Ole-Alexander Breithardt

Potential benefit of biventricular pacing in patients with congestive heart failure and ventricular tachyarrhythmia.

Treatment of congestive heart failure (CHF) aims for symptomatic relief and reduction of mortality both from sudden death and pump failure. The implantable cardioverter defibrillator (ICD) is highly effective in the prevention of sudden death, but no mortality benefit in advanced CHF has yet been shown. Biventricular pacing may lead to functional improvement in selected patients with CHF. Thus, a biventricular pacemaker with defibrillation capabilities may be ideal for patients with advanced CHF. We retrospectively analyzed the data from 384 patients (age 59 +/- 12 years, 322 male and 62 female) with regard to New York Heart Association (NYHA) CHF class, mean QRS duration, mean PR interval, presence of a QRS > 120 msec and incidence of atrial fibrillation at the time of ICD implantation. Based on eligibility criteria from studies in biventricular pacing, we analyzed how many patients may benefit from biventricular pacing. Patients with CHF were older (NYHA class III: 60.9 +/- 9.7, class II: 61.3 +/- 10 versus class I: 50.8 +/- 13.6 years, p < 0.001 each) and mean QRS duration was longer with advanced CHF (NYHA class III 127.8 +/- 30 msec; class II 119.4 +/- 27.7 msec; class 0-1: 103.9 +/- 17.7 msec, p < 0.001, analysis of variance) as was the mean PR interval (NYHA class III 189.9 +/- 33.5 msec; class II 176.1 +/- 29.3 msec; class 0-1 162.7 +/- 45.9 msec, p < 0.001, analysis of variance). The incidence of atrial fibrillation was higher in class III (25.5%) compared with class 0-1 (16.9%) and class II patients (14.1%, p = 0.043, chi-square test). A total of 28 patients (7.3%) fulfilled eligibility criteria for biventricular pacing if NYHA class III patients were considered candidates and 48 (12.5%) if patients with NYHA II CHF and ejection fraction < or = 30% were included. Thus, biventricular pacing may offer a promising therapeutic approach for a significant proportion of patients with CHF at risk for ventricular tachyarrhythmia.

Usefulness of brain natriuretic peptide release as a surrogate marker of the efficacy of long-term cardiac resynchronization therapy in patients with heart failure

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Successful thrombolysis of right atrial and ventricle thrombi encircling a temporary pacemaker lead in a patient with heparin-induced thrombocytopenia type II.

Only few reports exist addressing the problem of temporary pacemaker leads associated with thromboembolic disease. We report the case of a 67‐year‐old patient who required a temporary transfemoral pacemaker due to AV block grade III. The patient developed extensive right atrial and ventricle thrombus formation attached to the pacing wire, as well as venous thrombosis at the insertion site due to heparin‐induced thrombocytopenia type II (HIT type II). After short‐term thrombolysis with 1 mg rt‐PA/kg b.w. complete resolution of all clots could be shown by B‐mode sonography and transthoracic, as well as transesophageal echocardiography.

Long‐Term Effects of Dynamic Atrial Overdrive Pacing on Sleep‐Related Breathing Disorders in Pacemaker or Cardioverter Defibrillator Recipients

Introduction: Sleep‐related breathing disorders occur in 20–30% of Europeans and North Americans, including 10% of sleep apnea syndrome (SAS). A preliminary study suggested that atrial overdrive pacing with a fixed heart rate might alleviate SAS. However, it is not known whether dynamic atrial overdrive pacing alleviates SAS.

Mid-systolic septal deceleration. A new sign of left ventricular outflow tract obstruction obtained by color-coded tissue Doppler echocardiography.

Die hypertrophe, obstruktive Kardiomyopathie (HOCM) ist charakterisiert durch das Vorliegen einer dynamischen Obstruktion des linksventrikulären Ausflusstraktes. Wir untersuchten mittels farbkodierter Gewebe-Doppler-Echokardiographie (TDI) das septale longitudinale Bewegungsmuster bei einer 69-jährigen HOCM-Patientin während und nach Katheterbehandlung mittels Alkohol-Ablation der septalen Hypertrophie (TASH). Das Auftreten des Gradienten im linksventrikulären Ausflusstrakt ging mit einer charakteristischen mid-systolischen septalen Dezelerationsbewegung in der TDI-Geschwindigkeitskurve einher, welche 5 Wochen nach erfolgreicher Behandlung in Ruhe nicht mehr nachweisbar war. Hypertrophic obstructive cardiomyopathy (HOCM) is characterized by the presence of a dynamic left ventricular outflow tract gradient. We studied septal longitudinal motion by colorcoded tissue Dopppler echocardiography in a 69-year old HOCM patient during and after catheterbased treatment by transcoronary alcohol ablation of septal hypertrophy. The presence of dynamic left ventricular outflow tract obstruction was associated with a characteristic abrupt mid-systolic septal deceleration pattern in the tissue Doppler velocity trace. Five weeks after treatment, this pattern was no longer visible at rest.

