Biomedical subjects
Publications and source records attributed to J Sochman.
Large recurrent pericardial effusion can be managed by repeat pericardiocentesis or by surgery. A relatively new, catheter-based method uses a balloon catheter (percutaneous balloon pericardiotomy) for drainage from the pericardial sac to the pleural space. As an alternative, we present a newly developed device: Cutting pericardiotome.
We describe a new, catheter-based method for temporary management of hemodynamic instability after papillary muscle rupture in a patient with an acute myocardial infarction.
Our previous experimental research and initial clinical observations regarding the use of N-acetylcysteine in the treatment of ischemic and reperfusion injury in acute myocardial infarction gave rise to a study entitled the Infarct Size Limitation: Acute N-acetylcysteine Defense (ISLAND) trial. Today, this randomized, echocardiographically and angiographically controlled study includes the first 30 patients with a first anterior wall myocardial infarction: Group A (n = 10) consisting of patients with successful recanalization of the infarct-related left anterior descending artery by streptokinase without any further treatment, Group B (n = 10) consisting of patients with failed infarct-related artery recanalization, and Group C (n = 10) comprising patients who had successful streptokinase-induced recanalization of the left anterior descending artery plus N-acetylcysteine administration at a dose of 100 mg/kg body weight. The parameters monitored in our study include changes in global and regional left ventricular ejection fraction of the infarct-related segment using echocardiography and, using electrocardiograms and the Wagner QRS scoring system, the amounts of acutely jeopardized and finally infarcted myocardium. In Group A, global left ventricular ejection fraction rose nonsignificantly within 2 weeks from 37.5 +/- 9.6% to 38.5 +/- 13.8%; it declined significantly in Group B from 36.2 +/- 6.1% to 30.1 +/- 6.7% (p < 0.05), while it considerably improved in Group C from 41.7 +/- 4.1% to 59.6 +/- 8.1% (p < 0.001). Regional left ventricular ejection fraction changed significantly only in Group C: from -4.5 +/- 27.3 to 45.6 +/- 16.3 (p < 0.001). In Group A, in which the amount of acutely jeopardized myocardium was 21.7 +/- 7.2, infarction actually occurred in 20.4 +/- 9.7% (practically no myocardial salvage). In Group B, risk area was 18.1 +/- 4.3%, but infarct size rose to a resulting 29.1 +/- 6.0%. Significant myocardial salvage was accomplished only in Group C: of 26.2 +/- 8.1% of jeopardized myocardium, infarct size was reduced to 10.8 +/- 7.1% (salvage by 58.8%). Also, basic division of patients by therapy showed that, although those with nonidentical findings on their coronary arteries were included into the same groups, patients treated with streptokinase plus N-acetylcysteine had significantly more favorable values of the monitored parameters than those treated with streptokinase alone. We conclude our interim analysis suggests that N-acetylcysteine has a beneficial effect, reducing the functional and structural impacts of myocardial infarction.
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A 91-year-old woman, who had a pacemaker implanted in 1977, underwent replacement of a pulse generator and lead in 1995 because of recurrent syncope. The new lead dislodged the next day and migrated to the pulmonary artery. Because of her dependence on continued pacing, repeated resuscitation was required. Considering her advanced age and the impact of cardiopulmonary resuscitation on her general condition, we attempted catheter aided repositioning of the pacemaker lead. The procedure was technically successful; lead position was stable and optimal pacing parameters were attained. She was discharged in good condition.
As regards reperfusion therapy in patients with acute myocardial infarction, the general belief today is that early recanalization of the infarct-related artery--using either thrombolytic therapy or direct mechanical thrombolysis with angioplasty, and undertaken within 6 hours since the onset of ischaemia--can reduce the extent of necrosis, will reduce both mortality during hospitalization and one-year mortality, and will favourably limit regional expansion of the left ventricle affected by the infarction. Drawbacks include apparent reperfusion injury to the myocardium with possible impact on patients' mortality within the first 24 hours. The importance of reperfusion injury has not been fully established as yet. Delayed recanalization within 12 hours can only occasionally reduce the extent of necrosis (in specific cases where the development of necrosis has not yet been completed). The effect on patients' mortality remains unclear. While delayed institution of thrombolytic therapy must be considered on a case-by-case basis, it is not contraindicated. It does not seem advantageous to initiate thrombolytic therapy within 12 to 24 hours since the onset of ischemia. In such cases, percutaneous transluminal angioplasty may be more appropriate, but practical considerations and the costs involved render this option virtually unfeasible at present. However, delayed recanalization of the infarct-related artery using the latter method may exert a favourable effect on left ventricular remodeling. It should be noted it is no longer a mechanism of direct myocardial protection, as is the case in the early phase of infarction.
The technical aspects of temporary closure of a postinfarction interventricular septal rupture in a 76-year-old woman in critical circulatory status ruling out conservative therapy and making surgical management unfeasible, are described. The patient was in cardiogenic shock with hepatorenal failure in acute myocardial infarction of both the anterior and posterior walls. A balloon catheter developed in our unit was employed to close the rupture.
The authors describe the septic sequelae of an unobserved embolization of a central venous catheter into right-sided cardiac compartments. The finding of an embolized fragment of a catheter which was in the patient's circulation for 89 days was quite incidental. The previous period was associated with diagnostic doubts in various departments. The most frequent diagnosis of repeated septicaemia was bacterial endocarditis, although repeated echocardiographic examinations did not confirm it. Similarly, repeated X-rays did not contribute to the diagnosis--this can be explained by dilatation of the heart of the patient. Extraction of the embolized fragment by means of a catheter resolved the problem. The fragment was colonized by the causal agent of the febrile conditions--Staphylococcus aureus.
