Fibrinolysis for patients with intermediate-risk pulmonary embolism.

BACKGROUND: The role of fibrinolytic therapy in patients with intermediate-risk pulmonary embolism is controversial. METHODS: In a randomized, double-blind trial, we compared tenecteplase plus heparin with placebo plus heparin in normotensive patients with intermediate-risk pulmonary embolism. Eligible patients had right ventricular dysfunction on echocardiography or computed tomography, as well as myocardial injury as indicated by a positive test for cardiac troponin I or troponin T. The primary outcome was death or hemodynamic decompensation (or collapse) within 7 days after randomization. The main safety outcomes were major extracranial bleeding and ischemic or hemorrhagic stroke within 7 days after randomization. RESULTS: Of 1006 patients who underwent randomization, 1005 were included in the intention-to-treat analysis. Death or hemodynamic decompensation occurred in 13 of 506 patients (2.6%) in the tenecteplase group as compared with 28 of 499 (5.6%) in the placebo group (odds ratio, 0.44; 95% confidence interval, 0.23 to 0.87; P=0.02). Between randomization and day 7, a total of 6 patients (1.2%) in the tenecteplase group and 9 (1.8%) in the placebo group died (P=0.42). Extracranial bleeding occurred in 32 patients (6.3%) in the tenecteplase group and 6 patients (1.2%) in the placebo group (P<0.001). Stroke occurred in 12 patients (2.4%) in the tenecteplase group and was hemorrhagic in 10 patients; 1 patient (0.2%) in the placebo group had a stroke, which was hemorrhagic (P=0.003). By day 30, a total of 12 patients (2.4%) in the tenecteplase group and 16 patients (3.2%) in the placebo group had died (P=0.42). CONCLUSIONS: In patients with intermediate-risk pulmonary embolism, fibrinolytic therapy prevented hemodynamic decompensation but increased the risk of major hemorrhage and stroke. (Funded by the Programme Hospitalier de Recherche Clinique in France and others; PEITHO EudraCT number, 2006-005328-18; ClinicalTrials.gov number, NCT00639743.).

Altered Regional Myocardial Mechanics in Transplanted Hearts: Influence of Time and Transplantation.

Background Global longitudinal strain is reduced in heart transplant recipients, but little is known about regional contractility of the transplanted heart. Moreover, it is unclear if factors such as time after transplant and ischemic time have an influence on regional contractility. To test for regional changes in myocardial deformation, we assessed regional myocardial deformation using three-dimensional speckle tracking echocardiography in heart transplant recipients and controls. Methods Global and regional longitudinal, circumferential, and radial strain was assessed in 51 heart transplant recipients and a control group of healthy individuals (n = 26). Moreover, we correlated regional contractility with clinical characteristics and compared subgroups of heart transplant recipients with normal (n = 32) and reduced left ventricular ejection fraction (n = 32). Results Global longitudinal and circumferential strain was significantly reduced in all heart transplant recipients, as well as in the transplant group with normal ejection fraction compared with the control group (p < 0.001). Global radial strain (GRS) was elevated in both transplant groups, but was significantly higher in transplant recipients with normal ejection fraction compared with the control group (p < 0.01). Both transplant groups revealed lower longitudinal and circumferential strain values in the mid- and apical regions (p < 0.001), whereas longitudinal and circumferential strain was higher in the basal region (p < 0.01). In both groups, transplanted hearts showed increased radial strain in the basal (p < 0.05, p < 0.01) and midregions (p = 0.22; p < 0.01) and did not differ in the apical regions. Cold ischemic time (150 ± 12.6 minutes) was independently associated with reduction in circumferential strain. Time since transplantation ranging from 18 days to 21 years had no effect on myocardial deformation parameters. Conclusion Left ventricular mechanics in transplanted hearts display significantly different systolic deformation patterns than native hearts. Strain capability forms a regional gradient from the base toward the apex. The presence of a time-independent deformation pattern and the correlation with cold ischemic time suggest damage induced by the transplantation itself. These findings might be important for understanding pseudo-abnormal echocardiograms in heart transplant patients.

In-hospital resource utilization in surgical and transcatheter aortic valve replacement.

