[Atrial myxoma with clinical signs of systemic inflammatory disease]. / Vorhofmyxom mit klinischem Bild einer entzündlichen Systemerkrankung.

Atrial myxomas are detectable in 0.3 % of all autopsies and women are affected three times more often than men. The overall incidence of myxoma is relatively rare with 0.5 per one million inhabitants per year. Clinical signs, such as palpitations, dyspnea, dizziness and syncope or thromboembolic events may be found. Microembolic infarction or a higher expression of interleukin 6 may lead to misdiagnosis, such as vasculitis. This article presents the case of a 25-year-old woman with arthralgia, dysesthesia, staggering vertigo, cutaneous nodules and disturbed vision. Diagnostic procedures did not reveal a reason for these complaints. A therapeutic test with prednisolone did not improve the symptoms. Finally echocardiography showed a large space-occupying lesion in the left atrium which oscillated into the left ventricle during diastole. The patient was transferred to the department of cardiac surgery where the atrial myxoma could be removed without any complications and the patient ultimately made a complete recovery.

Transmyocardial laser revascularization combined with intramyocardial endothelial progenitor cell transplantation in patients with intractable ischemic heart disease ineligible for conventional revascularization: preliminary results in a highly selected small patient cohort.

OBJECTIVE: Transmyocardial laser revascularization for angina relief and intramyocardial autologous endothelial progenitor cell injection for neoangiogenesis may offer a new treatment strategy for patients with intractable ischemic heart disease. METHODS: Transmyocardial laser revascularization and intramyocardial injection of bone marrow-derived CD133+ cells was performed in six highly symptomatic patients. Transmyocardial laser channels were created and isolated CD133+ cells were injected intramyocardially. All patients were followed up for a minimum of 6 months postoperatively. RESULTS: One patient died shortly after the operation due to refractory heart failure. In the five survivors, CCS class improved as well as left ventricular ejection fraction. Left ventricular end-diastolic volume and myocardial perfusion varied between the patients. All patients described a considerable improvement in quality of life postoperatively. Repeated 24-hour Holter monitoring revealed no significant arrhythmias. CONCLUSIONS: In this small patient cohort, intramyocardial CD 133+ cell injection combined with transmyocardial laser revascularization led to an improvement in clinical symptomatology in all patients and in left ventricular function in 4 out of 5 patients, with an unclear effect on myocardial perfusion. Caution is advised when employing this therapy in patients with severely depressed left ventricular function.

High myocardial lactate concentration is associated with poor myocardial function prior to cardiopulmonary bypass.

AIM: This study was designed to analyse the relationship between myocardial lactate--determined by microdialysis--and hemodynamics during coronary artery bypass grafting (CABG) with cardiopulmonary bypass (CPB). METHODS: Twenty consecutive patients with coronary artery disease were enrolled for this prospective, observational study. Microdialysis measurements were performed in the apical region of the heart during periods of 15 to 20 min before, during, and after CPB; hemodynamics and plasma lactate concentrations were determined correspondingly. Correlation analysis revealed a relationship between myocardial lactate concentration and right ventricular ejection fraction at baseline (Spearman's r: 0.6; P=0.02). Patients were thus grouped according to the myocardial lactate concentration at baseline into a high-lactate group (2.5+/-0.7 mmol.l(-1), n=10) and low-lactate group (0.9+/-0.5 mmol.l(-1), n=10). RESULTS: Preoperative left ventricular ejection fraction was not different between the groups (high-lactate group: 53+/-16%; low-lactate group: 57+/-15%; P=n.s.) Patients in the high-lactate-group had a lower stroke volume index (P=0.005) and right ventricular ejection fraction (P=0.04) before, and higher central venous and pulmonary artery pressures (P<0.01) after CPB. Plasma lactate was significantly higher during CPB in the high-lactate-group (P<0.05). No correlation was observed between myocardial and plasma lactate. Six patients in the high-lactate but none in the low-lactate-group needed inotropic support after weaning from CPB (P=0.01). CONCLUSIONS: These data are suggestive of an association between subtle myocardial ischemia--detected by microdialysis--and perioperative myocardial dysfunction in patients undergoing CABG. The microdialysis technique may be a valuable adjunct for monitoring myocardial metabolism during cardiac surgery.

