Intrapericardial treatment of inflammatory and neoplastic pericarditis guided by pericardioscopy and epicardial biopsy--results from a pilot study

From a registry of 136 patients undergoing pericardiocentesis, 14 patients with autoimmune and 15 patients with neoplastic effusions were selected. All underwent pericardioscopy, epicardial and pericardial biopsy with histologic, immunohistologic, and polymerase chain reaction/or in situ hybridization analysis for microbial DNAs and RNA. Pericardioscopy identified neoplastic effusions by the high occurrence of protrusions. Fibrin threads and layers and neovascularization were found in both groups. For identification of the inflammatory and neoplastic process, the combined analysis of the cytology of the effusion and epicardial biopsy evaluation proved to be most important. Epicardial biopsy demonstrated a slightly higher sensitivity for identifying neoplastic disorders in the pericardium than cytology alone. Pericardial biopsy was inconclusive. Intrapericardial administration of 1 g of crystalloid triamcinolone in autoreactive pericarditis prevented recurrence in 13 of the 14 cases after 3 months and in 12 of the 14 cases after 1 year. In neoplastic effusion, intrapericardial administration of 50 mg cis-platin for 24 h prevented recurrence of a hemodynamically relevant effusion after 3 months in all, and after 6-12 months in 14 of 15 patients. Mortality in neoplastic effusion due to noncardiac tumor progression was 47 and 80%, respectively, after 3 and 6 months, as can be expected in endstage neoplastic disease. This pilot study demonstrates that local drug application is feasible, life-saving, and well tolerated by the patients. It opens perspectives for local drug application in other cardiac disorders as well.

[Retrospective studies and prospects of therapy for hypertension]

Future trends in hypertensive treatment have to rely on our past and present experience with antihypertensive drugs as well as on emerging concepts of blood pressure regulation, on which some new drugs in the "pipeline" are based. Early detection of hypertension, before organ manifestations particularly in the heart, the kidney and the vessels occur, remain mandatory since in most of the patients with mild and moderate hypertension the high blood pressure is not diagnosed at all or treated inadequately. Prevention of cardiac, vascular, renal or metabolic complications has always been better for the patient and less costly than their repair or reparation. Our present treatment goals have often not reached far enough. Normalisation of blood pressure demonstrates only surrogate efficacy of our treatment. Our ultimate goal has to be improvement of total or cerebrovascular or cardiovascular and cardiac mortality. Important steps on that road are the prevention or reparation of cardiac hypertrophy, of the increased extracellular matrix and collagen deposition, the conservation of vascular integrity including both coronary and systemic microangiopathy and macroangiopathy. For the patient this means integrated care of his associated disorders that is of coronary artery disease, diabetes mellitus, lipid disorders, overweight and the metabolic syndrome. True health efficacy (= reduction of total or cerebro- and cardiovascular mortality) has been demonstrated so far only by blood pressure reduction with diuretics (thiazides) and beta-blockers in long term studies, whereas sufficient surrogate efficacy, the lowering of blood pressure, has been demonstrated with almost all the others drugs either in mono- or in combinationtherapy. Together with ACE-inhibitors, which have demonstrated their prognostic value in patients with heart failure of different causes, thiazides (as the most representative diuretic) and betablockade can be considered first line drugs in the treatment of hypertension. Long-term mortality trials for ACE-inhibitors in hypertension are needed, however, to prove that the anticipated benefit from the heart failure megatrials can also be taken for granted for hypertensive patients without coronary artery disease as well. All other drugs should not or not yet be considered first line medication, although treatment behavior in the US and in Europe shows wide-spread use of calcium antagonists in short- and long-acting dihydropyridine type hypertensive patients. No peer reviewed journal has so far published a randomized double-blind trial with the endpoint of total or cardiovascular mortality in hypertension using calcium antagonists. A recent case control study, as well as the preliminary data from MIDAS and GLANT, for which event rates are available in abstract form, suggest that short acting calcium-antagonists of the dihydropyridine type, though controlling blood pressure well, are not reducing mortality but show a trend to increase cardiovascular events particularly when given in higher doses. In contrast the unpublished data from a Chinese megatrial with dihydropyridines (STONE) demonstrate effective blood pressure reduction and benefit in mortality in a population that differs from patients in Europe and in the USA because of the low prevalence of coronary artery disease. No randomized, double blindly acquired data on mortality as the primary end of antihypertensive treatment are yet available for verapamil, diltiazem and the new class of longer acting calciumantagonists. Only when speculating from trials with calcium antagonists in coronary artery disease e.g. the DAVIT II study, one could imagine so far that prognostic benefit may be expected from drugs that do not or very little activate the adrenergic and the renin-angiotensin-aldosterone system and the baroreceptors and reduce or at least maintain heart rate. The need for double blind, randomized trials with the different Ca-antagonists is obvious, before a further w

