[Therapy of cardiogenic shock : A success story of German cardiology]. / Therapie des kardiogenen Schocks : Eine Erfolgsgeschichte der deutschen Kardiologie.

In contrast to the situation in the 1960s and 1970s, the mortality risk for patients with myocardial infarction has been clearly reduced, particularly for those with myocardial infarction with cardiogenic shock (MICS). Approximately 5­10 % of patients with a myocardial infarction are affected by a MICS and the mortality risk is between 30 % and 50 %. The primary percutaneous coronary intervention with stent implantation should be carried out as quickly as possible in order to reduce the mortality to around 20 %. This article gives an overview of the currently available options for conservative and fibrinolytic treatment of MICS, of the interventional treatment of cardiogenic shock in the era of intravenous and intracoronary infarct treatment as well as without thrombolysis. In addition, the currently available mechanical support systems and the possibilities for surveillance and monitoring of patients are presented.

Impending paradoxical embolism from atrial thrombus: correct diagnosis by transesophageal echocardiography and prevention by surgery.

During recovery from a posterolateral myocardial infarction, a 56 year old patient developed signs of deep vein thrombophlebitis and subsequently of pulmonary embolism. After conventional echocardiography showed masses in both atria, transesophageal two-dimensional echocardiography clearly revealed an elongated mass overriding an atrial septal defect. Impending paradoxical embolism was confirmed at surgery.

CD59 (homologous restriction factor 20), a plasma membrane protein that protects against complement C5b-9 attack, in human atherosclerotic lesions.

Blood cells express a cell membrane protein, termed homologous restriction factor 20 (HRF20) and identical to CD59, that can inhibit complement C5b-9 insertion into their membranes. In this report, we investigated by immunohistochemistry whether CD59 was present on cells in human atherosclerotic lesions since membranous C5b-9(m) has been found in lesions. Using a monoclonal anti-CD59 antibody, a cellular CD59 staining pattern was apparent in nearly all lesion specimens. CD59 stain co-localised with macrophage (CD14), T lymphocyte (CD7), endothelial cell (anti-factor VIII related antigen) and smooth muscle cell cytoskeletal-specific antigens (anti-alpha actin and muscle myosin). Endothelial cells always exhibited a more intense stain than the other cell types. CD59 antigen was not localised to any one area of the lesions. Usually CD59-positive cells occurred in clusters rather than as randomly spaced individual cells. CD59 did not stain all cells of the lesion and in particular did not appear to stain all smooth muscle cells. Areas of CD59-negative cells were sometimes observed to exhibit a cellular C5b-9 staining pattern. C5b-9 deposits were also observed in CD59-positive regions. Normal saphenous vein stained strongly for CD59 at the endothelial lining and weakly in the media. Capillaries in atherosclerotic intima always stained strongly for CD59. We conclude that HRF20 is constitutively expressed on endothelium and is under regulatory control in smooth muscle cells. Cellular C5b-9 attack in atherosclerotic lesions is therefore most likely to occur on smooth muscle cells.

The ineffectiveness of the NO-cyclic GMP signaling pathway in the atrial myocardium.

1. This study was performed to determine whether nitric oxide (NO) has direct effects on force of contraction (Fc) in atrial myocardium from rats, rabbits, guinea-pigs, frogs, and man. 2. Glyceryl trinitrate, isosorbide dinitrate, 3-morpholino-sydnonimine hydrochloride (SIN-1), and S-nitroso-N-acetylpenicillamine (SNAP) did not significantly reduce Fc in the various preparations investigated, either given alone or after stimulation of alpha- or beta-adrenoceptors. 3. SNAP did not change the time course of contractions in rat, guinea-pig and human preparations. 4. 8-Bromo-guanosine-3':5'-cyclic monophosphate (8-Br-cyclic GMP) produced a negative inotropic effect in rat, guinea-pig and human atrial preparations and shortened time to peak tension and relaxation time in human preparations. 5. High K+ (85 mmol l-1)-induced contracture in rat heart muscle was reduced by 8-Br-cyclic GMP but not by SIN-1. 6. N-monomethyl-L-arginine (L-NMMA), an inhibitor of NO synthase, failed to influence muscarinic effects on Fc or frequency from rat and guinea-pig hearts. 7. We conclude that NO, under the experimental conditions described here, has no direct effects on the heart, although cyclic GMP may be involved in the regulation of myocardial contraction.

