Use of Pre- and Intensified Postprocedural Physiotherapy in Patients with Symptomatic Aortic Stenosis Undergoing Transcatheter Aortic Valve Replacement Study (the 4P-TAVR Study).

BACKGROUND: Physiotherapy prior to open-heart surgery lowers the rate of pneumonia and length of the hospital stay. Pneumonia is a major contributor to short-term mortality following transcatheter aortic valve replacement (TAVR). Hence, we hypothesized that pre- and intensified postprocedural physiotherapy in patients undergoing TAVR might impact the net functional and clinical outcome. METHODS AND RESULTS: The 4P-TAVR study was a prospective, monocentric, randomized trial. The study was designed to compare the efficacy and safety of intensified periprocedural physiotherapy including inspiratory muscle training versus standard postprocedural physiotherapy. Patients were randomized in a 1 : 1 fashion. 108 patients were included and followed up for 90 days after TAVR. While patients in group A (control group: 50 patients, age: 81.7 ± 5.0 years, 52% male) did not receive physiotherapy prior to TAVR, group B (intervention group: 58 patients, age: 82.2 ± 5.82 years, 47% male) participated in intensive physiotherapy. Compared to the control group, patients in the interventional group showed a lower incidence of postinterventional pneumonia (10 [20.0%] vs. 3 [5.1%], p=0.016) and had a 3-day shorter mean hospital stay (13.5 ± 6.1 days vs. 10.1 ± 4.7 days, p=0.02). The primary composite endpoint of mortality and rehospitalization was not different between the groups. CONCLUSION: Intensified physiotherapy is safe and has positive effects on clinical outcomes up to 90 days after TAVR but has no impact on the primary combined endpoint of mortality and rehospitalization. Longer follow-up, a multicenter design, and a higher number of subjects are needed to confirm these preliminary results. This trial is registered with DRKS00017239.

Interdisciplinary consensus on indications for transfemoral transcatheter aortic valve implantation (TF-TAVI) : Joint Consensus Document of the Arbeitsgemeinschaft Leitende Kardiologische Krankenhausärzte e.V. (ALKK) and cooperating Cardiac Surgery Departments.

Indications for TF-TAVI (transfemoral transcatheter aortic valve implantation) are rapidly changing according to increasing evidence from randomized controlled trials. Present trials document the non-inferiority or even superiority of TF-TAVI in intermediate-risk patients (STS-Score 4-8%) as well as in low-risk patients (STS-Score < 4%). However, risk scores exhibit limitations and, as a single criterion, are unable to establish an appropriate indication of TF-TAVI vs transapical TAVI vs SAVR (surgical aortic valve replacement). The ESC (European Society of Cardiology)/EACTS (European Association for Cardio-Thoracic Surgery) guidelines 2017 and the German DGK (Deutsche Gesellschaft für Kardiologie)/DGTHG (Deutsche Gesellschaft für Thorax-, Herz- und Gefäßchirurgie) commentary 2018 offer a framework for the selection of the best therapeutic method, but the individual decision is left to the discretion of the heart teams. An interdisciplinary TAVI consensus group of interventional cardiologists of the ALKK (Arbeitsgemeinschaft Leitende Kardiologische Krankenhausärzte e.V.) and cardiac surgeons has developed a detailed consensus on the indications for TF-TAVI to provide an up-to-date, evidence-based, comprehensive decision matrix for daily practice. The matrix of indication criteria includes age, risk scores, contraindications against SAVR (e.g., porcelain aorta), cardiovascular criteria pro TAVI, additional criteria pro TAVI (e.g., frailty, comorbidities, organ dysfunction), contraindications against TAVI (e.g., endocarditis) and cardiovascular criteria pro SAVR (e.g., bicuspid valve anatomy). This interdisciplinary consensus may provide orientation to heart teams for individual TAVI-indication decisions. Future adaptations according to evolving medical evidence are to be expected. Interdisciplinary consensus on indications for transfemoral transcatheter aortic valve implantation (TF-TAVI).

