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This position paper is a joint statement of the German Radiological Society (DRG) and the Professional Association of German Radiologists (BDR), which reflects the current state of knowledge about coronary computed tomography. It is based on preclinical and clinical studies that have investigated the clinical relevance as well as the technical requirements and fundamentals of cardiac computed tomography. Citation Format

Aims Very high-power short-duration (vHPSD) via temperature-controlled ablation (TCA) is a new modality to perform radiofrequency pulmonary vein isolation (PVI), conceivably at the cost of a narrower safety margin towards the oesophagus. In this two-centre trial, we aimed to determine the safety of vHPSD-based PVI with specific emphasis on silent oesophageal injury. Methods and results Ninety consecutive patients with atrial fibrillation (AF) underwent vHPSD-PVI (90 W, 3–4 s, TCA) using the QDOT MICRO catheter, in conjunction with the nGEN (Bad Neustadt, n = 45) or nMARQ generator (Bruges, n = 45). All patients underwent post-ablation oesophageal endoscopy. Procedural parameters and complications were recorded. A subgroup of 21 patients from Bad Neustadt underwent cerebral magnetic resonance imaging (cMRI) to detect silent cerebral events (SCEs). Mean age was 67 ± 9 years, 59% patients were male, and 66% patients had paroxysmal AF. Pulmonary vein isolation was obtained in all cases after 96 ± 29 min. No steam pop, cardiac tamponade, stroke, or fistula was reported. None of the 90 patients demonstrated oesophageal ulceration (0%). Charring was not observed in the nMARQ cohort (0% vs. 11% in the nGEN group). In 5 out of 21 patients (24%), cMRI demonstrated SCE (exclusively nGEN cohort). Conclusion Temperature-controlled vHPSD catheter ablation allows straightforward PVI without evidence of oesophageal ulcerations or symptomatic complications. Catheter tip charring and silent cerebral lesions when using the nGEN generator have led to further modification.

Eine junge Patientin prasentiert sich mit Palpitationen. Bei der Abklarung fallen im Langzeit-EKG gehaufte ventrikulare Extrasystolen (VES) auf, echokardiographisch eine hochgradige Mitralklappeninsuffizienz mit Mitralklappenprolaps. Es wurde daher eine Mitralklappenoperation geplant, nach weiterem diagnostischen Work-up der Patientin wurde jedoch eine andere Therapie durchgefuhrt, die sich retrospektiv als hocheffizient darstellt.

In the light of the increasing importance of cardiovascular cross-sectional imaging in current guidelines, the goal of this study is to provide a comprehensive overview of cardiovascular imaging (CVI) offered by radiological institutions across Germany.Data were extracted from the national certification program database of the German Roentgen Society (DRG) from 2015-2021. A nationwide online survey among radiology institutes (university hospitals, non-university hospitals, and private practices) was conducted for 2019, and data was extracted from the European Society of Cardiovascular Radiology (ESCR) registry. The data collection's key points included the number of centers and individuals certified for CVI, the number of cardiac CT and MRI examinations performed, the reporting habits, and the participation in the ESCR registry.71 centers and 1278 persons, both with a substantial increase since 2015, were registered and certified by the DRG to perform CVI. According to the survey, a total of 69,286 CT and 64,281 MRI examinations were performed annually. Data from the survey and the ESCR registry indicated that reporting was mostly done solely by radiologists or, to a lesser degree, in joint consensus meetings with non-radiologists. The overall participation rate in the ESCR registry was 48 % among the survey's participants.This comprehensive analysis demonstrates that high-quality CVI by radiologists is available nationwide. The current challenges are to provide the best medical and technical quality of CVI by radiology for patient care and to ensure economic sustainability in the German health care system to accommodate the predicted substantial need for CVI in the future.· High-quality advanced CVI service by radiologists is available nationwide.. · Highly qualified specialist knowledge is widely represented from university to private practices.. · Certification programs successfully contribute to the disseminationdeepening of CVI expertise.. · The ESCR registry is an established international tool for the documentation of CVI..· Sieren M, Maintz D, Gutberlet M et al. Current Status of Cardiovascular Imaging in Germany: Structured Data from the National Certification Program, ESCR Registry, and Survey among Radiologists. Fortschr Röntgenstr 2022; 194: 181 - 191.ZIEL: Vor dem Hintergrund der stark zunehmenden Bedeutung der kardiovaskulären Schnittbildgebung (KVB) in den aktuellen Leitlinien soll diese Arbeit einen umfassenden Überblick über die von radiologischen Einrichtungen in Deutschland angebotene KVB geben.Die Daten wurden aus der Datenbank des nationalen Zertifizierungsprogramms der Deutschen Röntgengesellschaft (DRG) von 2015–2021 extrahiert. Für den Zeitraum 2019 wurden eine bundesweite Online-Befragung unter radiologischen Einrichtungen (Universitätskliniken, nichtuniversitäre Krankenhäuser und niedergelassene Ärzte) durchgeführt sowie Daten aus dem Register der European Society of Cardiovascular Radiology (ESCR) extrahiert. Zu den Kernpunkten der Datenerhebung gehörten die Anzahl der für KVB zertifizierten Zentren und Personen, die durchgeführten kardialen CT- und MRT-Untersuchungen, die Befundungsgewohnheiten und die Teilnahme am ESCR-Register.71 Zentren und 1278 Personen, jeweils mit einem deutlichen Anstieg seit 2015, waren für KVB von der DRG zertifiziert. Laut der Umfrage wurden in den teilnehmenden Einrichtungen insgesamt 69 286 CT- und 64 281 MRT-Untersuchungen jährlich durchgeführt. Die Daten aus der Umfrage und dem ESCR-Register zeigten, dass die Befundung der Untersuchungen meist durch Radiologen, in geringerem Maße in gemeinsamen Konsensus-Meetings mit nichtradiologischen Fachdisziplinen erfolgte. Die Teilnahmequote am ESCR-Register lag bei 48 %.Diese umfassende Analyse zeigt, dass eine qualitativ hochwertige KVB durch Radiologen flächendeckend verfügbar ist. Die aktuellen Herausforderungen bestehen darin, die beste medizinische und technische Qualität in der KVB für die Patientenversorgung durch Radiologen sicherzustellen und die wirtschaftliche Nachhaltigkeit im deutschen Gesundheitssystem zu gewährleisten, um den prognostizierten, erheblichen Bedarf an kardiovaskulärer Bildgebung in der Zukunft zu decken.· Hochqualifizierte KVB durch Radiologen ist bundesweit flächendeckend verfügbar.. · Hochqualifizierte Expertise ist in Universitätskliniken, Krankenhäusern und niedergelassenen Praxen breit vertreten.. · Zertifizierungsprogramme tragen erfolgreich zur Verbreitung und Vertiefung der KVB-Expertise bei.. · Das ESCR-Register ist ein etabliertes internationales Instrument zur Dokumentation der KVB..

