[Late fields in magnetcardiography and late potentials in electrocardiography after acute myocardial infarction]

A high specificity and a high positive prediction has been reached in risk stratification for a sudden cardiac death after acute myocardial infarction (AMI) by combining multiple methods. But sensitivity and negative prediction are still not satisfying. There are the same physiological processes underlying magnetocardiography (MCG) and electrocardiography (ECG). Nevertheless, the signals in each method contain different information.

METHODS

We studied the cardiac magnetic fields in 50 patients after AMI and in 32 probands and calculated the magnetic late field (LF), according to Simsons late potential (LP) analysis. We defined normal values, according to the 95% confidence interval of the probands (QRS < =97 ms, RMS > = 0. 6, LAS < 25 ms).

RESULTS

We compared the results of LF and LP analysis regarding pathologic-nonpathologic and found 76% of the patients with the same results in both methods. Four patients had magnetic signals with low amplitude in the ST segment in contrast to the ECG result, while 6 patients with a "LP positive" diagnosis based on RMS and LAS only, did not show LF. In addition, we have found the magnetic QRS complex to be shorter than the electrical one.

DISCUSSION

In general, the results of LF measurement are similar to the ones of LP measurement. Presumably, there are intracardial currents, which are not detectable by ECG. Further studies are needed to evaluate the prognostic value in patients at high risk for cardiac arrhythmias.

Activation of the Jak-Stat pathway in cells that exhibit selective sensitivity to the antiviral effects of IFN-beta compared with IFN-alpha

We determined whether selective activation of components of the Jak-Stat pathway by different type I interferons (IFN) occurs in human myocardial fibroblasts that exhibit much higher sensitivity to the antiviral effects of IFN-beta than of IFN-alpha. Similar levels of activation of the Tyk2 kinase and the Stat3 transcription factor were induced in response to either IFN-beta or IFN-alpha treatment. However, activation of the Jak1 tyrosine kinase was detectable only in IFN-beta-treated but not IFN-alpha-treated cells. Consistent with this, tyrosine phosphorylation of Stat1 and Stat2 and formation of the IFN-stimulated gene factor 3 (ISGF3) complex occurred to a much higher degree in response to IFN-beta stimulation. These findings demonstrate that differential activation of distinct components of the Jak-Stat pathway by different type I IFN can occur. Furthermore, they strongly suggest that such selective activation accounts for the occurrence of differences in the antiviral properties of distinct type I IFN in certain cell types.

Cardiac sympathetic activity as measured by myocardial 123-I-metaiodobenzylguanidine uptake and heart rate variability in idiopathic dilated cardiomyopathy

In patients with idiopathic dilated cardiomyopathy (IDC) the increased sympathetic activity owing to chronic congestive heart failure leads to an imbalance of cardiac autonomic tone, as reflected by decreased heart rate variability (HRV). Iodine-123-metaiodobenzylguanidine (123-I-MIBG), which has the same affinity for sympathetic nerve endings as norepinephrine, can be used to assess the integrity and function of the cardiac sympathetic nervous system. The aim of the present study was to measure cardiac sympathetic activity by assessing 123-I-MIBG uptake compared with HRV in patients with IDC. In 12 patients with IDC and mild to moderate heart failure, myocardial MIBG uptake was calculated from the myocardial (M) to left ventricular cavity (C) voxel values density ratio and the 123-I activity in a blood sample as a reference (= M/C ratio) using a double radionuclide study with 123-I-MIBG and technetium-99m-MIBI. To investigate the relation between myocardial MIBG uptake and HRV in time domain, the linear regression between the M/C ratio, a new scintigraphic parameter, and the mean RR interval or the HRV triangular index, respectively, was determined. A significant correlation between the M/C ratio and mean RR interval (r = 0.52; p = 0.016) or M/C ratio and HRV triangular index (r = 0.76; p = 0.003), respectively, was found. Thus, the significant correlation between the M/C ratio and HRV indicate that they are both suitable noninvasive methods for evaluating cardiac sympathetic activity in patients with IDC and, furthermore, favor the view that there is evidence of a relation between HRV and the disorder of the cardiac presynaptic sympathetic nerve endings as demonstrated by a reduced M/C ratio.

