Differential involvement of ceramide in TNFalpha-mediated activation of NF-kappaB in primary human keratinocytes and HaCaT keratinocytes

The involvement of ceramide signaling in tumor necrosis factor alpha (TNFalpha) mediated nuclear transcription factor kappa B (NF-kappaB) activation was studied. The cell response modifier ceramide has been shown to modulate apoptosis, cell differentiation and cell proliferation in different cell populations. Sphingomyelin hydrolysis is one pathway generating intracellular ceramide increase. Previously, we could show that TNFalpha induces a ceramide increase in primary human keratinocytes and HaCaT keratinocytes and consequently apoptosis was initiated. It is well known that TNFalpha activates the transcription factor NF-kappaB, but there have been controversial reports on the role of ceramide in TNFalpha-mediated NF-kappaB activation. Here we show by different lines of experimental evidence that TNFalpha is a strong inducer of NF-kappaB in both cell types, whereas C2-ceramide failed to activate NF-kappaB in HaCaT keratinocytes in contrast to primary keratinocytes.

Hepatopulmonary syndrome: prevalence and predictive value of various cut offs for arterial oxygenation and their clinical consequences

BACKGROUND

The hepatopulmonary syndrome (HPS) is defined as the triad of liver disease, arterial deoxygenation, and pulmonary vascular dilatation. The reported prevalence of HPS in cirrhotic patients varies between 4% and 19%, and various threshold values defining arterial deoxygenation have been used and recommended previously. However, it is not known how the prevalence of HPS differs using different cut off values for arterial deoxygenation.

METHODS

We studied 127 patients for the presence of HPS using transthoracic contrast echocardiography for detection of pulmonary vasodilation, pulmonary function tests, and blood gas analysis.

RESULTS

Ninety eight patients were included in the study, of whom 33 (34%) had a positive contrast echocardiography. Using an increased alveolar-arterial difference for the partial pressure of oxygen (AaDO(2)) as an indication of hypoxaemia, the prevalence of HPS was considerably higher (>15 mm Hg, 32%; >20 mm Hg, 31%; and >age related threshold, 28%) than using reduced partial pressure of arterial oxygen (PaO(2)) as a threshold (<80 mm Hg, 19%; <70 mm Hg, 15%; and <age related threshold, 15%). For AaDO(2) as the cut off, the positive predictive value for a diagnosis of HPS was low (34%, 37%, and 53%, respectively). In contrast, PaO(2) as a cut off had considerably higher positive predictive values (44%, 93%, and 94%, respectively). Introducing PaO(2) <65 mm Hg as the cut off, the positive predictive value increased to 100%. Dyspnoea was more often present in patients with "clinically significant" HPS (57%) compared with "subclinical HPS" (8%), and patients without HPS (6%). The Child-Pugh score correlated significantly with the severity of HPS. Two of five liver transplanted patients with "subclinical HPS" had embolic brain infarcts, possibly induced by venous emboli passing through dilated intrapulmonary vessels.

CONCLUSIONS

Defining arterial hypoxaemia in HPS by different, previously used, cut off values for arterial oxygenation leads to a wide variation in the prevalence of HPS in the same sample of cirrhotic patients.

The spectrum of pathology in central core disease

Central core disease is a congenital myopathy with muscle weakness defined pathologically by the presence of extensive areas in muscle fibres that are devoid of oxidative enzyme activity. The gene responsible has been shown to be the ryanodine receptor 1 on chromosome 19q13 and mutations have now been identified in several patients. Some cases with the morphological defect remain molecularly undefined, particularly those studied before molecular studies were available. We have studied three families with congenital onset, each with a dominantly inherited mutation in a C-terminal exon of the ryanodine receptor 1. They illustrate the spectrum of pathology that can be observed in patients with the myopathic features of central core disease. We show that extensive fibrosis and fat may be present, type 1 fibre uniformity may occur in the absence of cores; cores may be central or peripheral, single or multiple; and that an appearance of multiple focal minicores might cause a diagnostic pathological dilemma. In addition, we show the value of immunocytochemistry in identifying cores, in particular the use of antibodies to desmin and gamma-filamin.

