[Infectious endocarditis: clinical aspects and diagnosis]. / Infektiöse Endokarditis: Klinik und Diagnostik.

In a discussion of infectious endocarditis (IE), the clinical picture, current most important diagnostic methods (especially echocardiography) and prognosis under conservative therapy and valve replacement are described in detail, in the light of experience at the Hanover Medical School in recent years. While the clinical picture is usually typical, at any rate in the early stages of the disease, antibiotic therapy (when started without blood cultures and exact characterization of the germs involved) or severe complications can change the symptoms to the extent that diagnosis becomes very difficult. Apart from blood cultures, echocardiography, is of prime importance in diagnosis, the latter allows demonstration of vegetations either by M-mode or two-dimensional echocardiography (conventional or esophageal) in some 80% of cases. A special situation is encountered in prosthetic valve endocarditis (PVE): although the incidence of early PVE (which follows hard on the heels of valve replacement) is decreasing, mortality is still high despite early reoperation. Late PVE (after a free interval of approximately 2 months to years) resembles IE of the native valves and often allows medical treatment, especially in the presence of biological valves. The prognosis in IE is still poor and depends mainly on early diagnosis, i.e. a very early start with antibiotic treatment, which must be based on a positive bacterial diagnosis.

[Constrictive pericarditis: results and problems of conservative and surgical treatment]. / Pericarditis constrictiva: Ergebnisse und Probleme konservativer und operativer Behandlung.

34 patients (pts.) with chronic constrictive pericarditis (CCP) were investigated by right and left heart catheterization and were followed at Hannover Medical School between 1975 and 1981. 12 pts. in NYHA stage II were treated medically (group I); 22 pts. (group II) in NYHA stages III or IV underwent surgery (pericardectomy). 7 pts. of group I and 12 pts. of group II underwent cardiac catheterization twice; the time interval between the two studies was at least 12 months, averaging 34 +/- 16 months in group I and 34 +/- 19 months in group II. 2 pts. of group I underwent pericardectomy after the second investigation. In group I the mortality was 16.7% (2 out of 12 pts.), both pts. being in stage IV. Hospital mortality in group II amounted to 20.8% (5 out of 24 pts.); late mortality was 4.2% (1 out of 24 pts.). However, 2 of 5 pts. who died in hospital had also undergone aortic and/or mitral valve replacement, and one was on chronic hemodialysis. Additional disorders of liver, lung, and/or kidney function or aortic and/or mitral valve replacement increased the operative risk considerably. Cardiac catheterization performed in 7 out of 12 pts. of group I yielded slight but significant hemodynamic deterioration under conservative management, and 2 of these pts. required surgery after reinvestigation. Cardiac catheterization performed postoperatively in 12 pts. of group II demonstrated normal hemodynamics, especially a decrease in right and left atrial and ventricular enddiastolic pressures (p less than 0.001) and an improvement in cardiac index (p less than 0.05) and stroke index (p less than 0.01). These observations suggest the following conclusions: Pts. in NYHA stage II can be treated medically as long as additional disorders are absent. Hemodynamic deterioration, however, is unpredictable, and approximately one third of pts. may deteriorate rapidly. Therefore, careful clinical observations and repeated hemodynamic studies are necessary. Pericardectomy is still associated with a rather high mortality, depending on additional disorders of liver, lung, and/or kidney function, which accumulate in pts. with long histories of right heart failure. On the other hand, late postoperative results are favorable. When the patient has liver, lung, and/or kidney damage or a long history of cardiac insufficiency, or is advanced in age, operation should be performed even in NYHA stage II because of the increasing operative risk attending higher stages of cardiac insufficiency.

Results after resection of postinfarction left ventricular aneurysms.

Although left ventricular aneurysmectomy (LVA) is a common surgical procedure, the late functional and hemodynamic results have not been well defined. This presentation describes our results with LVA in 135 patients operated between 1969 and 1979. Associated procedures were performed in 57 (42%) including coronary bypass grafting in 50, valve replacement in 5, closure of ventricular septal defect in 2, or combinations of these in 3 patients. One hundred four of the 122 hospital survivors were followed from 2 to 107 months (mean = 37 months). There were 13 hospital deaths (9.6%), 12 late deaths (9.8%) and an actuarial 5-year survival rate of 77%. Clinical improvement of preoperative heart failure occurred in 82%, and of angina in 70%. Only 33 patients (30%) returned to normal work. Bicycle exercise testing in 70 patients showed normal working capacity in 41 (59%). Recatheterization in 49 patients showed no significant changes in left ventricular end-diastolic pressure or cardiac index, and a borderline reduction of the total ejection fraction. Ventricular arrhythmias were detected by long-term ECG in 70% of all patients after surgery. Of those with preoperative life-threatening arrhythmias, rhythm improvement was noted in 50%, but only 2 of 13 patients were free of arrhythmias after operation. This study demonstrates a greater frequency of postoperative symptomatic and functional improvement as compared to hemodynamic and ECG improvement. Ventricular tachyarrhythmias originating from post-infarct scars increased intra- and postoperative risk and aneurysmectomy alone is considered insufficient for treatment of these disturbances. Further electrophysiologic investigations are needed and additional surgical measures may be necessary to improve the subset of patients with life-threatening arrhythmias.

[Echocardiographic diagnosis of thrombus on a Hancock bioprosthesis in mitral position following endocarditis (author's transl)]. / Echokardiographische Diagnose einer post-endokarditisch thrombosierten Hancock-Bioprothese in Mitralposition.

Acute stenosis of a Hancock bioprosthesis in mitral position was found eight months after surgery and three months following septic periproctitic abscess in a 59 year old woman. Echocardiography revealed almost complete valve obstruction by thrombus formation: unusual dense and inhomogenous structures between the anterior and posterior stent echos of the prosthesis were seen in systole as well as in diastole. Echocardiography appears to be a useful non-invasive method for detection of the rare thrombotic complications in Hancock bioprostheses.

[Determination of creatine kinase and CK-MB in heart failure (author's transl)]. / Bestimmung der Creatinkinase und des Isoenzyms Creatinkinase-MB bei Herzinsuffizienz.

Serum activity of creatine kinase and creatine kinase-MB have been investigated in 129 patients of various etiology in overt heart failure. Elevations in CK-MB were found in 19 patients, most frequently in patients with inflammatory heart disease. We found no correlation between CK-MB activity in serum and the severity of heart failure. CK-MB elevation in patients with chronic heart failure may be interpreted as a sign of progressive as well as regressive processes in the myocardium.