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ZfuerKardiologie.00890383.eng.abstr | ZfuerKardiologie.00890383.eng.abstr | [
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ZfuerKardiologie.00890398.eng.abstr | ZfuerKardiologie.00890398.eng.abstr | [
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"Background : The importance of renal artery stenosis as a cause of refractory hypertension , recurrent pulmonary edema and renal failure is being increasingly recognized . The prevalence and clinical consequences of renovascular and macroscopic renal parenchymal pathology in patients undergoing coronary angiography is assessed prospectively . Patients and methods : Selective renal artery angiography was performed in 190 consecutive patients following coronary angiography and prior to PTCA if indicated . Diagnostic yield , therapeutic consequences , complications and fluoroscopy time were noted . Results : Mean age as 63 ( +/- 11 ) years , 74% of patients were males . Mean fluoroscopy time ( including PTCA or PTA ) was 8 ( +/- 11 ) minutes . The pathological renal and renovascular findings included critical atherosclerotic renal artery stenosis in four patients ( 2% ) , non critical ( angiographically 60% ) stenosis in 22 patients ( 12% ) , double arterial supply on one side in 26 patients ( 14% ) , on both sides in seven patients ( 4% ) , fibromuscular dysplasia in two patients ( 1% ) and large renal cyst , renal artery aneurysm and aberrant blood supply of an ectopic pelvic kidney in one patient ( 0.5% ) . The four patients with critical renal artery stenosis underwent primarily successful PTA and stenting . Conclusions : Selective renal angiography in the wake of coronary angiography is safe and inexpensive . Furthermore , it can be performed easily in the majority of cases . The diagnostic yield of renal angiography ist not negligible ; 2% of patients had critical renal artery stenosis with an unequivocal indication for an interventional procedure . Progression of ( as yet ) nonsignificant renal artery stenosis is reported in a large number of cases , meaning that early diagnosis may have later therapeutic consequences . Ad hoc PTA and stenting is the treatment of choice for significant renal artery stenosis ."
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"Chronic pulmonary hypertension and septic lung failure display different clinical features resulting in severe disturbances in the pulmonary circulation . In these diseases , the pulmonary bloodflow is impaired by a pathologic constriction of blood vessels that may lead to right ventricular overloading as well as serious worsening of gas exchange mainly caused by ventilation/perfusion mismatch . Various mechanisms deteriorating the vascular function may induce both an irreversible and a reversible contraction of pulmonary vessels , respectively . Two pharmacological approaches exist to reduce the vascular resistance : ..."
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"Angioplasty in acute coronary syndromes is complicated by a high rate of early vessel reocclusion and restenosis . Therefore , it is recommended to achieve a \" stent-like \" result by percutaneous transluminal coronary angioplasty ( PTCA ) or otherwise use coronary stenting ( provisional stenting ) . This study sought to determine angiographic and patient-related factors that are associated with early target vessel reocclusion or luminal renarrowing after coronary intervention in acute coronary syndromes ( ACS ) . In an observational prospective study we investigated 161 patients with ACS ( acute myocardial infarction and unstable angina ) submitted to PTCA . In 140 patients a follow-up angiography after 10 days was obtained . All angiograms were quantitatively evaluated by computerized measurements . Target vessel reocclusion and early luminal renarrowing was observed in 10 patients ( 7.1% ) and 19 patients ( 13.6% ) , respectively . Using univariate analysis , significant risk factors ( P 0.05 ) for early reocclusion and renarrowing were diabetes mellitus ( relative risk [ RR ] 6.1 and 5.0 ) , arterial hypertension ( RR 7.7 and 3.3 ) , postprocedural lesion length > =2 . 5mm ( RR 6.8 and 7.1 ) , postprocedural minimal lumen diameter =2 . 5 mm ( RR9.0 and 5.8 ) , residual stenosis > =25% ( RR 4.8 and 3.5 ) and absence of stents ( RR 4.1 and 3.2 ) . Moreover , in multivariate analysis hypertension and postprocedural lesion length could be identified as independent risk factors for reocclusion and renarrowing . Diabetes mellitus was found to be an independent risk factor for renarrowing . Conclusions : In a consecutive series of patients with ACS undergoing PTCA with provisional stenting the occurrence of early target vessel reocclusion and luminal renarrowing is lower than previously reported for this subset of patients treated by PTCA alone . Adverse outcome is related to absence of stents , angiographic factors ( residual stenosis , lesion length , minimal lumen diameter after procedure ) and patient-related factors such as diabetes and hypertension ."
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ZfuerKardiologie.00890495.eng.abstr | ZfuerKardiologie.00890495.eng.abstr | [
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"Background : Complete arterial coronary artery bypass grafting seems to be an alternative surgical approach in the treatment of coronary artery disease . Complications in the long-term follow-up due to degeneration of venous grafts may be reduced using arterial conduits . Prolonged operating times and increased trauma due to harvesting of multiple arterial grafts have been arguments for the conventional operative approach . We present our experience using new operative techniques , such as skeletonization of arterial grafts and the T-graft configuration . Material and methods : Between 3/96 and 7/99 , 405 patients with multiple coronary artery disease underwent complete arterial revascularization at our institution . The operations were performed using only two skeletonized grafts , both internal thoracic arteries in 105 patients ( 25.9% ) , internal thoracic artery and radial artery in 299 patients ( 73.8% ) and 1 radial artery in 1 patient ( 0.3% ) . Results : In 346 patients ( 85.4% ) a T-graft configuration was used . A mean of 4.1 +/- 0.9 coronary anastomoses were performed per patient . In hospital mortality was 2% . Sternal dehiscence or infection occured in 0.8% of patients . Harvesting of the radial artery was performable with a low morbidity . One week postoperatively , coronary angiography showed 96.7% of coronary anastomoses free of stenosis > 50% . Conclusion : Complete arterial coronary revascularization using skeletonized grafts and the T-graft approach is a safe technique in the treatment of multiple coronary artery disease . Low perioperative morbidity and mortality make its usage on a routine basis possible ."
