The impact of the width of the tracking area on speckle tracking parameters-methodological aspects of deformation imaging.

AIMS: The aim of this study was to analyze the impact of the tracking area width on myocardial wall motion and deformation parameters in 2D speckle tracking. METHODS AND RESULTS: Standardized apical views were acquired in 30 healthy subjects and 15 patients with left ventricular systolic dysfunction using 2D echocardiography. Longitudinal peak systolic strain (PSS), longitudinal peak systolic strain rate (PSSR), postsystolic index (PSI), peak longitudinal (PLD), and peak transverse displacement (PTD) were determined by 2D speckle tracking to analyze the impact of the tracking area width on global and regional myocardial wall motion and deformation parameters. The dimension of the tracking area has a significant impact on all parameters. With increasing width of the tracking area higher values of PSS, PSSR, PSI, and lower values of PLD and PTD were determined. With increasing width of the tracking area a significant number of segments were not tracked. In summary, especially global PSS is significantly influenced by the width of the tracking area. CONCLUSIONS: The strain values determined by 2D speckle tracking are significantly influenced by the tracking area width. The tracking of the subendocardial layers only results in lower global strain values than tracking the complete ventricular wall using the medium or wide tracking area widths. The tracking quality in the far field is worse if the tracking area is too wide. The present data show that standard and reference values of deformation imaging should include detailed information about the position and the width of the tracking area.

[History of clinical electrophysiology in diagnosing and treatment monitoring of high ventricular vulnerability]. / Geschichte der klinischen Elektrophysiologie in Diagnostik und Therapiekontrolle ventrikulärer Vulnerabilität.

The paper presents the history of hope from 1980-1995 to predict the risk of sudden arrhythmic death using electrophysiologic techniques in individual patients. Even if this prediction seems possible in selected highly risk cohorts, many more patients will die in ventricular arrhythmia without fulfilling the criteria. Ultimately, high risk of sudden cardiac death can be predicted in selected patient groups, but not in the majority of patients at risk. It is a history of dashed hope.

The CINCH-FMR postmarket registry: Real-world long-term outcomes with percutaneous mitral valve repair with the Carillon Mitral Contour System®.

BACKGROUND: The Carillon® Mitral Contour System® has been studied in 4 prospective controlled studies in the treatment of functional mitral regurgitation (FMR) where it has been found to reduce mitral regurgitation, reduce left ventricular and atrial volumes, and be associated with improvements in clinical parameters. AIMS: The CINCH post-market registry is designed to evaluate immediate, mid-term and long-term outcomes from a post-approval study of the Carillon® device evaluated in real-world practice. METHODS: The CINCH post-market registry is a single-arm study of percutaneous mitral annuloplasty with the Carillon device in patients with functional (secondary) mitral regurgitation and symptomatic congestive heart failure when utilized in real-world conditions. Patient selection, echocardiographic hemodynamic measurements, and patient follow-up requirements were performed per standard of care at each institution. RESULTS: A total of 101 patients treated with the Carillon device at 13 sites in Germany were enrolled in the CINCH registry. The mean age was 75 ± 9 years, 57 % were male, and patient presentation included primarily NYHA class III (69 %) with MR grade 3 (68 %). Over 5 years of follow-up, all-cause mortality was 40.1 %, the incidence of HFH was 53.9 %, and the composite outcome of HFH or death was 66.4 %. At each follow-up interval through 5 years, statistically significant reductions in NYHA class (p < 0.05) and MR grade (p < 0.01) were reported. CONCLUSIONS: In this "real world" registry of the Carillon Mitral Contour System, procedural safety and medium-term follow-up outcomes is similar to the outcomes seen in the prospective, controlled clinical trials, despite being used in populations of patients that extend outside of those studied in the trials. The use of this therapy in patients with atrial functional mitral regurgitation, and heart failure with preserved ejection fraction, was notable, since these types of patients were excluded from the prospective, controlled trials. This supports possible additional patient populations who might benefit from this type of mechanical therapy. The safety profile of this therapy in this registry and in the earlier trials may support a potential role in earlier forms of secondary mitral regurgitation.

