34th R S RACTS

EFFECTS OF ALPROSTADIL INFU~ON cr A ~n~OREA L CIRCULATION ON PLATELET COUNT AND POSTOPERATIVE BLOOD LOSS WITH REFERENCE TO BLOOD RHEOLOGY: Abdusalam EI-Gatit, MD, FICA i Najib Al-Kaja, PhD, FICA; Ali Belboul, MD; Goran Radberg, MD, Donald Roberts, PhD, FICA; Department of Thoracic and Cardiovascular Surgery, Sahlgrens Hospital, Goteborg University, Goteborg, Sweden.

The blood protective effects of Alprostadil (synthetic prostaglandin El) were tested in 24 male patients undergoing coronary artery bypass graft surgery (CABG) with the use of cardiopulmonary bypass (CPB), 12 were given intravenous infusion of Alprostadil during surgery (20 nanograms/kg/minute) and the rest were controls. Blood rheology was assessed by measuring red and white cell filterability. The rheological loss and the reduction of the platelet count during and following surgery were significantly less in the Alprostadil group, p<0.001 and p<0.01 respectively. The postoperative blood loss and the use of blood products in the first 24 hours were significantly reduced to 40 % (p < 0.001) and 25 % (p < 0.02) respectively by Alprostadil.

This study shows that Alprostadil protects blood cells from the deleterious effects of CPB by preserving platelet count and blood cell filterability. These salutary effects were associated with significant reductions of postoperative blood loss and the need for the transfusion of blood products.

DIASTOLIC FUNCTION IN ACUTE CARDIAC REJECTION: A.M. Pellicelli, MD; C. Borgia, MD; J. Barba, MD; G. DePaola, MD; A. Gomez, MD; M.C. Borgia, MD, FICA; UTIC, Clinica Medica II, University of Rome, "La Sapienza', Rome, Italy and University Clinica, University of Navarra, Pamplona, Spain.

To evaluate the changes in left ventricular filling associated with acute cardiac rejection, serial Doppler echocardiography examinations were performed in 34 patients who underwent orthotopie heart transplantation. Recordings of mitral flow were made with pulsed Doppler from an apical four-chamber view; isovolumie relaxation time, peak early mitral flow and pressure half time were measured. The patients were classified into three groups on the basis of histopathologic findings: Group I, (20 patients without rejection), Group II, (7 patients with mild or moderate rejection), Group III, (7 patients with severe rejection).

The following table shows we report the results of Doppler indexes and the statistic correlation between the groups.

IRTV* (sec) Peak E (cm/sec) PHT** (sec)

Group I 0.088+/-0.013 74.17+/-0.21 0.046+/-0.010 Group II 0.078+/-0.010 77.12+/-0.21 0.054+/-0.01 Group III 0.074+/-0.011 85.27+/-0.12 0.046+/-0.011 I vs II NS NS NS I vs III p<0.05 p<0.01 NS

IRTV*=Isovolumic relaxation time PHT**=Pressure half time

We believe that the analysis of left ventricular diastolic function using Doppler recording of mitral flow for the diagnosis of cardiac rejection is of interest. In fact, it shows that rejection of increasing severity is associated with a progressive shortening of isovolumie relaxation and with an increase in peak early mitral flow but not with a decrease of pressure half time. The excellent correlation with endomyocardial biopsy suggests that Doppler echoeardiography can be used as a technique for the detection of cardiac allograft rejection.

152

Abstracts 153

EFFECTS OF VITAMIN E ON THE STATUS OF ()XYGEN FREE RADICAL ACTIVITY IN PATIENTS UNDERGOING AORTOCORONARY BYPASS SURGERY: Taras Mycyk, MDI Dorothy J. Thomson, MD; Jawahar Kalra, MD, Phi), FICA; Marion Prasad, BA; Subrahmanyam V. Mantha, Phi); Kailash Prasad, MD, PhD, FICA, Professor of Physiology; Officer and Vice President, Scientific Council, International College of Angiology; Departments of Surgery, Pathology, Physiology, College of Medicine, University of Saskatchewan and Royal University Hospital, Saskatoon, Saskatchewan, Canada.

We have previously show that oxygen free radicals (OFRs) depress cardiac function and contractility. Oxygen free radicals exert their cytotoxic effects by lipid peroxidation of cellular membrane resulting in the production of malondialdehyde (MDA). It is possible that postoperative cardiac dysfunction using CPB may be due to increased levels of OFR. Vitamin E, an antioxidant, should be able to reduce the lipid peroxidation and cardiac dysfunction in aortocoronary bypass surgery. To evaluate the possible role of OFR in post-pump cardiac dysfunction, OFR producing activity of polymorphonuclear (PMN) leukocytes and blood MDA were measured at induction of anesthesia, before cross clamping of aorta, after closure of the chest and 24 hours postoperatively in 27 patients undergoing aortoeoronary bypass surgery. The patients were divided into two groups: Group I, warm blood eardioplegia with Vit. E, n= 15; Group II, cold blood cardioplegia, n= 12. Oxygen free radical producing activity of PMN leukocytes increased significantly during aortocoronary bypass in both groups. Malondialdehyde levels of blood increased during aortocoronary bypass surgery and 24 hours postoperatively in Group I. However, the MDA levels of blood did not change significantly throughout the procedure in patients of Group II. These results suggest that (i) OFR might be responsible for cardiac dysfunction after CPB (ii) Vitamin E might be helpful in preventirig cardiac dysfunction during aortoeoronary bypass surgery.

AMIODARONE LUNG TOXICITY AND MAJOR SURGERY: Pertti Aarnio, MD, FICA, Co-Chairman, Scientific Program Committee, 34th Annual Congress; Officer and Vice President, Scientific Council, International College of Angiology; Jay H. Ryu, MD; Richard J. Rodeheffer, MD; Christopher GA McGregor, MB, FRCS; Mayo Clinic, Rochester, Minnesota, USA.

During a six-year period, 12 patients with a previous diagnosis of lung toxicity underwent major cardiac, pulmonary, or abdominal surgery. The diagnosis was based on new lung infiltrates in a patient receiving long-term amiodarone therapy and in whom other causes of line infiltration were excluded. Eight patients underwent bronchoalveolar lavage and transbronchial or open lung biopsy. Amiodarone maintenance dose was either 200 or 400 mglday with a cumulative mean dose of 2274 mg/kg (range 177 to 6761 mg/kg). The interval between the diagnosis of toxicity and surgery was a mean of 3.2 months (range 12 days to 12 months). The preoperative drug-free interval was a mean of 2 months (range 0 to 7 months). One of these 12 patients developed postoperative recurrence of lung toxicity. During the same time period, three additional patients were diagnosed with amiodarone lung toxicity developing following surgery: one after heart transplantation, another after left ventricular resection and coronary artery bypass graft, and the third after knee synovectomy. Amiodarone maintenance dose was 200 rag/day with a cumulative dose of 1409 mg/kg (range 829 to 2000 mg/kg). All three patients survived although intubation times, intensive care stays and time in hospital were all markedly prolonged. In this study, preoperative amiodarone lung toxicity did not appear to be a risk factor for the development of life-threatening postoperative pulmonary complications. In addition, postoperative lung toxicity could not be predicted by preoperative amiodarone dose and occurred with low-dose therapy.

154 IJA Summer 1992

NEW ASPECTS IN THE DIAGNOSIS AND MANAGEMENT OF ACUTE MESENTERIC INFARCTION: Philippe G. Bull, MD, FICA; G.W. Hagmuller, MD; W. Kreuzer, MD; Department of Surgery, Wilhelminenspital, Vienna, Austria.

A retrospective analysis of 121 patients suffering from mesenteric ischemia was carried out to compare the current diagnostic and therapeutic modalities. The average age was 72.9 years and 76 of the patients reviewed were female (63 %). The overall mortality was 76 %. In 45 patients (37 %) only exploratory laparotomy was performed with none surviving, and 11 patients (9 %) died before any form of therapy could be undertaken. Thirty-four patients (28%) had bowel resection alone with a perioperative mortality of 56 %, 21 patients (17 %) had bowel resection combined with a revascularization procedure with a mortality of 48%, and in 10 patients (8%) with revascularization alone a mortality of 70 % was observed. Significant findings for mortality in this group was duration of symptoms over 10 hours, central mesenterie occlusion with extensive intestinal infarction, stage of hypovolemie shock and age. Mean serum lactate concentration was 8.6+_.2.8 mmol/l (normal 1.5+1.0 mmol/l), and its return to normal following surgery was significant of an uncomplicated recovery (p<0.01). Patients treated with primary anastomosis (63 % mortality) did worse than those with a double stomata (48% mortality) but this was not significant (p > 0.1).

The authors conclude that high serum lactate concentration combined with abdominal symptoms and leucocytosis in the absence of shock are high indicators of bowel ischemia and warrants surgery without delay. Surgery should combine revascularization with extensive bowel resection. Postoperative monitoring of serum lactate seems to obviate routine second-look operations in those with primary anastomosis.

APPROACH TO MICROANGIOLOPATHIC ULCERATIONS: DIAGNOSIS AND THERAPY: Patricia Cristodor, MDI F.C. Rada, MD; M. Hancu, MD; Medical University of Timisoara, Timisoara, Romania.

Microangiolopathie ulcerations represent a particular sort of ulceration and, though not rare, are still not well enough known and not well enough treated, their treatment implying a long-term and deceiving therapy.

We have followed 52 patients with microangiolopathie ulcerations secondary to metabolic disorders (diabetes mellitus), vascular disorders (thromboangiitis obliterans, arteriosclerosis obliterans, livedo reticularis, hypertension, chronic pemio), and vasculitis.

We have followed some biological data, such as serum electrolytes, lipids, electrophoresis, blood ceils, as well as blood pressure, and other investigations: Doppler, arteriography, radiographies of soft tissues surrounding the ulcerations, and morphopathological exams of skin samples in the area of the lesions and from other parts of the body.

As a means of treatment we have used antibiotics, correlating them with variant pH values, as well as benzol peroxide and hydrophyllie wound dressings, together with other classical means of treatment.

Abstracts 155

LYMPHATIC OVERLOAD AND VENOUS DISEASES: F.C. Rada, MD; Patricia Cristodor, MD; I.O. Rada, MD, FICA; Medical University of Timisoara, Timisoara, Romania.

The main circulatory function of the lymphatic system consists of bringing in macromolecules back into blood circulation from interstice space of the sustaining lax connective tissue.

We have observed aspects of the lymphatic system in inferior limb injuries in 25 patients with post-thrombophlebitie syndrome (PTS) by means of: lymphangiochromy, lymphangiography with ultra fluid lipiodol, lymphographies with radioactive labeled macromolecules (RLM), histological exams of lymph vessels and lymph nodes, and protein and lipidic composition of the edema liquid.

We did not observe any obstacle in lymph circulation. RLM resorption was diminished in cellulitis areas and absent in ulcus and hypotrophie

sclerosing dermatitis areas. In edema liquid, proteins were below 0.77 g%. In the presence of PTS, the skin grows thinner and it lessens. Comparatively, from the clinical

point of view, in patients with lymphoedema, the skin of the calves becomes hypertrophic and the hair grows thicker and dense.

In some stages of PTS, lymphatic flow may increase. This increase generates the hypothesis of a false lymphatic overload syndrome. The aspect remains a pseudosyndrome in the absence of perceptible histological and functional alterations. This optional overload is generated by an increase in the extravascular liquid exodus following the alteration of venous circulation in the calves. The reaction to an increased load cannot be considered a disease of the structure responding to overload.

ERGOMETRIC TEST IN SUBJECTS OCCUPATIONALLY EXPOSED TO NOISE: Bruno Papaleo, MD, FICA; F. Tomei, MD, FICA, Associate Professor; E. Tomao, MD; T.P. Baccolo, MD, FICA; P. Alfi, MD; Occupational Medicine, University of Rome- "La Sapienza', Rome, Italy.

Three comparable groups of subjects were studied. The first two did the same type of work but were exposed to different levels of noise, and the third was not exposed to noise.

An ergometric test was done, gradually increasing effort in steps of 30 Watts/3 min., until heart rate reached 200 minus the subject's age. The responses of the three groups were assessed in relation to blood pressure and resting electrocardiographic anomalies.

The differences in response to the ergometrie test between subjects exposed to noise and the others suggest two variables are worth identifying in baseline conditions: diastolic BP 95 mmHg or more, and ECG anomalies. These can be considered as predictive - though not specifically - of cardiovascular susceptibility to chronic noise. These are easy to detect and could be employed for screening purposes.