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ZfuerKardiologie.00890502.eng.abstr | ZfuerKardiologie.00890502.eng.abstr | [
{
"id": "ZfuerKardiologie.00890502.eng.abstr-passage-0",
"type": "abstract",
"text": [
"In aortic atresia , coronary perfusion normally occurs through retrograde blood flow in the ascending aorta . We report on two patients with antegrade flow in the ascending aorta despite aortic atresia . In one patient with hypoplastic left heart syndrome ( aortic atresia , severe mitral stenosis ) , an intact interatrial septum/premature closure of the foramen ovale was found . While no other way of left atrial or ventricular decompression was found , echocardiography , angiography and the post-mortem examination showed left ventricular to coronary sinusoids as the sole pathway for systemic oxygenation . In a second patient with complex congenital heart disease , including aortic atresia , antegrade flow in the ascending aorta was through a left coronary fistula with shunt flow originating from the pulmonary trunc . This report describes systemic perfusion depending on retrograde coronary flow due to coronary-cameral ( sinusoids ) and coronary arterio-venous fistulas leading to the phenomenon of antegrade blood flow in the ascending aorta despite aortic atresia ."
],
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]
}
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"Background : Atrioventricular nodal reentrant tachycardia ( AVNRT ) is one of the most common forms of supraventricular tachycardia in the pediatric population . Patients and methods : 41 children with a mean age of 9.6 ( 3.7-16) years with recurrent atrioventricular nodal reentrant tachycardia ( AVNRT ) refractory to medical treatment ( n=38) and recurrent syncope ( n=3) underwent electrophysiologic ( EP ) study . In all patients dual AV-nodal physiology could be demonstrated during EP study and typical form of AVNRT ( mean heart rate 220/min) could be induced by programmed atrial stimulation . A steerable 7 F ablation catheter was placed at the inferoparaseptal region of the tricupid valve annulus close to the orifice of the coronary sinus with the intention to record a late fractionated local atrial electrogram during sinus rhythm . Starting at this point radiofrequency current ( 500 kHz ) with a target temperature of 70 °C was delivered with the intention to ablate the slow pathway . If a slowly accelerated junctional rhythm ( 120/min) occurred during energy discharge , programmed atrial stimulation was repeated . Otherwise radiofrequency current was delivered step by step up to a septal position next to the tricuspid valve annulus . Slow pathway ablation was defined as lack of evidence of dual AV nodal pathways during repeated atrial stimulation . Slow pathway modulation was defined as maximal one atrial echoimpulse after ablation . Results : The number of energy applications ranged from 1-19 ( median 6 ) . In 35/41 patients slow pathway ablation could be achieved ; in six patients the slow pathway was modulated . In none of the patients permanent high grade AV block was observed . During follow-up ( mean 4.1 years ) two patients had a recurrent episode of AVNRT after slow pathway modulation . All other patients are still free of AVNRT without medical treatment . Conclusion : Selective radiofrequency current ablation/modulation of the slow pathway is a safe and curative treatment of AVNRT in young patients ."
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"Supraventricular tachycardias are the most frequent forms of symptomatic tachyarrhythmias in infants , children and adolescents . Clinical symptoms depend on age and underlying cardiac anatomy . Newborn babies and infants with paroxysmal atrioventricular reentrant tachycardias usually present with signs of congestive heart failure due to rapid heart rate . In older children and adolescents , palpitations are the leading symptom . Patients with chronic-permanent tachycardias ( i.e. , atrial ectopic tachycardia , permanent form of junctional reciprocating tachycardia ) often develop a secondary form of dilated cardiomyopathy , the so-called \" tachymyopathy \" . Adenosine has evolved as the drug of choice in any age group for the termination of atrioventricular reentrant tachycardia of any origin . In addition , it serves as a diagnostic tool in primary atrial tachycardias . Long-term management of atrioventricular reentrant tachycardia in infancy and childhood is age dependent . In newborn babies and infants , pharmacological therapy is advised due to the high spontaneous cessation rate of those tachycardias at the end of the first year of life . In contrast to this , the probability of spontaneous cessation of tachycardia in children > 1 year of age is very low . Therefore , radiofrequency catheter ablation of the anatomical substrate of the tachycardia is a rational alternative to long-lasting antiarrhythmic therapy . Results in children with a structurally normal heart are comparable to those achieved in adults . In patients with congenital heart disease and supraventricular tachycardias , catheter ablation during preoperative cardiac catheterization is recommended . Atrial reentrant tachycardias have been identified as one major risk factor for late postoperative morbidity and mortality in young patients . Pharmacological therapy is often not sufficient to control the tachycardia . In addition , underlying sinus node dysfunction may be aggravated in a considerable portion of the patients affected . Catheter ablation based on conventional endocardial mapping techniques by multipolar electrode catheters with the aim of identifying the critical region of the reentrant circuit is associated with an impaired success rate and a considerable recurrence rate . It may be assumed that , using the modern mapping techniques currently available ( electroanatomical mapping and non-contact mapping ) , results of radiofrequency catheter ablation of atrial reentrant tachycardias after surgical correction of congenital heart disease will be significantly improved within the next few years ."
