Comparison of skeletal muscle strength between cardiac patients and age-matched healthy controls.

The purpose of the present study was to compare muscular strength of knee extensors and arm flexor muscles of cardiac patients (n = 638) and healthy controls (n = 961) in different age groups. Isometric torques were measured in a sitting position with the elbow, hip, and knee flexed to 90(0). For statistical analysis, age groups were pooled in decades from the age of 30 to 90 years. Additionally, the influence of physical lifestyle prior to disease on muscular strength was obtained in the patients. For statistical analysis three-way ANOVA (factors age, gender, and physical activity level) was used.Both in patients and in controls a significant age-dependent decline in maximal torque could be observed for arm flexors and knee extensors. Maximal leg extensor muscle showed statistically significant differences between healthy controls and cardiac patients as well as between subgroups of patients: Physically inactive patients showed lowest torques (male: 148 +/- 18 Nm; female: 82 +/- 25 Nm) while highest values were measured in control subjects (male: 167 +/- 16 Nm; female: 93 +/- 17 Nm). In contrast, arm flexor muscles did not show any significant influence of health status or sports history.This qualitative difference between weight-bearing leg muscles and the muscle group of the upper extremity suggest that lower skeletal muscle strength in heart patients is mainly a consequence of selective disuse of leg muscles rather than any pathological skeletal muscle metabolism. Since a certain level of skeletal muscle strength is a prerequisite to cope with everyday activities, strength training is recommended as an important part of cardiac rehabilitation.

[Integrated case fees in cardiosurgery--a pilot project for fast-track rehabilitation]. / Komplexfallpauschalen in der Herzchirurgie--ein Modellprojekt zur Frührehabilitation.

BACKGROUND: Lengthy recovery and treatment times following cardiosurgical interventions were the motivation for introducing a pilot procedure to integrate acute and rehabilitative treatment structures. The advantage of such a pilot procedure is the medico-economic link between direct transition from acute care to rehabilitation treatment and cutting average case costs. With this in mind, shared case fees for patients following cardiosurgery are being agreed in a pilot project between health insurance companies, acute-care hospitals and rehabilitation clinics. The aim of this study was thus to investigate whether rehabilitation directly after cardiosurgery without prior transferral to an acute-care hospital is comparable with the conventional procedure involving acute care. METHODS: A total of 221 patients were included in the investigation. The pilot project group comprised 159 patients (mean age 70 +/- 6 yrs, 117 men and 42 women) who were transferred directly to rehabilitation following cardiosurgery. The control group, comprising 62 patients (mean age = 71 +/- 6 yrs, 42 men and 20 women), was transferred to an acute-care hospital following cardiosurgery before commencing rehabilitation. Sociodemographic and clinical data were comparable between the two groups. RESULTS: At the end of rehabilitation, the mean maximum ergometric performance in the pilot group was 96 +/- 33 W, significantly higher than the control group's performance of 81 +/- 31 W. One difference between the two groups related to complications. During rehabilitation, complications occurred more frequently within the pilot group. In the pilot group, compared to the control group, postcardiotomy syndrome occurred in 45.3 versus 25.8% and impaired wound healing in 10.1 versus 4.8% of cases. Despite these results, the pilot group demonstrated a significantly shorter overall hospital stay of 39.5 +/- 7.5 days compared to the control group stay of 45.7 +/- 9.7 days. CONCLUSION: Compared to the control group, the pilot group was at no disadvantage with regard to clinical or performance data by the end of rehabilitation. Cardiac complications occur more often during rehabilitation taking place directly after cardiosurgery than with the conventional procedure. These can be viewed, however, as complications occurring directly in temporal conjunction with the operation and as to be expected. Complications attributed directly to fast-track rehabilitation can be excluded. In the pilot group the overall hospital stay was thus shortened. In an environment of legislative restructuring within the healthcare sector, this shows that adequate treatment of cardiosurgical patients is still guaranteed with fast-track rehabilitation.

Effect of an exercise training program on endothelial dysfunction in diabetic and non-diabetic patients with severe chronic heart failure.

