Search

We present a case of an 80-year-old male patient who complained of recurrent angina 2 years after coronary bypass grafting using a left mammary artery (LIMA). This was caused by a new subtotal subclavian artery stenosis before the origin of the LIMA. The left subclavian artery was stented and the patient experienced complete relief.

Aim: Examination of the integrity of the sympathetic nervous system in patients with angiographically proven coronary artery disease and ECG documented asymptomatic ST-segment depression., Method: Stress and rest myocardial perfusion scintigraphy using either Thallium-201 or 99mTc-isonitrile was performed in SPECT technique in order to localize ischemia or scar associated perfusion defects. 15 min and 4 h p.i. static anterior 123I-MIBG uptake was acquired. In order to localize norepinephrine depletion 4 h p.i. additional 123I-MIBG SPECT acquisition was performed. Incidence of arrhythmias was investigated by Holter ECG. Patients with diabetes mellitus were excluded., Results: SPECT images showed in all patients regional 123I-MIBG depletion which corresponded with scintigraphically infarcted or ischemic regions. Well perfused myocardial regions matched with regular 123I-MIBG uptake. There was no evidence of increased arrhythmias in long-term ECG., Conclusion: The finding of regular 123I-MIBG uptake in well-perfused myocardium and infarction- or ischemia-associated regional 123I-MIBG depletion confirms that silent ischemia is not caused by a global sympathetic nervous dysfunction in a sense of cardiac polyneuropathy.

A prospective documentation of patients data on an internal and a surgical intensive care unit (ICU) has been transacted. The physician and nursing staff used an online electronic documentation program, which has been developed in Frankfurt. Main emphasis has been placed on the epidemiological data, clinical diagnoses as well as diagnostically and therapy costs. The medical ICU of university hospital of Frankfurt has been analysed since 1992 and the surgical ICU of Städtisches Krankenhaus of Lüneburg since 1994. Up to now data from 2001 patients from Frankfurt are available. Period spent on the ICU was 4.7 +/- 0.16 days (average +/- SEM), mortality was 15%. 47% of the whole group suffered from cardiac disease, of which 211 had an acute myocardial infarction (10.6%), 156 patients a serious ventricular arrhythmia (7.8%) as well as 88 patients an unstable angina (4.4%). Long-term observation revealed a rise of the duration spent on the ICU (from 4.1 +/- 0.17 to 5.5 +/- 0.38 days, P < 0.0002), an increasing number of technical examinations (for example: chest x-ray from 2.25 +/- 0.13 to 4.52 +/- 0.4/patient, P < 0.0001) and a steady mortality between 1992 and 1994. Detailed analysis of patients with acute myocardial infarction showed an impressive reduction of total mortality within the 3 years observed. In Lüneburg data of 1004 patients have been recorded so far. The average time spent on the ICU was 6.4 +/- 0.33 days. 4.1% patients passed away. Neoplasia of gastric intestinal tract (143; 14.2%), femoral neck fracture (64; 6.4%) and ilei (54; 5.4%) have been the most frequent diagnoses. Patients underwent 2.2 +/- 0.12 chest x-rays and 1.4 +/- 0.1 ultrasound investigations. The study shows that an online data processing is practicable and can be integrated in the daily work flow. Furthermore, it can be seen that the collected data play an important role to secure the increasing administrative requisition to the modern medicine in view of costs and quality management.

Sympathetic reinnervation was evaluated in 15 patients 2-69 months after heart transplantation using a double-tracer technique with 123I-MIBG and 201Tl. Since MIBG is accumulated in the same manner as norepinephrine it may serve as a tracer of the integrity and function of the sympathetic nervous system. 201Tl was used for landmarking. Planar anterior imaging was performed 15 min and 4 h after i.v. injection of 220 MBq 123I-MIBG and 37 MBq 201Tl. Image quantitation was based on the ratio of myocardial to mediastinal MIBG-uptake. Cardiac regions of interest were defined according to the 201Tl uptake. There was no evidence of sympathetic reinnervation in 8 patients 2-34 months after transplantation. Increased MIBG-uptake could be observed in the anterior basal region in 6 long-term cardiac transplants (37-69 months). One patient with a 59-month-old transplanted heart did not reinnervate. Increased MIBG-uptake in the anterior basal region indicating partial sympathetic reinnervation could be shown in 40% of the investigated patients with an average organ age of 51 months.

