[The programme of managed ambulatory rehabilitation for patients after heart valve defect surgery]

THE AIM of our research was to evaluate the impact of 8-week comprehensive rehabilitation programme on circulatory parameters, left ventricular (LV) function and functional capacity of patients after aortal (ao) and mitral (mi) heart defect surgery.

PATIENT SAMPLE AND METHODOLOGY

The rehabilitation programme was completed by 54 patients (exercising, RHB+) following valve defect surgery (13 women/41 men), aged 27-83 (56 +/- 16) years. The majority were patients with aortal (ao) stenosis (39), the remainder had a combined ao defect (7), ao regurgitation (3) or mitral (mi) regurgitation (5). Myocardial revascularisation was concomitantly performed in 18 patients. There were 18 patients in the control group (non-exercising, RHB-). Patients from both groups were assessed before and after the rehabilitation with exercise echocardiography and spiroergometry to the individual maximum. The intervention group underwent the managed rehabilitation programme. The control group exercised individually.

RESULTS

Reduction of the heart rate (HR) values at rest and on exercise and of the systolic and diastolic blood pressure (sBP, dBP) was observed in the exercising group. However, these changes were not statistically significant. The systolic, diastolic and global LV function parameters showed improvement although, once again, not statistically significant. Highly significant improvement in exercise tolerance (1.41 W/kg before and 1.67 W/kg after, p < 0.01) and peak oxygen consumption (20.0 ml/min/kg before and 23.6 ml/min/kg after, p < 0.01) were observed in the exercising patients. Improvement in functional and aerobic capacity in the control group was not statistically significant. The resting and exercise parameters (SF, sBP, dBP) have not changed either.

CONCLUSION

The ambulatory rehabilitation programme was associated with improvement in circulatory response to exercise together with reduction in resting and exercise SF, sBP a dBP values. Tendency towards improvement in systolic, diastolic and global LV function parameters was observed even though not statistically significant in our sample. Unlike control group, the exercising group showed significant increase in exercise tolerance and aerobic capacity (p < 0.01). Managed rehabilitation programme enabled evaluation of the outcomes of the surgery, better education of the patients and optimal adjustment ofpharmacotherapy, the anticoagulation treatment in particular. We did not observe any adverse reactions or other complications associated with the exercise.

[Echocardiography in patients with ischemic heart disease]

The assessment of the patients with coronary artery disease is one of the most important clinical applications of echocardiography. The importance of this application lies in the fact that coronary artery disease is the most common form of heart disease and the leading cause of death in all industrial countries. Echocardiography plays a diagnostic role at all stages of the disease from the early detection of transient, stress-induced, ischemic dysfunction, through the phase of acute myocardial infarction and its attendant complications, to the development of chronic ischemic heart disease and heart failure. Finally, echocardiography often provides important prognostic data in patients with coronary artery disease.

[The influence of rehabilitation on peak oxygen consumption in patients after myocardial infarction treated with beta-blockers]

THE PURPOSE OF THE STUDY was to verify whether rehabilitation programs improve both stress tolerance and peak oxygen consumption (pVO2) plus the consumption of oxygen at the level of anaerobe threshold (AT) in patients after myocardial infarction treated with beta-blockers. Our objective was to find out the differences in changes in the above indicators in elderly patients. THE SET of consisted of 2 groups of patients aged over 65 (56 +/- 6.1) a > or = 65 let (69 +/- 4.7). The first group contained 96 and the second group 31 patients, respectively. Prior and after the rehabilitation program, stress echocardiography (SE) and symptom-limited spiroergometric test were performed in the patients.

RESULTS

A statistically significant improvement in stress tolerance and in the oxygen consumptions indicators was recorded in the group of younger patients (< 65 years of age), both at the peak and at the anaerobe threshold levels (p < 0.001). Patients aged 65 or older recorded a statistically significant improvement in stress tolerance (p < 0.01) on the one hand, but only minor, statistically insignificant improvement in pVO2 and AT oxygen consumption on the other.

CONCLUSION

A two-month rehabilitation program improves both stress tolerance and the peak oxygen consumption in patients after myocardial infarction treated with beta-blockers. The improvement is statistically insignificant in elderly patients. The above finding supports our opinion that elderly patients need long-term controlled training which should be performed at regular intervals and with the necessary intensity.