Determinants of stent restenosis in chronic coronary occlusions assessed by intracoronary ultrasound

Chronic coronary occlusions have a high recurrence rate that can be reduced by stenting, but this rate remains higher than in nonocclusive lesions. To analyze possible determinants of restenosis in these lesions, intracoronary ultrasound was performed during the recanalization procedure. A chronic coronary occlusion of > or = 1 month duration (range 1 to 33 months; median 3.3) was successfully recanalized in 41 patients. Quantitative ultrasound analysis was performed before and after stent placement, with measurement of the luminal area, the extent of the plaque burden at the site proximal and distal to the occlusion, and within the occlusion and the subsequent stent. The degree of compensatory enlargement of the coronary artery within the occlusion was determined by comparing the average of the total vessel area of the proximal and distal reference with the lesion site. Early reocclusion (subacute stent thrombosis) was observed in 1 patient (2.4%). The angiographic control after 6 months showed restenosis in 9 patients with 1 late reocclusion. The overall recurrence rate was 24%. There was no difference in clinical and procedural characteristics between lesions with restenosis and without restenosis. The latter had a larger minimum stent area (7.59 +/- 1.96 mm2 vs 5.71 +/- 0.90 mm2; p <0.01), and there was evidence for more compensatory vessel enlargement in lesions without restenosis. Thus, intracoronary ultrasound showed that a smaller minimum stent area was a major predictor of angiographic restenosis, and it occurred more often in occlusions without compensatory vessel enlargement.

Betaxolol versus carvedilol in chronic heart failure (BETACAR study). Rationale and design

The use of beta-blockers in heart failure for a long time was regarded as contra-indicated because of their negative inotropic effects. Nevertheless, there is growing evidence that beta-blockers slow down the progression of left ventricular dilatation that characterizes heart failure. In addition changes in left ventricular ejection fraction after several months of beta-blocker treatment appears to have predictive value for survival. This beneficial effect of beta-blockade in chronic heart failure needs to be assessed further. The presumed benefit of beta-blockade with betaxolol (CAS 63659-18-7), a highly selective beta-blocker with long duration of action in chronic heart failure (CHF) will be assessed in BETACAR, a comparative study versus carvedilol (CAS 72956-09-3). The design of this study is provided in this article.

Adenoviruses and enteroviruses as pathogens in myocarditis and dilated cardiomyopathy

BACKGROUND

Enteroviruses were detected in up to 50% in myocardium of patients with myocarditis and dilated cardiomyopathy, the latter being considered as a result of a prior subclinical myocarditis. A wide range of other infectious agents are being discussed as pathogens, often only based on reports of single cases. Adenovirus genome was recently identified in a significant number in the myocardium of paediatric patients with myocarditis. However, data on the role of adenoviruses for the aetiopathogenesis of myocarditis in adult patients is missing so far. Therefore, we studied the prevalence of adenoviral and enteroviral genome in myocardium of adults with myocarditis and dilated cardiomyopathy.

METHODS

15 patients were diagnosed at baseline with myocarditis, 16 patients with dilated cardiomyopathy according to clinical and histological criteria. Endomyocardial biopsies of these patients and 8 control patients with non-infectious heart diseases were evaluated by polymerase chain reactions for enterovirus and adenovirus genome.

RESULTS

Enteroviral genome was detected in 27.3% patients with myocarditis or dilated cardiomyopathy, whereas adenoviral genome was not identified in any patient. Samples from control subjects systematically yielded negative results.

CONCLUSIONS

From our data, it seems doubtful that adenoviruses are major pathogens of myocarditis or DCM, whereas enterovirus genome was identified in a significant number of patients with both diseases.

