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"Wir berichten ueber einen 31jaehrigen tuerkischen Patienten mit einer rechtskardialen Raumforderung , Leistungsminderung , Gewichtsabnahme und intermittierenden Fieberschueben . Im peripheren Blut bestand keine Eosinophilie , die kardiale Funktion war primaer unauffaellig . Neben einer Endokarditis fibroplastica Loeffler bestand differentialdiagnostisch der Verdacht auf ein entzuendliches Geschehen sowie einen malignen Herztumor . Bei echokardiographisch untypischer Morphologie der rechtsventrikulaeren Raumforderung konnte durch Myokardbiopsie die Diagnose nicht gesichert werden . Bei raschem Wachstum der Raumforderung , fulminanter Embolie und Infiltration in die Trikuspidalklappe konnte erst durch die operative Tumorexstirpation die histologisch-pathologische Diagnose einer Endokarditis fibroplastica Loeffler im thrombotischen Stadium gestellt werden . Die Behandlung bestand in einer antiphlogistischen Therapie mit Kortikosteroiden . Im Auslassversuch kam es nach 6 Monaten zu einem Tumorrezidiv . Eine Steroid-Dauermedikation in Kombination mit Azathioprin fuehrte anschliessend zu einer erneuten Tumorregression und Stabilisierung seit 8 Monaten nach Beginn der Medikation ."
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"Neuere klinische Studien zeigen , dass durch die intrakoronare Implantation eines Stents die Restenoserate gesenkt werden kann . Dieser Effekt wird als das Ergebnis eines hoeheren Lumengewinns durch die Stentimplantation im Vergleich zur perkutanen transluminalen koronaren Angioplastie ( PTCA ) verstanden . Unsere Studie basiert auf der Annahme , dass eine durch intravasalen Ultraschall ( IVUS ) gesteuerte und an den aeusseren Gefaessdurchmessder angepasste PTCA zu aehnlich guten Langzeitergebnissen fuehren kann wie die Implantation eines Stents . Ziel der vorliegenden Untersuchung war es zu pruefen , ob 1. eine IVUS-gesteuerte PTCA mit einem vertretbaren Risiko durchfuehrbar ist und 2. die Rate der klinischen Ereignisse und der angiographischen Restenoserate reduziert werden kann ."
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ZfuerKardiologie.80870353.ger.abstr | ZfuerKardiologie.80870353.ger.abstr | [
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"Als repetitive monomorphe ventrikulaere Tachykardie ( RMVT ) wird eine rechtsventrikulaere Tachykardie bei Patienten ohne strukturelle Herzerkrankung mit ueberwiegend singulaerer , bigeminiformer oder salvenartiger monomorpher ventrikulaerer Extrasystolie bezeichnet . Zumeist liegt eine Linksschenkelblock-Konfiguration mit Indifferenz- oder Steiltyp waehrend der ventrikulaeren Tachykardie vor . In unserem Kollektiv von 20 Patienten war es bei 35% anamnestisch zu Synkopen gekommen . In drei Faellen war eine Synkope Erstmanifestation der RMVT . Bei 25% unserer RMVT-Patienten waren auch anhaltende ventrikulaere Tachykardien mit einer Dauer > 3 min im Langzeit-EKG dokumentiert . Wesentliche Differentialdiagnose einer RMVT ist die paroxysmale anhaltende Form der idiopathischen ventrikulaeren Tachykardie . Neben dem typischen salvenartigen Auftreten der ventrikulaeren Extrasystolie ist die Belastungsabhaengigkeit wegweisend fuer die Diagnose einer RMVT . In 85-90% der Faelle gelang in unserem Patientenkollektiv die Ausloesung von Salven einer RMVT oder einer anhaltenden RMVT mittels Ergometrie oder eines Isoproterenol-Testes . Die Ausloesung einer RMVT mittels programmierter rechtsventrikulaerer Stimulation gelang in unserem Patientenkollektiv nur in 13% der Faelle . Somit ist die Durchfuehrung einer elektrophysiologischen Untersuchung nur zur Unterscheidung einer ventrikulaeren von einer supraventrikulaeren Tachykardie mit Schenkelblock oder zum Ausschluss einer anderen ventrikulaeren Tachyarrhythmie bei stattgehabter Synkope erforderlich . Die Prognose der RMVT ist gut ; in unserem Kollektiv von RMVT-Patienten traten waehrend einer Nachbeobachtungszeit von bis zu 4 Jahren keine lebensbedrohlichen ventrikulaeren Tachyarrhythmien auf . Die Mehrzahl der Patienten mit RMVT laesst sich mit Verapamil oder -Blocker ausreichend gut einstellen . Gelegentlich ist eine Therapie mit einem Klasse-III-Antiarrhythmikum erforderlich . Waehrend bei der paroxysmalen anhaltenden Form der idiopathischen ventrikulaeren Tachykardie bei medikamentoeser Therapierefraktaeritaet eine Katheterablation mit hervorragenden Erfolgsaussichten vorgenommen werden kann , ist die Durchfuehrung einer Katheterablation bei RMVT nur in seltenen Faellen indiziert ."
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ZfuerKardiologie.80870372.ger.abstr | ZfuerKardiologie.80870372.ger.abstr | [
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"Bei 55 konsekutiven Patienten mit dem gleichen Zweikammer-Schrittmacher ( Relay , Intermedics ) und verschiedenen Elektroden wurde der Stromverbrauch des Gesamtsystems in Abhaengigkeit von den programmierten Sicherheitsmargen untersucht . Im Mittel 2,8 +/- 0,9 Jahre nach der Implantation wurden in Vorhof ( A ) und Kammer ( V ) die Impulsdauer-Reizschwellen ( tRS ms ) ) ( bei 0,5 , 1,0 und 2,0 V bestimmt und die Ladungsabgabe ( µC) an der Reizschwelle bei 1,0 und 2,0 V telemetrisch gemessen . War tRS bei 0,5 V 1,5 ms , dann wurde in A und V eine Amplitude von 1,0 V programmiert , fuer alle anderen wurde , wenn tRS bei 1,0 V 1,5 ms war , eine Amplitude von 2,0 V eingestellt . Als Sicherheitsmargen programmiert wurden das Doppelte der Ladungs-Reizschwelle ( 2x QRS ) , das Dopelte der Amplituden-RS ( 2x URS ) und das Dreifache der Impulsdauer-RS ( 3x tRS ) . Der Batteriestrom ( IBat ) ( µA) wurde fuer jede Sicherheitsmarge als Mittelwert aus 5 Messungen im D00-Modus mit 70 bpm telemetriert . IBat aller Patienten lag mit 2x QRS signifikant niedriger als mit 2x URS ( 13,43 +/- 1,0 vs. 14,20 +/- 1,2 µA, p 0,01 ) und als mit 3x tRS ( 13,99 +/- 1,2 µA, p 0,05 ) . Die daraus errechneten Schrittmacherfunktionszeiten sind mit 2x QRS ( 112 +/- 8 Monate ) signifikant laenger als mit 2x URS ( 106 +/- 9 , p 0,01 ) und als mit 3x tRS ( 108 +/- 8 Monate , p 0,05 ) . Betrachtet man den Batteriestrom intraindividuell als eine Funktion der Stimulationsamplitude , so zeigt sich , dass IBat bei 1,0 V mit einer durchschnittlichen Reduktion von 0,63 µA ( -4 9% ; , p 0,05 ) signifikant niedriger war als bei 2,0 V , was einem Laufzeitgewinn von 5 Monaten entspricht . Dies gilt fuer alle hier untersuchten Sicherheitsmargen . Es ist zu erwarten , dass mit weiterer Reduktion des Inhibitionsstromes in zukuenftigen Schrittmacher-Generationen die aufgezeigten Differenzen im Batteriestrom zu einem groesseren Laufzeitgewinn fuehren werden ."
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"Wir berichten ueber einen Patienten mit einer symptomatischen akzessorischen Leitungsbahn in der rechten freien Wand . Nach zwei frustranen Ablationsversuchen in auswaertigen Kliniken erfolgte eine weitere Ablationssitzung . Hierbei wurde ein Mapping der rechten freien Wand ueber einen Katheter in der RCA durchgefuehrt . Der Fuehrungskatheter fuehrte ueber eine kritische Minderperfusion reproduzierbar zu einem bidirektionalen und reversiblen Praeexzitationsverlust . Durch Rueckzug des Fuehrungskatheters aus dem RCA-Ostium bei weiterhin liegendem Mapping-Katheter in der RCA gelang die exakte Lokalisation der akzessorischen Bahn und die Ablation ueber eine lange , vorgeformte intrakardiale Schleuse ."
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"Der Verdacht auf eine akute Aortendissektion erfordert eine sofortige Abklaerung mit geeigneten bildgebenden Verfahren , wie transoesophageale Echokardiographie , Computertomographie , Kernspintomographie oder Aortographie . Im hier dargestellten Fall wurde bei einem asymptomatischen Patienten echokardiographisch der Verdacht auf eine Aortendissektion geaeussert . Aufgrund der Diskrepanz zu dem klinischen Bild wurde neben anderen Schnittbildverfahren auch die Angiographie eingesetzt , um den Nachweis einer Haustrierung der aneurysmatisch erweiterten thorakalen Aorta zu diagnostizieren und eine Aortendissektion definitiv auszuschliessen ."
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ZfuerKardiologie.80870425.ger.abstr | ZfuerKardiologie.80870425.ger.abstr | [
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"type": "abstract",
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"Die bisherigen tier- und humanexperimentellen Daten lassen annehmen , dass die normale Herzfunktion zumindest teilweise von einer intakten GH/IGF-1-Achse ( Wachstumshormon/Insulin-like Growth Factor-1) abhaengig ist . Das Syndrom Herzinsuffizienz scheint mit einer gestoerten Aktivitaet dieses hormonellen Systems einherzugehen . Bislang sind vielversprechende Daten von Phase-II-Therapiestudien mit rekombinantem humanem Wachstumshormon bei chronisch-kongestiver Herzinsuffizienz infolge dilatativer Kardiomyopathie veroeffentlicht worden . Die Rationale hinter diesen Studien , das heisst hinter der Behandlung der dilatativen Kardiomyopathie mit Wachstumshormon , baut letztlich auf dem physikalischen Gesetz nach Laplace auf . Die zugrundeliegende Hypothese lautet Wachstumshormon : bewirkt bei der dilatativen Kardiomyopathie eine Zunahme der ventrikulaeren Wanddicke und damit die Abnahme des intraventrikulaeren Durchmessers . Daraus resultiert eine Abnahme der systolischen ) Wandspannunng , ( womit das kranke Herz erneut aus sich selbst heraus - autoregulatorisch - faehig wird , die vermehrte diastolische Fuellung ( vergroesserter enddiastolischer Durchmesser ) durch den Auswurf eines groesseren Schlagvolumens zu kompensieren . Somit darf angenommen werden , dass rekombinantes humanes Wachstumshormon die systolische Pumpfunktion des Herzens bei der dilatativen Kardiomyopathie verbessert . Die Zukunft wird zeigen , ob Wachstumshormon in besagter Indikation ( chronisch-kongestive Herzinsuffizienz infolge dilatativer Kardiomyopathie ) eine wertvolle zusaetzliche Behandlungssubstanz zu den bereits angewandten Arzneimitteln - Hemmstoffe des Angiotensin-Konversionsenzyms , Diuretika , Nitrate , Digoxin und Betablocker ( Carvedilol ) - darstellt . Die ins Feld gefuehrten Nachteile beruecksichtigend - hohe Medikamentenkosten , bislang noch Unmoeglichkeit der peroralen Wachstumshormon-Einnahme , potentiell gefaehrliche Therapie hinsichtlich Beguenstigung der Entstehung von Dickdarmkarzinomen , haeufigeres Auftreten von De-novo-Leukaemien , Rueckfaelle von Leukaemien und zentralnervoesen Tumoren unter Wachstumshormon - scheint die terminale , transplantationsbeduerftige Herzinsuffizienz infolge dilatativer Kardiomyopathie die einzige Kosten-Nutzen- und Risiko-Nutzen-guenstige Indikation zu sein , wo sich Wachstumshormon - alleine oder in Kombination mit einer der bisher verwendeten Substanzen zur Behandlung der chronisch-kongestiven Herzinsuffizienz - im klinischen Alltag etablieren koennte . Dies aus drei Gruenden : Erstens stellt die terminale chronisch-kongestive Herzinsuffizienz infolge dilatativer Kardiomyopathie nebst der ischaemisch bedingten Herzkrankheit die haeufigste Indikation fuer eine Herztransplantation im Erwachsenenalter dar . Zweitens befindet sich die herzchirurgische Transplantationsmedizin bei ausgepraegtem Mangel an menschlichen Spenderorganen weltweit aktuell in einem erheblichen Engpass , und drittens , weil in absehbarer Zukunft zur Herztransplantation alternative Therapiemodalitaeten gefunden werden muessen ."
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ZfuerKardiologie.80870436.ger.abstr | ZfuerKardiologie.80870436.ger.abstr | [
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"Die Bedeutung einer enteroviralen Infektion des Myokards bei dilatativer Kardiomyopathie konnte erst durch die Einfuehrung molekularbiologischer Techniken ( Polymerase-Kettenreaktion In-situ-Hybridisierung ) , in die virologische Diagnostik objektiviert werden . Die Einfuehrung histologischer und vor allem immunhistologischer Techniken fuer den Nachweis entzuendlicher Veraenderungen im Myokard , bei Patienten mit der klinischen Verdachtsdiagnose dilatative Kardiomyopathie , ermoeglicht eine Unterteilung in inflammatorische Kardiomyopathie und idiopathische dilatative Kardiomyopathie ( kein Nachweis entzuendlicher Veraenderungen im Myokard ) entsprechend der WHO-Klassifikation von 1995 ( 31 ) . Die inflammatorische Kardiomyopathie ist definiert als eine myokardiale Dysfunktion in Kombination mit einer myokardialen Entzuendungsreaktion , welche mit histologischen und vor allem immunhistologischen Techniken erfasst werden kann . Erst durch die Kombination von histologischen , immunhistologischen und molekularbiologischen Techniken gelang es , eine Subgruppenanalyse hinsichtlich der Haeufigkeit des Nachweises enteroviraler RNA im Myokard von Patienten mit inflammatorischer Kardiomyopathie im Vergleich zu Patienten mit idiopathischer dilatativer Kardiomyopathie durchzufuehren ."
