[Intrapericardial fibrinolysis as a therapeutic option in a case of purulent pericarditis]. / Intraperikardiale Fibrinolyse als therapeutische Option bei der Perikarditis purulenta.

HISTORY AND ADMISSION FINDINGS: A 23-year-old man known to have Hodgkin's disease in remission and C-protein deficiency presented with chest pain and symptoms of respiratory infection. INVESTIGATIONS: A purulent pericardial effusion was detected by echocardiography. The chest X-ray showed a left-sided pneumonia. TREATMENT AND CLINICAL COURSE: When pericardiocentesis failed to drain the purulent but pathogen-free effusion completely, streptokinase was several times instilled intrapericardially and achieved fibrinolysis without complication. The effusion did not recur. CONCLUSIONS: Intrapericardial application of fibrinolytic agents seems to be an effective treatment of a purulent pericarditis.

[Persistent left superior vena cava with right-left shunt into the left atrium]. / Persistierende linke Vena cava superior mit Rechts-Links-Shunt zum linken Atrium.

UNLABELLED: Persistent left superior vena cava with right-left shunt into the left atrium. HISTORY AND CLINICAL FINDINGS: A 72-year-old patient was admitted to the hospital following bleeding into the basal ganglia secondary to a hypertensive crisis. INVESTIGATIONS: The patient was found to suffer from marked hypoxaemia (pO2 49 mmHg) and erythrocytosis (Hb 18,5 g/dl). Subsequent investigations raised suspicion of a right-left shunt. This was verified by a contrast echocardiogram which was performed transthoracically by injection of echo-contrast material from the left. To improve imaging of the shunt a transoesophageal contrast-echocardiogram was carried out. This showed that the persistent left superior vena cava did not, as previously expected, lead directly into the left atrium, but had a connection to the left superior pulmonary vein. This anatomical variant, which so far to our knowledge has not been reported in the literature, could be confirmed by spiral computed tomography. Apart from an atrial septal aneurysm no other cardiac anomaly could be identified. TREATMENT AND COURSE: Ligation of the left superior vena cava could have been a therapeutic option, but the patient declined operative intervention. CONCLUSION: In cases of profound hypoxemia and erythrocytosis the differential diagnosis must include a persistent left superior vena cava with anomalous connection to the left atrium. Trans-thoracic and transoesophageal contrast-echocardiography is a simple and reliable method to diagnose persistent left superior vena cava as well as concomitant cardiac anomalies.

Value of repeated multiplane transesophageal echocardiography in a patient with mitral valve ring abscess and left ventricular pseudoaneurysm.

Mitral valve ring abscess and ventricular pseudoaneurysm are rare complications of infective endocarditis. We describe the case of a 58-year-old man who was admitted to our hospital with sepsis caused by Staphylococcus aureus and in whom tricuspid and mitral valve endocarditis developed within 2 weeks. Despite widespread antibiotic therapy, the endocarditis proceeded to form a mitral valve ring abscess and a left ventricular pseudoaneurysm. The diagnosis was set by repeated multiplane transesophageal echocardiography and confirmed by heart surgery.

[Neurocardiogenic syncopes in patients with implanted pacemakers]. / Neurokardiogene Synkopen bei Herzschrittmachertherapie.

BACKGROUND AND OBJECTIVE: Recently the tilting table test (tilting up to 70 degrees angle) has established itself for the diagnosis of neurocardiogenic syncope (NS). Usually patients with bradycardic arrhythmias or asystole are treated by pacemaker implantation. But if the syncope is of neurocardiogenic aetiology other therapeutic alternatives must be chosen. We here report on seven patients in whom a pacemaker had been implanted in the treatment of syncopes, in ignorance of their neurocardiogenic aetiology, yet they had recurred. PATIENTS AND METHODS: Pacemakers had been implanted in eight patients: two with sick sinus syndrome, three with sinus bradycardia, one with brady-tachyarrhythmia, one with asystole and one with Mobitz-type 2 degrees AV block. All patients continued to have syncopes, when sitting or standing, months to years after the pacemaker implantation. The tilting table test (up to 30 min at an angle of 70 degrees) was positive in all patients. There was no case of pacemaker malfunction. RESULTS: One patient declined further treatment. The remaining seven patients were symptom-free in the tilting table test on various medications: theophylline up to 2 x 350 mg, metoprolol up to 2 x 100 mg or disopyramide 3 x 100 mg. CONCLUSION: Patients with syncope while sitting or standing should undergo the tilting table test to determine whether the cause is neurocardiogenic so that pacemaker implantation can be avoided. The majority of patients with NS can be successfully treated by drugs. But in some patients pacemaker implantation may have to considered if drug treatment has failed.

