Complications of pelvic and acetabular fractures in 1331 morbidly obese patients (BMI ≥ 40): a retrospective observational study from the National Trauma Data Bank.

BACKGROUND: There have been no large-scale epidemiological studies of outcomes and perioperative complications in morbidly obese trauma patients who have sustained closed pelvic ring or acetabular fractures. We examined this population and compared their rate of inpatient complications with that of control patients. METHODS: We retrospectively reviewed the records of patients treated for closed pelvic ring or acetabular fracture, aged 16-85 years, with Injury Severity Scores ≤15 from the National Trauma Data Bank Research Dataset for the years 2007 through 2010. The primary outcome of interest was rate of in-hospital complications. Secondary outcomes were length of hospital stay and discharge disposition. Unadjusted differences in complication rates were evaluated using Student t tests and Chi-squared analyses. Multiple logistic and Poisson regression were used to analyze binary outcomes and length of hospital stay, respectively, adjusting for several variables. Statistical significance was defined as p < 0.05. RESULTS: We included 46,450 patients in our study. Of these patients, 1331 (3%) were morbidly obese (body mass index ≥40) and 45,119 (97%) were used as controls. Morbidly obese patients had significantly higher odds of complication and longer hospital stay in all groups considered except those with pelvic fractures that were treated operatively. In all groups, morbidly obese patients were more likely to be discharged to a skilled nursing/rehabilitation facility compared with control patients. CONCLUSIONS: Morbidly obese patients had higher rates of complications and longer hospital stays and were more likely to be discharged to rehabilitation facilities compared with control patients after pelvic ring or acetabular fracture.

Risk factors for clinical events at 1-year follow-up after drug-eluting stent implantation: results from the prospective multicenter German DES.DE registry.

BACKGROUND: Drug-eluting stents (DES) have substantially reduced target vessel revascularization (TVR) after percutaneous coronary interventions. Risk factors for clinical events need to be redefined with this treatment option. METHODS AND RESULTS: In the prospective DES.DE registry, baseline clinical and angiographic characteristics as well as in-hospital and follow-up events were recorded for all enrolled patients. Between October 2005 and May 2009, 21,774 patients receiving DES were enrolled at 98 DES.DE sites. The composite of death, myocardial infarction (MI) and stroke defined as major adverse cardiac and cerebrovascular events (MACCE) and TVR were predefined as primary endpoints. At 1-year follow-up rates for overall death, MI, stroke, MACCE, TVR and definite stent thrombosis were 2.7, 3.1, 1.4, 7.1, 11.5 and 0.6 %, respectively. Aside from well-known risk factors like age, diabetes mellitus and triple-vessel disease, stratification in patients with or without MACCE revealed atrial fibrillation, non-ST-segment elevation myocardial infarction, renal failure, impaired ejection fraction and peripheral vascular disease as strong predictors of MACCE at 1 year. CONCLUSION: Data collected in the DES.DE registry, reflecting the clinical practice in Germany, revealed favorable clinical outcomes after DES implantation in a real world setting but also identifying several high-risk populations.

Outcome of percutaneous coronary intervention with drug-eluting stents in unprotected left main versus non-left main native coronary artery disease: results from the prospective multicenter German DES.DE registry.

BACKGROUND: Unprotected left main coronary artery (ULMCA) disease is considered an indication for surgical revascularization. However, refined percutaneous coronary intervention (PCI) technology and modern drug-eluting stents (DES) render the ULMCA a target for interventional treatment. METHODS AND RESULTS: Between October 2005 and September 2009, 374 patients receiving DES in ULMCA and 18,678 patients receiving DES in non-left main coronary arteries (nLMCA) with no previous coronary artery bypass graft surgery, were registered at 130 DES.DE sites. The composite of death, myocardial infarction (MI), and stroke defined as major adverse cardiac and cerebrovascular events (MACCE) and target vessel revascularization (TVR) were defined as primary endpoints. Baseline clinical and descriptive morphology of coronary artery disease revealed more comorbidities and more complex anatomies in the ULMCA group. At 1-year follow-up, the ULMCA group suffered from higher rates of overall death (5.6 versus 2.3 %; p < 0.0001), stroke (2.0 versus 0.8 %; p < 0.05), MACCE (8.6 versus 4.9 %; p < 0.01); whereas rates for definite/probable stent thrombosis (2.4 versus 1.6 %; p = 0.29), TVR (14.2 versus 10.8 %; p = 0.06) and MI (1.3 versus 1.9 %; p = 0.44) were not statistically different. These results persisted even after adjustment for different baseline characteristics, except MACCE that was no longer statistically significant. CONCLUSION: Data collected in DES.DE revealed that ULMCA PCI with DES result in similar TVR rates as compared to PCI in nLMCA. Moreover, modern DES have not offset the higher comorbidity index and higher procedure-related complication rate with PCI of ULMCA lesions.

