[Long-term treatment with quinapril in chronic aortic and mitral insufficiency]. / Langzeittherapie mit Quinapril bei chronischer Aorten- und Mitralinsuffizienz.

The effect on myocardial function and structure of long-term administration of quinapril (10-20 mg daily), an angiotensin-converting-enzyme (ACE) inhibitor, was investigated in 24 patients (18 men, 6 women; mean age 48 [20-65] years) with chronic isolated asymptomatic aortic or mitral regurgitation. Coronary heart disease had been excluded angiographically. After one year's treatment the regurgitation fraction, compared with the pretreatment value, had decreased by 27% in those patients with aortic regurgitation (AR) and 42% in those with mitral regurgitation (MR) (P = 0.0001). The mean left ventricular enddiastolic volume was reduced from 150 +/- 33 to 128 +/- 30 ml/m2 in patients with AR, from 146 +/- 26 to 109 +/- 24 ml/m2 in those with MR (P = 0.0001). The mean endsystolic volume fell from 55 +/- 27 to 44 +/- 28 ml/m2 in patients with AR and from 63 +/- 43 to 47 +/- 29 ml/m2 in those with MR (P = 0.002). The mean left ventricular ejection fraction at rest and on exercise rose slightly in patients with AR, remaining unchanged in those with MR. The left ventricular mass, as measured by echocardiography, was reduced by 35% in patients with AR, and the left ventricular hypertrophy, demonstrated in all patients, regressed. In patients with MR the left ventricular mass decreased by 15% and septal thickness became normal (borderline hypertrophy). These data indicate that, after one year's treatment with quinapril, left ventricular dilatation, mass and hypertrophy regressed and left ventricular function improved in patients with AR or MR.

Effects of 12 months quinapril therapy in asymptomatic patients with chronic aortic regurgitation.

This study was performed to assess the effects of one year of ACE inhibition with quinapril on left ventricular performance and morphology in asymptomatic patients with chronic aortic regurgitation. Pre- and afterload reduction is known to have beneficial effects in patients with chronic aortic regurgitation. To date, no controlled study has been reported analyzing long term influence of ACE inhibitor treatment on asymptomatic patients with chronic aortic regurgitation. Twelve asymptomatic patients with isolated moderate to severe chronic aortic regurgitation, no coronary disease on coronary angiography and no previous vasodilator treatment were studied under control conditions and after three and 12 months of quinapril therapy (10-20 mg/day) using echocardiography and simultaneous right heart catheterization and radionuclide ventriculography at rest and during supine bicycle exercise. After one year quinapril therapy regurgitant fraction fell by 17% compared to control before therapy (p = 0.001), left ventricular enddiastolic volume at rest was reduced from 150 +/- 33 to 128 +/- 30 ml/m2 (p = 0.0003) and endsystolic volume decreased from 55 +/- 27 to 44 +/- 28 ml/m2 (p = 0.0005). Left ventricular ejection fraction at rest averaged 0.64 +/- 0.11 at control and increased after one year therapy to 0.67 +/- 0.11 (p = 0.05). With maximum exercise (100 W), ejection fraction failed to rise at control; after one year therapy with quinapril it increased to 0.70 +/- 0.15 (p = 0.019). Moreover, after one year quinapril therapy there was a significant reduction of 35% in left ventricular mass compared to control.(ABSTRACT TRUNCATED AT 250 WORDS)

Hemodynamic and morphologic changes after long-term angiotensin converting enzyme inhibition in patients with chronic valvular regurgitation.

