Prim?re Katheterablation von Vorhofflimmern

Hintergrund: Die primäre Katheterablation von Vorhofflimmern stellt eine neue, kurative Behandlungsoption für Patienten mit therapieresistentem Vorhofflimmern dar. Sie hat den langfristig stabilen Sinusrhythmus zum Ziel, mit daraus folgernder koordinierter Vorhofkontraktion. Ablationsmethoden: Zwei verschiedene Ablationsstrategien haben sich in den letzten Jahren etabliert: Die Triggerelimination versucht auslösende atriale Extrasystolen (meistens innerhalb der Pulmonalvenen) zu identifizieren und durch fokale Hochfrequenzstromapplikation auszuschalten oder innerhalb der Pulmonalvenen zu isolieren. Durch die Substratmodifikation sollen mittels Anlage langer Ablationslinien die Eigenschaften des Vorhofmyokards so verändert werden, dass Vorhofflimmern nicht mehr aufrechterhalten werden kann. Bewertung: Beide Behandlungskonzepte müssen ihre Effektivität noch im Rahmen von sorgfältigen Nachbeobachtungsstudien unter Beweis stellen, bevor sie für den generellen Einsatz bei Patienten mit Vorhofflimmern empfohlen werden können. Background: Primary catheter ablation of atrial fibrillation is a new and curative option for the treatment of patients with drug-refractory atrial fibrillation. It is aiming at a long-term restoration of sinus rhythm and thereby causing a coordinated atrial contraction. Ablation Methods: Two different ablation strategies have been established: The "trigger elimination" tries to identify triggering atrial extrasystoles (mostly within the pulmonary veins), followed by focal ablation or isolation within the pulmonary veins. The "substrate modification" changes by long linear radiofrequency-induced lesions the ability of the atrial myocardium to sustain atrial fibrillation. Valuation: Both treatment options still have to prove their effectiveness in carefully monitored follow-up, before they can be offered to the general patient population with atrial fibrillation.     

Die Rolle von Resilienz f��r die Bew?ltigung von Belastungen im Kontext von Alters��berg?ngen

Personality traits, e.g., resilience, which is defined as emotional strength, have a strong impact on lifespan development. In this paper, a cross-sectional study examining the protective character of resilience in aging is presented. In a sample of persons ranging in age from 30-80 years, a significant negative association between resilience and depression was observed for the oldest group of our sample (age >?70 years). Thus, resilience might serve as a "safe-guard" against depression over the life course that, however, was found to disappear when people are faced with a transition into dependency and being in need of care.     

