Matthias P. Heintzen

Incidence and clinical outcome of iatrogenic femoral arteriovenous fistulas: Implications for risk stratification and treatment

OBJECTIVES We sought to determine the incidence of arteriovenous fistulas (AVF), identify risk factors for AVF, and follow up the clinical outcome of femoral AVF. BACKGROUND Arteriovenous fistulas are a potential harmful complication of cardiac catheterization. Incidence and clinical outcome of iatrogenic AVF are unknown so far, although important for risk stratification and treatment. METHODS A total of 10,271 consecutive patients undergoing cardiac catheterization were followed up prospectively over a period of three years. Diagnosis of AVF was performed by duplex sonography. RESULTS The incidence of AVF was 0.86% (n = 88). The following significant and independent risk factors for AVF were identified: high heparin dosage (odds ratio [OR]) = 2.88), coumadin therapy (OR = 2.34), puncture of the left groin (OR = 2.21), arterial hypertension (OR = 1.86), and female gender (OR = 1.84). Within 12 months 38% of all AVF closed spontaneously. No signs of cardiac volume overload or limb damage were observed in patients with persisting AVF. None of the risk factors for AVF influenced the incidence or the rate of AVF closure. Only intensified anticoagulation showed a tendency to extend AVF persistence. CONCLUSIONS Almost 1% of patients undergoing cardiac catheterization acquire femoral AVF, for which patient- and procedure-related risk factors could be identified. One-third of iatrogenic AVF close spontaneously within one year. Cardiac volume overload and limb damage are highly unlikely with AVF persistence. Thus, a conservative management for at least one year seems to be justified.

The use of different buffers during continuous hemofiltration in critically ill patients with acute renal failure

Objective: To determine the impact of different hemofiltration (HF) replacement fluids on the acid-base status and cardiovascular hemodynamics in patients with acute renal failure (ARF) and continuous veno-venous hemofiltration (CVVH).¶Design: Prospective, cohort study.¶Setting: Intensive Care Unit of the Heinrich Heine University Hospital, Düsseldorf, Germany.¶Subject and methods: One hundred and thirty-two critically ill patients with acute renal failure and continuous veno-venous HF were studied. Fifty-two patients were subjected to lactate-based (group 1), and 32 to acetate-based hemofiltration (group 2)while 48 (group 3) were treated with bicarbonate-based buffer hemofiltration fluid. Fifty-seven had a septic, and 75 a cardiovascular, origin of the ARF. Creatinine, blood urea nitrogen (BUN), serum bicarbonate, arterial pH, lactate and Apache II scores were noted daily.¶Main results: The mean CVVH duration was 9.8 ± 8.1 days, mortality was 65 %. No difference was present between the groups under investigation with regard to the main clinical parameters. Lactate- and bicarbonate-based hemofiltration led to significantly higher serum bicarbonate and arterial pH values as compared to the acetate-based hemofiltration. Serum bicarbonate values at 48 h after the initiation of CVVH treatment were 25.7 ± 3.8 mmol/l (p < 0.001) in group 1, 20.6 ± 3.1 mmol/l in group 2 and 23.3 ± 3.9 mmol/l (p < 0.001) in group 3. While a lack of increase in serum bicarbonate and arterial pH was correlated to poor prognosis in lactate- and bicarbonate-based hemofiltration, no such observation was made in acetate-based hemofiltration. Cardiovascular hemodynamics were superior in patients treated with lactate- and bicarbonate-based buffer solution as compared to those treated with acetate-based buffer solution.¶Conclusions: The degree of correction of acidosis during hemofiltration was determined by patient outcome in patients treated with lactate- and bicarbonate-based buffer solutions, but not in patients receiving acetate-buffered solution. Bicarbonate and lactate-based buffer solutions were found to be superior to acetate-based replacement fluid.

