RESUMEN
Although polycrystalline lead oxide (PbO) belongs to the most promising photoconductors for optoelectronic and large area detectors applications, the charge transport mechanism in this material still remains unclear. Combining the conventional time-of-flight and the photo-generated charge extraction by linear increasing voltage (photo-CELIV) techniques, we investigate the transport of holes which are shown to be the faster carriers in poly-PbO. Experimentally measured temperature and electric field dependences of the hole mobility suggest a highly dispersive transport. In order to analyze the transport features quantitatively, the theory of the photo-CELIV is extended to account for the dispersive nature of charge transport. While in other materials with dispersive transport the amount of dispersion usually depends on temperature, this is not the case in poly-PbO, which evidences that dispersive transport is caused by the spatial inhomogeneity of the material and not by the energy disorder.
RESUMEN
We describe for the first time the misinterpretation of a wearable cardioverter defibrillator in the arrhythmia recognition algorithm with subsequent fatal outcome of a multi-morbid patient with an ischemic cardiomyopathy and a highly reduced left ventricular pump function (30 %). The patient's death was preceded by a life-threatening shockable rhythm which was repeatedly documented, but ultimately not correctly recognized by the system and therefore not treated.
Asunto(s)
Algoritmos , Muerte Súbita Cardíaca/etiología , Desfibriladores/efectos adversos , Diagnóstico por Computador/efectos adversos , Traumatismos por Electricidad/etiología , Traumatismos por Electricidad/diagnóstico , Diseño de Equipo , Falla de Equipo , Resultado Fatal , Humanos , Masculino , Errores Médicos/efectos adversos , Errores Médicos/prevención & control , Persona de Mediana Edad , Terapia Asistida por Computador/métodos , Insuficiencia del TratamientoRESUMEN
BACKGROUND: There is a comprehensive early defibrillation program in Bochum (Germany); since 2003 a total of 175 automated external defibrillators (AEDs) have been installed in urban areas by the city of Bochum and private companies. These were preferably installed in places with high foot traffic, e.g., public buildings, companies, and event/shopping centers. Approximately 15,000 laypeople who work in the vicinity of the AED locations were trained in the use of defibrillators and in basic resuscitation. In addition, rescue workers on fire trucks and medically trained personnel in physicians' medical practices were equipped as "first responders" with AEDs. RESULTS: After an initiation phase, all available information after each AED use since August 2004 has been collected by the project coordinator. During the period of data collection (August 2004 to August 2013), an AED was used in a total of 17 patients who had suffered sudden cardiac death (SCD) under the project in Bochum. Eleven patients had primary ventricular fibrillation (VF). Six of these survived without neurological deficit. In another 6 patients, a nondefibrillatable rhythm disorder was diagnosed. The AEDs are reliable and showed impeccable rhythm analysis before the instructions to provide any necessary shock. DISCUSSION: Compared to the number of existing units and an estimated number of 37-100 SCD/100,000, the use of the AEDs only 17 times appears relatively small. To improve the effectiveness of the AED program in Bochum, an analysis of the emergency service responses, which were necessary because of sudden circulatory collapse, is currently being performed. This will allow areas with an increased incidence of SCD to be identified and a plan for the strategic placement of AED and emergency services can be made.