Functional role of cholinoceptors and purinoceptors in human isolated atrial and ventricular heart muscle.

1. The effects of cholinergic and purinergic stimulation on action potential, force of contraction and 86Rb efflux were investigated in human atrial and ventricular heart muscle. 2. In atrial heart muscle, carbachol and (-)-N6-(R-phenyl-isopropyl)-adenosine (R-PIA) and 5'-(N-ethyl)-carboxamido-adenosine (NECA) evoked transient decreases of action potential duration and force of contraction; the steady-state effects on force of contraction were virtually identical to control values. In the presence of propranolol, steady-state values after carbachol, R-PIA or NECA amounted to about 50% of control values. 3. In ventricular heart muscle, carbachol, NECA and R-PIA did not significantly affect the action potential configuration or force of contraction. 4. Carbachol, NECA and R-PIA induced a maintained depression of the positive inotropic response to isoprenaline in both atrial and ventricular heart muscle. 5. The rate constant of 86Rb efflux was slightly increased by carbachol, NECA and R-PIA in atrial (10-20%) but not in ventricular heart muscle. 6. In the presence of isoprenaline, carbachol, NECA and R-PIA did not significantly affect the rate constant of 86Rb efflux in both atrial and ventricular heart muscle. Isoprenaline alone increased the rate constant of 86Rb by about 25% in both tissues.

Congenital obliteration of the suprahepatic inferior vena cava: case report.

A rare case of congenital obliteration of the suprahepatic portion of the inferior vena cava (IVC) associated with early liver cirrhosis is presented. The clinical signs of the condition and the standard methods of diagnosis are outlined. A survey of the available surgical management is given and a new alternative operation described. It consists of an indirect transatrial-transdiaphragmatic reconstruction of the IVC. For the first time, it has been used successfully for reconstruction of the interrupted vessel. Ten months following the operation, the patient shows no signs of portal hypertension or caval obstruction.

Surgical treatment of pulmonary artery sarcoma.

OBJECTIVE: Pulmonary artery sarcomas are rare and usually fatal tumors. The diagnosis is difficult and delayed in most cases. Newer imaging techniques could allow early diagnosis in patients with symptoms of pulmonary vascular obstruction. Surgical resection improves clinical symptoms and offers the only chance of cure. We report the case histories of 7 patients with primary pulmonary artery sarcomas treated by surgical resection with or without adjuvant therapy. METHODS: Seven patients (3 women and 4 men; mean age, 52.3 years; preoperative New York Heart Association functional class III/IV, n = 5/2) underwent operations. Malignancy was preoperatively suspected in 5 patients, and 2 patients had a presumptive diagnosis of chronic pulmonary embolism. Tumor resection with partial or total prosthetic replacement (n = 2), reconstruction (n = 5), or both, of central parts of the pulmonary arteries was performed in 6 patients. Thromboendarterectomy was necessary in 4 patients, and pneumonectomy was necessary in 2 patients. Six patients received adjuvant therapy. RESULTS: There was no perioperative mortality. All patients had a substantial improvement in exercise tolerance and hemodynamics 3 months after their operations. Four patients died 7, 9, 18, and 19 months after their operations because of recurrent tumor or pulmonary metastases. Two patients are alive 21 and 35 months after primary surgical repair, with pulmonary metastases detected by computed tomographic scans. One patient is alive 62 months after resection without clinical or radiologic signs of tumor recurrence or metastasis. CONCLUSIONS: Early diagnosis of primary pulmonary artery sarcomas can be improved by computed tomography and magnetic resonance scanning. Radical surgical resection probably presents the only chance for cure. The role of neoadjuvant or adjuvant treatment modalities has to be defined. Pulmonary artery sarcoma need not necessarily be a fatal diagnosis.

Complications of permanent transvenous cardiac pacing.

Clinical experience with permanent transvenous pacing during a 6 year period at Hannover Medical School is presented. A total of 1,376 pacemaker operations were performed in 799 patients, with a mortality rate of 1.1 per cent. The most common complications were premature battery failure, dislocation of endocardial electrodes, infections of the generator and/or electrodes, and skin ulcerations. In our cumulative follow-up period of 1,225 years, a complication necessitating a reoperation is to be expected after an average function-time of 31 months. Including normal battery exhaustion in this calculation will make reoperation necessary every 21.9 months.

