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Biomedical subjects

R Pacher

Publications and source records attributed to R Pacher.

At least 73 records · Page 4Linked to original sources
PubMed1996

Knotting of two central venous catheters: a rare complication of pulmonary artery catheterization.

An attempt was made to insert a balloon-tipped pulmonary arterial catheter (Swan-Ganz catheter) in a patient in cardiogenic shock during circulatory support by intraaortic balloon pumping, with a right jugular central venous catheter in place. Due to the low cardiac output it was impossible to advance the catheter tip into the pulmonary artery and after several futile attempts it was decided to withdraw the catheter. However, this was impossible because a knot had formed between the central venous catheter and the Swan-Ganz catheter and surgical removal become necessary. This is the first report on intravasal knot formation between two different catheters. This rare complication has to be included in the long list of complications associated with Swan Ganz catheterisation.

Aged↗
PubMed1996

Acceptance of a pump-driven infusion therapy with prostaglandin E1 as a bridge to heart transplantation.

Ambulatory pump-driven intravenous infusions are a novel and - compared with hospitalization-cost-effective procedure to bridge refractory heart failure patients to cardiac transplantation. In the present study 13 patients received chronic infusions with prostaglandin E1 alone or in conjunction with catecholamines and the acceptance of this bridging therapy was investigated over a period of seven weeks. Prostaglandin E1 was uptitrated from 2.5 ng/kg/min to a maximum of 40 ng/kg/min, according to individual tolerance. 50% of the maximum tolerated dose of prostaglandin E1 was used for chronic infusion with a further dose reduction if side effects occurred. Altogether 8 patients who completed the therapy were analysed; of the remaining 5 three patients had a heart transplant, one patient died and one patient did not comply with the protocol. The drugs were administered by an automatic portable pump, which was connected to a subcutaneous tunneled catheter. During hospitalization patients and their relatives were instructed how to prepare drug solutions and to handle the infusion system. Patients' perceptions were investigated by visual analog scale questionnaires (rating scale zero to ten) before, and at weekly intervals during bridging therapy. Initial acceptance was documented as belief in therapy (9.4 +/- 1.2 SD), absence of fear of handling the pump (8.9 +/- 1.2 SD) and confidence of receiving help of close relatives (8.7 +/- 1.8 SD). During the observation period there were no statistically significant differences compared with this favorable starting position and no significant disruption of life style occurred. Pain in the joints-a prostaglandin E1-associated side effect-increased significantly (p < 0.05) at week 5, but returned to baseline levels during the following two weeks. At study end patients confirmed that they would repeat the experience (7.6 +/- 1.4 SD) and advise other patients to undergo this form of therapy (8.2 +/- 1.9 SD). Thus, this pilot study suggests that ambulatory pump-driven intravenous infusion therapy comprising prostaglandin E1 and catecholamines is acceptable to patients as a bridge to heart transplantation and that there should be no major difficulties regarding compliance.

Adult↗
PubMed1995

Measuring extracellular matrix turnover in the serum of patients with idiopathic or ischemic dilated cardiomyopathy and impact on diagnosis and prognosis.

Circulating levels of extracellular matrix components were measured by radioimmunoassays and tested if they were useful for clinical staging in chronic heart failure. In 41 patients with dilated cardiomyopathy (33 idiopathic and 8 ischemic cases), the serum concentrations of procollagen type III aminoterminal peptide (PIIINP), type I collagen telopeptide (ICTP), and basement membrane laminin were significantly higher than in 30 healthy controls regardless of the underlying etiology. Patients with serum values of PIIINP, ICTP, and laminin > 7 micrograms/L, 7.6 micrograms/L, and 2.3 U/ml, respectively, were at higher relative risk for advanced clinical stage, poor hemodynamic condition, hyponatremia, heart transplantation, and death during follow-up than patients with low levels, with the exception that serum laminin > 2.3 U/ml was not significantly associated with hyponatremia and heart transplantation. Despite their interdependence on liver function, circulating levels of PIIINP and ICTP were independent predictors of mortality. In 17 of the 41 patients with cardiomyopathy whose explanted hearts were available for histologic evaluation, serum PIIINP, ICTP, and laminin significantly correlated with the myocardial area fractions of their tissue analogues (PIIINP vs myocardial collagen type III, r = 0.784, p = 0.0013; serum ICTP vs myocardial collagen type I, r = 0.603, p = 0.0527; and serum laminin vs myocardial laminin, r = 0.605, p = 0.0411). In conclusion, the increase in extracellular matrix turnover, which may partially be derived from fibrosis in the myocardium, can be measured in the serum of patients with dilated cardiomyopathy, and has an impact on risk stratification and prognosis.

