[Severe heart failure: treatment optimisation and monitoring using plasma NT-proBNP levels--an useful tool in clinical practice]. / Schwere Herzinsuffizienz: Therapieoptimierung/Therapie monitorisierung mittels NT-proBNP-Plasmaspiegels--ein lohnendes Werkzeug für die Praxis.

A young patient presented with a cardiomegaly of unknown origin. The cardiologic examination revealed a severe eccentric left ventricular hypertrophy and a dilatation of the other heart cavities as well as a strongly impaired global systolic function. The patient was treated with an ACE inhibitor, a diuretic and with a beta-blocking agent. The dosages of which were adapted accordingly to the plasma concentration of N-terminal-pro-brain-natriuretic peptide (NT-proBNP). After five months of treatment, a decrease of the NT-proBNP level to nearly normal values along with a significant reduction of the heart dimensions and a substantial improvement of left ventricular function were found.

[Mechanical circulatory assist devices in acute and chronic heart failure]. / Mechanische Kreislaufunterstützung bei akuter und chronischer Herzinsuffizienz - eine Standortbestimmung unter besonderer Berücksichtigung der Entwicklung in Deutschland.

The clinical use of mechanical circulatory assist devices as bridge to transplantation has been proved as life-saving therapy in a large population of patients. Learning from the clinical experience the construction of the blood pumps has been markedly improved over the last years. The better outcome of the patients has enabled a broader use of ventricular assist devices. The novel axial pumps are designed for long-term circulatory support. After further reduction of device related complications (first of all thromboembolic events) these systems may provide a future alternative to heart transplantation.

The Jarvik 2000 is associated with less infections than the HeartMate left ventricular assist device.

OBJECTIVES: Device-related infections remain a considerable problem of left-ventricular support. We compared the device-related-infections between the HeartMate left ventricular assist device (LVAD) and the Jarvik 2000 permanent LVAD, a device with a novel retroauricular power-supply. METHODS: Between December 2000 and September 2002 we implanted the HeartMate-vented, electrical-system in 11 patients and the permanent Jarvik 2000 in six patients. Total support time was 1626 patient-days (HeartMate, 26-271 days) versus 1246 patient-days (Jarvik 2000, 8-411 days). As potential risk factors for infection we analyzed age, preoperative hospital-days, total protein, cardiac index, maximal oxygen uptake, use of inotropes, LVAD risk-score-index and Aaronson-Mancini-score, intubation time, and intensive care unit stay. We used the Center of Disease Control definitions for surgical site infections. RESULTS: HeartMate-patients were younger than Jarvik 2000 patients (46+/-13 versus 58+/-6 years, P=0.056), there were no other differences in the risk factors. Four HeartMate-patients needed late (>or=48 h) surgical revisions for bleeding/hematomas versus no revisions in the Jarvik 2000 patients. In the HeartMate-patients, there were seven (64%) driveline-infections, five (45%) device-pocket infections, and three (27%) bloodstream-infections, or 0.43 device-related infections/100 patient-days. Infections occurred early (34+/-31 days). Three patients required urgent transplantation due to bloodstream infection. There were no adverse outcomes in the HeartMate-group due to infection. In the Jarvik 2000 patients, there was one driveline-infection (16%) after 270 days of support (0.08 device-related infections/100 patient-days), significantly less than in the HeartMate-group (P=0.044). Driveline infections resolved with antibiotics and local wound care in the Jarvik 2000 patient, but only in one of seven HeartMate-patients. CONCLUSIONS: Implantation of the Jarvik 2000 is associated with less device-related infections than the HeartMate-LVAD. The power-supply of the permanent Jarvik 2000 is suitable for long-term mechanical support.

Controlled limb reperfusion in patients having cardiac operations.

HYPOTHESIS: Severe limb ischemia in patients having cardiac operations may occur after intraaortic balloon pump insertion, prolonged femoral vessel cannulation, percutaneous cardiopulmonary bypass, dissecting aneurysms, or emboli. Normal blood reperfusion can cause a postischemic syndrome that increases morbidity and mortality. This clinical study is based on an experimental infrastructure patterned after controlled cardiac reperfusion. (1) It tests the hypothesis that controlled limb reperfusion (i.e., modifying the composition of the initial reperfusate and the conditions of reperfusion) reduces the local and systemic complications seen after normal blood reperfusion. (2) It reports initial clinical application of this strategy in three cardiac surgery centers. METHODS: Controlled limb reperfusion was applied to 19 patients with signs of severe prolonged unilateral or bilateral ischemia (including paralysis, anesthesia, and muscle contracture); six patients (32%) were in cardiogenic shock. The mean ischemic duration was 26 +/- 6 hours. The reperfusion method includes a 30-minute infusion into the distal vessels of a normothermic reperfusate solution mixed with the patient's arterial blood (obtained proximal to the obstruction) in a 6:1 blood/reperfusate ratio. Data are mean +/- standard error of the mean. RESULTS: Sixteen patients (84%) survived with salvaged and functional limbs at the time of discharge. No renal, cardiac, pulmonary, cerebral, or hemodynamic complications developed in the survivors. The three deaths occurred in patients undergoing controlled limb reperfusion while in profound postoperative cardiogenic shock; neither postischemic edema nor contracture developed in any of them. CONCLUSIONS: These findings show that controlled limb reperfusion can be applied readily with standard equipment that is used for cardiac surgery and may salvage limbs while reducing postreperfusion morbidity and mortality.

