[Clinical aspects of heart failure: trepopnea]. / Trepopnoe bei chronischer Herzinsuffizienz.

Most patients with chronic heart failure feel uncomfortable in left lateral decubitus position (LLD). They suffer from trepopnea. In LLD position cardiac sympathetic activity and preload are increased. Cardiac output is decrased. The right lateral decubitus position (RLD) can help to avoid discomfort in heart failure. RLD position may be a self-protective strategy of patients with heart failure to gain preferable hemodynamic parameters.

[Is endothelial dysfunction of practical relevance?]. / Droht Atherosklerose? Endothelfunktion messen.

Endothelial dysfunction is a "systemic disease" and a predictor of preclinical atherosclerosis. A relatively simple-to-perform and reliable diagnostic method of evaluating endothelial function is the measurement of the forearm blood flow (FBF). Unremarkable vasoreactivity of the brachial artery on performing FBF measurement is a prognostically favorable sign. This applies equally to patients with cardiovascular risk factors such as hypertension, hyperlipidemia or diabetes mellitus, and to patients with angina pectoris. A number of investigations suggest that cardiovascular endpoints can be significantly diminished by reducing the risk factors.

[Curative therapy in symptomatic atrial ectopy]. / Kurative Therapie bei symptomatischer atrialer Extrasystolie.

A female patient without underlying heart disease was highly symptomatic from short runs of atrial ectopy. Sustained atrial tachycardia or atrial fibrillation never occurred. Due to ineffective pharmacological therapy, catheter ablation combined with electroanatomic mapping (CARTO) was performed effectively. Characteristics of ectopic atrial tachycardia and the electrophysiological techniques are described.

[Acute aortic syndrome. A thoracic emergency--unfortunately with a large selection of symptoms]. / Das akute Aortensyndrom. Ein thorakaler Notfall--leider mit grosser Symptom-Bandbreite!

Acute aortic arch syndrome is a medical emergency associated with a high mortality rate. In view of the great variation in symptomatology, this condition can readily be overlooked. A carefully obtained history (pain!), a thorough physical examination (differences in pulse and blood pressure) may be suspicious for acute aortic arch syndrome, which today can be reliably and rapidly diagnosed by noninvasive imaging (CT, TEE). Confirmation of the suspected diagnosis must be followed by further intensive medical surveillance (Stanford B) or, in the event of involvement of the ascending aorta or aortic arch (Stanford A), referral without delay to a cardiosurgical center. Apart from a further shortening of the time lapse between diagnosis establishment and emergency surgery, new therapeutic (e.g. stenting) and surgical procedures may improve the prognosis of the syndrome. Maybe new diagnostic tools (monoclonal antibodies against aortic myosin and radio-immunoscintigraphy) will help to recognize the aortic syndrome more rapidly.

Thrombus formation after transcatheter closure of atrial septal defect.

Thrombotic layers and/or atrial thrombi were detected by transesophageal echocardiography as a usual finding after transcatheter closure of atrial septal defects with the ASDOS device. The size of the thrombotic structures regularly decreased within 6 months without any clinical signs of embolization.

High-speed rotational atherectomy of human coronary stenoses: acute and one-year outcomes from the New Approaches to Coronary Intervention (NACI) registry.

High-speed rotational atherectomy (RA) is a new percutaneous procedure for treatment of coronary stenoses that operates by the unique mechanism of plaque abrasion. This article reports acute (in-hospital) outcomes and 1-year follow-up in a large cohort of patients treated with this device by NACI investigators. A total of 525 patients with 670 lesions treated with RA form the substrate of this report. Patients tended to be older (mean age 64.8 years) than those in previously reported series of percutaneous transluminal coronary angioplasty (PTCA), with more extensive disease and more complex lesions. Calcification was present in 54% of lesions, and eccentricity in 41%. Balloon angioplasty postdilation was performed after RA in 88% of cases. Angiographic and procedural success (angiographic success without death, Q-wave myocardial infarction [MI] or emergency coronary artery bypass graft [CABG] surgery) rates were 89% and 88%, respectively. Acute in-hospital events included 4 deaths (1%) and 1 emergency CABG surgery (0.4%). MI occurred in 6% of patients, consisting predominantly of non-Q-wave MI (5%). After RA, angiographic complications included coronary dissection (12%), abrupt closure (5%), side branch occlusion (3%), and distal embolization (3%). Most of these were resolved after postdilation except for coronary dissection, which was present in 15% of lesions treated. Mean length of stay was 3 days. At 1-year follow-up, 27% of patients required target lesion revascularization and 30% had experienced death, Q-wave MI, or target lesion revascularization. Preprocedural characteristics that independently predicted 1-year death, Q-wave MI, or target lesion revascularization were male gender, high risk for surgery, target lesions that were proximal to or in bifurcations, eccentric, long, or highly stenosed. RA, even when applied to lesions of traditionally unfavorable morphology, appears to provide reasonable procedural and angiographic success rates. Restenosis and progression of disease contribute to subsequent clinical and procedural events.

[Dissection following balloon angioplasty: predictive possibilities using pre-interventional intravascular ultrasonography]. / Dissektion nach Ballonangioplastie: Vorhersagemöglichkeit mit präinterventionellem intravaskulärem Ultraschall.

The purpose of this study was to examine the association between qualitative and quantitative lesion characteristics before and the incidence of dissection after balloon angioplasty as assessed by intravascular ultrasound imaging. Thirty-seven patients (5 women, 32 men, aged 60 +/- 9 years) with 41 dilated lesions were examined with a 3.5 F, 20 MHz rotational tip intravascular ultrasound imaging system before and immediately after coronary balloon angioplasty. Images were assessed for plaque composition, topography and postinterventional effects on the plaque morphology. Quantitative measurements of lumen area, total arterial area and plaque area were performed in the dilated vessel segment. Plaque morphology was concentric in 18 lesions (44%) and eccentric in 23 lesions (56%). Fourteen lesions (34%) showed no calcification, 15 lesions (37%) were superficially and 12 lesions (29%) were deeply calcified. Four distinct changes of the plaque morphology were manifested by ultrasound imaging after balloon angioplasty. Dissection with detachment of the plaque from the underlaying wall was found in 10 lesions, plaque splitting in 9 lesions, superficial tears in 6 lesions, and smooth plaque contours in 16 lesions. The incidence of dissection detected by intravascular ultrasound was significantly greater in eccentric lesions (p = 0.03) and in stenoses with a small total arterial area (p = 0.006). The incidence of dissection was significantly increased in vessels in which balloon cross-sectional area exceeded 50% of the total cross-sectional vessel area as compared to those with a smaller balloon-to-vessel ratio. Preinterventional IVUS imaging provides information about the target stenosis which can be used to assess the risk of postinterventional dissections. In addition to the size of the balloon in relation to vessel cross-sectional area, the features small total vessel cross-sectional area and eccentric stenosis morphology in the preinterventional IVUS study predispose to an increased risk of dissection. Further studies have to elucidate the influence of dissections on late outcome after angioplasty.