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Biomedical subjects

F A Flachskampf

Publications and source records attributed to F A Flachskampf.

At least 19 recordsLinked to original sources
PubMed2002

Initial experience with the Endicor X-sizer thrombectomy device in patients with ST segment elevation myocardial infarction.

We investigated 16 patients with ST segment elevation myocardial infarction who had an occluded coronary artery (TIMI 0) at initial angiogram. Instead of balloon angioplasty and stenting, patients were subjected to thrombectomy (Endicor X-sizer) and stenting. In 15/16 patients the occlusion could be crossed by the thrombectomy device resulting in TIMI flow 3 in all of them. Thereafter, stenting was performed. At final angiogram all 15 patients continued to show TIMI flow grade 3. Twelve-lead ECG was performed prior to and post-intervention. ST elevation was measured as the sum of eight leads for anterior infarction and of five leads for inferior infarction. In 13/15 patients, ECG analysis was possible (2 developed bundle branch block post-intervention). In all 13 patients, a > 50% ST decrease of the initial amount of ST elevation was observed reaching a > 70% reduction in 11 patients. Procedural complications were low (one coronary dissection after thrombectomy) and 30 days follow-up was uneventful. Thrombectomy using the Endicor X-Sizer device may become an attractive mechanical reperfusion strategy for patients with acute myocardial infarction.

Aged↗
PubMed2002

[Why controlled studies may lead to misleading and unconfirmed therapeutic concepts--a critical view of evidence-based medicine].

The concept of evidence-based medicine has gathered widespread support during recent years. While this concept has clear merits in compiling and qualifying up-to-date information for clinical decisions, it should be viewed with caution as the sole valid knowledge source for clinical decision-making. The limitations of such an approach are particularly striking when reviewing two key developments in modern cardiology, fibrinolysis and acute percutaneous intervention in acute myocardial infarction. In both cases, early studies and meta-analyses showed no benefit for these therapeutic interventions over earlier treatment. Only after further refinement (mainly in dosage, time window, concomitant heparin therapy for fibrinolysis, and the introduction of stents and IIb/IIIa inhibitors for acute intervention) did these therapies become universally acknowledged. It is therefore crucial to understand that especially for physicians actively participating in the development of a clinical field clinical decisions cannot be exclusively based on published evidence. Another important problem to consider is the time gap between the emergence of new therapies and the publication and reception by the medical audience, in particular in rapidly evolving fields as cardiology. While it is clear that clinical decision-making must be backed by solid knowledge of the published evidence, in particular the specialist involved in-depth in the field may use not yet proven therapeutic concepts and measures to the patient's advantage.

Angioplasty, Balloon, Coronary↗
PubMed2002

[Role of glycoprotein IIb/IIIa inhibitors in the treatment of degenerated aortocoronary saphenous vein grafts].

Treatment of degenerated vein grafts is a large, growing portion of interventional procedures. Because the operative risk of repeat bypass surgery is substantially increased, percutaneous transluminal coronary angioplasty has been accepted as a less invasive treatment in symptomatic patients with significant stenoses of vein grafts. Stent placement has been established in the randomized SAVED trial as a safe and efficient treatment strategy of degenerated saphenous vein grafts, enhancing acute success, reducing the incidence of subsequent angiographic restenosis, and improving event-free survival. Despite coronary stents and new technological innovations like directional and transluminal extraction atherectomy distal embolization is still a frequent occurrence, with a reported incidence of 10-15% associated with an increased in-hospital mortality. Blockade of the platelet surface glycoprotein IIb/IIIa receptors has been convincingly demonstrated to reduce the ischemic complications of angioplasty in native coronary arteries. In degenerated vein grafts the efficacy of glycoprotein IIb/IIIa inhibitors in reducing distal embolization is uncertain. Major clinical events could not be reduced by glycoprotein IIb/IIIa antagonists administered periprocedurally. But prospective randomized trials are lacking. Protection devices could reduce the incidence of distal embolization during interventions in degenerated saphenous vein grafts. The relative role of these devices compared to pharmacologic interventions will require careful assessment in future clinical trials.

Abciximab↗
PubMed2001

Stent-supported recanalization of chronic iliac artery occlusions.