[Trimetazidine in the treatment of stable angina pectoris TRIADA-(trimetazidine in stable angina twice daily)]

The primary objective of the national study TRIADA was to evaluate the efficacy and tolerability of Preductal MR (trimetazidine) at a dose of 35 mg twice daily which was added to current therapy involving the maximum of two antianginal drugs. The outcome was evaluated after 12 weeks of therapy and compared with baseline data. The study included 74 patients with stable exertional angina pectoris (AP) and positive exercise testing results. Trimetazidine (Preductal MR) at a dose of 35 mg twice daily was added to their current therapy involving two drugs at most. TRIADA confirmed that the use of trimetazidine in a new pharmacological form is effective and well tolerated in the treatment of angina pectoris. The study also confirmed a beneficial effect of trimetazidine on the incidence of angina pectoris paroxysms and objective manifestations of ischaemia during exercise testing. Holter monitoring clearly showed that metabolic therapy added to standard antianginal therapy would reduce the incidence of symptomatic and asymptomatic ischaemia. In addition, 12-week therapy with trimetazidine helped improve all end points of quality of life of AP patients evaluated using a questionnaire for AP patients (The Seattle Angina Questionnaire).

[Late cardiotoxicity in patients with malignant lymphoma treated with doxorubicin chemotherapy]

AIM OF THE STUDY

Chronic cardiotoxicity of doxorubicin occurs at least one year after the chemotherapy is finished. As such, it is a serious late complication in patients with malignant lymphomas. The aim of the study was to identify the incidence of late clinical and subclinical doxorubicin cardiotoxicity and cardiopulmonary performance of patients being in remission for five and more years from the initial therapy.

GROUP OF PATIENTS

We worked with 96 patients (47 men and 49 women) aged 43 +/- 15 (median 41, 23-79) years. Average period of monitoring was 6.2 +/- 1.5 (median 6.5-10) years. On the basis of therapy protocol, the patients were administered a maximum doxorubicin cumulative dose (CD DOX) of 377 +/- 147 (median 300, 50-880) mg/m2. Additional treatment after initial conventional therapy was performed in 32 patients (33%) due to high risk, progression or relapse of tumour. EXAMINATION METHODS: Patients were examined by resting echocardiography before and after initial therapy, and during follow-up examination after 5 years. Also, dynamic stress echocardiography and spiroergometry were performed during follow-up examination. Left ventricle ejection fraction (LVEF) decrease below 50 %, progressive decrease of LVEF > 10 % as compared with initial value, and decreased peak oxygen intake pVO2 < 20 ml/kg/min were considered as pathological. We also evaluated systolic function and index of myocardial performance (Tei-index).

RESULTS

Clinical cardiotoxicity was observed in 4 % of patients, subclinical in 31% of patients. Diastolic dysfunction was found in 38 % of patients; pathological values of Tei-index were noted in 31% of patients. Value of stress increment of LVEF was 13 +/- 4 % (median 12; 5-25). Decreased pVO2 was observed in 15 % of patients. Cardiovascular disease and age > 60 years represent a higher risk of left ventricular dysfunction. Additional treatment after initial therapy represents a higher risk only if diastolic dysfunction is found (OR = 2.37, p < 0.05). Multi-dimensional regression analysis proved the relationship between pathological EF, CD DOX > or = 300 mg/m2, age > 60 years and cardiovascular disease (for CD DOX p < 0.05; age p < 0.01; concomitant cardiovascular disease p < 0.01, with r = 0.57 and p < 0.02 values for the overall model).

CONCLUSIONS

The above-mentioned findings should positively influence the approach of oncologists and haematologists to long-term cardiological monitoring (at least with the help of resting echocardiography) in adult patients treated with antracyclines during initial chemotherapy.

[Effect of high-dose chemotherapy with subsequent transplantation of blood-forming cells on left ventricle function in patients with malignant lymphomas treated with doxorubicin in primary chemotherapy]

PURPOSE OF STUDY

The authors examined whether high-dose chemotherapy with hematogenic tissue transplantation might negatively affect function of left ventricle (LV) in oncology patients with malignant lymphomas initially treated with conventional chemotherapy consisting of doxorubicin (DOX) in contrast to patients treated without the transplantation in medium-term follow up.

