Cardiac shock wave therapy and myocardial perfusion in severe coronary artery disease.

BACKGROUND: Ultrasound guided cardiac shock wave therapy (CSWT) is a noninvasive therapeutic option in the treatment of chronic-refractory angina. Clinical trials have shown that CSWT reduces angina symptoms, improves regional systolic function, LV ejection fraction, myocardial perfusion and quality of life parameters. Absolute measurements of myocardial perfusion before and after CSWT have not been performed so far. METHODS AND RESULTS: We studied a total of 21 CCS III patients with history of CAD and multiple interventions who suffered from disabling angina despite individually optimized medical therapy. An N-13 NH3 PET perfusion scan under adenosine was performed before and after CSWT treatment. CSWT was well tolerated in all patients. Absolute perfusion under adenosine of the global left-ventricular myocardium did not change under therapy or minimal coronary resistance. The treated segments, however, showed in terms of both perfusion and resistance a mild but significant improvement, by 11 and 15 %, respectively, whereas no change could be observed in the remote segments. Considering a threshold of increased perfusion of 5 %, 10 (77 %) out of 13 patients with a better target perfusion improved in their CCS class, whereas 3 (43 %) out of 7 patients without improved target perfusion improved in their CCS class too. CONCLUSION: Standard CSWT has the potential to improve myocardial perfusion of the therapy zone and clinical CAD symptomatology without affecting global myocardial perfusion. As a noninvasive and well tolerated therapeutic option, these data suggest the use of CSWT in patients with end-stage CAD.

[Infective endocarditis]. / Mikrobiell verursachte Endokarditis.

Colonization of native cardiac valves or polymer implants, e.g. valves, conduits, rings, electrode leads and polymer-associated endocarditis (PIE), by microorganisms, primarily gram-positive bacteria (infective endocarditis), constitutes a severe, prognostically unfavorable disease. Fever and in the majority of cases development of a valve regurgitant murmur are clinical landmark findings. The white blood cell count, erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) are regularly elevated. With a normal CRP level, infective endocarditis is extremely unlikely. Irrespective of body temperature, at least three blood cultures (aerobic and anaerobic) should be taken and if initiation of antimicrobial therapy is urgent, 1 h apart before therapy is initiated. Identification of the pathogen to the species level and testing antimicrobial susceptibility to antibiotics by a quantitative hemodilution test, not with agar diffusion tests, are obligatory. A minimum inhibitory concentration should be administered for antibiotics and usual combinations of antibiotics with an expected synergistic potential. Streptococci, staphylococci and enterococci are the most frequent causative organisms. Immediate initiation of transthoracic echocardiography (TTE) is mandatory followed by transesophageal echocardiography if imaging quality is poor, involvement of intracardiac implants is possible or TTE is insufficient to establish the diagnosis. An insufficiently long antimicrobial therapy promotes recurrent infections, thus a 4-week treatment is standard, while in special cases (e.g. PIE) treatment for 6 weeks should be the rule. If typical complications of infective endocarditis, such as uncontrolled local infection, systemic thromboembolism, central nervous involvement, development of a severe valve incompetence or mitral kissing vegetation in primary aortic valve endocarditis occur, urgent surgical intervention should be considered. If cardiac implants are involved, early surgical removal followed by a 6-week antimicrobial treatment is the rule. Adequate and timely diagnosis and treatment are the key to improve the overall prognosis.

[Knowledge of guidelines for anticoagulation management of patients with atrial fibrillation]. / Evaluation des Kenntnisstandes der Leitlinien zur Antikoagulation bei Vorhofflimmern.

