Prolonged mechanical systole and increased arterial wave reflections in diastolic dysfunction.

OBJECTIVE: To evaluate whether left ventricular ejection time indexed for heart rate (left ventricular ejection time index (LVETI)) and arterial wave reflections (augmented pressure (AP)) are increased in patients with diastolic dysfunction (DD). DESIGN: Prospective observational study. SETTING: University teaching hospital providing primary and tertiary care. SUBJECTS: 235 consecutive patients undergoing left heart catheterisation were categorised as having definite DD, possible DD or no DD (controls) on the basis of their left ventricular end diastolic pressures and N-terminal brain natriuretic peptide concentrations. MAIN OUTCOME MEASURES: LVETI and AP were prospectively assessed non-invasively by radial applanation tonometry. In addition, all patients underwent comprehensive echocardiography, including tissue Doppler imaging of mitral annulus velocity in early diastole (E'). RESULTS: LVETI was longer in patients with definite DD than in patients with possible DD and in controls (433.6 (SD 17.2), 425.9 (17.9) and 414.3 (13.6) ms, respectively, p < 0.000001). Arterial wave reflections were higher in definite DD than in possible DD and control groups (AP was 19.4 (SD 8.9), 15.2 (8.0) and 10.7 (6.8) mm Hg, respectively, p < 0.000001). In receiver operating characteristic curve analysis, LVETI detected DD as well as echocardiography (E:E'). Area under the curve for LVETI to differentiate patients with definite DD from normal controls was 0.81 (95% CI 0.72 to 0.89, p < 0.0001). In multivariable logistic regression analysis, LVETI added significant independent power to clinical and echocardiographic variables for prediction of DD. CONCLUSIONS: Mechanical systole is prolonged and arterial wave reflections are increased in most patients with DD. Rapid non-invasive assessment of these parameters may aid in confirming or excluding DD.

Spontaneous coronary artery dissection involving the left main stem: assessment by intravascular ultrasound.

This case report describes the devastating consequences of spontaneous coronary dissection in a 36 year old female patient who otherwise had a normal coronary arteriogram. Intravascular ultrasound showed coronary artery dissection and intramural haematoma at the left main stem coronary artery. Acute coronary syndrome developed and subsequently surgical revascularisation was performed successfully.

[Intracoronary brachytherapy--an update]. / Intrakoronare Brachytherapie--Ein Update.

Restenosis following angioplasty represents a major clinical problem in the field of percutaneous coronary interventions. Intravascular brachytherapy reduces risk of restenosis following percutaneous interventions of native lesions and in-stent restenosis up to 50%-60%. This effect can be shown for at least one to two years. This novel therapeutic strategy is limited by a higher rate of target vessel reinterventions, and late coronary thrombosis, when platelet inhibiting drugs has been withdrawn or after implantation of multiple stents. Currently, intracoronary brachytherapy is mainly considered for treatment of in-stent-restenosis.

[Coronary artery bypass graft dysfunction--clinical presentation, laboratory and electrocardiographic parameters]. / Aortokoronare Bypassdysfunktion--Wertigkeit klinischer, laborchemischer und elektrokardiographischer Parameter.

The recurrence of symptoms after coronary artery bypass surgery is often caused by bypass-dysfunction. In this study we tried to determine factors related to the long-term patency of arterial and venous bypass grafts. We evaluated all patients with bypass grafts undergoing coronary angiography in the year 1998 at our hospital (163 patients, mean age 67 years, mean interval since the operation 79 months, a total of 341 venous bypasses (VBP), 386 peripheral venous anastomoses and 85 arterial (LIMA = left internal mammarial artery) bypasses. The data were collected by a retrospective analysis of the hospital records. Statistics were performed using the Wilcoxon-Mann-Whitney-U test. After an interval of 53 months LIMA-bypasses were patent without stenosis in 92%. Symptoms were caused in only 2% by a dysfunction of the LIMA-graft. The patency of venous bypass grafts decreased with time (5 years after the operation 74% were patent without stenosis, 5-10 years 56%, more than 10 years 35%, p < 0.01). We found clear relations between the function of the venous grafts and the clinical presentation (patent grafts without stenosis in 43% with acute coronary syndromes, in 57% with stable angina [p = 0.08] and in 86% with atypical angina [p < 0.0001 for the difference between each of the first two and the last syndrome]), the resting-ECG (65% patent VBP without stenosis with normal ST-segments and 49% with abnormal ST-segments, p < 0.01), the body-mass-index (70% patent VBP without stenosis with a BMI < 25 and 56% with a BMI > 30, p = 0.05) and the erythrocyte sedimentation rate after 2 hours (79% patent VBP with an ESR < or = 20 mm vs. 64% with an ESR > 49 mm, p = 0.02). The function of VBP after coronary artery bypass graft (CABG)-procedure depends primarily upon the interval since the operation. In addition, we found correlations with clinical presentation, resting-ECG, body-mass-index and erythrocyte-sedimentation rate as a possible marker of inflammation in bypass-atherosclerosis. Therefore, inflammatory processes seem to play an important role in the development of venous graft dysfunction.

