Cornelia Piper

23S rDNA real-time polymerase chain reaction of heart valves: a decisive tool in the diagnosis of infective endocarditis

AIMS A new diagnostic strategy to improve the detection of pathogens in heart valves (HVs) from patients with infective endocarditis (IE) was evaluated. METHODS AND RESULTS Three hundred and fifty seven HVs surgically removed from 326 patients with proven IE or suspicious intra-operative findings, examined by 16S rDNA polymerase chain reaction (PCR) and culture were retrospectively analysed according to the predictive value of various PCR methods. Patients were classified into four categories: active IE, IE with ambiguous infective status, healed IE, and valve diseases but no IE. Retained samples of 200 HVs were analysed by real-time PCR targeting bacterial 23S rDNA, fungal 28S rDNA, and mycoplasmal tuf gene. 16S rDNA PCR revealed 80.6% sensitivity, 100% specificity, 100% positive predictive value, and 71% negative predictive value (NPV), compared with cultivation with 33.4, 96.6, 95.5, and 40.9%, respectively. The use of real-time PCR increased diagnostic sensitivity to 96.4%, and NPV to 92.5%. Bacterial load, C-reactive protein, and white blood cell counts (WBCs) decreased during antibiotic treatment. Bacterial load showed no correlation to C-reactive protein or WBCs, whereas C-reactive protein and WBCs were significantly correlated. CONCLUSION 23S rDNA real-time PCR of surgically removed HVs improves the diagnosis of IE. Polymerase chain reaction analysis of explanted HVs allow the optimization of the antimicrobial therapy, especially in patients with culture-negative IE.

Management of prosthetic valve thrombosis

Fibrinolysis and surgery with either valvular re-replacement or thrombectomy are both established therapies for prosthetic valve thrombosis. In both treatment strategies, the complication rate depends to a similar degree on pre-interventional clinical and haemodynamic status. Fibrinolysis serves to avoid a second operation, but the incidence of recurrent thrombosis is higher. Before deciding in favour of thrombolytic therapy, structural defects of the prosthetic valve or tissue in-growth, which increase the risk of rethrombosis, should be ruled out by transoesophageal echocardiography. Apart from those cases in which there are contraindications to either treatment, we recommend surgery in cases of underlying prosthetic valve dysfunction or recurrent thrombosis.