INTRODUCTION: In Germany, about 1 million people are affected by atrial fibrillation (AF). Morbidity and mortality are high especially due to the risk of thromboembolic events. A valid risk stratification by the CHADS2 criteria is critical regarding the indication for anticoagulation and thus to improve prognosis. To what extent these criteria and guidelines are known and have been implemented among cardiologists and general practitioners in Germany has not been evaluated so far. METHODS: A total of 558 cardiologists (46.8 %) and general practitioners (52.5 %) were surveyed during the annual meeting of the German Society of Cardiology or in writing in a representative sample of German general practitioners. RESULTS: Compared to 51.8 % of general practitioners, 87.6 % of cardiologists (p < 0.001) claimed to know the CHADS2 criteria. In the total cohort, CHADS2 criteria were correctly identified as risk factors by 55.6-86.9 %. Cardiologists had significantly better knowledge of these criteria (63.6-91.2 % vs. 55.6-86.9 %, p < 0.001). A previous history of cerebral stroke was known to be a risk factor in almost all physicians in contrast to heart failure (47.3 % of cardiologists vs. 36.0 % of general practitioners, p < 0.001). Physicians who had attended a training course on anticoagulation and atrial fibrillation (n = 380) in the 2 years prior to the survey performed significantly better (p = 0.007) than those without training (n = 173). CONCLUSION: While the majority of cardiologists knew the CHADS2 criteria and the related guidelines, these criteria were less known in the primary care sector. Nevertheless, even cardiologists do not always apply the guidelines for anticoagulation in AF correctly. Participants of training courses had a significantly better knowledge of these guidelines.

[Lipoprotein(a): influence on cardiovascular manifestation]. / Lipoprotein(a) ­ Einfluss auf die kardiovaskuläre Manifestation.

The clinical relevance of lipoprotein(a) (Lp(a)) as a cardiovascular risk factor is currently underestimated. The aim of our study was to assess the influence of increased Lp(a) values on the development and severity of coronary artery disease (CAD).In our retrospective analysis of 31,274 patients, who were hospitalized for the first time, we compared patients with isolated increased Lp(a) (> 110 mg/dl) and normal Lp(a) (< 30 mg/dl), with increased Lp(a) concentrations (30-60 mg/dl, 61-90 mg/dl, 91-110 mg/dl), and in a third analysis with additionally increased LDL cholesterol and HbA1c values.Patients with high Lp(a) levels showed a significantly higher incidence of advanced CAD with a three-vessel disease being present in 50.2 vs. 25.1 %. Patients with high Lp(a) levels had a significantly more frequent history of myocardial infarction (34.6 vs. 16.6 %, p < 0.001), surgical myocardial revascularization (40.8 vs. 20.8 %, p < 0.001) and percutaneous coronary intervention (55.3 vs. 33.6 %, p < 0.001). In addition, there was a marked difference in gender to the disadvantage of male patients regarding development and severity of CAD. CAD risk (Odds ratio) was increased 5.5-fold in patients with Lp(a) ≥ 110 mg/dl. Additionally elevated LDL and HbA1c levels were not associated with increased manifestation and severity of CAD.High Lp(a) concentration leads to an increased manifestation and severity of coronary artery disease. Additional risk factors do not aggravate manifestation of CAD.

Delayed recovery from Cheyne-Stokes respiration in heart failure after successful cardiac transplantation: a case report.

BACKGROUND: Sleep-disordered breathing (SDB), especially central sleep apnea with Cheyne-Stokes respiration (CSA-CSR), is highly prevalent in patients with severe heart failure (HF). SDB, and predominantly CSR, may improve after recovery of cardiac function, but available data are limited and inconclusive, particularly in patients who have undergone heart transplantation (HTX). CASE REPORT: The case of a 59-year-old man with dilated cardiomyopathy and advanced chronic HF, plus CSA-CSR, is reported. The patient showed normalization of cardiac function after successful HTX, with delayed but gradual stepwise improvements in CSA-CSR over time. CONCLUSIONS: Although there is a close relationship between cardiac function and manifestations of SDB and CSA-CSR, stabilization of nocturnal respiration after improvement in cardiac function may be delayed rather than immediate.

[Detection and therapy of respiratory dysfunction by implantable (cardiac) devices]. / Detektion und Therapie respiratorischer Störungen durch implantierbare (kardiale) Devices.

