In a prospective study, the clinical value of transoesophageal two-dimensional echocardiography (TOE) as compared with transthoracic two-dimensional echocardiography (TTE) was determined in patients with suspected infective endocarditis. Ninety-six patients were studied consecutively with an electronic sector scanner using 2.25 and 3.5 MHz probes for TTE and a 3.5 MHz probe embedded in tip of a flexible 12 mm gastroscope for TOE. Results of surgery and autopsy were available for 20 of the 96 patients with infective endocarditis and echocardiographically demonstrated vegetations and 70 control patients with valvular heart disease without infective endocarditis and no signs of vegetations, who were studied preoperatively with TTE and TOE. For TTE and TOE, the measured sensitivity was 63% and 100%, specificity 98% and 98%, positive predictive accuracy 92% and 95%, and negative predictive accuracy 91% and 100%, respectively. In 39 patients who had positive blood cultures, vegetations were found by TOE in 32 patients (82%), but in only 27 patients (69%) by TTE. Image quality was the main factor contributing to the superiority of TOE over TTE: it was reduced in 11/20 patients (55%) in whom vegetations were not detected by TTE. Another important factor was the size of vegetations. Only 6/24 vegetations (25%) of less than 5 mm but 9/13 vegetations of 6-10 mm, and 14/14 vegetations of greater than 11 mm detected by TOE were also observed with TTE. The clinical importance of detecting vegetations was demonstrated by the rate of embolism. In patients with vegetations embolism was 25% when blood cultures were positive and 21% when they were negative. In patients without echocardiographically detectable vegetations signs of embolism were seen in no patient with positive and 7% of the patients with negative blood cultures. Evidence of vegetations was found on the aortic valve in 14 patients and on the mitral valve in seven patients in whom valvular incompetence was not present, indicating that the valve had not yet been damaged significantly. TOE is superior to TTE in detecting vegetations in suspected infective endocarditis because of better image quality, particularly when vegetations are small. TOE seems to be indicated in patients with suspected endocarditis and reduced image quality or negative TTE results. Early detection of vegetations on valves may help confirm the diagnosis of infective endocarditis at an early stage and hopefully lead to an improved prognosis by reducing delay in instituting appropriate therapy.

Stored endogenous acetylcholine (ACh) and in vitro synthesis of [3H]ACh were measured in isolated, mucosa-intact and mucosa-denuded airways of rat, guinea pig, and humans. In addition, choline acetyltransferase (ChAT) activity and ACh content were measured in freshly isolated airway mucosa as well as in cultured epithelial cells of rat tracheas. Rat tracheas stored 25 nmol/g ACh, whereas guinea pig tracheas and human bronchi contained only 2-3 nmol/g ACh. When incubated with [3H]choline, the isolated airways of rat, guinea pig, and human synthesized significant amounts of [3H]ACh. In guinea pig and human airways, removal of the mucosa affected neither stored ACh nor in vitro synthesis of [3H]ACh. In rat tracheas, however, removal of the mucosa resulted in a 50% reduction of stored ACh. Freshly isolated mucosa wiped off from the luminal surface of rat tracheas contained large amounts of ACh (6.5 nmol/g airway), whereas in human mucosa (central bronchi) only small amounts of ACh were found. In enzymatically isolated mucosal cells of rat tracheas, a considerable ChAT activity (21 nmol.mg protein 1.h-1) was detected, blockable by bromoacetylcholine. Enzymatically isolated human mucosa contained a rather low ChAT-like activity (0.5 nmol.mg protein 1.h-1), not sensitive to bromoacetylcholine. In cultured epithelial cells of rat tracheas (4th-6th passage), neither ChAT activity nor ACh was detected. The large airways of rat, guinea pig, and humans contain considerable amounts of ACh, supporting histological evidence of a dense cholinergic innervation, particularly of rat tracheas. The mucosa of rat tracheas synthesizes and stores large amounts of ACh, whereas the low ChAT activity in human mucosa argues against the presence of cholinergic neurons able to synthesize and store ACh.

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The element concentrations (Cu, Zn, Se, Fe, K, Mg, P) of heart tissue taken from patients with coronary heart disease during bypass surgery were measured and related to physiological parameters of the heart. There was no relationship between the element concentrations and the number of vessels stenosed, the occurrence of myocardial infarction or classification according to the NYHA. When the element concentrations of the heart were related with parameters characterizing cardiac output, such as ejection fraction and cardiac index, positive statistically significant correlations were found for selenium, iron, copper, zinc and phosphorus.

CPB with cardioplegic cardiac arrest decreases beta-adrenoceptor-mediated adenylate cyclase activation in a manner compatible with an uncoupling of beta-adrenoceptors from the Gs-protein-adenylate cyclase complex. Such a beta-adrenoceptor desensitization may be the reason why after CPB many patients need inotropic support but do not respond sufficiently to catecholamines.