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Aims Despite its high incidence and mortality risk, there is no evidence-based treatment for non-ischaemic cardiogenic shock (CS). The aim of this study was to evaluate the use of mechanical circulatory support (MCS) for non-ischaemic CS treatment.Methods and results In this multicentre, international, retrospective study, data from 890 patients with non-ischaemic CS, defined as CS due to severe de-novo or acute-on-chronic heart failure with no need for urgent revascularization, treated with or without active MCS, were collected. The association between active MCS use and the primary endpoint of 30-day mortality was assessed in a 1:1 propensity-matched cohort. MCS was used in 386 (43%) patients. Patients treated with MCS presented with more severe CS (37% vs. 23% deteriorating CS, 30% vs. 25% in extremis CS) and had a lower left ventricular ejection fraction at baseline (21% vs. 25%). After matching, 267 patients treated with MCS were compared with 267 patients treated without MCS. In the matched cohort, MCS use was associated with a lower 30-day mortality (hazard ratio 0.76, 95% confidence interval 0.59-0.97). This finding was consistent through all tested subgroups except when CS severity was considered, indicating risk reduction especially in patients with deteriorating CS. However, complications occurred more frequently in patients with MCS; e.g. severe bleeding (16.5% vs. 6.4%) and access-site related ischaemia (6.7% vs. 0%).Conclusion In patients with non-ischaemic CS, MCS use was associated with lower 30-day mortality as compared to medical therapy only, but also with more complications. Randomized trials are needed to validate these findings. [GRAPHICS] Open Access funding enabled and organized by Projekt DEAL. Conflict of interest: B.S. reports speaker fees from Abiomed and AstraZeneca, outside of the submitted work. B.N.B. reports honoraria from Siemens Healthineers, outside of the submitted work. S.B. reports grants and personal fees from Abbott Diagnostics, Bayer, Siemens, Thermo Fisher, grants from Singulex, personal fees from Abbott, AstraZeneca, Amgen, Medtronic, Pfizer, Roche, Siemens Diagnostics, Novartis, outside of the submitted work. D.E. reports speaker fees from Abiomed, Bayer, Daiichi Sankyo, outside of the submitted work. P.H. reports travel compensation from Abiomed, outside of the submitted work. P.K. reports research support for basic, translational, and clinical research projects from European Union, British Heart Foundation, Leducq Foundation, Medical Research Council (UK) and German Centre for Cardiovascular Research, from several drug and device companies active in atrial fibrillation, and has received honoraria from several such companies in the past, but not in the last 3 years. He is listed as inventor on two patents held by University of Birmingham (Atrial Fibrillation Therapy WO 2015140571, Markers for Atrial Fibrillation WO 2016012783; unrelated to the submitted work). S.K. reports research support from Cytosorbents and Daiichi Sankyo. He also received lecture fees from Astra, Bard, Baxter, Biotest, Cytosorbents, Daiichi Sankyo, Fresenius Medical Care, Gilead, Mitsubishi Tanabe Pharma, MSD, Pfizer, Philips and Zoll. He received consultant fees from Fresenius, Gilead, MSD and Pfizer, outside of the submitted work. P.L. reports speaker fees from AstraZeneca, Bayer, EdwardsLifesciences, Medtronic and Pfizer outside the submitted work. N.M. reports lecture fees Pfizer/Bristol-Myers Squibb and grant research from Getinge Global USA and Italfarmaco, outside of the submitted work. M.O. reports speaker honoraria from Abbott Medical, AstraZeneca, Abiomed, Bayer vital, Biotronik, Bristol-Myers Squibb, CytoSorbents, Daiichi Sankyo Deutschland, Edwards Lifesciences Services, Sedana Medical, outside of the submitted work. A.P. reports an unrestricted educational grant from Abbott Vascular, outside of the submitted work. T.R. reports speaker fees from AstraZeneca, Daiichy, Bayer, Novartis, Abiomed outside the submitted work. D.W. reports speaker fees from Abiomed, AstraZeneca, Bayer, Berlin-Chemie, Boehringer Ingelheim, Novartis and Medtronic, outside of the submitted work. All other authors have nothing to disclose.

The non-physician employees in telemedicine centers (TMC) play a decisive role in the care and treatment of patients with heart failure. For this reason, a holistic profile consisting of professional and methodological as well as social and personal competences is necessary, which should be built up or promoted in corresponding training concepts. This position paper underlines the urgency of appropriate and standardized further training of non-physician employees for quality assurance in TMCs and summarizes the requirements for the additional qualification of a telemedical assistant across the board.

