Marianne Gwechenberger

Noninvasive assessment of cardiac output in critically ill patients by analysis of the finger blood pressure waveform.

OBJECTIVEnTo assess whether the measurement of cardiac output by computer-assisted analysis of the finger blood pressure waveform can substitute for the thermodilution method in critically ill patients.nnnDESIGNnProspective data collection.nnnSETTINGnEmergency department in a 2000-bed inner city hospitalnnnPATIENTSnForty-six critically ill patients requiring invasive monitoring for clinical management were prospectively studied.nnnINTERVENTIONSnUnder local anesthesia a 7-Fr pulmonary artery catheter was inserted via the central subclavian or jugular vein. Cardiac output was determined by the use of a cardiac output computer and injections of 10 mL ice-cold glucose 5%. Noninvasive cardiac output was calculated from the finger blood pressure waveform by the use of the test software program.nnnMEASUREMENTS AND MAIN RESULTSnThree hundred twenty-three pairs of invasive and noninvasive hemodynamic measurements were collected in intervals of 30 mins from 46 patients (mean age 61.9 +/- 12.4 yrs; 35 male, 11 female). The average cardiac index during the study period was 2.83 L/min/m2 (range 0.97 to 5.56). The overall discrepancy between both measurements was 0.14 L/min/m2 (95% confidence interval: 0.10-.018, p < .001). Seventy-five (23.2%) measurements had an absolute discrepancy > +/- 0.50 L/min/m2. Noninvasive and invasive comparisons of mean differential cardiac output were out of phase for 9.7% of all readings.nnnCONCLUSIONnComputer-assisted analysis of finger blood pressure waveform to assess cardiac output is not a substitute for the thermodilution method due to a high percentage (23.2%) of inaccurate readings; however, it may be a useful tool for the detection of relative hemodynamic trends in critically ill patients.

Ablation of atrial tachycardia originating from the vicinity of the atrioventricular node: significance of mapping both sides of the interatrial septum.

OBJECTIVESnThe purpose of the study was to examine the value of right- and left-sided mapping to identify the site of tachycardia origin.nnnBACKGROUNDnFocal atrial tachycardia may originate from the vicinity of the atrioventricular node from either side of the interatrial septum.nnnMETHODSnIn 16 patients undergoing radiofrequency catheter ablation of perinodal atrial tachycardia, activation mapping of the right and left side of the interatrial septum was performed.nnnRESULTSnAtrial tachycardia originated from the right side of the interatrial septum in 10 patients (group A) and from the left side in 6 patients (group B). On the right side, earliest atrial activity preceded the onset of the P-wave by 49 +/- 15 ms in group A and by 38 +/- 8 ms in group B (NS), and it preceded the signal recorded from the right atrial appendage by 59 +/- 19 ms in group A and by 60 +/- 13 ms in group B (NS). On the left side, earliest activity preceded the onset of the P-wave by 27 +/- 16 ms in group A and by 51 +/- 6 ms in group B (<0.01), and it preceded the signal obtained from the right atrial appendage by 38 +/- 19 ms in group A and by 73 +/- 9 ms in group B (<0.01). Atrial tachycardias were successfully eliminated in all patients without impairment of atrioventricular conduction. During follow-up, two patients had a recurrence of tachycardia.nnnCONCLUSIONSnMapping of only the right side cannot exclude a left-sided origin. Therefore, mapping of both sides of the interatrial septum is required prior to ablation of focal atrial tachycardia originating from the vicinity of the atrioventricular node.

