Interdisciplinary consensus on indications for transfemoral transcatheter aortic valve implantation (TF-TAVI) : Joint Consensus Document of the Arbeitsgemeinschaft Leitende Kardiologische Krankenhausärzte e.V. (ALKK) and cooperating Cardiac Surgery Departments.

Indications for TF-TAVI (transfemoral transcatheter aortic valve implantation) are rapidly changing according to increasing evidence from randomized controlled trials. Present trials document the non-inferiority or even superiority of TF-TAVI in intermediate-risk patients (STS-Score 4-8%) as well as in low-risk patients (STS-Score < 4%). However, risk scores exhibit limitations and, as a single criterion, are unable to establish an appropriate indication of TF-TAVI vs transapical TAVI vs SAVR (surgical aortic valve replacement). The ESC (European Society of Cardiology)/EACTS (European Association for Cardio-Thoracic Surgery) guidelines 2017 and the German DGK (Deutsche Gesellschaft für Kardiologie)/DGTHG (Deutsche Gesellschaft für Thorax-, Herz- und Gefäßchirurgie) commentary 2018 offer a framework for the selection of the best therapeutic method, but the individual decision is left to the discretion of the heart teams. An interdisciplinary TAVI consensus group of interventional cardiologists of the ALKK (Arbeitsgemeinschaft Leitende Kardiologische Krankenhausärzte e.V.) and cardiac surgeons has developed a detailed consensus on the indications for TF-TAVI to provide an up-to-date, evidence-based, comprehensive decision matrix for daily practice. The matrix of indication criteria includes age, risk scores, contraindications against SAVR (e.g., porcelain aorta), cardiovascular criteria pro TAVI, additional criteria pro TAVI (e.g., frailty, comorbidities, organ dysfunction), contraindications against TAVI (e.g., endocarditis) and cardiovascular criteria pro SAVR (e.g., bicuspid valve anatomy). This interdisciplinary consensus may provide orientation to heart teams for individual TAVI-indication decisions. Future adaptations according to evolving medical evidence are to be expected. Interdisciplinary consensus on indications for transfemoral transcatheter aortic valve implantation (TF-TAVI).

Percutaneous extraction of an abandoned coiled pacing lead.

Abandoning redundant pacing leads has been an accepted practice in most cases. Late migration of a lead is a rare, unpredictable, and potentially lethal complication of this approach and requires immediate removal. We report the case of an atrial pacing lead that had migrated and was found coiled in the right atrium. It was removed by a snare catheter via a femoral approach.

Inappropriate implantable defibrillator discharge caused by a retained pacemaker lead fragment.

INTRODUCTION: Inappropriate discharge is still a major issue of implantable cardioverter defibrillator therapy. The diagnostic options of modern devices facilitate classification of the underlying abnormality. METHODS AND RESULTS: A 65-year-old woman with depressed left ventricular performance received spurious shocks from an ICD, implanted for ventricular tachycardia. A lead fragment of an explanted VVI pacemaker system could be identified as cause of erroneous ventricular fibrillation detection by the ICD. The electrical noise caused by interaction between the lead remnant and the ICD lead was detectable even on the surface ECG. CONCLUSION: Based on our findings, removal of fragmented lead material should be considered prior to ICD implantation, to avoid potentially adverse and harmful interactions with ICD systems.

Laser angioplasty of restenosed coronary stents: results of a multicenter surveillance trial. The Laser Angioplasty of Restenosed Stents (LARS) Investigators.

OBJECTIVES: This study evaluated safety and efficacy of excimer laser angioplasty for treatment of restenosed or occluded coronary stents. BACKGROUND: Balloon angioplasty of in-stent restenosis is limited by a high recurrence rate. Debulking by laser angioplasty is a novel concept to treat in-stent restenosis. METHODS: A total of 440 patients with restenoses or occlusions in 527 stents were enrolled for treatment with concentric or eccentric laser catheters and adjunctive balloon angioplasty. RESULTS: Laser angioplasty success (< or =50% diameter stenosis after laser treatment or successful passage with a 2.0-mm or 1.7-mm eccentric laser catheter) was achieved in 92% of patients. Adjunctive balloon angioplasty was performed in 99%. Procedural success (laser angioplasty success followed by < or =30% stenosis with or without balloon angioplasty) was 91%. There was neither a significant difference in success with respect to lesion length, nor were there differences between small and large vessels or native vessels and vein grafts. Success was higher and residual stenosis lower using large or eccentric catheters. Serious adverse events included death (1.6%, not directly laser catheter related), Q-wave myocardial infarction (0.5%), non-Q-wave infarction (2.7%), cardiac tamponade (0.5%) and stent damage (0.5%). Perforations after laser treatment occurred in 0.9% of patients and after balloon angioplasty in 0.2%. Dissections were visible in 4.8% of patients after laser treatment and in 9.3% after balloon angioplasty. Reinterventions during hospitalization were necessary in 0.9% of patients; bypass surgery was performed in 0.2%. CONCLUSIONS: Excimer laser angioplasty with adjunctive balloon angioplasty is a safe and efficient technology to treat in-stent restenoses. These data justify a randomized comparison with balloon angioplasty.

