[Baroreflex activation therapy. A novel interventional approach to treat heart failure with reduced ejection fraction]

Sympathovagal imbalance plays an important role in the progression of heart failure with reduced ejection fraction. Baroreflex activation therapy (BAT), i. e. electrical stimulation of baroreceptors located at the carotid sinus, can reduce sympathetic and enhance parasympathetic tone. Large animal studies on BAT demonstrated improvements in cardiac function, arrhythmogenic risk and a survival benefit compared to untreated controls. The recently published Neo Randomized Heart Failure Study, the first multicenter, randomized and controlled trial of optimal medical and device therapy alone or plus BAT in patients with a left ventricular ejection fraction ≤ 35 %, demonstrated a reasonable safety profile of BAT in this severely ill patient population and no relevant interactions with other devices. The study found significant improvements in the New York Heart Association (NYHA) class of heart failure, quality of life as well as 6 min walking distance and data pointed to a reduction in hospitalization rates. Moreover, N-terminal pro-brain natriuretic peptide (NT-proBNP) levels were significantly reduced. This review gives an overview on BAT for the treatment of heart failure with reduced ejection fraction, from the rationale and animal experiments to the most recent clinical data and future perspectives.

Cardiac monitoring always required after electrical injuries?

BACKGROUND

Controversy still exists regarding inpatient monitoring of patients exposed to electrical injuries.

MATERIALS AND METHODS

In a monocentric retrospective study, we evaluated the medical records of 169 patients admitted to the University Hospital of Cologne from January 2000 to January 2014 because of electrical trauma. The electrocardiogram (ECG) data of 40 patients were missing.

RESULTS

Patients in our collective were predominantly young men (60 %) with an average age of 17.5 ± 17 years (1 year to 73 years). The electrical trauma occurred occupational (20 %), domestic (65 %), and during leisure time (15 %). In the high-voltage (≥ 1000 V) group (n = 7; 71 % male; 40.0 ± 19.4 years) one death was reported, related to an open intracranial injury and cardiac arrest. Of the six surviving patients five showed normal ECGs and one a sinus tachycardia. In the low-voltage (< 1000 V) group (n = 162, 56 % male; 5.0 ± 4.3 years) the ECG findings were as follows: 104 normal, 5 sinus tachycardia, 3 sinus arrhythmia, 6 ST segment changes, 3 premature atrial contraction, 1 premature ventricular contraction, 1 atrio-ventricular (AV)-Block and 1 delta wave. In all, one patient showed a self-limiting supraventricular tachycardia.

CONCLUSION

Asymptomatic and stable patients without any risk factors and with a normal initial ECG need no inpatient cardiac monitoring after an electrical injury.

Essential Hypertension: Cardiovascular Response to Breath Hold Combined with Exercise

Essential hypertension (EH) is a widespread disease and might be prevalent in apnea divers and master athletes. Little is known about the influence of EH and the antihypertensive drugs (AHD) on cardiovascular reactions to combined breath hold (BH) and exercise. In this pilot study, healthy divers (HCON) were compared with treated hypertensive divers with regard to heart rate (HR) and mean blood-pressure (MAP) responses to BH, exercise and the combination of both. Ten subjects with EH and ten healthy divers were tested. 3 different 20 s stimuli were applied: BH combined with 30 W or 150 W and 150 W without BH. The time-charts during the stress intervals and during recovery were compared. Subjects treated with an angiotensin-converting enzyme (ACE) inhibitor showed higher changes for MAP values if breath hold was performed. HR responses were obviously changed if a β-blocker was part of the medication. One subject showed extreme MAP responses to all stimuli and conspicuous HR if BH was involved. The modulation of HR-/MAP-response in EH subjects depends on the mechanisms of antihypertensive agents. The combination of an ACE inhibitor and a β-blocker may give the best protection. It is recommended to include short apnea tests in the fitness-to-dive examination to individually predict potential endangerment.