Sleep-disordered breathing (SDB) represents a common comorbidity in cardiac patients. The prevalence of obstructive sleep apnea (OSA) and central sleep apnea (CSA) is very high, particularly in patients with heart rhythm disorders and heart failure (HF). Patients with pacemakers (PM) and implantable defibrillators (ICD) including cardiac resynchronization therapy (CRT) show SDB prevalences up to 75%. However, some modern PM, ICD and CRT devices allow the detection of SDB via transthoracic impedance analysis with high sensitivity compared to polysomnographic (PSG) controls. Thus, this method could be of relevance in screening and monitoring SDB in patients with implantable cardiac devices. Preliminary studies demonstrated the possibility to treat OSA in selected patients by stimulation of the cranial nerves, especially the hypoglossal nerve. However, this requires extensive diagnostics and advanced surgical approaches including many medical disciplines and is not part of this review article. However, unilateral and transvenous stimulation of the phrenic nerve to treat central sleep apnea and Cheyne-Stokes respiration in HF patients in particular can be performed by cardiologists. This article summarizes preliminary data on the results of this promising therapy.

Hypertrophic cardiomyopathy in cardiac CT: a validation study on the detection of intramyocardial fibrosis in consecutive patients.

Hypertrophic Cardiomyopathy (HCM) confers a 4-5 %/year-risk for sudden cardiac death. Intramyocardial fibrosis (IF) is associated with this risk. The gold standard of IF visualization is cardiovascular magnetic resonance (CMR) with late gadolinium enhancement (LGE-CMR). In view of a number of CMR-limitations the hypothesis of this study was that late enhanced multi-slice computed tomography (leMDCT) enables demonstration of late enhancement (LE) indicating IF. In a prospective single-center validation study leMDCT research-scans were exclusively performed for IF-imaging in HCM-patients not including non-invasive coronary angiography during first-pass (64-slice; 80 kV; Iopromide, 150 mL, injected 7 min before scanning). Applying a 17-segment-polar-map short cardiac axis views (multiplanar reformations; 5 mm slice thickness) were analysed in order to exclude/detect, localize and measure LE practicing the manual quantification method if present. Finally, leMDCT and LGE-CMR data were unblinded for intermodal correlation. We included n = 24 patients consecutively (64.0 ± 14.5 years of age). LE was demonstrated by LGE-CMR in n = 14/24 patients (prevalence 58 %). Patient- and segment-based sensitivity in leMDCT was 100 and 68 %, respectively. In leMDCT tissue density of LE was 142 ± 51 versus 89.9 ± 19.3 HU in remote myocardium (p < 0.001). Signal-to-noise-ratio (SNR) and contrast-to-noise-ratio (CNR) appeared to be 7.3 ± 3.3 and 2.3 ± 1, respectively. Sizing of LE-area gave 2.2 ± 1.4 cm(2) in leMDCT versus 2.9 ± 2.4 cm(2) in LGE-CMR (r = 0.93). Intra-/interobserver variability was assessed with an accuracy of 0.36 cm(2) (r = 0.91) and 0.47 cm(2) (r = 0.82), respectively. In consecutive HCM patients leMDCT can reliably detect intramyocardial fibrosis marked by LE. In view of a comparatively low SNR and CNR leMDCT may alternatively be applied in case of CMR contraindications.

[Sleep-related breathing disorders and (resulting) cardiovascular diseases]. / Schlafbezogene Atmungsstörungen und kardiovaskuläre (Folge-)Erkrankungen.

Sleep-related breathing disorders occur in cardiology patients mostly as obstructive or central sleep apnea with Cheyne-Stokes respiration. The prevalence and incidence are clearly increased in comparison to the general population. Depending on the underlying cardiac disease up to 75% of patients can have obstructive or central sleep apnea and up to 50% have indications for therapy according to the current guidelines. Obstructive sleep apnea is considered to be an independent and well treatable risk factor for the development and deterioration of many cardiovascular diseases. This review briefly describes examples of prevalence, pathophysiology and current study situation with respect to the association between sleep-related breathing disorders and arterial hypertension, atrial fibrillation, arteriosclerosis with coronary heart disease, myocardial infarction and heart failure. Although the role of obstructive sleep apnea as a risk factor for the development of these diseases is well documented, central sleep apnea is less of a risk factor per se but is considered to mirror an underlying cardiac disease with then further negative consequences for this disease. It is not the sleep apnea per se but the subsequent cardiovascular diseases which limit the prognosis of these patients and therefore bring them into the focus of cardiology. Obstructive and central sleep apnea can be successfully and sustainably treated by various forms of nocturnal positive airway pressure therapy. Furthermore, there are several therapeutic procedures which are currently being tested and the significance will be investigated in the coming years.

