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Heart transplantation is an established therapeutic modality in patients with end-stage heart failure. In the 1st year after transplantation acute cellular rejection is still important. The diagnosis of acute cellular rejection is based on the histological evaluation of endomyocardial biopsy (EMB) specimens. EMB is an invasive procedure with a definite risk and poor tolerance in some patients. Imaging methods like echocardiography and magnetic resonance imaging as well as intracardiac ECG have been used for noninvasive diagnosis of acute cellular rejection. In addition, a large number of circulating biomarkers have been evaluated for noninvasive diagnosis of rejection. B-type natriuretic peptide, troponin and inflammatory markers are the most important biomarkers in this field. Although these parameters are useful, none of them has the potential to replace EMB as the gold standard for diagnosis of rejection. In the near future microarray technology might get important for diagnosis of acute cellular rejection. Using microarray technique gene expression profiles can be detected, which are associated with an increased risk for rejection. Ongoing studies will demonstrate, whether microarrays can at least reduce the number of EMBs.

2008 new guidelines for the management of patients with ST-elevation myocardial infarction were published by the European Society of Cardiology. For daily clinical practice, changes in recommendations concerning the preferred revascularization therapy according to different time delays are of great interest. This review focuses on possible implications of these new guidelines on the choice of reperfusion strategies in rural areas.

Myocarditis is the reason for sudden cardiac death in 5-22% of athletes < 35 years of age. Actually, parvovirus B19 and human herpes virus 6 are the most important pathogens. Clinical presentation of myocarditis is heterogeneous, with all courses between asymptomatic and fulminant reported. Especially in athletes it is important to take subtle discomforts seriously and initiate further evaluation. Electrocardiogram, laboratory parameters, serologic markers, and echocardiography are helpful in diagnosis of myocarditis, but are not specific. Magnetic resonance imaging (MRI) of the heart has become an important tool in the evaluation of patients with myocarditis and allows noninvasive appraisal of myocardial inflammation using late enhancement. However, MRI is not able to assess viral persistence. Therefore, endomyocardial biopsy (EMB) remains the gold standard in diagnosis of myocarditis. When considering EMB in these athletes one should not ignore spontaneous healing in 50% of patients with myocarditis. Contrariwise, specific therapy (e.g., immunosuppression, interferon, immunoglobulins) for myocarditis is only feasible after getting results of EMB. When myocarditis is verified, athletes have to withdraw from sport for at least 6 months. Before restarting physical activity, a detailed examination is necessary and most of the patients will undergo another EMB. For prevention of myocarditis and sudden cardiac death it is recommended to stop elite sport for 4 weeks after an unspecific infection. Whether moderate sport can be started earlier is unclear.

Background: Chronic heart failure is associated with high mortality and morbidity. In spite of a number of trials showing significant improvement in survival and reduction in hospitalization for patients who received ACE inhibitors/AT1 receptor antagonists (ACEI/ARB), beta-blockers and spironolactone, and notwithstanding the recommendations of national and international guidelines for the management of heart failure, substantial proportions of patients are not receiving this treatment. The aim of our study was to analyse 1. the efficiency of a specialized heart failure clinic in translating guidelines into clinical practice, and 2. the effect of optimized neurohormonal therapy on patient outcome., Methods and Results: The data of patients with systolic heart failure and an ejection fraction < or = 35% referred to the Innsbruck Heart Failure and Transplantation Program between February 2000 and October 2001 were analysed. The number of patients treated with ACEI/ARB, beta-blocker and spironolactone increased significantly in the investigation period (p < 0.05). Equivalent dose for captopril and bisoprolol per patient developed from 66.4 +/- 42.8 to 96.5 +/- 41.9 mg (p < 0.001) and from 2.0 +/- 2.9 to 6.3 +/- 4.0 mg (p < 0.001), respectively. Optimization of neurohormonal therapy was associated with a significant improvement in NYHA class (2.5 +/- 0.8 vs. 1.9 +/- 0.8; p < 0.001). No relevant changes were noticed for blood pressure, serum creatinine, serum sodium, and serum potassium, whereas heart rate dropped significantly. Kaplan-Meier curves examining the time to first event of the combined end point of mortality and hospitalisation for worsening heart failure revealed a clear benefit for patients on combined neurohormonal therapy (ACEI/ARB and beta-blocker, n = 86) when compared with patients on neurohormonal monotherapy (ACEI/ARB or beta-blocker, n = 35), (p < or = 0.001). Differences remained significant (p = 0.022) after adjusting for NYHA class at referral, age, gender, etiology of the underlying cardiomyopathy, ejection fraction, and atrial fibrillation in Cox regression analysis., Conclusion: Guidelines for the management of chronic heart failure patients can be translated efficiently into clinical practice by a specialized heart failure clinic. Optimization of therapy is associated with an improvement in functional status and a decrease in mortality or hospitalization for worsening heart failure. Therefore the nationwide installation of specialized heart failure clinics is required.

