SEVTAR-A multicenter randomized controlled trial to investigate the impact of prophylactic endoluminal placed vacuum sponge for prevention of anastomotic leakage after low rectal resections

Background

Low anterior resection for rectal cancer is commonly associated with a diverting stoma. In general, the stoma is closed 3 months after the initial operation. The diverting stoma reduces the rate of anastomotic leakage as well as the severeness of a potential leakage itself. Nevertheless, anastomotic leakage is still a life-threatening complication and might reduce the quality of life in the short and long term. In case of leakage, the construction can be converted into a Hartmann situation or it could be treated by endoscopic vacuum therapy or by leaving the drains. In recent years, endoscopic vacuum therapy has become the treatment of choice in many institutions. In this study, the hypothesis is to be evaluated, if a prophylactic endoscopic vacuum therapy reduces the rate of anastomotic leakage after rectal resections.

Methods

A multicenter parallel group randomized controlled trial is planned in as many as possible centers in Europe. The study aims to recruit 362 analyzable patients with a resection of the rectum combined with a diverting ileostoma. The anastomosis has to be between 2 and 8 cm off the anal verge. Half of these patients receive a sponge for 5 days, and the control group is treated as usual in the participating hospitals. There will be a check for anastomotic leakage after 30 days. Primary end point is the rate of anastomotic leakages. The study will have 60% power to detect a difference of 10%, at a one-sided alpha significance level of 5%, assuming an anastomosis leakage rate of 10%-15%.

Discussion

If the hypothesis proves to be true, anastomosis leakage could be reduced significantly by placing a vacuum sponge over the anastomosis for 5 days.

Trial registration

The trial is registered at DRKS: DRKS00023436. It has been accredited by Onkocert of the German Society of Cancer: ST-D483. The leading Ethics Committee is the Ethics Committee of Rostock University with the registration ID A 2019-0203.

A prospective cohort study on the impact of darbepoetin alfa on quality of life in daily practice following anemia treatment guideline revisions

OBJECTIVE

This study aimed to evaluate the impact of darbepoetin alfa (DA) on hemoglobin (Hb) levels and quality of life (QoL) in cancer patients with anemia in current daily practice following several revisions of anemia treatment guidelines.

METHODS

This was a prospective, multi-center, observational study across Germany in non-myeloid cancer outpatients with chemotherapy-induced anemia treated with DA. Age, sex, cancer type, stage, and therapy, performance status, anemia status and treatment, and Hb concentrations were recorded for up to 18 weeks in a web-based registry. Optional QoL assessments were collected at baseline and at the end of DA treatment.

MAIN RESULTS

Of 984 eligible patients, 978 had complete anemia data, 492 also had complete QoL data. In the 978 patients, mean age was 64 (standard deviation, SD 12) years, 62% of patients were women. Breast (26%) and gastrointestinal (22%) cancer were most prevalent. Therapy was palliative in 44% of patients and initiated with curative intent in 29%. Mean baseline Hb was 9.5 (SD 0.9) g/dL, which increased by an average of 1.2 g/dL. In 67% of patients Hb increased either to 10-12 g/dL or by ≥2 g/dL; no Hb response was seen in 219 patients (22%); increases of 0 to 1, >1 to 2, and >2 g/dl were seen in 216 (22%), 265 (27%), and 278 (28%) patients, respectively. Anemia treatment did not result in any significant differences of performance status. However, QoL improvements were significantly greater in Hb responders, although a linear relationship with Hb increments was lacking. None of 47 fatal cases was considered related to treatment with DA.

CONCLUSION

Patients treated with DA in routine clinical practice had increases in Hb and reported improvement in QoL. Due to the uncontrolled design, no conclusions can be made regarding causality to treatment and the clinical relevance of the improvement.

[Chilaiditi's syndrome complicated by subdiaphragmatic perforated appendicitis: unusual manifestation of a rare condition]

We report on a case of an 80-year-old female patient who presented to the emergency room of with right upper quadrant abdominal pain since the day before. During the initial diagnostic an abdominal x-ray study revealed an air-filled colonic section of the bowel under the right hemidiaphragm corresponding to Chilaiditi's sign. The clinical symptoms and laboratory results were mild at this time. After 12 h the patient developed right upper quadrant peritonitis due to a perforated, subdiaphragmatic appendicitis based on Chilaiditi's syndrome. During surgical treatment the cecum and parts of the ascending colon were found to be interposed between the liver and right hemidiaphragm. A right hemicolectomy was performed which led to complete recovery of the patient. In addition to presenting this interesting case this article highlights the regime of the diagnostics and therapy of a complication of the very rare condition of Chilaiditi's syndrome.

