[Chronic heart failure--treatment].
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Cardiovascular Agents↗
Biomedical subjects
M Kindermann
Publications and source records attributed to M Kindermann.
[Chronic heart failure--diagnosis].
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Blood Chemical Analysis↗
Manipulation of photon statistics of highly degenerate incoherent radiation.
Highly degenerate incoherent radiation has a Gaussian density matrix and a large occupation number of modes f. If it is passed through a weakly transmitting barrier, its counting statistics is close to Poissonian. We show that a second identical barrier, in series with the first, drastically modifies the statistics. The variance of the photocount is increased above the mean by a factor f times a numerical coefficient. The photocount distribution reaches a limiting form with a Gaussian body and highly asymmetric tails. These are general consequences of the combination of weak transmission and multiple scattering.
Journal Article↗
[Severe heart failure--effects of carvedilol therapy. The Copernicus Study].
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Adrenergic beta-Antagonists↗
Defining the optimum upper heart rate limit during exercise: a study in pacemaker patients with heart failure.
AIMS: There is no non-invasive method to determine the individual optimum of maximum exercise heart rate. Knowledge of this value is of particular interest in patients with structural heart disease who are prone to tachycardia intolerance. The purpose of this study was to define the optimal maximum heart rate using cardiopulmonary exercise testing and exercise Doppler echocardiography and to compare the results of both approaches. METHODS AND RESULTS: In 49 pacemaker patients with chronotropic incompetence, the optimum upper heart rate limit was determined using cardiopulmonary exercise testing and exercise Doppler echocardiography. The optimum upper rate limit was given by the highest pacing rate which still produced an increase in oxygen consumption, or by that pacing rate which was linked to the lowest value for the Doppler-derived myocardial performance index. In patients with normal left ventricular ejection fraction (>or=55%) the optimum upper rate limit was 86% of age-predicted maximum heart rate, in patients with left ventriuclar dysfunction (ejection fraction <or=45%) it was 75% of the age-predicted maximum rate (P=0.004). The optimum upper rate limit, as defined by cardiopulmonary exercise testing and exercise Doppler echocardiography, were closely correlated (P<0.0001) with a mean deviation of 6+/-6 beats x min(-1). CONCLUSION: Cardiopulmonary exercise testing and exercise Doppler echocardiography are valuable tools which help to determine the optimum upper rate limit in order to avoid excess heart rates in heart failure patients. The application of these methods is not limited to pacemaker patients but may be helpful in therapeutic interventions with chronotropic drugs.
Adult↗
Crystalline films of interdigitated structures formed via amidinium-carboxylate interactions at the air-water interface.
Electrostatic interactions between amidinium and carboxylates were used for the construction of interdigitated architectures at the air-solution interface. Spreading the water-insoluble amphiphile p-pentadecylbenzoic acid (A) on an aqueous solution of p-methylbenzamidinium (B) ions results in an intercalation of the water-soluble base between the acidic headgroups of the water-insoluble amphiphile to form an amorphousA-B-A-B monolayer according to grazing incidence X-ray diffraction (GIXD) and X-ray reflectivity measurements. Upon compression the monolayer transforms into a crystalline film composed of three bilayers with interdigitated hydrocarbon chains, and a top layer whose chains are disordered. Water-insoluble p-heptadecylbenzamidinium spread on an aqueous solution of benzoic acid displays a surface pressure-area isotherm similar to that obtained from the above system. A mechanism that accounts for the formation of these films is presented. Deposition of p-heptadecylbenzamidinium and p-pentadecylbenzoic acid amphiphiles in a 1:1 ratio on pure water led to the formation of a crystalline monolayer phase but which is partially disordered. Over an aqueous solution containing a 1:1 mixture of benzamidinium and benzoic acid no measurable binding of these solute molecules to the polar headgroups of the 1:1 mixed monolayer could be detected by X-ray reflectivity or GIXD.
Journal Article↗
Phase transitions in liquid 3He.
The phase transitions of liquid 3He are described by truncations of an exact nonperturbative renormalization group equation. The location of the first-order transition lines and the jump in the order parameter are computed quantitatively. At the triple point we find indications of partially universal behavior. We suggest experiments that could help to determine the effective interactions between fermion pairs.
Journal Article↗
Septal lead implantation for the reduction of paced QRS duration using passive-fixation leads.