PATIENTS AND METHODOLOGY

The follow up group included 77 patients (39 women/38 men) at the age of 36 +/- 15 (median 30, 16-67 years). All 77 patients were treated with initial chemotherapy with DOX, 22 out of that group later received high-dose chemotherapy with hematogenic tissue transplantation (HTT). 16 (73 %) patients of this subgroup underwent autologous transplantation and 5 (23 %) allogeneic transplantation. One female patient (4 %) underwent both autologous and allogeneic transplantation. The follow up period after completion of initial chemotherapy was 5-10 years (median 6 years). The patients were examined with rest echocardiography before start, after chemotherapy, and during follow-up examination. Spiroergometric test (SET) was only performed at the follow-up examination.

RESULTS

Both subgroups showed significant decrease of ejection fraction (EF) after chemotherapy, with further decrease in the control examination period, without mutual difference. While the HTT (HTT+) group showed no EF drop below 50 %, in the non-HTT (HTT-) group EF dropped in two (4 %) patients after chemotherapy and in four (8%) patients at the control examination. Progressing decrease of EF > 10 % was reported with 25 % of the HTT- patients (p < 0.05), but with just 13 % of the HTT+ patients (non-significant). The diastolic insufficiency (DF) was present identically in both groups with 36 % of the patients, which represents a statistically significant increase in comparison to the pre-chemotherapy condition. SET did not show any differences in burden toleration and circulation indicators between the two groups. The drop of pVO2 < 20 ml/kg/min occurred with 22 patients of both groups. Linear regression data analysis revealed existence of a significant relationship between EF change, some diastolic function indicators, pVO2 and cumulative dose of DOX (p < 0.05). The current age significantly and negatively correlated with pVO2 (p < 0.001) and DF indicators (p < 0.001). The follow up period inversely correlates with the changes of EF (p < 0.05) and pVO2 (p < 0.05), not correlating with diastolic function indicators. Multi-variant analysis did not confirm any higher risk of administration of high-dose chemotherapy with HTT for significant drop of EF or its drop down to the pathological zone below 50 % (OR = 0.46; non-significant), for discovery of reduced cardio-pulmonary performance (pVO2 < 20 ml/kg/min) (OR = 0.35; non-significant) or for development of diastolic dysfunction (OR = 1.0; non-significant).

CONCLUSIONS

Treatment with high-dose chemotherapy with HTT application within medium-term follow up does not result in any significant systolic or diastolic malfunction of myocardium and deterioration of cardiopulmonary performance in comparison to patients not undergoing this therapy. Treatment with cardiotoxic doxorubicin administered in the context of basic conventional chemotherapy is most likely to be responsible for occurrence of the pathological effects across the followed up group. Length of monitoring is a significant factor correlating with changed ejection fraction. This finding justifies the need for long-term prospective monitoring of ejection fraction of the left ventricle in adult patients treated with cardiotoxic chemotherapy.

The evaluation of left ventricular function in childhood cancer survivors by pharmacological stress echocardiography

Late cardiotoxicity after anthracycline chemotherapy for childhood cancer is well recognized sequelae. Many long-term survivors may have subclinical cardiac dysfunction undetectable at a baseline evaluation. Various tests have been utilized for the diagnosis of left ventricular impairment. Recently, low-dose dobutamine stress echocardiography has been proposed as a more sensitive screening test. We have applied low-dose dobutamine stress echocardiography (5-10 microg/kg/min) in 36 asymptomatic survivors (20 male/16 female aged 14.6+/-4.7 years) treated with a cumulative dose of 226+/-106 mg/m2 of doxorubicin. The median follow-up was 5 years. Control group consisted of 20 sex and age matched volunteers (12 male/8 female aged 12.6+/-4.9 years). We found significant differences in mean velocity of circumferential fibre shortening, myocardial performance index (Tei index), left ventricular posterior wall thickening and endsystolic wall stress at a baseline. The stress response was significantly blunted only in a patient group in the following parameters: endsystolic wall stress, isovolumic relaxation time and myocardial performance index. The threshold response was abnormal (0-5% improvement of a variable only) in 45% of subjects from a control group in one or two parameters. On the contrary, 63% of subjects from a patient group responded pathologically (the worsening of a variable) in one or more parameters. We have not found a good correlation between risk factors of late cardiotoxicity and stress changes of left ventricular function parameters. Low-dose dobutamine stress echocardiography is safe and feasible diagnostic tool in children and adolescents. Dobutamine significantly increases the differences in cardiac variables between healthy population and asymptomatic survivors for childhood cancer. In comparison to the controls, most asymptomatic patients revealed subclinical myocardial damage at test. The predictive value for the development of clinical symptoms and cardiac complications need to be assessed in a large prospective study.