Patterns of maintenance treatment (Tx) following first-line bevacizumab (bev) plus chemotherapy (CT) for metastatic colorectal cancer (mCRC): Results from a large German community-based cohort study

502

Background: As a result of the long PFS with bev-containing combinations in first-line mCRC, discontinuation of at least one CT component after an “induction” period and continuation with “maintenance” Tx is common. It is anticipated that duration and patterns of maintenance Tx may affect PFS.

Methods: We analysed induction and maintenance Tx in a large observational cohort study of bev + various first-line CT regimens. Results of the entire cohort were reported earlier [Arnold et al. ASCO GI 2010].

Results: From Jan 05 to Jun 08, 1620 patients (pts) were enrolled at 261 sites. 1,307 pts (81% of total) received bev + fluoropyrimidine-oxaliplatin (n=306, 23.5%) or fluoropyrimidine-irinotecan (n=1,001, 76.5%). While Tx reduction was not predefined, after induction 271 pts (21%) received de-escalated maintenance Tx: bev alone (n=106; 8%), or bev + CT (n=165; 13%). Median Tx duration for pts receiving bev alone was 8.7 mo for induction and 3.2 mo for maintenance. Pts receiving bev + CT maintenance had shorter induction (5.1 mo) but longer maintenance (4.4 mo). Median PFS (after induction) with bev maintenance was 10.8 mo vs. 13.5 mo for bev + CT maintenance. Data are available from 161 pts with bev + CT maintenance after induction with oxaliplatin (n=97) or irinotecan (n=64). Median total Tx duration was 9.6 mo for oxaliplatin-based induction and 10.9 mo for irinotecan-based induction; median induction duration was 4.1 and 5.5 mo, and maintenance duration was 4.3 and 4.4 mo, respectively. Median PFS (after induction) was 12.8 and 14.1 mo, respectively. Progressive disease (PD) has not yet occurred in 165 pts (62% of maintenance cohort). A high proportion of pts received Tx until PD (74% and 79%, respectively).

Conclusions: Both de-escalation strategies led to long PFS and a high number of pts treated ′until PD′. A trend towards better PFS was observed in pts receiving bev + CT maintenance vs. single-agent bev. The ongoing randomized AIO KRK 0207 trial is prospectively evaluating three different maintenance strategies after induction with bev + fluoropyrimidine + oxaliplatin.

[Table: see text]

A clinical phase I/II trial with the monoclonal antibody cG250 (RENCAREX®) and interferon-alpha-2a in metastatic renal cell carcinoma patients

PURPOSE

To evaluate the efficacy and safety of WX-G250, a chimeric monoclonal antibody that binds to carboxy anhydrase IX, combined with low-dose interferon-alpha (LD-IFNα) in patients with progressive metastatic renal cell carcinoma (mRCC).

PATIENTS AND METHODS

Thirty-one patients, nephrectomized for the primary tumor, clear cell progressive mRCC, were enrolled to receive weekly infusions of WX-G250 (20 mg i.v.; week 2-12) combined with LD-IFNα (3 MIU s.c. 3 times/week; week 1-12). At week 16, patients were evaluated for response and stratified into two groups: (a) responders into the extended treatment group for an additional 6 weeks of treatment or (b) the progressive group with no further study treatment.

RESULTS

Of the 31 treated patients, 26 were evaluable for response to treatment. Two patients showed partial remission and 14 patients had stable disease as assessed in week 16. One patient experienced partial remission resulting in a complete remission lasting at least 17 months. Nine patients had durable stable disease of 24 weeks or longer. Clinical benefit was obtained in 42% (11/26) patients. The median overall survival achieved was 30 months and the 2-year survival was 57%. Patients receiving extended treatment showed a significantly longer 2-year survival rate than discontinued patients (79 vs. 30%; P=0.0083). In general, treatment was well tolerated with little toxicity.

CONCLUSION

Treatment with the antibody WX-G250 in combination with LD-IFNα is safe, well tolerated, led to clinically meaningful disease stabilization and demonstrated clinical benefit in this progressive mRCC patient population.