In 120 consecutive patients with standard pacing indications, we tested the feasibility of RV septal lead implantation technique guided by surface ECG and the degree to which this technique reduces paced QRS duration compared to RV apical stimulation when passive-fixation leads are used. During implantation, an ECG was recorded with a paper speed of 100 mm/s using the orthogonal Frank leads, and QRS was measured from the earliest to the latest deflection in any of the Frank leads. Pace-mapping of the septum was performed until QRS was minimal. The lead was attached, where QRS, pacing threshold, lead impedance, and EGM amplitude provided the best compromise. An average of 3.7 +/- 2.5 attempts (range 1-18, median 7) was needed until a final implantation site was found. There were no technical problems during implantation. QRS could be reduced by 5-55 ms (mean delta QRS 19 +/- 11 ms) in 83 (69%) of 120 patients. In 22 (18%) patients, QRS was identical with apical and septal pacing, and in 15 (13%) patients, QRS was 5-20 ms (10 +/- 4) longer despite septal stimulation. Average QRS was significantly shorter during septal pacing compared with apical pacing (151 +/- 20 vs 162 +/- 23 ms, P < 0.001). There was a tendency towards greatest QRS reduction when the high septum was stimulated (22 +/- 11 ms reduction) as compared with mid- (18 +/- 11 ms) or apical parts of the RV septum (16 +/- 10 ms). QRS reduction was most likely if apical QRS width was > 170 ms (P = 0.0002), and there was an inverse correlation between apical QRS and delta QRS (r = 0.53, P < 10(-7)). During a mean follow-up of 14 months, there was no pacing or sensing problem and no lead dislodgment occurred.
Aged↗
Safety and efficiency of pulse charge multiplication for chronic ventricular output programming.
Fifty-one patients with Intermedics pacemakers and different chronic (> or = 12 months) ventricular lead models were investigated. Ventricular charge thresholds (microC) were measured telemetrically at 1.0, 2.0, 2.5, and 3.5 V, respectively. Then pulse duration was increased until charge per pulse (microC) was twice the threshold value in patients not being pacemaker dependent (n = 39) and three times the threshold in pacemaker dependent patients (n = 12), thus giving a 2:1 or 3:1 safety factor in terms of charge ("safety charge"). At safety charge settings, the battery current was measured telemetrically for all four pulse amplitudes (PA) in VVI mode at 70 beats/min. For safety purposes, only pulse amplitudes were considered that fulfilled two conditions: (1) pulse duration threshold (PDT) < or = 0.30 ms at PA and (2) PDT < or = 1.00 ms at a pulse amplitude of (PA-0.5 V). The combination of pulse amplitude and pulse duration that yielded the safety charge at the lowest battery current was defined as optimized ventricular output (Copt). It was found at 1.0 V in 27 patients and at 2.0 V in 24 patients. The safety pulse duration (SPD) that yielded a 2:1 safety charge in patients who were not pacemaker dependent was 0.32 +/- 0.12 ms for both, 1.0 V (n = 23) and 2.0 V (n = 16), respectively. In pacemaker dependent patients, the SPD for the 3:1 safety charge was 0.61 +/- 0.25 ms (at 1.0 V, n = 4) and 0.47 +/- 0.11 ms (at 2.0 V, n = 8), respectively. The safety factor for conversion of PDT into SPD was 3.15 (range 3.00-3.38) for pacemaker dependent patients and 2.04 (range 2.00-2.43) for patients who were not pacemaker dependent, respectively. Charge thresholds measured at study entrance, after 24 hours, and again after 6 months showed a median variation of 14% and a maximum individual variation of 55%. On day 0 and 180, 24-hour Holter recordings were obtained from all patients and revealed constant ventricular capture at output settings Copt. When the output was changed from a fixed setting (2.5 V at 0.50 ms) to Copt, the battery current decreased by 17.5% (P < 0.0001). In conclusion, pacing thresholds in patients with chronic ventricular leads are stable enough to permit programming battery-saving low output settings, if pacemakers are followed on a regular basis. Titration of a 2:1 safety charge (a 3:1 safety charge in pacemaker dependent patients) by prolongation of pulse duration is safe, provided that pulse amplitude is chosen carefully. Using this approach, current consumption can significantly be reduced without jeopardizing patient's life.
