G. Plehn

Hemostatic risk factors in patients with coronary artery disease and type 2 diabetes - a two year follow-up of 243 patients

BackgoundThrombosis is regarded to be a key factor in the development of acute coronary syndromes in patients with coronary artery disease (CAD). We hypothesize, that hemostatic and rheological risk factors may be of major relevance for the incidence and the risk stratification of these patients.MethodsIn 243 patients with coronary artery disease and stable angina pectoris parameters of metabolism, hemostasis, blood rheology and endogenous fibrinolysis were assessed. Patients were prospectively followed for 2 years in respect to elective revascularizations and acute coronary syndromes.ResultsDuring follow-up 88 patients presented with cardiac events, 22 of those were admitted to the hospital because of acute events, 5 Patients were excluded due to non- cardiac death. Patients with clinical events were found to be more frequently diabetic and presented with a more progressed coronary atherosclerosis. Even though patients with diabetes mellitus demonstrated a comparable level of multivessel disease (71% vs. 70%) the rate of elective revascularization was higher (41% vs. 28%, p < 0.05). The results were also unfavorable for the incidence of acute cardiovascular events (18% vs. 8%, p < 0.01). In comparison to non-diabetic patients diabetics demonstrated significantly elevated levels of fibrinogen (352 ± 76 vs. 312 ± 64 mg/dl, p < 0.01), plasma viscosity (1.38 ± 0.23 vs. 1.31 ± 0.16 mPas, p < 0.01), red blood cell aggregation (13.2 ± 2.5 vs. 12.1 ± 3.1 E, p < 0.05) and plasmin-activator-inhibitor (6.11 ± 3.4 vs. 4.7 ± 2.7 U/l, p < 0.05).ConclusionPathological alterations of fibrinogen, blood rheology and plasminogen-activator-inhibtor as indicators of a procoagulant state are of major relevance for the short-term incidence of cardiac events, especially in patients with diabetes mellitus type 2, and may be used to stratify patients to specific therapies.

First Experiences for Pulmonary Vein Isolation with the High-Density Mesh Ablator (HDMA): A Novel Mesh Electrode Catheter for Both Mapping and Radiofrequency Delivery in a Single Unit

Background: Interventional therapy of atrial fibrillation (AF) is often associated with long examination and fluoroscopy times. The use of mapping catheters in addition to the ablation catheter requires multiple transseptal sheaths for left atrial access.

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.

Comparison of Right Ventricular Functional Response to Exercise in Hypertrophic Versus Idiopathic Dilated Cardiomyopathy

Although the biventricular nature of the disease has been confirmed by morphologic studies, information on right ventricular (RV) function in hypertrophic cardiomyopathy (HC) is lacking. The aim of the study was to hemodynamically characterize RV performance in HC versus idiopathic dilated cardiomyopathy (IDC) during exercise. The hemodynamic data of 63 patients with HC who underwent hemodynamic exercise testing with thermodilution-derived assessment of RV ejection fraction were analyzed. The results were compared to a healthy control group (n = 20) and to patients with IDC (n = 86). The baseline RV ejection fraction was increased in the patients with HC compared to those with IDC (39 +/- 10% vs 33 +/- 12%; p = 0.002), but did not differ compared to controls (42 +/- 7% vs 39 +/- 10%; p = NS). An increase in end-diastolic volume from rest to exercise contributed to stroke volume augmentation in those with HC (121 +/- 38 vs 136 +/- 55 ml/m(2); p = 0.01) and control subjects (116 +/- 34 vs 138 +/- 31 ml/m(2); p = 0.002) but not in those with IDC (117 +/- 47 vs 120 +/- 52 ml/m(2); p = NS). At peak exercise the RV ejection fraction in those with HC was reduced compared to that in the controls (45 +/- 11% vs 59% +/- 9%; p <0.001), but it was increased compared to that in those with IDC (45 +/- 11% vs 35% +/- 11%; p <0.001). In conclusion, the extent of the pulmonary pressure increase was more pronounced in those with HC than in those with IDC, but the degree of functional impairment of the right ventricle was less severe, probably owing to its ability to recruit preload and contractile reserve with exercise.