Continuous monitoring of mixed venous oxygen saturation in infants after cardiac surgery.

Continuous mixed venous oxygen saturation (SvO2c) was measured in 16 infants immediately after cardiac surgery. A polyurethane 4F, dual channel catheter (Opticath, Modell U440, Oximetrix) with fiberoptic filaments was introduced into the pulmonary artery during cardiothoracic surgery. The catheters were left in place for an average of 67.5 h (range 27 h -125 h) and there were no catheter-related complications. Correlation between continuous in vivo SvO2 values and in vitro values was satisfactory (r = 0.85), whereas a correlation between SvO2c and arterial oxygen saturation (SaO2) was not found (r = 0.07). The sampled arterial lactate values were inversely correlated to the simultaneously measured SvO2c, but the correlation coefficient was only r = -0.4. There was an inverse correlation between SvO2c and arteriovenous oxygen content difference (Ca-vDO2) (r = -0.82), and a marked inverse correlation to the calculated oxygen utilization ratio (r = -0.97). Therefore SvO2c continuously reflects the overall balance between oxygen consumption and delivery, but the use of SvO2 as a predictor of blood lactate levels is unreliable. A further purpose of the present study was to demonstrate the clinical applications and to show the usefulness of SvO2c-monitoring; particularly as a surveillance and early warning system, as a guide for assessing therapy and its relevance in interpreting other monitored parameters. In our opinion continuous SvO2 measurement is a reliable and valuable indicator of cardiopulmonary function in the immediate post-operative period, even in infants with complicated repair of cardiac malformations.

Clinical experience with atrial inversion using a Gore-Tex baffle in 52 cases of transposition of the great arteries.

Atrial inversion was achieved by a modified Mustard operation in 334 patients with various types of transposition of the great arteries (TGA) between January, 1974, and January, 1983, in Hannover, West Germany. The overall mortality was 4.2% (N = 14). Between March, 1978, and January, 1983, 197 of the patients were operated on using a new design of a Gore-Tex prosthetic baffle. In February, 1982, a new step was integrated into our modification of the Mustard operation. It consisted of creating a pericardial flap that serves to enlarge the pulmonary venous atrium. This article describes the modified Mustard operations with Gore-Tex baffle used in 52 children with TGA between October, 1981, and January, 1983. Special attention is focused on operative techniques and on postoperative dysrhythmias and hemodynamics.

Pulmonary venous obstruction following repair of total anomalous pulmonary venous drainage.

Recurrent pulmonary venous obstruction has been reported as a serious late complication following the initial repair of total anomalous pulmonary venous drainage. It occurs either as true pulmonary venous obstruction or as stenosis of the retrocardiac anastomosis between the left atrium and pulmonary veins. The 2 patients reported herein demonstrated the typical history and course following stenosis of the retrocardiac anastomosis. Reoperation resulted in complete relief of symptoms. Both patients are well 36 and 17 months after reoperation, demonstrating the favorable prognosis of this lesion.

Relevance of immunologic reactions for tissue failure of bioprosthetic heart valves.

The use of biologic heart valve prostheses is decreasing because of the high incidence of failure of these bioprostheses resulting from tissue degeneration or tearing. Immunologic reactions might play a decisive role in this process. The present experimental and clinical studies were conducted to investigate the relevance of immunologic reactions to the tissue failure of glutaraldehydetanned bovine pericardial and porcine valves. Specimens of the two different types of valve material were implanted in the abdominal muscles of rats. Enzyme-linked immunosorbent assays and tritiated thymidine incorporation tests were performed to detect specific antibodies and activated T cells. All specimens were studied histologically. Identical enzyme-linked immunosorbent assays and tritiated thymidine incorporation tests were performed in 29 patients with bioimplants and in 48 controls. Twenty explanted bioprostheses were investigated using histologic and immune histologic methods. The results of the enzyme-linked immunosorbent assays and lymphocyte proliferation tests showed that glutaraldehyde-tanned bovine pericardial valves can provoke cellular and humoral immunologic reactions in rats and human beings. In explanted bovine valves, macrophages were found invading and degrading implant collagen, starting from surface lesions. The combination of the formation of mechanical lesions, the development of cellular infiltrates, and collagen disruption strongly indicates that initial surface lesions initiate the immunologic reactions in bovine pericardial valves as the result of the exposure of incompletely tanned collagen. These immune responses might accelerate tissue degeneration. Porcine valves do not provoke immunologic reactions.

