Bacterial contamination of pulmonary artery catheters.

The catheter tips of 152 patients, who were haemodynamically supervised by pulmonary artery monitoring or continuous cardiac output determination, were bacteriologically examined. 106 cultures remained sterile, 21 cultures revealed a growth of non pathogenic organisms. Staphylococcus aureus was cultured 15 times, pseudomonas aeruginosa 4 times, Citrobacter as well as Escherichia coli twice, and Klebsiella and Enterobacter once each. There was no statistically significant connection between dwelling period and contamination. Also diabetes mellitus or corticoid medication in high dosage had no significant influence on contamination rate.

Long-term prognosis of patients with silent ischemia, symptomatic ischemia and without ischemia after acute myocardial infarction.

The prognosis of 55 patients with silent ischemia (group I: asymptomatic ST segment depression of greater than or equal to 0.1 mV on symptom-limited ergometer exercise) was compared with that of 25 patients with angina and ST depression (group II), 22 patients with angina but without ST depression (group III) and 94 patients without angina and without ST depression (group IV) on ergometer testing in the first post-infarction month. Patients for whom PTCA or coronary artery bypass graft surgery was planned for the next months following discharge were excluded. Groups were well matched in terms of age, sex, diabetes, non-Q-wave infarctions and global left ventricular function, but groups I and II had more inferior wall infarctions (76% and 68% respectively) than groups III and IV (18% and 34%, p less than 0.0001). After a mean follow-up time of between 26 and 33 months 11% in group I, 16% in group II, 14% in group III, but only 6% in group IV had died from cardiac disease or reinfarcted (p = 0.06). Using Cox's model, the Killip index, presence of non-Q-wave infarction, maximal ST depression on ergometer exercise and global left ventricular ejection fraction were found to be important prognostic variables affecting reinfarction-free survival, whilst angina was not. Results suggest that the presence or absence of angina as an isolated symptom is not of prognostic important after acute myocardial infarction, in comparison with objectively determinable parameters.

[Pulmonary artery end-diastolic pressure recordings after myocardial infarction (author's transl)]. / Pulmonalarteriendruckverhalten nach Myokardinfarkt

29 patients with acute myocardial infarction were subdivided into 3 groups using the information gained by continuous measurement of the pulmonary artery end-diastolic pressure (PAEDP) during a stay of 3 to 5 days in the coronary care unit of this hospital. Group I comprised patients with a PAEDP of below 12 mm Hg (without treatment), group II those with a PAEDP of between 12 and 20 mm Hg and group III those patients with a PAEDP of above 20 mm Hg. 3 to 6 months after rehabilitation and ambulant ""coronary training'' a follow-up control PAEDP measurement was performed at rest and during ergometric stress with the bicycle exercise test. 2 out of the 15 patients in group I had a pathological PAEDP at rest, whilst exercise of 50 watts raised the PAEDP to pathological values in 40% of this group of patients. Group II: 58% of the patients with an initially-raised PAEDP showed a normal value at follow-up examination 3 months subsequently. Exercise of 50 watts raised the PAEDP to pathological values in 66% of the patients in this group. Group III. The pathologically high PAEDP recordings at rest made it impossible to subject these patients to stress with the bicycle ergometer. The prognostic value of the classification of patients with myocardial infarction into pressure groups and the importance of PAEDP follow-up measurements on patients after myocardial infarction at rest and after ergometric stress are discussed.

[The efficacy of the intra-aortic balloon pump for patients with heart failure complicating acute myocardial infarction (author's transl)]. / Die Effektivität der intraaortalen Ballonpumpe bei Patienten mit Herzinsuffizienz durch akuten Myokardinfarkt.

Assisted circulation was carried out with the help of an intra-aortic balloon pump in 22 patients with acute transmural myocardial infarction and heart failure (despite medication). Two patients died in hospital. The combination of the balloon pump and nitrates proved to be particularly effective. The follow-up examination of the survivors showed a distinct pulmonary arterial pressure during ergometry. All of the examined patients revealed extensive akinetic and diskinetic areas, significant stenosis being detectable either in the proximal area of the Ramus descendens anterior or in two or three blood vessels.

[Arrhythmias during catheterization of patients with acute myocardial infarction (author's transl)]. / Rhythmusstörungen beim Einschwemmkatheterismus akut Infarktkranker.

Arrhythmias in forty consecutive patients with acute myocardial infarction during ventricle passage of floating catheters were compared with those in forty patients with chronic heart disease. Lidocaine (1 mg/kg body weight i. v.) as a bolus proved to be effective in reducing the incidence of these arrhythmias, because the number of single ventricular premature beats (VPBs), and the number of VPBs in salves was significantly reduced. Haemodynamic changes due to this bolus are small and short-lasting, so that they are acceptable, especially when continuous monitoring of the patients is attempted. Furthermore dangerous arrhythmias are reported in 1600 cases treated with floating catheters.

