Safety and efficacy of transseptal puncture guided by real-time fusion of echocardiography and fluoroscopy.

AIMS: Visual guidance through echocardiography and fluoroscopy is crucial for a successful transseptal puncture (TSP) in a prespecified region of the fossa ovalis. The novel EchoNavigator system Release II (EchoNav II, Philips Healthcare, Andover, Massachusetts, USA) enables the real-time fusion of fluoroscopic and echocardiographic images. We evaluated this new imaging method in respect to safety and efficacy of TSP during MitraClip implantation and left atrial appendage closure. METHODS: Forty-four patients before (-EchoNav) and 44 patients after (+EchoNav) the introduction of real-time fusion were included in our retrospective, single-centre study. The primary endpoint was the occurrence of adverse events due to TSP. Secondary endpoints were successful puncture at the prespecified region and time until TSP (min). RESULTS: In both groups TSP was performed successfully in the prespecified region and no adverse events occurred during or due to the accomplishment of TSP. Time until TSP was significantly reduced in the +EchoNav group in comparison with the EchoNav group (18.48 ± 5.62 min vs. 23.20 ± 9.61 min, p = 0.006). CONCLUSIONS: Real-time fusion of echocardiography and fluoroscopy proved to be as safe and successful as standard best practice for TSP. Moreover, efficacy was improved through significant reduction of time until TSP.

3D printed dielectric rectangular waveguides, splitters and couplers for 120 GHz.

We use a 3D printer to fabricate rectangular dielectric single mode waveguides for 120 GHz. The rectangular waveguides consisting of polystyrene showed an attenuation of 6.3 dB/m, which is low enough for short devices. We also characterize 3D printed Y-splitters and a 1x3-splitter based on multimode interference. Further, we construct and measure a variable planar waveguide coupler which can be used as a 3-dB coupler, a cross-coupler and no coupler at all.

[Structure and function of the mitral valve. Eligibility criteria for surgical and interventional approaches]. / Mitralklappenstruktur und -function. Wie erfolgt die Auswahl für ein interventionelles oder chirurgisches Vorgehen?

Mitral valve disease, especially severe mitral valve insufficiency, is an increasing issue in our population. Older patients with multiple comorbidities in particular are often denied surgery due to an increased perioperative risk. Because conservative medical treatment of mitral valve disease is often unsatisfactory, interventional techniques to treat mitral valve disease have emerged in recent years as serious alternatives to surgical treatment. Innovative developments in cardiovascular imaging have opened up new ways of looking at the mitral valve for improved diagnostic and therapeutic management of patients with mitral valve disease. These advantages of imaging are important for correct patient selection with either surgical or interventional strategies. This review describes the diagnostic capabilities of echocardiographic techniques for a precise diagnosis of the mitral valve structure and function for planning and performing interventional or surgical procedures.

Cardiac troponin I for predicting right ventricular dysfunction and intermediate risk in patients with normotensive pulmonary embolism.

BACKGROUND: Right ventricular dysfunction (RVD) and cardiac troponin I (cTnI) are important tools for risk stratification in pulmonary embolism (PE). We investigate the association of RVD and cTnI in normotensive PE patients and calculate a cTnI cut-off level for predicting RVD and submassive PE. METHODS: Clinical, laboratory, radiological and echocardiagraphic data were analysed. Patients were categorised into groups with or without RVD and compared focussing on cTnI. Effectiveness of cTnI for predicting RVD and submassive PE was tested. RESULTS: One hundred twenty-nine normotensive PE patients, 71 with and 58 without RVD, were included. Patients with RVD were older (75.0 years (61.3/81.0) vs. 66.0 years (57.7/75.1), P = 0.019). cTnI (0.06 ng/ml (0.02/0.23) vs. 0.01 ng/ml (0.00/0.03), P < 0.0001) and D-dimer values (2.00 mg/l (1.08/4.05) vs. 1.23 mg/l (0.76/2.26), P = 0.016) were higher in PE with RVD. cTnI was associated with RVD (OR 3.95; 95 % CI 1.95-8.02, p = 0.00014). AUC for cTnI diagnosing RVD was 0.79, and for submassive PE0.87. Cut-off values for cTnI predicting RVD and submassive PE were 0.01 ng/ml, with a negative predictive value of 73 %. cTnI was positively correlated with age, D-dimer and creatinine. CONCLUSIONS: In normotensive PE patients, cTnI is helpful for risk stratification and excluding RVD. cTnI elevation is correlated with increasing age and reduced kidney function.

