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The prevalence of aortic valve stenosis is increasing due to the continuously growing geriatric population. Data on procedural success and mortality of very old patients are sparse, raising the question of when this population may be deemed as "too old even for transcatheter aortic valve replacement (TAVR)." We, therefore, sought to evaluate the influence of age on outcome after TAVR and the impact of direct implantation.The data of 394 consecutive patients undergoing TF-TAVR were analyzed. Patients were divided into four age groups: ≤75 (group 1, n = 28), 76-80 (group 2, n = 107), 81-85 (group 3, n = 148), and85 (group 4, n = 111) years. Direct implantation was performed when possible according to current recommendations. Survival was evaluated by Kaplan-Meier analysis.Mortality at 30 days and 1 year was not significantly different between the four age groups (3.6 vs. 6.7 vs. 5.4 vs. 2.7% and 7.6 vs. 17 vs. 14.5 vs. 13%m respectively, log-rank p = 0.59). Direct implantation without balloon aortic valvuloplasty was more frequently performed on patients aged85 vs. ≤85 years (33.3 vs. 14.1%, p 0.001). the incidence of procedural complications frequently associated with advanced age (stroke, vascular complications) was not significantly increased in group 4.Outcome after TF-TAVR is comparable among different age cohorts, even in very old patients. Direct implantation simplifies the procedure and could therefore play a role in reducing the incidence of peri-interventional complications in patients of advanced age.HINTERGRUND: Die Prävalenz der Aortenklappenstenose steigt durch eine kontinuierlich wachsende geriatrische Bevölkerung. Daten über prozeduralen Erfolg sowie Mortalität von sehr alten Patienten sind gering, sodass sich die Frage stellt, wann diese Population „als bereits zu alt“ für einen Transkatheter-Aortenklappenersatz (TAVR) anzusehen wäre. Ziel dieser Studie war es, den Einfluss der direkten Implantation auf die Ergebnisse nach transfemoraler (TF-)TAVR bei Patienten in fortgeschrittenem Alter zu evaluieren.Dazu wurden die Daten von 394 konsekutiven Patienten nach TF-TAVR ermittelt. Die Patienten wurden in 4 Altersgruppen eingeteilt: ≤75 Jahre (Gruppe 1, n = 28), 76–80 Jahre (Gruppe 2, n = 107), 81–85 Jahre (Gruppe 3, n = 148) und85 Jahre (Gruppe 4, n = 111). Sofern es die aktuellen Empfehlungen erlaubten, wurde eine direkte Implantation durchgeführt. Das Überleben wurde mittels Kaplan–Meier-Analyse evaluiert.Zwischen den 4 Altersgruppen waren keine signifikanten Unterschiede der Mortalität nach 30 Tagen und nach einem Jahr zu verzeichnen (entsprechend 3,6 vs. 6,7 vs. 5,4 vs. 2,7 % und 7,6 vs. 17 vs. 14,5 vs. 13 %; p = 0,59 für Log-Rank-Test). Eine direkte Implantation ohne Ballonvalvuloplastie wurde bei Patienten85 Jahre häufiger durchgeführt als ≤85 Jahre (33,3 vs. 14,1 %; p 0,001). Die Inzidenz von häufig mit fortgeschrittenem Patientenalter assoziierten prozeduralen Komplikationen (Schlaganfall, vaskuläre Komplikationen) war in der Gruppe 4 nicht signifikant erhöht.In verschiedenen Alterskollektiven zeigen sich vergleichbare Ergebnisse nach TF-TAVR, dies gilt sogar für Patienten sehr hohen Alters. Die direkte Implantation kann die Prozedur vereinfachen und zu einer konsekutiven Reduktion der Inzidenz von periprozeduralen Komplikationen bei Patienten mit fortgeschrittenem Alter führen.

Background Beside their role in the diagnosis of heart failure in symptomatic patients with dyspnea, natriuretic peptides have been suggested to improve risk prediction of cardiac events and mortality in asymptomatic cohorts. We aimed to evaluate the prognostic value of NT-proBNP for cardiovascular and all-cause mortality above traditional risk factors in a prospective cohort study of unselected elderly patients in a representative primary care setting. Methods We followed 6382 patients of the getABI-study for 7 years. Associations of NT-proBNP levels (≤125; 125–300; >300pg/ml for all) with all-cause and cardiovascular mortality were assessed using cox regression analysis. Results The incidence of all-cause and cardiovascular mortality was higher in subjects with higher levels of NT-proBNP (all-cause mortality/cardiovascular mortality: 35.4%/6% for NT-proBNP > 300 pg/ml; 16.2%/40% for NT-proBNP 125–300 pg/ml vs. 11.4%/4% for NT-proBNP ≤ 125 pg/ml. Participants with a NT-proBNP levels > 300pg/ml had increased incidence of hard endpoint (hazard ratio (HR) (95% confidence interval (CI)): 3.62 (3.15–4.17) for all-cause mortality, and 6.38 (4.84–8.41) for cardiovascular mortality). These associations remained after adjustment for traditional risk factors and cardiac medications and diseases (HR = 2.64 (2.26–3.08) for all-cause mortality, and HR = 3.93 (2.90–5.32) for cardiovascular mortality). Conclusion Our results show strong associations of higher NT-proBNP levels with cardiovascular and all-cause mortality in an unselected, large population of elderly patients in the primary care setting independent of traditional risk factors indicating that NT-proBNP can help identifying subjects at high risk for cardiac events.

Highlights • Transcatheter heart valve size selection is still challenging. • The overlap between two different prosthesis sizes for borderline annuli remains. • Undersizing but overfilling improves sizing in borderline annulus cases. • Undersizing but overfilling decreases the postprocedural THV-pressure gradient. • Prospective studies are needed considering the TAVR expansion to younger patients., Background Current recommendations for valve size selection are based on multidimensional annular measurements, yet the overlap between two different transcatheter heart valve (THV) sizes remains. We sought to evaluate whether undersizing but overfilling eliminates the gray zones of valve sizing. Methods Data of 246 consecutive patients undergoing transcatheter aortic valve replacement (TAVR) with the balloon-expandable bioprosthesis with either conventional sizing and nominal filling (group 1 (NF-TAVR), n = 154) or undersizing but overfilling under a Less Is More (LIM)-Principle (group 2 (LIM-TAVR), n = 92) were compared. Paravalvular leakage (PVL) was graded angiographically and quantitatively using invasive hemodynamics. Results Annulus rupture (AR) occurred only in group 1 (n = 3). Due to AR adequate evaluation of PVL was possible in 152 patients of group 1. More than mild PVL was found in 13 (8.6%) patients of group 1 and 1 (1.1%) patient of group 2 (p = 0.019). Postdilatation was performed in 31 (20.1%) patients of group 1 and 6 patients (6.5%) of group 2 (p = 0.003). For patients with borderline annulus size in group 1 (n = 35, 22.7%) valve size selection was left to the physiciańs choice resulting in selection of the larger prosthesis in 10 (28.6%). In group 2 all patients with borderline annulus (n = 36, 39.1%) received the smaller prosthesis (LIM-TAVR). The postprocedural mean transvalvular pressure gradient was significantly higher in the NF-TAVR-group (11.7 ± 4 vs. 10.1 ± 3.6 mmHg, p = 0.005). Conclusion LIM-TAVR eliminates the gray zones of sizing and associated PVL, can improve THV-performance, reduce incidence of annular rupture and simplify the procedure especially in borderline cases.