[Dynamic stress echocardiography in asymptomatic patients treated for malignant diseases in childhood]

INTRODUCTION

The authors used echocardiography at rest and dynamic stress echocardiography to assess left ventricular function in asymptomatic patients treated during childhood or adolescence by chemotherapy containing anthracyclines.

MATERIAL AND METHODS

137 patients were examined (81 men, 56 women) aged 16.6 +/- 4.8 years (median 17 years) where at the age of 9.1 +/- 4.8 years (median 9 years) malignant disease was detected and treatment with a cumulative dose of anthracyclines 242 +/- 110 mg/m2 (median 240 mg/m2) was administered. The control group was formed by 30 subjects (14 men, 16 women) aged 19.5 +/- 5.2 years (median 20 years). The echocardiographic examination was made at rest and immediately after a dynamic stress on an ergometer with a load of 25 W/2 mins.

RESULTS

In 8% patients (n = 11) a reduction of the fractional shortening (FS) LV < 30% was found. The values of the ejection fraction (EF), the median shortening of the circumferential fibre and endosystolic wall stress, excursion and thickening of the posterior wall of the LV were significantly worse as compared with the group with fractional shortening > or = 30% and the control group. The maximum drop of EF was to 40% and of FS to 20%. The values of the index of the global LV function (according to Teie) were as compared with the control group worse in both sub-groups of patients. No differences were found in the exercise tolerance between groups. Values of the ejection fraction at rest and after a exercise were in the sub-group with FS < 30% significantly lower as compared with the others. The values of the stress increment of EF were elevated in all sub-groups. In none of the subjects the load caused a decline of the EF.

CONCLUSIONS

Chemotherapy with anthracyclines leads to a late disorder of several indicators of left ventricular function. Asymptomatic patients with a drop of the EF value to 40% or FS to 20% preserve their load tolerance and contraction reserve of the left ventricle. The finding of a preserved contraction reserve and good exercise tolerance implies a more favourable prognosis of the patient. Echocardiography at rest should be made repeatedly after treatment, in case of a pathological finding a loading test must be indicated to evaluate the contraction reserve and its possible development.

[Diagnostic possibilities of late cardiotoxic sequelae of chemotherapy with anthracyclines]

Anthracyclines areamong the most frequently used cytostatics in the treatment of haematological malignities and some solid tumours in childhood and adult age. They affect cellular proliferation in several ways. One of them is the formation of semiquinone radicals which form with oxygen toxic peroxides which damage the myocyte and lead to cardiotoxicity. Cardiotoxicity of anthracyclines has become a clinical problem as it restricts the administered dose of the cytostatic and has become particularly urgent after discovery of the late toxicity which appears some years after termination of anti-tumourous treatment. Damage of the left ventricle is usually characterized by partial reversible contractile dysfunction (early damage) or progressing contractile dysfunction (late damage). The diagnosis of cardiotoxicity is important during the period of treatment but in particular after completed chemotherapy. The application of diagnostic methods before and in the course of chemotherapy is indicated when large doses of anthracyclines will be administered or when in the patient risk factors cumulate or if he developed signs of cardiotoxicity. The use of diagnostic methods after termination of treatment is valuable for early detection of late cardiotoxicity for timing of further diagnostic methods currently used in cardiology. In the routine diagnosis the authors prefer follow up of the left ventricle by assessment of the ejection fraction by echocardiography or by radionuclide examination. In paediatrics we follow up indicators of systolic left ventricular function in relation to changes of the after load. The authors present also a review of other diagnostic methods and procedures which may prove useful in the diagnosis of cardiotoxicity of anthracyclines.

