Morphological macrovascular alterations in complex regional pain syndrome type I demonstrated by increased intima-media thickness.

BACKGROUND: Although intima-media thickness (IMT) was increased in several inflammatory diseases, studies investigating whether the inflammatory processes lead to macrovascular alteration with increased IMT in complex regional pain syndrome (CRPS) lack. METHODS: Using ultrasound (high-resolution B-mode), we compared bilaterally the IMT of the common carotid artery (CCA-IMT), the radial artery (RA-IMT), the brachial artery (BRA-IMT) and the quotient QRA/CCA, in CRPS type I (n=17), peripheral nerve injury (PNI, n=17) and pain-free controls (PFC, n=22, matched to CRPS by gender, age and traditional cardiovascular risk factors). STATISTICS: Spearman's correlation, paired t-test, ANOVA (p<0.05). RESULTS: Compared to PFC, RA-IMT were significantly increased in both patient groups bilaterally (mean±standard deviation, CRPS affected side vs. PFC dominant side: 0.32±0.08 mm vs. 0.19±0.08 mm, p<0.001; PNI affected side vs. PFC dominant side: 0.27±0.09 mm vs. 0.19±0.08 mm, p< 0.05; CRPS non-affected side vs. PFC non-dominant side: 0.30±0.10 mm vs. 0.19±0.09 mm, p<0.001; PNI non-affected side vs. PFC non-dominant side: 0.25±0.10 mm vs. 0.19±0.09 mm, p<0.05) and QRA/CCA (CRPS affected-side vs. PFC dominant side: 0.49±0.12 vs. 0.30±0.11, p<0.001; PNI affected side vs. PFC dominant side: 0.41±0.10 vs. 0.30±0.11, p<0.05; CRPS non-affected side vs. PFC non-dominant side: 0.43±0.19 vs. 0.30±0.13, p<0.001; PNI non-affected side vs. PFC non-dominant side: 0.39±0.14 vs. 0.30±0.13, p<0.05), and BRA-IMT - only on the affected side in CRPS (CRPS: 0.42±0.06 mm vs. PFC: 0.35±0.08 mm; p<0.05). In CRPS, QRA/CCA was significantly higher on the affected side compared to PNI (p<0.05). However, only CRPS displayed within-group side-to-side differences with a significantly increased RA-IMT and QRA/CCA on the affected side (p<0.05). The CCA-IMT was comparable between all groups and sides. CONCLUSIONS: The increased IMT of peripheral arteries in CRPS suggests ongoing inflammatory process. Until now, only endothelial dysfunction has been reported. The presented morphological macrovascular alterations might explain the treatment resistance of some CRPS patients.

Transcatheter aortic valve implantation in patients with severe symptomatic aortic valve stenosis-predictors of mortality and poor treatment response.

BACKGROUND: Transcatheter aortic valve implantation (TAVI) has emerged as an alternative technique in patients with severe symptomatic aortic valve stenosis. However, a number of patients have no benefit after implantation. This prospective study attempted to identify predictors of poor treatment response. METHODS: From June 2008 to September 2010, consecutive patients with symptomatic severe aortic valve stenosis and high surgical risk were submitted to TAVI with the CoreValve prosthesis (Medtronic, Minneapolis, MN). The primary end point was all-cause mortality at 6 months. Secondary end point (poor treatment response) was defined as no improvement of symptoms assessed with the New York Heart Association class 6 months after TAVI. RESULTS: A total of 145 patients (mean age 79.1 ± 6.4 years, mean logistic EuroSCORE 21% ± 16.2%) were included. During the follow-up period, 23 (15.9%) patients died. Independent predictors of all-cause mortality were as follows: aortic mean gradient ≤40 mm Hg (odds ratio [OR] 3.93), moderate and severe tricuspid valve regurgitation (OR 4.50), and moderate and severe postprocedural aortic valve regurgitation (OR 4.26). In 122 surviving patients, 25 patients (20%) showed no improvement in symptoms. Independent predictors of poor treatment response were severe mitral valve regurgitation (OR 7.42) and moderate and severe postprocedural aortic valve regurgitation (OR 10.1). CONCLUSIONS: Cardiac comorbidities (low-gradient aortic stenosis, tricuspidal valve regurgitation) are associated with all-cause mortality, whereas mitral valve regurgitation is a risk factor for poor treatment response after TAVI. Postprocedural aortic valve regurgitation is a strong predictor of both-mortality and poor treatment response.

