[Semi-automatic defibrillators does not always interpret heart rhythms correctly. Five patients were defibrillated despite non-shockable rhythms]. / Halvautoma-tiska hjärtstartare tolkar inte alltid rätt - Fem patienter defibrillerades trots icke-defibrillerbar rytm.

Automated external defibrillators (AED) have become an important part of the ¼the chain of survival« in case of sudden cardiac arrest (SCA), where early defibrillation is lifesaving. The American Heart Association demands that AEDs have a specificity of >99 % to recognize normal sinus rhythm and >95 % for the other non-shockable rhythms. Reports on their performance in the field are scarce. We present five cases in which AED recommended shock for apparently non-shockable rhythms. This indicates the necessity to systematically reevaluate AED performance.

Left atrial diameter, aortic mean gradient, and hemoglobin for risk stratification in patients undergoing transcatheter aortic valve implantation.

BACKGROUND: Transcatheter aortic valve implantation (TAVI) is an alternative treatment of severe symptomatic aortic stenosis (AS) in patients with high operative risk. In spite of favorable entire results, long-term mortality of patients is high. HYPOTHESIS: The present study aims to identify independent preprocedural risk factors to improve risk stratification in these highly selected patients. METHODS: This prospective study included 202 consecutive patients with severe symptomatic AS and high operative risk (mean logistic European System for Cardiac Operative Risk Evaluation, 22±17%; mean age, 79±6 years; 107 female). Preprocedural comprehensive examinations were performed (laboratory, electrocardiography, echocardiography, cardiac catheterization). All patients received transfemoral or transaxillary TAVI with a CoreValve prosthesis (Medtronic, Minneapolis, MN). RESULTS: During a follow-up of 535±333 days, 56 patients (28%) reached the primary study end point (all-cause mortality). Independent predictors of long-term mortality were as follows: hemoglobin<12.5 g/dL (hazard risk [HR], 3.62; 95% confidence interval [CI], 2.025-6.468; P<0.001), aortic mean gradient≤41 mm Hg (HR, 2.16; 95% CI, 1.272-3.655; P=0.004), and left atrial diameter>42 mm (HR, 3.09; 95% CI, 1.588-6.019; P=0.001). Our risk-stratification model based on these independent predictors separated patients into 4 groups with high (74%), intermediate (37%), low (18%), and very low (3%) all-cause mortality. CONCLUSIONS: In patients undergoing TAVI, preprocedural assessment of hemoglobin, aortic mean gradient, and left atrial diameter provides independent prognostic information and therefore contributes to improved risk stratification in TAVI.

Annular rupture leading to fatal complications in an elderly patient with calcified aortic and mitral annulus undergoing transapical aortic valve implantation.

This case illustrates the awareness that must be taken of the high morphological risk due to the calcifications of both, the aortic and mitral annulus in elderly patients when performing transapical aortic valve implantation. In an 86-year-old, multimorbid woman (logistic EuroSCORE = 27%) with symptomatic aortic stenosis (annular diameter = 23.4 mm) and severe mitral annular calcification, the implantation of a 26-mm Edwards SAPIEN (Edwards Lifesciences, Irvine, California, United States) valve in aortic position was primary successful, with no paravalvular leakage, valve instability, or coronary malperfusion. Second, a persisting transmural bleeding led to hypovolemic shock, which could not be stabilized even after going on cardiopulmonary bypass, and the patient died in the operation room. The autopsy showed a subvalvular ventricular rupture due to a transmural perforation of the calcified fibrotic annulus during valvuloplasty.

Long-term outcome of patients with moderate and severe prosthetic aortic valve regurgitation after transcatheter aortic valve implantation.

