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Aims The subcutaneous cardioverter-defibrillator (S-ICD) may be a valuable option in patients after successful transvenous lead extraction (TLE) without indication for pacemaker therapy and persistent risk of sudden cardiac death. The aim of this study was to evaluate device performance, postoperative outcome, and safety in patients who received a S-ICD after TLE compared to patients who underwent de-novo S-ICD implantation. Methods A retrospective analysis of all patients included into our institution's S-ICD database between September 2010 and May 2019 was conducted.The patients were divided in two groups, depending on whether they had received their S-ICD after TLE (n = 31) or de-novo (n = 113). Results The TLE group was significantly older with a mean age of 54.3 ± 15.7 versus 46.7 ± 14.4 years; p = .007. Leading S-ICD indication in the TLE group was previous infection (50%), whereas in the de-novo group the S-ICD was primarily chosen due to young patient age (74.6%). Median duration of follow-up was 527.0 versus 472.5 days, respectively; p = .576. Most common complication during follow-up was inappropriate ICD therapy (12.9% vs. 13.3%); p = 1.000. Pocket erosion/infection occurred in 3.2% versus 3.5% with no reported cases of systemic (re-)infection in either group; p = 1.000. All-cause mortality was low (6.2% vs. 2.7%) and entirely unrelated to S-ICD implantation or the device itself; p = .293. Conclusion The S-ICD is a safe and effective alternative for patients after TLE with very similar results regarding device performance and postoperative outcome, when compared to patients who underwent de-novo S-ICD implantation.

Summary Systolic heart failure is frequently accompanied by a relevant functional mitral valve regurgitation (FMR) which develops as a direct sequela of the ongoing left ventricular remodelling. The severity of mitral regurgitation is further aggravated by progressive left ventricular enlargement causing leaflet tethering and reduced systolic leaflet movement. The prognosis of such patients is obviously limited by an underlying left ventricular disease, and the correction of secondary FMR has been previously suggested as predominantly ‘cosmetic’ surgery in the setting of ongoing cardiomyopathy. Inferior results of an isolated annuloplasty in type IIIb FMR supported the philosophy of malignant course of progressive cardiomyopathy and resulted in increasingly restricted indications for mitral valve surgery for FMR in the guidelines. The lack of a standardized pathophysiological approach to correct type IIIb FMR led to the development of valve replacement strategy and edge-to-edge catheter-based mitral valve procedures, which became the most frequent procedures in the FMR setting in Europe. Modern mitral valve surgery combines the advantages of 3-dimensional endoscopic minimally invasive surgical approach with standardized subannular repair to address the pathophysiological background of type IIIb FMR. The perioperative results have been significantly improved, and there is a growing evidence of improved long-term stability of subannular repair procedures as compared to isolated annuloplasty. This review article aims to present the current state-of-the-art of the modern mitral valve surgery in FMR and provides suggestions for future trials analysing the potential advantages in these patients.

Background The number of patients requiring lead extraction has been increasing in recent years. Despite significant advances in operator experience and technique, unexpected complications may occur. Prophylactic placement of femoral sheaths allows for immediate endovascular access for emergency procedures and may shorten response time in the event of complications. Objective The purpose of this study was to assess the benefits of routine prophylactic femoral access in patients undergoing transvenous lead extraction (TLE) and to evaluate the methods, frequency, and efficacy of the emergency measures used in those patients. Methods We conducted a retrospective analysis of patients who underwent TLE from January 2012 to February 2019. The data were analyzed with regard to procedural complications and deployment of emergency measures via femoral access. Results Two hundred eighty-five patients (mean age 65.3 ± 15.5 years) were included in the study. Median lead dwell time was 84 months (interquartile range 58–144). Overall complication rate was 4.2% (n = 12), with 1.8% major complications (n = 5). Clinical success rate was 97.2%. Procedure-related mortality was 1.1% (n = 3). Femoral sheaths were actively engaged in 9.1% (n = 26) of cases. Deployment of snares was the most common intervention (n = 10), followed by prophylactic (n = 6) or emergency placement (n = 1) of occlusion balloons, temporary pacing (n = 3), venous angioplasty (n = 3), diagnostic venography (n = 3), and extracorporeal membrane oxygenation (n = 1). We did not observe any femoral vascular complications due to prophylactic sheath placement. Conclusion Routine prophylactic placement of femoral sheaths shortens response time and quickly establishes control in the event of various complications that may occur during TLE procedures.