Aged↗
Longevity of dual chamber pacemakers: device and patient related determinants.
In 382 patients with three different dual chamber pulse generators, the median time interval to battery depletion was 98.3 months. Cox regression analysis revealed the following variables as significant predictors of battery longevity: programmed pacing rate, energy of the stimulation output, mode of stimulation (i.e., proportion of paced cycles in one or two chambers), battery capacity, and internal sensing current of the pacemaker. Although 27% of all patients died before the service life of the pacemaker was over and despite a rate of premature reoperations of 8.6%, the majority of pacemaker patients (55%) fully used the expected battery life span of the pulse generator. Patients who died before the pacemaker had reached its end of service were significantly older at implantation than patients who survived until pacemaker replacement. The vast majority (92%) of patients received another dual chamber pulse generator when replacement was required. These data underline the need for long-lasting dual chamber devices.
Aged↗
Do battery depletion indicators reliably predict the need for pulse generator replacement?
The aim of this study was to test the validity of battery depletion indicators to forecast end of service (EOS) in dual chamber pulse generators (PG). Two additional approaches for prediction of EOS were evaluated as well: the real-time telemetry of cell impedance and a battery stress test (BST) that used a transitory increase in pacing rate. The study population consisted of 119 patients with Intermedics dual chamber PG models Cosmos II and Relay, in which cell impedance had exceeded 2.5 k omega. The patients were followed in 6-month intervals. If the interrogation of the PG or the BST prompted the appearance of the intensified follow-up indicator (IFI), the next follow-up was scheduled within 2 months. PG replacement was performed on physician's discretion or immediately on appearance of the elective replacement indicator (ERI), regardless of the method of ERI provocation. During a period of 2 years/and 9 months, 33 patients underwent PG replacement. Out of 21 patients with positive ERI indicators, only 5 had positive warning indicators of approaching battery depletion in the preceding follow-up (IFI during BST, n = 4; ERI during BST n = 1). The majority of patients (n = 16, 76%) revealed ERI without prior activation of IFI, neither spontaneous nor during the BST. Four of these 16 ERI-positive patients had cell impedance values far below the ERI limits of the manufacturer. Based on battery depletion indicators, an exact prediction of EOS of dual chamber pacemakers is not possible. Measuring battery impedance allows for a statistical estimation of remaining service life but it may be misleading in the individual case. A BST that is based on a temporary increase of pacing rate is invalid in forecasting battery depletion. As activation of the ERI can trigger an abrupt change to the VVI backup mode, pacemaker dependent patients with low programmed basic pacing rates may be hemodynamically compromised by an unexpected activation of ERI. Close monitoring intervals and PG replacement before appearance of the ERI is recommended in those patients.
Electric Impedance↗
AAIR versus DDDR pacing in the bradycardia tachycardia syndrome: a prospective, randomized, double-blind, crossover trial.
In 19 patients paced and medicated for bradycardia tachycardia syndrome (BTS), AAIR and DDDR pacing were compared with regard to quality of life (QoL), atrial tachyarrhythmia (AFib), exercise tolerance, and left ventricular (LV)function. Patients had a PQ interval < or = 240 ms during sinus rhythm, no second or third degree AV block, no bundle branch block, or bifascicular block. In DDDR mode, AV delay was optimized using the aortic time velocity integral. After 3 months, QoL was assessed by questionnaires, patients were investigated by 24-hour Holter, cardiopulmonary exercise testing (CPX) was performed, and LV function was determined by echocardiography. QoL was similar in all dimensions, except dizziness, showing a significantly lower prevalence in AAIR mode. The incidence of AFib was 12 episodes in 2 patients with AAIR versus 22 episodes in 7 patients with DDDR pacing (P = 0.072). In AAIR mode, 164 events of second and third degree AV block were detected in 7 patients (37%) with pauses between 1 and 4 seconds. During CPX, exercise duration and work load were higher in AAIR than in DDDR mode (423+/-127 vs 402+/-102 s and 103+/-31 vs 96+/-27 Watt, P < 0.05). Oxygen consumption (VO2), was similar in both modes. During echocardiography, only deceleration of early diastolic flow velocity and early diastolic closure rate of the anterior mitral valve leaflet were higher in DDD than in AAI pacing (5.16+/-1.35 vs 3.56+/-0.95 m/s2 and 69.2+/-23 vs 54.1+/-26 mm/s, P < 0.05). As preferred pacing mode, 11 patients chose DDDR, 8 patients chose AAIR. Hence, AAIR and DDDR pacing seem to be equally effective in BTS patients. In view of a considerable rate of high degree AV block during AAIR pacing, DDDR mode should be preferred for safety reasons.
