[Which patient with chronic atrial fibrillation suits well for device closure of the left atrial appendage?]. / Welcher Patient mit chronischem Vorhofflimmern kommt in Frage für einen perkutanen Vorhofohrverschluss?

Atrial fibrillation affects about 3% of all persons older than 65 years of age. About 30% of patients with chronic atrial fibrillation suffer from at least one cerebrovascular accident. On the other hand, atrial fibrillation is responsible for 15 - 20% of all cerebrovascular insults. A CHADS2 score of 3 points or more has been found to be a reliable predictor of future cerebrovascular events in patients with chronic atrial fibrillation. Oral anticoagulation remains the mainstay of treatment to prevent thromboembolic complications. Percutaneous closure of the left atrial appendage is a promising approach and probably a valid alternative in older patients intolerant to oral anticoagulation.

[Selective kidney angiography within the scope of heart catheterization: pathological findings and therapeutic consequences]. / Selektive Nierenangiographie im Rahmen der Herzkatheteruntersuchung: Pathologische Befunde und therapeutische Konsequenzen.

BACKGROUND: The importance of renal artery stenosis as a cause of refractory hypertension, recurrent pulmonary edema and renal failure is being increasingly recognized. The prevalence and clinical consequences of renovascular and macroscopic renal parenchymal pathology in patients undergoing coronary angiography is assessed prospectively. PATIENTS AND METHODS: Selective renal artery angiography was performed in 190 consecutive patients following coronary angiography and prior to PTCA if indicated. Diagnostic yield, therapeutic consequences, complications and fluoroscopy time were noted. RESULTS: Mean age as 63 (+/- 11) years, 74% of patients were males. Mean fluoroscopy time (including PTCA or PTA) was 8 (+/- 11) minutes. The pathological renal and renovascular findings included critical atherosclerotic renal artery stenosis in four patients (2%), non critical (angiographically < 60%) stenosis in 22 patients (12%), double arterial supply on one side in 26 patients (14%), on both sides in seven patients (4%), fibromuscular dysplasia in two patients (1%) and large renal cyst, renal artery aneurysm and aberrant blood supply of an ectopic pelvic kidney in one patient (0.5%). The four patients with critical renal artery stenosis underwent primarily successful PTA and stenting. CONCLUSIONS: Selective renal angiography in the wake of coronary angiography is safe and inexpensive. Furthermore, it can be performed easily in the majority of cases. The diagnostic yield of renal angiography ist not negligible; 2% of patients had critical renal artery stenosis with an unequivocal indication for an interventional procedure. Progression of (as yet) nonsignificant renal artery stenosis is reported in a large number of cases, meaning that early diagnosis may have later therapeutic consequences. Ad hoc PTA and stenting is the treatment of choice for significant renal artery stenosis.

[Differential diagnosis and therapy of secondary hypertension (with special reference to renal artery stenosis) in general practice]. / Praxisbezogene Differentialdiagnose und Therapie der sekundären Hypertonie (unter besonderer Berücksichtigung der Nierenarterienstenose).

Secondary hypertension is present in 3-5% of patients suffering from high blood pressure. Some of the causes of secondary hypertension can be cured and all of them need specific treatment. This can only be provided when an accurate diagnosis is sought. On the other hand, adequate knowledge of the different etiologies and their respective clinical presentation avoids unnecessary and expensive laboratory and imaging investigations. Renal artery stenosis is increasingly being recognised as a relevant and frequent cause of secondary hypertension and renal insufficiency, this previously underdiagnosed entity is thus covered in some detail. Endocrine causes of secondary hypertension are discussed, their diagnosis and treatment should be discussed with an endocrinologist. Before diagnosing hypertension as being refractory to therapy, adequate treatment and patient-compliance have to be enforced. Some frequently overseen but important causes of hypertension in daily practice are also discussed (drug-induced, loss of vessel wall elasticity in old age, etc.).

[Catheter-induced dissection of the right coronary ostium and aortic root]. / Katheter-induzierte Dissektion des rechtskoronaren Ostiums und der Aortenwurzel.

We describe a catheter-induced dissection of the ostium of the right coronary artery extending to the aortic root. As an alternative to emergency surgery, a dacron stent-graft was placed in the proximal right coronary artery, thus, sealing the dissection. The patient later underwent elective aortocoronary bypass surgery. The therapeutic options in this situation with diffuse coronary disease, in which only one severe culprit lesion can be identified, are discussed.

[Physician referral versus self-referral for initial outpatient cardiological examination]. / Arztliche versus Selbstzuweisung zur ambulanten kardiologischen Erstuntersuchung.