[Noninvasive possibilities of X-ray diagnostic on prostetic heart valves (author's transl)]. / Nichtinvasive radiologisch-diagnostische Möglichkeiten bei künstlichen Herzklappen.

Characteristic mechanical qualities and possibly occurring complications are discussed in this paper. Noninvasive x-ray diagnostic with chest radiographex, fluoroscopy and 70mm camera makes possible an exact identification of any prosthetic valve. If there is any clinical suspicion, negative x-ray findings will not exclude malfunction of the prosthesis. Invasive diagnostic proceeding is necessary in such cases.

[Agranulocytosis after antiarrhythmic therapy with ajmalin (author's transl)]. / Agranulozytose nach Antiarrhythmikatherapie mit Ajmalin.

A case of agranulocytosis (min. leucocyte count 980/mm3) after 4 weeks of treatment with an ajmalin derivate is reported. Recovery could be achieved by taking away the antiarrhythmic drug. It appears that these agranulocytoses only happen after a dosage of more than 300 mg/die, and that they have an intermediate position between allergic and toxic agranulocytosis (phenothiazine type).

[Incidence and management of acute left main coronary artery dissection as a complication of acute transluminal coronary angioplasty]. / Häufigkeit und Management der akuten Links-Hauptstammdissektion als Komplikation der perkutanen transluminalen Koronarangioplastie.

Out of 1730 consecutive patients undergoing percutaneous transluminal coronary angioplasty (PTCA) of left descending coronary artery (LAD) or circumflex artery (CX) five patients (0.3%) suffered an acute dissection of left main coronary artery. In three patients dissection developed because of manipulation of the guiding catheter. In one patient retrograde dissection of the left main stem occurred because of balloon angioplasty of ostial LAD stenosis and in a second patient because of balloon rupture in the setting of stent deployment in the proximal part of the LAD. Four patients were selected for emergency operation, but one patient died before reacting the operation theatre. Out of the three remaining patients one patient died postoperatively and another patient suffered a transmural myocardial infarction. In the fifth patient three AVE Micro stents were implanted; one just at the origin of the LAD, one at the origin of the CX and the third in the left main stem. This patient was not sent for operation and was discharged without symptoms.

[Prognostic value of symptom-limited ergometry 3 weeks after acute myocardial infarct]. / Prognostische Bedeutung einer symptomlimitierten Ergometrie drei Wochen nach akutem Myokardinfarkt.

96 patients, under 70 years of age, underwent symptom-limited (maximal) exercise testing in the 3rd week after an acute myocardial infarction when neither cardiac insufficiency, angina pectoris (post-infarction) nor malignant arrhythmias were present. A further 29 patients, who could not be exercised because of the reasons mentioned, had a significantly higher frequency of coronary events during the 14 month observation period than those patients who could be exercised (55% vs. 23%, P = 0.05). When signs of (reversible) ischaemia occurred during exercise testing (angina pectoris, ST-segment depression greater than 0.1 mV), the one-year prognosis was significantly worse than in patients having no ischaemia. By means of this test the occurrence of a "coronary event" can be forecasted with high sensitivity (92%) but low specificity (46%). Thus, the negative test ("predictive value" 94%) is suitable for recognising patients with low spontaneous risk thus sparing them from further invasive investigations.

[Ventricular rupture during acute myocardial infarction (author's transl)]. / Herzruptur bei akutem Myokardinfarkt.

In a series of 523 consecutive patients with acute myocardial infarction (AMI) 112 died; among these were 18 with rupture of the free wall of the left ventricle (HR) (group RU); two other cohorts were formed: one sample of all patients with acute (transmural) myocardial infarction (group KO) and another cohort of death of AMI in 1976 (EX). 1. patients with HR are significantly older than the KO group; there is no difference in age compared to the patients who died of AMI other than HR (group EX). 2. Women with AMI have a higher chance to die of HR than men. 3. The RU group has significantly more often clinical signs of congestive heart failure than the control group. 4. Cardiogenic shock is significantly more frequent in the RU-group than in the control group. 5. All deaths (EX + RU) have worse hemodynamic data than the control group (KO). 6. Elevated blood pressure (before and after AMI) could not be identified as a risk factor for HR in our patients. 7. In the course of AMI, death in pump failure occurs significantly later than heart rupture.

[Influence of isosorbiddinitrate on hemodynamics at rest and during exercise (author's transl)]. / Beeinflussung der Ruhe- und Belastungshämodynamik durch Isosorbiddinitrat (ISDN). Untersuchungen an Patienten 3 Wochen nach akutem transmuralem Myokardinfarkt.

