High pressure versus standard port system: comparison of implantation and complications.

INTRODUCTION: Completely implantable access ports for high pressure contrast media injection have been in use in clinical routine for a relatively short time. The purpose of our study was to compare a high pressure port system with a standard port system with regard to implantation and complications. METHODS: In 94 oncological patients a completely implantable access port was implanted. Patients (n = 49) planned for oncological follow-up computed tomography (CT) received a high pressure port system. Other patients (n = 45) received a standard port system. Intrainterventional pain perception, postinterventional catheter tip migration and complications were analyzed. RESULTS: No major periinterventional complications occurred. Intrainterventional pain perception was not significantly different between the two groups. A significantly lower rate of tip migration was observed in the high pressure port group (P = 0.03) and when the port system was implanted on the right side (P = 0.03). In the standard port group catheter occlusion occurred in three patients (7%) and a catheter loop in one patient (2%) whereas no such complications occurred within the high pressure port group. Venous thrombosis was detected in one patient (2%) with a high pressure port; this did not occur in the standard port group. CONCLUSIONS: Implantation and use of a high pressure port device is safe and reliable: the complications are comparable to those of a standard port device. High pressure port systems should be considered for implantation, especially in patients who will require frequent CTs.

Dependency of cardiac resynchronization therapy on myocardial viability at the LV lead position.

OBJECTIVES: This study sought to analyze the effectiveness of cardiac resynchronization therapy (CRT) related to the viability in the segment of left ventricular (LV) lead position defined by myocardial deformation imaging. BACKGROUND: Echocardiographic myocardial deformation analysis allows determination of LV lead position as well as extent of myocardial viability. METHODS: Myocardial deformation imaging based on tracking of acoustic markers within 2-dimensional echo images (GE Ultrasound, GE Healthcare, Horton, Norway) was performed in 65 heart failure patients (54 ± 6 years of age, 41 men) before and 12 months after CRT implantation. In a 16-segment model, the LV lead position was defined based on the segmental strain curve with earliest peak strain, whereas the CRT system was programmed to pure LV pacing. Nonviability of a segment (transmural scar formation) was assumed if the peak systolic circumferential strain was >-11.1%. RESULTS: In 47 patients, the LV lead was placed in a viable segment, and in 18 patients, it was placed in a nonviable segment. At 12-month follow-up there was greater decrease of LV end-diastolic volumes (58 ± 13 ml vs. 44 ± 12 ml, p = 0.0388) and greater increase of LV ejection fraction (11 ± 4% vs. 5 ± 4%, p = 0.0343) and peak oxygen consumption (2.5 ± 0.9 ml/kg/min vs. 1.7 ± 1.1 ml/kg/min, p = 0.0465) in the viable compared with the nonviable group. The change in LV ejection fraction and the reduction in LV end-diastolic volumes at follow-up correlated to an increasing peak systolic circumferential strain in the segment of the LV pacing lead (r = 0.61, p = 0.0274 and r = 0.64, p = 0.0412, respectively). Considering only patients with ischemic heart disease, differences between viable and nonviable LV lead position group were even greater. CONCLUSIONS: Preserved viability in the segment of the CRT LV lead position results in greater LV reverse remodeling and functional benefit at 12-month follow-up. Deformation imaging allows analysis of viability in the LV lead segment.

Jugular versus subclavian totally implantable access ports: catheter position, complications and intrainterventional pain perception.

PURPOSE: To determine the safest and most tolerable method for totally implantable access ports (TIAPs) particularly in regard to patient's pain perception and catheter-related complications. MATERIALS AND METHODS: From January 2007 to October 2008 a subcutaneous TIAP (Bardport, Bard Access System, UT, USA) was implanted in 138 oncological patients (60 male, 78 female; 18-85 years old; mean age of 56 ± 6 years) by experienced interventional radiologists. 94 TIAP were implanted through the subclavian vein (subclavian group) and 44 TIAP were implanted through the internal jugular vein (jugular group). Intrainterventional pain perception (visual analogue scale from 1 to 10), postinterventional catheter tip migration and radiation dose were documented for each method and implantation side and differences were compared with Wilcoxon t-test. For ordinal variables, comparison of two groups was performed with the Fisher's exact test. RESULTS: No severe periinterventional complication occurred. Inadvertent arterial punctures without serious consequences were reported in one case for the jugular group versus four cases in the subclavian group. Significantly (p<0.05) lower pain perception, radiation dose and tip migration rate were observed in the jugular group. Catheter occlusions occurred in 4% (n=4) of the subclavian group versus 2% (n=1) of the jugular group. The corresponding values for vein thrombosis and catheter dislocation were 3% (n=3) and 1% (n=1) in the subclavian group, while none of those complications occurred in the jugular group. CONCLUSION: Both techniques, the TIAP implantation via fluoroscopy-guided subclavian vein puncture and via ultrasound-guided jugular vein puncture, are feasible and safe. Regarding intrainterventional pain perception, radiation dose, postinterventional catheter tip position and port function the jugular vein puncture under ultrasound guidance seems to be advantageous.