[Echocardiography during transcatheter interventions. New developments]. / Echokardiographie während Katheterinterventionen. Neue Entwicklungen.

Interventional techniques for percutaneous treatment of structural heart disease have become an important option for patients ineligible for conventional operating procedures in cardiovascular medicine. Echocardiography plays an essential role not only for patient selection but also for guiding transcatheter interventions in order to safely accomplish the procedure. Echocardiographic 2D and 3D techniques next to conventional fluoroscopy have therefore become an integral part for monitoring interventional procedures in the catheter laboratory. This review aims to describe new developments for the application of echocardiography during transcatheter interventions in the context of the current literature and current recommendations.

Vagal heart rate control in patients with atrial fibrillation: impact of tonic activation of peripheral chemosensory function in heart failure.

Heart failure (HF) and atrial fibrillation (AF), emerging as two epidemics of the twenty-first century, are commonly associated with each other. Both have been mechanistically linked to changes in cardiac vagal control. The importance of peripheral chemosensors, located in the carotid body, has not been elucidated so far. We therefore investigated whether tonic activation of excitatory chemoreceptor afferents contributes to the altered vagal control in HF patients with a history of AF. In 18 patients (72 ±9 year, 7 male) with sinus rhythm and a history of AF (n=9, without any evidence of structural heart disease, AF group; n=9 with structural heart disease and clinical presentation of HF, AFHF group) we investigated the impact of chemosensory deactivation (by breathing 100% oxygen) on heart rate, blood pressure, cardiac output, total peripheral resistance, oxygen saturation and breathing rate. Ten healthy individuals served as a control group. In addition, we performed a deep breathing test demonstrating an impaired heart rate variation in patients with and without HF as compared with controls (expiration/inspiration difference: 23.9±6.9 vs. 6.9±6.1 bpm, and 23.9±6.9 vs. 7.8±4.8 bpm; p<0.05). In both control and AF groups, heart rate decreased during chemoreceptor deactivation (control: -4.8±3.4%; AF: -5.1±3.0%; p<0.05), whereas heart rate did not change in AFHF patients. This resulted in impaired cardiac chemoreflex sensitivity in AFHF patients (1.9±1.6 vs. 0.5±1.2 ms/mmHg; p<0.05). In conclusion, our data suggest that tonic activation of excitatory chemoreceptor afferents contributes to a low vagal tone in heart failure patients with a history of AF (Clinical Trials NCT01262508).

Modulation of peripheral chemoreflex by neurohumoral adaptations after kidney transplantation.

BACKGROUND: Peripheral chemoreceptors residing predominantly in the carotid body monitor changes in arterial blood oxygen and are mechanistically linked to the cardiorespiratory control by the autonomic nervous system. Enhanced sympathetic activation is common in end-stage renal disease and kidney transplantation has been shown to improve cardiorespiratory reflex measures of autonomic function. OBJECTIVE: The aim of the present study was to test whether improvement in renal function following kidney transplantation is related to an improvement in chemosensory function. METHODS AND RESULTS: We compared hyperoxic chemoreflex sensitivity (CHRS) in patients after renal transplantation (RTX) to that in patients on maintenance hemodialysis (HD), and that of age- and gender-matched healthy controls. In addition, we investigated the impact of common confounding factors including pharmacological neurohumoral modulation and diabetes mellitus. The difference in the R-R intervals divided by the difference in the oxygen pressures before and after deactivation of the chemoreceptors by 5-min inhalation of 7 L oxygen was calculated as the hyperoxic CHRS. Autonomic activity was characterized by 24-h time-domain heart rate variability (HRV) parameters. CHRS was improved in RTX patients as compared to HD patients being related to HRV. CHRS was related to the concomitant presence of diabetes and medication with cyclosporine. CONCLUSION: Our findings indicate that chemosensory activity following kidney transplantation is related to cardiac autonomic control, but functional testing might only be useful to characterize the time course and extent of sympathetic activation in selected patients due to existing co-morbidities and immunosuppressive medication in this population.

Percutaneous interventions below the knee in patients with critical limb ischemia using drug eluting stents.

