Serratia sp. bacteremia in Canberra, Australia: a population-based study over 10 years.

The purpose of this paper was to determine the population incidence and clinical features of Serratia sp. bacteremia in Canberra, Australia. Demographic and clinical data were collected prospectively for episodes of Serratia sp. bacteremia over a 10-year period, and was confined to Canberra residents using residential postal codes. Thirty-eight episodes of Serratia sp. bacteremia occurred, with a yearly incidence of 1.03 per 100,000 population. The majority of episodes occurred in males (68%). The respiratory tract was the most common focus of infection (21%). Twenty-nine percent of episodes were community-associated. A further 18% of episodes had their onset in the community but were healthcare-associated. The 7-day and 6-month mortality rates were 5 and 37%, respectively. Antibiotic resistance to gentamicin (3%) and ciprofloxacin (0%) was low. Serratia sp. bacteremia is more common than generally appreciated, with a large proportion (47%) of episodes having their onset in the community.

The coronary-subclavian-vertebral steal syndrome (CSVSS).

OBJECTIVE: Reverse flow in the internal thoracic artery (ITA) after coronary bypass surgery due to an occlusion or severe stenosis of the subclavian artery is a rare situation. Symptoms can be recurrent and intermittent angina pectoris in the case of a coronary-subclavian steal (CSSS) or-in addition with cerebral symptoms-in the case of a coronary-subclavian-vertebral steal syndrome (CSVSS). METHOD: We describe the cases of four patients with recurrent angina pectoris 5, 11, and 14 years as well as directly after coronary bypass surgery with LITA grafts to LAD. In two patients there was the additional aspect of vertebral steal symptoms with dizziness and intermittent drop attacks. RESULTS: A PTA of the subclavian occlusions in three cases was not feasible, so that three patients were operated on by extrathoracal approach and carotido-subclavian bypass (CSB) in two cases, and local thrombendarteriectomy of the subclavian and vertebral artery (TEA)+ -patchplasty in one case. Patient 4 was treated by PTA and stent placement into the subclavian artery. Antegrade flow in all four LITAs could be achieved resulting in immediate relief from angina pectoris and cerebral symptoms. Patients 1 and 3 showed no further symptoms with equal BP of the upper extremities and anterograde flow in the LITA grafts and vertebral artery at 10-month follow-up. Patient 2 unfortunately died from an unrelated cause (asthmatic state) 4 months after the operation despite an uneventful recovery. CONCLUSION: The occurrence of a CSSS or CSVSS after coronary bypass surgery with retrograde flow in the ITA graft (as described in our four patients) is a rare, but potentially hazardous, situation. If the subclavian occlusion is not amenable to endovascular strategies, the extrathoracal approach by CSB or local TEA and patchplasty provides an excellent means with good midterm and long-term results.

In-hospital time to treatment of patients with acute ST elevation myocardial infarction treated with primary angioplasty: determinants and outcome. Results from the registry of percutaneous coronary interventions in acute myocardial infarction of the Arbeitsgemeinschaft Leitender Kardiologischer Krankenhausarzte.