Unexpanded, irretrievable stent in the proximal right coronary artery: successful management with stent graft implantation

Stent loss and failure of retrieval are rare; nevertheless, complications have to be taken into account during percutaneous coronary intervention. Here we report a case of an unexpanded, irretrievable Palmaz-Schatz stent in the proximal right coronary artery near to the ostium and the successful management by implanting a synthetic stent graft.

[Direct coronary stent implantation without predilatation--a new therapeutic approach with a special balloon catheter design]

Stent implantation serves as the gold standard for proximal lesions of the coronary arteries with a diameter between 2.75-3.5 mm. Our new concept aims at a reduced procedure duration and fluoro-time as well as a decreased ischemic period during stent implantation. A new therapeutic concept of a direct stent implantation without predilatation was tested using a specially developed balloon catheter on which various 14-16 mm long "slotted-tube" stents are mounted between two conical, radiopaque markers. In 105 consecutive patients, who were scheduled for angioplasty, this method of direct stent implantation was performed. Six of the procedures were performed for acute myocardial infarction and 8 in so-called high-risk procedures. The direct stent implantation was successful in 88%. In 6%, predilatation of the lesion site was necessary before stent placement. In the remaining 6%, a stent could not be successfully implanted despite the availability of various other systems. Comparison of the direct stent implantation with conventional stent placement with predilatation revealed that 1) The fluoro-time for direct stent implantation, compared to the conventional method, was 8.4 +/- 4.9 min vs. 13.7 +/- 8.0 min; p < 0.05, respectively. Furthermore, there were less balloons used per lesion for direct stent implantation (1.4 +/- 0.4) compared to the conventional method (1.7 +/- 0.7), but there was not a significant difference. 2) If we compare those patients with successful direct stent implantation with those with the unsuccessful procedures, the latter group had a higher percent of angiographically visible calcification at the site of the lesion (80% vs. 18%; p < 0.01). In addition, these patients had an increased average age (72 +/- 7 vs. 61 +/- 11 yrs; p < 0.01). The success rate of direct stent implantation did not depend on lesion diameter stenosis before PTCA. Stent dislocation was observed in 3.8% of the procedures, and a single case of stent embolism was seen. In conclusion, the direct stent implantation offers the advantages of a shortened fluoro-time, the use of fewer balloons, and has the potential of less ischemic stress compared to the conventional method of stent implantation with predilatation, if old patients with calcified lesions are excluded. This should be proved on a large scale in future studies also considering a learning curve with regard to the new method. Whether this new approach also reduces the restenosis rate, warrants further studies.

Safety of deferring angioplasty in patients with normal coronary flow velocity reserve

BACKGROUND

In the catheter laboratory there is a need for functional tests validating the hemodynamic significance of coronary artery stenosis.

OBJECTIVES

It was the objective of our study to compare the long-term cardiac event rate and the clinical symptoms in patients with reduced coronary flow velocity reserve (CFVR) and standard PTCA with patients with normal CFVR and deferred angioplasty.

METHODS

Our study included 70 patients with intermediate coronary artery stenoses (13 f, 57 m; diameter stenosis >50%, <90%) and an indication for PTCA due to stable angina pectoris and/or signs of ischemia in noninvasive stress tests. CFVR was measured distal to the lesion after intracoronary administration of adenosine using 0.014 inch Doppler-tipped guide wires.

RESULTS

In 22 patients (31%), PTCA was deferred due to a CFVR > or = 2.0 (non-PTCA group). In the remaining 48 patients (69%) mean CFVR of 1.4+/-0.23 (p < 0.001) was measured (PTCA group). CFVR increased to 2.0+/-0.51 after angioplasty. During follow-up (average 15+/-6.0 months), the following major adverse cardiac events (MACE) occurred: in the PTCA group re-PTCA was performed in nine patients (18.8%) because of unstable angina, five patients (10.4%) suffered an acute myocardial infarction (MI) (two infarctions occurred during the angioplasty, three patients suffered an infarction during follow-up), two patients (4.2%) needed blood transfusions due to severe bleedings, two patients (4.2%) underwent bypass surgery and one patient (2.1%) died. In the non-PTCA group, angioplasty was necessary only in two cases (9.1%) during follow-up. We did not observe any MI in the non-PTCA group. The overall rate of MACE was significantly lower in the non-PTCA group compared to the PTCA group (9.1% vs. 33.3%, p < 0.01). However, only 40% of the patients of the non-PTCA group were free of angina pectoris at stress. In the PTCA group, 63% did not complain of any symptoms at follow-up (p < 0.05).

