Regurgitant flow in cardiac valve prostheses: diagnostic value of gradient echo nuclear magnetic resonance imaging in reference to transesophageal two-dimensional color Doppler echocardiography.

Gradient echo nuclear magnetic resonance (NMR) imaging and transesophageal two-dimensional color Doppler echocardiography are flow-sensitive techniques that have been used in the diagnosis and grading of valvular regurgitation. To define the diagnostic value of gradient echo NMR imaging in the detection of regurgitant flow in cardiac valve prostheses and the differentiation of physiologic leakage flow from pathologic transvalvular or paravalvular leakage flow, 47 patients with 55 valve prostheses were examined. Color Doppler transesophageal echocardiography was used for comparison. Surgical confirmation of findings was obtained in 11 patients with 13 valve prostheses. Gradient echo NMR imaging showed regurgitant flow in 37 of 43 valves with a jet seen on transesophageal echocardiography and it detected physiologic leakage flow in 4 additional valves. There was 96% agreement between the two methods in distinguishing between physiologic and pathologic leakage flow. The methods differed on jet origin of pathologic leakage flow in six prostheses. The degree of regurgitation was graded by both NMR imaging and transesophageal echocardiography, according to the area of the regurgitant jet visualized; gradings were identical for 75% of valve prostheses. Quantification of jet length and area showed a good correlation between the two methods (r = 0.85 and r = 0.91, respectively). Gradient echo NMR imaging is a useful noninvasive technique for the detection, localization and estimation of regurgitant flow in cardiac valve prostheses. However, because transesophageal echocardiography is less time-consuming and less expensive, gradient echo NMR imaging is unlikely to displace transesophageal echocardiography and should be used only in the occasional patient who cannot be adequately imaged by echocardiography.

Pentamidine aerosol increases the number of alveolar macrophages in HIV-infected patients.

In order to determine the possible effect of aerosolized pentamidine on the cellular composition of the bronchoalveolar lavage fluid in HIV-infected patients, differential counts of 22 consecutive patients who had been rebronchoscopied after 3-19 months were reviewed. Eleven patients were started on pentamidine prophylaxis subsequent to their first presentation. Eleven patients had never taken pentamidine or had discontinued the prophylactic regimen. Compared to first bronchoscopy, the bronchoalveolar lavage (BAL) from patients on regular prophylaxis revealed a significant increase in absolute alveolar macrophage (AM) counts at second presentation (20.8 +/- 11.2 to 50.3 +/- 39.4 x 10(5) cells/100 ml BAL; P less than 0.01). The AM counts of those without pentamidine remained essentially unchanged. Lymphocytes, including CD4 and CD8 subtypes, and neutrophils did not change over time in either group. The results of this retrospective analysis suggest that, in addition to its antimicrobial action, pentamidine may modulate local lung defence mechanisms, particularly by increasing the absolute number of AM.

Feasibility of high-dose dipyridamole-magnetic resonance imaging for detection of coronary artery disease and comparison with coronary angiography.

To assess the feasibility, safety and usefulness of gradient-echo magnetic resonance imaging (MRI) combined with pharmacologic stress testing for the detection of coronary artery disease, 23 patients without previous myocardial infarction but with significant stenosis (greater than 70% diameter stenosis) of greater than or equal to 1 major coronary artery were selected for dipyridamole-MRI stress testing. Each patient underwent MRI at rest, and high-dose dipyridamole-MRI (0.75 mg/kg over 10 minutes) of corresponding basal and midventricular short-axis tomograms. Additionally, these patients performed symptom-limited exercise stress tests. All short-axis tomograms were evaluated on a standardized segmental basis by grading each segment as normal, hypokinetic, akinetic or dyskinetic. Dipyridamole-MRI was considered pathologic if segmental wall motion deteriorated by greater than or equal to 1 grade after dipyridamole. For comparison with coronary angiography, segmental wall motion gradings were related to the respective coronary artery territories in the short-axis plane. Pathologic dipyridamole-MRI was obtained in 18 of 23 (78%) patients. For 1- and 2-vessel diseases, sensitivity was 69 and 90%, respectively. Exercise stress tests were pathologic in 14 of 23 (66%) patients. For 1- and 2-vessel diseases, sensitivity of exercise stress test was 58% (7 of 12 patients) and 77% (7 of 9), respectively. Sensitivity/specificity of dipyridamole-MRI for the localization of the stenosed coronary artery was 78/100% for left anterior descending, 73/100% for left circumflex, and 88/87% for right coronary artery stenoses. It is concluded that dipyridamole-MRI is a feasible nonexercise-dependent test for detection and localization of functionally significant coronary artery disease.

