Biomedical subjects

J von der Emde

Publications and source records attributed to J von der Emde.

At least 19 recordsLinked to original sources

PubMed1995

[Thrombolysis of modified Blalock-Taussig shunts in childhood with recombinant tissue-type plasminogen activator].

Since 1983, when c-DNA was isolated, recombinant tissue plasminogen activator (rtPA), an endothelial-cell-produced activator of fibrinolysis is used, more increasingly often in therapy of thrombosis. Whereas some studies have been published regarding efficacy and safety rtPA in different thrombotic states of adults, only case reports exist in children. Doses vary widely (0.8-6 mg/kg/d), bleeding complications are reported in up to 50%. We report on four infants with complex cyanotic congenital heart disease who developed an early post-operative thrombosis of a modified Blalock-Taussig shunt. By local low dosage application of rtPA we could achieve a complete lysis of the thrombus in three of our four patients. In one patient we were unsuccessful due to a distal stenosis of the shunt. This infant required repeat surgery with creation of a central aortopulmonary shunt. We saw severe bleeding in one, requiring transfusion of packed cells, and formation of a perigraft reaction in another patient. In our experience local application of rtPA in low doses is a good therapeutical option in patients with thrombosis of aorto-pulmonary shunts, especially in the first postoperative days.

Dose-Response Relationship, Drug↗

PubMed1994

Pericardectomy for chronic constrictive pericarditis: risks and outcome.

From 1970 to 1990, 71 consecutive patients (51 men and 20 women) had pericardectomy for chronic constrictive pericarditis. The mean age was 44.2 +/- 16.1 years. In the preoperative state 2.8% were in NYHA class I, 18.3% in II, 43.6% in III and 35.2% in IV. The operative approach was median sternotomy in 93% and left anterolateral thoracotomy in 7%. The early mortality rate (within 30 days after operation) was 5.6%. All four early deaths were female (P < 0.001), in the preoperative state the patients were classified as NYHA class IV (P < 0.01). These patients had a significantly higher preoperative mean right atrial pressure then survivors (21.5 +/- 8.5 mmHg vs 13.6 +/- 5.6 mmHg, P < 0.005). Follow-up was obtained for 65 patients (91.5%) and averaged 11 +/- 5.8 years (the longest period was 21.5 years). Actuarial survival at 5, 10, 15 and 20 years for all patients was 84.6% +/- 4.5%, 80.1% +/- 5.3%, 70.5% +/- 6.9% and 65.8% +/- 7.9%, respectively. In the preoperative state 10 of the 12 late deaths (83%) were classified NYHA class IV and the remaining ones class III. Of the 49 patients alive 23% belong to NYHA class I, 42% to II and 35% to III; none is in class IV. Negative predictors of survival were found to be preoperative NYHA class IV (P < 0.01), low-voltage electrocardiogram (ECG) (P < 0.01), ascites (P < 0.01), dyspnea at rest (P < 0.05) and hyperbilirubinemia (P < 0.05).(ABSTRACT TRUNCATED AT 250 WORDS)

Adult↗

PubMed1994

R peak time prolongation and R peak delay in leads I, V5, or V6. Diagnostic values as signs of myocardial dysfunction in chronic mitral incompetence.

On the assumption that maximum R peak time prolongation in the left-sided leads I, V5, or V6 and its time relationship to the S peak time of the maximum S amplitude in leads V1, V2, or V3 (representing dorsally directed forces of ventricular depolarization) could indicate the extent of left ventricular volume overloading and possibly left ventricular systolic function, these variables and the preoperative findings of angiocardiography were compared between patients with chronic mitral incompetence who, late after corrective valve surgery, had either well-preserved radionuclide left ventricular ejection fraction (group 1, n = 36) or radionuclide left ventricular ejection fraction below 50% (group 2, n = 30). Before surgery, group 2 patients had a highly significant lower mean left ventricular ejection fraction, a highly significant greater mean end-systolic volume index, a significantly greater mean end-diastolic volume index, a significantly greater mean maximum R peak time in leads I, V5, or V6, and a significantly greater prolongation of the maximum R peak time above the S peak time in the right precordial leads, as compared with group 1. R peak times greater than 50 ms or the presence of R peak delay (maximum R peak time greater than the S peak time of the maximum right precordial S amplitude) yields less sensitive but highly reliable results in predicting radionuclide left ventricular ejection fraction below 50% with both specificity and positive predictive values of 100%. Thus, in chronic mitral regurgitation surgery should not be delayed if patients present these signs because they are specific markers of irreversibly impaired chamber function.

