[Severe accidental hypothermia : Treatment using an intravascular temperature management catheter]. / Schwere akzidentelle Hypothermie : Behandlung mithilfe eines intravaskulären Katheters zum Temperaturmanagement.

Different techniques have been reported for the treatment of severe accidental hypothermia. In this case, we successfully used an intravascular catheter temperature management system which has been developed to induce reversible therapeutic hypothermia in patients following resuscitation. In our patient, the initial core temperature was 26.7 °C, and the temperature management system allowed for successful rewarming without complications with a maximum rate of about 1 °C/h.

2015 Update on Acute Adverse Reactions to Gadolinium based Contrast Agents in Cardiovascular MR. Large Multi-National and Multi-Ethnical Population Experience With 37788 Patients From the EuroCMR Registry.

OBJECTIVES: Specifically we aim to demonstrate that the results of our earlier safety data hold true in this much larger multi-national and multi-ethnical population. BACKGROUND: We sought to re-evaluate the frequency, manifestations, and severity of acute adverse reactions associated with administration of several gadolinium- based contrast agents during routine CMR on a European level. METHODS: Multi-centre, multi-national, and multi-ethnical registry with consecutive enrolment of patients in 57 European centres. RESULTS: During the current observation 37,788 doses of Gadolinium based contrast agent were administered to 37,788 patients. The mean dose was 24.7 ml (range 5-80 ml), which is equivalent to 0.123 mmol/kg (range 0.01 - 0.3 mmol/kg). Forty-five acute adverse reactions due to contrast administration occurred (0.12%). Most reactions were classified as mild (43 of 45) according to the American College of Radiology definition. The most frequent complaints following contrast administration were rashes and hives (15 of 45), followed by nausea (10 of 45) and flushes (10 of 45). The event rate ranged from 0.05% (linear non-ionic agent gadodiamide) to 0.42% (linear ionic agent gadobenate dimeglumine). Interestingly, we also found different event rates between the three main indications for CMR ranging from 0.05% (risk stratification in suspected CAD) to 0.22% (viability in known CAD). CONCLUSIONS: The current data indicate that the results of the earlier safety data hold true in this much larger multi-national and multi-ethnical population. Thus, the "off-label" use of Gadolinium based contrast in cardiovascular MR should be regarded as safe concerning the frequency, manifestation and severity of acute events.

[The 2014 ESC guidelines on the diagnosis and management of hypertrophic cardiomyopathy : what is new?]. / ESC-Leitlinie 2014 zur Diagnose und zum Management der hypertrophischen Kardiomyopathie : Was ist neu?

The 2014 European Society of Cardiology (ESC) guidelines on the diagnosis and management of hypertrophic cardiomyopathy (HCM) comprise 133 recommendations with 506 references. In comparison to the last 10-year-old American College of Cardiology Foundation (ACCF)/ESC guidelines new data have been added, such as recent studies on genetics, updated recommendations for family and genetic screening, a special emphasis on red flags in clinical symptomatology and diagnostic features for the identification of non-obstructive variants of HCM, on multimodality non-invasive imaging by echocardiography and cardiac magnetic resonance imaging (MRI) and a HCM risk formula for the assessment of sudden cardiac death within 5 years. Nevertheless, it should not be forgotten that the majority of patients with HCM lead a normal life. This detailed update and the structured recommendations are an excellent summary of the current knowledge on HCM for the cardiomyopathy specialist and also for internists and general physicians.

[Consensus recommendations of the German Radiology Society (DRG), the German Cardiac Society (DGK) and the German Society for Pediatric Cardiology (DGPK) on the use of cardiac imaging with computed tomography and magnetic resonance imaging]. / Konsensusempfehlungen der DRG/DGK/DGPK zum Einsatz der Herzbildgebung mit Computertomografie und Magnetresonanztomografie.

Cardiac magnetic resonance imaging (MRI) and computed tomography (CT) have been developed rapidly in the last decade. Technical improvements and broad availability of modern CT and MRI scanners have led to an increasing and regular use of both diagnostic methods in clinical routine. Therefore, this German consensus document has been developed in collaboration by the German Cardiac Society, German Radiology Society, and the German Society for Pediatric Cardiology. It is not oriented on modalities and methods, but rather on disease entities. This consensus document deals with coronary artery disease, cardiomyopathies, arrhythmias, valvular diseases, pericardial diseases and structural changes, as well as with congenital heart defects. For different clinical scenarios both imaging modalities CT and MRI are compared and evaluated in the specific context.

