Electrocardiogram changes and wall motion abnormalities in the acute phase of Tako-Tsubo syndrome.

BACKGROUND: The Tako-Tsubo syndrome is still rarely diagnosed in patients presenting with symptoms of acute myocardial ischaemia. It is accompanied by wall motion abnormalities of the left ventricle but significant narrowings or occlusions of epicardial coronary arteries are absent. We investigated a potential relationship between electrocardiogram (ECG) changes, wall motion abnormalities and gender influence of Tako-Tsubo syndrome in an Austrian cohort of Tako-Tsubo syndrome patients. METHODS AND RESULTS: We were recently able to describe four different anatomical types of Tako-Tsubo syndrome in 153 patients of the Austrian Tako-Tsubo syndrome registry. In the present retrospective analysis we investigated ischaemia-related changes in the first diagnostic ECG for the different types of Tako-Tsubo syndrome: the apical and the combined apical-midventricular type showed most frequently a ST elevation (41.1% and 35.3%), whereas the midventricular type of Tako-Tsubo syndrome was more often accompanied by T wave inversion (60%). ECG changes in relation to the Tako-Tsubo syndrome type were similar in women and men. There was no difference in the prevalence of clinical complications among patients presenting with ST elevation or left bundle branch block (14.5%) compared with patients without ST elevation (10.4%) (p=0.476). CONCLUSION: Patients with Tako-Tsubo syndrome show characteristic ECG changes in the first diagnostic ECG which are associated to some extent with the anatomical type of Tako-Tsubo syndrome, but these ECG changes were not related to clinical outcome.

Stress-induced cardiomyopathy (Tako-Tsubo syndrome) in Austria.

BACKGROUND: Tako-Tsubo syndrome (TS) is a still rarely diagnosed clinical syndrome, which is characterized by acute onset of chest pain, transient cardiac dysfunction with (frequently) reversible wall motion abnormalities (WMAs), but with no relevant obstructive coronary artery disease. METHODS AND RESULTS: Among 179 consecutive patients with proven diagnosis of TS that were retrospectively analysed in this multicentre registry, women represented the majority of patients (94%) while only 11 men (6%) developed TS. Mean age was 69.1±11.5 years (range 35-88 years). Cardinal symptoms of TS, which led to admission, were acute chest pain (82%) and dyspnoea (32%), respectively. All patients demonstrated typical WMAs, whereby four different types of WMAs could be defined: (1) a more common apical type of TS (n=89; 50%); (2) a combined apical and midventricular form of TS (n=23; 13%); (3) the midventricular TS (n=6; 3%); and (4) an unusual type of basal WMAs of the left ventricle (n=3). Only in 101 patients (57%), a clear causative trigger for onset of symptoms could be identified. In-hospital cardiovascular complications occurred in 25 patients (14%) and consisted of cardiac arrhythmias in 10 patients (40%), cardiogenic shock in six patients (24%), cardiac decompensation in eight patients (32%) and cardiovascular death in one patient, respectively. Echocardiographic control of left ventricular function after the initial measurement was available in almost 70% of the patients: complete recovery of WMAs was found in 73 patients (58.87%); 49 patients (39.52%) showed persistent WMAs. Recurrences of TS were only seen in four patients. During the follow-up period, 13 patients died: three of cardiovascular causes and 10 of non-cardiac causes. In-hospital mortality was 0.6%, 30-day mortality was 1.3% and 2-year mortality was 6.7%. CONCLUSIONS: This study represents to date the largest series of patients suffering from TS in Austria and worldwide. Similar to others, in our series the prevalence of TS was significantly higher in women than in men, while in contrast to other studies, the apical type of TS was detected most frequently. The similar clinical presentation of TS patients to the clinical picture of acute myocardial infarction demonstrates the importance of immediate coronary angiography for adequate differential diagnosis of TS. TS is not necessarily a benign disease due to cardiovascular complications as well as persistent WMAs with delayed recovery.

A validated risk score to predict outcomes after carotid stenting.

