[Time costs cardiac muscle tissue--prehospital therapy of acute myocardial infarct--a case report]. / Zeit kostet Herzmuskelgewebe--prähospitale Therapie des akuten Myokardinfarktes--eine Kasuistik.

Symptoms of an acute myocardial infarction are a common reason for calling the emergency physician. Pre-hospital mortality caused by cardiac infarction is constantly high. The main potential for decreasing infarction mortality lies in the pre-hospital period. The problems and prospects of treatment in the early period are described in the case of a 73-year-old patient with an acute anterior infarction. The diagnostic and therapeutic approach is shown and discussed in this concrete case, taking into consideration the guidelines for diagnostics and therapy of acute myocardial infarction in the pre-hospital period of the German Society for Cardiology. A particular focus is the management of pre-hospital thrombolysis, the preconditions, realization and risks of which are described. In this context, the experience and competence of the emergency physician is prerequisite for the exact diagnosis and therapy. Furthermore, the importance of a smooth transition from pre-hospital therapy to intensive care is emphasized.

Vascular hamartoma of the left ventricle.

Primary tumors of the heart are very rare. We report a case of a 28-year old female patient in whom a tumor of the left ventricle was first diagnosed by transthoracic echocardiography. Angiography, nuclear magnetic resonance imaging and fasting positron emission tomography with 18-fluorodesoxyglucose suggested the diagnosis of a well vascularized tumor. The tumor was subtotally excised during heart surgery under total cardiopulmonary bypass and histological examination identified a predominantly vascular hamartoma.

[Congenital coronary artery aneurysm: a rare cause of acute myocardial infarct]. / Kongenitales Koronararterienaneurysma: Eine seltene Ursache des akuten Myokardinfarktes.

An 18-year-old female presented with acute posterior wall infarction after exercise stress. Coronary angiography showed an aneurysm of the proximal right coronary artery partially occluded with thrombi, followed by a complete occlusion of the vessel. The left coronary artery was normal. Despite immediate intracoronary thrombolysis she developed a large posterior wall necrosis. Angiographic follow-up revealed worsening left ventricular function but not progression of the aneurysmatic ectasia. The diagnosis congenital coronary artery aneurysm was made since there was no evidence for an atherosclerotic, infectious or inflammatory vascular disease. The patient was treated conservatively and within 2 years of follow-up the clinical course was uneventful.

Myocardial scintigraphy with thallium-201 and technetium-99m-hexakis-methoxyisobutylisonitrile in left bundle branch block: a study in patients with and without coronary artery disease.

In left bundle branch block (LBBB) thallium-201 myocardial scintigraphy frequently reveals septal abnormalities in the absence of coronary artery disease (CAD) and gives rise to "false-positive" results in patients with suspected CAD. It has not yet been clarified which pathophysiological mechanism is responsible for these perfusion abnormalities. A total of 66 patients with constant LBBB were investigated with 201Tl or technetium-99m-hexakis-methoxyisobutylisonitrile (MIBI), 62 underwent coronary angiography. Of 12 patients without left anterior descending artery (LAD) or right coronary artery (RCA) stenoses, 11 had a reversible septal activity deficit after 201Tl stress injection, whereas 20 of 22 patients without relevant CAD showed a constant stress/rest septal deficit using MIBI. Regarding patients with significant LAD and/or RCA stenoses, both radio-pharmaceuticals almost always showed a "reversible" septal deficit: with 201Tl in 15 of 16 individuals and with MIBI in 14 of 15. In 12 patients 201Tl was reinjected at rest. In those who had LAD or RCA stenoses (n = 5), early septal activity uptake after stress injection was poorer than that after rest injection; in the absence of CAD (n = 7), septal stress uptake corresponded with that of rest injection. It is concluded that septal perfusion abnormalities in LBBB and the absence of CAD are characterized by an exercise-independent reduction of septal blood flow per mass of viable myocardium and that stress/rest injection protocols of myocardial perfusion tracers are able to differentiate between LBBB with and without CAD.

Indium-111-labelled antimyosin antibody imaging in a patient with cardiac sarcoidosis.

