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D Horstkotte

Publications and source records attributed to D Horstkotte.

At least 37 records · Page 2Linked to original sources
PubMed2004

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↗
PubMed2003

[Coronary heart disease in childhood in familial hypercholesteremia. Maximum therapy with LDL apheresis].

In children with familial hypercholesterolemia, coronary heart disease requires both medical theraphy and LDL apheresis. We report a case of verified occlusion of the anterior descending branch of the left coronary artery in a 10-year-old patient. The pathological findings revealed by ergometry established the diagnosis. The goal was to achieve the greatest possible reduction of lipid parameters and fibrinogen by lowering plasma viscosity employing LDL apheresis. It is astonishing that this treatment is also well tolerated by children. The basic vascular approaches suffice and shunt operations are not absolutely necessary. The efficacy of this method became vividly apparent by the changes in the skin lesions. Additional angiographic follow-up and further clinical course wil provide information on the usefulness of this treatment strategy with maximum lipid theraphy and the expected improvement in prognosis.

Anticholesteremic Agents↗
PubMed2003

[Predicting the risk of atrioventricular conduction lesions after percutaneous septal ablation for obstructive hypertrophic cardiomyopathy].

BACKGROUND AND INTRODUCTION: Damage to the AV conduction system is a frequent complication of percutaneous septal ablation (PTSMA) that needs early and reliable identification of those patients (pts.) at risk for complete heart block (CHB) and subsequent pacemaker implantation. METHODS AND RESULTS: In the first 39 pts. who underwent PTSMA in 1996, AV conduction recovery needed up to 11 days. One pt. suffered from unexpected CHB after 9 days. Seven pts. who needed a DDD pacemaker (DDD-PM) were compared to those without conduction disturbances. A score was established which identified all DDD-PM candidates retrospectively if they presented with >12 score points. In the following 137 consecutive pts. treated in 1997 and 1998, this score was applied prospectively, and again correctly identified all candidates for a DDD-PM. In addition, a low risk group was identified with <8 score points. From 1999 on, the score was applied in routine clinical decision-making in 120 consecutive pts. with respect to DDD-PM implantation. All low risk pts. (<8 points) remained free from bradycardias, while 2/54 pts. (4%) of the intermediate risk group, and 20/23 pts. (87%) of the high risk group had to undergo DDD-PM implantation. Pts. with a first-degree AV block or those with a right bundle branch block at baseline had no excess risk, while 50% of the pts. with a left bundle branch block (LBBB) needed a DDD-PM. CONCLUSIONS: Based on pre-interventional data and careful monitoring of the first 48 hours after PTSMA, identification of pts. at risk for CHB and subsequent DDD-PM implantation seems to be possible. Pts. with a score <8 seem to be at low, those with >12 points at high risk. In the remaining cases watchful waiting with prolonged monitoring may allow AV conduction to recover, thus, reducing the number of unnecessary DDD-PM implantations. In cases with LBBB at baseline, however, implantation of a DDD-PM should be considered first-line therapy.

Adult↗
PubMed2003

[Analysis of inter- and intraventricular asynchrony by tissue Doppler echocardiography].

BACKGROUND AND INTRODUCTION: Cardiac resynchronization therapy (CRT) is a promising non-pharmacological treatment option for patients (pts) with severe severe heart failure (CHF), systolic left ventricular (LV) dysfunction, and ventricular conduction abnormalities (VCA). Pt selection for CRT, however, is still controversial. Tissue Doppler echocardiography (TDE) can be used to analyze regional wall motion with high temporal resolution. PATIENTS AND METHODS: In 33 CHF pts with VCA (QRS width > or =140 ms) and 20 normal probands, left and right ventricular (RV) filling and emptying were analyzed by flow and tissue Doppler to assess regional (anterior, lateral, inferior, and septal) asynchrony within the LV as well as asynchrony between the RVand LV. All time measurements were corrected for a heart rate of 60 bpm. Results Maximum interventricular and segmental intraventricular delay was 30 ms in the normals. LV asynchrony, defined as a regional delay of > or =40 ms, was found in 29/33 (88%) of the CHF pts, in 4 cases there was synchronous LV contraction despite VCA. In the pts with LV asynchrony, 22 (67%) showed the maximum delay in the lateral wall, 7 (21%) in the septum. Inter- and intra-ventricular asynchrony correlated weakly. CONCLUSIONS: In many CHF pts with VCA, there is a delay both between the two ventricles, and among different LV regions. Predominantly but not exclusively, the LV lateral wall shows the maximum intra-LV delay. Some CHF pts, however, seem to have a synchronous LV contraction despite VCA. TDE thus adds important information for pt selection with respect to CRT.