[Strength training in patients after myocardial infarct]

The objective of the work was to evaluate the suitability and safety of resistance training in patients after myocardial infarction (IM), in older patients and to assess the suitable time for including resistance exercise into the rehabilitation programme. The group comprises a total of 74 patients after IM aged 27-76 years (57 +/- 9). The group included 65 men and 9 women. The authors divided the whole group into two sub-groups by age. The first group is formed by patients under 65 years and the second one by those aged > 65 years. The authors included resistance training from the third week of the rehabilitation programme. During the resistance exercise none of the patients suffered from impaired rhythm or stenocardia. The total muscular strength during the initial tests was in the first group (< 65 years) 105 +/- 26 kg and 93 +/- 26 kg in the group of older patients. At the end of the rehabilitation programme in both groups a statistically significant increase of the total strength was recorded. In the first group it was 120 +/- 20 kg and in the older patients 108 +/- 23 kg, i.e. an increase by 14 and 16%. The mean value of the ejection fraction (EF) was at the onset of rehabilitation 58 +/- 7% and did not differ substantially in the two groups. The mean EF value at the end of rehabilitation was 59 +/- 9% in the first group and 58 +/- 10% in the second group (n.s.). The body weight expressed as the body mass index was initially significantly lower in the older patients (25.5 +/- 2.6 kg/m2 vs. 27.4 +/- 3.3 kg/m2, p < 0.01). During the rehabilitation programme in both groups a slight but statistically significant decline of body weight was recorded. In the first group (< 65 years) to 27.0 +/- 3.2 kg/m2 and in the group of older patients to 25.2 +/- 2.4 kg/m2 (p < 0.01). It can be concluded that the application of resistance exercise as a supplement of classical aerobic training is a suitable, beneficial and safe extension of the regabilitation programme. The use of resistance exercise is suitable even in older patients, it is well tolerated and is not associated with cardiovascular complications. Resistance exercise can be applied already after two weeks of the aerobic programme.

[Damage of left ventricular function after treatment with doxorubicin in patients with malignant lymphomas]

The authors evaluated using clinical and echocardiographic examination the effect of chemotherapy involving bolus administration of doxorubicin on the heart muscle in 90 patients with non-Hodgkin lymphoma and with Hodgkin lymphoma. In 18% of patients they found an asymptomatic decrease of the left ventricular ejection fraction during chemotherapy, chronic cardiotoxicity was recorded in 5% patients, in 2% of the patients one year after termination of chemotherapy a clinically latent myocardial infarction was found. The diastolic function was impaired (impaired relaxation) in 44% patients after terminated chemotherapy and in 50% after one year. Echocardiographic examination provided evidence that the impaired systolic and diastolic function persists even after one year following termination of chemotherapy. High-dose chemotherapy with administration of peripheral stem cells did not lead to marked deterioration of left ventricular function as compared with patients who did not undergo this treatment. The main clinical complications--death, cardiotoxicity, relapse of the malignant disease, cardiovascular complications--were present in the course of a 18.5-month follow up after establishment of the diagnosis in 32% of the patients.

[Cardiotoxicity of antineoplastic therapy]

Cardiotoxicity is a serious complication of anti-tumorous treatment. Cytostatics can cause a number of undesirable side-effects such as arrhythmias, angina pectoris, acute myocardial infarction, sudden death, cardiac failure. The probably most serious cardiotoxicity is chronic cardiac failure after treatment with anthracyclines. Interest in the diagnosis, monitoring and treatment of cardiotoxicity revealed new findings of cardiac complications after various cytostatics, high-dosage chemotherapy and transplantation of haematopoietic cells. Prospective paediatric studies provided evidence of the serious character of late cardiotoxicity of anthracyclines. The authors review the most frequent cardiac complications of anti-tumorous treatment. They emphasize in particular the toxicity of anthracyclines and its possible prevention.