BACKGROUND: Little is known about preoperative predictors of resource utilization in the treatment of high-risk patients with severe symptomatic aortic valve stenosis. We report results from the prospective, medical-economic "TAVI Calculation of Costs Trial". METHODS: In-hospital resource utilization was evaluated in 110 elderly patients (age ≥ 75 years) treated either with transfemoral (TF) or transapical (TA) transcatheter aortic valve implantation (TAVI, N = 83), or surgical aortic valve replacement (AVR, N = 27). Overall, 22 patient-specific baseline parameters were tested for within-group prediction of resource use. RESULTS: Baseline characteristics differed between groups and reflected the non-randomized, real-world allocation of treatment options. Overall procedural times were shortest for TAVI, intensive care unit (ICU) length of stay (LoS) was lowest for AVR. Length of total hospitalization since procedure (THsP) was lowest for TF-TAVI; 13.4 ± 11.4 days as compared to 15.7 ± 10.5 and 21.2 ± 15.4 days for AVR and TA-TAVI, respectively. For TAVI and AVR, EuroScore I remained the main predictor for prolonged THsP (p <0.01). Within the TAVI group, multivariate regression analyses showed that TA-TAVI was associated with a substantial increase in THsP (55 to 61 %, p <0.01). Additionally, preoperative aortic valve area (AVA) was identified as an independent predictor of prolonged THsP in TAVI patients, irrespective of risk scores (p <0.05). CONCLUSIONS: Our results demonstrate significant heterogeneity in patients baseline characteristics dependent on treatment and corresponding differences in resource utilization. Prolonged ThsP is not only predicted by risk scores but also by baseline AVA, which might be useful in stratifying TAVI patients. TRIAL REGISTRATION: German Clinical Trial Register Nr. DRKS00000797.

Prevalence of potential retrograde embolization pathways in the proximal descending aorta in stroke patients and controls.

BACKGROUND: Retrograde diastolic blood flow in the proximal descending aorta (DAo) connecting complex plaques (≥4 mm thick) with brain-supplying supra-aortic arteries may constitute a source of stroke. Yet, data only from high-risk populations (cryptogenic stroke patients with aortic atheroma≥3 mm) regarding the prevalence of this potential stroke mechanism are available. We aimed to quantify the frequency of this mechanism in unselected patients with cryptogenic stroke after routine diagnostics and controls without a history of stroke. METHODS: 88 patients (67 stroke patients, 21 cardiac controls) were prospectively included. 3D T1-weighted bright blood MRI of the aorta was applied for the detection of complex DAo atheroma. ECG-triggered and navigator-gated 4D flow MRI allowed measuring time-resolved 3D blood flow in vivo. Potential retrograde embolization pathways were defined as the co-occurrence of complex plaques and retrograde blood flow in the DAo reaching the outlet of (a) the left subclavian artery, (b) the left common carotid artery, or/and (c) the brachiocephalic trunk. The frequency of these pathways was analyzed by importing 2D plaque images into 3D blood flow visualization software. RESULTS: Complex DAo plaques were more frequent in stroke patients (44 in 31/67 patients (46.3%) vs. 5 in 4/21 controls (19.1%); p=0.039), especially in older patients (29/46 (63.04%) patients≥60 years of age with 41 plaques vs. 2/21 (9.14%) patients<60 years of age with 3 plaques; p<0.001). Contrary to our assumption, retrograde diastolic blood flow at the DAo occurred in every patient irrespective of the existence of plaques with a similar extent in both groups (26±14 vs. 32±18 mm; p=0.114). Therefore, only the higher prevalence of complex DAo plaques in stroke patients resulted in a three times higher frequency of potential retrograde embolization pathways compared to controls (22/67 (32.8%) vs. 2/21 (9.5%) controls; p=0.048). CONCLUSIONS: This study revealed that retrograde flow in the descending aorta is a common phenomenon not only in stroke patients. The existence of potential retrograde embolization pathways depends mainly on the occurrence of complex plaques in the area 0 to ∼30 mm behind the outlet of the left subclavian artery, which is exposed to flow reversal. In conclusion, we have shown that the frequency of potential retrograde embolization pathways was significantly higher in stroke patients suggesting that this mechanism may play a role in retrograde brain embolism.

Patent foramen ovale and cryptogenic stroke in older patients.

