["Everything will be easier" (interview by Jochen Aumiller)].
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Cardiopulmonary Resuscitation↗
Biomedical subjects
G Görge
Publications and source records attributed to G Görge.
Can serum NT-proBNP detect changes of functional capacity in patients with chronic heart failure?
Recently, in a cross-sectional study, a correlation of moderate degree was documented between serum BNP (brain natriuretic peptide) and exercise capacity in patients with chronic heart failure (CHF). However, it remains unknown if BNP, which increases in response to high myocardial wall stress, is sufficiently sensitive for changes in exercise capacity during clinical follow-up. To elucidate this, 42 CHF patients were recruited and randomized into a training (T; 58 +/- 10 years; n = 14 NYHA II; n = 5 NYHA III) and a control group (CO; 54 +/- 9, n = 17 NYHA II; n = 6 NYHA III). T carried out 12 weeks of endurance training on a cycle ergometer (4 sessions per week, 45 min duration). Venous blood sampling and cycle ergometry with simultaneous gas exchange measurements were carried out prior to and after the experimental phase. Due to its superior stability during laboratory procedures, NTproBNP was determined instead of BNP. Both proteins are secreted in equimolar amounts and share an identical diagnostic meaning. In both groups, NT-proBNP decreased slightly (T: from 1092 +/- 980 to 805 +/- 724 pg x ml(-1); CO: from 1075 +/- 1068 to 857 +/- 1138 pg x ml(-1); T vs CO: p = 0.65). Anaerobic threshold (AT) as a measure of exercise capacity went up in T (from 0.96 +/- 0.17 to 1.10 +/- 0.22 l x min(-1)) but remained almost constant in CO (pre: 1.02 +/- 0.27; post: 1.00 +/- 0.27 l x min(-1); T vs CO: p < 0.001). The correlation between changes in NT-proBNP and changes in AT remained insignificant (r = 0.02, p = 0.89)-even if only T was considered (r = 0.09, p = 0.72). Improved exercise capacity in CHF patients due to 3 months of endurance training is not reflected in the course of NT-proBNP. These findings are inconsistent with a sufficient sensitivity of this parameter to detect changes in exercise capacity during clinical follow-up. Changes in NT-proBNP beyond its spontaneous variability are more likely to be detected following therapeutical interventions which aim more clearly at the myocardium. In determining alterations of functional capacity ergometric testing cannot be replaced by serial determinations of NT-proBNP.
Aged↗
[Competitive sports and dilated cardiomyopathy: the case of a 32-year-old soccer player with ventricular tachycardia].
HISTORY AND ADMISSION FINDINGS: A 32-year-old competitive soccer player presented with palpitations he had felt for 4 weeks during maximal activity (soccer training and match). The physical examination and an exercise electrocardiogram were carried out by his general practitioner up to 19 s at 350 W and a heart rate of 147/min without showing any abnormalities. INVESTIGATIONS: All blood parameters revealed no signs of illness. During treadmill exercise at a heart rate of 181/min, a non-sustained ventricular tachycardia was induced. Echocardiography showed a dilated left ventricle with an enddiastolic diameter of 70 mm and low fractional shortening (28 %). Cardiac catheterization demonstrated a diminished left ventricular ejection fraction (38 %) and an enlarged enddiastolic volume (199 ml) without signs of coronary artery disease. Electrophysiologic testing induced a non-sustained ventricular tachycardia. DIAGNOSIS, TREATMENT AND COURSE: The echocardiographic and angiographic results indicated a dilated cardiomyopathy. Competitive sports activities were stopped and treatment with a beta-blocker (metoprolol) and an ACE-antagonist (ramipril) was started. CONCLUSION: In young male and female athletes, the possibility of severe cardiac abnormalities have to be considered even in the presence of good physical fitness and performance. To reach a high sensitivity for diagnostic ergometry, the work-load must reach the maximal capacity of the cardio-pulmonary system. Differences in the exercise performance of athletes and untrained subjects have to be considered.
