Gerrit Hagenah

Cheyne-stokes respiration and prognosis in congestive heart failure

Patients with congestive heart failure (CHF) frequently demonstrate Cheyne-Stokes respiration (CSR) with repetitive arousals and oxygen desaturations during sleep. Although it was evident from early publications that CSR during the daytime is a poor prognostic indicator in patients with CHF, it was speculated recently that CSR occurring during sleep could impede left ventricular function and even survival. We therefore followed up 36 patients with CHF and a left ventricular ejection fraction < or = 40% who underwent a sleep study at our institution. The patients showed a reduced ejection fraction (20 +/- 8%) and CSR with a median of 19% of total sleep time (lower and upper quartiles 9% and 56%). In 12 +/- 9% of their time in bed, the arterial oxygen saturation was <90%. No patient was lost to follow-up, which lasted for 32 +/- 15 months (range 11 to 53). One-year survival was 86 +/- 6%, and 2-year survival was 66 +/- 8%. Univariate comparisons for survival between groups stratified by the amount of CSR revealed no significant difference (log rank test, p = 0.84). However, the 20 patients with a left ventricular ejection fraction <20% had a shorter mean survival time than patients with an ejection fraction >20% (9.5 vs 28.3 months; log rank test, p = 0.013). Two patients with CSR during the daytime died within 1 month. No other patient had CSR during the daytime, and only 1 patient without daytime CSR died within 1 month (chi-square test, p <0.001). Higher age, reduced carbon dioxide end-tidal partial pressure, and increased transit time were found to be significantly related to the amount of nocturnal CSR. In conclusion, CSR occurring during sleep has no important prognostic impact in patients with CHF, but CSR present during the daytime suggests a high likelihood of dying within a few months.

Association of Cheyne–Stokes respiration and cardiac cachexia in congestive heart failure

In patients with congestive heart failure (CHF) cachexia as well as Cheyne-Stokes respiration (CSR) are well known disorders. The relationship between CSR and cardiac cachexia however, remains unclear so far. Clinical as well as full-night polysomnographic data from 12 cachectic patients were compared to 13 non-cachectic patients with CHF. The non-cachectic patients did not differ significantly in age (57.3+/-11.6 vs 64.8+/-14.5 years), body mass index (26.4+/-4.0 vs 25.2+/-3.2 kg m-(2)) or ejection fraction (21.8+/-5 vs 23.3+/-7%) from cachectic patients. The weight loss was 2.1+/-2.3 kg in non-cachectic vs 11.5+/-2.7 kg in cachectic patients (p<0.0001). A significant difference was detected for the prevalence CSR (5 vs 10 patients, p<0.03). In this study a high prevalence of sleep breathing disorders, in particular of CSR in CHF patients with cachexia was detected.

Importance of surfactant proteins B and D for the differential diagnosis of acute dyspnea

