Primary percutaneous coronary intervention in acute myocardial infarction: direct transportation to catheterization laboratory by emergency teams reduces door-to-balloon time.

BACKGROUND: Primary percutaneous coronary intervention (PCI) is the recommended revascularization strategy for patients presenting with acute ST-elevation myocardial infarction (STEMI). In most hospitals, transfer of patients with STEMI is organized from the emergency site via emergency room (medical and cardiologic evaluation) and then to the catheterization laboratory. HYPOTHESIS: In this prospective study, we sought to evaluate the effect of a logistic modification in this treatment process. METHODS: Local emergency ambulance teams were instructed to identify and evaluate patients with STEMI eligible for direct PCI and to transport them directly to the cardiac catheterization laboratory for immediate percutaneous coronary intervention ("ER bypass"). This study prospectively included 74 consecutive patients with acute coronary syndromes (STEMI) and compared them with a matched historic control group ("ER evaluation"). Primary endpoint was the reduction in door-to-balloon time; secondary endpoint was quality of preclinical emergency diagnosis. RESULTS: Median door-to-balloon time was reduced by 27 min. Primary interventional success was achieved in 92% of patients. Preclinical emergency diagnoses were correct in 95% of patients. CONCLUSION: The preclinical emergency diagnosis of STEMI was reliable. Direct transport of patients with STEMI to the cardiac catheterization laboratory and early preclinical alert by the interventional PCI team significantly reduces door-to-balloon-times compared with established standard processes-of-care for patients considered for primary PCI.

Implantation of the permanent Jarvik-2000 left ventricular assist device: a single-center experience.

OBJECTIVES: We sought to evaluate the surgical results and effects of continuous support with the permanent Jarvik-2000 left ventricular assist device (LVAD). We report the early outcomes. BACKGROUND: A shortage of transplant donors necessitates the testing of alternative treatments. The Jarvik-2000 is an axial flow pump with a percutaneous retro-auricular power connector, designed for permanent use. METHODS: Patients with severe heart failure (HF), unsuitable for heart transplantation or conventional LVAD support, were offered implantation. The surgical approach included a left lateral thoracotomy. The device was implanted into the left ventricular apex on femoro-femoral bypass. It is set to allow pulsatile flow with an aortic valve opening. Anticoagulation is adjusted the same as for patients with a heart valve. RESULTS: Between May 2001 and August 2001, we implanted the Jarvik-2000 in two patients with dilated cardiomyopathy and in one with cardiac amyloidosis, all with severe HF (cardiac index 1.8 +/- 0.3 l/m(2) per min). One patient required preoperative inotropic support. All patients did well, with no repeat operations or infections. Patients received 4.3 +/- 3.2 packed red blood cells and were intubated at 14 +/- 3 h, and the intensive care unit stay was 7.0 +/- 0.5 days. The cardiac index increased from 3.7 +/- 1.5 l/min per m(2) at 8,000 rpm to 5.9 +/- 2.9 l/min per m(2) at 12,000 rpm. All patients currently have mild hemolysis not requiring transfusion. The following postoperative events were recorded: a transient ischemic attack with complete recovery, a short re-intubation due to ventricular arrhythmia, loss of consciousness with a battery change while standing, knee-joint effusion after ergometry training, a minor wound problem and a short hospital re-admission due to dehydration. Patients were discharged home after 49 +/- 7 days; one has returned to work. All quality-of-life scores have improved. CONCLUSIONS: The permanent Jarvik-2000 appears safe. It can be used for dilative or restrictive disease. The Jarvik-2000 might prove a valid option for the long-term treatment of patients with severe HF.

Corrective Operation in an Intramyocardial Dissecting Hemorrhage After Subacute Anterior Myocardial Infarction.

Intramyocardial dissecting hemorrhage is a very rare and potentially lethal complication of myocardial infarction. The diagnosis is typically made by echocardiography, by cardiac magnetic resonance imaging, at operation, or during postmortem examination. Medical treatment is most often associated with high mortality, and surgical treatment is required. We report a 53-year old man admitted to the urology department with a large left-sided kidney infarction. A subacute myocardial infarction by electrocardiogram, elevated troponin T level, and typical clinical signs of an acute coronary syndrome 5 days and 2 weeks before admission were also evident. Intramyocardial dissecting hemorrhage with an adjacent thrombotic formation was suspected by echocardiography and cardiac computed tomography and confirmed by magnetic resonance imaging. The patient underwent successful surgical correction and was discharged in good clinical condition.

