[ECG results: tips and tricks for the correct diagnosis : Bradycardia and tachycardia rhythm disorders]. / EKG-Befunde: Tipps und Tricks zur richtigen Diagnose : Bradykarde und tachykarde Rhythmusstörungen.

The 12-lead surface electrocardiogram (ECG) is of great importance for the diagnostics of cardiac arrhythmias. For the correct and systematic analysis it has a sensitivity and specificity for the correct diagnosis of supraventricular tachycardia or ventricular tachycardia of more than 95%. Nevertheless, the assessment of cardiac rhythm disorders is difficult for many physicians. In this way errors can occur, frequently due to a non-systematic analysis of the ECG; therefore, the aim of this article is to present the techniques and the necessary knowledge for assessment of the most frequent bradycardiac and tachycardiac heart rhythm disorders. Additionally, special features in the analysis of the ECG results in children are discussed.

[Sudden cardiac death and automated external defibrillators. Where we are in 2012?]. / Plötzlicher Herztod und automatisierte externe Defibrillatoren. Wo stehen wir 2012?

Sudden cardiac death (SCD) is one of the major problems in the western world with approximately 70.000-100.000 SCD patients (pts) in Germany and 450.000 SCD victims in the US. SCD is not caused by a single factor but is a multifactorial problem. SCD is caused by ventricular tachyarrhythmias in approximately 90% of pts, whereas SCD is caused by bradyarrhythmias in 5-10%. In 50% of SCD victims, sudden cardiac death is the first manifestation of a heart disease. There is general agreement that early defibrillation with automated external defibrillators (AED) is an effective tool to treat pts with ventricular fibrillation. Nevertheless, further stragies on cardiopulmonary resuscitation and AED therapy are necessary to improve survival of patients with cardiac arrest.

[Congenital left ventricular aneurysm in a 17-year-old competitive athlete]. / Angeborenes linksventrikuläres Aneurysma bei einem 17-jährigen Leistungssportler.

We present the case of a 17-year-old competitive athlete with an asymptomatic left ventricular aneurysm (LVA). Echocardiography demonstrated hypoplasia of the septum and a large apical LVA. Magnetic resonance imaging (MRI) detected a very thin and fibrotic wall of the LVA. Due to the potential risk of rupture the LVA was surgically resected and the apex of the left ventricle was covered with a patch plasty. The patient had an event-free postoperative course. Because of the potential risk of arrhythmia, the patient was recommended not to participate further in competitive sport.

[Echocardiographic tissue Doppler imaging analysis of the systolic and early diastolic velocities of the mitral annulus motion in hypertrophic cardiomyopathy and in top-level athletes]. / Echokardiografische Gewebedoppleranalyse der Mitralringgeschwindigkeiten bei Patienten mit hypertropher Kardiomyopathie und bei Hochleistungssportlern.

BACKGROUND AND OBJECTIVE: Echocardiographic Tissue Doppler Imaging (TDI) has been proposed for the differentiation of pathological left ventricular hypertrophy (e. g. hypertrophic cardiomyopathy, HCM) and physiologic left ventricular hypertrophy (athlete's heart). The aim of this study was the TDI analysis of the systolic (S') and early diastolic (E') velocities in patients (pts.) with non-obstructive hypertrophic cardiomyopathy (HCM) and in top-level athletes in consideration of the previously published cut-off values (S' < 9 cm/s, E' < 9 cm/s). PATIENTS AND METHODS: Pulsed-wave TDI of the systolic and early-diastolic velocities was performed at the lateral and septal mitral annulus in the four-chamber view in 17 HCM pts (12 men; mean age 44 ± 16 years) and 80 consecutive athletes (80 men; mean age 26 ± 5 years). RESULTS: Pts with HCM showed significantly decreased systolic velocities of the septal (S' septal: 5.1 ± 1.2 cm/s versus 9.5 ± 1.5 cm/s, p < 0.001) and lateral mitral annulus (S' lateral: 6.4 ± 2.0 cm/s vs. 10.5 ± 2.1 cm/s, p < 0.001). The early diastolic velocity of the mitral annulus E' was significantly decreased in HCM, too (E' septal: 5.9 ± 2.2 cm/s vs. 13.1 ± 2.9 cm/s, p < 0.001; E' lateral: 8.2 ± 3.0 cm/s vs. 16.5 ± 3.4 cm/s, p < 0.001). CONCLUSION: Tissue Doppler Imaging of the systolic and early diastolic velocity of the mitral annulus might be helpful as a promising additional method for the echocardiographic differentiation between pathological and physiologic left ventricular hypertrophy.

