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AV-Knoten-Reentry-Tachykardien (AV-junktionale Reentry- Tachykardien, AVNRT) gehoren neben den Tachykardien unter Einbeziehung akzessorischer Leitungsbahnen zu den haufigsten Ursachen paroxysmaler supraventrikularer Tachykardien [6]. Wahrend in fruheren Jahren das Konzept der aus schlieslich intranodal gelegenen Kreisbahn bestanden hatte, konnte in der letzten Zeit durch experimentelle und intra operative Mappinguntersuchungen sowie durch Ergebnisse der Hochfrequenzstrom-Katheterablation gezeigt werden, das den AVNRT ein komplexes pathophysiologisches Substrat unter Einbeziehung des AV-Knotens und des perinodalen Vorhofmyokards zugrunde liegt [2,4,5,7,8,12].

The sudden infant death syndrome (SIDS) is defined as a sudden death in appar- ently healthy infants which is unexpected from their history and in which a post- mortem examination fails to demonstrate an adequate cause of death. SIDS has a peak rate at between 2 and 3 months of life [1, 2] and is highest among premature babies and male infants.

Molecular genetics of inherited cardiac arrhythmias had a late onset compared to the advances of genetics achieved in other inherited cardiac disorders. This was related to the high mortality and early disease onset of these arrhythmias resulting in mostly small nucleus families. Thus, traditional linkage studies that are based on the genetic information obtained from large multi-generation families were made more difficult.

Die deutliche Zunahme von Menschen mit Herzinsuffizienz im Endstadium und die demgegenuber stehende sinkende Organspendebereitschaft in der Bevolkerung, erfordert ein immer anspruchsvoller werdendes Vorgehen bei der Auswahl von geeigneten Transplantionskandidaten. Die dadurch steigenden medizinischen aber auch logistischen Anforderungen haben weltweit zunehmend zur Einrichtung spezialisierter Zentren gefuhrt (7). Die gerechte und medizinisch sinnvolle Zuweisung von Organen fur Herz- und Lungenverpflanzungen erfolgt dann auf der Basis von Wartelisten, in denen alle relevanten Befunddaten, der zur Transplantation angemeldeten Patienten, dokumentiert sind. Die wichtigsten Anforderungen an eine solche Ubersicht sind vor allem Aktualitat, Zuverlassigkeit und komfortable Handhabung. Neben dem kliniksinternen Management erfordert insbesondere die Koordination von mehreren Zentren erweiterte Konzepte und Umsetzungsstrategien. Vor diesem Hintergrund war das Ziel dieses Projektes eine EDV-gestutzte Wartelistenverwaltung, zum einen fur die Universitat Munster, wie auch fur die 5 ubrigen Kliniken des Transplantationsverbundes NRW, zu entwickeln.

The Brugada-Brugada syndrome is a rhythmologic disorder which can be diagnosed because of typical ECG criteria. A high-take off descending ST segment localized to the right chest leads, associated with right bundle branch block and ventricular fibrillation or syncopes are characteristic of the syndrome. ECG alterations in the right precordial leads were recorded in a 47 year old female patient who was admitted to hospital because of enteritis and associated syncope. The ECG alterations were initially not realized as Brugada-Brugada syndrome. Because of "recognizing" comparable ECG alterations during a congress lecture, the diagnosis was made. The patient was treated with an ICD.

Optimal allocation of donor organs is an ongoing matter of debate. We report on the impact of the foundation of UNI NRW, a close transplant collaboration of seven university centers with the intention of improving donor organ allocation, on the heart transplant program in Münster. All donor organs retrieved were offered first to the patients within this region before going into the Eurotransplant (ET) Foundation pool. The heart transplant program data were prospectively (for 1997) and retrospectively (for 1996) analyzed with regard to donor organ availability and allocation. There was a slight decrease in the number of donor hearts offered and accepted within the UNI NRW region in 1997 as compared to in 1996. However, due to the significantly lower organ export rate, the number of heart transplantations performed in UNI NRW rose from 47 to 72 procedures. In Münster, only six donor organs (16%) were procured from outside UNI NRW in 1997, and these were, in part, due to special urgency requests. In conclusion, the institutionalization of UNI NRW within the framework of ET offers more flexibility, decreases total ischemic time, and may help to lower costs.

