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Background/purpose Delineation of the lymph node levels of the neck for irradiation of the elective clinical target volume in head and neck cancer (HNC) patients is time consuming and prone to interobserver variability (IOV), although international consensus guidelines exist. The aim of this study was to develop and validate a 3D convolutional neural network (CNN) for semi-automated delineation of all nodal neck levels, focussing on delineation accuracy, efficiency and consistency compared to manual delineation. Material/methods The CNN was trained on a clinical dataset of 69 HNC patients. For validation, 17 lymph node levels were manually delineated in 16 new patients by two observers, independently, using international consensus guidelines. Automated delineations were generated by applying the CNN and were subsequently corrected by both observers separately as needed for clinical acceptance. Both delineations were performed two weeks apart and blinded to each other. IOV was quantified using Dice similarity coefficient (DSC), mean surface distance (MSD) and Hausdorff distance (HD). To assess automated delineation accuracy, agreement between automated and corrected delineations were evaluated using the same measures. To assess efficiency, the time taken for manual and corrected delineations were compared. In a second step, only the clinically relevant neck levels were selected and delineated, once again manually and by applying and correcting the network. Results When all lymph node levels were delineated, time taken for correcting automated delineations compared to manual delineations was significantly shorter for both observers (mean: 35 vs 52 min, p 85%). Manual corrections necessary for clinical acceptance were 1.4 mm MSD on average and were especially low ( 87%). Manual corrections necessary for clinical acceptance were 1.3 mm MSD on average. IOV was significantly smaller with automated compared to manual delineations (MSD: 0.8 mm vs 2.3 mm, p Conclusion The CNN developed for automated delineation of the elective lymph node levels in the neck in HNC was shown to be more efficient and consistent compared to manual delineation, which justifies its implementation in clinical practice.

Objective To describe ultrasonography as a diagnostic method of in vivo Descemet's membrane detachment (DMD) in horses. Animals studied: Seven horses (three Icelandic horses, two Dutch Warmblood horses, one Appaloosa, and one Welsh Pony), presenting with moderate‐to‐severe focal or diffuse corneal edema, in whom DMD was suspected on ultrasonographic examination and confirmed with histopathology, were studied. Procedure A retrospective analysis of case records of horses with suspected DMD was performed. Results Median age at presentation was 14 years (range 11‐24). Clinical signs in eyes with DMD were unilateral in all horses and included blepharospasm and epiphora (6/7), buphthalmos (5/7), moderate‐to‐severe focal or diffuse corneal edema (7/7), corneal epithelial bullae (4/7), corneal neovascularization (4/7), Haab's striae (2/7), corneal endothelial precipitates (1/7), fibrin in the anterior chamber (1/7), focal cataract (2/7), and pigment deposits on the anterior lens capsule (1/7). During transpalpebral ultrasonography, a distinct linear echogenic structure was noted in the anterior chamber, initially diverging from, and later running parallel to, the posterior lining of the cornea in all eyes studied. In all cases, the cornea was severely thickened and echogenic, consistent with edema, and DMD was suspected. In all horses, the clinical signs progressed and the affected eye was eventually enucleated. Histopathology revealed DMD (7/7), spindle cell proliferation (4/7), Descemet's membrane reformation (3/7), and inflammation of the anterior uvea (5/7). Overall incidence was 1.04%. Conclusions Ultrasonography is an adequate tool in diagnosing DMD in horses. Descemet's membrane detachment should be included in the differential diagnosis in horses with dense focal or diffuse corneal edema.

Robotic (RNS) or magnetic navigation systems (MNS) are available for remotely performed catheter ablation for atrial fibrillation (AF). The present study compares remotely assisted catheter navigation (RAN) to standard manual navigation (SMN) and both systems amongst each other. The analysis is based on a sub-cohort enrolled by five hospitals from the multicenter German ablation Registry. Out of 2442 patients receiving catheter ablation of AF, 267 (age 61.4 ± 10.4, 69.7% male) were treated using RAN (RNS n = 187, 7.7% vs. MNS n = 80, 3.3%). Fluoroscopy time [RNS median 17 (IQR 12–25) min vs. MNS 22 (16–32) min; p

Spannungsbasierte Methoden bilden aktuell die diagnostische und therapeutische Grundlage der klinischen kardialen Elektrophysiologie. Dies gilt sowohl fur Methoden, fur welche kein direkter Kontakt mit dem Myokard notwendig ist – wie das Oberflachen-Elektrokardiogramm – als auch fur etablierte kontaktbasierte 3‑D-Mappingsysteme. Die raumliche Auflosung dieser Verfahren kann dabei u. a. abhangig von Elektrodengrose, Elektrodenabstand, Umgebungssignalen und verwendeten Algorithmen begrenzt werden. Dadurch konnten Details komplexer Aktivierungsmuster, wie sie beispielsweise beim Vorhofflimmern beobachtet werden, bisher nur unzureichend erfasst werden. Das Dipole-density-Mapping stellt einen alternativen Ansatz zur Erfassung und Darstellung der elektrischen Aktivitat des Herzens dar. Er zielt darauf ab, die lokale Aktivitat der inneren Oberflache einer Herzkammer mit hoher raumlicher und zeitlicher Auflosung simultan und kontaktlos zu erfassen. Dies konnte helfen, das Verstandnis fur die Mechanismen und therapeutische Moglichkeiten weiter zu verbessern. Die vorliegende Arbeit gibt eine systematische Ubersicht uber dieses Verfahren, potenzielle Moglichkeiten und bisher vorliegende klinische Erfahrungen.

Als wissenschaftliche Fachgesellschaft vertritt die Deutsche Gesellschaft fur Kardiologie den Standpunkt, dass die Standards zur Durchfuhrung einer Katheterablation bei Patienten mit Vorhofflimmern (VHF) stetig kritisch betrachtet und angepasst werden mussen, um dauerhaft eine gute Behandlungsqualitat mit hoher Erfolgs- und geringer Komplikationsrate zu gewahrleisten. Das ist insbesondere auch deshalb notwendig, weil die Anzahl von Zentren und Kardiologen, die diese Intervention durchfuhren, rasant ansteigt. Im vorliegenden Positionspapier werden daher zunachst die aktuelle Datenlage zur Katheterablation von VHF sowie die Indikationsstellung zur Ablation, Komplikationen des Verfahrens und neueste Entwicklungen detailliert ausgefuhrt, bevor abschliesend eine Darstellung der personellen, technischen und raumlichen, strukturellen sowie organisatorischen Anforderungen an klinische Zentren erfolgt, an denen Katheterablationen von VHF durchgefuhrt werden.