Elevation of Prostate-Specific Markers After Cardiopulmonary Resuscitation

BACKGROUND-Prostate-specific antigen (PSA), acid phosphatase (AP), and prostatic acid phosphatase (PAP) are serum markers for adenocarcinoma of the prostate gland. Previous studies indicated that prostatic ischemia may also produce elevations of PSA. Cardiopulmonary resuscitation (CPR) is frequently associated with profound tissue hypoperfusion. The present study investigated whether PSA, AP, and PAP are influenced by prolonged CPR. METHODS AND RESULTS-PSA, AP, and PAP were assessed immediately, 12 hours, 24 hours, 2 days, 3 days, 5 days, and 7 days after prolonged CPR (>5 minutes) in 14 male and 5 female patients. No changes were noted in women. In men, serum levels increased significantly after CPR and gradually decreased to near baseline values after 7 days. PSA, AP, and PAP values above the normal range were observed in 63%, 71%, and 64% of all patients, respectively. Compared with survivors, nonsurvivors exhibited higher peak serum levels of PSA (98.6+/-14.3 versus 1.1+/-2.2 mcg/L; P<0.03), AP (57.0+/-71 versus 8.6+/-8.8 U/L; P<0.05), and PAP (47.0+/-62 versus 5.7+/-8.0 U/L; P=NS). Patients with poor neurological outcome exhibited higher peak serum levels of PSA (86.4+/-135.5 versus 12.0+/-23.8 mcg/L; P<0.05), AP (50.9+/-68.1 versus 8.7+/-9.6 U/L; P=NS), and PAP (41.6+/-59.5 versus 5.8+/-8.8 U/L; P=NS) than patients with good neurological outcome. CONCLUSIONS-Prolonged CPR is frequently associated with increases of PSA, AP, and PAP serum levels. Therefore, PSA cannot be used for diagnosis of adenocarcinoma of the prostate during the first weeks after CPR. Further evaluation of these parameters as additional prognostic markers after CPR is warranted.

Assessment of left ventricular function: comparison between radionuclide angiography and semiquantitative two-dimensional echocardiographic analysis

Measurement of global left ventricular function is important in the follow-up of cardiac patients and is a good prognostic indicator in acute cardiac situations. We compared quantitative measurements of global left ventricular function made with radionuclide angiography (RNA) and contrast cardiac ventriculography (CVG) to visual semiquantitative estimates from two-dimensional echocardiographic images (2D-echo). Three hundred and thirty-nine consecutive patients who underwent RNA were assessed with 2D-echo within 3 months. In addition, 92 of these patients also underwent CVG (correlation of ejection fraction between CVG and RNA:r=0.82;P<0.0001). The RNA mean ejection fractions in the four 2D-echo groups (0=normal, 1=slightly, 2=moderate, or 3=severe reduced left ventricular function) differed markedly (P<0.0001); however, there was overlapping among the groups (2D-echo score/RNA ejection fraction: 0=57.3%±12.8%; 1=46.0%±12.9%; 2=29.6%±12.2%; and 3=24.6%±11.5%) and the difference between 2D-echo scores 2 and 3 was not significant. 2D-echo showed a good concordance in RNA classes (0=≥505; 1=35%–49%; 2=21%–34%; and 3=≤520% ejection fraction) 0 (133/166; 80%) and 3 (18/30; 60%) but low concordance in classes 1 (27/82; 33%) and 2 (21/61; 34%). For accurate assessment of global left ventricular ejection fraction, visual semiquantitative judgement of a 2D echocardiographic image is limited in comparison to CVG or RNA, especially in patients with a slight or moderate reduction in left ventricular ejection fraction.

Prediction of early complications in patients with acute myocardial infarction by calculation of the ST score.

STUDY OBJECTIVEnTo assess the relationship between the sum of ST-segment elevations (ST score) in the admission ECG and the occurrence of early complications in patients with acute myocardial infarction (MI).nnnMETHODSnWe conducted an observational study of patients who presented with acute anterior or inferior MI to the ED of a 2,000-bed inner-city hospital. Age, sex, time from onset of pain and the start of thrombolysis, and ST score were evaluated by the emergency physician. Early complications were defined as acute congestive heart failure or severe rhythm disturbances in the 24 hours after the start of thrombolysis. The outcome measures were the relationship between ST score and the occurrence of early complications; the influence of age, sex, or time between onset of pain and thrombolysis; and identification of a cutoff value with the highest sensitivity and specificity for prediction of complications.nnnRESULTSnWe included 243 patients (194 men, 49 women; mean age, 56.6 years) with acute MI (anterior, 119; inferior, 124) who underwent thrombolysis in our analysis. ST score was significantly greater in patients with early complications, compared with patients without complications (anterior, 10.3 versus 19.4 mm [P < .001]; inferior, 6.9 versus 10.4 mm [P < .001]). Receiver-operator curve analysis revealed an ST score of 13 mm in patients with anterior MI and 9 mm in patients with inferior MI as the cutoff value with the greatest sensitivity and specificity for predicting early complications of MI. (For anterior MI, sensitivity was .79, specificity .73; for inferior MI, sensitivity was .64 and specificity .68.). On multivariate regression analysis, ST score was an independent predictor of the occurrence of at least one complication. (For anterior MI, the odds ratio [OR] was 9.7 and the 95% confidence interval [CI] 3.9 to 25.1; for inferior MI the OR was 5.0 and the 95% CI 2.0 to 12.8). Age, sex, and interval from onset of pain to treatment had no significant effect on the occurrence of early complications.nnnCONCLUSIONnThe absolute ST score is useful in estimating the probability of early complications in patients with acute MI receiving thrombolytic therapy. A cutoff value of 13 mm for anterior MI and 9 mm for inferior MI stratifies patients into high- and low-risk subgroups for the development of acute congestive heart failure and severe rhythm disturbances during the first 24 hours of hospitalization.