PURPOSE: Iliac artery occlusions that are more than a few centimeters in length are normally treated with surgical bypass grafting. The aim of this study was to evaluate the results of primary stent implantation after Excimer laser-assisted recanalization of iliac artery occlusions. SUBJECTS AND METHODS: We studied 212 consecutive patients with chronic unilateral iliac artery occlusions (mean [+/- SD] length 8.9 +/- 3.9 cm) who were treated with Excimer laser-assisted recanalization and stent implantation. Based on the criteria of the Society of Cardiovascular and Interventional Radiology, lesions were graded as class III occlusions (<5 cm) in 46 patients and as class IV (> or =5 cm) in 166 patients. A total of 527 stents (Palmaz stent, 346; Wallstent, 94; Strecker stent, 38; covered stents, 49) were implanted. RESULTS: Technical success was achieved in 190 (90%) patients. There was a clinical improvement of three grades in 112 (53%) patients and of two grades in 67 (32%) patients. The rate of major complications was 1.4%, which included arterial rupture (1) and embolic events (2). Primary patency rates were 84% at 1 year, 81% at 2 years, 78% at 3 years, and 76% at 4 years. Secondary patency rates were 88% at 1 year, 88% at 2 years, 86% at 3 years, and 85% at 4 years. CONCLUSION: Stent-supported angioplasty is an effective treatment for iliac artery occlusions, with less morbidity and mortality than is associated with surgery. However, reported long-term patency rates after bypass surgery are greater than those we observed with interventional treatment. The value of primary stenting as compared with angioplasty alone should be evaluated in a randomized trial.

Arterial Occlusive Diseases↗
PubMed2001

Shu 508 A (Levovist)-enhanced Doppler echocardiography improves the assessment of valvular heart disease.

OBJECTIVE: To investigate whether intravenous injection of SHU 508 A improves the diagnostic accuracy of Doppler echocardiography in the assessment of valvular pathologies. METHODS AND RESULTS: One hundred and twenty-five consecutive patients with valvular pathology (aortic stenosis, n = 48; aortic regurgitation, n = 20; mitral stenosis, n = 21; and mitral regurgitation, n = 36) and diagnostically insufficient Doppler signal were enrolled in this multicenter study. The severity of valvular pathology was graded on a four-point scale using unenhanced and contrast-enhanced Doppler echocardiography as well as cardiac catheterization. Agreement with cardiac catheterization findings increased from 63% using the unenhanced examination to 73% using the contrast-enhanced Doppler examination. Grading was possible in all patients using SHU 508 A, whereas the unenhanced Doppler examination remained inconclusive in six patients. The weighted kappa coefficient between contrast-enhanced Doppler and cardiac catheterization for all diagnoses was 0.76 as compared to 0.68 between unenhanced Doppler and cardiac catheterization. Agreement was especially improved in aortic stenosis (kappa 0.69 unenhanced vs 0.81 contrast-enhanced) and in aortic regurgitation (kappa 0.45 unenhanced vs 0.75 contrast-enhanced). Patients with mitral stenosis and mitral regurgitation experienced less improvement. CONCLUSIONS: In case of an inconclusive unenhanced Doppler echo study, the administration of a left heart contrast agent should be considered. SHU 508 A is especially useful in improving the severity grading of aortic stenosis and aortic regurgitation, while grading of mitral stenosis and mitral regurgitation is less improved.

Adult↗
PubMed2001

Native tissue second harmonic imaging improves endocardial and epicardial border definition in dobutamine stress echocardiography.