[Puerperal sepsis caused by streptococcus group A with a severe form of progression like "toxic shock-like syndrome"]. / Puerperalsepis durch Streptokokken der Gruppe A mit schwerer Verlaufsform als "Toxic Shock-like Syndrome".

HISTORY AND CLINICAL FINDINGS: A previously healthy 32-year-old woman was admitted with shock symptoms 5 days after an uneventful home delivery. She developed a fever up to 39.5 degrees C during the days after delivery with sore throat, diarrhoea and muscle aches in all limbs. On physical examination there were swellings of the arms and lower legs as well as macular and vesicular erythrodermia, especially of the trunk. INVESTIGATIONS: Abnormal laboratory findings were thrombocytopenia (20,000/microliters), increased serum concentrations of fibrin breakdown products (102 mg/dl) and of C-reactive protein (> 200 mg/dl), increased creatine kinase (5700 U/l), transaminases (GOT 220 U/l, GPT 52 U/l), creatinine (2.0 mg/dl) and urea (114 mg/dl). Streptococcus pyogenes was grown on blood culture and from vaginal smear. Sonography, echocardiography and radiological examinations failed to demonstrate a septic focus. TREATMENT AND COURSE: Mechanical ventilation was required for 7 days because of respiratory failure and shock symptoms (toxic shock-like syndrome, TSLS). Penicillin G and tobramycin were given after the bacteriological diagnosis. Severe consumption coagulopathy was successfully treated with antithrombin III and platelet concentrates. After extubation she was found to have a flaccid tetraparesis, especially of the right and of the legs, due to soft-tissue necrosis and damage to peripheral nerves. An embolic occlusion of the right brachial artery 4 weeks after onset of the disease required upper-arm amputation. CONCLUSION: One of the decisive factors for the prognosis of TSLS is early antibiotic treatment. The prodromal symptoms in this case underline the necessity of early recognition and treatment to prevent a full-blown picture of the syndrome.

[Ball variance and fracture of a Smeloff-Cutter prosthesis 24 years after aortic valve replacement]. / Ballvarianz und Fraktur einer Smeloff-Cutter-Prothese 24 Jahre nach Aortenklappenersatz.

This report documents a case of ball variance in a Smeloff-Cutter aortic prosthesis occurring 24 years after implantation. After episodes of embolic complications the patient died in acute shock. The silicone rubber ball showed several alterations including discoloration, grooving, cracking, swelling and subtotal fracture of the poppet. Terminal valvular malfunction was caused by complete thrombosis of the prosthesis. In most patients ball variance occurred during the first years after valve replacement; thus, the observed case is a very rare late complication of a ball-valve prosthesis.

[Complete gastric wall necrosis after endoscopic sclerotherapy for a gastric ulcer with visible arterial stump]. / Vollständige Magenwandnekrose nach endoskopischer Sklerosierungstherapie eines Ulcus ventriculi mit sichtbarem Gefässstumpf.

HISTORY AND CLINICAL FINDINGS: A 43-year-old man with a gastric ulcer was admitted because of sudden onset of epigastric pain, cold sweats and dizziness. He had tachycardia (100/min); his blood pressure was 120/80 mm Hg: his epigastrium was tender to palpation. There were no tarry stools. INVESTIGATIONS: Haemoglobin concentration was 12.7 g/dl. WBC count 17,900/microliter. Gastroscopy revealed residual haematin and an ulcer with an arterial stump at the angular fold. TREATMENT AND COURSE: 3 ml epinephrine, diluted 1:20,000, and 13 ml of 1% polidocanol were injected around the arterial stump, most of the latter solution flowing back into the gastric lumen from the rather hard ulcer base. Haematemesis four days later necessitated laparotomy followed by gastrectomy with reconstruction and a Roux-Y anastomosis because of complete necrosis of the gastric wall. Histological examination of the surgical specimen showed chronic scarred gastric ulcer and ulcerating pangastritis with haemorrhagic necrosis of the wall and associated peritonitis, caused by accidental injection of polidocanol into the artery. CONCLUSION: Since the tissue-sparing injection of epinephrine, fibrin glue or salt solution is alone effective in the endoscopic treatment of bleeding gastroduodenal ulcers, polidocanol should not be injected as well.

[Löffler's parietal fibroplastic endocarditis. Echocardiographic course over 5 years]. / Endocarditis parietalis fibroplastica Löffler. Echokardiographischer Verlauf über 5 Jahre.

