[Biventricular thrombi dissolution and antibody development with lepirudin therapy]. / Biventrikuläre Thrombenauflösung und Antikörper-Bildung unter Lepirudin-Therapie.

HISTORY AND ADMISSION FINDINGS: A 50-year-old patient presented with clinical symptoms of heart failure with orthopnoe and edema (NYHA IV). INVESTIGATIONS: Echocardiography revealed a dilated left ventricle with severely reduced left ventricular function and biventricular floating thrombi, due to dilatative cardiomyopathy. TREATMENT AND COURSE: With a heart failure medication clinical symptoms reduced and body weight decreased > 10 kg in 3 weeks. Due to the high-risk constellation, anticoagulation was performed with lepirudin and the biventricular thrombi were dissolved within 17 days. At this point in time, the patient suffered from petechial bleedings, hemoptysis and gross hematuria. Despite breaking anticoagulation and substitution of PPSB with not measurable fibrinogen, subarachnoid hemorrhage occurred leading to exitus letalis. CONCLUSION: Lepirudin is a highly effective anticoagulant, that can induce severe hemorrhagic side effects in individual cases. The present case report demonstrates an immunological reaction as a rare cause with activation of prothrombin and formation of fibrin.

Cardioversion of atrial fibrillation in the elderly. ALKK-Study Group. Arbeitsgemeinschaft Leitender Kardiologischer Krankenhausaerzte.

The purpose of this investigation was to define cardioversion success rates, frequency of complications of cardioversion, and current treatment practices in elderly patients (aged > or = 65 years) with atrial fibrillation (AF). The results were compared with those in younger patients (aged < 65 years). The investigation was a prospective multicenter observational study with 61 participating cardiology clinics. Consecutive patients in whom cardioversion of AF was planned had to be prospectively registered. Of 1,152 patients registered, 570 (49.5%) were < 65 years old (group 1) and 582 (50.5%) were > or = 65 years (group 2). The overall success rate of cardioversion on an intention-to-treat basis was 76.1% in group 1 and 72.7% in group 2 (p = 0.18). In multivariate analysis, left atrial size and New York Heart Association functional class before cardioversion were identified as predictors of success (p < 0.001, respectively; p = 0.025). These clinical factors were not equally distributed between the age groups: Left atrial size was larger in the elderly than in younger patients (44.0 +/- 6.4 mm vs 42.8 +/- 6.4 mm; p = 0.006) and a New York Heart Association functional class > or = II was more prevalent in group 2 than in group 1 (48.6% vs 29.6%; p < 0.001). The overall complication rates were not significantly different between the 2 groups (4.2% in group 1 vs 5.3% in group 2; p = 0.37). The frequency of patients who were adequately anticoagulated for cardioversion was 56.9% in age group 1 and 39.6% in age group 2 (p < 0.001). In chronic AF the same trend for age-dependent underuse of anticoagulation was observed. Age itself was not a predictor of cardioversion success and did not predispose to higher complication rates. Therefore, cardioversion should be considered in older patients with the same criteria and emphasis as in younger patients. Anticoagulation and antithrombotic medication is underused for cardioversion and in treating chronic AF, especially in elderly patients.

Interleukin-1 beta upregulates tissue-type plasminogen activator in a keratinocyte cell line (HaCaT).

Human keratinocytes synthesize and secrete tissue-type plasminogen activator (tPA). tPA converts the inactive precursor enzyme plasminogen into the trypsin-like proteinase plasmin. tPA is not found in normal epidermis, but in lesional epidermis from patients with a variety of cutaneous diseases, including psoriasis, pemphigus and pemphigoid. The presence of tPA is probably a reaction to the disease process rather than the initiating event in these etiologically and histopathologically diverse lesions. However, the factor(s) that upregulate tPA expression and secretion in keratinocytes have remained largely elusive. We sought to determine whether the inflammatory cytokine interleukin-1 beta (IL-1 beta), which is commonly present in diverse epidermal lesions, influences tPA production. Accordingly, we studied the influence of IL-1 beta on secretion of tPA by cells of the human keratinocyte cell line HaCaT. We found that IL-1 beta increased tPA secretion in these cells. Given the observation that IL-1 beta is a common proinflammatory mediator in cutaneous diseases, our findings may explain the increase in tPA in clinically and etiologically diverse inflammatory epidermal lesions.

Upregulation of cell-surface-associated plasminogen activation in cultured keratinocytes by interleukin-1 beta and tumor necrosis factor-alpha.

Keratinocytes synthesize and secrete urokinase-type plasminogen activator (uPA) which is bound in an autocrine manner to a specific receptor (uPA-R) at the keratinocyte surface. Plasminogen that is also bound to specific membrane binding sites is readily activated by uPA-R-bound uPA. Thus, plasmin is provided for proteolysis of pericellular glycoproteins. The expression of uPA and the uPA-R is confined to migrating keratinocytes during epidermal wound healing, rather than to keratinocytes of the normal epidermis. The regulatory factors of uPA/uPA-R expression in keratinocytes remained largely elusive. Proinflammatory cytokines, such as tumor necrosis factor-alpha (TNF-alpha) or interleukin-1 beta (IL-1 beta), are present in epidermal wounds. We have therefore tested IL-1 beta and TNF-alpha for their influence on surface-associated plasminogen activation in a human keratinocyte cell line (HaCaT) as well as in primary cultures of normal human epidermal keratinocytes. Both cytokines induced the secretion of uPA into the culture supernatants and a concomitant increase in uPA activity as well as in uPA and uPA-R antigen at the cell surface. The increase was preceded by an increase in specific mRNA. The induction was accompanied by an accelerated uPA-dependent and plasmin-mediated detachment of HaCaT cells from the culture substratum. Taken together, the proinflammatory cytokines IL-1 beta and TNF-alpha induced a coordinated increase in uPA and uPA-R as well as increased pericellular plasmin-mediated proteolysis in human epidermal keratinocytes. This function might be an element of the molecular cell biological events during epidermal wound healing.