[The heart team in planning and performance of revascularization : ESC guidelines versus clinical routine]. / Das Herzteam bei der Planung und Durchführung von Revaskularisationen : ESC-Leitlinien versus klinischer Alltag.

The heart team, consisting of conservative cardiologists, cardiac surgeons and interventional cardiologists, is important for a balanced, multidisciplinary decision-making process for patients suffering from coronary artery disease (CAD). Standard evidence-based, interdisciplinary, institutional protocols can be used for commonly encountered case scenarios to avoid the need for a systematic case by case review. Complex cases with a SYNTAX score of more than 32, diabetes mellitus and lesions of the left main stem or three-vessel disease should in general not be treated by an ad hoc percutaneous coronary intervention (PCI) but first discussed in the heart team. Culprit lesion PCI is usually the first choice in most patients with acute coronary syndrome. If complete percutaneous revascularization is not possible, coronary artery bypass grafting (CABG) should be considered by the heart team. In patients assigned for CABG, timing of the procedure should be decided on an individual basis, depending on the symptoms, hemodynamic stability, coronary anatomy and signs of ischemia. In stabilized patients with acute coronary syndrome, the choice of revascularization modality can be made in analogy to patients with stable CAD.

[Evaluation and Optimization of Microvascular Arterial Anastomoses by Transit Time Flow Measurement]. / Evaluation und Optimierung arterieller Anastomosen durch Transit-Zeit Flussvolumenmessungen.

UNLABELLED: INDRODUCTION: The regular application of transit time flow measurement in microvascular anastomoses during heart surgery has lead to improvements of the outcome of coronary artery bypass grafts. Our study was meant to discover whether this measurement method was also applicable for evaluation and optimization of microvascular arterial anastomoses of radial forearm flaps. METHODS: In this prospective examination a combining ultrasound imaging and transit time flow measurement device (VeriQ, MediStim) was used during surgery to assess anastomotic quality of 15 radial forearm flaps. Pulsatility index (PI) and mean blood flow were measured immediately after opening the arterial anastomosis as well as 15 min afterwards. Furthermore, application time and description of handling were recorded seperately for every assessment. RESULTS: Mean blood flow immediately after opening the anastomosis and 15 min later were 3.9 and 3.4 ml/min resepectively showing no statistically significant difference (p=0.96). There was no significance in the increase of pulsatility index from 22.1 to 27.2 (p=0.09) during the same time range, either. Due to measurement results showing atypical pulse curves in 2 cases decision for surgical revision of the anastomoses was made. All forearm flaps showed good vascularisation during follow-up. Time for device set up, probe placement and measurements was about 20 min. Handling was described to be uncomplicated without exception. There were no noteworthy problems. CONCLUSION: Transit time flow measurement contributes to the improvement of anastomotic quality and therefore to the overall outcome of radial forearm flaps. The examined measurement method provides objective results and is useful for documentation purposes.

[Basic standards for a department of cardiac surgery. Quality requirements for the care of cardiac patients in connection with operations on the heart, the heart vessels and thoracic organ transplantation]. / Basisstandards einer Fachabteilung für Herzchirurgie. Qualitätsanforderungen für die Versorgung von herzkranken Patientinnen und Patienten im Zusammenhang mit Operationen/Eingriffen am Herzen, den herznahen Gefäßen und der thorakalen Organtransplantation.

Current evolutions and substantial amendments of the German health care system in combination with distinguished progress in cardiac surgery over the past years require both a reflection of principles in patient-centered care and an update of basic standard requirements for a department of cardiac surgery in Germany. In due consideration of the data from the voluntary registry of the German Society for Thoracic and Cardiovascular Surgery, this article accurately defines core requirements for a cardiac surgical department (cardiac surgery on-site), subdivided into facilities, staff and processes. If based on these standards, one may anticipate that cardiac surgical care is performed under appropriate conditions leading to an intrinsic benefit for patients.

[Ischemic mitral regurgitation : pathomechanisms and current therapeutic options]. / Ischämische Mitralklappeninsuffizienz : Pathomechanismen und aktuelle Therapieoptionen.