Pr?vention von Vorhofarrhythmien durch Stimulation

Hintergrund: Vorhofflimmern ist die häufigste Herzrhythmusstörung. Es beeinträchtigt die Lebensqualität oft erheblich und ist wegen seiner thrombembolischen Komplikationen für einen großen Teil der Morbidität und Mortalität sowie die Behandlungskosten der betroffenen Patienten verantwortlich. Prävention: Während chronisches Vorhofflimmern vorwiegend die Kontrolle der Herzfrequenz und eine ausreichende Antikoagulation erfordert, gilt es bei (noch) intermittierendem Vorhofflimmern, das Fortschreiten in chronisches Vorhofflimmern zu verhindern oder zumindest zu verzögern. Da Vorhofflimmern infolge negativer Remodeling-Prozesse die Neigung hat, sich selbst zu perpetuieren, dürften alle Maßnahmen, die die Anzahl und die jeweilige Dauer von Vorhofflimmerepisoden ("atriale Arrhythmielast") reduzieren, grundsätzlich geeignet sein, dieses Ziel zu erreichen. Bisher wurden zur Rhythmusstabilisierung und Rezidivprophylaxe vor allem medikamentöse Maßnahmen eingesetzt und in unterschiedlichem Maße proarrhythmische Wirkungen in Kauf genommen. Inzwischen vorliegende, allerdings noch nicht beweisende Daten lassen es sinnvoll erscheinen, Schrittmachersysteme mit präventiven Stimulationsalgorithmen zur Reduktion der atrialen Arrhythmielast einzusetzen. Neben konsequenter Überstimulation der Sinusknotenfrequenz wurden weitere Algorithmen entwickelt, mit denen es grundsätzlich möglich ist, dem größten Teil der Auslösemechanismen von Vorhofflimmern entgegen zu wirken. Darüber hinaus konnte neuerdings gezeigt werden, das ebenfalls in Schrittmacher integrierte Algorithmen zur antitachykarden Stimulation (ATP = antitachykardes Pacing), die ohne Latenz direkt nach der Wahrnehmung einer Vorhoftachyarrhythmie einsetzen, in der Lage sind, etwa zwei Drittel der Vorhoftachyarrhythmien aktiv zu terminieren. Laufende Studien: Gegenstand aktueller klinischer Studien ist es außerdem, den optimalen Implantationsort der üblicherweise einen oder aber auch mehrerer Vorhofelektroden herauszufinden. Neben den klassischen Implantationsorten (Vorhofohr, freie laterale Wand) werden die Stimulation des interatrialen Septums und des Koch'schen Dreiecks sowie multifokale Stimulationskonfigurationen (bifokale rechtsatriale und biatriale Stimulation) in Kombination mit präventiven Stimulationsalgorithmen untersucht. Die meisten dieser prospektiven Studien werden mit schrittmacherpflichtigen Patienten durchgeführt. Ihre Ergebnisse müssen abgewartet werden, bevor der klinische Stellenwert der Elektrostimulation bei intermittierenden Vorhoftachyarrhythmien abschließend beurteilt werden kann. Background: Atrial fibrillation is the most frequent arrhythmia. It can impair quality of life considerably. Due to thromboembolic complications it contributes to the patients' morbidity and mortality and to the costs for their medical treatment. Prevention: In chronic atrial fibrillation there is a need for adequate anticoagulation and heart rate control. In paroxysmal and intermittent atrial fibrillation it should be sought to prevent its progression to chronic atrial fibrillation. Since atrial fibrillation initiates negative processes of remodeling within the atrial myocardium, it has the tendency to perpetuate itself. From a theoretical point of view, it can be expected that all means which prevent episodes of atrial fibrillation or which terminate it immediately after its onset, are able to prevent or at least to delay the progression to chronic atrial fibrillation. Pharmacologic treatment is usually used to prevent recurrences of atrial fibrillation. Based on the actual data it can also be expected that pacemakers with special preventive pacing algorithms are able to reduce the atrial arrhythmic burden. Besides consequent overdrive pacing, more sophisticated algorithms like "suppression of premature atrial contractions", "post exercise response", "automatic rest rate" or "post mode-switch pacing" have been developed. They can be applied either alone or in combination with special lead positions (inter-atrial septal pacing or pacing of the triangle of Koch) or special stimulation configurations like dual site right atrial pacing or biatrial pacing. These pacing strategies cover the most relevant onset mechanisms of atrial fibrillation. Furthermore, there are algorithms to treat atrial tachyarrhythmias actively by antitachycardia pacing (ATP). First clinical results have shown that about 2/3 of the diagnosed atrial tachyarrhythmias could be terminated by these means immediately after their onset. Ongoing Trials: This article gives an overview over the principles of pacing in the management of atrial arrhythmias and ongoing clinical trials in this field. Before a definite judgement on the clinical relevance of these new preventive and therapeutic pacing strategies can be given, the results of these ongoing controlled clinical studies have to be analyzed.     

EKG-Ver?nderungen bei Besuchern von Kirmes-Attraktionen

Introduction

Modern engineering techniques allow the building of spectacular fairground rides. Visiting such fairground rides induces stress and anxiety. However, a case of sudden death has recently been reported. In this study we tested whether this stress induces measurable changes in electrocardiograms.

Material and methods

In this study five young healthy volunteers were enrolled. All volunteers were connected to a long-term electrocardiogram which recorded heart rate during the visit of two different fairground rides.

