[Coronary intervention and occupational rehabilitation--a prospective, randomized intervention study]. / Koronarintervention und berufliche Reintegration--Eine prospektive, randomisierte Interventionsstudie (KIRL).

Coronary catheter revascularisation is less costly than bypass surgery due to lower direct (medical) and indirect costs (loss of work). Many studies show that the time patients stay out of work following coronary intervention is much longer than necessary. This leads to a considerable increase of indirect costs, which can far exceed the medical costs of the treatment. This prospective randomised study was done to determine whether specific information to patient and family doctor results in an earlier return to work. After catheter revascularisation 100 working patients (mean age 52.4 years) were randomised either to the intervention group (information to patient and family doctor) or to the control group (no specific information about return to work). Four months later 81 patients had returned to their previous jobs (mean sick leave 18.9 +/- 24.8 days) while 19 were still out of work. In the control group, the rate was 79% and the mean sick leave was 16.4 +/- 22.0 days (median 7); in the intervention group 83% had returned to work after a mean of 21.5 +/- 27.4 days (median 10). There was no significant difference between the two groups, neither according to the rate of returned workers nor to the duration of sick leave. In the subgroup of patients with a private insurance (23% of all) 96% started to work again (mean sick leave 5.7 +/- 5.1 days median 3.5), while the rate was 77% in the group of panel patients (mean sick leave 23.7 +/- 27.4 days, median 11). The difference in sick leave between these two groups was highly significant (p = 0.0003). Specific information to the patient and family doctor has no effect on the time patients stay out of work following catheter revascularisation. It seems that the observed delay depends on social and psychological factors that cannot be influenced directly.

[First annual report of practitioners of interventional cardiology in private practice in Germany. Results of procedures of left heart catheterization and coronary interventions in the year 1996]. / Erster Jahresbericht niedergelassener Invasivkardiologen in Deutschland. Ergebnisse für diagnostische Linksherzkatheteruntersuchungen und Koronarinterventionen 1996.

The German Society for Cardiac Angiography and Interventions in Private Practice has started a registry of cardiac procedures since 1996 in order to establish a standard for performance. Although quality management for the cath lab makes sense and is also legally required, there is no generally recommended infrastructure for quality assurance existing in Germany at this time. Therefore, the German Society of Cardiologists in Private Practice (BNK) initiated a project in 1994 to develop a computer program for paperless documentation of diagnostic cardiac catheterizations and coronary interventions (PTCA) using a minimal data set. In 1996, 8 private associated groups participated in this project. The (anonymous) analysis of 10,316 diagnostic cardiac catheterizations and 2597 PTCA yielded the following results: In 95% of the patients, diagnostic cardiac catheterization was performed using the femoral and in 5% the brachial/radial approach. The mean volume of administered contrast medium was 164 +/- 138 ml/patient. The mean LV-EF was greater than 50% in 58.4% of the patients and between 30% and 50% in 10.1%. Coronary artery disease was diagnosed in 69.6% of the patients and valvular/congenital heart disease in 8.5%. In 18.4% of the patients undergoing diagnostic cardiac catheterizations no significant heart disease was identified. Mortality in the cath lab as well as the rate of cerebral insults was 0.05%. In 22.9% and 19% of the patients PTCA and cardiac surgery respectively was recommended. In patients undergoing PTCA, stable angina was present in 74.4% and unstable angina in 13.1%. Of the total number of PTCA procedures, 5.8% were performed in the setting of acute myocardial infarction. The PTCA lesion success rate was 96%, the mean diameter stenosis was 81% pre and 6% post-intervention. The mortality rate at 1 month post-PTCA was 0.4%, and myocardial infarction 1.0%. An acute occlusion occurred in 1.3% of the PTCA patients; 0.6% had to be transferred for emergency bypass surgery. None of the cath labs had on-site surgery. In comparison to other registries, our data show some similarities but also some different trends. Thus, our newly developed software proved to be reliable, fast and easy to use. Participating centers receive immediate feedback regarding their position within the whole group.

Management of unstable angina in patients over 75 years old.

BACKGROUND: Although there have been reports of successful percutaneous transluminal coronary angioplasty (PTCA) and coronary artery bypass grafting (CABG) in elderly patients, few data are available on the optimal management of unstable angina in such patients. This study was therefore designed to identify the preferred revascularization strategy in patients with unstable angina over 75 years of age. METHODS: Early and late results were evaluated for patients over 75 years with unstable angina undergoing PTCA (n = 51) or CABG (n = 53). The two groups were comparable with respect to age, sex distribution, clinical manifestation of symptoms, left ventricular ejection fraction and accompanying non-cardiac diseases. In the CABG group, significantly more patients had left main coronary artery stenosis (13 and 2%, respectively). RESULTS: Both PTCA and CABG treatment showed similar procedural success rates (91 and 94% respectively) and hospital mortality rates (4 and 6% respectively). Procedural complications were comparable regarding Q-wave myocardial infarction, stroke, renal failure and vascular complications. Patients undergoing CABG received significantly more blood transfusions than those undergoing PTCA (17 and 2% respectively). During follow-up, the mortality rate was comparable in both groups (4% with CABG and 8% with PTCA), but significantly fewer patients in the CABG group developed unstable angina (8 versus 21% in the PTCA group), fewer patients were readmitted to hospital for cardiac reasons (CABG group 17%, PTCA group 31%) and fewer patients needed repeat coronary interventions (CABG group 4%, PTCA group 18%). CONCLUSION: Both PTCA and CABG were comparable with regard to short- and long-term mortality, but CABG treatment was favourable with regard to clinical symptoms, readmission to hospital and repeat coronary interventions.