Reversible volume changes of trapped gas in nonspecific bronchoprovocation tests.

Thirty patients with a history of asthma and ten patients with suspected bronchial hyperreactivity underwent nonspecific provocation testing. The control group consisted of ten normal volunteers without a history of lung disease. The patients' baseline FEV1 (percent predicted) revealed mild obstructive disease (72.9 +/- 8.9 percent and 74.6 +/- 7.7 percent) compared with controls (87.2 +/- 8.5 percent, p less than 0.001). The mean volume of trapped gas (D) (ie, TLCB-TLCHe) was not significantly different between groups (0.11 +/- 0.49 L vs 0.15 +/- 0.4 L vs 0.18 +/- 0.45 L), and no correlation was established with any of the remaining lung function data. Bronchial hyperreactivity in response to inhaling acetylcholine could be observed in the asthma group only. Their mean D increased significantly from 0.11 +/- 0.49 L to 0.62 +/- 0.66 L (p less than 0.001), and returned to baseline (0.26 +/- 0.55, NS) subsequent to inhaling salbutamol. D changes induced by acetylcholine correlated weakly with concurrent changes of FEV1 (r = -0.44, p = 0.01), RV (r = 0.59, p less than 0.001), and Rs (r = 0.59, p less than 0.001). In response to bronchodilating doses of salbutamol, however, D was changed in close correlation with FEV1 (r = -0.82, p less than 0.0001), RV (r = 0.85, p less than 0.0001), and Rs (r = 0.76, p less than 0.0001). Provided that D is a valid parameter of small airways function, these data may give a clue to the site of action of both drugs. Acetylcholine affects small and large airways alike with no clear-cut preference, whereas salbutamol's predominant target appears to be the small airways. These conclusions are only partially supported by the pertinent literature.

Left ventricular geometry and function before and after mitral valve replacement.

Left ventricular geometry and function were assessed in 20 patients with mitral stenosis (MS) and in another 20 patients with mitral insufficiency (MI) five days before and 12 days after mitral valve replacement by transthoracic (TTE) and transesophageal (TEE) echocardiography, as well as late postoperatively (mean: 194 days) by TTE. The continuity of the subvalvular apparatus could not be preserved in any of these patients. In mitral stenosis the area ejection fraction (AEF) in the short axis of the left ventricle (LV) did not change significantly early or late postoperatively. There was a significant lengthening of the left ventricular longitudinal axis in the apical four chamber view whereas the transverse axis remained unchanged. This was likely the result of the discontinuity between the mitral valve and the papillary muscles. AEF and ejection fraction (EF) determined in the four chamber view showed a slight tendency to decrease in the postoperative phase. Patients with mitral insufficiency likewise showed a significant increase of the LV longitudinal diameter postoperatively. In the short axis of the left ventricle and in the apical four chamber view a significant reduction of the AEF was observed. Furthermore, left ventricular EF dropped significantly postoperatively. This decrease was caused by the extension of the LV longitudinal axis accompanied by an enlargement of the transverse diameter as well as by an afterload increase, and a masked impairment of left ventricular function preoperatively. Wall motion analysis of the LV in both groups documented new postoperative hypokinesis especially in the septal segments. At late postoperative examination the hypokinesis disappeared in about 50% of the patients.(ABSTRACT TRUNCATED AT 250 WORDS)

[Cinematographic and clinical findings from simultaneous two-plane coronary angiography (author's transl)]. / Kinematographische und klinische Ergebnisse bei gleichzeitiger 2-Ebenen-Koronarographie

Simultaneous cine-angiographic examination of the coronary arteries in two planes is now possible, due to technical advances, without losing any of the information that may be obtained by a single-plane technique. This method shortens the examination, reduces the radiation dose when compared with a large film technique and significantly reduces the risk to the patient. Our experience in 67 examinations is recorded.

[Magnetic resonance tomography in patients with a heart valve prosthesis]. / Magnetresonanztomographie bei Patienten mit Herzklappenersatz.

