Use of FemoStop system for arterial puncture site closure after coronary angioplasty.

Different protocols exist concerning the method and timing of post-coronary angioplasty arterial puncture site closure. Easy handling and good effectiveness are well-documented for the Femostop femoral artery compression system; however, no hard data exist concerning the relationship between heparin anticoagulation level and femoral artery compression time (FSCT). Thus, we prospectively randomized 267 patients after elective percutaneous transluminal coronary angioplasty (PTCA) into two groups [group A (n=137) had early sheath removal 6 to 8 hours after PTCA; group B (n=130) had late sheath removal 14 to 16 hours after PTCA] and analyzed the dependence of the FSCT on the heparin anticoagulation level (aPTT) and the incidence of vagal reactions and puncture site complications. FSCT was significantly longer in group A (69+/-27 minutes versus 45+/-15 minutes; p<0.001) with high heparin anticoagulation level (aPTT, 88+/-46 seconds) in comparison to group B with low heparinization (aPTT, 59+/-34 seconds). Vagal reactions occurred more frequently in group A (15.3% versus 10.0%; p<0.01) and the incidence of minor hemorrhage at the arterial puncture site was also increased (9.5% versus 3.1%; p<0.05). In the clinical setting of intensive heparin anticoagulation and early sheath removal after PTCA (<8 hours), the FemoStop system cannot be recommended due to prolonged femoral artery compression times.

Improvement of cardiac output in patients with severe heart failure by use of ACE-inhibitors combined with the AT1-antagonist eprosartan.

BACKGROUND: The efficacy of ACE-inhibitor therapy is well documented in the treatment of chronic heart failure. As pharmacological mechanisms of ACE-inhibition and angiotensin II AT1-receptor-antagonists differ, an additional positive effect concerning left ventricular function can be expected in combining both classes of drugs. METHODS: Twenty patients (64.9+/-8.5 years) with advanced chronic heart failure (NYHA class III) receiving long-term medication with digitalis, diuretics and ACE-inhibitors were randomized to either eprosartan (540+/-96 mg/day) or placebo, according to a blinded protocol. Hemodynamic measurements by impedance cardiography were performed at baseline and after 8.85+/-1. 5 days of study medication treatment. RESULTS: Additional treatment with eprosartan resulted in a higher cardiac output than in the control group (P<0.05). While in the active treatment group cardiac output increased significantly from baseline (2.27-3.24 l/min, P=0. 039), there was no change in the control group. CONCLUSIONS: The additional treatment with the AT1-receptor antagonist eprosartan, given to severe heart failure patients, who received digitalis, diuretics and ACE-inhibitors, resulted in a beneficial effect by increasing cardiac output. This effect may be due to eprosartan's additional property of blocking the autocrine interaction of locally and not ACE-generated angiotensin II with their respective vascular and myocardial AT1-receptors as well as the influence on prejunctional AT1-receptors located on sympathetic nerve terminals.

[Verapamil sensitive ventricular tachycardia with myocardial failure in a 2-year-old child]. / Verapamilsensitive ventrikuläre Tachykardie mit myokardialer Funktionseinschränkung bei einem zweijährigen Kind.

UNLABELLED: Ventricular arrhythmias can both result from and cause myocardial dysfunction. We report a case of a two-year-old girl with ventricular tachycardia showing signs of heart failure consisting with a tachycardiomyopathy. The therapy with class I and class III antiarrhythmic drugs did not improve the cardiac situation significantly. The cardiologic investigations were consistent with the verapamil-sensitive ventricular tachycardia in young adults. The treatment with verapamil led to a normal rhythm and function of the heart. CONCLUSION: Verapamil-type calcium channel blockers can also be used in children for the treatment of ventricular tachycardias if the corresponding investigations show characteristic findings.

Dobutamine stress echocardiography.

