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Rupture of the ventricular septum after acute transmural myocardial infarction occurred in four patients aged between 53 and 79 years. The rupture was verified by means of right-side cardiac catheterization. Only in two cases did two-dimensional echocardiography reveal the rupture; in both cases the rupture site located by echocardiography was confirmed at autopsy. In each of the four patients the left-to-right shunt could be identified by means of pulsed Doppler echocardiography which showed a turbulence in the right ventricle. Furthermore, the combination of two-dimensional echocardiography and Doppler echocardiography allowed a correct localization of the turbulent left-to-right flow in all cases. In view of these findings, the combination of Doppler echocardiography and two-dimensional echocardiography may be regarded as a suitable method for a readily available, non-invasive diagnosis of ventricular septum rupture in patients with acute myocardial infarction in an intensive care unit.

The value of persistent ST-T elevations in the standard 12-lead ECG for the diagnosis of left-ventricular aneurysm (VA) was retrospectively analysed for 200 patients (171 males and 29 females) who had sustained a myocardial infarction at least 12 weeks previously. 105 patients (group 1) had a left-ventricular aneurysm confirmed by ventriculography; in 95 patients (group 2) an aneurysm had been excluded by ventriculography. Persistent ST-T elevations were present in 98 patients of group 1 (sensitivity 93.3%) and in 26 of group 2 (specificity 72.6%). In the 26 patients without VA, ST-T elevations occurred in at most three leads, but in 60 with aneurysm in four to nine leads. In addition, the area under the ST-T elevations and its height 1 mm after onset of the elevation and its maximal height were measured. The sums of the values in the limb and chest leads were statistically significantly different between the two groups for all three parameters. These measurements thus contribute to a reliable differentiation between patients with and without VA. The results also emphasize the importance of the 12 standard leads in the diagnosis of VA.

SummaryThe purpose of the study was to evaluate alterations of the hemostatic system and the effect of anticoagulant therapy in nonvalvular atrial fibrillation. A set of molecular hematologic markers was measured prospectively in 69 patients with atrial fibrillation and 28 age-matched patients in sinus rhythm. Significantly elevated levels of thrombin-antithrombin III complex (8.5 ± 1.6 vs. 2.5 ± 0.3 αg/1; p

In a previous study on the diagnostic efficiency of troponin T measurements in patients with suspected acute myocardial infarction (AMI), the authors found a high variability of troponin T serum concentration changes on day 1 in patients with AMI who underwent thrombolytic treatment. Therefore, the aims of the present study were to investigate the intracellular compartmentation of troponin T and to analyze the effects of AMI reperfusion on the appearance kinetics of cardiac troponin T in serum. Cardiac troponin T was measured with a newly developed bideterminant sandwich assay using cardiospecific, affinity-purified polyclonal antibodies and peroxidase-labeled monoclonal antibody. An unbound cytosolic troponin T pool was found in ultracentrifuged homogenates of myocardial tissue of different species ranging from 0.013 to 0.036 mg/g wet weight. The soluble troponin T molecule had electrophoretic properties identical to troponin T compartmented in the myofibrils. The clinical study group comprised 57 patients with AMI undergoing thrombolytic treatment. Blood flow to the infarct zone and point of time of reperfusion were tested by immediate and late angiography. The appearance of troponin T in serum on day 1 after the onset of AMI depended strongly on reperfusion and on duration of ischemia before reperfusion. Thus, in patients with early reperfused AMI, a marked peak in troponin T serum concentrations was found at 14 hours after the onset of pain. This early troponin T peak was absent in patients with AMI reperfusion occurring greater than 5.5 hours after the onset of pain and in patients with nonreperfused AMI. By contrast, the kinetics of troponin T release after the first day after AMI were unaffected by reperfusion.(ABSTRACT TRUNCATED AT 250 WORDS)

