Interobserver variability of CT angiography for evaluation of aortic annulus dimensions prior to transcatheter aortic valve implantation (TAVI).

OBJECTIVE: Assessment of aortic annulus dimensions prior to transcatheter aortic valve implantation (TAVI) is crucial for accurate prosthesis sizing in order to avoid prosthesis-annulus-mismatch possibly resulting in complications like valve dislodgement, paravalvular regurgitation or annulus rupture. Contrast-enhanced multidetector computed tomography allows 3-dimensional assessment of aortic annulus dimensions. Only limited data exist about its interobserver variability. METHODS: In 100 consecutive patients with symptomatic severe aortic stenosis (51 male, BMI 27±5kg/m(2), age 81±7 years, heart rate 72±15bpm, Logistic Euroscore 31±14%, STS-Score 7±4%), pre-interventional aortic annulus assessment was performed by dual source computed tomography (collimation 2×128×0.6mm, high pitch spiral data acquisition mode, 40-60ml contrast agents, radiation dose 3.5±0.9mSv). The following aortic annulus characteristics were determined by three independent observers: aortic annulus maximum, minimum and mean diameters (Dmax, Dmin, Dmean), eccentricity index (EI), effective aortic annulus diameter according to its circumference (Dcirc), effective aortic annulus diameter according to its area (Darea), distance from the aortic annulus plane to the left (LCA) and right coronary artery (RCA) ostia, maximum (DmaxAR) and minimum aortic root diameter (DminAR), maximum (DmaxSTJ) and minimum diameter of the sinotubular junction (DminSTJ). Subsequently, interobserver variabilities were assessed. RESULTS: Correlation between the three observers showed moderate to close agreement (between r=0.67 and r=0.97, all p<0.001). Mean differences (SE) between the three observers ranged from 0.07 (0.06)mm to 0.24 (0.07)mm for assessing the mean AA diameter (Dmean), from 0.28 (0.04)mm to 0.60 (0.06)mm for determining the effective AA diameter derived from the annulus area (Darea) and from 0.03 (0.07)mm to 0.07 (0.11)mm derived from the AA perimeter (Dcirc). For measurements of LCA and RCA distances to the AA level, mean interobserver differences (SE) ranged from 0.36 (0.07)mm to 0.76 (0.09)mm and from 0.15 (0.06)mm to 0.45 (0.11)mm. CONCLUSION: Computed tomography provides reproducible measurements of the aortic annulus and root geometry in patients scheduled for TAVI. The perimeter-derived aortic annulus diameter shows the lowest interobserver differences. Interobserver variabilities in prosthesis size recommendation were further reduced, if all three sizing methods were considered and stated as a "consensus result".

Sequential changes in myocardial function after valve replacement for aortic stenosis by speckle tracking echocardiography.

AIMS: Regional myocardial function may change differently in different pathology. Speckle tracking echocardiography (STE) was applied to evaluate longitudinal, radial, and circumferential function in patients with aortic stenosis (AS) before, within 1 week, and 6 months after aortic valve replacement (AVR). METHODS AND RESULTS: In 40 consecutive patients with severe AS, we acquired apical four-, three-, and two-chamber views and standard short-axis view pre- and post-AVR and after 6 months. Longitudinal, radial, and circumferential (LS, RS, and CS) were calculated by commercial STE software. Further, we analysed diastolic myocardial function by measuring E/e' ratio. With AVR, valve area increased and remained stable at 6 months follow-up. Left ventricular mass was unchanged 1 week after AVR (270 +/- 58 g vs. 267 +/- 58 g, n.s.) but decreased significantly during the next 6 months (219 +/- 50 g, P < 0.05). Left ventricular ejection fraction remained unchanged. Strain values did not change significantly within 1 week after AVR but increased significantly after 6 months (LS by 16%, RS by 21%, and CS by 28% of baseline values). E/e' ratio was highly augmented before AVR (26.1 +/- 12.5) and decreased significantly 6 months after AVR (15.9 +/- 5.9). CONCLUSION: Myocardial function significantly recovers after replacing the stenosed aortic valve. However, there is a considerable difference between the response of longitudinal, radial, and circumferential function. Our data suggest that echocardiographic assessment of regional function is feasible and of potential clinical importance.

CD40/CD154 system and pro-inflammatory cytokines in young healthy male smokers without additional risk factors for atherosclerosis.

OBJECTIVE AND DESIGN: Atherosclerosis, as an inflammatory disease, is characterized by pathologically altered levels of cytokines. We investigated whether smoking affects the CD40/CD154 system and pro-inflammatory cytokines in young males without other risk factors for atherosclerosis. SUBJECTS: Young male smokers (n=13) and 14 non-smoking controls were investigated. METHODS: The differences in CD40/CD154 system and serum cytokines between the groups were measured using flow cytometry and ELISA. RESULTS: In smokers, there was a strong trend (P<0.06) for increased CD40 expression on platelets as compared with non-smokers. However, there were no significant differences in CD40 expression on monocytes or in CD154 expression on platelets and T-cells between smokers and non-smokers. There was a strong trend for increased platelet-monocyte aggregates in smokers (P<0.06). Also, smokers had slightly but not significantly elevated hsCRP and IL-6 levels, and slightly decreased TNF-alpha and MCP-1. Interestingly, IL-18, a cytokine which has the ability to promote both Th1 and Th2 responses, was significantly decreased in smokers group (P=0.03 vs controls). CONCLUSIONS: In young healthy males, smoking is not associated with dramatic changes in CD40/CD154 system. However, cigarette smoke alters the secreted cytokine profile, leading to significant decrease in systemic IL-18 levels.

