Background and objective: Echocardiographic tissue Doppler imaging (TDI) has been proposed for differentiating between constrictive pericarditis (CP) and restrictive cardiomyopathy (RCM). The aim of this retrospective study was to analyse TDI in patients with severe diastolic dysfunction associated with proven constrictive pericarditis or restrictive cardiomyopathy.Patients and methods: The cohort included 34 consecutive patients (24 men. 10 women; mean age 58 +/- 12 years), 20 of whom had proven CP (pericardectomy) and 14 had RCM due to amyloidosis (proven by biopsy). Tissue Doppler Imaging was performed online by pulsed-wave TDI at the lateral and septal mitral annulus in the four-chamber view. Filling pressures were measured invasively.Results: 20 of the 34 patients (60%) were in NYHA class III. 19 of the 34 patients were in sinus rhythm (56%) and 15 had atrial fibrillation. Left ventricular systolic function was normal in all patients with CP. Eight patients with RCM had normal, 3 patients near normal and 3 patients slightly impaired left ventricularcontractile function (EF 50-55% and EF 40%, respectively). Respiratory variation of the transmitral inflow was increased in 10 of 12 patients with CP and sinus rhythm. TDI of the early diastolic velocity across the mitral annulus E' was significantly higher in patients with CP than in those with RCM at the septal and at the lateral mitral annulus (13.8 +/- 4.2 cm/s vs. 4.0 +/- 1.2 cm/s; p < 0.01 and 11.4 +/- 3.4 cm/s vs. 4.4 +/- 1.7 cm/s; p < 0.01, respectively). A cut-off value 8 cm/s for the diagnosis of RCM showed a sensitivity of 100% and a specificity of 90% (septal) and 80% (lateral), respectively. The E/E' ratio also was significantly different between both groups (septal: 11.2 +/- 8.8 vs. 25.1 +/- 8.7; p < 0.01).Conclusion: TDI of the early diastolic velocity of the mitral annulus E' makes it possible to differentiate between constrictive pericarditis and restrictive cardiomyopathy and should be part of the echocardiographic work-up in clinical routine.

Drug Prescribing for Patients with Chronic Kidney Disease in General Practice: a Cross-Sectional Study

AIM:The aim of this study was to analyze hemodynamic and clinical outcome in a cohort of 312 patients who were followed up over a period of 12 months after alcohol septal ablation (PTSMA) for symptomatic hypertrophic obstructive cardiomyopathy (HOCM).METHODS AND RESULTS:PTSMA was intended in 337 patients with HOCM (mean age: 54+/-15 years), with 312 procedures completed by injection of 2.8+/-1.2 ml of alcohol. In 25 patients (8%) the intervention was aborted, mostly because of contrast echocardiographic findings. In the 312 patients who received alcohol, permanent pacing was necessary in 22 cases (7%); and in-hospital mortality was 1.3% (four patients). During follow-up, contact to six patients (2%) was lost, and three additional patients (1%) died. The 299 patients who either underwent non-invasive reassessment in our institution or transmitted followup data from their local physician formed the study population. Improvement in symptoms was reported by 272 patients (91%). Mean NYHA functional class was reduced from 2.9+/-0.4 to 1.5+/-0.7 (p<0.0001) along with a gradient reduction (echo-Doppler) from 59+/-32 to 8+/-15 mmHg at rest, and from 120+/-42 to 28+/-32 mmHg with provocation (p<0.0001 each). Exercise capacity improved from 94+/-51 to 119+/-40 watts (p=0.001), and peak oxygen consumption from 18+/-4 to 21+/-6 ml/ kg/min (p=0.01). Younger age and higher outflow gradients at baseline and immediately after intervention were associated with a less favorable hemodynamic outcome. The degree of limitation of exercise capacity at baseline was the only predictor of symptomatic improvement.CONCLUSIONS:Catheter-based septal ablation is an effective non-surgical technique for reducing symptoms and outflow gradients in HOCM. In contrast to a previous study, in this cohort of 312 patients there was no association between post-interventional enzyme release and hemodynamic success. Younger patients with high baseline gradients, however, tended to have a less favorable hemodynamic outcome with higher residual gradients.