Immediate postoperative recovery of regional wall motion after unilateral and bilateral internal mammary artery revascularization.

Within the last few years the importance of the internal mammary artery (IMA) for coronary revascularization has increased rapidly. Although there is no doubt about the superior long-term patency of this artery in comparison to saphenous vein grafts, the discussion about early postoperative results is controversial. The aim of the present study was to assess segmental wall motion after unilateral and bilateral IMA revascularization. Thirty-three patients who underwent elective myocardial revascularization were examined. In addition to vein grafts, bilateral IMA grafts were used in 8 patients and unilateral ones in 25 patients. Myocardial segmental wall motion was assessed by transesophageal echocardiography perioperatively. Myocardial protection was achieved by standard cold blood cardioplegia. Global left ventricular function remained unchanged postoperatively (4 h) in both groups (unilateral IMA: 52.8% +/- 7.1% vs 49.8% +/- 11.1%; bilateral IMA; 47.7% +/- 8.7% vs 48.7% +/- 7.7%, ns). Anterior wall motion (left IMA grafts to left anterior descending artery (LAD) was decreased early postoperatively (30 min) in both groups (unilateral IMA: 50.9% +/- 15.3% vs 37.8% +/- 14.5%; bilateral IMA: 47.3% +/- 20.1% vs 30.4% +/- 8.5%, P < 0.05). Posterior wall motion was decreased in the bilateral IMA group (right IMA to right coronary artery (RCA), 47.8% +/- 7.2% vs 28.0% +/- 8.9%, P < 0.05) and remained unchanged in the unilateral IMA patients (vein grafts to RCA, 39.5% +/- 9.9% vs 41.4% +/- 17.5%, ns). Internal mammary artery revascularization may result in deterioration of segmental myocardial function in the early (< 4 h) postoperative period. Bilateral IMA grafts should therefore be used with caution in patients with impaired ventricular function.

[Factor VII and protein-C markers are no prognostic indicators in acute coronary heart disease]. / Faktor VII und Protein-C-Marker sind keine prognostischen Indikatoren bei akuter koronarer Herzkrankheit.

Fibrinogen and factor VII have been identified as independent risk factors in cardiovascular morbidity. A relationship between factor VII coagulant activity (VII:C) and prognostically different manifestations of acute coronary heart disease (aCHD) has recently been suggested. In order to validate and to extend these observations, we prospectively studied patients admitted for aCHD (n = 76) and a control group without aCHD (CG, n = 27). According to their clinical evolution, the aCHD cases were subdivided into unstable angina (UA, n = 26), myocardial infarction without (M-I, n = 23) and with heart failure (M-II, n = 27). Before treatment blood was collected for the following assays: fibrinogen, factor VII procoagulant activity (VII:C), amidolytic test (VII:am), immunological (VII:Ag), protein C functional (PCf) and immunological (PC:Ag). We found no statistically significant difference between control and aCHD cases and between their subgroups for any assay of fibrinogen, factor VII and protein C. The VII:C/VII:Ag ratio was higher for UA, M-I, M-II and the entire aCHD group compared with the CG. However, it was not possible to separate the prognostically different aCHD subgroups from each other by ratios of measured values. Therefore, determinations of factor VII, protein C and fibrinogen in aCHD have no prognostic relevance.

Controlled reperfusion during emergency coronary artery bypass surgery after angioplasty failure restores immediate segmental contractility.

This study tests the hypothesis that careful control of the composition of the initial reperfusate and the conditions of the reperfusion during emergency CABG will restore immediate segmental contractility in the previously ischemia area despite ischemic intervals of greater than 2 hours. Between January 1987, and October 1990, 41 consecutive patients with acute coronary occlusion (90% due to PTCA failures) were reperfused during emergency myocardial revascularization according to one of two different protocols: in 25 patients the reperfusate was normal blood given at systemic pressure ("uncontrolled reperfusion"); in 16 patients the ischemic segment was reperfused during the first 20 minutes with a regional blood cardioplegic solution (substrate-enriched, hyperosmotic, hypocalcemic, alkalotic, diltiazem-containing) at 37 degrees C at a pressure of 50 mmHg. Thereafter, total bypass was prolonged for an additional 30 minutes before extracorporeal circulation was discontinued ("controlled reperfusion"). Assessment of regional contractility (echocardiography, radionuclide ventriculography), electrocardiographic evidence of myocardial infarction, release of CK and CK-MB enzymes, and hospital mortality were performed. Quantification of regional contractility was done with a scoring system from 0 (normokinesis) to 4 (dyskinesis). Data are expressed as mean +/- standard error of the mean. Both groups were well matched for age, sex, and the distribution of the occluded artery. In the controlled reperfusion group there was a higher incidence of previous infarctions (50% vs 30%), additional significant stenosis (1.1 +/- 0.2 vs 0.8 +/- 0.1), and cardiogenic shock (38% vs 20%) as compared to uncontrolled reperfusion.(ABSTRACT TRUNCATED AT 250 WORDS)