Introduction:Cryoballoon (CB) guided pulmonary vein isolation (PVI) is an established procedure in the treatment of atrial fibrillation (AF). Transseptal access is an indispensable step during PVI and may be associated with severe complications. For specific interventions, specific puncture sites of the fossa ovalis are advantageous. Here, we analyzed the potential impact of a transesophageal echocardiography (TOE) guided transseptal puncture on nadir temperatures in CB PVI. Methods and Results:We retrospectively analyzed 209 patients undergoing CB PVI in our hospital. The use of TOE had been at the operator's discretion. No TOE-related complications such as perforation of the pharynx or esophagus or loss of teeth were noted. Concerning the applied freezes, we found significantly lower nadir temperatures in all PVs in the TOE group than in the non-TOE group. Procedure time and fluoroscopy time and complications were similar in both groups. Conclusion:TOE-guided TSP in CB PVI is safe and feasible. Our study found significantly lower nadir temperatures of CB freezes after TOE-guided TSP which potentially underscores the value of a more infero-anterior puncture site.

Background: In patients with reduced left ventricular ejection fraction (LVEF) who are at risk of sudden cardiac death, a wearable cardioverter-defibrillator (WCD) is recommended as a bridge to the recovery of LVEF or as a bridge to the implantation of a device. In addition to its function to detect and treat malignant arrhythmia, WCD can be used via an online platform as a telemonitoring system to supervise patients’ physical activity, compliance, and heart rate. Methods: We retrospectively analyzed 173 patients with regard to compliance and heart rate after discharge. Results: Mean WCD wearing time was 59.75 ± 35.6 days; the daily wearing time was 21.19 ± 4.65 h. We found significant differences concerning the patients’ compliance. Men showed less compliance than women, and younger patients showed less compliance than patients who were older. Furthermore, we analyzed the heart rate from discharge until the end of WCD prescription and found a significant decrease from discharge to 4, 8, or 12 weeks. Conclusion: WCD can be used as a telemonitoring system to help the involved heart failure unit or physicians attend to and adjust the medical therapy. Furthermore, specific patient groups should be educated more intensively with respect to compliance.

An 87-year-old woman presenting with myocardial infarction and ST-segment elevation in the electrocardiogram suffered from pericardial effusion due to left ventricular rupture. After ruling out obstructive coronary artery disease and aortic dissection, she underwent cardiac surgery showing typical infarct-macerated myocardial tissue in situ. This case shows that even etiologically unclear and small-sized myocardial infarctions can cause life-threatening mechanical complications.

Background: Percutaneous coronary intervention (PCI) of total chronic coronary occlusions (CTOs) still remains a major challenge in interventional cardiology. There is little knowledge in the literature about differences in CTO-PCI between diabetic and nondiabetic patients in the era of third-generation drug-eluting stents (DESs). In this study, we analyzed the impact of diabetes mellitus (DM) on procedural characteristics, complications, and acute outcomes in a cohort of 440 patients. Methods: Between 2012 and 2016, we recruited 440 consecutive patients, 116 of them with DM. All the patients underwent PCI for at least 1 CTO. Antegrade and retrograde CTO recanalization techniques were applied. Only third-generation DESs were used. We used t-tests and the Pearson chi-quadrat test to test the significant differences in the variables between the 2 groups. Results: The patients with DM were older than the nondiabetics (64.5 y vs. 61.1 y; P=0.003), and they suffered more frequently from a chronic kidney disease (7.1% vs. 2.4%; P=0.001). The nondiabetics less frequently had arterial hypertension (75.3% vs. 89.7%; P=0.001); however, they more often had a family liability for CAD (32.1% vs. 22.4%; P=0.050) and had a higher left ventricular ejection fraction (59.2% vs. 56.7%; P=0.011). The success rate was 85.2% in the patients without DM and 81.2% in the patients with DM (P=0.403). The existence of DM had no impact on the procedural success and complication rates. Conclusion: Our study on 440 patients shows that diabetics and nondiabetics have similar success and complication rates after the recanalization of CTOs using third-generation DESs. It is a feasible and safe procedure and can be recommended as an alternative treatment.

The number of patients with implanted left ventricular assist devices is constantly increasing. Numerous patients suffer from drug-resistant ventricular tachycardias. Only a few studies and reports about ablation therapy in this cohort of patients are available. Electromagnetic interferences between the left ventricular assist device and the three-dimensional mapping system which is used for ablation has been described as disabling the investigator to create a proper map of the left ventricle. We observed that this interference is interrupted by hot mapping meaning that one pretends an ablation with only 5 W, permitting the creation of a clear map in areas of interference.

