Background: We report a case of a 50-year-old Jehova´s Witness male with Abiotrophia defectiva endocarditis on the mitral valve (MV) with severe mitral regurgitation (MR), multiple septic emboli and accompanying anemia. Due to his religious beliefs, he strictly refused blood transfusion. The aim of this case is to show that with an individual preoperative management a surgical valve replacement without blood transfusion is feasible. Case Summary: Our patient presented with a 6-month history of B-symptoms, abdominal pain and shortness of breath. In clinical examination cardiac murmur was found, ultrasound showed splenomegaly with suspicion of segmental splenic infarct which was confirmed by magnetic resonance imaging (MRI). A severe MR with multiple vegetation's was found by transthoracic echocardiogram (TTE) and trans-oesophageal echocardiogram (TEE). Multiple blood culture samples detected the streptococcus Abiotrophia defectiva. First, a calculated antibiotic treatment was initiated and as the patient refused blood transfusion, an additional iron treatment as well as recombinant human erythropoietin substitution were performed to address the anemia. Finally, the patient underwent open cardiac surgery with biological valve replacement using autologous transfusion. Following surgery, he showed regular function of the MV-prothesis by TTE up to 24 months postoperative. Discussion: Infective endocarditis (IE) is mostly caused by common pathogens like staphylococcus aureus, streptococcus viridans and enterococcus faecalis. Nevertheless, multiple rare pathogens are described to provoke IE. In our case the streptococcus Abiotrophia defectiva, belonging to the natural environment of the oral cavity, the gastrointestinal and urogenital tract, was found. Due to its slow growing rate, its identification is challenging. As our patient refused blood transfusion and early surgical valve replacement, but showed hemodynamic stability we could develop this individual therapeutic management with intravenous antibiotics as well as iron and erythropoietin substitution to achieve operability.

Introduction: Transradial access, or forearm artery access (FAA) in general, has established itself as the preferred arterial access for cardiac catheterization. Difficult vascular anatomy (DVA) is a noticeable threat to procedural success. Methods: We retrospectively analyzed 1397 consecutive procedures of cardiac catheterization to estimate the prevalence and identify predictors of DVA.Results: Severe DVA, causing procedural failure, was found in 2.5% of procedures at the right forearm vs. 1.7% at the left forearm (χ2=0.77, p=0.38), and in 2.4% at the right upper arm vs. 0.7% at the left upper arm (χ2=5.1, p=0.023). Bilateral severe DVA was found in 0.9% of patients. In multivariate analysis, advanced age (odds ratio (OR) 1.025/year of age, 95% confidence interval (CI) 1.001 to 1.049, p=0.039), lower height (OR 0.957/cm, 95% CI 0.927 to 0.988, p=0.008) and left FAA (OR 2.148, 95% CI 1.450 to 3.182, p<0.001) were found to be independent predictors of DVA at the forearm. At the upper arm, independent predictors were advanced age (OR 1.037/year of age, 95% CI 1.014 to 1.060, p=0.001) and right FAA (OR 2.519, 95% CI 1.718 to 3.690, p<0.001).Conclusion: The prevalence of severe DVA at one arm was relevant but severe bilateral DVA was rare. Predictors of DVA at the upper arm were right forearm access and advanced age. At the forearm, left-sided access, advanced age and lower height. Gender, arterial hypertension, body mass, and smoking were not harming the FAA. Left FAA might be preferable.

Introduction: Complications after atrial fibrillation (AF) ablation are rare and therefore consequent analysis of risk factors is often hard. Although, in asymptomatic patients silent cerebral events (SCE) in magnetic resonance imaging (MRI) and endoscopically detected esophageal thermal lesions (EDEL) have been documented in a much higher percentage of these patients. These asymptomatic complications may serve as surrogate indicators for the potential for severe complications. Hypothesis: We evaluated the incidence of SCE and EDEL in patients undergoing AF ablation using irrigated radiofrequency ablation technologies. Methods: Overall 375 pts undergoing either single-tip contact-force irrigated RF ablation (N=231) or multipolar irrigated RF (nMARQ, N= 170). EDEL using post-ablation endoscopy (days 1 - 4) and SCE using diffusion-weighted brain MRI (days 1 - 3) were documented and related to procedural and patient-specific parameters. No symptomatic complications occurred in this patient cohort. Results: 327 pts underwent post-ablation endoscopic evaluation for EDEL and 335 post-ablation MRI to detect SCE. Overall incidence of EDEL was 16% (53) including 4.5% (15) esophageal ulcers and 21% (72) had SCE. In the single-tip RF ablations 12% had EDEL and 20% SCE whereas in the nMARQ ablations 21% had EDEL and 23% SCE. The incidence of EDEL was higher in patients undergoing esophageal temperature monitoring using a thermal esophagus probe with non-insulated large metal electrodes (30% versus 6% in single tip and 31% versus 6% in nMARQ ablations). The use of this specific probe was the only independent predictor of EDEL. The incidence of SCE was relevantly lower in patients ablated under continuous oral anticoagulation (12% versus 37% for single tip and 15%versus 31% for nMARQ ablations). Conclusions: AF ablation using irrigated RF involves a risk of asymptomatic complications to the esophagus and brain relevantly higher than symptomatic complications. Reduction of asymptomatic complications may warrant beneficial effects on the most severe complications of AF ablation like periprocedural stroke and atrio-esophageal fistula.