BACKGROUND: Periprocedural outcome has been extensively investigated in patients undergoing carotid artery stenting. However, risk factors contributing to long-term mortality have not been comprehensively assessed. We aimed to establish a validated clinical risk score for long-term mortality in patients after carotid artery stenting. METHODS AND RESULTS: Two independent cohorts after successful carotid artery stenting (602 and 552 patients) were prospectively investigated. Multivariable Cox regression and bootstrap variable selection were used to select the best-fitting multivariable model. The mortality rate was 35% in the derivation and 39% in the validation cohort during a median follow-up of 6.5 and 7.4 years, respectively. The following variables were identified as most robust risk factors in the derivation cohort: age, heart failure, diabetes mellitus, relative lymphocyte count, prothrombin time, peripheral artery disease, and contralateral carotid occlusion. A weighted multimarker risk score yielded an area under the receiver operating characteristic curve of 0.79 in the derivation (P<0.001) and of 0.69 (P<0.001) in the validation cohort. In comparison, the best area under the receiver operating characteristic curves for single risk factors were 0.67 and 0.63, respectively. For optimal clinical use, a simplified risk score was also developed, which discriminated very well from very low to very high risk. The risk of all-cause mortality ranged from 8% for a score of 1 to 93% for a score of 7 (P<0.001) in the derivation and from 11% to 100% in the validation cohort (P<0.001). CONCLUSIONS: A multimarker risk score outperformed the prognostic value of single risk factors for the prediction of long-term mortality.

False left ventricular apical aneurysm--a rare complication after transapical aortic valve replacement.

We report on a case of a false aneurysm at the access site after transapical aortic valve replacement. Although this is not the first case report about this issue, our case emphasizes the importance of follow-up echocardiography after transapical aortic valve replacement that focuses not only on prosthesis function, but also on detecting probable complications of the surgical access site.

Pulmonary vein isolation with Mesh Ablator versus cryoballoon catheters: 6-month outcomes.

INTRODUCTION: We sought to compare the results of pulmonary vein (PV) ablation using the high-density Mesh Ablator catheter (MESH) versus the cryoballoon (CRYO). METHODS AND RESULTS: From August 2007 to November 2009, all patients with paroxysmal atrial fibrillation scheduled for a first procedure of PV isolation were screened by cardiac computed tomography for anatomical suitability to undergo ablation with a circumferential ostial ablation catheter. The procedure was finally performed in 79 out of 120 patients matching the criteria of four clearly separated PVs with an ostial diameter of 15-25 mm. The first consecutive 43 patients were treated with the MESH; the following 36 consecutive patients were treated with the CRYO. The procedures were performed with up to 900 s of either pulsed radiofrequency energy delivered by the MESH or cryoenergy applied with the CRYO. The clinical success rate was evaluated 6 months after a single procedure. Isolation of all PVs could be achieved in 40 patients (93%) in the MESH group compared to 31 patients (89%) in the CRYO group (p = ns). Major complications consisted of one tamponade in the MESH group and one reversible phrenic nerve palsy in the CRYO group. After 6 months, the clinical success rate was 44% (19/43 P) in the MESH versus 69% (25/36 P) in the CRYO group (p < 0.05). CONCLUSION: Both methods of simplified circumferential PV ablation reveal a high acute success rate. The clinical 6-month results of the MESH are statistically significant inferior compared to the CRYO.

Clinical experience with routine use of a single combined mapping and ablation catheter for isolation of pulmonary veins in patients with paroxysmal atrial fibrillation.