[Value of lung ultrasound in emergency and intensive care medicine]

Lung ultrasound has traditionally been limited to evaluation of pleural effusion and as guidance for thoracocentesis. However, in recent years, thoracic ultrasound became an increasingly valuable diagnostic tool in emergency and intensive care medicine. The relative easy use of bedside examination made chest ultrasonography diagnostic valuable additional tool to be used in any clinical acute context. Various pulmonary diseases like pleural effusion, pulmonary-venous congestion und edema, pneumonia and pneumothorax can be detected very fast under emergency conditions.

[Value of emergency echocardiography using the example of acute aortic dissection]

A 52-year-old woman was admitted to our emergency department with a suspected diagnosis of a thoracic disc prolapse. She presented with acute thoracic and vertebral pain of sudden onset that increased on movement and change of body position. An emergency echocardiography that was performed at the bedside showed aortic insufficiency, dilation of the aortic root, and membrane dissection in the ascending aorta. A thoracic contrast-enhanced CT angiogram verified acute aortic dissection Stanford type A, which resulted in immediate referral to the department of cardiothoracic surgery for an emergency replacement of the ascending aorta. In the emergency department, emergency bedside echocardiography facilitates the rapid evaluation of potential differential diagnoses in patients presenting with acute thoracic pain.

Neural correlates of ideomotor effect anticipations

How does our mind produce physical, goal-directed action of our body? For about 200years, philosophers and psychologists hypothesized the transformation from mind to body to rely on the anticipation of an action's sensory consequences. Whereas this hypothesis received tremendous support from behavioral experiments, the neural underpinnings of action control via such ideomotor effect anticipations are virtually unknown. Using functional magnetic resonance imaging, the present study identified the inferior parietal cortex and the parahippocampal gyrus as key regions for this type of action control - setting the stage for a neuroscientific framework for explaining action control by ideomotor effect anticipations and thus enabling a synthesis of psychological and neuroscientific approaches to human action.

[Perioperative approach to restless legs syndrome]

Restless legs syndrome (RLS) is one of the most common neurological disorders. The key feature is the urge to move, especially in the legs. New onset RLS can develop perioperatively or an existing RLS can be exacerbated. Severe insomnia, forced immobilization and acute iron deficiency are common trigger factors. Medicinal treatment can also be an important triggering or exacerbating factor. Drugs with dopamine antagonistic, serotonergic and opioid antagonistic effects should be avoided. The long-term medicinal treatment should be terminated as quickly as possible and if necessary bridged non-orally. For diseases which can be associated with secondary RLS a provocation or an exacerbation of RLS should be taken into consideration. This is particularly true for Parkinson's disease, diabetes mellitus, terminal renal insufficiency, spinal cord lesions and pregnancy. So far, there is not sufficient evidence that any form of anesthesia has a negative influence on RLS.

[Extracorporeal membrane oxygenation as bridge to recovery in infarction-related refractory right heart failure]

HISTORY AND CLINICAL FINDINGS

We present a 41-year-old man with cardiac arrest in need of cardiopulmonary resuscitation (CPR) with the diagnosis of a posterior wall infarction, who was hospitalized in our cardiac centre.

INVESTIGATIONS

The cardiac catheterization showed a thrombotic obstruction of the right coronary artery. After percutaneous coronary revascularization a hemodynamically stable situation could be achieved and the patient was admitted to the intensive care unit (ICU).

TREATMENT AND CLINICAL COURSE

The patient became again hemodynamically unstable and a CPR was required. Based on the acute right heart failure with therapy refractory cardiogenic shock we decided within our heart team for an extra corporeal membrane oxygenation (ECMO) applied during CPR in the ICU. The extracorporeal support was needed for three days. Seven days after the emergency cardiac catheterization the patient was extubated and transferred to our intermediate care.

CONCLUSION

Extracorporeal life support is feasible und effective for bridging therapy in patients with acute ischemic right heart failure with refractory cardiogenic shock and successful reperfusion therapy.

