[Ventricular long-term support with implantable continuous flow pumps: on the way to a gold standard in the therapy of terminal heart failure]. / Ventrikuläre Langzeitunterstützung mit implantierbaren kontinuierlichen Flusspumpen : Auf dem Weg zum Goldstandard in der Therapie der terminalen Herzinsuffizienz.

Mechanical circulatory support nowadays represents an important option in the treatment of patients with advanced heart insufficiency. Once developed as a bridging to heart transplantation, it is now a valuable option for permanent support in patients for whom a heart transplantation is not possible due to contraindications or a lack of available organs. Furthermore, it can be used as a bridging to myocardial recovery and explantation. The number of implantations of left ventricular assist devices (LVAD) has clearly increased in recent years and approximately one half of these implantations is already carried out in centers not specialized in transplantations. This development necessitates that every practicing physician is aware of the basic principles of mechanical circulatory support and with the possible complications. This article gives a summary of the current state of the technology and treatment of patients with long-term VADs.

[Non-invasive diagnosis of pulmonary hypertension: ESC/ERS Guidelines with commentary of the Cologne Consensus Conference 2010]. / Nicht-invasive Diagnostik der pulmonalen Hypertonie: ESC/ERS-Leitlinien mit Kommentierung der Kölner Konsensus-Konferenz 2010.

The 2009 European Guidelines on Diagnosis and Treatment of Pulmonary Hypertension have been adopted for Germany. The guidelines contain detailed recommendations for the diagnosis of pulmonary hypertension. However, the practical implementation of the European Guidelines in Germany requires the consideration of several country-specific issues and already existing novel data. This requires a detailed commentary to the guidelines, and in some aspects an update y appears necessary. In June 2010, a Consensus Conference organized by the PH working groups of the German Society of Cardiology (DGK), the German Society of Respiratory Medicine (DGP) and the German Society of Pediatric Cardiology (DGPK) was held in Cologne, Germany. This conference aimed to solve practical and controversial issues surrounding the implementation of the European Guidelines in Germany. To this end, a number of working groups was initiated, one of which was specifically dedicated to non-invasive diagnosis of PH. This commentary summarizes the results and recommendations of the working group on treatment of PAH.

Maintenance immunosuppression with mycophenolate mofetil: long-term efficacy and safety after heart transplantation.

BACKGROUND: Mycophenolate mofetil (MMF) is superior to azathioprine (AZA) in preventing allograft rejections episodes (ARE) early after heart transplantation (HTx). However, long-term efficacy and adverse events are barely known. We evaluated the long-term efficacy and safety, comparing patient outcomes with either MMF or AZA as components of maintenance immunosuppression regimens. METHODS: We evaluated all patients who underwent HTx between January 1994 and May 2003 and received the same induction immunosuppression followed by treatment with cyclosporine (CsA), prednisolone, and with either MMF or AZA. We analyzed the survival, number, and severity of ARE, development of coronary allograft vasculopathy (CAV), and main adverse effects (infections, tumors). RESULTS: Patients receiving MMF (n = 137) showed a lower mortality rate than those treated with AZA (n = 121). There were significant differences between the groups for all parameters evaluated (P < .01). The prevalence of deaths was 18.3% in the MMF group and 47.9% in the AZA group. Biopsy-proven ARE greater than grade 1A and antirejection therapies per patient were lower among the MMF than the AZA group (0.20 vs 0.31 and 0.96 vs 1.24, respectively). Prevalence of coronary stenoses was 11.7% in the MMF group and 24.8% in the AZA group. Rate of extracutaneous and cutaneous malignancies was lower in the MMF than the AZA group (7.3% and 5.8% vs 18.2% and 9.1%, respectively). The prevalence of infections was higher in the MMF group. Patients who were switched during the first post-HTx year from AZA to MMF (n = 97) and thereafter received CsA plus MMF for >1 year also showed significantly better survival than those who remained on AZA treatment. CONCLUSIONS: Among a cohort of patients being followed long term, MMF appeared to be highly efficient to prevent both ARE and the development of coronary artery stenoses. The use of MMF also significantly improved the survival of heart transplant recipients compared with AZA, despite a greater incidence of infections linked to MMF therapy.

Prediction of short-term outcomes in patients with idiopathic dilated cardiomyopathy referred for transplantation using standard echocardiography and strain imaging.