Valvuloplasty with glutaraldehyde-treated autologous pericardium in patients with complex mitral valve pathology.

BACKGROUND: Severe mitral regurgitation associated with complex mitral valve disease often precludes successful surgical repair. The feasibility and the results of valvuloplasty with glutaraldehyde-treated autologous pericardium remain largely unknown. METHODS: The cases of 63 patients who underwent operation within an 11-year period were studied. A pretreated autologous pericardial patch was used for leaflet extension plasty, for paracommissural plasty, as a substitute for part of the leaflet, and for reimplantation of ruptured papillary muscles to eliminate severe mitral regurgitation. Patients with a severely calcified annulus after en bloc decalcification had straddling endoventricular pericardial patch annuloplasty for reconstruction of the affected atrioventricular groove. Chordal replacement with a strip of pericardium was chosen if no suitable chordae were available. Pericardium-reinforced suture annuloplasty was used in patients with acute endocarditis resistant to medical therapy. Associated valvuloplasty procedures with Carpentier techniques were also employed. RESULTS: There were no operative deaths in this series. At a mean follow-up of 61.1 months (range, 4 to 132 months), mitral regurgitation was absent or trivial in 92.1% of patients by echocardiography. Freedom from reoperation was 95.2% at 1 year and 5 years. Thromboembolic events have not been detected. Thirty percent of patients returned to sinus rhythm. Two patients required valve replacement. CONCLUSIONS: Our beneficial results indicate that glutaraldehyde-treated autologous pericardium is suitable for valvuloplasty. It provides durable and predictable repair of valves that might otherwise need to be replaced because of the complex mitral valve disease. The technique is reliable, allows further efficacious repair possibilities, and improves postoperative outcomes. Whether it can prevent late deterioration and calcification requires more investigation.

Early investigation of silver-coated Silzone heart valves prosthesis in 126 patients.

BACKGROUND AND AIM OF THE STUDY: Permanent silver (Silzone) coating of the sewing cuff of St. Jude Medical prosthetic heart valves may reduce the rate of prosthetic valve endocarditis (PVE). However, the incidence of paravalvular leaks and stroke in patients after implantation of Silzone-coated heart valve prostheses is largely unknown. METHODS: Complications were analyzed among 126 consecutive patients (78 males, 48 females; mean age 64.7 years; range: 40-80 years) who received Silzone-coated prostheses at our institution between February 1998 and December 1999. Among patients, 94 had aortic valve replacement, 29 mitral valve replacement, and three had aortic and mitral valve replacement. Concomitant cardiac procedures (mainly coronary bypass) were performed in 47 patients (37.3%). RESULTS: Hospital mortality was 1.6% (2/126) and freedom from valve-related mortality 99.2+/-0.9%. Total follow up was 137.4 patient-years, and 98.4% complete. Strokes or transitory ischemic attacks (TIAs) occurred in four cases (two strokes, two TIAs; stroke rate 1.5%/year; 95% CI 0.4-2.6%/year; stroke+TIA rate 3%/year; 95% CI 0.4-5.25%/year). There was no case of prosthetic valve dysfunction or PVE. Freedom from reoperation due to procedure-associated complications was 97.6% (one aortic dissection, two major bleeds). Paravalvular leak was detected in 19 cases, and graded trivial or mild in 17 cases (11 grade 0-I, six grade I), and moderate in two cases (grade I-II in one, grade II in one). No patient needed reoperation due to paravalvular leak. Left ventricular (LV) function was normal in 80 cases, but was impaired mildly in 20 cases, moderately in 16, and severely in eight. Bicycle exercise testing in 92 patients (73%) showed median exercise performance (81.4+/-23.9% of normal) after correction for age and weight. Cerebral magnetic resonance imaging was performed in 64 patients (50.8%); median MRI score was 2.0+/-1.8 according to a 12-scaled score system. CONCLUSION: The overall incidence of echocardiographic paravalvular leak graded more than trivial or mild was low (1.6%) in patients followed for a mean of 1.1+/-0.5 years (range: 1-27 months) after valve replacement with Silzone-coated heart valve prostheses. No patient required reoperation due to paravalvular leak; moreover, the stroke rate (1.5%/year) was low in these patients. The present data indicated no significant disadvantages or higher rate of complications related to silver coating compared with other, non-silver-coated prostheses. Future investigation is needed to determine long-term outcome.