Does Dyspnoea during dipyridamole cardiac stress testing indicate bronchospasm and is the pretest clinical history predictive of this side-effect?

This study investigates the acute effects of intravenous dipyridamole (0.7 mg/kg) on pulmonary airflow in relation to clinical paramaters suggestive of chronic obstructive pulmonary disease (COPD) in order to assess predictive and causative factors of dyspnoea during cardiac stress testing. Mild pulmonary airflow obstruction was noted in all patients, but reached statistical significance only in small airways (FEF75–85%: −7%;P=0.034). The changes in pulmonary function parameters were independent of the clinical history. Dyspnoea under dipyridamole stress testing occurred in parallel with angina, yet was not associated with ischaemic or non-ischaemic left ventricular dysfunction. These data do not support the use of dipyridamole stress testing in asthmatics, but show that (1) the acute effects of a diagnostic dose of dipyridamole on pulmonary airflow are mild even in patients with a history suggestive of COPD and (2) dyspnoea during dipyridamole testing is not necessarily indicative of bronchospasm.

Does motion analysis in Postexercise gated sestamibi SPECT reflect rest left ventricular motion even in severe coronary artery disease

Purpose Evidence has suggested that postexercise gated Tc-99m sestamibi SPECT (GSPECT) provides combined information about resting wall motion and exercise perfusion. No data have been published about possible differences in wall motion analysis between postexercise and resting GSPECT. Methods Fifty patients underwent postexercise (symptom-limited bicycle stress) and rest GSPECT and cardiac catheterization with contrast ventriculography. In 35 patients, additional rest planar Tc-99m RBC radionuclide ventriculography (RNV) was performed. Four observers independently performed left ventricular ejection fraction (LVEF) calculations and visual analysis of regional wall motion (graded in four stages) for all studies. Results The LVEF calculations in GSPECT revealed a statistically significant difference between postexercise (45.8 ± 15.7%) and rest (48.0 ± 16.1%;P < 0.05) determination. Postrest GSPECT LVEF showed a better correlation with LVEF determination performed with contrast ventriculography and RNV than did postexercise GSPECT LVEF. The reduced postexercise wall motion could be shown in segments with exercise-induced ischemia and in those with normal regional perfusion but not in segments with irreversibly abnormal perfusion. Conclusions Postexercise GSPECT provides reliable information regarding global wall motion even in severe coronary artery disease, but regional wall motion is underestimated compared with rest GSPECT, because of an imprecise surface detection algorithm in ischemic wall segments and possibly postexercise stunning in severe coronary artery disease.

Additional ST-segment elevation during thrombolytic therapy in patients with acute ST-elevation myocardial infarction: Impact on myocardial salvage and final infarct size