Aortic Valve↗

PubMed1994

[Aorto-left ventricular tunnel with origin in the left sinus of Valsalva: a rare cause of congenital aortic insufficiency].

Aortico-left-ventricular tunnel is a rare congenital cardiac lesion that often results in severe aortic insufficiency in infancy. Normally, the defect appears immediately above the right coronary sinus of Valsalva and consists of a tunnel-like connection between the aortic root and the left ventricle. The differential diagnosis to coronary artery fistulae and ruptured aneurysms of the sinus of Valsalva is often difficult. We describe a patient with an aortico-left-ventricular tunnel originating from the left aortic sinus. Similar findings have been described in only three case reports. Additionally, in our case there was a stenosis in the midportion of the tunnel which was connected to an intraseptal aneurysm communicating with the left ventricular chamber via a "septal" defect. The infant underwent successful surgical correction of this malformation at 1 year and 5 months of age.

Angiocardiography↗

PubMed1994

[Effect of intravenous glucose versus glucose-xylose (1:1) administration on carbohydrate and lipid metabolism after trauma and during infection].

OBJECTIVE: To detect the effects of glucose-xylitol infusion versus glucose infusion alone on carbohydrate and lipid metabolism in postoperative stress and during sepsis. DESIGN: Prospective randomized study (study I after cardiac surgery) and intraindividual cross-over control study (study II in septic patients), respectively. SETTING: Intensive care unit of a university hospital. PATIENTS: 18 patients after aortocoronary bypass (ACVB) and 5 patients with sepsis. INTERVENTIONS: In study I during the first 24 postoperative hours one group (K I, n = 6) received glucose only (2 mg/kg BW/min), a second group (K II, n = 6) a mixture of glucose and xylitol (1:1; 2 mg/kg BW/min) and a third group (K III, n = 6) a glucose-containing electrolyte solution (0.8 mg/kg BW/min). Glucose, lactate, insulin and free fatty acid concentrations were measured pre- and postoperatively in 6-hour intervals over 36 h. In study II patients were firstly given 4 mg glucose/kg BW/min over 6 h, then infusion was changed to a 1:1 glucose-xylitol mixture (4 mg/kg BW/min) for another 6 h. Hepatic glucose production, palmitate oxidation rates and lactate concentrations were determined at the end of both infusion regimens. RESULTS: Glucose and insulin concentrations were significantly lower in K II and K III than in K I. The highest lactate values were observed 6 h postoperatively in K I. Concentrations of all fatty acids were lower in K I than in K II and K III during the infusion periods. In study II the glucose production and lactate values were significantly reduced during xylitol infusion, whereas palmitate oxidation rates were significantly increased when the infusion regimen changed from glucose to glucose-xylitol mixture. CONCLUSIONS: These data indicate that energetically ineffective high glucose concentrations were avoided and lactate production was diminished by infusion of glucose-xylitol in study I. In addition, xylitol achieved a higher endogenous release and oxidative utilisation of free fatty acids representing important fuel substrates after trauma and during sepsis.

Adult↗

PubMed1993

Electrocardiographic characteristics indicating a risk of irreversibly impaired myocardial function in chronic aortic regurgitation.