Increased prolactin in acute coronary syndromes as putative Co-activator of ADP-stimulated P-selectin expression.

Prolactin and leptin are newly recognized platelet co-stimulators due to enhancement of ADP-induced platelet aggregation. The aim of our study was to assess whether both hormones prolactin and leptin play a role as co-activators of platelet activation in patients with acute coronary syndromes. Twenty-one patients with acute coronary syndromes, 10 with stable angina pectoris and 10 controls were studied. Patients with acute coronary syndromes showed significantly higher prolactin and leptin values and a significant increased P-selectin expression on platelets compared to patients with stable angina pectoris or controls. However, patients with acute myocardial infarction as a subgroup of acute coronary syndromes showed the highest prolactin levels as well as ADP stimulated P-selectin expression. In the myocardial infarction subgroup prolactin values showed a significant correlation to ADP stimulated P-selectin expression on platelets (r (2)=0.41; p=0.025), whereas leptin was not correlated. Our data indicate an association between increased prolactin values and enhanced P-selectin expression on platelets in patients with acute coronary syndromes. Therefore, the stress hormone prolactin could be a co-stimulator of platelet activation in these patients. In contrast, the putative platelet activator leptin does not seem to play a major role in acute coronary syndromes.

Simultaneous hemodialysis during coronary angiography fails to prevent radiocontrast-induced nephropathy in chronic renal failure.

BACKGROUND: Radiocontrast medium- (RM) associated nephrotoxicity continues to be a common cause of acute renal failure and may lead in patients with pre-existing chronic renal insufficiency even to end-stage renal failure requiring chronic dialysis. Since extracorporeal removal of RM after RM administration has been shown to be effective but does not prevent radiocontrast-induced nephropathy, the effect of a simultaneous dialysis during RM administration on renal function is not clear. METHODS: In a prospective, randomized and controlled trial, we studied the effect of a 4-hour online dialysis during RM (iomeprol) application in patients with advanced chronic renal failure (serum creatinine > or = 3 mg/dl) undergoing coronary angiography. All patients received hydration with saline before and after standardized coronary angiography and were randomized to receive a simultaneous high-flux hemodialysis (7 patients, HD group) or to control group (10 patients). 24-hour creatinine clearance (CrCl) was measured in all patients before, 1 week and 8 weeks after coronary angiography. The clinical follow-up comprised 8 weeks after RM application. RM plasma levels were measured in both groups 15, 30, 60 minutes, 2, 4, 12, 24, 48 and 72 hours after application by high-pressure liquid chromatography. RESULTS: At baseline, CrCl (19 +/- 10 vs 17 +/- 7 ml/min), percentage of diabetics (57 vs 70%) and dose of RM (77 +/- 27 vs 86 +/- 21 ml) were similar in both groups. Pharmacokinetics: Total clearance of iomeprol was significantly higher (54 +/- 15 vs 20 +/- 12 ml/min, p < 0.001) and the area under curve (AUC) was significantly lower (23 +/- 10 g x h/l vs 94 +/- 57 g x h/l, p < 0.001) in the HD group compared to control group. RM peak plasma levels 15 min after application were not different in both groups (3.0 +/- 1.1 vs 4.2 +/- 1.7 mmol/l, NS), however, significantly lower 60 min (1.6 +/- 0.4 vs 3.7 +/- 1.5 mmol/l, p < 0.01) and 240 min (0.7 +/- 0.3 vs 2.3 +/- 0.7 p < 0.001) after angiography. CLINICAL RESULTS: CrCl showed no difference 1 week (24 +/- 11 vs 19 +/- 9 ml/min, ns) and 8 weeks (24 +/- 5 vs 20 +/- 9 ml/min, NS) after angiography from baseline or between the groups. In each group, 2 patients developed end-stage renal disease and requested permanent dialysis during the 8-week follow-up. CONCLUSION: Simultaneous dialysis reduces AUC of iomeprol significantly, however, does not influence plasma peak concentration after angiography. Renal function and incidence of end-stage renal failure were not influenced by online-dialysis.

Initial experience with the Endicor X-sizer thrombectomy device in patients with ST segment elevation myocardial infarction.

