Purpose: Low-intensity extracorporeal shock wave (SW) therapy (SWT) has been shown to improve symptoms and exercise tolerance in patients (pts.) with coronary artery disease (CAD) not suitable for conventional revascularization strategies. Induction of neovascularization and improvement of myocardial perfusion are mechanisms hypothetized to be involved. Methods: 43 pts. with advanced CAD (mean age 67±10 years) not suitable for catheter-based or surgical revascularization were suffering from severe stable angina pectoris (CCS class III or IV) refractory to individually optimized medical treatment underwent a series of 9 echocardiography-targeted SW applications (3 SW applications/week during weeks 1, 5, and 9). The antero-septal wall (LAD territory) was targeted in 19, the lateral wall (RCX territory) in 18, and the inferior wall (RCA territory) in 6 pts. A series of 300-500 shock waves was applied per session. Anti-anginal medication (combination of 2 or 3 drugs) was kept unchanged. Regional myocardial blood flow (MBF) was measured quantitatively by NH3-PET at baseline and 4-6 weeks after completion of SWT. Results: Complications of SWT did not occur, markers of myocardial cell damage were all negative during SWT. At follow-up, 30 pts. (64%) reported improvement of angina to a tolerable level. CCS angina class decreased from 3.1±0.6 to 2.5±0.6 (p<0.0001). Maximum ergometric workload increased from 78±53 to 90±46 watts (p=0.04). MBF in the LV region targeted by SWT improved from 119+42 mL/min/100g at baseline to 129±48 mL/min/100g at follow up (p=0.047), while there was no change in the opposite wall (136±52 vs. 137±53 ml/min/100g; p=0.9). Conclusions: SWT improves symptoms in a sizeable number of pts. with chronic refractory angina. Regional improvement of MBF in the region targeted by SWT was also documented by PET imaging. Additional studies are warranted to clarify the role of SWT in the armamentarium for this challenging patient group.

Nach Zulassung des ersten direkten Thrombinantagonisten Dabigatran und des ersten Faktor Xa-Inhibitors Rivaroxaban zur Thromboembolieprophylaxe bei nicht-valvulärem Vorhofflimmern haben die Vitamin-K-Antagonisten (VKA) ihr Alleinstellungsmerkmal als orale Antikoagulantien verloren. Inwieweit sich die neuen Substanzen im primär zugelassenen Indikationsbereich und darüber hinaus durchsetzen, werden die Ergebnisse weiterer Zulassungsstudien, die klinischen Erfahrungen mit den neuen Substanzen und deren Akzeptanz angesichts der hohen Tagestherapiekosten zeigen.

Introduction In hypertrophic cardiomyopathy (HCM) risk assessment with respect to sudden cardiac death (SCD) is currently based on the presence or absence of different risk markers (RM). Recently, myocardial fibrosis as detected by gadolinium-enhanced magnetic resonance imaging (GE-MRI) has been suggested as additional RM. We evaluated the prevalence of myocardial fibrosis and examined correlations with other risk markers in patients considered to be at increased risk.Methods We included 50 patients with HCM with >1(2-4) RM who underwent GE-MRI to check for myocardial fibrosis. Late enhancement was assessed semi-quantitatively using a 17-segment model of the LV (from 0 = absent, 1 = point-shaped, 2 = limited to 1 LV segment, 3 = involving >= 2 segments). Outflow obstruction was present in 25 patients, the other 25 (1 after septal ablation and after myectomy) were non-obstructive.Results Patients (33 men; mean age 44 +/- 13 years; NYHA class: 2.0 +/- 0.9) had a number of RM of 1.7 +/- 0.8. Evidence of myocardial fibrosis >= 2 was found in 39 patients (mean score: 2.3 +/- 0.9). Correlations were found between left atrial diameter (eta = 0.5), septum thickness (eta = 0.6), and severity of fibrosis. Patients with fibrosis >= 2 had larger left atria (50 +/- 7 vs 43 +/- 7 mm, P = 0.007) and a thicker septum both on echocardiography (25 +/- 6 vs 17 +/- 5 mm, P < 0.001) and on GE-MRI (28 +/- 5 vs 20 +/- 4 mm, P=0.01). No correlations were found between fibrosis score and other RM, global LV mass on GE-MRI, or other clinical variables.Conclusions Left ventricular hypertrophy and left atrial size, as two markers for global disease severity, correlate with the severity of fibrosis on GE-MRI.