Evaluation of an active vena cava filter for MR imaging in a swine model.

PURPOSE: To evaluate the feasibility of magnetic resonance (MR) imaging-guided placement of an active vena cava filter (AVCF) in a swine model, the effectiveness of the system in filtering thrombi, and the detection of thrombi with MR imaging. MATERIALS AND METHODS: This study was approved by the government committee on animal investigations. An AVCF tuned to the Larmor frequency of a 1.5-T MR unit was placed in the inferior vena cava (IVC) of seven pigs under real-time MR imaging guidance. Steady-state free precession sequences with four different flip angles (90°, 40°, 25°, and 15°), T1-weighted turbo spin-echo sequences with two flip angles (90° and 15°), and black-blood proton-density-weighted sequences with a flip angle of 90° were performed before and after filter placement. In six cases, extracorporeally produced thrombi were injected through the femoral access to test filter function. The signal-to-noise ratio (SNR) and contrast-to-noise ratio (CNR) were assessed before and after filter deployment and compared by using the signed-rank test. RESULTS: All AVCFs were successfully deployed. Significant differences (P < .05) in the SNR and CNR of the IVC were found before and after AVCF placement and between sequences with different flip angles. Intravenous thrombi were caught in all cases and clearly depicted with MR imaging. On black-blood proton-density-weighted images, high-signal-intensity thrombi inside the filter were clearly detectable without any overlaying artifacts. CONCLUSION: MR imaging-guided deployment and monitoring of an AVCF is feasible. The AVCF enhances the SNR and CNR, resulting in clear depiction of thrombi inside the filter without the need for contrast material. Design modifications for improved intracaval fixation and retrieval of the prototype AVCF will be required.

Myocardial rotation but not circumferential strain is transducer angle dependent: a speckle tracking echocardiography study.

BACKGROUND: Doppler derived strain analysis has been shown to be angle dependent. Speckle tracking analysis using 2D echocardiographic images is thought to provide angle independent parameters of regional and global myocardial function. This study sought to evaluate whether myocardial circumferential strain and rotation derived from automatic frame-by-frame tracking of natural acoustic markers is dependent on angulation of the transducer. METHODS: In 48 healthy volunteers (mean age 36 ± 3 years, 20 male) parasternal short-axis views at apical level were obtained as follows: at the standard parasternal position (5th intercostal space) with a most possible circular short-axis image of the left ventricle (angulation 1), at an angulation of the transducer by 20° from this standard position to the apex (angulation 2) and at an angulation of the transducer by 20° to the base of the left ventricle (angulation 3). Using an automatic frame-by-frame tracking system of natural acoustic echocardiographic markers (EchoPAC, GE Ultrasound, Horton, Norway) circumferential strain and rotation were calculated for six segments within a short-axis circumference. RESULTS: Image quality was sufficient for acquisition and analysis of images at all three-transducer angulation in 90% of the analyzed segments. Rotation was measured to be 7.7 ± 1.2° at angulation 1, 2.7 ± 0.9° at angulation 2 and 4.3 ± 1.1° at angulation 3 (p < 0.05). Average circumferential strain data was found to be -27.2 ± 5.1% at angulation 1, -26.5 ± 3.8% at angulation 2 and 28.9 ± 4.4% at angulation 3 (p = 0.287). CONCLUSION: Circumferential strain analysis is not dependent on transducer angulation. In contrast, determination of myocardial rotation is dependent on transducer angulation. Therefore, accurate transducer angulation has to be taken care of if rotation measurements are performed.

Impact of systolic and diastolic deformation indexes assessed by strain-encoded imaging to predict persistent severe myocardial dysfunction in patients after acute myocardial infarction at follow-up.