Atrial fibrillation (AF) is the most frequent cardiac arrhythmia. However, despite manifold publications reflecting numerous clinical trials about treatment of AF, the management of this arrhythmia is still under controversial discussion, in daily clinical work as well as in research. The present study concentrates on three major questions: 1. How frequent are recurrences of AF in long-term follow-up? Most of the previous studies used the occurrence of symptoms as a surrogate parameter for recurrences of AF, despite the expected high rate of asymptomatic relapses. In the present study a daily transtelephonic ECG transmission enables a rhythm monitoring independent of symptoms. 2. Is the frequency of AF recurrences significantly reduced by antiarrhythmic medication? A direct comparison of class I and III antiarrhythmic drugs, which still are most frequently used for this indication, and of placebo will answer this question. 3. How safe is the long-term treatment for the prevention of AF recurrences with special respect to proarrhythmic effects? The daily transtelephonic ECG transmission enables a quantitative and qualitative monitoring of tachy- and bradyarrhythmias independent of symptoms. Additionally, the daily analysis of ECG measures may detect parameters predicting subsequent life threatening arrhythmias. The study design provides a prospective, randomised, double-blind, placebo controlled, multicenter parallel group comparison. In Germany and in the Czech Republic about 90 hospitals will include 900 patients with documented chronic AF, age 18 to 80 years, if they are eligible for electrical cardioversion without concomitant antiarrhythmic drug therapy and if they are anticoagulated for at least three weeks prior to inclusion. Neither the size of the left atrium nor the duration of chronic AF are exclusion criteria. A few hours after successful electrical cardioversion the patients are randomised either to sotalol (2 x 160 mg) or quinidine + verapamil (3 x 160 mg + 3 x 80 mg) or placebo. Starting at the day after cardioversion, the patient is asked to record and transmit electrocardiograms of one minute duration at least once a day using his personal transtelephonic ECG recording unit (Tele-ECG recorder, credit card size), in case of symptoms as often as necessary. The ECGs can be transmitted at any time by any regular phone without additional equipment using a toll free number. A custom made, computer based, fully automated receiving centre is handling the patient calls interactively with voice control, including a voice recording of the patient's symptoms. The ECG tracings and the patient's voice messages are subsequently computer based analysed by experienced technicians. All ECG measures are stored in a database. In case of AF recurrence, any other relevant arrhythmia or additional abnormalities (e.g. QT prolongation) the correspondent hospital is immediately informed by fax. In case of AF recurrence, a subsequent Holter recording discriminates in paroxysmal and permanent AF. Study medication is ended if either permanent AF or the third episode of paroxysmal AF are detected or after 12 months of follow-up. Regular follow-up visits are performed monthly. Major endpoints are the time to first recurrence of AF or the time to death, secondary parameters are the number of AF recurrences, the time to end of medication and AF related symptoms. The recruitment started in the last days of 1996. Until the end of June 1998, 424 patients have been randomised. It is expected to end recruitment in spring 1999 and to close the study in spring 2000. Final results will be available in summer 2000.

The scientific basis and the reasoning underlying the changes in antiarrhythmic approaches to ventricular arrhythmias during recent decades are discussed. The early enthusiasm in the use of antiarrhythmic drugs in patients after myocardial infarction to prevent sudden cardiac death was severely affected by the results of the Cardiac Arrhythmia Suppression Trial (CAST) which show an increased mortality of patients on sodium-channel antagonist antiarrhythmic drugs. A transient euphoria for drugs that prolong repolarization received criticism after premature termination of the Survival With Oral D-sotalol-trial (SWORD). Recently, attention has focused on the use of the implantable cardioverter defibrillator in both secondary and primary prevention of sudden death. In contrast, catheter ablation, although very useful in supraventricular tachycardia, still plays a limited role in the management of ventricular tachyarrhythmias in the presence of organic heart disease.