Aim: To provide tools for predicting the course of AV conduction disturbances after ethanol-induced septal ablation (PTSMA) for hypertrophic obstructive cardiomyopathy (HOCM). Methods and Results: Based on a scoring system developed 1996-1998 and including parameters from baseline ECG, heart rate profile, severity of outflow obstruction (LVOTO), peri-interventional enzyme kinetics, and peri-interventional conduction problems, the risk of permanent AV block following PTSMA was assessed in 155 consecutive HOCM patients (pts.; mean age: 53 13 years) between 1999 and 2004. During PTSMA with 2.1 +/- 0.5 ml of ethanol, transient complete AV block occurred in 71 pts. (46%). Pts. were grouped into a low, intermediate, and high risk group for permanent conduction damage, and treated accordingly (early discharge from monitoring, prolonged monitoring, early DDD-PM implantation). Permanent pacing was necessary in 11 cases (7%), 0/116 of these (0%) in the low, 4/31 (13%) in the intermediate, and 7/8 (87%) in the high-risk group. While a new right bundle branch block was the most frequent ECG finding after PTSMA, a left bundle branch block at baseline was associated with 4 of the 11 DDD-PM implantations (p < 0.000 1). In-hospital mortality was 0%, short-term (3-months) follow up was complete. During follow-up, AV conduction recovered in 4 pts. (46%) with a DDD-PM. New onset AV blocks did not occur. Significant improvement of symptoms was reported by 141 pts. (91%). Conclusions: Catheter-based septal ablation is an effective non-surgical technique for reducing symptoms and outflow gradients in HOCM. The proposed scoring system appears to reliably discriminate pts. with a high risk for permanent PM dependency from those with stable AV conduction after PTSMA. Pts. with left bundle branch block at baseline should undergo DDD-PM implantation prior to ablation. (c) 2006 Elsevier Ireland Ltd. All rights reserved.

Hypercholesterolemia impairs endothelial function and subsequently decreases coronary vasodilatatory capacity. We examined the quantitative effects of one single LDL apheresis on vasodilatatory capacity. Using N-13 ammonia as a tracer for dynamic quantitative positron emission tomography (PET), mean myocardial perfusion measurements were carried out before and 20 h later after LDL apheresis, both under resting conditions and after pharmacological vasodilatation with dipyridamole. LDL apheresis was carried out using the heparin induced extracorporeal LDL precipitation (H.E.L.P.) procedure. We examined 47 patients (12 women and 35 men), with angiographically-proven coronary artery disease. All of them suffered from hypercholesterolemia. Of the patients, 35 received a chronic weekly H.E.L.P. procedure (group A), while H.E.L.P. procedure treatment was started for the first time in 12 patients, who were subsequently enrolled in a chronic apheresis program (group B). H.E.L.P. apheresis was combined with cholesterol lowering drugs in all patients. Both groups underwent positron emission tomography twice (prior to LDL apheresis and 20 h later). In group A, LDL cholesterol levels decreased from 175 +/- 50 mg/dL to 60 +/- 21 mg/dL immediately after H.E.L.P. (77 +/- 25 mg/dL before the second PET). Corresponding values for fibrinogen levels were 287 +/- 75 mg/dL to 102 +/- 29 mg/dL (155 +/- 52 mg/dL), minimal coronary resistance dropped from 0.56 +/- 0.20 to 0.44 +/- 0.17 mm Hg x 100 g x min/mL (P < 0.0001). Plasma viscosity decreased by 7.8%. In group B, LDL cholesterol decreased from 187 +/- 45 mg/dL to 75 +/- 27 mg/dL (85 +/- 29 mg/dL) and fibrinogen from 348 +/- 65 mg/dL to 126 +/- 38 mg/dL (168 +/- 45 mg/dL). Minimal coronary resistance was reduced from 0.61 +/- 0.23 to 0.53 +/- 0.19 mm Hg x 100 g x min/mL (P < 0.01). Plasma viscosity was observed to decrease by 7.6%. The strong LDL drop in patients under chronic H.E.L.P. treatment has a significant impact on coronary vasodilatatory capacity within 20 h leading to an improved overall cardiac perfusion. Nearly the same effect can be seen in patients after their first H.E.L.P. treatment.

Aims of present study were: a) to demonstrate whether Quantitative Myocardial Contrast Echocardiography (QMCE) could detect coronary flow reserve through the analysis of "refilling curves" generated by micro bubbles transit into myocardium both at rest and after vasodilatation induced by dipyridamole; b) to explore with this method coronary microcirculatory function in two different models: essential hypertension and healthy controls.Methods and Results: Two groups of strictly age-matched males were studied (case-control study): twelve, young, a symptomatic and never treated essential hypertensive patients with a mild degree of left ventricular hypertrophy with a normal left ventricular function and eleven healthy controls.QMCE was performed in all study subjects.We used as echocardiography contrast agent the SonoVue TM, a second generation ultrasound micro bubbles.Real-time Color-coded Power Modulation was performed with a phased-array system interfaced to a S3 transducer (1.3 -3.6 MHz).In healthy subjects there was a little increase in Myocardial Blood Volume (30%) between basal and hyperemic status (p<0.05);so in hypertensives this parameter increases of 22% (p<0.05).Coronary blood velocity (ß) increased after dipyridamole of 270% in healthy (p<0.01),while in hypertensive this parameter increased only of 150% (p<0.02).Coronary Blood Flow Reserve was significantly lower in hypertensive (C: 4.4±0.3;H: 3.3 ±0.3; p<0.01). Conclusion:Results of our study documented that coronary microcirculation in young adult hypertensive patients, showed an early impairment both in the vasodilatation capacity of the resistance arterioles under dipyridamole induced hyperemia, as demonstrated by a reduction of Coronary Reserve.

