Biomedical subjects
Publications and source records attributed to U Gleichmann.
Twenty patients with end-stage heart failure and preexisting malignancies underwent heart transplantation at a single center, with a neoplasm-free interval before the procedure of 0 to 240 months. Twelve patients were long-term survivors (2 to 72 months); there were 2 early and 6 late deaths, thus justifying heart transplantation in patients with preexisting malignancies in individual cases.
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BASIC PROBLEMS AND OBJECTIVE: In addition to medication with negative inotropic drugs, surgical myectomy and DDD pacemaker implantation are standard procedures in the treatment of hypertrophic obstructive cardiomyopathy (HOCM). In a preliminary series the results obtained with a recently described method, consisting of transcatheter myocardial reduction, are evaluated. PATIENTS AND METHODS: Six patients (two women, four men; mean age 52.7 [44-68] years), who remained in moderate heart failure despite medical treatment, underwent the procedure. After atrial transseptal puncture (via a catheter introduced percutaneously into the femoral vein) the left ventricular outflow tract (LVOT) gradient was measured at rest and after 5-minute balloon occlusion of the first septal branch of the left coronary artery. After demonstration of significant reduction of the gradient by the occlusion, one (n = 3) or two (n = 3) septal branches were occluded by the injection of 2-5 ml of 96% alcohol. RESULTS: The LVOT gradient was reduced from 57.8 +/- 22.4 (38-97) mm Hg to 11.3 +/- 8.6 (0-21) mm Hg and postextrasystolic from 131.0 +/- 40.7 (78-198) mm Hg to 44.0 +/- 35.6 (19-69) mm Hg. All patients had angina for 24 hours after the procedure. Maximal rise in creatine kinase activity was 982 +/- 589 (392-1729) U/l after 8.0 +/- 3.9 (4-15) hours. In three patients transitory complete atrioventricular block developed 10 min to 5 days later, requiring temporary pacemaker implantation. The further course was without complication in all patients and they were discharged after 7.5 +/- 1.8 (6-11) days. CONCLUSION: The described catheter method provides a nonsurgical means of reducing the amount of septal myocardium with subsequent reduction of the LVOT gradient in HOCM. Long-term observation in a larger group of patients and comparison with conventional forms of treatment are required to determined the method's ultimate place in the treatment of HOCM.
OBJECTIVE: To assess a new transvenous transcatheter method of closing a persistent ductus arteriosus, combining advantages of the Porstmann and Rashkind techniques. PATIENTS AND METHODS: Five patients (three men, two women, mean age 36.2 [19-56] years) underwent the procedure. The diameter of the duct was 3-6 mm. A compressed ivalon (poly-vinyl-alcohol) foam plug, introduced and held by a modified biopsy forceps, was placed into the duct via a percutaneously and transvenously placed catheter sheath. Small titanium legs attached to the plug at the aortic and pulmonary ends unfolded once the plug was correctly placed, ensuring safe fixation. RESULTS: Closure was achieved in all five patients and no shunt demonstrated immediately afterwards in four. In one patient a small shunt briefly persisted but was not longer present the day after. One patient had a fever of up to 39 degrees C for several weeks that required no treatment and was thought to have been a foreign body reaction. Follow-up examination after 5-19 months confirmed complete closure. CONCLUSION: The described method appears to be safe and superior to the Porstmann and Rashkind techniques, but the results must be tested on a larger number of patients with longer follow-up.
Intimointimal intussusception is a rare type of aortic dissection. The intimal tear occurs circumferentially with intussusception of the intimal flap downstream into the aortic arch causing obstruction of the great supraaortic vessels. A CT diagnosis has only once been reported. CT and angiographic findings of this rare complication of aortic dissection are described.
Spontaneous coronary artery dissection is a rare cause of acute myocardial infarction, primarily in young women. The etiology of dissections is still under discussion. Possible factors are inflammation, changes of flow dynamics, and preexisting intima lesions. We report on two young women, 49 and 30 years of age, who suffered and acute anterior wall infarction. Coronary angiography confirmed diagnosis of spontaneous coronary artery dissection of the LAD in the acute an subacute phase of acute myocardial infarction. The patients suffered no further cardiac events at long-term follow-up of up to 9 years.
