Predictors of colonization with Staphylococcus species among patients scheduled for cardiac and orthopedic interventions at tertiary care hospitals in north-eastern Germany-a prevalence screening study.

As methicillin-resistant Staphylococcus aureus (MRSA) colonization and infection in humans are a global challenge. In Mecklenburg and Western Pomerania (Germany) 1,517 patients who underwent surgical interventions were systematically screened for MRSA and MSSA colonization on the day of hospital admission and discharge. Demographic data, risk factors and colonization status of the (i) nose, (ii) throat, (iii) groin, and (iv) thorax or site of surgical intervention were determined. Of the 1,433 patients who were included for further evaluation, 331 (23.1%) were colonized with MSSA, while only 17 (1.2%) were MRSA carriers on the day of hospital admission. A combination of nose, throat and groin swabs returned a detection rate of 98.3% for MSSA/MRSA. Trauma patients had lower prevalence of MRSA/MSSA (OR 0.524, 95% CI: 0.37-0.75; p < 0.001) than patients with intended orthopedic interventions. Males showed significantly higher nasal S. aureus carrier rates than females (odds ratio (OR) = 1.478; 95% CI: 1.14-1.92; p = 0.003). Nasal S. aureus colonization was less frequent among male smokers as compared to non-smokers (chi2 = 16.801; phi = 0.154; p < 0.001). Age, gender and smoking had a significant influence on S. aureus colonization. Combining at least three different swabbing sites should be considered for standard screening procedure to determine S. aureus colonization at patients scheduled for cardiac or orthopedic interventions at tertiary care hospitals.

Corrigendum to: 2014 ESC Guidelines on the diagnosis and treatment of aortic diseases.

Corrigendum to: 2014 ESC Guidelines on the diagnosis and treatment of aortic diseases [Eur Heart Journal (2014) 35, 2873­2926,doi:10.1093/eurheartj/ehu281]. In Table 3, the radiation for MRI is "0" and not "-". The corrected table is shown below.

Guideline-adherent therapy in patients with acute coronary syndromes. The EPICOR registry in Germany.

BACKGROUND: Representative data on the current management of patients with acute coronary syndromes (ACS) are of high interest. The EPICOR registry aimed to prospectively collect such real-life data with particular focus on antithrombotic drug utilization and outcomes. METHODS: As part of the international prospective EPICOR registry, 29 hospitals in Germany documented 296 patients with ST-elevation myocardial infarction (STEMI)-ACS and 333 with unstable angina or non-STEMI (NSTEMI)-ACS surviving the hospital phase. The statistical analysis was performed in a descriptive manner. The ClinicalTrials.gov identifier is NCT01171404. RESULTS: The mean age of patients was 62 ± 13 years, and 77.4 % were men. Treatment with antithrombotic agents was initiated in the prehospital phase in 50.7 % of STEMI and 33.3 % of NSTEMI patients. During the hospital stay (median 7.0 days), cardiac catheterization was performed in 97.6 %, percutaneous coronary intervention in 85.6 %, thrombolysis in 4.6 %, and coronary bypass surgery in 2.7 % patients. The use of acetylic salicylic acid (ASA) was reported in 95.6 % vs. 96.1 %, clopidogrel in 60.8 % vs. 73.0 %, prasugrel in 45.6 % vs. 22.5 %, any GP IIb/IIIa inhibitor in 52.4 % vs. 18.9 % [any dual combination of ASA+(clopidogrel/prasugrel)in 94.0 vs. 91.0 %], statins in 94.6 % vs. 92.2 %, beta blockers in 96.3 % vs. 94.6 %, and ACE-I/ARB in 91.6 % vs. 87.7 % of STEMI vs. NSTEMI patients, respectively. Combined use of the five drug classes recommended in the guidelines-ASA, P2Y12 antagonists, statin, beta blocker, and ACE-I/ARB-was reported in 81.1 % vs. 69.4 % of STEMI vs. NSTEMI patients, respectively. CONCLUSION: In Germany a high proportion of patients with ACS are treated according to current guidelines, receiving primary revascularization as well as antithrombotic drugs and other agents for prevention of secondary events; associated bleeding complications were less frequent as compared with published registries.

