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Eight months after ICD implantation with an electrically active case the patient presented with ICD system sensing failure. Upon reoperation, we found an insulation defect of the proximal sensing lead and the generator case showed arc marks suggesting a short circuit between the sensing lead and case. The generator was replaced, the original sensing lead insulated, and a new sensing lead inserted. Bench testing of the explanted generator showed a damaged internal circuitry. Proximal lead insulation defects combined with electrically active cases may result in damage of the case. The potential damage of internal circuitry warrants generator replacement.

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Biopsies taken from the myocardium of 5 patients with Morbus Fallot and from 1 patient with ventricle septum defect were investigated with a combination of morphometric, biochemical and histophotometric techniques in order to study the cardioprotective effect of cold Kirsch's solution. At the final phase of cardioplegia the cardiomyocytes reveal the following alterations: The volume densities of mitochondria, of their degenerated areas and that of cytoplasmic vacuoles show a significant increase whereas that of myofilaments decreases. Cristae and matrix mitochondriales, however, show only moderate alterations without statistical significance. Biochemically the total ATP-concentration and creatine phosphate (CP)-concentration were more or less diminished, in most of the cases the activity of the myosin ATPase was increased, that of the creatine phosphate kinase (CPK) diminished. Compared with the biochemical estimations of the ATPase activity, its histophotometric estimations yielded corresponding results in 2 of 4 cases. In general our findings confirm the cardioprotective effect of Kirsch's solution. The combination of methods used gives more reliable results than one technique alone.

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It is reported on an at present 32-year-old male patient, in whom at the age of 30 years an excessive mediastinal lipoma was excised. For 12 years the cardiological diagnosis was not clear and could completely be clarified only with the help of the computed tomography of the heart.

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In individual cases the computed tomography renders possible the ascertainment of the coarctation of the aorta. Despite modified examination method (secondary section technique, continuous application of contrast medium) the reliability is insignificant. Therefore, the method cannot be recommended for the primary diagnostics of the coarctation of the aorta. The computed tomography is extraordinarily suited for the detection of aneurysms of anastomoses after operation of coarctations of the aorta. In 50 computed-tomographic examinations of 48 patients 11 times an aneurysm could be ascertained. This high proportion of late postoperative complications is above all to be traced back to the surgical suture material used in the sixties. There were only two falsely positive findings, in which cases also here relevant pathological changes were present. The computed tomography can more exactly than the aortography adopt a definite attitude to the question of the dissection of prostheses or to pseudoaneurysms.

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For the reduction of the functional obstruction of the left-ventricular outflow in hypertrophic obstructive cardiomyopathy since 1978 in selected cases conventional VAT cardiac pacemakers with shortened AV retardation time have been implanted. On the basis of 4 casuistics the insufficient adaptation of these systems to unexpectedly appearing disturbances of the cardiac rhythm is demonstrated. Thus already extreme sinus bradycardias lead to parasystole by the unchangeably given asynchronous basic frequency of the pacemakers. Furthermore, all tachycardiac supraventricular arrhythmias and retrograde atrium activations evoke haemodynamically unfavourable and partly even threatening ventricular tachycardies caused by the pacemakers. Control ECG made under these conditions are frequently inexactly interpreted by the continuing intact natural AV conduction and technical defects of the pacemakers are assumed. The individual diagnostic steps necessary for the assessment of the function of the devices and the inevitable immediate therapeutic measures are, therefore, explained. Finally the demands to more modern differentiated physiological pacemaker systems are derived which should be used in patients with hypertrophic obstructive cardiomyopathy.

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For the hypertrophic obstructive cardiomyopathy with left-ventricular pressure gradient in rest a causal therapy is nowadays not yet known. Therefore, it should be tested, in what respect from former observations over reductions of the pressure gradient by an untimely foreign excitation of the ventricles from the apex of the right ventricle a therapy principle can be derived. For this purpose out of a group of 84 patients by left-right heart catheterization, coronarography, computer cardio-tomography and scintigraphy of the myocardium 23 test persons with typical hypertrophic obstructive cardiomyopathy and a left-ventricular gradient in rest greater than or equal to 30 mm Hg were selected for the transitory electrostimulation. After placing of one electrode in the right atrium and another one in the right ventricle one after another a VOO-, VAT- and DOO-pacing were used. For the two last mentioned forms of stimulation as electronic atrio-ventricular retardation times 100, 40, 20, 10 and 5 ms were selected. With all three kinds of stimulation in 5 of the patients (group A) reductions of gradients greater than or equal to 51% and in 12 cases of hypertrophic obstructive cardiomyopathy (group B) diminishments between 30 and 50% could be obtained. Only in 6 patients (group C) reductions of less than or equal to 29% were registered. The optimum of prematurity necessary for obtaining maximum pressure reductions is individually different, but is almost in every case between 5 and 20 ms. Further seven parameters measured during the stimulation phases showed that these reductions are not caused by a decrease of the stroke volume, but by an enlargement of the effective opening of the outlet. Apparently, in a part of the patients with hypertrophic obstructive cardiomyopathy by the foreign excitation from the apex of the ventricle a temporary and spatial course of excitation can be induced, by means of which the degree of functional stenosing is decreased. Since for several patients the removal of the disturbance of the systolic function is to be regarded as therapeutically reasonable partial success, the transitory diagnostic pacing is recommended for all patients with typical hypertrophic obstructive cardiomyopathy and a gradient in rest greater than or equal to 30 mm Hg. The indications and technical prerequisites for a permanent electrostimulation with suitable systems are represented.