BACKGROUND The present study was designed to evaluate the efficiency of a newly developed troponin T enzyme immunoassay for the detection of acute myocardial infarction. METHODS AND RESULTS The study comprised 388 patients admitted with chest pain and suspected myocardial infarction and 101 patients with skeletal muscle damage and additional suspected myocardial cell damage. Troponin T was elevated to more than twice the analytical sensitivity of the assay (0.5 microgram/l) in all patients with non-Q wave (range, 1.2-5 micrograms/l) and Q wave infarction (range, 3-220 micrograms/l). Troponin T appeared in serum as early as 3 hours after onset of pain in 50% of the patients and remained elevated in all patients for more than 130 hours, revealing release kinetics of both free cytosolic and structurally bound molecules. The diagnostic efficiency of troponin T was superior to that of creatine kinase-MB (98% versus 97%) and remained at 98% until 5.5 days after admission, if patients with unstable angina were excluded from analysis. In the 79 patients with unstable angina, troponin T was elevated (range, 0.55-3.1 micrograms/l) in at least one blood sample from each of 37 patients (56%). Circulating troponin T was correlated to the presence of reversible ST segment or T wave changes on the electrocardiogram (p less than 0.005) and to the frequency of in-hospital complications. In the 101 patients with skeletal muscle damage and suspected additional cardiac muscle damage, troponin T was the most useful test; its efficiency was 89% or 94% (depending on the discriminator value used) as compared with 63% for creatine kinase-MB. CONCLUSIONS Thus, the data of the study indicate that the newly developed troponin T test improves the efficiency of serodiagnostic tools for the detection of myocardial cell necrosis as compared with conventionally used cardiac enzymes.

The purpose of the study was to evaluate alterations of the hemostatic system and the effect of anticoagulant therapy in nonvalvular atrial fibrillation. A set of molecular hematologic markers was measured prospectively in 69 patients with atrial fibrillation and 28 age-matched patients in sinus rhythm. Significantly elevated levels of thrombin-antithrombin III complex (8.5 +/- 1.6 vs. 2.5 +/- 0.3 micrograms/l; p0.001), fibrin monomers (27.1 +/- 3.2 vs. 13.4 +/- 3.7 nM; p0.001), D-dimers (788 +/- 76 vs. 405 +/- 46 micrograms/l; p0.005), and tissue-type plasminogen activator (9.6 +/- 0.5 vs. 7.2 +/- 0.5 micrograms/l; p0.05) were observed in patients with atrial fibrillation compared to those in sinus rhythm. In a subgroup of patients in whom anticoagulant therapy with oral coumadin or standard intravenous heparin was established after the initial study, hemostatic activation decreased significantly. In conclusion, molecular hematologic markers indicate a hypercoagulable state in atrial fibrillation which may characterized a group of patients at elevated risk of thromboembolic disease.

We report on a 44-year-old male with primary cardiac angiosarcoma who died 11 months after onset of nonspecific symptoms (thoracic pain and general fatigue) of intracerebral metastases. A right atrial tumor mass and a pericardial effusion could be demonstrated by transthoracic and transesophageal echocardiography. Cardiac angiography showed a right atrial hemangioma, fed by the right coronary artery. In a review of 108 cases of primary cardiac angiosarcoma we summarize clinical features, diagnostic means, therapeutic approaches and life expectancy of this rare disease.

In anesthetized rats under artificial respiration, intravenous infusion of nisoldipine (0.1 mg/kg x min) caused significant decreases in blood pressure, heart rate, cardiac output and peripheral resistance. The animals died 54.7 +/- 11.1 min after initiation of the infusion. The electrocardiogram showed sinus bradycardia, increasing AV blockade and displacement of the pacemaker into the AV node or the bundle of His. Survival time under nisoldipine infusion increased more than two-fold with simultaneous infusion of calcium gluconate, isoprenaline (isoproterenol) or dopamine. Norepinephrine (noradrenaline) had no significant effect on survival time; the latter decreased to 19.4 +/- 1.6 min by plasma volume expansion with polygeline. All antidotes prolonging survival time also normalized the cardiac output diminished after nisoldipine. Electrocardiographic changes were antagonized only by isoprenaline. Suitable antidotes for intoxication or over-dosage of nisoldipine are calcium salts as well as beta-sympathomimetic drugs; sheer volume substitution and peripheral vascular constriction should not be resorted to.