The effect of zoledronic acid on bone metastasis in patients suffering from renal cell cancer (RCC): A German prospective single-arm clinical trial

5107

Background: The incidence of RCC increased over the last decades and about 30% of patients will develop bone metastasis. These pts. face considerable skeletal morbidity e.g. bone pain, pathologic fractures, spinal cord compression or tumor induced hypercalcemia (TIH). A prospective trial was initiated in RCC metastatic to bone evaluating the SRE (skeletal related event) rate under therapy with zoledronic acid (ZA). Primary objective was the proportion of pts. with at least one SRE after 12 months. Methods: Patients with RCC must have had ≥1 bone metastasis and ≤2 prior applications of a bisphosphonate. Bone lesions were diagnosed by bone scan and ≥1 lesion was confirmed using X-ray, CT or MRI. Pts. passed a 12 months treatment period receiving 4 mg ZA every 3 weeks. Pts. were followed every 3 weeks for 54 weeks for development of SREs (radiation or surgery to bone, spinal cord compression, pathologic bone fractures) and TIH. A bone scan was done, if AP or LDH were >2xULN or symptoms occurred. Suspected SRE was confirmed by X-ray, CT or MRI. After end of treatment patients entered a survival follow-up. Results: 51 pts. participated in the study. Median age was 63 years and 2/3 were male. Proportions of MSKCC risk groups good/intermediate/poor for pretreated pts. were 8%, 56%, and 18%, respectively. 78% of pts. suffered from ≤6 bone metastases. 18% had already experienced at least one SRE before study entry. 26% obtained prior medications, mainly interferons (20%), interleukins (16%) and chemotherapy (16%). 25 pts. completed the 12 months treatment period. Based on a preliminary analysis 13 pts. (26%) experienced at least one SRE with an absolute number of 23 events. No TIH was observed. Bone lesions response was observed in 3 pts. (2 CR, 1 PR) out of 33 pts. currently available. Final efficacy and safety results of the 12 months treatment phase will be shown at presentation. Conclusions: Pts. with mRCC and bone metastases are at high risk for experiencing an SRE with a reported incidence of up to 74%. This is the first study prospectively evaluating SRE rate in patients with mRCC and bone lesions receiving ZA. A preliminary analysis indicates an SRE-rate of 26% and no TIH was observed. Final results of this trial could further support the use of ZA in mRCC.

[Table: see text]

Bevacizumab (BV) plus chemotherapy (CT) as first-line treatment of patients with metastatic colorectal cancer (mCRC): First results from a large community-based observational cohort study in Germany

e15057

Background: BV prolongs overall survival (OS) and progression-free survival (PFS) when added to standard CT for patients (pts) with mCRC. After approval of BV in Germany in 01/05, this observational cohort study was initiated in pts receiving BV with various first-line CT regimens to evaluate safety events and effectiveness. Methods: To facilitate and evaluate enrollment of a typical mCRC population, eligibility criteria were minimized. Choice of the CT regimen was at physician´s discretion, but influenced by the current registration status. Predefined endpoints were treatment characteristics, response rate (RR), PFS, OS, and adverse events assessed as potentially related to the treatment (AERT) or as severe (SAE). Pts are followed for up to 4 years, and clinical data were updated every cycle (2–4 weeks). Results: 1,300 pts were enrolled at 261 sites from 01/05 through 06/08; abstract data cutoff date was 11/24/08. Median age: 64 (range 19–100) years, > 70 years.: 25%; male 63%; ECOG PS status 0–1/2/>2 88%/11%/1%. CT choice was fluoropyrimidine (FU)/BV alone (any 5-FU or capecitabine) 12%; FU/BV/oxaliplatin 18%; FU/BV/irinotecan 69%; other 1%. Median treatment duration with BV was 7.4 (range 0–28) months; duration > 10 months 21%. 60-day mortality was 4.0%. In total, 183 AERT were reported in 10% of pts., most commonly diarrhea (34 AERT), nausea (26) and hypertension (18). Reported SAE were deep venous TE in 0.8% of pts, bleeding 1.2%, pulmonary embolism 0.5%, arterial TE 0.4%. Best investigator- assessed RR was 59% (CR 10%, PR 49%; all pts) with 64% for FU/BV/oxaliplatin, 59% for FU/BV/irinotecan and 53% for FU/BV alone. Conclusions: The safety profile of BV in this population of mCRC pts with different CT regimens appears consistent with that observed in the other reports like BRiTE or first BEATrial. RR in this preliminary dataset are higher than that reported in the randomized controlled trials, but likely biased by the methodology of evaluation. However, activity with FU/BV alone was surprisingly high. Updated efficacy data including PFS will be presented.