Annuloplasty is essential in aortic valve repair. The most appropriate technique is highly controversial, however. We aimed to evaluate changes in postoperative annulus diameter on serial echocardiography after external and internal suture annuloplasty.We retrospectively reviewed serial transthoracic echocardiography of consecutive patients from our institutional aortic valve repair registry who had received suture annuloplasty. Midsystolic annulus diameter was measured on parasternal long-axis view preoperatively, at discharge, 3-6 months, and at 1, 2 and 3 years postoperatively. Primary endpoint was the prevalence of annulus redilatation. Secondary endpoints were the correlation between annulus redilatation and (1) external vs internal technique and (2) reoccurrence of aortic insufficiency ≥2.A total of 70 patients (mean ± SD age: 43 ± 13 years, 91% male) underwent aortic valve repair including external (n = 27) or internal (n = 43) suture annuloplasty between February 2016 and November 2019. Mean follow-up was 17 ± 11 (range: 3-50) months. Mean preoperative annulus diameter of 29.7 ± 2.8 (23.8-37.8) mm was significantly reduced to 22.7 ± 2.9 (16.7-31.7) mm, P.001 at discharge and increased to 23.8 ± 2.3 (20.9-27.0) mm, P = .037 during follow-up. The mild increase in postoperative annulus diameter did not correlate with the reoccurrence of aortic insufficiency ≥2. Preoperative annulus was significantly larger in the external group (external: 30.6 ± 3.2 mm; internal: 29.1 ± 2.5 mm; P = .032). However, we found no significant difference in postoperative annulus increase rate between both techniques.Although mild, a significant continuous increase of annulus diameter after suture annuloplasty was seen, which did not correlate with the reoccurrence of aortic insufficiency ≥2 at mid-term follow-up. Annulus redilatation was comparable between external and internal technique.

BACKGROUND: The therapeutic success in patients with congenital heart disease (CHD) leads to a growing number of adults with CHD (adult CHD [ACHD]) who develop end-stage heart failure. We aimed to determine patient characteristics and outcomes of ACHD listed for heart transplantation. METHODS: Using data from all the patients with ACHD in 20 transplant centers in the Eurotransplant region from 1999 to 2015, we analyzed patient characteristics, waiting list, and post-transplantation outcomes. RESULTS: A total of 204 patients with ACHD were listed during the study period. The median age was 38 years, and 62.3% of the patients were listed in high urgency (HU), and 37.7% of the patients were in transplantable (T)-listing status. A total of 23.5% of the patients died or were delisted owing to clinical worsening, and 75% of the patients underwent transplantation. Median waiting time for patients with HU-listing status was 4.18 months and with T-listing status 9.07 months. There was no difference in crude mortality or delisting between patients who were HU status listed and T status listed (p = 0.65). In multivariable regression analysis, markers for respiratory failure (mechanical ventilation, hazard ratio [HR]: 1.41, 95% CI: 1.11-1.81, p = 0.006) and arrhythmias (anti-arrhythmic medication, HR: 1.42, 95% CI: 1.01-2.01, p = 0.044) were associated with a higher risk of death or delisting. In the overall cohort, post-transplantation mortality was 26.8% after 1 year and 33.4% after 5 years. CONCLUSIONS: Listed patients are at high risk of death without differences in the urgency of listing. Respiratory failure requiring invasive ventilation and possibly arrhythmias requiring anti-arrhythmic medication indicate worse outcomes on waiting list. (C) 2020 International Society for Heart and Lung Transplantation. All rights reserved.