Due to limitations in transthoracic and occasionally transesophageal 2-D echocardiography with respect to volumetric analysis and morphologic and functional assessment in patients with congenital malformations and valvular heart disease, additional diagnostic tools have been established. In parallel with the rapid evolution in computer technology, 3-D echocardiography has grown into a well-developed technique, such as volume-rendered 3-D reconstruction, capable of displaying dynamic morphology depicting depth of the structures, their attachment, and spatial relation to the surrounding tissue. Nevertheless, the complexity of data acquisition and data processing required for adequate dynamic 3-D echocardiographic imaging and volumetric analysis does not allow to use this approach routinely. The commonly used dynamic 3-D echocardiography means off-line computer-assisted image reconstruction from a series of cross-sectional echocardiographic images using currently available transesophageal and transthoracic transducers. Alternatively, real-time 3-D echocardiography based on novel matrix, phased-array transducer technology has been introduced. Although this technique can be easily combined with any routine examination, its clinical use is limited because of a lower image quality in comparison with dynamic 3-D echocardiography. Up to now, there is no transesophageal approach available using real-time 3-D echocardiography. Recently, dynamic 3-D echocardiographic technique has matured noticeably. Beside the well-known sequential scanning, which is characterized by a fixed probe and patient in space and predetermined motion of the transducer, the freehand scanning using an electromagnetic location system has found its way to clinical environment. The main advantage of this technique is that the transducer can be freely moved by the examiner and, thus, the data set acquired within a routine examination. Also 3-D rendering and display have been developed further. In this respect, especially the "real-time rendering mode" allowing the reconstructed 3-D image to be animated and moved in space and to look at it from different perspectives has gained increasing acceptance. In valvular heart disease, reconstructive surgical treatment is aspired. 3-D echocardiographic imaging is the only technique providing "surgical views" prior to opening the heart. It is capable of distinguishing particular destructive substructures of the valves and the valvular apparatus. Especially in mitral valvular reconstruction, it is of clinical importance to achieve optimal surgical results. With respect to volumetric and mass analysis, 3-D echocardiography is more accurate and reproducible in comparison with conventional 2-D analysis. It provides data independent of geometric assumptions, what may considerably influence the results in the presence of wall motion abnormalities, especially in aneurysmatic ventricles. Volumetric analysis of the aneurysmal portion may also be helpful prior to surgical resection. 3-D echocardiography can also be recommended as a valuable additional approach to atrial septal defect (ASD), corrected transposition of the great arteries, cor triatriatum, and, within limits, to ventricular septal defect (VSD) as well. Especially with respect to ASD and VSD, the potential significance of 3-D echocardiography prior to device closure is emphasized. At present, its additional information in decision-making and the increasing number of clinical cases that can be addressed and answered already justify the clinical use of this technique.

The state-versus-trait discussion in coping research would become more meaningful if attention is paid to the variability both of coping patterns in individual patients as well as stability of single coping strategies over time. 35 patients undergoing coronary artery bypass surgery were interviewed three times about their coping and stress experience: after cardiac catheterization, on the day before surgery, and six days after surgery. Anxiety and depression were measured. A coping attitude of "positive passivity" was present at all three points of time. While the group means were stable, vast interindividual differences occurred. Also, there was a high degree of scatter in the stability of single coping items; emotion related coping modes were more stable than cognition and action related ones. The variability of the patients' coping patterns correlated positively with the amount of stress experienced and with preoperative depression. Different coping strategies are linked to a different degree with personality traits, emotional coping modes revealing the closest connection. The variability of individual coping efforts might be linked to a personality disposition characterized by a vulnerability for stress and depressive reactions.