[Changes in left ventricular function during chemotherapy with doxorubicin]

The authors investigated by echocardiography changes of left ventricular function in 79 patients with non-Hodgkin lymphoma or Hodgkin's disease who were treated by chemotherapy containing doxorubicin. In 22% patients they diagnosed during treatment a significant gradual decline of the left ventricular ejection fraction (change > 10% or a drop of EF below 50%) after a cumulative dose of 185 +/- 52 mg/m2 doxorubicin (median 200 mg/m2). Changes of the ejection fraction were at the expense of an increasing endsystolic left ventricular volume. These changes correlated closely with the increase of endsystolic stress of the left ventricular wall (r = -0.87). After administration of a cumulative doxorubicin dose of 100 mg/m2 a significant deterioration of indicators of diastolic filling of the left ventricle occurred--of the isovolumic relaxation period (IRP) and deceleration time (DT). The contribution of these early changes of diastolic function of the left ventricle for assessment of the risk of development of systolic dysfunction is not unequivocal. Prolongation of IRP > 12% as compared with the baseline value and at the same time above 95 ms had a 50% sensitivity, 50% specificity, a 26% positive prediction value a 74% negative prediction value and 50% diagnostic accuracy, change of DT > 13%, and at the same time prolongation above 200 ms had a 47% sensitivity 55% specificity, a 22% positive prediction value, a 78% negative prediction value and a 53% diagnostic accuracy. The authors found a significant relationship between the assessed changes of left ventricular function and clinical and haemodynamic indicators. Only the patients' age correlated significantly with IRP and DT values. Changes of the left ventricular ejection fraction were not associated with clinical signs of cardiac failure, they did not call for cardiological intervention and did not affect the course of chemotherapy. Contrary to some statements in the literature, the authors did not consider the described functional changes as sufficient to justify interference with chemotherapy. On the other hand, their importance for the development of late sequelae of chemotherapy with anthracyclines in adult patients must be based on long-term prospective follow-up.

[Involvement of the cardiac muscle in anemia]

Anemia is probably the most widespread syndrome associated with a very wide spectrum of pathological conditions with a different genesis. In malignities and their treatment it is one of the very serious complications the impact of which is manifested in particular in the state of the circulation. Thus anemia can cause deterioration of primary cardiac and cardiovascular complications which develop either as a result of the malignant disease or as a result of its treatment by cardiotoxic drugs. Thus risk conditions with the functional consequence of cardiovascular impairement are potentiated. This can complicate the disease or limit therapeutic possibilities. In the submitted work the authors tried to analyze the importance of anemia from the aspect of cardiovascular pathophysiology and outline results of their own observation supported by data from the literature concerned with this problem. From the observations ensues that in the group of patients studied by the authors who had careful substitution treatment with erythrocyte concentrates there were no serious drops of Hb which could be of fundamental importance from the aspect of cardiovascular damage. For this reason the cardiovascular status can be evaluated only from the aspect of primary toxicity of oncological treatment (if we omit direct damage by the disease) and it is not necessary to consider the consequences of hematological complications which must be taken into account when HB levels are lower than 70 g/l.

[Stress echocardiography in "non-ischemic myocardial disease"]

Stress echocardiography is nowadays an integral part of the diagnosis of ischaemic heart disease. In the submitted review the authors draw attention to the fact that ischaemic heart disease is no longer the domain of stress echocardiography. In recent years the interest of cardiologists in this method increased also in other cardiac diseases. Based on the appropriate pathophysiological mechanism of cardiac affection stress echocardiography is used to test left ventricular function after a dynamic or pharmacological stress, i.e. increased cardiac activity and cardiac minute volume in a number of heart diseases where we must know the extent of left ventricular affection and the functional reserve of the myocardium. These tests were also introduced to evaluate the impact of valvular disease and function of artificial grafts to evaluate left ventricular function in the transplanted heart. Stress echocardiograph holds its place also in paediatrics.

[Dobutamine stress echocardiography in patients with acute myocardial infarct]