ZusammenfassungDas Ziel dieser Studie was die klinische Bedeutung der während der Thrombolyse fort-schreitenden ST-Strecke nelevation zu ergründen. Deshalb teilten wir 153 Patienten mit einem erstmaligen akuten Myokardinfarkt (MI) in zwei Gruppen: Gruppe A, 55 Patienten mit einer fortschreitenden ST-Streckenelevation ≥1 mm über die ursprügliche ST-Elevation während der thrombolytischen Therapie und Gruppe B, 98 Patienten ohne dieses elektrokardiografische Muster. Die Patienten mit einem anterior MI in der Gruppe A (n=33) zeigten im Vergleich zur Gruppe B (n=41) keine Reduktion von der initialen ST-bestimmten zur endgültigen QRS-bestimmten Infarktgröße (+12% versu−27%; p=0.0005) und ein größeres Infarktareal (QRS-score: 18% versus 12%; p=0.00002). Patienten mit einem inferioren MI der Gruppe A (n=22) zeigten im Vergleich zur Gruppe B (n=57) eine geringere Reduktion von der initialen ST-bestimmten zur endgültigen QRS-bestimmten Infarktgröße (−30% versus −53%; p=0.03) und ein größeres Infarktareal (QRS-score: 15% versus 9%; p=0.03). Die Fläche unter der Kurve (AUC) der CK und CK-MB war in Gruppe A höher als in Gruppe B (anteriorer MI: AUCK-CK: 22048 versus 19490 U.h.I−1; p=0.07; AUC-MB: 2227 versus 2016 U.h.I−1; p=0.11; inferiorer MI: AUC-CK: 17206 versus 11004 U.h.I−1; p=0.01; AUC-MB: 2193 versus 1046 U.h.I−1; p=0.007). Sowohl die globale Linksventrikelfunktion als auch der Rückgang der ST-Strecke waren bei Patienten der Gruppe B signifikant besser. Eine Zwei- und Dreigefäßerkrankung wurde häufiger in Gruppe A beobachtet.Eine fortschreitende ST-Streckenelevation während der thrombolytischen The rapie weist auf eine verminderte Rettung von Myokard durch die thrombolytische Therapie und ein größeres endgültiges Infarktareal hin.SummaryThe aim of the study was to investigate the clinical significance of additional ST-segment elevation that occurs during thrombolytic therapy. Therefore, we classified 153 patients with a first acute myocardial infarction (MI) into two groups: Group A, 55 patients with additional ST-segment elevation >-1 mm above the initial ST elevation during thrombolytic therapy and Group B, 98 patient without this electrocardiographic pattern. Among the patients with anterior MI, Group A (n=33) had no reduction from ST-predicted to final QRS-estimated infarct size (+12% versus −27%; p=0.0005) and a larger final infarct size (QRS-score; 18% versus 12%: p=0.0002) than Group B (n=41). Among the patients with inferior MI, Group A (n=22) had a smaller reduction from ST-predicted to final QRS-estimated infarct size (−30% versus −53%; p=0.03) and a larger final infarct size (QRS-score; 15% versus 9%; p=0.03) than Group B (n=57). The area under the curve (AUC) of CK and CK-MB was higher in patients from Group A compared with those from Group B (anterior MI: AUC-CK: 22048 versus 19490 U.h.I−1; p=0.07; AUC-MB: 2227 versus 2016 U.h.l−1; p=0.11; inferior MI: AUC-CK: 17206 versus 11004 U.h.l.−1; p=0.01; AUC-MB: 2193 versus 1046 U.h.l−1; p-0.007). Both global left ventricular function and ST-segment elevation resolution were significantly better in Group B. Two and three vessel disease was observed more frequently in Group A. Additional ST-segment elevation during thrombolytic therapy suggests reduced myocardial salvage by thrombolytic therapy and thus may result in larger final infarct size.

937-6 Biphaslc Response to Dobutamlne Stimulation of Asynergic Myocardial Segments - An Uncommon Phenomenon

To evaluate the incidence of biphasic wall motion response and the relationship between dobutamine augmentation of asynergic segments and coronary stenosis severity in chronic coronary artery disease, we studied 9 pts (age 58xa0±xa07 yrs; 7 male) with dobutamine echocardiography and quantitative coronary angiography, Wall motion was assessed in a 16-segment model at 5 and 10 mcg/kg/min and at the highest achievable dosage (34xa0±xa06,8 mcg/kg/min). Analysis was possible in 140 (97%) of 144 segments, Abnormal wall motion at rest was found in 105 segments (75%), 36 were hypokinetic and 69 akinetic, Overall, 41 segments (39%) improved during dobutamine infusion (80% improved at 5 to 10 mcg/kg/min and 20% at higher dosage), Improvement was found in 86% of hypokinetic segments and 15% of akinetic segments, Thirty-three segments with improvement were supplied by vessels with ≥65% diameter stenoses (mean 82xa0±xa014%), Only 3 of these segments (9%) supplied by vessels with significant stenoses showed a biphasic response to dobutamine with worsening of wall motion at maximal dosage, whereas improvement persisted in the remaining 30 segments despite comparable stenosis severity, Twenty percent of the improving segments were supplied by vessels without significant stenoses. (These segments were hypokinetic at rest and wall motion abnormality was probably not due to ischemia). Thus, wall motion improvement of hibernating myocardium during low dose dobutamine surprisingly persists in the majority of segments at higher dosages normally used to provoke ischemia although these segments are generally supplied by vessels with severe stenoses. The expected biphasic response to dobutamine seems to be uncommon and not related to stenosis severity.