DRINGLICHER HERZKLAPPENERSATZ NACH AKUTER HIRNEMBOLIE WAHREND FLORIDER ENDOKARDITIS

Zusammenfassung□ HintergrundWegen der hohen Rezidivgefahr verlangt das Auftreten embolischer Komplikationen während florider Endokarditiden, die Indikation zu einer operativen Klappenintervention zu prüfen. Bei zerebraler Embolisation ist deren prognostischer Nutzen umstritten, da im Gefolge der Operation sekundäre zerebrale Blutungskomplikationen gefürchtet werden. Wir analysierten die Häufigkeit thromboembolischer Komplikationen, mögliche Prädispositions-faktoren und den prognostischen Einfluß der jeweils gewählten Therapiestrategie (medikamentös-konservativ versus dringlich-operativ) bei Patienten mit gesicherter Endokarditis. Insbesondere wurde geprüft, wie hoch das sekundäre zerebrale Blutungsrisiko nach dringlich durchgeführter klappenchirurgischr Intervention unter Einsatz der Herz-Lungen-Maschine zu veranschlagen ist.⌖ Patienten und MethodikZwischen 1978 und 1993 wurde bei 288 konsekutiven, prospektiv beobachteten Patienten (131 Frauen, 157 Männer; mittleres Alter 53,6±8,7 [9 bis 81] Jahre) eine mikrobiell verursachte Nativklappenendokarditis gesichert. Um den prognostischen Nutzen einer früh nach zerebraler Embolisation durchgeführten klappenchrirurgischen Intervention abzuschätzen, wurden die kumulativen Überlebensraten von Patienten mit und ohne Operation unter Berücksichtigung des Operationszeitpunktes und inkrementaler Risikofaktoren verglichen.□ ErgebnisseDer Krankheitsverlauf war bei 50 Patienten (17,4%) durch eine und bei 58 Patienten (20,2%) durch rezidivierende Emboline kompliziert. 80% der Erstembolien traten innerhalb von 33 Tagen nach Geginn der initialen Endodarditissymptomatik, 80% der Rezidive innerhalb von 32 Tagen nach dem initialen embolischen Ereignis auf. 71% der diagnostizierten Embolien waren Hirnembolien. Bei Patienten mit computertomographisch bestätigten zerebralen Embolien war der klinische Verlauf in 12,5%, bei Patienten ohne zerebrale Embolien in 1,5% durch Hirnblutungen kompliziert. Von 49 Patienten mit rezidivierenden, mindestens einmal das Zerebrum betreffenden Embolien war bei 11 im Abstand von vier bis 366 Stunden nach der Erstembolie notfallmäßig ein Herzklappenersatz erforderlich. Die kumulativen Überlebensraten der während der ersten 72 Stunden nach Auftreten der Hirnembolie operierten Patienten erwiesen sich als erheblich günstiger (p<0,000) als für nicht oder später als acht Tage nach der Embolie operierte Patienten.□ SchlußfolgerungenEine Embolie während florider Endokarditis prädisponiert mit einer Wahrscheinlichkeit von über 50% zu Rezidiven. Bei Patienten mit kurzer Erkrankungsdauer und postembolisch echokardiographisch weiterhin nachweisbaren Vegetationen beträgt das Risiko mehr als 80%, so daß zumindest bei diesem Teilkollektiv eine dringliche Operation zur Beseitigung von Infektions- und Emboliequelle sinnvoll ist. Nach zerebraler Embolisation sollte die Operation möglichst rasch durchgeführt werden, da dann ein signifikant niedrigeres (p≤0,000) zerebrales Blutungsrisiko besteht als bei Operationen, die mit einer Latenz von 72 Stunden oder mehr durchgeführt werden. Zum Ausschluß einer insgesamt seltenen, frühen Reperfusionsblutung im Gefolge spontaner Thrombusfragmentation ist zeitnah vor der Herzoperation eine zerebrale computertomographische Kontrolle erforderlich.Abstract□ BackgroundThe indication for urgent cardiac surgical interventions in patients with active infective endocarditis has to be considered carefully following thromboembolic events, because of the high recurrence rate of such complications. In the case of brain embolisms the prognostic benefit of urgent surgery has been discussed controversially as effective anticoagulation during open heart surgery may result in secondary cerebral hemorrhages.□ Patients and MethodsBetween 1978 and 1993 infective endocarditis (IE) was proven in 288 consecutive and prospectively followed patients (131 females, 157 males; mean age 53.6±8.7 [9 to 81] years). To analyze potential benefits and risks of an urgent surgical intervention early after embolic cerebral infarction, cumulated survival rates were calculated for patients with and without surgical intervention with special reference to incremental risk factors and the timing of surgery.□ ResultsIn 50 patients (17.4%) the clinical course was complicated by one, and in 58 patients (20.2%) by recurrent embolic events. In 80% the first embolism occurred within 33 days following the first manifestation of typical signs and symptoms of IE. 80% of recurrent events were observed within 32 days following the initial embolism. 71% of all embolic events were cerebral. In patients with cerebral embolism corroborated by computed tomography (CCT), the clinical course was complicated by intracranial hemorrhage in 12.5% while it was only 1.5% for patients without cerebral embolism. Because of a lack of therapeutic alternatives, 22 of 49 patients with recurrent embolic events, of which at least one was cerebral, underwent urgent cardiac surgery within 4 to 366 hours after the first cerebral manifestation. The cumulated survival rate of patients operated within 72 hours after the initial cerebral embolism was significantly more favorable (p<0.000) than for unoperated patients or those who were operated after more than 8 days.□ ConclusionAn embolic event during IE carries a more than 50% risk of recurrence. In patients with short duration of signs and symptoms of IE and postembolic echocardiographic demonstration of persistent vegetations the probability is >80%. At least for those patients urgent surgical intervention to remove the source of infection and embolic hazard seems to be beneficial. Surgical intervention using the heart-lung-machine should be performed within 72 hours. Such early timing results in a significant lower rate of secondary cerebral hemorrhages (p<0.000) than a postponed operation. To exclude early reperfusion hemorrhage due to spontaneous thrombus fragmentation, CCT should be repeated directly preoperatively.BACKGROUND The indication for urgent cardiac surgical interventions in patients with active infective endocarditis has to be considered carefully following thromboembolic events, because of the high recurrence rate of such complications. In the case of brain embolisms the prognostic benefit of urgent surgery has been discussed controversially as effective anticoagulation during open heart surgery may result in secondary cerebral hemorrhages. PATIENTS AND METHODS Between 1978 and 1993 infective endocarditis (IE) was proven in 288 consecutive and prospectively followed patients (131 females, 157 males; mean age 53.6 +/- 8.7 [9 to 81] years). To analyze potential benefits and risks of an urgent surgical intervention early after embolic cerebral infarction, cumulated survival rates were calculated for patients with and without surgical intervention with special reference to incremental risk factors and the timing of surgery. RESULTS In 50 patients (17.4%) the clinical course was complicated by one, and in 58 patients (20.2%) by recurrent embolic events. In 80% the first embolism occurred within 33 days following the first manifestation of typical signs and symptoms of IE. 80% of recurrent events were observed within 32 days following the initial embolism. 71% of all embolic events were cerebral. In patients with cerebral embolism corroborated by computed tomography (CCT), the clinical course was complicated by intracranial hemorrhage in 12.5% while it was only 1.5% for patients without cerebral embolism. Because of a lack of therapeutic alternatives, 22 of 49 patients with recurrent embolic events, of which at least one was cerebral, underwent urgent cardiac surgery within 4 to 366 hours after the first cerebral manifestation. The cumulated survival rate of patients operated within 72 hours after the initial cerebral embolism was significantly more favorable (p < or = 0.000) than for unoperated patients or those who were operated after more than 8 days. CONCLUSION An embolic event during IE carries a more than 50% risk of recurrence. In patients with short duration of signs and symptoms of IE and postembolic echocardiographic demonstration of persistent vegetations the probability is > 80%. At least for those patients urgent surgical intervention to remove the source of infection and embolic hazard seems to be beneficial. Surgical intervention using the heart-lung-machine should be performed within 72 hours. Such early timing results in a significant lower rate of secondary cerebral hemorrhages (p < or = 0.00) than a postponed operation. To exclude early reperfusion hemorrhage due to spontaneous thrombus fragmentation, CCT should be repeated directly preoperatively.