An 18-year-old female presented with acute posterior wall infarction after exercise stress. Coronary angiography showed an aneurysm of the proximal right coronary artery partially occluded with thrombi, followed by a complete occlusion of the vessel. The left coronary artery was normal. Despite immediate intracoronary thrombolysis she developed a large posterior wall necrosis. Angiographic follow-up revealed worsening left ventricular function but not progression of the aneurysmatic ectasia. The diagnosis congenital coronary artery aneurysm was made since there was no evidence for an atherosclerotic, infectious or inflammatory vascular disease. The patient was treated conservatively and within 2 years of follow-up the clinical course was uneventful.
BACKGROUND AND AIMS OF THE STUDY: Percutaneous mitral valvulotomy has been shown to be an accept able alternative to surgery as treatment for selected patients with severe mitral stenosis. Uncertainty still exists regarding predictors of unsuccessful outcome. MATERIALS AND METHODS: 308 patients with severe mitral stenosis underwent Inoue single balloon valvulotomy over a 48-month period and were followed up for a mean of 14.5 +/- 16.8 months (range one to 64 months). Two hundred and sixty-seven (Group I) improved clinically and remained stable throughout the follow up, while subsequent surgery was required in 41 (Group II) after 38.2 +/- 143.5 days (range one to 1,212). Clinical and echocardiographic parameters of the two groups were compared to find significant predictors of an unsuccessful outcome. RESULTS: Significant differences between the groups were observed for NYHA class (2.7 +/- 0.6 vs. 2.9 +/- 0.6, p < 0.05), mitral valve area (1.0 +/- 0.3 vs. 0.9 +/- 0.2 cm2, p < 0.01), left atrial end-systolic dimension by echo (51.3 +/- 8.0 vs. 55.4 +/- 10.2 mm, p < 0.01) and an echocardiographic scoring system including grading for eccentricity of the mitral orifice and distribution of commissural calcification (7.5 +/- 2.0 for Group I and 8.7 +/- 2.0 for Group II, p < 0.001). CONCLUSIONS: Mitral valves that are more likely to have an unsuccessful outcome can be identified by hemodynamic, clinical and echocardiographic criteria, including grading for eccentricity of the mitral orifice and distribution of commissural calcification.
Fully-automated blood pressure measurement has become increasingly widespread over the last few years, especially in the field of blood pressure self-measurement. The high prevalence of arterial hypertension among the aged (over 30%) means that, frequently, the users additionally suffer from cardiac irregularity and valvular heart disease. Using comparative, invasive blood pressure measurements, we investigated the reliability and accuracy of the currently authorized blood pressure measuring devices, both in patients with the most common cardiac irregularity, atrial fibrillation, and in patients with aortic regurgitation, as an example of blood pressure measurement in connection with hypercirculation. Certain things must be taken into account when carrying out auscultatory blood pressure measurement according to Riva-Rocci and Korotkoff if blood pressure levels are to be determined accurately. Firstly, considering the individual variability of blood pressure levels in connection with atrial fibrillation, the mean value from three consecutive blood pressure measurements is more accurate than a single measurement. Secondly, the diastolic blood pressure of patients with significant aortic regurgitation should always be determined with Phase 4 according to Korotkoff. In patients with atrial fibrillation, the accuracy of the blood pressure devices being considered should be investigated individually. In comparison, devices employing the oscillometric measuring technique for blood pressure self-measurement in the upper arm determine blood pressure levels more accurately and reliably than devices for measurement in the wrist or auscultatory devices. In patients with significant aortic regurgitation, diastolic blood pressure levels determined with currently authorized, fully-automated blood pressure measuring devices are reliable and accurate. Systolic blood pressure levels determined in the upper arm are, however, too high.