BACKGROUND: Catheter-based isolation of pulmonary veins has become established treatment for patients with paroxysmal atrial fibrillation. We wished to simplify the interventional procedure by using a single novel multipolar catheter for mapping and ablation in appropriate patients. METHODS: Sixty-four patients with paroxysmal atrial fibrillation scheduled for pulmonary vein isolation were screened by cardiac computed tomography for anatomic suitability to undergo a simplified procedure with the high-density mesh ablator catheter (MESH) as the only left atrial device. The procedure was undertaken in 38 patients matching the criteria of four clearly separated pulmonary veins with ostial diameters 15-25 mm; the remaining 26 patients served as a control group and were treated using a three-dimensional mapping system guided ablation using a circular mapping catheter and a single-point ablation catheter. RESULTS: In all 38 patients, all four pulmonary veins could be accessed and mapped with the MESH. Using the MESH, electrical isolation was achieved in 142/148 (96%) pulmonary veins with recorded potentials. In the control group, 100/105 (95%) pulmonary veins with recorded potentials could be isolated. After 6 months, clinical results did not differ significantly between the two treatment groups. CONCLUSION: In appropriate patients, the routine single catheter approach with the MESH for mapping and ablation yields a high acute success rate despite the reduced complexity of the procedure. Long-term data on clinical success rates are needed to justify this simplified approach.

One-year follow-up after pulmonary vein isolation using a single mesh catheter in patients with paroxysmal atrial fibrillation.

BACKGROUND: Catheter-based pulmonary vein (PV) isolation has emerged as established therapy for patients with paroxysmal atrial fibrillation (AF). OBJECTIVE: The purpose of this study was to determine the results at 1-year follow-up after PV isolation was performed using a single novel multipolar catheter for mapping and ablation. METHODS: Patients with paroxysmal AF were screened by cardiac computed tomography for anatomic suitability to undergo PV ablation with the Bard HD Mesh Ablator Catheter (MESH). PV isolation with the MESH was performed only in patients who matched the criteria of four clearly separated PVs with an ostial diameter of 15 to 25 mm. RESULTS: PV isolation with the MESH was performed in 36 (55%) of 65 screened patients. In all 36 patients, all PVs could be mapped with the MESH. Electrical isolation could be achieved in 135 (96%) of 140 PVs that revealed PV potentials. One-year follow-up was completed for 35 patients; one patient was lost to follow-up. Ten (29%) patients reported to be symptom-free and had no AF during three 48-hour ECGs, whereas 25 (71%) patients suffered from AF recurrences. Reablation performed in 11 patients revealed reconnection of three PVs in 6 patients and four PVs in 5 patients. CONCLUSION: The single-catheter approach using the MESH for mapping and ablation was associated with a high AF recurrence rate within the first year despite a high acute success rate. Thus, the minimalist complexity of the procedure must be balanced with the poor clinical success leading to a high number of second procedures.

Pre-injection of magnesium sulfate enhances the efficacy of ibutilide for the conversion of typical but not of atypical persistent atrial flutter.

BACKGROUND: Ibutilide is a class III antiarrhythmic drug, frequently used for conversion of atrial fibrillation and flutter. Retrospective cohort evaluations found that intravenous application of magnesium enhances the efficacy of ibutilide for chemical conversion of these arrhythmias. This prospective study sought to investigate the effects of intravenously pre-injected magnesium on the conversion rate of ibutilide for typical and atypical atrial flutter. METHODS: We performed a prospective, randomized, placebo-controlled study. Patients with typical atrial flutter (TAF) or atypical atrial flutter (AAF) were randomized to receive either 4 g of intravenous magnesium sulfate or placebo immediately before administration of a maximum dose of 2 mg of ibutilide fumarate. Continuous rhythm monitoring for 4 h provided information on conversion to sinus rhythm. QT interval durations were measured before randomization, after magnesium, as well as 30 min and 4 h after starting ibutilide infusion. RESULTS: We randomized 117 patients (58 with and 59 without pre-injection of magnesium; 65 with TAF and 52 with AAF). In patients with TAF, pre-injection of magnesium significantly improved the efficacy of ibutilide for conversion (85% with magnesium vs. 59% with placebo, p=0.017). In patients with AAF, no significant difference in conversion rates between patients receiving magnesium or placebo was detected (48% vs. 56%, p=0.189). Pre-injection of magnesium did not significantly influence the QT intervals at any time after administration of ibutilide. CONCLUSIONS: Pre-injection of magnesium significantly enhances the efficacy of ibutilide for the conversion of TAF but not of AAF.