AIM: Midterm technical and clinical evaluation of stent angioplasty with drug-eluting stents in infrapopliteal lesions in patients with critical limb ischemia (CLI). METHODS: Percutaneous stent angioplasty was performed in 128 limbs in 114 patients presenting with 320 vascular lesions. Lesions with up to 6 cm in length and at least one patent vessel below the obstruction were treated; 341 drug-eluting Cypher(R) stents (diameter of 2.5-3.5 mm; length of 18-33 mm) were implanted. Follow-up examinations were performed up to 18 months postinterventionally using clinical examination, ankle-brachial index (ABI) calculation, and color coded Duplex sonography. Patency rates were calculated on the basis of the Kaplan-Meier life-table analysis. RESULTS: Technical success was achieved in 99.06%. Minor complications (hematoma, distal emboli, and vessel dissection) were documented in 8.77% of the patients. The 6, 12, and 18 months primary patency rate as controlled by Duplex sonography was 89.8, 84.2 and 83.3%, respectively; 77.6% of the lesions healed postinterventionally. The cumulative limb salvage rate was 95.6%. CONCLUSION: Drug-eluting stent (DES) angioplasty in infrapopliteal arteries is a safe and effective technique for the treatment of patients with CLI. The use of a DES results in favorable technical and clinical outcome in the midterm follow-up.

Sympathetic hyperactivity influences chemosensor function in patients with end-stage renal disease.

BACKGROUND: Autonomic neuropathy is common in patients suffering from end-stage renal disease (ESRD). This may in part explain the high cardiovascular mortality in these patients. Chemosensory function is involved in autonomic cardiovascular control and is mechanistically linked to the sympathetic tone. OBJECTIVE: The aim of the present study was to assess whether sympathetic hyperactivity contributes to an altered chemosensory function in ESRD. MATERIAL AND METHODS: In a randomized, double-masked, placebo controlled crossover design we studied the impact of chemosensory deactivation on heart rate, blood pressure and oxygen saturation in 10 ESRD patients and 10 age and gender matched controls. The difference in the R-R intervals divided by the difference in the oxygen pressures before and after deactivation of the chemoreceptors by 5-min inhalation of 7 L oxygen was calculated as the hyperoxic chemoreflex sensitivity (CHRS). Placebo consisted of breathing room air. Baseline sympathetic activity was characterized by plasma catecholamine levels and 24-h time-domain heart rate variability (HRV) parameters. RESULTS: Plasma norepinephrine levels were increased (1.6 +/- 0.4 vs. 5.8 +/- 0.6; P<0.05) while the SDNN (standard deviation of all normal R-R intervals: 126.4 +/- 19 vs. 100.2 +/- 12 ms), the RMSSD (square root of the mean of the squared differences between adjacent normal R-R intervals: 27.1 +/- 8 vs. 15.7 +/- 2 ms), and the 24-h triangular index (33.6 +/- 4 vs. 25.7 +/- 3; each P<0.05) were decreased in ESRD patients as compared to controls. CHRS was impaired in ESRD patients (2.9 +/- 0.9 ms/mmHg, P<0.05) as compared to controls (7.9 +/- 1.4 ms/mmHg). On multiple regression analysis 24 h-Triangular index, RMSSD, and plasma norepinephrine levels were independent predictors of an impaired hyperoxic CHRS. CONCLUSION: Sympathetic hyperactivity influences chemosensory function in ESRD resulting in an impaired hyperoxic CHRS.

Airborne asbestos concentrations associated with heavy equipment brake removal.