Echocardiography versus intracardiac electrocardiography-based optimization for cardiac resynchronization therapy : a comparative clinical long-term trial.

BACKGROUND: Optimization of AV and VV delay programming has been shown to be essential for the success of cardiac resynchronization therapy (CRT). Acute hemodynamic improvement can be obtained by intracardiac electrocardiogram (IEGM)-based optimization. The aim of the present study was to evaluate whether this IEGM-based algorithm is comparable to the current gold standard of echocardiography. METHODS: After device implantation patients with standard criteria for CRT, AV and VV delay programming was either optimized by an IEGM-based algorithm (IEGM group, n = 24) or by echocardiography (echo group, n = 24). Cardiopulmonary exercise capacity was assessed after 3 and 12 months on the basis of NYHA class and the 6-min-walk test. Left ventricular ejection fraction was evaluated by echocardiography. RESULTS: In both groups there was a significant decrease in NYHA class and a significant increase in 6-min-walk distance and ejection fraction after 3 and 12 months. After 12 months there was no significant difference in the proportion of responders, NYHA class and 6-min-walk distance between the IEGM the echo group. CONCLUSION: The present data show that a sustained improvement of cardiopulmonary exercise capacity can be obtained by optimizing CRT patients on the basis of an IEGM algorithm. The comparable results for cardiopulmonary exercise parameters suggest that this new method might become an important tool for adjusting CRT programming in daily practice.

Dobutamine stress cardiovascular magnetic resonance imaging in patients after invasive coronary revascularization with stent placement.

BACKGROUND: High-dose dobutamine stress magnetic resonance (DSMR) is a well-established imaging technique for the detection of coronary artery disease (CAD). PURPOSE: To investigate the value of DSMR for the detection of in-stent restenoses (ISR) in patients with prior coronary stenting, using invasive coronary angiography (ICA) as the standard of reference. MATERIAL AND METHODS: 50 patients with 74 stents and without wall motion abnormalities at rest were examined on a 1.5T MR scanner and underwent ICA for clinical reasons within 14 days after DSMR examination. A dobutamine/atropine stress protocol was employed until age-predicted heart rate was achieved, and imaging was performed in at least three long- and three short-axis views using a segmented steady-state free precession sequence (repetition/echo time [TR/TE] 3/1.5 ms, flip angle 60 degrees). All examinations were read by an experienced cardiologist and radiologist in consensus, with myocardial ischemia being defined as a new stress-induced wall motion abnormality in at least one myocardial segment. Statistical analysis was performed on a per-vessel (left circumflex artery [LCX], left anterior descending artery [LAD], and right coronary artery [RCA]) basis and with regard to the number of affected vessels (one-, two- or three-vessel disease). RESULTS: ICA yielded seven ISR, of which one was missed by DSMR (sensitivity 86%, 95% confidence interval [CI] 0.42-0.99). Sixty-seven coronary arteries showed no ISR in ICA; however, due to new wall motion abnormalities, seven ISR were suspected in DSMR (2xRCA, 3xLCX, and 2xLAD; sensitivity 86%, specificity 90%, positive predictive value 46%, negative predictive value 98%, and diagnostic accuracy 89%). The per-vessel analysis of the three main coronary arteries revealed highest sensitivity (100%), specificity (93%), and diagnostic accuracy (94%) for the LAD. CONCLUSION: High-dose DSMR is an accurate, noninvasive technique for the detection of ISR and reliably allows identification of patients who need to undergo control ICA.

Amygdala and insula response to emotional images in patients with generalized social anxiety disorder.

