Anastomosis to the wrong vessel during off-pump bypass surgery via mini-thoracotomy.

Recently, minimally invasive coronary artery bypass graft operation has been established as a new treatment strategy for cardiac surgeons. We report on a patient who underwent off-pump coronary artery bypass graft operation through a mini-thoracotomy to the wrong coronary artery (first diagonal) with consecutive successful percutaneous transluminal coronary angioplasty of the vessel involved (left anterior descending coronary artery) to demonstrate a special risk that is associated with this kind of operation.

Long-term follow-up of global and regional left ventricular function by two-dimensional echocardiography after thrombolytic therapy in acute myocardial infarction.

In order to evaluate changes in left ventricular volumes and regional left ventricular function after thrombolytic therapy in acute myocardial infarction serial two-dimensional echocardiography was performed during a follow-up of 2 years in 206 consecutive patients treated with streptokinase and adjunctive angioplasty in a randomized group of patients. Unexpected progressive left ventricular enlargement was detected both with and without angioplasty. In anterior wall infarction, end-diastolic volume index increased from 55 +/- 14 to 91 +/- 28 ml/m2 (+65%, P < 0.01) and end-systolic volume index increased from 31 +/- 11 to 55 +/- 23 ml/m2 (+79%, P < 0.01), whereas ejection fraction decreased from 45 +/- 9 to 41 +/- 7% (-9%, P = NS). Averaged regional anterior wall motion improved during the first 4 weeks (11 +/- 10 to 16 +/- 12%), but subsequently deteriorated (16 +/- 12 to 10 +/- 6, P < 0.05). The number of segments with pathological wall motion increased. Similar volumetric and regional wall motion data were demonstrated in inferior wall infarction. We believe this reflects a chronic ventricular remodelling phenomenon. This process takes place predominantly during the first 3 months, but continues over the whole follow-up period. Forty percent of the patients suffered symptoms of heart failure on long-term follow-up. Attenuation of progressive ventricular enlargement remains a therapeutic challenge in the long-term care of these patients. Angiotensin-converting enzyme inhibitors are promising agents in this regard.

[Long-term follow-up of thrombolytic treatment of acute infarct in combination with acute and elective revascularization]. / Langzeitverlauf nach thrombolytischer Behandlung des akuten Infarktes in Kombination mit akuter und elektiver Revaskularisation.

From March 1983 to June 1986 in 206 patients with acute transmural myocardial infarction, combined intravenous and intracoronary therapy with streptokinase was initiated. After intravenous thrombolysis and randomization in two groups we performed a coronary angiography with selective intracoronary lysis. Infarct related vessels still occluded after intracoronary streptokinase application were opened mechanically in group I. In group II we performed additionally a percutaneous transluminal coronary angioplasty (PTCA) after mechanical recanalisation (occluded vessels) or after thrombolysis (open vessels). In 85 of 87 cases in group II, PTCA could be performed in the acute phase. Elective PTCA was performed in 22 patients of group I (21%) and in nine patients of group II (9%). Up to five years after myocardial infarction, coronary artery bypass grafting (CABG) was necessary in 22 patients (21%) of group I and in 23 patients (22%) of group II. Within four weeks after infarction CABG was performed in 32% and 17% of group I and II respectively. The six-year survival rate was 78% in group I and 82% in group II. Taken all patients together, the six-year survival rate was significantly higher (p = 0.002) for those with early reperfusion (less than or equal to 3.5 h). The survival rates of CABG-patients, PTCA-patients and patients without reperfusion were 91%, 74% and 65% respectively. Streptokinase thrombolysis results, combined with acute or elective PTCA and/or coronary bypass surgery, in a high six-year survival rate after acute transmural myocardial infarction. This rate is about 20% higher than ten years ago.

Echocardiographic and angiographic evaluation of left ventricular function during percutaneous transluminal aortic valvuloplasty.

