Biomedical subjects
Publications and source records attributed to I Assmann.
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Due to fundamental considerations and especially after Braunwald's et al. (1962 (4)) examinations of 5 patients with severe hypertrophic obstructive cardiomyopathy (HOCM) with 0.5-0.75 mg of Ouabain, cardiac glycosides in cases of this disease are to be regarded as contraindicated. Own examinations (right and left-heart catheterizations, monoplane cineangiography of the left ventricle, determination of the cardiac output, and the ejection fraction (EF) were performed in 10 patients with HOCM of different stages. Applying the usual dosage of 0.25-0.375 mg of strophanthin, different hemodynamic effects were observed in discrete forms. In cases with a higher severity, the observations of Braunwald et al. could actually be confirmed. The left ventricular systolic pressure gradients were increased, but cardiac output, left ventricular enddiastolic pressure, pulmonary pressure and resistance, and also arterial pressure and peripheral resistance behaved differently. EF increased slightly. The right infundibular gradients were decreased with one exception, or resp., they were unchanged. Obviously, HOCM reacts especially unfavourably with so-called left-ventricular cavity obliteration. The main importance might belong to the behaviour of the free lumen of the left ventricle. In regard of the principally reserved attitude towards the cardiac glycoside therapy in HOCM, no change has occurred. Only in patients with atrial fibrillation and a rapid heart rate, a therapy trial could be considered, if necessary in combination with beta-blocking agents or calcium antagonists under hemodynamic control. In cases of HOCM with serious obstruction and signs of cardiac failure and inadequate affecting by calcium antagonists, an early surgical intervention should be executed.
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On 9 patients with acute myocardial infarction the influence of talinolol (cordanum) on haemodynamic parameters in intravenous administration and after this in oral application was examined. Talinolol led to a slight decrease of the heart rate, of the arterial blood pressure and of the cardiac output as well as to a more distinct reduction of the contractility in nearly uninfluenced left-ventricular filling pressure. In comparison to a conventionally treated control group (n = 11) the decrease of the heart rate as well as of the contractility was somewhat more distinct. The changes found are to be explained in the sense of a heart exoneration. In one patient possibly by talinolol a deterioration of the pumping function developed 56 hours after the acute event. In another patient a depressive effect on the sinus node is not to be excluded. Ventricular fibrillation and disturbances of the atrioventricular conduction did not appear in contrast to the control group. The influence on supraventricular and ventricular cardiac dysrhythmias was distinctly favourable in other 9 patients with acute myocardial infarction despite clinical signs of cardiac decompensation. Only in one patient a further deterioration of the pumping function developed despite control of the disturbance of rhythm. According to the experimental and up to now existing clinical experiences beta-receptor blockers are indicated above all in the early phase of the acute myocardial infarction, if shock, acute heart insufficiency and bradycardiac disturbances of the heart rhythm are not existing. Here paticularly at the beginning of the therapy is a proved change in the first 2-4(-8) hours to prevent the expansion of the infarct size or the onset of large infarctions.
61 patients at the age of 18 to 70 years with untreated atrial septum defect were examined 7.5 to 21 (on the average 10.5) years after the first recognition. Subjective symptomatology, clinical picture, size of the heart, mean pressure of the pulmonary artery and shunt volume at the beginning and at the end of the period of observation were analysed. The results reveal an above all favourable prognosis of the congenital malformation. In a course without complications an age can be reached adequate to the average life-expectance. After the 40th year of age, however, in 75% of the patients complaints appeared or their number increased. With growing age the size of the heart and the frequency of disturbances of the cardiac rhythm increased. In the small left-to right-shunt (less than 30% of the pulmonary flow) in the majority of the cases (85%) the prognosis proved to be good. Even in shunt volumes of more than 60% in half of the patients no essential deterioration developed in the period of observation. No clear relations were found between the mean pressure of the pulmonary artery and the clinical degree of severity. The indication to the operative correction of the atrial septum defect diagnosed only at the adult age demands a critical individual judgement, in which case apart from the haemodynamic parameters anamnesis and clinical findings within a cardiological observation of the course are of particular importance.
The surface ECG only in a restricted number allows evidence on the course off conduction in the atria. By introduction of the intracardial electrography into the clinic as well as various stimulation techniques has become possible better to analyse the formation of stimuli and the conduction system in man. The diagnosis of supraventricular arrhythmias renders particular difficulties. By recording of the intracardial potentials in as many as possible and defined points of the atria in relation to the fixed point possibly near to the sinus node (endocardial mapping) a better analysis of the excitation and conduction is possible. Only own examinations on 9 patients with sinus rhythm and supraventricular dysrhythmias by means of atrial mapping showed that origin and course of the conduction of cardial arrhythmias may be clarified better. The method mentioned according to our experiences hitherto made and reports in literature despite several lacks and difficulties in an enrichment of the diagnostic possibilities in supraventricular dysrhythmias.