PURPOSE/OBJECTIVE: Precise delineation of organs at risk (OARs) in head and neck cancer (HNC) is necessary for accurate radiotherapy. Although guidelines exist, significant interobserver variability (IOV) remains. The aim was to validate a 3D convolutional neural network (CNN) for semi-automated delineation of OARs with respect to delineation accuracy, efficiency and consistency compared to manual delineation. MATERIAL/METHODS: 16 OARs were manually delineated in 15 new HNC patients by two trained radiation oncologists (RO) independently, using international consensus guidelines. OARs were also automatically delineated by applying the CNN and corrected as needed by both ROs separately. Both delineations were performed two weeks apart and blinded to each other. IOV between both ROs was quantified using Dice similarity coefficient (DSC) and average symmetric surface distance (ASSD). To objectify network accuracy, differences between automated and corrected delineations were calculated using the same similarity measures. RESULTS: Average correction time of the automated delineation was 33% shorter than manual delineation (23 vs 34 minutes) (p

Current radiotherapy planning workflows start with segmentation of the organs at risk (OARs) together with target volumes (TVs) in order to determine a patient specific optimal treatment plan and its corresponding 3D dose distribution. This is a time-consuming optimization process including many manual interventions. Despite strong resemblance between patients treated for the same indication, the optimization is almost always performed without 3D prior knowledge. Automated segmentation of OARs and TVs and automated generation of dose distributions are thus expected to be more time-efficient. We investigate the feasibility of CT-only dose prediction and the profitability of additional isocenter and contour information. To evaluate the network’s performance, a 5-fold cross-validation is performed on 79 prostate patients, all treated with volumetric modulated arc therapy.

© Springer Nature Switzerland AG 2018. Delineation of organs at risk (OAR) on CT images is a crucial step in the planning of radiotherapy treatment. Manual delineation is time-consuming and high interrater variability is observed within and across radiotherapy centers. Automated delineation of OAR is fast and can lead to more consistent treatment plans. We developed an auto-delineation tool based on a 3D convolutional neural network (CNN) to automatically delineate 16 OAR structures in head and neck cancer (HNC) patients. The CNN was trained off-line using 70 previously collected patient datasets and implemented to be available on-line in clinical routine practice. The tool was applied prospectively for delineation of 20 consecutive new HNC cases within the department of Radiation Oncology, with subsequent manual editing and approval of the contours by the clinical expert. Validation based on the automatically proposed and edited contours shows that the auto-delineation tool is able to achieve highly accurate segmentation results for most OAR. As a result, 3D delineation time is reduced to less than 19 min on average (about 1 min/structure), compared to usually 1 h or more without auto-delineation tool. ispartof: pages:223-232 ispartof: Lecture Notes in Computer Science (including subseries Lecture Notes in Artificial Intelligence and Lecture Notes in Bioinformatics) vol:11041 LNCS pages:223-232 ispartof: 7th international workshop on clinical image-based procedures: Translational research in medical imaging - CLIP 2018, held in conjunction with MICCAI 2018 location:Granada, Spain date:16 Sep - 16 Sep 2018 status: published

BACKGROUND: Catheter ablation (CA) for atrial fibrillation (AF) is an effective therapeutic option for the treatment of symptomatic drug-refractory AF. According to current guidelines, the prevention of stroke and embolism is the most important therapeutic goal in AF and the recommendations for anticoagulation (OAC) after successful CA are based upon the CHA2DS2-VASc-Score 3. The aim of this study was to evaluate the use of OAC in patients with a high risk for thromboembolic events 1 year after CA and to identify predictor variables for discontinuation of OAC. METHODS: Between January 2007 and January 2010 13092 patients were enrolled in the study. A total of 52 German electrophysiological centers agreed to participate in this prospective multicenter registry. 41 centers included patients undergoing CA for AF. Analysis included patients who were discharged with OAC after CA and had a CHA2DS2-VASc-Score ≥ 2. A centralized 1 year follow-up (FU) was conducted via telephone. RESULTS: 1300 patients fulfilled the inclusion criteria. One year after CA 51.8 % of these patients were on OAC. Factors significantly associated with discontinuation of OAC included no AF recurrence in FU (adjusted odds ratio (OR): 2.14, [95 % confidence interval (CI): 1.73-2.66], P < 0.001) and paroxysmal AF (OR: 1.53 [95 % CI: 1.29-1.81], P < 0.001). Factors associated with continuation of OAK were patient age (OR per 10 years: 0.79 [95 % CI: 0.68-0.91], P = 0.002), valvular heart disease (OR: 0.67 [95 % CI: 0.48-0.92], P = 0.013), an implanted pacemaker, defibrillator or a cardiac resynchronization therapy system (OR: 0.55 [95 % CI: 0.41-0.74], P < 0.001) and neurological events in hospital or during FU (OR: 0.40 [95 % CI: 0.18-0.88], P < 0.022). CONCLUSION: Almost half of the patients with an indication for OAC are not adequately anticoagulated one year after CA for AF. Paroxysmal AF or freedom from AF is significantly associated with discontinuation of OAC.