Lebensbedrohliche Akut-Komplikationen der Dobutamin-Atropin-Streßechokardiographie – ein kasuistischer Beitrag

Über zwei seltene Komplikationen der Dobutamin-Atropin Streßechokardiographie wird berichtet. Bei einem 66jährigen Patienten entwickelten sich klinische, elektro- und echokardiographische Zeichen eines akuten Vorderwandinfarktes nach der zweiten Atropin-Bolusgabe unter maximaler Dobutamin-Stimulation mit 40 μg/kg/min. Die akut durchgeführte Koronarangiographie zeigte einen proximalen Verschluß des Ramus interventricularis anterior, welcher primär erfolgreich rekanalisiert werden konnte. Ein zweiter Patient wurde nach Stimulation mit 40 μg/kg/min Dopamin und zusätzlicher Gabe von 0,5 mg Atropin reanimations- und intubationspflichtig im Rahmen einer akuten Hinterwandischämie mit Kammerflimmern. Die möglichen Ursachen und Inzidenzen solcher lebensbedrohlicher Komplikationen werden diskutiert und der konventionellen Fahrradergometrie gegenübergestellt. Die beschriebenen lebensbedrohlichen Komplikationen weisen auf die Bedeutung entsprechender notfallmedizinischer Einrichtungen als Voraussetzung zur Durchführung einer medikamentösen Streßechokardiographie hin. The presented case report describes lifethreatening complications of pharmacological stress echocardiography with dobutamine. A 66-year old male suffered an acute anterior wall myocardial infarction during dobutamine-atropine stress echocardiography. Symptoms and signs of myocardial infarction developed after maximal dobutamine-dose (40 μg/kg/min) and the additional application of atropine. Emergency coronary angiography revealed extensive coronary artery disease with proximal occlusion of the left anterior descending artery which was successfully recanalized. In a second patient ventricular fibrillation echocardiography and electrocardiographic signs of acute myocardial ischemia developed after high-dose dobutamine stress and required prolonged resuscitation. The possible mechanisms, incidence and risk of acute myocardial ischemia during dobutamine-atropine stress are discussed and compared to bicycle ergometry. The presented lifethreatening complications of dobutamine-atropine stress echocardiography emphasize the importance of available and adequate emergency facilities.

Einsatz der Echokardiographie in der kardialen Resynchronisationstherapie: Identifizierung geeigneter Patienten, Nachsorge und Therapieoptimierung

Hintergrund und Ziel:Die kardiale Resynchronisationstherapie (CRT) mittels biventrikulärer Stimulation ist eine neue, zusätzliche Therapieoption für Patienten mit schwerer Herzinsuffizienz NYHA III–IV und asynchronem Kontraktionsablauf. Als wichtigstes Selektionskriterium für die CRT gilt das Vorhandensein eines Linksschenkelblocks. Mittels transthorakaler Echokardiographie können wertvolle zusätzliche Hinweise über den kardialen Kontraktionsablauf und die hämodynamischen Auswirkungen gewonnen werden, welche eine verbesserte Identifizierung geeigneter Patienten für die CRT und eine optimierte Nachsorge versprechen. Die vorliegende Übersicht diskutiert die möglichen Verfahren und Limitationen und gibt eine praktische Hilfestellung für die individuelle Patientenbetreuung.Background and Aim:Cardiac resynchronization therapy (CRT) with biventricular stimulation is a new therapeutic option for patients with advanced heart failure and left ventricular asynchrony. The presence of a left bundle branch block morphology in the electrocardiogramm is presently the most important selection criterion. Transthoracic echocardiography provides important additional information on the ventricular contraction sequence and the hemodynamic consequences of asynchrony. This may help to identify suitable patients, to improve the selection criteria and to optimize CRT during follow-up. This article discusses the potential techniques and limitations and provides practical guidance for the individual patient follow-up.

