Multiple AV nodal pathways in patients with AV nodal reentrant tachycardia--more common than expected?

AIMS: It was the purpose of this study to determine the incidence of more than two AV nodal pathways in patients with AVNRT. METHODS AND RESULTS: In 78 consecutive patients with AV-nodal reentrant tachycardias (AVNRT) (50 females, 28 males, mean age 52.8 +/- 14.6 years), the number of sudden AH increases by 50 ms or more (AH-jump) was analysed during atrial extrastimulation. The incidence of two AV nodal pathways was accepted to be present in patients with AVNRT without an AH-jump ('smooth curve'). The following forms of tachycardia were induced: a typical AVNRT (slow-fast) in 67 patients, an atypical AVNRT (fast-slow) in 12 patients and a slow-slow-AVNRT in 4 patients. Five patients had two forms of AVNRT. 47 patients (60.3%) showed two AV nodal pathways, 27 patients (34.6%) had three AV-nodal pathways and 4 patients (5.1%) exhibited four AV-nodal pathways. For successful catheter ablation of AVNRT in patients with more than two pathways, more radiofrequency energy applications were required (9.2 +/- 6.3) compared with patients with only two pathways (6.7 +/- 4.8). Furthermore, in patients with more than two AV-nodal pathways, the catheter intervention resulted more frequently in a modulation of slow pathway conduction than in an ablation of the slow pathway(s). CONCLUSION: The incidence of more than two AV-nodal pathways in patients with AVNRT was unexpectedly high at about 40%. Thus, these tachycardias require a meticulous electrophysiological evaluation for successful ablation.

[Primary chylopericardium--stepwise diagnosis and therapy of a differential diagnostically important illness]. / Primäres Chyloperikard--Stufendiagnostik und -therapie einer differentialdiagnostisch wichtigen Erkrankung.

Primary chylopericardium is a rare disease with a highly variable clinical course. We report on a 24-year old female with chylopericardium detected during a pulmonary infection. Despite successful treatment of the infectious disease, the chylopericardium persisted and led to cardiac tamponade. From this case, as well as from the literature, it is intriguing to postulate an inflammatory injury of preexisting anomalous lymphatic vessels leading to onset or aggravation of primary chylopericardium. The clinical hallmark of chylopericardium is a milky white, but odorless pericardial fluid at pericardiocentesis. For cases where conservative treatment and pericardiocentesis fail, we newly introduced the method of pericardio-peritoneal shunting by a pericardial window. With postoperative reaccumulation of pericardial fluid, total parenteral nutrition followed by medium chain triglyceride diet was successfully reinitiated. This combined surgical and conservative approach was performed for the first time and may have helped to avoid the more aggressive treatment of thoracic duct ligation and resection. During 2 years of follow-up the patient was asymptomatic and had no recurrence of pericardial effusion.

[Systemic inflammatory reactions to extracorporeal therapy measures (II): Cardiopulmonary bypass]. / Systemische Entzündungsreaktionen extrakorporaler Therapieverfahren (II): Der kardiopulmonale Bypass.

About 65,000 cardiac patients undergo surgery annually in Germany with the assistance of cardiopulmonary bypass. The "post pump inflammatory response" (the systemic and myocardial inflammatory response syndrome post cardiac surgery), triggered at least in part by the cardiopulmonary bypass, contributes substantially towards morbidity (e.g., myocardial depression) and mortality in these patients. The main mechanisms underlying this inflammatory response are the complement cascade, the activation of blood cells, the release of cytokines and the induction to nitric oxide synthesis. The relative importance of each individual factor, however, is still a matter of debate. Scoring systems and measurements of tumor necrosis factor-alpha, as well as soluble tumor necrosis factor receptors, allow the early detection of an "escalating inflammatory response" in 2-10% of all patients, which is associated with a worse prognosis. Therapeutic attempts to suppress these systemic and myocardial inflammatory reactions focus on blockade of the complement system, coating of CPB membranes with heparin, leucocyte depletion and attenuation of leucocyte function, elimination of toxins and mediators by means of hemofiltration, as well as on the administration of antiproteases, antioxidants, oxygen radical scavengers and also of immune globulins.

Preliminary experience with the Toronto SPV stentless porcine bioprosthesis for aortic valve replacement.

