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Background Traditional access for the treatment of below-the-knee (BTK) lesions is the femoral approach, but in failed anterograde cases transpedal access can be utilized. The aim of the study was to evaluate the safety and technical and clinical success of endovascular BTK artery revascularization by a primarly retrograde transpedal access. Methods The clinical and angiographic data of 115 consecutive patients treated via transpedal access with symptomatic BTK stenosis were evaluated two cardiovascular centers (Europe and USA). We have selected patients with good distal run-off and non-infected distal puncture zone. The distal pedal artery was punctured by ultrasound guidance, and the procedural guidance was done by transpedal (TPA) or transradial angiography (TRA). Distal pressure at the end of the pedal sheath was also measured before and after the intervention. The primary endpoint was a composite of procedural success, major adverse events, and rate of access site complications. Secondary endpoints were: angiographic result of BTK intervention, fluoroscopy time, X-ray dose, procedure length, cross over rate to another puncture site and duration of hospitalization. Results The indication of the intervention was critical limb ischemia in all patients. Overall technical success was achieved in 99.1% of the patients at least in one BTK artery. The distal puncture was successful in 114/115 patients 99.1% of the patients and the access site was anterior tibial artery in 96 patients (83.55), posterior tibial artery in 15 patients (13%) and peroneal artery in 4 patients (3.5%). Pedal to femoral access site cross over was 0.5%. Control angiography was done in 73 patients (63.5%) from radial and in 42 patients (36.5%) from transpedal access. The average contrast, procedure and fluoroscopy time was 109.9 [97–123]vs 31.4 [27–35]ml (p Conclusion Below-the-knee artery angioplasty can be safely and effectively performed using radial and transpedal access in selective patient population.

Aims The aim of our study was to demonstrate the feasibility and safety of the distal transradial approach (DTRA) for carotid artery stenting (CAS). Methods and results We included 209 consecutive patients (151 Trans-Radial Access (TRA) and 58 DTRA) treated in a single center by CAS with cerebral protection between 2016 and 2018. DTRA punctures were performed by ultrasound guidance, and the carotid artery cannulations were done using a 6.5 F coronary sheathless guiding catheter. The groups showed similar demographic profile regarding age, gender and comorbidities, however the proportion of symptomatic patients was significantly higher in the DTRA cohort (DTRA: 75,86% vs. TRA: 46.36% p Conclusion DTRA is a safe and effective alternative of conventional trans-radial approach for CAS, with a potential to further improve the patient comfort.

WHAT THIS PAPER ADDS Minimally invasive interventional procedures tend to be even less invasive. In this spirit, 4F sheath compatible femoropopliteal stents have been developed. The number of studies regarding the safety, clinical outcome, and fracture rate of 4F stents is limited. Access site complications occurred in 2% of the patients.The overall primary patency rate was 80% with 85% freedom from target lesion revascularization at 12 months. The incidence of stent fractures was 26% after an average follow up of 25 months. These results confirm the validity of 4F stents in patients with femoropopliteal occlusive disease. Objective: To determine the safety, clinical outcome, and fracture rate of femoropopliteal interventions using 4F stents. Methods: Between January 2010 and December 2011, 112 symptomatic patients were treated by stent implantation. Ten patients were lost to follow up; therefore, 102 patients (62 men; mean age 66.4 � 10.1 years) were retrospectively analyzed. The indication for femoropopliteal revascularization was severe claudication (RutherfordeBecker score ¼ 3) in 63 (62%) patients and chronic critical limb ischemia (RutherfordeBecker score ¼ 4e6) in 39 (38%). Follow up included palpation of peripheral pulses and measurement of ankle brachial index. In patients with suspected in-stent restenosis duplex ultrasonography was performed. In 2013, patients were asked to return for a fluoroscopic examination of the stents. Results: 114 lesions (Trans-Atlantic InterSociety Consensus-C and D, n ¼ 45) were treated with 119 stents (Astron Pulsar, n ¼ 42; Pulsar-18, n ¼ 77). Lesions were long (� 100 mm) in 49 cases and heavily calcified in 35. Stents were long (� 120 mm) in 46 cases. Ten stents were partially overlapped. The technical and clinical success rates were 100%. Two puncture related complications were noted, neither of which required surgical repair. Eleven patients died (myocardial infarction, n ¼ 4; stroke, n ¼ 2; cancer, n ¼ 5) and nine patients underwent major amputation (above knee, n ¼ 4). The primary patency rate was 83% at 6 months and 80% at 12 months. The primary assisted patency rate was 97% at 6 months and 94% at 12 months. The secondary patency rate was 86% at 6 months and 85% at 12 months. The prevalence of fractures was 26% (type III and IV, 10%) after an average follow up of 25 months. Conclusion: Femoropopliteal stenting using a 4F compatible delivery system can be accomplished with a low complication rate, acceptable fracture rate, and with similar 12 month patency and revascularization rates as

