3-D-Mapping der Pulmonalvenen mit einem multipolaren Basketkatheter

BACKGROUND: Focal discharges from pulmonary veins are the major sources of paroxysmal atrial fibrillation. The aim of this study was to analyze the activation pattern of pulmonary veins during sinus rhythm and ectopy with the help of a multipolar basket catheter and to disconnect them from the left atrium by localized radiofrequency catheter ablation. PATIENTS AND METHODS: We studied 65 patients (43 male, 22 female, mean age 54 +/- 12 years) with drug-refractory atrial fibrillation (paroxysmal n = 42, persistent n = 23). A 64-pole basket catheter (Figure 1) with a diameter of 31 or 38 mm (Constellation, Boston Scientific) was placed transseptally into the pulmonary veins to record its activation during ectopic beats and during sinus rhythm or coronary sinus pacing (Figure 2). The ablation catheter was placed as ostial as possible next to the electrodes showing the earliest pulmonary vein activation during sinus rhythm or coronary sinus pacing (Figures 3 and 4a). The radiofrequency energy was delivered with a maximum temperature of 50 degrees C and a maximum power of 30 W. In 32 patients, an irrigated-tip catheter (Thermocool, Biosense-Webster) was used. Endpoint of the procedure was the complete elimination of all distal pulmonary vein potentials during sinus rhythm (Figure 4b). RESULTS: The mean number of procedures per patients was 1.25, mean procedure time 236 +/- 79 min, and mean fluoroscopy time 40 +/- 17 min, respectively. In 16 veins, repetitive discharges (more than three) could be recorded under stable conditions (Figures 2 and 5). In twelve of these 16 pulmonary veins (75%), the activation pattern during ectopic beats was identical in the same vein, but different from one vein to another (Figure 2). In four veins, changing activation patterns were observed in the same vein. Focal atrial fibrillation was recorded in four pulmonary veins (Figures 6 and 7). A total of 187 out of 190 mapped veins were successfully isolated at the ostium by ablating 2.3 +/- 1.1 separated conduction pathways. In 16 patients, a second EP study was performed for recurrence of atrial fibrillation. Recovery of conduction of a previously isolated pulmonary vein was identified as the primary reason for recurrence of atrial fibrillation. The second reason were ostial foci, localized proximal to the ablation line (Figure 8). COMPLICATIONS AND FOLLOW-UP: One pericardial tamponade occurred. Carbonization on the splines of the basket catheter-observed in twelve cases with use of a nonirrigated-tip catheter-was prevented by use of irrigated-tip catheters. At 12 months, 36 out of 65 patients (55%) are in sinus rhythm without antiarrhythmic drug use, 28 of 42 patients (67%) with paroxysmal atrial fibrillation. Only one pulmonary vein stenosis > 50% was detected by angiomagnetic resonance imaging 1 year after the procedure. CONCLUSION: 75% of the arrhythmogenic pulmonary veins showed a stable and specific pattern during repetitive ectopic activity. Ostial ablation of 2.3 +/- 1.1 separated conduction pathways from the left atrium into the pulmonary veins resulted in complete conduction block in 187 of 190 veins.     

Pneumothorax in AIDS

OBJECTIVE: To determine risk factors for the development of pneumothorax in patients with the acquired immunodeficiency syndrome (AIDS). DESIGN: Prospective cohort study. SETTING: Tertiary care center. PATIENTS: Of 1030 patients with AIDS who were followed at Memorial Sloan-Kettering Cancer Center between 1 January 1980 and 30 September 1989, 20 (2%) developed pneumothorax that was unrelated to trauma or a pulmonary procedure. RESULTS: Of 20 patients with AIDS who presented with pneumothorax, 19 had compelling evidence of concurrent Pneumocystis carinii pneumonia. Using bivariate analysis, patients receiving aerosol pentamidine prophylaxis (relative risk, 17.6) and those with a history of P. carinii pneumonia (relative risk, 14.5) were more likely to develop pneumothorax. By Mantel-Haenszel stratified analysis, aerosol pentamidine use was a statistically significant risk factor independent of a history of P. carinii pneumonia. The pneumothorax-related mortality rate was 10% and there was considerable morbidity. CONCLUSIONS: Patients with AIDS at the highest risk for developing pneumothorax are those with a history of P. carinii pneumonia who are receiving aerosol pentamidine prophylaxis but who nevertheless develop P. carinii pneumonia. The benefits of aerosol pentamidine prophylaxis in these patients far outweigh this risk. Pneumocystis carinii pneumonia should be considered as the most likely diagnosis in any patient with AIDS who develops a pneumothorax.     