BACKGROUND AND OBJECTIVE: To compare the clinical characteristics of patients who referred themselves for specialist cardiological examination with those of patients referred by a general practitioner, to assess the usefulness of inserting a general practitioner or general physician before referral, and to project the likely cost effectiveness. PATIENTS AND METHODS: The data on 77 patients referred by a medical practitioner (group 1) were prospectively compared with those of a cohort of 65 patients who referred themselves for specialist cardiological examination (group 2). All patients fulfilling the inclusion criteria had been included consecutively over a period of one year. Excluded were patients with confirmed cardiological disease; those who had previously undergone specialist cardiological examination elsewhere; those who came for a second opinion; and those who had been referred as part of a medical insurance assessment or primarily for invasive tests. Comparisons were made regarding symptoms, investigations performed and the number of new cardiological diagnoses in each group. The assessments of the cardiologists regarding the presence or organic heart disease (before the performance of any diagnostic tests) was tested as to their sensitivity, specificity as well as their positive or negative predictive value. RESULTS: Symptoms and incidence of organic heart disease differed significantly between the two groups. A doctor's referral to a cardiologist seemed to have a greater diagnostic and therapeutic advantage (filtre function). The cost of establishing a diagnosis of organic heart disease for group 1 patients was only about 80% of that for group 2 patients. A large proportion of group 2 patients did not wish the results to be transmitted to their general practitioner. CONCLUSIONS: The relationship between patient and general practitioner needs improvement. Not included in this study were patients with organic heart disease who had not had any access to specialist cardiological investigation or only after a cardiac event.

Long-term Doppler echocardiographic follow up in normally functioning aortic St. Jude Medical prosthesis.

BACKGROUND AND AIMS OF THE STUDY: Mean and peak Doppler gradients remain the most frequently used parameters for follow up of prosthetic aortic valves. Gradients that deviate from baseline recordings can lead to uncertainty among physician and patient, especially if symptoms have not completely subsided after surgery, or have recurred. This study aimed to document long-term evolution of mean and peak gradients in patients with stationary clinical symptoms and signs. METHODS: Seventy-six patients (48 men, 28 women), of mean age 56.1 +/- 14.5 years (range: 23 to 82 years) who underwent St. Jude Medical bileaflet prosthesis implantation were followed up for a mean of 3.9 years (range: 1 to 7 years), both clinically and echocardiographically. Evolution of mean and peak gradients, left ventricular function, other valvular lesions and rhythm as well as adequacy of anticoagulation were examined. RESULTS: Mean gradient increased from 12.3 +/- 5.5 to 14 +/- 5.7 mmHg (p = 0.002). Mean gradient increased in 47 patients, decreased in 17 and was unchanged in 12. There was no correlation between left ventricular function, appropriate anticoagulation, left ventricular hypertrophy, age or gender with change in mean or peak gradient. Change in peak gradient correlated excellently (r2 = 0.82) with that in mean gradient. CONCLUSIONS: The range of evolution of Doppler gradients in normally functioning St. Jude Medical prostheses has been defined in this study. Slight long-term increases in mean and peak pressure gradients are normal findings and do not warrant a change in management strategy if unaccompanied by deterioration of symptoms and/or clinical signs. Although we recommend routine determination of baseline flow measurements within three months of prosthesis implantation, mean and peak gradients are adequate follow up parameters. Peak gradient correlated well with mean gradient and may be a useful adjunct for follow up in clinical practice.

Regional wall motion changes with dobutamine as a pharmacological stress test during cardiac catheterization in patients with significant coronary artery disease.

BACKGROUND: Preliminary study to test the feasibility of pharmacological stress testing during cardiac catheterization, thus combining anatomical and functional information. PATIENTS AND METHODS: 21 consecutive patients with known or suspected coronary artery disease, referred for diagnostic catheterization. Biplane ventriculography was performed before and during dobutamine infusion. The patients were subdivided into 3 groups: Group I (n = 11, 52%) with at least one territory supplied by a significantly stenosed coronary artery and showing normal resting regional wall motion. Group II (n = 6, 29%) patients in whom the affected vessel(s) supplied exclusively a territory with regional wall motion abnormalities at rest. Group III (n = 4, 19%) had no significant coronary artery disease and served as control. RESULTS: In group I, 9/11 (82%) patients and in group II, 3/6 (50%) patients showed either ischemia or viability reactions or both after dobutamine stress. Overall, substantial functional information was gathered in 12/17 patients (71%). Control patients showed no worsening of regional wall motion under dobutamine. Neither global left ventricular ejection fraction nor left ventricular end diastolic pressure were as accurate in detecting ischemia as regional wall motion analysis. In patients who had only ischemia and no viability reaction as judged by regional wall motion analysis, ejection fraction fell significantly in 4/6 (67%) patients; end diastolic pressure on the other hand rose significantly in 3/6 (50%). CONCLUSIONS: Dobutamine stress testing performed during cardiac catheterization is convenient, feasible and safe and yields clinically useful information in a high percentage (71%) of patients with significant coronary artery disease. Further experience is needed to evaluate the sensitivity, specificity and predictive value of this new approach.