Dobutamine is a synthetic catecholamine with predominant beta-stimulation. Its half-life is approximately 2 min. The positive chronotropic and inotropic effects of dobutamine induce myocardial ischaemia if significant coronary artery obstruction is present. Regional ischaemia produces regional wall motion abnormalities which can be detected by echocardiography. Most dobutamine stress protocols start at an infusion rate of 5 micrograms.kg-1.min-1 and increase to a peak dose of 40 or 50 micrograms.kg-1.min-1; to further increase heart rate, a bolus injection of 0.25-1.0 mg atropine is added. Test endpoints are the detection of new wall motion abnormalities, the occurrence of severe complications or achievement of the target heart rate. Viable myocardial regions have a positive inotropic reserve, which can be stimulated by dobutamine and detected by echocardiography. Indications for the use of dobutamine stress echocardiography are to prove stress-inducible myocardial ischaemia and to detect myocardial viability. The test should only be performed for the detection of stress-induced myocardial ischaemia if patients are unable to undergo exercise echocardiography, or if patients fail to reach their required test level in exercise echocardiography.

Detection of myocardial viability using stress echocardiography.

Asynergic myocardial regions in patients with coronary artery disease can be viable. They may have the ability to improve their function after restoring coronary blood flow. Asynergic but viable myocardial regions have a positive inotropic reserve which can be stimulated by catecholamines. Because echocardiography is an established method for evaluating regional left ventricular function, it has the potential to detect the inotropic response of asynergic myocardial regions. In the clinical setting, prediction of left ventricular functional improvement after revascularization is particularly important. Dobutamine stress echocardiography is the most frequently used stress echocardiographic test for detection of myocardial viability. Dobutamine is infused at low rates of 2.5 to 20 micrograms.kg-1.min-1 to detect myocardial viability. This paper reports on the sensitivity and specificity of the method for the detection of viability and its usefulness for prediction of left ventricular functional improvement after revascularization.

[Treatment of myocardial infarction by primary PTCA within 12 to 24 hours after onset of pain]. / Myokardinfarkt-Therapie mit primärer PTCA innerhalb von 12 bis 24 Stunden nach Schmerzbeginn.

BACKGROUND AND OBJECTIVE: The time elapsed until effective infarct vessel perfusion has been identified as an essential determinant of survival after acute myocardial infarction (MI). Significant mortality rate reduction has not been demonstrated for patients who received thrombolytic treatment more than 12 to 24 hours after MI. For this reason such patients have so far largely been denied reperfusion treatment and have thus been excluded from any potential benefit of an reopened infarct vessel. It was the aim of this study to assess the applicability and safety of achieving reperfusion by percutaneous transluminal coronary angioplasty (PTCA) without prior thrombolysis (primary PTCA) within 12 (> 12) to 24 (< or = 24) hours after onset of pain, taking into account early and late results in selected consecutive patients. PATIENTS AND METHODS: The data were analysed retrospectively of 35 patients (29 men, 6 women; mean age 60 [49-78] years) who had been admitted and treated by primary PTCA for MI more than 12-24 hours after onset of pain, with persisting ECG changes and (or) continuing chest pain. Reperfusion rates, acute haemodynamic parameters, acute cardiac and noncardiac complications, 30-day mortality rate, 3-month angiographic results and late mortality rate were obtained after an average of 23 (4-36) months. RESULTS: Complete infarct vessel reperfusion was achieved in 30 patients (85.7%), the infarct vessel remaining occluded in five. The early measurement of mean left ventricular ejection fraction was 53% (8-76%). A small, conservatively managed pericardial effusion occurred in one patient due to coronary artery penetration. Three patients who were in cardiogenic shock on admission died (8.6% 30-day mortality rate). Nine cases of restenosis and two of re-occlusion of the infarct vessel were documented in 24 patients who were investigated invasively 3 months after the primary PTCA. One patient had sustained a nonfatal MI. During the follow-up period one patient died of a noncardiac cause. INTERPRETATION: In this selected group of patients who received treatment more than 12 to 24 hours after MI primary PTCA achieved a high rate of reperfusion, while early and late complications were rare. Using individualized criteria of patient selection, primary PTCA can accomplish recanalization. The question of prognostic advantage can only be answered by results in a larger and randomized cohort of patients.

[A rare form of heart metastasis: hypernephroma. Successful surgical treatment]. / Seltene Form von Herzmetastasen: Hypernephrome. Erfolgreiche chirurgische Behandlung.

An unusual cardiac metastasis, occurring in a 63-year-old man 19 years after nephrectomy because of renal cell carcinoma, is reported. The tumor extended from the right ventricle apex to the mid-portion of the interventricular septum. A complete excision could be achieved. To our knowledge, this is the third case of a renal cell carcinoma metastasis to the right ventricle which could be detected during a patient's lifetime and treated surgically. A review of the literature is also reported.

