[Outcome quality in terms of product safety in preoperative autologous blood donation]. / Ergebnisqualität im Sinne der Produktsicherheit bei der präoperativen Eigenblutspende.

OBJECTIVE OF THE STUDY: The most common form of autologous blood transfusion is where blood is donated in anticipation of elective surgery. The aim of this study is to critically evaluate the product safety of autologous blood units. METHODS: The results are based on an analysis of the documented data and records of 22,630 cases with 21,553 patients and 49,650 autologous blood donations, blood processing and testing protocols, and reported transfusion reactions following autologous transfusions. RESULTS AND CONCLUSIONS: Autologous blood components are prepared individually, and an established system of quality assurance with controls of processes and products is particularly important to meet quality standards. The red cell content of autologous units cannot be standardized as in allogeneic components. Due to the differences between the laboratory screening programmes for patients and donors, the risk of transmission of virus infections is different from that of allogeneic blood components. The quality of stored autologous red cells is comparable to that of allogeneic products. Results of systematic sterility monitoring lead to the conclusion that under the conditions practised the risk of transfusion-associated sepsis is not higher to that of allogeneic products. Soluble biological response modifiers which accumulate during storage, are assumed to be the cause of reactions that occur in one of 4,500 autologous transfusions. Incorrect allocation and handling errors continue to be a serious problem in autologous transfusions.

Influence of tissue affinity of angiotensin-converting enzyme inhibitors on left ventricular remodeling after myocardial infarction.

BACKGROUND: The demonstration of local renin-angiotension systems has raised the question of whether angiotensin-converting enzyme (ACE) inhibitors with different tissue affinities differ with regard to their effects on postinfarction remodeling. HYPOTHESIS: The study was undertaken to investigate the influence of ACE inhibitors with different tissue affinity on morphology and function of the infarcted left ventricle. METHODS: In all, 52 patients (17 women, 35 men, 38-73 years) with large acute myocardial infarction were randomized to receive either 25-75 mg/day captopril or 10-20 mg/day fosinopril beginning on the Day 7 after infarction. Of these, 28 had anterior and 24 had posterior wall infarctions. Infarct size was determined by the creatine kinase integral method. Fifty patients were examined by cinemagnetic resonance imaging (CMRI) 1 and 26 weeks after infarction. The following parameters were determined: left ventricular end-diastolic and end-systolic volume index (LVEDVI, LVESVI), ejection fraction (LVEF), infarct weight, and muscle mass (LVMM). The volume-to-mass ratio (VMR) was calculated and the clinical status according to the guidelines of the New York Heart Association (NYHA) was documented at each examination time. The results were compared with those of a historical sample without ACE-inhibitor therapy examined in an identical manner (n = 31, 10 women, 21 men, 36-75 years). RESULTS: LVEDVI and LVESVI increased in the first 6 months after infarction by 24.9 and 36.6%, respectively, in the historical sample; by 11.0 and 7.8%, respectively, under captopril; and by 13.1 and 10.7%, respectively, under fosinopril. LVEF decreased by 14.9% in the untreated sample, by 3.7% under captopril and by 5.0% under fosinopril. Infarct weight and LVMM increased by 12.7 and 15.3%, respectively, without ACE inhibition, by 5.7 and 10.1%, respectively, in patients treated with captopril, and by 6.1 and 9.3%, respectively, in patients treated with fosinopril. The VMR increased by 7.4% in the historical sample, by 3.5% in the captopril group, and by 1.8% in the fosinopril group. The NYHA clinical status improved by 18.2% without ACE inhibition, by 42.9% in the captopril group, and by 26.3% in the fosinopril group. The differences between the two ACE-inhibitor groups and the reference group were all significant, while the differences between the captopril group and the fosinopril group were significant only for VMR (p < 0.01) and NYHA class (p < 0.05). CONCLUSIONS: Both captopril and fosinopril have a comparable positive influence on postinfarction remodeling and on clinical status. Lipophilicity and tissue affinity do not seem to play a clinically important role in ACE-inhibitor therapy after infarction.