[Cardiac computed tomography and magnetic resonance imaging in patients with coronary artery disease]. / Diagnostik der koronaren Herzerkrankung mit Computer- und Magnetresonanztomographie.

Coronary angiography by computed tomography (CTCA) is most suitable for symptomatic patients with an intermediate likelihood to exclude a coronary stenosis as the cause of the symptoms. It would also be appropriate in a patient in whom an equivoval stress test result has led to uncertainty about the patient's further management. CTCA may occasionally be acceptable in a high risk symptomatic patient who refuses the necessary invasive coronary angiography if the results of CTCA are likely to alter patient management.The main indication for cardiac magnetic resonance imaging (CMR) is for pharmacologic stress testing. If such a test is indicated, dobutamine stress CMR is an alternative to stress echocardiography and adenosine perfusion CMR is the alternative to nuclear myocardial perfusion imaging but without radiation. Late gadolinium enhancement CMR is the current gold standard for the assessment of myocardial scars and hence is well suited to predict recovery of function in dysfunctional myocardial regions following revascularisation (viability testing).

[Cardiac amyloidosis--cardiovascular magnetic resonance imaging as a valuable diagnostic tool]. / Kardiale Amyloidose--Kardio-MRT als hilfreiches diagnostisches Werkzeug.

HISTORY: A 90-year-old man presented at the emergency room with symptoms of severe heart failure. A few weeks earlier he had been seen with the same symptoms at another hospital where the diagnosis of severe aortic valve stenosis had been made and aortic valve replacement was recommended. However, the patient did not consent to surgery and was discharged after medical treatment. INVESTIGATIONS: Echocardiography demonstrated global hypertrophy, pronounced at the ventricular septum. Interestingly the transaortic pressure gradient was only slightly elevated, revealing mild aortic stenosis. Thus, for work-up of discrepancies between the recent and previous (in the other hospital) exam results, cardiac magnetic resonance imaging (CMR) was performed. DIAGNOSIS: CMR planimetry confirmed that the aortic stenosis was only mild. However, contrast CMR revealed typical circular subendocardial late gadolinium enhancement in the entire left ventricle, which is typically seen in cardiac amyloidosis. This diagnosis was confirmed by endomyocardial biopsy revealing transthyretin-type amyloidosis. TREATMENT AND COURSE: Recompensation was achieved using diuretics and usual heart failure medication. Unfortunately, there is no causal treatment for transthyretin-type amyloidosis. However, the unnecessary aortic valve replacement surgery could be avoided. CONCLUSION: CMR is capable to precisely assess the aortic valve area even in cases with discrepant findings by other techniques. In addition, contrast CMR allows noninasive detection of myocardial abnormalities in living patients. Based on the pattern of contrast enhancement, differentiation between etiologies is possible.

Safety of gadoversetamide in patients with acute and chronic myocardial infarction.

PURPOSE: To assess the safety data from two large, multicenter, phase 2 trials on the use of gadoversetamide (OptiMARK, Tyco Healthcare/Mallinckrodt, St. Louis, MO) as a contrast agent in delayed hyperenhancement magnetic resonance imaging (DE-MRI) in patients with acute and chronic myocardial infarction (MI). MATERIALS AND METHODS: The study population from both trials comprised 577 patients who were randomly assigned to one of four dose groups (0.05, 0.1, 0.2, or 0.3 mmol/kg) before undergoing DE-MRI. Safety evaluations included physical and electrocardiographic (ECG) examinations. Vital signs, laboratory values, adverse events (AE), and serious adverse events (SAE) were monitored before and after contrast administration. RESULTS: Of the 577 patients who received gadoversetamide, 124 (21.5%) reported a total of 164 AEs; most were mild (139 AEs; 84.8%) or moderate (25 AEs; 15.2%). ECG-related changes were the most frequent AE. Site investigators judged only eight AEs as likely related to gadoversetamide and only two of the eight as clinically relevant. Further evaluation suggested neither AE was related to gadoversetamide. Two SAEs were reported, but none was judged related to gadoversetamide by the site investigators. CONCLUSION: Gadoversetamide is safe for use in patients with acute or chronic MI up to a dose of 0.3 mmol/kg.

Coronary vasospasm as the underlying cause for chest pain in patients with PVB19 myocarditis.

