African and Asian leopards are highly differentiated at the genomic level.

Leopards are the only big cats still widely distributed across the continents of Africa and Asia. They occur in a wide range of habitats and are often found in close proximity to humans. But despite their ubiquity, leopard phylogeography and population history have not yet been studied with genomic tools. Here, we present population-genomic data from 26 modern and historical samples encompassing the vast geographical distribution of this species. We find that Asian leopards are broadly monophyletic with respect to African leopards across almost their entire nuclear genomes. This profound genetic pattern persists despite the animals' high potential mobility, and despite evidence of transfer of African alleles into Middle Eastern and Central Asian leopard populations within the last 100,000 years. Our results further suggest that Asian leopards originated from a single out-of-Africa dispersal event 500-600 thousand years ago and are characterized by higher population structuring, stronger isolation by distance, and lower heterozygosity than African leopards. Taxonomic categories do not take into account the variability in depth of divergence among subspecies. The deep divergence between the African subspecies and Asian populations contrasts with the much shallower divergence among putative Asian subspecies. Reconciling genomic variation and taxonomy is likely to be a growing challenge in the genomics era.

Ancestral mitogenome capture of the Southeast Asian banded linsang.

Utilising a reconstructed ancestral mitochondrial genome of a clade to design hybridisation capture baits can provide the opportunity for recovering mitochondrial sequences from all its descendent and even sister lineages. This approach is useful for taxa with no extant close relatives, as is often the case for rare or extinct species, and is a viable approach for the analysis of historical museum specimens. Asiatic linsangs (genus Prionodon) exemplify this situation, being rare Southeast Asian carnivores for which little molecular data is available. Using ancestral capture we recover partial mitochondrial genome sequences for seven banded linsangs (P. linsang) from historical specimens, representing the first intraspecific genetic dataset for this species. We additionally assemble a high quality mitogenome for the banded linsang using shotgun sequencing for time-calibrated phylogenetic analysis. This reveals a deep divergence between the two Asiatic linsang species (P. linsang, P. pardicolor), with an estimated divergence of ~12 million years (Ma). Although our sample size precludes any robust interpretation of the population structure of the banded linsang, we recover two distinct matrilines with an estimated tMRCA of ~1 Ma. Our results can be used as a basis for further investigation of the Asiatic linsangs, and further demonstrate the utility of ancestral capture for studying divergent taxa without close relatives.

[Coronary intervention. 2012 update]. / Koronarintervention. Update 2012.

In-stent restenosis and stent thrombosis are still the main topics of any update on coronary intervention. One of the challenging issues in the past year lay in answering the question of whether the data on first-generation drug-eluting stents are still relevant in the light of newer stent designs and drugs. Other issues include new strategies in antiplatelet therapy, treatment of in-stent restenosis, particularly drug-eluting stent restenosis, treatment of multivessel and left-main disease, as well as the latest developments in bioresorbable polymers and "scaffolds". In the light of demographic changes, the main challenge for the interventional community is to build an evidence base for the adequate treatment of elderly patients in order to resolve uncertainties in the treatment of this challenging patient group.

[Diabetes and dementia]. / Diabetes und Demenz.

Diabetes mellitus is a known risk factor for cognitive dysfunction and dementia. Chronic hyperglycemia, genetic predisposition, arterial hypertension, hyperlipoproteinemia, micro- and macrovascular diseases, and depression play a major role in the development of cognitive dysfunction. Both pathophysiology of diabetes and dementia and the specifics of diabetes therapy in patients with dementia are presented in this review.

Dual source multidetector CT-angiography before Transcatheter Aortic Valve Implantation (TAVI) using a high-pitch spiral acquisition mode.

OBJECTIVES: Transcatheter Aortic Valve Implantation (TAVI) is an alternative to surgical valve replacement in high risk patients. Angiography of the aortic root, aorta and iliac arteries is required to select suitable candidates, but contrast agents can be harmful due to impaired renal function. We evaluated ECG-triggered high-pitch spiral dual source Computed Tomography (CT) with minimized volume of contrast agent to assess aortic root anatomy and vascular access. METHODS: 42 patients (82 ± 6 years) scheduled for TAVI underwent dual source (DS) CT angiography (CTA) of the aorta using a prospectively ECG-triggered high-pitch spiral mode (pitch = 3.4) with 40 mL iodinated contrast agent. We analyzed aortic root/iliac dimensions, attenuation, contrast to noise ratio (CNR), image noise and radiation exposure. RESULTS: Aortic root/iliac dimensions and distance of coronary ostia from the annulus could be determined in all cases. Mean aortic and iliac artery attenuation was 320 ± 70 HU and 340 ± 77 HU. Aortic/iliac CNR was 21.7 ± 6.8 HU and 14.5 ± 5.4 HU using 100 kV (18.8 ± 4.1 HU and 8.7 ± 2.6 HU using 120 kV). Mean effective dose was 4.5 ± 1.2 mSv. CONCLUSIONS: High-pitch spiral DSCTA can be used to assess the entire aorta and iliac arteries in TAVI candidates with a low volume of contrast agent while preserving diagnostic image quality.