[Table: see text]

Cytoarchitectonic mapping of the human amygdala, hippocampal region and entorhinal cortex: intersubject variability and probability maps

Probabilistic maps of neocortical areas and subcortical fiber tracts, warped to a common reference brain, have been published using microscopic architectonic parcellations in ten human postmortem brains. The maps have been successfully applied as topographical references for the anatomical localization of activations observed in functional imaging studies. Here, for the first time, we present stereotaxic, probabilistic maps of the hippocampus, the amygdala and the entorhinal cortex and some of their subdivisions. Cytoarchitectonic mapping was performed in serial, cell-body stained histological sections. The positions and the extent of cytoarchitectonically defined structures were traced in digitized histological sections, 3-D reconstructed and warped to the reference space of the MNI single subject brain using both linear and non-linear elastic tools of alignment. The probability maps and volumes of all structures were calculated. The precise localization of the borders of the mapped regions cannot be predicted consistently by macroanatomical landmarks. Many borders, e.g. between the subiculum and entorhinal cortex, subiculum and Cornu ammonis, and amygdala and hippocampus, do not match sulcal landmarks such as the bottom of a sulcus. Only microscopic observation enables the precise localization of the borders of these brain regions. The superposition of the cytoarchitectonic maps in the common spatial reference system shows a considerably lower degree of intersubject variability in size and position of the allocortical structures and nuclei than the previously delineated neocortical areas. For the first time, the present observations provide cytoarchitectonically verified maps of the human amygdala, hippocampus and entorhinal cortex, which take into account the stereotaxic position of the brain structures as well as intersubject variability. We believe that these maps are efficient tools for the precise microstructural localization of fMRI, PET and anatomical MR data, both in healthy and pathologically altered brains.

Efficacy and safety of inhaled recombinant interleukin-2 in high-risk renal cell cancer patients compared with systemic interleukin-2: an outcome study

Systemic IL-2 is an effective treatment for low to intermediate risk mRCC patients, its efficacy is marginal in high-risk cases. Therefore, other treatment approaches are required for this population. Ninety-four high-risk patients with RCC and pulmonary metastases were treated with inhaled plus concomitant low-dose subcutaneous rhIL-2. Clinical response, survival and safety were compared with those from IL-2 given systemically at the registered dose and schedule in 103 comparable historical controls. In the rhIL-2 INH group, treatment consisted of 6.5 MIU rhIL-2 nebulized 5x/day and 3.3 MIU rhIL-2 SC once daily. The rhIL-2 SYS group received treatment which consisted of intravenous infusion of 18.0 MIU/m2/day rhIL-2 or SC injection of 3.6-18.0 MIU rhIL-2. Some patients in both groups also received IFNalpha. Mean treatment durations were 43 weeks rhIL-2 INH and 15 weeks rhIL-2 SYS. Significantly longer overall survival and progression-free survival durations were observed in the rhIL-2 INH group. The probability of survival at 5 years was 21% for the rhIL-2 INH group. No patients survived 5 years in the rhIL-2 SYS group. A multivariate analysis of overall survival adjusting for differences in baseline characteristics between the two treatment groups resulted in a risk ratio of 0.43 (95% CI 0.30-0.63; P < 0.0001). The data suggested an association between the response (SD or better) and survival, especially in the rhIL-2 INH group. The inhalation regimen was well tolerated. This outcome study suggests that administration of rhIL-2 by inhalation is efficacious and safe in high-risk mRCC patients with pulmonary metastases, who have no other treatment option available.

A phase II trial of gemcitabine in combination with 5-fluorouracil (24-hour) and folinic acid in patients with chemonaive advanced pancreatic cancer

BACKGROUND

Gemcitabine (Gemzar) and 5-fluorouracil (5-FU) plus folinic acid (FA) both have proven activity in the treatment of patients with advanced pancreatic cancer. The present study was initiated to investigate the efficacy of gemcitabine in combination with 5-FU-FA.

PATIENTS AND METHODS

Thirty-eight patients, median age 60 years (range 34-70) with inoperable, stage IV, pancreatic cancer were enrolled into the study and treated on an outpatient basis. All except one patient received at least one cycle of treatment with gemcitabine (1000 mg/m2), followed by FA (200 mg/m2) and 5-FU (750 mg/m2) administered as a 24-hour continuous infusion on days 1, 8, 15 and 22 of a 42-day schedule. No patient had received prior chemotherapy or radiotherapy. All 38 patients were assessed for efficacy, toxicity and time to progressive disease.

