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The present population-based cohort study investigated long-term mortality after surgical aortic valve replacement (AVR) with bioprosthetic (B) or mechanical aortic valve prostheses (M) in a European social welfare state.We analysed patient data from health insurance records covering 98% of the Austrian population between 2010 and 2018. Subsequent patient-level record linkage with national health data provided patient characteristics and clinical outcomes. Further reoperation, myocardial infarction, heart failure and stroke were evaluated as secondary outcomes.A total of 13,993 patients were analysed and the following age groups were examined separately:50 years (727 patients: 57.77% M, 42.23% B), 50-65 years (2612 patients: 26.88% M, 73.12% B) and65 years (10,654 patients: 1.26% M, 98.74% B). Multivariable Cox regression revealed that the use of B-AVR was significantly associated with higher mortality in patients aged 50-65 years compared to M-AVR (HR = 1.676 [1.289-2.181], p 0.001). B-AVR also performed worse in a competing risk analysis regarding reoperation (HR = 3.483 [1.445-8.396], p = 0.005) and myocardial infarction (HR = 2.868 [1.255-6.555], p = 0.012). However, the risk of developing heart failure and stroke did not differ significantly after AVR in any age group.Patients aged 50-65 years who underwent M-AVR had better long-term survival, and a lower risk of reoperation and myocardial infarction. Even though anticoagulation is crucial in patients with M-AVR, we did not observe significantly increased stroke rates in patients with M-AVR. This evident survival benefit in recipients of mechanical aortic valve prostheses aged65 years critically questions current guideline recommendations.

Background Systemic inflammation and apoptosis-specific immune activation play a major role in acute coronary syndromes (ACS) including acute myocardial infarction (AMI). The role of systemic and coronary obtained inflammatory plasma protein interleukin-1β precursor (IL-1βp), IL-1β-converting enzyme (ICE) and the apoptosis-specific caspase-cleaved cytokeratin-18 (ccCK-18) are not known in ACS. Materials and methods Plasma samples were obtained from stable angina (SA, n = 34), unstable angina (UA, n = 37) and patients with AMI (n = 39). Coronary blood was acquired by means of thrombectomy devices (X-sizer) in AMI patients. IL-1βp, ICE and ccCK-18 were determined by enzyme-linked immunosorbent assay (ELISA). Group comparisons were evaluated by parametric Tukey test. Multivariate logistic regression analysis was performed to determine predictive values of IL-1βp, ICE and ccCK-18 as compared to creatine kinase (CK) and troponin T (TnT) in order to relate these markers with the occurrence of myocardial damage. Results IL-1βp, ICE and ccCK-18 were identified to be significantly altered in the peripheral blood of patients suffering from AMI as compared to SA and UA. ROC curves were plotted and revealed that ccCK-18 is a novel sensitive marker for the detection of myocardial damage as compared to TnT or CK. (AUC ccCK-18 0·925, TnT AUC 0·62 and CK AUC 0·858.) Moreover, ICE and ccCK-18 were significantly increased at the site of coronary occlusion as compared to peripheral blood samples in AMI patients (both P