[Pregnancy-related cardiac problems]. / Kardiale Probleme in der Schwangerschaft.

All women of child-bearing age suffering from congenital cardiac valve malformations or acquired valvular disease, pulmonary hypertension or arterial hypertension and who are at risk for coronary heart disease should receive early counseling and optimal treatment before pregnancy. They should be treated by an interdisciplinary team composed of gynecologists, cardiologists, geneticists and, if necessary, cardiac surgeons. This interdisciplinary approach should be used for all pregnant women with cardiac disease in order to minimize maternal and fetal mortality. As physicians will only rarely be confronted with such critically ill patients, guidelines and access to worldwide information from databanks are particularly important (http://www.safetus.com und http://www.emryotox.de).

[Stent graft of the thoracic aorta]. / Stentversorgung der thorakalen Aorta.

Considering the demographic changes in our society and the proliferation of imaging-based improved diagnostics, both acute and chronic aortic diseases attract increasing attention and require dedicated care. Cardiac as well as vascular surgery used to represent the gold standards for therapeutic management of pathologies of the ascending aorta and the arch; however, the technological evolution of endoluminal strategies has had a serious impact on the treatment of the descending aorta, the aortic arch in combination with vascular debranching or bypass, and in selected cases even on managing pathologies of the ascending aorta. Although several case series and meta-analyses of published observations hint towards superiority of endografting in comparison to open surgical repair, the affected usually multimorbid patients with highly complex aortic disease should be subjected to an individual evaluation by a team of cardiologists, cardiac and vascular surgeons as well as imaging specialists; a dedicated individualized treatment concept in highly experienced centers of excellence is likely to provide the best results for such challenging patients.

Enhanced mobilization of the bone marrow-derived circulating progenitor cells by intracoronary freshly isolated bone marrow cells transplantation in patients with acute myocardial infarction.

Autologous bone marrow cell transplantation (BMCs-Tx) is a promising novel option for treatment of cardiovascular disease. We analysed in a randomized controlled study the influence of the intracoronary autologous freshly isolated BMCs-Tx on the mobilization of bone marrow-derived circulating progenitor cells (BM-CPCs) in patients with acute myocardial infarction (AMI). Sixty-two patients with AMI were randomized to either freshly isolated BMCs-Tx or to a control group without cell therapy. Peripheral blood (PB) concentrations of CD34/45(+) - and CD133/45(+)-circulating progenitor cells were measured by flow cytometry in 42 AMI patients with cell therapy as well as in 20 AMI patients without cell therapy as a control group on days 1, 3, 5, 7, 8 and 3, 6 as well as 12 months after AMI. Global ejection fraction (EF) and the size of infarct area were determined by left ventriculography. We observed in patients with freshly isolated BMCs-Tx at 3 and 12 months follow up a significant reduction of infarct size and increase of global EF as well as infarct wall movement velocity. The mobilization of CD34/45(+) and CD133/45(+) BM-CPCs significantly increased with a peak on day 7 as compared to baseline after AMI in both groups (CD34/45(+): P < 0.001, CD133/45(+): P < 0.001). Moreover, this significant mobilization of BM-CPCs existed 3, 6 and 12 months after cell therapy compared to day 1 after AMI. In control group, there were no significant differences of CD34/45(+) and CD133/45(+) BM-CPCs mobilization between day 1 and 3, 6 and 12 months after AMI. Intracoronary transplantation of autologous freshly isolated BMCs by use of point of care system in patients with AMI may enhance and prolong the mobilization of CD34/45(+) and CD133/45(+) BM-CPCs in PB and this might increase the regenerative potency after AMI.