The transradial approach. An increasingly used standard for coronary diagnosis and interventions.

In the 20 years since its introduction, radial access for diagnostic and interventional coronary procedures has been well validated in countless scientific studies. Nevertheless, the use of this access route varies greatly among--and even within--countries. Fear of the unknown may make some experienced interventionalists hesitant to adopt the transradial approach in spite of its proven advantages. In our review, we describe practical aspects of the transradial access, such as the role of Allen's test in patient selection and considerations on the optimal puncture technique of the radial artery. Catheter selection, anatomic variations which may complicate access, as well as strategies to avoid and/or manage possible complications are outlined. Finally, we review the literature on the reduction of access site complications by adopting the transradial approach. Even in interventions for acute myocardial infarction, transradial access can be used safely and effectively. In addition to a reduced rate of access site complications, a reduction in overall in-hospital major adverse cardiac events has been demonstrated. The advantage regarding access site complications could be seen even when closure devices were utilized for transfemoral procedures.

Recommendations for transoesophageal echocardiography: update 2010.

Transoesophageal echocardiography (TOE) is a standard and indispensable technique in clinical practice. The present recommendations represent an update and extension of the recommendations published in 2001 by the Working Group on Echocardiography of the European Society of Cardiology. New developments covered include technical advances such as 3D transoesophageal echo as well as developing applications such as transoesophageal echo in aortic valve repair and in valvular interventions, as well as a full section on perioperative TOE.

Sequential changes in myocardial function after valve replacement for aortic stenosis by speckle tracking echocardiography.

AIMS: Regional myocardial function may change differently in different pathology. Speckle tracking echocardiography (STE) was applied to evaluate longitudinal, radial, and circumferential function in patients with aortic stenosis (AS) before, within 1 week, and 6 months after aortic valve replacement (AVR). METHODS AND RESULTS: In 40 consecutive patients with severe AS, we acquired apical four-, three-, and two-chamber views and standard short-axis view pre- and post-AVR and after 6 months. Longitudinal, radial, and circumferential (LS, RS, and CS) were calculated by commercial STE software. Further, we analysed diastolic myocardial function by measuring E/e' ratio. With AVR, valve area increased and remained stable at 6 months follow-up. Left ventricular mass was unchanged 1 week after AVR (270 +/- 58 g vs. 267 +/- 58 g, n.s.) but decreased significantly during the next 6 months (219 +/- 50 g, P < 0.05). Left ventricular ejection fraction remained unchanged. Strain values did not change significantly within 1 week after AVR but increased significantly after 6 months (LS by 16%, RS by 21%, and CS by 28% of baseline values). E/e' ratio was highly augmented before AVR (26.1 +/- 12.5) and decreased significantly 6 months after AVR (15.9 +/- 5.9). CONCLUSION: Myocardial function significantly recovers after replacing the stenosed aortic valve. However, there is a considerable difference between the response of longitudinal, radial, and circumferential function. Our data suggest that echocardiographic assessment of regional function is feasible and of potential clinical importance.

Clinical characteristics of patients with obstructive coronary lesions in the absence of coronary calcification: an evaluation by coronary CT angiography.