Prosthetic valve thrombosis: predisposition and diagnosis

Prosthetic valve thrombosis (PVT) is an obstruction of a prosthesis by non-infective thrombotic material. The interaction of a variety of prosthesis- and patient-related factors account for risk for PVT. The typical clinical finding in PVT is diminution of occluder clicks, which may be detected using sound spectroscopy. Fluoroscopy facilitates prompt and reliable assessment of occluder movements. Interpretation of echocardiographic findings is not so simple. Echo-Doppler derived gradients that are twice as high as those found in ‘normal’ prostheses are suspicious and indicate PVT. Early diagnosis and prompt therapeutic intervention are required for successful management of PVT.

Lipopolysaccharide-Binding Protein: A New Biomarker for Infectious Endocarditis?

BACKGROUND Infectious endocarditis (IE) is a bacterial infection of the endocardium. Diagnosis is based on results obtained from echocardiography, blood cultures, and molecular genetic screening for bacteria and on data for inflammatory markers such as the leukocyte (WBC) count and the C-reactive protein (CRP) concentration. The aim of the present study was to evaluate lipopolysaccharide-binding protein (LBP) as a supportive biomarker for the diagnosis and therapeutic monitoring of IE. METHODS We measured LBP and CRP concentrations and WBC counts in 57 IE patients at hospital admission, 40 patients with noninfectious heart valve diseases (HVDs), and 55 healthy blood donors. The progression of these 3 markers and the influence of cardiac surgery on them were evaluated in 29 IE patients and 21 control patients. RESULTS Serum LBP concentrations were significantly higher in IE patients [mean (SD), 33.41 (32.10) mg/L] compared with HVD patients [6.67 (1.82) mg/L, P < 0.0001] and healthy control individuals [5.61 (1.20) mg/L]. The progression in the LBP concentration during therapy of IE patients correlated with the changes in the CRP concentration. The 2 markers were equally influenced by antibiotic treatment and surgical intervention. CONCLUSIONS Serial LBP measurement may provide an effective and useful tool for evaluating the response to therapy in IE patients. We found a strong correlation between LBP and CRP concentrations; LBP has a tendency to increase earlier in cases of reinfection.