Loss of diastolic time as a mechanism of exercise-induced diastolic dysfunction in dilated cardiomyopathy

BACKGROUND Cardiac performance can be characterized in terms of the relative duration of left ventricular systole and diastole. Little is known about exercise-induced abnormalities of the systolic-diastolic phase proportion and its impact on hemodynamic variables in patients with idiopathic dilated cardiomyopathy (IDCM). METHODS The phases of the cardiac cycle were derived with high temporal resolution from the left ventricular time-activity curve simultaneous with hemodynamic measurements. In patients with IDCM, the loss of diastolic time (LDT) per beat was quantified using a regression equation obtained from a healthy control group (n = 26). According to the median LDT at peak exercise, patients were divided into 2 subgroups: subgroup A with an LDT <or=22 milliseconds (n = 28) and subgroup B with an LDT >22 milliseconds (n = 27). RESULTS The relative duration of left ventricular systole was increased in patients with IDCM during peak exercise compared to healthy subjects (29.3 vs 26.7 s/min, P < .02). This abnormality translated into a significant LDT when observed, and predicted values of diastolic time were compared. Subgroup B patients had a higher increment in mean pulmonary capillary wedge pressure but a smaller increase in stroke volume index from rest to peak exercise (14.3 vs 8.6 mm Hg [P = .007] and 12.5 vs 7.2 mL/m(2) [P = .04]) compared to subgroup A patients. CONCLUSION An abnormal shortening of diastolic time during exercise can restrict left ventricular filling to an extent that is sufficient to limit left ventricular stroke volume reserve and to cause pulmonary congestion.

Systolic and early diastolic left ventricular velocities assessed by tissue Doppler imaging in 100 top-level handball players

Background and objective Echocardiographic tissue Doppler imaging (TDI) has been proposed for the differentiation of physiologic left ventricular hypertrophy and pathologic left ventricular hypertrophy in athletes. In addition, cutoff values for systolic (S’ < 9 cm/s) and early diastolic (E’ < 9 cm/s) myocardial velocities had been defined. The aim of our study was the analysis of the morphologic cardiac changes by standard echocardiography, and the myocardial velocities S’ and E’ by TDI in top-level handball players with respect to the predefined cutoff values. Patients and methods Pulsed-wave TDI of the systolic and early diastolic velocities was performed at the lateral and septal mitral annulus (MA) in the four-chamber view in 100 athletes (100 Caucasian men; professional handball players of the first German handball league and the German national team; mean age 25.8 ± 4.8 years). Results Global and regional left ventricular systolic function was normal in all athletes. They showed an eccentric hypertrophy of the left ventricle (LV), which was characterized by an increased mass of the LV (287.3 ± 58.4 g), and an increased end diastolic diameter of the LV (LVEDD: 58 ± 5.9 mm), but no echomorphologic signs of pathologic hypertrophy or hypertrophic cardiomyopathy. TDI showed a systolic velocity S’ of the MA of 9.3 ± 1.5 cm/s at the septal and 10.5 ± 2.1 at the lateral MA. Ten of the 100 athletes showed a S’ <9 cm/s at both sides of the MA. TDI showed an early diastolic velocity E’ of the MA of 13.2 ± 2.8 cm/s at the septal and of 16.6 ± 3.4 cm/s at the lateral MA. None of the 100 athletes showed reduced systolic or early diastolic velocities below the proposed cutoff values (S’ and E’ < 9 cm/s) at any sides of the MA. Conclusion Our study provides further insights into systolic and diastolic function as assessed by TDI in top-level handball players. Owing to the large cohort of individuals, our findings might be helpful as reference values for the echocardiographic assessment of handball players, who are performing a moderate static and high dynamic sport. Eur J Cardiovasc Prev Rehabil 17:342-348

Disproportionate shortening of left ventricular diastolic duration in patients with dilated cardiomyopathy