OBJECTIVE: To determine the predictors of time between presentation and primary angioplasty and the influence of this delay time on in-hospital mortality in clinical practice. DESIGN: Analysis of data from the registry of percutaneous coronary interventions in acute myocardial infarction of the Arbeitsgemeinschaft Leitender Kardiologischer Krankenhausärzte (ALKK). PATIENTS: Data of 4815 patients registered at 80 hospitals between 1994 and 2000 were analysed. RESULTS: Mean age of the patients was 61.4 (12.5) years. Cardiogenic shock was present in 14.1%. Mean time from admission to primary angioplasty ("door to angiography" time) was 83 (122) minutes. Logistic regression analysis showed the presence of a bundle branch block (odds ratio (OR) 1.95, 95% confidence interval (CI) 1.15 to 3.29), prior coronary artery bypass grafting (OR 1.67, 95% CI 1.08 to 2.59), pre-hospital delay > 3 hours (OR 1.61, 95% CI 1.37 to 1.89), and female sex (OR 1.21, 95% CI 1.01 to 1.45) to be independently associated with longer door to angiography times, whereas a higher hospital volume of performing primary angioplasty (OR 0.53, 95% CI 0.46 to 0.62) and the year of the investigation (OR 0.96, 95% CI 0.92 to 1.00) were independently associated with shorter door to angiography times. Independent predictors of in-hospital mortality were cardiogenic shock (41.6% v 4.0% without cardiogenic shock, p < 0.0001), technical success (29.2% with TIMI (thrombolysis in myocardial infarction) flow < 3 v 6.5% with TIMI flow 3, p < 0.0001), age (16.5% > or = 70 years v 6.6% < 70, p < 0.0001), three vessel disease (16.5% v 6.8% with < 3 vessel disease, p < 0.0001), anterior location of infarction (12% v 7.4% without anterior infarction, p < 0.0001), year of inclusion (adjusted OR 0.92 per year, p = 0.011), and volume of primary angioplasty at the hospital (11% for < 20 angioplasty procedures/year v 8.3% for > or = 20/year, p = 0.027) but not the door to angiography time (adjusted OR 1.14 per tertile, p = 0.397). CONCLUSIONS: In current clinical practice in Germany median door to angiography time is quite short (83 (122) minutes). Some patients and hospital factors are independently associated with a longer door to angiography time. Within the observed short in-hospital delays door to angiography time did not influence in-hospital mortality. However, efforts to keep them as short as possible should be continued.

[Platypnea-orthodeoxia of a 69-year old woman with a patent foramen ovale]. / Platypnoe-Orthodeoxie-Syndrom einer 69-jährigen Patientin bei offenem Foramen ovale.

Platypnea-orthodeoxia is a rare syndrome that is often associated with interatrial shunting through a patent foramen ovale (PFO) or atrial septal defect. We describe the case of a 69-year-old woman with progressive dyspnea and hypoxia when standing, which was relieved by assuming the recumbent position. After detection of a PFO by transesophageal echocardiography the diagnosis was confirmed by transthoracic echocardiography using saline contrast injection while lying supine and standing upright. This maneuver demonstrated a large right-to-left shunt through a patent foramen ovale while the patient was in a upright position and no significant shunt while being in a recumbent position. The patient showed a rapid improvement after closure of the PFO. This case demonstrates that platypnea-orthodeoxia caused by a patent foramen ovale can be easily demonstrated by the technique of contrast transthoracic echocardiography and a simple positioning maneuver.

Determinants of mortality after cardiac surgery: results of the registry of the Arbeitsgemeinschaft Leitender Kardiologischer Krankenhausärzte (ALKK) on 10 525 patients.

BACKGROUND: Mortality from cardiac surgery is an essential indicator of quality and forms the basis of treatment strategy decisions in eligible patients. No contemporary complete data on unselected adult cardiac surgery patients are available in Germany. METHODS AND RESULTS: A registry was started in June 1997 of all patients referred to surgery from 85 cardiology centres in Germany. The registry was intended to include 10 000 patients and this number was reached in March 1998. Follow-up of the patients was by simple questionnaire, reporting the date of surgery, major complications, and symptomatic improvement. If the questionnaire was not returned, a reminder letter was sent and, if necessary, further telephone investigations were performed. This resulted in 99.9% complete data. Of 10 525 patients operated on, 3.91% had died by 30 days after surgery. The overall operative mortality was 4.57%, which included 69 patients who died after more than 30 days from complications related to surgery. By multivariate analysis, the following predictors of mortality were identified: previous surgery, emergency or complex operation; age >75 years, female gender, cardiac failure, angina CCS class IV, and three-vessel coronary disease. An integral part of the registry was a pre-operative prediction of surgical risk in five categories. This risk estimate revealed a surprisingly correct prediction of the mortality observed. CONCLUSIONS: In a representative unselected group of cardiac surgery patients, operative mortality was 4.57%. Several procedural and clinical parameters were significantly correlated with mortality, but the risk increment by each of these factors was small. Unstructured clinical judgement reliably predicted the operative risk.