Infarct size can be estimated noninvasively by analysis of circulating CK-MB and/or cardiac myosin light chains. To investigate whether myosin light chains release is correlated with the impairment of left ventricular function in acute myocardial infarction, this marker protein was determined by liquid phase radioimmunoassay in serial blood samples of 25 patients. Likewise CK-MB was measured in the same blood samples. From the serum concentration changes the cumulative appearance was calculated as an estimate of infarct size. Left ventricular enddiastolic pressure, global and regional ejection fraction were measured immediately and 3 weeks after admission. Particularily during the chronic phase of myocardial infarction a close correlation was found between serological estimates of infarct size and impairment of left ventricular function. The cumulative appearance of myosin light chains was superior to CKMB in assessing the hemodynamic impact of myocardial infarction in the acute and chronic stage. Therefore, myosin light chains are an appropriate serological indicator for the hemodynamic significance of myocardial infarction during the acute and chronic stage and might allow an assessment of the patients' risk.

Lidocaine was supplied to 10 cats by 2 comparative infusions of 7.5 mg/kg respectively. Once the drug was dissolved in a physiological and the other time in a K-Mg-concentrated electrolyte solution. The sequence of both infusions alternated. Serum potassium remained constant during infusion of the physiological electrolyte solution, but increased by about 1 mEqu/1 under K-concentrated solution. Lidocaine caused an enhancement of ventricular fibrillation threshold to an absolutely identical degree in both groups. Increase in cardiac output and stroke volume and decrease of sinus rate was significant in both groups, but more pronounced under K-Mg concentrated solution. Mean arterial pressure, peripheral vascular resistance, PQ, QRS, and QT interval remained constant on the whole. We deduce from these results for antiarrhythmic therapy on normokalemic patients, that the addition of potassium and magnesium to lidocaine solution does not enhance its antifibrillatory effect. This statement is valid for doses up to 20 mEqu/h of magnesium and 40 mEqu/h of potassium.

Im Rahmen einer elektrokardiographischen Untersuchung wurden bei 100–105 herzgesunden Versuchspersonen die rechtsthorakalen Ableitungen V4r und V3r, die dorsale thorakale Ableitung v2 2 ICR tiefer und die hochthorakalen Ableitungen V1–6 2 ICR hoher aufgezeichnet. Aus dem gewonnenen Material wurden die Extrem- und Mittelwerte einschlieslich der mittleren quadratischen Abweichung samtlicher vorhandener Ausschlage bestimmt und z. T. graphisch dargestellt. Auserdem wurden die verschiedenen Formen der Kammerkomplexe beschrieben und es wurde die prozentuale Haufigkeit ihres Vorkommens errechnet. In der anschliesenden Diskussion wurden die Indikationen fur die Anfertigung zusatzlicher Brustwandableitungen besprochen. Insbesondere wurden die Grenzwerte des Normalen herausgestellt und mit den entsprechenden Daten der vorhandenen Literatur verglichen. Es wurde hervorgehoben, das die rechtsthorakalen Ableitungen in erster Linie der Feststellung einer Rechtsuberlastung des Herzens dienen, wahrend die ubrigen Ableitungen ihren Wert in der Infarktdiagnostik haben: die dorsale Ableitung V8 2 ICR tiefer fur die Erkennung von Hinterwandinfarkten und die hochthorakalen Ableitungen fur die Diagnose basaler Vorder- und Seitenwandinfarkte.

Bei 35 Patienten mit Vorhofseptumdefekt wurden die Beziehungen zwischen hamodynamischen und elektrokardiographischen Grosen untersucht. Ein Einflus des Shuntvolumens auf den Beginn der grosten Negativitatsbewegung im Bereich des rechten Ventrikels konnte nicht nachgewiesen werden. Dagegen fand sich eine deutliche-wenn auch im Einzelfall nicht verlasliche-Abhangigkeit verschiedener elektrokardiographischer Amplitudenwerte von der Hohe des systolischen Druckes im rechten Ventrikel. Die elektrophysiologische Bedeutung desrSR′-Komplexes wurde diskutiert. Abschliesend wurde zur Frage der elektrokardiographischen Aussagemoglichkeiten uber die Druck-bzw. Volumenuberlastungsform eines Herzabschnittes Stellung genommen.