RESULTS

Two patients (5%), achieved a partial response and thirty-four patients (89%) achieved stable disease. There were two early deaths (< or = 4 weeks). The median time to progression was 7.1 months (range 0.4-18.1+; 95% confidence interval (95% CI): 5.3-7.9 months). Three patients had a progression-free interval of greater than 12 months and 12 of 38 patients (32%) survived longer than 12 months. The median overall survival was 9.3 months (range 0.5-26.5; 95% CI: 7.3-13.0 months). The incidence of grade 3 and 4 toxicities was low.

CONCLUSIONS

The combination of gemcitabine and 5-FU-FA is active and well tolerated and seems to offer an improvement in progression-free interval over both gemcitabine monotherapy and 5-FU-FA therapy.

Effect of current and forthcoming European legislation and standardization on the setting of quality specifications by laboratories

A network of national and international guidelines and directives developed in the last few decades by various bodies will lead to a new concept of total quality for medical laboratory services comprising legislative regulations on national and international levels, standardizations backed up by legislation and recommendations of professional societies. One example is the IVD Directive of the European Community. It will not only stimulate accreditation in the field of laboratory medicine, but also necessitate numerous standardization activities which are presently co-ordinated by the European Committee for Standardization (CEN). Another standardization example is the development of quality management systems, mainly by ISO. The ISO 9000 series has become the most successful family of standards world-wide. Meanwhile, specific standards for the needs of laboratories (ISO 17025), and in particular of medical laboratories (ISO 15189), are being worked out. A new trend to develop quality management systems towards total quality management systems can be observed including additional aspects such as economic and quality interests of society, customers and owners of laboratories. The goal of all activities is to create a network of confidence which provides some guarantee to the clients, i.e. the physicians and their patients, that they will receive a high-quality medical laboratory service.

Follow-up of breast cancer patients

The existing follow-up standard for breast cancer patients has been reviewed by a representative trial involving 1,004 curatively treated patients, who underwent surgery between 1977 and 1987. The objective of the study has been to establish whether intensive diagnostics of recurrences and metastases will lead, as a result of the follow-up, to life prolongation or improvement of life quality, and which methods will be adequate to achieve this goal. The analysis has shown that metastases are recognized only insignificantly earlier, and that improvement of survival is not achieved. The results of the trial have led to a recommendation for an effective follow-up programme for breast cancer patients, with emphasis on subtle case history data and exact clinical investigations.

[Determination of active components of amrinone by analysis of pressure-volume results; use of the conductance (volume) catheter technic and rapid load change by balloon occlusion of the inferior vena cava]

Endsystolic pressure-volume relationships (ESPVR) were determined using the conductance (volume) catheter-technique and the required rapid load changes by applying vasoactive drugs (nitroprusside = NP; phenylephrine = PE) or brief preload reduction by balloon occlusion of the vena cava inferior (BOVCI). With this load-independent index of contractility, we analyzed the hemodynamically active components of amrinone (AM) over a range of different LV-loading conditions. In 19 patients (study I) with still normal LV-function (LVF) in group A (dP/dtmax 1585 +/- 386 mmHg/s; n = 10) and impaired LVF in group B (dP/dtmax 1044 +/- 164 mmHg/s; n = 9) an infusion of AM, 1.5 mg/kg over 2 min, failed to induce changes in ESPVR (p greater than 0.05), but rather caused load changes, resembling like those seen with NP. During continuously paced heart rates (90/min) brief infusion phases with NP and PE provided the necessary load changes. In 11 patients (study II) with impaired LVF (dP/dtmax = 1177 +/- 163 mmHg/s) 2.5 mg/kg AM i.v. induced an increase in contractility, which was more pronounced after the additional application of dobutamine (DOB) at 10 micrograms/kg/min.; (1) Slope k rose from 0.52 to 0.80 mmHg/ml; (2) dP/dtmax increased by an average of 39% and 57% (p less than 0.01), respectively. The BOVCI provided the necessary load changes. Thus AM demonstrates its contractility-increasing effects in a dose-related fashion, probably (at least in part) via an increase in heart rate; inotropic effects further increased with the combination of AM and DOB. The use of the conductance technique for the assessment of ESPVR during acute decrease of preload by temporary BOVCI is innocuous to the patient, reproducible and can be carried out under the conditions of a routine cardiac catheter procedure. This technique seems to be useful in the assessment of relative inotropic effects of the newer cardiotonic drugs.