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1951
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"Venous Thromboembolism develops as the result of multiple interactions between non-genetic and genetic risk factors . The most important non-genetic risk factors are age , tissue damage , oral contraception , pregnancy , obesity and lack of physical activity . Inborn factors predisposing to thrombosis are present in the majority of patients . These comprise defects affecting the anticoagulant pathways of blood coagulation like antithrombin III , protein C and protein S. Together these defects are found in 15-20% of thrombophilia families . The relatively rare defects of antithrombinIII , protein C and protein S stand in contrast to two common genetic polymorphisms of procoagulant molecules , factor V-Leiden , the most frequent cause for resistance to activated protein C , and the prothrombin 20210 A allele . Together , these anomalies are found in almost two third of the thrombophilia families . The identification of factor FV-Leiden and prothrombin 20210 A has allowed to examine in detail interactions between genetic and non-genetic risk factors of thromboembolism . The results of these studies indicate that many symptomatic individuals are endowed with more than one ( genetic and/or environmental ) risk factor . Thrombophilia thus represents an oligogenetic rather than monogenetic clinical phenotype , the expression of which is amplified by circumstantial risk factors . As a consequence of the \" multiple hit \" concept , the laboratory screening of thrombosis patients needs to include all of the known genetic risk factors even if the \" clinical \" situation seemingly provides sufficient \" explanation \" for a thrombotic event ."
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"In patients with progressive muscular dystrophy ( PMD ) invasive electrophysiologic studies can detect hidden intracardiac conduction disturbances . The aim of this study was a long-term follow-up of these patients . Twelve consecutive patients ( 9m , 3f , age 28 +/- 4 yrs ) without cardiac symptoms and with normal echocardiographic findings were included in the study . They suffered from different stages of PMD type Erb ( n=4), Becker-Kiener ( n=4), Duchenne ( n=2) and Landouzy-Déjerine ( n=2). At the beginning of the study all patients underwent an invasive electrophysiologic study ( EPS ) . The follow-up of 5.5 yrs included regular clinical visits , ECGs , and Holter recordings ( every 3 months ) as well as an echocardiography every 6 months . In 4 patients the EPS revealed a hidden interatrial conduction disturbance ( AHRS-ACS 120 +/- 18ms ) , and in 10 pts an infrahisian conduction disturbance was found ( HV max . 156 +/- 4ms ) . Conduction defects were seen independently from the type of PMD and the stage of the disease . During the follow-up the initially hidden interatrial conduction disturbance became evident in the surface ECG in 2 of 4 pts . One of them developed paroxysmal atrial fibrillation . Five of 10 pts with an initially hidden infrahisian conduction disturbance developed an AV block grade I-III and in one case additionally a bundle branch block . Four of these pts - whose PMD showed progression or who developed congestive cardiomyopathy - needed pacemaker implantation because of a first-degree AV block + bifascicular bundle branch block ( n=1), a Mobitz II second-degree AV block ( n=1) or a third-degree AV block ( n=2). None of the pts with normal findings at the EPS showed abnormal p-waves , an AV block , or an intraventricular conduction disturbance during the follow-up . We conclude that intracardiac conduction disturbances , especially infrahisian defects including high-degree AV blocks , are a common finding in pts with PMD . Therefore a regular cardiological screening including an ECG and a Holter recording is reasonable in these patients ."
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ZfuerKardiologie.00890599.eng.abstr | ZfuerKardiologie.00890599.eng.abstr | [
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"The number of women with congenital cardiac disease , who mature into adulthood is increasing . Unfortunately , there are no prospective data published about the relative risk of different forms of contraception for these patients . Most women with congenital cardiac disease can safely use oral contracetives , especially low-estrogen combination or progestin-only preparations , with the exception of those , who are at particular risk because of thrombembolic complications ( especially in cyanosis , pulmonary hypertension , Eisenmenger reaction , rhythm disturbances ) , fluid retention ( especially in reduced ventricular function and congestive heart failure ) , arterial hypertension ( important in coarctation ) , infectious complications ( endocarditis ) or hyperlipidemia . Oral contraceptives should be avoided in patients at increased risk for thrombembolic events . Intrauterine devices are very effective , have no metabolic side effects and merely cary a small risk of endocarditis . Newer devices containing progesterone only may put the patients at a still smaller risk . Contraceptive subdermal implants ( e.g. levonorgestrel ) are used with good results in the United States for patients with contraindications to estrogen-containing oral contraceptives and may well become more widely accepted in patients in Germany in the coming years . Barrier methods can be used , but have a higher failure rate , which may be inacceptable in patients at risk ( e.g. Eisenmenger's ) . Especially in Eisenmenger's , permanent sterilisation should be advised ."
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"Hypertrophic cardiomyopathy ( HCM ) is a myocardial disease with variable phenotpye and genotype . To demonstrate that the mutation Arg719Trp in the cardiac -myosin heavy chain ( MHC ) gene is a high risk factor for sudden death and can be associated with an unusual apical non-obstructive HCM , we report the case of a 61/2 year old boy , who suffered cardiac arrest . The proband had a de novo mutation of the MHC gene ( Arg719Trp) on the paternal MHC allele and a second maternally transmitted mutation ( Met349Thr), as was shown previously ( Jeschke et al. 1998 ( 11 ) ) . Here we report the clinical phenotype of the proband and of his relatives in detail . The proband had a marked apical and midventricular hypertrophy of the left and right ventricle without obstruction . There was an abnormal relaxation of both ventricles . Holter monitoring detected no arrhythmia . Ventricular fibrillation was inducible only by aggressive programmed stimulation . The boy died 31/2years later after another cardiac arrest due to arrhythmia . Five carriers of the Met349Thr mutation in the family were asymptomatic and had no echocardiographic changes in the heart , suggesting a neutral inherited polymorphism or a recessive mutation . It is concluded that there is an association of the mutation Arg719Trp in the -myosin heavy chain with sudden cardiac death in a young child . Disease history in conjunction with the genetic analysis suggests that the implantation of a defibrillator converter would have been a beneficial and probably life saving measure ."