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Muerte Súbita Cardíaca/prevención & control , Desfibriladores/estadística & datos numéricos , Desfibriladores/tendencias , Servicios Médicos de Urgencia/organización & administración , Salud Urbana , Reanimación Cardiopulmonar/educación , Muerte Súbita Cardíaca/epidemiología , Servicios Médicos de Urgencia/tendencias , Socorristas/educación , Predicción , Alemania , HumanosRESUMEN
BACKGROUND: Despite the known effects of drug-eluting stents (DES), other cofactors attributed to patient characteristics affect their success. Interest focused on designing a study minimizing these factors to answer continuing concerns on the heterogeneity of response to different DESs. The study's aim was to investigate the feasibility and impact of an intra-individual comparison design in patients (pts) with two coronary artery stenosis treated with a Sirolimus- (SES) and a Paclitaxel- (PES) eluting stent. METHODS AND RESULTS: The study was conducted as a prospective, randomized, multi-center trial in 112 pts who consented to treatment with a SES and a PES. Pts were eligible if they suffered from the presence of two single primary target lesions in two different native coronary arteries. Lesions were randomized to either SES or PES treatment. The primary endpoint was in-stent luminal late loss (LLL), as determined by quantitative angiography at 8 months; clinical follow up was obtained at 1, 8, and 12 months additionally. The LLL (0.13 ± 0.28 mm SES vs. 0.26 ± 0.35 mm PES, p=0.011) showed less neointima in SES. With a predefined cut-off criterion of 0.2mm difference in LLL, 53/87 pts SES and PES were similar effective. 34/87 pts had a divergent result, 26 pts had greater benefit from SES while 8 pts had greater benefit from PES. Overall, MACE (MI, TLR, and death) occurred in 19 (17%) pts. Based on lesion analysis of 108 lesions treated with SES and 110 lesions treated with PES, 5 (4.6%) lesions with SES and 3 (2.7%) lesions with PES required repeated TLR. CONCLUSION: An intra-individual comparison design to assess differences in efficacy of different DESs is feasible, safe and achieves similar results to inter-individual studies. This study is among the first to show that failure of one DES does not necessarily implicate failure of another DES and vice versa.
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Estenosis Coronaria/diagnóstico , Estenosis Coronaria/cirugía , Stents Liberadores de Fármacos , Paclitaxel/administración & dosificación , Intervención Coronaria Percutánea/métodos , Sirolimus/administración & dosificación , Adulto , Anciano , Anciano de 80 o más Años , Estenosis Coronaria/epidemiología , Femenino , Estudios de Seguimiento , Humanos , Masculino , Persona de Mediana Edad , Variaciones Dependientes del Observador , Intervención Coronaria Percutánea/normas , Estudios ProspectivosRESUMEN
BACKGROUND AND AIMS: Echocardiographic tissue Doppler imaging (TDI) has been proposed as diagnostic tool for the differentiation between constrictive pericarditis (CP) and restrictive cardiomyopathy (RCM). The aim of this study was a comprehensive TDI analysis of systolic (S') and early diastolic (E') velocities of the septal and lateral mitral annulus (MA) in patients (pts) with severe diastolic dysfunction caused either by CP or RCM. METHODS AND RESULTS: Sixty consecutive pts (34 men, mean age 61 +/- 11 years), 34 pts with proven CP and 26 pts with RCM due to cardiac amyloidosis, were included in the study. Forty-two of the 60 pts were in NYHA class III (70%). In pts with RCM systolic longitudinal velocity (S') was significantly decreased when compared to CP (septal MA 4.1 +/- 1.5 vs. 7.3 +/- 2.1 cm/s, p < 0.001; lateral MA 4.3 +/- 1.9 vs. 7.0 +/- 1.9 cm/s, p < 0.001). In addition, the RCM group showed a significantly decreased early diastolic longitudinal velocity (E'), both on the septal (4.1 +/- 1.6 vs. 12.9 +/- 4.9 cm/s, p < 0.001) and lateral side (4.8 +/- 1.9 vs. 11.3 +/- 3.7 cm/s; p < 0.001) of the mitral annulus. ROC analysis demonstrated an area under the curve of 0.889 (S' septal), 0.823 (S' lateral), 0.974 (E' septal), and 0.915 (E' lateral) for the differentiation of RCM and CP with a cutoff value of <8 cm/s. The combined use of an averaged S' cutoff value <8 cm/s as well as an E' cutoff value <8 at the lateral and septal MA demonstrated 93% sensitivity and 88% specificity for the diagnosis of RCM. CONCLUSION: TDI provides a diagnostic superiority and an accurate discrimination between RCM and CP by using the combined cutoff value of <8 cm/s for S' and E' at both sides of the MA.