Background: Venoarterial extracorporeal membrane oxygenation (VA-ECMO) is increasingly used to treat cardiogenic shock. However, VA-ECMO might hamper myocardial recovery. The Impella unloads the left ventricle. This study aimed to evaluate whether left ventricular unloading in patients with cardiogenic shock treated with VA-ECMO was associated with lower mortality. Methods: Data from 686 consecutive patients with cardiogenic shock treated with VA-ECMO with or without left ventricular unloading using an Impella at 16 tertiary care centers in 4 countries were collected. The association between left ventricular unloading and 30-day mortality was assessed by Cox regression models in a 1:1 propensity score–matched cohort. Results: Left ventricular unloading was used in 337 of the 686 patients (49%). After matching, 255 patients with left ventricular unloading were compared with 255 patients without left ventricular unloading. In the matched cohort, left ventricular unloading was associated with lower 30-day mortality (hazard ratio, 0.79 [95% CI, 0.63–0.98]; P =0.03) without differences in various subgroups. Complications occurred more frequently in patients with left ventricular unloading: severe bleeding in 98 (38.4%) versus 45 (17.9%), access site–related ischemia in 55 (21.6%) versus 31 (12.3%), abdominal compartment in 23 (9.4%) versus 9 (3.7%), and renal replacement therapy in 148 (58.5%) versus 99 (39.1%). Conclusions: In this international, multicenter cohort study, left ventricular unloading was associated with lower mortality in patients with cardiogenic shock treated with VA-ECMO, despite higher complication rates. These findings support use of left ventricular unloading in patients with cardiogenic shock treated with VA-ECMO and call for further validation, ideally in a randomized, controlled trial.

Anhand der 4. Universellen Definition des Myokardinfarkts (MI) wird dieses Krankheitsbild mit seinen zahlreichen ischamischen und nichtischamischen Ursachen klassifiziert. Ein akuter Myokardschaden ist durch einen signifikanten Anstieg der kardialen Troponine (cTn) gekennzeichnet. Bei zusatzlichem Vorliegen einer myokardialen Ischamie, die anhand von EKG-, klinischen, bildgebenden und angiographischen Kriterien definiert wird, kann die Diagnose eines akuten MI gestellt werden. Atiologisch lassen sich die MI in 5 Typen unterteilen (Typ 1: ischamisch durch Plaqueruptur oder Plaqueerosion mit Thrombenbildung, Typ 2: Missverhaltnis zwischen myokardialem Sauerstoffangebot und -bedarf, Typ 3: Post-mortem-Verdachtsdiagnose vor Moglichkeit einer cTn-Bestimmung, Typ 4a

Die Prognose der Herzinsuffizienz hat sich in den letzten Jahren durch die Einfuhrung verschiedener neuer Therapien stetig verbessert, dennoch ist die 5‑Jahres-Mortalitat mit >50 % sowohl der systolischen auch der diastolischen Herzinsuffizienz immer noch sehr hoch. Mogliche Therapieoptionen sind die medikamentose Therapie, die Device-Therapie sowie die interventionelle Therapie der chronischen Herzinsuffizienz.

ZusammenfassungUm der wachsenden Anzahl von Herzinsuffizienz-Patienten besser gerecht zu werden, empfehlen die Europäischen Behandlungsleitlinien für das Syndrom Herzinsuffizienz strukturierte Nachsorgeprogramme. In diesen Programmen können wesentliche Aufgaben (wie Beratung, Monitoring, Kommunikation, Organisation, Dokumentation) an nichtärztliches Fachpersonal delegiert werden. Das hier beschriebene, durch die Deutsche Gesellschaft für Kardiologie konsentierte Fortbildungscurriculum „Spezialisierte Herzinsuffizienz-Assistenz“ will zur Verbesserung der Versorgung von Herzinsuffizienz-Patienten beitragen.

ObjectiveTo assess current management practice of heart failure with reduced ejection fraction (HFrEF) in multinational primary care (PC) and determine whether N-terminal-pro-B-type natriuretic peptide (NT-pro-BNP)-guided referral of HFrEF patients from PC to a cardiologist could improve care, defined as adherence to European Society of Cardiology (ESC) guideline-recommended pharmacotherapy.MethodsPRospective Evaluation of natriuretic peptide-based reFERral of patients with chronic HF in PC (PREFER) study enrolled HFrEF patients from PC considered clinically stable and those with NT-pro-BNP ≥600 pg/mL were referred to a cardiologist for optimisation of HF treatment. The primary outcome of adherence to ESC HF guidelines after referral to specialist was assessed at the second visit within 4 weeks of cardiologist’s referral and no later than 6 months after the baseline visit. Based on futility interim analysis, the study was terminated early.ResultsIn total, 1415 HFrEF patients from 223 PCs from 18 countries in Europe were enrolled. Of these, 1324 (96.9%) were considered clinically stable and 920 (65.0%) had NT-pro-BNP ≥600 pg/mL (mean: 2631 pg/mL). In total, 861 (60.8%) patients fulfilled both criteria and were referred to a cardiologist. Before cardiologist consultation, 10.1% of patients were on ESC guideline-recommended HFrEF medications and 2.7% were on recommended dosages of HFrEF medication (defined as ≥50% of ESC guideline-recommended dose). Postreferral, prescribed HFrEF drugs remained largely unchanged except for an increase in diuretics (+4.6%) and mineralocorticoid receptor antagonists (+7.9%). No significant increase in patients’ adherence to guideline-defined drug combinations (11.2% post-referral vs 10.1% baseline) or drug combinations and dosages (3.3% postreferral vs 2.7% baseline) was observed after cardiologist consultation.ConclusionsPREFER demonstrates substantial suboptimal treatment of HFrEF patients in the real world. Referral of patients with elevated NT-pro-BNP levels from PC to cardiologist did not result in meaningful treatment optimisation for treatments with known mortality and morbidity benefit.