In the present study pulmonary function test data were obtained from 15 healthy volunteers and 15 patients with slightly impaired ventilation during both normal and maximally reduced opening of the mouth (trismus, intercuspid position). The aim of the study was to examine the effects of complete trismus on pulmonary function using objective and subjective parameters. In maximally reduced mouth opening, both groups showed an impairment of all subjective and objective pulmonary function test data. In healthy volunteers, the significant changes in the test data (p < 0.05) simulated mild to moderate pulmonary impairment, whereas patients with an already impaired pulmonary function showed a marked deterioration of their initial respiratory condition. The results of the subjective and objective parameters examined indicate that an intercuspid position (trismus) further aggravates pulmonary functional impairments. Complete trismus can be considered a risk factor to pulmonary function in patients using mouth-breathing as primary or supportive mode of respiration.

History and Clinical Findings: Case 1: a 20-year-old previously healthy man sustained multiple nonvascular injuries without visible chest trauma in a car accident. Four days later a loud systolic murmur was heard over the heart. Case 2: a 21-year-old man similarly sustained in a car accident multiple injuries without visible chest involvement but causing haemorrhagic shock. A loud systolic heart murmur was heard and after shock treatment he developed left heart failure requiring catecholamine infusions., Investigations: Echocardiography demonstrated posttraumatic ventricular septal rupture in both patients. Cardiac catheterisation revealed a small left to right (1 : 1.6) shunt in case 1, and a large one, 1 : 3, with markedly elevated pulmonary artery pressure in case 2., Course: In case 1, no treatment was needed as the intracardiac shunt was small and there were no symptoms. But in case 2 the large shunt with pulmonary hypertension required operative closure with a Dacron patch 2 days after the diagnosis had been established., Conclusion: Ventricular septal rupture after blunt trauma to the chest is a rare occurrence. Even though in general the prognosis is good, a large intracardiac shunt may require early surgical repair.

The detection of all teeth with periapical pathological conditions and optimal treatment of the affected teeth are a part of the evaluation program for patients who are scheduled to undergo cardiac value replacement. 48 patients (50 value replacement operations) were evaluated for the incidence of periapical pathological conditions, as well as for the different kinds of oral surgical interventions. A periapical pathological condition was present in 28 of 48 patients (58.3%). In general, the incidence of a dental focus was significantly higher in patients awaiting aortic valve replacement than in patients undergoing mitral valve replacement (69.7% vs. 23.1%; p < 0.01). Patients for aortic valve replacement presented significantly more periapical pathological conditions than patients for mitral valve replacement (1.7 vs. 0.8). Optimal timing of dental consultations is helpful in the oral rehabilitation of patients about to undergo a valve replacement procedure. Furthermore, close interdisciplinary cooperation is necessary to minimize the social and psychological problems following unexpected tooth extractions. Cardiologists and heart surgeons have an important role in the organisation of the oral rehabilitation of patients undergoing valve replacement procedures.

The development of left main coronary artery stenosis is a rare complication arising after aortic valve replacement. We report the different clinical course of two cases. One patient developed typical exertional angina 3 months after uneventful aortica valve replacement. Coronary stenosis had been excluded on preoperative coronary angiography. One day before hospital admission for coronary angiography the patient died suddenly. The second patient reported symptoms typical of angina 6 months after aortic valve replacement. Coronary angiography revealed critical left coronary ostial stenosis, which was successfully treated by surgical revascularization. These cases demonstrate the rare, yet potentially fatal complication of left coronary ostial stenosis. Early coronary angiography seems warranted in the event of typical exertional angina, even after angiographic exclusion of relevant coronary artery stenosis before aortic valve replacement.

The renin-angiotensin system (RAS) plays an important role in blood pressure regulation and fluid homeostasis in people with and without hypertension. The ACE-inhibitors were the first of the RAS blocking agents to have a wide clinical acceptance. Several trials demonstrated their usefulness in the treatment of essential hypertension, congestive heart failure, post myocardial infarction and diabetic renal disease. The recent development of selective angiotensin II type 1 receptor II blockers offers the compelling concept of interfering on the receptor level without disruption of the prostaglandin and bradykinin biosystems. Losartan, the prototype of orally active angiotensin II type 1 receptor antagonists, has been shown to be safe and effective in control of elevated blood pressure and improvement of the abnormal hemodynamics in the patient with congestive heart failure. These early encouraging results have to be confirmed by studies translating the circulatory benefits into augmented end-organ protection and prolongation of life.