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Cardiomiopatía Restrictiva/diagnóstico por imagen , Ecocardiografía Doppler/métodos , Pericarditis Constrictiva/diagnóstico por imagen , Anciano , Diagnóstico Diferencial , Femenino , Humanos , Masculino , Persona de Mediana Edad , Válvula Mitral/diagnóstico por imagen , Sensibilidad y EspecificidadRESUMEN
We present the case of a 41-year-old woman who was admitted to our centre with progressive symptoms of congestive heart failure (NYHA class III) 5 years after a radical nephrectomy for renal cell carcinoma. Magnetic resonance imaging demonstrated a 5 x 3 cm homogeneous intracardial mass causing right ventricular outflow tract obstruction, not accessible to surgical resection. Serial echo-guided, percutaneous coil embolization of the cardial metastasis was performed with Contour SE Microparticles (150-250 or 300-500 microm) after identification of the target region of the metastasis by contrast injection (Levovist) through the balloon catheter into the coronary artery under transoesophageal echocardiographic control prior to induction of the necrosis, corresponding to the technique which has been described for septal ablation in hypertrophic obstructive cardiomyopathy. Follow-up after serial embolization showed a good haemodynamic and a marked clinical response (dyspnoea NYHA I-II) which lasted during the 19 month of survival after the index procedure.
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Carcinoma de Células Renales/secundario , Ecocardiografía , Embolización Terapéutica/métodos , Neoplasias Cardíacas/complicaciones , Neoplasias Cardíacas/terapia , Ventrículos Cardíacos/patología , Neoplasias Renales/patología , Obstrucción del Flujo Ventricular Externo/etiología , Obstrucción del Flujo Ventricular Externo/terapia , Adulto , Cateterismo , Femenino , Neoplasias Cardíacas/secundario , Humanos , Imagen por Resonancia MagnéticaRESUMEN
BACKGROUND AND OBJECTIVE: Echocardiographic tissue Doppler imaging (TDI) has been proposed for differentiating between constrictive pericarditis (CP) and restrictive cardiomyopathy (RCM). The aim of this retrospective study was to analyse TDI in patients with severe diastolic dysfunction associated with proven constrictive pericarditis or restrictive cardiomyopathy. PATIENTS AND METHODS: The cohort included 34 consecutive patients (24 men. 10 women; mean age 58 12 years), 20 of whom had proven CP (pericardectomy) and 14 had RCM due to amyloidosis (proven by biopsy). Tissue Doppler Imaging was performed online by pulsed-wave TDI at the lateral and septal mitral annulus in the four-chamber view. Filling pressures were measured invasively. RESULTS: 20 of the 34 patients (60%) were in NYHA class III. 19 of the 34 patients were in sinus rhythm (56 %) and 15 had atrial fibrillation. Left ventricular systolic function was normal in all patients with CP. Eight patients with RCM had normal, 3 patients near normal and 3 patients slightly impaired left ventricular contractile function (EF 50-55% and EF 40%, respectively). Respiratory variation of the transmitral inflow was increased in 10 of 12 patients with CP and sinus rhythm. TDI of the early diastolic velocity across the mitral annulus E} was significantly higher in patients with CP than in those with RCM at the septal and at the lateral mitral annulus (13.8 4.2 cm/s vs. 4.0 1.2 cm/s; p < 0.01 and 11.4 3.4 cm/s vs. 4.4 1.7 cm/s; p < 0.01, respectively). A cut-off value 8 cm/s for the diagnosis of RCM showed a sensitivity of 100% and a specificity of 90% (septal) and 80% (lateral), respectively. The E/E}ratio also was significantly different between both groups (septal: 11.2 8.8 vs. 25.1 8.7; p < 0.01). CONCLUSION: TDI of the early diastolic velocity of the mitral annulus E} makes it possible to differentiate between constrictive pericarditis and restrictive cardiomyopathy and should be part of the echocardiographic work-up in clinical routine.
