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Our senescent society includes a growing number of elderly people suffering from ST-elevation myocardial infarction (STEMI); however, exactly this population is often underrepresented in randomized trials. Hence, our aim was to investigate the influence of age on patient characteristics, as well as short- and long-term outcome in the Vienna STEMI registry. We included all patients of the Vienna STEMI registry (2003–2009). Patients were stratified into age cohorts (≤45, 46–59, 60–79 and ≥80 years, respectively). Differences between cohorts were investigated by descriptive statistics and regression models. Crude and adjusted mortality rates were investigated using log rank test and Cox regression models, respectively. The influence of treatment on mortality was further investigated using propensity score matching. A total of 4579 patients fulfilled the criteria for further investigation. With rising age of cohorts, the number of females, diabetes mellitus (DM), hypertension (HTN), previous myocardial infarction (MI), shock, no reperfusion therapy and anterior wall infarction significantly increased. In contrast, the number of patients with a positive family history, smoking and hyperlipidemia (HLP) significantly declined. Log rank analysis showed significant differences between age cohorts for short- and long-term mortality. Cox regression analysis for short-term mortality revealed an independent association for age at the event, HTN and shock, while age, smoking, DM, HTN, HLP, previous MI and shock independently influenced long-term mortality after correction for confounders. Also, we found a significant association of age and total ischemic time (TIT), which however had no influence on long-term mortality (interaction term p = 0.236). Propensity score matching revealed reduced mortality rates for patients who received reperfusion therapy compared to conservative management, irrespective of age. Increasing age independently influenced short- and long-term mortality in patients with STEMI in the Vienna STEMI network. The TIT significantly increased with baseline age, but had no impact on mortality. Furthermore, reperfusion therapy exerted beneficial effects irrespective of the patients’ age.

We have analyzed the pathway networks of ischemia-affected and remote myocardial areas after repetitive ischemia/reperfusion (r-I/R) injury without ensuing myocardial infarction (MI) to elaborate a spatial- and chronologic model of cardioprotective gene networks to prevent left ventricular (LV) adverse remodeling. Domestic pigs underwent three cycles of 10/10 min r-I/R by percutaneous intracoronary balloon inflation/deflation in the mid left anterior descending artery, without consecutive MI. Sham interventions (n = 8) served as controls. Hearts were explanted at 5 h (n = 6) and 24 h (n = 6), and transcriptomic profiling of the distal (ischemia-affected) and proximal (non-affected) anterior myocardial regions were analyzed by next generation sequencing (NGS) and post-processing with signaling pathway impact and pathway network analyses. In ischemic region, r-I/R induced early activation of Ca-, adipocytokine and insulin signaling pathways with key regulator STAT3, which was also upregulated in the remote areas together with clusterin (CLU) and TNF-alpha. During the late phase of cardioprotection, antigen immunomodulatory pathways were activated with upregulation of STAT1 and CASP3 and downregulation of neprilysin in both zones, suggesting r-I/R induced intrinsic remote conditioning. The temporo-spatially differently activated pathways revealed a global myocardial response, and neprilysin and the STAT family as key regulators of intrinsic remote conditioning for prevention of adverse remodeling.

The pleiotropic cytokine oncostatin M (OSM), a member of the glycoprotein (gp)130 ligand family, plays a key role in inflammation and cardiovascular disease. As inflammation precedes and accompanies pathological angiogenesis, we investigated the effect of OSM and other gp130 ligands on vascular endothelial growth factor (VEGF) production in human vascular smooth muscle cells (SMC). Human coronary artery SMC (HCASMC) and human aortic SMC (HASMC) were treated with different gp130 ligands. VEGF protein was determined by ELISA. Specific mRNA was detected by RT-PCR. Western blotting was performed for signal transducers and activators of transcription1 (STAT1), STAT3, Akt and p38 mitogen-activated protein kinase (p38 MAPK). OSM mRNA and VEGF mRNA expression was analyzed in human carotid endaterectomy specimens from 15 patients. OSM increased VEGF production in both HCASMC and HASMC derived from different donors. OSM upregulated VEGF and OSM receptor-specific mRNA in these cells. STAT3 inhibitor WP1066, p38 MAPK inhibitors SB-202190 and BIRB 0796, extracellular signal-regulated kinase1/2 (Erk1/2) inhibitor U0126, and phosphatidylinositol 3-kinase (PI3K) inhibitors LY-294002 and PI-103 reduced OSM-induced VEGF synthesis. We found OSM expression in human atherosclerotic lesions where OSM mRNA correlated with VEGF mRNA expression. Interferon-γ (IFN-γ), but not IL-4 or IL-10, reduced OSM-induced VEGF production in vascular SMC. Our findings that OSM, which is present in human atherosclerotic lesions and correlates with VEGF expression, stimulates production of VEGF by human coronary artery and aortic SMC indicate that OSM could contribute to plaque angiogenesis and destabilization. IFN-γ reduced OSM-induced VEGF production by vascular SMC.

