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Objectives: To analyse the implementation, applicability and accuracy of the pretest probability calculation provided by NICE clinical guideline 95 for decision making about imaging in patients with chest pain of recent onset. Methods: The definitions for pretest probability calculation in the original Duke clinical score and the NICE guideline were compared. We also calculated the agreement and disagreement in pretest probability and the resulting imaging and management groups based on individual patient data from the Collaborative Meta-Analysis of Cardiac CT (CoMe-CCT). Results: 4,673 individual patient data from the CoMe-CCT Consortium were analysed. Major differences in definitions in the Duke clinical score and NICE guideline were found for the predictors age and number of risk factors. Pretest probability calculation using guideline criteria was only possible for 30.8 % (1,439/4,673) of patients despite availability of all required data due to ambiguity in guideline definitions for risk factors and age groups. Agreement regarding patient management groups was found in only 70 % (366/523) of patients in whom pretest probability calculation was possible according to both models. Conclusions: Our results suggest that pretest probability calculation for clinical decision making about cardiac imaging as implemented in the NICE clinical guideline for patients has relevant limitations. Key Points: • Duke clinical score is not implemented correctly in NICE guideline 95. • Pretest probability assessment in NICE guideline 95 is impossible for most patients. • Improved clinical decision making requires accurate pretest probability calculation. • These refinements are essential for appropriate use of cardiac CT.

A 63 years old male with a history of arterial hypertension presented with a current onset of chest pain and discrete headaches accompanied with dizziness. His blood pressure, 210/110 mmHg, had worsened and showed a reversed circadian rhythm with an average of 150/90 mmHg during night time. A CT angiography of the aorta demonstrated a type B dissection involving the right renal artery causing reduced perfusion of the right kidney. Subsequent invasive aortic angiography showed a continuously moving aortic dissection flap resulting in a dynamic stenosis proven by varying pressure gradients of between 5 and 35 mmHg. Stent placement of the renal artery ostium kept the vessel open and fixed the reno-aortic dissection flap in order to prevent it from progressing into the right kidney. Follow-up examinations revealed improved blood pressure control allowing for physiologic drop of blood pressure during night-time.

Transradial coronary angiography (TRC) can be performed applying only one catheter fitting into the right and left coronary ostia (R/LCO). In this bicentric study (n = 2953), we analyzed the ostial performance of the Tiger_II_catheter widely used in TRC. Compared to Judkins catheters, the Tiger_II is frequently associated with ostial instability within the LCO but fits better into the RCO-irrespective of tube size. Judkins catheters generally need more peri-procedural contrast and radiation exposure. TRC may be started using a 5F_Tiger_II on the right side in order to be switched to 5F Judkins in case of propable LCO instability.

The original version of this article, published on 19 March 2018, unfortunately contained a mistake. The following correction has therefore been made in the original: The names of the authors Philipp A. Kaufmann, Ronny Ralf Buechel and Bernhard A. Herzog were presented incorrectly.

8 pags., 10 figs., 3 tabs., The Borromean drip-line nucleus Ne-17 has been suggested to possess a two-proton halo structure in its ground state. In the astrophysical rp-process, where the two-proton capture reaction O-15(2p,gamma) Ne-17 plays an important role, the calculated reaction rate differs by several orders of magnitude between different theoretical approaches. To add to the understanding of the Ne-17 structure we have studied nuclear and electromagnetic dissociation. A 500 MeV/u Ne-17 beam was directed toward lead, carbon, and polyethylene targets. Oxygen isotopes in the final state were measured in coincidence with one or two protons. Different reaction branches in the dissociation of Ne-17 were disentangled. The relative populations of s and d states in F-16 were determined for light and heavy targets. The differential cross section for electromagnetic dissociation (EMD) shows a continuous internal energy spectrum in the three-body system O-15 + 2p. The Ne-17 EMD data were compared to current theoretical models. None of them, however, yields satisfactory agreement with the experimental data presented here. These new data may facilitate future development of adequate models for description of the fragmentation process., This project is supported by NAVI, GSI-TU Darmstadt cooperation, HIC for FAIR, EMMI, and BMBF and from DFG through Grant No. SFB1245 and from BMBF via Project No. 05P15RDFN1, and from the Spanish Ministry by research grant FPA2015-64969-P. C.A.B. acknowledges support by the US DOE Grant No. DE-FG02-08ER41533 and the US NSF Grant No. 1415656.

INTRODUCTION With subgroups of patients with hypertrophic cardiomyopathy (HCM) confers a 4% to 5% risk for adverse prognosis. Besides left-ventricular muscle mass (LV-MM) myocardial fibrosis (MF) assessable by late gadolinium enhancement in cardiovascular magnetic resonance (LGE-CMR) has been related to that. Myocardial fibrosis can also be demonstrated by late enhancement (LE) in late-enhanced multislice computed tomography (leMDCT). This analysis investigates leMDCT whether to enable quantification of LE load in terms of LE mass by percent LV-MM in HCM. METHODS In a prospective validation study, we included 30 consecutive patients with HCM who underwent leMDCT (64 slice) and LGE-CMR (1.5 T). The leMDCT scan was performed 7 minutes after injection of iodine contrast (Iopromid). Endocardial and epicardial planimetry served for the assessment of LV-MM. Visually detectable LE was quantified using the manual quantification method resulting in LE by percent LV-MM (%LE). The LGE-CMR data served for validation. RESULTS Mean (SD) age was 64.1 (13.9) years. Myocardial fibrosis prevalence was 63.3% (19/30 patients indentified by both leMDCT and LGE-CMR). In leMDCT, tissue density in LE areas compared with normal myocardium was higher (138.2 [23.9] HU vs 98.4 [16.5] HU, P < 0.001) but lower than in the LV cavity (138.2 [23.9] HU vs 169.2 [35.9] HU, P < 0.001). Late enhancement mass in leMDCT seemed to be 7.9 (8.5) g LE versus 8.6 [11] g LGE in CMR (P = 0.497, r = 0.95) resulting in a leMDCT/LGE-CMR relation of 1.2. Referring LE mass to LV-MM gave an LE proportion measured by leMDCT of 4 (3.9) %LE versus 3.9 (4.1) %LGE in LGE-CMR (r = 0.88, P = 0.75). Intraobserver/interobserver reliability of LE mass assessment showed an intraclass correlation coefficient of 0.99 and 0.97. CONCLUSIONS In patients with HCM, leMDCT provides volumetric assessment of LE mass-absolutely and by percent LV-MM.