CONCLUSIONS

We conclude that determination of the CFVR is a valuable parameter for stratifying the hemodynamic significance of coronary artery stenosis. PTCA can safely be deferred in patients with significant coronary stenosis but a CFVR > or = 2.0. The total rate of MACE at follow-up was below 10% among these patients. However, if PTCA was deferred the number of patients who are free of angina is lower compared to those patients who underwent angioplasty.

Clinical experience with the percutaneous hemopump during high-risk coronary angioplasty

The percutaneous Hemopump showed beneficial effects during coronary angioplasty in 32 high-risk patients with unloading of the left ventricle during ischemia and maintaining cardiac output with mean aortic pressures of 50 mm Hg in case of cardiac arrest (3 patients). High procedure-related morbidity (occlusion of femoral artery in 2 patients; bleeding with need of transfusion in 4 patients) and mortality (4 of 32 patients) rates demonstrate the need for a very careful selection of patients.

Portosystemic hepatic encephalopathy after transjugular intrahepatic portosystemic shunt in patients with cirrhosis: clinical, laboratory, psychometric, and electroencephalographic investigations

A prospective study of hepatic encephalopathy (HE) including neuropsychiatric and psychometric evaluation, electroencephalography, and determination of arterial ammonia levels was performed in 55 cirrhotic patients treated consecutively by transjugular intrahepatic portosystemic shunt (TIPS). The cumulative HE rate increased from 23.6% within the 3-month interval before TIPS to 50. 9% within the first 3-month interval post-TIPS (P = .003). Significant and independent predictors of HE post-TIPS were the presence of HE pre-TIPS and reduced liver function. The cumulative HE rate declined in the second 3-month interval post-TIPS and reached the pre-TIPS level. Chronic forms of HE exceeding grade I were not observed. In a subgroup of 22 nonencephalopathic TIPS patients, the prevalence of subclinical HE did not change after TIPS. Among individual psychometric tests, the block design test gave the highest proportion of pathological results (about 50%), whereas selective reminding gave the lowest (10%-25%). Electroencephalography (EEG) showed a temporary increase of pathological results at 1 month after TIPS, when patients with overt HE (grade I) were included (proportion of 21.1% before vs. 57.1%, P = .005). Arterial ammonia concentration increased from a mean of 94 +/- 26 microgram/dL to 140 +/- 28 microgram/dL at 3 months after TIPS (P < .001). Elevated ammonia levels persisted. TIPS led to a temporary increase of HE incidence within 3 months. The decline of the HE rate beyond 3 months despite a sustained increase of arterial ammonia levels could not entirely be explained by reduction of shunt flow, nor by alteration of liver function. Instead, cerebral adaptation to gut-derived neurotoxins might be anticipated.

Low prevalence of hepatitis C virus antibodies and RNA in patients with myocarditis and dilated cardiomyopathy

We investigated the prevalence of hepatitis C virus in patients with dilated cardiomyopathy (DCM) and myocarditis in comparison to a control group of patients suffering from noninflammatory cardiac diseases such as aortic stenosis. In contrast to the results of previous studies on small numbers of patients, no significant difference in the prevalence of hepatitis C infections was observed. Our data suggest that HCV is not an important causal agent for myocarditis and DCM.

[Percutaneous balloon pericardiotomy for the treatment of a malignant pericardial tamponade]

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.