BACKGROUND: Endothelial dysfunction is found both in patients with chronic heart failure and in patients with insulin-treated type 2 diabetes mellitus. This endothelial dysfunction leads to a significant reduction in endothelium-derived vasodilation. Physical exercise can have a positive effect on endothelial dysfunction in patients with coronary artery disease, chronic heart failure and diabetes mellitus. It is not clear, however, whether an exercise program influences endothelial function in diabetics with chronic heart failure. Our study was thus aimed at investigating whether a special exercise program would affect endothelial function. Comparisons were made with insulin-treated type 2 diabetics and with non-diabetics suffering from chronic heart failure. METHODS: 42 patients with severe chronic heart failure (LVEF < or = 30%), insulin-dependent diabetics (n=20, mean age 67+/-6 yrs, 16 male, 4 female), non-diabetics (n=22, mean age 68+/-10 yrs, 20 male, 2 female) participated in a 4-week exercise program consisting of ergometer and special muscle strength training. Before (T1) and at the end (T2) of the training program endothelium-dependent and endothelium-independent vasodilatory capacity were assessed by brachial artery diameter measurement. RESULTS: At the end of the training program, there were no significant results within the two groups. The endothelium-dependent vasodilation changed between T1 and T2 as follows: In the diabetic group, the endothelium-dependent vasodilation at T1 and T2 was 5.1+/-3.6 and 4.9+/-2.5%, respectively. For the non-diabetics, the endothelium-dependent vasodilation was 6.8+/-4.5 and 7.6+/-4.0% at T1 and T2, respectively. The endothelium-independent vasodilation in the diabetics was 10.5+/-5.6 at T1 and dropped to 8.7+/-4.1% at T2. The results for the non-diabetics were 13.2+/-5.8 and 12.3+/-6.3% at T1 and T2, respectively. The LVEF in the diabetics was 24.2+/-3.4% at T1, increasing to 27.8+/-5.8% at T2. In the non-diabetics, the LVEF was 22.9+/-3.8 at T1 vs. 28.6+/-6.9% at T2. In the groups of diabetics, the maximum oxygen uptake (VO2-max) was 10.3+/-3.9 at T1 vs. 11.4+/-2.8 ml/kg/min at T2 and in the group of non-diabetics 10.0+/-3.1 vs. 13.5+/-5.0 ml/kg/min. No correlations were found between the change in endothelium-dependent vasodilation and the increase in oxygen uptake. CONCLUSION: In our study, a program of physical exercise had no influence on endothelium-dependent or endothelium-independent vasodilation in insulin-treated type 2 diabetics or in non-diabetics with considerably reduced ejection fraction. In both groups, however, an exercise-related influence on medical parameters and physical performance could be observed.

Effects of education, self-care instruction and physical exercise on patients with chronic heart failure.

BACKGROUND: Evidence is now evolving of the importance of team management for patients with chronic heart failure. This includes education, patient self-care and physical exercise training. How such programs should be implemented is still under discussion. AIM: To assess the efficacy of an in-hospital rehabilitation clinic-based program, we studied its influence on cardiopulmonary parameters and quality of life in an outpatient setting. METHODS AND RESULTS: 75 patients (62 male, 13 female, mean age 65+/-8 years) underwent an exercise program including education, bicycle ergometer, muscle strength training and the 6-min walk test as a training unit for 4 weeks. Patients were studied at baseline (T1), before discharge (T2) and after a follow-up period of 29.9+/-5.5 weeks (T3). Baseline data (T1): left ventricular ejection fraction (LVEF): 33.8+/-7.6%, left ventricular end-diastolic volume (LVEDV): 130+/-51 ml, peak VO(2): 12.3+/-4.3 ml/kg, maximum work load (Watt max): 71+/-27 W. At discharge (T2) and follow-up (T3) LVEF increased to 36.8+/-8% and 41.8+/-9.2%, LVEDV decreased to 127+/-43 ml and 114+/-40 ml, peak VO(2) increased to 14.1+/-5.1 ml/kg and 15.2+/-5 ml/kg, and Watt max increased to 84+/-28 Wand 98+/-42 W (all p<0.01). Quality of life improved significantly at discharge and follow-up in nearly all domains and in the summary score for physical health. There were no significant changes for anxiety and depression at T2 and T3. CONCLUSION: A specialized in hospital rehabilitation program including education, patient self management and training has a sustained positive effect on cardiopulmonary parameters and physical well-being.