Recently, moderate and severe postprocedure aortic regurgitations (ARs) have been identified as independent risk factors for short- and midterm mortality after transcatheter aortic valve implantation (TAVI). However, very few data exist on the long-term outcome of postprocedure AR. From 2008 to 2011, 198 consecutive patients with severe aortic stenosis successfully underwent TAVI with the CoreValve prosthesis (Medtronic CV, Minneapolis, Minnesota). After the procedure, patients were subdivided into groups depending on the presence of moderate/severe AR. The primary study end point was death from any cause after TAVI. The secondary end point was defined as cardiovascular death. In study patients (80 ± 6 years old, logistic European System for Cardiac Operative Risk Evaluation 22 ± 16%, left ventricular ejection fraction 53 ± 13%), moderate/severe AR occurred in 28 patients (14%). Despite similar baseline characteristics, patients with moderate/severe AR had higher 30-day and 1-year mortality rates than patients with none/mild AR (21% vs 6%, p = 0.019; 57% vs 16%, p <0.001, respectively). During a mean follow-up of 535 ± 333 days, the primary end point was reached in 54 and the secondary end point in 33 patients. Moderate/severe AR was the strongest independent risk factor of all-cause-mortality (hazard ratio 4.89, 95% confidence interval 2.78 to 8.56, p <0.001) and the strongest independent risk factor of cardiovascular mortality (hazard ratio 7.90, 95% confidence interval 3.95 to 15.81, p <0.001). In conclusion, moderate and severe postprocedure ARs are not uncommon complications after TAVI. Although long-term outcome of patients with none/mild AR is favorable, outcome of patients with moderate/severe AR is dismal.

Heart failure in severe aortic valve stenosis: prognostic impact of left ventricular ejection fraction and mean gradient on outcome after transcatheter aortic valve implantation.

AIMS: This prospective study aimed to evaluate the prognostic impact of left ventricular ejection fraction (LVEF) and aortic mean gradient patterns on outcome after transcatheter aortic valve implantation (TAVI). METHODS AND RESULTS: From 2008 to 2011, 202 consecutive patients with severe symptomatic aortic valve stenosis (aortic valve area <1.0 cm(2)) were submitted to TAVI. Patients were divided into four groups according to LVEF (>50% vs. ≤ 50%) and aortic mean pressure gradient (>40 mmHg vs. ≤ 40 mmHg): group 1, preserved LVEF/high gradient (n = 86); group 2, preserved LVEF/low gradient (n = 27); group 3, reduced LVEF/high gradient (n = 45); and group 4, reduced LVEF/low gradient (n = 44). A CoreValve prosthesis (Medtronic, Minneapolis, MN, USA) was inserted retrogradely. Echocardiography was performed before and 1 year after TAVI. The primary study endpoint (1-year all-cause mortality) was reached in 47 patients (23%). All-cause mortality was lowest in group 1 (14%), intermediate in group 2 (22%) and group 3 (27%), and highest in group 4 (39%) (P = 0.007). In survivors, aortic mean gradient decreased in all patients (baseline 48 ± 13 mmHg vs. 10 ± 4 mmHg at 1 year, P < 0.001). LVEF improved in group 3 and group 4 (baseline 42 ± 8% vs. 51 ± 11% at 1 year, P < 0.001). CONCLUSION: Severe aortic stenosis with low gradient and/or reduced LVEF is associated with worse outcome after TAVI compared with aortic stenosis with preserved LVEF/high gradient. The evaluation of these haemodynamic parameters may help to improve risk stratification in patients undergoing TAVI.

From pressure overload to volume overload: aortic regurgitation after transcatheter aortic valve implantation.

Severe aortic valve stenosis is a common valvular heart disease that is characterized by left ventricular (LV) pressure overload. A lasting effect of pressure overload is LV remodeling, accompanied by concentric hypertrophy and increased myocardial stiffness. Transcatheter aortic valve implantation (TAVI) has emerged as an alternative to surgical aortic valve replacement for patients with severe symptomatic aortic valve stenosis and high surgical risk. Although TAVI has favorable hemodynamic performance, aortic valve regurgitation (AR) is the most frequent complication because of the specific technique used for implantation of transcatheter valves. During implantation, the calcified native valve is pushed aside, and the prosthesis usually achieves only an incomplete prosthesis apposition. As a consequence, the reported prevalence of moderate and severe AR after TAVI is 6% to 21%, which is considerably higher than that after a surgical valve replacement. Although mild AR probably has minor hemodynamic effects, even moderate AR might result in serious consequences. In moderate and severe AR after TAVI, a normal-sized LV with increased myocardial stiffness has been exposed to volume overload. Because the noncompliant LV is unable to raise end-diastolic volume, the end-diastolic pressure increases, and the forward stroke volume decreases. In recent years, an increasing number of patients have successfully undergone TAVI. Despite encouraging overall results, a substantial number of patients receive neither symptomatic nor prognostic benefits from TAVI. Aortic valve regurgitation has been considered a potential contributor to morbidity and mortality after TAVI. Therefore, various strategies and improvements in valve designs are mandatory to reduce the prevalence of AR after TAVI.

