Sudden cardiac death while wearing a Holter monitor

The Holter tapes of 61 patients (46 men, mean age +/- standard deviation 65 +/- 11 years) with sudden cardiac death while being monitored were analyzed. Thirty-eight patients were known to have coronary artery disease, 5 had cardiomyopathy, and 7 had aortic valve disease. Etiology remained unknown in 11 patients. Mean New York Heart Association functional class was 2.5 +/- 0.7. Thirty patients had received antiarrhythmic drugs and 32 had received digitalis. Sudden death occurred at rest in 73%. In the hours before death, repetitive ventricular arrhythmias were found in 50 patients (82%), with atrial fibrillation in 34%. Patients with bradyarrhythmic death (18%) had less complex ventricular …

Aktuelle Komplikationsrate der perkutanen transluminalen Koronarangioplastie bei stabiler und unstabiler Angina

During a four-year period (1983-1986) percutaneous transluminal coronary angioplasty (PTCA) was performed on 930 patients with stable or unstable angina with a mortality rate of 0.4%. A transmural myocardial infarct developed in 1.1% and 1.0% of patients required an urgent aorto-coronary bypass. Thus the total rate of severe cardiac complications was 2.5%. Compared with the years 1983-1985, there was in 1986 a significant fall in the number of deaths and of myocardial infarcts from 2.2% to 0.5% (P less than 0.05), while there was a nonsignificant increase in emergency coronary bypass surgery from 0.7 to 1.3%. Patients with unstable angina compared with those with stable angina had a signifi…

Influence of digoxin on sinus node function after pharmacologic autonomic blockade.

The effect of iv digoxin on normal sinus node function was studied after pharmacologic autonomic blockade (AB) in ten patients. Sinus cycle length (SCL), sinus node recovery time (SNRT) and sinoatrial conduction time (SACT) were determined before and after AB with propranolol (0.2 mg/kg body weight) and atropine sulfate (0.04 mg/kg body weight) iv, and 15 min, 30 min, and 45 min after 1 mg iv digoxin. AB resulted in a significant decrease (P less than 0.01) in SCL (916 +/- 158 to 716 +/- 120 ms), in SNRT (1,229 +/- 221 to 871 +/- 190 ms), and in SACT (79 +/- 34 to 44 +/- 10 ms). Fifteen minutes after iv digoxin there was no significant change observed in SCL (716 +/- 120 to 708 +/- 92 ms), …

Separation of left atrium from right pulmonary artery: a new echocardiographic sign of pericardial effusion.

We report a new echocardiographic sign of pericardial effusion in patients with pericardial effusion examined by the suprasternal approach. In normal individuals the right pulmonary artery is closely connected with the superior wall of the left atrium. A separation of these structures is only to be noticed during atrial contraction. In 12 of 17 patients with a pericardial effusion observed a separation of the left atrium from the right pulmonary artery ranging from 3 to 20 mm throughout the cardial cycle. We suggest that this echo-free zone represents fluid in the transverse pericardial sinus which is located between the two structures. In five patients with a small pericardial effusion (le…

Intensivtherapie des Myokardinfarktes — Limitierung der Infarktgröße

Der akute Myokardinfarkt gehort mit der instabilen Angina pectoris und dem plotzlichen Herztod zu den drei akuten Koronarsyndromen, die sich nur im Ausmas und der Geschwindigkeit der Thrombusentstehung unterscheiden [16]. Ein solcher Koronarverschlus (Abb. 1) fuhrt zu einem akuten Ausfall der Myokardperfusion und innerhalb weniger Sekunden zum Ausfall der Funktion des nicht mehr perfundierten Myokards. Wird das Gefas innerhalb weniger Minuten wieder geoffnet [34, 37, 38, 48], erholt sich das Myokard vollstandig. Bleibt die Durchblutung langere Zeit blockiert, entwickelt sich ein Infarkt, der von subendokardial nach epikardial sich ausbreitet [24, 46, 47, 52, 53]. t bedeutet eine kurze Ischa…

Indications for early PTCA after thrombolysis

There are several ways to reopen an acutely occluded coronary artery. Thrombolysis can be achieved with various methods (1, 5, 7, 10). After thrombolysis we find that the residual thrombus can sometimes be seen, but in most cases, a more or less high grade coronary stenosis remains (2). It is also a question of whether it is always optimal to reopen the vessel, because if the vessel remains occluded, another occlusion cannot occur. With this situation one faces the possibility that the patient will suffer another infarction, and that the vessel will occlude again (4).