OBJECTIVE: Angiotensin converting enzyme (ACE) inhibitors decrease preload and afterload and are therefore of potential value in valvular regurgitation. The present study was designed to assess the effects of treatment for 1 year with an ACE inhibitor on myocardial performance. PATIENTS AND METHODS: Twenty-four patients with isolated moderate to severe chronic aortic regurgitation or mitral regurgitation who were free of coronary disease were studied before treatment (control) with the ACE inhibitor quinapril and were then followed for 1 year during quinapril therapy (10-20 mg/day). RESULTS: After 1 year of ACE inhibition, the regurgitant fraction fell by 27 and 42%, compared with control values, in the aortic and mitral regurgitation groups, respectively (P = 0.0001). The left ventricular end-diastolic volume was reduced from 150 +/- 33 to 128 +/- 30 ml/m2 in the aortic regurgitation group, and from 146 +/- 26 to 109 +/- 24 ml/m2 in the mitral regurgitation group (P = 0.0001 for each). End-systolic volume decreased from 55 +/- 27 to 44 +/- 28 ml/m2 in the aortic regurgitation group (P = 0.005) and from 63 +/- 43 to 47 +/- 29 ml/m2 in the mitral regurgitation group (P = 0.002). The left ventricular ejection fraction increased slightly at rest and during exercise in patients with aortic regurgitation, but showed no change in the mitral regurgitation patients after 1 year of quinapril treatment. Echocardiographic studies showed that after 1 year of therapy there was a decrease of about 10% in the left ventricular end-diastolic and end-systolic diameter in both patient groups. Moreover, the left ventricular mass was reduced by 35% in the aortic regurgitation group (P = 0.0001), and left ventricular hypertrophy, which was present in all patients, was reversed completely. In the mitral regurgitation group, a mass reduction of 15% was observed after 1 year of quinapril treatment, and the septal wall thickness, which indicated borderline hypertrophy, decreased to normal. CONCLUSION: These results demonstrate that long-term ACE inhibition in patients with valvular regurgitation reverses left ventricular dilation and reduces left ventricular mass and hypertrophy, thereby improving left ventricular function. Further, they suggest that ACE inhibition may have the potential to delay aortic or mitral valve replacement.

Quinapril therapy in patients with chronic mitral regurgitation.

Pre- and afterload reduction is known to have beneficial effects in patients with chronic mitral regurgitation. To date, no controlled study has been reported analyzing the long term influence of angiotensin-converting enzyme inhibitor treatment on patients with chronic mitral regurgitation. Therefore the aim of this study was to assess the effects of one year angiotensin-converting enzyme inhibition with quinapril on myocardial performance in patients with chronic mitral regurgitation. Twelve patients with moderate to severe isolated chronic mitral regurgitation and no coronary disease on coronary angiography were studied under control conditions and followed up until one year of quinapril therapy (10-20mg/day) using echocardiography and simultaneous right heart catheterization, and radionuclide ventriculography at rest and exercise. As the result of a significant pre- and afterload reduction after one year quinapril treatment regurgitant fraction fell from 0.43 +/- 0.10 at control before therapy to 0.25 +/- 0.08 (p = 0.0001), left ventricular end-diastolic volume was reduced from 146 +/- 26 to 109 +/- 24 ml/m2 (p = 0.0001) and end-systolic volume decreased from 63 +/- 43 to 47 +/- 29 ml/m2 (p = 0.02). Left ventricular ejection fraction at control averaged 0.59 +/- 0.20 at rest, increased to 0.65 +/- 0.21 with maximum exercise and was unchanged after one year quinapril therapy. After one year treatment left ventricular mass was reduced by 15% (p = 0.0004) and septal wall thickness decreased from 11.8 +/- 0.7 to 10.8 +/- 0.8 mm (p = 0.0006). Moreover, there was significant functional improvement of nearly one NYHA class after one year quinapril therapy. In conclusion, in patients with chronic mitral regurgitation long term angiotensin-converting enzyme inhibition with quinapril reduces regurgitation and decreases left ventricular size and mass thereby demonstrating functional improvement. In addition, these data suggest that angiotensin-converting enzyme inhibition might have the potential of delaying mitral valve surgery.

Beneficial effects of a single dose of quinapril on left ventricular performance in chronic mitral regurgitation.

To evaluate the effect of a single dose of the angiotensin-converting enzyme inhibitor quinapril on left ventricular (LV) performance and size in patients with moderate to severe chronic mitral regurgitation (MR), 12 patients with angiographically proven isolated MR grade II to III and no evidence of coronary artery disease were studied. In all patients a baseline right heart catheterization and simultaneous radionuclide angiogram were performed at rest and during supine exercise (maximum 100 W) as well as 2 hours after oral administration of 10 mg of quinapril. Quinapril reduced heart rate slightly and lowered mean blood pressure at rest and during maximal exercise (p < 0.05). Systemic vascular resistance at rest was decreased from 1,484 +/- 505 to 1,150 +/- 427 dynes s cm-5 and with maximal exercise from 999 +/- 455 to 734 +/- 395 dynes s cm-5 (p < 0.005). Pulmonary capillary arterial pressure at rest decreased from 13 +/- 6 to 10 +/- 4 mm Hg (p = 0.01) and during maximal exercise from 29 +/- 10 to 20 +/- 7 mm Hg (p = 0.001). LV end-diastolic volume at rest (146 +/- 26 ml/m2) decreased after administration of quinapril to 128 +/- 24 ml/m2 (p = 0.001) and was also reduced during exercise (p = 0.001). LV end-systolic volume decreased from 63 +/- 43 to 49 +/- 35 ml/m2 at rest (p = 0.001) and with maximal exercise from 56 +/- 49 to 44 +/- 39 ml/m2 (p < 0.01).(ABSTRACT TRUNCATED AT 250 WORDS)

[Changes in infectious endocarditis--analysis of a disease picture in the last decade]. / Die infektiöse Endokarditis im Wandel--Analyse eines Krankheitsbilds im letzten Jahrzehnt.

