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Endovascular repair (ER) has been established as an alternative treatment option for aortic aneurysm (AA) in case of a suitable morphology. However, there are specific problems related to diagnostic and therapeutic management including potential complications of the new procedure.Between 8/1996 and 11/1999, 41 patients (6 female, mean age 67.9 (range 55-84) years) underwent an operation with the intention of ER. Modular, self-expanding stent-grafts were used for aorto-biiliacal (36), aorto-monoiliacal (1), and aorto-aortal (infrarenal-1, thoracic-1) aortic aneurysm (AA) exclusion. Postoperatively and during the follow-up period, diagnostic measures included clinical investigation, native X-ray, and color-coded Doppler sonography, and spiral computed tomography, and digital subtraction angiography. Results were analysed with special reference to complications and resulting therapeutic consequences.Technical success was achieved in 36/41 patients (87.8%). There were 2 primary distal endoleaks and 3 conversions because of lacking vascular access. Of 4 primary endoleaks, a proximal one was treated successfully by overstenting, a distal one was sealed off by iliac extension, and 2 distal ones were treated conservatively. Three secondary endoleaks, a proximal and 2 distal ones, required conversion each by retro- and transperitoneal approach. Presently, there are 4 endoleaks, with the maximal aortic diameter remaining constant except one case. Five secondary occlusions of an iliac limb (4) or artery (1) were treated by thrombectomy (1), PTA (1), PTA with overstenting (1), and cross-over (1) or ilicofemoral bypass (1). Three patients died of unrelated disease during the follow-up period.On condition of a critical indication, improved diagnostic management and further refinement of stent-graft systems ER constitutes an alternative, minimally invasive treatment option for AA. Long-term results must be obtained by means of continued prospective and comparative studies to definitely evaluate ER.

Interventional pneumology includes both bronchological and vascular methods of diagnostic and therapy, especially in case of pneumological emergency, such as pulmonary hemorrhage and superior vena cava syndrome. In massive pulmonary hemorrhage bronchological diagnosis is needed to determine the location and activity of the bleeding, as well as angiography of bronchial arteries, and of pulmonary arteries, respectively. Bronchus occlusion by aid of balloon catheter or double lumen tube are intermediate methods to bridge over till defenitive surgery or embolisation of bronchial or pulmonal arteries as complementary methods in patients with pulmonary hemorrhage. In patients suffering from superior vena cava syndrome caused by neoplasms venous angioplasty and Wallstent implantation provide immediate clinical improvement.

A 58-year-old man was hospitalized because of threatened asphyxia resulting from massive obstruction to neck vein flow and increased venous markings over the ventral and dorsal thorax. The previous year he had received radiotherapy (total of 55.8 Gy) for squamous cell carcinoma in the right upper lobe of the lung (primary stage T2 N2 M0). The signs of venous congestion had developed over several months.Emergency phlebography demonstrated obstruction to superior vena cava (SVC) flow by tumour compression.It was possible to pass the SVC obstruction with a hydrophilic guide-wire and then perform a balloon angioplasty, followed later by implantation of two intraluminal expandable stents ("Wallstent"). The dyspnoea quickly improved after the successful recanalization. The day after the intervention palliative radiotherapy of the SVC obstruction was begun. But increased venous markings over the thorax recurred, but without dyspnoea, after 4 1/2 months free of signs of venous congestion. Repeat phlebography again demonstrated complete obstruction of the SVC by the tumour. Recanalization by balloon angioplasty was again achieved.This case underlines the value of percutaneous balloon angioplasty with stent implantation as supplementary treatment in the late stages of SVC obstruction by tumour.

The long-term results of 222 patients (pts) with transvenously implanted vena cava filters are critically reviewed. A total of 98 pts were given a Mobin-Uddin filter, 102 pts a Günther filter, and 16 pts a LGM filter. Among the serious complications observed during long-term follow-up were vena cava occlusions and increasing symptoms ranging from congestion of the deep leg veins, perforations into ureters, fractures and embolizations of the filters in up to 40% of the patients, if Günther filters were implanted.

