Patients benefit from surgical seclusion of atrial septal defect but have excessive cardiovascular morbidity after the operation. We evaluated haemodynamics and looked for abnormalities of cardiac structures and function late after surgical seclusion of the defect. Serum N-terminal natriuretic peptide measurement and transthoracic and transoesophageal echocardiography were performed in 61 patients aged 43±15 years (mean±standard deviation) 21±5 years after surgery. The findings were compared with 67 control subjects. The patients had higher serum N-terminal atrial natriuretic peptide concentration than the control subjects (0.40±0.32 vs. 0.24±0.12 nmol/l, P=0.0001). Peptide levels correlated with current age (P=0.0001) and age at operation (P=0.0014), but not with age in the control subjects. In the patients, echocardiography measurements of cardiac dimensions correlated with hormone levels (atrial natriuretic peptide concentration with left atrial end-systolic diameter (P=0.042), left ventricular end-diastolic (P=0.021) and end-systolic diameter (P=0.042). There were only 10 patients (16%) without any abnormality in echocardiography. Their peptide concentration was 0.25±0.18 nmol/l (P=not significant compared to the control subjects). The association between increasing N-terminal atrial peptide levels and operation age together with echocardiography findings support the clinical consensus of treating atrial septal defect patients in their childhood and adolescence.

Background The significance of various risk factors for cardiovascular disease (CVD) in the pathogenesis of atherosclerosis in patients with chronic renal failure (CRF) is, to a great deal, unresolved. The high risk for CVD in patients with CRF may be caused by the high prevalence of recognized risk factors for CVD or by factors characteristic of CRF in these patients. In this prospective cross-sectional study, we examined risk factors for thoracic aortic atherosclerosis in a population of patients with CRF consisting of predialysis and dialysis patients, as well as renal transplant recipients. Methods: Of 118 patients, 52 patients had moderate to severe predialysis CRF, 32 patients were on dialysis treatment, and 34 patients were renal transplant recipients. Mean age was 52 +/- 12 years, and 35 patients (30%) had diabetes. Multiplane transesophageal echocardiography (TEE) was performed using local anesthesia. Results: Large aortic plaques (LAPs; greater than or equal to3.0 mm in diameter) were found in 39 patients (33%). In univariate analysis, age, duration of hypertension, pulse pressure, low diastolic blood pressure, elevated fibrinogen level, C-reactive protein level, total cholesterol level, low-density lipoprotein cholesterol level, and duration of dialysis or a functioning renal transplant were significantly associated (P < 0.05) with LAP. In multivariate analysis, age, duration of hypertension, and total cholesterol level were associated with LAP. Conclusion: Results of the present TEE study suggest that in addition to duration of hypertension and renal disease, hypercholesterolemia has a role in the pathogenesis of atherosclerosis in patients with CRF.

BACKGROUND Beta-blockers, used as an adjunctive to diuretics, digoxin and angiotensin converting enzyme inhibitors, improve survival in chronic heart failure. We report a prospectively planned economic analysis of the cost of adjunctive beta-blocker therapy in the second Cardiac Insufficiency BIsoprolol Study (CIBIS II). METHODS Resource utilization data (drug therapy, number of hospital admissions, length of hospital stay, ward type) were collected prospectively in all patients in CIBIS II. These data were used to determine the additional direct costs incurred, and savings made, with bisoprolol therapy. As well as the cost of the drug, additional costs related to bisoprolol therapy were added to cover the supervision of treatment initiation and titration (four outpatient clinic/office visits). Per diem (hospital bed day) costings were carried out for France, Germany and the U.K. Diagnosis related group costings were performed for France and the U.K. Our analyses took the perspective of a third party payer in France and Germany and the National Health Service in the U.K. RESULTS Overall, fewer patients were hospitalized in the bisoprolol group, there were fewer hospital admissions per patient hospitalized, fewer hospital admissions overall, fewer days spent in hospital and fewer days spent in the most expensive type of ward. As a consequence the cost of care in the bisoprolol group was 5-10% less in all three countries, in the per diem analysis, even taking into account the cost of bisoprolol and the extra initiation/up-titration visits. The cost per patient treated in the placebo and bisoprolol groups was FF35 009 vs FF31 762 in France, DM11 563 vs DM10 784 in Germany and pound4987 vs pound4722 in the U.K. The diagnosis related group analysis gave similar results. INTERPRETATION Not only did bisoprolol increase survival and reduce hospital admissions in CIBIS II, it also cut the cost of care in so doing. This 'win-win' situation of positive health benefits associated with cost savings is favourable from the point of view of both the patient and health care systems. These findings add further support for the use of beta-blockers in chronic heart failure.

