Abstract Background The relevance of an angiosome model for infrapopliteal endovascular interventions (EVT) in diabetic patients is still in debate because the lesions are more likely to be diffuse with a different pattern of collateral arteries ranging from reduced to normal caliber. The aim of this study was to analyse the outcome of two different endovascular infrapopliteal interventional strategies (Group I: angiosome-based direct revascularization -DR- vs. Group II: complete (direct + indirect) revascularization strategy -CR-) in diabetic patients with critical limb ischemia. Furthermore we analyzed the outcome if DR or CR failed and only indirect revascularization (IR) or no revascularization was possible. Both groups were differentiated in patients with collaterals, defined as an intact pedal arch (immediate or after pedal PTA). Patients and methods We performed a prospective cohort study in routine angiologic patients. The database includes 91 consecutive EVT with two intrapopliteal interventional strategies performed in 68 diabetic patients (pts.; 24 female, 44 male, mean age 73±10 years) between 2013–2015 and 2016–2019. The study included only patients with CLI (Rutherford class 4 or greater) with a critical subtotal stenosis or occlusion of at least one artery below the knee. EVT were performed mainly by an antegrade approach and with the use of 5F sheaths. In case of failure to recanalise, a retrograde approach was attempted. Positive clinical outcome was defined as wound healing without amputation or wound healing after minor amputation, combined with a symptom improvement to Rutherford category 0 or 1 after 6 months. The clinical outcome proportions were compared using the Fisher's exact test. Results An angiosome-based direct reperfusion (DR) of the artery supplying the ischemic tissue and a complete (both direct and indirect, CR) revascularization strategy demonstrated a similar positive clinical outcome (92,6% vs. 90,5%; p=0.594). Indirect revascularization showed a significantly lower positive outcome in comparison to a successful DR as well as CR strategy (33,3% vs 92,6%, p=0.0003; 40% vs 90,5%, p=0.001). IR outcome improved by the presence of collaterals (66,7% vs. 30,8%). Conclusions In case of successful intervention, both strategies (DR and CR) yielded a similarly high proportion of positive clinical outcome. The role of collaterals and the pedal arch are important for the clinical outcome in patients in whom only indirect revascularization was possible, because of unsuccessful CR or DR. The time of the procedure/radiation, the risk to reopen more than one vessel, the necessary amount of contrast medium and final the costs of the procedure should also be considered for an individually based decision process to perform an angiosome-based direct or a complete revascularization. Funding Acknowledgement Type of funding source: None

Background: Infrapopliteal endovascular interventions (ET) which follow the angiosome concept for wound healing will have an improved clinical outcome. The aim of this study was to assess the primary success rate of ET in respect of the angiosome concept in diabetic patients with critical limb ischemia (CLI).

A cyclosporine (CsA)-based immunosuppression is associated with an increased incidence of cholelithiasis after heart transplantation. It is not known if tacrolimus (Tac) has comparable biliary side effects in humans. We evaluated the incidence of gallbladder sludge and cholelithiasis under Tac-based immunosuppression by ultrasound examinations in 31 cardiac transplants (25 male, 6 female, mean age: 59 ± 11 years). Data were compared to 57 patients (47 male, 10 female, mean age: 58 ± 11 years) who received CsA-based immunosuppression. 6 patients receiving Tac and 6 patients receiving CsA had already gallstones prior to transplantation so that finally 25 patients of the Tac group and 51 patients of the CsA group could be evaluated. In the Tac group the incidence of biliary sludge was 4% (1 of 25), of gallstones 28% (7 of 25). In comparison, patients receiving CsA developed biliary sludge in also 4% (2 of 51) and gallstones in 25% (13 of 51). Nine of 42 males in the CsA group (21%) and eight of 20 males in the Tac group (40%) developed either gallstones or sludge (n.s). Six of nine females in the CsA group (67%), but none of five females in the Tac group (0%) developed either gallstones or sludge (p = 0.01). In summary, the incidence of biliary disease in patients with Tac is comparable with CsA-based immunosuppression. We recommend regular sonographical examinations to detect biliary diseases as early as possible. In cases of clinically, laboratory and sonographical signs of cholecystitis cholecystectomy is indicated. It seems that towards lithogenicity female patients benefit more from a Tac-based treatment because the occurrence of gallstones is rare.

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

Echocardiographic diagnosis has t r a d i t i o n a l l y been based on the analysis of re f lec t ions from the smooth, large interfaces wi th in the heart, such as the endoand epicardial surfaces and the valves. Over the past years, however, there hasbeen growing in terest in the analysis of composition and physical nature of cardiac structures. Ultrasonic t issue characterization is based on the assumption of a reproducible re lat ionship between tissue morphology and the acoustic properties of the myocardium. In i t s c l i n i ca l approach, th is method re l ies on quant i tat ive analysis of myocardial backscatter, that is of the scattered low in tens i ty echoes or ig inat ing from small re f lec tors within the heart muscle i t s e l f . I ts primary c l i n i ca l goal is to d i f fe ren t ia te betwen normal and diseased myocardium. As a second step, i t aims at the d i rect noninvasive iden t i f i ca t ion of speci f ic types of t issue pathology.