Valve repair in mitral regurgitation complicated by severe annulus calcification.

BACKGROUND: Valvuloplasty has significant advantages over valve replacement for mitral regurgitation, but the presence of severe calcification of the mitral valve apparatus has been thought to preclude successful valve reconstruction in general. The purpose of this report is to assess the results of valvuloplasty in patients with severe mitral regurgitation having extensive calcification extending from the mitral annulus to underlying myocardium and parts of the papillary muscles. METHODS: Thirty-seven adult patients with severe mitral regurgitation and calcification were operated on between April 1990 and January 1998. Twenty-six patients had degenerative disease, 4 had acute bacterial endocarditis, 6 had postrheumatic fever, and 1 patient had Marfan's disease. The valve repair comprised of en bloc decalcification with extensive leaflet debridement and reconstruction of the annulus. Autologous pericardium was used in patch-extended endocardial annuloplasty or leaflet repair. Valve competence was retained after correction of regurgitation by sliding atrioplasty, rotation paracommissural sliding plasty, cusp remodeling, or chordal repair. All patients required a prosthetic annuloplasty. RESULTS: Follow-up echocardiography at 47 months (range, 3 to 92 months) showed no or only trivial mitral regurgitation in 33 patients; 3 had grade I-II mitral regurgitation and 1 required valve replacement after 3 months. Freedom of reoperation at 1 and 5 years was 94.6%. At last examination, 33 patients were in New York Heart Association functional class I and 3 in class I-II; there has been no mortality and no thromboembolic events. CONCLUSIONS: Valvuloplasty can be safely and successfully carried out in patients suffering from regurgitation associated with severe calcification of the mitral apparatus. With encouraging beneficial midterm results, we suggest patients with calcified valves should not be excluded from mitral repair.

[Coronary angiography in patients over 80 years of age: indications, results, consequences]. / Koronarangiographie bei über achtzigjährigen Patienten: Indikationen, Resultate, Procedere.

Due to the continuous increase of elderly individuals in the society the cardiologist has to deal with elderly patients more often. The apparative expenditures and the invasive procedure require a critical consideration of benefits and risks prior to performing coronary angiography in these patients. The indication and frequency of coronary angiography in patients with eighty years or above were investigated. Furthermore, the results of angiography, the risks of the procedure and the therapeutic consequences were evaluated. The whole study population consisted of 2,500 consecutive patients (1,557 men, 943 women), who underwent coronary angiography at our institution from January 1st to November 16th in 1998. A retrospective analysis of 66 coronary angiographies (3%) in 61 patients (26 men, 35 women) aged 80 years or older was performed. Among these 61 patients, 51 were referred because of suspected coronary artery disease. Due to the clinical presentation a high percentage (42 patients = 82%) was classified as having unstable angina. 10 patients were referred due to valvular heart disease. Single-vessel disease was found in 14, two-vessel disease in 5 and multi-vessel disease in 28 patients, respectively. Percutaneous coronary intervention was performed in 17 patients, among these were 9 patients with multi-vessel disease and PTCA of the culprit lesion, and 3 patients underwent bypass surgery. Medical therapy was decided as to 28 patients. Aortic valve replacement was performed in 2 of 9 patients with aortic stenosis. The clinical appearance of coronary artery disease in elderly patients was mostly unstable angina, explaining the need for intervention. Coronary angiography disclosed multi-vessel disease in 55% of patients. A revascularization procedure could be performed at least in 43% of patients with multi-vessel disease.

Cardiac tamponade following acupuncture.

We present a rare complication of acupuncture in a 83-year-old woman who developed syncope and cardiogenic shock shortly after an acupuncture procedure into the sternum. Echocardiography revealed cardiac tamponade, and pericardiocentesis disclosed hemopericardium. Due to hemodynamic instability, thoracotomy was indicated. A small but actively bleeding perforation of the right ventricle was found and successfully closed. Although acupuncture represents a relatively safe therapeutic intervention, this case report should remind all acupuncturists of possible and sometimes life-threatening adverse effects.

[Rupture of a congenital right coronary sinus of Valsalva aneurysm as etiology of acute cardiac decompensation]. / Die Ruptur eines kongenitalen rechtskoronaren Sinus-Valsalva-Aneurysmas als Ursache einer akuten kardialen Dekompensation.