Since 24-hour blood pressure monitoring seems to be superior to occasional blood pressure measurement as far as risk stratification is concerned, we compared the two methods in patients with secondary hypertension and left ventricular hypertrophy. In 26 haemodialysis patients (12 male, mean age 54 +/- 13 years), the mean occasional blood pressure values during haemodialysis were 147 +/- 18/82 +/- 9 mmHg, the mean 24-hour blood pressure values were 145 +/- 21/ 85 +/- 13 mmHg, during the day 145 +/- 23/86 +/- 13, during the night 143 +/- 25/81 +/- 13 mmHg. The nocturnal reduction of mean blood pressure was -3.6 +/- 7%. Both methods of blood pressure monitoring showed a significant correlation with the relevant echocardiographic parameters of left ventricular hypertrophy, cardiac mass and interventricular septum diameter. Patients with and without a nocturnal reduction in blood pressure could not be differentiated by the mean occasional blood pressure values. Therefore, 24 h ambulatory blood pressure monitoring seems warranted in this high risk group, especially to monitor antihypertensive drug therapy.

265 carotid endarterectomies in 210 patients (all vein patch in the carotid bifurcation) were investigated postoperatively for the presence and reversibility of cranial nerve palsy especially for N. facialis, N. hypoglossus, and N. vagus paresis. Additionally, the anatomical relationship between the affected cranial nerve and the carotid artery and the influence of surgical case load on the incidence of cranial nerve paresis were investigated. Altogether 28 (10.5%) cranial nerve injuries were registered. In 6 (2.2%) cases the hypoglossus nerve was injured, in 13 (4.9%) the vagal nerve (N. laryngeus recurrens) and in 9 (3.4%) facial nerve paresis occurred. Cranial nerves VII and X, which are not directly connected with the area operated on, show significantly more injuries than the hypoglossal nerve (p < 0.01), which is located closer to the carotid artery. Significantly lower rates of cranial nerve injuries (p < 0.01) were recorded in cases operated on by surgeons with greater experience (> 30 cases) than by surgeons with a case load below this threshold. Although different reasons for cranial nerve injuries such as direct pressure, retraction or edema are known, all pareses show an excellent spontaneous recovery rate within the period of one year.

In a retrospective study the indications and the long-term results of percutaneous atherectomy of a nonselected group of patients were analysed. From March 1988 to November 1989, 94 patients suffering from peripheral vascular disease were treated using Simpson's atherectomy technique. There were 132 lesions, 101 stenoses and 31 occlusions in a total of 94 patients. The primary success rate was 95%. After 12 months of follow-up the cumulative patency rate was 69% and after 24 months, 42%. After a follow-up period of 15 months patent arteries and recurrences were recorded and the results used to analyse the factors that influence patency after Simpson atherectomy. The patency rate is 71% in diabetics and 62% in non-diabetics. It is 51% in occlusions and 73% in stenoses. The patency rate in patients with fair runoff is 69%, in patients with poor runoff 60%. Comparing these results with historical studies concerning balloon dilation the results are poor. Residual stenoses after balloon dilation seem to be the optimal indication for percutaneous atherectomy.

Twenty-eight patients (17 women, 11 men, average age 67 years, range 40-85 years) with embolic occlusions of the popliteal arteries were treated by aspiration embolectomy. 6 patients were in clinical stage IIb and 22 in stage III. In 25 of the 28 patients the occlusion was treated successfully. Complications could be treated non-surgically at the same time. 2 of the patients died within the first week of cerebral emboli, 2 further patients suffered recurrent emboli in the treated extremity during the first month. 17 patients who were followed up for six months were free of recurrences.

A thrombotic occlusion of the femoral artery with a history of 16 days is recanalized using the Rotational-Aspiration-Thromboembolectomy catheter according to Starck. The underlying stenosis is treated by balloon dilatation.

Percutaneous atherectomy, using a Simpson atherectomy catheter, was performed in 70 patients (43 men, 27 women) whose average age was 72 years (range 42 to 87 years). Between June 1988 and July 1989 all patients with disease in suitable localisations were treated in this way. The Doppler sonographic index before treatment was 0.6 (SD = 0.15), after treatment 0.89 (SD = 0.13). Recurrence was 21% after six months and 29% after twelve months. Atherectomy is superior to balloon dilation in the treatment of solitary eccentric stenoses of the superficial femoral artery and of the popliteal artery.

