Intermittent complete atrioventricular block in a 20-year-old woman with cardiac sarcoidosis: a case report.

Background: Atrioventricular conduction disturbance may rarely be caused by cardiac involvement of sarcoidosis. Case summary: A 20-year-old Caucasian female with exertional dyspnoea was admitted to the hospital. Electrocardiogram revealed intermittent complete atrioventricular block with ventricular escape rhythm. Laboratory findings indicated no obvious cause for the complete heart block, and echocardiography showed no abnormalities with normal systolic left ventricular function. However, in gadolinium-enhanced cardiovascular magnetic resonance imaging, a mass at the basal septum with high intensity of T2-weighted signal was found, and 18-fluorodeoxyglucose positron emission tomography revealed severe enhancement in this area and in the mediastinal lymph nodes. The diagnosis of cardiac sarcoidosis was established by the detection of non-caseating epithelioid granulomas in the endobronchial lymph node biopsy. Corticosteroid therapy with oral administration of 30 mg prednisolone was initiated, and complete recovery of atrioventricular block was observed within several weeks, obviating the need for permanent pacemaker implantation. Discussion: Cardiac sarcoidosis can cause complete atrioventricular block and should always be considered, especially in younger patients. Early diagnosis and initiation of corticosteroid therapy may lead to complete recovery of conduction system without the need for permanent pacemaker implantation.

The ALSTER-TAVI All-Comers Registry: Procedural and 1-Year Clinical Outcomes of Balloon-Expandable vs Self-Expanding Contemporary TAVI Valves.

OBJECTIVES: Both balloon-expandable and self-expanding transcatheter aortic valves are used for transcatheter aortic valve implantation (TAVI). We compared procedural and clinical outcome variables of Sapien 3 and Evolut R/Pro in an all-comers collective. METHODS: In this single-center registry, patients were consecutively treated with the Sapien 3 from November 2014 to March 2017 (n = 129) and from April 2017 to December 2018 mainly (>95%) with the Evolut R/Pro (n = 124), due to a switch in the main TAVI supplier driven by hospital management. Data were retrospectively analyzed before and after the switch. RESULTS: One-year follow-up data were available for 122 (94%) of the Sapien and 112 (90%) of the Evolut patients. Baseline characteristics were comparable (EuroSCORE: Sapien 21.8 ± 0.9% vs Evolut 22.5 ± 0.8%; P=.20). Evolut implantation was associated with a higher radiation dose (Sapien 35770 ± 2345 mGy•cm² vs Evolut 85072 ± 8202 mGy•cm²; P<.001), more postimplantation balloon dilations (Sapien 17.1% vs Evolut 37.1%; P<.001), but similar procedure time (Sapien 75.2 ± 3.8 min vs Evolut 74.6 ± 3 min; P=.30). In-hospital mortality (Sapien 3.1% vs Evolut 4.0%; P=.70), all-cause mortality (Sapien 13.2% vs Evolut 15.3%; P=.70), all-stroke rate (Sapien 1.5% vs Evolut 6.5%; P=.05), and pacemaker implantation rate (Sapien 13.2% vs Evolut 18.5%; P=.30) were similar at 1 year. Permanent pacemaker rate was numerically higher in the first 6 months with Evolut (<6 months 26.7% vs >6 months 16%; P=.62); furthermore, radiation dose and balloon dilations also suggest a learning curve with Evolut. CONCLUSIONS: Switching from Sapien 3 to Evolut R/Pro was not associated with a difference regarding periprocedural or 1-year clinical outcomes.

Initial experience and procedural efficacy of pulmonary vein isolation using the fourth-generation cryoballoon - a step forward?