Echocardiographic assessment of left atrial appendage morphology and function-an expert proposal by the German Working Group of Cardiovascular Ultrasound.

The left atrial appendage is a blind ending cardiac structure prone to blood stasis due to its morphology. This structure is a preferred region of thrombogenesis in relation to reduced myocardial contractility of the atrial wall. Blood stasis occurs primarily in low flow conditions. One of the tasks of echocardiography is the analysis of morphology and function of the left atrial appendage. The detection of thrombi by echocardiography is difficult and must be carried out thoroughly and carefully to avoid potential complications-especially in the context of rhythm control. The assessment of thromboembolic risk, especially in patients with unknown and presumed atrial fibrillation is a second challenge by characterizing atrial function and flow conditions in the left atrial appendage. Thus, this proposal focuses on the obvious problems of echocardiography when assessing left atrial appendage and the role of this method in planning a potential interventional closure of left atrial appendage.

Echocardiographic assessment of atrial, ventricular, and valvular function in patients with atrial fibrillation-an expert proposal by the german working group of cardiovascular ultrasound.

Echocardiography in patients with atrial fibrillation is challenging due to the varying heart rate. Thus, the topic of this expert proposal focuses on an obvious gap in the current recommendations about diagnosis and treatment of atrial fibrillation (AF)-the peculiarities and difficulties of echocardiographic imaging. The assessment of systolic and diastolic function-especially in combination with valvular heart diseases-by echocardiography can basically be done by averaging the results of echocardiographic measurements of the respective parameters or by the index beat approach, which uses a representative cardiac cycle for measurement. Therefore, a distinction must be made between the functionally relevant status, which is characterized by the averaging method, and the best possible hemodynamic status, which is achieved with the most optimal left ventricular (LV) filling according to the index beat method with longer previous RR intervals. This proposal focuses on left atrial and left ventricular function and deliberately excludes problems of echocardiography when assessing left atrial appendage in terms of its complexity. Echocardiography of the left atrial appendage is therefore reserved for its own expert proposal.

Optimal timing of invasive angiography in stable non-ST-elevation myocardial infarction: the Leipzig Immediate versus early and late PercutaneouS coronary Intervention triAl in NSTEMI (LIPSIA-NSTEMI Trial).

AIMS: The optimal timing of intervention in non-ST-elevation myocardial infarction (NSTEMI) remains uncertain. The aim of this multicentre trial was to assess whether an immediate invasive approach is superior to an early invasive or a selective invasive approach with respect to reduction of large infarction. METHODS AND RESULTS: Patients with NSTEMI were randomized to either an immediate (<2 h after randomization; n= 201), an early (10-48 h after randomization; n= 200), or a selective invasive approach with high invasive percentage (n= 201). The primary outcome was the peak creatine kinase (CK)-myocardial band (MB) activity during index hospitalization; key secondary clinical endpoints were the composite of (i) death and non-fatal infarction; (ii) death, non-fatal infarction, and refractory ischaemia; (iii) death, non-fatal infarction, refractory ischaemia, and rehospitalization for unstable angina within 6 months. The median time from randomization to angiography was 1.1 h in the immediate vs. 18.6 h in the early and 67.2 h in the selective invasive group (P< 0.001). There was no significant difference in the peak CK-MB activity between groups. The key secondary clinical endpoints were similar between groups at 6-month follow-up: death and infarction: 21.0 vs. 16.0 vs. 14.5%; P= 0.17; death, infarction, refractory ischaemia: 20.9 vs. 21.5 vs. 22.0%; P= 0.98; death, infarction, refractory ischaemia, rehospitalization: 26.0 vs. 26.5 vs. 24.5%; P= 0.91, respectively. CONCLUSIONS: In NSTEMI patients, an immediate invasive approach does not offer an advantage over an early or a selective invasive approach with respect to large myocardial infarctions as defined by peak CK-MB levels, which is supported by similar clinical outcomes. ClinicalTrials.gov NCT00402675.

First case report of the use of two stents following coronary artery obstruction during indirect mitral annuloplasty.