[Automated implantable cardioverter/defibrillators. Indications for implantation and clinical results]. / Automatische implantierbare Kardioverter/Defibrillatoren. Indikationen zur Implantation und klinische Ergebnisse.

Since the first implantation in 1980 about 55,000 automatic Cardioverter/Defibrillators (ICD) were implanted worldwide. This paper overviews the development of indications for ICD implantation as well as clinical results especially with respect to prophylaxis of sudden cardiac death.

[Ventricular bigeminy with fixed with fixed coupling at rest and during exercise as the cause of recurrent dizziness and syncope--successful anti-arrhythmic therapy by high frequency current catheter ablation of a right ventricular arrhythmogenic focus. A case report]. / Ventrikulärer Bigeminus mit fixer Kopplung in Ruhe und unter Belastung als Ursache für rezidivierende Schwindelattacken und Synkopen--erfolgreiche antiarrhythmische Therapie durch Hochfrequenzstrom-Ablation eines rechtsventrikulären arrhythmogenen Fokus. Ein Fallbericht.

In a 52-year-old patient with beginning dilatative cardiomyopathy dizziness and syncopes could be observed due to a ventricular bigeminy at rest and under exercise conditions. The patient also showed a marked reduction of exercise capacity and was handicapped in his profession as electrician and unable to work for more than 10 months. Antiarrhythmic drug therapy including the subsequent use of all available antiarrhythmic agents failed in suppressing this arrhythmia. In an electrophysiological study the arrhythmogenic focus could be localized in the right ventricular outflow tract. Application of radiofrequency current resulted in instantaneous termination of the extrasystoly; this result could be documented in repeat Holter monitorings over 12 weeks to present. This case report shows that radiofrequency catheter ablation can in special cases be applied for therapy of extrasystolic phenomena when clinical symptoms necessitate treatment and antiarrhythmic drug therapy fails.

[Successful high frequency current catheter ablation of an accessory conduction pathway in the "neck region" of a coronary sinus aneurysm. A case report]. / Erfolgreiche Hochfrequenzstrom-Katheterablation einer akzessorischen Leitungsbahn im "Halsbereich" eines Koronarsinus-Aneurysmas. Ein Fallbericht.

In this case report the electrophysiological findings in a 24 year old female patient are demonstrated. For about 12 years she suffered from recurrent atrioventricular reentrant tachycardia with a rate of 230 beats per minute. Electrophysiological study resulted in diagnosis of a posteroseptal accessory pathway. Ablation was attempted primarily from a left ventricular access, but the pathway could not be reached from this position. After contrasting the coronary sinus a large coronary sinus aneurysm could be diagnosed. The accessory pathway was located in the "neck"-region of the aneurysm. By application of radiofrequency current in this location the bypass tract could be ablated. This case report shows that accessory pathways in coronary sinus aneurysms can be ablated without complications in this location.

Cardiogenic shock in acute myocardial infarction. Improving survival rates by primary coronary angioplasty.