Changes of the left ventricle after myocardial infarction--estimation with cine magnetic resonance imaging during the first six months.

BACKGROUND: In recent years, the interest of cardiologists has focused increasingly on the morphologic and functional changes of the left ventricle after myocardial infarction (MI), due to their great prognostic significance for the patient. HYPOTHESIS: The aim of this study was to evaluate changes in left ventricular morphology and function during the first 6 months following MI. METHODS: In all, 61 patients (17 women, 44 men, age 36-83 years) were examined with cine magnetic resonance imaging (CMRI) 1, 4, and 26 weeks after myocardial infarction. Thirty-two patients had anterior MI and 29 patients had posterior MI. According to enzyme-derived infarct weight, 15 patients had small infarcts (< 20 g), 19 had intermediate-sized infarcts (20-40 g), and 27 patients had large infarcts (> 40 g). CMRI was performed in the true short axis of the left ventricle. In each examination, left ventricular end-diastolic and end-systolic volume indices (LVEDVI, LVESVI), stroke volume index (LVSVI), ejection fraction (LVEF), and regional thickness, mass, and motility of the myocardial wall-diastolic thickness (IDdia), infarct mass (IM) and motility (IMOT) of the infarct area and diastolic and systolic thickness (VDdia, VDsys), muscular mass (VM), and motility (VMOT)-were determined. In addition, patients were divided into subgroups according to New York Heart Association (NYHA) functional status at baseline. RESULTS: In the total group, LVEDVI increased from 73.9 +/- 23.5 ml/m2 to 85.4 +/- 28.1 ml/m2 (p < 0.001) and LVESVI from 40.5 +/- 19.4 ml/m2 to 51.2 +/- 29.0 ml/m2 (p < 0.001). In the subgroups the development depended on infarct size and location. LVSVI and LVEF remained more or less constant except for large anterior infarctions. All changes of the myocardial wall depended on infarct size and location: In all patients IDdia decreased from 10.4 +/- 1.6 mm to 8.9 +/- 1.7 mm (p < 0.001), IMOT from 2.0 +/- 1.6 mm to 0.5 +/- 2.9 mm (p < 0.001). IM increased from 41 +/- 21 g to 45 +/- 25 g (p < 0.001). In the total group, VDdia increased from 11.9 +/- 1.6 mm to 12.4 +/- 1.8 mm (p < 0.05), VDsys from 16.6 +/- 2.5 mm to 17.2 +/- 3.1 mm (p < 0.05). In the subgroups changes varied: VDdia and VDsys decreased markedly in large anterior wall infarctions. VM increased in the total cohort from a mean of 246 +/- 66 g to 276 +/- 80 g (p < 0.001). VMOT decreased from 7.1 +/- 2.4 mm to 6.3 +/- 2.7 mm (p < 0.05). Loss of motility was most pronounced in anterior infarctions. The volume-mass ratio, a measure of the success of compensation of volume increase by myocardial hypertrophy, decreased in small infarcts, remained unchanged in intermediate infarcts, and increased in large infarcts. There was a trend toward improvement of the NYHA functional status during the observation period. CONCLUSIONS: Changes of the left ventricular chamber during the first 6 months following MI are dependent on its size and location, with large anterior infarctions having the worst course. Myocardial wall remodeling is also dependent on infarct size and location, and the volume-mass ratio increases in the presence of large areas of necrosis, indicating the non-compensatory effect of myocardial hypertrophy. However, these changes have no clinical effect during the first half year after MI.

[Effect of infarct size and site, patency of the infarct vessel and perfusion of vital myocardium on remodeling of the left ventricle--studies with cine-magnetic resonance tomography in the first 6 months following myocardial infarct]. / Einfluss von Infarktgrösse und -lokalisation, Offenheit des Infarktgefässes sowie Perfusion des vitalen Myokards auf das Remodeling des linken Ventrikels--Untersuchungen mit der Cine-Magnetresonanztomographie in den ersten 6 Monaten nach Myokardinfarkt.