Directions in antihypertensive treatment--our future from the past

Future directions in antihypertensive treatment will rely on our present experience with antihypertensive drugs, on new concepts of cardiovascular regulation and on novel antihypertensive agents. At present, we seek early detection of hypertension; treatment should focus on normalization of blood pressure, the reversal or prevention of left ventricular hypertrophy, associated coronary artery disease and on the prevention of, or reparation of, myocardial fibrosis and microangiopathy. Therefore, combination therapy is advisable in severe cases, and any monotherapy should focus on the pharmacological principles compatible with these goals. ACE inhibitors and calcium antagonists appear to meet these requirements. There are, in addition, novel drugs i.e. angiotensin II receptor antagonists and renin inhibitors, as well as therapeutic stimulation of endothelial nitric oxide by L-arginine, the inhibition of endothelin-1 mediated vasoconstriction, and potassium-channel openers. All are examined in this contribution to delineate the perspectives in antihypertensive therapy.

Prevention of structural changes in the heart in hypertension by angiotensin converting enzyme inhibition

BACKGROUND

The long-term effects of hypertension on the heart culminate in congestive heart failure. The underlying causes are contractile impairment due to myocyte loss and reduced compliance due to myocardial fibrosis. Newer strategies in antihypertensive therapy must, therefore, focus on prevention of myocardial damage ('cardioprotection') or, if an abnormality has occurred, on reversal towards normal myocardial structure and function ('cardioreparation').

OBJECTIVE

To investigate the question of whether angiotensin converting enzyme (ACE) inhibition can influence myocardial remodelling in hypertension to produce cardioprotective and cardioreparative effects.

METHODS AND RESULTS

Infusion of pathophysiological levels of circulating angiotensin II in rats causes cardiac myocyte necrosis, followed by fibroblast proliferation. This necrosis is not secondary to adrenergic activation or raised blood pressure. Similarly, renovascular hypertension results in cardiac myocyte necrosis, which can be prevented by pretreatment with the ACE inhibitor captopril. In established genetic hypertension in rats, sustained treatment with high-dose lisinopril normalizes the blood pressure, reverses left ventricular hypertrophy, reverses excessive interstitial and perivascular fibrosis (and consequently the impaired compliance), and reverses excessive coronary artery medial thickening (thereby normalizing coronary vascular reserve). With a low dose of lisinopril that does not reduce blood pressure significantly, only the excessive fibrosis is reversed.

CONCLUSION

ACE inhibition has demonstrated promising myocardial remodelling effects in experimental models of hypertensive heart disease.

[Low-dose enalapril as additional medication in severe chronic heart failure]

A prospective, randomized efficacy study of low-dose enalapril was undertaken in 38 outpatients (24 men, 14 women; mean age 58 [41-69] years) with chronic heart failure (NYHA functional class III-IV). All patients were pretreated with digitalis and diuretics, some also with conventional vasodilators. 19 patients (group E) received in addition to their previous medication, 5 mg enalapril daily, while the other 19 (group K) continued with their previous therapy. Three months later, 15 patients in group E improved by at least one NYHA functional class and none died (P less than 0.02). Four patients in group K died and only one patient improved by one class. After three months, left ventricular ejection fraction was significantly higher (P less than 0.0001) in group E (39 +/- 19%) compared to group K (30 +/- 14%). In group E, plasma aldosterone concentration decreased significantly (P less than 0.0001) by 33.4 +/- 6.5 ng/dl, while in group K no significant change occurred (delta 1.1 +/- 1.2 ng/dl). Thus, low-dose enalapril in addition to conventional therapy may improve the clinical status of patients in severe chronic heart failure. This improvement is associated with an increase in left ventricular ejection fraction and reduction in secondary hyperaldosteronism.