This study reports on 16 patients suffering from cardiogenic shock in the setting of acute myocardial infarction (11 men, five women; average age: 52.5 +/- 14 years) treated by means of primary coronary angioplasty: These 16 patients were part of a total population of 261 patients suffering from acute myocardial infarction at the time of admittance to the Wuppertal Heart Center, who were consecutively treated during the period from 1/90 to 6/94 by primary coronary angioplasty without having received any prior thrombolytic therapy. For all patients, primary re-opening of the vessel infarcted was successful. The period of time between onset of pain until re-opening of the vessel averaged 176 +/- 49 min. Eleven patients suffered from multi-vessel coronary artery disease. Prior to re-opening, systolic blood pressures averaged 66 +/- 10 mm Hg; average biplan left ventricular ejection fraction, 40 +/- 12%; left ventricular end-diastolic pressures (LVEDP), 26 +/- 7 mm Hg. In 63% of the cases evaluated, it proved possible to document collaterals to the infarcted vessel. Thirteen patients survived acute coronary occlusion. Two patients died due to protracted myocardial pumping failure, despite re-opened arteries that effectively re-established coronary flows. Showing symptoms of re-occlusion, one patient developed electromechanical decoupling. Thirteen patients were discharged from the hospital for normal life or subsequent treatment. Overall, this corresponds to an in-hospital survival rate of 81%. During follow-up examinations performed over 14 +/- 8 months (range 3 to 30 months), all of the patients are alive. Mean left ventricular ejection fraction increased to 56% +/- 17%; mean left ventricular end-diastolic pressure dropped to 14 mm Hg +/- 5 mm Hg. In the infarct-related artery there was no recurrence of stenoses exceeding 50%. By now, one of the patients has received elective aorto-coronary bypass grafting; for another one, multi-vessel PTCA of non-infarcted arteries is being employed; 77% of the patients state that they are satisfied with the quality of their lives. These results demonstrate that rapid revascularization using coronary angioplasty in cardiogenic shock following acute myocardial infarction substantially improves the prognosis for survival and favorably influences long-term outcome. Thus, primary PTCA is the method of choice for treating cardiogenic shock; any patient-and particularly those resistant to lyse therapy-should immediately receive this treatment.

Primary mechanical recanalization of occluded coronary arteries without prior thrombolytic therapy in patients with acute myocardial infarction. A single-center study reporting acute results and complications.

This study reports on 261 consecutive patients admitted to the Wuppertal Heart Center with acute myocardial infarction (186 men, 75 women; average age: 58.2 +/- 11.6 years) and then treated by primary coronary artery angioplasty. Sixteen patients with cardiogenic shock were included, as well as 42 patients aged > or = 70 years, 51 patients with contraindications for thrombolysis, and 13 patients with prior coronary bypass surgery. All patients were treated between 12/89 to 6/94 and had not received prior thrombolytic therapy. The period of time between onset of pain and revascularization of the infarct-related vessel averaged 224 +/- 205 min. Half of the patients had multi-vessel disease, and about 31% had had a prior myocardial infarction. 100 patients suffered from an anterior wall infarction, 109 patients from an inferior wall infarction, 50 patients from a posterolateral infarction, and in two cases the infarct localization could not be determined from the ECG. Mean biplane left ventricular ejection fraction averaged 56 +/- 13%, left ventricular end-diastolic pressure 20 +/- 7 mm Hg. In about 50% of the patients collaterals to the infarct-related coronary artery could be documented. With the first contrast injection into the infarct-related vessel TIMI flow 0/I was demonstrated in 94.9%, TIMI flow II in 5.7% and TIMI flow III in 0.4%. Reopening of the infarct-related coronary artery with establishment of TIMI-flow III was primarily successful in 91.9%. Average time for coronary angiography and angioplasty in the cathlab was 69 +/- 28 min. In 29 patients an autoperfusion balloon catheter was used to treat manifest or threatening reocclusion. Thirty-day-mortality in the total study group was 3.4%. In patients aged > or = 70 years mortality raised to 14.3%; in patients in cardiogenic shock mortality increased to 18.7%, in patients with inferior wall infarction up to 5.5%, and in cases with multi-vessel disease up to 5.0%. The in-hospital and 30-day course were complicated by major peripheral bleeding in seven patients (2.7%) requiring blood transfusions and surgical femoral vascular repair, and in another two patients with a false aneurysm which was treated by surgical means. No hemorrhagic stroke occurred, but three ischemic strokes with complete restitutio ad integrum within the 30-day-observation period were registered. As major cardiac complication early re-occlusion of the initially reopened infarct-related coronary artery was diagnosed in 10 patients; 11 patients developed a re-infarction within the first 30-days, in three cases leading to a fatal outcome.(ABSTRACT TRUNCATED AT 400 WORDS)

Left ventricular malposition of a transvenous cardioverter defibrillator lead: a case report.

A case of left ventricular endocardial malposition of a transvenous implantable cardioverter defibrillator (ICD) lead through a patent foramen ovale is presented. Diagnostic modalities include lateral chest radiography, echocardiography, and electrocardiographic analysis during lead placement. The operative therapy consists of open lead replacement. Measures to avoid lead misplacement are suggested.

Post-ischemic myocardial function after pre-ischemic application of propranolol or verapamil.