Background: Cryoballoon (CB)-based pulmonary vein isolation (PVI) is an established treatment modality for patients suffering from paroxysmal or persistent atrial fibrillation (AF). Recently, the novel fourth-generation cryoballoon (CB4) was introduced which mainly provides a 40% shorter distal tip as compared to the second-generation cryoballoon (CB2). This two-centre analysis sought to assess the primary efficacy of the 28 mm CB4 for PVI and the feasibility of real-time signal recordings from the PVs considering the time-to-isolation (TTI).Methods and results: Eighty-four patients with paroxysmal or short-standing persistent AF underwent CB4-based PVI at two different hospitals. Individual freeze-cycle duration was set at TTI + 120 seconds. No bonus freeze was applied. A total of 331 pulmonary veins (PVs) including five left common PVs were identified and all PVs were successfully isolated. Mean freeze-cycle duration was 165.7 ± 31.5 seconds. The mean minimal CB temperature was -45.6 ± 7.6 °C with a real-time PVI visualisation rate of 78% (67/84 (79.8%) RSPVs, 55/84 (65.5%) RIPVs, 67/79 (84.8%) LSPVs, 66/79 (83.5%) LIPVs and 2/5 (40%) LCPV). Transient phrenic nerve palsy occurred in 2/84 (2.4%) patients during cryo-application along the RSPV.Conclusions: The novel CB4 provides both, a high acute efficacy and a high rate of real time electrical PV-recordings, thus facilitating individual ablation strategies based on TTI.

Efficacy and Safety of Cryoballoon Ablation in Patients With Heart Failure and Reduced Left Ventricular Ejection Fraction　- A Multicenter Study.

BACKGROUND: Second-generation cryoballoon (CB2)-based pulmonary vein isolation (PVI) has demonstrated encouraging results in the treatment of atrial fibrillation (AF). This study sought to assess data on the safety, efficacy and clinical success of CB2-based PVI in patients with heart failure (HF) and reduced ejection fraction (HFrEF).Methods and Results:CB2-based PVI was performed in 551 consecutive patients in 3 highly experienced EP centers. Patients with HF and LVEF ≤40% were included (HFrEF group, n=50/551, 9.1%). Data were compared with propensity score-matched patients without HF and preserved left ventricular EF (LVEF) (n=50, control group). The median LVEF was HFrEF: 37% (35, 40) and control: 55% (55, 55), P<0.0001. Major periprocedural complications were registered in 4/50 (8%, HFrEF group) and 3/50 (6%, control group), P=0.695. The 12-month freedom from AF recurrence was 73.1% (95% confidence interval (CI): 61-88, HFrEF group) and 72.6% (95% CI: 61-87, control group), P=0.25. NYHA class decreased from 2.4±0.8 (baseline) to 1.7±0.8 at 12-month follow-up (P<0.0001). LVEF improved from a median of 37% (35, 40) prior to ablation to a median of 55% (40, 55), P<0.0001. CONCLUSIONS: CB2-based PVI in patients with HFrEF appeared to be safe, was associated with comparable periprocedural complications and showed promising clinical success rates equal to those for patients with preserved LVEF. NYHA class and LVEF significantly improved at 12-month follow-up.

Predictors of freedom from atrial arrhythmia recurrence after cryoballoon ablation for persistent atrial fibrillation: A multicenter study.

AIMS: We sought to assess (1) clinical outcomes of second-generation cryoballoon (CB) ablation for persistent atrial fibrillation (AF), and (2) the association of baseline and procedural covariates with atrial arrhythmia recurrence (AAR) after ablation. METHODS: A total of 135 patients (63 ± 11 years, 96 men [71%]) with persistent AF underwent CB ablation at three experienced electrophysiology centers. Freedom from AAR was estimated with the Kaplan-Meier method. A Cox proportional-hazards model was used to estimate the effects of baseline and procedural covariates on the likelihood of AAR. RESULTS: Freedom from AAR at 6, 12, and 18 months was estimated at 91% (95% confidence interval [CI] 86%-96%), 75% (95% CI, 67%-83%), and 53% (95% CI, 43%-65%), respectively. The presence of an implantable cardiac device (Hazard ratio [HR] 3.09; 95% CI, 1.37-7.00; P = .007), a left atrial (LA) diameter > 50 mm (HR 1.69; 95% CI, 1.02-2.79; P = .043), and absence of antiarrhythmic drug (AAD) therapy before the ablation procedure (HR 3.12; 95% CI, 1.72-5.64; P < .001) were associated with AAR. A trend toward an increased risk of AAR was revealed for women (HR 1.73; 95% CI, 0.96-3.11; P = .069). CONCLUSIONS: CB ablation for persistent AF resulted in freedom from AAR about that reported for RF ablation. The presence of an implantable cardiac device, LA size, and absence of AAD therapy at baseline were associated with the risk of AAR.