Background After catheter ablation there is often a discrepancy between acute and chronic success rates. We aimed to evaluate major determinants for lesion quality and understand different manifestations of lesion structures. Methods In a canine thigh muscle model radiofrequency (RF) current was delivered for 60 seconds at 30 W (n = 39) or 50 W (n = 18) with 15-g contact force. A second-generation 12-hole gold open irrigation catheter (SGIT) and a first-generation six-hole platinum-iridium catheter (FGIT; Biotronik, Berlin, Germany) were used. Electrode and tissue temperatures (at the surface and 3.5-mm and 7-mm depth) were recorded and lesion dimensions were measured. Lesions with steam pops were excluded. Histological examination was performed to evaluate homogeneity of the lesions. Inhomogeneity was defined as a visual multiband lesion pattern indicating different histological characteristics. Results In total 57 lesions were created. Seventeen lesions were excluded (steam pops) and 40 lesions were analyzed. A total number of 11 homogeneous and 29 inhomogeneous lesions were identified. Using the SGIT catheter 16.7% of the lesions was homogeneous and 83.3% inhomogeneous; for FGIT it was 43.8% and 56.2% (P = 0.065), respectively. Homogeneous lesions had lower volumes as compared to inhomogeneous lesions (514.0 ± 198.8 vs 914.8 ± 399.1 mm, P = 0.003). Multiple logistic regression analysis indicated that the SGIT catheter is a significant predictor for inhomogeneous lesions (odds ratio 6.5, 95% confidence interval 1.1–38.8; P = 0.040) independent from power setting and flow rate. Conclusions The development of inhomogeneous lesions after acute RF ablation is associated with higher lesion volumes and the use of the second-generation irrigation gold-tip catheter.

BACKGROUND: High irrigation rates during radiofrequency (RF) ablation may cause fluid overload and limit lesion size. This in vivo animal study assessed the safety and efficacy of RF ablation at low irrigation rates using a novel 12-hole gold catheter. METHODS: A total of 103 lesions, created on the thigh of five mongrel dogs, were analyzed. Lesions were created using a 12-hole irrigated gold-tip (Au) and a six-hole irrigated platinum-iridium (PtIr) catheter (both 7F/3.5-mm electrode; BIOTRONIK SE & CO, KG, Berlin, Germany) in parallel and perpendicular orientation. RF current was delivered for 60 seconds at 30 W using 8 mL/min and 15 mL/min irrigation. Electrode temperature, steam pops, lesion dimensions, and coagulum formation were recorded. RESULTS: Electrode temperatures were lower for Au compared to PtIr in parallel (8 mL/min: 38.1 +/- 1.7 degrees C vs 48.0 +/- 4.8 degrees C, P < 0.0001; 15 mL/min: 36.0 +/- 1.5 degrees C vs 46.9 +/- 5.4 degrees C, P < 0.0001) and perpendicular position (15 mL/min: 35.5 +/- 1.2 degrees C vs 38.4 +/- 2.5 degrees C, P = 0.003). The number of steam pops between Au and PtIr was comparable for parallel (8 mL/min: 14% vs 27%, P = 0.65; 15 mL/min: 14% vs 43%, P = 0.21) and perpendicular orientation (8 mL/min: 25% vs 17%, P = 1.00; 15 mL/min: 18% vs 0%, P = 0.48). Au created larger volumes than PtIr at 8 mL/min irrigation (861 +/- 251 mm3 vs 504 +/- 212 mm3 , P = 0.004); however, for 15 mL/min, volumes were comparable (624 +/- 269 mm3 vs 768 +/- 466 mm3 , P = 0.46). No coagulum formation was observed for any of the catheters on the surface and catheter tip. CONCLUSION: RF ablation at low flow rate using a novel 12-hole irrigation Au catheter is safe and results in larger lesions than with a PtIr electrode.