Adrenergic beta-Antagonists↗
[Non-surgical therapy of iatrogenic false aneurysms].
SUMMARY: False aneurysms occur after 0.1 - 1.5 % of all diagnostic and up to 6 % of all therapeutic percutaneous interventions. Surgery used to be the treatment of choice in symptomatic patients. But two non-invasive measures of treatment gain more attention: ultrasound guided compression (UGC) and ultrasound guided thrombin injection (UGTI). UGC with compression times from 30 - 120 min is effective in 80 % of patients without anticoagulation. However, UGC is often painful and results in prolongation of in-hospital time. UGTI is effective in 95 % of patients. Usually, 100 - 2000 U of thrombin are injected into the false aneurysm. UGTI is also effective in the presence of anticoagulation or antiplatelet therapy. UGTI is not indicated in patients with a large communication with the native vessel and in arterio-venous-fistulas. In patients with large haematomas, ongoing bleeding, damage of the native vessel, compression of arteries, veins or neurological deficits, or with infections, early surgical repair is still the treatment of choice.
Aneurysm, False↗
A prospective study on ultrasound-guided compression therapy or thrombin injection for treatment of iatrogenic false aneurysms in patients receiving full-dose anti-platelet therapy.
BACKGROUND: False aneurysms (FA) develop at the puncture site in up to 6% of percutaneous cardiovascular procedures. Previous management included surgery or manual compression. Recently, selective injection of thrombin has been proposed as an alternative. However, there has been no direct comparison of thrombin injection to manual compression. AIM: To study the effectiveness of manual compression compared to that of thrombin injection in patients with false aneurysms on full-dose aspirin and clopidogrel. METHODS AND PROTOCOL: All patients with a clinically suspected FA after percutaneous invasive procedures were recruited for the study. The patients were examined with color ultrasound (7.5 MHz transducer). The minimum and maximum diameters of the false aneurysm and the distance between the surface and the false aneurysm were measured online. Under local anesthesia, manual compression was applied under sonographic guidance in all patients. If compression stopped flow into the false aneurysm, manual compression was applied for a maximum of 40 min followed by compression bandage for a minimum of 12 hours. If compression failed, thrombin was injected under ultrasound guidance. RESULTS: Thirty-six patients had a FA. Their age ranged from 58 to 90 years (mean 71+/-9 years). All patients were taking aspirin (median dose 100 mg per day) and clopidogrel (median dose 75 mg per day). Additionally, 24 patients had received subcutaneous heparin (7500 to 12 500 units) or enoxaprin (0.4-1.0 ml) 3 to 12 hours before treatment. The mean width of the false aneurysm was 22.1+/-3 mm, mean length 33.6+/-35.4 mm, and mean depth 19.5+/-8.2 mm. In six patients (17%), ultrasound-guided manual compression was tolerated, succeeding after 5 to 31 minutes. Thirty patients received thrombin injections (100-1800 units, mean 880+/-470 units, median 800 units). Complete thrombosis occurred in 28 patients (93%). Surgery was performed in the other two patients. The thrombin injection was not associated with any complications. In particular, there were no peripheral vascular complications. CONCLUSION: In patients with FA taking aspirin and clopidogrel, selective thrombin injection is more effective than manual compression.
Aged↗
[Reimbursement questions for cardiology services within the scope of GOA:2. Position of the DRG and GOA Project Group].
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Aftercare↗
Management of complex, two chamber false aneurysm by thrombin injections.
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Aged↗
[Smoking cessation. A physician's responsibility].
Giving up smoking is a cost-effective measure in the secondary prevention of chronic arterial disease and chronic obstructive pulmonary disease. The involvement of the physician in the primary prevention of smoking and kicking the habit in the case of tobacco-related disease, must receive greater emphasis than has so far been the case in Germany. Weaning smokers suffering from tobacco-related disease from their habit is a task for the physician, and may take the form either of a single minimal intervention, or successive consultations that can be integrated in every medical activity. The concept of stepwise smoking dishabituation is supported by evidence-based consensus recommendations on the part of relevant national and international medical societies and public institutions.