Platelet inhibition with cangrelor in patients undergoing PCI.

BACKGROUND: Cangrelor, a nonthienopyridine adenosine triphosphate analogue, is an intravenous blocker of the adenosine diphosphate receptor P2Y(12). This agent might have a role in the treatment of patients who require rapid, predictable, and profound but reversible platelet inhibition. METHODS: We performed a large-scale international trial comparing cangrelor with 600 mg of oral clopidogrel administered before percutaneous coronary intervention (PCI) in patients with acute coronary syndromes. The primary efficacy end point was a composite of death from any cause, myocardial infarction, or ischemia-driven revascularization at 48 hours. RESULTS: We enrolled 8877 patients, and 8716 underwent PCI. At 48 hours, cangrelor was not superior to clopidogrel with respect to the primary composite end point, which occurred in 7.5% of patients in the cangrelor group and 7.1% of patients in the clopidogrel group (odds ratio, 1.05; 95% confidence interval [CI], 0.88 to 1.24; P=0.59). Likewise, cangrelor was not superior at 30 days. The rate of major bleeding (according to Acute Catheterization and Urgent Intervention Triage Strategy criteria) was higher with cangrelor, a difference that approached statistical significance (3.6% vs. 2.9%; odds ratio, 1.26; 95% CI, 0.99 to 1.60; P=0.06), but this was not the case with major bleeding (according to the Thrombolysis in Myocardial Infarction criteria) or severe or life-threatening bleeding (according to Global Utilization of Streptokinase and Tissue Plasminogen Activator for Occluded Coronary Arteries criteria). A secondary exploratory end point of death from any cause, Q-wave myocardial infarction, or ischemia-driven revascularization showed a trend toward a reduction with cangrelor, but it was not significant (0.6% vs. 0.9%; odds ratio, 0.67; 95% CI, 0.39 to 1.14; P=0.14). CONCLUSIONS: Cangrelor, when administered intravenously 30 minutes before PCI and continued for 2 hours after PCI, was not superior to an oral loading dose of 600 mg of clopidogrel, administered 30 minutes before PCI, in reducing the composite end point of death from any cause, myocardial infarction, or ischemia-driven revascularization at 48 hours. (ClinicalTrials.gov number, NCT00305162.)

2-year results of the AUTAX (Austrian Multivessel TAXUS-Stent) registry beyond the SYNTAX (synergy between percutaneous coronary intervention with TAXUS and cardiac surgery) study.

OBJECTIVES: The multicenter AUTAX (Austrian Multivessel TAXUS-Stent) registry investigated the 2-year clinical/angiographic outcomes of patients with multivessel coronary artery disease after implantation of TAXUS Express stents (Boston Scientific, Natick, Massachusetts), in a "real-world" setting. BACKGROUND: The AUTAX registry included patients with 2- or 3-vessel disease, with/without previous percutaneous coronary intervention (PCI) and concomitant surgery. METHODS: Patients (n = 441, 64 +/- 12 years, 78% men) (n = 1,080 lesions) with possible complete revascularization by PCI were prospectively included. Median clinical follow-up was 753 (quartiles 728 to 775) days after PCI in 95.7%, with control angiography of 78% at 6 months. The primary end point was the composite of major adverse cardiac (nonfatal acute myocardial infarction [AMI], all-cause mortality, target lesion revascularization [TLR]) and cerebrovascular events (MACCE). Potential risk factor effects on 2-year MACCE were evaluated using Cox regression. RESULTS: Complete revascularization was successful in 90.5%, with left main PCI of 6.8%. Rates of acute, subacute, and late stent thrombosis were 0.7%, 0.5%, and 0.5%. Two-year follow-up identified AMI (1.4%), death (3.6%), stroke (0.2%), and TLR (13.1%), for a composite MACCE of 18.3%. The binary restenosis rate was 10.8%. The median of cumulative SYNTAX score was 23.0 (range 12.0 to 56.5). The SYNTAX score did not predict TLR or MACCE, due to lack of scoring of restenotic or bypass stenoses (29.8%). Age (hazard ratio [HR]: 1.03, p = 0.019) and acute coronary syndrome (HR: 2.1, p = 0.001) were significant predictors of 2-year MACCE. Incomplete revascularization predicted death or AMI (HR: 3.84, p = 0.002). CONCLUSIONS: With the aim of complete revascularization, TAXUS stent implantations can be safe for patients with multivessel disease. The AUTAX registry including patients with post-PCI lesions provides additional information to the SYNTAX (Synergy Between Percutaneous Coronary Intervention With TAXUS and Cardiac Surgery) study. (Austrian Multivessel TAXUS-Stent Registry; NCT00738686).

