[The therapy of chronic heart failure]. / Die Therapie der chronischen Herzinsuffizienz.

A rational therapy of the chronic cardiac insufficiency should be performed according to a certain scheme, in which case the knowledge of the basic disease is necessary for the causal treatment. Apart from the general measures the medicamentous therapy is of particular significance. Hereby up to now the digitalis glycosides remained the remedy of primary choice. They are without doubt indicated in the latent and manifest cardiac insufficiency, consequently from the transition of the NYHA stage II into stage III, in tachycardiac disturbances of rhythm also without cardiac insufficiency in form of auricular fibrillation and auricular flutter as well as in the paroxysmal supraventricular tachycardia. Prophylactic, preoperative applications of glycosides and such ones which are performed only for reasons of age are not justified. Also a maintenance therapy is in most cases no more necessary after removal of the cause of the cardiac insufficiency. - Diuretics are to be used in an insufficiency which continues existing despite application of glycosides. Their application must be performed as protracted as possible. - The therapies with vasodilators, such as prazosin, hydralazine and nitrates, which were performed during the last years, showed, indeed, initial success, but no long-term effect. Another fact it is, however, with the angiotensin-converting enzyme (ACE) inhibitors captopril and enalapril, which are to be regarded as second grade medicaments in combination with glycosides and diuretics. Whether or not they will supersede the glycosides, is at present still an open question. Other positively inotropic medicaments which in comparison to the glycosides show a larger therapeutic breadth are still being developed.(ABSTRACT TRUNCATED AT 250 WORDS)

[Confirming a mediastinal lipoma with cardiac computerized tomography]. / Sicherung eines mediastinalen Lipoms durch Kardio-Computertomographie.

It is reported on an at present 32-year-old male patient, in whom at the age of 30 years an excessive mediastinal lipoma was excised. For 12 years the cardiological diagnosis was not clear and could completely be clarified only with the help of the computed tomography of the heart.

[Rational diagnosis of coronary heart disease]. / Rationale Diagnostik der koronaren Herzkrankheit.

Despite all preventive efforts the coronary heart disease also furthermore is of great health-political importance with regard to frequency and as pre-stage of the myocardial infarction. The early stage of the coronary heart disease up to now cannot be diagnosed, but the cases in question are always already manifest morphological changes of the coronary vessels. Alone by an exact anamnesis concerning the evocation and enlargement of the angina pectoris by physical, psychic or thermic stress and its reactivity to nitroglycerin already the most important diagnostic information is to be obtained. It is confirmed by the ECG, in which case the decisive evidence mostly appears under ergometry in form of the horizontal or descending decrease of the ST-interval. This examination should possibly be performed without medication and under exertion. The sensitiveness of circa 70% is increased to 90%, when a simultaneous angina pectoris is present. For the most patients with coronary heart disease thus already the non-invasive diagnostic process has finished, particularly then, when only a medicamentous therapy is planned. The other clinical, radiological and laboratory examinations as well as the echo-cardiography are without any decisive diagnostic value for the coronary heart disease. They above all serve for the recognition of risk factors and the exclusion of other diseases. The biphasic 201-thallium myocardial scintigraphy is not necessary in an unequivocal anamnesis and ECG-findings, but only when taking into consideration the high expenses in atypical complaints, non-evaluable ECG and in asymptomatic patients with positive electrocardiogram after work.(ABSTRACT TRUNCATED AT 250 WORDS)

[Pre- and postoperative computer tomography diagnosis of aortic isthmus stenosis]. / Prä- und postoperative computertomographische Diagnostik der Aortenisthmusstenose.

In individual cases the computed tomography renders possible the ascertainment of the coarctation of the aorta. Despite modified examination method (secondary section technique, continuous application of contrast medium) the reliability is insignificant. Therefore, the method cannot be recommended for the primary diagnostics of the coarctation of the aorta. The computed tomography is extraordinarily suited for the detection of aneurysms of anastomoses after operation of coarctations of the aorta. In 50 computed-tomographic examinations of 48 patients 11 times an aneurysm could be ascertained. This high proportion of late postoperative complications is above all to be traced back to the surgical suture material used in the sixties. There were only two falsely positive findings, in which cases also here relevant pathological changes were present. The computed tomography can more exactly than the aortography adopt a definite attitude to the question of the dissection of prostheses or to pseudoaneurysms.