Context: Assessment of response to cardiac resynchronization therapy (CRT) is essential.Objective: To assess the predictive value of CT-apelin together with NT-proBNP in patients undergoing CRT.Methods: Serum CT-apelin and NT-proBNP were measured by ELISA before, and six months after CRT. Primary endpoint was non-response (

Objective We describe a method to stabilize CS lead position using stent implantation in a CS side branch to anchor the electrode to the wall of the vein, in cases of intraoperative or postoperative lead dislocation, unstable lead position and phrenic nerve stimulation (PNS). Methods 403 patients were treated with stenting. After finding the desired lead position bare metal coronary stent was introduced via another guide wire, but in the same CS sheath. The stent was deposited 5–35 mm proximal to the tip of the electrode with a pressure of 6 to 14 atmospheres. Results Mechanical damage of the CS side branch or pericardial effusion was not observed. During follow-up (median 39, 23–48, max. 82 months) re-operation was necessary in only two patients because of high pacing threshold, while repositioning with ablation catheter was performed in 7 cases because of PNS. Impedance measurements did not suggest lead insulation failure. Transvenous extraction of stented CS leads was successful after 3, 18 and 49 months, while 4 leads were extracted easily during heart transplantation. Conclusion Stent implantation to stabilize CS lead position seems to be effective and safe for the prevention and treatment of CS lead dislocation in special cases.

Molecular chaperones play key roles in protein quality control, signal transduction, proliferation, and cell death, and confer cytoprotection and assure survival after environmental stress. The heat-shock response is implicated in a variety of conditions including ischemic diseases, infection and immunity, neurodegeneration, and aging. Physiologic and pharmacologic chaperone inducers were shown to be an efficient therapeutic approach in different acute and chronic diseases. Here we characterize resveratrol, a polyphenol from red wine, as an inducer of the heat-shock response. Resveratrol activated the heat-shock promoter and the expression of the major chaperone Hsp70 in cell lines and in human peripheral lymphocytes, comparable to moderate heat stress. This effect was not due to its antioxidant property, because 5 mM N-acetylcysteine was unable to activate the heat-shock response. Moreover, resveratrol failed to upregulate Grp78, and tunicamycin was unable to induce Hsp70, suggesting that the resveratrol-induced heat-shock response was not mediated by canonic endoplasmic reticulum stress. Resveratrol synergized with mild to moderate heat shock and conferred cytoprotection against severe heat stress. Our results reveal resveratrol as a chaperone inducer that may contribute to its pleiotropic effects in ameliorating stress and promoting longevity.

Chronic heart failure patients with a left ventricular (LV) conduction delay, mostly due to left bundle branch block (LBBB), generally derive benefit from cardiac resynchronization therapy (CRT). However, 30-50% of patients do not show a clear response to CRT. We investigated whether T-wave analysis of the ECG can improve patient selection.The study population comprised 244 CRT recipients with baseline 12-lead electrocardiogram recordings. Echocardiographic response after 6-month CRT was defined as a ≥5% increase in LV ejection fraction (LVEF). Vectorcardiograms (VCGs) were constructed from the measured 12-lead ECGs using an adapted Kors algorithm on digitized ECGs. Logistic regression models indicated repolarization variables as good predictors of CRT response. The VCG-derived T-wave area predicted CRT response (odds ratio [OR] per 10 μVs increase 1.172 [P0.001]) even better than QRS-wave area (OR = 1.116 [P = 0.001]). T-wave area had especially predictive value in the LBBB patient group (OR = 2.77 in LBBB vs. 1.09 in non-LBBB). This predictive value persisted after adjustment of multiple covariates, such as gender, ischemia, age, hypertension, coronary artery bypass graft, and the usage of diuretics and β-blockers. In LBBB patients, the increase in LVEF was 6.1 ± 9.7% and 11.3 ± 9.1% in patients with T-wave area below and above the median value, respectively (P0.01).In patients with LBBB morphology of the QRS complex, a larger baseline T-wave area is an important independent predictor of LVEF increase following CRT.