Ventricular arrhythmias (VAs) in patients with chronic heart failure (CHF) are sometimes refractory to antiarrhythmic drugs and cardiac ablation. This study aimed to investigate catheter-based renal sympathetic denervation (RDN) as antiarrhythmic strategy in refractory VA. These are the first data from a pooled analysis of 13 cases from five large international centers (age 59.2 ± 14.4 years, all male) with CHF (ejection fraction 25.8 ± 10.1 %, NYHA class 2.6 ± 1) presented with refractory VA who underwent RDN. Ventricular arrhythmias, ICD therapies, clinical status, and blood pressure (BP) were evaluated before and 1–12 months after RDN. Within 4 weeks prior RDN, a median of 21 (interquartile range 10–30) ventricular tachycardia (VT) or fibrillation (VF) episodes occurred despite antiarrhythmic drugs and prior cardiac ablation. RDN was performed bilaterally with a total number of 12.5 ± 3.5 ablations and without peri-procedural complications. One and 3 months after RDN, VT/VF episodes were reduced to 2 (0–7) (p = 0.004) and 0 (p = 0.006), respectively. Four (31 %) and 11 (85 %) patients of these 13 patients were free from VA at 1 and 3 months. Although BP was low at baseline (116 ± 18/73 ± 13 mmHg), no significant changes of BP or NYHA class were observed after RDN. During follow-up, three patients died from non-rhythm-related causes. In patients with CHF and refractory VA, RDN appears to be safe concerning peri-procedural complications and blood pressure changes, and is associated with a reduced arrhythmic burden.

Die Deutsche Gesellschaft fur Kardiologie (DGK) legt hiermit ein Curriculum zur Erlangung einer Zusatzqualifikation „Spezielle Rhythmologie“ vor, um besondere Kenntnisse, Erfahrungen und Fertigkeiten anzuerkennen, das sich an die Anforderungen der European Heart Rhythm Association (EHRA) anlehnt. Neben dem Erwerb der Zusatzqualifikation „Spezielle Rhythmologie“ (24 Monate) konnen auch die Blocke „Invasive Elektrophysiologie“ bzw. „Aktive Herzrhythmusimplantate“ separat erworben werden (jeweils 15 Monate). Die Erteilung des Zertifikats setzt die Anerkennung als „Arzt fur Innere Medizin und Kardiologie“ voraus. Beschrieben werden Ziele und die zugehorigen theoretischen und praktischen Inhalte des Programms. Zusatzlich wurden Kriterien fur die Eignung einer Statte zur Erlangung der Zusatzqualifikation und fur die Qualifikation des Leiters formuliert. Der Ablauf der Zusatzqualifikation wird in einem Logbuch dokumentiert. Die Akkreditierung der Zentren und der Leiter erfolgt durch eine Kommission „Zusatzqualifikationen in der Kardiologie“ der DGK. Fur die Zeitdauer von 2 Jahren gelten Ubergangsregelungen. Dieses strukturierte Programm zur optionalen Erlangung der Zusatzqualifikation soll einer optimalen Patientenversorgung dienen sowie die Attraktivitat der Speziellen Rhythmologie innerhalb der Kardiologie erhohen.

Die vasovagale Synkope ist die haufigste Ursache von rezidivierenden Synkopen. Obwohl die Prognose exzellent ist, ist das diagnostische und therapeutische Vorgehen oft zeit- und kostenintensiv. Diese Ubersicht konzentriert sich auf das Management von vasovagalen Synkopen und gibt einen Uberblick uber nichtpharmakologische und pharmakologische Behandlungsmoglichkeiten, insbesondere die Verwendung von Midodrin und selektiven Serotoninwiederaufnahmehemmern. Der fruhe Einsatz eines implantierbaren Loop-Rekorders spielt bei der Abklarung zur rechtzeitigen Erkennung von arrhythmogenen Synkopen eine elementare Rolle. Ein ausfuhrliche Information des Patienten und Counterpressure-Manover stellen die Basis jeder Therapie einer vasovagalen Synkope dar. Der Stellenwert der Herzschrittmachertherapie bleibt weiterhin umstritten. Sie ist allenfalls fur eine Untergruppe von Patienten mit schwerer Bradykardie oder Asystolien sinnvoll.

PURPOSE: The preoperative assessment of mechanical dyssynchrony can help to improve patient selection in candidates for cardiac resynchronization therapy (CRT). The present study compared the performance of velocity-encoded (VENC) MRI to cine-magnetic resonance imaging (MRI) for quantifying mechanical ventricular dyssynchrony. MATERIALS AND METHODS: VENC-MRI and cine-MRI were performed in 20 patients with heart failure NYHA class III and reduced ejection fraction (median: 24 %, interquartile range: 18 - 28 %) before CRT device implantation. The interventricular mechanical delay (IVMD) was assessed by VENC-MRI as the temporal difference between the onset of aortic and pulmonary flow. Intraventricular dyssynchrony was quantified by cine-MRI, using the standard deviation of time to maximal wall thickening in sixteen left ventricular segments (SDt-16). The response to CRT was assessed in a six-month follow-up. RESULTS: 14 patients (70 %) clinically responded to CRT. A similar accuracy was found to predict the response to CRT by measurements of the IVMD and SDt-16 (75 vs. 70 %; p = ns). The time needed for data analysis was significantly shorter for the IVMD at 1.69 min (interquartile range: 1.66 - 1.88 min) compared to 9.63 min (interquartile range: 8.92 - 11.63 min) for the SDt-16 (p < 0.0001). CONCLUSION: Measurements of the IVMD by VENC-MRI and the SDt-16 by cine-MRI provide a similar accuracy to identify clinical responders to CRT. However, data analysis of the IVMD is significantly less time-consuming compared to data analysis of the SDt-16.

Beschrieben wird der Fall eines bisher gesunden 43-jahrigen Mannes, der sich mit dem Bild einer akuten schweren Herzinsuffizienz mit beginnendem Multiorganversagen auf dem Boden einer orthodromen atrioventrikularen Reentrytachykardie (AVRT) vorstellt. Echokardiographisch zeigen sich neben der hochgradig eingeschrankten linksventrikularen Pumpfunktion (LVEF) im Sinne einer Tachymyopathie (TMC) 2 grose Thromben im linken Ventrikel. In der elektrophysiologischen Untersuchung (EPU) bestatigt sich eine AVRT mit Nachweis einer posteroinferioren akzessorischen Leitungsbahn. Ablation der akzessorischen Leitungsbahn fuhrte zur Terminierung in einen normofrequenten Sinusrhythmus. Nach erfolgreicher Ablation zeigte sich eine rasche Besserung der akuten Herzinsuffizienz sowie der klinischen Symptome. Eine fruhe EPU mit evtl. Ablation kann Komplikationen einer TMC verhindern.

