Optical, structural and electrical investigations of TiO2/multi-walled carbon nanotube composites.

Nanocomposites of TiO2 and multi-walled carbon nanotubes (MWNTs) were produced by the addition of different concentrations of MWNTs to a TiO2 sol matrix. Conductive coatings were prepared by spin coating the nanocomposite sols on glass substrates and sintering the samples at 300 degrees C for 15 min. No crystalline phase of TiO2 was formed at this temperature. The sheet resistance of the coatings was decreased from some hundreds of Momega/sq to just a few komega/sq by the addition of MWNTs to the TiO2 matrix. Moreover, sintering of the coatings in a reducing atmosphere has lead to a lower sheet resistance than that presented by coatings sintered in air. The lowest resistivity of 2.0 x 10(-1) omega x cm was obtained by coatings prepared with 5.0 mg/ml MWNTs in the composite sol. The optical, structural and electrical properties of the coatings were correlated and demonstrated.

Echo-guided percutaneous coil embolization of a symptomatic massive metastasis of a renal cell carcinoma in the right ventricular outflow tract.

We present the case of a 41-year-old woman who was admitted to our centre with progressive symptoms of congestive heart failure (NYHA class III) 5 years after a radical nephrectomy for renal cell carcinoma. Magnetic resonance imaging demonstrated a 5 x 3 cm homogeneous intracardial mass causing right ventricular outflow tract obstruction, not accessible to surgical resection. Serial echo-guided, percutaneous coil embolization of the cardial metastasis was performed with Contour SE Microparticles (150-250 or 300-500 microm) after identification of the target region of the metastasis by contrast injection (Levovist) through the balloon catheter into the coronary artery under transoesophageal echocardiographic control prior to induction of the necrosis, corresponding to the technique which has been described for septal ablation in hypertrophic obstructive cardiomyopathy. Follow-up after serial embolization showed a good haemodynamic and a marked clinical response (dyspnoea NYHA I-II) which lasted during the 19 month of survival after the index procedure.

Percutaneous transluminal septal myocardial ablation in hypertrophic obstructive cardiomyopathy: acute results and 3-month follow-up in 25 patients.

OBJECTIVES: We report the acute results and midterm clinical course after percutaneous transluminal septal myocardial ablation (PTSMA) in symptomatic patients with hypertrophic obstructive cardiomyopathy (HOCM). BACKGROUND: In the treatment of HOCM, surgical myectomy and DDD pacemaker therapy are considered the standard procedural extensions to drug therapy with negatively inotropic drugs. As an alternative nonsurgical procedure for reducing the left ventricular outflow tract (LVOT) gradient, PTSMA by alcohol-induced septal branch occlusion was introduced. However, clinical follow-up has not been sufficiently described. METHODS: In 25 patients (13 women, 12 men; mean [+/- SD] age 54.7 +/- 15.0 years) who were symptomatic despite sufficient drug therapy, 1.4 +/- 0.6 septal branches were occluded with an injection of 4.1 +/- 2.6 ml of alcohol (96%) to ablate the hypertrophied interventricular septum. After 3-months, follow-up results of LVOT gradients and clinical course were determined. RESULTS: The invasively determined LVOT gradients could be reduced in 22 patients (88%), with a mean reduction from 61.8 +/- 29.8 mm Hg (range 4 to 152) to 19.4 +/- 20.8 mm Hg (range 0 to 74) at rest (p < 0.0001) and from 141.4 +/- 45.3 mm Hg (range 76 to 240) to 61.1 +/- 40.1 mm Hg (range 0 to 135) after extrasystole. All patients had angina pectoris for 24 h. The maximal creatine kinase increase was 780 +/- 436 U/liter (range 305 to 1,810) after 11.1 +/- 6.0 h (range 4 to 24). Thirteen patients (52%) developed a trifascicular block for 5 min to 8 days requiring temporary (n = 8 [32%]) or permanent (DDD) pacemaker implantation (n = 5 [20%]). An 86-year old woman died 8 days after successful intervention of uncontrollable ventricular fibrillation in conjunction with beta-sympathomimetics in chronically obstructive pulmonary disease. The remaining patients were discharged after 11.3 +/- 5.4 days (range 5 to 24), after an uncomplicated hospital course. Clinical and echocardiographic follow-up was achieved in all 24 surviving patients after 3 months. No cardiac complications occurred. Twenty-one patients (88%) showed clinical improvement, with a New York Heart Association functional class of 1.4 +/- 1.1. A further reduction in LVOT gradient was shown in 14 patients (58%). CONCLUSIONS: PTSMA of HOCM is a promising nonsurgical technique for septal myocardial reduction, with a consecutive reduction in LVOT gradient. Possible complications are trifascicular blocks, requiring permanent pacemaker implantation, and tachycardiac rhythm disturbances. Clinical long-term observations of larger patient series and a comparison with conventional forms of therapy are necessary to determine the conclusive therapeutic significance.