23 patients with acute transmural myocardial infarction were exercised (4 min. 30 Watt) at the end of the hospital period (14-26 days after administration) (probatory exercise). This test was repeated identically after 5 mg of ISDN; again hemodynamic measurements were done (heart rate, arterial pressure, pulmonary artery pressure, cardiac output). 60% of the investigated patients had elevated (above 20 mm Hg) wedge pressures (pulmonary diastolic pressure) during exercise. The elevated PA-pressure was lowered significantly by administration of ISDN. In Group II (with exercise PADP above 20 mm Hg) this reduction of preload improved ventricular performance significantly. In Group I (PADP ex below 20 mm Hg) reduction of the preload worsened ventricular performance (not significant). Heart rate rose at rest and was reduced during exercise after ISDN. Arterial pressure was lower after ISDN as well as during exercise. ISDN proved to be a valuable drug in the postinfarction period even in patients free of angina pectoris since it may help to normalize disturbed hemodynamics (which can only be detected by exercise testing in many cases).

[Behavior of pulmonary artery pressure in the egometric exercise test in chronic coronary disease]. / Zum Pulmonalisdruckverhalten im ergometrischen Arbeitsversuch bei chronisch koronarer Herzkrankheit

Bicycle exercise stress tests of 39 patients with coronary heart disease are compared to those of 33 healthy persons. The difference in enddiastolic pulmonary artery pressure (PAEDP) of the patients compared to the healthy is low at rest (PAEDPhec healthy = 8.49 +/- 2.80, PAEDPCHD = 10.51 +/- 5.09, p = 0.05). Stress testing (50 Watts) brings significant differences of the average enddiastolic pressures (PAEDP healthy = 12.76 +/- 3.61, PAEDPCHD = 19.38 +/- 7.96, p = 0.001). More important than this (already well known difference) is the wide divergence of results within the group of patients with CHD. For this reason this type of investigation seems to be a good "screening method" regarding selection for coronary arteriography. The reason for the pathological rise of PAEDP can be found in a decrease of compliance due to ischaemia ("coronary factor"), or in exercise induced temporary heart failure ("myocardial factor"), or both.

Early diagnosis of subacute free wall rupture complicating acute myocardial infarction.

Of 2608 consecutive patients with acute myocardial infarction, 24 developed subacute free wall rupture (= 0.92%; 95% C.I. = 0.6-1.4). Clinical manifestations varied widely (shock on admission; 25% of cases; severe arrhythmias followed by shock: 17%; shock during hospital stay: 42%; symptoms suggestive of infarct extension without shock: 17%). The electrocardiograms were confusing rather than revealing: 56% of patients showed new ST segment elevations of 0.2 to 1 mV in the infarct-related leads, while autopsy or creatinine phosphokinase evidence of infarct extension was missing. In the first 21 cases, therefore, no definitive diagnosis was made before autopsy. Using 197 infarct patients in cardiogenic shock or with infarct extension during the acute stage, i.e. a patient group with comparable clinical manifestations, as control group, a logistic regression model was generated in which the variables age, lateral wall involvement and history of hypertension were used for estimating the probability of subacute rupture. In fact, probability may rise to more than 40% in major subgroups. As death occurred after a median interval of 8 h (45 min-6.5 weeks) following the onset of rupture symptoms, echocardiography must be performed urgently in all cases presenting symptoms of shock or infarct extension. Pretest probability which can be roughly estimated from our model as well as sensitivity and specificity of individual echocardiographic or clinical parameters are indispensable for correct therapeutic decisions. The routine application of this algorithm in our department contributed to a timely diagnosis in the last three consecutive cases of whom one patient survived.

[The prognostic value of continuously measured pulmonary artery pressure in recent myocardial infarct]. / Die prognostische Bedeutung der bei frischem Myokardinfarkt kontinuierlich gemessenen Pulmonalarteriendrucke

Enddiastolic pulmonary artery pressure (PAEDP) was measured continuously in 100 patients with acute transmural myocardial infarction, beginning on admission to the CCU and lasting till the 3rd, 4th or 5th day. The PAEDPs of the first day were averaged and on this basis the patients were divided into three groups. Mortality in Group I (41 patients with PAEDP below 12 mm Hg) was 4.9%, in Group II (43 patients with PAEDP of 12-20 mm Hg) 16.3%, and in Group III (16 patients with PAEDP above 20 mm Hg) 43.8%. Use of additional hemodynamic parameters such as cardiac output, cardiac index, and cardiac work index increased prognostic precision for patients in the acute stage. However, they did not improve prognostic precision on fatal outcome in the post-acute stage. Bicycle exercise stress tests carried out several months later with simultaneous evaluation of hemodynamics (PAEDP) showed a good suitability for rehabilitation in Group I and in 58% of the patients in Group II. The other 42% had a significant rise in pulmonary artery pressure, could not undergo stress, and, in our view, are suitable for rehabilitation only in exceptional cases.