Comparative efficacy of the new cardiotonic agent DPI 201-106 versus dobutamine in dilated cardiomyopathy: analysis by serial pressure/volume relations and "on-line" MVO2 assessment

DPI 201-106 (DPI) as a positive inotropic drug might be useful in treating dilated cardiomyopathy (DCM). In seven DCM patients with normal (group A) and eight DCM patients with abnormal (group B) left ventricular (LV) function, we analyzed serially (computer-assisted) pressure/volume (P/V) effects as P/V loops (microtip catheter/99mTc scintigraphy) using DPI (30 micrograms/kg X min i.v.) and dobutamine (DOB) (10 micrograms/kg X min i.v.) for quantitative comparison of hemodynamic effects. Contractility (dP/dtmax) improvement was greater with DPI (group A, +23%; group B, +47%) than with DOB (group A, +21%; group B, +32%), as was the simultaneous LV end-diastolic pressure decrease--DPI (group A, -39%; group B, -42%) versus DOB (group A, -21%; group B, -18%). LV efficiency increased with DPI (group A, +22%; group B, +55%), but myocardial oxygen consumption (MVO2) did not change significantly. Five of 15 patients showed an increase in dP/dtmax with DPI only; with DPI there were fewer "nonresponders" than with DOB. Thus, DPI increases contractility in DCM hearts while reducing preload rather than causing higher metabolic costs. Such beneficial hemodynamic effects appear to be stronger in the more impaired myocardium (group B patients) and quantitatively superior to those induced by DOB. This might indicate that residual myocardial reserves are more readily accessible to the influences of DPI than to those of DOB. Serial P/V loops and MVO2 assessment aided the demonstration of DPI's efficacy in a more complex way.

Analysis of the efficacy of the new cardiotonic agent TA-064

TA-064 is a new cardiotonic agent which is also effective orally, according to investigations conducted in Japan. We analyzed computer-assisted alterations of pressure-volume relationships serially and of indirect myocardial oxygen consumption (MVO2) estimations on line during TA-064 influence in 16 patients with congestive cardiomyopathy: left ventricular function was moderately decreased in seven patients (group A) and drastically decreased in nine (group B). Results showed that TA-064, 8 micrograms/kg/min intravenously, exerted positive inotropic effects in both groups and induced mean maximal delta percentage changes at about 5 minutes of infusion as follows: left ventricular stroke work index +65% and +47%; dP/dtmax +61% and 59%; left ventricular efficiency +62% and 53%; MVO2 +31% and +11% (p less than 0.05). TA-064, 20 mg by mouth induced serum levels (group A = 23.8 +/- 12ng/ml and group B = 26.4 +/- 20 ng/ml) corresponding to the effects with dosages of 1 to 2 ng/kg/min intravenously (p greater than 0.05), thus implying that significant changes in left ventricular function require higher oral dosages. We conclude that TA-064 improves left ventricular function, primarily via a contractility increase, also in group B patients without toxic side effects. On-line indirect MVO2 assessment and analysis of serial pressure-volume relationships helped to provide a more complex definition of the mechanism and efficiency of the cardiotonic agent under study.

[Comparative echocardiographic volume determinations using a dynamic heart model]

Using a dynamic and symmetrical cardiac phantom different echocardiographic mathematical models (Simpson 7 slices, area-length method, Simpson 2 slices and method according to Teichholz) were compared. 9 different end-diastolic (EDV) and end-systolic (ESV) volumes, 9 different stroke volumes (SV) and ejection fractions (EF) were used. EDV and ESV varied between 39-298 ml; SV between 29-100 ml and EF between 14-46%. In addition 10 fixed volumes of the same shape were evaluated using the same echocardiographic mathematical models. While symmetrical fixed volumes can be assessed correctly (r = 0.97-0.98), apart from the formula according to Teichholz (r = 0.89, significant underestimation of volumes), the correlation coefficients decrease using a dynamic cardiac phantom. In the modification of Simpson with 7 slices the best correlation was found for all parameters (EDV: r = 0.93; ESV: r = 0.94; EF: r = 0.87; SV: r = 0.81). The biplane area-length method has no advantages over Simpson's rule with 2 slices in the short axis; for symmetrical models both methods are comparable, both having high correlation coefficients (for volumes r = 0.85 and r = 0.88; for EF 0.78 and 0.84). Using the method according to Teichholz symmetrical volumes can be well assessed (r = 0.90), for the determination of EF the correlation coefficient decreases to r = 0.65 and for stroke volume to 0.33, reflecting no significant correlation to the actual SV. Possible causes for a poorer correlation are discussed for moving objects as opposed to the fixed volumes.