After catheter ablation there is often a discrepancy between acute and chronic success rates. We aimed to evaluate major determinants for lesion quality and understand different manifestations of lesion structures.In a canine thigh muscle model radiofrequency (RF) current was delivered for 60 seconds at 30 W (n = 39) or 50 W (n = 18) with 15-g contact force. A second-generation 12-hole gold open irrigation catheter (SGIT) and a first-generation six-hole platinum-iridium catheter (FGIT; Biotronik, Berlin, Germany) were used. Electrode and tissue temperatures (at the surface and 3.5-mm and 7-mm depth) were recorded and lesion dimensions were measured. Lesions with steam pops were excluded. Histological examination was performed to evaluate homogeneity of the lesions. Inhomogeneity was defined as a visual multiband lesion pattern indicating different histological characteristics.In total 57 lesions were created. Seventeen lesions were excluded (steam pops) and 40 lesions were analyzed. A total number of 11 homogeneous and 29 inhomogeneous lesions were identified. Using the SGIT catheter 16.7% of the lesions was homogeneous and 83.3% inhomogeneous; for FGIT it was 43.8% and 56.2% (P = 0.065), respectively. Homogeneous lesions had lower volumes as compared to inhomogeneous lesions (514.0 ± 198.8 vs 914.8 ± 399.1 mm, P = 0.003). Multiple logistic regression analysis indicated that the SGIT catheter is a significant predictor for inhomogeneous lesions (odds ratio 6.5, 95% confidence interval 1.1-38.8; P = 0.040) independent from power setting and flow rate.The development of inhomogeneous lesions after acute RF ablation is associated with higher lesion volumes and the use of the second-generation irrigation gold-tip catheter.

High irrigation rates during radiofrequency (RF) ablation may cause fluid overload and limit lesion size. This in vivo animal study assessed the safety and efficacy of RF ablation at low irrigation rates using a novel 12-hole gold catheter.A total of 103 lesions, created on the thigh of five mongrel dogs, were analyzed. Lesions were created using a 12-hole irrigated gold-tip (Au) and a six-hole irrigated platinum-iridium (PtIr) catheter (both 7F/3.5-mm electrode; BIOTRONIK SECO, KG, Berlin, Germany) in parallel and perpendicular orientation. RF current was delivered for 60 seconds at 30 W using 8 mL/min and 15 mL/min irrigation. Electrode temperature, steam pops, lesion dimensions, and coagulum formation were recorded.Electrode temperatures were lower for Au compared to PtIr in parallel (8 mL/min: 38.1 ± 1.7°C vs 48.0 ± 4.8°C, P0.0001; 15 mL/min: 36.0 ± 1.5°C vs 46.9 ± 5.4°C, P0.0001) and perpendicular position (15 mL/min: 35.5 ± 1.2°C vs 38.4 ± 2.5°C, P = 0.003). The number of steam pops between Au and PtIr was comparable for parallel (8 mL/min: 14% vs 27%, P = 0.65; 15 mL/min: 14% vs 43%, P = 0.21) and perpendicular orientation (8 mL/min: 25% vs 17%, P = 1.00; 15 mL/min: 18% vs 0%, P = 0.48). Au created larger volumes than PtIr at 8 mL/min irrigation (861 ± 251 mm(3) vs 504 ± 212 mm(3) , P = 0.004); however, for 15 mL/min, volumes were comparable (624 ± 269 mm(3) vs 768 ± 466 mm(3) , P = 0.46). No coagulum formation was observed for any of the catheters on the surface and catheter tip.RF ablation at low flow rate using a novel 12-hole irrigation Au catheter is safe and results in larger lesions than with a PtIr electrode.