The COVID-19 pandemic is placing a heavy burden on healthcare systems worldwide with the risk that acute cardiovascular diseases are treated too late. The present study aims to analyze patients with acute coronary syndrome in the current pandemic. A total of 966 patients (2019 n = 463, 2020 n = 503) can be evaluated. A comparison of patient care during and before the COVID-19 pandemic was made in terms of patient characteristics and pre- and in-hospital processes. Another aim is to show how many patients seek clinical care at a late stage of the disease. After Lockdown in Germany at week 12, 2020, there was a significant decrease in patients with an acute coronary syndrome (ACS), significant for STEMI cases in the first weeks after Lockdown (calendar week 13–16 2019 n = 43, 2020 n = 30; p = 0.02). The time from pain to first medical contact (time to FMC) is significantly extended during Lockdown, while internal clinical processes are unchanged. The rate of subacute myocardial infarction is numerically, but not significantly increased in calendar weeks 15, 2020 (p = 0.40) and 16 (p = 0,19). In addition, elderly patients avoid treatment for multifactorial reasons, and the longer overall pain to FMC may impact long-term mortality.

The non-physician employees in telemedicine centers (TMC) play a decisive role in the care and treatment of patients with heart failure. For this reason, a holistic profile consisting of professional and methodological as well as social and personal competences is necessary, which should be built up or promoted in corresponding training concepts. This position paper underlines the urgency of appropriate and standardized further training of non-physician employees for quality assurance in TMCs and summarizes the requirements for the additional qualification of a telemedical assistant across the board.Das nichtärztliche Personal in Telemedizinzentren (TMZ) nimmt in der Betreuung und Behandlung von Patienten mit Herzinsuffizienz eine entscheidende Rolle ein. Aus diesem Grund ist ein ganzheitliches Anforderungsprofil bestehend aus Fach- und Methodenkompetenz sowie sozialer und persönlicher Kompetenz gefordert, welches in entsprechenden Schulungskonzepten aufgebaut bzw. gefördert werden sollte. Das vorliegende Positionspapier betont die Dringlichkeit einer angemessenen und standardisierten Fortbildung des nichtärztlichen Personals zur Qualitätssicherung in TMZ und fasst die Anforderungen an die Zusatzqualifikation einer Telemedizin-Assistenz übergreifend zusammen.

Indications for TF-TAVI (transfemoral transcatheter aortic valve implantation) are rapidly changing according to increasing evidence from randomized controlled trials. Present trials document the non-inferiority or even superiority of TF-TAVI in intermediate-risk patients (STS-Score 4–8%) as well as in low-risk patients (STS-Score

ZusammenfassungAufgrund der zunehmenden Spezialisierung in den verschiedenen Bereichen der Kardiologie und den immer anspruchsvolleren administrativen Strukturvorgaben und Mindestanforderungen an die ärztliche Qualifikation und Präsenz entwickelt sich ein Spannungsfeld zwischen verschiedenen eigenständigen Kliniken bzw. Departments innerhalb der Kardiologie in großen kardiologischen Kliniken und einer „allgemeinen Kardiologie“, die alle Schwerpunkte ohne Abteilungen oder Departmentstrukturen in sich vereint. Ganz prinzipiell ist eine Unterteilung in Departments bzw. verschiedene Abteilungen nur dann sinnvoll, wenn die Klinik eine entsprechende Größe und Struktur hat. Auf der anderen Seite muss aber auch bedacht werden, dass die Schnittstellen zwischen den verschiedenen Bereichen/Abteilungen/Departments so geregelt sind, dass die genannten Strukturvorgaben vollumfänglich realisiert werden können, um nachhaltig Qualitätsvorgaben und die inzwischen mannigfaltigen Erlösvoraussetzungen zu erfüllen. Das setzt auch interne Regelungen wirtschaftlicher Interessen im Vorfeld voraus wie z. B. ein einheitliches Budget mit jedoch differenzierter Darlegung der Leistungsdaten in den verschiedenen Bereichen inklusive Deckungsbeiträgen. Das kardiologische Behandlungsspektrum ist in weiten Teilen bestimmt durch Notfälle. Deshalb muss die Behandlung dieser Patienten in der Notaufnahme (Chest Pain Unit) und auf der Intensivstation in der Hand der Kardiologen bleiben, um eine optimale Versorgung zu sichern. Eine Unterteilung in eigenständige kardiologische Kliniken widerspricht zum Teil dem politischen Wunsch und den derzeitigen positiven Erfahrungen von Zentrumsbildungen. Wenn eine Einrichtung die entsprechende Größe hat, kann es sinnvoll sein, sogenannte Herzzentren mit Integration der Herzchirurgie zu bilden. Die wirtschaftliche Struktur dieser Herzzentren muss sehr differenziert etabliert werden, um Fehlentwicklungen und einen ungesunden internen Wettbewerb zu verhindern. Die robuste Erfüllung von Strukturvorgaben bestimmt inzwischen die Planung fast mehr als die Erfüllung medizinisch-fachlich gebotener Voraussetzungen, um einen nachhaltigen Bestand der gewählten Organisationsform der kardiologischen Klinik zu sichern. Sektorenübergreifende Versorgungsformen müssen in Zukunft mehr zur Anwendung kommen.