Nach dem Ergebnis der tierexperimentellen Synchronisationsversuche ist festzustellen, das eine „mechanische Kopplung“ von Vorhofund Kammeraktion sowohl am isolierten Froschherzen als auch am Saugetierherzen in situ als gesichert gelten kann. Die Adaptation der Sinusfrequenz an die Kammerfrequenz erfolgt am Ganztier offenbar nicht durch unmittelbare mechanische Einwirkung der heterotopen Ventrikelerregung auf den Sinusknoten, sondern indirekt uber eine Vorhofkontraktion gegen geschlossene AV-Klappen. Die am Kaltbluterherzen beobachtete, durch ausschlieslich elektrische Leitung bedingte Rhythmenverknupfung, die nach physikalisch-technischen Modellversuchen auch am Warmbluterherzen eine Rolle spielen konnte, lics sich bisher am Ganztier nicht bestatigen.

Bei 13 Patienten mit verschiedenen Herzfehlern ohne Kurzschlusverbindungen wurde mit Hilfe des Kalte- bzw. des Farbstoffverdunnungsverfahrens nach Indikatorinjektion in die V. cava sup. das Herzzeitvolumen in der A. pulmonalis und der A. iliaca simultan registriert. Statistisch signifikante Unterschiede zwischen den beiden Messtellen konnten nicht festgestellt werden. Man kann auf diese Weise das Herzzeitvolumen des rechten und des linken Ventrikels getrennt bestimmen.

The case of acute purulent group B streptococcal myocarditis in a 29-year-old Turk is described, no similar case having previously been published. He fell ill suddenly with gastro-intestinal symptoms, high fever and pain in arms and legs. The ECG had low voltage in the limb leads and signs of a large acute myocardial infarct. The sedimentation rate was slightly raised, an initial leukopenia was followed by leukocytosis and high enzyme activity. He died in cardiogenic shock on the third day of illness. The post-mortem examination revealed acute purulent myocarditis, and numerous group B streptococci (Strept. agalactiae) were found in the myocardium.

Tierexperimentelle Untersuchungen uber den antiarrhythmischen Effekt von Brufacain® wurden zuerst 1971 von Zetler und Strubelt, spater von uns mit der von Diederich beschriebenen Methodik zur Bestimmung der Flimmerschwelle an Katzen durchgefuhrt [3]. Auch klinische Erfahrungen mit Brufacain® liegen bereits vor [1, 2].

Im Rahmen einer Doppelblindstudie mit niedergelassenen und Notarzten wurde die Wirkung einer vorstationaren Lidocaingabe auf Letalitat und Arrhythmiehaufigkeit bei akutem Myokardinfarkt untersucht. Anlasslich einer Zwischenanalyse, die einen signifikanten Letalitatsunterschied zwischen der Lidocain-und der Placebogruppe ergeben hatte, entzundete sich eine kontroverse Diskussion uber das weitere Vorgehen. Die Argumente fur eine Fortsetzung der Studie basierten vorwiegend auf sachlichen Uberlegungen, die Argumente fur ihren Abbruch mehr auf ethischen Bedenken. Der Abbruch wurde schliesslich durch die geringe Zahl der verbleibenden kooperationsbereiten. Arzte besiegelt.

Bei der Prufung von antiarrhythmischen Substanzen hat sich der Einsatz des His-Bundel-Elektrogramms als auserordentlich wertvoll erwiesen. Es ermoglicht eine topographische Analyse des Angriffspunktes verschiedener Antiarrhythmika. Unerwunschte Nebenwirkungen dieser Pharmaka infolge Uberdosierung konnen beim Menschen nur auf Grund einzelner klinischer Beobachtungen, z. B. bei Suizidversuchen (Larbig u. Mitarb., 1970) und gestorter Pharmakokinetik beob achtet werden.

