Karl Heinrich Scholz

Frequency of complications of cardiopulmonary resuscitation after thrombolysis during acute myocardial infarction

Prolonged external cardiac massage is often regarded as a contraindication for thrombolytic therapy because of the risk of fatal hemorrhage. The influence of cardiopulmonary resuscitation on complications of thrombolytic bleeding was assessed analyzing data of all patients with myocardial infarction admitted to our clinic during the 10-year period between 1978 and 1987. From the total of 2,147 patients with acute myocardial infarction, 590 received thrombolytic therapy (intracoronary in 229, intravenous in 400). Of these, 43 patients underwent prolonged cardiopulmonary resuscitation and received thrombolysis within a time interval of less than 24 hours. In 21 patients, resuscitation was performed within a short period of time (5 minutes to 20 hours) after thrombolysis (10 intracoronary, 10 intravenous, 1 intravenous + intracoronary) had been initiated; 9 of these patients survived (43%). In the other 22 patients, thrombolytic therapy was initiated during ongoing resuscitation (n = 6: intravenous in 5, intravenous + intracoronary in 1) or in the early phase (10 to 120 minutes) after successful resuscitation (n = 16: intracoronary in 10, intravenous in 4, intravenous + intracoronary in 2). From this group, 14 patients survived (in-hospital mortality 36%). The mean duration of cardiopulmonary resuscitation was 36 +/- 32 minutes (range 4 to 120). Autopsy studies were performed in 16 of 20 decreased patients. Bleeding complications occurred in 8 of 43 patients. No case of bleeding was directly related to cardiocompression despite the often traumatic procedure with rib fractures verified in 17 patients.(ABSTRACT TRUNCATED AT 250 WORDS)

Reduction in Treatment Times Through Formalized Data Feedback : Results From a Prospective Multicenter Study of ST-Segment Elevation Myocardial Infarction

OBJECTIVES This study sought to evaluate the effect of systematic data analysis and standardized feedback on treatment times and outcome in a prospective multicenter trial. BACKGROUND Formalized data feedback may reduce treatment times in ST-segment elevation myocardial infarction (STEMI). METHODS Over a 15-month period, 1,183 patients presenting with STEMI were enrolled. Six primary percutaneous coronary intervention hospitals in Germany and 29 associated nonpercutaneous coronary intervention hospitals participated. Data from patient contact to balloon inflation were collected and analyzed. Pre-defined quality indicators, including the percentage of patients with pre-announced STEMI, direct handoff in the catheterization laboratory, contact-to-balloon time <90 min, door-to-balloon time <60 min, and door-to-balloon time <30 min were discussed with staff on a quarterly basis. RESULTS Median door-to-balloon time decreased from 71 to 58 min and contact-to-balloon time from 129 to 103 min between the first and the fifth quarter (p < 0.05 for both). Contributing were shorter stays in the emergency department, more direct handoffs from ambulances to the catheterization laboratory (from 22% to 38%, p < 0.05), and a slight increase in the number of patients transported directly to the percutaneous coronary intervention facility (primary transport). One-year mortality was reduced in the total group of patients and in the subgroup of patients with primary transport (p < 0.05). The sharpest fall in mortality was observed in patients with primary transport and TIMI (Thrombolysis In Myocardial Infarction) risk score ≥ 3 (n = 521) with a decrease in 30-day mortality from 23.1% to 13.3% (p < 0.05) and in 1-year mortality from 25.6% to 16.7% (p < 0.05). CONCLUSIONS Formalized data feedback is associated with a reduction in treatment times for STEMI and with an improved prognosis, which is most pronounced in high-risk patients. (Feedback Intervention and Treatment Times in ST-Elevation Myocardial Infarction [FITT-STEMI]; NCT00794001).