HISTORY AND CLINICAL FINDINGS: A 28-year-old man, who had sustained a traumatic displaced fracture of the left lateral clavicle requiring operative realignment, was admitted to hospital because of the incidental finding of pathological electrocardiographic findings (suggestive of past anterior myocardial infarction). He had dyspnoea on effort and episodes of irregular tachycardia without other cardiac symptoms, as well as regular tachycardia (120/min) without pulse deficit. Body temperature was 37.3 degrees C, blood pressure 110/70 mm Hg. INVESTIGATIONS: Transoesophageal echocardiography showed regular myocardial contractility but a 3.27 cm cap-like area of echo-poor and echo-dense layers at the left ventricular apex. There was leucocytosis (25,400/microliter) with 45% eosinophilia (11,430/microliter). IgE was raised to 134.6 kU/l. Bone marrow smear showed marked eosinophilic but little neutrophilic hyperplasia. Parasitic infection was excluded. TREATMENT AND COURSE: The clinical and echocardiographic findings suggested the diagnosis of Löffler's eosinophilic endocarditis (endomyocardial fibrosis), later confirmed histologically. After initial treatment, first only with cortisone then also hydroxyurea, the eosinophilia finally responded to combined cortisone and interferon alpha 2. The dosage schedule was governed by the clinical and echocardiographic findings. In the further course of the disease there occurred progressive heart failure with severe tricuspid and mitral regurgitation, secondary pulmonary hypertension and severe fibrosis of both ventricles, 41 months after diagnosis the patient underwent tricuspid and mitral valve reconstruction with removal of the endocardial fibrotic layers. Follow-up examinations found the cardiac condition to be adequately controlled without further cardiac infiltration since 20 months. CONCLUSIONS: Echocardiography, in conjunction with the clinical findings, provides a firm foundation for successfully treating Löffler's endocarditis. In selected cases cardiac surgery can markedly improve the course.

[Tricuspid valvulectomy in antibiotic-refractory right-heart endocarditis]. / Trikuspidalvalvulektomie bei antibiotikarefraktärer Rechtsherzendokarditis.

HISTORY AND CLINICAL FINDINGS: A 19-year-old man, known to be addicted to intravenous heroin, was admitted because of respiratory failure with a septic fever up to 40.0 degrees C. An abscess at the site of intravenously heroin injection on the right arm had been previously opened. At examination he was pale and his general condition was poor. There were numerous puncture sites over lower arm veins, some of them thrombosed. There were no signs of septic emboli to the skin and to visible mucosae. The spleen was not palpable. INVESTIGATIONS: There was leucocytosis with shift to the left, thrombocytopenia (54,000/microliter), anaemia (haemoglobin 7.9 g/dl) and markedly raised C-reactive protein (202 mg/dl). Blood culture grew Staphylococcus aureus. Transthoracic and transoesophageal echocardiography revealed a large vegetation on the tricuspid valve, confirming infectious endocarditis involving the tricuspid valve. Chest radiogram showed an infiltrate and pleural effusion of the left lung. TREATMENT AND COURSE: Infectious emboli to the lung necessitated artificial ventilation. The septic process could not be controlled by antibiotics. The whole of the tricuspid valve was therefore removed, followed by high doses of antibiotics (vancomycine, gentamicine, rifampicine). This successfully controlled the infection and a postoperative sacroileitis. Postoperative echocardiography revealed severe tricuspid regurgitation with marked enlargement of the right ventricle, paradoxical movement of the interventricular septum and a dilated inferior vena cava. 7 months postoperatively there were no clinical signs of severe right heart failure. CONCLUSION: Removal of the tricuspid valve without valve replacement can be successfully undertaken to control the infection in intravenously heroin addicts in whom the valve has been destroyed by infectious endocarditis.

[Pre-syncope and syncope at the operating table--diagnostic and therapeutic possibilities]. / Präsynkopen und Synkopen am Operationstisch--diagnostische und therapeutische Möglichkeiten.

Standing in long-lasting operations can be a trigger for neurocardiogenic syncopes for the personal in the operating theatre. We report on a 37-year-old surgeon who suffered since childhood from more than 100 syncopes and presyncopes. That was the reason for him to think of giving up his profession. The head-up tilt-test proved the mechanism of a neurocardiogenic syncope. No further syncope has occurred for 16 months during the therapy with theophyllin.

Right ventricular apical view--a new window for Doppler echocardiography of aortic valve stenosis.

We studied a new Doppler echocardiographic approach in 56 patients with valvular aortic stenosis from the right ventricular apex (AS-RV) and compared the transvalvular gradients with the results of the standard view from the left ventricular apex (AS-LV). AS-RV resulted in good or acceptable velocity curves in 59% of patients. The correlation between the two apical views for the peak/mean gradients were close (r = 0.95/0.96). Using all typical positions for Doppler investigation of aortic stenosis, highest peak gradients were best recorded in five cases by AS-RV. In one woman with a narrow left ventricular cavum and severe aortic stenosis, only AS-RV yielded a technically good spectral curve. Thus, in selected patients--probably those with a small left ventricular cavity or an enlarged right ventricle--AS-RV may be the best window or even the only possibility in Doppler investigation of aortic valve stenosis.

