: As a tomographic method with a good spatial resolution, MRI allows identification of visceral atrial situs, type of ventricular loop, and relationship of the great vessels. From a comparison with angiographic and 2-D echocardiographic images, MRI provides accurate anatomic diagnosis in complex congenital heart diseases. In some instances, MRI can replace the need for invasive cardiac catheterization or reduce the number of catheteri-zations required in management of patients with complex congenital heart disease. MR imaging of complex con-gential heart diseases is necessary for preoperative assessment in adults and in infants, and influences surgical planning by knowledge of the anatomic topography of the vascular malformation and relation to the bronchial system.In cardiac tumors magnetic resonance imaging provides a non-invasive and three-dimensional assessment of masses involving the cardiac chambers, the pericardium, and the extracardiac structures. MRI has become an established method to yield complementary diagnostic information and to guide cardiac surgeons in the design of an appropriate therapeutic strategy. Furthermore, MRI allows to some extent characterization of tumor tissue. The

Introduction: In patients with severe sepsis, low levels of activated protein C are associated with high morbidity and mortality. In an observational study we investigated whether patients with cardiogenic shock have decreased circulatory levels of activated protein C, and if these are associated with increased mortality.Methods: We measured serum activated protein C and interleukin-6 levels in 43 patients with cardiogenic shock following acute myocardial infarction and in 15 control patients with uncomplicated myocardial infarction at days 0-5 and 7 after the onset of shock/myocardial infarction.Results: Activated protein C levels were significantly lower in patients with cardiogenic shock compared to controls. In cardiogenic shock patients, there was no difference in activated protein C levels at baseline, whereas activated protein C levels significantly declined in 28-day non-survivors at day 2, compared with 28-day survivors. Lower levels of activated protein C were associated with a higher degree of vasopressor need, whereas there was no significant association with multiple organ failure in the first days. Regarding the inflammatory response, a strong inverse correlation was observed between interleukin-6 and activated protein C levels.Conclusion: Patients with cardiogenic shock who did not survive up to 28 days showed a decline in activated protein C levels during the course of the disease, which was inversely correlated with interleukin-6. This study underlines sustained inflammatory mechanisms in the development and persistence of cardiogenic shock, highlighting a potential effect of anti-inflammatory interventions early during cardiogenic shock.

Background: The Tako-Tsubo syndrome is still rarely diagnosed in patients presenting with symptoms of acute myocardial ischaemia. It is accompanied by wall motion abnormalities of the left ventricle but significant narrowings or occlusions of epicardial coronary arteries are absent. We investigated a potential relationship between electrocardiogram (ECG) changes, wall motion abnormalities and gender influence of Tako-Tsubo syndrome in an Austrian cohort of Tako-Tsubo syndrome patients. Methods and results: We were recently able to describe four different anatomical types of Tako-Tsubo syndrome in 153 patients of the Austrian Tako-Tsubo syndrome registry. In the present retrospective analysis we investigated ischaemia-related changes in the first diagnostic ECG for the different types of Tako-Tsubo syndrome: the apical and the combined apical-midventricular type showed most frequently a ST elevation (41.1% and 35.3%), whereas the midventricular type of Tako-Tsubo syndrome was more often accompanied by T wave inversion (60%). ECG changes in relation to the Tako-Tsubo syndrome type were similar in women and men. There was no difference in the prevalence of clinical complications among patients presenting with ST elevation or left bundle branch block (14.5%) compared with patients without ST elevation (10.4%) (p=0.476). Conclusion: Patients with Tako-Tsubo syndrome show characteristic ECG changes in the first diagnostic ECG which are associated to some extent with the anatomical type of Tako-Tsubo syndrome, but these ECG changes were not related to clinical outcome.

BackgroundAtrial fibrillation (AF) is associated with raised levels of P-selectin and an apparent prothrombotic state. However, levels of tissue plasminogen activator (t-PA)-antigen are increased also. We investigated whether high levels of endogenous t-PA-antigen or soluble P-Selectin (sP-Selectin), independently of CHADS(2)- or CHA(2)DS(2)VASc-scores, predict major adverse cardiovascular events (MACE) in patients with AF when treated according to current guidelines.MethodsThis prospective, longitudinal single-center study included 269 patients with AF. Blood samples were analyzed for sP-Selectin and t-PA-antigen concentration by means of commercially available enzyme-linked immunoassays.ResultsPatients were followed for a median duration of 1933 (1517-2277) days, during which 78 MACE and 82 deaths occurred. In multivariable analyses t-PA-antigen above the median of 4.22ngmL(-1) was associated with MACE and all-cause death (HR 2.55 [1.43-4.57]; P=0.002) and (HR 2.54 [1.38-4.68]; P=0.003), respectively. There was no association of sP-Selectin with MACE or all-cause death. Furthermore, t-PA-antigen above the median independently of the CHADS(2)- or CHA(2)DS(2)VASc-scores predicted MACE and all-cause death. In patients with low and intermediate-risk for cardiovascular events according to the CHADS(2)-score the addition of high t-PA-antigen levels (>4.22ngmL(-1)) had a significant impact on the patients' outcome (low-risk group, HR 3.25 [1.13-9.38]; P=0.029 and intermediate-risk group, HR 2.33 [1.27-4.26]; P=0.006, respectively).ConclusionHigh endogenous t-PA-antigen independently predicts MACE and all-cause death in patients with AF. Accordingly, t-PA-antigen as an indicator of a prothrombotic state represents a novel biomarker, which might add to risk stratification in patients with AF.