BACKGROUND: Aim of the study was to evaluate the influence of infarct size and location and patency of the infarction and non-infarction vessels on left ventricular morphology and function in the first 6 months after myocardial infarction. METHODS: 61 patients (17 female, 44 male, 36-83 years) were examined with Cine Magnetic Resonance Imaging (CMRI) 1 and 26 weeks, and with coronary angiography 4 weeks after infarction. 32 patients had anterior, 29 patients posterior myocardial infarction. 15 patients had small infarcts (< 20 gm), 19 intermediate sized (20-40 gm) and 27 patients large infarcts (> 40 gm). CMRI was done in short axis of the left ventricle. Left ventricular enddiastolic and endsystolic volume indices (LVEDVI, LVESVI), ejection fraction (LVEF), muscle mass (VM) and motility (VMOT) of the vital myocardium, mass (IM) and area (IA) of the infarction zone, and volume-mass-ratio (VMR) of the left ventricle were determined on each examination. RESULTS: After 6 months large infarctions had 25% more LVEDVI, 41% more LVESVI, 20% less LVEF, 11% more VM, 13% less VMOT, 13% more IM, 47% more IA, and a 17% increased VMR compared to small infarcts. Anterior infarctions showed 11% more LVEDVI, 19% more LVESVI, 7% less LVEF, 4% more VM, the same VMOT, 5% more IM, 21% more IA, and 6% more VMR than posterior infarctions. If the infarction vessel was not perfused, after 6 months LVEDVI was 12% more, LVESVI 19% more, LVEF 7% smaller, VM 4% less, VMOT the same, IM 5% more, IA 17% more, and VMR 7% more increased than in the group with open infarction artery. When both non-infarction vessels were stenosed, LVEDVI rose 24% more, LVESVI 49% more, LVEF fell 25% more, VM rose 12% more, VMOT fell 26% more, and VMR rose 12% more than in patients with indisturbed perfusion of the vital myocardium. CONCLUSION: Perfusions of the vital myocardium and infarct size seem to be the most important factors for post infarction remodeling of the left ventricle. Infarct location and patency of the infarction vessel are of less influence.

Magnetic resonance angiography as a technique for the visualization of hemodialysis shunts.

In order to test the suitability of magnetic resonance angiography for the visualization of Brescia-Cimino hemodialysis shunts, 20 patients (8 women, 12 men, aged 24-69 years) were examined with this technique. The shunt arm was placed in an extremity coil. The time-of-flight method was applied. Examination time was less than 15 min. Arterial digital subtraction angiography (DSA) of the shunt arm was carried out additionally in 8 patients in whom pathological results had been obtained. Surgery was performed on 2 patients. In all cases, the feeding artery, anastomosis, and shunt were clearly visible. The results corresponded exactly to those of DSA and, in the patients who had undergone surgery, also to the situs. The patients stated that the examination technique was not very disturbing. Magnetic resonance angiography in the time-of-flight technique seems to be recommendable for the examination of Brescia-Cimino dialysis shunts. Compared to DSA, it has major advantages: it is noninvasive, and no ionizing radiation or contrast medium are associated with the procedure.

[Optimized "baby preserves" of transfusion in premature infants]. / Optimierte "Babykonserven" für die Transfusion bei Frühgeborenen.

For transfusion therapy of premature infants special packed red cells '0 rh-negative, anti-CMV-negative, hemolysin-free' are of great value. To optimize the preparations, we examined the influence of leukocyte depletion, suspension in SAGM and irradiation on ATP level, pH, free hemoglobin and potassium level. Results show the advantage of filtration and SAGM solution especially in respect to the ATP level. Irradiation leads to an increase of potassium to a twofold level, but is not of clinical significance in running time.

Assessment of cardiac output during exercise. Transthoracic impedance vs. heart rate alone.