64-Detector CT angiography in renal artery stent evaluation: prospective comparison with selective catheter angiography.

PURPOSE: To prospectively assess the diagnostic accuracy of 64-detector computed tomographic (CT) renal artery (RA) angiography for the evaluation of RA in-stent restenosis (ISR) by using selective catheter RA angiography as the reference standard. MATERIALS AND METHODS: Institutional review board approval and written informed consent were obtained. Eighty-six patients (46 men, 40 women; mean age +/- standard deviation, 71 years +/- 9) with 95 RA stents were examined with 64-detector CT RA angiography by experienced radiologists 1 day before selective catheter RA angiography was performed by experienced cardiologists. Each group was blinded to the results of the other imaging method. For image reconstruction, a standard (B25f) and an edge-enhancing (B46f) kernel were chosen. An ISR of more than 50% was considered as hemodynamically significant. Sensitivity, specificity, and positive and negative predictive values for the detection of ISR by using CT RA angiography were calculated. RESULTS: At CT RA angiography, 93 (98%) of 95 stents were assessable for diagnosis. Two stents could not be evaluated owing to hardening artifacts affected by vessel calcifications. All nine cases of significant ISR seen at selective catheter RA angiography were correctly diagnosed by using CT RA angiography, giving a sensitivity of 100% and a negative predictive value of 100%. One case of nonsignificant ISR seen at selective catheter RA angiography was interpreted as significant by using CT RA angiography, giving a specificity of 99% and a positive predictive value of 90%. In four of 78 patients without ISR seen at selective catheter RA angiography, CT RA angiography showed nonsignificant ISR, giving a specificity of 95% and a positive predictive value of 56%. CONCLUSION: Sixty-four-detector CT RA angiography can provide an excellent noninvasive technique to help detect and evaluate ISR within the RA stents used in our study.

Incidence of stent thrombosis in patients with drug eluting stents and short-term dual antiplatelet therapy.

AIMS: This study sought to investigate the incidence of stent thrombosis (ST) in patients treated with drug-eluting stents (DES) and clearly defined short-term dual antiplatelet therapy (DAT) for three or six months for sirolimus-eluting stents (SES) or paclitaxel-eluting stents (PES), respectively. METHODS AND RESULTS: A series of 1023 consecutive patients with 1,414 stented lesions and prescribed short-term DAT were followed for at least two years after DES implantation. The individual durations of DAT, the rate of ischaemic events, and survival status were assessed. Follow-up was completed for 1017 patients (99.4%) with a mean follow-up of 3.0 +/- 0.7 years. DAT duration was 2.8 +/- 0.4 and 5.9 +/- 0.8 months in patients with SES and PES, respectively. Adherence to continued single antiplatelet therapy was 98.4%. We identified 14 patients with definite ST (1.4%) and no patients with probable ST with a cumulative incidence of 0.6% at 30 days, of 0.8% at one year, of 1.2% at 2 years, and of 1.4% at three years. CONCLUSIONS: Definite or probable ST after DES implantation and short DAT occurs with a cumulative incidence of 1.4% at 3 years if excellent patient adherence to the continued single antiplatelet therapy can be achieved.

Acute results of pulmonary vein isolation in patients with paroxysmal atrial fibrillation using a single mesh catheter.