HINTERGRUND: Arterielle Hypertonie ist eine der haufigsten Erkrankungen in der westlichen Welt. Auch unter Kombinationstherapie erreicht ein hoher Prozentsatz der Patienten nicht ihre vorgegebenen Zielblutdruckwerte. Als neuer Therapieansatz bietet sich bei diesen Patienten seit kurzem ein Verfahren an, bei dem die sympathischen Nervenfasern der Nierenarterien mittels perkutaner Radiofrequenzablation in beiden Nierenarterien unterbrochen werden. METHODIK UND RESULTATE: In diesem Fallreport berichten wir von der ersten renalen Denervierung bei therapieresistenter Hypertonie in Osterreich welche im Rahmen der "SIMPLICITY HTN-2" Studie durchgefuhrt wurde. Die von uns behandelte 59-jahrige Patientin leidet unter einem langjahrigen Hypertonus der trotz 6-fach medikamentoser Therapie nicht adaquat einstellbar ist. In den aus mehrfachen Messungen gemittelten Basiswerten prasentiert sich die Patientin mit einem Blutdruck von 238/132, im 3 Monats Follow-up nach renaler Denervierung betrug dieser 154/87. Im weiteren Verlauf konnte die antihypertensive Medikation um 2 Praparate reduziert werden. Im Rahmen der 6-Monats Kontrolle erfolgte zur weiteren Quantifizierung eine 24h Blutdruckmessung welche unter der neuen, reduzierten Therapie einen durchschnittlichen Wert von 132/81 ergab. Ein etwaiger Einfluss auf die Nierenfunktion konnte nicht nachgewiesen werden. DISKUSSION: Unser Fallbericht bestatigt die potentielle Wirksamkeit dieses neuen Verfahrens. Aufgrund der bisherigen Datenlage kann die renale Denervierung als eine vielversprechende und komplikationsarme Therapieform bei therapieresistenter Hypertonie angesehen werden. Nichtsdestotrotz ist fur das Abschatzen des Therapieerfolges, der Langzeiteffekte und der Indikation die Durchfuhrung weiterer prospektiver randomisierter kontrollierter Studien unumganglich.

We have investigated the effect of stem cell delivery on the release of hypoxia-inducible factor 1 alpha (HIF-1alpha) in peripheral circulation and myocardium in experimental myocardial ischemia. Closed-chest, reperfused myocardial infarction (MI) was created in domestic pigs. Porcine mesenchymal stem cells (MSCs) were cultured and delivered (9.8 +/- 1.2 x 10(6)) either percutaneously NOGA-guided transendocardially (Group IM) or intracoronary (Group IC) 22 +/- 4 days post-MI. Pigs without MSC delivery served as sham control (Group S). Plasma HIF-1alpha was measured at baseline, immediately post- and at follow-up (FUP; 2 h or 24 h) post-MSC delivery by ELISA kit. Myocardial HIF-1alpha expression of infarcted, normal myocardium, or border zone was determined by Western blot. Plasma level of HIF-1alpha increased immediately post-MI (from 278 +/- 127 to 631 +/- 375 pg/ml, p0.05). Cardiac delivery of MSCs elevated the plasma levels of HIF-1alpha significantly (p0.05) in groups IC and IM immediately post-MSC delivery, and returned to baseline level at FUP, without difference between the groups IC and IM. The myocardial tissue HIF-1alpha expression in the infarcted area was higher in Group IM than in Group IC or S (1,963 +/- 586 vs. 1,307 +/- 392 vs. 271 +/- 110 activity per square millimeter, respectively, p0.05), while the border zone contained similarly lower level of HIF-1alpha, but still significantly higher as compared with Group S. Trend towards increase in myocardial expression of HIF-1alpha was measured in Group IM at 24 h, in contrast to Group IC. In conclusion, both stem cell delivery modes increase the systemic and myocardial level of HIF-1alpha. Intramyocardial delivery of MSC seems to trigger the release of angiogenic HIF-1alpha more effectively than does intracoronary delivery.