Direct percutaneous transluminal coronary angioplasty in acute myocardial infarction. Predictors of short-term outcome and the impact of coronary stenting. Study Group of The Arbeitsgemeinschaft Leitender Kardiologischer Krankenhausärzte (ALKK).

BACKGROUND: Direct percutaneous transluminal coronary angioplasty (PTCA) is widely accepted in the treatment of acute myocardial infarction since excellent results had been reported from several small randomized trials. Less favourable results were observed in large-scale registries. In particular, the use of stents in acute myocardial infarction has become common practice without documented evidence of clinical efficacy. METHODS: Data were analysed from a registry of all consecutive percutaneous transluminal coronary angioplasty procedures from 62 centres in Germany, including 2331 direct percutaneous transluminal coronary angioplasty in acute myocardial infarction from July 1994 to April 1997. RESULTS: The overall angiographic success rate of percutaneous transluminal coronary angioplasty, defined as complete antegrade perfusion of the infarct vessel, was 87%. In-hospital mortality was 11.2%. The most important predictor of death was the presence of cardiogenic shock in 15% of patients, of whom 52% died. Mortality in patients without shock was 3.9%. Failed percutaneous transluminal coronary angioplasty was associated with a mortality of 36%. Further independent predictors of death were older age, multivessel disease, and anterior myocardial infarction. Stents were used in 4.1% of the procedures in 1994, increasing to 53% in 1997. However, this was not accompanied by improved clinical outcome. Mortality with coronary stenting was 9.9% vs 11.6% without stents (ns). CONCLUSIONS: Direct percutaneous transluminal coronary angioplasty is a valuable treatment strategy in acute myocardial infarction, although the results are less exceptional than reported from some highly specialized centres. Failed percutaneous transluminal coronary angioplasty seems to be harmful, thus outweighing much of the benefit from successful procedures. Stents did not improve the clinical outcome significantly, despite technically successful placement in 98%. Mortality from cardiogenic shock continues to be excessively high despite direct PTCA.

PTCA registry of German community hospitals. Arbeitsgemeinschaft Leitender Kardiologischer Krankenhausärzte (ALKK) Study Group.

BACKGROUND: Percutaneous transluminal coronary angioplasty (PTCA) is widely used, but no quality control has been systematically performed as yet. METHODS: A registry of all PTCA procedures has been established since October 1992 for the majority of the German community hospitals performing PTCA, representing about one third of all PTCA activity in Germany. Baseline demographic data, indication for PTCA, primary success and in-hospital clinical events were recorded. Each centre was visited at regular intervals to assure completeness and reliability of the data. RESULTS: Of 52453 procedures performed from October 1992 to December 1994 the catheter laboratory and discharge forms were 99.7% and 98.1% complete, respectively. In 85.9% a single lesion was dilated per procedure, but 48.7% of the patients had multivessel disease. The success rate was 66.5% in complete occlusions (residual stenosis < 70%) and 91.2% in non-occluded vessels (residual stenosis < 50%). Abrupt vessel closure occurred in 3.4%, of which 77.5% could be recanalized by repeat intervention. In procedures not done for acute myocardial infarction, the in-hospital mortality was 0.52%, the procedure-related mortality 0.37%. In 3.02% of all patients a severe complication occurred (procedure-related death, myocardial infarction or emergency bypass surgery). CONCLUSION: Complete recording of all PTCA procedures is feasible even on a nationwide basis. This is a pre-requisite for continuous quality control. The reporting of the procedures by itself very probably, has an impact on the quality which is, however, not measurable quantitatively.

[Myocardial infarct with oral contraceptives: simultaneous thrombotic occlusion of the anterior interventricular ramus and the circumflex ramus]. / Herzinfarkt unter oralen Kontrazeptiva: Simultaner thrombotischer Verschluss des Ramus interventricularis anterior und des Ramus circumflexus.