Efficacy and safety of cryoballoon ablation in the elderly: A multicenter study.

BACKGROUND: The prevalence of atrial fibrillation (AF) increases with age. Second-generation cryoballoon (CB2)-based PVI has demonstrated encouraging clinical results in the treatment of paroxysmal (PAF) and persistent atrial fibrillation (PersAF). The objective of this study was to assess data on safety, efficacy and long-term clinical success of CB2-based pulmonary vein isolation (PVI) in patients ≥75 years of age. METHODS: CB2-based PVI was performed in 104 patients ≥75 years of age (elderly group) and symptomatic AF (PersAF: n = 44, 42.3%) in three highly experienced German EP centers. The data was compared to propensity score matched patients with age <75 years (n = 104, control group; PersAF: n = 45, 43.3%, p = 0.956). RESULTS: The median age of the elderly group was 77.5 [75, 80] years while it was 63 [52, 70] years of control group patients (p = 0.0001). The median procedure time was 92.5 [75, 120] minutes (elderly group) and 100 [75, 120] (control group), p = 0.124. Major complications were registered in 7/104 (6.7%) elderly patients and 7/104 (6.7%) control group patients (p = 0.999). Clinical success in terms of freedom from AF recurrence after one-year follow-up was 80% (95% CI: 72-88) and 82% (95% CI: 75-90) and after three-year follow-up 59% (95% CI: 47-74) and 49% (95% CI: 37 64) for the elderly group and the control group, respectively (p = 0.7). CONCLUSIONS: CB2-based PVI in patients ≥75 years of age appears safe, is associated with low procedure times and shows promising clinical success rates equal to patients of the younger population.

What is the real recurrence rate after cryoballoon-based pulmonary vein isolation? Lessons from rhythm follow-up based on implanted cardiac devices with continuous atrial monitoring.

BACKGROUND: Second-generation cryoballoon (CB2)-based pulmonary vein isolation (PVI) has demonstrated encouraging clinical results for the treatment of paroxysmal atrial fibrillation (AF) and persistent AF. However, rhythm follow-up after PVI is mainly based on Holter electrocardiography of limited duration. OBJECTIVE: The purpose of this study was to assess the real AF burden following CB2-based PVI in patients with implanted cardiac devices. METHODS: A total of 670 consecutive patients underwent CB2-based PVI at 3 electrophysiology centers. In 66 patients (9.9%), an implantable cardiac device with continuous monitor function was independently implanted before the procedure (device group). This patient cohort was compared to propensity score-matched patients without cardiac devices (n = 66; control group). RESULTS: A total of 254 of 258 PVs (98.4%0 in the device group were successfully isolated using only CB2. Postprocedural device interrogation found no device or lead malfunction related to the procedure. Periprocedural complications were registered in 7 of 66 patients (11%) in the device group and in 6 of 66 patients (9%) in the control group (P = .770). Phrenic nerve palsy occurred in 6 of 66 patients (9%) in the device group) and in 2 of 66 patients (3%) in the control group) (P = .274). Clinical success in terms of freedom from AF recurrence after a 1-year follow-up period was 63.8% (95% confidence interval 53-77) in the device group and 77.3% (95% confidence interval 68-88) in the control group (P = .038). In the device group, AF/AT burden decreased from 41.8% ± 35.0% before the procedure to 10.2% ± 22.4% after 1 year (P <.0001). CONCLUSION: CB2-PVI seems safe and feasible in patients with an implanted cardiac device. A significantly higher AF/AT burden was seen in patients with an implanted cardiac device compared to a control group.