The cutting balloon is a new device for coronary angioplasty, that, by the combination of incision and dilatation of the plaque, is believed to be promising for treatment of in-stent restenosis. The purpose of the study was to evaluate the safety and efficacy of CBA. We reviewed the immediate and 6-month follow-up angiographic and clinical outcome of 147 patients (109 men and 38 women) with a mean age of 67.3 +/- 10 undergoing this procedure at eight interventional centers in Austria. The target lesions treated with CBA were in-stent restenosis in 61% of patients, stenosis after balloon angioplasty in 8% of patients, and native lesions in 33% of patients. Sixty-five percent of the patients included had multivessel disease. Lesion type was A in 18% of patients, B1 in 31% of patients, B2 in 39% of patients, and C in 12% of patients. The degree of stenosis was 87% +/- 9%, the length of the target lesion treated with CBA was 8.8 +/- 5.1 mm. Target vessel was left circumflex artery in 22 cases, right coronary artery in 36 cases, and left anterior descending artery in 89 cases. The overall procedural success rate was 90.5%. "Stand-alone" CBA was performed in 63% of patients, the procedure was combined with coronary stenting in 16% of patients, and with balloon angioplasty in 21% of patients. Coronary complications occurred in eight cases (5.4%) with coronary dissection in seven (total dissection rate of 4.7%) and urgent bypass surgery in one case (0.7%). No further complications such as death, occlusion, or perforation of coronary arteries, embolization, or thrombosis were observed. Six-month clinical follow-up revealed q-wave myocardial infarction in 2.7% of patients, aortocoronary bypass surgery in 8.5% of patients, and repeated percutaneous coronary intervention in 17% of patients (11.5% with stenting). Six-month angiographic follow-up of patients with recurrent angina showed target lesion restenosis (50% diameter stenosis) in 14% of patients, late lumen loss withor = 50% diameter stenosis in 6% of patients and progression of "other than target" lesions with50% diameter stenosis in 14% of patients. This series demonstrates the safety and feasibility of cutting balloon angioplasty in patients with complex coronary artery disease and in-stent restenosis.

Recanalization of occluded coronary arteries is the aim of percutaneous interventions with acute myocardial infarction. Moreover, chronic coronary occlusion is a common finding during diagnostic coronary angiography and is often a contributing factor in the choice of revascularisation by surgery rather than by percutaneous coronary interventions (PCI). An occluded coronary artery with some degree of collateral supply is functionally comparable to a severe coronary stenosis. Therefore, recanalization of chronic occluded coronary arteries results in less angina and often in improvement of left ventricular function. Success is limited in particular in longer lasting occlusions. Characterization of lesions, where recanalization can performed successfully is warranted. We correlated primary success rates of attempted coronary recanalizations with localisation of lesions and procedural characteristics. We analyzed records of 124 consecutive patients, who underwent attempted coronary recanalization of chronically occluded coronary arteries at our institution in 1998. Revascularisation was successful in 84 (64 male, 20 female) of 124 (92 male, 32 female) patients. Therefore, success rate was 67.7% (69.9% in men, 62.5% in women, p = 0.42). Target vessel was the left anterior descending artery (LAD) in 49 cases. Success rate in the LAD did not differ significantly from that in "non-LAD"-vessels (65.3% versus 69.3%; p = 0.35). Successful recanalizations were performed using only one guide-wire in 77.3%. More than one guide-wires were used during procedures without success in 44.5% and exceeded use in successful interventions (p < 0.05). Procedures, failing to be successful after an attempt with a first guide-wire, could be performed successfully using at least a second wire in 50%. Coronary stenting after recanalization has been performed in 84.4% in the LAD and in 59.7% in non-LAD vessels (p < 0.01). Success rate of attempted recanalizations of chronic occluded coronary arteries in unselected patients is high. Most procedures can be performed successfully using only one guidewire. Additional use of other wires can increase success rates in procedures with primary failure to pass the occlusion. Stenting has been performed in three out of four patients with successful recanalization of chronically occluded coronary arteries.

Restenosis following angioplasty represents a major clinical problem in the field of percutaneous coronary interventions. Intravascular brachytherapy reduces risk of restenosis following percutaneous interventions of native lesions and in-stent restenosis up to 50%-60%. This effect can be shown for at least one to two years. This novel therapeutic strategy is limited by a higher rate of target vessel reinterventions, and late coronary thrombosis, when platelet inhibiting drugs has been withdrawn or after implantation of multiple stents. Currently, intracoronary brachytherapy is mainly considered for treatment of in-stent-restenosis.