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ZfuerKardiologie.80870459.ger.abstr | ZfuerKardiologie.80870459.ger.abstr | [
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"Hintergrund . Veraenderte elektrische Leitungseigenschaften waehrend myokardialer Ischaemie und Herzfrequenzveraenderungen koennen die Nachweisbarkeit von Spaetpotentialen im Oberflaechen-EKG beeinflussen . Unklar ist , ob eine Analyse funktioneller Spaetpotentialveraenderungen Vorteile zur Erkennung von Postinfarktpatienten haben kann , die durch Kammertachykardien oder vom ploetzlichen Herztod bedroht sind . Methode . Deshalb wurde retrospektiv bei 100 selektionierten Postinfarktpatienten ( 25 Patienten mit dokumentierten ventrikulaeren Tachykardien ( 230/min) in der chronischen Infarktphase ( VT-Gruppe ) , 25 Patienten , die Kammerflimmern ueberlebten ( VF-Gruppe ) , und 50 Patienten ohne ventrikulaere Rhythmusstoerungen ( VT/VF-Gruppe ) eine Spaetpotentialanalyse in Ruhe , waehrend atrialer Stimulation mit 100/min und 120/min ( n=60), waehrend und nach Ballonokklusion bei PTCA ( n=70) und unmittelbar nach Fahrradausbelastung unter Verwendung selektiver Signalmitteilung durchgefuehrt . Ergebnisse . In Ruhe hatten 72% der Patienten der VT-Gruppe , 32% der VF-Gruppe und 6% der VT/VF-Gruppe Spaetpotentiale . Waehrend atrialer Stimulation waren bei 80% der untersuchten Patienten der VT-Gruppe , 72% der VF-Gruppe und bei 10% der VT/VF-Gruppe , waehrend myokardialer Ischaemie bei PTCA bei 86% der VT-Gruppe , 70% der VF-Gruppe und 20% der VT/VF-Gruppe Spaetpotentiale nachzuweisen . Die Analyse unmittelbar nach Fahrradausbelastung , die sowohl zu erhoehter Herzfrequenz als auch partiell zu myokardialer Ischaemie fuehren konnte , zeigte Spaetpotentialbefunde bei 92% der Patienten der VT-Gruppe , 80% der VF-Gruppe und 14% der VT/VF-Gruppe . Gleiche Ergebnisse liessen sich auch erzielen , wenn die Analyse nach Signalaufnahme unter Verwendung exakter Korrektur von Rekorder-Gleichlaufschwankungen mit einem Langzeit-EKG-Rekorder erfolgte . 62% der Patienten mit ausschliesslich provozierbaren Spaetpotentialen und alle Patienten mit vorbestehenden und durch PTCA unbeeinflussbaren Spaetpotentialen entwickelten Rezidivtachykardien waehrend der Nachbeobachtungsphase von einem Jahr . Bei Patienten ohne Spaetpotentiale auch unter Provokation ( n=50) und bei Patienten , deren vorbestehende Spaetpotentiale nach PTCA beseitigt waren ( n=11), sind keine Rezidive aufgetreten . Die Zykluslaengen der klinischen Tachykardie und der Rezidivtachykardie waren bei Patienten mit vorbestehenden , durch PTCA unveraenderten Spaetpotentialen ( n=18) signifikant laenger als bei Patienten mit ausschliesslich provozierbaren Spaetpotentialen ( n=21). Schlussfolgerung . Eine Analyse funktioneller Spaetpotentialveraenderungen bei Ergometrie oder im Langzeit-EKG koennte die nichtinvasive Risikostratifizierung insbesondere des von Kammerflimmern bedrohten Postinfarktpatienten entscheidend verbessern ."
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"Die haemodynamische Beeintraechtigung bei akuter Aortendissektion ( Stanford A ) tritt durch einen akuten Volumenverlust , eine akute Aortenklappeninsuffizienz , gegebenenfalls durch ein Haemoperikard mit Tamponadebildung auf . Bei Auftreten des letzteren kann durch eine Perikardiozentese eine haemodynamische Stabilisierung erreicht werden . Sie ist jedoch erst bei verminderter Perfusion vitaler Organe indiziert . Durch Entlastung des Perikardergusses kann ein Druckgradient zwischen Dissektions- und Perikardraum geschaffen werden , der sowohl eine erneute haemodynamische Verschlechterung durch den Blutfluss in den Perikardraum als auch eine Ausweitung der Aortendissektion verursachen kann . Nach der Perikardiozentese sollte umgehend eine Operation erfolgen ."
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ZfuerKardiologie.80870487.ger.abstr | ZfuerKardiologie.80870487.ger.abstr | [
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"type": "abstract",
"text": [
"Bei einer AL-Amyloidose findet sich in bis zu 90% der Faelle eine kardiale Beteiligung im Rahmen eines multiplen Myeloms . Wir berichten ueber zwei Patienten , bei denen die haematologische Erkrankung im Rahmen einer Durchuntersuchung wegen kardialer Symptome entdeckt wurde . Beide Patienten praesentierten sich mit zunehmender Belastungsdyspnoe . Im Routinelabor waren keine Auffaelligkeiten festzustellen , insbesondere waren sowohl die Blutsenkungsreaktion als auch die Elektrophorese unauffaellig . Aufgrund des echokardiographischen Befundes einer massiven linksventrikulaeren Hypertrophie mit restriktivem Einflussprofil ueber der Mitralklappe im Doppler sowie peripherer Niedervoltage und R-Verlust ueber der Vorderwand im Elektrokardiogramm wurde nach invasivem Ausschluss einer koronaren Herzerkrankung der Verdacht auf eine infiltrative Kardiomyopathie gestellt . Dieser konnte in der weiteren Abklaerung durch den Nachweis eines Leichtkettenmyeloms bestaetigt werden . Ergibt die Abklaerung einer Belastungsdyspnoe bei entsprechender Befundkonstellation aus Echokardiographie und Elektrokardiogramm den Verdacht auf eine infiltrative Kardiomyopathie , so sollte auch bei unauffaelligem Routinelabor eine Immunfixationselektrophorese zum Nachweis einer Leichtkettenerkrankung durchgefuehrt werden ."
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ZfuerKardiologie.80870492.ger.abstr | ZfuerKardiologie.80870492.ger.abstr | [
{
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"type": "abstract",
"text": [
"Ueber zwei seltene Komplikationen der Dobutamin-Atropin Stressechokardiographie wird berichtet . Bei einem 66jaehrigen Patienten entwickelten sich klinische , elektro- und echokardiographische Zeichen eines akuten Vorderwandinfarktes nach der zweiten Atropin-Bolusgabe unter maximaler Dobutamin-Stimulation mit 40 µg/kg/min. Die akut durchgefuehrte Koronarangiographie zeigte einen proximalen Verschluss des Ramus interventricularis anterior , welcher primaer erfolgreich rekanalisiert werden konnte . Ein zweiter Patient wurde nach Stimulation mit 40 µg/kg/min Dopamin und zusaetzlicher Gabe von 0,5 mg Atropin reanimations- und intubationspflichtig im Rahmen einer akuten Hinterwandischaemie mit Kammerflimmern . Die moeglichen Ursachen und Inzidenzen solcher lebensbedrohlicher Komplikationen werden diskutiert und der konventionellen Fahrradergometrie gegenuebergestellt . Die beschriebenen lebensbedrohlichen Komplikationen weisen auf die Bedeutung entsprechender notfallmedizinischer Einrichtungen als Voraussetzung zur Durchfuehrung einer medikamentoesen Stressechokardiographie hin ."
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"Im Gegensatz zur konventionellen Computertomographie ( CT ) rotiert bei der Elektronenstrahltomographie ( EBT ) keine Roentgenroehre mechanisch um den Patienten , sondern es wird ein Elektronenstrahl auf semizirkulaer um den Patienten angeordnete Targets gelenkt , an denen dann die eigentliche Roentgenstrahlung entsteht . Mit dieser ultraschnellen Technik ist es moeglich geworden , axiale Schnittbilder des Herzens in 50 bzw. 100 ms zu erzeugen und mit einer Ortsaufloesung 0,5 mm2 saemtliche Strukturen des Herzens praezise abzubilden . Die Akquisition von 30-40 axialen , EKG-getriggerten Schnittbildern ( Schichtdicken 2-3 mm ) im kurzen Atemstillstand erlaubt die komplette , dreidimensionale Abbildung des Herzens eines Patienten . Die Gesamtmesszeiten liegen zwischen 30 und 50 s. Auch wenn mit der EBT eine vollstaendige Beurteilung der Morphologie und der Funktion des Herzens bis hin zur Messung der Myokardperfusion moeglich ist , liegt doch der wesentliche Vorteil der Methode in der nichtinvasiven Beurteilung der Koronararterien . Ohne Gabe von Kontrastmittel koennen in den einzelnen axialen Schnitten auch geringe Koronarkalzifizierungen exakt quantifiziert werden . Der Nachweis von Koronarkalk mit der EBT muss als der derzeit empflindlichste nichtinvasive Marker fuer das Vorliegen einer koronaren Atheromatose einschliesslich ihrer Fruehformen angesehen werden . Die peripher-venoese Kontrastmittelgabe waehrend der Datenakquisition erlaubt zudem eine Darstellung von Koronargefaessinnenlumina einschliesslich signifikanter Stenosierungen . Die Methode eignet sich insbesondere zur Beurteilung des Verlaufs nach Angioplastie und aortokoronarer Bypass-Operation . Die wesentlichen Probleme und Grenzen der Methode sind unter der Voraussetzung eines stabilen Sinusrhythmus in Atem- und Bewegungsartefakten sowie Ueberlagerung der Koronararterien durch Venen und durch ausgepraegte Koronarkalzifizierungen zu sehen . Trotzdem sind bereits bisher mit der EBT klinisch beurteilbare , nichtinvasive Darstellungen von Koronararterien moeglich geworden , die durch einen weiteren technischen Fortschritt moeglicherweise noch optimiert werden koennen ."
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"Aus mehreren Laendern wurde ueber Benachteiligungen von Frauen in der Therapie der koronaren Herzerkrankung berichtet . Die vorliegende Uebersicht will anhand von bevoelkerungsbezogenen Datensaetzen ( Nationaler Untersuchungssurvey [ NUS ] , Krankenhausdiagnoseregister , Mortalitaetsraten ) fuer die Bundesrepublik Deutschland untersuchen , ob mittlerweile Veraenderungen zugunsten weiblicher Patienten eingetreten sind . Laut NUS weisen Maenner gegenueber Frauen hoehere Praevalenzen von Bluthochdruck , Uebergewicht und Rauchen auf , waehrend die Praevalenz der Hypercholesterinaemie sich bei beiden Geschlechtern insgesamt gleicht . Von 1984/85 bis 1990/91 zeigt sich im NUS ein deutlicher Rueckgang des Zigarettenrauchens bei Maennern und ein ausgepraegter Anstieg bei Frauen . In der Praevalenz von Brustschmerzen in der Bevoelkerung gibt es keine wesentlichen Unterschiede zwischen den Geschlechtern , bei Maennern weisen Brustschmerzen aber haeufiger auf eine Koronarbeteiligung hin . Bei akutem Myokardinfarkt ( AMI ) werden Thrombolyse und PTCA gleich haeufig eingesetzt . Die durchschnittliche Verweildauer im Krankenhaus liegt bei Frauen mit AMI hoeher . Koronare Bypass-Operationen und Anschlussheilbehandlungen sind bei Frauen seltener als bei Maennern . Ueber geschlechtsspezifische Unterschiede in der psychosozialen Adaptation nach AMI ist wenig bekannt . Die AMI-Mortalitaet von Frauen liegt nach wie vor in allen Altersgruppen unter der der Maenner , und das mittlere Sterbealter liegt bei ihnen hoeher ; allerdings haben Frauen von der langfristigen Senkung der AMI-Mortalitaet seit 1980 weniger profitiert ."
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"Die Gefaessperforation nach transluminaler Koronarangioplastie ( PTCA ) stellt eine seltene Komplikation dieser etablierten Behandlungsmethode dar . Die Therapie wird bestimmt durch die haemodynamische Beeintraechtigung des linken oder rechten Ventrikels . Wir berichten ueber den Fall einer Gefaessperforation nach PTCA mit Shuntbildung von der rechten Koronararterie in den rechten Ventrikel , wobei der Shuntfluss sowohl kernspintomographisch als auch dopplersonographisch dargestellt werden konnte ."
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ZfuerKardiologie.80870594.ger.abstr | ZfuerKardiologie.80870594.ger.abstr | [
{
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"In den letzten 5 Jahren sind im Bereich der Herzchirurgie neue weniger invasive Operationsverfahren , entwickelt worden , die unter dem Oberbegriff minimal-invasive Herzchirurgie zusammengefasst werden . Man unterscheidet dabei Verfahren , die auf die Anwendung der extrakorporalen Zirkulation verzichten und in erster Linie in der Koronarchirurgie zum Einsatz kommen sogenannte minimal-invasive direkte koronare Bypasschirurgie oder MIDCAB-Verfahren ) . ( Diese Operation kann entweder ueber eine kleine Thorakotomie oder ueber eine volle Sternotomie vorgenommen werden . Demgegenueber gibt es Operationstechniken , bei denen ueber einen limitierten Zugang ein endovaskulaeres Bypass-System zum Einsatz kommt und ein Abklemmen der Aorta ascendens mit Gabe von kardiopleger Loesung moeglich ist sogenannte Port-Access-Technik ) . ( Auch in der Klappenchirurgie sind in den letzten Jahren verschiedene Operationsverfahren entwickelt worden , welche den Zugang zur Herzklappe ueber eine limitierte Sternotomie oder kleine Thorakotomie ermoeglichen . In der Chirurgie kongenitaler Vitien sind ebenfalls weniger invasive Operationsverfahren zum Einsatz gekommen . Dieser Artikel soll nun die einzelnen Operationsverfahren naeher beschreiben und die Indikationen fuer diese Eingriffe definieren ."