OBJECTIVES: This study evaluated the value of systolic and diastolic deformation indexes determined by strain-encoded imaging to predict persistent severe dysfunction at follow-up in patients after reperfused acute myocardial infarction (AMI) in comparison with late gadolinium enhancement (LGE). BACKGROUND: Animal studies suggest that regional diastolic function provides information about myocardial viability after AMI. However, data in humans are sparse. METHODS: Twenty-six patients underwent magnetic resonance imaging 3 ± 1 days after successfully reperfused ST-segment elevation myocardial infarction and at a follow-up of 6 months. Cine, strain-encoded, and LGE images were acquired. Peak systolic circumferential strain (E(cc)) and early diastolic strain rate (E(cc)/s) were calculated for each segment at baseline and at follow-up. A cutoff E(cc) value of -9% was used to define severe dysfunction at follow-up. RESULTS: A total of 312 segments were analyzed; 119 segments showed abnormal baseline function. Thirty-five segments showed severe dysfunction at follow-up, which was defined as E(cc) at follow-up <9%. The area under the curve for E(cc)/s was 0.82 (95% confidence interval [CI]: 0.72 to 0.89), for E(cc) 0.74 (95% CI: 0.64 to 0.83), and for LGE 0.85 (95% CI: 0.77 to 0.92). A comparison of receiver-operating characteristic curves demonstrates that LGE is not significantly different than E(cc)/s but is significantly different than E(cc) (p = 0.32 vs. p < 0.05) for prediction of severe dysfunction at follow-up. CONCLUSIONS: Regional diastolic function provides similar accuracy to predict persistent severe dysfunction at follow-up to LGE and is superior to regional systolic function in patients after AMI. Diastolic deformation indexes may serve as a new parameter for assessment of viability in patients after AMI. (SENC in AMI Study; NCT00752713).

The right ventricular response to high afterload: comparison between healthy persons and patients with transposition of the great arteries: a 2D strain study.

OBJECTIVE: To evaluate the contraction pattern of the systemic right ventricle (RV) in comparison to healthy controls. METHODS: 31 patients (14 female, mean age 21.5 ± 3.3 years) with congenital corrected (ccTGA) and surgical corrected (D-TGA) TGA and 31 age-matched healthy controls (17 female, mean age 23.1 ± 2.6 years) were included in the study. We compared the contraction pattern of the systemic RV with findings in the right and left ventricle (LV) of healthy controls. Echocardiograms were performed for all patients (19.3 ± 2.5 years after the operation) and all healthy controls. Using a novel computer software (GE Ultrasound, Horton, Norway) that allows automatic frame-by-frame tracking of accoustic markers during the heart cycle longitudinal and circumferential strain and strain rate were defined as parameters of myocardial deformation. RESULTS: In the systemic free RV wall, circumferential strain was greater than longitudinal strain (-25.6 ± 4.2% vs. -15.2 ± 3.9%, P < 0.001), opposite to the contraction pattern of the subpulmonary free RV wall (-17.7 ± 4.1% vs. -28.3 ± 3.3%, P < 0.001). Compared with controls, segmental analysis of the free RV wall resulted in lower systolic longitudinal and higher systolic circumferential strain and strain rate values. In the free LV wall, circumferential strain was lower than longitudinal strain (-19.1 ± 2.7% vs. -26.8 ± 4.5%, P < 0.001) in contrast to the data in the systemic free LV wall (-24.5 ± 3.1% vs. -16.7 ± 3.5%, P < 0.001). CONCLUSIONS: Myocardial deformation parameters were significantly different in systemic and normal RV indicating a dependency of myocardial deformation parameters on right ventricular afterload. The use of myocardial deformation imaging identified a shift from longitudinal to circumferential contraction pattern in the systemic RV in comparison to the LV. This might demonstrate a response to the systemic load creating a myocardial hypertrophy.

Analysis of LV lead position in cardiac resynchronization therapy using different imaging modalities.

