Medium or high risk for venous thromboembolism, acute deep venous thrombosis, mechanical heart valve prothesis or phospholipid antibody syndrome require prophylactical or therapeutical anticoagulation during pregnancy. Under these conditions individual benefit-to-risk-relationships must be considered for the mother as well as for the fetus. Until recently conventional unfractioned heparins were used as standard anticoagulants in pregnant women. In the future, low-molecular weight heparins should be increasingly used in these circumstances due to their superior pharmacological properties, Unfractioned as well as low-molecular weight heparins have to be carefully applied in dosages as established for various prophylatic and therapeutic indications. Cumarine derivates are widely assumed to be contra-indicated in pregnancy as they are associated with cumarine embryopathy, feto-pathy, and a high rate of fetal loss. Thus, international recommendations justify their application only after mechanical heart valve replacement. However low-molecular weight heparins will probably offer an attractive alternative in these women.
History and clinical findings: A 29 year old healthy man showed a pulslessness for six seconds occurring immediately after bicycle ergometry The patient was admitted to our clinic for clarification of etiologyInvestigations: Clinical and laboratory findings were in normal range. The ECG was without abnormalities. in the x-ray of the thoracic organs no pathologic findings were detected Sonography of the abdomen and the thyroid gland Doppler ultrasonography of the extracranial vessels and echnocardiography were normal for age. Tilt-table testing with pharmacological stimulation could reproduce a vasovagal syncope of the type I or mixed vasovagal syncope with a predominant vaodepressive componentTreatment and course: The patient did not tolerate beta-blocker therapy for suppression of maximum excitability of the sympathicus. Hence a physical endurance training avoiding maximum efforts was started.Conclusion: Tilt-table testing is capable of clarifying the etiology of syncope. This case underlines the necessity of permanent presence of a physician and immediate availability of emergency equipment during bicycle ergometry.
Interventions under X-ray control are known as connected with expositions, which are unusual on diagnostical methods. Therefore in 1997 the commission of radiation protection gaves recommendations to minimize the exposition.With our project,Interventional Radiology" we have investigated the situation in X-ray-protection in Berlin and we started several protection methods to minimize the radiation exposition. We have registered the technical fittings and the results of the personal dosimetry including the dosimetry of eyes and hands. For the eyes there were expositions of 10...20 mSv per year registered, while the personal doses were lower than 3 mSv If the personal doses increase, eye doses can reach the dose rate threshold.
Aim of the present study was to investigate the influence of bench press exercise on echocardiographic parameters. 14 healthy male students (24.8 +/- 2.3 years, 181.6 +/- 5.4 cm, 773 +/- 5.9 kg) performed 30s isometric bench press exercises with workloads of 10 kg and 20 kg. M-Mode was used for measuring of left atrial (LA), left end diastolic and end systolic ventricular diameters (LVEDD/LVESD). Maximal systolic pressure of pulmonary artery (P-RV (sys)) has been estimated by means of CW-Doppler measurements of the transtricuspidal regurgitation. The bench press exercise led to significant reductions in LA and LVEDD. LA decreased from 32.4 +/- 3.7 mm (rest) to 29.1 +/- 2.7 mm (10 kg load) and to 27.6 +/- 2.9 mm (20 kg load). LVEDD diminished from 53.6 +/- 4.2 mm (rest) to 51.4 +/- 4.4 mm (10 kg load) and to 49.2 +/- 5.1 mm (20 kg load). LVESD, however; showed no significant changes. P-RV (sys) increased significantly from 16.5 +/- 5.9 mmHg (rest) to 25.1 +/- 8.4 mmHg (10 kg load) and to 31.0 +/- 10.8 mmHg (20 kg load). The responses of LA, LVEDD and P-RV (sys) to 30 s isometric bench press exercise indicate no additional cardiac risks for healthy subjects. There might be, however higher risks for people with unknown pulmonary hypertension. in particular, dynamic bench press exercise with maximal workloads could enlarge cardiac occurrences.
Interactions in the therapy with phenprocoumon and the tuberculostatic therapy with rifampin are already known. In the endocarditis-therapy of prosthetic cardiac valves with the germ staphylococcus aureus, the first choice treatment is the combination of flucloxacillin, gentamicin and rifampin. We report here about a fiftyone year old patient of our clinic. whose anticoagulation needed unusual doses of phenprocoumon, after the endocarditis-therapy of the prosthetic aortic valve with rifampin was started.
Inflammatory events play a key role in various stages of coronary arteriosclerosis. The discussion on a possible influence of infectious components is still ongoing and controversial. Whereas seroepidemiologic data do rather not support a major interrelationship between Chlamydia pneumoniae and coronary artery disease, there is growing evidence from histopathology molecular biology and animal studies focused on coronary artery lesions. Recent data from clinical trials are uncertain, antibiotic treatment outside clinical trials is not justified. In the near future, large trials will give clear messages concerning possible indications, efficacy and safety of a coronary macrolid medication.