Ischemic mitral regurgitation (MR) is a complication of myocardial infarction due to coronary heart disease and may occur during the course of acute ischemia or delayed following adverse left ventricular remodeling. Acute ischemic MR represents a life-threatening condition and requires immediate surgical correction. Chronic ischemic MR develops time-delayed from acute ischemia and is caused by pathological remodeling of the left ventricle or valvular apparatus and mostly affects older patients with severe comorbidities. This common manifestation of ischemic MR contributes to the poor prognosis of such patients. Therapeutic options for the treatment of patients with chronic ischemic MR are limited as current guidelines are based on weak evidence and the optimal treatment is still a matter of controversy. Surgical correction of chronic ischemic MR is only advised in patients with indications for concomitant surgical revascularization and modern interventional or surgical treatment strategies to reduce MR are not included in these guidelines. Modern surgical options and new interventional procedures are available and will influence future treatment strategies of this chronic manifestation of MR.

The German Aortic Valve Registry (GARY): a nationwide registry for patients undergoing invasive therapy for severe aortic valve stenosis.

Background The increasing prevalence of severe aortic valve defects correlates with the increase of life expectancy. For decades, surgical aortic valve replacement (AVR), under the use of extracorporeal circulation, has been the gold standard for treatment of severe aortic valve diseases. In Germany ~12,000 patients receive isolated aortic valve surgery per year. For some time, percutaneous balloon valvuloplasty has been used as a palliative therapeutic option for very few patients. Currently, alternatives for the established surgical procedures such as transcatheter aortic valve implantation (TAVI) have become available, but there are only limited data from randomized studies or low-volume registries concerning long-time outcome. In Germany, the implementation of this new technology into hospital care increased rapidly in the past few years. Therefore, the German Aortic Valve Registry (GARY) was founded in July 2010 including all available therapeutic options and providing data from a large quantity of patients.Methods The GARY is assembled as a complete survey for all invasive therapies in patients with relevant aortic valve diseases. It evaluates the new therapeutic options and compares them to surgical AVR. The model for data acquisition is based on three data sources: source I, the mandatory German database for external performance measurement; source II, a specific registry dataset; and source III, a follow-up data sheet (generated by phone interview). Various procedures will be compared concerning observed complications, mortality, and quality of life up to 5 years after the initial procedure. Furthermore, the registry will enable a compilation of evidence-based indication criteria and, in addition, also a comparison of all approved operative procedures, such as Ross or David procedures, and the use of different mechanical or biological aortic valve prostheses.Results Since the launch of data acquisition in July 2010, almost all institutions performing aortic valve procedures in Germany joined the registry. By now, 91 sites which perform TAVI in Germany participate and more than 15,000 datasets are already in the registry.Conclusion The implementation of new or innovative medical therapies needs supervision under the conditions of a well-structured scientific project. Up to now relevant data for implementation of TAVI and long-term results are missing. In contrast to randomized controlled trials, GARY is a prospective, controlled, 5-year observational multicenter registry, and a real world investigation with only one exclusion criterion, the absence of patients' written consent.

Randomized comparison of synchronous CABG and carotid endarterectomy vs. isolated CABG in patients with asymptomatic carotid stenosis: the CABACS trial.

RATIONALE: High-grade carotid artery stenosis is present in 6-8% of patients undergoing coronary artery bypass graft surgery. Many cardiovascular surgeons advocate staged or synchronous carotid endarterectomy to reduce the high perioperative and long-term risk of stroke associated with multivessel disease. However, no randomized trial has assessed whether a combined synchronous or staged carotid endarterectomy confers any benefit compared with isolated coronary artery bypass grafting in these patients. AIMS: The objective of this study is to compare the safety and efficacy of isolated coronary artery bypass grafting vs. synchronous coronary artery bypass grafting and carotid endarterectomy in patients with asymptomatic high-grade carotid artery stenosis. DESIGN: Coronary Artery Bypass graft surgery in patients with Asymptomatic Carotid Stenosis (CABACS) is a randomized, controlled, open, multicenter, group sequential trial with two parallel arms and outcome adjudication by blinded observers. Patients with asymptomatic high-grade carotid stenosis scheduled for elective coronary artery bypass grafting will be assigned to either isolated coronary artery bypass grafting or synchronous coronary artery bypass grafting and carotid endarterectomy by 1 : 1 block-stratified randomization with three different stratification factors (age, gender, modified Rankin scale). STUDY: The trial started in December 2010 aiming at recruiting 1160 patients in 25 to 30 German cardiovascular centers. The composite primary efficacy end point is the number of strokes and deaths from any cause (whatever occurs first) within 30 days after operation. A 4·5% absolute difference (4% compared to 8·5%) in the 30-day rate of the above end points can be detected with >80% power. OUTCOMES: The results of this trial are expected to provide a basis for defining an evidence-based standard and will have a wide impact on managing this disease.