Cardiac allograft vasculopathy (CAV) remains a major long-term complication after heart transplantation (HTx). We recently demonstrated semi-quantitatively that myocardial contrast echocardiography (MCE) is a promising noninvasive technique to evaluate microvascular perfusion and to identify significant coronary stenosis caused by CAV. The aim of this study was to evaluate the prognostic value of a quantitative assessment of stress MCE to detect CAV.

Fractional flow reserve (FFR) is a new but well established parameter for the hemodynamic evaluation of coronary stenoses. A FFR below 0.75 was validated as functionally significant in coronary one or two vessel disease. This study was designed to prospectively define the best FFR cut off value (BCV) in patients with multivessel disease using two noninvasive tests, myocardial perfusion scintigraphy (SPECT) and contrast-enhanced dobutamine stress echocardiography (DSE) as reference methods.

OBJECTIVE:To determine the prognostic value of fractional flow reserve (FFR) measurements after coronary stent implantation including multiple clinical and angiographic parameters collected in one centre.METHODS:119 consecutive patients were enrolled who had a stent implanted with the use of a pressure wire as a guidewire. Patients were followed up for at least six months. Any death, myocardial infarction, and target vessel revascularisation were considered major adverse cardiac events (MACE). Multivariate logistic regression was used to determine adjusted odds ratios (OR) and 95% confidence intervals (CI) for FFR and covariates.RESULTS:Complete follow up data were available for all 119 patients. Pre-interventional FFR increased from 0.65 (0.15) to 0.94 (0.06) (p < 0.0001) after stent implantation. Eighteen MACE (15%) occurred during follow up including 15 (12.6%) target vessel revascularisations. Final FFR was significantly higher in patients without than in patients with an event (0.95 (0.05) v 0.88 (0.08), p = 0.001). In the multivariate logistic regression analysis, only final FFR < 0.95 (OR 6.22, 95% CI 1.79 to 21.62, p = 0.004) and reduced left ventricular function (OR 0.95, 95% CI 092 to 0.99, p = 0.021) remained as significant independent predictors for MACE.CONCLUSION:These results including multiple parameters underline that FFR after coronary stenting is a strong and independent predictor for subsequent cardiac events after six months' follow up.

Objectives: This study evaluates the impact of immunosupressive combinations with Cyclosporine A (CSA), Azathioprine (Aza), Tacrolimus (Tac) and Mycophenolate Mofetil (MMF) on the time of onset, extent and progression of graft vessel disease (GVD).

BACKGROUND AND OBJECTIVE:Accelerated bone loss is a well recognized complication after cardiac transplantation (HTx). The role of an immunosuppressive-induced hypogonadism, a well-known cause of osteoporosis in men and its prevention are less defined after HTx. The aim of this study was first, to evaluate the incidence of hypogonadism after HTx and its influence on bone mineral metabolism and second, to assess the effect of a testosterone replacement therapy in hypogonadal transplants. PATIENTS AND METHODS:Due to hormonal status, 88 male cardiac transplants were randomised to a normogonadal or hypogonadal group. At baseline as well as after 1 and 2 years bone mineral density (BMD g/cm (2), T-score) was measured at the lumbar spine with DEXA. All patients received a basic therapy of calcium and vitamin D. The hypogonadal patients received additional testosterone. RESULTS:21 patients (24 %) showed an age-independent hypogonadism. Hypogonadal transplants showed a significant lower BMD (p < 0.001) (BMD = 0.8070 g/cm (2), T-value = -2.6514) than normogonadal patients (BMD = 0.9882 g/cm (2), T-value = -1.0568). Despite testosterone replacement hypogonadal patients showed no significant additional increase in BMD over 1 - 2 years compared with the normogonadal. CONCLUSION:Male cardiac transplants in all age groups show an high prevalence of hypogonadism (approximately 25 %) which contributes to a significant bone loss. An additional testosterone substitution did not significantly increase BMD.

Background: Accelerated osteoporosis is a long-term complication after heart transplantation (HTx). The role of an immunosuppressive induced hypogonadism, a well-known cause of osteoporosis in men and its prevention are less defined after HTx. The aim of this study was first, to evaluate the incidence of hypogonadism and its influence on bone mineral metabolism and second, to assess the effect of a testosterone (T) replacement therapy in hypogonadal transplants.

