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The microcirculatory status depicts an indicator of organ perfusion in hemodynamic shock. Distribution pattern of microcirculatory disturbances reflects the underlying cause of shock: In septic shock, organ perfusion is severely impaired via arteriolo-venous shunting with shutting up small vessel perfusion; however, cardiogenic shock is characterized by a global impairment of microcirculation, involving all vascular beds. Hence, a differentiated evaluation of microcirculatory disturbances not only supports an early diagnosis of an imminent multiorgan dysfunction syndrome (MODS), but also allows a more accurate evaluation of severity of hemodynamic compromise in critical care medicine. Bedside sidestream darkfield (SDF) technique offers the opportunity to describe the microcirculatory status quo semiquantitatively and to evaluate the effect of novel therapeutic approaches on microcirculation. Further technical improvements of this technique may open new fields of diagnostic and therapeutic applications in intensive care medicine by supporting an early diagnosing of MODS, evaluating prognosis, and optimizing therapeutic measures ., (© Georg Thieme Verlag KG Stuttgart · New York.)

The prognosis of cardiogenic shock is still dismal despite advancements in diagnostic and therapeutic options. One of the major problems is the development of multi-organ failure caused by impaired organ perfusion with inadequate microcirculation. The diagnosis of cardiogenic shock is based on clinical signs of hypoperfusion, echocardiography, and hemodynamic parameters. Because of its high prognostic relevance microcirculation has become more interesting for clinicians recently. Signs of severe cardiogenic shock are reduced vascular density and impaired microflow, especially in the smallest vessels and the location of exchange of gas and nutrients. Recent studies revealed that intravital-microscopy is a valuable tool for on-line and in-vivo measuring of microcirculatory parameters. The assessment of microcirculation during modifications of the treatment of cardiogenic shock is valuable, e. g. during catecholamine therapy or when using of circulatory assist devices. This article summarizes new findings regarding microcirculation in cardiogenic shock, the use of assist devices, and novel pharmacological treatment. Evaluation of microcirculatory changes with its new insights in the complex pathophysiology of cardiogenic shock has the potential to become part of diagnostic algorithms., (Georg Thieme Verlag KG Stuttgart.New York.)

One out of 13 patients with an acute myocardial infarction is endangered of cardiogenic shock. In addition, acute valvular leakage, shunt vitiae, and acute myocarditis can lead to acute myocardial failure. As a therapeutic option, mechanical assist devices offer cardiac support and hemodynamic stabilization under these circumstances. The following minimal-invasive devices are used in cardiology and intensive care medicine: intra-aortic balloon pulsation (IABP), intra-vascular axial screw pumps, extra-corporal centrifugal pumps with and without additional membrane oxygenator. The IABP improves left ventricular function by a systolic reduction of the after-load, and an increase of diastolic blood pressure dependent on myocardial function. In contrast, axial screw pumps and centrifugal pumps can provide circulatory support independently of myocardial function. Mechanical assist devices can prevent irreversible damage not only by offering a reduction of myocardial work load, but also by improving organ perfusion in cardiogenic shock situations. Another indication for mechanical circulatory support depicts high-risk coronary angioplasty if the left ventricular ejection fraction is severely reduced or the target vessel supplies more than 50 % of vital myocardium. In case of irreversible heart failure, turbine pumps or centrifugal pumps offer a stabilization for the patient's transfer to a cardiac surgery center. They can also be used for bridging to heart transplantation in acute situations. Technical improvements will enhance the use of mechanical assist devices in the near future. Especially the development of portable emergency devices will enrich therapeutic possibilities in cardiology and intensive care medicine.

Background and Objective: Animal data suggest that mobilized bone marrow cells (BMC) may contribute to tissue regeneration after myocardial infarction (MI). However the safety, feasibility and efficacy of treatment with granulocyte colony-stimulating factor (G-CSF) to mobilize BMC after acute myocardial infarction in patients is unknown. We analysed cardiac function and perfusion in 5 patients who were treated with G-CSF in addition to standard therapeutical regimen., Methods and Results: 48 h after successful recanalization and stent implantation in 5 patients with acute MI, the patients received 10 micro g/kg bodyweight/day G-CSF subcutaneously for a mean treatment duration of 7.6+/-0.5 days. Peak value of CD34 (+) cells, a multipotent subfraction of bone marrow cells, was reached after 5.0+/-0.7 days. After 3 months of follow-up global left ventricular ejection fraction (determined by radionuclid-ventriculography) increased significantly from 42.2+/-6.6 % to 51.6+/-8.3 % (P<0.05). The wall motion score and the wall perfusion score (determined by ECG gated SPECT) decreased from 13.5+/-3.6 to 9.9+/-3.5 (P<0.05) and from 9.6+/-2.9 to 7.0+/-4.5 (P<0.05), respectively, indicating a significant improvement of myocardial function and perfusion. No severe side effects of G-CSF treatment could be observed. Malignant arrhythmias were not observed either., Conclusion: In patients with acute MI, treatment with G-CSF to mobilize BMC appears to be well tolerable under clinical conditions. Improved cardiac function and perfusion may be attributed to BMC-associated promotion of myocardial regeneration and neovascularization.