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ZfuerKardiologie.80870604.ger.abstr | ZfuerKardiologie.80870604.ger.abstr | [
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ZfuerKardiologie.80870613.ger.abstr | ZfuerKardiologie.80870613.ger.abstr | [
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ZfuerKardiologie.80870667.ger.abstr | ZfuerKardiologie.80870667.ger.abstr | [
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"Myokardischaemie fuehrt zu Stoerungen der myokardialen Funktion , die sich als Stunning \" \" verzoegert erholen , bei persistierend reduzierter Durchblutung als Hibernation \" \" persistieren oder in Nekrose muenden koennen . Diese Stoerungen koennen im Rahmen einer Myokardischaemie zur Herzinsuffizienz beitragen . Darueber hinaus kommt es jedoch bei nicht direkt von der Ischaemie betroffenem Myokard zu Anpassungsvorgaengen , insbesondere Hypertrophie und Dilatation , die zur chronischen Linksherzinsuffizienz fuehren koennen . Diese Entwicklung ist von haemodynamischen und neurohumoralen Veraenderungen sowie progredienten morphologischen Veraenderungen des Herzens charakterisiert , welche in enger Beziehung zueinander stehen . Die haemodynamischen Veraenderungen bestehen im wesentlichen in einer Zunahme des linksventrikulaeren Fuellungsdrucks und einer Abnahme der globalen Ejektionsfraktion , meist jedoch erst Jahre nach dem Infarkt , schliesslich in einer Zunahme des systemischen Gefaesswiderstandes und rechten Vorhofdruckes . Die neurohumoralen Veraenderungen bestehen in einer Zunahme von Plasmakatecholaminen , atrialem natriuretischem Faktor und Vasopressin , schliesslich in einer Aktivierung des Renin-Angiotensin-Systems . Endothelin-1 wurde neuerdings bei Patienten mit Herzinsuffizienz erhoeht gefunden mit einer prognostischen Bedeutung gesteigerter Endothelin-Plasmaspiegel . Ein vermindertes Ansprechen der Gefaesse auf eine Endothel- ( EDHF/NO- ) abhaengige Vasodilatation spricht fuer weitere Stoerungen des Gefaessendothels bei der Herzinsuffizienz . Lokale Veraenderungen von kardialen neurohumoralen Systemen koennten an Strukturveraenderungen des Herzens , systemische Aktivierung an haemodynamischen Veraenderungen beteiligt sein . Die Strukturveraenderungen des Herzens sind charakterisiert durch eine Volumenzunahme und Dickenzunahme des ueberlebenden Myokardes sowie eine Expansion des ischaemischen und nekrotischen Myokards . Die molekulare Steuerung dieser Prozesse , die verschiedene Zelltypen , insbesondere die Kardiomyozyten und Kardiofibroblasten betrifft , ist zur Zeit Gegenstand intensiver Forschung und koennte eine besondere therapeutische Bedeutung erlangen ."
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ZfuerKardiologie.80870683.ger.abstr | ZfuerKardiologie.80870683.ger.abstr | [
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"Wir untersuchten die haemodynamischen Effekte einer einmaligen PGE1-Infusion ( 60 µg ueber 2 h=ED zur Therapie der pAVK ) bei Patienten mit einer chronischen Herzinsuffizienz NYHA II-III ( EF 55% ; mittleres Alter : 58,4 J , STD 10 J ; stabiler Krankheitszustand ) . Bei 19 Patienten lag eine koronare Herzkrankheit , bei einem Patient ein Z. n . Myokarditis vor . Die haemodynamische Analyse erfolgte invasiv mittels Rechts- und Linksherzkatheter . Blutdruck und Puls wurden manuell gemessen . Die intravenoese Infusion von PGE1 in einer Konzentration von 60 µg ueber zwei Stunden fuehrte zu keiner signifikanten Aenderung der Kontraktilitaet und Haemodynamik . Fakt Dp/dtmax , dp/dtmax/p und dp/dt/DP40, : als Parameter fuer die linksventrikulaere Kontraktilitaet mittels Katheter-Tipmanometer bestimmt , zeigten gegenueber der Placebo-Kontrollgruppe keine signifikante Aenderung im Verlauf . Die weiteren erhobenen Parameter ergaben ebenfalls keinen Hinweis auf eine haemodynamische bzw. myokardiale Wirkung der PGE1-Gabe, so dass die Anwendung bei der pAVK als haemodynamisch unbedenklich anzusehen ist ."
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ZfuerKardiologie.80870707.ger.abstr | ZfuerKardiologie.80870707.ger.abstr | [
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"Hintergrund : Langstreckige Dissektionen sind seltene aber gefuerchtete Komplikationen , der PTCA . Stentimplantation ohne Vordehnung erscheint bei morphologisch geeigneten Stenosen in der Lage , eine entstehende Dissektion sofort anzulegen und damit zu verhindern ."
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ZfuerKardiologie.80870715.ger.abstr | ZfuerKardiologie.80870715.ger.abstr | [
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ZfuerKardiologie.80870777.ger.abstr | ZfuerKardiologie.80870777.ger.abstr | [
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"text": [
"Die Atherosklerose ist eine komplizierte , multifaktorielle Erkrankung , die von einer besonderen genetischen Disposition und einer Vielzahl verschiedener Risikofaktoren abhaengig ist . Als zweifellos wichtigster Kausalfaktor ist eine Erhoehung des Plasma-LDL-Cholesterins anzusehen , dessen atherogene Wirkung durch andere Faktoren erheblich verstaerkt werden kann . Vermutlich determinieren mehrere Kandidatengene die individuell sehr unterschiedliche Atheroskleroseempflindlichkeit der Gefaesswand . In den letzten Jahren wurde eine wachsende Zahl von Genpolymorphismen identifiziert , die mit einem erhoehten Myokardinfarktrisiko assoziiert sind . Dies betrifft insbesondere Gene und Gencluster , die im Fettstoffwechsel , der Blutdruckregulation und der Blutgerinnung eine zentrale Rolle spielen . Im Gegensatz zu den seltenen monogenetischen Erkrankungen , die mit einem schweren Krankheitsbild einhergehen ( z.B. familiaere Hypercholesterinaemie ) , sind Genpolymorphismen relativ haeufig . Aufgrund ihrer hohen Frequenz ist das Zusammentreffen mehrerer fuer die Atherosklerose praedisponierender Allele in einem Individuum durchaus wahrscheinlich , dies koennte die koronare Risikodisposition eines Patienten entscheidend bestimmen . Genetische Polymorphismen wirken sich klinisch meist erst durch die Interaktion mit Lebensstil- und Umweltfaktoren oder bei endogenen Stoffwechselstoerungen aus ."
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"Die akute intramurale Haemorrhagie ( IMH ) ist klinisch nicht von der klassischen Dissektion der Aorta zu unterscheiden ; sie weist jedoch weder einen Riss der Intima noch ein falsches Lumen auf . Die hier vorgelegte Literaturanalyse fasst 209 in vivo diagnostizierte Faelle mit IMH zusammen ; ihr Anteil an den Dissektionen liegt mit durchschnittlich 17% etwas hoeher als im Sektionsgut mit 4% bis 13% . Die transoesophageale Echokardiographie liefert in 57% der Faelle den Nachweis einer IMH , die Computertomographie in 49% , die Kernspintomographie in 43% und die Angiographie ( zum Ausschluss einer Dissektion ) in 38% ; Daten zur Sensitivitaet und Spezifitaet liegen bislang nicht vor . Die Aorta ascendens ist in durchschnittlich 34% beteiligt ( Typ-A-IMH ) ; zu 64% sind Maenner betroffen , und das Durchschnittsalter liegt zwischen 55 und 65 Jahren . Bei 12% finden sich zusaetzlich Bauchaortenaneurysmen . Wesentlicher Risikofaktor ist mit 87% der Faelle ein arterieller Hypertonus . Klinisch besteht stets der Verdacht auf Aortendissektion ; 97% der Faelle treten akut auf , und in 90% liegt ein thorakales Schmerzsyndrom vor . Eine Verbreiterung des Mediastinums im Roentgen-Thorax findet sich bei 83% ; ein Haematothorax/Pleuraerguss wird in 38% der Faelle beobachtet ; eine akute Aorteninsuffizienz tritt bei 26% auf ; ein Perikarderguss bei 23% , ein Mediastinalhaematom bei 16% , neurologische Komplikationen bei 12% und eine Blutdruckdifferenz oder fehlende Extremitaetenpulse bei 5% der Faelle . Bei 18% treten Dissektionen und bei weiteren 15% Aortenrupturen auf , die sich zu 25% bzw. 28% bei Typ-A-IMH , aber nur zu 12% bzw. 9% bei Typ-B-IMH finden . Die 30-Tage-Letalitaet der IMH liegt bei 24% , mit 36% beim Typ A und 12% beim Typ B ( p 0,05 ) . Bei chirurgischer Intervention ist die Letalitaet der Typ-A-IMH mit 18% gegenueber 60% bei konservativer Therapie deutlich geringer ( p 0,01 ) . Bei Typ-B-IMH dahingegen ist die Sterblichkeit unter konservativer Therapie mit 8% niedriger als mit 33% bei chirurgischen Interventionen ( p 0,05 ) . Entsprechend dem Konzept fuer klassische Dissektionen sollten Typ-A-IMH daher primaer chirurgisch , Typ-B-IMH dagegen primaer konservativ behandelt werden ."
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"Ziel dieser prospektiven Laengsschnittstudie war es , Lebensqualitaet Lebenszufriedenheit und subjektiv beurteilte Gesundheit , vor und zu verschiedenen Zeitpunkten nach Herztransplantation ( HTx ) zu vergleichen . Zwischen Februar 1994 und Dezember 1997 wurden an 175 Patienten zu definierten Messzeitpunkten ( bei Aufnahme auf die Warteliste und 1,5 , 3 , 6 und 12 Monate nach HTx ) folgende Frageboegen ausgegeben : German SF-36, krankheitsspezifischer Beschwerdebogen , Einschaetzung der globalen Lebensqualitaet , Muenchner Lebensqualitaets-Dimensionen-Liste ( MLDL ) , Erwartete bzw. erlebte Veraenderungen nach HTx . Einschlusskriterien waren die Listung zur HTx , gute Deutschkenntnisse und ein Mindestalter von 18 Jahren . Bei der Auswertung wurden Einzelmesswerte durch Median ( Me Mittelwert ( ) , M ) und Standardabweichung ( SD ) dargestellt . Praeoperativ schaetzten 84% der terminal-herzinsuffizienten Patienten ihre Lebensqualitaet als sehr schlecht ein ; bereits 6 Wochen postoperativ verbesserte sich dieser Parameter , und 74% der Transplantierten empfanden ihre Lebensqualitaet als sehr gut bis ausgezeichnet . Auch mit der koerperlichen Leistungsfaehigkeit ( 87% ) und der gesundheitlichen Verfassung ( 80% ) waren die Patienten praeoperativ sehr unzufrieden . Sechs Wochen nach der Transplantation verbesserten sich diese Bereiche signifikant , 76% der Patienten zeigten ein hohes Zufriedenheitsniveau mit der gesundheitlichen Verfassung und 51% mit der koerperlichen Leistungsfaehigkeit . Obwohl die Patienten bereits vor HTx ihre psychische Befindlichkeit als gut beurteilten , verbesserte sich dieser Parameter postoperativ noch und erreichte nach einem Jahr signifikant hoehere Werte ( praeop . M=3,66; SD=0,9; Range ( R ) =3 , 78 vs. 12 Mon . postop . M=4,61; SD=0,6; R=2,67; p 0,05 ) . Lebensqualitaet korrelierte vor HTx am besten mit dem Gesundheitszustand ( r=0,61, p 0,01 ) , 6 Monate nach Transplantation am besten mit Zufriedenheit mit der gesundheitlichen Verfassung ( r=0,76, p 0,01 ) . Die Bereiche Sexualitaet , berufliche Situation und Freizeitgestaltung verbesserten sich nach HTx nur bei ca. 28% der Patienten . 90% litten nach der Transplantation unter einer oder mehreren Beschwerden , meist Nebenwirkungen der immunsuppressiven Therapie . Die Studie zeigt , dass sich fuer Patienten mit terminaler Herzinsuffizienz bereits 6 Wochen nach HTx alle Bereiche der Lebensqualitaet mit Ausnahme der psychischen Befindlichkeit signifikant verbessern . Trotz zu hoher Erwartungen und postoperativer Beschwerden sind Herztransplantierte mit ihrer postoperativen Lebenssituation signifikant zufriedener ."
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"Ziele der Studie waren einerseits eine Analyse der Praevalenz von schlafbezogenen Atmungsstoerungen ( SBAS ) bei Patienten mit implantierbarem Kardioverter-Defibrillator ( ICD ) und andererseits die prospektive Untersuchung des moeglichen Einflusses von SBAS auf die Haeufigkeit und zirkadiane Verteilung von Arrhythmierezidiven sowie auf die kardiale Mortalitaet im Langzeitverlauf . Vierzig konsekutive ICD-Patienten mit kardialer Grundkrankheit und dokumentierten malignen ventrikulaeren Tachyarrhythmien wurden polysomnographisch untersucht und anschliessend 2 Jahre nachbeobachtet . Bei 16 von 40 Patienten ( 40% ) wurden SBAS diagnostiziert ( Apnoe-Hypopnoe-Index > 10 ) : bei 9 dieser 16 Patienten ( 56% ) traten zentrale Schlafapnoen ( ZSA ) auf ( bei 8 dieser 9 Patienten Cheyne-Stokes-Atmung ) und bei 7 der 16 Patienten mit SBAS ( 44% obstruktive Schlafapnoen ( ) OSA ) . Der AHI betrug 32 +/- 15 ( 12-60 ) bei Patienten mit ZSA und 32 +/- 27 ( 11-86 ) bei Patienten mit OSA . Patienten mit und ohne SBAS waren vergleichbar bezueglich des Ausmasses der linksventrikulaeren Funktionseinschraenkung , NYHA-Klassifikation , kardialer Grunderkrankung , ICD-Indikation und begleitender Medikation . Defibrillatorregistrierte Arrhythmierezidive traten bei 10 von 24 Patienten ( 42% ) ohne SBAS , bei 4 von 9 Patienten ( 44% ) mit ZSA und bei 3 von 7 Patienten ( 44% ) mit OSA auf . Anzahl und tageszeitliche Verteilung der registrierten Arrhythmien bei Patienten ohne SBAS , mit OSA und ZSA waren vergleichbar ( 14 +/- 25 , Median 4 vs. 15 +/- 15 , Median 7 vs. 4 +/- 5 , Median 2,5 ) . Die kardiale 2-Jahres-Mortalitaet war am hoechsten bei Patienten mit ZSA ( 4/9 ( 44% ) vs. 0/7 Patienten ( 0% ) mit OSA vs. 3/24 Patienten ( 12,5% ) ohne SBAS . Die Praevalenz von SBAS bei Patienten mit ICD ist also hoch , wobei das Auftreten von ZSA mit einer hohen kardialen Mortalitaet assoziiert ist . Ein Einfluss von maessiggradigen SBAS auf die Haeufigkeit und tageszeitliche Verteilung von Arrhythmierezidiven im Langzeitverlauf ist nicht nachweisbar ."
