Diastolic intraventricular gradient in hypertrophic cardiomyopathy with apical hypertrophy

Patients with hypertrophic cardiomyopathy and additional diastolic flow abnormalities are relatively rare. This report describes a case of apical ventricular hypertrophy with complete systolic obstruction and holodiastolic intraventricular pressure gradient.

Morphological quantification and differentiation of left ventricular hypertrophy in hypertrophic cardiomyopathy and hypertensive heart disease. A two dimensional echocardiographic study

Differentiation between hypertrophic cardiomyopathy and hypertensive heart disease is a diagnostic challenge. M-mode echocardiography only permits assessment of hypertrophy in limited areas of the left ventricular wall. 2-D echocardiography allows visualization of most of the myocardium. To assess the reliability of conventional M-mode echocardiographic and 2-D echocardiographic criteria in patients with hypertrophic cardiomyopathy (HCM) and hypertensive heart disease (HY), 30 patients with hypertrophic cardiomyopathy and 30 patients with hypertension and severe cardiac hypertrophy were examined using M-mode and 2-D echocardiography. Although the M-mode echocardiographic features showed statistically significant differences between the mean values in the two groups, the degree of overlap made the differentiation of the individual patients difficult. The diagnostic sensitivity and specificity of classic echocardiographic features were assessed: ventricular septal thickness greater than or equal to 1.5 cm, 90% and 43% (sensitivity and specificity, respectively); ventricular septal thickness to posterior wall ratio greater than or equal to 1.5, 83% and 56%; cross-sectional area at papillary level greater than 21 cm2m-2, 80% and 73%; septal segment of the myocardial ring at papillary level greater than 6.5 cm2m-2, 80% and 87%; and the combined criteria of cross-sectional area at papillary level greater than 21 cm2m-2 and septal segment greater than 6.5 cm2m-2, 77% and 93%. Quantitative 2-D echocardiography is useful to differentiate patients with hypertrophic cardiomyopathy from those with secondary myocardial hypertrophy due to hypertension. Hypertrophic cardiomyopathy is characterized by a spectrum of different morphological patterns of hypertrophy. Patients with the predominant region of hypertrophy in the anterolateral free wall or the apical region of the left ventricle were not detected with our quantitative method. Patients with this type of hypertrophy are relatively rare in the western population.

Impaired fibrinolytic capacity and tissue plasminogen activator release in patients with restenosis after percutaneous transluminal coronary angioplasty (PTCA)

To assess the role of the fibrinolytic system in the pathogenesis of restenosis after percutaneous transluminal coronary angioplasty (PTCA), we determined the components of this system in a retrospective study, including 16 patients with restenosis (gr. A) and 19 patients with long-term success (gr. B). In both groups at baseline fibrinolytic activity (FA) is unchanged, whereas tissue plasminogen activator antigen (tPA-Ag) is significantly increased (gr. A: 147.0%; gr. B: 139.8%; p less than 0.01). Fibrinolytic capacity (FC) and tPA-Ag release are significantly reduced in the restenosis group (FC: 46.5%, p less than 0.05; tPA-Ag release: 48.3%, p less than 0.01) compared to normal controls as well as to gr. B (FC: 84.3%, p less than 0.05; tPA-Ag release: 79.0%, p less than 0.05). Relating to the contact activation system, F XII (79.5%, p less than 0.05) is significantly, and F XI (82.3%) is clearly reduced in gr. A. Protein C (PC) is significantly elevated in gr. B (117.5%, p less than 0.05). There is a negative correlation between plasminogen activator inhibitor (PAI 1) and HDL-cholesterol (r = 0.37, p less than 0.05). It appears, that there is a typical pattern of defective fibrinolysis in patients with restenosis after PTCA and that this might be a pathogenetic factor in the development of restenosis.

Ventricular function in cirrhosis and portasystemic shunt: a two-dimensional echocardiographic study

Cardiovascular alterations such as increased heart rate, high cardiac output, reduced systemic vascular resistance, and in most of the cases, increased contractility parameters have been recognized in patients with advanced liver disease. Some investigators define a cirrhotic cardiomyopathy as a hyperdynamic failure of the heart. Consequently, in patients with cirrhosis, the risk of developing further circulatory deterioration may be increased in situations which stress the cardiovascular system. After opening a portocaval shunt, it is expected that a large amount of blood will be distributed from the splanchnic to the pulmonary circulation and put a strain on the heart. This two-dimensional echocardiographic study was made in 30 patients with cirrhosis and in 20 patients who were chronically treated (range: 16 to 156 months) with portasystemic shunt for prevention of hemorrhage from esophageal variceal bleeding. Patients with portasystemic shunts revealed a change in hemodynamic pattern. There was a significant increase in the left ventricular end-diastolic volume index and also a slight increase in the left ventricular end-systolic index. Cardiac output remained high despite a significant decrease in heart rate due to an elevated left ventricular stroke volume index. The parameters of systolic ventricular performance were normal. In contrast to the acute opening of the portacaval shunt, the chronic shunt volume put no strain of clinical significance on the heart.