BACKGROUND: Studies to date have shown an association between the presence of patent foramen ovale and cryptogenic stroke in patients younger than 55 years of age. This association has not been established in patients 55 years of age or older. METHODS: We prospectively examined 503 consecutive patients who had had a stroke, and we compared the 227 patients with cryptogenic stroke and the 276 control patients with stroke of known cause. We examined the prevalences of patent foramen ovale and of patent foramen ovale with concomitant atrial septal aneurysm in all patients, using transesophageal echocardiography. We also compared data for the 131 younger patients (< 55 years of age) and those for the 372 older patients (> or = 55 years of age). RESULTS: The prevalence of patent foramen ovale was significantly greater among patients with cryptogenic stroke than among those with stroke of known cause, for both younger patients (43.9% vs. 14.3%; odds ratio, 4.70; 95% confidence interval [CI], 1.89 to 11.68; P<0.001) and older patients (28.3% vs. 11.9%; odds ratio, 2.92; 95% CI, 1.70 to 5.01; P<0.001). Even stronger was the association between the presence of patent foramen ovale with concomitant atrial septal aneurysm and cryptogenic stroke, as compared with stroke of known cause, among both younger patients (13.4% vs. 2.0%; odds ratio, 7.36; 95% CI, 1.01 to 326.60; P=0.049) and older patients (15.2% vs. 4.4%; odds ratio, 3.88; 95% CI, 1.78 to 8.46; P<0.001). Multivariate analysis adjusted for age, plaque thickness, and presence or absence of coronary artery disease and hypertension showed that the presence of patent foramen ovale was independently associated with cryptogenic stroke in both the younger group (odds ratio, 3.70; 95% CI, 1.42 to 9.65; P=0.008) and the older group (odds ratio, 3.00; 95% CI, 1.73 to 5.23; P<0.001). CONCLUSIONS: There is an association between the presence of patent foramen ovale and cryptogenic stroke in both older patients and younger patients. These data suggest that paradoxical embolism is a cause of stroke in both age groups.

Three-dimensional echocardiography for quantitative analysis of left-ventricular aneurysm.

BACKGROUND: Quantitative analysis of left-ventricular (LV) aneurysms after myocardial infarction is prognostically relevant and assists in planning surgery. Three-dimensional (3D) echocardiography facilitates clear visualization of cardiac anatomy and accurate assessment of functional parameters. The aim of the present study was to determine the ability of 3D echocardiography to quantify LV aneurysms. METHODS: Ten patients with a known LV-aneurysm after myocardial infarction underwent 3D echocardiography and cardiac magnetic resonance (CMR) imaging at 1.5 Tesla within 3 days. For 3D echocardiography, a multiplanar transesophageal examination was performed with full LV coverage and the 3D dataset was analyzed offline. The LV-aneurysm was defined by a wall thickness <5 mm. The following quantitative parameters were determined: left ventricular end-diastolic and end-systolic volumes, LV myocardial mass (LV-mass) and mass of the LV-aneurysm. LV ejection fraction and percentage of aneurysm mass (%-aneurysm) were calculated. RESULTS: LV volumes and ejection fraction showed a strong correlation between 3D echocardiography and CMR (r = 0.94-0.97; P < 0.01). Importantly, the mass and percentage of mass of the LV-aneurysm demonstrated a high correlation as well (r = 0.94 and r = 0.86, respectively; P < 0.01). For all parameters, the calculated bias between both methods was found to be minimal (0.8-7.6%). CONCLUSIONS: Three-dimensional echocardiography proved to be a reliable tool for quantitative analysis of LV volumes, ejection fraction and aneurysm size in patients with prior myocardial infarction. In addition, 3D visualization of the complex cardiac anatomy in patients with LV-aneurysm may assist surgical procedure planning.

Pegylated liposomal doxorubicin and trastuzumab as 1st and 2nd line therapy in her2/neu positive metastatic breast cancer: a multicenter phase II trial.