The case of a 71-year-old male with end stage heart failure and severe mitral regurgitation is presented, where percutaneous indirect mitral annuloplasty was performed. During device implantation in the coronary sinus the circumflex artery was compromised at two anatomic locations, while the mitral regurgitation was efficiently reduced. After weighing risks and alternative therapeutic options, stent implantation was chosen as bailout strategy to leave the device in place and retain the efficient MR reduction. The anatomical proximity of Cx and coronary sinus in the mitral valve plane bears the risk of circumflex artery damage during surgical and interventional mitral repair. Usually, a device exchange solves the problem of arterial flow limitation in most cases. While stent implantation remains off label use in this setting and should not be performed without critical evaluation, it has been performed successfully in similar clinical settings as well (e.g. artery stenosis by surgical suture).

Single application of high-intensity focused ultrasound as a first-line therapy for clinically localized prostate cancer: 5-year outcomes.

UNLABELLED: Study Type--Therapy (case series) Level of Evidence 4. What's known on the subject? and What does the study add? High-intensity focused ultrasound (HIFU) therapy has been proposed for the treatment of localized prostate cancer (PCa) for all risk levels of tumour recurrence. The study adds data on the efficacy of a single HIFU application in the treatment of PCa with different risks of recurrence. Durable cancer control was achieved in 81.7% of patients with low-risk disease, with rates of efficacy declining in intermediate- and high-risk tumours. The data suggest that the principal domain for minimal invasive HIFU should be low-risk disease. OBJECTIVE: • To report cancer control results after a single application of high-intensity focused ultrasonography (HIFU) in patients with localized prostate cancer (PCa), stratified by tumour recurrence risk according to D'Amico risk classification. PATIENTS AND METHODS: • In a retrospective single-centre study, we analysed the outcomes of patients with localized PCa who were treated with curative intent between December 2002 and October 2006 using an Ablatherm HIFU device (EDAP-TMS, France). • Transurethral resection of the prostate or adenomectomy were performed before HIFU to downsize large prostate glands. • Oncological failure was determined by the occurrence of biochemical relapse, positive biopsy and/or metastasis. Biochemical relapse was defined as a PSA nadir +1.2 ng/mL (Stuttgart definition), or as a rise in PSA level to ≥ 0.5 ng/mL if PSA doubling time was ≤ 6 months. Kaplan-Meier analysis was performed for survival estimates. RESULTS: • A total of 191 consecutive patients were included in the study. The median (range) patient age was 69.7 (51-82) years, and 38, 34 and 28% of these patients were in the low-, intermediate- and high-risk groups, respectively. • The median (range) follow-up was 52.8 (0.2-79.8) months. • At 5 years, overall and cancer-specific survival rates were 86.3% and 98.4%, respectively. • Stratified by risk group, negative biopsy rates were 84.2%, 63.6%, and 67.5% (P = 0.032), 5-year biochemical-free survival rates were 84.8%, 64.9% and 54.9% (P< 0.01), and 5-year disease-free survival rates were 81.7%, 53.2% and 51.2% (P < 0.01), respectively. CONCLUSION: • Single-session HIFU is recommended as a curative approach in elderly patients with low-risk PCa. Patients at higher risk of tumour progression should be counselled regarding the likely need for salvage therapy, including repeat HIFU.

Clinical efficacy of left ventricular pacing vector programmability in cardiac resynchronization therapy defibrillator patients for management of phrenic nerve stimulation and/or elevated left ventricular pacing thresholds: insights from the Efface Phrenic Stim study.