OBJECTIVES: This study sought to evaluate whether left ventricular (LV) lead position in cardiac resynchronization therapy (CRT) can be determined by myocardial deformation imaging during LV pacing and to compare imaging techniques for analysis of LV lead position. BACKGROUND: LV lead position has a significant impact on effectiveness of CRT, but clinically applicable methods to determine LV lead position are less defined. METHODS: In 56 patients (53 +/- 5 years, 34 men) undergoing CRT, fluoroscopy and 2 myocardial deformation imaging-based approaches were applied to determine the LV lead position. Myocardial deformation imaging-based techniques were used to determine 1) the segment with maximal temporal difference of peak circumferential strain before and while on biventricular CRT; and 2) the segment with earliest peak systolic circumferential strain during pure LV pacing. Twelve-month echocardiography was performed to determine LV remodeling and improvement in function. Optimal LV lead position was defined as concordance or immediate neighboring of the determined LV lead position to the segment with latest systolic strain prior to CRT. RESULTS: LV lead position determined during LV pacing correlated to the position determined by fluoroscopy (kappa = 0.761). Patients with optimal LV lead position had greater improvement in LV ejection fraction and decrease in end-diastolic volume than those with nonoptimal LV lead position (12 +/- 4% vs. 7 +/- 3%, p < 0.001, and 28 +/- 13 ml vs. 14 +/- 8 ml, p < 0.001, respectively). Determination of the LV lead position based on myocardial deformation imaging during LV pacing showed greater discriminatory power for improvement of ejection fraction (difference optimal vs. nonoptimal lead position group: 4.64 +/- 1.01 ml; p < 0.001) than deformation imaging with biventricular pacing (3.03 +/- 1.08 ml; p = 0.007) and fluoroscopy (2.22 +/- 1.12 ml; p = 0.053). CONCLUSIONS: Myocardial deformation imaging during LV pacing allows determination of the LV lead position in CRT. Improvement in LV function and remodeling as indicators of optimal LV lead position can be best predicted by LV lead position analysis during LV pacing. (Left Ventricular Lead Position in Cardiac Resynchronization Therapy; NCT00748735).

Multi-slice computed tomography: A tool for non-invasive temperature measurement?

PURPOSE: To investigate the potential of multi-slice computed tomography (MSCT) as a tool for non-invasive temperature measurement. MATERIALS AND METHODS: Samples of water, 0.9% saline, sunflower oil and dilutions of (1:32, 1:64, 1:128) contrast agent (Iopromid 370, BayerSchering Pharma, Berlin) were heated in a plexiglass phantom. In a first set-up, samples of 0.9% saline solution were scanned at defined temperatures (25 degrees -75 degrees C; 5 degrees C intervals) using a clinical CT scanner. Scan parameters (tube current-time product, tube voltage, collimation, slice thickness) were systematically varied. In a second set-up samples of the different fluids (water, sunflower oil, contrast agent dilutions) were scanned using the following scan protocol: 250 mAs, 140 kV, 1.2 mm collimation, 9.6 mm slice thickness. CT numbers were measured in reconstructed axial images at the different temperatures. A regression analysis was performed to investigate the relationship between temperature and CT number. RESULTS: Standard deviation of measured CT numbers decreased with increasing tube current-time product, increasing tube voltage, thicker collimation and higher slice thickness. Regression analysis showed an inverse relationship between temperature and CT number for all fluids with regression coefficients of -0.471 (0.9% saline), 0.447 (water), -0.679 (sunflower oil), -0.420 (contrast agent 1:32), -0.414 (contrast agent 1:64) and -0.441 (contrast agent 1:128), respectively. CONCLUSION: Multi-slice computed tomography can depict thermal density expansion of different fluids. Based on these results the implementation of a temperature discrimination of several degrees C at a high spatial resolution is achievable.

Clinical periodontal and microbiologic parameters in patients with Crohn's disease with consideration of the CARD15 genotype.

BACKGROUND: Crohn's disease (CD) was reported to have oral manifestations. However, data on periodontal parameters and oral microbiology in CD are rare. Recent studies showed associations of variants in the caspase recruitment domain (CARD)15 gene with CD that are involved in the immune response toward bacterial products. Our aim is to investigate the periodontal status and prevalence of periodontal pathogens in patients with CD under consideration of the CARD15 polymorphism. METHODS: Oral soft tissue alterations and periodontal parameters of 147 patients with CD were assessed. Subgingival plaque samples were analyzed for the periodontal pathogens Aggregatibacter actinomycetemcomitans (Aa; previously Actinobacillus actinomycetemcomitans), Porphyromonas gingivalis (Pg), Tannerella forsythia (Tf; previously T. forsythensis), Prevotella intermedia (Pi), and Campylobacter rectus (Cr ) using dot-blot hybridization. CARD15 genotyping was performed with the a polymerase chain reaction (PCR) based assay. RESULTS: A total of 36.7% of patients had oral manifestations predominated by gingival swellings (27.2%) and hyperplastic lesions of the buccal mucosa (20.4%). The mean probing depth and mean clinical attachment level were 3.6 and 3.8 mm, respectively. A total of 57.8% of the patients had a Community Periodontal Index of Treatment Needs (CPITN) score 3, and 31.3% of had a CPITN score 4. The prevalence of Aa, Pg, Pi, Tf, and Cr was 76.9%, 62.6%, 79.6%, 64.6%, and 94.6%, respectively. Pi was significantly less frequent in carriers of CARD15 mutations compared to the wild type (69.7% versus 87.7%; P = 0.008). All other pathogens and clinical periodontal parameters did not differ significantly as to the CARD15 polymorphism. CONCLUSIONS: Our findings suggest that patients with CD have an increased prevalence and moderate severity of periodontitis. The colonization of periodontal pathogens, in particular Cr, might be of particular value for the periodontal manifestation of CD. Although a modulating impact on periodontal microbiota can be supposed, our data do not support the role of CARD15 in oral symptoms and periodontal lesions in patients with CD.