Vascular hamartoma of the left ventricle.

Primary tumors of the heart are very rare. We report a case of a 28-year old female patient in whom a tumor of the left ventricle was first diagnosed by transthoracic echocardiography. Angiography, nuclear magnetic resonance imaging and fasting positron emission tomography with 18-fluorodesoxyglucose suggested the diagnosis of a well vascularized tumor. The tumor was subtotally excised during heart surgery under total cardiopulmonary bypass and histological examination identified a predominantly vascular hamartoma.

Surgical repair of pulmonary stenosis with intact ventricular septum in a 68-year-old woman.

Patients with mild pulmonary stenosis after infancy rarely have symptoms or develop increasing obstruction. We experienced a 68-year-old woman with severe pulmonary valvar and infundibular stenosis (peak to peak pressure gradient = 80 mmHg). She had been pointed out heart disease at the age of six. Endocarditis at the age of 17 might induce calcification of valve and affect the progression of pulmonary stenosis, and moreover, which might gradually develop severe subvalvar obstruction and poststenotic aneurysm of pulmonary trunk. She refused operative intervention because of mild clinical symptoms (NYHA class II), but we recommended surgical repair due to repeated transient ischemic attacks, which were suspected paradoxical embolism through persistent foramen ovale. She underwent pulmonary valvotomy and infundibular resection and is doing well.

[Value of intravascular ultrasound in angiographically underestimated coronary findings: exemplified by 2 case reports]. / Bedeutung des intravaskulären Ultraschalls bei angiographisch unterschätztem Koronarbefund: Darstellung anhand zweier Fallbeispiele.

Coronary angiography is considered to be the most important component in the diagnosis of coronary artery disease. Only the lumen may be visualized using contrast radiography of the coronary arteries, however. With intravascular ultrasound, on the other hand, pathological changes in the vascular wall can be recorded. Despite typical symptoms, an angiographical image of the coronary arteries is sometimes unable to show unambiguous stenotic lesions of the coronary arteries. In such cases, intravascular ultrasound provides a new complementary diagnostic tool for detecting even early forms of arteriosclerosis or angiographically underestimated coronary findings. Two cases are used to illustrate this. In those, angiographic visualization of the coronary arteries was unable to produce an unambiguous finding despite typical clinical symptoms, yet intravascular ultrasound could detect considerable arteriosclerotic wall changes.

Pathomorphological characteristics of resected mitral valves after unsuccessful valvuloplasty.

OBJECTIVE: Percutaneous mitral valvuloplasty has been shown to be an acceptable alternative to surgery as treatment for selected patients with severe mitral stenosis. We examined hemodynamic, echocardiographic, and pathomorphologic findings in a series of 308 patients undergoing balloon valvuloplasty, 41 of whom underwent subsequent surgery, in search of possible predictors of an unsuccessful outcome. INTERVENTION AND RESULTS: Patients with severe mitral stenosis underwent Inoue single ballon valvuloplasty over a 48-month period and had follow-up for a mean of 14.5+/-16.8 months (range 1 to 64 months). Of the 308 patients, 267 (Group I) were clinically improved and stable throughout follow-up, while subsequent surgery was required in 41 (Group II) after 38.2+/-143.5 days (range 1 to 1212). Significant differences between the groups were observed for NYHA class (2.7+/-0.6 vs 2.9+/-0.6, p<0.05), mitral valve area (1.0+/-0.3 vs 0.9+/-0.2 cm2, p<0.01) and left atrial endsystolic dimension by echo (51.3+/-8.0 vs 55.4+/-10.2 mm, p<0.01). Two of the 41 Group II patients underwent surgery for left to right shunting, 1 for tamponade and 2 were lost to follow-up. The excised mitral valves of the remaining 36 patients all showed calcification and/or fibrosis: 9 homogenous, 5 non-homogenous; 19 were classified as having a funnel-shaped deformity, and 3 did not fit into a discrete category. Among the funnel-shaped valves, 13 had a tear versus 6 where dilation was primarily accomplished by stretching. Only one of 9 valves with homogenous calcification was torn, whereas a tear was noted in 3 of the 5 with non-homogenous calcification. CONCLUSION: Funnel-shaped valves and those with non-homogenous distribution of calcification and/or fibrosis appear to be least suitable for balloon valvuloplasty.

