2 The free internal Ca+ concentration in human red cells is set according to the leak 2 and-pump principle: There is a finite passive Ca+ influx at the physiological 2 2 Ca+ -gradient across the membrane which is compensated by Ca+ pumping in the outward direction with a rate given by the degree of saturation of the A TP-fuelled Ca 2 pump at the steady-state internal Ca+ concentration. Simons (1982) recently devised a method allowing the measurement of the steady 2 2 state internal Ca+ concentration. Cells are suspended in media of different Ca+ con 2 2 tent whose Ca+ concentration is monitored by a Ca+ -selective electrode. When the cells are lysed (by digitonin) there is an upward or downward deflection of the elec 2 trode signal. At the point of zero deflection, the cellular Ca+ concentration equals that 2 of the medium. The result is, that in fresh human red blood cells the Ca+ concentra tion is ;;;; O.4,uM (this is an upper estimate; the true value may be considerably lower).

Although many books deal with isolated problems of calcium disturbance in relation to cardiac and cerebral function, this is the first to focus specifically on calcium metabolism and cerebral ischemia. Internationally acknowledged experts present recent data and new concepts in an interdisciplinary approach to the subject. They examine basic information on the pathophysiology of cellular events, the damage caused by excitotoxic substances, and the effects of calcium antagonistic drugs as measured in experimental animals. These contributions may help lead to possible therapeutic interference for the prevention of calcium imbalance.

This book is an up-to-date summary of all aspects of aortic disease, written by international experts in their fields, covering diagnostic concepts of all aortic diseases, the most modern therapeutic approaches in various aortic syndromes, the pathogenic origin and the most recent molecular and cellular findings that have revolutionized our present knowledge of aortic diseases. The reader will come to understand the aorta as a functional organ with a complex regulatory system rather than just a major arterial vessel, and will have a better understanding of the prognostic impact of various aortic syndromes, and of the most recent therapeutic concepts for chronic as well as acute aortic pathology. As a unique feature of this book, the aorta is placed in the center of systemic illnesses, such as atherosclerosis, diabetes, hypertension, infectious diseases and connective tissue disorders, storage diseases, trauma and toxic factors; this concept aims to attract the attention of both clinical specialties such as cardiology, radiology and cardiovascular surgery and adjacent areas like pathology and clinical genetics. The book portrays the aorta as an integral part of the cardiovascular system and the entire organism and features the complexity and clinical impact of all major aortic diseases.

Recently, much progress has been made with echocardiography and Doppler techniques and these ultrasound methods have grown in importance and reliability as non-invasive diagnostic procedures for many cardiovascular disorders. The objective of this t~xtbook is to offer a detailed yet concise overview of the echocardiographic diagnosis of the various cardiovascular diseases. The book focuses upon the practical echocardiographic (including Doppler) exam ination. Accordingly, the fundamental principles of echocardiography and the Doppler techniques (pulsed and continuous wave and color flow mapping are covered briefly but comprehensively). A copious amount of representative figures and illustrations is included so that the reader is able to understand the clinical application of each modality in the various cardiovascular pathologies and the echocardiographic diagnosis. In keeping with the concept of an integrated echocardiographic examination, the two-dimensional, M-mode and Doppler echocardiographic findings are included in many of the diseases. Usually, the echocardiographic examination is approached first by two-dimensional imag ing to give an understanding of the anatomical correlations, if necessary adding M-mode to clarify the time course of intracardiac movements, and secondly by each Doppler technique to evaluate the hemodynamic conditions. When familiar with these approaches, one can make not only the diagnosis of many cardiovascular diseases with echocardiography alone, but also the rational and expeditious management of patients. Today, some of the cardiac diseases (Atrial Myxoma, Atrial Septal Defect, Infective endocarditis and so forth) have been oper ated based only on echocardiographic findings.

by JULIEN IE HOFFMAN One of the earliest coronary physiologists was Scaramucci who, in 1695, postu lated that during systole the contracting myocardium inhibited coronary blood flow. Since then, the many contributions that have been made to our knowledge of the coronary circulation can be arbitrarily divided into three phases based on advances in technical methods. The early phase of research into the coronary circulation, done with great difficulty with crude methods, may be regarded as ending in the 1940s, and it included major discoveries made by such well known investigators as Georg von Anrep, Ernest Starling, Carl Wiggers, and Louis Katz, who formulated much of our basic understanding of the field. After 1940, the field of coronary physiology entered a new phase when instruments for high fidelity registration of coronary flow and pressure became available. This era was domi nated by Donald Gregg who combined careful attention to the function of these instruments (some of which he helped to develop) with an extraordinary ability to discern mechanisms from apparently minor changes in coronary flow and pressure patterns. His book 'The Coronary Circulation in Health and Disease' set a new standard in the field. After 1960, techniques for measuring regional myocardial blood flow became available, and enabled a large group of eminent investigators to make major advances in understanding the physiology and pathophysiology of myocardial blood flow.