Die elektrokardiographische Differenzialdiagnostik von Tachykardien mit breitem QRS-Komplex (Breitkomplex-Tachykardien, BKT) stellt eine Herausforderung an den befundenden Arzt dar, ist aber für die weitere Differenzialtherapie und Risikoabschätzung entscheidend. Komplexe Algorithmen erhöhen im Einzelfall zwar die Spezifität der Diagnose, müssen aber oft einem pragmatischen Vorgehen zur schnellen EKG-Differenzialdiagnostik weichen.

Identification of signs of atrioventricular (AV) dissociation or a negative precordial concordance of QRS are indicative of VT. In V1 positive BCTs a positive precordial concordance, QRS width > 140 ms, superiorly directed QRS axis, monophasic or biphasic QRS complexes in V1 and deep S wave in V6 are indications of a VT. In V1 negative BCTs, QRS width > 160 ms, right-sided QRS axis, broad R peak (> 40 ms) in V1/V2, slurred S downstroke in V1/V2 and any Q peak in V6 are all indications of VT as the mechanism.

Catheter ablation has been shown to be an effective treatment for rhythm stabilization in patients with multiple ventricular arrhythmia episodes called electrical storm (ES). These procedures may be complex and are usually only performed in highly specialized and experienced centers. Still the optimum timing for catheter ablation in ES remains unclear.Early access to perform acute ablation should be considered in patients who are not rhythm stabilized with antiarrhythmic medical treatment. Also patients with hemodynamic compromise (cardiogenic shock) are candidates for an early interventional strategy. In specialized centers it is consensus to perform catheter ablation in these patients as early as eligible especially when considering a high early and late mortality without interventional management. Establishing a structured protocol for treatment and admission to EP centers has helped to further reduce pre-ablation mortality and may optimize treatment of ES. Large scale networking to optimize and structure access to experienced electrophysiology centers is of importance to create a basis for optimizing treatment strategies.

Purpose. To evaluate the usefulness of serial compression B-scan and Doppler sonography (US) in screening for deep venous thrombosis (DVT) of the lower extremities in patients with spinal cord injuries.Method. Patients with paraplegia and tetraplegia due to spinal cord injuries were screened by a serial compression B-scan and Doppler US protocol for DVT of the bilateral lower extremities within the first 36 hours after admission, at day 7 and at day 21. In patients with DVT, a follow-up US examination was performed 3 weeks after diagnosis to assess thrombi distribution.Results. Between January 2007 and March 2008, a total of 115 patients (75 males, 40 females), aged 19 to 85 years, were included. The first US examination documented a DVT in 44 cases (38.3%). After an initial negative scan, sonography after 7 days and 21 days showed DVT in 6 patients and 2 patients, respectively. Cumulative rate of DVT after the first 3 weeks was 45.2% (n=52). Follow-up US after 3 weeks in patients with DVT documented a complete recanalization in 19 patients (36.5%), no change in 12 patients (23.1%), and residual thrombi with partial recanalization in 21 patients (40.4%).Conclusion. Our study supports the use of serial compression B-scan and Doppler US as a screening tool for DVT of the lower extremities in patients with spinal cord injuries early after injury. (C) 2009 Wiley Periodicals, Inc. J Clin Ultrasound 38:17-20, 2010; Published online in Wiley InterScience (www.interscience.wiley.com). DOI: 10.1002/jcu.20634

In this prospective study, we aimed to document the rate and localization of deep venous thromboses in patients with spinal cord injuries. Patients with paraplegia or tetraplegia were screened by a serial color duplex sonography protocol for deep venous thrombosis within the first 36 hours after admission, at day 7, and at day 21. Sonography was performed by a complete scan including the veins below the knee. A total of 139 patients were included (19-90 years, 63.5% male). Cumulative rate of deep venous thrombosis after 3 duplex scans was 45.3% (n = 63). In 71.4% (n = 45), thromboses were localized below the knee. Because of the relevant number of distal vein thromboses, inclusion of the calf veins during screening scans is suggested. Further studies are needed to analyze the clinical benefit of diagnosing and treating distal vein thromboses.