Adenosine induces coronary vasodilation and simultaneously reduces splanchnic perfusion. This effect can be absent in adenosine non-responders. Imaging of splanchnic arteries under adenosine assessing this effect has not been performed in humans previously. In 26 patients, splenic artery color Doppler was performed during an infusion of adenosine. Peak velocity in the splenic artery was measured before the infusion and at 2 min. Results were compared qualitatively with perfusion imaging in magnetic resonance. A total of 24 patients showed a drop of splenic artery peak velocity from 62.3 ± 18.1 to 40.4 ± 15.7 cm/s (p 0.001), which corresponded to perfusion restriction in magnetic resonance. Two patients with constant splenic artery velocity did not show perfusion restriction. We showed feasibility of assessing changes in splenic artery velocity under adenosine for the first time in humans. Further studies are needed to investigate whether this novel application is a robust tool to rule out inadequate adenosine effect during measurement of fractional flow reserve in coronary catheterization.

Summary Background Current guidelines recommend potent platelet inhibition with prasugrel or ticagrelor for 12 months after an acute coronary syndrome managed with percutaneous coronary intervention (PCI). However, the greatest anti-ischaemic benefit of potent antiplatelet drugs over the less potent clopidogrel occurs early, while most excess bleeding events arise during chronic treatment. Hence, a stage-adapted treatment with potent platelet inhibition in the acute phase and de-escalation to clopidogrel in the maintenance phase could be an alternative approach. We aimed to investigate the safety and efficacy of early de-escalation of antiplatelet treatment from prasugrel to clopidogrel guided by platelet function testing (PFT). Methods In this investigator-initiated, randomised, open-label, assessor-blinded, multicentre trial (TROPICAL-ACS) done at 33 sites in Europe, patients were enrolled if they had biomarker-positive acute coronary syndrome with successful PCI and a planned duration of dual antiplatelet treatment of 12 months. Enrolled patients were randomly assigned (1:1) using an internet-based randomisation procedure with a computer-generated block randomisation with stratification across study sites to either standard treatment with prasugrel for 12 months (control group) or a step-down regimen (1 week prasugrel followed by 1 week clopidogrel and PFT-guided maintenance therapy with clopidogrel or prasugrel from day 14 after hospital discharge; guided de-escalation group). The assessors were masked to the treatment allocation. The primary endpoint was net clinical benefit (cardiovascular death, myocardial infarction, stroke or bleeding grade 2 or higher according to Bleeding Academic Research Consortium [BARC]) criteria) 1 year after randomisation (non-inferiority hypothesis; margin of 30%). Analysis was intention to treat. This study is registered with ClinicalTrials.gov, number NCT01959451, and EudraCT, 2013-001636-22. Findings Between Dec 2, 2013, and May 20, 2016, 2610 patients were assigned to study groups; 1304 to the guided de-escalation group and 1306 to the control group. The primary endpoint occurred in 95 patients (7%) in the guided de-escalation group and in 118 patients (9%) in the control group (p non-inferiority =0·0004; hazard ratio [HR] 0·81 [95% CI 0·62–1·06], p superiority =0·12). Despite early de-escalation, there was no increase in the combined risk of cardiovascular death, myocardial infarction, or stroke in the de-escalation group (32 patients [3%]) versus in the control group (42 patients [3%]; p non-inferiority =0·0115). There were 64 BARC 2 or higher bleeding events (5%) in the de-escalation group versus 79 events (6%) in the control group (HR 0·82 [95% CI 0·59–1·13]; p=0·23). Interpretation Guided de-escalation of antiplatelet treatment was non-inferior to standard treatment with prasugrel at 1 year after PCI in terms of net clinical benefit. Our trial shows that early de-escalation of antiplatelet treatment can be considered as an alternative approach in patients with acute coronary syndrome managed with PCI. Funding Klinikum der Universitat Munchen, Roche Diagnostics, Eli Lilly, and Daiichi Sankyo.

BACKGROUND Pulmonary vein isolation (PVI) is a standard treatment for atrial fibrillation (AF). Identification of gaps in the ablation line is difficult. Tip-ring electrograms from ablation catheters represent relative large areas of myocardial tissue. Recently, an ablation catheter with three minielectrodes (ME) on the catheter tip with closer interelectrode spacing was introduced. The aim of our study was to evaluate the novel electrodes during PVI. METHODS PVI was performed with an irrigated ablation catheter equipped with conventional electrodes and three additional radial tip electrodes. Detection of pulmonary vein potentials (PVPs), local signal amplitude, amplitude reduction during ablation, and loss of capture after ablation were compared between the ME and the conventional tip-ring electrodes. RESULTS Thirty-one patients (mean age 67.8 ± 10.3 years, 45.2 % men) were included. A total of 306 mapping/lesion points were analyzed. A PVP was significantly more often obtained with the ME compared to the conventional tip-ring electrodes (99.2% vs 83.5%, P

Objectives This study is the first head-to-head analysis of StarClose vs. ProGlide in patients undergoing 5F or 6F percutaneous coronary catheterization or peripheral artery interventions. Background The clip based StarClose and the suture mediated ProGlide vascular closure device are well established for femoral hemostasis in endovascular therapy. However, until now no prospective randomized study compared the safety and efficacy of the two devices. Methods This prospective, randomized, single-center study enrolled 505 patients (69.6 ± 11.2 years) resulting in 538 procedures due to more than one intervention in several patients: We analyzed 422 cardiac catheterization and 116 peripheral artery interventions via a common femoral artery access. Patients were randomized to StarClose or ProGlide (1:1). In-hospital complications (major bleeding, hematoma, pseudoaneurysm, vessel occlusion, and arteriovenous fistula) and device failure were recorded. The puncture site was assessed by ultrasound in all patients prior to discharge. Results Overall complication rate was 3.9%. There were more complications after utilization of StarClose compared to ProGlide (5.6 vs. 2.2%, P = 0.064), which was significant in adjusted logistic regression analysis with a 2.9-fold increased risk of complications for StarClose (P

