[Brugada syndrome]. / Das Brugada-Syndrom.

BACKGROUND: A high take-off descending ST segment associated with right bundle branch block is the typical ECG criterion of the Brugada-Brugada syndrome. It leads to ventricular fibrillation or syncopes in case of a familiar disposition. CASE REPORT: We describe a 56-year-old man in whom oral prajmalium bitartrate therapy previously prescribed for symptomatic ventricular extrasystoles unmasked an electrographic pattern characteristic of a Brugada syndrome. After the ongoing invasive diagnostic a right ventricular dysplasia in the same case is possible. The patient was treated with an ICD pacemaker.

Determinants of mortality after cardiac surgery: results of the registry of the Arbeitsgemeinschaft Leitender Kardiologischer Krankenhausärzte (ALKK) on 10 525 patients.

BACKGROUND: Mortality from cardiac surgery is an essential indicator of quality and forms the basis of treatment strategy decisions in eligible patients. No contemporary complete data on unselected adult cardiac surgery patients are available in Germany. METHODS AND RESULTS: A registry was started in June 1997 of all patients referred to surgery from 85 cardiology centres in Germany. The registry was intended to include 10 000 patients and this number was reached in March 1998. Follow-up of the patients was by simple questionnaire, reporting the date of surgery, major complications, and symptomatic improvement. If the questionnaire was not returned, a reminder letter was sent and, if necessary, further telephone investigations were performed. This resulted in 99.9% complete data. Of 10 525 patients operated on, 3.91% had died by 30 days after surgery. The overall operative mortality was 4.57%, which included 69 patients who died after more than 30 days from complications related to surgery. By multivariate analysis, the following predictors of mortality were identified: previous surgery, emergency or complex operation; age >75 years, female gender, cardiac failure, angina CCS class IV, and three-vessel coronary disease. An integral part of the registry was a pre-operative prediction of surgical risk in five categories. This risk estimate revealed a surprisingly correct prediction of the mortality observed. CONCLUSIONS: In a representative unselected group of cardiac surgery patients, operative mortality was 4.57%. Several procedural and clinical parameters were significantly correlated with mortality, but the risk increment by each of these factors was small. Unstructured clinical judgement reliably predicted the operative risk.

[Basic diagnostic program in dizziness and syncope symptoms: value of electrophysiologic studies of the heart]. / Diagnostisches Basisprogramm bei der Symptomatik Schwindel und Synkope: Stellenwert elektrophysiologischer Untersuchungen des Herzens.

Syncopes and preceding signs and symptoms, particularly also in form of appearances of giddiness, are, including specialists of various branches, among others ENT, neurology, orthopaedics and ophthalmology, always to be classified according to the fact whether or not a cardiovascular disease is to be regarded as cause. If there is the suspicion, both special non-invasive investigations and such ones which possibly are to be performed invasively are indicated. The latter come after the non-invasive investigations partly on account of the expenditure (technique of heart catheterization) and the possibilities of complication. The testing of the sinus node with the highly frequent atrial stimulation and single stimulus technique, the lead of the His-potential and the performance of a ventricular programmed stimulation are the fundamental programmes of an electrophysiologic investigation. In an analysis carried out more than 3 years could be found that in two thirds of the 45 invasively examined patients the diagnosis could be precised and enhanced, respectively, and that the main disturbances related to the signs and symptoms were a sick sinus syndrome, AV-asequences and ventricular arrhythmias.

[Diagnosis and therapy of ventricular tachycardia in heart failure]. / Diagnostik und Therapie der ventrikulären Tachykardie bei Herzinsuffizienz.

In a survey diagnostic and therapeutic problems of the ventricular arrhythmias in cardiac insufficiency are described. It is expressed that prevalence and prognosis of the arrhythmia in cardiac insufficiency are not yet sufficiently investigated both in the acute and in the chronic phase. Furthermore, ascertained investigations concerning the effect of the individual antiarrhythmic drugs have not come to hand. Certain situations and preliminary electrocardiographic findings are to be regarded as premonitory signs; in the individual case they are entitled to a prophylactic therapy with antiarrhythmic drugs. The consideration of pharmacokinetic laws is particularly significant in the disturbed metabolization and the reduction of the hepatic blood in this phase.

[Clinical aspects of reperfusion arrhythmia following intravenous thrombolysis in acute myocardial infarct]. / Zur Klinik und Therapie von Reperfusionsarrhythmien nach intravenöser Thrombolyse bei akutem Myokardinfarkt.

In accordance with the majority of the reports in the literature reperfusion arrhythmias were observed in more than 30% of the patients with acute myocardial infarction (n = 25) under or immediately after a highly dosed short-term infusion with streptokinase. With reference to indirect signs the recanalisation rate was assumed with 75%. Only one third of the reperfusion arrhythmias had haemodynamically significant characteristics and required an influence. Though in literature from animal experimental findings directive conclusions for the therapy are to be derived, the procedure in practice is still vastly empirical. In the ventricular tachycardia lidocaine, procainamide and ajmalin may be recommended. In ineffectiveness or particularly threatening situations the electrotherapy (cardioversion, DC-shock) is to be preferred. The concept inaugurated by Corr and Witkowski apply alpha-adrenoreceptor blockers has not yet entered the clinical practice. Possible problems in the treatment of reperfusion arrhythmias in the prehospital phase should at present still be a reason not to antedate the thrombolytic therapy into this phase.

