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Biomedical subjects

C Piper

Publications and source records attributed to C Piper.

At least 19 recordsLinked to original sources
PubMed1998

[Emergency heart valve replacement after acute cerebral embolism during florid endocarditis].

BACKGROUND: The indication for urgent cardiac surgical interventions in patients with active infective endocarditis has to be considered carefully following thromboembolic events, because of the high recurrence rate of such complications. In the case of brain embolisms the prognostic benefit of urgent surgery has been discussed controversially as effective anticoagulation during open heart surgery may result in secondary cerebral hemorrhages. PATIENTS AND METHODS: Between 1978 and 1993 infective endocarditis (IE) was proven in 288 consecutive and prospectively followed patients (131 females, 157 males; mean age 53.6 +/- 8.7 [9 to 81] years). To analyze potential benefits and risks of an urgent surgical intervention early after embolic cerebral infarction, cumulated survival rates were calculated for patients with and without surgical intervention with special reference to incremental risk factors and the timing of surgery. RESULTS: In 50 patients (17.4%) the clinical course was complicated by one, and in 58 patients (20.2%) by recurrent embolic events. In 80% the first embolism occurred within 33 days following the first manifestation of typical signs and symptoms of IE. 80% of recurrent events were observed within 32 days following the initial embolism. 71% of all embolic events were cerebral. In patients with cerebral embolism corroborated by computed tomography (CCT), the clinical course was complicated by intracranial hemorrhage in 12.5% while it was only 1.5% for patients without cerebral embolism. Because of a lack of therapeutic alternatives, 22 of 49 patients with recurrent embolic events, of which at least one was cerebral, underwent urgent cardiac surgery within 4 to 366 hours after the first cerebral manifestation. The cumulated survival rate of patients operated within 72 hours after the initial cerebral embolism was significantly more favorable (p < or = 0.000) than for unoperated patients or those who were operated after more than 8 days. CONCLUSION: An embolic event during IE carries a more than 50% risk of recurrence. In patients with short duration of signs and symptoms of IE and postembolic echocardiographic demonstration of persistent vegetations the probability is > 80%. At least for those patients urgent surgical intervention to remove the source of infection and embolic hazard seems to be beneficial. Surgical intervention using the heart-lung-machine should be performed within 72 hours. Such early timing results in a significant lower rate of secondary cerebral hemorrhages (p < or = 0.00) than a postponed operation. To exclude early reperfusion hemorrhage due to spontaneous thrombus fragmentation, CCT should be repeated directly preoperatively.

Adolescent↗
PubMed1998

[Optimal management of primary and secondary mitral regurgitation].

While morphologic alteration of parts of the mitral valve apparatus (ventricular wall, papillary muscles, chordae tendineae, valve annulus and leaflets) may result in a loss of its functional integrity (primary mitral regurgitation, MR) mitral annulus dilatation following left ventricular enlargement or change in chamber geometry and consecutive opening of the angle between papillary muscles and valve annulus cause secondary MR. Irrespective of these etiologies MR is chronically progressive and much more than the severity of MR the grade of myocardial adaptation to the chronic volume overload is of prognostic significance. Inadequate myocardial adaptation is demonstrated by an increase of the echocardiographically determined radius (r) to wall thickness (Th) ratio (r/Th > 3.0), indicating increasing left ventricular wall stress or by an insufficient increase of the left ventricular ejection fraction (< or = 5% of resting values) under exercise conditions, e.g. with radionuclide angiocardiography (RNV). Stressecho may replace RNV in the future for this indication. Actually, stress echo is not reliable to determine changes in left ventricular ejection fraction at rest versus exercise because of systematic errors and error reproduction. There are preliminary reports on biochemical markers like noradrenaline or tumor necrosis factor alpha being helpful to determine the breakdown of myocardial adaptation mechanisms. Surgical intervention is indicated in chronic MR irrespective of the hemodynamic severity, if myocardial adaptation is inadequate. If mitral reconstruction, the surgical technique of choice, remains insufficient to restore normal valve function, mitral valve replacement with preservation of the subvalvular apparatus is unavoidable. For a deceleration of the progressive volume overload in chronic MR for which a surgical intervention is not yet indicated, a long-term afterload reducing medical therapy preferably with long acting ACE-inhibitors seem to be prognostically favorable.

Angiotensin-Converting Enzyme Inhibitors↗
PubMed1998

[Diagnostic approach and optimal treatment of aortic valve stenosis].