[Doppler sonographic short- and long-term studies of portal hemodynamics following transjugular intrahepatic portasystemic shunt (TIPSS)]

Shunt insufficiency due to shunt occlusion or stenosis is frequent after TIPS (about 50% after one year). Controversially discussed is whether Doppler sonography is effective in detecting shunt stenosis or whether regular angiographies are required. The experience with a noninvasive method of surveillance primarily based on Doppler sonography is reported here. 58 patients (35 men, 23 women, mean age 55 years, range 33-82 years) were treated by TIPS because of complications of portal hypertension (43 x gastroesophageal bleeding, 14 x refractory ascites, 1 x venoocclusive disease). Liver cirrhosis (alcoholtoxic etiology in 63%) was present in 55 cases, according to Child-Pugh's classification 23 patients = A, 19 patients = B and 13 patients = C. Within a mean observation period of 14 months, Doppler sonography was performed in three months intervals, endoscopy in six months intervals and angiography only when shunt insufficiency was suspected by Doppler sonography and/or because of clinical events, e.g. recurrent bleeding. Immediately after TIPS, maximal flow velocity and flow volume in the portal vein increased by 116% and 115%, respectively. Three months later, a significant increase of portal vein diameter of about 15% was measured. Shunt flow was initially 2.700 ml/min (one week after TIPS) and decreased progressively by about 30% within the first nine months of follow-up. Correspondingly, angiographically proven shunt insufficiency was present in 22 patients (33 episodes). A total of twelve bleeding episodes recurred in seven patients (rebleeding rate of 16% after one year and 19% after two years). In the remaining 15 patients (68%; 21 episodes) shunt insufficiency could be corrected prior to complications because of detection by Doppler sonography (19x) and endoscopy (2x). Therefore, Doppler sonography is an effective diagnostic tool for the detection of shunt insufficiency and should be performed at three months intervals for at least 18 months. In this context it appears allowable to avoid routine angiographies.

Coxsackievirus genome in myocardium of patients with arrhythmogenic right ventricular dysplasia/cardiomyopathy

Enteroviruses are known as major infectious agents for inflammatory heart diseases such as myocarditis and dilated cardiomyopathy (DCM). Arrhythmogenic right ventricular dysplasia/cardiomyopathy (ARVC) is characterized by replacement of right ventricular myocardium by fatty and fibrous tissue. In about 65% of patients inflammatory infiltrates suggest an inflammatory or infectious etiopathogenesis. To test this hypothesis, we investigated endomyocardial biopsies of patients with ARVC, with myocarditis or DCM, and from patients with non-inflammatory cardiac disorders for the presence of enteroviral genome. Enteroviral RNA with homology to coxsackieviruses type B was detected in 3 of 8 patients with ARVC (37.5%), in 7 of 23 patients with myocarditis or DCM (30.4%), but in none of 5 patient with non-infectious myocardial diseases (p < 0.05 compared to ARVC patients). These results support earlier suggestions that coxsackievirus infection of the myocardium is possibly related to the pathogenesis of ARVC.

[Clinical picture and differential diagnosis of cardiomyopathy and myocarditis]

The main feature of idiopathic dilated cardiomyopathy is the dilation and impaired contractility of the left ventricle or both ventricles. The clinical picture with forward and backward failure is based on the pump impairment of the left ventricle. However, the clinical presentation of patients with dilated cardiomyopathy is indistinguishable from any other secondary form of heart failure. The symptoms of myocarditis are also often determined by the degree of left ventricular dysfunction and--apart from perimyocarditis-associated precordial discomfort--therefore also often indistinguishable from dilated cardiomyopathy. The differentiation of dilated cardiomyopathy from other myocardial diseases by noninvasive methods is insufficient. Without invasive tests about 1/3 of the patients will be diagnosed incorrectly. Therefore, invasive diagnostics including coronary angiography are necessary to differentiate dilated cardiomyopathy from other diseases, especially coronary artery disease. Standard laboratory findings and cytokine serum concentrations (e.g. TNF-alpha) are not suitable to differentiate dilated cardiomyopathy and myocarditis and endomyocardial biopsy is indicated. Endomyocardial biopsies have to undergo evaluation by standard histology and immunohistology, and should be tested for the persistence of infectious agents. According to cardiac catheterization and evaluation of the endomyocardial biopsy idiopathic left ventricular dysfunction can be further stratified using the criterion of a myocardial virus persistence and the presence/absence of inflammatory infiltrates. Idiopathic dilated cardiomyopathy (approximately 70 to 75%), virus-associated dilated cardiomyopathy (approximately 20 to 25%), myocarditis (approximately 7%) and autoimmune myocarditis (approximately 3%) are the 4 possible resulting forms of idiopathic left ventricular dysfunction. Beside conventional medical therapy there are new therapeutic concepts e.g. using interferon for enterovirus-positive patients and immunosuppression for autoimmune, virus-negative patients with a cellular infiltrate.