Health economic evaluation of the use of drug-eluting stents : First results from the Drug-Eluting Stent Registry (DES.de).

OBJECTIVE: The purpose of the economic evaluation of the German Drug-Eluting Stent (DES) registry includes the investigation of the economic impact and cost-effectiveness of DES compared to bare-metal stents (BMS) and between paclitaxel-eluting (PES) and sirolimus-eluting stents (SES). Here, methodology and initial results are presented. METHODS: Patients were recruited in 2005 and 2006 in 87 centres across Germany. Selection of PES, SES, or BMS was made at the discretion of the cardiologists in charge. Clinical, economic, and quality of life (QoL) data were collected at baseline and up to 12 months. Group comparisons were conducted using Fisher's exact and t test. RESULTS: Overall, 3,930 patients were enrolled: 3,471 (75% male, 65 ± 11 years) received DES and 458 (74% male, 67 ± 11 years) BMS. Among the DES patients, 1,821 received PES (75% male, 65 ± 10 years) and 1,600 SES (76% male, 65 ± 11 years). There were baseline differences in clinical and procedural characteristics but not in QoL. During the hospital stay, major adverse cardiac and cerebrovascular events occurred in 1.6% of DES (PES 1.9%, SES 1.1%) and 2.2% of BMS patients (BMS vs. DES, PES, and SES p = 0.327, 0.706, and 0.098, respectively). Hospital treatment costs were 4,989 ± 1,284  and 3,609 ± 924 , respectively, in DES and BMS patients (p < 0.001) with no significant difference between PES and SES. CONCLUSION: The economic evaluation of the large DES registry demonstrates increased initial hospitalisation costs associated with DES compared to BMS. Further analysis of the economic impact and cost-effectiveness of DES will provide estimates on large "real world" patient populations for decision makers and aid in reimbursement decisions of DES within the German and other health care systems.

[Dynamic left ventricular outflow tract obstruction in pulmonary embolism]. / Dynamische Obstruktion des linksventrikulären Ausflusstrakts bei Lungenembolie.

Left ventricular hypertrophy, dehydration, sepsis, vasodilatation, excessive sympathetic stimulation, pericardial tamponade and surgical treatment of the atrioventricular valve are known causes of left ventricular outflow tract (LVOT) obstruction. We report the rare case of a patient who developed dynamic LVOT obstruction as a complication of acute pulmonary embolism.

TEVAR: the solution to all aortic problems?

Chronic as well as acute diseases of the thoracic aorta are attracting increasing attention, both in the light of an ageing Western and Oriental population and with the proliferation of modern diagnostic imaging modalities. While classic surgical strategies still dominate the treatment of pathology of the ascending aorta and the proximal arch region, new endovascular concepts are emerging and are likely to evolve as primary treatment strategies for descending and abdominal aortic pathology. Additionally, aortic arch pathologies are becoming the target of hybrid approaches combining surgical head-vessel debranching and interventional stent-graft implantation in an attempt to improve outcome by avoiding the high risk of open arch repair or complete replacement. Nonetheless, due to the complexity of the underlying vascular disease, each patient should be discussed in a team consisting of cardiologists, cardiac surgeons, and an imaging specialist in order to design an individualized therapeutic strategy carried out best in a center with experience in both endovascular and surgical procedures.

Second- and third-generation drug-eluting coronary stents: progress and safety.