During the 1990–1998 diphtheria epidemic in the newly independent states of the former Soviet Union, more than 150,000 infections and 5,000 deaths occurred. During this period, more than 10 million trips were made from Finland to Russia or vice versa. This resulted in only 10 cases of diphtheria in Finland. There was no secondary spread to healthcare workers or other close contacts. Three patients had severe respiratory tract diphtheria. All three were middle-aged men who had made a short visit to Russia, during which time they had intimate contact with local women. These findings suggest diphtheria was transmitted mainly by direct saliva contact. All patients with severe diphtheria had a nonprotective level of antitoxin antibodies during the first days of the disease. Only the patient whose antibody titre rose rapidly to a protective level (>1 IU/ml) had an uncomplicated recovery. The other two, one of whom died, had myocarditis and severe polyneuropathy.

Purpose: Baroreflex sensitivity (BRS) and diastolic relaxation are impaired in non-insulin dependent diabetes mellitus (NIDDM). Acute ischemia reduces BRS which is a predisposing factor of ventricular fibrillation. In addition, poor control of NIDDM may lead to left ventricular (LV) dysfunction and heart failure. The aim of this study was to assess the effects of endurance (2x/w) and muscle strength training (2x/w) on BRS and myocardial relaxation in NIDDM patients without clinical diabetic neuropathy. Methods: 48 men (52.3 ± 5.6 yrs, BMI 29.1 ± 4 kg/m2) with NIDDM diagnosed 0.5–3 years earlier volunteered for the study. The men were randomized to supervised training four times a week (Exe) or normal treatment (C). Body mass index (BMI), glycocylated hemoglobin (HbA1c,%), oxygen consumption in spiroergometry (VO2, ml/kg/min), and muscle strength (Sit-up, times) were measured. BRS (ms/mmHg) was determined by the phenylephrine method (2mg/kg). Mitral annular peak systolic (Sv), early (Ev) and late (Av) diastolic velocities (cm/s) were determined (VingMed System V,>100 fps). Results: VO2 (31,9 ± 5,1 to 34.2 ± 5.8, p < 0.001 vs. C), Sit-up (12.9 ± 7 to 21.6 ± 7 times, p < 0.001 vs. C) and HBA1c (8.2 ± 2.0 to 7.6 ± 1.5, p < 0.007 vs. C) improved significantly in the Exe group. BMI was unchanged. BRS increased in the Exe group (7.4 ± 4.4 to 8.4 ± 4.6, p < 0.05 vs. C ANOVA) and decreased in the C group. Mitral annular velocities were unchanged (Exe Sv 6.7 ± 2.1 to 6.6 ± 2.1, p = 0.088 vs. C; Exe Ev 8.1 ± 1.8 to 8.2 ± 1.8, p = 0.71 vs. C). Conclusions: Exercise training improves cardiorespiratory performance, muscle strength and glygemic control significantly in NIDDM patients. Vagal responsives was improved significantly perhaps due to enhanced microcirculation. These changes may reduce the risk of fatal arrhythmias. However, diastolic dysfunction probably related to myocardial fibrosis seems not to be reversible by exercise. Our data suggest that strict glygemic control should be the early target in order to improve the prognosis of NIDDM.

