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We report on the history of a 36-year-old woman with untreated coarctation of the aorta and patent ductus arteriosus who developed refractory heart failure due to severely impaired left ventricular function. After coarctation repair and duct resection, left ventricular function improved to normal. Even in the presence of longstanding left ventricular pressure and volume overload, subsequent severe myocardial failure may be reversible by surgical repair.

A 53-year-old man developed severe acute systemic illness three weeks after an upper respiratory tract infection. Serial blood cultures grew Moraxella catarrhalis. During antibiotic treatment, fever and infectious parameters disappeared, but severe aortic regurgitation developed. Aortic valve replacement was performed, during which extensive destruction of the aortic valve was noted. Endocarditis due to M. catarrhalis is very rare with, to our knowledge, only six cases having been reported to date. M. catarrhalis is a normal commensal of the upper respiratory tract, but in unpredictable circumstances can become an important pathogen. Bacteremia due to this organism therefore requires prompt treatment, as serious organ complications, including endocarditis, can occur.

Clinical symptoms and diagnostic findings in patients with mitral stenosis are usually determined by the extent of the stenosis. Compared to a normal mitral valve area (MVA) of > 4 cm2, MVA in patients with severe mitral stenosis is usually reduced to < 1.5 cm2. In older patients symptoms are frequently influenced by concomitant diseases (e.g. atrial fibrillation, arterial hypertension or lung disease). An important diagnostic element besides anamnesis, auscultation, ECG and chest X-ray is echocardiography, which is required in order to measure non-invasively and reliably the mitral valve gradient (MVG), the MVA and morphologic changes to the valves, as well as concomitant valvular disease, ventricular functions and, where appropriate, left-atrial thrombi. In addition to the surgical treatment of patients with severe mitral stenosis, which has been an established procedure for 50 years, percutaneous balloon mitral valvuloplasty (MVP) has recently established itself as an alternative option. At the current time, the Inoue technique seems to display the most advantages. Following transseptal puncture, the Inoue balloon is guided transvenously into the left atrium and then into the left ventricle using a special support wire. The balloon is short and soft. Its special unfolding character enables it to be placed securely in the mitral valve without any risk of ventricular perforation (Figure 1). As with surgical commissurotomy, balloon valvuloplasty leads to a separation of fused commissures. This results in a significant reduction of MVG, accompanied by an increase in the MVA (Figure 2). The results and success of MVP are influenced by the morphology of the valves and the changes to the subvalvular apparatus. In randomized studies, the results of surgical commissurotomy were comparable with those of balloon mitral valvulotomy. In our hospital, an increase in MVA from 1.0 to 1.8 cm2 could be achieved in 899 patients (mean age 56 +/- 3 years). In younger patients with less significantly changed valves, the results were correspondingly more favorable than in older patients (Figure 3). Provided valve morphology is suitable, a relapse following previous surgical commissurotomy is not a contraindication for MVP. The MVP complication rate is very low in skilled hands: mortality is below 1%; mitral insufficiency occurs in 3 to 10% of interventions; we observed a severe mitral insufficiency in 5% of our patient group. Thromboembolic complications may be prevented after exclusion of atrial thrombi by transesophageal echocardiography. The occurrence of a hemodynamically significant atrial septum defect is a very rare event. The mid-term results (5 to 10 years) and the low restenosis rate following MVP in patients with suitable valves are comparable with those of surgical commissurotomy. In older patients with considerably changed, calcified and fibrotic valves, restenosis may be expected within 1 to 5 years. In these patients MVP represents no more than a palliative intervention in order to prolong the point of surgery, for example in patients where a concomitant aortic valve disease in itself is not yet an indication for surgery. Special indications are to be found in young patients with severe mitral stenosis yet few symptoms, in pregnant females and in emergency situations, as well as in patients with Grade II mitral stenosis with intermittent atrial fibrillation. Catheter therapy is much less invasive than surgery. In case of failure the patient still has the option of surgical therapy. Patients with morphologically significantly altered valves usually receive a valve replacement since an unsuccessful reconstruction would lead to a second operation within a very short time interval. Contraindications for MVP are thrombi in the left atrium, a previously existing > Grade II mitral regurgitation and marked, degenerative destruction of the subvalvular apparatus or extensive calcification of the valves. MVP thus represents a significant addi