Mitral valve disease as well as uncommon extensive epipericardial and intramyocardial calcification secondary to massive mitral annular calcification.

A 71-year-old woman with a history of childhood pulmonary tuberculosis was admitted to our hospital for exertional dyspnoea (NYHA functional class II). Transthoracic and transoesophageal echocardiography demonstrated moderate to severe mixed mitral valve disease due to massive mitral annular calcification (MAC) and extensive infiltrative calcification of the atrioventricular groove. In addition, a very uncommon intramyocardial calcification of the ventricular septum and the lateral free wall was diagnosed. This case demonstrates a rare combination of mitral valve disease secondary to MAC, and a small hypertrophied left ventricle, as well as epipericardial and myocardial calcification likely due either to the massive MAC with myocardial extension or to former tuberculous perimyocarditis. The multidimensional imaging approach, which has been used in this particularly case, provided an excellent visualization and clinical evaluation of this rare finding.

Papillary fibroelastoma prolapsing into the left ventricular outflow tract: diagnosis using three-dimensional TEE.

A 72-year-old woman was admitted to our hospital with exertional dyspnea and atrial tachycardia due to atypical atrial flutter. Comprehensive three-dimensional transesophageal echocardiography (3D-TEE) with offline reconstruction of the dataset (Siemens Foursight TEE, Erlangen, Germany) allowed visualization of the origin of the tumor and gave important additional information about the tumor: the tumor surface was floppy, it had the appearance of a "sea anemone", and it was attached to the endocardium of the head of the papillary muscle by a short stalk. The tumor was assessed to be 1.9 × 1.4 × 0.9 cm, and a prolapsing of the tumor into the left ventricular outflow tract during systole was demonstrated.A tumor size of 8 × 10 mm and an infiltration of the head of the anterior papillary muscle were found during surgery. The histopathological findings were typical for a papillary fibroelastoma (PFE) with involvement of the head of the papillary muscle.Our case indicates that a PFE might be difficult to distinguish from myxoma by echocardiography. Thus, the multimodal imaging approach and the three-dimensional visualization of the surface, the localization, and the attachment of the tumor to the head of a papillary muscle were very helpful for the identification of a fibroelastoma in this particular case.

[Life-threatening brady- and tachyarrhythmias]. / Vital bedrohliche brady- und tachykarde Herzrhythmusstörungen.

Bradycardic (heart rate<50/min) and tachycardic heart rhythm disturbances (100/min) require rapid therapeutic strategies. Supraventricular tachycardias (SVT) are sinus tachycardia, atrial tachycardia, AV-nodal reentrant tachycardia and tachycardia due to accessory pathways. Mostly SVT are characterized by small QRS complexes (QRS width<0.12 ms). It is essential to evaluate the arrhythmia history, to perform a good physical examination and to exactly analyze the 12-lead electrocardiogram. An exact diagnosis is then possible in >90% of SVT patients. Ventricular tachycardias have a broad QRS complex (>or=0.12 s), ventricular flutter and ventricular fibrillation are associated with chaotic electrophysiologic findings. For acute therapy, we will present the new concept of the "5A" that includes adenosine, adrenaline, ajmaline, amiodarone and atropine. Additional "B, C and D strategies" include betablocking agents, cardioversion as well as defibrillation. The "5A" concept allows a safe and effective antiarrhythmic treatment of all bradycardic and tachycardic arrhythmias as well as asystolia.

[Quality of life and posttraumatic stress disorder after out-of-hospital cardiac arrest]. / Lebensqualität und posttraumatische Belastungsstörung nach außerklinischer Reanimation.