[Continuous monitoring of the pulmonary artery pressure in acute myocardial infarction (author's transl)]. / Kontinuierliche Uberwachung des Pulmonalarteriendruckes beim akuten myokardinfarkt.

The method of continuous pulmonary artery pressure (PAP) monitoring and its use in 66 patients with acute myocardial infarction is described. Measurement of PAP should be the first diagnostic step in hemodynamic monitoring and early recognition of left ventricular failure. In cases of elevated PAP and critical general state of the patient, monitoring should be extended by measuring pulmonary wedge pressure and cardiac output. Hemodynamic monitoring should be continued for 3 to 5 days, since some cases of acute myocardial infarction with increasing PAP up to the 4th day after the onset were recorded. With the safety precautions mentioned, neither threatening, arrhythmia, nor thromboembolic or septic complications were observed.

[Importance of risk factors in myocardial infarction (author's transl)]. / Die Bedeutung der Risikofaktoren für den Verlauf des Myokardinfarktes.

Importance of risk factors as hypertension, hyperlipidaemia, diabetes mellitus and cigarette smoking because of hemodynamic and complication during acute myocardial infarction and influence of live quality during the first year after myocardial infarct was pointed out in this study. No risk factor was found in 12.1% out of 248 patients. 25.8% had one, 33.5% two, 12.9% three and 3.2% four risk factors. If only one risk factor for coronary heart disease was documented, 35.9% showed cigarette smoking. If there were two risk factors, most of the people had diabetes mellitus and hypertension, and the combination diabetes mellitus, hyperlipidaemia and cigarette smoking was favourite if there were three risk factors present. The mean age of all patients was 65.9 +/- 10.8 years. Patients who smoked or had hyperlipidaemia were statistically significantly younger (p < 0.001). There was no correlation between number of risk factors or kind of it and pulse frequence, cardiac index, pulmonary artery pressure and third heart sound during phase of acute myocardial infarction. Also no correlation was found between the risk factors hypertension, diabetes mellitus and cigarette smoking and rhythm disturbance of reinfarction. Patients with normal lipids had significant more bradycard or tachycard rhythm disturbances as patients with hyperlipidaemia (p < 0.05). Patients without diabetes mellitus or hypertension had better bicycle tests than patients with this risk factors (p < 0.01). 92% of hypertensive patients had regular drug medication; 14.1% of smoking patients continued smoking cigarettes after acute myocardial infarction. Only 62.1% of diabetic patients, 54.1% of hyperlipidaemic patients and 40% of overweight patients kept diet. Because of this bad quality of patient compliance there was no exact information possible in predicting value of secondary preventive measurements after acute myocardial infarction.

[Changes in antithrombin III, prothrombin fragment 1 + 2 and thrombin-antithrombin III complex following implantation of a coronary Palmaz-Schatz stent]. / Veränderungen von Antithrombin III, Prothrombinfragment 1 + 2 und Thrombin-Antithrombin-III-Komplex nach Implantation von koronaren Palmaz-Schatz-Stents.

To detect changes in the clotting parameters antithrombin III (AT III), prothrombin-fragment 1 + 2 (F 1 + 2) and thrombin-antithrombin-III-complex (TAT) after implantation of Palmaz Schatz stents, coagulation was monitored at standardized time points in 35 patients for 10 days. All patients were anticoagulated using a combination of heparin, phenprocoumon, and acetyl salicylic acid. Heparin therapy was guided by APTT levels (normal range 25-35 s), which were still within the therapeutic range (median 49.6 s (25%/75% percentiles 41.6/54.4) on day 10. Simultaneous oral anticoagulation was found to be effective on day 8 on average (INR median 2.24 (1.93/2.50)). The AT III activity dropped significantly (p < 0.0001) after a heparin loading dose of 15,000 IU during stenting. As the heparin dose was reduced on the following days, AT III levels increased significantly (p < 0.0001) during the observation time. There was a highly significant (p < 0.001) negative correlation between AT III and heparin levels. On days 4 and 5 F 1 + 2 values were significantly (p < 0.001 and p < 0.05) higher than on the day of stenting (median 1.07 (0.90/1.31) 1.13 nmol/l and 1.06 (0.85/1.23) nmol/l vs. 0.97 (0.69/1.15) nmol/l) and dropped during anticoagulation. F 1 + 2 levels showed a significant negative correlation (p < 0.0005) with APTT values. TAT values showed no significant changes during the observation period.(ABSTRACT TRUNCATED AT 250 WORDS)