High frequency of diastolic dysfunction in a population-based cohort of elderly women--but poor association with the symptom dyspnea.

BACKGROUND: The European Society of Cardiology recently proposed a new algorithm "How to diagnose heart failure with normal ejection fraction". Central element of the diagnostic strategy is the demonstration of diastolic dysfunction, either by tissue Doppler-derived indices in first line, or in second line by a combination of elevated blood levels of natriuretic peptide with abnormal tissue Doppler findings. We thought to use this diagnostic flowchart in a population-based cohort of elderly women, in whom the prevalence of diastolic dysfunction and heart failure is believed to be high. The purpose was to evaluate the association of dyspnea with the presence of diastolic dysfunction. METHODS: The study cohort recruited from a cross-sectional follow-up examination of the SALIA cohort (study on the influence of air pollution on lung function, inflammation, and aging). Participants with cardiac or pulmonary disease were excluded, 291 participants formed the final study group (all women, age range 69 to 79 years, all in sinus rhythm, LV ejection fraction > 50%, LV enddiastolic volume index < 97 mL/m2). Quality of life was assessed by the Minnesota living with heart failure questionnaire, and actual symptoms by a structural questionnaire; the examination consisted of a physical examination, measurement of B-type natriuretic peptide, ECG and tissue Doppler echocardiography. Diastolic dysfunction was assumed when the E/E' ratio exceeded 15 as derived from tissue Doppler. In case, tissue Doppler yielded an E/E' ratio ranging from 8 to 15, additional non-invasive parameters had to be fulfilled: left atrial volume index > 40 ml/m2 body surface, or left ventricular mass index > 122 g/m2 body surface, or transmitral E/A ratio < 0.5 plus deceleration time > 280 ms, or blood level of brain natriuretic peptide (BNP) > 200 pg/mL. RESULTS: The examinations were concordant with the presence of diastolic dysfunction in 122/291 participants (41.9%). The diagnosis based in 94% of cases on two criteria: in 50 cases on the criterion "E/E' ratio > 15", and in 65 cases on the criterion "15 > E/E'>8 and LV mass index > 122 g/m2". The participants with diastolic dysfunction had on average a higher body mass index, more frequent a history of arterial hypertension and of hospitalization for congestive heart failure, poorer quality of life, and higher BNP blood levels as compared to those participants without signs of diastolic dysfunction. The number of participants complaining exertional dyspnea, however, was similar distributed among the subgroups with and without signs of diastolic dysfunction (40.2 vs 40.8%; p = n.s). In a logistic regression model, the symptom dyspnea was best predicted by systolic pulmonary artery pressure, followed by left atrial volume index, BNP, and body mass index. CONCLUSION: The demonstration of diastolic dysfunction showed only a poor association with the symptom dyspnea in a cohort of elderly women with otherwise normal systolic function. Additional structural or hemodynamic changes are necessary to "explain" the symptom dyspnea. It is unclear whether these additional factors are secondary to a more advanced stage of diastolic dysfunction, or are related to cardiovascular co-morbidities, or both.

Hemodynamic results and changes in myocardial function after transcatheter aortic valve implantation.