A common approach to studying $\beta$-delayed proton emission is to measure the energy of the emitted proton and corresponding nuclear recoil in a double-sided silicon-strip detector (DSSD) after implanting the $\beta$-delayed proton emitting ($\beta$p) nucleus. However, in order to extract the proton-decay energy, the measured energy must be corrected for the additional energy implanted in the DSSD by the $\beta$-particle emitted from the $\beta$p nucleus, an effect referred to here as $\beta$-summing. We present an approach to determine an accurate correction for $\beta$-summing. Our method relies on the determination of the mean implantation depth of the $\beta$p nucleus within the DSSD by analyzing the shape of the total (proton + recoil + $\beta$) decay energy distribution shape. We validate this approach with other mean implantation depth measurement techniques that take advantage of energy deposition within DSSDs upstream and downstream of the implantation DSSD., Comment: Published in Nuclear Instruments and Methods in Physics Research A

Late enhancement (LE) multi-slice computed tomography (leMDCT) was introduced for the visualization of (intra-) myocardial fibrosis in Hypertrophic Cardiomyopathy (HCM). LE is associated with adverse cardiac events. This analysis focuses on leMDCT derived LV muscle mass (LV-MM) which may be related to LE resulting in LE proportion for potential risk stratification in HCM.N=26 HCM-patients underwent leMDCT (64-slice-CT) and cardiovascular magnetic resonance (CMR). In leMDCT iodine contrast (Iopromid, 350 mg/mL; 150mL) was injected 7 minutes before imaging. Reconstructed short cardiac axis views served for planimetry. The study group was divided into three groups of varying LV-contrast. LeMDCT was correlated with CMR.The mean age was 64.2 ± 14 years. The groups of varying contrast differed in weight and body mass index (p 0.05). In the group with good LV-contrast assessment of LV-MM resulted in 147.4 ± 64.8 g in leMDCT vs. 147.1 ± 65.9 in CMR (p 0.05). In the group with sufficient contrast LV-MM appeared with 172 ± 30.8 g in leMDCT vs. 165.9 ± 37.8 in CMR (p 0.05). Overall intra-/inter-observer variability of semiautomatic assessment of LV-MM showed an accuracy of 0.9 ± 8.6 g and 0.8 ± 9.2 g in leMDCT. All leMDCT-measures correlated well with CMR (r 0.9).LeMDCT primarily performed for LE-visualization in HCM allows for accurate LV-volumetry including LV-MM in 90% of the cases.• LeMDCT of relatively low contrast allows for LV planimetry in HCM. • The correlation of leMDCT-based LV volumetry with gold-standard CMR was excellent (r 0.9). • LeMDCT requires approximately 2.0mL/kgBW of dye to achieve acceptable contrast.

Hypertrophic Cardiomyopathy (HCM) confers a 4-5 %/year-risk for sudden cardiac death. Intramyocardial fibrosis (IF) is associated with this risk. The gold standard of IF visualization is cardiovascular magnetic resonance (CMR) with late gadolinium enhancement (LGE-CMR). In view of a number of CMR-limitations the hypothesis of this study was that late enhanced multi-slice computed tomography (leMDCT) enables demonstration of late enhancement (LE) indicating IF. In a prospective single-center validation study leMDCT research-scans were exclusively performed for IF-imaging in HCM-patients not including non-invasive coronary angiography during first-pass (64-slice; 80 kV; Iopromide, 150 mL, injected 7 min before scanning). Applying a 17-segment-polar-map short cardiac axis views (multiplanar reformations; 5 mm slice thickness) were analysed in order to exclude/detect, localize and measure LE practicing the manual quantification method if present. Finally, leMDCT and LGE-CMR data were unblinded for intermodal correlation. We included n = 24 patients consecutively (64.0 ± 14.5 years of age). LE was demonstrated by LGE-CMR in n = 14/24 patients (prevalence 58 %). Patient- and segment-based sensitivity in leMDCT was 100 and 68 %, respectively. In leMDCT tissue density of LE was 142 ± 51 versus 89.9 ± 19.3 HU in remote myocardium (p0.001). Signal-to-noise-ratio (SNR) and contrast-to-noise-ratio (CNR) appeared to be 7.3 ± 3.3 and 2.3 ± 1, respectively. Sizing of LE-area gave 2.2 ± 1.4 cm(2) in leMDCT versus 2.9 ± 2.4 cm(2) in LGE-CMR (r = 0.93). Intra-/interobserver variability was assessed with an accuracy of 0.36 cm(2) (r = 0.91) and 0.47 cm(2) (r = 0.82), respectively. In consecutive HCM patients leMDCT can reliably detect intramyocardial fibrosis marked by LE. In view of a comparatively low SNR and CNR leMDCT may alternatively be applied in case of CMR contraindications.

Objective: This feasibility study examined safety and effectiveness of the new EXOSEAL™ Vascular Closure Device (VCD) designed to promote hemostasis and early ambulation after percutaneous procedures. Background: Most VCDs currently approved by the United States FDA have been associated with significantly shorter time-to-hemostasis (TTH) and time-to-ambulation (TTA) compared to standard manual or mechanical compression, but their ease of use, patient comfort during deployment, and safety profiles are variable. Methods: Patients underwent diagnostic or interventional procedures using 7F introducer sheaths. Primary safety endpoint was the 30-day combined rate of access-related complications and primary effectiveness endpoints were TTH and TTA. Results: Sixty patients were enrolled prospectively (mean age 63.3 ± 11.3 year, 17% diabetics). Device and procedural success was achieved in 92% and 93%, respectively. Mean TTH and TTA was 3.2 ± 3.0 minutes and 3.0 ± 6.2 hours, respectively. No deaths or serious access-related adverse events occurred. A ≥6 cm access-site hematoma was the only adverse event, observed in 3 patients. Conclusions: Use of the 7F EXOSEAL™ VCD was associated with short TTH and TTA, as well as low rates of procedural and 30-day access-related complications. (J Interven Cardiol 2012;25:518–525)

OBJECTIVE Cardiac adaptation to sports activity in endurance athletes is considerably different from that in power athletes. The effects of a high-level team sport like handball, one of the most popular sports in the world, performed at a younger age, on cardiac rhythm in individuals above the age of 50 have not been investigated to date. METHODS Thirty-three former top-level handball players from the first German league (6 former world champions and numerous Olympians) (57.5 +/- 5.5 y) joined our screening programme for former athletes and underwent electrocardiography, echocardiography and spiroergometry. Data were compared to 24 sedentary healthy controls. RESULTS Ten of the 33 athletes suffered from atrial fibrillation (AF). Left ventricular diameter was 53.68 +/- 4.88 mm in the athletes group and 50.58 +/- 4.12 mm in the healthy controls. Analysing the subgroups of handball players ('AF group' and 'non-AF group'), spiroergometry showed oxygen consumption at the anaerobic threshold of 27.54 +/- 6.77 ml/kg/min in the AF group and 31.24 +/- 10.33 ml/kg/min in the non-AF group (P = 0.228). Absolute left atrial diameter was 44.34 +/- 4.41 mm in the AF group (non-AF group 38.94 +/- 3.77 mm, P < 0.001) (healthy controls 37.54 +/- 4.34 mm, compared with all athletes P = 0.015). In all individuals left ventricular wall thickness was within normal limits. However, myocardial walls were thicker in the AF group (11.28 +/- 1.83 mm) than in the non-AF group (9.44 +/- 1.26 mm, P = 0.002). Athletes in the AF group (187.6 +/- 6.42 cm) were significantly taller than in the non-AF group (180.91 +/- 7.31 cm, P = 0.018). CONCLUSION Not only endurance training, but also sports activity with a relevant static component, like team handball, might predispose for AF above the age of 50. LA size, height and myocardial wall thickness seem to affect the risk of developing AF. More data in non-endurance sports are mandatory to confirm this hypothesis.

