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Background: Wearable cardioverter defibrillators (WCD) are used as a 'bridging' technology in patients, who are temporarily at high risk for sudden cardiac death (SCD). Several factors should be taken into consideration, for example patient selection, compliance and optimal drug treatment, when WCD is prescribed. We aimed to present real‐world data from seven centres from Germany and Switzerland according to age differences regarding the outcome, prognosis, WCD data and compliance. Materials and Methods: Between 04/2012 and 03/2021, 1105 patients were included in this registry. Outcome data according to age differences (old ≥45 years compared to young <45 years) were analysed. At young age, WCDs were more often prescribed due to congenital heart disease and myocarditis. On the other hand, ischaemic cardiomyopathy (ICM) was more present in older patients. Wear days of WCD were similar between both groups (p =.115). In addition, during the WCD use, documented arrhythmic life‐threatening events were comparable [sustained ventricular tachycardia: 5.8% vs. 7.7%, ventricular fibrillation (VF).5% vs..6%] and consequently the rate of appropriate shocks was similar between both groups. Left ventricular ejection fraction improvement was documented over follow‐up with a better improvement in younger patients as compared to older patients (77% vs. 63%, p =.002). In addition, at baseline, the rate of atrial fibrillation was significantly higher in the older age group (23% vs. 8%; p =.001). The rate of permanent cardiac implantable electronic device implantation (CiED) was lower in the younger group (25% vs. 36%, p =.05). The compliance rate defined as wearing WCD at least 20 h per day was significantly lower in young patients compared to old patients (68.9% vs. 80.9%, p <.001). During the follow‐up, no significant difference regarding all‐cause mortality or arrhythmic death was documented in both groups. A low compliance rate of wearing WCD is predicted by young patients and patients suffering from non‐ischaemic cardiomyopathies. Conclusion: Although the compliance rate in different age groups is high, the average wear hours tended to be lower in young patients compared to older patients. The clinical events were similar in younger patients compared to older patients. [ABSTRACT FROM AUTHOR]

The use of extracorporeal membrane oxygenation (ECMO) is discussed to improve patients' outcome in severe COVID-19 with respiratory failure, but data on ECMO remains controversial. The aim of the study was to determine the characteristics of patients under invasive mechanical ventilation (IMV) with or without veno-venous ECMO support and to evaluate outcome parameters. Ventilated patients with COVID-19 with and without additional ECMO support were analyzed in a retrospective multicenter study regarding clinical characteristics, respiratory and laboratory parameters in day-to-day follow-up. Recruitment of patients was conducted during the first three COVID-19 waves at four German university hospitals of the Ruhr University Bochum, located in the Middle Ruhr Region. From March 1, 2020 to August 31, 2021, the charts of 149 patients who were ventilated for COVID-19 infection, were included (63.8% male, median age 67 years). Fifty patients (33.6%) received additional ECMO support. On average, ECMO therapy was initiated 15.6 ± 9.4 days after symptom onset, 10.6 ± 7.1 days after hospital admission, and 4.8 ± 6.4 days after the start of IMV. Male sex and higher SOFA and RESP scores were observed significantly more often in the high-volume ECMO center. Pre-medication with antidepressants was more often detected in survivors (22.0% vs. 6.5%; p = 0.006). ECMO patients were 14 years younger and presented a lower rate of concomitant cardiovascular diseases (18.0% vs. 47.5%; p = 0.0004). Additionally, cytokine-adsorption (46.0% vs. 13.1%; p < 0.0001) and renal replacement therapy (76.0% vs. 43.4%; p = 0.0001) were carried out more frequently; in ECMO patients thrombocytes were transfused 12-fold more often related to more than fourfold higher bleeding complications. Undulating C-reactive protein (CRP) and massive increase in bilirubin levels (at terminal stage) could be observed in deceased ECMO patients. In-hospital mortality was high (Overall: 72.5%, ECMO: 80.0%, ns). Regardless of ECMO therapy half of the study population deceased within 30 days after hospital admission. Despite being younger and with less comorbidities ECMO therapy did not improve survival in severely ill COVID-19 patients. Undulating CRP levels, a massive increase of bilirubin level and a high use of cytokine-adsorption were associated with worse outcomes. In conclusion, ECMO support might be helpful in selected severe cases of COVID-19. [ABSTRACT FROM AUTHOR]

Background: Pulmonary embolism (PE) is a common cardiovascular disease. Elderly patients with acute PE have very high mortality rates. Data concerning the safety and effectiveness of ultrasound-accelerated thrombolysis (USAT) in this age group are lacking. Methods: Nineteen octogenarians with acute pulmonary embolism underwent USAT between August 2020 and February 2023 at two centres in Germany and were retrospectively analysed. The main efficacy measures were the right ventricle to left ventricle diameter (RV/LV) ratio, systolic right ventricle function, and invasive and echocardiographic measured systolic pulmonary artery pressure (sPAP). The main safety measures were in-hospital death and the bleeding rate according to the GUSTO bleeding score. Results: USAT was associated with an improved RV/LV ratio (0.36 ± 0.29, p < 0.001), systolic right ventricle function (5.0 ± 3.8, p < 0.001), and systolic pulmonary artery pressure (sPAP) at 24 h after therapy (24.2 ± 11.2 mmHg and 19 ± 13.4 mmHg, p < 0.001). No in-hospital deaths or bleeding complications occurred. Conclusions: USAT with EKOSTM may be a safe and effective therapeutic option for octogenarians with acute pulmonary embolism. [ABSTRACT FROM AUTHOR]

Background: The effects of sacubitril/valsartan in patients with chronic heart failure with reduced ejection fraction (HFrEF) were recently reported. However, the hemodynamic impact of this well-established treatment in patients with HFrEF has been poorly systematically researched. Aim: We aimed to investigate the hemodynamic effects of sacubitril/valsartan among patients with HFrEF. Methods: Between 2016 and 2020, we retrospectively collected data for patients with HFrEF treated at the University Medical Center Mannheim, Germany. Data for 240 patients with HFrEF were available. We systematically analyzed echocardiographic parameters, all-cause hospitalization, and congestion rate. Results: The left ventricular ejection fraction (LVEF) improved from a median (minimum; maximum) of 28% (3; 65) before initiation of sacubitril/valsartan to a median of 34% (13; 64) at 24-month follow-up (p < 0.001). Systolic pulmonary atrial pressure (PAPsys) decreased from a median of 30 mmHg (13; 115) to 25 mmHg (20; 80) at 24-month follow-up (p = 0.005). The median (minimum; maximum) tricuspid annular plane systolic excursion improved from 17 mm (3; 31) at baseline to 20 mm (9; 30) at 12-month follow-up (p = 0.007). The incidence of severe and moderate mitral, tricuspid, and aortic valvular insufficiency improved after treatment. Hospitalization and congestion rates reduced at 24-month follow-up. The mortality rate in echocardiographic and functional nonresponders was higher than in responders (12.1 vs. 5.2%; p = 0.1 and 11.3 vs. 3.1%; p = 0.01, respectively). Conclusion: Follow-up 24 months after starting treatment with sacubitril/valsartan revealed sustained improvements in echocardiographic parameters, including LVEF, PAPsys, and cardiac valvular insufficiency. Rates of all-cause hospitalization and congestion had decreased significantly at follow-up. The mortality rate was higher in echocardiographic and functional nonresponders. [ABSTRACT FROM AUTHOR]