BACKGROUND:Treatment of symptomatic coronary artery disease with percutaneous intervention requires antithrombotic therapy. Patients with elevated thromboembolic risk benefit from therapy with glycoprotein IIb/IIIa inhibitors. The safety and effectiveness of glycoprotein IIb/IIIa inhibition have been well documented in clinical trials. Drug-induced bleeding complications in elderly patients have not been specifically addressed.METHODS:Between 2006 and 2009, a total of 439 unselected patients 80 years of age and older undergoing percutaneous intervention for symptomatic coronary artery disease were included in the present nonrandomized retrospective study. In one-half of the patients, glycoprotein IIb/IIIa inhibitors were administered peri-interventionally. The in-hospital occurrence of bleeding complications (access site, gastrointestinal and cerebral) were analyzed in the groups with and without glycoprotein IIb/IIIa inhibitors.RESULTS:The mean age of the patients was 84 years. Nearly all patients (95%) received dual antiplatelet therapy. Patients treated with glycoprotein IIb/IIIa inhibitors had more complex coronary lesions and bypass graft interventions, and a tendency toward more access site bleeding complications than patients without inhibitors, which included femoral hematomas (4.6% versus 2.3%, respectively; P not significant) and femoral pseudoaneurysms (6% versus 3.2%, respectively; P not significant). The rate of blood transfusion was equal in both groups (0.9%). Major hemorrhagic events did not occur. Vessel closure devices were used more often in patients without glycoprotein inhibition.CONCLUSIONS:An increase in minor bleedings must be expected when using glycoprotein IIb/IIIa inhibitors in patients 80 years of age and older. However, this issue must not prevent this treatment option from being offered to elderly patients. There appears to be no elevated risk for major bleeding complications. Broadened use of vascular closure devices in this specific patient population may lower the rate of access site complications.

Four months after a diagnostic coronary angiography followed by application of a vascular closure device, a female patient presented with an acute femoral pulsing tumor with strong pain in the groin area. There was no prior trauma. Color duplex sonography showed a large pseudoaneurysm of the right femoral artery. In addition, signs of an old hematoma were documented. Due to the large tumor affecting the arterial perfusion of distal arteries, the pseudoaneurysm was treated immediately by thrombin injection. After this procedure, arterial perfusion in the tumor was not detectable anymore and local symptoms decreased rapidly. This is a rare case of late pseudoaneurysm after femoral artery puncture.

We have recently identified four complementation groups in fibroblasts from patients deficient in peroxisomes. Here we describe a kinetic analysis of the complementation process. The kinetics of peroxisome assembly was assessed in heterokaryons of complementary cell lines by measuring the rate of incoporation of catalase, initially present in the cytosol, into particles. In two combinations of cell lines assembly was rapid and insensitive to cycloheximide. Thus the components required for peroxisome assembly must have been present in the parental cell lines, at least one of which presumably contained peroxisomal ghosts. In three other combinations of cell lines assembly of peroxisomes was slow and sensitive to cycloheximide.

Die ambulante Versorgung von Patienten mit einer koronaren Herzkrankheit (KHK) sollte neben der Diagnostik vor allem die medikamentöse Therapie und Prävention gewährleisten. Ziel dieser Studie war die Erhebung der Versorgungsqualität im medikamentösen und präventiven Bereich bei Patienten mit einer KHK.

Die Pumpschwäche bei Herzinsuffizienz ist durch mehrere Faktoren verursacht. Neben der myokardialen Schädigung spielt eine elektromechanische Entkopplung bei Patienten mit AV-Block I° und Linksschenkelblock mit diastolischer Funktionsstörung eine Rolle.

Background and aim of the study: Although several determinants of survival after aortic valve replacement (AVR) have been identified, current knowledge regarding factors influencing the postoperative quality of life (QoL) is poor. The study aim was to evaluate health-related QoL (using Medical Outcome Study Short Form-36) in six-month survivors after AVR, and to determine predictors of outcome.Methods: All patients undergoing heart valve surgery at the authors' hospital between 1992 and May 1999 were included. Data from 201 patients (119 males, 82 females; mean age 66.6 years) after AVR were obtained. The mean observation period was 42.5 months.Results: Patients in preoperative NYHA classes I and II had a postoperative QoL comparable to that of the general population, while subjects in NYHA classes III and IV scored significantly lower. Multivariate analysis identified four independent predictors (preoperative NYHA class, diabetes mellitus, prosthetic valve type, sternal complications) for the Physical component score. NYHA class, atrial fibrillation, sternal complications and type of valvular heart disease were predictors for the Mental component score. No correlation was found between preoperative left ventricular function or size, pre-existing coronary artery disease or prior myocardial infarction and the postoperative QoL.Conclusion: Notably, preoperative aortic stenosis was identified as a strong and independent predictor of the postoperative QoL in six-month survivors after AVR. This effect was independent of left ventricular size and function. These findings support the proposal that patients with aortic stenosis should be operated on at an earlier stage, if possible before they develop symptoms.