Implantable left ventricular assist device for treatment of pulmonary hypertension in candidates for orthotopic heart transplantation-a preliminary study.

OBJECTIVES: Elevated pulmonary vascular resistance (PVR) unresponsive to pharmacological intervention is a major limitation in heart transplantation (HTX). The post-operative course of these patients is associated with an increased risk of life-threatening right heart failure. We evaluated the efficiency of an implantable left ventricular assist device (LVAD) to decrease PVR by unloading the left ventricle and to lower the risk of later orthotopic HTX. METHODS: Six patients with end-stage heart failure (NYHA class IV) and 'fixed' pulmonary hypertension (PVR 5.7+/-0.7, range 4.4-6.5 Wood units) were analyzed. Despite maximal pharmacological intervention at initial evaluation (oxygen inhalation, nitrates, alprostadil infusion) PVR could not be reduced to under 2.5 Wood units. Four patients received a TCI Heartmate, one patient a Novacor, and one patient a Jarvik 2000. RESULTS: All patients survived the LVAD implantation, four patients could be discharged from hospital. Cardiac index and pulmonary artery pressure values returned to normal during the early post-operative phase. After a mean support time of 191+/-86 days PVR had fallen to 2.0+/-1.2 (range 0.8-3.6) Wood units. All patients could be bridged to transplantation, one patient died 3 months after transplant, five patients are still alive after a mean follow-up of 16.2+/-10.5 months. CONCLUSIONS: Mechanical support using an implantable LVAD is a very efficient approach with an acceptable risk to treat severe pulmonary hypertension in end-stage heart failure patients before HTX. Adequate reduction of PVR can be expected within 3-6 months. Subsequent HTX is associated with a good outcome.

A "little bit illegal"? Withholding and withdrawing of mechanical ventilation in the eyes of German intensive care physicians.

UNLABELLED: RESEARCH QUESTIONS AND BACKGROUND: This study explores a highly controversial issue of medical care in Germany: the decision to withhold or withdraw mechanical ventilation in critically ill patients. It analyzes difficulties in making these decisions and the physicians' uncertainty in understanding the German terminology of Sterbehilfe, which is used in the context of treatment limitation. Used in everyday language, the word Sterbehilfe carries connotations such as helping the patient in the dying process or helping the patient to enter the dying process. Yet, in the legal and ethical discourse Sterbehilfe indicates several concepts: (1) treatment limitation, i.e., withholding or withdrawing life-sustaining treatment (passive Sterbehilfe), (2) the use of medication for symptom control while taking into account the risk of hastening the patient's death (indirekte Sterbehilfe), and (3) measures to deliberately terminate the patient's life (aktive Sterbehilfe). The terminology of Sterbehilfe has been criticized for being too complex and misleading, particularly for practical purposes. MATERIALS AND METHODS: An exploratory study based on qualitative interviews was conducted with 28 physicians from nine medical intensive care units in tertiary care hospitals in the German federal state of Baden-Wuerttemberg. The method of data collection was a problem-centered, semi-structured interview using two authentic clinical case examples. In order to shed light on the relation between the physicians' concepts and the ethical and legal frames of reference, we analyzed their way of using the terms passive and aktive Sterbehilfe. RESULTS: Generally, the physicians were more hesitant in making decisions to withdraw rather than withhold mechanical ventilation. Almost half of them assumed a categorical prohibition to withdraw any mechanical ventilation and more than one third felt that treatment ought not to be withdrawn at all. Physicians showed specific uncertainty about classifying the withdrawal of mechanical ventilation as passive Sterbehilfe, and had difficulties understanding that terminating ventilation is not basically illegal, but the permissibility of withdrawal depends on the situation. CONCLUSIONS: The physicians' knowledge and skills in interpreting clinical ethical dilemmas require specific improvement on the one hand; on the other hand, the terms passive and aktive Sterbehilfe are less clear than desirable and not as easy to use in clinical practice. Fear of making unjustified or illegal decisions may motivate physicians to continue (even futile) treatment. Physicians strongly opt for more open discussion about end-of-life care to allow for discontinuation of futile treatment and to reduce conflict.

