Christoph Langer

Sleep-disordered breathing in heart failure with normal left ventricular ejection fraction

In patients with systolic heart failure (SHF) a high prevalence of sleep‐disordered breathing (SDB) has been documented. The purpose of this study was to investigate the prevalence and type of SDB in patients with heart failure with normal left ventricular ejection fraction (HFNEF).

Pulmonary capillary wedge pressure and pulmonary arterial pressure in heart failure patients with sleep-disordered breathing.

BACKGROUNDnThere is a high prevalence of central sleep apnea (CSA) in patients with chronic heart failure (CHF). The present study investigates the hypotheses that CSA in CHF patients reflects heart failure severity as measured by cardiac index (CI), pulmonary artery pressure (PAP) and pulmonary capillary wedge pressure (PCWP).nnnMETHODSnIn 105 patients with stable CHF (NYHAII, LV-EF40%) cardiorespiratory polygraphy and simultaneous right and left heart catheterization was performed.nnnRESULTSnCSA was present in 58% and obstructive sleep apnea (OSA) in 23% of patients. In CSA patients, PAP and PCWP were significantly higher when compared to patients without SDB. In CSA patients, but not in OSA patients, PCWP showed a significant correlation with apnea-hypopnea index (AHI; r=0.41, p=0.005), apnea index (AI; r=0.44, p=0.003) and central AI (cAI; r=0.358, p=0.015). Cardiac index was more impaired in CSA (1.93+/-0.5 l/min/m(2)) than in OSA patients (2.55+/-1.0 l/min/m(2)) or those without SDB (2.22+/-0.4 l/min/m(2)). A negative correlation of CI and cAI (r=-0.344, p=0.008), AI (r=-0.31, p=0.02) and AHI (r=-0.21, p<0.05) was documented exclusively in CSA patients.nnnCONCLUSIONnThe present study supports the hypotheses that the occurrence and severity of CSA in CHF patients reflects heart failure severity.

Scanning electron microscopic analysis of different drug eluting stents after failed implantation: From nearly undamaged to major damaged polymers†

Background: Implantation of drug eluting stents (DES) in tortuous and/or calcified vessels is much more demanding compared with implantation of bare metal stents (BMS) due to their larger diameters. It is unknown whether drug eluting stent coatings get damaged while crossing these lesions. Methods: In 42 patients (34 male, 68.1 ± 10 years) with 45 calcified lesions (15.9 mm ± 7.9 mm), DES could not be implanted, even after predilatation. Diabetes was present in 19 patients (45 %). Sixty‐one stents were used; 19 Cypher select™, 18 Taxus Liberté™, 10 CoStar™, 5 Endeavor RX™, 4 Xience V™. 3 Janus Carbostent™, 1 Yukon Choice S™, and 1 Axxion™ DES. The entire accessible surface area of these stents, in either the unexpanded and expanded state, were examined with an environmental scanning electron microscope (XL30 ESEM, Philips) to evaluate polymer or surface damage. Results: The polymers of Taxus Liberte, Cypher Select, Xience V, CoStar, and Janus DES were only slightly damaged (less than 3% of surface area), whereas the Endeavor RX Stents showed up to 20% damaged surface area. In DES without a polymer (Yukon and Axxion), it could be shown that most of the stent surface (up to 40%) were without any layer of drug. Conclusion: Placement of drug eluting stents in tortuous vessels and/or calcified lesions could cause major surface damage by scratching and scraping of the polymer or drug by the arterial wall, even before implantation. There were remarkable differences among the stents examined, only minor damage with the Cypher, Taxus Costar, Janus, and Xience V, whereas the Endeavor, the Yukon, and the Janus DES showed large areas of surface injury.