Introduction: Multiple myeloma (MM) is a plasma cell disease that affects more men than women. Although there is an obvious imbalance in incidence, knowledge of differences in biology and outcome between the sexes is surprisingly rare. Methods: We performed a unicentric retrospective analysis of patients with MM treated at a tertiary cancer centre between 2003 and 2018. Results: We present a sex-disaggregated analysis of the characteristics and outcome of MM in a cohort of 655 patients (median age at diagnosis 62 years; 363 men with a median age at diagnosis 62 years and 292 women with a median age at diagnosis 63 years, p = 0.086). Most patients (n = 561, 86%) received myeloma-specific treatment. Median overall survival was 76 months (95% CI 63–89) (72 months in men [95% CI 54–90] and 83 months in women [95% CI 66–100], p = ns). Apart from a higher incidence of moderate and severe anaemia in women (p < 0.001), there were no statistically significant differences in the biology of the underlying MM. Similarly, in the group of patients who received high-dose therapy with autologous stem-cell transplantation (ASCT, n = 313), no statistically significant differences apart from more frequent anaemia in women were detected regarding the biology of the disease. However, there was a trend toward a higher plasma cell infiltration of the bone marrow and toward more frequent high-risk features in women. In contrast, relevant comorbidities were significantly more common in men (for example, coronary heart disease in 13% of men vs. 2% of women, p < 0.001). Toxicities after ASCT were not significantly different between the sexes with the exception of severe mucositis, which occurred in 22% of men versus 40% of women (p = 0.001). Conclusion: In conclusion, this first sex-disaggregated analysis of MM patients in Germany supports previous findings that survival is comparable amongst sexes, but women experience more toxicity of high-dose therapy. The higher incidence of clinically relevant anaemia in women warrants further investigation to exclude underlying treatable causes. [ABSTRACT FROM AUTHOR]

Background: There are few large studies on which factors are associated with the occurrence of arrhythmias. Implantable loop recorders (ILR) are useful in detecting arrhythmia due to prolonged and continuous ECG monitoring. Therefore, the aim of this study is to identify and evaluate clinical characteristics and ECG parameters for predicting arrhythmias requiring pacemaker/ICD implantation by analyzing a study cohort with ILR. Methods: This bicentric study comprised a study cohort of 451 patients (mean age 64 ± 16 years, 209 women) receiving ILR implantation between 2011 and 2021. Patients were followed up on a 3 monthly outpatient interval. All arrhythmias with a pacemaker or ICD indication were considered clinically relevant. The primary study endpoint was the detection of clinically relevant arrhythmia. Results: During a follow up of 678 ± 392 days, a clinically relevant arrhythmia was detected in 81 of 451 patients (18%). Multivariate analysis revealed five independent risk factors: coronary artery disease (HR 1.954, CI 1.077–3.546, p =.028), atrial fibrillation (HR 2.253, CI 1.201–4.228, p =.011), previous syncope (HR 6.404, CI 3.202–12.808, p <.001), right bundle branch block (HR 4.370, CI 2.215–8.621, p <.001) and left bundle branch block (HR 2.685, CI 1.116–6.461, p =.028). Our risk model, based on these independent predictors, divided the study cohort into patients with low (2%), intermediate (18%), medium (34%), and high (45%) risk for clinically relevant arrhythmia. Conclusion: By the use of ILR, a clinically relevant arrhythmia has been detected in almost one fifth of the study cohort. In addition, clinical and electrocardiographic parameters were shown to be suitable predictors of clinically relevant arrhythmia. [ABSTRACT FROM AUTHOR]

Background: Optimization of cardiac resynchronization therapy (CRT) is often time‐consuming and therefore underused in a clinical setting. Novel device‐based algorithms aiming to simplify optimization include a dynamic atrioventricular delay (AVD) algorithm (SyncAV, Abbott) and multipoint pacing (MPP, Abbott). This study examines the acute effect of SyncAV and MPP on electrical synchrony in patients with newly and chronically implanted CRT devices. Methods: Patients with SyncAV and MPP enabled devices were prospectively enrolled during implant or scheduled follow‐up. Blinded 12‐lead electrocardiographic acute measurements of QRS duration (QRSd) were performed for intrinsic QRSd (Intrinsic), bi‐ventricular pacing (BiV), MPP, BiV with SyncAV at default offset 50 ms (BiVSyncAVdef), BiV with SyncAV at patient‐specific optimised offset (BiVSyncAVopt), MPP with SyncAV at default offset 50 ms (MPPSyncAVdef), and MPP with SyncAV at patient‐specific optimised offset (MPPSyncAVopt). Results: Thirty‐three patients were enrolled. QRSd for Intrinsic, BiV, MPP, BiVSyncAVdef, BiVSyncAVopt, MPPSyncAVdef, MPPSyncAVopt were 160.4 ± 20.6 ms, 141.0 ± 20.5 ms, 130.2 ± 17.2 ms, 121.7 ± 20.9 ms, 117.0 ± 19.0 ms, 121.2 ± 17.1 ms, 108.7 ± 16.5 ms respectively. MPPSyncAVopt led to greatest reduction of QRSd relative to Intrinsic (−31.6 ± 11.1%; p <.001), showed significantly shorter QRSd compared to all other pacing configurations (p <.001) and shortest QRSd in every patient. Shortening of QRSd was not significantly different between newly and chronically implanted devices (−51.6 ± 14.7 ms vs. −52.7 ± 21.9 ms; p =.99). Conclusion: SyncAV and MPP improved acute electrical synchrony in CRT. Combining both technologies with patient‐specific optimization resulted in greatest improvement, regardless of time since implantation. Whats new Novel device‐based algorithms like a dynamic AVD algorithm (SyncAV, Abbott) and multipoint pacing (MPP, Abbott) aim to simplify CRT optimization. Our data show that a combination of patient tailored SyncAV optimization and MPP results in greatest improvement of electrical synchrony in CRT measured by QRS duration, regardless if programmed in newly or chronically implanted devices. This is the first study to our knowledge to examine a combination of these device‐based algorithms. The results help understanding the ideal ventricular excitation in heart failure. [ABSTRACT FROM AUTHOR]

Although international proclamations increasingly recognize legal sex beyond binary categories, domestic legislation is lagging behind. Germany and the Netherlands are the first countries in Western Europe where courts have ruled in favour of a third option. While the German constitution was amended to guarantee a third option, the Dutch government has refrained from implementing comparable legislation. What explains this difference? This article draws on parliamentary debates, newspapers and statements from activists to follow the trajectory of the third option. Building on literature on intersex rights legislation and the diffusion of LGBT rights norms, we find that an established progressive reputation can lead states like the Netherlands to take a back seat, while mobilization by activists was crucial in establishing the self‐determination of legal sex on the German political agenda. Our study contributes to unravelling the complex ways in which new norms shape – or fail to shape – domestic political outcomes. [ABSTRACT FROM AUTHOR]

Background Left atrial ablation can be accompanied by discomfort or pain. The purpose of this study was to systematically compare pain reactions during ablation of atrial fibrillation under deep sedation with cryothermal and radiofrequency energy. Methods and Results Circumferential ablation was performed in patients with atrial fibrillation using either radiofrequency (RF) or cryoenergy. Deep sedation was achieved with a combination of propofol and midazolam. Pain reactions were counted and painful ablation sites located. To determine the severity of the pain reactions a Face, Legs, Activity, Cry, Consolability (FLACC) Behavioral Pain Assessment Scale was used: 79 patients (53 RF- vs 26 Cryoablations) were included. A total of 92% of patients treated with RF energy showed ≥1 pain reaction during the procedure compared to only 13% in the cryoenergy group (<0.001). The total number of pain reactions was significantly higher in the RF energy group (3.6 ± 4.7 vs1.3 ± 0.6, P = 0.005). Determination of painful sites was performed in the RF group only. Pain reactions were significantly more often observed during RF application left superior pulmonary vein (LSPV) ostium compared to other left atrial ablation sites (Total FLACC Score 2.8 ± 0.6 LSPV, 1.4 ± 0.4 left inferior pulmonary vein [P = 0.009], 1.4 ± 0.3 right superior pulmonary vein [P = 0.044], 1.1 ± 0.3 right inferior pulmonary vein [P = 0.032]). Conclusions Our results show that despite deep sedation pain reactions often occur during RF ablation. Knowledge of areas with more frequent pain reactions may help electrophysiologists to reduce pain reactions and related patient movements. Ablation with cryoenergy was significantly less painful compared to ablation with RF energy. Cryoablation therefore may be considered for patients at a higher risk for anesthesia-related complications. [ABSTRACT FROM AUTHOR]