The slow progression of valvular aortic stenosis enables the left ventricular myocardium to adapt itself to the increasing afterload. When myocardial adaption is exhausted, surgical intervention is urgent, the prognosis, however, is already limited. To quantify the hemodynamic severity of aortic stenosis, transaortic pressure gradients (dp) measured by Doppler echocardiography or hemodynamically are inappropriate, because dp is significantly dependent on the transaortic flow volume. In severe aortic stenosis, despite constant narrowing of the aortic valve area, the reduced stroke volume results in decreasing transaortic pressure gradients. With aortic valve resistance or transaortic pressure loss (PL)--the quotient of pressure gradient and stroke volume--the hemodynamic severity of aortic stenosis can be described accurately. If PL is known, a decompensated aortic stenosis (PL > 1 mm Hg/ml) may be differentiated from myocardial failure of another etiology and a concomitant left ventricular outflow tract obstruction. With respect to medical therapy, the prevention of bacterial endocarditis and thromboembolic complications is important. Knowing the potential danger of syncopies and ventricular arrhythmias during exercise with increasing severity of aortic stenosis, patients have to be informed about their limited functional capacity. The occurrence of typical symptoms during the natural history of chronic aortic stenosis (e.g. dizziness, syncopes, angina pectoris, arrhythmias) manifestation of ST-T-alterations or silent myocardial ischemias and demonstration of an inadequate myocardial adaptation to the chronic pressure overload in asymptomatic patients are accepted indications for a surgical intervention. If the indication for surgery remains uncertain, stress tests (e.g. radionuclidventriculography) may be performed to demonstrate an exhausted myocardial adaptation. If the PL and the severity of aortic valve/anulus calcification is known, the progression of a chronic aortic stenosis can be estimated. This might be important, if a cardiosurgical intervention has to be performed for other indications and aortic stenosis is co-existent but does not require an intervention at that time. For prognostic reasons myocardial decompensation due to aortic stenosis is an indication for an urgent surgical intervention. Attempts for medical recompensation or bridging strategies (e.g. balloon valvotomy) worsens the prognosis significantly.

Aortic Valve Stenosis↗
PubMed1998

[Prospective study of the incidence, pathogenesis and therapy of spontaneous, by coronary angiography diagnosed coronary artery dissection].

Spontaneous coronary artery dissection is a rare cause of ischemic heart disease. Incidence, etiology and optimal treatment are ill-defined. Between July 1995 and December 1997, we prospectively identified 42 patients (36 men, six women, mean age 59 +/- 12 years) with spontaneous coronary artery dissection among 3803 consecutive angiographic examinations in which the diagnosis of coronary artery disease was established for the first time (incidence 1.1%). In comparison to the remaining study population with stable angina pectoris (8 cases of spontaneous coronary artery dissection among 2852 patients; incidence: 0.3%), the incidence of spontaneous coronary artery dissection was significantly higher in the patient subgroups with acute myocardial infarction (13/450; 2.9%) and with unstable angina pectoris or postinfarction angina (21/501; 4.2%). Dissection was most frequently located in the left anterior descending coronary artery (19 cases), followed by the right coronary artery (15 cases) and the left circumflex coronary artery (8 cases). Because of an ambiguous angiographic lesion appearance intravascular ultrasound imaging was performed in 13 patients to confirm the diagnosis. The presumed etiology of spontaneous coronary artery dissection was atherosclerotic plaque rupture in 35 cases, heavy physical exercise in four cases and hormonal influences related to pregnancy and contraception in one case. In two cases, no obvious risk factor could be identified. Therapy consisted of intracoronary stenting in 24 patients (including ten patients with acute myocardial infarction), coronary artery bypass grafting (CABG) in 8 patients and balloon angioplasty (PTCA) in seven patients. Three patients were treated conservatively. During a mean follow-up period of 13.5 +/- 9.9 months, two patients died and 31 patients remained entirely asymptomatic, including all patients who were treated with CABG. Restenosis developed in three patients after stent implantation (restenosis rate: 12.5%). Following primary PTCA, spontaneous coronary artery dissection recurred in two patients, one of whom subsequently died.

Adult↗
PubMed1998

[Intracardiac thrombosis and consecutive thromboembolisms in patients with heart valve diseases: predisposition and concepts for prevention].