PURPOSE:Pulmonary vein isolation (PVI) is a cornerstone therapy in patients with symptomatic atrial fibrillation. One current method is performing a PVI using a cryoballoon (CB). The CB is inserted into the left atrium via a steerable sheath. However, at times, passing of the interatrial septum by the sheath is hindered, e.g., due to septal fibrosis. Here we report our experience with an evasion maneuver to facilitate this approach using a 6F multipolar and steerable coronary Sinus catheter (CS) for predilatation of the interatrial septum. METHODS AND RESULTS:We report 10 patients undergoing a CB-PVI, where the investigator experienced difficulties in passing the interatrial septum with the CB sheath. In these cases, after three conventional abortive attempts, we predilated the transseptal puncture site using both the CS catheter and the dilatator of the CB sheath. Thereafter access of the CB sheath to the left atrium could be achieved instantly and without further resistance. CONCLUSION:We report a safe and feasible maneuver to facilitate transseptal access with the CB steerable sheath in cases complicated by excessive interatrial resistance.

Background: The aim of the study was to compare trends in frequency of atrial fibrillation (AF) with the prescription rates of oral anticoagulants (OAC) and the incidence of embolic stroke (ES) from 2005 through 2014. Methods: Annual numbers of hospitalized patients with AF and ES were extracted from the Federal Bureau of Statistics. Defined daily doses (DDD) of prescribed OAC among outpatients were extracted from the insurance drug information system. Results: The number of cases hospitalized with the diagnosis AF increased continuously by 78.3% (1.25 Million in 2005 to 2.19 Million in 2014, p < 0.001), likewise frequency of ES increased by 89.0% (from 46,068 to 87,050, p < 0.001) and the number of prescribed DDD of OAC almost doubled by 105.4% (from 271,328 to 557,281, p < 0.001). There is an almost linear correlation between occurrence of AF and ES (R-2 = 0.9683). In contrast association between prescription rate of OAC and incidence of ES is not linear as there was a disproportional increase in OAC prescriptions beginning in the year 2010 that is not accompanied by a reduction of cases hospitalized with ES. Conclusions: Our analysis of drug treatment rates for OAC in outpatients and hospitalization rates for ES revealed a disproportional increase in prescription of OAC beginning in the year 2010 that does not affect the number of cases hospitalized with ES. (c) 2018 Elsevier Inc. All rights reserved.

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

Percutaneous coronary intervention (PCI) of total chronic coronary occlusion (CTO) still remains a major challenge. The prevalence of a CTO has been reported to be up to 30% among patients with a clinical indication for coronary angiography. Progress has been made with further advanced interventional techniques and continuously sophisticated interventional tools. Nevertheless the number of interventions carried out to recanalize a CTO is less than 10% of all procedures. Benefits of a successful CTO recanalization include relief of angina pectoris and ischemia-related dyspnea, substantial improvement in left ventricular function and, avoidance of surgery treatment. A vast variety of new CTO PCI techniques and materials has been introduced into clinical practise and pushed success rates of reopening a CTO up to around 90% in experienced hands. Particulary the introduction of the retrograde technique was a milestone. New developed microcatheters and special polymer coated wires allow to recanalize via small collaterals and vessels. Other tools such as intravascular ultrasound (IVUS) and multislice computertomography (MSCT) help to identify the anatomy and the characteristic of the lesions. Any invasive cardiac center should adopt CTO PCI procedures as standard therapy.OBJECTIVE:This review wants to assess and describe the latest development in CTO recanalization strategies.

Ein 42-jähriger Mann klagt über zunehmende Atemnot (Stadium II nach NYHA) und kann maximal 100 Meter gehen. Er gibt an, vor drei Tagen gestürzt zu sein. Echokardiografisch zeigt sich eine normale linksventrikuläre Ruhefunktion. Die kardialen Doppler-Profile und der pulmonalarterielle Druck sind unauffällig. Der NT-pro-BNP-Wert (N-terminales-pro-brain-natriuretisches Peptid) liegt mit 10 pg/ml im Normbereich. Röntgenaufnahmen und eine Computertomografie des Abdomens zeigen drei pathologische Befunde (Abb.1).

A 29-year-old man suffered from an industrial accident as a piece of metal of a die-cutter burst and shards of metal penetrated his right upper arm. One shard was localized via x-ray and computer tomography within the apex of the right ventricle. Here we report on a successful retrieval of this shard of metal by aspirating it via a 6F multipurpose (MP) catheter.