Clinical outcome of transcatheter aortic valve implantation in patients with low-flow, low gradient aortic stenosis.

BACKGROUND: Low-flow, low-gradient aortic stenosis is associated with relevant postoperative mortality whereas conservative management results in dismal prognosis. We present the initial experience of low-flow, low-gradient aortic stenosis treated with transcatheter aortic valve implantation (TAVI). METHODS: From June 2008 to December 2010 167 consecutive patients with native severe aortic stenosis and an excessive operative risk underwent TAVI. Of these, 15 patients presented with low-flow, low-gradient aortic stenosis (aortic valve area < 1 cm(2) , left ventricular (LV) ejection fraction < 40%, aortic mean gradient < 40 mm Hg). The CoreValve prosthesis 18-F-generation (Medtronic, Minneapolis, Minnesota) was inserted retrograde. Clinical follow-up and echocardiography were performed 6 months after procedure. RESULTS: Patients with low-flow, low-gradient aortic stenosis (mean LV ejection fraction 32 ± 6%, mean aortic gradient 27 ± 7 mm Hg) had higher all-cause mortality 6 months after TAVI compared to patients without low-flow, low-gradient aortic stenosis (33% vs. 13%, P = 0.037). In the surviving 10 patients with low-flow, low-gradient aortic stenosis, LV ejection fraction increased (34 ± 6% before vs. 46 ± 11% 6 months after TAVI, p = 0.005) and more distance covered in the 6-minute walk test (218 ± 102 meters before vs. 288 ± 129 meters 6 months after TAVI, p = 0.038). CONCLUSION: Our study suggests that TAVI is feasible in patients with severe co-morbidities and low-flow, low-gradient aortic stenosis. Within the first 6 months after treatment all-cause mortality was considerable high, but the surviving patients showed symptomatic benefit and significant improvement of myocardial function and exercise capacity.

Transcatheter aortic valve implantation in patients with severe symptomatic aortic valve stenosis-predictors of mortality and poor treatment response.

BACKGROUND: Transcatheter aortic valve implantation (TAVI) has emerged as an alternative technique in patients with severe symptomatic aortic valve stenosis. However, a number of patients have no benefit after implantation. This prospective study attempted to identify predictors of poor treatment response. METHODS: From June 2008 to September 2010, consecutive patients with symptomatic severe aortic valve stenosis and high surgical risk were submitted to TAVI with the CoreValve prosthesis (Medtronic, Minneapolis, MN). The primary end point was all-cause mortality at 6 months. Secondary end point (poor treatment response) was defined as no improvement of symptoms assessed with the New York Heart Association class 6 months after TAVI. RESULTS: A total of 145 patients (mean age 79.1 ± 6.4 years, mean logistic EuroSCORE 21% ± 16.2%) were included. During the follow-up period, 23 (15.9%) patients died. Independent predictors of all-cause mortality were as follows: aortic mean gradient ≤40 mm Hg (odds ratio [OR] 3.93), moderate and severe tricuspid valve regurgitation (OR 4.50), and moderate and severe postprocedural aortic valve regurgitation (OR 4.26). In 122 surviving patients, 25 patients (20%) showed no improvement in symptoms. Independent predictors of poor treatment response were severe mitral valve regurgitation (OR 7.42) and moderate and severe postprocedural aortic valve regurgitation (OR 10.1). CONCLUSIONS: Cardiac comorbidities (low-gradient aortic stenosis, tricuspidal valve regurgitation) are associated with all-cause mortality, whereas mitral valve regurgitation is a risk factor for poor treatment response after TAVI. Postprocedural aortic valve regurgitation is a strong predictor of both-mortality and poor treatment response.

One-year results of transcatheter aortic valve implantation in severe symptomatic aortic valve stenosis.