[Löffler fibroblastic endocarditis in the thrombotic stages in isolated right ventricular tissue eosinophilia]. / Endokarditis fibroplastica Löffler im thrombotischen Stadium bei isolierter rechtsventrikulärer Gewebe-Eosinophilie.

We report on a male, 31 year old, Turkish patient with an intracardiac mass in the right ventricle, reduction of performance and weight, as well as intermittent fever. No eosinophilia was documented in the peripheral blood; cardiac function was primarily normal. Besides the differential diagnosis of Löffer's endocarditis (endomyocardial fibrosis) an inflammatory disease and a malignant cardiac tumor were suggested. The diagnosis of Löffler's endocarditis could not be confirmed morphologically by echocardiography nor histologically by right ventricular biopsy. Operative removal of the mass lesion was necessary because of fast tumor progression, fulminant pulmonary embolism, and infiltration of the tricuspid valve. Only then, histologically Löffler's eosinophilic endocarditis of thrombotic stage was diagnosed. Antiphlogistic therapy with cortisone was initially performed. With a dose reduction after 6 months, a relapse of the thrombotic mass occurred. Therefore, continuous treatment with cortisone and azathioprine was induced followed by further tumor regression and further clinical stabilization since 8 months of treatment.

[Acute posterior wall infarct after factor VIII concentrate administration to a patient with severe hemophilia A]. / Akuter Hinterwandinfarkt nach Faktor-VIII-Konzentrat bei schwerer Hämophilie A.

HISTORY AND CLINICAL FINDING: A 69-year-old man with severe haemophilia A sustained an acute myocardial infarction (MI) after self-administration of 3000 units factor VIII over 10 min. On admission he had no signs of heart failure. INVESTIGATIONS: The ECG showed an acute posterior wall MI. Creatinekinase rose to a maximum of 321 U/l with a significant MB proportion. The echocardiogram demonstrated hypokinesia of the posterior wall. TREATMENT AND COURSE: After initial thrombolysis treatment with a total of 100 mg rtPA according to an accelerated scheme coronary angiography, performed because the symptoms persisted, revealed two-vessel disease. A subtotal stenosis of the right coronary artery was balloon-dilated with good primary results. Regular factor VIII substitution was temporarily administered with the aim of initially achieving high normal levels of factor VIII activity. CONCLUSION: Factor VIII substitution in haemophilia A may promote thrombotic complications. Thrombolytic treatment and balloon angioplasty of acute MI can be successfully performed even in patients with severe haemophilia A.

Changes in platelet size and count in unstable angina compared to stable angina or non-cardiac chest pain.

AIMS: An increase in platelet aggregability is associated with unstable angina and myocardial infarction. Platelet size and activity correlate and mean platelet volume was found to be increased before acute myocardial infarction. We measured the mean platelet volume and platelet count in patients with stable angina, unstable angina and non-cardiac chest pain. METHODS AND RESULTS: We studied 981 patients (734 men; 247 women) defined clinically as stable angina (n = 688), unstable angina (n = 108) and unstable angina requiring immediate angioplasty (n = 52). After coronary angiography the patients were subdivided into single (n = 269), double (n = 304) and triple-vessel disease (n = 311) and the control group of non-cardiac chest pain (n = 97). There was no significant difference in platelet count between the control group and patients with 1, 2, or 3-vessel disease. However, the platelet size in patients with coronary artery disease was significantly larger (single: 8.7 +/- 1.19 fl; double: 8.7 +/- 1.12 fl; triple-vessel disease: 8.8 +/- 1.18 fl) than the control group (8.2 +/- 0.95 fl) (P < 0.01). Patients with stable angina similarly had no, significant difference in platelet count compared to the control group but did have a significantly increased mean platelet volume (8.7 +/- 1.13; P < 0.01). In contrast, patients with unstable angina had a decreased platelet count (245 +/- 56 x 10/l) compared to either stable angina (262 +/- 62 x 10/l; P < 0.05) or the control group (261 +/- 58 x 10/l; P < 0.05); furthermore, the mean platelet volume (9.4 +/- 1.23 fl) was significantly greater than for stable angina (P < 0.01). Patients with unstable angina requiring immediate PTCA had an even lower platelet count (231 +/- 55 x 10/l) and higher mean platelet volume (10.4 +/- 1.03 fl) (P < 0.01) than the rest of the population with unstable angina. CONCLUSIONS: In stable angina the platelet count is unchanged compared to patients with normal coronary arteries but the platelet size is increased. However, in unstable angina there is a decrease in platelet count and an even larger increase in platelet size. We interpret this as meaning that unstable angina might be associated or preceded by an increase in platelet destruction rate that is not completely compensated for by an increase in platelet production rate. The large, more reactive platelets might be causally related to an ongoing coronary artery obstruction in unstable angina.