BACKGROUND: Survival rate after out-of-hospital cardiac arrest (OHCA) is increasing. However, there is a lack of data concerning long-term quality of life of affected patients. OBJECTIVES: This study aims to investigate the psychological effects of out-of-hospital cardiopulmonary resuscitation. METHODS: All patients who were admitted to our hospital after OHCA between 01 January 2008 and 30 June 2015 and could be discharged in good neurological condition were asked to fill out the Impact of Event Scale-Revised (IES-R) and 36-Item Short Form Health Survey (SF-36). For statistical analysis, the mean, standard deviation and student's t­test were used (level of significance p < 0.05). RESULTS: Of 280 OHCA survivors, 56 patients (20.0%) were discharged from the hospital in good neurological condition. Of those, 20 patients (35.7%) were willing to participate in this study, among them 11 women and 9 men. Compared to the cohort of the German normative data, the results of the SF-36 questionnaire of OHCA survivors showed significantly lower values in all SF-36 subscales and also for the summary scores. There was no significant difference compared to patients with myocardial infarction. Average values of the IES-R subscales for intrusion and avoidance were 9.9 ± 9.3 and 9.7 ± 7.7, respectively, and 11.3 ± 7.4 for hyperarousal. Calculations indicated the suspected diagnosis of posttraumatic stress disorder in 2 of the 20 patients (10%). DISCUSSION: Even in patients who could be discharged from the hospital after OHCA in good neurological condition, the quality of life is significantly lower compared to the standard population but not compared to patients with myocardial infarction. The data also suggest that a relevant number of patients after OHCA is affected by posttraumatic stress disorder. Further research efforts on optimization of post-resuscitation care should not only focus on survival rates but also on improving quality of life.

[Supraglottic airway devices and intraosseous access in the treatment of patients after out-of-hospital cardiac arrest : Do we use the wrong tool too often?] / Supraglottische Atemwegssicherung und intraossärer Zugang in der Behandlung von Patienten nach außerklinischem Herz-Kreislauf-Stillstand : Verwenden wir das falsche Hilfsmittel zu oft?

INTRODUCTION: Only a little is known about the frequency of use of supraglottic airway devices (SADs) and intraosseous (IO) access in patients who have had out-of-hospital cardiac arrest (OHCA). MATERIALS AND METHODS: We analyzed data from all patients who had had OHCA admitted to our hospital between 1 January 2008 and 31 December 2017. RESULTS: A total of 135 (33.8%) patients who had had OHCA were admitted with a SAD, 223 (55.8%) with an endotracheal tube, 3 (0.8%) with mask ventilation, and 32 (8.0%) breathed spontaneously on admission to hospital. Three hundred and twenty-eight patients (82.0%) were admitted with a peripheral intravenous line, one (0.3%) with a central venous catheter, one (0.3%) with a port catheter, and 32 (8.0%) with IO access. CONCLUSIONS: Irrespective of an increasing number of studies that raise the question whether the airway management of patients who have had OHCA using an SGA might be inferior to that with endotracheal tubes, approximately one third of all patients who have had OHCA were admitted with an SAD in this study. On the other hand, IO access is significantly less frequently used, despite fewer critical study results overall.

Acute simultaneous proximal occlusion of two major coronary arteries in acute myocardial infarction: successful treatment with percutaneous coronary intervention.