156 IJA Summer 1992

ACTIONS OF TETRAMETHYLPYRAZINE, A NON-SULFONYLUREA K + ATP-CHANNEL B L O C K E R , U P O N I S C H E M I A - I N D U C E D C O R O N A R Y D I L A T I O N IN I S O L A T E D LANGENDORFF-PERFUSED GUINEA PIG HEARTS: M. Grisold, MD; M. Wallner, MD; J. Dusleag, MD, FICA; C. Furian, MD; W. Klein, MD; Robert Gasser, MD, Phi), FICA, Co-Chairman, Scientifc Program Committee, 34th Annual Congress; Officer and Vice President, Scientific Council, International College of Angiology; Department of Medicine, University of Graz, Graz, Austria.

The compound 2,3,5,6-Tetramethylpyrazine (TMP, Ligustrazin), a flavoring component (Fr. Demande 2, 128:744, 1972) and sweetness enhancer for beverages (Japan. Kokai 73:17, 073), constitutes a commonly used food additive.

Now we studied the effect of TMP on coronary artery dilation during ischemia. In our experiments we used isolated Langendorff-perfused guinea pig hearts, arrested with K+-rich normal Tyrode solution (in MM: NaCI 129.5, KCI 15, MgCI 2 0.8, CaC12 1.0, glucose 10), buffered with 10 mM HEPES to pH 7.4 at 37 ~ C, equilibrated with 100% 02. Ischemia was simulated by equimolar replacement of glucose by 2-deoxyglucose (DOG), an inhibitor of oxydative phosphorylation.

We found that coronary perfusion pressure (CPP) decreased by 20__+1.2 cm H20 (from initially 90 cm H20; n=6,+SEM) within 15 minutes from the onset of DOG. In the presence of 1 mM TMP the decrease in CPP was largely attenuated and CPP declined by 1.4__+1.0 cm H20 (n=6, + SEM; P<0.01). In 2 out of the 6 TMP experiments even a slight increase in CPP ( < 2 cm 1-/20 ) could be s e e n .

We conclude that TMP, a blocker of ATP-dependent K+-channels in pancreatic -cells (FEBS, 261:5, 1990) and possibly in arterial smooth muscle cells, prevents coronary dilation in response to ischemia. The possible suppression of this vital mobilization of coronary reserve during ischemia in patients with coronary artery disease certainly merits further attention and may question the use of this compound as a food additive.

HAEMATIC FIBRINOGEN VARIATIONS IN DIABETIC PATIENTS: Prof. Paolo Pola, MD, FICA; P. Tondi, MD; D. DeMartini, MD; L. Gerardino, MD; Department of Angiology, Catholic University of Sacred Heart, Rome, Italy.

In 1978 we published in the review "Atherosclerosis" our study about the role of fibrinogen as a vascular risk factor.

Our following studies confirmed such" results and demonstrated that haematie fibrinogen variations are related to age and are more evident, in most cases, in patients affected by arteriopathy than in healthy subjects being the same age. In particular, fibrinogen concentrations increased in subjects with such vascular risk factors as diabetes.

In this study, the authors report haematic fbrinogen variations observed in diabetic patients in different clinical and experimental conditions.

Abstracts 157

ASSOCIATION OF ANTI -TRYPANOSOMA CRUZI , ANTI-SCIATIC NERVE, AND ANTI-GANGLIOSIDE ANTIBODIES IN CHAGAS DISEASE: S. Gea, PhDi P. Ordonez, PhD; Daniel Iosa, MD, Phi), FICA, Officer and Vice President, Scientific Council, International College of Angiology; F. Cerban, PhD; C. Chizzolini, MD; E. Votero-Cima, Phi); Dpto. Bioq. Clinic Fat., C. Quimicas, Univ. Nac. Cordoba, Cordoba, Argentina; Centro Priv. Med., Cordoba, Argentina; Fidia S.p.A., Abano Terme, Italy.

We have demonstrated that a Trypanosoma cruzi cytosol acidic fraction named F IV is target of substantial antibody response in patients with chronic Chagas' disease (ClaP). It has been reported in the presence of antibodies and T cells reactive with 7". cruzi that recognized nervous tissue antigens. In this work, we have studied the anti F IV and autoreactive immune responses by ELISA. ClaP with positive serology were classified in: group (G) I (n= 12) with normal ECG, G II (n= 12) with abnormal ECG and G III (n= 12) with cardiomegaly. Sera from G II ChP showed the highest reactivity against F IV, 8/9 had titres > 8.6. The autoreactive response was studied against human sciatic nerve saline extract (SNS), a lipid extract of it (SNL) and gangliosides from bovine brain (Ga) (FIDIA). The binding oflgG to SNS was positive in G I (58%), G II (66%) and G III (75%) of the patients. The reactivity against SNL was revealed in a high proportion of all groups of patients. The treatment of SNS with periodate eliminated the ability of antigens to fix IgG from ChP suggesting the carbohydrate nature of SNS epitopes. The reactivity against Ga was detected in 33% o fG I patients, 66% of G II and 50% of G III. We also detected cross reactivity between SNS and F IV. In fact, F IV was able to inhibit the ELISA reactivity of ChP sera by 31-54% when the SNS was used as antigen. Overall these results suggest that Z cruzi and sciatic nerve components possess at least one epitope, possibly of carbohydrate nature, in common.

LOW MOLECULAR WEIGHT HEPARIN (LOGIPARIN TM) COMPARED WITH LESS INTENSE WARFARIN PROPHYLAXIS AGAINST VENOUS THROMBOEMBOLISM FOLLOWING MAJOR ELECTIVE HIP SURGERY: Russell Hull, MBBS; Gary Raskob, MSc; Graham Pineo, MD, FICA~ Frank Smith, MD; William Evans, MD; Thomas Mallory, MD; David Rosenbloom, PharmD; C. Gregory Elliot, MD; American-Canadian Orthopedic Clinical Trials Group, University of Calgary, Calgary, Alberta, Canada.

The promise of experimental findings that low molecular weight (LMW) heparin may be less hemorrhagic remains to be fulfilled unequivocally in man. The relative effectiveness and safety of LMW heparin compared with less intense warfarin sodium prophylaxis remains uncertain. We have performed a double-blind randomized trial using a single daily injection of LMW heparin (75 F XaI U/kg) compared with less intense warfarin sodium adjusted to maintain the INR between 2.0 and 3.0; both approaches were commenced postoperatively the day of surgery. The results of an interim analysis required by the Federal Drug Administration showed in 365 patients a venographie deep-vein thrombosis rate of 22.6% (42/186 patients) in the Logiparin group and 26.3% (471179 patients) in the warfarin group. Proximal-vein thrombosis occurred in 4.8 % (9/186 patients) in the Logiparin group and in 5.0% (91179 patients) in the warfarin group. Hemorrhagic complications occurred in 5.4% (10/186 patients) in the Logiparin group and in 3.4% (61179 patients) in the warfarin group. Wound hematomas occurred more frequently in the Logiparin group, 9.7% (181186 patients) compared with 1.7% (31179 patients) in the warfarin group (p = 0.003). Both approaches are effective against venous thrombosis. Entry of patients continues to allow definitive conclusions about relative frequencies of hemorrhagic complications. Our findings confirm the effectiveness and safety of less intense warfarin prophylaxis. LMW heparin prophylaxis has the advantage of simplicity because of the lack of need for monitoring.

158 IJA Summer 1992

INTRAVENOUS HEPARIN THERAPY FOR VENOUS THROMBOEMBOLISM: A QUALITY ASSURANCE PROTOCOL: Russell Hull~ MBBSI Gary Raskob, MSc; Jeffrey Ginsberg, MD; Akbar Panju, MD; University of Calgary, Calgary, Alberta, Canada; McMaster University, Hamilton, Ontario, Canada.

Inadequate heparin therapy is causally linked with a 20% to 50% risk of recurrent venous thromboembolism. Empirical heparin dosing frequently results in inadequate therapy. We performed a prospective study in 186 consecutive patients with proximal-vein thrombosis by venography. The objective was to test the precision of an intravenous beparin protocol for achieving and maintaining adequate short-course heparin therapy (activated partial thromboplastin time [APTY] > l . 5 x control; >55s). All patients received an intravenous bolus of 5,000 units followed by continuous infusion of 30,000 to 40,000 units/24 hour. The APT was done at 4 hours Because heparin has nonlinear kinetics, a sliding scale was used to adjust the 24 hour infusion dose (units): APT<45s, +5,760; 45-54s, +2,880; 55-85s, 0 change; 96-110s, stop infusion 1 hour, -2880; > ll0s, stop infusion I hour, -5,760. Repeat APT and dose changes were made every 4 to 6 hours until within range and daily thereafter. The number (%) of patients who achieved an adequate beparin response on days 1 through 4 were 185 (99 %), 179 (96 %), 178 (96 %), 173 (93 %) respectively. The protocol during the course maintained an adequate response in 91% of patients. A statistically significant diurnal variation was noted in the APT levels. Quality assurance of drugs, including utilization, is a key feature of the World Health Organization essential drugs program. Our protocol ensures an adequate heparin response and provides a practical approach for quality assurance of heparin therapy.

GANGLIOSIDES EFFECT ON CARDIONEUROPATHY OF CHAGASIC ETIOLOGY: AN INTERNATIONAL, DOUBLE-BLIND PARALLEL, RANDOMIZED, PLACEBO-CONTROL TRIAL: Daniel losa, MD, PhD, FICA, Officer and Vice President, Scientific Council, International College of Angiology; Juan Puigbo, MD, PhD; Hugo Giordano, MD, Phi); R. Fiorentini, MD, Phi); Centro Priv. de Medicina, Cordoba, Argentina; University Hospital, Caracas, Venezuela; Fidia, Washington, DC, USA.

Chagas' disease is one of the most common causes of congestive heart failure (CHF) and sudden death in the world and is characterized by dysautonomia with severe vascular implication, for which to date, there is no effective pharmacological treatment.

We carded out this trial under a FDA-approved Investigational New Drug Application with Cronassial (mixed gangliosides), 40 mg daily IM injection for 4 or 8 weeks in 128 adults with positive serology (Machado-Guerreiro and Immunofluorescent tes 0. All patients were analyzed for safety assessments, but 31 were excluded from the statistical analysis because of CHF that interfered with the data obtained during the tests. In the 97 remaining patients we measured: Postural Response (heart rate, systolic and diastolic blood pressure and double product changes in response to standing), heart rate changes induced by cough and hyperventilation reflex tests. Cronassial was safe and by ANOVA significantly improved systolic blood pressure and double product response compared with placebo. Results confirm the previous first report of a drug safe and effective in Chagas' cardioneuropathy with autonomic nervous system involvement.

Abstracts 159

P R O T E C T I O N OF I S C H E M I A / R E P E R F U S I O N - INDUCED CARDIAC I N J U R Y BY b[ETHIONINE: Kailash Prasad, MD, Phi), FICA, Professor of Physiology; Officer and Vice President, Scientific Council, International College of Angiology; Debjani Debnath, BSc; Jawahar Kalra, MD, Phi), FICA; Departments of Physiology and Pathology, University of Saskatchewan and Royal University Hospital, Saskatoon, Saskatchewan, Canada.

There are various sources of activation of polymorphonuclear leukocytes (PMNL) during ischemia and reperfusion. Activation of PMNL results in production of hypochlorous acid (HOCI) and oxygen free radicals (OFR). Hypochlorous acid and OFR are known to depress cardiac function and produce tissue injury. Methionine, a quencher of hypochlorous acid, should be able to protect the myocardium from the deleterious effects of ischemia and reperfusion. We investigated the effects of methionine on cardiac function and contractility, blood malondialdehyde (MDA), creatine kinase (CK), CK-MB, and lactate; and infarct size after 3 hours or reperfusion following 11/2 hours of occlusion of left circumflex coronary artery in dogs. Animals were divided into three groups: Group I (sham control), 41/2 hours duration; Group II, 3 hours of reperfusion following 1 '/2 hours of of coronary occlusion; Group III, same as Group II but methionine was administered before ligation of coronary artery. There was a decrease in the cardiac function and contractility associated with an increase in the blood MDA, CK, CK-MB and lactate in the dogs of Group II. The infarct size was 38.1+3.9 percent of the area at risk in Group II. Cardiac function and index of myocardial contractility was better preserved in dogs o f Group III as compared with that in Group II. The blood MDA, CK, CK-MB, and lactate were lower in dogs of Group III as compared to Group II. The infarct size in dogs of Group III was smaller than that in Group II. These results suggest that methionine was able to reduce the cardiac injury during ischemia and reperfusion.

PLACEBO-CONTROLLED, RANDOMIZED, DOUBLE-BLIND TRIAL OF THE THROMBOXANE R E C E P T I O N ANTAGONIST DALTROBAN IN THE TREATMENT OF INTERMITTENT CLAUDICATION: Curt Diehm, MD; E. Bohm, MD; W. Meyer-Sabellek, MD; Department of Internal Medicine, University of Heidelberg, Heidelberg, Germany.

In this pilot study the effect of Daltroban (D) on pain-free walking distance (WD) and on safety parameters was investigated in patients with intermittent claudication.