BACKGROUND:DSE and SPECT are two well-established methods to non-invasively investigate the functional significance of coronary artery stenoses in patients with coronary artery disease. The measurement of Fractional Flow Reserve has emerged a new invasive reference standard for lesion specific quantification of coronary artery stenoses. The objective of our prospective study was to compare sensitivity and specificity of Dobutamine Stress Echocardiography (DSE) and Single Photon Emission Computer tomography (SPECT) with the pressure derived Fractional Flow Reserve (FFR) for the identification of hemodynamic relevant coronary lesions in patients with predominately coronary multivessel disease and angiographically intermediate stenoses.METHODS:Inclusion criteria were a coronary lesion of 50-75% diameter stenosis by visual assessment in patients with known or suspected CAD. SPECT, DSE and FFR testing was performed within one week of coronary angiography.RESULTS:The study comprised 48 consecutive symptomatic patients. In 41 cases, a coronary multivessel disease was present. Mean FFR was 0.80 +/- 0.13 (0.41-1.0). Overall sensitivity of DSE and SPECT was 67% and 69% whereas specificity reached 77% and 87%. However, sensitivity was significantly reduced if the target lesion was located distally. DSE showed poor results if the lesions were located in the circumflex artery or if a history of prior myocardial infarctions was present.CONCLUSION:DSE and SPECT are both useful methods for the non-invasive assessment of coronary artery disease. DSE showed reasonable combination of sensitivity and specificity even in patients with multivessel disease. Although use of noninvasive stress tests is only limited in patients with prior myocardial infarctions and invasive stress testing should be preferred in these patients.

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

Background and objective: Accelerated bone loss is a well recognized complication after cardiac transplantation (HTx). The role of an immunosuppressive-induced hypogonadism, a well-known cause of osteoporosis in men and its prevention are less defined after HTx. The aim of this study was first, to evaluate the incidence of hypogonadism after HTx and its influence on bone mineral metabolism and second, to assess the effect of a testosterone replacement therapy in hypogonadal transplants.Patients and methods: Due to hormonal status, 88 male cardiac transplants were randomised to a normogonadal or hypogonadal group. At baseline as well as after 1 and 2 years bone mineral density (BMD g/cm(2), T-score) was measured at the lumbar spine with DEXA. All patients received a basic therapy of calcium and vitamin D. The hypogonadal patients received additional testosterone.Results: 21 patients (24%) showed an age-independent hypogonadism. Hypogonadal transplants showed a significant lower BMD (p < 0,001) (BMD = 0,8070 g/cm(2), T-value = -2,6514) than normogonadal patients (BMD = 0,9882 g/cm(2), T-value = -1,0568). Despite testosterone replacement hypogonadal patients showed no significant additional increase in BMD over 1-2 years compared with the normogonadal.Conclusion: Male cardiac transplants in all age groups show an high prevalence of hypogonadism (similar to25%) which contributes to a significant bone loss. An additional testosterone substitution did not significantly increase BMD.

Background: Risk stratification in patients with congestive heart failure (CHF) is an obligatory part of the heart transplantation (HTx) selection process. New medical therapies and the predictive value of hemodynamic changes over time have not been adequately taken into account in previous stratification models. In this study we assessed the prognostic value of 55 variables at baseline and 9 variables representing changes of hemodynamic parameters over time.Methods: A total of 178 patients with CHF were examined on 3.4 +/- 2.6 occasions (mean follow-up 19 19 months). Using the Cox proportional hazards model, univariate and multivariate relative risks (RRs) with 95% confidence intervals (CI) were determined for predicting event-free survival. A prognostic score (Munich score) was derived from the multivariate Cox model and three risk groups were derived.Results: During follow-up, 23 patients (13%) died and 63 (35%) underwent HTx. The univariate analysis yielded 21 statistically significant (p < 0.05) predictors of event-free survival. However, only four baseline variables (etiology of ischemic cardiomyopathy, systolic blood pressure, left ventricular [IV] end-diastolic diameter, maximal workload) and the change over 12 months in fractional shortening remained statistically significant (p < 0.05) in the multivariate Cox model and were used for the prognostic score. Within 12 months, no event occurred in the low-risk group, 8.1% in the intermediate, and 30.1% in the high-risk group.Conclusions: The incorporation of changes over time in hemodynamic parameters allowed for an improved baseline risk stratification model for the HTx selection process, especially in the era of new medical therapies such as beta-blocker therapy. All significant variables of the Munich score can be obtained in routinely performed non-invasive tests.

Purpose: Cardiac allograft vasculopathy (CAV) remains a major long-term complication after heart transplantation (HTx) which is usually monitored by coronary angiography and intravascular ultrasound (IVUS). Myocardial contrast echocardiography (MCE) is a new, promising noninvasive technique to evaluate microvascular perfusion and to identify significant coronary stenosis. The aim of the study was to assess the prognostic value of stress MCE in comparison to coronary angiography including IVUS and stress 99mTC Sestamibi perfusion imaging.

Problemstellung: In der immunsuppressiven Therapie nach Herztransplantation nehmen die Calcium-Calmodulin-Phosphatase-Inhibitoren, Cyclosporin A (CyA) und Tacrolimus (FK506) eine Schlüsselrolle zur Verhinderung akuter Abstoßungsreaktionen ein. Die Nephrotoxizität dieser Substanzen ist eine schwerwiegende Nebenwirkung, wobei der genaue Pathomechanismus bisher noch nicht endgültig geklärt ist. Als mögliche Ursache kommt eine renal-arterioläre Vasokonstriktion infrage.