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ZfuerKardiologie.00890620.eng.abstr | ZfuerKardiologie.00890620.eng.abstr | [
{
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"text": [
"Coronary anomalies are rare and usually benign . The case of a symptomatic woman aged 53 years is presented . Here the single coronary artery with a long left main trunk was treated by bypass grafting ."
],
"offsets": [
[
0,
202
]
]
}
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{
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"Background : It has been suggested that inflammatory processes play a role in the pathogenesis of acute coronary syndromes ( ACS ) . C-reactive protein ( CRP ) is a classic acute phase protein . It is yet unclear whether , in addition to established markers as troponin T ( TnT ) , determination of CRP in patients admitted for ACS contributes significantly to the diagnosis and prognosis of ACS . Patients and Methods : We investigated 50 patients with ACS ( 59.4 SD 13.9 years ) in the first hour after admission and 4-24h later with respect to TnT ( Elecsys , Roche Diagnostics ) and CRP ( biokit , modified Quantex CRP plus , analytical sensitivity 0.02mg/dL). Fifty percent of the patients were classified as having unstable angina retrospectively . All patients were followed in the 6 weeks post discharge regarding death and recurrent ACS . Results : The cumulative event rate at 6 weeks after discharge was 62.5% for patients being CRP and TnT positive compared to 35.3% in TnT positive and CRP negative patients . In TnT negative patients a positive CRP test predicted 33.3% of events and 28.8% of patients negative for CRP and TnT had events at 42 days post discharge . Logistic regression analysis regarding the primary endpoint including TnT and CRP ( 4-24h values ) , age , gender and diagnosis resulted in independent prediction of ACS or death by TnT ( cutoff 0.1µg/L, p=0.048, odds ratio=7.5) and CRP ( cutoff 0.862mg/dL, p=0.026, odds ratio=5.3). Sensitivity/specificity for AMI diagnosis were 69.6%/75% for TnT and 12%/72% for CRP in the first hour and 91.3%/68.2% for TnT and 68%/72% for CRP 4-24h later . Conclusions : Besides TnT , high sensitivity CRP determination has no additional value for early AMI diagnosis . The prognosis of these patients during the first 24 hours is significantly and independently predicted by CRP measurements in addition to troponin T."
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"Follow-up studies after stent implantation of native coronary arteries have reported reduced rates of angiographic restenosis . In contrast , stent implantation in the treatment of obstructive disease of coronary artery bypass grafts is complicated by higher restenosis rates . We sought to determine , if different predictors contribute to the high restenosis rate following stent implantation of coronary artery bypass grafts . We investigated long-term angiographic outcome of 205 stent implantations performed in 177 patients . Multivariate analysis correlated clinical , procedural and angiographic variables with the incidence of angiographic restenosis defined as diameter stenosis > 50% at follow-up . Angiographic restenosis was observed in 34% of lesions treated . Multiple logistic regression analysis defined diabetes mellitus ( OR 6.89 , CI2.41-9.69), graft recanalization ( OR 2.69 , CI 1.08-6.63), lesion at the aortic anastomosis ( OR6.98, CI2.76-19.25), lesion at the coronary anastomosis ( OR 2.95 , CI1.18-7.49), high diameter stenosis after stent placement ( OR 7.01 , CI 2.64-15.71), placement of long stents ( OR2.78, CI1.11-7.36) and implantation of more than one stent ( OR7.34, CI2.08-20.15) as independent predictors of graft in-stent restenosis . Critical consideration of these variables may help to identify patients who are poor candidates for stent implantation and who may benefit from different interventional approaches ."
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ZfuerKardiologie.00890682.eng.abstr | ZfuerKardiologie.00890682.eng.abstr | [
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"Background : Na+-Ca2+ exchanger ( EXCH ) is an important regulator of intracellular calcium homeostasis . To maintain a normal intracellular Ca2+ concentration , EXCH expression may be upregulated before the onset of end-stage heart failure . We tested for a correlation between the EXCH transcription level and the degree of myocardial dysfunction as well as the suitability of EXCH transcription as a molecular marker for early detection of a transition from adequate to inadequate myocardial adaptation to chronic pressure and/or volume overload in valvular heart disease ( VHD ) . Methods : The level of EXCH transcription was analyzed in myocardial biopsies from eleven patients with aortic stenosis ( AS ) , five with aortic regurgitation ( AR ) and six with primary mitral regurgitation ( MR ) of different hemodynamic severity and myocardial impairment using the quantitative rt-PCR technique . In addition , endomyocardial tissue from thirteen explanted hearts with end-stage heart failure and biopsies from seven individuals without heart disease were investigated . Results : The mean level of EXCH transcription in patients with AS was : 1.8 +/- 1.4amol/ng total RNA , with AR : 1.9 +/- 0.8amol/ng and with MR : 2.2 +/- +2 . 1 amol/ng . This was not from different controls ( 2.6 +/- 1.2 amol/ng total RNA ) . However , in myocardium from end-stage heart failure , EXCH transcription was increased fourfold amounting to 8.9 +/- 1.9amol/ng total RNA . No difference in the EXCH transcription was found in VHD with respect to the degree of myocardial dysfunction : cardiac index ( CI ) > 3.5l/min/m2 ( EXCH 1.4 +/- 1.1amol/ng total RNA ) ; CI 3.5-2.4 ( EXCH 2.5 +/- 1.8 ) ; CI 2.4 ( EXCH 1.8 +/- 1.0 ) ; EF-angio > 50% ( EXCH 1.9 +/- 1.8 ) ; EF-angio =50% ( EXCH 1.9 +/- 0.9 ) ; EF-RNV > 50% ( EXCH 2.4 +/- 1.8 ) , EF-RNV =50% ( EXCH 1.7 +/- 1.0 ) . Conclusion : Myocardial EXCH transcription does not change parallel to the degree of myocardial dysfunction in VHD . Consequently , myocardial EXCH transcription does not appear to be suitable as a parameter indicating the transition from adequate to inadequate myocardial adaptation to chronic volume and/or pressure overload ."