Asbestos-containing brake linings were used in heavy-duty construction equipment such as tractors, backhoes, and bulldozers prior to the 1980s. While several published studies have evaluated exposures to mechanics during brake repair work, most have focused on automobiles and light trucks, not on heavy agricultural or construction vehicles. The purpose of this study is to characterize the airborne concentration of asbestos to workers and bystanders from brake wear debris during brake removal from 12 loader/backhoes and tractors manufactured between 1960 and 1980. Asbestos content in brake lining (average 20% chrysotile by polarized light microscopy) and brake wear debris [average 0.49% chrysotile by transmission electron microscopy (TEM)] was also quantified. Breathing zone samples on the lapel of mechanics (n = 44) and area samples at bystander (n = 34), remote (n = 22), and ambient (n = 12) locations were collected during 12 brake changes and analyzed using phase contrast microscopy (PCM) [National Institute for Occupational Safety and Health (NIOSH) 7400] and TEM (NIOSH 7402). In addition, the fiber distribution by size and morphology was evaluated according to the International Organization for Standardization method for asbestos. Applying the ratio of asbestos fibers:total fibers (including non-asbestos) as determined by TEM to the PCM results, the average airborne chrysotile concentrations (PCM equivalent) were 0.024 f/cc for the mechanic and 0.009 f/cc for persons standing 1.2-3.1 m from the activity during the period of exposure ( approximately 0.5 to 1 h). Considering the time involved in the activity, and assuming three brake jobs per shift, these results would convert to an average 8-h time-weighted average of 0.009 f/cc for a mechanic and 0.006 f/cc for a bystander. The results indicate that (i) the airborne concentrations for worker and bystander samples were significantly less than the current occupational exposure limit of 0.1 f/cc; (ii) approximately 2% of respirable fibers were >20 microm in length; and (iii) approximately 95% of chrysotile in the brake linings degraded in the friction process. The industrial hygiene data presented here should be useful for conducting retrospective and current exposure assessments of individuals, as well as hazard assessments of work activities that involve repairing and replacing asbestos-containing brakes in heavy construction equipment.

Retrospective exposure assessment of airborne asbestos related to skilled craftsmen at a petroleum refinery in Beaumont, Texas (1940-2006).

Despite efforts over the past 50 or more years to estimate airborne dust or fiber concentrations for specific job tasks within different industries, there have been no known attempts to reconstruct historical asbestos exposures for the many types of trades employed in various nonmanufacturing settings. In this paper, 8-h time-weighted average (TWA) asbestos exposures were estimated for 12 different crafts from the 1940s to the present day at a large petroleum refinery in Beaumont, TX. The crafts evaluated were insulators, pipefitters, boilermakers, masons, welders, sheet-metal workers, millwrights, electricians, carpenters, painters, laborers, and maintenance workers. This analysis quantitatively accounts for (1) the historical use of asbestos-containing materials at the refinery, (2) the typical workday of the different crafts and specific opportunities for exposure to asbestos, (3) industrial hygiene asbestos air monitoring data collected at this refinery and similar facilities since the early 1970s, (4) published and unpublished data sets on task-specific dust or fiber concentrations encountered in various industrial settings since the late 1930s, and (5) the evolution of respirator use and other workplace practices that occurred as the hazards of asbestos became better understood over time. Due to limited air monitoring data for most crafts, 8-h TWA fiber concentrations were calculated only for insulators, while all other crafts were estimated to have experienced 8-h TWA fiber concentrations at some fraction of that experienced by insulators. A probabilistic (Monte Carlo) model was used to account for potential variability in the various data sets and the uncertainty in our knowledge of selected input parameters used to estimate exposure. Significant reliance was also placed on our collective professional experiences working in the fields of industrial hygiene, exposure assessment, and process engineering over the last 40 yr. Insulators at this refinery were estimated to have experienced 50th (and 95th) percentile 8-h TWA asbestos exposures (which incorporated 8-h TWA fiber concentrations, respirator use and effectiveness, and time spent working with asbestos-containing materials) of 9 (16) fibers/cc (cubic centimeter) from 1940 to 1950, 8 (13) fibers/cc from 1951 to 1965, 2 (5) fibers/cc from 1966 to 1971, 0.3 (0.5) fibers/cc from 1972 to 1975, and 0.005 (0.02) fibers/cc from 1976 to 1985 (estimated exposures were <0.001 fibers/cc after 1985). Estimated 8-h TWA exposures for all other crafts were at least 50- to 100-fold less than that of insulators, with the exception of laborers, whose estimated 8-h TWA exposures were approximately one-fifth to one-tenth of those of insulators. In spite of the data gaps, the available evidence indicates that our estimates of 8-h TWA asbestos exposures reasonably characterize the typical range of values for these categories of workers over time.

[Transarterial chemoperfusion of the pelvis--results in symptomatic locally recurrent tumors and lymph node metastases]. / Transarterielle Chemoperfusion des Beckens--Ergebnisse bei symptomatischen Rezidivtumoren und Lymphknotenmetastasen.