BACKGROUND AND OBJECTIVE Echocardiographic Tissue Doppler Imaging (TDI) has been proposed for the differentiation of pathological left ventricular hypertrophy (e. g. hypertrophic cardiomyopathy, HCM) and physiologic left ventricular hypertrophy (athlete's heart). The aim of this study was the TDI analysis of the systolic (S') and early diastolic (E') velocities in patients (pts.) with non-obstructive hypertrophic cardiomyopathy (HCM) and in top-level athletes in consideration of the previously published cut-off values (S'

AIMS Recent trials with different designs indicated that drug-eluting stents may be superior to vascular brachytherapy (VBT) for the treatment of in-stent restenosis (ISR). We performed a randomised, double-centre, clinical, quantitative coronary angiographic (QCA) and intravascular ultrasound (IVUS) acute and 3-years comparison of 90Sr/90Y-VBT and sirolimus-eluting stent implantation (SES) for ISR. METHODS AND RESULTS Ninety-one (91) consecutive patients were included. By QCA, SES led to a higher acute gain (2.08 ± 0.41 mm vs. 1.54 ± 0.70 mm, p < 0.0001), higher postprocedural minimum lumen diameter (2.76 ± 0.39 mm vs. 2.39 ± 0.52 mm; p < 0.0001), lower late lumen loss at follow-up (0.09 ± 0.29 vs. 0.39 ± 0.79 mm, p = 0.042), and a higher net lumen gain of the target lesion (2.05 ± 0.51 vs 1.18 ± 1.08 mm, p < 0.0001). By IVUS, the smaller acute gain following VBT was the result of residual intima hyperplasia, the intima hyperplasia formation following SES was extremely low, and the edge-effect was virtually absent after SES, respectively. At 6-month follow-up, both the angiographic restenosis rate (4.7 vs. 22.7%; p < 0.0001) and target lesion revascularisation rate (2.3 vs. 10.4%; p = 0.025) were lower in SES. Importantly, SES showed a stable clinical course at 3-year follow-up while VBT was associated with a sustained incidence of target vessel failure (11.6 vs. 46.7%; p < 0.0001). CONCLUSIONS SES for ISR is associated with superior QCA, IVUS and clinical results at 6-month and 3-year of follow-up when compared with VBT.

Aims The aim of this first large-scale long-term study was to investigate whether obstructive sleep apnoea (OSA) and/or central sleep apnoea (CSA) are associated with an increased risk of malignant cardiac arrhythmias in patients with congestive heart failure (CHF). Methods and results Of 472 CHF patients who were screened for sleep disordered breathing (SDB) 6 months after implantation of a cardiac resynchronization device with cardioverter-defibrillator, 283 remained untreated [170 with mild or no sleep disordered breathing (mnSDB) and 113 patients declined ventilation therapy] and were included into this study. During follow-up (48 months), data on appropriately monitored ventricular arrhythmias as well as appropriate cardioverter-defibrillator therapies were obtained from 255 of these patients (90.1%). Time period to first monitored ventricular arrhythmias and to first appropriate cardioverter-defibrillator therapy were significantly shorter in patients with either CSA or OSA. Forward stepwise Cox models revealed an independent correlation for CSA and OSA regarding monitored ventricular arrhythmias [apnoea-hypopnoea index (AHI) >= 5 h(-1): CSA HR 2.15, 95% CI 1.40-3.30, P < 0.001; OSA HR 1.69, 95% CI 1.64-1.75, P = 0.001; AHI >= 15 h(-1): CSA HR 2.06, 95% CI 1.40-3.05, P < 0.001; OSA HR 1.69, 95% CI 1.14-2.51, P = 0.02] and appropriate cardioverter-defibrillator therapies (AHI >= 5 h(-1): CSA HR 3.24, 95% CI 1.86-5.64, P < 0.001; OSA HR 2.07, 95% CI 1.14-3.77, P = 0.02; AHI >= 15 h(-1): CSA HR 3.41, 95% CI 2.10-5.54, P < 0.001; OSA HR 2.10, 95% CI 1.17-3.78, P = 0.01). Conclusion In patients with CHF, CSA and OSA are independently associated with an increased risk for ventricular arrhythmias and appropriate cardioverter-defibrillator therapies.

Introduction Transradial coronary angiography (TRC) can be performed with a one-catheter approach for the right and left coronary ostium (R/LCO). We investigated the performance of a special diagnostic catheter widely used for the one-catheter-approach, the Tiger (Tiger II, TerumoTM). Methods In a dual center registry we analyzed 1412 TRC-procedures exclusively performed by experienced TRC-operators. We compared the performance of the Tiger with Judkins catheters by retrospectively judging ostial catheter stability during contrast injection, and by measuring contrast use, fluoroscopy time (FT) and complication rate. Results Poor or failed ostial engagement was found in 40.5% in the Tiger group, compared to 46.6% with the use of Judkins catheters (p

Background There is a high prevalence of central sleep apnea (CSA) in patients with chronic heart failure (CHF). The present study investigates the hypotheses that CSA in CHF patients reflects heart failure severity as measured by cardiac index (CI), pulmonary artery pressure (PAP) and pulmonary capillary wedge pressure (PCWP). Methods In 105 patients with stable CHF (NYHA⩾II, LV-EF⩽40%) cardiorespiratory polygraphy and simultaneous right and left heart catheterization was performed. Results CSA was present in 58% and obstructive sleep apnea (OSA) in 23% of patients. In CSA patients, PAP and PCWP were significantly higher when compared to patients without SDB. In CSA patients, but not in OSA patients, PCWP showed a significant correlation with apnea–hypopnea index (AHI; r =0.41, p =0.005), apnea index (AI; r =0.44, p =0.003) and central AI (cAI; r =0.358, p =0.015). Cardiac index was more impaired in CSA (1.93±0.5l/min/m 2 ) than in OSA patients (2.55±1.0l/min/m 2 ) or those without SDB (2.22±0.4l/min/m 2 ). A negative correlation of CI and cAI ( r =−0.344, p =0.008), AI ( r =−0.31, p =0.02) and AHI ( r = − 0.21, p Conclusion The present study supports the hypotheses that the occurrence and severity of CSA in CHF patients reflects heart failure severity.