BACKGROUND: Multidetector CT allows detection of coronary artery calcium and, after contrast injection, visualisation of the coronary artery lumen. It is commonly assumed that the absence of coronary calcification makes the presence of obstructive coronary lesions highly unlikely. This study evaluates the clinical characteristics of patients with at least one symptomatic, high-grade coronary artery stenosis in both computed tomography and invasive angiography but absence of any coronary calcification and compares the results with patients with stenoses in the setting of detectable coronary calcium PATIENTS AND METHODS: The study retrospectively identified 21 consecutive patients with symptoms in whom a high-grade coronary artery stenosis had been identified in 64-slice or dual-source CT coronary angiography (Siemens Sensation 64 or Siemens Definition, 120 kV, 50 to 85 ml of intravenous contrast at 5 ml/s) in the absence of coronary calcium and in whom that finding had been confirmed by invasive coronary angiography. Clinical presentation ("unstable": all forms of acute coronary syndrome versus "stable": stable chest pain or dyspnoea on exertion) and standard cardiovascular risk factors were assessed, and the results were compared with 42 consecutive patients with symptoms in whom both coronary calcium and coronary stenoses had been identified in computed tomography and invasive coronary angiography. RESULTS: The majority of patients with coronary stenoses in the absence of coronary calcium presented with "unstable" symptoms (non-ST-segment elevation myocardial infarction (NSTEMI) or unstable angina), significantly more frequently than patients with detectable calcification (71% vs 26%, p = 0.001). The age range of patients without calcium was 33 to 76 years, their mean age was younger (53 (SD 13) vs 63 (8) years, p<0.001), but none of the risk factors showed any significant difference compared with patients with calcification. CONCLUSION: The presence of significant coronary artery stenosis in the absence of coronary calcium is possible. It is more likely in the setting of unstable angina or NSTEMI than in stable chest pain and occurs more frequently in younger patients.

[Initial experience with prospectively triggered, sequential CT coronary angiography on a 128-slice scanner]. / Erste Erfahrungen mit der sequenziellen, prospektiv getriggerten CT-Koronarangiografie an einem 128-Schicht-Computertomografen.

PURPOSE: Spiral CT angiography (CTA) of the coronaries using low-pitch scanning and ECG-gated image reconstruction is a robust method for detecting or excluding relevant coronary plaque. However, the resulting dose exposure is considerable. The aim of the present study was to evaluate image quality and artifacts as well as to record dose values for sequential coronary CTA using a 128-slice scanner with a temporal resolution of 150 ms. MATERIALS AND METHODS: 20 patients with a regular heart rate and without contraindications for oral/I.V. beta blockers, who were referred for CTA of the coronaries for exclusion or detection of relevant plaques, were examined by sequential CTA with the following parameters: 120 kV, 200 ref mAs, collimation 2 x 64 x 0.6, table feed of 34.5 mm at a detector width of 38.4 mm. A total acquisition time of 380 ms per table position allowed for mild shifting of the reconstruction window within the cardiac cycle of +/- 5 %. 50 ml of contrast agent were injected at 5 ml/s followed by a 50 ml split bolus (20 % contrast). The individual start delay was determined by a test bolus scan (10 ml contrast + 50 ml saline flush at 5 ml/s). The image quality for each segment, coronary artery, and patient was determined on a 4-point scale. Dose values were estimated based on the individual dose length product as provided by the scanner's patient protocol. Artifacts were evaluated to determine the cause (calcium vs. motion). RESULTS: All patients received beta blocker pretreatment. The mean heart rate was 62 +/- 5 beats/min. 5 % (13 / 286) of all segments in 5 / 20 patients were rated as non-diagnostic. The mean dose length product was 213 mGy x cm, and the mean effective dose was 3.6 mSv. Calcifications were the major cause of non-diagnostic images. However breathing or other motion artifacts occurred as well. CONCLUSION: In select patients with effective heart rate control and thorough instruction for breath hold compliance, sequential CTA of the coronaries using a 128-slice scanner with a temporal resolution of 150 ms is technically feasible. The resulting effective dose values are clearly below those of spiral coronary CT scans.

CD40/CD154 system and pro-inflammatory cytokines in young healthy male smokers without additional risk factors for atherosclerosis.

OBJECTIVE AND DESIGN: Atherosclerosis, as an inflammatory disease, is characterized by pathologically altered levels of cytokines. We investigated whether smoking affects the CD40/CD154 system and pro-inflammatory cytokines in young males without other risk factors for atherosclerosis. SUBJECTS: Young male smokers (n=13) and 14 non-smoking controls were investigated. METHODS: The differences in CD40/CD154 system and serum cytokines between the groups were measured using flow cytometry and ELISA. RESULTS: In smokers, there was a strong trend (P<0.06) for increased CD40 expression on platelets as compared with non-smokers. However, there were no significant differences in CD40 expression on monocytes or in CD154 expression on platelets and T-cells between smokers and non-smokers. There was a strong trend for increased platelet-monocyte aggregates in smokers (P<0.06). Also, smokers had slightly but not significantly elevated hsCRP and IL-6 levels, and slightly decreased TNF-alpha and MCP-1. Interestingly, IL-18, a cytokine which has the ability to promote both Th1 and Th2 responses, was significantly decreased in smokers group (P=0.03 vs controls). CONCLUSIONS: In young healthy males, smoking is not associated with dramatic changes in CD40/CD154 system. However, cigarette smoke alters the secreted cytokine profile, leading to significant decrease in systemic IL-18 levels.