Transesophageal echocardiography was used to study the effect of the balloon inflation on left ventricular function in 20 patients with critical aortic stenosis undergoing balloon valvuloplasty. Balloon inflation caused an increase of end-diastolic (15% to 34%) and end-systolic (57% to 72%) left ventricular volume. Left ventricular wall stress increased from 30 +/- 10 x 10(3) dyn/cm2 at diastole and 121 +/- 40 x 10(3) dyn/cm2 at systole to 44 +/- 11 x 10(3) dyn/cm2 and 191 +/- 55 x 10(3) dyn/cm2, respectively, when the balloon was inflated (P less than 0.05). Turbulent regurgitant jet across the mitral valve increased from 15 +/- 2% to 25 +/- 3% during balloon inflation (P less than 0.01). Continued monitoring of left ventricular function after balloon deflation demonstrated prolonged enlargement of left ventricular volumes. Our data show that balloon inflation causes an increase of left ventricular volume and impairment of contraction. Increase of left ventricular wall stress--associated with a reduction of coronary blood flow, due to lower aortic pressure--could result in ischemic myocardial injury.

Detection of dissection of the aortic intima and media after angioplasty of coarctation of the aorta. An angiographic, computer tomographic, and echocardiographic comparative study.

Balloon coarctation angioplasty (BCA) was performed in eight patients (five male and three female) who were 14-49 years old (mean, 27.3 years) with isolated discrete unoperated coarctation of the aorta (n = 7) and postoperative recoarctation (n = 1). BCA was successful in seven of eight patients, resulting in a decrease in the gradient (64 +/- 19 to 16 +/- 13 mm Hg, p less than 0.01), an increase in the diameter at the coarctation site (0.9 +/- 0.4 to 1.6 +/- 0.4 mm, p less than 0.01). Follow-up (6 months) has demonstrated continued gradient relief (6 +/- 9 mm Hg) and diameter increase (1.6 +/- 0.2 cm). Monitoring was performed by transesophageal echocardiography (TEE) during BCA, and before and after BCA angiography and after BCA computed tomography. In three of seven patients, immediately distal to the BCA site, intimal flaps (1-2 cm) could be detected by TEE but not by angiography or computed tomography. Follow-up TEE showed spontaneous healing in two and persistence in one patient. By TEE and computed tomography in one of eight patients during follow-up, intima and media dissection was found with pleural effusion and spontaneous healing. In one female patient, aortic dissection occurred after successful uneventful BCA, detected by TEE at the 6-month follow-up study and subsequently confirmed by biplane angiography, not detected by computed tomography and previous monoplane angiography. Because of the significant morbidity of BCA in this group of patients, its role in the management of adults with coarctation has yet to be determined. Further long-term follow-up studies will demonstrate whether the observed intima and media dissection by TEE after BCA are related to aneurysm formation.

Additive effects of enoximone and nitroprusside in unstable chronic heart failure.

In the present study, the safety and efficacy of the combined administration of intravenous nitroprusside and oral enoximone, an experimental compound with phosphodiesterase inhibitory properties, were evaluated. Ten patients with unstable chronic heart failure maintained on digitalis and diuretics were selected to receive enoximone because of their poor response to intravenous nitroprusside. For a mean peak dose of 115 micrograms min-1 nitroprusside, cardiac index increased from 1.8 +/- 0.4 to 2.0 +/- 0.4 l min-1 m-2, while pulmonary artery diastolic pressure and mean right atrial pressure decreased from 29 +/- 6 to 24 +/- 5 and from 15 +/- 6 to 11 +/- 3 mmHg respectively; mean arterial pressure and heart rate were unchanged. The addition of 1.6 mg kg-1 oral enoximone t.i.d. to nitroprusside resulted in a substantial improvement of cardiac function: cardiac index increased further to 2.8 +/- 0.5 l min-1 m-2 (P less than 0.001), pulmonary artery diastolic pressure and right atrial pressure decreased to 18 +/- 5 and 7 +/- 3 mmHg (P less than 0.01), respectively, while mean arterial pressure rose from 90 +/- 11 mmHg to 95 +/- 0 mmHg (P less than 0.05); heart rate was unchanged. The salutary haemodynamic response to combined nitroprusside-enoximone therapy persisted for more than 32 h, and cardiac performance remained improved on enoximone for a further 8 h despite the discontinuation of nitroprusside. No serious side-effects or changes in the arrhythmia profile were observed. The addition of oral enoximone to nitroprusside has beneficial haemodynamic effects in unstable chronic heart failure.

[Detection of bone marrow embolism in femoral intramedullary nailing using transesophageal echocardiography]. / Nachweis von Markembolien während Oberschenkelmarknagelungen mittels transösophagealer Echokardiographie.