PURPOSE: To evaluate local transarterial chemoperfusion (TACP) of therapy-resistant, locally recurrent malignant tumors and lymph node metastases in the pelvis with respect to clinical response, tumor response and survival. MATERIALS AND METHODS: Between 2003 and 2005, 24 outpatients (median age 56.5 years, range 33-82) were treated with 128 TACPs (min. 3; mean 5 sess/patient) in 4-week intervals. Depending on the tumor location and vascularization, a fluoroscopy catheter was placed either in the abdominal aorta or internal pelvic artery. A combination of mitomycin C (6 mg/m (2)) and gemcitabine (1500 mg/m (2)) was administered over 60 minutes. The tumor size was measured using CT or MRI. The radiological response was classified according to RECIST (Response Evaluation Criteria In Solid Tumors) as "complete response" (CR), "partial response" (PR), "stable disease" (SD) and "progressive disease" (PD). The clinical response was classified as "response (clinical)" if the symptoms improved distinctly, "stable disease (clinical)" if complaints were stabilized, and "progression (clinical)" if symptoms deteriorated or new symptoms appeared. After the third TACP, patients were evaluated for clinical and radiological response. In the case of clinical and radiological progression, therapy was stopped and the patient was referred to the hospital's tumor board. In the case of radiological response and clinical progression or clinical response and radiological progression, therapy was continued. Therapy could be stopped by the patient at any time. RESULTS: Treatment was tolerated well by all patients. No clinically relevant problems and no grade III or IV toxicity according to CTC (Common Toxicity Criteria) appeared. Tumor-related pain, bleeding, restricted mobility of the lower extremities, incontinence, urinary tract obstruction, and constipation were reduced in 9/17, 5/6, 3/3, 1/3, 2/5, and 1/3 of cases (clinical response rate: 54%). Radiologically, 4/24 (17%) patients showed PR, 12/24 (50%) SD, and 8/24 (34%) PD (tumor control (PR+SD): 67% of cases). Tumor response (median survival since first TACP) was as follows: colorectal: 2 PR, 7 SD, 2 PD (11.5 months), ovarian: 1 SD, 2 PD (8.5 mon), cervical: 1 PR, 1 SD (6 mon), breast: 2 SD (6 mon), gastric: 1 PD (11 mon), adrenal gland: 1 PD (12 mon), anal: 1 PD (10 mon), prostate: 1 PD (20 mon), Gartner's duct: 1 PR (20 mon), renal cell carcinoma: 1 SD (10 mon). CONCLUSION: Since tumor-related complaints were improved in 54% of the cases and control of tumor growth (PR+SD) was achieved in 67% of the cases, TACP for recurrent pelvic malignancies should be considered as a palliative oncological treatment option.

[Transarterial chemoembolization (TACE) in hepatocellular carcinoma: technique, indication and results]. / Transarterielle Chemoembolisation (TACE) des hepatozellulären Karzinoms: Technik, Indikationsstellung und Ergebnisse.

UNLABELLED: To present current data on technique, indications and results of transarterial chemoembolization (TACE) for hepatocellular carcinoma (HCC). The principle of TACE is the intra-arterial injection of chemotherapeutic drug combinations like doxorubicin, cisplatin and mitomycin into the hepatic artery, followed by lipiodol injection, Gelfoam for vessel occlusion and degradable microspheres. The side effects and complications after TACE range from fever, upper abdominal pain and vomiting to acute or chronic liver cell failure. The palliative effect in unresectable HCC using TACE allows local tumor control in 15 to 60% of cases and 5-year survival rates ranging from 8-43%. The potentially curative treatment option allows local tumor control from 18-63%. The neoadjuvant treatment option of TACE in combination with other treatment options like percutaneous ethanol injection (PEI) or radiofrequency ablation (RFA) reach local tumor control rates between 80-96%. The bridging effect of TACE before liver transplantation reaches 5-year survival rates from 59-93%. The symptomatic therapy option of TACE is used to counteract pain directly caused by HCC and acute/subacute bleeding in the HCC. The local tumor response reaches up to 88% and the bleeding control is from 83 to 100%. CONCLUSION: TACE is a potentially curative, palliative, neoadjuvant, bridging and symptomatic therapy option for local and diffuse HCC.

"One-stop-shop" ultrasound diagnosis of functional, structural and physicomechanical properties of the brachial artery.