Case Report: A 26-year-old pregnant woman (18th week of pregnancy) was admitted to a hospital with right heart failure and pulmonary congestion. After establishing the diagnosis of mitral stenosis, a first stabilization could be achieved by medical therapy with digitalis, diuretics, and beta-blockers. Readmission was necessary in the 23rd week. After failure of medical treatment the patient was transferred to our center. We decided to perform an emergency mitral valvulotomy with the Inoue balloon. Taking care of maximal radiation protection for mother and fetus doubling of the mitral valve opening are (from 0.6 cm2 to 1.3 cm2) could be achieved. The pleural effusions and tricuspid regurgitation disappeared. The patient was symptom-free and could be delivered from a male infant on schedule.

The hemodynamic deterioration associated with acute aortic dissection (Stanford A) is caused by an acute loss of volume, acute aortic valve insufficiency, or possibly by hemopericardium with tamponade. In the latter case, a pericardiocentesis may restore hemodynamic stability. However, it is only indicated in the case of reduced perfusion of vital organs. The relief of the pericardial effusion can produce a pressure gradient between dissection and pericardial space, which again might cause hemodynamic deterioration by the blood flow into the pericardial space as well as extension of the aortic dissection. Following pericardiocentesis immediate surgery is indicated. In the present case, after a primarily effect hemodynamic stabilization by pericardiocentesis, this mechanism has very probably led to a repeated tamponade and extension of aortic dissection, which was successfully repaired by the implantation of a vascular prosthesis immediately following invasive diagnosis.

Background: In hypertrophic obstructive cardiomyopathy (HOCM) therapy, surgical myectomy and DDD pacemaker implantation are considered to be established extensions to medical treatment. As an alternative procedure for reducing the left ventricular outflow tract gradient (LVOTG), percutaneous transluminal septal myocardial ablation (PTSMA) by alcohol-induced septal branch occlusion has been introduced. We report on the acute results and the short-term clinical course following 66 PTSMA interventions in symptomatic patients (pts.) with HOCM., Methods: In pts. who were symptomatic despite adequate drug therapy (31 women, 35 men; mean age 52.9 +/- 15.0 years, range: 16-86) 66 PTSMA interventions were performed (4 pts. with a re-intervention). Septal branches were occluded by injection of 3.5 +/- 1.8 (1.5-11.0) ml ethanol (96%). In the first 30 pts. the target vessel was determined by probatory balloon occlusion (PBO) alone, in the following 36 by additional myocardial contrast echocardiography (MCE). In-hospital follow-up of LVOTG and clinical course were determined., Results: The invasively determined LVOTG could be reduced by > 50% or eliminated in 54 interventions (82%) with a mean reduction from 71.2 +/- 34.4 (4-174) to 18.0 +/- 21.5 (0-105) mmHg at rest and from 145.7 < or = 42.3 (68-257) to 63.7 +/- 49.3 (0-185) mmHg post extrasystole (p < 0.0001). All pts. experienced angina pectoris within the first 24 hours. The creatine kinase peak was 690 +/- 364 (201-1810) U/l after 11.0 +/- 5.4 (4-24) hours. 45 pts. (68%) developed trifascicular block, requiring temporary, or in 9 cases (14%) permanent, (DDD) pacemaker implantation. Two pts. (3%) died 9 and 2 days after successful intervention, due to uncontrollable ventricular fibrillation associated with betasympathomimetic and theophylline treatment for chronic obstructive pulmonary disease in one case, and fulminant pulmonary embolism in the other. The remaining pts. were discharged after 11.1 +/- 4.6 (5-24) days following an uncomplicated hospital course. The introduction of MCE was associated with a higher percentage of short-term success (92% vs. 70%, p < 0.015)., Conclusions: PTSMA in HOCM is a promising non-surgical technique for septal myocardial reduction with a consecutive reduction of the LVOTG. MCE has shown to be a useful addition to PBO for selection of the target vessel. Possible complications are trifascicular blocks requiring permanent pacemaker implantation and tachycardiac rhythm disturbances. Prospective, long-term observations of larger populations and a comparison with the established forms of therapy are necessary in order to determine the definitive significance of PTSMA.