Angeborene Herzfehler und erworbene Herzklappenfehler in der Schwangerschaft

Zusammenfassung.Hintergrund: Die jährliche Zahl schwangerer Herzfehlerpatientinnen beträgt in Deutschland etwa 6 000 (jede 130. Schwangerschaft). Die voraussehbaren hämodynamischen Veränderungen in der Schwangerschaft erlauben in der Mehrzahl der Fälle eine recht zuverlässige Vorhersage des Schwangerschaftsverlaufs für Mutter und Kind. Folgende fünf Aspekte sind von beträchtlicher klinischer Bedeutung. Unkorrigierte angeborene Herzfehler: Patientinnen mit nicht korrigierbaren komplexen Herzfehlern, einer nach Palliationsoperation persistierenden myokardialen Insuffizienz oder beträchtlichen pulmonalvaskulären Widerstandserhöhungen sollte von einer Schwangerschaft abgeraten werden. Prätrikuspidale Kurzschlussverbindungen werden in der Schwangerschaft in aller Regel gut toleriert. In den seltenen Fällen einer deutlichen symptomatischen Verschlechterung ist der katheterinterventive Shuntverschluss heute Therapie der Wahl. Bei Patientinnen mit Ventrikelseptumdefekt oder persistierendem Ductus Botalli liegt in aller Regel ein flussbegrenzender Defekt vor, der sich im Verlauf einer Schwangerschaft meist nicht negativ auswirkt. Bei unbehandelten Aortenisthmusstenosen sind in 2,3% der Fälle schwere Hypertonien, myokardiale Dekompensationen, Aortendissektionen und zerebrale Blutungen berichtet worden, deren Prävention spezifische Beratung und Therapie erfordert. Korrigierte angeborene Herzfehler: Die Gefährdung von Mutter und Kind ist nach Korrekturoperationen einer Fallotschen Tetralogie vom Korrekturergebnis abhängig. Das Risiko erscheint gut abschätzbar. Bei komplexen zyanotischen Vitien besteht ein deutlich erhöhtes maternales Risiko bezüglich myokardialen Pumpversagens, thromboembolischer Komplikationen, komplexer Arrhythmien und Endokarditiden. Die Inzidenz fetaler Aborte, Frühgeburten, Unreife bei der Geburt sowie kongenitaler Fehlbildungen beträgt > 50%. Erworbene Herzklappenfehler: Aufgrund der Schwangerschaftsphysiologie verschlechtert sich die hämodynamische Situation bei Mitralstenosen regelhaft. Patientinnen mit Klappenöffnungsflächen < 1,5 cm2 tolerieren diese Schwangerschaftsbedingungen häufig nicht. Sind die begrenzten Möglichkeiten einer medikamentösen Therapie erschöpft, ist die perkutane Ballonvalvulotomie heute Therapie der Wahl. Die in Kompetenzzentren erzielten Behandlungsergebnisse sind außerordentlich günstig. Die schwangerschaftstypische periphere Vasodilatation und Frequenzerhöhung führen dazu, dass die hämodynamischen Auswirkungen einer Mitral- und Aorteninsuffizienz während der Schwangerschaft in aller Regel nicht aggraviert werden. Aortenklappenstenosen sind bei Schwangeren außerordentlich selten. Der transaortale Blutfluss und Gradient nehmen im Verlauf der Schwangerschaft aufgrund der relativ verlängerten Systolendauer ab. Die linksventrikuläre Wandspannung nimmt dagegen zu, so dass trotz Abnahme des Gradienten eine myokardiale Dekompensation resultieren kann. Hypertrophe Kardiomyopathie: Der Verlauf gestaltet sich meist günstig. Eine präexistente Herzinsuffizienz wird bei etwa 20% der Patientinnen in der Schwangerschaft aggraviert. Besonders schlecht toleriert werden Vorhofflimmerepisoden und supraventrikuläre Tachykardien. Beide können Mutter und Fetus gefährden. Orale Antikoagulation: Die möglichen Antikoagulationsstrategien sind mit einem unterschiedlich hohen maternalen und fetalen Risiko verbunden. Bei gegebener Indikation ist die ununterbrochene orale Antikoagulation mit Phenprocoumon mit dem geringsten Risiko für die Mutter, die Beendigung jeglicher Antikoagulation mit dem geringsten Risiko für das ungeborene Kind verbunden. Einzelentscheidungen sind schwierig und sollten in die Hand eines erfahrenen Kompetenzzentrums gegeben werden.Abstract.Background: In Germany, about 6,000 pregnancies in women with grown-up congenital heart disease or acquired valvular lesions are expected per year. The pregnancy-related physiology is characterized by a 50% increase in plasma volume and a 25% increase in erythrocyte volume. The cardiac output increases by 40% due to 30% increase in stroke volume and 10% increase in heart rate during the first half, and 10% increase in stroke volume but 30% increase in heart rate during the second half of pregnancy. As a consequence of the decrease of systemic vascular resistance, the systolic and, even more, the diastolic blood pressures are reduced during approximately the first 20 weeks of pregnancy. Uncorrected Congenital Lesions: Women with uncorrectable congenital heart disease, congestive heart failure (NYHA III and IV) despite optimized medical treatment after palliative surgery, or pulmonary vascular resistances > 