Background: Tako-Tsubo syndrome (TS) is a still rarely diagnosed clinical syndrome, which is characterized by acute onset of chest pain, transient cardiac dysfunction with (frequently) reversible wall motion abnormalities (WMAs), but with no relevant obstructive coronary artery disease. Methods and results: Among 179 consecutive patients with proven diagnosis of TS that were retrospectively analysed in this multicentre registry, women represented the majority of patients (94%) while only 11 men (6%) developed TS. Mean age was 69.1±11.5 years (range 35–88 years). Cardinal symptoms of TS, which led to admission, were acute chest pain (82%) and dyspnoea (32%), respectively. All patients demonstrated typical WMAs, whereby four different types of WMAs could be defined: (1) a more common apical type of TS (n=89; 50%); (2) a combined apical and midventricular form of TS (n=23; 13%); (3) the midventricular TS (n=6; 3%); and (4) an unusual type of basal WMAs of the left ventricle (n=3). Only in 101 patients (57%), a clear causative trigger for onset of symptoms could be identified. In-hospital cardiovascular complications occurred in 25 patients (14%) and consisted of cardiac arrhythmias in 10 patients (40%), cardiogenic shock in six patients (24%), cardiac decompensation in eight patients (32%) and cardiovascular death in one patient, respectively. Echocardiographic control of left ventricular function after the initial measurement was available in almost 70% of the patients: complete recovery of WMAs was found in 73 patients (58.87%); 49 patients (39.52%) showed persistent WMAs. Recurrences of TS were only seen in four patients. During the follow-up period, 13 patients died: three of cardiovascular causes and 10 of non-cardiac causes. In-hospital mortality was 0.6%, 30-day mortality was 1.3% and 2-year mortality was 6.7%. Conclusions: This study represents to date the largest series of patients suffering from TS in Austria and worldwide. Similar to others, in our series the prevalence of TS was significantly higher in women than in men, while in contrast to other studies, the apical type of TS was detected most frequently. The similar clinical presentation of TS patients to the clinical picture of acute myocardial infarction demonstrates the importance of immediate coronary angiography for adequate differential diagnosis of TS. TS is not necessarily a benign disease due to cardiovascular complications as well as persistent WMAs with delayed recovery.

Patients with acute pulmonary embolism (APE) present with highly variable symptoms and ECG abnormalities. As ST-elevation in lead aVR has recently been described to predict right ventricular dysfunction (RVD), we aimed to correlate this sign to the severity of APE.

OBJECTIVE:Plasma N-terminal pro-B-type natriuretic peptide (Nt-pro-BNP) levels are frequently elevated in critically ill patients and are associated with an increased mortality. In this study, we determined Nt-pro-BNP levels in patients with cardiogenic shock (CS) and evaluated its association with clinical and hemodynamic parameters and 30-day mortality. DESIGN:Retrospective study. SETTING:Two, eight-bed intensive care units at a university and a community hospital. PATIENTS:Retrospective study on stored plasma samples of 58 patients with CS, obtained at admission to the intensive care unit. INTERVENTIONS:None. MEASUREMENTS AND MAIN RESULTS:Massively elevated Nt-pro-BNP concentrations showed no significant association with duration of shock, total Sequential Organ Failure Assessment score, or invasive hemodynamic parameters at the time of blood sampling but a significant association with estimated glomerular filtration rate (p < 0.001), C-reactive protein (p = 0.03), age (p = 0.005), and body weight (p = 0.03). Both in univariate and multivariate survival analyses, Nt-pro-BNP levels above the median (>12,782 pg/mL) were significant predictors of 30-day mortality (p < 0.001) and showed a complementary role with interleukin (IL)-6 in predicting outcome. Patients with IL-6 >195 pg/mL and Nt-pro-BNP above the median value had the highest 30-day mortality (93.7%), whereas patients with lower IL-6 levels together with lower Nt-pro-BNP levels had significantly better survival (mortality rate 26.3%). Among patients who had acute myocardial infarction, those with Nt-pro-BNP concentrations above the median level showed a highly impaired clinical course even if coronary revascularization was successful (30-day mortality 90.9% vs. 29.4%, p = 0.001), whereas survival of patients with unsuccessful revascularization did not differ significantly with respect to the median of Nt-pro-BNP (30-day survival rate 81.8% vs. 75.0%, p = 0.71). CONCLUSION:The massive elevations of Nt-pro-BNP observed in the early phase of CS seem to be independent of ventricular performance. Nt-pro-BNP levels are nevertheless predictive of 30-day survival in patients with CS especially in those with successful revascularization and might be used in combination with IL-6 for estimation of outcome early on.