BACKGROUND: The pathogenesis of atherosclerosis comprises endothelial dysfunction, thickening as well as impaired compliance of the arterial vessel wall. Early assessment of these alterations of the vessel wall at the same site of the vascular tree has yet been hampered by the lack of highly sensitive diagnostic approaches suitable for clinical routine. We therefore aimed to develop and validate a single non-invasive examination of the brachial artery for simultaneous and highly accurate measurement of functional, structural and physicomechanical parameters of the brachial artery. PATIENTS AND METHODS: 20 healthy individuals were investigated using high resolution ultrasound. Flow-mediated dilation (FMD), fractional diameter changes (FDC) and intima-media-thickness (IMT) were measured in the same segment of the brachial artery. Coefficients of variation, day-to-day-variability, between- and within-observer-variability were investigated in 5 individuals. All measurements were performed manually and by an automated PC-based analyzing system. RESULTS: Mean values for all measured parameters were 7.65 +/- 0.8% for FMD, 0.02 +/- 0.002 for FDC, 0.351 +/- 0.007 mm for IMT and followed an even distribution throughout the study population. Automated analysis of coefficient of variation, day-to-day-, between- and within-observer variabilities were: 0. 78%, 1.3%, 0.8%, 0.8% (FMD); 4.7%, 2.8%, 4.2%, 2.7% (FDC); 1.8%, 1.1%, 1.9%, 1.1% (IMT). Coefficient of variation, day-to-day-, between- and within-observer variabilities for the manual readings were significantly higher. CONCLUSIONS: Functional, structural and physicomechanical parameters of the brachial artery can be quantified consecutively, time-saving and highly reproducibly as an "one-stop-shop" in a single session using high resolution ultrasound with digitized post-processing. This highlights the future possibility of early, sensitive and non-invasive diagnostic testing of vascular function in patients prone to vascular disease.

In vivo biological response to recombinant interferon-gamma during a phase I dose-response trial in patients with metastatic melanoma.

Interferon-gamma (IFN gamma), as produced by recombinant DNA technology, has shown a wide range of immunomodulatory activity in vitro and in vivo. Clinical studies have attempted to establish a dose-response relationship to define optimal dosage ranges for induction of effector cell function and host response in patients with cancer. We conducted a randomized trial to test the in vivo biologic activity of five daily dosages ranging from 3 to 3,000 micrograms/m2, administered by daily 2-hour bolus injection or by continuous infusion for 14 days. We demonstrate comparable immunobiologic effects of recombinant IFN gamma (rIFN gamma; Biogen, Inc, Cambridge, MA) administered by these two schedules at the various dosages tested, and have defined a relationship of dose to biologic response over this 3-log10 dose range. Oligo 2'5' adenylate synthetase (2'5'As) induction, natural-killer (NK) cell activity, and T-cell subset distribution (heightened T helper/suppressor ratio) showed the most consistent treatment-associated changes and the greatest immunobiologic effects at dosages of 300 to 1,000 micrograms/m2. Mononuclear cell DR and DQ antigen expression showed no consistent dose-related treatment effect. The relevance of the phenotypic, functional, and enzymologic effects observed in this trial to any clinical antitumor effects of IFN gamma in cancer therapy must now be established.

Modified Bova score for risk stratification and short-term outcome in acute pulmonary embolism.