Moraxella catarrhalis endocarditis: report of a case and literature review.

A 53-year-old man developed severe acute systemic illness three weeks after an upper respiratory tract infection. Serial blood cultures grew Moraxella catarrhalis. During antibiotic treatment, fever and infectious parameters disappeared, but severe aortic regurgitation developed. Aortic valve replacement was performed, during which extensive destruction of the aortic valve was noted. Endocarditis due to M. catarrhalis is very rare with, to our knowledge, only six cases having been reported to date. M. catarrhalis is a normal commensal of the upper respiratory tract, but in unpredictable circumstances can become an important pathogen. Bacteremia due to this organism therefore requires prompt treatment, as serious organ complications, including endocarditis, can occur.

[Emergency percutaneous valvulotomy with the Inoue balloon in high grade mitral valve stenosis in pregnancy]. / Notfallmässige perkutane Valvulotomie mit dem Inoue-Ballon bei hochgradiger Mitralstenose in der Schwangerschaft.

CASE REPORT: A 26-year-old pregnant woman (18th week of pregnancy) was admitted to a hospital with right heart failure and pulmonary congestion. After establishing the diagnosis of mitral stenosis, a first stabilization could be achieved by medical therapy with digitalis, diuretics, and beta-blockers. Readmission was necessary in the 23rd week. After failure of medical treatment the patient was transferred to our center. We decided to perform an emergency mitral valvulotomy with the Inoue balloon. Taking care of maximal radiation protection for mother and fetus doubling of the mitral valve opening are (from 0.6 cm2 to 1.3 cm2) could be achieved. The pleural effusions and tricuspid regurgitation disappeared. The patient was symptom-free and could be delivered from a male infant on schedule.

A consensus protocol for the standardization of cerebrospinal fluid collection and biobanking.

There is a long history of research into body fluid biomarkers in neurodegenerative and neuroinflammatory diseases. However, only a few biomarkers in CSF are being used in clinical practice. One of the most critical factors in CSF biomarker research is the inadequate powering of studies because of the lack of sufficient samples that can be obtained in single-center studies. Therefore, collaboration between investigators is needed to establish large biobanks of well-defined samples. Standardized protocols for biobanking are a prerequisite to ensure that the statistical power gained by increasing the numbers of CSF samples is not compromised by preanalytical factors. Here, a consensus report on recommendations for CSF collection and biobanking is presented, formed by the BioMS-eu network for CSF biomarker research in multiple sclerosis. We focus on CSF collection procedures, preanalytical factors, and high-quality clinical and paraclinical information. The biobanking protocols are applicable for CSF biobanks for research targeting any neurologic disease.

[Long-term follow-up after percutaneous septal ablation in hypertrophic obstructive cardiomyopathy ]. / Langzeitverlauf nach perkutaner Septumablation bei hypertropher obstruktiver Kardiomyopathie.