Elevated VEGF-plasma levels in young patients with mild essential hypertension.

BACKGROUND: Growing evidence shows that inflammation plays a pivotal role in the pathophysiology of essential hypertension (EH). Vascular endothelial cell growth factor (VEGF) is currently discussed as a possible mediator of inflammation. To investigate the hypothesis that VEGF plays a role as an inflammatory mediator in EH we performed the present pilot study of young patients in a very early stage of EH. MATERIALS AND METHODS: 15 young patients with mild EH [33.8 +/- 7.3 years, systolic blood pressure (SBP): 143.8 +/- 10.5 mmHg, diastolic blood pressure (DBP): 88.2 +/- 11.1 mmHg, mean arterial pressure (MAP) 106.6 +/- 10.4 mmHg] and 15 healthy controls (31.7 +/- 10.6 years) were examined. Blood was drawn from a peripheral vein and serum levels of VEGF, monocyte-chemoattractant-protein (MCP)-1, high-sensitivity C-reactive protein (hsCRP), interleukin (IL)-6, and tumour-necrosis-factor (TNF)-alpha were measured via commercially available enzyme-linked immunoassays. RESULTS: Hypertensives showed increased plasma levels of VEGF (P < 0.05) and MCP-1 (P < 0.05). VEGF positively correlated with MAP (r = 0.46, P < 0.05) and MCP-1 (r = 0.63, P < 0.01). Multivariate analysis demonstrated VEGF to be an independent predictor of MCP-1 levels. Furthermore, hypertensives had higher levels of hsCRP (P < 0.01), IL-6 (P < 0.001) and TNF-alpha (P < 0.05). IL-6 levels correlated with SBP (r = 0.59, P < 0.001), DBP (r = 0.67, P < 0.001) and MAP (r = 0.46, P < 0.001). A significant positive correlation was also found between hsCRP levels and SBP (r = 0.39, P < 0.05). CONCLUSIONS: This pilot study demonstrates that in an early state of EH, inflammatory pathways have already been activated. Besides classical pro-inflammatory cytokines, VEGF serum levels are significantly elevated. The positive correlation of VEGF with MCP-1 is suggestive for the already described induction of MCP-1 via VEGF.

Assessment of regional left ventricular function by dual source computed tomography: interobserver variability and validation to laevocardiography.

OBJECTIVE: Assessment of left ventricular function is possible in contrast-enhanced cardiac CT data sets. However, rapid ventricular motion especially in systole can lead to artifacts. Dual Source Computed Tomography (DSCT) has high temporal resolution which effectively limits motion artifact. We therefore assessed the accuracy of DSCT to detect regional left ventricular wall motion abnormalities in comparison to invasive cine angiocardiography. METHODS: We analyzed DSCT data sets of 50 patients (39 male, 11 female, mean age: 61+/-10 years) which were acquired after intravenous injection of 55-70 mL contrast agent (rotation time: 330 ms, collimation: 2 mm x 64 mm x 0.6 mm, 120 kV, 380 mAs, ECG-correlated tube current modulation). 10 data sets consisting of transaxial slices with a slice thickness of 1.5 mm, an increment of 1.0 mm and a matrix of 256 x 256 pixels were reconstructed at 10 time instants during the cardiac cycle (0-90% in 10% increments). The data sets were analyzed visually by two independent readers, using standard left ventricular planes, concerning regional wall motion abnormalities. DSCT was verified in a blinded fashion against cine ventriculography performed during cardiac catheterization (RAO and LAO projection), using a 7-segment model. Analysis was performed on a per-patient (presence of at least one hypo-, a- or dyskinetic segment) and on a per-segment basis. RESULTS: Concerning the presence of a wall motion abnormality, the two observers agreed in 340/350 segments (97%) and 48/50 patients (96%). In invasive cine angiocardiography, 22 of 50 patients displayed at least one segment with abnormal contraction. To detect these patients, DSCT showed a sensitivity of 95% (21/22), specificity of 96% (27/28), positive predictive value of 95% and negative predictive value of 96%. Out of a total of 350 left ventricular segments, 66 segments had abnormal contraction in cine angiocardiography (34 hypokinetic, 26 akinetic, 6 dyskinetic). For detection of these segments, DSCT had a sensitivity of 88% (58/66), specificity of 98% (278/284), positive predictive value of 91% (58/64) and negative predictive value of 97% (278/286). CONCLUSION: DSCT allows the detection of regional wall motion abnormalities with high interobserver agreement as well as high sensitivity and specificity. Whereas sensitivity and positive predictive value were higher in a per-patient- in comparison to a per-segment-based analysis, specificity, negative predictive value and interobserver agreement did not differ considerably between both analyzing methods.

