[Cardiogenic shock. Therapy].
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Arrhythmias, Cardiac↗
Biomedical subjects
R Erbel
Publications and source records attributed to R Erbel.
[Thrombolytic therapy and balloon dilatation. The effect on infarct time, reperfusion and reocclusion].
127 patients, admitted within six hours of onset of symptoms of acute transmural myocardial infarction, received at first 250 000 U streptokinase intravenously over 20 min, followed by an intracoronary infusion of 250 000 U after coronary angiographic demonstration of the infarct vessel. Those in whom the infarct vessel was closed were randomized into two groups. An attempt at recanalization was made either by thrombolysis alone, through a specially developed 3F catheter (group I, 64 patients), or by thrombolysis and dilatation with 4F Grüntzig balloon catheter (group II, 63 patients). There was no significant difference between the two groups with regard to sex, age, infarct site, creatine-kinase level and interval between onset of symptoms and treatment. Re-perfusion rate for group I was 92% (59 patients), for group II 89% (56 patients). Re-occlusion during the hospital stay occurred in 10 of 59 patients in group I, in 9 of 55 in group II. Re-occlusion occurred in only 8% (3 patients) after successful dilatation, but in 35% (6 patients) after failed dilatation. In the subsequent six months further occlusions were observed in seven group I and two group II patients. Combined drug-mechanical recanalization thus increased the re-perfusion rate, shortened the infarction time and made possible full revascularization by subsequent dilatation which led to a reduction in the re-occlusion rate.
Aged↗
New balloon catheter for prolonged percutaneous transluminal coronary angioplasty and bypass flow in occluded vessels.
A new balloon catheter was developed for continuous perfusion of coronary arteries during angioplasty (CPC catheter). Steerable Grüntzig balloon catheters (3.7 mm) with two lumina were formed. The first lumen was used for balloon inflation. Side holes to the second lumen proximally and distally to the balloon were created for coronary perfusion even during inflation phase. At a perfusion pressure of 120 mmHg, a flow rate of 63 +/- 3 ml/min with 0.9% saline and 43 +/- 1 ml/min with plasma expander were measured. In experiments on five dogs, dilation time until appearance of signs of ischemia could be prolonged in three of five dogs from 30 to 40 s, 120 to 203 s, and 180 to 420 s comparing conventional and CPC balloon catheters. In 11 patients with proximal lesions, dilation time could be increased from 39.5 +/- 23.9 s to 81.1 +/- 36.3 s (p less than 0.01) until appearance of angina pectoris. ST segment changes were observed in 10/11 patients using conventional catheters. Using CPC catheters, no ST segment changes were observed in four patients; time until appearance of ST segment changes was delayed in the other seven patients. The CPC catheter seems to be an alternative catheter in proximal lesions of the left and right coronary artery, allowing the possibility of prolonged dilation and increased safety to the patient. In case of dissection or perforation, the CPC catheter can be used for perfusion of the distal part of the coronary vessel until emergency bypass surgery.
Adult↗
Detection of spontaneous echocardiographic contrast within the left atrium by transesophageal echocardiography: spontaneous echocardiographic contrast.
Transesophageal echocardiography was performed in 314 patients over a period of 24 months using a 3.5 MHz phased-array system fitted to the distal end of a conventional 12 mm endoscope. In 12 patients (2.6%) transesophageal echocardiography could not be performed because of adverse reaction to the gastroscopic procedure. Side effects were a transient A-V block in one patient and asthmatic attack in another. Mitral valve lesions were found in 99 of 314 patients. In 9 of these 99 patients (11%), including 1 patient with mitral valve stenosis and sinus rhythm, 2 with atrial fibrillation, 3 with disc, and 3 with porcine mitral prosthesis, spontaneous echocardiographic contrast was found within the left atrium, described as faint echoes in 2 patients and dense echoes filling the whole left atrium and following turbulent flow in the other 7 patients. Only in 2 patients was left atrium shown to have additional echoes within its cavity in the four-chamber view by transthoracic echocardiography. Signs of cerebral emboli were found in 5 of 9 patients and of peripheral embolism in 3 of 9 patients. Their mechanism seems to involve red cell aggregation, which is greatest at low flow velocity such as in dilated left atria in the case of mitral valve stenosis or prosthesis. The additional effect of platelet aggregation must be discussed because increased platelet aggregation was detected in all patients with spontaneous echocardiographic contrast. Transesophageal echocardiography seems to be of great diagnostic value in patients with mitral valve lesions and cerebral and peripheral embolism, giving new insight into the pathophysiologic mechanism and possibly improving the therapeutic approach in the near future.