In order to define which of selected ECG variables could indicate irreversibly impaired myocardial function in chronic aortic regurgitation 54 patients were stratified according to normal (> or = 50%; Group A, n = 41) or subnormal radionuclide left ventricular ejection fraction (LVEF < 50%; Group B, n = 13) late after aortic valve replacement. Preoperatively, Group B patients had a significantly greater QRS duration, greater R-peak time (RPT) prolongation in I, V5 or V6, greater RPT relative to the S-peak time of the maximum S in V1, V2 or V3 (R-peak delay) and a greater negative T-wave in I or V6, as compared with Group A. These ECG variables together with preoperative angiocardiographic LVEF and end-systolic volume index were subjected to stepwise linear discriminant analysis. The maximum RPT, angio-LVEF and the maximum RPT relative to the S-peak time of the maximum S in V1, V2 or V3 emerged as the most promising variables. Of of Group A patients 82.9% and 84.6% of Group B patients were correctly classified by the three variables. If applied separately, APT prolongation or the presence of the R-peak delay in the left-sided leads, although less sensitive, have reasonably high specificity as risk indicators of irreversibly impaired chamber function, their positive predictive value being 60 and 62.5%, respectively. In conjunction with preoperative LVEF the diagnostic contribution of the two ECG variables amounts to the greatest overall separation of postoperatively preserved from irreversibly impaired systolic function.

Aortic Valve Insufficiency↗

PubMed1993

Surgical removal of a lipoma of the heart.

In a 29-year-old woman echocardiography revealed a tumour originating from the anterior wall of the right ventricle. Noninvasive findings aroused suspicion of a lipoma. The tumour was removed under cardiopulmonary bypass, the resulting defect in the right ventricular wall being covered with a Goretex patch. Histological examination classified the tumour as a rhabdomyolipoma.

Adult↗

PubMed1993

Total cavopulmonary anastomosis: selection criteria related to postoperative results.

In this study we review our experience with total cavopulmonary anastomosis (modified Fontan procedure) which was performed in 31 patients. One patient died from postoperative cardiac low-output syndrome, the other died from a neurological complication (early mortality 6.5%). During a mean follow-up period of 15 months there was no late mortality. Preoperative assessment showed that one, two, or three of the Choussat criteria (defining the ideal Fontan candidate) were not fulfilled by 39%, 16% and 6% of our patients. In the 2 patients who died 2 and 3 of those criteria were not fulfilled. Poor outcome could not be predicted based on assessment of the pulmonary artery size (expressed as the McGoon-ratio or the Nakata-index) alone. In order to assess the relationship of pulmonary artery size and pulmonary arteriolar resistance (PVR) as a predictor of outcome, we introduced two new indices (McGoon-ratio/PVR and Nakata-index/PVR). The patient who died from poor postoperative hemodynamics had the lowest values of all patients. Among the 29 survivors we did not observe significant acquired postoperative arrhythmias. In our experience the total cavopulmonary anastomosis can be performed with a low mortality and good postoperative results. Patients who do not fulfill at least 8 of the Choussat criteria and children with a low ratio of pulmonary artery size to PVR are high-risk patients. In these children we recommend either a bidirectional Glenn anastomosis as a first-step procedure or a total cavopulmonary anastomosis with a fenestration of the intraatrial tunnel.

Adolescent↗

PubMed1993

The influence of age and other risk factors on the results of coronary reoperation.

In a retrospective analysis of 115 patients who underwent a coronary reoperation between 1984 and 1989, we studied the influence of age and other risk factors on the perioperative morbidity and mortality and on the long-term results. The mean age of the population was 59.4 years, 55 patients were below 60, 52 between 60 and 70 and 8 patients over 70 years, respectively. The distribution of risk factors was similar to other populations suffering from coronary heart disease. The mean time between first and second coronary operation was 7.1 years. Complete revascularisation at the reoperation could be achieved in only 20.9% (n = 24) of the patients. A mean of 1.9 vein grafts were implanted. The perioperative mortality (within 30 days) was 5.2% (n = 6) for the whole group, whereas the highest mortality rate could be observed in the patients aged over 70 with 25% (n = 2). The incidence of perioperative complications was also higher in the elderly patients, comparing them to the whole group. Mean follow-up time was 39 months. During follow up 14 patients (12.4%) died, most of the deaths were cardiac related. The cumulative survival rate was 91% after one, 90% after three, and 88% after five years. We found no statistically significant differences in the survival rates and the myocardial infarction rates regarding the different age groups. The exercise capacity and functional status at the time of follow up were quite acceptable.(ABSTRACT TRUNCATED AT 250 WORDS)