Background: Venous vascular access with higher sheath size is common in interventional electrophysiology. In contrast to arterial vascular access, no dedicated closure devices exist for closure after venous access with higher sheath sizes. The Figure-of-8-Suture, an easy to apply suture, may be as a feasible approach for closure venous puncture. Our aim was to evaluate the feasibility of closure of femoral venous access. Methods: From November 2016 to February 2018, patients undergoing electrophysiological procedures, closure of left atrial appendage or patent foramen ovale were included. Until May 2017, manual compression was performed to achieve haemostasis at venous access site (control group). From May 2017, patients were treated with a Figure-of-8-Suture (treatment group, Figure 1). Turnaround time and incidence of vascular complications were compared between the two groups. Results: In total, 290 patients were included, 132 in the control group and 158 in the Figure-of-8-Suture group. Hemostasis after sheath removal was achieved in 100% of the cases in the control group by manual compression and in 98.7% of the cases with the Figure-of-8-Suture (p=0.2). Vascular complications were more common in the control group (6.8 vs. 1.3 %, p=0.01). Turnaround time was significantly lower in the Figure-of-8-Suture group (58.6 ± 14 vs. 77 ± 33.9 min, p=0.004). In a sub-analysis in obese patients with body mass index (BMI) ≥30 kg/m2 (Figure-of-8 n=45, controls n=35), vascular complications were significantly more common in the control group (9.4 vs 0%, p=0.045). Conclusion: The Figure-of-8-Suture is an easy-to-apply, effective approach for venous closure after electrophysiological procedures.

Background: Patient-activated event recorders (ER) can facilitate diagnosis in unclear palpi­tations, however impact of ER screening on further treatment in clinical routine is unknown. We investigated the feasibility and clinical value of a network-based telemetric monitoring using a patient activated ER. Methods: The network consisted of 12 general practitioners (GP) and a department of car­diology (DC). GP-patients sent electrocardiograms (ECGs) twice daily and in case of palpitations. ECGs were transferred by email to GP and DC and analyzed independently by both. The therapeutic strategy was discussed between GP and DC. The monitoring period ended after 4 weeks or in case of detected arrhythmia. Results: A group of 184 consecutive patients were retrospectively analyzed. Mean age was 57.5 ± 14.4 years (range 17–82), 104 (56.5%) were female. Significant arrhythmia occurred in 71 (38.5%) patients: Recurrence of known paroxysmal atrial fibrillation (AF; n = 27, 14.7%), de novo AF (n = 19, 10.3%), premature complexes/bigeminus (n = 13, 7.1%), sinus tachycar­dia (n = 7, 3.8%), atrioventricular nodal reentrant tachycardia (n = 3, 1.6%), and ventricular tachycardia (n = 2, 1.1%). A therapeutic consequence resulted in 63 (88.7%) patients with de­tected arrhythmia: new oral anticoagulation (n = 29, 40.8%), new antiarrhythmic medication (n = 27, 38.0%), behavioral intervention (n = 19, 26.8%), electrophysiology-study/catheter ablation (n = 4, 5.6%), cardioversion (n = 2, 2.8%), implantable cardioverter-defibrillator- -implantation (n = 1, 1.4%), and left atrial appendage occluder (n = 1, 1.4%). Conclusions: The investigated cross-sector telemetric network is a feasible approach to detect arrhythmia in patients with palpitations and may have high impact on further treatment, notably in those at risk for stroke due to AF.

Aims Pulmonary vein isolation (PVI) is a standard treatment of atrial fibrillation (AF). AF recurrence after PVI occurs in a substantial number of cases. A novel ablation catheter equipped with mini-electrodes (ME) may facilitate PVI. Our study evaluated outcome after PVI with the ME catheter compared to a standard catheter. Methods Patients undergoing PVI with the ME catheter were compared to a control group ablated with a standard contact force sensing catheter. Freedom of AF after 12 months was the study endpoint. Additionally, low voltage areas (LVA) Results A total of 110 patients underwent PVI with ME catheter (n = 59) or the standard catheter (n = 51). Procedure duration (117.4 ± 43 vs. 103.1 ± 32.8 min, p = 0.15), radiation dose (1135.6 ± 1125.7 vs. 1078.8 ± 951.4 μGy/m2, p = 0.91), incidence of complications and 12-month success rate (64.4 vs 72.5%, p = 0.36) were not significantly different between the groups. LVA were significantly smaller when obtained with the standard catheter compared to the CMC (14 ± 13 vs. 58.5 ± 22.1 cm2, p Conclusion Clinical outcomes are comparable between ME catheter and a standard contact force sensing catheter. Furthermore, better LVA detection points to improved mapping capabilities of the ME catheter.

Recent studies have suggested a strong association between obstructive sleep apnoea (OSA) and atrial fibrillation (AF). However, the impact of continuous positive airway pressure (CPAP) therapy on reverse atrial remodelling in patients with OSA is poorly understood. We aimed to determine the impact of CPAP therapy on total atrial conduction time measured by PA tissue Doppler imaging (TDI) interval in patients without history of AF.Thirty-five patients with first diagnosed OSA (group 1) and 20 reference patients without OSA (group 2) were prospectively enrolled. Group 1 was divided into 25 patients with starting CPAP therapy (intervention group) and 10 patients without CPAP therapy (control group). PA-TDI interval, measured by tissue Doppler imaging, and B-type natriuretic-peptide (BNP) were determined at baseline and repeated after 30 days in group 1. Patients with OSA had a significantly longer PA-TDI interval (131.4±16.0 ms vs. 120.1±6.4 ms, p0.001) compared to reference patients. PA-TDI interval shortened significantly after 30 days of CPAP therapy (131±17.1 ms vs. 124.6±15.7 ms, p0.001), whereas no significant change was found in the control group (132.6±13.6 ms vs. 133.2±13.1 ms, p=0.31) and BNP-levels decreased significantly (39.1±50.7 pg/ml vs. 28.2±42.4 pg/ml, p0.01), while BNP-levels remained unaffected after 30 days in control group (31.5±20 pg/ml vs. 34.4±20.5 pg/ml, p=0.41).Change in PA-TDI interval, as an indirect surrogate marker of atrial remodelling, suggests reverse atrial remodelling in patients with OSA and treated by CPAP. This effect may ensue from decreased atrial pressure or volume overload, as indicated by significantly reduced BNP levels. These observations suggest that the substrate pre-disposing to AF may be reversible and moreover can be measured by PA-TDI interval and BNP.