Background: The vascular access in transcatheter aortic valve replacement (TAVR) was initially dominated by a surgical approach. Meanwhile, percutaneous closure systems became a well-established alternative. The aim of this study was to compare the clinical outcome between the two approaches. Methods: In this retrospective study, we observed 787 patients undergoing a TAVR-Procedure between 2013 and 2019. Of those, 338 patients were treated with surgical access and 449 with the Perclose ProGlide™-System (Abbott, Chicago, IL, USA). According to the Bleeding Academic Research Consortium (BARC) and Valve Academic Research Consortium (VARC) criteria, the primary combined endpoints were defined. Results: Overall hospital mortality was 2.8% with no significant difference between surgical (3.8%) and percutaneous (2.2%) access (p = 0.182). Major vascular complications or bleeding defined as the primary combined endpoint was not significantly different in either group (Surgical group 5.3%, ProGlide group 5.1%, p = 0.899). In the ProGlide group, women with pre-existing peripheral artery disease (PAD) were significantly more often affected by a vascular complication (p = 0.001 for female sex and p = 0.03 for PAD). Conclusions: We were able to show that the use of both accesses is safe. However, the surgical access route should also be considered in case of peripheral artery disease.

Background Cardiogenic shock (CS) in patients (pts) with acute ST elevation myocardial infarction (STEMI) is the strongest predictor of hospital mortality. Radial in contrast to femoral access in STEMI pts might be associated with a lower mortality. However, little is known on radial access in CS pts. Methods We retrospectively analysed all STEMI pts between 2009 and 2015 who sufferend from CS and who were included into the ALKK PCI registry. Pts treated via a radial access were compared to those treated via a femoral access. Results Between 2009 and 2015 23796 STEMI pts were included in the registry. 1763 (7.4%) of pts were in CS. The proportion of radial access was 6.6%: in 2009 4.0% and in 2015 19.6%, p for trend Conclusions Radial access was only used in 6.6% of STEMI pts presenting in CS. However, a significant increase in the use of radial access was observed over time (2009: 4%, 2015 19.6%, p Funding Acknowledgement Type of funding source: None

This disease with its multiple ischemic and non-ischemic manifestations is classified based on the fourth universal definition of myocardial infarction (MI). An acute myocardial injury is defined as a significant increase of cardiac troponins (cTn). In patients with an additional myocardial ischemia, which is defined by certain clinical, electrocardiographic, imaging and angiographic criteria, the diagnosis of acute MI can be made. Etiologically, MI can be divided into 5 types: type 1 ischemic by plaque rupture or plaque erosion with thrombus formation, type 2 imbalance between myocardial oxygen demand and supply, type 3 MI as suspected cause of death before determination of cTn, type 4a48 h after percutaneous coronary intervention (PCI), type 4b stent thrombosis, type 4c in-stent stenosis and type 548 h after coronary artery bypass grafting (CABG). This classification reflects the heterogeneity of acute MI. Based on clearly defined criteria the guidelines attempt to provide clinically active physicians with assistance in the diagnosis and treatment of this specific disease. Nevertheless, it is still necessary to take a holistic view of the patient with all the individual characteristics.

Aims Left ventricular (LV) dysfunction in viral myocarditis is attributed to myocardial inflammation and fibrosis, inducing acute and long‐time cardiac damage. Interventions are not established. On the basis of the link between inflammation, fibrosis, aldosterone, and extracellular matrix regulation, we aimed to investigate the effect of an early intervention with the mineralocorticoid receptor antagonist (MRA) eplerenone on cardiac remodelling in a murine model of persistent coxsackievirus B3 (CVB3)‐induced myocarditis. Methods and results SWR/J mice were infected with 5 × 104 plaque‐forming units of CVB3 (Nancy strain) and daily treated either with eplerenone (200 mg/kg body weight) or with placebo starting from Day 1. At Day 8 or 28 post infection, mice were haemodynamically characterized and subsequently sacrificed for immunohistological and molecular biology analyses. Eplerenone did not influence CVB3 load. Already at Day 8, 1.8‐fold (P

Iron deficiency (ID) has been recognized as a relevant comorbidity in heart failure with reduced ejection fraction (HFrEF); however, study data have shown that diagnostic and therapeutic efforts on ID are primarily performed in patients with anemia. The RAID-HF registry investigated consecutive patients with ID and HFrEF in 11 heart centers in Germany and Switzerland. The present analysis focuses on 1-year follow-up data in patients with versus without anemia. In 505 patients with HFrEF and ID and 418 patients with HFrEF without ID 1-year follow-up was performed. Patients with ID had a higher long-term mortality compared to those without ID (19.5% vs. 13.7%, p = 0.02) and reported a lower quality of life. Only a minority of patients with ID (9.3%) received iron supplementation during long-term course, just 4.7% intravenously. Anemia was associated with an elevated mortality whereas ID versus no ID did not predict mortality in anemic patients (log-rank p = 0.78). However, in patients without anemia ID versus no ID predicted mortality (log-rank p = 0.002). In the adjusted analysis a significant interaction remained, with ID being a significant predictor of 1-year mortality in patients without anemia (HR 2.15, 95% CI 1.12–3.78), but not in anemic patients (HR 0.99, 95% CI 0.65–1.49). RAID-HF demonstrates the impact of ID on long-term mortality and quality of life in patients with HFrEF and reveals an underuse of iron supplementation in current clinical practice. Particularly in patients without anemia the diagnosis of ID is of clinical relevance to identify patients at higher mortality risk.