Perioperative management of anticoagulation for patients who have been receiving long-term cumarin therapy remains controversial. The strategy whether to continue or stop anticoagulation perioperatively must be based on individual patients risk factors for thromboembolism and bleeding. Anticoagulation in pregnant patients is a particular challenge because complications may affect both mother and fetus. The gestational use of warfarin has medico-legal implications and should be completely discussed with the pregnant women. lmwh (low-molecular weight heparins) are established in many indications (i.e. deep vein thrombosis). In some fields (i.e. mechanical heart valves) the safe use of low-molecular heparins is matter of ongoing trials.
A 35-year old patient was admitted to our hospital because of progressive dyspnea and radiological signs of confluent bilateral perihilar shadowing. The initial echocardiogram and flow-directed right heart catheter results were normal and therefore atypical pneumonia was the assumed diagnosis. The patient required long-term mechanical ventilation and weening attempts remained unsuccessful. After 3 weeks the patient became hemodynamically unstable with beginning multiorgan failure and progressive right heart failure. Pulmonary embolism was suspected but transthoracic echocardiography now showed a turbulent flow from the basal interventricular septum into the right ventricle with enlargement of the right-heart cavities. Transesophageal echocardiography revealed a ruptured sinus of Valsalva aneurysm with a left-to-right shunt into the right ventricular outflow tract Pulmonary artery flow and left heart catheterization confirmed the diagnosis with a calculated shunt volume of 78%. Surgical repair was performed immediately and the patient recovered rapidly Four months later a second operation was performed because of recurrence of the fistula.Diagnosis, etiology, pathology and operative therapy of ruptured sinus of Valsalva aneurysms are critically analysed and compared with the literature.
Background and Study Aims: Pseudoaneurysms (or false aneurysms) of the heart are very rare and develop usually after free wall rupture as a result of myocardial infarction.Patients and Methods: Of 138 patients undergoing surgery for a left ventricular aneurysm in a 15-year-period (1980-1994) only 4 patients had had a pseudoaneurysm. Repair was accomplished by resection of the false aneurysm and direct closure of the defect over Teflon felt Three patients underwent additional coronary artery bypass graftingResults: All 4 patients developed the condition after myocardial infarction. The interval between myocardial infarction and diagnosis of the pseudoaneurysm was between one month and 5 years, All patients survived the operation and remained well after a mean follow-up period of 136 months.Conclusion: The detection of pseudoaneurysms of the heart is indication for surgical treatment because of their tendency for rupture The results of surgical repair are excellent.
The incidence of thromboembolic events in unselected patients with chronic left ventricular dysfunction and an ejection fraction of 35% or less is 1.5 to 3.5% per year Atrial fibrillation is the only established and generally accepted thromboembolic risk factor in these patients. In patients in sinus rhythm a mobile LV thrombus, previous thromboembolic events and a severely reduced LV function (particularly in women) seem to be associated with an increased thromboembolic risk. The clinical degree of heart failure, the presence of a LV aneurysm or the reason for myocardial failure - ischemic or non ischemic - are not yet generally accepted thromboembolic risk factors in chronic left ventricular dysfunction. Patients with chronic left ventricular dysfunction and atrial fibrillation benefit from long time anticoagulant therapy and should be treated with an international normalized ratio value between 2 and 3. For patients in sinus rhythm anticoagulant therapy is indicated in those with a previous history of thromboembolic events. in these patients the most benefit seems to result from an international normalized ratio value of 3. Anticoagulation in patients in sinus rhythm with very low LV ejection fraction or intracardiac thrombi seems to be acceptable and may be done in individual cases.
Background: Typical EGG-changes in respective leads are able to localize the side of coronary obstruction in myocardial infarction. The purpose of this retrospective investigation was to find out, if there is a similar correlation between stress induced ST segment depression and the side of myocardial ischemia and coronary stenosis, respectivelyMethods and patients. 118 patients with one-vessel-disease and significant ST-segment depression during exercise ECG were investigated. All patients were tested with a bicycle ergometer Leads I, II, II and V-2, V-4, V-6 were recorded.Four Groups: Group I: Patients with stenosis and occlusions in one of the three major coronary artery (total group); Group 2. Patients with stenosis but no occlusions in one of the three major coronary artery; Group 3 and 4. Patients with and without respectively, angiographically proven wall motion abnormalities.Results: There were no significant differences between the individual patients concerning the basic data of stress testing (heart rate, work load, exercise duration, blood pressure and symptoms). The basic data (age, gender wall motion abnormalities, collaterals) were not different in all patients in correlation to the three major coronary arteries (left anterior descending artery, circumflex artery and right coronary artery). Significant more female patients revealed a stenosis or occlusion of the left anterior descending artery and a dominant left coronary artery.The highest rate for stress-induced ST segment depression in all three coronary arteries was found in lead V-6. The changes in the other leads cannot be correlated to one of the vessels (stenosed or occluded). A differentiation regarding wall motion abnormalities and collaterals in patients with occluded vessels was not possible. Therefore ECG changes in defined leads or a combination of certain leads did not refer to stenosis/ occlussion in a specific vessel.Conclusion: These results indicate that the localization of stress induced ECG changes does not correlate with the localisation of coronary stenosis. The stress ECG is therefore not able for the determination of the localization of coronary artery stenosis in patients with one vessel disease.