The obstruction of the hepatic venous outflow tract with or without involvement of the inferior vena cava results in the Budd-Chiari syndrome (BCS). With its very heterogenous etiology and variable epidemiology the rare disease either takes a chronic or an acute foudroyant clinical course. In general the prognosis is poor. Together with the clinical signs the diagnosis is based on radiological measures and the histology of the hepatic parenchyma. The exact etiological investigation of the BCS is of great significance. Typical findings are discussed and a diagnostic scheme is developed. Between 1979 and 1991, altogether 16 operations were carried out in 13 patients with a BCS. Predominantly there were undertaken a porto-systemic shunt procedure or an orthotopic liver transplantation, respectively, in 6 cases each. The need for an always individually tailored therapeutic strategy of the BCS is underlined by a case history. An overview analyzes the different therapeutic modalities of the BCS and their differential indications.

In detailed angiographic follow-up examinations in patients after heart transplantation, coronary artery-ventricular fistulas were observed in two of ten patients. In one patient, in the first postoperative year, 19 right ventricular biopsy procedures were performed obtaining a total of 71 tissue specimens and one year after transplantation, additionally, three specimens were obtained from the left ventricle. Coronary angiography demonstrated a fistula from the first anterior ventricular branch of the right coronary artery into the right ventricle (Figure 1) as well as a second smaller fistula between from a septal perforator of the left anterior descending artery into the left ventricle. At follow-up angiography two months later, the fistulas were unchanged in site and extent (Figure 2). Angiographically there was diffuse hypokinesis of the right ventricle and moderate tricuspid regurgitation. In the second patient, in the first year after transplantation, 20 right ventricular biopsy procedures were performed obtaining a total of 80 tissue specimens. One year after transplantation coronary angiography showed a fistula between a septal perforator of the left anterior descending artery into the right ventricle (Figure 3) which, two months later, was unchanged in morphology and, as in the first case, the size of the shunt was small. Angiographically, there was moderate tricuspid regurgitation and apical hypokinesis of the left ventricle. If a relationship between the fistulas and biopsies is postulated, from a total 196 biopsy procedures obtaining 748 tissue specimens, the rate of this complication would be calculated at 1.5%. It cannot be ruled out, however, that the fistulas had been congenitally present in the donor hearts.(ABSTRACT TRUNCATED AT 250 WORDS)

In 40 male coronary patients during heart catheterization the coronary flow reserve was investigated by continuous thermodilution in the coronary sinus after intracoronary papaverine application. Simultaneously a number of heart function parameters were recorded. Already the lowest dosage of papaverine (5 mg) was able to induce a maximal flow acceleration. Higher dosages were accompanied with haemodynamic side effects (increase of heart rate and left ventricular end-diastolic pressure, decrease of left ventricular systolic pressure, appearance of myocardial ischemia) without further increase of coronary flow. After at most 5 minutes time the papaverine effects completely disappeared. In conclusion, a safe, short-lasting and repeatable determination of the coronary flow reserve (for instance during PTCA) proved to be possible after intracoronary papaverine injection in low dosages (5 mg).

The concentration of thiobarbituric acid reactive substances (TBARS) formed as a result of lipid peroxidation and prostanoid metabolism was measured in the plasma of patients with coronary or peripheric atherosclerosis. From the results conclusions were deduced to the function of reactive O2-species in the atherogenesis. We found in plasma of patients with coronary as well as with peripheric atherosclerosis increased TBARS concentrations dependent on the dimension of atherosclerosis as an index of activation of reactive O2-species formation. The TBARS concentration correlated with the cholesterol and LDL-cholesterol concentration in plasma.