Aims In patients with systolic heart failure (SHF) a high prevalence of sleep-disordered breathing (SDB) has been documented. The purpose of this study was to investigate the prevalence and type of SDB in patients with heart failure with normal left ventricular ejection fraction (HFNEF). Methods and results Two hundred and forty-four consecutive patients (87 women, aged 65.3 ± 1.4 years) with HFNEF underwent capillary blood gas analysis, measurement of NT-proBNP concentrations, echocardiography, cardiopulmonary exercise testing (CPX), cardiorespiratory polygraphy, and simultaneous right and left heart catheterization. Sleep-disordered breathing was defined as an apnoea–hypopnoea-index (AHI) ≥5/h. Sleep-disordered breathing was documented in 69.3% of all patients, 97 patients (39.8%) presented with OSA and 72 patients (29.5%) with CSA. With an increasing impairment of diastolic function the proportion of SDB, and CSA in particular, increased. Patients with SDB performed worse on CPX and six-minute walk test. Partial pressure of CO2 was lower in CSA, whereas AHI, left atrial diameter, NT-proBNP, LVEDP, PAP, and PCWP were higher. Conclusion There is a high prevalence of SDB in HFNEF. In parallel to SHF, CSA patients in particular are characterized by a more impaired cardiopulmonary function. Whether SDB is of prognostic relevance in HFNEF needs to be determined.

Noninvasive coronary angiography (NCA) is recommended to be applied as a filter before invasive coronary angiography in patients with intermediate cardiovascular risk.In this prospective single-center study, we validated multislice computed tomography (MSCT) and magnetic resonance imaging (MRI)-based NCA by primarily selecting patients with atypical angina pectoris (AAP).In 68 patients (63.6+/-11.4 years) with AAP, the Prospective Cardiovascular Muenster Study score and the Agatston score equivalent (ASE; calcium score) were initially determined for cardiovascular risk assessment. Subsequently, MSCT and MRI-based NCA were performed followed by quantitative invasive coronary angiography for validation. All tests were finally analyzed.CAD (prevalence 38.2%) was diagnosed in 67.7% of patients at high, 61.5% at intermediate, and 37.8% at low cardiovascular risk according to the Prospective Cardiovascular Muenster Study. CAD was diagnosed in 88.2% of patients with an ASEor=75th percentile and in 90.9% with an ASEor=90th percentile. With regard to NCA, patient-based analysis resulted in a sensitivity of 96.2% for MSCT versus 69.2% for MRI, in a specificity of 95.2 versus 64.3%, in a positive predictive value of 97.6 versus 77.1%, in a negative predictive value of 92.6 versus 54.5%, and a diagnostic accuracy of 95.6 versus 66.2% (P0.05).In a patient group with a heterogeneous cardiovascular risk, primarily considering AAP allows for effective patient preselection for NCA. This may be optimized by precluding patients with an ASEor=75th percentile. MSCT rather than MRI may then effectively be involved.

Sleep disordered breathing (SDB) has a high prevalence and prognostic impact in patients with chronic heart failure (CHF). Aim of this study was to investigate variability of SDB parameters in patients with stable CHF. Cardiorespiratory polygraphy was used to determine SDB in two consecutive nights in 50 CHF patients (NYHA classor = II, LV-EFor = 40%). The apnea-hypopnea-index (AHI) and apnoea-index (AI) were used to quantify SDB severity. Central, obstructive or mixed SDB were classified according to the majority of events. There was an excellent correlation in AHI (r = 0.948, P0.001) and AI (r = 0.842, P0.001) results of both nights. The overall number of detected apnea and hypopnea during the first night as compared to the maximum of both nights was 85% for the AHI and 77% for the AI. The reproducibility was dependent on SDB severity: AHI 15-29/h = 87%, AHIor = 30/h = 92% and AIor = 10/h = 83%. Classification was identical in 17 out of 19 patients with AIor = 10/h. In patients with stable CHF a single night of cardiorespiratory monitoring leads to representative results on severity and type of SDB. This may enhance the applicability and dissemination of cardiorespiratory polygraphy in clinical practice.

Background and aims Sleep disordered breathing (SDB), especially Cheyne–Stokes respiration (CSR) is common in patients with chronic heart failure (CHF). Adaptive servoventilation (ASV) was recently introduced to treat CSR in CHF. The aim of this study was to investigate the effects of ASV on CSR and CHF parameters. Methods In 29 male patients (63.9±9 years, NYHA≥II, left ventricular ejection fraction [LV-EF]≤40%), cardiorespiratory polygraphy, cardiopulmonary exercise (CPX) testing, and echocardiography were performed and concentrations of NT-proBNP determined before and after 5.8±3.5 months (median 5.7 months) of ASV (AutoSet CS™2, ResMed) treatment. All patients also received guideline-driven CHF therapy. Results Apnoea–hypopnoea-index was reduced from 37.4±9.4/h to 3.9±4.1/h (p

Background Patients older than 75 years undergoing percutaneous coronary interventions are at increased risk for major adverse cardiac events strongly influenced by comorbidities. In various randomized trials, sirolimus-eluting stent (SES) implantation has been shown to decrease the incidence of in-stent restenosis and to reduce repeat revascularization regardless of patient age. Methods The present study evaluates the outcome after SES implantation in 954 patients older than 75 years compared with 5801 patients younger than 75 years enrolled in the German Cypher Registry in a routine clinical setting. Results The elderly were at higher risk regarding renal failure, diabetes, hypertension, impaired left ventricular function, and 3-vessel disease. The SES implantation resulted in an impressive relief of angina. As expected, in-hospital and 6-month mortality rates were higher in the elderly. However, there was no difference with respect to the rate of major adverse cardiac events (death, myocardial infarction, ischemia-driven target vessel revascularization) at 6-month follow-up. Conclusions Nonfatal complications such as myocardial infarction or repeat target vessel revascularization did not increase with age, even taking patients older than 80 years into account.