Does Switzerland train tomorrow's surgeons today? Today's reflections on tomorrow's surgeons

Various factors are influencing the Swiss health care system, and therefore, surgeons' actual and future profession. Initiated by the current president of the Swiss Society of Surgery, a group of eight young Swiss surgeons constituted the ad hoc committee "Chirurgie 2020". The goal was to develop several scenarios of the surgeon's professional situation in 20 years. The future direction of surgery will be markedly influenced by medical innovation, political and economic relationships between Switzerland and Europe. However, the development of health care costs represents the most powerful factor predicting all further changes. The current situation of today's surgeons is best characterised as "hamsters in the treadmill" who try to fulfill a multitude of diverging tasks causing major demotivation. In order to retain a leading role in the health care system, surgeons must take part in social and political activities. To provide an excellent curriculum, university and county hospitals must join together to form clinical and educational networks. A clearly defined and structured curriculum must be introduced by the Swiss Society of Surgery. From our current point of view, only everyone's strong personal commitment will help to find solutions and to improve the current and future situation. In particular, today's surgical residents must actively take part in the development of tomorrow's surgery.

[Duplex ultrasound for follow-up examination after stent-angioplasty of ostial renal artery stenoses]

AIM

Renal artery stenosis (RAS) may lead to deterioration of renal function and/or hypertension. Stent angioplasty has become the method of choice in the treatment of atherosclerotic ostial RAS. We describe the changes of the following duplex parameters: intrarenal resistance index RI according to Pourcelot and the renal-aortic flow velocity ratio (RAR) directly after intervention and during follow-up (FU). We also examine the value of the method in detecting restenosis.

PATIENTS AND METHODS

We present the results of a prospective study of 241 patients with stent angioplasty for the treatment of 355 severe RAS (extent of stenosis >/= 70 % of vessel diameter). Duplex examinations during FU were performed before discharge, after 6 and 12 months, and then annually resulting in 1292 examinations.

RESULTS

RAR could be calculated in 98.9 % (1278/1292), RI was calculated in 100 % of the examinations. The RAR decreased significantly from 5.9 +/- 2.1 to 1.2 +/- 0.4 after intervention (p < 0.00001) with a slight increase during follow-up. RI increased significantly from 0.64 +/- 0.11 to 0.74 +/- 0.06 after intervention (p < 0.00001), equalling the RI of the contralateral side (0.74 +/- 0.07). During a mean FU of 27 +/- 15 months, 37 restenosis (10.4 %) and 12 re-restenosis were detected and confirmed angiographically, resulting in 48 reinterventions. In case of restenosis, RAR increased from 1.3 +/- 0.4 to 6.3 +/- 2.8 (p < 0.001) with a decrease to 1.3 +/- 0.6 after reintervention (p < 0.001), and RI decreased from 0.75 +/- 0.08 to 0.64 +/- 0.11 (p < 0.001) with an increase to 0.75 +/- 0.07 after reintervention (p < 0.001).

CONCLUSIONS

Duplex ultrasound is a reliable method for FU of patients after renal artery stent-angioplasty and for detecting restenosis.

[Normal values for the internal thoracic artery by Doppler ultrasound and modification of the Doppler curve after bypass to the left anterior descending artery]

AIM

In coronary heart disease, the surgical therapy of choice is the construction of an artenal bypass of the left anterior descending artery (LAD) using the internal thoracic artery 8ITA). We define age dependent normal values for the ITA such as diameter of the lumen (LD), peak systolic (Vs) and diastolic (Vd) flow velocity and the ratio of these two values (SDR) measured by duplex ultrasound. Furthermore, the modification and pathological changes of the Doppler curve after minimal invasive bypass of the LAD (MIDCAB) are described.

MATERIAL AND METHODS

96 people, age 18 - 87 years, subdivided into 6 age groups were examined by duplex to define the normal values of the ITA, and 55 patients (mean age 63 +/- 10 years, 48 men, 7 women) were evaluated after MIDCAB-surgery to describe the postoperative modification of the Doppler curve. The examinations were performed using a 4 - 7 MHz linear ultrasound transducer in the right and left 1. or 2. intercostal space parasternally.