[Effect of a pressure dressing on angiologic complications after diagnostic coronary angiography]. / Einfluss des Druckverbandes auf angiologische Komplikationen nach diagnostischer Koronarangiographie.

500 consecutive patients undergoing diagnostic coronary angiography were studied for vascular complications using either a conventional (n = 250) or a special mechanical device for compression dressing (n = 250). In both groups one case of arterial occlusion occurred. Using the conventional pressure dressing, we observed four pseudoaneurysms, whereas there were none in the special mechanical device dressing group (p < 0.05). In contrast, eight patients developed a deep vein thrombosis after mechanical device pressure dressing compared to only 1 venoust in the conventional dressing group (p < 0.02). Five patients, four of the eight patients with mechanical device dressing, suffered from clinical apparent pulmonary embolism (p = 0.1801). Thus, a mechanical device pressure dressing may decrease the number of arterial pseudoaneurysms but is associated with an increased risk of deep vein thrombosis and pulmonary embolism. Therefore, we recommend the use of the mechanical device pressure dressing only in selected patients with severe obesity.

Outpatient coronary angiography--safety and feasibility.

The feasibility and safety of outpatient coronary angiography were studied in 2,106 patients. Patients were discharged with a pressure dressing 2 h after the angiographic study. No complications occurred in 99.53% of all patients. Severe complications were seen in 10 patients (0.47%). 9 patients (0.43%) had to be admitted to hospital, either for immediate treatment (4 patients) or due to complications (5 patients). Our results revealed a very low complication rate for outpatient coronary angiography. The number and severity of complications following coronary angiography did not differ significantly between inpatients and outpatients. Therefore, outpatient coronary angiography can be considered as a safe and feasible diagnostic method which may help cut health care costs.

[Hemodynamics and differentiated CO transfer following fulminant lung embolism and pulmonary artery embolectomy and following recurrent lung embolism]. / Hämodynamik und differenzierter CO-Transfer nach fulminanter Lungenembolie und Pulmonalisembolektomie sowie nach rezidivierenden Lungenembolien.

Pulmonary embolectomy as an emergent surgical treatment after massive pulmonary embolism often is necessary in cardiogenic shock (CS) and even without previous diagnostic. If complete dissolution of the thromboembolus is possible or spreading of microemboli may occur is unknown. Therefore we studied 21 patients surgically treated by embolectomy, ten of these with consecutive cardiogenic shock (CS) and twelve patients after repetitive microembolism and cava-blocking. Besides lung-functional parameters for special CO-diffusion capacity (DLCO), differentiated in membrane (DM) and vascular (VC) component (Roughton and Forster), we measured mean pulmonary artery pressure (PAP) at rest and at exercise. Patients after repetitive embolism showed considerably more diminution of DLCO (-31%) than those after single massive embolic event (-15%) even concomitant by CS (-10%). Repetitive microembolism lowered VC by 21%. Slight decrease of DM was found after CS. Mean pulmonary artery pressure was elevated at rest (26 mm Hg) and exercise (33 mm Hg) after repetitive microembolism and normal after massive embolism or CS. Pulmonary embolectomy may prevent disturbances of DLCO or PAP even after CS. Damage of vascular integrity (VC) was found after microembolism. Pulmonary embolectomy seems to remove total embolic material and therefore seems to be optimal.

[Difficulties in the diagnosis of AIDS-associated intrapulmonary Kaposi sarcoma]. / Schwierigkeiten in der Diagnostik eines AIDS-assoziierten intrapulmonalen Kaposi-Sarkoms.

Diagnosis of intrapulmonary Kaposi's sarcoma in HIV-infected patients may be extremely difficult. This is demonstrated in a case of a male patient with disseminated Kaposi's sarcoma and lethal pulmonary involvement. The value of various diagnostic procedures is discussed.

[Mechanical recanalization of chronic coronary artery occlusion by balloon dilatation. Hemodynamic and ventricular kinetic long-term results]. / Mechanische Rekanalisation chronischer Koronararterienverschlüsse durch Ballondilatation. Hämodynamische und ventrikelkinetische Langzeitergebnisse.

Abundant collaterals may prevent infarction in a region of myocardium supplied by an acutely occluded coronary artery. However, these patients often present with severe angina on exertion which cannot be sufficiently treated with antianginal drugs but require revascularization. Beginning in 1984, recanalization of chronic coronary artery occlusion using balloon catheters was attempted in 48 patients at Medizinische Klinik III, University of Cologne. Interventional therapy was successful in 29/48 patients (60%). The mean diameter narrowing of residual stenoses was 35%. Invasive follow-up at 3 months was possible in 17 of these 29 patients. Restenosis was noted in 41% and reocclusion was found in 18%. In contrast to angiographic findings, clinical symptoms were clearly improved in the majority of cases (88%). This correlates with increased regional contractility of the myocardial region supplied by the previously occluded artery. Contractility was also improved in patients with significant restenosis. The clinical benefit and the improvement of regional myocardial function indicate that it is justified to attempt balloon recanalization in highly symptomatic patients with short distance coronary occlusions despite the relatively high incidence of restenosis and reocclusion.

Fanconi's anemia: terminal leukemia and "Forme fruste" in one family.

Two adult sisters are described. One with a full clinical, hematological and cytogenetic picture of Fanconi's anemia died of monocytic leukemia. The other woman has several malformations and clinical signs which are found in Fanconi's anemia, but does not show any hematological disorder or sign of bone marrow insufficiency. Cytogenetic findings in this case are comparable to those typical cases with Fanconi's anemia. This case is therefore considered to represent a "forme fruste" of Fanconi's anemia.