Atrial fibrillation in carcinoid heart disease: The role of serotonin. A review of the literature.
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Aged↗
Biomedical subjects
C Piper
Publications and source records attributed to C Piper.
[Aortic valve stenosis in the senium: diagnostics and therapeutic strategies].
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Aged↗
New aspects of infective endocarditis.
The current incidence of infective endocarditis (IE) is estimated as 7 cases per 100,000 population per year and continues to increase. The prognosis is significantly influenced by proper diagnosis and adequate therapy. In cases with unconfirmed IE, transesophageal echocardiography is the imaging technique of choice. Culture-negative endocarditis requires either termination of antimicrobial treatment initiated without mircobiological test results and reevaluation of blood samples or serological/molecular biological techniques to identify the causative organism. Antimicrobial therapy should be established only after quantitative sensitivity tests of antibiotics (minimal inhibitory concentrations, MIC) and guided by drug monitoring. In the first 3 weeks after primary manifestation, an index embolism is frequently followed by recurrencies. If vegetations can still be demonstrated by echocardiography after an embolic event, a surgical intervention should seriously be considered. Cerebral embolic events are no contraindication for cardiac surgery, as long as a cerebral bleeding has been excluded by cranial computed tomography immediately preoperatively and the operation is performed before a significant disturbance of the blood-brain barrier (<72 hours) has manifested. A significant prognostic improvement has also been demonstrated for patients with early surgical intervention suffering from myocardial failure due to acute valve incompetence, acute renal failure, mitral kissing vegetations in primary aortic valve IE, and in patients with sepsis persisting for more than 48 hours despite adequate antimicrobial therapy.
Aminoglycosides↗
Tolerability and efficacy of multidose epoetin beta (Reco-Pen) for subcutaneous administration in patients with anemia due to renal failure.
AIMS: To assess the tolerability, safety and efficacy of the epoetin beta multidose cartridge formulation, self-administered subcutaneously via a pen device (Reco-Pen), in adult patients with renal anemia. METHODS: Patients receiving maintenance epoetin therapy were switched to the subcutaneous (SC) multidose formulation of epoetin beta (NeoRecormon). The frequency of adverse events, local tolerability, and changes in blood pressure and laboratory variables were recorded. Hematologic parameters, transfusion requirements and epoetin beta dosage were also assessed. RESULTS: A total of 406 patients were entered in the intention-to-treat analysis. Mean treatment duration was 82.3 days. Fifty patients (12.3%) withdrew from the study; 14 (3.4%) discontinued because of adverse events. Treatment was well tolerated, with adverse events considered probably related to treatment in only 5 cases, and 1 case of local intolerability. There were no clinically significant changes in blood pressure or laboratory variables, and no changes in hematologic parameters or transfusion requirements. Unexpectedly, the epoetin beta dose was reduced by almost one-third in patients previously maintained on SC epoetin. CONCLUSION: SC administration of this multidose epoetin beta formulation with the Reco-Pen device was well tolerated and effective. It is possible that the improved capacity to individualize dose may have contributed to the considerable reduction in SC epoetin beta dosage requirement.
Adult↗
[The Lyme carditis as a rare differential diagnosis to an anterior myocardial infarction].
An acute Lyme carditis affects about 0.3-4% of patients with Lyme borreliosis. The acute period of the disease may be associated with critical atrioventricular conduction abnormalities (complete heart block), supraventricular and ventricular arrhythmias as well a left ventricular failure. Normally, Lyme carditis is completely reversible. Therefore the prognosis largely depends on the management of the acute complications and early antibiotic therapy. Even if the symptoms are spontaneously reversible, antibiotic therapy should be applied to prevent a chronic cardiomyopathy and other manifestations of Lyme borreliosis. We report on a 47-year old patient with acute ECG changes initially suggesting an acute coronary syndrome. However, case history and the erythema migrans indicated an acute Lyme carditis which was confirmed serologically and by myocardial biopsy later.