Follow-up of bypass patients in the early postoperative phase involves the management of complications such as perioperative myocardial infarction, postoperative arrhythmias, pericarditis, postcardiotomy-syndrome, fever, infection and chest pain. The longterm management has to focus on changes in lifestyle with particular regard to risk factors for coronary atherosclerosis. Diagnostic tools for work-up of postoperative chest pain include stress testing and radionuclide techniques; ultrafast computerized tomography is superior in the evaluation of bypass function to cine-NMR. Conventional angiography is still the only method to reliably visualize graft patency and anastomotic sites. Indications for reoperations can be well defined.

The behaviour of red blood cells was studied in 17 patients with aortic stenosis and 14 patients with mitral stenosis. Anemia was present only in 1 out of 17 patients with highgraded aortic stenosis. 8 of the 17 patients showed a reduced survival time of the red blood cells indicating hemolysis in a compensated stage. 14 cases of mitral stenosis showed no evidence of hemolysis. There was a significant inverse relationship (r = --0,85) between the valve gradient and the survival time of the erythrocytes in patients with aortic stenosis; valve area and survival time were directly related (r = 0,75). In mitral stenosis, there was no significant correlation between gradient or valve area and survival time. This suggests that the gradient through the valve rather than the reduced valve area is responsible for the damage of the erythrocytes; in addition, hemolysis appears to be dependent on pressure gradient rather than on valve pathology or reduction of valve area per se.

89 patients (78 with coronary artery disease, 11 normals) were studied comparatively with T1-201 planar myocardial scintigraphy and 7-pinhole emission tomography with a mobile gamma-camera. In 46 patients stress studies were performed, the other studies were performed as resting protocols. In 13 patients a correlation of scintigraphically determined infarct size calculated from the T1-201 tomograms with CK and CK-MB values (maximum values) in the acute infarction period was performed. 17 patients having undergone intracoronary streptolysis were studied to investigate the effect of this intervention. In patients without previous myocardial infarction (n = 35) sensitivity of 7-pinhole tomography was significantly superior over planar reading of images (83% for qualitative evaluation, 91% for quantitative analysis). In patients with previous myocardial infarction (n = 26) comparative sensitivities were not significantly different, although slightly higher, nevertheless the fraction of questionable findings was reduced from 9 to 4%, furthermore in 31% an additional information concerning size or localization could be obtained from the tomograms. Predictive diagnostic accuracy was highest for quantitative 7-pinhole tomography (91%) but not significantly different from qualitative tomography but higher than for planar imaging. Specificities of all methods were comparable. In patients during the acute phase of myocardial infarction a significant correlation (r = 0.76 for CK, r = 0.78 for CK-MB, p less than 0.01) was obtained with enzymatic markers of infarct size. In the group after intracoronary streptolysis 7-pinhole tomography was able to demonstrate a quantitative reduction of thallium infarct size in patients after successful lysis (23.5% vs 48.7%, p less than 0.01) although absolute quantitation is not possible with thallium-201 due to inherent biological limitations. Emission tomography using 7-pinhole collimation leads to an improvement of diagnostic accuracy in all patients with reversible ischemia and helps for better delineation of size and localization of infarct areas and could help in the assessment of interventional effects, as after intracoronary streptolysis.

Myocardial revascularization was performed in 13 patients between two and 14 days following initial infarction because of impending re-infarction. The diagnosis of impending re-infarction was made on the basis of the following criteria: myocardial infarction; repeated stenocardia despite medical treatment; renewed ST-T changes in the ECG. The intra-aortic balloon pump was installed in 7 patients for haemodynamic reasons (shock, massively raised pressure in the pulmonary artery). 12 patients survived the surgical intervention and were eventually discharged free of stenocardia. The presented findings suggest that surgical intervention in impending re-infarction appears of value in those cases which have not been satisfactorily controlled by conventional medical treatment.