Ultrasound examination of stenotic mitral valves: an in vitro study.

To determine the feasibility of currently used, intravascular ultrasound catheters (12.5 and 20 MHz, 6F and 9F, Boston Scientific Corp., Watertown, MA) for mitral valve disease, ten excised mitral valves from patients with severe mitral stenosis were examined. The specimens were fixed in a glass cylinder perfused with water. The valves were planimetered with the intravascular ultrasound system and investigated regarding pathomorphological changes. The depth field of penetration was between 1.5 and 2 cm (3 to 4 cm diameter) in the 20 MHz catheter and between 2 and 2.5 cm (4 to 5 cm diameter) in the 12.5 MHz catheter. A good correlation of the experimentally recorded valve areas could be ascertained with the Gorlin formula (r = .71, P < .05), the Doppler echocardiography method (r = .69, time method (r = .75, p < .05), and with the two-dimensional echocardiography method (r = .69, P < .05). These results show a sufficient feasibility of the currently used, intravascular ultrasound catheters and enable further steps to be taken with regard to evaluating mitral valve morphology in vivo.

Predictors of unsuccessful outcome after percutaneous mitral valvulotomy including a new echocardiographic scoring system.

BACKGROUND AND AIMS OF THE STUDY: Percutaneous mitral valvulotomy has been shown to be an accept able alternative to surgery as treatment for selected patients with severe mitral stenosis. Uncertainty still exists regarding predictors of unsuccessful outcome. MATERIALS AND METHODS: 308 patients with severe mitral stenosis underwent Inoue single balloon valvulotomy over a 48-month period and were followed up for a mean of 14.5 +/- 16.8 months (range one to 64 months). Two hundred and sixty-seven (Group I) improved clinically and remained stable throughout the follow up, while subsequent surgery was required in 41 (Group II) after 38.2 +/- 143.5 days (range one to 1,212). Clinical and echocardiographic parameters of the two groups were compared to find significant predictors of an unsuccessful outcome. RESULTS: Significant differences between the groups were observed for NYHA class (2.7 +/- 0.6 vs. 2.9 +/- 0.6, p < 0.05), mitral valve area (1.0 +/- 0.3 vs. 0.9 +/- 0.2 cm2, p < 0.01), left atrial end-systolic dimension by echo (51.3 +/- 8.0 vs. 55.4 +/- 10.2 mm, p < 0.01) and an echocardiographic scoring system including grading for eccentricity of the mitral orifice and distribution of commissural calcification (7.5 +/- 2.0 for Group I and 8.7 +/- 2.0 for Group II, p < 0.001). CONCLUSIONS: Mitral valves that are more likely to have an unsuccessful outcome can be identified by hemodynamic, clinical and echocardiographic criteria, including grading for eccentricity of the mitral orifice and distribution of commissural calcification.

[Circular dissection of the ascending aorta with intimo-intimal invagination. CT diagnosis of a rare form of aortic dissection]. / Zirkuläre Dissektion der Aorta ascendens mit intimointimaler Invagination. CT-Diagnose einer seltenen Form der Aortendissektion.

Intimointimal intussusception is a rare type of aortic dissection. The intimal tear occurs circumferentially with intussusception of the intimal flap downstream into the aortic arch causing obstruction of the great supraaortic vessels. A CT diagnosis has only once been reported. CT and angiographic findings of this rare complication of aortic dissection are described.

[Clinical significance of the cardiovascular risk factor fibrinogen in secondary prevention]. / Klinische Bedeutung des kardiovaskulären Risikofaktors Fibrinogen in der Sekundärprävention.