Cardiomyopathy, Dilated↗
PubMed1995

Diurnal variation of ventricular response to atrial fibrillation in patients with advanced heart failure.

Variability of ventricular rate was quantified by two measures of heart rate variability: the SD of the mean R-R interval (SDNN) and the SD of the 5-minute mean R-R interval (SDANN). In 35 patients with atrial fibrillation and advanced heart failure (left ventricular ejection fraction 20% +/- 9%, cardiac index 2.4 +/- 0.7 L/min/m2), SDNN and SDANN were compared to 13 preselected clinical and hemodynamic variables for prediction of outcome. During a 12-month follow-up period, 8 (23%) patients deteriorated clinically; 3 (9%) died, and 5 (14%) underwent heart transplantation. SDNN and SDANN correlated to the difference of the mean R-R interval between night (2 AM to 3 PM) and day (11 AM to noon) with r values of 0.62 and 0.77, respectively. From 15 preselected variables, only SDANN (chi 2 = 6.7, p = 0.01) was independently associated with survival on multivariate analysis. Dichotomized SDANN at 100 msec accurately predicted 12-month survival in 28 (80%) patients (relative risk = 9.77, p = 0.001). In conclusion, analysis of heart rate variability is useful in quantifying diurnal variation of ventricular rate in atrial fibrillation and might be useful in predicting survival in patients with advanced heart failure.

Aged↗
PubMed1995

Sudden death and staged therapy for hemodynamic stabilization in patients enrolled in a heart transplantation program.

To investigate the impact of staged therapy for advanced heart failure on therapeutic endpoints, 236 consecutive patients (coronary artery disease/dilated cardiomyopathy in 61/175 patients, left ventricular ejection fraction 14% +/- 5%, New York Heart Association Class II/III/IV in 102/79/55 patients, respectively) with advanced heart failure were prospectively followed. One hundred thirty-seven patients enrolled from January 1989 to December 1991 were treated conventionally with digoxin, furosemide, and low dose angiotension converting enzyme (ACE) inhibition. Patients refractory to this therapy underwent urgent heart transplantation. Ninety-nine patients enrolled from January 1992 to August 1993 underwent staged therapy: stage 1: maximal tolerated ACE inhibition; stage 2: therapy with PGE1 for pre- and afterload reduction to achieve hemodynamic stabilization; or stage 3: refractory patients bridged to heart transplantation with continuous outpatient dobutamine. Sudden death was defined as death within 1 hour of symptoms if heart failure symptoms remained stable over the previous 7 days. Conventionally treated patients were followed for 10 +/- 9 months; patients who underwent staged therapy for 9 +/- 5 months. In the group of patients that underwent standard therapy, 39 of 137 (28%) patients died: 5 (13%) deaths occurred suddenly, and death due to progressive pump failure occurred in the remaining 34 (87%) patients. In the group of patients that underwent staged therapy, 25 of 99 (25%) patients died: 13 (52%) deaths occurred suddenly, and 12 (48%) deaths occurred due to progressive pump failure.(ABSTRACT TRUNCATED AT 250 WORDS)

Alprostadil↗
PubMed1995

Comparative assessment of right ventricular volumes and ejection fraction by thermodilution and magnetic resonance imaging in dilated cardiomyopathy.