The extent of akinesis is predictive of the in-hospital mortality from endoaneurysmorrhaphy.

Endoaneurysmorrhaphy (EAR) has become an important therapeutic option in the treatment of patients with left ventricular (LV) aneurysm and congestive heart failure. Today, more and more patients are referred for EAR with a dilated akinetic LV rather than a classic dyskinetic LV aneurysm. Little is known about the contribution of the extent of akinesis to perioperative mortality. We reviewed the data of 147 patients with anterior left ventricular aneurysms undergoing EAR. Seventy percent of the patients were male; mean age was 62+/-9 years. Demographic, hemodynamic, angiographic and surgical variables were analyzed using univariate statistic tests in order to determine risk factors for in-hospital mortality.Eighty-two percent of the LV aneurysms had at least some dyskinesia, but 70% were mainly akinetic. 133 patients had additional bypass surgery, one had additional mitral valve replacement. In-hospital mortality was 4.1% (n=6). Risk factors for in-hospital mortality were the total extent of akinetic myocardium (p=0.027) in the 30 degrees RAO view and the duration of cardiopulmonary bypass (CPB, p=0.0068) which was itself dependent on the LV ejection fraction (p=0.001), the number of stenosed coronary arteries (p=0.004), and the extent of akinesis (p=0.023). The extent of dyskinesia was not associated with either perioperative mortality (p=0.36) or CPB duration. EAR can be performed with acceptable perioperative results. Because akinesis increases in many patients with time, and because the duration of ECC was dependent on variables reflecting the severity of the underlying heart disease, our findings underscore the importance of optimal timing for the surgical intervention.

Norepinephrine release is reduced in cardiac tissue of Type 2 diabetic patients.

AIMS/HYPOTHESIS: The aim of this study was to assess whether cardiac catecholamine release is affected in patients with Type 2 diabetes mellitus. METHODS: A trial tissue was obtained from 19 diabetic (Type 2) and 43 non-diabetic patients undergoing coronary surgery. Endogenous norepinephrine release was examined under baseline conditions as well as during electrical field stimulation (effective voltage 5 V, stimulation frequency 4 Hz, pulse width 2 msec) by high performance liquid chromatography and electrochemical detection. Cardiac function and arterial blood pressure was assessed from coronary angiography. RESULTS: In atrial tissue from diabetic patients, stimulation-induced norepinephrine release was reduced by 25% compared with non-diabetic patients, while baseline norepinephrine release did not differ between both groups. Preoperative plasma glucose and haemoglobin A(1C) concentrations were increased in patients with diabetes, however, no relation was found to catecholamine release. Diabetic and non-diabetic patients did not differ regarding left ventricular ejection fraction and arterial blood pressure. CONCLUSION/INTERPRETATION: Cardiac norepinephrine release is suppressed in patients with Type 2 diabetes which could contribute to sympathetic neuropathy. The difference of norepinephrine release in diabetic and non-diabetic patients was independent of cardiac function and arterial blood pressure.

Remifentanil-clonidine-propofol versus sufentanil-propofol anesthesia for coronary artery bypass surgery.