TACT Assessed by PA-TDI Interval Background The aim of this study was to investigate whether total atrial conduction time (TACT) assessed via tissue Doppler imaging (PA-TDI interval) can identify patients with early recurrent atrial fibrillation (ERAF) after successful direct-current electrical cardioversion (CV) of persistent atrial fibrillation (persPAF). Methods and Results A total of 54 patients without antiarrhythmic drug medication (mean ± SD: 66 ± 10.4 years; 33% women) with persPAF and successful CV were enrolled between May 2012 and May 2013. TACT was measured 6 hours after successful CV in the left atrium by tissue Doppler imaging (PA-TDI interval). ERAF was determined via Holter-electrocardiogram over a period of 7 days after CV. Receiver opearting characteristic analysis was used to determine an optimal cutoff value of PA-TDI interval for prognosis of ERAF. Based on this result, recurrence-free survival was assessed with Mantel-Haenszel's log-rank test. ERAF occurred in 23 patients (43%). PA-TDI interval was longer in patients with ERAF compared to those who maintained sinus rhythm (mean ± SD: 163.5 ± 11.1 vs 132.3 ± 11.2 milliseconds; P < 0.00001). At the cutoff value of 152 milliseconds, PA-TDI interval sensitivity and specificity related to ERAF were 87% and 100%, respectively. Conclusion Measuring PA-TDI interval may help to predict ERAF after successful CV in patients with persAF. [ABSTRACT FROM AUTHOR]

Atrial Conduction Time Background Recent studies identified total atrial conduction time (TACT) as an independent and powerful predictor of new-onset atrial fibrillation (AF). The purpose of this study was to assess the association between the degree of atrial fibrosis, TACT, and frequency of postoperative atrial fibrillation (POAF) among patients undergoing cardiac surgery. Methods and Results Sixty patients in sinus rhythm (mean ± SD age 66 ± 10 years; 22% women) and without a history of AF undergoing cardiac surgery were prospectively enrolled. TACT was measured preoperatively in the left atrium by tissue-Doppler Imaging (PA-TDI interval). Holter-ECG/telemetry was used to screen for POAF throughout 10 days after cardiac surgery. Right atrial appendages (RAA) were obtained in 33 patients during surgery; atrial fibrosis was assessed by visual quantification (% area of positive van Gieson elastic staining). POAF occurred in 23 patients (38%). Fibrosis extent of RAA was higher in patients with POAF as compared to those without (27.5 ± 1.93 vs 15.8 ± 0.81% area; mean ± SEM; P < 0.001). PA-TDI interval was longer in patients with POAF versus patients who maintained in sinus rhythm (152.1 ± 3.0 vs 120.8 ± 1.8 milliseconds; P < 0.001) and correlated with the degree of atrial fibrosis (r = 0.73; P < 0.01). At the cut-off value of 133 milliseconds, TACT sensitivity and specificity related to POAF were 100% and 86%, respectively. Conclusion PA-TDI interval is useful to identify patients at risk for POAF undergoing cardiac surgery and correlates with the degree of atrial fibrosis. [ABSTRACT FROM AUTHOR]

Background and Objective: Despite a measurable increase in recent years, the bystander resuscitation rate in Germany lags behind the European comparison. Special centers for the care of patients after cardiac arrest, so-called cardiac arrest centers (CAC), have been established. The aim of this work is to evaluate the role of CACs, in addition to in-hospital patient care, in improving the bystander resuscitation rate in Germany and what obstacles exist in the implementation of resuscitation training., Materials and Methods: Online survey by the working group cardiopulmonary resuscitation (AG42) of the German Society of Cardiology (DGK) and the German Resuscitation Council (GRC) RESULTS: Of the 74 participating clinics (78.4% certified as CAC), 23 (31.1%) conduct lay resuscitation training. These mainly take place within the framework of action days for resuscitation (82.6%) or in schools (39.1%). Permanent cooperation with at least one school existed in 52.2%. Basic life support (BLS) resuscitation dummies are available in 63.5% of these clinics and an automated external defibrillator (AED) demonstration device in 43.2%. According to the interviewees, the biggest obstacles to the consistent implementation of resuscitation courses in schools include lack of qualified instructors, lack of refinancing and difficulties with regard to coordinating activities between schools and providers., Conclusions: Direct training of lay rescuers by hospitals faces several obstacles. To increase the bystander resuscitation rate, focusing on targeted training of teachers as multipliers (train-the-trainer) can be a good approach for cardiac arrest centers., (© 2023. The Author(s), under exclusive licence to Springer Medizin Verlag GmbH, ein Teil von Springer Nature.)

Background and Aims: Oral anticoagulation is effective for stroke prevention in atrial fibrillation (AF). However, strokes may still occur in high-risk individuals. We conducted a prospective trial to assess the association between adipocytokine serum levels and surrogate parameters for thromboembolic events., Methods and Results: In this cross-sectional multicenter trial, we enrolled 189 patients with AF who were on oral anticoagulation. The primary endpoint was defined as either the presence of spontaneous echo contrast (SEC), a left atrial appendage (LAA), or a left atrial (LA) thrombus on transesophageal echocardiography. We investigated the association of adipocytokine serum levels with the combined endpoint using logistic regression analysis. Forty-eight individuals (25%) were assigned to group 1 (G1) due to the occurrence of at least one of the components of the combined endpoint (41 [21.7%] SEC, 3 [1.6%] LA thrombus, 13 [6.9%] LAA thrombus), whereas the remaining patients formed group 2 (G2). The BMI, logarithmized (log e ) leptin (G1: 2.0 ± 1.3 μg/ml, G2: 2.0 ± 1.1 μg/ml, p = 0.746) and visfatin serum levels (G1: 3.4 ± 0.3 ng/ml, G2: 3.4 ± 0.5 ng/ml, p = 0.900) did not significantly differ between the groups. Conversely, logarithmized adiponectin (G1: 3.3 ± 0.6 ng/ml, G2: 3.1 ± 0.7 ng/ml, p = 0.036) and resistin levels (G1: 1.8 ± 0.5 ng/ml, G2: 1.6 ± 0.5 ng/ml, p = 0.009) were higher in patients with the primary endpoint. Multivariate logistic regression analysis using a score that combined the individual adiponectin and resistin values in each patient corroborated this association., Conclusions: Our results suggest that adiponectin and resistin may act as potential biomarkers to identify individuals with AF who are at high thromboembolic risk., Competing Interests: Declaration of competing interest None declared., (Copyright © 2020 The Italian Diabetes Society, the Italian Society for the Study of Atherosclerosis, the Italian Society of Human Nutrition and the Department of Clinical Medicine and Surgery, Federico II University. Published by Elsevier B.V. All rights reserved.)