A 28-year-old, previously healthy mother of one child, with cigarette smoking and oral contraceptive medication as only risk factors suffered an acute anterior myocardial infarction without prior anginal complaints. Angiographically there were thrombotic occlusions of the LAD after the first septal branch and also of the distal left circumflex coronary artery. Six days after catheter recanalisation of the LAD and i.e. infusion of urokinase, there were small residual thrombi in the otherwise perfectly normal LAD and in a diagonal branch whereas the circumflex coronary artery was completely normal. The left ventricle showed anteroseptal (but not inferior) akinesis. The case report supports the hypothesis that myocardial infarctions under oral contraceptive medication are a separate disease entity unrelated to coronary atherosclerosis and may be the consequence of a "coagulation accident".

-Recanalization of chronic coronary artery occlusions: effect on clinical symptoms and left ventricular function-. / Rekanalisation chronischer Koronararterienverschlüsse: Einfluss auf klinisches Beschwerdebild und linksventrikuläre Funktion.

UNLABELLED: Angioplasty of chronically occluded coronary arteries is discussed controversially. This study was performed to investigate the potential benefit of recanalization procedures. Between 1/91 and 10/93 occlusion angioplasty was attempted in 408 patients. 322 persons were followed with repeat angiography performed in 177 patients. Quantitative analysis of left ventricular function was performed in 34 patients before and after successful occlusion angioplasty. Primary reopening rate was about 71% with highest success rate for occluded LAD (82%). Angiographic controls showed open arteries in 80 (45.2%) patients, 53 (30.0%) had restenosis and 44 (24.8%) reocclusion. Anginal status was improved by one CCS-class or more in 197 patients (61%), mean exercise workload increased from 115.8 watts to 136.1 watts (p < 0.0001). Out of 34 patients, 25 (73.5%) showed improvement of regional ventricular function, mean ejection fraction increased from 56.9% to 64.1% (p < 0.001). Follow-up angiography revealed open arteries in 58% of patients if dissection was absent. When dissection type B, C or D NHLBI was present, only 32% of the vessels were open. CONCLUSION: In selected patients occlusion angioplasty is feasible with acceptable primary results. Anginal complaints and functional status were influenced positively, left ventricular function showed improvement indicating the presence of hibernating myocardium. In patients with suboptimal primary results (dissection) repeat angiography may be indicated.

[Results of immediate and delayed bypass operation in PTCA emergencies]. / Ergebnisse der sofortigen und der verzögerten Bypass-Operation beim PTCA-Notfall.

UNLABELLED: The therapeutic strategy for irreversible coronary occlusion as a complication of PTCA is influenced by the rate of myocardial infarctions and mortality after emergency bypass surgery. If immediate bypass operation cannot prevent myocardial infarction, medication will be the treatment of choice. Since the duration of ischemia is of critical importance for the preservation of myocardium, we analyzed our results with respect to the time interval from the onset of ischemia to surgery. From 12/84 to 12/93 there were 49 emergency operations for 4,478 PTCAs. In 38 patients acute closure occurred in the cath lab; because of very strict standby arrangements these patients could be brought to the operating rooms without delay (group A). In 11 patients acute closure occurred during the following 24 hours in the intermediate care unit (group B); attempts of catheter recanalisation and/or preparation for surgery accounted for an additional time delay until surgery of 79 minutes. RESULTS: In the 38 patients of group A there were only one small transmural (CKmax 533/U/l) and four non-Q wave (CK-max 322 U/l) myocardial infarctions. Of the 11 patients in group B only two did not suffer any loss of myocardium. In seven cases there were transmural (CKmax 1,296 U/l) and in two cases non-Q wave (CKmax 721 U/l) myocardial infarctions. Two patients of group B died on the second and third postoperative day. Thus the results of emergency bypass operations were excellent if surgery could be performed immediately after failure of catheter interventions (all survived, no transmural M.I. in 97%).(ABSTRACT TRUNCATED AT 250 WORDS)

[Massive proteinuria and HELLP syndrome]. / Proteinuria masiva y síndrome HELLP.