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"Sauerstoffradikale und Folgeprodukte ( ROS ) sind nicht nur \" toxischer Abfall \" eines oxidativen Metabolismus , sondern in vielen physiologischen Prozessen als Intermediaerprodukte oder Botensubstanzen integriert ( u.a. in der antimikrobiellen Abwehr , Regulation von Zellproliferation und Wachstum , Gefaesstonusregulation ) . ROS koennen intra- und extrazellulaer entstehen , u.a. auch durch spezifische , membranstaendige Enzymsysteme ( NAD ( P ) H-Oxidasen ) . Die zellulaere ROS-Produktion wird durch Scherkraefte , Umweltfaktoren/Gifte , das Peptid Angiotensin II , Zytokine , Low-density-Lipoproteine ( LDL ) sowie durch die Anwesenheit von Spuren von Metallionen stimuliert . Die Beteiligung von ROS in der oxidativen Modifikation von LDL , in der Inaktivierung von endothelialem Stickstoffmonoxid ( NO ) und in der Verstaerkung der Expression von Genen , die fuer die Rekrutierung von Entzuendungszellen wichtig sind , lassen eine kausale Beziehung zwischen ROS-Produktion und der Pathogenese der Arteriosklerose vermuten . In tierexperimentellen Studien konnten mit antioxidativ-wirksamen Substanzen ( u.a. Probucol , Butyl-Hydroxytoluol , N ' , N'-Diphenylendiamid , Vitamin E , Superoxiddismutase ) sowohl die Bildung von Atheromen als auch die abnorme endotheliale Dysfunktion therapeutisch verhindert bzw. korrigiert werden . In klinischen Studien kann mit antioxidativ-wirksamen Substanzen ( z.B. Vitamin E ) die oxidative Modifizierbarkeit von LDL erschwert werden . In fallkontrollierten und prospektiven Beobachtungsstudien scheint das kardiovaskulaere Risiko sowohl mit dem Plasmaspiegel von natuerlichen Antioxidantien als auch der dietaetischen Vitaminzufuhr invers korreliert zu sein . In einer ersten randomisierten Studie zur Sekundaerpraevention war das Risiko nicht-toedlicher Myokardinfarkte mit der Einnahme von Vitamin E ( 400-800 U/d ) signifikant reduziert . Die Datenlage , sowohl aus theoretischen Ueberlegungen als auch tierexperimentellen und nun auch ersten klinischen Studien , rechtfertigt die Konzeptierung weiterfuehrender grossangelegter klinischer Studien , zur Ueberpruefung des Nutzens von Antioxidantien in der Primaer- und auch Sekundaerpraevention der koronaren Herzkrankheit ."
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ZfuerKardiologie.80870894.ger.abstr | ZfuerKardiologie.80870894.ger.abstr | [
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"Eine 72 Jahre alte Frau wurde wegen Kollaps und zunehmender Luftnot als Notfall stationaer behandelt . Die Roentgenaufnahme des Thorax zeigte eine deutliche Herzvergroesserung , besonders zur rechten Seite . In der Echokardiographie wurde eine ausgepraegte Verlagerung der Herzhoehlen nach links nachgewiesen , verursacht durch eine grosse ( 11x5x5 cm ) aneurysmatische Raumforderung anterior und medial des rechten Herzens , die mit dem rechten Atrium kommunizierte und eine deutliche Kompression des basalen rechten Ventrikels verursachte . In dem Aneurysma konnten mehrere hochmobile Thromben sowie ausgepraegter spontaner Echokontrast dargestellt werden . Diese Befunde liessen sich auch durch MRT sowie Angiokardiographie der rechtsseitigen Herzhoehlen dokumentieren . Die Koronarangiographie zeigte eine auffaellige bogige Verlagerung der rechten Koronararterie nach links . Mit Perfusionsszintigraphie der Lunge und DSA der Pulmonalarterien wurden bilaterale segmentale Lungenembolien , nachgewiesen . Unter oraler Antikoagulation blieb der Verlauf ueber jetzt mehr als vier Jahre ohne weitere Komplikationen ."
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"Atheromatoese Plaques der Aorta koennen sich durch Erosion zu einem zentralen penetrierendem Ulkus ( PAU ) entwickeln . PAU werden als Differentialdiagnose und Ursache klassischer Aortendissektionen diskutiert . Die Literaturanalyse von 93 Faellen mit PAU zeigte eine Haeufung maennlicher Patienten mit einem Durchschnittsalter > 60 Jahre bei 60% der Faelle . Ein arterieller Hypertonus findet sich bei 85% , ein Nikotinabusus bei 72% , eine Hyperlipoproteinaemie bei 35% und ein Diabetes mellitus bei 31% der Betroffenen . Bei 61% liegt eine koronare Herzerkrankung , bei 53% eine Bauchaorten- oder thorakales Aneurysma , bei 31% eine Niereninsuffizienz , bei 17% eine periphere arterielle Verschlusskrankheit und bei 12% ein alter zerebraler Insult vor . Bei 73% ist ein Mediahaematom nachweisbar ; in 16% entstehen Dissekate von 10 cm Ausdehnung mit dicker , verkalkter Intimamembran . Die Diagnose eines PAU wurde in 66% , 64% , 23% und 14% durch Angiographie , Computertomographie , Kernspintomographie oder transoesophageale Echokardiographie gestellt , deren Sensitivitaet bei 83% , 65% , 86% und 61% lag . Ein thorakaler Schmerz trat in 76% auf 68% ; wurden im akuten Stadium diagnostiziert . Zeichen der Mediastinalerweiterung lagen in 59% vor , neurologische Komplikationen in 8% , Puls- und Blutdruckdifferenzen in 4% , eine Aortenklappeninsuffizienz in 7% , ein Mediastinalhaematom in 27% und ein Pleura- oder Perikarderguss in 42% und 10% . In 57% aller PAU der Aorta ascendens und des Aortenbogens ( Typ A ) kam es zur lokalisierten Dissektion oder transmuralen Ruptur verglichen mit nur 12% und 5% in der Aorta descendens ( Typ B ) . Die Fruehletalitaet der Typ-A-PAU ist mit 57% hoch und erfordert eine rasche operative Versorgung , waehrend bei Typ-B-PAU die Letalitaet 14% betraegt , ohne Unterschiede bei konservativer und chirurgischer Therapie . Unkomplizierte Langzeitverlaeufe unter konservativer Therapie wurden in 20 Faellen ausschliesslich bei Typ-B-PAU beobachtet . In Analogie zur klassischen Dissektion sollten Typ-A-PAU daher primaer chirurgisch behandelt werden , waehrend bei Typ-B-PAU ein konservativer Behandlungsversuch gerechtfertigt scheint ."
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ZfuerKardiologie.80870928.ger.abstr | ZfuerKardiologie.80870928.ger.abstr | [
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"Mediakalzinose MK ) ( ist eine Erkrankung der Arterien vom muskulaeren Typ , die durch eine zunehmende Ablagerung von Kalksalzen in der mittleren Gefaesswandschicht , der Media , charakterisiert ist . Am haeufigsten erkranken die Arterien der unteren Extremitaet , wobei ein ausgedehnter Befall mit Einbeziehung der Beckenarterien und der Bauchaorta nicht ungewoehnlich ist . Eine systemische Ausbreitung der MK mit Beteiligung der Herzkranzarterien wurde ebenfalls beschrieben , ist jedoch nach heutiger Auffassung selten ."
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ZfuerKardiologie.80870939.ger.abstr | ZfuerKardiologie.80870939.ger.abstr | [
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"Ziel der Studie : Das Ergebnis einer erfolgreichen Ballondilatation von chronischen Koronarverschluessen ist wegen der hohen Restenose- und Reokklusionsrate nicht zufriedenstellend . Diese kontrollierte Studie untersucht , ob die protektive Implantation eines Stents die Langzeitergebnisse nach Rekanalisation verbessern kann ."
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ZfuerKardiologie.80870954.ger.abstr | ZfuerKardiologie.80870954.ger.abstr | [
{
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"Nach aortokoronarer Bypass-Operation ist in Abhaengigkeit vom Graftalter in 2 bis 30% der Faelle mit der Notwendigkeit einer erneuten Revaskularisationsmassnahme zu rechnen . Die Wahl der zu ergreifenden Revaskularisationstechnik - kathetergestuetzte Angioplastie oder erneute Bypass-Operation - ist von vielfaeltigen Einflussfaktoren , unter anderem Koronarmorphologie , linksventrikulaere Funktion , Verfuegbarkeit von Venenmaterial und Komorbiditaet , abhaengig zu machen . Eine Angioplastie an Bypass-Gefaessen ist moeglich , die primaere Erfolgsrate ist jedoch niedriger , die Rezidivrate hoeher als bei nativen Gefaessen . Eine Reoperation ist mit einer maessiggradig erhoehten perioperativen Morbiditaet und Mortalitaet assoziiert , weiterhin sind die Offenheitsraten und das klinische Ergebnis im Verlauf gegenueber einem Primaereingriff weniger guenstig . Wir berichten ueber einen vor 4 Jahren operativ revaskularisierten Patienten , der eine hoehergradige ostiale Stenose eines die RCA , die LAD und die Cx versorgenden Sequentialbypasses sowie Stenosen an der nativen RCA und der LAD aufwies . Zur Therapie fuehrten wir eine primaer und im Langzeitverlauf unkomplizierte und erfolgreiche serielle Angioplastie an Nativgefaessen und Bypass unter Zuhilfenahme ergaenzender Techniken ( direktionale koronare Atherektomie ) und Kontrolle durch intravaskulaeren Ultraschall durch . Die Kasuistik soll zeigen , dass bei Abwaegung aller kritischen Einflussgroessen und Anwendung differentialtherapeutischer Ueberlegungen auch komplexe kathetergestuetzte Interventionen erfolgreich vorgenommen und Zweitoperationen hinausgezoegert werden koennen ."
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"Die spontane Koronararteriendissektion ist eine seltene Ursache einer ischaemischen Herzkrankheit , ueber deren genaue Inzidenz , Aetiologie und optimale Therapie bisher wenig bekannt ist . In einer prospektiven Datenerhebung ermittelten wir 42 spontane Koronararteriendissektionen ( 36 Maenner , sechs Frauen , mittleres Alter 59 +/- 12 Jahre ) in einem Kollektiv von 3803 konsekutiv koronarangiographisch untersuchten Patienten , bei denen zwischen Juli 1995 und Dezember 1997 erstmals die Diagnose einer koronaren Herzkrankheit gestellt worden war ( Inzidenz 1,1% ) . : Die Haeufigkeit spontaner Koronararteriendissektionen war in der Teilgruppe von 450 Patienten mit akutem Myokardinfarkt ( 13 Faelle ; 2,9% ) und in der Teilgruppe von 501 Patienten mit instabiler Angina pectoris bzw. Postinfarktangina ( 21 Faelle ; 4,2% ) signifikant hoeher als im uebrigen Patientenkollektiv mit stabiler Angina pectoris ( 8 Faelle ; 0,3% ) . Am haeufigsten war der Ramus interventricularis anterior der linken Herzkranzarterie von der Dissektion betroffen ( 19 Faelle ) , gefolgt von der rechten Herzkranzarterie ( 15 Faelle ) und dem Ramus circumflexus der linken Herzkranzarterie ( 8 Faelle ) . Zur eindeutigen Diagnosestellung war bei 13 Patienten die zusaetzliche Durchfuehrung einer intravaskulaeren Ultraschalluntersuchung erforderlich . Als Ausloeser der spontanen Koronararteriendissektionen waren in 35 Faellen eine arteriosklerotische Plaqueruptur , in vier Faellen eine schwere koerperliche Anstrengung und in einem Fall hormonelle Einfluesse durch Schwangerschaft und Einnahme oraler Kontrazeptiva anzunehmen . In zwei Faellen liess sich keine offensichtliche Ursache finden . Die Therapie umfasste eine intrakoronare Stentimplantation bei 24 Patienten ( davon zehn Patienten mit akutem Myokardinfarkt ) , eine Bypassoperation bei acht Patienten und eine Ballonangioplastie ( PTCA ) bei sieben Patienten . Drei Patienten wurden konservativ behandelt ."
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ZfuerKardiologie.80870971.ger.abstr | ZfuerKardiologie.80870971.ger.abstr | [
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"Ziel vorliegender Untersuchung war es , die Reproduzierbarkeit der Effektivitaet der nach einem modifizierten Protokoll intraoperativ bestimmten Defibrillationsschwellenenergie im Langzeitverlauf zu ueberpruefen . Hierzu wurden im Rahmen einer Substudie einer prospektiven , randomisierten Multizenterstudie ( \" Low Energy Endotak Trial LEET ) ) \" zwischen Dezember 1993 und Januar 1996 83 Patienten , die im Rahmen einer Erstversorgung mit einem implantierbaren Kardioverter-Defibrillator ( ICD ) in Kombination mit einem transvenoesen Einzelelektrodensystem eine intraoperativ bestimmte Defibrillationsschwelle ( DFT ) =15 J aufwiesen , eingeschlossen . Zur Bestimmung der DFT wurde ein Protokoll mit absteigenden Energiemengen ( 15 , 10 , 8 , 5 J ) eingesetzt . Die Defibrillationseffektivitaet der DFT wurde intraoperativ unter Verwendung der gleichen Energiemenge bestaetigt ( DFT+). Nach Implantation des ICD , vor Krankenhausentlassung und ein Jahr nach ICD-Implantation erfolgte eine erneute Ueberpruefung der Defibrillationseffektivitaet der DFT+ ( erster Schock : DFT+, zweiter Schock ; 2xDFT+). Die intraoperativ bestimmte DFT+ lag bei 9,6+3,3 J. Unmittelbar nach ICD-Implantation war eine Konversion von induziertem Kammerflimmern bei 70/79 ( 89% ) der Patienten unter Verwendung der DFT+ moeglich . Bei 7/8 ( 89% ) Patienten gelang eine Konversion in Sinusrhythmus nach Abgabe eines Schocks , der auf 2xDFT+ programmiert war , und bei einem Patienten war erst eine dritte Entladung mit maximaler Energie ( 34 J ) erfolgreich . Die DFT+ war vor Krankenhausentlassung bei 61/77 ( 79% ) Patienten reproduzierbar effektiv , die verbliebenen 16 Patienten konnten erfolgreich mit 2xDFT+ defibrilliert werden . Bei 52/62 ( 84% ) Patienten liess sich ein Jahr nach ICD-Implantation induziertes Kammerflimmern mit der intraoperativ bestimmten DFT+ und bei den uebrigen 10 Patientem mit 2xDFT+ terminieren . Insgesamt konnten 183/218 84% ) ( Episoden von induziertem Kammerflimmern erfolgreich unter Verwendung der Energiemenge an der DFT+ terminiert werden . Ein Zusammenhang zwischen der intraoperativ bestimmten DFT+ oder der kardialen Grunderkrankung und der Reproduzierbarkeit der Defibrillationseffektivitaet bestand nicht . In vorliegender Untersuchung konnte unmittelbar nach ICD-Implantation , bei Krankenhausentlassung und ein Jahr nach Implantation eine vergleichbare Defibrillationseffektivitaet der intraoperativ bestimmten DFT+ gezeigt werden . Eine auf das Doppelte der DFT+ programmierte Energie scheint eine aeusserst zuverlaessige Defibrillation im ersten Jahr nach ICD-Implantation zu ermoeglichen ."