Objectives: The transfemoral approach for transcatheter aortic valve implantation (TF-TAVI) is associated with a significant survival benefit for intermediate and high-risk patients. Due to the increased procedural risk, many operators avoid TF-TAVI in patients with aortic disease. Moreover, significant peri-interventional device interaction may occur in patients with previous endovascular aortic repair (EVAR). We evaluated the feasibility of TF-TAVI in patients with aortic disease in combination with simultaneous or sequential EVAR., Methods: Data from 15 TF-TAVI patients with concomitant aortic disease treated between 2009 and 2019 in three German heart centers representing 4410 TAVI procedures were analyzed., Results: Two patients with progressive penetrating atherosclerotic ulcers (PAUs) in the descending thoracic aorta underwent sequential and simultaneous thoracic EVAR (TEVAR), respectively. One patient with stable PAU and 4 patients with not yet relevant abdominal aortic aneurysm (AAA) underwent isolated TF-TAVI. One patient with relevant AAA underwent TF-TAVI and sequential EVAR. Seven patients with previous EVAR due to an AAA underwent TF-TAVI (5 with a bifurcated graft and 2 with a straight graft). TF-TAVI and sequential or simultaneous TEVAR were technically successful in all patients. Vascular complications occurred in 1 patient. One patient died within 30 days and 2 patients died within 12 months., Conclusion: TF-TAVI can be performed successfully in patients with aortic disease or previous endovascular aortoiliac intervention. Simultaneous and sequential (T)EVAR is feasible.

Background: Persons of lower socio-economic status are at higher risk of disease, especially with respect to severe and chronic illnesses. To date, there have not been any studies with large case numbers regarding acute medical emergencies in this population., Methods: In a retrospective study, data were obtained on all cases treated by emergency physicians in Bochum, Germany, in 2014/2015, including the diagnoses that were made by the emergency physicians. There were a total of 16 767 cases. The local unemployment rate was taken as an indicator of the socioeconomic situation of a neighborhood; it was defined as the percentage of registered unemployed persons among persons aged 15 to 64 with their domicile in the neighborhood. 12 168 cases were grouped by emergency medical diagnosis and analyzed with respect to the three most heavily represented diagnostic categories (cardiovascular, neurological, and pulmonary emergencies), which accounted for nearly two-thirds of all diagnoses., Results: The overall rates of deployment involving emergency physicians were found to be positively correlated with the unemployment rate. After adjustment for age, sex, and possible confounders, this correlation was statistically significant (p<0.01). The indirectly standardized rate ratio (IRR) for the overall case-activity rate ranged from 0.841 (95% confidence interval: [0.808; 0.875]) with less than 5% unemployment to 1.212 [1.168; 1.256] with 9.5% unemployment or higher. The same finding was obtained with respect to diagnosis-specific case activity in each of the three main diagnostic categories (cardiovascular, neurological, and pulmonary emergencies), as well as for the respective commonest individual diagnoses (acute coronary syndrome/circulatory arrest [1498 cases], transient ischemic attack/ischemic stroke/intracerebral hemorrhage [1274 cases], and asthma/chronic obstructive pulmonary disease [663 cases])., Conclusion: This study shows that the case-activity rate of the emergency medical services is significantly higher in socially disadvantaged neighborhoods, both with respect to total numbers and with respect to individual diseases. It demonstrates a problem affecting society as a whole, which should be taken into account in the organization of medical rescue services.

Background: Insertable cardiac monitor (ICM) increases the detection rate of occult atrial fibrillation (AF) after cryptogenic stroke. The aim of this study was to evaluate the prognostic significance of total atrial conduction time (TACT) assessed by tissue Doppler imaging (PA-TDI interval) to predict AF presence in patients with cryptogenic stroke., Methods: Ninety patients (57.7 ± 12.3 years, 48 % women) after acute cryptogenic stroke and ICM implantation were prospective recruited at four centers for continuous rhythm monitoring. In all patients, TACT was measured by PA-TDI interval via echocardiography. Patients were followed up (331 ± 186 days) for detection of AF (defined by episode lasting ≥30 s)., Results: AF was detected in 16 patients (18 %) during follow-up (331 ± 186 days). The median period to AF detection was 30 days (q1-q3; 16-62 days). Patients who exhibited occult AF were characterized by significantly longer PA-TDI intervals (154.7 ± 12.6 vs. 133.9 ± 9.5 ms, p < 0.0001). The cut-off value of PA-TDI interval at 145 ms demonstrated sensitivity and specificity for AF detection of 93.8 and 90.5 %, respectively. In multivariate analysis, CHA2DS2-VASc score (HR 1.96 per 1 point, p < 0.01) and longer PA-TDI interval (HR 4.05 per 10 ms, p < 0.0001) were independent predictors of occult AF., Conclusion: Our data suggest that measurement of TACT could help to predict future AF detection in patients with cryptogenic stroke. The clinical importance of prolonged rhythm monitoring or indication of direct anticoagulation therapy after cryptogenic stroke based on TACT should be further investigated.

Background: Single-shot ablation devices for pulmonary vein isolation (PVI) in patients with symptomatic atrial fibrillation (AF) have been increasingly used in clinical practice., Objective: A novel mapping-system integrated irrigated multipolar circular ablation catheter (nMARQ) has been introduced for PVI but data on larger patient cohorts on acute safety and efficacy are lacking., Methods: A total of 145 consecutive patients undergoing AF ablation treated with the nMARQ underwent endoscopic evaluation of esophageal thermal damage (EDEL) and brain MRI for detection of silent cerebral events (SCE). During the course of our experience different modifications of the ablation strategy, including energy delivery at the left atrial posterior wall, were evaluated., Results: Effective PVI was achieved in 99% of all PVs during a mean procedure-duration of 115 (±36) minutes and ablation-duration of 18 (±8) minutes. Acute major complications occurred in 3 patients (2.1%) and asymptomatic complications like SCE in 26% and EDEL in 21%. There was a significant reduction in EDEL when not using a thermal esophageal probe (0% vs. 28%, P < 0.0001). Ablation under oral anticoagulation led to lower SCE incidences compared to interrupted anticoagulation regimen (15% vs. 31%, P = 0.7). Out of 65 patients with completed 12-month follow-up, 43 (66%) were in stable sinus rhythm., Conclusions: PVI using the nMARQ is safe and effective in patients with symptomatic AF. Not using an esophageal temperature probe during ablation has relevantly reduced the incidence of EDEL. Ablations under continued oral anticoagulation have reduced incidence of SCE. Further studies on long-term efficacy are needed., (© 2015 Wiley Periodicals, Inc.)

Background: The study aims to determine the impact of different lung diseases on morbidity and mortality after transcatheter aortic valve implantation (TAVI)., Methods: Transcatheter aortic valve implantation was performed transfemoral or transaxillary with CoreValve prosthesis or Edwards SAPIEN prosthesis in patients with symptomatic severe aortic valve stenosis and high surgical risk. Examinations comprised spirometry, body plethysmography echocardiography, and x-ray before TAVI. The primary study end point was death from any cause after TAVI., Results: During follow-up of 750 ± 538 days, 63 of 212 patients died. Logistic European System for Cardiac Operative Risk Evaluation (hazard risk [HR] 1.032, P < .001), aortic mean gradient (HR 0.96, P < .001), chronic obstructive pulmonary disease (COPD; each degree of COPD: HR 1.436, P = .001), restrictive ventilatory disease (HR 2.252, P = .002), oxygen dependency (HR 3.291, P = .004), and noninvasive ventilation (HR 3.799, P = .005) were independent predictors of long-term mortality. Restrictive ventilatory disease was associated with lower left ventricular ejection fraction, higher B-type natriuretic peptide levels, and pulmonary edema., Conclusion: In patients undergoing TAVI, lung diseases are an independent predictor of all-cause mortality. In particular, oxygen dependency patients and patients with severe COPD and noninvasive ventilation indicate a dismal prognosis. Transcatheter aortic valve implantation seems to have a dubious prognostic benefit in these patients., (Copyright © 2015 Elsevier Inc. All rights reserved.)