In 27 patients presenting with angina pectoris at rest and normal serum creatine kinase (CK) activity, cardiac myosin light chains (CM-LC), myoglobin (MG), and CK-B isoenzyme were determined in 7 serial blood samples by radioimmunoassays. Measurable amounts of CM-LC were found in at least one serum sample in 13 patients. MG was found to be elevated in 9, and CK-B in 8 of these patients. In the 189 serum samples determined, CM-LC were found more frequently elevated (21.7%) than MG (13.2%, P less than 0.05) or CK-B (12.2%, P less than 0.05). Coronary angiograms were obtained in 21 of the 27 patients. Elevated marker protein concentrations were found only in patients with coronary artery stenosis greater than or equal to 70% of at least one coronary artery. The incidence of elevated serum concentrations of any of the 3 marker proteins determined was higher in patients with 3 vessel disease than in those with 1 or 2 vessel disease (33.9% vs 15.6%, P less than 0.05), and it was higher in patients with a history of previous myocardial infarction than in those without (34.5% vs 11.4%, P less than 0.001). The findings suggest that in a subgroup of patients with angina pectoris at rest but without evidence of acute myocardial infarction, ischaemic damage of small myocardial areas can be detected by serological assays of high sensitivity. Among the marker proteins studied, CM-LC were found the most sensitive.

A coronary artery-to-left ventricular fistula is a rare finding; to the best of our knowledge, a total of only 35 cases have been reported. Only 5 cases of a generalized arterio-systemic fistula with three vessel involvement have been reported in the literature. We describe another case involving all major coronary arteries. A review of the literature is presented and the data of the reported cases are analyzed. A 55 year old woman was examined because of recurrent chest pain which had persisted for 2 years. On physical examination, the only abnormal finding was a fourth heart sound. Exertional chest pain, a positive exercise stress test, and the results of a lactate extraction study suggested severe myocardial ischemia. Thallium myocardial scintigraphy showed no evidence of a perfusion defect. Cardiac catheterization revealed an irregular left ventricular endocardial pattern (Thebesian veins). Selective coronary angiography showed communicating fistulae of all three major coronary arteries with the left ventricular cavity. We assume that this vascular anomaly causes a coronary steal phenomenon and subsequent myocardial ischemia.

The kinetics of cytosolic and structural marker protein release from myocardium were studied in 44 patients with acute myocardial infarction. After intracoronary infusion of streptokinase, there was early recanalization of the infarct-related artery in 8 patients and late recanalization in 18. In 18 patients the infarct-related artery remained occluded. Creatine kinase (CK) level peaked and normalized significantly earlier in patients with early reperfusion than in patients with late reperfusion, and in patients with late reperfusion earlier than in patients with permanent occlusion. Thus, the interval of absolute diagnostic sensitivity of CK depends on early infarct perfusion. In contrast, release of myosin light chains was not significantly changed by recanalization of the infarct-related artery compared with that in nonreperfused myocardial infarction. Thus, in patients with acute myocardial infarction, myosin light chains may be superior to CK as a diagnostic means and for estimation of infarct size.

To detect myocardial cell damage, serum samples of 42 consecutive patients with angina at rest were screened for cardiac myosin light chains, which were detected in 22 patients (52%). In 17 of these patients there was a persistent release of myosin light chains lasting until the 4th hospital day, whereas in 7 patients myosin light chains were only detectable during the initial 24 h after admission. The presence of myosin light chains correlated with signs of ischemia in the electrocardiogram (ECG) (p less than 0.05) and with the extent of coronary artery narrowing (p less than 0.05). Cardiac myosin light chains were elevated in serum only if there was a greater than or equal to 75% diameter narrowing in at least one major vessel. In all five patients who developed transmural myocardial infarction during the course of their hospital stay, myosin light chains were detectable greater than or equal to 28 h before the diagnosis of myocardial infarction could be established by ECG criteria and conventional serum enzymes. Thus the detection of circulating cardiac myosin light chains enables one to identify a subgroup of patients with angina at rest having more severe coronary artery disease with a worse outcome.