Previous investigators demonstrated divergent results, when comparing impedance to other established methods for the assessment of cardiac output. Cardiac output is defined as stroke volume multiplied by heart rate. Heart rate is easy to measure and the main determinant of cardiac output during exercise under physiologic conditions. Therefore, cardiac output (CO) by tetrapolar impedance cardiography (TIC) was compared to thermodilution (TD) in 35 patients (P). In a second step it was examined how heart rate alone would perform as a predictor of CO under exercise. Measurements were done at rest, 25, 50, 75, and 100 w. Results were corrected for hematocrit (HCT). There was no correlation between CO by TD and by TIC at rest (r = -0.006). Under exercise correlation was somewhat better with r = 0.45 despite correction for HCT. Mean values were similar, but scatter was wide. Relative increase in CO by both methods was also correlated (r = 0.46), while heart rate alone correlated best to TD (r = 0.65). Transthoracic impedance cardiography is not a reliable technique to measure absolute values of cardiac output at rest. During exercise large scatter limits this method to the measurement of CO in larger groups. At exercise heart rate alone appears to be a better indicator of increase of cardiac output than impedance cardiography.

[Severe course of delirium tremens. Results of treatment and late prognosis]. / Das schwer verlaufende Delirium tremens. Behandlungsergebnisse und Spätprognose.

80 patients (P) (68 men and twelve women) with the diagnosis of delirium tremens were retrospectively analyzed and reexamined over a period of ten years (1974 to 1984). Included were only patients who--after failure of oral medication--required intravenous therapy with Chlomethiazol and thereby intensive care treatment. Mean age was 46.2 (26 to 75) years. During the observation period delirium tremens increased in frequency by 11% each year. Nine patients had two, six patients three and two patients four episodes of delirium tremens. In 86.7% delirium tremens occurred with fatty liver and alcoholic hepatitis, epileptic seizures, cirrhosis and hepatic coma, gastrointestinal hemorrhage and pancreatitis. Eight patients (10%) died in hospital at a mean age of 53.2 years. None of the deceased had less than three (on average four) complicating or associated diseases. These were mostly pneumonia, cirrhosis, hepatic coma, and gastrointestinal hemorrhage. The mean duration of intravenous Chlomethiazol therapy was 4.7 (0.25 to 20) days, the applied dose 26.2 (0.8 to 78.6) grams, there being no significant difference between survivors and non-survivors. Of the 72 survivors 62 were invited for follow-up examination after an average of five years. During this period another twelve patients (15%) died of pneumonia, gastrointestinal bleeding, cardiocirculatory failure and accidents. Life expectancy was only 9.3 years. Of 29 patients who came for follow-up, 55% showed clinical evidence of alcohol dependency, 65% had elevated gamma-glutamyl-transferase.(ABSTRACT TRUNCATED AT 250 WORDS)

[Left ventricular diastolic function in heart failure--a Doppler echocardiography study]. / Die linksventrikuläre diastolische Funktion bei der Herzinsuffizienz--eine dopplerechokardiographische Untersuchung.

Assessment of transmitral flow by Doppler echocardiography allows measurement of changes in left ventricular filling patterns in patients with cardiac disease. Typically a decrease in early diastolic flow velocity and increase in late diastolic flow velocity is found in various cardiac diseases. In order to assess the influence of overt heart failure on transmitral velocity profiles these were measured in 20 patients with a history of myocardial infarction and in 10 normal controls (group I). Of those patients with coronary heart disease 10 patients were in overt heart failure according to clinical and radiological criteria (group II); another 10 patients were compensated after treatment for heart failure (group III). In decompensated group II early diastolic flow velocity (E) was 91.2 cm/s and higher than 67.9 cm/s in group III (p less than 0.05) compared to 68.8 cm/s in the control group. In contrast late diastolic flow (A) at the time of atrial contraction was 41.2 cm/s in group II, 81.3 cm/s in group III, and 65.0 cm/s in group I (p less than 0.05). The ratio between early and late diastolic flow velocities (E/A) was 2.58 in group II, 0.87 in group III, and 1.06 in group I (p less than 0.05). Deceleration halftime was significantly shorter in group II as compared to the other two groups (p less than 0.05). These results can be interpreted as masking of the pathological flow patterns of the underlying heart disease (E/A ratio) by elevated left atrial filling pressure that leads to inversion of the pathologically altered velocity profiles of the underlying heart disease. These results might gain practical value for the care of patients in congestive heart failure if follow-up studies should demonstrate conversion of the flow pattern of group II to that of group III under treatment.