Pharmacologic myocardial protection during percutaneous transluminal coronary angioplasty by intracoronary application of dipyridamole: Impact on hemodynamic function and left ventricular performance

OBJECTIVES The aim of this study was to investigate whether intracoronary infusion of dipyridamole represents a suitable tool for preventing deterioration of left ventricular performance and hemodynamic function during percutaneous transluminal coronary angioplasty (PTCA). BACKGROUND Coronary angioplasty represents a suitable model for establishing myocardial ischemia in humans. Balloon inflation is usually accompanied by significant deterioration in left ventricular systolic and diastolic properties. A brief episode of ischemia followed by reperfusion, termed preconditioning, has been identified as a mechanism for rendering the myocardium more resistant to ischemia. Adenosine is considered an important mediator of preconditioning. Dipyridamole is an important drug that interferes with myocardial adenosine metabolism by inhibiting its cellular reuptake. METHODS In 20 patients undergoing elective coronary angioplasty of a major vessel, assessment of angiographic left ventricular performance and hemodynamic variables was performed before, during and after PTCA. Patients were randomly allocated to pretreatment with intracoronary infusion of dipyridamole before percutaneous transluminal coronary angioplasty (10 patients) or conventional pretreatment without dipyridamole (10 patients). RESULTS Dipyridamole pretreatment resulted in significant preservation of systolic and diastolic left ventricular performance during percutaneous transluminal coronary angioplasty, as documented by an unaffected global ejection fraction (vs. a deterioration of 29.2% with conventional pretreatment, p < 0.01) and an increment in diastolic stiffness of only 12.7% (vs. an increment of 57.3% with conventional pretreatment, p < 0.01). Apart from one instance of coronary steal phenomenon, no significant side effects of dipyridamole infusion could be detected. CONCLUSIONS It is concluded that intracoronary application of dipyridamole may result in the induction of myocardial preconditioning by improving systolic and diastolic ventricular performance during percutaneous transluminal coronary angioplasty, thereby potentially reducing the risk of the angioplasty procedure.

Refractory angina pectoris in end-stage coronary artery disease: Evolving therapeutic concepts ☆ ☆☆ ★

Refractory angina pectoris in coronary artery disease is defined as the persistence of severe anginal symptoms despite maximal conventional antianginal combination therapy. Further, the option to use an invasive revascularization procedure such as percutaneous coronary balloon angioplasty or aortocoronary bypass grafting must be excluded on the basis of a recent coronary angiogram. This coronary syndrome, which represents end-stage coronary artery disease, is characterized by severe coronary insufficiency but only moderately impaired left ventricular function. Almost all patients demonstrated severe coronary triple-vessel disease with diffuse coronary atherosclerosis, had had one or more myocardial infarctions, and had undergone aortocoronary bypass grafting (70% of cases). We present three new approaches with antiischemic properties: long-term intermittent urokinase therapy, transcutaneous and spinal cord electrical nerve stimulation, and transmyocardial laser revascularization.