N-acetylcysteine attenuates nitroglycerin tolerance in patients with angina pectoris and normal left ventricular function.

The aim of this study was to assess whether N-acetylcysteine (NAC) is able to prevent tolerance to a 48-hour infusion of nitroglycerin (NTG) in the setting of normal left ventricular function. In 16 patients, the hemodynamic response to 0.8 mg sublingual (s.l.) NTG was assessed by measuring mean arterial, pulmonary artery, pulmonary capillary wedge and right atrial pressures, cardiac output, and calculation of the systemic and pulmonary vascular resistances. The parameters were obtained at baseline and 1 to 10 minutes after the s.l. NTG application (day 1). NTG was started at 1.5 microg/kg/min; concomitantly, a bolus of 2,000 mg of NAC was administered, followed by an infusion of 5 mg/kg/hour. Both infusions were continued for 48 hours, and the hemodynamic study was repeated (day 3). The same measurements were obtained in a matched control group of 15 patients with NTG infusion alone. Plasma renin activity, aldosterone, and norepinephrine were measured before and after the infusion period. The first s.l. NTG infusion (day 1) caused a significant decrease in mean arterial (p <0.01), pulmonary artery (p <0.001), and right atrial pressures (p <0.001), and in systemic (p <0.01) and pulmonary vascular resistances (p <0.001) in both groups. After the 48-hour infusion (day 3), there was a total loss of nitrate-mediated vasodilation (pressure values and vascular resistances day 3 > day 1) in 5 of 16 patients (NAC nonresponders), whereas in the other 11 of 16 patients (NAC responders), there was significant vasodilation throughout the infusion period. Tolerance had developed in 14 of 15 patients with NTG infusion alone. The same difference (responder vs nonresponder vs NTG alone) held true regarding the response to the second s.l. NTG infusion after 48 hours. The neurohormonal counter-regulation and intravascular volume expansion (increase in plasma renin activity, p <0.001, and norepinephrine, p <0.05; decrease in aldosterone, p <0.01) did not differ between responders and nonresponders. We conclude that NAC attenuates tolerance development to a continuous NTG infusion in a specific patient subgroup and that this occurs despite the same amount of neurohormonal counter-regulation and intravascular volume expansion compared with patients with tolerance development.

[Persistent dilatation of non-stenosed epicardial arteries in 24- and 48-hour nitroglycerin infusion]. / Persistierende Dilatation nichtstenosierter Epikardarterien unter 24- und 48stündiger Nitroglycerin-Infusion.