Background Determination of the Fractional Flow Reserve (FFR) has become part of routine clinical practice. Contemporary clinical use, consequences as well as complications in consecutive, large cohorts have not been thoroughly investigated. We report the results of the prospective Fractional Flow Reserve Fax Registry F (FR2) conducted in Germany. Purpose To systematically analyze indications, procedural parameters, complications and consequences of intracoronary pressure measurements in a large contemporary cohort. Methods Data of 2000 consecutive patients undergoing clinically indicated FFR, iFR or pd/pa measurements in 8 interventional centres in Germany were prospectively collected in a systematic fashion. Data included basic patient characteristics, procedural aspects of intracoronary pressure measurements, associated complications, visual stenosis degree, measurement results and treatment decisions. Results Mean patient age was 68±11 years, 73% of patients were male. Of all patients, 300 patients (15%) had an acute coronary syndrome (STEMI: 9; NSTEMI: 94; unstable angina: 197) and 1002 patients (50%) had undergone previous revascularization. A mean of 1.7±0.9 measurements were performed per patient, for which an average of 1.02 pressure wires were required (more than 1 wire in 64 patients). For all 3373 interrogated lesions, median stenosis degree was 60%. Vasodilator-free measurements were performed in 415/3373 cases (12%, iFR: 346; pd/pa: 69). For vasodilation, i.v. adenosine was used in 396 cases (13%), i.c. adenosine in 2628 cases (87%), and other drugs in 10 cases (0.3%). Measurement was performed before potential revascularization in 3232 cases (96%) and during or following PCI in 141 cases. In 2958 lesions analyzed by FFR, mean FFR was 0.87, with 588 FFR measurements ≤0.80 (19.8%). Median FFR values were higher for i.c than i.v. adenosine administration (0.88 vs. 0.84), but not significantly different after adjustment for stenosis degree. In 735 cases (20.2%), intracoronary pressure measurement was followed by revascularization measures, while in 2637 cases (79.8%), no revascularization or no further revascularization was performed. In 36 out of 117 stenoses visually estimated to be ≥90%, revascularization was deferred following pressure measurement (31%). In 75 out of 2958 lesions analyzed by FFR, revascularization was performed even though FFR was >0.80 (3%). Severe complications (vessel dissection or occlusion) occurred in 5 out of 2000 patients as a consequence of intracoronary pressure measurement, resulting in death of 1 patient. Conclusion In clinical practice, the majority of intracoronary pressure measurements are performed in stenoses of intermediate angiographic severity and revascularization is deferred in approximately 80% of lesions. Vasodilator-free measurements are infrequent and route of adenosine administration has no effect on results. Complication rate is low but not negligible. Acknowledgement/Funding Abbott Vascular

Background Veno-arterial extracorporeal membrane oxygenation therapy (VA-ECMO) is increasingly used for treatment of severe cardiogenic shock, although it causes an increase in left ventricular (LV) afterload and might therefore hamper myocardial recovery. Recently, the addition of catheter-based left ventricular assist device (cLVAD) on top of VA-ECMO has been used to unload the LV and to improve outcome measures. However, there is limited data on predictors of outcome in this high-risk population. Aim The aim of this study was to evaluate predictors of 30-day survival in a multicentre cohort of severe cardiogenic shock patients treated with cLVADon top of VA-ECMO. Material and methods We report on consecutive patients from six tertiary care centers being treated with cLVAD in addition to VA-ECMO for treatment of cardiogenic shock. The primary endpoint is 30-day all-cause mortality. To identify predictors of the primary endpoint, multivariate analysis using an “elastic net” variable selection algorithm was done after imputation of missing variables. Results A total of 220 patients treated with cLVAD on top of VA-ECMO were included in the analysis. Of these, 79.1% were male with a median age of 55.5 (25thpercentile 48.0, 75thpercentile 65.6) years. In 60.5% of the patients, acute myocardial infarction was the underlying cause of cardiogenic shock and in 44.6% VA-ECMO was used for refractory cardiac arrest (eCPR). In the multivariable analysis, the following baseline parameters were significantly associated with the primary endpoint: Age (odds ratio of 1.68 per standard deviation), duration of cardiopulmonary resuscitation (OR 2.08 per SD), lactate (OR 1.04 per SD) and time from onset of shock to VA-ECMO (OR 1.30 per SD). Conclusion and outlook In this large-scale multicentre analysis of severe cardiogenic shock patients treated with VA-ECMO plus additional cLVAD unloading, age, duration of cardiopulmonary resuscitation, lactate and time from onset of shock to VA-ECMO were significantly associated with 30-day all-cause mortality. To further investigate this topic, we will evaluate predictors of outcome in distinct patient populations such as acute myocardial infarction vs. acute heart failure and patients without vs. patients with prior cardiopulmonary association.