Automatic 24 h Ambulatory Blood Pressure Monitoring (ABPM) has become an established method in the diagnosis and treatment control of arterial hypertension. Fully automatic blood pressure devices for blood pressure self-measurement (BPSM) in the upper arm and in the wrist using the oscillometric measuring technique have been available in Germany for several years. After evaluating the blood pressure devices boso Oscillomat (upper arm) and Omron HEM-601 (wrist) by means of simultaneous invasive measurements, we studied the suitability of this new method for the control of treated hypertension. Using the device Space Labs 90207, we had ABPM carried out in 100 men (aged 58 +/- 8 years) with mild to moderate hypertension. They recorded hourly blood pressure measurements in the wrist between 6 a.m. and 6 p.m., in the same arm as the blood pressure monitoring using the device Omron HEM-601, or in the other arm using the device boso Oscillomat. The values of systolic and diastolic blood pressure were measured using both methods. Since the random samples probably consisted of non-standard distribution differences, we applied the Wilcoxon matched pairs signed rank test for statistical analysis. No significant differences were recorded between the daily mean systolic (p < .07) and diastolic (p < .97) blood pressure values determined by ABPM and by frequent blood pressure self-measurement. Multiple blood pressure readings obtained using blood pressure self-measurement in the upper arm as well as in the wrist are an alternative to the established, automatic 24-h, ambulatory blood pressure measurement for the treatment control of arterial hypertension, that nightly blood pressure measurement can be omitted. It has advantage of unrestricted and desired frequent use under standardized conditions.
To determine the feasibility of currently used, intravascular ultrasound catheters (12.5 and 20 MHz, 6F and 9F, Boston Scientific Corp., Watertown, MA) for mitral valve disease, ten excised mitral valves from patients with severe mitral stenosis were examined. The specimens were fixed in a glass cylinder perfused with water. The valves were planimetered with the intravascular ultrasound system and investigated regarding pathomorphological changes. The depth field of penetration was between 1.5 and 2 cm (3 to 4 cm diameter) in the 20 MHz catheter and between 2 and 2.5 cm (4 to 5 cm diameter) in the 12.5 MHz catheter. A good correlation of the experimentally recorded valve areas could be ascertained with the Gorlin formula (r = .71, P < .05), the Doppler echocardiography method (r = .69, time method (r = .75, p < .05), and with the two-dimensional echocardiography method (r = .69, P < .05). These results show a sufficient feasibility of the currently used, intravascular ultrasound catheters and enable further steps to be taken with regard to evaluating mitral valve morphology in vivo.
OBJECTIVE: Percutaneous mitral valvuloplasty has been shown to be an acceptable alternative to surgery as treatment for selected patients with severe mitral stenosis. We examined hemodynamic, echocardiographic, and pathomorphologic findings in a series of 308 patients undergoing balloon valvuloplasty, 41 of whom underwent subsequent surgery, in search of possible predictors of an unsuccessful outcome. INTERVENTION AND RESULTS: Patients with severe mitral stenosis underwent Inoue single ballon valvuloplasty over a 48-month period and had follow-up for a mean of 14.5+/-16.8 months (range 1 to 64 months). Of the 308 patients, 267 (Group I) were clinically improved and stable throughout follow-up, while subsequent surgery was required in 41 (Group II) after 38.2+/-143.5 days (range 1 to 1212). Significant differences between the groups were observed for NYHA class (2.7+/-0.6 vs 2.9+/-0.6, p<0.05), mitral valve area (1.0+/-0.3 vs 0.9+/-0.2 cm2, p<0.01) and left atrial endsystolic dimension by echo (51.3+/-8.0 vs 55.4+/-10.2 mm, p<0.01). Two of the 41 Group II patients underwent surgery for left to right shunting, 1 for tamponade and 2 were lost to follow-up. The excised mitral valves of the remaining 36 patients all showed calcification and/or fibrosis: 9 homogenous, 5 non-homogenous; 19 were classified as having a funnel-shaped deformity, and 3 did not fit into a discrete category. Among the funnel-shaped valves, 13 had a tear versus 6 where dilation was primarily accomplished by stretching. Only one of 9 valves with homogenous calcification was torn, whereas a tear was noted in 3 of the 5 with non-homogenous calcification. CONCLUSION: Funnel-shaped valves and those with non-homogenous distribution of calcification and/or fibrosis appear to be least suitable for balloon valvuloplasty.