Is less more? Impact of different ablation protocols on periprocedural complications in second-generation cryoballoon based pulmonary vein isolation.

Aims: Second-generation cryoballoon (CB2) based pulmonary vein isolation (PVI) has emerged as an effective treatment option for symptomatic atrial fibrillation (AF). The current study sought to assess the impact of different ablation protocols on the incidence and characteristics of procedural complications in a large patient cohort. Methods and results: A total of 563 consecutive patients with symptomatic AF who underwent CB2-based ablation between July 2012 and January 2016, were assessed. Three different ablation protocols were applied and characterized by (#1) a bonus-freeze following PVI, (#2) no bonus-freeze after PVI, and (#3) a 'time-to-effect'-guided strategy. Major complications occurred in 30/563 patients (5.3%) with phrenic nerve palsy (PNP) as the most frequent complication occurring in 2.7% of the cases. The overall incidence of complications was significantly lower in patients treated with a 'time-to-effect' guided ablation strategy compared with the other ablation protocols (8.1% [17/211] (protocol #1+#2) vs. 3.7% [13/352] (protocol #3), respectively; P = 0.026). The 'time-to-effect' guided ablation protocol was associated with less applied freeze-cycles and shorter freeze-cycle durations. Additionally, shorter procedure times, radiation exposures and lower volumes of contrast medium needed were assessed for the 'time-to-effect' guided protocol as compared with the other ablation protocols. Conclusion: The overall incidence of complications was 5.3% in our analysis. The most frequent complication was PNP. The use of a time-to-effect guided ablation protocol was associated with a lower incidence of major complications compared with a bonus-freeze and no bonus-freeze protocol.

Acute efficacy, safety, and long-term clinical outcomes using the second-generation cryoballoon for pulmonary vein isolation in patients with a left common pulmonary vein: A multicenter study.

BACKGROUND: Second-generation cryoballoon (CB2)-based pulmonary vein isolation (PVI) has demonstrated encouraging clinical results in the treatment of paroxysmal (PAF) and persistent atrial fibrillation (PersAF). However, the CB2 features a maximal diameter of 28 mm, and its adaptability to anatomic variations of the pulmonary veins (PVs) might be challenging. OBJECTIVE: The purpose of this study was to assess the acute efficacy, safety, and long-term clinical results of CB2-based PVI in patients with a left common pulmonary vein (LCPV). METHODS: Six hundred seventy consecutive patients underwent CB2-based PVI in 3 electrophysiology centers. In 74 patients (11%), an LCPV was identified (LCPV group). The data were compared to those from matched patients (n = 74) with normal PV anatomy and comparable baseline characteristics (control group). An antral occlusion of the complete LCPV ostium was feasible in 50% of patients in the LCPV group. If an antral occlusion could not be obtained, a sequential isolation of the first superior and inferior branches was applied. RESULTS: All 74 LCPVs were successfully isolated. A total of 64% patients (LCPV group) and 66% patients (control group) remained in sinus rhythm after mean follow-up of 1.9 ± 0.9 years (P = .820). In 18 of 26 patients (69%) with atrial tachyarrhythmia recurrence, a repeat procedure using radiofrequency energy was performed, and a total of 56% LCPVs were found to be persistently isolated (control group: 61% of left-sided PVs, P = .801). CONCLUSION: Patients with an LCPV undergoing CB2-based PVI demonstrate a high acute success rate. Comparable results with regard to clinical success and durability of PVI were shown when comparing patients of the LCPV group and the control group.

Three-Year Clinical Outcome After 2nd-Generation Cryoballoon-Based Pulmonary Vein Isolation for the Treatment of Paroxysmal and Persistent Atrial Fibrillation　- A 2-Center Experience.