Aged↗
The influence of right atrial septal pacing on the interatrial contraction sequence.
UNLABELLED: Right atrial septal pacing yields shorter interatrial conduction delays than conventional right atrial pacing at the free wall or the right atrial appendage. However, the hemodynamic effects of right atrial septal pacing are less well known. This study measured the delay between right and left atrial contractions during right atrial septal pacing (n = 21), conventional right atrial pacing (n = 32) and atrial multisite pacing (n = 6) by pulse Doppler echocardiography of transtricuspidal and transmitral blood flow. The effects of right atrial septal pacing (n = 14) versus conventional right atrial pacing (n = 22) on the optimal AV delay during dual chamber pacing was examined in patients with high degree atrioventricular (AV) block. Compared to sinus rhythm, conventional right atrial pacing increased P wave duration from 119 +/- 21 ms to 137 +/- 24 ms (P < 0.001), whereas both right atrial septal pacing (119 +/- 10 ms before, 106 +/- 13 ms during pacing, P = 0.002) and atrial multisite pacing (123 +/- 20 ms before, 112 +/- 11 ms during pacing, P = 0.5) shortened P wave duration. Atrial pacing caused a significant (P < 0.002) prolongation of atrial contraction [corrected] delays from 24 +/- 21 ms to 41 +/- 26 ms during conventional right atrial pacing, and reversed the right-to-left into a left-to-right contraction sequence in 20 of 21 patients during right atrial septal pacing (atrial conduction delay during sinus rhythm: 34 +/- 23 ms vs -37 [corrected] +/- 26 ms during atrial pacing, P < 0.0001). Atrial multisite pacing caused a nonsignificant shortening of the usual right-to-left contraction delay from 22 +/- 34 ms to 11 +/- 18 ms. The optimal left heart AV delay during AV sequential pacing was significantly (P = 0.002) shorter during right atrial septal pacing (108 +/- 38 ms) than during conventional right atrial pacing (152 +/- 33 ms). During conventional right atrial pacing the optimal right heart AV delay was significantly (P = 0.029) shorter than the optimal left heart AV delay. The opposite relation was observed for right atrial septal pacing (P = 0.033). CONCLUSIONS: Interatrial septal pacing does not synchronize right and left atrial contractions. It reverses the atrial mechanical timing from a right-to-left to a left-to-right contraction sequence, and requires the setting of shorter AV delays during dual chamber pacing if based on the optimization of left heart timing. Interatrial septal pacing is a technique which allows pacing of the left atrium from a right atrial site, rather than a single site approach to biatrial pacing.
Adolescent↗
Evolution of an active fixation atrial pacing lead.
UNLABELLED: Three bipolar atrial pacing leads from one manufacturer differing in a single electrode design characteristic were compared. Each lead had nonretractable screw and a microporous electrode tip made of activated carbon. Model S84F had a tip surface area of 8 mm2. In model S44F, the tip surface area was reduced to 4 mm2 by insulation of the screw, and in model BS45D, steroid elution was added to the 4 mm2 tip. Ten patients in each group received identical pulse generators. During implantation, atrial potentials (5.4 +/- 2.0, 4.2 +/- 2.0, 4.6 +/- 2.1 mV), pacing thresholds at 0.5 ms (0.47 +/- 0.14, 0.41 +/- 0.15, 0.55 +/- 0.33 V) and lead impedance at 2.5 V/0.5 ms (515 +/- 80, 575 +/- 152, 546 +/- 131 omega) were comparable among groups. The early postoperative threshold peak was significantly lower with the BS45D than with the S84F and S44F lead models. One year after implantation, charge threshold was significantly lower with the BS45D lead than with the S84F and the S44F model (0.34 +/- 0.11 vs. 0.68 +/- 0.20 and 0.56 +/- 0.21 microC; P < 0.05). Lead impedance at 2.5 V/0.5 ms (557 +/- 90, 549 +/- 36, 524 +/- 72 omega) and atrial sensing (4.3 +/- 2.1, 4.7 +/- 1.9, 4.7 +/- 0.9 mV) were not significantly different. One year postimplant, current drain of the pacing system was measured by pacemaker telemetry at chronic output settings in AAI mode/70 beats/min. Battery current measured among the three atrial lead models did not differ significantly (S84F: 11.9 +/- 0.90, S44F: 12.2 +/- 1.8, BS45D: 11.5 +/- 0.26 microA). IN CONCLUSION: reduction of the tip surface area by insulation of the screw did not improve pacing performance. Addition of steroid elution to the 4 mm2 tip significantly lowered the early threshold peak and the long-term pacing threshold. Lowering of the pacing threshold, however, did not lower the current drain of the pacing system.