For patients with acquired heart valve lesions with increased risk for intracardiac thrombosis and consequent cardiogenic embolism there is consensus that oral anticoagulation therapy improves the overall prognosis. In mitral valve lesions anticoagulation is necessary after manifestation of atrial fibrillation or in cases of unstable sinus rhythm. The risk for thromboembolic events is increasing parallel to the enlargement of the left ventricular enddiastolic diameter, the left atrial size and dropping cardiac index. Spontaneous echo contrast (so called smoke like echos) indicate a prethrombotic state. In these cases an intensive anticoagulation is indicated. Aortic valve lesions require anticoagulation after manifestation of atrial fibrillation, the first manifestation of a thromboembolism or of spontaneous echo contrast. The risk for thromboembolism is increasing parallel to the reduction of left ventricular pump function. Life long oral anticoagulation therapy should be managed by use of the International Normalized Ratio (INR), and should be individualized taking into account patient related cardiac morphology and physiology, which may predispose to cardiogenic embolism. The target INR can range between 2.0 and 4.0.

Fibrinolytic Agents↗
PubMed1998

[Thrombosis of prosthetic heart valves: diagnosis and management].

The incidence of prosthetic valve thrombosis (PVT) has been reported to be < 0.1-0.25%/year following isolated aortic valve replacement and < 0.1-2.5%/year after mitral valve implantation. In a consecutive series 10.3% of PVT occurred after an interruption of oral anticoagulant therapy for weeks or months, in 20.7% with inadequate low anticoagulation while in 34.5% of PVT cases intensity of the oral anticoagulant therapy showed significant ups and downs. There was an obvious increase of PVT incidences during the winter months, concomitant with increasing fibrinogen levels and plasma viscosity. The diagnosis of PVT can be made with a high specificity and sensitivity by analysis of the typical opening and closing clicks of the valve occluder. Parameters indicating chronic intravascular hemolysis, fluoroscopy and echocardiography are additionally helpful to confirm the diagnosis. The therapy of choice is prosthetic valve re-replacement. Systemic thrombolytic therapy may be an alternative in selected patient groups.

Fibrinolytic Agents↗
PubMed1997

[Acute myocardial infarct caused by a muscle bridge of the anterior interventricular ramus: complicated course with vascular perforation after stent implantation].

UNLABELLED: A 47-year-old male patient was admitted to our hospital with acute anterior myocardial infarction. Immediate coronary angiography was carried out, which showed proximal occlusion of the left anterior descending artery (LAD). After mechanical recanalization, a reduction in vessel caliber at the site of occlusion was visible, and balloon angioplasty with consecutive stent implantation because of vessel wall dissection was performed. After the procedure, diameter reduction of the entire vessel segment distal to the stent and muscular bridging with subtotal systolic obliteration of the LAD and one diagonal branch were demonstrated. Diastolic coronary flow did not appear to be limited (TIMI 3). Dipyridamole-thallium cardiac imaging revealed an incomplete perfusion defect of the anteroseptal region and a reversible perfusion reduction of the anterolateral region. For definitive treatment, we decided to implant a 3.0 mm-stent at the site of muscular bridging. Although balloon sizing was adapted to the diameter of the proximal reference segment, measured by quantitative coronary angiography, coronary perforation into the right ventricular outflow tract due to balloon oversizing in the distal dilation segment occurred. The patient remained asymptomatic at rest as well as under exercise testing, and hemodynamics remained stable. Coronary re-angiography after 1 week demonstrated a persistent fistula with complete opacification of the LAD and normal coronary flow (TIMI 3). Within the following 3 months, the coronary fistula closed spontaneously. CONCLUSIONS: Muscular bridging is a rare cause of acute myocardial infarction. Balloon angioplasty and stent implantation in the bridged segment may be complicated by coronary artery perforation due to balloon oversizing. Risks and benefits of this therapeutic option, therefore, have to be critically evaluated, and careful selection of balloon size using measurements of proximal and distal reference diameter assessed by intravascular ultrasound is recommended. Coronary artery perforation into the myocardium with subsequent development of a fistula may be treated conservatively as long as the patient remains asymptomatic. The frequency of spontaneous closure of the fistula is high.

Angioplasty, Balloon, Coronary↗
PubMed1996

[Severe HELLP syndrome with temporary kidney and lung failure].

