Detachable balloon technique for transvenous closure of patent ductus arteriosus.
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Ductus Arteriosus, Patent↗
Biomedical subjects
G Kober
Publications and source records attributed to G Kober.
[Long-term antihypertensive effect of delayed-action molsidomine].
The long-term antihypertensive efficacy of molsidomine 8 mg bid was studied in 24 patients with coronary artery disease in a double-blind, placebo-controlled trial of 3 weeks duration. Ambulatory 24-h blood pressure measurements were performed at days 1, 2, 7, 14, and 21. Sphygmomanometric measurements of blood pressure heart rate and a protocol for number and time of angina pectoris attacks were also taken. Following the application of molsidomine a reduction of mean 24-h systolic blood pressure of 14% and of mean diastolic blood pressure of 11% was observed. The duration of the blood-pressure-lowering action was 7 h. After 3 weeks of treatment with 8 mg molsidomine sr bid a persistent and significant reduction of systolic and diastolic blood pressure was found. A similar acute and long-term effect was found by manually measured blood pressures. Heart rate was unchanged under molsidomine while the frequency of angina pectoris was diminished. In conclusion, a long-lasting antihypertensive efficacy (without signs of tolerance) was found over a 3-week period of treatment with 8 mg molsidomine in a slow-release formulation given twice a day.
Blood Pressure↗
[Reopening of chronic coronary occlusions--initial references for prognostic indications].
Today indication for percutaneous transluminal coronary angioplasty is based on typical chest pain and objective signs of myocardial ischemia during exercise. Especially in chronic coronary occlusions, however, prognostic implications may play an increasing role in the future. The case report describes long-term follow-up of a patient in whom a chronic complete occlusion of the right coronary artery could be reopened successfully back in September 1988. At this time, the peripheral part of the occluded RCA was filled retrogradely by septal collaterals from the LAD. After reopening the patient remained symptom-free for more than two years. In January 1991 again severe angina recurred and ECG showed a non-transmural anterior myocardial infarction. The LAD was occluded proximal and the peripheral part was filled retrogradely by septal collaterals coming from the right coronary artery which was still open (flow reversal). Left ventricular function was only slightly impaired and the LAD occlusion could be reopened successfully too. The case suggests that prognostic implications should be taken into consideration in addition to symptoms especially in complete coronary occlusions.
Aged↗
[Angiography follow-up after transluminal angioplasty of coronary bypass grafts].
Between January 1979 and October 1991, percutaneous transluminal angioplasty of stenosed or occluded coronary bypass grafts was attempted 180 times in 146 patients (180 lesions in 157 bypass grafts); 6/157 grafts were internal mammary grafts. The procedure was successful in 129/157 grafts (82%) and in 151/180 lesions (84%). Failures occurred almost exclusively in recanalization attempts. Cardiac complications occurred in 4/146 patients (2.7%). Three patients developed an acute myocardial infarction, another patient died after acute occlusion of a native vessel dilated during the same procedure. In successful attempts the severity of stenosis was reduced from 87 +/- 10% to 33 +/- 15%. 113/129 successfully dilated grafts had at least one (mean 2.7) control angiogram. 54/113 (48%) showed recurrence after a mean follow up of 6 months. An additional 15 grafts showed late restenosis in a second control angiogram (mean follow-up 23 months). The total restenosis rate was 61%. Restenoses were dilated again one to six times (mean 1.9) with comparable success and recurrence rate. Two patients died during the sixth angioplasty. Finally, 32/129 (25%) grafts were occluded or presumably occluded, and 97/129 (75%) were angiographically confirmed open without restenosis. Thus, angioplasty of bypass grafts is an alternative to a repeat revascularization surgery. The acute results are comparable to the results of angioplasty in native coronary arteries. The restenosis rate is high. One has to be aware of late restenosis. Restenosis can be dilated repeatedly with a comparable success rate and with no significant increase in restenosis rate.
Adult↗
Angiographic predictors of recurrence of restenosis after Wiktor stent implantation in native coronary arteries.