Transluminal coronary angioplasty (PTCA) causes transient occlusion of the coronary artery and temporary ischemia of the left ventricle. Left ventricular dysfunction during silent and symptomatic episodes of myocardial ischemia during PTCA was evaluated continuously with a newly developed miniature, non-imaging scintillation probe. Parameters of left ventricular function were compared before and during balloon inflations of 60 s duration: ejection fraction (EF), indices of end-systolic and end-diastolic volumes (ESV, EDV), peak ejection and peak filling rates (PER, PFR). 13 patients (age 54 +/- 7.4 years) were symptomatic, 10 patients (age 61 +/- 8 years) were asymptomatic. Impairment of left ventricular function during ischemia did not show any significant differences between the symptomatic and asymptomatic patients. It is therefore concluded that symptomatic and asymptomatic episodes of myocardial ischemia during PTCA cause similar impairment of systolic and diastolic left ventricular function. The degree of left ventricular dysfunction during PTCA cannot be estimated on the basis of clinical symptoms.

The purpose of this study was to evaluate left ventricular function and perfusion at rest before and after percutaneous transluminal coronary angioplasty. In consecutive 69 patients in whom coronary stenoses were dilated, the radionuclide left ventricular ejection fraction at rest increased significantly. In 26 of these patients, the ejection fraction increased by at least 4%. In these patients, exercise-induced ischemic ST depression had been more pronounced than in the others. 36 other patients underwent 201TI myocardial scintigraphy before and after angioplasty. Twelve patients in whom pre-PTCA images had revealed regions with irreversible 201TI uptake defects, showed normal 201TI distribution patterns on post-PTCA scintigrams. Post-exercise 201TI uptake (representing myocardial perfusion and metabolic activity) during pre-PTCA exercise stress tests was significantly lower in these cases. It is concluded that PTCA can improve left ventricular function and perfusion at rest. This improvement is most obvious in patients with pronounced exercise-induced myocardial ischemia as diagnosed by typical ST segment depression and reduced thallium uptake.

Left ventricular systolic and diastolic performance was evaluated by radionuclide angiography in 17 patients following cardiac transplantation and compared with normal persons. Both groups performed supine bicycle exercise during the investigation, the control group at 102 +/- 73 W and the transplanted patients at 61.2 +/- 15 W. The ejection fraction increased in the normal persons from 61 +/- 8 to 69 +/- 10% whereas in the transplanted patients it did not increase significantly. There were no relevant changes in systolic parameters during exercise in the transplant recipients. The changes in diastolic parameters were significantly smaller in transplant patients than in normals. After correction for heart rate-induced changes a significantly different time course of the systolic-diastolic sequence during the cardiac cycle became evident in the transplanted group at rest. During exercise the systolic-diastolic sequence during the cardiac cycle became similar in both groups. It is concluded that the reduced exercise capacity of patients in the late phase after cardiac transplantation is partially due to the absence of an EF increase and a limitation of diastolic reserve during exercise.

21 patients with LAD-stenoses of at least 70% and 21 patients with LAD-stenoses and additional intramural anterior wall infarctions were studied. 20 patients without heart disease or after successful transluminal coronary angioplasty and 18 patients with intramural anterior wall infarction after successful transluminal dilatation of the LAD (remaining stenosis maximal 30%) served as controls. The normal range of global and regional left ventricular ejection fraction response to exercise was defined based on the data of 25 further patients without relevant coronary heart disease. Thus, a decrease in global ejection fraction and regional wall motion abnormalities were judged pathological. All patients were comparable with respect to age, ejection fraction at rest and work load. Myocardial ischemia could be detected by the exercise ECG in 81% of all patients without infarction and in 71% of patients with infarction. The corresponding values for global left ventricular ejection fraction were 76% and 81%, respectively, and for regional ejection fraction 95% in both groups. No false-positive exercise ECGs were observed in the healthy controls and 2 (11%) in the corresponding group with intramural infarction. The global ejection fraction was pathological in 1 (5%) healthy subject without infarction and in 3 (17%) corresponding patients with infarction. Sectorial analysis revealed 5 and 22%, respectively. Our findings suggest that the exercise ECG has a limited sensitivity to detect myocardial ischemia in patients with isolated LAD-stenoses and intramural myocardial infarction. Radionuclide ventriculography yields pathological values more often; however, false-positive results also occur more frequently.