Sirs: A 68-year-old man with mitral valve replacement but former mitral regurgitation II (left atrial size 39 mm) and coronary artery sclerosis suffered syncope due to a sustained ventricular tachycardia. Before this event, the patient had neither palpitations nor was arrhythmia documented by Holter ECGs. A single chamber cardioverter/defibrillator (SJM, Atlas VR) was implanted. Routine abdominal ultrasound did not reveal pathologic findings at that

Acute chest pain and progressive dyspnea led to the admission of an 83-year-old female patient with known severely impaired left ventricular (LV) function and secondary mitral regurgitation II due to dilated cardiomyopathy (DCM). Recurrent decompensations had led to cardiac resynchronization therapy via defibrillator (CRTD) implantation. Present cardiovascular risk stratification revealed metabolic syndrome (obesity, diabetes mellitus type 2, arterial hypertension and hyperlipoproteinemia) complicated by previous stroke, whereas relevant coronary artery disease had been excluded years before. Moreover, recurrent exacerbating obstructive lung disease (COLD, GOLD III) was reported and advanced renal failure was documented [K/DOQI III, serum creatinine 2.2 mg/dL, urea 96 mg/dL, glomerular filtration rate (GFR, MDRD) 23 mL/min]. Initial clinical examination revealed wheezing over both lungs and mild edema of the lower limbs. There was sinus rhythm at a normal heart rate and bothsided blood pressure of 220/100 mmHg. Chest pain did not completely diminish, whereas myocardial infarction was ruled out using highly sensitive troponin T assay. The patient’s antihypertensive medication included seven substances with several second-line antihypertensives, all at high dose. Under additional intravenous (i.v.) nitrates, blood pressure remained merely controllable. With the addition of an oral central a-2 agonist and an oral reninreceptor antagonist, i.v. nitrates could be weaned (Table 1). In view of severely reduced glomerular filtration rate, the patient was refused to be treated with mineralocorticoidreceptor antagonist (MRA) as spironolactone or eplerenone, but left with sequential nephron blockade [1]. Coronary angiography demonstrated a high-grade stenosis of the left anterior descending coronary artery, contributing to recurrent angina pectoris. Percutaneous coronary intervention (PCI) was performed immediately. Post-PCI, we decided to angiographically search for underlying renal artery stenosis (RAS) in a hypertensive patient with continuously decreasing renal function and known coronary atherosclerosis. We demonstrated a highgrade RAS on the left (Fig. 1) and a rudimental renal artery on the right side. Further diagnostic workup including kidney ultrasound revealed a right-sided renal hypoplasia with no measurable resistance index (RI) and a normal appearing left kidney with a moderately reduced RI of 0.85. Thus, renal artery revascularization was considered, but defined as an ultima ratio after having exhausted all medical options. Under extended medical therapy (Table 1), the patient recurrently presented with blood pressures of up to 190/100 mmHg with accompanying angina and dyspnea due to flash pulmonary edema on days 4 and 7. Finally, stenting of the left renal artery was performed (Fig. 1). Hemodynamically relevant RAS (C70 % diameter stenosis) is one potential cause of secondary hypertension, also leading to impairment of renal function. Its diagnosis and its causal connection to hypertension and renal failure can be ambiguous. There are two underlying pathologies: 95 % of RAS is caused by atherosclerosis typically found at the proximal or ostial vessel. Fibromuscular dysplasia showing a string of beat pattern of the mid and/or distal renal artery is less T. Demming N. Frey C. Langer (&) Klinik fur Kardiologie und Angiologie, Universitares Gefaszentrum Nord, Universitatsklinikum Schleswig–Holstein, Campus Kiel, Christian-Albrechts Universitat Kiel, Schittenhelmstr. 12, 24105 Kiel, Germany e-mail: christoph.langer@uksh.de

We report on a 60 year-old male who was one of the first patients who underwent percutaneous transluminal septal myocardial ablation (PTSMA) in our institution in 1996. Contrast enhanced cardiac magnetic resonance imaging (MRI) 11 years after the PTSMA demonstrated extensive scarring, in septal and inferior segments of the left ventricle, and an excellent functional result. It has been previously demonstrated that contrast-enhanced MRI allows detailed evaluation of size and location of septal myocardial infarction induced by PTSMA, and that infarction size detected by MRI correlates well with clinical indexes of infarct size. Our case report underlines the importance of ongoing specialized care and reassessment of patients after PTSMA including continuous clinical risk assessment.

BACKGROUND Aortic or mitral valvular regurgitation (left cardiac valvular regurgitation, LCVR) of less than second-degree (< degree II) occasionally found in competitive athletes is of questionable relevance. Precisely detectable by echocardiography there is scarce published data that clarifies cardiopulmonary capacity or any limitations LCVR < degree ll may cause. METHODS In this single-centre study we consecutively recruited highly trained athletes (n= 14) with LCVR < degree ll detected in 2D echo. Not included were athletes with multi- or right-cardiac valvular dysfunction and structural heart disease other than bicuspid aortic valve or mitral valve prolaps. Target parameters were determined by 2D echo and spiroergometry. RESULTS There were no significant differences with regard to age and body mass index. Echocardiographically determined muscle mass index was increased in both groups (134 14.7 vs 129.6+/-27.5; P=0.69), whereas the left-ventricular end-diastolic diameter index was significant higher in the LCVR < degree II group (27.3 +/- 1.3 vs 25.2 +/- 2.4; P = 0.04). However, there were no significant differences with regard to (oxygen uptake) V02, at baseline (athletes with LCVR < degree II 5.7 +/- 0.9 vs controls 5 +/- 0.96, P= 0.06), at the anaerobic threshold (athletes with LCVR < degree II 47.3 +/-8.4 vs controls 47.4 +/- 5, P= 0.97) and maximally (VO2max; athletes with LCVR < degree II 57.7 6.3 vs controls 57.1 +/- 5.1, P= 0.81). Neither levels of lactate nor of brain natriuretic peptide differed significantly. CONCLUSION High level athletes presenting with aortic or mitral regurgitation < degree II in are not disadvantaged with regard to their cardiopulmonary capability.

At the ALADIN-LAND setup at GSI the unbound nucleus Be-13 has been produced in one-neutron knockout reactions from a 304 MeV/nucleon relativistic beam of Be-14 ions impinging on a liquid hydrogen target. An analysis of the data including all available information about Be-13, and in particular recent data from a similar experiment performed at RIKEN, has been performed. A consistent description is reached. It is found that the excitation spectrum is dominated by s-waves at low energy, which solves problems from previous seemingly contradictory interpretations. A possible interference between two s-states in Be-13 is also discussed. The results indicate that the ground-state wave function of Be-14 is dominated by valence neutrons in the s-shell contributing with 60-75% of the total neutron knockout cross section.