BACKGROUND: This prospective study was designed to evaluate the hemodynamic results of transcatheter aortic valve implantation (TAVI) with the CoreValve prosthesis (Medtronic, Minneapolis, Minnesota) and the effects on left ventricular function. METHODS: From June 2008 to June 2009, consecutive patients with severe symptomatic aortic valve stenosis (aortic valve area <1 cm(2)) and the indication for TAVI were included. Aortic valve prosthesis was inserted retrograde. Examinations of study patients were performed before, 30 days, and 6 months after TAVI and comprised measurement of B-type natriuretic peptide and echocardiography. Severe prosthesis-patient mismatch was defined as an indexed effective aortic valve area < or =0.65 cm(2)/m(2). RESULTS: In 39 patients, follow-up examinations were performed after TAVI. Severe prosthesis-patient mismatch seldom occurred (n = 1), but mild to moderate aortic valve regurgitation due to paravalvular leaks was common (n = 24, 62%). After 6 months, left ventricular mass index declined (158 +/- 46 vs 138 +/- 45 g/m(2), P = .001), and peak early diastolic mitral annular velocity (E') and peak systolic mitral annular velocity (S') increased (P = .004 and P < .001, respectively). B-type natriuretic peptide levels decreased (744 +/- 708 at baseline vs 367 +/- 273 at 30 days, P = .003, 279 +/- 186 pg/mL at 6 months, P = .001). Left ventricular diameters and ejection fraction remained unchanged. CONCLUSION: Despite the high incidence of paravalvular regurgitation after TAVI, hemodynamic results were favorable. Furthermore, TAVI had positive effects on left ventricular remodeling and improved neurohormonal activity, myocardial hypertrophy, and diastolic function.

Normal values for longitudinal function of the right ventricle in healthy women >70 years of age.

AIMS: The application of tricuspid annular plane systolic excursion (TAPSE) as an additional echocardiographic tool to analyse right ventricular (RV) systolic function has been recently established and two-dimensional-guided M-mode measurements of systolic long axis function of the RV are simple, repeatable, and highly reproducible. However, rare data are available on normal values. We aimed to analyse normal values in healthy women >70 years of age. METHODS AND RESULTS: In a cross-sectional survey, we investigated a cohort of randomly selected, non-hospitalized women >70 years of age. History of myocardial infarction, valvular heart disease, and diastolic dysfunction were exclusion criteria. In order to rule out left ventricular or RV dysfunction, a normal left ventricular ejection fraction and normal values of B-type natriuretic peptide (BNP) were necessary prior to study inclusion. A detailed echocardiographic examination was performed. A total of 80 participants were included (mean age 75 +/- 2.6 years). Mean left ventricular ejection fraction was 63.8 +/- 5.7%. Tissue Doppler derived mean E/E' ratio was 10 +/- 2.3. Mean right atrial diameter was 31.3 +/- 4.7 mm. Mean values for RV outflow tract and RV dimension were 27.3 +/- 3.6 and 28.8 +/- 3.7 mm, respectively. Mean TAPSE was 23.7 +/- 3.5 mm. Mean value of BNP was normal (42.5 +/- 35.7 pg/mL). CONCLUSION: In women >70 years of age without heart failure, structural heart disease, and neurohormonal activation, normal TAPSE values are approximately 24 mm.

Beating-heart coronary artery bypass grafting with miniaturized cardiopulmonary bypass results in a more complete revascularization when compared to off-pump grafting.

The technique of miniaturized cardiopulmonary bypass (M-CPB) for beating-heart coronary artery bypass grafting (CABG) is relatively new and has potential advantages when compared to conventional cardiopulmonary bypass (CPB). M-CPB consists of less tubing length and requires less priming volume. The system is phosphorylcholine coated and results in minimal pump-related inflammatory response and organ injury. Finally, this technique combines the advantages of the off-pump CABG (OPCAB) with the better exposure provided by CPB to facilitate complete revascularization. The hypothesis is that CABG with M-CPB has a better outcome in terms of complete coronary revascularization and perioperative results as that compared to off-pump CABG (OPCAB). In a retrospective study, 302 patients underwent beating-heart CABG, 117 (39%) of them with the use of M-CPB and 185 (61%) with OPCAB. After propensity score matching 62 patients in both groups were demographically similar. The most important intra- and early-postoperative parameters were analyzed. Endpoints were hospital mortality and complete revascularization. Hospital mortality was comparable between the groups. The revascularization was significantly more complete in M-CPB patients than in patients in the OPCAB group. Beating-heart CABG with M-CPB is a safe procedure and it provides an optimal operative exposure with significantly more complete coronary revascularization when compared to OPCAB. Beating-heart CABG with the support of a M-CPB is the operation of choice when total coronary revascularization is needed.