ZusammenfassungHintergrund und Ziel:Grundlage für eine optimale Therapie kardiopulmonaler Erkrankungen ist die frühzeitige Diagnosestellung. Dies beinhaltet die differentialdiagnostische Beurteilung der akuten Dyspnoe. In zahlreichen Studien wurden die natriuretischen Peptide als zusätzliche, aussagekräftige Parameter für die Beurteilung der linksventrikulären Funktion beschrieben. In neueren Studien finden die lungenepithelspezifischen Surfactant-Proteine B (SP-B) und D (SP-D) als diagnostische Parameter Eingang in die weitere Abklärung einer Dyspnoe. Ziel dieser Untersuchung war es, die differentialdiagnostische Wertigkeit von NT-proBNP (N-terminales Spaltprodukt des „brain natriuretic peptide“) und Surfactant-Proteinen bei Patienten mit akuter Dyspnoe zu vergleichen.Patienten und Methodik:NT-proBNP, SP-B und SP-D wurden bei 81 Patienten mit akuter Dyspnoe in der Notaufnahme bestimmt und mit klinischen und echokardiographischen Parametern im Rahmen der endgültigen Diagnosestellung korreliert. Hierzu wurden die Patienten nach klinischen und echokardiographischen Parametern in verschiedene Untergruppen entsprechend der Ursache der akuten Dyspnoe eingeteilt.Ergebnisse:Patienten mit kardial bedingter akuter Dyspnoe hatten gegenüber Patienten mit nichtkardiopulmonaler Ursache einen signifikant erhöhten NT-proBNP-Spiegel (p = 0,04). Das SP-D zeigte bei Patienten mit kardialer Ursache einer akuten Dyspnoe die signifikant höchsten Plasmaspiegel, ist aber nach Durchführung der Regressionsanalysen von geringerer Bedeutung für die Differentialdiagnose der akuten Dyspnoe als das NT-proBNP. Die SP-B-Plasmaspiegel waren in den einzelnen Untergruppen nicht signifikant verschieden.Schlussfolgerung:Das NT-proBNP ist für die Differentialdiagnose der akuten Dyspnoe von Bedeutung. Auch wenn das SP-D ähnliche Plasmaspiegelveränderungen wie das NT-proBNP für die einzelnen Subgruppen aufweist, scheint es insgesamt von geringerer Bedeutung für die Differentialdiagnose zu sein. Das SP-B scheint für die Diagnosestellung einer kardialen oder pulmonalen Ursache bei akuter Dyspnoe ohne Bedeutung zu sein.AbstractBackground and Purpose:The basis for an optimal therapy of cardiopulmonary diseases is the assessment of an early diagnosis. This implies an evaluation of possible differential diagnoses of acute dyspnea. In numerous studies, natriuretic peptides were characterized as additional, meaningful parameters for the assessment of left ventricular function. Current studies could demonstrate that surfactant proteins B (SP-B) and D (SP-D) are of importance for the differentiation of patients with acute dyspnea. The aim of this study was to compare the values of NT-proBNP (N-terminal brain natriuretic peptide) and surfactant proteins for the assessment of a final diagnosis in patients with acute dyspnea.Patients and Methods:NT-proBNP, SP-B and SP-D were measured in 81 patients with acute dyspnea in the emergency room and were correlated with clinical and echocardiographic parameters with respect to the final diagnosis. For this, patients were classified with respect to clinical and echocardiographic parameters in different subgroups concerning the final diagnosis of acute dyspnea.Results:In patients with a cardiac origin of acute dyspnea, plasma levels of NT-proBNP were significantly higher as compared to patients with a noncardiac diagnosis (p = 0.04). SP-D was highest in patients with a cardiac origin of acute dyspnea, but after performing regression analysis it seems to be of less importance for the differential diagnosis of acute dyspnea as compared to NT-proBNP. SP-B plasma levels were not different between the four subgroups.Conclusion:NT-proBNP is of importance for the differential diagnosis of acute dyspnea. Although SP-D shows similar changes of plasma levels between the four subgroups, it seems to be of less importance for the differential diagnosis of acute dysnea. SP-B occurs to be of no relevance for the differentiation between cardiac and noncardiac origin of acute dyspnea.

Accidental left ventricular placement of a defibrillator probe due to a patent foramen ovale in arrhythmogenic right ventricular dysplasia.

Arrhythmogenic right ventricular dysplasia (ARVD) is a heart muscle disease characterized pathologically by fibrofatty replacement of right ventricular myocardium. It is further characterized by an electrical instability that precipitates ventricular arrhythmias and sudden death.The prevalence is estimated at 0.4% depending on geographic circumstances.The incidence of sudden death in patients with ARVD is approximately 2.5% a year.The disease is often familial with an autosomal inheritance. We report a case of a 35-year-old woman with ARVD and a patent foramen ovale discovered after accidental placement of the defibrillator probe in the left ventricle. To avoid malpositioning of a defibrillator probe postoperative control should be performed using different diagnostic modalities.

Bedeutung der Surfactant-Proteine B und D in der Differentialdiagnostik der akuten Dyspnoe@@@Importance of Surfactant Proteins B and D for the Differential Diagnosis of Acute Dyspnea

