Antitumor activity of human umbilical cord blood cells: A comparative analysis with peripheral blood and bone marrow cells

OBJECTIVES: To determine the predictive value of quantitative evaluation of myocardial viability on changes in left ventricular function, exercise capacity, and quality of life after coronary artery bypass grafting in patients with ischemic heart failure (congestive heart failure, New York Heart Association class > or = III) with and without angina. METHODS: Thirty-five patients, 14 with congestive heart failure and angina (CHF-angina) and 21 with congestive heart failure without angina (CHF-no angina) were studied at baseline and 6 months after coronary bypass grafting. Left ventricular function was evaluated with transthoracic echocardiography and radionuclide ventriculography. Myocardial viability was assessed with [18F]-2-fluoro-2-deoxy-D-glucose using positron emission tomography. Peak aerobic capacity (peak oxygen consumption) and anaerobic threshold were assessed with treadmill exercise test and quality of life with a questionnaire. RESULTS: A total of 286 of 336 dysfunctional left ventricular segments were viable. There were two perioperative deaths (5.7%) and three late deaths. Left ventricular ejection fraction increased from 23% +/- 7% to 32% +/- 9% (p < 0.0001), and a linear correlation was found between the number of viable segments and the changes in ejection fraction (r = 0.65; p = 0.0001). Receiver operating characteristics curve identified eight viable segments as the best predictor for increase of ejection fraction more than 5 percentage points. Peak oxygen consumption increased from 15 +/- 4 to 22 +/- 5 ml/kg per minute (p < 0.0001). Preoperatively, anaerobic threshold was identified in one patient from the CHF-angina group and in all from the CHF-no angina group and increased from 13 +/- 4 to 19 +/- 4 ml/kg per minute (p < 0.0001). Quality of life scores improved significantly in both groups. No correlation was found between the amount of viable dysfunctional myocardium and changes in exercise capacity or quality of life. CONCLUSIONS: In patients with postischemic congestive heart failure the amount of viable myocardium dictates the degree of improvement in left ventricular function after revascularization.     

Acute coronary surgery

While the indications for surgical treatment of chronic angina pectoris are exactly defined, the delineation between conservative and surgical therapy of acute complications of coronary diseases is not standardized. The application of possible surgical procedures to acute coronary surgery (aorto-coronary bypass, infarctectomy, correction of post-infarction ventricular septal defects and mitral insufficiency) are discussed in relation to the following clinical pictures: 1. Unstable angina 2. Surgery after myocardial infarction a) recent infarction b) cardiogenic shock after infarction c) impending reinfarction d) post-infarction tachyarrhythmia unresponsive to conservative and electrical therapy e) acute heart failure caused by post-infarction defect of the ventricular septum or by mitral insufficiency. The following therapeutic guide-lines can be laid down on the basis of an analysis of experience gained in this field by other workers and ourselves: surgical therapy is indicated in the cases of unstable angina, impending reinfarction, or acute heart failure caused by a post-infarction ventricular septal defect or by mitral insufficiency which do not respond rapidly to conservatives measures. By contrast, the superiority of surgical intervention, even with the assistance of intraaortic balloon pumping, has not yet been established for the treatment of the remainder of the above-mentioned clinical pictures and requires evaluation by further investigations.     