ZusammenfassungHintergrund und Ziel:Das Verhältnis von Systolen- und Diastolendauer wird als eine wichtige Determinante der Herzfunktion angesehen. Bei Kindern mit dilatativer Kardiomyopathie (DCM) konnte eine abnorme Verkürzung der Diastolendauer beobachtet werden. In der vorliegenden Studie wurde untersucht, ob sich dieser Befund bei Erwachsenen reproduzieren lässt und welches Verhalten der diastolische Anteil des Herzzyklus unter stufenweiser ergometrischer Belastung zeigt.Patienten und Methodik:Die Untersuchung schloss konsekutiv 61 Patienten mit DCM im NYHA-Stadium (New York Heart Association) II–III ein. Bei diesen wurde unter ergometrischer Belastung eine Radionuklidventrikulographie mit hoher zeitlicher Auflösung durchgeführt. Aus der Zeit-Aktivitäts-Kurve wurde neben der linksventrikulären Ejektionsfraktion die Dauer von linksventrikulärer Systole und Diastole abgeleitet. Als Vergleichskollektiv dienten 26 Patienten, bei denen eine normale linksventrikuläre Pumpfunktion mittels Radionuklidangiographie vor geplanter Chemotherapie sichergestellt wurde.Ergebnisse:Der Vergleich der relativen Systolendauer ergab bei Patienten mit DCM bereits in Ruhe eine signifikante Verlängerung gegenüber Herzgesunden (23,9 vs. 21,5 s/min; p = 0,006). Dieser Befund blieb unter maximaler Belastung signifikant (29,2 vs. 26,7 s/min; p = 0,01), obwohl der Herzfrequenzanstieg in der Patientengruppe vermindert war (118 vs. 127/min; p = 0,04). Um den Einfluss der Herzfrequenz auf die Diastolendauer der DCM-Patienten zu eliminieren, wurden die beobachteten Werte mit den rechnerisch aus der Regressionsgleichung Herzgesunder ermittelten Werten verglichen. Dieses Vorgehen bestätigte eine signifikante Verkürzung der Diastolendauer auf maximaler Belastungsstufe und eine Zunahme des Verlusts an diastolischer Zeit pro Herzschlag gegenüber dem Ruhewert.Schlussfolgerung:Patienten mit fortgeschrittener DCM weisen eine abnorme Verkürzung der linksventrikulären Diastolendauer auf. Diese ist unter körperlicher Belastung besonders ausgeprägt und kann die kardiale Effizienz durch Restriktion von ventrikulärer Füllung und Perfusion beeinträchtigen.AbstractBackground and Purpose:Cardiac performance can be characterized in terms of the relative duration of systole and diastole. In pediatric patients with dilated cardiomyopathy (DCM), a disproportionate shortening of left ventricular diastole was observed. The present study was intended to reproduce these findings in an adult patient group and to evaluate exercise-related changes of both time intervals.Patients and Methods:Exercise radionuclide angiography was used in 61 patients with DCM NYHA (New York Heart Association) stage II–III. The phases of the cardiac cycle were derived from a radionuclide time-activity curve with high temporal resolution. The control group consisted of 26 patients referred for ventricular function assessment with radionuclide angiography before cardiotoxic cancer treatment.Results:When the duration of systole was expressed as the product of systolic time and heart rate, DCM patients exhibited a significant increase in left ventricular systolic time at rest (23.9 vs. 21.5 s/min; p = 0.006) and during peak exercise (29.2 vs. 26.7 s/min; p = 0.01). The prolongation of left ventricular systole at peak exercise was evident, although the peak heart rate was significantly lower in the patient group than in the control group (118 vs. 127/min; p = 0.04). In DCM patients the diastolic time loss per beat was further quantified using a regression equation obtained from the healthy control group. A significant shortening of left ventricular diastolic time was confirmed during peak exercise. Furthermore, a progressive loss in diastolic time per beat from rest to peak exercise was noted.Conclusion:Cardiac cycle abnormalities of patients with DCM are characterized by a prolongation of left ventricular systole and an abnormal shortening of left ventricular diastole. The systolic-diastolic mismatch is accentuated during exercise and has the potential to impair the cardiac reserve in these patients by restricting ventricular filling and perfusion.

Abnorme Verkürzung der linksventrikulären Diastolendauer unter körperlicher Belastung bei Patienten mit dilatativer Kardiomyopathie