Drug-eluting stents (DES) have revolutionized the treatment of coronary artery disease by reducing the rate of in-stent restenosis from 20-40% with bare-metal stent (BMS) to 6-8% with DES. However, with widespread use of DES, safety concerns have risen due to the observation of late stent thrombosis. With this in mind and better understanding of mechanism and pathophysiology of stent thrombosis, the technological platform, especially innovative anti-restenotic agents, polymeric coatings, and stent platforms, improved with newer DES. Two second-generation DES, the Endeavor zotarolimus-eluting stent (ZES) and the Xience-V everolimus-eluting stent (EES), have provided promising results in both randomized controlled trials (SPIRIT and ENDEAVOR) and registries (E-Five, COMPARE) compared with bare-metal stents (BMS) and first-generation DES. Newer third-generation stent technology, especially biodegradable polymers, polymer-free stents, and biodegradable stents on the basis of poly-L-lactide (PLLA) or magnesium, has been evaluated in preclinical and initial clinical trials. However, despite encouraging initial results, long-term data of large-scale randomized trials as well as registries comparing them to currently approved first- and second-generation DES are still lacking.

[Therapy strategies for acute coronary syndrome and after coronary interventions. Antiplatelet agents and anticoagulants]. / Therapiestrategien beim akuten Koronarsyndrom und nach koronaren Interventionen. Antiaggregation und Antikoagulation.

There is ongoing development of new therapeutic regimens in the use of antithrombotic agents and anticoagulants focussing on acute coronary syndrome (ACS) with an increasing impact on current guidelines over the last years. This was especially accompanied by an increase in innovative percutaneous coronary interventional (PCI) methods in patients with ACS, non-ST-segment elevation myocardial infarction (NSTEMI) or ST-segment elevation myocardial infarction (STEMI) with a need for therapeutics with more sufficient and effective antiplatelet action. On the other hand, newer direct and indirect thrombin inhibitors with primary use in prevention and therapy of thromboembolic events have been shown to have beneficial and even superior effects in ACS with or without PCI. The current review aims to report on the evidence-based use of approved antithrombotic agents and anticoagulants in ACS with special focus on PCI according to the actualized European guidelines.

Acute aortic dissection: perspectives from the International Registry of Acute Aortic Dissection (IRAD).

Acute aortic dissection is a rare but deadly disease first described over 200 years ago by the physician to the late King George II on necropsy. Over the ensuing 2 centuries, the understanding of the pathophysiology, presentation, diagnosis, treatment and follow-up has matured. In an effort to understand the contemporary treatment of this disease, the International Registry of Acute Aortic Dissection (IRAD) has enrolled over 2000 patients over the past 12 years. In this article we summarize the key lessons learned from this multi-national registry of patients presenting with acute aortic dissection.

Indication, timing and results of endovascular treatment of type B dissection.

Aortic dissection is an uncommon but a highly lethal condition. Dissection of the ascending aorta is associated with a mortality rate of 1-2% per hour within the first 24h and should be managed by an open surgery. An uncomplicated, acute, type B dissection, which should be treated medically, is less frequently lethal, with survival rates of 84% within 1 year. Unfortunately, long-term outcome of medical therapy alone is suboptimal, with a reported 30-50% mortality rate at 5 years and a delayed expansion of the false lumen in 20-50% of patients at 4 years. In this setting, endovascular treatment should be considered when the aortic diameter exceeds 55-60mm, in case of uncontrolled pain, blood pressure and rapid growth of the dissecting aneurysm (>1cm per year). About 30-42% of acute, type B aortic dissections are complicated, as evidenced by haemodynamic instability or peripheral vascular ischaemia with a mortality rate of 50-85% if not treated properly. In this scenario, stent-graft repair is an attractive alternative to surgical repair for correcting ischaemic complications. The long-term therapy of patients with aortic dissection includes aggressive medical therapy, follow-up visits and serial imaging.

[Position paper nuclear cardiology: update 2008]. / Positionsbericht Nuklearkardiologie Update 2008: Aktueller Stand der szintigraphischen Methodik.

Nuclear cardiology is well established in clinical diagnostic algorithms for many years. This is an update 2008 of the first common position paper of the German Association of Nuclear Medicine and the German Association of Cardiology, Heart and Circulation Research published in 2001 aiming at an overview of state-of-the-art scintigraphic methods.

[Thoracic aorta aneurysms]. / Das thorakale Aortenaneurysma.