One hundred and twenty patients were treated with placebo or I00 mg D b.i.d, or 200 mg D b.i.d, for six weeks. Ninety-three patients could be evaluated with respect to painfree walking distance. The safety variables, particularly the laboratory values did not indicate any relevant change. The following table shows the increase in WD in the three treatment groups before and after administration (medians):

BEFORE (m) AFTER (m) NUMBER Placebo 97 121 26 i00 mg b.i.d. 89 114 32 200 mg b.i.d, i00 150 35

Accordingly, increase in WD was about the same in the placebo and in the low dose group. Although the difference was not statistically significant, the increase in the high dose group was markedly higher.

The results of the study reported demonstrate that D is well tolerated at the dose range investigated. The increase in WD in the high dose group compared to placebo can be regarded as a favorable trend.

160 IJA Summer 1992

FUTURE OR PAST: Ca2+ AND Mg2+ SELECTIVE MICROELECTRODES. A STATE OF THE ART: E. Kickenweiz, MD; M. Grisold, MD; W. Klein, MD, FICA; C. Fufian, MD; R. Gasser. MD. PhD, FICA, Co-Chairman, Scientific Program Committee, 34th Annual Congress; Officer and Vice President, Scientific Council, International College of Angiology; Division of Experimental Cardiology, Department of Medicine, University of Graz, Graz, Austria.

Since both Ca2+ and Mg2-t- are biologically active only in their ionized form, it is of major interest to determine their free unbound concentrations in the cytoplasm. For this purpose specific Ca2+__ and Mg2__+ selective microelectrodes have been employed. Both techniques harbor a number of pitfalls and are certainly not easy to use. For Ca2+ selective microelectrodes the ion-selective ligands ETH 1001 and ETH 129 have been used with variable success. The technique, however, is hampered by the extremely low cytoplasmatie considerations of Ca2+ which are in the range of the detection limit of the method (Gasser, Ionselect. Rev., 10:49-70, 1988). Some improvement has been achieved by adding PVC to the ligand. Mg2+ selective microelectrodes have been constructed using ETH 117 and ETH 5214, success also varied (e.g. Gasser & Vaughan-Jones, J.Physiol., 430:70P, 1990). The main problem with ETH 117 was the Ix)or selectivity over Na+, K+ and Ca2+, selectivity over K+ and Na+ improved with ETH 5214, but remained poor over Ca2 +.

PERSONAL METHOD OF THERMOTHERAPY IN TREATING LYMPHOSTATIC DISEASES OF EXTREMITIES: prof. Corradino Campisi, MD, FICA; F. Boccardo, MD; I. Faraj, MD; A. Peressini, MD; A. Lombardi, MD; Department of General and Emergency Surgery, Microsurgery Unit, Center of Lymphatic Diseases; University of Genoa, Genoa, Italy.

As concerns the recent proposals of thermotherapy with Chang-Ti-Sheng's microwave ovens, on the basis of their experience, considering the ancient efficacy of the so-called hot and wet compresses in the treatment of superficial phlebites and lymphangites of extremities, and also the necessity to often associate a proper lymph drainage to this kind of treatment, apart from the obvious necessity of an adequate antibiotic therapy, the authors propose a new kind of device which "a la demande ~ can, above all, associate the various methods of therapy for lymphangiitis and post-lymphangiitis lymphedemas.

Among the remarkable advantages of this original device, the authors will point out the greater efficacy of the therapy and the considerable decrease of costs.

THE EVIDENCE OF THE CLINICAL EFFICACY OF SOLCOSERYL IN THE TREATMENT OF PAOD OF FONTAINE STAGE IIb: L. Ciaeys, MD; S. Horsch, MD, FICA; Krhs. Porz am Rhein, Koln, Germany.

The clinical efficacy of Solcoseryl (Actihaemyl) 20% infusion was evaluated in 138 hospitalized patients with stage lib peripheral arterial occlusive disease (PAOD) by a randomized placebo-controlled double-blind multicenter study comparing parallel groups in five centers.

Pain-free walking disease (PFWD) and maximum walking distance (MWD) improved significantly more in the verum than in the placebo treated patients. (PFW: p=0.005 and MWD: p=0.012).

PFWI~. lengthened by 65% and MWD by 53 % in the verum group. No significant variations were observed at any stage in the study of the ankle/arm pressure ratio at rest and after standard treadmill exercise. These results confirm the clinical efficacy of Actihaemyl 20% infusions in patients with PAOD stage IIb.

Abstracts 161

PICOTAMIDE INHIBITS TxA2 INTERNALIZATION BY HUMAN PLATELETS: P.A. Modesti, MD, PhD, FICAI A. Colella, MD; I. Cecioni, MD; G.F. Gensini, MD; R. Abbate, MD; Clinica Medica I, University of Florence, Florence, Italy.

The effect of a TxA2 reception inhibitor (Picotamide) on TxA2 binding to and internalization by human blood platelets of a radiolabelled structural TxA2 analogue (1251-PTA-OH) was investigated in 5 healthy male volunteers. The kinetic constants (Kobs, K1 and K-l) were calculated by time course experiments according to Weiland and Molinoff. The characteristics of the internalization process (Kin and Vmax) were determined by Lineweaver-Burk plot. The inhibition of TxA2 internalization by Picotamide and other reicosanoids (PGE, PGI:, U46619 and ONOIl120) was evaluated at 4 and 22 ~ C.

The kinetieally determined dissociation constant (Kd) was 10 nmol/L. At 22~ an internalization of 125I-PTA-OH by platelets was observed, and in the uptake experiments the process was found to be saturable at increased ligand concentration. A Michaelis Menten type of kinetics was obtained, and the Vmax was found to be 32.44 fmol/108plt/h with a Km of 6.39 nmol/L, suggesting that the uptake was a carder-mediated active transport. This process is specifically inhibited by TxA2 analogues (U46619 and ONOll120). PGI z and TxB2 showed no effect. Picotamide showed an IC50 of 40 jumol/L.

These findings seem to suggest that the TxA2 analogue ONO11120 is internalized by platelets with simple Michaelis Menten kinetics and the internalization process can be inhibited by Picotamide.

ASPECTS CONCERNING THE HEALING OF CALVES' SKIN IN PATIENTS WITH PRIMARY LYMPHOEDEMA AND POST-THROMBOPHLEBITIC SYNDROME: F.C. Rada, MD; Patricia Cristodor, MD~ !.O. Rada, MD, FICA; Medical University ofTimisoara, Timisoara, Romania.

Normally, the healing of skin wounds is more difficult on the inner part of the calves, compared to other areas of the body. A coexisting post-thrombophlebitie syndrome (PTS) makes the healing of this region even more difficult.

We have comparatively studied, from the clinical point of view, the healing of the skin on the inner aspect of the calves in 10 patients with primary lymphoedema (PL), who previously underwent lympho-venous anastomosis in this area, and 25 patients with PTS, on whom the COCKET ligation of the veins was performed.

The skin wounds healed after 5 days in patients with PL. In the patients with PTS, some unhealed spots were still present after 12 days. Almost 80% of the wounds in PL regions led to keloid scars. We noted important morphological differences between the aspect of the skin in the PL and PTS patients: thickness, trophicity, vascularization, hair, etc., which all explain the specific features of healing.

When an impairment of the lymphatic circulation of the affected side occurs in patients with PTS (following reiterated erysipellas, inguinal adenitis, etc.), the ulcers of the inner aspect of the calves heal rapidly.

162 IJA Summer 1992

ALTERNATIVE APPROACHES TO UNUSUALLY LOCATED POSTERIOR CIRCULATION VASCULAR LESIONS: R.A. de los Reyes, MD; A.B. Kantrowitz, MD; J.G. Feghali, MD; J.B. Bederson, MD, FICA; S. Eisig, MD; C. Hall, MD; Montefiore Medical Center, Bronx, New York, USA.

Vascular lesions at the far ends of the posterior circulation may require approaches other than the standard pterional or subtemporal due to their extremely high or extremely low locations. We have reviewed our experience over the past four years and have identified six cases requiring transclival (2), extradual transpetrous (2), intradural transpical (1), and transcallosal interseptal (1) approaches. The lesions included 5 aneurysms and 1 cavernous angioma. Access to the lesions was greatly enhanced in each ease using a tailored non-standard approach, and several would have been difficult or impossible to manage through the standard approaches.

Alternative approaches are infrequently necessary but greatly enhance the management of unusually-located posterior circulation vascular lesions.

TREATMENT OF MULTIPLE INTRACRANIAL ANEURYSMS: R.A. de los Reyes, MD; Ron L. Alterman, MD; Patrick LaSala, MD; Joshua B. Bederson, MD, FICA; Montefiore Medical Center, Bronx, New York, USA.

We report our experience treating 26 patients with multiple aneurysms over a three-year period. Seventy-five patients underwent 92 eraniotomies and clipping of 119 aneurysms during this time. The average age of the patients was 47.6 + 14 years. The female to male ratio of 1.6:1 rose to 2.7:1 in the group with 2 aneurysms or more. Twenty-three percent of the aneurysms were located on the posterior communicating artery, 22% on the middle cerebral, 15% on the anterior communicating, 12% on the internal carotid and 8% at the basilar bifurcation. The 26 patients with multiple aneurysms represented 35 % of all patients treated. Whenever possible, grade I and II patients underwent vessel cerebral angiography and eraniotomy within 48 hours of their hemorrhage; grade III and IV patients were treated in a delayed fashion unless their condition improved with ventriculostomy. A treatment algorithm was then formulated as follows:

1. The aneurysm causing subarachnoid hemorrhage was determined using the criteria of Nehls, et al. 2. The ruptured aneurysm was clipped at the initial eraniotomy. Additional aneurysms were clipped at the initial craniotomy only if they were ipsilateral to the primary lesion and within the primary operative field. 3. Aneurysms in distal vascular fields, even ifipsilateral to the primary lesion, were addressed in subsequent procedures. 4. The additional unruptured aneurysms were routinely operated upon 4-6 weeks following the primary procedure.

Four of 26 patients (15 %) experienced postop vasospasm. In only one ease (2 %) was there an intraoperative rupture. No patient suffered adverse effects from a secondary procedure. Seventy-seven percent of the multiple aneurysm patients made a good to fair recovery. Of the 6 patients (23%) who had a poor outcome, 3 had giant aneurysms and 3 were grade III on admission. We conclude that patients with multiple intracranial aneurysms can be treated according to the above- mentioned algorithm with acceptable morbidity and mortality.

Abstracts 163

C O N T R A S T - E N H A N C E D T R A N S C R A N I A L D O P P L E R U S I N G A S A C C H A R I D E MICROPARTICLE SUSPENSION: K. Rosenkranz, MD, FICA~ W. Zendel, MD; R. Langer, MD; P. Schubeus, MD; T. Heim, MD; R. Felix, MD; R. Schlief, MD; R. Schurmann, MD; Strahlenklinik UKRV, Berlin, Germany; Schering AG, Berlin, Germany.

The purpose of this study was to assess the diagnostic efficacy of a new transpulmonary echocontrast agent in transeranial Doppler (TCD).

Patients and method: Twenty patients with uni- or bilaterally insufficient Doppler signals intranstemporal precontrast TCD were studied after IV injection of galactose microparticle suspension, applied in 3 concentrations (200, 300 and 400 mg/ml). In a subpopulation of 14 patients, the basilar artery (BA) was investigated (200 and 300 mg/ml). The dose dependent maximal Doppler signal enhancement in the middle cerebral artery (MCA) and BA was determined.

Results: A substantial increase of Doppler signal intensity in the MCA and BA was found in all patients, consequently leading to sufficient evaluable Doppler recordings. The enhancement started 15 see p.i. and lasted 163-240 see p.i. Doppler signal intensity increase in the MCA was 11 dB at a concentration of 200 mg/ml, 15 dB at 300 mg/ml, and 17 dB at 400 mg/ml, respectively. The BA showed a Doppler enhancement of 5 dB at a concentration of 200 mg/ml and 9 dB at 300 mg/ml.

Conclusion: IV injection of a galactose microparticle suspension improves feasibility and diagnostic validity of TCD in cases of suboptimal Doppler signal intensity.

A N E W BLOODLESS PUNCTURE ENTRY NEEDLE FOR ARTERIOGRAPHY: Thomas A. Sos, MD~ David W. Trost, MD; Department of Radiology, The New York Hospital-Cornell Medical Center, New York, New York, USA.

OBJECTIVES: Common sense, government and hospital regulations dictate that splashing and spraying of blood potentially infected by HIV, hepatitis and other viruses should be minimized during arterial procedures. A new percutaneous entry needle was designed to eliminate free pulsatile blood flow during successful arterial puncture.