Cardioprotection in patients undergoing chemo- and/or radiotherapy for neoplastic disease. A pilot study.

OBJECTIVES: To assess the cardioprotective efficiency of an antioxidant regimen (vitamins E, C and N-acetylcysteine) in patients receiving high dose chemo- and/or radiotherapy for malignant disease. METHODS: Prospective, placebo controlled, randomized and double blinded pilot study involving 13 patients receiving chemotherapy and 12 patients receiving radiotherapy. RESULTS: In patients receiving antioxidants, left ventricular ejection fraction did not change (63 +/- 4% to 63 +/- 4%). In the placebo group, ejection fraction changed from 67 +/- 6% to 61 +/- 4% (p = 0.03). No patient in the antioxidant group and 6/13 (46%) patients in the placebo group showed a fall of > 10% in the left ventricular ejection fraction. In the chemotherapy group, the left ventricular ejection fraction changed from 62% (+/- 2) to 63% (+/- 2) in the patients treated with antioxidants (ns) and from 63% (+/- 5) to 61% (+/- 5) in patients treated with placebo (ns). No patient showed a significant fall in ejection fraction in the antioxidant group, whereas 2/7 (29%) in the placebo group showed a reduction > or = 10%. In the radiotherapy group, left ventricular ejection fraction did not change ¿64% (+/- 6) to 64% (+/- 5)¿ in patients treated with antioxidants (ns) and changed from 70% (+/- 8) to 60% (+/- 4) in patients treated with placebo (p = 0.008). No patient in the antioxidant group, but 4/6 (66%) patients in the placebo group showed a fall of > or = 10% in ejection fraction. CONCLUSION: The small number of patients in the study precludes a definitive statement. The preliminary results however suggest efficient cardioprotection by this nontoxic and inexpensive antioxidant combination, so larger studies are warranted for confirmation.

High dose dipyridamole as a pharmacological stress test during cardiac catheterisation in patients with coronary artery disease.

AIM: To validate dipyridamole as a pharmacological stress test during cardiac catheterisation, allowing both functional and morphological estimation of stenosis severity. METHODS: The study encompassed 74 patients: 62 patients with significant coronary artery disease (age 61 (SD 8) years; seven women, 55 men) and 12 controls. Regional wall motion, left ventricular ejection fraction and end diastolic pressure were analysed in the resting state and after high dose intravenous dipyridamole. Patients were subdivided into four groups: group I (n = 32, 43%) had stopped all anti-ischaemic treatment for > 24 h, group II (n = 14, 19%) was under treatment, group III (n = 16, 22%) had significant coronary artery disease only in regions with regional wall motion abnormalities at rest, and group IV consisted of 12 control patients (16%) with no significant coronary artery disease (age 62 (8) years, three women, nine men). RESULTS: The sensitivity of dipyridamole testing in patients with coronary artery disease was poor. The best sensitivity was obtained with regional wall motion analysis (26/62 = 42%) and with global left ventricular ejection fraction (25/62 = 40%). Specificity was 100% for regional wall motion and 100% for ejection fraction. Calculated positive and negative predictive values for regional wall motion were 100% and 63%, respectively. CONCLUSIONS: Although safe, handy, and inexpensive, dipyridamole is not an adequate pharmacological stress test during cardiac catheterisation because of its low sensitivity.

-Aneurysm of the pulmonary artery and pulmonary artery hypertension 22 years after Mustard reversal operation in transposition of great vessels-. / Aneurysma der Pulmonalarterie und pulmonalarterielle Hypertonie 22 Jahre nach Mustard-Umkehroperation bei Transposition der grossen Gefässe.

An increasing number of patients with transposition of great arteries reaches adult age after an atrial redirection operation. The well known late sequelae of the Mustard and Senning operations include supraventricular brady-tachyarrhythmias, dilatation and failure of the systemic ventricle, severe tricuspid valve incompetence, obstruction of either the systemic or pulmonary venous return as well as left ventricular outflow tract obstruction, and baffle leaks. The case of a 26-year-old woman with a rarer postoperative course, namely severe aneurysmal dilatation of the pulmonary artery and pulmonary arterial hypertension 22 years after a Mustard operation is described. The pros and contras of the available therapeutic alternatives are discussed.