Coronary artery bypass grafting in cases with poor left ventricular function

From January 1987 through June 1992, 18 patients with poor left ventricular function (left ventricular ejection fraction [LVEF] less than 0.3) underwent elective isolated primary coronary artery bypass surgery. The mean age was 56.4 years (range, 46 to 72 years), and 15 were males and 3 were females. Mean pre-operative LVEF measured by ventriculography was 0.26 +/- 0.03 (range, 0.19 to 0.30). Sixteen patients (88.9%) had a prior myocardial infarction and 9 (50%) had a history of congestive heart failure. Complete revascularization was the goal for all patients, and the mean number of bypass grafts was 3.0 +/- 0.8 per patient. The left anterior descending coronary artery (LAD) was revascularized in all patients. There were no operative deaths. Post-operative LVEF improved significantly from 0.26 +/- 0.03 to 0.42 +/- 0.11 (p = 0.0002), and the regional left ventricular wall motion improved in the diaphragmatic and posterobasal regions (p < 0.01). The patency of the grafts was 93.9% in all, and 100% for LAD. The mean follow-up period was 77 months, and the overall actuarial survival rate was 88.9% at 10 years. During follow-up periods, two patients died of congestive heart failure (CHF), and two required three rehospitalizations because of CHF. The overall cardiac event free rate was 75.8% at 10 years. In patients with poor left ventricular function, surgical revascularization can be performed safely, but congestive heart failure sometimes occurs during follow-up periods and may be the cause of death. Therefore alternate forms of therapy such as cardiac transplantation and/or TMLR should be considered in selected patients.     

Lethal arrhythmias in a patient with coarctation of the aorta and severe heart failure: their control by combination of low dose amiodarone with procainamide for 3 years

In 1970, a 19 year-old man was diagnosed as having coarctation of the aorta (CoA). But the patient and his family rejected further examination for CoA and high blood pressure was treated after that time. When the patient was 37 years old, he was admitted to our hospital because of congestive heart failure. During the 2nd admission for determining the operability of CoA in December, 1988, non-sustained ventricular tachycardia was detected. Immediately, intravenous administration of lidocaine or/and mexiletine were started. However, cardiac arrest occurred. After his recovery, lethal ventricular arrhythmias were still observed frequently despite administration of class Ia or Ib antiarrhythmic drugs. Oral amiodarone administration (600 mg) with procainamide (1000 mg) was started on 1st of May, 1989. Axillo-femoral bypass graft was performed during the 2nd admission because curable operation was abandoned because of severely impaired cardiac function. Subsequently, the patient was admitted 5 times due to exacerbated congestive heart failure. However, lethal arrhythmias were able to be controlled by the combination of low dose amiodarone (100-200 mg) with procainamide until he died of congestive heart failure on 9th of May, 1992. We reported a rare adult case with CoA and severe heart failure. Lethal arrhythmias in this case were well controlled by the combined administration of low dose amiodarone with procainamide regardless of severely impaired cardiac function.     

Preventing congestive heart failure

The morbidity, mortality and health care costs associated with congestive heart failure make prevention a more attractive public health strategy than treatment. Aggressive management of etiologic factors, including hypertension, coronary artery disease, valvular disease and excessive alcohol intake, can prevent the left ventricular remodeling and dysfunction that lead to heart failure. Early intervention with angiotensin converting enzyme inhibitors in patients with chronic left ventricular dysfunction can prevent, as well as treat, the syndrome. Several intervention strategies in patients with acute myocardial infarction can slow or prevent the left ventricular remodeling process that antedates congestive heart failure. The primary care physician must be alert to the need for aggressive intervention to reduce the burden of heart failure syndrome on the patient and on society.     

Congestive heart failure and ischaemic heart disease treated with trandolapril and verapamil. DAVIT Study Group. Danish Verapamil Infarction Trial

CLINICAL TRIALS WITH VERAPAMIL AND TRANDOLAPRIL: In the Danish Verapamil Infarction Trial II, verapamil improved survival in patients without heart failure but had no effect in patients with heart failure who were receiving diuretic treatment. In the Acute Infarction Ramipril Efficacy study ramipril improved survival in patients receiving diuretic treatment but had no effect in patients not receiving diuretics. COMBINATION WITH THERAPY WITH VERAPAMIL AND TRANDOLAPRIL: By combining verapamil with trandolapril we hypothesized that we could obtain an improvement in left ventricular function and prevent cardiac events. In an open study of 14 patients with angina pectoris and left ventricular ejection fraction below 40%, treatment with trandolapril-verapamil significantly improved left ventricular function. In a double-blind randomized study of 100 postinfarct patients with congestive heart failure the cardiac event rate was significantly lower in verapamil-trandolapril-treated than in the trandolapril-treated patients. These results indicate that the combined treatment with verapamil and trandolapril might be beneficial in patients with ischaemic heart disease and congestive heart failure.     

