Between June 1986 and June 1989, percutaneous balloon valvuloplasty (PBV), using the transseptal, single-balloon technique, was performed in 50 consecutive patients (38 women and 12 men; mean age 54 +/- 14 years) with mitral stenosis. The procedure was technically successful in 48 patients (in one patient the atrial septum could not be crossed, in the other cardiac tamponade occurred). The mean diastolic gradient was decreased from 12.5 +/- 6.6 to 6.1 +/- 3.1 mmHg, mean pulmonary artery pressure (PAP) reduced from 29 +/- 12 to 22 +/- 6 mmHg, and valve opening area increased from 1.0 +/- 0.25 to 1.6 +/- 0.4 cm2. Redilatation had to be undertaken in four patients because of restenosis. Commissurotomy had to be performed in one patient, valve replacement in nine (restenosis in 4, poor primary results in 3, increase in regurgitation in 2). One patient died of a noncardiac cause. Follow-up observations for an average of 14 (3-36) months indicated in 30 of the remaining 33 patients without additional intervention a stable clinical improvement of at least one class (NYHA classification), as well as stable haemodynamic findings (gradient: 6.0 +/- 2.7 mmHg, valve opening area 1.5 +/- 0.3 cm, PAP 23 +/- 7 mmHg. Thus PBV achieved, at least in the medium term, clinical improvement in about two thirds of patients, and an operation was avoided.

OBJECTIVE:The formerly observed volume-outcome relation for percutaneous coronary interventions (PCIs) has recently been questioned. DESIGN:We analysed data of the PCI registry of the Arbeitsgemeinschaft Leitende Kardiologische Krankenhausärzte. PATIENTS:In 2003 a total of 27 965 patients at 67 hospitals were included. RESULTS:The median PCI volume per hospital was 327. In-hospital mortality was 1.85% in hospitals belonging to the lowest PCI volume quartile and 1.21% in the highest quartile (p for trend <0.001). Two groups of patients were then compared according to their treatment at hospitals with either <325 PCIs (n = 5754) or >325 PCIs (n = 22 211) per year. Logistic regression analysis showed that a PCI performed at hospitals with a volume of >325 PCI/year was independently associated with a lower hospital mortality (OR = 0.67, 95% CI: 0.52 to 0.87; p = 0.002). If PCI was performed in patients with acute myocardial infarction there was a significant decline in mortality with increasing volume (p for trend = 0.004); however, there was no association in patients without a myocardial infarction. CONCLUSIONS:This analysis of contemporary PCI in clinical practice shows a small but significant volume-outcome relation for in-hospital mortality. However, this relation was only apparent in high-risk subgroups, such as patients presenting with acute myocardial infarction.

Objective: To determine the predictors of time between presentation and primary angioplasty and the influence of this delay time on in-hospital mortality in clinical practice.Design: Analysis of data from the registry of percutaneous coronary interventions in acute myocardial infarction of the Arbeitsgemeinschaft Leitender Kardiologischer Krankenhausarzte (ALKK).Patients: Data of 4815 patients registered at 80 hospitals between 1994 and 2000 were analysed.Results: Mean age of the patients was 61.4 (12.5) years. Cardiogenic shock was present in 14.1%. Mean time from admission to primary angioplasty ("door to angiography'' time) was 83 (122) minutes. Logistic regression analysis showed the presence of a bundle branch block ( odds ratio ( OR) 1.95, 95% confidence interval (CI) 1.15 to 3.29), prior coronary artery bypass grafting (OR 1.67, 95% CI 1.08 to 2.59), prehospital delay. 3 hours (OR 1.61, 95% CI 1.37 to 1.89), and female sex (OR 1.21, 95% CI 1.01 to 1.45) to be independently associated with longer door to angiography times, whereas a higher hospital volume of performing primary angioplasty (OR 0.53, 95% CI 0.46 to 0.62) and the year of the investigation (OR 0.96, 95% CI 0.92 to 1.00) were independently associated with shorter door to angiography times. Independent predictors of in-hospital mortality were cardiogenic shock (41.6% v 4.0% without cardiogenic shock, p < 0.0001), technical success (29.2% with TIMI (thrombolysis in myocardial infarction) flow, 3 v 6.5% with TIMI flow 3, p < 0.0001), age (16.5% >= 70 years v 6.6%, 70, p < 0.0001), three vessel disease (16.5% v 6.8% with, 3 vessel disease, p < 0.0001), anterior location of infarction (12% v 7.4% without anterior infarction, p < 0.0001), year of inclusion (adjusted OR 0.92 per year, p = 0.011), and volume of primary angioplasty at the hospital (11% for, 20 angioplasty procedures/ year v 8.3% for >= 20/year, p = 0.027) but not the door to angiography time adjusted OR 1.14 per tertile, p = 0.397).Conclusions: In current clinical practice in Germany median door to angiography time is quite short (83(122) minutes). Some patients and hospital factors are independently associated with a longer door to angiography time. Within the observed short in-hospital delays door to angiography time did not influence in-hospital mortality. However, efforts to keep them as short as possible should be continued.