BACKGROUND AND OBJECTIVE: Persisting disabling symptoms despite optimal medical treatment in patients with hypertrophic cardiomyopathy and significant outflow tract obstruction prompt surgical or interventional therapy targeted at relief of obstruction. While surgical treatment was introduced more than 40 years ago, there are only a few data on the long-term results of percutaneous septal ablation. This study gives the results of a large number of patients with hypertrophic obstructive cardiomyopathy (HOCM) who underwent septal ablation in our institution. PATIENTS AND METHODS: 347 patients (156 females, 191 males, 54 +/- 15 years) in NYHA functional class III or IV, or in class II but with evidence of more severe limitation on exercise testing, underwent percutaneous transluminal septal myocardial ablation (PTSMA). Mortality and morbidity, as well as clinical and echocardiographic parameters were assessed during follow-up, either at our institution, or by the referring cardiologist. RESULTS: During an average follow-up of 58 +/- 35 months the overall mortality was about 1,8 % per year, with a cardiovascular-related mortality of about 1 % per year. 8 % of patients needed a second procedure. A significant and sustained improvement of symptoms (89 % patients were in NYHA class I or II a follow-up) and obstruction were demonstrated (74 % of patients were free from obstruction at rest, 60 % did not exhibit provokable gradients). Supraventricular arrhythmias, especially atrial fibrillation, were observed in 12 % of patients. CONCLUSION: Percutaneous septal ablation provides significant and sustained beneficial effects on symptoms and echocardiographic variables, without evidence of an excess mortality. But independently of the clinical success of the procedure persistence of the underlying structural heart disease should be kept in mind. Periodic re-evaluation is mandatory to identify and treat high-risk patients.

[Constrictive pericarditis or restrictive cardiomyopathy? Echocardiographic tissue Doppler analysis]. / Konstriktive Perikarditis oder restriktive Kardiomyopathie? Die echokardiografische Gewebedoppler-Analyse.

BACKGROUND AND OBJECTIVE: Echocardiographic tissue Doppler imaging (TDI) has been proposed for differentiating between constrictive pericarditis (CP) and restrictive cardiomyopathy (RCM). The aim of this retrospective study was to analyse TDI in patients with severe diastolic dysfunction associated with proven constrictive pericarditis or restrictive cardiomyopathy. PATIENTS AND METHODS: The cohort included 34 consecutive patients (24 men. 10 women; mean age 58 12 years), 20 of whom had proven CP (pericardectomy) and 14 had RCM due to amyloidosis (proven by biopsy). Tissue Doppler Imaging was performed online by pulsed-wave TDI at the lateral and septal mitral annulus in the four-chamber view. Filling pressures were measured invasively. RESULTS: 20 of the 34 patients (60%) were in NYHA class III. 19 of the 34 patients were in sinus rhythm (56 %) and 15 had atrial fibrillation. Left ventricular systolic function was normal in all patients with CP. Eight patients with RCM had normal, 3 patients near normal and 3 patients slightly impaired left ventricular contractile function (EF 50-55% and EF 40%, respectively). Respiratory variation of the transmitral inflow was increased in 10 of 12 patients with CP and sinus rhythm. TDI of the early diastolic velocity across the mitral annulus E} was significantly higher in patients with CP than in those with RCM at the septal and at the lateral mitral annulus (13.8 4.2 cm/s vs. 4.0 1.2 cm/s; p < 0.01 and 11.4 3.4 cm/s vs. 4.4 1.7 cm/s; p < 0.01, respectively). A cut-off value 8 cm/s for the diagnosis of RCM showed a sensitivity of 100% and a specificity of 90% (septal) and 80% (lateral), respectively. The E/E}ratio also was significantly different between both groups (septal: 11.2 8.8 vs. 25.1 8.7; p < 0.01). CONCLUSION: TDI of the early diastolic velocity of the mitral annulus E} makes it possible to differentiate between constrictive pericarditis and restrictive cardiomyopathy and should be part of the echocardiographic work-up in clinical routine.