The aetiology of cardiac dysfunction caused by sarcoid granulomatous inflammation may be difficult to clarify, and the potential of imaging methods is limited. We report on a patient who presented with acute biventricular decompensation. Pulmonary sarcoidosis was confirmed after hospitalization. Four weeks after the initiation of corticosteroid treatment, scintigraphy with indium-111-labelled antimyosin antibody Fab fragments (AMAB) revealed distinct activity accumulation in major parts of the left ventricular wall (heart-lung ratio: 1.6) 72 h following injection. There may be a role for AMAB scintigraphy in the early detection of cardiac sarcoidosis.

Management of concomitant occlusive disease of coronary and carotid arteries using cardiopulmonary bypass for both procedures.

The incidence of neurological complications following operative treatment of concomitant occlusive disease of coronary and carotid arteries has been reported to be between 0.7 and 18 per cent by different preoperative screening methods and surgical strategy. From the opening of our institution in November 1984 until March 1988 5443 open-heart procedures were performed. In 116 patients of 3540 consecutive coronary artery bypass grafting (CABG) candidates simultaneous carotid endarterectomy (TEA) was carried out because of hemodynamically relevant stenosis of one or both carotid arteries; 50 patients were neurologically symptomatic with TIA's and amaurosis fugax preoperatively. Sixty of 66 patients with asymptomatic carotid artery stenosis had either a morphologically severe stenosis of the carotid artery or multifocal occlusive disease of the extracranial supraaortic arteries. Prior to carotid-TEA cardiopulmonary bypass was inserted with mild hypothermia maintaining a beating heart for pulsatile body perfusion. An intraluminal shunt was only used in patients with bilateral carotid stenosis. Intraoperative EEG-monitoring was carried out to detect cerebrovascular insufficiency. In 108/116 patients no neurological complications were observed, but 6/116 patients had transient minor neurological symptoms. Two of 116 patients sustained a severe neurological deficit with hemiplegia and one of them died on the 21st postoperative day. Based on these data we conclude that patients requiring carotid TEA and CABG should be operated upon simultaneously using cardiopulmonary bypass for both procedures.

[Long term therapy of coronary heart disease with 120 mg slow release isosorbide dinitrate once a day. Study of duration of action and development of tolerance]. / Vereinfachte Langzeittherapie der koronaren Herzkrankheit mit 120 mg retardiértem Isosorbiddinitrat einmal täglich. Untersuchung zur Wirkdauer und Toleranzentwicklung.

Twenty-one patients (3 women, 18 males, mean age 55.7 +/- 6 years) with coronary heart disease proven by coronary angiography entered a double blind randomised study with isosorbide dinitrate slow release 120 mg once a day. 2, 12 and 24 hours after acute medication patients underwent a symptom-limited exercise-ECG. The following parameters were measured: ST-depression, blood pressure, heart rate and working capacity. After one week of therapy the same parameters were measured to look for the development of tolerance. Two and twelve hours after acute medication working capacity increased to 220% and 139% respectively. After 24 hours there was no statistically significant effect. The sum of ST-depression in three leads decreased from 4.85 +/- 3.02 mV to 1.87 +/- 0.96 mV (38.5%; p less than 0.05) 2 hours after medication, and to 2.10 +/- 1.73 mV 12 hours after medication. 24 hours after medication there was still a slight but not significant reduction of ST-depression. There was no statistically significant effect in the placebo group. After one week of therapy there was a slight reduction of action, but no development of tolerance.

[4 different nitrate preparations with regard to the possible development of tolerance in long-term treatment]. / Untersuchung vier untershiedlicher Nitratpräparationen hinsichtlich einer möglichen Toleranzentwicklung unter Langzeitbehandlung.