202 patients with congestive cardiomyopathy have been classified according to their hemodynamic, angiographic, echocardiographic and scintigraphic findings: 72 patients were in the late stage (LS), 103 patients in an early stage (ES) and 17 patients showed a latent form of the disease. 48% of the hemodynamic ES were found to be clinically in stage IV NYHA and 53% of ES fell in class III. 40% of the patients with LS showed a stationary clinical course whereas 46% could improve their classification by one grade. The mortality in hemodynamic LS was 46% within an interval of 18 +/- 14 months after the diagnosis. In ES 64% showed a stable clinical course, where a 22% were deteriorating. Mortality in this group was 10%. Sensitivity and specificity of echocardiography (93 vs 80%) and radionuclide methods (80 vs 71%) were quite good in the late stage whereas in ES specificity was only 71% vs 80%. There was a discrepancy between the degree of myocardial impairment and clinical symptoms in the late stage whereas in the early stage there was no correlation between exercise capacity and LV-hemodynamics. Non-invasive methods allow the hemodynamic evaluation of the disease; invasive methods are required for clarification of diagnosis or establishing prognosis.

An analysis is given for the differential therapeutical drug treatment in the acute phase of myocardial infarction. In first line the correction of hemodynamic disorders is taken into consideration following an exact diagnosis of hemodynamic dysfunction. On that basis different subgroups can be identified. In 5% of the patients exists a hypoperfusion. The therapy of choice is a substitution of volume. 25% of the patients with an acute myocardial infarction develop acute left ventricular failure, with a mortality of 40 to 50%. The treatment of choice in patients with clinical signs of congestion of the lungs but normal cardiac output will be diuretics and vasodilators. In patients with global insufficiency afterload reduction with vasodilators and/or stimulation with positive inotropic substances such as catecholamines has proven successful. Cardiac glycosides have lost their place in the treatment of acute but not of chronic cardiac failure. The use of intraaortic counterpulsation will be reserved for patients with mechanical complications.

The present report describes a case of a massive transmural anterior wall myocardial infarction in a woman with angiographically normal coronary arteries. The possible mechanisms of production of myocardial infarction in the presence of normal coronary arteriograms are discussed. With the increasing application of coronary arteriography, such diagnostic problems will undoubtedly become more frequent.

The efficiency of thrombolytic therapy in acute myocardial infarction has been documented in a large number of studies. The reduction of mortality has been shown for streptokinase (SK) and APSAC and various combinations (SK and aspirin). The recanalisation-rate is higher for rtPA as is the reocclusion-rate. Major bleeding complications are similar for all agents. However, the incidence of intracranial bleedings seems to be higher with rtPA; thus the cost-effectiveness for the tissue plasminogen activators is questionable. Attempts are made to focus on the implications of the major clinical trials for the therapeutic strategy in different patient-groups.

The effects of selective thrombolysis with intra-coronary streptokinase in regard to myocardial protection are still debated. In 25 patients with acute myocardial infarction we evaluated regional metabolism with 123 radio-iodinated heptadecanoic acid and segmental 201 thallium scintigraphy in the distribution of the recanalized coronary vessel. Lysis was successful in 11/16 occlusions of LAD-, 4/7 RCA- and 1/2 CX-vessels. In this group (A) the average defect size on TI-scintigrams was 19 +/- 6% 24 hours after the intervention, whereas unsuccessful recanalisation (group B) resulted in a defect size of 38 +/- 7% (p less than 0.01). There was good concordance between thallium defect size and fatty acid metabolism in group B. However, in group A 6 of 11 patients showed significantly smaller fatty aid accumulation than the thallium defect size reflected. These data suggest that successful reperfusion does result in protection of myocardium in the majority of infarct patients reflected in the smaller TI infarct size. Successful reperfusion, however, does not always immediately restore metabolic dysfunction. This discrepancy will have to be analyzed by further follow-up studies of these patients.

15 patients were injected 2 mg/kg Propafenon intravenously in 3 minutes. In 10 patients the changes of the atrio-ventricular conduction and the sinus-node recovery time were measured. In 5 out of these 10 patients the influence on the left ventricular systolic pressure, the left ventricular enddiastolic pressure and the dp/dtmax was also measured. 4 patients had a WPW-syndrom and one patient an AV nodal tachycardia. There was a significant increase of the PQ-time (16,7%), the AH interval (9%), HV interval (33%) and the width of the QRS complex (13.8%). The intratrial conduction (PA-time), the heart rate and the sinus-node recovery time were not influenced. In 6 out of 7 patients the effective refractory period of the AV node was prolonged and in one it remained unchanged. There was a statistically significant decrease of the dp/dt, the heart rate staying the same. The systolic pressure decreased slightly and the enddiastolic pressure increased insignificantly. In 3 out of 4 patients with WPW syndrome the accessory pathway was blocked and in the 4th the effective refractory period of the pathway prolonged. In 3 out of these 4 patients a tachycardia could be initiated by the extra-stimulus method which was not possible after administration of the drug.