Adult↗
Right ventricular volume determination in isolated human hearts.
For right ventricular volume determination a new method was developed that took into account right ventricular imaging by apical two-dimensional echocardiography in the four- and two-chamber views. Right ventricular volume was calculated by subtraction of the partial volume of the left ventricle and interventricular septum from the total heart volume of the right and left ventricles including the interventricular septum. Accuracy of the subtraction method was evaluated in isolated human hearts by two-dimensional echocardiography and radiography. Regression analysis indicated that for both the echocardiographic and radiologic procedures, the subtraction method gave the best correlation with the right ventricular filling volume. The correlation coefficients obtained using the echocardiographic procedure were 0.964, 0.848, and 0.851 for the subtraction method, pyramid method, and Simpson's rule method, respectively. For the radiographic procedure, these values were 0.946, 0.860, and 0.872. Percentage difference calculations indicated that the subtraction method systematically underestimated (-7.4%) the filling volume in the echocardiographic procedure, but this was not seen with the radiologic procedures. The random error associated with the subtraction method was only half (10.5%, 13.9%) of that seen with the other two methods in both the echocardiographic and radiological procedures. These results indicate that right ventricular volume determination by the subtraction method seems to be suitable for apical two-dimensional echocardiography and is more accurate than the pyramid method and Simpson's rule method.
Echocardiography↗
Percutaneous transluminal coronary angioplasty after thrombolytic therapy: a prospective controlled randomized trial.
In 162 patients with acute transmural myocardial infarction, combined intravenous and intracoronary thrombolytic therapy with streptokinase was initiated. In vessels that remained occluded, mechanical recanalization was performed with a 3F recanalization catheter (group I, n = 79) or a 4F Grüntzig balloon catheter (group II, n = 83). After reperfusion, intracoronary streptokinase was administered superselectively. After termination of streptokinase infusion, angioplasty was performed only in patients in group II. There was no difference between the groups in relation to sex, age, infarct location, creatine kinase levels and time between onset of symptoms and start of treatment. Initial coronary angiography showed an open vessel in 27 (34%) of 79 patients in group I and 21 (25%) of 83 patients in group II. The final reperfusion rate was 90% (71 of 79) in group I and 86% (71 of 83) in group II. Angioplasty was attempted in 69 of the 71 patients in group II with a success rate of 65% and an occlusion rate of 3%. During the hospital stay, reocclusion occurred in 14 (20%) of 71 patients in group I. After thrombolytic therapy, coronary luminal narrowing in group I was 75 +/- 17% in patients without and 87 +/- 6% in patients with reocclusion (p less than 0.05). In group II, reocclusion was found in 10 (14%) of 71 patients. After angioplasty, the degree of coronary stenosis in group II was reduced from 82 +/- 12 to 51 +/- 30% (p less than 0.001). Reocclusion was found in 3 (7%) of the 45 patients with successful angioplasty and in 7 (32%) of the 22 patients with unsuccessful angioplasty (p less than 0.01). Improvement in regional left ventricular function was observed only in patients from group II with anterior myocardial infarction. In conclusion, by combined medical and mechanical recanalization, the rate of coronary reperfusion can be increased and infarct time shortened, providing the possibility of full revascularization by angioplasty, with improvement of regional wall motion and reduction of the rate of reocclusion.
Adult↗
Stimulus-induced vulnerability in the early and late postinfarction phase.
In 45 survivors of myocardial infarction, cardiac catheterization was performed one and six months after the acute event. After completion of the angiographic investigation, ventricular vulnerability was assessed, using programmed right ventricular stimulation (rates 120 and 140 min-1, single and double premature impulses). In 27/45 patients the results of programmed electrical stimulation were comparable at one and six months. The overall incidence of repetitive ventricular response did not change. There was no correlation between the change of repetitive ventricular response and the change of effective right ventricular refractory period and the change of angiographic parameters (Gensini score, left ventricular ejection fraction and volume indices). It is concluded that between the first and the sixth month after infarction there is no relevant alteration in the propensity to repetitive ventricular response.