OBJECTIVE: To compare a remifentanil-clonidine-propofol regimen with conventional sufentanil-propofol anesthesia. DESIGN: Randomized, nonblinded trial. SETTING: A single university hospital. PARTICIPANTS: Male patients scheduled for coronary artery bypass graft (CABG) surgery. INTERVENTIONS: In the control group, anesthesia was induced with 0.5 microg/kg of sufentanil and 0.2 to 0.3 mg/kg of etomidate after preoxygenation. Propofol (50 to 100 microg/kg/min) and sufentanil (0.5 to 1.0 microg/kg/h) were started after endotracheal intubation. Sufentanil was stopped after aortic decannulation. In the remifentanil-clonidine group, anesthesia was started with remifentanil (0.15 to 0.3 microg/kg/min), followed by etomidate (0.2 to 0.3 mg/kg). Propofol was started at 50 to 100 microg/kg/min, and after endotracheal intubation, clonidine infusion was started (6 to 20 microg/h). Patients received piritramide (0.15 mg/kg) and metamizole (20 mg/kg) for transitional analgesia. In both groups, propofol infusion was reduced to 30 to 60 microg/kg/min at skin closure and stopped when assisted spontaneous breathing led to adequate gas exchange. MEASUREMENTS AND MAIN RESULTS: The main outcomes were recovery times; somatic variables; plasma catecholamine levels; and self-recorded pain, nausea, and vomiting. Patients in the remifentanil-clonidine group were extubated earlier and had lower plasma epinephrine and norepinephrine levels. After transitional analgesia, the remifentanil-clonidine patients had similar postoperative analgesic use and self-reported pain and side-effect scores. CONCLUSION: Compared with a sufentanil-propofol regimen, an anesthetic regimen for CABG surgery that combines remifentanil, clonidine, and propofol provides similar hemodynamics. The remifentanil-clonidine regimen reduces catecholamine levels and hastens recovery from anesthesia.

Survival after transmyocardial laser revascularization in relation to nonlasered perfused myocardial zones.

BACKGROUND: Transmyocardial laser revascularization for severe diffuse coronary artery disease reduces angina significantly. The effect on survival, however, is questionable, and risk factors are not adequately addressed. Considering that transmyocardial laser revascularization channels do not remain patent for improving direct myocardial blood supply, other variables such as perfusion through open native or grafted vessels in remote non-transmyocardial laser revascularization areas are probably more important for survival. This hypothesis is the subject of the study. METHODS: Transmyocardial laser revascularization was performed with a CO2 laser system in 63 patients between October 1995 and December 1997. Patients received transmyocardial laser revascularization alone or in combination with coronary artery bypass grafting. The heart was divided into three perfusion zones as determined by the three major coronary arteries. Patients were divided into three groups according to the number of zones that were perfused by either a native coronary artery or a patent bypass graft: group 1 (n = 9), none; group 2 (n = 24), one; and group 3 (n = 30), two. Follow-up was performed at 3, 6, 12, 24, and 36 months and was 100% complete. Mean latest follow-up was 26.2 months, minimal follow-up of survivors was at least 12 months. RESULTS: Overall mortality was remarkably higher in group 1 (77.8%) compared with group 2 (20.8%, p = 0.005) and group 3 (13.3%, p = 0.001). Hospital mortality was 22.2% in group 1, 0% in group 2, and 3.3% in group 3. Late mortality was also higher in group 1 (55.5% versus 20.8%, and versus 9.9%, respectively). Cardiac deaths were more frequent in group 1 (55.5% versus 12.5% in group 2, p = 0.02, and versus 9.9% in group 3, p = 0.009). The number of perfused myocardial zones showed a significant influence for survival (p = 0.002). CONCLUSIONS: These data give some directional evidence that survival seems to be beneficially affected by the number of nonlasered perfused myocardial zones through native vessels or grafts in patients undergoing transmyocardial laser revascularization.

The structure of health and illness in a Brazilian favela.

The purpose of this study was to describe the understanding of health and illness within the culture of women living in a favela (urban slum) in southeastern Brazil. The methodology described by Spradley structured the study. Interviews were conducted with 10 informants, and multiple interviews were conducted with the key informant. Analysis yielded a taxonomic structure for the domains of health and illness. Six components play a part in both health and illness: cleanliness, nutrition, doctor visits, herbal remedies (tomar cha), sympathetic magic, and spirituality. Attention to the six components is believed to be necessary in maintaining health. The indigenous components of health can be integrated into health teaching to enhance correspondence between nursing care and the worldview of favela residents.