Adult↗
Comparison of aortic valve gradient during exercise after aortic valve reconstruction.
PURPOSE: Aortic valve preservation is a promising alternative to conventional composite replacement of aortic valve and ascending aorta. This approach may have a physiologic benefit compared with valve replacement similar to that seen in mitral valve reconstruction. We investigated aortic valve gradients at rest and during exercise in patients who had undergone valve-preserving aortic replacement and compared them with composite replacement of valve and aorta. METHODS: Four groups were studied: nine patients underwent composite valve replacement (group A: valve diameter, 23 to 27 mm), eight patients underwent remodeling of the aortic root (group B), and another nine patients had reimplantation of the aortic valve (group C). Healthy volunteers were studied as a control group (group D). Using continuous-wave Doppler echocardiography, all patients were examined on a bicycle ergometer for aortic valve gradients (0 to 75 W). RESULTS: There were no differences among the groups with respect to age, body surface, left ventricular end-diastolic diameter, fractional shortening, or left ventricular mass. Maximum resting gradients were significantly elevated in group A compared with groups B, C, and D (group A: 21.3 +/- 7.1 mm Hg; group B: 9.0 +/- 4.5 mm Hg; group C: 8.6 +/- 3.7 mm Hg; group D: 4.9 +/- 1.6 mm Hg; p < 0.05). At 75 W, group A exhibited significantly higher gradients than all other groups (group A: 31.3 +/- 7.5 mm Hg; group B: 13.9 +/- 6.6 mm Hg; group C: 12.8 +/- 3.5 mm Hg; group D: 9. 2 +/- 1.9 mm Hg; p < 0.05). There was no significant difference among the other groups. Both valve-preserving groups had only insignificantly higher gradients than the control group. CONCLUSION: Our data strongly support the suggestion that preserving the aortic valve restores nearly normal hemodynamic function of the aortic valve. Long-term observations will have to prove the clinical relevance of restoring physiologic aortic valve hemodynamics.
Adult↗
[Reconstructive surgery of the aortic root].
Surgical treatment of proximal aortic disease traditionally consists of composite replacement of valve and aorta. Recent reconstructive procedures on the aortic root allow for treatment of aortic dilatation and concomitant aortic valve regurgitation without the associated disadvantages of mechanical heart valves. From 10/95 to 09/99 we treated 84 patients for regurgitation of the aortic valve and dilatation of the aortic root. Valve preserving replacement of the root consisted of root remodeling (n = 68) or reimplantation of the aortic valve (n = 16). Operative mortality in valve-preserving surgery was not elevated compared to overall results of proximal aortic replacement (3.6% vs 5.6%); this applied to elective procedures (1.8% vs 2.3%) as well as emergency operations (9.3% vs 16.3%). Initial aortic valve function was adequate in all cases. Actuarial freedom from regurgitation grade II or higher was 98% after root remodeling and 92% after valve reimplantation. Freedom from reoperation at two years was 96% in remodeling and 100% in valve reimplantation. Hemodynamic function of the reconstructed valve was investigated in 17 patients under conditions of rest and exercise. These were compared to 9 patients with a mechanical composite valve. Patients with reconstructed valves had almost physiologic gradients during rest and exercise. These gradients were thus significantly lower than the increased gradients of patients after composite replacement. Application of reconstructive procedures to the aortic root allows for restoration of aortic valve function in the majority of patients. Disadvantages of heart valve prostheses can be avoided, and the hemodynamic performance of the reconstructed valve appears almost physiologic.