RESULTS

In all 96 people, the ITA was detectable on both sides presenting a typical bi- or triphasic Doppler flow profile. A linear age dependent increase in the LD of 1.95 +/- 0.15 mm (right ITA) and 1.93 +/- 0.27 mm (left ITA) respectively to 2.65 +/- 0.48 mm and 2.55 +/- 0.43 mm was found. No significant side difference was found for Vs and Vd, nor were there any age dependent differences for Vs. The SDR showed an age dependent linear increase on the right side from 3.5 +/- 1.1 to 6.1 +/- 2.2, p < 0.0012, and on the left from 3.9 +/- 1.2 to 6.7 +/- 1.7, p < 0.0001. Postoperatively, the Doppler spectrum was modified into a mono- or biphasic Doppler curve with a reduced Vs and an increased Vd resulting in a significantly decreased SDR on the left side compared with the right side (1.3 +/- 0.8 vs. 5.4 +/- 2.0, p < 0.00001). Three patients with angiographically proven graft failure had an SDR of 2.6 - 5.2 (mean 3.8), as opposed to a value of < 2.0 in case of a patent bypass. An SDR > 2.0 has a sensitivity of 100 % and a specificity of 97 % in the detection of a haemodynamically relevant (>70 %) ITA-graft-stenosis.

CONCLUSIONS

With rising age, there is an increase in the LD of the ITA and the peripheral resistance, expressed as SDR. After MIDCAB surgery the former triphasic Doppler flow curve changes into a mono- or biphasic curve corresponding to the coronary blood flow. An SDR >2.0 is a strong indicator of bypass failure.

A method to assess biochemical activity of liver cells during clinical application of extracorporeal hybrid liver support

Biochemical activity of a hybrid liver support system based on porcine liver cells was investigated in patients suffering from acute liver failure, coma stage III-IV Patient plasma was drawn systemically and after circulation through the bioreactor at four hour intervals. A method is used that takes into account the rate of plasma flow and the differences in plasma concentration systemically and after circulation through the liver support system to determine the net release or uptake of metabolites such as ammonia, urea and glucose. Urea release (mean 2.28+/-0.37 micromol/h/g cells) and ammonia uptake (mean 0.17+/-0.11 micromol/h/g cells) was seen during treatment, an active role of the system in glucose metabolism was observed. All patients were bridged successfully to liver transplantation.

Preoperative evaluation of chronic alcoholics assessed for surgery of the upper digestive tract

BACKGROUND

Alcoholics are at risk of developing major complications in the postoperative period. Adequate prophylactic treatment, as well as preoperative abstinence, can significantly decrease the rate of complications. However, the preoperative diagnosis of alcoholism is difficult to establish. The purpose of this study was to assess whether three preoperative visits, an alcohol-related questionnaire (CAGE), and the laboratory markers carbohydrate-deficient transferrin (CDT) and gamma-glutamyltransferase (GGT) would increase the rate of detection of chronic alcoholics.

METHODS

The study included the Departments of ENT, Facial and Maxillofacial Surgery, and General Surgery of a university hospital; 705 male patients were assessed for tumor surgery of the upper digestive tract and were allocated to 5 different groups. All patients were seen three times, and five different strategies were used to detect chronic alcoholics. The gold standard was the diagnosis of alcohol misuse made by an experienced (blinded) investigator according to the DSM-III-R. The main outcome measurements were the detection rates of the different test strategies.

RESULTS

By clinical routine alone, only 16% were detected during the first visit and 34% after three visits. If the CAGE questionnaire was added, sensitivity increased to 64%. The further addition of GGT or CDT led to 80 and 85% detections, respectively. A combination of all tests had a sensitivity of 91%.

CONCLUSIONS

To detect more alcoholic patients at risk for major complications, patients should be seen more often, and additional diagnostic tools such as the CAGE, CDT, and GGT should be used before surgery.

Potentially therapeutically relevant differences of antisense oligonucleotide uptake in CD34+ hematopoietic stem cells, leukemic blasts and cancer cells from patients

Antisense oligonucleotide (ON) technology, e.g. against drug resistance or antiapoptotic factors, may play an important role in future cancer chemotherapy. An unanswered question in this field is the capacity for uptake of antisense molecules in normal and malignant patients' cells. Therefore, we examined the cellular uptake of FITC-labeled phosphorothioate modified ONs in: i) cells from the T-lymphoblastoid cell line CCRF-CEM, ii) CD34+ hematopoietic progenitors from healthy donors, iii) blasts from ALL or AML patients, iv) cells from the ovarian cancer cell line A2780 and v) cancer cells from malignant fluids. The cationic polymer ExGen was taken as a carrier for transfection, while FITC-ON uptake was evaluated by flow cytometry. We found marked differences between these cell types. Cancer cells from the cell line A2780 and from patients showed a distinctly enhanced uptake compared to hematopoietic progenitors and leukemic blasts. Since bone marrow toxicity substantially limits any conventional chemotherapeutic regimen, a better ON uptake in cancer cells compared to hematopoietic precursors might give an advantage for therapeutic approaches using e.g. ON-based chemosensitization.