Transcatheter aortic valve implantation (TAVI) is an alternative therapy for symptomatic severe aortic valve stenosis in high-risk patients with several co-morbidities. We evaluated the 1-year effects of TAVI on quality of life, exercise capacity, neurohormonal activation, and myocardial hypertrophy. From June 2008 to October 2009, consecutive patients aged ≥75 years with symptomatic severe aortic valve stenosis (area <1 cm(2)) and a logistic euroSCORE ≥15% or aged >60 years with additional specified risk factors underwent TAVI. An aortic valve prosthesis (CoreValve) was inserted in a retrograde fashion. Examinations were performed before and 30 days and 1 year after TAVI. An assessment of the quality of life (Minnesota Living with Heart Failure Questionnaire), a 6-minute walking test, measurement of B-type natriuretic peptide, and echocardiography were performed. In 51 patients (mean age 78 ± 6.6 years, mean left ventricular ejection fraction 58.4 ± 12.2%), the follow-up examinations were performed after TAVI. The 1-year follow-up visit after TAVI revealed significantly improved quality of life (baseline Minnesota Living with Heart Failure Questionnaire score 39.6 ± 19 vs 26.1 ± 18, p <0.001) and more distance covered in the 6-minute walking test (baseline 185 ± 106 vs 266 ± 118 m, p <0.001). The B-type natriuretic peptide level had decreased (baseline 642 ± 634 vs 323 ± 266 pg/ml, p <0.001), and the left ventricular mass index had decreased (156 ± 45 vs 130 ± 42 g/m(2), p <0.001). The left ventricular diameter and ejection fraction remained unchanged. In conclusion, TAVI leads to significantly reduced neurohormonal activation, regression of myocardial hypertrophy, and lasting enhancement of quality of life and exercise capacity in patients with symptomatic and severe aortic stenosis 1 year after intervention.

Bleeding complications associated with glycoprotein IIb/IIIa inhibitors in patients 80 years of age and older undergoing percutaneous coronary intervention.

BACKGROUND: Treatment of symptomatic coronary artery disease with percutaneous intervention requires antithrombotic therapy. Patients with elevated thromboembolic risk benefit from therapy with glycoprotein IIb/IIIa inhibitors. The safety and effectiveness of glycoprotein IIb/IIIa inhibition have been well documented in clinical trials. Drug-induced bleeding complications in elderly patients have not been specifically addressed. METHODS: Between 2006 and 2009, a total of 439 unselected patients 80 years of age and older undergoing percutaneous intervention for symptomatic coronary artery disease were included in the present nonrandomized retrospective study. In one-half of the patients, glycoprotein IIb/IIIa inhibitors were administered peri-interventionally. The in-hospital occurrence of bleeding complications (access site, gastrointestinal and cerebral) were analyzed in the groups with and without glycoprotein IIb/IIIa inhibitors. RESULTS: The mean age of the patients was 84 years. Nearly all patients (95%) received dual antiplatelet therapy. Patients treated with glycoprotein IIb/IIIa inhibitors had more complex coronary lesions and bypass graft interventions, and a tendency toward more access site bleeding complications than patients without inhibitors, which included femoral hematomas (4.6% versus 2.3%, respectively; P not significant) and femoral pseudoaneurysms (6% versus 3.2%, respectively; P not significant). The rate of blood transfusion was equal in both groups (0.9%). Major hemorrhagic events did not occur. Vessel closure devices were used more often in patients without glycoprotein inhibition. CONCLUSIONS: An increase in minor bleedings must be expected when using glycoprotein IIb/IIIa inhibitors in patients 80 years of age and older. However, this issue must not prevent this treatment option from being offered to elderly patients. There appears to be no elevated risk for major bleeding complications. Broadened use of vascular closure devices in this specific patient population may lower the rate of access site complications.

Beating-heart coronary artery bypass grafting with miniaturized cardiopulmonary bypass results in a more complete revascularization when compared to off-pump grafting.

The technique of miniaturized cardiopulmonary bypass (M-CPB) for beating-heart coronary artery bypass grafting (CABG) is relatively new and has potential advantages when compared to conventional cardiopulmonary bypass (CPB). M-CPB consists of less tubing length and requires less priming volume. The system is phosphorylcholine coated and results in minimal pump-related inflammatory response and organ injury. Finally, this technique combines the advantages of the off-pump CABG (OPCAB) with the better exposure provided by CPB to facilitate complete revascularization. The hypothesis is that CABG with M-CPB has a better outcome in terms of complete coronary revascularization and perioperative results as that compared to off-pump CABG (OPCAB). In a retrospective study, 302 patients underwent beating-heart CABG, 117 (39%) of them with the use of M-CPB and 185 (61%) with OPCAB. After propensity score matching 62 patients in both groups were demographically similar. The most important intra- and early-postoperative parameters were analyzed. Endpoints were hospital mortality and complete revascularization. Hospital mortality was comparable between the groups. The revascularization was significantly more complete in M-CPB patients than in patients in the OPCAB group. Beating-heart CABG with M-CPB is a safe procedure and it provides an optimal operative exposure with significantly more complete coronary revascularization when compared to OPCAB. Beating-heart CABG with the support of a M-CPB is the operation of choice when total coronary revascularization is needed.