Intracoronary stenting has been proposed as an adjunct to balloon angioplasty to improve the immediate and long-term results. However, late luminal narrowing has been reported following the implantation of a variety of stents. One of the studies conducted with the Wiktor stent is a prospective registry designed to evaluate the feasibility, safety and efficacy of elective stent implantation in patients with documented restenosis of a native coronary artery. To identify angiographic variables predicting recurrence of restenosis, the angiograms of the first 91 patients with successful stent implantation and without clinical evidence of (sub)acute thrombotic stent occlusion were analyzed with the Computer Assisted Angiographic Analysis System using automated edge detection. The incidence of restenosis was 44% by patient and 45% by stent according to the 0.72 mm criterion, and 30% by patient and 29% by stent according to the 50% diameter stenosis criterion. The risk for restenosis for several angiographic variables was determined using an univariate analysis and is expressed as odds ratio with corresponding confidence interval. The only statistically significant predictor of restenosis was the relative gain when it exceeded 0.48 using the 0.72 mm criterion (odds ratio 2.7, 95% confidence interval 1.1-6.4). Furthermore, the relation between the relative gain (increase in minimal luminal diameter normalized to vessel size) as angiographic index of vessel wall injury and relative loss (decrease in minimal luminal diameter normalized to vessel size) as index of neointimal thickening was analyzed using a linear regression analysis. When using the categorical approach to address restenosis, there is an increased risk for recurrent restenosis when the relative gain exceeds 0.48. The continuous approach underscores this concept by indicating a weak but positive relation between the relative gain and relative loss.
Aged↗
[Effect of cardiovascular disorders on traffic fitness].
BASIC REMARKS: The large number of cardiovascular diseases affecting in particular the elderly represents a potential traffic hazard. MAJOR Points discussed: The significance of various cardiovascular diseases on a person's fitness to drive is presented with particular attention being paid to coronary heart disease. Our present knowledge about cardiovascular disease as a cause of accidents is extremely modest, and expert recommendations are often unrealistic and impractical. The risk of a disease leading to unfitness to drive decreases with increasing quality of medical management and treatment. The particular responsibility of the physician is, however, instruction and counselling, and especially the choice of proper treatment. CONCLUSION: In view of a deterioration in critical faculties and in the ability to compensate for loss of performance, due in particular to the multimorbidity commonly met with in old age, a general examination of the geriatric for fitness to drive is worth considering.
Accidents, Traffic↗
Effect of balloon valvuloplasty for mitral stenosis on right ventricular function.
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Adult↗
Coronary anomalies: incidence and importance.
Most patients with coronary anomalies are asymptomatic. The knowledge of those variations could be important in regard to invasive catheter treatment or bypass surgery. In a retrospective study, the angiographic findings based on 4,016 patients (1985-1989) were analyzed concerning coronary anomalies and malformations. Of the patients studied, 39 (0.97%) had coronary anomalies, and in 26 of these patients it was an anomalous circumflex branch. In 14 cases, the circumflex branch arose from a separate origin in the left aortic sinus. In 11 patients the origin was from the proximal segment of the right coronary artery. A singular coronary artery was found in five patients, originating from the right aortic sinus in two patients and from the left aortic sinus in three patients. An origin of the left coronary artery from the pulmonary artery, a coronary fistula, or an origin of the left anterior descending coronary artery from the RCA could be found in only one patient. Unexpected findings during invasive procedures would suggest a possibly existing coronary anomaly, especially when main branches cannot be opacified by selective contrast medium injection.
Cardiac Catheterization↗
SIN-1 has no direct myocardial anti-ischemic action.
Anti-ischemic drugs may develop their cardiac activity via peripheral (reduction in preload and/or afterload) or cardiac (coronary vasculature, myocardial cell metabolism) effects. The aim of the study was to investigate whether SIN-1, the active metabolite of molsidomine, develops a direct myocardial anti-ischemic property. Three groups of seven patients each were treated with 0.4 mg SIN-1 administered via either the intracoronary (IC) or intravenous (IV) route, or with placebo in a double-blind randomized investigation. SIN-1 had no influence on either the ischemic parameters in the surface electrocardiogram (ECG) or the intracoronary ECG. There was also no change in peripheral or central hemodynamics or in the severity of angina following this low IC or IV dosage. There is no evidence of a direct myocardial anti-ischemic response of SIN-1. The well known anti-ischemic activity of SIN-1 or molsidomine has to be attributed to the proven peripheral and cardiac vascular responses.
Angioplasty, Balloon, Coronary↗
Myocardial cytoprotection during percutaneous transluminal coronary angioplasty.