Background: Endoscopically detected esophageal lesions (EDELs) have been identified in apparently asymptomatic patients after catheter ablation of atrial fibrillation (AF). The use of esophageal probes to monitor luminal esophageal temperature (LET) during catheter ablation to protect esophageal damage is currently controversial., Objective: The purpose of this study was to investigate the impact of the use of esophageal temperature probes during AF catheter ablation on the incidence of EDELs., Methods: Eighty consecutive patients (mean age 63.8 ± 11.36 years; 68.8% men) with symptomatic, drug-refractory paroxysmal (n = 52, 65%) or persistent AF who underwent left atrial radiofrequency catheter ablation were prospectively enrolled. Posterior wall ablation was power limited (≤25 W). In the first 40 patients, LET was monitored continuously (group A), whereas no esophageal temperature probe was used in group B (n = 40 patients). Assessment of EDEL was performed by endoscopy within 2 days after radiofrequency catheter ablation., Results: Overall, 13 patients (16%) developed EDELs after AF ablation. The incidence of EDELs was significantly higher in group A than group B (30% vs 2.5%, P < .01). Within group A, patients who developed EDEL had higher maximal LET during AF ablation than patients without EDEL (40.97 ± 0.92°C vs 40.14 ± 1.1°C, P = .02). Multivariable logistic regression analysis revealed the use of an esophageal temperature probe as the only independent predictor for the development of EDEL (odds ratio 16.7, P < .01)., Conclusion: The use of esophageal temperature probes in the setting of AF catheter ablation per se appears to be a risk factor for the development of EDEL., (Copyright © 2015 Heart Rhythm Society. Published by Elsevier Inc. All rights reserved.)

Purpose: To prospectively assess the safety and efficacy of a novel absorbable vascular closure device (ExoSeal) in patients undergoing cardiac catheterization with femoral access compared to the established collagen-based (Angio-Seal) and suture-mediated (ProGlide) closure devices., Methods: This prospective, observational, dual-center, non-randomized, non-blinded study enrolled 1013 patients (65.1 ± 11.8 years) undergoing cardiac catheterization via a common femoral artery access in which hemostasis was achieved using a vascular closure device (255 Angio-Seal, 258 ProGlide, and 500 ExoSeal). In hospital complications (bleeding, hematoma, pseudoaneurysm, vessel occlusion, dissection, and arteriovenous fistula) of the puncture site and device failures (persistent bleeding) were recorded and compared for ExoSeal vs. the established devices (Angio-Seal + ProGlide)., Results: There were more complications after utilization of ExoSeal compared to established devices (3.6% vs. 1.2%, p=0.012). No significant difference was observed in the device success rate between the established vascular closure devices (96.3%) and the novel device (94.8%, p=0.28). Considering each closure system, Angio-Seal had the lowest complication rate (0.4%) and the highest efficacy (99.2%); the latter differed significantly from ExoSeal (94.8%, p=0.001). Logistic regression analysis revealed a >3-fold odds of complications when using ExoSeal, which remained unchanged in multivariate analysis., Conclusion: Utilization of the novel vascular closure device is associated with a higher complication rate and a similar device failure rate compared to collagen-based and suture-mediated devices, with Angio-Seal having the lowest complication and device failure rates.

Catheter ablation has been shown to be an effective treatment for rhythm stabilization in patients with multiple ventricular arrhythmia episodes called electrical storm (ES). These procedures may be complex and are usually only performed in highly specialized and experienced centers. Still the optimum timing for catheter ablation in ES remains unclear.Early access to perform acute ablation should be considered in patients who are not rhythm stabilized with antiarrhythmic medical treatment. Also patients with hemodynamic compromise (cardiogenic shock) are candidates for an early interventional strategy. In specialized centers it is consensus to perform catheter ablation in these patients as early as eligible especially when considering a high early and late mortality without interventional management. Establishing a structured protocol for treatment and admission to EP centers has helped to further reduce pre-ablation mortality and may optimize treatment of ES. Large scale networking to optimize and structure access to experienced electrophysiology centers is of importance to create a basis for optimizing treatment strategies.

Background: The survival of in-hospital cardiac arrest (8-25%) has not changed substantially in the past. Until now, most hospitals in Germany had no standardized protocols available for a course of action in case of emergency, and there are no continuous registry data for in-hospital cardiac arrest and survival., Objective: Our aim was to improve survival and receive outcomes data, so we implemented a structured hospital-wide automated first-responder system in the hospital. Here our 5-year experience with 443 emergency calls is outlined., Methods: Throughout the hospital, 15 automated external defibrillator (AED) "access spots," which can be easily reached within 30 s, were identified. AEDs were then installed at these locations (Lifepak 500 and Lifepak 1000, Medtronic equipped with a Biolog 3000i portable ECG monitor). At the same time, a training program was initiated in which the employees of the hospital participated once a year. Participants learned how to apply and activate an AED in case of cardiac arrest even before the designated Cardiac Arrest Team arrived at the scene., Results: A witnessed cardiac arrest event was confirmed in 126 cases. In 56 of the 126 cases, the primary arrest rhythm was either ventricular tachycardia or ventricular fibrillation and the AED delivered a shock. In this group, spontaneous circulation was reached in 44 cases (79%) and 23 patients (41%) were discharged. In 44% (24 from 55 patients) of the cases, a shock was recommended by AED and delivered by the first responders before the rescue team arrived., Conclusions: The first-responder AED program successfully gave training lessons to the hospital staff. The training included how to initiate the cardiac arrest call, how to use the AED, and how to start immediate resuscitation. As a result, a higher survival rate after in-hospital cardiac arrest can be accomplished., (Copyright © 2013 Elsevier Inc. All rights reserved.)

Recently, moderate and severe postprocedure aortic regurgitations (ARs) have been identified as independent risk factors for short- and midterm mortality after transcatheter aortic valve implantation (TAVI). However, very few data exist on the long-term outcome of postprocedure AR. From 2008 to 2011, 198 consecutive patients with severe aortic stenosis successfully underwent TAVI with the CoreValve prosthesis (Medtronic CV, Minneapolis, Minnesota). After the procedure, patients were subdivided into groups depending on the presence of moderate/severe AR. The primary study end point was death from any cause after TAVI. The secondary end point was defined as cardiovascular death. In study patients (80 ± 6 years old, logistic European System for Cardiac Operative Risk Evaluation 22 ± 16%, left ventricular ejection fraction 53 ± 13%), moderate/severe AR occurred in 28 patients (14%). Despite similar baseline characteristics, patients with moderate/severe AR had higher 30-day and 1-year mortality rates than patients with none/mild AR (21% vs 6%, p = 0.019; 57% vs 16%, p <0.001, respectively). During a mean follow-up of 535 ± 333 days, the primary end point was reached in 54 and the secondary end point in 33 patients. Moderate/severe AR was the strongest independent risk factor of all-cause-mortality (hazard ratio 4.89, 95% confidence interval 2.78 to 8.56, p <0.001) and the strongest independent risk factor of cardiovascular mortality (hazard ratio 7.90, 95% confidence interval 3.95 to 15.81, p <0.001). In conclusion, moderate and severe postprocedure ARs are not uncommon complications after TAVI. Although long-term outcome of patients with none/mild AR is favorable, outcome of patients with moderate/severe AR is dismal., (Copyright © 2012 Elsevier Inc. All rights reserved.)