Humans↗
[Epidural spinal cord stimulation in the treatment of therapy-resistant angina pectoris].
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Angina Pectoris↗
Microgenerators for energy autarkic pacemakers and defibrillators: fact or fiction?
BACKGROUND: Implantable devices for medical use like permanent pacemakers, defibrillators, and fluid pumps depend on an energy provided by batteries. Unfortunately, the battery usually determines the duration of life of these devices, while technical problems occur infrequent. Device replacement for battery exhaustion requires surgical procedures and account for up to 1/3 of all pacemakers sold. Attempts to provide unlimited power support using radio transmission, nuclear energy etc. did not gain clinical acceptance. METHOD: We therefore evaluated the potential role of a microgenerator (designed for use in wrist watches) to recharge pacemaker batteries. We used the Epson-Seiko Caliber 5M22 that uses a "Gold-Cap" for energy storage. The mass of the actuator is 1.6 g and an angle of > 10 degrees is needed to overcome friction. Output at a rotor frequency of 200 Hz is 1.8 mWatt To measure the power provided, various experiments were made with the microgenerator taped to the chest of a normal person working in an office. Range of 11 experiments over 8 hours each was 0.2 to 3.1 microWatt (median 0.5 microWatt). Therefore, the power generated was 10 to 100 times less than the calculated power needed to recharge a typical pacemaker battery. A second type of generator (Mondaine, Zurich, Switzerland) with less mechanical parts, available in a "black box" version only, generated not more power. CONCLUSION: Thus, commercially available, yet not optimized microgenerators provided only between 1 to 10% of the power requirements of a pacemaker. However, modifications in design and mainly the orientation and weight of the actuator to generate more power from the G-forces during walking, would result in a more meaningful energy output.
Costs and Cost Analysis↗
[Increased demand for psychosomatic consultation service (C-service) in a department of cardiology/pneumology due to psychometric screening].
The aim of the study was to test whether the routine use of the Hospital Anxiety and Depression Scale HADS changes the frequency and the duration of calling the psychosomatic C-service. 70% of all patients of the department of cardiology/pneumology were registered by the HADS. Psychometric screening raised the number of patients checked by the C-service (15.3 vs. 2.7% of all patients of the department; p < 0.01) and reduced the duration of the call for the C-service (2.7 vs. 6.4 days; p < 0.01) compared to conventional C-service. Elevated scores in HADS were found in 26% of the patients (21% depression, 12% anxiety).
Aged↗
Augmented alpha-adrenergic constriction of atherosclerotic human coronary arteries.
BACKGROUND: Although adrenergic activation plays a major role in the initiation of experimental myocardial ischemia, the significance of alpha-adrenergic coronary constriction in humans has been questioned. The present study assessed the impact of selective alpha-adrenergic receptor activation in patients with normal or atherosclerotic coronary arteries. METHODS AND RESULTS: In 39 patients, coronary blood flow (CBF, mL/min) was determined from combined angiography and Doppler measurements. In 8 patients with normal coronary arteries (group 1) and 9 with single coronary artery stenosis (group 2), doses of 1, 2.5, 5, and 10 mg IC of the alpha1-agonist methoxamine (M) were injected. Identical doses of the alpha2-agonist BHT933 (B) were injected in 8 patients with normal coronary arteries (group 3) and 8 with single stenosis (group 4). In 6 additional patients with single stenosis (group 5), aortocoronary sinus lactate differences were measured in response to M and B. CBF remained unchanged in group 1. In contrast, CBF was decreased dose-dependently in group 2, with a maximum at 10 mg M (39.0+/-9.4 versus 15.2+/-7.0). In groups 3 and 4, CBF was also decreased dose-dependently, with a maximum at 10 mg B (63.3+/-24.8 versus 49. 1+/-27.9 and 41.5+/-19.0 versus 12.7+/-8.0, respectively). In group 5, there was more net lactate production with B than with M (-0. 34+/-0.11 versus -0.04+/-0.09 mmol/L). CONCLUSIONS: In normal coronary arteries, alpha1-adrenergic activation does not reduce CBF, whereas alpha2-adrenergic activation reduces CBF by microvascular constriction. Both alpha1- and alpha2-adrenergic epicardial and microvascular constriction are augmented by atherosclerosis and can induce myocardial ischemia.