primary goal of all forms of therapy is not just prolonging life, but improving the quality of life, has forced analysis of what constitutes quality of life, a concept whose structure pervades all walks of life and eludes definition. Global well being, happiness, morale, vitality, fullness of social life, and satisfaction must be integrated and assessed for the effects of the disease and the therapy, in the context of specific personality traits, attitudes to life, family situation, and socio-economic and political freedom. A growing inter est in research on this subject has led to a clearer understanding of the components which come to determine quality of a patient's life, and how they can be measured in a reproducible manner so that valid comparisons can be made. Keeping these recommendations of analysing quality of life within the context of patients who have undergone open heart surgery, it seemed appro priate to me to separate the influence of various forms of open heart surgery into five aspects of life which can comprehensively reflect the quality of life outcome of the operation. These five 'components' are (1) Physiological state, which summarises the traditionally reported incidence of operative mortality and morbidity, objectively and subjectively measured physical ca pacity, and the residual symptoms, treatment and long-term survival. (2) Intellectual functioning relates to the psychoneurolgocial deficit in memory, reasoning or judgement because of cerebral microembolism and hypo perfusion during cardiopulmonary bypass.

In the past few years it has become clear that left ventricular dysfunction, even of severe degree, may be reversible after coronary revascularization in some patients. As a result, myocardial viability has captured the imagination of researchers and clinicians seeking to unravel the cellular and subcellular mechanisms and define appropriate diagnostic modalities. These diagnostic modalities include: cardiac catheterization, positron-emission tomography, magnetic resonance imaging, two-dimensional echocardiography and single-photon imaging. This book, for the first time, brings together a diverse array of information in a comprehensive and concise fashion using a template of ten chapters written by experts in the field. It will be required reading for cardiologists, radiologists, nuclear medicine specialists, cardiac surgeons, anesthesiologists, internists and basic researchers and their trainees who are involved in the management of patients with coronary artery disease in whom myocardial viability is a clinically relevant issue.

Since the first pacemaker implantation in October 1958 by Senning and Elmqvist in Sweden, cardiac pacing for bradycardia has become a well-established therapy. The impressive growth of clinical experience and the rapid development of pacemaker devices have greatly contributed to this situation. The electrical therapy appears to be so easy that insertion of the lead and its connection to the pacemaker generator requires little effort, skill or insight. However, after implantation a patient's condition seldom remains stable, which requires a flexible pacing program to cover all new cardiac events, and broad insight from clinician and technical colleagues. The Pacemaker Clinic of the 90's teaches anatomical and electrophysiological aspects of pacing, supports the prevention of complications, and points to new developments in the field. Apart from classical indications for cardiac pacing, the book discusses the validity of the latest indications, supporting the cardiologist and the associated professional in selecting the appropriate pacing mode and pacemaker follow-up in individual patients. The Pacemaker Clinic of the 90's will be a helpful companion for years to come.

To our knowledge, this is the first book dealing exclusively with myocardial contrast two-dimensional echocardiography (MC-2DE), a new and exciting diagnostic methodology for assessment of myocardial perfusion, which has seen rapid development and has now entered the clinical stage. The experi mental research and human applications have been described in technical papers published in a variety of journals, but our objective is to provide the reader with a comprehensive and concentrated overview of the field and of the current state of the art. To facilitate appreciation of the significant ad vances made and issues yet to be resolved, we are pleased to have several well known specialists contribute their own assessment of specific aspects of MC- 20E and illustrate the method's principles as well as applications. We were faced with inevitable overlaps and some repetitions in the discussion of quan titative potentials or limilations of the methodology. Rather than strictly 'streamlining' the text, we decided to accept some redundancy in the interest of presenting a diversity of points of views, reflecting the current evolutionary state of MC-20E. Following a brief reference to the established clinical contrast echocardiog raphy, recent developments and validations of the specialized MC-2DE tech nique are reviewed, bearing in mind that the field is in a flux and some of the ongoing activities have not as yet been formally reported. Mechanisms of the echo contrast and several new agents are decribed next, and an additional chapter illustrates current thoughts-on optimizing the echo contrast medium.

Obstruction of coronary blood flow and the resultant consequences are the center stage pathophysiologic events in cardiology today. The speculations of Jenner, Burns, Heberdin, McKenzie, Prinzmetal and many others had until now been left to observations of isolated tissue and intact animal experimentation. Only with the advent of Gruentzig's technique, which allowed us to 'work safely inside the coronary arteries' are we able to observe the effects of coronary occlusion in living conscious man. PTCA provides not only a therapeutic modality for non-operatively opening coronary obstructions, but has also provided the best model for studying the effects of acute ischemia on the heart. The procedure also lead the way to all other interventional cardiology developments, including modern thrombolysis in the setting of acute myocardial infarction. In his previous works, Serruys has examined how PTCA can serve as a model for studying acute ischemia. In this book, he and his co-authors discuss the effects of balloon-induced ischemia on the electrocardiographic changes, coronary blood flow dynamics, cardiac muscle metabolism and left ventricular function, as well as measures to counter these effects and provide for reperfusion in unstable angina and acute myocardial infarction. Technology has expanded the 'eyes' of the observer of these events. The authors use many techniques including ECG recording from surface, endocardium, and intracoronary electrodes; angiographic assessment of coronary flow pattern using digital techniques, as well as doppler flow measurements; biochemical assessment of metabolic products stimulated by ischemia; and digital angiographic and echo doppler assessment of left ventricular function.