The combination therapy of doxorubicin and trastuzumab has been proven to be highly effective for metastatic breast cancer (MBC) patients with Her2/neu over-expressing tumors. However, this regimen is characterized by frequent cardiac toxicity, occurring in 27% of all treated patients and aggravating when the two substances are given concurrently. Pegylated liposomal doxorubicin (PLD) as a single agent reduces significantly cardiac toxicity and maintains efficacy compared to conventional doxorubicin. This prospective open labeled, multicenter phase II study assessed the potential cardiotoxicity and efficacy of PLD and trastuzumab as first and second line combination therapy in Her2/neu over-expressing MBC patients. Patients with Her2 over-expressing, measurable MBC with a baseline left ventricular ejection fraction (LVEF) > or =50% were treated with PLD 40 mg/m(2) every 4 weeks for 6 up to 9 cycles and weekly trastuzumab (4 mg/kg loading dose, then 2 mg/kg). Cardiotoxicity was defined as the appearance of clinical signs or symptoms of congestive heart failure in combination with a decrease in LVEF < or =44% or > or =10 units below the normal value of 50% in the obligatory, subsequently performed transthoracic echocardiography. Due to conflicting interests, the planned accrual goal of 30 patients was not reached. Finally 16 patients were enrolled. Ten patients presented with more than one metastatic site and six of them were in second-line therapy. The median LVEF in the study cohort was 66.1 +/- 8.68% at baseline, 62.7 +/- 5.11% after 6 cycles of therapy, 64.4 +/- 7.61% at the first follow up and did not change significantly (61.0 +/- 5.56% even at the 5th follow-up). Six out of 12 assessable patients (50.0%) demonstrated a clinical benefit and after a median follow-up of 15.4 months a median progression free survival of 9.67 and a median overall survival of 16.23 months. Non-cardiac side effects were mild with only 3 CTC grade 3 events of 247 treatment cycles (1.2%) and no grade 4 toxicities. The combination of PLD and trastuzumab in patients with Her2/neu over-expressing metastatic breast cancer is a safe, feasible and effective therapy. However, cardiac function should be monitored at close intervals. Due to the promising clinical response rates and mild toxicity profile in this prognostically unfavorable group, this combination therapy should be evaluated in larger studies.

Patent foramen ovale and cryptogenic stroke: a matter of age?

A patent foramen ovale (PFO) enables a right-to-left shunt in about a quarter of the population. The marked association between cryptogenic stroke and PFO supports the hypothesis that paradoxical embolism could be a relevant cause of stroke. Although this association has been described in several studies for patients <55 years of age, only limited data are available on the role of PFO in older patients. Recent studies, however, have also shown a significant association between cryptogenic stroke and PFO in patients >55 years of age. The relationship is especially marked in the presence of atrial septum aneurysm (ASA). This finding is in accordance with previous reports indicating that PFO and concomitant ASA is a high-risk feature. Factors promoting paradoxical embolism, such as deep vein thrombosis (DVT) and elevated right-heart pressure, are more frequently encountered in older than in younger patients. Independent of age, contrast-enhanced transthoracic and transesophageal echocardiography are the methods of choice for the detection and imaging of PFO and atrial septal aneurysm. Transcranial Doppler can be used as a screening method in patients with cryptogenic stroke to detect a right-to-left shunt. Proof of DVT strongly supports the suspicion of paradoxical embolism and should lead to oral anticoagulation. If paradoxical embolism is suspected without proof of DVT, both drug therapy with aspirin or warfarin and percutaneous closure of the PFO are available as therapeutic options. Recent studies have shown that percutaneous closure can be performed safely and with a low rate of recurrence both in older and younger patients. Thus far, however, there is no clear-cut evidence of superiority for either therapeutic strategy.

Cardiac involvement after respiratory tract viral infection--detection by cardiac magnetic resonance.

OBJECTIVE: The purpose of our study was to investigate whether cardiovascular magnetic resonance imaging can detect early myocardial tissue edema as a first step in the development of myocarditis. METHODS: We examined 36 consecutive patients who were presented with symptoms of fatigue, weakness, and/or palpitations after respiratory tract infection but normal left ventricular function and compared these patients with 21 consecutive controls without acute symptoms. Electrocardiogram-triggered, T2-weighted, fast spin echo triple-inversion recovery sequences were performed in all patients. RESULTS: We found a significant difference between patients with suspected myocarditis and controls in global myocardial signal intensity. The ratio of global myocardial signal intensity/muscle signal intensity was 2.4 +/- 0.3 in patients and 1.9 +/- 0.3 in controls, which was highly significant (P < 0.001). CONCLUSIONS: Patients with symptoms of fatigue, weakness, and/or palpitations after respiratory tract infection showed an elevated signal intensity of the myocardium, indicating edematous tissue, which may be the first step in the development of myocarditis.

Rupture of an aneurysm of the noncoronary sinus of Valsalva into the right atrium.

A 32-year-old woman presented to the emergency department after the sudden onset of palpitations, dyspnoea and left-sided tinnitus. Echocardiography revealed a ruptured aneurysm of the noncoronary sinus of Valsalva into the right atrium. Due to deterioration of right heart failure with rapidly progressive decline of systemic blood pressure, the patient underwent immediate surgery with a patch repair of the ruptured aneurysm. A few days later, the patient was discharged home in good condition.

