[Position dependent dyspnea and cyanosis of the lips at the daily round - A case of Platypnea-Orthodeoxia Syndrome]. / Lageabhängige Dyspnoe und Lippenzyanose im Rahmen der täglichen Visite ­ Platypnoe-Orthodeoxie Syndrom.

HISTORY AND CLINICIAL FINDINGS: We elaborate a case of a 79-year-old patient who presented with position dependent shortness of breath and cyanosis of the lips at the daily round. INVESTIGATIONS: In supine position the patient's oxygen saturation was normal > 95 %, in upright position we noticed a reproducible decrease to 76-85 %. Echocardiographic examination revealed a patent foramen ovale (PFO) with spontaneous right-left shunt and additionally a thoracic aortic aneurysm. DIAGNOSIS: Due to a typical position dependent cyanosis, dyspnea and decreased oxygen saturation in combination with patent foramen ovale and aortic aneurysm, Platypnea-Orthodeoxia Syndrome was our suspected diagnosis. TREATMENT AND COURSE: After percutaneously occlusion of the foramen ovale the patient presented symptom-free und oxygen saturation remained stable in supine and upright positions. In the follow up examination a significant right-left shunt could no longer be found. CONCLUSION: The combination of position dependent shortness of breath and decreased oxygen saturation should lead to the diagnosis of Platypnea-Orthodeoxia Syndrome. The underlying reasons are diverse and not only of cardiologic origin.

[Heart Failure Despite Low BNP-Level: Paradoxon or Pathfinder? - - A Case of Pericarditis constrictiva]. / Herzinsuffizienz bei niedrigem BNP-Wert: Paradoxon oder Wegweiser?

HISTORY AND CLINICIAL FINDINGS: We elaborate a case of a 48-year old patient of indian descent who presented with shortness of breath, lower extremity edema and ascites in our emergency unit.One year beforehand tuberculous pleuritis was diagnosed and treated in accordance with guidelines. INVESTIGATIONS: CT-Scan of the heart revealed a pericardial thickening with calcifications. Echocardiographic examination and invasive pressure measurement did not provide any clear evidence of pericarditis constrictiva. Coronary artery disease was ruled out. In laboratory tests, the BNP-level was noticeably low despite severe cardiac decompensation. DIAGNOSIS: Due to a typically low BNP-level, pericarditis constrictiva was our suspected diagnosis TREATMENT AND COURSE: After an intraoperative diagnosis confirmation by our cardiosurgery colleagues, a complete pericardiectomy was performed. In the follow up, the patient presented symptom-free and with normal capacity. CONCLUSION: In case of incongruent findings, the BNP-level seems to be a useful additional diagnostic tool in the diagnosis of pericarditis constrictiva.

Point-by-point versus multisite electrode mapping in VT ablation: does freedom from VT recurrences depend on mapping catheter? An observational study.

PURPOSE: This study was conducted with the purpose of determining whether or not the potential technical advantages of multi-electrode mapping catheters in catheter ablation (CA) of ventricular tachycardia (VT) result in any relevant clinical benefit for VT patients. METHODS: A single-center VT study, having taken place from 2012 to 2014 using a standard 3.5-mm catheter (Thermocool SF® group 1) and from 2014 to 2016 using a 1-mm multi-electrode-mapping catheter (PentaRay® group 2), was conducted. The endpoint was the complete elimination of late potentials (LPs), local abnormal ventricular activities (LAVA), and VT non-inducibility. Follow-up consisted of device interrogation to monitor for VT recurrence. RESULTS: Out of 74 VT patients aged 64.5 ± 12.0 years (66 male [89.2%], 56 with ICM [75.7%], and 18 with NICM [24.3%)]), 48 patients (64.9%) were investigated in group 1 and 26 (35.1%) in group 2. Using the multi-point acquisition approach, a tendency to require less mapping time (group 1 65.2 ± 37.6 min, group 2 55.6 ± 34.4 min, p ns) was determined. During 12-month follow-up, 57 patients had freedom from VT recurrences (79.2%). The result was insignificant between the groups (38 patients (79.2%) in group 1 and 19 patients (73.1%) in group 2). CONCLUSIONS: In a single-center observational study, both conventional and high-density mapping approaches in VT patients are comparable in terms of procedure duration and outcome. Mapping time when using a multi-electrode catheter seems to have the tendency of being shorter. We should be encouraged to recruit more patients comparing the benefit of different catheter types.