Patients (pts) with hypertrophic cardiomyopathy (HCM) may present with a variety of symptoms, including sudden cardiac death. Sudden cardiac death due to ventricular fibrillation correlates with the extent of intramural fibrosis (IF). IF can be detected using cardiac magnetic resonance (CMR) by

Background Coronary computed tomography angiography has become the foremost noninvasive imaging modality of the coronary arteries and is used as an alternative to the reference standard, conventional coronary angiography, for direct visualization and detection of coronary artery stenoses in patients with suspected coronary artery disease. Nevertheless, there is considerable debate regarding the optimal target population to maximize clinical performance and patient benefit. The most obvious indication for noninvasive coronary computed tomography angiography in patients with suspected coronary artery disease would be to reliably exclude significant stenosis and, thus, avoid unnecessary invasive conventional coronary angiography. To do this, a test should have, at clinically appropriate pretest likelihoods, minimal false-negative outcomes resulting in a high negative predictive value. However, little is known about the influence of patient characteristics on the clinical predictive values of coronary computed tomography angiography. Previous regular systematic reviews and meta-analyses had to rely on limited summary patient cohort data offered by primary studies. Performing an individual patient data meta-analysis will enable a much more detailed and powerful analysis and thus increase representativeness and generalizability of the results. The individual patient data meta-analysis is registered with the PROSPERO database (CoMe-CCT, CRD42012002780). Methods/Design The analysis will include individual patient data from published and unpublished prospective diagnostic accuracy studies comparing coronary computed tomography angiography with conventional coronary angiography. These studies will be identified performing a systematic search in several electronic databases. Corresponding authors will be contacted and asked to provide obligatory and additional data. Risk factors, previous test results and symptoms of individual patients will be used to estimate the pretest likelihood of coronary artery disease. A bivariate random-effects model will be used to calculate pooled mean negative and positive predictive values as well as sensitivity and specificity. The primary outcome of interest will be positive and negative predictive values of coronary computed tomography angiography for the presence of coronary artery disease as a function of pretest likelihood of coronary artery disease, analyzed by meta-regression. As a secondary endpoint, factors that may influence the diagnostic performance and clinical value of computed tomography, such as heart rate and body mass index of patients, number of detector rows, and administration of beta blockade and nitroglycerin, will be investigated by integrating them as further covariates into the bivariate random-effects model. Discussion This collaborative individual patient data meta-analysis should provide answers to the pivotal question of which patients benefit most from noninvasive coronary computed tomography angiography and thus help to adequately select the right patients for this test.

Echocardiographic tissue Doppler imaging (TDI) has been proposed for the differentiation of physiologic left ventricular hypertrophy and pathologic left ventricular hypertrophy in athletes. In addition, cutoff values for systolic (S'9 cm/s) and early diastolic (E'9 cm/s) myocardial velocities had been defined. The aim of our study was the analysis of the morphologic cardiac changes by standard echocardiography, and the myocardial velocities S' and E' by TDI in top-level handball players with respect to the predefined cutoff values.Pulsed-wave TDI of the systolic and early diastolic velocities was performed at the lateral and septal mitral annulus (MA) in the four-chamber view in 100 athletes (100 Caucasian men; professional handball players of the first German handball league and the German national team; mean age 25.8+/-4.8 years).Global and regional left ventricular systolic function was normal in all athletes. They showed an eccentric hypertrophy of the left ventricle (LV), which was characterized by an increased mass of the LV (287.3+/-58.4 g), and an increased end diastolic diameter of the LV (LVEDD: 58+/-5.9 mm), but no echomorphologic signs of pathologic hypertrophy or hypertrophic cardiomyopathy. TDI showed a systolic velocity S' of the MA of 9.3+/-1.5 cm/s at the septal and 10.5+/-2.1 at the lateral MA. Ten of the 100 athletes showed a S'9 cm/s at both sides of the MA. TDI showed an early diastolic velocity E' of the MA of 13.2+/-2.8 cm/s at the septal and of 16.6+/-3.4 cm/s at the lateral MA. None of the 100 athletes showed reduced systolic or early diastolic velocities below the proposed cutoff values (S' and E'9 cm/s) at any sides of the MA.Our study provides further insights into systolic and diastolic function as assessed by TDI in top-level handball players. Owing to the large cohort of individuals, our findings might be helpful as reference values for the echocardiographic assessment of handball players, who are performing a moderate static and high dynamic sport.

Two-dimensional strain (2DS) is a novel method to measure strain from standard two-dimensional echocardiographic images by speckle tracking, which is less angle dependent and more reproducible than conventional Doppler-derived strain. The objective of our study was to characterize global and regional function abnormalities using 2DS and strain rate analysis in patients (pts) with pathological left ventricular hypertrophy (LVH) caused by non-obstructive hypertrophic cardiomyopathy (HCM), in top level athletes, and in healthy controls. The hypothetical question was, if 2DS might be useful as additional tool in differentiating between pathologic and physiologic hypertrophy in top-level athletes. We consecutively studied 53 subjects, 15 pts with hypertrophic cardiomyopathy (HCM), 20 competitive top-level athletes, and a control group of 18 sedentary normal subjects by standard echocardiography according to ASE guidelines. Global longitudinal strain (GLS) and regional peak systolic strain (PSS) was assessed by 2DS in the apical four-chamber-view using a dedicated software. All components of strain were significantly reduced in pts with HCM (GLS: −8.1 ± 3.8%; P < 0.001) when compared with athletes (−15.2 ± 3.6%) and control subjects (−16.0 ± 2.8%). In general, there was no significant difference between the strain values of the athletes and the control group, but in some of the segments, the strain values of the control group were significantly higher than those in the athletes. A cut-off value of GLS less than −10% for the diagnosis of pathologic hypertrophy (HCM) resulted in a sensitivity of 80.0% and a specificity of 95.0%. The combination of TDI (averaged S′, E′) and 2DS (GLS) cut-off values for the detection of pathologic LVH in HCM demonstrated a sensitivity of 100%, and a specificity of 95%. Two-dimensional strain is a new simple and rapid method to measure GLS and PSS as components of systolic strain. This technique could offer a unique approach to quantify global as well as regional systolic dysfunction, and might be used as new additional tool for the differentiation between physiologic and pathologic LVH.

Background: Implantation of drug eluting stents (DES) in tortuous and/or calcified vessels is much more demanding compared with implantation of bare metal stents (BMS) due to their larger diameters. It is unknown whether drug eluting stent coatings get damaged while crossing these lesions. Methods: In 42 patients (34 male, 68.1 ± 10 years) with 45 calcified lesions (15.9 mm ± 7.9 mm), DES could not be implanted, even after predilatation. Diabetes was present in 19 patients (45 %). Sixty-one stents were used; 19 Cypher select™, 18 Taxus Liberte™, 10 CoStar™, 5 Endeavor RX™, 4 Xience V™. 3 Janus Carbostent™, 1 Yukon Choice S™, and 1 Axxion™ DES. The entire accessible surface area of these stents, in either the unexpanded and expanded state, were examined with an environmental scanning electron microscope (XL30 ESEM, Philips) to evaluate polymer or surface damage. Results: The polymers of Taxus Liberte, Cypher Select, Xience V, CoStar, and Janus DES were only slightly damaged (less than 3% of surface area), whereas the Endeavor RX Stents showed up to 20% damaged surface area. In DES without a polymer (Yukon and Axxion), it could be shown that most of the stent surface (up to 40%) were without any layer of drug. Conclusion: Placement of drug eluting stents in tortuous vessels and/or calcified lesions could cause major surface damage by scratching and scraping of the polymer or drug by the arterial wall, even before implantation. There were remarkable differences among the stents examined, only minor damage with the Cypher, Taxus Costar, Janus, and Xience V, whereas the Endeavor, the Yukon, and the Janus DES showed large areas of surface injury. © 2009 Wiley-Liss, Inc.