Haemodynamic effects of amrinone in the anaesthetized pig

The vasodilator and inotropic actions of amrinone were investigated in mini-pigs under pentobarbitone anaesthesia. Left ventricular volume was determined angiocardiographically under afterload and isovolumetric conditions. Furthermore, aortic flow, left ventricular pressure and aortic pressure were measured. In some of the animals, the beta-adrenergic receptors were blocked with propranolol prior to the administration of amrinone. Without blockade of the beta-receptors, amrinone (2 mg kg-1) caused a significant reduction in mean aortic pressure. Due to less end-diastolic ventricular filling, stroke volume decreased, and thus ejection fraction remained constant. Since heart rate increased under amrinone, cardiac output remained constant. At the same time, the maximum rate of pressure rise increased, despite less end-diastolic ventricular filling. After blockade of the beta-adrenergic receptors, aortic pressure, end-diastolic ventricular filling, and stroke volume also decreased with amrinone. In contrast, heart rate remained practically constant, so that cardiac output declined. The maximum rate of pressure rise also declined due to less end-diastolic ventricular filling. It can be concluded from these results that, in situ, the primary action of amrinone occurs on vascular smooth muscle and that a positive inotropic activity with a normal dosage of amrinone is only an indirect outcome of reflex activation of the sympathetic system. Analysis of isovolumetric mechanograms and the ejection phase does not indicate a direct positive inotropic effect of amrinone. In the failing heart, however, beneficial effects can be expected, since the maxima curves follow a flatter course. Thus a reduction in afterload can lead to a significant increase in stroke volume, provided that aortic pressure does not fall below the critical coronary perfusion pressure.

[Effect of tricuspid annuloplasty in mitral/aortic valve replacement on the clinical aspects and global function of the right heart chamber]

The clinical improvement after mitral or aortic valve surgery is primarily due to the correction of the aortic/mitral valve function and the subsequent decrease of pulmonary artery pressure. The hemodynamic effect of an additional tricuspid annuloplasty, however, is still unclear. To assess the influence of a tricuspid annuloplasty using DeVega- or Carpentier-technique on the clinical outcome, hemodynamics, and right ventricular function in patients with moderate to severe tricuspid insufficiency, 38 patients were studied pre- and 11 +/- 4 months postoperatively. The clinical degree of left heart failure was graded according to the criteria of the NYHA. The extent of right heart failure (RHF) was determined using a clinical score from 0 (no signs) to 3 (severe RHF with pleural effusion/ascites). Mean pulmonary artery pressure (PAPm), end-diastolic volume index (RVEDVI), and ejection fraction (RVEF) of the right ventricle using biplane cineventriculography, as well as the angiographic and dopplerechocardiographic degree of tricuspid insufficiency were determined. The patients were assigned to three groups: gr.I (n = 12): preoperatively no tricuspid insufficiency (TI), gr. II (n = 12): with preop. TI and without tricuspid annuloplasty (TA), gr. III (n = 14): with preop. TI and TA. The patients of all three groups improved postoperatively from NYHA functional class III to class II (p less than 0.001). The clinical score of RHF decreased from 0.8 +/- 0.5 to 0.3 +/- 0.5 in gr. I, from 1.4 +/- 1.1 to 0.6 +/- 0.7 in gr. II, and from 1.7 +/- 1.0 to 0.8 +/- 0.8 in gr. III (p less than 0.02).(ABSTRACT TRUNCATED AT 250 WORDS)

[Effect of tricuspid annuloplasty on the clinical course following mitral or aortic valve operation]

To assess the effect of additional tricuspid annuloplasty during mitral/aortic valve surgery on the clinical postoperative course in patients with severe preoperative tricuspid insufficiency, 64 patients were investigated pre- and 11 +/- 4 months postoperatively. Extent of left-side heart failure was graded as well as severity of right-side heart failure using a defined clinical score. Using preoperative biplane angiography of the right ventricle the patients were assigned to three different groups: group I (n = 30) with no preoperative tricuspid insufficiency (TI), group II (n = 19) with preoperative TI and without tricuspid annuloplasty, group III (n = 15) with preoperative TI and with annuloplasty of the tricuspid valve. The patients of all three groups postoperatively improved from an average of NYHA class III to class II. The clinical score of right-side heart failure in gr. III and gr. II was 1.4 +/- 1.0 and 1.5 +/- 1.0, respectively, and was significantly (p less than 0.05) higher than in gr. I (0.8 +/- 0.8). In all three groups there was a postoperatively significant decrease: gr. I: 0.3 +/- 0.5 (p less than 0.01); gr. II: 0.6 +/- 0.9 (p less than 0.02); gr. III: 0.7 +/- 0.8 (p less than 0.05). Mortality was 3% in gr. I; 5% in gr. II and 6% in gr. III. 3% of patients in gr. I, 30% in gr. II and 6% in gr. III had early postoperative hemodynamic complications.(ABSTRACT TRUNCATED AT 250 WORDS)

Significance of right ventricular filling for left ventricular enddiastolic pressure-volume relationship under acute hypoxia in the dog

