[New and established aspects of cardiological diagnostics using TEE : Do we need 3D technology in clinical routine?] / Neues und Bewährtes in der kardiologischen Diagnostik mithilfe der TEE : Wird die 3­D-Technik in der klinischen Routine benötigt?

In comparison to transthoracic echocardiography (TTE) transesophageal echocardiography (TEE) enables an acquisition of images with better spatial resolution due to the use of higher ultrasound frequencies. Thus, the morphology and function of cardiac structures can principally be analyzed better and more accurately with TEE than with TTE. In addition, using three-dimensional (3D) TEE data sets standardized sectional planes can be constructed by post-processing, which enables quantitative assessment of the target structures. The size and function of the left ventricle can objectively and reproducibly be measured. End diastolic left ventricular volume and total stroke volume of the left ventricle can be accurately determined in patients with heart valve disease. Furthermore, particular cardiac structures that cannot be totally evaluated by two-dimensional (2D) echocardiography, can be completely analyzed by 3D TEE. In 2D images for example, only analyses of the right coronary cusp of the aortic valve are possible because only the center of the right coronary cusp can be visualized using conventional sectional level presentation. Using 3D TEE the non-coronary cusp and the left coronary cusp can also be visualized in the mid-sectional plane by post-processing of the 3D data set. Additional important structures of 3D TEE analysis are the left atrial auricle, the interatrial septum and the mitral valve. Planimetry of valvular and regurgitation orifices as well as the monitoring of interventions for treatment of structural heart diseases are further fields of application of clinically established 3D TEE diagnostics.

[Alcohol and arrhythmias]. / Alkohol und Rhythmusstörungen.

The effects of alcohol on induction of arrhythmias is dose-dependent, independent of preexisting cardiovascular diseases or heart failure and can affect otherwise healthy subjects. While the probability of atrial fibrillation increases with the alcohol dosage, events of sudden cardiac death are less frequent with low and moderate consumption but occur more often in heavy drinkers with alcoholic cardiomyopathy. Men are first affected at higher dosages of alcohol but women can suffer from arrhythmias at lower dosages. Thromboembolisms and ischemic stroke can occur less often at lower dosages of alcohol; however, hemorrhagic stroke and subarachnoid hemorrhage are increased with higher alcohol dosages. Recognizable protective mechanisms of alcohol with respect to cardiovascular diseases only occur with lower amounts of alcohol of less than 10 g per day. Underlying mechanisms explain these controversial effects. Specific therapeutic options for alcohol-related arrhythmias apart from abstinence from alcohol consumption are not known.

[Acute right heart failure after intravenous application of heroin and flunitrazepam]. / Akutes Rechtsherzversagen nach intravenöser Applikation von Heroin und Flunitrazepam.

HISTORY: A 32-year-old woman was admitted to the emergency department because of acute dyspnea and syncope. A few minutes before the onset of symptoms, she had self-administered an intravenous injection of one gram of heroin combined with grinded flunitrazepam tablets. INVESTIGATIONS: Signs of acute cor pulmonale were detected on transthoracic echocardiography despite lack of pulmonary embolism in computed tomography. It was assumed that microembolisms were the cause of acute pulmonary hypertension after intravenous injection of heroin and flunitrazepam. TREATMENT AND COURSE: Because of lack of thrombus in CT scan therapeutic anticoagulation with unfractionated heparin and oxygen insufflation was initiated resulting in rapid improvement of oxygen saturation and blood pressure. On the following day pulmonary pressure in transthoracic echocardiography was already decreased significantly. Without signs of deep venous thrombosis in duplex scan and only a marginal sub segmental perfusion deficit in ventilation-perfusion-scintigraphy therapeutic anticoagulation was recommended for three months. CONCLUSION: The most likely cause of micro embolisms in this case are particles of talc, which are often used to cut heroin, or the microcrystalline cellulose used in tablets. There have been reports of tissue necrosis due to arterial embolism/vasospasm by crystalloid or oily substances (embolia cutis medicamentosa) in the extremities after intraarterial injection of grinded flunitrazepam tablets. Therefore it seems plausible that intravenous application may cause a serve but transient deficit of perfusion in pulmonary circulation.

Recurrent strokes under anticoagulation therapy: Sticky platelet syndrome combined with a patent foramen ovale.

The sticky platelet syndrome (SPS) is a congenital disorder characterized by platelet hyperaggregability to epinephrine and/or adenosine diphosphate; this predisposes affected individuals to acute myocardial infarction, ischemic optic neuropathy, recurrent venous thromboembolism, and transient ischemic cerebral attacks and strokes. Here, we describe an unusual case with recurrent cerebrovascular accidents due to SPS, in the presence of a patent foramen ovale (PFO). We report an unusual case of a 56-year-old female patient with a PFO, who suffered from recurrent strokes despite long-term medication with clopidogrel for SPS. The patient underwent successful transcatheter closure of the PFO, and, in addition, she has been placed on low-dose acetylsalicylic acid. After 18-month follow-up, she demonstrated an intact atrial septum without any vegetations on the percutaneous device until today. She has had no further thromboembolic events.

[Do results of transoesophageal echocardiography during closure of patent foramen ovale influence interventional therapy?]. / Beeinflussen Befunde der transösophagealen Echokardiographie bei katheterinterventionellem PFO-Verschluss die Therapie?

PURPOSE: The aim of the present study was to characterise the morphology of patent foramen ovale (PFO) by a standardised protocol during transoesophageal echocardiography and to estimate the final and successful position of PFO-occluding devices (PFO-Star) by evaluation of parameters determined by echocardiography. The echoacardiographic parameters of septum- and PFO-morphology determined before the intervention were analysed with regard to choosing the optimal device-system for transcatheter PFO-closure. MATERIALS AND METHODS: Transoesophageal echocardiography combined with application of contrast-media was performed in 31 patients before, during and after PFO-closure by using the PFO-Star-Device. The pre-interventional morphological parameters were compared with the result after PFO-closure. RESULTS: Quantitative contrast-bubble-shunting, PFO-channel-length and Vena contracta detected by colour flow Doppler do not show any correlation. PFO-channel-length in cases with small angles between aorta and septum seems to be associated with higher risk of clinically irrelevant device-shift as well as residual shunt. CONCLUSION: A standardised procedure in transoesophageal echocardiography is suitable for characterising the morphology of PFO. Neither the morphology in 2D-imaging nor the amount of shunt microbubble seen in the left atrium allows a conclusive statement about the PFO size. For obtaining an optimal closure result, it is important to identify the channel-length and the distance between the interatrial septum and the PFO together with the angles between septum and the surrounding intracardiac structures.

[A 49-year-old woman with deep vein thrombosis, pulmonary embolism, and left-sided paralysis]. / 49-jährige Patientin mit tiefer Beinvenenthrombose, Lungenembolie und linksseitiger Hemiparese.

We report the case of a 49-year-old female patient who was admitted stationary because of a left-sided paralysis which had appeared some hours before. An embolic occlusion of the right A. cerebri media turned out to be the cause. A paradoxical embolism could be assumed because of an existing deep vein thrombosis and an increased right-ventricular pressure within a hemodynamically relevant fulminant pulmonary embolism as well as the additional existence of a patent foramen ovale (PFO). Systemic lysis as treatment of the pulmonary embolism was contraindicated because slight bleeding had occurred in the area of the right basal ganglia after treatment of the embolic occlusion of the right A. cerebri media by a local lysis. Subsequently and in the acuteness, a catheter interventional PFO-closure via a double-umbrella device was placed and the pulmonary embolism was effectively treated by a local lysis through the insertion of a pigtail-catheter into the right pulmonary artery.