Characterization and biological properties of a hepatitis B virus isolated from a patient without hepatitis B virus serologic markers

We have developed a rapid method to characterize genomic diversity of low-level hepatitis B and related viral agents after their identification in serum by high-affinity HBsAg-antibody monoclonal antibody capture and subsequent polymerase chain reaction amplification. Serum from an individual with chronic liver disease and without hepatitis B virus serological markers but reactive by monoclonal antibody capture/polymerase chain reaction amplification was inoculated into a chimpanzee. After inoculation, an acute hepatitis B virus-like hepatitis developed in the chimpanzee. Analysis of serial liver biopsy samples showed the persistence of hepatitis B virus DNA for more than 17 mo after resolution of acute hepatitis and seroconversion. Applying the technique of restriction enzyme fragment analysis to serial chimpanzee liver biopsy samples and acute-phase sera, along with the serum inoculum, we established that all hepatitis B virus DNA sequences are derived from the same viral agent. We present evidence that the viral DNA persisted as a nonreplicating episomal form in the nucleus of hepatocytes. This study demonstrates that after clinical and serological recovery from an acute hepatitis, there may be persistence of low-level hepatitis B virus-related genome in the liver despite the presence of antibodies to HBsAg. Such persistence of viral genome may be a natural sequela of infection and may serve as a source of viral latency and possible reactivation. Finally, cloning and complete nucleic-acid sequencing of this virus have demonstrated multiple nucleotide and amino acid changes compared with all known hepatitis B virus subtypes. These changes may have contributed in part to a different antigenic composition or immunological reactivity of the host to this hepatitis B virus isolate.     

Development and psychometric properties of a disease-specific quality of life questionnaire for adult patients with growth hormone deficiency

BACKGROUND: Adults with growth hormone (GH) deficiency (GHD) may experience physical and psychological disturbances, which can affect their quality of life (QOL). OBJECTIVES: To develop and validate a disease-specific module from the previously published QOL measure Questions on Life Satisfaction Modules (QLS(M)): the QLS(M)-H that specifically addressed the needs of patients with hypopituitarism. A second aim was for the questionnaire to be applicable across different cultural backgrounds in order to evaluate the efficacy of therapy in large, international clinical trials, thus providing additional clinical endpoints for these studies. DESIGN: A preliminary German language version of the QLS(M)-H was developed from 26 semi-structured interviews of adults with GHD. The questionnaire was then independently translated into five other languages and applied in open, non-controlled, multicentre, longitudinal studies to patient (n=717) and normative populations (n=2700). METHODS: A revised, nine-item version of the questionnaire was developed, based on previously defined criteria, and was evaluated for reliability and validity. Sensitivity to detect changes after GH replacement was also assessed. RESULTS: The 16 items of the preliminary questionnaire were reduced to nine items on the basis of the correlation of items/factors from initial patient interviews. Psychometric analysis revealed the reliability of the nine-item scale. The Cronbach's alpha scores ranged from 0.81 to 0.89 and the test-retest correlations ranged from 0.76 to 0.88, all of which indicate reliability over time. Mean scores increased significantly during GH replacement therapy, with observed changes greater than those seen with the non-specific modules of the QLS(M), indicating the sensitivity of the scale. CONCLUSIONS: The QLS(M)-H questionnaire is concise, easy to complete, and can be effectively applied across different cultural backgrounds. Psychometric evaluation of the questionnaire reveals that it is a valid, reliable and sensitive tool useful for assessing impaired life satisfaction in adult patients with GHD and also for monitoring the efficacy of GH therapy.     