Background In patients with heart failure, beta-blochade has improved morbidity and left-ventricular function, but the impact on survival is uncertain. We investigated the efficacy of bisoprolol, a beta(1) selective adrenoceptor blocker in decreasing all-cause mortality in chronic heart failure.Methods In a multicentre double-blind randomised placebo-controlled trial in Europe, we enrolled 2647 symptomatic patients in New York Heart Association class III or IV, with left-ventricular ejection fraction of 35% or less receiving standard therapy with diuretics and inhibitors of angiotensin-converting enzyme. We randomly assigned patients bisoprolol 1.25 mg (n=1327) or placebo (n=1320) daily, the drug being progressively increased to a maximum of 10 mg per day. Patients were followed up for a mean of 1.3 years. Analysis was by intention to treat.Findings CIBIS-II was stopped early, after the second interim analysis, because bisoprolol showed a significant mortality benefit. All-cause mortality was significantly lower with bisoprolol than on placebo (156 [11.8%] vs 228 [17.3%] deaths with a hazard ratio of 0.66 (95% CI 0.54-0.81, p<0.0001). There were significantly fewer sudden deaths among patients on bisoprolol than in those on placebo (48 [3.6%] vs 83 [6.3%] deaths), with a hazard ratio of 0.56 (0.39-0.80, p=0.0011). Treatment effects were independent of the severity or cause of heart failure.Interpretation beta-blocker therapy had benefits for survival in stable heart-failure patients. Results should not, however, be extrapolated to patients with severe class IV symptoms and recent instability because safety and efficacy has not been established in these patients.

Several stress echocardiography (SE) modalities have been introduced for diagnosing coronary artery disease (CAD). Exercise and dobutamine SE are commonly considered to have a better diagnostic accuracy than vasodilator SE. The purpose of this study was to assess the agreement between the test results and the segmental concordance between three SE tests in patients with chest pain. A total of 60 patients (mean age, 55.1 years; SD, 2.1) were tested by symptom‐limited bicycle (BSE), dipyridamole‐atropine (DiASE), and dobutamine (DSE) tests. CAD (50% stenosis) was present in 44 patients, and 26 patients had one‐vessel disease. In BSE and DSE, the double product at peak stress (26.5 and 16.1 vs 13.3 × 103, respectively, P < 0.005 vs DiASE) and the peak wall motion score index were higher than in DiASE (1.40 and 1.35 vs 1.26, respectively, P < 0.05 vs DiASE). BSE, DiASE, and DSE did not differ in sensitivity in diagnosing CAD (90%, 93%, and 95%, respectively). Similarly, there were no statistically significant differences in the diagnostic accuracy of BSE, DiASE, and DSE (78%, 88%, and 87%, respectively). The intermethod agreement was moderate between BSE and DiASE (k = 0.51), good between BSE and DSE (k = 0.62), and moderate between DiASE and DSE (k = 0.57). The segmental agreement between BSE, DiASE, and DSE was mostly moderate. Agreement was best between the pharmacologic tests due to test protocols, especially the anterior wall (k > 0.60). Also, the basal segments showed good agreement. In conclusion, BSE, DiASE, and DSE have a similar diagnostic accuracy in detecting CAD. The overall agreement between the tests was good, and the assessment of wall motion was variable. Nevertheless, concordant diagnosis of a patient can be obtained by BSE, DiASE, and DSE without loss of diagnostic power.