[Pigment epithelium detachments in AMD (age-associated macular degeneration) and "polypoid choroidal vasculopathy". A fluorescein and indocyanine green angiography study]

AIMS

A prospective analysis to differentiate the angiographic appearance of pigment epithelial detachments (PED) in age-related macular degeneration (AMD) was performed. The aim was to verify if characteristics of polypoidal choroidal vasculopathy (PCV) can be observed in elderly patients with Central European background.

PATIENTS AND METHODS

Fluorescein and indocyanine green angiography was performed in 101 consecutive patients (53-87 years, 63 females, 38 males) with clinical signs of PED and drusen.

RESULTS

Different types of PED could be differentiated: PCV-associated PED in 14 patients (13.9%), vascularized PED in 72 patients (71.2%), and nonvascularized PED in 15 patients (14.9%).

CONCLUSIONS

The clinical diagnosis of PED in AMD can be differentiated by angiography into PCV-associated PED, vascularized PED, and nonvascularized PED. This differentiation is important because PCV-associated PED may have a pathogenetic and genetic background other than age-related changes in Bruch's membrane. These patients also may share a natural course and treatment options different from PED in AMD.

Intestinal ischemia after bushmaster (Lachesis muta) snakebite--a case report

After a snakebite by the Costa Rican bushmaster Lachesis stenophrys, a 64-year-old patient developed cardiovascular shock and coagulopathy. After intensive care and antivenom treatment, he was discharged after 4 days but had to be hospitalised again 3 days later because of abdominal pain and bowel obstruction. An emergency laparotomy revealed a necrotic ileum and caecum, and an obstruction of the superior mesenteric artery. Until now, this type of intestinal ischemic complication after a snakebite has not been reported in the literature. The effects of bushmaster venom are discussed.

[First experiences with a 6F-sheath compatible self-expanding nitinol stent]

BACKGROUND

To evaluate the efficacy, safety and limitation of a new 6F-compatible nitinol stent (Dynalink(TM).

MATERIAL AND METHODS

We treated 50 patients (17 women, 33 men, mean age 72 +/- 8 years) by implanting 80 Dynalink(TM)-stents into 75 vessels during a 6-month period. Target lesions were: iliac artery: 25, femoral artery: 31, popliteal artery: 16, femoro-popliteal bypass: 5, subclavian vein: 3. Preinterventional Rutherford classifications: Class 1 : 3 legs (5 %), class 2 : 27 legs (51 %), class 3 : 16 legs (31 %), class 4 : 2 legs (4 %), class 5 : 5 legs (9 %). 40 % stents each were implanted ipsilateral, 60 % cross-over.

RESULTS

All interventions were successful regardless of a sometimes anatomically difficult access to the lesion. The device was characterised by a high flexibility and radial force and the stent did not shorten.

COMPLICATIONS

One distal stent dislocation during placement occurred, no puncture site complication. The mean diameter stenosis was reduced from 91 +/- 10 % (75 - 100 %) to 4 +/- 8 % (0 - 30 %). The ankle-brachial index was improved from 0.46 +/- 0.22 to 0.75 +/- 0.23 (p < 0.001). Post-interventional Rutherford classifications: Class 0 : 43 legs (81 %), class 1 : 5 legs (4,5 %), class 5 : 5 legs (4,5 %).

CONCLUSIONS

The new 6F-sheath compatible nitinol stent is characterised by a good flexibility, radial force, and a lack of shortening. By the reduction of the diameter of the device to 6F, the potential risk of a local bleeding complication may be reduced and 6F sealing devices will be usable. Disadvantages are the 0.018 inch guide-wire lumen and the limited stent sizes.