Anamnese und klinischer Befund: Eine 62-jahrige Patientin litt unter rezidivierendem Herzrasen und Synkopen. Dauer und Intensitat der Episoden nahmen zu. Bereits in einem externen Krankenhaus konnte eine ventrikulare Tachykardie (VT) im Rahmen einer elektrophysiologischen Untersuchung induziert werden. Die Patientin wurde mit der Frage nach ICD-Implantation vs. Ablation der ventrikularen Tachykardie zugewiesen. Untersuchungen: Im TTE kein Anhalt fur eine strukturelle Herzerkrankung. Ebenfalls extern wurde bereits invasiv eine koronare Herzkrankheit ausgeschlossen. Bekannte arterielle Hypertonie. Bisher keine ICD-Implantation. Therapie und Verlauf: Erneute Induktion der klinischen VT im Rahmen der elektrophysiologischen Untersuchung mit anschliesendem Mapping nach Pace-Map und Fruhzeitigkeit mit typischer EKG- Morphologie. Bei einer Fruhzeitigkeit von 50 ms und gutem Pace-Map in der Middle Cardiac Vein erfolgte dort die erfolgreiche Ablation. Folgerung: Ablation epikardialer VT foci kann erfolgreich via Koronarvenensinus erfolgen. Berucksichtigung spezifischer EKG Parameter konnen bereits Hinweise auf einen epikardialen Fokus liefern. Die Great Cardiac Vein ist der haufigste epikardiale Ursprungsort, doch die Region der Crux cordis stellt ebenfalls einen moglichen Ursprungsort mit guter Erreichbarkeit via Middle Cardiac Vein dar.

In den letzten Jahren haben sich wesentliche Entwicklungen in der Diagnostik und Therapie des Vorhofflimmerns (AF) ergeben, die insbesondere den Stellenwert der interventionellen Therapie erhohen. Basierend auf der Erkenntnis, dass fokale Trigger aus den Pulmonalvenen (PV) die pradominanten Ursprungsorte des paroxysmalen Vorhofflimmerns (PAF) darstellen, hat sich die Katheterablation in Form einer elektrophysiologisch gefuhrten Diskonnektion der PV zunehmend etabliert. Das Prinzip dieser Therapie stellt die Elimination der Trigger dar, die fur die Initiierung insbesondere des PAF verantwortlich sind. Bei Patienten mit lang anhaltendem, persistierendem Vorhofflimmern (CAF) stellen die PV sehr selten das alleinige Substrat zur Initiierung und Aufrechterhaltung des Vorhofflimmerns dar, sodass die Pulmonalvenenisolation bei einem grosen Teil dieser Patienten nicht ausreichend ist. Es konnte in den letzten Jahren gezeigt werden, dass Patienten mit CAF von einer zusatzlichen Substratmodifikation profitieren. Hierbei werden die herkommlichen Ansatze in einem „stepwise ablation approach“ kombiniert angewendet mit dem Ziel der Terminierung des Vorhofflimmerns durch die Ablation. Die Katheterablation bei CAF ist derzeit noch nicht „klinisch etabliert“ und sollte nur in erfahrenen Zentren durchgefuhrt werden. Im Gegensatz dazu konnte auch im Vergleich zur medikamentosen Therapie eine Uberlegenheit der Katheterablation zur symptomatischen Behandlung von PAF gezeigt werden.

PURPOSE: To compare the ability of delayed-enhancement magnetic resonance imaging (DE-MRI) and other MRI and clinical parameters to identify diseases mimicking stress cardiomyopathy (SCM). MATERIALS AND METHODS: The study included 14 consecutive patients fulfilling the American Heart Association (AHA) criteria for SCM with acute left ventricular dysfunction in the absence of coronary artery disease, triggered by psychological stress. The MRI protocol consisted of cine, T 2-weighted, first-pass-perfusion (FPP) and DE-MRI. RESULTS: Six patients with DE were classified as mimicking SCM (non-SCM) and 8 patients without DE as SCM. FPP defects were found in 4 patients with non-SCM and in none with SCM (p < 0.05). Myocardial edema was found in 5 patients with non-SCM and in 2 patients with SCM (p = ns). No significant differences in clinical findings such as ECG, cardiac markers and echocardiographic recovery of left ventricular function were found between patients with non-SCM and SCM. CONCLUSION: Non-SCM defined by DE-MRI is a frequent finding in patients fulfilling the AHA criteria for SCM. Clinical findings seem to be of limited value to differentiate between non-SCM and SCM.

Vorhofflimmern tritt mit einer hohen Inzidenz bevorzugt am 2. und 3. postoperativen Tag nach Bypass- und Klappenoperationen sowie bei Intensivpatienten auf. Auch bei thoraxchirurgischen Eingriffen wie der videoassistierten Thoraxchirurgie, Lobektomie oder extrapleuraler Pneumonektomie kann Vorhofflimmern auftreten. Die Prophylaxe mit β-Blockern reduziert die Inzidenz von postoperativem Vorhofflimmern signifikant. Neu aufgetretenes Vorhofflimmern bei Intensivpatienten kann je nach hamodynamischer Stabilitat mittels Rhythmus- oder Frequenzkontrolle behandelt werden. Zur Frequenzkontrolle konnen β-Blocker oder Kalziumantagonisten verwendet werden. Amiodaron ist ein effektives und sicheres Medikament zur Konversion von Vorhofflimmern. Eine Konversion nach 48 h Dauer ohne effektive Antikoagulation sollte nur nach vorangegangenem Thrombenausschluss mittels transosophagealer Echokardiographie durchgefuhrt werden. Nach erfolgter Kardioversion muss auf eine effektive Antikoagulation geachtet werden, um thrombembolische Komplikationen zu vermeiden.