The aim of the study was to demonstrate the possibility of transfemoral balloon occlusion of the coronary sinus and to detect changes of the left ventricular function during this occlusion in patients with angina pectoris. In 9 of 18 patients a stable occlusion over 15 seconds was performed. There were found only short term negative effects on the left ventricular contraction and relaxation. The coronary sinus pressure increased to 53 +/- 11 mm Hg. Numerous venous anastomoses made it difficult to occlude completely the sinus. The retrograde perfusion of the myocardium reached 20-30% of the antegrade one.

From a pool of patients, treated because of cardiac diseases on ward for 4 years, 8 subjects, the mean age of which amounted to 46 (SD 12) years, showing stable angina pectoris in usual physical activity, were chosen. In these patients widespread examinations including invasive procedures had not been evident for one of the well defined heart diseases. In two patients dysrhythmias appeared during standardized exercise test while in four other subjects acute cardiac findings consisted of chest pain, significant depression of ST segments or inversion of T waves were observed. One patient had a normal result of the exercise test. A myocardial thallium-201 imaging was performed in four subjects. In three patients imaging showed questionable or mild signs of ischemia. The result suggest the existence of unknown shapes in coronary heart disease, the origin of which is possibly connected with a disorder of microvascular smooth muscle reactivity.

Since the introduction into practice in may 1986 at the Institute of Cardiovascular Diagnostics we performed 45 valvuloplasties until March 1990 in 34 children (6.2 +/- 4.9 years old) and 11 adults (29.5 +/- 9.6 years) with valvular pulmonary stenosis. The invasively obtained pressure gradient at the valve diminished from 83.4 +/- 30.7 mm Hg to 35.7 +/- 19.0 mm Hg. Intraoperative complications in three patients (short term asystole, severe bradycardia, increase of right ventricular pressure to 300 mm Hg after valvuloplasty) were controlled, but demanded the end of the intervention. No significant insufficiency of pulmonary valves after valvuloplasty was seen. 18 patients were clinically investigated 14.6 +/- 9.4 months after intervention. The late results for these patients proved the method as a long term curing treatment. According to our present results pulmonary valvuloplasty is the alternative method for valve surgery especially in critical pulmonary valve stenosis in newborns.

Within a short term of 7 years percutaneous valvuloplasty of congenital and acquired stenosis, the cardiac valves and the great central vessels has significantly improved. If strict criteria for the selection of patients are used the method is an important addition to cardiac therapy, since it requires no thoracotomy, no heart lung machine surgery, no complicated interventional follow up treatment and gives remarkable short and long term results. Starting from a thorough study of 300 publications (4836 patients) a survey of possible complications, their frequency and in percutaneous valvuloplasty is given for various methods. The compiled data and commentaries give a negative survey and shall lead to a new evaluation of indications. Some types of interventions (primarily the percutaneous rupture of degenerative calcified stenosis of the aortic valve in higher age) will lead only by significant improvements of technique (stabilization of myocardiac circulation, prevention of extreme hypotonic phases, use of cutting and sawing instruments: valvuloplasty under cardioscopy?) to acceptable long term therapy results.

315 percutaneous transluminal coronary angioplasties performed during 1978-1988 in 261 patients with ischemic heart disease were analyzed for three different variants according to primary effectiveness, failure rate the most frequent complications and costs of materials as well as duration of intervention and fluoroscopy. Only variant 3 of the proceeding (soft-tip-applicators, flat profile balloon catheter, Kaltenbach long-wire technique, streptokinase rinsing of instruments, permanent infusion of instruments during the procedure) is an applicable routine method. It has a primary effectiveness of 86%. For multiple vessel PTCA this variant however resulted in significantly prolonged investigation and fluoroscopy intervals, so it is advisable only for selected groups of patients.