Adult↗
Balloon coronary angioplasty in patients with acute myocardial infarction.
After successful thrombolysis, approximately 75% of all patients will have significant coronary stenosis, which can be dilated by means of percutaneous transluminal balloon angioplasty (PTCA). In a randomized control study, 95 of our patients (Group I) had thrombolysis alone, whereas 95 others (Group II) had thrombolysis and PTCA. Both groups were comparable with respect to age, sex, infarct location, and maximal creatine kinase (CK) value. The clinical outcome during the hospital phase was better in Group II, which had a reocclusion rate of 13%, a reinfarction rate of 5%, a lethal reinfarction rate of 2%, and a cardiac death rate of 7%, compared with respective rates of 20%, 13%, 7%, and 13% in Group I. Furthermore, in Group I, residual coronary stenosis immediately after thrombolysis (75% +/- 20%) did not improve significantly until the end of the hospital phase, when it decreased to 69% +/- 21%. In Group II, stenosis (78% +/- 16%) was improved by PTCA to 33% +/- 21%, and this improvement remained constant during the hospital phase (30% +/- 26%). In Group-II patients who had an unsuccessful PTCA, stenosis was approximately the same before dilatation (83% +/- 12%), after dilatation (80% +/- 17%), and at the control study (83% +/- 17%). The end-diastolic, end-systolic, and stroke volume indices, as well as the ejection fraction, also remained unchanged. In Group I, the number of pathologic wall segments (12.2 +/- 5.0) did not improve during the hospital phase (12.2 +/- 7.9), but in Group II, the improvement was significant (14.0 +/- 5.7 vs. 10.9 +/- 8.2) (p < 0.05). PTCA seems to improve the clinical outcome, reduce the infarction and mortality rates, and enhance myocardial perfusion and performance.
Journal Article↗
[Combined use of thrombolysis and PTCA in myocardial infarct. Effect on global and regional ventricular function].
The study was performed to evaluate the combined effect of thrombolysis therapy and percutaneous coronary transluminal angioplasty (PTCA) on global and regional left ventricular function. In 127 patients with acute transmural myocardial infarction combined intravenous (250 000 U) and intracoronary (50 000 U) streptokinase therapy was started. When the infarct related vessel was occluded mechanical recanalization was performed with recanalization by Gruentzig balloon catheters. Patients were randomized in two groups, group I, n = 64, thrombolysis without PTCA; group II, n = 63, thrombolysis with PTCA. Both groups demonstrated no difference in relation to sex, age, infarct location, as well as CPK levels and time between onset of symptoms and start of treatment. First coronary angiography showed an open vessel in 23/64 patients (36%) of group I and in 12/63 patients (19%) of group II (p less than 0.001). Mechanical recanalization with 3 F catheters could be achieved in 27/41 patients (66%) of group I and with 4 F catheters in 26/51 patients (51%) of group II. In 9/41 patients (22%) of group I and in 18/51 patients (35%) in group II reperfusion took place before mechanical recanalization could be performed or occurred during superselective thrombolysis therapy, when mechanical recanalization failed. Thus, reperfusion rate in group I was 59/64 patients (92%) and in group II 56/63 patients (89%). PTCA was attempted in 55/56 patients in group II with a success rate of 65% and reocclusion rate of 4%. During hospital stay, reocclusion occurred in 10/59 patients in group I (17%) and in group II in 9/55 patients (16%). The patients were divided in those with and without successful angioplasty. Reocclusion was found in 3/36 patients (8%) and 6/17 patients (35%), respectively. Improvement with PTCA of regional and global left ventricular function was observed in patients with anterior myocardial infarction. With combined medical-mechanical recanalization, reperfusion rate can be increased and infarct time shortened, thus, providing the possibility of full revascularization by PTCA, improving coronary blood flow as well as improving global and regional left ventricular function.
Angioplasty, Balloon↗
Early and long-term exercise performance after percutaneous transluminal coronary angioplasty of the left anterior descending coronary artery.
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Adult↗
[Myocardial scintigraphy and nuclear ventriculography 6 months after acute myocardial infarct].
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Angioplasty, Balloon↗
[PTCA and intracoronary lysis in acute myocardial infarct].
