Ziele: Vergleich der mittels MRT ermittelten myokardialen Perfusionsreserve (MPR) mit dem Grad der Stenosierung der Koronargefäße im intravaskulären Ultraschall (IVUS) zur Evaluation der Erkennbarkeit einer Transplantatvaskulopathie nach erfolgter Herztransplantation (HTx). Methode: 16 herztransplantierte Patienten (5,6±4,5 Jahre nach HTx) ohne aktuelle klinische Zeichen einer Abstoßungsreaktion erhielten während ihrer jährlichen Nachkontrolle eine Herzkatheter-Untersuchung mit IVUS und die kardiale MRT-Untersuchung (Intera 1.5, Philips, Best, NL). Dabei wurde eine kontrastmittelgestütze (Gd-DTPA; 0.05 mmol/kgKG; 4ml/s) „First-pass“ MRT-Perfusions-Studie (EKG-getriggerte TFE-EPI Sequenz; 3 Schichten, Kurzachse) unter Adenosin-Stress (140µg/kg/min i.v. in 6min) und in Ruhe durchgeführt. Mittels Fermi-modellgestützer Dekonvolution erfolgte die quantitative Analyse und Berechnung der myokardialen Perfusionsreserve (MPR). Aus der IVUS-Untersuchung wurden die mittleren und maximalen Stenosierungsgrade des Ramus interventricularis anterior (RIVA) und des Ramus circumflexus (RCX) durch Planimetrie der Intima-Media-Dicke ermittelt. Ergebnis: Die Quantifizierung der MPR (Mw 2,3±0,9) ließ sich für alle untersuchten Patienten durchführen. Die mittels IVUS gemessenen, mittleren Stenosierungsgrade betrugen 23,2±10,8% (RIVA) bzw. 23,1±9,9% (RCX), die maximalen Stenosierungsgrade 37,4±17,4% (RIVA) bzw. 38,8±16,2% (RCX). Der Vergleich dieser Parameter mittels der Spearman-Rangkorrelation ergab eine hohe positive Korrelation der mittleren Stenosierungsgrade von RIVA und RCX (p<0,01) (für maximale Stenosierungsgrade: p=0,09). 15 von 16 Patienten wiesen eine mittlere Stenosierung unter 40% auf. Die MPR korrelierte nicht mit den Stenosierungsgraden und lag für 14 der 16 Patienten in einem konstanten Bereich zwischen 1,5 bis 3,0. Die beiden Patienten mit den maximalen Stenosen (72,8% bzw. 71.4%) zeigten auch die minimale MPR des Kollektivs (1,1 bzw. 1,5). Schlussfolgerung: Die hohe Korrelation der mittleren Gefäßeinengung zwischen RIVA und RCX in den IVUS-Untersuchungen bestätigt die Annahme einer diffusen Gefäßwandverdickung im Zuge der Entwicklung einer Transplantatvaskulopathie. Die MPR als Methode der funktionellen Perfusionsmessung scheint mittlere und niedrige Stenosegrade nicht erfassen zu können und somit für die Frühdiagnostik der Transplantatvaskulopathie nicht geeignet zu sein. Hingegen scheint sie funktionell relevante Stenosierungen erfassen zu können.