Patients with idiopathic ventricular tachycardia or fibrillation have no additional structural or functional myocardial abnormalities. However, the inducibility of typical tachyarrhythmias by physical or mental stress or by catecholamine infusion suggests the involvement of the adrenergic system in the pathogenesis of these potentially life-threatening diseases.45 patients with idiopathic right ventricular outflow tract tachycardia (RVO-VT), 25 patients with idiopathic left ventricular tachycardia (ILVT), 15 patients with idiopathic ventricular fibrillation (IVF) and 10 age-matched control patients were investigated in this study. Diagnoses were made on the basis of detailed evaluation of the results of two-dimensional echocardiography, left and right ventricular angiography, coronary angiography and endomyocardial biopsy. Local presynaptic norepinephrine re-uptake was assessed using the norepinephrine analog 1231-metaiodobenzylguanidine (MIBG), SPECT and semiquantitative 33-segment bull's-eye analysis.Locally reduced 123I-MIBG uptake was found in 27 of 45 RVO-VT patients (60%), 5 of 15 ILVT patients (33%) and 17 of 25 IVF patients (68%). Unlike ILVT patients, RVO-VT and IVF patients had significantly reduced segmental 123I-MIBG uptake of the posterior wall compared with control patients.Patients with idiopathic tachycardia and fibrillation show abnormal 1231-MIBG uptake, which indicates presynaptic sympathetic dysfunction. RVO-VT and IVF patients exhibit significantly reduced 123I-MIBG uptake in the posterior left ventricular wall, whereas ILVT patients do not.

Purpose: Restenosis after catheter-based revascularization has been demonstrated to be primarily caused by smooth muscle cell proliferation. This study examines the effects of external beam irradiation on neointimal proliferation after external injury to the central artery of the rabbit ear. Methods and Materials: Thirty male New Zealand White rabbits were used in this study. Crush lesions were performed on each ear under general anesthesia and bilateral auricular nerve blockade. A single dose of 1200 cGy (n = 10), 1600 cGy (n = 10), or 2000 cGy (n = 10) gamma radiation was delivered to the left or right central artery of the ear 24 hours after injury; the contralateral central artery served as control. All rabbits were sacrificed after 21 days and the central arteries of both ears were fixed for morphometric measurements. Results: Mean (±SD) neointimal area was 0.062 ± 0.005 mm 2 (1200 cGy), 0.022 ± 0.005 mm 2 (1600 cGy), and 0.028 ± 0.006 mm 2 in irradiated arteries compared with 0.081 ± 0,009 mm 2 in the control group. Mean (±SD) luminal area was 0.049 ± 0.004 mm 2 (1200 cGy), 0.059 ± 0.002 mm 2 (1600 cGy), and 0.072 ± 0.006 mm 2 (2000 cGy) in irradiated arteries compared with 0.043 ± 0.008 mm 2 in the control group. The differences in neointimal and luminal area between control and irradiated arteries were significant (p < 0.05) for the 1600 and 2000 cGy group only. Conclusion: We conclude that in this model, external beam X-ray irradiation was successful in reducing neointimal proliferation after injury of the central artery of the rabbit ear. Marked reductions in neointimal proliferation were demonstrated in vessels subject to 1600 and 2000 cGy radiation; a less prominent effect was noted for 1200 cGy. Whether this approach can be used successfully to inhibit restenosis in the clinical setting requires further investigation.

Because the number of patients on the waiting list for transplantation is increasing and the stagnation in the number of organs donated has led to a more restrictive listing for transplantation, an increased fraction of patients needs to be bridged mechanically. We examined the hypothesis that selection of these patients with regard to urgency status is critical in determining outcome.A cohort of 631 patients referred for transplantation to our center between January 1, 1990, and December 31, 1996, was analyzed. Two hundred ninety-seven patients were listed for transplantation and 157 were given transplantation. Forty-one patients had to undergo ventricular assist device implantation (n=34, Novacor; n=6, TCI Heartmate; n=1, Medos), 39 for bridging to transplantation and 2 for permanent support. Initial transplantation evaluation data were analyzed in 3 subgroups (elective bridging, urgent bridging, emergency bridging) and compared with another and with other patients referred for transplantation, specifically those who did not have to be bridged on the waiting list.Patients who underwent elective or urgent assist device bridging were younger and more compromised than the rest of patients accepted on the waiting list (higher functional class, lower mean arterial pressure, lower cardiac index, lower serum sodium, higher pulmonary capillary wedge pressure). In the elective group, overall survival including perioperative mortality rate was better than in the urgent/emergency group and at least as good as in patients who were stable on the waiting list and did not undergo heart transplantation during follow-up. This should prompt cardiologists and cardiac surgeons to consider assist device implantation earlier.

