Antiischemic effectiveness of long-term urokinase therapy and isovolemic hemodilution therapy has been reported in patients with symptomatic coronary artery disease, but both interventions have never been compared. In patients with refractory angina pectoris and end-stage coronary artery disease (clinical functional class III), isovolemic hemodilution (n = 9) (hydroxyethyl starch solution 6%, 1-2 times/week), and urokinase therapy (n = 11) (500,000 U urokinase per i.v. injection, 3 times a week) were performed over a period of 12 weeks, each additionally to maximal conventional treatment. Apart from the assessment of clinical symptoms and rheologic parameters, invasive hemodynamic measurements were carried out at rest and during exercise testing before and after treatment. After treatment with urokinase, patients showed a significant reduction of clinical symptoms (from 19.8 +/- 6.5 to 5.0 +/- 4.3 anginal events/week, p < 0.001), fibrinogen (from 410 +/- 88 to 238 +/- 40 mg/dl, p < 0.001), plasma viscosity (from 1.45 +/- 0.10 to 1.33 +/- 0.03 mPa x s-1, p < 0.01), and no changes of hematocrit (from 0.45 +/- 0.02 to 0.45 +/- 0.02) and whole blood viscosity (from 4.7 +/- 0.5 to 4.4 +/- 0.7 mPa x s-1); however, hemodilution resulted in a decrease of hematocrit (from 0.46 +/- 0.01 to 0.39 +/- 0.01, p < 0.001) and whole blood viscosity (from 4.7 +/- 0.5 to 4.0 +/- 0.3 mPa x s-1, p < 0.001) and no changes of initially comparable levels of clinical symptoms, fibrinogen, and plasma viscosity. Hemodynamic parameters at rest improved after urokinase therapy with a reduction of pulmonary capillary wedge pressure (from 9.1 +/- 5.1 to 5.5 +/- 2.8 mmHg, p < 0.05) at comparable levels of systemic vascular resistance (from 1510 +/- 340 to 1420 +/- 510 dyn x s x cm-5). Hemodilution did not result in any significant hemodynamic changes. Apart from clinical symptoms, long-term intermittent urokinase therapy reduces pulmonary capillary wedge pressure at rest. This may reflect an improved diastolic function due to a rheological enhancement of myocardial perfusion at the level of the coronary microcirculation. Isovolemic hemodilution seems to be of no benefit.
To investigate right ventricular function, 24 patients with arterial hypertension and five normotensive controls underwent equilibrium radionuclide ventriculography with simultaneous right heart catheterization. In normal subjects, left ventricular ejection fraction was 57 +/- 2% at rest and 71 +/- 5% on effort, and right ventricular ejection fraction (RVEF) averaged 51 +/- 5% at rest and 65 +/- 2% during exercise. Pulmonary vessel resistance (PVR) was 56 +/- 37 dyn.s.cm-5 at rest and 46 +/- 10 dyn.s.cm-5 on effort. Hypertensive patients were divided into three groups according to their left ventricular function: group 1 (n = 10) had normal left ventricular ejection fraction (LVEF) at rest and on effort (57 +/- 9%; 65 +/- 6%), in this group, right ventricular systolic reserve was reduced (RVEF 52 +/- 7% at rest, ns; RVEF 57 +/- 7% on effort, P less than 0.01 compared to controls). Pulmonary vessel resistance during exercise averaged 78 +/- 24 dyn.s.cm-5, which was significantly higher compared to controls (P less than 0.01). In group 2, left ventricular contractions were normal at rest (60 +/- 6%, ns) but deteriorated during exercise to 56 +/- 8% (P less than 0.001, compared to controls). These patients also showed a lack of right ventricular augmentation at ejection fraction (54 +/- 8% at rest, ns; 56 +/- 8% under exercise, P less than 0.05). PVR was significantly enhanced during exercise (88 +/- 40 dyn.s.cm-5, P less than 0.05 compared to controls).(ABSTRACT TRUNCATED AT 250 WORDS)
Summary: Percutaneous transluminal laser angioplasty has become an accepted method of treatment of peripheral arterial occlusive disease. To minimize the risk of arterial wall perforation during laser angioplasty, a novel laser catheter system was developed. In 113 obliterated postmortem human arteries the perforation rate was 0.9%. The mean degree of stenosis was reduced from 89 i-9 % before, to 53 -f 11 % after laser irradiation. Clinical Nd:YAG laser angioplasty was performed in 19 patients suffering from peripheral arterial occlusive disease. The Fontaine stage improved in 16 patients; in no case did it deteriorate. The mean degree of stenosis was reduced by laser angioplasty from 9 1 & 12 % to 3 1 * 19 % . A further reduction down to 13 k 18 % was achieved by subsequent percutaneous transluminal balloon angioplasty . The systolic Doppler ankle-arm pressure gradient was improved from 0.58k0.26 to 0.89k0.25. In 7 patients microemholisms were detectable on the final angiogm . There was no acute reocclusion and no perforation. Within a followup period of 12 months, four restenoses were diagnosed by digital subtraction angiography. On average, the Doppler index was 0.75k0.32.
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