BACKGROUND: Pulmonary vein isolation (PVI) using the 2nd-generation cryoballoon (CB2) for the treatment of atrial fibrillation (AF) has demonstrated encouraging acute and mid-term results. However, follow-up data on outcomes beyond 1 year are sparse. We investigated the 3-year outcome after PVI using the CB2.Methods and Results:100 patients with paroxysmal (PAF, 70/100 [70%] patients) or persistent AF (pAF, 30/100 [30%] patients) underwent CB2-based PVI in 2 experienced centers in Germany. Freeze-cycle duration was 240 s. After successful PVI a bonus freeze-cycle of the same duration was applied in the first 71 patients but was omitted in the following 29 patients. Phrenic nerve palsy occurred in 3 patients (3%); 2 patients were lost to follow-up. After a median follow-up of 38 (29-50) months, 59/98 (60.2%) patients remained in stable sinus rhythm (PAF: 48/70 (69%), pAF: 11/28 (39%) P=0.0084). In 32/39 (77%) patients with arrhythmia recurrence, a second ablation procedure using radiofrequency energy was conducted. Persistent PVI was noted in 76/125 (61%) PVs. After a mean of 1.37±0.6 procedures and a median follow-up of 35 (25-39) months, 77/98 (78.6%) patients remained in stable sinus rhythm (PAF: 56/70 (80%), pAF: 20/28 (71%), P=0.0276). CONCLUSIONS: CB2-based PVI resulted in a 60.2% single-procedure and a 78.6% multiple-procedure success rate after 3 years. Repeat procedures demonstrated a high rate of durable PVI.

Gender-specific diagnostic performance of a new high-sensitivity cardiac troponin I assay for detection of acute myocardial infarction.

BACKGROUND: The determination of cardiac troponin is essential for diagnosing myocardial infarction. A troponin I assay has recently been developed that provides the highest analytical sensitivity to date. METHODS: The analysis included 1560 patients with chest pain, of whom 1098 were diagnosed with non-coronary chest pain, 189 with unstable angina pectoris and 273 with non-ST-segment elevation myocardial infarction. The troponin I concentration was determined on admission (0 hours) and 3 hours later. The diagnostic algorithm incorporated troponin I elevation above the gender-specific 99th percentile as well as predefined relative or absolute 3-hour changes in the troponin I concentration (delta). RESULTS: The diagnostic criterion of troponin I above the 99th percentile resulted in a negative predictive value of 98.0% and 98.2% in men and women, respectively. For rule-in of non-ST-segment elevation myocardial infarction, the use of absolute deltas yielded higher positive predictive values and sensitivities compared to relative deltas. With detection rates of about 85% and 82% in men and women, respectively, non-ST-segment elevation myocardial infarction was diagnosed with a positive predictive value close to 84% in men and 80% in women. CONCLUSIONS: The investigational troponin I assay provides an excellent non-ST-segment elevation myocardial infarction rule out. With gender-specific differences, the application of absolute changes in troponin concentration was superior to relative changes to rule in patients with non-ST-segment elevation myocardial infarction.

Total serum transforming growth factor-ß1 is elevated in the entire spectrum of genetic aortic syndromes.