Thirty-two hospitalized patients with angiographically-documented coronary artery disease and stable angina pectoris (NYHA class III) were randomly assigned to one of four treatment groups. After a one-week washout period, baseline examinations (systolic time intervals, blood pressure and exercise ECG) were performed. The patients were then treated with either 20 mg isosorbide dinitrate in sustained-release form (sustained-release ISDN), 20 mg isosorbide 5-mononitrate (IS 5-MN), 2.5 mg buccal nitroglycerin in sustained-release form (NTGB) or 6.5 mg oral nitroglycerin in sustained-release form (NTGO) and one hour thereafter, the heart rate, blood pressure and systolic time intervals were determined. Subsequently, the patients were treated with the respective nitrates four times daily for two weeks. On the seventh and 14th days, the heart rate, blood pressure and systolic time intervals were again determined before and after the first dose of the day. Additionally, after the first dose on the 14th day, an exercise ECG was performed. The effect of the nitrates on the venous capacitance system is reflected by the increase in the PEP/LVET ratio where NTGO and NTGB elicited marked actions and those of sustained-release ISDN and IS 5-MN were of a lesser extent. An effect on systolic and diastolic blood pressure at rest and during exercise could be documented only after administration of NTGB. The anti-ischemic effect of the nitrates was based on the reduction of ST-segment depression during exercise; after two weeks of treatment, sustained-release ISDN and IS 5-MN were associated with complete tolerance development while NTGO continued to exert a slight, and NTGB a clear reduction in ST-segment depression. Personal protocols documented that nitrate consumption and rate of anginal attacks during longterm treatment were unaffected by sustained-release ISDN, IS 5-MN and NTGO, but were reduced by 50% while on treatment with NTGB.

Correlation between R-wave amplitude and left ventricular volume at rest and with exercise.

In 52 patients with exercise angiography (12 normals, 31 with coronary heart disease, 9 with congestive cardiomyopathy) exercise ECGs were examined for R-wave changes. An increasing R-wave amplitude was found an insensitive sign of ischemia in patients with coronary heart disease (sensitivity 29%, specificity 81%). Sensitivity and specificity of the observed ST depression in this study were 83% and 71%, respectively, as reported by others. There was no positive correlation between the changes in the R-wave amplitude and left ventricular end-diastolic volume during exercise, thus there was no proof of the existence of the so-called Brody effect in humans.

[Hemodynamics of the St. Jude Medical aortic prosthesis in comparison to the Björk-Shiley and Lillehei-Kaster prostheses]. / Hämodynamik der St.-Jude-Medical-Aortenklappenprothese im Vergleich zur Björk-Shiley- und Lillehei-Kaster-Prothese.

Pre- and postoperative hemodynamic data in 10 patients in whom the aortic valve was replaced by a St. Jude Medical (SJM) prosthesis are compared with those in 29 patients who received a Lillehei-Kaster tilting disk (LK) valve prosthesis and 11 patients with a Björk-Shiley tilting disk (BS) valve prosthesis. The SJM aortic prosthesis of the small size (A 21) has advantages over the LK and BS types, and it is therefore particularly suited to use in a small aorta. There are also good hemodynamic results for the larger sizes of the SJM prosthesis. As a result of the 85-degree opening angle and the favorable ratio between the inner and outer diameters of the valve (suture ring), there is only minor impedance of blood flow. The SJM aortic prosthesis thus involves a lesser degree of hemolysis than the BS and the LK. In spite of the promising hemodynamic data, however, long-term findings on the durability of the SJM prosthesis in vivo have not yet been published. It therefore seems to us justifiable, especially where the aorta is large, to continue to use BS prostheses.

[Clinical follow-up of patients after valve replacement with Omniscience cardiac valves: can this valve be recommended? (author's transl)]. / Postoperative klinische Verlaufsbeobachtung nach Omniscience-Klappenersatz: Ist diese Prothese empfehlenswert?

Clinical evaluation of 9 patients, after valve replacement with Omniscience cardiac valves (5 with aortic, 4 with mitral valve replacement) showed opening angles significantly lesser than the theoretical in-vitro valve of 80 degrees opening angles were essential by cineangiography. In 3 of 4 patients with mitral valve replacement, reoperation became necessary due to prosthetic valve dysfunction. Thus the implantation of Omniscience cardiac valves cannot be recommended.

The influence of beta-adrenoceptor antagonists with and without intrinsic sympathomimetic activity on local wall motion abnormalities in patients with coronary heart disease.