The objective of the present work was to evaluate dobutamine echocardiography in patients after myocardial infarction. The group of patients comprises 39 subjects, age 54 +/- 10 years with a first non-complicated myocardial infarction treated by thrombolysis. The patients were examined on the 5th-7th day with small amounts of dobutamine (5 and 10 micrograms/kg/min.) and a maximal test after two weeks and three months after the myocardial infarction. During the week after the first maximal test coronarography was made in 33 patients. During the first examination at rest the authors observed asynergy in 237 of 780 segments. Low dobutamine doses revealed the presence of a viable myocardium in 87 segments (36%). The sensitivity, specificity, positive predictive value and negative predictive value were 72%, 77%, 55% and 88%. In eleven patients several arteries were affected, the sensitivity of dobutamine echocardiography for prediction of affection of several vessels was 70% and the specificity 95%. During examinations after three months in some of the patients the kinetics improved, in particular in patients after revascularization operations and in patients who were subjected to a rehabilitation programme. The authors conclude that dobutamine echocardiography is a safe loading method with a minimum of side-effects even in patients in early stages of myocardial infarction. The use of low dobutamine doses is a new promising method for assessment of reversible but also irreversible myocardial dysfunction. The maximal test will help to detect patients with affections of several vessels and help to differentiate patients with a greater risk and necessity of more aggressive treatment.

[Analysis of adverse effects of dobutamine stress echocardiography]

Recently in various departments interest in dobutamine stress echocardiography is increasing. Originally this examination was meant for the diagnosis of suspected ischaemic heart disease in patients unable to tolerate a physical load. Clinical applications of this test are constantly expanding and comprise a number of risk patients. The purpose of the submitted paper is to discuss the safety of dobutamine stress echocardiography. The authors submit an analysis of 259 examinations of patients with suspected ischaemic heart disease (46%), after acute myocardial infection (42%) and patients with significant left ventricular dysfunction (12%). 231 examinations (89%) were made up to the defined maximum. The test was terminated prematurely in 12 patients on account of arrhythmia, in 10 because the test was positive, in two because of extracardiac effects, in three instances on account of hypotension and in one patient on account of pressure hyperreaction. Arrhythmias were recorded in 26%, discontinuous ventricular tachycardia was recorded only in two patients (0.7) with severe left ventricular dysfunction. Hypotension was found in 13%, pressure hyperreaction in 2%. Palpitations were noted in 15% of the examined patients and extracardiac side-effects in 31%. None of the side-effects called for therapeutic intervention. The authors consider dobutamine stress echocardiography a safe test which is well tolerated by the majority of patients and there is a minimum of side-effects. A higher risk must be foreseen in patients with reduced left ventricular function, hypertrophy of the left ventricle and those with an history of arrhythmias.

[Evaluation of the cardioprotective effect of bispiperazinedione ICRF-187 (Cardioxane) in patients treated with anthracyclines--an echocardiographic study]

The cardiotoxicity of anthracycline antibiotics is a serious complication of anti-tumourous treatment. One of the possible ways how to prevent it or at least restrict it substantially is to use cardioprotective substances. The latter include ICRF-187 bispiperazinedione (dexrazoxan) which is manufactured and supplied by CHIRON Cop. under the name Cardioxane. The authors investigated by echocardiography indicators of systolic and diastolic function of the left ventricle in patients where cumulative doses of 180-240 mg/sq.m of doxorubicin were achieved. In 10 patients to whom Cardioxane was administered no changes of left ventricular function were recorded. In 18 patients treated with boluses of doxorubicin significant deterioration of left ventricular diastolic function developed. The authors provided evidence that relatively small cumulative doses of doxorubicin administered as boluses lead to impaired left ventricular diastolic function. These changes were not recorded in patients who were given the cardioprotective substance ICRF-187 (Cardioxane).

Cultivation of Escherichia coli with mixtures of 3-phenylpropionic acid and glucose: dynamics of growth and substrate consumption

In technical as well as natural ecosystems, pollutants are often mineralised in the presence of easily degradable carbon sources. A laboratory model system consisting of Escherichia coli ML 30 growing with mixtures of 3-phenylpropionic acid (3ppa, 'pollutant') and glucose (easily degradable substrate) was investigated in batch and carbon-limited continuous culture. Untypically, a linear growth pattern was observed during batch cultivation with 3ppa as the only carbon/energy source. When exposed to mixtures of both substrates in batch culture, E. coli utilised the two compounds sequentially. However, 3ppa and glucose were consumed simultaneously in continuous culture. Whereas a pulse of excess glucose to a batch culture growing with 3ppa led to the repression of 3ppa utilisation, an excess of glucose added into continuous culture did not inhibit the utilisation of 3ppa. During continuous cultivation the 3ppa-degrading enzyme system operated close to saturation.

