[Interventional therapy of heart valve diseases: future perspectives]. / Interventionelle Therapie von Herzklappenerkrankungen : Ein Ausblick.

Transcatheter procedures have been adopted as novel treatment strategy for patients with valvular heart disease, particularly for those who are inoperable or at high risk for surgical valve procedures. Significant technological advances have resulted in an improvement of devices for transcatheter aortic valve replacement (TAVI) with downsizing of crossing profiles, reduction in the rate of paravalvular leakage and conduction abnormalities as well as a lower short- and mid-term mortality and a higher patient acceptance. In the near future, TAVI may potentially develop as first-line treatment for the majority of patients with aortic valve disease. For patients with mitral and pulmonary stenosis, balloon valvuloplasty is effective and well established and should be preferred over valve replacement, last but not least also for economic reasons. For treatment of mitral regurgitation, several transcatheter devices aiming to restore or replace mitral valve function are currently under investigation. This review summarizes the current state of interventional treatment of valvular heart disease along with implications for the future.

[Thyreotoxicosis in early pregnancy with partial cystic mole--a case report]. / Thyreotoxikose in der Frühschwangerschaft bei partieller Blasenmole--ein Fallbericht.

INTRODUCTION: With an incidence of 1:2,000-1:3,000 in Europe, mole pregnancy is rare. Partial mole is a benign form of gestational trophoblastic disease in which triploidy is thought to be caused by the insemination of an ovum by 2 sperms. A vital embryo is often dystrophic and growth retarded. The disease can present with vaginal bleeding, secondary anaemia, jaundice, signs of gestosis, as well as hyperthyroidism. CASE HISTORY: A 29-year-old, 2G1P, visited our hospital in the 13+3 week of gestation for first -trimester screening of trisomy 21. The patient was re-appointed for an ultrasound scan at 16 weeks of gestation to follow-up the appearance of a -cystic, hyperplasic placenta and minimal foetal pericardial effusion. She appeared at the 15+1 week gestation with acute upper abdominal pain, -tachycardia, hypertension (up to 160/100 mmHg) and double elevated liver enzymes. The performed ultrasound scan revealed a hydratiform placenta along with symmetrical foetal intrauterine growth retardation (IUGR). A cytogenetic examination revealed a triploidy (69, XXY). ß-hCG-values approximated 2,225,000 IU/L. Due to the severe progression of hyperthyroid symptoms (TSH<0.1 mU/L and fT4 29.6 pmol/L) and the poor foetal prognosis, abortion was induced with intravaginal supplements of gemeprost after cervical priming with mifepriston. Hyperthyroidism symptoms were managed with methizol and propanolol. The clinical situation improved rapidly following the expulsion of all foetal tissues. Histopathology of all aborted specimens verified the suspected diagnosis of partial mole including a slightly dystrophic fetus. Patient follow-up did not reveal any further pathology of the thyroid nor of the cardiopulmonary situation. ß-hCH values sank to below detection levels after 12 weeks. CONCLUSIONS: Gestational trophoblastic disease should be considered in the differential diagnosis when acute onset of symptoms pointing to hyperthyroidism occurs in women of child-bearing age.

[Evaluation of microcirculatory disorders in shock patients]. / Diagnostik von Mikrozirkulationsstörungen bei Schockpatienten.

The microcirculatory status depicts an indicator of organ perfusion in hemodynamic shock. Distribution pattern of microcirculatory disturbances reflects the underlying cause of shock: In septic shock, organ perfusion is severely impaired via arteriolo-venous shunting with shutting up small vessel perfusion; however, cardiogenic shock is characterized by a global impairment of microcirculation, involving all vascular beds. Hence, a differentiated evaluation of microcirculatory disturbances not only supports an early diagnosis of an imminent multiorgan dysfunction syndrome (MODS), but also allows a more accurate evaluation of severity of hemodynamic compromise in critical care medicine. Bedside sidestream darkfield (SDF) technique offers the opportunity to describe the microcirculatory status quo semiquantitatively and to evaluate the effect of novel therapeutic approaches on microcirculation. Further technical improvements of this technique may open new fields of diagnostic and therapeutic applications in intensive care medicine by supporting an early diagnosing of MODS, evaluating prognosis, and optimizing therapeutic measures .

[Evaluation of microcirculation in cardiogenic shock]. / Messung der Mikrozirkulation im kardiogenen Schock.

The prognosis of cardiogenic shock is still dismal despite advancements in diagnostic and therapeutic options. One of the major problems is the development of multi-organ failure caused by impaired organ perfusion with inadequate microcirculation. The diagnosis of cardiogenic shock is based on clinical signs of hypoperfusion, echocardiography, and hemodynamic parameters. Because of its high prognostic relevance microcirculation has become more interesting for clinicians recently. Signs of severe cardiogenic shock are reduced vascular density and impaired microflow, especially in the smallest vessels and the location of exchange of gas and nutrients. Recent studies revealed that intravital-microscopy is a valuable tool for on-line and in-vivo measuring of microcirculatory parameters. The assessment of microcirculation during modifications of the treatment of cardiogenic shock is valuable, e. g. during catecholamine therapy or when using of circulatory assist devices. This article summarizes new findings regarding microcirculation in cardiogenic shock, the use of assist devices, and novel pharmacological treatment. Evaluation of microcirculatory changes with its new insights in the complex pathophysiology of cardiogenic shock has the potential to become part of diagnostic algorithms.

In vivo evaluation of tissue microflow under combined therapy with extracorporeal life support and intra-aortic balloon counterpulsation.