History and Clinical Findings: A 72-year old man was admitted because of increasing dyspnoea, failing fitness and weight loss. Physical examination was unremarkable except for decreased heart sounds., Investigations: He was anaemic (haemoglobin 11.7 g/dl), erythrocyte sedimentation rate was raised (80/90 mm) as was C-reactive protein (169 mg/dl). Chest radiogram showed tent-like widening of the cardiac silhouette and a 6 cm space-occupying lesion in the left hilus. Echocardiography revealed pericardial effusion of up to 2.3 cm (epi- to pericardium)., Treatment and Course: Because of an increase in dyspnoea and pericardial effusion a pericardiocentesis was performed. This fluid and needle biopsy of the space-occupying lesion revealed small-cell carcinoma. 6 days after the pericardiocentesis the dyspnoea further increased as did the pericardial effusion (to 3.9 cm). Percutaneous balloon pericardiotomy was uneventfully performed. During a follow-up period of 14 months there were no further pericardial effusions., Conclusion: Percutaneous balloon pericardiotomy can be undertaken as a minimally invasive treatment of symptomatic pericardial effusion. It should be considered as an alternative to surgical creation of a pericardial window, especially in very ill patients.

History and Clinical Findings: A 55-year-old woman with known primary biliary cirrhosis (PBC) was hospitalized because of increasing dyspnoea. A year before she had for the first time experienced a right-sided pleural effusion which had to be drained every 4 weeks. Physical examination revealed dullness on percussion and greatly decreased breath sounds on auscultation over the entire right thorax. In addition there were signs of moderate ascites and leg oedema., Investigations: Chest radiograph showed a homogeneous shadowing of the right thorax without mediastinal shift. Diagnostic thoracocentesis produced a serous effusion, a transudate on chemical analysis, comparable to the composition of the ascitic fluid. Bacteriological and cytological tests on both fluids were unremarkable., Treatment and Course: The right pleural effusion was presumed to be due to a hydrothorax from the ascites caused by portal hypertension associated with the PBC. Despite continuous diuretic treatment and thoracocentesis with albumin substitution every 3 days there was no improvement and implantation of a transjugular intrahepatic portosystemic stent shunt (TIPSS) was performed. This effectively lowered portal pressure and markedly improved the patient's condition so that further thoracocentesis were no longer necessary. 3 weeks after TIPSS implantation she was discharged in good condition. Radiography 3 weeks later demonstrated continued reduction in the hydrothorax., Conclusion: Hydrothorax is a rare complication of liver cirrhosis. TIPSS implantation can provide lasting resolution and corresponding clinical improvement of a hydrothorax, especially in those conditions which are refractory to diuretic treatment and thoracocentesis.

History and Clinical Findings: A 41-year-old woman, known for 10 month to have polycythaemia vera, developed severe right upper abdominal pain. The abdomen was tense from marked ascites and the liver enlarged by 18 cm in the mid-clavicular line., Investigations: Serum bilirubin was slightly elevated to 2.2mg/dl, liver synthesis being much reduced (recalcifying time minimally 23%, albumin minimally 2.8 g/dl). Doppler sonography detected no flow in the right and middle hepatic veins, indicating Budd-Chiari syndrome. Portal vein flow was diminished., Treatment and Course: Heparin treatment had to be stopped because of heparin-associated type II thrombocytopenia and hirudin was substituted. Attempted lysis with a total of 100 mg r-tPA failed. As the patient's condition deteriorated a TIPSS was implanted to provide portal decompression. Incomplete portal vein thrombosis was demonstrated and worsened during the procedure until nearly complete occlusion. Local lysis treatment for 2 days with urokinase, 50,000-60,000 U/h, and two shunt revisions finally succeeded in completely dissolving the thrombus. Portocaval pressure fell from 32 to 21 mm Hg, and the size and function of the liver became almost normal and the ascites disappeared. Anticoagulation with a coumarin derivative was started and hydrocarbamide again given for recurrent thrombocytosis. The patient remained largely symptom-free one year after TIPSS., Conclusion: This case demonstrates the effectiveness of TIPSS in Budd-Chiari syndrome, even in complicated portal vein thrombosis.