Objectives: We report the acute results and midterm clinical course after percutaneous transluminal septal myocardial ablation (PTSMA) in symptomatic patients with hypertrophic obstructive cardiomyopathy (HOCM)., Background: In the treatment of HOCM, surgical myectomy and DDD pacemaker therapy are considered the standard procedural extensions to drug therapy with negatively inotropic drugs. As an alternative nonsurgical procedure for reducing the left ventricular outflow tract (LVOT) gradient, PTSMA by alcohol-induced septal branch occlusion was introduced. However, clinical follow-up has not been sufficiently described., Methods: In 25 patients (13 women, 12 men; mean [+/- SD] age 54.7 +/- 15.0 years) who were symptomatic despite sufficient drug therapy, 1.4 +/- 0.6 septal branches were occluded with an injection of 4.1 +/- 2.6 ml of alcohol (96%) to ablate the hypertrophied interventricular septum. After 3-months, follow-up results of LVOT gradients and clinical course were determined., Results: The invasively determined LVOT gradients could be reduced in 22 patients (88%), with a mean reduction from 61.8 +/- 29.8 mm Hg (range 4 to 152) to 19.4 +/- 20.8 mm Hg (range 0 to 74) at rest (p < 0.0001) and from 141.4 +/- 45.3 mm Hg (range 76 to 240) to 61.1 +/- 40.1 mm Hg (range 0 to 135) after extrasystole. All patients had angina pectoris for 24 h. The maximal creatine kinase increase was 780 +/- 436 U/liter (range 305 to 1,810) after 11.1 +/- 6.0 h (range 4 to 24). Thirteen patients (52%) developed a trifascicular block for 5 min to 8 days requiring temporary (n = 8 [32%]) or permanent (DDD) pacemaker implantation (n = 5 [20%]). An 86-year old woman died 8 days after successful intervention of uncontrollable ventricular fibrillation in conjunction with beta-sympathomimetics in chronically obstructive pulmonary disease. The remaining patients were discharged after 11.3 +/- 5.4 days (range 5 to 24), after an uncomplicated hospital course. Clinical and echocardiographic follow-up was achieved in all 24 surviving patients after 3 months. No cardiac complications occurred. Twenty-one patients (88%) showed clinical improvement, with a New York Heart Association functional class of 1.4 +/- 1.1. A further reduction in LVOT gradient was shown in 14 patients (58%)., Conclusions: PTSMA of HOCM is a promising nonsurgical technique for septal myocardial reduction, with a consecutive reduction in LVOT gradient. Possible complications are trifascicular blocks, requiring permanent pacemaker implantation, and tachycardiac rhythm disturbances. Clinical long-term observations of larger patient series and a comparison with conventional forms of therapy are necessary to determine the conclusive therapeutic significance.

Basic Problems and Objective: In addition to medication with negative inotropic drugs, surgical myectomy and DDD pacemaker implantation are standard procedures in the treatment of hypertrophic obstructive cardiomyopathy (HOCM). In a preliminary series the results obtained with a recently described method, consisting of transcatheter myocardial reduction, are evaluated., Patients and Methods: Six patients (two women, four men; mean age 52.7 [44-68] years), who remained in moderate heart failure despite medical treatment, underwent the procedure. After atrial transseptal puncture (via a catheter introduced percutaneously into the femoral vein) the left ventricular outflow tract (LVOT) gradient was measured at rest and after 5-minute balloon occlusion of the first septal branch of the left coronary artery. After demonstration of significant reduction of the gradient by the occlusion, one (n = 3) or two (n = 3) septal branches were occluded by the injection of 2-5 ml of 96% alcohol., Results: The LVOT gradient was reduced from 57.8 +/- 22.4 (38-97) mm Hg to 11.3 +/- 8.6 (0-21) mm Hg and postextrasystolic from 131.0 +/- 40.7 (78-198) mm Hg to 44.0 +/- 35.6 (19-69) mm Hg. All patients had angina for 24 hours after the procedure. Maximal rise in creatine kinase activity was 982 +/- 589 (392-1729) U/l after 8.0 +/- 3.9 (4-15) hours. In three patients transitory complete atrioventricular block developed 10 min to 5 days later, requiring temporary pacemaker implantation. The further course was without complication in all patients and they were discharged after 7.5 +/- 1.8 (6-11) days., Conclusion: The described catheter method provides a nonsurgical means of reducing the amount of septal myocardium with subsequent reduction of the LVOT gradient in HOCM. Long-term observation in a larger group of patients and comparison with conventional forms of treatment are required to determined the method's ultimate place in the treatment of HOCM.

