns), respectively. Negative predictive value of dobutamine and dipyridamole was 48% and 69% (p = 0.05), respectively. In the group of patients with most severe dyskinesia (regional ejection fraction < 35%, 42 segments) positive predictive value was 73% and 82%, while negative predictive value was 42% and 64% for low dose dobutamine and low dose dipyridamole respectively (p = ns). CONCLUSION: Although low dose dobutamine induced higher rate of positive responses during radionuclide ventriculography imaging, dipyridamole radionuclide ventriculography has shown superior, particularly negative, prognostic value for predicting functional recovery of infarcted regions.

[Stress ulcer in a patient with a subacute subdural hematoma]. / Stres ulkus kod bolesnika sa subakutnim subduralnim hematomom.

During the onset and development of pathologic events, numerous changes occur in the body as the result of an attempt of dynamic equilibrium maintenance. Results of such sequence of events may lead to organic, as well as psychic impairment of the body that is often referred to as the onset of psychosomatic disease. This paper deals with the disorder that could provide better insight in the possible physiopathologic mechanisms of psychosomatic disease or disorders. In a patient, chronic alcoholic subdural hematoma was diagnosed. Peptic ulcer hemorrhage occurred after surgical removal of the hematoma. Possible physiopathologic mechanisms in the origin of this disorder have been described.