[Cardioprotection in chemo- and radiotherapy for malignant diseases--an echocardiographic pilot study]. / Kardioprotektion bei Chemo- und Radiotherapie für maligne Erkrankungen--eine echokardiographische Pilotstudie.

AIM: Pilot study, examining the cardioprotective effect of an antioxidant regimen in patients with malignancies receiving high dose chemo- or radiotherapy. PATIENTS AND METHODS: 14 patients with chemotherapy and 10 patients with radiotherapy were randomized in a double-blind fashion (placebo versus vitamin E and C and N-acetylcysteine). Systolic and diastolic echocardiographic parameters were determined before and within three weeks of treatment completion. RESULTS: Left ventricular ejection fraction fell significantly in patients receiving placebo (radiotherapy: 67 +/- 6 to 56 +/- 2%, p = 0.008, chemotherapy: 67 +/- 7 to 60 +/- 8%, p = 0.05). Patients on antioxidants showed no significant fall in EF (radiotherapy: 63 +/- 8 to 61 +/- 7%, chemotherapy: 67 +/- 5 to 64 +/- 6%). CONCLUSION: The small number of patients in the study precludes a definitive statement. The preliminary results, however, suggest efficient cardioprotection by this cheap and safe antioxidant combination, so that larger studies are warranted for confirmation.

[Adult patients with congenital heart diseases: Berne statistics]. / Adulte Patienten mit kongenitalen Herzvitien: Berner Zahlen.

Data of the 272 adult patients with congenital heart disease followed up in our department are analyzed. We emphasize the lack of reliable statistical surveys of this group of patients at the present time. The need for better intra- and interdisciplinary cooperation, specially between referring physicians and tertiary centers, is stressed.

Plasma potassium response to acute respiratory alkalosis.

Acute respiratory alkalosis (hyperventilation) occurs in clinical settings associated with electrolyte-induced complications such as cardiac arrhythmias (such as myocardial infarction, sepsis, hypoxemia, cocaine abuse). To evaluate the direction, magnitude and mechanisms of plasma potassium changes, acute respiratory alkalosis was induced by voluntary hyperventilation for 20 (18 and 36 liter/min) and 35 minutes (18 liter/min). The plasma potassium response to acute respiratory alkalosis was compared to time control, isocapnic and isobicarbonatemic (hypocapnic) hyperventilation as well as beta- and alpha-adrenergic receptor blockade by timolol and phentolamine. Hypocapnic hypobicarbonatemic hyperventilation (standard acute respiratory alkalosis) at 18 or 36 liter/min (delta PCO2-16 and -22.5 mm Hg, respectively) resulted in significant increases in plasma potassium (ca + 0.3 mmol/liter) and catecholamine concentrations. During recovery (post-hyperventilation), a ventilation-rate-dependent hypokalemic overshoot was observed. Alpha-adrenoreceptor blockade obliterated, and beta-adrenoreceptor blockade enhanced the hyperkalemic response. The hyperkalemic response was prevented under isocapnic and isobicarbonatemic hypocapnic hyperventilation. During these conditions, plasma catecholamine concentrations did not change. In conclusion, acute respiratory alkalosis results in a clinically significant increase in plasma potassium. The hyperkalemic response is mediated by enhanced alpha-adrenergic activity and counterregulated partly by beta-adrenergic stimulation. The increased catecholamine concentrations are accounted for by the decrease in plasma bicarbonate.

[Balloon valvuloplasty of a discrete subvalvular aortic stenosis]. / Ballonvalvuloplastie einer diskreten subvalvulären Aortenstenose.

We describe the successful percutaneous balloon valvuloplasty of a discrete subaortic stenosis in an adult patient. The maximal gradient of 160 mm Hg (mean 100) was reduced to 45 and 33 mm Hg respectively. The procedure required only one overnight hospital stay.

[Successful thrombolysis of a thrombosed mitral valve prosthesis]. / Erfolgreiche Thrombolyse einer thrombosierten Mitralklappenprothese.

Thrombosis of a cardiac valve prosthesis is a rare but life-threatening event. The diagnosis may be suspected clinically and verified by Doppler echocardiography and/or fluoroscopy. Thrombolysis is being increasingly used as an alternative to emergency surgery (thrombectomy or prosthesis replacement). We describe the clinical course of successful thrombolysis of a thrombosed double leaflet Carbomedics No 29 prosthesis in mitral position, using urokinase, in an elderly female presenting with severe NYHA class IV dyspnea. Thrombolysis should be considered as a first line of treatment for thrombosed cardiac valve prostheses. The addition of a platelet inhibitor is warranted in patients with an episode of prosthetic cardiac valve thrombosis under adequate oral anticoagulation.