Differentiation of total occlusion and high-grade stenosis in coronary CT angiography.

In coronary CT angiography (CTA), both high-grade stenoses and total occlusions of a coronary artery may appear as a complete interruption of the contrast-enhanced lumen. Parameters to differentiate between occlusions and stenoses have not been systematically assessed. We evaluated 40 consecutive patients with a lesion demonstrating complete interruption of the contrast-enhanced lumen in coronary CTA and in whom invasive coronary angiography was available. Length of the vessel segment without luminal contrast enhancement; luminal enhancement proximal, in and distal to the lesion; degree of coronary remodelling; and the degree of lesion calcification were assessed by a blinded observer unaware of the invasive angiogram. Mean length of complete occlusions (n = 20; range 4-54 mm; mean 16.6 +/- 3.5 mm) was significantly longer than for high-grade stenoses (n = 20; 2-8 mm; mean 4.6 +/- 1.7 mm, p < 0.001). A lesion length > or = 9 mm was 100% specific and 70% sensitive for an occlusion. No significant differences were found for vessel enhancement in or distal to the lesion, remodelling index or degree of calcification. Lesion length is the only parameter that may differentiate complete occlusions and high-grade stenoses in coronary CTA. For lesions > or = 9 mm, an occlusion is very likely.

Platelets contribute to enhanced MCP-1 levels in patients with chronic heart failure.

BACKGROUND: Increasing scientific data suggest a role for inflammation in chronic heart failure (CHF), but up to now the exact mechanisms are still not clear. Recently, platelets were identified as inducing inflammation partly by releasing cytokines. This new aspect necessitates further studies about the contribution of platelets for the inflammatory setting of CHF. METHODS: 50 CHF patients (mean 66.9 (SD 12.6) years, mean EF 22.1% (SD 9.1)) and 25 healthy controls (mean 63.6 (SD 10.2) years) were examined. MCP-1 serum levels were measured via EIA, expression of platelet CD154 by flow cytometry. In in-vitro experiments activated platelets were cocultured with human umbilical vein endothelial cells (HUVEC) in the presence and absence of anti-CD154 antibodies. MCP-1 in the supernatants was measured by EIA. RESULTS: CHF patients showed significantly enhanced MCP-1 levels (median: 191.8; 25th centile: 153.7; 75th centile: 227.1 pg/ml vs median: 101.0; 25th centile: 86.7; 75th centile: 117.5 pg/ml, p<0.001). MCP-1 levels positively correlated with severity of CHF. In the cell coculture model activated platelets were able to significantly induce MCP-1 release from HUVEC in a CD154-dependent manner. Furthermore, CHF patients showed enhanced platelet CD154 expression with a positive correlation with MCP-1 levels. Aspirin therapy had no influence on either CD154 expression or MCP-1 levels. CONCLUSIONS: Platelets can contribute to enhanced MCP-1 levels in CHF. MCP-1 is markedly elevated in serum of CHF patients showing a direct correlation with the severity of symptoms and the degree of left ventricular dysfunction. Further studies are required to test whether MCP-1 blocking or sophisticated anti-platelet strategies may represent new therapeutic options in CHF.

Interobserver variability of 64-slice computed tomography for the quantification of non-calcified coronary atherosclerotic plaque.