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ZfuerKardiologie.80870978.ger.abstr | ZfuerKardiologie.80870978.ger.abstr | [
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"Bei ICD-Patienten koennen Elektrodenkomplikationen fatale Folgen nach sich ziehen . Nach Subclaviapunktion zur ICD-Implantation sind Elektrodenbrueche im Spaetverlauf bekannt . Manipulationen durch den Patienten an durch die Haut tastbaren subkutan gelegenen Elektrodenabschnitten , koennen zu Beschaedigungen der Sonde fuehren . Wir stellen eine einfache Implantationstechnik vor , um sowohl subkutane Elektrodenverlaeufe als auch eine transmuskulaere Subclaviapunktion zu vermeiden ."
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ZfuerKardiologie.8087s003.ger.abstr | ZfuerKardiologie.8087s003.ger.abstr | [
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"Die Inzidenz des akuten Myokardinfarktes ( AMI ) zeigt ausgepraegte regionale Differenzen . Diese Variabilitaet ist nicht allein durch Unterschiede in den klassischen Risikofaktoren erklaerbar . Die 28-Tage Letalitaet des AMI ist trotz verbesserter therapeutischer Moeglichkeiten unveraendert hoch und betraegt weltweit im Mittel 50% . Zeitliche Trends der Mortalitaet der koronaren Herzkrankheit ( KHK ) zeigen eine Abnahme in den meisten westeuropaeischen Laendern und eine Zunahme in Osteuropa . Der Einfluss der medizinischen Versorgung auf die Prognose des AMI ist auf Bevoelkerungsebene nur teilweise nachvollziehbar . Trotz der Fortschritte in der Primaer- und Sekundaerpraevention wird die Inzidenz und Praevalenz der KHK in Zukunft aufgrund der unguenstigen Entwicklung der Altersstruktur der Bevoelkerung weiter zunehmen ."
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"Eine mikrovaskulaere Dysfunktion bei koronarer Herzkrankheit kann bei haemodynamisch relevanten Stenosen der epikardialen Koronararterien , bei Endotheldysfunktion in Abwesenheit signifikanter Lumeneinengungen oder in der Erholungsphase des Herzmuskels nach erfolgreicher Angioplastie einer stenosierten oder verschlossenen Koronararterie beobachtet werden . Diagnostisch laesst sie sich durch morphologische/morphometrische Analysen , Messung der globalen Koronarreserve , Erfassung der regionalen koronaren Mikrozirkulation ( Myokardszintigraphie Positronen-Emissions-Tomographie ) oder laborchemische Analyse , haemorheologischer Veraenderungen ( Plasma Erythrozyten , Granulozyten ) , nachweisen . So findet sich nach erfolgreicher Angioplastie erst nach drei bis sechs Monaten eine Normalisierung der Glutamat-Extraktionsrate . Bei Patienten mit instabiler Angina pectoris sind eine Erhoehung der Plasmaviskositaet , Veraenderungen der Erythrozytenaggregation und -Verformbarkeit sowie eine Aktivierung von Granulozyten nachweisbar . Eine Aktivierung neutrophiler Granulozyten tritt auch nach erfolgreicher Angioplastie bei akutem Myokardinfarkt auf und laesst sich sogar bei elektiver Angioplastie im Koronarsinusblut nachweisen . Therapeutisch koennen Stoerungen der Mikrozirkulation durch Steigerungen des Perfusionsdruckes ( Revaskularisation Nitrate , Calcium-Antagonisten , koerperliches Training ) , , durch Verbesserung der Fliessfaehigkeit des Blutes und durch eine Verminderung der extravasalen Komponente des Koronarwiderstandes ( antihypertensive Therapie ) guenstig beeinflusst werden ."
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"Die Prognose von Patienten mit Herzinsuffizienz , gleich welcher Genese , wird wesentlich durch das Ausmass der sympathoadrenergen Aktivierung bestimmt . Bei der Entstehung der Herzinsuffizienz geht die Aktivierung des kardialen Sympathikus einer systemischen sympathoadrenergen Aktivierung voraus . Auf kardialer Ebene findet sich eine erhoehte Konzentration des Neurotransmitters Noradrenalin . Dies beruht zum einen auf einer gesteigerten Freisetzung aus den sympathischen Nervenenden zum anderen auf einer verminderten neuronalen Wiederaufnahme . Wir konnten zeigen , dass diese Stoerungen in fortgeschrittenen Stadien der Herzinsuffizienz im Herzen heterogen verteilt sind ."
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"Ein Zusammenhang zwischen akuter Myokardischaemie und Arrhythmieausloesung laesst sich bei der koronaren Herzkrankheit im Gegensatz zu primaer nicht ischaemischen Herzerkrankungen durch kombinierte metabolisch-elektrophysiologische Untersuchungen ( programmierte atriale und ventrikulaere Stimulation mit simultaner arterio-koronarvenoeser Messung von Laktat , Pyruvat , freien Fettsaeuren und Aminosaeuren ) nachweisen . Dabei zeigen sich signifikante metabolische Unterschiede zwischen beiden Erkrankungen unter Stimulationsbedingungen und z.T. auch in Ruhe . Bei Patienten , die im chronischen Postinfarktverlauf anhaltende ventrikulaere Tachyarrhythmien ( VT/VF ) entwickeln , finden sich haeufiger als bei Patienten ohne VT/VF-Ereignisse Areale \" hibernierenden Myokards , \" szintigraphisch definiert als sog . Mismatchzonen mit reduzierter Perfusion und erhaltenem Stoffwechsel . Diese sind moeglicherweise als bedeutsame Risikofaktoren fuer Arrhythmieereignisse und ploetzlichen Herztod nach Herzinfarkt aufzufassen . Hierbei gewinnt das Konzept , dass die Interaktion zwischen akuter Ischaemie und chronischer Ischaemie bzw. Narbe zur Tachyarrhythmie , insbesondere polymorphen VT's und Kammerflimmern , fuehrt , zunehmend an Bedeutung . Dagegen entstehen monomorphe Reentrytachykardien in der ueberwiegend durch Fibrose und vereinzelte vitale Inseln gekennzeichneten Narbenrandzone , die durch eine ausgepraegte gleichgerichtete Reduktion von Perfusion und Stoffwechsel gekennzeichnet ist . In diesen Faellen kann nur durch interventionelle Verfahren ( Katheterablation ICD-Implantation oder antitachykarde Operation ) , neben einer antiarrhythmischen medikamentoesen Therapie eine Arrhythmiekontrolle erzielt werden . Eine antiischaemische Kausaltherapie ( PTCA oder ACB-Operation ) stellt fuer maximal 40% der Patienten mit ischaemischer Tachyarrhythmie in der Vorgeschichte eine allein ausreichende Therapieoption dar . Sie erscheint vor allem gerechtfertigt bei Patienten mit guter linksventrikulaerer Funktion , funktionellem Ischaemienachweis und postinterventioneller Arrhythmiesuppression bzw. prae- und postoperativer Nichtausloesbarkeit . In allen uebrigen Faellen ist eine zusaetzliche Absicherung durch Antiarrhythmika oder ICD-Implantation notwendig ."
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"Die Stentrestenose stellt heute die Hauptlimitation der koronaren Stentimplantation dar . Trotz verschiedener prospektiv randomisierter Studien , die im Vergleich zur konventionellen Ballonangioplastie reduzierte Restenoseraten nach Stentimplantation bei umschriebenen de-novo Stenosen , Rezidivstenosen , Bypasstenosen oder symptomatischen Dissektionen aufzeigen konnten , finden sich im klinischen Alltag je nach behandelter Laesion deutlich hoehere Rezidivraten zwischen 18% und 78% . Die anschliessenden therapeutischen Optionen bei symptomatischen Stentrestenosen schliessen von koronarinterventioneller Seite die Ballonangioplastie , die Kombination von ablativen Verfahren ( Hochfrequenzrotationsangioplastie Laserangioplastie , direktionale Atherektomie ) und Ballonangioplastie sowie , die Moeglichkeit einer erneuten Stentimplantation ( Stent-in-Stent Sandwich ) ein . All diese Verfahren scheinen in der Behandlung von fokalen ( =10 mm ) Stentrestenosen mit einer Rezidivrate von durchschnittlich 30% gleichwertig zu sein , waehrend bei eher diffusen ( > 10 mm ) Stentrestenosen die Rezidivrate nach Redilatation bei 35-85% liegt . Dabei erscheint es pathophysiologisch verstaendlich , dass die Ballonangioplastie der obstruierenden Neointimamassen im Stent nur ein unzureichendes Ergebnis erzielen kann . Hier versprechen zusaetzliche ablative Verfahren , die die Neointima abtragen und hierdurch eine schonendere Lumenerweiterung erzielen sollen , mit Rezidivraten von 25-56% eher vorteilhaft zu sein . Prospektiv randomisierte Studien muessen jedoch erst die Wertigkeit der ablativen Techniken im Vergleich zur konventionellen Ballonangioplastie in der Behandlung von Stentrestenosen definieren ."
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"Die Verwendung der Arteria thoracica interna zur koronaren Revaskularisierung hat sich in den letzten 25 Jahren als Gefaess der Wahl etabliert . Neben dem etablierten Verfahren der Angiographie wird in den letzten Jahren die Duplexsonographie zunehmend als nicht invasives bildgebendes Verfahren zur Untersuchung dieses Gefaesses eingesetzt . Bei der praeoperativen Evaluierung von 117 Patienten konnte im Vergleich zur Angiographie bei einem hohen Anteil der Patienten ein uebereinstimmendes Untersuchungsergebnis festgestellt werden . Waehrend in der praeoperativen Phase das Strompulskurvenprofil entsprechend der arteriellen Versorgung eines Skelettmuskels durch einen hohen systolischen Anteil dominiert wird , kommt es zu einer postoperativen Anpassung an das koronararterielle Strombett in Form eines vermehrten diastolischen Flussanteils . Diese nicht invasiven Befunde der transthorakalen Duplexsonographie konnten durch invasive intravaskulaere Dopplermessungen bestaetigt werden . Ebenso wie beim praeoperativen Vergleich ergibt sich auch postoperativ ein hohes Mass an Uebereinstimmung zwischen Angiographie und Duplexsonographie bei der Beurteilung des Revaskularisationsergebnisses . Im Hinblick auf die zunehmende Verwendung der Arteria thoracica interna als Bypassgefaess sollte dieses nicht invasive Verfahren zunehmend an Bedeutung gewinnen ."
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"Die Dobutamin-Stressechokardiographie hat sich als hinreichend genaues Verfahren zum Nachweis vitalen Myokards bei chronischer Myokardischaemie erwiesen . Neuere Publikationen belegen zudem die prognostische Bedeutung des Vitalitaetsnachweises durch diese Methode sowohl nach akutem Myokardinfarkt als auch bei chronischer Myokardischaemie mit reduzierter linksventrikulaerer Pumpfunktion . Gegenueber szintigraphischen Verfahren zeichnet sich die Dobutamin-Stressechokardiographie durch eine hoehere Spezifitaet und Genauigkeit zur Vorhersage einer postoperativen Erholung chronisch dysfunktionaler Segmente nach erfolgreicher Revaskularisation aus . Die Gruende fuer diesen Unterschied erklaeren sich unter anderem aus den methodisch unterschiedlichen Ansaetzen des Vitalitaetsnachweises ( kontraktile Funktion versus Perfusion und Metabolismus ) und aus der Variation des zugrundeliegenden pathomorphologischen Substrates , da Segmente mit einem Nekroseanteil von ueber 20% der Wanddicke vor und nach erfolgreicher Revaskularisation als Vitalitaetsnachweis keine systolische Wanddickenzunahme in Ruhe , aber noch eine szintigraphische Anreicherung zeigen koennen . Die wesentlichen Limitationen der Methode liegen in der eingeschraenkten Bildqualitaet bei einem nicht zu vernachlaessigenden Teil der Untersuchungen sowie in der Subjektivitaet der Beurteilung subtiler Wandbewegungsstoerungen ."
