[Effectiveness of Psychocardiological Care in Inpatient Rehabilitation: A Pilot Study]. / Effektivität von psychokardiologischer Versorgung in der stationären Rehabilitation ­ ein Pilotprojekt.

An integrative patient-centered care concept is increasingly demanded for treatment of cardiac patients with concomitant mental disorders. The present study aims to investigate the effect of an integrated concept of psycho-cardiac care (PK) versus a monodisciplinary cardiac (K) or psychosomatic (PSO) care. Patients were examined at baseline (T0), at the time of discharge from the rehabilitation program (T1) and after 6 month (T2). General anxiety, depression (HADS), cardiac anxiety (HAF) and quality of life (SF-12) were evaluated using computer-assisted questionnaires. A total of 93 patients were included (PK: n=37, 55.5 years SD=8.0, 43.2% female; K: n=32, 53.6 years SD=8.2, 34.4% female; PSO: n=24, 55.5 years SD=5.0, 45.8% female). Patients in the PK-group showed a significant reduction of heart-focused anxiety (HAF fear p=0.004) and a significant improvement in quality of life (SF-12 physical p=0.034) during follow-up. In contrast, these parameters remained unchanged in patients in the K- and PSO-groups. The results indicate that cardiac-patients with concomitant mental disorders benefit only from an integrated psycho-cardiac treatment concept. The findings provide first data to psycho-cardiac treatment in stationary rehabilitation and support previous clinical experiences. But further research is required to show the advantage of a psycho-cardiac concept towards monodisciplinary care.

Multidimensional ECG-based analysis of cardiac autonomic regulation predicts early AF recurrence after electrical cardioversion.

BACKGROUND: Heart rate turbulence, deceleration capacity (DC), and symbolic dynamics (SD) are promising novel domains of autonomic indices representing the multidimensional qualities of autonomic heart rate dynamics. PURPOSE: The aim of this study was to test the impact of these novel indices in predicting early AF recurrence within the first month after electrical cardioversion (CV). METHODS: In 45 patients with AF, standard Holter recordings were commenced immediately after CV. Holter-based indices were retrospectively analyzed using computerized algorithms. The best indices were applied in a multivariate model to select the optimal combination set that correctly classified patients who developed early AF recurrence. RESULTS: Early AF recurrence occurred in 25 vs 20 patients with stable sinus rhythm. The set with the highest predictive power consisted of DC, turbulence onset, VLF/P, and PTH19 as a parameter of SD. The receiver operating curve analysis applied to this optimum set produced an area under the curve of 0.86, thus correctly classifying patients with 95.0% specificity and 76.0% sensitivity. CONCLUSION: The analysis of novel multidimensional Holter-based autonomic indices after CV appears of clinical value because the procedure identifies patients with high risk of early AF recurrence. Furthermore, it indicates a substantial alteration of autonomic regulation.

In patients with aortic stenosis increased flow-mediated dilation is independently associated with higher peak jet velocity and lower asymmetric dimethylarginine levels.

BACKGROUND: Recently, it has been shown that endothelial dysfunction and aortic stenosis (AS) share several risk factors. Endothelial function represents a crucial factor for the regulation of vascular tonus and its malfunction influences the formation of thrombosis and inflammation. However, the role of endothelial dysfunction in AS remains unclear. METHODS: Echocardiographic, clinical, and laboratory data of 34 patients (age 74.5 ± 7.9 years, 20 men) with at least moderate AS (peak jet velocity 3.8 ± 0.8 m/s) were collected. In all patients, endothelial function was determined by brachial artery flow-mediated dilation (FMD). Patients with rheumatic or endocarditic valve disease, bicuspid valves, a left ventricular ejection fraction of ≤40%, and coronary artery disease were excluded. Sixteen volunteers (age 69.3 ± 9.4 years, 10 men) without valve disease served as controls. RESULTS: Patients with AS had a trend toward a lower FMD than controls with a comparable risk profile (5.4% ± 3.6% vs 7.4% ± 4.1%, P = .1). Univariate correlates of FMD in patients with AS were peak jet velocity, medication with angiotensin-converting enzyme inhibitor, diabetes, diastolic blood pressure, and asymmetric dimethylarginine. Backward elimination identified peak jet velocity (ß = 0.51, P = .001), and asymmetric dimethylarginine (ß = -0.45, P = .003) as independent predictors of FMD in multivariate analysis. CONCLUSIONS: In patients with AS, we found a strong positive relation between the peak jet velocity and a higher FMD. This effect might be mediated by nitric oxide release due to turbulent poststenotic blood flow or the rising transvalvular gradient, and the increasing pulse pressure may be counteracted by a parallel increase in FMD.