[Computer tomography diagnosis of cardiac and pericardial space-occupying lesions]. / Computertomographische Diagnostik der kardialen und parakardialen Raumforderungen.

Cardial and paracardial space occupations need a rapid, possibly non-invasive diagnosis. The echocardiography and the computer tomography are practically available. At the instance of 17 intracardial space occupations (4 solid tumours and 13 thrombi), which were found in a total number of 600 cardio-computer-tomographies, and several selected peri- und paracardial space occupations the high diagnostic significance of the computer tomography is demonstrated. With the computer tomography a standardized method independent of the investigator is available which in qualitative respect appears of the same value as to echocardiography in the diagnostics of the intracardial space occupations and in the peri- and paracardial space occupations the non-invasive method is the method of choice.

[Application of therapy with atrial controlled ventricular pacemakers with shortened AV delay time]. / Applikative Aspekte der Therapie mit vorhofgesteuerten Ventrikelschrittmachern (VAT) mit verkürzter AV-Verzögerungszeit.

For the reduction of the functional obstruction of the left-ventricular outflow in hypertrophic obstructive cardiomyopathy since 1978 in selected cases conventional VAT cardiac pacemakers with shortened AV retardation time have been implanted. On the basis of 4 casuistics the insufficient adaptation of these systems to unexpectedly appearing disturbances of the cardiac rhythm is demonstrated. Thus already extreme sinus bradycardias lead to parasystole by the unchangeably given asynchronous basic frequency of the pacemakers. Furthermore, all tachycardiac supraventricular arrhythmias and retrograde atrium activations evoke haemodynamically unfavourable and partly even threatening ventricular tachycardies caused by the pacemakers. Control ECG made under these conditions are frequently inexactly interpreted by the continuing intact natural AV conduction and technical defects of the pacemakers are assumed. The individual diagnostic steps necessary for the assessment of the function of the devices and the inevitable immediate therapeutic measures are, therefore, explained. Finally the demands to more modern differentiated physiological pacemaker systems are derived which should be used in patients with hypertrophic obstructive cardiomyopathy.

[Stress studies with dipyridamole in patients with coronary heart disease in comparison to coronary angiography, myocardial scintigraphy and ergometry findings]. / Belastungsuntersuchungen mit Dipyridamol bei Patienten mit koronarer Herzkrankheit im Vergleich zu koronarangiographischen, myokardszintigraphischen und ergometrischen Befunden.

In 102 patients with typical symptoms of angina pectoris who underwent a coronary angiography a Dipyridamol test was performed. The result was a sensitivity of about 84% concerning the coronary heart disease and a specifity of about 93%. In the same test persons the ECG after work showed a sensitivity of about 84% and a specifity of about 57%. Dipyridamol test and bicycle ergometry are methods of the same value for the preinvasive diagnostics of the coronary heart disease which should supplement each other. The higher specifity of the ECG changes in the Dipyridamol test was evident in comparison to the bicycle ergometry. In 85 of our patients the Tl-201-scintigraphy was carried out under Dipyridamol and ergometer stress. For the Tl-201-scintigraphy under Dipyridamol a sensitivity of about 70% and a specifity of about 81,5% was the result. In the Tl-201-scintigraphy under ergometer load a sensitity ob about 84% and a specifity of about 57% was the result. The proportion of exactly positive findings increased with the number of the stenosed vessels under ergometer as well as Dipyridamol intervention. A negative load scintigraphy does not exclude a coronary heart disease, but renders a three-vessel-disease very improbable.

[Atrial synchronous ventricular stimulation with reduced a.v. delay time as a therapeutic principle in hypertrophic obstructive cardiomyopathy]. / Vorhofsynchrone Ventrikelstimulation mit verkürzter a.v. Verzögerungszeit als Therapieprinzip der hypertrophischen obstruktiven Kardiomyopathie.