The vast majority of patients with supraventricular tachycardias present with specific 12-lead surface ECG characteristics allowing the diagnosis of the underlying mechanisms prior to the invasive electrophysiological study. However, an accurate diagnosis remains challenging in a subset of patients, even when using well-established stimulation maneuvers and sophisticated conventional mapping methods. Thus, the aim of the present manuscript is to describe some cases with uncommon entities of supraventricular tachycardias where the combined interpretation of 12-lead ECG presentation and invasive electrophysiological characteristics revealed the correct diagnoses.

Vorhofflimmern ist die haufigste Arrhythmie im Erwachsenenalter. Die Therapie hat sich in den letzten Jahren erheblich verandert. Basistherapie sind β-Rezeptorenblocker und – insbesondere bei struktureller Herzkrankheit – ACE-Inhibitoren bzw. AT1-Blocker. Klasse-1C-Antiarrhythmika (Flecainid bzw. Propafenon) sollen nur bei normaler oder leicht eingeschrankter linksventrikularer Funktion eingesetzt werden. Fur therapierefraktare Patienten und solche mit deutlich eingeschrankter linksventrikularer Funktion ist Amiodaron die derzeit einzig verbleibende medikamentose Alternative. Patienten mit symptomatischen, aber seltenen Anfallen von Vorhofflimmern und normaler linksventrikularer Funktion konnen mit einer sog. „Pill-in-the-pocket-Therapie“ behandelt werden. Durch die 2006 publizierten europaischen und US-amerikanischen Leitlinien wurde die Katheterablation bei Vorhofflimmern in die „alltagliche Praxis“ eingefuhrt. Hochsymptomatische Patienten mit paroxysmalem oder kurz dauerndem anhaltendem Vorhofflimmern konnen unter folgenden Umstanden mit der Katheterablation behandelt werden: Es besteht keine schwerwiegende Herzkrankheit, der linke Vorhof ist nicht wesentlich vergrosert und es besteht Therapierefraktaritat oder Intoleranz gegenuber Antiarrhythmika. Bei allen anderen Patienten (z. B. solchen mit Herzinsuffizienz oder Herzklappenfehlern) ist die interventionelle Katheterablation von Vorhofflimmern derzeit experimentell und nur im Einzelfall als Heilversuch indiziert.

Cardiac papillary fibroelastomas (CPFs), the second most common primary cardiac tumor, are benign endocardial papillomas predominantly affecting the cardiac valves. Although CPFs are rare and benign tumors, they may result in life-threatening complications. Early diagnosis of this condition is important, since it represents a surgically correctable cause of systemic embolism, myocardial infarction, stroke, acute valve dysfunction, and sudden cardiac death. This review summarizes the significance and clinical approach for the diagnosis of this cardiac entity. The differential diagnosis, histological characteristics of CPF and current treatment strategies are also discussed.

Ziel: Paroxysmales Vorhofflimmern (PVHF) wird haufig durch ektope Erregungen in den distalen Pulmonalvenen ausgelost, und detaillierte Informationen uber die Vorhofanatomie sind notwendig fur eine erfolgreiche Katheterablation dieser arrhythmogenen Zentren. Im Rahmen dieser Arbeit wurde bei Patienten mit PVHF untersucht, ob durch den Einsatz einer prainterventionellen Computertomografie (CT) des Herzens prozedurale Charakteristika der Pulmonalvenenisolation (PVI) gunstig beeinflusst werden. Material und Methoden: Ausgewertet wurden PVI von 54 Patienten mit PVHF (23 Frauen, 31 Manner). Unter diesen waren 27 Patienten, die vor der Katheterablation eine zusatzliche CT des Herzens erhielten (CT-Gruppe, 12 Frauen, 15 Manner, Alter 59,7 ± 9,9 Jahre): Kollimation 16 × 1,5 mm, Pitch 0,2, 120 kV Rohrenspannung, 400 effektive mAs. Durchleuchtungszeiten, Effektivdosen und die Anzahl der Radiofrequenzimpulse der nachfolgenden PVI wurden mit den Untersuchungen der ubrigen Patienten verglichen, die einer entsprechenden Ablationsstrategie ohne additive CT zugefuhrt wurden (11 Frauen, 16 Manner, Alter 62,0 ± 9,9 Jahre). Statistische Signifikanzprufungen der Gruppenunterschiede erfolgten mit dem Mann-Whitney-Test. Ergebnisse: Die Integration des CT-Datensatzes war bei allen Patienten der CT-Gruppe erfolgreich. Die Anzahl der Radiofrequenzimpulse war in der CT-Gruppe signifikant niedriger (22,1 ± 8,0 vs. 29,1 ± 11,9, p = 0,030), und die Durchleuchtungszeit wurde in der CT-Gruppe signifikant reduziert (41,8 ± 12,0 min vs. 51,2 ± 16,0 min, p = 0,005). Die Effektivdosen nahmen in der CT-Gruppe in einer entsprechenden Grosenordnung, jedoch insgesamt nicht signifikant ab (14,9 ± 10,0 mSv vs. 20,0 ± 16,0 mSv, p = 0,203). Die durchschnittliche Effektivdosis der CT betrug 8,5 ± 0,3 mSv. Schlussfolgerung: Die prainterventionelle Anfertigung einer CT des Herzens ermoglicht kurzere Durchleuchtungszeiten bei der PVI des PVHF. Aufgrund der multifaktoriellen Abhangigkeit individueller Durchleuchtungsdosen ist ein einheitlicher Effekt auf die Strahlenexposition der PVI nicht nachweisbar. Da die kardiale CT eine additive Dosis verursacht, ist ein optimiertes Atriografieprotokoll zu entwickeln, das bei geringerer Dosis eine gleichwertige Bildqualitat liefert. Die Verringerung der Anzahl der zur vollstandigen Isolation notwendigen Hochfrequenzimpulse lasst Ruckschlusse auf eine gesteigerte Sicherheit und Effizienz der CT-assistierten Vorgehensweise zu. Purpose: Detailed anatomic information of the left atrium is necessary for securely performing radiofrequency ablation of atrial fibrillation-triggering ectopies in the pulmonary vein ostia. In this study the impact of a preinterventionally acquired cardiac computed tomography (CT) on pulmonary vein isolation (PVI) was assessed. Materials and Methods: Examinations of 54 patients with paroxysmal atrial fibrillation undergoing PVI were analyzed. In 27 patients a supplementary cardiac CT was obtained prior to PVI (CT group, 12 women, 15 men, 59.7 ± 9.9 years of age): 16 × 1.5 mm collimation, 0.2 pitch, 120 kV tube voltage, 400 effective mAs. The fluoroscopy time, effective dose and quantity of radiofrequency (RF) pulses of the following catheter ablation were compared to 27 patients undergoing stand-alone PVI (11 women, 16 men, 62.0 ± 9.9 years of age). Mann-Whitney tests served for statistical comparison. Results: CT datasets were successfully integrated into the ablation procedure of each patient in the CT group. The mean quantity of RF pulses was significantly lower in the CT group (22.1 ± 8.0 vs. 29.1 ± 11.9, p = 0.030), and a significant reduction of fluoroscopy time was found (41.8 ± 12.0 min vs. 51.2 ± 16.0 min, p = 0.005). Effective doses of the catheter ablation differed in an equivalent dimension but altogether not significantly (14.9 ± 10.0 mSv vs. 20.0 ± 16.0 mSv, p = 0.203). The mean additive effective dose of the cardiac CT was 8.5 ± 0.3 mSv. Conclusion: CT-guided ablation of atrial fibrillation requires less fluoroscopy time than stand-alone PVI. Due to the multi-faceted dependency of individual fluoroscopy doses, a consistent reduction of the effective dose was not observed. Since supplementary CT constitutes an additive dose, optimized CT atriography needs to be designed in order to provide sufficient image quality while reducing X-ray exposure. The reduction in RF pulses implies an increase in the effectiveness and safety of catheter ablation.