Transesophageal echocardiographic artifact mimicking pseudoaneurysm of the aorta.

Transesophageal echocardiography (TEE) is a sensitive and specific procedure that gives detailed images of the thoracic aortic anatomy and blood flow; however, there are few reports on pitfalls with TEE. This case describes a patient with a typical history of a possible aortic rupture; artifacts in the TEE mimicked aortic rupture and development of a pseudoaneurysm. Echocardiographers should know this possible pitfall to make the correct diagnosis.

[Toxic diphtheria caused by Corynebacterium ulcerans]. / Toxische Diphtherie durch Corynebacterium ulcerans.

A 42-year-old woman with bronchial asthma since childhood was admitted to hospital because of severe dyspnoea. Emergency bronchoscopic intubation had to be performed for life-threatening inspiratory and expiratory stridor. This demonstrated that the larynx was covered by a dirty-grey membrane and the vocal-cord gap was narrowed to a mere slit. As laryngeal diphtheria was suspected 2000 IU/kg diphtheria antitoxin was administered together with 1 mega U penicillin G four times daily intravenously. On the same day, Corynebacterium ulcerans, a very rare cause of diphtheria, was isolated from a coughed-up piece of the membrane. Toxic, massive swelling of the lymph nodes and soft tissues of the neck necessitated maintenance of an open upper airway by intubation and (later) tracheostomy for 41 days. A week later the patient was discharged without any permanent defect.

Use of a latex cover sheath for transesophageal echocardiography (TEE) instead of regular disinfection of the echoscope?

Better visualization of cardiac structures is an advantage of transesophageal echocardiography (TEE). Because of this, the transesophageal approach is an essential window in the assessment of various cardiovascular disorders. Quick consecutive access to this instrument should not be delayed by time-consuming cleansing procedures of the probe. In this study we used a sterile latex condom in routine TEE examinations as a barrier to contamination of the echoscope, observing practical use and the incidence of perforations. Defects were detected after the procedure by visual inspection and by an airtightness test. Maneuvers or situations associated with an increased likelihood of injury were checked for. In 180 studies a total of 168 patients were consecutively examined; insertion was feasible in all but one case (99.5%). We found 8 of 181 (4.4%) sheaths defective following the procedure. Visual inspection was less sensitive (only 3 of 8) for finding defects than an airtightness test (8 times). Teeth in situ and/or a bite guard are the only sharp edges during insertion and removing the probe; these seem to be the main risk factors in latex perforation. Application of a cover sheath for each examination saves approximately two-thirds of the time otherwise necessary for a cleansing bath, and easy handling of cover sheaths for TEE make them an alternative to regular disinfection in general. For reasons of safety we recommend checking each used cover sheath after examination for holes so as not to jeopardize the following patient by the possible spread of germs from contaminated probes. Not only visual inspection but also a second method, for example, an airtightness test, is mandatory.

[The color Doppler-guided compression therapy of a large false aneurysm of the femoral artery following left heart catheterization]. / Farbdoppler-gesteuerte Kompressionstherapie eines grossen Aneurysma spurium der Arteria femoralis nach Linksherzkatheterisierung.

A ventrally located false aneurysm (7 x 5.2 x 3.4 cm) of the right common femoral artery occurred, after left-heart catheterization by the Judkins technique via this artery, in an 83-year-old woman with aortic valve stenosis. Colour Doppler sonography demonstrated a puncture canal (neck of the aneurysm) filling in both systole and diastole, as well as turbulent flow within the aneurysm. Flow into the aneurysm was considerably reduced when the transducer head compressed the aneurysm, while flow continued in the femoral artery and vein. This compression, maintained for 25 min, completely thrombosed the puncture canal and aneurysm so that no vascular surgery was required.

Denver shunt causing abnormal right atrial mass: noninvasive determination of shunt patency by color-coded Doppler shuntography.

An unusual floating mass was detected in the right atrium of a 71-year-old man with liver cirrhosis and intractable ascites using two-dimensional echocardiography. The mass was caused by the venous tip of a Denver peritoneovenous shunt. Shunt patency could be assessed easily by compression of the pump body; this maneuver resulted in a laminar or turbulent flow that was recorded at the tip of the shunt in the right atrium by color-coded Doppler echocardiography. We are reporting the first case demonstrating the value of echocardiography in diagnosing a Denver shunt in the heart and shunt patency by color-coded Doppler shuntography.