Periphere arterielle Komplikationen nach Herzkatheteruntersuchung

After diagnostic and interventional cardiac catheterization, local vascular complications at the arterial entry site must be expected. With respect to the method applied for catheterization and the puncture site, the type of complications may vary. With transfemoral approach a large variety of vascular complications have to be feared, mostly in the form of bleeding complications and hematomas, arterial dissections or occlusions, pseudoaneurysms and AV-fistulas. Each of these complications may have the potential for serious morbidity. When cardiac catheterization is performed via the arteries of the arm (either in the classical Sones technique by arterial cutdown to the brachial artery or by direct puncture of the brachial or radial artery) vascular occlusions will mostly occur as local vascular complications. These occlusions can often be managed conservatively or by a surgical procedure. The incidence of a vascular complication is mainly dependent on patient-related (sex, age, height, weight, arterial hypertension, diabetes, presence of peripheral vascular disease and compliance of the patient after withdrawal of the sheath) and procedure-related (arterial access site, diagnostic or interventional study, sheath size, periprocedural anticoagulation, duration of intra-arterial sheath placement, faulty puncture technique, operator skill) factors. In addition, the definition of a complication, the publication year of a certain study and the technique used for identification of complications seem to play a role for the reported incidence of peripheral vascular complications after cardiac catheterization. Currently, incidences of 0.1 to 2% for significant local vascular complications after diagnostic transfemoral catheterization are reported, after interventional transfemoral treatment 0.5 to 5% and after complex procedures using large sheath sizes with periprocedural anticoagulation (directional atherectomy, IABP, left-heart assist, valvuloplasty) up to 14%. Following transbrachial and transradial catheterization, local vascular complications at the entry site amount to 1 to 3% after diagnostic and 1 to 5% after interventional procedures. Local vascular complications may be diminished by a cautious and sensitive puncture technique with additional care in patients at higher risk for vascular complications (females, prediagnosed peripheral vascular disease, mandatory anticoagulation, necessity for large sheaths). By using smaller sized catheters and an adequate, defensive anticoagulation regimen, the rate of arterial access site complications may be reduced. Proper methods for achievement of hemostasis as well as a close and careful observation after sheath withdrawal are required.ZusammenfassungIm Rahmen der Herzkatheterdiagnostik und-therapie muß bei einem Teil der Patienten mit einer lokalen Komplikation im Bereich des arteriellen Gefäßzuganges gerechnet werden. Die Komplikationsraten sind je nach Untersuchungstechnik und Ort der Punktion unterschiedlich. Bei der am häufigsten durchgeführten Katheteruntersuchung von der Arteria femoralis aus sind vielfältige Komplikationen möglich; als bedeutsam müssen Blutung und Hämatombildung, Dissektion und/oder arterieller Gefäßverschluß sowie Entwicklung eines Aneurysma spurium oder einer AV-Fistel angesehen werden. Bei einer Herzkatheteruntersuchung über die Arterien des Armes (klassische operative Sones-Technik, Punktion der Arteria brachialis oder in neuerer Zeit Radialispunktion) sind ganz überwiegend lokale Gefäßverschlüsse im Bereich des Zuganges zu befürchten. Die Inzidenz einer Gefäßkomplikation ist wesentlich abhängig von patientenseitigen (Geschlecht, Alter, Größe, Gewicht, manifester Hochdruck, Diabetes mellitus, Vorliegen einer arteriellen Verschlußkrankheit, Compliance des Patienten nach Entfernen der Schleusen) und untersuchungsbedingten (Ort des arteriellen Gefäßzugangs, diagnostische oder interventionelle Katheterisierung, Durchmesser der Schleusen und Katheter, Notwendigkeit einer periprozeduralen Antikoagulation, Verweildauer der Schleusen, fehlerhafte Punktionstechnik, Erfahrung des Untersuchers) Faktoren. Darüber hinaus spielt es für die berichteten Häufigkeiten einer Komplikation eine Rolle, wie sie defininiert und in welchen Untersuchungsjahren und mit welcher Untersuchungsmethode nach ihnen gesucht wurde.Aktuell muß bei einer Katheteruntersuchung über die Arteria femoralis in der Technik nach Judkins mit einer Häufigkeit schwerwiegender arterieller Komplikationen von 0,1 bis 2% nach diagnostischen und 0,5 bis 5% nach interventionellen Eingriffen gerechnet werden.Nach komplexen Prozeduren über sehr großlumige Schleusen mit lauger Schleusenverweildauer und effektiver Antikoagulation (zum Beispiel IABP, Ballonvalvuloplastie, passagere. Linksherzunterstützung) sind schwerwiegende periphere Komplikationsraten von bis zu 14% berichtet. Bei transbrachialem und transradialem Zugang sind lokale Komplikationsraten von 1 bis 3% nach diagnostischen und 1 bis 5% nach interventionellen Eingriffen zu befürchten. Zur Verringerung dieser Komplikationen sind eine große Erfahrung des Untersuchers mit sorgfältiger und sensibler Punktionstechnik sowie besondere Vorsicht bei Patienten mit Risikokonstellation (Frauen, Patienten mit arterieller Verschlußkrankheit, Patienten unter Antikoagulation, Eingriffe über großlumige Schleusen) zu fordern. Im Rahmen der Katheterdiagnostik und-therapie kann durch Verwendung von dünnlumigeren Kathetern und einer angemessenen, nicht zu aggressiven Antikoagulation die Zahl der lokalen arteriellen Gefäßkomplikationen gesenkt werden. Eine sichere Blutstillung und eine engmaschige Überwachung nach Entfemen der Schleusen sind notwendig.SummaryAfter diagnostic and interventional cardiac catheterization, local vascular complications at the arterial entry site must be expected. With respect to the method applied for catheterization and the puncture site, the type of complications may vary. With transfemoral approach a large variety of vascular complications have to be feared, mostly in the form of bleeding complications and hematomas, arterial dissections or occlusions, pseudoaneurysms and AV-fistulas. Each of these complications may have the potential for serious morbidity. When cardiac catheterization is performed via the arteries of the arm (either in the classical Sones technique by arterial cutdown to the brachial artery or by direct puncture of the brachial or radial artery) vascular occlusions will mostly occur as local vascular complications. These occlusions can often be managed conservatively or by a surgical procedure.The incidence of a vascular complication is mainly dependent on patient-related (sex, age, height, weight, arterial hypertension, diabetes, presence of peripheral vascular disease and compliance of the patient after withdrawal of the sheath) and procedure-related (arterial access site, diagnostic or interventional study, sheath size, periprocedural anticoagulation, duration of intra-arterial sheath placement, faulty puncture technique, operator skill) factors. In addition, the definition of a complication, the publication year of a certain study and the technique used for identification of complications seem to play a role for the reported incidence of peripheral vascular complications after cardiac catheterization.Currently, incidences of 0.1 to 2% for significant local vascular complications after diagnostic transfemoral catheterization are reported, after interventional transfemoral treatment 0.5 to 5% and after complex procedures using large sheath sizes with periprocedural anticoagulation (directional atherectomy, IABP, left-heart assist, valvuloplasty) up to 14%. Following transbrachial and transradial catheterization, local vascular complications at the entry site amount to 1 to 3% after diagnostic and 1 to 5% after interventional procedures.Local vascular complications may be diminished by a cautious and sensitive puncture technique with additional care in patients at higher risk for vascular complications (females, prediagnosed peripheral vascular disease, mandatory anticoagulation, necessity for large sheaths). By using smaller sized catheters and an adequate, defensive anticoagulation regimen, the rate of arterial access site complications may be reduced. Proper methods for achievement of hemostasis as well as a close and careful observation after sheath withdrawal are required.