Effects of long-term treatment with 120 mg of sustained-release isosorbide dinitrate and 60 mg of sustained-release nifedipine on myocardial perfusion

Forty patients with coronary artery disease and scintigraphically proven myocardial ischemia were randomized into 2 groups receiving 4 weeks of treatment with either 120 mg of isosorbide dinitrate (ISDN) release or 60 mg of nifedipine release. Control exercise testing and myocardial scintigraphy were continued until anginal pains occurred, and repeated at identical individual workloads at the end of the 4 weeks of drug therapy. Myocardial scintigrams were evaluated by quantitative recording of counts in 60 segments/frame. Twenty patients in the ISDN group (group I) exhibited 47 significantly ischemic areas. The remaining 20 patients (group II), treated with nifedipine, had 50 ischemic areas before therapy. In the ischemic areas in group I, there was a mean difference of 30.9% between counts at rest and during exercise in the pretreatment period, and a difference of 18.1% after therapy (39.0%). In group II, the pretreatment difference was 28.8%, decreasing to 20.6% after therapy (17.8%). Both groups of patients were subsequently subdivided into 3 subsets: (1) significantly improved perfusion, (2) significant worsening, and (3) unchanged myocardial perfusion. Group I had 59.5% of areas with significant improvement and 10.6% of areas with significant worsening. In 29.7% of the areas, the findings were unchanged. Group II had improvement in 40% of areas, of significantly worsened areas in 6%, and unchanged areas in 54%, in both groups myocardial ischemia was reduced by therapy, but ISDN improved myocardial perfusion to a considerably greater extent than did nifedipine.

Unusual mechanism of PR interval variation and nonreentrant supraventricular tachycardia as manifestation of simultaneous anterograde fast and slow conduction through dual atrioventricular nodal pathways

Noninvasive recordings in a 69-year-old woman showed two distinct PR intervals of about 0.21 and 0.58 s, suggestive of dual AV nodal conduction. Various unusual mechanisms of transition from short to long and from long to short conduction intervals and phenomena of concealed conduction were due to the presence of two functionally separated intranodal pathways. Refractoriness of the slow pathway was associated with bradycardia. Episodes of tachycardia exhibited a one-to-two relationship between P-waves and ventricular activations as a consequence of simultaneous anterograde fast and slow conduction leading to double ventricular responses to single P-waves.

[Tachycardias caused by double ventricular responses and unusual atrioventrio-ventricular relations in linear dissociation of the AV node]

Noninvasive recordings in a 69-year-old woman showed phasic shifts between two distinct PR intervals of about 0.21 and 0.58 s suggestive of dual AV nodal conduction in the presence of two intranodal pathways. Episodes of tachycardia exhibited a one to two relationship between P waves and QRS complexes, with the same short and long PR intervals interpreted as simultaneous anterograde fast and slow conduction via the two AV nodal pathways, leading to a double ventricular response to single P waves. Various mechanisms of transition from short to long or long to short conduction times and concealed conduction phenomena could be demonstrated supporting the concept of two functionally separated intranodal pathways.

[Lorcainide in stable ventricular extrasystole. A double-blind study with 48-hour continuous ECG recording]

In a randomized double-blind cross-over trial, the effectiveness of lorcainide at a dosage of three times 100 mg/d by mouth was compared with that of a placebo for the treatment of subjectively disturbing stable ventricular extrasystoles (VES), using 48-hour continuous ECG monitoring. In 11 of 20 patients there was a regression in the VES rate to under 5%, in other 3 patients to under 50% of the initial values. Continuing the treatment, good therapeutic effect was still demonstrable 14 and 28 days later. However, only three patients had no side-effects. The others had sleep disturbances, hot flushes, sweating, restlessness, anxiety, dizziness, hallucinations and gastrointestinal symptoms. Lorcainide thus has a good anti-arrhythmic effect but, because of its side-effects, it should be used only in special circumstances.

Lipomatous hypertrophy of interatrial septum presenting as recurring pericardial effusion and mistaken for constrictive pericarditis

A case of interatrial septal lipoma, presenting as recurrent pericardial effusion with signs of constrictive pericarditis, was described. The tumor was removed successfully. The case demonstrated that the difficulties in the differential diagnosis between right atrial tumor and any other cardiac disease still exist. Because of its extreme rarity, the interatrial septal lipoma is rarely considered in the differential diagnosis.

[A controlled clinical study of early mobilisation of patients with myocardial infarction (author's transl)]

This is the report about 265 patients with recent transmural myocardial infarction. In the first week of hospital treatment 63 died. From the remaining 201 patients 101 fulfilled the conditions for early mobilisation of the WHO. In a controlled study these patients were divided in 2 groups: group 1 started the programme of early mobilisation the 7th day and group 2 was the control group which was mobilized after 3 weeks of bed rest. The 2 groups were comparable in the clinical course and had 2% of letality. The remaining 100 patients with conditions against early mobilisation were conservatively treated with 3 weeks of bed rest. The letality in this group was very high with 23%.

[Longterm therapy of angina pectoris patients with a new beta-receptor blocker (author's transl)]

The beta-receptor blocker Timolol was investigated for 28 weeks in a double blind trial and then for up to 100 weeks in an open trial in patients with angina pectoris. In both phases of the investigation. Timolol caused a quite marked regression in the frequency of attacks and in the pulse rate at rest. The evaluation of therapeutic success by doctor and patient was positive for Timolol.