Zusammenfassung: Spezifische Umbauvorgange im Bereich der Randzone des Infarkts und im Bereich des nicht infarzierten Myokards werden als „Remodeling” bezeichnet. Der Prozes des ventrikularen Remodelings dauert uber Wochen und Monate nach der initialen Myokardschadigung bis ein Gleichgewicht zwischen Wandspannung und Festigkeit der Narbe aus kollagenem Bindegewebe erreicht ist. Der Prozes des Remodelings nach Myokardinfarkt wird in zwei Phasen eingeteilt, einer fruhen Phase innerhalb der ersten 72 Stunden und einer spaten Phase jenseits der ersten drei Tage. Eine wesentliche Rolle spielen Hypertrophie und Kollagenabbau. Geschadigte Myozyten sezernieren Zytokine, die einen Trigger fur nachfolgende biochemische Ablaufe im Rahmen des Remodelings darstellen. Neben Revaskularisationsmasnahmen zur Wiederherstellung eines offenen Infarktgefases spielt der Einsatz pharmakotherapeutischer Strategien, wie ACE-Hemmer und β-Adrenorezeptorenblocker zur Beeinflussung des „Remodelings” in der Therapie nach abgelaufenem Myokardinfarkt eine wesentliche Rolle. Therapy of Left Ventricular Remodeling After Myocardial Infarction Summary: Left ventricular remodeling is the process by which ventricular size, shape, and function are regulated by mechanical, neurohormonal, and genetic factors. Remodeling may be physiological and adaptive during normal growth or pathological due to myocardial infarction, cardiomyopathy, hypertension, or valvular heart disease. Postinfarction remodeling has been divided into an early phase within 72 hours and a late phase beyond 72 hours. The early phase involves expansion of the infarct zone, which may result in early ventricular rupture or aneurysm formation. Late remodeling involves the left ventricle globally and is associated with time-dependent dilatation, the distortion of ventricular shape, and mural hypertrophy. Hypertrophy and collagen degradation are adaptive responses during postinfarction remodeling. Myocardial repair is triggered by cytokines released from injured myocytes. Ventricular remodeling is influenced most by infarct artery patency. Once infarct evolution has occurred, pharmacological intervention, like ACE inhibition and β-adrenoreceptor blocking agents, may minimize infarct expansion and ventricular dilatation and improve the long-term prognosis.

Recent large-scale clinical trials have confirmed that statin-induced lipid modification can significantly reduce cardiovascular morbidity and mortality. Statins are now the drugs of choice in lipid management but fail to meet the criteria for an ideal therapy in several respects. Therefore, the search continues for lipid modifying treatments that meet even higher standards. Lipid-lowering drugs currently in development may meet these more exacting standards and together with complementary methods could ultimately form ideal combination therapy. (Prev Cardiol. 2001;4:89‐92) © 2001 by CHF, Inc.

The recurrence of symptoms after coronary artery bypass surgery is often caused by bypass-dysfunction. In this study we tried to determine factors related to the long-term patency of arterial and venous bypass grafts. We evaluated all patients with bypass grafts undergoing coronary angiography in the year 1998 at our hospital (163 patients, mean age 67 years, mean interval since the operation 79 months, a total of 341 venous bypasses (VBP), 386 peripheral venous anastomoses and 85 arterial (LIMA = left internal mammarial artery) bypasses. The data were collected by a retrospective analysis of the hospital records. Statistics were performed using the Wilcoxon-Mann-Whitney-U test. After an interval of 53 months LIMA-bypasses were patent without stenosis in 92%. Symptoms were caused in only 2% by a dysfunction of the LIMA-graft. The patency of venous bypass grafts decreased with time (5 years after the operation 74% were patent without stenosis, 5-10 years 56%, more than 10 years 35%, p 30, p = 0.05) and the erythrocyte sedimentation rate after 2 hours (79% patent VBP with an ESR 49 mm, p = 0.02). The function of VBP after coronary artery bypass graft (CABG)-procedure depends primarily upon the interval since the operation. In addition, we found correlations with clinical presentation, resting-ECG, body-mass-index and erythrocyte-sedimentation rate as a possible marker of inflammation in bypass-atherosclerosis. Therefore, inflammatory processes seem to play an important role in the development of venous graft dysfunction.

Leflunomide is a novel drug recently introduced for treatment of rheumatoid arthritis as a DMARD (disease-modifying antirheumatic drug). So far, leflunomide has not been associated with severe bone marrow toxicity and pancytopenia. We report of a 62-year-old woman with a 14-year history of rheumatoid arthritis with bone marrow toxicity and reversible pancytopenia developing after treatment with leflunomide.