The neural substrate of the ideomotor principle revisited: evidence for asymmetries in action-effect learning

Ideomotor theory holds that the perception or anticipatory imagination of action effects activates motor tendencies toward the action that is known to produce these effects, herein referred to as ideomotor response activation (IRA). IRA presupposes that the agent has previously learned which action produces which effects, and that this learning process has created bidirectional associations between the sensory effect codes and the motor codes producing the sensory effects. Here, we refer to this process as ideomotor learning. In the presented fMRI study, we adopted a standard two-phase ideomotor learning paradigm; a mixed between/within-subjects design allowed us to assess the neural substrate of both, IRA and ideomotor learning. We replicated earlier findings of a hand asymmetry in ideomotor processing with significantly stronger IRA by left-hand than right-hand action effects. Crucially, we traced this effect back to more pronounced associative learning for action-contingent effects of the left hand compared with effects of the right hand. In this context, our findings point to the caudate nucleus and the angular gyrus as central structures of the neural network underlying ideomotor learning.

[De novo left ventricular thrombus during tako-tsubo cardiomyopathy]

HISTORY AND CLINICAL FINDINGS

A 70-year-old woman complained of persistent angina pectoris and exertional dyspnoea after a fierce row with a dog owner. Five days after the conflict she visited our clinic.

INVESTIGATIONS

The ECG showed T-wave inversions across the inferior and anterior leads as well as a prolonged QTc interval (490 ms). NTproBNP was elevated (6733 ng/l) while troponin T was normal. Echocardiography and ventriculography during cardiac catheterisation demonstrated an impaired left ventricular function (EF 55 %) with apical akinesia. Coronary artery disease was ruled out by coronary angiography. Based on these findings stress-related cardiomyopathy (Tako-tsubo syndrome) was diagnosed.

TREATMENT AND CLINICAL COURSE

Guideline-based therapy of heart failure was performed. At control examination 13 days after the initial event left ventricular function had improved but now a new left ventricular apical thrombus was detected. Therefore, oral anticoagulation therapy was started.

CONCLUSION

In cases of tako-tsubo cardiomyopathy with apical akinesia it should be noted that a left ventricular thrombus can develope within few days.

[Contrast-enhanced ultrasound]

Contrast enhanced ultrasound (CEUS) is increasingly accepted in the clinical use for diagnostic imaging. The new guidelines and recommendations provide general advice for the use and procedure of CEUS.

Thymoma--an important differential diagnosis of mediastinal tumours

A 69-year-old man with slight dyspnoea underwent routine X-ray examination by his primary care physician. The X-ray and the CT showed a homogenous mass at the right side of the anterior mediastinum. The benignity and the origin of the tissue were still unknown. Therefore, we performed a CT-guided fine needle aspiration biopsy of the mediastinal mass. Histopathological examination finds out a spindle-cell or type A thymoma. Based on these findings we decide for a thoracoscopic resection of the thymoma. After the surgical intervention the patient was completely asymptomatic. In conclusion, because thymomas are prone to ectopic occurrence, they should be considered in the differential diagnosis of mediastinal tumors.

[De novo sarcoidosis after kidney transplantation]

HISTORY AND CLINICAL FINDINGS

A 39-year-old man complained of unspecific chest pains four years after kidney transplantation.

INVESTIGATIONS

Laboratory tests revealed a slow increase of retentions values; the value of soluble IL-2 receptor was slightly elevated. Computed tomography of the chest confirmed mediastinal and bilateral hilar masses. The broncho-alveolar lavage (BAL) showed a marked increase of the CD4/CD8 T-lymphocyte ratio and the aspiration cytology of these lymphadenopathies revealed the cytopathological characteristics of sarcoidosis.

TREATMENT AND CLINICAL COURSE

An asymptomatic stage I sarcoidosis was diagnosed, and the immunosuppressive treatment with cyclosporine, mycophenolatmofetil and prednisone was retained. The patient has remained asymptomatic for now six months.

CONCLUSION

When bilateral hilar / mediastinal lymphadenopathies occur after organ transplantation with immunosuppression de novo sarcoidosis should be taken into account.