Transluminal coronary angioplasty (PTCA) is a well defined controlled model inducing regional myocardial ischaemia in man. Direct cardiac anti-ischaemic effects of anti-anginal drugs can be assessed by intracoronary injection of small doses which do not affect systemic parameters. Trimetazidine (TMZ) has recently been shown to improve anginal symptoms without modifying haemodynamic variables. A randomized, double-blind, placebo-controlled trial was conducted in 20 patients to study the effects of TMZ on the severity of myocardial ischaemia during PTCA of the left anterior descending coronary artery. Five minutes after a first successful dilation (D0), a control balloon inflation (D1) was performed until onset of ischaemic signs on both the intracoronary (i.c.) and precordial ECG. Two minutes later, patients received either trimetazidine 6 mg or placebo i.c. Another inflation (D2) was performed 5 min after D1. No differences were found between the two groups regarding responses in heart rate, systemic and i.c. pressures during the study. TMZ decreased maximum ST segment shift at D2 as compared to D1 (0.8 +/- 0.1 vs 1.4 +/- 0.3 mV, P = 0.023) and delayed its onset (46 +/- 4 vs 36 +/- 5 s, P = 0.024). TMZ also decreased maximum T wave changes (1.06 +/- 0.24 vs 2.19 +/- 0.3 mV, P = 0.001), and significantly reduced the area under the curve (AUC:mV.s-1) of the i.c. ST segment and T wave changes during balloon inflation (P = 0.002 and P < 0.001 respectively). Placebo had no effect on any of these parameters.(ABSTRACT TRUNCATED AT 250 WORDS)
Angioplasty, Balloon, Coronary↗
Effects of nitrendipine and lisinopril on blood pressure and sodium excretion in ciclosporin-associated hypertension after heart transplantation.
Hypertension associated with ciclosporin A may be mediated by sodium and volume retention. Therefore, the effects of an antihypertensive therapy (6 weeks) with nitrendipine (10-20 mg twice daily) or lisinopril (10-20 mg once daily) on office blood pressure, 24-hour ambulatory blood pressure, and left ventricular function were evaluated in a randomised, double-blind cross-over trial in patients after heart transplantation. Nitrendipine and lisinopril were equally effective in lowering office and ambulatory systolic and diastolic blood pressures. After an acute sodium load (210 mval/2 h i.v.), sodium excretion was significantly increased during therapy with lisinopril but only slightly during nitrendipine, indicating that angiotensin-converting enzyme inhibition may improve the sodium-retaining state of heart transplant recipients associated with ciclosporin A.
Adult↗
Effects of exercise or temporary coronary occlusion during angioplasty on right ventricular function with consideration of left-anterior-descending- and right-coronary-artery-related myocardial ischemia.
Whether exercise causes right ventricular ischemia severe enough to depress right ventricular function is still controversial. Therefore, right ventricular function was evaluated in 44 patients with isolated coronary artery disease of either the proximal left anterior descending or right coronary artery during exercise (n = 22) or balloon occlusion during percutaneous transluminal coronary angioplasty (PTCA) (n = 22). Central hemodynamics and right ventricular volumes were determined using a new thermodilution Swan-Ganz catheter. Exercise increased right ventricular end-diastolic volume index [from 89 (66-127) to 101 (70-130) ml m-2, p = 0.00005; median (range)] and stroke volume index [from 44 (27-68) to 53 (36-75) ml m-2, p = 0.0005]. During PTCA, right ventricular end-diastolic volume index remained unchanged, while stroke volume index decreased from 49 (38-60) to 40 (26-49) ml m-2 (p = 0.00005). The decrease in right ventricular ejection fraction during exercise from 56 (41-64) to 52% (39-64) reached only borderline significance (p = 0.06) and was significantly (p = 0.02) smaller than during angioplasty [from 53 (44-62) to 41% (25-66; p = 0.0008)]. Right ventricular ejection fraction did not differ between left anterior descending or right coronary artery obstruction and did not depend on right ventricular afterload. In comparison to exercise angioplasty caused a decreased systolic pressure-volume ratio and a leftward shift of the diastolic pressure-volume curve. In conclusion, exercise has only little effect on right ventricular ejection fraction, whereas inadequate oxygen supply during balloon angioplasty induces severe depression of right ventricular function.
Adult↗
[Single coronary artery with branching of the right coronary artery from the left atrioventricular ramus of the circumflex artery. Incidence and significance].
In a series of 8500 consecutive coronary angiographies, we found three times an "anatomic single coronary artery" with origin of the right coronary artery from the AV-branch of the dominant circumflex artery (incidence 0.035%). In all three patients the investigation was made because of the suspicion of coronary heart disease. All 59 previously published cases (44 found at coronary angiography, 15 at necropsy) and our own three cases were not associated with other cardiovascular anomalies. A pathophysiological significance of this anomaly alone with regard to inducing myocardial ischemia can almost be excluded. The knowledge of this anomaly however is important to avoid errors in diagnosis and to evaluate the exact degree of severity of coronary heart disease.