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The efficacy of adenosine triphosphate (ATP, Spofa) in controlling supraventricular tachycardia (SVT) was assessed in a group of 20 consecutive patients with this condition. Sinus rhythm was restored in a total of 19 patients (95% efficacy). SVT termination was followed, in a full 40% of patients, by asystole with a mean duration of 8.6 seconds; there were, however, no sequelae and no measures had to be taken. ATP can be regarded as a welcome addition to the current range of pharmacological options available for the treatment of SVT.
The authors, presenting a group of 23 cardiac myxomas over the past 20 years, provide a review of the most common clinical symptoms, such as mitral valve stenosis, dyspnoea, tachycardia, and/or myxoma mass embolizing the systemic circulation as well as the diagnostic modalities available, echocardiography and angiography in particular. Based on the histologic picture and the ultrastructure. They assume that, histogenetically, cardiac myxomas are true neoplasms from undifferentiated mesenchymal cells. Echocardiographic confirmation of cardiac myxomas warrants immediate surgical removal of the neoplasm.
In this report we describe our first use of N-acetylcysteine in a patient with his first acute myocardial infarction in an effort to reduce the infarct size and to protect left ventricular function by pharmacological and mechanical therapy (thrombolysis and percutaneous transluminal coronary angioplasty). This comprehensive therapy caused normalization of previously depressed left ventricular systolic function.
The author presents data from the literature pertaining to the possible use of adenine nucleosides in recent years. The main action of adenosine or adenosine triphosphate is focused above all on influencing supraventricular tachycardia which developed as a result of the reentry mechanism. Based on his own observation, the author presents his initial experience with adenosine triphosphate (ATP, Spofa) in different indications: interference with supraventricular tachycardia with slim QRS complexes, interference of tachycardia with wide QRS complexes, termination of atrial flutter in digitalis intoxication and finally induction of an electrocardiographic tracing of latent ventricular preexcitation of the Wolf-Parkinson-White syndrome type.
In a patient with repeated dissection of the ascendent aorta where the first episode was resolved surgically by an intraluminal prosthesis the authors describe the rare consequence of the development of a new dissection manifested by an aorto-oesophageal fistula. In the described case an inoperable episode was involved which fully confirmed the clinical validity of the pathognomic Chiari triad.
The authors present ten years' experience with endomyocardiac biopsy of the heart (EMB) using the percutaneous, endovasal catheterization needle technique. EMB was performed in 314 patients, a total of 1362 biopsies, and for evaluation 5564 specimens of cardiac tissue were taken. Based on this experience the authors emphasize methodical principles which make expedient, rapid and safe collection of cardiac tissue specimens possible. They also mention the main indication criteria for endomyocardial biopsy. Endomyocardial biopsy is a valuable clinical examination method which, no doubt, holds its place in the series of diagnostic methods of modern cardiological catheterization departments.
In 22 patients with a first myocardial infarction the authors assessed the relationship between morphological changes of the QRS complex and systolic left ventricular function. Using a 56-lead computer-assisted electrocardiogram from the precordium in the form of a map (apparatus Cardiomap-1), the authors prepared a record during the first days after initiating treatment with a thrombolytic agent and again after a period of three weeks. They found only one correlation between the decrement of Q waves and the increase of the left ventricular ejection fraction (p less than 0.05). This correlation, however, is of no practical importance due to the low correlation coefficient. The relationship is moreover markedly influenced by the time of the first record. After the third day of thrombolytic treatment it is not expedient to make the initial record. No relationship between the change of R waves, ST segments and left ventricular function was found. Similarly, due to the great dispersal of values it is not possible to differentiate between patients with inferior infarctions of the heart muscle and anterior myocardial infarctions.
In a 27-year-old patient with an infarction of the anterior myocardial wall, significant from the haemodynamic aspect, a complex procedure is described by which in the course of four hours after the beginning of complaints normalization of the lumen and blood flow of the coronary artery supplying the infarction focus was achieved. The authors used thrombolytic intravenous treatment which involved infusion of 1.5 million u. of streptokinase (Streptase, Boehringer, Ingelheim) in the course of 45 mins., N-acetylcysteine 2.0 g i.v. (Broncholysin, Spofa) and percutaneous transluminal coronary angioplasty. In the course of 16 days the left ventricular function recovered completely: the ejection fraction was 67% before the infarction, on the first day of infarction 45% and before discharge 64%.
A total of 31 dogs were investigated with the aim to evaluate possibilities of pharmacological reduction of ischaemic perfusion damage of the heart muscle. In the experiment two-hour complete ischaemia was used (ligature of the ramus interventricularis anterior) and a subsequent two-hour period of reperfusion. The magnitude of the infarction focus evaluated as the percentage of the ischaemic risk area, using the triphenyltetrazolium method, extended by colour detection of collaterals, was evaluated. Furthermore the authors also evaluated the prevalence of ventricular dysrhythmias in the reperfusion period. In a group of 10 dogs treated by N-acetylcysteine, 100 mg per kg body weight, the authors revealed on comparison with 11 dogs of the control group a diminution of the infarction focus by 32.7%. By addition of Panthenol, 50 mg/kg to N-acetylcysteine in another 10 dogs, a diminution of the infarction by 49% was achieved. The magnitude of the infarction focus was 55.0 +/- 7.0% in the control group, 37.0 +/- 12.6% in dogs treated with N-acetylcysteine (p less than 0.01) and 28.0 +/- 13.3% after administration of N-acetylcysteine and Panthenol (p, as compared with control, again less than 0.01). N-acetylcysteine reduces also significantly the prevalence of ventricular dysrhythmias in the reperfusion period. As compared with the control group this difference is most marked after 60 minutes have elapsed following release of the ligature (p less than 0.001).