Cardiac pacing in premature infants and neonates: steroid eluting leads and automatic output adaptation.

BACKGROUND: Appropriate generator and lead selection as well as techniques of implantation are most important aspects of cardiac pacing in the extremely young patient. Here we report the clinical results using a new technique with automatic output adaptation based on evoked response in combination with steroid-eluting epicardial leads in small children. METHODS: One neonate and 2 premature infants underwent permanent pacemaker implantation because of congenital high-degree atrioventricular block or postoperative complete heart block, respectively. Steroid-eluting epicardial leads and a multiprogrammable pacemaker with automatic output adaptation were used. RESULTS: Intermuscular abdominal generator placement and epicardial suture-fixation of the bipolar lead through a subcostal approach was without complications. Serial follow-up examinations revealed safe and consistent pacemaker function up to 12 months after operation. CONCLUSIONS: The technique represents an excellent alternative for permanent cardiac pacing in extremely small patients. We believe that it provides an increase in functional lifetime of the devices and delays the need for battery replacement with its associated complications in this young patient population.

Surgical treatment of double-outlet left ventricle in 2 patients with D-position and L-position of the aorta.

Two cases of double-outlet left ventricle (DOLV) are described, 1 with D-position and 1 with L-position of the aorta. Both patients had situs solitus, atrioventricular concordance with D-relationship of the two ventricles, a ventricular septal defect, and subpulmonary stenosis. The patient with D-position of the aorta was operated on using a technique similar to that for repair of Fallot's tetralogy but including emergency implantation of a bioprosthesis into the pulmonary artery position on the eighth postoperative day. Surgical correction in the patient with L-position of the aorta required the implantation of a composite valved conduit between the right ventricle and the pulmonary artery. The various surgical techniques for correction of DOLV are described, and the literature is reviewed. Postoperative right heart failure in both patients is explained by the impaired function of the right ventricle being exposed to gross pulmonary incompetence or by the persistence of elevated right ventricular pressure.

Malfunction of a St. Jude medical heart valve in mitral position.

Early postoperative intermittent malfunction in a St. Jude mitral valve prosthesis is described. The patient underwent reoperation and had an uneventful recovery. After explantation, the prosthesis underwent laboratory examination. The findings included a minimal disproportion between leaflets and valve ring causing intermittent inhibition of leaflet motion. The unpredictable irregularity of the malfunction phenomenon in vivo, confirmed by laboratory investigations, is explained as a result of a changing myocardial tension status sufficient to alter the ring to leaflet proportion of the valve in either direction.

Coronary artery bypass grafting in adult coronary artery disease due to suspected Kawasaki disease in childhood.

Development of coronary artery aneurysms is one typical complication of Kawasaki disease and can cause coronary artery disease even in early childhood. Information about course and outcome in adults is rare. Here, we present a 49-year-old man with serious three-vessel coronary artery disease and giant coronary artery aneurysms following suspected Kawasaki disease.

Histopathological evaluation of woven and knitted Dacron grafts for right ventricular conduits: a comparative experimental study.

Composite extracardiac conduits consisting of a low-porosity woven graft and a high-porosity knitted double-velour Dacron graft presealed with fibrin glue were implanted between the right ventricle and the pulmonary artery in 6 dogs under partial heparinization. Two grafts were explanted after 6 weeks, 2 after 12 weeks, and 2 after 6 months. The healing properties of both types of prosthesis were studied macroscopically, under light microscopy, and with scatter electron microscopy. Spontaneous peeling of both the inner and outer capsules of the graft occurred in 3 of 6 woven prostheses during transection. In the remaining 3, peeling could be easily induced by blunt dissection; this was impossible in the knitted grafts. Microscopically, in a comparison of the different weaves after identical time intervals, the inner capsule was noticeably thicker in woven than in knitted grafts. Transtitial ingrowth of fibroblastic tissue could be observed in knitted grafts after 6 weeks; only poor transmural tissue bridging was detectable in woven prostheses after 6 months. Neovascularization of the inner capsule was detectable earlier and was more advanced toward the luminal surface of highly porous grafts. In conclusion, knitted grafts in the position of extracardiac right ventricular conduits showed firmer attachment of both inner and outer capsules to the prosthetic material. Also, the inner capsule remained thinner and revealed a higher degree of neovascularization than in the woven Dacron grafts.