METHODS: The bloodless entry needle consists of a conventional arterial puncture needle with a one-way silicone valve in the hub and a 5 ml collection bag into which blood flow is diverted from the needle hub through soft flexible clear tubing and a three-way stopcock. The new needle is available in 18 and 19 gauge versions. Arterial puncture is performed by standard Seldinger technique. Intra-arterial position is indicated by brisk blood flow into the tubing and the collection bag. In low flow or low pressure vessels intraluminal position can also be confirmed by gentle suction with a syringe connected to the three-way stopcock or by test injections and/or roadmapping.

RESULTS: Twenty adult patients, many with extensive vascular disease, underwent successful arterial puncture and guidewire placement without complications.

CONCLUSIONS: The Bloodless Entry Needle eliminates free pulsatile blood flow during arterial punctures.

164 IJA Summer 1992

ENDOVASCULAR TREATMENT OF INTRACTABLE, IDIOPATHIC TINN1TUS: B.A. Mehta, MD, FICAI W.P. Sanders, MD, FICA; T.H. Burke, RT; Henry Ford Hospital, Detroit, Michigan, USA.

PURPOSE: We describe eight cases of idiopathic tinnitus, in which high-resolution CT, MR imaging, and superselective angiography revealed no anatomic or pathologic finding to account for the tinnitus.

METHODS AND MATERIALS: Eight adult patients with tinnitus underwent superselective angiography of internal carotid, vertebral and individual branches of ipsilateral external carotid arteries. If no lesion was found, the ipsilateral occipital artery was occluded with suture material and/or platinum coils, being careful to bridge that portion of the occipital artery that usually gives rise to branches to the middle ear.

RESULTS: There were seven complete successes and one patient with moderate reduction in tinnitus. There was only one complication, a questionable allergic reaction consisting only of hives, becoming visible 48 hours after embolization.

CONCLUSION: Coil/suture occlusion of the ipsilateral occipital artery may be effective in treating tinnitus in patients without an identifiable structural cause.

ANEURYSMS OF SUPERIOR MESENTERIC ARTERY: DIAGNOSIS BY CT AND COLLECTIVE REVIEW OF LITERATURE: Jang Sang Park, MD, PhD, FICAI Yong Bok Koh, MD, Phi), FICA; In Chul Kim, MD, PhD; Department of Surgery, Kang-Nan St. Mary's Hospital, Catholic University Medical School, Seoul, South Korea.

Aneurysms of the superior mesenteric artery (SMA) are rare, accounting for only 5.5 % of all visceral artery aneurysms, with a incidence at autopsy of 1 in 12000. These rare aneurysms have unusual features that are the major cause of infection, and it is estimated that 58 % of these are mycotic secondary to septic emboli from endocarditis. Since the first description of an SMA aneurysm by Koch in 1851, at least 145 cases have been documented in English literature, including our case. DeBakey and Cooley were the first to report successful excision of an SMA aneurysm, and our patient appears to be the 39th case report of successful surgical management.

In most SMA aneurysms, the abdominal pain is not characteristic and may be mistaken for pancreatitis or choleeystitis. In contrast to nonspecific abdominal pain, and rare jaundice and gastrointestinal hemorrhage, a triad of fever, abdominal pain and a pulsatile abdominal mass indicates a mycotic aneurysm. A history of preceding bacterial endocarditis commonly accompanies the triad.

A pulsatile mass in many patients with SMA aneurysms is detected on physical examination. Abdominal CT scanning and selective angiography are valuable diagnostic tools, and surgery should soon follow confirmation of this lesion to avoid the complications of thrombosis or ruptures.

Several methods appear in the literature for treatment of SMA aneurysms. Operative treatment consists of ligation of the SMA with debridement of the aneurysmal sac and careful evaluation of bowel viability. Bowel resection or revascularization may also be necessary. The patient should receive a 6-week course of appropriate antibiotic therapy. In this paper we report a case of an SMA aneurysm diagnosed by CT scan and treated successfully by aneurysmectomy and arterial repair using autogenous saphenous vein graft. One hundred forty-five cases reported between 1851 and March 1992 also were reviewed.

Abstracts 165

REPAIR OF PERIPHERAL ARTERIOVENOUS FISTULAS BY INTRALUMINAL AUTOGENOUS VENOUS BYPASS GRAFI'ING (AN EXPERIMENTAL STUDY): Nevzat Dogan, MD; Assistant Professor; Mustasim Sungun, MD; Fuat Bilgen, MD; Ihrahim Oztek, MD, Associate Professor; Enver Duran, MD, Professor; GATA Haydarpase Fgt. Hastanesi, Istanbul, Turkey.

In this study, side-to-side arteriovenous fistulas were created between femoral artery and femoral vein in 10 dogs. These fistulas were repaired by using intraluminal venous grafts placed in the arteries that had been harvested from the contralateral lower limb. In 5 of these cases the distal end of the grafts was fixed with arteriotomy sutures while in the remaining they were not. All the vessels were evaluated by intraoperative angiography before and after the procedure.

Three weeks after the operation, the dogs were reoperated to remove the repaired arterial and venous segments for histopathological examination.

In two of these cases, in which the distal end of the grafts was not fixed, graft thrombosis was detected. The repaired arterial and venous flows were normal in the remaining 8 dogs.

In conclusion, the repair of arteriovenous fistulas was successfully performed, like the aneurysms that were repaired with the "elephant trunk" method, and the vein grafts were found to be well organized with the surrounding artery in the histopathological studies.

MIDDLE CEREBRAL ARTERY MEAN FLOW VELOCITY MONITORING IN SHY-DRAGER SYNDROME: Marinella Marinoni, MD, FICA~ Andrea Gianneschi, MD; Pietro A. Modesti, MD, PhD, FICA; Domenico Inzitari, MD; Department of Neurological Psychiatric Sciences, Clinica Medica I, University of Florence, Florence, Italy.

Shy-Drager syndrome is characterized by pandysautonomia, in addition to signs of multiple nervous system areas involvement. Whether cerebral circulation autoregulation is preserved in these patients is controversial. To evaluate cerebrovascular hemodynamics in this syndrome, we submitted to Transeranial Doppler five Shy-Drager patients (4 male, 1 female, mean age 65+9 years) and five healthy controls (4 male, 1 female, mean age 72+6 years). All previous therapies were discontinued at least 10 days before assessment.

Middle cerebral artery (MCA) mean flow velocities (mv) were measured at rest and in orthostatie position as obtained by a tilt-table. Systemic blood pressure (BP) values were continuously and simultaneously registered.

After the tilting, MCAmv markedly decreased in Shy-Drager patients (-52.9%), while it did not substantially change in controls (-13.6%), (p=0.001). Although mean BP values decreased considerably in Shy-Drager patients (-31.1%), they remained over the threshold for maintenance of cerebral autoregulation. This observation may suggest an alteration of cerebral autoregulation in Shy-Drager syndrome.

SOME SPECIFIC FEATURES OF ARTERIAL PATHOLOGY IN THE UPPER LIMBS (THROMBOANGI1TIS OBL1TERANS - TAO -): I.O. Rada, MD, FICA~ Patricia Cristodor, MD; R.C. Rada, MD; Domnita Rada, MD; Medical University of Timisoara, Timisoara, Romania.

Of the 136 patients with TAO, between the ages of 19 and 45 years, whom we followed for 15 years (1976-1990), in 28 cases we detected lesions on superior limbs (of which, in 4 cases, bilateral lesions). A free interval of 6 months - 2 years passed between the onset of TAO in inferior limbs and the moment of the onset in the superior limbs. All the patients were smokers. The superior limbs arteriography showed the presence of radial and/or cubital artery obliteration. TAO lesions did not affect the humeral artery in the studied group. In the forearm, the interbone artery performed an efficient alternative path (being opaque on the arteriography).

Gangrene occurred in the distal digital segments of the hand simultaneously with a degenerated evolution of the disease in the inferior limbs, or independently of it.

Treatment consisted of slow intravenous perfusions of 2 ampullae or 5% ephedrine in 10% glucose and extirpation of necrosis in the digital segments. In 9 patients with lesions of the hand, we noted local relapses on the same side during the next years, along with resuming of smoking. We did not perform sympathectomy aiming at superior limb in any of the patients. In 43 of the patients with TAO, lumbar sympathectomy was carded out, but we are reserved as far as results are concerned. Sequelae following extension of TAO over the superior limb were significantly less disabling than in the inferior limbs.

166 IJA Summer 1992

D I L A T E D C A R D I O M Y O P A T H Y ASSOCIATED W I T H B O R R E L I A B U R D O R F E R I : OBSERVATIONS UPON TREATMENT AND REVERSIBILITY: J. Dusleag, MD, FICA~ R. Gasser, MD, Phi3, FICA, Co-Chairman, Scientific Program Committee, 34th Annual Congress; Officer and Vice President, Scientific Council, International College of Angiology; E. Reisinger, MD; R. Stauber, MD; B. Feigl, MD; S. Pongratz, MD; C. Furian, MD; W. Klein, MD, FICA; The Borreliosis Study Group, Department of Cardiology, University of Graz, Graz, Austria.

It has been suggested that B. burgdorferi could be associated with dilated cardiomyopathy and thus has been isolated from the tissue (New Engl. J. Meal., 322:249, 1990). However, data concerning this topic are scant.

Here we report a prospective study where we examined the serum of 42 patients with dilated eardiomyopathy (Mean LV-EF: 30% __+ 1.2%) for B. burgdorferi, testing for IgG and IgM (ELISA). Nine (21%) out of 42 showed positive serology for B. burgdorferi. Those 9 patients have been treated with IV ceftriaxone 2 g b.i.d, for 14 days. Six recovered completely and showed a normal EF after 6 months, two improved their left ventricular function and one did not improve at all.

Our results confirm that B. burgdorferi infection plays some role in the development of dilated CMP. Furthermore, we conclude that the damage can be reversed and LV-EF improved in a significant number of these patients.

P O S S I B L E CAUSES OF I N C R E A S E D C A R D I O V A S C U L A R M O R T A L I T Y IN SULFONYLUREA-TREATED PATIENTS: Robert Gasser, MD, PhD, FICA, Co-Chairman, Scientific Program Committee, 34th Annual Congress; Officer and Vice President, Scientific Council, International College of Angiology; M. Grisold, MD; W. Wallner, MD; B. Eber, MD, FICA; J. Dusleag, MD, FICA; R. Zweika, MD; C. Furian, MD; W. Klein, MD, FICA; Division of Experimental Cardiology, Department of Medicine, University of Graz, Graz, Austria.

It has been known for over 20 years that patients treated with sulfonylurea compounds are subject to increased cardiovascular mortality (Ann Rev Med, 25:69-74, 1974). The mechanisms underlying this phenomenon have, however, not been elucidated so far.

Here we studied the effect of glibenclamide and tolbutamide on ischemia-induced coronary vasodilation in isolated Langendorff-perfused guinea pig hearts refused with normal Tyrode (in raM: NaCI 129.5; KCI 15; MgCI 2 0.8; CaCI 2 1.0; glucose 10.0) buffered with 10 mM HEPES to pH 7.4, at 37~ equilibrated with 100% 02. Coronary perfusion pressure (CPP) fell from 90 mmHg by 18 + 1.6 cm H20 (n=5 + SEM) when ischemia was simulated metabolically by equimolar replacement of 10 mM glucose with 2-deoxyglucose (DOG), an inhibitor of oxidative phosphorylation. This fall in CPP was prevented by 0.5 mM Tolbutamide or 5 uM glibenclamide where CPP fell by 1.5 + 0.7 and 2.1 + 2.4 cm tLzO respectively (in the glibenclamide group we saw even a slight increase of CPP during ischemia in 2 experiments). This suggests that sulfonylureas may prevent the vital coronary response to ischemia (local vasodilation and mobilization of coronary reserve). Secondly, as we have shown earlier (J.Physiol, 431:713-714, 1990), sulfonylureas prevent ischemia-induced K + efflux.

Abstracts 167

PROGRESSION OF CAROTID ATHEROSCLEROSIS IN JAPANESE PATIENTS WITH CORONARY ARTERY DISEASE: Kenji Sueyoshi, PhD. MDA Hidekazu Tanaka, MD; Kenji Mandai, MD; Masami Nishino, MD; Ryuzo Fukunaga, Phi), MD; Hiroshi Abe, Phi), MD; Department of Internal Medicine, Osaka Rosai Hospital, Osaka, Japan.

Background and Purpose: In Japan, the incidence of coronary artery disease has increased while the incidence of stroke appears to have decreased. We investigated the relationship between the progression of carotid atherosclerosis and the severity of coronary artery disease in the Japanese population.

Methods: The 2-year change of extracranial carotid atherosclerosis in 50 Japanese patients with coronary artery disease, who underwent coronary angiography, were evaluated using carotid echotomography. To quantify the extent of carotid atherosclerosis, the maximal thickness of all plaques were summed for an individual "plaque score."

