[Fulminant sepsis after Capnocytophaga canimorsus infection]. / Fulminante Sepsis nach Capnocytophaga-canimorsus-Infektion.

Capnocytophaga canimorsus is a Gram-negative bacterium present in the oral cavities of cats and dogs. It is known for its capability to cause life-threatening sepsis following a dog bite, especially in immunocompromised patients. We report the case of a 67-year-old man who suffered from septic shock and multiorgan failure presumably following contamination of a pre-existing minor skin lesion by canine saliva. The purpose of this report is to raise awareness of Capnocytophaga canimorsus among physicians when faced with a patient presenting with fulminant septic shock and Gram-negative bacteremia, who has been exposed to dogs.

Rate of change in aortic valve area during a cardiac cycle can predict the rate of hemodynamic progression of aortic stenosis.

BACKGROUND: The ability to predict the rate of hemodynamic progression in an individual patient with valvular aortic stenosis has been elusive. The purpose of the present study was to evaluate whether the rate of change in aortic valve area (AVA) measured during the ejection phase of a cardiac cycle predicts the rate of hemodynamic progression in patients with asymptomatic aortic stenosis. METHODS AND RESULTS: In 84 adults with initially asymptomatic aortic stenosis and a baseline AVA of > or =0.9 cm(2), annual echocardiographic data were obtained prospectively (mean follow-up 2.8+/-1.3 years). With the initial echocardiogram, the ratio of AVA measured at mid-acceleration and mid-deceleration to the AVA at peak velocity was calculated. The primary outcome variable was the annual rate of change in AVA (rate of progression), with rate of progression classified as rapid (a reduction in AVA of > or =0.2 cm(2)/y) or slow (<0.2 cm(2)/y). Rapid progression was significantly associated with an AVA ratio of > or =1.25 (P=0.004, risk ratio 3.1, 95% CI 1.2 to 7.9). The sensitivity, specificity, and positive predictive value of AVA ratio of > or =1.25 for the prediction o rapid progression of valvar aortic stenosis was 64%, 72%, and 80% respectively. The decrease in ejection fraction measured from the initial to final echocardiogram was small but greater for patients with an AVA ratio of > or =1.25 (-4+/-7% versus +2+/-7%, P<0.001). CONCLUSIONS: A flow-dependent change in AVA can be measured during a routine transthoracic echocardiographic study. The rate of change in AVA is an additional measure of disease severity and may be used to predict an individual's risk for subsequent rapid disease progression.

[Patient with heparin-induced thrombocytopenia type II and implanted left ventricular assist device]. / Patient mit heparininduzierter Thrombozytopenie Typ II und implantiertem linksventrikulärem Assistdevice.

The administration of heparin can lead to life-threatening heparin-induced thrombocytopenia (HIT) type II, which is caused by antibodies against heparin-platelet factor 4-complexes. The multimorbid patient presented here suffered from HIT II. Preoperative and postoperative prevention of thrombosis was successfully conducted with argatroban and the management of anticoagulation is presented. During therapy with argatroban, discrepancies in the partial thromboplastin time (PTT) and the international normalized ratio (INR) appeared sporadically. The clinical causes for these differences remain unclear.

[Transesophageal echocardiography as intraoperative monitoring for the resection of an intra-atrial tumor]. / TEE bei fibrolamellärem Leberzellkarzinom. Transösophageale Echokardiographie als intraoperatives Monitoring bei Resektion eines intraatrialen Tumors.

Fibrolamellar hepatocellular carcinomas (FLHCC) can grow into the inferior vena cava and the right atrium thus rendering it impossible to insert a pulmonary artery catheter or increasing the risk of tumor embolisation. We report of a young patient with intraatrial growth of a FLHCC where intraoperative transesophageal echocardiography (TEE) instead of a pulmonary artery catheter for continuous monitoring of hemodynamics was used. Hemodynamic parameters as well as the surgical result could easily be assessed.

The 'TEI-index' is preload dependent and can be measured by transoesophageal echocardiography during mechanical ventilation.

BACKGROUND AND OBJECTIVE: The Doppler-derived echocardiographic TEI-index, defined as the sum of the left ventricular isovolumic contraction and isovolumic relaxation times divided by ejection time, quantifies combined systolic and diastolic ventricular functions. The index has been proposed to be independent of arterial pressure and heart rate, implying a broad clinical usefulness. However, it is unclear whether the index is preload independent. We assessed whether and to what degree the TEI-index is altered by left ventricular loading conditions, and the feasibility of measurement by transoesophageal echocardiography during anaesthesia and mechanical ventilation. METHODS: We studied 17 anaesthetized mechanically ventilated patients with coronary artery disease during variations in left ventricular preload evoked by head-up and head-down tilt, respectively. RESULTS: A head-down tilt increasing left ventricular end-diastolic area from 18.8 +/- 4 to 23.7 +/- 4 cm2 (P < 0.05) significantly decreased the TEI-index from 0.5 +/- 0.17 to 0.33 +/- 0.15 (P < 0.05). In contrast, the TEI-index remained unchanged with decreased left ventricular preload (14.4 +/- 3.7 cm2) during head-up tilt. CONCLUSIONS: An increase in preload decreases the TEI-index indicating its sensitivity to acute increases in left ventricular preload. The TEI-index can be measured perioperatively by transoesophageal echocardiography.