The incomplete aetiopathogenetic knowledge, the non-uniform clinical and diagnostic criteria as well as the course of the myocarditis which is prognostically not to be foreseen cause controversial therapeutic consequences. In the first place of the treatment is the causal treatment of the factors evoking or maintaining the inflammation. By means of immunosuppression an improvement of the findings is obtained in approximately 50% of the patients with myocarditis. Thus the immunosuppressive therapy cannot be recommended in general. It is sought for new active agents. The disturbed haemodynamics is, apart from medicamentous measures, positively influenced above all by convalescent treatment. Individually reconciled measures of the complex rehabilitation are accompanyingly necessary and render possible an improvement of the quality of life at long sight. In individual cases only the heart transplantation may have a favourable influence on the prognosis of the in most cases young patients.

The serum concentration of thiobarbituric acid reactive substances (TBARS), which can be used in the characterization of O2-radical metabolism, was analyzed in patients with myocardial infarction in the acute phase, 10-14 days, 1 month, and 6 months after infarction, and compared with the TBARS concentration of a healthy group and a group with atherosclerosis. After myocardial infarction we found increased TBARS concentration at all moments of investigation in comparison with the healthy and atherosclerosis groups. Maximum concentration was found 10-14 days after infarction, afterwards the TBARS concentration decreased, without however attaining the values which we found in the comparison groups. The increased TBARS concentration 6 months after myocardial infarction demonstrates a manifestation of disturbances in the O2-radical metabolism. Such disturbances may be regarded as a high-risk factor to the cardiovascular system.

In 25 (5.3%) of surgically treated coronary patients the mammarocoronary anastomosis was performed. A follow-up angiographic checkings made after 1 to 3.5 years proved its patency in all instances. The minimal lumen of the internal thoracic artery at the anastomosis site should be 1.5 mm. The use of the internal thoracic artery, with the appropriate indication, is limited to the anterior ventricular branches of the left coronary artery. The peculiarities of the operation are described.

Report on the application of a new (valve equipped) detachable balloon for percutaneous transvasal embolization therapy in 372 patients with (noncerebral) curative preoperative and palliative indications.

An account is given in this paper of first experience from orthotopic heart transplantation. Six of eight patients with transplants have so far survived, with two of these having been in very good general condition for more than a year. All surgical indications were derived from myocardial dilatation. A triple combination of cyclosporine A, prednisone, and azathioprine was used for immunosuppression.

In a prospective study we tested the possibility to differentiate myocardial tissue by means of the quantitative texture analysis of two-dimensional echocardiographic images. 12 patients with a bioptically ascertained myocarditis and 12 healthy patients of a control group were echocardiographically examined. The results demonstrated that the echocardiographic image texture in myocarditis is characterized by an increase of the texture parameters entropy, second difference moment and long-run emphasis as well as by a decrease of the parameters angular second moment, inverse difference moment and run-length nonuniformity as well as by different values of the ring and sector sums of the power spectre. The digital image processing of echocardiography images seems thus to open a new way to the noninvasive diagnostic of myocarditis.

The influence of injections of Amidotrizoate and Iopromide into the left coronary artery on global myocardial perfusion and function (pressures in the left ventricle, heart rate) as well as excitation formation and transmission was studied in 16 patients with ischaemic heart disease. No statistically significant differences in myocardial perfusion measured were found with xenon-133 in this small group between rest and dipyridamole load for ionic and non-ionic contrast media.

In the present case an artery originating from the abdominal aorta and running through the diaphragma into the inferior lobe of the left lung was identified by retrograde aortography. It ended in a vascular coil which was drained by regular pulmonary veins. By transthoracal resection of pulmonary parenchyma and malformation was removed without complications. Such anomalies represent absolute but not urgent indications for surgery. Without treatment, the shunt volume will cause additional straining for the heart. Furthermore, pulmonary complications and thromboembolic processes may arise.