Metabolic engineering of the morphology of Aspergillus

The morphology of filamentous organisms in submerged cultivation is a subject of considerable interest, notably due to the influence of morphology on process productivity. The relationship between process parameters and morphology is complex: the interactions between process variables, productivity, rheology, and macro- and micro-morphology create difficulties in defining and separating cause and effect. Additionally, organism physiology contributes a further level of complexity which means that the desired morphology (for optimum process performance and productivity) is likely to be process specific. However, a number of studies with increasingly powerful image analysis systems have yielded valuable information on what these desirable morphologies are likely to be. In parallel, studies on a variety of morphological mutants means that information on the genes involved in morphology is beginning to emerge. Indeed, we are now beginning to understand how morphology may be controlled at the molecular level. Coupling this knowledge with the tools of molecular biology means that it is now possible to design and engineer the morphology of organisms for specific bioprocesses. Tailor making strains with defined morphologies represents a clear advantage in optimization of submerged bioprocesses with filamentous organisms.

Circulatory arrest and renal function in open-heart surgery on infants

This study was designed to evaluate the impact of circulatory arrest on renal function in open-heart surgery on infants. Renal function was described by diuresis, urine/plasma creatinine ratio, creatinine clearance, urinary albumin, and N-acetyl-beta-D-glucosaminidase measurements. Seven patients who underwent circulatory arrest (group 1) were compared with 37 patients operated on with cardiopulmonary bypass without circulatory arrest (group 2). In group 1, bypass time was 164 minutes and the lowest body temperature was 25.6 degrees C (median), compared with 106 minutes and 31.3 degrees C in group 2 (p < 0.05). Although diuresis and creatinine clearance revealed no differences between the groups, urine measurements, which had normal values before cardiopulmonary bypass, increased during reperfusion to 58.6 (range 16.2-75.5) mg gCrea(-1) albumin and to 14.8 (range 1.6-21.8) U gCrea(-1) N-acetyl-beta-D-glucosaminidase in group 1, compared with 8.1 (range 0-127.7) mg gCrea(-1) and 1.9 (range 0-47.8) U gCrea(-1) in group 2 (p < 0.05). Thus, deep hypothermic circulatory arrest (DHCA) subjected the kidney to ischemia reperfusion injury. Although the findings are mild and do not indicate severe ischemic renal damage, potential renal damage by DHCA should be taken into account when planning surgical procedures for congenital heart disease patients with additional risks of acute renal failure.

Improvement of lung preservation -- from experiment to clinical practice

BACKGROUND

Reperfusion injury represents a severe early complication following lung transplantation. Among the pathogenetic factors, the high potassium content of Euro-Collins(reg) solution is discussed.

MATERIAL AND METHODS

In a pig model of orthotopic left-sided lung transplantation we investigated the effect of Euro-Collins solution (EC: n = 6) versus low potassium dextran (LPD: Perfadex: n = 6). Sham-operated (n = 6) animals served as control. Transplant function, cellular energy metabolism and endothelial morphology served as parameters. In a clinical investigation, 124 patients were evaluated following single (EC: n = 31; LPD n = 37) or double (EC: n = 17; LPD n = 39) lung transplantation, whose organs where preserved with EC (n = 48) or LPD (n = 76). Duration of ischemia, duration of ventilation and stay on ICU were registered. Primary transplant function was evaluated according to AaDO(2) values. Cause of early death (30 days) was declared.

RESULTS

Experimental results: After flush with EC and 18 h ischemia, a reduction of tissue ATP content (p < 0.01 vs inital value and LPD) was noted. Endothelial damage after ischemia was severe (p < 0.05 vs control), paO(2) was significantly decreased.

CLINICAL RESULTS

In the LPD group, duration of ischemia was longer for the grafts transplanted first (SLTx and DLTx: p = 0.0009) as well as second (2. organ DLTx: p = 0.045). Primary transplant function was improved (day 0: SLTx: p = 0.0015; DLTx: p = 0.0095, both vs EC). Duration of ventilation and stay on ICU were shorter (n.s.). Reperfusion injury-associated death was reduced from 8% (EC) to 0 (LPD).

CONCLUSION

In experimental lung preservation, LPD lead to an improved graft function. These results were confirmed in clinical lung transplantation. Clinical lung preservation, therefore, should be carried out by use of LPD.

