[Current recommendations for diagnostic echocardiography in cancer patients : Is echocardiography too late or too early?] / Aktuelle Empfehlungen für die echokardiographische Diagnostik bei Tumorpatienten : Kommt die Echokardiographie zu spät oder zu früh?

Cardiac dysfunction caused by cardiotoxic treatment can appear at any time during or after therapy and sometimes even after years. To evaluate systolic left ventricular (LV) function assessment of the ejection fraction (EF), especially using 3D technology, is the established base value for cancer therapy-related cardiac dysfunction (CTRCD). It has been found that additional analysis of the LV function using deformation imaging is a more accurate and sensitive tool for detecting subclinical systolic LV dysfunction. Diastolic function parameters are not recommended for screening. The decision to modify oncological treatment and/or to begin specific cardiac treatment after detecting LV dysfunction is based on known data taking both the prognosis and quality of life into consideration and performed in individual cases by a cardio-oncological team of experts. There is a widely held consensus that these patients should be examined in an echocardiographic laboratory which has the appropriate equipment and diagnostic expertise. The lack of multicenter studies and the paucity of outcome data do not yet answer the question if echocardiography is carried out too early or too late. Recommendations on the frequency of standardized follow-up examinations and standardized echocardiographic parameter vary between the specialist societies. Although increased morbidity and mortality due to cardiotoxic treatment are now well known facts, too few patients undergo appropriate examinations.

[Clinical classification and initial diagnosis of pulmonary hypertension: recommendations of the Cologne Consensus Conference 2016]. / Klinische Klassifikation der pulmonalen Hypertonie und initiale Diagnostik: Empfehlungen der Kölner Konsensus Konferenz 2016.

The 2015 European Guidelines on Diagnosis and Treatment of Pulmonary Hypertension are also valid for Germany. The guidelines contain detailed information about the clinical classification and diagnosis of pulmonary hypertension, and furthermore provide novel recommendations for risk stratification and follow-up assessments. However, the practical implementation of the European Guidelines in Germany requires the consideration of several country-specific issues and already existing novel data. This requires a detailed commentary to the guidelines, and in some aspects an update already appears necessary. In June 2016, a Consensus Conference organized by the PH working groups of the German Society of Cardiology (DGK), the German Society of Respiratory Medicine (DGP) and the German Society of Pediatric Cardiology (DGPK) was held in Cologne, Germany. This conference aimed to solve practical and controversial issues surrounding the implementation of the European Guidelines in Germany. To this end, a number of working groups was initiated, one of which was specifically dedicated to the clinical classification and initial diagnosis of PH. This article summarizes the results and recommendations of this working group.

[Telemonitoring of implantable devices. Practical aspects and ongoing studies]. / Telemonitoring implantierbarer Aggregate. Praktische Aspekte und laufende Studien.

Telemedicine is used in various areas of cardiology, e.g., for the detection of cardiac arrhythmias and monitoring coronary artery disease and heart failure. Telemedicine is playing an increasing role is the monitoring of implantable devices (pacemakers, defibrillators, and event recorders). Most manufacturers of these devices have, in the meantime, telemedical concepts. The current guidelines of cardiac societies advocate the implantation of telemedicine-controlled devices. In the practical implementation of telemedicine devices, recruitment and involvement of patients, setting up of telemedicine consultation, legal aspects, and financing questions are of special relevance.

Validity of continuous wave Doppler and colour Doppler in the assessment of aortic regurgitation.

Continuous wave Doppler, colour Doppler, and their combined use were compared for their validity in the semiquantitative evaluation of aortic regurgitation in 80 angiographically proven cases. The diastolic decay slope, as measured from the continuous wave Doppler signal of the aortic regurgitation, correlated well with angiographic data (r = 0.82) and, after classification in three grades, coincided in 78% of all patients. When rated on a three-grade scale the intensity of the aortic regurgitation signal measured by continuous wave Doppler corresponded with invasive data in 82% of patients, and a three-graded maximal width at the base of the colour Doppler regurgitant jet relative to the aortic outflow tract showed agreement in 71%. The best results were obtained by combining continuous wave and colour Doppler indices, which yielded agreement with angiography in 85% of patients. Subdivision of the patient group into those with pure aortic regurgitation and those with combined aortic lesions revealed less accurate gradings with both Doppler methods in the presence of aortic stenosis.

[Balloon valvuloplasty of calcified aortic stenosis is a realistic alternative to surgery: clinical and invasive results 17 months following the 1st or 2d dilatation]. / Die Ballon-Valvuloplastie der kalzifizierten Aortenstenose ist keine realistische Alternative zur Operation: Klinische und invasive Ergebnisse 17 Monate nach 1. oder evtl. 2. Dilatation.

Aortic balloon valvuloplasty was performed in 33 elderly patients (age 60-84, mean 74 years). In six cases, repeat-valvuloplasty was performed six months later. Mean follow-up so far has been 17 months (10-24 months). Follow-up included 23 invasive controls and repeat Doppler-echocardiographic estimation of valve gradient in all patients. At valvuloplasty, peak aortic gradient was reduced from 84 +/- 27 mm Hg to 40 +/- 18 mm Hg, valve area was increased from 0.39 +/- 0.11 cm2 to 0.74 +/- 0.16 cm2. Immediately after valvuloplasty, 76% of the patients were asymptomatic or significantly improved. At follow-up, 10 patients died and 12 patients underwent surgical valve replacement. Only seven patients are still improved or asymptomatic after 1st or 2nd valvuloplasty. Invasive control six to nine months after the 1st valvuloplasty showed satisfactory results for valve gradient and valve area in only one patient. At repeat-valvuloplasty, a mean valve gradient of 29.6 +/- 12.5 mm Hg was achieved. All patients with repeat-valvuloplasty again had invasive control after six months; peak gradient then was 56 +/- 17 mm Hg. Balloon valvuloplasty of acquired aortic valve stenosis is a palliative procedure with a high restenosis-rate. At the most, aortic valve area is doubled. In our opinion, it is only indicated in patients with an unacceptable high surgical risk. Today, old age alone is no contraindication to surgical valve replacement.