ZusammenfassungHintergrund und Ziel:Grundlage für eine optimale Therapie kardiopulmonaler Erkrankungen ist die frühzeitige Diagnosestellung. Dies beinhaltet die differentialdiagnostische Beurteilung der akuten Dyspnoe. In zahlreichen Studien wurden die natriuretischen Peptide als zusätzliche, aussagekräftige Parameter für die Beurteilung der linksventrikulären Funktion beschrieben. In neueren Studien finden die lungenepithelspezifischen Surfactant-Proteine B (SP-B) und D (SP-D) als diagnostische Parameter Eingang in die weitere Abklärung einer Dyspnoe. Ziel dieser Untersuchung war es, die differentialdiagnostische Wertigkeit von NT-proBNP (N-terminales Spaltprodukt des „brain natriuretic peptide“) und Surfactant-Proteinen bei Patienten mit akuter Dyspnoe zu vergleichen.Patienten und Methodik:NT-proBNP, SP-B und SP-D wurden bei 81 Patienten mit akuter Dyspnoe in der Notaufnahme bestimmt und mit klinischen und echokardiographischen Parametern im Rahmen der endgültigen Diagnosestellung korreliert. Hierzu wurden die Patienten nach klinischen und echokardiographischen Parametern in verschiedene Untergruppen entsprechend der Ursache der akuten Dyspnoe eingeteilt.Ergebnisse:Patienten mit kardial bedingter akuter Dyspnoe hatten gegenüber Patienten mit nichtkardiopulmonaler Ursache einen signifikant erhöhten NT-proBNP-Spiegel (p = 0,04). Das SP-D zeigte bei Patienten mit kardialer Ursache einer akuten Dyspnoe die signifikant höchsten Plasmaspiegel, ist aber nach Durchführung der Regressionsanalysen von geringerer Bedeutung für die Differentialdiagnose der akuten Dyspnoe als das NT-proBNP. Die SP-B-Plasmaspiegel waren in den einzelnen Untergruppen nicht signifikant verschieden.Schlussfolgerung:Das NT-proBNP ist für die Differentialdiagnose der akuten Dyspnoe von Bedeutung. Auch wenn das SP-D ähnliche Plasmaspiegelveränderungen wie das NT-proBNP für die einzelnen Subgruppen aufweist, scheint es insgesamt von geringerer Bedeutung für die Differentialdiagnose zu sein. Das SP-B scheint für die Diagnosestellung einer kardialen oder pulmonalen Ursache bei akuter Dyspnoe ohne Bedeutung zu sein.AbstractBackground and Purpose:The basis for an optimal therapy of cardiopulmonary diseases is the assessment of an early diagnosis. This implies an evaluation of possible differential diagnoses of acute dyspnea. In numerous studies, natriuretic peptides were characterized as additional, meaningful parameters for the assessment of left ventricular function. Current studies could demonstrate that surfactant proteins B (SP-B) and D (SP-D) are of importance for the differentiation of patients with acute dyspnea. The aim of this study was to compare the values of NT-proBNP (N-terminal brain natriuretic peptide) and surfactant proteins for the assessment of a final diagnosis in patients with acute dyspnea.Patients and Methods:NT-proBNP, SP-B and SP-D were measured in 81 patients with acute dyspnea in the emergency room and were correlated with clinical and echocardiographic parameters with respect to the final diagnosis. For this, patients were classified with respect to clinical and echocardiographic parameters in different subgroups concerning the final diagnosis of acute dyspnea.Results:In patients with a cardiac origin of acute dyspnea, plasma levels of NT-proBNP were significantly higher as compared to patients with a noncardiac diagnosis (p = 0.04). SP-D was highest in patients with a cardiac origin of acute dyspnea, but after performing regression analysis it seems to be of less importance for the differential diagnosis of acute dyspnea as compared to NT-proBNP. SP-B plasma levels were not different between the four subgroups.Conclusion:NT-proBNP is of importance for the differential diagnosis of acute dyspnea. Although SP-D shows similar changes of plasma levels between the four subgroups, it seems to be of less importance for the differential diagnosis of acute dysnea. SP-B occurs to be of no relevance for the differentiation between cardiac and noncardiac origin of acute dyspnea.

Bedeutung der Surfactant-Proteine B und D in der Differentialdiagnostik der akuten Dyspnoe