The authors describe the case of a 76-year-old woman who presented with acute inferior myocardial infarction 8 years after prosthetic aortic valve replacement. Echocardiography and cardiac catheterization revealed a false aneurysm of the ascending aorta with fistulous communication to the right ventricle. The right coronary artery originated from the false aneurysm with no antegrade perfusion.

Einleitung: Höhergradige AV-Überleitungsstörungen (AVB) stellen eine häufige Komplikation der perkutanen Septumablation (PTSMA) dar und erfordern eine frühzeitige und verlässliche Identifikation derjenigen Patienten (Pat.), die einen permanenten DDD-Schrittmacher (DDD-SM) benötigen. Methoden und Ergebnisse: Wir beobachteten den Spontanverlauf des AVB bei den ersten 39 im Jahr 1996 mittels PTSMA behandelten Pat., ausgenommen 6 Pat. mit bereits implantiertem DDD-SM bzw. vorbestehenden Erregungsleitungsstörungen, wobei die stabile Erholung einer gestörten Überleitung maximal 11 Tage benötigte. Sieben der verbleibenden 33 Pat. erhielten einen DDD-SM. Der Vergleich dieser Pat. mit denen ohne AVB resultierte in einem Scoresystem, welches mit >12 Punkten retrospektiv alle DDD-SM-Kandidaten identifizierte. Bei den 137 nachfolgenden Pat. der Jahrgänge 1997 und 1998 wurde dieser Score prospektiv angewendet und klassifizierte ebenfalls alle weiteren DDD-SM-Kandidaten korrekt. Darüber hinaus konnte eine Gruppe niedrigen Risikos mit <8 Score-Punkten ermittelt werden. Ab dem Jahr 1999 an erfolgte die Anwendung des Score-Systems bei 120 konsekutiven Pat. in der klinischen Routine. In der Niedrig-Risikogruppe (<8 Punkte) blieben sämtliche Pat. ereignisfrei. Ein DDD-SM war bei 2/52 (4%) der Gruppe mit mittlerem Risiko, und bei 20/23 (87%) der Hochrisikogruppe erforderlich. Ein AV-Block Grad I oder ein Rechtsschenkelblock im Ausgangs-EKG vor PTSMA erhöhte die Wahrscheinlichkeit einer DDD-SM-Implantation nicht, während Pat. mit Linksschenkelblock (LSB) eine Schrittmacher-Quote von 50% aufwiesen. Schlussfolgerung: Basierend auf der Kombination präinterventioneller Daten mit einer sorgfältigen Überwachung der ersten 48 h nach PTSMA erscheint die zuverlässige Identifikation von DDD-SM-Kandidaten möglich. Patienten mit <8 Punkten des vorgestellten Score haben ein äußerst geringes, solche mit >12 Punkten ein sehr hohes Risiko für einen permanenten AVB. In den verbleibenden Fällen kann unter prolongiertem Monitoring die Erholung der AV-Überleitung abgewartet und so die Zahl langfristig unnötiger DDD-SM-Implantationen verringert werden. Bei Pat. mit LSB erscheint die primäre Versorgung mit einem DDD-SM sinnvoll.

Klinische Symptome und diagnostische Befunde bei Patienten mit Mitralstenose werden in der Regel vom Ausmaß der Stenose bestimmt. Bei einer normalen Mitralklappenöffnungsfläche von über 4 cm2 ist bei Patienten mit höhergradiger Mitralstenose die Mitralklappenöffnungsfläche meist auf < 1,5 cm2 reduziert. Bei älteren Patienten beeinflussen Begleiterkrankungen häufig die Symptomatik (zum Beispiel Vorhofflimmern, arterielle Hypertonie und Lungenerkrankungen). Wichtigster Bestandteil der Diagnostik neben Anamnese, Auskultation, EKG und Röntgenaufnahmen des Thorax ist die Echokardiographie, um nichtinvasiv zuverlässig Mitralklappengradienten, Mitralklappenöffnungsfläche und morphologische Veränderungen der Klappen sowie begleitende Vitien, Ventrikelfunktionen und eventuelle linksatriale Thromben zu erfassen.