Evaluation of a new bipyridine inotropic agent--milrinone--in patients with severe congestive heart failure

Milrinone, a derivative of amrinone, has nearly 20 times the inotropic potency of the parent compound and does not cause fever or thrombocytopenia in normal volunteers or in animals sensitive to amrinone. In 20 patients with severe congestive heart failure, intravenous milrinone resulted in significant decreases in left ventricular end-diastolic pressure (from 27 +/- 2 to 18 +/- 2 mm Hg), pulmonary wedge pressure, right atrial pressure, and systemic vascular resistance, as well as a slight reduction in mean arterial pressure. Significant increases occurred in cardiac index (from 1.9 +/- 0.1 to 2.9 +/- 0.2 liters per minute per square meter) and the peak positive first derivative of left ventricular pressure, with a slight increase in heart rate. Hemodynamic improvement was sustained during a 24-hour continuous infusion. Nineteen of the 20 patients subsequently received oral milrinone (29 +/- 2 mg per day) for up to 11 months (mean, 6.0 +/- 0.8), with sustained improvement in symptoms of heart failure. In 10 patients receiving long-term oral milrinone (greater than or equal to 6 months) radionuclide ventriculography showed continued responsiveness, with a 27 per cent increase in left ventricular ejection fraction after 7.5 mg of the drug. Four patients died after a mean of 4.8 months of therapy, and three patients with severe underlying coronary-artery disease and angina pectoris required additional antianginal therapy. No patient had fever, thrombocytopenia, gastrointestinal intolerance, or aggravation of ventricular ectopy. We conclude that milrinone shows promise for the longterm treatment of congestive heart failure.     

Limited clinical diagnostic specificity of technetium-99m stannous pyrophosphate myocardial imaging in acute myocardial infarction

To test the sensitivity and specificity of technetium-99m stannous pyrophosphate myocardial imaging in the diagnosis of acute myocardial infarction, myocardial scintigrams were performed in 115 patients. Positive scintigrams were found in all 48 patients with acute myocardial infarction; uptake was localized in 29 patients with transmural infarction and diffuse in 2 patients with transmural infarction and in the remaining 17 patients with subendocardial myocardial infarction. Positive scintigrams were also found in 31 of 67 patients without clinical evidence of acute myocardial infarction. Diffusely positive scintigrams were found in 3 of 3 patients with unstable angina pectoris, 7 of 30 patients with stable angina pectoris, 4 of 13 patients who had undergone aortocoronary bypass surgery, 4 of 4 patients with congestive cardiomyopathy and 1 patient studied 1 day after direct current cardioversion. Localized uptake of 99mTc-pyrophosphate was found in 9 of 10 patients with left ventricular aneurysm and in 3 of 13 patients after aortocoronary bypass surgery. All four patients with atypical chest pain and two patients with pericarditis had normal scintigrams. Our data confirm the previously reported sensitivity of 99mTc-pyrophosphate imaging in detection of acute myocardial infarction but indicate that positive scintigrams are not specific for this entity.     

Eosinophil chemotactic activity in bronchoalveolar lavage fluid obtained from Toxocara canis-infected rats