INTRODUCTION: Catheter-based pulmonary vein isolation (PVI) is an established therapy to treat patients with paroxysmal atrial fibrillation. We evaluated the efficacy of a simplified interventional procedure for PVI by using a single mesh catheter for mapping as well as ablation and with guidance of fluoroscopic imaging only. METHODS AND RESULTS: Forty-eight patients with paroxysmal atrial fibrillation were screened by cardiac computed tomography for their anatomical suitability to undergo PVI with the high-density mesh ablator catheter as the only left atrial device. The procedure was performed in 26 patients (12 males, mean age 61 years) who met the criteria of four clearly separated pulmonary veins (PVs) with an ostial diameter of 15-25 mm. No three-dimensional mapping systems or additional ablation devices were used. In all 26 patients, all four PVs could be accessed and mapped with the high-density mesh ablator catheter. Electrical isolation was achieved in 99 of 102 (97%) of the pulmonary veins that revealed PV potentials. Mean total procedure time and fluoroscopy time were 187 +/- 36 minutes and 34.6 +/- 10.0 minutes, respectively. CONCLUSION: The single-catheter approach using the high-density mesh ablator catheter for mapping as well as ablation reveals a high acute success rate of PVI while, at the same time, reducing the complexity of the procedure, and the procedure time. Long-term data on clinical success are needed to justify this simplified approach.

TIMI 3 flow after primary angioplasty is an important predictor for outcome in patients with acute myocardial infarction.

BACKGROUND: Growing evidence suggests that poor coronary blood flow after primary percutaneous coronary intervention (PCI) is associated with unfavorable clinical out-come. We retrospectively evaluated data from our single center "real world patients" database of patients undergoing primary PCI to determine differences in clinical and angiographic patterns in patients with or without restoring thrombolysis in myocardial infarction (TIMI) flow 3. METHODS AND RESULTS: Between 2001 and 2006, 500 patients underwent primary PCI for STEMI. In 430 patients, post-interventional TIMI flow 3 could be established. In this group, in-hospital mortality was significant lower (6.4% Vs. 32.9%; P < 0.0001), left ventricular ejection fraction was better (51.3 Vs. 44.2%; P < 0.0001), and prehospital fibrinolytic therapy (6.3% Vs. 14.3%; P = 0.015), cardiogenic shock (10.9% Vs. 24.3%; P = 0.002) and use of intra-aortic balloon pump were all more unlikely (5.8% Vs. 11.4%; P = 0.045) compared to patients with TIMI flow < or = 2. In patients with post-interventional TIMI flow < or = 2 the left anterior descending coronary artery (LAD) was significantly more often seen as the target vessel (54.3% Vs. 44.6%; P = 0.039). A regressions analysis showed that predictors leading to such flow patterns are diabetes (P = 0.013), pre-hospital fibrinolytic therapy (P = 0.017), cardiogenic shock (P = 0.002) and a 3-vessel disease (P = 0.003). After 6 months, patients without restored normal TIMI flow had worse New York Heart Association functional class (NYHA), and had to undergo repeat coronary angiography more often. CONCLUSION: Post-interventional TIMI flow < or = 2 is strongly associated with adverse out-come during hospitalization and after 6 months following hospitalization.

Resolution of a coronary embolus by intravenous application of bivalirudin.

We report on a case of non-ST-segment myocardial infarction in the absence of coronary artery disease, caused by coronary embolism from the left atrial appendage. Due to the fact that the angiographically confirmed embolus did not resolve within 4 days of treatment with aspirin, clopidogrel and low molecular weight heparin (LMWH), we intravenously administered bivalirudin instead of LMWH for another 2 days and could demonstrate complete resolution of the embolus following this protocol. No bleeding complications or recurrence of myocardial ischemia occurred. Our observations may draw attention to bivalirudin therapy for coronary emboli, when LMWH is not effective.

In-stent restenosis in bare metal stents versus sirolimus-eluting stents after primary coronary intervention for acute myocardial infarction and subsequent transcoronary transplantation of autologous stem cells.