Purpose The most common protocols in the initial diagnostic of acute ischemic stroke do not assess cardiogenic or aortic causes of embolism. These are usually evaluated later by transthoracic (TTE) or transesophageal (TEE) echocardiography. This study aimed to evaluate the feasibility of a diagnostic tool for thoracic cardiovascular thrombi according to the first experience with a new extended cardio-stroke protocol (Big 5—Jena eCS protocol) in acute stroke patients. Methods Retrospective analyses of the tomography scans database of the Jena University Hospital were performed. We included a total of 67 patients in the feasibility analyses, based on the evaluation of three outcomes. Results Primary outcome: the Big 5—Jena eCS protocol was able to detect thoracic cardiovascular thrombi in a total of 20 patients in different locations including the arch of the aorta, the aortic valve, the left atrium, the left atrial appendage, the left ventricle, and the pulmonary arteries. Secondary outcome: implementating the protocol did not result in a significant elevation of the radiation exposure compared to traditional protocols. Tertiary outcome: the new protocol identified seven cases that were considered negative by echocardiography. Conclusion The implementation of an extended cardio-stroke protocol is feasible, no significantly time-consuming, acquiring assessable imaging, and maintaining radiation exposure acceptable. The Big 5—Jena eCS protocol was also able to detect some thrombi not reported by TTE or TEE; however, due to our data’s explorative character, a conclusive comparison with cardiac ultrasound is not possible. A prospective pilot study and clinical trials should be conducted to assess the diagnostic accuracy of this protocol compared to echocardiography and determine the potential impact on diagnostic and treatment decisions.

ZusammenfassungDie klinischen Zeichen einer Infektion an der Hand können anfangs oder beim chronischen Verlauf subtil sein. Aber auch bei einem fortgeschrittenen Befund ist oft schwer abzuschätzen, inwieweit Weichteile, Gelenke und Knochen betroffen sind. Der folgende Artikel zeigt die diagnostischen Möglichkeiten der radiologischen Bildgebung. Die Röntgenaufnahme der betroffenen Region stellt die Basisdiagnostik dar. Die Sonografie gibt Aufschluss über eine Abszess- und Ergussbildung zur Abgrenzung gegenüber diffusen Flüssigkeitseinlagerungen. Beide stehen in der Regel zeitnah zur Verfügung. Bei chronischen Prozessen und unklaren Befunden kommt die MRT zum Einsatz, bei knöcherner Beteiligung und Verdacht auf eine Osteomyelitis bei liegenden Implantaten liefert die CT wichtige Informationen.

To investigate whether the current standard voltage cut-off of0.5 for dense scar definition on endocardial bipolar voltage mapping (EBVM), using a high-resolution multipoint mapping catheter with microelectrodes (HRMMC), correctly identifies the actual scar area described on CT with myocardial thinning (CT MT).Forty patients (39 men; 67.0 ± 9.0 y/o) with a history of transmural myocardial infarction (mean time interval since MI 15.0 ± 7.9 years) and sustained ventricular tachycardia (VT) were consecutively enrolled. A CT MT was performed in each patient before VT ablation. The CT MT 3D anatomical model, including MT layers, was merged with the 3D electroanatomical and EBVM. Different predefined cut-off settings for scar definition on EBVM were used to identify the optimal ones, which showed the best overlap in terms of scar area with the different MT layers.A cut-off value of0.2 mV demonstrated the best correlation in terms of scar area with the 2 mm thinning on CT MT (p = .04) and a cut-off of1 mV best overlapped with the 5 mm thinning (p = .003). The currently used0.5 mV cut-off for scar definition on EBVM proved to be the best area correlation with 3 mm thinning (p = .0002).In order to better identify the real extent of scar areas after transmural MI as described on preprocedural CT MT, higher cut-off values for scar definition should be applied if the EBVM is performed using a HRMMC.

OBJECTIVES The study objective was to describe the technique and outcomes of original coronary ostial slide plasty in patients with anomalous coronary artery origin (ACAO) localized in the aneurysmal ascending aorta (AA) being replaced because of its isolated pathology and otherwise non-pathological aortic root. METHODS A total of 23 patients (median age 52 years) with the ascending phenotype of proximal aorta aneurysm and ACAO of at least 1 coronary artery localized in the AA being replaced underwent ostial slide plasty to transpose the ACAO to the respective sinus of Valsalva and, consequently, to allow an AA replacement with placement of the proximal anastomosis at the level of the sinotubular junction (STJ). In 15 patients, the aortic valve was bicuspid, and all but 3 patients presented with a relevant valve defect. In addition to remodelling the STJs (all patients), valve-sparing repair or replacement was performed in 12 and 8 patients, respectively. RESULTS No patient died during the entire follow-up (median 72, range 3–183 months). One patient required replacement of a recurrently insufficient valve that was repaired primarily using cusp patch plasty, but there were no further cardiac reoperations nor any re-interventions on the proximal aorta, aortic valve and/or coronary artery ostia. Two patients received peripheral coronary stents (8 and 7 years after surgery, respectively) due to coronary heart disease. CONCLUSIONS Transposition of the ACAO from the replaced AA into the normal sinus of Valsalva using the ostial slide plasty offers a simple and safe surgical option enabling a recreation of a durable STJ at the level of the anastomosis between the root and the aortic graft.

ZusammenfassungKlinische und radiologische Diagnostik sind die Grundlage jeder differenzierten Therapieplanung karpaler Pathologien. Gerade bei der Kahnbeindiagnostik sind nicht nur die Auswahl und korrekte Durchführung der bildgebenden Verfahren entscheidend, sondern es müssen auch deren methodische Limitationen berücksichtig werden. Kaum eine andere Fraktur wird so häufig nicht erkannt, da nicht abgeklärt oder übersehen. Gleichzeitig führen die Folgen einer verspätet und/oder nicht behandelten Kahnbeinfraktur zu aufwändigen, nicht immer erfolgreichen Folgetherapien und langfristig zu funktionellen Einschränkungen. Diese Arbeit gibt einen Überblick über die klinische und bildgebende Diagnostik bei Kahnbeinfrakturen und -pseudarthrosen.