Objective: To assess a new transvenous transcatheter method of closing a persistent ductus arteriosus, combining advantages of the Porstmann and Rashkind techniques., Patients and Methods: Five patients (three men, two women, mean age 36.2 [19-56] years) underwent the procedure. The diameter of the duct was 3-6 mm. A compressed ivalon (poly-vinyl-alcohol) foam plug, introduced and held by a modified biopsy forceps, was placed into the duct via a percutaneously and transvenously placed catheter sheath. Small titanium legs attached to the plug at the aortic and pulmonary ends unfolded once the plug was correctly placed, ensuring safe fixation., Results: Closure was achieved in all five patients and no shunt demonstrated immediately afterwards in four. In one patient a small shunt briefly persisted but was not longer present the day after. One patient had a fever of up to 39 degrees C for several weeks that required no treatment and was thought to have been a foreign body reaction. Follow-up examination after 5-19 months confirmed complete closure., Conclusion: The described method appears to be safe and superior to the Porstmann and Rashkind techniques, but the results must be tested on a larger number of patients with longer follow-up.

Spontaneous coronary artery dissection is a rare cause of acute myocardial infarction, primarily in young women. The etiology of dissections is still under discussion. Possible factors are inflammation, changes of flow dynamics, and preexisting intima lesions. We report on two young women, 49 and 30 years of age, who suffered and acute anterior wall infarction. Coronary angiography confirmed diagnosis of spontaneous coronary artery dissection of the LAD in the acute an subacute phase of acute myocardial infarction. The patients suffered no further cardiac events at long-term follow-up of up to 9 years.

Objective: The prognostic significance of recanalisation of a chronically occluded infarct vessel in single-vessel coronary disease remains controversial, in contrast to early re-opening of the infarct vessel in the acute state of infarction. It was the purpose of this prospective study to discover whether successful recanalisation in the former influences the incidence of cardiac events (death, infarction, by-pass operation) and clinical symptoms in the long term., Patients and Method: Recanalisation procedures were successful in 58, unsuccessful in 41 of 99 patients (81 men, 18 women; mean age 55 [28-79] years) with anterior wall (n = 53) or posterior wall (n = 46) myocardial infarction (AMI and PMI, respectively). The two groups were similar with respect to age, sex, left-ventricular function, indication, exercise capacity and premedication. But the interval between infarction and recanalisation was shorter in the patients who had successful recanalisation (5.1 +/- 5.3 vs 7.8 +/- 7.6 months; P < 0.05). Mean follow-up period for all patients was 55.8 +/- 8.9 months after the recanalisation procedure., Results: There were significantly fewer cardiac events after successful than failed recanalisation, both for the total group of patients (5% vs 23%; P < 0.01) and those with AMI (9 vs 36%; P = 0.012). In the patients with PMI there was only a trend in favour of those with successful recanalisation (0% vs 14%; P = 0.058). Symptomatic improvement was reported by 73% of patients after successful but only 40% after failed recanalisation (P < 0.01)., Conclusion: The results provide pointers towards prognostic indications of recanalisation even after chronic occlusion of the infarct vessel. The procedure should therefore be attempted if the occlusion is morphologically suitable.