AIMS: Elevated left ventricular (LV) pacing thresholds or phrenic nerve stimulation (PNS) might be possible reasons for absence of continuous and effective biventricular stimulation. This study investigated the benefit and clinical efficacy of the ability to choose one out of three different LV pacing vectors for the management of suboptimal LV pacing thresholds and PNS. METHODS AND RESULTS: This prospective, observational multicentre study enrolled 132 patients (Pts) implanted with a cardiac resynchronization therapy defibrillator, that offers three LV pacing vectors: (i) Bipolar; (ii) LVtip ↔ RVcoil; (iii) LVring ↔ RVcoil (RV = right ventricular). Left ventricular pacing thresholds and PNS thresholds were obtained in sitting and left lateral body position for all programmable LV pacing vectors at hospital discharge and follow up (FU). In 97%, a bipolar transvenous LV lead was successfully implanted. In 87% of Pts at least one acceptable pacing vector could be identified that provides good pacing threshold (≤ 2.5 V at 5 ms) and acceptable margin to PNS (≥ 2:1). This is an increase of 18% compared with conventional bipolar systems (74%) with two LV vectors and of 25% compared with unipolar systems (70%). The LVtip ↔ RVcoil vector provided the best LV pacing thresholds, but the highest rate of PNS. CONCLUSIONS: The programmability of LV pacing vectors is a powerful feature to avoid PNS and obtain acceptable LV pacing thresholds. In order to retain reprogramming options for LV vectors during FU, LV pacing leads with at least two electrodes should be chosen whenever possible.

Echocardiographic analysis of acute effects of percutaneous mitral annuloplasty on severity of secondary mitral regurgitation.

AIMS: Percutaneous mitral annuloplasty (PMA) represents a new treatment option for secondary mitral regurgitation (SMR) being associated with higher morbidity and mortality. The present study was aimed to evaluate whether or not acute effects on SMR severity can quantitatively be assessed after PMA. METHODS AND RESULTS: PMA was performed in 30 patients (mean age 76 ± 9; 37% males) with moderate (n = 14) or severe (n = 16) SMR. Vena contracta (VC), left ventricular (LV) velocity-time-integral ratio (VTIMV/LVOT ), effective regurgitant orifice area (EROA) by two-dimensional proximal isovelocity surface area (PISA), regurgitant volume (RVolPISA ) and regurgitant fraction (RFPISA ) by PISA, RVolvolume and RFvolume by LV volume analyses, and parameters describing LV morphology, function, and cardiac performance were assessed by transthoracic echocardiography prior to and after PMA. According to RFPISA /RFvolume , 14 patients showed mild, 15 moderate, and 1 severe SMR after PMA. Mean RF, RVol, EROA, VC, and VTIMV/LVOT were lower directly after PMA (RFPISA : 49% ± 11 vs. 34% ± 13, P < 0.001; RFvolume : 46% ± 10 vs. 34% ± 13, P < 0.001; RVolPISA : 33 mL ± 13 vs. 25 mL ± 12, P < 0.001; RVolvolume : 28 mL ± 17 vs. 20 mL ± 14, P < 0.05; EROAPISA : 0.24 cm2  ± 0.1 vs. 0.19 cm2  ± 0.1, P < 0.05; VC: 5.2 ± 0.1 vs. 4.1 ± 0.2, P < 0.001; VTIMV/LVOT : 1.9 ± 0.4 vs. 1.6 ± 0.5, P < 0.05). Parameters of LV morphology, function, and cardiac performance did not change directly after PMA. CONCLUSIONS: PMA leads to a reduction of MR severity in >80% of SMR patients. Acute effects of PMA can quantitatively be assessed by transthoracic echocardiography.

[History of catheter ablation]. / Geschichte der Katheterablation.

After His bundle electrography was established in 1967, the step from invasive electrophysiologic diagnosis of arrhythmias to interventional treatment by catheter ablation was imminent. The time interval of 15 years between the diagnosis and treatment of arrhythmias was even shorter than the 19 years between the first selective coronary angiography in 1958 at the Cleveland Clinic in the USA and the first percutaneous coronary intervention in 1977 in Zurich. During each time period, a great amount of knowledge was gained in cardiac surgery, which proved to be very helpful for the development of the interventional treatment. The history of endovascular treatment is an impressive reminder that the preparation and support of cardiovascular surgeons and their handling of complications played a decisive role in the further development of cardiovascular internal medicine. The history of catheter ablation teaches us that the joint work of cardiologists and cardiovascular surgeons is of great importance for the choice and further development of the best possible treatment as for future development of the techniques of therapy.

Signal transduction and transcriptional control of cardiac connexin43 up-regulation after alpha 1-adrenoceptor stimulation.