There are still significant deficits in communication between different partners in the care of cardiac patients with specific problems in cardiac rehabilitation. The development of telemedicine adds new possibilities of organization and cooperation. A computer network between an interventional Cardiology Center and a Cardiac Rehabilitation Facility based on ISDN Cable Communication is presented. The Structure and Function of the network as well as legal aspects are discussed.
The clinical and electrophysiological findings in a 53-years old Female patient with symptomatic and incessant supraventricular tachycardias are presented in a case report The underlying mechanism was a double ventricular response in dual AV nodal pathways. The correct diagnosis of this rare phenomenon allows a curative approach by slow pathway ablation.
in the invasive diagnosis of ischemic heart disease usually left ventriculography in addition to selective coronarangiography is performed for assessment of left ventricular size, function and wail motion. in consideration of published data with high agreement between 2D-echocardiography and ventriculography the aim of the present study was to analyse whether a routine left ventriculography is replaceable in case of adequate diagnostic usable echocardiography. In a prospective investigation of 100 consecutive, non-selectioned patients (55% male, 45% female, mean age 64,24+/-9,54 years) with a suspected diagnosis of ischemic heart disease and without any clinical evidence of valvular, congenital or primary muscle heart disease left ventricular volumes, global left ventricular ejection fraction and regional wail motion were calculated by 2D-echocardiography. These results were compared with the invasive data from left ventriculography. There was a high grade of correlation between angiographic and echocardiographic findings concerning enddiastolic and endsystolic volumes (EDV r = 0,71; ESV r = 0.74) as well as the left ventricular ejection fraction (EF r = 0.74). Also regional wail motion assessment revealed no significant difference between the two image modalities Beyond echocardiographic results in none case any modification of diagnostic or therapeutic strategy by additional invasive data was necessary. Summarized apart from proved exceptions left ventriculography should not be considered mandatory for the rational investigation of ischemic heart disease in case of current diagnostically usable 2D-echocardiography.
Only half of the patients after myocardial infarction recieve beta-adrenergic agonists despite their beneficial effects on survival Recent studies show that patients with conditions that are often considered contraindications to beta-blockade benefit especially from mis treatment including patients with diabetes, heart failure, pulmonary disease, and older age. The mechanism of action of the beneficial effects of beta-blockers is still not completely understood, but the lowering of heart rate and the reduction of sudden cardiac death seems to play an important role.
The prevalence of chronic heart failure is increasing in the developed countriesThirteen trials showed that there could be reached a reduction of all cause mortality in patients with chronic heart failure during the last fifteen years by additional therapy with different drugs (hydralazine+isosorbiddinitrate. enalapril, bisoprolol, metoprolol, amiodipine, carvedilol digoxin, spironolactone).The relative and absolut risk reduction of all cause mortality varies between 1% and 59% (mean 17,3%) respectively 1% and 18% (mean 34%), with different functional classes of heart failure and the drug used.Considering only the studies with positive results the relative and absolute risk reduction amount to nearly 30% respectively 6%.115 patients in ail studies respectively 21 patients in the significant positive studies must be treated to avoid one fatal case.With enalapril the risk reduction seems to be greater in patients with higher than lower functional class of heart failure. With the other agents statements are not possible in this regardWith regard to the different drugs statements can only be made that digoxin have no or only a small effect on risk reduction of all cause mortality With the other agents no sure effects are derivable on different efficacies ii, terms of reduction of mortalityThe different parameters of efficacy (relative and absolute risk reduction, number needed to treat to save one fatal case) have limitations.The best way to judge the mortality reduction is to start with the placebo and verum mortality and to compare the verum mortality with the age- and genderrelated mortality in the population.The annual mortality rates in the patients examined in the studies of different countries are comparable with the annual mortality rates of the Federal Republic of Germany.The estimated yearly mortality rates of about 10% in the verum group in the patients with chronic heart failure of the studies are distinctly higher about the factor 5 respectively 10 than the mean rates in the German population in relation to age and gender bout 2% in men and about 1% in women.Further research work is necessary to improve the prognosis in patients with chronic heart failure.