OBJECTIVES Mitral valve (MV) repair in functional mitral regurgitation is still associated with suboptimal outcomes. Our goal was to determine whether the clinical outcome following MV repair correlates with preoperative tenting parameters. METHODS We retrospectively identified consecutive patients with functional mitral regurgitation who underwent an isolated MV annuloplasty during a 7-year period (2010–2016) from our institutional database. Preoperative tenting parameters (i.e. tenting height, coaptation length, tenting area, posterior mitral leaflet and anterior mitral leaflet angles and interpapillary muscle distance) were systematically measured. The primary end point was the composite of survival and freedom from adverse cardiac events. The follow-up protocol consisted of a structured clinical questionnaire and an analysis of the echocardiographic data. RESULTS A total of 240 patients (mean age 67.8 ± 9.8 years, 57% of men) were analysed. The overall 5-year survival rate for the whole study cohort was 74.7 ± 4.2%, and freedom from adverse cardiac events was 84.8 ± 3.4%. A tenting area ≥2.4 cm2 was identified as a cut-off value, independently predicting the composite primary study end point (hazard ratio 2.0; P = 0.03). Furthermore, a Kaplan–Meier analysis revealed a strong tendency towards worse 5-year outcomes in patients with a tenting area ≥2.4 cm2 (n = 153) versus patients with a tenting area CONCLUSIONS MV annuloplasty is associated with acceptable clinical and echocardiographic outcomes in patients with functional mitral regurgitation 5 years postoperatively. A preoperative tenting area ≥2.4 cm2 showed a strong trend towards a worse 5-year survival rate and an increased risk of adverse cardiac events after an isolated MV annuloplasty.

Background To study the effect of tricuspid valve repair/replacement on outcomes of patients with reduced systolic right ventricular function. Methods Between January 2012 and July 2016, 191 patients with isolated tricuspid valve regurgitation and/or in combination with other valve diseases were enrolled into this retrospective study. We compared early postoperative outcomes (i.e., 30 days after surgery) between patients' cohort with a preoperative reduced (i.e., at least moderately) versus normal (or mildly reduced) right ventricular function as defined by means of preoperative echocardiography. Results A total of 82 (43%) patients had preoperatively reduced right ventricle function with tricuspid annular plane systolic excursion (TAPSE) of 13.3 ± 3.3 versus 20.2 ± 4.9 mm (p Conclusion Tricuspid valve repair/replacement effectively eliminated severe tricuspid regurgitation and improved clinical signs of heart failure. Although mortality and morbidity were increased in the group with reduced right ventricular function, even these patients benefitted from improved functional status and right ventricular systolic function early postoperatively.

BACKGROUND Many patients awaiting heart transplantation (HTX) have a cardiac implantable electronic device (CIED). Lead removal is often still a part of the HTX procedure. Abandoned lead fragments carry a risk for infections and prohibit magnetic resonance imaging (MRI) imaging. This study evaluated the concept of an elective lead management algorithm after HTX. METHODS AND RESULTS Between 2009 and 2018, 102 consecutive patients with previously implanted CIED underwent HTX. Lead removal by manual traction during HTX was performed in 74 patients until December 2014. Afterward, treatment strategy was changed and 28 patients received elective lead extraction procedures in a hybrid operating room (OR) using specialized extraction tools. Total of 74 patients with 157 leads underwent lead extraction by manual traction during HTX. The mean lead age was 32.3 ± 38.7 months. Postoperative X-ray revealed abandoned intravascular lead fragments in 31(41.9%) patients, resulting in a complete lead extraction rate of only 58.1%. The high rate of unsuccessful lead extractions led to the change in the extraction strategy in 2015. Since then, HTX was performed in 28 CIED patients. In those patients, 64 leads with a mean lead age of 53.8 ± 42.8 months were treated in an elective lead extraction procedure. No major or minor complications occurred during lead extraction. All leads could be removed completely, resulting in a procedural success rate of 100%. CONCLUSION Our results demonstrate that chronically implanted leads should be removed in an elective procedure, using appropriate extraction tools. This enables complete lead extraction, which reduces the infection risk in this patient population with the necessity for permanent immunosuppressive therapy and allows further MRI surveillance.