BACKGROUND: Total serum transforming growth factor-beta 1 (tsTGF-ß1) is increased in patients with Marfan syndrome (MFS), but it has not been assessed in thoracic aortic aneurysm and dissection (TAAD), Loeys-Dietz syndrome (LDS), and bicuspid aortic valve disease (BAVD). HYPOTHESIS: tsTGF-ß1 is increased in genetic aortic syndromes including TAAD, LDS, MFS, and BAVD. METHODS: We measured tsTGF-ß1 and performed sequencing of the genes FBN1, TGFBR1, and TGFBR2 in 317 consecutive patients with suspected or known genetic aortic syndrome (167 men, 150 women; mean age 43 ± 14 years). TAAD was diagnosed in 20, LDS in 20, MFS in 128, and BAVD in 30 patients, and genetic aortic syndrome was excluded in 119 patients. RESULTS: Elevated tsTGF-ß1 levels were associated with causative gene mutations (P = 0.008), genetic aortic syndrome (P = 0.009), and sporadic occurrence of genetic aortic syndrome (P = 0.048), whereas only genetic aortic syndrome qualified as an independent predictor of tsTGF-ß1 (P = 0.001). The tsTGF-ß1 levels were elevated in FBN1 and NOTCH1 mutations vs patients without mutations (both P = 0.004), and in NOTCH1 mutations vs ACTA2/MYH11 mutations (P = 0.015). Similarly, tsTGF-ß1 levels were elevated in MFS (P = 0.003) and in BAVD (P = 0.006) vs patients without genetic aortic syndrome. In contrast to specific clinical features of MFS, FBN1 in-frame mutations (P = 0.019) were associated with increased tsTGF-ß1 levels. CONCLUSIONS: tsTGF-ß1 is elevated in the entire spectrum of genetic aortic syndromes. However, gradual differences in the increases of tsTGF-ß1 levels may mirror different degrees of alteration of tsTGF-ß1 signaling in different genetic aortic syndromes.

MitraClip therapy in surgical high-risk patients: identification of echocardiographic variables affecting acute procedural outcome.

OBJECTIVES: The aim of the study was to assess predictors of acute procedural failure in surgical high-risk patients undergoing MitraClip (Abbott Vascular, Abbott Park, Illinois) therapy. BACKGROUND: MitraClip implantation is a novel percutaneous option to treat significant mitral regurgitation (MR). METHODS: In 300 patients (75 ± 9 years of age, 190 [63%] men), of whom 32 (10.7%) had been unsuccessfully treated (discharge MR grade of >2+), baseline clinical and echocardiographic variables were evaluated by exact logistic regression and classification tree analyses to assess their impact on acute procedural failure. Acute procedural failure was differentiated into aborted procedure (no MitraClip implanted; n = 11) and "clip failure" (inadequate MR reduction despite MitraClip implantation; n = 21). RESULTS: Multivariate logistic regression identified effective regurgitant orifice area (EROA), mitral valve orifice area (MVOA), and mean transmitral pressure gradient (TMPG) as independent predictors of overall acute procedural failure. Classification tree analysis revealed that an EROA >70.8 mm(2) (n = 28) was associated with a high rate (25%) of clip failures, whereas the combination of an MVOA ≤3.0 cm(2) and a TMPG ≥4 mm Hg (n = 16) was associated with a high rate (37.5%) of aborted procedures. Failure rates of ≤10% were observed in all patients with an EROA ≤70.8 mm(2) and either an MVOA >3.0 cm(2) (n = 217) or an MVOA ≤3.0 cm(2) in concert with a TMPG ≤3 mm Hg (n = 39). Multinomial logistic regression identified an EROA >70.8 mm(2) and a TMPG ≥4 mm Hg as independently predictive of clip failure, but an MVOA ≤3.0 cm(2) and a TMPG ≥4 mm Hg as independently predictive of procedure abortion. CONCLUSIONS: In surgical high-risk patients undergoing MitraClip therapy, a TMPG ≥4 mm Hg, an EROA ≥70.8 mm(2), and an MVOA ≤3.0 cm(2) carry an increased risk of procedural failure.

Liberation of vessel-adherent myeloperoxidase reflects plaque burden in patients with stable coronary artery disease.