Actuarial Analysis↗

PubMed1993

[Recurrent myxoma].

In a now 53-year-old woman, who suffered from recurrent syncope and dizziness, a biatrial myxoma originating from the interatrial septum was resected nearly 4 years ago, and the resulting septal defect was closed by a Dacron patch. In the symptomless patient the recurrent myxoma was revealed by echocardiography. The left atrial myxoma was surgically removed without repeat heart catheterization. This case underlines the importance of regular, echocardiographic follow-up examinations in patients in whom a myxoma has been excised. In case of suspicious findings, an additional transesophageal examination or nuclear magnetic resonance imaging should be performed.

Echocardiography↗

PubMed1992

[Carbohydrate and lipid metabolism following heart bypass operations. The effect of the intravenous hypocaloric administration of glucose versus glucose xylitol (1:1)].

The effect of glucose-xylitol infusion on carbohydrate and lipid metabolism was investigated in 18 metabolically normal men (mean age 56.1 [35-65] years) with coronary heart disease after they had undergone a coronary artery bypass operation. During the first postoperative hours, group I (n = 6) received glucose only (2 mg/kg.min), group II (n = 6) glucose+xylitol (1 mg/kg.min each), and group II a glucose-containing electrolyte solution (0.83 mg/kg.min glucose). Blood glucose and insulin concentrations during the infusion period were significantly (P < 0.05) lower in groups II and III than I (glucose after 6 h: group I 21.5 [15.3-26.8] mmol/l; group II 14.2 [11.2-18.1] mmol/l; group III 12.6 [6.8-16.0] mmol/l). The highest lactate concentrations were reached in group I, 6 hours after the operation. Palmitine and stearine, as well as oleic and linoleic acid concentrations were significantly lower 12 hours postoperatively in group I than groups II and III (P < 0.05). These data indicate that energy-ineffective high glucose concentrations were avoided and endogenous lactate production reduced by the postoperative infusion of glucose+xylitol. In addition, it achieved a higher supply of free fatty acids as energy source to the myocardium without reaching toxic concentrations in the postischaemic myocardium.

Adult↗

PubMed1992

Is epicardial dual chamber pacing a realistic alternative to endocardial DDD pacing? Initial results of a prospective study.

Seventeen patients, in whom an epicardial (n = 7) or a transvenous DDDM pacemaker system had been implanted between June 1988 and October 1990, were followed up for pacemaker and lead related complications, pacemaker longevity, and electrophysiological lead parameters. The mean follow-up interval was 18 +/- 12 months, maximum 34 months. There were no differences in chronic atrial and ventricular sensing thresholds between epicardial and endocardial stimulation, nor were there any differences concerning lead related complications between the two pacing modalities. However, atrial as well as ventricular chronic stimulation thresholds were significantly higher with epicardial stimulation resulting in a twofold increase in atrial energy consumption and a threefold increase in the ventricular energy consumption. Thus, in one patient with an epicardial DDD system, the pacemaker had to be replaced prematurely because of battery depletion. It is concluded that epicardial DDD stimulation can be reliably performed as far as atrial and ventricular sensing is concerned, but that the energy requirements of available myocardial leads are not satisfactory for making optimal use of modern pacemaker capability.

Adult↗

PubMed1991

[Cardiac surgery interventions in patients over 70 years of age].