UNLABELLED: It is still a matter of dispute to what extent a direct loss of nitrate mediated vasodilatation (true tolerance) contributes to the development of nitrate tolerance. Aim of this study was to assess to what extent the dilatation of non-obstructed segments of epicardial arteries is attenuated during a continuous 24- and 48-h-infusion of nitroglycerin. In a prospective, randomized and blinded study we investigated 32 patients who underwent diagnostic coronary angiography. All cardiac medication was withdrawn at least for 24 h; patients were randomized to either a 24 h NTG-infusion (group A; 0-24 h saline infusion followed by a 24 h NTG-infusion; n = 16) or a 48 h NTG-infusion (group B; 0-48 h of NTG-infusion; n = 16) in a dosage of 1.5 micrograms/ kg/min. The patients were included if 5 proximal segments of the left coronary artery showed no visible atherosclerosis. A coronary angiography was performed after 24 and 48 h respectively. The lumen diameters were measured by quantitative coronary analysis at baseline and 1 and 3 min after application of 0.2 mg of NTG intracoronarially (i.c.). Blood samples were drawn before and after 24 and 48 h of infusions to measure hematocrit and neurohormones. In group A after 24 h of saline infusion there was a significant increase in lumen diameter from 3.14 +/- 0.17 mm at baseline to 3.51 +/- 0.11 mm (p < 0.001) and 3.60 +/- 0.21 mm (p < 0.001) after 1 and 3 min of NTG i.e. respectively. After 24 h of NTG-infusion there were no significant changes in baseline and values after further NTG i.e. In group B after 24 h of NTG-infusion no significant change in lumen diameter was detectable after NTG i.e. (3.57 +/- 0.23 mm to 3.63 +/- 0.13 mm) and the mean diameter remained unchanged after prolongation of NTG to 48 h (3.58 +/- 0.33 mm). There were no significant differences between the baseline values and the responses to i.e. NTG after 24 and 48 h of NTG infusion. Hematocrit and aldosterone levels decreased significantly after NTG-infusion but not following saline. Renin and norepinephrine remained unchanged throughout the NTG-infusion-periods. IN CONCLUSION: The vasodilatation of non-obstructed segments of epicardial arteries persists during a prolonged infusion period and there is no induction of vascular tolerance between the 24 and 48 h infusion period. These findings further support that there is a different susceptibility of arteries and veins to nitrate tolerance.

[Community-acquired pneumonia requiring inpatient treatment: outcome and prognostic rule]. / Stationär behandlungspflichtige ambulant erworbene Pneumonien: Ausgang und prognostische Regel.

OBJECTIVE: Mortality in community-acquired pneumonia (CAP) may be reduced by early identification of patients requiring intensive care treatment. The purpose of the study was to determine prognostic factors of outcome in patients with CAP in order to establish a clinically applicable discriminant rule. METHODS: 93 episodes of 92 patients with CAP were reviewed with regard to epidemiological, clinical, laboratory and microbiologic data. The prognostic analysis included a univariate as well as a multivariate approach in order to identify parameters correlated with death using the Cox regression hazard function in a backward stepwise selection model. The three parameters found to contribute most to the significance of the model were used in a discriminant rule for classification of outcome. RESULTS: The parameters found to be significantly different between survivors and non-survivors were heart rate, systolic, diastolic as well as mean blood pressures, leucocyte count, percentage of laymphocytes, and LDH values. The multivariate analysis revealed that heart rate, systolic arterial pressure, and LDH serum levels were associated best with lethal outcome (overall significance of the model p < 0.005). A prognostic rule composed of the variables heart rate > or = 90 beats/min, systolic arterial blood pressure < or = 80 mmHg and LDH > or = 260 U/l achieved a sensitivity of 77%, a specificity of 75% and positive and negative predictive values of 42% and 93%, respectively. It was associated with a 6-fold increased risk of lethal outcome. CONCLUSIONS: Heart rate, systolic blood pressure, and LDH values were associated best with death in a multivariate analysis. A discriminant rule consisting of these three variables achieved favourable classification results. The rule qualifies for further prospective validation and may prove useful in the management of hospital treated CAP.

[Sleep apnea as a risk marker in coronary heart disease]. / Schlafapnoe als Risikomarker bei koronarer Herzkrankheit.

UNLABELLED: Obstructive sleep apnea (OSA) and coronary heart disease (CHD) are both frequent in the middle ages. Both disease share a similar spectrum or risk factors and attendant diseases. The aim of the study was to determine the prevalence of obstructive sleep apnea in patients with coronary heart disease diagnosed by coronary angiography. Furthermore, influence of sleep apnea and attendant diseases and risk factors for coronary heart disease, especially the risk for myocardial infarction and reduced left ventricular ejection fraction, was investigated. We included in this study 143 patients (121 men, 22 women mean age 60 +/- 8 years (35-81) who underwent coronary angiography because of angina pectoris or were suspicious for CHD due to noninvasive investigations. These patients has symptoms of OSA based on a standardized questionnaire. They underwent a four-channel screening with a non-laboratory-monitoring-system (NLMS) for detection of sleep-related breathing disorders. In addition, spectrum of risk factors and concomitant diseases were considered. Sleep apnea was more frequent in patients with CHD (30.6%) in comparison to patients without CHD (21.8%), but did not reach statistical significance. Patients with CHD and OSA had a significantly higher frequency of a history of myocardial infarction and had a significantly lower left ventricular ejection fraction than patients without OSA. IN CONCLUSION: Patients with the combination of OSA and CHD are at higher risk for myocardial infarction and reduced left ventricular ejection fraction. Patients with CHD should be screened for OSA in case of secondary prevention.