Objectives To associate coronary wall volume and composition, derived from coronary computed tomography angiography (CTA), with cardiac allograft vasculopathy (CAV) detected on invasive coronary angiography (ICA) in heart-transplanted (HTX) patients. Methods We included consecutive adults who received ICA and coronary CTA for evaluation of CAV ≥ 10 months after HTX. In all coronary segments, we assessed lumen and wall volumes and segmental length, calculated volume-length ratio (VLR) (volumes indexed by segmental length; mm3/mm), wall burden (WB) (wall/wall + lumen volumes; %), and assessed proportions of calcified, fibrotic, fibro-fatty, and low-attenuation tissue (%) in coronary wall. We rendered independent CTA measures associated with CAV by ICA, tested their discriminatory capacity, and assessed concordance between CTA and ICA. Results Among 50 patients (84% men; 53.6 ± 11.9 years), we analyzed 632 coronary segments. Mean interval between HTX and CTA was 6.7 ± 4.7 years and between ICA and CTA 1 (0–1) day. Segmental VLR, WB, and proportion of fibrotic tissue were independently associated with CAV (OR = 1.06–1.27; p ≤ 0.002), reaching a high discriminatory capacity (combination of all three: AUC = 0.84; 95%CI, 0.75–0.90). Concordance between CTA and ICA was higher in advanced CAV (88%) compared with that in none (37%) and mild (19%) CAV. Discordance was primarily driven by a large number of segments with coronary wall changes on CTA but without luminal stenoses on ICA (177/591; 25%). Conclusion CTA-derived coronary wall VLR, WB, and the proportion of fibrotic tissue are independent markers of CAV. Combination of these three parameters may aid the detection of early CAV not detected by ICA, the current standard of care. Key Points • Coronary CTA detects CAV in HTX patients. • Coronary wall volume-length ratio, wall burden, and proportion of fibrotic tissue are independently associated with CAV. • In contrast to ICA, coronary CTA may identify the early stages of CAV.

High power short duration (HPSD) ablation proved to be an effective and safe ablation technique for atrial fibrillation (AF). In former case series, a significant amount of postablation coagulation at the catheter tip as well as silent cerebral lesions (SCL) in postprocedural cerebral magnetic resonance (cMRI) have been identified in patients undergoing de-novo AF ablations with very high power 90 W short duration (vHPvSD) ablations using the QDot ablation catheter in combination with a novel RF generator (nGEN, Biosense Webster). Therefore, the RF generator software has been recently modified.Consecutive patients undergoing a first AF ablation including pulmonary vein isolation (PVI) with vHPvSD (90 W, with a predefined ablation time of 3 s at posterior left atrium (LA) wall sites and 4 s at other ablation sites) using the QDOT Micro ablation catheter (Biosense Webster) in conjunction with the technically modified nGEN RF generator (software V1c; Biosense Webster) were included. Procedural characteristics including first-pass isolation per pulmonary vein (PV) pair and early reconnection location within the 30-min waiting period were recorded. In all patients postablation endoscopy to document any thermal esophageal injury (EDEL) and in eligible patients a cMRI to detect silent cerebral events (SCEs)/lesions were performed. All acute procedure-related complications were recorded during the time until hospital discharge. Furthermore, short-term and midterm success after 3 and 6-12 months of follow-up was investigated. In total, 34 consecutive patients (67 ± 9 years; 62% male; 68% paroxysmal AF) were included. First-pass isolation of all PVs was achieved in 6/34 (18%) patients. First-pass isolation was seen in 37/68 (54%) of PV pairs. Early reconnection occurred in 11 (32%) patients (including reconnections at posterior LA wall sites n = 6 and at nonposterior sites n = 5). No patient had an EDEL (0%). In 6/23 (26%) patients undergoing postablation cerebral MRI SCEs were identified. In six patients, coagulation on the catheter tip was detected at the end of the procedure. No further peri- or postprocedural complications were detected. Early AF recurrence before discharge was seen in 1/34 (3%) of the patients included in this study. Within 3 months 10/34 (29%) revealed AF recurrence during blanking period. After a mean follow-up of 7 months, 31/34 (88%) patients revealed sinus rhythm.AF ablation using 90 W vHPvSD with a specialized ablation catheter in conjunction with a recently modified RF generator was associated with no EDEL in the whole study cohort and 26% SCEs in a subgroup of patients undergoing acute postablation cerebral MRI. Accordingly, to our previously published results, a relevant number of catheter tip coagulations was identified in this patient cohort even after modifications of the RF generator. The vHPvSD ablation technique using the present and the previous generator seems to be associated with a very low rate of esophageal injury. However, the recently revised generator software also produced a relevant number of catheter tip coagulum formation and SCEs.

To compare the use of coronary computed tomography angiography (CCTA) between academic and non-academic sites across Europe over the last decade.We analyzed a large multicenter registry (ESCR MR/CT Registry) of stable symptomatic patients who received CCTA 01/2010-01/2020 at 47 (22%) academic and 165 (78%) non-academic sites across 19 European countries. We compared image quality, radiation dose, contrast-media-related adverse events, patient characteristics, CCTA findings, and downstream testing between academic and non-academic sites.Among 64,317 included patients (41% female; 60 ± 13 years), academic sites accounted for most cases in 2010-2014 (52%), while non-academic sites dominated in 2015-2020 (71%). Despite less contemporary technology, non-academic sites maintained low radiation doses (4.76 [2.46-6.85] mSv) with a 30% decline of high-dose scans (7 mSv) over time. Academic and non-academic sites both reported diagnostic image quality in 98% of cases and low rate of scan-related adverse events (0.4%). Academic and non-academic sites examined similar patient populations (41% females both; age: 61 ± 14 vs. 60 ± 12 years; pretest probability for obstructive CAD: low 21% vs. 23%, intermediate 73% vs. 72%, high 6% both, CAD prevalence on CCTA: 40% vs. 41%). Nevertheless, non-academic sites referred more patients to non-invasive ischemia testing (6.5% vs. 4.2%) and invasive coronary angiography/surgery (8.5% vs. 5.6%).Non-academic and academic sites provide safe, high-quality CCTA across Europe, essential to successfully implement the recently updated guidelines for the diagnosis and management of chronic coronary syndromes. However, despite examining similar populations with comparable CAD prevalence, non-academic sites tend to refer more patients to downstream testing.• Smaller non-academic providers increasingly use CCTA to rule out obstructive coronary artery disease. • Non-academic and academic sites provide comparably safe, high-quality CCTA across Europe. • Compared to academic sites, non-academic sites tend to refer more patients to downstream testing.