Percutaneous balloon mitral valvulotomy (PBMV) with the Inoue-balloon is a proven therapy in young patients with mitral stenosis. In this study, we investigated primary results in PBMV of elderly patients. In 383 patients with mitral stenosis PBMV was done with the Inoue-balloon. We compared primary success rates and short-term follow-up of 287 (74.9%) < 65-year-old patients and 96 (26.1%) > or = 65-year-old patients. Elderly patients were more likely to have atrial fibrillation (58% vs. 45%; p < 0.05), tricuspid regurgitation < or = II degrees (58% vs. 45%; p < 0.05), coronary artery disease (16% vs. 6%; p < 0.01), and previous pulmonary edema (42% vs. 30%; p < 0.05). PBMV was successful in 73.9% of the elderly and 84.7% of the younger patients (p < 0.05). Mitral valve gradients could be reduced from 12.5 +/- 11.6 mm Hg to 6.2 +/- 6.8 mmHg (p < 0.001) in elderly patients and from 15.5 +/- 6.9 mm Hg to 7.0 +/- 3.2 mm Hg (p < 0.001) in younger patients. Mitral valve areas increased from 1.0 +/- 0.3 cm2 to 1.6 +/- 0.5 cm2 (p < 0.001) in elderly patients and from 1.0 +/- 0.3 cm2 to 1.7 +/- 0.4 cm2 (p < 0.001) in younger patients. No patient died during the procedure. Two younger patients had emergency surgery because of pericardial tamponade following transseptal puncture. After PBMV elderly patients had more often an increase of mitral regurgitation (47% vs. 35%; p < 0.05) without need of an emergency mitral valve replacement.(ABSTRACT TRUNCATED AT 250 WORDS)

A 30-year-old woman with severe mitral stenosis was admitted to hospital in cardiogenic shock (tachycardia, hypotension, low cardiac output) requiring artificial ventilation. As the cardiovascular state failed to respond to drug treatment, percutaneous mitral valvoplasty (MVP) was performed as an emergency with the Inoue balloon catheter. This brought about immediate improvement in the clinical and haemodynamic condition. As later seen at open-heart surgery, the MVP had produced a tear in the anterior mitral leaflet with considerable regurgitation. Mitral valve replacement was performed as an elective procedure 4 weeks after the MVP, at a time when the patient was mobile. MVP with the Inoue catheter system can achieve a stable clinical and haemodynamic state when there is cardiogenic shock due to severe mitral stenosis and conservative measures have failed.

Cardiac tamponade following coronary perforation is a rare complication in conventional balloon angioplasty. In a series of 8000 dilatations we observed this complication after PTCA in 2 female patients (0.25/1000). In both cases cardiac tamponade occurred 2 h after PTCA of small, in 1 case calcified, coronary arteries during monitoring on the coronary care unit. By immediate percutaneous pericardiocentesis and subsequent drainage by a pigtail catheter we could manage the complication. One patient suffered an acute myocardial infarction 3 days after PTCA because of a subacute occlusion of the perforated vessel.

Because of the increasing use of the internal mammaria artery (IMA) in bypass grafting pre- and postoperative angiography of the artery is more often necessary. Selective IMA angiography is frequently difficult and time- and fluoroscopy-consuming. Therefore, different procedures of nonselective angiography have been developed. We report on the improved nonselective visualization of the IMA by manual injection in the subclavian artery and simultaneous ipsilateral compression of the brachial artery by inflating a blood pressure cuff above systolic blood pressure. Thereby a reduction of fluoroscopy time is possible without significant loss of diagnostic information.

In this prospective nonrandomized study, we analyzed the influence of the degree of revascularization--determined by anatomic, morphologic, and functional criterias--on clinical follow-up after PTCA in patients with multivessel disease. 283 patients (74% with double vessel disease, 26% with triple vessel disease; mean age 59.2 +/- 8.2 years; 250 (88%) men) were treated. Clinical successful PTCA was achieved in 247 patients (87.2%): in 239 patients (84.4%) all attempted lesions and in 8 patients (2.8%) at least the culprit lesions were successfully dilated. Complications were seen in 15 patients (5.3%): seven patients underwent emergency bypass surgery, one patient had bypass surgery 8h after PTCA because of an early re-occlusion, five patients suffered an acute myocardial infarction during PTCA, and two patients, who had PTCA because of cardiogenic shock, died during PTCA. Post PTCA, 39 patients (13.8%) had anatomic complete (AK), 35 patients (12.4%) anatomic incomplete but functional complete (FK), 148 patients (52.3%) anatomic incomplete but functional adequate (FA), and 46 patients (16.2%) anatomic and functional incomplete (IR) revascularization. All patients had follow-up after 30.5 +/- 5.5 months. Fifteen patients (5.3%) died, 15 patients (5.3%) suffered a myocardial infarction, and 39 patients (13.8%) underwent an elective bypass operation during follow-up. Cumulative 2-year survival and cumulative 2-year infarct-free survival were not influenced by the degree of revascularization. In contrast to that, the cumulative 2-year bypass-free survival was significant lower in patients with IR (71.0%) compared to patients with AK (92.5%; p < 0.01), FK (89.3%; p < 0.05), and FA (92.7%; p < 0.001). Patients with IR were more likely to have PTCA of previous untreated lesions and were often less likely to have clinical improvement compared to the other subgroups. Thus, in patients with multivessel disease PTCA is a therapeutic option if AK, FK, and FA revascularization can be achieved. Provided that just an IR revascularization can be achieved by PTCA, angioplasty should be performed only for treatment of acute ischemic syndromes in order to improve clinical symptoms. Otherwise, an increased incidence of further revascularization procedures and a reduced clinical improvement can be expected.