Cardiopulmonary complications are known in intramedullary nailing, especially of the femur. Transesophageal echocardiography now allow intraoperative detection of embolized bone-marrow, recognizable as reflecting particles in the right atrium. In intramedullary nailing of a femoral fracture with a closed distal fragment bone-marrow embolism was detectable in the right atrium during reaming of the medullary canal. This technique should permit further research on the pathophysiology of pulmonary alterations during intramedullary nailing and also testing the effectiveness of pressure-relief in the medullary canal as proposed by drilling a bone-hole.

[Percutaneous angioplasty of the stenotic aortic valve: results, hemodynamic effects and complications]. / Perkutane Angioplastie der stenosierten Aortenklappe: Ergebnisse, hämodynamische Auswirkungen, Komplikationen.

UNLABELLED: In 24 patients with aortic stenosis (13 men and 11 women, aged 47 to 80 years; mean age 67 years) a percutaneous angioplasty of the aortic valve was performed. The NYHA functional class improved in 20 patients. There was also a significant (p less than 0.01) decrease of the mean aortic gradient from 75.1 +/- 21.8 mm Hg to 45.3 +/- 11.7 mm Hg as well as an increase of the aortic valve area from 0.61 +/- 0.12 cm2 to 0.96 +/- 0.3 cm2. The end diastolic volume index decreased from 121.3 +/- 37.4 ml/m2 to 99.6 +/- 24.8 ml/m2 to the end diastolic volume index from 49.1 +/- 26.6 ml/m2 to 34.6 +/- 13.4 ml/m2 (both significant: p less than 0.01). The ejection fraction increased from 61.3 +/- 11.8% to 65.8 +/- 7.8% (p less than 0.05). Four patients presented a transient left bundle branch block. The corrected QT interval increased significantly (p less than 0.01) from 388.9 +/- 29 ms to 401.4 +/- 42.6 ms. Complications occurred in eight patients, being severe in three of them (one death from intractable internal hemorrhage, two cases of right sided hemiparesis). CONCLUSIONS: Percutaneous aortic valve angioplasty represents an alternative to the surgical procedure. In our patients there was not only an increase in the aortic valve area, but also an improvement in the ejection fraction. Nevertheless, unforeseeable complications may occur which obscure the results. In the future, widened experience and improved technique will reduce complications.

Enhanced postischemic ATP repletion by pharmacological inhibition of nucleoside washout and catabolism.

We tested the hypothesis that inhibition of adenosine transport by dipyridamole and inhibition of adenosine deamination by erythro-9-(2-hydroxy-3-nonyl)adenine (EHNA) prevents nucleoside loss and stimulates postischemic ATP-repletion. In an open chest canine model, dipyridamole (0.5 mg/kg/h) and EHNA (5 mg/kg/h) were infused intra-atrially during a coronary occlusion period of 45 min and a reperfusion period of 180 min. Transmural needle biopsies, obtained during the ischemic period and within the reperfusion period, were analyzed using high performance liquid chromatography for adenine nucleotides and adenosine, inosine, xanthine, and hypoxanthine as well as creatine phosphate. During ischemia and under the influence of dipyridamole plus EHNA, 56% of the catabolized adenine nucleotides were recovered stoichiometrically as adenosine, whereas in the untreated group less than 10% of the nucleotides were recovered as adenosine because of rapid deamination to inosine. In the control group, ATP levels decreased during ischemia from control values of 5.25 +/- 0.28 microns/g to 2.01 +/- 0.18 microns/g. In the group treated with dipyridamole and EHNA, ATP levels fell to 2.2 +/- 0.22 microns/g but rose to 3.22 +/- 0.29 microns/g within 180 min of reperfusion, whereas in the untreated control group tissue levels of ATP did not increase. However, a significant proportion of the adenosine accumulated during ischemia under the influence of dipyridamole plus EHNA was not used for the restoration of the ATP level during reperfusion. A significant amount of adenosine was probably trapped in the interstitial space and could not be transported back into the myocytes in the presence of dipyridamole during reperfusion. In both groups, creatine phosphate levels were restored to normal levels during reperfusion.

Combination of calcium channel blocker and thrombolytic therapy in acute myocardial infarction.

