Prevalence of microvascular disease in patients with significant coronary artery disease

Coronary flow velocity reserve (CFVR) measurement using intracoronary Doppler techniques has been increasing accepted for the assessment of physiological significance of epicardial stenosis and the functional changes after coronary interventions. However, large discrepancy exists concerning the acute changes of CFVR immediately after intervention. The purpose of this study was to investigate the prevalence of microvascular dysfunction in patients with significant coronary artery disease. Intracoronary Doppler flow measurements were performed in a total of 212 patients who underwent coronary interventions because of significant epicardial stenosis using 0.014" Doppler flow wire (Cardiometrics, Inc, Mountain View, CA). Intracoronary bolus injection of adenosine (12 micrograms for the right coronary and 18 micrograms for the left coronary arteries) was used to induce hyperemic reaction. CFVR was registered as the ratio of average peak velocity during hyperemia (hAPV) to at baseline (bAPV). Successful coronary interventions either by percutaneous transluminal coronary balloon angioplasty (PTCA) or by stenting could significantly improve the CFVR. In 80 patients with PTCA, the bAPV elevated from 16.6 +/- 2.1 cm/s to 20.6 +/- 13.4 cm/s and hAPV from 30.1 +/- 15.9 cm/s to 45.2 +/- 17.7 cm/s (both p < 0.001) with PTCA and the CFVR increased from 1.94 +/- 0.78 to 2.58 +/- 0.87 correspondingly (p < 0.001). Significant elevation of coronary flow parameters were also found in 132 patients with subsequent stent implantation (bAPV from 15.3 +/- 6.7 cm/s to 18.7 +/- 9.1 cm/s, hAPV from 28.7 +/- 14.4 cm/s to 44.3 +/- 17.7 cm/s and CFVR from 1.90 +/- 0.70 to 2.59 +/- 0.87, all p < 0.001). Reduction of CFVR (< 3.0) after intervention still existed in 46 (61.3%) of 80 patients after PTCA and 88 (66.7%) of 132 patients after stenting. Moreover, CFVR < 3.0 were found in 50 (45.9%) of 109 reference vessels in patients with single vessel disease. Significant improvement of coronary flow velocity and coronary flow velocity reserve could be obtained after successful angioplasty. However, microvascualr dysfunction existed in a large proportion of patients either in normal reference vessels or in target vessels after interventions.     

Penetrating atherosclerotic ulcer of the aorta: treatment by endovascular stent-graft placement

PURPOSE OF THE REVIEW: To summarize the current clinical experience with endovascular stent-graft repair in patients presenting with penetrating atherosclerotic ulcer of the descending thoracic aorta. RECENT FINDINGS: Penetrating atherosclerotic ulcer is increasingly acknowledged as a pathologic variant of classic false lumen aortic dissection with a high incidence of bleeding complications and rupture in up to 40% of patients. So far, no generally accepted therapeutic regimen has been established, as the natural history of penetrating atherosclerotic ulcer is not yet fully understood. Recently, however, penetrating atherosclerotic ulcer is increasingly considered to be treated more aggressively (preferentially surgically). Given the high morbidity and mortality of aortic surgery, endovascular stent-graft repair may be an attractive, less invasive alternative in selected patients with penetrating atherosclerotic ulcer. Sealing of a penetrating ulcer by the stent-graft reduces wall stress and thus provides stabilization of the diseased aortic segment. SUMMARY: To date, there is limited experience with endovascular repair in penetrating atherosclerotic ulcer, suggesting that endovascular stent-graft repair is safe and effective. Long-term results are, however, required to fully establish the efficacy of endovascular repair in penetrating atherosclerotic ulcer.     

Impact of intraventricular conduction delay on coronary haemodynamics: a study with intracoronary Doppler in patients with bundle branch blocks and normal coronary arteries.