Results

In this group of presumably healthy individuals, visiting modern fairground rides led to a reproducible rise in heart rate from 78–90/min at rest to 135–157/min, which then returned to normal within 10 min after finishing the rides. Supraventricular or ventricular tachyarrhythmias were not detected in any of the individuals.

Conclusions

There is a low risk for cardiovascular events in young people despite a significant rise in heart rate. However, in individuals with pre-existing heart disease, an increase in heart rate raises the possibility of acute cardiovascular events.     

Hauterkrankungen als Spiegel von Magen-Darm-Ver?nderungen

The skin is the most obvious organ of man and may be affected in a strictly isolated manner or within the context of a systemic disease, thus reflecting internal processes. Bowel diseases with malabsorption can present on the skin as itching or scaling or as characteristic diseases like pellagra and acrodermatitis enteropathica. Dermatitis herpetiformis as a distinct cutaneous entity shows immunological similarities with celiac disease like the presence of anti-transglutaminase antibodies, yet characteristic discrepancies at the same time. Chronic inflammatory bowel diseases are associated with erythema nodosum or pyoderma gangrenosum as defined dermatological entities which are indicative for, yet not proof of an underlying disease. Inflammatory processes of the oral cavity or perianal region are mostly unspecific, yet aphthous membrane involvement, fistulae, and pyostomatitis vegetans are more or less pathognomonic for chronic inflammatory bowel diseases. Apart from these more or less typical skin manifestations, a number of skin diseases have been found to be associated with bowel diseases, however mostly without a specific pathogenic relation. Therapeutic approaches are in many cases only successful when the underlying bowel disease is targeted or treated as well.     

Entwicklung von Morbidit?t und Mortalit?t bei Spondyloarthritiden

This review presents data on morbidity and mortality in patients with spondyloarthritis (SpA). Morbidity in patients with SpA is mainly determined by impairment of function and development of structural lesions. The course of illness in patients with ankylosing spondylitis (AS) is influenced by comorbidities, such as cardiovascular disease and fractures of the spine and in patients with psoriatic arthritis by peripheral joint manifestations. The mortality of patients with SpA has probably not increased but exact data are lacking. Approximately one third of AS patients will develop a severe disease state in which the mortality rate is increased by 50%.     

Kosteneffektivit?t des Einsatzes von Studienschwestern in der Betreuung von Patienten mit Herzinsuffizienz

übersichtsarbeit

Kosteneffektivit?t des Einsatzes von Studienschwestern in der Betreuung von Patienten mit Herzinsuffizienz     

Atriale Stimulation zur Pr?vention von Vorhofflimmern

Background

Atrial overdrive and optimized interatrial conduction time can reduce atrial fibrillation (AF). Increased ventricular stimulation results in a higher incidence of atrial fibrillation.

Patients and methods

In 25 patients with paroxysmal AF, a dual-chamber pacemaker (Identity DR 5370, St. Jude Medical) was implanted. Atrial leads were placed randomly either septal (n=12) or conventional (n=13). Dynamic atrial overdrive (DAO) was activated and the AV delay was optimized according to Koglek’s method. After 3, 6, 9, and 12 months automatic mode switch (AF burden) was analysed.

Results

No difference in implantation parameters were observed between groups. Technical implantation parameters were in the normal range for both groups. After 12 months patients in the septal group had less AF burden (1% vs. 7%, p=0.06), and the total number of AF episodes was reduced.

Conclusion

Septal pacing is safe. In combination with DAO and AV delay optimization it may reduce the AF burden, which can be observed after 12 months.     

Sind Mitglieder von Fibromyalgiesyndrom-Selbsthilfegruppen „anders“?

Background

No data were available on demographic and clinical characteristics of members of fibromyalgia syndrome (FMS) self-help groups in Germany.

Material and methods

The study was carried out from November 2010 to April 2011. A set of questionnaires was distributed by the German League Against Rheumatism and the German Fibromyalgia Association to members and to all consecutive FMS patients at nine clinical centres of different levels of care. The set included a self-developed questionnaire on demographic and medical data and on previously and currently used therapies, the patient health questionnaire (PHQ 4) and the fibromyalgia survey questionnaire.

