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Background: Risk stratification in patients with congestive heart failure (CHF) is an obligatory part of the heart transplantation (HTx) selection process. New medical therapies and the predictive value of hemodynamic changes over time have not been adequately taken into account in previous stratification models. In this study we assessed the prognostic value of 55 variables at baseline and 9 variables representing changes of hemodynamic parameters over time. Methods: A total of 178 patients with CHF were examined on 3.4 ± 2.6 occasions (mean follow-up 19 ± 19 months). Using the Cox proportional hazards model, univariate and multivariate relative risks (RRs) with 95% confidence intervals (CI) were determined for predicting event-free survival. A prognostic score (Munich score) was derived from the multivariate Cox model and three risk groups were derived. Results: During follow-up, 23 patients (13%) died and 63 (35%) underwent HTx. The univariate analysis yielded 21 statistically significant (p < 0.05) predictors of event-free survival. However, only four baseline variables (etiology of ischemic cardiomyopathy, systolic blood pressure, left ventricular [LV] end-diastolic diameter, maximal workload) and the change over 12 months in fractional shortening remained statistically significant (p < 0.05) in the multivariate Cox model and were used for the prognostic score. Within 12 months, no event occurred in the low-risk group, 8.1% in the intermediate, and 30.1% in the high-risk group. Conclusions: The incorporation of changes over time in hemodynamic parameters allowed for an improved baseline risk stratification model for the HTx selection process, especially in the era of new medical therapies such as β-blocker therapy. All significant variables of the Munich score can be obtained in routinely performed non-invasive tests. [Copyright &y& Elsevier]

Cocaine use is a major problem worldwide and there are numerous reports about cocaine-associated myocardial infarction. Nevertheless minimal data are available from randomised clinical trials to suggest evidence-based approaches to the management of cocaine-associated myocardial ischemia. Moreover, most reports have been limited to conservative management of cocaine-associated myocardial infarction. We report a case of a young male cocaine user with acute myocardial infarction, undergoing diagnostic coronary angiography and intravascular ultrasound revealing severe atherosclerosis, followed by successful stent implantation. [Copyright &y& Elsevier]

BACKGROUND: Pressure derived myocardial FFR, a functional index of epicardial stenosis has been proposed for the assessment of optimal stent deployment. The following study evaluated the potential of serial fractional flow reserve (FFR) measurements in comparison to the ‘gold standard’ intravascular ultrasound (IVUS) for optimal stent deployment and its long‐term outcome. METHODS: 35 patients with a single de novo lesion underwent PTCA followed by stent implantation with an initial inflation pressure of 12 atm. If optimal stent expansion using IVUS‐criteria were not fulfilled, re‐dilatation at 16 atm as well as additional inflations with larger balloon sizes were performed to reach the procedural end‐point. IVUS and FFR were performed after each dilatation ( n = 136). Angiography was repeated after 6 months. RESULTS: In 30 pts who fulfilled IVUS criteria, mean lumen area (2.9±1.3 mm 2 ) increased after PTCA and stent implantation to 10.0±3.0 mm 2 . In six pts, optimum stent deployment according to a value of FFR&geqslant;0.94 was not reached. Four of six pts reached the IVUS criteria at 12 atm and two pts at 16 atm, respectively. Positive and negative predictive values of FFR were 26 and 64%. Three of the 30 pts (10%) revealed a restenosis at three months follow‐up. One of these restenosis was seen in a patient with a post‐procedural FFR [ABSTRACT FROM AUTHOR]

Background: Elevated pulmonary vascular resistance (PVR) is relevant to prognosis of congestive heart failure and heart transplantation. Proof of reversibility by pharmacologic testing in potential transplantation candidates is important because it indicates a reduced probability of right ventricular failure or death in the early post-transplant period. This study aimed to clarify the possible extent of acute reversibility of elevated PVR in a large, consecutive cohort of heart transplant candidates. Methods: This study included 208 consecutive patients (age 52 ± 10 years, 89% men and 11% women, ejection fraction 21 ± 9%, Vo 2max 12.6 ± 4.2 ml/kg/min) being evaluated for heart transplantation in 7 transplant centers in Germany and Switzerland. Testing was performed with increasing intravenous doses of prostaglandin E1 (PGE1; average maximum dose 173 ± 115 ng/kg/min for at least 10 minutes) in 92 patients exhibiting a baseline PVR of >2.5 Wood units (WU) and/or a transpulmonary gradient (TPG) of >12 mm Hg. Results: PGE1 testing lowered PVR from 4.1 ± 2.0 to 2.1 ± 1.1 WU (p < 0.01), increased cardiac output from 3.8 ± 1.0 to 5.0 ± 1.5 liters/min (p < 0.01), and decreased TPG from 14 ± 4 to 10 ± 3 mm Hg (p < 0.01), mean pulmonary artery pressure (PAM) from 39 ± 9 to 29 ± 9 mm Hg (p < 0.01) and mean pulmonary capillary wedge pressure (PCWP) from 24 ± 7 to 19 ± 9 mm Hg (p < 0.01). Mean aortic pressure (MAP) decreased to 85% and systemic vascular resistance (SVR) to 65% of baseline values (p < 0.01). Symptomatic systemic hypotension was not observed. For the whole population the percentage of patients with PVR >2.5 WU was reduced from 44.2% to 10.5% with PGE1. PVR decreased in each patient; only 2 patients (1%) remained ineligible for listing because of a final PVR of >4.0 WU. TPG, ejection fraction and male gender were independent predictors of reversibility of PVR. Conclusions: Elevated PVR in heart transplant candidates is highly reversible and can be normalized during acute pharmacologic testing with PGE1. [Copyright &y& Elsevier]

BACKGROUND: DSE and SPECT are two well-established methods to non-invasively investigate the functional significance of coronary artery stenoses in patients with coronary artery disease. The measurement of Fractional Flow Reserve has emerged a new invasive reference standard for lesion specific quantification of coronary artery stenoses. The objective of our prospective study was to compare sensitivity and specificity of Dobutamine Stress Echocardiography (DSE) and Single Photon Emission Computer tomography (SPECT) with the pressure derived Fractional Flow Reserve (FFR) for the identification of hemodynamic relevant cororonary lesions in patients with predominantely coronary multivessel disease and angiographically intermediate stenoses. METHODS: Inclusion criteria were a coronary lesion of 50-75% diameter stenosis by visual assessment in patients with known or suspected CAD. SPECT, DSE and FFR testing was performed within one week of coronary angiography RESULTS: The study comprised 48 consecutive symptomatic patients. In 41 cases, a coronary multivessel disease was present. Mean FFR was 0.80 ± 0.13 (0.41-1.0). Overall sensitivity of DSE and SPECT was 67% and 69% whereas specificity reached 77% and 87%. However, sensitivity was significantly reduced if the target lesion was located distally. DSE showed poor results if the lesions were located in the circumflex artery or if a history of prior myocardial infarctions was present. CONCLUSION: DSE and SPECT are both useful methods for the non-invasive assessment of coronary artery disease. DSE showed reasonable combination of sensitivity and specificity even in patients with multivessel disease. Although use of noninvasive stress tests is only limited in patients with prior myocardial infarctions and invasive stress testing should be preferred in these patients. (Int J Cardiovasc Intervent 2004; 6: 142-147) [ABSTRACT FROM AUTHOR]