For the hypertrophic obstructive cardiomyopathy with left-ventricular pressure gradient in rest a causal therapy is nowadays not yet known. Therefore, it should be tested, in what respect from former observations over reductions of the pressure gradient by an untimely foreign excitation of the ventricles from the apex of the right ventricle a therapy principle can be derived. For this purpose out of a group of 84 patients by left-right heart catheterization, coronarography, computer cardio-tomography and scintigraphy of the myocardium 23 test persons with typical hypertrophic obstructive cardiomyopathy and a left-ventricular gradient in rest greater than or equal to 30 mm Hg were selected for the transitory electrostimulation. After placing of one electrode in the right atrium and another one in the right ventricle one after another a VOO-, VAT- and DOO-pacing were used. For the two last mentioned forms of stimulation as electronic atrio-ventricular retardation times 100, 40, 20, 10 and 5 ms were selected. With all three kinds of stimulation in 5 of the patients (group A) reductions of gradients greater than or equal to 51% and in 12 cases of hypertrophic obstructive cardiomyopathy (group B) diminishments between 30 and 50% could be obtained. Only in 6 patients (group C) reductions of less than or equal to 29% were registered. The optimum of prematurity necessary for obtaining maximum pressure reductions is individually different, but is almost in every case between 5 and 20 ms. Further seven parameters measured during the stimulation phases showed that these reductions are not caused by a decrease of the stroke volume, but by an enlargement of the effective opening of the outlet. Apparently, in a part of the patients with hypertrophic obstructive cardiomyopathy by the foreign excitation from the apex of the ventricle a temporary and spatial course of excitation can be induced, by means of which the degree of functional stenosing is decreased. Since for several patients the removal of the disturbance of the systolic function is to be regarded as therapeutically reasonable partial success, the transitory diagnostic pacing is recommended for all patients with typical hypertrophic obstructive cardiomyopathy and a gradient in rest greater than or equal to 30 mm Hg. The indications and technical prerequisites for a permanent electrostimulation with suitable systems are represented.

[Computer tomographic evaluation of left ventricular kinetics]. / Computertomographische Beurteilung der linksventrikulären Kinetik.

The judgment of the function of the left ventricle is computer-tomographically possible using the ECG-regulated cardio-computer-tomography in a temporary resolution of about 0.1 sec. The qualitative and quantitative evaluation of the systolic and diastolic changes of the ventricle in patients with normal CT-findings, with idiopathic hypertrophic subaortic stenosis and with disturbances of motility in chronic ischaemic heart disease confirms the possible functional evidence known from literature. The quantitative parameters, in particular the systolic abbreviation of the axis, allow an estimation of the motility. The measurement of the thickness at the interventricular septum and at the lateral wall of the myocardium as well as the systolic abbreviation of the axis and the left-ventricular ejection fraction are essentially higher in the idiopathic hypertrophic subaortic stenosis than in the normal group. The values of the patients with disturbances of motility in the ischaemic heart disease were clearly below. The diagnosis of the idiopathic hypertrophic subaortic stenosis with response of the size of obstruction by the telesystolic and telediastolic pictures is possible in a high percentage. Sequelae of the chronic ischaemic heart disease, e.g. scars, become visible by a narrowing or an absence of the normal edge of the myocardium. Global and localized disturbances of motility are diagnosable by phase-referred systolic and diastolic ECG-regulated pictures.

[The value of computer tomography in the postoperative long-term surveillance of patients with a vascular prosthesis for aorta replacement]. / Der Stellenwert der Computertomographie in der postoperativen Langzeitüberwachung von Patienten mit gefässprothetischem Aortenersatz.

Because of the possibility of life-threatening late complications by anastomotic aneurysms and the danger of their rupture, all patients in whom a coarctation of the aorta was resected and replaced by a vascular prosthesis must be followed up continuously for life. Their chest x-rays show-in addition to unequivocally normal or pathological findings-sometimes questionable variations of the aortic outline, which must be diagnosed definitely by further investigations. By means of computerized tomography, the suspicion of an anastomotic aneurysm can either be refuted or confirmed in almost all cases. Thus, the invasive examination by aortography, which is desirable before operation of an aneurysm, may be omitted in the group of unsuspicious patients. Out of 198 patients, who received a vascular prosthesis for correction of an aortic coarctation in the time from 1960 to 1980, 27 were examined by computerized tomography because of irregular findings in their chest x-rays. In 6 patients the suspicion of an anastomotic aneurysm was confirmed and could be proved by aortography and reoperation. In 21 patients an aortography could be omitted because of its unsuspicious findings by computerized tomography.

[Diagnosis and therapy of supraventricular tachycardia]. / Diagnostik und Therapie supraventrikulärer Tachykardien.