Angioplasty of the internal mammary artery (IMA) bypass graft has been shown to be a safe and effective revascularization procedure. However, angiographic and long term clinical outcomes in the high-risk group of patients presenting with rest angina has not been well documented. We report the results of IMA angioplasty in 20 patients with rest angina out of 614 (3.2%) who received a left IMA graft at our institution between April 1987 and September 1994. All patients were admitted with rest angina, 12 patients demonstrated persistent ischemia despite medical therapy, two patients were in heart failure, and one patient was in cardiogenic shock. Balloon angioplasty was successful in 15 of 20 patients (75%). Failed angioplasty was associated with either severe IMA tortuousity (three patients) or inability to cross the anastomotic stenosis with the guide wire (two patients). Each of these five patients required angioplasty of either the native left anterior descending artery or other saphenous vein grafts for clinical stabilization. No patient suffered a major complication (myocardial infarction, emergent coronary bypass surgery, death). Clinical follow-up was obtained in all 20 patients (6 months, 7 years, mean 27 months). Twelve patients (60%) were asymptomatic or had stable angina at follow-up, and 8 returned with anginal symptoms. Four patients required repeat angioplasty for disease in other vessels, two were treated medically for angina, one underwent repeat CABG, and cardiac transplantation was performed in one patient for refractory heart failure. Angiographic follow up was obtained in 10/15 (66%) successful angioplasty patients, and only one patient demonstrated restenosis at the treated site (10%). During follow up one patient developed an IMA stenosis at a previous dissection site in the body of the graft that was treated with angioplasty. These results suggest that IMA angioplasty in patients with rest angina is associated with excellent long term patency and clinical efficacy, as well as low procedural risk.     

Congenital hypoplasia of portions of both right and left ventricular myocardial walls. Clinical and necropsy observations in two patients with parchment heart syndrome

Clinical and morphologic findings are described in two patients with congenital hypoplasia of portions of both right and left ventricular free walls in the absence of associated coronary or valvular heart disease. One, a 61 year old man who had never had clinical evidence of cardiac dysfunction, died suddenly and unexpectedly. The second, a 55 year old woman, died of progressive, eventually intractable congestive heart failure of 29 months' duration. Although at least 22 necropsy patients have previously been reported to have "parchment-like" thinning of portions of the right ventricular free wall, only one patient has previously been described with such thinning of portions of both right and left ventricular free walls. The spectrum of right or right and left ventricular wall congenital hypoplasia is a broad one, with nearly half of described patients dying of congestive heart failure in the 1st year of life and the other half reaching adulthood with or without manifestations of cardiac dysfunction.     

Effect of centrifugation on the pressure resistance of exponential phase cells of Escherichia coli 8164

OBJECTIVE: To assess the efficacy of partial left ventriculectomy as a treatment for patients with end-stage heart failure. METHODS: From February to June 1995, 7 patients with end-stage heart failure underwent partial left ventriculectomy. Subsequently, patients underwent clinical evaluation every 2 months, and 2-dimensional echocardiography at the 6th and 12th months after cardiac surgery. All patients were given digitalis and diuretics at conventional doses, and captopril or enalapril at maximal tolerated doses. RESULTS: Two (28%) patients died; 1 from cardiac arrhythmia associated with gastrointestinal hemorrhage, and the other suddenly. One (14%) patient developed an embolic cerebrovascular accident. Four (57%) patients were hospitalized for congestive heart failure; all of them had either decreased the daily dose of captopril or enalapril or discontinued the drugs by themselves. Twelve months after ventriculectomy, left ventricular ejection fraction values were greater and left ventricular diastolic dimension and functional class values lower than those found before cardiac operation. CONCLUSION: Beneficial effects of partial left ventriculectomy are observed one year after the surgical procedure. This technique, therefore, can be useful for the treatment of patients with end-stage heart failure.     

Regulation by serotonin of tooth-germ morphogenesis and gene expression in mouse mandibular explant cultures

