[A rare cause of exertional dyspnea in a 63-year-old woman]. / Seltene Ursache einer Belastungsdyspnoe bei einer 63-jährigen Patientin.

HISTORY AND CLINICAL FINDINGS: A 63-year-old woman was referred because of excertional dyspnea, pulmonary artery hypertension and right heart dilatation without evidence of pulmonary embolism. INVESTIGATIONS: Echocardiography, magnetic resonance tomography and right heart catheterisation revealed a left to right shunt through an sinus venosus defect and partial anomalous pulmonary venous return. DIAGNOSIS, TREATMENT AND COURSE: After surgical repair the hemodynamic changes normalized. The patient is doing well 12 weeks after surgery. CONCLUSION: Congenital heart disease should be considered as a rare cause of exertional dyspnea in the elderly. Before percutaneous interventional closure of atrial septal defects, concomitant anomalous partial pulmonary venous return should be ruled out.

[A 40-year-old female with headache and infarction ECG]. / 40-jährige Patientin mit Kopfschmerzen und Infarkt-EKG.

Cerebral lesions may contribute to a transient left ventricular ballooning syndrome that can mimic acute myocardial infarction. Fibrinolytic therapy or GP IIb/IIIa antagonists should be withheld in cases of neurologic disorder or unconsciousness even in the presence of ST-elevation.ECG transmission by telemetry and myocardial infarction alarm networks allow correct diagnosis and catheter treatment within required time limits.

[Myocardial infarction and coronary artery ventricular fistulas due to blunt chest trauma]

Myocardial infarction and coronary artery ventricular fistulas due to blunt chest trauma. HISTORY AND CLINICAL FINDINGS: An 18-year-old previously healthy, cigarette smoking man with no other risk factors for ischaemic heart disease, was admitted to hospital after being kicked in the chest by a horse. On arrival he complained about pain in the lower mediastinum. INVESTIGATIONS: The ECG showed sinus rhythm, right bundle branch block and convex bowed ST elevation in leads V1-V3. Sixty minutes after the incident the cardiac enzymes (creatinekinase-MB fraction, troponin I) were significantly raised. Despite an only slightly reduced left ventricular function documented by transthoracic echocardiography, SPECT-thallium scan showed large scintigraphic defects. Coronary heart disease was excluded by coronary angiography. Four small coronary-ventricular fistulas were identified. Laevocardiography showed a hypokinesia in the antero-septal region. DIAGNOSIS, TREATMENT AND COURSE: We assumed traumatic myocardial infarction of the anterior wall and rupture of multiple small coronary vessels, leading to coronary-ventricular fistulas. No interventional or surgical therapy was performed. Later on the left ventricular function became normal. Echocardiography merely outlined an akinetic scar in the middle of the septum. At exercise ECG test sixteen months later, the patient remained asymptomatic and was able to exercise without any signs of ischaemia up to a work load of 175 W. Furthermore, the fistulas could be seen by echocardiography. CONCLUSION: Cardiac involvement should be considered in all cases of blunt chest trauma. In addition to a traumatic myocardial infarction fistulas may also, though rarely, occur. Myocardial scintigraphy after cardiac contusion is not suitable for diagnosing myocardial ischaemia or vitability.

[A rare cause of myocarditis in a 30-year-old patient]. / Seltene Ursache einer Myokarditis bei einem 30-jährigen Patienten.

CASE REPORT: A 30-year-old male was admitted to hospital because of chest pain and raised cardiac enzymes. Coronary heart disease was excluded by coronary angiography. Assuming myocarditis serological testing was performed and showed markedly raised antibody titers against Coxiella Burnetii. We treated the patient with doxycycline, 2 times 100 mg daily for 5 months. CONCLUSION: Acute Q-fever should be considered as a possible cause of myocarditis, especially in rural areas.

[Fever, negative blood culture findings and absence of response to antibiotic therapy in a patient after a second aortic valve prosthesis]. / Fieber, negative Blutkulturbefunde und Fehlen des Ansprechens auf Antibiotikatherapie bei einem Patienten nach erneutem Aortenklappenersatz.

HISTORY AND CLINICAL FINDINGS: A 53-year-old patient had a prosthetic valve (St. Jude Medical 25) 9 years ago because of a Staphylococcus aureus endocarditis with severe aortic regurgitation. An initially mild, progressively more severe, aortic regurgitation then developed as a result of an empty paravalvular abscess cavity, requiring another valve replacement. Fever started on the 3rd postoperative day and persisted despite combined treatment with beta-lactam antibiotics and aminoglycoside. INVESTIGATIONS: At first no infectious focus could be identified radiologically or by echocardiography. But transoesophageal echocardiography revealed vegetations in the old abscess cavity. Several blood cultures were negative, while serological tests gave markedly raised antibody titers against Coxiella burnetii. DIAGNOSIS, TREATMENT AND COURSE: Assuming Coxiella burnetii endocarditis the patient was given doxycycline, 2 x 100 mg daily and cotrimoxazole, 1 x 960 mg daily. The fever subsided and the vegetations had disappeared after four weeks. Because of the high risk of recurrence the antibiotic treatment was to be continued for two years. CONCLUSION: Coxiella burnetii should be considered as a possible cause of fever of unknown origin, especially in patients with existing or operated cardiac valvar defects, when endocarditic vegetations have been demonstrated and several blood cultures have been negative.

Efficacy of low-molecular-weight heparin delivery with the Dispatch catheter following balloon angioplasty in the rabbit iliac artery.

Local drug delivery can be achieved with active injection systems or passive contact of a compound with the arterial wall. The Dispatch catheter allows for passive diffusion of drugs from drug compartments while preserving blood flow through the central conduit. The aim of this study was to investigate whether a reduction in neointima formation can be achieved by local delivery of a limited amount of a highly concentrated solution of the low-molecular-weight heparin Reviparin. In 16 New Zealand white rabbits, successful balloon dilatation was performed in both iliac arteries, followed by local delivery of 4 ml Reviparin (1,000 IU/ml). The arteries were harvested at 7, 28, or 56 d following the procedure. The intimal cell layers increased substantially between 7 and 28 d following balloon dilatation with or without local drug delivery. The medial cell layers showed only a little increase. Proliferation of smooth muscle cells reached an early peak after 7 d, with a significantly higher proliferation index following local delivery. The maximum amount of macrophages in the intima and media was detected after 28 d. The lumen area decreased with time and was 0.6 +/- 0.7 mm2 in the local delivery group at 56 d compared with 0.5 +/- 0.5 mm2 in the control group. In conclusion, local delivery of Reviparin with the Dispatch catheter is safe and feasible. However, the infusion of highly concentrated low-molecular-weight heparin over a short period of time did not result in a reduction of neointima formation and restenosis following balloon dilatation in the rabbit iliac artery.