Comparison of a Lactate- Versus Acetate-Based Hemofiltration Replacement Fluid in Patients with Acute Renal Failure

The objective of the study was to determine the impact of a lactate- and an acetate-based hemofiltration replacement fluid (HF) on the acid-base status in patients with acute renal failure (ARF) and continuous venovenous hemofiltration (CVVH). The prospective, cohort study was carried out in the intensive care unit of the Heinrich-Heine University Hospital, Düsseldorf, FRG. Subjects were 84 critically ill patients with ARF and CVVH. Fifty-two patients were subjected to lactate-based (group 1) and 32 to acetate-based hemofiltration (group 2). Thirty-eight patients had a septic, 46 a cardiovascular origin of the ARF. Creatinine, BUN, serum bicarbonate, arterial pH, lactate and APACHE II score were noted daily. Mean CVVH duration was 9.8 +/- 8.1 days; mortality was 65%. The groups did not differ with regard to the main clinical parameters. Lacate-based hemofiltration led to significantly higher serum bicarbonate and arterial pH values as compared to the acetate-based hemofiltration. Baseline serum bicarbonate values were 23.3 +/- 8.3 mmol/L in group 1 and 21.6 +/- 4.3 mmol/L in group 2 (NS); values at 48 h after initiating CVVH treatment were 25.7 +/- 3.8 mmol/L and 20.6 +/- 3.1 mmol/L, respectively (p < 0.001). Arterial pH prior to CVVH treatment was 7.36 +/- 0.1 in group 1 and 7.34 +/- 0.1 in group 2 (NS), and 7.43 +/- 0.07 versus 7.37 +/- 0.06 (p < 0.001) on day 2. These findings were maintained throughout therapy. While a lack of increase in serum bicarbonate and arterial pH was correlated to a poor prognosis in lactate-based hemofiltration, no such observation could be made in acetate-based hemofiltration. Septic patients did not differ in their acid-base status from nonseptic patients. Lactic acidosis occurred in 8 septic patients irrespective of the substitution fluid. All 8 patients died. There was a significant increase in HCO3 and arterial pH values in lactate-based as compared to acetate-based HF.

