Johannes B. Dahm

Potential Role of Autoantibodies Belonging to the Immunoglobulin G-3 Subclass in Cardiac Dysfunction Among Patients With Dilated Cardiomyopathy

Background—Immunoadsorption capable of removing circulating autoantibodies represents an additional therapeutic approach in dilated cardiomyopathy (DCM). The role played by autoantibodies belonging to the immunoglobulin (Ig) subclass G-3 in cardiac dysfunction remains to be elucidated. Methods and Results—Patients with DCM (left ventricular ejection fraction <30%) participated in this case-control study. Nine patients underwent immunoadsorption with protein A (low affinity to IgG-3), and 9 patients were treated with anti-IgG, which removes all IgG subclasses. Immunoadsorption was performed in 4 courses at 1-month intervals until month 3. In the 2 groups, immunoadsorption induced comparable reduction of total IgG (>80%). IgG-3 was effectively eliminated only by anti-IgG adsorption (eg, during the first immunoadsorption course; protein A, −37±4%; anti-IgG, −89±3%;P <0.001 versus protein A). The &bgr;1-receptor autoantibody was effectively reduced only by anti-IgG (P <0.01 versus protein A). Hemodynamics did not change in the protein A group. In the anti-IgG group during the first immunoadsorption course, cardiac index increased from 2.3±0.1 to 3.0±0.1 L · min−1 · m−2 (P <0.01 versus protein A). After 3 months, before the last immunoadsorption course, cardiac index was 2.2±0.1 L · min−1 · m−2 in the protein A group and 3.0±0.2 L · min−1 · m−2 in the anti-IgG group (P <0.01 versus protein A). Left ventricular ejection fraction increased only in the anti-IgG group (P <0.05 versus protein A). Conclusions—Autoantibodies belonging to IgG-3 may play an important role in cardiac dysfunction of DCM. The removal of antibodies of the IgG-3 subclass may represent an essential mechanism of immunoadsorption in DCM.

A randomized trial of 5 vs. 6 french transradial percutaneous coronary interventions

Transradial coronary interventions (TCI) are occasionally limited by radial spasms and postprocedural radial occlusions, which are related to the radial diameter and which possibly may be reduced by the use of smaller guiding catheter. However, 5 Fr, 0.058″ lumen diameter guiding catheter affords less strength, visibility, and backup. In a randomized study, we investigated procedural and clinical success and vascular access complications of 5 Fr in comparison to 6 Fr guiding catheter. One hundred seventy‐one patients with coronary lesions suitable for at least 5 Fr transradial approach (i.e., normal Allen test, only balloon angioplasty and stent) were randomly assigned for 5 or 6 Fr TCI. The primary combined endpoint was procedural and clinical success, and secondary endpoints were vascular access complications and the occurrence of postprocedural radial occlusions at 1‐month follow‐up. Procedural success was achieved in 95.4% of 5 Fr and 92.9% of 6 Fr patients. Selective cannulation of the coronary ostium failed in 1.1% of 5 Fr and 4.8% of 6 Fr patients (P = 0.08). Minor hematomas without need for surgical repair or blood transfusions occurred in 1.1% (5 Fr) and 4.8% (6 Fr; P = 0.07); 1.1% of 5 Fr and 5.9% of 6 Fr patients (P = 0.05) suffered loss of radial pulse due to radial occlusion. Selected noncomplex coronary lesions can successfully and safely be treated either with 5 or 6 Fr guiding catheters. A tendency of higher procedural success rates and lower vascular access complications was documented after 5 Fr in comparison to 6 Fr TCI. This was particularly the case among patients with small radial diameters. Cathet Cardiovasc Intervent 2002;57:172–176.

Significant reduction of radiation exposure to operator and staff during cardiac interventions by analysis of radiation leakage and improved lead shielding