AIMS: The impact of right bundle branch block (RBBB) and left bundle branch block (LBBB) on myocardial perfusion is not completely understood as data are often blurred by underlying cardiac disease. The present study investigates whether conduction delays per se affect coronary perfusion-an indirect measure of myocardial oxygen demand. METHODS AND RESULTS: Intracoronary Doppler and ultrasound were performed in 8 patients with RBBB, 10 patients with LBBB, and 10 control subjects. All patients had angiographically normal coronary arteries and normal left ventricular function. Baseline (bAPV) and adenosine-induced hyperaemic average flow velocity and coronary flow velocity reserve (CFVR) were measured in left anterior descending arteries. Intravascular ultrasound showed no difference in lumen cross-sectional area and plaque burden between groups. Patients with RBBB and LBBB had higher bAPV values than controls (19.0 +/- 4.9, 21.9 +/- 5.1, and 14.6 +/- 2.4 cm/s, respectively; ANOVA P = 0.003). There was no difference between patients with LBBB and RBBB compared with controls in CFVR (2.8 +/- 0.5, 3.0 +/- 1.0, and 3.4 +/- 0.7, respectively; ANOVA P = 0.21). CONCLUSION: Bundle branch blocks, in particular LBBB, are associated with an increased coronary flow velocity, which indicates enhanced myocardial oxygen demand on the basis of mechanoenergetic disturbance. This may contribute to the unfavourable outcome of patients with intraventricular conduction delay.     

The value of prognostic parameters for the stratification of advanced breast cancer patients

Summary One hundred seventy-five patients with metastatic breast cancer, treated with a combination chemotherapy (Cooper regimen), were analyzed retrospectively to identify the value of the traditional prognostic parameters (disease-free interval; menopausal status; dominant site of metastatic lesion) for the stratification of patients before randomization. Response rate and survival time were not significantly affected by the disease-free interval and menopausal status. A significant difference was detected among the three categories total extent of disease (according to Swenerton) was found to be the most important factor for predicting response and survival time after combination cytotoxic treatment. The differences between the dominant size of metastatic disease are mainly influenced by different size of metastatic spread. Therefore, there is found a significant correlation between the different types of dominant lesions and total extent of disease. In conclusion, the particular sites of metastatic spread seem to be of less importance than overall extent of disease in predicting the outcome. A critical evaluation of the three traditional stratification parameters and introduction of a semiquantitative estimation of total tumor burden as a new stratification parameter seems to be necessary when planning and comparing future trials.     

Preinfarction angina: no interference of coronary microembolization with acute ischemic preconditioning

Transient episodes of angina preceding acute myocardial infarction may both, protect the myocardium by ischemic preconditioning or damage it when associated with coronary microembolization. We now studied the potential loss of ischemic preconditioning with coronary microembolization. Anesthetized pigs (group 1; n=8) were subjected to 90 min sustained low-flow ischemia. Group 2 (n=8) was subjected to coronary microembolization (i.e. microspheres; 42 microm slashed circle; 3000 per ml min-1 inflow) 35 min before sustained ischemia. In group 3, coronary microembolization was followed 10 min later by one cycle of ischemic preconditioning (10 min ischemia/15 min reperfusion) before subsequent sustained ischemia. Infarct size was determined after 2 h reperfusion by triphenyl tetrazolium chloride staining. Infarct size after sustained ischemia alone (group 1) was 19.4+/-3.4% of the area at risk (mean+/-S.E.M.). With coronary microembolization before sustained ischemia (group 2) infarct size was only slightly larger (23.6+/-4.6%, ns). In group 3 with microembolization followed by ischemic preconditioning, infarct size was reduced to 12.7+/-3.0% (P<0.05 vs. group 2). The relationships between infarct size and transmural blood flow in groups 1 and 3 were not different, giving the impression that ischemic preconditioning failed to protect microembolized myocardium. However, additional coronary microembolization shifted the relationship between infarct size and blood flow upwards to a larger infarct size at any given blood flow. Thus when comparing the relationship of group 3 to its true control (group 2), it was shifted downwards (P<0.05; analysis of covariance (ANCOVA)) indicating persistent protection of microembolized myocardium by ischemic preconditioning. Coronary microembolization induces additional infarction when superimposed on sustained ischemia but does not interfere with the endogenous protection by ischemic preconditioning.     