OBJECTIVE: To evaluate the incidence of coronary vasospasm as a possible pathophysiological mechanism causing chest pain symptoms in patients with clinically suspected myocarditis. DESIGN AND SETTING: Prospective study in a teaching hospital. PATIENTS: 85 patients who presented at hospital with atypical chest pain and demonstrated clinical signs suggestive of myocarditis. MAIN OUTCOME MEASURES: Incidence of coronary vasospasm demonstrated by intracoronary acetylcholine (ACh) testing. METHODS: The combined procedure of intracoronary ACh testing and endomyocardial biopsy (EMB) was performed after ruling out significant coronary artery disease (CAD). EMBs were analysed for myocardial inflammation by immunohistological methods and for virus genome persistence. RESULTS: Pathological biopsy results, including myocardial inflammation or detection of viral genomes, or both, were found in 55 (64.7%) patients while 30 (35.3%) patients showed neither cardiac inflammation nor viral genomes and were defined as the control group. Coronary vasospasm was demonstrated in 39/55 (70.9%) patients with pathological results compared with only 12/30 (40.0%) with normal biopsy results (p = 0.01). Patients with isolated PVB19 infection (n = 22) demonstrated a significantly higher incidence of coronary vasospasm than both those with isolated HHV6 infection (86.4% vs 46.7%; p = 0.025) and those with normal biopsy results (86.4% vs 40.0%; p<0.001). Univariate and multivariate logistic regression analysis showed that only PVB19 infection was independently correlated with coronary vasospasm (OR = 4.9, 95% CI 1.56 to 15.28, p = 0.006). CONCLUSIONS: Coronary vasospasm is one of the main reasons for atypical chest pain in patients with clinical signs of myocarditis and biopsy-proven PVB19 myocarditis in the absence of significant CAD.

Cardiac magnetic resonance in myocardial disease.

For a number of patients it is difficult to diagnose the cause of cardiac disease. In such patients cardiac magnetic resonance is useful for helping to make a differential diagnosis between ischaemic and dilated cardiomyopathy; identifying patients with myocarditis; diagnosing cardiac involvement in sarcoidosis and Chagas' disease; identifying patients with unusual forms of hypertrophic cardiomyopathy and those with continuing myocardial damage; and defining the sequelae of ablation treatment for hypertrophic obstructive cardiomyopathy.

[Diagnosis of myocarditis: description and assessment of available methods]. / Diagnostik der Myokarditis: Darstellung und Bewertung der verfügbaren Methoden.

Myocarditis is a common disease in all age groups. Correct diagnosis of myocarditis is difficult, but of clinical and scientific importance. It is the aim of this review to describe and evaluate diagnostic possibilities. It is not possible to make a definitive diagnosis of myocarditis by electrocardiography, laboratory tests or echocardiography. Nor can techniques of nuclear medicine or coronary angiography provide an unequivocal diagnosis of myocarditis. Myocarditis can be diagnosed with certainty only by endomyocardial biopsy, which must be examined by histological, immunohistological and molecular techniques to obtain maximal sensitivity. But optimal diagnosis of a biopsy is subject to the problem of sampling error. Furthermore, myocardial biopsy is in practice used only rarely, despite a low complication rate. Thus the diagnosis of myocarditis is often based merely on suspicion. The limitations of standard methods employed so far have made cardiac magnetic resonance imaging (CMR) a valuable new additional test when there is the clinical suspicion of myocarditis. A myocardial biopsy will often reveal myocarditis in patients with cardiac symptoms and CMRI findings typical of myocarditis, especially if the biopsy was obtained near the area of contrast enhancement in the CMRI. CMRI can also be used for noninvasive and low-risk follow-up of functional parameters and tissue damage.

New non-invasive approaches for the diagnosis of cardiomyopathy: magnetic resonance imaging.

Cardiac magnetic resonance imaging (CMR) permits a detailed look at the myocardium in patients with recent onset heart failure. Late-enhancement CMR provides information that is similar to that obtained by the naked eye of a pathologist. Myocardial scarring is endocardial in myocardial infarction, but it is epicardial in myocarditis and intramyocardial in hypertrophic cardiomyopathy. Thus, the distinction between these entities is possible by depicting scar via late-enhancement CMR and observing myocardial function by cine magnetic resonance imaging. Moreover, non-invasive follow-up--and hence observation of the healing or remodelling process--can be achieved using CMR. New CMR pulse sequences also permit depiction of myocardial oedema, which may occur early in patients with myocarditis and may be the only sign of the disease in the absence of necrosis. It is anticipated that cardiac MRI will become a standard diagnostic technique in patients with new onset of heart failure, left-ventricular hypertrophy or clinical symptoms suggestive of myocarditis.