BACKGROUND: Functional brain imaging studies have demonstrated amygdala and insula hyper-reactivity to probes of social threat in participants with generalized social anxiety disorder (gSAD). The amygdala and insula are known to serve broad functions in emotional processing, including integration of affective information. However, few studies have examined brain responses in socially anxious participants during general emotional processing. We examined brain response to emotionally evocative images in patients with gSAD and matched healthy controls. METHODS: Eleven patients with gSAD who were not taking psychotropic medications and did not have psychiatric comorbidities and 11 matched healthy controls underwent functional magnetic resonance imaging while viewing blocks of emotionally salient (positive, negative, neutral) pictures. RESULTS: Participants with gSAD exhibited enhanced bilateral amygdala and insula reactivity to negative (v. neutral) images compared with healthy controls who did not exhibit enhanced reactivity. Within the gSAD group, the extent of amygdala activation was correlated with social anxiety severity, whereas the extent of insula activation was correlated with trait anxiety. LIMITATIONS: The small sample size may have limited our ability to detect group differences in other relevant brain regions and in behavioural measures. CONCLUSION: In addition to prior findings of probes of social information processing, our findings suggest that the amygdala and insula responses are hyper-reactive to general emotional images with negative emotional content and that these brain regions may play divergent roles in their representation of different phenotypes.

Myocardial scars are an underestimated cardiovascular burden in patients with internal carotid artery stenosis.

BACKGROUND: Patients with internal carotid artery (ICA) stenosis have an increased incidence of coronary heart disease. Evidence about the incidence of clinically silent myocardial infarction (MI) in these patients is limited. Contrast-enhanced cardiac magnetic resonance (CMR) imaging allows for the detection of minor myocardial damage. OBJECTIVE: We tested whether patients with ICA stenosis exhibit a relevant incidence of silent MI when assessed by CMR. METHODS: In a single-center study, 77 consecutive patients (age 68 +/- 7 years) with suspected ICA stenosis were imaged prospectively with a combined MRI protocol including T(1), T(2), diffusion-weighted imaging, fluid-attenuated inversion recovery, and contrast-enhanced MR angiography (CEMRA) imaging of the brain and a short (11 min) CMR protocol with left ventricular function and late gadolinium enhancement imaging. Blinded to any clinical information, two readers evaluated the cardiac and neuroradiologic examinations. RESULTS: Of 154 imaged ICA, 85 presented with stenosis and 17 were occluded. In 7 patients, the suspected ICA stenosis could not be confirmed by CEMRA. In the remaining 70 patients with ICA stenosis, 34.3% had cerebral lesions (15.7% with a homodynamic pattern,18.6% with territorial infarction). CMR detected MI in 29 (41%) patients, whereas ECG and medical history enabled diagnosis in only 7 (10%) patients. CONCLUSIONS: ICA stenosis patients have a higher incidence of myocardial scars proving silent MI when detected by contrast-enhanced CMR than clinically expected. Whether the presence and extent of silent MIs detected by CMR affect peri-interventional risk and prognosis of ICA stenosis patients remains to be evaluated in a large patient cohort with long-term follow-up.

Comparison of aortic valve area measured by magnetic resonance imaging and dual-source computed tomography.

BACKGROUND: Aortic valve stenosis is the most common type of valve lesion in Europe and North America. Patient treatment is based on disease severity, which is classified by determining the aortic valve area (AVA). PURPOSE: To compare dual-source computed tomography (DSCT) with magnetic resonance (MR) imaging for quantifying AVA. MATERIAL AND METHODS: Thirty-two patients, 28 with normal aortic valve function and four with aortic valve stenosis, who underwent DSCT coronary angiography (Somatom Definition; Siemens, Erlangen, Germany), were included in this study. Retrospective ECG-gated contrast-enhanced DSCT scans with dose-reducing tube current modulation were performed, and data sets were reconstructed in 3% steps of the R-R interval (slice thickness 0.75 mm, increment 0.6 mm). Planimetry of the AVA in systole was assessed on cross-sectional images by multiplanar reformations. Within 48 hours, MR was performed with a 1.5T scanner (Magnetom Sonata; Siemens, Erlangen, Germany) using a balanced steady-state free-precession cine sequence (repetition/echo time 3/1.5 ms, flip angle 60 degrees, spatial resolution 1.4 x 1.4 mm(2)). Cine sequences of the left ventricular outflow tract (LVOT) were obtained in two orthogonal planes, and MR planimetry was performed on cross-sectional images of the aortic valve perpendicular to the LVOT images. RESULTS: AVA assessment by DSCT and MR was feasible in all 32 patients. Mean AVA values determined by DSCT and MR were 4.73+/-1.5 cm(2) and 4.69+/-1.4 cm(2), respectively. A strong positive correlation was found between both imaging modalities (R=0.98, P<0.001). Bland-Altman analysis demonstrated an excellent intermodality agreement, with a slight underestimation of AVA by DSCT. The mean difference was -0.04 cm(2), with a standard deviation of 0.32 cm(2). CONCLUSION: Retrospective ECG-gated contrast-enhanced DSCT with tube current modulation provides an accurate imaging technique for the assessment of the AVA. Further studies are required to determine whether DSCT also allows for AVA quantification in patients with aortic valve stenosis.