In 76% of all patients in whom thrombolysis was successful a residual stenosis exceeding 75% luminal diameter was found. Some patients suffered from single, others from multi-vessel disease. In single vessel diseases immediate intracoronary balloon dilatation of the residual stenosis is feasible. In multi-vessel diseases an aortocoronary bypass operation may follow. In a non-randomized study of 411 patients treated successfully with thrombolysis the best prognosis during the hospital phase and the subsequent 12 months was found in those who had had bypass surgery; patients treated with PTCA had the next best prognosis, and those treated with medical therapy had the worst. In a randomized study 95 patients were treated with thrombolysis alone and another 95 patients with thrombolysis plus immediate PTCA. PTCA diminished the degree of stenosis significantly (78 +/- 16% vs. 33 +/- 21%; p less than 0.001). This value remained constant during the following four weeks (30 +/- 26%). The clinical course, segmental wall motion and myocardial perfusion were more favourable in the PTCA group. No differences were found regarding spontaneous and inducible ventricular electrical vulnerability. Immediate PTCA without prior thrombolysis was performed in 27 patients with overt cardiogenic shock. The clinical mortality was significantly lower than in comparative studies. Recanalisation was successful in 24 of 27 patients. PTCA is complementary to successful thrombolysis in acute myocardial infarction to improve the prognosis and myocardial perfusion.
Aged↗
Diagnosis and treatment of heart failure in different European countries: a young AEMIE questionnaire.
To compare diagnosis and treatment of heart failure among different European countries, an anonymous questionnaire was developed and sent to young AEMIE members all over Europe. 159 filled-in questionnaires were received: 30 p. 100 from France (F), 25 p. 100 from Great Britain (GB), 21 p. 100 from the Benelux countries (NL), 13 p. 100 from Italy (I) and 11 p. 100 from West-Germany (D). Baseline characteristics of the participating physicians (age, years of hospital training, available equipment, etc.) were comparable among the different countries. There was good agreement in the value of history, clinical examination, ECG and chest X-ray for the diagnosis of heart failure. In all countries breathlessness, basal crepitations and gallop rhythm were counted among the most important signs of left heart failure. Whereas the value of gated-blood-pool scanning and Holter monitoring as a first diagnostic approach was unanimously denied, the value of 2D-echocardiography in heart failure was discussed controversially: in I, F and D 50-80 p. 100 of the physicians thought echocardiography a first-hand diagnostic tool, whereas only 20-30 p. 100 of the physicians in GB and NL recommended echocardiography in the first place. Diuretics, sodium reduced diet and afterload reduction (in GB only) are the first therapeutic measures in GB, NL and F. However, in I and D digitalis is still the cornerstone of therapy (greater than or equal to 50 p. 100!). Physicians of all European countries with the exception of the physicians in D prefer pure digoxin as the first digitalis preparation.(ABSTRACT TRUNCATED AT 250 WORDS)
Adult↗
[Color Doppler echocardiography in emergency diagnosis of ventricular septal rupture after acute myocardial infarct].
A 58-year-old man developed a rupture of the interventricular septum after acute posterior myocardial infarction. The two-dimensional echocardiographic features of the ruptured interventricular septum included akinesia of posterior wall, hyperkinesia of the interventricular septum and anterior wall, inferior basal septum aneurysm and visualization of the ventricular septum defect. Injection of echocardiographic contrast (Gelatin solution) into the right atrium showed a small right-to-left shunt, injection into the left ventricle (during heart catheterization) demonstrated massive crossing of echocontrast similar to the results of cineventriculography of the left ventricle. By coloured Doppler-echocardiography the left-to-right shunt could directly be visualized, as well as a diastolic right-to-left shunt. By calculation of pressure gradient using adjusted continuous wave Doppler, estimation of right ventricular pressure was possible. The results demonstrated that colour Doppler in addition to two-dimensional echocardiography has an important diagnostic role in patients with complications of myocardial infarction.
Echocardiography↗
[Combination of color Doppler and transesophageal echocardiography in emergency diagnosis of type I aortic dissections].
We report on the use of colour Doppler- and transesophageal echocardiography in 2 patients with acute type I aortic dissection according to DeBakey. Using transesophageal echocardiography we obtained information on the extension and the entry site of the dissection without interfering with respiration and external thorax configuration. Using colour Doppler we were able to differentiate between the true and false lumen in the thoracic and abdominal aorta due to characteristic phasic flow patterns. In one patient the site of the entry tear of the intimal flap was localized by this method. Furthermore, a noninvasive semiquantitative evaluation of accompanying aortic regurgitation was possible. Colour Doppler gives additional information in the emergency diagnosis of patients with aortic dissection.