Low night-to-night variability of sleep disordered breathing in patients with stable congestive heart failure

Sleep disordered breathing (SDB) has a high prevalence and prognostic impact in patients with chronic heart failure (CHF). Aim of this study was to investigate variability of SDB parameters in patients with stable CHF. Cardiorespiratory polygraphy was used to determine SDB in two consecutive nights in 50 CHF patients (NYHA classxa0≥xa0II, LV-EF ≤xa040%). The apnoea—hypopnoea—index (AHI) and apnoea—index (AI) were used to quantify SDB severity. Central, obstructive or mixed SDB were classified according to the majority of events. There was an excellent correlation in AHI (rxa0=xa00.948, Pxa0<xa00.001) and AI (rxa0=xa00.842, Pxa0<xa00.001) results of both nights. The overall number of detected apnoea and hypopnoea during the first night as compared to the maximum of both nights was 85% for the AHI and 77% for the AI. The reproducibility was dependent on SDB severity: AHI 15–29/hxa0=xa087%, AHI ≥xa030/hxa0=xa092% and AI ≥xa010/hxa0=xa083%. Classification was identical in 17 out of 19 patients with AI ≥xa010/h. In patients with stable CHF a single night of cardiorespiratory monitoring leads to representative results on severity and type of SDB. This may enhance the applicability and dissemination of cardiorespiratory polygraphy in clinical practice.

Primary malignant pericardial mesothelioma - a rare cause of pericardial effusion and consecutive constrictive pericarditis: a case report

IntroductionPrimary malignant pericardial mesothelioma is a very rare pericardial tumor of unknown etiology.Case presentationA 61-year-old Caucasian woman was admitted to our hospital complaining of exertional dyspnea due to a large pericardial effusion. Intrapericardial fluid volume declined after repeated pericardiocentesis, but the patient progressively developed a hemodynamically relevant pericardial constriction. Pericardiectomy revealed a pericardial mesothelioma. Subsequently, four cycles of chemotherapy (dosage according to recently published trials) were administered. The patient remained asymptomatic, and there was no recurrence of the tumor after three years.ConclusionPericardial mesothelioma should be considered and managed appropriately in non-responders to pericardiocentesis, and in patients who develop constrictive pericarditis late in their clinical course.

Echocardiography-Guided Percutaneous Aspiration of a Large Pericardial Cyst

A 42-year-old man was admitted with exertional breathlessness (New York Heart Association class II) and atypical chest pain. These symptoms were caused by a growing pericardial cyst situated in the left cardiophrenic angle, which had been diagnosed by chest radiography 17 years earlier (Figure 1A). Transthoracic echocardiography confirmed the presence of a large fluid-filled cyst within the pericardial space and excluded any compression of the left ventricular free wall by the cyst (Figure 2). Magnetic resonance imaging revealed …

Left Ventricular Mass and Oxygen Uptake in Top Handball Athletes

The key challenge in athletes screening is the distinction between abnormal and normal which is hindered by the fact that the adaptation to sports activity in endurance athletes is different to that in power athletes. Especially cardiomyopathies provoke changes in ECG and echocardiography (echo) at an early stage when clinical symptoms are absent. ECG and echo data and their relationship to fitness peculiar to top handball players have never been described. We studied 291 male first league handball players (32 Olympians/47 national players) (25.3±4.4 years). Check up consisted of ECG, spiroergometry and echocardiography. None had T-wave inversions, 3.1% showed early repolarisation abnormalities in the precordial leads. Sokolow-Lyon voltage criterion for left ventricular hypertrophy was positive in 19.3%. Spiroergometry showed a maximum oxygen uptake (peakVO₂) of 50.3±7.7 ml/min/kg body weight. LVmass was increased in comparison to normal values. There was a correlation between peakVO₂ and LVindex (p<0.001, r=0.341), (LVmass/peak VO₂ p=0.053, r=0.125). A relationship between cardiac dimensions and peakVO₂ could not be confirmed. In professional handball players early repolarisation abnormalities were less frequent and LVmass was increased when compared with soccer players. The need for normal values for different types of sports is crucial to guarantee a proper evaluation of athletes.