Das akute Koronarsyndrom (ACS) – gegliedert in „ST-elevation myocardial infarction“ (STEMI), „non-ST-segment elevation acute coronary syndrome“ (NSTE-ACS) und instabile Angina pectoris – stellt besonders beim alteren Menschen eine besondere Herausforderung in Bezug auf Diagnostik und Therapie dar. Begonnen mit der ggf. schwierigen Anamnese uber die laborchemischen Befunde bis hin zu Besonderheiten in EKG, Echokardio- und Angiographie sollten diese Patienten different zu Jungeren betrachtet werden. Aufgrund der besonders im hohen Alter bestehenden Mortalitat und Morbiditat nach ACS gilt es, evidente Strategien in Diagnostik und Therapie einzuhalten und speziell geschultes Personal fur Menschen mit akutem Brustschmerz einzusetzen, um Prognose und Lebensqualitat der Betroffenen zu bessern. Der erste wichtige Schritt sind zertifizierte „chest pain units“, die die reibungslose Diagnostik und Therapie sicherstellen und die innerklinischen Entscheidungsprozesse positiv beeinflussen.

Transcatheter alcohol septal ablation (ASA) treatment of symptomatic patients with hypertrophic obstructive cardiomyopathy (HOCM) is based on the existence and degree of intraventricular obstruction. Patients with significant gradient and symptoms who do not respond to optimal medical therapy are eligible to gradient reduction through a surgical (septal myectomy) or a transcatheter (alcohol septal ablation) septal reduction. The latter encompasses occlusion of a septal branch perfusing the hypertrophied septum, which is involved in the generation of obstruction, by injecting ethanol into the supplying septal branch(es). ASA has been established as a highly effective and safe method and has outnumbered the surgical gold standard. Although the technique is straightforward, patient selection and some technical details may influence the efficacy and safety of the procedure. The technique is based on echocardiographic contrast guidance, which allows accurate target septal branch selection and optimisation of the result. Published long-term results from high-volume centres have confirmed the effectiveness of ASA and have shown excellent survival, which is comparable to that in the general population. Choice and performance of the surgical or interventional treatment should be implemented in highly specialised centres in terms of a heart-team approach, taking notice of anatomic characteristics as well as comorbidities. Involvement of all cases in international registries may reveal the individual merits and indications for the surgical and interventional treatment in HOCM.

ZusammenfassungDie präoperative Anamnese und körperliche Untersuchung sind anerkannter Standard bei der Risikoevaluation von Patienten vor elektiven chirurgischen Eingriffen. Ob und unter welchen Umständen technische Voruntersuchungen dazu beitragen können, das perioperative Risiko zu reduzieren, ist bislang nur unzureichend untersucht. Auch besteht unter Anästhesisten, Chirurgen und Internisten vielfach Unsicherheit im perioperativen Umgang mit der Dauermedikation. Die deutschen wissenschaftlichen Fachgesellschaften für Anästhesiologie und Intensivmedizin (DGAI), Chirurgie (DGCH) und Innere Medizin (DGIM) haben daher eine gemeinsame Empfehlung zur präoperativen Evaluation erwachsener Patienten vor elektiven, nicht herz-thoraxchirurgischen Eingriffen erarbeitet und erstmals im Jahr 2010 publiziert. Die vorliegende Fassung ist eine Überarbeitung der Stellungnahme von 2010 unter Einbeziehung der seither publizierten Literatur sowie von aktuellen Leitlinien internationaler Fachgesellschaften. Zunächst werden die allgemeinen Prinzipien der präoperativen Evaluation dargestellt (Teil A). Das Vorgehen bei Patienten mit bekannten oder vermuteten kardiovaskulären Vorerkrankungen wird gesondert betrachtet (Teil B: „Erweiterte kardiale Diagnostik“). Abschließend wird der perioperative Umgang mit der Dauermedikation diskutiert (Teil C). Die vorgestellten Konzepte stellen fachübergreifende Empfehlungen dar, die ein strukturiertes und gemeinsames Vorgehen ermöglichen sollen. Ihr Ziel ist es, durch transparente und verbindliche Absprachen eine hohe Patientenorientierung unter Vermeidung unnötiger Voruntersuchungen zu gewährleisten, präoperative Untersuchungsabläufe zu verkürzen sowie letztlich Kosten zu reduzieren. Die gemeinsamen Empfehlungen von DGAI, DGCH und DGIM spiegeln den gegenwärtigen Kenntnisstand, aber auch die Meinungen von Experten wider, da nicht für jede Fragestellung wissenschaftliche Evidenz besteht. Daher werden eine regelmäßige Überprüfung und Aktualisierung der Empfehlungen erfolgen, sobald gesicherte neue Erkenntnisse vorliegen.