BACKGROUND:Hypertrophic cardiomyopathy (HCM) is the most common hereditary disease of the heart.METHODS:In this article, we summarize the current state of the diagnosis and treatment of HCM on the basis of a selective review of recent publications with relevance to clinical practice.RESULTS:Several hundred mutations in more than 27 genes, most of which encode sarcomeric structures, are associated with the HCM phenotype. Thus, HCM can be thought of as a sarcomeric disease, with myocardial fiber disarray as its histological hallmark. There are two types of HCM, a more common, obstructive type (HOCM, 70%) and a less common, non-obstructive type (HNCM; in all cases of HCM, testing should be performed to detect outflow obstruction at rest and/or on provocation, and to thereby determine whether HOCM or HNCM is present. The symptoms of HCM include dyspnea, angina pectoris, palpitations, dizziness, and occasionally syncope. Because sudden cardiac death is the most serious complication of HCM, particularly in young and asymptomatic patients, it follows that correct diagnosis, followed by risk stratification of patients with regard to the need for prophylactic implantation of an implantable cardiac defibrillator (ICD), can be of life-saving importance. The pharmacotherapy of symptomatic HNCM consists of the treatment of heart failure with a normal ejection fraction (HFNEF). In HOCM, the patient's symptoms and the obstructive gradient are the guide to treatment with beta-blockers or verapamil. For patients with drug-resistant disease, surgical myectomy and percutaneous septal ablation are now standard treatments.CONCLUSION:A near-normal life expectancy and a highly satisfactory quality of life are now realistic treatment goals for patients with HCM.

Speckle tracking echocardiography (STE) or two-dimensional (2D) strain imaging is a novel ultrasound method to assess myocardial deformation. Peak systolic longitudinal strain (PSLS) of the basal septum (IVS) and the opposite lateral (LVFW) wall were measured in addition to standard echocardiography in 88 consecutive patients (pts) with obstructive hypertrophic cardiomyopathy (HOCM) who underwent a septal ablation procedure (PTSMA) and who were re-evaluated 12 ± 12 after months. At baseline, PSLS was substantially reduced both in basal regions. While PSLS remained unchanged in the basal IVS, i.e. the target region for PTSMA (baseline: −5.3 ± 4.1%; follow-up: −6.0 ± 4.3%; P = 0.06), it improved in the opposite LVFW (from −9.4 ± 4.7 to −12.4 ± 4.8%; P < 0.0001). Wall thickness decreased in both regions (Septum: from 20 ± 4 to 17 ± 4 mm; P < 0.0001; LV free wall: from 13 ± 2 to 12 ± 2 mm; P = 0.001). PSLS correlated significantly with wall thickness, both at baseline and at follow-up. NYHA functional class (from 2.9 ± 0.4 to 1.6 ± 0.6; P < 0.0001) and objective exercise capacity (from 96 ± 42 to 114 ± 42 W; P = 0.001) improved together with the reduction of outflow obstruction (LVOTO: from 62 ± 30 to 11 ± 19 mm Hg at rest, from 121 ± 26 to 43 ± 40 mm Hg with provocation; P < 0.0001). During the 12 months of observation, no patient had a severe adverse event. Regional myocardial deformation can be assessed quantitatively by STE. Reduction of LV afterload by elimination of the outflow gradient following a successful PTSMA with low doses of alcohol results in improvement of systolic lateral longitudinal function.

We sought to determine whether correction of mechanical left ventricular (LV) dyssynchrony as defined by tissue Doppler imaging (TDI) is predictive for transplant-free long-term survival in patients (pts.) undergoing cardiac resynchronization therapy (CRT). In 76 CRT recipients TDI curves from the septal, lateral, anterior, and inferior basal LV were obtained at baseline and after 6 ± 4 months. A time difference between regional electromechanical delays (EMD) of ≥40 ms was considered dyssynchronous. At follow-up, pts. were classified as TDI-responders (TDI-R: dyssynchrony at baseline, corrected by CRT) versus non-responders (TDI-NR: either not dyssynchronous at baseline, or persisting dyssynchrony). Pts. were then followed by standard echocardiography over 21 ± 6 months and were re-classified as LV remodelers (LV-R: LV volume reduction of >10%) versus non-remodelers (LV-NR). The end-point during clinical long-term follow-up of 65 ± 38 months was all-cause mortality or heart transplantation. 44 out of the 76 pts. (58%) were classified as TDI-R, 32 (42%) as TDI-NR. Significant reverse LV remodeling was observed in 41 (54%) pts., while 35 (46%) did not improve LV size and function. TDI-R was associated with LV-R in 35 pts. (85%; P < 0.001). During long-term follow-up, 38 pts. (50%) reached the end point, 11 (30%) in the TDI-R group, and 27 (70%) in the TDI-NR group (P < 0.0003). Mechanical resynchronization as defined by TDI translates into a significant survival benefit in CRT recipients.

INTRODUCTION:Although the incidence of sudden cardiac death (SCD) is as low as 1%/year in un-selected patients (pts) with hypertrophic cardiomyopathy (HCM), higher-risk populations may benefit from prophylactic implantation of an ICD. Risk assessment in HCM is thus important and currently based on the presence or absence of different risk markers (RM). STUDY AIM:The objective of this study is to correlate the incidence of adequate ICD interventions in HCM with the presence of different RM. METHODS:Fifty pts with HCM had ICD implantation, either for secondary (n = 2/4%), or primary prophylaxis of SCD (n = 48/96%). ICD for primary prophylaxis pts had more than 1 (2-4) RM. Outflow obstruction was present in 25 pts, the other 25, including I patient each after septal ablation and myectomy, were non-obstructive. ICD memories were read out and interpreted in accordance with established guidelines. RESULTS:The number of RM per patient was 1.7 +/- 0.8. During follow-up of 2.0 +/- 0.5 [0.2-6.3] years, adequate ICD interventions (11 episodes) were documented in 5, inadequate ICD interventions in 3 pts.Thirteen pts had at least I episode of atrial fibrillation. Pts with versus without events had a longer follow-up (3.2 +/- 4.3 vs. 1.8 +/- 2.6 years, P < 0.05), and were more frequently nonobstructive (all 5; P = 0.05).Within the time period observed no single RM was predictive for arrhythmic events. CONCLUSIONS:Incidence of appropriate ICD discharges was 4-5%/patient-year, supporting the proposed risk stratification. No single RM was predictive for future arrhythmic events.