Taking into consideration the frequent combination of hypertension, ischaemic heart disease and heart insufficiency the effect of blood pressure as well as the influence of pre- and afterload gain increasing importance, when nitrates are used. It is the question, whether the blood pressure reducing effect may be used with a certain aim or not. In own investigations acute haemodynamic experiments with glycerol trinitrate were carried out on 10 patients with arterial hypertension (catheterization, estimation of HMV and so on) in rest and under ergometric load, clinical therapeutic experiments on 10 patients with crisis of hypertension with cerebral and/or cardiac complications as well as long-term experiments with pentaerythrityl tetranitrate on 6 patients with in most cases severe arterial hypertension. The acute effects on the haemodynamics correspond to those in normal blood pressure, in which case the reduction of blood pressure and resistance is more expressed. The favourable effect of glycerol trinitrate in the crisis of hypertension with cardiovascular complications can be regarded as proved. First own experiences with the long-term application of nitrates do not yet result in a clear estimation of effectivity and indications.
It is reported on intracardiac electrophysiological findings of a 50-year-old patient in whom an atrial arrest could be diagnosed. With the help of the intracardiac mapping electric residual activities could be proved in the area of the sinus node, of the anterior atrial bundle as well as of the left atrium. The electrophysiological mechanism, the causes, the ways of conduction as well as the valency of the diagnostic measures are discussed.
The pharmacodynamic effects (changes of systolic time intervals, STI, reaction of pulmonary arterial pressure) of digitoxin were studied in 7 patients with severe congestive heart failure in comparison with the corresponding plasma level. STI indicated glycoside-dependent changes, i.e. shortening of LVETc and QS2c and normalization of prolonged PEPc, while ICT shortening was less observed. In 2 patients with cor pulmonale a pulmonary oedema occurred accompanied with prolonged LVETc. During the early period of glycoside-dependent recompensation no significant correlation between STI shortening and glycoside plasma level was observed. Because of the retarded normalization of the haemodynamics of the pulmonary circulation and because of possible side-effects, rapid digitalization has to be reconsidered.
On the patients with moderate and severe heart insufficiency haemodynamic, clinical and electrocardiographic examinations were carried out. After the application of digitoxin at the beginning in the majority of cases no favourable effects on clinical and haemodynamic findings could be proved. In 2 patients with cor pulmonale even a drastic deterioration with increase of the pulmonary pressure and formation of a pulmonary oedema developed. The temporary analysis of the systole and the estimation of the glycoside level did not give any reliable references. The recompensation began only after 2-3 days. In 5 out of 10 patients in whom the cardiac rhythm was continuously controlled by means of a tape storage device, after the application of digoxin ventricular extrasystoles appeared. Also in these cases increased as well as subtherapeutic digoxin-plasma levels were present. In 2 patients with hypertrophic obstructive cardiomyopathy the infundibular gradients were considerably increased by strophantin. The causes of the different reaction patters are to be sought in disease-specific peculiarities, in the degree of severity of the heart insufficiency, in the speed of the flooding of glycoside and several extracardiac factors.
It is reported on two rare complications occurring in the pulmonary catheterisation with long-term control of the pressure of the pulmonary artery. In case 1 in confluenting bronchopneumonias the formation of an abscess in the region of the point of the catheter developed, in which case by the infusion therapy with very peripheral position of the catheter local lesions are very probable. In case 2 the catheter via an atrial septum defect passed into a pulmonary vein in PCA-position. A haemorrhagic infarction of the lung developed. In the two cases after removal of the catheter and adequate therapy the pulmonary complications healed.
The effect of the Ca++ -antagonist Verapamil on the ECG, the haemodynamic parameters and the systolic time intervals was investigated in the long-term experiment on 12 patients with ascertained chronic ischaemic heart disease at reat and during exercise. The dosage was 3 x 80 mg/die during 4 weeks. The tolerance was not increased. The load-induced decrease of the ST-T-distance in the ECG was improved under load and in the recreation phase. The function of the myocardium, measured on the quotient LVET/ICT, improved under load with simultaneous decrease of the double product and the TTI, the pulmonary pressure, however, remained uninfluenced. Side-effects were not observed.
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Because of its antiarrhythmic and antifibrillatory qualities as well as its positively inotropic effect bretylium tosylate increasingly finds interest. The first results of a clinical and haemodynamical mechanocardiographic investigation with bretylium tosylate are presented. In doses between 1.6 and 6.2 mg/kg body weight intravenously and intramuscularly after an initial increase of blood pressure a clear decrease of the systolic system blood pressure develops. The resistance of the peripheral vessels decreases by 10 to 20%. It is an increase of the heart index and the stroke volume index by 10 to 30% to be proved as an expression of a positively inotropic effect. In orientating investigations the antiarrhythmic effect could be confirmed. The side-effects observed cause us to give a strong indication and to observe the patients carefully. The main area of application of bretylium tosylate might be seen in the possibility to achieve a pharmacological defibrillation of the ventricles.
In experiments of treatment carried out on 39 patients with cardiac insufficiency with tachyarrhythmia for the partially synthetic, new heart glycoside 3',4'-dipropionyl helveticosol the following clinico-pharmacological data of efficacy were approximately established on an average: level of full efficacy 2.7 mg, daily coefficient of disappearing 40%, coefficient of enteral absorption 30%, daily maintenance dose intravenously 1.1 mg and orally 3.7 mg.