Adult↗
PubMed2003

[Myocardial perfusion under H.E.L.P. -apheresis. Objectification by PET].

Due to endothelial dysfunction (ED), coronary vasodilation capacity is reduced in patients with hypercholesterolemia. Cholesterol lowering may largely restore endothelial function. Currently, it is supposed that the onset of this therapeutic effect takes weeks or even months. However, by means of LDL apheresis, a significant LDL reduction may be achieved within hours. Dynamic quantitative positron emission tomography (PET) performed before and after LDL apheresis showed that mean global myocardial perfusion can be measured at rest and after pharmacological vasodilation with dipyridamole using N13 ammonia as tracer.A total of 35 patients (11 women and 24 men) with documented coronary heart disease and hypercholesterolemia underwent PET immediately prior to LDL apheresis and 18-20 hours thereafter. In addition to the decrease in LDL cholesterol (from 175+/-50 to 77+/-25 mg/dl) and fibrinogen (from 287+/-75 to 155+/-52 mg/dl), a significant improvement of myocardial blood flow under dipyridamole (177+/-59 vs 217+/-82 ml/min 100 g, p<0.0001), of coronary flow reserve (2.10+/-0.82 vs 2.62+/-1.02, p<0.0001) and of minimal coronary resistance (0.56+/-0.20 vs 0.44+/-0.17 mmHg 100 g min/ml, p<0.0001) were achieved. Plasma viscosity decreased only by 7.8%. Within 20 hours after single LDL apheresis a 20% improvement of coronary vasodilation capacity was noninvasively demonstrated and quantified.

Anticoagulants↗
PubMed2003

[Heparin-induced extracorporeal LDL precipitation (H.E.L.P.)].

The H.E.L.P procedure (heparin-induced extracorporeal LDL precipitation) is a selective and sophisticated apheresis procedure. By means of heparin and lowering the pH level, lipoproteins and fibrinogen are reduced by 50-60%. In addition to lipoprotein (a) reduction (50- 60%) adhesion molecules (ICAM- 1, VCAM-1, P selectin), which play a major role in the development and progression of atherosclerosis, are significantly lowered. Within 20 hours after LDL apheresis, positron emission tomography was able to verify an improvement of coronary vasodilation capacity. This is likely to result from a considerable reduction of LDL cholesterol and fibrinogen with a consecutive improvement of both endothelial function and rheology.

Anticoagulants↗
PubMed2003

[H.E.L.P. apheresis and oxidative stress].

LDL apheresis according to the H.E.L.P. procedure is used to treat severe hypercholesterolemia in patients with coronary artery disease (CAD). It has been argued that either hypercholesterolemia or extracorporeal treatment may enhance oxidative stress. The balance between antiand pro-oxidative agents during H.E.L.P. apheresis was investigated by several groups. An increased resistance of LDL to oxidative modification after H.E.L.P. treatment is the leading result of these investigations.We studied the influence of a single H.E.L.P. apheresis on plasma concentrations of lipid peroxidation parameters in patients with heterozygous familiar hypercholesterolemia and advanced CAD enrolled in a chronic apheresis program once a week. Single H.E.L.P. apheresis reduced plasma concentrations of oxidized LDL and malondialdehyde without having an influence on cellular Cu/Zn superoxide dismutase (Cu/ZnSOD). The antioxidative serum capacity declined to some degree after apheresis whereas plasma concentration of 8-isoprostan- PGF2 alpha increased.In H.E.L.P. apheresis, the antioxidative effects prevail. Oxidation of lipids and severe modification of enzymatic and non-enzymatic antioxidants during extracorporeal circulation do not counterbalance the benefit of LDL reduction.

Anticoagulants↗
PubMed2002

[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↗
PubMed2002

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↗
PubMed2002

Coronary vein leads for cardiac pacing in patients with tricuspid valve replacement.

BACKGROUND: Because after tricuspid valve replacement (TVR) the transvenous implantation of endocardial leads is contraindicated, myocardial screw-in leads were used to ventricular pacing. Recently available coronary vein (CV) leads are stimulating the left ventricle epicardially and can be implanted transvenously, too. METHOD AND RESULTS: We implanted these leads in patients (pts) with TVR (n = 7) or after valve repair (n = 1) without complications. In 7 pts we used bended CV leads with a microporous tip and only in one pt a CV lead with a stimulation via metal ring. The stimulation thresholds (ST) were stable in all pts. CONCLUSIONS: The use of CV leads offers a minimal invasive approach for permanent cardiac stimulation after TVR. Low chronic ST are resulting in an energy saving pacemaker mode. CV leads can be used after previous heart surgery as well as for difficult anatomical situations.

Cardiac Pacing, Artificial↗
PubMed2001

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↗