Serial compression B-scan and Doppler sonography for the screening of deep venous thrombosis in patients with spinal cord injuries.

PURPOSE: To evaluate the usefulness of serial compression B-scan and Doppler sonography (US) in screening for deep venous thrombosis (DVT) of the lower extremities in patients with spinal cord injuries. METHOD: Patients with paraplegia and tetraplegia due to spinal cord injuries were screened by a serial compression B-scan and Doppler US protocol for DVT of the bilateral lower extremities within the first 36 hours after admission, at day 7 and at day 21. In patients with DVT, a follow-up US examination was performed 3 weeks after diagnosis to assess thrombi distribution. RESULTS: Between January 2007 and March 2008, a total of 115 patients (75 males, 40 females), aged 19 to 85 years, were included. The first US examination documented a DVT in 44 cases (38.3%). After an initial negative scan, sonography after 7 days and 21 days showed DVT in 6 patients and 2 patients, respectively. Cumulative rate of DVT after the first 3 weeks was 45.2% (n=52). Follow-up US after 3 weeks in patients with DVT documented a complete recanalization in 19 patients (36.5%), no change in 12 patients (23.1%), and residual thrombi with partial recanalization in 21 patients (40.4%). CONCLUSION: Our study supports the use of serial compression B-scan and Doppler US as a screening tool for DVT of the lower extremities in patients with spinal cord injuries early after injury.

Non-invasive determination of the optimized atrioventricular delay in patients with implanted biventricular pacing devices.

BACKGROUND: Biventricular (BiV) is extensively used in the treatment of congestive heart failure but so far no recommendations for optimized programming of atrioventricular-delay (AVD) settings have been proposed. Can AVD optimization be performed using a simple formula based on non-invasive doppler-echocardiography? METHODS: 25 patients (ejection fraction 30+/-8%) received BiV ICDs. Doppler-echocardiographic evaluation of diastolic and systolic flow was performed for different AVDs (30ms to 150ms) and different stimulation sites (left ventricular (LV), right ventricular and BiV). The optimal atrioventricular delay was calculated applying a simple formula based on systolic and diastolic mechanical delays determined during doppler-echocardiography. RESULTS: The mean optimal AVD was calculated to be 112+/-29ms (50 to 180ms) for BiV, 95+/-30ms (65 to 150ms) for LV and 75+/-28ms (40 to 125ms) for right ventricular pacing with wide interindividual variations. Compared to suboptimal AVDs diastolic optimization improved preejection and ejection intervals independent to pacing site. Optimization of the AVD significantly increased ejection time during BiV pacing (279ms versus 266ms; p<0.05). Compared to LV or right ventricular pacing BiV pacing produced the shortest mean pre-ejection and longest ejection intervals as parameters of improved systolic ventricular contractile synchrony. Diastolic filling times were longest during BiV pacing compared to LV or RV pacing. CONCLUSIONS: Individual programming of BiV pacing devices increases hemodynamic benefit when implementing the inter-individually widely varying electromechanical delays. Optimization applying a simple formula not only improves diastolic ventricular filling but also increases systolic functional parameters.

Long-term sinus rhythm stability after intraoperative ablation of permanent atrial fibrillation.