BACKGROUND:Failure of delivering a stent or a balloon across the target lesion during percutaneous coronary intervention (PCI) of chronic total occlusion (CTO), especially in arteries with calcified tortuous anatomy, is often due to insufficient backup support from the guiding catheter. The purpose of this study was to assess the feasibility of the GuideLiner (GL) catheter use. METHODS:We examined 18 patients and used the GL catheter to overcome poor support and excessive friction in standardized antegrade and retrograde CTO procedures. The GL is a coaxial, monorail guiding catheter extension delivered through a standard guiding catheter and is available in different sizes. RESULTS:Almost all lesions were classified as severely calcified (94.4 ± 0.24%). The Japanese CTO score reflecting lesion complexity was 3.56 ± 0.78. All procedures were performed femorally; the retrograde approach was used in 27.8 ± 0.46% of cases. The overall success rate was 88.9 ± 0.32%; there were no relevant complications. CONCLUSIONS:The GL catheter is an adjunctive interventional device which enhances and amplifies CTO-PCI. Its use is indicated in cases in which back-up force needs to be strengthened to pass a CTO despite advanced calcification. It can be recommended as an important additional tool in advanced interventional cardiology such as antegrade and retrograde CTO-PCI if other techniques like anchor balloon or anchor wire are not possible.

Ein 42-jähriger Mann klagt über zunehmende Atemnot (Stadium II nach NYHA) und kann maximal 100 Meter gehen. Er gibt an, vor drei Tagen gestürzt zu sein. Echokardiografisch zeigt sich eine normale linksventrikuläre Ruhefunktion. Die kardialen Doppler-Profile und der pulmonalarterielle Druck sind unauffällig. Der NT-pro-BNP-Wert (N-terminales-pro-brain-natriuretisches Peptid) liegt mit 10 pg / ml im Normbereich. Röntgenaufnahmen und eine Computertomografie des Abdomens zeigen drei pathologische Befunde (▸ Abb. 1 ).

Ein 59-jähriger und ein 74-jähriger Mann werden vom Notarzt in die Notaufnahme eingewiesen. Beide klagen über Übelkeit, Schwindel und eine ausgeprägte Schwäche – insbesondere der Beine. Die Untersuchung zeigt einen deutlich herabgesetzten Muskeltonus. Bei dem 74-Jährigen liegt zudem eine schwere Gastroenteritis mit Exsikkose vor. Bei dem jüngeren Patienten ist eine chronische Niereninsuffizienz (Stadium III–IV), ein Diabetes mellitus, eine Herzinsuffizienz, eine COPD und ein obstruktives Schlafapnoe-Syndrom bekannt. Vor Beginn einer Therapie werden oben abgebildete Elektrokardiogramme abgeleitet. Diese zeigen vier pathologische Befunde.

Ein 67-jähriger Patient leidet wiederholt an einer thrombotisch-thrombozytopenischen Purpura (TTP). Er erhält eine Plasmapherese und wird zusätzlich mit Rituximab behandelt. Als akzidenziell der Shaldon-Katheter entfernt wird, kommt es zu einer Synkope. Mittels Thorax-CT kann eine Lungen- oder Luftembolie ausgeschlossen werden. Bei der Neuanlage des Shaldon-Katheters zeigt sich sonografisch in der rechten V. jugularis interna ein pathologischer Befund (Abb. 1 ).

Seit Operation eines Sinus pilonidalis klagt ein 18-Jähriger über zunehmende Nacken-, Kopf- und Gliederschmerzen, Abgeschlagenheit und Fieber. 10 Tage nach dem Eingriff verschlechtert sich sein Allgemeinzustand akut. Bei der umgehenden stationären Aufnahme sind unklare Hautveränderungen zu sehen (Abb. 1 A, B ). Laborbefunde: Leukozyten im Liquor 591 / µl (< 5, 78 % neutrophile Granulozyten), CRP 290,2 mg / l (< 5), Procalcitonin 14,1 mg / l (< 0,5). In Blut- und Liquorkulturen werden Staphylokokken (S. aureus) nachgewiesen. Im CT-Abdomen sind embolische Niereninfarkte zu sehen. Ein MRT des Beckens ist unauffällig, ebenso eine transösophageale Echokardiografie (TEE) am Aufnahmetag. Zwei Tage später zeigt eine erneute TEE ein anderes Bild (Abb. 1C ).