High-Density Mapping in Ventricular Tachycardia Ablation: A PentaRay® Study.

BACKGROUND: High-density mapping of ventricular tachycardia (VT) with PentaRay® (Biosense-Webster) provides high resolution with discrimination of local abnormal electrograms and slow conducting channels. We evaluate the feasibility of PentaRay® to characterize the anatomical substrate and assume an influence of the outcome despite limitations. METHODS: Over a 24-month period, 26 endocardial and four epicardial maps were obtained of 26 VT patients (18 ischemic cardiomyopathy (ICM, 69.2%) and 8 non-ischemic cardiomyopathy (NICM, 30.8%), age 65 ± 9 years). Catheter ablation (CA) was performed with the aim of transecting the isthmus. The endpoint was non-inducibility of any VT. Manual review of the maps was performed and focused on evaluating scarring, bipolar electrograms, and procedure times. RESULTS: In 55.6 ± 34.4 min, 1,085.9 ± 726.2 points were created. The mean ablation time was 50.8 ± 30.1 min. The endpoint was achieved in 12 patients (46.2%). The mean dense scar area and the mean patchy scar area were 49.4 ± 51.8 cm2 (range 0 - 190 cm2) and 14.7 ± 14.9 cm2 (range 0 - 110 cm2), respectively. Analyzing the learning curve, we found a tendency in decreasing procedure times. During the course of follow-up treatment averaging a 14-month period, device interrogation showed that 17 patients (65.4%) had remained free of any arrhythmia recurrence. CONCLUSION: The high-density maps with PentaRay® were safely created in a short period of time. Our manual review of the maps reveals limitations of current annotation criteria; nevertheless, medium-term outcomes were encouraging. Further prospective studies are required to validate our findings in a larger cohort of patients.

Ischemic preconditioning for prevention of contrast medium-induced nephropathy: randomized pilot RenPro Trial (Renal Protection Trial).

BACKGROUND: Contrast medium-induced acute kidney injury is associated with substantial morbidity and mortality. The underlying mechanism has been attributed in part to ischemic kidney injury. The aim of this randomized, double-blind, sham-controlled trial was to assess the impact of remote ischemic preconditioning on contrast medium-induced acute kidney injury. METHODS AND RESULTS: Patients with impaired renal function (serum creatinine >1.4 mg/dL or estimated glomerular filtration rate <60 mL · min(-1) · 1.73 m(-2)) undergoing elective coronary angiography were randomized in a 1:1 ratio to standard care with (n=50) or without ischemic preconditioning (n=50; intermittent arm ischemia through 4 cycles of 5-minute inflation and 5-minute deflation of a blood pressure cuff). Overall, both study groups were at high risk of developing contrast medium-induced acute kidney injury according to the Mehran risk score. The primary end point was the incidence of contrast medium-induced kidney injury, defined as an increase in serum creatinine ≥25% or ≥0.5 mg/dL above baseline at 48 hours after contrast medium exposure. Contrast medium-induced acute kidney injury occurred in 26 patients (26%), 20 (40%) in the control group and 6 (12%) in the remote ischemic preconditioning group (odds ratio, 0.21; 95% confidence interval, 0.07-0.57; P=0.002). No major adverse events were related to remote ischemic preconditioning. CONCLUSIONS: Remote ischemic preconditioning before contrast medium use prevents contrast medium-induced acute kidney injury in high-risk patients. Our findings merit a larger trial to establish the effect of remote ischemic preconditioning on clinical outcomes. CLINICAL TRIAL REGISTRATION: URL: http://www.germanctr.de. Unique identifier: U1111-1118-8098.