Cardioversion of atrial fibrillation in the elderly. ALKK-Study Group. Arbeitsgemeinschaft Leitender Kardiologischer Krankenhausaerzte.

The purpose of this investigation was to define cardioversion success rates, frequency of complications of cardioversion, and current treatment practices in elderly patients (aged > or = 65 years) with atrial fibrillation (AF). The results were compared with those in younger patients (aged < 65 years). The investigation was a prospective multicenter observational study with 61 participating cardiology clinics. Consecutive patients in whom cardioversion of AF was planned had to be prospectively registered. Of 1,152 patients registered, 570 (49.5%) were < 65 years old (group 1) and 582 (50.5%) were > or = 65 years (group 2). The overall success rate of cardioversion on an intention-to-treat basis was 76.1% in group 1 and 72.7% in group 2 (p = 0.18). In multivariate analysis, left atrial size and New York Heart Association functional class before cardioversion were identified as predictors of success (p < 0.001, respectively; p = 0.025). These clinical factors were not equally distributed between the age groups: Left atrial size was larger in the elderly than in younger patients (44.0 +/- 6.4 mm vs 42.8 +/- 6.4 mm; p = 0.006) and a New York Heart Association functional class > or = II was more prevalent in group 2 than in group 1 (48.6% vs 29.6%; p < 0.001). The overall complication rates were not significantly different between the 2 groups (4.2% in group 1 vs 5.3% in group 2; p = 0.37). The frequency of patients who were adequately anticoagulated for cardioversion was 56.9% in age group 1 and 39.6% in age group 2 (p < 0.001). In chronic AF the same trend for age-dependent underuse of anticoagulation was observed. Age itself was not a predictor of cardioversion success and did not predispose to higher complication rates. Therefore, cardioversion should be considered in older patients with the same criteria and emphasis as in younger patients. Anticoagulation and antithrombotic medication is underused for cardioversion and in treating chronic AF, especially in elderly patients.

Comparison of saruplase and alteplase in acute myocardial infarction. SESAM Study Group. The Study in Europe with Saruplase and Alteplase in Myocardial Infarction.

Four hundred seventy-three patients with acute myocardial infarction (AMI) were treated with either saruplase (80 mg/hour, n = 236) or alteplase (100 mg every 3 hours, n = 237). Comedication included heparin and acetylsalicylic acid. Angiography was performed at 45 and 60 minutes after the start of thrombolytic therapy. When flow was insufficient, angiography was repeated at 90 minutes. Coronary angioplasty was then performed if Thrombolysis In Myocardial Infarction (TIMI) trial 0 to 1 flow was seen. Control angiography was at 24 to 40 hours. Baseline characteristics were similar. Angiography showed comparable and remarkably high early patency rates (TIMI 2 or 3 flow) in both treatment groups: at 45 minutes, 74.6% versus 68.9% (p = 0.22); and at 60 minutes 79.9% versus 75.3% (p = 0.26). Patency rates at 90 minutes before additional interventions were also comparable (79.9% and 81.4%). Angiographic reocclusion rates were not significantly different: 1.2% versus 2.4% (p = 0.68). After rescue angioplasty, angiographic reocclusion rates of 22.0% and 15.0% were observed. Safety data were similar for both groups. Thus, (1) early patency rates were high for saruplase and alteplase treatment, (2) reocclusion rates for both drugs were remarkably low, and (3) complication rates were similar. Thus, saruplase seems to be as safe and effective as alteplase.

HBW 023 (recombinant hirudin) for the acceleration of thrombolysis and prevention of coronary reocclusion in acute myocardial infarction: results of a dose-finding study (HIT-II) by the Arbeitsgemeinschaft Leitender Kardiologischer Krankenhausärzte.