One-year follow-up of percutaneous septal ablation for symptomatic hypertrophic obstructive cardiomyopathy in 312 patients: predictors of hemodynamic and clinical response.

AIM: The aim of this study was to analyze hemodynamic and clinical outcome in a cohort of 312 patients who were followed up over a period of 12 months after alcohol septal ablation (PTSMA) for symptomatic hypertrophic obstructive cardiomyopathy (HOCM). METHODS AND RESULTS: PTSMA was intended in 337 patients with HOCM (mean age: 54+/-15 years), with 312 procedures completed by injection of 2.8+/-1.2 ml of alcohol. In 25 patients (8%) the intervention was aborted, mostly because of contrast echocardiographic findings. In the 312 patients who received alcohol, permanent pacing was necessary in 22 cases (7%); and in-hospital mortality was 1.3% (four patients). During follow-up, contact to six patients (2%) was lost, and three additional patients (1%) died. The 299 patients who either underwent non-invasive reassessment in our institution or transmitted followup data from their local physician formed the study population. Improvement in symptoms was reported by 272 patients (91%). Mean NYHA functional class was reduced from 2.9+/-0.4 to 1.5+/-0.7 (p<0.0001) along with a gradient reduction (echo-Doppler) from 59+/-32 to 8+/-15 mmHg at rest, and from 120+/-42 to 28+/-32 mmHg with provocation (p<0.0001 each). Exercise capacity improved from 94+/-51 to 119+/-40 watts (p=0.001), and peak oxygen consumption from 18+/-4 to 21+/-6 ml/ kg/min (p=0.01). Younger age and higher outflow gradients at baseline and immediately after intervention were associated with a less favorable hemodynamic outcome. The degree of limitation of exercise capacity at baseline was the only predictor of symptomatic improvement. CONCLUSIONS: Catheter-based septal ablation is an effective non-surgical technique for reducing symptoms and outflow gradients in HOCM. In contrast to a previous study, in this cohort of 312 patients there was no association between post-interventional enzyme release and hemodynamic success. Younger patients with high baseline gradients, however, tended to have a less favorable hemodynamic outcome with higher residual gradients.

[Percutaneous transluminal coronary angioplasty in coronary multivessel disease: clinical course in relation to degree of functional revascularization]. / Perkutane transluminale Koronarangioplastie bei koronarer Mehrgefässerkrankung: Klinischer Verlauf in Abhängigkeit vom funktionellen Revaskularisationsgrad.

In this prospective nonrandomized study, we analyzed the influence of the degree of revascularization--determined by anatomic, morphologic, and functional criterias--on clinical follow-up after PTCA in patients with multivessel disease. 283 patients (74% with double vessel disease, 26% with triple vessel disease; mean age 59.2 +/- 8.2 years; 250 (88%) men) were treated. Clinical successful PTCA was achieved in 247 patients (87.2%): in 239 patients (84.4%) all attempted lesions and in 8 patients (2.8%) at least the culprit lesions were successfully dilated. Complications were seen in 15 patients (5.3%): seven patients underwent emergency bypass surgery, one patient had bypass surgery 8h after PTCA because of an early re-occlusion, five patients suffered an acute myocardial infarction during PTCA, and two patients, who had PTCA because of cardiogenic shock, died during PTCA. Post PTCA, 39 patients (13.8%) had anatomic complete (AK), 35 patients (12.4%) anatomic incomplete but functional complete (FK), 148 patients (52.3%) anatomic incomplete but functional adequate (FA), and 46 patients (16.2%) anatomic and functional incomplete (IR) revascularization. All patients had follow-up after 30.5 +/- 5.5 months. Fifteen patients (5.3%) died, 15 patients (5.3%) suffered a myocardial infarction, and 39 patients (13.8%) underwent an elective bypass operation during follow-up. Cumulative 2-year survival and cumulative 2-year infarct-free survival were not influenced by the degree of revascularization. In contrast to that, the cumulative 2-year bypass-free survival was significant lower in patients with IR (71.0%) compared to patients with AK (92.5%; p < 0.01), FK (89.3%; p < 0.05), and FA (92.7%; p < 0.001). Patients with IR were more likely to have PTCA of previous untreated lesions and were often less likely to have clinical improvement compared to the other subgroups. Thus, in patients with multivessel disease PTCA is a therapeutic option if AK, FK, and FA revascularization can be achieved. Provided that just an IR revascularization can be achieved by PTCA, angioplasty should be performed only for treatment of acute ischemic syndromes in order to improve clinical symptoms. Otherwise, an increased incidence of further revascularization procedures and a reduced clinical improvement can be expected.