[Percutaneous balloon dilatation of membraneous subaortic stenosis in the adult]. / Perkutane Ballondilatation einer membranösen Subaortenstenose beim Erwachsenen.

We report a successful balloon dilatation for discrete subvalvular aortic stenosis in a 26-year-old, highly symptomatic patient. The intraventricular peak gradient was reduced from 140 mm Hg to 40-45 mm Hg; there were no complications. Two months after the procedure, the patient was asymptomatic and the gradient unchanged.

[Patients with transient ischemic attacks. Their cardiac status and its prognostic significance]. / Patienten mit transitorischer ischämischer Attacke. Ihr kardialer Status und seine prognostische Bedeutung.

In 51 consecutive patients with acute transitory cerebral ischaemia cross-sectional echocardiograms, 24-hour electrocardiograms (ECG) and exercise ECGs were recorded. The subsequent observation period averaged 13 (3-30) months. The echocardiogram was abnormal in 27 of 46 patients (58%). A holosystolic mitral-valve prolapse was found in eight: cerebral ischaemia recurred in five. There was no correlation between arrhythmias in the 24-hour ECG and renewed cerebral ischaemia. In addition to the 14 patients who--according to history and resting ECG--had already had a myocardial infarction, the exercise ECG revealed probably coronary heart disease in a further 11, i.e. half of the patients had coronary heart disease. Renewed attacks of cerebral ischaemia occurred in 13 patients during the follow-up period; four patients died, all of them also having had coronary heart disease. Because of the high prevalence of coronary heart disease (often previously undiagnosed) in the whole group, routine exercise ECGs are recommended for patients with transitory ischaemic attacks, protracted ischaemic neurological deficit or "minimal stroke", while 24-hour ECG monitoring does not seem essential. Randomized trials are needed to determine whether patients with cerebral ischaemia and echocardiographic evidence of mitral-valve prolapse should be treated prophylactically.

[Doppler echocardiographic findings in hypertrophic cardiomyopathy]. / Doppler-echokardiographische Befunde bei hypertropher Kardiomyopathie.

This study was performed to evaluate diastolic and systolic flow parameters in patients with hypertrophic cardiomyopathy as assessed by Doppler echocardiography. We examined 45 patients with hypertrophic cardiomyopathy (35 of which had an obstruction) and compared the results of diastolic and systolic measurements with those of two groups of normals (less than 25 years, n = 15; greater than 40 years, n = 10). For the diastolic parameters the isovolumetric relaxation time showed a significant prolongation with 107 +/- 23 ms as compared to normals (greater than 40 years) with 86 +/- 10 ms. No differences were found for the time-to-peak velocity in early diastole. The ratio of the time-velocity-integrals of early and late diastolic filling (E/A) with 2.4 +/- 1.3 was significantly lower as compared to young normals with 4.0 +/- 1.9 but not for the group of normals greater than 40 years with 2.5 +/- 1.0. The time-to-peak velocity in systole (TPVS) of the left ventricular outflow was prolonged in patients with an intracavitary obstruction, and the ratio of TPVS/LVET significant lower as compared to normals. Pressure gradients measured with Doppler showed good correlations to invasive measurements with an r = 0.88, SEE 28.5 mmHg. In color-coded Doppler echocardiography turbulent flow is portrayed as a color-mosaic. The location of turbulence in the outflow tract as well as an accompanying mitral insufficiency are immediately visible, but color-flow Doppler does not allow for quantifying the degree of an obstruction. Conventional and color-coded Doppler echocardiography is an enhancement of noninvasive diagnostics also in hypertrophic cardiomyopathy with respect to the assessment of pathologically changed systolic and diastolic flow parameters, the localization and quantification of an obstruction and the assessment and semiquantification of an concomitant mitral regurgitation.

[Non-invasive determination of left ventricular ejection fraction using a mobile ECG-triggered scintillation measuring probe. Comparison of cineventriculography, echocardiography and radionuclide ventriculography]. / Nichtinvasive Bestimmung der linksventrikulären Ejektionsfraktion mit einer mobilen EKG-getriggerten Szintillationsmesssonde. Korrelation zu Cineventrikulographie, Echokardiographie und Radionuklidventrikulographie.

In 29 unselected patients, the left ventricular ejection fraction was evaluated using a mobile ECG-gated scintillation probe (Nuclear Stethoscope) after in vivo labeling of the erythrocytes with 15 mCi technetium-99m. To validate the method, the Nuclear Stethoscope measurements were correlated to the results of: 1. Single-plane contrast cineventriculography in the right and left anterior oblique projections (RAO, LAO), 2. Radionuclide ventriculography with a gamma camera computer system, 3. Two-dimensional echocardiography from the apical two- and four-chamber views. The ejection fraction measured by the Nuclear Stethoscope showed a close correlation to the values obtained by cineventriculography in the RAO projection (r = 0.748) and radionuclide ventriculography (r = 0.785). In this group of unselected patients, the correlations with the results of two-dimensional echocardiography were poor (r = 0.451 and 0.557). Cineventriculographic findings and radionuclide ventriculography correlated well (RAO: r = 0.786; LAO: r = 0.758). The Nuclear Stethoscope provides a simple, reliable, and noninvasive method for measuring ventricular ejection fraction. Ongoing studies indicate that the Nuclear Stethoscope is a valid method even at a lower dose of 5 mCi technetium-99m.