BACKGROUND: Many different stent types are available for intracoronary placement. No clinical trial has demonstrated clearly the superiority of any stent design over another. METHODS: This study was designed to analyze clinical and angiographic results after using intracoronary PURA-VARIO (Devon Medical, Hamburg, Germany) (PUVA) stents. A total of 306 implanted stents were investigated in a series of 217 unselected patients (61.2 ± 10.7 years, 74.3% male). Stenting was performed electively and during acute coronary syndromes. Stents were manually mounted on angioplasty balloons and expanded in the target lesion. Angiographic measurements were carried out by quantitative coronary angiography. RESULTS: Stenting was successful in 214/217 patients (98.8%). During hospitalization (median three days) 206 patients (94.9%) were free from adverse cardiac events. Stent thrombosis occurred in five patients (2.3%), Q-wave infarction in one (0.5%) and urgent percutaneous target vessel revascularization in four (1.8%). Follow-up angiography, performed in 170 patients (78.3%) showed a restenosis (≥50% diameter stenosis) in 44/170 patients (25.9%), requiring angioplasty in 29 (17.2%). A surgical revascularization was recommended in 13 patients (7.6%). One patient died during follow-up from an unknown cause; however, sudden cardiac death was most likely. CONCLUSIONS: PUVA stents are characterized by a high level of safety and efficacy. Clinical and angiographic results are comparable with those of other approved stents. (Int J Cardiovasc Intervent 2003; 5: 156-160)

Background—Intravascular brachytherapy is being applied more and more in patients with coronary artery disease for the prevention of restenosis subsequent to balloon angioplasty, in particular after stent implantation. Several radiation sources (&bgr;- and &ggr;-emitters) are available in clinical routine. It was the purpose of this study to compare the radiation doses at the level of the adventitia in diseased and stented human coronary arteries for 192Ir and 90Sr/Y emitters in routine use. In contrast to previously published work, we performed dosimetry instead of calculating depth-dose distribution by use of the Monte Carlo system. Methods and Results—Postmortem calcified human coronary artery segments were stented and placed in an organ bath. Commercially available &ggr;-emitters (192Ir; Cordis Checkmate) and &bgr;-emitters (90Sr/Y; Novoste Beta-Cath) were used. Relative dose distributions along the adventitia were measured by a specially designed scintillation detector system. Whereas dose perturbations caused by stents and calcified plaque were negligible for the 192Ir source, radiation from the beta source was significantly impaired (as much as 40%) at the level of the adventitia (3.0-mm vessel diameter). Dose perturbation was clearly dependent on the extent and severity of calcification, less affected by stent material. Conclusions—Dose perturbation caused by calcified plaque and metallic stents is significant for &bgr;-sources. This dosimetric difference between &bgr;- and &ggr;-emitters in diseased coronary arteries should be considered when calculating doses in intravascular brachytherapy.

Primary success rates, and the angiographic and clinical outcome after percutaneous coronary intervention, are influenced by many different factors. Clinical features and morphologic characteristics of the target lesion are important. Also, interventionally caused endothelial trauma may trigger atherogenetic and procoagulatory factors leading to intraluminal thrombosis. The study population consisted of 228 consecutive, unselected patients with symptomatic coronary artery disease or exercise-induced myocardial ischemia and coronary artery stenoses eligible for percutaneous intervention. We analyzed different clinical, morphological, and laboratory (total cholesterol, high-density lipoprotein-cholesterol, low-density lipoprotein-cholesterol, triglycerides, fibrinogen) features in those patients with adverse cardiac events (stent thrombosis, myocardial infarction, urgent target vessel revascularization, death) after primary successful coronary artery stenting, compared with a control group without adverse events. In the group with adverse cardiac events we found a significantly higher level of fibrinogen compared with the control group. Other laboratory data and clinical characteristics were not significantly different between the two groups. The study shows a possible association between hyperfibrinogenemia and adverse cardiac events after intracoronary stenting. In clinical practice, the potential role of elevated levels of fibrinogen in an unfavorable outcome after percutaneous coronary interventions should be considered when planning coronary artery stenting.