Objective: To identify echocardiographic and surgical risk factors for failure after mitral valve repair. Methods: We identified a total of 77 consecutive patients from our institutional mitral valve surgery database who required redo mitral valve surgery due to recurrence of mitral regurgitation after primary mitral valve repair. A control group of 138 patients who had a stable echocardiographic long-term result was included based on propensity score matching. Systematic analysis of echocardiographic parameters was performed before primary surgery, after mitral valve repair and prior to redo surgery. Risk factor analysis was performed using multivariate Cox regression model. Results: Redo surgery was associated with the presence of pulmonary hypertension &ge, 50 mmHg (p = 0.02), a mean transmitral gradient &gt, 5 mmHg (p = 0.001), left ventricular ejection fraction &le, 45% (p = 0.05) before surgery and mitral regurgitation &ge, moderate at time of discharge (p = 0.002) in the whole cohort. Patients with functional mitral valve regurgitation had a higher tendency to undergo redo surgery if preoperative left ventricular end-diastolic diameter exceeded 65 mm (p = 0.043) and if postoperative tenting height exceeded 6 mm (p = 0.018). Low ejection fraction was not significantly associated with the need for redo mitral valve surgery in the functional subgroup. Conclusions: Recurrent mitral regurgitation is still a valuable problem and is associated with relevant perioperative mortality. Patients with severe mitral regurgitation should undergo early mitral valve repair surgery as long as systolic pulmonary artery pressure is low, left ventricular ejection fraction is preserved, and LVEED is deceeds 65 mm.

Background The major drawback of isolated annuloplasty in secondary mitral regurgitation (MR) is the reoccurrence of MR. We prospectively compared the results of isolated annuloplasty vs annuloplasty with simultaneous standardized subannular repair. Methods The study comprised 101 patients with secondary type IIIb MR. Of these, 51 underwent annuloplasty plus standardized subannular repair with realignment of both papillary muscles (subannular repair) and 50 underwent isolated annuloplasty. The primary study end point was the reoccurrence of MR >2 at the 1-year follow-up. Secondary end points were survival, freedom from major adverse cardiac events, and residual leaflet tethering. Results Baseline characteristics were comparable in both groups. There was no significant difference in in-hospital mortality (P = .3). Although postrepair MR was comparable between the subannular repair and isolated annuloplasty subgroups, the residual leaflet tethering (tenting area, 127.6 ± 35.8 mm2 vs 166.3 ± 47.3 mm2, P = .02; posterior mitral leaflet angle, 19.2 ± 4.7 degrees vs 24.8 ± 5.2 degrees, P = .001; anterior mitral leaflet angle, 25.4 ± 5.8 degrees vs 34.1 ± 4.0 degrees, P = .001; and tenting height, 5.9 ± 1.4 mm vs 9.2 ± 2.2 mm, P = .001) were significantly increased in the isolated annuloplasty group (P 2 of 98% (50 of 51) for subannular repair vs 86.7% (39 of 45) for isolated annuloplasty (P = .045) and mortality of 0% (0 of 51) for subannular repair vs 10% (5 of 50) for isolated annuloplasty (P = .025). Conclusions In secondary MR with reduced leaflet motion, the combination of annuloplasty and standardized subannular repair is associated with a significantly reduced MR reoccurrence, decreased residual leaflet tenting, and significantly improved 1-year outcome compared with annuloplasty alone.

Current balloon expandable and self-expanding valves have limitations for the treatment of the enlarged right ventricular outflow tract. We report the first use of a tailored Zenith graft in composition with an Edwards Sapien S3 valve as an alternative to high-risk surgery for the treatment of a spontaneously ruptured homograft in an adult congenital heart disease patient.

Aortic valve repair in adult congenital heart disease (ACHD) went through a major development during the last two decades to become an increasingly established treatment option in experienced heart valve repair centers. This mini-review addresses valve-sparing treatment strategies in the two most common clinical entities of patients with adult congenital aortic valve disease, namely those presenting with bicuspid (BAV) and unicuspid (UAV) aortic valve disease. Both diseases are integral components of the continuum of congenital aortic valve diseases and represent one of the most common reasons of cardiovascular morbidity in young and otherwise healthy adult patients. The review will highlight the most important advantages of aortic valve sparing procedures as compared to the conventional valve replacement strategy. New treatment aspects will be reviewed including minimally-invasive surgical approaches for aortic valve repair as well as modern protocols of enhanced perioperative recovery which will potentially improve the perioperative recovery and quality of life of the patients undergoing valve-sparing surgical procedures in the future.