OBJECTIVE: To define an optimal dose of hirudin that would improve early coronary artery Thrombolysis in Myocardial Infarction grade 3 (TIMI 3) patency and prevent reocclusions in patients with acute myocardial infarction treated with front-loaded recombinant tissue-type plasminogen activator (rt-PA). METHODS: Recombinant hirudin (HBW 023) was tested in a sequential dose-escalating study as adjunct to front-loaded rt-PA in 143 patients with acute myocardial infarction. The sequential model was assigned two 'decision boundaries': it triggered an increase in dosage if the 60-min TIMI 3 flow rate in a dosage group was statistically not consistent with a target patency rate of 75%, or if the deterioration in coronary blood flow (of at least one TIMI grade, from TIMI 2 or 3, from one angiography to the next) exceeded 5%. RESULTS: The decision boundary for TIMI 3 flow grade at 60 min was crossed when 18 patients were treated with 0.1/0.06 mg/kg (bolus/infusion per hour over 48 h) r-hirudin (dosage group I), 42 patients treated with 0.2/0.1 mg/kg (dosage group II), and 83 patients with 0.4/0.15 mg/kg (dosage group III). TIMI 3 flow at 60 min was 50%, 58%, and 63% in dosage groups I-III, respectively (P = 0.15). Early, complete, and sustained patency (TIMI 3 flow at 60 min, 90 min and 48 h) were 44%, 55% and 64% (P = 0.07). Reocclusion between 90-min and 48-h angiograms or reinfarction occurred in 0 to 15, two of 36, and one of 72 patients, respectively (P = 0.5). Four patients (2.8%) died in hospital and 14 patients suffered a major bleeding event, but no intracranial bleeding was encountered. CONCLUSIONS: With increasing doses of hirudin, there was a trend towards greater early and complete patency, but no clear dose--response relationship was observed. A borderline significant effect was observed with respect to early, complete, and sustained patencies. In all groups, reocclusions or reinfarctions were rare. Neither clinical nor laboratory data predicted the imbalance in haemorrhagic events observed in a subsequent, prematurely terminated, phase III trial with hirudin and rt-PA.

Carotid artery stenting in clinical practice results from the Carotid Artery Stenting (CAS)-registry of the Arbeitsgemeinschaft Leitende Kardiologische Krankenhausarzte (ALKK).

BACKGROUND: Carotid artery stenting (CAS) for symptomatic and asymptomatic carotid stenosis seems to be on the doorstep of more widespread use. However, its feasibility and safety in clinical practice at a broad spectrum of hospitals needs to be determined. METHODS: We analyzed data of the prospective multi-centre Carotid Artery Stenting (CAS) Registry of the German Arbeitsgemeinschaft Leitende Kardiologische Krankenhausarzte (ALKK). RESULTS: From 7/1996 to 5/2004 1888 patients from 28 hospitals were included in the CAS Registry. The median hospital stay from CAS until hospital discharge was 3 days (quartiles: 2-6 days). Median patients age was 70 years (quartiles: 64-76 years) with 72.1% males. CAS for symptomatic stenosis was performed in 55% of cases. Patients treated with CAS suffered from coronary artery disease in 66.5%, had arterial hypertension in 91.7%, hyperlipidemia in 86.3% and 34.2% were diabetics. The intended CAS procedure was completed in 98.1% of cases. A stent was implanted in 97.3% of completed cases. The median intervention time was 43 min (quartiles: 30-60 min). During the hospital stay death rate was 0.3% (5/1888) and the rate of ipsilateral stroke 3.2% (58/1840). A contralateral ischemic event occurred in 1.4% (26/ 1840) of patients. The combined rate of all death or strokes was 3.8% (70/1841). Between 1996 and 2004 there was a steady increase in the use of protection devices during CAS (0% in 1996 and 97.9% in 2004; p for trend <0.0001). There was also an increase in the proportion of patients treated for asymptomatic stenoses (p for trend <0.0001). We observed a decrease of the combined endpoint of death or stroke from 6.3% in 1996 to 1.9% in 2004 (p for trend=0.021). CONCLUSION: The multi-centre ALKK CAS Registry data confirm the feasibility and shot-term safety of CAS even in daily clinical practice. There was a rapid penetration of the use of embolic protection devices, an increase in treatment of asymptomatic carotid stenoses and a decrease in acute complication rates from 1996 to 2004.