Acute renal failure (ARF) is one of the major complications after cardiopulmonary bypass for open heart operations. The present study was undertaken to identify the risk factors for the development of ARF following cardiopulmonary bypass (CPB). Four hundred and forty-seven consecutive patients who underwent open heart procedures from July 1994 to June 1995 were analyzed retrospectively. Their mean age was 55.6 +/- 14.2 (SD) years (range, 18 to 80). Dialysis was instituted whenever a patient exhibited inadequate urine output (<0.5 mL/kg/hr) for 2 to 3 hours despite correction of hemodynamic status and diuretic therapy, especially if fluid overload, hyperkalemia, or metabolic acidosis were also present. Twenty variables were analyzed by univariate analysis; these included nine preoperative variables--age, sex, hypertension, atherosclerosis, diabetes mellitus, left ventricular end-diastolic dimension (LVEDD) >5 cm, preoperative congestive heart failure, renal insufficiency (serum creatinine > or =130 micromol/L on two occasions), and sepsis--10 intraoperative variables--duration of CPB, redo procedures, emergency surgery, use of intraaortic balloon pump (IABP) in operating room, use of gentamicin, use of ceftriaxone, use of sulbactam/ampicillin, requirement of deep hypothermic circulatory arrest, duration of low mean perfusion pressure (mean pressure <50 mmHg for more than 30 minutes), operation on multiple valves--and one postoperative variable--significant hypotension (systolic blood pressure less than 90 mmHg for more than 1 hour). Significant variables or the variables having a trend (p<0.1) to be associated with ARF were included in stepwise multiple logistic regression analyses. Three regression analyses were performed separately. The incidence of ARF requiring dialysis in the study period was 15.0%. Significant risk factors for whole group of patients (regression I) were preoperative renal insufficiency (p<0.0001), postoperative hypotension (p<0.0001), cardiopulmonary bypass time more than 140 min (p<0.005), preoperative congestive heart failure (p<0.01), and history of diabetes mellitus (p<0.01). The risk factors in the valve group of patients (regression II) were preoperative renal insufficiency (p<0.0001) and postoperative hypotension (p<0.05). Risk factors in the CABG patients (regression III) were postoperative hypotension (p=0.0001), CPB time more than 140 min (p<0.05), preoperative renal insufficiency (p<0.05), and age (p<0.05). The authors conclude that preoperative renal insufficiency and postoperative hypotension are the most important independent risk factors for ARF in postcardiac surgical patients. In addition, CPB time greater than 140 minutes and old age are also independent risk factors for ARF in CABG patients. CPB time more than 140 minutes, history of diabetes mellitus, and preoperative congestive heart failure are independent risk factors for development of ARF in our total group of patients. These findings may have important clinical implications in the prevention of ARF in postcardiac surgical patients.     

Reexploration for bleeding is a risk factor for adverse outcomes after cardiac operations

OBJECTIVE: Although previous studies have included early reexploration for bleeding as a risk factor in analyzing adverse outcomes after cardiac operations, reexploration for bleeding has not been systematically examined as a multivariate risk factor for increased morbidity and mortality after cardiac surgery. Furthermore, multivariate predictors of the need for reexploration have not been identified. Accordingly, we performed a retrospective analysis of 6100 patients requiring cardiopulmonary bypass from January 1, 1986, to December 31, 1993. METHODS: Eighty-five patients who had ventricular assist devices were excluded from further analysis because of the prevalence of bleeding and the significant morbidity and mortality associated with placement of a ventricular assist device, unrelated to reexploration. In the remaining 6015 patients, potential adverse outcomes analyzed included operative mortality, mediastinitis, stroke, renal failure, adult respiratory distress syndrome, prolonged mechanical ventilation, sepsis, atrial arrhythmias, and ventricular arrhythmias. To control for the confounding effects of other risk factors, we performed a multivariate logistic regression analysis. Potential covariates considered in the logistic model included age, sex, race, history of reoperation, urgency of the operation, congestive heart failure, prior myocardial infarction, renal failure, diabetes, hypertension, chronic obstructive pulmonary disease or stroke, and the bypass and crossclamp time. RESULTS: The overall incidence of reexploration was 4.2% (253/6015). Four independent risk factors--increased patient age (p < 0.001), preoperative renal insufficiency (p = 0.02), operation other than coronary bypass (p < 0.001), and prolonged bypass time (p = 0.0.3)--were identified as predictors of the need for reexploration. The preoperative use of aspirin, heparin, or thrombolytic agents and the bleeding time were not identified as predictors. Reexploration for bleeding was identified as a strong independent risk factor for operative mortality (p = 0.005), renal failure (p < 0.0001), prolonged mechanical ventilation (p < 0.0001), adult respiratory distress syndrome (p = 0.03), sepsis (p < 0.0001), and atrial arrhythmias (p = 0.006). CONCLUSION: These data indicate that meticulous attention to surgical hemostasis and possibly application of recently developed modalities designed to facilitate perioperative correction of coagulopathy could improve outcomes after cardiac operations.     