[Transvenous closure of persistent ductus arteriosus with an Ivalon plug]. / Transvenöser Verschluss des persistierenden Ductus arteriosus mit einem Ivalon-Pfropf.

OBJECTIVE: To assess a new transvenous transcatheter method of closing a persistent ductus arteriosus, combining advantages of the Porstmann and Rashkind techniques. PATIENTS AND METHODS: Five patients (three men, two women, mean age 36.2 [19-56] years) underwent the procedure. The diameter of the duct was 3-6 mm. A compressed ivalon (poly-vinyl-alcohol) foam plug, introduced and held by a modified biopsy forceps, was placed into the duct via a percutaneously and transvenously placed catheter sheath. Small titanium legs attached to the plug at the aortic and pulmonary ends unfolded once the plug was correctly placed, ensuring safe fixation. RESULTS: Closure was achieved in all five patients and no shunt demonstrated immediately afterwards in four. In one patient a small shunt briefly persisted but was not longer present the day after. One patient had a fever of up to 39 degrees C for several weeks that required no treatment and was thought to have been a foreign body reaction. Follow-up examination after 5-19 months confirmed complete closure. CONCLUSION: The described method appears to be safe and superior to the Porstmann and Rashkind techniques, but the results must be tested on a larger number of patients with longer follow-up.

[Nonselective angiography of the internal mammary artery--improved imaging by simultaneous compression of the ipsilateral brachial artery]. / Nichtselektive Angiographie der Arteria mammaria interna-Verbesserte Darstellung durch simultane Kompression der ipsilateralen Arteria brachialis.

Because of the increasing use of the internal mammaria artery (IMA) in bypass grafting pre- and postoperative angiography of the artery is more often necessary. Selective IMA angiography is frequently difficult and time- and fluoroscopy-consuming. Therefore, different procedures of nonselective angiography have been developed. We report on the improved nonselective visualization of the IMA by manual injection in the subclavian artery and simultaneous ipsilateral compression of the brachial artery by inflating a blood pressure cuff above systolic blood pressure. Thereby a reduction of fluoroscopy time is possible without significant loss of diagnostic information.

[Aortic isthmus stenosis with open ductus Botalli as etiology of severe heart failure in a 36-year-old patient--case report of successful surgical treatment]. / Aortenisthmusstenose mit offenem Ductus Botalli als Ursache einer schweren Herzinsuffizienz bei einer 36-jährigen Patientin--Fallbericht über eine erfolgreiche operative Behandlung.

We report on the history of a 36-year-old woman with untreated coarctation of the aorta and patent ductus arteriosus who developed refractory heart failure due to severely impaired left ventricular function. After coarctation repair and duct resection, left ventricular function improved to normal. Even in the presence of longstanding left ventricular pressure and volume overload, subsequent severe myocardial failure may be reversible by surgical repair.

[Recanalization of occluded coronary arteries using the Magnum system]. / Rekanalisierung verschlossener Koronararterien mit dem Magnum-System.