OBJECTIVES Subannular repair techniques in addition to undersized ring annuloplasty have been developed to address high mitral regurgitation (MR) recurrence rates after mitral valve repair in type IIIb MR. We compared the results of annuloplasty with simultaneous standardized subannular repair versus isolated annuloplasty, focusing on the periprocedural outcomes of minimally invasive procedures. METHODS A consecutive series of 108 patients with type IIIb functional MR with severe signs of bileaflet tethering underwent an annuloplasty + subannular repair (group A; n = 60) versus isolated annuloplasty (group B; n = 48). The primary end point of this prospective, parallel cohort study was death or recurrent MR >2, 1 year postoperatively. The secondary end points were survival and clinical outcomes, with special regard for the minimally invasively treated subgroups. RESULTS Duration of surgery, cardiopulmonary bypass time and aortic cross-clamp time were comparable between both study groups. Procedural outcomes as well as echocardiographic outcome parameters were similar and independent of access (fully endoscopic versus full sternotomy). At the 12-month follow-up, death or MR >2 occurred in 3.3% (2/60) of patients in group A vs in 20.8% (10/48) of patients in group B (P = 0.037). The overall mortality rate during the follow-up period was 1.7% (1/60) in group A vs 12.5% (6/48) in group B (P = 0.041). CONCLUSIONS Standardized realignment of papillary muscles is feasible and reproducible via a minimally invasive approach, resulting in excellent periprocedural outcomes, and has a clear potential to significantly decrease MR recurrence and improve 1-year outcomes compared to isolated annuloplasty.

Background Treatment of patients presenting with possible acute myocardial infarction (AMI) is based on timely diagnosis and proper risk stratification aided by biomarkers. We aimed at evaluating the predictive value of GDF-15 in patients presenting with symptoms suggestive of AMI. Methods Consecutive patients presenting with suspected AMI were enrolled in three study centers. Cardiovascular events were assessed during a follow-up period of 6 months with a combined endpoint of death or MI. Results From the 1818 enrolled patients (m/f = 1208/610), 413 (22.7%) had an acute MI and 63 patients reached the combined endpoint. Patients with MI and patients with adverse outcome had higher GDF-15 levels compared with non-MI patients (967.1pg/mL vs. 692.2 pg/L, p

Introduction The need for transesophageal echocardiography (TEE) before catheter ablation of atrial fibrillation (CA-AF) is still being questioned. The aim of this study is to analyze patients’ (pts) risk factors of left atrial appendage thrombus (LAAT) prior to CA-AF in daily clinical practice, according to oral anticoagulation (OAC) strategies recommended by current guidelines. Methods and results All pts scheduled for CA-AF from 01/2015-12/2016 in our center were included and either treated with NOACs (novel-OAC; paused 24-hours pre-ablation) or continuous vitamin K-antagonists (INR 2.0-3.0). All pts received a preprocedural TEE at the day of ablation. Two groups were defined: 1) pts without LAAT, 2) pts with LAAT. The incidence of LAAT was 0.78% (13/1658 pts). No LAAT was detected in pts with a CHA2DS2-VASc score of ≤ 1 (n = 640 pts) irrespective of the underlying AF type. Independent predictors for LAAT are: higher CHA2DS2-VASc scores (odds ratio (OR) 1.54, 95%-confidence interval (CI): 1.07–2.23, P = 0.0019), a history of non-paroxysmal AF (OR 7.96, 95%-CI: 1.52–146.64, P = 0.049), hypertrophic cardiomyopathy (HCM; OR 9.63, 95%-CI: 1.36–43.05, P = 0.007) and a left ventricular ejection fraction (LVEF) < 30% (OR 8.32, 95%-CI: 1.18–36.29, P = 0.011). The type of OAC was not predictive (P = 0.70). Conclusions The incidence of LAAT in pts scheduled for CA-AF is low. Therefore, periprocedural OAC strategies recommended by current guidelines seem feasible. Preprocedural TEE may be dispensed in pts with a CHA2DS2-VASc score ≤ 1. However, a CHA2DS2-VASc score ≥ 2, reduced LVEF, HCM or history of non-paroxysmal AF are independently associated with an increased risk for LAAT. This article is protected by copyright. All rights reserved