Aims: Implantable cardioverter-defibrillators (ICD) reduce mortality in patients with severely impaired left ventricular function. In randomized studies, female patients are underrepresented and data on ICD therapy is limited. Atrial fibrillation (AF) is a determinant of poor prognosis but has not been consistently evaluated. We evaluated the risk factors for the occurrence of ventricular arrhythmia episodes in patients with primary ICD prophylaxis., Methods: Consecutive patients after ICD implantation for primary prophylaxis were followed. During follow-up, detected sustained episodes of ventricular arrhythmia were documented. Multivariate analysis controlled for propensity score was used to evaluate the correlation between gender, history of AF, and the occurrence of ventricular arrhythmia episodes., Results: A total of 400 patients (19.8% female; n = 79) were included. During follow-up, 64 patients (16%) had appropriate ICD therapy episodes. Men (18%) had significantly more often episodes than women (8%; p = 0.025). Patients with a history of AF (102, 25.5%) had significantly more often episodes (30%) compared to patients without a history of AF (11%; p < 0.001). In a multivariate model, only gender (p = 0.02) and history of AF (p < 0.001) were significantly associated predictors of the occurrence of appropriate ICD therapies during follow-up. Based on the propensity score model, the adjusted hazard ratio for male gender was 2.7 (p = 0.02) and 2.6 (p = 0.0004) for history of AF., Conclusion: Male gender and history of AF are independent predictors for the occurrence of sustained ventricular arrhythmia in primary ICD prophylaxis. Further studies need to evaluate whether history of AF in female patients might be an indicator for higher risk of sudden cardiac arrhythmic death.

Background: Transcatheter aortic valve implantation (TAVI) has emerged as an alternative technique in patients with severe symptomatic aortic valve stenosis. However, a number of patients have no benefit after implantation. This prospective study attempted to identify predictors of poor treatment response., Methods: From June 2008 to September 2010, consecutive patients with symptomatic severe aortic valve stenosis and high surgical risk were submitted to TAVI with the CoreValve prosthesis (Medtronic, Minneapolis, MN). The primary end point was all-cause mortality at 6 months. Secondary end point (poor treatment response) was defined as no improvement of symptoms assessed with the New York Heart Association class 6 months after TAVI., Results: A total of 145 patients (mean age 79.1 ± 6.4 years, mean logistic EuroSCORE 21% ± 16.2%) were included. During the follow-up period, 23 (15.9%) patients died. Independent predictors of all-cause mortality were as follows: aortic mean gradient ≤40 mm Hg (odds ratio [OR] 3.93), moderate and severe tricuspid valve regurgitation (OR 4.50), and moderate and severe postprocedural aortic valve regurgitation (OR 4.26). In 122 surviving patients, 25 patients (20%) showed no improvement in symptoms. Independent predictors of poor treatment response were severe mitral valve regurgitation (OR 7.42) and moderate and severe postprocedural aortic valve regurgitation (OR 10.1)., Conclusions: Cardiac comorbidities (low-gradient aortic stenosis, tricuspidal valve regurgitation) are associated with all-cause mortality, whereas mitral valve regurgitation is a risk factor for poor treatment response after TAVI. Postprocedural aortic valve regurgitation is a strong predictor of both-mortality and poor treatment response., (Copyright © 2011 Mosby, Inc. All rights reserved.)

An electrical storm (ES) is defined as multiple ventricular arrhythmia episodes leading to implantable cardioverter defibrillator interventions. Although conventional rhythm stabilization might be of help acutely, ES involves high mortality and morbidity. We evaluated the effect of catheter ablation strategies in the setting of an interhospital collaborative network on the recurrence of ventricular arrhythmia episodes and mortality in patients with ES. Consecutive patients presenting for invasive treatment of ES from December 2007 to December 2009 were included. All patients underwent catheter ablation of ventricular arrhythmia. The strategies were adapted to the individual cardiac pathologic features. The follow-up examination constituted periodic implantable cardioverter defibrillator interrogation. A total of 32 patients were included. Of the 32 patients, 29 (91%) had monomorphic ventricular tachycardia and 3 ventricular fibrillation. The mean number of implantable cardioverter defibrillator-treated episodes within 7 days before ablation was 16 ± 11. Of the 32 patients, 27 underwent ablation within 24 hours after admission, and 5 underwent acute ablation within 8 hours. In 3 patients, epicardial ablation was performed. In all but 2 patients (6%), the clinical arrhythmia was successfully ablated. During a median follow-up of 15 months, 10 patients (31%) had recurrences of sustained ventricular arrhythmia, including 2 patients (6%) with recurrent ES. Three patients (9%) died during the follow-up period. In conclusion, catheter ablation effectively suppressed ventricular arrhythmia midterm recurrences in patients presenting with ES. Catheter ablation is complex in these severely sick patients. The recurrence rate of ventricular arrhythmia appears to be 31% and the mortality rate to be 9%. Collaborative hospital networks to increase the prompt availability of ES ablation might help to optimize the ES outcome., (Copyright © 2011 Elsevier Inc. All rights reserved.)

Background: Hypertensive urgency/emergency occurs frequently, yet no prospective data on common secondary causes, including sleep apnea (SA), renal artery stenosis (RAS), and hyperaldosteronism, are available., Methods: Patients presenting to the emergency room for over 1 year with systolic blood pressure > or =180 mmHg and/or diastolic blood pressure > or =100 mmHg and typical symptoms were included. RAS was diagnosed by direct duplex/Doppler ultrasound of the renal artery, resistance index, and imaging. The aldosterone/renin ratio (ARR) was determined from morning blood samples taken with the patients supine after > or =2 h of rest. A positive ARR (>50) was followed by saline infusion to exclude primary hyperaldosteronism. SA was evaluated by nasal breathing flow screening; when positive [apnea/hypopnea index (AHI) >5/h], complete polysomnography was performed., Results: Of 161 patients (age, 66.0 +/- 13.1 years; BMI, 28.6 +/- 5.1 kg), 131 had previously identified hypertension (duration, 12.7 +/- 11.5 years; 1.9 +/- 1.5 antihypertensive medications). SA was found in 114 (70.8%) patients [18% mild (AHI: 5-15/h), 26.8% moderate (15.1-30/h), and 24.2% severe (>30/h)]. Aldosterone levels exceeded 160 pg/ml in 22 of 23 patients with hyperaldosteronism; 4 had primary and 12 had secondary hyperaldosteronism. Thirteen (8.1%) patients had RAS. Three secondary causes were found in 1 patient (0.6%), > or =2 in 25 (15.5%), and > or =1 in 124 patients (77.0%). Of 150 detected secondary causes, only 5 were recognized previously., Conclusions: Secondary causes of hypertension are common and predominantly unrecognized in patients with hypertensive urgency/emergency. Co-prevalence of secondary causes occurs in about 15% and should be considered before therapeutic intervention.