PURPOSE: Multidetector CT (MDCT) is a reliable tool to assess and quantify calcified plaque in coronary arteries. Only very limited information is available concerning the accuracy of MDCT for evaluating non-calcified plaque. We determined the interobserver variability for measuring non-calcified plaque volumes in the three main coronary arteries using 64-slice computed tomography. MATERIALS AND METHODS: We retrospectively evaluated data sets of 41 patients who received a 64-slice CT scan (Sensation 64, Siemens Forchheim, Germany, 330 msec rotation, 0.6 mm collimation, 60 ml contrast agent i. v. at 5 ml/sec) due to suspected stable coronary artery disease. The patients showed presence of non-calcified plaque in the proximal part of at least one main coronary artery. The image quality was defined on the basis of a 4-point rating scale. Two independent and blinded investigators measured the plaque volume of the non-calcified plaque by manually tracing plaque areas in contiguous cross-sectional reconstructions rendered along the vessel centerline using a slice thickness of 1 mm and an increment of 0.5 mm. The interobserver variability was evaluated and the influence of plaque volume and image quality on interobserver variability was determined. RESULTS: The mean volume of non-calcified plaque was 157 +/- 85 mm (3), 76 +/- 43 mm (3) and 133 +/- 80 mm (3) for the LAD, LCX and RCA, respectively (LAD vs. LCX: p < 0.01; LAD vs. RCA: p = 0.33; LCX vs. RCA: p < 0.01). There was a mean absolute difference in plaque volume between the two observers of 23 +/- 15 mm (3), of 20 +/- 9 mm (3) and of 38 +/- 21 mm (3), which corresponds to a mean interobserver variability of 17 +/- 10 %, 29 +/- 13 % and 32 +/- 13 % for the LAD, LCX and RCA, respectively (LAD vs. LCX: p < 0.01; LAD vs. RCA: p < 0.01; LCX vs. RCA: p = 0.87). A significant inverse correlation between interobserver variability and the extent of the plaque volume (r = - 0.48; p = 0.01) was found. Interobserver variability was dependent on image quality: The highest image quality was observed in the LAD (2.4 +/- 0.5), while the image quality in the LCX (2.1 +/- 0.7) and the RCA (2.0 +/- 0.6) was lower. CONCLUSION: Interobserver variability for the quantification of non-calcified plaque volumes in 64-slice MDCT is substantial. Interobserver variability in the LAD was significantly lower than in the LCX and the RCA. This might be due to a larger mean plaque volume and better image quality in the LAD than in other coronary arteries.

[Chance finding of a bilateral central pulmonary embolism while using cardiac computed tomography for the clarification of a coronary anomaly]. / Zufallsbefund beidseitiger zentraler Lungenembolien bei kardialer Computertomographie zur Klärung einer Koronaranomalie.

HISTORY: A 42 year-old man reported transient breathlessness and chest pain on the first day after a four-hour flight. During the following five months the symptoms recurred four times. After another episode he went to an outpatient department for further assessment. INVESTIGATIONS: Blood tests demonstrated slightly elevated LDH (343 U/l) and also a minor increase of the D-dimers (710 microg/l). Hypercholesterolemia was also found (LDL-cholesterol 180 mg/dl). The rest of the blood tests, including the cardiac enzymes, were within normal limits. The electrocardiogram (ECG) showed sinus rhythm, heart rate 85 bpm and pre-terminal T-negativity in the precordial leads V1 to V3. Resting echocardiography and chest X-ray showed no significant abnormalities. The exercise ECG demonstrated no further ECG changes. However, because of the symptoms and a cardiovascular risk profile (family history, hypercholesterolemia and smoking) a coronary angiography was performed, which excluded coronary artery disease but revealed a so-called "right-sided single coronary artery", the left and right coronary arteries originating with a common stem from the right sinus of valsalva. To define the exact course of the left main coronary artery (whether in front of the pulmonary artery, between the two great arteries, retroaortic or septal) a contrast-enhanced cardiac computed tomography (CT) was performed, which demonstrated an anomalous position of the left main coronary artery in front of the pulmonary artery. Bilateral pulmonary embolism was an additional and unexpected finding. TREATMENT AND COURSE: Oral anticoagulation was initiated after a coagulopathy had been excluded. The ultrasonography of the leg did not demonstrate any thrombosis. There was no evidence of malignant disease. CONCLUSION: Mild symptoms and absence of right heart congestion do not exclude pulmonary embolism. Depending on the symptoms and history, pulmonary thrombembolism has to be considered, especially if cardiac or extra-cardiac causes have been eliminated. The diagnostic method of choice for the detection or exclusion of pulmonary embolism is contrast-enhanced multi-slice spiral CT.