In consequence of a longer life expectancy and improved surgical results, patients aged over 70 years now account for 10 to 15% of patients undergoing surgery on the heart. Such patients do, however, make greater demands on peri-operative management; the adaptability of the cardiopulmonary and renal functions to stress is reduced, homeostasis is fragile, and the diseases that commonly accompany old age represent an additional risk. Furthermore, greater demands are also made on the operating skills of the surgeon. Nevertheless, no patient should be considered inoperable merely on account of advanced age. However, the indications for surgery must always be established on an individual basis, and against the background of the expected risk/benefit ratio. The biological rather than the chronological age is always decisive. The main aim of surgical treatment is to achieve an improvement in the patient's quality of life.

Aged↗

PubMed1991

Brachial plexus lesions following median sternotomy in cardiac surgery.

The incidence of neurological deficits of the upper extremity was studied in a prospective trial on 201 consecutive patients who underwent median sternotomy at cardiac surgery. In 13 patients (6.5%), a brachial plexus paresis was diagnosed postoperatively. We were unable to demonstrate any statistically significant correlation between brachial plexus paresis and the side of arm placement, the side of cannulation of the jugular vein, the duration of operation, the bypass time, sex, or type of operation. All patients who suffered from neurological deficit were aged 50 years and more, however without any statistically significant correlation. In our opinion, brachial plexus lesions following median sternotomy in cardiac surgery depend on the extent of sternal spread and the height of placement of the retractor in dependence of the rigidity of the rib cage. By reason of the iatrogenic cause of brachial plexus lesions, it appears to us that these complications should be included in those of which the patient needs to be informed preoperatively.

Brachial Plexus↗

PubMed1991

Role of the electrocardiogram in assessing irreversibly impaired left ventricular systolic function in chronic mitral regurgitation.

The study set out to determine whether the electrocardiogram (ECG) might be useful in assessing left ventricular (LV) volumes and systolic function in patients with pure, chronic mitral regurgitation. To do this preoperative haemodynamic and angiocardiographic data, QRS duration, total 12-lead QRS amplitude, R peak time in V6, R peak delay in V6 (RPDV6) (i.e. the R peak in V6 is later than the S peak in V2) and a T wave score assigned to the extent of LV strain were evaluated. Twenty-seven out of 62 patients were subjected to stepwise discriminant multivariate analysis. Radionuclide (RN) LV ejection fraction (EF) was obtained postoperatively; RPDV6, gender, LVEF and LV end-diastolic volume index (EDVI) were selected in decreasing order of discriminatory importance to identify 13 (81.3%) of 16 patients with RNEF greater than or equal to 50% and 10 (90.9%) of 11 with RNEF less than 50% at rest. Preoperatively, 18 subjects with RPDV6 had a significantly greater end-systolic volume index (ESVI) (75.6 +/- 37.8 ml.m-2 versus 50.7 +/- 31.5 ml.m-2, P = 0.003), greater EDVI (196.9 +/- 73.4 ml.m-2 versus 155.2 +/- 48.5 ml.m-2, P = 0.034) and lower LVEF (61.1 +/- 11.9% versus 68.8 +/- 12.7%, P = 0.014) compared to 44 cases without this finding. With respect to postoperative RNEF, eight subjects with RPDV6 had a significantly lower EF compared to 19 cases without this finding (40.1 +/- 8.2% versus 56.0 +/- 9.9%, P = 0.001).(ABSTRACT TRUNCATED AT 250 WORDS)

Adolescent↗

PubMed1990

Thromboembolic and bleeding complications after mitral valve replacement.