Regulation and possible function of beta-catenin in human monocytes

In this study, we demonstrate that adherence factors, serum constituents, LPS, and zymosan are capable of inducing a cellular accumulation of beta-catenin in human monocytes. Whereas adherence-dependent accumulation of beta-catenin can be blocked by wortmannin, an inhibitor of phosphatidylinositol 3-kinase, accumulation induced by the remaining stimuli cannot be prevented by inhibition of phosphatidylinositol 3-kinase, implying the involvement of beta-catenin in other not yet described signal transduction pathways. A role of beta-catenin in adherence-dependent processes by interacting with classical cadherins can be excluded as we could not detect cadherins in monocytes. To test whether it is possible that beta-catenin interacts with LEF/TCF (lymphoid enhancer factor/T cell factor) transcription factors, we studied the expression of this protein family. TCF-4 was identified as the LEF/TCF transcription factor present in human monocytes. However, neither cellular induction of beta-catenin nor cotransfection experiments with beta-catenin conducted in the monocytic cell line THP-1 resulted in the activation of a LEF/TCF-dependent promoter, suggesting the requirement of additional signals. Concurrent with this suggestion, we found that LPS and zymosan, two physiological inducers of beta-catenin, caused an increase in the expression of genes that are positively regulated by beta-catenin.

Sequestration of host plant glucosinolates in the defensive hemolymph of the sawfly Athalia rosae

Interactions between insects and glucosinolate-containing plant species have been investigated for a long time. Although the glucosinolate-myrosinase system is believed to act as a defense mechanism against generalist herbivores and fungi, several specialist insects use these secondary metabolites for host plant finding and acceptance and can handle them physiologically. However, sequestration of glucosinolates in specialist herbivores has been less well studied. Larvae of the tumip sawfly Athalia rosae feed on several glucosinolate-containing plant species. When larvae are disturbed by antagonists, they release one or more small droplets of hemolymph from their integument. This "reflex bleeding" is used as a defense mechanism. Specific glucosinolate analysis, by conversion to desulfoglucosinolates and analysis of these by high-performance liquid chromatography coupled to diode array UV spectroscopy and mass spectrometry, revealed that larvae incorporate and concentrate the plant's characteristic glucosinolates from their hosts. Extracts of larvae that were reared on Sinapis alba contained sinalbin, even when the larvae were first starved for 22 hr and, thus, had empty guts. Hemolymph was analyzed from larvae that were reared on either S. alba, Brassica nigra, or Barbarea stricta. Leaves were analyzed from the same plants the larvae had fed on. Sinalbin (from S. alba), sinigrin (B. nigra), or glucobarbarin and glucobrassicin (B. stricta) were present in leaves in concentrations less than 1 micromol/g fresh weight, while the same glucosinolates could be detected in the larvae's hemolymph in concentrations between 10 and 31 micromol/g fresh weight, except that glucobrassicin was present only as a trace. In larval feces, only trace amounts of glucosinolates (sinalbin and sinigrin) could be detected. The glucosinolates were likewise found in freshly emerged adults, showing that the sequestered phytochemicals were transferred through the pupal stage.

Left ventricular function and infarct size 20 months after primary angioplasty for acute myocardial infarction

OBJECTIVE

To study changes in left ventricular function and infarct size during long-term follow-up after acute myocardial infarction treated with primary angioplasty.

DESIGN

From 1996 to 1998, 100 consecutive patients were treated with primary angioplasty for acute ST-elevation myocardial infarction. Angioplasty was successful in 95% of the patients. Global left ventricular ejection fraction (LVEF) was determined by radionuclide ventriculography before discharge, after 6 weeks and after a mean follow-up time of 20 months. Infarct size was assessed by technetium 99m-tetrofosmin myocardial perfusion tomography (SPECT) at rest, performed at the same time intervals.

RESULTS

Mean LVEF was 56% at discharge, 55% after 6 weeks and 57% after 20 months of follow-up. No significant improvement in LVEF was observed. Only 8% of the patients at follow-up had LVEF lower than 40%. After 1 week, a mean perfusion defect of 19% was measured by SPECT. After 6 weeks and 20 months of follow-up, the mean perfusion defects were reduced to 14% (p < 0.001) and 15%, respectively.

CONCLUSION

Left ventricular function was well preserved with a mean LVEF of 57% 20 months after primary angioplasty for acute myocardial infarction. No significant change in LVEF was observed from 1 week after angioplasty to follow-up. Infarct sizes as assessed by SPECT imaging with tetrofosmin were reduced from 1 to 6 weeks, but did not change further during long-term follow-up. The reduction in the perfusion defects over time was probably due to gradual relief of stunning.