Implantation of left ventricular epicardial leads in cardiosurgical patients with impaired cardiac function--a worthwhile procedure in concomitant surgical interventions?

BACKGROUND: Cardiac resynchronization therapy (CRT) by means of multisite biventricular pacing is an effective therapeutic option for the treatment of severe heart failure. The present study estimates how many open heart-surgery patients could benefit from the implantation of permanent left ventricular (LV) pacing leads. After routine preoperative screening, epicardial electrodes were implanted in selected patients. Lead performance and outcomes were investigated. METHODS: Primarily, 1059 patients were retrospectively investigated with regard to LV function, left bundle branch block and QRS duration. Afterwards, suitable patients were identified and epicardial electrodes [Medtronic 5071 (ME) or Enpath (EP)] were implanted during concomitant procedures. Mean follow-up time was 6.3 ± 5.5 months. RESULTS: The retrospective study showed that 24 patients (2.3%) could potentially profit from CRT. After routine preoperative screening for CRT-responders, 22 patients (1.6%) were identified who finally received epicardial leads. No complications occurred. Acute capture threshold was 0.9 ± 0.4 V (ME, n = 17) and 0.5 ± 0.2 V (EP, n = 5). While leads in 18 patients were implanted as an upgrade to an existing pacemaker or implantable cardioverter-defibrillator (ICD) technologies (Group B), 4 patients underwent prophylactic implantation with no device attached (Group A). CRT-ICDs were implanted at follow-up in 3 Group A patients (75%). In Group B patients, the QRS duration decreased (from 189 ± 35 ms to 152 ± 16 ms, p < 0.02) and their postoperative mean NYHA functional class improved significantly (2.2 ± 0.5 versus 2.8 ± 0.6). CONCLUSION: A small group of cardiac surgery patients may benefit from LV-lead implantation during concomitant procedures. A protocol for responder identification is useful. Existing devices should be upgraded to CRT systems. As CRT-ICD implantation is frequent, the additional costs and time are justified.

Comparison of an intermittent high-intensity vs continuous low-intensity physiotherapy service over 12 months in community-dwelling people with stroke: a randomized trial.

OBJECTIVE: This study compared two modes of physiotherapy service over 12 months in community-dwelling people with stroke, either following a train-wait train paradigm by providing bouts of intense physiotherapy, or a continuous less intense programme. DESIGN: Randomized trial. SETTING: Community-dwelling people with stroke. INTERVENTIONS: Fifty patients, first-time stroke, discharged home, following inpatient rehabilitation, allocated to two groups, A and B. Over 12 months, Group A (n = 25) received three two-month blocks of therapy at home, each block contained four 30 to 45 minute sessions per week, totalling 96 sessions. Group B (n = 25) continuously received two 30 to 45 minute sessions per week, totalling 104 sessions. MAIN OUTCOME MEASURES: Primary Rivermead Mobility Index (0-15), secondary upper- and lower-limb motor functions, Activities of Daily Living competence, tone and number of falls. RESULTS: Both groups were comparable at onset, the mean age in Group A (B) was 62.4 (61.9) years. A and B patients equally improved functions over time, between group differences did not occur. The initial (terminal) Rivermead Mobility Index was 9.4 ± 2.8 (12.2 ± 2.1) in Group A, and 8.5 ± 3.5 (11.2 ± 2.7) in Group B. More Group B patients fell seriously (7 versus 1). CONCLUSIONS: The intermittent high-intensity and continuous low-intensity therapy protocols were equally effective, the sheer intensity seems more important than the time-mode of application. The relatively young patients functionally improved in the first year after stroke, the reduced risk of serious falls in the intermittent high-intensity group should be validated.