The cost-benefit balance of coronary artery bypass grafting: need for hospitalization during the two years before and the two years after

To derive and compare the need for hospitalization during 2 years prior to coronary artery bypass grafting (CABG) and 2 years after, all the patients from western Sweden in whom CABG without simultaneous valve surgery was performed between June 1988 and June 1991 were evaluated. Hospitalization prior to and after surgery was derived via questionnaires sent to the patients and via data from their hospital medical record forms. In all, 2099 patients were studied. The mean total number of days in hospital was 16 during the 2 years before and 24 including surgery and postoperative complications during the 2 years after the operation (p < 0.001). When the days for operation and postoperative complications were excluded, the mean number of days after operation was 7 (p < 0.001). Hospitalization due to myocardial infarction, angina pectoris, percutaneous transluminal coronary angioplasty and other investigations for heart disease were significantly reduced after CABG. On the other hand, hospitalization due to chest pain with causes other than ischemic heart disease, congestive heart failure, arrhythmias, and reoperation was more frequent during the 2 years after surgery. The total number of days in hospital was higher during the 2 years after CABG than during the 2 years before, despite the fact that hospitalization due to ischemic events was significantly reduced after the operation.     

Cardiac failure secondary to hypoparathyroidism. An unusual presentation

The case of a 37 year old woman with hypoparathyroid congestive heart failure (CHF) is reported. Thyroidectomy had been performed eight years earlier and she had experienced symptoms of hypocalcemia postoperatively. CHF improved rapidly and completely with the treatment of hypocalcemia. Good prognosis is emphasized but it is necessary to think about this cause of ventricular dysfunction in a patient with CHF and a history of neck surgery in order to make an early diagnosis. Pathogenic mechanisms and differential diagnosis are discussed.     

Treatment of subacute cardiac rupture after myocardial infarction

Five successfully treated cases of subacute cardiac rupture after myocardial infarction are described. There were 4 men and 1 woman, ranging in age from 51 to 71 years. Two patients had systemic hypertension. Rupture occurred during the first myocardial infarction in all patients. The interval from the onset of myocardial infarction to cardiac rupture ranged from 1 to 6 days (mean 4 days). In one patient, the rupture was repaired under cardiopulmonary bypass using an autologous pericardial patch over the infarcted myocardium. Two patients underwent sutureless repair with fibrin glue; one of them developed a left ventricular pseudoaneurysm 2 years after the operation, requiring resection. These three patients were operated on through a median sternotomy. The remaining two patients were treated for cardiac tamponade by pericardial drainage through a subxiphoid incision; one died 38 days after the operation due to congestive heart failure. The four surviving patients are currently well 22, 39, 41 and 60 months after surgery. In summary, a conservative approach may be effective for treatment of subacute cardiac rupture.     

In situ detection of DNA fragmentation and expression of bcl-2 in human neuroblastoma: relation to apoptosis and spontaneous regression