Artificial valve prostheses are often regarded as a contraindication for magnetic resonance imaging (MRI), although preliminary in vitro studies suggested, that patients with these metallic implants might safely undergo MR examination. This study reports on the experience with a group of 89 patients with 100 heart valve prostheses who were examined by spin-echo MR and gradient-echo MR. MR examination was performed in all patients without complications. The spin-echo sequence showed advantages in the depiction of anatomical structures like paravalvular abscesses. Anatomical structures adjacent to the artificial valve were clearly visible and the metal components of the valves showed no or only small artifacts. Artifacts were accentuated when using gradient-echo sequences. Gradient-echo sequences provided valuable information regarding the presence of valvular insufficiency. Physiological valvular regurgitation was easy to differentiate from pathological paravalvular or transvalvular regurgitation. These results demonstrate that patients with artificial valve prostheses can be imaged by MR without risk and that prosthesis-induced artifacts do no interfere with image interpretation.

[Non-invasive diagnosis of atrial septal defects and anomalous pulmonary venous return using magnetic resonance tomography]. / Nichtinvasive Diagnostik von Vorhofseptumdefekten und fehlmündenden Lungenvenen mit der Kernspintomographie.

The present study was to evaluate the diagnostic information that may be obtained in patients with atrial septal defect (ASD) and/or with anomalous pulmonary venous return using spin echo and gradient echo magnetic resonance imaging (MRI). The interatrial septum and pulmonary veins were studied in 31 patients and in 16 healthy volunteers. In all patients cardiac anatomy and dilatation due to right-sided volume overload was well depicted. In 87% of the patients examined by spin echo technique and in 100% of the patients examined by gradient echo technique the defect was reliably documented. All cases of anomalous pulmonary venous return were shown. MRI diagnosis of ASD was improved by combined use of spin echo and gradient echo techniques. The new MRI sequence was particularly helpful in patients with small ASDs and anomalous pulmonary venous return.

[Noninvasive assessment of aortocoronary bypass using magnetic resonance tomography]. / Nichtinvasive Beurteilung aortokoronarer Venenbrücken mit Kernspintomographie.

Forty-four patients with recent cardiac catheterization because of recurrent chest pain after coronary artery bypass surgery were studied by magnetic resonance imaging to evaluate graft patency. To assess the efficacy of this non-invasive method 92 coronary artery bypass grafts were examined by the spin-echo technique. ECG-gated transversal sections were acquired between the diaphragm and the aortic arch. The specificity of magnetic resonance imaging was 83% (48/58) for patent grafts. However, the sensitivity in the detection of occluded bypasses was only 56% (19/34). Despite the good specificity, clinical applications of this method are limited because of its low sensitivity.

[Effort-induced myocardial wall motion abnormalities in the magnetic resonance tomogram: a comparison with effort MIBI SPECT]. / Belastungsinduzierte Myokardbewegungsstörungen im Kernspintomogramm: Vergleich zu Belastungs-MIBI-SPECT.

In 20 patients with an angiographically documented coronary artery stenosis of > or = 70% and normal LV function at rest MRI was performed before and after dipyridamole infusion (0.75 mg/kg BW). In all patients MIBI-SPECT was obtained at rest and after dynamic symptom-limited exercise. In 18 patients MIBI-SPECT showed ischemia and in 18 patients dipyridamole MRI showed a wall motion impairment. In the segments representing the 29 stenosed vessels ischemia in MIBI-SPECT was diagnosed correctly in 24 instances (sensitivity 83%, specificity 90%) and a wall motion abnormality was present in MRI in 23 instances (sensitivity 79%, specificity 90%). Dipyridamole GE-MRI is not superior to MIBI-SPECT in the diagnosis of ischemia.

Functional health status in male patients without restenosis following successful PTCA.

In a prospective pilot study, subjective and objective parameters of the health status were assessed in 148 male patients (mean age 56 +/- 8.4 years) before and 4 months after successful coronary angioplasty (PTCA). Restenosis was defined as residual diameter stenosis > 50%. Although 96 patients (65%) had not developed restenosis at 4 months' invasive follow-up, subjective assessment of general well-being was unchanged in 26% or worse in 71%; overall anginal status and exercise performance had however improved. Of 71 men younger than 60 years who had no restenosis at follow-up, 4 men retired and 13 remained on medical leave. The striking disparity between subjective and objective parameters was not related to significant differences of age, exercise capacity, and left ventricular ejection fraction, as well as to baseline characteristics (previous myocardial infarction, extent of coronary heart disease, comorbidity) compared with 52 patients with restenosis. Thus, despite documented sustained success after PTCA, the majority of patients failed to resume the status of subjective well-being.