Adrenergic alpha-Agonists↗
Stepwise intravascular ultrasound (IVUS) guidance of high-pressure coronary stenting does not result in an improved acute or long-term outcome: a randomized comparison to "final-look" IVUS assessment.
The objective of this study was to evaluate the potential benefit of stepwise intravascular ultrasound (IVUS)-guided coronary stent deployment compared to angiographic stent implantation with final IVUS assessment only. Acute procedural success and 6-month angiographic follow-up were compared in both groups. Intravascular ultrasound was performed using a 20- or 30-MHz mechanically rotated catheter in 85 patients who were prospectively randomized to group A (n=42; IVUS-guided) and group B (n=43; angiography +/- final IVUS assessment). There was no difference in the number of stents implanted (1.5+/-0.9 stents/lesion in group A and 1.3+/-0.6 stents/lesion in group B), the duration of the procedure, or the amount of contrast medium used. Defined criteria of optimal stent deployment (stent apposition, stent symmetry, complete coverage of dissections, >90% in-stent lumen area/reference lumen area) were achieved in 54.2% in group A and 56.6% in group B (NS). Angiographic follow-up was 87.1% at 6+/-2 months, and clinical follow-up was 100% at 8+/-1 months. There was no significant difference in restenosis rate (33.3% vs. 34.9%) applying a binary >50% diameter stenosis criterion for both groups. There was no significant difference in minimal in-stent lumen area at both baseline (7.91+/-2.64 mm2 vs. 7.76+/-2.21 mm2) and follow-up (5.84+/-2 mm2 vs. 5.52+/-1.87 mm2). With regard to immediate procedural lumen gain and rate of restenosis, multiple IVUS examinations during the procedure showed no advantage compared to final IVUS assessment only.
Coronary Angiography↗
Role of intravascular ultrasound imaging in identifying vulnerable plaques.
UNLABELLED: A plaque that has a large lipid core and a thin fibrous cap may undergo rupture. Once it ruptures, it may lead to thrombus formation and subsequent vessel occlusion. To identify unstable plaques before they rupture is essential for clinical management and patient's prognosis. Intravascular ultrasound (IVUS) opens a new window for the assessment of plaque morphology to identify vulnerable plaques and plaque rupture. We examined 144 patients with angina and ischemic ECG changes using IVUS. Ruptured plaques, characterized by a plaque cavity and a tear on the thin fibrous cap, were identified in 31 patients (group A) of which 23/31 (74%) clinically presented as unstable angina. Plaque rupture was confirmed by injecting contrast medium filling the plaque cavity during IVUS examination. Of the patients without plaque rupture (group B, n = 108), only 19 (18%) had unstable angina. No significant differences between the 2 groups were found concerning the vessel and plaque areas (p > 0.05). The percent stenosis in group A (56.2 +/- 16.5%) was significantly lower than in group B (67.9 +/- 13.4%) (p < 0.001). Area of the plaque cavity in group A (4.1 +/- 3.2 mm2) was significantly larger than the echolucent zone in group B (1.32 +/- 0.79 mm2) (p < 0.001). The plaque cavity/plaque ratio in group A (38.5 +/- 17.1%) was larger than the echolucent area/plaque ratio in group B (11.2 +/- 8.9%) (p < 0.001). The thickness of the fibrous cap in group A (0.47 +/- 0.20 mm) was significantly thinner than that (0.96 +/- 0.94 mm) in group B (p < 0.001). CONCLUSIONS: Plaques seem to be prone to rupture when the echolucent area is larger than 1 mm2, the echolucent area/plaque ratio greater than 20% and the fibrous cap thinner than 0.7 mm. IVUS has the capacity of identifying plaque rupture and vulnerable plaques. This may have potential influence on patients management and therapy.