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Cardiomiopatía Restrictiva/diagnóstico por imagen , Ecocardiografía Doppler de Pulso/métodos , Pericarditis Constrictiva/diagnóstico por imagen , Amiloidosis/complicaciones , Biopsia , Velocidad del Flujo Sanguíneo , Cardiomiopatía Restrictiva/etiología , Cardiomiopatía Restrictiva/fisiopatología , Estudios de Cohortes , Diagnóstico Diferencial , Femenino , Humanos , Masculino , Persona de Mediana Edad , Miocardio/patología , Pericarditis Constrictiva/etiología , Pericarditis Constrictiva/fisiopatología , Curva ROC , Estudios Retrospectivos , Sensibilidad y EspecificidadRESUMEN
BACKGROUND AND AIM OF THE STUDY: A treatment dilemma arises when endocarditis is complicated by cerebral embolism. Secondary cerebral hemorrhagic complications may arise following suppression of coagulation during extracorporeal circulation. Extensive valvular vegetation is regarded as an indicator for urgent surgery. The study aim was to determine the relative risk of thromboembolic complications, and to analyze the prognostic influence of different treatment strategies following onset of these complications, in particular, secondary cerebral hemorrhagic events after urgent surgery. METHODS: Between 1978 and 1993, endocarditis was diagnosed in 288 consecutive patients. Patients treated before 1982 (6.9%) were analyzed retrospectively. The remaining patients (93.1%) were followed prospectively (mean 4.3+/-1.7 years). RESULTS: In 50 patients (17.4%), the clinical course was complicated by one embolism, and in 58 patients (20.2%) by recurrent embolisms. In total, 71% of all embolisms were cerebral events. The operated patients were categorized with regard to the time between recurrent thromboembolic events and cardiac surgery (<72 h, 3-8 days, and >8 days). The prognosis for patients operated within 72 h was significantly more favorable (p <0.0001) than for those treated medically. Patients undergoing cardiac surgery more than eight days after stroke, and those treated conservatively, had poor prognoses. CONCLUSION: When endocarditis is complicated by stroke, it is recommended that cardiac surgery be performed within 72 h of the cerebral embolism, when the risk of secondary cerebral hemorrhage appears to be low. Cranial computed tomography is obligatory immediately before surgery in order to identify patients with early reperfusion hemorrhages due to spontaneous fragmentation of the thrombus. In these patients, cardiac surgery must be postponed because of the high risk of severe cerebral bleeding during extensive perioperative anticoagulation, and is only justified in the case of an otherwise unfavorable prognosis.
Asunto(s)
Endocarditis/complicaciones , Endocarditis/cirugía , Enfermedades de las Válvulas Cardíacas/complicaciones , Enfermedades de las Válvulas Cardíacas/cirugía , Implantación de Prótesis de Válvulas Cardíacas/efectos adversos , Accidente Cerebrovascular/etiología , Tromboembolia/etiología , Enfermedad Aguda , Adolescente , Adulto , Anciano , Anciano de 80 o más Años , Hemorragia Cerebral/etiología , Hemorragia Cerebral/terapia , Niño , Contraindicaciones , Femenino , Humanos , Masculino , Persona de Mediana Edad , Pronóstico , Factores de Riesgo , Accidente Cerebrovascular/terapia , Tromboembolia/terapia , Resultado del TratamientoRESUMEN
UNLABELLED: A 49 year old male developed cardiocirculatory arrest following laparoscopic surgery of an inguinal hernia. Cardiopulmonary resuscitation (CPR) was started. The primary ECG showed ventricular fibrillation, after defibrillation a tachyarrhythmia and a newly developed right bundle branch block were documented. In addition, ST-elevations were seen in the left precordial leads. After 20 min of CPR the circulation was reestablished with high doses of catecholamines. Transthoracic echocardiography demonstrated a 7 mm pericardial effusion with mild impression of the right ventricular free wall. The patient underwent urgent heart catheterization for suspected pulmonary embolism (differential diagnosis: acute myocardial infarction). Pulmonary angiography demonstrated floating thrombi in the left main pulmonary artery, which could be fragmented using a pigtail catheter. Pulmonary angiography was followed by coronary angiography, which demonstrated a sharply interrupted left anterior descending artery (LAD), while the coronary arteries in general were found to be regular. The history, the morphology of the LAD-interruption, the concomitant pericardial effusion and the sternal and rib fractures were consistent with a type III coronary perforation in the classification of Sutton and Ellis. As contrast medium penetration into the pericardial space persisted after recanalization of the LAD, a 19 mm stent graft (Jostent) was used for closure. These grafts are constructed using a sandwich technique with an ultrathin layer of expandable polytetrafluorethylene being placed between two stents. After implantation of the stent graft no more contrast medium penetration was documented. CONCLUSION: Coronary perforations following blunt chest trauma is a rare complication, which has been described only once following CPR (2). Stent grafts can be used safely for acute closure of such perforations.