Measurements of right ventricular (RV) ejection fraction (EF) and volumes using a new thermodilution technique were compared to serially performed magnetic resonance imaging (MRI) in 21 patients with dilated cardiomyopathy. For RVEF (%) and RV volume indices (ml/m2) the following correlation coefficients were found: RVEF r = 0.82; end-diastolic volume index (EDVI) r = 0.45; end-systolic volume index (ESVI) r = 0.65; stroke volume index (SVI) r = 0.61; all p < 0.05. However, RVEF by thermodilution was significantly lower (RVEF thermo = 31 +/- 14 vs. RVEF MRI = 50 +/- 14, p < 0.01) and RV EDV and ESVI were significantly higher compared to MRI, while SVI showed no significant difference. Exclusion of patients with atrial fibrillation (n = 8) improved the correlations (RVEF r = 0.94, EDVI r = 0.77, ESVI r = 0.87, SVI r = 0.65, all p < 0.05), but did not reduce the mean difference between both methods.

Cardiomyopathy, Dilated↗
PubMed1995

[Strategies in management of heart transplantation candidates with tachycardic ventricular arrhythmia anamnesis].

We followed up 73 consecutive patients with a history of syncopal ventricular tachyarrhythmias on the waiting list for a heart transplant between 1st March 1992 and 15th September 1994 with the aim of evaluating the impact of implantable cardioverter defibrillator (ICD) on survival. On registration 60 patients were considered fit enough to be ambulant whilst awaiting transplantation. 30 were given ICD therapy (group 1) and 30 were not (group 2). 13 patients required inpatient supervision for ventricular arrhythmias whilst awaiting transplantation, but received no ICD therapy (group 3). The 13 in-patients were in a worse clinical state (NYHA) than the 30 out-patients not given ICD (p < 0.05). With respect to all other clinical and hemodynamic characteristics all groups were comparable. Waiting time for transplantation was also comparable in all groups (n.s., log-rank method). ICD therapy resulted in a significant improvement of survival in these high-risk patients prior to transplantation. Only 1 out of the 30 ICD patients (group 2) and 5 out of the 13 in-patients (group 3) (p < 0.05 log-rank method). During the waiting time group 3 patients were hospitalised longest (p < 0.05), but there was a clear trend that also ICD patients had to be hospitalised to an increased extent (n.s.). Cox multivariate regression analysis of this study population showed that the cardiac index (p = 0.001) and lack of ICD therapy (p = 0.035) were the only independent significant predictors of mortality on the waiting list. ICD therapy had no influence on mortality after transplantation (n.s. log-rank method).

Adult↗
PubMed1994

Beneficial hemodynamic effects of prostaglandin E1 infusion in catecholamine-dependent heart failure: results of a prospective, randomized, controlled study.