Mit der Einfuhrung des Streckreduzierblocks (SRB)1 steht dem Markt ein auserst flexibles Werkzeug fur das Fertigwalzen von Rohren zur Verfugung. Einzeln angetriebene Geruste (und sogar Walzen), schneller Walzenwechsel, anstellbare Geruste und eine Fernanstellung ermoglichen eine optimale Produktion. Die technologischen Eigenschaften und Funktionen des SRB steigern die Produktion des gesamten Walzwerks: Ein kleiner Gerustabstand minimiert die Verluste durch verdickte Enden. Dynamische Antriebe ermoglichen individuelle Drehzahlsteuerung fur jedes Gerust, z. B. zur Wanddickenkontrolle, und Free-size-Walzen2 ermoglicht das Walzen von verschiedenen Abmessungen ohne Walzen- oder Gerustwechsel. Obwohl fruhere Streckreduzierwalzwerke (SRW) mit technologischen Funktionen wie der Regelung zur Minimierung verdickter Enden HEC (Heavy End Control) sowie der automatischen Wanddickenregelung AWC (Automatic Wall Thickness Control)3 ausgestattet waren, war ihre Wirkung begrenzt, z. B. durch die Fahigkeiten des Gruppenantriebs4 und die Leistungsfahigkeit der Antriebe und deren Regelung. Um alle neuen Eigenschaften optimal einsetzen zu konnen, hat KOCKS ein integriertes Management-, Steuerungs- und Optimierungssystem entwickelt – TUMICON, das bei allen Arten von Streckreduzierwalzwerken angewandt werden kann. Dieser Aufsatz beschreibt die wichtigsten Funktionen des TUMICON-Systems.

Neurally mediated syncope (NMS) is a transient and self-limited loss of consciousness that affects all ages and is associated with high rates of falls and hospitalizations.

For the control of norovirus outbreaks, it is widely recommended that exposed but asymptomatic patients should be cohorted separately from unexposed patients and from symptomatic patients. The frequency of subsequent symptomatic norovirus infection in contact patients has not been investigated systematically. We retrospectively investigated the development of typical norovirus symptoms in contact patients during seven norovirus outbreaks affecting 57 patients between November 2014 and May 2015. Only one of 14 contact patients developed typical norovirus symptoms, calling into question current recommendations to isolate contact patients.

Bei der Therapie supraventrikularer Herzrhythmusstorungen haben sich in den letzten Jahren tief greifende Veranderungen ergeben: nichtmedikamentose Strategien werden fruhzeitiger eingesetzt und haben teilweise die medikamentosen Verfahren abgelost. Haufig dient die medikamentose Therapie, die uber viele Jahre den Goldstandard darstellte, nur noch als Uberbruckung bis zur kurativen Therapie durch Katheterablation des arrhythmogenen Substrates. Ein weiterer Schwerpunkt ist die adjuvante antiarrhythmische Therapie bei Patienten mit Cardioverter-Defibrillatoren. Bei der Akut- und Dauertherapie bestimmter Herzrhythmusstorungen, wie z. B. dem Vorhofflimmern, sind medikamentose Ansatze unverzichtbar und weiterhin als primare Therapie etabliert. Pharmaka, die zur Behandlung von Herzrhythmusstorungen eingesetzt werden, sind im Hinblick auf Struktur, Wirkmechanismus, potenzielle Nebenwirkungen und Interaktionen heterogen. Ihr Einsatz sollte nur bei strenger Indikationsstellung und engmaschiger kardiologischer Uberwachung erfolgen. Angesichts ihrer haufig begrenzten therapeutischen Wirksamkeit ist die Nutzen-Risiko-Relation dieser Therapie besonders kritisch zu prufen.

Simultaneous occurrence of narrow and broad QRS complex tachycardias in patients with WPW syndrome usually indicates a macroreentry in an orthodromic atrioventricular reentry-tachycardia using the AV node as antegrade and the accessory pathway as retrograde conduction and vice versa in an antidromic circuit. We report on a 32-year-old woman with WPW syndrome presenting with both a narrow and a broad QRS complex tachycardia using two accessory pathways with different unidirectional conduction properties in combination of an exclusively antegrade conducting AV node. This case report describes conventional mapping techniques and ablation of this unusual entity of a WPW syndrome.

