[Limits of intensive care medicine. Medical and legal aspects]. / Grenzen der Intensivmedizin. Arztliche und juristische Aspekte.

Modern intensive care can extend life. However, it may also extend the dying period. Because of this fact, doctors have been publicly accused of extending dying beyond human dignity, rather than accepting the end of life. In an attempt to regulate the abandonment, reduction or interruption of intensive care, the "Bundesärztekammer" has released new guidelines in 1993: measures which extend life - medicinal or apparative - may be interrupted if the delay of the patient's death results in an unreasonable extension of his suffering, and his terminal illness can not be influenced. Under these circumstances, a possible shortening of life may be accepted. A prescription of pain- and anxiety relieving drugs is both medically and legally accepted, even if it results in a shortening of life for a limited time. Today, an insufficient analgesia of seriously ill patients should be considered a treatment error.

[Single or multiple balloon inflations in coronary angioplasty? Acute results and long-term angiography results of a prospective, randomized study of 300 patients]. / Einmalige oder mehrmalige Balloninsufflation bei der Koronarangioplastie? Akutresultate und angiographische Langzeitergebnisse einer prospektiven, randomisierten Studie bei 300 Patienten.

325 coronary lesions in 300 consecutive patients (257 male, 43 female, 52 +/- 8 years) undergoing either single-vessel (n = 275) or double-vessel PTCA in two independent procedures (n = 25) were prospectively randomized to either one (group A, n = 167) or three (group B, n = 168) balloon inflations. By clinical and angiographic criteria, PTCA was successful in 295/325 lesions (90.8%) with no significant difference for group A (88.6%) and B (93.0%). Clinical follow-up was achieved in 92% of patients and angiographic follow-up was obtained in 261/295 (88.5%) successfully dilated lesions (A: 87.8%; B: 89.1%). Angiographic appearance of the dilated lesion (in % diameter stenosis) prior to PTCA, directly following PTCA and at follow-up was comparable for both groups: gr. A: 71 +/- 11%, 32 +/- 10%, and 40 +/- 21%; gr. B: 70 +/- 11%, 30 +/- 10%, and 40 +/- 20% resp. Restenosis rate was similar with 26.9% in group A and 29.8% in group B. The randomization had to be abandoned in 144/325 cases (44.3%) due to medical reasons. Results of only those lesions where it was possible to follow the initial randomization demonstrated a different pattern. Success rate was slightly higher in those with 3 inflations (gr. B1, n = 111) with 93.0% as compared to lesions with only one inflation (gr. A1, n = 70) with 88.6% success (p = ns). Subsequently, the initial angiographic result was slightly better for B1 with a reduction in diameter stenosis from 69 +/- 11% to 29 +/- 10% compared to A1 (71 +/- 11% and 32 +/- 10% resp.).(ABSTRACT TRUNCATED AT 250 WORDS)

[Electrocardiographic diagnosis of acute graft rejection after heart transplantation]. / Elektrokardiographische Diagnostik akuter Abstossungsreaktionen nach Herztransplantation.

In order to evaluate the diagnostic value of standard-ECG (ST-ECG) and precordial mapping-ECG with 63 unipolar leads (PM-ECG) for detection of acute cardiac allograft rejection, 15 patients (12 male, 3 female; age range 24-64 years) were studied. ST-ECG and PM-ECG were recorded along with 94 endomyocardial biopsies. Twenty-four acute rejections were detected histologically. Using the ST-ECG, a reduction of the QRS-amplitude-sum (lead I, II, III, V1 and V6) greater than or equal to 5% in comparison with the ECG obtained 1 week before was found to be the best diagnostic criterion (sensitivity 63%, specificity 74%, positive predictive value 48%, negative predictive value 85%). By analysing the PM-ECG a drop of the QRS-amplitude greater than or equal to 12% in greater than or equal to 14/63 precordial leads was determined to be the most reliable parameter (sensitivity 79%, specificity 71%, positive predictive value 49%, negative predictive value 91%). In contrast to the high sensitivity of PM-ECG, ST-ECG was less suitable for detection of acute rejection. However, taking into account the high negative predictive value of PM-ECG, acute rejection could be excluded with high probability, if the QRS-amplitudes of the PM-ECG remained stable. This may lead to a lower frequency of routinely performed endomyocardial biopsies.

[Heart damage after electric injury]. / Herzschädigung nach Stromunfall.