Adult↗
Does remodeling occur in the diseased human saphenous vein bypass grafts? An intravascular ultrasound study.
BACKGROUND: Coronary artery remodeling is a common phenomenon in human atherosclerotic arteries. Controversies exist concerning the presence of absence of the remodeling process in diseased human coronary saphenous vein bypass grafts. The purpose of the study was to observe the vessel and lumen dimensions in patients who had undergone saphenous vein grafting with intravascular ultrasound to find out whether the remodeling process exists in the diseased human saphenous vein bypass grafts. METHODS: A total of 43 saphenous vein bypass grafts from 43 patients (39 males, 4 females, mean age 63+/-8 years); 1-16 years (mean 9.3+/-4.0 years) after grafting, who had not undergone previous catheter intervention, were studied using intravascular ultrasound. The vessel, lumen and plaque area were measured at the lesion segment as well as in the proximal and distal reference segments. The percent stenosis was calculated. RESULTS: In 43 bypass grafts having severe stenosis before intervention, plaque was eccentric in 69.4% and concentric in 30.6%. No calcification was detected in 75% cases and 25% cases has mild-moderate intimal calcification. The vessel area in the lesion segment was 19.0+/-9.7 mm2, significantly larger than the proximal reference segment 12.8+/-4.0 min2 as well as the distal reference segment 12.9+/-3.6 mm2 (p < 0.001). It was also larger than that of the average area of the proximal and distal reference segments (p < 0.001). The vessel area increased in accordance with plaque area (p < 0.001). A weak relationship existed between vessel area and percent stenosis (r = 0.37, p = 0.04). CONCLUSION: In contrary to previous findings, diseased human saphenous vein bypass grafts undergo focal compensatory enlargement (remodeling) in the presence of plaque formation. The underlying mechanism is probably similar to that in de novo atherosclerosis.
Adaptation, Physiological↗
New signs characteristic of myocardial bridging demonstrated by intracoronary ultrasound and Doppler.
BACKGROUND: Large discrepancies exist concerning the incidence of myocardial bridging. This has been reported to be 0.5%-2.5% following coronary angiography but 15%-85% following autopsy. The purpose of the study was to use intravascular ultrasound and intracoronary Doppler to study the morphology and flow characteristics of myocardial bridging in order to find feasible parameters of this syndrome. METHODS AND RESULTS: Intravascular ultrasound was performed in 62/69 patients in whom typical angiographic 'milking effects' were present. In 48 patients, intracoronary Doppler was performed. A specific, echolucent 'half moon' phenomenon surrounding the myocardial bridge was found in all the patients. The thickness of the half moon area was 0.47 +/- 0.19 mm in diastole and 0.52 +/- 0.23 mm in systole. There was systolic compression of the myocardial bridge with a lumen reduction during systole of 36.4 +/- 8.8%. Using intracoronary Doppler, a characteristic early diastolic 'finger tip' phenomenon was observed in 42 (87%) of the patients. All patients showed no or reduced antegrade systolic flow. Coronary flow velocity reserve was 2.03 +/- 0. 54. After intracoronary nitroglycerin injection, retrograde systolic flow occurred in 37 (77%) of the 48 patients, with a velocity of -22. 2 +/- 13.2 cm. s(-1). Intravascular ultrasound revealed atherosclerotic involvement of the proximal segment in 61 (88%) of the 69 patients, with an area stenosis of 42 +/- 13%. No plaques were found in the bridge or distal segments in the 62 patients in whom it was possible to introduce the ultrasound catheter throughout the bridging segment. CONCLUSION: Myocardial bridging is characterized by the following morphological and functional signs: a specific, echolucent half moon phenomenon over the bridge segment, which exists throughout the cardiac cycle; systolic compression of the bridge segment of the coronary artery; accelerated flow velocity at early diastole (finger-tip phenomenon); no or reduced systolic antegrade flow; decreased diastolic/systolic velocity ratio; retrograde flow in the proximal segment, which is provoked and enhanced by nitroglycerin injection.