Anti-Bacterial Agents↗
The importance of secondary mitral valve involvement in primary aortic valve endocarditis; the mitral kissing vegetation.
AIMS: Secondary involvement of the mitral valve is well documented in primary aortic valve endocarditis. A poorly considered, but probably important causative mechanism, involving both left-sided valves, is 'mitral kissing vegetation'. This results from large aortic vegetations prolapsing into the left ventricular outflow tract and making contact with the ventricular aspect of the anterior mitral leaflet thus causing secondary infection. METHODS AND RESULTS: In 192 consecutive patients with aortic valve endocarditis, two to 18 (7.6+/-2.6) serial transoesophageal echocardiographic examinations were analysed per patient to demonstrate the development of mitral kissing vegetation on initially competent, morphologically normal mitral leaflets. In 19 patients (9.9%) with aortic valve endocarditis, mitral kissing vegetation was diagnosed within 11.6+/-9.0 (range 1-31) days following primary transoesophageal echocardiography. In all patients with mitral kissing vegetation, vegetations attached to aortic cusps were >6 mm. On hospital admission, patients with aortic valve endocarditis plus mitral kissing vegetation presented more often with a positive sepsis score, embolic events, renal failure and had larger aortic valve vegetations (9.9+/-3.3 vs 5.7+/-2.3 mm). Prognosis of aortic valve endocarditis plus mitral kissing vegetation was unfavourable (P<0.005) when compared to patients with aortic valve endocarditis alone. CONCLUSION: In aortic valve endocarditis early echocardiographic detection of mitral kissing vegetation and timely surgery may preserve the mitral valve apparatus, and favourably influence the long-term prognosis.
Adolescent↗
Higher risk of post-partum hemorrhage in malarious than in non-malarious areas of Papua New Guinea.
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Adolescent↗
Prosthetic valve endocarditis.
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Antibiotic Prophylaxis↗
Stroke is not a contraindication for urgent valve replacement in acute infective endocarditis.
BACKGROUND AND AIM OF THE STUDY: A treatment dilemma arises when endocarditis is complicated by cerebral embolism. Secondary cerebral hemorrhagic complications may arise following suppression of coagulation during extracorporeal circulation. Extensive valvular vegetation is regarded as an indicator for urgent surgery. The study aim was to determine the relative risk of thromboembolic complications, and to analyze the prognostic influence of different treatment strategies following onset of these complications, in particular, secondary cerebral hemorrhagic events after urgent surgery. METHODS: Between 1978 and 1993, endocarditis was diagnosed in 288 consecutive patients. Patients treated before 1982 (6.9%) were analyzed retrospectively. The remaining patients (93.1%) were followed prospectively (mean 4.3+/-1.7 years). RESULTS: In 50 patients (17.4%), the clinical course was complicated by one embolism, and in 58 patients (20.2%) by recurrent embolisms. In total, 71% of all embolisms were cerebral events. The operated patients were categorized with regard to the time between recurrent thromboembolic events and cardiac surgery (<72 h, 3-8 days, and >8 days). The prognosis for patients operated within 72 h was significantly more favorable (p <0.0001) than for those treated medically. Patients undergoing cardiac surgery more than eight days after stroke, and those treated conservatively, had poor prognoses. CONCLUSION: When endocarditis is complicated by stroke, it is recommended that cardiac surgery be performed within 72 h of the cerebral embolism, when the risk of secondary cerebral hemorrhage appears to be low. Cranial computed tomography is obligatory immediately before surgery in order to identify patients with early reperfusion hemorrhages due to spontaneous fragmentation of the thrombus. In these patients, cardiac surgery must be postponed because of the high risk of severe cerebral bleeding during extensive perioperative anticoagulation, and is only justified in the case of an otherwise unfavorable prognosis.
Acute Disease↗
[Is the estimation of the progression of valvular aortic stenosis possible?].