A 54 year old woman was admitted to a hospital because of acute thoracal pain, dyspnea, and clinical signs of overt right heart failure. Transthoracic and multiplane echocardiography established the diagnosis of a ruptured aneurysm of the right coronary sinus of valsalva into the right atrium which could be confirmed by cardiac catheterization. During heart surgery, which was done without complications, the defect was closed with a suture. Six months later echocardiography showed a normal right ventricle; the function of the aortic valve was regular. Acute heart failure may be due to a congenital structural cardiac anomaly in spite of the age of 54. In such conditions transthoracic and especially transesophageal echocardiography serve as noninvasive excellent tools to make an exact diagnosis.

[Clinical presentation and coronary angiographic results in unstable angina pectoris]. / Klinische Präsentation und koronarangiographische Befunde bei instabiler Angina pectoris.

The syndrome "unstable angina" (UA) covers a broad spectrum of patients. In this study we tried to determine the relationship between the severity of UA and angiographic findings. We evaluated 1000 consecutive patients undergoing coronary angiography. Those with the clinical diagnosis "UA" were included in the study. In a retrospective analysis of their records we categorized them, using the Braunwald-classification for determination of the severity of the disease. 352 patients were include, 209 men and 143 women, the mean age was 65 years. 47% met Braunwald-Class I, 26% Class II and 27% Class III. Coronary single-vessel disease was present in 29%, two-vessel disease in 20%, three-vessel disease in 25%, normal coronaries in 13% and coronary atherosclerosis without critical narrowing in 13%. Left ventricular function was preserved in 72%, mild systolic dysfunction was found in 10%, moderate in 13% and severe in 5%. There was no overall correlation between clinical presentation (Braunwald-Classes) and angiographic findings. Women showed a similar distribution of Braunwald-Classes, but significantly more coronary arteries without critical obstruction. In patients with reduced systolic function the percentage of multi-vessel disease was significantly higher, the percentage without relevant coronary artery narrowing was significantly lower. 1) The lack of overall correlation between clinical presentation and angiographic findings supports the importance of coronary angiography in the evaluation of patients with UA. 2) The assessment of women with chest pain is more difficult than of men with regard to coronary heart disease. 3) UA in patients with impaired left ventricular function is a predictor of severe coronary artery disease.

[AL amyloidosis--a hematologic disease with initial cardiac manifestation. 2 case reports]. / AL-Amyloidose - Eine hämatologische Erkrankung mit kardialer Erstmanifestation. 2 Fallberichte.

Cardiac involvement in AL-amyloidosis due to a multiple myeloma is present in up to 90% of cases. We present two patients with cardiac symptoms in whom a hematologic disease could be diagnosed because of suspicious cardiac finding. The leading symptom was dyspnea. The routinely performed laboratory tests, especially the erythrocyte sedimentation rate and the electrophoresis, were normal. After exclusion of coronary artery disease an infiltrative cardiomyopathy was suspected because of the echocardiographic examination with marked left ventricular hypertrophy, the restrictive flow pattern at the mitral valve and the electrocardiogram with a low voltage in limb leads and absent R waves in left precordial leads. Further, hematologic workup confirmed the production of light chains due to a myeloma. If the echocardiographic examination and the electrocardiogram raises the suspicion of an infiltrative cardiomyopathy as the cause of dyspnea, an immunofixation should be done in spite of normal laboratory tests to confirm or rule out the presence of a light chain disease due to a myeloma.

[Lambl's excrescence as tumorous heart valve mass]. / Die Lambl'sche Exkreszenz als tumoröse Herzklappenveränderung.

HISTORY AND CLINICAL FINDINGS: A 44 year old woman consulted a general physician because of weakness and fatigue. 5 months ago otitis media and a urinary tract infection had been treated successfully with antibiotics. The physical examination was unremarkable except for healed scars after an orthopedic operation about 35 years ago and a resection of a benign tumor of the left breast about 14 years ago. INVESTIGATIONS: Except for a slightly elevated antistreptolysin titer the laboratory tests were normal. The ECG showed sinus rhythm, left axis deviation and normal ST-segments. In the transthoracic echocardiogram an echogenic mass adherent on the ventricular side of the noncoronary cusp of the aortic valve in size of 2 x 1.5 cm could be demonstrated. The mass moved with the normally functioning valve and prolapsed into the aorta ascendens. The Doppler-echocardiogram was normal. TREATMENT AND COURSE: Because of the size of this echogenic mass with unknown origin and the risk of an embolic event its removal was indicated. This was done without destroying the aortic valve. Postoperative echocardiography demonstrated normal valve function. The histologic examination showed an endothelialized mass, rich in fibers and with only a few fibroblasts and histiocytes, without smooth muscle cells, according to a Lambl's excrescence. CONCLUSION: Cardiac valve tumors are rare. The differentiation between surface excrescences on the cardiac valve and neoplasia is only possible by histologic examination. Because of its possible malignancy and the potential risk of emboli surgical treatment is indicated.