Evaluation of aortic stenosis by cardiovascular magnetic resonance imaging: comparison with established routine clinical techniques.

OBJECTIVE: To evaluate whether direct planimetry of aortic valve area (AVA) by cardiac magnetic resonance (CMR) imaging is a reliable tool for determining the severity of aortic stenosis compared with transthoracic echocardiography (TTE), transoesophageal echocardiography (TOE), and cardiac catheterisation. METHODS: 44 symptomatic patients with severe aortic stenosis were studied. By cardiac catheterisation AVA was calculated by the Gorlin equation. AVA was measured with CMR from steady state free precession (true fast imaging with steady state precession) by planimetry. AVA was also determined from TOE images by planimetry and from TTE images by the continuity equation. RESULTS: Bland-Altman analysis evaluating intraobserver and interobserver variability showed a very small bias for both (-0.016 and 0.019, respectively; n = 20). Bias and limits of agreement between CMR and TTE were 0.05 (-0.35, 0.44) cm2 (n = 37), between CMR and TOE 0.02 (-0.39, 0.42) cm2 (n = 32), and between CMR and cardiac catheterisation 0.09 (-0.30, 0.47) cm2 (n = 36). The sensitivity and specificity of CMR to detect AVA < or = 0.80 cm2 measured by cardiac catheterisation was 78% and 89%, of TOE 70% and 70%, and of TTE 74% and 67%, respectively. CONCLUSION: CMR planimetry is highly reliable and reproducible. Further, CMR planimetry had the best sensitivity and specificity of all non-invasive methods for detecting severe aortic stenosis in comparison with cardiac catheterisation. Therefore, CMR planimetry of AVA with steady state free precession is a new powerful diagnostic tool, particularly for patients with uncertain or discrepant findings by other modalities.

[Use of Abciximab in threatening vascular occlusion after PTCA]. / Einsatz von Abciximab bei drohendem Gefässverschluss nach PTCA.

UNLABELLED: The administration of GP IIb/IIIa antagonists has been shown to be effective in reducing myocardial infarction and cardial death when given before PTCA. This prospective study was performed to determine the efficacy of abciximab in a bail-out situation to manage threatened or acute vessel closure. METHODS: Acute or threatened vessel closure was observed in 104 (5.5%) out of 1903 consecutive patients treated with PTCA in our institution. Of the 104 patients 46 (44%) were treated for unstable angina (CCS IV). Abciximab was administered in bail-out situations in a dosage of 0.25 mg/kg given as a bolus, which was followed by an intravenous infusion of 10 micrograms/min over 12 hours. Repeat PTCA was performed shortly after the administration of the abciximab bolus. After the procedure, the sheath was left in place and control angiography was carried out 24 h later. RESULTS: In 100 of the 104 patients TIMI flow III could be restored by abciximab therapy and RePTCA. In 4 patients an additional stent implantation was necessary due to persistent flow limitation. One day post PTCA, early follow-up angiography demonstrated patency of all vessels except two. In-hospital events occurred in 4 patients. Three of these patients underwent emergency CABG due to subacute vessel closure a few hours after PTCA and died during or directly after surgery. Follow-up after one year included clinical status and control angiography of the target vessel. During long-term follow-up, MACE occurred in 15 patients (2 MI, 8 CABG and 5 RePTCA). CONCLUSION: The results of this prospective trial demonstrate the efficacy of abciximab therapy in bail-out situations occurring during or early after PTCA. The use of abciximab in bail-out situations appears clinically beneficial. Further studies have to compare the efficacy of this approach with prophylactic abciximab treatment.

The impact of untreated coronary dissections on acute and long-term outcome after intravascular ultrasound guided PTCA.