[Efficacy and safety of treatment of acute ischemic stroke with glycoprotein IIb/IIIa receptor blocker in routine clinical practice]. / Wirksamkeit und Sicherheit einer Akuttherapie mit GPIIb/IIIa-Rezeptorblockern bei ischämischem zerebralem Insult in der klinisch-internistischen Routine.

BACKGROUND: Platelet aggregation plays an important pathophysiological role in the incidence of myocardial infarction and ischemic stroke. The expression of glycoprotein IIb/IIIa receptors on the surface of activated platelets is the final common pathway of platelet aggregation. PATIENTS AND METHODS: Encouraged by the favorable outcome in acute coronary syndromes and by preliminary results, which substantiate the efficacy and safety of GP IIa/III antagonists (GP) in ischemic stroke, we treated 21 cases/20 patients (13 male, 7 female, age 39-79 y.) and conducted a retrospective study using a clinical graduation scale (Modified Rankin Scale MRS). Patients received tirofiban (n = 18) or eptifibatide (n = 3) in the usual cardiological dose 3 h (0.5-8 h) after beginning of symptoms together with "full dose " heparin (n = 8) or "low dose" heparin (n = 12) in the acute phase, with aspirin 100 mg (n = 4), Clopidrogel 75 mg (n = 5), aspirin + clopidogrel (n = 4) in the chronic phase. All patients had a cranial CT, 95% an echocardiography and Doppler sonography of the carotid artery system and some cranial MRI (43%). RESULTS: There was no significant clinical deterioration. All except one patient showed a rapid and impressive improvement during the first 24 h after initiation of treatment (median MRS pre/post 3/1). CONCLUSION: The results with GP in acute ischemic stroke are promising and further studies should be initiated using especially tirofiban, but with monitoring by cerebral diffusion-weighted MRI before and after treatment.

Ventricular late potentials and inducible ventricular tachyarrhythmias as a marker for ventricular tachycardia after myocardial infarction.

To assess the predictive value of ventricular late potentials and programmed ventricular stimulation, 379 patients without a history of sustained ventricular tachycardia, dizziness or syncope were studied prospectively. Group I included patients referred for coronary angiography. Group II consisted of patients who survived an episode of acute myocardial infarction and who were studied within 6 weeks after onset. During follow-up (mean 13 months), 16 patients died. Six of these patients died suddenly within one hour. The prevalence of sudden cardiac death was lower (0.8%) in group I compared to group II (3.0%). There was no correlation between results of both methods and the subsequent occurrence of sudden cardiac death. Symptomatic sustained ventricular tachycardia was documented in 10 patients (2.6%). Only one patient in group I later developed symptomatic sustained ventricular tachycardia in contrast to nine cases in group II. Symptomatic sustained ventricular tachycardia could be predicted in patients in the early postmyocardial infarction period (group II). By using various combinations of parameters, the highest predictive value for subsequent sustained ventricular tachycardia was reached by the following combination: Late potentials of 40 ms duration or more, induction of monomorphic sustained ventricular tachycardia at rates below 270 beats min-1 and interval after myocardial infarction less than 6 weeks. In conclusion, both techniques seemed to be promising for the identification of patients at risk of ventricular tachycardia after myocardial infarction.

[Paradoxic response to disopyramide and quinidine (author's transl)]. / Paradoxe Reaktion nach Disopyramid und Chinidin.