In 14 closed-chest dogs, the significance of right ventricular filling for left ventricular enddiastolic pressure-volume relationship was investigated under acute hypoxia by means of single plane cineventriculography and simultaneous intraventricular pressure recording. Both after 5 min asphyxia (respirator switched off) (n = 5) and after 3 min hypoxia (ventilation with pure N2) (n = 9), there was a significant leftward shift (p less than 0.005) of the left ventricular enddiastolic pressure-volume curve as compared to the control curves under normoxia. To simulate the elevated filling of the right ventricle under acute hypoxia, rapid intraventricular infusion was applied under normoxic conditions to raise right ventricular enddiastolic pressure to the same values as that measured under hypoxia. The extent of the ensuing leftward shift of the left ventricular enddiastolic pressure-volume curve was on average 60% of the shift under hypoxia in both sets of experiments. Neither the slope of the relationship between volume stiffness and enddiastolic pressure, nor the relationship between tangent elastic modulus and left ventricular wall stress, was affected by hypoxia or asphyxia. Thus, the shift of the left ventricular enddiastolic pressure-volume curve in the early stage of hypoxia is predominantly due to the influence of increased right ventricular filling. Since the increased volume of the atria under acute hypoxia limits left ventricular distensibility additionally, the changes in left ventricular enddiastolic pressure-volume relationships observed in the early stage of hypoxia are mainly, or even entirely, the result of interaction of the various heart compartments, and not a reflection of alterations in myocardial tissue elasticity.

[Tricuspid valve insufficiency in patients with rheumatic mitral valve disease: angiographic diameter of the tricuspid ring and function of the right ventricle]

Dilatation of the right ventricle and a consecutive enlargement of the tricuspid valve ring are thought to be the main causes of functional tricuspid regurgitation in patients with rheumatic mitral valve disease. To study the effect of right ventricular dilatation as well as the dimension of the tricuspid valve ring, right ventricular volume indices, ejection fraction, regional shortening, pulmonary artery pressure, and the diameter and systolic shortening of the tricuspid valve were determined in 67 patients with rheumatic mitral valve disease (NYHA class II and III) from biplane ventriculographies. Patients with right ventricular enlargement (greater than 90 ml/m2) were divided into groups with (group IIA) and without (group IIB) tricuspid regurgitation and compared with patients with normal right ventricular size and function without tricuspid regurgitation (group I). There was no difference in the end-diastolic volume index, in the afterload or in the diameter of the tricuspid ring. Right ventricular ejection fraction was decreased in group IIA (51 +/- 9% vs. 59 +/- 10% (IIB) and 61 +/- 6% (control); (p less than 0.05). Regional function was also decreased in group IIA. 73% of the patients with tricuspid regurgitation had right ventricular enlargement, but only 44% of the patients with right ventricular enlargement had tricuspid regurgitation. Thus right ventricular dilatation promotes the development of a tricuspid insufficiency, but is not the only cause. Additional factors like decreased local wall motion, alterations of the valve or the valve apparatus may also account for functional tricuspid regurgitation.

[Effect of chronic pressure and volume stress on the function of the right ventricle]

Biplane right ventricular angiography was performed in 36 patients with chronic pressure overload of the right ventricle; 12 patients additionally had tricuspid insufficiency (TI). There were 4 subgroups: patients with systolic pulmonary artery pressure less than or equal to 40 mm Hg without (group I, n = 10) and with TI (group II, n = 6), as well as patients with systolic pulmonary artery pressure greater than 40 mm Hg without (group III, n = 14) and with TI (group IV, n = 6). Compared with the normal volumes of groups I and III, a significant increase in end-diastolic right ventricular volumes (p less than 0.01) was found in groups II and IV with 112.2 +/- 22.3 ml/m2 and 116.3 +/- 27.4 ml/m2, respectively. In both groups II and IV end-systolic volumes were also significantly increased, with 51.0 +/- 10.3 ml/m2 in group II and 49.7 +/- 11.3 ml/m2 in group IV. Right ventricular ejection fraction was 53.8 +/- 11.9% in group II, 57.3 +/- 8.5% in group III and 57.8 +/- 7.3% in group IV. There was no significant difference between the ejection fraction of these groups in comparison to the normal ejection fraction of group I with 63.4 +/- 10.9%. The results suggest that the right ventricle can compensate for moderate chronic pressure and volume overload using the Frank-Starling mechanism. Overall right ventricular dysfunction is not determined primarily by the loading conditions alone. Local myocardial and septal involvement is suspected to be an important determinant of right ventricular function.