Background Cardiovascular Magnetic Resonance (CMR) imaging with adenosine stress is an important diagnostic tool in patients with known or suspected coronary artery disease (CAD). However, the method is not yet established for CAD patients with pacemakers (PM) in clinical practice. A possible reason is that no recommendations exist for PM setting (paused pacing or asynchronous mode) during adenosine stress. We elaborated a protocol for rhythm management in clinical routine for PM patients that considers heart rate changes under adenosine using a test infusion of adenosine in selected patients. Methods 47 consecutive patients (mean age 72.3 ± 10,0 years) with MR conditional PM and known or suspected CAD who underwent CMR in clinical routine were studied in this prospective observational study. PM indications were sinus node dysfunction (SND, n = 19; 40,4%), atrioventricular (AV) block (n = 26; 55.3%) and bradyarrhythmia in permanent atrial fibrillation (AF, n = 2; 4.3%). In patients with SND, normal AV-conduction and resting HR >45 bpm at the time of CMR and in AF the PM was deactivated for the scan. In intermittent AV-block a test infusion of adenosine was given prior to the scan. All patients with permanent higher degree sinuatrial or AV-block or deterioration of AV-conduction in the adenosine test were paced asynchronously during CMR, in patients with preserved AV-conduction under adenosine the pacemaker was deactivated. CMR protocol included cine imaging, adenosine stress perfusion and late gadolinium enhancement. Results The adenosine test was able to differentiate between mandatory PM stimulation during CMR and safe deactivation of the device. In patients with permanent sinuatrial or AV-block (n = 11; 23.4%) or deterioration of AV conduction in the adenosine test (n = 5, 10.6%) asynchronous pacing above resting heart rate did not interfere with intrinsic rhythm, no competitive stimulation was seen during the scan. 10 of 15 (66,7%) patients with intermittent AV-block showed preserved AV-conduction under adenosine. As in SND and AF deactivation of the PM showed to be safe during CMR, no bradycardia was observed. Conclusion Our protocol for rhythm management during adenosine stress CMR showed to be feasible and safe and may be recommended for pacemaker patients undergoing routine CMR.

Pulmonary vein isolation (PVI) is a standard treatment for atrial fibrillation (AF). Identification of gaps in the ablation line is difficult. Tip-ring electrograms from ablation catheters represent relative large areas of myocardial tissue. Recently, an ablation catheter with three minielectrodes (ME) on the catheter tip with closer interelectrode spacing was introduced. The aim of our study was to evaluate the novel electrodes during PVI.PVI was performed with an irrigated ablation catheter equipped with conventional electrodes and three additional radial tip electrodes. Detection of pulmonary vein potentials (PVPs), local signal amplitude, amplitude reduction during ablation, and loss of capture after ablation were compared between the ME and the conventional tip-ring electrodes.Thirty-one patients (mean age 67.8 ± 10.3 years, 45.2 % men) were included. A total of 306 mapping/lesion points were analyzed. A PVP was significantly more often obtained with the ME compared to the conventional tip-ring electrodes (99.2% vs 83.5%, P 0.001). Local amplitude was significantly higher on the ME (0.8 ± 0.6 mV vs 0.67 ± 0.46 mV, P = 0.003). Amplitude reduction during 1 RF pulse was significantly greater on the ME (82.9 ± 19.5% vs. 61.8 ± 26.9%, P 0.001). During pace mapping, loss of capture after 1 RF pulse was observed significantly more often on ME (98.3% vs 63.3%, P 0.001).Signal amplitude is higher and sensitivity during PVP mapping and ablation is increased when ME are used. ME may facilitate catheter ablation of AF in the future.

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.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).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 a3-fold odds of complications when using ExoSeal, which remained unchanged in multivariate analysis.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.

Background Left atrial (LA) size is associated with cardiovascular mortality and morbidity. Once cardiac computed tomography (CT) is performed, information on LA size is readily available without additional contrast media or radiation exposure. Purpose To determine the association of CT-derived LA area and body surface area-adjusted (BSA) LA index with cardiovascular risk factors and describe age- and gender-specific normative values in a general population cohort. Material and Methods This study included 3945 participants (mean age, 59 ± 8 years; 53% women) from the community-based Heinz Nixdorf Recall Study. LA area in an axial image at the level of the mitral valve was quantified from non-contrast-enhanced electron-beam CT by manual delineations of the boundaries of the LA with exclusion of subjects with prevalent cardiovascular disease. Definition of normative values was performed in subjects without predictors of LA enlargement. Results LA quantification was feasible in all subjects. Men had larger LA size (1856 mm2 vs. 1677 mm2, P 2/m2 vs. 933 mm2/m2 for men and women, P 2 = 0.195, BSA: R2 = 0.216, both P 2/10 mmHg for systolic, 31.4 (25.4–37.4) mm2/5 mmHg for diastolic blood pressure, 214.6 (186.9–242.3) mm2 for antihypertensive medication, P 2 ≤ 0.026). Current smoking was associated with reduced LA size (–115.9 [–149.0 – –82.8] mm2, P Conclusion Non-contrast-enhanced cardiac CT enables LA quantification with body size, hypertension, and smoking status being predictors of LA size.

Several biomarkers including B-type natriuretic peptide (BNP) have been suggested to improve prediction of coronary events and all-cause mortality. Moreover, coronary artery calcium (CAC) as marker of subclinical atherosclerosis is a strong predictor for cardiovascular mortality and morbidity. We aimed to evaluate the predictive ability of BNP and CAC for all-cause mortality and coronary events above traditional cardiovascular risk factors (TRF) in the general population.We followed 3782 participants of the population-based Heinz Nixdorf Recall cohort study without coronary artery disease at baseline for 7.3 ± 1.3 years. Associations of BNP and CAC with incident coronary events and all-cause mortality were assessed using Cox regression, Harrell's c, and time-dependent integrated discrimination improvement (IDI(t), increase in explained variance).Subjects with high BNP levels had increased frequency of coronary events and death (coronary events/mortality: 14.1/28.2% for BNP ≥100 pg/ml vs. 2.7/5.5% for BNP 100 pg/ml, respectively). Subjects with a BNP ≥100 pg/ml had increased incidence of hard endpoints sustaining adjustment for CAC and TRF (for coronary events: hazard ratio (HR) (95% confidence interval (CI)) 3.41(1.78-6.53); for all-cause mortality: HR 3.35(2.15-5.23)). Adding BNP to TRF and CAC increased measures of predictive ability: coronary events (Harrell's c, for coronary events, 0.775-0.784, p = 0.09; for all-cause mortality 0.733-0.740, p = 0.04; and IDI(t) (95% CI), for coronary events: 2.79% (0.33-5.65%) and for all-cause mortality 1.78% (0.73-3.10%).Elevated levels of BNP are associated with excess incident coronary events and all-cause mortality rates, with BNP and CAC significantly and complementary improving prediction of risk in the general population above TRF.

Objectives This study sought to determine whether epicardial fat volume predicts coronary events in the general population. Background Epicardial adipose tissue (EAT) is suggested to promote plaque development in the coronary artery tree. Methods We quantified EAT volume in participants from the prospective population-based Heinz Nixdorf Recall cohort study free of cardiovascular disease. Incident coronary events were assessed during a follow-up period of 8.0 ± 1.5 years. Multivariable association of EAT with cardiovascular risk factors, coronary artery calcification (CAC), and coronary events was assessed using regression analysis. Results From the overall 4,093 participants (age 59.4 years, 47% male), 130 subjects developed a fatal or nonfatal coronary event. Incidence of coronary events increased by quartile of EAT (0.9% vs. 4.7% for 1st and 4th quartile, respectively, p Conclusions Epicardial fat is associated with fatal and nonfatal coronary events in the general population independent of traditional cardiovascular risk factors and complements information from cardiac computed tomography above the CAC score.