Assessment of myocardial scarring by contrast enhanced magnetic resonance imaging in a patient 11 years after percutaneous transluminal septal myocardial ablation in hypertrophic obstructive cardiomyopathy

We report on a 60 year-old male who was one of the first patients who underwent percutaneous transluminal septal myocardial ablation (PTSMA) in our institution in 1996. Contrast enhanced cardiac magnetic resonance imaging (MRI) 11 years after the PTSMA demonstrated extensive scarring, in septal and inferior segments of the left ventricle, and an excellent functional result. It has been previously demonstrated that contrast-enhanced MRI allows detailed evaluation of size and location of septal myocardial infarction induced by PTSMA, and that infarction size detected by MRI correlates well with clinical indexes of infarct size. Our case report underlines the importance of ongoing specialized care and reassessment of patients after PTSMA including continuous clinical risk assessment.

Uncommon intraventricular thrombus formation between the posterior mitral leaflet and the lateral left ventricular wall

Transthoracic echocardiography demonstrated an intraventricular mass between the posterior mitral leaflet and the lateral left ventricular (LV) free wall in a 61-year-old man. Because of this uncommon localization an intracardial tumor, an endocarditis of the mitral valve or an intraventricular thrombus was suspected. Magnetic resonance imaging (MRI) ruled out an intracardial tumor and revealed a myocardial scarring of the LV free wall covered by an intraventricular thrombus by late gadolinium enhancement. MRI can distinguish subacute clots-which do not enhance after contrast material injection-from organized thrombi. The characterization of thrombi can be used to predict the risk of embolism, which is higher for subacute clots than for organized thrombi.

The potential of multi-slice computed tomography based volumetry for demonstrating reverse remodeling induced by cardiac resynchronization therapy

BACKGROUNDnMulti-slice computed tomography (MSCT) was proved to provide precise cardiac volumetric assessment. Cardiac resynchronization therapy (CRT) is an effective treatment for selected patients with heart failure and reduced ejection fraction (HFREF). In HFREF patients we investigated the potential of MSCT based wall motion analysis in order to demonstrate CRT-induced reversed remodeling.nnnMETHODSnBesides six patients with normal cardiac pump function serving as control group seven HFREF patients underwent contrast enhanced MSCT before and after CRT. Short cardiac axis views of the left ventricle (LV) in end-diastole (ED) and end-systole (ES) served for planimetry. Pre- and post-CRT MSCT based volumetry was compared with 2D echo. To demonstrate CRT-induced reverse remodeling, MSCT based multi-segment color-coded polar maps were introduced.nnnRESULTSnWith regard to the HFREF patients pre-CRT MSCT based volumetry correlated with 2D echo data for LV-EDV (MSCT 278.3+/-75.0mL vs. echo 274.4+/-85.6mL) r=0.380, p=0.401, LV-ESV (MSCT 226.7+/-75.4mL vs. echo 220.1+/-74.0mL) r=0.323, p=0.479 and LV-EF (MSCT 20.2+/-8.8% vs. echo 20.0+/-11.9%) r=0.617, p=0.143. Post-CRT MSCT correlated well with 2D echo: LV-EDV (MSCT 218.9+/-106.4mL vs. echo 188.7+/-93.1mL) r=0.87, p=0.011, LV-ESV (MSCT 145+/-71.5mL vs. echo 125.6+/-78mL) r=0.84, p=0.018 and LV-EF (MSCT 29.6+/-11.3mL vs. echo 38.6+/-14.6mL) r=0.89, p=0.007. There was a significant increase of the mid-ventricular septum in terms of absolute LV wall thickening of the responders (pre 0.9+/-2.1mm vs. post 3.3+/-2.2mm; p<0.0005).nnnCONCLUSIONnMSCT based volumetry involving multi-segment color-coded polar maps offers wall motion analysis to demonstrate CRT-induced reverse remodeling which needs to be further validated.