ZusammenfassungHintergrund und Ziel:Das Verhältnis von Systolen- und Diastolendauer wird als eine wichtige Determinante der Herzfunktion angesehen. Bei Kindern mit dilatativer Kardiomyopathie (DCM) konnte eine abnorme Verkürzung der Diastolendauer beobachtet werden. In der vorliegenden Studie wurde untersucht, ob sich dieser Befund bei Erwachsenen reproduzieren lässt und welches Verhalten der diastolische Anteil des Herzzyklus unter stufenweiser ergometrischer Belastung zeigt.Patienten und Methodik:Die Untersuchung schloss konsekutiv 61 Patienten mit DCM im NYHA-Stadium (New York Heart Association) II–III ein. Bei diesen wurde unter ergometrischer Belastung eine Radionuklidventrikulographie mit hoher zeitlicher Auflösung durchgeführt. Aus der Zeit-Aktivitäts-Kurve wurde neben der linksventrikulären Ejektionsfraktion die Dauer von linksventrikulärer Systole und Diastole abgeleitet. Als Vergleichskollektiv dienten 26 Patienten, bei denen eine normale linksventrikuläre Pumpfunktion mittels Radionuklidangiographie vor geplanter Chemotherapie sichergestellt wurde.Ergebnisse:Der Vergleich der relativen Systolendauer ergab bei Patienten mit DCM bereits in Ruhe eine signifikante Verlängerung gegenüber Herzgesunden (23,9 vs. 21,5 s/min; p = 0,006). Dieser Befund blieb unter maximaler Belastung signifikant (29,2 vs. 26,7 s/min; p = 0,01), obwohl der Herzfrequenzanstieg in der Patientengruppe vermindert war (118 vs. 127/min; p = 0,04). Um den Einfluss der Herzfrequenz auf die Diastolendauer der DCM-Patienten zu eliminieren, wurden die beobachteten Werte mit den rechnerisch aus der Regressionsgleichung Herzgesunder ermittelten Werten verglichen. Dieses Vorgehen bestätigte eine signifikante Verkürzung der Diastolendauer auf maximaler Belastungsstufe und eine Zunahme des Verlusts an diastolischer Zeit pro Herzschlag gegenüber dem Ruhewert.Schlussfolgerung:Patienten mit fortgeschrittener DCM weisen eine abnorme Verkürzung der linksventrikulären Diastolendauer auf. Diese ist unter körperlicher Belastung besonders ausgeprägt und kann die kardiale Effizienz durch Restriktion von ventrikulärer Füllung und Perfusion beeinträchtigen.AbstractBackground and Purpose:Cardiac performance can be characterized in terms of the relative duration of systole and diastole. In pediatric patients with dilated cardiomyopathy (DCM), a disproportionate shortening of left ventricular diastole was observed. The present study was intended to reproduce these findings in an adult patient group and to evaluate exercise-related changes of both time intervals.Patients and Methods:Exercise radionuclide angiography was used in 61 patients with DCM NYHA (New York Heart Association) stage II–III. The phases of the cardiac cycle were derived from a radionuclide time-activity curve with high temporal resolution. The control group consisted of 26 patients referred for ventricular function assessment with radionuclide angiography before cardiotoxic cancer treatment.Results:When the duration of systole was expressed as the product of systolic time and heart rate, DCM patients exhibited a significant increase in left ventricular systolic time at rest (23.9 vs. 21.5 s/min; p = 0.006) and during peak exercise (29.2 vs. 26.7 s/min; p = 0.01). The prolongation of left ventricular systole at peak exercise was evident, although the peak heart rate was significantly lower in the patient group than in the control group (118 vs. 127/min; p = 0.04). In DCM patients the diastolic time loss per beat was further quantified using a regression equation obtained from the healthy control group. A significant shortening of left ventricular diastolic time was confirmed during peak exercise. Furthermore, a progressive loss in diastolic time per beat from rest to peak exercise was noted.Conclusion:Cardiac cycle abnormalities of patients with DCM are characterized by a prolongation of left ventricular systole and an abnormal shortening of left ventricular diastole. The systolic-diastolic mismatch is accentuated during exercise and has the potential to impair the cardiac reserve in these patients by restricting ventricular filling and perfusion.

Mitral valve disease as well as uncommon extensive epipericardial and intramyocardial calcification secondary to massive mitral annular calcification

A 71-year-old woman with a history of childhood pulmonary tuberculosis was admitted to our hospital for exertional dyspnoea (NYHA functional class II). Transthoracic and transoesophageal echocardiography demonstrated moderate to severe mixed mitral valve disease due to massive mitral annular calcification (MAC) and extensive infiltrative calcification of the atrioventricular groove. In addition, a very uncommon intramyocardial calcification of the ventricular septum and the lateral free wall was diagnosed. This case demonstrates a rare combination of mitral valve disease secondary to MAC, and a small hypertrophied left ventricle, as well as epipericardial and myocardial calcification likely due either to the massive MAC with myocardial extension or to former tuberculous perimyocarditis. The multidimensional imaging approach, which has been used in this particularly case, provided an excellent visualization and clinical evaluation of this rare finding.

Multiple cardiac metastases from a malignant melanoma causing consecutive pulmonary embolism.

A 63-year-old patient, with a history of extirpation of a right atrial myxoma 11 years ago, and a history of malignant skin melanoma surgically removed 7 years ago, was admitted to our department due to fatigue and progressive dyspnea. Transesophageal echocardiography demonstrated multiple metastases in the right atrium and the right ventricle (Figure 1a). A large mobile mass in the right atrium was prolapsing through the tricuspid valve during diastole, mimicking mechanical tricuspid valve stenosis (Figure 1b) [1–3]. Magnetic resonance imaging (MRI) demonstrated three intracardial masses with a maximum size of 3.0 × 3.1 cm (Figures 1c and 1d), which had not been detected in a previous MRI performed 5 months earlier. This rapid progression and growth of the metas1 Department of Cardiology and Angiology, Marienhospital Herne, Ruhr University Bochum, Germany.