[Effect of histamine H2 receptor blockers on hepatic elimination of drugs]. / Der Einfluss von Histamin-H2-Rezeptorenblocker auf die hepatische Elimination von Arzneimitteln.

In an investigation is proved that already after a treatment with the histamine-H2-receptor blocker Cimetidine (Altramet) lasting 14 days the elimination of Antipyrine is significantly delayed. In 14 male patients suffering from peptic ulcer the half-life period of Antipyrine (t50) was 8.6 +/- 0.6 h, whereas in the second test after 14 days it was 13 +/- 0.8 h. The systemic clearance (Cltot) was estimated with 78 +/- 11.3 ml X min-1 before treatment and with 40.8 +/- 3.6 ml X min-1 after treatment. It is pointed out that under a therapy with Cimetidine preparations and simultaneous application of medicaments which were eliminated by the so-called phase-I-reaction a hepatic interaction may occur.

[Prevention, clinical aspects and therapy of the side-effects of lidocaine]. / Zur Prophylaxe, Klinik und Therapie von Lidokain-Nebenwirkungen.

In 134 patients with an acute myocardial infarction a prolonged lidocaine infusion was performed. In 6.7% of the patients severe side effects occurred. They appeared with central-nervous and haemodynamic symptomatology. In 6 patients with a high degree of severity of the side effect a determination of the plasma content could be performed, which in every case showed contents during the process above the therapeutic region. It was confirmed that side effects of lidocaine are to be apprehended, when the therapeutic region (2-6 mg/l-1) of the antiarrhythmic drugs is transgressed. On the basis of own experiences and reports from literature the therapeutic approach in lidocaine side effects is concerned and possibilities are shown to avoid them.

[Lidocaine elimination and dose adjustment in acute heart infarct and heart insufficiency]. / Die Lidocain-Elimination und -Dosisanpassung bei akutem Herzinfarkt und Herzinsuffizienz.

In 40 patients with an acute myocardial infarction a prolonged lidocaine infusion was indicated. The dosage of lidocain was done according to the body-weight. Patients suffering from a heart insufficiency received the anti-arrhythmic drug with a reduced dose referring to the degree of severity. The lidocaine-plasma content was determined by means of a gas-chromatographic method. Furthermore, the half-value time, the clearance and the distribution coefficient were computed. Despite the reduction of the dose the plasma contents were highest in patients with manifest heart insufficiency. As we expected, the half-value time was shorter in the patients with infarction without heart insufficiency than in the patients with manifest heart insufficiency. The behaviour of the total clearance was analogous in the adequate groups of patients. The lidocain dosage performed which referred to more recent investigations of the behaviour of the half-value time after prolonged infusion is regarded as more precisely in comparison to the previous proposals. Corresponding to the findings got, a dosage scheme is given for patients with myocardial infarction and heart insufficiency, which should allow a secure and effective treatment.

[Preoperative examinations by internists before reoperation]. / Internistische Voruntersuchungen bei operativen Zweiteingriffen.

Special attention should be focused upon the cardiopulmonary system and the liver function as well. The concomitant medical therapy in the pre-, intra- and postoperative phase has to be adapted to the patients actual requirements in order to avoid undesirable side-effects due to toxic plasma levels of the admitted drugs.

[Determination of hepatic metabolic capacity: antipyrine pharmacokinetics in circulatory liver damage due to cardiac insufficiency]. / Die Bestimmung der hepatischen metabolischen Kapazität: Untersuchungen zur Antipyrin-Pharmakokinetik bei zirkulatorischer Leberschädigung infolge Herzinsuffizienz.

As it was demonstrated in a study, antipyrin halftime and clearance totalis are prolonged resp. reduced in patients with circulatory liver damage due to cardiac failure in myocardial infraction (group H) and in patients with chronic congested liver due to diseases of the heart valves (group V). group H: t50,2 +/- 11,7 h, Cltot 27 +/- 13,3 ml. min-1; group V: t50 19,3 +/- 6,3 h, Cltot 21,9 +/- 8,6 ml. min-1. Those patients with acute myocardial infarction and normal liver condition had a prolonged half-time as well though the clearance was decreased just insignificantly (t50 12 +/- 4,9 h, Cltot 42,6 +/- 15,8 ml. min-1). In the three groups we obtained the expected biochemical results. There was only a slight correlation of both the antipyrin half-time and the clearance totalis to biochemical parameters, Conclusions: In chronic inflammatory liver diseases and other forms of hepatic malfunctions as well as in circulatory liver damages the antipyrin half-time is influenced. Because of this reason, reduction of metabolic capacity should be expected. It is referred to necessary adaptation of the drug doses if capacity limiting medicaments are administered to patients with circulatory liver damage.

[Obesity--a surgical problem?]. / Die Adipositas--ein chirurgisches Problem?

This a a survey or morbid obesity in man, its causes and possibilities of conservative and surgical treatment. The different aetiological types of obesity are dealt with. Special attention is focused on the mitochondrial oxidation-process.

[Serum level determination in patients with acute myocardial infarction under diphenylhydantoin therapy]. / Serumspiegelbestimmungen bei Patienten mit akutem Myokardinfarkt unter der Therapie mit Diphenylhydantoin.

For the therapy of disturbances of the cardiac rhythm with phenytoin 3 different dosage regimes are examined, in which cases an oral application of phenytoin proves as not suitable. Only by a stepped infusion with following oral treatment a rapid saturation and therapeutically effective serum levels are achieved which are decisive for the effectiveness of the therapeutic measures.