Asunto(s)
Reanimación Cardiopulmonar , Vasos Coronarios/lesiones , Paro Cardíaco/terapia , Lesiones Cardíacas/terapia , Complicaciones Posoperatorias/terapia , Materiales Biocompatibles Revestidos , Angiografía Coronaria , Diseño de Equipo , Paro Cardíaco/diagnóstico por imagen , Lesiones Cardíacas/diagnóstico por imagen , Hernia Inguinal/cirugía , Humanos , Masculino , Persona de Mediana Edad , Politetrafluoroetileno , Complicaciones Posoperatorias/diagnóstico por imagen , StentsRESUMEN
HISTORY AND CLINICAL FINDINGS: A 49-year-old patient, a hobby hunter, fell ill acutely with joint and limb pain, abdominal pain, nausea and subfebrile temperatures. At hospitalization, the patient was in bad general condition, showing ascites and lid edema, and acute renal failure was diagnosed. INVESTIGATIONS: Laboratory tests revealed marked thrombocytopenia (15,000/ml), leucocytosis, elevated levels of creatinine, blood urea nitrogen and liver enzymes, respectively. Blood gas analysis showed metabolic acidosis. Chest X-ray showed an interstitial fluid accumulation, abdominal ultrasound disclosed ascites and enlarged kidneys as in acute renal failure. Immunologic tests verified the diagnosis of an acute hantavirus infection, by use of specific molecular biology techniques a previously unknown virus strain was identified. TREATMENT AND COURSE: Hantavirus infections in western Europe usually show a benign course. However, in the present case, acute progressive pulmonary failure developed despite effective dialysis so that mechanical ventilation was necessary for several weeks. Dialysis had to be carried out for 17 days. As a complication a severe ulcero-destructive tracheobronchitis developed, caused by Aspergillus fumigatus. After several weeks, both renal and pulmonary function had returned to normal. CONCLUSION: Hantavirus infections may lead to severe and complicated courses also in western Europe. By use of new immunologic and molecular biology techniques a specific diagnosis is possible.
Asunto(s)
Virus Hantaan/genética , Fiebre Hemorrágica con Síndrome Renal/virología , Diagnóstico Diferencial , Virus Hantaan/patogenicidad , Fiebre Hemorrágica con Síndrome Renal/complicaciones , Fiebre Hemorrágica con Síndrome Renal/diagnóstico , Humanos , Masculino , Persona de Mediana Edad , Factores de Riesgo , Virulencia/genéticaRESUMEN
While morphologic alteration of parts of the mitral valve apparatus (ventricular wall, papillary muscles, chordae tendineae, valve annulus and leaflets) may result in a loss of its functional integrity (primary mitral regurgitation, MR) mitral annulus dilatation following left ventricular enlargement or change in chamber geometry and consecutive opening of the angle between papillary muscles and valve annulus cause secondary MR. Irrespective of these etiologies MR is chronically progressive and much more than the severity of MR the grade of myocardial adaptation to the chronic volume overload is of prognostic significance. Inadequate myocardial adaptation is demonstrated by an increase of the echocardiographically determined radius (r) to wall thickness (Th) ratio (r/Th > 3.0), indicating increasing left ventricular wall stress or by an insufficient increase of the left ventricular ejection fraction (< or = 5% of resting values) under exercise conditions, e.g. with radionuclide angiocardiography (RNV). Stressecho may replace RNV in the future for this indication. Actually, stress echo is not reliable to determine changes in left ventricular ejection fraction at rest versus exercise because of systematic errors and error reproduction. There are preliminary reports on biochemical markers like noradrenaline or tumor necrosis factor alpha being helpful to determine the breakdown of myocardial adaptation mechanisms. Surgical intervention is indicated in chronic MR irrespective of the hemodynamic severity, if myocardial adaptation is inadequate. If mitral reconstruction, the surgical technique of choice, remains insufficient to restore normal valve function, mitral valve replacement with preservation of the subvalvular apparatus is unavoidable. For a deceleration of the progressive volume overload in chronic MR for which a surgical intervention is not yet indicated, a long-term afterload reducing medical therapy preferably with long acting ACE-inhibitors seem to be prognostically favorable.