Tobacco-related instruction in undergraduate nursing education in Illinois.

Tobacco use is responsible for more deaths in the United States than any other factor. Nurses are in a unique position to convey life-saving messages to clients regarding tobacco use. To gauge the type and extent of tobacco-related background knowledge acquired by nurses in the course of their education, the Nurses' Committee of the Illinois Division of the American Cancer Society (ACS) surveyed 70 nursing programs in the state of Illinois. The number of lecture hours spent on tobacco-related issues was greater in LPN programs than in either associate or baccalaureate degree programs, and instruction was scattered throughout the curriculum of each program. Most schools reported heavy reliance on adult medical-surgical textbooks to convey tobacco-related content. The most recent editions of the textbooks used by the schools were reviewed, and they also were found to adopt a scattered approach, with a disappointing lack of depth regarding the hazards of tobacco. It is recommended a single course be identified as responsible for relaying tobacco-related content and information supplied by general medical-surgical textbooks be supplemented by materials drawn from other sources.

[The connection between myocardial oxygen partial pressure and intragastric CO2--three cases]. / Zum Zusammenhang zwischen myokardialem Sauerstoffpartialdruck und intragastralem CO2--Drei Fallbeispiele.

In patients after heart surgery gastric mucosal pH registration via tonometry gains increasing importance. Furthermore it is possible to place an intramyocardial probe into the myocardium to observe the intramyocardial partial oxygen tension for several days. From the observations in the three patients evaluated in this study we have reason to believe that within the context of cardiac surgery intragastral CO2 may be an indicator of intramyocardial partial oxygen tension. In these three patients pathological intragastral CO2 values are accompanied with those in pathological intramyocardial PTIO2. The efficiency of therapeutical measures--such as volume and catecholamine substitution--can be documented by monitoring intragastral CO2 and intramyocardial PTIO2. It needs to be established whether intragastral CO2 is a parameter responding earlier than intramyocardial PTIO2 as is suggested by the findings in these three patients.

Electron-microscopic findings after transmyocardial laser revascularization in an acute ischemic pig model.

OBJECTIVE: The clinical benefit in terms of angina reduction after transmyocardial laser revascularization (TMLR) in patients with diffuse coronary artery disease who are not candidates for conventional procedures has been proved. The exact mechanisms of TMLR however, are still unknown. The aim of this study was to investigate the cellular changes in relation to intramyocardial partial oxygen pressure (ptiO2) after TMLR in a model of acute ischemia in pigs by electron microscopical methods (TEM). METHODS: Seven pigs were included in this study (five animals with acute myocardial ischemia and additional TMLR and two animals with acute myocardial ischemia and without TMLR for control). Acute ischemia was induced by ligation of diagonal branches of the left anterior descending artery (LAD). Intramyocardial partial oxygen pressure was measured before induction of ischemia and thereafter continuously for up to 6 h in all animals. Biopsies of all animals were taken before induction of ischemia and thereafter at 30 min, 3 and 6 h. Analysis of the myocardial ultrastructure was focused on mitochondria, cell nucleus, T-tubules and myofibrils. RESULTS: Ultrastructural changes were seen in all animals. At 6 h after induction of ischemia, mitochondria showed a destruction of the internal as well as the external membrane and of the cristae. The nuclei showed margination of the chromatin. Myofibrils were characterized by ruptures in the Z-stripes. Lipid droplets as an indicator of ischemia could be identified. PtiO2 between 40 and 80 mmHg before intervention decreased down to 0-2 mmHg within the first 9 min after diagonal branch ligation and did not increase even after TMLR. CONCLUSIONS: In this acute ischemic model using pigs, TEM evaluation following TMLR proves irreversible changes of the myocardial ultrastructure. Furthermore, TMLR was not able to increase ischemically induced decrease of ptiO2. These data provide some evidence that TMLR thus, may not be able to ameliorate acute ischemia at least in the pig model. Further investigations are needed to investigate the effect of TMLR in chronic myocardial ischemia.