Temporal relationship between exercise and QT shortening in patients with QT pacemakers.

The present study was undertaken to examine the temporal relationship between exercise and QT interval shortening as one of the principal determinants for the functioning of QT pacemakers. Ten patients (mean age of 72.6 years) with implanted QT pacemakers were subjected to supine bicycle exercise with two different slopes, 90% and 80%. The QT interval as seen by the pacemaker was monitored by telemetry and stored on magnetic tape. After the beginning of exercise QT prolongation of a few msec occurred up to 40 sec in most patients. The earliest QT shortening of 4 msec was noted after 63.4 sec with 90% slope and 75.7 sec with 80% slope. The difference was not significant. The further time course was dependent on slope and pacemaker algorithm. Maximal QT shortening was 65.9 msec with 90% and 69.8 msec with 80% slope. It was seen 29.2 sec after termination of exercise with 90% slope and 69.5 sec with 80% slope (P less than 0.05). There was no correlation of the measured delays with age. Earliest rate response in QT driven pacemakers is determined by earliest QT shortening on one hand and by the slope setting of the pacemaker on the other, where the limiting parameter appears to be QT shortening, which occurs after the first minute of exercise.

Improved rate responsive algorithm in QT driven pacemakers--evaluation of initial response to exercise.

The QT pacemaker is a rate modulated pacemaker that uses the evoked QT interval as an indicator to determine its optimal pacing rate. Despite the generally favorable clinical results with this form of pacing, some flaws in the system have been reported, such as the frequently observed rather slow initial response of the pacing rate to physical exercise, and the phenomenon of oscillation of the heart rate. These problems can be attributed to the rate adaptive algorithm used in the current QT pacemaker. Recently, in a reexamination of the relationship between evoked QT interval and pacing rate, a curvilinear relationship between these parameters has been demonstrated. As a result, a new algorithm has been developed for the next generation of the QT pacemaker. Before this new algorithm was implemented in new implantable devices, it was evaluated in a multicenter clinical investigation, with emphasis on the initial response of the pacing rate to exercise. This study was carried out by means of special software in the programmer of the QT pacemaker. By employing real-time bidirectional telemetry, it was possible to submit the study population, consisting of 37 patients with implanted QT pacemakers of the current generation, to identical exercise tests. Comparing these exercise tests, it appears that a considerable gain in speed of response to exercise can be achieved by using the same sensor with a faster reacting, nonlinear rate adaptive algorithm.

[Impedance cardiography during exercise in the evaluation of left-ventricular function]. / Das Impedanzkardiogramm unter Belastung zur Beurteilung der linksventrikulären Funktion.

The measurement of mean pulmonary artery pressure is an important parameter for the assessment of left ventricular function. Transthoracic impedance cardiography is a method which, by measurement of transthoracic impedance, gives information on hemodynamic events, parameters of contractility, and valvular heart disease. In 50 patients mean pulmonary artery pressure was measured at rest and during exercise and compared to the corresponding changes in the impedance cardiogram. It was examined whether by means of impedance cardiography an elevated pulmonary artery pressure could be predicted. Group I consisted of 25 patients with normal pulmonary artery pressure at rest and during exercise, group II of 25 patient with pathologic pressure elevation. While the behavior of stroke volume, cardiac output, left ventricular ejection time, and Heather Index as measured by impedance cardiography did not allow a prediction of elevated pulmonary artery pressure, the impedance ratio O/dz/dtmin (IQ) was significantly greater in group II than in group I. In the patients tested elevated and normal pulmonary artery pressure during exercise could be predicted with an accuracy of 84%. The mean value of dz/dtmin at a work load of 100 watt was slightly but significantly higher in group I than in group II. The results show that the impedance ratio (IQ) can be used to assess left ventricular function non-invasively.