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"Der ploetzliche Herztod bei koronarer Herzkrankheit ist Folge eines komplexen Zusammenwirkens zahlreicher anatomischer , funktioneller und akzidenteller arrhythmogener Faktoren . Lange Zeit war umstritten , ob die myokardiale Ischaemie fuer die Ausloesung des ploetzlichen Herztodes ueberhaupt eine Rolle spielt . In den letzten Jahren konnte zunaechst in experimentellen und nachfolgend in einer zunehmenden Zahl klinischer Studien gezeigt werden , dass die akute Myokardischaemie bei verschiedenen Manifestationsformen der koronaren Herzkrankheit mit einem deutlich erhoehten Risiko zur Ausloesung und/oder Aggravation lebensbedrohlicher Herzrhythmusstoerungen verbunden ist . In der vorliegenden Uebersicht , die sich auf den klinischen Aspekt einer ischaemiebedingten Proarrhythmie konzentrieren soll , werden pathologische Beobachtungen bei Opfern des ploetzlichen Herztodes , Befunde bei Ueberlebenden eines ploetzlichen Herztodes sowie bei prospektiv untersuchten Patientengruppen dargestellt . Diese Befunde zeigen uebereinstimmend , dass die akute Myokardischaemie als interaktiver und arrhythmogener Risikofaktor im Rahmen des ploetzlichen Herztodes bei Patienten mit einer koronaren Herzkrankheit eine bisher meist unterschaetzte Bedeutung zukommt . Dies konnte sowohl fuer Patienten mit einer stabilen Angina pectoris , insbesondere aber fuer Patienten mit einer instabilen Angina pectoris und in der Phase nach Myokardinfarkt gezeigt werden . Der positive Vorhersagewert einer nachweisbaren Myokardischaemie zur Vorhersage eines ploetzlichen Herztodes erweist sich jedoch in den meisten Patientengruppen als zu gering , sodass sich hieraus keine klinisch relevante Risikostratifikation ableiten laesst . Die Arrhythmiediagnostik im konventionellen Sinne z.B. mittels Langzeit-EKG muss hier ebenfalls versagen , da entsprechende Untersuchungen in aller Regel nach Beseitigung einer gegebenenfalls vorhandenen Ischaemie durchgefuehrt werden und somit kaum eine Aussage bezueglich der Arrhythmiegefaehrdung des Patienten beim erneuten Auftreten einer Ischaemie liefern kann . Praeventive Therapieansaetze zur Vermeidung einer Myokardischaemie erscheinen , abgesehen von ihrem allgemeinen Nutzen bei der Reduktion von Morbiditaet und Mortalitaet der koronaren Herzkrankheit , als der vielversprechendste Ansatz und Antiarrhythmikum \" der Wahl \" zur Vermeidung ischaemiebedingter lebensbedrohlicher Proarrhythmien . ,"
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"In der Herzchirurgie ist die Wartezeit immer schon eng gekoppelt mit dem Tod . In einer retrospektiven Untersuchung wurden die Patienten analysiert , die in dem Beobachtungszeitraum A von 1980 bis 1984 oder in dem Beobachtungszeitraum B von 1988 bis 1992 praeoperativ starben . Waehrend des Zeitraums A starben 100 Patienten und in der Beobachtungsperiode B 136 Patienten bei annaehernd gleicher Gesamtzahl an Operationen am offenen Herzen . Die demographischen Angaben machten deutlich , dass waehrend B mehr Patienten mit einer KHK starben als im Vergleichszeitraum A. In beiden Zeitraeumen gehoerte die Mehrzahl der Patienten dem klinischen Schweregrad III ( 71% in A bzw. 64% in B ) an . Der einzige signifikant unterschiedliche Parameter der beiden Gruppen war das mittlere Alter , welches in A 55,7 und in B 62,8 Jahren betrug ( p 0,001 ) . Der Anteil von dringlichen zu elektiven Eingriffen erhoehte sich waehrend B auf 53,7% . Die Analyse der einzelnen Zeitintervalle machte deutlich , dass sich auch im Gesamtkollektiv die Intervalle von der invasiven Diagnostik bis zur Anmeldung zur Operation und von der Anmeldung bis zum Todeszeitpunkt signifikant verringert haben ( p 0,02 ) . Das letztgenannte Intervall in B betrug nur noch 34 Tage . Die Alters- und Morbiditaetszunahme muessen fuer diese Entwicklung verantwortlich gemacht werden . Die praeoperative Letalitaetsrate nahm signifikant von 2,0% ( A ) auf 2,7% ( B ) im Gesamtkollektiv zu ( p 0,02 ) . In den Einzelkollektiven erhoehte sich die Letalitaet im Zeitraum B ebenfalls . Fuer die KHK-Patienten beider Zeitraeume errechnete sich eine mittlere Letalitaet von 2,3% und fuer die Patienten mit einem Aortenvitium eine Sterberate von 4,3% . Eine Morbiditaets- und Letalitaetsanalyse der auf der Warteliste Verstorbenen is dringend erforderlich , da die Letalitaetsraten fuer das Gesamt- und die Einzelkollektive unerwartet hoch und nicht akzeptabel sind ."
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"Allgemeinmassnahmen wie Gewichtsreduktion und -kontrolle , Reduktion der Gesamtfettaufnahme 30% der Gesamtkalorien , Modifikation der Fette , insbesondere Reduktion der tierischen Fette , evtl. Reduktion der Kochsalzaufnahme , verstaerkte Aufnahme ballaststoffreicher Kohlenhydrate , vermehrte koerperliche Aktivitaet in Form der dynamischen Ausdauerbelastung , bewusste Einhaltung von Ruhe- und Entspannungsphasen stellen die Basis der Therapie dar . Fuer die Umsetzung benoetigen jedoch Arzt und Patient Motivation , Information , Geduld und eine klare Zielsetzung . Die 10 Grundregeln aerztlicher Information fuer die Durchsetzung und Kommentierung praeventiver Massnahmen sind dabei zu beruecksichtigen . Dem Patienten muss der neue Lebensstil \" \" mit seiner Ernaehrungsumstellung nicht als eine Strafmassnahme , sondern als ein Gewinn neuer Lebensqualitaet dargestellt werden . Unter dem Aspekt des weit verbreiteten Hyperinsulinismus infolge Insulinresistenz kommt der Gewichtsreduktion , insbesondere bei der maennlichen Adipositas mit vermehrtem Bauchfett , grosse Bedeutung zu , da der Hyperinsulinismus eine Vielzahl von pathogenen Wirkungen auf die Progression der Atherosklerose ausuebt . Der Patient sollte Eigenverantwortung uebernehmen und sein Koerpergewicht und den Blutdruck selbst messen und hierueber Protokoll fuehren ."
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"Die Behandlung der symptomatischen koronaren Mehrgefaesserkrankung mit Ballondilatation ( PTCA ) oder Bypass-Operation ist nach den Ergebnissen von 5 grossen , randomisierten Studien mit vergleichbarem klinischen Erfolg und Risiko moeglich . Nach PTCA ist allerdings die Zahl der Reinterventionen deutlich hoeher . Im Langzeitverlauf war nach der BARI-Studie bei diabetischen Patienten die Letalitaet in der operierten Gruppe geringer . Die individuelle Therapieempfehlung durch den behandelnden Arzt hat sich ebenfalls als wichtiger Faktor fuer die Prognose des Patienten erwiesen . Der Einfluss der neueren Techniken ( Stents ) wird derzeit in weiteren gross angelegten randomisierten Studien untersucht ."
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ZfuerKardiologie.8087s205.ger.abstr | ZfuerKardiologie.8087s205.ger.abstr | [
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"Der hohen Rate an kardiovaskulaerer Mortalitaet , insbesondere der koronaren Herzerkrankung , muessen wir durch praeventive Massnahmen begegnen . Es liegen mehrere Studien vor , die zeigen , dass LDL-Cholesterinsenkung zu einer Reduktion der Koronarereignisse in der Primaerpraevention fuehrten . In der West of Scotland Coronary Prevention Study kam es im Durchschnitt zu einer Risikoreduktion um etwa ein Drittel . Die Umsetzung der vorliegenden Studienergebnisse bedeutet auch , nicht Patienten mit nur erhoehten Cholesterinwerten , sondern mit Hyperlipidaemien und Hochrisikokonstellationen fuer die koronare Herzerkrankung einer Primaerpraevention zuzufuehren . Diese Hochrisikopatienten werden nach ihren weiteren Risikofaktoren , wie z.B. positive Familienanamnese fuer fruehe koronare Ereignisse , arterielle Hypertonie , Rauchen , niedriges HDL-Cholesterin , Diabetes mellitus , erfasst und behandelt . Die Behandlung besteht zunaechst in diaetetischen Massnahmen und Lebensstilaenderungen , wie die Raucherentwoehnung und die Gewichtsreduktion , um LDL-Cholesterinwerte je nach Risikokonstellation zwischen 115 und 175 mg/dl ( 3-4 , 5 mmol/L ) zu erreichen . Durch diese Auswahlstrategie kann die Anzahl der zu behandelnden Patienten , um ein Infarktereignis zu verhindern ( Number Needed to Treat , NNT , 2 ) von 56 bei isolierter Hypercholesterinaemie auf 14-24 reduziert werden . Durch diese Auswahlstrategie kommen wir den 13 zu behandelnden Patienten bei der Sekundaerintervention der koronaren Herzerkrankung durch effektive Lipidsenkung sehr nahe ."
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] |
ZfuerKardiologie.90880010.ger.abstr | ZfuerKardiologie.90880010.ger.abstr | [
{
"id": "ZfuerKardiologie.90880010.ger.abstr-passage-0",
"type": "abstract",
"text": [
"Hypokalzaemie ist eine seltene , reversible Ursache fuer Herzinsuffizienz im Kindesalter . Die wenigen bisher publizierten Faelle von Patienten mit Herzinsuffizienz durch Hypokalzaemie bei Hypoparathyreoidismus wiesen allesamt andere krankheitstypische Symptome auf , bevor sich im Schulalter bzw. in der Adoleszenz eine Herzinsuffizienz entwickelte . Wir berichten ueber ein Kleinkind mit Mitralinsuffizienz , bei der eine Hypokalzaemie durch einen bis dahin asymptomatischen familiaeren Hypoparathreoidismus bereits im Alter von 3,7 Jahren zu einer ausgepraegten Herzinsuffizienz fuehrte . Eine antikongestive Therapie mit Digitals , Diuretika und ACE-Hemmern fuehrte zu keiner Besserung . Erst nach Normalisierung des Serumkalziums kam es zu einer raschen Besserung der klinischen Beschwerden , einem Rueckgang der Hepato- und Kardiomegalie sowie einer Normalisierung der linksventrikulaeren Verkuerzungsfraktion ."
],
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"Hypokalzaemie"
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{
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{
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}
] | [] | [] | [
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"arg2_id": "ZfuerKardiologie.90880010.ger.abstr-s5-t1",
"normalized": []
}
] |
ZfuerKardiologie.90880014.ger.abstr | ZfuerKardiologie.90880014.ger.abstr | [
{
"id": "ZfuerKardiologie.90880014.ger.abstr-passage-0",
"type": "abstract",
"text": [
"Einleitung : Daten zur Prognose der Herzinsuffizienz stuetzen sich bislang auf bevoelkerungsepidemiologische und retrospektive krankenhausepidemiologische Untersuchungen sowie klinische Interventionsstudien . Alle diese Quellen sind nur eingeschraenkt auf den klinischen Alltag uebertragbar ."
],
"offsets": [
[
0,
292
]
]
}
] | [
{
"id": "ZfuerKardiologie.90880014.ger.abstr-s1-t1",
"type": "umlsterm",
"text": [
"Prognose"
],
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23,
31
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],
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"db_id": "C0033325"
}
]
},
{
"id": "ZfuerKardiologie.90880014.ger.abstr-s1-t2",
"type": "umlsterm",
"text": [
"krankenhausepidemiologische"
],
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127,
154
]
],
"normalized": [
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}
]
},
{
"id": "ZfuerKardiologie.90880014.ger.abstr-s1-t3",
"type": "umlsterm",
"text": [
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],
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186,
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]
],
"normalized": [
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"db_name": "UMLS",
"db_id": "C0022023"
}
]
}
] | [] | [] | [
{
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"arg2_id": "ZfuerKardiologie.90880014.ger.abstr-s1-t1",
"normalized": []
}
] |
ZfuerKardiologie.90880023.ger.abstr | ZfuerKardiologie.90880023.ger.abstr | [
{
"id": "ZfuerKardiologie.90880023.ger.abstr-passage-0",
"type": "abstract",
"text": [
"Die Verwendung der A. thoracica interna ( IMA ) als Bypass-Graft bis ins hohe Alter hat sich als Standardverfahren in der Koronarchirugie etabliert . Bei Patienten mit deutlich reduzierter linksventrikulaerer Funktion wird der Einsatz der IMA jedoch in Deutschland noch kontrovers diskutiert , wobei als Hauptargumente gegen die IMA verlaengerte Operationszeiten , hoehere Komplikationsraten sowie ein initial verminderter Blutfluss der IMA angefuehrt werden . In unserer Untersuchung wollten wir die Frage klaeren , ob die Patienten mit reduzierter linksventrikulaerer Funktion ( LVEF 40% ) empfohlen werden kann . 137 Koronarpatienten ( 105 m/32 w ) mit erniedrigter LVEF ( 12-40% ) wurden in die Untersuchung einbezogen . 67 der Patienten erhielten ausschliesslich Venenbypaesse ( Gruppe I ) , bei 70 Patienten wurde routinemaessig die linke IMA als Bypass-Graft verwendet . Als Kriterien fuer Vor- oder Nachteile der IMA wurden Operationszeiten Blutverlust , postoperativer Katecholaminbedarf , , Verweildauer auf der Intensivstation , Myokardinfarktrate und Operationsmortalitaet geprueft . Die Bypassversorgung war mit durchschnittlich 3,1 Bypaessen ( 2-5 ) in beiden Gruppen identisch . Die Operationszeiten ergaben in Abhaengigkeit von der Anzahl peripherer Anastomosen keine signifikanten Unterschiede zwischen den Gruppen . Der Drainageblutverlust betrug in der Gruppe II im Mittel 905 ml bis zu 2. Postoperativen Tag und war damit im Vergleich zu 569 ml in der Gruppe I fast doppelt so hoch ( p > 0,05 ) . Der postoperative Katecholaminbedarf wie auch die haemodynamischen Parameter waren in beiden Gruppen vergleichbar , signifikante Unterschiede ergaben sich nicht . Die postoperative Verweildauer auf der Intensivstation betrug im Mittel 1,6 Tage in beiden Gruppen , die Nachbeatmungszeit war mit 5,8 Stunden ( Gruppe I ) versus 7,9 Stunden ( Gruppe II ) nicht signifikant unterschiedlich . Perioperaktive Ischaemien oder Myokardinfarkte liessen sich bei 2 Patienten ( 3% der Gruppe I ) gegenueber 4 Patienten ( 5,7% ) der Gruppe II nachweisen , der Unterschied war nicht signifikant . Low-output-Syndrome ohne Infarktnachweis traten bei 9 Patienten der Gruppe I ( 13,5% ) versus 2 Patienten der Gruppe II ( 2,9% ) im postoperativen Verlauf auf , der Unterschied zwischen den Gruppen war mit p 0,05 signifikant . Die Operationsmortalitaet betrug 5,9% in der Gruppe I versus 4,3% in der Gruppe II , signifikante Unterschiede zwischen den Gruppen bestanden jedoch nicht . Die Operationsmortalitaet war jedoch in beiden Gruppen deutlich erhoeht gegenueber Koronarpatienten mit normaler Ventrikelfunktion . Zusammenfassend kann festgestellt werden , dass Patienten mit reduzierter LVEF ein deutlich erhoehtes Operationsrisiko haben , die Verwendung der IMA als Bypass-Graft jedoch abgesehen von einem erhoehten Blutungsrisiko keinerlei Nachteile mit sich bringt und somit in Hinsicht auf bessere Langzeitergebnisse auch bei dieser Patientengruppe routinemaessig als Bypass-Graft verwendet werden sollte ."