Recanalization procedures with the "Magnum" system were undertaken in 137 patients (113 men, 24 women; mean age 57.1 +/- 8.1 years) with complete occlusion of a coronary artery. The system consists of a 0.021 inch guidewire with a flexible 1 mm diameter olive tip, a double-lumen probing catheter and a Magnarail balloon catheter. Chronic coronary artery occlusion of maximally 3 months was present in 51 patients (37%), for over 3 months in 52 (38%), while the duration of occlusion was unknown in 18 (13%). An acute coronary occlusion was successfully recanalized in 7 patients (5%), while in 9 (7%) it was accomplished when it had occurred during or shortly after a percutaneous coronary artery angioplasty (PCTA). The occlusion was successfully passed in 87 patients (64%); in 15 of them recanalization with another system had failed. The highest success rates were obtained with an acute occlusion (5 of 7; 71%), occlusion of 3 months' duration or less (39 of 51; 76%), and occlusion during PTCA (8 of 9; 89%). The success rates were lower for occlusions over 3 months' duration (25 of 52; 48%; P < 0.05) and of unknown duration (10 of 18; 56%; n.s.). Recanalization after failed recanalization was successfully accomplished by rotation-angioplasty (n = 2) or a standard system (n = 4).--These results indicate that the Magnum system is suitable for recanalizing chronic or acute coronary occlusion. But cardiologists should be capable of using several systems to increase the chances of successful recanalization.

[The recanalization of the chronically occluded infarct vessel in single-vessel coronary disease. The reduction of cardiac events in long-term clinical follow-up]. / Rekanalisation des chronisch verschlossenen Infarktgefässes bei koronarer Ein-Gefäss-Krankheit. Reduktion kardialer Ereignisse im klinischen Langzeitverlauf.

OBJECTIVE: The prognostic significance of recanalisation of a chronically occluded infarct vessel in single-vessel coronary disease remains controversial, in contrast to early re-opening of the infarct vessel in the acute state of infarction. It was the purpose of this prospective study to discover whether successful recanalisation in the former influences the incidence of cardiac events (death, infarction, by-pass operation) and clinical symptoms in the long term. PATIENTS AND METHOD: Recanalisation procedures were successful in 58, unsuccessful in 41 of 99 patients (81 men, 18 women; mean age 55 [28-79] years) with anterior wall (n = 53) or posterior wall (n = 46) myocardial infarction (AMI and PMI, respectively). The two groups were similar with respect to age, sex, left-ventricular function, indication, exercise capacity and premedication. But the interval between infarction and recanalisation was shorter in the patients who had successful recanalisation (5.1 +/- 5.3 vs 7.8 +/- 7.6 months; P < 0.05). Mean follow-up period for all patients was 55.8 +/- 8.9 months after the recanalisation procedure. RESULTS: There were significantly fewer cardiac events after successful than failed recanalisation, both for the total group of patients (5% vs 23%; P < 0.01) and those with AMI (9 vs 36%; P = 0.012). In the patients with PMI there was only a trend in favour of those with successful recanalisation (0% vs 14%; P = 0.058). Symptomatic improvement was reported by 73% of patients after successful but only 40% after failed recanalisation (P < 0.01). CONCLUSION: The results provide pointers towards prognostic indications of recanalisation even after chronic occlusion of the infarct vessel. The procedure should therefore be attempted if the occlusion is morphologically suitable.

[Clinical and haemodynamic results after repeat valvotomy of the mitral valve using the Inoue balloon. A comparison with the results after primary valvotomy]. / Klinische und hämodynamische Ergebnisse nach Re-Valvotomie der Mitralklappe mittels Inoue-Ballon. Ein Vergleich zu Ergebnissen nach primärer Valvotomie.