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"The administration of GP IIb/IIIa antagonists has been shown to be effective in reducing myocardial infarction and cardial death when given before PTCA . This prospective study was performed to determine the efficacy of abciximab in a bail-out situation to manage threatened or acute vessel closure . Methods : Acute or threatened vessel closure was observed in 104 ( 5.5% ) out of 1903 consecutive patients treated with PTCA in our institution . Of the 104 patients 46 ( 44% ) were treated for unstable angina ( CCS IV ) . Abciximab was administered in bail-out situations in a dosage of 0.25mg/kg given as a bolus , which was followed by an intravenous infusion of 10µg/min over 12 hours . Repeat PTCA was performed shortly after the administration of the abciximab bolus . After the procedure , the sheathe was left in place and control angiography was carried out 24 h later . Results : In 100 of the 104 patients TIMI flow III could be restored by abciximab therapy and RePTCA . In 4 patients an additional stent implantation was necessary due to persistent flow limitation . One day post PTCA , early follow-up angiography demonstrated patency of all vessels except two . In-hospital events occurred in 4 patients . Three of these patients underwent emergency CABG due to subacute vessel closure a few hours after PTCA and died during or directly after surgery . Follow-up after one year included clinical status and control angiography of the target vessel . During long-term follow-up , MACE occured in 15 patients ( 2 MI , 8 CABG and 5 RePTCA ) . Conclusion : The results of this prospective trial demonstrate the efficacy of abciximab therapy in bail-out situations occurring during or early after PTCA . The use of abciximab in bail-out situations appears clinically beneficial . Further studies have to compare the efficacy of this approach with prophylactic abciximab treatment ."
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ZfuerKardiologie.00890747.eng.abstr | ZfuerKardiologie.00890747.eng.abstr | [
{
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"To explore the relationship between coronary artery disease and renal vascular disease , we performed renal arterial angiography in 609 patients undergoing coronary angiography for suspected coronary artery disease . We defined renal artery stenosis as nonsignificant ( 40% ) , borderline ( 40-60% ) and significant ( > 60% ) . One-hundred fifty-two patients had renal artery stenosis , while 457 did not . Two-hundred and ten patients had no coronary disease ; of these , only 9 had renal artery stenosis . On the other hand , the 143 patients with renal artery stenosis , when subdivided , had similar degrees of coronary disease ; three vessel disease was significantly more common than one or two vessel disease in all groups . Renal artery stenosis of all severity degrees was associated with common atherosclerotic risk factors . However , hypertension was not a clue to the presence of renal artery stenosis . To evaluate the effect of percutaneous revascularization on hypertension and renal function all 51 patients with significant renal artery stenosis were treated by primary stent implantation and were follwed up for 6 months . Stent implantation showed a marked decrease in systolic and diastolic blood pressure ( 163 +/- 30 to 145 +/- 17 and 93 +/- 18 to 83 +/- 10 mmHg ; p=0.008) with a decrease in the amount of antihypertensive medication but without beneficial effect on serum creatinine during follow-up ( 1.46 +/- 0.70 mg/dl to 1.39 +/- 0.58 mg/dl , p=ns). We conclude that renal artery stenosis of any severity is strongly suggestive of three vessel coronary artery disease . The fact that renal stenting lowers blood pressure decreases antihypertensive drugs and increases medication flexibility in patients with coronary artery disease would support the notion of revascularization in patients with significant stenoses ."
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"Endoaneurysmorrhaphy ( EAR ) in postinfarct ventricular aneurysms leads to excellent short-term results . However , the temporal response of EAR is widely unknown . Thus , the indication for surgical treatment of patients with ventricular aneurysms is not well defined . EAR was performed in 157 patients ( 6/1993-6/1999 ) with symptomatic ventricular aneurysms ( median NYHA III ) . Factors influencing cardiac mortality and morbidity during follow-up were determined by univariate and multivariate analysis . Perioperative mortality was low : 5% . Mortality during follow-up was 3.3% per year , resulting in a 5-year survival rate of 78% . NYHA classification ameliorated significantly from the preoperative status compared to the follow-up period ( median NYHA II ; p 0.001 ) . Multivariate analysis identified preexisting arterial occlusive disease and advanced age ( > 70 years ) as significant factors influencing medium-term mortality . Implantation of the left internal mammary artery was associated with a better survival rate . Endoaneurysmorrhaphy can be performed with low perioperative mortality , will result in a significant amelioration of the cardiac clinical status and offers low medium-term mortality . Our data indicate that EAR seems to be the procedure of choice for patients with symptomatic ventricular aneurysms ."