BACKGROUND: Following stenting for acute myocardial infarction, transcoronary transplantation of granulocyte-colony stimulating factor (G-CSF) mobilized autologous stem cells (ASC) has been shown to result in an increased in-stent restenosis rate of bare metal stents (BMS). HYPOTHESIS: This study sought to compare the extent of neointimal growth in BMS and sirolimus-eluting stents (SES) after primary implantation, and subsequent transcoronary transplantation of G-CSF mobilized stem cells. METHODS: Patients with stenting of the left anterior descending coronary artery for acute anterior myocardial infarction were randomly assigned to receive a BMS or SES. Intracoronary stem cell injection was performed after G-CSF application for at least 4 d and cell apheresis. The angiograms obtained after cell transplantation and after 6 mo were analyzed by quantitative coronary angiography. RESULTS: We performed primary stenting and stem cell transplantion in 16 patients who received a BMS (n = 8) or an SES (n = 8). In 2 patients with a BMS, late stent thrombosis occurred after 58 d and 177 d, respectively. In the remaining patients, control angiography after 6 mo revealed in-stent restenosis of >50% in no patients with SES but in 4 patients with BMS (67%). Late lumen loss and in-stent plaque volume were significantly higher in patients with BMS compared with patients with SES. CONCLUSIONS: Compared with BMS, SES impair in-stent intima hyperplasia after stenting for acute myocardial infarction and transcoronary transplantation of G-CSF mobilized ASC.

Predictors of death and stroke after carotid angioplasty and stenting: a subgroup analysis of the Pro-CAS data.

BACKGROUND AND PURPOSE: Little is known about the significance of patient characteristics, clinical indications, and technical details on the risk of carotid angioplasty and stenting (CAS). The purpose of this study was to test these parameters as to their predictive value for the peri-interventional risk of CAS. METHODS: Pro-CAS is a prospective, multicenter registry of CAS. Logistic regression analysis of possible predictive factors was performed on 5341 interventions that had been entered by 25 clinical centers between July 1999 and June 2005. RESULTS: The combined in-hospital mortality and stroke rate was 3.6%. The following were found to be significant predictors of peri-interventional stroke and death: center experience (< or = 50 versus 51 to 150 versus > or = 151 interventions), age, prior symptoms, primary intervention as compared with intervention for restenosis, angioplasty without stent, predilatation, and heparin dosage > 5000 IU. No statistically significant result was found for year of intervention, patient volume, gender, interval between symptoms and CAS, ocular versus neurological symptoms, side of CAS, degree of stenosis of the target lesion, presence of contralateral high-degree stenosis or occlusion, method of gaining access to the carotids, stent type, and use of a protection system. CONCLUSIONS: Our findings underline the need for dedicated training and strict credentialing rules for CAS. In addition, they might help to identify subgroups of patients at differential risk for CAS and carotid endarterectomy and yield a basis for correcting risks due to differences in case mix in reports about CAS.

Long-term outcomes in patients with atrioventricular block undergoing septal ventricular lead implantation compared with standard apical pacing.

AIMS: Left ventricular function may be altered by right ventricular apical pacing. The aims of the study were to compare the long-term course of different parameters of left ventricular dysfunction in patients undergoing implantation of a dual-chamber pacemaker with the ventricular lead in a septal position vs. in a standard apical position. METHODS: We randomized 98 patients with atrioventricular block (AV-block) undergoing pacemaker implantation to positioning the ventricular lead in the high or mid septum (n = 53) or in the apex (n = 45) of the right ventricle. N-terminal pro-brain natriuetic peptide (BNP) levels, left ventricular ejection fraction (LVEF), and exercise capacity were analysed 3 days, 3 months, and 18 months after the implantation. The primary endpoints were the changes of these parameters from baseline to 18 months. RESULTS: Changes of BNP levels, LVEF, and exercise capacity from baseline to 18 months were statistically not different between septal and apical stimulation. The clinical occurrence or deterioration of overt heart failure was similar in both treatment arms. CONCLUSION: With regard to different parameters of congestive heart failure, a septal stimulation site is not superior to conventional apical pacing in unselected patients undergoing pacemaker implantation for AV-block.