Aged↗
[Right ventricular function in patients with rheumatic mitral valve stenosis. Effect of balloon mitral valvuloplasty].
UNLABELLED: Postrheumatic mitral stenosis might cause impairment of right ventricular (RV) function due to both an increase in RV afterload and rheumatic myocardial disease. Therefore, we investigated in 19 patients with postrheumatic mitral stenosis and sinus rhythm right ventricular volumes and hemodynamics by a computerized thermodilution catheter during rest and supine bicycle exercise. In 14 patients the investigation was repeated within 2 days after balloon mitral valvuloplasty. Resting RV ejection fraction was decreased (43 (15-53)%, median (range)) and correlated significantly with RV end-systolic volume index (r = -0.90), stroke volume index (r = 0.77), RV end-diastolic volume index (r = -0.76), heart rate (r = -0.69), pulmonary artery resistance (r = -0.69), and mean pulmonary artery pressure (r = -0.68). RV end-diastolic volume index was 107 (81-200) ml/m2. Exercise induced a decrease of RV ejection fraction to 36 (13-48)% at 50 Watt (p < 0.001), while it increased RV end-diastolic volume index to 131 (78-231) ml/m2 (p < 0.001). Balloon mitral valvuloplasty improved RV ejection fraction at rest from 41 (15-47)% to 48 (39-55)% (p < 0.005) and from 30 (13-46)% to 43 (27-56)% during exercise (p < 0.005). The increase of RV ejection fraction after valvuloplasty was caused by an increase in stroke volume, but not by a reduction in RV end-diastolic volume. CONCLUSION: Depending on the increased RV afterload, RV function is markedly depressed in mitral stenosis. An immediate and almost complete improvement of RV function occurs with the reduction of RV afterload after balloon mitral valvuloplasty.(ABSTRACT TRUNCATED AT 250 WORDS)
Adult↗
[Heart volume determination as an indication of rejection after orthotopic heart transplantation].
Endomyocardial biopsy in cardiac transplantation is still the most exact test (gold standard) to confirm or exclude a suspected rejection. Up to now, all available noninvasive tests suffer from a low sensitivity and specificity. For a further reduction of biopsies early available noninvasive methods are desirable. In the data presented a comparison between histological findings and heart volume measurements is shown in 40 patients (112 histological findings) after orthotopic cardiac transplantation. In 46 cases with no evidence of histological rejection the echocardiographically or radiologically determined heart volume was 869 +/- 142 ml/1.73 m2 body surface area, compared to 1026 +/- 178 ml/1.73 m2 in 29 cases with mild cardiac rejection. In 37 cases with a moderate or severe rejection heart volume as 1094 +/- 181 ml/1.73 m2. The diagnosis of a moderate or severe rejection by biopsy is combined with a heart volume above 950 ml/1.73 m2 with a sensitivity of 78% and a specificity of 73%. Intramyocardial edema as well as an increase in right and left ventricular volumes due to heart failure may be the causes for heart volume increase in rejection. Thus, heart volume measurement which can be performed easily during routine echocardiography gives additional information about whether a rejection has to be assumed or can be excluded. Today, sensitivity and specificity of the test does not allow a reduction of biopsy frequency. Further investigations are necessary to analyze the course of heart volume changes during an episode of rejection.
Biopsy↗
Wiktor stent implantation in patients with restenosis following balloon angioplasty of a native coronary artery.
Intracoronary stenting has been introduced as an adjunct to balloon angioplasty aimed at overcoming its limitations, namely acute vessel closure and late restenosis. This study reports the first experience with the Wiktor stent implanted in the first 50 consecutive patients. All patients had restenosis of a native coronary artery lesion after prior balloon angioplasty. The target coronary artery was the left anterior descending artery in 26 patients, the circumflex artery in 7 patients and the right coronary artery in 17 patients. The implantation success rate was 98% (49 of 50 patients). There were no procedural deaths. Acute or subacute thrombotic stent occlusion occurred in 5 patients (10%). All 5 patients sustained a nonfatal acute myocardial infarction. Four of these patients underwent recanalization by means of balloon angioplasty; the remaining patient was referred for bypass surgery. A major bleeding complication occurred in 11 patients (22%): groin bleeding necessitating blood transfusion in 6, gastrointestinal bleeding in 3 and hematuria in 2. Repeat angiography was performed at a mean of 5.6 +/- 1.1 months in all but 1 patient undergoing implantation. Restenosis, defined by a reduction of greater than or equal to 0.72 mm in the minimal luminal diameter or a change in diameter stenosis from less than to greater than or equal to 50%, occurred in 20 (45%) and 13 (29%) patients, respectively. In this first experience, the easiness and high technical success rate of Wiktor stent implantation are overshadowed by a high incidence of subacute stent occlusion and bleeding complications.(ABSTRACT TRUNCATED AT 250 WORDS)
Angioplasty, Balloon, Coronary↗
Long-term follow-up after percutaneous transluminal coronary angioplasty in patients with single-vessel disease.