To evaluate the protective effect of nifedipine on ischemic myocardium, in addition to thrombolytic therapy, a total of 149 patients with acute myocardial infarction were included in a double-blind controlled study in which they received 20 mg sublingual nifedipine (74 patients in group 1) or placebo (75 patients in group 2) in the emergency ward, either intracoronary nifedipine, 0.2 mg before and 0.2 mg after reperfusion of the infarct-related vessel and 20 mg three times/day during the hospital stay, or placebo. Combined intravenous and intracoronary thrombolytic therapy was initiated by means of mechanical recanalization in nonreperfused vessels. There were no differences between group 1 and 2 with regard to age, sex, body weight, or location of infarct. Evolution of CK-MB release and cumulative CK-MB was higher in group 1 than in group 2. Changes with regard to regional and global left ventricular function and coronary anatomy were not significantly different (NS) between the two groups. Reocclusion occurred in 15 of 74 (20%) and 10 of 75 (13%) patients in groups 1 and 2, respectively. During the reperfusion period, second- and third-degree atrioventricular block occurred in 5.4% and 6.7% (NS), ventricular couplets in 17.6% and 24% (NS), ventricular tachycardia in 2.7% and 9.3%, and ventricular fibrillation in 2.7% and 8% of the patients, respectively. Mortality rates were 13% and 8%. The study demonstrates that even very early administration of nifedipine combined with intracoronary administration does not enhance the salvage of ischemic myocardium achieved by reperfusion.

[Coronary insufficiency in type II aortic dissection]. / Koronarinsuffizienz bei Aortendissektion Typ II.

After coronary sclerosis, aortic dissection represents an important differential diagnosis in the evaluation of acute thoracic pain. We report on a 55-year-old patient with aortic dissection, type II, in whom the diastolic collapse of the true aortic lumen was verified by angiography and transesophageal echocardiography. The collapse led to a temporary perfusion deficit of the left coronary artery with clinical symptoms and ECG changes. Clinical symptoms, additional diagnostic procedures and follow-up of this patient, as well as the value of transesophageal echocardiography, are presented.

Influence of repetitive coronary occlusions on myocardial adenine nucleosides, high energy phosphates and ultrastructure.

We compared the effects of repeated short periods of myocardial ischemia with those of permanent occlusion (canine open-chest) with regard to tissue content of adenine nucleotides, nucleosides, creatine phosphate, and ultrastructure. Coronary occlusion for 3 min followed by a reperfusion period of 7 min was repeated up to a cumulative occlusion time of either 45 or 90 min. After cumulative occlusions of 15, 30, 45, and 90 min, transmural needle biopsies were taken from the ischemic area to be analyzed for adenine nucleotides, nucleosides, creatine phosphate, and ultrastructural changes. At the end of each experiment, tetrazolium salt staining was used for macroscopic detection of myocardial necrosis. These data were obtained with those obtained from dogs with a permanent coronary occlusion of 45 and 90 min, respectively. After repeated coronary occlusions at a cumulative occlusion time of 45 min, macroscopic detection of necrosis was negative, and after 90 min of cumulative coronary occlusion, patchy subendocardial tissue necrosis was found in only one out of 13 dogs, whereas in the group with permanent coronary occlusion, small patchy subendocardial necrosis was found in 95% after 45 min, and after 90 min permanent coronary occlusion, large subendocardial necrotic areas spreading towards the epicardial layers were found in 90% of the hearts. Ultrastructural investigations showed only slight to moderate ischemic injury after 45 and 90 min intermittent coronary occlusion, whereas permanent coronary occlusion produced moderate to severe ischemic injury after 45 min; and 90 min permanent coronary occlusion produced irreversible ischemic injury in all subendocardial tissue samples and in 80% of the subepicardial tissue samples.(ABSTRACT TRUNCATED AT 250 WORDS)

Balloon coronary angioplasty in patients with acute myocardial infarction.