Results

Members of FMS self-help groups (N?=?1,014) were older and reported a longer duration of chronic widespread pain, less anxiety and depression and a more frequent current use of aerobic exercise, relaxation training and complementary alternative medication than participants not affiliated with FMS self-help groups (N?=?630).

Conclusions

Membership in FMS self-help groups was associated with less psychological distress and a more frequent use of active self-management strategies.     

Qualit?tsverbesserung von Koronardiagnostik und -intervention durch ?Virtual-Reality��-Simulation

Currently, more than 800,000 diagnostic procedures and 300,000 percutaneous coronary interventions are performed annually in 556 catheter laboratories in Germany. These numbers document the importance of training programs in interventional cardiology. However, this need is in sharp contrast to the time constraints for continuing medical education in Germany due to personnel and financial restrictions. A possible solution for this dilemma could be new training programs which partially supplement conventional clinical training by simulation-based medical education. Currently five virtual reality simulators for diagnostic procedures and percutaneous coronary interventions are available. These simulators provide a realistic hands-on training comparable to flight simulation in aviation.The simulator of choice for a defined training program depending on the underlying learning objectives could either be a simple mechanical model (for puncture training) or even a combination of virtual reality simulator and a full-scale mannequin (for team training and crisis resource management). For the selection of the adequate training program the basic skills of the trainee, the learning objectives and the underlying curriculum have to be taken into account. Absolutely mandatory for the success of simulation-based training is a dedicated teacher providing feedback and guidance. This teacher should be an experienced interventional cardiologist who knows both the simulator and the selected training cases which serve as a vehicle for transferring knowledge and skills.In this paper the potential of virtual reality simulation in cardiology will be discussed and the conditions which must be fulfilled to achieve quality improvement by simulation-based training will be defined.     

Antibakterielle Aktivit?t und β-Laktamase-Stabilit?t von elf Oralcephalosporinen

Oralcephalosporine (Cefixim, Cefdinir, Cefetamet, Ceftibuten, Cefpodoxim, Loracarbef, Cefprozil, Cefuroxim, Cefaclor, Cefadroxil und BAY 3522) wurden nach antibakteriellem Profil und Stabilität gegenüber neuen -Laktamasen verglichen. Erhöhte Aktivität plus Erweiterung des antibakteriellen Spektrums wurde insbesondere bei den von parenteralen Cephalosporinen (vom Oximino-Typ) hergeleiteten Substanzen wie Cefixim, Cefdinir, Cefetamet, Ceftibuten und Cefpodoxim festgestellt. Die höchste Antistaphylokokkenwirkung unter den Oralcephalosporinen liegt vor bei Cefdinir, Cefprozil und BAY 3522. Cefetamet, Ceftibuten und Cefixim verfügen über keine klinisch relevante Antistaphylokokkenwirkung, die übrigen Substanzen unterscheiden sich nur unwesentlich in ihrer Aktivität gegenüber Staphylokokken. Die größte Breite im antibakteriellen Spektrum erreichen Cefdinir und Cefpodoxim. Wirkungslücken im Spektrum der bisherigen Oralcephalosporine, die auch durch die neuen Substanzen nicht geschlossen werden, bestehen beiEnterobacter-Arten,Morganella, Listeria, Pseudomonas- undAcinetobacter-Arten, methicillinresistenten Staphylokokken,Enterococus-Arten, penicillinresistenten Pneumokokken und Anaerobiern. Neue -Laktamasen (TEM-3, TEM-5, TEM-6, TEM-7, SHV-2, SHV-3, SHV-4, SHV-5, CMY-1, CMY-2, CTX-M) hydrolysieren die Mehrzahl der Oralcephalosporine. Über -Laktamase-Stabilität, die zum Teil deutlich höher liegt als die parenteraler Cephalosporine, verfügen jedoch Ceftibuten, Cefetamet, Cefixim und Cefdinir. Neue Oralcephalosporine lassen aufgrund ihres antibakteriellen Profils einen Fortschritt in der Therapie mit resorbierbaren Cephalosporinen erwarten, und zwar einmal bei Erregern aus dem Wirkungsspektrum bisheriger Oralcephalosporine (günstigere Relation zwischen MHK und Serumspitzenspiegel), insbesondere aber bei Infektionen mit Erregern außerhalb des Spektrums der älteren Oralcephalosporine (z. B.Proteus spp.,Providencia spp.Citrobacter spp.,Serratia spp.).Oral cephalosporins (cefixime, cefdinir, cefetamet, ceftibuten, cefpodoxime, loracarbef, cefprozil, cefuroxime, cefaclor, cefadroxil and BAY 3522) were compared by their antibacterial profile including stability against new betalactamases. Both activity and antibacterial spectrum of compounds structurally related to third generation parenteral cephalosporins (of the oximino class) were superior to established compounds. Activity against staphylococci was found to be highest for cefdinir, cefprozil and BAY 3522. Cefetamet, ceftibuten and cefixime demonstrate no clinically meaningful antistaphylococcal activity while the other compounds investigated demonstrate intermediate activity. The antibacterial spectrum was broadest for cefdinir and cefpodoxime. New oral cephalosporins are equally inactive as established compounds againstEnterobacter spp.,Morganella, Listeria, Pseudomonas andAcinetobacter spp., methicillin-resistant staphylococci,Enterococcus spp., penicillin-resistant pneumococci and anaerobes. New extended broad-spectrum betalactamases (TEM-3, TEM-5, TEM-6, TEM-7, SHV-2, SHV-3, SHV-4, SHV-5, CMY-1, CMY-2, and CTX-M) are active against the majority of oral cephalosporins. Ceftibuten, cefetamet, cefixime and cefdinir were stable against some of these enzymes even to a higher extent than parenteral cephalosporins. New oral cephalosporins should improve the therapeutic perspectives of oral cephalosporins due to their higher activity against pathogens marginally susceptible to established compounds (higher multiplicity of maximum plasma concentrations over MICs of the pathogens) and furthermore by including in their spectrum organisms resistant to established absorbable cephalosporins (e. g.Proteus spp.,Providencia spp.,Citrobacter spp., andSerratia spp.).     