Seven prospective, epidemiological studies indicate plasma fibrinogen levels (over 300-350 mg/dl) as an important, independent cardiovascular risk factor for subsequent myocardial infarction and stroke. Furthermore, several clinical studies revealed an association between fibrinogen and both the angiographic and clinical degree of coronary heart disease. In addition, a significant relation of fibrinogen with the number of occluded coronary vessels was found. The following pathophysiologic mechanism are of particular importance: Fibrinogen is a main determinant of plasma viscosity and red cell aggregation. Both phenomena deteriorate blood fluidity especially in the microcirculation. Fibrinogen plays a central role in platelet aggregation and performs an essential substrate in the coagulation cascade. Thus, high fibrinogen levels may favor a hypercoagulable state resulting in final thrombotic events of cardiovascular disease. Fibrinogen is also involved in atherogenesis by stimulating proliferation and migration of smooth muscle cells. Several determinants of fibrinogen levels are known. Smoking is the strongest one in healthy persons. This clinically important effect is dose related. Consequently, cessation of smoking is a major step to lower fibrinogen and subsequently the individual cardiovascular risk. Reduction of overweight and maintenance of regular physical activity are further nonpharmacologic means. Fibrates decrease fibrinogen about 10-30% on an average. Finally, intermittent low-dose Urokinase for end-stages of coronary artery disease and LDL-apheresis (HELP) represent additional approaches to reduce fibrinogen.

[Fibrinogen and leukocyte number in coronary heart disease. Correlation with angiography and clinical degree]. / Fibrinogen und Leukozytenzahl bei koronarer Herzkrankheit. Korrelationen zum angiographischen und klinischen Schweregrad.

In 302 consecutively patients fibrinogen (Clauss method) and leucocyte count were related to the angiographic and clinical degree of coronary atherosclerosis. Fibrinogen (mg/dl) was statistically higher compared to control (C, 267 +/- 55) in patients with one-vessel disease (1-vd (306 +/- 67), 2-vd (331 +/- 73), and 3-vd (328 +/- 62)). Patients with coronary sclerosis (Scl, luminal irregularities and/or stenosis under 50%) showed a tendency to higher fibrinogen levels (291 +/- 58) as compared to controls. Leucocyte count (10(9)/L) compared to C (6.7 +/- 1.8) was significantly higher in 1-vd (7.6 +/- 2.0) and 2-vd (7.6 +/- 1.9). A subgroup analysis was performed with 100 patients having severe forms of angina pectoris (AP III according to the CCS classification, unstable angina). Hundred-sixteen patients with unstable angina (390 +/- 79), particularly with angina at rest during the last 48 h were characterized by the highest fibrinogen values (423 +/- 89, class III B/C Braunwald). Leucocyte count in patients with stable angina (7.2 +/- 1.4) and angina at rest (9.3 +/- 2.7) was significantly higher as compared to control (6.7 +/- 1.8). Hyperfibrinogenemia and relative leucocytosis correlate with the angiographic and clinical extent of coronary artery disease and may offer evidence of a higher degree of thrombogenesis associated with components of inflammation.

[Right ventricular outflow obstruction due to accessory tricuspid valve tissue in corrected transposition of the great arteries with ventricular septal defect]. / Rechtsventrikuläre Ausflussbahnobstruktion durch akzessorisches Trikuspidalgewebe bei korrigierter Transposition der grossen Arterien mit Ventrikelseptumdefekt.

A 27-year-old man known to have corrected transposition of the great arteries (CTGA) associated with a ventricular septal defect (VSD) was admitted to our hospital with a suspected increase of the shunt volume. The patient is a first class bodybuilder. Heart catheterization confirmed the diagnosis of a "right-ventricular" mass obstructing the "right-ventricular" outflow tract, which had already been seen at echocardiography. The intraoperative finding showed the tumor to be accessory tissue of the anterior tricuspid leaflet prolapsing through the VSD into the subvalvular outflow tract of the right ventricle. The accessory tricuspid valve tissue was removed by transatrial access. The VSD was closed by a dacron patch using the same route. The postoperative course was uneventful.