Open, noncontrolled dose-finding study with a novel recombinant plasminogen activator (BM 06.022) given as a double bolus in patients with acute myocardial infarction.

The novel recombinant plasminogen activator (r-PA) (BM 06.022) is a mutant of tissue-type plasminogen activator expressed in escherichia coli which can be given as a bolus because of a prolonged half-life. The primary objective of this trial was to determine the efficacy of an intravenous r-PA double bolus (first bolus of 10 MU followed by 5 MU after 30 minutes) in patients with acute myocardial infarction. All patients received heparin intravenously and acetylsalicylic acid orally. Efficacy was assessed from infarct artery patency by coronary angiography (Thrombolysis in Myocardial Infarction trial perfusion grades 2 or 3) in 50 patients. Ninety minutes after administration of the first r-PA bolus, the infarct-related coronary artery was patent in 39 of 50 patients (78%; 95% confidence interval 64 to 88%). An angiographically confirmed reocclusion occurred in 1 patient between 90 minutes and 24 to 48 hours. The reocclusion rate was influenced by 8 interventions and 1 angiogram missing at 24 to 48 hours. Measurements of hemostatic parameters showed a decrease in fibrinogen to 37% of baseline value. There were 3 clinical reinfarctions before discharge and 2 major puncture site hemorrhages. No further serious bleeding and no serious adverse event with lethal outcome occurred. The 10 + 5 MU r-PA double bolus regimen appears to be effective with regard to patency and the success of thrombolysis. The incidence of reocclusion is very low. From the limited number of patients treated in this study, one need not be concerned about the safety profile of r-PA.

[Cardiac output determination by respiratory gas exchange measurement during submaximal exercise (author's transl)]. / Bestimmung der Herzförderleistung mittels submaximaler Spiroergometrie.

Under linearly increasing work load the point of rise of the ventilatory equivalent for oxygen (VEO = V(E)/V(O2) depends upon the degree of cardiac output increment. The latter being low, the slope of the minute ventilation (V(E) curve is correspondingly steep and that of the oxygen consumption (V(O2) curve flat. Consequently, the upslope of VEO (after an initial downslope) begins earlier in case of a poor cardiac exercise performance, and vice versa. By means of continuous measurement of respiratory data with a pneumotachygraphic system and on the basis of the values of V(O2), O2-pulse and Relative Ventilatory Equivalent (= VEO/V(O2) determined at the point of rise of VEO it was possible to divide 126 patients (mostly with coronary heart disease) into 4 groups of different cardiocirculatory capacity. These differed significantly with respect to the values measured at the point of rise of VEO as well as with respect to those related to work load. There ist good reproducibility of the values determined at the point of rise of VEO. The described method represents a rapid non-invasive means of determining different stages of impairment of cardiac pump function.

[Non-invasive determination of cardiac pump function by respiratory gas exchange measurement during submaximal exercise -- comparison with hemodynamic (heart catheterisation) data (author's transl)]. / Nichtinvasive Bestimmung der kardialen Pumpfunktion unter Belastung mittels submaximaler Spiroergometrie. Vergleich mit invasiv gewonnenen /ämodynamischen Parametern.

The continuous measurement of respiratory gas exchange under linearly increasing work load allows a relatively exact and reproducible localization of the point of rise of the ventilatory equivalent for oxygen (ASV). On the basis of the values of oxygen consumption (V(O2)(ASV)), oxygen pulse (O2-pulse(asv)) and relative ventilatory equivalent (Vetn. Equivalent(asv)/V(O2(ASV)), measured at the point ASV, it is possible to divide patients with different severity of heart disease into 4 groups of cardiac response to exercise: group I = normal, group II = diminished, group III = definitely limited and group IV = severely limited cardiocirculatory capacity. Simultaneous cardiac output measurements (thermodilution method) as well as the comparison with hemodynamic and angiographic data acquired during separate heart catheterization reveal good correlations between V(O2(ASV) and O2-pulse(asv) on the one hand and exercise values of cardiac output and stroke volume on the other (r = 0.82). Consequently, definite relations exist between the absolute ASV values as well as the group classification (I--IV) based on these and further heart catheterization data such as left bentricular (LV) enddiastolic pressure, LV ejection fraction, contraction pattern of the left ventricle and coronary angiogram respectively. The described method of measuring respiratory gas exchange under submaximal unsteady state bicycle exercise represents a reliable and rapid non-invasive stress test of cardiac pump function without putting too much strain on the heart patient as is frequently the case with the more familiar steady state (maximal) tests.