Epidemiology of invasive Streptococcus pyogenes disease in Germany during 2003-2007.

A nationwide laboratory-based surveillance study of invasive Streptococcus pyogenes infections was conducted in Germany. Invasive isolates (n=586) were obtained between 2003 and 2007. Most isolates were obtained from blood (53.9%) or skin lesions (17.6%). The most common emm types were emm 1 (30.5%), emm 28 (18.3%) and emm 3 (9.6%). Overall, speA was positive in 45.9%, speC in 44.7% and ssa in 14.8% of isolates. SpeA was common in emm type 1 (100%) and emm type 3 (96.4%), whereas speC was often observed in emm type 28 (93.5%). The most frequent clinical manifestations included sepsis (40.1%), necrotizing fasciitis (20.8%) and streptococcal toxic shock syndrome (16.6%). All isolates were susceptible to penicillin G, cefotaxime and levofloxacin. Tetracycline shows the highest rate of resistant or intermediate isolates with 11.6%, followed by clarithromycin (5.5%) and clindamycin (1.2%). The most prominent trend is the reduction of tetracycline-nonsusceptible isolates from 18.6% in 2003 to 8.9% in 2007.

Association of serotypes of Streptococcus pneumoniae with age in invasive pneumococcal disease.

A total of 7,764 isolates from patients with invasive pneumococcal disease (IPD) were collected from 1992 to June 2006. Data on serotypes were available for 5,022 isolates (64.7% of all invasive isolates). Some 54.0% of the isolates originated from adults >or=16 years of age, and 46.0% were from children <16 years of age. The leading serotypes were 14, 23F, 1, 6B, 7F, 3, and 4. The serotypes significantly more common in children were 14, 6B, 19F, and 18C, while among adults, serotypes 3 and 4 were predominant. Serotype 7F was statistically more prevalent among children <4 months old than among the other age groups. Among children aged >or=4 months and <1 year, serotype 19F occurred statistically more frequently; and among children aged >or=1 year to <5 years, serotypes 14, 6B, and 18C were overrepresented. The serotypes predominantly affecting patients younger than the remaining collective of patients were 14, 6B, 19F, and 18C, while patients with IPD caused by serotypes 3, 4, and 9V were older than the collective, on average.

The removal of Al2O3 particles from grit-blasted titanium implant surfaces: effects on biocompatibility, osseointegration and interface strength in vivo.

For the improvement of surface roughness and mechanical interlocking with bone, titanium prostheses are grit-blasted with Al(2)O(3) particles during manufacturing. Dislocated Al(2)O(3) particles are a leading cause of third-body abrasive wear in the articulation of endoprosthetic implants, resulting in inflammation, pain and ultimately aseptic loosening and implant failure. In the present study, a new treatment for the removal of residual Al(2)O(3) particles from grit-blasted, cementless titanium endoprosthetic devices was investigated in a rabbit model. The cleansing process reduces residual Al(2)O(3) particles on titanium surfaces by up to 96%. The biocompatibility of the implants secondary to treatment was examined histologically, the bone-implant contact area was quantified histomorphometrically, and interface strength was evaluated with a biomechanical push-out test. Conventional grit-blasted implants served as control. In histological and SEM analysis, the Al(2)O(3)-free implant surfaces demonstrated uncompromised biocompatibility. Histomorphometrically, Al(2)O(3)-free implants exhibited a significantly increased bone-implant contact area (p=0.016) over conventional implants between both evaluation points. In push-out testing, treated Al(2)O(3)-free implants yielded less shear resistance than conventional implants at both evaluation points (p=0.018). In conclusion, the new surface treatment effectively removes Al(2)O(3) from implant surfaces. The treated implants demonstrated uncompromised biocompatibility and bone apposition in vivo. Clinically, Al(2)O(3)-free titanium prostheses could lead to less mechanical wear of the articulating surfaces and ultimately result in less aseptic loosening and longer implant life.

Clinical evaluation of a biphasic calcium composite grafting material in the treatment of human periodontal intrabony defects: a 12-month randomized controlled clinical trial.