This report is on a severe case fo a HELLP-syndrome (H haemolysis, EL elevated liver enzymes, and LP low platelets). A 32-year old gravida developed severe preeclampsia with epigastric pain at 33 weeks' gestation. During a few hours post partum she showed disseminated intravascular coagulation (DIC) and required intensive care. The severe HELLP-syndrome was combined with a fast increasing acute respiratory distress syndrome (ARDS) and acute oligo-anuric renal failure. She was treated in the intensive-care unit for several days with artificial respiration, 10 acute haemodialyses, 4 plasma exchanges with fresh-frozen plasma and many blood and platelet transfusions. An early Caesarean section and treatment in the intensive care unit managed to turn the otherwise complicated progression of the disease. It is pointed out that plasma exchange with fresh-frozen plasma is a rarely employed treatment.

Acute Kidney Injury↗
PubMed1995

Late prosthetic valve endocarditis.

Prosthetic valve endocarditis remains an extremely serious complication, with a low but increasing incidence. 'Late' endocarditis, occurring more than 60 days after surgery, is relatively infrequently associated with staphylococci, Gram-negative bacteria and fungi so characteristic of the endocarditis that occurs earlier. A probable source of infection can be found in 25%-80% of patients, the most frequent causes being dental procedures, urological infections and interventions, and indwelling catheters. The most common organisms are S. epidermidis, S. aureus, viridans streptococci and enterococci. The general principles of antibiotic treatment are similar to those for native valve endocarditis, but antibiotic treatment needs to be more prolonged and dosages should be used which result in maximal, nontoxic concentrations. Oral anticoagulants should be stopped and replaced by intravenous heparins. Surgical reintervention is called for if there are large highly mobile vegetations in the mitral position or within 72 h if there are cerebral thrombo-embolic episodes.

Endocarditis, Bacterial↗
PubMed1994

[Brain abscess in patients with cyanotic heart defects].

As a result of hypoxia following right-to-left shunts, cerebral bacterial spreading and an altered blood-brain-barrier permeability, brain abscesses (BA) are typical complications in patients with cyanotic congenital heart disease. In 483 prospectively followed patients the incidence of BA was 0.45%/year. It was higher (0.57%/year) for patients with tetralogy of Fallot where the cumulative risk within the first two decades of life was 12.1 +/- 1.7%. The risk of BA complicating cyanotic heart disease is inconstant and continuously increasing up to approximately age 12 (instantaneous risk at that time: 1.75 +/- 0.12%), decreasing thereafter. With respect to etiology, infectious endocarditis, infections per continuitatem, bacterial meningitis, bacterial lung diseases with intrapulmonary shunts, and thromboembolic complications of systemic infections have to be differentiated. The stepwise diagnosis includes CCT to demonstrate the typical contrast enhancement and a lumbar puncture which shows granulocytic pleocytosis. If the cerebral spinal fluid fails to demonstrate the typical findings, cerebral angiography may be necessary to exclude a malignant vascularized neoplasma. In cases of doubt, stereotactic cerebral biopsy should be performed. Optimal antibiotic therapy after determining the minimal bactericidal concentration and combination of antibiotics is of utmost prognostic significance. Cranial computed tomography should be repeated after 6, 14, and 24 days. Infections resistant to antibiotics may necessitate local instillation of antibiotics.

Adolescent↗
PubMed1993

Diagnostic and therapeutic considerations in acute, severe mitral regurgitation: experience in 42 consecutive patients entering the intensive care unit with pulmonary edema.

Forty-two consecutive patients received emergency treatment for acute mitral insufficiency causing pulmonary edema between 1984 and 1992. The underlying diagnoses were acute myocardial infarction (n = 21), acute bacterial endocarditis on the native mitral valve (n = 9), prosthetic endocarditis in the mitral position (n = 4), acute failure of a replacement valve (n = 5), blunt chest trauma (n = 1) and chordal rupture in Marfan's syndrome (n = 2). Dysfunction of the subvalvular apparatus was present in 24 patients, verified by transthoracic echocardiography in 18 (75%) and by transoesophageal echocardiography in all patients in whom this technique was used. There were four cases of outflow strut fracture of a Björk-Shiley mitral prosthesis; a reliable diagnosis was made by fluoroscopy in all patients. Bedside hemodynamic monitoring was found to be unreliable both for differential diagnosis and for the quantitative assessment of the degree of mitral insufficiency. The right ventricular filling pressure was normal in 32/39 patients (82%), and the pulmonary artery and pulmonary capillary pressures elevated in 37/39 (95%). Diagnostically important, high pulmonary capillary v-waves were documented in 13 patients (33%). The left ventricular impedance could be influenced with sodium nitroprussid combined in some cases with dobutamin, and the resultant decrease of the peripheral vascular resistance from 1480 +/- 222 to 702 +/- 86 dyn x sec x cm-5 was followed by a proportionate reduction in the transmitral regurgitant fraction. Three patients died prior to the intended emergency surgical intervention. Emergency surgery was completed in 21 patients with an early mortality of 23.8% (n = 5). Ten patients underwent elective surgery within, and another three later than one year from the onset of the acute symptoms with an early mortality of 7.7% (n = 1). Four patients are alive and clinically well with medical treatment alone.

