Jens Treptau

NT-proBNP Indicates Left Ventricular Impairment and Adverse Clinical Outcome in Patients With Tetralogy of Fallot and Pulmonary Regurgitation

BACKGROUND The goal of this study was to interrelate N-terminal B-type natriuretic peptide (NT-proBNP) levels and cardiac magnetic resonance imaging-derived ventricular function, mass, and volumes in adults with pulmonary regurgitation after Fallot repair and to evaluate the prognostic relevance of these parameters regarding adverse clinical outcome. METHODS Eighty-one patients (aged 26.3 ± 7.4 years; male sex, 45.7%; New York Heart Association class I, 72.8%; pulmonary valve velocity, < 3 m/s) were included. At baseline cardiac magnetic resonance imaging and NT-proBNP measurements were performed. RESULTS During a mean observation time of 6.9 ± 2.6 years, 13 patients (16.1%) had sustained supraventricular arrhythmias or heart failure (2.4 per 100 patient-years). Multivariate Cox analysis identified NT-proBNP, left ventricular (LV) end-systolic volume index and LV ejection fraction, right ventricular (RV) end-diastolic volume index, and tricuspid regurgitation as independent predictors of adverse events. NT-proBNP correlated with LV but not with RV parameters. In receiver operating characteristic curve analysis using significant variables of the multivariate analysis, NT-proBNP was superior to all other parameters to detect patients at risk (area under the curve [AUC], 0.873; 95% confidence interval, 0.772-0.974). LV end-systolic volume index (AUC, 0.734), RV end-diastolic volume index (AUC, 0.645) und tricuspid regurgitation (AUC, 0.747) showed lower diagnostic accuracy. CONCLUSIONS Even in mildly symptomatic patients with pulmonary regurgitation after Fallot repair NT-proBNP is a strong predictor of adverse outcome. It is rather associated with LV but not with RV impairment. In severe pulmonary regurgitation an increase in the level of NT-proBNP and LV impairment seem to provide additional useful information for the timing of pulmonary valve replacement.

Leukocytoclastic vasculitis associated with endocarditis in a patient with transposition of the great arteries and mechanical valve replacement

Immunological vascular phenomena can be the initial manifestation of bacterial infection and endocarditis. Here, we report a rare case of leukocytoclastic vasculitis without immune complexes or cryoglobulinemia in a patient with infective endocarditis, congenital heart disease, and a prior mechanical valve replacement. The patient completely recovered following antibiotic therapy, and skin lesions disappeared without immune suppression, which suggested infection-mediated vasculitis. While the treatment of leukocytoclastic vasculitis typically involves immunosuppressive therapy, the treatment for infection-mediated vasculitis is eradication of the infection.

Giant pericardial effusion: drain it all?

An 82-year-old patient was admitted to our hospital with dyspnoea from chronic pericardial effusion associated with connective tissue disease. Pericardiocentesis had been performed several times before in other hospitals. Transthoracic echocardiography on admission showed massive pericardial effusion with a ‘swinging heart’ ( Panel A and see Supplementary material online, Video S1 …

Angiographic detection of fatal acute aortic dissection Stanford type A under resuscitation

After resuscitation for out-of-hospital cardiac arrest (OHCA), emergent cardiac catheterization is recommended in patients with ST-segment elevation, and should be considered early in those without [1, 2]. Here, we present a patient with OHCA and inferior ST-segment elevation who inadvertently had fatal acute aortic dissection, which is only rarely documented by angiography. A 77-year-old female with know atrial fibrillation on phenprocoumon and arterial hypertension was admitted to our emergency department after cardiopulmonary resuscitation (CPR) for OHCA. The patient had suffered from angina for 24 h and collapsed in the waiting room, while expecting an appointment with a general practitioner. After 20 min of CPR for asystole, spontaneous circulation returned. Electrocardiogram (ECG) demonstrated ST-segment elevation in leads II, III, aVF and V6. The ventilated patient, who was then stable with vasopressors, was immediately transferred to our hospital. After arrival in the emergency department, ECG confirmed ST-segment elevations, Q waves in leads II, III, aVF and V6, and incomplete right bundle branch block (Fig. 1A). Fast-track echocardiography showed mild aortic regurgitation but no pericardial effusion or severe right ventricular dysfunction. Therefore, the patient was transferred to the cathlab. On the way, hypotension occurred and CPR was performed with a mechanical resuscitation device (LUCAS, Physio-Control). Aortography revealed acute aortic dissection Stanford type A (AADA) extending to both iliac arteries, with the brachiocephalic trunk and the left carotid artery originating from the false lumen (Fig. 1B, C; Supplementary Video 1 — see journal website). Due to prolonged resuscitation and fatal neurological prognosis, resuscitation was terminated. Autopsy confirmed AADA with an entry in the aortic bulb (Fig. 1D) without affecting the right coronary artery ostium, as well as an aneurysm of the abdominal aorta (Fig. 1E). Prognosis of AADA is poor with 50% mortality after 48 h without surgery and 17.1% mortality after 30 days with surgery [3]. In our case, the clinical picture and ECG findings were indeed suggestive of inferior myocardial infarction, and typical echocardiographic signs of AADA, such as pericardial effusion or relevant aortic regurgitation were missing. Incidence of AADA is low compared to that of ST-segment elevation myocardial infarction, but is probably underestimated [4]. The prevalence of ST-segment elevation in AADA is 3.2% [5], and fast rule-out echocardiography in patients with ST-segment elevation in inferior leads is useful [6] and allowed by current guidelines, as long as it does not delay angiography [1, 7]. The present case prototypically illustrates fatal AADA and reminds us of considering AADA in cases of chest pain and ST-segment elevation in inferior leads, and further points to the eminent role of computed tomography in cases of successful resuscitation for OHCA [1]. clinical cardiology