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Insuficiencia de la Válvula Mitral/diagnóstico , Insuficiencia de la Válvula Mitral/terapia , Inhibidores de la Enzima Convertidora de Angiotensina/uso terapéutico , Prueba de Esfuerzo , Humanos , Insuficiencia de la Válvula Mitral/etiología , Insuficiencia de la Válvula Mitral/cirugía , Índice de Severidad de la EnfermedadRESUMEN
The slow progression of valvular aortic stenosis enables the left ventricular myocardium to adapt itself to the increasing afterload. When myocardial adaption is exhausted, surgical intervention is urgent, the prognosis, however, is already limited. To quantify the hemodynamic severity of aortic stenosis, transaortic pressure gradients (dp) measured by Doppler echocardiography or hemodynamically are inappropriate, because dp is significantly dependent on the transaortic flow volume. In severe aortic stenosis, despite constant narrowing of the aortic valve area, the reduced stroke volume results in decreasing transaortic pressure gradients. With aortic valve resistance or transaortic pressure loss (PL)--the quotient of pressure gradient and stroke volume--the hemodynamic severity of aortic stenosis can be described accurately. If PL is known, a decompensated aortic stenosis (PL > 1 mm Hg/ml) may be differentiated from myocardial failure of another etiology and a concomitant left ventricular outflow tract obstruction. With respect to medical therapy, the prevention of bacterial endocarditis and thromboembolic complications is important. Knowing the potential danger of syncopies and ventricular arrhythmias during exercise with increasing severity of aortic stenosis, patients have to be informed about their limited functional capacity. The occurrence of typical symptoms during the natural history of chronic aortic stenosis (e.g. dizziness, syncopes, angina pectoris, arrhythmias) manifestation of ST-T-alterations or silent myocardial ischemias and demonstration of an inadequate myocardial adaptation to the chronic pressure overload in asymptomatic patients are accepted indications for a surgical intervention. If the indication for surgery remains uncertain, stress tests (e.g. radionuclidventriculography) may be performed to demonstrate an exhausted myocardial adaptation. If the PL and the severity of aortic valve/anulus calcification is known, the progression of a chronic aortic stenosis can be estimated. This might be important, if a cardiosurgical intervention has to be performed for other indications and aortic stenosis is co-existent but does not require an intervention at that time. For prognostic reasons myocardial decompensation due to aortic stenosis is an indication for an urgent surgical intervention. Attempts for medical recompensation or bridging strategies (e.g. balloon valvotomy) worsens the prognosis significantly.
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Estenosis de la Válvula Aórtica/terapia , Estenosis de la Válvula Aórtica/diagnóstico , Estenosis de la Válvula Aórtica/fisiopatología , Humanos , PronósticoRESUMEN
HISTORY AND CLINICAL FINDINGS: A 39-year-old man was hospitalized for investigation of increasing dyspnoea for 3 month. On admission he was found to have bilateral ankle oedema, an enlarged liver and loud systolic murmur over the lower sternum. INVESTIGATIONS: There were signs of right heart strain/hypertrophy on the chest radiogram and echocardiogram. After treatment of right heart failure cardiac catheterization indicated moderate precapillary pulmonary hypertension (PH) with a mean pulmonary artery pressure (PAPm) of 24 mm Hg and pulmonary vascular resistance (PVR) of 470 dyn.s.cm-5 at rest. All known causes having been excluded, the PH was classified as idiopathic. TREATMENT AND COURSE: Evidence of acute pulmonary vascular reactivity was obtained with nitric oxide (NO) inhalation and oral diltiazem, a calcium-channel blocker. The latter, at a dosage of 3 x 120 mg daily, had after 13 days achieved a persisting reduction of PVR at rest and a reduction in PAP rise during exercise. CONCLUSION: After exclusion of other causes, the acute right heart failure was found to be due to primary pulmonary hypertension. The therapeutic efficacity of diltiazem as a vasodilator can be predicted from the response to inhaled NO.