OBJECTIVE: We sought to evaluate the short-term prognostic value of echocardiography including two-dimensional (2D) strain imaging in patients with end-stage idiopathic dilated cardiomyopathy (IDCM). METHODS: To evaluate the short-term (6-month) prognostic value of different parameters used for the assessment of IDCM patients referred for heart transplantation, we performed at the baseline transthoracic echocardiography including 2D strain imaging, N-terminal pro-BNP measurements, and exercise testing for all patients included in the study. After 6 months, all parameters, including endsystolic strain (ESS), peak systolic strain rate (SSR(max)), early and late diastolic strain rates, their ratio (diastolic strain rate E [DSR(E)], dialostolic strain rate A [DSR(A)], diastolic strain rate E and A wave ratio [DSR(E/A)]), and systolic intraventricular dyssynchrony indexes (IVDSI) were tested for their prognostic value to predict a patient's outcome. RESULTS: At the baseline stable patients had significantly lower transmitral E and A wave ratio (E/A), DSR(E/A), higher DSR(A) values, longer transmitral E wave deceleration time (DcT), higher longitudinal ESS and SSR(max) values, lower systolic circumferential and longitudinal IVDSI. CONCLUSION: The highest sensitivity for rapid heart failure progression was shown by DcT <100 ms, E/A > 1.5, DSR(A) < 0.3/s, circumferential IVDSI > 0.16, and longitudinal IVDSI > 0.22 (91%, 78%, 94%, 83%, and 75%, respectively).

[Pulmonary bleeding after lung transplantation]. / Pulmonale Blutungen nach Lungentransplantation.

BACKGROUND: Bronchial arteries are not anastomosed during lung transplantation. We analyzed the occurrence of pulmonary hemorrhage after transplantation. PATIENTS AND METHODS: 235 patients were included. RESULTS: We observed pulmonary bleeding in 4/235 patients (1.7 %). All four cases were due to transplant-specific disorders (arrosion of pulmonary artery in three cases, coagulopathy in one patient). CONCLUSIONS: The analysis shows, that usual pulmonary hemorrhage does not occur in lung transplant recipients. This underlines the role of bronchial arteries in pulmonary hemorrhage of non-LTX-patients.

[Non-invasive monitoring of rejection after cardiac transplantation. The method and retrospective analysis of data on 734 patients]. / Nicht-invasive Uberwachung von Abstossungsreaktionen nach Herztransplantation - Eine Ubersicht über die Methode und retrospektive Analyse der Daten von 734 Patienten -

BACKGROUND AND OBJECTIVE: Endomyocardial biopsy is the gold standard for monitoring rejection in cardiac recipients. The death rate due to rejection with this invasive method is 5-6 % in the first postoperative year. The aim of this retrospective data analysis from cardiac recipients was to prove the diagnostic reliability of a non-invasive electrophysiological method for rejection monitoring. PATIENTS AND METHODS: We daily analyzed the QRS-complex amplitude of the intramyocardial electrogram, which we received over a period from one year via a pacemaker with a telemetric capability. The diagnostic guideline for a suspected rejection was the reduction of the QRS-complex amplitude by more than 8 %. Out of 734 patients 558 were included in the study. Biopsy was only performed when the non-invasive rejection monitoring data (QRS-complex amplitude plus echocardiography) showed a discrepancy for rejection. RESULTS: None of the patients died due to rejection, 273 at least once underwent a biopsy, and 285 never had a biopsy. The method reached a sensitivity of 0.9777, a specificity of 0.9634, a negative predictive value of 0.9850, and a positive predictive value of 0.9459. CONCLUSION: Daily electrophysiological non-invasive monitoring of rejection seems to be superior to endomyocardial biopsy. Death of patients due to rejection can be minimised. The number of necessary biopsies can be drastically reduced when compared to the usual number performed.

Reliability of tissue Doppler wall motion monitoring after heart transplantation for replacement of invasive routine screenings by optimally timed cardiac biopsies and catheterizations.

BACKGROUND: Invasive screenings at predefined time intervals for acute rejection and transplant coronary artery disease (TxCAD) are standard procedures. However, cardiac biopsies and catheterizations are distressing and risky for the patients and are also costly. We assessed the reliability of pulsed-wave tissue Doppler imaging (PW-TDI) for the timing of invasive examinations in heart recipients in an attempt to avoid unnecessary endomyocardial biopsies (EMBs) and catheterizations. METHODS AND RESULTS: PW-TDI obtained at the basal left ventricular posterior wall before 408 EMBs and 293 catheterizations was tested for its diagnostic value regarding rejection and TxCAD with the use of International Society of Heart and Lung Transplantation biopsy grading, coronary angiography, and intravascular ultrasound as standards. Early diastolic peak wall motion velocity and relaxation time showed high sensitivities for clinically relevant rejection diagnosis (90.0% and 93.3%, respectively). The negative and positive predictive values for rejection of diastolic parameter changes appeared high enough (up to 96% and 92%, respectively) to allow a reliable noninvasive PW-TDI monitoring with efficiently timed, instead of routinely scheduled, EMBs. At definite cutoff values for systolic parameters, the probability for TxCAD reached 92% to 97%. The Fisher classification functions allowed TxCAD exclusion with 80% probability. CONCLUSIONS: Without diastolic parameter changes, acute rejection can be practically excluded, and serial PW-TDI can save patients from routine EMBs. The high specificity and negative predictive value for TxCAD of reduced systolic peak velocities and extended systolic time allow optimized timed catheterizations. Peak systolic velocity and systolic time allow diagnostic classifications that enable patients without known TxCAD but with high risk for catheterization to be spared routine angiographies.