Percutaneous caval stent valve implantation: investigation of an interventional approach for treatment of tricuspid regurgitation.

AIMS: Severe tricuspid regurgitation (TR) reduces cardiac output (CO) and increases central venous pressure leading to secondary organ dysfunction. To date, the open surgical approach is the only option to treat TR. Herein, we report our experience of treatment by percutaneous implantation of valved stents in the inferior vena cava (IVC) and superior vena cava (SVC) to substitute tricuspid valve function in a model of acute insufficiency. METHODS AND RESULTS: Acute TR grades III-IV was created in 13 sheep (54-75 kg) via papillary muscle and chordae avulsion using a 0.07 inch wire blade. Successful creation of TR was confirmed using angiography and by a prominent ventricular wave in central venous pressure recording. Two self-expanding nitinol stents containing a porcine pulmonary valve were then implanted in the IVC and SVC in a transcatheter approach. Implantation was performed through the right jugular vein by means of a 21 F catheter and guided by fluoroscopy. Haemodynamics were continuously monitored and valve function was verified by angiography and epicardial echocardiography. After successful implantation and proof of concept in the acute study (acute group, n = 9), chronic studies were (n = 4, 4 weeks follow-up) performed. Tricuspid regurgitation grades III-IV was successfully created in all animals and resulted in a significant reduction of CO. A ventricular wave in the IVC of 16.2 +/- 2.33 mmHg (acute group) and 14.9 +/- 1.71 mmHg (chronic group) confirmed the presence of severe TR. After deployment of the IVC and the SVC valve, the ventricular wave in the IVC significantly decreased to 13.9 +/- 2.97 mmHg (acute group) and 12.7 +/- 1.15 (chronic group), whereas CO significantly increased to 4.20 +/- 0.84 L/min (acute group) and 5.4 +/- 0.67 L/min (chronic group). At autopsy, correct device position was verified in all successfully implanted animals, no macroscopic damage resulting from the implantation procedure was observed. CONCLUSION: In high-grade tricuspid insufficiency, percutaneous implantation of valved stents in the central venous position reduces venous regurgitation and improves haemodynamics in the animal experiment. Implantation of one or two valves in central venous position is technically feasible. Functional replacement of the insufficient tricuspid valve leads to an increase in CO. This technique expands the potential therapeutic options for patients with relevant tricuspid valve regurgitation having a high risk for open heart surgery.

Impact of rapid ventricular pacing during TAVI on microvascular tissue perfusion.

BACKGROUND: Rapid ventricular pacing (RVP) is an established technique to temporarily reduce left ventricular output during transcatheter aortic valve implantation (TAVI). The purpose of this study was to evaluate the impact of RVP on microvascular tissue perfusion (MTP) in patients undergoing TAVI. METHODS AND RESULTS: We studied 42 patients (mean age 81.8 ± 6.9 years, n = 18 females. EuroSCORE 33 ± 12 %) during TAVI. MTP was analyzed using Sidestream-Darkfield imaging, of the sublingual microvasculature. Microvascular flow index (MFI) was continuously measured in small (10-25 µm)- and medium (26-50 µm)-sized vessels, starting 10 s before and ending 12 s after RVP. Further, perfused capillary density, total vessel density and the proportion of perfused vessels were assessed. After a mean RVP duration of 14.3 s (range 6-29), mean arterial pressure decreased from 68 ± 05 to 40 ± 7 mmHg (p < 0.001). This was associated with a significant decrease of MFI in small- and medium-sized vessels from 2.29 ± 0.64 and 2.36 ± 0.6 to 0.87 ± 0.66 (p < 0.001) and 1.0 ± 0.83 (p < 0.001), respectively. MFI remained significantly below baseline values (small: 1.75 ± 0.8, p = 0.001 vs. baseline; medium: 1.77 ± 0.85; p = 0.005 vs. baseline) at 12 s after end of RVP. CONCLUSIONS: The study demonstrates a time-dependent effect of RVP on microflow, leading to 50 and 25 % of baseline at 8 and 18 s of RVP, respectively. In a substantial proportion of patients, RVP is associated with microcirculatory arrest and a delayed recovery of microflow. Although the impact of these findings on outcome is yet unclear, TAVI operators should be aware of the potentially adverse effects of even short periods of RVP.