BACKGROUND: The aim of this study was to compare the clinical outcome of a novel biphasic calcium composite (BCC) biomaterial versus autogenous bone spongiosa (ABS) or open flap debridement (OFD) for the treatment of intrabony periodontal defects. METHODS: Forty-five subjects with at least one intrabony defect with a probing depth (PD) >or=7 mm and a vertical radiographic bone loss >or=3 mm were enrolled in the study. Subjects were randomly assigned to treatment with BCC (n = 15), ABS (n = 15), or OFD (n = 15). Clinical parameters were recorded at baseline and 12 months after surgery and included the plaque index, gingival index, PD, clinical attachment level (CAL), and gingival recession. RESULTS: In all treatment groups, significant PD reductions and CAL gains occurred during the study period (P <0.0001). At 12 months, patients treated with BCC exhibited a mean PD reduction of 3.6 +/- 0.7 mm and a mean CAL gain of 3.0 +/- 0.8 mm compared to baseline. Corresponding values for patients treated with ABS were 3.4 +/- 0.8 mm and 2.9 +/- 0.9 mm, whereas OFD sites produced values of 2.8 +/- 0.8 mm and 1.6 +/- 0.7 mm. Compared to OFD, the additional CAL gain was significantly greater in patients treated with BCC (P = 0.002) and ABS (P = 0.001). The additional PD reduction was significant for the BCC group (P = 0.011) and borderline significant for the ABS group (P = 0.059). There were no significant differences of PD and CAL changes between BCC and ABS groups. CONCLUSIONS: The clinical benefits of BCC were equivalent to ABS and superior to OFD alone. BCC may be an appropriate alternative to conventional graft materials.

Impact of occluder device type on success of percutaneous closure of atrial septal defects--a medium-term follow-up study.

OBJECTIVE: To identify differences between various occluder types regarding thromboembolic event rates and existence of residual shunts during medium-term follow-up. METHODS: Three hundred nine consecutive patients with presumed paradoxical embolism and scheduled for percutaneous closure of patent foramen ovale or atrial septal defect between 1997 and 2006 were considered for this study. Device implantation failed in seven patients (nonstable device position), so 302 patients (46 +/- 12 years, 190 males) formed the study group using Amplatzer (n = 208), Starflex (n = 61), and Cardiastar (n = 33) occluders. Follow-up transesophageal echocardiography was performed 1, 3, and 6 months after implantation. RESULTS: Periinterventional complications occurred in two patients (cardiac arrhythmias). There were more residual shunts in the Starflex and Cardiastar group than in the Amplatzer group at 6-month follow-up (8/61 vs. 7/33 vs. 8/208, P = 0.0005). Performing logistic regression, the type of occluder device was a significant risk factor for the presence of residual shunt 6 months after implantation (P = 0.0033; Cardiastar vs. Amplatzer OR 6.346, 95% CI 1.998 - 20.156; Starflex vs. Amplatzer OR 4.369, 95% CI 1.444 - 13.222). During mean follow-up of 31 +/- 8 months 16 recurrent thromboembolic events occurred; the annual recurrence was 2.1% for combined end-point stroke, TIA, and peripheral embolism (Amplatzer: 1.3%, Starflex: 3.9%, and Cardiastar: 3.6%, P = 0.0467). The presence of an atrial septal aneurysm was the only significant risk factor (P = 0.0168, OR 3.664, 95% CI 1.263 - 10.630) for the occurrence of thromboembolic events. CONCLUSIONS: Percutaneous closure of patent foramen ovale or atrial septal defect is a safe procedure with little incidence of peri- and postprocedural complications. There is a significant difference between the Amplatzer, Cardiastar, and Starflex occluders in regard to complete closure of the defects and annual recurrence of thromboembolic events.

Clinical periodontal and microbiologic parameters in patients with acute myocardial infarction.

BACKGROUND: The aim of this study was to evaluate the impact of clinical periodontal parameters and the presence of periodontal pathogens in patients with acute myocardial infarction (AMI). METHODS: A total of 104 subjects (54 patients with AMI and 50 healthy controls) were included. Subgingival plaque samples were analyzed for periodontal pathogens Aggregatibacter actinomycetemcomitans (Aa; previously Actinobacillus actinomycetemcomitans), Porphyromonas gingivalis (Pg), Tannerella forsythia (Tf; previously T. forsythensis), and Prevotella intermedia (Pi) using dot-blot hybridization. RESULTS: Patients with AMI had a significantly higher frequency of probing depths (PDs) >or=4 mm than controls (39.2% versus 14.9%; P <0.0001). Among different cutoff levels, the frequency of >50% sites with PDs >or=4 mm showed the highest discrepancy between both groups (33% versus 0%; P <0.001). All periodontal pathogens were overrepresented in patients with AMI and positively correlated with increased periodontal PD and clinical attachment level (CAL). After adjustment for age, gender, smoking, body mass index, hypertension, plaque index, statin intake, and ratio of cholesterol to high-density lipoprotein, Pg remained a significant predictor for AMI (odds ratio [OR]: 13.6; 95% confidence interval [CI]: 3.1 to 59.8; P = 0.0005). Furthermore, the simultaneous presence of Aa + Pg (P = 0.0005) and Aa + Pg + Tf (P = 0.0018) were found with significantly higher frequency in patients with AMI than controls. CONCLUSIONS: The results of our study confirm an association between periodontitis and AMI in which periodontal destruction was correlated with the presence of periodontal pathogens. In particular, Pg might be considered a potential risk indicator for AMI.