Continuous venovenous haemofiltration in neonates with renal insufficiency resulting from low cardiac output syndrome after cardiac surgery.

Acute renal insufficiency is a common complication after surgery for congenital cardiovascular defects in neonates and is associated with a high incidence of morbidity and mortality. The authors reviewed their experience with continuous venovenous haemofiltration in neonates and infants with acute renal insufficiency resulting from low cardiac output following cardiovascular surgery. Twelve critically ill patients with pharmacologically intractable fluid overload were treated with continuous venovenous haemofiltration over a period of 42 months. All patients were mechanically ventilated and dependent on high doses of catecholamines. Continuous venovenous haemofiltration was started 64.2(28.2) h postoperatively and maintained for a period of 8 to 195 h. A negative fluid balance was achieved in all patients (2.1(0.5) ml/kg per h). No complications relating to continuous venovenous haemofiltration were evident during the treatment. The survival rate was 59% (seven of 12). Continuous venovenous haemofiltration is a valid and simple method for controlling fluid overload in neonates and infants with low cardiac output.

First clinical application of the Medos-HIA ventricular support system: monitoring of the thrombotic risk by means of the biomarker prothrombin fragment F1 + 2 and scanning electron microscopy evaluation.

BACKGROUND: The medos-HIA ventricular support system was designed as an artificial heart assist device for intractable heart failure to act as a bridge for transplantation or recovery. The aim of this study is to report on the first clinical application of the system and to evaluate the thrombotic risk with the use of the biomarker prothrombin fragment F1 + 2 and scanning electron microscopy of the blood contacting surface. METHODS AND RESULTS: This device worked without any failure for 462 hours, and a sufficient output of 5.2 to 6 L was observed. No activation of the procoagulatory system occurred during pumping until the occurrence of the septicemia. Preseptic F1 + 2 levels were normal, at about 1 nmol/L. The blood contacting surfaces of the pump and the polyurethane valves were examined by means of scanning electron microscopy, and the surfaces were found to have smooth fibrin layers with no thrombogenic deposits. This fibrin layer is considered to prevent thrombotic adhesions, thereby minimizing the risk of thromboembolic complications. Post mortem examinations after pneumonia with septic shock showed no thrombus formation in this support system and around the inserted cannulas. CONCLUSIONS: The low risk for thromboembolic complications, no measurable activation of the coagulation system, and the excellent surface characteristics encourage further use of this inexpensive working device.

A new experimental model and formula for flow determination and possible application in sizing of interatrial communication.

The concept of an artificial interatrial communication in application of the Fontan procedure in high risk patients has raised the problem to exactly determine the shunt amount. This experimental study shows that in vitro flow studies of interatrial communications can be performed without animal blood and PTFE membranes respectively. Furthermore the simulation of an pulmonary vascular venous flow is not necessary. Additionally a new formula with acceptable accuracy for flow estimation is derived from the presented data obtained by this study.

Cardiovascular dynamics and dimensions after bicaval and standard cardiac transplantation.

Bicaval orthotopic cardiac transplantation leaving the right atrium intact has been introduced recently into clinical practice as an alternative to the standard method. To determine the effect of the surgical technique, 27 patients were studied at rest and supine exercise 19 +/- 5 months after bicaval orthotopic cardiac transplantation (group A, n = 15) and 22 +/- 7 months after standard orthotopic cardiac transplantation (group B, n = 12). Resting hemodynamics showed no difference between groups. With exercise, a significantly higher right atrial pressure was noted in group B. Echocardiographic analysis showed asynchronous right atrial contraction in 83% of group B patients versus none in group A. Resting right ventricular dimensions were significantly greater in group B (right ventricular end-diastolic diameter, 3.27 +/- 0.44 cm versus 2.88 +/- 0.35 cm [p < 0.05]; right ventricular end-diastolic area, 21.3 +/- 2.85 cm2 versus 17.1 +/- 2.01 cm2 [p < 0.005]). A higher incidence and significantly higher grade of tricuspid regurgitation were found throughout exercise in group B. The exercise duration (17.34 +/- 3.53 minutes versus 14.04 +/- 4.11 minutes [p < 0.05]) and the exercise capacity (1.17 +/- 0.25 W/kg versus 0.93 +/- 0.34 W/kg [p < 0.05]) were increased in group A. These data provide some evidence that the bicaval technique of cardiac transplantation improves cardiovascular dynamics and dimensions as well as exercise capacity.