Hemodynamic results and changes in myocardial function after transcatheter aortic valve implantation.

BACKGROUND: This prospective study was designed to evaluate the hemodynamic results of transcatheter aortic valve implantation (TAVI) with the CoreValve prosthesis (Medtronic, Minneapolis, Minnesota) and the effects on left ventricular function. METHODS: From June 2008 to June 2009, consecutive patients with severe symptomatic aortic valve stenosis (aortic valve area <1 cm(2)) and the indication for TAVI were included. Aortic valve prosthesis was inserted retrograde. Examinations of study patients were performed before, 30 days, and 6 months after TAVI and comprised measurement of B-type natriuretic peptide and echocardiography. Severe prosthesis-patient mismatch was defined as an indexed effective aortic valve area < or =0.65 cm(2)/m(2). RESULTS: In 39 patients, follow-up examinations were performed after TAVI. Severe prosthesis-patient mismatch seldom occurred (n = 1), but mild to moderate aortic valve regurgitation due to paravalvular leaks was common (n = 24, 62%). After 6 months, left ventricular mass index declined (158 +/- 46 vs 138 +/- 45 g/m(2), P = .001), and peak early diastolic mitral annular velocity (E') and peak systolic mitral annular velocity (S') increased (P = .004 and P < .001, respectively). B-type natriuretic peptide levels decreased (744 +/- 708 at baseline vs 367 +/- 273 at 30 days, P = .003, 279 +/- 186 pg/mL at 6 months, P = .001). Left ventricular diameters and ejection fraction remained unchanged. CONCLUSION: Despite the high incidence of paravalvular regurgitation after TAVI, hemodynamic results were favorable. Furthermore, TAVI had positive effects on left ventricular remodeling and improved neurohormonal activity, myocardial hypertrophy, and diastolic function.

Normal values for longitudinal function of the right ventricle in healthy women >70 years of age.

AIMS: The application of tricuspid annular plane systolic excursion (TAPSE) as an additional echocardiographic tool to analyse right ventricular (RV) systolic function has been recently established and two-dimensional-guided M-mode measurements of systolic long axis function of the RV are simple, repeatable, and highly reproducible. However, rare data are available on normal values. We aimed to analyse normal values in healthy women >70 years of age. METHODS AND RESULTS: In a cross-sectional survey, we investigated a cohort of randomly selected, non-hospitalized women >70 years of age. History of myocardial infarction, valvular heart disease, and diastolic dysfunction were exclusion criteria. In order to rule out left ventricular or RV dysfunction, a normal left ventricular ejection fraction and normal values of B-type natriuretic peptide (BNP) were necessary prior to study inclusion. A detailed echocardiographic examination was performed. A total of 80 participants were included (mean age 75 +/- 2.6 years). Mean left ventricular ejection fraction was 63.8 +/- 5.7%. Tissue Doppler derived mean E/E' ratio was 10 +/- 2.3. Mean right atrial diameter was 31.3 +/- 4.7 mm. Mean values for RV outflow tract and RV dimension were 27.3 +/- 3.6 and 28.8 +/- 3.7 mm, respectively. Mean TAPSE was 23.7 +/- 3.5 mm. Mean value of BNP was normal (42.5 +/- 35.7 pg/mL). CONCLUSION: In women >70 years of age without heart failure, structural heart disease, and neurohormonal activation, normal TAPSE values are approximately 24 mm.

Clinical outcome following conservative vs revascularization therapy in patients with stable coronary artery disease and borderline fractional flow reserve measurements.