The influence of pre-ischemic treatment with propranolol (0.8 mg/kg bw) or with verapamil (0.1 mg/kg bw) on myocardial O2 consumption and on coronary resistance after cardioplegic arrest (300 minutes at 22 degrees - 24 degrees C) was investigated, using a Langendorff technique in open chest experiments (canine hearts). For myocardial protection histidine buffered Bretschneider solution was used, while for standardization all hearts were postischemically reperfused with a modified Tyrode solution at 35 degrees C. Both drugs were given intravenously in two fractions, 60 and 30 minutes before the onset of cardioplegic perfusion; a third group was not pretreated. Although the verapamil group had the lowest O2 consumption post-ischemically, the most impressive results were found in coronary resistance. Propranolol significantly diminished coronary resistance (p less than 0.05), while verapamil distinctly enhanced it compared to the non treated group. The "membrane labilizing" effect of verapamil combined with calcium-free cardioplegic solution was confirmed by a massive postischemic myocardial sodium uptake.

Calcium-free cardioplegia--pro.

Preischaemic doubling of the myocardial buffer capacity optimizes the energy supply of the ischaemic heart by anaerobic glycolysis. For osmotic reasons this method of improving ischaemia tolerance can only be realized in combination with cardioplegia by extracellular Na+ and Ca2+ reduction. The cardioplegic solution 'HTK' which has been developed according to these considerations. (1) delays the decay velocity of myocardial ATP by a factor of 7-8 in comparison with pure ischaemia; (2) leads to a good myocardial recovery with regard to metabolic, morphological, and functional criteria after an ischaemic stress of 300 min at 23 +/- 1 degrees C--especially after the addition of quinine; (3) is considerably reduced in its protective efficacy by adding 50 mumol l-1 Ca2+; (4) causes a calcium paradox if it is infused for 30 min at 35 degrees C; this does not happen if it is infused for 60 min at 25 degrees C or for 120 min at 15 degrees C; on adding 50 mumol l-1 Ca2+ to the solution the risk of a calcium paradox is significantly reduced, even after infusion for 35 min at 35 degrees C; (5) effects an evident delay of recovery, if a continuous ischaemic stress of 300 min at 23 degrees +/- 1 degree C is reduced to 3 X 100 min of ischaemia at 17 +/- 1 degrees C by intermittent cardioplegic reperfusion; (6) considerably improves the myocardial recovery even after intermittent cardioplegia if 50 mumol l-1 Ca2+ are added or Mg2+ is reduced from 9 to 4 mmol l-12. The metabolic, morphological, and functional results are equivalent to those after 300 min of continuous ischaemia. Further investigations must show to what extent the 'membrane stabilizing effect' of [Ca2+]o can be achieved by taking advantage of mutual ionic interaction on the level of plasmalemma (e.g. H+-Mg2+-Ca2+) or by adding membrane effective substances (quinine).

[Problems of angiographic determination of diastolic pressure-volume relationship of the left ventricle (author's transl)]. / Untersuchungen zur angiographishcen Bestimmung der diastolischen Druck-Volumen-Beziehung des linken Ventrikels.

The problems of determination of the left ventricular diastolic pressure-volume relationship were demonstrated by analysis of post-extrasystolic beats and of two consecutive normal beats. Quantitative high-speed left ventriculography with simultaneous pressure recording was performed in 16 patients with reduced left ventricular function. The diastolic pressure-volume relationship was evaluated using the formula of Diamond and Forrester (p = b . e(a) V + c) (formula [1]) and a simplified expression (p = b' . e(a') . V) (formula [2]), usually used. The parameters b, a and c of formula (1) showed significant but nonuniform alterations. The parameters b' and a' of formula (2) did not change significantly. The residual sums of squares of the approximation using formula (1) were about 8% less than those of formula (2); i.e.: the measured left ventricular pressures and volumes could be fitted more exactly by formula (1). Two pressure-volume-curves with identical slopes but different operating pressure-levels could not be described by formula (2), because in this case the computed slope of the pressure-volume curve was influenced by shifts of the operating pressure-level. The results show that the diastolic pressure-volume relationship cannot exactly be described by formula (2). The application of formula (1) proved the angiographic determination of left ventricular volumes to be insufficient for the evaluation of the diastolic pressure-volume relationship.