Syncytial behavior of cardiac tissue is mainly controlled by the expression of cardiac gap junction proteins, and of these, connexin43 (Cx43) represents the predominant connexin in the working myocardium. Because the alpha(1)-adrenoceptor is involved in many cardiac diseases, the following experiments were performed to clarify the pathway whereby alpha(1)-adrenoceptor stimulation may control Cx43 expression. Cultured neonatal rat cardiomyocytes were stimulated with phenylephrine for 24 h, and Cx43 expression was investigated. Moreover, we investigated activation of p38 mitogenic-activated protein kinase (MAPK), p42/44-MAPK, and c-JUN NH(2)-terminal kinase (JNK) by phosphospecific enzyme-linked immunosorbent assay and nuclear translocation of the transcription factors c-fos and activator protein 1 (AP1). For verification of our results, a Cx43-promoter-enhanced green fluorescent protein (EGFP) construct using the complete promoter [2771 base pairs (bp)] or fragments (0-2421 bp) with EGFP under control of the Cx43 promoter was transfected into cardiomyocytes, and fluorescence intensity was investigated. Phenylephrine exposure caused approximately 2-fold up-regulation of Cx43 protein with an EC(50) of approximately 5 nM, which was significantly inhibited by bisindolylmaleimide I [protein kinase C (PKC) inhibitor], 4-(4-fluorophenyl)-2-(4-methylsulfinylphenyl)-5-(4-pyridyl)-1H-imidazole (SB203580; p38 inhibitor), or 2-(2-amino-3-methoxyphenyl)-4H-1-benzopyran-4-one (PD98059; p42/44 inhibitor). Similar findings were obtained for Cx43 mRNA. Furthermore, Cx43 up-regulation was accompanied by phosphorylation of p38, p42/44, and JNK. Moreover, we found translocation of c-fos and AP1 to the nucleus. Phenylephrine stimulation of Cx43-promoter EGFP-transfected cardiomyocytes significantly increased fluorescence, depending on the length of promoter fragments. A 91-bp fragment containing the first AP1 binding site produced approximately 50% of the fluorescence intensity of the complete promoter. Therefore, we conclude that alpha(1)-adrenoceptor stimulation up-regulates cardiac Cx43 expression via a PKC p38- and p42/44 MAPK-regulated pathway, possibly involving AP1.

[Latest proceedings: remote medicine - ready for clinical practice?!]. / Telemedizin in der Kardiologie - Relevanz für die Praxis?!

Changes in the demographic structure, increasing multimorbidity in connection with a rise in the number of chronic illnesses and the absence of an effective coordination of the different levels of healthcare services with its discontinuous processes and redundancies will increase the economic burdens in the German health-care system. Recent developments and appropriate logistic premises nowadays offer a realistic basis for implementing remote medicine as a central service and information tool as well as an instrument controlling the information and data flow between patient, hospital and medical practitioner. This article highlights current and future strategies including diagnostic and therapeutic options. The focus will concentrate on patients with heart rhythm disturbances, advanced congestive heart failure, and patients with implantable devices, i.e., pacemaker and implantable cardioverter defibrillator (ICD).

[ECG telemonitoring]. / EKG-Telemonitoring : Nucleus der Arbeitsgruppe "Telemonitoring" der Deutschen Gesellschaft für Kardiologie - Herz- und Kreislaufforschung.

ECG telemonitoring is the application of single- or multichannel ECGs transmitted by telephone to the physician or an expert center. This enables the control of the health status despite the spatial separation of patient and physician. Cardiac arrhythmias, palpitations of unknown causes, the outcome of antiarrhythmic drug therapy or interventional ablation therapy can be diagnosed using ECG telemonitoring. Even asymptomatic arrhythmias, e.g. paroxysmal atrial fibrillation, may be detected. The use of a multichannel ECG facilitates the early prehospital diagnosis of an acute coronary syndrome and thus helps to optimize the chain of rescue. The telemonitoring of the ECG and additional physiological data enables the tele-care of patients with chronic heart failure. New types of implanted pacemaker or cardioverter/defibrillator devices allow telemonitoring of device data or ECG data for close control.