Biventrikuläre Stimulation bei Herzinsuffizienz

Zum ThemaDie Therapie der schweren Herzinsuffizienz, die medikamentös nicht mehr zu beeinflussen ist, stellt bekanntermaßen ein großes Problem dar. Die gegenwärtige ultima ratio der Behandlung ist die Herztransplantation, realistisch gesagt: wäre sie. Bei Mangel an Spenderorganen besteht eine so eklatante Diskrepanz zwischen Angebot und Nachfrage, daß gegenwärtig nur wenige Patienten hierzulande transplantiert können.Unter Berücksichtigung der Tatsache, daß Herzinsuffizienz und Störungen des Reizleitungssystems häufig miteinander verbunden sind, hat man die Methode der biventrikulären Elektrostimulation entwickelt. Man glaubt, es können ca. 10±5% von Patienten mit fortgeschrittener Herzinsuffizienz von der Anwendung dieses Verfahrens profitieren. Über die elektrophysiologischen Voraussetzungen, die Technik und erste ermutigende klinische Studien der biventrikulären Elektrostimulation wird in dieser Arbeit referiert.

[Echocardiography in cardiac resynchronization therapy: identification of suitable patients, follow-up and therapy optimization].

Hintergrund und Ziel:Die kardiale Resynchronisationstherapie (CRT) mittels biventrikulärer Stimulation ist eine neue, zusätzliche Therapieoption für Patienten mit schwerer Herzinsuffizienz NYHA III–IV und asynchronem Kontraktionsablauf. Als wichtigstes Selektionskriterium für die CRT gilt das Vorhandensein eines Linksschenkelblocks. Mittels transthorakaler Echokardiographie können wertvolle zusätzliche Hinweise über den kardialen Kontraktionsablauf und die hämodynamischen Auswirkungen gewonnen werden, welche eine verbesserte Identifizierung geeigneter Patienten für die CRT und eine optimierte Nachsorge versprechen. Die vorliegende Übersicht diskutiert die möglichen Verfahren und Limitationen und gibt eine praktische Hilfestellung für die individuelle Patientenbetreuung.Background and Aim:Cardiac resynchronization therapy (CRT) with biventricular stimulation is a new therapeutic option for patients with advanced heart failure and left ventricular asynchrony. The presence of a left bundle branch block morphology in the electrocardiogramm is presently the most important selection criterion. Transthoracic echocardiography provides important additional information on the ventricular contraction sequence and the hemodynamic consequences of asynchrony. This may help to identify suitable patients, to improve the selection criteria and to optimize CRT during follow-up. This article discusses the potential techniques and limitations and provides practical guidance for the individual patient follow-up.

Cardio-respiratory exercise testing early after the use of the Angio-Seal system for arterial puncture site closure after coronary angioplasty.

AIMS The vascular closure device (VCD) Angio-Seal is an easy-to-use system for the closure of arterial puncture sites after percutaneous coronary intervention (PCI), and allows for early mobilisation of the patient. However, little data are available about exercising early after the use of VCDs in PCI patients. METHODS AND RESULTS A total of 230 consecutive patients were screened. Of these, 45 (20%) were excluded due to the inability to perform exercise testing, or anatomical conditions which prevented the insertion of a VCD. The 185 remaining patients (139 male, mean age 68 ± 12 years) received Angio-Seal after PCI. After four hours, 30 patients (16%) showed a small local haematoma, 11 patients (6%) complained about minor -and one patient (0.5%) about strong- groin pain. There were no major bleeding complications, six pseudo-aneurysmata, and one arterio-venous fistula. Overall, nine patients (6%) showed moderate to severe groin problems. Patients without major complications underwent bicycle cardiopulmonary exercise testing the subsequent day. Exercise testing was performed up to 136 ± 60 W in 176 patients (94%). Maximum workload was 104 ± 33 W, peak oxygen consumption 17.6 ± 5.1 ml/min/kg, and oxygen consumption at the anaerobic threshold 15.4 ± 4.2 ml/min/kg. After exercise testing there were no cardiovascular complications noted. CONCLUSIONS In patients receiving VCD after PCI, exercise testing above the anaerobic threshold was feasible after Angio-Seal deployment in those patients with no complications after the use of the device.