Adult↗
PubMed1990

[Non-tropical pyomyositis in Germany].

Haematogenous primary pyomyositis predominantly caused by staphylococcus aureus is a well-known entity in tropical regions. It is sporadicly observed in non-tropical areas. Lack of clinical familiarity not seldom contributes to delayed recognition of pyomyositis in the suppurative or complicated state. Initially, healing usually can be achieved by antibiotic treatment adjusted by antibiotic treatment adjusted to pyogenic staphylococci. Late stages require concomitant surgical or transcutaneous drainages of pus. In addition, treatment for osteomyelitis or bacterial carditis as typical complications may be necessary. The review of pyomyositis is illustrated by three case-reports from Germany.

Adult↗
PubMed1989

[Acute interstitial nephritis following piperacillin].

A 75-year-old woman developed fever, exanthema and nonoliguric renal failure 16 days after the beginning of Piperacillin treatment. Renal biopsy revealed lympho-plasma-cellular acute interstitial nephritis (AIN). A lymphocyte-transformation-test showed significant stimulation of patient's lymphocytes by Piperacillin. Corticosteroid-therapy correlated to clinical and renal improvement. Nevertheless the patient died of foudroyant septicemia caused by E. coli. Our report describes the first immunologically documented case of AIN following Piperacillin treatment.

Aged↗
PubMed1989

[Oral contraceptives: undesirable effects in internal medicine].

Eight instructive clinical case reports on younger women demonstrate the actual problem of severe adverse reactions (ADR) associated with oral contraceptives. Complications consisted of cerebral arterial thrombosis, peripheral arterial thrombosis, cerebral embolism, pelvic vein thrombosis, pulmonary embolism, thrombosis of the sinus sagittalis, recurrent pancreatitis and focal nodular hyperplasia of the liver. Contraindications of hormonal contraception (i.e. heavy smoking) were not always taken seriously by the prescribing physician. The data bank of the Medicines Commission of the German Medical Association contributed 648 cases to draw an ADR frequency profile, according to age, doses, duration of prescription and deaths. 25 deaths in close connection to oral contraception intake were reported, mostly caused by arterial or venous thromboembolism. Deaths predominantly were reported in women less than or equal to 30 years old, mostly following exposition to low-dose-preparations and after relatively short duration of intake (less than or equal to 3 years). These non-representative observations call for strict consideration of contraindications and use of low-dose-preparations, even in younger women.

Adult↗
PubMed1989

Pharmacokinetics of the thromboxane A2 receptor antagonist sulotroban (BM 13.177) in renal failure.

1. Ten healthy volunteers and 26 hospital in-patients with endogenous creatinine clearances of 98 to 4 ml min-1 received an oral dose of 800 mg sulotroban (BM 13.177). The plasma and urine concentrations of sulotroban were measured by gas-chromatography over 72 h and the pharmacokinetic parameters were calculated. 2. The AUC rose from 28.5 mg l-1 h in healthy volunteers to 631.4 mg l-1 h in preterminal renal failure (medians). The CLR decreased from 317.0 ml min-1 to 6.5 ml min-1 at the lowest renal capacity. 3. According to the AUC values, reduction of the dose is not necessary at CLCr greater than 50 ml min-1, a dose of 20-40% of normal is appropriate at CLCr of 20-50 ml min-1 At CLCr less than or equal to 20 ml min-1 the normal dose should be reduced to less than 20% of normal. 4. Vaginal spotting was noted in three female patients and a gastro-intestinal haemorrhage that did not require transfusion in one male patient. These may be associated with the action of sulotroban.

Adult↗