Strain-encoded MRI for evaluation of left ventricular function and transmurality in acute myocardial infarction.

BACKGROUND: Strain-encoded imaging (SENC) is a new technique for myocardial deformation analysis in cardiac MRI. The aim of the study was, therefore, to evaluate whether myocardial deformation imaging performed by SENC allows for quantification of regional left ventricular function and is related to transmurality states of infarcted tissue in patients with acute myocardial infarction. METHODS AND RESULTS: Cardiac MRI was performed in 38 patients with acute myocardial infarction 3+/-1 days after successful reperfusion using a clinical 1.5-T MRI scanner. Ten healthy volunteers served as controls. SENC is a technique that directly measures peak circumferential strain from long-axis views and peak longitudinal strain from short-axis views. Measurements were obtained for each segment in a modified 17-segment model. Wall motion and infarcted tissue were evaluated semiquantitatively from steady-state free-precession cine sequences and contrast-enhanced MR images and were then related to myocardial strain. Comparison of peak circumferential strain assessed by SENC and MR tagging was performed. In total, 456 segments were analyzed. Peak circumferential and longitudinal strain calculated from SENC images was significantly different in regions defined as normokinetic, hypokinetic, or akinetic (P<0.001). A cutoff peak systolic circumferential strain value of -10% differentiated nontransmural from transmural infarcted myocardium, with a sensitivity of 97% and a specificity of 94%. Strain analysis of SENC and MR tagging correlated well (r=0.76) with narrow limits of agreement (-9.9% to 8.5%). CONCLUSIONS: SENC provides rapid and objective quantification of regional myocardial function and allows discrimination between different transmurality states in patients with acute myocardial infarction.

Comparison of manual, semi- and fully automated heart segmentation for assessing global left ventricular function in multidetector computed tomography.

PURPOSE: To evaluate the reliability of global left ventricular (LV) function and mass measurements with the aid of a semi-automated (Circulation; Siemens, Forchheim, Germany) and a new fully automated software (Philips Research Europe, Aachen, Germany) versus an established manual segmentation method (Argus; Siemens). MATERIAL AND METHODS: Forty-one patients (31 men, 10 women; mean age: 62 +/- 5 years) with known or suspected coronary heart disease underwent contrast-enhanced Dual-Source computed tomography of the heart (120 kV, 410 mAs/rotation, collimation 2 x 32 x 0.6 mm, gantry rotation time 0.33 milliseconds). Global LV function measurements of end-diastolic volume (EDV), end-systolic volume (ESV), stroke volume, ejection fraction (EF), and LV mass were each assessed with a manual, a semi- and fully automated method. The latter were compared with the manual contour tracing method, which was considered as standard of reference. Postprocessing time for each method was recorded. For statistical analysis, repeated-measures analysis of variance, post hoc t test, and concordance correlation coefficients were calculated. Bland-Altman plots were generated. RESULTS: In general, ESV and EF assessed with the semi-automated and with the fully automated prototype version agreed well with the manual contour tracing method. The mean ESV (+/-SD) calculated from the manual, the semi-automated, and the fully automated method was 67 +/- 43 mL, 74 +/- 54 mL, and 75 +/- 48 mL, respectively. No statistically significant differences between the methods were found for ESV and EF. In contrast, significant variations (P < 0.05) among the different segmentation methods were shown for EDV, stroke volume, and LV mass. This variation was predominantly due to variation in endocardial delineations among the different techniques. Concordance correlation coefficients demonstrated a better accuracy for the fully automated method than for the semi-automated technique when compared with the manual drawing method. Furthermore, fully automated postprocessing heart segmentation yielded time savings of approximately 80% compared with the manual segmentation tool and 63% compared with the semi-automated technique. Mean postprocessing time (+/-SD) for the manual, the semi-automated, and the fully automated method was 345 +/- 75 seconds, 192 +/- 58 seconds, and 72 +/- 58 seconds, respectively. CONCLUSION: LV function and mass analyses using semi- or fully automated segmentation algorithms are feasible even if significant differences in EDV assessment are observed. The fully automated method results in better accuracy and time savings when compared with manual and semi-automated data analysis.