A computer-supported system was designed for processing of 2-dimensional echocardiographic images of the left ventricle. The purpose of the method is to improve quantitative analysis of regional contraction patterns of the ventricle, using a 3-dimensional reconstruction technique. The definition of the spatial position of the transducer and a computer assisted outlining of the ventricle are the main features of the system. The usefulness of this method was demonstrated in a preliminary study.

The case of a 17-year-old boy with the homozygous form of familial hypercholesterolaemia is reported. The patient presented tuberous and tendinous xanthomas, arcus lipoides, complete occlusion of the LAD of the coronary arteries, a characteristic family history, and total cholesterol levels greater than 600 mg/dl. Among the available therapeutic regimens we decided to perform plasma exchange treatment, which was introduced by Thompson in 1973 as therapy of this metabolic disorder. After each plasmapheresis, performed so far 7 times, the cholesterol and LDL-cholesterol concentrations dropped to normal levels; they increased again within the next 3 weeks, without, however, reaching the pretreatment levels. Undergoing this treatment, the xanthomas decreased markedly; there are reasons to assume that atherosclerotic lesions might also decrease during this treatment.

In 10 patients with angiographically proven coronary artery disease we investigated the influence of the glycoside 14-hydroxy-3beta-[(4-O-methyl-alpha-L-rhamnopyranosyl)oxy]-14beta-bufa-4,20,22-trienolide (meproscillarin, Clift) on left ventricular performance with invasive methods. After a single i.v. bolus injection a decrease in left ventricular end-diastolic pressure associated with an increase of the maximum rate of pressure rise (dp/dtmax) and left ventricular pressure (LVP) was observed. These changes were not accompanied by significant alterations of the heart rate during an observation period of 60 min.

In 65 out of 79 patients with WPW syndrome who had extensive electrostimulation studies, a follow-up evaluation (mean follow-up period 2.5 years) was performed. The patients were divided into 2 groups: Group 1: No therapy or therapy only during tachycardia. Group 2: Continuous oral drug therapy. There was no difference of antegrade and retrograde refractory periods, but there was a significant difference in the initiation of tachycardias. In group 1, the typical reentry tachycardia using the AV node antegradely and the accessory pathway retrogradely was predominant, while in group 2, complex arrhythmias (atrial fibrillation + reentry tachycardia, tachycardias using the accessory pathway in both directions, reentry tachycardia + AV-nodal tachycardia, isolated atrial fibrillation) during electrostimulation could be induced. all except 1 patient in whom no tachycardia could be initiated were in group 1 (statistically significant difference). Thus the type of tachycardia which can be initiated during electrostimulation is a better predictor for the condition in the follow-up period than the refractory period. As concomitant disease there were 4 cases with Ebstein disease (2 had additional mitral valve prolapse syndrome) and 3 cases with mitral valve prolapse syndrome. 3 of the 4 patients with Ebstein disease were in group 2. 1 of the 64 patients died during the follow-up period suddenly, but the cause of death is not known and possibly due to medical therapy. The mortality in a non-selected group of patients with WPW syndrome seems to be very low.

Echocardiography offers a non-invasive method ideal for the patient and the observer. It improved the diagnostic possibilities during the past few years significantly and reached highest diagnostic sensitivity in certain cardiovascular diseases. It is ideally suited for follow-up examinations and for the evaluation of medical or surgical interventions. In addition it can be helpful as screening method for invasive diagnostic procedures. Despite all advantages one has to keep in mind that it is only one single diagnostic step within the whole diagnostic framework. For the management of patients it is decisive to know the information which can be gained and to know the possibilities and limitations of the method.

The appearance of neovascularity on coronary angiography is described in two patients. A large thrombus was documented in one case at autopsy, whilst in the second case the presence of a thrombus was confirmed by two subsequent coronary arteriographic and ventriculographic studies. Thus, the observation of neovascularity of the left ventricle on angiography is indicative of thrombus formation rather than the presence of a neoplasm.