Recovery of ventricular late potentials from body surface using the signal averaging and high resolution ECG techniques.

In 70 patients (3 females and 67 males), aged 16-72 years (mean: 51 +/- 9 years), the low noise ECG was recorded from body surface by the signal averaging and the high resolution beat-to-beat techniques. We found 61 patients were suffering from coronary heart disease, 4 had atypical coronary heart disease (syndrome X), 4 had dilatative cardiomyopathy, and one had the long QT syndrome (Romano-Ward syndrome). We found the following recovery rates for ventricular late potentials within the ST segment with the averaging technique: clearcut in 13/53 patients, doubtful in 16/53 patients, and late potentials absent in 26/53 patients. With the beat-to-beat technique the following recovery rates were found: clearcut late potentials in 27/70 patients, doubtful in 23/70 patients, none in 20/70 patients, and intermittently occurring late potentials in 18/70 patients (categorized as doubtful late potentials). When comparing the detection of late potentials with both methods in individual patients, we found concordant results in 39/53 patients studied (positive with both methods in 24/53 patients, negative with both methods in 15/53 patients), and discordant results in 14/53 patients (positive with the beat-to-beat technique and negative with the averaging technique in 12 individuals, negative with the beat-to-beat technique and positive with the averaging technique in the remaining 2 patients). The correlation between the incidence of late potentials and the presence of exercise-induced myocardial ischemia (submaximal bicycle exercise) was higher when using the high resolution beat-to-beat technique, as holds also true for the correlation to complex ventricular arrhythmias.(ABSTRACT TRUNCATED AT 250 WORDS)

[Long-term effects of low dosage fish oil on serum lipids and lipoproteins]. / Langzeiteffekte von niedrigdosiertem Fischöl auf Serumlipide und Lipoproteine.

In a prospective and double-blind study, the long-term effects of low dose fish oil on serum lipids and lipoproteins was tested in patients with normal or moderately elevated serum lipids and compared to the effects of olive oil. The compliance to the study medication was evaluated by analysis of serum fatty acids and proved to be very good. Dietary supplementation with 9 g fish oil, respective 3.15 g n-3 fatty acids per day over one year resulted in a decrease of serum-triglycerides by 26% and increase of HDL-cholesterol by 26%. Treatment with 9 g olive oil resulted in an 18% increase of HDL-cholesterol. There was no effect on serum-triglyceride levels.

[Hemodynamics and differentiated CO transfer following fulminant lung embolism and pulmonary artery embolectomy and following recurrent lung embolism]. / Hämodynamik und differenzierter CO-Transfer nach fulminanter Lungenembolie und Pulmonalisembolektomie sowie nach rezidivierenden Lungenembolien.

Pulmonary embolectomy as an emergent surgical treatment after massive pulmonary embolism often is necessary in cardiogenic shock (CS) and even without previous diagnostic. If complete dissolution of the thromboembolus is possible or spreading of microemboli may occur is unknown. Therefore we studied 21 patients surgically treated by embolectomy, ten of these with consecutive cardiogenic shock (CS) and twelve patients after repetitive microembolism and cava-blocking. Besides lung-functional parameters for special CO-diffusion capacity (DLCO), differentiated in membrane (DM) and vascular (VC) component (Roughton and Forster), we measured mean pulmonary artery pressure (PAP) at rest and at exercise. Patients after repetitive embolism showed considerably more diminution of DLCO (-31%) than those after single massive embolic event (-15%) even concomitant by CS (-10%). Repetitive microembolism lowered VC by 21%. Slight decrease of DM was found after CS. Mean pulmonary artery pressure was elevated at rest (26 mm Hg) and exercise (33 mm Hg) after repetitive microembolism and normal after massive embolism or CS. Pulmonary embolectomy may prevent disturbances of DLCO or PAP even after CS. Damage of vascular integrity (VC) was found after microembolism. Pulmonary embolectomy seems to remove total embolic material and therefore seems to be optimal.