To evaluate the results after selective sinus replacement (SSR) for aortic root remodeling in bicuspid aortopathy.Among 662 patients who underwent root repair using SSR between 2005 and 2020, there were 114 with bicuspid aortopathy. SSR was performed either as an isolated procedure (31) or as an adjunct to aortic valve repair (83) and was adjusted to the existing aortic annulus diameter rather than a downsized diameter. In valves with asymmetrical commissural orientation, the repair aimed for the achievement of a 180°-commissural orientation.Abolishment of aortic insufficiency (AI) ≥2+ using root repair alone was only possible in 2 patients with acute-dissection-related AI, yet isolated root repair was also performed in 29 further patients with no/mild AI. All remaining patients with AI ≥2+ presented cusp-related regurgitation and necessitated an additional valve repair. During the mean follow-up of 91 months (range, 13-196), a relevant valve defect (AI ≥3+ in 8, stenosis in 2) occurred in 10 patients (all after combined repair) resulting in an estimated freedom from a relevant aortic valve defect and/or reoperation of 96 ± 2%, 89 ± 4%, and 82 ± 6% at 5, 10, and 12 years, respectively. Echocardiographically, no patient revealed a considerable change of form or size of the repaired root nor was any root reintervention necessary.Patient-tailored root repair using SSR is a very effective and durable valve-sparing approach for bicuspid aortopathy. Aortic cusp repair is decisive for both abolishment of AI in bicuspid aortopathy and for the functional durability of the repaired aortic valve.

We report a rare case of complex coronary fistula that contained two aneurysms and was connected to the descending aorta. The fistula was also associated with further aortic pathologies necessitating surgery. Preoperative computed tomography angiography, which revealed an abnormal vessel communication, was crucial for choosing the appropriate operative strategy. During a one-stage procedure comprising closure of both arterial (aortic and coronary) fistula origins and repair of the aortic valve and thoracic aorta, the coronary origin of the fistula was ligated and the frozen elephant trunk technique was used to close the aortic origin.

Background Computed tomography (CT) can be used as the primary screening modality for the evaluation of patients suspected of having acute mesenteric ischemia known to show high sensitivity and specificity rates. Purpose To prove the value of CT in patients with pathological abdominal findings following cardiac surgery. Material and Methods In a retrospective case-control study, 12 different CT scan parameters of patients with or without mesenteric ischemia following cardiac surgery were compared using univariate and logistic regression analyses. Results Of 14,176 patients, 133 (0.9%) received an abdominal CT scan during postoperative care due to pathological abdominal findings. Sixty-eight patients were diagnosed with acute mesenteric ischemia. In-hospital mortality was 73.5% for this group. CT parameters with the highest specificity for indicating colonic ischemia were intestinal (99%) or porto-venous (96%) pneumatosis, abnormal contrast medium enhancement (89%), and occlusion of the proximal inferior mesenteric artery (81%). All of those parameters showed low sensitivity levels in the range of 15%–23%. A statistically significant association between acute mesenteric ischemia and CT appearance was obtained for contrast medium enhancement (odds ratio [OR] 12.2, 95% confidence interval [CI] 1.5–99.2) and intestinal pneumatosis (OR 21.0, 95% CI 2.7–165.2) only. Conclusion The typical CT criteria indicating mesenteric ischemia lose their accuracy in patients under critical clinical conditions. As CT remains the first-line diagnostic imaging modality for abnormal abdominal findings following cardiac surgery, negative signs should not prevent early laparotomy if clinical suspicion remains high.

Accurate assessment of the aortic annulus is crucial for successful transcatheter aortic valve replacement (TAVR), in particular to prevent paravalvular regurgitation (PVR). We compared aortic annular sizing using multidetector computed tomography (MDCT) and three-dimensional transoesophageal echocardiography (3-D TEE) to determine the predictive value of MDCT. All patients admitted for transfemoral TAVR [n = 227; 48.9% balloon expandable (Edwards Sapien 3); 51.1% self-expandable (Core Valve, Evolut R)] at our institution from January 2015 until December 2016 were analysed retrospectively. Aortic annular parameters were obtained either by MDCT or 3-D TEE. Additionally, we included a cohort of patients (n = 27) assessed by both MDCT and 3D TEE between October 2017 and April 2018 to enable intra-individual comparison of the two methods. Indications for TAVR were severe degenerative aortic stenosis (AS; 94.7%) or re-stenosis after surgical AVR (5.3%). 74.4% were classified as high-gradient AS. The mean age was 80 (37–94) years and 75.8% presented with NYHA III/IV. STS risk of mortality was intermediate (3.5 ± 2.3). MDCT and 3-D TEE were performed in 116 and 111 patients for aortic annulus sizing, respectively. Significantly larger implants were chosen in the CT group irrespective of prosthesis type or post-dilatation. Follow-up (median at 79 days) revealed significantly less PVR in the MDCT compared to 3-D TEE group (absence of PVR in 59.3% and 40.7%, p = 0.016), without differences in mortality. Patients without PVR or mild PVR had a better clinical performance according to NYHA class (p = 0.016). MDCT is superior to 3-D TEE in terms of sizing accuracy and clinical outcomes. Reduction of PVR after TAVR with MDCT is likely due to valve annulus undersizing by TEE.

Introduction Aim of this study was to evaluate efficacy and safety of ventricular tachycardia (VT) catheter ablation in patients with structural heart disease (SHD) in relation to the presence of an intramural septal substrate. Methods Consecutive patients undergoing VT ablation between January 2019 and October 2020 were included. All patients were stratified based on the presence of relevant septal substrate and freedom from VT recurrences were analyzed. Results In total, 199 consecutive patients (64.2 ± 13.0 years; 89% male; 55% ischemic cardiomyopathy (ICM)) undergoing VT ablation were included. 129/199 patients (65%) showed significant septal substrate (55/90 patients (61%) with non-ischemic cardiomyopathy (NICM) compared to 74/109 patients (68%) with ICM; p = 0.37). Acute procedural success with elimination of all inducible VTs was achieved in 66/70 patients (94%) without and in 103/129 patients (80%) with a septal substrate (p = 0.007). In the cohort including patients with a clinical FU, 15/60 patients (25%) without a septal substrate and 48/123 patients (39%) with a septal substrate experienced VT recurrence during a FU of 8.1 ± 5.9 months (p = 0.069). Conclusion Presence of septal VT substrate in patients with a structural heart disease or coronary artery disease is common. Acute success of VT catheter ablation was significantly higher and mid-term success tended to be higher in patients without a septal substrate.