BACKGROUND: Fractional flow reserve (FFR) measurements in the so-called gray-zone range of > or = 0.75 and < or =0.80 are associated with uncertainty concerning the guidance of patient therapy. It is unclear whether any difference in clinical outcome exists when revascularization treatment of FFR-evaluated lesions in this borderline range is deferred or performed. The objective of this study is to compare the clinical outcome of these patients with respect to their recommended treatment strategy. METHODS: Out of a single center database of 900 consecutive patients with stable coronary artery disease, 97 patients with borderline FFR measurements were identified and included in the study. The rate of major adverse cardiac events (MACE; cardiac death, myocardial infarction (MI), coronary revascularization) and the presence of angina were evaluated at follow-up. RESULTS: A total of 48 patients were deferred from revascularization and 49 patients underwent revascularization. There was no difference in risk profile between these groups. At a mean follow-up of 24+/-16 months, event-free survival in the deferred group was significantly better regarding overall MACE, combined rate of cardiac death, and MI, as well as MACE related to the FFR-evaluated vessel. No difference with regard to the presence of angina was observed. CONCLUSIONS: Patients with coronary lesions in the borderline FFR range can be deferred from revascularization without putting them at increased risk for major adverse events. Revascularization may be considered in the course of therapy on an individual basis if typical angina persists or worsens despite maximal medical treatment.

Short-term effects of transcatheter aortic valve implantation on neurohormonal activation, quality of life and 6-minute walk test in severe and symptomatic aortic stenosis.

OBJECTIVE: This prospective study aimed to determine to what extent clinical symptoms and neurohumoral activation are improved in patients with severe aortic valve stenosis after transcatheter aortic valve implantation (TAVI) with the CoreValve prosthesis. METHODS: From June 2008 to June 2009 consecutive patients with symptomatic severe aortic valve stenosis (area<1 cm(2)), age>or=75 years with a logistic EuroSCORE >or=15% or age>60 years plus additional specified risk factors were evaluated for TAVI. Examinations of study patients were performed before and 30 days after TAVI and comprised assessment of quality of life (Minnesota living with heart failure questionnaire, [MLHFQ]) 6-minute walk test, measurement of B-type natriuretic peptide and echocardiography. Aortic valve prosthesis was inserted retrograde using a femoral arterial or a subclavian artery approach. RESULTS: In 44 consecutive patients (mean age 79.1+/-7 years, 50% women, mean left ventricular ejection fraction 55.8+/-8.5%) TAVI was successfully performed. Follow-up 30 days after TAVI showed a significantly improved quality of life (baseline 44+/-19.1 vs 28+/-17.5 MLHFQ Score, p<0.001) and an enhanced distance in the 6-minute walk test (baseline 204+/-103 vs 266+/-123 m, p<0.001). B-type natriuretic peptide levels were reduced (baseline 725+/-837 vs 423+/-320 pg/ml, p=0.005). CONCLUSIONS: Our preliminary results show a significant clinical benefit and a reduction of neurohormonal activation in patients with severe and symptomatic aortic valve stenosis early after TAVI.

Do not forget the distal lower limb veins in screening patients with spinal cord injuries for deep venous thromboses.

In this prospective study, we aimed to document the rate and localization of deep venous thromboses in patients with spinal cord injuries. Patients with paraplegia or tetraplegia were screened by a serial color duplex sonography protocol for deep venous thrombosis within the first 36 hours after admission, at day 7, and at day 21. Sonography was performed by a complete scan including the veins below the knee. A total of 139 patients were included (19-90 years, 63.5% male). Cumulative rate of deep venous thrombosis after 3 duplex scans was 45.3% (n = 63). In 71.4% (n = 45), thromboses were localized below the knee. Because of the relevant number of distal vein thromboses, inclusion of the calf veins during screening scans is suggested. Further studies are needed to analyze the clinical benefit of diagnosing and treating distal vein thromboses.

Serial compression B-scan and Doppler sonography for the screening of deep venous thrombosis in patients with spinal cord injuries.