AIMS: Native tissue second harmonic imaging (SHI) implemented in two-dimensional (2D) echocardiography was found to improve left ventricular (LV) endocardial border delineation. Dobutamine stress echocardiography (DSE) depends on the ability to adequately visualize these borders. We analysed whether SHI, compared to fundamental imaging (FI), can improve echogenicity qualitatively and quantitatively, as well as looking at the diagnostic accuracy of the stress test. METHODS AND RESULTS: Fifty consecutive patients with suspected or known coronary artery disease (history of myocardial infarction and/or coronary artery bypass grafting) underwent DSE sequentially by SHI as well as FI 3 days before or after quantitative coronary angiography. Regional mean echogenicity scores (0=uninterpretable; 4=excellent imaging) for SHI and FI at peak dobutamine titration were 1.8 +/- 0.8 and 1.0 +/- 0.6 (P=0.0020) for the anterior region, 2.3 +/- 0.8 and 1.5 +/- 0.7 (P=0.0002) laterally, 2.7 +/- 1.0 and 1.9 +/- 0.8 (P=0.0001) posteriorly, 2.9 +/- 0.8 and 2.2 +/- 0.7 (P<0.0006) inferiorly, 3.0 +/-0.7 and 2.2 +/- 0.7 (P=0.0001) septally, and 3.1 +/- 1.0 and 2.1 +/-0.8 (P=0.0001) anteroseptally, respectively. Medians [upper; lower quartiles] of a global endocardial visualization index (calculated analogously with the wall motion score index based on a 16-segment model recommended by the American Society of Echocardiography) for the harmonic and the fundamental techniques were 2.59 [2.91; 2.22] and 1.87 [2.19; 1.53] (P=0.0001) at rest, 2.62 [2.94; 2.13] and 1.84 [2.19; 1.50] (P=0.0001) at low dose dobutamine, 2.51 [3.00; 2.13] and 1.74 [2.00; 1.44] (P=0.0001) at peak dose dobutamine, and 2.52 [2.94; 2.19] and 1.76 [2.19; 1.38] (P=0.0001) at recovery, respectively. For repeated quantitative LV volumetry in the harmonic and fundamental modality by the same observer, coefficients of variation were 4.4 +/- 0.4 vs. 6.0 +/- 0.5 (P<0.0001) for end-diastolic volume, 7.4 +/- 0.8 vs. 9.2 +/- 1.1 (P<0.0001) for end-systolic volume, and 5.2 +/- 1.1 vs. 8.2 +/- 1.3 (P<0.0001) for ejection fraction, respectively. Sensitivity and specificity related to coronary angiography for both methods were 80% and 60% as well as 90% and 93%, respectively. CONCLUSION: Native tissue SHI enhances LV image quality in all stress stages of DSE in unselected patients. This translates into beneficial effects on not only qualitative but also quantitative testing and diagnostic accuracy. SHI should be recommended as a standard tool in DSE and extends its applicability to difficult-to-image patients previously deemed unsuitable.

Adult↗
PubMed2001

Evaluation of septal hypertrophy and systolic function in diseases that cause left ventricular hypertrophy: a 3-dimensional echocardiography study.

OBJECTIVES: The goals of this study were to determine regional systolic function of the septum and to relate it to regional wall thickness and wall stress. BACKGROUND: Wall thickening, a parameter of systolic function, is determined by wall thickness and wall stress. In patients with hypertrophic obstructive cardiomyopathy (HOCM), hypertrophic nonobstructive cardiomyopathy (HNCM), and hypertensive heart disease (HHD), regional systolic function of normal and hypertrophic septal regions has been incompletely characterized by 2-dimensional echocardiography. Thus, multiplane transesophageal echocardiography with 3-dimensional reconstruction of the septum was used. METHODS AND RESULTS: In 49 patients (15 controls, 11 with HOCM, 8 with HNCM, and 15 with HHD) 4 parallel (2 basal and 2 apical) equidistant short-axis cross sections from base to apex were obtained from the reconstructed septum. In each short-axis cross section, 6 wall-thickness measurements were made in 15 degrees intervals at end diastole and end systole, for a total of 48 measurements in each patient. Fractional thickening was calculated as wall thickening divided by end-diastolic wall thickness. Wall thickness of the basal cross sections was significantly thicker (P < .001) in HOCM and HNCM than in HHD. However, circumferential wall thickness was more evenly distributed in HNCM and HHD when compared with HOCM. In the basal cross sections, fractional thickening was similarly reduced in all hearts, though basal wall stress was significantly different in all groups (P < .001). In the apical cross sections, wall thickness was similar in all diseased hearts, but fractional thickening was better (P < .001) and wall stress lower (P < .001) in HNCM than in HOCM and HHD. CONCLUSIONS: In septal regions without or with only mild hypertrophy, regional systolic function is preserved and appears to be determined by hemodynamic factors such as wall stress. However, in regions with moderate to severe hypertrophy, systolic function is markedly and uniformly impaired in all groups, which seems not to be caused by differences in wall thickness and wall stress but by the degree of the myocardial disease process.

Cardiomyopathy, Hypertrophic↗
PubMed2000

[Mitral valve prolapse].

Mitral valve prolapse has previously been found to be associated with severe cardiovascular complications such as embolic insults, infectious endocarditis, and sudden cardiac death. However, at the same time, in particular after adopting M-mode and 2D echo for diagnosis, prevalence of the disease was found to be very high, especially in the young. The dilemma of a disease which is frequent and mostly asymptomatic, but in some cases has catastrophic complications, has been solved by implementation of more restrictive diagnostic criteria based on an appreciation of the spatial morphology of the mitral annulus. These criteria call for diagnosis exclusively based on long axis views and a prolapse of > 2 mm beyond a line connecting the leaflet insertion points. "Classic prolapse" additionally requires diastolic thickness of the mitral leaflets of at least 5 mm. Two recent studies, a population-based study of mitral valve prolapse prevalence, and a case-control study of juvenile stroke patients compared to a group of young patients without a history of stroke, shed further light on this disease. The authors found that prevalence of mitral valve prolapse in an average population is 2-3% (1.3% for classic prolapse), without age or sex preponderance; the rate of cerebrovascular insults, congestive heart failure, and atrial fibrillation of patients with prolapse does not exceed that of the rest of the population; however, mitral insufficiency is more frequent; young patients with a history of cerebrovascular insult do not have higher mitral valve prolapse rates than young patients without previous insult.