The objectives of this study were to disclose and to reduce occupational radiation leakage in invasive cardiology. Prospectively, we analyzed various dose parameters for 330 coronary procedures. We used a Rando phantom to measure scatter entrance skin air kerma to the operator (S-ESAK-O) during fluoroscopy for all standard tube angulations, and to plot isodose lines for 0 degrees /0 degrees -posterior anterior angulation. The patients measured dose area product due to diagnostic catheterization and elective percutaneous transluminal coronary angioplasty was 6.2 and 10.4 Gycm(2), which represents 11% and 13% of currently typical values, respectively. With use of 0.5- and 1.0-mm overcouch and undercouch shielding, it was possible to reduce the mean of 4,686 nSv/Gycm(2) to 677 and 277 nSv/Gycm(2), respectively. Closure of radiation leakage up to 897 microSv/hour at the operators gonadal height (80 to 105 cm), not heretofore described, was achieved by an additional 1.0-mm, lead-equivalent undercouch-top and overcouch-flap adjacent to the table, down to a S-ESAK-O/dose area product level of 47.5 nSv/Gycm(2). With use of a 0.5-mm lead apron, collar, glasses, foot-switch shield and 1.0-mm lead cover around the patients thighs, the operator received a mean S-ESAK-O of 8.5, while his forehead, eyes, thyroid, chest, gonads, and hands were exposed to 68.2, 1.2, 1.2, 1.2, 0.8, and 58.2 nSv/Gycm(2), respectively. In conclusion, radiation-attenuating intervention techniques and improved lead protection can effectively contribute to a new state of the art in invasive cardiology, with reduction of operator radiation exposure to 0.8% of typical S-ESAK-O levels in advanced catheterization laboratories.

Association Between High Serum Ferritin Levels and Carotid Atherosclerosis in the Study of Health in Pomerania (SHIP)

Background and Purpose— Several studies have provided evidence for a relationship between body iron load and cardiovascular disease. We analyzed the association of serum ferritin levels with carotid atherosclerosis. Methods— We assessed intima-media thickness and plaque prevalence in the carotid arteries by high-resolution ultrasound among 2443 participants (1200 women; age, 45 to 79 years) in the Study of Health in Pomerania (SHIP), a population-based study in northeast Germany. Results— In multivariate analysis, serum ferritin levels were not independently associated with carotid intima-media thickness among women or men. In contrast, the relationship between serum ferritin levels and carotid plaque prevalence was significant among men (odds ratio per 1-SD increase of serum ferritin levels, 1.33; 95% confidence interval, 1.08 to 1.44) yet not among women (odds ratio, 1.29; 95% confidence interval, 0.98 to 1.75). However, both men and women showed a dose-response relation between serum ferritin levels and carotid atherosclerosis in which higher serum ferritin levels were associated with greater odds ratios for carotid plaque prevalence. Additionally, there was an interaction of serum ferritin levels with low-density lipoprotein (LDL) cholesterol (P =0.039) among men in which the association of serum ferritin levels with carotid plaque prevalence became stronger with increasing LDL cholesterol levels. Conclusions— Our study identified a relationship between serum ferritin levels and carotid atherosclerosis that was potentiated by LDL cholesterol. This relationship adds support to the hypothesis of a link between iron and cardiovascular disease.

Relation of degree of laser debulking of in-stent restenosis as a predictor of restenosis rate

precludes a precise estimate of coronary disease, the increased prevalence of traditional risk factors (e.g., smoking, hypertension, diabetes) among the cases compared with the controls is consistent with the presence of underlying coronary atherosclerosis in a signifi cant proportion of the sudden death cases. Because of the community-based nature of the study, paramedics were able to obtain blood specimens only from patients for whom an intravenous line was placed as part of provision of emergency medical care once the patient was clinically stable or resuscitation had proved ineffective. Thus, the circumstances of the cardiac arrest or the provision of medical care often precluded the blood draw, and specimens for genotyping were available from only a fraction (25%) of all sudden deaths that occurred during the study period, which may introduce some bias. However, the characteristics of study participants with and without blood drawn were similar among cases as well as controls. Although medical history data were collected through spousal interviews and not fully validated by medical record review, a small validation study demonstrated that spouses accurately provide