The following retrospective study analyzes 51 patients aged 45.8 +/- 11 years with infective endocarditis diagnosed from January 1, 1980-December 31, 1989. The aortic valve was mainly affected (59%). 92% of patients showed predisposing factors or a directly related incident. Positive blood cultures were found in 63% of patients. The dominating bacterium was streptococcus viridans (31%) with decreasing tendency compared to the previous decade, followed by staphylococcus aureus (22%) with significantly increasing tendency. Clinical and laboratory findings were not different from those of the previous decade. Main complications in the early period of disease turned out to be acute heart failure (69%) and arterial embolism (41%) which was dependent on the severity of disease. Mortality within the initial 6 months was significantly lower than in the previous decade (16% vs 31%). Patients undergoing heart-valve replacement within the first 6 months of disease (59%) had a mortality rate of 10%, which was significantly smaller than the 24% mortality rate of patients not being operated during the same period. Furthermore, patients with staphylococcus aureus endocarditis demonstrated a markedly worse early prognosis (6 month survival rate 28.6 +/- 17.2% vs 80.0 +/- 6.1% in patients with infective endocarditis other than staphylococcus aureus-related). Late mortality was not different in the above-mentioned subgroups with a 5-year survival of more than 80%. However, surgically treated patients significantly improved their functional class in the follow-up period over medically treated patients.(ABSTRACT TRUNCATED AT 250 WORDS)

[Heart valve surgery: an analysis of the causes and peri- and postoperative course]. / Herzklappenreoperationen: Eine Analyse der Ursachen sowie des peri- und postoperativen Verlaufs.

From a total of 1,152 consecutive patients with heart valve replacement (1964-87) 108 patients (9.4%) had to be reoperated. Mechanical valves had to be replaced (n = 89) mainly because of perivalvular leakage followed by prosthetic stenosis and dysfunction. The lowest reoperation rate was found with Björk-Shiley prostheses (3.4%). Bioprostheses (reoperation rate 8.2%) had to be reoperated predominantly as a consequence of dysfunction. Ten years following implantation 30% of bioprostheses had to be replaced. Patients with reoperations demonstrated, in comparison to patients with singular valve replacement, no significant change in early mortality during the last 6 years (6.8% vs 5.4%). Furthermore, both patient groups revealed similar survival rates (10 years; 78% vs 76%) and improvement of life quality. However, non-lethal peri- and postoperative complication rates were higher in reoperated patients compared to patients with first valve replacement.

[Criteria for the optimal time of heart valve surgery]. / Kriterien für den optimalen Zeitpunkt von Herzklappenoperationen.

The timing for heart surgery in mitral and aortic stenosis is still determined by the clinical situation such as NYHA-classification III and IV (or II in exceptional cases). In symptomatic patients with aortic incompetence surgery should be performed quickly. Patients with slight symptoms should only be operated if there are sings of left ventricular insufficiency at rest. There is still a discussion about patients with signs of left ventricular dysfunction on exercise; in such patients controls at short intervals are recommended. As long as left ventricular function is normal patients with aortic incompetence have a good prognosis. In patients with mitral incompetence the same criteria can be used but there are no sufficient studies on patients with normal left ventricular function which were operated. Non-invasive diagnostic techniques seem to be sufficient for the follow-up-examinations.

[Heart valve replacement in patients over age 60: analysis of the peri- and postoperative course compared to patients under age 60]. / Herzklappenersatz bei über 60jährigen Patienten: Analyse des peri- und postoperativen Verlaufs im Vergleich zu unter 60jährigen.

During recent years, advances in cardiology and cardiac surgery have led to an increased number of older patients submitted for heart valve replacement. The following retrospective study analyses perioperative risk and long-term prognosis of 168 patients older than 60 years of age, compared with 942 patients younger than 60 years of age with heart valve replacement. There was no significant difference in 7-year actuarial survival, late mortality, late complications and postoperative functional improvement for both groups. However, early mortality was higher in patients over 60 years of age than in the group of patients under 60 years (7.9% vs. 4.5% from 1980-85, p less than 0.05), especially when multivalvular replacement was performed or the patients were in preoperative functional class NYHA IV. The results indicate that in patients over 60 years of age, heart valve replacement can be performed with a good long-term prognosis and a marked improvement in the quality of life. Early mortality can be reduced to an acceptable rate if the patient is operated in time.