Background: The PASCAL system (Edwards Lifescience, Irvine, CA, USA) is a novel device for edge-to-edge treatment of mitral regurgitation (MR). The aim of our study was to examine the functional and hemodynamic outcome after repair of functional (FMR) and degenerative mitral regurgitation (DMR) using the PASCAL system in a real-world setting. Methods: A total 92 consecutive patients with symptomatic MR 3+/4+ were treated in our institute using the PASCAL device. Primary endpoints included procedural success, clinical success, and major adverse event rate at 30 days and 7 months. Results: 68.5% had a functional and 31.5% a degenerative etiology. Overall success rate was achieved in 97.8% patients (98.4% FMR, 96.6% DMR). At follow-up, 85.7% of the patients (89.2% FMR, 78.3% DMR) had MR grade ≤ 1. 96.4% (97.4% FMR, 94.4% DMR) were in New York Heart Association class I or II. Six-minute walking distance improved by 96 m (92 m FMR, 106 m DMR), Kansas City Cardiomyopathy Questionnaire improved by 19 points (19 points FMR, 19 points DMR). Pro-B-type natriuretic peptide (proBNP) levels decreased from 4673 to 2179 pg/dl (5239–2018 pg/ml FMR, 3418–2530 pg/ml DMR) and mean pulmonary capillary wedge pressure from 21 to 16 mmHg (21–17 mmHg FMR, 19–13 mmHg DMR). At 30 days, there was 1 cardiovascular death (1.2%) with DMR. At 1 year, Kaplan-Meier survival was 86% (86% FMR, 86% DMR). Conclusions: Severe MR can successfully and safely be treated with the PASCAL device regardless of etiologies. This interventional approach resulted in a sustained MR reduction, improvement in exercise capacity, quality of life, proBNP levels, and hemodynamics in FMR and DMR at follow-up.

Clinical signs of an infection of the hand can be subtle initially or in a chronic state. But even in a progressive stadium it might be difficult to define an involvement of soft tissue, joint or bone. This review article addresses the diagnostic options of radiologic imaging. Radiographs of the affected region are the basic diagnostics. Sonographics provides information about an abscess or effusion versus diffuse edema and phlegmon. Both are in most situations promptly available. In chronic cases and unclear findings, MRI is of value. With bone involvement and an implant related osteomyelitis suspected, CT is the most valid method.Die klinischen Zeichen einer Infektion an der Hand können anfangs oder beim chronischen Verlauf subtil sein. Aber auch bei einem fortgeschrittenen Befund ist oft schwer abzuschätzen, inwieweit Weichteile, Gelenke und Knochen betroffen sind. Der folgende Artikel zeigt die diagnostischen Möglichkeiten der radiologischen Bildgebung. Die Röntgenaufnahme der betroffenen Region stellt die Basisdiagnostik dar. Die Sonografie gibt Aufschluss über eine Abszess- und Ergussbildung zur Abgrenzung gegenüber diffusen Flüssigkeitseinlagerungen. Beide stehen in der Regel zeitnah zur Verfügung. Bei chronischen Prozessen und unklaren Befunden kommt die MRT zum Einsatz, bei knöcherner Beteiligung und Verdacht auf eine Osteomyelitis bei liegenden Implantaten liefert die CT wichtige Informationen.

Objectives The study aim was to evaluate long-term results after anatomic restoration of the aortic root. Methods During an 18-year period, a total of 669 patients underwent valve-sparing root repair (aneurysm 554, dissection 115) using selective sinus replacement. None/trivial, mild, moderate, and severe (grades 3+ and 4+) insufficiency were present in 57, 146, 204, and 262 patients, respectively. Results The anatomic repair was adjusted to the existing aortic annulus diameter, which was 27.0 ± 3.0 mm on average. Replacement of 1, 2, or 3 sinuses of Valsalva was performed in 209, 234, and 226 patients, respectively. Altogether, 454 additional procedures on the cusps were performed, mostly as cusp patch plasty with pericardium (210). Thirty-day mortality was 0.6%. The mean follow-up duration was 7.1 ± 4.1 years (range, 0.01-19.1 years). The estimated freedom from relevant aortic insufficiency grade 3+ or greater (15 events) was 98% ± 1%, 97% ± 1%, and 94% ± 3% at 5, 10, and 15 years, respectively. On echocardiogram, no patient revealed a considerable change of the form or size of the repaired root, which was confirmed radiologically in 160 patients who received computed tomography angiography for any reason. Multivariate logistic regression analysis identified cusp prolapse/pseudo-prolapse as the only independent risk factor for the development of recurrent insufficiency grade 2+ or greater (41 occurrences), with a hazard ratio of 3.258 (95% confidence interval, 1.658-6.403; P = .001). An association between aortic annulus size and functional results could not be demonstrated. Conclusions Patient-tailored root repair using isolated sinus replacement offers excellent functional long-term results regardless of underlying root pathology or annulus size. Aortic cusp pathology was decisive for long-term valve function.

Clinical and radiological diagnostics are the base of a differentiated treatment of carpal disorders. With special regard to diagnostics of the scaphoid, not only the choice and the correct implementation of the imaging methods are crucial, but also their methodical limitations have to be taken into account. No other common fracture is more often undiagnosed, because neglected or overlooked. Concomitantly, delayed or untreated scaphoid fractures require demanding therapies in the sequel and may lead to functional restrictions in the long-term. This review article aims to discuss the clinical and imaging diagnostics for scaphoid fractures and non-union.Klinische und radiologische Diagnostik sind die Grundlage jeder differenzierten Therapieplanung karpaler Pathologien. Gerade bei der Kahnbeindiagnostik sind nicht nur die Auswahl und korrekte Durchführung der bildgebenden Verfahren entscheidend, sondern es müssen auch deren methodische Limitationen berücksichtig werden. Kaum eine andere Fraktur wird so häufig nicht erkannt, da nicht abgeklärt oder übersehen. Gleichzeitig führen die Folgen einer verspätet und/oder nicht behandelten Kahnbeinfraktur zu aufwändigen, nicht immer erfolgreichen Folgetherapien und langfristig zu funktionellen Einschränkungen. Diese Arbeit gibt einen Überblick über die klinische und bildgebende Diagnostik bei Kahnbeinfrakturen und -pseudarthrosen.