Heparin plus alteplase compared with heparin alone in patients with submassive pulmonary embolism.

BACKGROUND: The use of thrombolytic agents in the treatment of hemodynamically stable patients with acute submassive pulmonary embolism remains controversial. METHODS: We conducted a study of patients with acute pulmonary embolism and pulmonary hypertension or right ventricular dysfunction but without arterial hypotension or shock. The patients were randomly assigned in double-blind fashion to receive heparin plus 100 mg of alteplase or heparin plus placebo over a period of two hours. The primary end point was in-hospital death or clinical deterioration requiring an escalation of treatment, which was defined as catecholamine infusion, secondary thrombolysis, endotracheal intubation, cardiopulmonary resuscitation, or emergency surgical embolectomy or thrombus fragmentation by catheter. RESULTS: Of 256 patients enrolled, 118 were randomly assigned to receive heparin plus alteplase and 138 to receive heparin plus placebo. The incidence of the primary end point was significantly higher in the heparin-plus-placebo group than in the heparin-plus-alteplase group (P=0.006), and the probability of 30-day event-free survival (according to Kaplan-Meier analysis) was higher in the heparin-plus-alteplase group (P=0.005). This difference was due to the higher incidence of treatment escalation in the heparin-plus-placebo group (24.6 percent vs. 10.2 percent, P=0.004), since mortality was low in both groups (3.4 percent in the heparin-plus-alteplase group and 2.2 percent in the heparin-plus-placebo group, P=0.71). Treatment with heparin plus placebo was associated with almost three times the risk of death or treatment escalation that was associated with heparin plus alteplase (P=0.006). No fatal bleeding or cerebral bleeding occurred in patients receiving heparin plus alteplase. CONCLUSIONS: When given in conjunction with heparin, alteplase can improve the clinical course of stable patients who have acute submassive pulmonary embolism and can prevent clinical deterioration requiring the escalation of treatment during the hospital stay.

Possible gender-related differences in the risk-to-benefit ratio of thrombolysis for acute submassive pulmonary embolism.

The indications for thrombolytic treatment in normotensive patients with pulmonary embolism (PE) are still the subject of debate, and it also remains questionable whether the efficacy and safety of thrombolysis are similar in men and women. To address the latter issue, the present study analyzed a large population of 428 women and 291 men with acute submassive PE derived from a prospective multicenter registry. Initial treatment consisted either of thrombolysis (<24 hours after diagnosis) or heparin alone. Thirty-day overall mortality was almost identical (11%) in heparin-treated men and women. Early thrombolysis was associated with drastically reduced death rates (2.7% vs 11% in the heparin group, p = 0.033) in men, whereas the reduction was nonsignificant (p = 0.181) in women. Multivariate analysis revealed that early thrombolysis was independently associated with reduced mortality rates in men (odds ratio 0.21, 95% confidence interval 0.05 to 0.96). In comparison, its favorable effect in women was marginal (odds ratio 0.77, 95% confidence interval 0.30 to 1.97). Gender-specific differences were also observed with regard to the reduction of symptomatic PE recurrence (in men, from 21.6% to 8.2%, p = 0.009; in women, from 16.9% to 8.3%, p = 0.049). In contrast, thrombolysis resulted in a more than threefold increase in major bleeding in women (from 8.4% to 27.1%, p <0.001), a more pronounced effect than in men (from 6.9% to 15.1%, p = 0.055). In conclusion, the present study generated the hypothesis that women with submassive PE might benefit less from thrombolytic treatment in terms of survival and PE recurrence and that they could be exposed to a higher bleeding risk compared with men.

Depressive coping is a predictor for emotional distress and poor quality of life in a German-Austrian sample of cardioverter-defibrillator implant recipients at 3 months and 1 year after implantation.