],
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0,
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]
]
}
] | [
{
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{
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},
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"id": "ZfuerKardiologie.90880023.ger.abstr-s10-t1",
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1535,
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"type": "umlsterm",
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1930
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],
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},
{
"id": "ZfuerKardiologie.90880023.ger.abstr-s12-t2",
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1951
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],
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1980
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},
{
"id": "ZfuerKardiologie.90880023.ger.abstr-s13-t1",
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"text": [
"Low-output-Syndrome"
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},
{
"id": "ZfuerKardiologie.90880023.ger.abstr-s13-t2",
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"text": [
"Infarktnachweis"
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2125,
2140
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},
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},
{
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},
{
"id": "ZfuerKardiologie.90880023.ger.abstr-s14-t1",
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"Im Rahmen des Koelner Modells ( KM ) der ambulanten kardiologischen Rehabilitation der Phase II erfolgten Untersuchungen zur Ermittlung des Bedarf an ambulanter kardiologischer Anschlussrehabilitation ( AR ) nach akuten schwerwiegenden Herzerkrankungen . Analysiert wurde jeweils das koronare Krankengut eines Jahrganges dreier Krankenhaeuser der Grundversorgung , der Kardiologischen Universitaetsklinik sowie der herzoperierten Patienten der Thoraxchirugischen Universitaetsklinik Koeln . Folgende Fragen wurden untersucht : Gesamtzahl der koronaren bzw. herzoperierten Patienten , Anzahl der Patienten mit Indikation zu einer AR sowie der Patienten , die nach den stark eingeengten Kriterien des KM geeignet waren ( nur Patienten unter 65 Jahren , leichterer Krankheitsverlauf , keine herzoperierten Patienten ) . Bei diesen Patienten wurde die Durchfuehrung der Rehabilitation bzw. \" Reha-Verweigerung \" ueberprueft . Anschliessend wurde jeweils eine Stichprobe von KM-geeigneten bzw. herzoperierten Patienten mit dem zusaetzlichen Angebot einer AR konfrontiert . Die Motivation hinsichtlich der Entscheidung fuer stationaer , ambulant oder gegen jede Reha wurde erfragt ."
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ZfuerKardiologie.90880085.ger.abstr | ZfuerKardiologie.90880085.ger.abstr | [
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"Zusammenfassung In der sekundaeren Praevention sind Statine kosteneffizient , sie sind vorteilhafter als andere Lipidsenker insbesondere bei Patienten mit durchgemachtem Herzinfart im Vgl. zu Patienten mit Angina pectoris . Statine sollten deshalb in der Sekundaerpraevention der koronaren Herzerkrankung grosszuegig verabreicht werden . Statine sind in der primaeren Praevention zwar wirksam , aber nicht sehr kosteneffizient . Besonders unguenstige Ergebnisse sind bei Frauen vor der Menopause , juengeren Patienten und solchen mit einem geringen Risikoprofil zu erwarten . Fuer eine bevoelkerungsbezogene primaere Praevention der koronaren Herzerkrankung kommt eigentlich nur eine diaetetische Behandlung in Betracht , die aber eine schlechte Compliance aufweist und deren Wirksamkeit nicht hinreichend belegt ist . Da praeventive Massnahmen ihren eigenen Preis haben und den Ausbruch einer koronaren Herzerkrankung nicht verhindern duerften , duerfte eine derartige Therapie kaum eine Senkung , sondern eher eine Steigerung der \" direkten \" , medizinischen Kosten bedingen . Eine erfolgreiche Praevention der koronaren Herzerkrankung duerfte infolge der Lebensverlaengerung wegen Alters und/oder Erkrankung zu einer Zunahme der Arbeitsunfaehigen und der Behinderten fuehren , so dass nicht nur die direkten \" Kosten , \" sondern vor allem auch die indirekten \" \" fuer Renten , Sozialhilfe , Pflegeheime usw. ansteigen ."
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ZfuerKardiologie.90880090.ger.abstr | ZfuerKardiologie.90880090.ger.abstr | [
{
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"Zusammenfassung Die Zahl der Herzkatheterlabors steigt seit Jahren an . Waehrend es fuer aerztliches Personal allgemeingueltige Aus- und Weiterbildungsverordnungen gibt , fehlt eine solche im Bereich des nichtaerztlichen Assistenzpersonals . Die Qualifikation findet innerbetrieblich statt . Ziel dieser Untersuchung ist die Bestimmung des Aus- und Weiterbildungsbedarfs fuer nichtaerztliches Personal in der interventionellen Kardiologie . Befragt wurden die aerztlichen Leiter sowie das Assistenzpersonal der nordrhein-westfaelischen Herzkatheterlabors . 227 nichtaerztliche Mitarbeiter und 43 aerztliche Leiter aus 48 Labors ( Ruecklaufquote 54,0% ) haben geantwortet . Das Assistenzpersonal rekrutiert sich aus den Pflegeberufen ( 59,1% ) , aus Arzthelfern ( -helferinnen ) ( 28,2% ) und Medizinisch-Technischen Assistenten ( 10,1% ) . 85,0% sind weiblich , das Durchschnittsalter liegt bei 34,3 Jahren . 73,1% wurden nicht in der eigenen Klinik oder Praxis ausgebildet . 51,8% der Beschaeftigten waren vor der jetzigen Taetigkeit in der Krankenpflege , 17,6% in den internistischen Funktionsbereichen beschaeftigt . Keiner der 227 befragten Mitarbeiter befand sich zum Zeitpunkt der Befragung in Ausbildung im Herzkatheterbereich , obwohl 68,3% der Kliniken und Praxen selber ausbilden . Neun von zehn Labors bieten betriebsinterne Weiterbildungsmassnahmen an - vor allem in den Bereichen \" Strahlenschutz \" ( 82,1% und \" medizinische Themen \" ( ) 66,7% ) - , und 85,3% der befragten Mitarbeiter haben bereits an diesen teilgenommen . Von den aerztlichen Leitern und nichtaerztlichen Assistenten erachten 90,0% resp. 99,2% allgemeine Fort- und Weiterbildungsmassnahmen fuer notwendig . Das Assistenzpersonal sieht den Bedarf vor allem in den Fachgebieten \" Medizin \" ( 77,6% ) , \" Untersuchungsassistenz \" ( 67,0% ) und EDV \" ( \" 60,4% ) , waehrend die aerztlichen Leiter die Themen \" Qualitaetssicherung \" ( 89,2% ) und Strahlenschutz \" ( \" 86,5% ) fuer wichtig erachten . Allgemeine Ausbildungsmassnahmen begruessen 82,9% der aerztlichen Leiter . Die Stellensituation fuer Assistenzpersonal in der interventionellen Kardiologie ist , gemessen an anderen Bereichen , gut . Viele Labors planen , neue Mitarbeiter einzustellen ( 14,3% ) oder die Zahl an Planstellen konstant zu halten ( 61,9% ) . Der Anteil an Teilzeittaetigkeit ist gering ( 16,8% ) . Die bisherige Praxis der Berufsausbildung ist nicht bedarfsorientiert . Es fehlt an allgemeinen Weiterbildungsmassnahmen fuer bereits beschaeftigte Mitarbeiter , ausserdem sollten Ausbildungsmoeglichkeiten fuer Assistenzpersonal angeboten werden . Ein allgemeingueltiges Unterrichts- und Pruefungsverfahren ist anzuzstreben , die Ausbildung sollte in speziellen Schulungs- und Qualifikationszentren durchgefuehrt werden ."
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ZfuerKardiologie.90880097.ger.abstr | ZfuerKardiologie.90880097.ger.abstr | [
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"Zusammenfassung Atriale Reentry-Tachykardien ( ART ) stellen eine potentiell lebensbedrohliche Frueh- oder Spaetkomplikation nach Operationen angeborener Herzfehler dar . Im Zeitraum von Juli 1993 bis Dezember 1997 wurden 29 Episoden einer ART bei 19 postoperativen Patienten transoesophageal elektrisch konvertiert . Das Alter der Patienten betrug 1 Monat bis 26 Jahre ( Mittel 9,8 Jahre ) . Das Zeitintervall zwischen Operation und Auftreten der ersten Tachykardieepisode reichte von 1 Tag bis zu 19 Jahren . Bei 6 Patienten trat die ART-Episode in den ersten 2 Wochen nach Operation des Vitiums auf , bei 13 Patienten zu einem spaeteren Zeitpunkt ( 1 bis 19 Jahre postoperativ ) . Zum Zeitpunkt der transoesophagealen Untersuchung waren 17 von 19 Patienten medikamentoes antiarrhythmisch behandelt ; 2 Patienten waren mit einem Einkammer-Schrittmachersystem ( VVIR-Modus ) versorgt . Zur Konversion wurde ein quadripolarer Elektrodenkatheter in Vorhofhoehe im Oesophagus plaziert , ueber den ein Oesophagussignal abgeleitet und die Vorhofstimulation durchgefuehrt wurde . Die atrialen Zykluslaengen der Tachykardien betrugen 160-380 ms mit 1:1- bis 4:1-AV-Ueberleitung. Zur Konversion wurde ein Algorithmus , beginnend mit 4 Extrastimuli ( 20 ms kuerzer als die atriale Zykluslaenge der Tachykardie ) , eingesetzt . Die Konversion der ART wurde bei 27 von 29 Tachykardieepisoden ( 93% ) effektiv und komplikationslos durchgefuehrt . In 3 Faellen gelang die elektrische Konversion erst nach Gabe von Amiodarone 5 mg/kg KG i.v. In 20 Faellen bestand unmittelbar nach Konversion Sinus- bzw. Schrittmacherrhythmus . In 9 Faellen kam es zum Auftreten von Vorhofflimmern , das in 7 Faellen spontan in einem Sinusrhythmus konvertierte und in 2 Faellen persistierte , so dass zu einem spaeteren Zeitpunkt eine externe Kardioversion durchgefuehrt werden musste . Zusammenfassend ist nach diesen Ergebnissen die transoesophageale Elektrokonversion als effektive , wenig invasive Methode zur Akuttherapie postoperativer atrialer Reentry-Tachykardien anzusehen ."
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ZfuerKardiologie.90880103.ger.abstr | ZfuerKardiologie.90880103.ger.abstr | [
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"Zusammenfassung Ziel dieser kontrollierten , prospektiven , randomisierten Studie war die Untersuchung der Effektivitaet und der Sicherheit einer reduzierten Defibrillationsenergie mit biphasischer Schockform und einem endokardialem ICD-Sondensystem . 176 Patienten , die klinisch ein typisches ICD-Patientenkollektiv darstellten , wurden im Rahmen der Studie untersucht . Alle Patienten erhielten ein ICD-Aggregat mit der Moeglichkeit der Episodenspeicherung ( Ventak TM PRx II , PRx III ) in Verbindung mit einem rein endokardialem Sondensystem ( Endotak TM Serie 0070 ; 0090 , CPI ) . Die intraoperative Defibrillationsschwelle ( DFT ) sollte =15 J betragen . Die DFT wurde in einem Protokoll mit absteigenden Energiemengen ( 15 , 10 , 8 , 5 J ) ermittelt . Die niedrigste effektive Energiemenge zur Terminierung von induziertem Kammerflimmern musste einmal bestaetigt werden und wurde als DFT+ definiert . Eine Ueberpruefung der Effektivitaet der DFT+ erfolgte im Rahmen der ICD-Implantation , vor der Krankenhausentlassung und nach einem Jahr . Die Randomisierung erfolgte in zwei Gruppen , wobei in der Studiengruppe der erste Schock auf einen Wert von 2x DFT+ und alle folgenden auf die maximale Energie ( 34 J ) programmiert wurden . In der Kontrollgruppe wurden alle Schocks auf 34 J eingestellt . Verglichen wurden die Ergebnisse der reduzierten und maximalen Schockenergie bei induziertem Kammerflimmern sowie die Effektivitaet bei spontanen Arrhythmieepisoden im Langzeitverlauf . Eine DFT+ =15 J ( im Mittel 9,6+/-3,2 J , Studiengruppe ; 10,1+/-3,5 J , Kontrollgruppe ) wurde bei 166/176 Patienten ( 94% ) ermittelt . Die Reproduzierbarkeit der Defibrillationseffektivitaet mit der DFT+-Energie nach einem Jahr betrug 84% . Induziertes Kammerflimmern ( VF ) konnte in der Studiengruppe in 217/218 Faellen ( 99,5% ) und in der Kontrollgruppe in 201/203 Faellen ( 99% ) erfolgreich durch den ersten Schock terminiert werden . Im klinischen Verlauf wurden in der Studiengruppe 83/86 Episoden ( 96,5% spontaner monomorpher Kammertachykardien ( ) MVT ) und 38/40 Episoden VF ( 95% ) mit dem 2x DFT+-Schock beendet . In der Kontrollgruppe konnte eine erfolgreiche Konversion mit dem ersten Schock bei 151/156 spontaner MVT-Episoden ( 96,8% ) und bei 30/33 VF-Episoden ( 91% ) beobachtet werden . Die Effektivitaet des ersten Schocks in der Studiengruppe war unabhaengig von der kardialen Grunderkrankung , der linksventrikulaeren Funktion , einer begleitenden Amiodarontherapie der Haeufigkeit der spontanen Arrhythmieepisoden und von dem DFT+-Wert selbst . Die Inzidenz des ploetzlichen Herztodes ( 2,4% Studien- vs. 3,8% Kontrollgruppe ) unterschied sich nicht signifikant . Die Effektivitaet einer auf 2x DFT+-reduzierten Energiemenge des ersten Schocks unterscheidet sich nicht von der bei einer Einstellung auf 34 J , sowohl in bezug auf induziertes VF als auch bei spontanen Episoden von VT oder VF . Durch die Programmierung der 2x DFT+-Schockenergie wurde die Sicherheit der ICD-Therapie nicht beeintraechtigt ."