To examine the functional and hemodynamic mid-term outcome at 5 months of mitral regurgitation (MR) reduction using the PASCAL repair system. Between July 2019 and February 2020 31 consecutive patients with MR 3 +/4 + (mean age 77.5 years, all in New York Heart Association (NYHA) class III–IV, STS score 9.1 ± 7.4) underwent MR reduction in our institute using the PASCAL device. 61.3% had a functional, 29.0% a degenerative, and 9.7% a mixed etiology. Successful implantation was achieved in 30/31 (96.8%) patients. 27/31 patients (87.1%) completed 5-month follow-up with clinical, echocardiographic, laboratory and hemodynamic assessment. At 5 months, 70.4% of the patients had MR grade ≤ 1 (p

To identify CT parameters independently associated with infectious mediastinitis after cardiac surgery and to improve the discrimination of patients with acute infection from those with normal postoperative changes. In this single-center, retrospective, observational cohort study, we evaluated thoracic CT scans of poststernotomy cardiac surgery patients. Inclusion criteria were clinically suspected mediastinitis, unclear CT signs (e.g., retrosternal mass), and subsequent deep revision surgery. Revision surgery and microbiological samples determined the mediastinitis status. Overall, 22 qualitative and quantitative CT imaging parameters were assessed and associated with infectious mediastinitis in univariate and multivariate regression models. Discriminative capacity and incremental value of the CT features to available clinical parameters were determined by AUC and likelihood-ratio tests, respectively. Overall 105 patients (82% men; 67.0 ± 10.3 years) underwent CT and deep revision surgery. Mediastinitis was confirmed in 83/105 (79%) patients. Among available clinical parameters, only C-reactive protein (CRP) was independently associated with infectious mediastinitis (multivariate odds ratio (OR) (per standard deviation) = 2.3; p

Die koronare CT-Angiografie hat in den Leitlinien und in der Klinik einen immer hoheren Stellenwert in der Primardiagnostik der koronaren Herzkrankheit – mit einer hohen Sensitivitat und einem hohen negativen pradiktiven Wert. Die Spezifitat der Methode kann jedoch noch besser werden – z. B. mit neuen Methoden der Ischamiediagnostik wie der CT-FFR und der CT-Perfusion. Coronary CT-angiography (CCTA) plays an increasing role in the primary diagnostics of coronary artery disease (CAD) according to the present guidelines but also in clinical reality. The sensitivity and negative predictive value of CCTA is very high, but the specificity could still be improved. Newer techniques to assess myocardial ischemia like CT-FFR and CT-Perfusion may help to achieve that goal.

To compare cardiac left ventricular (LV) parameters in simultaneously acquired hybrid fluorine-18-fluorodeoxyglucose ([18F] FDG) positron emission tomography/magnetic resonance imaging (PET/MRI) in patients with residual tracer activity of upstream PET/CT. Twenty-nine patients (23 men, age 58±17 years) underwent cardiac PET/MRI either directly after a non-cardiac PET/CT with homogenous cardiac [18F] FDG uptake (n=20) or for viability assessment (n=9). Gated cardiac [18F] FDG PET and cine MR sequences were acquired simultaneously and evaluated blinded to the cross-imaging results. Image quality (IQ), end-diastolic (LVEDV), end-systolic volume (LVESV), ejection fraction (LVEF) and myocardial mass (LVMM) were measured. Pearson correlation and intraclass correlation coefficient (ICC), regression and a Bland–Altman analysis were assessed. Except LVMM, volumetric and functional LV parameters demonstrated high correlations (LVESV: r=0.97, LVEDV: r=0.95, LVEF: r=0.91, LVMM: r=0.87, each p

Ventricular tachycardias (VT) in patients with structural heart diseases have predominantly a scar-associated reentry mechanism so that substrate-based ablation approaches also have to be used in nearly all procedures. In many VT cases-especially in nonischemic cardiomyopathy (NICM) and arrhythmogenic right ventricular cardiomyopathy-a critical epicardial substrate can be identified as an essential component of the reentry circuit so that for the ablation-based modification of the substrate in these cases an epicardial approach is necessary. In cases of redo-VT ablation procedures in ischemic cardiomyopathy (after a previously endocardial ablation), an epicardial approach should also be considered. There are also cases in whom no endocardial substrate can be identified and an isolated epicardial substrate can be identified. Worldwide epicardial VT ablations are usually performed after gaining epicardial access using subxyphoidal puncture. The results of recent studies show a higher efficiency with stabilization of cardiac rhythm and reduction of recurrent VT episodes (about 70% event-free survival at the 2‑year follow-up) after endo-plus epicardial substrate modification. In electrical storm cases, an early epicardial VT ablation approach also appears to be relevant, especially in NICM. Epicardial instrumentation and ablation represents a complex procedure which should only be performed in experienced centers with cardiac surgery back-up. In these experienced centers, the complications rate is less than 5%.

Background: Triangular fibrocartilage complex (TFCC) lesions commonly cause ulnar-sided wrist pain and instability of the distal radioulnar joint. Due to its triangular shape, discontinuity of the TFCC is oftentimes difficult to visualize in radiological standard planes. Radial multiplanar reconstructions (MPR) may have the potential to simplify diagnosis in CT wrist arthrography. The objective of this study was to assess diagnostic advantages provided by radial MPR over standard planes for TFCC lesions in CT arthrography. Methods: One hundred six patients (49 women, 57 men; mean age 44.2 ± 15.8 years) underwent CT imaging after wrist arthrography. Two radiologists (R1, R2) retrospectively analyzed three randomized datasets for each CT arthrography. One set contained axial, coronal and sagittal planes (MPR\(_{Standard}\)), while the other two included an additional radial reconstruction with the rotating center either atop the ulnar styloid (MPR\(_{Styloid}\)) or in the ulnar fovea (MPR\(_{Fovea}\)). Readers evaluated TFCC differentiability and condition. Suspected lesions were categorized using Palmer’s and Atzei’s classification and diagnostic confidence was stated on a fivepoint Likert scale. Results: Compared to standard planes, differentiability of the superficial and deep TFCC layer was superior in radial reconstructions (R1/R2; MPR\(_{Fovea}\): p < 0.001; MPRStyloid: p ≤ 0.007). Palmer and Atzei lesions were present in 86.8% (92/106) and 52.8% (56/106) of patients, respectively. Specificity, sensitivity and accuracy for central Palmer lesions did not differ in radial and standard MPR. For peripheral Atzei lesions, sensitivity (MPR\(_{Standard}\) 78.6%/80.4%, MPR\(_{Styloid}\) 94.6%/94.6%, MPR\(_{Fovea}\) 91.1%/89.3%) and accuracy (MPR\(_{Standard}\) 86.8%/86.8%, MPR\(_{Styloid}\) 96.2%/96.2%, MPR\(_{Fovea}\) 94.3%/93.4%) improved with additional styloid-centered (p = 0.004/0.008) and foveacentered (p = 0.039/0.125) reconstructions. No substantial difference was observed between both radial MPR (p = 0.688/0.250). Interrater agreement was almost perfect for each dataset (κ\(_{Standard}\) = 0.876, κ\(_{Styloid}\) = 0.894, κ\(_{Fovea}\) = 0.949). Diagnostic confidence increased with addition of either radial MPR (p < 0.001). Conclusions: Ancillary radial planes improve accuracy and diagnostic confidence for detection of peripheral TFCC lesions in CT arthrography of the wrist.