Combined intracoronary and intramyocardial administration might improve outcomes for bone-marrow-derived stem cell therapy for acute myocardial infarction. In this paper patients with left ventricular ejection fraction less than 45% after acute myocardial infarction were randomly assigned stem cell delivery via intramyocardial injection and intracoronary infusion 3–6 weeks or 3–4 months after AMI. Their data shows that combined cardiac stem cell delivery induces a moderate but significant improvement in myocardial infarct size and left ventricular function. Background Combined intracoronary and intramyocardial administration might improve outcomes for bone-marrow-derived stem cell therapy for acute myocardial infarction (AMI). We compared the safety and feasibility of early and late delivery of stem cells with combined therapy approaches. Methods Patients with left ventricular ejection fraction less than 45% after AMI were randomly assigned stem cell delivery via intramyocardial injection and intracoronary infusion 3–6 weeks or 3–4 months after AMI. Primary end points were changes in infarct size and left ventricular ejection fraction 3 months after therapy. Results A total of 60 patients were treated. The mean changes in infarct size at 3 months were −3.5 ± 5.1% (95% CI −5.5% to −1.5%, P = 0.001) in the early group and −3.9 ± 5.6% (95% CI −6.1% to −1.6%, P = 0.002) in the late group, and changes in ejection fraction were 3.5 ± 5.6% (95% CI 1.3–5.6%, P = 0.003) and 3.4 ± 7.0% (95% CI 0.7–6.1%, P = 0.017), respectively. At 9–12 months after AMI, ejection fraction remained significantly higher than at baseline in both groups. In the early and late groups, a mean of 200.3 ± 68.7 × 106 and 194.8 ± 60.4 × 106 stem cells, respectively, were delivered to the myocardium, and 1.30 ± 0.68 × 109 and 1.29 ± 0.41 × 109 cells, respectively, were delivered into the artery. A high number of cells was required for significant improvements in the primary end points. Conclusions Combined cardiac stem cell delivery induces a moderate but significant improvement in myocardial infarct size and left ventricular function.

The objective of this study was to investigate the expression of the arylhydrocarbon receptor (AhR) and its partner AhR-nuclear translocator (ARNT) in left ventricle specimens from explanted hearts from patients with cardiomyopathy (CMP). Explanted hearts from 16 patients with ischemic (n=9, age 63+/-12 years) and dilative (n=7, age 54+/-12 years) CMP, undergoing heart transplantation were examined. Healthy donor hearts from five accident victims served as controls. As these donors were of younger age (32+/-11 years), additionally, donor hearts from three older accident victims (age 48+/-15 years) without clinical symptoms but with signs of ventricular hyperthrophy (n=1) or atherosclerotic lesions (n=2) were included ("pathological controls"). Expression of AhR and ARNT was analyzed using semi-quantitative immunohistochemistry, and in selected samples, Western blot- and reverse-transcription polymerase chain reaction analysis were performed to confirm AhR and ARNT expression. Immunohistological analysis revealed weak to intermediate staining of anti-AhR in control, but weak to intense staining in CMP- and "pathologic control" specimens, indicating significantly increased AhR levels in the diseased heart. Moreover, in CMP specimens, the percentage of AhR-positive cells was strongly increased. Higher anti-AhR staining was also seen in two atherosclerotic "pathologic control" specimens. In all groups, the intensity of anti-ARNT staining was more pronounced than AhR staining, but significant differences or any age-related alterations were not observed. In conclusion, the increased cellular content of AhR in left ventricular specimens from CMP patients suggests a role for AhR in heart disease.