Observation of a reversible, medication-induced change in pitch perception

This paper reports a study of an absolute pitch possessor who, upon administration of the psychoactive drug Tegratol (carbamazepine), experienced a significant change in her pitch perception. The subject's performance both in producing, as well as in identifying, random-frequency tones was measured, covering the period of administration of the drug, as well as control periods before and after. The main effect of the drug was a downward shift of the perceived pitch as compared to the two control periods. The magnitude of the shift was observed to increase with increasing fundamental frequency of the stimulus; the average shift was about one semitone. Detailed results on the frequency dependence and time dependence of the pitch shifts are presented. This may be the first documented report of a significant, reversible change of pitch perception caused by a medication.

[Changes in hypertrophy and diastolic left ventricular function during hypertension therapy]

The authors examined a group of hitherto not treated patients with primary hypertension and hypertrophy of the left ventricle. By means of echocardiography and isometric loading they investigated the effect of treatment on the left ventricular morphology and function. Despite long-term normalization of casual and loading values of the blood pressure the authors did not observe a significant regression of LV hypertrophy. The authors did not find a relationship between the casual blood pressure and weight of the left ventricle with exception of the diastolic pressure after a load. The indicators of diastolic function did not correlate with the weight of the left ventricle but with changes of the end diastolic volume and blood pressure.

[Ebstein's anomaly (a group of 47 patients)]

In a group of 47 patients with Ebstein's anomaly followed up on a long-term basis the authors describe the natural course of the disease as well as contemporary diagnostic and therapeutic possibilities. The authors draw attention to typical symptoms of Ebstein's anomaly and emphasize the importance of early diagnosis by two-dimensional echocardiographic and Doppler examination and the introduction of individual conservative or surgical treatment.

[Stress echocardiography in clinical cardiology]

In their generally designed presentation the authors focus on practical problems concerning indication, different stress modalities and projections, evaluation and interpretation of findings, as well as on technical novelties and their use. Only dynamic exercise echocardiography is being discussed. Currently available knowledge is assessed in the light of the authors' own experience. Problems of evaluation and interpretation are considered to be most intricate. In the authors' opinion, many technical problems which have prevented the routine use of the method in practice will be eliminated by introducing technical novelties such as digitalization of the display with image loop. Other innovations will certainly be used to advantage and render the method less demanding and far more widespread.

[Segmental analysis of left ventricular wall mobility]

The authors present their experience with subjective and quantitative evaluation of the mobility of the left ventricular wall of the heart. The combination of computer technique and two-dimensional echocardiography makes it possible to evaluate quantitatively the function of the left ventricule of the heart by the method of segmental analysis of wall mobility. Segmental analysis has proved to be a suitable method for assessing the function of the left ventricle particularly in subjects with threshold or slightly decreased functional values. The authors use the method in studying the functional response of the left ventricle to diagnostic or therapeutic intervention. The method yields important information also on the development of left ventricular function after myocardial infarction in follow-up studies. Subjective assessment is a less demanding approach and when carried out expertly, the extent of muscular damage can satisfactorily be evaluated.

[Long-term monitoring of changes in contractility of the left ventricular wall in patients with myocardial infarct]

Using two-dimensional echocardiography, the authors made a one-year investigation of left ventricular function in a group of patients after a first transmural myocardial infarction. They evaluated subjectively and quantitatively changes in the contractility and the development of the diastolic area of the left ventricle. They revealed a certain improvement of the contractility, probably as a result of the development of a collateral circulation and altered structure of the infarction focus associated with dilatation of the left ventricle by the Frank-Starling mechanism.

[Comparison of changes in the mobility of the left ventricular wall with coronarographic findings in patients after myocardial infarct]

The authors examined by echocardiography at rest and after exertion a group of 55 patients after a clinically confirmed first transmural infarction. They compared the echocardiographic findings with coronarographic ones. The finding at rest, as regards impaired mobility of the left ventricular wall, corresponded to the clinical finding and the coronarographic finding. By diagnosis of the extended asynergy of contraction during an isometric load it was not possible to differentiate the functional and organic cause of impaired mobility and thus to assess the extent of the coronary affection. The impaired mobility of the left ventricular wall is associated above all with the state of the blood supply rather than with the finding on the coronary artery.