[Electrical myostimulation: improvement of quality of life, oxygen uptake and left ventricular function in chronic heart failure]. / Elektromyostimulation: Verbesserung von Lebensqualität, Sauerstoffaufnahme und linksventrikulärer Funktion bei chronischer Herzinsuffizienz.

AIM OF THE STUDY: Regular physical activity has found to be a strategy to increase exercise capacity in patients with chronic heart failure (CHF). Next to endurance training also electromyostimulation (EMS) of thigh and gluteal muscles results in an increased capacity in CHF patients. EMS therapy was either done by stimulating 8 major muscle groups involving also trunk and arm muscles (extended electromyostimulation (exEMS)) in comparison to EMS therapy limited to gluteal and leg muscles (limEMS). METHODS: 31 individuals completed the EMS training program. Stable CHF patients (NYHA class II-III) received either exEMS (18 patients, 11 males, mean age 59.8±13.8 years) or limEMS (13 patients, 10 males, 63.6±9.4 years). Training was performed for 10 weeks twice weekly for 20 min, the level of daily activity remained unchanged. Effects on exercise capacity, left ventricular function (EF - ejection fraction) and QoL (quality of life) were evaluated. RESULTS: QoL was found to be improved in all domains of the SF-36 questionnaire. In the exEMS group there was a significant improvement in the domain physical functioning (54.09±29.9 to 75.45±15.6, p=0.48) and emotional role (63.63±45.8 to 93.93±20.1 p=0.048). LimEMS group showed significant improvement in the domain vitality (37.5±6.9 to 52.8±12.5, p=0.02).There was a significant increase of oxygen uptake at aerobic threshold in all groups (exEMS: +29.6%, p<0.001; limEMS +17.5%, p<0.001). EF -increased from 36.94±8.6 to 42.36±9.1% (+14.7%, p=0.003) in the exEMS group (limEMS 37.7±3.6 to 40.3±5.9% [+6.9%, p=0.18]). CONCLUSION: EMS contributes to an improved quality of life and can improve oxygen uptake and EF in CHF. It may be an alternative therapy in CHF patients who are otherwise unable to undertake conventional forms of exercise training.

[The "asymptomatic" patient with chronic acquired heart valve disease]. / Der "asymptomatische" Patient mit chronischem Herzklappenfehler.

An intervention for chronic acquired valvular heart disease may either be indicated in symptomatic patients to relieve symptoms and improve quality of life or in asymptomatic patients to improve long-term prognosis, e.g., by preventing disease-related complications like chronic heart failure or arrhythmias. For proper action according to current guidelines, the systematic evaluation of symptoms related to the underlying valve disease is of utmost importance. If a discrepancy between symptoms reported or not reported by the patients and the severity of the valve disease is supposed, true absence of symptoms and exercise tolerance should be verified by spiroergometry. In the truly asymptomatic patient with a severe valvular lesion, preservation of myocardial adaption to the chronic volume or pressure overload should be tested utilizing appropriate imaging techniques like radionuclide ventriculography under exercise conditions. The proper evaluation of the functional status is of growing importance in our aging population with its sedentary lifestyle. In this context, the results of a survey should be kept in mind, which indicated that a significant proportion of patients still have interventions too late during the natural history of their valve disease with symptoms of congestive heart failure, arrhythmias, and the risk of sudden cardiac death persisting after a primarily successful valve repair or replacement.

Intra-individual head-to-head comparison of Sirolimus®- and Paclitaxel®-eluting stents for coronary revascularization. A randomized, multi-center trial.