Thoracic aortic calcification (TAC) is associated with cardiovascular (CV) risk factors and prevalent coronary artery disease. We aimed to investigate whether TAC burden is associated with incident myocardial infarction (MI) and all-cause mortality in subjects without known coronary artery disease and to determine its predictive value for these endpoints.We used longitudinal data from the population-based prospective Heinz Nixdorf Recall Study. TAC and coronary artery calcification (CAC) scores were quantified from non-contrast enhanced electron beam computed tomography. Cox regression analysis was used to determine the association of TAC with incident MI or all-cause mortality, adjusting for CV risk factors and additionally for CAC-score in a separate step. Predictive value of TAC was assessed using Harrell's C index.Overall, 4040 participants without known coronary artery disease (59.4 years, 47% male) were included in this analysis. During a mean follow-up of 8.0 ± 1.5 years, we observed 136 coronary events and 304 deaths. In subjects with TAC0 vs TAC = 0, the incidence of nonfatal MI was 4.2% vs 2.0% (p 0.001), and all-cause mortality was 8.9% vs 5.2% (p 0.001). Risks for coronary events and for all-cause mortality increased significantly with increasing TAC-scores (p 0.001). After adjustment for CV risk factors, body mass index (BMI) and CV medication, a unit increase of TAC on a logarithmic scale (log(TAC + 1)) remained independently associated with coronary events (hazard ratio (HR) (95% confidence interval (CI)): 1.06 (1.00-1.14), p = 0.03) and all-cause mortality (HR 1.06 (1.01-1.12), p 0.01). After further adjustment for CAC-score (log(CAC + 1)), hazard ratios were attenuated for both endpoints (coronary events: 0.98 (0.91-1.05), p = 0.56, all-cause mortality: 1.03 (0.98-1.08), p = 0.33). When adding log(TAC + 1) to the model containing traditional risk factors and CAC, Harrell's C indices did not increase for coronary events (0.773-0.772, p = 0.66) or for all-cause mortality (0.741-0.743, p = 0.49).TAC is associated with incident coronary events and all-cause mortality independent of traditional CV risk factors in the general population. TAC fails to improve event prediction over CAC in both coronary events and all-cause mortality.

This study is the first head-to-head analysis of StarClose vs. ProGlide in patients undergoing 5F or 6F percutaneous coronary catheterization or peripheral artery interventions.The clip based StarClose and the suture mediated ProGlide vascular closure device are well established for femoral hemostasis in endovascular therapy. However, until now no prospective randomized study compared the safety and efficacy of the two devices.This prospective, randomized, single-center study enrolled 505 patients (69.6 ± 11.2 years) resulting in 538 procedures due to more than one intervention in several patients: We analyzed 422 cardiac catheterization and 116 peripheral artery interventions via a common femoral artery access. Patients were randomized to StarClose or ProGlide (1:1). In-hospital complications (major bleeding, hematoma, pseudoaneurysm, vessel occlusion, and arteriovenous fistula) and device failure were recorded. The puncture site was assessed by ultrasound in all patients prior to discharge.Overall complication rate was 3.9%. There were more complications after utilization of StarClose compared to ProGlide (5.6 vs. 2.2%, P = 0.064), which was significant in adjusted logistic regression analysis with a 2.9-fold increased risk of complications for StarClose (P 0.05). In the subgroup of coronary catheterizations there were significantly more complications for StarClose compared to ProGlide (1.4 vs. 5.2%, P 0.05) with a 4.7-fold increased risk. Device failure rate was not significantly different between the two devices.In this first randomized trial comparing the two closure systems complication rate was higher for StarClose with equal efficacy compared to ProGlide. © 2017 Wiley Periodicals, Inc.

BACKGROUND N-terminal pro-B type natriuretic peptide (NT-proBNP) is a marker of cardiac stress and is linked with silent cardiac diseases. While associations of cognitive impairment with manifest cardiovascular diseases are established, data on whether subclinical elevation of NT-proBNP levels below clinically established threshold of heart failure is related with cognitive functioning, especially mild cognitive impairment (MCI), is rare. OBJECTIVE Aim of the present study was to investigate the cross-sectional association of NT-proBNP levels and MCI in a population-based study sample without heart failure. METHODS We used data from the second examination of the population based Heinz-Nixdorf-Recall-Study. Subjects with overt coronary heart disease and subjects with NT-proBNP levels indicating potential heart failure (NT-proBNP≥300 pg/ml) were excluded from this analysis. Participants performed a validated brief cognitive assessment and were classified either as MCI [subtypes: amnestic-MCI (aMCI), non-amnestic-MCI (naMCI)], or cognitively-normal. RESULTS We included 419 participants with MCI (63.1±7.4 y; 47% men; aMCI n = 209; naMCI n = 210) and 1,206 cognitively normal participants (62.42±7.1 y; 48% men). NT-proBNP-levels≥125 pg/ml compared to

There are only limited data on the impact of device-related artifacts on image quality in cardiovascular magnetic resonance imaging (CMR) in patients with pacemakers (PM). Adenosine stress perfusion, T1-weighted imaging and flow measurement as well as valve characterization have not been evaluated previously concerning artifact burden. We aimed to assess image quality in all routinely used CMR sequences. We analyzed 2623 myocardial segments in CMR scans of 61 patients with MR conditional PM (mean age 72.1 ± 11.5 years), 23 (37.7%) with right sided, 38 (62.3%) with left-sided devices. There were no relevant artifacts in patients with right-sided devices irrespective of the imaging sequence. In left-sided implants no PM-induced artifacts were found in first pass perfusion sequence, flow analysis and T1 weighted imaging. Only few patients with left-sided devices showed significant PM-artifacts in aortic (3/38, 7.9%)/mitral (n = 2/38, 5.3%) valve imaging and STIR (n = 3/35, 8.6%). In STIR only 14/805 (1.7%) segments were involved. In left-sided PM SSFP cine sequences had more artifact burden than LGE with 377/1505 (25.0%) vs. 162/1505 (10.8%) myocardial segments involved by relevant artifacts respectively (p

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. 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). 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

Aims To compare the predictive value of coronary artery calcification (CAC), carotid intima-media thickness (CIMT) and ankle-brachial index (ABI) in a primary prevention cohort depending on risk factor profile to determine which of the three markers improves cardiovascular (CV) risk discrimination best in which risk group. Methods and Results We quantified CAC, CIMT, and ABI in 3108 subjects (mean age 59.2 ± 7.7, 47.1% male) without prevalent CV diseases from the population-based Heinz Nixdorf Recall study. Associations with incident major CV events (coronary event, stroke, CV death; n = 223) were assessed during a follow-up period of 10.3 ± 2.8 years with Cox proportional regressions in the total cohort and stratified by Framingham risk score (FRS) groups. Discrimination ability was evaluated with Harrell’s C. All three markers were associated with CV events (hazard ratio [95% confidence interval (CI)]: CAC: 1.31 (1.23–1.39) per 1-unit increase in log(CAC + 1) vs. CIMT: 1.27 (1.13–1.43) per 1 SD vs. ABI: 1.30 (1.14–1.49) per 1 SD, in FRS adjusted models). Considering reclassification, CAC lead to highest reclassification in the total cohort, while also for CIMT and ABI significant improvement in net-reclassification was observed [NRI (95% CI): CAC: 0.55 (0.42–0.69); CIMT: 0.32 (0.19–0.45); ABI: 0.19 (0.10–0.28)]. Conclusion Coronary artery calcification provides the best discrimination of risk compared with CIMT and ABI, particularly in the intermediate risk group, whereas CIMT may be an alternative measure for reassurance in the low risk group.