Need for Active Left-Ventricular Decompression during Percutaneous Cardiopulmonary Support in Cardiac Arrest

During ventricular fibrillation, myocardial hemodynamic and metabolic effects of percutaneous cardiopulmonary support (PCPS) were analyzed in 11 adult sheep (body weight 77-112 kg). During supported fibrillation, an abrupt increase in left-ventricular pressures with alignment to aortic pressures was observed in 2 animals, which was probably due to spontaneous aortic regurgitation, and resulted in deterioration of coronary perfusion. In 9 animals, left-ventricular pressures rose from 22.9 +/- 4.9 to 31.2 +/- 7.9 mm Hg elevating left ventricular wall stress from 16,750 +/- 8,745 to 28,835 +/- 8,892 dyn/cm2 after 10 min of PCPS-supported fibrillation (mean flow rate 4.5 +/- 0.7 liters/min). Simultaneously, myocardial perfusion pressures decreased from an average of 32.4 +/- 11.7 to 22.3 +/- 9.4 mm Hg and myocardial lactate release was observed. Additional transapical LV venting using a 9-Fr catheter led to a decrease in both LV pressure (to 25.7 +/- 5.3 mm Hg) and wall stress (to 20,612 +/- 7,499 dyn/cm2). Left-ventricular decompression decreased myocardial oxygen consumption (from 5.3 +/- 1.4 to 4.8 +/- 0.9 ml/min.100 g), and reduced myocardial lactate release, which indicates myocardial protection. Protective effects were most pronounced using 12-Fr-, and 21-Fr-venting cannulas (with 21 Fr: decrease in myocardial oxygen consumption to 2.7 +/- 0.6 ml/min.100 g, and reversal of myocardial lactate release to lactate uptake during fibrillation). Conclusions. Hemodynamic and metabolic data clearly demonstrate the deleterious effects of PCPS to the unvented left ventricle during cardiac arrest. The results emphasize the need for active left-ventricular decompression during PCPS in ventricular fibrillation.

Myocardial infarction in young patients with Hodgkin's disease — potential pothogenic role of radiotherapy, chemotherapy, and splenectomy

SummaryAmong a total of 2147 patients admitted to our hospital for acute myocardial infarction between 1978 and 1987, three young patients aged 24, 29, and 39 years had previously been treated for Hodgkins disease. Staging laparotomy, including splenectomy, had been performed in all three patients. Two patients had both mediastinal irradiation (21 and 27 months before infarction) and chemotherapy. In the first patient, postmortem histologic examination of the coronary arteries revealed fibrotic changes, which were probably induced by radiotherapy. In our second patient, myocardial infarction developed 5 days after vinblastine treatment; early angiography showed thrombotic occlusion of the proximal right coronary artery, which was recanalized using the diagnostic Sones catheter. Subsequent angiography revealed normal coronary arteries. This is, to our knowledge, the first case of documented coronary artery thrombosis after treatment with vinca-alkaloids. In our third patient, neither mediastinal irradiation nor chemotherapy had been performed prior to myocardial infarction. However, a marked increase in platelet counts following splenectomy was observed in this patient. The role of radiotherapy, chemotherapy, and splenectomy with consecutive thrombocytosis as a third possible pathogenic factor for subsequent development of myocardial infarction is discussed.

PTCA with the use of cardiac assist devices: Risk stratification, short‐ and long‐term results