Werner Mohl and coauthors present their Viewpoint examining pressure-controlled intermittent coronary sinus occlusion (PICSO). Here they postulate that PICSO should be introduced into the clinic as a valuable technique for activation of venous endothelium to initiate myocardial recovery and induce regeneration.

Lp(a), one of the most atherogenic lipoproteins, is believed to contribute significantly to vascular diseases in non-insulin-dependent diabetic (NIDDM) patients. Contradictive data have been published on these patients concerning plasma concentrations of Lp(a) and their relation to renal function. Since apo(a) fragments appear in urine, we measured urinary apo(a) in 134 NIDDM patients and 100 matched controls and related urinary apo(a) concentrations to plasma Lp(a) levels and kidney function. Plasma Lp(a) values were found to be significantly higher in NIDDM patients. NIDDM patients also secreted significantly more apo(a) into their urine as compared to control subjects. There was no correlation between creatinine clearance or albumin excretion and urinary apo(a) concentrations. Patients with macroalbuminuria exhibited a twofold higher apparent fractional excretion of apo(a) in comparison to patients with normal renal function. Urinary apo(a) values in both patients and control subjects were highly correlated to plasma Lp(a), yet no correlation was found with HbA1 c or serum lipoproteins. It is concluded that urinary apo(a) excretion is correlated to plasma Lp(a) levels but not to creatinine clearance in patients suffering from NIDDM. [Diabetologia (1997) 40: 1455–1460]

Ths experimental study described myocardial echo contrast enhancement through coronary venous injections. Retrograde administration of renografin was performed in 15 closed-chest dogs. Two-dimensional echocardiography was used to study myocardial echo contrast enhancement before and after coronary artery occlusion. Digital subtraction venography was used to assess delivery, drainage and shunting of the retrograde injectate. Systolic/diastolic blood pressure in the great cardiac vein measured 7 +/- 3/1 +/- 0.6 mm Hg and increased to 29 +/- 11/5 +/- 3 after coronary sinus occlusion and to 55 +/- 2.3/15 +/- 12 mm Hg during coronary sinus contrast injection. Myocardial contrast echo appearance in a midpapillary left ventricular short axis cross-section was limited to the anteroseptal region, extending to 28.4 +/- 11.3% of the section circumference after great cardiac vein injections and 35.3 +/- 17% after coronary sinus injections (difference NS). After occlusion of the left anterior descending coronary artery, great cardiac vein contrast injections resulted in opacification of 36.6 +/- 9.7% of the section circumference (N.S. vs preocclusion control) and opacified most, but not all asynergic segments. After occlusion of the circumflex coronary artery, myocardial echo contrast uptake was restricted to the septum and the anterior wall. The ischemic and asynergic posterolateral myocardial segments were not opacified. Digital subtraction coronary venography revealed rapid drainage of retrogradely injected contrast to the right atrium, in spite of coronary sinus balloon occlusion via venovenous anastomoses. Retrograde coronary venous contrast injections may help define myocardial regions which are accessible with retrograde coronary venous interventions.

Intraoperative color Doppler offers rapid and accurate information about the presence and severity of mitral regurgitation at the time of surgery. This technique provides instantaneous evaluation of the adequacy of mitral and tricuspid valvuloplasty and appears capable of predicting their postoperative outcome. This approach may ultimately allow for valve repair procedures to be performed in greater numbers of patients with better control over outcome and lower reoperation rates.

Echocardiography has evolved as important diagnostic tool in cardiac imaging. Color flow mapping and transoesophageal transducers provide a new dimension to echocardiography. Improved image quality allows for quantification of left ventricular (LV) function. It therefore becomes obvious that this new technology can be efficiently applied when fast and effective decision making and strategy planning are required such as during surgery, and specifically in cardiac surgery. There are three major goals of intraoperative echocardiography: Decision making and strategy planning, quality assurance, and monitoring of LV function.