Purpose The aim of this study was to introduce population-based sex and age-stratified distributions of carotid intima media thickness (CIMT), to compare fixed cut-off and percentile values for subjects with and without known coronary heart disease (CHD) and to describe CIMT percentiles. Methods Between 2000 and 2003, a total of 4,814 subjects aged 45-75 years were recruited into the Heinz Nixdorf recall study (HNR). Ultrasound examination of extracranial arteries was performed and the CIMT was measured manually over a distance of 1 cm proximal to the bulb in the common carotid artery (CCA). Both sides were measured and the average of the right and left artery were calculated (mean CIMT). Results The CIMT was measured for 1,749 men and 1,802 women without prevalent CHD and 177 men and 50 women with prevalent CHD. Mean CIMT values were higher in men compared to women (men 0.71 ± 0.14 mm vs. women 0.65 ± 0.11 mm, p ≤ 0.0001) and in subjects with CHD compared to those without (men with and without CHD: 0.76 ± 0.14 mm and 0.70 ± 0.14 mm, p ≤ 0.0001, respectively; women with and without CHD: 0.73 ± 0.15 mm and 0.64 ± 0.11 mm, p ≤ 0.0001, respectively). In men the mean CIMT increased from 0.62 ± 0.10 mm in the youngest (45-49 years old) up to 0.79 ± 0.13 mm in the highest age group (≥ 70 years) (0.57 ± 0.08 mm up to 0.71 ± 0.12 mm in women, p ≤ 0.0001 for both). Conclusions Compared to international studies similar CIMT distributions were found in this study using both continuous and percentile distributions. However, lower CIMT values were observed in older participants, which can be explained by exclusion of carotid plaque formation in CIMT measurements.

Die Messung des Anstiegs der Intima-Media-Dicke in der Arteria carotis communis (carotid intima-media thickness: CIMT) ist eine wichtige Untersuchungsmethode zur Quantifizierung der subklinischen Atherosklerose.

Background Studies linking particulate matter (PM) with heart failure (HF) show inconsistent results. However, the association of air pollution with diastolic function, an important determinant of heart failure, has not been studied yet and is addressed in the presented study. Methods 402 women (69–79 years) of the clinical follow-up (2007–2010) of the ongoing population-based prospective SALIA (Study on the influence of Air pollution on Lung function, Inflammation and Ageing) cohort were examined using Doppler echocardiography: Of the 291 women with preserved ejection fraction, the ratio of peak early diastolic filling velocity and peak early diastolic mitral annulus velocity ( E / E ′) was collected in 264 and left atrial volume index (LAVI) in 262 women. Residential long-term air pollution exposure (nitrogen oxides, size-fractioned PM) was modeled at baseline and at follow-up, applying land use regression models. We used linear regression to model the cross-sectional associations of air pollutants per interquartile range (IQR) with different measures of diastolic function, adjusting for personal risk factors. Results Median concentrations of annual NO x , NO 2 , PM 2.5 , and PM 10 at follow-up were 37.7, 25.9, 17.4 and 26.4 μg/m 3 , respectively. In the fully adjusted models, LAVI was associated with an IQR increase in PM 2.5 (1.05 [0.99; 1.12]) and NO x (1.04 [1.00; 1.09]) at follow-up, and with NO x and NO 2 (both 1.05 [1.00; 1.11]) at baseline. None of the pollutants were clearly associated with E / E ′. Conclusions In this analysis of elderly women, we found suggestive evidence for an association of air pollution with impaired diastolic function.

Hypereosinophilic syndrome represents a rare cause for cerebral infarctions and inflammatory neurological disorders. Various possible pathogenic mechanisms for cerebral infarctions have already been discussed. Complex mechanisms including a local hypercoagulability by eosinophilic granules as well as a direct damage to endothelial cells, leading to alterations of the microcirculation seem to be involved. The changing pattern of heroin use to inhalation/sniffing leading to an increasing abuse may cause a rise in the prevalence of Heroin induced eosinophilia, as it has been reported in a case of eosinophilic pneumonia associated with heroin inhalation. To our knowledge, the present case report displays the first description of stroke in the setting of heroin induced hypereosinophilia. Thus, besides usual vasoconstriction, HES should be considered in drug-induced cerebral infarctions.

Several platelet function test systems exist for the evaluation of the platelet inhibitory effect in patients on P2Y12 inhibitors and/or acetylsalicylic acid (ASA, aspirin) therapy. Studies comparing different available assays found only a poor correlation. The objective of the present study was to evaluate the correlation and agreement between single electrode (SEA) and multiple electrode (MEA) aggregometry.In whole blood arachidonic acid (AA) and adenosine diphosphate (ADP)-induced platelet aggregation was measured simultaneously using SEA (Chrono-Log) and MEA (Multiplate). We analyzed a total of 226 measurements taken from 58 patients on single ASA therapy or dual antiplatelet therapy with ASA and a thienopyridine. A cut-off value for clopidogrel/prasugrel high on-treatment platelet reactivity (HPR) of47 units (U) was chosen for MEA testing using hirudin and5 Ohm for SEA with citrate anticoagulated blood samples. The respective cut-off values for ASA HPR were30 U for the MEA assay and1 Ohm for SEA testing. There was a good correlation of the prevalence of thienopyridine-HPR in both whole blood assays (Spearman rank correlation coefficient r = 0.698) and a good inter-rate accordance (Cohen's Kappa statistic κ = 0.648). For AA-induced aggregation, the correlation of the results obtained was significant (r = 0.536; p0.001) and detecting ASA-HPR revealed a moderate (κ = 0.482) correlation between both impedance aggregometry assays.Platelet function testing using SEA and MEA provided both good accordance and correlation and therefore study results obtained by these two assays similarly enabled the detection of HPR of thienopyridine (and ASA) therapy.