History and Clinical Findings: A 68-year-old woman, with a cardiac murmur known since childhood and suffering from increasing dyspnoea for several years, was admitted to hospital after echocardiography had suggested pulmonary valve stenosis and an atrial septal defect. While her general condition was satisfactory, she had marked central cyanosis with clubbed fingers and moderate bilateral oedema of the lower legs. A rough, diamond-shaped systolic murmur was heard, loudest over the left 2nd intercostal space. In addition to a cardiac defect with right to left shunt, primary pulmonary disease with cor pulmonale was considered in the differential diagnosis., Examinations: Haemoglobin content was 25.1 g/dl, haematocrit 72.4%, red cell count 7.44 x 10(6). Arterial oxygen partial pressure was 40 mm Hg, arterial oxygen saturation 81.8%, Echocardiography further revealed right ventricular enlargement, marked tricuspid regurgitation and a stenosed calcified pulmonary valve. At right heart catheterization a right to left interatrial shunt was calculated at 47% of systemic flow and a systolic pressure gradient between right ventricle and pulmonary artery of 131 mm Hg was measured., Treatment and Course: Haemoglobin content was lowered to 19.4 g/dl after bloodletting. Balloon pulmonary valvuloplasty reduced the transvalvular systolic gradient to 31 mm Hg. The further course was without complication: 4 months later the patient had only grade II (NYHA) dyspnoea, the oxygen saturation was 91.3%., Conclusion: Severe pulmonary valve stenosis with right to left interatrial shunt can be successfully treated by balloon dilatation even in elderly patients.

Using a recently developed, percutaneously introduced cardiopulmonary support system (PCPS) seven high-risk patients (four men, three women; mean age 61 [41-77] years) underwent percutaneous transluminal coronary angioplasty. In one patient, with unstable angina and in incipient cardiogenic shock, perfusion with PCPS was begun immediately before coronary angioplasty. In six patients it was undertaken with the PCPS on stand-by, but eventually not needed. Coronary angioplasty was successful in six patients, partially successful in one. Angina was considerably improved long-term in all patients, but one of them died 2.5 months afterwards at home. In two other patients (men, aged 41 and 71 years) with acute myocardial infarction, the PCPS was employed under circumstances of emergency resuscitation. In both cases recanalization of the occluded coronary artery was achieved mechanically during perfusion with PCPS; one patient survived. Availability of PCPS, also in an emergency, makes it possible to extend the indications for coronary angioplasty to include even high-risk patients.

In a prospective study 38 patients (35 men, 3 women; median age 56 [37-71] years) with known coronary heart disease in whom conventional thallium-201 exercise-redistribution myocardial scintigraphy (ERMS) had demonstrated segments with diminished activity, thallium-201 was again injected ("reinjection scintigraphy"). Its purpose was to test whether in myocardial segments with persisting diminished radioactivity improved activity after reinjection provided evidence for still viable myocardium. Seven myocardial segments were evaluated in each patient, i.e. a total of 266 segments. Activity in the conventional ERMS was diminished in 94 of the 166 abnormal segments, but improved on reinjection in 21 of the 94 segments (22.3%). Nine of the 38 patients (23.7%) benefitted from the reinjection: only scar tissue without any viable myocardium would have been diagnosed by conventional ERMS in four patients, while extent and spread of ischaemic myocardium was better visualized in five.

High doses of verapamil, diltiazem or nifedipin were administered to three groups of eight patients each, with severely abnormal left-ventricular (LV) function (mean ejection fraction 0.29). Various haemodynamic measurements were made immediately before and 30 minutes after drug administration: LV ejection fraction, ratio of peak systolic pressure to endsystolic volume index, stroke index, pulmonary capillary closing pressure, and maximal diastolic filling rate. None of these were reduced. In fact, ejection fraction rose by a mean of 0.05, stroke index by a mean of 5 ml/m2, while p.c. closing pressure and contractility did not alter significantly. Verapamil and diltiazem reduced the pressure X rate product (an important determinant of oxygen consumption); nifedipine reduced total systemic resistance. It is concluded that verapamil and diltiazem can be used with advantage in cases of unstable angina, if there are severe abnormalities of LV function; they are to be preferred to beta-blockers in this situation. Nifedipin is the calcium antagonist of choice in hypertension and abnormal LV function.