Adult↗
[18 years after a penetrating heart injury: follow-up].
This report presents a case of penetrating chest trauma leading to pericardial tamponade and ventricular septum defect successfully resuscitated by surgery in 1968 in an 11-year-old boy. 10 years later a first-size calcified hematoma was removed. However the 30% left to right intracardiac shunt flow as established by complete heart catheterization prior to surgery was not corrected. Non-invasive methods were used to assess cardiac function 18 years after the initial event including physical examination, chest X-ray, thoracic computer tomography, ECG, 24 h Holter monitoring and exercise testing, combined with myocardial scintigraphy and radionuclide angiography and echocardiographic techniques using the transthoracic and the transoesophageal approach. The diagnostic value of echocardiographic examinations is emphasized with special reference to contrast- and Doppler-echocardiography including the color-coded Doppler-flow-imaging technique.
Adult↗
Randomised trial of intravenous recombinant tissue-type plasminogen activator versus intravenous streptokinase in acute myocardial infarction. Report from the European Cooperative Study Group for Recombinant Tissue-type Plasminogen Activator.
In a single-blind randomised trial in patients with acute myocardial infarction of less than 6 h duration, the frequency of coronary patency was found to be higher after intravenous administration of recombinant human tissue-type plasminogen activator (rt-PA) than after intravenous streptokinase. 64 patients were allocated to 0.75 mg rt-PA/kg over 90 min, and the infarct-related coronary artery was patent in 70% of 61 assessable coronary angiograms taken 75-90 min after the start of infusion; 65 patients were allocated to 1 500 000 IU streptokinase over 60 min, and the infarct-related vessel was patent in 55% of 62 assessable angiograms. The 95% confidence interval of the differences ranges from +/- 30 to -2% (p = 0.054). Bleeding episodes and other complications were less common in the rt-PA patients than in the streptokinase group. Hospital mortality was identical in the 2 treatment groups. At the end of the rt-PA infusion the circulating fibrinogen level was 61 +/- 35% of the starting value, as measured by a coagulation-rate assay, and 69 +/- 25% as measured by sodium sulphite precipitation. After streptokinase infusion, corresponding fibrinogen levels were 12 +/- 18% and 20 +/- 11%. In the rt-PA group only 4.5% of the fibrinogen was measured as incoagulable fibrinogen degradation products, compared with 30% in the streptokinase group. Activation of the systemic fibrinolytic system was far less pronounced with rt-PA than with streptokinase.
Adult↗
[Intracoronary streptokinase in acute myocardial infarct. Experience with 461 patients].
Between March 1980 and July 1984, coronary angiography was performed on 461 consecutive patients (no age limit) with acute myocardial infarction, and the partially or completely obstructing thrombus lysed by selective intracoronary infusion of streptokinase. At the time of first coronary angiography 96 patients (21%) had a high degree of stenosis but no total occlusion of the infarct vessel (group A). In 365 patients (79%) there was complete occlusion which in 315 patients (86%) was removed successfully after an occlusion period of 213 +/- 87 minutes (group B). In 50 patients (14%) (group C) attempts at reperfusion failed. In 129 of 163 patients (79.1%) with one-vessel disease, PTCA (percutaneous transluminal coronary angioplasty) was successful. Patients with multiple-vessel disease and an occlusion time of less than four hours, on the other hand, were treated surgically within the first ten days (78 patients). In the remaining 254 patients conservative treatment was practised. Within the first 30 days there were seven deaths (14%) in group C, while among group A and B patients, under conservative treatment, 16 died (7.8%). After successful PTCA four patients (3.1%) died. The lowest mortality was among patients with a short occlusion time and early bypass operation (2.6%). The most frequent cause of death was cardiogenic shock (20 of 29 patients), more rarely ventricular fibrillation (3) or other causes (4). Ventricular rupture occurred in three patients, one of whom was saved by pericardial tap. One year later the mortality among the conservative group was 21.2%, after successful PTCA or bypass operation 9.3% and 6.4%, respectively.
Aged↗