INTRODUCTION: Short- and medium-term sinus rhythm (SR) rates after intraoperative radiofrequency ablation to treat permanent atrial fibrillation (AF) are well documented. Is rhythm success stable during a long-term follow-up? METHODS AND RESULTS: A total of 130 patients who had undergone intraoperative radiofrequency cooled-tip endocardial ablation (SICTRA) of permanent AF (mean AF duration 6+/-5 years) concomitant to open heart surgery more than 3 years ago were followed up using electrocardiogram (ECG), Holter-ECG, and echocardiography and compared with 12-month follow-up data. In 55% of patients, only the left atrium and in 45%, both atria were treated using SICTRA. Mitral valve replacement was performed in 21, mitral valve reconstruction in 25, aortic valve replacement in 13, CABG procedures in 51 (including 11 patients with additional mitral valve surgery), and complex procedures in 20 patients. Sixty-nine percent of patients (90/130) were in stable SR after a median period of 48 months, whereas 28% (36/130) were in AF and 3% (4/130) were in atrial flutter. In between the 12-month follow-up and the long-term follow-up, seven patients converted to AF after having documented SR, two patients converted to typical right atrial flutter after being in SR, and two patients from AF to left atrial macroreentry. After left and biatrial SICTRA, SR rates were comparable (73% vs 66%, P = 0.45). Echocardiography revealed 73% of patients in SR to have effective left atrial contraction. CONCLUSIONS: SICTRA restores long-term stable SR in 69% of all patients. Nine percent of patients reconverted back to atrial arrhythmia after having documented SR at 12 months.

Clinical, genetic, and cardiac magnetic resonance imaging findings in primary desminopathies.

We report the clinical, genetic and cardiac magnetic resonance imaging (MRI) findings in 11 German patients with heterozygous E245D, D339Y, R350P and L377P desmin mutations and without cardiac symptoms. Clinical evaluation revealed a marked variability of skeletal muscle, respiratory and cardiac involvement even between patients with identical mutations, ranging from asymptomatic to severely affected. While echocardiography did not show any pathological findings in all 11 patients, cine MRI revealed focal left ventricular hypertrophy in 2 patients and MR delayed enhancement imaging displayed intramyocardial fibrosis in the left ventricle in 4 patients indicating early myocardial involvement. Our data argue against distinct genotype-phenotype correlations and suggest that comprehensive cardiac MRI is superior to conventional echocardiography for the detection of early and clinically asymptomatic stages of cardiomyopathy in desminopathy patients. Therefore, cardiac MRI may serve as a screening tool to identify patients at risk, which might benefit from early pharmacological and/or interventional (e.g. implantable cardioverter-defibrillator devices) therapy.

Clinical and morphological phenotype of the filamin myopathy: a study of 31 German patients.

Mutations in the filamin C gene (FLNC) cause a myofibrillar myopathy (MFM), morphologically characterized by focal myofibrillar destruction and abnormal accumulation of several proteins within skeletal muscle fibres. We studied 31 patients from four German families to evaluate the phenotype of filaminopathy. All patients harboured the same p.W2710X mutation in FLNC. Haplotype analysis suggested a founder mutation in these German filaminopathy families. The mean age at onset of clinical symptoms was 44 +/- 6 years (range, 24-57 years). Slowly progressive muscle weakness was mostly pronounced proximally, initially affecting the lower extremities and involving the upper extremities in the course of disease progression, similar to the distribution of weakness seen in limb-girdle muscular dystrophies (LGMD). Patients frequently developed respiratory muscle weakness. About one-third of the patients showed cardiac abnormalities comprising conduction blocks, tachycardia, diastolic dysfunction and left ventricular hypertrophy indicating a cardiac involvement in filaminopathy. Serum creatine kinase levels varied from normal up to 10-fold of the upper limit. Magnetic resonance imaging studies showed a rather homogenous pattern of muscle involvement in the lower extremities differing from that in other types of MFM. Myopathological features included perturbation of myofibrillar alignment, accumulation of granulofilamentous material similar to that seen in primary desminopathies and abnormal intracellular protein deposits typical of MFM. Decreased activities of oxidative enzymes and fibre hypertrophy seem to be early features, whereas dystrophic changes were present in advanced stages of filaminopathy. Rimmed vacuoles were detected in only a few cases. The intracellular aggregates were composed of a variety of proteins including filamin C, desmin, myotilin, Xin, dystrophin and sarcoglycans. Therapy is so far limited to symptomatic treatment. The German filaminopathy cohort, the largest group of patients studied so far, shares phenotypic features with LGMD and presents with characteristic histopathological findings of MFM.

[Mitral valve incompetence after blunt chest trauma. Case report and review of the literature in special consideration of legal medical opinions]. / Mitralklappeninsuffizienz nach stumpfem Thoraxtrauma. Kasuistik und Literaturübersicht unter besonderer Berücksichtigung begutachtungsmedizinischer Aspekte.