Effects of alpha-adrenergic stimulation and blockade on parathyroid hormone responses to beta-adrenergic agonists in cattle

Experiments were designed to investigate the effect of alpha-adrenergic stimulation on parathyroid hormone (PTH) responses to isoproterenol (ISO). In addition, PTH responses to adrenaline (A) and hypocalcaemia were studied with and without alpha-adrenergic blockade by phentolamine. Infusions of phenylephrine (a 'pure' alpha-adrenergic agonist) did not modify basal PTH levels and PTH responses to ISO infusions, whereas the heart rate response to ISO was reduced (P less than 0.05). The results demonstrate that alpha-adrenergic stimulation by phenylephrine does not reduce PTH responses to beta-adrenergic agonists. In response to phentolamine the heart rate increased and plasma levels of Ca and Ca++ decreased. Plasma PTH concentrations were slightly but not significantly raised and PTH responses to adrenaline (P less than 0.05), but not to hypocalcaemia, were enhanced. The potentiation of PTH responses to A in the presence of phentolamine may have ben due to inhibiton of alpha-adrenergic properties of A. It may have been also, in part, the consequence of the hypocalcaemia, which is known to augment PTH responses to A.     

Use of abciximab prior to primary angioplasty in STEMI results in early recanalization of the infarct-related artery and improved myocardial tissue reperfusion - results of the Austrian multi-centre randomized ReoPro-BRIDGING Study.

AIMS: The aim of the ReoPro-BRIDGING Austrian multi-centre study was to investigate the effects of abciximab (ReoPro) on early reperfusion in ST-elevation myocardial infarction prior to or during primary percutaneous coronary angioplasty (pPCI). METHODS AND RESULTS: Fifty-five patients with STEMI were randomized either to start abciximab (0.25 mg/kg bolus followed by 10 microg/min infusion) during the organization phase for pPCI (Group 1, n=28) or immediately before pPCI (Group 2, n=27). The time between first bolus of abciximab and first balloon inflation of pPCI was 83+/-18 vs 21+/-13 min in Group 1 vs 2. The pre-pPCI ST-segment resolution (55+/-21.4% vs 42.4+/-18.2%, p=0.005), TIMI flow grade 3 (29% vs 7%, p=0.042), corrected TIMI frame count (58.4+/-32.7 vs 78.9+/-28.4 frame, p=0.018) %diameter stenosis (76.3 /63.5-100/ vs 100 /73.5-100/; median /interquartile range/, p=0.023), were significantly higher in Group 1 vs Group 2. Quantitative myocardial dye intensity measurement revealed a significantly higher grade of myocardial tissue perfusion (1 /0-9.25/ vs 0 /0-3.0/ grey pixel unit, p=0.048) in Group 1 before pPCI. Rapid release of cardiac enzymes was observed in Group 1 as compared with Group 2: rate of rise of CK was 210+/-209 vs 97+/-95 U/l/h (p=0.015). QRS score indicated a smaller infarct size in Group 1 (4.8+/-3.8 vs 7.6+/-3.5, p=0.011) on day 7. CONCLUSION: The use of abciximab in the organization phase for pPCI results in signs of early recanalization of the infarct-related artery and a subsequent improved myocardial tissue reperfusion.     

Regionale Therapie von Lebertumoren

Malignant liver tumors are either originating from the liver, such as the primary liver tumors hepatocellular carcinoma and the cholangiocellular carcinoma, or metastases from extrahepatic malignancies. Apart from surgical procedures (resection, liver transplantation) percutaneous local-ablative (ethanol injection, radiofrequency thermal ablation as well as radiation therapy) and transarterial interventions are non-surgical therapeutic options. While these regional therapies have been shown in randomised controlled studies to be effective for hepatocellular carcinoma, their therapeutic efficacy in cholangiocellular carcinoma and liver metastases has not been shown. In the following we will summarize the regional therapeutic options in primary and secondary liver tumors.