HELLP syndrome continues to be a clinical entity of difficult diagnosis. Weinstein first defined it in 1982 giving the practicing obstetrician a sequence of useful initials (H = hemolysis; EL = elevated liver enzymes; LP = low platelets). Since then a lot has been written and it has become clear that the syndrome is a form of severe preeclampsia. The American College of Obstetrics and Gynecology does not include HELLP in the description of severe pre-eclampsia as such but does accept each of its components as being part of severe pre-eclampsia. The case presented deals with a 33 year old white female, admitted at 27 weeks gestation with nausea, epigastric pain resembling acute abdomen, nose bleeding and mild hypertension. The analysis revealed an abnormal liver profile with elevated GOT, GPT and LDH, heavy proteinuria (14.4 g/day), decreased platelet count (92000/mm3) and elevated total bilirubin. Pregnancy was terminated by cesarean section 24 hours after admission because the patient's condition was deteriorating. Obviously in pre-eclampsia/eclampsia there is a systematic injury to all tissues. Proof of this is the hypertension as a consequence of vascular spasm and proteinuria due to glomerular injury. In HELLP the sequence of events is probably altered; hepatic injury precedes vascular and renal injury of conventional preeclampsia. The syndrome results from many clinical and pathological symptoms derived from endothelial microvascular injury which determine a rapid platelet activation causing vascular spasm, platelet aggregation and further endothelial injury through a feedback mechanism.(ABSTRACT TRUNCATED AT 250 WORDS)

Proteinuria masiva y sindrome HELLP / Massive proteinuria and HELLP syndrome

El sídrome de HELLP (Hemolysis, Elevated Liver Enzymes and Low Platelets) descripto por Weinstein en 1982, continúa siendo un cuadro clínico de dificil diagnóstico, no sólo por su escasa frecuencia sino por la dificultad en la interpretación de sus sítomas iniciales. La fisiopatología de esta enfermedad resulta de la afección del endotelio microvascular, que determina una rápida activación plaquetaria, liberando tromboxano A2 y serotonina, elementos que retroalimentan la injuria endotelial. Se presenta una paciente de 33 años de edad con embarzo de 27 semanas que ingresa al hospital por náuseas, epigastralgia intensa que simula un abdomen agudo, epistaxis e hipertensión arterial de 7 días de evolución. Al ingreso la enferma presentaba proteinuria de 14 g/día, plaquetopenia severa (92000/mm3), enzimas hepáticas elevadas e hiperbilirrubinemia. Con diagnóstico de síndrome de HELLP se interrompe el embarazo por operación cesárea obteniéndose a las 24 hs. una respuesta clínica favorable en la evolución de la paciente, normalizándose en días sucesivos sus valores de laboratorio y presión arterial. Se bien la proteinuria masiva superior a los 10 g es excepcional asociándose a una mayor morbimortalidad fetal, tal sucede en el caso aquí descripto

Proteinuria masiva y síndrome HELLP. / [Massive proteinuria and HELLP syndrome]

HELLP syndrome continues to be a clinical entity of difficult diagnosis. Weinstein first defined it in 1982 giving the practicing obstetrician a sequence of useful initials (H = hemolysis; EL = elevated liver enzymes; LP = low platelets). Since then a lot has been written and it has become clear that the syndrome is a form of severe preeclampsia. The American College of Obstetrics and Gynecology does not include HELLP in the description of severe pre-eclampsia as such but does accept each of its components as being part of severe pre-eclampsia. The case presented deals with a 33 year old white female, admitted at 27 weeks gestation with nausea, epigastric pain resembling acute abdomen, nose bleeding and mild hypertension. The analysis revealed an abnormal liver profile with elevated GOT, GPT and LDH, heavy proteinuria (14.4 g/day), decreased platelet count (92000/mm3) and elevated total bilirubin. Pregnancy was terminated by cesarean section 24 hours after admission because the patients condition was deteriorating. Obviously in pre-eclampsia/eclampsia there is a systematic injury to all tissues. Proof of this is the hypertension as a consequence of vascular spasm and proteinuria due to glomerular injury. In HELLP the sequence of events is probably altered; hepatic injury precedes vascular and renal injury of conventional preeclampsia. The syndrome results from many clinical and pathological symptoms derived from endothelial microvascular injury which determine a rapid platelet activation causing vascular spasm, platelet aggregation and further endothelial injury through a feedback mechanism.(ABSTRACT TRUNCATED AT 250 WORDS)