The Sirolimus-eluting coronary stent in daily routine practice in Germany: trends in indications over the years. Results from the prospective multi-centre German Cypher Stent Registry.

BACKGROUND: Drugeluting coronary stents (DES) are increasingly used during percutaneous coronary interventions (PCI). Due to limited budgets in Germany, no special reimbursement has been given for their use and therefore they were mainly used in selected patients. METHODS: In order to determine the change in indications in patients treated with a Sirolimus-eluting stent (SES) in daily clinical practice between 2002 and 2005, we analysed data from a prospective multi-centre DES registry, the German Cypher Stent Registry. RESULTS: From April 2002 until September 2005, 11 507 patients at 132 hospitals, who received at least one SES during their PCI, were included. Between 2002 and 2005, the median age of patients increased from 63 years to 66 years (p for trend <0.0001), whereas the prevalence of prior coronary bypass surgery (p<0.0001) and prior PCI (p<0.001) significantly decreased. Initial presentation of patients was stable over time, with a small increase of patients treated for non-ST elevation myocardial infarction (p=0.05). We found a significant increase in the treatment of complex stenoses (p<0.0001) as well as an increase in the proportion of chronic total occlusions (p<0.01). There was a steady increase in the proportion of patients treated for de novo lesions (p<0.0001), which was accompanied by a relative decrease in the proportion of patients treated for in-stent restenosis (p<0.0001). Concerning interventional characteristics a significant increase in the length of SES implanted per lesion, the numbers of SES implanted per lesion as well as an increase of the proportion of patients treated for more than one stenosis during one intervention could be observed (all p<0.0001). There was a significant decrease in the use of glycoprotein II b/IIIa antagonists during the PCI (2002: 26.5 to 14.2% in 2005, p<0.0001). MACE rates until hospital discharge did not change significantly over time. CONCLUSIONS: Between 2002 and 2005 there were two trends in the use of SES: a) a significant increase in the use of SES for de novo lesions and b) a significant trend to use SES for longer lesions, smaller arteries, more complex lesions and more SES per lesion. In summary these findings indicate that still SES are mainly used in patients with lesions that are at high risk for restenosis.

Acute myocardial infarction in a young adult: a case report and literature review.

Sudden cardiac death related to sports in young patients can have many causes. Hypertrophic cardiomyopathy, congenital coronary abnormalities, and myocarditis make up about half of the causes of sudden cardiac death after sports. Screening for all athletes is important to prevent such episodes. This involves yearly examinations including clinical examinations, stress echocardiograms, echocardiography, and laboratory investigations. Also, behavioral follow up should be addressed, as cocaine administration and doping can both lead to cardiac problems and sudden cardiac death after sports. We present a case of a 17-year-old boy who collapsed after an ice hockey competition as a result of an acute myocardial infarction, which was first represented by ventricular fibrillation. We also review the main causes of sudden cardiac death in such young athletes and the main investigations that have to be performed to reach the proper diagnosis and etiology of the condition.

[Integrated Health Care in cardiology at Essen]. / Qualitätspartnerschaft zur kardiologischen Versorgung in der Stadt Essen--Ein Projekt der Integrierten Versorgung in Essen.

This paper reports in detail on a project of Integrated Health Care in cardiology at Essen, Germany. Information on the structure of the contract, the participants, the agreed claiming of benefits and provision of services are provided as well as relevant figures and contact data.

Sirolimus-eluting stent treatment for isolated proximal left anterior descending artery stenoses. Results from the prospective multi-center German Cypher Registry.