Thoracic aorta aneurysms are life-threatening diseases which can lead to rupture or dissection due to structural alterations. The exact etiology is still unclear but extended life-expectancy with arterial hypertension, positive family history for aneurysmic diseases, atherosclerosis, smoking and chronic obstructive lung disease are all considered to be risk factors. Nowadays, a diagnosis can often be made in the symptom-free stage. The risk of rupture varies between 46 and 74% for a diameter clearly greater than 5.5 cm and with a 2-year mortality rate of 70%. The 5-year survival rate with conservative treatment can be as low as 13-34% compared to 70-79% after optimal surgical treatment. Medical, operative and percutaneous interventional therapeutic strategies are basically available.

Interventional strategies for treatment of aortic dissection.

Endovascular treatment of chronic aneurysmatic diseases of the thoracic aorta has demonstrated encouraging peri-interventional mortality and morbidity and is accepted as a preferred strategy. The emerging of endovascular strategies for acute thoracic aortic dissection is an even more exciting new territory for nonsurgical interventions considering the sobering results of open surgery. Although it is apparent that patients at high risk for open surgery will benefit from endovascular strategies, the exact role of stent-graft placement remains to be defined at present as the community awaits solid long-term data and as devices and techniques continue to improve. While some indications and scenarios such as acute type B dissection with associated malperfusion syndrome or imminent aortic rupture have shown to benefit from stent-graft treatment, others are less settled. The current paper discusses both the established and emerging indications, as well as all technical aspects of this fascinating new therapeutic alternative. Moreover, the currently available data from small studies and registries are commented and analysed. Based on the available information the cardiovascular community is in the early phase of integrating a new rapidly evolving interventional concept into the care of patients with type B aortic dissection that so far lacked a reasonable therapeutic option other than blood pressure lowering medication. With the use and interpretation of current information the reader will understand the potential of interventional stent-graft induced thoracic aortic repair in type B aortic dissection.

Percutaneous transcatheter closure of patent foramen ovale.

In presence of a patent foramen ovale (PFO) with cryptogenic cerebral embolism, traditional therapy consists of oral anticoagulation or antiplatelet therapy. Surgery was considered only in case of recurrence. Transcatheter closure of PFO is currently performed. The availability of new user friendly devices and the increasing knowledge of pathophysiology, epidemiology, and follow-up of these patients has broadened the indications and marked reduced morbidity related to interventional PFO closure. This review presents the current knowledge and our own data concerning transcatheter closure of PFO.

[Left ventricular electromechanical latency period is an additional indicator to upgrade from right to biventricular DDD pacing]. / Die linksventrikuläre elektromechanische Latenzzeit ist ein zusätzlicher Indikator für ein Upgrading zur biventrikulären Stimulation.

In DDD pacing, the left-ventricular electromechanical latency period defines the duration between premature ventricular stimulation and the prematurely ending left-atrial contribution to left-ventricular filling. It has to be considered in diastolic AV delay optimization. Individual duration of this parameter seemed to reflect the ventricular function. Therefore, we compared the left-ventricular electromechanical latency period due to right ventricular stimulus with the documented ejection fraction of two groups, 33 congestive heart failure patients carrying biventricular systems and 13 right ventricular paced bradycardia patients. A mean latency period of 168+/-26 ms was found in the heart failure patients (ejection fraction: 25+/-5%) which was significantly longer (p=0.0039) compared to the bradycardia patients (ejection fraction: 51+/-12%) with a mean latency of 119+/-13 ms. Thus, an increasing latency period during right ventricular DDD pacing therapy indicates decreasing ejection fraction. A cut-off interval of 135 ms allowed the discrimination of 93% of our patients as having an individual ejection fraction of either up to 35% or above. Thus, the left ventricular electromechanical latency period can be used as an additional parameter indicating the necessity to upgrade from right to biventricular DDD pacing.