Radiation exposure benefit of a lead cap in invasive cardiology

Background: Occupational head exposure to radiation in cardiologists may cause radiation induced cataracts and an increased risk of brain cancer. Objective: To determine the effectiveness of 0.5 mm lead equivalent caps, not previously used in invasive cardiology, in comparison with a 1.0 mm lead equivalent ceiling mounted lead glass screen. Design: An anthropomorphic Alderson-Rando phantom was used to represent the patient. Scatter entrance skin air kerma to the operator position (S-ESAK-O) was measured during fluoroscopy for all standard angulations and the S-ESAK-O per dose–area product (DAP) calculated, as applied to the phantom. Results: Measured mean (SD) left/right anterior oblique angulation ratios of S-ESAK-O without lead devices were 23.1 (10.1), and varied as a function of tube angulation, body height, and angle of incidence. S-ESAK-O/DAP decreased with incremental operator body height by 10 (3)% per 10 cm. A 1.0 mm lead glass shield reduced mean S-ESAK-O/DAP originating from coronary angiography from 1089 (764) to 54 (29) nSv/Gy × cm2. A 0.5 mm lead cap was effective in lowering measured levels to 1.8 (1.1) nSv/Gy × cm2. Both devices together enabled attenuation to 0.5 (0.1) nSv/Gy × cm2. The most advantageous line of vision for protection of the operator’s eyes was ⩾ 60° rightward. Conclusions: Use of 0.5 mm lead caps proved highly effective, attenuating S-ESAK-O to 2.7 (2.0) × 10−3 of baseline, and to 1.2 (1.4) × 10−3 of baseline where there was an additional 1.0 mm lead glass shield. These results could vary according to the x ray systems used, catheterisation protocols, and correct use of radiation protection devices.

The challenge presented by right atrial myxoma.

Background and Purpose:Right atrial myxoma can be heralded by nonspecific constitutional symptoms—i. e., remittent or lasting fever; weight loss; chronic anemia and general arthralgia—and may escape timely diagnosis until severe complications develop: i. e., pulmonary hypertension due to embolism from fragments originating from the tumor mass, or, by blocking the right atrioventricular ostium, a Budd-Chiari syndrome with acute abdominal pain. Myocardial tamponade and infected right atrial myxomas are reported casuistically.Meta-Analysis:This study, covering 1,029 patients from 32 reports, represents the most extensive meta-analysis to date of recent publications on patients with intracardiac myxomas who had undergone surgery followed by histological confirmation. 83.0% of myxomas studied were located in the left and 12.7% in the right atrial cavity. Even more rarely, the tumor was present in the left (0.6%) or right (1.7%) ventricles; it was biatrial in 1.3% and multilocular in 0.8% of cases. The age of all reported individuals varied between 1 month and 81 years (mean value of reported mean ages: 50 years); 65% of the patients were female. In a subpopulation of 154 individuals, the fraction of familial cardiac myxomas was 4.5%.Case Study:For a 68-year-old patient with recurrent fever of unknown origin, weight loss, exertional dyspnea, and tachycardia, the authors further describe epidemiology, clinical symptoms, prognosis, and the specific diagnostic and therapeutic challenges involved in the rare case of a right sided atrial myxoma.Hintergrund und Ziel:Die Diagnose rechtsatrialer Myxome kann durch sehr unspezifische konstitutionelle klinische Erscheinungsbilder mit interkurrentem oder länger währendem Fieber, Gewichtsverlust, chronischer Anämie und generalisierten Arthralgien erschwert sein. Nicht selten manifestieren sie sich erst durch schwere Komplikationen: Rechtsherzinsuffizienz und pulmonale Hypertonie aufgrund embolisierter Tumorfragmente, seltener Abdominalschmerzen mit der Klinik eines Budd-Chiari-Syndroms infolge Verlegung der Trikuspidalklappe. Nur kasuistisch beschrieben werden myokardiale Tamponade und infizierte Vorhofmyxome.Metaanalyse:In der vorliegenden, derzeit umfassendsten Metaanalyse von 32 Publikationen der letzten 10 Jahre, die 1 029 Patienten mit chirurgisch und histologisch gesicherten kardialen Myxomen einbezieht, waren 83,0% im linken, 12,7% im rechten Vorhof lokalisiert, nur 1,7% der Myxome hingegen im linken und 0,6% im rechten Ventrikel. Biatrial lokalisiert waren sie in 1,3% und multilokulär in 0,8%. Die Patienten waren bei Diagnosestellung zwischen 1 Monat und 81 Jahren alt, der Mittelwert der durchschnittlichen Altersangaben betrug 50 Jahre. 65% der Patienten waren weiblich. Der Anteil familiärer kardialer Myxome betrug in einer Metaanalyse dreier 154 Patienten umfassender Studien 4,5%. Das durchschnittliche Wachstum von Myxomen wird, basierend auf Intervallberechnungen bis zur Operation von Myxomrezidiven, mit ca. 1,8 cm bzw. 14 g/Jahr angegeben, ihre histologische Herkunft ist bis heute nicht eindeutig geklärt.Kasuistik:Die Autoren beschreiben am Beispiel eines 68-jährigen Patienten mit rezidivierenden Fieberschüben unklarer Genese, Belastungsdyspnoe und Tachykardieneigung Epidemiologie, klinische Symptome, Prognose sowie die spezifischen diagnostischen und therapeutischen Herausforderungen der seltenen Krankheitsentität rechtsatrialer Myxome.

