[Papillary muscle rupture during stress ECG after myocardial infarct]. / Papillarmuskelriss während eines Belastungs-EKGs nach Myokardinfarkt.

The case of a 57 year old patient is reported, who suffered from an acute myocardial infarction with maximum CK and CKMB values of 821 and 84 U/l, respectively. The patient underwent bicycle exercise testing 9 days after a myocardial infarction in 25 W steps every 2 min starting with 50 W. The ergometry was interrupted at 125 W because of ST segment depression of 0.28 mV in V6. Systolic blood pressure dropped to 55 mm Hg, combined with severe angina and shock. Volume substitution and catecholamines did not elevate blood pressure. Immediate M-mode and Doppler echo revealed a "stiletto"-shaped mitral regurgitation profile typical of acute mitral valve insufficiency. The transesophageal echocardiogram showed a distinct mass moving between the left ventricle and left atrium, diagnostic of papillary muscle rupture. Despite of shock, mitral valve replacement was performed successfully. To our knowledge, this is the first report of a papillary muscle rupture during exercise testing after myocardial infarction. Papillary muscle rupture can be induced by exercise. This fateful event may not be predicted by the course of the ergometry. In case of hypotension during exercise, papillary muscle rupture should be considered. The diagnosis is to be established by transesophageal echocardiography.

[Emergency bypass operation after failed elective percutaneous transluminal coronary angioplasty]. / Notfallmässige Bypassoperation nach frustraner elektiver perkutaner transluminaler Koronarangioplastie.

This retrospective study was performed to evaluate the clinical and angiographic characteristics and the in-hospital complications after failed percutaneous coronary angioplasty (PTCA) that necessitates coronary artery bypass graft surgery (CABG). The study population consisted of 123 patients from January 1990 to December 1992. The failed PTCA was secondary to an acute occlusion of the dilated but dissected vessel in 36.5% of the study population. 43 patients (35%) had an emergency CABG due to hemodynamic instability and a large area of myocardium at risk for infarction. 93% of these patients had an acute closure of the dissected vessel. 19 patients (15%) were operated 24 hours after failed PTCA and 61 patients (49.5%) electively 3.8 +/- 1.1 months after PTCA. Mean time interval from the acute occlusion up to the establishment of the extracorporeal circulation (ischemic interval) was 70 +/- 9 min. in patients from our cardiological department and 136 +/- 14 min. in patients from external departments. Analysis of the surgical data revealed that neither a patient of the emergency group nor of the elective group needed the intra-aortic balloon pump. Overall 2.3 +/- 0.8 bypass grafts were placed, with increased use of the internal mammarian artery in the elective (57%) versus the emergency group (17%). Postoperative peak values of CK and CK-MB were significantly higher in the emergency group as compared to the patients operated 24 hours and electively after failed PTCA. Patients with an ischemic interval up to 70 min. had considerably lower CK and CK-MB values compared to patients with longer ischemic intervals.(ABSTRACT TRUNCATED AT 250 WORDS)

[Coronary stent implantation: infection and abscess with fatal outcome]. / Koronare Stentimplantation: Infektion und Abszedierung mit letalem Ausgang.

We report a case of coronary stent-implantation using a Palmaz-Schatz-stent in the right coronary artery (RCA) of a 66-year old woman. Coronary stenting was performed following local dissection and high-grade stenosis after PTCA. Following stent thrombosis re-PTCA was successful, but within 4 weeks progressive reduction of the patient's general condition, plus leucocytosis, subfebril temperatures, and a pericardial effusion occurred. Transesophageal echocardiography documented a perivascular myocardial abscess near the RCA stent; puncture demonstrated pericardial empyema. Emergency cardiac operation was done with segmental resection of the destructed RCA, stent explantation, and CABG to the peripheral RCA, but the patient died. To our knowledge, this is the first case of stent infection reported in the international literature. Transesophageal echocardiography was very helpful in diagnosing this fatal complication of coronary stenting.

[Prevention of pulmonary embolism using a vena cava filter and cava clip]. / Lungenembolie-Prophylaxe durch Vena cava-Schirm und Cava-Clip.

Surgical prophylaxis of pulmonary embolism by implantation of Vena-cava-filter (Greenfield) or Vena cava clip (Adams de Weese) was performed in 24 patients. The following indications were used: Recurrent pulmonary embolism under adequate anticoagulation, Pulmonary embolism in cases of contraindications to anticoagulation, Floating thrombus occurring late following deep vein thrombosis, After pulmonary embolectomy. In a retrospective study we recognized 0% recurrent pulmonary embolism, a vena cava occlusion rate of 4% and no clinically relevant signs of bilateral venous stasis in the lower limbs.