We investigated 16 patients with ST segment elevation myocardial infarction who had an occluded coronary artery (TIMI 0) at initial angiogram. Instead of balloon angioplasty and stenting, patients were subjected to thrombectomy (Endicor X-sizer) and stenting. In 15/16 patients the occlusion could be crossed by the thrombectomy device resulting in TIMI flow 3 in all of them. Thereafter, stenting was performed. At final angiogram all 15 patients continued to show TIMI flow grade 3. Twelve-lead ECG was performed prior to and post-intervention. ST elevation was measured as the sum of eight leads for anterior infarction and of five leads for inferior infarction. In 13/15 patients, ECG analysis was possible (2 developed bundle branch block post-intervention). In all 13 patients, a > 50% ST decrease of the initial amount of ST elevation was observed reaching a > 70% reduction in 11 patients. Procedural complications were low (one coronary dissection after thrombectomy) and 30 days follow-up was uneventful. Thrombectomy using the Endicor X-Sizer device may become an attractive mechanical reperfusion strategy for patients with acute myocardial infarction.

Patients with acute coronary syndromes express enhanced CD40 ligand/CD154 on platelets.

OBJECTIVE: To investigate whether CD40L/CD154 on platelets and soluble CD40L/CD154 may play a role in the inflammatory process of acute coronary syndromes. DESIGN AND SETTING: Observational study in a university hospital. PATIENTS: 15 patients with acute myocardial infarction, 25 patients with unstable angina, 15 patients with stable angina, and 12 controls. MAIN OUTCOME MEASURES: CD40L/CD154 on platelets, P-selectin/CD62P on platelets, soluble CD40L/CD154 serum concentrations. RESULTS: Mean (SD) CD40L/CD154 expression on platelets was 6.2 (2.8) MFI (mean fluorescence intensity) in the infarct group, 11 (3.3) MFI in the unstable angina group (p < 0.001 v infarction), 3.6 (0.9) MFI in the stable angina group (p < 0.01 v infarction; p < 0.001 v unstable angina), and 3.2 (1.0) MFI in the controls (p < 0.01 v infarction; p < 0.001 v unstable angina; NS v stable angina). Soluble CD40L/CD154 concentration was 5.2 (1.1) ng/ml in the infarct group, 4.2 (0.7) ng/ml in the unstable angina group (p < 0.001 v infarction), 2.9 (1.0) ng/ml in stable angina group (p < 0.001 v infarction and unstable angina), and 3.0 (0.5) ng/ml in the controls (p < 0.001 v infarction and unstable angina; NS v stable angina). At a six months follow up, there was lower expression of CD40L/CD154 on platelets in patients with unstable angina (12.3 (3.6) v 3.8 (1.2) MFI, p < 0.0001) and acute myocardial infarction (6.2 (2.8) v 3.5 (0.8) MFI, p < 0.01) compared with their admission values six months earlier. Patients with unstable angina who needed redo coronary angioplasty (PTCA) or who had recurrence of angina were characterised by increased CD40L/CD154 expression on platelets compared with the remainder of the study group (recurrence of angina: 12.7 (3.2) v 9.7 (1.6) MFI, p < 0.05; re-do PTCA: 14.3 (4.2) v 10.3 (2.1) MFI, p < 0.05). CONCLUSIONS: Both CD40L/CD154 on platelets and soluble CD40L/CD154 are raised in patients with unstable angina and myocardial infarction. These findings suggest that CD40-CD40L/CD154 interactions may play a pathogenic role in triggering and propagation of acute coronary syndromes.

[Transesophageal imaging of a coronary fistula in simultaneous endocarditis lenta]. / Transösophageale Darstellung einer Koronarfistel bei gleichzeitiger Endocarditis lenta.

A 61 year old diabetic patient with bacterial endocarditis probably caused by a congenital coronary fistula is presented. The fistula was already detected by transthoracic echocardiography. Transesophageal color-Doppler echocardiography identified the precise localization and course of the fistula. Additionally, in some parts of the fistula echogenic material could be seen that decreased in size after antibiotic treatment. Therefore, it was considered as corresponding to bacterial vegetations. Coronary angiography disclosed an ectopic aneurysmatic and elongated circumflex coronary artery. Thus, even in rare conditions such as coronary fistulas transesophageal echocardiography may be helpful to allow detection of morphological substrate of associated infective endocarditis.

The trigonometric regressive spectral analysis--a method for mapping of beat-to-beat recorded cardiovascular parameters on to frequency domain in comparison with Fourier transformation.

Heart rate and peripheral blood pressure as physiological recorded vegetative parameters are very often rhythmically investigated with the Fourier Transformation (FT). In contrast to the original use of FT these parameters are still stochastic with overlaying rhythmical structures. The R-R intervals as independent variables of time are not equidistant. The mathematical structure for the spectral decomposition is critically analysed. The purpose of this article is the presentation of a mathematical method, considering both the statistical and rhythmical features of such time series. On the basis of trigonometric regressions, this method is presented to eliminate the equidistance problems, arising with the usage of FT, by a new mathematical approach. This method computes more precisely the spectral power especially in the VLF range (0.003-0.04 Hz) than FT, because this method of trigonometric regression does not perform a frequency quantization. This method has been used and successfully tested for the analysis of peripheral blood pressure and R-R intervals including an effective reduction of input data.