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The continuous traction of firmly grown-in collar electrodes from the right ventricle is a simple technique poor in complications with a high success rate, which can be recommended taking into consideration the indications in the failure of the immediate manual extraction and which can be performed in every centre for cardiac pacemakers. Apart from the consideration of adequate informations in literature this evidence above all depends on the evaluation of data of 29 cases from 10 centres for cardiac pacemakers.

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The severity of the functional obstruction of the outflow tract of an idiopathic hypertrophic subaortic stenosis is essentially determined by the contractility of the myocardium, the left-ventricular volume and the peripheral vascular resistance. Though in the acute experiment a clear reduction of the degree of stenosis by beta-receptor-blockers may be proved the long-term results of such a therapy are unsatisfactory, particularly in patients with obstruction in rest. The use of calcium antagonists seems to promise more favourable results. The progression of the disease is, however, scarcely influencible by pharmacological measures alone. Nitrobodies are not suitable for treatment and glycosides should be used only within a manifest insufficiency of the left heart. An effective reduction or removal of the ventriculo-ventricular pressure gradient as well as a decrease of the left-ventricular telediastolic pressure may be achieved on operative way. There is an indication to this, when the complaints increase despite medicamentous therapy. At present the transaortic myotomy under use of the heart-lung-machine is regarded as most favourable method. A simultaneous or only substitute of the mitral valve should be restricted only to those cases which, apart from the functional, still show an organically conditioned insufficiency of the mitral valve. The early and late results of the palliative surgical interventions are very favourable in experienced centres. However, secure long-term prognoses may not yet be derived from this.

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Idiopathic hypertrophic subaortic stenosis is a noncompensatory hypertrophy of the myocardium which above all concerns the ventricular septum in its upper part near to the basis. The etiology is not yet sufficiently clarified, though a genetic component is regarded as ascertained on account of the proved familial accumulations. Haemodynamically the morphologic changes effect a systolic obstruction of the left-ventricular outflow, an insufficiency of the mitral valve and an aggravated diastolic filling of the left ventricle. Further pathophysiological symptoms of the functional subaortic stenosis are an extremely rapid ejection of blood in the early, not obstructive phase of the systole as well as a pathological forward movement of the mitral valve beginning in the midst of the systole. The disease has a bad prognosis. To be sure, the natural course is usually characterized only by a slow progression of the complaints, however, particularly in adolescents frequently sudden cases of death appear by disturbances of the cardiac rhythm or a relative coronary insufficiency. The disease which is already frequently to be diagnosed according to anamnesis, auscultation, ECG and form of the pulse curve may be ascertained using the ultrasound echocardiography as well as heart catheterization including angiography. Apart from a direct measurement of the ventriculo-ventricular pressure gradient during wuch examinations the size of the functional obstruction may further be characterized by certain pharmaca or physical methods which influence the volume of the ventricle or the afterload.

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A new simple variant of the transvernous implantation of atrial electrodes for the pacemaker therapy is reported. It consist in the fact that via the V. saphena magna under fluorography a hook electrode is shifted into the right auricular appendix by means of a slightly bent conducting wire and is anchored by leading out the hooks.

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It is reported on a successful removal of torn off or knotted parts of a heart catheter, which were extracted without difficulties from the superior vena cava and from the right atrium via the vena saphena magna by means of the catcher of ureteroliths after Dormia. One case in question was a 27-year-old male patient with pentalogy of Fallot, in whom was the danger of embolisation into the greater circulatory system on account of the torn off catheter conducting wire. In the other 57-year-old patient with acute myocardial infarction after knotting of a subclavian catheter a mechanical irritation of the endocardium with repeated appearance of ventricular fibrillation developed. Before deciding on a thoracotomy for the removal of parts of a catheter from the central vessels and the heart it should be tried before a transvasal extraction with the help of special catheters.

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The authors report on a new segment plethysmograph by help of which quick and completely automatic measuring of top flow is possible in high quality. The device is present as model for laboratory use and has proven good in practice. It was used, e.g., for the control of arterial blood supply in legs of patients who years ago were perfused via an external iliac artery during open heart surgery. Corresponding with the clinical findings, also by plethysmography no statistically significant differences of blood flow values were found in the legs with perfused or non-injured arteries.

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