A high prevalence of nocturnal Cheyne-Stokes respiration (CSR) has been documented in patients with heart failure with normal left ventricular ejection fraction (HFNEF). The aim of the present study was to investigate the effects of adaptive servoventilation (ASV) for treatment of CSR in these patients. In 60 patients with HFNEF, defined according to current European Society of Cardiology guidelines, CSR was documented by polysomnography (apnoea/hypopnoea index (AHI) of >15 events.h(-1)). ASV treatment was offered to all patients; 21 initially rejected treatment, withdrew from treatment or presented noncompliant during follow-up (controls), whereas ongoing ASV therapy was initiated in 39 patients (ASV group). Echocardiography, cardiopulmonary exercise testing and measurement of N-terminal-pro-brain natriuretic peptide were performed at baseline and follow-up (11.6 +/- 3 months). ASV therapy led to a significant reduction in AHI, longest apnoea and hypopnoea length, maximum and mean oxygen desaturation by pulse oximetry, percentage of study time with an oxygen saturation of

Echocardiographic tissue Doppler imaging (TDI) has been proposed as diagnostic tool for the differentiation between constrictive pericarditis (CP) and restrictive cardiomyopathy (RCM). The aim of this study was a comprehensive TDI analysis of systolic (S′) and early diastolic (E′) velocities of the septal and lateral mitral annulus (MA) in patients (pts) with severe diastolic dysfunction caused either by CP or RCM. Sixty consecutive pts (34 men, mean age 61 ± 11 years), 34 pts with proven CP and 26 pts with RCM due to cardiac amyloidosis, were included in the study. Forty-two of the 60 pts were in NYHA class III (70%). In pts with RCM systolic longitudinal velocity (S′) was significantly decreased when compared to CP (septal MA 4.1 ± 1.5 vs. 7.3 ± 2.1 cm/s, p

Objective Calcification is a principal problem in noninvasive coronary angiography (CA) performed with multislice computed tomography (MSCT). Magnetic resonance imaging (MRI) supposedly neglects calcium. We compared both modalities. Methods Sixty-eight patients admitted for CA underwent MSCT- and MRI-based noninvasive CA the day before. Stenosis detection (>or=50%) was visually performed and validated by quantitative CA. Results The patient-based overall sensitivity, specificity, positive predictive value, and negative predictive value were 96.2%, 95.2%, 92.6%, and 97.6% for MSCT versus 69.2%, 64.3, 54.5%, 64.3%, and 77.1% for MRI, respectively. The segment-based overall results were 74.7%, 97.8%, 75.7%, and 97.6% for MSCT versus 40%, 93.8%, 37.5%, and 94.4% for MRI, respectively. Investigating the impact of coronary calcifications in the patient group with a volume score of 300 microL or greater resulted in 100%, 80%, 92.3%, and 100% for MSCT versus 70.8%, 86.7%, 89.5%, and 65% for MRI, respectively. The segment group with considerable hardening artifacts resulted in 85.3%, 83.9%, 76.3%, and 90.4% for MSCT versus 52.9%, 92.9%, 81.8%, and 76.5% for MRI, respectively. Conclusions There are no major advantages of MRI in cases of advanced coronary calcification.

In humans with normal hearts multi-slice computed tomography (MSCT) based volumetry was shown to correlate well with the gold standard, cardiac magnetic resonance imaging (CMR). We correlated both techniques in patients with various degrees of heart failure and reduced ejection fraction (HFREF) resulting from cardiac dilatation. Twenty-four patients with a left ventricular end-diastolic volume (LV-EDV) of ≥ 150 ml measured by angiography underwent MSCT and CMR scanning for left and right ventricular (LV, RV) volumetry. MSCT based short cardiac axis views were obtained beginning at the cardiac base advancing to the apex. These were reconstructed in 20 different time windows of the RR-interval (0–95%) serving for identification of enddiastole (ED) and end-systole (ES) and for planimetry. ED and ES volumes and the ejection fraction (EF) were calculated for LV and RV. MSCT based volumetry was compared with CMR. MSCT based LV volumetry significantly correlates with CMR as follows: LV-EDV r = 0.94, LV-ESV r = 0.98 and LV-EF r = 0.93, but significantly overestimates LV-EDV and LV-ESV and underestimates EF (P

SUMMARY Background: Obstructive sleep apnea (OSA) is more common in patients with atrial fibrillation (AFib). Recently, an additional association between central sleep apnea/CheyneStokes respiration (CSA/CSR) and AFib has been described. The aim of this study was to investigate the prevalence and type of sleep-disordered breathing in patients with AFib and normal systolic left ventricular function. Methods: 150 patients (110 men and 40 women, aged 66.1 ± 1.7 years) underwent cardiorespiratory polygraphy, capillary blood gas analysis, measurement of NT-proBNP, and echocardiography to determine the diameter of the left atrium (LAD) and the peak systolic pulmonary artery pressure (PAP). Results: Sleep-disordered breathing was documented in 74% of all patients with AFib (43% had OSA and 31% had CSA/CSR). Patients with CSA/CSR had a higher PAP, a higher apnea-hypopnea index, a greater LAD, and a lower capillary blood pCO2 than patients with OSA. Conclusions: Patients with AFib were found to have not only a high prevalence of obstructive sleep apnea, as has been described previously, but also a high prevalence of CSA/CSR. It remains unknown whether CSA/CSR is more common in AFib because of diastolic dysfunction or whether phenomena associated with CSA/CSR predispose to AFib. Further research on this question is needed.