Purpose The transaortic axial flow device Impella 5.0 (Abiomed, Danvers, Massachusetts, USA) is an established and approved short-term device for patients with left ventricular failure in need of mechanical circulatory support, especially in those patients who are in need of full left ventricular circulatory support. However, it is approved for up to 6 (10 in CE countries) days only. In certain situations, longer duration of support is needed. Therefore, the Impella 5.5 was developed and has currently a CE-approval for 30 days of support. Methods Recently, the Impella 5.5 received CE mark approval. The newly developed pump has new motor bearings, new optical flo and pressure sensing and measurement, a shorter and stiffer housing and cannula and is lacking a pig-tail extension at the tip of the pump. Compared to the former Impella 5.0 the only access site for implantation of the Impella 5.5 is the axillary artery. Results We present the experience of the first-in-man implantations of the Impella 5.5 in a single center. To date, the first four out of six implantations have been performed in our institution in patients in cardiogenic shock. In all patients end-organ function recovered. 30 day survival was 50%. One patient was bridged to a permanent device and in another the cardiac function recovered. Conclusion The newly designed Impella 5.5 provides full support with a flow up to 5.5 l/min and is CE approved for up to 30 days. Implantation and placement of the device is feasible and safe. During support, no pump related adverse events occurred. More implantations are planned in Europe to evaluate the encouraging first experiences.

Cardiovascular disease is the most common cause of death in the western world and prevention is the key. Risk can be assessed by validated risk scoring systems. However, about 40 percent of individuals are in the intermediate risk group with a 10-year probability of a cardiovascular event between 10 – 20 % and additional methods are needed to further risk stratify these patients. The measurements of inflammatory biomarkers have been suggested for better risk prediction, but did not enter guidelines so far. Methods to examine arterial morphology and function have been the focus of interest in the last decades. Electron beam computertomography (EBCT) is a tool to measure the degree of calcification in the coronary arteries and further risk stratify individuals. Non-invasive methods have been introduced to examine arterial stiffness and endothelial function. Arterial stiffness in the large arteries reflects compliance, atherosclerotic disease leads to a loss of compliance that is correlated with incident cardiovascular events. Microvascular function may be an early indicator of end-organ damage. Flow-mediated dilation of the brachial artery tests the reactivity of the endothelium to shear stress. Diseased vessels lose their ability to generate nitric oxide, and the reduced or missing dilation can be measured by ultrasound. Data on the cost-benefit ratio of the reviewed methods are needed before general recommendations for the use in clinical practice can be made.

Background The intention of this study was to evaluate the outcome of patients with gastric stump cancer (GSC) in comparison with patients treated for primary proximal gastric cancer (PPGC). Methods Nineteen patients with GSC undergoing surgery between January 1989 and August 2005 were compared with 194 PPGC patients treated during the same time period. Various factors such as epidemiologic data, type of treatment, and histopathologic data were evaluated in the analysis. Results The overall 5-year disease-specific survival was 42% for resected GSC patients in comparison with 37% for resected PPGC patients. There was no statistically significant difference in the survival rate detected between these 2 groups. On multivariate analysis the infiltration of the gastrojejunal anastomosis by the carcinoma was shown to be a significant predictor for the outcome of patients with GSC. Conclusions In summary, no significant difference in the outcome between GSC and PPGC has been detected.

Background: Pulmonary disease has consistently been related to increased mortality. We investigated central spirometry variables in relation to total mortality in individuals from the general population without diagnosed lung disease also accounting for cardiac function. Methods: In 15,010 individuals from the general population (mean age 55±11 years, age range 35-74 years, 50.5% men) in the Gutenberg Health Study we performed spirometry and multimodal transthoracic echocardiography. The biomarkers N-terminal pro-B-type natriuretic peptide (Nt-proBNP) and high-sensitive troponin I (TnI) were measured in the first 5000 individuals using commercially available assays. Multivariable Cox regression analyses were computed for the lung function parameters forced expiratory volume in 1 second (FEV1), forced vital capacity (FVC) and the Tiffeneau-Pinelli index (FEV1/FVC ratio) after exclusion of individuals with prevalent pulmonary disease (N=1135). Results: The median FEV1/FVC ratio was 79.1%, 19.5% were current smokers, 4.2% had prevalent heart failure. After a median follow-up of 5.5 years 360 deaths were recorded. Multivariable-adjusted Cox regression analyses for the common cardiovascular risk factors (age, sex, body mass index, current smoking, diabetes mellitus, hypertension, dyslipidemia) and heart failure revealed that an increase of one standard deviation (SD) of FEV1 was associated with a 38% risk reduction (hazard ratio (HR) per SD 0.62 [95% confidence interval (CI): 0.52-0.73]). The association remained statistically highly significant after additional adjustment for ejection fraction, stroke volume, Nt-proBNP or TnI. Comparable results were seen for FVC, whereas no association of FEV1/FVC ratio with mortality could be shown. No significant interaction by heart failure was observed. Conclusions: The central lung function parameters FEV1 and FVC were related to all-cause mortality in individuals without manifest lung disease. Our findings indicate that subtle, subclinical pulmonary impairment constitutes a risk for increased mortality independent of cardiac performance.