INTRODUCTION: Risk stratification in acute pulmonary embolism (PE) is crucial to identify those patients with a poorer prognosis. We aimed to investigate a modified Bova score for risk stratification in acute PE. MATERIALS AND METHODS: We performed a retrospective analysis of PE patients treated in the internal medicine department. Both haemodynamically stable and unstable PE patients, ≥ 18 years with measurements of cardiac troponin I (cTnI) and existing echocardiography were included in the analysis. RESULTS: Data from 130 patients were included for this retrospective analysis. Three patients (2.3%) died in hospital; 84 patients had a Bova score of < 4 points and 46 ≥ 4 points. PE patients with a score ≥ 4 points were older (71.2 ± 13.8 vs. 66.3 ± 15.5 years, p = 0.0733), died more frequently during the in-hospital course (6.5% vs. 0.0%, p = 0.0183), had a more prevalent high-risk PE status (10.9% vs. 1.2%, p = 0.0122), more often had right ventricular dysfunction (100.0% vs. 35.7%, p < 0.000001), presented more frequently with syncope/collapse (21.7% vs. 3.6%, p = 0.00101) and had a higher heart rate (104.6 ± 23.5 vs. 90.0 ± 20.6/min, p = 0.000143), shock index (0.91 ± 0.59 vs. 0.62 ± 0.18, p = 0.000232), cTnI (0.36 ± 0.42 vs. 0.03± 0.10ng/ml, p < 0.000001) and creatinine (1.32 ± 0.50 vs. 1.03 ± 0.27 mg/dl, p = 0.000170). Adjusted multivariate logistic regressions revealed significant associations between the Bova score and in-hospital death (OR 4.172, 95% CI 1.125-15.464, p = 0.0326) as well as pneumonia based on PE-related lung infarction (OR 1.207, 95% CI 1.005-1.449, p = 0.0442). ROC analysis for Bova score predicting in-hospital death and pneumonia based on PE-related lung infarction showed area under the curve values of 0.908 and 0.606 with Bova score cut-off values of 3.5 points and 1.5 points, respectively. CONCLUSIONS: The modified Bova score is highly effective to predict poorer outcome in acute PE.

Cerebrovascular reserve in patients with carotid occlusive disease assessed by stable xenon-enhanced ct cerebral blood flow and transcranial Doppler.

BACKGROUND AND PURPOSE: Cerebrovascular reserve (CVR) by both transcranial Doppler ultrasonography (TCD) and quantitative cerebral blood flow (CBF) can identify subgroups of patients at increased risk for stroke. A direct comparison of CVR measurements obtained with both technologies in patients with cerebrovascular occlusive disease is lacking. METHODS: CVRs before and after acetazolamide administration (1 g IV) were measured by TCD insonation of the middle cerebral artery (MCA) and CBF obtained with stable xenon CT (Xe/CT) in 38 patients with carotid occlusive disease. Sensitivity/specificity calculations were based on 2 Xe/CT MCA values: an average over 4 levels and the level with the lowest percent change in CBF. Compromised CVR was defined as no reactivity or a decrease in reactivity. RESULTS: Using the analysis of the systolic TCD, we found that velocity changes compared with the average Xe/CT MCA CVR showed a sensitivity of 33%, specificity of 90.6%, positive predictive value of 54.5%, and negative predictive value of 80%. The sensitivity of TCD compared with the lowest Xe/CT CBF CVR was 35.5%, specificity and positive predictive values were 100%, and negative predictive value was 66.7%. The index of validity was between 72% and 76%. CONCLUSIONS: TCD is much less sensitive than Xe/CT CBF in identifying patients with compromised CVR. This may be a result of the inability of TCD to identify patients with compromised reserves when their MCA blood flow comes from collateral sources. The lack of correlation between TCD and Xe/CT CBF for identifying patients with compromised CVR should be considered when stroke risk assessments are made by TCD.

Stent-supported recanalization of chronic iliac artery occlusions.

PURPOSE: Iliac artery occlusions that are more than a few centimeters in length are normally treated with surgical bypass grafting. The aim of this study was to evaluate the results of primary stent implantation after Excimer laser-assisted recanalization of iliac artery occlusions. SUBJECTS AND METHODS: We studied 212 consecutive patients with chronic unilateral iliac artery occlusions (mean [+/- SD] length 8.9 +/- 3.9 cm) who were treated with Excimer laser-assisted recanalization and stent implantation. Based on the criteria of the Society of Cardiovascular and Interventional Radiology, lesions were graded as class III occlusions (<5 cm) in 46 patients and as class IV (> or =5 cm) in 166 patients. A total of 527 stents (Palmaz stent, 346; Wallstent, 94; Strecker stent, 38; covered stents, 49) were implanted. RESULTS: Technical success was achieved in 190 (90%) patients. There was a clinical improvement of three grades in 112 (53%) patients and of two grades in 67 (32%) patients. The rate of major complications was 1.4%, which included arterial rupture (1) and embolic events (2). Primary patency rates were 84% at 1 year, 81% at 2 years, 78% at 3 years, and 76% at 4 years. Secondary patency rates were 88% at 1 year, 88% at 2 years, 86% at 3 years, and 85% at 4 years. CONCLUSION: Stent-supported angioplasty is an effective treatment for iliac artery occlusions, with less morbidity and mortality than is associated with surgery. However, reported long-term patency rates after bypass surgery are greater than those we observed with interventional treatment. The value of primary stenting as compared with angioplasty alone should be evaluated in a randomized trial.