In patients with alcoholic cardiomyopathy there is evidence that mild heart failure is reversible if patients abstain from alcohol, but there is no consensus whether the disease is progressive once structural myocardial dilation has evolved. The aim of the present study was to compare the long-term course of congestive heart failure due to alcoholic and idiopathic dilated cardiomyopathy. Of 75 patients with overt congestive heart failure, 23 had alcoholic cardiomyopathy and were compared to 52 patients with idiopathic cardiomyopathy. The mean age was 48 +/- 12 years. Despite medical therapy, heart failure class New York Heart Association III-IV was present in 52% of patients with alcoholic and 47% of patients with idiopathic cardiomyopathy (not significant). Their mean left ventricular ejection fraction was 30 +/- 12% vs 28 +/- 12% and left ventricular end-diastolic volumes were 264 +/- 125 ml and 254 +/- 100 ml respectively (not significant). Overall survival at 1, 5 and 10 years was 100%, 81% and 81% for the group with alcoholic dilated cardiomyopathy and 89%, 48% and 30% for the group with idiopathic cardiomyopathy, respectively (P = 0.041), and the difference was even greater for transplant-free survival P = 0.005). Clinical and invasive signs of left and right heart failure as well as left ventricular dimensions were predictive of a fatal outcome; however, symptom duration and left ventricular volumes were only predictive in patients with idiopathic cardiomyopathy, suggesting that in the two patient groups different mechanisms may lead to death. Mortality in patients with severe congestive heart failure and left ventricular dilatation due to alcoholic cardiomyopathy is significantly lower than that in patients with idiopathic cardiomyopathy and similar degrees of heart failure. Thus, despite structural changes inherent in marked left ventricular dilatation, disease progression in alcoholic dilated cardiomyopathy is different from that in idiopathic cardiomyopathy and thus may have implications for the choice of therapy.     

New aspects of the treatment of left ventricular failure: Nitroglycerin (author's transl)

The effectiveness of Nitroglycerin and its derivates in angina pectoris is well-known. One of the main effects is the reduction of left ventricular filling pressure. Therefore in patients with left ventricular failure after acute myocardial infarction or with chronic coronary heart disease the indication for Nitroglycerin has to be proved. In 51 patients with 76 measurements Nitroglycerin sublingual, intravenous Nitroglycerin, Isosorbide-Dinitrate and Myocardon were investigated. All substances decreased pulmonary artery pressure especially left ventricular filling pressure. Cardiac output increased or decreased in dependence to the height of left ventricular enddiastolic pressure. In the patients with myocardial infarction and left ventricular failure with filling pressures over 20 mm Hg a significant increase in cardiac output was observed. On the contrary in patients without left ventricular failure cardiac output decreased slightly. Nitroglycerin sublingual is especially useful in the most severe form of left ventricular failure: in pulmonary oedema. 0.8 mg of Nitroglycerin 3 to 4 times in 5 to 10 minutes distance is necessary dependent on the severity of the pulmonary oedema and the height of the blood pressure. The permanent intravenous infusion of Nitroglycerin (3 to 6 mg per hour) is very efficient in the treatment of congestive failure in acute myocardial infarction. The left ventricular filling pressure decreased from 28 to 16 mm Hg with an increase in cardiac output from 3.5 to 4.01/min. The mean arterial pressure dropped about 10 mm Hg. Also with oral derivates of Nitroglycerin (Isosorbide-Dinitrate and Myocardon) an extensive decrease in left ventricular filling pressure and an increase in cardiac output has been observed in patients with left heart failure.     

The analgesic effect of PCA buprenorphine in Taiwan''s gynecologic patients

Bloodless cardiac surgery would be optimal for all patients undergoing major or complex heart surgery; however, for Jehovah's Witnesses it involves a religious law and is fundamentally mandated. In this context, we review a case of unstable angina with associated anemia requiring catheterization and definitive intervention in a Jehovah's Witness patient. Coronary stenting to stabilize the acute coronary syndrome is described with definitive total revascularization performed by coronary artery bypass graft surgery after utilizing erythropoietin and aggressive blood conservation techniques.     

Livedo reticularis, acral necroses and renal failure. Cholesterol crystal embolisms

In a 67 year old patient with multiple cardiovascular risk factors a livedo reticularis, ischemic acral lesions as well as deterioration of renal function five weeks after cardiac catheterism and aorto-coronary bypass surgery led to suspicion of cholesterol embolism. Fundoscopy revealed cholesterol crystals in retinal vascular branches thus delivering important diagnostic information. Atheromatous lesions of the entire aorta and the ilio-femoral arteries were possible sources for embolism. The outcome was favorable. The lesions of the toes regressed and renal failure did not progress to dialysis. The diagnostic steps taken, the clinical picture of cholesterol embolism, the use of imaging and therapeutic options are discussed.