Death from electrical accident due to low voltage (220 Volt/380 Volt) is usually caused by ventricular fibrillation. In humans who sustain non fatal electrical injury abnormal ECG findings due to myocardial damage are rare. 243 (76%) of 320 ECGs of survivors of an electrical accident were diagnosed as normal. In 42 patients (13%) unspecific electrographic changes were seen and in 35 (11%) abnormal ECGs were found. In comparison to findings in normal populations no significant accumulation of ECG changes was observed. A causal relationship between abnormal ECG findings and electrical accident is only then probable if ECG abnormalities are documented immediately after injury and serial ECG controls demonstrate significant changes in comparison to the initial abnormality.

[Long-term results of elective percutaneous transluminal coronary angioplasty. A clinico-angiography study of 289 consecutive patients]. / Langzeitresultate nach elektiver perkutaner transluminaler Koronarangioplastie (PTCA). Eine klinisch-angiographische Studie mit 289 konsekutiven Patienten.

289 consecutive patients (255 male, 34 female, 50 +/- 6 years) had an elective single-vessel-PTCA between October 1978 and March 1983. A clinical long-term follow-up was obtained after 4.7 (3-10) years. The PTCA success-rate was 73% with a non steerable balloon catheter being used in 95% of the cases. For 271/289 patients with follow-up (94%), the 56-month-survival rate was 96%, the incidence of non-fatal myocardial infarctions 11%, and the need for a second intervention (PTCA and/or bypass surgery) was 39%. The most favorable long-term outcome was observed in patients without need of a second intervention (97% survival, 7% non-fatal myocardial infarction, 83% without cardiac complaints during everyday life), and in patients with elective bypass surgery after an unsuccessful PTCA (100% survival, 5% myocardial infarction). 32/138 (23%) of patients without a second intervention during follow-up underwent an angiographic control after an average of 4.7 years. In comparison with the first follow-up angiogram 6 months after PTCA, the mean residual stenosis at the PTCA-site showed a slight decrease. It is concluded that PTCA offers good clinical and angio-graphic long-term results in single-vessel disease, with an excellent prognosis of patients without need for a second intervention.

[Incidence of pathologic ECG findings in survivors of electric accidents]. / Häufigkeit pathologischer EKG-Befunde bei Uberlebenden nach Stromunfällen.

ECGs of 320 male survivors of electrical accidents were examined. The results were compared with findings in normal populations reported in previous epidemiological studies. 243/320 electrocardiograms (75.9%) were considered to be normal. In 42/320 (13.2%) unspecific electrocardiographic changes were seen, and in 35/320 (10.9%) abnormal ECGs were found. No significant accumulation of ECG changes was observed in comparison to the control groups. Results confirm abnormal ECG-findings to be rare in humans who sustain non-fatal electrical injury. If an ECG is considered to be abnormal, a causal relationship is only probable if findings are documented immediately after injury, and if serial ECT controls demonstrate significant changes in comparison to the initial abnormality.

[ECG in acute myocardial infarct. Continuous registration in thrombolytic therapy]. / Das EKG beim akuten Myokardinfarkt. Kontinuierliche Registrierung während der thrombolytischen Therapie.

For 35 patients with acute myocardial infarction undergoing thrombolytic therapy (31 patients with streptokinase and 4 with rt-PA), the treatment effect was assessed angiographically and correlated with ECG changes. These ECG changes were found by continuous registration of eight "strategically" located precordial leads in patients with anterior myocardial infarction, and five precordial leads plus three limb leads in those with posterior myocardial infarction. In 31 patients (group A), successful reperfusion could be verified by angiography, while in 4 patients the infarct-related vessel remained closed. In 3 further cases (group B), recanalization could be achieved only by additional mechanical intervention. The average duration of ECG surveillance was 87 min in group A and 85 min in group B. A significant change of R-amplitudes during this period of time could not be observed. ST-60-value of group A (total of ST-elevations and depressions 60 msec after S of all surveillance electrodes, divided by number of electrodes) was reduced under thrombolysis from 0.377 mV (SD +/- 0.270) to 0.133 mV (SD +/- 0.118) (p less than 0.004). This means a reduction of 64%, while the corresponding values in group B did not change (0.535 mV, respectively 0.546 mV) before and after therapy. When only the electrode with the highest ST-60-value was checked before therapy ("sensitive lead"), reduction in group A was as high as 71%. Except for two patients, all other 29 patients with successful reperfusion either precordially or in the limb leads showed a reduction of ST-segment abnormalities (ST 60) of more than 50% during surveillance time. This could not be observed in any of the unsuccessfully treated patients.(ABSTRACT TRUNCATED AT 250 WORDS)

The geometry of the aortic root in health, at valve disease and after valve replacement.