Influence of captopril on nitroglycerin-mediated vasodilation and development of nitrate tolerance in arterial and venous circulation.

We investigated whether captopril is able to potentiate vasodilation and prevent tolerance to a 48-hour infusion of nitroglycerin (NTG). Twenty-six patients were randomly assigned to a 7-day regimen of captopril (50 mg/day) or placebo. The hemodynamic response to a 0.8 mg sublingual NTG dose was assessed by measuring mean arterial pressure (MAP), mean pulmonary artery pressure (PAP), pulmonary capillary wedge pressure (PCWP), right atrial pressure (RAP), and cardiac output (CO), and calculating systemic (SVR) and pulmonary vascular resistances (PVR). The parameters were obtained serially at baseline and 1 to 10 minutes after the sublingual NTG application (day 1). Then intravenous NTG was started and maintained for 48 hours (1.5 micrograms/kg/min), and the hemodynamic study was repeated (day 3). There was no difference between the captopril and the placebo groups at day 1 (baseline values and response to sublingual NTG). After the 48-hour infusion, there was a complete loss of the NTG effects in the placebo group (day 1 vs day 3: PAP, 20 +/- 5 mm Hg vs 21 +/- 8 mm Hg; MAP, 86 +/- 11 mm Hg vs 90 +/- 9 mm Hg; SVR, 1295 +/- 330 mm Hg vs 1380 +/- 465 dyne.sec.cm-5) whereas there was still evidence of a persistent vasodilation in the captopril group (day 1 vs day 3: PAP, 19 +/- 4 mm Hg vs 13 +/- 4 mm Hg; MAP, 84 +/- 9 mm Hg vs 74 +/- 10 mm Hg; SVR, 1265 +/- 280 mm Hg vs 1140 +/- 425 dyne.sec.cm-5). The response to sublingual NTG on day 3 was markedly attenuated in the placebo group only. We conclude that captopril does not increase the vasodilatory response to nitroglycerin but is able to prevent developing nitrate tolerance in arterial and venous circulation.

Valvular aortic stenosis: risk of syncope.

BACKGROUND AND AIMS: Syncope is a serious complication of aortic stenosis. The aim of this study was to determine whether hemodynamic parameters are useful for estimating the risk of syncope in aortic stenosis. METHODS: In 43 patients with aortic stenosis, cardiac catheterization and echocardiography were performed to measure the pressure gradient across the aortic valve, the aortic valve area, left ventricular mass index, systolic left ventricular wall stress and peak systolic coronary artery flow velocities. Hemodynamic parameters were correlated with syncope and the accuracy of those parameters for determining the risk of syncope were assessed. RESULTS: Ten out of 43 patients experienced syncope. The highest correlation with syncope was found for systolic left ventricular wall stress (R = 0.74, p < 0.001). In descending order of correlation were peak systolic coronary artery flow velocity (R = 0.68, p = 0.002), the pressure gradient across the aortic valve (R = 0.62, p = 0.01) and the aortic valve area (R = 0.43, p = 0.03). Left ventricular mass index was not significantly correlated with syncope. Multivariate analysis revealed systolic left ventricular wall stress to be the only factor contributing to determining syncope (F-to-remove: 47.8). A discriminative value of > 225 dyn/cm-2 x 103 for left ventricular wall stress identified patients with a history of syncope with a specificity of 97% and a sensitivity of 90%. CONCLUSIONS: Syncope in aortic stenosis is closely correlated to increased left ventricular wall stress and attenuated, peak systolic coronary flow velocities. Cut off values may be used to identify patients with an increased risk of syncope.

Clinical characteristics and outcome of Pneumocystis carinii pneumonia in HIV-infected and otherwise immunosuppressed patients.