Intra-aortic counterpulsation for hemodynamic support in patients with acute ischemic versus non-ischemic heart failure.

BACKGROUND: Intra-aortic counterpulsation (IABP) is frequently applied to provide hemodynamic support in patients with refractory cardiogenic shock (CS) of ischemic and non-ischemic cause. However, clinical data comparing outcomes are lacking for both indications. The purpose of this analysis was to evaluate outcome and safety of IABP support in patients with ischemic and non-ischemic CS and to identify predictors of early mortality in this severely ill patient population. METHODS AND RESULTS: For the period between 1998 to 2010, data from 489 consecutive patients (age, 67.2 ± 12.2 years; 65.9% male) who had received IABP support for CS at the University Heart Center Jena were retrospectively analyzed. The primary endpoint was overall mortality at 7 and 30 days. Secondary endpoints included the incidence of vascular and neurologic complications as well as long-term survival. Follow-up data on current health status of the patients were acquired either from health insurance records or based on patient and physician interviews. After data compilation, patients were assigned to one of the following subgroups: ST-elevation myocardial infarction (STEMI; n = 368; 75.3%), non-STEMI (n = 75; 15.3%) and congestive heart failure (CHF; n = 46; 9.4%). Of the 489 patients enrolled, 422 (86.4%) were successfully weaned from IABP support. However, a significantly lower proportion of patients were weaned successfully in the STEMI group (n = 310; 84.1%) compared to the other two groups (non-STEMI: n = 70, 92.4%; CHF: n = 45, 97.8%; P=.041). Overall mortality at 30 days was 36.4% (n = 178) and was not significantly different between the subgroups. Significant predictors of 30-day mortality included age >70 years (odds ratio [OR], 16.81; confidence interval [CI], 1.241-227.54), ejection fraction <40% (OR, 36.33; CI, 2.93-451.05) and mechanical ventilation (OR, 12.42; CI, 1.21-127.17). Long-term follow-up was 803 ± 1061 days (range, 0-1380 days), with a long-term survival rate of 38.3%. CONCLUSION: IABP represents a safe technology for hemodynamic support and is associated with low complication rates. Parameters relating to early mortality include age >70 years, respiratory failure requiring mechanical ventilation, and left ventricular function <40%, which represent an additional risk of death. However, the etiology of CS had no effect on mortality in this analysis. This observation should encourage physicians to apply IABP for hemodynamic support in patients with nonischemic left ventricular failure.

Microvascular tissue perfusion is impaired in acutely decompensated heart failure and improves following standard treatment.