Cross-Sectional Studies↗
PubMed2000

[3D echocardiography].

Three-dimensional echocardiography has been realized in two different technical approaches: first as reconstruction of previously acquired multiple two-dimensional cross-sections, and recently as real-time 3D echo. Both approaches allow one to measure quantitative parameters of cardiac structures, such as mass and volume, with an accuracy far superior to 2D echo and equal to nuclear magnetic resonance techniques. However, such measurements are labor and time intensive. Other spatially complex cardiac structures such as valves, atrial and ventricular septal defects, or dynamic outflow tract obstruction in hypertrophic obstructive cardiomyopathy can be assessed adequately in both qualitative and quantitative fashion. Furthermore, the advent of real-time 3D echo with its ability to gather the full 3D data set within seconds promises to widen the potential applications of 3D echo, for example, including stress echo.

Cardiac Volume↗
PubMed2000

[Assessment of myocardial vitality with dobutamine echocardiography: current review].

Myocardial stunning (contractile dysfunction in the presence of normalized perfusion) and myocardial hibernation (contractile dysfunction matching reduced perfusion) have represented separate concepts of viable, but dyssynergic myocardium in the past. However, in vivo experimental and clinical work suggests that repetitive ischemia due to coronary artery disease may induce a gradual transition between stunned and hibernating myocardium. Myocardial hibernation itself can result from a spectrum of ischemic conditions ranging from impaired myocardial blood flow reserve to frank hypoperfusion. With increasing severity and duration of ischemia, degeneration of cardiac myocytes, accumulation of glycogen and cell death ensue. Additionally, there is an increase of extracellular matrix protein content leading to reparative fibrosis, which in turn limits functional recovery. In the light of these structural features, the available methods for detection of viable myocardium, in particular dobutamine echocardiography and nuclear imaging techniques, offer complementary rather than contradictory information. Dobutamine echo has satisfactory sensitivity, excellent specificity, and high diagnostic accuracy for the detection of viable dyssynergic myocardium. While in the past only its predictive accuracy for segmental recovery has been validated, newer data show an improved survival after revascularization if at least four viable dyssynergic left ventricular segments in a 16 segment model can be identified by dobutamine echocardiography. The complete (low and high dose) dobutamine protocol can elicit several types of contractile responses (sustained improvement in contraction or monophasic response, biphasic response, new wall motion abnormality) which should be interpreted in view of other clinical data including a previous infarction. The test protocol can be used safely at the end of the first week after myocardial infarction. If ischemia or viability is documented, revascularization should be performed promptly. A similar strategy should be followed in the setting of chronic coronary heart disease with left ventricular dysfunction. Since the structural changes of hibernating myocardium are progressive, time to revascularization is critical. On the other hand, responsible therapeutic planning requires proof of ischemia or viability before initiating a potentially hazardous revascularization procedure.

Cardiotonic Agents↗
PubMed2000

Aortic dissection.

Aortic dissection is a life-threatening cardiovascular emergency requiring immediate diagnosis and treatment. It is mainly associated with hypertension and the Marfan syndrome. Diagnosis has been revolutionized by the use of transesophageal echocardiography (TEE), which allows for rapid and safe assessment of this condition. Echocardiographic hallmarks of aortic dissection ar the presence of a dissection membrane separating a true from a false lumen, rupture sites in the membrane with to-and-from flow, aortic regurgitation, and pericardial effusion. Dissection of the ascending aorta, which has an extremely high mortality and necessitates emergency surgery, is diagnosed quickly and accurately by TEE.

Aortic Dissection↗
PubMed2000

Analysis of shape and motion of the mitral annulus in subjects with and without cardiomyopathy by echocardiographic 3-dimensional reconstruction.