Rezidiviernende ventrikulare Tachykardien nach abgelaufenem Myokardinfarkt sind nicht selten medikamentos therapierefraktar. Bei Induktion von hamodynamisch tolerierbaren und monomorphen Formen im Rahmen einer programmierten Ventrikelstimulation ist eine endokardiales Mapping moglich. Wichtigster Baustein der Lokalisationsdiagnostik ist die Identifikation von kritischen Teilen der Kreiserregung durch Stimulationsmanover (“Entrainment-Mapping”) und Analyse des “Post-Pacing”-Intervalles. Das Auftreten multipler Formen erschwert haufig Mapping und Katheterablation. Bei klinischem Auftreten und Induktion von lediglich singularen Kammertachykardien ist in etwa 60–70% der Falle durch die Hochfrequenzstrom-Katheterablation ein Akuterfolg mit Terminierung und Unterdruckung der Induzierbarkeit moglich. Wesentlich geringer ist diese Erfolgsrate bei multiplen Formen ventrikularer Tachykardien. In etwa 20–30% der Falle mus mit einem Rezidiv gerechnet werden. Auch nach Ablation besteht bei diesen Patienten eine hohe kardiale Mortalitat. Ursachliche Faktoren sind eine progrediente Herzinsuffizienz und das Auftreten von hamodynamisch relevanten ventrikularen Tachyarrhythmien. Bei unaufhorlichen (“incessant”) Kammertachykardien und haufigen ventrikularen Tachykardien nach Implantation eines Kardioverter-Defibrillators besteht die Indikation zur fruhzeitigen Katheterablation. Derzeit ist die Katheterablation ventrikularer Tachykardien ein zur medikamentosen Behandlung und der Implantation eines Kardioverter-Defibrillators komplementares Therapieverfahren. Es ist zu erwarten, das die Effektivitat dieser Methode in naher Zukunft durch neue Mapping- und Ablationstechniken weiter verbessert werden kann.

Objectives The primary objectives of this study were to assess the feasibility of temperature-controlled radiofrequency catheter ablation of left and right sided manifest accessory pathways in patients with Wolff-Parkinson-White syndrome and to gain more insights into biophysical aspects of temperature-controlled catheter ablation in humans. Background The electrode-tissue interface temperature and other biophysical parameters are among important variables determining the efficacy and safety of radiofrequency ablation of accessory pathways. Experimental studies have shown that radiofrequency-induced tissue necrosis can be accurately predicted by monitoring of catheter tip temperature. Methods 38 consecutive patients (14 f, 24 m; aged 42 ± 12 years) with anterograde conducting accessory pathways (left sided: n=22; right sided: n=l6) underwent temperature-controlled radiofrequency ablation (HAT 200S, Dr Osypka, Germany). The electrode temperature was monitored via a thermistor embedded into a 4 mm catheter tip. Power output was adjusted automatically during energy delivery in a closed loop system (preselected temp.: 70·1 ± 5·8°C). Results Accessory pathway conduction was successfully abolished in all patients after the delivery of 2·3 ± 2·1 radiofrequency pulses (range: 1–9, median: 2). Interruption of the accessory pathway as evidenced by loss of preexcita tion occurred after 5·9 ± 5·4 s. At the time of the interruption of the accessory pathway the catheter tip temperature measured 54·2 ± 11· 2 ° C in patients with left and 44·9 ± 5·0° C in patients with right sided accessory pathways, respectively ( P

Ablation with Temperature-Controlled 5-French Catheters. Introduction: In the present study, we assessed the feasibility of radiofrequency (RF) ablation of accessory pathways and AV nodal reentrant tachycardias with novel 5-French catheters with 4-mm tip electrodes using established mapping criteria and temperature-controlled power output control. Methods and Results: In this prospective study, 60 consecutive adult patients (mean age 36 ± 20 years) with accessory pathways (n = 37; 24 left-sided) or AV nodal reentrant tachycardia (n = 23) underwent RF catheter ablation. A 5-French catheter with a 4-mm tip electrode and an embedded thermistor was used for RF application. The surface of the tip electrodes was 26 mm2 compared to 38 mm2 of 7-French catheters with 4-mm tip electrodes from the same catheter series. Power output was automatically and continuously adjusted according to the preset catheter tip temperature of 60° to 70°C. Pulse duration was 90 seconds. For left-sided accessory pathways, the retrograde route via the femoral artery was used. After removing the 5-French sheaths, only 4 hours of bed rest were advised. For ablation of AV nodal reentrant tachycardia, the so-called slow pathway was targeted for ablation. Acute success was achieved in 34 (92%) of 37 patients with accessory pathways and 23 (100%) of 23 patients with AV nodal reentrant tachycardia. A mean of 3 ± 4 RF pulses (median 2 pulses; range 1 to 20 pulses) was applied. The mean fluoroscopy time was 26 ± 21 minutes. No complete AV block or other procedure-related complications were observed. Recurrences occurred in 2 patients with accessory pathways and in 2 patients with AV nodal reentrant tachycardia during a follow-up of 9 ± 4 months. Conclusions: Temperature-controlled RF ablation of accessory pathways and AV nodal reentrant tachycardia in adults using 5-French catheters is feasible, effective, and safe. Ablation with 5-French catheters might help to reduce the complication rate of catheter ablation techniques.