Geriatrietypische Multimorbidit?t im Spiegel von Routinedaten – Teil?1

Background

In Germany, typical geriatric multimorbidity is—next to age itself—of special significance for the identification of target groups for specific geriatric care offers. The present article primarily focuses on typical geriatric multimorbidity in the claims data of statutory health insurance and long-term care insurance in Germany. Using the definition of “the geriatric patient” that is agreed on by providers of services as well as by cost bearers, geriatric multimorbidity is defined as the coexistence of at least 2?of 15?typical geriatric conditions. A suggestion made by the German Geriatric Association was to assign ICD-10-GM codes to each of these 15?conditions. Thus, it becomes possible to identify the corresponding geriatric conditions in claims data.

Methods

The article investigates the frequency of geriatric conditions and, thus, of geriatric multimorbidity of patients aged ≥?60?years admitted to a hospital with a geriatric ward. Patients treated in a geriatric ward were compared with those who did not receive geriatric care. In anticipation of a high correlation between typical geriatric conditions and specific features that are preconditions for receiving long-term care insurance benefits (such as care levels and status of a nursing home resident), claims data of the long-term care insurance were included for external validation.

Results

The analyses showed a distinctly higher proportion of insured people with typical geriatric multimorbidity or rather a certain care level among the geriatrically treated cases than among those patients not receiving geriatric treatment (68.5%/67.9% versus 24.2%/33.4%). The different proportions of typical geriatric multimorbidity coded among the patients with features of a certain care level in the two given groups give rise to the suspicion that typical geriatric multimorbidity is not always statistically recorded—especially in cases of treatment without provision of geriatric care.

Conclusion

The frequency of cases of typical geriatric multimorbidity and a certain care level shows that—even when a specific geriatric offer exists—a considerable proportion of cases with typical geriatric conditions are treated in other medical departments.     