Impact of infarct transmurality on layer-specific impairment of myocardial function: a myocardial deformation imaging study.

AIMS: To evaluate deformation parameters of an endocardial, mid-myocardial, and epicardial myocardial layer in different transmurality of myocardial infarction and assess whether layer-specific deformation analysis allows definition of infarct transmurality. METHODS AND RESULTS: Fifty-six patients (mean age 55 +/- 9 years, 38 men) with chronic ischaemic left ventricular (LV) dysfunction underwent two-dimensional echocardiography and contrast-enhanced magnetic resonance imaging (ceMRI). The extent of myocardial infarction was determined as relative amount of hyperenhancement by ceMRI in a 16-segment LV model (0%, no infarction; 1-50%, non-transmural infarction; 51-100%, transmural infarction). On the basis of two-dimensional echocardiographic parasternal short-axis views peak systolic circumferential strain was determined for the total wall thickness and for each of three myocardial layers (endocardial, mid-myocardial, and epicardial) using an automatic frame-by-frame tracking system of acoustic echocardiographic markers (EchoPAC, GE Ultrasound). In non-transmural infarction impairment of circumferential strain was greater in the endocardial than the epicardial layer, relative reduction compared with control segments, 45% vs. 28% (P < 0.001), respectively. In transmural infarction additional impairment of circumferential strain was greater in the epicardial than the endocardial layer, relative reduction compared with non-transmural infarction 29% vs. 7% (P < 0.001), respectively. Endocardial layer circumferential strain allowed distinction of non-transmural vs. no infarction with higher accuracy than total wall thickness strain [area under the curve (AUC) 0.842 vs. 0.774, respectively, P = 0.001]. Epicardial layer circumferential strain allowed distinction of transmural from non-transmural infarction with higher accuracy than total wall thickness strain (AUC 0.819 vs. 0.762, respectively, P = 0.005). CONCLUSION: Non-transmural infarction results in greater functional impairment of the endocardial than of the epicardial myocardial layer. In transmural infarction both layers are affected similarly compared with controls. A layer-specific analysis of myocardial deformation allows accurate discrimination between different transmurality categories of myocardial infarction.

Unmasking pedal arteries in patients with critical ischemia using time-resolved contrast-enhanced 3D MRA.

OBJECTIVE: To test the diagnostic relevance of fast Gadobenate dimeglumine (Gd-BOPTA) enhanced, time-resolved, three-dimensional magnetic resonance angiography (t3D MRA) of distal calf and pedal vasculature in critical limb ischemia in a prospective comparison with conventional selective digital subtraction angiography (DSA) and high-resolution duplex ultrasound (US) scan. METHODS: From April 2007 to June 2008, 34 feet of 29 consecutive patients suffering from limb-threatening ischemia underwent diagnostic US scan, DSA, and t3D MRA before treatment. The investigations took place within 3 days. A t3D MRA was performed using a 3 Tesla whole-body magnetic resonance (MR) system with an eight-element phased-array coil. Image quality and diagnostic findings were subjectively analyzed by two radiologists and one vascular surgeon. Each distal calf and foot was divided into six arterial segments for DSA and t3D MRA, and four segments were investigated by US scan. Patency or occlusion was studied with all the techniques, whereby DSA and t3D MRA were additionally evaluated in patients having greater or less than 50% stenosis. Finally, images were visually assessed by the three observers by applying a six-point grading scale. The acquired data was statistically analyzed using McNemar's test and Wilcoxon's matched-pairs signed-rank sum test. The P values of less than an alpha level of .05 were considered to be statistically significant. RESULTS: We achieved MRA images of diagnostic quality in all patients. Significantly more patent pedal arteries were identified by applying t3D MRA than DSA (P < .001) and US scan (P < .02). For estimating the degree of stenosis, no technique proved to be superior (P > .28). Overall image quality was rated best for t3D MRA. Additionally, potential bypass target vessels could be clearly discriminated from pedal veins due to the temporal resolution. CONCLUSION: In our prospective study, t3D MRA has been proven to be superior to DSA and US scan in pedal vasculature imaging in critical limb ischemia. This is a valuable, noninvasive method for detecting potential pedal bypass target arteries.