Prior Cytomegalovirus Infection and the Risk of Restenosis After Percutaneous Transluminal Coronary Balloon Angioplasty

BACKGROUND Restenosis is a common problem after all revascularization procedures in atherosclerotic coronary arteries. Reactivated human cytomegalovirus (CMV) has been detected in tissues of restenotic vascular lesions and was hypothesized to be a contributing pathogenic factor. Recent data suggest an association of restenosis after optimal coronary atherectomy with CMV serostatus, and a possible role of antiviral therapy was discussed. We therefore tested the hypothesis that prior CMV infection might be a risk factor for restenosis after conventional coronary balloon angioplasty (PTCA). METHODS AND RESULTS We analyzed 92 consecutive patients who had been admitted for control angiography after previous PTCA within a mean interval of 6 months. Anti-CMV antibodies were measured as an indicator of prior CMV infection and latency. The coronary angiograms before PTCA, directly after, and 6 months later were analyzed quantitatively. Sixty-five percent of the patients were CMV-positive. Before PTCA, the degree (mean+/-SD) of stenosis was 69+/-10% in CMV-positive and 68+/-8.3% in CMV-negative subjects. PTCA resulted in a residual stenosis of 39% in both groups. After 6 months, the late losses of luminal diameter in the CMV-positive and -negative groups were 11+/-13% and 12+/-15%, respectively (P=0.658). In an ANCOVA with 25 potential risk factors for restenosis, CMV serostatus was not significantly associated with restenosis development. CONCLUSIONS Our data indicate that prior CMV infection, in contrast to optimal atherectomy, is not associated with chronic restenosis after conventional coronary balloon angioplasty. The results do not support a possible benefit from antiviral therapy.

Incidence and therapy of peripheral arterial vascular complications after heart catheter examinations

