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Thrombolytic treatment with recombinant tissue plasminogen activator (rt-PA) at a dosage of 40-150 mg was given to five patients with acute and five with recurrent pulmonary emboli (three women and seven men; mean age 54 [30-78] years). Mean pulmonary artery pressure fell from 29 +/- 7 mm Hg before to 20 +/- 5 mm Hg after treatment (P = 0.001), and in recurrent emboli from 47 +/- 19 to 18 +/- 10 mm Hg (P = 0.01). Pulmonary vascular resistance fell from 546 +/- 262 to 318 +/- 116 dyn.s.cm-5 (P = 0.02) in the former group and from 993 +/- 583 to 377 +/- 438 dyn.s.cm-5 (P = 0.01) in the latter. Pulmonary arteriograms were assessed using the Miller index. This indicated a drop from an average of 23 points before to an average of 10.5 points after treatment. Mild bleedings occurred in all patients, but in two it was severe enough to require discontinuation of treatment. These results demonstrate that rt-PA is highly effective as a thrombolytic agent in acute and in subacute recurrent pulmonary embolism.

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The usual method of investigating dermatographism (D), which is typically white in atopic eczema (AE), allows only a qualitative rating. To allow reproducible quantification of D we have developed an easily usable device termed Dermography. This can be fitted with one to three blunt tapered metal bars of different weight applying a constant stretching pressure over the whole skin area to be examined with different pressures at isolated lines. We used this device to study D in 27 patients with AE and in 20 healthy controls. Of the 27 patients, 21 had white D, 2 had red D, and 4 none at each pressure applied. In 18 of the 20 controls D was red. Both groups differed significantly with regard to the time until the onset of D and its duration, the former being prolonged and the latter shortened in patients with AE. Simultaneous and constant application of distinct grades of pressure for quantitative dermographometry is a method than can reliably be used for the study of inter- and intraindividual variations in vascular reactivity.

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The diagnosis of a left circumflex coronary artery--coronary sinus fistula draining into the right atrium was confirmed by echocardiographic analysis. Two-dimensional echocardiography revealed a dilatation of the left main coronary artery, the left circumflex artery, the coronary sinus and a fistulous communication. Pulsed Doppler echocardiographic study showed a turbulent, continuous flow within the dilated coronary artery, in the coronary sinus and at the site of its drainage into the right atrium. There was a diastolic flow-reversal in the descending aorta in absence of aortic insufficiency. Color Doppler echocardiography enhanced the finding of the correct diagnosis by simultaneously displaying blood flow within various parts of the heart and the coronary vessels. This technique aided in establishing the exact location of the fistula by demonstrating a turbulent blood flow, even in narrow cardiac structures. The echocardiographic diagnosis was confirmed by coronary angiography.

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Five patients (four males and one female, aged 29 to 75 years) with subaortic stenoses were examined by transthoracal and transoesophageal echocardiography, including two-dimensional Doppler echocardiography. In only one patient could the obstruction of the left ventricular outflow tract be definitively evaluated by transthoracal echocardiography, whereas by transoesophageal echocardiography the presence of a subaortic membrane could be demonstrated in all patients. The latter method thus proved to be reliable in evaluating the extent of obstruction.

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The usual method of checking dermatographism (D), which is typically white in atopic eczema (AE), allows only a qualitative rating. To allow reproducible quantification of D we have developed an easily used instrument, called a Dermographometer. This can be fitted with one to three blunt tapered metal bars of different weights applying a constant stretching pressure over the whole skin areas to be examined or different pressures at isolated points. We used this device to study D in 27 patients with AE and in 20 healthy controls. Of the 27 patients, 21 had white D, 2, red D, and 4, none at each pressure applied. In 18 of the controls D was red. In addition, the two groups differed significantly in the time to onset and the duration of the D elicited, which was much longer in patients with AE. Simultaneous and constant application of distinct grades of pressure for quantitative dermatographometry is a method that can reliably be used for the study of inter- and intraindividual variation in vascular reactivity in the course of various dermatoses, especially.

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An increased cytoplasmatic calcium level seems to play an important role in the pathogenesis of Adriamycin (ADM)-induced cardiomyopathy. Experiments have shown that calcium channel blockers such as verapamil may prevent this type of cardiomyopathy in animals, but data are contradictory. In a clinical pilot trial, the left ventricular function of 22 patients undergoing ADM-chemotherapy in combination with verapamil was examined. M-mode echocardiograms were performed parallel to every chemotherapy course. Left ventricular function was determined by fractional shortening rate (FS) and peak fibre shortening velocity (V ef max.). Three 40-mg doses of verapamil were given p.o./day continuously. Data of these patients were compared with a control group of 61 patients treated and checked equally without additional verapamil therapy. In the course of therapy parameters of left ventricular function remained almost constant in the verapamil group but decreased significantly in the control group. In the verapamil group FS changed by -0.05 FS %/100 mg ADM/m2, V ef max. by +0.015 circ./s/100 mg ADM/m2 compared with -2.31 FS % and -0.33 circ./s in the control group (P 0.01 and 0.001, respectively). In the verapamil group no congestive heart failure occurred and no patient showed FS below 30%, whereas in the control group in 23% (14) of the cases ADM therapy had to be stopped because FS fell below 30%. One congestive heart failure was observed. These clinical results suggest that verapamil may be a useful drug for preventing ADM-induced cardiomyopathy but further investigations are necessary.

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Two adult patients with left ventricular inflow obstruction are presented. Conventional two-dimensional echocardiography had failed to yield a definite diagnosis, whereas transesophageal two-dimensional echocardiography clearly documented a membraneous echo structure within the left atrium, diagnostic of cor triatriatum. On the basis of the transesophageal echocardiographic findings, left heart catheterization and angiocardiography were not performed and both patients successfully underwent cardiac surgery.