B-type natriuretic peptide (BNP) as well as N-terminal-proBNP (NT-proBNP) are associated with cardiac events in the general population. Yet, data from the general population comparing both peptides for their prognostic value is lacking.Participants from the population-based Heinz-Nixdorf-Recall-study without cardiovascular diseases were included. Associations of BNP and NT-proBNP with incident cardiovascular events (incident myocardial infarction, stroke, or cardiovascular death) were assessed using Cox regression; prognostic value was addressed using Harrell's c statistic.From overall 3589 subjects (mean age: 59.3 ± 7.7 yrs, 52.5% female), 235 subjects developed a cardiovascular event during 8.9 ± 2.2 yrs of follow-up. In regression analysis both natriuretic peptides were associated with incident cardiovascular events, independent of traditional risk factors (hazard ratio (HR) per unit increase on log-scale (95% CI): NT-proBNP: 1.60 (1.39; 1.84); BNP: 1.37 (1.19; 1.58), p0.0001 respectively). Specifically looking at subjects60 yrs only NT-proBNP, was linked with events (HR (95% CI): 1.59 (1.19; 2.13) for NT-proBNP, p=0.0019; HR: 1.25 (0.94; 1.65) for BNP, p=0.12, after adjustment for age and gender). Similar results were observed for females (HR (95% CI) 1.65 (1.28; 2.12), p=0.0001 for NT-proBNP, and 1.24 (0.96; 1.61), p=0.10 for BNP after adjustment for age). Adding NT-proBNP/BNP to traditional risk factors increased the prognostic value, with effects being stronger for NT-proBNP (Harrell's c, 0.724 to 0.741, p=0.034) as compared to BNP (0.724 to 0.732, p=0.20).Both, NT-proBNP and BNP are associated with future cardiovascular events in the general population. However, when both are available, NT-proBNP seems to be superior due to its higher prognostic value, especially in younger subjects and females.

Background: Familial Mediterranean Fever (FMF) is a hereditary autoinflammatory disease associated with subclinical inflammation, which includes atherosclerosis arising from endothelial inflammation, which in turn increases the risk of atrial or ventricular arrhythmias. Conduction abnormalities can be detected using the electrocardiographic (ECG) indices P and QT dispersion (Pdisp and QTdisp). Currently, it is unknown whether patients with FMF are more likely to have abnormalities of these ECG indices. Moreover, existing studies were conducted in countries with higher FMF prevalence. We therefore perform the first prospective study assessing Pdisp and QTdisp in adult FMF patients in Germany, where prevalence of FMF is low. Method: Asymptomatic FMF patients (n=30) of Turkish ancestry living in Germany and age-matched healthy controls (n=37) were prospectively assessed using 12-lead ECG. Results: Patients and controls were comparable in gender and body mass index, and patients had higher erythrocyte sedimentation rate (ESR), C-reactive protein (CRP) and serum amyloid A (SAA) compared to controls (ESR: 23.7±14.3 vs. 16.1±13,3 mm/1sth, p=0.03, CRP: 0.73±0.9 vs. 0.26±0.4 g/dl, p=0.01, SAA: 3.14±4,8 vs. 0.37±0.3 mg/dl, p

^^ Purpose: To compare complication rates of a collagen-based vascular closure device (VCD) in patients with vs. without significant peripheral artery disease (PAD). Methods: A total of 382 patients (268 men; mean age 64.6610.8 years) undergoing either an endovascular procedure of the lower limb (PAD group, n¼132) or a percutaneous coronary intervention (PCI group, n¼250) via a common femoral artery access were enrolled in this prospective study if hemostasis was achieved using the collagen-based Angio-Seal. In the PCI group, significant PAD was excluded by measurement of the ankle-brachial index. Inhospital major complications (bleeding, large hematoma, pseudoaneurysm, vessel occlusion, dissection) were recorded. Results: Similar and low rates of major complications were observed in both arms of the study: 2 (1.5%) major complications in the PAD group and 3 (1.2%) in the PCI group (p¼1.0). There was no significant difference in efficacy of the VCDs in the groups (PAD group 99.2% vs. 100% in PCI group, p¼0.35). Conclusion: Our study shows no significant differences in the rate of major complications after utilization of a collagen-based VCD for femoral artery access site closure in patients with severe lower limb PAD compared to those without; however, complications in the PAD group tended to be more severe, with the need for surgical repair. J Endovasc Ther. 2014;21:79–84

Aims Epicardial adipose tissue (EAT) is increased in subjects with atrial fibrillation (AF). Likewise, EAT is associated with left atrial (LA) size, as itself is a strong predictor of AF. We aimed to determine the association of EAT and LA size as computed tomography (CT)-derived measures with prevalent and incident AF and investigated whether both measures independently predict AF. Methods and results Participants from the Heinz Nixdorf Recall study without known cardiovascular disease were included. At baseline, EAT, defined as fat volume inside the pericardial sac, and LA size, defined as an axial area at the level of the mitral valve, were quantified from non-contrast enhanced cardiac CT. AF was determined from electrocardiogram at baseline and also at 5-year follow-up examination. Overall, 3467 participants (age: 58.9 ± 7.6 years, 47% male) were included. Ninety-six subjects had AF (46 prevalent and 50 incident). A 1-standard deviation (SD) change of EAT was associated with nearly two-fold increased prevalence of AF in univariate analysis, which persisted after adjustment for AF risk factors [odds ratio (OR) (95% confidence interval, 95% CI): 1.38 (1.11–1.72), P = 0.003]. Ancillary adjusting for LA reduced the effect [1.26 (0.996–1.60), P = 0.054]. For incident AF, no relevant effect was observed for EAT when adjusting for risk factors [1.19 (0.88–1.61), P = 0.26]. In contrast, a 1-SD chance of LA was strongly associated with AF independently of EAT and risk factors [2.70 (2.22–2.20), P < 0.0001]. LA but not EAT as non-contrast CT-derived measures improved the prediction of AF over risk factors (receiver operating characteristics: 0.810–0.845, P = 0.025). Conclusion LA size from non-contrast CT is strongly associated with prevalent and incident AF and ultimately diminishes the link of EAT with AF.

A B-type natriuretic peptide (BNP) threshold of 100 pg/ml is used in practice for identification of heart failure, but data about the “normal” distribution of BNP in a large population in primary prevention are rare. We aimed to characterize the BNP distribution in a healthy subset of a population-based cohort and to evaluate the association of elevated BNP levels with major events. In a first step, we determined gender-specific distribution and 90th percentiles of BNP in participants who were at baseline free from known determinants of increased BNP, i.e. cardiovascular disease, hypertension or chronic kidney disease. Consecutively, the association of BNP levels above these 90th percentiles with subsequent cardiovascular and coronary events was assessed in the entire cohort. In the BNP-normal sub-sample (n = 1,639), we defined gender-specific 90th percentile of BNP (31.3 pg/ml for men, 45.5 pg/ml for women). From overall 3,697 subjects (mean age 59.4, 52.4 % female), 194 subjects developed a major cardiovascular event and 122 myocardial infarction during a mean follow-up period of 8.0 ± 1.5 years. The 90th percentiles derived from the normal subset as threshold showed strong associations with major events in the entire cohort even after adjusting for traditional risk factors: hazard ratio (95 % CI): 1.86 (1.37; 2.53), p

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).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; P0.00001). At the cutoff value of 152 milliseconds, PA-TDI interval sensitivity and specificity related to ERAF were 87% and 100%, respectively.Measuring PA-TDI interval may help to predict ERAF after successful CV in patients with persAF.