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"Treatment of tachycardic atrial fibrillation ( AF ) is difficult in patients with congestive heart failure because many drugs which exert negative dromotropic effects ( beta-blockers , calcium channel antagonists ) may depress ventricular contractility and/or decrease arterial blood pressure . We have identified 2 intravascular sites in the superior ( SVC ) and inferior vena cava ( IVC ) where parasympathetic nerves , which innervate the atrioventricular node , can be stimulated electrically . In 8 dogs , a 7-F catheter with an expandable electrode basket at its tip was non-fluoroscopically positioned in the SVC and in the proximal IVC ( time for positioning : 3-5 minutes ) . High-frequency electrical parasympathetic stimulation ( PS ) with 20 Hz at an impulse duration of 0.1 ms was performed during pacing induced AF . Results : With increasing stimulus strength , a graded ventricular rate slowing was observed during PS in the SVC and IVC ( P 0.01 , ANOVA ) . The negative dromotropic effect started instantaneously after onset of PS and ceased immediately after termination of PS . During ventricular pacing at a constant rate , no decrease of the arterial blood pressure was observed during PS . PS in the IVC yielded significantly lower stimulation thresholds than in the SVC . Conclusions : Transvenous parasympathetic stimulation for ventricular rate control during AF can easily be achieved in the SVC and IVC in dogs . This procedure may provide a foundation for investigating the usefulness of PS in humans . If the results translate to patients , PS may be very beneficial in the treatment of AF in patients with congestive heart failure ."
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"The majority of cardioverter/defibrillator ( ICD ) implantations are currently performed with a non-thoracotomy approach . From November 1993 to January 1995 , 46 patients underwent implantation of a PCD 7219C with an \" active-can \" lead configuration at our institution . While the chronic stability of the defibrillation threshold ( DFT ) for an epicardial lead system is well established , the results are still inconsistent for non-thoracotomy lead systems . Accordingly , the aim of the present study was to compare the acute and chronic defibrillation thresholds of the ICDs implanted with an \" active-can \" lead system in order to assess the chronic stability of these systems . The defibrillation energy requirements were measured at implant , prior to hospital discharge , three , six and twelve months after implantation of the defibrillator . The patient group consisted of 8 females and 38 males with a mean age of 57.2 years . The mean left ventricular ejection fraction was 43.8% . The most frequent underlying heart disease was coronary artery disease in 31 of 46 patients . Eight patients had idiopathic dilated cardiomyopathy . In 39 of 46 patients , the defibrillation threshold could be successfully determined at all 4 time points after implantation . The mean defibrillation energy requirement at the time of implantation was 9.2 +/- 5.9 Joules ( J ) . The subsequent mean energy requirements were 7.6 +/- 4.8 J at pre-hospital discharge , 8.6 +/- 5.7 J at the 3 month , 8.1 +/- 6.0 J at the 6 month and 8.6 +/- 5.8 J at the 12 month follow-up visits . The mean defibrillation threshold was lowest at the time of prehospital discharge , significantly lower than at the time of initial implantion ( p=0.021). However , at all later time points up to one year , there was no significant difference in the DFT as compared with the time of initial implantation . Comparing the DFT at the time of implantation and the DFT at all other time points , there were no significant differences ( 9.23 vs. 8.56 J , p=0.291). Although there was an initial decrease in the DFT at seven to ten days , the long-term stability of the DFT up to one year remained stable in the devices with the \" active-can \" lead system ."
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"Late postoperative arrhythmias are a common problem associated with significant morbidity following Fontan operations . We analyzed in our patients whether age at the time of a modified Fontan procedure ( total cavopulmonary connection ) has an influence on the frequency of late postoperative arrhythmias . We examined all 66 long-term surviving patients who underwent a total cavopulmonary connection ( TCPC ) in our center during a nine year period . At the time of TCPC , 31 children were younger ( group I ) and 35 children were older than 4years ( group II ) . The follow-up period was almost identical in both groups ( group I : 4.29 years , group II : 4.52 years ) . We evaluated all ecgs performed at maximum intervals of 6 months and all Holter ecgs performed at intervals of 12 months . Atrial tachyarrhythmias ( supraventricular tachycardias , atrial flutter ) were registered in six patients ( 9% ) . All of these patients belonged to group II ( 17% ) . Ventricular arrhythmias ( couplets , ventricular tachycardia ) were found in 3% of the younger and 17% of the older patients . Abnormalities of sinus node function were registered in equal frequency in younger and older children ( group I : 35% , group II : 31% ) , while pauses with a duration of > 2s where present only in older children ( group II : 14% ) . Pacemaker implantation or antiarrhythmic therapy became necessary in 10/66 patients ( 15% ) affecting none of the children who underwent the TCPC 4 years ( group I ) but 10/35 children ( group II ) who underwent the TCPC at an older age ( 29% ) . According to our findings in the medium-term follow-up after TCPC , atrial tachyarrhythmias and complex ventricular arrhythmias are registered less frequently in children who underwent the modified Fontan procedure at an age of less than 4years . Although further studies will have to show whether these differences persist in the long-term follow-up , these findings represent an additional argument for the elective performance of modified Fontan operations at an age of less than 4 years ."
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"The current approach for the assessment of myocardial perfusion using contrast echocardiography involves black-and-white gray scale imaging in b-mode . For better appreciation of perfusion abnormalities , off-line postprocessing techniques including color encoding are used . In this study , we examined whether we could exploit the contrast microbubble response to high ultrasound amplitude - the phenomenon of stimulated acoustic emission - that could be recorded with harmonic power Doppler ( HPD ) in color to identify myocardial perfusion defects . To assess the potential of HPD , we occluded branches of the left coronary artery for 2-3h followed by 1h reperfusion in 10 dogs . After transvenous administration of the new air-filled contrast agent SHU 563A , echocardiographic imaging was performed with ECG-triggered harmonic b-mode ( HBM ) and the harmonic power Doppler ( HPD ) approach in different short ( SAX ) and long axis ( LAX ) views . Post-mortem TTC staining was performed to verify infarction . HBM , HPD and TTC data were analyzed by independent observers . During coronary occlusion , HPD with SHU 563A showed perfusion defects in 10 dogs in all SAX and LAX views . HBM demonstrated perfusion defects in all dogs in SAX and in 8 dogs in LAX . The correlation of perfusion defect size between HPD and HBM images was good ( SAX : r=0.9, p 0.001 , LAX : r=0.7, p 0.01 ) . One hour after reperfusion , both HPD and HBM showed perfusion defects with SHU 563A in 7 dogs . Five dogs showed TTC evidence of infarction . Perfusion defect size by HPD correlated well with residual infarct size ( r=0.8, p 0.01 ) , while defect size by HBM showed poor correlation ( r=0.3, p=ns). Myocardial contrast echocardiography with HPD and contrast agent SHU 563A identifies perfusion defects in acute coronary occlusion as reliably as HBM . After reperfusion HPD and SHU 563A accurately portray the site and size of residual myocardial infarction on line , in color . This approach has excellent potential for clinical application ."