A 29-year-old male was admitted to our outpatient clinic because of palpitation and documented narrow QRS arrhythmia. Based on the ECG, supraventricular tachycardia was diagnosed, electrophysiological examination was indicated and ablation therapy was recommended. During positioning of the catheter the patient developed arrhythmia. On the coronary sinus catheter the activation spread from distal to proximal electrodes, suggesting left atrial origin. During atrial entrainment pacing long return cycle was observed and distal coronary sinus pacing resulted in a 15 ms longer cycle length than the arrhythmia. Therefore, the left atrial origin of the arrhythmia was confirmed and double transseptal puncture was performed. Lasso and irrigated tip catheter were introduced into the left atrium and electroanatomical mapping was performed with CARTO3 system. After electroanatomical mapping the origin of tachycardia was located proximally in the left superior pulmonary vein. Ablation was started at the earliest activation point, where acceleration was observed and the arrhythmia stopped after the first ablation. Pulmonary vein isolation was completed, and bidirectional block could be confirmed. After 30 minutes the arrhythmia was not inducible. During follow-up, Holter-examination was negative and the patient remained asymptomatic. The pulmonary vein tachycardia is a supraventricular arrhythmia that can occur at any age, but the diagnosis based on the ECG is not always simple. Detailed electroanatomical mapping is very important in the diagnosis of this type of arrhythmia, although it can be verified with conventional electrophysiological methods as well. Focal ablation may be a therapeutic option; however, total isolation of pulmonary veins can be more effective. Orv. Hetil., 2011, 152, 1374–1378.

Molecular chaperones (heat shock proteins) are important components of cellular networks, such as protein–protein and gene regulatory networks. Chaperones participate in the folding of immunologically important proteins, presentation of antigens and activation of the immune system. Here, we propose that chaperone-related immune dysfunction might be more general than was previously thought. Mutations and polymorphism of chaperones and the regulators of their synthesis, heat shock factor-1, chaperone diseases, sick chaperones and chaperone overload might all affect (mostly impairing) immune responses.

Purpose: Previous studies on open irrigation radiofrequency (RF) ablation catheters focused on created lesion volumes, and did not evaluate lesion quality. The aim of this study was to evaluate the effect of different irrigation levels on lesion quality and volume. Methods: A canine thigh model was used. A skin incision was made and a cradle was created and filled with blood (37 °C, 250 ml/min). The ablation catheter was positioned parallel or perpendicular to the muscle surface using a constant force of 10 g. RF lesions were created using a gold tip electrode catheter with 12 irrigation holes and a PtIr catheter with 6 irrigation holes (Biotronik, Berlin, Germany). Both catheters were 7F and had a 3.5 mm electrode tip. RF current was delivered for 60 s at either 50 W (n=18) or 30 W (n=39). Temperature probes were inserted immediately below the surface and at 3.5 and 7 mm depth. Histological examination was performed to evaluate lesion size as well as the homogeneity of the RF lesions. Inhomogeneity was defined as a visual observed multi-band lesion pattern indicating different histological characteristics. Electrode temperature and lesion dimensions were measured. Results: Data of 57 lesions, created in a mongrel dog model, were analyzed. A total number of 47 inhomogeneous and 10 homogeneous lesions were detected. Inhomogeneous lesions were deeper (7.5±1.4 vs. 6.3±2.1 mm, p=0.036), however lesion volume was comparable between the two groups (652±487 vs. 834±396, p=0.249). Lesions with inhomogeneous histological characteristics had lower maximum electrode temperatures during ablation (42.9±6.6 vs. 48.2±8.6 °C, p=0.049). The mean temperatures at 3,5 and 7 mm below the muscle surface were lower for inhomogeneous lesions (41.2±8.1 vs. 50.2±21.4 °C, p=0.035; 38.7±4.0 vs. 45.2±19.0 °C, p=0.034). Inhomogeneity of the lesion was not associated with catheter type (p=0.164), orientation (p=0.185), amount of saline infusion (p=0.305) and power output (p=0.213). Conclusions: Our data suggest that lower catheter tip and tissue temperatures are associated with the development of inhomogeneous acute RF lesion formation. The presence of inhomogeneous RF lesions can theoretically be responsible for the differences between acute and chronic ablation success rates.

Recently transradial (TR) approach became a safe and effective alternative of percutaneous carotid intervention (CI). We report the learning curve over 5 years in two high-volume interventional centers during the transition from transfemoral (TF) to transradial approach. Between 2010 and 2014, 1541