Atrial fibrillation belongs to the group of cardiovascular diseases that most frequently predispose to arterial thromboembolic events. Within the last years, the AFASAK, BAATAF, SPAF I, SPINAF, and CAFA trials have consistently demonstrated a significant, approximately 70%, risk reduction for stroke on oral anticoagulation in patients with nonrheumatic atrial fibrillation. This benefit by far outweighed the slight increase in annual major hemorrhage. Recently, additional trials (SPAF II, EAFT, SPAF III, and others) have shed further light on important questions concerning risk factors, secondary prophylaxis, the optimal intensity of anticoagulation, and the role of aspirin and other antiplatelet drugs. The main results of these studies are discussed in this review. The majority of patients with atrial fibrillation are65 years of age and have other clinical or echocardiographic risk factors. In these patients, adjusted-dose warfarin with target international normalized ratios (INRs) 2.0 to 3.0 is effective and safe. The risk of stroke rises with INR values2.0, whereas INR values3.0 result in an increase in intracerebral hemorrhages, especially in the very elderly. In contrast, no anticoagulation seems warranted in younger atrial fibrillation patients60 years of age without any clinical or echocardiographic risk factor. An overview of all randomized trials that compared aspirin with placebo and/or adjusted-dose warfarin indicates that adjusted-dose warfarin is approximately 50% more effective than aspirin for primary and secondary prevention of stroke, at least in patients with atrial fibrillation who have clinical risk factors. Therefore, oral anticoagulation clearly is the therapy of choice for prevention of thromboembolism in patients with atrial fibrillation.

Transcranial Doppler sonography has become a widely used method for detecting cerebral circulating microemboli (ME) arising from the carotid arteries or the heart. Yet, studies on subgroups of patients with distinct cardiac sources of embolism are still limited. The same holds true for investigation on the relationship between microembolization and hemorheological parameters. A total of 142 patients suffering from left ventricular aneurysm (LVA, n = 52), severe left ventricular dysfunction (LVD, n = 43), or chronic atrial fibrillation (AF, n = 47) were enrolled in this study. All patients had been neurologically asymptomatic for at least 1 month. Further relevant embolic disorders of the carotid arteries and the heart had been excluded. Unilateral monitoring for ME over the middle cerebral artery was performed for 30 min. Blood was drawn after each monitoring for determination of plasmatic coagulation parameters, as well as plasma viscosity, and platelet reactivity. The overall prevalence of ME was 31%, with a slightly higher prevalence in patients with LVA (37%) compared to patients suffering from AF (30%) or LVD (26%). With single-factor analysis, a trend towards higher ME prevalences was found with (a) a history of remote embolic events, (b) ineffective anticoagulation, (c) increased platelet aggregation, or (d) increased plasma viscosity (all p0.1). The combination of ineffective anticoagulation in conjunction with increased platelet aggregation, however, was significantly associated with higher ME rates even after adjustment for other factors by logistic regression analysis. Our results demonstrate a low ongoing microembolic activity in asymptomatic patients suffering from LVA, LVD and AF. An activated plasmatic coagulation system together with increased platelet aggregation contributes to ME generation.

In the early period after cardiac transplantation, differential diagnosis of graft failure due to rejection, infection, and other causes is important but difficult.In 22 consecutive patients undergoing heart transplantation, we prospectively determined levels of interleukin-6 as well as T-cell and monocyte subsets at eight points in time during biopsy and right heart catheterization and within 12 hr of echocardiography during the first 3 months after transplantation.Worse hemodynamic parameters, as characterized by dichotomization according to median values (pulmonary capillary wedge pressure10 mmHg, mean pulmonary arterial pressure18 mmHg, pulmonary vascular resistance115 dyn x sec x cm(-5), right atrial pressure5 mmHg, cardiac index3 L/min/m2, early mitral deceleration time135 msec, and isovolumic relaxation time80 msec), were associated with higher levels of interleukin-6, C-reactive protein, polymorphonuclear cells, CD71+/CD14+ monocytes, and IgM levels and, in contrast, with lower levels of immunocompetence markers such as CD3+ T cells, CD4+ T cells, CD8+ T cells, CD3+/CD25+ T cells, CD4+/ CD45RO+ T cells, NK cells, and lower biopsy scores.Early after cardiac transplantation, elevated levels of inflammatory cells and soluble inflammatory molecules and lower levels of immunocompetence markers are associated with impaired allograft function in the absence of cellular rejection.