Until recently, severe paradoxic responses to disopyramide have been believed to occur only, if at all, at extremely high doses. This credo has been shaken by some recent reports on severe ventricular tachyarrhythmias occurring in some patients on disopyramide. A further case (62 years, female, mitral commissurotomy in 1966, combined mitral valve lesion) is presented in whom a normal oral regimen (100 mg disopyramide four times daily) induced syncope due to ventricular tachycardia and flutter. The patient exhibited a long QT time before medication without deafness. Indication for treatment was the preservation of sinus rhythm as intermittent atrial fibrillation or flutter has been documented before. The serum potassium level was in the range of normal. Similar side-effects occurred some days later when the patient received quinidine sulfate. A survey of the most recent literature reveals a total of 20 patients with proven or suspected paradoxic responses to disopyramide. Factors that might favour the occurrence of paradoxic effects were preexisting QT prolongation, hypokaliemia, or massive overdosage. Though the total incidence of these side-effects seems to be relatively low, disopyramide should be given to special subgroups of patients only under careful monitoring.

[Antiarrhythmic effect of disopyramide in ventricular extrasystole and auricular fibrillation]. / Zur antiarrhythmischen Wirksamkeit von Disopyramid bei ventrikulärer Extrasystolie und Vorhofflimmern

Disopyramide (B 712) was tested in 39 patients with chronic arrhythmias of different kind: 23 cases with atrial fibrillation, 16 cases with ventricular ectopic beats, two cases with supraventricular tachycardias. The effect of disopyramide was compared to a pretreatment with one or several antiarrhythmic drugs (quinidine, beta-blocking agents, verapamil, ajmalin-bitartrat, aprindine, propafenone, diphenylhydantoin) which had been discontinued either due to ineffectiveness or the occurrence of intolerable side effects. Therapeutical effectiveness was controlled by on-line arrhythmia computers in the CCU or Holter monitoring. 15 patients were treated longer than 4 weeks up to 16 months (mean 35+/-22,6 weeks). The following results were achieved: 1 atrial fibrillation, abolition or significant reduction of the rate of recurrence in 10 out of 23 patients; slight reduction or no effect in 13 patients; 2. ventricular ectopic beats: abolition or significant reduction in 6 out of 16 patients, slight reduction or no effect in the remaining 10 patients. Patients who were treated successfully received the same dosis as those without therapeutical success. In cases with atrial fibrillation, the success was dependent on the duration of this arrhythmia prior to treatment. In comparison to the pretreatment with one or several of the above-mentioned anti-arrhythmic drugs, disopyramide was as effective as the drug given before. The analysis of the Ecg revealed a slight but insignificant prolongation of the time intervals. In 22 patients reversible dosage-dependent side effects were observed which are due to the vagolytic action of the drug: dry mouth, blurred vision, urinary hesitancy, nausea, headache. These side effects occurred at daily dosages between 400 to 800 mg increasing markedly in patients on 800 mg a day. The drug had to be discontinued in 4 cases because of side effects. During long-term treatment no severe side effects were observed. Thus, disopyramide may serve as an alternative to quinidine, especially if the latter has to be stopped because of side effects.

[A 17-years follow-up study after closed mitral commissurotomy (author's transl)]. / Verlaufsstudie bis 17 Jahre nach Mitralkommissurotomie.

410 patients were operated upon by closed mitral commissurotomy in 1961-62. Of this group, 224 patients were followed up until 1978. The actuarial survival rate after 16 to 17 years postoperatively was 58%. Overall 43 patients were reoperated (second commissurotomy or mitral valve replacement). The cumulative reoperation rate of these patients was 1.5% per year. The mortality rate in patients with reoperation was 1.2% per year, without reoperation 2% per year. 87 patients are still alive 17 years after mitral commissurotomy without reoperation. 59% of this group belong to functional class II or I (NYHA). Most of them have combined mitral valve disease with predominant mitral stenosis. Atrial fibrillation was present in 33% (n = 29) preoperatively and in 58% (n = 50) postoperatively at the end of the study. Only 20% of all patients were on anticoagulant therapy. Nevertheless, the total embolic rate (5.7%) and the cumulative embolic rate (0.2% per year) remained low. The good long-term results show that mitral commissurotomy is an effective therapeutic approach in patients with mitral stenosis.