ZusammenfassungHintergrund und Ziel:Grundlage für eine optimale Therapie kardiopulmonaler Erkrankungen ist die frühzeitige Diagnosestellung. Dies beinhaltet die differentialdiagnostische Beurteilung der akuten Dyspnoe. In zahlreichen Studien wurden die natriuretischen Peptide als zusätzliche, aussagekräftige Parameter für die Beurteilung der linksventrikulären Funktion beschrieben. In neueren Studien finden die lungenepithelspezifischen Surfactant-Proteine B (SP-B) und D (SP-D) als diagnostische Parameter Eingang in die weitere Abklärung einer Dyspnoe. Ziel dieser Untersuchung war es, die differentialdiagnostische Wertigkeit von NT-proBNP (N-terminales Spaltprodukt des „brain natriuretic peptide“) und Surfactant-Proteinen bei Patienten mit akuter Dyspnoe zu vergleichen.Patienten und Methodik:NT-proBNP, SP-B und SP-D wurden bei 81 Patienten mit akuter Dyspnoe in der Notaufnahme bestimmt und mit klinischen und echokardiographischen Parametern im Rahmen der endgültigen Diagnosestellung korreliert. Hierzu wurden die Patienten nach klinischen und echokardiographischen Parametern in verschiedene Untergruppen entsprechend der Ursache der akuten Dyspnoe eingeteilt.Ergebnisse:Patienten mit kardial bedingter akuter Dyspnoe hatten gegenüber Patienten mit nichtkardiopulmonaler Ursache einen signifikant erhöhten NT-proBNP-Spiegel (p = 0,04). Das SP-D zeigte bei Patienten mit kardialer Ursache einer akuten Dyspnoe die signifikant höchsten Plasmaspiegel, ist aber nach Durchführung der Regressionsanalysen von geringerer Bedeutung für die Differentialdiagnose der akuten Dyspnoe als das NT-proBNP. Die SP-B-Plasmaspiegel waren in den einzelnen Untergruppen nicht signifikant verschieden.Schlussfolgerung:Das NT-proBNP ist für die Differentialdiagnose der akuten Dyspnoe von Bedeutung. Auch wenn das SP-D ähnliche Plasmaspiegelveränderungen wie das NT-proBNP für die einzelnen Subgruppen aufweist, scheint es insgesamt von geringerer Bedeutung für die Differentialdiagnose zu sein. Das SP-B scheint für die Diagnosestellung einer kardialen oder pulmonalen Ursache bei akuter Dyspnoe ohne Bedeutung zu sein.AbstractBackground and Purpose:The basis for an optimal therapy of cardiopulmonary diseases is the assessment of an early diagnosis. This implies an evaluation of possible differential diagnoses of acute dyspnea. In numerous studies, natriuretic peptides were characterized as additional, meaningful parameters for the assessment of left ventricular function. Current studies could demonstrate that surfactant proteins B (SP-B) and D (SP-D) are of importance for the differentiation of patients with acute dyspnea. The aim of this study was to compare the values of NT-proBNP (N-terminal brain natriuretic peptide) and surfactant proteins for the assessment of a final diagnosis in patients with acute dyspnea.Patients and Methods:NT-proBNP, SP-B and SP-D were measured in 81 patients with acute dyspnea in the emergency room and were correlated with clinical and echocardiographic parameters with respect to the final diagnosis. For this, patients were classified with respect to clinical and echocardiographic parameters in different subgroups concerning the final diagnosis of acute dyspnea.Results:In patients with a cardiac origin of acute dyspnea, plasma levels of NT-proBNP were significantly higher as compared to patients with a noncardiac diagnosis (p = 0.04). SP-D was highest in patients with a cardiac origin of acute dyspnea, but after performing regression analysis it seems to be of less importance for the differential diagnosis of acute dyspnea as compared to NT-proBNP. SP-B plasma levels were not different between the four subgroups.Conclusion:NT-proBNP is of importance for the differential diagnosis of acute dyspnea. Although SP-D shows similar changes of plasma levels between the four subgroups, it seems to be of less importance for the differential diagnosis of acute dysnea. SP-B occurs to be of no relevance for the differentiation between cardiac and noncardiac origin of acute dyspnea.

Acute gastrointestinal bleeding due to oesophageal varices: an unusual case of a thoracic spleen.

Upper gastrointestinal bleeding is often seen in patients admitted to intensive care units. Ulcers are the most common cause of these haemorrhages, but other factors such as oesopageal varices or malignancy may also be sources [1]. We report a 36-year-old male patient (BMI \ 30 kg/m) admitted to hospital because of a first session of haematemesis and recurrent dyspnoea only days before. Patient’s history revealed only 15 years of nicotine abuse and an undefined infection episode 17 years ago. On admission, clinical examination, vital parameters, chest X-ray and ECG findings were unremarkable. Initial laboratory tests revealed no pathologic coagulation tests, but impaired hemoglobin levels (12.3 g/dl). An oesophagoscopy was performed and revealed varices grade 3 [2]. Nine consecutive ligatures were placed. Furthermore, since there was no history or ultrasonic findings of liver disease, a thoracic CT scan was performed, revealing a large retrocardial mass (12 9 12 9 6 cm, Fig. 1) between the main bronchi displacing the oesophagus. An endosonography excluded an infiltration of the oesophagus, and a pathological specimen taken by video-assisted thoracoscopy showed a vascularised tumor without malignancy. Meanwhile, an emergency oesophagoscopy was indicated due to another session of haematemesis with need for mass transfusion. In the following days, an anterolateral rightsided thoracotomy with tumor resection followed. The arterial delivery was provided by a number of bronchial arteries of both main bronchi. The cause of the paraoesophageal plexus varices was more likely the tumorous venous drainage than the compression by the tumour itself (Fig. 2). Histological examination and further immunohistochemical differentiation of the resected mass revealed an ectopic accessory spleen confirmed by a second, independent pathologist. A deep venous thrombosis occurred preoperatively promoted by lack of anticoagulation despite immobilization. Because postoperatively the thrombosis reached the pelvic vessels, a venous thrombectomy was also performed. The postoperative oesophagoscopy showed varices decreased to grade 2, and anticoagulation with coumadin was started.