Analysis of chronic aortic regurgitation by 2D and 3D echocardiography and cardiac MRI.

Purpose The study compares the feasibility of the quantitative volumetric and semi-quantitative approach for quantification of chronic aortic regurgitation (AR) using different imaging modalities. Methods Left ventricular (LV) volumes, regurgitant volumes (RVol) and regurgitant fractions (RF) were assessed retrospectively by 2D, 3D echocardiography and cMRI in 55 chronic AR patients. Semi-quantitative parameters were assessed by 2D echocardiography. Results 22 (40%) patients had mild, 25 (46%) moderate and 8 (14%) severe AR. The quantitative volumetric approach was feasible using 2D, 3D echocardiography and cMRI, whereas the feasibility of semi-quantitative parameters varied considerably. LV volume (LVEDV, LVESV, SVtot) analyses showed good correlations between the different imaging modalities, although significantly increased LV volumes were assessed by cMRI. RVol was significantly different between 2D/3D echocardiography and 2D echocardiography/cMRI but was not significantly different between 3D echocardiography/cMRI. RF was not statistically different between 2D echocardiography/cMRI and 3D echocardiography/cMRI showing poor correlations (r < 0.5) between the different imaging modalities. For AR grading by RF, moderate agreement was observed between 2D/3D echocardiography and 2D echocardiography/cMRI and good agreement was observed between 3D echocardiography/cMRI. Conclusion Semi-quantitative parameters are difficult to determine by 2D echocardiography in clinical routine. The quantitative volumetric RF assessment seems to be feasible and can be discussed as an alternative approach in chronic AR. However, RVol and RF did not correlate well between the different imaging modalities. The best agreement for grading of AR severity by RF was observed between 3D echocardiography and cMRI. LV volumes can be verified by different approaches and different imaging modalities.

Five-year effectiveness of low-dose-rate brachytherapy: comparisons with nomogram predictions in patients with non-metastatic prostate cancer presenting significant control of intra- and periprostatic disease.

PURPOSE: To assess the effectiveness of low-dose-rate (LDR) brachytherapy in patients with localized prostate cancer and to compare the outcome with predictions from Kattan and Partin nomograms at 60 months after seed implantation. MATERIAL AND METHODS: One thousand, one hundred and eighty-seven patients with localized prostate cancer at low-, intermediate-, or high-risk of progression received LDR brachytherapy using iodine-125 seeds with curative intent, applied as monotherapy or in combination with external beam radiation therapy (EBRT), and/or androgen deprivation therapy (ADT). At 60 months after seed implantation, data of 1,064 patients (1,058 alive + 6 who died of prostate cancer) were analyzed for biochemical progression-free survival (bPFS) based on prostate-specific antigen (PSA) levels using the Phoenix definition. Five-year bPFS probabilities were determined for various risk group classifications (d'Amico, Mt. Sinai, MSKCC/Seattle, NCCN). Outcomes were also compared to patient-individualized nomogram predictions of 5-year bPFS (Kattan 2002) and probability of organ-confined disease (Kattan 2002, Partin 2007). RESULTS: Overall, 93.3% (993/1,064) of the patients were free of biochemical progression within 5 years, while the average 5-year bPFS probability according to the Kattan nomogram was significantly lower (85%, p < 0.001). Outcomes were significantly better than Kattan nomogram predictions in the subgroup of patients with monotherapy as well as in patients additionally treated with EBRT. Comparison of the overall outcome with nomogram predictions for organ-confined disease (Kattan nomogram: 50%; Partin nomogram: 65%) revealed a significant probability of LDR brachytherapy to destroy periprostatic tumor spread (p < 0.001) in all risk group constellations, even in high-risk patients. CONCLUSIONS: The results indicate high effectiveness of LDR brachytherapy in all risk groups, significantly better than predicted with the Kattan nomogram in most subgroups. The significant superiority of LDR brachytherapy compared to nomogram predictions of organ-confined disease suggests that LDR brachytherapy effectively controls both intra- and periprostatic disease.