Direct coronary stenting without predilatation: a new therapeutic approach with a special balloon catheter design

Coronary stenting is the primary therapeutic option for many coronary lesions, after the risk of subacute stent thrombosis and bleeding complications has been reduced by antithrombotic regimens and improved stent expansion. It would be desirable to shorten the procedure and the duration of ischemia, and to reduce the risk of ischemic complications during balloon inflation by implanting the stent without previous dilatation of the lesion. This is not possible with the presently available stent delivery systems. This new therapeutic concept was tested with a specially designed balloon catheter, on which slotted-tube stents can be fixed between two conical radiopaque markers. Sixty-one patients eligible for angioplasty underwent direct stent implantation without predilatation. Four procedures were performed for acute myocardial infarction, and two as high-risk PTCA. Single slotted-tube stents (Palmaz-Schatz, NIR, or JOStent) of 14-16-mm length were mounted between the conical radiopaque markers of a special balloon which provided a fixation for the crimped stent. The direct implantation was successful in 80% of all patients, while in 10% the stent could be deployed after predilatation of the lesion. In 10% of lesions a stent could not be implanted with this and any other delivery system. When patients with successful direct stenting were compared with those with indirect (after predilatation) or unsuccessful stent deployment, the presence of angiographically visible calcification was higher in the unsuccessful cases (75% vs. 19%; P < 0.01), and the patients were older (72+/-8 vs. 61+/-12 years; P < 0.01). Radiation exposure time was only 8.7+/-5.1 min as compared with 12.6+/-7.6 min in conventional stent procedures with predilatation (P < 0.05). The number of balloons used per lesion was also lower than with conventional stenting. Stent dislocation was observed in 5%, and no embolization occurred. The new therapeutic approach of direct stenting without predilatation proved to be a safe and successful procedure in this initial series of coronary angioplasties. When calcified coronary lesions are avoided, it provides a way to rationalize stent implantation with shorter radiation exposure times, fewer balloons, and the potential advantage of fewer ischemic complications as no balloon predilatation is required.

Monocyte activation in congestive heart failure due to coronary artery disease and idiopathic dilated cardiomyopathy

OBJECTIVE

To investigate plasma tumor necrosis factor (TNF)alpha, tumor necrosis factor alpha soluble receptor I, interleukin-1beta and neopterin concentrations as markers of monocyte activation in patients with heart failure.

STUDY DESIGN

The group consisted of patients with heart failure due to dilated cardiomyopathy (n=19) and coronary artery disease (n=11). Patients without cardiac failure served as controls (n=10).

RESULTS

TNFalpha concentrations were elevated only in heart failure patients with coronary artery disease (2.9+/-0.3 pg/ml versus 1.7+/-0.3 pg/ml; P<0.05). When the patients were grouped according to acute and chronic failure, TNFalpha concentrations were significantly elevated in acute failure (3.1+/-0.4 pg/ml, n=6 versus 1.7+/-0.2 pg/ml, n=8; P<0.05). TNFalpha concentrations were elevated in patients with coronary artery disease and chronic heart failure compared to coronary artery disease patients without failure (2.0+/-0.4 pg/ml, n=6 versus 1.8+/-0.3 pg/ml, n=7; P<0.05). A higher proportion of patients with myocardial insufficiency showed increased lipopolysaccharide-inducible TNFalpha concentrations (10/30 versus 0/9, P<0.05).