BACKGROUND: Despite the known effects of drug-eluting stents (DES), other cofactors attributed to patient characteristics affect their success. Interest focused on designing a study minimizing these factors to answer continuing concerns on the heterogeneity of response to different DESs. The study's aim was to investigate the feasibility and impact of an intra-individual comparison design in patients (pts) with two coronary artery stenosis treated with a Sirolimus- (SES) and a Paclitaxel- (PES) eluting stent. METHODS AND RESULTS: The study was conducted as a prospective, randomized, multi-center trial in 112 pts who consented to treatment with a SES and a PES. Pts were eligible if they suffered from the presence of two single primary target lesions in two different native coronary arteries. Lesions were randomized to either SES or PES treatment. The primary endpoint was in-stent luminal late loss (LLL), as determined by quantitative angiography at 8 months; clinical follow up was obtained at 1, 8, and 12 months additionally. The LLL (0.13 ± 0.28 mm SES vs. 0.26 ± 0.35 mm PES, p=0.011) showed less neointima in SES. With a predefined cut-off criterion of 0.2mm difference in LLL, 53/87 pts SES and PES were similar effective. 34/87 pts had a divergent result, 26 pts had greater benefit from SES while 8 pts had greater benefit from PES. Overall, MACE (MI, TLR, and death) occurred in 19 (17%) pts. Based on lesion analysis of 108 lesions treated with SES and 110 lesions treated with PES, 5 (4.6%) lesions with SES and 3 (2.7%) lesions with PES required repeated TLR. CONCLUSION: An intra-individual comparison design to assess differences in efficacy of different DESs is feasible, safe and achieves similar results to inter-individual studies. This study is among the first to show that failure of one DES does not necessarily implicate failure of another DES and vice versa.

Left ventricular mass and oxygen uptake in top handball athletes.

The key challenge in athlete's screening is the distinction between abnormal and normal which is hindered by the fact that the adaptation to sports activity in endurance athletes is different to that in power athletes. Especially cardiomyopathies provoke changes in ECG and echocardiography (echo) at an early stage when clinical symptoms are absent. ECG and echo data and their relationship to fitness peculiar to top handball players have never been described. We studied 291 male first league handball players (32 Olympians/47 national players) (25.3±4.4 years). Check up consisted of ECG, spiroergometry and echocardiography. None had T-wave inversions, 3.1% showed early repolarisation abnormalities in the precordial leads. Sokolow-Lyon voltage criterion for left ventricular hypertrophy was positive in 19.3%. Spiroergometry showed a maximum oxygen uptake (peakVO2) of 50.3±7.7 ml/min/kg body weight. LVmass was increased in comparison to normal values. There was a correlation between peakVO2 and LVindex (p<0.001, r=0.341), (LVmass/peak VO2 p=0.053, r=0.125). A relationship between cardiac dimensions and peakVO2 could not be confirmed. In professional handball players early repolarisation abnormalities were less frequent and LVmass was increased when compared with soccer players. The need for normal values for different types of sports is crucial to guarantee a proper evaluation of athletes.

Lipid apheresis: oxidative stress, rheology, and vasodilatation.

In the treatment of homozygous and therapy-resistant hypercholesterolemia, lipid apheresis enables not only low density lipoprotein (LDL) cholesterol to be lowered by approximately 60%, but also oxidative stress factors to be influenced and adhesion molecules reduced. This was investigated in a group of 12 patients using the heparin-induced extracorporeal LDL precipitation (H.E.L.P.) procedure.A significant lowering of LDL cholesterol and fibrinogen leads to an improvement in rheology and endothelial function, detectable and measurable within approximately 20 h by assessing minimum coronary resistance using positron emission tomography (PET) performed in 35 patients. This effect is detectable even after the first lipid apheresis session (H.E.L.P. procedure), documented in 12 patients.Lipid apheresis appears to be the most effective procedure in the treatment of elevated lipoprotein(a) [Lp(a)]. A chosen group of nine patients with selective elevated Lp(a) illustrated both the influence on endothelial dysfunction, in the shape of sharply increased minimum coronary resistance, and the reduction through lipid apheresis, indicating that Lp(a) seems to exert a similar effect on the vascular wall and vascular function as LDL cholesterol.