Treatment with percutaneous extracorporeal mechanical assist devices provides the ultimate therapeutic option to improve the macrocirculation in patients suffering from refractory cardiac arrest, severe cardiogenic shock or during high-risk interventions. However, the flow in the smallest vessels in these critical periods is poorly understood but prognostically of high importance. Using sidestream darkfield intravitalmicroscopy, we visualised the sublingual microflow in a patient suffering from severe cardiogenic shock supported by extracorporeal membrane oxygenation and intra-aortic balloon pump. Our results show that intra-aortic balloon counterpulsation applied in addition to extracorporeal membrane oxygenation further improves the microflow. This in vivo finding supports pilot studies favouring the application of devices supporting cardiac output (extracorporeal membrane oxygenation) together with devices aimed at pulsatility (intra-aortic balloon pump).

Postocardiotomy failure after Ross operation: implantation of intravascular flow pump through pulmonary autograft.

We report a case of a patient with severe aortic stenosis, who underwent replacement of the aortic valve as a Ross procedure. Postoperatively the patient suffered postcardiotomy failure. Despite prolonged reperfusion and other methods of circulatory support, the patient could not be weaned from cardiopulmonary bypass (CPB). Therefore, an Impella intravascular flow pump was implanted, which is technically easy and has good weaning attributes. For implantation, a vascular prosthesis was sewn to the ascending aorta and the microaxial flow pump was placed under echocardiographic guidance across the pulmonary autograft into the left ventricle. With this support, the patient could be weaned from CPB. The report evaluates the Impella microaxial hemopump as a device that is technically easy to implant with no injury to the pulmonary autograft in patients after Ross operation. Surgeons should consider the device as a short-term support in borderline indications.

[Acute electrophysiological effects of cardiac glycosides on sinus node function and ventricular repolarization under clinical conditions]. / Elektrophysiologische Akuteffekte herzwirksamer Glykoside auf Sinusknotenfunktion und ventrikuläre Repolarisation unter klinischen Bedingungen.

The influence of digoxin, digitoxin and g-strophanthin (ouabain) on the sinus node function (recovery time, sinoatrial conduction time, PP-interval) and on ventricular repolarisation (corrected QT interval and QT during permanent atrial stimulation) was studied in 101 patients (36 with sick sinus syndrome-SSS, 34 with ischaemic heart disease-IHD, and 31 control patients without cardiac disease). Digoxin caused marked prolongation of sinoatrial conduction time (in SSS and in control patients), digitoxin prolonged the PP interval (in IHD and SSS patients); digitoxin and ouabain shortened the QTcorr in SSS patients, ouabain shortened also QT during atrial pacing. The results do not point to specific indication of individual glycosides in sinus node function disturbances. Under certain clinical prerequisites, however, digitoxin can be recommended in ventricular ectopic contractions caused by prolonged or inhomogeneous repolarisation, and also the capacity of ouabain to shorten the repolarisation time deserves attention.

[Clinical and angiographic appearance of traumatic peripheral arteriovenous fistula]. / Klinisches und angiographisches Erscheinungsbild der traumatischen peripheren arteriovenösen Fistel.

Issuing from 33 patients with traumatic peripheral arteriovenous fistulas on the basis of an impressive case is reported on pathophysiological changes and it is referred to a possibly early operative correction of these peripheral arteriovenous shunt connections.

[Digoxin and sinus node function in the sick-sinus syndrome (author's transl)]. / Digoxin und Sinusknotenfunktion beim Sinusknotensyndrom.

In 12 patients with sinus node syndrome, the influence of Digoxin on the sinus-node function was examined. After having determined the sinus-node recovery time (SNRT), the calculated sinuatrial conduction time (SACT), and the mean cycle length, 1.2 mg Digoxin were applied intravenously; 45 minutes later the above mentioned determinations were repeated. Before applying Digoxin, the mean value of the SNRT was 1665.8 +/- 1381.5 ms, after Digoxin it was 1372.1 +/- 546.1 ms; there was no statistical significance. In regard of the SACT the values were 95.9 +/- 38.6 ms before and 125.0 +/- 31.9 ms after Digoxin (p less than 0.05). The mean cycle length remained almost unchanged (841 +/- 113.2 ms before and 847 +/- 138.4 ms after Digoxin, no significance). Thus it is to be regarded as the clinical therapeutic consequence that in these patients the glycoside application in absence of syncopes or equivalents can be administered in most of the cases without previous pacemaker-implantation. In special cases, however, mainly if there are signs of greater disturbances of the sinus node function and of the SACT, electrophysical functional-analytic examination previous to the Digoxin long-term therapy should be performed.

[Simultaneous occurrence of arteriosclerosis obliterans and venous diseases]. / Zur Koinzidenz von Arteriosclerosis obliterans und der Venenerkrankungen.

It is reported on the pathophysiological peculiarities which may appear in the coincidence of the two vascular diseases. As therapy the fibrinolysis with Awelysin should always be taken into consideration.

[Complications during long-term control of the pressure in the pulmonary artery]. / Komplikationen bei Langzeitkontrolle des Pulmonalisdruckes.

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.

[Premonitory sign of myocardial rupture]. / Prämonitorische Zeichen der Myokardruptur

It is reported on 14 cases in which a rupture of the myocardium occurred following a myocardial infarction. The moment of the appearance as well as anamnestic and clinical peculiarities are examined. As the only usable symptom of the rupture the symptomatology of the electromechanic dissociation must be taken into consideration. Finally it is referred to the on principle possible operative consequences of the rupture of the myocardium (oversewing or infarctetomy).