Aims To correlate oesophageal magnetic resonance imaging (MRI) abnormalities with ablation-induced oesophageal injury detected in endoscopy. Methods and results Ablation-naïve patients with atrial fibrillation (AF), who underwent ablation using a contact force sensing irrigated radiofrequency ablation catheter, received a cardiac MRI on the day of ablation, and post-ablation oesophageal endoscopy (OE) 1 day after ablation. Two MRI expert readers recorded presence of abnormal oesophageal tissue signal intensities, defined as increased oesophageal signal in T2-fat-saturated (T2fs), short-tau inversion-recovery (STIR), or late gadolinium enhancement (LGE) sequences. Oesophageal endoscopy was performed by experienced operators. Finally, we correlated the presence of any affection with endoscopically detected oesophageal thermal lesions (EDEL). Among 50 consecutive patients (age 67 ± 7 years, 60% male), who received post-ablation MRI and OE, complete MRI data were available in 44 of 50 (88%) patients. In OE, 7 of 50 (14%) presented with EDEL (Category 1 lesion: erosion n = 3, Category 2 lesion: ulcer n = 4). Among those with EDEL, 6 of 7 (86%) patients presented with increased signal intensities in all three MRI sequences, while only 2 of 37 (5%) showed hyperintensities in all three MRI sequences and negative endoscopy. Correspondingly, sensitivity, specificity, positive predictive value, and negative predictive value (NPV) for MRI (increased signal in T2fs, STIR, and LGE) were 86%, 95%, 75%, and 97%, respectively. Conclusion Increased signal intensity in T2fs, STIR, and LGE represents independent markers of EDEL. In particular, the combination of all three has the highest diagnostic value. Hence, MRI may represent an accurate, non-invasive method to exclude acute oesophageal injury after AF ablation (NPV: 97%).

Three-dimensional rotational angiography (3D-RA) is routinely used in many different medical fields including neurovascular treatments and electrophysiological procedures. With the advent of transcatheter valve implantation and extensive aortic repair, 3D-RA has evolved to be an additional valuable imaging tool to optimize procedural success in endovascular treatment and cardiothoracic surgery.

Objectives The aim of the study was to evaluate the incidences of innominate artery (IA) involvement in aortic arch pathology necessitating surgery, the surgical strategies and the operative results. Methods Among the 366 patients who underwent total/subtotal arch replacement because of non-acutely dissected aortic pathology between 2004 and June 2017, there were 46 (12.6%) patients (29 males; mean age 69 ± 10, range 35-84 years) with IA involvement. Pathologies necessitating replacement of the IA were chronic aneurysm including progression of chronic dissection, severe atherosclerosis with or without an aneurysmatic dilatation, and inflammatory vasculitis in 34, 11 and 1 patient, respectively. All data were collected prospectively, and intention-to-treat analysis was performed. Results All patients underwent total/subtotal aortic arch replacement using unilateral cerebral perfusion (mean duration 44.6 ± 15.7 min) under mild hypothermia (30.6 ± .4°C). In addition to arch and IA replacement, repair of one or two further supra-aortic arteries was performed in 20 and 23 patients, respectively. One patient underwent complete thoracic aorta replacement via clamshell thoracotomy. The aortic valve, which was the most frequent object of concomitant surgery, was replaced in 18 (including 3 valve composite-grafts) and repaired in 20 (18 valve-sparing root repairs) patients. Early (30-day and/or in-hospital) mortality was 0. The rate of permanent neurological deficit was 2.2% (1 patient with a huge, partially thrombosed arch and innominate aneurysm). Transient neurological dysfunctions such as agitation were observed in 6 patients. Conclusions Involvement of the IA in aortic arch surgery is not infrequent, and its concomitant replacement using well-considered cannulation, perfusion and surgical strategy offers excellent operative outcomes.

Introduction Dilatation of the ascending aorta is a common finding in Tetralogy of fallot (TOF). We sought to provide aortic dimensions in children and adolescents after corrected TOF obtained by contrast-enhanced cardiac-magnetic-resonance angiography (CE-CMRA) that could serve as reference values. Materials and methods We enrolled 101 children and adolescents (56 male) with a median age of 10.9 years. All patients underwent CE-CMRA imaging using a 3-dimensional spoiled gradient-echo-sequence. Aortic diameters were measured at the level of the aortic valve (AV), aortic sinus (AS), sino-tubular junction (STJ) and the ascending aorta (AA) and compared with normal values obtained from literature. Sex-specific aortic dimensions are given as percentile curves as well as z scores. Furthermore CMR volumetric and functional parameters as well as clinical and anamnestic data were analyzed to identify parameters that are associated with aortic dilatation. Results Diameters for aortic size for males were 3.6 + 16.6*BSA0.5 at the AV level, 7.0 + 19.5*BSA0.5 at the AS level, 7.0 + 14.4*BSA0.5 at the STJ level and 7.3 + 15.5*BSA0.5 at the AA level. Diameters for females were 5.8 + 14.1*BSA0.5 at the AV level, 7.2 + 17.6*BSA0.5 at the AS level, 5.2 + 15.4*BSA0.5 at the STJ level and 2.0 + 17.8*BSA0.5 at the AA level. All diameters in TOF patients were larger compared with normal values. The postoperative interval and age at examination were the only parameters associated with aortic size at all measured levels. Conclusion We provide CE-CMRA data of aortic dimensions in children and adolescents after correction of TOF. Our data might be useful for an estimation of the “normal” aortic size in this patient cohort and can serve as a basis for future longitudinal studies adding prognostic data.