BACKGROUND: Acute myocardial infarction (AMI) due to acute simultaneous proximal occlusion of two major coronary arteries (ASOMC) is a rare but life-threatening situation. Most patients die suddenly or go into cardiogenic shock (CS). In patients with AMI due to ASOMC identified by coronary angiography (CA), percutaneous coronary intervention (PCI) performed in both infarct-related arteries (IRAs) at the same time as diagnostic CA is the fastest option to complete revascularization. However, no prospective studies regarding the outcome of such procedures have been published so far. METHODS: In this prospective single-center study, between October 2004 and March 2007, consecutive patients with acute coronary syndrome (ACS) reporting to our university hospital and regional referral center were evaluated for ASOMC by means of emergent CA. When diagnosed with ASOMC, PCI of the IRAs was performed. Clinical data were obtained at baseline, discharge, after 6 months, and after 1 year. RESULTS: Out of 417 patients with ACS, 379 patients (90.9%) suffered an AMI. In 5 patients CA revealed an ASOMC. PCI was performed in 4 patients. One patient with severe triple-vessel disease was referred for emergent coronary artery bypass graft (CABG) surgery after conventional PCI of one IRA. One patient died in-hospital due to early in-stent thrombosis after PCI. At 6-month follow-up and at 1-year follow-up, 4 patients were alive. CONCLUSION: In spite of the complex interventions, PCI patients had low in-hospital mortality and good clinical results at 1-year follow-up. Our observations are important in the clinical decision-making process of AMI due to ASOMC.

Prolapsing left atrial myxoma: preoperative diagnosis using a multimodal imaging approach with magnetic resonance imaging and real-time three-dimensional echocardiography.

Real-time three-dimensional echocardiography (RT3DE) is a new promising technique for the evaluation of intracardiac masses. We present the diagnostic work-up using a multimodal-imaging approach in a 74-year-old patient with a prolapsing tumour in the left atrium suggestive of a myxoma, causing severe congestive heart failure attributable to dynamic left ventricular inflow obstruction, and mimicking severe mitral valve stenosis. Real-time three-dimensional echocardiography allowed to accurately image the entire volume of the myxoma, and to analyse the dynamic left ventricular inflow obstruction. The size of the lobulated mass as assessed by RT3DE was 65 x 25 x 22 mm. The mass was surgically removed, histology was diagnostic for myxoma, and the patient had an uneventful recovery. Real-time three-dimensional echocardiography images the entire volume of a mass allowing for accurate measurements in multiple planes, and allowing for real-time evaluation of obstructive effects on ventricular in- or outflow. This case shows how RT3DE and other non-invasive imaging modalities may be used as complementary techniques for evaluation of intracardiac masses.

Non-determinable defibrillation threshold and inefficacy of implantable cardioverter/defibrillator shocks due to defective connections of the defibrillator lead terminals in the device header port.

Inefficacy of implantable cardioverter/defibrillator (ICD) shocks or inappropriate shocks in ICD patients may occur due to mechanical or technical failure of the device. In our unusual case of ICD defibrillation failure, faulty insertion and configuration of the defibrillation lead in the header port resulted in ineffective shock therapies and a non-determinable defibrillation threshold. In cases of successless defibrillations during or after ICD implantation, this problem should be considered.

[Ethics in intensive care and euthanasia : With respect to inactivating defibrillators at the end of life in terminally ill patients]. / Ethik in Intensivmedizin und Sterbehilfe : Zur Frage der Inaktivierung von Defibrillatoren vor dem Lebensende bei Schwerstkranken.

BACKGROUND: In critically ill patients, intensive care medical procedures allow diseases to be cured or controlled that were considered incurable many years ago. For patients with terminal heart failure or heart disease with other severe comorbidities (cancer, stroke), the questions whether the deactivation of defibrillators is appropriate or must be regarded as active euthanasia may arise. MATERIALS AND METHODS: Notable cases from the author's hospital are analyzed. The literature on the topic euthanasia and basic literature regarding defibrillator therapy are discussed. DISCUSSION AND CONCLUSION: It is undisputed that patients as part of their self-determination have the right to renounce treatment. Active euthanasia and the thereby deliberate induction of death is prohibited by law in Germany and will be prosecuted. Passive euthanasia is the omission or reduction of possibly life-prolonging treatment measures. Passive euthanasia requires the patient's consent and is legally and ethically permissible. Indirect euthanasia takes into account acceleration of death as a side effect of a medication. Unpunishable assisted suicide ("assisted suicide") is the mere assistance of self-controlled and self-determined death. Assisted suicide is fundamentally not a criminal offense in Germany. Deactivation of a defibrillator is a treatment discontinuation, which is only permitted in accordance with the wishes of the patient. It is not a question of passive or active euthanasia. Involvement of a local ethics committee and/or legal consultation is certainly useful and sometimes also allows previously unrecognized questions to be answered.