Doxorubicin is one of the most effective antineoplastic drugs in clinical practice. Its clinical usefulness extends from acute leucemia and lymphoma to a wide range of solid tumors. However, the use of this drug is limited by its cardiac toxicity, that is often life-threatening. A number of clinical approaches discussed in this paper have been used to circumvent the problem of doxorubicin-induced congestive heart failure. A summarizing survey of the literature has led to establish two principles for prevention of doxorubicin-induced congestive heart failure with clinical meaning in the moment: --the way of administration --the clinical use of Ca-antagonist. The two principles provide an objective basis for preventation of congestive heart failure. The pathobiochemical background, analysed in this paper in detail, demonstrates that the same metabolic condition exist in the myocardial cell as in red blood cell. These interactions are the basis for a further analysis of metabolism in the cell, especially the redox metabolism of glutathione.

53 patients with coronary heart disease were investigated synchronously by means of impedance and angiocardiography combined with the measurement of the pressure in the aorta and the left ventricle. In these cases relatively close correlations were found between the stroke volumes and systolic time intervals, determined by the two methods, as well as between the ejection fraction on the one hand and the parameter dz/dt max on the other. The pressures, measured invasively, do not correlate significantly with the impedance cardiography parameters. With help of the relations found it is possible to coordinate the changes of the thoracic impedance curve depending on the heart action with the various phases of the left-ventricular volume change.

To investigate still uncertain aspects of the diagnosis of ischemic heart disease (IHD) in women, between 1969 and 1984, repeated exercise studies were performed in 706 asymptomatic women (between the ages of 17 and 63 years). On observation of pathologic ST-segment depression of more than 0.1 mV, the exercise study was repeated after administration of 0.8 mg nitroglycerin. Pathologic ST-segment depression was seen in 310 women (44%). In 217 patients (31%), nitroglycerin had no effect (NTG negative); in 93 women (13%), there was normalization of the ST-segment changes (NTG positive). Additionally, in selected subgroups of patients, pulmonary artery pressure was measured at rest and during exercise and ECG mapping performed (n = 114); radionuclide ventriculograms (n = 64) and 201-thallium scintigrams (n = 99) were obtained and coronary angiography (n = 85) was performed. In the NTG-negative women, ejection fraction, myocardial perfusion and coronary arteries were normal. NTG-positive women had lower mean ejection fractions but still within normal limits and indications of impaired myocardial perfusion. High-grade coronary stenoses were found in 25%. No patient with pathologic ST-segment depression had mitral valve prolapse. NTG-positive women had significantly more risk factors than NTG-negative women. In the former group, pulmonary artery pressure measurements showed pathologic exercise hemodynamics, only in 25% of whom IHD with significant stenosis was found to be the cause. For this condition, differential diagnostic considerations include cardiomyopathy or small vessel disease.

Peripheral perfusion abnormalities are considered a possible reason for myocardial ischemia in the absence of visible coronary artery stenoses. In 85 women (age: 41-58 years, mean age: 46 +/- 8) with pathological exercise ECG (precordial mapping: 50 leads), hemodynamic studies were performed without medication, after sublingual nitroglycerin (NTG, 0.8 mg), sublingual Nifedipin (N, 30 mg), and intravenous Dipyridamol (D, 0.5 mg/kg). Eighteen women showed normal coronary arteries and a normal myocardial perfusion (group I), 21 an impaired perfusion due to coronary stenoses (Group II), and 46 women a reduced perfusion without visible changes (Group III). Reference methods were measurement of pulmonary artery pressure, 201-TI-scintigraphy, and coronary angiography. In group II, enddiastolic and endsystolic left ventricular volume (EDV, ESV) as well as enddiastolic pulmonary artery pressure (pAd) were increased, the ejection fraction (EF) was reduced, and cardiac output (CO) was normal. In group III, ESV, EDV, EF, and CO were significantly reduced, while pAd increased. In group II, N led to a normalization of ESV, EDV, EF, and pAd. In group III, NTG led to a reduction of pAd and EDV, and concomitantly to a further reduction of the already low CO. In both groups the reduction of ST-segment depressions after NTG was significant. N led to a moderate reduction of pAd and ST-segment depression, but to an increase of CO in both groups. D exhibited a comparable effect in group III. In group II an increase of ST-segment changes and of pAd with unchanged CO was observed. With regard to longterm treatment of women in group III, N and D seemed to be more efficacious than nitrates due to a beneficial effect on cardiac output.