1 A single-blind randomized study of the effects of a beta-adrenoceptor antagonist with intrinsic sympathomimetic activity (pindolol 0.4 mg i.v., n = 10) and a drug lacking this property (metoprolol 5 mg i.v., n = 11) on local wall motion abnormalities was carried out in 21 patients with coronary heart disease and anterior wall hypokinesia. 2 The drugs produced similar changes in left ventricular end diastolic pressure (LVEDP) and end diastolic volume index (EDVI) but differed in their effects on heart rate and ejection fraction. Pindolol did not exert any marked effect on heart rate or ejection fraction whereas after metoprolol treatment both were significantly decreased. 3 Shortening of the hypokinetic wall segments was improved by both drugs. Shortening of the non-hypokinetic contralateral segments was unchanged after pindolol administration but was decreased after metoprolol. 4 The differing effects of beta-adrenoceptor antagonists on regional wall motion appear to be dependent on the presence or absence of intrinsic sympathomimetic activity.

Hemodynamics and prognosis of patients with angina pectoris without coronary heart disease (syndrome X).

A history of exercise-induced chest pain or even typical angina pectoris combined with normal coronary arteries is usually described with terms like small vessel disease or syndrome X [2, 5]. The aim of this paper is to study the hemodynamics at rest, and with exercise, and the outcome of patients with this syndrome.

[Hospital-acquired serum hepatitis (author's transl)]. / Krankenhaus-Hepatitis.

During a prospective study of blood transfusions at the Cardiac Surgery Unit of the University Surgical Clinic, Free University, Berlin, a patient developed hepatitis B although he had not received any blood transfusion. Soon after, two further patients developed B-hepatitis and a third had HBs-antigenaemia. A virus marker confirmed the infectious pathways. None of the three infected patients had received foreign blood or large-pool clotting preparations. These special circumstances made it possible to diagnose hospital-acquired serum hepatitis. Otherwise all three cases would probably have been considered as caused by transfusion of foreign blood or blood products. It is, therefore, recommended that in similar cases one should speak of hospital-acquired hepatitis and of transfusion hepatitis only when this can be proven.

[Hepatitis risk of human plasma-fraction concentrates of pooled plasma (author's transl)]. / Hepatitisrisiko von humanen Gerinnungspräparaten aus gepoolten Plasmen. Ergebnisse einer Prospektivstudie.

In 1975/76 the risk of hepatitis from human clotting preparations (fibrinogen, prothrombin complex) prepared from pooled plasma was studied prospectively in patients who had undergone open-heart surgery with cardiopulmonary bypass. Of 247 patients 25 (10%) developed hepatitis postoperatively, while of 17 recipients of plasma-fraction concentrates 12 developed hepatitis (71%). Even taking into account other potential risk factors this rate of hepatitis is statistically significant. It demonstrates that even with the most modern screening methods it is not possible to produce clotting preparations from "large pool" human plasma which is free of hepatitis risk, unless additional virus-inactivating measures are taken.

[Autologous blood donation and transfusion in cardiosurgical high risk patients (author's transl)]. / Eigenblutspende und Eigenbluttransfusion bei kardiochirurgischen Risikopatienten.

In an unselected group of patients undergoing a wide variety of cardiovascular operations, the possibilities of long-term preoperative autologous blood collection combined with oxygenator hemodilution were examined. The mean number of preoperative donations was 2.5 units of blood. It was 50 p.c. higher in men than in women. One third of the men, but no female patient, collected 4-5 units of autologous blood, thus equalling the mean calculated blood requirements. Short- or long-term disavantages of the donations were not seen. --The total amount of homologous blood required could be diminished by 50 p.c., in atrial septal defects even by 70 p.c. The percentage of patients without homologous blood increased from 3 to 25 p.c. of the total material, but in atrial septal defects from 13 to 67. Further improvements of these values may be expected from an earlier entry into the program of autologous donations and, correspondingly, by an earlier iron substitution. Only thus, without special methods of storage, roughly calculated one half of all cardiovascular surgical patients may come through without homologous blood. In view of the risks of homologous blood transfusion, already now no atrial septal defect and, with limitations, no valve replacement should come to surgery without adequate autologous blood collection.