In form of a survey is demonstrated which contributions make, apart from clinic and routine ECG, the storage ECG, the load ECG as well as special ECG derivation techniques, such as the oesophagus ECG, intracardiac ECG derivations with electrostimulation as well as the endocardiac mapping technique for the analysis of various forms of supraventricular tachycardias including the preexcitation syndromes. Also the discussion of medicamentous and electrotherapeutic methods is performed above all under the clinical aspects of applicability, in which cases the hierarchy and combination in therapy are dealt with.

[Effect of obesity on cardiovascular performance]. / Untersuchungen zum Einfluss des Ubergewichtes auf die kardiovaskuläre Leistung.

On 55 healthy test persons with normal weight and 76 healthy middle-aged obese test persons the measurement of systolic time intervals was performed standing and lying. In 39 obese patients and 55 test persons with normal weight a load ergometry was carried out. No significant difference between persons with normal weight and extreme overweight was recognized with regard to the index of tension. However, there were clear differences between persons with normal and overweight as to the time of tension and left-ventricular ejection time lying and standing, independent of the behaviour of blood pressure. In persons with overweight a significantly lower cardiac output was found. The index of tension of obese persons with a degree of efficacy below 75 Watt was on an average 1.04. Only half of the persons with overweight reached a degree of efficacy of 100 Watt. In 32 obese persons with a degree of efficacy of more than 75 Watt the regulation of frequency and blood pressure did not differ from that of persons with normal weight.

[Occurrence of repetitive ventricular responses in programmed right ventricular stimulation]. / Zum Auftreten von Repetitive Ventricular Responses bei programmierter rechtsventrikulärer Stimulation.

In 30 patients with various disturbances of rhythm (17 males, 13 females) at the age of 16-72 years during a conduction analysis a programmed stimulation relating to the right ventricle was carried out and the occurrence of repetitive ventricular responses was evaluated. 9 patients did not show any repetitive ventricular responses. In 14 patients with various disturbances of rhythm a V3-phenomenon was evoked which as an interventricular reentry is a physiological phenomenon. In 6 patients with myocardial scar and extreme bradycardia, respectively, apical torsades were observed via a V3-phenomenon with transition into an intraventricular reentry (one persisting interventricular reentry) and like 2 provoked ventricular tachycardias (one with, one without observation of apical torsades) were valuated as a reference to the electric instability of the ventricular myocardium. The obtainability of apical torsades as well as of V3 was possible only in a minimal retardation of the conduction to His's bundle depending upon the frequency of stimulation and precociousness of S2. Only in a transition into an intraventricular reentry apical torsades speak for, non-evokable apical torsades do not speak against an increased electric instability of the ventricular myocardium, but for existing and not existing, respectively, suitable distal conduction conditions to the stimulation reentry.

Severe late complications after operative correction of aortic coarctation by interposition of prosthesis.

Out of 198 patients with aortic coarctation who were operated on with the implantation of an orthotopic bypass vascular prosthesis, 7 developed severe late complications 9-20 years postoperatively with late anastomosis dehiscence which resulted either in acute rupture and sudden death from massive hemorrhage (2 patients) or in false aneurysms with or without delayed rupture. Reoperation was done in 4 patients. After elective reoperation 2 of 3 patients survived, one elective and one emergency case died. The only evident reason for the late suture disruption was complete absorption of polyamide suture material in 6 cases. Therefore all patients with polyamide-sutured anastomosis should be followed-up thoroughly even in the late postoperative period in order to detect indications for elective reoperation. Suture material for anastomosis with any prosthesis must be nonabsorbable for lifetime.

[Treatment of ventricular arrhythmias with mexiletine]. / Zur Behandlung ventrikulärer Rhythmusstörungen mit Mexiletin.

The development of new antiarrhythmic drugs allows to a certain extent the performance of a differential therapy and prophylaxis. This also concerns the lidocaine-like substance mexiletine, which according to Vaughan-Williams is to be classified into class I B of the antiarrhythmic drugs with direct membrane effect. It is effective in disturbances of the ventricular rhythm also in oral therapy, which in most cases are more life-endangering than the supraventricular ones. In own examination in 21 of 26 patients a complete or far-reaching suppression of accumulated extrasystoles and particularly of ventricular tachycardias could be achieved by an oral long-term therapy with 600--800 mg mexiletine. In the acute experiment short-term infusions were not effective in patients with ventricular tachycardias, since apparently no sufficient plasma level was obtained, wherefore also a following permanent drop infusion is recommended. The rate of side-effects was insignificant and in no case led to a withdrawal of the therapy.