OBJECTIVE: To study the hemodynamic effects of prostaglandin E1 (PGE1) administered in addition to a standard catecholamine infusion in patients with severe chronic heart failure. DESIGN: Prospective, placebo-controlled, randomized, single-blind study. SETTING: Intensive care unit at a university hospital. PATIENTS: Thirty patients with severe chronic heart failure, New York Heart Association functional class IV (28 men, two women, with a mean age of 54 +/- 2 yrs, mean left ventricular ejection fraction 10 +/- 0.6%). All patients received oral therapy with digitalis, furosemide (mean dose 300 +/- 46 mg/day), and enalapril (20 +/- 2.7 mg/day). INTERVENTIONS: Hemodynamic measurements using pulmonary artery flotation catheters were performed at baseline, > or = 24 hrs after standardized catecholamine infusion with dopamine (3 micrograms/kg/min) and dobutamine (5 micrograms/kg/min), as well as 48 hrs after randomization to infusion therapy with PGE1 (30 ng/kg/min) or a placebo. MEASUREMENTS AND MAIN RESULTS: The addition of PGE1 to an ongoing catecholamine infusion in 20 patients caused a 16 +/- 4% decrease in mean pulmonary arterial pressure (p < .001), a 22 +/- 5% decrease in pulmonary artery occlusion pressure (p < .0001), a 24 +/- 8% decrease in pulmonary vascular resistance index (p < .001), a 20 +/- 9% decrease in right atrial pressure (p < .01), a 14 +/- 3% decrease in mean arterial pressure (p < .001), and a 29 +/- 4% decrease in systemic vascular resistance index (p < .0001). These PGE1-induced decreases occurred without a change in heart rate. Stroke volume index increased with PGE1 therapy by 34 +/- 7% (p < .0001), and cardiac index increased by 34 +/- 6% (p < .0001). No hemodynamic changes were observed during combined infusion with catecholamines and placebo in ten patients. CONCLUSION: PGE1 improves the hemodynamic state in end-stage chronic heart failure patients already receiving a standard dose dopamine/dobutamine infusion.

Alprostadil↗
PubMed1994

Sinus node dysfunction after orthotopic heart transplantation: the Vienna experience 1987-1993.

In the present study, the annual incidence of postoperative sinus node dysfunction and the type of sinus node abnormality after cardiac transplantation were followed over a 6 1/2-year period in 185 patients. Each year the sinus node function was systematically characterized by rhythm and corrected sinus node recovery time in a significant number of patients. Over the entire study period, there were 131 patients with normal sinus node function (corrected sinus node recovery time 318 +/- 55 msec) while 54 patients had latent (n = 24, sinus rhythm, corrected sinus node recovery time 8,053 +/- 2,198 msec) or manifest (n = 30, absence of sinus rhythm or pacemaker dependence) sinus node dysfunction. Twenty-nine patients had pacemaker placement. The incidence of sinus node dysfunction declined in absolute terms and when indexed by the actual number of patients transplanted per year (index 1987: 38.5; 1998: 17.6; 1989: 23.2; 1990: 29.1; 1991: 10.4; 1992: 7.5; 1993: 2.2). Among those with sinus node dysfunction, the annual percentage of patients presenting with prolonged recovery time, escape rhythm, and those reverting back to sinus rhythm until discharge did not change significantly over the study period (P = 0.22). On multivariate analysis, only the date of transplantation was significantly associated with the occurrence of postoperative sinus node deficiency (P = 0.0007) while age of recipient (P = 0.85) or donor (P = 0.96), the type of cardioplegia used (P = 0.09) and ischemic time (P = 0.09) were insignificant.(ABSTRACT TRUNCATED AT 250 WORDS)

Adult↗
PubMed1994

Safety of concomitant potassium-sparing diuretics in angiotensin-converting enzyme inhibitor therapy in severe congestive heart failure. Xamoterol in Severe Heart Failure Study Group.

The safety of concomitant use of angiotensin-converting enzyme (ACE) inhibitors and potassium-sparing diuretics (PSD) in severe heart failure remains a controversial issue. The database of the recently reported double-blind international trial, "Xamoterol in Severe Heart Failure," was investigated to elucidate this question. Of 516 patients with New York Heart Association (NYHA) class III-IV, despite diuretics and ACE inhibitor therapy, 352 were randomized to xamoterol, a beta 1 partial agonist, and 164 were randomized to placebo. During the 13-week study, 28% of all patients (xamoterol, 104; placebo, 42) received potassium-sparing diuretics. All groups were comparable in hemodynamics and dose of other diuretics. At study end, patients with or without PSD showed no significant differences in serum K+ or creatinine, independent of xamoterol or placebo therapy. Mortality rate was consistently lower: 4.6% in patients with PSD and 8.5% in patients without PSD, although statistical significance was not reached. As compared with baseline, K+ values of 6 patients with and 17 patients without PSD had increased by > 5.0 mM at study end (p = NS); 1 patient with and 11 patients without PSD had a creatinine level > 180 microM (p = NS). For 3 patients receiving PSD, and 2 patients not receiving PSD because of renal impairment, study was discontinued because of hyperpotassemia. No significant differences were noted in long and short action or different dosages of ACE inhibitors. PSD may be administered concomitantly with ACE inhibitors, but serum K+ should be monitored as with other diuretics.