Recanalization procedures with the "Magnum" system were undertaken in 137 patients (113 men, 24 women; mean age 57.1 +/- 8.1 years) with complete occlusion of a coronary artery. The system consists of a 0.021 inch guidewire with a flexible 1 mm diameter olive tip, a double-lumen probing catheter and a Magnarail balloon catheter. Chronic coronary artery occlusion of maximally 3 months was present in 51 patients (37%), for over 3 months in 52 (38%), while the duration of occlusion was unknown in 18 (13%). An acute coronary occlusion was successfully recanalized in 7 patients (5%), while in 9 (7%) it was accomplished when it had occurred during or shortly after a percutaneous coronary artery angioplasty (PCTA). The occlusion was successfully passed in 87 patients (64%); in 15 of them recanalization with another system had failed. The highest success rates were obtained with an acute occlusion (5 of 7; 71%), occlusion of 3 months' duration or less (39 of 51; 76%), and occlusion during PTCA (8 of 9; 89%). The success rates were lower for occlusions over 3 months' duration (25 of 52; 48%; P < 0.05) and of unknown duration (10 of 18; 56%; n.s.). Recanalization after failed recanalization was successfully accomplished by rotation-angioplasty (n = 2) or a standard system (n = 4).--These results indicate that the Magnum system is suitable for recanalizing chronic or acute coronary occlusion. But cardiologists should be capable of using several systems to increase the chances of successful recanalization.

In this study we examine the influence of the initial grade of revascularisation on clinical follow-up in patients with multivessel PTCA instead of CABG. Between I/85 and VII/89 multivessel PTCA was performed in 231 patients (202 m, 29 w; age 57 +/- 9 years). 71% of the patients had 2-vessel disease (VD), 14% 3-VD. 15% had angioplasty of one major and at least one important side branch. Clinical follow-up was achieved by a questionnaire 19.8 +/- 10.1 months after PTCA. 473 of 508 (93.1%) treated stenoses were successfully (residual stenosis less than 50%). 198 patients (86%) had successful angioplasty of all treated lesions. 31 patients (13%) had failed PTCA of one stenosis, 1 patient of both treated lesions. 1 patient underwent emergency CABG. A complete revascularisation (group A) - no residual stenosis greater than 50% in any coronary artery - was achieved in 164 patients (71%). 65 patients (28%) had incomplete revascularisation [group B]. 206 patients (89.1%) had clinical follow-up by questionnaire, 144 patients in group A (87.8%) and 60 patients in group B (92.3%) [n.s.]. 3 patients had died by noncardiac reasons (two in group A and one in group B), 1 patient of group A by cardiac reason. 70% in group A and 68% in group B had continuous clinical improvement (n.s.). Total amount of cardiac events (PTCA, CABG, cardiac death, MI) showed no significance between both groups - 35 (24%) vs 23 (38%). Patients in group B had more CABG (12% vs 3%) and angioplasty of further lesions (7% vs 1%) [p less than 0.05] during follow-up. We conclude multivessel PTCA shows good primary results with low risk.(ABSTRACT TRUNCATED AT 250 WORDS)