AIMS: Acutely decompensated heart failure (ADHF) leads to neurohumoral activation potentially affecting vascular tone and organ perfusion and may be linked to unfavourable outcome. Global haemodynamic, clinical, and laboratory parameters may severely underestimate tissue hypoperfusion. Therefore, the purpose of this study was to evaluate microvascular flow index (MFI) in patients with ADHF and to assess the effect of standard pharmacological therapy using Sidestream Dark Field (SDF) imaging. METHODS AND RESULTS: Twenty-seven patients (mean age 75.5 ± 10.1 years, 48% male) with ADHF in New York Heart Association functional class ≥III were included. Serum markers of neurohumoral activation [brain natriuretic peptide (BNP)], endothelin-1 (ET-1), noradrenaline (NA), and echocardiographic parameters of left ventricle-function were determined at hospital admission and the day before discharge. Using SDF imaging, MFI was evaluated at both time-points in semi-quantitative vessel categories (small: 10-25 µm; medium: 26-50 µm; and large: 51-100 µm). At admission, increased serum levels of BNP, NA, and ET-1 and a severely reduced MFI were observed in association with ADHF. Serum levels of BNP, NA, and ET-1 decreased significantly with standard pharmacological therapy (BNP: 2163 ± 1577 vs.1006 ± 945 pg/mL, P< 0.05; NA: 349 ± 280 to 318 ± 265 pg/mL, P< 0.05; ET-1: 5.08 ± 0.72 to 4.81 ± 0.59 pg/mL; P< 0.01). Standard pharmacological treatment also had a profound impact on tissue perfusion by significantly improving median MFI in small [2.6; inter-quartile range (IQR) 2.3-2.9 vs. 2.9; IQR 2.8-3.0; P= 0.01) and medium-sized (2.0; IQR 1.9-2.5 vs. 2.7; IQR 2.5-2.8; P< 0.01) vessels. CONCLUSION: In patients with ADHF, microvascular tissue perfusion is impaired even when global haemodynamic or laboratory signs of hypoperfusion are absent. Effective pharmacological treatment to decrease neurohumoral activation significantly improves microflow. Hypoperfusion in ADHF is potentially linked to neurohumoral activation with increased plasma levels of vasoconstrictors and sympatho-adrenergic activity.

Effect of mechanical ventilation on microvascular perfusion in critical care patients.

PURPOSE: Microvascular perfusion, pivotal for adequate tissue oxygenation is potentially linked to outcome in critical care therapy. Mechanical ventilation (MV) and positive end-expiratory pressure (PEEP) as standard concepts of respiratory management are known to have deleterious effects on regional organ perfusion especially in the splanchnic area. As these effects have been attributed to different physiologic mechanisms, the purpose of this study was to investigate the effect of positive pressure ventilation on extra-abdominal tissue perfusion in non-surgical intensive care patients. METHODS: Sublingual microcirculation was evaluated in 46 severely ill patients (group 1: n=26 requiring MV and PEEP; group 2: n=20 spontaneous breathing) admitted to the intensive care unit using sidestream darkfield intravitalmicroscopy. According to current guidelines, sublingual vessels were categorized by means of size and flow in semi-quantitative categories determining microvascular flow index (MFI). Total microvascular flow index (TMFI) was calculated for each patient as mean value of flow in all vessel categories. RESULTS: No significant difference was observed between both groups in microvascular flow index in each vessel category and in total microvascular flow index. Patients requiring mechanical ventilation presented with more comorbidities and higher acuity of illness scores resulting in a higher ICU mortality, which however was not accompanied by microcirculatory differences at the time of measurement. CONCLUSION: Mechanical ventilation and PEEP have no general deleterious effects on microvascular perfusion of the sublingual mucosa. However, further clinical studies are required to investigate potential effects of higher levels of ventilation pressure or PEEP on microvascular perfusion.

Acute and long-term outcome of unprotected left main coronary angioplasty compared to the anticipated surgical risk.

OBJECTIVES: Percutaneous coronary intervention of unprotected left main (ULM) stenosis is increasing despite surgical revascularisation being the recommended treatment by the current guidelines. We compared the 30-day and 9-month mortality after ULM stenting with the predicted surgical outcome as determined by the EuroSCORE. METHODS AND RESULTS: We included 81 consecutive patients who underwent ULM stenting. The patient cohort was divided into a normal risk group (EuroSCORE 5, predicted 30-day mortality 11%). Follow-up examinations were scheduled for one and nine months after the initial PCI. The average EuroSCOREs in the normal- and high-risk group were 3.0 (29 patients, 36%) and 10.0 (52 patients, 64%), respectively. Mortality rates at 30 days were 3% in the normal-risk group and 8% in the high-risk group. Subacute stent thrombosis occurred in 3.4% (three patients) undergoing elective PCI. Major adverse cardiac events during the nine months follow-up were registered in 24% of patients in the normal-risk group, and in 27% of the patients in the high-risk group. CONCLUSION: Short-term outcome of ULM stenting in our high-risk patients is comparable to surgical outcome predicted by the EuroSCORE. Long-term outcome was less favourable due to a high mortality rate. ULM stenting in patients with low surgical risk could be associated with higher mortality rates compared to CABG because of the unpredictable risk of a fatal stent thrombosis.