The factors contributing to unequal mortality rates following Pneumocystis carinii pneumonia (PCP) in different groups at risk are poorly understood. We therefore compared the first episodes of PCP without prophylaxis in human immunodeficiency virus infected (HIV) and otherwise immunosuppressed patients in this retrospective study. A total of 58 HIV-infected and 16 otherwise immunosuppressed patients were analysed. The comparison included epidemiological, clinical, laboratory, radiological and microbiological data, as well as therapy and clinical course. A prognostic analysis was performed using a logistic regression model. The mortality was significantly different in the two groups (HIV group 17 versus non-HIV group 50%). Renal transplant patients had a higher survival rate as compared to malignancy or collagen vascular disease as underlying diseases at risk. Acute respiratory failure was more common in the non-HIV group. Variables found to be significantly associated with lethal outcome in univariate analysis were alveolar to arterial pressures difference for oxygen (P(A-a),O2), haemoglobin, platelet count, total protein, serum albumin, and gamma-globulins in the HIV-group, and serum albumin in the non-HIV group. In the multivariate analysis of the HIV group, platelet count and gamma-globulins remained independent prognostic factors. In conclusion, in the HIV-group, mortality is closely related to the severeness of PCP as well as to the severeness of the acquired immune deficiency syndrome (AIDS) disease. In the non-HIV group, malignancy and collagen vascular disease as underlying conditions at risk account for the high mortality rate. Its severeness was mainly reflected by serum albumin, which represented the only variable found to be significantly associated with death in both groups.

Prognostic analysis and predictive rule for outcome of hospital-treated community-acquired pneumonia.

In community-acquired pneumonia (CAP) mortality may be reduced by early identification of patients requiring intensive care treatment. The purpose of this study was to determine prognostic factors of outcome in patients with CAP in order to establish a clinically applicable discriminant rule. Ninety three episodes of CAP in 92 patients were retrospectively reviewed with regard to epidemiological, clinical, laboratory and microbiological data. The prognostic analysis included a univariate as well as a multivariate approach, in order to identify parameters associated with death using the Cox regression hazard function in a backward stepwise selection model. The three parameters found to contribute most to the significance of the model were used in a discriminant rule for classification of outcome. The parameters found to be significantly different between survivors and non-survivors were heart rate, systolic and diastolic as well as mean blood pressures, leucocyte count, percentage of lymphocytes, and lactate dehydrogenase (LDH) values. The multivariate analysis revealed that heart rate, systolic arterial pressure, and LDH serum levels were most closely associated with fatal outcome. A prognostic rule composed of the variables heart rate > or = 90 beats.min-1, systolic arterial blood pressure < or = 80 mmHg, and LDH > or = 260 U.l-1 achieved a sensitivity of 77%, a specificity of 75%, and positive and negative predictive values of 42 and 93%, respectively. It was associated with a six fold increased risk of fatal outcome. In conclusion, heart rate, systolic blood pressure, and LDH values were most closely associated with death in a multivariate analysis.(ABSTRACT TRUNCATED AT 250 WORDS)

Paraprosthetic regurgitation in aortic prostheses: determination of the hemodynamic significance by pulsed Doppler examination of the subclavian artery flow.

Paraprosthetic leaks in aortic prostheses may cause significant aortic regurgitation. Color flow Doppler echocardiography is the method of choice for detecting paraprosthetic leaks, but quantitation of regurgitation is limited by this method. This study investigated the value of pulsed Doppler of the left subclavian artery flow for assessing the hemodynamic significance of paraprosthetic regurgitation in aortic prostheses in 32 patients with, and in 77 control subjects without paraprosthetic leaks. Paraprosthetic leaks were either detected by transthoracic or transesophageal color flow echocardiography. The hemodynamic significance of paraprosthetic regurgitation was determined by means of a dichotomous angiographic classification - significant versus insignificant regurgitation. Pulsed Doppler was performed to measure the maximal diastolic and systolic velocities, and diastolic and systolic velocity-time-integrals (VTI) and their ratios in the subclavian artery flow. The accuracy of these parameters for differentiating significant versus insignificant regurgitation was assessed. Angiography revealed 13 significant and 19 insignificant forms of aortic regurgitation. In all patients, examination of the subclavian artery was feasible by pulsed Doppler. The highest correlation between Doppler derived parameters and regurgitation was calculated for the ratios of diastolic and systolic VTI (r = 0.84), diastolic VTI (r = 0.82) and ratio of diastolic and systolic velocities (r = 0.80). An increase of the ratio of diastolic and systolic VTI (> 45%) and ratio of diastolic to systolic velocity (> 0.4), and increased diastolic VTI (> 60 cm) in the subclavian artery velocity profile identified significant paraprosthetic regurgitation with a sensitivity of 94%, 75% and 87%, and specificity of 87%, 80% and 87%, respectively.(ABSTRACT TRUNCATED AT 250 WORDS)