Several stress echocardiography (SE) modalities have been introduced for diagnosing coronary artery disease (CAD). Exercise and dobutamine SE are considered to have better diagnostic accuracy than vasodilator or isometric SE, but there are no studies in a single group of patients comparing these 3 tests with heavy 2-arm isometric SE. The purpose of this study was to determine the diagnostic characteristics of 4 SE methods in patients with chest pain. Altogether, 60 patients (age +/- SD 55.1 +/- 2.1 years) were tested with bicycle, heavy 2-arm isometric, dipyridamole-atropine and dobutamine SE. CAD (>50% stenosis) was present in 44 patients; 26 patients had 1-vessel disease. During bicycle SE, the double product at peak stress was higher than during dobutamine and dipyridamole-atropine SE (26.5 x 10(3), p <0.005 vs dobutamine and dipyridamole-atropine SE), and peak wall motion score index (1.40) was higher than during dipyridamole-atropine and isometric SE (1.26 and 1.07, respectively, p <0.05 vs bicycle SE). Bicycle, dipyridamole-atropine, and dobutamine SE had higher sensitivity than isometric SE (90%, 93%, 95%, and 30%, respectively, p <0.05 isometric SE vs others). There were no statistically significant differences with regard to specificity. Similarly, bicycle, dipyridamole-atropine, and dobutamine SE had a higher diagnostic accuracy than isometric SE (78%, 88%, 87% and 47%, respectively, p <0.05 isometric SE vs others). We conclude that bicycle, dipyridamole-atropine, and dobutamine SE have an equal diagnostic accuracy in detecting CAD despite higher double product and ischemic burden at peak stress during bicycle and dobutamine SE over dipyridamole-atropine SE. Heavy isometric SE is inaccurate.

Doppler echocardiographic analysis of mitral flow is a noninvasive tool for analyzing left ventricular diastolic function. Changes in preload alter both, nor mal and abnormal Doppler patterns of left ventricular filling. The velocities of mitral flow measured by transthoracic pulsed-Doppler echocardiography are different when measured at the mitral leaflet tips and at the mitral annulus. Transesophageal echocardiography provides an excellent image of cardiac anatomy whereby it is possible to place the Doppler sample volume exactly at the mitral annulus or at the tips of mitral leaflets. We studied with the use of transesophageal echocardiography how changes in preload and measurement at the annulus or valve tips affect the velocities of mitral flow. Upper body-up tilting (60 degrees) decreased maximum E wave velocity by 16% and, hence, E/A ratio by 15%. A wave did not change by tilt. E wave velocity was 13%-15% Lower at the annulus than. at the tips of the mitral valve in both the supine and tilt position. E/A ratio was significantly higher at the tips than at the annulus of the mitral valve (supine, P = 0.048; tilt, P = 0.001). E/A ratio was 38% lower if the measurements were done at the annulus in, the tilt position than at the tips with the patient lying horizontal. It may be important for pulsed-Doppler. mitral flow-velocity measurements to be standardized for sample volume location. and for body position.

An epidemic of respiratory tract diphtheria began in Russia in 1989. In 1994 more than 2,500 cases occurred in St. Petersburg alone. We describe clinical findings in the 1,860 adult patients treated in Botkin's Hospital. The study is based on a retrospective review of patient records. In 98% of the patients the diagnosis was confirmed by a positive throat culture growing a toxin producing strain of Corynebacterium diphtheriae. A catarrhal disease without membranes was present in 1,256 (67.5%) patients, 150 patients had membranes on tonsils only, 268 patients on tonsils, the uvula, soft palate and posterior pharynx and 35 patients on larynx or in the lower respiratory tract. 42 patients (2.3%) died. Among the deceased patients 26 were alcoholics, whereby the death rate for non-alcoholics was probably around 1%. 151 patients (8.1%) had a toxic form of the disease with swelling of the neck. This form of the disease carried a high mortality, 25.7%. In a subgroup of 1,045 patients the protective efficacy of vaccination could be evaluated. A 2.2-fold protection was found, but the study may underestimate the efficacy. We conclude, that if a wide diphtheria epidemic affects an industrialized country, it would probably not any more be the big killer that it was in Europe and in the United States in the 1950's and 1960's.

An epidemic of respiratory tract diptheria began in Russia in 1989., In 1994 more than 2,500 cases occurred in St. Petersburg alone. We describe clinical findings in the 1,860 adult patients treated in Botkin's Hospital, The study is based on a retrospective review of patient records. In 98% of the patients the diagnosis was confirmed by a positive throat culture growing a toxin producing strain of Corynebacterium diphtheriae. A catarrhal disease without membranes was present in 1,256 (67.5%) patients, 150 patients had membranes on tonsils only, 268 patients on tonsils, the uvula, soft palate and posterior pharynx and 35 patients on larynx or in the lower respiratory tract. 42 patients (2.3%) died, Among the deceased patients 26 were alcoholics, whereby the death rate for non-alcoholics was probably around 1%. 151 patients (8.1%) had a toxic form of the disease with swelling of the neck. This form of the disease carried a high mortality, 25.7%. In a subgroup of 1,045 patients the protective efficacy of vaccination could be evaluated. A 2.2-fold protection was found, but the study may underestimate the efficacy, We conclude, that if a wide diphtheria epidemic affects an industrialized country, it would probably not any more be the big killer that it was in Europe and in the United States in the 1950's and 1960's.