Entwicklung von Morbidit?t und Mortalit?t bei ANCA-assoziierten Vaskulitiden

The outcome of ANCA (antineutrophil cytoplasmic antibody)-associated vasculitis (AAV) has been significantly improved due to the combined use of cyclophosphamide (CYC) and glucocorticosteroids. Recent studies demonstrated a normalization of life expectancy for several subgroups of AAV patients. Mortality is highest in the first year after diagnosis and infections are the most frequent cause of death. Older age and renal failure are associated with worse outcome. The use of Pneumocystis jiroveci prophylaxis and subsequent activity-adapted GC dose reduction (target: below 10?mg per day) can substantially reduce the risk of severe infections. Late sequelae of CYC medication, such as cystitis and malignancy should be recognized and can be minimized by the usage of uroprotection with mesna and avoidance of high cumulative CYC doses.     

Geriatrietypische Multimorbidit?t im Spiegel von Routinedaten – Teil?2

Background

Due to demographics, characteristic multimorbidity in geriatric patients is resulting in increased social, medical, and healthcare challenges. Geriatric multimorbidity (GM) can be defined as the simultaneous occurrence of at least two diseases that require medical care with an interdisciplinary focus on independence in activities of daily living. Typical conditions of GM are, e.g., incontinence, cognitive impairment, frailty, and decubitus.

Material and methods

Part 2 of this study is based on claims data of 240,502 AOK insurants (AOK is one of the major health insurance companies of the German statutory health insurance system) aged ≥?60 years with at least one admission to a hospital with a geriatric ward. Geriatric conditions (GCs) were ascertained in two ways: diagnoses from physicians in the ambulant care setting and diagnoses in a hospital setting in 2008. A total of 15 GC were assessed using diagnoses based on ICD-10 codes (as per suggestion from scientific geriatric societies). An insurant was defined as a person with GM, if he/she had at least two GCs.

Results

The proportion of GCs in ambulant or inpatient diagnoses of 240,502 insurants varied significantly in most cases. For specific GCs, considerably higher proportions of ambulant diagnoses (e.g., pain, impairment of vision, or hearing) or for inpatient diagnoses (e.g., electrolyte or fluid metabolism disorders, malnutrition, incontinence) were identified. Only on rare occasions were small differences observed comparing the proportions of specific GCs in the diagnoses of the two different care sectors. This finding reduces considerably the accordance between the two care sectors with reference to the presence or absence of a GC for ambulant or inpatient diagnoses. The main agreement was with the non-coding of specific GCs, not with ambulant or inpatient diagnoses. Insurants with a geriatric hospital admission or certain care level (level ≥?1) generally had higher proportions for specific GCs for inpatient and ambulant diagnoses than non-geriatric treated insurants or insurants without a certain care level. Of the geriatric treated insurants and those with certain care levels, 90% were characterized by the presence of GM for both ambulant or inpatient diagnoses. This percentage is remarkably higher than for patients who featured no geriatric treatment or had no certain care level.

Conclusion

The inclusion of ambulant diagnoses in addition to inpatient diagnosis offers comprehensive possibilities to identify insurants with GM in claims data. The contribution of the diagnoses of both care sectors for the identification of GC and GM varies with regard to attribute and insurant orientation. Furthermore, significant attribute-oriented overlap of insurants claiming geriatric treatments and insurants with certain care levels became visible, which can open new possibilities for simpler identification of a portion of patients with GM.     

Was ist neu in der ESC-Leitlinie von 2009?

The 2009 ESC guideline emphasizes active risk stratification and the diagnostic strategy of prolonged ECG monitoring using an implantable loop recorder. The initial evaluation aims at establishing a prima vista diagnosis or at least a diagnostic hypothesis and risk stratification according to ECG criteria and clinical findings. Carotid sinus massage as a diagnostic procedure remains controversial. Electrophysiological study for evaluation of suspected arrhythmogenic syncope is of decreasing relevance. The loop recorder enables documentation of the rhythm during a subsequent syncope. Neurological work-up is not routinely recommended. A standardized evaluation minimizes the rate of unexplained syncopes. Therapeutic decisions include ICD or pacemaker, as indicated in cases of arrhythmogenic syncope or carotid sinus syncope, and mostly general measures in case of other reflex syncopes.     