.Results: The plaque score increased by -3.2 mm to 10.1 mm (mean 1.06 ram, SD 2.42 nun). The extent of coronary atherosclerosis (p <0.02), and serum total cholesterol level (p <0.01) were different between progressing group (n=20) and nonprogressing group (n=25) or carotid atherosclerosis. There was a significant positive linear corrdation between carotid disease progression and Gensini's coronary disease score (r=0.411, p<0.005). Neither age, serum triglyceride concentration, serum HDL-Cholesterol concentration, pack-years of smoking, % smokers, % hypertensive, nor % diabetic were different between the two groups.

Conclusion: Our data showed that severe coronary artery disease was one of the strong predictors for carotid disease progression, and high serum total cholesterol level was also a major risk factor for carotid disease progression in Japanese patients with coronary artery disease.

EVALUATION OF THE RISK FACTORS FOR THORACIC AORTIC ATHEROSCLEROSIS: .M. asami Nishino, MD; Shoji Ebisuno, Phi), MD; Shusakn Ohnishi, MD; Hideo Tanahashi, MD; Masao Yasuno, MD, FICA; Yoshio Yamada, Phi), MD; Hiroshi Abe, Phi), MD; Department of Cardiology, Osaka Rosai Hospital, Osaka, Japan.

To evaluate the risk factors for thoracic aortic atherosclerosis, transesophageal echocardiography flEE) was performed in 73 successive patients. We divided atherosclerosis into atherornatie change (AC), which primarily shows intimal change, and sclerotic change (SC), which primarily shows medial change. The mean thickness of max intima-media complex at 6 areas of thoracic aorta (IMC) as the index of AC and stiffness parameter,6'(/5) as the index of SCX were measured by TEE. ~ was calculated by the following formula: .,~ =In(Ps/Pd) x Dsl(Ds-Dd), In: natural logarithm, Ps: systolic blood pressure, Pd: diastolic blood pressure, Ds: dimension of aorta at Ps, Dd: dimension of aorta at Pd. We assessed the correlation between IMC for age (p < 0.005) and hyperlipidemia (p < 0.05) and with x3 for age (p < 0.005), hypertension (13 < 0.05) and hyperlipidemia (p < 0.05), and the others were not significant.

These findings suggest that except age, AC is influenced by hyperlipidemia and SC is influenced by both hypertension and hyperlipidemia in thoracic aortic atherosclerosis.

168 IJA Summer 1992

HOME DOBUTAMINE THERAPY FOR END-STAGE CONGESTIVE HEART FAILURE: FEASIBILITY, SAFETY, EFFICACY AND COST SAVINGS: Robert E. Hobbs, MD; Gustavo Rineo, MD; Corrine Bott-Silverman, MD; Karen James, MD; Mark Jorosz, RN; Elizabeth Barr, RN; David Pelegrin RN/PA; Department of Cardiology, Cleveland Clinic Foundation, Cleveland, Ohio, USA.

Forty-two patients (73% males, mean age 65) with severe end-stage heart failure (50% CAD, 48% DCM, 2% other) were treated at home with continuous intravenous Dobutamine infusion. Indications for treatment were failure to wean Dobutamine in hospital (67 %) or frequent recurrent hospitalizations for CHF (33 %). All patients received Dobutamine via a Hickman catheter. Cardiac arrhythmias were not increased by Dobutamine therapy. Home Health Care nursing visits averaged 3 per week. Home Dobutamine represented a cost savings of 80% versus hospitalization charges. All patients were New York Heart Association functional class IV at the initiation of Dobutamine, and functional class improved by at least 1 category in the majority of patients. Patients averaged 3 hospital admissions during the preceding 6 months, but while on Dobutamine, hospital admissions were reduced to 1 per patient. Length of treatment ranged from 1 day to 4 years (average 130 days). Four percent of patients were able to be weaned off Dobutamine. Fourteen percent of patients subsequently underwent cardiac transplant. Survival on home Dobutamine was 80% at one month and 50% at 6 months. The mean follow-up interval was 8 months. Causes of death included CHF (84%), sudden death (8%), and other causes (8%). Conclusions: Intravenous Dobutamine can be administered safely at home for refractory end-stage CHF. This therapy resulted in reduced hospitalizations and substantial cost savings. Patients improved functionally, but overall survival was poor.

E N D O T H E L I A L CELL DYSFUNCTION OF C O R O N A R Y A R T E R Y AND PLASMA CHOLESTEROL LEVEL: Yasuhide Nakashima, MD, FICA; Takashi Kawashima, MD; Y. Oka, MD; T. Kaku, MD; H. Nandate, MD; Y. Murasato, MD; E. Himeno, MD; K. Takahara, MD; A. Kuroiwa, MD; 2nd Department of Internal Medicine, University of Occupational and Environmental Health, Kitakyushu, Japan.

Purpose: To study the characteristics of the spontaneous regression of infarct-related artery after PTCR, we studied the clinical feature, coronary angiography (CAG), left ventriculography (LVG) or regression group (Reg[R]) with those of non-regression group (Non-Reg[NR]).

Methods: In 68 consecutive patients who had their first acute myocardial infarction, CAG was done immediately after PTCR and also CAG and LVG after one month. The spontaneous regression of an infarct-related artery is defined as two steps under stenotie change by AHA classification during immediate CAG after PTCR and follow-up CAG after one month. The following results as shown in the Table below are compared between regression (R) group and non-regression (NR) group.

Results:

R Group NR Group p-value

Pts (n) 30 38 ns Max CK (IU/L) 3574--+3001 3214+3165 ns Vessels 1.4--+1.1 1.5_+0.8 ns A:ColI(%)* 27 -+ 45 52 + 51 p<0.05 C:ColI(%)* i0 -+ 31 47 + 51 p<0.001 Thrombus (%) 33 + 48 42 -+ 50 ns EF(%) 56 _+ 15 54 -+ 15 ns

* % of collateral: Acute phase (A), Chronic phase (C)

Discussion: These results suggest the following: I) Collateral which was opacified after PTCR will be a good predictor of regression; 2) Collateral which was residual after one month relates to preserve left ventricular function in NR group.

Abstracts 169

SIMPLE QUANTITATIVE EVALUATION OF THE SEVERITY OF AORTIC REGURGITATION (AR) IN CINE MAGNETIC RESONANCE (MR) IMAGING: Yuichi Oka, MD; Shiroh Mukae, MD; Naoki Yoshida, MD; Yasuhide Nakashima, MD, FICA; Akio Kuroiwa, MD; Second Department of Internal Medicine, University of Occupational and Environmental Health, Kitakyushu, Japan.

Purpose: Though the regurgitation flow of AR is well estimated as low intensity signal (LS) of left ventricle (LV) by cine MR imaging, this method would be of no difficulty with time to estimate or method for calculation. In this study, we tried the simple method for the quantitative evaluation of AR and compared these results with the data obtained by aortogram.

Methods: Twenty-three patients with AR were given both examinations of angiography and of cine MR imaging angiography. Cine MR images were obtained by means of the FLASH (fast low-angle shot) technique, which used the low flap angle of 30 ~ and gradient-refocused echoes with an echo time of 12 msee. The repetition time was 40 msec. The acquisition matrix was 128 x 256 interpolated to 256 x 256 for display. In cine image analysis, we measured the length and area of maximum AR-LS and end-diastole left ventricle and calculated the volume of maximum AR-LS by using the area-length method. The grading of the severity was based upon the findings of angiography.

Results: Seller's gradings

I II III+ IV Mild (n=8) Moderate (n=6) Severe (n=9)

%AR-LS Length 41 • 59 ~13 a 78 ~ 15 b'e %AR-LS Area 13 • 23 • a 41 ~ 16 b'c %AR-LS Volume 1.02• 3.66• d 7.31• b'e

a) p<0.05 vs. Mild; b) p<0.001 vs. Mild; c) p<0.05 Moderate; d) p<0.01 vs Mild; e) p<0.02 vs. Moderate

Discussion: We conclude that our method is very simple and useful for the evaluation of the severity of AR.

v s .

CARDIAC SENSATION MAY BE ALTERED IN SYNDROME X PATIENTS: A. Chauhan, MRCP; P.Mullin% MRCP; C. Taylor; P.M. Schofield, MRCP, MD, FICA; Papworth Hospital, Cambridge, England.

The mechanism of chest pain in SYNDROME X patients is not clear. We studied the response of three groups of patients to right atrial instrumentation: 20 patients with Syndrome X (group I), 15 patients with mitral valve disease and normal coronary arteries (group 11), and 15 heart transplant patients (group III). The patients were instructed to report any chest pain during catheter. A Gensini catheter was advanced to the right atrium through a femoral venous sheath. The catheter was then rotated rapidly and moved forward and backward in the right atrium without warning the patient. In group I patients a 3.6F intracoronary Doppler-tipped catheter was also positioned in the proximal left anterior descending coronary artery to measure coronary flow velocity. Nineteen patients in group 1 reported their usual chest pain during right atrial stimulation. There was no significant difference in the coronary flow velocity measured before (4.8 SD 1.7 cm/see) and after (4.9 SD 1.7) the period of stimulation. None of the patients in groups H and III reported any chest pain on right atrial stimulation. We conclude that there may be altered awareness of cardiac sensation in Syndrome X patients.

170 IJA Summer 1992

ROLE OF ELECTROPHYSIOLOGIC TESTING IN THE THERAPY OF PATIENTS WITH CARDIAC ARRHYTHMIAS AND SYNCOPE:\ G. Veress, MD, FICA; J. Masszi, MD; J. Falukozy, MD; Z. Vegh, MD; D. Nagy, MD; State Hospital foi'Cardiology, Balatonfured, Hungary.

Electrophysiologie studies (EPS) were performed on 257 patients with cardiac arrhythmias. Of these, 28 (10.8 %) had syncope or presyneope. Detailed clinical investigation prior to EPS did not establish an evident cause of syncope in our patients. One hundred fifty-nine (61.5 %) had organic heart disease. EPS revealed conduction abnormalities in 26 (I0.1%), SSS in 75 (29.1%), SVT in 27 (10.5%), VT in 14 (5.5%). Twenty-eight (10.8%) received permanent pacing or selected antiarrhythmie therapy compared to the remaining patients (15.9%) who had negative EPS and received empiric therapy.

EPS were providing for the mechanism of diagnosis of cardiac arrhythmlas and in the correct indication for pacemaker implantation in the assessment of drug prevention of sustained junctional and monomorphie ventricular tachyarrhythmias and in the slowing of rapid rates during atrial fibrillation with preexcitation.

EFFECTS OF SUSTAINED RELEASE DILTIAZEM (TA2006) IN PATIENTS WITH STABLE EFFORT ANGINA PECTORIS: Tohru Kaku, MD~ Etsuroh Himeno, MD; Yasuhide Nakashima, MD, FICA; Akio Kuroiwa, MD; Second Department of Internal Medicine, University of Occupational and Environmental Health, Kitakyushu, Japan.

Ca-antagonist is effective not only for variant angina but also for effort angina. The effects of sustained release diltiazem TA2006 (TA) and ,d i-blocker atenolol (Aten) on exercise tolerance were studied in 8 patients with stable effort angina m cross-over trial. TA (100 mg) or Aten (50 rag) once a day was given, each treatment period lasting two weeks after a two-week control period ((2). Treadmill exercise test was performed on the last day of each period.

Mean responses were as follows:

Rest Max. exercise

C TA Aten C T Aten

HR(bpm) 70 63** 53* 130 134 108. SBP(mmHg) 121 114 114 165 172 150 PRP 8539 7155.* 6061. 21664 23036 16299**

*p<0.01 **p<0.05; C versus TA or Aten

Both TA and Aten decreased HR at rest, the decrease with Aten was more pronounced. SBP was unchanged at rest by both drugs. At maximal work levels, Aten decreased HR and PRP significantly, but TA did not. Both TA and Aten significantly prolonged exercise time (average 137 and 165 see, respectively), time to onset of 1 mm ST depression (240 and 288 see, respectively). There was no significant difference in exercise tolerance between TA and Aten. These data suggests that TA 2006, sustained released Ca-antagonist, provides beneficial effects in patients with stable effort angina.

Abstracts 171

MANAGEMENT OF HEPATIC ARTERY ANEURYSMS: IS PRESERVATION OF COMPLETE ARTERIAL FLOW T() THE LIVER AL~VAYS NECESSARY? Dimitrios Psathakis, MDI G.Muller, MD; M. Noah, MD; Prof. H-P. Bruch, MD; Department of Surgery, University Medical School, Lubeck, Germany.