Objective: The aim of this prospective study was to analyse the yield of programmed ventricular stimulation at the right ventricular apex compared with the outflow tract. Methods: A stepwise randomized cross-over protocol of programmed ventricular stimulation with alternating stimulation at both sites was used in 66 patients who were studied because of sustained ventricular tachycardia (n = 30), ventricular fibrillation (n = 7), or non-sustained ventricular tachycardia and/or syncope (n = 29). Results: There were no significant differences between the results of stimulation from either right ventricular site with regard to the presence or absence of structural heart disease, spontaneous arrhythmia, ejection fraction or effective refractory periods. Overall, monomorphic ventricular tachycardia was inducible in 33 patients (50%); in 25 patients (75.8%), this arrhythmia was induced from both sites. However, in only 17 of these 25 patients (68%) did the induced monomorphic ventricular tachycardias have the same morphologies and similar (± 50 ms) cycle lengths. Ventricular fibrillation was inducible in 11 patients (17%), mostly by three extrastimuli (n=8; 73%). Conclusions : (1) stimulation from at least two right ventricular sites is desirable because of their independent contribution to the induction of ventricular tachyarrythmias, (2) the non-inducibility or inducibility at one ventricular site does not predict the effect at another stimulation site, (3) the effective refractory period at the right ventricular apex and outflow tract do not differ, (4) the inducibility of multiple ventricular tachycardia morphologies emphasizes the importance of documenting the cause of spontaneous arrhythmias with multiple electrocardiographic leads to ensure the correct interpretation of arrhythmias induced by programmed stimulation, (5) clinical or haemodynamic features cannot predict whether one or more stimulation sites will be required for induction of ventricular tachycardia. These results are important for the diagnostic evaluation and assessment of pharmacological or non-pharmacological interventions.

Background The feasibility of radiofrequency (RF) catheter ablation for the treatment of sustained ventricular tachycardia (VT) in patients with coronary artery disease and remote myocardial infarction has recently been demonstrated. At present, therapeutic options for VT in patients with idiopathic dilated cardiomyopathy (DCM) include antiarrhythmic drugs and implantable cardioverter/defibrillators (ICD). The purpose of the present study was to investigate the feasibility of RF catheter ablation in patients with idiopathic DCM who could not be adequately treated by conventional treatment modalities because of incessant or frequent, recurrent VT. Methods and Results RF current application for ablation of 9 VTs (mean cycle length, 402±78 ms) was attempted in 8 patients with idiopathic DCM (4 men, 4 women; mean age, 54±6 years; mean left ventricular ejection fraction, 30±9%). Inclusion criteria for ablation were incessant VT (n=4) or frequent, recurrent VT reproducibly inducible with programmed electrical stimulation (n=5). Three patients had suffered aborted sudden cardiac death, and 2 had experienced syncope. Two patients were artificially ventilated and catecholamine dependent for hemodynamic reasons at the time of attempted ablation. Potential target sites for RF current application were identified by detailed endocardial mapping during sinus rhythm, activation and entrainment mapping during VT, and pace mapping. After 7±5 RF pulses (range, 2 to 18 pulses; median, 6 pulses) applied with 32±7 W for 39±9 seconds, 6 of the 9 target VTs (67%) were rendered noninducible (4 of 4 incessant VTs and 2 of 5 chronic recurrent VTs). In 6 patients, VTs with ECG morphologies other than the target VTs were inducible after RF catheter ablation. Seven patients were on antiarrhythmic drugs during the ablation procedure and during the follow-up period of 8±5 months (range, 2 to 17 months). One patient received an ICD before RF ablation, 4 patients after RF ablation, and 1 patient after ablation of an incessant VT and before attempted ablation of frequent, recurrent VTs. One patient underwent heart transplantation 5 months after ablation in end-stage heart failure. There were no acute complications during the mapping and ablation procedure. During the follow-up period, 1 patient had been resuscitated from ventricular fibrillation 6 weeks after ablation and finally died of congestive heart failure 2 weeks later. No further episodes of incessant VT occurred in the patients who had undergone RF current application for ablation of incessant VT. A complete prevention of VT could be achieved in 2 of 8 patients, whereas in 5 patients, VT episodes were stored in the ICD devices during follow-up. Conclusions The results of the present study indicate that RF current application for ablation of VT in a select group of patients with idiopathic DCM is feasible. The efficacy of RF ablation may be high in patients presenting with incessant VT, whereas the success rate seems to be only moderate in patients with chronic recurrent VT. In all patients, additional treatment options, including antiarrhythmic drugs, ICDs, and/or heart transplantation, were applied after RF ablation, indicating that RF ablation for this indication may be an adjunctive and not a curative treatment option.

Our objective was to report the mammographic and sonographic appearance of four patients with superficial subcutaneous fat necrosis of the breast. This type of fat necrosis of the breast is poorly known. We retrospectively reviewed all of the clinical and pathological information, as well as the radiological studies, on four cases of subcutaneous fat necrosis of the breast. Mammograms and sonograms were available for review in all cases. Diagnosis was made by excisional biopsy in three patients and fine-needle aspiration in the other. The lesions were apparent clinically as a palpable mass, and were not seen at mammography. At high-frequency US each lesion was identified as an ill-defined area of increased echogenicity of the subcutaneous fat. The authors believe the sonographic appearance to be suggestive of subcutaneous fat necrosis of the breast.

Up to now there have been no descriptions in the literature of endocardial catheter mapping and successful radiofrequency catheter ablation of the right sided accessory pathway during sustained atrial fibrillation. We attempted ablation of a right posterolateral and a right lateral accessory pathway during sustained atrial fibrillation with rapid anterograde conduction over the accessory pathway in two patients with Wolff-Parkinson-White syndrome. In both patients (aged 47 and 52 years), sustained atrial fibrillation occurred during the electrophysiological study to assess accessory pathway conduction properties. The mean ventricular rate during atrial fibrillation was 180 and 170 beats.min-1, respectively. Both patients were successfully ablated with a single radiofrequency impulse. At the successful ablation sites, a potential of the accessory pathway was consistently recorded preceding the onset of preexcitation in the surface electrogram, by 25 ms in patient 1 and 30 ms in patient 2. The unipolar electrogram recorded from the ablation catheter showed a QS morphology and the accessory pathway potential preceded the intrinsic deflection by 10 ms in both patients. Onset of the ventricular electrogram (patient 1: -20 ms; patient 2: -15 ms) and its activation time (patient 1: -15 ms; patient 2: +5 ms) in relation to the onset of preexcitation in the surface electrocardiogram also indicated the close proximity of the ablation catheter to the accessory pathway. Preexcitation disappeared within 2 s after energy application in both patients. Thus, radiofrequency catheter ablation of right sided accessory pathways during sustained atrial fibrillation is feasible and may obviate the need for medical or electrical cardioversion.(ABSTRACT TRUNCATED AT 250 WORDS)