Adult↗
PubMed1993

Plasma big endothelin-1 concentrations in congestive heart failure patients with or without systemic hypertension.

Plasma endothelin concentrations were evaluated in 53 chronic, congestive heart failure (CHF) patients with or without history of systemic hypertension, as well as in 9 with hypertension only and in 22 healthy control subjects. Plasma renin, aldosterone and atrial natriuretic peptide, as well as clinical and hemodynamic data were determined. In patients with CHF, big endothelin-1 was, independent of hypertension history, significantly greater than in hypertensive patients with normal cardiac function and in control subjects (both p < 0.0001). Patients with severe CHF had significantly greater big endothelin-1 values than did those with moderate CHF. During 12-month follow-up, 11 patients with CHF underwent heart transplantation, and 9 died; these patients had significantly greater big endothelin-1 concentrations than did the 33 clinically stable patients (p < 0.001). Big endothelin-1 and atrial natriuretic peptide correlated with right atrial pressure, pulmonary capillary wedge pressure, left ventricular ejection fraction, effort capacity and severity of CHF (New York Heart Association functional class).

Adult↗
PubMed1993

Serum-soluble CD4 as clinical and immunological marker in patients with dilated cardiomyopathy.

Serological markers of cell-mediated immunity, i.e., soluble CD4, soluble interleukin-2 (Il-2) receptor and beta 2-microglobulin, were determined in 60 patients with dilated cardiomyopathy. Compared with normal healthy donors (n = 30) and controls who had coronary artery disease with preserved left ventricular function (n = 20), significantly increased levels associated with the New York Heart Association functional classes have been found in the cardiomyopathy patients, irrespectively of the etiology. Out of the immunological variables tested, serum-soluble CD4 most closely reflected the clinical and hemodynamic stage, predicted the presence of lymphocytic aggregates in the myocardium and correlated with the CD4/CD8 ratios of endomyocardial lymphocytes (r = 0.6, P < 0.05). Conversely, focal mononuclear infiltration of the myocardium was associated with significantly elevated CD4/CD8 ratios (2.1 +/- 0.6 vs. 1.3 +/- 0.2, P < 0.05), higher total numbers and percentages of endomyocardial lymphocytes expressing the pan T-markers CD2 and CD3, more CD45RO/UCHL1-positive cells and more CD4-positive T-helper cells, compared with non-reactive cases the lymphocytes of which were scattered throughout the myocardium. In conclusion, in a subset of cardiomyopathy patients lymphocytic clusters in the myocardium indicated an enhanced cellular immune response predominantly mediated by CD4-positive T-helper lymphocytes with active memory function. This immunopathological condition in the heart can be monitored by serum-soluble CD4.

CD4 Antigens↗
PubMed1993

Clinical and neurohumoral response of patients with severe congestive heart failure treated with two different captopril dosages.