Measurement of myocardial fatty acid metabolism: kinetics of iodine-123 heptadecanoic acid in normal dog hearts.

To define the potential of iodine-123 heptadecanoic acid (IHA) for the noninvasive assessment of myocardial fatty acid metabolism with gamma camera imaging, the influence of myocardial oxygen consumption (MVO2) and blood flow (MBF) on extraction and half-times of IHA were investigated in dogs. Following IHA injection into the left circumflex coronary artery, extraction fraction and half-times were derived from the peak and slope of the IHA time activity curve, which consisted of a vascular, early, and late phase. Single-pass extraction fraction of IHA averaged 0.53 +/- 0.11 s.d. at control and was not influenced by MVO2 and MBF. The half-time of the early phase (T = 9.3 min +/- 2.8 s.d. in controls) as well as the ratio between the size of the early and late phase increased with MVO2 (r = 0.82, r = 0.87, respectively). Thus, early phase intracellular turnover of IHA increased, yet clearance of 123I activity was slowed by augmented cardiac work. Preliminary data of HPLC and electrophoretic analysis of myocardial arterial and venous blood samples over time indicate that the early phase is characterized by a decreasing washout of IHA and a relative increase of radioiodine washout. The half-time of the late phase (T = 245 min +/- 156 s.d. at control) was not related to MVO2 and MBF. In conclusion, myocardial fatty acid metabolism cannot be measured from the half-time of the early phase but might be analyzed from the ratio between the size of the early and late phase when using IHA.

I-123 heptadecanoic acid--value and limitations in comparison with C-11 palmitate.

To define the potential of 123I-labeled heptadecanoic acid (IHA) for the noninvasive assessment of myocardial free fatty acid (FFA) metabolism, the kinetics of IHA were compared to those of physiologic 11C-palmitate (CPA). The single-pass myocardial extraction fraction of IHA was lower than that of CPA (0.53 +/- 0.11 vs 0.65 +/- 0.10 under control conditions). Following an intracoronary injection of IHA and CPA, the myocardial time-activity curves showed biphasic clearance of both tracers. While, for CPA, the half-time of the early phase of the time-activity curve was a function of myocardial oxygen consumption (MVO2), this phase was not found to reflect the oxidative metabolism of IHA. However, for both tracers, the size of the early phase increased with augmented MVO2, whereas the size of the late phase decreased. The late phase represents storage of both tracers in triglycerides and phospholipids. Hence, while quantitative measurement of CPA oxidation is possible from the early phase of the time-activity curve, only the ratio between the size of the early and late phase might be of value in assessing myocardial FFA metabolism using IHA.

Are bioprostheses superior to mechanical valves?

After 8 years of comparison to MV, BP reveal no significant difference in early mortality and late survival statistics, yet demonstrated a higher rate of late complications such as endocarditis and perivalvular leak. In conclusion our data indicate that BP are not superior to MV after 8 years of follow-up.

Hemolytic anemia with pyruvate kinase deficiency presenting as paravertebral myelolipoma.

The case of a patient with erythrocyte pyruvate kinase (PK) deficiency hemolytic anemia leading to extramedullary hematopoiesis in a paravertebral myelolipoma is presented.

[Positron computed tomography: a new method for quantitative determination of cardiac metabolism, blood circulation and function. I. Technical and experimental bases]. / Positronen-Computertomographie: Eine neue Methode zur quantitativen Bestimmung von Stoffwechsel, Durchblutung und Funktion des Herzens. I. Technische und experimentelle Grundlagen.

Positron computed tomography represents a new method which permits qualitative and quantitative assessment of physiologic processes in different organs on a molecular basis. Thus this 'physiologic imaging device' enables noninvasive detection of regional myocardial metabolism, perfusion and global as well as regional myocardial function. The unique capability of simultaneous measurement of the interdependent parameters perfusion, metabolism and function will provide new insights in physiologic and pathophysiologic processes of the heart and, hence, in the understanding of heart disease. Since a great number of cardiac disorders is related to disturbances at the cellular and metabolic level, this new method may contribute to the early detection and eventually to an early treatment of heart disease. With improvements in instrumentation as well as the development of new physiologic indicators and small generator-like cyclotrons, positron computed tomography will become clinically more widespread in various medical centers.