In large autopsy-series splanchnic artery aneurysms have an incidence of 0.1%. Left hepatic artery aneurysms have an incidence of 0.8% among the splanchnie artery aneurysms. Atherosclerosis (30-32%) is the most prevalent etiology, followed by trauma (22-28%) and inflammatory lesions (11%). The average age is 40 (10-83) years, the male to female ratio 2:1. In 64-80% of the cases, rupture of the aneurysm is the first dramatic clinical manifestation. The mortality is then about 35%. Our case of a 64-year-old female with a perforated aneurysm of the left hepatic artery, who underwent emergency laparotomy for hemorrhagic shock, and the case of a 70-year--old female, who underwent emergency laparotomy for acute colorectal hemorrhage with a right hepatic artery aneurysm, which perforated into the gallbladder, with simultaneous colocholecystie fistula, are reported. In the first case, the left hepatic artery aneurysm was resected and the artery itself ligated. In the second case, complete arterial flow to the liver was restored. The postoperative course was monitored in case 1 up to one year and in case 2 up to 10 months postoperatively by a combined regimen of laboratory tests, abdominal ultrasound, CT scans and scintigraphy of the liver. Etiology, histology, and current diagnostic and therapeutic management of hepatic artery aneurysms is presented.

ADEQUATE AND ACCURATE INVESTIGATION OF THE VENOUS HEMODYNAMICS OF THE LOWER LIMB: Dimitrios N. Psathakis, MD; Nikolaos D. Psathakis, MD, FICA, Officer and Vice President, Scientific Council, International College of Angiology; Lubeck and Bad Karlshafen, Germany.

Investigation of the venous hemodynamics of the lower limb must aim not only to confirm venous insufficiency but also mainly to elucidate the capabilities of the deep venous system and to detect deep venous incompetence (DVI). Because deep venous incompetence is necessarily connected with a popliteal reflux accounted for by valvular incompetence of the popliteal vein, its presence must be clarified; its assessment should be limited to the noninvasive and to the most adequate, efficient and accurate methods. Since the Doppler ultrasound and/or the Duplex fulfills these requirements, we start the assessment with it and continue by phlebography and venous pressure measurements only when required. By Doppler and Duplex the popliteal reflux can be calculated as percent of compressed blood by venous reflux index (VRI). For this purpose, the Duplex ultrasound is preferred as more accurate. A statistical comparison of the values confirmed by Doppler and by venous pressures was significant with a correlation-coeffifcient (r) of 0.7, which correlates with the clinical findings. In the last 5 years we have made the assessment of DVI only by Doppler with success in the prediction and indication for operation. Its validation is made by the results achieved after substitute valve operation by Technique II using a silastie tendon, which is designed to overcome reflux in the deep veins producing a valve like mechanism. With this procedure, we operated on 221 patients (257 lower limbs) in the last 11 years. Assessment of the results shows that by Doppler preop popliteal reflux of 167 limbs was abolished or minimized in 145 limbs. The high AVP was reduced early postop from 71+11 mmHg to 36+17 rnmHg, and the short RT was prolonged from 9+5 see to 27+17 see, maintained 6 years later.

172 IJA Summer 1992

REVASCULARIZATION OF THE HYPOGASTRIC ARTERY DURING RECONSTRUCTIVE SURGERY OF THE AORTOILIACAL ANEURYSMS: INDICATION, METHODS, RESULTS: Jose Alemany, MD, FICAi Officer and Vice President, Scientific Council, International College of Angiology; Bottrop, Germany.

Necrosis of the gluteal region, gangrene of the rectosigmoid area and vascular impotence are complications after vascular operations for aneurysms of the aortoiliacal region.

We are able to document 18 patients with lethal complication who underwent vascular surgery of the aortoiliaeal vessels between 1971-1983. The reason was an acute interruption of blood flow of the hypogastric arteries with no preexisting collateralization.

The analysis of these complications led us to perform the simultaneous reconstruction of the hypogastrie arteries when the flow to these arteries seemed insufficient.

Since 1987, this indication has been established at our department because of preoperative angiography and operative findings.

We compared the analysis of the operation from 1983-1987 to those from 1987-1992 with revascularization of the hypogastrie arteries.

Our results, based on more than 500 infrarenal aortoiliac aneurysms, show a significant reduction of postoperative complications concerning ischemic damage in the gluteal and colorectal area and of vascular impotence.

Revascularization Of the hypogastric artery has been made by reimplantation in the prosthesis, by interposing a Dacron tube, or retrograde by anastomosis of internal and external artery after extirpation of the aneurysm. Although the time of the operation is extended slightly, there is a reduction of the lethality.

MODIFICATIONS IN TRANSCUTANEOUS OXYGEN PRESSURE AFTER PTA IN PERIPHERAL VASCULAR DISEASE: Elmo Mannarino, MD, FICA, Officer and Vice President, Scientific Council, International College of Angiology; L. Pasqualini, MD; S. Innocente, MD; V. Scricciolo, MD; G. Fuscaldo, MD; Angiology Section, II Department of Internal Medicine, University of Perugia, Perugia, Italy.

Foot and chest transcutaneous oxygen tension (TePO2), the Regional Perfusion Index (RPI) (RPI=foot TcPO2/chest TcPO2), and ankle/brachial systolic blood pressure index (ABI) were calculated before and after a successful percutaneous transluminal angioplasty (PTA) in 38 limbs with intermittent claudication and in 4 with rest pain. In patients affected by intermittent claudication, walking times and the half recovery time (HRT) to the TcPO 2 basal value after an induced ischemia were also determined. After PTA, rest pain disappeared in the 4 severely ischemie legs and significant differences were observed not only in the TcPO 2 basal values, which rose from 17 + 8.9 to 41 + 11.7 mmHg (p<0.001), but also in the RPI, which increased from 0.24 + 0.15 to 0.68 + 0.19 (p<0.001). In all patients with intermittent claudication, the TcPO 2 HRT shortened significantly from 120.83 + 40.8 to 75.18 + 50.16 secs (p<0.001). This decrease correlated with an improvement in walking capacity. The ABI could not be calculated in 7 limbs because the arteries could not be compressed. After PTA, it significantly increased in the other limbs from 0.46 __+ 0.23 to 0.80 + 0.12 (p<0.001). Our results indicate a substantial increase in TePO 2 parameters can be observed after successful PTA, and these measurements, unaffected as they are by noncompressible arteries, are an appropriate noninvasive method for assessing results of revascularization procedures.

Abstracts 173

PATENCY AND VIABILITY OF ARTERIAL GRAFTS AFTER CRYOPRESERVATION: Bharadwai, MB, BS, BSc, FRCS(C), FICA, Professor and Chief, CVT Surgery; E. Zacher, MD; E. Lew, MD, FRCP(C); W. Lester, MD; Departments of CVT Surgery and Pathology, Foothills Hospital, University of Calgary, Calgary, Alberta, Canada; University of Saskatchewan, Saskatoon, Saskatchewan, Canada.

The use of homograft arteries and conduits has been limited in the past because of inability to preserve grafts in a viable form for any extended period of time. The development of new methods and materials for rapid eryopreservation has made the concept of graft preservation with subsequent implantation a feasible one.

In this study, we examined the effects of rapid cryopreservation on the viability and patency of interpositional arterial grafts in rats. Thirty Sprague-Dawlay male rats were divided into three groups of 10 each: Group A - Control, Group B - Cryopreserved in glycerol medium, Group C - Cryopreserved in glycerol plus dextrose medium. Rats in group A received a segment of arterial graft from left femoral artery to right femoral artery. Similarly, Groups B and C received a preserved graft according to protocol. Grafts were harvested 14 days post implantation.

Results: Histology: Group A, the Intima and media were well preserved; Group B, concentric proliferation of Intima and loss of cellularity of media; and in Group C, though Intima was well preserved, there was a cellularity of media.

B_~.

UNILATERAL ILIAC ARTERY LESIONS: IS THE DIRECT ANATOMIC APPROACH THE TREATMENT OF CHOICE.'? Loris Nardella, MD, FICA; E.A. Belgrano, MD; F. Palladino, MD; F. Maiolo, MD; Department of Vascular Surgery, Ospedale S. Croce, Cuneo, Italy.

Unilateral iliac artery occlusive disease, except discrete stenosis susceptible of PTA, may be resolved by direct anatomic approach or femoro femoral bypass. We retrospectively studied our series of vascular reconstructions to classify surgical indication and related problems. Between 1981 and 1991, a total of over 207 surgical procedures for symptomatic unilateral iliac artery, we performed 63 endarterectomy (TEA), 85 iliofemoral bypass (IF), and 59 femorofemoral bypass (FF). All patients discharged with patent arterial reconstruction were followed from 6 months to 7 years with a mean of 4.3 years. No operative mortality occurred in our series. Pateney status was assessed by finger palpation of femoral pulse, Doppler examination of iliac and femoral artery, segmental limb pressure, and ABI and analyzed by the life-table method. We observed a 30-day pateney of 95% for IF (90% TEA, 97% Bypass) and 85% for FF Bypass; 5-year patency was 85% for IF (83.5 TEA, 88.6 Bypass) and 78.3 % for FF grafts.

Although it is difficult to compare these different series because of the various indications of treatment, our policy is to perform direct revascularization whenever possible and to reserve FF bypass only in poor risk patients considering the shorter operation time and the patency rate only slightly inferior to anatomic approach.

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SUPPRESSION OF INTIMAL THICKENING BY CYCLOSPORINE AFTER EPTFE GRAFTING: Kensuke Esato, MD, FICA, Officer and Vice President, Scientific Council, International College of Angiology; Mikihiko Harada, MD; Kentarouh Fujioka, MD; First Department of Surgery, Yamaguehi University School of Medicine, Yamaguchi, Japan.

The purpose of this experimental investigation is to know the effect of cyclosporine on suppression of anastomotic and graft intimal hyperplasia using 10 mm long and 3 mm internal diameter expanded polytetrafluoroethylene (EPTFE) infrarenal aortic grafts.

Material and Methods: A control group (n=6) received commercial rabbit chow; a cholesterol group (n=6) received rabbit chow with 1% cholesterol; a cyclosporine group (n=6) received the cholesterol diet plus cyclosporine 5 mg/kg daily subcutaneously. All animals were killed 3 months after grafting. The intimal thickness was measured in the central portion of the graft and at the proximal and distal anastomoses.

Results: In the control group and the cyclosporine group, the intraluminal surface of the EPTFE graft was smooih and more even than in the cholesterol group. The intimal thickness in the central portion was 10.3 + 3.5 jam, 145 + 60.3 :um and 86.1 + 29.6 ~am in the control, cholesterol and eyclospodne groups, respectively. The intimal thickness in the central portion was significantly less in the control and cyclosporine groups than in the cholesterol group (p <0.05). However, no significant intergroup difference in intimal thickness was observed at the proximal and distal anastomoses.

Conclusion: Cyclosporine inhibits intimal thickening in arterial grafts.

EFFECT OF PROSTAGLANDIN I z ANALOGUE TRK-100 ON THE SUPPRESSION OF INTIMAL FIBROUS PROLIFERATION: Yasuhiro Kouchi, MD; Kensuke Esato, MD, FICA, Officer and Vice President, Scientific Council, International College of Angiology; Masaki O-Hara, MD; Nobuya Zempo, MD; First Department of Surgery, Yamaguchi University School of Medicine, Yamaguchi Japan.

This study investigated the effect of Prostaglandin 12 analogue (rRK-100) on the healing arterial anastomoses. The infrarenal abdominal aorta was divided and reanastomosed immediately in rabbits. A control group of rabbits were fed commercial chow (ORC 4); a cholesterol group of rabbits were fed a diet with 1% cholesterol added to ORC 4; and the TRK group of rabbits received the same diet as the cholesterol group, but TRK-100 was given subcutaneously at a dose of 0.3 mg (TRK-I group) or 1.0 mg (TRK-II group) every other day. After 3 months, a blood sample was taken for biochemical analysis, and the abdominal aorta was harvested for histologie examination. The serum lipid and thromboxane B 2 concentrations and the thromboxane B2/6-keto prostaglandin Ft ~e ratio in the TRK groups were significantly lower than in the cholesterol group. The proliferative connective tissue did not cover the anastomotie suture line in either the control or the TRK groups. However, the suture line was covered completely by connective tissue in the cholesterol group. Intimal thickness in the cholesterol group was greater than in either the control or the TRK-II groups (p < 0.01 and p < 0.05, respectively).

This data suggests that TRK-100 may suppress intimal fibrous proliferation at anastomotie suture lines by a mechanism affecting the TXB2/6-keto PGFt.~ratio.

BALLOON ANGIOPLASTY AND STENTING OF CENTRAL VEINS IN CHRONIC HEMODIALYSIS PATIENTS: R.P. Sharma, MD, FICA~ P.C. Shetty, MD; M. Burke, MD; G. Guy, MD; D. Kastan, MD; T. Burke, RT, Henry Ford Hospital, Detroit, Michigan, USA.

Over the past five years, we have successfully performed balloon angioplasty of central veins in over 30 chronic hemodialysis patients. The technique, results and complications of performing balloon angioplasty of central veins will be discussed. Our recent experience of placing intravascular stents in central veins will also be discussed.