[Are emergency physicians influenced by nonmedical aspects in their choice of the hospital : Observations in 280 victims of out-of-hospital cardiac arrest in times of hospital alliances]. / Sind Notärzte bei der Wahl der Zielklinik durch nichtmedizinische Aspekte beeinflusst : Beobachtungen an 280 Patienten nach außerklinischem Herzstillstand in Zeiten der Krankenhauskooperationen.

INTRODUCTION: Emergency physicians are responsible for the out-of-hospital treatment of victims from out-of-hospital cardiac arrest (OHCA), not only with regard on the medical treatment, but also in terms of the choice of the most suitable hospital. We therefore wanted to determine whether nonmedical processes such as hospital alliances lead to changing rates of hospital admissions of patients following OHCA. MATERIALS AND METHODS: All patients who were admitted in our hospital following OHCA between 1 January 2008 and 30 June 2015 were identified and their data were anonymously stored in a central database. Afterward, we divided the study period into three periods: (1) the period prior to the publication of the ERC guidelines 2010, (2) the period after the publication of the ERC guidelines 2010, and (3) the period after a contract for hospital alliances with another hospital in town was signed. RESULTS: Of the 280 OHCA victims, we could analyze the emergency physician's reports of 238 victims from nontraumatic OHCA; there were 143 men (60.1 %) and 95 women (39.9 %) with an age of 69.1 ± 13.7 years. Following the changes in the guidelines in 2010, we observed a 42.8 % increase of hospital admissions from 2.15 admissions per month to 3.07 in period 2 following OHCA compared to period 1. After signing of the hospital alliance, there was an additional increase of 42.3 % to an average of 4.37 hospital admissions per month. DISCUSSION AND CONCLUSION: According to our data, it might be possible that not only medical influences (e.g., changes in the guidelines) but also nonmedical aspects (e.g., hospital alliances) might influence the choice of hospital for the further treatment of victims from OHCA.

[Fundamentals of 12-lead electrocardiography in intensive care medicine]. / Grundlagen der 12-Kanal-Elektrokardiographie in der Intensivmedizin.

The surface electrocardiogram (ECG) is an important diagnostic tool for the diagnosis of arrhythmias and acute coronary syndrome. Arrhythmias are divided into bradycardias (heart rate < 50/min) and tachycardias (heart rate > 100/min). Among tachycardias, differentiation between small QRS complexes (QRS width < 0.12 s) and broad QRS compexes (≥ 0.12 s) during tachycardia is necessary. It is important to analyze the relationship between P wave and QRS complex, to look for an electric alternans as a leading finding for an accessory pathway. Wide QRS complex tachycardias (QRS width ≥ 0.12 s) occur in supraventricular tachycardias (SVT) with aberrant conduction, SVT with bundle branch block or ventricular tachycardia (VT). In broad complex tachycardias, atrioventricular (AV) dissociation, negative or positive concordant pattern in V1-V6, a notch in V1, and qR complexes in V6 in tachycardias with left bundle branch block morphologies are findings indicating VT. In addition, an R/S relationship < 1 in V6 favors VT when right bundle branch block tachycardia morphologies are present. By correctly analyzing the surface ECG with a systematic approach, the specificity and sensitivity of correctly identifying a SVT or VT can be increased to greater than 95 %. The12-lead surface ECG is an important diagnostic tool for intensive care medicine. However, good ECG knowledge and systematic analysis are necessary to make the right diagnosis.

Lack of prognostic value of syncope in patients with Wolff-Parkinson-White syndrome.