BACKGROUND AND OBJECTIVE: Percutaneous mitral valvotomy (MVT) with the Inoue balloon is the most frequently performed therapeutic alternative to surgical commissurotomy in patients with symptomatic mitral valve stenosis. Few data are available on the results of repeat MVT. PATIENTS AND METHODS: We compared the immediate and 3-month results of all patients who had a repeat MVT (n = 39) with those who had a primary intervention (n = 1,117) in our institution between February 1989 and January 2001. Mean age of the 31 women and 8 men with repeat MVT was 53 +/- 14 years at the first and 57 +/- 14 years at the second intervention performed 3 - 10 years later. RESULTS: Following primary intervention the invasively assessed mitral valve are (MVA) had increased from an average of 1.0 +/- 0.2 cm(2) to 1.7 +/- 0.4 cm(2). Echocardiography three months after the intervention revealed a MVA of 1.7 +/- 0.3 cm(2). Repeat MVT resulted in an immediate increase of MVA from 1.0 +/- 0.2 cm(2) to 1.6 +/- 0.4 cm(2), after 3 months the average MVA was 1.6 +/- 0.3 cm(2). According to the NYHA classification clinical symptoms had improved on average from 2.6 to 1.6 three months after primay intervention and from 2.8 to 2.1 three months following the repeat procedure. The incidence of significant procedure-related complications was less than 3 % for both primary and repeat MVT. CONCLUSION: The clinical and hemodynamic results demonstrated in our patients suggests repeat MVT as the treatment option of choice in mitral restenosis after previous balloon intervention, if mitral valve morphology is still suitable.

[Catheter treatment of hypertrophic obstructive cardiomyopathy]. / Kathetertherapie der hypertrophen obstruktiven Kardiomyopathie.

BASIC PROBLEMS AND OBJECTIVE: In addition to medication with negative inotropic drugs, surgical myectomy and DDD pacemaker implantation are standard procedures in the treatment of hypertrophic obstructive cardiomyopathy (HOCM). In a preliminary series the results obtained with a recently described method, consisting of transcatheter myocardial reduction, are evaluated. PATIENTS AND METHODS: Six patients (two women, four men; mean age 52.7 [44-68] years), who remained in moderate heart failure despite medical treatment, underwent the procedure. After atrial transseptal puncture (via a catheter introduced percutaneously into the femoral vein) the left ventricular outflow tract (LVOT) gradient was measured at rest and after 5-minute balloon occlusion of the first septal branch of the left coronary artery. After demonstration of significant reduction of the gradient by the occlusion, one (n = 3) or two (n = 3) septal branches were occluded by the injection of 2-5 ml of 96% alcohol. RESULTS: The LVOT gradient was reduced from 57.8 +/- 22.4 (38-97) mm Hg to 11.3 +/- 8.6 (0-21) mm Hg and postextrasystolic from 131.0 +/- 40.7 (78-198) mm Hg to 44.0 +/- 35.6 (19-69) mm Hg. All patients had angina for 24 hours after the procedure. Maximal rise in creatine kinase activity was 982 +/- 589 (392-1729) U/l after 8.0 +/- 3.9 (4-15) hours. In three patients transitory complete atrioventricular block developed 10 min to 5 days later, requiring temporary pacemaker implantation. The further course was without complication in all patients and they were discharged after 7.5 +/- 1.8 (6-11) days. CONCLUSION: The described catheter method provides a nonsurgical means of reducing the amount of septal myocardium with subsequent reduction of the LVOT gradient in HOCM. Long-term observation in a larger group of patients and comparison with conventional forms of treatment are required to determined the method's ultimate place in the treatment of HOCM.

[Acute aortic dissection (Stanford A) with pericardial tamponade--extension of the dissection after emergency pericardial puncture]. / Akute Aortendissektion (Stanford A) mit Perikardtamponade--Ausdehnung der Dissektion nach notfallmässiger Perikardpunktion.