Was beeinflusst die Uebertragbarkeit von Mäusetumoren?

Ohne Zusammenfassung     

PTA oder Operation bei der Therapie von Karotisstenosen?

Hintergrund: Internationale Studien (NASCET, ECST, ACAS) haben die Diskussion über die Indikation für eine operative Behandlung an der Arteria carotis zu Gunsten des operativen Eingriffs beendet. Die eindrucksvollen Ergebnisse haben bewiesen, dass die Operation für den Patienten weniger gefährlich ist als der Spontanverlauf. Aber kann man diese Studienergebnisse auf das Stenting der Arteria carotis übertragen? Vergleichende Studien laufen zurzeit, sind aber noch nicht vollständig und daher nicht aussagefähig.Ob eine operative oder interventionelle Therapie der Karotisstenose gleiche oder ähnliche Resultate für den Patienten bringt, wird daher kontrovers diskutiert und bleibt abzuwarten. In allen Studien wird nur der Stenosegrad als Maßstab für den Wert der operativen Maßnahmen genommen, nicht aber plaquemorphologische Kriterien, die aufgrund der vorliegenden Literatur eindeutig aufgrund des hohen Embolierisikos gegen das Stenting und für den operativen Eingriff sprechen.Untersuchungsmethoden und Ergebnisse: In einer prospektiven Studie verglichen wir Patienten mit einer Karotisstenose hinsichtlich der Plaquemorphologie, die präoperativ mit Ultraschall-Duplex untersucht wurde, mit den pathohistologischen Untersuchungsbefunden. Hierbei wurde bereits für die einfache Unterscheidung in weiche und harte Plaques nur eine Sensitivität und Spezifität von etwa 80% aufgrund der nichtinvasiven Untersuchungen gefunden. Der Stenosegrad konnte in 98% aller Fälle sehr gut präoperativ ermittelt werden. In Fällen eines progredienten Insultes oder bereits stattgehabten Schlaganfalls wurden in der histologischen Untersuchung bei 72% der Patienten Ulzerationen oder gefährliche thrombotische Auflagerungen gefunden, die duplexsonographisch nur bei jedem Zweiten nachweisbar waren. Ischämische Attacken und Schlaganfälle ereigneten sich bei einer weichen Plaquemorphologie signifikant häufiger. Bei asymptomatischen Patienten fanden sich häufiger glattwandige harte Plaques. Patienten mit einer weichen Plaquemorphologie hatten außerdem ein höheres Risiko für ein postoperatives neurologisches Defizit. Gefährliche Plaquemorphologien mit thrombotischen Auflagerungen oder Ulzerationen und mit hohem Embolierisiko konnten mit Ultraschall nicht ausreichend sicher dargestellt werden. Diese Betrachtung ist für das Karotisstenting sicher von Bedeutung.Neben den histopathologischen Befunden wurde während der Karotisoperation nach High Intensity Transient Signals (HITS) gesucht. Es fand sich eine signifikant höhere Anzahl von HITS bei gefährlichen Plaqueformationen wie Ulzerationen oder thrombotischen Auflagerungen. Die Zahl der HITS war während einer Karotisangioplastie mit Stent acht- bis zehnmal höher als in der schlechtesten operativen Gruppe, ohne dass in diesen Fällen die Plaquemorphologie bekannt war.Schlussfolgerung: Wegen des unzureichenden Wissens über den Nutzen eines Stentings an der Arteria carotis zeigen eigene Beobachtungen und die Auswertung der Literatur, dass die chirurgische Behandlung der Karotisstenose nicht vergleichbar ist mit der interventionellen Behandlung. Die Operation ist so lange als Goldstandard zu betrachten, bis die Ergebnisse prospektiver randomisierter Vergleichsstudien mit dem Stenting gleichwertige Ergebnisse auch im Langzeitverlauf hinsichtlich einer Schlaganfallgefährdung für den Patienten beweisen können.