For the design of aortic valve prostheses with a separation-free flow field and minimum pressure drop the geometry of the aortic root is of high importance, since an appropriate adjustment of the prostheses to the surrounding geometry could largely reduce the risk of thromboembolic complications. For the investigation of the geometry of the aortic root 604 angiographic films out of a total stock of 15,000 of the Medical Clinic I were evaluated. The film material was preclassified into five clinical categories according to the patient's data. For each category characteristic geometries could be derived in non-dimensional form.

Controversial aspects of coronary endarterectomy.

Between 1980 and 1987, 635 patients underwent coronary bypass grafting combined with coronary endarterectomy. A total of 728 vessels were endarterectomized and grafted. There were 15 early deaths (2.3%). The mortality rate was higher (7.8%) for multiple-vessel endarterectomy (p less than 0.05). The ratio of MB fraction of creatine kinase to total creatine kinase was greater than or equal to 0.10 in 48% of the cases. The first consecutive 132 survivors were followed for an average of 16 months (range, 4 months to 5 years). No late deaths occurred. Fifty-nine unselected patients underwent postoperative recatheterization at a mean interval of 18 months. An improvement in heart wall contractility could be detected in 13 patients (16.5%) and deterioration in 14 patients (17.7%). A more detailed analysis of wall contractility showed a higher rate of improvement in the posterior wall than in the anterior wall (p greater than 0.05). Furthermore, the better the contractility before operation, the greater the rate of deterioration after operation (p less than 0.05). Despite an average of 55% of all endarterectomized vessels being occluded or severely restenosed, 90% of the patients were clinically improved. A multiparametric analysis revealed that the revascularization of myocardial areas that required endarterectomy had no significant influence with respect to clinical improvement. Endarterectomy should be limited, whenever possible, to myocardial areas with already impaired contractility. Endarterectomy of multiple branches should be treated with caution because the risk of deterioration is potentiated, with a significantly higher perioperative mortality rate.

Evolution of left ventricular function after intracoronary thrombolysis for acute myocardial infarction.

The temporal evolution of left ventricular (LV) function after intracoronary streptokinase therapy for acute myocardial infarction (AMI) was assessed from the data of 264 patients who had complete occlusion of either the left anterior descending or the right coronary artery before treatment. Angiography was performed immediately, and at 3 days and 6 months after AMI in 91%, 71% and 47% of the study group, respectively. Wall motion was measured by the centerline method. In patients with sustained reperfusion, the ejection fraction decreased at 3 days (delta = -2.0 +/- 9.9%, n = 134, p = 0.02) and recovered later (from 54 +/- 12% acutely to 57 +/- 12% at 6 months, n = 82, p less than 0.05). These changes in global function were associated with a marked regression in hyperkinesis in the noninfarcted wall by 3 days, and delayed recovery of wall motion in the infarct region (delta = 0.2 +/- 0.9 at 3 days, p = 0.055; 1.0 +/- 1.2 at 6 months, p less than 0.001). Patients without reperfusion or with reocclusion had a more severe decrease in ejection fraction at 3 days, and little or no subsequent functional recovery. The length of the hypokinetic segment increased significantly by 3 days but subsequently diminished to slightly less than the acute value. It is concluded that full recovery of ischemically impaired myocardium takes greater than 3 days, but compensatory hyperkinesis regresses earlier so that global LV function deteriorates by the third day. Variability or deterioration of LV function early after AMI need not be due to infarct extension; it can reflect regression of hyperkinesis in the noninfarcted region.

Late results after intracoronary thrombolysis and early bypass grafting for acute myocardial infarction.

Successful thrombolysis for acute myocardial infarction reduces early mortality. For definite correction of the underlying arteriosclerotic lesion, invasive treatment is mandatory. Early bypass grafting has been performed in 70 patients with an ischemic interval of less than 4 hours before reperfusion by thrombolysis. Surgery was undertaken an average of 4.5 days after the streptokinase administration. The hospital mortality rate was 1.4%. At 8 years the actuarial survival rate was 88% and the complication-free survival rate, 84%. At the latest follow-up study, 90% of the patients were in functional class I or II. Because of advanced age, 37% of the survivors have retired and 29% are working. Thirty-four percent did not return to work after the operation. In 24 patients a transmural needle biopsy specimen was taken at operation to study the extent of ischemic damage. Surprisingly, the extent of necrosis did not correlate with the ischemic interval (r = 0.17), whereas enzyme activity and extent of necrosis did correlate (r = 0.76). Late angiography was done in 44 patients (56%). The correlation between ischemic interval and regional wall motion score was weak when the whole group was considered (r = 0.35), but 70% of the patients with an ischemic interval of less than 3 hours had normal or near normal regional wall motion. In patients with prolonged ischemia, distribution between normal function and severe damage was uniform. In patients with ultrastructural and wall motion studies, early necrosis and late left ventricular function correlated fairly well (r = 0.69). We conclude that additional early bypass grafting after successful thrombolysis yields excellent long-term clinical results, especially in patients with an ischemic interval of less than 3 hours.