Arrhythmogenic right ventricular cardiomyopathy (ARVC) is characterized by regional atrophy of right ventricular myocardium and subsequent replacement by fatty and fibrous tissue. The disease manifests in young adulthood with a predominance of males. Hallmarks of ARVC are ventricular tachyarrhythmias of left bundle branch block pattern which frequently occur during exercise. However, sudden death may also be the first manifestation of the disease. Characteristic findings are repolarization abnormalities and QRS prolongation in the right precordial leads of the surface ECG and regional abnormalities of right ventricular structure and wall motion. Left ventricular involvement may occur in later stages of the disease but rarely leads to progressive biventricular heart failure. Therapeutic efforts are mainly directed to the treatment of ventricular tachyarrhythmias and the prevention of sudden death. A tailored treatment strategy including antiarrhythmic drug therapy, catheter ablation and implantation of cardioverter-defibrillators may be used to improve the long-term prognosis of patients with ARVC.

This retrospective study was undertaken to provide information on occurrence, risk prediction and prevention of syncope in patients with an implantable cardioverter-defibrillator (ICD).ICDs effectively terminate ventricular tachycardia and fibrillation (VT/VF). Incapacitating symptoms, such as syncope, may still occur.We performed a retrospective analysis of data from 421 patients (clinical history, outpatient chart reviews and episode data) with mean (+/-SD) follow-up of 26 +/- 18 months.Of 421 patients, 229 (54.4%) had recurrent VT/VF, and 62 (14.7%) had syncope. The actuarial survival rate free of VT/VF was 58%, 45% and 37% and that for survival free of syncope was 90%, 85% and 81% at 12, 24 and 36 months after implantation, respectively. Once VT/VF had occurred, 76%, 68% and 62% of patients remained free of syncope during the following 12, 24 and 36 months, and 68%, 64% and 56% remained free of second syncope 12, 24 and 36 months after first syncope, respectively. In cases of syncope, the mean cycle length (CL) of VT was 251 +/- 56 ms. A low baseline left ventricular ejection fraction (LVEF), induction of fast VT (CL300 ms) during programmed ventricular stimulation and chronic atrial fibrillation (AF) were associated with an increased risk of syncope. If the LVEF was40%, fast VT had not been induced, and patients had no chronic AF; 96%, 92% and 92% of patients remained free of syncope after 12, 24 and 36 months, respectively. Once patients had a VT recurrence, syncope during the first VT and a high VT rate were the strongest risk predictors of future syncope.Identification of patients with an ICD with a low and high risk of syncope seems to be feasible and might help as a guide to driving restrictions in such patients.

In patients after atrial switch operation (Mustard or Senning procedure) for transposition of the great arteries (TGA), the anatomic right (anterior) ventricle works as the systemic ventricle. Although this is associated with an increased rate of congestive heart failure, the prognosis for long-term survival is good. Therefore a large proportion of these patients has reached their reproductive years and consult cardiologists and obstetricians because they plan a pregnancy or are already pregnant. Because of the substantial hemodynamic changes and the increase in cardiac output during pregnancy, potential risk factors and complications have to be considered.Initiated by the presentation of a pregnant patient with TGA after surgery in our hospital, we analyzed the information referenced in MEDLINE. Including our patient, there were reports on 27 patients after the Mustard procedure with a total of 39 pregnancies. FETAL OUTCOME: Three abortions occurred during the first trimenon, another one was electively induced because of maternal cardiac deterioration. One late abortion occurred in the 23rd week of pregnancy. 35 babies (one twinpair) were born healthy without cardiovascular anomalies. MATERIAL OUTCOME: No maternal deaths occurred. Eight women developed clinical signs of systemic (= right) heart failure including all three patients with former complex TGA. Four of these patients recovered after delivery, four showed persistent reduction of physical abilities or signs of heart failure. Further complications were supraventricular tachycardias (five patients) and a high incidence of hypertension and pre-eclampsia (22% of patients).Overall, the outcome for mothers after Mustard procedure for TGA and their children is good, but there is need for intensive and specialized follow-up.