BACKGROUND:Transesophageal echocardiography with transversal planes offers many advantages in the evaluation of patients with congenital anomalies of atrium, allowing visualization of obscure areas, not visualized with traditional echocardiography, as appendages, venous connections, upper interatrial defects. The aim of this paper is to check what advantages the transesophageal imaging in longitudinal plane, recently insert in biplane probes, might confer over transversal plane imaging in the evaluation of patients with congenital heart disease of atrium and venous connections.METHODS:We carried out a prospective study on 70 patients (49 adults and 22 children) with congenital heart diseases of this area. Fifty-six studies out of 71 were preoperative diagnostic, 15 were carried out in the late postoperative period. Twenty-two studies were performed under general anaesthesia during concomitant cardiac catheterisation, 49 were carried out in outpatient clinic. All the transesophageal diagnoses were subsequently confirmed at either catheterization or surgery. Lesions studied included 36 atrial septal defects (ASD) ostium secundum, 6 interatrial septal aneurysms, 1 ASD coronary sinus, 5 ASD venous sinus, 5 partial and 2 complete atrioventricular septal defects, 1 double outlet right ventricle; in operated patients 2 ASD ostium secundum, 2 ASD sinus venosus, 11 post Mustard or Senning in TGA.RESULTS:Anomalies either better defined or that obtained important additional informations by long axis scanning (vs transverse scanning) included: ASD ostium secundum 36/36, ASD multiple 1/3, caval obstruction in Mustard or Senning 4/5, anterior mitral valve cleft 2/5, left superior vena cava to coronary sinus 3/3. Features visualized by longitudinal plane alone were: ASD coronary sinus 1/1, caval obstruction in sinus venosus operated 1/1, multiple ASD 2/3, coronary artery fistula to right atrium 1/1; for associated features anterior bringing leaflets 2/2, left ventricular outflow tract obstruction 2/2, right ventricular outflow tract obstruction 1/1. Anomalies better characterized by transversal plane versus longitudinal plane were: ASD ostium primum 2/7, ASD sinus venosus sinus 3/5; for associated anomalies VSD inlet 1/1. Features visualized by transversal plane alone were: right upper pulmonary vein in superior vena cava 4/4, right upper pulmonary vein to right atrium 1/1, DIA ostium primum 5/7, ASD sinus venosus 2/5, superior vena cava obstruction in Mustard 1/5, left juxtaposition of the atrial appendages 1/1. The transversal plane alone provided the correct morphologic and hemodynamic diagnosis in 74/88 (84%) (in this group longitudinal plane gave 68% additional informations), the longitudinal planes in 69/88 (78%). However in 11% of cases longitudinal plane was the only means for identifying the congenital lesion and transversal plane in 16%. It was the combination of longitudinal and transverse scanning which gave in 97% the correct complete morphologic diagnosis.CONCLUSIONS:Thus we conclude that both planes are required for optimal transesophageal evaluation of congenital disease of atrium and venous connection.

