Zeitschrift für Kardiologie
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A 53-year-old male patient with severe chronic heart failure due to ischemic cardiomyopathy (LVEF 25%) awaiting heart transplantation was admitted for resection of a bladder tumor. The patient underwent implantation of a Chronicle implantable hemodynamic monitor (IHM) two years before. Thus, perioperative monitoring of heart rate, right ventricular systolic, diastolic and pulse pressure, dP/dt and estimated pulmonary artery diastolic pressure through a lead implanted in the right ventricle was performed. ⋯ Patients with cardiac disease are known to be at increased risk for cardiovascular complications after noncardiac surgery. Therefore, it has been suggested that such patients could potentially benefit from perioperative invasive hemodynamic monitoring. For the first time, we report a case of perioperative continuous hemodynamic monitoring with a long term-implanted device in a potential heart transplant patient.
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Case Reports
[Hemorrhagic nonspecific pericardial effusion as an initial symptom of angiosarcoma of the right heart].
A 45-year old woman presented at our hospital with intermittent fever in the last three weeks and progressive exertional dyspnea. In addition she suffered from physical asthenia. Seven months ago the patient was treated for symptomatic pericardial effusion in our clinic. ⋯ Primary malignant cardiac tumors are rare and their prognosis is very poor. The heart angiosarcoma is often disseminated into the lungs and the liver at the time of clinical presentation. This case indicates that hemorrhagic nonspecific pericardial effusion, negative for tumor cells, can appear any time before a heart angiosarcoma is detectable by echocardiography.
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Comparative Study
[Urgent or emergent coronary revascularization using bilateral internal thoracic artery after previous clopidogrel antiplatelet therapy].
Application of clopidogrel before diagnostic or therapeutical percutaneous coronary interventions has become standard for stent-thrombosis prevention. The irreversible platelet inhibition causes increasing bleeding complications if urgent coronary artery bypass grafting becomes necessary. This study evaluates the effect on bleeding complications of clopidogrel in urgent CABG using bilateral internal thoracic artery (ITA) and saphenous veins in all patients. ⋯ Previous application of clopidogrel in combination with aspirin before urgent CABG induces increased chest tube output, reexploration rate and necessity of blood products, especially of plateletes. Nevertheless, routine use of both ITAs in patients after clopidogrel exposure can be performed with acceptable bleeding complications.
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Comparative Study
[Prediction of outcome in ST elevation myocardial infarction by the extent of ST segment deviation recovery. Which method is best?].
Simple and rapid measures are needed for timely assessment of the quality of reperfusion therapy early after fibrinolysis in acute STEMI. Sum ST segment elevation resolution (sum STR) categorized into the three groups of low risk (complete ST resolution), medium risk (partial ST resolution), and high risk (no ST resolution) has become an established method to predict infarct size, left ventricular function, epicardial vessel patency, and mortality. However, measurement of the sum of ST elevation from all leads of repeated ECG's is time-consuming. For routine practice more simple measures are needed. This report summarizes recent findings on direct comparisons between different modes of evaluation of ST segment deviation recovery employed for risk stratification in large-scale mortality trials. With respect to predictive accuracy combined with simplicity, two methods were superior to the conventional model of sum STR: 1) ST segment deviation resolution in only the one ECG lead showing the maximal deviation (single lead STR), and 2) the existing ST segment deviation in the single ECG lead of maximum deviation present 90 or 180 min after start of fibrinolysis (max STE). In multivariate analyses the ST segment deviation recovery models including sum STR were significant independent predictors of short- and long-term mortality. In receiver-operating characteristic (ROC) curves for predicting mortality the analysis of single lead STR and max STE performed better than sum STR. After categorization into risk groups patients are best classified by max STE. With an ECG recorded at 90 min in 2719 patients, the proportion of patients of sum STR, single lead STR, and max STE were 40, 34, and 43% in the low risk groups, and 24, 31, and 25% in the high risk groups. Cardiac mortality rates at 30 days were 2.0, 1.2, and 1.0% in low risk versus 9.6, 10.3, and 12.8% in the high risk groups, respectively. Long-term mortality with a followup of 5 years was best predicted by max STE risk groups. ⋯ Single lead STR and max STE are very simple, inexpensive, non-invasive, and highly reliable measures which provide very strong early prognostic information. The relationship between degree of ST segment deviation recovery and subsequent mortality is remarkably consistent. Both methods perform better than sum STR in predicting mortality. They can be used for very early risk stratification and can form a basis for an individual treatment of patients after fibrinolysis for STEMI within 6 hours of symptom onset. Of the two methods max STE is even simpler to use and has better accuracy in predicting outcome.