Radiofrequency catheter ablation of a right septal accessory pathway was performed in a 66‐year‐old patient with incessant orthodromic atrioventricular reentrant tachycardia. Intravenous administration of flecainide, ajmaline, verapamil, and d, l‐sotalol had been ineffective in controlling the tachycardia. After the ablation procedure, precordial T‐wave inversion was observed during sinus rhythm. These repolarization abnormalities persisted and were suggested to represent “cardiac memory”. Three days later, atrial fibrillation with a fast ventricular response developed and oral d, l‐sotalol, which had been well tolerated previously on a long‐term basis, was started again. However, at this time, and in the presence of the persisting repolarization abnormalities, the T waves became deeper and broader within a few hours after the introduction of d, l‐sotalol. Marked QT prolongatio that was paralleled by the occurrence of repeated episodes of torsade de pointes developed. Serum electrolytes were nomal. Direct current cardioversion was necessary due to the degeneration of torsade de pointes into ventricular fibrillation. Further sustained arrhythmia episodes were suppressed by temporary endocardial ventricular pacing. The patient recovered without any sequela. This case demonstrates that replarization abnormalities after catheter ablation, which may be due, at least in part, to the “cardiac memory,” are not always benign but may contribute significantly to proarrhythmia.

Im Mittelpunkt der Aufgabenbereiche der Herzkatheterlabore steht die Diagnostik angeborener Herzfehler, erworbener Herzklappenfehler, von Herzmuskelerkrankungen, von Erkrankungen der Herzkranzgefase und von peripheren Gefasen, die Vorbereitung von Patienten mit Herzinsuffizienz und nach Herztransplantation, die elektrophysiologische Diagnostik und die Therapie von Herzrhythmusstorungen mit Katheterverfahren (Katheterablation) und die postoperative Uberprufung von automatischen implantierten Kardioverter-Defibrillator-Systemen.

Arrhythmogenic right ventricular cardiomyopathy (ARVC) is a frequent cause of ventricular tachyarrhythmias and cardiac arrest in young patients with apparently normal hearts. The cardiomyopathy is characterized by a localized or generalized myocardial atrophy predominantly affecting the right ventricle with subsequent infiltration by fatty and fibrous tissue [1]. The arrhythmogenic substrate is formed by islands of surviving strands of hypertrophied myocytes, predisposing for localized slow conduction and reentrant arrhythmias. The predominant sites of involvement in ARVC are the outflow tract, apex and subtricuspid area of the right ventricle, which were described as the “triangle of dysplasia” [2]. Left ventricular involvement has been described in patients with extensive ARVC and a long history of arrhythmias [3].

Jervell Lange-Nielsen syndrome (JLNS) is a recessive disorder with congenital deafness and long-QT syndrome (LQTS 1). Mutations in the potassium-channel gene KVLQT1 (LQTS 1) have been identified in JLNS and in autosomal-dominant LQTS as well. We performed haplotype analysis with microsatellite markers in a Lebanese family with JLNS, but failed to detect linkage at LQTS 1. Moreover, using this approach, we excluded two other ion-channel genes involved in autosomal-dominant LQTS, HERG (LQTS 2) and SCN5A (LQTS 3). Our findings indicate that JLNS is genetically heterogeneous and that, in this family, an unknown LQTS gene causes the disease.

Heparan sulfate proteoglycans are obligatory for receptor binding and mitogenic activity of the basic fibroblast growth factor (bFGF). In the present study the influence of undersulfated heparan sulfate on the expression of basic fibroblast growth factor and coronary smooth muscle cell (cSMC) proliferation was investigated. Chlorate, known to be an inhibitor of ATP-sulfurylase, was used as a tool to suppress sulfation of heparan sulfate. When cultured cSMC were treated with 10 mM sodium chlorate in sulfate-depleted medium, the cell number and [3H]thymidine incorporation decreased by 76% and 66% respectively, while the protein content per cell was doubled. At the same time the [35S]sulfate incorporation into cell-associated proteoglycans was reduced by 90%. The remaining minimal amount of available [35S]radioactivity was preferably incorporated into heparan sulfate. Under the same conditions the [6-(3)H]glucosamine incorporation into glycosaminoglycans was not impaired. The chlorate-induced increase of cell protein content includes an overexpression of bFGF, which increased from 6-8 ng to 18-22 ng/mg cell protein. However, no changes in the distribution of bFGF between the intracellular and pericellular compartment could be observed. Cell cycle analysis by FACS revealed a G1 arrest of the cell cycle with increase of the G1/S ratio from 2.9 (control) to 6.1 (chlorate) but the DNA content per cell corresponded to normal diploid cells both in control and chlorate-treated cells. The chlorate effect can be abolished by addition of 5 mM sodium sulfate to the cultures. Our results demonstrate an inverse association between the sulfation of heparan sulfate and the expression of bFGF. They suggest that chlorate blocks the cell cycle in the late G1-phage and that mitogenesis of cSMC requires fully sulfated cell-associated proteoheparan sulfate.