Conference Abstract| March 01 1993 Left Ventricular Diastolic Function in Chronic Heart Failure J Nolan; J Nolan 1Departments of Cardiology and Medical Physics, Royal Infirmary, and Department of Respiratory Medicine, City Hospital, Edinburgh Search for other works by this author on: This Site PubMed Google Scholar K Groundstroem; K Groundstroem 1Departments of Cardiology and Medical Physics, Royal Infirmary, and Department of Respiratory Medicine, City Hospital, Edinburgh Search for other works by this author on: This Site PubMed Google Scholar P M Warren; P M Warren 1Departments of Cardiology and Medical Physics, Royal Infirmary, and Department of Respiratory Medicine, City Hospital, Edinburgh Search for other works by this author on: This Site PubMed Google Scholar N E Goodfield; N E Goodfield 1Departments of Cardiology and Medical Physics, Royal Infirmary, and Department of Respiratory Medicine, City Hospital, Edinburgh Search for other works by this author on: This Site PubMed Google Scholar F Taddei; F Taddei 1Departments of Cardiology and Medical Physics, Royal Infirmary, and Department of Respiratory Medicine, City Hospital, Edinburgh Search for other works by this author on: This Site PubMed Google Scholar J Hannan; J Hannan 1Departments of Cardiology and Medical Physics, Royal Infirmary, and Department of Respiratory Medicine, City Hospital, Edinburgh Search for other works by this author on: This Site PubMed Google Scholar G R Sutherland; G R Sutherland 1Departments of Cardiology and Medical Physics, Royal Infirmary, and Department of Respiratory Medicine, City Hospital, Edinburgh Search for other works by this author on: This Site PubMed Google Scholar P Bloomfield P Bloomfield 1Departments of Cardiology and Medical Physics, Royal Infirmary, and Department of Respiratory Medicine, City Hospital, Edinburgh Search for other works by this author on: This Site PubMed Google Scholar Clin Sci (Lond) (1993) 84 (s28): 19P. https://doi.org/10.1042/cs084019P Views Icon Views Article contents Figures & tables Video Audio Supplementary Data Peer Review Share Icon Share Twitter LinkedIn Cite Icon Cite Get Permissions Citation J Nolan, K Groundstroem, P M Warren, N E Goodfield, F Taddei, J Hannan, G R Sutherland, P Bloomfield; Left Ventricular Diastolic Function in Chronic Heart Failure. Clin Sci (Lond) 1 March 1993; 84 (s28): 19P. doi: https://doi.org/10.1042/cs084019P Download citation file: Ris (Zotero) Reference Manager EasyBib Bookends Mendeley Papers EndNote RefWorks BibTex toolbar search Search nav search search input Search input auto suggest search filter All ContentAll JournalsClinical Science Search Advanced Search This content is only available as a PDF. © 1993 The Biochemical Society and the Medical Research Society1993 Article PDF first page preview Close Modal You do not currently have access to this content.

OBJECTIVES:To determine whether biplane transoesophageal imaging offers advantages in the evaluation of mitral prostheses when compared with standard single transverse plane imaging or the precordial approach in suspected prosthetic dysfunction.DESIGN:Prospective mitral valve prosthesis in situ using precordial and biplane transoesophageal ultrasonography.SETTING:Tertiary cardiac referral centre.SUBJECTS:67 consecutive patients with suspected dysfunction of a mitral valve prosthesis (16 had bioprostheses and 51 mechanical prostheses) who underwent precordial, transverse plane, and biplane transoesophageal echocardiography. Correlative invasive confirmation from surgery or angiography, or both, was available in 44 patients.MAIN OUTCOME MEASURES:Number, type, and site of leak according to the three means of scanning.RESULTS:Transverse plane transoesophageal imaging alone identified all 31 medial/lateral paravalvar leaks but only 24/30 of the anterior/posterior leaks. Combining the information from both imaging planes confirmed that biplane scanning identified all paravalvar leaks. Five of the six patients with prosthetic valve endocarditis, all three with valvar thrombus or obstruction, and all three with mitral annulus rupture were diagnosed from transverse plane imaging alone. Longitudinal plane imaging alone enabled diagnosis of the remaining case of prosthetic endocarditis and a further case of subvalvar pannus formation.CONCLUSIONS:Transverse plane transoesophageal imaging was superior to the longitudinal imaging in identifying medial and lateral lesions around the sewing ring of a mitral valve prosthesis. Longitudinal plane imaging was superior in identifying anterior and posterior lesions. Biplane imaging is therefore an important development in the study of mitral prosthesis function.