BACKGROUND: Blunt thoracic trauma may lead to cardiac lesions including cardiac valve dysfunctions. In these cases, mitral valve is quite often involved. Preexisting mitral valve disease, especially the prolapse syndrome, has to be differentiated from trauma-induced dysfunction. This differentiation may be important for delivering an official legal medical opinion. CASE REPORT AND REVIEW OF THE LITERATURE: The authors report on a patient, presenting with acute severe mitral valve insufficiency 4 months after blunt chest trauma due to a motor vehicle accident. After a review of the literature concepts to differentiate trauma-induced mitral valve dysfunction from preexisting valve disease are discussed in special consideration of aspects of official legal medical opinions. CONCLUSION: To get complete information on the initial cardiac status at the time of chest trauma, detailed echocardiographic evaluation is necessary independent of the severity or mechanism of trauma. If valve surgery is required, macroscopic valve description and microscopic diagnosis are important to clarify the etiology of valve dysfunction. This diagnostic evaluation allows to assess the causality between trauma and valve dysfunction in most of the cases.

Single-center experience with the On-X prosthetic heart valve between 1996 and 2005.

BACKGROUND AND AIM OF THE STUDY: Herein are presented long-term results for the On-X mechanical heart valve. All On-X heart valve recipients since the first implantation worldwide at the University of Bochum in September 1996 were followed retrospectively; the present authors' single-center experience over a period of almost 10 years is reported. METHODS: A total of 428 patients (255 males, 173 females; mean age 62.7 years) underwent either aortic valve replacement (AVR; n = 264) or mitral valve replacement (MVR; n = 164) using the On-X prosthesis. Preoperatively, 329 patients (76.8%) were in NYHA class III or IV. Approximately 5% of AVR and 23% of MVR patients had undergone previous cardiac surgery. Concomitant surgery was performed in 189 patients (44.2%). The mean follow up was 3.9 years, and cumulative follow up 1,625 patient-years (pt-yr); the overall follow up rate was 98.7%. RESULTS: Early mortality (< or = 30 days) was 3.7% after AVR and 14.0% after MVR, with valve-related mortality rates of 0.4% and 1.2%, respectively. At autopsy (n = 12) all implants were intact. Freedom from valve-related death at nine years was 85.0 +/- 3.9% after AVR and 87.6 +/- 3.2% after MVR. The overall survival rate was 67.9 +/- 4.3% after AVR and 52.7 +/- 8.1% after MVR. The linearized rate of thromboembolism for AVR and MVR was 1.49%/pt-yr and 1.61%/pt-yr; of thrombosis 0%/pt-yr and 0.35%/pt-yr; of hemorrhage 0.93%/pt-yr and 1.43%/pt-yr; of endocarditis 0.37%/pt-yr and 0.17%/pt-yr; of non-structural failure 0.18%/pt-yr and 1.43%/pt-yr; and of reoperation 0.28%/pt-yr and 0.53%/pt-yr. There were no cases of structural valve failure. CONCLUSION: After almost one decade of clinical experience in a single center, the On-X heart valve continues to be reliable and effective.

Clinical outcome in patients with intermediate or equivocal left main coronary artery disease after deferral of surgical revascularization on the basis of fractional flow reserve measurements.