Visualization of the Adamkiewicz artery in patients with acute stanford a dissections: a prospective 64-row multi-detector CT study.

PURPOSE: To evaluate the detectability of the Adamkiewicz artery (AA) in patients with acute Stanford type A aortic dissections with multi-detector computed tomography (MDCT). MATERIALS AND METHODS: 51 patients with Stanford type A dissection underwent contrast-enhanced 64-row MDCT of the entire aorta (collimation 64 x 0.625 mm; rotation time 0.4sec; 120 kV; 300 mAs). The visualization of the AA, its origin, and whether it originated from the true or false lumen were analyzed using source and multiplanar reformation images. RESULTS: A single anterior radicular artery that formed a hairpin turn constituting the anterior spinal artery was visualized in 36 (70 %) patients. Thirty (83 %) of these arteries originated from the left side, and 35 (97 %) originated between the level T 7 and L 2. Twenty-three (64 %) arteries originated from the true and 13 (36 %) from the false lumen. Two AAs in the same patient were not observed. CONCLUSION: MDCT depicts the AA in a high percentage of patients with acute Stanford type A aortic dissection.

[Pedestrians in Berlin after stroke. Recommendations for street and subway transit]. / Fussgänger in Berlin nach einem Schlaganfall. Anforderungen im Strassenverkehr und in der U-Bahn.

BACKGROUND: The yearly incidence of stroke in Germany is 180 per 100,000 inhabitants. Three months after stroke onset, 20% of these patients are still wheelchair-bound and walking ability and endurance are markedly decreased in 70%. Our work group evaluated which abilities the patients need to master the local road traffic and use the subway (underground) to guarantee mobility and sustain social contacts. METHODS: We assessed the time needed to cross the street at traffic lights and use subway stations in Berlin, Germany. RESULTS: The mean gait velocity needed was 0.89+/-0.41 m/s to cross the street during the green phase at selected traffic lights. Fourteen of 29 (48.28%) subway stations on the U2 line in Berlin had neither lift nor escalator to the surface. Travellers had to climb a mean of 25.41+/-2.67 steps. Berlin's U7 line has 40 stations, four of which (10%) had no lift or escalator. There it was necessary to climb a mean of 27.13+/-7.03 steps. CONCLUSION: The recommendations for renewing walking ability in chronic stroke patients are considerable. Therefore the emphasis of physiotherapy should be on increasing walking speed and endurance.

"Rapid two-stage" Norwood operation in a child with multiorgan failure.

The Norwood I operation continues to be a procedure with significant operative mortality. One well-accepted risk factor for death after the first step of the Norwood operation is critical preoperative status. We describe herein a new concept for the treatment of patients with hypoplastic left heart syndrome (HLHS) in very poor preoperative condition. This is a case report of a child who was born in a rural hospital. On the second day of life he was referred to our center in multiorgan failure. There were signs of liver dysfunction and the child was anuric. Therapy was started immediately with prostaglandin and vasodilators as well as diuretics, milrinone, and dobutamine. However, systemic perfusion continued to be insufficient. Finally, the child was placed on a ventilator. On the fourth day of life, bilateral pulmonary artery (PA) banding was performed and circulation stabilized immediately. Two hours after the operation urine output started. Liver function stabilized over the next couple of days. Two days after PA banding the child was weaned from the ventilator. On the 12th day of life a Norwood operation with PA debanding and a right ventricle-PA conduit was performed, and 2 days postoperatively the child was weaned from the ventilator. Twenty days after the operation he was discharged home. When the boy was 4 months old a bidirectional cavopulmonary anastomosis was performed. In selected cases of patients with HLHS with very poor hemodynamic conditions, a rapid two-stage approach with bilateral banding followed by a Norwood operation after cardiac stabilization can be recommended.

