U. Tebbe

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)

Single-bolus injection of recombinant tissue-type plasminogen activator in acute myocardial infarction

Recombinant tissue-type plasminogen activator (rt-PA) has hitherto been administered in acute myocardial infarction as an intravenous infusion with an initial bolus of about 10% of the total dose, both due to its short half-life and to avoid possible early reocclusions. A single-bolus dose would simplify the therapeutic regimen. Therefore, 20 patients with symptom duration of 125 +/- 58 minutes were given a single bolus of 50 mg of rt-PA over 2 minutes. Coronary angiography 60 minutes after the rt-PA bolus revealed a patent infarct-related artery in 15 of 20 patients (patency rate 75%, 95% confidence limits 51 to 91%). In the remaining patients, reperfusion was achieved by coronary angioplasty and intracoronary fibrinolysis; in 2 patients coronary artery bypass grafting was necessary. Control angiograms at 24 hours showed reocclusions in 4 of 18 patients. One woman died due to an intracranial hemorrhage 48 hours after the rt-PA bolus injection. Circulating fibrinogen decreased from 2.7 +/- 0.5 to 1.5 +/- 0.9 g/liter after 2 to 4 hours and reached the initial value within 24 hours. Pharmacokinetic parameters were obtained in 7 patients by measuring rt-PA antigen levels in multiple plasma samples. Mean peak rt-PA concentration was 9.8 +/- 3.6 micrograms/ml, total plasma clearance 476 +/- 148 ml/min and dominant half-life 4.8 +/- 1.0 minutes. Thus, rt-PA administered as a 50-mg single bolus appears to provide similar patency rates and shows similar kinetics in comparison with the conventional infusion regimen. Assessment of the incidence of bleeding complications requires further studies.

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.

Budd-Chiari Syndrome as the Primary Manifestation of a Fibrolamellar Hepatocellular Carcinoma

An 18-year-old female patient was admitted with ascites, right upper abdominal tenderness and peripheral edema. Angiography showed complete occlusion of the vena cava inferior up to the level of the right atrium. By open heart surgery, masses of thrombotic material were pulled out of the v. cava inferior/vv. iliacae which histologically contained tumor cell populations consistent with a hepatocellular carcinoma. Celiacography showed a highly vascularized tumor in the right hepatic lobe. Histologically, it proved to be fibrolamellar subtype hepatocellular carcinoma.

Intravenous Streptokinase in Acute Myocardial Infarction (I.S.A.M.) trial: Serial evaluation of left ventricular function up to 3 years after infarction estimated by radionuclide ventriculography

The Intravenous Streptokinase in Acute Myocardial Infarction (I.S.A.M.) trial was a prospective, placebo-controlled, double-blind multicenter trial of high-dose short-term intravenous streptokinase in acute myocardial infarction administered within 6 h after the onset of symptoms. Global and regional left ventricular ejection fractions were determined by radionuclide ventriculography in a subset of 120 patients 3 days, 4 weeks, 7 months, 18 months and 3 years after acute myocardial infarction. In patients with anterior myocardial infarction, left ventricular ejection fraction was higher in the streptokinase than in the placebo group 3 days after acute infarction (49 +/- 14% vs. 40 +/- 11%, p = 0.02). This difference of about 10% units in ejection fraction persisted during the 3 year follow-up period. Among streptokinase-treated patients, regional left ventricular ejection fraction was higher within the infarct zone as well as in remote myocardium throughout the follow-up period. Among patients with inferior infarction, no significant differences between the treatment and control groups were demonstrable with respect to global and regional left ventricular ejection fraction. Thus, intravenous administration of streptokinase within 6 h after the onset of symptoms of acute myocardial infarction preserves left ventricular function over a period of greater than or equal to 3 years in patients with acute anterior myocardial infarction. It improves regional myocardial function within the infarct zone as well as in remote areas. In patients with acute inferior myocardial infarction, benefit from intravenous streptokinase is of only minor degree.

Pharmacological therapy after coronary angioplasty. Early experience with low molecular weight heparin for prophylaxis of reocclusion.