BACKGROUND: Correct assessment of the significance of left main stem lesions is of pivotal importance to the patient with coronary artery disease. On the basis of clinical and angiographic information alone, this evaluation often cannot be done reliably. Limited data suggest that coronary pressure-derived fractional flow reserve (FFR) supports decision making in equivocal left main disease. METHODS: All patients presenting to our institution between June 1999 and June 2004 with intermediate left main coronary artery disease (40%-80% diameter stenosis by angiography), or in whom left main coronary disease was suspected but could not be quantified angiographically, were included in this prospective single-center follow-up study. If FFR was <0.75 along the left main stem, surgical revascularization was recommended; if FFR was >0.80, medical treatment or percutaneous coronary intervention elsewhere in the coronary tree was chosen. If FFR was in the "gray zone," between > or = 0.75 and < or = 0.80 treatment recommendation was dependent on additional individual criteria. Primary end points were freedom from death, myocardial infarction, any coronary revascularization procedure, and stroke. RESULTS: Fifty-one patients (mean age 62.2 +/- 9.6 years, 41 male) were included. In 27 patients (53%), coronary artery bypass surgery was performed. The remaining 24 patients (47%) were treated nonsurgically. Mean follow-up was 29 +/- 16 months. Estimated survival after 4 years of follow-up was 81% among patients in the surgical group and 100% among patients in the nonsurgical group. Event-free survival was 66% in the surgical group and 69% in the nonsurgical group. CONCLUSIONS: Fractional flow reserve is helpful to identify patients with intermediate left main disease in whom deferral of surgical revascularization is associated with excellent survival and low event rates.

Severity of mitral regurgitation may be underestimated in the presence of a left atrial myxoma.

It is well known that mobile or large left atrial myxoma may lead to valve obstruction and insufficiency, and affect transmitral valve flow. The case is reported of a 47-year-old woman with severe mitral regurgitation (MR) and huge left atrial myxoma (6?4?3 cm). Preoperatively, the MR appeared related to the myxoma and was classified as moderate. Following extirpation of the myxoma, intraoperative transesophageal echocardiography (TEE) revealed a severe mitral regurgitant jet. After mitral valve repair by ring implantation, the MR was reduced to minor insufficiency. Hence, a large atrial tumor may mask the severity of concomitant unrelated MR in routine echocardiography. Intraoperative TEE helped in assessing correct mitral valve function after tumor extirpation. Preoperative echocardiography should focus on mitral valve dysfunction in order to separate tumor-related and -unrelated valvular pathologies.

Recurrent myocardial ischemia due to riding left main coronary artery bifurcation thrombus--noninterventional therapy with glycoprotein blocker and thrombolysis.

BACKGROUND: Acute coronary syndrome (ACS) comprises different manifestations of coronary artery disease. Angiograms performed at the time of an ACS may present different coronary morphologies; mostly there are acute vessel occlusions, ruptured atherosclerotic plaques, or thrombotic lesions that require reperfusion therapy. In the presence of intracoronary thrombi localized in the left main coronary artery, the clinical situation is challenging. Hemodynamic situation, symptoms, and rhythm status may change immediately and entail high mortality. Catheter-based therapy and surgical revascularization are associated with a high mortality rate. A noninterventional approach may be chosen in patients with stable hemodynamics and reestablished perfusion. METHODS AND PATIENT: We describe a patient with acute ST-elevation myocardial infarction with chest pain and stable hemodynamics. Angiography revealed a large thrombus in the left main coronary artery bifurcation with ostial subtotal narrowing of the circumflex and left anterior descending artery. However, coronary perfusion was maintained. Immediate treatment with the glycoprotein IIb/IIIa inhibitor abciximab was performed. The patient became asymptomatic. Angiography the next day showed no change in thrombus formation, so abciximab infusion was prolonged. Initial elevated enzymes decreased to normal values. Three days later the patient developed a new unstable angina with newly elevated cardiac enzymes. At this time, a thrombolytic agent was administered. Angiography 2 days later demonstrated normal coronaries. CONCLUSION: This case demonstrates the impact of intracoronary thrombi on repetitive myocardial ischemia and the effectiveness of a noninterventional pharmacological approach for the treatment of acute myocardial infarction due to intracoronary thrombus even in the left main coronary bifurcation.

Air pollution and diastolic function in elderly women - Results from the SALIA study cohort.