A novel, hemodynamically guided exercise protocol with two different left ventricular assist device settings in two long-term recipients is presented. This protocol allows for quantitation of the contribution of the native left ventricle to total cardiac output. It facilitates estimation of the risk associated with device dysfunction, as well as prediction of left ventricular recovery and the potential for weaning.

Postoperative tests of implantable cardioverter defibrillators (ICDs) are routinely performed to ensure appropriate defibrillation by the device. However, efficacy and complications of this procedure are unknown. To scrutinize the currently accepted indications to test the defibrillation function of the ICD we retrospectively analyzed 844 ICD-tests in 439 ICD-systems and 409 patients. 755 ICD-tests (89.4%) were routinely performed (57% before discharge and 43% during follow-up); 58 tests (6.9%) were performed after a change of the antiarrhythmic drug regimen, 24 tests (2.9%) after a revision of a part of the ICD-system, and seven tests (0.8%) because of a suspected dysfunction of the ICD. During routine-tests six ICD-systems (0.8%) failed to defibrillate the patient. However, in all but one test abnormalities of the ICD-system had been observed before the test. After addition of antiarrhythmic drugs, three of 58 ICD-systems (5.2%) failed to defibrillate the patient during the test (amiodarone: n = 2, flecainide: n = 1). Four of seven ICD-systems (57%) tested due to a suspected dysfunction failed to defibrillate the patient. After revisions of parts of the ICD-systems, ICD-tests never revealed a failure of defibrillation. During 16 ICD-tests (1.9%) complications occurred. The most frequent complications was inappropriate shocks (n = 10; 1.2%), the most severe one (transient) neurologic symptoms (n = 4; 0.48%). Our experience demonstrates that postoperative tests of the defibrillation function of ICDs rarely reveal ICD-dysfunction. As testing is unpleasant for the patient and not free of complications, tests might be restricted to those patients in whom an ICD-dysfunction is suspected (based on clinical presentation, results of chest-x-ray, testing of sensing signal and stimulation threshold) or class I or class III antiarrhythmic drugs have been added to the antiarrhythmic drug regimen.

All 181 patients with malignant arrhythmias who have been provided with an implantable cardioverter-defibrillator (ICD) at the University Clinics of Muenster during the last 3 years, were investigated by a clinical questionnaire on quality of life (QOL). 132 patients answered and could be included in the study (response rate 73%). The mean age of the patients was 55 +/- 11.8 years, 73% males, 60% had already retired. In the general view 51% of the patients reported fair to excellent quality of life, while 24% gave a negative description of their QOL. 26% of the patients suffered from side-effects of the treatment, primarily from unspecific psychological complaints and ICD-related disturbances. "Unrest" was the predominant psychological complaint (64% of the patients), followed by rumification, shortness of breath, weakness and sleep disturbances. Somatic function and sex life were the functional areas primarily affected (more than half of the patients complaining about these). The "Psychological General Well-Being Index (PGWB)" showed reduced well-being in 61% of the patients. Comparing with the literature and regarding the PGWB-scales well-being, anxiety, and depression no significant differences could be found in comparison with other cardiologic samples after bypass-surgery or valve replacement. The results indicate the need of individual counseling and offers of psychosocial support for this highly strained group to reduce anxiety and to improve the quality of life in order to help the patient to gain greater overall benefit from the new ICD-therapy.