Elektrokardiographische Infarktlokalisation: Ein Beitrag zur EKG-Nomenklatur

Intracardiac Cardioversion for Ablation of the Atrioventricular Conduction System in Patients with Drug Resistant Atrial Flutter

The technique of intracardiac cardioversion for the ablation of the atrioventricular conduction system was used in three male patients (65, 53 and 57 years of age) with atrial flutter unresponsive to medical management. In the first patient a DC current of 80 J was applied while the other patients required 300 and 400 J respectively. In the first patient a transient third degree AVblock was induced enabling the ventricular rate to be easily controlled with drugs. This patient died 5 months later of resistant congestive heart failure. Autopsy revealed no gross evidence of myocardial damage in the tricuspid valve area or in the interventricular septum. In the other two patients a permanent th…

Coronary Angioplasty in Unstable Angina

When Gruntzig introduced the revolutionary method of percutaneous transluminal coronary angioplasty (PTCA) for the treatment of coronary artery stenoses, he initially devoted this technique only to patients with stable angina pectoris [8]. Very soon, however, it was discovered simultaneously by Williams et al. [19] and by our group [12] that this method can also be used in patients with unstable angina pectoris. The earliest experiences with PTCA in 1980 were published by our two groups (Table 1). In these series the average degree of stenosis was somewhat lower than that today, while the residual stenosis after treatment was slightly higher. The very rough balloons and guiding catheters av…

PTCA of the left main stem following protective coronary artery bypass grafting.

Percutaneous transluminal coronary angioplasty (PTCA) was performed in 14 patients with significant left main stem stenosis following protective coronary artery bypass grafting (CABG). The procedure was successful in 13/14 patients (93%), achieving a decrease in mean diameter stenosis from 74% +/- 7% to 31% +/- 12% (P less than 0.01). Accordingly, the absolute stenosis diameter increased from 0.9 mm +/- 0.3 mm to 2.4 mm +/- 0.5 mm (P less than 0.01). Dissection of the left main stem artery and a transient significant fall of blood pressure each occurred in one patient. No other serious complications were noted. Eight of 13 patients (62%) with successful PTCA underwent control angiography. R…

Detection of dissection of the aortic intima and media after angioplasty of coarctation of the aorta. An angiographic, computer tomographic, and echocardiographic comparative study.

Balloon coarctation angioplasty (BCA) was performed in eight patients (five male and three female) who were 14-49 years old (mean, 27.3 years) with isolated discrete unoperated coarctation of the aorta (n = 7) and postoperative recoarctation (n = 1). BCA was successful in seven of eight patients, resulting in a decrease in the gradient (64 +/- 19 to 16 +/- 13 mm Hg, p less than 0.01), an increase in the diameter at the coarctation site (0.9 +/- 0.4 to 1.6 +/- 0.4 mm, p less than 0.01). Follow-up (6 months) has demonstrated continued gradient relief (6 +/- 9 mm Hg) and diameter increase (1.6 +/- 0.2 cm). Monitoring was performed by transesophageal echocardiography (TEE) during BCA, and befor…

Effect of intravenous flecainide on atrial vulnerability in man.

Sixteen patients were investigated by means of programmed atrial stimulation at 2 different driving rates: 100/min and 120/min. All patients had an increased atrial vulnerability at both driving rates. After the administration of intravenous flecainide (1 mg/kg bodyweight as a bolus, followed by the same amount infused over a period of 20 minutes), the increased vulnerability was abolished in 11 and 9 patients, respectively. In the remaining patients the rate of induced atrial tachyarrhythmia decreased. These findings correlate with a significant prolongation of the effective refractory period of the right atrium and a corresponding significant shortening of its relative refractory period. …

“Three-level shock” in ablation-refractory paroxysmal atrial fibrillation

His-bundle ablation is a very effective method to control drug-refractory supraventricular arrhythmias. We present a 69-year-old woman with paroxysmal atrial fibrillation, in whom several attempts of unipolar and bipolar His-bundle ablation were ineffective. Ultimately a stable 2/1 atrioventricular block was induced when three successive shocks of 400 W were applied. The first shock was given in that position with the largest His-potential deflection. The other two shocks were applied at catheter positions more distal and more proximal from the first one, respectively. We suppose that the initial lack of success was due to an atypical atrioventricular junction anatomy.