Proteinuria masiva y síndrome HELLP. / [Massive proteinuria and HELLP syndrome]

HELLP syndrome continues to be a clinical entity of difficult diagnosis. Weinstein first defined it in 1982 giving the practicing obstetrician a sequence of useful initials (H = hemolysis; EL = elevated liver enzymes; LP = low platelets). Since then a lot has been written and it has become clear that the syndrome is a form of severe preeclampsia. The American College of Obstetrics and Gynecology does not include HELLP in the description of severe pre-eclampsia as such but does accept each of its components as being part of severe pre-eclampsia. The case presented deals with a 33 year old white female, admitted at 27 weeks gestation with nausea, epigastric pain resembling acute abdomen, nose bleeding and mild hypertension. The analysis revealed an abnormal liver profile with elevated GOT, GPT and LDH, heavy proteinuria (14.4 g/day), decreased platelet count (92000/mm3) and elevated total bilirubin. Pregnancy was terminated by cesarean section 24 hours after admission because the patients condition was deteriorating. Obviously in pre-eclampsia/eclampsia there is a systematic injury to all tissues. Proof of this is the hypertension as a consequence of vascular spasm and proteinuria due to glomerular injury. In HELLP the sequence of events is probably altered; hepatic injury precedes vascular and renal injury of conventional preeclampsia. The syndrome results from many clinical and pathological symptoms derived from endothelial microvascular injury which determine a rapid platelet activation causing vascular spasm, platelet aggregation and further endothelial injury through a feedback mechanism.(ABSTRACT TRUNCATED AT 250 WORDS)

Proteinuria masiva y sindrome HELLP / Massive proteinuria and HELLP syndrome

El sídrome de HELLP (Hemolysis, Elevated Liver Enzymes and Low Platelets) descripto por Weinstein en 1982, continúa siendo un cuadro clínico de dificil diagnóstico, no sólo por su escasa frecuencia sino por la dificultad en la interpretación de sus sítomas iniciales. La fisiopatología de esta enfermedad resulta de la afección del endotelio microvascular, que determina una rápida activación plaquetaria, liberando tromboxano A2 y serotonina, elementos que retroalimentan la injuria endotelial. Se presenta una paciente de 33 años de edad con embarzo de 27 semanas que ingresa al hospital por náuseas, epigastralgia intensa que simula un abdomen agudo, epistaxis e hipertensión arterial de 7 días de evolución. Al ingreso la enferma presentaba proteinuria de 14 g/día, plaquetopenia severa (92000/mm3), enzimas hepáticas elevadas e hiperbilirrubinemia. Con diagnóstico de síndrome de HELLP se interrompe el embarazo por operación cesárea obteniéndose a las 24 hs. una respuesta clínica favorable en la evolución de la paciente, normalizándose en días sucesivos sus valores de laboratorio y presión arterial. Se bien la proteinuria masiva superior a los 10 g es excepcional asociándose a una mayor morbimortalidad fetal, tal sucede en el caso aquí descripto (AU)

[Immediate bypass operation prevents heart infarct in PTCA emergencies]. / Die sofortige Bypass-Operation verhindert den Herzinfarkt beim PTCA-Notfall.