Sequential intervention procedures after intracoronary thrombolysis; balloon dilatation,bypass surgery,and medical treatment

After successful intracoronary thrombolysis of an acute myocardial infarction in 145 patients subsequent intervention procedures were evaluated. In 48 of 62 patients (43%), percutaneous transluminal coronary angioplasty was performed successfully (success rate 77%), 41 patients (28%) were operated on and 56 patients (39%) were treated only medically.During the hospital phase in the angioplasty group, 4 reinfarctions were noted and 3 repeat angioplasties were required, while 41 of the 48 successfully treated patients (85.4%) remained clinically stable. In the surgical group, one cardiac failure occurred, while 40 patients (97.6%) were without cardiac event. In the medical group, 5 patients died (8.9%), 8 patients (14.3%) had a reinfarction, and 76.8% were clinically stable.During the follow-up period in the surgical group of 6 months 37 patients (90.2%) were clinically stable, all in functional classes I and II. In the angioplasty group 33 patients were stable (68.8%), and in the medical group 26 patients were stable (46.6%). In the whole group of 145 patients the hospital mortality together with that in the 6 months follow-up period was 9.7% with a reinfarction rate of 22.8%.After successful thrombolysis, the underlying coronary artery disease with its mostly severe stenoses poses a high risk of reinfarctions, recurrent angina, and flow obstructions. Bypass surgery or angioplasty may diminish these risks and improve myocardial perfusion and survival rate in carefully selected patients.     

Importance of calibration for diameter and area determination by intravascular ultrasound

Background: Intravascular ultrasound (IVUS) permits quantitative assessment of the lumen diameter and area of coronary arteries. The experimental study was performed to evaluate the accuracy of diameter and area measurements.Methods and results: Lumen quantitation (lumen diameter D and cross-sectional area A) in lucite tubes (lumen diameter 2.5 to 5.7 mm, Plexiglas) was performed using a mechanical IVUS system (HP console, 3.5F catheter, Boston Scientific, 30 MHz). The influence of fluid type (blood, water and saline solution), fluid temperature (20°C/37°C), catheter to catheter variation, gain setting and ultrasound frequency (12, 20 and 30 MHz) was determined. In blood at 20°C there was a constant deviation of the measured diameter from the true luminal diameter of –0.29 ± –0.04 mm (p<0.06). In water and saline solution at 20°C the mean deviation from true diameter was –0.21 ± –0.06 mm (p<0.06). At 37°C, the deviation in blood was greater than at 20° (–0.34 ± –0.02 mm) which is >10% in a 3mm tube (p<0.06). Three of the ten catheters tested in water at 20°C underestimated true diameter by more than –0.3 mm. The deviation from true diameter (5mm tube) with varying gain settings was –0.14 mm to –0.23 mm compared to –0.19 mm at standard settings (p>0.288). At 12 MHz diameter measured was over-estimated. The error in absolute area estimation increased with increasing diameter tested in blood at 37°C (–1.21 to –2,72mm²), whereas the relative error ([Measured Area-True Area]/True Area × 100 [%]) was more striking at smaller diameters (up to –25% in the 2.5 mm tube).Conclusion: Luminal diameters and areas are underestimated by this particular IVUS system. When IVUS imaging and measurements are made during coronary interventions this error should be taken into account with regard to appropriate sizing of the device and the assessment of the postprocedure result. Because systematic errors might also occur in other IVUS systems (not tested in this study), it is advisable to ensure that each system is validated prior to clinical use, especially when exact measurements are required.This paper is followed by an Editorial Comment written by V. Bhargava et al. (see pp. 231–232).     

Cardiovascular health behaviors and associations of sex,age, and education in adolescents - Results from the EVA Tyrol study

Background and aimsIdeal cardiovascular health (CVH) behaviors in adolescents are defined by body mass index (BMI), diet, physical activity and smoking, and are directly associated with better health in later life. To further improve health prevention programs we investigated the prevalence of these behaviors in a cohort of healthy adolescents and focused on the associations with sex, age, and education.Methods and resultsThe Early Vascular Aging Tyrol study is a cross-sectional study assessing 14- to 19-year-old pupils and apprentices in Western Austria and South Tyrol. Between May 2015 and July 2018 2047 adolescents (43.6% males, mean age 16.4 years) with complete data for all 4 health behaviors were included. The prevalence of ideal body mass index (BMI) was 78.3%, of ideal physical activity 42.5%, of non-smoking 70.4% and of ideal diet 8.1%. Females showed a higher smoking prevalence and a lower physical activity, but better dietary habits than males. Older adolescents of both sexes had lower prevalence of ideal smoking and diet. Apprentices and pupils of vocational schools had a higher BMI and a less favorable diet compared to secondary academic school students. Smoking prevalence was highest in apprentices. Non-ideal BMI was independently associated with smoking.ConclusionIn our cohort, only a minority showed ideal CVH behaviors which were best in adolescents younger than 16 years. We observed significant differences between males and females and a clear impact of school education with apprentices being at risk for non-ideal CVH behaviors.Clinical trial registration numberNCT03929692, clinicaltrials.gov.     