In 9 patients with patent ductus arteriosus, quantification of left-to-right shunt was performed with dye dilution curves after peripheral injection and with radionuclide ventriculography. The study was repeated within 7 days after successful transluminal occlusion of the ductus with an Ivalon-plug. Reproducubility of the method could be studied in one patient in whom reopening of the ductus occurred. Dye dilution curves were analyzed using the method of Carter et al. Radionuclide ventriculography was performed as a combined first-pass and equilibrium study: effective stroke volume was derived from the first pass of the tracer through the heart; during the equilibrium phase left ventricular ejection fraction (EF) and left ventricular enddiastolic volume (EDV) were evaluated. The difference between total left ventricular stroke volume (product of EF and EDV) and effective stroke volume was taken as shunt volume. This volume as a fraction of total left ventricular stroke volume resulted in percent left-to-right shunt. The sensitivity of the dye technique was 78%; a quantification of the shunt lesion was possible in 55% of all cases (shunt greater than 35%). The sensitivity of the radionuclide technique was 90%. The severity of the lesion could not be determined in one patient with a minimal shunt. After successful occlusion of the ductus, dye dilution curves normalized in all cases. Radionuclide ventriculography showed normalization in all but one patient. This patient with concomitant mitral regurgitation still showed moderate left ventricular volume overload.(ABSTRACT TRUNCATED AT 250 WORDS)

This study compares exercise radionuclide ventriculography (RNVG) and exercise myocardial scintigraphy with 201Tl (MSC) both computed trisectorially. 137 patients before and after transluminal angioplasty (TCA) were investigated. While specificity equivalent was set at 90% for both methods (10% percentile of the controls [n = 29]) overall sensitivity for RNVG was 79% (n = 86) and for MSC 78% (n = 98). Sensitivity of RNVG for lesions of the posterior wall was lower than for the anterior wall: LAD stenoses 83% (n = 46), RCA stenoses 71% (n = 17), and LCX stenoses 63% (n = 8). Sensitivity of MSC presents only a slight difference between anterior and posterior wall lesions: LAD stenoses 78% (n = 51), RCA stenoses 73% (n = 22), RCX stenoses 100% (n = 8). Reproducibility of pathological findings before and after non-successful TCA and the determination of the stenosed vessel was slightly better with MSC than with RNVG. Functional improvement after a successful TCA is predictable by MSC, whereas RNVG documents the functional improvement.

Between January 1975 and December 1985 214 patients underwent prosthetic aortic valve replacement for isolated aortic regurgitation. Patient follow-up averaged 5.4 years after the operation (range 0.7-10.7 years). Preoperative staging showed 9 patients to be in NYHA stage II, 111 patients in stage III, and 94 patients in stage IV. At follow-up 3 patients complained of increased fatigue, 9 patients remained stable and 167 patients had improved. 103 of these patients were free of symptoms under stress, i.e. NYHA stage I. The hospital mortality was 3.7% (8/214 patients). An additional 26 patients died within an average of 2.8 years. The cumulative 5-year survival rate was 85%; the 10-year survival rate was 81.5%. 10 patients underwent a second operation within an average of 3.4 years. The correlation between the end-diastolic volume and the regurgitated blood volume has prognostic significance. 25 patients with appropriate enlargement of the left ventricle showed a significant decrease of the end-diastolic volume and the roentgenographic heart volume combined with an increase of ejection fraction. None of these 25 patients died from cardiac complications. A control group of 9 patients with myocardial damage showed no significant change in the above parameters. 4 patients in the control group died. We conclude that the relationship of regurgitated blood volume and the left ventricular end-diastolic volume is of prognostic significance for patients with chronic aortic regurgitation presenting with minimal symptoms.