Analysis of risk factors for restenosis after PTCA

To identify risk factors for restenosis, we evaluated data in 473 patients with single-vessel percutaneous transluminal coronary angioplasty (PTCA) and control angiography after 6 months. Restenosis, defined as (1) loss greater than 50% of the initial gain, and (2) stenosis greater than 50% was found in 138 patients (29.2%). Univariate analysis revealed eight factors related to restenosis: (1) duration of symptoms less than 1 month (P = 0.005), (2) unstable angina (P = 0.004), (3) high-grade stenosis before PTCA (P = 0.014), (4) large residual stenosis after PTCA (P = 0.001), (5) insufficient improvement of stenosis (P = 0.042), (6) prolonged single inflation time (P = 0.017), (7) prolonged…

Manifestation und Therapie von Reperfusionsarrhythmien bei der Thrombolyse des akuten Myokardinfarktes

Schon seit 1943 ist bekannt, das die Wiederherstellung der Durchlassigkeit eines verschlossenen Kranzgefases zu Rhythmusstorungen fuhren kann (9). Diese Art von Rhythmusstorungen werden Reperfusionsarrhythmien genannt. Seitdem die intrakoronare und intravenose Streptokinaseapplikation bei Patienten mit frischem Herzinfarkt immer haufiger verabreicht werden, ist auch das Interesse fur die Reperfusionsarrhythmien gestiegen.

Effect of intravenous flecainide on atrial vulnerability in man.

Sixteen patients were investigated by means of programmed atrial stimulation at two different driving rates: 100 and 120/min. All patients had an increased atrial vulnerability at both driving rates. After intravenous flecainide application (1 mg/kg body weight as a bolus followed by the same amount given by infusion over a period of 20 min) the increased vulnerability was abolished in 11 and 9 patients respectively. In the remaining patients the rate of induced atrial tachyarrhythmia decreased. These findings correlate with a significant prolongation of the effective refractory period of the right atrium and a significant shortening of the relative refractory period of the right atrium. It…

Coronary Spasm in Patients Treated by Percutaneous Transluminal Coronary Angioplasty

The appearance of coronary spasm during PTCA was analyzed in 140 consecutive patients with stable and unstable angina. Coronary spasm was found in 27 patients (19%) and was more common in unstable than in stable angina pectoris (22 versus 5 patients). While coronary spasm could be seen in the first coronary angiogram in 5/27 patients, it developed during the diagnostic procedure in 6/27 patients. In 16/27 patients coronary spasm was induced by the balloon or the guide wire itself.

Prognostic significance of repetitive ventricular response in chronic coronary artery disease.

A prospective study was conducted in 267 patients with angiographically defined coronary artery disease without documented ventricular tachycardia to determine the prognostic significance of repetitive ventricular response (RVR) after programmed electrical stimulation (PES). The patients were classified inducible if RVR with 3 or more echo beats (RVR greater than or equal to 3) could be induced. 89 patients without previous myocardial infarction (MI), 61 survivors of MI occurring between 6 weeks and 3 months before and 117 patients who had survived longer than 3 months after MI were studied. A standardized stimulation protocol with single (S1S2) and double (S1S2S3) extrastimuli during ventr…

Combined medical and mechanical recanalization in acute myocardial infarction

A technique of combined medical and mechanical recanalization was employed in 96 patients with acute transmural myocardial infarction. The mean time between onset of symptoms and admission to hospital was 170 +/- 65 min (X +/- SD). After 10 +/- 16 min, 250,000 U streptokinase was administered intravenously for 20 min. Intracoronary thrombolysis was commenced within 38 +/- 14 min. First coronary angiograms demonstrated reperfusion, an open vessel in 25/96 patients (26%). In 15/71 patients (21%) reperfusion occurred during thrombolysis therapy, before mechanical recanalization could be performed. Recanalization was achieved mechanically in 37/71 patients (52%) with occluded coronary vessels. …

Recanalization of Totally Occluded Coronary Vessels by Percutaneous Transluminal Coronary Angioplasty

Since its introduction in 1977, percutaneous transluminal coronary angioplasty (PTCA) has become an effective approach for treatment of patients with single-vessel disease [1–3, 5]. Treatment of double- and multiple-vessel disease has also been attempted [5, 6]. In patients with angina pectoris total occlusion of coronary vessels is found, and PTCA has also been used in an attempt to restore coronary blood flow in such patients [8, 10]. Even main stem occlusions have been recanalized [11]. In patients with total occlusion of coronary vessels, collateral flow is sufficient to maintain cardiac function at rest but not during exercise [12–14]. Therefore, PTCA seems to be an ideal method for re…

Vulnerability of the right ventricle to cathodal, anodal, and bipolar stimulation at double diastolic threshold strength

The repetitive ventricular response (RVR) to three stimulation techniques (bipolar, cathodal and anodal) was investigated in 35 patients. 26 patients suffered from coronary heart disease and 9 patients from dilative cardiomyopathy. The stimulation study was performed at a ventricular driving rate of 120/min with one and two premature ventricular extrastimuli. We used rectangular impulses of 1.8 ms duration at duable diastolic threshold strength. RVR was scored as follows: 0: no RVR, 1: one nonstimulated RVR, 2: two nonstimulated RVR, 3: three nonstimulated RVR, 4: four to ten nonstimulated RVR, 5: more than ten nonstimulated RVR lasting less than 2 minutes, 6: sustained ventricular tachycar…

Supernormal conduction in the right bundle branch: lack of influence of autonomic blockade.