Wir analysierten die Inzidenz und Therapie aller in unserer Klinik aufgetretenen signifikanten lokalen Gefäßkomplikationen an der Punktionsstelle nach invasiver diagnostischer und interventioneller Herzkatheterisierung. Während eines 7jährigen Untersuchungszeitraums wurden 27387 Herzkatheteruntersuchungen durchgeführt, es handelte sich um 19581 diagnostische und 7806 interventionelle Herzkatheter. Insgesamt traten bei 114 der insgesamt 27387 Herzkatheterisierungen (0,42%) signifikante periphere lokale Gefäßkomplikationen auf. In 36 Fällen (0,13%) handelte es sich um arterielle Verschlüsse am Ort der Punktion, bei 34 Patienten (0,12%) um bedeutsame Hämatome an der Punktionsstelle (OP oder Bluttransfusion erforderlich), bei 32 Patienten (0,12%) um persistierende Pseudoaneurysmen, bei 9 Patienten (0,03%) um eine AV-Fistel und bei 3 Patienten (0,01%) um andere schwerwiegende Komplikationen. Lokale Gefäßkomplikationen waren deutlich häufiger bei Frauen als bei Männern nachweisbar, außerdem war nach interventioneller Kathetertherapie unter Verwendung großlumiger Schleusen mit der Notwendigkeit einer effektiven Heparintherapie die Häufigkeit von Komplikationen deutlich gegenüber rein diagnostischen Untersuchungen erhöht. Bei vorbestehender arterieller Verschlußkrankheit war die Häufigkeit eines lokalen Gefäßverschlusses erhöht. Eine operative Revision der Gefäßkomplikation war bei 62 Patienten (54%) notwendig, 34 Patienten (30%) wurden konservativ behandelt. Bei 18 Patienten (17%) konnte durch Kathetertechniken (PTA, lokale Lyse, Stent-Implantation) ein Gefäßverschluß eröffnet werden. Insgesamt ist die Inzidenz einer signifikanten lokalen Gefäßkomplikation nach Herzkatheteruntersuchung selten. Zukünftig werden diese vaskulären Komplikationen zunehmend auch durch konservative Maßnahmen (z.B. lolake Kompressionsbehndlung bei Pseudoaneurysmen) oder Kathetertechniken (vor allem zur Rekanalisation von arteriellen Verschlüssen) behandelt werden können. We analyzed the incidence and management of major vascular complications at the arterial puncture site following diagnostic or interventional cardiac catheterization. 27387 cardiac catheterization procedures were performed for diagnostic (n = 19581) or interventional (n = 7806) purposed at our institution during a 7-year study period. A total number of 114 major vascular complications (0.42%) were identified. In 36 (0.13%) patients an arterial occlusion at the puncture site was detected, 34 patients (0.12%) had severe hematoma (blood transfusion or surgical repair necessary), 32 patients (0.12%) developed false aneurysms, 9 patients (0.03%( with av-fistulas and 3 patients (0.01%) had other complications. The following factors were predictive for a significant increase in the incidence of major vascular complications: Female gender, interventional catheterization using larger introducer sheaths and necessitating effective perioperative doses of heparine, and peripheral vascular disease. Operative repair was necessary in 62 patients (54%), 34 patients (30%) were treated conservatively. In 18 patients (17%) acute vascular occlusion could be managed by percutaneous transluminal balloon dilatation and intravascular thrombolysis of the obstructionn, in 3 patients additional stent-implantation was necessary in the presence of a large occlusive dissection. Overall the rate of clinically significant major vascular complications is low. In the future a greater number of vascular complications at the entry site for cardiac catheterization will be treated with nonoperative methods (e.g. manual compression of pseudoaneurysms or catheter-based techniques for recanalization of acutely occluded vessels).

Intracoronary administration of dipyridamole prior to percutaneous transluminal coronary angioplasty provides a protective effect exceeding that of ischemic preconditioning.

Background Ischemic preconditioning renders hearts more resistant to the deleterious consequences of ischemia. Adenosine is an important mediator in the induction and maintenance of ischemic preconditioning. Percutaneous transluminal coronary angioplasty (PTCA) allows the investigation of the consequences of ischemia in humans. The severity of myocardial ischemia decreases with subsequent balloon inflations during the course of PTCA. Objective To compare the effect of intracoronary administration of dipyridamole with the effect of consecutive balloon inflations. Methods We investigated 30 patients undergoing PTCA of the left anterior descending coronary artery in the setting of stable angina pectoris. Patients were randomly allocated to be administered either 0.5 mg/kg body weight dipyridamole intracoronarily or an equal amount of saline. Patients administered saline served as a control group. All patients were subjected to three consecutive balloon inflations. Severity of myocardial ischemia was assessed in terms of severity of chest pain, electrocardiographic signs of ischemia, and duration of balloon inflation tolerated. Results Patients administered dipyridamole intracoronarily tolerated significantly longer durations of balloon inflation than did patients in the control group. Severity of anginal pain and extent of electrocardiographic signs of ischemia were significantly lower after intracoronary administration of dipyridamole. The reductions in anginal pain and ST-segment shift caused by intracoronary administration of dipyridamole during the first balloon inflation were even more pronounced than the protection that was afforded by the third balloon inflation for patients in the control group. Conclusions Intracoronary administration of dipyridamole prior to PTCA is associated with a significant gain in tolerance of ischemia. The protection afforded by intracoronary administration of dipyridamole is even more pronounced than the effect of ischemic preconditioning.

Right atrial metastasis as primary clinical manifestation of hepatocellular carcinoma

We present an 81-year-old man with right atrial metastasis associated with hepatocellular carcinoma. Antemortem diagnosis was made by two-dimensional echocardiography, cardiac catheterisation and computed tomography, followed by surgical intervention and histological examination of the right atrial tumour. To our knowledge, this is the second case with intravital diagnosis and histological confirmation.