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Disnea/etiología , Insuficiencia Cardíaca/etiología , Hipertensión Pulmonar/complicaciones , Adulto , Bloqueadores de los Canales de Calcio/farmacología , Bloqueadores de los Canales de Calcio/uso terapéutico , Cateterismo Cardíaco , Diagnóstico Diferencial , Diltiazem/farmacología , Diltiazem/uso terapéutico , Insuficiencia Cardíaca/complicaciones , Humanos , Hipertensión Pulmonar/tratamiento farmacológico , Hipertensión Pulmonar/etiología , Masculino , Óxido Nítrico , Presión Esfenoidal Pulmonar/efectos de los fármacos , Resistencia Vascular/efectos de los fármacos , Vasodilatadores/farmacología , Vasodilatadores/uso terapéutico , Disfunción Ventricular Derecha/etiologíaRESUMEN
BACKGROUND: The indication for urgent cardiac surgical interventions in patients with active infective endocarditis has to be considered carefully following thromboembolic events, because of the high recurrence rate of such complications. In the case of brain embolisms the prognostic benefit of urgent surgery has been discussed controversially as effective anticoagulation during open heart surgery may result in secondary cerebral hemorrhages. PATIENTS AND METHODS: Between 1978 and 1993 infective endocarditis (IE) was proven in 288 consecutive and prospectively followed patients (131 females, 157 males; mean age 53.6 +/- 8.7 [9 to 81] years). To analyze potential benefits and risks of an urgent surgical intervention early after embolic cerebral infarction, cumulated survival rates were calculated for patients with and without surgical intervention with special reference to incremental risk factors and the timing of surgery. RESULTS: In 50 patients (17.4%) the clinical course was complicated by one, and in 58 patients (20.2%) by recurrent embolic events. In 80% the first embolism occurred within 33 days following the first manifestation of typical signs and symptoms of IE. 80% of recurrent events were observed within 32 days following the initial embolism. 71% of all embolic events were cerebral. In patients with cerebral embolism corroborated by computed tomography (CCT), the clinical course was complicated by intracranial hemorrhage in 12.5% while it was only 1.5% for patients without cerebral embolism. Because of a lack of therapeutic alternatives, 22 of 49 patients with recurrent embolic events, of which at least one was cerebral, underwent urgent cardiac surgery within 4 to 366 hours after the first cerebral manifestation. The cumulated survival rate of patients operated within 72 hours after the initial cerebral embolism was significantly more favorable (p < or = 0.000) than for unoperated patients or those who were operated after more than 8 days. CONCLUSION: An embolic event during IE carries a more than 50% risk of recurrence. In patients with short duration of signs and symptoms of IE and postembolic echocardiographic demonstration of persistent vegetations the probability is > 80%. At least for those patients urgent surgical intervention to remove the source of infection and embolic hazard seems to be beneficial. Surgical intervention using the heart-lung-machine should be performed within 72 hours. Such early timing results in a significant lower rate of secondary cerebral hemorrhages (p < or = 0.00) than a postponed operation. To exclude early reperfusion hemorrhage due to spontaneous thrombus fragmentation, CCT should be repeated directly preoperatively.