Adolescent↗
Influence of right ventricular stimulation site on left ventricular function in atrial synchronous ventricular pacing.
OBJECTIVES: The study investigates the correlation between left ventricular function and QRS duration obtained by alternate right ventricular pacing sites. BACKGROUND: 1. Right ventricular apical pacing is associated with alterations of left ventricular contraction sequence. 2. A stimulation producing narrow QRS complexes is supposed to provide for better left ventricular contraction patterns. METHODS: Fourteen patients with third degree AV block received one ventricular pacing lead in apical position. The alternate lead was attached to that site on the septum that produced the smallest QRS complex as measured from the earliest to the last deflection in any of the orthogonal Frank leads (xyz). During atrial synchronous ventricular pacing, the AV delay was optimized individually and for each stimulation site using mitral valve doppler or impedance cardiography. By radionuclide ventriculography, the phase distribution histogram of left ventricular contraction was evaluated as area under the curve (AuC); systolic function was determined as ejection fraction (EF) and as absolute ejected counts (EC) in random order. The difference (delta) in QRS duration between apical and septal stimulation (deltaxyz) was correlated with the difference in phase distribution (deltaAuC) and ejection parameters (deltaEF, deltaEC). RESULTS: QRS duration was shorter with septal than with apical pacing in 9 out of 14 patients (64%); it was longer in 4 (29%), and no difference was seen in 1 patient. There was a significant positive correlation between the change in QRS duration (deltaxvz) and phase distribution (deltaAuC: r = 0.66393, p = 0.010) and a significant negative correlation to systolic function (deltaEF: r = 0.70931, p = 0.004; deltaEC: r = 0.74368, p = 0.002). CONCLUSIONS: In atrial synchronous right ventricular pacing, if the AV delay is adapted individually, decreased QRS duration obtained by alternate pacing sites is significantly correlated with homogenization of left ventricular contraction and with increased systolic function in acute tests.
Aged↗
Atrial lead implantation during atrial flutter or fibrillation?
In patients with sinoatrial disease, unexpected atrial flutter (Af) or fibrillation (AF) is a common problem during implantation of atrial-based pacing systems. As an alternative approach to blind atrial lead placement, lead positioning could be optimized by atrial electrogram mapping. It was the object of this study to evaluate if atrial lead implantation according to this approach and during ongoing arrhythmia is reasonable or if it should be postponed until restoration of sinus rhythm (SR). Twenty-nine consecutive patients (group I) with sick sinus syndrome received a dual-chamber pacemaker during an episode of Af (n = 11) or AF (n = 18). All but two atrial leads were of the screw-in type and had bipolar sensing. Atrial lead position was optimized by mapping the electrogram under fluoroscopy to find locations with high potential amplitudes. The patients were followed for 15.1 +/- 9.8 months, and atrial sensing threshold (AST), atrial pulse width threshold (PWT) at 2.0 V, the pacing mode programmed, and the clinical outcome (OUT) were recorded. The control group consisted of 30 patients (group II) who equally had a history of AF or Af, but were in SR during implantation. The atrial peak-to-peak potential (APEAK) after final lead placement was lower for AF (median value 2.5 mV, lower-upper quartile: 1.7-3.1 mV) as compared to Af (3.8 mV, 2.7-4.9 mV, P < 0.05) and SR (4.1 mV, 3.3-6.2 mV, P < 0.001). There was a correlation (P < 0.01) between APEAK during Af/AF and the postoperative AST immediately after restoration of SR. No lead in any group had to be corrected due to improper sensing in the postoperative course. Median chronic AST was 2.8 mV (2.0-4.0 mV) in group I and 4.0 mV (2.8-4.0 mV) in group II. Median chronic PWT at 2.0 V was 0.15 ms (0.12-0.26 ms) in group I and 0.15 ms (0.09-0.20 ms) in group II. There was no significant difference in chronic AST and PWT between both groups. All but two patients in group I preserved SR as the basic rhythm. A stable SR was observed in 10 of 29 patients, intermittent Af/AF was documented in 17 of 29 patients, seven of whom were asymptomatic. There was no significant difference in OUT between group I and II. Hence, sinus rhythm is not a prerequisite of atrial lead implantation. Mapping the Af or AF waves appears to be useful to guide lead placement and to achieve sufficient sensing and pacing conditions after conversion to sinus rhythm.
Aged↗