800 dyn × s × cm−5 should be advised against pregnancy. The presence of congestive heart failure or persistent cyanosis in the mother are the most important predictors of fetal hypoxia. Patients with pretricuspid shunts (e.g., atrial septal defect [ASD]) are at low risk of a hemodynamic deterioration or first onset of arrhythmias. In the rare case of a marked clinical deterioration, catheter-based closing of the shunt is the first-line treatment. Also, ventricular septal defects and persistent ducti arteriosi are usually well tolerated during pregnancy, as they are highly resistant to flow. In some cases, arrhythmias may occur. The prognosis is less favorable, if myocardial compromise has already been present before pregnancy. The fatal complication rate correlates closely with the degree of congestive heart failure. In aortic coarctation, development of severe hypertension, myocardial decompensation, aortic dissection, and cerebral hemorrhage have been reported in 2.3% of cases. To prevent aortic dissection and rupture of cerebral vascular aneurysms, patients should be advised to reduce their physical activity and have their blood pressure controlled closely. If, during pregnancy, a therapeutic intervention is inavoidable, stent placement is the therapy of choice. The maternal complication rate is low in pulmonary artery stenosis. Hemodynamically significant stenoses should be treated before pregnancy. In the rare case of progressive right heart failure or cyanosis during pregnancy, balloon valvotomy is the first-line therapeutic option. Congenital Heart Disease with Prior Palliation: Women with incomplete correction of a tetralogy of Fallot or significant residual gradients or shunts carry a particular risk of myocardial deterioration. A maternal hematocrit > 60%, an arterial O2 saturation < 80%, markedly elevated right ventricular pressures, and the former presentation of syncopes are indicators of a poor prognosis. Fatal complication rates have been reported in 3–17% of cases. Other cyanotic lesions have been linked with a poor maternal and fetal prognosis. A 32% incidence of severe cardiovascular complications (pump failure, thromboembolic events, life-threatening arrhythmias, infective endocarditis) has been reported during 96 pregnancies of women with cyanotic heart disease. In addition, the frequency of abortions, premature birth, fetal distress, and congenital malformation of the child was 57%. Acquired Valve Lesions: Mitral stenosis is the lesion that most frequently requires therapeutic intervention during pregnancy, as the transmitral flow increases and time of diastole decreases during pregnancy due to the increase in cardiac output and heart rate. A consequent increase in mean pulmonary artery pressure by approximately 50% and a deterioration by one to two NYHA classes must be expected. While patients with a mitral orifice area > 1.5 cm2 can usually be treated medically, more advanced mitral stenoses often require percutaneous mitral balloon valvotomy, a procedure with a very low complication rate in experienced centers. A chronic mitral or aortic regurgitation without jeopardized myocardial function is usually well tolerated during pregnancy, as the drop in peripheral vascular resistance results in a favorable left ventricular impedance, which reduces the transmitral regurgitant fraction and improves left ventricular antegrade ejection. Moreover, the increase in heart rate limits diastolic transaortic regurgitation. Hemodynamically advanced aortic stenosis is rare among patients in child-bearing age. The hemodynamic changes during pregnancy result in a decrease of the transaortic flow per time and thus in a decrease of the transaortic pressure loss. On the other hand, myocardial wall stress and oxygen consumption are significantly increased. If aortic valve orifice area is > 1.5 cm2, the hemodynamic situation is usually well tolerated during pregnancy. In the case of more advanced aortic stenosis, there is a considerable risk of myocardial decompensation. The development of symptoms such as dyspnea, near syncopes or syncopes, and arrhythmias are indicators of a complicated course. If treatment is unavoidable, aortic valve replacement is the therapy of choice. Oral Anticoagulation: With respect to anticoagulation during pregnancy, there is an ongoing debate about the potential risk and benefit of phenprocoumon, standard heparins, and low molecular heparins. Withdrawal of any anticoagulation results in the most favorable fetal outcome, oral anticoagulation throughout pregnancy in the best prognosis for the mother. An individual approach by an experienced center taking all therapeutic options into account is probably the best strategy.