Background Multi-slice computed tomography (MSCT) was proved to provide precise cardiac volumetric assessment. Cardiac resynchronization therapy (CRT) is an effective treatment for selected patients with heart failure and reduced ejection fraction (HFREF). In HFREF patients we investigated the potential of MSCT based wall motion analysis in order to demonstrate CRT-induced reversed remodeling. Methods Besides six patients with normal cardiac pump function serving as control group seven HFREF patients underwent contrast enhanced MSCT before and after CRT. Short cardiac axis views of the left ventricle (LV) in end-diastole (ED) and end-systole (ES) served for planimetry. Pre- and post-CRT MSCT based volumetry was compared with 2D echo. To demonstrate CRT-induced reverse remodeling, MSCT based multi-segment color-coded polar maps were introduced. Results With regard to the HFREF patients pre-CRT MSCT based volumetry correlated with 2D echo data for LV-EDV (MSCT 278.3±75.0mL vs. echo 274.4±85.6mL) r =0.380, p =0.401, LV-ESV (MSCT 226.7±75.4mL vs. echo 220.1±74.0mL) r =0.323, p =0.479 and LV-EF (MSCT 20.2±8.8% vs. echo 20.0±11.9%) r =0.617, p =0.143. Post-CRT MSCT correlated well with 2D echo: LV-EDV (MSCT 218.9±106.4mL vs. echo 188.7±93.1mL) r =0.87, p =0.011, LV-ESV (MSCT 145±71.5mL vs. echo 125.6±78mL) r =0.84, p =0.018 and LV-EF (MSCT 29.6±11.3mL vs. echo 38.6±14.6mL) r =0.89, p =0.007. There was a significant increase of the mid-ventricular septum in terms of absolute LV wall thickening of the responders (pre 0.9±2.1mm vs. post 3.3±2.2mm; p Conclusion MSCT based volumetry involving multi-segment color-coded polar maps offers wall motion analysis to demonstrate CRT-induced reverse remodeling which needs to be further validated.

In grading mitral regurgitation (MR) magnetic resonance imaging is the gold standard but 2D echo is mostly used in clinical practice. However, each single echo parameter is prone to confounding influences. With regard to chronic primary and secondary MR the purpose of this study was to compare a new multi-dimensional echo-based grading system with an independent pre-operatively used invasive standard.In a retrospective study we analyzed 177 patients with different degrees of MR severity, who were examined both by echocardiography and by cardiac catheterization. For MR grading a combination of four echocardiographic parameters was used: density of the regurgitation velocity profile, peak mitral inflow velocity (Vmax E-wave), radius of the proximal flow convergence zone (PISA), and vena contracta (Vc) width. Invasive grading was based on left ventriculography (Seller's method), V wave hight, and regurgitation fraction. Both methods resulted in an integrative score on an eight point scale (I-IV in half-steps). Echocardiographic and invasive data were correlated.There was a reasonable overall correlation of r = 0.72 (p = 0.001) between both grading systems. Echo tended to slightly overestimate MR severity. In patients with secondary MR, agreement was worse (p = 0.01) than in primary MR. The most powerful single echo parameter was Vc r = 0.71 (p = 0.001). Presence or absence of sinus rhythm had no significant influence on echo grading.The proposed echocardiographic multidimensional MR grading system is feasable and shows good correlation with invasive grading.

Echocardiography demonstrated pronounced asymmetric left ventricular (LV) hypertrophy and thickened right ventricular muscular components in a 54-year-old woman with a history of dyspnoea (NYHA III), and recurrent syncopes. Left ventricular outflow peak gradient was 80 mmHg at rest and 125 mmHg during Valsalva manoeuvre. Cardiac cine and gadolinium-enhanced T1 weighted magnetic resonance imaging (MRI) provided striking images of a right ventricular outflow tract obstruction and a markedly abnormal gadolinium uptake in the interventricular septum consistent with myocardial fibrosis. Right and left heart catherization, with simultaneous measurement of aortic and LV pressures revealed a 150 mmHg subaortic gradient and a 130 mmHg subpulmonic gradient at rest. Impediment to right ventricular (RV) outflow was due to massive hypertrophy of the crista supraventricularis with an 'hour-glass' deformity. A surgical intervention with LV septal myotomy-myectomy and RV ventriculotomy was performed successfully. Hypertrophic obstructive cardiomyopathy with significant RV and LV outflow tract obstruction is a very rare finding. Echocardiography and MRI can be used in combination for non-invasive evaluation of morphological and haemodynamic information because mechanisms of obstruction are different in each ventricle.

Background Contrast enhanced multi-slice computed tomography (MSCT) is the leading modality in non-invasive coronary angiography (CTA) today. We investigated MSCT based assessment of coronary artery bypass grafts (CABG) by analyzing assets and drawbacks of CTA in order to define demands on latest technology. Methods In a clinical setting 39 CABG patients (69.2 ± 1.4 years; male n = 36) underwent CTA (collimation 16 × 0.75 mm, contrast medium 100 ml; 320 mAs, 120 KV). Ninety-seven CABG (61 venous, 36 arterial grafts) were evaluated. A subgroup of 18 patients underwent additional invasive coronary angiography (CA). Results CTA for CABG assessment resulted in an overall sensitivity (sens.) of 100%, specificity (spec.) of 92.4% and positive and negative predictive values (PPV, NPV) of 60% and 100%, respectively. CABG anastomoses showed slightly inferior diagnostic accuracy than other CABG segments. Limitations in imaging quality caused 21% unevaluable segments of the CABG anastomoses. Evaluation of native vessel segments proximal and distal to the anastomoses resulted in a sens, spec, PPV and NPV of 57.5, 94.6, 92 and 67.3%, respectively. With 28.5% unevaluable segments, the native vessel segments showed serious limitations in imaging quality. Radiation exposure was 9.88 ± 3.20 mSv (9.69 ± 3.25 mSv male; 12.08 ± 1.35 mSv female). Conclusion 16-slice MSCT based CABG assessment offers sufficient diagnostic accuracy. However, focussing on the bypass anastomoses and the native revascularized coronary arteries, clinical value is limited.

By describing the way of diagnosis, we report a case of coronary artery kinking associated with poststenotic dilatation. We give a review of the literature considering the different coronary morphology variations, etiological differential diagnosis, and the preferable terminology.

A 42-year-old man was admitted with exertional breathlessness (New York Heart Association class II) and atypical chest pain. These symptoms were caused by a growing pericardial cyst situated in the left cardiophrenic angle, which had been diagnosed by chest radiography 17 years earlier (Figure 1A). Transthoracic echocardiography confirmed the presence of a large fluid-filled cyst within the pericardial space and excluded any compression of the left ventricular free wall by the cyst (Figure 2). Magnetic resonance imaging revealed …

According to the guidelines of the European Society of Cardiology on the diagnosis and management of pericardial diseases, tissue Doppler imaging (TDI) is proposed to be part of the diagnostic work-up in patients with suspected constrictive pericarditis (CP). We describe a case which illustrates that TDI analysis may be misleading in patients with severe pericardial calcifications of the lateral mitral annulus. Multi-slice computed tomography (MSCT) data in this case contributed much to a better understanding of the impact of heterogeneous calcification patterns on the results of TDI assessment in CP.