OBJECTIVE: Myeloperoxidase (MPO) has emerged as an important pathophysiological determinant of inflammatory vascular artery disease. It is appreciated that vessel immobilized, rather than circulating, MPO is critical for the progression of atherosclerotic lesions. The objective of this study was to investigate whether vessel-immobilized MPO is associated with the extent of coronary plaque burden. METHODS: MPO plasma levels were determined by ELISA before and after heparin-release of vessel-bound MPO, to study the relation between vascular MPO deposition and densitometrically assessed coronary plaque burden in 77 patients with stable coronary artery disease. RESULTS: Patients with a low increase in MPO plasma levels upon heparinization had a significantly smaller total plaque area and volume (12.1[IR:6.2-19.4]mm(2) vs. 19.8[IR:11.3-31.5]mm(2), p < 0.01; 27.8[IR:12.3-44.8]mm(3) vs. 55.2[IR:24.2-87.5]mm(3), p < 0.05). Multivariable linear regression revealed that ΔMPO was independently associated with plaque area, and that ΔMPO increased with the number of affected vessels. Selective sampling confirmed the predominant role of coronary MPO deposition. CONCLUSION: Our data demonstrate that heparin-induced mobilization of vessel-bound MPO is closely linked to coronary plaque burden and thus further corroborate the evidence for the intimate involvement of this enzyme in vascular pathophysiology, as well as the importance of inflammation in atherosclerosis.

Aetiology of mitral regurgitation differentially affects 2-year adverse outcomes after MitraClip therapy in high-risk patients.

AIMS: To assess, and identify predictors of 2-year adverse outcomes of surgical high-risk patients after successful MitraClip therapy (MC), differentiated by the aetiology of mitral regurgitation (MR). METHODS AND RESULTS: Kaplan-Meier analysis was used to assess survival free from death, heart failure rehospitalization, and reintervention up to 2 years in 202 successfully treated patients [74 ± 9 years, 132 men (65%); secondary MR aetiology in 140 patients, primary MR in 62]. Predictors for study endpoints were determined using Cox regression analyses. Mortality was 20% at 1 year and 33% at 2 years in both primary and secondary MR patients; independent predictors of death were reduced forward stroke volume, impaired LV function, and renal failure in primary MR, yet only an increased logistic EuroSCORE in functional MR patients. The rate of rehospitalizations was not different between the patient subgroups for 6 months, but then diverged significantly in favour of primary MR patients (estimated 2-year incidence, primary MR 40% vs. secondary MR 66%). No predictor was found for primary MR patients, but increased LV end-diastolic volume significantly increased the risk of rehospitalization in functional MR patients. Reinterventions were overall rare (7.4% at 1 year, 9.7% at 2 years); primary MR patients required all except one reintervention within 2 months of MC, with again no predictors found, whereas secondary MR patients (all except one with discharge MR of 2+) exhibited a steadily declining freedom from reintervention curve throughout follow-up. CONCLUSION: MR aetiology affects rehospitalization and reintervention, but not mortality, differently after successful MC.

Diagnostic value of MPO plasma levels in patients admitted for suspected myocardial infarction.

BACKGROUND: Besides its well-established role in atherosclerosis, myeloperoxidase (MPO) has gained attention as a prognostic indicator in cardiovascular disease. Previous studies assessed MPO retrospectively and at a single time point. The current study aimed to evaluate the prognostic information of MPO prospectively and in consecutive measurements in patients presenting with chest pain. METHODS: MPO plasma levels were determined in 274 consecutive chest pain patients admitted to the emergency room. RESULTS: A total of 100 patients (36.5%) were finally diagnosed for acute myocardial infarction (AMI). Patients with AMI had significantly higher MPO levels than patients without AMI. Importantly, MPO levels were elevated in patients finally diagnosed for AMI even when troponin I (TNI) was negative (cutoff: 0.032 ng/ml). Overall, MPO yielded a negative predictive value (NPV) of 85.5% (95% confidence interval (CI): 82.6-88.4) and a sensitivity for diagnosing AMI of 80.0% (95% CI: 75.8-84.2) compared to a NPV of 91.7% (95% CI: 89.5-94.0) and a sensitivity of 85.9% (95% CI: 82.3-89.5) for TNI. For patients with a symptom onset of ≤ 2 h the sensitivity of MPO increased to 95.8% (95% CI: 93.7-97.9) whereas the sensitivity of TNI dropped to 50.0% (95% CI: 44.8-55.2). The negative predictive value of MPO for this group of patients was 95.6% (95% CI: 94.0-97.3) compared to 73.3% (95% CI: 69.8-76.9) for TNI. DISCUSSION: The current data underscore the role of MPO as diagnostic marker in acute coronary disease; however the additive information derived from MPO is restricted to patients presenting in the early phase of symptom onset.