The epidemiology of valvar heart disease is changing with decreasing numbers of patients with "rheumatic" lesions and increasing numbers of patients with "degenerative" lesions (mainly calcific aortic valve stenosis (AS) and mitral regurgitation), which is accompanied by the constant increase in patient age at the time of surgical intervention [1, 2].

Different therapeutic options are being used for chronic coronary artery disease (CAD). We report about a 51-year-old female with CAD and refractory angina pectoris despite maximally tolerated medical therapy and after both percutaneous coronary intervention (PCI) and coronary artery bypass grafting (CABG). The patient received cardiac shock wave therapy (CSWT) over a period of 6 month. There was no arrhythmia during or after treatment; enzyme levels were normal at all times. PET imaging showed a substantial improvement of myocardial stress perfusion. Since the patient reported that she now was fully capable to deal with her everyday life, further treatment options were postponed. Our case report suggests that ultrasound-guided CSWT is able to improve symptoms and perfusion in ischemic myocardium.

AimsIn patients with systolic heart failure (SHF) a high prevalence of sleep‐disordered breathing (SDB) has been documented. The purpose of this study was to investigate the prevalence and type of SDB in patients with heart failure with normal left ventricular ejection fraction (HFNEF).Methods and resultsTwo hundred and forty‐four consecutive patients (87 women, aged 65.3 ± 1.4 years) with HFNEF underwent capillary blood gas analysis, measurement of NT‐proBNP concentrations, echocardiography, cardiopulmonary exercise testing (CPX), cardiorespiratory polygraphy, and simultaneous right and left heart catheterization. Sleep‐disordered breathing was defined as an apnoea–hypopnoea‐index (AHI) ≥5/h. Sleep‐disordered breathing was documented in 69.3% of all patients, 97 patients (39.8%) presented with OSA and 72 patients (29.5%) with CSA. With an increasing impairment of diastolic function the proportion of SDB, and CSA in particular, increased. Patients with SDB performed worse on CPX and six‐minute walk test. Partial pressure of CO2 was lower in CSA, whereas AHI, left atrial diameter, NT‐proBNP, LVEDP, PAP, and PCWP were higher.ConclusionThere is a high prevalence of SDB in HFNEF. In parallel to SHF, CSA patients in particular are characterized by a more impaired cardiopulmonary function. Whether SDB is of prognostic relevance in HFNEF needs to be determined.

To evaluate the long-term outcome of percutaneous septal ablation (PTSMA) after a previous myectomy.

BACKGROUND AND AIMS OF THE STUDY:In patients carrying mechanical valve prostheses it is assumed that cardioembolic strokes account for 70 - 90 % of clinically diagnosed thromboembolic complications. The etiology of stroke especially in older patients with mechanical heart valves may thus be multiple and not prosthetic valve-related in a substantial percentage. It was the aim of this prospective study to analyze the etiology of stroke in consecutive patients, who had mechanical heart valve replacement before.METHODS:During a 10-year period, 89 consecutive patients were hospitalized at the authors' institution late (> 90 days) after mechanical valve replacement with definite stroke according to the WHO Monica criteria for stroke registers.RESULTS:CCT or MRI revealed cerebral bleedings in 69 (77.5 %) patients, which were small in 42 (60.9 %), intermediate in 24 (34.8 %), and massive in three (4.3 %). Non-embolic, lacunary infarctions were documented in seven (8 %) and embolic strokes in 13 (17%) patients. According to the findings by CCT/ MRI and duplex sonography of the carotid arteries, stroke was considered atherothrombotic in seven of these 13 patients with embolic strokes (53.8 %). Six of these seven patients (86 %) had recurrent neurologic symptoms. In the other four, prosthesis-related stroke was most likely due to a yet undiagnosed active prosthetic valve endocarditis. In only two (2.3%) of the 89 stroke patients, was etiology probably prosthesis-related. Patients with an INR > 5.0 had ischemic stroke in three, and bleedings in four, patients with an INR < 1.8 ischemic strokes in one, and bleedings in three cases.CONCLUSIONS:In conclusion, the vast majority of strokes after mechanical valve implantation in our cohort study were hemorrhagic rather than ischemic in origin, irrespective of the intensity of the oral anticoagulation. For proper treatment decisions, it is therefore essential to discriminate the underlying etiology of stroke.