One thousand six hundred and sixty-eight consecutive patients who underwent isolated mitral valve replacement (MVR) from 1963 to 1984 were evaluated retrospectively. Thromboembolism occurred with a linearised rate of 2.5% +/- 0.2%/patient-year (PY) for Starr-Edwards disc prosthesis Model 6520, 2.4% +/- 0.3%/PY for Bjørk-Shiley plane prosthesis, 3.0% +/- 0.8%/PY for Bjørk-Shiley convexo-concave 60 degrees prosthesis, 3.0% +/- 0.8%/PY for St. Jude Medical prosthesis and 3.4% +/- 0.5%/PY for Carpentier-Edwards tissue valve without the differences reaching significance. In the SJM group, the incidence of thromboembolism was significantly higher (P less than 0.025) in smaller sizes (less than M29) probably due to a more turbulent flow. The linearised rate for major haemorrhage was 1.6% +/- 0.1%/PY. Twenty-three percent of the thromboembolic and 18% of the bleeding events were fatal. Sixty-eight percent of the emboli involved the central nervous system and bleeding apart from fatalities was predominantly non-cerebral (81%). Whereas thromboembolism was a time-related event with more than twice as high a risk in the first postoperative year (4.2% +/- 0.5% vs. 1.7% +/- 0.8%, P less than 0.01), bleeding occurred with a constant rate over time (0.9% +/- 0.4%). Adequacy of anticoagulation was an important risk factor for postoperative embolism with the prothrombin time (PT) exceeding the therapeutic range in 65% of all events. A preoperative history of embolism was the only additional patient-related risk factor for postoperative embolism (18.3% vs. 9.6%, P less than 0.001). In 30% of all haemorrhage, the PT was below 15%.(ABSTRACT TRUNCATED AT 250 WORDS)

Adolescent↗

PubMed1990

[20 years surgery of the thoracic aorta].

Between 1969 and 1990, 119 patients underwent operations for aneurysmatic disease of the thoracic aorta in our department: 63 patients suffered from an aneurysm of the ascending aorta, 32 from an acute dissection (26 Type A, 6 Type B), 2 from an isolated aneurysm of the arch, 10 from an aneurysm of the descending aorta and 12 had a traumatic rupture of the aorta. The death rate due to operations for aneurysms of the thoracic aorta and acute type A dissections was clearly lowered. In case of an acute type A dissection emergency intervention is indicated; in acute type B dissection primarily conservative treatment.

Aortic Dissection↗

PubMed1989

R peak delay in V6. Diagnostic implications in coronary heart disease.

Epimyocardial excitation is delayed in areas overlying infarcted myocardium. On the assumption that a delayed R peak in V6 could indicate anterior myocardial infarction (AMI) in the absence of diagnostic Q waves, the findings of angiocardiography (n = 148) and thallium scanning (n = 46) of 194 patients with suspected coronary heart disease (CHD) were compared with regard to two criteria: A (R peak in V6 precedes S peak in V2, or both peaks occur simultaneously, n = 158) and B (R peak in V6 is later than S peak in V2 [R peak delay in V6], n = 36). Of 92 patients with unconfirmed CHD, 4 fit criterion B, and 3 of these had hypertensive heart disease. In 102 patients with confirmed CHD, B was present in 15 of 79 evaluated with angiocardiography and in 17 of 23 patients who had nuclear scanning. Anterior akinesis or dyskinesis was more prevalent in group B (13 cases, 86%) than in group A (17 cases, 26.6%; p = 0.000), as were irreversible anterior thallium defects, with 16 cases in group B (94.1% and 3 cases in group A (50%) (p = 0.016). Two of the three false positives had anterior hypokinesis and one had hypertensive cardiovascular disease. B was less sensitive (59.2%) but demonstrated a specificity of 95.2% and a positive predictive value of 80.6% for the detection of AMI. If used in conjunction with C (poor or reverse R wave progression from V1 to V4, notching at the R upstroke or rsR' in V4, V5, or V6), sensitivity was decreased (38.6%) but false positives were eliminated (specificity and positive predictive value reached 100%). Thus, in the setting of CHD, B can be recommended as a marker of non-Q wave AMI, and its diagnostic reliability is maintained, even in systemic arterial hypertension, if C is taken into consideration.

Adolescent↗