Blood Flow Velocity↗
Intravascular ultrasound classification of atherosclerotic lesions according to American Heart Association recommendation.
BACKGROUND: Intravascular ultrasound (IVUS) offers a new modality by which to image the vessel wall in high resolution. The aim of the study was to classify atherosclerotic lesions using IVUS according to American Heart Association (AHA) recommendation. METHODS: IVUS was performed using a 20 or 30 MHz mechanically rotated catheter in 190 patients (aged from 35 to 75 years, mean 59 +/- 9 years) who presented with suspicion of coronary artery disease based on clinical examination. RESULTS: Of the 190 patients, 49 (26%) (group A) were found to have normal or nearly normal coronary arteries, whereas the other 141 (74%) (group B) had significant angiographic stenosis (> 50% luminal narrowing). IVUS image interpretation was based on the recommendation of the Committee on Vascular Lesions of the Council on Atherosclerosis (AHA). In group A, a total of 822 segments were evaluated with IVUS; 444 (54%) were found to have plaque formation. Among these 444 segments, type II lesions were found in 145 (33%), type III lesions in 110 segments (25%), type IV and Va lesions in 169 segments (38%), and type Vb in 18 segments (4%). The severity of plaque area stenosis increased from type II to IV. In group B, only the most stenotic segments (n = 141) on angiography were selected for analysis. No significant differences were found among different lesion types with respect to the severity of plaque area stenosis. Type Vb and Vc lesions presented mainly, but not exclusively, as stable angina, whereas type VI lesions presented mainly as unstable angina. Some patients (12%) with stable angina had complicated lesions (type VIa-VIc). CONCLUSIONS: It is now possible to use intravascular ultrasound to classify atherosclerotic lesions according to the AHA recommendations that were based on histological examination. Standardized reports of IVUS can now be based on these recommendations. Even in angiographically normal coronary arteries, advanced atherosclerotic lesions are found, explaining the potential risk of acute coronary syndromes in this group of patients. In patients with angiographically severe coronary disease, clinical symptoms correlate mainly with plaque characteristics, rather than with the severity of stenosis.
Adult↗
Screening of ruptured plaques in patients with coronary artery disease by intravascular ultrasound.
AIM: To visualise the characteristics of ruptured plaques by intravascular ultrasound (IVUS) and to correlate plaque characteristics with clinical symptoms to establish a quantitative index of plaque vulnerability. METHODS: 144 consecutive patients with angina were examined using IVUS. Ruptured plaques, characterised by a plaque cavity and a tear on the thin fibrous cap, were identified in 31 patients (group A), of whom 23 (74%) presented with unstable angina. Plaque rupture was confirmed by injecting contrast medium filling the plaque cavity during IVUS examination. Of the patients without plaque rupture (group B, n = 108), only 19 (18%) had unstable angina. RESULTS: No significant differences were found between groups A and B in relation to plaque and vessel area (p > 0.05). Mean (SD) per cent stenosis in group A was less than in group B, at 56.2 (16.5)% v 67.9 (13.4)%; p < 0.001. Area of the emptied plaque cavity in group A (4.1 (3.2) mm2) was larger than the echolucent zone in group B (1.32 (0.79) mm2) (p < 0.001). The plaque cavity to plaque ratio in group A (38.5 (17.1)%) was larger than the echolucent area to plaque ratio in group B (11.2 (8.9)%) (p < 0.001). The thickness of the fibrous cap in group A was less than in group B, at 0.47 (0.20) mm v 0.96 (0.94) mm; p < 0.001. CONCLUSIONS: Plaques seem to be prone to rupture when the echolucent area is larger than 4.1 (3.2) mm2, when the echolucent area to plaque ratio is greater than 38.5 (17.1)%, and when the fibrous cap is thinner than 0.7 mm. IVUS can identify plaque rupture and vulnerable plaques. This may influence patient management and treatment.
Adult↗