HomeCirculationVol. 110, No. 19Primary Stenting of an Anomalous Left Anterior Descending Coronary Artery Originating From the Proximal Right Coronary Artery in a Patient With Acute Non–ST-Elevation Myocardial Infarction Free AccessReview ArticlePDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessReview ArticlePDF/EPUBPrimary Stenting of an Anomalous Left Anterior Descending Coronary Artery Originating From the Proximal Right Coronary Artery in a Patient With Acute Non–ST-Elevation Myocardial Infarction Hans Hölschermann, MD, Michael Coch, MD, Ali Erdogan, MD and Harald Tillmanns, MD Hans HölschermannHans Hölschermann From the Department of Internal Medicine, Division of Cardiology, Justus-Liebig-University, Giessen, Germany. , Michael CochMichael Coch From the Department of Internal Medicine, Division of Cardiology, Justus-Liebig-University, Giessen, Germany. , Ali ErdoganAli Erdogan From the Department of Internal Medicine, Division of Cardiology, Justus-Liebig-University, Giessen, Germany. and Harald TillmannsHarald Tillmanns From the Department of Internal Medicine, Division of Cardiology, Justus-Liebig-University, Giessen, Germany. Originally published9 Nov 2004https://doi.org/10.1161/01.CIR.0000147179.18412.B1Circulation. 2004;110:e494–e495An isolated single coronary artery is a rare congenital anomaly with an incidence of 0.03% to 0.4% and an uncommon finding (0.6% to 1.2%) in patients undergoing cardiac catheterization. An anomalous origin of the left anterior descending coronary artery (LAD) from the right proximal coronary artery (RCA) is rare, found in 1.2% to 6.1% of all coronary anomalies. A 44-year-old patient with this anomaly developed acute non–ST-elevation myocardial infarction during exercise and was admitted to a hospital. Detection of creatine kinase-MB and troponin I elevation led to this patient being transferred to the university hospital for cardiac catheterization. Coronary angiography revealed the presence of an isolated single coronary artery, with the left coronary artery (LCA) originating from the RCA (Figure 1). A singular 80% Ambrose's type II excentric lesion indicating plaque rupture and residual thrombus was found in the middle portion of the LAD and was considered to be the culprit lesion (Figure 2). The RCA and left circumflex artery were free of any significant obstruction. In the absence of a left coronary ostium, the patient underwent successful "retrograde" LAD stenting via the origin of the right coronary artery (Figure 3). The procedure eliminated the ischemia. Until now, no report of percutaneous transluminal coronary angioplasty and stenting in a patient with this anomaly has been published. Download figureDownload PowerPointFigure 1. Coronary angiogram showing the isolated single coronary artery, with the LCA originating from the proximal RCA. The arrow indicates the location of the culprit lesion.Download figureDownload PowerPointFigure 2. Angiogram of the singular 80% Ambrose's type II excentric lesion indicating plaque rupture and residual thrombus in the middle portion of the LAD.Download figureDownload PowerPointFigure 3. A, Angiogram of the guide wire passing "retrograde" through the LAD stenosis by approaching through the origin of the RCA. B, Angiogram of the stent being deployed within the mid-LAD stenosis. C, Angiogram showing the resolution of the stenosis after the angioplasty and stent deployment.FootnotesCorrespondence to Hans Hölschermann, MD, Department of Internal Medicine, Division of Cardiology, University of Giessen, Klinikstrasse 36, D-35392 Giessen, Germany. E-mail [email protected] Previous Back to top Next FiguresReferencesRelatedDetailsCited By Kawashima S, Shiraishi J, Hyogo M, Shima T, Sawada T and Kohno Y (2014) Main trunk crossover stenting in a patient with left internal thoracic artery—protected single coronary artery, Cardiovascular Intervention and Therapeutics, 10.1007/s12928-014-0293-1, 30:3, (307-310), Online publication date: 1-Jul-2015. Rosenmann D, Meerkin D and Almagor Y (2006) Retrograde dilatation of chronic total occlusions via collateral vessel in three patients, Catheterization and Cardiovascular Interventions, 10.1002/ccd.20597, 67:2, (250-253), Online publication date: 1-Feb-2006. November 9, 2004Vol 110, Issue 19 Advertisement Article InformationMetrics https://doi.org/10.1161/01.CIR.0000147179.18412.B1PMID: 15533873 Originally publishedNovember 9, 2004 PDF download Advertisement SubjectsAcute Coronary SyndromesAngiographyStent

In vivo hearts show fine beat to beat temporal variation during normal sinus rhythm (NSR). These changes have been termed “heart rate variability” (HRV). Accurate measurements of the beat to beat variation have enable investigators to determine the parameters of HRV.1 Routine assessment of HRV is derived from measurements of QRS-to-QRS (RR) intervals in the surface ECG. Activation of the heart starts with impulse formation in the sinus node and ends with excitation of the ventricular myocardium resulting in a QRS complex. Therefore, RR interval variation is likely to be the result of both sinus and atrioventricular (AV) node action. However, the relative contribution of each structure to HRV is not known. We hypothesised that, by calculating and comparing HRV during NSR and different pacing manoeuvres, we would be able to elucidate the relative contribution of both nodes to HRV. Therefore, we measured and compared HRV during AAI pacing (elimination of impulse formation in the sinus node) and VAT pacing (elimination of contribution of the AV node). Twenty consecutive patients were studied during diagnostic electrophysiological testing. Informed written consent was obtained from all subjects. A time period of 600 seconds was used to calculate HRV during each pacing manoeuvre and NSR. HRV of NSR was calculated twice before and after the pacing manoeuvres. AAI pacing was done at a pacing rate 15% faster than the sinus rate, and VAT pacing with an AV delay of 80 ms. For pacing manoeuvres, an external AV …

Tachycardia induced alternation of the T wave (TWA) has been associated with arrhythmia morbidity in mixed patient populations. However, less is known concerning the general incidence of TWA and its usefulness in risk stratification early after acute myocardial infarction (MI). TWA was prospectively and systematically assessed in 140 consecutive patients 15 +/- 6 days after acute MI and prior to discharge. Results of TWA measurements were compared to other noninvasive risk markers, LV function, and coronary angiography. Sustained TWA was present at rest or inducible during exercise in 27% of patients. The patient-specific heart rate for the onset of TWA was 98 +/- 9 beats/min. After multivariate analysis, TWA correlated with age (P = 0.02) and LV function (P = 0.002) and occurred more often in patients after nonanterior MI (P = 0.03). Acute results of Holter monitoring, late potentials by signal-averaged ECG, and heart rate variability were unrelated to the TWA status. During follow-up (451 +/- 210 days) two major arrhythmic events occurred. The incidence of TWA early after MI is about 25%. TWA is related to age and LV function but not to other common arrhythmia markers. Although TWA does not appear to be related to excessive cardiac morbidity, evaluation of the prognostic significance of TWA requires further study.