OBJECTIVE: The implantable cardioverter defibrillator (ICD) has been proven to prolong the lives of patients with life-threatening ventricular arrhythmia. However, implant recipients must cope with numerous challenges. We studied the effects of specific coping strategies and the adaptability of coping in ICD implant recipients. METHOD: This prospective study investigated the subjective well-being and objective disease course in 180 patients with life-threatening cardiac arrhythmias, who were recruited while awaiting implantation of a cardioverter defibrillator. Patients completed well-validated self-assessment questionnaires before implantation (T0), as well as 3 months (T1) and 1 year (T2) after implantation. In addition, cardiological findings were documented. RESULTS: Depressive coping (range Beta, -0.36 to -0.58) was found to be a stable highly-significant predictor for low emotional well-being and quality of life. Active problem-oriented coping showed small positive influence (range Beta, 0.10 to 0.19). Employing a broad range of coping strategies was predictive of less emotional distress and better quality of life. CONCLUSIONS: Depressive coping is a risk factor for emotional distress and poor quality of life after ICD implantation. Patients with this tendency should be identified early and offered supportive psychotherapy.

N-terminal pro-brain natriuretic peptide or troponin testing followed by echocardiography for risk stratification of acute pulmonary embolism.

BACKGROUND: Brain natriuretic peptide (BNP) and N-terminal (NT)-proBNP have recently emerged as promising parameters for risk assessment in acute pulmonary embolism (PE). However, their positive predictive value is low, and the prognostic implications of NT-proBNP or troponin elevation alone are questionable. METHODS AND RESULTS: To determine whether the combination of NT-proBNP testing with echocardiography may identify both low-risk and high-risk patients with PE, we examined 124 consecutive patients with proved PE. All underwent echocardiography on admission to detect right ventricular dysfunction. NT-proBNP and troponin concentrations were measured in one core laboratory. The primary end point was death or major in-hospital complications. The cutoff level of 1000 pg/mL had a high negative predictive value (95% for a complicated course, 100% for death), but NT-proBNP > or =1000 pg/mL did not independently predict an adverse outcome. Combination of NT-proBNP testing with echocardiography identified 3 major risk groups. A positive echocardiogram was associated with a 12-fold elevation in complication risk compared with patients with low NT-proBNP (P=0.002), whereas NT-proBNP elevation without right ventricular dysfunction on echocardiography only slightly increased the risk of an adverse outcome (P=0.17). The combination of cardiac troponin testing with echocardiography yielded similar complication rates in the lowest-risk group and a similar magnitude of risk elevation for the highest-risk patients, but it also increased the number of intermediate-risk groups. CONCLUSIONS: Our results support a simple risk stratification algorithm for patients with PE, with the use of NT-proBNP or troponin testing as an initial step that should be followed by echocardiography if elevated levels of the biomarker are found.

Therapeutic strategies after examination by transesophageal echocardiography in 503 patients with ischemic stroke.

BACKGROUND AND PURPOSE: Transesophageal echocardiography (TEE) is the gold standard in detecting high-risk (ie, aortic thrombi) and potential sources (ie, patent foramen ovale [PFO]) of cerebral embolism. We sought to evaluate the additional information and therapeutic impact provided by TEE in stroke patients and to characterize patients in whom TEE is indispensable. METHODS: We included 503 consecutive patients (mean age 62.2 years) with acute brain ischemia. Each patient received TEE and the following routine diagnostics: ultrasound of brain supplying arteries, ECG or Holter-ECG, transthoracic echocardiography, and brain imaging (computed tomography or MRI). Stroke etiology was classified according to the Trial of Org 10172 in Acute Stroke Treatment (TOAST) criteria. High-risk sources in TEE were: aortic thrombi or plaques > or =4 mm, thrombi in left atrial cavity/left atrial appendage, spontaneous echo contrast, and left atrial flow velocity <30 cm/s. Potential sources in TEE were PFO, atrial septal aneurysm, and aortic plaques <4 mm. RESULTS: Stroke etiology was determined by routine diagnostics in 276 of 503 patients (54.9%). Of the remaining 227 patients (undetermined etiology), 212 (93.4%) were candidates for oral anticoagulation (OA). TEE revealed a high-risk source, with indication for OA in 17 of them (8.0%). A potential source leading to OA was found in an additional 48 patients (22.6%). The remaining 147 patients (69.3%) were treated by platelet inhibitors or statins. CONCLUSIONS: TEE strongly influenced secondary prevention and led to OA in one third of our patients with stroke of undetermined etiology. TEE is indispensable in all patients being candidates for OA when routine diagnostics cannot clarify stroke etiology.

[Effects of psychotherapeutic interventions on length of stay in cardiology inpatients]. / Der Einfluss eines psychosomatischen Liaisondienstes auf die stationäre Verweildauer von Patienten in der Kardiologie.