Therapeutic optimization of atrioventricular delay in cardiosurgical ICU patients by noninvasive cardiac output measurements versus pulse contour analysis.

BACKGROUND: Optimizing atrioventricular (AV) delay improves cardiac output and postoperative outcome. Impedance cardiography (ICG) is a non-invasive method for CO measurement. This study evaluates the ability of two ICG methods to determine the optimal AV delay (OAVD) and to compare ICG with invasive PICCO measurements. METHODS: In 14 cardiosurgical ICU patients (age 70.4 +/- 12.0 yrs) with temporary pacing wires, OAVD was determined by pulse contour analysis (PICCO) and ICG (conventional ICG [CI] and electrical velocimetry [EV] ICG monitors). Cardiac output (CO) and stroke volume (SV) were measured during DDD pacing with AVD varying from 70 to 270 ms in 20-ms increments. RESULTS: Measured OAV showed a linear correlation between PICCO and ICG: CI (r = 0.82, P < 0.0002) and EV (r = 0.84, P < 0.0002). The mean OAVD deviation between PICCO and ICG was 15.7 +/- 21.0 ms (CI) and 17.1 +/- 20.5 ms (EV). Hemodynamic parameters (SV increase OAVD against worst case) improved significantly (+ 11.7 +/- 7.2 %, P < 0.0001). CONCLUSION: Inappropriate selection of AVD can compromise the hemodynamic situation of cardiosurgical patients. As it is totally noninvasive, ICG is a reliable and effective tool for tailoring AVD. Both systems (CI and EV) offer valid OAV determination.

Short-term tissue response of lapine carotid artery microanastomoses to BioGlue.

BACKGROUND: Minimally invasive coronary artery surgery needs fast, reliable and easy methods of carrying out anastomoses. The aim of our study was to evaluate the use of BioGlue in sutureless vascular anastomoses in the lapine model. METHODS: In 24 New Zealand white rabbits, 43 transsected carotid arteries were re-anastomosed using either a combination of balloon catheterisation and BioGlue or a conventional suture. In five carotid arteries, only BioGlue was applied. The animals were euthanised and tissue samples were taken for histological and immunohistological examination. RESULTS: A higher inflammatory cell infiltrate was present in the glue control and glue anastomosis groups, with the invasion of inflammatory cells located especially at the junction between the wall with and the wall without glue. Early calcification was detected in two arteries. CONCLUSION: The results of this short-term study show that the rabbit is an adequate as well as a sensitive model for the study of microanastomoses by glueing. Marked inflammatory reactions developed which may lead to vascular sclerosis or stenosis, and long-term studies are necessary to elucidate this problem further.

Interleukin-6 enhancement after direct autologous retransfusion of shed thoracic blood does not influence haemodynamic stability following coronary artery bypass grafting.

BACKGROUND: Direct autologous retransfusion of shed thoracic blood is carried out to reduce homologous transfusion after cardiac surgery, but it contains high concentrations of inflammatory mediators. The purpose of the study was to investigate whether retransfusion of shed thoracic blood induces plasma interleukin-6 (IL-6) expression and influences haemodynamics. METHODS: Following uncomplicated coronary artery bypass graft surgery, forty-four patients were randomised in case postoperative blood loss via thoracic drains exceeded 350 ml. The course of plasma IL-6 levels and haemodynamics including cardiac output, extravascular lung water and intrathoracic blood volume were investigated prior to (T0), 30 minutes (T1), 1 (T2), 3 (T3) and 12 hours (T4) after retransfusion of 350 ml shed blood in comparison to 350 ml saline. RESULTS: Plasma IL-6 levels at T1 (1892 +/- 202 vs. 485 +/- 30 pg/ml) and T2 (1059 +/- 119 vs. 413 +/- 30 pg/ml) were significantly higher in the verum group (n = 20) compared to controls (n = 24) ( P < 0.01). Severe haemodynamic side effects were not detected. CONCLUSION: This study found significantly elevated plasma IL-6 levels following direct autologous retransfusion of shed thoracic blood but failed to show severe adverse effects affecting haemodynamic stability.