Whether acute and direct percutaneous transluminal coronary angioplasty improves the incidence of nonsustained ventricular tachycardia in patients surviving acute myocardial infarction is not known. In 400 consecutively studied patients, Lown classification IVb on Holter monitoring was only associated with arrhythmia morbidity, whereas reduced ejection fraction was related to total and cardiac mortality and arrhythmia morbidity.

The objective of this study was to determine the long‐term prognosis and the sudden death risk for patients with coronary artery disease and spontaneous nonsustained ventricular tachycardia who are not inducible by electrophysiological testing. Patients with coronary artery disease (CAD) who have spontaneous or inducible sustained ventricular tachycardia (VT) by electrophysiological testing are at increased risk of dying suddenly, and noninducibility is often considered as a favorable prognostic factor in their risk assessment. We studied 120 consecutive patients with CAD and nonsustained VT during Holter monitoring and followed the patients who were noninducible (n = 93) for 3.5 ± 1.6 years. None of these patients received antiarrhythmic therapy except β‐blockade. Overall mortality and the sudden death risk was assessed by the Kaplan‐Meier estimation. Predictors for overall mortality and sudden death were determined by multivariate analysis. During follow‐up, 23 of the 93 patients died, including 13 suddenly. Overall mortality was 9% after 1 year, 16% after 2years, and 21% after 3 years, respectively. The incidence of sudden death was 1 % after 1 year, 8% after 2 years, and 13% after 3 years, respectively. Patients with a LVEF ≤ 0.55 had an increased overall mortality risk with 15% after 1 year, 29% after 2 years, and 34% after 3 years (P = 0.012) and a risk of dying suddenly of 4% after 1 year, 12% after 2 years, and 18% after 3 years (P = NS), respectively. LVEF was the only independent predictor for overall mortality. In conclusion, patients with coronary artery disease and nonsustained ventricular tachycardia who are not inducible by electrophysiological testing have a moderate long‐term overall mortality risk. The risk of dying suddenly in this patient group is small but not negligible, especially in patients with impaired LVEF.

Die Beschreibung der Herzfrequenzvariabilität mittels statistischer und spektraler Parameter ist ein bislang in vielerlei Hinsicht nicht befriedigend gelöstes Problem. Methoden der fraktalen Geometrie können hier möglicherweise Vorteile bieten, da neben der RR-Intervallänge auch der Informationsgehalt der Reihenfolge der einzelnen RR-Intervalle berücksichtigt wird. Diese Methode kann auch zwischen eher zufälliger Verteilung oder deterministisch chaotischem Verhalten differenzieren. Aus diesem Grunde entwickelten wir Techniken, um mittels Dimensionsanalyse die Herzfrequenzvariabilität zu beschreiben. Methoden: Bei 20 herzgesunden Probanden wurde der Verlauf der Informationsdimension über 24h aus Zeitreihen einer digitalen Langzeit-EKG-Aufzeichnung (Wandlungsrate 1000Hz, Rekorder FD3 Fa. Oxford Instruments) ermittelt. Aus einem 2500 RR-Intervalle langem Fenster wurde die Informationsdimension zu den Einbettungsdimensionen 2 bis 6 berechnet, im Anschluß das Analysefenster um 1000 RR-Intervalle entlang der Zeitachse verschoben und der Vorgang wiederholt. Ergebnisse: Bei der graphischen Darstellung der Informationsdimensionsverläufe über 24h fanden sich bei allen Probanden tagsüber deutliche Schwankungen der Informationsdimension. Hingegen kam es während der Nachtstunden zu zwei verschiedenen Musterbildungen: entweder eine anhaltende Phase mit erhöhter Zufälligkeit oder eine Periode mit deterministisch chaotischem Verhalten gegenüber dem Tagesmittel. Dieses Verhalten war weder mit der Herzfrequenz, noch mit anderen erhobenen oder berechneten Parametern signifikant korreliert. Schlußfolgerungen: Wir entwickelten eine Methode, die es ermöglicht, die Informationsdimension sowohl im Zeitverlauf, als auch bei ansteigender Einbettungsdimension zu beurteilen. Somit steht für die HRV-Beschreibung neben den statistischen und spektralen Verfahren eine weitere Analysemethode zur Verfügung. Ob sich hieraus neue, klinisch relevante Gesichtspunkte ergeben, muß durch Studien geklärt werden.