PURPOSE: To evaluate the usefulness of serial compression B-scan and Doppler sonography (US) in screening for deep venous thrombosis (DVT) of the lower extremities in patients with spinal cord injuries. METHOD: Patients with paraplegia and tetraplegia due to spinal cord injuries were screened by a serial compression B-scan and Doppler US protocol for DVT of the bilateral lower extremities within the first 36 hours after admission, at day 7 and at day 21. In patients with DVT, a follow-up US examination was performed 3 weeks after diagnosis to assess thrombi distribution. RESULTS: Between January 2007 and March 2008, a total of 115 patients (75 males, 40 females), aged 19 to 85 years, were included. The first US examination documented a DVT in 44 cases (38.3%). After an initial negative scan, sonography after 7 days and 21 days showed DVT in 6 patients and 2 patients, respectively. Cumulative rate of DVT after the first 3 weeks was 45.2% (n=52). Follow-up US after 3 weeks in patients with DVT documented a complete recanalization in 19 patients (36.5%), no change in 12 patients (23.1%), and residual thrombi with partial recanalization in 21 patients (40.4%). CONCLUSION: Our study supports the use of serial compression B-scan and Doppler US as a screening tool for DVT of the lower extremities in patients with spinal cord injuries early after injury.

Adenosine-induced maximal coronary hyperemia for myocardial fractional flow reserve measurements: comparison of administration by femoral venous versus antecubital venous access.

BACKGROUND: Maximal hyperemia is a critical prerequisite for correct fractional flow reserve (FFR) measurements. Continuous administration of adenosine by femoral venous access is considered the gold-standard. However, antecubital venous access is used as an alternative route of administration due to the increasing popularity of radial versus femoral access for coronary catheterization. Because of a potentially larger cross sectional venous area in the arm-theoretically associated with slower flow velocities-and the extremely short half-life of adenosine, there are concerns whether this route of administration is truly equivalent to the femoral route. METHODS: Fifty randomly selected patients with coronary artery disease were included. FFR was measured with a pressure monitoring wire and the recording was digitally stored. Hyperemia was successively induced by adenosine via the antecubital vein at a dose of 140 microg kg(-1) min(-1) (A140), via the antecubital vein at a dose of 170 microg kg(-1) min(-1) (A170), and via the femoral vein at a dose of 140 microg kg(-1) min(-1) (F140). RESULTS: Induction of hyperemia by A140 yielded significantly lower hyperemic responses than compared with A170 (P = 0.038) and F140 (P = 0.005). No significant difference was seen between adenosine administration by A170 versus F140. Hyperemic stimulation by A140 underestimated lesion severity near the ischemic threshold of FFR more frequently than the other modalities. There were no differences in side-effects between any of the dosages and routes of administration. CONCLUSIONS: The intravenous application of adenosine via antecubital venous access is feasible but slightly less effective than the femoral approach. In this setting, an antecubital dosage of 170 microg kg(-1) min(-1) is comparable to the standard dosage of 140 microg kg(-1) min(-1) in the femoral vein. In some patients, this regimen might prevent an underestimation of lesion severity.

Long-term sinus rhythm stability after intraoperative ablation of permanent atrial fibrillation.

INTRODUCTION: Short- and medium-term sinus rhythm (SR) rates after intraoperative radiofrequency ablation to treat permanent atrial fibrillation (AF) are well documented. Is rhythm success stable during a long-term follow-up? METHODS AND RESULTS: A total of 130 patients who had undergone intraoperative radiofrequency cooled-tip endocardial ablation (SICTRA) of permanent AF (mean AF duration 6+/-5 years) concomitant to open heart surgery more than 3 years ago were followed up using electrocardiogram (ECG), Holter-ECG, and echocardiography and compared with 12-month follow-up data. In 55% of patients, only the left atrium and in 45%, both atria were treated using SICTRA. Mitral valve replacement was performed in 21, mitral valve reconstruction in 25, aortic valve replacement in 13, CABG procedures in 51 (including 11 patients with additional mitral valve surgery), and complex procedures in 20 patients. Sixty-nine percent of patients (90/130) were in stable SR after a median period of 48 months, whereas 28% (36/130) were in AF and 3% (4/130) were in atrial flutter. In between the 12-month follow-up and the long-term follow-up, seven patients converted to AF after having documented SR, two patients converted to typical right atrial flutter after being in SR, and two patients from AF to left atrial macroreentry. After left and biatrial SICTRA, SR rates were comparable (73% vs 66%, P = 0.45). Echocardiography revealed 73% of patients in SR to have effective left atrial contraction. CONCLUSIONS: SICTRA restores long-term stable SR in 69% of all patients. Nine percent of patients reconverted back to atrial arrhythmia after having documented SR at 12 months.