Tissue resident C reactive protein in degenerative aortic valves: correlation with serum C reactive protein concentrations and modification by statins.

OBJECTIVE: To assess aortic valve probes for valvar C reactive protein (CRP) presence, the relation between valvar and serum CRP, and a possible modification of CRP by statin medication. SETTING: Tertiary referral centre. PATIENTS AND DESIGN: End stage, degenerative valve tissue was taken from 81 patients, 57 with non-rheumatic aortic valve stenosis (AS) and 24 with degenerative aortic valve bioprosthesis (BP). Five non-stenosed valves served as controls. Tissue from four non-implanted bioprostheses was also examined. The presence and location of CRP was analysed by use of immunostaining and morphometry. Serum CRP concentrations were measured preoperatively. RESULTS: The majority of AS and BP valves exhibited CRP labelled cells, predominantly localised to the valvar fibrosa. The expression of CRP was much higher in BP than in AS (by a factor of 3.7, p = 0.03). Notably, non-stenosed aortic valves and non-implanted bioprostheses did not have CRP signalling. Serum CRP was also increased with BP (by a factor of 2.5, p = 0.02) and was significantly correlated with valvar CRP expression (r = 0.54, p < 0.001). The main finding in patients with (n = 26) and without statin treatment (n = 55) was that both valvar CRP expression (p = 0.02) and serum CRP concentrations (p = 0.04) were lower in the statin treated group. CONCLUSIONS: CRP was found in a large series of degenerative aortic valves, more often in bioprostheses than in native cusps. Serum CRP concentrations may reflect inflammatory processes within the aortic valve. The association of statin treatment with decreases in both valvar and serum CRP concentrations may explain known pleiotropic effects of statins in patients with aortic stenosis.

[CT coronary angiography in patients with atrial fibrillation]. / CT-Koronarangiographie bei Patienten mit Vorhofflimmern.

PURPOSE: Reliable visualization of the coronary arteries with multislice spiral CT angiography (MSCTA) in patients with atrial fibrillation (AF) remains a challenge despite retrospective ECG gating. A recently developed new algorithm automatically compensates dynamic changes in the heart rate during the scan, thus reducing misregistration and motion artifacts. The HeartBeat-RT algorithm combines a fixed-percent delay determined from the first R wave and the fixed offset delay based on the second R wave in the ECG cycle. The purpose of this study was to find out the optimal reconstruction window in MSCTA in patients with AF for each of the three major coronary arteries during the cardiac cycle. MATERIALS AND METHODS: 20 patients with permanent AF were imaged on a 16-slice scanner (slice collimation: 16 x 0.75 mm; rotation time 0.42 s; 140 kV; 380 mAs; 120 ml Ultravist 370 (R) i.v.). The patients had not received any previous drugs for heart frequency regulation. Acquisition was started after bolus tracking of a biphasic bolus of 120 ml Ultravist 370 injected intravenously. Each coronary segment was reconstructed at 0 % - 90 % of the cardiac cycle in increments of 10 %. For image analysis we used coronary segments as defined by the American Heart Association. Two blinded independent readers assessed the image quality in terms of visibility and artifacts (five-point rating scale 1 = very poor, 2 = poor, 3 = fair, 4 = good and 5 = excellent) and the degree of stenosis (five-point rating scale 1 = 0 %, 2 = 1 % - 49 %, 3 = 50 % - 74 %, 4 = 75 % - 99 %, 5 = 100 %) on axial slices, multiplanar reconstructions and three-dimensional volume-rendered images. RESULTS: The heart rate during examination ranged between 42 and 156 beats per minute, the average heart rate was 78 +/- 23. Each of the two readers evaluated 300 segments in 20 patients. Visualization of all coronary artery segments was superior at 40 % (mean score of the image quality 2.79) as compared to the standard diastolic reconstruction window at 80 % (image quality 2.33). The second best image quality (2.57) was acquired at 0 % of the cardiac cycle. CONCLUSION: The use of a frequency adapted delay algorithm with the choice of an end-systolic reconstruction window provided diagnostically valuable images in patients with AF.