The hemodynamic deterioration associated with acute aortic dissection (Stanford A) is caused by an acute loss of volume, acute aortic valve insufficiency, or possibly by hemopericardium with tamponade. In the latter case, a pericardiocentesis may restore hemodynamic stability. However, it is only indicated in the case of reduced perfusion of vital organs. The relief of the pericardial effusion can produce a pressure gradient between dissection and pericardial space, which again might cause hemodynamic deterioration by the blood flow into the pericardial space as well as extension of the aortic dissection. Following pericardiocentesis immediate surgery is indicated. In the present case, after a primarily effect hemodynamic stabilization by pericardiocentesis, this mechanism has very probably led to a repeated tamponade and extension of aortic dissection, which was successfully repaired by the implantation of a vascular prosthesis immediately following invasive diagnosis.

[Diagnosis and differential therapy of mitral stenosis]. / Diagnose und Differentialtherapie der Mitralstenose.

Clinical symptoms and diagnostic findings in patients with mitral stenosis are usually determined by the extent of the stenosis. Compared to a normal mitral valve area (MVA) of > 4 cm2, MVA in patients with severe mitral stenosis is usually reduced to < 1.5 cm2. In older patients symptoms are frequently influenced by concomitant diseases (e.g. atrial fibrillation, arterial hypertension or lung disease). An important diagnostic element besides anamnesis, auscultation, ECG and chest X-ray is echocardiography, which is required in order to measure non-invasively and reliably the mitral valve gradient (MVG), the MVA and morphologic changes to the valves, as well as concomitant valvular disease, ventricular functions and, where appropriate, left-atrial thrombi. In addition to the surgical treatment of patients with severe mitral stenosis, which has been an established procedure for 50 years, percutaneous balloon mitral valvuloplasty (MVP) has recently established itself as an alternative option. At the current time, the Inoue technique seems to display the most advantages. Following transseptal puncture, the Inoue balloon is guided transvenously into the left atrium and then into the left ventricle using a special support wire. The balloon is short and soft. Its special unfolding character enables it to be placed securely in the mitral valve without any risk of ventricular perforation (Figure 1). As with surgical commissurotomy, balloon valvuloplasty leads to a separation of fused commissures. This results in a significant reduction of MVG, accompanied by an increase in the MVA (Figure 2). The results and success of MVP are influenced by the morphology of the valves and the changes to the subvalvular apparatus. In randomized studies, the results of surgical commissurotomy were comparable with those of balloon mitral valvulotomy. In our hospital, an increase in MVA from 1.0 to 1.8 cm2 could be achieved in 899 patients (mean age 56 +/- 3 years). In younger patients with less significantly changed valves, the results were correspondingly more favorable than in older patients (Figure 3). Provided valve morphology is suitable, a relapse following previous surgical commissurotomy is not a contraindication for MVP. The MVP complication rate is very low in skilled hands: mortality is below 1%; mitral insufficiency occurs in 3 to 10% of interventions; we observed a severe mitral insufficiency in 5% of our patient group. Thromboembolic complications may be prevented after exclusion of atrial thrombi by transesophageal echocardiography. The occurrence of a hemodynamically significant atrial septum defect is a very rare event. The mid-term results (5 to 10 years) and the low restenosis rate following MVP in patients with suitable valves are comparable with those of surgical commissurotomy. In older patients with considerably changed, calcified and fibrotic valves, restenosis may be expected within 1 to 5 years. In these patients MVP represents no more than a palliative intervention in order to prolong the point of surgery, for example in patients where a concomitant aortic valve disease in itself is not yet an indication for surgery. Special indications are to be found in young patients with severe mitral stenosis yet few symptoms, in pregnant females and in emergency situations, as well as in patients with Grade II mitral stenosis with intermittent atrial fibrillation. Catheter therapy is much less invasive than surgery. In case of failure the patient still has the option of surgical therapy. Patients with morphologically significantly altered valves usually receive a valve replacement since an unsuccessful reconstruction would lead to a second operation within a very short time interval. Contraindications for MVP are thrombi in the left atrium, a previously existing > Grade II mitral regurgitation and marked, degenerative destruction of the subvalvular apparatus or extensive calcification of the valves. MVP thus represents a significant addi