[Double nuclide myocardial scintigraphy with thallium 201 and iodine 123-heptadecanoic acid--the possibilities in cardiological diagnosis]

We studied in 11 patients the individual variable pattern of coronary blood supply after the end of diagnostic coronary catheterisation by intracoronary injection of T1201 into the left and J 123-heptadeconic acid into the right coronary artery. In 4 static views computer aided quantitative analysis of circumferential profiles was performed. Based on Schlesinger's criteria three types of coronary arterial patterns were defined (right, left preponderant, balanced) after the presentation in the angiographic projections.

CONCLUSIONS

Sharp boders between different perfusion areas could be detected by the gamma camera. If patients with right preponderant circulation are compared with balanced circulation, the perfusion areas of the left coronary artery are greater in all cases with balanced circulation than expected. More important for the indication of coronary artery surgery is that a considerable area of the left ventricular myocardium is perfused by the right coronary artery independent of the anatomical perfusion pattern with the exception of the left preponderant type.

[Effects of the new cardiotonic agent TA-064: serial computer-assisted analyses of pressure-volume relations and online myocardial 02 consumption]

According to investigations conducted in Japan, TA-064 is a new cardiotonic agent, which is also effective orally. We analyzed computer-assisted alterations of pressure-volume relations serially and of MVO2 online (Bretschneider) during TA-064 influence in 16 patients with congestive cardiomyopathy: LV-function of 7 patients was only moderately decreased (group A) and in 9 patients massively (group B).

RESULTS

1) TA-064, 8 micrograms/kg/min, i.v. had positive inotropic effects in both groups and induced mean maximal delta% changes at about the 5th minute of infusion as follows: LVSWI + 65% and 47%; DP/DTmax + 61% and 59%; LV-efficiency + 62% and 53%; MVO2 + 31% and + 11% (p less than 0.05). 2) TA-064, 20 mg p.o. induced serum levels (A: 23.8 +/- 12 and B: 26.4 +/- 20 ng/ml) corresponding to the effects with the dosages 1-2 micrograms/kg/min, i.v. (p greater than 0.05), thus implying that significant changes in LV-function require higher p.o. dosages. 3) TA-064 i.v. on the 6th day of exposure to the medication produced less LV-function improvement than on day 1 (p greater than 0.05).

CONCLUSIONS

In both groups A and B TA-064 improves LV-function primarily via increased contractility, without toxic side effects. For a more complex definition of the efficiency and mechanism of cardiotonic agents, the validity and importance of using on-line MVO2 assessment and analysis of serial pressure-volume relations is stressed.

[Comparison of T1201 stress scintigraphy and rest and stress ventriculography with respect to the degree of stenosis and collateral findings]

The influence of coronary obstructions and collaterals on the results of T1 201 myocardial scans and regional wall motion on ventriculography at rest and after pacing was examined with digital observer-independent methods, whereby criteria for positive and negative findings were defined in advance. The results indicate the high accuracy of 201-thallium scans in the detection of coronary artery disease in symptomatic single vessel disease, when the lesions obstruct greater than 60% of the vascular diameter. Cineventriculography at rest is inefficient as a test for this purpose. Ventriculography after pacing produced regional dysfunction in most of the patients and was comparable in its accuracy to T1 201 scans. A correlation of severity of stenoses and regional wall motion was not possible in the presented population. Collateral function is able to provide O2 supplies for normal myocardial function at rest and becomes insufficient during exercise and pacing. These results of T1201 stress scintigraphy correspond with results of stress ventriculography.

Influence of fluid removal rate during hemodialysis on left ventricular performance and exercise tolerance in patients with coronary artery disease

The effect of hemodialysis (HD) on left ventricular (LV) function and exercise tolerance were measured at rest and during exercise using gated equilibrium radionuclide ventriculography in seven patients with confirmed coronary artery disease (CAD). To separate the effects of fluid removal rate on LV function in CAD, we investigated the same patients with identical overall volume loss of 4 liters during two different treatment times (4 hr and 2 hr). HD significantly increased resting LV ejection fraction (EF) from 55.7 +/- 8% to 64.7 +/- 8% (P less than 0.01) during the 4 hr HD and from 58.1 +/- 9 to 68.1 +/- 10 (P less than 0.05) during the 2 hr HD. Indicating ischemia, EF decreased at pre- and postdialysis peak exercise without differences between both treatments. HD also resulted in an improved segmental wall motion score. Exercise duration as well as S-T segment depression and angina score improved during HD, whereas heart rate, blood pressure and double product remained unchanged. We conclude that HD improves global and regional resting LV function and exercise tolerance in patients with CAD. The degree of interdialytic hydration and not the degree of fluid removal per time affects LV performance in CAD. Since LV function is the major prognostic factor in CAD, those patients require volume restriction and/or shorter interdialytic phases.