Abstracts 175

EPIDURAL SPINAL CORD STIMULATION (ESCS) IN THE TREATMENT OF SEVERE PERIPHERAL ARTERIAL OCCLUSIVE DISEASE: S. Horsch, MD, FICA; Krhs. Porz am Rhein, Koln, Germany.

ESCS has been shown to control pain and to improve the peripheral circulation. From January 1988 to September 1991, 156 patients with severe PAOD of the lower limb were treated by ESCS in order to evaluate pain relief and limb salvage.

Medical therapy was ineffective and vascular surgery had failed or was impossible. In all patients PAOD was attributed to arteriosclerosis, 32 of whom were diabetics. Clinical status was classified as Fontaine stage III in 105 patients and as Fontaine stage IV in 51 patients. One hundred nineteen patients had one or more previously failed bypass operations on the involved leg. Eighty-three "stage III patients" experienced very good pain relief. Nineteen patients underwent an amputation.

A significant increase in pain-free walking distance was noted in the 82 non-amputated patients. The regional perfusion index (RPI) increased in the non-amputated group from 0.52 to 0.91. Thirty-six "stage IV patients" experienced good pain relief. Thirty patients underwent an amputation. No changes in RPI were recorded. Overall mortality amounted to 12%, 7 patients were lost from follow-up. Technical complications occurred in 20 %.

We conclude that ESCS is promising in patients with severe PAOD when medical and surgical therapies have failed or reconstruction is impossible.

MYOCARDIAL DEPRESSION AFTER THE DECLAMPING OF INFRARENAL AORTIC CROSS-CLAMP: Kazuro Sugi, MDI Akira Furutani, MD; Kentaro Fujioka, MD; Hidetoshi Tuboi, MD; Kensuke Esato, MD, FICA, Officer and Vice President, Scientific Council, International College of Angiology; First Department of Surgery, Yamaguclai University of Medicine, Yamaguchi, Japan.

We evaluated intrinsic cardiac contractility during and after the infrarenal aortic clamping. METHODS: Under general anesthesia, 11 dogs were instrumented with ultrasonic crystals on

the anterior and posterior aspects of the left ventricle to measure the external minor diameter. A pressure transducer was placed in the left ventricle. Aortic and Swan-Ganz catheters were introduced. Animals were divided into two groups. In CLAMP group (n-6), cardiovascular data were collected during one-hour infrarenal cross-clamping and for the following 2 hours. In CONTROL group (n=5), time-control data were collected without aortic cross-clamping.

RESULTS: In CLAMP group, cardiac function did not change during clamping. However, it was significantly depressed at 1 and 2 hours after declamping. Cardiac output decreased from 1.70+__0.22 L/rain to 1.30+__0.14 and 1.19+._0.10 at 1 and 2 hours after declamping respectively. Emax (End-systolic pressure-volume relationship) decreased from 29.7+11.3 mmHg/mm to 17.2+___3.5 and 17.2+3.5 at 1 and 2 hours after declamping respectively. In the CONTROL group, there were no significant cardiovascular changes throughout the experimental period.

CONCLUSION: Infrarenal aortic cross-clamping induced myocardial depression after declamping but not during cross-clamping.

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CYCLOSPORINE A IN THE DEVELOPMENT OF SUBINTIMAL HYPERPLASIA: S. Lepidi, MD; Thomas Schmitz-Rixen, MD; C. Berwanger; R. Kurth; D. Vietmeier; K. Addicks, MD; Departments of Surgery and Anatomy, University of Cologne, Cologne, Germany.

INTRODUCTION: The development of Subintimal Hyperplasia (SIH) of the feeding arteries is a frequent cause of failure of transplanted organs, especially in heart transplants.

In an experimental transplantation of arterial allografts, we found this SIH in recipients treated with Cyclosporine A(CsA) as well as in recipients without any immunomodulation. This study is designed to elucidate the degree to which the intimal toxic effects of CsA found in vitro is responsible for the development of SIH in vivo.

MATERIALS AND METHODS: Abdominal aortic aUografts were transplanted in animals (Brown-Norway/Lewis rats) with a major hystocompatibility complex barrier (MHC). Anesthesia, analgesia and treatment of the animals followed the laws of animal protection. The animals were divided into Iso-0..ewis-Lewis Inbreed) and allograft control groups as well as iso- and allograft CsA treated groups. The transplants were examined after 15, 30, 60, 100, and 360 days according to the following criteria:

1) pateney rated; 2) aneurysmatie degeneration; 3) changes in the media; 4) cell infiltration, concerning especially 5) W 3/25 and Ox 8 positive Lymphocytes (T cells); 6) morphometrie analysis of the development of SIH, and 7) morphology and structure of the media and intimal cells by electronmieroscopy.

RESULTS: Every allograft had developed SIH. Even in immunosuppressed animals using CsA, this was observed. As treatment with CsA also inaugurated the development of SIH in Isograft which had not shown any SIH without immunomodulation, we can conclude the following: CsA immunomodulation shows an influence on the development of SIH in vascular transplantation in animals. This could be the reason for the observed late changes in the coronary arteries after heart transplants.

PRIMARY AORTOENTERIC FISTULA: REPORT OF TWO CASES AND LITERATURE REVIEW: Asterios Katsamouris, MD, FICA, Officer and Vice President, Scientific Council, International College of Angiology; George Halkiadakis, MD; John Askoxylalds, MD; Dimitris Tsiflsis, MD; University of Crete Medical School, Herakleion, Crete, Greece.

This report describes two cases of primary aortoenterie fistula and reviews the subject. Case 1. A 56-year-old woman, who underwent fight hemieolectomy for carcinoma in 1986,

presented with a massive upper gastrointestinal (GI) bleeding. An emergency laparotomy was done. At operation a large fistulous communication was found between the third portion of the duodenum and aorta caused by carcinomatous retroperitoneal lymph nodes. The patient recovered from the operation well, but she died on the 29th postoperative day from massive upper GI bleeding. Autopsy revealed infiltration of the duodenum and abdominal aorta by the metastatic carcinomatous retroperitoneal lymph nodes.

Case 2. A 67-year-old man presented with a 24-hour history of weakness and millennia. Ultrasonic and CT examination revealed a small abdominal aortic aneurysm. Endoscopy and flexible colonoscopy failed to def'me the source of bleeding. Three hours from his admission he experienced hematochezia. The patient was taken to the operating room with a possible diagnosis of aortoenterie fistula. Indeed at operation a fistula was found between the jejunum and a small atherosclerotie abdominal aortic aneurysm. A woven Dacron tube graft was placed and the jejunum was closed. Recovery was uneventful and the patient remains well nine months later.

Abstracts 177

CHANGES OF THE INTERNAL DIAI~IETER OF CORONARY ARTERY BYPASS GRAF's OVER TIME: ASSESSMENT BASED ON X-RAY COMPUTED TOMOGRAPHY: Eiii Tamiya, MD, PhD, FICA~ Nobuhiko Ito, MD; Teruhiko Aoyagi, MD; Yoshiyuki Hada, MD; Ken-ichi Asano, MD; Departments of Cardiology and Thoracic Surgery, JR Tokyo General Hospital, Tokyo, Japan.

We used x-ray computed tomography (CT) for follow-up of the changes of the inner diameter (ID) of coronary artery bypass grafts. After the level of the bifurcation of the truncus pulmonalis had been detected by localizing scans from the ascending aorta to the superior margin of the left ventricle (scanning time, 3 seconds; slice thickness, 5 ram), 30 ml of Iohexol 350 were injected at a rate of 3 mils via a cubital vien. Five scans were obtained consecutively, starting 8 seconds after initiation of the contrast medium injection. Based on the two CT scans (4+6 and 36+___20 months postoperatively), and a selective graft angiogram (12 +15 months postoperatively), 21 patients (20 males, mean age 55_.+8 years) were included with a total of 35 saphenous vein grafts (RCA: 7; LAD: 19; LCX: 9). The t'mdings were compared with the results of intraoperative electromagnetic flowmeter (EMF). Results: The mean ID of the 28 grafts which were patent at the time of the latest CT was 4 .9+ 1.9 ram. This was significantly smaller (p<0.01) than the mean ID at the time of the early CT (5.9+1.9 mm). The ID of 24 grafts had decreased, for 9 it had remained unchanged, and for 2 it had increased. A significant correlation between the EMF and the ID did not exist. All 7 grafts which were occluded at the time of the late scans could not be visualized in any slice of the plain CTs as well as of the contrast enhanced CTs. Conclusions: The ID of grafts frequently decreases in the late postoperative period and shows no significant correlation with the EMF. Occluded grafts cannot be visualized by CT.

HYPERVENTILATION REDUCED CORONARY BLOOD FLOW IN SYNDROME X PATIENTS: A.__~. Chauhan, MRCP~ P. Mullins, MRCP; G. Taylor, MD; P.M. Schofield, MRCP, MD, FICA; Papworth Hospital, Cambridge, England.

The mechanism of chest pain in SYNDROME X patients is not clear. We investigated the effect of hyperventilation in a group of 18 syndrome X patients. All patients first underwent hyperventilation tests on the ward 24 hours prior to the cardiac catheter. A 3.6F intraeoronary Doppler catheter was positioned in the proximal left anterior descending coronary artery. The resting coronary blood flow velocity was measured with the patient in the supine position and breathing normally and after hyperventilation. During the tests performed on the ward, 10 patients experienced their usual chest pain on hyperventilation, but none of these episodes produced significant ischemie ECG changes. This exact pattern was repeated during the cardiac catheter with hyperventilation. Hyperventilati0n produced a significant increase in heart rate from 77 SD17 to 85 SDI6 (13=0.0001). There was no significant change in the systolic blood pressure. The rate-pressure product increased significantly from 9267 SD2216 to 10528 SD3045 (p=0.009). Coronary blood flow velocity, however, decreased significantly from 7.6 cm/sec SD 4.9 to 6.6 cm/sec SD 5 (p=0.02, Paired t-Tes 0. We conclude that in syndrome X patients hyperventilation can reduce coronary blood flow significantly.

MEASUREMENT OF VARIATIONS IN RESTING CORONARY BLOOD FLOW: A. Chauhan, MRCP; P. Mullins, MRCP; G. Taylor; P.M. Schofield, MRCP, MD, FICA~ Papworth Hospital, Cambridge, England.

The recent development of intracoronary Doppler catheters has allowed the measurements of coronary flow velocity and coronary flow reserve. To assess the presence of spontaneous variability in resting coronary flow velocity, which should be taken into account when investigating the effects of various interventions on the coronary circulation, we studied 12 syndrome X patients who were undergoing coronary flow reserve studies. Using a standard femoral approach, a 3.6F intracoronary Doppler catheter was positioned in the proximal left anterior descending coronary artery. The coronary flow velocity was measured over a 15-minute period with the patient in the supine position and breathing normally. There was no significant difference in the coronary flow velocity measured at the start (7.3 SD, 4.5 cm/see), at 5 minutes (7.3 SD, 4.6), at 10 minutes (7.1 SD, 4.4) and at 15 minutes (7.3 SD, 4.7). These results demonstrate that under resting conditions, with stable heart rates and mean arterial pressure, the coronary flow velocity remains relatively constant and any changes observed under these conditions are likely to be related to the intervention.

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L E F T A N T E R I O R H E M I B L O C K S T U D I E D BY C O M P U T E R G R A P I I I C ELECTROCARDIOGRAPHY: Yasuhiro Kinoshita, MD, PhD, FICA, Director and Professor of Internal Medicine; Isao Sato, MD; Teruhiko Marushima, BE; Taichi Nishimura, BE; Health Sciences Center, Chiba University, Chiba, Japan.

In order to find the three-dimensional distribution of ventricular excitation potentials in left anterior hemiblock (LAHB) diagnosed by the conventional scalar ECG, subjects of LAHB aged 19 to 62 years old, who were otherwise healthy, were studied by computer graphic electrocardiography (CGECG). Twenty-one electrodes including V1, V2, V3, V5 and V6 were placed on the anterior body surface and 11 on the posterior body surface of which potentials were determined by an average reference obtained by connecting all 32 leads to one point. The potentials were then digitized and transmitted to a 32 bit personal computer by which they were texture-mapped onto the surface (divided into 720 segments) of a human torso model and a spherical model. Each segment analyzed at 20 microvolts was painted either red > magenta > white (0) > eyan > blue> black, depending on the value of the input signal determined or calculated by a lineal interpolation routine.

Two modes of the initial ventricular depolarization (IVD) were noted: 1) The IVD appeared separately and irregularly on the central and mid-lower regions of the anterior body surface; 2) The IVD appeared normally on the central region of the anterior body surface. Both (1 and 2) potentials spread toward the left lower regions of the anterior body surface as normally observed; however, they were far lower in voltage than those observed in intact subjects.

From the results, we have concluded that LAHB may not be a block, but rather a left anterior low-voltage syndrome appearing mainly during ventricular depolarization and occasionally during ventricular repolarization.