Aim: Superoxide dismutase (SOD) is important to control reactive oxygen species, but the relevance to human disease like coronary artery disease (CAD) and underlying ischemia/reperfusion injury is not clarified. Methods: For this study, 2239 patients with known CAD were prospectively followed with a median follow-up time period of 3.6 years and a maximum of 6.9 years. During follow-up cardiovascular death was reported in 103 cases. Results: SOD activity (log-transformed) was investigated as continuous and categorical variable, showing a significant influence on outcome in the fully adjusted model (p = 0.045). Conclusion: Increased SOD activity beyond the normal range in the human physiology is related to an adverse outcome in patients with CAD.

Hedinger syndrome is a paraneoplastic disease encountered in metastatic neuroendocrine tumor and is often the cause for the fatal outcome in this disease. Diagnostic work-up of a 59-year-old woman was initiated after finding of typical features of the tricuspid and pulmonic valves (TV and PV) on

Background— Several methods of noninvasive vascular function testing have been suggested for cardiovascular risk screening in the community. A direct comparison of the different methods and their relation to classical cardiovascular risk factors in a large cohort is missing. Methods and Results— In 5000 individuals (mean age, 55.5±10.9 years; age range, 35 to 74 years; women, 49.2%) of the population-based Gutenberg Heart Study, we performed simultaneous measurement of flow-mediated dilation (FMD) and peripheral arterial volume pulse determined by infrared photo (reflection index) and pneumatic plethysmography (PAT) and explored their associations. All function measures were recorded at baseline and after reactive hyperemia induced by 5-minute brachial artery occlusion. Correlations between different measures of vascular function were statistically significant but moderate. The strongest association for hyperemic response variables was observed for PAT ratio and FMD (Spearman r =0.17; age- and sex-adjusted partial correlation, 0.068). Classical risk factors explained between 15.8% (baseline reflection index) and 58.4% (brachial artery diameter) of the baseline values but only accounted for 3.2% (reflection index), 15.4% (FMD), and 13.9% (PAT ratio) of the variability of reflective hyperemic response. Regression models varied in their relations to classical risk factors for the individual vascular function measures. Consistently associated with different vascular function methods were age, sex, body mass index, and indicators of hypertension. Peripheral tonometry also showed a relation to fasting glucose concentrations. Conclusions— Noninvasive measures of conduit artery and peripheral arterial function are modestly correlated, differ in their relation to classical cardiovascular risk factors, and may thus reflect different pathologies.

Background— Echocardiography, the dominant imaging modality for quantification of left ventricular metrics, has undergone continuing development in the past few decades. However, given the lack of population-based data, current guidelines are still based on restricted and small data sets analyzed with methods including expert opinion. This work presents empirically derived reference values from a large-scale, epidemiologic study conducted with state-of-the-art imaging technology and methods. Methods and Results— The distribution of echocardiographic measurements of the left ventricle was analyzed in a population-based sample of 5000 mid-Europeans from the Gutenberg Heart Study in Germany. The randomly selected, noninstitutionalized sample provides data on apparently healthy individuals, as well as on those with prevalent disease. Standardized echocardiograms were recorded in a comprehensive data set at a single site with centralized training and certification of sonographers. Sex-specific reference limits and categories indicating the grade of deviation from the reference were calculated, and nomograms were created by quantile regression. Detailed information is given on the association between left ventricular geometry and age. Conclusions— The rapidly evolving echocardiographic technology with persistent improvements in image quality and new measurement conventions require the evaluation of new reference limits for left ventricular metrics. The present investigation formulates reference limits and nomograms from state-of-the-art technology and methods based on a large population-based data set. The distribution of echocardiographic measures of left ventricular geometry presents, in part, nonlinear associations with age, which should be the subject of future investigations.