Is myocardial Na+/Ca2+ exchanger transcription a marker for different stages of myocardial dysfunction? Quantitative polymerase chain reaction of the messenger RNA in endomyocardial biopsies of patients with heart failure.

OBJECTIVES This study was designed to determine the stage of myocardial dysfunction at which an upregulation of the Na+/Ca2+ exchanger (EXCH) transcription takes place. BACKGROUND Because EXCH is an important regulator of intracellular calcium homeostasis, alterations in EXCH expression may occur before the onset of end-stage heart failure (HF) to maintain normal intracellular Ca2+ concentrations. We analyzed whether the EXCH transcription level is correlated to the degree of myocardial dysfunction and whether it can be a suitable molecular marker to define the transition to myocardial decompensation early on. METHODS By quantitative polymerase chain reaction technique, the level of EXCH transcription was analyzed in myocardial biopsies from 40 patients with various degrees of myocardial dysfunction due to valvular heart disease (VHD; n = 22) or dilated cardiomyopathy (DCM; n = 18). Additionally, biopsies from 7 individuals with excluded heart disease and explanted heart tissue from 13 patients with end-stage HF were investigated. RESULTS The level of EXCH transcription of controls (2.6 +/- 1.2 attomoles [amol]/ng total RNA) did not differ from that of patients with DCM (2.3 +/- 1.5 amol/ng) or VHD (2.1 +/- 1.5 amol/ng). No alteration in the EXCH transcription was found in VHD and DCM patients with respect to the severity of myocardial dysfunction. However, patients with end-stage HF showed a four-fold increase in EXCH transcription, amounting to 8.9 +/- 1.9 amol/ng (p < 0.05). CONCLUSIONS The upregulation in EXCH transcription either occurs very late in human heart failure or is a phenomenon of heart transplantation in end-stage HF. Consequently, myocardial EXCH transcription cannot be used as a marker for early myocardial decompensation.