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Therapy of coronary artery disease in elderly patients will gain in importance due to the demographic changes in industrialized societies. In our own institution 6.5% of all dilated patients were over 70 years of age in 1989, compared to 17.5% in 1995. Elderly patients were more likely to be women and to have unstable angina or multivessel disease. Primary success rates in elderly and younger patients are comparable. The current 3-year survival rate of 84 patients > or = 70 years of age is 92.9%. Long-term follow-up is primarily influenced by non-cardiac comorbidity. In conclusion, percutaneous transluminal coronary angioplasty (PTCA) results in a symptomatic improvement in elderly patients with single-vessel and most patients with multivessel disease.
OBJECTIVE: The prognostic significance of recanalisation of a chronically occluded infarct vessel in single-vessel coronary disease remains controversial, in contrast to early re-opening of the infarct vessel in the acute state of infarction. It was the purpose of this prospective study to discover whether successful recanalisation in the former influences the incidence of cardiac events (death, infarction, by-pass operation) and clinical symptoms in the long term. PATIENTS AND METHOD: Recanalisation procedures were successful in 58, unsuccessful in 41 of 99 patients (81 men, 18 women; mean age 55 [28-79] years) with anterior wall (n = 53) or posterior wall (n = 46) myocardial infarction (AMI and PMI, respectively). The two groups were similar with respect to age, sex, left-ventricular function, indication, exercise capacity and premedication. But the interval between infarction and recanalisation was shorter in the patients who had successful recanalisation (5.1 +/- 5.3 vs 7.8 +/- 7.6 months; P < 0.05). Mean follow-up period for all patients was 55.8 +/- 8.9 months after the recanalisation procedure. RESULTS: There were significantly fewer cardiac events after successful than failed recanalisation, both for the total group of patients (5% vs 23%; P < 0.01) and those with AMI (9 vs 36%; P = 0.012). In the patients with PMI there was only a trend in favour of those with successful recanalisation (0% vs 14%; P = 0.058). Symptomatic improvement was reported by 73% of patients after successful but only 40% after failed recanalisation (P < 0.01). CONCLUSION: The results provide pointers towards prognostic indications of recanalisation even after chronic occlusion of the infarct vessel. The procedure should therefore be attempted if the occlusion is morphologically suitable.
Seven prospective, epidemiological studies indicate plasma fibrinogen levels (over 300-350 mg/dl) as an important, independent cardiovascular risk factor for subsequent myocardial infarction and stroke. Furthermore, several clinical studies revealed an association between fibrinogen and both the angiographic and clinical degree of coronary heart disease. In addition, a significant relation of fibrinogen with the number of occluded coronary vessels was found. The following pathophysiologic mechanism are of particular importance: Fibrinogen is a main determinant of plasma viscosity and red cell aggregation. Both phenomena deteriorate blood fluidity especially in the microcirculation. Fibrinogen plays a central role in platelet aggregation and performs an essential substrate in the coagulation cascade. Thus, high fibrinogen levels may favor a hypercoagulable state resulting in final thrombotic events of cardiovascular disease. Fibrinogen is also involved in atherogenesis by stimulating proliferation and migration of smooth muscle cells. Several determinants of fibrinogen levels are known. Smoking is the strongest one in healthy persons. This clinically important effect is dose related. Consequently, cessation of smoking is a major step to lower fibrinogen and subsequently the individual cardiovascular risk. Reduction of overweight and maintenance of regular physical activity are further nonpharmacologic means. Fibrates decrease fibrinogen about 10-30% on an average. Finally, intermittent low-dose Urokinase for end-stages of coronary artery disease and LDL-apheresis (HELP) represent additional approaches to reduce fibrinogen.