[Gastrointestinal hemorrhage after operation for dissecting aneurysm of the thoracic aorta]. / Gastrointestinale Blutung nach Operation eines Aneurysma dissecans der Aorta thoracica.

We present the case of a 45-year-old man who underwent surgical repair of a dissecting aneurysm of the descending thoracic aorta. 25 days postoperatively, the patient unexpectedly developed hematemesis and hypovolemic shock. Emergency gastroscopy was performed and a suspected aortoesophageal fistula was diagnosed. Unfortunately, the patient died prior to emergency surgery. Aneurysms of the aorta or of aortic grafts occasionally lead to the development of fistulae to the upper gastrointestinal tract. Once this rare, but life-threatening complication is suspected, endoscopy must be performed immediately. Emergency surgery is associated with a high risk, but represents the only possibly chance of survival for the patient.

[Ventricular septal rupture after blunt chest trauma]. / Ventrikelseptumruptur nach stumpfem Thoraxtrauma.

HISTORY AND CLINICAL FINDINGS: Case 1: a 20-year-old previously healthy man sustained multiple nonvascular injuries without visible chest trauma in a car accident. Four days later a loud systolic murmur was heard over the heart. Case 2: a 21-year-old man similarly sustained in a car accident multiple injuries without visible chest involvement but causing haemorrhagic shock. A loud systolic heart murmur was heard and after shock treatment he developed left heart failure requiring catecholamine infusions. INVESTIGATIONS: Echocardiography demonstrated posttraumatic ventricular septal rupture in both patients. Cardiac catheterisation revealed a small left to right (1 : 1.6) shunt in case 1, and a large one, 1 : 3, with markedly elevated pulmonary artery pressure in case 2. COURSE: In case 1, no treatment was needed as the intracardiac shunt was small and there were no symptoms. But in case 2 the large shunt with pulmonary hypertension required operative closure with a Dacron patch 2 days after the diagnosis had been established. CONCLUSION: Ventricular septal rupture after blunt trauma to the chest is a rare occurrence. Even though in general the prognosis is good, a large intracardiac shunt may require early surgical repair.

Clinical presentation of rupture of the left-ventricular free wall after myocardial infarction: report of five cases with successful surgical repair.

Rupture of the left-ventricular free wall may not always result in immediate irreversible hemodynamic collapse. We report a series of five patients (4 male, 1 female; age 59-79 years) successfully operated for postinfarction free-wall rupture with good long-term results. Two patients presented with syncopy and acute tamponade three days after an acute myocardial infarction. In two patients with atypical chest pain and congestive heart failure, a large pericardial effusion and an extreme localized thinning of a myocardial scar region was seen several weeks after an uncomplicated myocardial infarct. In one patient a pseudoaneurysm was detected, which developed asymptomatically within three weeks after a posterior myocardial infarct. In all cases myocardial rupture was suspected after an echocardiographic examination. At surgery a hemopericardium and a localized rupture site were found. The surgical procedure included closure of the defect by direct suture or patch, CABG in 3 cases, and mitral valve replacement in one patient. The postoperative course was uneventful, only one patient needed IABP for 24 hours. Three patients returned to NYHA functional class I, one patient to class II, and one patient to class III. The latter patient died of heart failure 17 months postoperatively, and the other patients are still alive 4,18,24, and 26 months postoperatively. Thus clinical representation of left-ventricular free-wall rupture after myocardial infarction can be highly variable. But close cooperation between experienced echocardiographers and surgeons may allow successful corrections with good long term-results.

[Ostium stenosis of the left coronary artery after aortic valve replacement--2 case reports]. / Ostiumstenose der linken Koronararterie nach Aortenklappenersatz--2 Fallberichte.

The development of left main coronary artery stenosis is a rare complication arising after aortic valve replacement. We report the different clinical course of two cases. One patient developed typical exertional angina 3 months after uneventful aortica valve replacement. Coronary stenosis had been excluded on preoperative coronary angiography. One day before hospital admission for coronary angiography the patient died suddenly. The second patient reported symptoms typical of angina 6 months after aortic valve replacement. Coronary angiography revealed critical left coronary ostial stenosis, which was successfully treated by surgical revascularization. These cases demonstrate the rare, yet potentially fatal complication of left coronary ostial stenosis. Early coronary angiography seems warranted in the event of typical exertional angina, even after angiographic exclusion of relevant coronary artery stenosis before aortic valve replacement.