Unter transsektoraler Versorgung von Patienten mit Herzinsuffizienz versteht man das koordinierte optimale Zusammenwirken verschiedener Leistungserbringer im stationaren und ambulanten Bereich. Hierdurch kann die Mortalitat und Rehospitalisierungsrate signifikant reduziert werden bzw. die Leistungsfahigkeit und Lebensqualitat nicht zuletzt durch eine Starkung der Selbstverantwortung und -bestimmung dieser Patienten gesteigert werden. Voraussetzung ist allerdings ein supervidiertes, spezialisiertes Pflegepersonal, das die Vernetzung mehrerer Versorgungsebenen mit dem heimischen Umfeld des Patienten sicherstellt. Entscheidend fur den Erfolg eines solchen multidisziplinaren Managements ist weiterhin, das Disease-Management-Programm den individuellen regionalen Anforderungen, Bedurfnissen und nicht zuletzt limitierten finanziellen Ressourcen anzupassen.

In der Abb. 1 des Beitrags wurden 2 Felder vertauscht. „Sinusrhythmus, Herzfrequenz ≥70 bmp“ folgt richtigerweise „Ivabradin“. „Sinusrhythmus, QRS-Intervall ≥130 msec“ folgt richtigerweise „Indikation fur CRT evaluieren“. Wir bitten Sie, die korrigierte Abb. 1 zu beachten und den Fehler zu …

Iron deficiency (ID) has been identified as an important co-morbidity in patients with heart failure (HF). Intravenous iron therapy reduced symptoms and rehospitalizations of iron-deficient patients with HF in randomized trials. The present multicenter study investigated the "real-world" management of iron status in patients with HF. Consecutive patients with HF and ejection fraction ≤40% were recruited and analyzed from December 2010 to October 2015 by 11 centers in Germany and Switzerland. Of 1,484 patients with HF, iron status was determined in only 923 patients (62.2%), despite participation of the centers in a registry focusing on ID and despite guideline recommendation to determine iron status. In patients with determined iron status, a prevalence of 54.7% (505 patients) for ID was observed. Iron therapy was performed in only 8.5% of the iron-deficient patients with HF; 2.6% were treated with intravenous iron therapy. The patients with iron therapy were characterized by a high rate of symptomatic HF and anemia. In conclusion, despite strong evidence of beneficial effects of iron therapy on symptoms and rehospitalizations, diagnostic and therapeutic efforts on ID in HF are low in the actual clinical practice, and the awareness to diagnose and treat ID in HF should be strongly enforced.

Meta-analysis on immunohistological (IHC) concepts for the detection of inflammatory cardiomyopathy (InfCM) in endomyocardial biopsies (EMB). We included 61 publications, with 10,491 patients (mean age 47.1 years; men 66%) who underwent EMB and IHC evaluation. The 460 control patients were devoid of IHC proof of InfCM. The mean IHC detection rate of InfCM was 50.8% (95% CI 47.7–53.8%; range 18.4–91.7%). A publication bias was excluded (Funnel Plot p = 0.4264). This IHC detection rate was significantly (p

Background: Percutaneous mechanical circulatory support devices are increasingly used in acute myocardial infarction complicated by cardiogenic shock (AMI-CS), despite limited evidence for their effectiveness. The aim of this study was to evaluate outcomes associated with use of the Impella device compared with intra-aortic balloon pump (IABP) and medical treatment in patients with AMI-CS. Methods: Data of patients with AMI-CS treated with the Impella device at European tertiary care hospitals were collected retrospectively. All patients underwent early revascularization and received optimal medical treatment. Using IABP-SHOCK II (Intraaortic Balloon Pump in Cardiogenic Shock II) trial inclusion and exclusion criteria, 372 patients were identified and included in this analysis. These patients were matched to 600 patients from the IABP-SHOCK II trial. The following baseline criteria were used as matching parameters: age, sex, mechanical ventilation, ejection fraction, prior cardiopulmonary resuscitation, and lactate. Primary end point was 30-day all-cause mortality. Results: In total, 237 patients treated with an Impella could be matched to 237 patients from the IABP-SHOCK II trial. Baseline parameters were similarly distributed after matching. There was no significant difference in 30-day all-cause mortality (48.5% versus 46.4%, P =0.64). Severe or life-threatening bleeding (8.5% versus 3.0%, P P =0.01) occurred significantly more often in the Impella group. Limiting the analysis to IABP-treated patients as a control group did not change the results. Conclusions: In this retrospective analysis of patients with AMI-CS, the use of an Impella device was not associated with lower 30-day mortality compared with matched patients from the IABP-SHOCK II trial treated with an IABP or medical therapy. To further evaluate this, a large randomized trial is warranted to determine the effect of the Impella device on outcome in patients with AMI-CS. Clinical Trial Registration: URL: https://www.clinicaltrials.gov . Unique identifier: NCT03313687.