CONCLUSIONS

TNFalpha is elevated in patients with acute cardiac decompensation. Among patients with chronic heart failure only those with coronary artery disease exhibit increased levels. Cytokine concentrations are similar in heart failure due to dilated cardiomyopathy and coronary artery disease. Monocytes of patients suffering from cardiac insufficiency show an increased sensitivity towards stimuli such as lipopolysaccharides.

Transjugular intrahepatic portosystemic stent-shunt after orthotopic liver transplantation in a patient with early recurrence of portal hypertension of unknown origin

A 65-year-old italian patient developed complicated portal hypertension immediately after orthtopic liver transplantation (OLT) necessitating shunt creation. One to five weeks after OLT, massive ascitic fluid losses of up to 121/day developed. Vascular and major hepatic-parenchymal abnormalities were excluded by duplexsonography, angiography and initial histology, respectively. A peritoneovenous shunt (Denver-shunt) on day 31 after OLT reduced (by about 50%) but did not stop ascitic fluid losses. Furthermore, three variceal bleedings occurred after implantation of the Denver-shunt. Direct portography on day 45 after OLT revealed portal hypertension (pressure gradient of 26 mmHg) requiring the implantation of a transjugular intrahepatic portosystemic stent-shunt (TIPS) leading to a reduction of the pressure gradient to 13 mmHg. Subsequently, ascites resolved within ten days and esophageal varices improved. Liver function parameters normalized inspite of recurrence of HCV infection with detection of HCV RNA in serum already in the fifth week after OLT. During follow-up, histological findings deteriorated from mild changes to extended fibrosis at day 61 after OLT, which might have contributed to the maintenance of portal hypertension. The deterioration of liver histology was accompanied by an improvement/normalization of liver graft function. There was no evidence for additional viral liver infections, e.g. hepatitis B or cytomegalovirus infection. This case illustrates an etiologically unclear syndrome developing directly after OLT and reaffirms the effectiveness of TIPS in the treatment of complicated portal hypertension even after liver transplantation.

Thrombus formation on transcatheter ASD occluder device in a patient with coagulation factor XII deficiency

Transcatheter occlusion of cardiac defects has become an effective and less invasive alternative to open heart surgery. Thromboembolic complications are rare events, after both surgical and transcatheter closure of atrial septal defects [Galal et al.: Eur Heart J 15:1381-1384, 1994]. We report on a case of thrombus formation on the atrial septal defect occluder system (ASDOS) [Sievert et al.: Cathet Cardiovasc Diagn 36:232-240, 1995; Hausdorf et al.: Heart 75:83-88, 1996]. Two days after transcatheter occlusion, the patient suffered an acute stroke due to embolism despite anticoagulation with intravenous heparin. A coagulation disorder with reduced factor XII concentration was deduced as the likely cause. Repeated transesophageal echocardiographic (TEE) studies revealed an involution of the intracardial thrombus within weeks of subsequent anticoagulatory treatment. First off, this case shows that patients with factor XII deficiency are at risk for thromboembolism. Second, it again clarifies that even large amounts of intraartrial thrombotic material may not be seen by transthoracic echocardiography (TTE) and underscores the necessity of performing TEE. Screening patients for coagulation disorders (Quick's value (Q), partial thromboplastin time (PTT)) before they are selected for treatment with thrombogenic devices is indispensable. With regard to their personal history (earlier thromboembolism) and the result of this screening (e.g., prolongation of PTT), quantitative determination of coagulation factors is reasonable. If patients endangered by thromboembolic complications nevertheless undergo ASD occlusion procedures, anticoagulation monitoring requires exceptional attention. Furthermore, it is recommended that TEE should be carried out in these patients 2 days after treatment, since transthoracic echocardiography (TTE) might be unable to detect thrombus formation on the device.