Background and Purpose: Sudden cardiac arrest appears in 1-5 patients/ 1,000 clinical admissions. In spite of different research approaches, the prognosis after in-hospital resuscitation has not significantly improved in the last 40 years. This account presents the experiences with a hospital-wide emergency plan using the concept of defibrillation by first responders., Methods: In 2003, a hospital-wide emergency plan was implemented. The concept comprised the setup of 15 "defibrillator points", training of the entire hospital personnel as first responder, and the introduction of an emergency team. Over the following 3 years, the concept was optimized. In a period from May 2006 to April 2008, the data of all patients who received an in-hospital resuscitation were collected., Results: Within 24 months, a total of 41 resuscitations were conducted. Out of these, 24 patients (58%) were under intensive monitoring when the event occurred. Initially, 15 patients (36%) showed ventricular fibrillation, 15 (36%) a pulseless electrical activity, and eleven (27%) an asystoly. A total of twelve patients (29%) left hospital alive. About half of them (42%) experienced ventricular fibrillation and were under observation at the time of event., Conclusion: The data collected since the implementation of the hospital- wide emergency plan in 2003 reflect the daily clinical routine. The results show that there is a better outcome especially in patients with ventricular fibrillation when receiving first-responder defibrillation.

Purpose: To evaluate the usefulness of serial compression B-scan and Doppler sonography (US) in screening for deep venous thrombosis (DVT) of the lower extremities in patients with spinal cord injuries., Method: Patients with paraplegia and tetraplegia due to spinal cord injuries were screened by a serial compression B-scan and Doppler US protocol for DVT of the bilateral lower extremities within the first 36 hours after admission, at day 7 and at day 21. In patients with DVT, a follow-up US examination was performed 3 weeks after diagnosis to assess thrombi distribution., Results: Between January 2007 and March 2008, a total of 115 patients (75 males, 40 females), aged 19 to 85 years, were included. The first US examination documented a DVT in 44 cases (38.3%). After an initial negative scan, sonography after 7 days and 21 days showed DVT in 6 patients and 2 patients, respectively. Cumulative rate of DVT after the first 3 weeks was 45.2% (n=52). Follow-up US after 3 weeks in patients with DVT documented a complete recanalization in 19 patients (36.5%), no change in 12 patients (23.1%), and residual thrombi with partial recanalization in 21 patients (40.4%)., Conclusion: Our study supports the use of serial compression B-scan and Doppler US as a screening tool for DVT of the lower extremities in patients with spinal cord injuries early after injury., ((c) 2009 Wiley Periodicals, Inc. J Clin Ultrasound, 2010.)

Purpose: Is onset of symptoms in AV nodal re-entrant tachycardia (AVNRT) and accessory pathway-mediated re-entrant tachycardia (AVRT) patients gender-specific?, Methods: Intra- and inter-gender differences in onset of symptoms and mechanism of supraventricular tachycardia in adult patients undergoing catheter ablation for AVNRT or AVRT (N=230) were documented., Results: Women with AVNRT were significantly younger at onset of symptoms compared to men (38+/-18, 51+/-18 years, p=0.01). Male AVNRT patients were significantly older at onset of symptoms compared to male AVRT patients (51+/-18, 25+/-11 years, p=0.04) but there was no difference in women. Symptoms beginning <30 years in men predicted AVRT in 73%, and beginning >or=30 years the predominant mechanism was AVNRT (85%). In women AVNRT was the most likely mechanism independent of symptom onset (>75%)., Conclusions: Symptoms beginning in patients with AVNRT and AVRT prior to age 30 correlates with a 70% incidence of AVRT in men and a 80% incidence of AVNRT in women. Onset of palpitations >or= age 30 relates to AVNRT in 85% of patients.

Background: Cytochrome P450 (CYP) enzyme 2J2, an epoxygenase predominantly expressed in the heart, metabolizes arachidonic acid to biologically active eicosanoids. One of the CYP2J2 products, 11, 12-epoxyeicosatrienoic acid, has several vasoprotective effects. The CYP2J2-G-50T-promotor polymorphism decreases gene expression and is associated with coronary artery disease. This association supports the vascular protective role of CYP-derived eicosanoids in cardiovascular disease. In the present study, we investigated the influence of this polymorphism on survived myocardial infarction in two study groups of patients with on average high cardiovascular risk profile., Methods: The CYP2J2 polymorphism was genotyped in two groups of patients that were collected with the same method of clinical data collection. Data from 512 patients with sleep apnoea (group: OSA) and on average high cardiovascular risk profile and from another 488 patients who were admitted for coronary angiography (CAR-group) were evaluated for a potential correlation of the CYP2J2 polymorphism G-50T and a history of myocardial infarction. The G-50T polymorphism of the CYP2J2 gene was genotyped by allele specific restriction and light cycler analysis., Results: The T-allele of the polymorphism was found in 111 (11.1%; CAR-group: N = 65, 13.3%; OSA: N = 46, 9.0%). 146 patients had a history of myocardial infarction (CAR: N = 120, 24.6%; OSA: N = 26, 5.1%). Cardiovascular risk factors were equally distributed between the different genotypes of the CYP2J2 G-50T polymorphism. In the total group of 1000 individuals, carriers of the T-allele had significantly more myocardial infarctions compared to carriers of the wild type (T/T or G/T: 21.6%; G/G: 13.7%; p = 0.026, odds ratio 1.73, 95%-CI [1.06-2.83]). In the multivariate logistic regression analysis the odds ratio for a history of myocardial infarction in carriers of the T-allele was 1.611, 95%-CI [0.957-2.731] but this trend was not significant (p = 0.073)., Conclusion: In presence of other risk factors, the CYP2J2 G-50T failed to show a significant role in the development of myocardial infarction. However, since our result is close to the border of significance, this question should be clarified in larger, prospective studies in the future.

Background: Blunt thoracic trauma may lead to cardiac lesions including cardiac valve dysfunctions. In these cases, mitral valve is quite often involved. Preexisting mitral valve disease, especially the prolapse syndrome, has to be differentiated from trauma-induced dysfunction. This differentiation may be important for delivering an official legal medical opinion., Case Report and Review of the Literature: The authors report on a patient, presenting with acute severe mitral valve insufficiency 4 months after blunt chest trauma due to a motor vehicle accident. After a review of the literature concepts to differentiate trauma-induced mitral valve dysfunction from preexisting valve disease are discussed in special consideration of aspects of official legal medical opinions., Conclusion: To get complete information on the initial cardiac status at the time of chest trauma, detailed echocardiographic evaluation is necessary independent of the severity or mechanism of trauma. If valve surgery is required, macroscopic valve description and microscopic diagnosis are important to clarify the etiology of valve dysfunction. This diagnostic evaluation allows to assess the causality between trauma and valve dysfunction in most of the cases.

Background and Purpose: The most important goals in the rehabilitation of patients with a coronary heart disease (CHD) include the diagnosis and treatment of risk factors, health promotion, and education. The knowledge on and awareness of cardiovascular risk factors is an important precondition for a high patient compliance. Former studies on patients in cardiologic departments of hospitals showed no effect of health promotion and education on patients' knowledge on risk factors, presumably because of the setting in acute therapy. Therefore, the possible effects of health promotion and education on the knowledge of patients were studied in the setting of an inpatient rehabilitation., Methods: Over 1 year, 426 patients, admitted to an inhospital rehabilitation, were questioned on the first and last day of their stay using a validated instrument ("Bochumer Bewertungsbogen-Kardiovaskuläre Risikofaktoren" [BBKR], Table 1). 1 year after discharge, the same questionnaire was sent to the surviving 423 patients. Of these, 267 patients (63.1%) answered. The average age was 64.3 years (standard deviation [SD] 11.3). Demographic data and clinical history are summarized in Table 2., Results: For most of the known risk factors of CHD, the number of patients mentioning them significantly increased during the observation period. On the day of admittance, only 59.2% mentioned diabetes mellitus as a risk factor compared to 74.6% 1 year after discharge. Especially patients with a CHD improved their knowledge on their disease (Figure 1). Education and number of rehabilitations in the past had an influence on the knowledge of interviewed patients on the day of admittance. Especially elderly patients had an increase in knowledge, indicated by a higher score in the questionnaire (Table 3). Participation in patients' self-help meetings within the observation time had no influence on the knowledge. Patients with known hypertension or hyperlipoproteinemia and overweight patients could increase knowledge on the cardiovascular risk of their disease (Figure 2)., Conclusion: The results of this query document the lack of knowledge on cardiovascular risk factors of patients before rehabilitation. Especially the results of patients with a diagnosed (and treated) CHD after an inpatient stay in an acute hospital in the past were surprising. The stationary rehabilitation is an appropriate measure to improve this knowledge. It can be used for secondary prevention. The raise in knowledge was evident 1 year after discharge; a long-term effect of health education during stationary rehabilitation is likely.