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Transoesophageal cross-sectional echocardiography has special advantages when investigating the interatrial septum which is imaged perpendicularly without echo dropouts from an oesophageal transducer position. The technique was successfully used in 19 out of 20 patients (95%) with an ostium secundum atrial septal defect and in 30 control subjects. In all of the latter the interatrial septum was visualised as a continuous echo structure separating the atria, whereas a distinct discontinuity representing the septal defect was apparent in all patients with atrial septal defect. Echocardiographic measurement of the defect size correlated well with surgical findings in 11 patients who underwent open heart surgery in the course of this study. In a comparative transthoracic examination, adequate recordings were obtained in 18 of the 20 patients and in 26 of the 30 control subjects. Direct subcostal visualisation of the defect was reliable in 10 of 18 patients. Peripheral venous contrast studies were also performed with the transoesophageal as well as the transthoracic technique. Echo contrast remained confined to the right heart in the control subjects. Left sided contrast appearance diagnostic of an interatrial communication was shown in the patients using the transoesophageal technique (100% sensitivity), with an additional right atrial negative contrast apparent in seven patients. The transthoracic approach, on the other hand, showed left sided echo contrast in 14 of 18 patients and an additional negative contrast effect in two of the 14. It is concluded that transoesophageal is superior to transthoracic cross-sectional echocardiography as a highly sensitive method for the detection and evaluation of ostium secundum atrial septal defects.

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Open-heart surgery was performed in 26 of 56 patients with acute bacterial endocarditis seen in three years. Non-controllable infection, cardiac failure or embolism were the indications for operation. In all instances pre-operative invasive angiographic diagnosis was dispensed with, indications being based entirely upon clinical findings plus the results of M-mode or cross-sectional echocardiography. In 22 of the 26 patients the pre-operative echocardiographic diagnosis coincided with the intra-operative one. In the other four patients the pre-operative echocardiographic findings were incomplete, but no surgically important information had been missed.

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During a period of 4 years, 32 patients with acute bacterial endocarditis were admitted for cardiac surgical intervention. Uncontrollable infections, heart failure or embolism presented indications for the operation. In all cases, a preoperative, invasive angiography diagnostic was abandoned. The indication for surgical intervention was based on clinical criteria as well as the findings of one-dimensional or two-dimensional echocardiography. In 26 out of 32 patients who underwent surgical intervention, the preoperative echocardiography findings were in agreement with the intraoperative findings. In the remaining 6 patients, the preoperative echocardiographic findings were incomplete; in 2 cases particularly, it is important to note that an aneurysm of the ascending aorta had been missed. In view of these findings and results, we think that in acute bacterial endocarditis, the combined use of one- and two-dimensional echocardiography together with clinical findings can replace preoperative hemodynamic diagnostics.

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This case report describes the echocardiographic documentation of a 60 year old patient with tricuspid regurgitation due to carcinoid heart disease. The carcinoid syndrome was histologically proven by liver metastases and by an increased 5-hydroxytryptamin secretion. Tricuspid involvement was echocardiographically documented by immobile, thickened leaflets. Diffuse endocardial thickening of the right chamber and pulmonary valve involvement was absent.

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The value of transesophageal pulsed Doppler echocardiography (PDE) was studied in six patients with competent mitral valve and in 12 patients with angiographically proved mild to moderately severe mitral regurgitation. The results were compared with those from the standard transthoracic method of investigation. The advantages of the esophageal over the transthoracic approach in the detection of mitral regurgitation are (1) absence of anatomic obstacles between the ultrasound transducer and the heart; (2) nearly parallel alignment of the ultrasound beam with the blood flow direction; (3) the use of high pulse repetition frequencies; and (4) detection of localized regurgitant jets by left atrial scanning. This results in a superior recording quality and greater sensitivity. Based on a specific systolic flow pattern in the time-interval histogram, mitral regurgitation was detected in all patients by the transesophageal technique (100% sensitivity), but in only 58% by the precordial approach. Thus, transesophageal pulsed Doppler echocardiography can accurately detect the presence of mitral regurgitation, particularly in cases of mild or moderate severity.

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In order to evaluate left ventricular function during dynamic exercise transoesophageal M-mode recordings of the left ventricle were carried out with a newly developed transducer gastroscope system. Twelve healthy subjects performed a graded supine bicycle exercise test. Stable and good quality images of the left ventricle at rest and during exercise at different steps up to a maximum workload of 100 watts were obtained in all patients. Isotonic maximum exercise resulted in a significant increase in fractional shortening of the left ventricle, peak shortening rate, and peak lengthening rate of the left ventricular minor axis. Left ventricular end-diastolic dimension decreased significantly. With increasing workload the pressure rate product increased significantly. It is concluded that transoesophageal M-mode echocardiography is a useful method of evaluating left ventricular performance during dynamic exercise.

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Cardiac imaging by transthoracic two dimensional echocardiography is impaired in patients with chronic lung disease, those with obesity, and those with abnormal chest wall configuration. In order to overcome these limitations, a miniature phased array ultrasound transducer fitted to the tip of a commercially available gastroscope was developed. Transducer position and orientation can be adjusted completely by external control of vertical displacement inside the oesophagus, rotation, and angulation. Introduction and operation of the transducer gastroscope system are usually well tolerated by the patients, since no mechanical vibrations are generated and there is no need for an oil bag to secure oesophageal wall contact. Cardiac images of high quality are obtained even from structures and regions that are poorly or not at all imaged from external transducer positions.

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