After successful thrombolysis, approximately 75% of all patients will have significant coronary stenosis, which can be dilated by means of percutaneous transluminal balloon angioplasty (PTCA). In a randomized control study, 95 of our patients (Group I) had thrombolysis alone, whereas 95 others (Group II) had thrombolysis and PTCA. Both groups were comparable with respect to age, sex, infarct location, and maximal creatine kinase (CK) value. The clinical outcome during the hospital phase was better in Group II, which had a reocclusion rate of 13%, a reinfarction rate of 5%, a lethal reinfarction rate of 2%, and a cardiac death rate of 7%, compared with respective rates of 20%, 13%, 7%, and 13% in Group I. Furthermore, in Group I, residual coronary stenosis immediately after thrombolysis (75% +/- 20%) did not improve significantly until the end of the hospital phase, when it decreased to 69% +/- 21%. In Group II, stenosis (78% +/- 16%) was improved by PTCA to 33% +/- 21%, and this improvement remained constant during the hospital phase (30% +/- 26%). In Group-II patients who had an unsuccessful PTCA, stenosis was approximately the same before dilatation (83% +/- 12%), after dilatation (80% +/- 17%), and at the control study (83% +/- 17%). The end-diastolic, end-systolic, and stroke volume indices, as well as the ejection fraction, also remained unchanged. In Group I, the number of pathologic wall segments (12.2 +/- 5.0) did not improve during the hospital phase (12.2 +/- 7.9), but in Group II, the improvement was significant (14.0 +/- 5.7 vs. 10.9 +/- 8.2) (p < 0.05). PTCA seems to improve the clinical outcome, reduce the infarction and mortality rates, and enhance myocardial perfusion and performance.

Influence of beta-aminopropionitril on media hypertrophy and baroreceptor reflex in normotensive and hypertensive rats.

Experiments were performed to investigate the antihypertensive action of beta-aminopropionitril (BAPN) in normotensive and hypertensive rats and to elucidate the role of media hypertrophy and arterial wall distensibility on baroreceptor reflex and blood pressure (BP) regulation. Normotensive Wistar-Kyoto rats (WKY), DOCA-salt hypertensive WKY, and stroke-prone spontaneously hypertensive rats (SHRSP) were treated with BAPN (100 mg/kg per day, intraperitoneally) for 10 weeks. The respective control groups (n = 10 per group) received 0.9% NaC1 instead of BAPN. In BAPN-treated groups the BP of DOCA-salt WKY (145 versus 170 mmHg) and SHRSP (170 versus 208 mmHg) was lower than that of controls at the end of the treatment period. In BAPN-treated rats, the medial cross-sectional area was reduced, postmortem distensibility of vascular wall was greater, and baroreceptor reflex, estimated from heart rate responses to BP changes, showed steeper regression curves. The BAPN-induced BP decrease in the hypertensive rats demonstrates that the level of sensitivity of the baroreceptor reflex is related to the mechanical properties of the arterial wall.

Percutaneous transluminal coronary angioplasty after thrombolytic therapy: a prospective controlled randomized trial.

In 162 patients with acute transmural myocardial infarction, combined intravenous and intracoronary thrombolytic therapy with streptokinase was initiated. In vessels that remained occluded, mechanical recanalization was performed with a 3F recanalization catheter (group I, n = 79) or a 4F Grüntzig balloon catheter (group II, n = 83). After reperfusion, intracoronary streptokinase was administered superselectively. After termination of streptokinase infusion, angioplasty was performed only in patients in group II. There was no difference between the groups in relation to sex, age, infarct location, creatine kinase levels and time between onset of symptoms and start of treatment. Initial coronary angiography showed an open vessel in 27 (34%) of 79 patients in group I and 21 (25%) of 83 patients in group II. The final reperfusion rate was 90% (71 of 79) in group I and 86% (71 of 83) in group II. Angioplasty was attempted in 69 of the 71 patients in group II with a success rate of 65% and an occlusion rate of 3%. During the hospital stay, reocclusion occurred in 14 (20%) of 71 patients in group I. After thrombolytic therapy, coronary luminal narrowing in group I was 75 +/- 17% in patients without and 87 +/- 6% in patients with reocclusion (p less than 0.05). In group II, reocclusion was found in 10 (14%) of 71 patients. After angioplasty, the degree of coronary stenosis in group II was reduced from 82 +/- 12 to 51 +/- 30% (p less than 0.001). Reocclusion was found in 3 (7%) of the 45 patients with successful angioplasty and in 7 (32%) of the 22 patients with unsuccessful angioplasty (p less than 0.01). Improvement in regional left ventricular function was observed only in patients from group II with anterior myocardial infarction. In conclusion, by combined medical and mechanical recanalization, the rate of coronary reperfusion can be increased and infarct time shortened, providing the possibility of full revascularization by angioplasty, with improvement of regional wall motion and reduction of the rate of reocclusion.