HOLOGRAPHIC INTERFEROMETRY FOR IN VITRO INVESTIGATIONS OF PROSTHETIC HEART VALVES: A.W. Geiger, MD, FICA; Z. Zarubin, PhD; D. Hammel, MD; G.V. Bally; H.H. Scheld, MD, FICA; Department of Cardiovascular Surgery; Hospital of the Westphalian Wilhelms University of Muenster, Muenster, Germany.

In prosthetic heart valve replacement the possibility of valve dysfunction is of particular importance. A preoperative nondestructive testing of each individual valve could prevent the implantation of a - due to material failure - potentially dysfunctional valve. For that purpose holographic interferometry as a noncontacting, nondestructive, highly sensitive, three-dimensional measurement technique has been applied. Samples of seven different types of prosthetic heart valves were investigated in our experiments. The valve under investigation was mounted in a specially developed liquid-filled test chamber, which provided the optical access to the valve from four sides, and stressed in closed position at physiological level of loading. Deformations of the valve due to small pressure differences applied between exposures were recorded by double exposure holography. A fringe pattern superimposed on the image of the valve reconstructed from the hologram clearly indicated - with the sensitivity and accuracy of a fraction of the used laser wave length - the presence of any slightest defect in the valve material.

The series of experiments carried out with different valves has demonstrated that this fringe pattern can be reproduced and that its shape is specific for each type of valve. Deviations of these shapes from the typical ones point out the irregularities of the valves, which could be responsible for a high level of hemolysis or other functional disorders.

The investigations have demonstrated the possibility of a nondestructive holographic screening test to assure high quality and a long lifetime of each individual valve prior to surgical implantation.

Abstracts 179

PARAMETERS OF DIASTOLIC HYPERTENSION DURING THE COURSE OF THE 30-MINUTE TILT TEST: J.E. Naschitz, MD, FICA, Co-Chairman, Scientific Program Committee, 34th Annual Congress; Officer and Vice President, Scientific Council, International College of Angiology; Senior Lecturer in Medicine; Y. Yeshurun, MD; S. Boyrer, MD; S. Yanovskaya, MD; V. Geidelberg, MD; F. Fefer, MD; Department of Medicine A, Bnai Zion Medical Center, Technion Israel Institute of Technology, Haifa, Israel.

The 30-minute tilt test combines the advantages of a provocative maneuver with that of repeat observation. This test is currently under investigation for use in diagnosis and management of hypertension.

Total Diastolic Overload (rDO), was determined with the aid of the tilt test. TDO, defined as the sum of the diastolic pressures above 89 mmHg, is an expression of excess diastolic pressure over time. Recent studies with chronic ambulatory BP patients have shown that the TDO may be a significant parameter for management of hypertensive patients. Several other parameters were compared with the TDO in order to fred a simpler index that could replace the more time- consuming tilt test.

One hundred consecutive examinations of patients with diastolic hypertension (by office measurement) were reviewed. Statistically significant correlations were found between TDO and the pretest average BP (PTA) as well as the orthostatic diastolic overload (ODO) at 3, 5, 15 and 30 minutes (p<0.001). In a multiple regression analysis, ODO at 15 minutes was the strongest predictor of TDO (r= 0.76). The addition of the PTA brought the r to 0.85 where TDO = -159.5 +PTA x (1.97)+ODO x (4.82).

In addition to the TDO, several other parameters elicited by the tilt test may be of value in guiding hypertensive treatment. These include the diastolic pressure deficit, early orthostatic hypertension and late orthostatic hypertension-bradycardia. Further studies are needed to establish the role the tilt test can play in the diagnosis and management of hypertension.

VASOTONIC MYOCARDIAL INFARCTION: Tali T. Bashour, MD; University of California at San Francisco, San Francisco, California, USA; Seton Hospital, Daly City, California, USA.

Myocardial isehemia due to enhanced coronary arterial vascular t one is now well recognized and is probably a common phenomenon. Acute myocardial infarction (AMI) due solely to vasoconstriction is less common. In the past 5 years, 6 cases of vasotonie AMI were studied at our center. Five patients were females and one was a male. Non-Q-MI occurred in 4 and Q waves developed in 2. Mean age was 50 years. Hypertension was present in 2 and 2 were smokers. None had either hypercholesterolemia or diabetes. AMI was preceded by excessively stressful emotional situations in 5 patients. In 5 patients chest pain was not related to effort and was induced by exercise testing in only 1 patient. Coronary angiograms were normal in 4 and showed segmental spasm in 1 and generalized spasm in the left anterior descending artery in 1. Left ventricular function was normal in 3 patients, 2 had mild segmental dysfunction, and one developed ventricular aneurysm. Post-infarction angina occurred in 3 patients and was controllable by nitrates and calcium antagonist in all.

It is concluded that vasotonie AMI is probably more common than generally appreciated. It tends to occur in females suffering from severe emotional stress and may lead to significant impairment of left ventricular function. Nitrates and calcium antagonists are effective in symptom control, and probably in prevention of AMI. Our previous experience with vasotonic myocardial ischemia and that reported in the literature will be emphasized.

180 IJA Summer 1992

CELLULAR MECHANISMS OF MYOCARDIAL HIBERNATION: C. Furian, MD; R. Gasser, MD, Phi), FICA, Co-Chairman, Scientific Program Committee, 34th Annual Congress; Officer and Vice President, Scientific Council, International College of Angiology; W. Klein, MD, FICA; Experimental Cardiology, Division of Cardiology, University of Graz, Graz, Austria.

Myocardial hibernation has recently become an o•quoted term in the literature, but both definition and underlying mechanisms have remained a matter of dispute.

Here we present an update on current views on myocardial hibernation: laboratory and clinical investigations on reperfusion have recognized a so far unknown phenomenon concerning regional myocardial contractile function. It has been shown that after prolonged ischemia or low perfusion, recovery of contraction may occur in the affected tissue. This is particularly true in semi-perfused or not very well-perfused regions where myocardial contractility is reduced and recovers very rapidly upon reperfusion. Thus, we look at a physiological cardioprotective mechanism which is intended to reduce 0: consumption in ischemie areas in order to save myocardial tissue.

Gasser and Vaughan-Jones have shown that, during ischemia, the action potential duration is drastically shortened by opening of ATP-dependant K + channels which, in turn, leads to a shortened plateau phase with less Ca2+ influx through voltage gated Ca2+ channels (J. Physiol. 431:713-741, 1990). The decreased Ca2+ influx reduced myocardial contractility which is followed by a decrease in O consumption. Furthermore, intracellular acidosis, a rise in unbound intraeellular Mg :§ led to a further decrease in contractile function by reducing the sensitivity of contractile proteins towards Ca-ions.

The understanding of myocardial hibernation and its antithesis myocardial stunning is essential for any therapeutic effort aimed at saving viable myocardium.

ORGAN CULTURE OF HUMAN CORONARY ARTERY FOLLOWING BALLOON ANGIOPLASTY: A.G. Violaris, MRCP; S.E. Francis, Phi); C.M. Holt, PhD; C. Clelland, MB; P.A. Gadsdon, FIMLS; G.D. Angelini, FRCS; Department of Cardiac Surgery, Northern General Hospital, Sheffield, England.

Intimal smooth muscle cell proliferation is the primary cause of restenosis following balloon angioplasty. Its progression is difficult to monitor in humans and studies had to rely on limited amounts of postmortem material. To overcome this, we attempted to develop an organ culture model of human coronary artery previously subjected to angioplasty.

Segments of coronary artery (obtained from the cardiac transplantation program) were dissected free from the heart and divided into two segments. The control segment was carefully opened out and cultured intimal surface uppermost. The other segment was subjected to balloon angioplasty using a 3 mm balloon inflated to I0 atmospheres for 2 minutes prior to being opened out and cultured. Segments were maintained at 37~ in RPMI 1640 medium containing 30% foetal bovine serum for 14 days and supplemented with [3H] thymidine for the last 24 hours.

Tissue viability assessed by ATP concentration (nmollgm wet weight) remained high during culture of control artery (265 + 14[SEM], day 0 and 205 + 15, day 13, n=9). Artery subjected to angioplasty had a reduced ATP concentration at day 0 (II1 + 12, n=6, p<0.05 versus control) which shows that angioplasty causes severe medial injury. This, however, was reversed following 14 days in culture (265 + 14, n=6).

Neointimal thickening was observed in histological sections of cultured control and angioplasty vessels. Autoradiography showed the presence of proliferating cells in the neointimal layers with few dividing cells in the media. Immunostaining revealed that these new intimal cells were positive for R-actin, suggesting a differentiation towards smooth muscle cells.

Thus an organ culture of human coronary artery subjected to angioplasty has been established where intimal proliferation occurs reproducibly. This model can now be used to study the progression of restenosis in human tissue.

Abstracts 181

DISTRIBUTION OF VENTRICULAR LATE POTENTIAL IN PATIENTS WITH PREVIOUS MYOCARDIAL INFARCTION ACCORDING TO THE LOCATION OF MYOCARDIAL NECROSIS: J. Masszi, MDI G. Veress, MD, FICA; D. Nagy, MD; State Hospital for Cardiology, Balatonfured, Hungary.

We evaluated the distribution of ventricular late potential with a noninvasive method of signal- averaged electrocardiogram according to the location of myocardial necrosis in patients with previous myocardial infarction. Two hundred forty-three consecutive patients were enrolled in the study, each had transmural infarction. We excluded patients with left or right bundle branch block, and those who had double location infarction. Ninety-five patients had previously suffered an anterior myocardial infarction, and 148 patients had experience an inferior infarction. The mean age was 51 and 53 years respectively.

Among the characteristic parameters of the terminal part of the QRS, the duration of the filtered QRS was 109 + 9 ms in patients with anterior infarction and 114 4- 14 ms in inferior infarction; the duration of high frequency low amplitude signals was 24 + 9 ms and 32 4- 15 ms respectively, the RMS voltage in the terminal 40 ms of QRS was 54 4- 24 ~uV and 37 4- 23 ~V respectively.

Between the two groups we found significant difference at the level of p<0.001 in all parameters. The values characterizing the terminal portion of the QRS moved toward the abnormal range at inferior infarction.

Concerning the accepted criteria, the prevalence of ventricular late potential was 5.2% in anterior infarction and 23.6 % in inferior infarction.

Our observation is that ventricular late potential which represents the slow conduction and predictive for re-entry malignant ventricular arrhythmias more frequently occurs in patients with inferior myocardial infarction.

DEMONSTRATION OF VARIOUS ARRHYTHMIAS WITH HOLTER MONITORING IN PATIENTS WITH INTRAVENTRICULAR CONDUCTION DISORDERS (IVCD): D. Navy, MD; G. Veress, MD, FICA; J. Masszi, MD; State Hospital for Cardiology, Balatonfured, Hungary.

We studied the occurrence of various arrhythmias in 134 patients with IVCD (LBBB: 58, LAH + RBBB: 25, RBBB: 15, LAH 33, LPH 3 patients) with repeated 24-hour Holter monitoring. The mean age was 62 (50-80) years; 85 (64.1%) males and 48 (35.8%) females. Holter monitoring disclosed paroxysmal atrial fibrillation in 16 (11.9%), PSVT in 16 (II.9%), bradyarrhythrnias in 22 (16./4%). Of these, 25 (18.6%) had syncope or presyncope. Low I-II grade premature ventricular beats occurred in 40 (29.8 %).

Occurrence of major ventricular arrhythmias were demonstrated in 12 (8.9%) with deteriorated left ventricular function, primarily in patients with LBBB. Due to SSS and/or conduction disorders 12 (8.9 %) received definitive PM therapy.

Repeated 24-hour Holter monitoring is very helpful in the recognition and demonstration of various cardiac arrhythmias in patients with IVCD.

OXIDIZED LDL AND NEOPTERIN IN RESTENOSIS AFTER PTCA: Bernd Eber, MD, FICA; Martin Schumacher, MD~ Franz Tatzber, PhD; Peter Kaufmarm, MD; Olef Luha, MD; Werner Klein, MD, FICA; Medizinische Universitatsklinik Graz, Graz, Austria.

Both oxidized LDL (oLDL) and neopterin, a specific marker for activated macrophages, appear to play an important role in the progression of atherosclerosis. In this study, therefore, LDL/oLDL-IgG-immune complexes (sandwich ELISA-system; IC) and serum neopterin levels were determined in a series of 61 randomly selected males (mean age 55, range 38-70) with (group A) and with (group B) restenosis following successful PTCA. Follow-up angiography as well as blood sampling were done 12 months after PTCA; restenosis was defined as a loss of > 2 5 % of initial result. Thirty-one patients had restenosis and 30 were without. Both groups did not differ significantly in age, past medical history and routine lipid profile as well as fibrinogen values. LDL/oLDL-IgG-IC and neopterin levels are listed in table (n.s.).