Bicaval versus atrial anastomoses in cardiac transplantation. Right atrial dimension and tricuspid valve function at rest and during exercise up to thirty-six months after transplantation.

Conventional cardiac transplantation with atrial anastomoses alters atrial integrity, geometry, and possibly function. Theoretically, this may also contribute to the development of tricuspid insufficiency that is frequently observed after the operation. Thus more anatomic transplantation techniques using bicaval anastomoses were recently introduced into clinical practice. Knowledge of their efficacy, however, is scarce. Therefore right atrial size and tricuspid valve function were compared in patients with bicaval (group A) and standard atrial (group B) anastomoses in a randomized, prospective study. The results of this echocardiographic study at rest and exercise in 18 patients (bicaval n = 8; atrial n = 10) on the average 28 months after transplantation are presented. The right atrial dimension was comparable between group A patients and control subjects and larger in group B patients (p < 0.05). The incidence of tricuspid regurgitation was not different between the two groups at rest, but it was at exercise (50 watts of workload) (p < 0.05). This study suggests that up to 36 months after cardiac transplantation the technique of bicaval in contrast to atrial anastomoses preserves right atrial size and reduces tricuspid regurgitation during exercise. Whether this leads to improved hemodynamics and increased exercise capacity remains to be evaluated in a larger series of patients.

Rapidly growing Epstein-Barr virus-associated pulmonary lymphoma after heart transplantation.

There is strong evidence to show an association of Epstein-Barr virus (EBV) infection with the development of post-transplant lymphoproliferative disease. We report the rapid development of a malignant lymphoma in a heart transplant recipient, which occurred within less than eight weeks. The diagnosis of this malignant high grade B-cell lymphoma was established by open lung biopsy, and classified as centroblastic lymphoma of polymorphic subtype. Immunohistochemically, the lymphoma showed reactivity with the B-cell markers L-26 (CD20) and Ki-B5 and with the activation marker Ber-H2 (CD30). Furthermore, an expression of the bcl-2 oncoprotein was detected. Monoclonal JH gene rearrangement was demonstrated by polymerase chain reaction (PCR), indicating monoclonal proliferation of B-blasts. Although serum EBV immunoglobulin M (IgM) antibodies were negative, the association to an EBV infection could be demonstrated by EBV immunostaining pattern which revealed an expression of the latent membrane protein (LMP) of EBV in the atypical blasts. The results give clear evidence of an EBV association of this rapidly growing lymphoma developed after heart transplantation.

Clinical relevance of soluble HLA and interaction of papain derived class I molecules with alloreactive CTL.

MHC class I and class II molecules are expressed in soluble form in the serum of both healthy and diseased individuals. Our aim was to investigate whether soluble class I (sHLA) levels in allograft patients correlate with their clinical status. Altogether, 20 renal and 30 cardiac graft recipients were examined. High levels of sHLA were measured at least 5 days preceding acute rejection episodes. Immune complexes between anti-HLA antibodies and sHLA were detected in a patient who died of a severe vascular rejection. In another study the interaction of papain-derived sHLA on alloreactive CTL in vitro was investigated. In a chromium-51-release cytotoxicity assay, 1.25 microg/ml of papain-digested class I molecules reduced CTL cytotoxicity to background levels. On the contrary, immobilized molecules triggered the release of serine esterase allospecifically. These data showed that the MHC molecule alone was a sufficient ligand for the interaction with alloreactive CTL.