Early recovery of left ventricular function after thrombolytic therapy for acute myocardial infarction: an important determinant of survival.

Thrombolytic therapy for acute myocardial infarction reduces early mortality, but full recovery of left ventricular function after reperfusion is delayed. Therefore, the relations among reperfusion, survival and the time course of left ventricular functional recovery were examined in 226 patients treated with intracoronary streptokinase; 77% (134 patients) had sustained reperfusion and 31 patients had no reperfusion or had reocclusion by day 3. Wall motion was measured from contrast ventriculograms performed in the acute period and 3 days later in the central and peripheral infarct regions and the noninfarct region by the centerline method in 165 patients. Patients with reperfusion had better survival (p less than 0.05, mean follow-up 4.5 years) and a higher ejection fraction at 3 days (52 +/- 12 versus 46 +/- 10%, p less than 0.02) attributable to a significantly different change in peripheral infarct region function between the acute and 3 day studies (0.1 +/- 1.0 versus -0.3 +/- 0.9 SD, p less than 0.05). These early functional changes were significant in patients with anterior myocardial infarction and showed similar trends in those with inferior myocardial infarction. On Cox regression analysis, function measured at 3 days was more predictive of survival than was function measured acutely (chi square for acute ejection fraction = 11.48 versus 24.59 at 3 days). Although, as previously reported, greater than 45% of total recovery of left ventricular function occurs later, the ejection fraction achieved by day 3 is already predictive of survival. Thus, the mechanism by which successful thrombolytic therapy enhances survival is improvement of regional and global left ventricular function early after acute myocardial infarction.

[Reocclusion following successful thrombolytic therapy in acute myocardial infarct]. / Reokklusion nach erfolgreicher thrombolytischer Therapie beim akuten Myokardinfarkt.

Following successful reperfusion of the previously occluded coronary artery in acute myocardial infarction, reocclusion remains an at least partially unsolved problem. The literature reports figures between 10 and 30%. In the present study, 130 out of 543 patients with successful thrombolysis by means of intracoronary streptokinase underwent a follow-up angiography at the 3rd day (106/130, 80%) and/or 6 months (76/130, 59%) after the acute intervention. During the observation period, neither PTCA nor bypass surgery were performed. Reocclusion could be documented in 5.5% of patients at the early stage, and in 25.0% half a year later. In more than 75% of patients, who presented with a reoccluded infarct related artery, clinical evidence of reinfarction had been recorded during the follow-up period.

Residual coronary stenosis after thrombolysis with rt-PA or streptokinase: acute results and 3 weeks follow-up.

Ninety-one patients with acute myocardial infarction were assigned to intravenous treatment with streptokinase or rt-PA as part of the randomized trial carried out by the European Study Group for Recombinant Tissue-Type Plasminogen Activator (rt-PA). A patent coronary artery was found in 37 of 45 (82%) patients treated with rt-PA and in 27 of 46 (59%) patients treated with streptokinase 75-90 minutes after start of infusion. Patients were subsequently anticoagulated with heparin or dicoumarol up to a repeat angiography 3 weeks after the infarction. Of the 64 patients with successful reperfusion, 3 died and 3 suffered reocclusion of the vessel. Quantitative analysis of the coronary stenosis both immediately after thrombolysis and at 3 weeks follow-up was possible in 33 cases. Residual stenosis (percentage narrowing of diameter) decreased from 74 +/- 14% to 56 +/- 17% (P less than 0.05). No difference was observed between the groups of patients treated with streptokinase (74 +/- 9% to 57 +/- 12%, N = 17) and with rt-PA (74 +/- 17% to 56 +/- 21%, N = 16). Despite the significant regression, a coronary stenosis of more than 50% of the diameter persisted in 82% of the patients three weeks after the infarction.