Drug Insight: an overview of current anticoagulation therapy after heart valve replacement

Vitamin K antagonists, such as warfarin, are the gold standard approach for the long-term anticoagulant therapy of patients with mechanical heart valves. Management decisions are, however, based predominantly on expert consensus and on data from nonrandomized, follow-up studies, which have inherent limitations in their methods. Low-intensity anticoagulation therapy provides protection against thromboembolic complications in patients with most types of modern prosthetic heart valve. The addition of low-dose aspirin is safe if international normalized ratio values below 3.5 are maintained. A combined regimen should be considered in high-risk patients and those with coexistent coronary artery or cerebrovascular disease, and in patients who have suffered a thromboembolic event despite a therapeutic international normalized ratio. Thromboprophylaxis with unfractionated or low-molecular-weight heparins is restricted to specific situations, such as when a patient is intolerant to vitamin K antagonists, when surgical procedures require discontinuation of oral anticoagulation, or when the patient is pregnant. A lack of uniformity across practice guidelines make it difficult to reach treatment decisions. Each patients preference, expressed after counseling about the risks and benefits of each treatment strategy, and an individual assessment of the patients risk factors, should guide treatment decisions. At present, new anticoagulant agents such as factor Xa inhibitors do not represent a treatment option for heart valve recipients.

Sleep apnoea in severe aortic stenosis

Background There are as yet no data on the prevalence of sleep apnoea in patients with severe aortic stenosis (AS). Aims To assess the occurrence, severity and clinical correlates of sleep apnoea in patients with AS. Methods During a 4-month period in 2010, 67 patients were consecutively included in this study, 42 of which (19 men; mean±SD age 72±9 years) had severe AS (aortic valve opening area ≤1.0 cm2); all were investigated with cardiorespiratory polygraphy. Sleep apnoea was diagnosed if the apnoea–hypopnoea index (AHI) (median (lower quartile, upper quartile)) was ≥5/h. The control group of 25 patients matched for age, body mass index and sex had angiographic exclusion of coronary artery disease, regular left ventricular ejection fraction, and no valve disease. Results Sleep apnoea was found in 30/42 patients with AS (71%; AHI=23/h (14/h, 36/h)). The severity was significantly greater in patients with severe AS than in the control group (AHI=12/h (8/h, 17/h)) (p<0.01). Half of the patients with sleep apnoea had obstructive sleep apnoea (OSA) (AHI=15/h (9/h, 28/h)), and half had central sleep apnoea (CSA) (AHI=25/h (18/h, 45/h)). New York Heart Association classification and severity of sleep apnoea correlated with η=0.5 (η2=0.3). The severity of CSA correlated with pulmonary artery pressure (r=0.7, p<0.01) and pulmonary capillary wedge pressure (r=0.7, p<0.01). Patients with AS and CSA had a lower Pco2 than those with OSA and those without sleep apnoea (p<0.01). Conclusions Sleep apnoea is common in patients with severe AS. The severity of CSA correlates with pulmonary hypertension, which may suggest that myocardial adaptation is exhausting.

Atrial fibrillation in carcinoid heart disease

Sirs: A 68-year-old man with mitral valve replacement but former mitral regurgitation II (left atrial size 39 mm) and coronary artery sclerosis suffered syncope due to a sustained ventricular tachycardia. Before this event, the patient had neither palpitations nor was arrhythmia documented by Holter ECGs. A single chamber cardioverter/defibrillator (SJM, Atlas VR) was implanted. Routine abdominal ultrasound did not reveal pathologic findings at that