In 30 patients the influence of ionic (Amidotrizoate) and non-ionic (Iopromide) contrast agents on the heart parameters contractility, relaxation, perfusion and the rate of extrasystoles was investigated. They were significantly less influenced by Iopromide than by Amidotrizoate. A negative inotropic action was detectable only for Amidotrizoate. It is concluded that non-ionic contrast media should be used especially for critical patients.

384 patients with ischaemic heart disease were treated surgically. Out of 165 patients operated upon consecutively, in 38 (23%) an intramural course of coronary arteries was found. Peroperative diagnosis of the intramural course of the anterior interventricular branch is feasible with a high probability; diagnostic criteria were also elaborated for the intramural course of the marginal branch. Several aspects of the operation technique and tactics are discussed.

To assess changes in resting left ventricular function after reestablishment of myocardial perfusion, echocardiographic studies were performed before, at three resp. six days after as well as three months after successful PTCA in 19 patients and after coronary artery bypass grafting in 20 patients. Reference data were obtained from analog processing of values from 20 healthy control subjects. Baseline values (in addition to primary morphologic criteria) were indicative of a clearly functional selection pattern. As compared with those undergoing PTCA, patients who underwent bypass surgery had more unfavorable values for ejection fraction at rest. Immediately after the intervention, there was a consistent tendency to transiently reduced resting pump function. At three months, however, in both groups, cardiac performance had returned to control values and the global and regional parameters of contractility had either reached or exceeded the preoperative values. The mean values showed more improvement in the PTCA group, a finding most probably attributable to the more favorable baseline situation. Paradoxic septum motion was found frequently in those who had undergone bypass surgery. All patients with grafting to the right coronary artery were included in the latter group. Whether perioperative injury, the varying perfusion conditions or the pericardiotomy is responsible for this phenomenon, remains to be established.

In 364 women who died of myocardial infarction, autopsy was performed to assess the extent of chronic ischemic heart disease. The mean age at the time of death at 70.5 years was higher than that of men who died of myocardial infarction; only 4% of the women were less than 50 years of age. In all cases, there were severe arteriosclerotic changes in all coronary arteries. Three-forths of the patients had luminal narrowing of more than 50%, one-forth less than 50%. Accordingly, with respect to morphology, for acute myocardial infarction as cause of death, there were no differences between the sexes. The muscle mass averaging 440 g was less than that reported for comparable studies in men. In 59 women less than 50 years of age with complaints consistent with angina pectoris and angiographically-documented normal coronary arteries, left ventricular biopsies were examined for evidence of chronic ischemic heart disease. In ten patients changes in the terminal vascular beds were found which were considered to be compatible with small vessel disease and in 19 patients there were microscars and a fibrotic pattern as seen in chronic ischemic heart disease. Twelve patients had scarring and fibrosis similar to that seen after myocarditis and 18 patients had a round-cell myocarditis without evidence of involvement of the terminal vascular beds. Thus, heart muscle biopsies appear to be of value in the diagnosis of changes in peripheral arterial beds.

Macroscopic and microscopic studies on the anterior interventricular ramus of left coronary artery, internal thoracic artery, and great saphenous vein were carried out 50 dead, aged 21 to 60 years. The internal thoracic artery was always normal whereas in 40 cases stenosing coronary sclerosis was found. At mammography, 25 patients with operable coronary obstruction also showed no degenerative alterations of this systematic artery. With a diameter of 1.5 mm in the 5th intercostal space the internal thoracic artery was fit for performing an anastomosis.