BACKGROUND: Stenting of isolated proximal LAD stenoses is still a controversial issue since it is associated with higher target vessel revascularization (TVR) rate than both bypass surgery using the internal mammary artery, and stenting of other coronary artery territories. The sirolimus- eluting stent (SES) has been reported to significantly reduce restenosis rates in de novo coronary lesions. Therefore, we compared patients from the German Cypher Registry treated with SES for isolated proximal LAD lesions with those stented for isolated lesions in the proximal LCX or RCA. METHODS: A total of 349 patients treated with SES were analyzed. 249 patients were treated for proximal LAD stenosis, and 100 for proximal LCX/RCA stenoses. The combined clinical endpoint was MACCE (death of any cause, non-fatal MI and non-fatal stroke) and TVR at 6 months. RESULTS: In-hospital events (death, MI and TVR) did not differ significantly between both groups (3.2% for the LAD group vs 2.0% for the LCX/RCA-group, p=0.73). The combined end point of death of any cause, non-fatal MI and non-fatal stroke at six months was 2.6% in the LAD group, and 2.2% in the LCX/RCA group (p=1.0). TVR occurred in 4.8% of the LAD group and in 6.5% of the LCX/RCA group at six months (p=0.58). The percentage of patients free from angina at daily activities was 80.6% in the LAD group, and 77.4% in the LCX/ RCA group (p=0.52). CONCLUSION: SES once implanted into isolated proximal LAD stenoses appears as effective as reported in other vessel territories. Accordingly, stenting of the proximal LAD using SES might prove a suitable alternative to surgery.

[Detection and characterization of left ventricular thrombi by MRI compared to transthoracic echocardiography]. / Detektion und Charakterisierung linksventrikulärer Thromben mittels MRT im Vergleich zur transthorakalen Echokardiographie.

PURPOSE: Transthoracic echocardiography is the routine diagnostic procedure in assessing patients with left ventricular thrombi, but is limited by the acoustic window and poor contrast between thrombus and adjacent myocardium. This study evaluates the role of cardiac MRI in the detection of left ventricular thrombi in patients with chronic myocardial infarction compared to standard transthoracic echocardiography. MATERIALS AND METHODS: In 82 patients (55 men and 27 women, age 36 to 79 years, median 59 +/- 11 years) who suffered a myocardial infarction more than 6 months earlier, transthoracic echocardiography and MRI were performed. The MRI protocol included steady state cine imaging (true FISP: TR 3.0 ms, TE 1.5 ms, FA 65 degrees ) in standard long and short axis orientation and contrast-enhanced imaging using a 3D IR-FLASH sequence with long inversion time (TR 4 ms, TE 1.43 ms, FA 10 degrees , TI 300 ms) early, and a 2D IR-FLASH sequence with optimized inversion time (TR 8 ms, TE 4.3 ms, FA 20 degrees , TI 180 - 280 ms) late after administration of gadolinium. RESULTS: Transthoracic echocardiography depicted 12 thrombi. Contrast-enhanced MRI confirmed these 12 thrombi and detected 23 additional thrombi. With the exception of 2 very small apical thrombi only visible on contrast-enhanced MR images, spherical thrombi were diagnosed by both techniques, whereas only contrast-enhanced MRI was able to visualize mural thrombi. Left ventricular thrombi were more frequently diagnosed in patients with moderate to severe impairment of the left ventricular systolic function, 32/42 (76 %), or in patients with left ventricular aneurysms, 21/24 (84 %). CONCLUSION: Contrast-enhanced MRI is mostly superior to transthoracic echocardiography in diagnosing mural left ventricular thrombi in patients who had suffered a myocardial infarction. Intracavitary thrombi are more frequently found in patients with impaired regional and global left ventricular function.

["Integrated care"--the Essen concept: organizational strategies in the treatment of acute myocardial infarction]. / Integrierte Versorgung am Beispiel des Herzinfarktverbundes Essen.

The German "GKV-Modernisierungsgesetz" offers new opportunities for patient care. The concept of "integrated care" provides organizational structures for an standardized treatment of myocardial infarction by bridging the different sectors of the German health care system. Apart from guideline-based therapy, innovative diagnostic (cardiac MRI) and therapeutic (drug-eluting stents) techniques are implemented in the "integrated care" model as well. The "Herzinfarktverbund Essen" is the first national real world experience of the integrated care concept in the treatment of myocardial infarction.