Although angiotensin converting enzyme inhibitor therapy is an established approach in the treatment of chronic heart failure, the required dosage remains unclear. This open 6 month study investigated the influence of different captopril dosages on the clinical course and neurohumoral activity of patients with severe heart failure (left ventricular ejection fraction < or = 20%). Eighty-five patients in New York Heart Association class II-IV despite treatment with digitalis, diuretics, and captopril (mean dose +/- SEM 28 +/- 2 mg.day-1 at baseline) for > or = 3 months received either 'low dose' captopril (< 75 mg.day-1, mean 32 +/- 2 mg.day-1; n = 46) or 'high dose' captopril (> or = 75 mg.day-1, mean 99 +/- 4 mg.day-1; n = 39) during the follow-up period. Both groups were comparable in clinical, haemodynamic and neurohumoral parameters at baseline. Functional state improved significantly only in the high dose group (P < 0.0001). Of 31 low dose and 20 high dose patients considered as heart transplantation candidates at baseline, 21 low dose and only six high dose patients remained on the waiting list (P < 0.0001). In patients in the low dose group, eight deaths were observed (P < 0.001). Seven patients remained on low dose captopril due to adverse effects. The initially elevated plasma levels of aldosterone and atrial natriuretic peptide decreased significantly only in high dose patients (P < 0.01). Renin increased significantly in both groups. These observations underline the necessity of suppressing neurohumoral overactivation with adequate doses of captopril reflected by sequential humoral plasma determination.

Aldosterone↗
PubMed1993

Doppler sonographic evaluation of the Duromedics-Edwards bileaflet valve at five-year follow up.

In order to define normal flow characteristics at mid-term follow up, prospective Doppler echocardiographic studies were performed in 145 patients (mean age 49.3 years) with Duromedics-Edwards bileaflet valve prostheses (76 aortic, 55 mitral and 14 double aortic and mitral) at a mean interval of 5.2 years following operation. All patients had clinically normal prosthetic valve function and no clinical or radiographic signs of heart failure. None of the patients had severely impaired left ventricular function as assessed by cross sectional 2D echocardiography. Mean peak velocity across prostheses in the aortic position was 2.8 +/- 0.5 m/sec, corresponding to a calculated instantaneous peak pressure gradient of 31.4 +/- 10.2 mmHg. Gradients varied inversely to valve size, although differences were significant only when comparing the 19mm and 21mm versus the 27mm valve (p < 0.05). In the mitral position the mean of peak velocity was 1.8 +/- 0.3 m/sec and pressure half time was 102 +/- 14 msec, representing a calculated mean orifice size of 2.2 +/- 0.5 cm2, with no significant difference between valves of different sizes. Paravalvular regurgitation was more common in the aortic than in mitral position (39% vs. 4%, p < 0.05), although in all cases it was mild (range less than one centimeter from prosthesis ring) and clinically insignificant. We conclude that normally functioning DE valve prostheses have a predictable range of Doppler echocardiographic parameters, although the individual variability of pressure gradients and effective valve area (in mitral valves) has to be emphasized. Nevertheless, the Duromedics Edwards valve shows good hemodynamic properties at mid-term follow up.

Adolescent↗
PubMed1992

Heart rate behaviour at different stages of congestive heart failure.

Depressed heart rate variation has been shown to predict a high mortality rate in patients with severe congestive heart failure. To determine whether the degree of altered heart rate correlates with the clinical state, 24-h Holter monitoring was performed in 21 patients (mean ejection fraction: 18 +/- 11%) at baseline and after 6 months of oral therapy. At baseline, the overall 24-h heart rate variation and night/day heart rate ratio was reduced, depending on the NYHA functional class. The typical morphology of R-R interval histograms was a sensitive marker of the clinical state at baseline: the higher the NYHA class, the smaller the R-R interval variability and standard deviation of R-R intervals (total variability NYHA III versus II: P less than 0.05). Clinical deterioration after 6 months (n = 8) was accompanied by a tendency to further shortening of the mean total R-R interval variability (676 +/- 34 to 586 +/- 25 ms). This was shown in three patients, who were reclassified to NYHA class IV. In stable patients (n = 5) and those with clinical improvement (n = 8) no significant change in R-R variability was observed. It is concluded that variations in R-R interval histogram shapes correspond to different NYHA functional classes. While severe clinical disease progression may be associated with further reductions in the heart rate variability, improvement in the clinical state of congestive heart failure is not necessarily associated with changes in heart rate behaviour.

Adult↗