Seven hundred ninety-eight patients with symptomatic single-vessel disease who underwent percutaneous transluminal coronary angioplasty (PTCA) between 1977 and 1985 were reevaluated by questionnaire 78 +/- 23 months after dilatation. Indication for PTCA was stenosis of > or = 70%, anginal symptoms, and objective signs of myocardial ischemia. The immediate success rate was 81.2%, and severe complications occurred in 7.1%, which included two fatal complications (0.3%). Repeat angiograms were performed in 582 of 648 patients who underwent successful dilatation and showed restenosis in 143 cases (24.6%). Within 1 year after the first dilatation, 586 patients had been successfully revascularized by PTCA (i.e., there was no evidence of restenosis or redilatation was successful), and 113 patients had undergone bypass surgery. The remaining 99 patients were treated medically if PTCA was unsuccessful or if restenosis (> or = 70%) that was not amenable to redilatation was present. The 8-year overall survival probability was 91.7%, and cardiac survival was 95.5%. The 8-year event-free survival probability was 52.7% for all patients: 62.5% in patients who had successful PTCA and 14.5% in patients who had unsuccessful PTCA (p = 0.0000). The cardiac survival probabilities of patients with lasting PTCA success at 1 year and of surgically treated patients were significantly better than those of patients who did not have successful revascularization (at 8 years 97.2% and 98.1% vs 88.9%; p < 0.04). Late events (> or = 1 year) occurred more often in patients who did not have successful revascularization compared with patients who had successful PTCA (at 8 years 57.9% were event-free vs 74.4%; p < 0.0001); even fewer late events were observed in surgically treated patients (at 8 years 88.2% were event-free; p < 0.004). Cox's proportional hazards regression analysis revealed left ventricular ejection fraction and revascularization status at 1 year as determinants of overall, cardiac, infarct-free, and event-free survival probabilities. At the time of reevaluation significantly more patients in the successful PTCA subgroup were still free of symptoms or had experienced improvement than patients in the bypass or medical subgroups (86.8% vs 68.9% and 59.5%, respectively; p < 0.0001), and more patients in the successful PTCA subgroup were still working (75.4% vs 53.3% and 56.9%, respectively; p < 0.001). We concluded that patients with single-vessel disease who have undergone successful dilatation have an excellent long-term prognosis with regard to survival, cardiac symptoms, and vocational status.(ABSTRACT TRUNCATED AT 400 WORDS)
Adult↗
Myocardial protection during percutaneous transluminal coronary angioplasty: effects of trimetazidine.
Trimetazidine (TMZ) has recently been shown to improve anginal symptoms without altering haemodynamic variables. A randomized, double-blind, placebo-controlled study was conducted in 20 patients to study the effects of TMZ on the severity of myocardial ischaemia during PTCA of the left anterior descending coronary artery. Five minutes after a first successful dilatation (D0), a control balloon inflation (D1) was performed until onset of ischaemic signs on both the intracoronary (i.c.) and precordial ECG. Two minutes later, patients received either TMZ 6 mg or placebo i.c. Another inflation (D2) was performed 5 min after D1. No differences were found between the two groups regarding responses in heart rate, systemic and i.c. pressures during the study. TMZ decreased the maximum ST-segment shift at D2 compared with D1 (0.8 +/- 0.1 vs 1.4 +/- 0.3 mV, P = 0.023) and delayed its onset (46 +/- 4 vs 36 +/- 5 s, P = 0.024). TMZ also decreased maximum T-wave changes (1.06 +/- 0.24 vs 2.19 +/- 0.3 mV, P = 0.001), and significantly reduced the area under the curve (mv s-1) of the i.c. ST-segment and T-wave changes during balloon inflation (P = 0.042 and P = 0.009 respectively). The placebo had no effect on these parameters. These results support the hypothesis that trimetazidine has a direct anti-ischaemic effect on human myocardial cells.
Angioplasty, Balloon, Coronary↗