UNLABELLED: Between December 1984 and June 30, 1989, we performed PTCAs on 1438 patients. The procedures were performed with strict cardiosurgical standby. In 24 patients (22 X LAD, 2 X RCA), abrupt coronary occlusion necessitated immediate bypass surgery. In 19 cases, abrupt coronary closure occurred during PTCA in the cath lab; in five patients, during the following 24 h on the intermediate care ward. No patient died. Immediate bypass surgery prevented myocardial infarction (MI) in 79.2% of the cases. None of the 19 patients with abrupt coronary closure in the cath lab had a Q-wave myocardial infarction postoperatively. One of these 19 patients had an R-wave reduction (non-Q-MI) and one patient had a new terminally negative T-wave in the postoperative ECG. Two of the five patients with evidence of acute coronary occlusion on the intermediate care ward had small Q-wave MIs and one had a non-Q-wave MI postoperatively. Time of ischemia (defined als time interval between the end of PTCA and the beginning of extracorporal circulation) was 65 +/- 28 min in the former group and 122 +/- 30 min in the latter. CONCLUSION: Because immediate bypass surgery prevents Q-wave MI after abrupt closure during PTCA, strict temporal and spatial cooperation with the cardiac surgeon is mandatory.

[Hemodynamic and clinical results following percutaneous aortic valve valvuloplasty in adults]. / Hämodynamische und klinische Ergebnisse nach perkutaner Aortenklappenvalvuloplastie bei Erwachsenen.

We analyzed the results and the follow-up in our first 80 patients after percutaneous balloon aortic valvuloplasty (BAV) since November 1986. Mean age was 74 +/- 10 years, 78 patients were in the NYHA functional classes III or IV. Initially we used relatively small balloons (15-18 mm), later balloons of 20 mm and, with increasing frequency, of 23 mm diameter were utilized, providing very strong inflations at the end of the procedure. The average valve area after BAV increased from initially 0.75 +/- 0.18 to 0.87 +/- 0.28 cm2 after July 1987. Using the 23-mm balloon a mean valve area of 1.05 +/- 0.19 cm2 was obtained. The procedure-related mortality was 2.5%, the total early mortality (30 days) was 6.25%. Other non-fatal complications included two cases of severe valve incompetence requiring valve replacement, one dissection in the aortic root, one cerebrovascular accident, and eight cases of arterial damage (surgical repair). Twenty-six patients with initially successful dilation were restudied hemodynamically, 12 of whom had a restenosis (46%) after 5 months; 13 patients had a second dilatation. The clinical improvement was remarkable (at least 1 NYHA functional class) in 79% of the patients. 33% were improved 1 year and 20% 18 months after the first or eventually the second BAV. Eighteen of the discharged patients died in the follow-up period (two after valve replacement); 20 patients had aortic valve replacement due to restenosis. Our results show a correlation of the maximal balloon size to the valve area after BAV. However, even a perfect technique cannot prevent the restenosis that occurs mostly during the first year. Therefore, BAV may be useful and appropriate for selected patients with inoperable aortic stenosis, but it is no alternative to valve replacement.

[Endocardial dual-chamber stimulation in an anomalous persistent left superior vena cava]. / Endokardiale Zwei-Kammer-Stimulation bei singulärer linkspersistierender oberer Hohlvene.

A persistent left superior vena cava was noted in a 63-year-old woman during pacemaker implantation because of sinus bradycardia and AV dissociation. During atrial test stimulation a 2 degree AV block occurred at a rate of only 110/min and dual-chamber provision was thus necessary. Both catheters were introduced into the right heart via the coronary sinus, but placement of the right-ventricular lead was made more difficult than usual because of looping. One year later pacemaker function (DDI mode) was unchanged and the patient symptom-free.

[Coronary spasm immediately following coronary revascularization]. / Koronarspasmus unmittelbar nach Koronarrevaskularisation.

Of 2,600 coronary operations performed from August 1983, to December 1988, two ischemic reactions of the inferior wall immediately after operation were observed. In both patients the right coronary artery was either dissected or revascularized intraoperatively. Under the diagnosis of postoperative spasm both patients had reangiography three hours after surgery. Right coronary artery spasm was demonstrated in both patients. After intracoronary injection of calcium channelblockers the spasm resolved completely. Patient 1 demonstrated a small inferior infarction during control angiography, patient 2 remained free of a myocardial infarction. The possible causes of coronary spasm during or after surgery are discussed. The diagnosis and an approach to therapy are outlined.