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Urgencias Médicas , Endocarditis Bacteriana/cirugía , Implantación de Prótesis de Válvulas Cardíacas , Embolia y Trombosis Intracraneal/cirugía , Adolescente , Adulto , Anciano , Anciano de 80 o más Años , Niño , Endocarditis Bacteriana/complicaciones , Femenino , Humanos , Embolia y Trombosis Intracraneal/etiología , Masculino , Persona de Mediana Edad , Complicaciones Posoperatorias/etiología , Estudios Prospectivos , Recurrencia , Factores de RiesgoRESUMEN
The antithrombotic effect of oral anticoagulation therapy and the incidence of anticoagulant-related bleeding complications are both closely correlated with the intensity of treatment. The optimal intensity of oral anticoagulation for an individual patient is the target INR that results in the lowest incidence of thromboembolic plus bleeding complications. For patients with native valve lesions, one must consider the cardiac morphology and pathophysiology, for example, the etiology of the disease, left atrial diameters, loss of active atrial contraction (atrial fibrillation), left ventricular pump function, and left ventricular diameters, to determine an optimal INR target. In patients with prosthetic devices, the "thrombogenicity" of the heart valve prosthesis is an additional risk factor for intracardiac thrombus formation and thromboembolic episodes. This "thrombogenicity" may vary significantly from device to device. INR self-testing improves the overall prognosis of patients on lifelong oral anticoagulation therapy because patients remain more precisely within that target therapeutic INR range. For most patients under phenprocoumon, one to two INR measurements per week are a sufficient frequency to provide a stable intensity of anticoagulation.
RESUMEN
HISTORY AND CLINICAL FINDINGS: In a 66-year-old woman with unstable angina, treated with 20,000 IU heparin daily for 6 days, platelet count fell dramatically from 310,000 to 1000/microliters 8 hours after injection of 90 ml of contrast medium (Iopromide) during coronary angiography. In addition to a marked tendency towards spontaneous bleeding she developed a large haematoma at the site of the arterial puncture, with a fall in haemoglobin to 9 g/dl, and acute renal failure. TREATMENT AND COURSE: Red blood cell and platelet infusions were given, together with cortisone, 1000 mg, and immunoglobulins. Platelet count returned to within normal limits after 8 days. Two haemodialyses initiated polyuria, followed by rapid normalization of kidney function. No antibodies against iopromide, iopamidol, heparin or heparinoids were found. At an emergency coronary balloon angioplasty 3 weeks later iopamidol was injected (45 ml). Again there was a profound fall in platelets to 1000/microliters, associated with acute renal failure. Treatment identical to that after the first episode brought about complete normalization. CONCLUSION: The reported reactions were most likely due to immune thrombocytopenia after administration of contrast medium.
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Medios de Contraste/efectos adversos , Yohexol/análogos & derivados , Yopamidol/efectos adversos , Trombocitopenia/inducido químicamente , Lesión Renal Aguda/inducido químicamente , Anciano , Angioplastia Coronaria con Balón/efectos adversos , Antiinflamatorios/administración & dosificación , Angiografía Coronaria/efectos adversos , Cortisona/administración & dosificación , Transfusión de Eritrocitos , Femenino , Humanos , Inmunoglobulinas/administración & dosificación , Yohexol/efectos adversos , Transfusión de Plaquetas , Recurrencia , Trombocitopenia/inmunología , Trombocitopenia/terapia , Factores de TiempoRESUMEN
Prosthetic valve endocarditis remains an extremely serious complication, with a low but increasing incidence. 'Late' endocarditis, occurring more than 60 days after surgery, is relatively infrequently associated with staphylococci, Gram-negative bacteria and fungi so characteristic of the endocarditis that occurs earlier. A probable source of infection can be found in 25%-80% of patients, the most frequent causes being dental procedures, urological infections and interventions, and indwelling catheters. The most common organisms are S. epidermidis, S. aureus, viridans streptococci and enterococci. The general principles of antibiotic treatment are similar to those for native valve endocarditis, but antibiotic treatment needs to be more prolonged and dosages should be used which result in maximal, nontoxic concentrations. Oral anticoagulants should be stopped and replaced by intravenous heparins. Surgical reintervention is called for if there are large highly mobile vegetations in the mitral position or within 72 h if there are cerebral thrombo-embolic episodes.