The first year experience with a hospital-wide first-responder automated external defibrillator (AED) programme implemented in a 683-bed University Hospital is reported. Throughout the hospital, 14 "AED access spots" were identified which could be easily reached from all wards and diagnostic rooms within 30s. AEDs were installed (Lifepak 500; Medtronik PhysioControl Corp., Redmond, USA, equipped with a Biolog 3000i portable ECG monitor; Micromedical Industries Ltd., Labrador, Australia). Within 3 months, 120 medical officers, 750 nurses, and 50 administrative or technical staff underwent a 2h training programme. An AED was applied and activated by nurses/medical staff before the cardiac arrest team arrived in 27 of 33 cases (81.8%) of witnessed cardiac arrest. The median time from onset of the emergency call to the activation of the AED (record of ECG) was on average 2.1 min (range 1.0--4.5 min). In 18 of 27 cases in which the AED was installed promptly, the primary arrest rhythm was either VT or VF, and the AED delivered a shock. For this subgroup, the rate of return of spontaneous circulation and the rate of discharge at home were 88.9 and 55.6%, respectively. This encourages us to extend the concept of first-responder AED-defibrillation throughout our hospital.

Microbe-induced (infectious) endocarditis is an endovascular infection, caused mainly by bacteria, of cardiovascular structures. The major predilection site are the native heart valves, but involvement of implanted intracardiac foreign material is increasingly being seen. The mortality rate of infectious endocarditis depends on clinical factors and the causal agent, but also on the time of the establishment of the diagnosis and the initiation of appropriate treatment. In Germany, the current mortality rate ranges up to 18%. Between January 2003 and July 2004, with the aim of improving patient care and thus the outcome of this condition, a guideline commission worked out recommendations for the diagnosis, treatment and management of the disease for the use of general practitioners and hospital physicians, in particular microbiologists, infectiologists, cardiologists and cardiac surgeons. The basis for this guideline was the systematic search through the literature of the European guideline. On the 16th and 28th of June 2004, the entire guideline was formerly approved in a nominal group process.

Background: There is increasing evidence that obstructive sleep apnea is an independent risk factor for arterial hypertension. Previous studies on the antihypertensive effects of positive airway pressure therapy on daytime blood pressure (BP) revealed inconsistent results., Methods: The relations between the apnea/hypopnea index (AHI) and BP or heart rate (HR) were investigated in a cohort of 540 consecutive patients (age, 55.4 +/-11.1 years) with moderate or severe obstructive sleep apnea (OSA). The mean AHI was 28.2 +/- 22.0 events/h before OSA therapy. A group of 196 patients in whom antihypertensive medication was kept unchanged was followed for 6 months during bilevel or continuous positive airway pressure (Bi-/CPAP) therapy., Results: Significant associations were found between AHI and systolic BP (beta = 0.078, P = .014), diastolic BP (beta = 0.056, P = .003), HR (beta = 0.096, P < .001), and the prevalence of arterial hypertension (odds ratio = 0.015, P = .003), independent of age, body mass index, and gender. During the follow-up period with effective Bi-/CPAP therapy, the mean daytime systolic BP decreased from 130.7 +/- 15.5 mm Hg to 128.6 +/- 15.9 mm Hg (P = .051), diastolic BP from 80.2 +/- 9.3 mm Hg to 77.5 +/- 9.5 mm Hg (P = .001), and HR from 77.7 +/- 8.8 to 75.7 +/- 8.1 beats/min (P = .001). Multiple linear regression analysis revealed that the absence of antihypertensive drugs and the level of the initial BP are significant and independent predictors for the lowering effect of Bi-/CPAP therapy on systolic and diastolic BP., Conclusions: This study confirms an independent relationship between the severity of OSA and BP/HR. Absence of BP-lowering medication and BP values before treatment are independent predictors for the reduction of BP with Bi-/CPAP therapy.

Background: Cytochrome P450 (CYP) 2J2 is expressed in the vascular endothelium and metabolizes arachidonic acid to biologically active epoxyeicosatrienoic acids (EETs). The EETs are potent endogenous vasodilators and inhibitors of vascular inflammation. However, it is not known whether genetic polymorphisms of CYP2J2 are associated with increased cardiovascular risks., Methods and Results: All 9 exons of the CYP2J2 gene and its proximal promoter were sequenced in 132 patients to identify potential variants. Functional consequence of a single nucleotide polymorphism (SNP) in the promoter of CYP2J2 was further evaluated by use of transcription factor-binding and reporter assays. A total of 17 polymorphisms were identified. One of the most relevant polymorphisms in terms of frequency and functional importance is located at -50 (G-50T) in the proximal promoter of CYP2J2. Screening of 289 patients with coronary artery disease and 255 control subjects revealed 77 individuals with the G-50T SNP (17.3% of coronary artery disease patients, 10.6% of control subjects; P=0.026). The association of the G-50T polymorphism remained significant after adjustment for age, gender, and conventional cardiovascular risk factors (OR, 2.23; 95% CI, 1.04 to 4.79). The G-50T mutation resulted in the loss of binding of the Sp1 transcription factor to the CYP2J2 promoter and resulted in a 48.1+/-2.4% decrease in CYP2J2 promoter activity (P<0.01). Plasma concentrations of stable EET metabolites were significantly lower in individuals with the G-50T SNP., Conclusions: A functionally relevant polymorphism of the CYP2J2 gene is independently associated with an increased risk of coronary artery disease.

Background and Purpose: Next to noninvasive-recently also invasive-diagnostics, ambulant care in patients with coronary heart disease (CHD) should focus on optimal medication and prevention. The aim of this study was to evaluate actual health care quality concerning drug prescription and preventive care in patients with CHD., Patients and Methods: This prospective study was conducted from March 1999 to February 2002 at the University Hospital Bergmannsheil, Bochum, Germany. 300 patients admitted with a suspected CHD and without previous coronary angiography or myocardial infarction were enrolled. Diagnostic and therapeutic regimen complied with actual guidelines. 248 patients (82.7%) including 116 patients with angiographically confirmed CHD were examined after 1 year., Results: On follow-up, only 70.9% of patients with confirmed CHD received a beta-blocker, 83.6% were treated with platelet aggregation inhibitors. Body mass index, portion of overweight patients, and HbA(1c) in patients with diabetes did not change during observation. After 1 year, 48.0% of the subjects had a systolic blood pressure > 139 mmHg, in 22.6% diastolic pressure level was > 89 mmHg. Blood level of low-density cholesterol exceeded the recommended range in 57.0% of the cases observed with equally high portion of inadequately treated patients in the group with confirmed CHD and in the group without CHD., Conclusion: Drug therapy, primary and secondary prevention in the observed subjects were fairly poor. Remarkable deficits in health care quality became obvious. There is no lack in availability of evaluated, effective and efficient measures. Thus, physicians' efforts to implement evidence-based guidelines into clinical practice have to be strengthened.