Biomedical subjects
Publications and source records attributed to K L Neuhaus.
After instillation of mitomycin C into the urinary bladder severe pulmonary changes developed in a 35-year-old man. This complication has previously been described only after systemic administration of the drug. If mitomycin C is administered locally the lungs should be regularly examined.
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In 50 patients without renal insufficiency, fibrinolytic activity, as reflected by euglobulin lysis time, was determined in blood obtained from the renal veins, the renal artery and a peripheral vein. Fibrinolytic activity was found to be significantly higher in the renal veins than in the renal artery and the peripheral vein. Other coagulation and fibrinolysis parameters did not show such differences. In addition, a patient with acute oligoanuric renal failure was investigated. This patient demonstrated reduced overall fibrinolytic activity, but there were no differences between the activity in the blood of the renal veins and that of the renal artery or peripheral vein. It seems, therefore, that the kidneys release plasminogen activators into the systemic circulation. This may be decreased in renal failure, probably contributing to the well-known diminished fibrinolysis in some kidney diseases.
UNLABELLED: Emergency coronary angiography was performed in 188 patients with treatment-resistant unstable angina. Criteria analysed were: duration of angina less than 72 h; angina despite heparin and nitroglycerin infusion; no significant S-T segment elevation in the ECG; creatine-kinase rise up to 150 U/l. Coronary heart disease (CHD) was found in 130 patients (group A). In 47 of them a recent coronary occlusion was demonstrated angiographically (main stem: 1; anterior interventricular branch: 8; circumflex branch: 27; right coronary artery: 11 patients). An at least 90% occlusion of one coronary artery was found in 58 patients. A 75% stenosis of several vessels was found in 25 patients making it impossible to identify the vessel that had caused the angina. A bypass operation was performed in 62 patients within two weeks. During the acute coronary angiography, intracoronary streptokinase infusion was performed in 11 (success rate 55%), percutaneous transluminal coronary angioplasty in 26 (success rate 88%). In 58 patients (group B) CHD was excluded. The final diagnosis in these was: mitral valve prolapse (31); pericarditis (6), dilated cardiomyopathy (3); coronary anomaly (3); muscle bridge in the anterior interventricular branch (2): normal (13). CONCLUSION: It is not possible to decide with certainty, in the absence of typical infarction signs in the ECG and clinically, whether treatment-resistant angina is due to CHD or other causes. Acute coronary angiography is indicated in such cases, because even without S-T segment elevation an acute coronary occlusion is present in 25%, and in 50% of cases an acute therapeutic intervention is indicated.
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A 62-year-old man was admitted to our hospital with unstable angina. The coronary arteriography showed the occlusion of the left anterior descending artery and other stenotic lesions. The patient underwent an aortocoronary bypass operation, but unfortunately he did not survive. Surprisingly, the necropsy revealed him to be affected by an inflammatory process, involving the aorta and the coronary arteries. According to the clinical history and examination, the findings at necropsy and the histologic picture, the diagnosis of Takayasu's arteritis appears the most probable. Coronary arteritis has to be considered as a possible etiology of ischemic symptoms also in subjects who appear affected by typical atherosclerotic ischemic heart disease.
For the vast majority of patients with acute myocardial infarction, intravenous thrombolysis is at present the only therapeutic approach aimed at early reperfusion of the ischemic myocardium. Rapid recanalization of the infarct-related coronary artery is achieved in at least 50-60% of the patients by short-term high-dose infusions of streptokinase or urokinase with a low risk of bleeding. A substantial reduction of infarct size, however, can be expected in only a minority of patients, mostly in those who are treated very early. The effects of intravenous thrombolysis on early and late mortality from acute myocardial infarction are still equivocal; more conclusive data may be expected from ongoing randomized trials.
The total occlusion of the left main coronary artery is rarely observed (approximately 0.05% of coronary angiographic studies). We have tried to draw the clinical and pathophysiological outline of this condition, starting from our experience and reviewing the published reports. A hard selection, principally by the high mortality in patients with left main coronary stenosis, limits the number of those who present total occlusion. These subjects show a remarkable variability in their clinical presentation. It is not possible to find out a significant correlation with a single risk factor, clinical manifestation or electrocardiographic picture. Therefore, these patients cannot be distinguished from other subjects affected by severe atherosclerotic ischemic heart disease. The angiographic finding of a dominant right coronary artery is most frequent. A rich collateral circulation to the left coronary is usually observed. From a pathophysiological point of view, the efficiency of coronary collateral circulation is confirmed by the significant correlation of its extent with the left ventricular function. An important role is also played by the rate of progression of left main stenosis in total occlusion and by the presence of right coronary lesions. Even if statistical evidence is still lacking, surgical treatment is unanimously indicated and achieves satisfying results. The use of nonsurgical recanalization techniques, such as intracoronary thrombolysis and transluminal angioplasty, may be lifesaving in those patients in whom left main coronary occlusion suddenly occurs.