Hemodynamic studies after De Vega's tricuspid annuloplasty.

Postoperative hemodynamic studies were conducted at rest and during exercise in 24 patients who, in addition to mitral and/or aortic valve surgery, had De Vega's tricuspid annuloplasty. To determine the degree of tricuspid insufficiency (TI), right atrial pressure (PRA) tracings, biplane right ventricular cineangiograms, and ultrasonic Doppler flow patterns were obtained. The TI improved in 14 patients, but still remained mild to moderate in 20 patients. In addition, a mild-to-moderate tricuspid stenosis with pressure gradients from 2 to 7.8 mm Hg were found in 12 patients. There was no significant change in the mean PRA, with 8.0 +/- 4.5 mm Hg preoperatively and 7.5 +/- 3.5 mm Hg postoperatively at rest. During exercise, PRA rose to 17.0 +/- 6.5 mm Hg. The unsatisfactory results are also due to the persistent elevation of left atrial and pulmonary artery pressure after left heart surgery. De Vega's annuloplasty does not answer the tricuspid challenge, since the results are unpredictable.

[Echocardiographic determination of the severity of mitral stenosis by the mitral valve closure index (author's transl)]. / Die Wertigkeit des Mitralklappenschliessungsindex in der echokardiographischen Quantifizierung der Mitralstenose.

In 34 patients with mitral stenosis or combined mitral valve disease class II, III or IV (NYHA), the mitral valve closure index (MVCI, Shiu et al. 1977), based on the rate of diastolic apposition of the anterior and posterior mitral leaflet echos, and the diastolic closure rate (EF-slope) were determined and compared with hemodynamic data such as mean left atrial pressure (PLA), mean diastolic pressure gradient across the stenotic valve (DP) and mitral valve orifice area (Q), calculated by the Gorlin formula. MVCI and EF-slope correlated more favorably with DP (MVCIr = -0.71, EF-sloper = -0.53) than with Q and PLA. The results were not different in patients with sinus rhythm or atrial fibrillation. Using MVCI or EF-slope thie discrimination between severe and moderate or between moderate and light mitral stenosis was uncertain. Nevertheless, MVCI below 30 was associated with light, above 50 with severe mitral stenosis. In spite of the relationship between MVCI or EF-slope and the severity of mitral stenosis, in the individual case an exact quantification of mitral stenosis is not possible due to the great variability of echocardiographic data. For the assessment of the severity of mitral stenosis the mitral valve closure index is not superior to the EF-slope.

[Long term results after operation of patent ductus arteriosus or ventricular septal defect and pulmonary hypertension (author's transl)]. / Langzeitbeobachtungen nach operativer Behandlung von Ductus arteriosus apertus und Ventrikelseptumdefekt mit Widerstandserhöhung in der Lungenstrombahn

The behaviour of pulmonary hypertension and elevated pulmonary vascular resistance was followed up to 12 years postoperatively in 29 patients with patent ductus arteriosus (DAA) and 34 patients with ventricular septal defect (VSD). 8 of 11 patients with VSD and rest defect underwent a second operation. All patients had preoperatively pulmonary hypertension due to elevated pulmonary vascular resistance (RPA) and elevated pulmonary blood flow. Pulmonary arterial mean pressure (PPA) was usually reduced immediately after operation corresponding to the reduced pulmonary blood flow. In the later postoperative period PPA and RPA were either reduced to normal values, reduced but not normalized or increased progressively. In patients with moderate elevation of RPA before operation (200-800 dyn - sec cm-5) 34 % showed normalisation of RPA, 11 % increase of RPA in the follow-up period. In patients with severe elevation of RPA before operation (greater than 800 dyn - sec - cm-5) 11 % showed normalisation, 30 % an increase of RPA in the follow-up period. There was no correlation between age at operation and the late postoperative results. Exercise test were useful to confirm normalisation of the pulmonary vascular changes. The results in patients with VSD and rest defect demonstrate that apparently small left-t0-right shunts are able to stop the involution of organic changes in the pulmonary arteries. Prognosis of follow-up cannot be established from the hemodynamic results obtained early after operation. Therefore repeated hemodynamic investigations have to be performed in the later follow-up period.