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"Myocardial stunning ( contractile dysfunction in the presence of normalized perfusion ) and myocardial hibernation ( contractile dysfunction matching reduced perfusion ) have represented separate concepts of viable , but dyssynergic myocardium in the past . However , in vivo experimental and clinical work suggests that repetitive ischemia due to coronary artery disease may induce a gradual transition between stunned and hibernating myocardium . Myocardial hibernation itself can result from a spectrum of ischemic conditions ranging from impaired myocardial blood flow reserve to frank hypoperfusion . With increasing severity and duration of ischemia , degeneration of cardiac myocytes , accumulation of glycogen and cell death ensue . Additonally , there is an increase of extracellular matrix protein content leading to reparative fibrosis , which in turn limits functional recovery . In the light of these structural features , the available methods for detection of viable myocardium , in particular dobutamine echocardiography and nuclear imaging techniques , offer complementary rather than contradictory information . Dobutamine echo has satisfactory sensitivity , excellent specificity , and high diagnostic accuracy for the detection of viable dyssynergic myocardium . While in the past only its predictive accuracy for segmental recovery has been validated , newer data show an improved survival after revascularization if at least four viable dyssynergic left ventricular segments in a 16 segment model can be identified by dobutamine echocardiography . The complete ( low and high dose ) dobutamine protocol can elicit several types of contractile responses ( sustained improvement in contraction or monophasic response , biphasic response , new wall motion abnormality ) which should be interpreted in view of other clinical data including a previous infarction . The test protocol can be used safely at the end of the first week after myocardial infarction . If ischemia or viability is documented , revascularization should be performed promptly . A similar strategy should be followed in the setting of chronic coronary heart disease with left ventricular dysfunction . Since the structural changes of hibernating myocardium are progressive , time to revascularization is critical . On the other hand , responsible therapeutic planning requires proof of ischemia or viability before initiating a potentially hazardous revascularization procedure ."
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ZfuerKardiologie.00890932.eng.abstr | ZfuerKardiologie.00890932.eng.abstr | [
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ZfuerKardiologie.00890939.eng.abstr | ZfuerKardiologie.00890939.eng.abstr | [
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"Radiofrequency catheter ablation is the treatment of choice in atrioventricular nodal reentrant tachycardia . Electrophysiologic investigations in 623 patients revealed eight mechanisms of tachycardia ablation : Ablation of fast ( I ) or slow ( II ) , modification of fast ( III ) or slow AV nodal pathways ( IV ) , modification of both pathways ( V ) , ablation of fast and modification of slow ( VI ) , ablation of slow and modification of fast pathways ( VII ) and ablation of both pathways ( VIII ) . The criteria of diagnosis of these eight mechanisms of tachycardia ablation are described . Follow-up showed fewer relapses in patients with ablation ( 0-2% ) in comparison to patients with modification of a single AV nodal pathway ( 8-12% ) . Alteration of both pathways includes an increasing risk of total AV nodal block , which occured in 7 patients ( 1.1% ) . Detailed analysis of the mechanism of catheter ablation is recommended in all patients after radiofrequency current delivery for AV nodal reentrant tachycardia to estimate the risk of relapsing during follow-up or development of total AV block in the particular patient in case of a further ablation procedure ."
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ZfuerKardiologie.0089iii128.eng.abstr | ZfuerKardiologie.0089iii128.eng.abstr | [
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"Antiarrhythmic drugs can be divided into four Vaughan Williams classes ( I-IV ) according to defined electrophysiological effects on the myocardium . Thus , the Vaughan Williams classification also co-incides with the main myocardial targets of the antiarrhythmics , i.e. , myocardial sodium- , potassium- , and calcium-channels or -adrenergic receptors . A more detailed characterization which is also based on the myocardial targets of a drug is given by the \" Sicilian Gambit \" approach of classification . Nevertheless , the appropriate drug for the management of a given clinical arrhythmia has to be chosen according to the electrophysiological effects of the respective drug . A main determinant of the antiarrhythmic or proarrhythmic properties of a drug is the frequency dependence of its electrophysiological effects . The sodium-channel blockade induced by class-I substances is enhanced with increasing heart rates . Thus , class-I antiarrhythmics can be subclassified as substances showing a more exponential , an approximately linear , or rather saturated block-frequency relation . Class-III antiarrhythmics ( potassium-channel blockade ) can be further differentiated according to the component of the delayed rectifier potassium current ( IK ) which is inhibited by a drug . Class-III drugs inhibiting selectively the rapidly activating and deactivating IKr component exhibit a marked reverse rate dependence , i.e. , the drug induced prolongation of the cardiac action potential is minimized at high rates . O the other hand , during bradycardia the pronounced action potential prolongation may cause early afterdepolarizations and triggered activity leading to torsades de pointes arrhythmias ( acquired QT syndrome ) . Class-III substances inhibiting the slowly activating IKs component are currently under investigation and are expected to show a direct rate dependence . Experimental data available so far point to an action potential prolonging effect at least independent of rate . However , it is uncertain whether proarrhythmic effects can be thus avoided , especially in light of the fact that one form of congenital QT syndrome ( LQT1) seems to be linked to dysfunction of the IKs-channel ."