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The extension of cardiac diagnostics by invasive and non invasive, imaging procedures results in an extension of indication for cardiac surgery of patients over 70 years. From August 1977 to July 1985 a total of 212 patients over 70 years were operated upon with extracorporeal circulation for different heart diseases. The mean age was 73.2 years (from 70 to 84 years). In almost 57% (121) of the patients with coronary heart disease (CHD) an aortocoronary venous-bypass (ACVB) was performed, with a mean of 3.3 grafts (ranged from 1 to 5). In 84 patients an isolated or combined heart valve replacement was carried out: Aortic valve replacement (AVR) in 51, mitral valve replacement (MVR) in 11, AVR and MVR in 4, AVR and ACVB in 16 and AVR and aortic ascendens replacement in 2 patients. The overall mortality was 8.5%, with isolated AVR 7.8%, with isolated ACVB it was at the lowest with 5.2%. Postoperative complications could be observed in 48% of patients: low output syndrome (LOS) in 4, arrhythmia in 11, respiratory insufficiency (5%) or stroke in 2, mental confusion in 5. The long-term results after heart valve operation in patients over 70 years emphasize the indication for surgery, despite the higher rate of postoperative complications. The hospital mortality does not differ from that of younger patients. Especially with extreme valvular aortic stenosis after acute AVR one can expect a quick improvement of the cardiac situation after unloading of the left ventricle.(ABSTRACT TRUNCATED AT 250 WORDS)
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Chronic transplant rejection with diminished renal function and development of serious hypertension resistant to treatment occurred in a 36-year-old patient 3 years after kidney transplantation. Symptoms of vascular obstruction resulted in detection of advanced stenosis of the external iliac artery prior to branching of the transplant artery. Obstruction disappeared after percutaneous transluminal dilatation of the stenosis, renal function improved, and blood pressure returned to normal with reduced medication.
The further development of coronary balloon catheters has encouraged their use for dilating small vessels of other organs and stenoses in larger vessels not passable by conventional catheters. The technique was used successfully as a primary intervention in two stenoses of the external carotid artery preparatory to extra-intracranial anastomosis, in four anastomotic stenoses in three patients with Blalock-Taussig anastomosis, and in a subtotal anastomosis of a Cimino shunt. After failed dilatation attempts with a standard dilatation catheter in three patients with four renal artery stenoses and two with subclavian artery stenosis, coronary angioplasty catheters successfully dilated the stenoses. In two infants with severe valval aortic stenosis and left-heart failure, retrograde transluminal balloon dilatation reduced the transvalval gradient from 70 to 30-40 mm Hg.
Patients with mitral valve prolapse (MVP) frequently have chest pain, which may be difficult to differentiate from angina pectoris in coronary artery disease (CAD). We performed resting and exercise ECGs, pulmonary arterial pressure measurements, radionuclide ventriculography (99mtechnetium), and perfusion scintigrams (201thallium) in 56 patients with angiographically proven MVP and no CAD. Pathological results were obtained in 31% of exercise ECGs, 33% of pulmonary arterial pressure measurements during exercise, 22% of radionuclide ventriculographies, and in 75% of thallium perfusion scintigrams. A significant correlation in pathological results was found only between exercise ECG and both radionuclide ventriculography and pulmonary arterial pressure measurements. Because of the high prevalence of false-positive perfusion scintigrams in patients with typical or atypical chest pain, the use of exercise 201Tl imaging as a screening method to separate patients with MVP from those with CAD will not be appropriate. The variability of cardiac abnormalities in our patients with MVP and angiographically normal coronary arteries suggests that the MVP syndrome may represent a variable combination of metabolic, ischemic, or myopathic disorders.
An unusual case of a successfully operated ruptured thoracic aneurysm of the aorta with bleeding into the atelectatic pulmonary left lower lobe and acute occlusion of the prosthesis in a 28-year-old woman is reported. The underlying disease was congenital aortic arch hypoplasia still present following implantation of a prosthetic bypass from the ascending aorta to the descending aorta performed in 1963.
An unusual case of non-Hodgkin lymphoma (centroblastic B-cell type) is described presenting with severe tricuspid stenosis due to a large right atrial intracavitary tumor mass obstructing the tricuspid orifice. The clinical picture of cardiogenic shock was relieved by surgical removal of the greater part of the tumor mass from the right atrium.
32 patients with a large anterolateral aneurysm were studied by using biplane ventricular angiography and rest and exercise radionuclide ventriculography (gated-blood-pool method). The correlation coefficient of biplane ejection fraction by angiography and radionuclide ventriculography was poor (r = 0.65), but repeated investigations and interobserver comparison showed nearly identical values, therefore we used the gated-blood-pool method (GBP) for follow-up investigations in patients with an aneurysm of the anterolateral wall. 11 patients were studied before and 17 +/- 6 months after left ventricular aneurysmectomy. Resting ejection fraction (LVEF) increased significantly from 28 +/- 8 to 38 +/- 8% (p less than 0.005), but exercise LVEF did not. In 21 patients with medical therapy the second GBP measurement after 16 +/- 6 months showed so significant changes in biplane LVEF (33 +/- 9 and 31 +/- 7%, respectively). During exercise LVEF remained unchanged after aneurysmectomy but increased slightly by 5% (p less than 0.05) in the medically treated group. The regional wall motion was unchanged in patients with medical therapy, but after aneurysmectomy there was a significant increase in local ejection fractions in the anterolateral, apical and posterolateral region. The gated-blood-pool methods is suitable for the determination of left ventricular function in patients with anterolateral aneurysm and may be used for follow-up studies. Left ventricular aneurysmectomy is effective in improving resting ventricular function, whereas in patients with medical therapy LV function remains unchanged.
With increasing number of noninvasive techniques in clinical cardiology, the question emerges whether it is still justified to continue with cardiac catheterization in the assessment of valvular lesions on a routine basis. Therefore, advantages and disadvantages of invasive and noninvasive procedures are compared with respect to the information they provide in patients with valvular heart disease. Usefulness of invasive criteria in the assessment and quantification of valvular lesions have been analyzed. Limitations of these invasive criteria are derived from a score relating the accuracy obtained to the methodical expense incurred with a given diagnostic parameter. From these analyses and in consideration of findings in the literature, we conclude that cardiac catheterization is not only justified but necessary, particularly in patients prior to valve surgery in order to quantitate the valvular lesion, differentiate between valvular and myocardial dysfunction and screen for associated abnormalities such as concomitant coronary artery disease. Despite the progress in recent years, noninvasive techniques cannot provide this combination of precise information.