Improved cerebral protection through replacement of residual intracavital air by carbon dioxide: a porcine model using diffusion-weighted magnetic resonance imaging.

BACKGROUND: Major risk of central or peripheral organ damage is attributed to air embolism from incompletely de-aired cardiac chambers after cardiac operations. Replacement of air by carbon dioxide insufflation into the thoracic cavity is widely used. Diffusion-weighted magnetic resonance imaging of the brain detects ischemia within minutes after onset. The reversibility of ischemia in cerebral tissue after massive gaseous emboli has not yet been described. METHODS: After selective catheterization of a common carotid artery in 15 pigs, boli of 1 mL/kg body weight of air (n = 5) or carbon dioxide (n = 5, "low dose") were applied. Five pigs received 2 mL/kg body weight of carbon dioxide ("high dose"). Diffusion-weighted magnetic resonance imaging of the brain was performed 2, 5, 10, 15, and 25 minutes after embolization. RESULTS: All animals of the "air" group showed important circulatory reactions leading to death of 2 animals. In the whole group, diffusion-weighted magnetic resonance imaging revealed irreversible hyperintense signals in both hemispheres. In the low-dose group, no change in signal intensity was observed in 2 pigs, and 3 others showed reversible changes in signal intensity, without important circulatory reactions. In 3 animals of the high-dose group, hyperintense signals were reversible, but 2 others presented with bilateral, irreversible signals in diffusion-weighted magnetic resonance imaging, accompanied by minor circulatory reactions. CONCLUSION: In contrast to the dramatic effect of air emboli, identical quantities of carbon dioxide injected into cerebral arteries of the pigs were not associated with major clinical symptoms. The early reversibility of ischemic reactions visualized in diffusion-weighted magnetic resonance imaging encourages the use of carbon dioxide insufflation as a protective method in cardiac surgery.

Magnetic resonance imaging of focal liver lesions. Comparison of the superparamagnetic iron oxide resovist versus gadolinium-DTPA in the same patient.

RATIONALE AND OBJECTIVES: The authors assess the efficacy of static and dynamic magnetic resonance (MR) imaging using the superparamagnetic iron oxide SHU-555A (Resovist) versus standard dose of gadolinium (Gd)-DTPA in patients with focal liver lesions. METHODS: Magnetic resonance imaging was performed in 30 patients suffering from histopathologically verified malignant (n = 22) and benign (n = 8) liver lesions. T2-weighted conventional and fat-suppressed as well as T1-weighted sequences were used before, during, and after fast intravenous administration of Resovist (1 mL/minute) at three doses of 4, 8, and 16 mumol/kg body weight. One week before the Resovist-enhanced MR imaging study 20 patients underwent Gd-DTPA-enhanced MR imaging. RESULTS: Detection rate was improved for metastatic lesions revealing 36 lesions unenhanced versus 53 focal lesions using Resovist-enhanced MR imaging. Gadolinium-DTPA-enhanced scans showed no additional lesion versus unenhanced and Resovist-enhanced MR imaging. Static and dynamic imaging demonstrated no measurable percentage signal intensity loss (PSIL) using Resovist-enhanced MR imaging versus a percentage enhancement of 79.7% in Gd-DTPA enhanced scans. In the dynamic T2-weighted sequences, hepatocellular carcinoma nodules (n = 4) showed a rapid decrease in signal intensity starting at 44 seconds. Postinfusion of Resovist followed by a low, constant increase in signal intensity. Gadolinium-DTPA enhanced scans showed a percentage enhancement of 73.4 focal nodular hyperplasia (FNH) and hemangioma revealed a strong and early dose-dependent PSIL 44 to 60 seconds postinfusion with a prolonged signal loss for the FNH in the late study. Statistical evaluation revealed a statistically significant superiority of Resovist-enhanced MR imaging concerning the detection and delineation of focal liver lesions compared with unenhanced and Gd-DTPA enhanced scans (P < 0.05). CONCLUSIONS: The fast infusion of the new superparamagnetic contrast agent Resovist shows advantages for dynamic and static MR imaging of focal liver lesions.