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"Zusammenfassung Waehrend eines 4woechigen ambulanten Rehabilitationsprogramms wurden 262 KHK-Patienten , 235 Maenner und 27 Frauen , Durchschnittsalter 53,6+/-10,2 Jahre , im Mittel 30,5+/-2,9 Therapiestunden im Bereich der Bewegungs- und Sporttherapie unterzogen . Inhaltlicher Schwerpunkt war ein dosiertes Ergometertraining 5 mal pro Woche . Im Mittel wurden 18,4+/-1,8 Trainingseinheiten auf dem Ergometer absolviert . Vor und nach der Rehabilitation wurde die Leistungsfaehigkeit mittels einer Belastungsuntersuchung auf dem Fahrradergometer ueberprueft . Auf jeder Belastungsstufe wurde neben Pulsfrequenz- und Blutdruckmessung auch eine Blutprobe aus dem hyperaemisierten Ohrlaeppchen entnommen fuer die Bestimmung der Laktatkonzentration im arterialisierten Blut . Die Bestimmung der Laktatkonzentration bei ansteigender Belastung ermoeglicht eine exakte Beurteilung der Ausdauerleistungsfaehigkeit und dadurch eine gezielte Intensitaetssteuerung waehrend der Therapie . Weiter kann durch die Kontrolle des Laktatwertes der Therapieerfolg objektiv nachgewiesen werden . Die Ergebnisse der Vor- und Nachuntersuchung zeigten eine hochsignifikante Steigerung der maximalen Ergometerleistung von 105,3+/-32,3 auf 121,9+/-37,3 Watt . Die relative Leistungsfaehigkeit wurde von 1,30+/-0,39 auf 1,51+/-0,44 Watt/kg Koerpergewicht erhoeht . Die mittlere Leistung bei 2,0 mmol/l Laktat im Blut wurde von 72,2+/-23,5 auf 86,4+/-25,8 Watt um 19,7% , bei 2,5 mmol/l von 83,5+/-23,2 auf 97,4+/-26,4 Watt um 16,6% und , bei 3,0 mmol/l von 93,1+/-23,0 auf 106,6+/-26,1 Watt um 14,5% jeweils hochsignifikant gesteigert . Die Herzfrequenz bei der Belastung von 2,0 , 2,5 und 3,0 mmol/l Laktat blieb trotz erhoehter Wattleistung unveraendert . Die Leistung fuer definierte Herzfrequenzwerte wurde bei allen definierten Herzfrequenzwerten ( 85 , 90 , 95 , 100 , 105 , 110 ) jeweils hochsignifikant erhoeht . Am deutlichsten war die Steigerung bei Herzfrequenz 110/min mit 22,8% . Die Ergebnisse zeigen , dass durch die Rehabilitation die Leistungsfaehigkeit der Patienten verbessert wurde . Wie die Veraenderung der erreichten Wattleistung fuer definierte Laktat- und Herzfrequenzwerte zeigt , basiert die beobachtete Leistungssteigerung auf einer Verbesserung der Ausdauerleistungsfaehigkeit mit Oekonomisierung der Herzkreislauffunktion , verbunden mit einer fuer den Herzpatienten wertvollen Senkung der Herzfrequenz , und nicht lediglich auf dem psychologischen Effekt einer gesteigerten Ausbelastung auf Grund einer staerkeren Motivation des untersuchten Patietnen bzw. der Untersucher . Der Bezug auch auf die Laktatwerte liess diesen Effekt auch unabhaengig von eventueller medikamentoeser Einwirkung ( -Rezeptoren-Blocker ) nachweisen ."
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"Zusammenfassung Die Stentimplantation ist bei proximalen Laesionen eines Koronargefaesses mit grossem Versorgungsbereich und einem Gefaessdurchmesser von 2,75-3,5 mm das Mittel der Wahl . Eine Verkuerzung der Untersuchungsdauer , der Durchleuchtungszeit sowie der Ischaemiezeit , des der Laesion nachgeschalteten Myokards bei der Implantation von Stents wird angestrebt . Im folgenden wird ein neues therapeutisches Konzept der direkten Implantation eines Stents ohne vorherige Vordilatation vorgestellt , das mit einem speziell entwickelten Ballonkatheter getestet wurde , auf welchem verschiedene 14-16 mm lange \" Slotted-tube \" -Stents zwischen zwei konischen , roentgendichten Markern befestigt sind . Bei 105 konsekutiven Patienten , welche zu einer Angioplastie vorgesehen waren , wurde die direkte Stentimplantation durchgefuehrt . 6 Eingriffe fanden bei akuten Myokardinfarkten , 8 Eingriffe im Rahmen von Hochrisiko-Ballondilatationen statt . Die direkte Stentimplantation war bei 88% der Patienten erfolgreich . In 6% der Faelle konnte der Stent erst nach Vordehnung der Laesion eingesetzt werden . In 6% der Laesionen konnte der Stent auch mit anderen verfuegbaren Systemen nicht implantiert werden . Vergleicht man die Patienten , bei denen die direkte Stentimplantation erfolgreich war , mit den Patienten , bei denen die herkoemmliche Methode der Stentimplantation mit Vordilatation angewendet wurde , oder mit den Patienten , bei denen keine erfolgreiche Stentimplantation durchgefuehrt werden konnte , war der Nachweis angiographisch sichtbarer Verkalkungen im Bereich der Laesion bei den erfolglosen Untersuchungen haeufiger ( 80% vs. 18% ; p 0,01 ) , und die Patienten waren im Durchschnitt aelter ( 72+/-7 vs. 61+/-11 Jahre ; p 0,01 ) . Die Erfolgsrate der direkten Stentimplantation wurde nicht durch den primaeren Stenosegrad vor PTCA beeinflusst . Die Durchleuchtungszeit betrug bei der direkten Stentimplantation 8,4+/-4,9 min , bei der Stentimplantation mit Vordilatation 13,7+/-8,0 min ( p 0,05 ) . Bei der direkten Implantation eines Stents war die Anzahl der verwendeten Ballons pro Laesion ( 1,4+/-0,4) im Vergleich zur Stentimplantation mit Vordilatation ( 1,7+/-0,7) niedriger , aber nicht signifikant verschieden . Stentdislokationen wurden in 3,8% der Behandlungen beobachtet , in einem Fall fuehrte dies zu einer Embolisation des Stents . Vermeidet man erheblich verkalkte koronare Laesionen bei den Behandlungen der Patienten mittels direkter Stentimplantation , stellt diese Methode eine Moeglichkeit dar , die Stentimplantationen mit kuerzeren Durchleuchtungszeiten , weniger Ballons und dem potentiellen Vorteil kuerzerer Ischaemiezeiten zu realisieren . Dies sollte in weiteren , umfangreicheren Studien , auch unter Beachtung einer Lernkurve hinsichtlich der neuen Methode , geprueft werden . Ob dieses Vorgehen die Restenosenquote senken wird , bleibt weiteren Untersuchungen vorbehalten ."
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"Zusammenfassung Eine Erhoehung des pulmonalen Gefaesswiderstandes ( PVR ) oder des transpulmonalen Gradienten ( TPG ) ist ein wesentlicher Risikofaktor einer erhoehten 3-Tages- und 3-Monats-Letalitaet nach Herztransplantation . Die Reversibilitaet erhoehter PVR- oder TPG-Werte gilt als Praediktor einer geringeren Wahrscheinlichkeit eines perioperativen Rechtsherzversagens und Letalitaet . Bei 29 Rechtsherzkatheteruntersuchungen von 23 Patienten ( 54+/-8 Jahre , mittlerer NYHA-Grad 3,1+/-0,6) mit ischaemischer ( n=8) bzw. dilatativer ( n=15) Kardiomyopathie und einem PVR > 2,5 WU ( Wood-Einheiten ) oder einem TPG > 15 mm Hg testeten wir die Reversibilitaet der pulmonalvaskulaeren Widerstandsparameter durch Prostaglandin I2 i.v. ( PGI2, mittlere Dosierung 13,5+/-6,4 ng/kg/min ) in stufenweise ansteigender Dosierung . Eine moegliche Korrelation der Reversibilitaet von PVR und TPG unter PGI2 zu haemodynamischen und echokardiographischen Parametern , Patientendaten und Laborwerten wurde untersucht . Bei allen HTx-Kandidaten konnte ohne symptomatische systemische Hypotension eine Senkung des PVR in transplantable Bereiche ( 4 WU ) erreicht werden ( im Mittel von 4,7+/-1,3 WU auf 2,3+/-0,6 WU , p 0,01 ) . Im Schnitt wurde der PVR unter PGI2 auf 52+/-17% des Ausgangswertes gesenkt . Nicht reversible Erhoehungen von PVR und TPG wurden nicht beobachtet . In 62% der Untersuchungen konnten PVR und TPG in den optimalen Zielbereich ( PVR =2 , 5 WU , TPG =15 mm Hg ) gesenkt werden . Das Ausmass der Reversibilitaet von PVR und TPG war individuell verschieden und zeigte keine Korrelation zum pulmonalarteriellen oder pulmonalkapillaeren Mitteldruck , Herzzeitvolumen , Aortenmitteldruck , zu echokardiographischen Parametern ( EDD , FS , ES-Abstand ) , Laborwerten ( Natrium Harnstoff , Bilirubin ) , , zur Medikation , zum Patientenalter oder zur Erkrankungsdauer . Der Ausgangs-PVR korrelierte jedoch invers mit dem prozentualen PVR-Wert unter PGI2 ( r=-0,76, p 0,05 ) . Bei hoehergradiger Herzinsuffizienz senkt Prostaglandin I2 regelhaft und systemisch tolerabel erhoehte PVR-Werte in transplantable Bereiche . Das individuell unterschiedliche Ausmass der Reversibilitaet ist durch basale haemodynamische Parameter und Patientendaten nicht erklaerbar ."
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"Zusammenfassung Neben der Blutung stellt die Heparin-induzierte Thrombozytopenie Typ II ( HIT Typ II ) die schwerwiegendste Komplikation einer Heparintherapie dar . Ein 71jaehriger Patient zeigte am 11. postoperativen Tag nach einer 4-fach aortokoronaren Bypass-Operation einen posterolateralen Myokardinfarkt und eine Thrombozytopenie von 80000/µl, die als postoperativ bedingt gedeutet wurde . Koronarangiographisch zeigte sich ein Verschluss der Venenbypaesse . Die rechte Koronararterie ( RCA ) wurde durch perkutane transluminale koronare Angioplastie ( PTCA ) mit konsekutiver Stentimplantation revaskularisiert . Prediagnostisch und peri-interventionell erhielt der Patient bei unveraenderter Thrombozytopenie um 80000/µl Heparin . Vier Tage spaeter erlitt der Patient einen Hinterwandinfarkt mit AV-Block III und Synkope . Nach passagerer Schrittmachereinlage zeigte sich koronarangiographisch ein Verschluss der RCA . Unter dem Verdacht auf eine HIT Typ II wurde die Rekanalisation unter Antikoagulation mit Lepirudin ( Refludan ) durchgefuehrt . Bei frischen Thromben in der RCA nach Drahtrekanalisation wurde zusaetzlich Abciximab Reo ( pro ) appliziert . Die Kontrollkoronarangiographie am Folgetag zeigte lediglich eine kleine Restthrombusperle in der proximalen RCA . Der AV-Block III Grad bildete sich spontan zurueck . Die Diagnose HIT Typ II wurde durch den Heparin-induzierten Plaettchenaktivierungstest ( Hipa-Test ) und den Immunassay nach Amiral et al. ( PF 4/Heparin-ELISA) bestaetigt . Der vorliegende Fall demonstriert die oft schwierige Diagnose einer HIT Typ II und den erfolgreichen , simultanen Einsatz von Lepirudin ( Refludan ) und Abciximab ( Reo pro ) . Zur Prophylaxe einer HIT Typ II sollten die Thrombozytenzahlen regelmaessig kontrolliert , bei Unsicherheit ueber das Vorliegen einer HIT Typ II Heparin fruehzeitig abgesetzt und die Bestimmung des Hipa-Tests und des PF 4/Heparin-ELISA eingeleitet werden ."
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"Durch die Einfuehrung der minimalinvasiven Koronarchirurgie ist das methodische Spektrum zur Behandlung der koronaren Herzerkrankung erneut differenzierter geworden . Die Moeglichkeiten des minimalen Zugangs durch Teilsternotomie oder durch interkostale anteriore Minithorakotomie koennen mit videoskopischen Methoden und mit sog . Port-access-Verfahren kombiniert werden . Neben der normalen atrio-aortalen Kanuelierung fuer den Anschluss der Herz-Lungen-Maschine sind jugular- und femoro-femorale Anschluesse an die Herz-Lungen-Maschine moeglich . Sogar die intravasale endoluminale Ballonokklusion der Aorta ascendens und die Applikation von kardioplegischer Loesung ueber den Okklusionskatheter in den Aortenbulbus koennen in die Ueberlegung einbezogen werden ."
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"Vorhofflimmern ( VHF ) ist die haeufigste aller Herzrhythmusstoerungen . Trotz einer grossen Zahl klinischer Studien sowie einer Vielzahl von Publikationen in den vergangenen Jahrzehnten wird die Therapie des VHF in der klinischen Routine wie auch in wissenschaftlichen Untersuchungen kontrovers diskutiert . Die vorliegende Studie soll folgende wesentliche Fragen beantworten : 1. Wie hoch ist die spontane Rezidivquote von VHF im Langzeitverlauf nach Kardioversion ? Die Mehrzahl bisher veroeffentlichter Studien benutzte das Auftreten von Symptomen als Surrogatparameter fuer VHF-Rezidive . Angesichts der grossen Zahl asymptomatischer VHF-Episoden erscheint diese Methode nicht geeignet . In dieser Studie soll die taegliche , nicht symptomgebundene transtelephonische EKG-Uebertragung valide Erkenntnisse ueber den Spontanverlauf nach elektrischer Kardioversion ergeben . 2. Laesst sich die Anzahl von VHF-Episoden im Langzeitverlauf durch eine antiarrhythmische Dauermedikation signifikant senken ? Ein direkter Vergleich von Klasse-I- und -III-Antiarrhythmika und Placebo soll diese Frage beantworten . 3. Wie sicher ist die medikamentoese Prophylaxetherapie im Langzeitverlauf ? Die taegliche transtelefonische EKG-Uebertragung ermoeglicht die quantitative und qualitative Erfassung von Tachy- und Bradyarrhythmien , auch unabhaengig von Symptomen . Darueber hinaus sollen auf der Basis taeglicher Messwerte EKG-Parameter entwickelt werden , die nachfolgende lebensbedrohliche Arrhythmien fruehzeitig erkennen lassen ."
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