A programmed atrial stimulation at a driving rate of 100/min was performed in a 47-year-old woman with left bundle branch block. Supernormal conduction lasting 40 ms was revealed within the right bundle branch. After autonomic blockade (0.2 mg propranolol/kg body weight and 0.04 mg atropine/kg body weight) the position and duration of the supernormal conduction did not change. This suggests that the autonomic nervous system has no influence on the supernormal phase of conduction in the human intraventricular conduction system.

Assessment of left ventricular function during aortic balloon valvuloplasty by transesophageal echocardiography

Several reports have documented the feasability and utility of balloon aortic valvuloplasty as a palliative treatment for high-surgical-risk patients with critical aortic valve stenosis (1–3).

Experience in the long term use of new antiarrhythmic drugs.

Meinertz et a1. (1984) investigated the long term efficacy and tolerability of flecainide in patients with ventricular arrhythmias. 15 patients were studied, 8 women and 7 men, aged 19 to 74 (mean 58.7) years, with more than 30 ventricular premature complexes (VPCs) per hour, and ventricular arrhythmias of Lown grade IVA or IVB. 11 had coronary artery disease and 2 had idiopathic dilated cardiomyopathy. Patients were excluded on the basis of sustained ventricular tachycardia (VT) [defined as ~ 3 consecutive beats at a rate of> 100 beats/min]; myocardial infarction within the last 6 months; unstable angina; severe congestive heart failure; or conduction abnormalities. Previously unsuccessful…

Ein diagnostisch-therapeutischer Stufenplan bei instabiler Angina pectoris

Unter instabiler Angina pectoris wird 1. eine Crescendo-Angina-pectoris verstanden, die an Starke und Haufigkeit zunimmt oder sich auf eine bestehende typische Belastungs-Angina-pectoris aufpfropft, 2. eine Angina pectoris in Ruhe und bei minimaler Belastung und 3. eine neu auftretende Angina pectoris, die bei geringster Belastung ausgelost wird [3].

Autonome Blockade: Bedeutung in der elektrophysiologischen Diagnostik des kranken Sinusknotens

Die normale Sinusknotenfunktion ist von einer komplexen und ausgewogenen Interaktion zwischen intrinsischen elektrophysiologischen Eigenschaften des Sinusknotens und der sinuatrialen Leitung einerseits sowie von extrinsischen Faktoren andererseits abhangig [1]. Unter letzteren spielt das autonome Nervensystem die wichtigste Rolle. Vagale Stimulation oder Acetylcholin fuhren zu einer Senkung der Herzfrequenz und zu einer Verlangsamung der sinuatrialen Leitungszeit. Im Gegensatz dazu steigert Sympathikusstimulation oder Katecholamingabe die Herzfrequenz und verkurzt die sinuatriale Leitungszeit [2].

Langzeitverlauf über 10 Jahre nach Ballondilatation bei stabiler und instabiler Angina pectoris

OBJECTIVE To assess the cardiac status of patients ten years after percutaneous transluminal coronary artery angioplasty (PTCA). PATIENTS AND METHODS Data of 534 patients (436 men, 98 women; mean age 53.2 +/- 8 years) in whom a PTCA had been performed between 1983 and 1986 were analysed, based on a questionnaire answered 121 +/- 11 months after the initial procedure. At the time of PTCA 184 patients (35%) had unstable angina, 350 (65%) stable angina. RESULTS 116 patients (63%) with unstable angina and 164 (47%) with stable angina had at least one cardiac event after the initial PTCA (repeat PTCA, bypass operation, myocardial infarction, death). None of these events occurred in 68 patients (…

Short-and long-term outcome after PTCA in patients with stable and unstable angina

Acute results and follow-up data over a period of 36 months after attempted PTCA in 406 patients with stable angina and 202 patients with unstable angina are reported. The rate of acute complications (death, myocardial infarction and bypass grafting (CABG) amounted to 1.5% in stable and 6.4% in unstable patients (P less than 0.005). Within the first week after PTCA a significantly lower percentage (1.7% vs 10.4%) of cardiac events (death, myocardial infarction, CABG and repeat PTCA) was observed in the stable group (P less than 0.001). During a 12-month follow-up period, another 16.3% of the patients in the stable group and 30.7% of unstable patients suffered a new cardiac event (P less tha…