"Real life" use of sirolimus-eluting coronary stents in Germany. Results from the prospective multi-centre German Cypher Registry.

BACKGROUND: Drugeluting stents (DES) are currently judged to be a "break-through" technology for the prevention of restenosis after percutaneous coronary interventions (PCI). However, experience is limited to randomised controlled clinical trials (RCT) in selected lesions and the currently available DES are more expensive compared to conventional "bare" stents. Therefore, actual clinical practice may be very different to RCT. METHODS: We analysed the data of the German Cypher trade mark Registry, a nationwide registry which was initiated in parallel to the launch of the first DES, the Cypher trade mark sirolimus-eluting coronary stent, in April 2002. RESULTS: From April 2002 until March 2003, 1638 procedures at 88 hospitals were included in the German Cypher trade mark Registry. The mean inclusion rate per centre and month remained low (<3 procedures/month and participating hospital) during the whole inclusion period. Most patients presented with stable angina pectoris (45.8%); however, 6.4% of patients were treated for a non-ST elevation myocardial infarction, 10.3% of patients for ST elevation myocardial infarction and 1.7% in cardiogenic shock. In patients without ST elevation myocardial infarction, a de novo stenosis was treated in 68.4% of cases, a restenosis in 4.1%, and an in-stent restenosis in 25.5% of cases. Chronic total occlusions were treated in 6.1% of patients. Predilatation was performed in 68.3% of patients and 1.05 +/- 0.35 Cypher trade mark stents were implanted per patient with a median (quartiles) stent length of 18 (13-21) mm. PCI-related death occurred in 0.1% of patients and a Q-wave myocardial infarction in 1.1%. Urgent re-PCI before hospital discharge was performed in 1.3% and urgent bypass surgery in 0.1% of cases. CONCLUSIONS: The use of the sirolimus-eluting coronary stents in this "real life" registry was found to be safe concerning acute complications. In about one half of the registry patients, the DES was implanted in lesions that were excluded from RCTs.

[Comparison of gradient-echo and steady state free precession sequences for 3D-navigator MR angiography of coronary arteries]. / Vergleich von Gradienten-Echo und steady state free precession Sequenzen zur 3D-Navigator-MR-Koronarangiographie.

AIM: Purpose of our study was to compare the image quality of 3D-navigator steady state free precession (SSFP) and gradient echo (GE) sequences for magnetic resonance coronary angiography (MRCA) in volunteers and patients. METHODS: Following informed consent 8 volunteers and 12 patients were included into this study. In all subjects a 3D navigator MRCA of the right and the left coronary artery was performed with a SSFP (TR 3.9 ms, TE 1.7 ms, FA 65 degrees, bandwidth 540 Hz) and a GE (TR 5.8 ms, TE 2.2 ms, FA 25 degrees, bandwidth 200 Hz) sequence using a 1.5 T-MR-System (Magnetom Sonata, Siemens Erlangen). The slice thickness was 1.5 mm and the in-plane resolution was 0.9 x 0.7 mm (2) for all measurements. RESULTS: The blood pool showed a significantly (p < 0.01) higher signal intensity on SSFP images (147 +/- 36) compared to GE images (103 +/- 36). Although noise increased with SSFP (9.3 +/- 1.4 versus 5.3 +/- 0.9), the contrast-to-noise ratio between myocardium and the coronaries was significantly (p < 0.01) higher on SSFP images (7.8 +/- 3.7 versus 3.4 +/- 3.3). The CNR between the coronaries and the epicardial fat showed no significant differences (12 +/- 5 versus 13 +/- 4). CONCLUSION: The 3D-navigator SSFP sequence is a promising new technique for MRCA which improves the contrast between the coronaries and the myocardium and shortens the data acquisition compared to gradient-echo imaging.

Transcatheter closure of muscular ventricular septal defects in two patients after myocardial infarction.

Acquired muscular ventricular septal defects (MVSD) after myocardial infarction (MI) can lead to right heart failure and cardiogenic shock with high mortality. Early surgical therapy is often difficult to perform but can reduce the mortality. The closure of congenital septal defects is performed with high safety. Therefore, the interventional closure of an acquired post-MI VSD might be feasible and of potential benefit. To date, experiences with closure of post-MI MVSDs are minimal. We report on two patients with post-MI VSD.