BACKGROUND AND OBJECTIVE: It is of great importance to assess progression of aortic valvar stenosis (AVS) when cardiac surgery is planned for other indications when established criteria for aortic valve replacement are not fulfilled at that moment. These considerations have often been ignored in prospective planning of treatment, necessitating a second cardiac surgical intervention just a few years later. The aim of this study was to establish criteria for estimating the rate of progression of AVS. PATIENTS AND METHODS: Clinical, echocardiographic and haemodynamic data were analysed for 169 patients with aortic valvar stenosis (169 men, 88 women; mean age at first cardiac catheterization [CC] 55.2 +/- 15.7 years, at second CC 63.4 +/- 15.6 years. RESULTS: The degree of AVS increases exponentially in relation to the extent of calcification (graded 0-3) and the fall in transaortic gradient (TG), from a TG > 0.6 mmHg/ml stroke volume and can be sufficiently predictable for clinical purposes. But neither age, sex nor the aetiology/pathology of the valvar defect have a sustained influence on the progression of AVS. CONCLUSIONS: These data indicate that knowing the current reduction in TG and the degree of calcification makes it possible to assess the likely progression of previously asymptomatic AVS and thus greatly facilitate the decision of whether or not to combine aortic valve replacement with another indicated cardiac operation.
Adolescent↗
[Congenital tubular supravalvular aortic stenosis with massive coronary artery dilatation in a 35-year-old man].
Supravalvular aortic stenosis is a rare cause of left ventricular outflow obstruction in adults. It occurs as an isolated defect sporadically or on a hereditary basis with an autosomal dominant trait without further phenotypical anomalies, or as part of the Williams syndrome with mental retardation and multiple other anomalies. This lesion was proved to result from a defect of the elastin coding gene. Supravalvular aortic stenosis is frequently associated with cardiovascular defects, particularly of the peripheral pulmonary arteries, thoracic aorta, carotid, subclavian, and coronary arteries and the aortic valve. The coronary arteries are subject to an increased perfusion pressure leading to dilatation, tortuosity and accelerated arteriosclerosis. We give details of a 35-year-old patient in whom a previously asymptomatic supravalvular aortic stenosis is associated with an excessive dilatation of the right coronary artery and the left anterior descending coronary artery as well as an ostium stenosis of the left common carotid artery. The patient did not present any phenotypical anomalies of the Williams syndrome.
Adult↗
[Is Na+Ca(2+) exchanger expression altered in the endomyocardium of patients with chronic heart valve diseases parallel to myocardial dysfunction?].
BACKGROUND: Na(+)-Ca2+ exchanger (EXCH) is an important regulator of intracellular calcium homeostasis. To maintain a normal intracellular Ca2+ concentration, EXCH expression may be upregulated before the onset of end-stage heart failure. We tested for a correlation between the EXCH transcription level and the degree of myocardial dysfunction as well as the suitability of EXCH transcription as a molecular marker for early detection of a transition from adequate to inadequate myocardial adaptation to chronic pressure and/or volume overload in valvular heart disease (VHD). METHODS: The level of EXCH transcription was analyzed in myocardial biopsies from eleven patients with aortic stenosis (AS), five with aortic regurgitation (AR) and six with primary mitral regurgitation (MR) of different hemodynamic severity and myocardial impairment using the quantitative rt-PCR technique. In addition, endomyocardial tissue from thirteen explanted hearts with end-stage heart failure and biopsies from seven individuals without heart disease were investigated. RESULTS: The mean level of EXCH transcription in patients with AS was: 1.8 +/- 1.4 amol/ng total RNA, with AR: 1.9 +/- 0.8 amol/ng and with MR: 2.2 +/- +2.1 amol/ng. This was not from different controls (2.6 +/- 1.2 amol/ng total RNA). However, in myocardium from end-stage heart failure, EXCH transcription was increased fourfold amounting to 8.9 +/- 1.9 amol/ng total RNA. No difference in the EXCH transcription was found in VHD with respect to the degree of myocardial dysfunction: cardiac index (CI) > 3.5 l/min/m2 (EXCH 1.4 +/- 1.1 amol/ng total RNA); CI 3.5-2.4 (EXCH 2.5 +/- 1.8); CI < 2.4 (EXCH 1.8 +/- 1.0); EF-angio > 50% (EXCH 1.9 +/- 1.8); EF-angio < or = 50% (EXCH 1.9 +/- 0.9); EF-RNV > 50% (EXCH 2.4 +/- 1.8), EF-RNV < or = 50% (EXCH 1.7 +/- 1.0). CONCLUSION: Myocardial EXCH transcription does not change parallel to the degree of myocardial dysfunction in VHD. Consequently, myocardial EXCH transcription does not appear to be suitable as a parameter indicating the transition from adequate to inadequate myocardial adaptation to chronic volume and/or pressure overload.