Improved Assessment of Pathological Regurgitation in Patients with Prosthetic Heart Valves by Multiplane Transesophageal Echocardiography

The aim of this study was to evaluate the diagnostic increment of individually optimized axes in the assessment of pathological prosthetic valve regurgitation. Forty-two patients with pathologically regurgitant prostheses in the aortic (n = 21), mitral (n = 15), and tricuspid (n = 6) positions were examined by multiplane transesophageal echocardiography. The investigation was performed utilizing the transverse axis first, the longitudinal axis second, and the intermediate axes afterwards. The presence of regurgitation, the differentiation between trans- and perivalvular origin, and the localization of perivalvular leakages at the sewing ring were evaluated. Findings in the biplane and intermediate axes were compared to surgery or autopsy in all patients. There was slightly higher detection rate for aortic prosthetic regurgitation using the intermediate axes than the biplane axes. The intermediate axes revealed significantly fewer differences to the morphological control than the biplane axes with regard to the differentiation of peri- and transprosthetic aortic regurgitation and to the localization of a periprosthetic aortic regurgitant origin. The intermediate axes provided significantly better agreement to surgery/autopsy than the biplane axes regarding the localization of the origin of mitral periprosthetic regurgitation. Morphological visualization of the perivalvular gap adds important information on the precise localization of the regurgitant origin. The pathological gap was visualized significantly more often using the intermediate than the biplane axes in all types of prostheses. The data in this study therefore suggest that multiplane transesophageal echocardiography is superior to biplane transesophageal echocardiography in the assessment of pathologic prosthetic regurgitation.     

S2-Leitlinie zur Diagnostik und Therapie der infektiösen Endokarditis

Ohne ZusammenfassungChristoph K. Naber (1), Artur Bauhofer, Michael Block, Michael Buerke, Raimund Erbel, Wolfgang Graninger, Mathias Herrmann (2), Dieter Horstkotte (3), Peter Kern, Hartmut Lode, Uwe Mehlhorn (4), Jürgen Meyer (5), Andreas Mügge, Jörg Niebel (6), Georg Peters (7), Pramod M. Shah, Karl Werdan (8)Herausgegeben von der Paul-Ehrlich-Gesellschaft für Chemotherapie (PEG) und dem Vorstand der Deutschen Gesellschaft für Kardiologie, Herz- und Kreislaufforschung (DGK) in Zusammenarbeit mit der Deutschen Gesellschaft für Thorax-, Herz- und Gefäßchirurgie (DGTHG), der Deutschen Gesellschaft für Infektiologie (DGI), der Deutschen Gesellschaft für Internistische Intensivmedizin und Notfallmedizin (DGIIN), der Deutschen Gesellschaft für Hygiene und Mikrobiologie (DGHM) und der Deutschen Gesellschaft für Innere Medizin (DGIM)Bearbeitet im Auftrag des Vorstandes der PEG (G. Peters, P. Kern, G. Gross, K. Tröster, M. Kresken, F. Vogel sowie P.M. Shah, U. Ullmann, B. Wiedemann) und der Kommission für Klinische Kardiologie der DGKHK (R. H. Strasser, D. Andresen, G. Ertl, F. de Haan, C.W. Hamm, H. Mudra, A. Osterspey, K. Werdan sowie G. Arnold, H.M. Hoffmeister, E. Fleck, H. J. Trappe)(1) für die DGK, (2) für die DGI, (3) ESC Task Force, (4) für die DGTHG, (5) für die DGIM, (6) für die PEG, (7) für die DGHM, (8) für die DGIINMethodische Beratung: Ina Kopp (Arbeitsgemeinschaft wissenschaftlich-medizinischer Fachgesellschaften, AWMF). Kommentare und Durchsicht: E. Gams (Düsseldorf), W. Handrick (Frankfurt/Oder), W. Kern (Freiburg), H. Mauch (Berlin), A. Podbielski (Rostock), A. A. Schmaltz (Essen), H. Schroten (Düsseldorf)