Aortic dissection is the most common fatal condition that involves the aorta. Occasionally, symptoms mimic acute myocardial infarction leading to thrombolytic treatment. Accurate diagnosis in patients with chest pain is therefore essential. We describe a case of acute aortic dissection which resulted in myocardial infarction due to obstruction of the left coronary ostium. A 65-year-old female patient with no previous cardiac history was admitted to a local hospital because of severe chest pain of acute onset. Physical examination was normal except for a low blood pressure (90/50 mm Hg), heart rate 45 beats/min and parasthesia in both hands. The ECG showed sinus bradycardia with negative T-wave in VI and with 1 mm ST-segment elevation in V3. A chest X-ray was normal. Five hours later, the patient experienced once more severe chest pain followed by non-sustained polymorphic ventricular tachycardia (Figure 1). Another ECG showed bifascicular bundle branch block (right bundle branch block and left anterior fascicular block). The ECG was interpreted as showing acute myocardial infarction and treatment with intravenous streptokinase started. Since the patient remained severely hypotensive despite infusion of dobutamine, she was intubated, ventilated and transferred to our hospital. Cardiac catheterization showed acute dissection of the ascending aorta with an aortic intimal flap and an occlusion of the left coronary artery (Figures 2a and b). During catheterization, she suffered a cardiac arrest from which she could not be resuscitated. A postmortem examination confirmed the acute aortic dissection which reached to the ostium of the left coronary artery (Figures 3a and b, 4a and b) and an anterior myocardial infarction probably due to intermitted diastolic obstruction of the ostium of the left coronary artery by an aortic intimal flap.

New recommendations for secondary prevention of coronary heart disease (CHD) were issued by the European Society of Cardiology (ESC), the European Atherosclerosis Society (EAS) and the European Society of Hypertension (ESH) in 1994. The main objective of the EUROASPIRE study (European Action on Secondary Prevention by Intervention to Reduce Events) was to evaluate to what degree the new recommendations have been implemented and whether a significant risk factor reduction in patients who presented with CHD has been achieved. The present study was conducted in the region of Münster, Westphalia, Germany, as part of the nine-country EUROASPIRE study.A total of 524 patients (58.6 +/- 8.2 years) were included in the study by abstracting data from their medical records. According to the clinical event which led to admission to the hospital, patients belonged to the following four groups: 1) coronary artery bypass graft (CABG), 2) percutaneous transluminal coronary angioplasty (PTCA), 3) acute myocardial infarction, 4) acute myocardial ischemia. Initially, a pre-specified number of patients had been recruited with the goal of having 100 patients in each of the four groups participate in the follow-up interview and examination. At least 6 months and, on average, 20 months after hospital discharge for the acute event, 74.8% of the patients came to an interview and examination for an evaluation of their risk profile.At the interview, 15.6% of the patients smoked, 22.7% were obese, 54.6% had blood pressure levels above 140/90 mm Hg and 31.3% a total cholesterol/HDL-cholesterol-ratio greater than 5. Risk factor modification over time was insufficient as only one-fifth of patients had values of their risk factors within the target range at the time of the interview.The goals of secondary prevention have not been achieved in the region of Münster-there is clearly room for improvement. Considering the treatment of patients with CHD, the recommended strategies of secondary prevention need to be applied more intensively in clinical practice.

The continuing disappointing results from recent major studies with antiarrhythmic drugs combined with the continuing excellent outcomes with implantable cardioverter-defibrillators is making it exceedingly difficult, ethically, to conduct future randomized trials comparing the 2 treatment options. On the other hand, the high quality of stored Holter electrograms and the therapy history retrievable from current implantable cardioverter-defibrillators creates opportunities for needed trials on drug efficacy without this ethical dilemma.

Die zunehmende Inzidenz und Pravalenz von Patienten mit Herzinsuffizienz im Endstadium, die angesichts des Spendermangels immer kritischer werdende Auswahl von Herztransplantationskandidaten, die Erforschung pathophysiologisch begrundeter prognostischer Parameter der schweren Herzinsuffizienz und die Validierung von Ergebnissen alternativer Behandlungsmethoden der Herztransplantation mit Vasodilatatoren, Hochrisikoherzchirurgie und Ventrikelunterstutzungssystemen hat weltweit zunehmend zur Einrichtung spezialisierter regionaler Zentren gefuhrt (6). Seit 1990 entwickelte sich im Rahmen des Herzzentrums der Universitat Munster ein interdisziplinares Betreuungsprogramm unter Einbeziehung der Herzchirurgie, Erwachsenen-und Kinderkardiologie, Anasthesiologie, Labormedizin, Immunologie und Pathologie (1). Das Management dieses neuen Modells erforderte die Entwicklung eines masgeschneiderten, innerhalb des Munsteraner EDV-Dokumentationssystemes (2–5) voll integrierten und dennoch eigenstandigen, Instrumentariums. Dieses wird im folgenden beschrieben.