Since the introduction of percutaneous transluminal coronary angioplasty (PTCA) in 1979, this method has become established for treatment of coronary artery disease. Despite various technical improvements, one of the main problems, that of early restenosis, still could not be solved. Rates of restenosis after successful PTCA between 12% and 42% within the first six months after the operation have been described [1, 3]. However, the vast majority of restenoses appears to have occured after three months already [5]. Attempts to reduce the rate of recurrences with various drugs in follow-up treatment have been unsuccessful. Based on the notion of a thrombocyte aggregation on an endothelial lesion after balloon dilatation, the concept of thrombocyte aggregation inhibitor therapy with acetylsalicylic acid or dipyridamol, or a combination of both drugs was developed. The incidence of early occlusion a short time after PTCA could be lowered under the combination treatment. However there was no reduction in the rate of restenosis compared to the placebo group [4]. In the present pilot investigation, the effect on the rate of restenosis of a chronic treatment with low molecular weight heparin (LMWH) as compared to the treatment with low-dose acetylsalycilic acid (ASA), which is the most widespread at present, was determined. This was a prospective investigation in which the results of 11 successfully by dilated stenoses per group were compared. The LMWH Fragmin| (developed by Kabi-Vitrum) was used. The individual dose of heparin was determined on the basis of the anti-factor Xa activity in patient plasma 2 hours after a single injection in the morning. In addition, serial blood samples were taken to determine the anti-Xa activity over 24 hours. A peak level of 0.3 to 0.6 was aimed for 2 hours after injection. In the further course, each patient in this group administered the single daily dose him/herself. The mean dose of Fragmin| was 6000 units (=80 units/kg). The dose of ASA in the second group was between 100 mg and 300 rag/day. The concomitant therapy with coronary therapeutics, antihypertensires or other drugs was retained unchanged by the investiga-

Analysis of left ventricular regional motility: a comparison of different methods

Multiple gated blood pool (MUGA) and contrast ventriculographic studies were performed within 24 h in 80 patients, 20 with 120 normokinetic wall segments and 60 with wall motion abnormalities in 239 of 360 wall segments. Three methods of evaluation of the radionuclide ventriculograms were compared with the results of the biplane contrast ventriculography which served as a standard: (1) qualitative analysis of the cine mode, (2) analysis of parametric scans (amplitude and phase images) and the phase histogram obtained by Fourier analysis, (3) quantitative determination of regional ejection fraction. Normal values were obtained from 20 patients with normal wall motion in the contrast angiogram. The overall sensitivity for the detection of wall motion abnormalities of high degree was 96% for method 1, 95% for method 2, and 90% for method 3, for those of low degree 72% for method 1, 63% for method 2, and 75% for method 3. Combining methods 2 and 3 the sensitivity was increased to 99% for high grade and to 81% for low grade wall motion abnormalities. The two methods showed a complementary effect because of different sensitivities in dependence of the localization of the wall motion abnormality. Although a high efficiency for the evaluation of left ventricular function was provided by the qualitative analysis of the cine mode the combination of Fourier analysis and the determination of regional ejection fraction should be preferred. It increases the sensitivity for the detection of wall motion abnormalities. Moreover, it offers quantitative data which improve the reproducibility and decrease the observer variability.

Videodensitometric Measurement of Coronary Flow

The first attempts to measure coronary artery flow velocities using densitometry were done nearly 15 years ago (Rutishauser et al. 1967, 1970a, 1970b; Smith et al. 1971). Methodological improvements have been reported by Pannek et al. (1978) and Fermor et al. (1979). Using the method described below, phasic flow velocity in native human coronary arteries can be obtained during routine coronary angiography.

Influence of long-term treatment with ketanserin on blood pressure, pulmonary artery pressure, and cardiac output in patients with heart failure

SummaryKetanserin is a selective serotonin2-receptor blocker and by this mechanism decreases peripheral resistance and blood pressure in hyertensives. We examined the hemodynamic effects of ketanserin during long-term treatment in patients with heart failure. Five male patients with coronary artery disease and heart failure (NYHA classes II–III) were treated with ketanserin (80 mg daily) for 12 months. Before treatment, after 4 weeks, and after 12 months treatment, a Swan-Ganz catheter was placed into the pulmonary artery and pulmonary wedge pressure, cardiac output, mean arterial pressure, and heart rate were measured at rest and on exertion. The pulmonary wedge pressure at rest decreased from 8 mmHg before to 6 mmHg after 4 weeks and 12 months treatment; on exertion, it decreased from 31 mmHg before treatment to 24 mmHg after 4 weeks treatment and to 21 mmHg after 12 months treatment. The mean arterial pressure also decreased at rest and on exertion after 4 weeks treatment as well as after 12 months treatment. Cardiac output increased slightly and heart rate was unaltered. No serious side effects occurred. Ketanserin could become an alternative vasodilator drug in the treatment of patients with heart failure.

Underestimation of left-ventricular ejection fraction by radionuclide ventriculography in patients with aneurysm

The left-ventricular ejection fraction (LVEF) of 72 patients with aneurysm of the anterior wall was measured by multiple gated blood pool acquisition (MUGA) in the anterior and left anterior oblique (LAO) positions, and by cineangiography (CA) in right anterior oblique (RAO) and LAO projections of 30° and 60°, respectively. The LVEF was overestimated by CA in the LAO projection and by MUGA in the anterior position, but underestimated by CA in the RAO projection (6.1 percentage points) and by MUGA in the LAO position (6.2 percentage points). In 50 patients without aneurysm, no systematical error occurred using MUGA. The underestimation of the LVEF in patients with aneurysm by MUGA in the LAO position is due to differences of photon attenuation in various parts of the cardiac blood pool. This systematical error can be overcome by biplane MUGA.