Chronic heart failure represents an increasing challenge for our health system due to increasing life expectancy and better management of hypertension and coronary artery disease. Gender-specific differences regarding diagnosis and therapy further ag-gravate management. While arterial hypertension and diabetes mellitus are the most important risk factors for the development of chronic heart failure in women, whereas coronary artery disease plays the major role in men. Women tend to develop heart failure at higher age and with a better-preserved left ventricular systolic function than men. Although morbidity associated with heart failure in women is increased, prognosis is better in women compared with men since women with heart failure generally survive longer. The current guidelines of the European and North American scientific societies (ESC, ACC/AHA) for diagnosis and treatment of chronic heart failure are based on large clinical trials in which women were usually under-represented. For this reason, gender-specific studies on chronic heart failure are required.

Chronic Heart Failure in Women. Chronic heart failure represents an increasing challenge for our health system due to increasing life expectancy and better management of hypertension and coronary artery disease. Gender-specific differences regarding diagnosis and therapy further ag-

Aims: Endothelin 1 (ET-1), a major player of the neurohumoral defense reaction triggered after myocardial infarction (MI), has been associated with adverse, long-term post-MI remodeling processes. The objective of this study was to monitor time- and therapy-dependent changes in post-MI remodeling under early selective endothelin receptor A (ET-A) blockade by combining classic tools of physiology with pharmacogenomics.

Objective: Nuclear factor-kappa B (NF-kappa B) orchestrates genes involved in inflammation and extracellular matrix (ECM) remodeling following myocardial infarction (MI). The objective of the present study was to investigate the effect of overexpression and mode of function of I kappa B, the natural inhibitor of NF-kappa B, on ECM remodeling in a rat model of MI.Methods: MI was induced in male Sprague-Dawley rats by ligation of the left anterior descending coronary artery (LAD) and was followed by adenovirus-mediated intramyocardial transfection of I kappa B (n = 26) or LacZ reporter genes (n = 26). Sham-operated animals (n = 14) served as controls.Results: In transthoracic echocardiography 49 days after MI, systolic and diastolic left ventricular dimensions were reduced while fractional shortening was preserved in the treatment group. Additionally, evaluation on the isolated heart showed an attenuated downward shift of pressure-volume relationships in the I kappa B group compared to LacZ. NF-kappa B p65 DNA binding activity was diminished both at 5 and 49 days post-MI in the treatment group. Five days post-MI in the treatment group, protein levels of tumor necrosis factor (TNF)-alpha and interleukin (IL)-1 beta were significantly reduced by 72.6% and 73.2%, respectively, compared to LacZ (p < 0.05). In parallel, matrix metalloproteinase (MMP)-2 and MMP-9 levels were reduced 5 days post-MI, with MMP-9 still being decreased 49 days post-MI (p < 0.01). In contrast, tissue inhibitors of metalloproteinases (TIMP)-1, -2, and -3 were increased compared to LacZ (p < 0.01 and p < 0.05, respectively) 5 days post-MI. After 49 days, TIMP-2, -3, and -4 expressions were significantly elevated (p < 0.05).Conclusion: Reducing NF-kappa B activity via I kappa B overexpression after MI positively influences ECM remodeling by reducing MMP-2 and -9 levels while increasing TIMP-1, -2, -3, and -4 levels. Therefore, I kappa B overexpression prevents ventricular dilation and consequently preserves cardiac function. (c) 2005 European Society of Cardiology. Published by Elsevier B.V All rights reserved.

Recent experimental and clinical data suggests that treatment with SiNiTang, an herbal cocktail used in Traditional Chinese Medicine, might improve survival and cardiac function after myocardial infarction. First data with SiNiTang have shown an anti-platelet and anti-arrhythmic effects and a reduction in MMP activity. Therefore, it is the purpose of our experiments to evaluate whether SiNiTang prevents the adverse effects of ventricular remodeling post MI. In 16 adult male Sprague-Dawley rats MI was induced by coronary ligation, 16 rats underwent sham-operation. The first day rats were randomized to receive either SiNiTang (TeaMI n=8; TeaSham n=8) or placebo (MI n=8; Sham n=8) over a period of 6 weeks. Prior to sacrifice in vivo measurements of left ventricular function were made by echocardiography (M-mode, ATL 15MHz). At the time of sacrifice there was no difference in body weight, tibia length or infarct size between the groups (mean±SD). The LV/body weight ratio was significantly reduced in TeaMI compared to MI (2.5±0.42 vs. 3.12±0.2; p<0.05). Left ventricular end-diastolic (ED) and –systolic (ES) dilation was less pronounced in TeaMI compared to MI (ED: 9.4±0.4 vs. 10.3±0.1mm; p<0.05; ES: 6.4±0.5 vs. 7.8±0.2mm; p<0.05). Consequently, fractional shortening (FS) was significantly higher in TeaMI compared to MI (FS: 0.33±0.05 vs. 0.24±0.05%; p<0.05). It can be concluded that treatment with SiNiTang post MI (1) reduced LV hypertrophy (2) prevented diastolic and systolic left ventricular dilation and dysfunction in a rat model of MI. Therefore SiNiTang could be valuable in the treatment of congestive and ischemic heart failure in future.