Aims Acute myocardial infarction complicated by cardiogenic shock is associated with an exceedingly high mortality, even if patients are treated with early reperfusion therapy. The aim of this study was to evaluate predictors of in-hospital mortality of a large cohort of consecutive patients with cardiogenic shock treated with primary percutaneous coronary intervention (PCI). Methods and results Between July 1994 and March 2001 all interventions performed in 80 centres in Germany were prospectively entered into the primary PCI registry of the ALKK. A total of 9422 procedures were registered, of these 1333 (14.2%) were performed in patients with cardiogenic shock. Total in-hospital mortality was 46.1% and was dependent on TIMI flow grade after PCI, with mortality rates of 78.2%, 66.1% and 37.4% in patients with TIMI 0/1, TIMI 2 and TIMI 3 flow, respectively. In a multivariate analysis left main disease, TIMI <3 flow after PCI, older age, three-vessel disease and longer time-intervals between symptom onset and PCI were significant independent predictors of mortality. The relative number of PCIs performed in patients with cardiogenic shock did not change significantly from 1995-2000. There was a significant decrease in mortality over the years (P for trend 0.02). Conclusions In-hospital mortality in patients with acute myocardial infarction complicated by cardiogenic shock remains high, even with early interventional therapy. However, our data demonstrate that the PCI in these high-risk patients is feasible in a wide spectrum of community hospitals with acceptable success rates. Our results seen in connection with the results of the randomized SHOCK study advocate an early invasive approach in younger patients with cardiogenic shock, while the best strategy in elderly patients is still a matter of debate.

In this large German registry of >250,000 coronary interventions, the overall in-hospital complication rate, but not mortality rate, decreased from 1993 to 2000 despite the worsening risk profile of patients and more complex interventions. The increased use of coronary stents from <5% to >70% contributed to this improvement, especially in higher-risk patients; however, time was independently associated with reduced complication rates.

Percutaneous transluminal coronary angioplasty (PTCA) is offered only reluctantly to elderly patients, as the general conviction is that this invasive form of treatment carries a substantial risk whilst offering only modest benefits [1, 5, 6]. However, in the last few years interventional techniques have improved and stents have become more widely used, and it is especially in elderly patients that success rates have risen and complication rates fallen [3, 4]. The effectiveness of PTCA is seen in angiographic and functional results, improvements in clinical symptoms and quality of life and finally also in cost [2].

Coronary stent embolization is an uncommon but potentially hazardous complication of percutaneous transluminal coronary angioplasty (PTCA). Previous small-sized clinical studies reported incidence rates ranging from 0.9% to 8.4%.(1-5) In this study we report the incidence, management, and hospital follow-up of a large, consecutive series of patients with coronary stent embolization.

Background: Elective coronary stenting has hem shown to reduce the rate of recurrent stenoses after angioplasty but no firm data are available on its possible association with in‐hospital ischemic complications. Methods: We analyzed the data of the registry of the German community hospitals covering approximately one quarter of all interventions in Germany. We included all angioplasty procedures performed in patients with stable coronary artery disease in 1996. Interventions with elective coronary stenting were compared to those with conventional balloon angioplasty. Interventions with bailout stenting were excluded. Results: Of 19,170 angioplasty procedures, 32.2% included elective coronary stenting. The immediate angiographic success rate (residual stenosis < 50%) was 90.6% of the procedures with stents versus 86.3% of those without stents (P < 0.001). The overall incidence of complications (death, myocardial infarction, bypass surgery, vessel closure, reintervention) was 3.9% and 3.8% (NS). Major events (death, myocardial infarction, bypass surgery) were more common in the stent‐treated group (1.8% vs 1.4%, P = 0.027). In multivariate analysis, the following factors were significantly associated with complications: residual stenosis ≥ 50%, female gender, angioplasty of proximal left anterior descending coronary artery, morphological fype of lesion B2 or C, and multivessel disease. Angioplasty of restenoses after previous angioplasty was associated with significantly less risk than of de novo lesions. Stents were neutral with respect to the overall incidence of complications. Conclusions: Complications after elective coronary angioplasty remain largely unpredictable in individual patients despite the identification of several clinical and procedural risk factors. Elective coronary stenting is not associated with the immediate therapeutic risk of angioplasty in stable coronary artery disease.

BACKGROUND:Mortality from cardiac surgery is an essential indicator of quality and forms the basis of treatment strategy decisions in eligible patients. No contemporary complete data on unselected adult cardiac surgery patients are available in Germany.METHODS AND RESULTS:A registry was started in June 1997 of all patients referred to surgery from 85 cardiology centres in Germany. The registry was intended to include 10 000 patients and this number was reached in March 1998. Follow-up of the patients was by simple questionnaire, reporting the date of surgery, major complications, and symptomatic improvement. If the questionnaire was not returned, a reminder letter was sent and, if necessary, further telephone investigations were performed. This resulted in 99.9% complete data. Of 10 525 patients operated on, 3.91% had died by 30 days after surgery. The overall operative mortality was 4.57%, which included 69 patients who died after more than 30 days from complications related to surgery. By multivariate analysis, the following predictors of mortality were identified: previous surgery, emergency or complex operation; age >75 years, female gender, cardiac failure, angina CCS class IV, and three-vessel coronary disease. An integral part of the registry was a pre-operative prediction of surgical risk in five categories. This risk estimate revealed a surprisingly correct prediction of the mortality observed.CONCLUSIONS:In a representative unselected group of cardiac surgery patients, operative mortality was 4.57%. Several procedural and clinical parameters were significantly correlated with mortality, but the risk increment by each of these factors was small. Unstructured clinical judgement reliably predicted the operative risk.