The DANISH trial raised doubts about the effectiveness of primary prevention of sudden cardiac death by ICD implantation among patients with non-ischemic heart failure. We sought to analyse data from the EVITA-HF registry to give an answer from real-world registry data to the DANISH trial. 1804 patients were identified from the EVITA-HF registry with chronic heart failure (CHF) due to ischemic or dilated heart disease and reduced left ventricular ejection fraction of ≤ 35%. The patients were divided into two groups: Patients with newly implanted cardioverter–defibrillator (ICD group; mean age 66 ± 12 years, 77% male) and without ICD (no-ICD group; mean age 66 ± 14 years, 77% male). The subgroups were compared with regard to mortality and predictive parameters affecting survival. Cardiovascular risk factors were similar among patients in the non-ICD group (n = 1473) compared to ICD group (n = 331). After 1-year follow-up patients with ischemic heart disease showed a significant improved survival in the ICD group compared to non-ICD group [92.1% vs. 80.6%, HR 0.37 (0.22–0.62)]. Patients with non-ischemic cardiomyopathy did not show a difference with regard to survival between the ICD and the non-ICD group [93.7% vs. 93.1%, HR 0.92 (0.43–1.97)]. The data were stable in a Cox-regression model. In a real-world setting, no benefit was evident for patients with non-ischemic cardiomyopathy and reduced left ventricular ejection fraction by adding ICD therapy in a short-term follow-up of 12 months in contrast to patients with ischemic cardiomyopathy.

The treatment of severe symptomatic aortic valve stenosis by conventional aortic valve replacement (AVR) or by transcatheter aortic valve implantation (TAVI) has a good perinterventional prognosis even for patients of advanced age. Having a heart team select the best management strategies based on current guidelines for each individual patient is essential for success. Especially in elderly and increasingly multimorbid patients with sometimes severe preconditions, the detection of functional deficits is relevant not only for the mortality but also for perioperative and postoperative complications as well as the functional outcome. Various methods of geriatric assessment are important supplements to standard risk scores. The aim is to implement targeted interventions to minimize the risk factors and to improve the prognosis for elderly patients. The aim of this article is to provide an overview of the current therapy options for aortic valve replacement and to summarize current aspects of treatment options for elderly patients.

Herzinsuffizienz (HI) geht mit hoher Mortalitat und haufigen Hospitalisierungen einher; Pravalenz und Krankheitskosten steigen kontinuierlich. Zur Optimierung der Versorgung bei HI mussen strukturierte sektorenubergreifende Kooperationen etabliert und die Behandlungsqualitat und -kontinuitat sichergestellt werden. Kooperationspartner sind Hausarzte, kardiologische Praxen, Abteilungen regionaler Krankenhauser und uberregionale Zentren mit umfassendem, auch kardiochirurgischem Behandlungsspektrum. Die Deutsche Gesellschaft fur Kardiologie – Herz- und Kreislaufforschung (DGK) und die Deutsche Gesellschaft fur Thorax-, Herz- und Gefaschirurgie (DGTHG) empfehlen die Einrichtung von Herzinsuffizienz-Netzwerken (HF-NETs), die modular auf den verschiedenen Versorgungsebenen in Herzinsuffizienz-Einheiten („Heart Failure Units“, HFUs) organisiert sind und damit uberprufbare Qualitatsmerkmale fur die sektorenubergreifende Versorgung von HI-Patienten aufweisen. Das dazu vorgelegte Positionspapier wurde von der Kommission fur Klinische Kardiologie mit Vertretern von DGK, DGTHG, sowie des Bundes Niedergelassener Kardiologen (BNK) und der Arbeitsgemeinschaft Leitender Kardiologischer Krankenhausarzte (ALKK) erarbeitet. Es formuliert die Voraussetzungen, die von den modularen HFUs im HF-NET fur eine Zertifizierung erfullt sein sollen.

Chronic viral infections of the heart are considered one antecedent event leading to progressive dysfunction of the myocardium, often with an impaired prognosis due to a virus- or immune-mediated myocardial injury. Symptomatic treatment does not influence the viral cause of heart failure, and the effect of antiviral treatment has not been determined, yet.In this phase II study 143 patients with symptoms of heart failure and biopsy-based confirmation of the enterovirus (EV), adenovirus, and/or parvovirus B19 genomes in their myocardial tissue were randomly assigned to double-blind treatment, and received either placebo (n = 48) or 4 × 10(6) (n = 49) and 8 × 10(6) IU (n = 46) interferon beta-1b (IFN-β-1b) for 24 weeks, in addition to standard heart failure treatment. Patients with active myocarditis or other specific causes of heart failure were excluded. Compared to placebo, virus elimination and/or virus load reduction was higher in the IFN-β-1b groups (odds ratio 2.33, p = 0.048), similarly in both interferon groups and both strata. IFN-β-1b treatment was associated with favourable effects on NYHA functional class (p = 0.013 at follow-up week 12), improvement in quality of life (Minnesota Heart Failure score; p = 0.032 at follow-up week 24) and patient global assessment (follow-up week 12 to follow-up week 24; p = 0.039). The frequency of adverse cardiac events was not higher in the IFN-β-1b groups compared to the placebo group.Immunomodulatory IFN-β-1b treatment is a well-tolerated and safe treatment option, leading to effective virus clearance or reduction of the virus load in patients with chronic viral cardiomyopathy. Favourable clinical effects assess quality of life, NYHA functional class, and patient global assessment. ClinicalTrials.gov identifier: NCT001185250.