OBJECTIVES: Mental comorbidities as recorded in the DRG system by the Patient Comorbidity and Complication Level (PCCL) cause extended length of stay in cardiology with resultant higher costs. Studies analyzing the influence of a psychiatric consultation and liaison service on the length of stay and the costs incurred thereby have generated inconsistent results. The present prospective study examines the effects of the psychotherapeutic liaison service on the length of stay. METHODS: In the course of 6 months, two cardiology wards were alternately provided traditional psychotherapeutic consultation and psychotherapeutic liaison service based on a Cross-Over-Design (A-B-A). Inclusion criteria for patients was the presence of one of the four most common cardiological diagnoses (ischemic heart diseases, heart valve defects, cardiomyopathies, arrhythmias). After the exclusion of patients with a length of less than five days, the random sampling comprised n = 317 patients. RESULTS: The study showed no direct correlation between the intensified care system of the liaison service and a reduction in the length of stay. The results obtained remained consistent even after controlling for age, sex, and case complexity. Recommendations for further investigations are discussed.

New three-dimensional echocardiographic system using digital radiofrequency data--visualization and quantitative analysis of aortic valve dynamics with high resolution: methods, feasibility, and initial clinical experience.

BACKGROUND: Common 3D systems have only limited spatial and temporal resolution (frame rate of 25 Hz). Thin structures such as cardiac valves are not imaged exactly; rapid movement patterns cannot be precisely recorded. The objective of the present project was to achieve radiofrequency (RF) data transmission to the 3D workstation to improve image resolution. METHODS AND RESULTS: A commercially available echocardiographic system (5-MHz transesophageal echocardiography probe) with an integrated raw data interface enables transmission of RF data (up to 40 megabytes per second). A 3D data set may contain up to 3 gigabytes, so that all of the high-resolution ultrasound information of the 2D image is available. Frame rates of up to 168 Hz result in temporal resolution 6 times that of standard 3D systems. The applicability of the system and the image quality were tested in 10 patients. The structure of the aortic valve and the dynamic changes were depicted by volume rendering. The changes in the orifice areas were measured in frame-by-frame planimetry. The mean number of frames recorded per cardiac cycle was 122+/-16. The improved structural resolution enabled a detailed imaging of the morphology of the aortic cusps. The rapid systolic movement patterns were recorded with up to 51 frames. The high number of frames enabled creation of precise area-time diagrams. Thus, the individual phases of aortic valve movement (rapid opening, slow valve closing, and rapid valve closing) could be analyzed quantitatively. CONCLUSIONS: A 3D system based on RF data enables high-resolution imaging of cardiac movement patterns. This offers new perspectives for qualitative and quantitative analyses, especially of cardiac valves.

Importance of cardiac troponins I and T in risk stratification of patients with acute pulmonary embolism.

BACKGROUND: Assessment of risk and appropriate management of patients with acute pulmonary embolism (PE) remains a challenge. Cardiac troponins I (cTnI) and T (cTnT) are reliable indicators of myocardial injury and may be associated with right ventricular dysfunction in PE. METHODS AND RESULTS: The present prospective study included 106 consecutive patients with confirmed acute PE. cTnI was elevated (> or =0.07 ng/mL) in 43 patients (41%), and cTnT (> or =0.04 ng/mL) was elevated in 39 (37%). Elevation of cTnI or cTnT was significantly associated with echocardiographically detected right ventricular dysfunction (P=0.001 and P<0.05, respectively). Moreover, a significant correlation was found between elevation of cTnI or cTnT and the two major end points overall mortality and complicated in-hospital course. The negative predictive value of cardiac troponins for major clinical events was 92% to 93%. Importantly, there was obvious escalation of in-hospital mortality, the rate of complications, and the incidence of recurrent PE, when patients with high troponin concentrations (cTnI >1.5; cTnT >0.1 ng/mL) were compared with those with only moderately elevated levels (cTnI, 0.07 to 1.5; cTnT, 0.04 to 0.1 ng/mL). Logistic regression analysis confirmed that the mortality risk (OR) was significantly elevated only in patients with high cTnI (P=0.019) or cTnT (P=0.038) levels. Furthermore, the risk of a complicated in-hospital course was almost 5 times higher (15.47 versus 3.16) in the high-cTnI group compared with patients with moderate cTnI elevation. CONCLUSIONS: Our results indicate that cTnI and cTnT may be a novel, particularly useful tool for optimizing the management strategy in patients with acute PE.