[Prognostic significance of programmed ventricular stimulation in the noninvasive registration of ventricular late potentials in the postinfarct period]. / Prognostische Bedeutung der programmierten Ventrikelstimulation und der nichtinvasiven Registrierung ventrikulärer Spätpotentiale in der Postinfarktperiode.

The prognostic significance of programmed ventricular stimulation for assessing ventricular vulnerability and of signal averaging for detection of ventricular late potentials was assessed prospectively in 132 survivors of acute myocardial infarction. The median day of these studies was the 22nd. Programmed ventricular stimulation (PVS) included single and double premature stimuli during sinus rhythm and paced ventricular rhythms at rates of 120, 140, 160 and 180 bpm. The endpoint for stimulation was the induction of 4 or more consecutive echo beats. 59 of 132 patients (45%) had late potentials in their body surface signal-averaged ECG. The prevalence was 35% in those with anterior wall infarction and 54% in those with inferior wall infarction (chi 2 = 3.9; p less than 0.05). In 61 patients (46%), 4 or more consecutive echo beats were induced. In 28 of these patients, sustained ventricular tachycardia or fibrillation were initiated. During follow-up (15 +/- 11 months; mean +/- S.D.), there were 4 sudden deaths. Neither PVS nor signal averaging were able to predict these events. Spontaneous symptomatic sustained ventricular tachycardia occurred in a total of 9 patients, all of whom had an abnormal PVS result (sensitivity 100%); 7 of these patients also had late potentials (sensitivity 78%). Stepwise analysis revealed that the combination of late potentials (duration greater than or equal to 40 ms), and of induction of sustained ventricular tachycardia at rates less than 270 bpm had the highest predictive value (50%). In contrast, the prevalence of sustained ventricular tachycardia was as low as 3% in those without late potentials.(ABSTRACT TRUNCATED AT 250 WORDS)

Central hemodynamics at rest and during exercise after mitral valve replacement with different prostheses.

To compare the hemodynamic features of different prosthetic heart valves that have equal tissue anulus diameter (29 mm or comparable), 75 patients with isolated mitral valve replacement (19 with Björk-Shiley Standard [BS], five with Hall-Kaster [HK], seven with Ionescu-Shiley [IS], 12 with Lillehei-Kaster [LK], 12 with Starr-Edwards [type 6120, SE], and 20 with St. Jude Medical [SJ] prostheses) were reexamined approximately 1 year after operation by right and left heart catheterization while they were at rest and during bicycle exercise. Mean pulmonary artery and mean left atrial pressure were reduced significantly in all the groups postoperatively. However, pulmonary artery and left atrial pressure were somewhat lower after BS and SJ implantation than the comparable pressures in the other groups. Normal values were reached only in a small number of patients, and the cardiac index remained at the lower limit of normal. Average diastolic pressure gradients in patients at rest were 2.3 +/- 0.6 mm Hg after SJ, 4.5 +/- 1.6 after BS, 5.2 +/- 3.3 after HK, 5.3 +/- 1.6 after IS, 7.1 +/- 1.3 after LK, and 6.3 +/- 2.0 after SE implantation. Effective valve orifice areas were calculated to be 3.1 +/- 0.8 cm2 in the SJ group and 2.2 +/- 0.5 cm2 in the BS group and even smaller in the other groups. Total volume loss does not seem to be significantly different among the valve types reexamined as determined by left ventricular angiography. For hemodynamic reasons, of all those prosthetic valves we compared, the SJ prosthesis appears to perform best in terms of lowest pressure gradients and largest effective orifice areas.