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Assessment of cardiac energetics at the level of ATP-synthesis,
chemomechanical energy transformation and whole organ dynamics as a
function of haemodynamic load, ventricular configuration and
oxygen- and substrates supply is basic to understanding cardiac
function under physiological and pathophysiological (hypertrophy,
hypoxia, ischaemia and heart failure) conditions. Moreover, cardiac
energetics should be an important consideration in the choice and
application of drugs especially in the case of vasodilators,
inotropic agents and in cardioprotective measures. Only by
considering energetics at the subcellular, cellular, and
whole-heart level we can arrive at a better understanding of
cardiac performance and ultimately better clinical judgement and
drug therapy. Quantification of myocardial energetics will also
help to determine the optimal time for surgical interventions such
as valvular replacement or aneurysm resection. The present volume
is the outcome of an international symposium on cardiac energetics
held in Gargellen/Montafon (Austria), June 1986. The contributions
will certainly help bridge the existing gap between basic research
involving isolated structures and that involving the whole organ,
on the one hand, and render the results derived from basic research
applicable to clinical problems, on the other hand.
Alteration of excitation-contraction coupling in the failing human
heart was deemed an interesting subject for a dialogue between
basic scientists and clinical researchers in continuation of
previous Gargellen Conferences concerned with the function of the
normal and failing human myocardium. In 1987 basic mechanisms and
clinical implications of then new insights into cardiac energetics
was followed by a comprehensive review of inotropic stimulation and
myocardial energetics in 1989. Here, we undertook a re-evaluation
of the principles of inotropic stimulation and of its potential
therapeutic value, based on new observa tions from experiments with
human myocardium. In 1992 the risk due to myocardial phenotype
change as a consequence of adaptation in heart failure was
published. Here, alterations of subcellular structures and
functions as a consequence of chronic heart failure, summarized as
phenotype change, could be described as an essential characteristic
of the failing human myocardium. This topic was discussed in
greater depth in the volume "Cellular and Molecular Alterations in
the Failing Human Heart," considering both the sarcolemma and the
phosphodiesterases, as well as excitation-contraction coupling and
contractile proteins, extracellular matrix, and mitrochondrial
function."
Primary myocardial disease, nowadays referred to as congestive or,
more re cently, dilating cardiomyopathy, comprises disorders of
varied etiology. Most oftenly the pathogenetic mechanism or
causative agent remains unknown. The significance of inflammatory
processes, i.e. myocarditis in a wider sense as the etiologic
factor has been debated for many years. In a few instances,
especially in children and newborns viral infections can be
incriminated. In adults this etiology can be ascertained only in
rare instances. And it has remained entirely uncertain if, or under
which circumstances, and how often virus myocarditis can lead to a
chronic disorder of the heart, namely dilated cardiomyopathy.
Although it would seem conceivable that an immunological response
to an infectious agent might induce parenchymal damage with
subsequent loss of cellular function and structural integrity of
permanent nature, i.e. dilatation, functional deterioration and
dysrhythmias, numerous attempts to establish such a pathogenetic
mechanism have not yet furnished convinicing results. Therefore the
reader will direct his attention specifically to the respective
contribution in this volume. Morphologic studies have yielded a
host of new and intriguing findings in cardiomyopathy, but have
likewise failed to settle the basic question as to which etiology
can be held responsible in a given case, especially if an inflam
matory process can be incriminated. Specific processes such as
sarcoidosis of the heart undoubtedly furnish examples of chronic
inflammation as a cause of dilating cardiomyopathy. This disorder,
however, as a specific inflammato ry myocardial affection, i.e.
myocarditis, is encountered only infrequently."
Inspite of considerable progress in prevention, diagnosis, and
treatment, pulmonary embolism has remained a threat to the patient
and a challenge for the physician both in conservative, as well as
in operative disciplines. Pulmonary embolism is according to
pathology observations still the most frequently overlooked
clinical diagnosis. In 1-5 per 100 autopsies, clinically unexpected
pulmonary emboli are found. In addition, the sequelae of recurrent
pulmonary emboli, the syndrome of pulmonary hypertension with or
without right heart failure, continues to present a therapeutic
dilemma - and no progress is in sight. In intensive care medicine
pulmonary embolism, either acute, massive, and/or recur- rent,
continues to be both a therapeutic as well as a preventive
challenge mobilizing pharmacotherapeutic, catheter-interventional,
and operative resources. Diagnostic, therapeutic, and preventive
strategies are currently in use. Their basis, however, seems
surprisingly thin, as far as our knowledge on the natural course of
this chameleon-like illness with and without fibrinolytic,
anticoagulative, catheter or opera- tive treatment is concerned. A
large European multicenter register has been initiated by
Professors Kasper and Geibel with the help of Boehringer Ingelheim
Pharmaceutics, in order to better describe the natural course of
pulmonary embolism under current treat- ment modalities.
Furthermore, recently the clinical significance of the valve patent
foramen ovale as a source of paradoxical emboli is beginning to be
better understood. Many concepts therefore require revision.
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