The shape and dynamics of the mitral annulus of 10 patients without heart disease (controls), 3 patients with dilated cardiomyopathy, and 5 patients with hypertrophic obstructive cardiomyopathy and normal systolic function were analyzed by transesophageal echocardiography and 3-dimensional reconstruction. Mitral annular orifice area, apico-basal motion of the annulus, and nonplanarity were calculated over time. Annular area was largest in end diastole and smallest in end systole. Mean areas were 11.8 +/- 2.5 cm(2) (controls), 15.2 +/- 4.2 cm(2) (dilated cardiomyopathy), and 10.2 +/- 2.4 cm(2) (hypertrophic cardiomyopathy) (P = not significant). After correction for body surface, annuli from patients with normal left ventricular function were smaller than annuli from patients with dilated cardiomyopathy (5.9 +/- 1.2 cm(2)/m(2) vs 7.7 +/- 1.0 cm(2)/m(2); P <.02). The change in area during the cardiac cycle showed significant differences: 23.8% +/- 5.1% (controls), 13.2% +/- 2.3% (dilated cardiomyopathy), and 32.4% +/- 7.6% (hypertrophic cardiomyopathy) (P <.001). Apico-basal motion was highest in controls, followed by those with hypertrophic obstructive and dilated cardiomyopathy (1.0 +/- 0.3 cm, 0.8 +/- 0.2 cm, 0.3 +/- 0.2 cm, respectively; P <.01). Visual inspection and Fourier analysis showed a consistent pattern of anteroseptal and posterolateral elevations of the annulus toward the left atrium. In conclusion, although area changes and apico-basal motion of the mitral annulus strongly depend on left ventricular systolic function, nonplanarity is a structural feature preserved throughout the cardiac cycle in all three groups.

Adult↗
PubMed2000

Transesophageal echocardiography: first-line imaging for aortic diseases.

Transesophageal echocardiography (TEE) is now commonly used to evaluate the thoracic aorta, because it is widely available and provides high-resolution images and flow information by Doppler. This article reviews the essential features on TEE of acute and chronic aortic diseases, such as aortic dissection, aneurysm, and atherosclerosis, and discusses its strengths, weaknesses, and indications.

Aortic Dissection↗
PubMed1999

Transesophageal echocardiography diagnosis of intramural hematoma of the ascending aorta: A word of caution.

The diagnosis of intramural hematoma by echocardiography classically requires the presence of an echolucent, crescentic region in the wall of the aorta. Recently we have encountered 2 patients in whom intramural hematoma was characterized only by thickening of the aortic wall, which was circumferential in one patient, thus making the diagnosis difficult to distinguish from common atherosclerotic thickening of the aorta. In one case, computed tomography showed more clearly the abnormal tissue signature of the intramural blood. In summary, absence of an echolucent zone does not exclude the diagnosis of intramural hematoma. Alternative imaging procedures such as computed tomography and magnetic resonance imaging may enhance the diagnostic accuracy.

Aged↗
PubMed1998

Standardized guidelines for the interpretation of dobutamine echocardiography reduce interinstitutional variance in interpretation.

Subjective interpretation of dobutamine echocardiograms provides only moderate interinstitutional observer agreement if nonunified data acquisition and assessment criteria are applied. The present study was undertaken to evaluate parameters associated with low interinstitutional observer agreement in the interpretation of dobutamine echocardiograms and to analyze whether standardized interpretation criteria improve interinstitutional observer agreement. One hundred fifty dobutamine echocardiograms (dobutamine up to 40 microg/kg/min body weight and atropine up to 1 mg) were evaluated at 5 centers. Clinical, procedural, and echocardiographic parameters were included in the analysis of variables with significant impact on interinstitutional agreement. Standardized interpretative criteria were established, and 90 dobutamine echocardiograms were reanalyzed by 3 observers using a standardized image display. Multivariate analysis demonstrated low image quality (odds ratio [OR] 0.19, 95% confidence interval [CI] 0.08 to 0.45, p=0.0002), low severity of induced wall motion abnormality (OR 0.17, 95% CI 0.07 to 0.40, p <0.0001), and a low peak rate-pressure product (OR 0.93, 95% CI 0.43 to 2.27, p=0.0382) to result in a low interinstitutional agreement. Standardization of image display in cine loop format and of dobutamine stress echo interpretation criteria resulted in improvement in test result categorization as normal or abnormal, with a kappa value of 0.50, compared with 0.39 using the original subjective interpretation. In conclusion, image quality, the severity of induced wall motion abnormalities, and the obtained rate-pressure product have a significant impact on the interpretation homogeneity of dobutamine echocardiograms. Standardization of image display in cine loop format and of reading criteria results in improved interinstitutional agreement in interpretation of stress echocardiograms.

Adult↗