A systematic diagnostic and therapeutic approach for the treatment of patients after cardio-pulmonary resuscitation: a prospective evaluation of 212 patients over 5 years.

A literature on systematic treatment protocols for patients after resuscitation for cardiac arrest is lacking. We evaluated a systematic protocol, including ECG, echocardiogram, urgent cardiac catheterisation ("STEMI-like" workflow), CT scans, laboratory findings, IABP, hypothermia, and cMRI, prospectively over 5 years. The primary endpoint was the Cerebral Performance Category Scale (CPCS). During the period from January 2008 to December 2012, 212 patients were included. The mean age was 66.7 years, n = 151 (71.2 %) were male, mean time from the first medical contact to start of catheterisation was 76.6 min, and ventricular fibrillation (VF) was present in n = 99 (46.7 %). A significant coronary artery stenosis was seen in n = 130 (61.3 %), PCI was performed in n = 101 (47.6 %), an ACS was found in n = 100 (47.2 %), n = 91 patients (42.9 %) had another cardiac cause, an extra-cardiac cause was found in n = 12 (5.7 %, mostly a cerebral process), and in 9 patients (4.3 %), no cause was identifiable. A significant difference in mortality was found for patients with TIMI flow 2/3 vs. 0/1 (65.4 vs. 95.7 %, p < 0.01). The difference of intra-aortic balloon pumping vs. no pumping was not significant, performing hypothermia reduced mortality significantly (52.7 vs. 68.2 %, p = 0.04). The survival rate was n = 76 (35.9 %), a CPCS of 1/2 was reached in n = 68 pts (32.1 %), patients with ongoing resuscitation had a 100 % mortality (n = 41), and VF had a lower mortality (54.6 vs. 72.6 %, p < 0.01). A systematic algorithm may improve the outcome of patients after reanimation compared with classically reported outcomes. The data are hypothesis generating for further studies.

Treatment of coronary bifurcation lesions: stent-covering of the side branch with and without PCI of the side branch: a retrospective analysis of all consecutive patients.

BACKGROUND: Treatment of coronary bifurcation lesions is a complex problem. METHODS: This retrospective single-center study included all consecutive patients with PCI of coronary bifurcations with stent covering of the side branch (SB) between January 2008 - August 2011. RESULTS: Our study group (n = 98) was group A (n = 64, 65.3%) and group B (n = 34, 34.7%). Mean follow-up was 14.1 (group A) vs 12.3 (group B, p = ns) months. CONCLUSION: In patients with coronary bifurcations a simpler strategy has a significantly lower MACE. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT01538186.

Acute syphilitic blindness in an HIV-positive patient.

This case report describes a rare manifestation of syphilis. An HIV-positive patient with severe immunosuppression presented with rapid loss of vision due to eye involvement of Treponema pallidum infection. The ophthalmologic examination on admittance showed a chorioretinitis, an uveitis, and a swollen optical disc of both eyes. Reconstitution of vision after application of intravenous penicillin occurred within 3 weeks. Despite low HIV prevalence in central Europe, behaviors that promote transmission of HIV and other sexually transmitted diseases tend to increase. The clinical presentation of syphilis may be atypical and the rate of complications is often higher in HIV-infected patients. Thus, Treponema pallidum infection should be considered in immunosuppressed HIV-positive patients presenting with chorioretinitis. Patients should receive treatment similar to that for neurosyphilis if there is suspicion of involvement of the central nervous system.

Norepinephrine-induced expression of cytokines in isolated biventricular working rat hearts.