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"Persistent atrial fibrillation ( AF ) is associated with shortened action potential duration ( APD ) and reduced atrial refractoriness . Remodeling of ion currents responsible for AP morphology has been proposed as a major mechanism in persistent AF . In the present study we investigated the activity of the cardiac L-type Ca2+ channel and the mRNA transcription of the cardiac L-type Ca2+ channel subunits in patients with persistent AF compared to patients in sinus rhythm ( SR ) . Right atrial appendages of 10 patients in SR and of 5 patients with AF were used for myocyte isolations to record L-type Ca2+ currents ( ICa , L ) by the patch-clamp technique . Right atrial appendages of 16 patients in SR and of 5 patients with AF served as sources for determining the mRNA expression of the L-type Ca2+ channel 1c-, 2/- , a- , and b/c-subunits by semiquantitative RT-PCR . ICa , L density was reduced by 70% ( p 0.001 ) in AF patients compared to the sinus rhythm group . Cell sizes , expressed as cell capacitance , were identical in both groups . mRNA expressions of the 1c-subunit and the b/c-subunits were reduced in AF patients by 18.9% ( p 0.05 ) and 77.7% ( p 0.005 ) , respectively , while mRNA transcriptions of the 2/- and the a-subunits were not significantly different between SR and AF patients . A decrease in the availability of functional L-type Ca2+ channels in AF patients , due to reduced 1c-subunit and substantial lack of b/c-subunit transcription seems to contribute to the shortening pf APD and refractory periods in AF , thereby favoring increased atrial excitation rate and perpetuation of AF ."
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"Acute myocardial infarction ( AMI ) remains a leading cause of morbidity and mortality in the developed countries . Thrombotic occlusion of a coronary artery has been shown to cause acute myocardial infarction in over 90% of the cases . Early and complete restoration of bloodflow in the infarct-related coronary artery is the principal mechanism by which reperfusion therapy improves outcomes in patients with acute myocardial infarction . Thrombolytic therapy has been shown to reduce mortality when given early after symptom onset . However , even the most effective , approved thrombolytic regimens achieve normal ( so-called TIMI 3 ) flow in the infarct vessel at 60-90 minutes only in about half of the patients and reocclusion occurrs in 5-10% . Bleeding events , especially intracranial bleedings , observed in up to 1% of the patients , are the most severe complication of thrombolysis . Primary percutaneous transluminal coronary angioplasty ( PTCA ) is associated with somewhat higher patency rates and significantly fewer strokes than thrombolysis , but confers a reocclusion rate of about 5-10% and it is not universally available . While smaller randomized studies suggested a significant advantage of PTCA over thrombolysis , these results could not be confirmed in the larger GUSTO IIb angioplasty study in over 1000 patients and in non-randomized comparisons in large registries . Therefore , a general mortality advantage of PTCA over thrombolysis could not be demonstrated . Primary PTCA should be preferred in patients with contraindications against thrombolysis , patients with a high risk for intracranial bleedings ( age > 75 and high blood pressure on admission ) and hemodynamically unstable patients ."
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"Atherosclerotic changes of the carotid tree comprise changes of the wall structure , the wall stiffness , and local blood flow properties . They are associated with atherosclerotic changes in other arterial beds such as the coronary and cerebral arteries and with manifest atherosclerotic diseases . It has also been shown that they are at least in part potent predictors for future cardiovascular disease . Transcutaneous ultrasound of the carotid tree offers the possibility of detecting ahterosclerotic changes on a noninvasive basis . In the following , the different methods for the assessment of atherosclerotic changes of the carotid wall structure , wall stiffness , and local hemodynamics with noninvasive ultrasound are briefly reviewed . The combined assessment of all these arterial properties may increase the predictive value of noninvasive ultrasound in detecting early atherosclerosis in other arterial beds . However , more prospective studies are necessary to examine the possible value of increased wall stiffness , altered local hemodynamics , and the combined assessment of these parameters together with the assessment of arterial wall structure in this respect . Therefore , the current ultrasound methods for the measurement of structure , function , and hemodynamics has yet to be optimized for usage in routine medical examinations ."
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ZfuerKardiologie.0089vii60.eng.abstr | ZfuerKardiologie.0089vii60.eng.abstr | [
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ZfuerKardiologie.0089vii7.eng.abstr | ZfuerKardiologie.0089vii7.eng.abstr | [
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ZfuerKardiologie.0089vii85.eng.abstr | ZfuerKardiologie.0089vii85.eng.abstr | [
{
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"type": "abstract",
"text": [
"Thoracic organ transplantation has evolved as standard therapy in end-stage cardiac and pulmonary failure . Meanwhile more than 50.000 heart , 2500 heart-lung and 10.000 lung transplantations have been performed worldwide . Improvements in patient selection as well as in the postoperative management have led to 1-year survival rates of 70-90% . Long-term results are still influenced by the development of graft vessels disease , bronchiolitis obliterans syndrome and malignancies . Furthermore , indications and results of different procecures will be presented and new developments discussed ."
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"Atrial fibrillation is the most common arrhythmia in need of treatment in clinic and practice . Nevertheless , many principles of therapy for the treatment of atrial fibrillation are based still at present on empirical principles but not on knowledge obtained in proved clinical trials . So far scientific data are not sufficient for therapy recommendation \" cardioversion or rate control \" . At present this quesion is examined in randomized clinical trials ; however , the results will not be available until at least the year 2000. Currently , the therapy strategy ( cardioversion versus rate control ) is decided individually . Doing this the complaints of the patients and the principle \" nihil nocere \" mainly determine the decision ."
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