Zeitschrift für Kardiologie
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With the increasing use of cross-sectional echocardiography in patients with overt or suspected pulmonary thromboembolism in the emergency rooms, more and more right atrial thrombi are detected. These are so-called "transitthrombi" from the venous system on their way to the pulmonary arteries and they are a severe presentation of thromboembolic disease. They appear as an imminent pulmonary embolism and usually coexists with an already massive embolism. ⋯ In about half of the cases transesophageal echocardiography was done additionally for diagnosis and monitoring. Therapeutic options were thrombectomy, fibrinolysis or anticoagulants. We treated one of our patients with thrombectomy, eleven patients with fibrinolysis and two patients with anticoagulants.
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There is a significantly higher incidence of cerebral ischemia among patients with an atrial septal aneurysm and/or a patent foramen ovale. According to the information provided by modern diagnostic procedures--and in particular by transesophageal echocardiography--two pathogenic mechanisms should be considered as possible causes of the cerebral ischemia. Thrombi may develop locally in the left atrium or atrial septal aneurysm and lead to embolization or, alternatively, thrombi from the inflow region of the inferior vena cava may become trapped in the atrial septal aneurysm and pass through the patent foramen ovale to bring about embolization in the arterial bloodstream. ⋯ As with the surgical treatment of atrial septal defects in general, the risk of the operation (or of subsequent complications) is very slight indeed. No such problems arose in any of our patients, no blood transfusions were necessary, and after short postoperative treatment they could all be discharged. For younger patients with little risk from the treatment itself, we regard surgical intervention in cases of atrial septal aneurysm with a patent foramen ovale and cerebral ischemia as an important therapeutic alternative.
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Coronary surgery is at this point of time the standard therapy of unprotected left main coronary artery stenosis. Coronary angioplasty (PTCA) is performed only in bail out situations. The number of publications of successful percutaneous intervention in unprotected left main coronary stenosis is increasing because of increasing use of stents and ticlopidine to avoid stent-thrombosis. ⋯ Two patients out of these 6 had restenoses in the left main coronary artery which were re-dilated (17%). Another 2 patients had stenoses in other coronary segments and were also dilated. Thus, stenting of left main coronary artery stenoses is feasible, however, with acceptable risks and could be considered in selected patients as an alternative to coronary artery surgery.
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Minimally invasive direct coronary artery bypass (MIDCAB) grafting without cardiopulmonary bypass (CPB) through an anterolateral minithoracotomy has become a promising therapeutical option especially in multimorbid, elderly and reoperative patients with single vessel disease. However, this procedure precludes complete revascularization in multivessel disease because the minithoracotomy limits the surgical access either to anterior or lateral or posterior vessels of the beating heart. To expand the benefits of the MIDCAB concept to patients with multivessel disease, new interdisciplinary approaches have recently been introduced. ⋯ Our preliminary results of a "hybrid" approach to myocardial revascularization suggest that this concept is a safe and effective approach of complete revascularization for selected patients with multivessel involvement. Especially elderly and reoperative patients with significant comorbidity may benefit from hybrid procedures avoiding cardiopulmonary bypass and midsternotomy.