Hypertrophic cardiomyopathy (HCM) has various manifestations with respect to the localization of the hypertrophy. In this study we report clinical, electrocardiographic (ECG), echocardiographic (echo), and hemodynamic findings in midventricular obstruction (MO), an uncommon form of hypertrophic obstructive cardiomyopathy (HOCM) in 9 patients. The prevalence of systolic anterior motion of anterior mitral leaflet (SAM) in MO, an echocardiographic diagnostic hallmark in HOCM, was another purpose of this study. All patients had complete clinical, ECG, echo, and hemodynamic workup, including left ventricular (in 4 patients simultaneous biventricular, SBVA) and coronary angiograms. All patients had dyspnea and palpitations, chest pain, 2 had syncope. In the ECG, atrial fibrillation was present in 2, and left ventricular hypertrophy in 9 patients. Septal and left ventricular free wall thickening was significantly present in all patients in echo, and SAM in 1 patient. The intraventricular gradient (IVG) was 40-176 mmHg, in 1 case 40 mmHg by provocation, Brockenbrough was positive in all patients. Two patients had right ventricular IVG. A positive beta-blocking agent effect was present in 6 cases. The best localization of the obstruction was possible with SBVA and 2D-echo. We conclude that MO has all the signs of HOCM, but SAM in echocardiography is uncommon. SAM is occasionally present and is not a necessary factor to produce an intraventricular pressure gradient in HOCM, especially in MO. It seems that hypertrophic right ventricular obstruction is relatively common in MO (2 of 9 cases), and may have the same obstructive mechanism.

Erste klinische Untersuchungen von Bauch u. Mitarb. (1973) uber eine antiarrhythmische Wirkung des Lokalanaesthetikums Brufacain® hatten positive Effekte ausschlieslich bei ventrikularen Ektopien gezeigt. Der klinischen Erprobung waren tierexperimentelle Untersuchungen vorausgegangen, welche u. a. eine Verlangerung der Refraktarzeit an Meerschweinchenvorhofen, einen antagonistischen Effekt auf aconitininduzierte Arrhythmien bei Ratten (Zetler u. Strubelt, 1971) sowie eine Anhebung der ventrikularen Flimmerschwelle bei Katzen (Djonlagic, 1974) erkennen liesen. Siegers u. Mitarb. (1974) haben an Ratten bei einem Vergleich von Lidocain, Procainamid und Brufacain® im oralen Versuch eine Uberlegenheit von Brufacain® gegen aconitininduzierte Arrhythmien nachgewiesen. Die Halbwertzeit von Brufacain® war deutlich langer, als sie fur Lidocain und Procainamid angegeben wird. Die Ursache fur die unterschiedlich lange Wirkdauer wird in der chemischen Struktur von Brufacain® gesehen.

After the loss of membrane integrity cardiospecific myosin light chains are released as a result of proteolytic degradation of the insoluble myosin pool. Thus, as with cytosolic enzymes, the measurement of the serum concentration changes of myosin light chains may allow a non-invasive estimation of infarct size. A two compartment model was used to describe the serum concentration changes of myosin light chains after a bolus injection into awake beagle dogs. The initial distribution volume was 7.4% of body weight, whereas the second compartment accounted for 4.7% of body weight. The fractional disappearance rate of 0.0092.min-1 resulted in a serum half life of myosin light chains of 75 min. In 30 patients with acute non-reperfused myocardial infarction a close correlation was found between the cumulative appearance of myosin light chains and their maximal serum concentration. In these patients the cumulative appearance of myosin light chains correlated with serum creatine kinase estimates of infarct size, with impairment of left ventricular ejection fraction, and with mortality during hospital admission. Thus the maximal serum concentration and the cumulative appearance of myosin light chains allow a non-invasive estimation of infarct size and may serve as a serological indicator of the patient's prognosis.

Bei Patienten mit frequenzstarren elektrischen Pacemakern schlagen Vorhofe und Kammern normalerweise unabhangig voneinander. Die Ventrikel werden vom kunstlichen Schrittmacher, die Vorhofe vom Sinusknoten aus erregt. Eine retrograde Erregungsleitung vom Reizort im Ventrikel auf die Vorhofe kommt vor, ist aber selten.