Neutrophil activation precedes myocardial injury in patients with acute myocardial infarction.

Myeloperoxidase (MPO), a heme protein abundantly expressed and secreted by polymorphonuclear neutrophils (PMN), has emerged as a critical mediator in coronary atherosclerosis. Retrospective analyses have suggested that free plasma levels of MPO predict adverse outcome in patients with low troponin T (TnT) levels who subsequently experience myocardial injury. The aim of this study was to evaluate the time course of MPO plasma levels in the early stages of acute myocardial infarction (AMI). Of 155 consecutive patients hospitalized for acute coronary syndromes, 38 presenting within 2 h of the onset of symptoms and subsequently diagnosed for AMI were included in the study. Serial blood samples taken between 1 and 24 h after the onset of chest pain were analyzed for MPO, TnT, creatine kinase MB, myoglobin, and high sensitive C-reactive protein. Fifty patients with angiographically proven but stable coronary artery disease (CAD) served as controls. In contrast to all other investigated markers, MPO was markedly elevated within 2 h of symptom onset in patients with AMI. Heparin, which is known to increase MPO plasma levels in patients with stable CAD, had no effect on MPO plasma levels in AMI patients. High levels of MPO plasma levels at the time of admission and the rapid peak of free plasma MPO levels after the onset of symptoms suggests that PMN activation is an early event in AMI and potentially precedes myocardial injury.

Fluoroscopy to assess late heart and lung perforation by a permanent ventricular pacemaker lead. A case complicated by isolated hemothorax.

We report a female patient with a ventricular lead perforation late after implantation. The lead perforated heart and lung parenchyma and caused hemothorax but no cardiac effusion or tamponade. No definitive evidence for lead perforation was found by standard diagnostic assessment. Definitive diagnosis was established by cath-lab fluoroscopy. The surgical treatment including thoracotomy, lead removal, repair suture of the right ventricle and finally placement of an epicardial electrode was successful.

Coronary plaque injury triggers neutrophil activation in patients with coronary artery disease.

Activation of leukocytes, in particular polymorphonuclear neutrophils (PMN), is considered an early event in unstable coronary disease. Upon activation PMN liberate myeloperoxidase (MPO), an enzyme which binds to the vessel wall and depletes vascular NO bioavailability. Using coronary balloon angioplasty as a trigger to provoke coronary plaque injury, we assessed the time course of neutrophil activation, local and peripheral levels of myeloperoxidase, and systemic vascular NO bioavailability in patients with stable coronary artery disease. Twenty-four patients with stable CAD were enrolled prior to undergoing percutaneous interventions (PCI, n=14) and diagnostic coronary angiography (n=10), respectively. Following angioplasty arterial MPO plasma levels increased (231.5+/-67.6 to 273.8+/-80.4 pg/mg protein; P<0.01) whereas MPO levels in the coronary sinus decreased (240.8+/-74.4 vs 205.4+/-60.1 pg/mg protein; P<0.01) in the absence of elevated serum markers for myocardial necrosis. Following PCI, patients revealed impaired vascular NO bioavailability as reflected by reduced brachial flow-mediated dilation (FMD; 6.25+/-3.03 to 4.90+/-2.70%; P<0.01), whereas FMD increased in the angiography group. Coronary plaque injury provokes rapid activation of PMN in the absence of myocardial necrosis; the coronary circulation emerges as a primary site for deposition of MPO following injury of the coronary vessel wall. Activation of PMN with release of MPO is not only restricted to the target site, but can be assessed systemically and may represent a critical mechanistic link for impaired systemic vascular NO bioavailability in patients suffering unstable coronary disease.