Radiation dose reduction in invasive cardiology by restriction to adequate instead of optimized picture quality

Abstract— In this study, the cinegraphic image intensifier entrance dose level for coronary angiography was changed in four steps from dose level A (0.041 &mgr;Gy frame−1), allowing high contrast, but coarse mottled background, to level D (0.164 &mgr;Gy frame−1), affording high transparency and sharpness. Using this new approach throughout the course of 404 consecutive cardiac catheterizations, we reduced patient radiation exposures down to 11 to 16% of currently typical values: i.e., mean dose area products of 5.97 Gy cm2 (n = 91), 6.73 (n = 113), 8.11 (n = 91), and 8.90 (n = 109); cinegraphic dose area products of 2.34, 3.64, 4.56, and 5.49; and cinegraphic dose area products frame−1 of 13.3, 19.8, 27.0, and 30.2 mGy cm2, for levels A, B, C, and D, respectively. The number of cinegraphic frames ranged within 168 to 182 per case. Our results show that during catheterization interventionalists should vary image intensifier entrance dose levels in accordance with documented structure, angulation, and body mass index. With the exception of cases with special requirements, lower dose levels typically guarantee an adequate image quality.

Usefulness of rotational spin for coronary angiography in patients with advanced renal insufficiency

Coronary angiography in patients with advanced renal insufficiency is typically restricted to cases of life-threatening circumstances such as acute myocardial infarction and unstable angina. To gather a large amount of visual information with a minimum number of cine runs, and consequently, with a minimum volume of contrast medium, we rotated the gantry at 40 degrees /s throughout an angle of 120 degrees, from the right toward the left anterior oblique positions. This technique of rotational spin during cinegraphic runs has not yet become established in invasive cardiology. Three experienced cardiologists independently evaluated all coronary segments in rotational versus standard coronary angiography modes for 15 patients, on the basis of an 11-point scale (0 = cardiac spin far better to 10 = standard mode far better). A score of 5 signified that there was no difference in quality between the 2 modes. The arithmetic mean of the assessment values was 4.9 +/- 0.3 for coronary segments, 5.4 +/- 1.3 for coronary lesions, 5.1 +/- 1.4 for bifurcations, and 5.0 +/- 0.1 for coronary flow. The arithmetic means for the volume of contrast medium (25 +/- 4 ml), for the overall dose area product (8.6 +/- 4.5 Gy x cm(2)), and for the number of cine graphic frames (203 +/- 65) for a diagnostic cardiac spin were significantly below published typical values in standard mode. Cardiac spin enables 3-dimensional coronary impression under conditions of adequate image quality and represents a new, useful, and beneficial method in invasive cardiology for applications involving the special indication of advanced renal insufficiency.

Excimer laser revascularisation: current indications, applications and techniques.

Abstract. The ultraviolet pulsed excimer laser (308 nm wavelength) is currently the only laser approved by the FDA for percutaneous intervention in patients with ischemic coronary artery disease. The clinical presentation of the treated patients varies from stable and unstable angina to acute myocardial infarction. Potential advantages of excimer laser revascularisation in acute coronary syndromes and in ischaemic obstructive peripheral vascular disease include concomitant plaque debulking and thrombus removal; absence of systemic lytic state; shortened thrombus clearing time and facilitation of adjunct balloon angioplasty and stenting. Improved understanding of laser–tissue interactions and positive clinical outcomes through the use of safe lasing techniques have led to expansion of indications/applications for laser angioplasty. These include stent restenosis, complex lesions and thrombotic stenoses, bifurcation lesions, balloon failure, total occlusions, focal saphenous vein graft lesions and peripheral arterial obstructions. The excimer laser can be effectively utilised in patients with depressed left ventricular ejection fraction and does not require implantation of a temporary pacemaker as no-reflow phenomenon and severe arrhythmias are rarely encountered. Careful case selection, proper utilisation of equipment and incorporation of efficient lasing techniques play a crucial role in effective and safe cardiovascular laser applications.