BACKGROUND: Studies linking particulate matter (PM) with heart failure (HF) show inconsistent results. However, the association of air pollution with diastolic function, an important determinant of heart failure, has not been studied yet and is addressed in the presented study. METHODS: 402 women (69-79 years) of the clinical follow-up (2007-2010) of the ongoing population-based prospective SALIA (Study on the influence of Air pollution on Lung function, Inflammation and Ageing) cohort were examined using Doppler echocardiography: Of the 291 women with preserved ejection fraction, the ratio of peak early diastolic filling velocity and peak early diastolic mitral annulus velocity (E/E') was collected in 264 and left atrial volume index (LAVI) in 262 women. Residential long-term air pollution exposure (nitrogen oxides, size-fractioned PM) was modeled at baseline and at follow-up, applying land use regression models. We used linear regression to model the cross-sectional associations of air pollutants per interquartile range (IQR) with different measures of diastolic function, adjusting for personal risk factors. RESULTS: Median concentrations of annual NOx, NO2, PM2.5, and PM10 at follow-up were 37.7, 25.9, 17.4 and 26.4µg/m(3), respectively. In the fully adjusted models, LAVI was associated with an IQR increase in PM2.5 (1.05 [0.99; 1.12]) and NOx (1.04 [1.00; 1.09]) at follow-up, and with NOx and NO2 (both 1.05 [1.00; 1.11]) at baseline. None of the pollutants were clearly associated with E/E'. CONCLUSIONS: In this analysis of elderly women, we found suggestive evidence for an association of air pollution with impaired diastolic function.

Reaction patterns of the tracheobronchial wall to implanted noncovered metal stents.

BACKGROUND: Endoluminal implantation of stents has evolved as a nonsurgical treatment option for stenosis of the central airways. Based on the favorable results in treatment of tumorous tracheobronchial stenosis, stenting has been introduced into the therapy of nonmalignant stenosis. AIM: To study the long-term biocompatibility and incorporation of implanted bronchial stents based on the pathoanatomic reaction of the tracheobronchial system in humans. The incorporation of bronchial stents was documented, with specific interest in transformation or induction of dysplasia in the implantation zone. METHODS: The tracheobronchial reaction was studied in 18 patients 2 days to 18 months after implantation of 24 noncovered metal stents (Wallstent; Schneider; Bülach, Switzerland; n = 8; and Ultraflex; Boston Scientific; Natick, MA; n = 16). RESULTS: Stenting produced slow papillomatous growth of granulative tissue through the interfilamentary space of the stents. A nonspecific inflammatory response of nontumorous tissue could be documented. Sparse spots of superficial squamous cells occurred. No epithelial dysplasia or giant cells were detected within the stented region. The number of superficial ciliated cells in the implantation zone was markedly reduced. CONCLUSION: After stent insertion in the upper airways, no malignant transformation of initially nontumorous tissue occurs. Stenting seems to be a safe therapy option when considered even for nonmalignant airway stenoses.

Optimizing revascularization strategies in patients with multivessel coronary disease: impact of intracoronary pressure measurements.

OBJECTIVES: In patients with multivessel coronary disease, the functional significance of each lesion is often unclear, and preinterventional stress tests may be inconclusive. In this setting, intracoronary pressure measurements may be helpful to define the optimal revascularization strategy. METHODS: Twenty-five consecutive patients (aged 64 +/- 11 years) with multivessel disease, inconclusive stress tests or not performed stress tests, and an angiographically intermediate coronary artery stenosis in at least 1 major vessel underwent intracoronary pressure measurements. Myocardial fractional flow reserve was measured for the intermediate lesions under the condition of maximum hyperemia induced by intravenous adenosine (140 microg x kg(-1) x min(-1). Revascularization strategies based on angiographic information alone were compared with treatment strategies based on fractional flow reserve results. RESULTS: The original recommendation of the revascularization procedure of choice (bypass operation or angioplasty) was changed in 9 patients (36%) on the basis of the results of fractional flow reserve measurements. In 6 more patients, pressure measurements led to a change in the recommended number of anastomoses to be aimed for during the operation. Within diffusely diseased vessels, fractional flow reserve provided an exact segmental resolution of pathologic vessel resistance for optimal graft placement. Significant left main disease was confirmed in 3 of 6 patients and was detected in 3 angiographically unsuspected cases. CONCLUSIONS: In patients with multivessel disease, coronary pressure-derived fractional flow reserve is a valuable tool to guide clinical decision making and support cardiologists and cardiovascular surgeons in the composition of optimal revascularization strategies.