Percutaneous cardiopulmonary assist devices (PCPS) have become available in interventional cardiology within recent years. These tools offer the opportunity of performing percutaneous transluminal coronary angioplasty (PTCA) in high-risk patients characterized by significant stenoses of several coronary arteries and a poor left ventricular function. It is unclear for which patients PCPS are necessary and which patients will profit by PTCA as compared to coronary artery bypass grafting (CABG). Therefore, the anticipated risk of CABG and of PTCA without assist devices was calculated according to risk scores and compared with our results of assisted PTCA. In addition the long-term survival rate was investigated. In 35 patients (mean 65.5 years of age, 12 females, 23 males), we performed PTCA concomitant with the use of cardiac assist devices. The indications for the use of a cardiac assist device were severely impaired LV function (EF 30% +/- 8.9%) in combination with significant coronary artery disease (2.7 +/- 0.3 vessels) and a significant supply area of the vessel to be dilated. In 6 patients, PCPS was started before coronary angioplasty because of hemodynamic instability. In 21 cases, PCPS was on a standby basis without being connected to the patients circulation. In 8 patients, a left heart assist device, the 14F-Hemopump, was inserted percutaneously. The patients were analyzed using risk scores of angioplasty and of coronary bypass graft surgery. The calculated risk of hemodynamic compromise during PTCA according to the risk scores was more than 50%. The anticipated risk of a fatal outcome following CABG would have been 19.8%. PTCA was performed on an average of 2.0 coronary arteries per patient and was successful in 85%. We observed a decline in angina pectoris classification (CCS) from 3.5 to 1.6. An average reduction of 1.1 NYHA class was achieved. The in-hospital mortality was 8.6% (3 patients: 1 x sepsis, 1 x early reocclusion, 1 x cerebral embolism). At 24 months follow-up, a re-PTCA was necessary in four cases because of restenosis. In the remainder, NYHA and CCS class were stable during the follow-up period. An additional five patients died during the first year and two patients in the second year. We conclude that PTCA with the use of a cardiac assist device shows favorable short-term results in a subset of patients with extended coronary artery disease and severely impaired LV function who are not suitable for nonsupported PTCA or CABG due to their risk profile. However, the long term results are not satisfying and stress the need for complete revascularisation with CABG once the patients condition is stabilized by means of supported PTCA.

Determinants of stent restenosis in chronic coronary occlusions assessed by intracoronary ultrasound

Chronic coronary occlusions have a high recurrence rate that can be reduced by stenting, but this rate remains higher than in nonocclusive lesions. To analyze possible determinants of restenosis in these lesions, intracoronary ultrasound was performed during the recanalization procedure. A chronic coronary occlusion of > or = 1 month duration (range 1 to 33 months; median 3.3) was successfully recanalized in 41 patients. Quantitative ultrasound analysis was performed before and after stent placement, with measurement of the luminal area, the extent of the plaque burden at the site proximal and distal to the occlusion, and within the occlusion and the subsequent stent. The degree of compensatory enlargement of the coronary artery within the occlusion was determined by comparing the average of the total vessel area of the proximal and distal reference with the lesion site. Early reocclusion (subacute stent thrombosis) was observed in 1 patient (2.4%). The angiographic control after 6 months showed restenosis in 9 patients with 1 late reocclusion. The overall recurrence rate was 24%. There was no difference in clinical and procedural characteristics between lesions with restenosis and without restenosis. The latter had a larger minimum stent area (7.59 +/- 1.96 mm2 vs 5.71 +/- 0.90 mm2; p <0.01), and there was evidence for more compensatory vessel enlargement in lesions without restenosis. Thus, intracoronary ultrasound showed that a smaller minimum stent area was a major predictor of angiographic restenosis, and it occurred more often in occlusions without compensatory vessel enlargement.

Nasal oxygen effects on arterial carbon dioxide pressure and heart rate in chronic heart failure

Nasal oxygen applied by nasal prongs reduced tidal volume and increased carbon dioxide partial pressure in patients with chronic heart failure but not in comparable controls, whereas the patients showed a more pronounced decrease in heart rate with oxygen. These findings indicate that nasal oxygen has distinct effects on ventilation and heart rate in chronic heart failure.

Closure of an iatrogenic aortocoronary arteriovenous fistula: Transcatheter balloon embolization following failed coil embolization and salvage of coils that migrated into the coronary venous system

We report a 50‐year‐old patient with successful percutaneous closure of a large inadvertent surgical aortocoronary arteriovenous fistula (shunt flow: 1.8 L/min). With initial embolization of multiple coils, no lasting occlusion of the large fistula could be achieved. Above that, two coils migrated into the coronary venous system. Following rescue of the migrated coils through a retrograde coronary sinus approach, the fistula was occluded using a detachable balloon. Follow‐up angiograms confirmed successful closure of the fistula. In contrast to coil embolization, use of a detachable balloon seems to be the appropriate technique for percutaneous closure of such fistulas. Cathet Cardiovasc Intervent 2002;55:109–112.