AIM: Vessel size adapted PTCA results in the use of larger balloons with an increased incidence of severe vascular dissections. The aim of our trial was (a) to evaluate the effect of severe dissections on the acute outcome and (b) to study the natural history of dissections after 1 year. METHODS AND RESULTS: One hundred and seventy-eight patients with 195 lesions underwent vessel size adapted PTCA using intravascular ultrasound. Clinical and angiographic 1 year follow-up was obtained for all patients. Intravascular ultrasound was performed before PTCA to measure the external elastic membrane diameter at the lesion site so that the balloon size could be adopted (external elastic membrane-10%) and post-interventionally to determine the procedural success and the incidence of intracoronary dissections. Stent implantation was reduced to persistently flow limiting dissections (TIMI I, II). Dissections were detected by intravascular ultrasound in 128/195 (66%) lesions (by angiography in 111/195 [58%] lesions) and classified by intravascular ultrasound criteria into four groups: group I: no dissection (67 lesions [34%]), group II: mild dissections (21 lesions [11%]), group III: medium dissections (19 lesions [10%]) and group IV: severe dissections (88 lesions [45%]). Because of threatened vessel closure, GPIIb/IIIa antagonists were used in eight (4.5%) patients and a stent was implanted in two (1. 1%) patients. The cumulative event rate after 1 year was 12% and the global angiographic restenosis rate was 19%. The post-interventional evidence of severe dissections was associated with a decrease in clinical events during long-term follow up (group I: 13 events [19%] vs group IV: seven events [7%];P=0.03). This was also true for the occurrence of restenosis which was significantly lower in patients with severe dissections (group I: 19 [28%] lesions vs group IV:10 [11%] lesions;P=0.01). CONCLUSIONS: According to the theory of 'therapeutic dissections', our data suggest that substantial dissections following PTCA, which do not diminish antegrade blood flow, do not lead to an increase in acute or long-term events. The natural history of vessel injury seems to provide favourable wound healing without increase of restenosis. Thus, stenting for treatment of large dissections without flow limitation does not seem to be mandatory.

Frequency and efficacy of glycoprotein IIb/IIIa therapy for treatment of threatened or acute vessel closure in 1332 patients undergoing percutaneous transluminal coronary angioplasty.

BACKGROUND: Glycoprotein (GP) IIb/IIIa antagonists are potent inhibitors of thrombocyte aggregation and thrombus formation. Several large-scale randomized studies for prevention of thrombotic complications have shown their potential to reduce these complications in patients undergoing percutaneous transluminal coronary angioplasty (PTCA). It was the purpose of this observational trial to assess the frequency and efficacy of primary GP IIb/IIIa antagonist therapy as a bailout procedure for the prevention of threatened or abrupt vessel closure in patients after conventional balloon angioplasty. METHODS AND RESULTS: From January 1995 to December 1996, PTCA was performed in 1332 consecutive patients with coronary artery disease. Overall, threatened or abrupt vessel closure was observed in 63 (4.7%) patients of the patient population. In these patients, abciximab was administered (0.25 mg/kg body weight intravenous bolus, followed by a 12-hour infusion at 10 mg/min). Repeat PTCA was performed shortly after the administration of the abciximab bolus to achieve an optimal flow at the time of active GP IIb/IIIa therapy. One day after intervention, early follow-up angiography was performed. Follow-up after 1 year included the clinical status of all patients and, if possible, control angiography. Overall, the preintervention minimum lumen diameter (MLD) measured 0.74 +/- 0.27 mm and the diameter stenosis was 75% +/- 24%. The postintervention MLD increased to 2.60 +/- 0.55 mm, and the diameter stenosis decreased to 24% +/- 22%. At 24-hour angiographic follow-up, the MLD decreased to 2.47 +/- 0.49 mm and the diameter stenosis increased to 28% +/- 24%, correspondingly. The thrombus score decreased from 2.8 +/- 1.5 before abciximab treatment to 0.88 +/- 0.81 after abciximab treatment, and Thrombolysis In Myocardial Infarction flow grade increased from 2.1 +/- 1.1 to 2.9 +/- 0.3. In-hospital events occurred in 2 patients. Both patients had to undergo emergency coronary artery bypass grafting (1 of these patients died). During long-term follow-up, there were 10 clinical events (1 death, 3 repeat PTCA, and 6 coronary artery bypass graft operations for restenosis at the target lesion site). The cumulative event rate after 1 year (including acute and follow-up events) for both the total group and for the target vessel was 19%. CONCLUSIONS: The results of this study demonstrate that GP IIb/IIIa antagonists are able to prevent vessel occlusion after PTCA complicated by subsequent threatened or abrupt vessel closure. In these situations, GP IIb/IIIa antagonists provide effective treatment for the reduction of thrombus at the target lesion site, which constitutes a second key element for threatened or abrupt vessel occlusion.