The norepinephrine (NE)-induced hypertrophy of the left ventricle (LV) in the rat is associated with increased interleukin (IL)-6 and IL-1beta expression. In the present study, a newly established model of isolated biventricular working rat heart was used to examine whether NE may directly induce cytokine mRNA expression in a preparation devoid of other circulating hormonal and humoral factors. Representative hemodynamic parameters and the expression of various cytokines of the isolated biventricular working heart (IBWH) were compared with the respective in vivo results. Systolic pressure (SP) of the right ventricle (RVSP) was higher in the IBWH than in the intact anesthetized rat (42.9 +/- 1.89 vs. 32.3 +/- 1.06). However, heart rate (HR), LVSP and the maximal rate of pressure development of LV (LV dP/dt(max)) were lower. After NE infusion (30 nM), SP and dP/dt(max) were increased by 30 and 90%, respectively, in both ventricles. In vivo, the ventricles showed a different response to NE (0.1 mg/kg x h): LVSP increased by 15%, RVSP and RV dP/dt(max) was doubled, LV dP/dt(max) was tripled. The analysis of cytokine mRNA expression with the RNase protection assay revealed that in vivo IL-6 and IL-1beta were increased between 4 and 12 h 80- and 12-fold, respectively, while there was weak expression under control conditions. In the IBWH IL- 1alpha, IL-1beta, IL-6 and tumor necrosis factor (TNF)alpha were increased already during control perfusion. The increase of these stress-activated cytokines indicates that the isolation and perfusion procedure may exert a stress on the heart. NE induced an additional time-dependent increase of IL-6 mRNA after 1 h of infusion. Thus, NE has a direct effect on the cardiac IL-6 expression, which occurred earlier in the in vitro preparation than in the rat heart in vivo.

Comparison between left and right heart function in the isolated biventricular working rat heart.

OBJECTIVE: To provide a basic characterization of the crystalline perfused isolated rat heart preparation in its biventricular working mode. ANIMALS AND METHODS: In 110 isolated biventricular heart preparations, flows and intraventricular pressures were examined by applying 24 and 28 different loading conditions to the left (LV) and right ventricle (RV), respectively. RESULTS: LV and RV flows responded analogously to changes in loading conditions and were in accordance with the Frank-Starling principle. Linearization of parameters derived from the LV and RV function curves showed that the operation of both ventricles was quantitatively similar when unloaded and increasingly dissimilar when loaded. With increasing RV preload, the characteristics of the RV pump function curves changed; however, those of the LV hardly changed. Power, contractility and relaxation data of the ventricles were compared by applying the concept of corresponding afterloads, which showed that these parameters, except for power, had an inconsistent preload and afterload dependence in the LV and RV. Even though LV and RV performances displayed coexisting analogies, quantitative similarities and qualitative dissimilarities, in the case of relaxation, a concept unifying the heterogeneous data set for both ventricles has been developed. The hypothesis may be put forward that the macroscopic relaxation process of the heart muscle runs in parallel with cellular calcium handling. CONCLUSIONS: At the level of the isolated denervated rat heart model, the common LV and RV functional parameters were only partially similar between the ventricles. However, a particular functional interdependence of relaxation data has been proposed to provide a unifying description of both LV and RV function.

Afterload- and preload-dependent interactions in the isolated biventricular working rat heart.

OBJECTIVES: The afterload- (AL) and preload- (PL) dependent interactions between the left and right ventricle (LV, RV, respectively) of an isolated biventricular ejecting rat heart were measured in terms of left (L) and right (R) intraventricular peak pressure (LP(max) and RP(max), respectively) and aortic and pulmonary flow (AF, PF, respectively). METHODS: Starting with standardized loading conditions, LVPL was varied in six steps for each of five distinct LVALs (n=28) and then RVPL was varied in seven steps for each of five distinct RVALs (n=37). Thus, the entire range of loading conditions was covered. RESULTS: Identification of AL-dependent systolic interactions revealed an important DeltaLP(max)-DeltaRP(max) gain of 0.25 (r(2)=0.78) and a still more dominant DeltaRP(max)-DeltaPF gain of 0.45 (r(2)=0.84). At least 26% of maximal PF were attributable to LV systolic function. In contrast, R-L systolic interaction impeded PF; there was no global crosstalk pressure gain and no ipsilateral pressure-flow gain. Reduction of RV activity augmented AF by at least 15%. PL-dependent L-R interactions were absent except for minimal LVAL. In contrast, the reverse interaction reflected an inverse correlation between RVPL and AF, which is coincidential with other studies (-11% AF for a doubling of the standard RVPL). For the minimal RVAL, there was a biphasic response of AF to RVPL. Unloading the maximally loaded RV revealed an overall inhibition of AF by 37% for the standardized LV. Unloading the standardized RV revealed a basal inhibition of AF by 6% for the standardized LV and a 4.5% augmentation for the highly loaded LV. Consequently, basal contribution of RV to LV performance depended on the conditions of LV loading. CONCLUSIONS: The authors suggest a unidirectional transseptal R-L mechanism for diastolic interactions, and transseptal L-R and paraseptal R-L mechanisms for systolic interactions.