From November 1992 to March 1993 fourteen patients received the Toronto SPV stentless porcine xenograft as aortic valve replacement. Median age was 56 years (range 32-70 years). 7 patients were male and 7 female. Implanted valve sizes ranged from 23 mm to 29 mm, the majority of patients received valves with 27 and 29 mm tissue diameter. A learning process was evident by aortic crossclamp time decreasing with experience. No valve-related mortality or morbidity occurred. Postoperatively echocardiography showed near normal valve performance in most patients. The longevity of the valve, however, still has to be established. Meanwhile we continue the implant of stentless bioprostheses as aortic valve substitutes in selected patients.

[Incomplete thrombosis of the inferior vena cava, a cause of chronic recurrent lung embolism. Diagnostic possibilities and case report]. / Die inkomplette V. cava-inferior-Thrombose, eine Ursache für chronisch rezidivierende Lungenembolien. Diagnostische Möglichkeiten und Fallbeschreibung.

Detection of complete inferior vena cava thrombosis is relatively simple because of the clinical symptoms and the pathological results of cw Doppler sonography in the region of the common femoral vein. Drainage volume detectable by means of venous occlusion plethysmography is considerably reduced during the acute phase, but normalizes with increasing degree of collateralization. In case of incomplete inferior vena cava thrombosis clinical signs, cw. Doppler sonography and venous occlusion plethysmography are not very relevant. Therefore, imaging technique is additionally required. Basing on a case report, the article demonstrates that ultrasound-B-method and echocardiography, or preferable endoechocardiography, may contribute to a more reliable diagnosis. Cavography is still the gold standard if invasive therapy is planned.

[Case reports of arteriovenous fistulas of coronary vessels in adulthood]. / Fallbeispiele arteriovenöser Fisteln der Koronargefässe im Erwachsenenalter.

It is reported on the diagnosis and therapy of arteriovenous fistulae of coronary arteries. With the help of 5 casuistic instances external fistulae could be demonstrated by invasive diagnostic procedures. In three cases the fistulae drained from the left coronary into the pulmonary artery, at the second instance from the right coronary artery into the right ventricle, in the fifth instance from the right coronary artery into the right atrium. In addition to this there were coronary stenoses which needed a bypass. In all cases the tentative diagnoses were confirmed intraoperatively. The indication to operative ligatures of the congenital fistulae is discussed and supported depending upon the picture of the complaint.

[Coronarography findings following systemic short-term lysis of acute myocardial infarct]. / Koronarographiebefunde nach systemischer Kurzzeitlyse des akuten Myokardinfarktes.

In 50 patients with acute infarction who were admitted within 6 hours after the beginning of the complaints randomizedly an intravenous streptokinase short-term lysis or a conventional heparin phenprocoumon treatment was performed and 4 weeks later the results were objectified by coronarography and ventriculography. The patients were subdivided into 3 groups: 1. control group (without fibrinolysis), 2. early lysis (within 4 hours) and 3. late lysis (4-6 hours). Four weeks after the infarction the proportions of the open infarction vessels are approximately of the same size in all three groups, the functional results are best (end-diastolic pressure and kinetics of the cardiac wall) in the group of patients who underwent an early lysis. Successfully lysed patients with remaining residual stenosis must be regarded as particularly threatened by infarction and remain under special control (residual angina, ergometrically objectified exercise tolerance, perhaps coronarography) in the phase of rehabilitation.

[ECG changes in the late postoperative course of patients following alloplastic heart valve replacement]. / Zur Bedeutung von Ekg-Veränderungen im späten postoperativen Verlauf bei Patienten nach alloplastischem Herzklappenersatz.

Based upon a total of 50 patients with alloplastic heart valve substitute an attempt was made to verify postoperative retrogression of the signs of hypertrophy in the ECG and to correlate them with the clinical findings. In accordance with the pertaining literature, the essential criterion for assessing left hypertrophy is the Sokolow index. In corrected aortic lesions there is a close relation between retrogression of electrocardiographic signs of hypertrophy and the clinical degree of severity. All patients with a retrogressive tendency of the signs of hypertrophy showed definite improvement of clinical findings. Patients in whom the ECG deteriorated did not have good clinical findings either. This clear relationship is not demonstrable in mitral lesions, since mitral stenosis and mitral insufficiency influence the left ventricle, the left atrium and the pulmonary circulation in various ways. A discussion of the assessment of the individual ECG symptoms and their causes is added.