Adaptation, Physiological↗
Is myocardial Na+/Ca2+ exchanger transcription a marker for different stages of myocardial dysfunction? Quantitative polymerase chain reaction of the messenger RNA in endomyocardial biopsies of patients with heart failure.
OBJECTIVES: This study was designed to determine the stage of myocardial dysfunction at which an upregulation of the Na+/Ca2+ exchanger (EXCH) transcription takes place. BACKGROUND: Because EXCH is an important regulator of intracellular calcium homeostasis, alterations in EXCH expression may occur before the onset of end-stage heart failure (HF) to maintain normal intracellular Ca2+ concentrations. We analyzed whether the EXCH transcription level is correlated to the degree of myocardial dysfunction and whether it can be a suitable molecular marker to define the transition to myocardial decompensation early on. METHODS: By quantitative polymerase chain reaction technique, the level of EXCH transcription was analyzed in myocardial biopsies from 40 patients with various degrees of myocardial dysfunction due to valvular heart disease (VHD; n = 22) or dilated cardiomyopathy (DCM; n = 18). Additionally, biopsies from 7 individuals with excluded heart disease and explanted heart tissue from 13 patients with end-stage HF were investigated. RESULTS: The level of EXCH transcription of controls (2.6 +/- 1.2 attomoles [amol]/ng total RNA) did not differ from that of patients with DCM (2.3 +/- 1.5 amol/ng) or VHD (2.1 +/- 1.5 amol/ng). No alteration in the EXCH transcription was found in VHD and DCM patients with respect to the severity of myocardial dysfunction. However, patients with end-stage HF showed a four-fold increase in EXCH transcription, amounting to 8.9 +/- 1.9 amol/ng (p < 0.05). CONCLUSIONS: The upregulation in EXCH transcription either occurs very late in human heart failure or is a phenomenon of heart transplantation in end-stage HF. Consequently, myocardial EXCH transcription cannot be used as a marker for early myocardial decompensation.
Adult↗
[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↗
[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↗
[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↗
[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↗
Optimal Frequency of Patient Monitoring and Intensity of Oral Anticoagulation Therapy in Valvular Heart Disease.
The antithrombotic effect of oral anticoagulation therapy and the incidence of anticoagulant-related bleeding complications are both closely correlated with the intensity of treatment. The optimal intensity of oral anticoagulation for an individual patient is the target INR that results in the lowest incidence of thromboembolic plus bleeding complications. For patients with native valve lesions, one must consider the cardiac morphology and pathophysiology, for example, the etiology of the disease, left atrial diameters, loss of active atrial contraction (atrial fibrillation), left ventricular pump function, and left ventricular diameters, to determine an optimal INR target. In patients with prosthetic devices, the "thrombogenicity" of the heart valve prosthesis is an additional risk factor for intracardiac thrombus formation and thromboembolic episodes. This "thrombogenicity" may vary significantly from device to device. INR self-testing improves the overall prognosis of patients on lifelong oral anticoagulation therapy because patients remain more precisely within that target therapeutic INR range. For most patients under phenprocoumon, one to two INR measurements per week are a sufficient frequency to provide a stable intensity of anticoagulation.
Journal Article↗