High-dose epsilon-aminocaproic acid versus aprotinin: antifibrinolytic efficacy in first-time coronary operations.

BACKGROUND: The antifibrinolytic efficacy of a high-dose regimen of epsilon-aminocaproic acid (epsilon-ACA) was compared with aprotinin in first-time coronary operations. METHODS: In a prospective, double-blinded, randomized study, 20 patients received high-dose epsilon-ACA (10 g both as a loading and cardiopulmonary bypass priming dose, 2.5 g/h until 4 hours after protamine), and another 20 patients received aprotinin (2 x 10(6) KIU [280 mg] for loading and priming, 0.5 x 10(6) KIU/h [70 mg/h]). Ten untreated patients served as controls. RESULTS: Both agents reduced postoperative levels of thrombin/antithrombin III complexes, D-dimers, fibrin degradation products, free plasma hemoglobin (epsilon-ACA versus aprotinin, p = not significant; p < 0.05 versus controls), and amount of retransfused autologous blood (p < 0.001). Epsilon-ACA increased, aprotinin suppressed antiplasmin-plasmin complex generation (epsilon-ACA versus controls, p < 0.02; epsilon-ACA versus AP, p < 0.0001). For 4 hours after discontinuation, more chest drainage occurred with epsilon-ACA than aprotinin (137 +/- 90 mL versus 62 +/- 29 mL; means +/- standard deviation; p < 0.02). Cumulative 12-hour drainage was similar for aprotinin (391 +/- 220 mL) and epsilon-ACA (582 +/- 274 mL), but higher without inhibitor (1,091 +/- 541 mL; p < 0.001 versus drugs). Postoperatively, aprotinin was associated with the lowest autologous retransfusion incidence and highest hematocrits (p < 0.01 versus epsilon-ACA). Homologous transfusion exposures did not differ. CONCLUSIONS: In first-time coronary operations, higher postoperative hematocrit and less shed blood retransfusion constitute only subtle advantages of aprotinin over high-dose epsilon-ACA.

Complete correction of total anomalous pulmonary venous drainage: experience with 53 patients.

From January, 1973, to August, 1984, 53 infants with total anomalous pulmonary venous drainage (TAPVD) underwent a corrective operation in our unit. TAPVD was of the supracardiac type in 41% of the patients, cardiac in 17%, infracardiac in 36%, and mixed in 6%. Overall operative mortality was 23%; it was highest at 42% in the infracardiac group. Factors determining the outcome were the anatomical type of the lesion, the degree of pulmonary venous obstruction, the severity of pulmonary hypertension, and the young age of the patients. In addition, surgical experience appears to be an important factor in determining the outcome. During the study, hospital mortality decreased considerably to 11%. A corrective procedure offers the only chance of survival for patients with TAPVD. With some experience, excellent results can be obtained.

Adjustable tourniquet to manipulate pulmonary blood flow after Norwood operations.

BACKGROUND: Survival after first-stage palliative Norwood operations for single ventricle with systemic outflow obstruction is mainly dependent on a balanced ratio of pulmonary blood flow to systemic blood flow. Here we report the clinical results using a modified technique that allows a controlled systemic-to-pulmonary shunt flow to prevent pulmonary overcirculation. METHODS: From 1995 to 1998, of 26 infants undergoing first-stage palliative Norwood operations, 7 had placement of an adjustable tourniquet around a modified right Blalock-Taussig shunt. RESULTS: Hospital survival was 20 of 26 patients (77%). All 7 patients in whom snaring of the shunt was indicated survived. Two patients underwent repeated adjustment, in 5 patients the tourniquet could be removed during delayed sternal closure, and 2 patients were discharged with the shunt partially snared. CONCLUSIONS: The snare-controlled systemic-to-pulmonary shunt allows improved hemodynamic stability after reconstructive surgery for hypoplastic left heart syndrome or other similar complex cardiac defects by reducing the risk of pulmonary overcirculation. It is simple and rapidly executed. The option of graded banding of the shunt depending on the hemodynamic situation increases flexibility and safety after cardiopulmonary bypass or at any time in the postoperative period.