Syncope in patients with Wolff-Parkinson-White syndrome may be considered a premonitory event heralding the future development of sudden death. Therefore, the clinical and electrophysiologic data of 101 patients with Wolff-Parkinson-White syndrome referred for invasive evaluation of known arrhythmias were reviewed to assess the incidence and clinical relevance of syncope. Thirty-six patients reported the occurrence of one or more syncopal episodes (group 1) and 65 patients had no syncope (group 2). These two groups did not differ significantly with regard to age, gender, incidence and characteristics of arrhythmia, clinical history, frequency of arrhythmic events and presence of associated cardiac disease. There were 10 patients in group 1 and 12 in group 2 who had ventricular fibrillation. There were no statistical differences between the two groups with respect to the effective refractory period of the right atrium, atrioventricular node, accessory pathway and right ventricle. Furthermore, no differences between the two groups were noted with respect to cycle length of circus movement tachycardia, mean heart rate during atrial fibrillation, and minimum RR interval during atrial fibrillation. In addition, the accessory pathway location was not significantly different between group 1 and group 2. The occurrence of syncope could not be predicted from any electrophysiologic finding and this symptom had a low sensitivity and specificity for recognition of dangerous rapid heart rates. Furthermore, the prognostic value of syncope was less accurate and predictive than the shortest RR interval during atrial fibrillation and the anterograde effective refractory period of the accessory pathway for aborted sudden death occurrence.(ABSTRACT TRUNCATED AT 250 WORDS)

Prognosis of patients with ventricular tachycardia and ventricular fibrillation: role of the underlying etiology.

The prognosis of 149 patients with ventricular tachycardia (n = 108) or ventricular fibrillation (n = 41) was analyzed to assess the importance of the underlying etiology of the arrhythmia. Seventy-three patients (Group I) had a previous myocardial infarction and documented late sustained monomorphic ventricular tachycardia. Thirty-five (Group II) also had a previous myocardial infarction but had late ventricular fibrillation. There were 41 patients (Group III) without coronary artery disease: 9 patients with right ventricular dysplasia, 26 with idiopathic sustained ventricular tachycardia and 6 with idiopathic ventricular fibrillation. The mean follow-up period for all patients was 22 to 57 months. The total mortality rate in Group I (16%) and Group II (34%) and the arrhythmic mortality rate in Group I (5%) and Group II (11%) were significantly higher than the rates in Group III. In the latter group the total mortality rate was 4% for those with idiopathic ventricular tachycardia and 11% for those with right ventricular dysplasia, and there were no deaths due to arrhythmia (p less than 0.05). Left ventricular ejection fraction was significantly lower and left ventricular end-diastolic pressure was significantly higher in Group I and Group II than in Group III. There were nonfatal recurrences of ventricular tachycardia in 33 to 56% of patients, and the number of these episodes did not differ significantly in those with and without coronary artery disease.(ABSTRACT TRUNCATED AT 250 WORDS)

Incidence of ventricular arrhythmias during transient myocardial ischemia in patients with stable coronary artery disease.

To determine the incidence of ventricular arrhythmias related to episodes of transient myocardial ischemia during ambulatory electrocardiographic (ECG) monitoring, 97 patients with stable angina pectoris, angiographically proved coronary artery disease and an abnormal exercise test were studied. A total of 573 episodes with ST segment depression were documented: in 118 episodes (21%) the patients were symptomatic and in 455 (79%) they remained asymptomatic. Ventricular arrhythmias (greater than 5 premature ventricular beats/min, bigeminy, couplets or salvos of premature ventricular beats) occurred during 27 (5%) ischemic episodes in a subset of 10 patients (10%) (group A). The other 87 patients (90%) (group B) showed exclusively ischemic episodes without ventricular arrhythmias. Comparison of patients in group A and group B showed no differences in hemodynamic, angiographic, exercise testing and ambulatory ECG monitoring data. Ischemic episodes with and without ventricular arrhythmias showed a similar duration and amplitude of ST segment depression and a comparable heart rate at the onset of ischemia. Both types of ischemic episodes, with and without arrhythmias, occurred predominantly during the morning hours between 6:00 AM and noon, and both types remained asymptomatic to within similar percentages. The data demonstrate that ventricular arrhythmias are related to transient myocardial ischemia in only a few patients with stable angina pectoris; these arrhythmias are related neither to the degree of ischemia during ambulatory ECG monitoring nor to the occurrence of anginal symptoms.