The aim of this study was to analyze the angle between the left ventricular (LV) long axis and the LV outflow tract (αLV-LVOT) on cardiac computed tomography and to describe its effect on the occurrence of paravalvular leakage (PL), fluoroscopy time, and postoperative creatine kinase-MB levels in transapical transcatheter aortic valve replacement (TA-TAVR).High-risk patients with severe aortic stenosis scheduled for TA-TAVR using an Edwards SAPIEN (Edwards Lifesciences, Irvine, CA) prosthesis were retrospectively included. The αLV-LVOT was measured during systole and diastole as far as retrospectively gated data sets were available. The αLV-LVOT was correlated with the occurrence of PL, total fluoroscopy time, and postoperative creatine kinase-MB levels. Interobserver variability was assessed in all cases.The study included 81 patients (57 women [70.4%], 24 men [29.6%]) with an average age of 81.9±5.8 years. The mean αLV-LVOTs were 61.8±9.9 degrees during systole and 61.1±10.0 degrees during diastole. There was a minimal, nonsignificant change in the αLV-LVOT between systole and diastole of 0.2±4.1 degrees (p=0.7). PL was found in 39 patients: grade 0 in 42 (51.9%), grade I in 30 (37.0%), and grade II in 9 (11.1%). Patients with a clinically significant PL (grade≥II) showed a significantly greater mean αLV-LVOT than patients with grade I or without PL (mean difference, 13.8±3.2 degrees; p0.001). No significant correlation was found between the αLV-LVOT and total fluoroscopy time (r=-0.17, p=0.16) and postoperative creatine kinase-MB levels (r=-0.1, p=0.44).During TA-TAVR, greater αLV-LVOTs were associated with significantly higher grades of PL. Thus, the αLV-LVOT might influence the selection of the transapical implantation path and could have a significant effect on designs for future stents or novel delivery devices.

Background Intramyocardial haemorrhage (IMH) and microvascular obstruction (MVO) represent reperfusion injury after reperfused ST-elevation myocardial infarction (STEMI) with prognostic impact and “hypointense core” (HIC) appearance in T2-weighted images. We aimed to distinguish between IMH and MVO by using T2*-weighted cardiovascular magnetic resonance imaging (CMR) and analysed influencing factors for IMH development. Methods and results A total of 151 patients with acute STEMI underwent CMR after primary angioplasty. T2-STIR sequences were used to identify HIC, late gadolinium enhancement to visualise MVO and T2*-weighted sequences to detect IMH. IMH+/IMH− patients were compared considering infarct size, myocardial salvage, thrombolysis in myocardial infarction (TIMI) flow, reperfusion time, ventricular volumes, function and pre-interventional medication. Seventy-six patients (50 %) were IMH+, 82 (54 %) demonstrated HIC and 100 (66 %) MVO. IMH was detectable without HIC in 16 %, without MVO in 5 % and HIC without MVO in 6 %. Multivariable analyses revealed that IMH was associated with significant lower left ventricular ejection fraction and myocardial salvage index, larger left ventricular volume and infarct size. Patients with TIMI flow grade ≤1 before angioplasty demonstrated IMH significantly more often. Conclusions IMH is associated with impaired left ventricular function and higher infarct size. T2 and HIC imaging showed moderate agreement for IMH detection. T2* imaging might be the preferred CMR imaging method for comprehensive IMH assessment. Key Points • Intramyocardial haemorrhage is a common finding in patients with acute reperfused myocardial-infarction. • T2*imaging should be the preferred CMR method for assessment of intramyocardial haemorrhage. • Intramyocardial haemorrhage can be considered as an important influencing factor on patient’s outcome.

Objective Comparing the diagnostic value of multi-sequential cardiac magnetic resonance imaging (CMR) with endomyocardial biopsy (EMB) for sub-clinical cardiac allograft rejection. Methods One hundred and forty-six examinations in 73 patients (mean age 53 ± 12 years, 58 men) were performed using a 1.5 Tesla system and compared to EMB. Examinations included a STIR (short tau inversion recovery) sequence for calculation of edema ratio (ER), a T1-weighted spin-echo sequence for assessment of global relative enhancement (gRE), and inversion-recovery sequences to visualize late gadolinium enhancement (LGE). Histological grade ≥1B was considered relevant rejection. Results One hundred and twenty-seven (127/146 = 87 %) EMBs demonstrated no or mild signs of rejection (grades ≤1A) and 19/146 (13 %) a relevant rejection (grade ≥1B). Sensitivity, specificity, positive predictive, and negative predictive values were as follows: ER: 63 %, 78 %, 30 %, and 93 %; gRE: 63 %, 70 %, 24 %, and 93 %; LGE: 68 %, 36 %, 13 %, and 87 %; with the combination of ER and gRE with at least one out of two positive: 84 %, 57 %, 23 %, and 96 %. ROC analysis revealed an area under the curve of 0.724 for ER and 0.659 for gRE. Conclusion CMR parameters for myocarditis are useful to detect sub-clinical acute cellular rejection after heart transplantation. Comparable results to myocarditis can be achieved with a combination of parameters. Key Points • Magnetic resonance imaging is useful for the assessment of cardiac allograft rejection. • CMR has a high negative predictive value for exclusion of allograft rejection. • Diagnostic performance is not yet good enough to replace endomyocardial biopsy.

To assess if real-time magnetic resonance (MR) imaging-guided radiofrequency (RF) ablation for atrial flutter is feasible in patients.The study complied with the Declaration of Helsinki and was approved by the local ethics committee. All patients were informed about the investigational nature of the procedures and provided written informed consent. Ten patients (six men; mean age ± standard deviation, 68 years ± 10) with symptomatic atrial flutter underwent isthmus ablation. In all patients, two MR imaging conditional steerable diagnostic and ablation catheters were inserted into the coronary sinus via femoral sheaths and into the right atrium with fluoroscopic guidance. The patients were then transferred to a 1.5-T whole-body MR imager for an ablation procedure, in which the catheters were manipulated by an electrophysiologist by using a commercially available interactive real-time steady-state free precession MR imaging sequence.All catheters were placed in standard positions successfully. Furthermore, simple programmed stimulation maneuvers were performed. In one of 10 patients, a complete conduction block was performed with MR imaging guidance. In nine of 10 patients, creating only a small number of additional touch-up lesions was necessary to complete the isthmus block with conventional fluoroscopy (median, three lesions; interquartile range, two to four lesions).Real-time MR imaging-guided placement of multiple catheters is feasible in patients, with subsequent performance of stimulation maneuvers and occasional complete isthmus ablation.

Es wird uber die „Hybridtherapie“ eines ausgedehnten thorakalen Aneurysmas des Aortenbogens und der Aorta descendens mithilfe der Transposition der supraaortalen Gefase („debranching“) und anschliesender Stentgraft-Implantation („thoracic endovascular aortic repair“, TEVAR) bei einem 81-jahrigen Patienten berichtet. Nach erfolgreicher Operation entwickelte der Patient am 10. postoperativen Tag eine retrograde Typ-A-Dissektion der Aorta ascendens bis in die Aortenwurzel mit hamodynamisch-relevanter Herzbeuteltamponade. Daraufhin erfolgte die notfallmasige Reoperation mit suprakoronarem Aszendensersatz durch Anlage einer „Elephant-trunk“-Anastomose.