[Regularization of ventricular intervals in atrial fibrillation--electrophysiologic findings on the underlying mechanism]

In 13 patients with chronic atrial fibrillation, programmed right ventricular pacing was performed before and after intravenous administration of 4 mg gallopamil. Application of the Ca-antagonist resulted in a marked decrease in the ventricular response in all and in a regularization of the ventricular response (variation coefficient of the ventricular cycle length: less than 10%) in 7 of 13 cases, while atrial fibrillation persisted. During regularization right ventricular extrastimulus testing showed a constancy of the postextrasystolic interval irrespective of the changes in the coupling interval of the extrasystole. The postextrasystolic cycle was slightly longer than the basic cycle; the difference amounts to a mean value of 107 +/- 22 ms. During the control period the postextrasystolic cycle showed the same irregularity as the basic cycle. The same random distribution was observed if the first 10 cycles of the spontaneous rhythm were analyzed after a short period of ventricular overdrive pacing. After regularization the first 2-3 postpacing cycles were markedly prolonged, and during the following cycles a gradual adjustment to the length of the basic cycles before overdrive pacing was seen, resembling the warming up of a pacemaker. It is concluded that regularization is most probably due to atrioventricular nodal depression and the occurrence of a junctional escape pacemaker.

[Complete revascularization surgery in patients with coronary disease with severely reduced left ventricular function. Discrepancies in the evaluation of results]

Clinical data, function and compliance of left ventricle as well as regional wall motion were analysed in 17 patients with preoperatively limited left-ventricular function and signs of myocardial ischaemia after complete revascularisation surgery. Recatheterisation after 5.2 months on average after surgery showed improvement by one NYHA class, an increase of mean left-ventricular enddiastolic pressure, which was interpreted as "improved status of ischaemia", a decrease of left-ventricular compliance by 30%, of enddiastolic volume by 14% and of endsystolic volume by 20% (P less than 0.05). Loss of function occurred in 3 out of 92 bypasses. Up to the time of reporting, 22.4 months postoperatively, all patients have survived in a relatively satisfactory clinical state. All parameters of left-ventricular function as well as regional wall motion showed a tendency for improvement after surgery in the majority of patients. However, pre- and postoperative mean values were not significantly different (P greater than 0.05). Thus, despite clearcut improvement of clinical state and "ischaemia index", improvement of left-ventricular function and regional wall motion are not consistently demonstrable. The reasons of this discrepancy cannot be ascertained by this investigation. The quality of the surgical intervention and the sensitivity of parameter assessment cannot be held responsible.

Effects of AR-L 115 BS (Sulmazol), a new cardiotonic agent, in coronary artery disease: improved ventricular wall motion, increased pump function and abolition of pacing-induced ischemia

AR-L 115 BS (Sulmazol) is a new noncatechol, nonglycosidic cardiotonic agent. In 17 patients with significant coronary artery disease, the influence of AR-L 115 BS on hemodynamics and regional wall motion was investigated under the following conditions: 1) control, 2) the immediate postpacing period without medication, and 3) the postpacing period under the peak influence of AR-L 115 BS, 2 mg/kg intravenously. During the postpacing phase without medication, all patients developed ischemia (angina, ST segment alterations, increase of mean left ventricular end-diastolic pressure from 13 to 30 mm Hg), left ventricular pump function diminished and overall regional wall motion showed a tendency to decrease (p greater than 0.05). However, during the postpacing period with AR-L 115 BS medication, ischemia was abolished (no angina; mean left ventricular end-diastolic pressure decreased to 13 mm Hg; hemodynamic variables returned to control levels and left ventricular pump function showed some improvement while overall regional wall motion showed tendencies to improve. A comparison of alterations of hemodynamics and regional wall motion during the postpacing phase without medication with those under the influence of AR-L 115 BS shows that overall left ventricular pump function and regional wall motion improved while angina and an increase in left ventricular end-diastolic pressure were prevented. It is concluded that AR-L 115 BS improves left ventricular pump function and regional wall motion in coronary artery disease without inducing ischemia, probably by means of a reduction in extravascular resistance.