Left-Ventricular Unloading by Transvalvular Axial Flow Pumping in Experimental Cardiogenic Shock and during Regional Myocardial Ischemia

The efficacy of the transfemoral left-ventricular assist device Hemopump (HP; 21 Fr outer diameter) was examined in experiments with adult sheep in two different models of cardiogenic shock (tachycardia shock; ischemia shock), and during ventricular fibrillation. During tachycardia (high frequency pacing-induced; n = 14), HP assist led to a significant increase in cardiac output (from 2.2 to 2.8 liters/min), mean aortic pressure (from 47.6 to 65.6 mmHg), and myocardial perfusion pressure (from 25.5 to 59.0 mmHg). Simultaneously, a normalization of body oxygen-uptake (from 1.4 to 2.5 ml/min.kg), a decrease in myocardial oxygen consumption (from 6.1 to 4.8 ml/min.100 g), and a normalization of myocardial lactate metabolism were observed during HP assist. During regional myocardial ischemia (PTCA balloon occlusion of the proximal LAD (3.5 min; n = 12), HP assist led to significant decrease in LV end-diastolic pressure (from 21.1 to 12.1 mmHg), and increase in diastolic aortic pressure (from 58 to 67 mmHg) resulting in significant increase in coronary perfusion pressure. In the early reperfusion period, myocardial release of both lactate and potassium was significantly lowered with HP assist. During ventricular fibrillation (induced by electrical stimulation; n = 9), HP flow rates decreased from 2.5 (after 10 min) to 2.1 liters/min (after 30 min). Mean aortic pressures simultaneously decreased from 64.0 to 54.6 mmHg. Perfusion conditions were sufficient for maintenance of aerobic myocardial metabolism, but were borderline for peripheral circulation. Our hemodynamic and metabolic data demonstrate beneficial effects of cardiac assist with the Hemopump 21 Fr in both tachycardia-induced severe cardiogenic shock and during acute regional myocardial ischemia.(ABSTRACT TRUNCATED AT 250 WORDS)

Impact of treatment delay on mortality in ST-segment elevation myocardial infarction (STEMI) patients presenting with and without haemodynamic instability: results from the German prospective, multicentre FITT-STEMI trial

Abstract Aims The aim of this study was to investigate the effect of contact-to-balloon time on mortality in ST-segment elevation myocardial infarction (STEMI) patients with and without haemodynamic instability. Methods and results Using data from the prospective, multicentre Feedback Intervention and Treatment Times in ST-Elevation Myocardial Infarction (FITT-STEMI) trial, we assessed the prognostic relevance of first medical contact-to-balloon time in n = 12 675 STEMI patients who used emergency medical service transportation and were treated with primary percutaneous coronary intervention (PCI). Patients were stratified by cardiogenic shock (CS) and out-of-hospital cardiac arrest (OHCA). For patients treated within 60 to 180 min from the first medical contact, we found a nearly linear relationship between contact-to-balloon times and mortality in all four STEMI groups. In CS patients with no OHCA, every 10-min treatment delay resulted in 3.31 additional deaths in 100 PCI-treated patients. This treatment delay-related increase in mortality was significantly higher as compared to the two groups of OHCA patients with shock (2.09) and without shock (1.34), as well as to haemodynamically stable patients (0.34, P < 0.0001). Conclusions In patients with CS, the time elapsing from the first medical contact to primary PCI is a strong predictor of an adverse outcome. This patient group benefitted most from immediate PCI treatment, hence special efforts to shorten contact-to-balloon time should be applied in particular to these high-risk STEMI patients. Clinical Trial Registration NCT00794001.