Stenting of unprotected left main stem stenosis in cardiogenic shock after orthotopic heart transplantation.

We report the spectacular case of a young patient who developed cardiogenic shock caused by significant stenosis of the left main stem 8 years after orthotopic cardiac transplantation. Immediate percutaneous coronary intervention was a life saving procedure. The report illustrates the importance of early coronary angiography for the clinical management of heart transplant patients in cardiogenic shock as a relevant differential diagnosis to acute rejection. Allograft vasculopathy can develop unexpectedly even after years of uncomplicated follow-up.

A fistula between the circumflex artery and the coronary sinus mimicks coronary artery disease in a 63-year-old woman.

A 63-year-old woman presented with angina and shortness of breath (NYHA III). Selective coronary angiography revealed a gross AV-fistula between the circumflex artery and the coronary sinus. The patient underwent operative closure of the fistula and was discharged home without symptoms.

Hirudin in acute coronary syndromes.

Acute coronary syndromes are a major cause of morbidity and mortality in Western societies. The term describes a spectrum from unstable angina, the recently defined non-Q wave infarction (the Non ST-Elevation Myocardial Infarction [NSTEMI]), to acute transmural myocardial infarction. With regard to treatment, a series of recently published studies compared the specific direct thrombin inhibitor hirudin with standard unfractionated heparin. Initial small studies showed promising results and led to the initiation of large-scale clinical trials addressing patients with acute coronary syndromes. However, in these studies, an unacceptably high incidence of serious hemorrhagic complications prompted safety boards to stop trials. In those studies carried out according to the protocol, no significant clinical benefit of hirudin over standard heparin was proved. Here, hirudin has been shown to be equivalent to unfractionated heparin for the treatment of unstable coronary syndromes with or without ST elevation and as an adjunct to percutaneous coronary balloon angioplasty. Because of its narrow therapeutic window between clinical benefit and increased bleeding hazards, hirudin should be used cautiously. For patients with heparin-induced thrombocytopenia, hirudin is accepted as an important therapeutic alternative.

Results after MIDCAB and OPCAB surgeries: problems and consequences of incomplete angiographic follow-up in the mid-term course.

OBJECTIVE: The aim of this study was to evaluate the mid-term course of all patients who had undergone minimally invasive coronary artery bypass grafting in our department between January 1996 and September 2001. The procedures were performed on the beating heart without the use of cardiopulmonary bypass. Either median sternotomy (60 patients) or anterolateral thoracotomy (29 patients) was used for access. Evaluation focused on perioperative complications, quality of life, clinical status, graft patency, survival and freedom from cardiac events. Special emphasis was put on the problems and consequences of incomplete angiographic follow-up. METHODS: Survival and postoperative cardiac events of all patients were evaluated. All surviving patients were invited for follow-up examination. Angiographic control was recommended to all patients. RESULTS: Survival after 30 days was 100%. Two patients (2%) suffered from perioperative myocardial infarction due to early graft failure, which required reoperation in standard technique in both cases. Mean follow-up period was 25 months. Mean NYHA class improved from preoperative 2.3 to current 1.6, and the mean CCS class from 2.1 to 0.8. Angiographic controls were performed in 46/89 patients. Fifty-three anastomoses were evaluated, 47 of which showed no occlusion (patency rate 89%). Forty-two anastomoses (79%) were free of significant stenosis. In 27 patients without symptoms we recommended angiography for control purposes and observed a patency rate of 97%. Nineteen patients had already undergone angiographic control due to clinical complaints prior to follow-up examination. That group's graft patency rate was 78%. Survival was 98% after 1 year and 94% after 3 years. Survival free of cardiac events (myocardial infarction, reoperation, percutaneous transluminal coronary angioplasty) was 86% in the first year and 80% after 3 years. CONCLUSIONS: The results concerning survival, freedom from events, and clinical status are encouraging. It was not possible to perform angiographic controls in all patients since some of them and their primary physicians could not be convinced of the necessity of this control in the absence of clinical complaints. This explains the negative bias in our results.