Collagen-based vascular closure devices (VCD) are commonly used after catheterization with femoral access. However, data about complication rates due to the utilization of VCDs in patients with known peripheral artery disease (PAD) of the lower limbs are inconsistent and patients with significant PAD are excluded in most VCD trials. In this study, we aimed to assess complication rates of collagen-based VCDs in patients with significant PAD.Patients with significant PAD treated with a VCD (Angio-Seal; St Jude Medical, Inc) after percutaneous therapeutic interventions of lower extremities were included in this study. Significant PAD was defined as Fontaine ≥2b. In-hospital complications (bleeding, spurious aneurysm, vessel occlusion, dissection, surgical repair, vasovagal reaction) were recorded.A total of 121 patients (64.6 ± 11.3 years, 77% male) were included. PAD stage IIb was present in 99 patients (stage III in 8 patients, stage IV in 14 patients). A total of 112 treatments (93.3%) processed without complications (major complication rate, 1.7%; minor complication rate, 5.0%). There was a trend toward higher prevalence of complications with increasing size of closure device and with the stage of PAD; however, this trend was not statistically significant (P.05 for all).We report moderate complication rates of collagen-based VCDs in patients with significant PAD. Our data suggest that Angio-Seal may be safe in patients with PAD after catheter intervention. Further randomized trials with larger sample size comparing VCD with standard manual compression in patients with significant PAD are required.

This study sought to determine whether epicardial fat volume predicts coronary events in the general population.Epicardial adipose tissue (EAT) is suggested to promote plaque development in the coronary artery tree.We quantified EAT volume in participants from the prospective population-based Heinz Nixdorf Recall cohort study free of cardiovascular disease. Incident coronary events were assessed during a follow-up period of 8.0 ± 1.5 years. Multivariable association of EAT with cardiovascular risk factors, coronary artery calcification (CAC), and coronary events was assessed using regression analysis.From the overall 4,093 participants (age 59.4 years, 47% male), 130 subjects developed a fatal or nonfatal coronary event. Incidence of coronary events increased by quartile of EAT (0.9% vs. 4.7% for 1(st) and 4th quartile, respectively, p0.001). Doubling of EAT was associated with a 1.5-fold risk of coronary events when adjusting for cardiovascular risk factors (hazard ratio [HR] [95% confidence interval (CI)]: 1.54 [1.09 to 2.19]), which remained unaltered after further adjustment for CAC score (HR [95% CI]: 1.50 [1.07 to 2.11]). For discrimination of subjects with events from those without, we observed a trend for improvement of Harrell's C and explained variance by EAT over traditional cardiovascular risk factors, which, however, did not reach statistical significance (0.720 to 0.730 for risk factors alone and with EAT added, respectively, p = 0.10, R(2) = 2.73% to R(2) = 2.92%, time-dependent integrated discrimination improvement = 0.196%).Epicardial fat is associated with fatal and nonfatal coronary events in the general population independent of traditional cardiovascular risk factors and complements information from cardiac computed tomography above the CAC score.

BackgroundAtrial fibrillation (AF) is the most common arrhythmia and is associated with increased morbidity and mortality. Thus, identifying subjects with unknown AF or at higher risk for future AF in the general population is of importance. B-type natriuretic peptide (BNP) is linked with silent cardiac diseases. We evaluated the association of BNP with incident AF in a large population-based cohort study.MethodsWe included subjects from the population-based Heinz Nixdorf Recall study without known coronary heart disease, prior stroke, history of open heart surgery, heart-device therapy, or prevalent AF at baseline. Association of continuous and binary (≥31pg/ml for male, ≥45pg/ml for female) BNP with incident AF after 5 years was assessed using logistic regression analysis.ResultsA total of 3067 subjects (mean age 58.9 years, 47.9% male) were included in this analysis. Subjects with incident AF (n=42) had higher levels of BNP (median (Q1; Q3): 33.2pg/ml (19.4; 50.5) vs. 16.9pg/ml (9.2; 30.2)). Likewise, BNP was associated with incidence of AF both in univariate model and when adjusting for AF risk factors (odds ratio (OR) (95% confidence interval (CI)): BNP as continuous variable: 1.27 (1.09; 1.47), p=0.002; BNP as binary variable: 2.68 (1.41; 5.11) with AF risk factor adjustment). Notably, especially younger subjects (70 years).ConclusionsElevated levels of BNP are associated with significant excess of incident AF, independent of traditional AF risk factors in the general population. Gender-specific BNP thresholds may help in prevention by detecting unknown or future AF, which carries a high risk of stroke events.

Background Cardiovascular Magnetic Resonance (CMR) with adenosine stress is a valuable diagnostic tool in coronary artery disease (CAD). However, despite the development of MR conditional pacemakers CMR is not yet established in clinical routine for pacemaker patients with known or suspected CAD. A possible reason is that adenosine stress perfusion for ischemia detection in CMR has not been studied in patients with cardiac conduction disease requiring pacemaker therapy. Other than under resting conditions it is unclear whether MR safe pacing modes (paused pacing or asynchronous mode) can be applied safely because the effect of adenosine on heart rate is not precisely known in this entity of patients. We investigate for the first time feasibility and safety of adenosine stress CMR in pacemaker patients in clinical routine and evaluate a pacing protocol that considers heart rate changes under adenosine. Methods We retrospectively analyzed CMR scans of 24 consecutive patients with MR conditional pacemakers (mean age 72.1 ± 11.0 years) who underwent CMR in clinical routine for the evaluation of known or suspected CAD. MR protocol included cine imaging, adenosine stress perfusion and late gadolinium enhancement. Results Pacemaker indications were sinus node dysfunction (n = 18) and second or third degree AV block (n = 6). Under a pacing protocol intended to avoid competitive pacing on the one hand and bradycardia due to AV block on the other no arrhythmia occurred. Pacemaker stimulation was paused to prevent competitive pacing in sinus node dysfunction with resting heart rate >45 bpm. Sympatho-excitatory effect of adenosine led to a significant acceleration of heart rate by 12.3 ± 8.3 bpm (p < 0.001), no bradycardia occurred. On the contrary in AV block heart rate remained constant; asynchronous pacing above resting heart rate did not interfere with intrinsic rhythm. Conclusion Adenosine stress CMR appears to be feasible and safe in patients with MR conditional pacemakers. Heart rate response to adenosine has to be considered for the choice of pacing modes during CMR.

The prevalence of clinical relevant extracardiac findings (ECF) on cardiac computed tomography (CT) scans in the general population is still not described. Participants aged 45-75yrs from the prospective population-based Heinz Nixdorf Recall Study were studied by non-contrast enhanced cardiac