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We present a case of an 85-year-old patient who underwent clinical work-up for chronic heart failure, acute coronary syndrome, and pulmonary embolism, until she was diagnosed with a cardiac mass that was histologically identified as sarcoma. The aim of this educational case report is to raise awareness of cardiac masses and to point out diagnostic hints towards a cardiac tumor on chest X-ray, coronary angiography, echocardiography, and chest CT. Moreover, the vital role of cardiac magnetic resonance for the diagnosis of a cardiac mass is highlighted.

Transcatheter aortic valve implantation (TAVI), especially via the transfemoral (TF) route, is increasingly performed in patients considered in the 'gray zone' between TAVI and surgery. However, the best treatment option in this patient population remains to be established.Since 2010, a total of 923 patients underwent either TAVI (n = 538) or sutureless aortic valve replacement (AVR) (n = 385) at the authors' institutions. Among these patients, 79 treated with TF-TAVI were compared with 79 propensity score-matched patients who had undergone elective isolated AVR with the sutureless Perceval bioprosthesis.In-hospital mortality did not differ significantly between patients who underwent sutureless AVR or TF-TAVI (none versus three; 3.8%; p = 0.123). Similarly, postoperative complications were comparable between groups. Atrioventricular block requiring postoperative pacemaker implantation occurred in seven patients (9.2%) of the sutureless group and in eight patients (11.1%) of the TF-TAVI group (p = 0.455). The use of blood products varied between groups in terms of red blood cell transfusions (1.7 ± 2 versus 0.3 ± 0.9 units for the sutureless group versus TF-TAVI group; p0.001). Paravalvular leakage at discharge was present in three patients (3.8%) in the sutureless group and in 26 patients (32.9%) in the TF-TAVI group (p0.001). The mean follow up was longer for sutureless AVR (36 ± 21 versus 27 ± 20 months; p = 0.003). Survival rates were 97.5% and 84.8% in the sutureless and TF-TAVI groups, respectively (p = 0.001).Both, TF-TAVI and sutureless AVR are well-standardized, safe and effective procedures. TF-TAVI seems to be a valuable alternative to surgical AVR for frail patients, reducing the need for perioperative blood transfusion. In contrast, in patients with a favorable long-term survival outcome, minimally invasive AVR remains the procedure of choice as it is associated with better long-term results.

Aims Oesophagogastroduodenoscopy (OGD) after catheter ablation (CA) of atrial fibrillation (AF) revealed a high rate of procedure related oesophageal lesions. We hypothesized that magnetically guided CA with careful radiofrequency energy titration at the posterior left atrial (LA) wall limits the incidence of oesophageal tissue damage. Methods and results As a part of the prospective "Remote MAGNetic catheter Ablation for Atrial Fibrillation" (MAGNA-AF) registry, 251 out of 266 consecutive patients underwent OGD after magnetically guided single-CA for AF. All detected pathologies were analysed. Simultaneous pacing and ablation from the tip of the magnetically guided catheter was found to be a safe and feasible method for energy titration. Post-interventional OGD documented midoesophageal tissue damage in four (1.6%) patients. Although a thermal origin of these injuries must be discussed, none of them was located at the anterior oesophageal wall. Risk factors for midoesophageal lesions were female gender and concomitant acetylsalicylic acid (ASA) treatment. Mechanical lesions in 16 patients were attributed to periprocedural transoesophageal echocardiography (TOE). There was no atrio-oesophageal fistula (AOF). Five hundred and one incidental pathologies were found endoscopically, most frequent axial oesophageal herniation (71%), oesophagitis (22%), and gastritis (57%). Conclusion Magnetically guided CA for AF with careful energy titration at the posterior LA wall and no oesophageal temperature monitoring is not associated with an increased incidence of oesophageal thermal injury. The routine use of periprocedural TOE may cause a low rate of mechanical oesophageal lesions but reliably prevents major complications like transient ischaemic attack, stroke, or cardiac tamponade. An observed high prevalence of upper digestive system inflammation (63%) may further support the recommendation for a routine post-interventional treatment with a proton-pump-inhibitor.

Aims An anti-angiogenic cleaved prolactin fragment is considered causal for peripartum cardiomyopathy (PPCM). Experimental and first clinical observations suggested beneficial effects of the prolactin release inhibitor bromocriptine in PPCM. ................................................................................................................................................................................................... Methods and results In this multicentre trial, 63 PPCM patients with left ventricular ejection fraction (LVEF) < _35% were randomly assigned to short-term (1W: bromocriptine, 2.5mg, 7 days) or long-term bromocriptine treatment (8W: 5 mg for 2weeks followed by 2.5mg for 6weeks) in addition to standard heart failure therapy. Primary end point was LVEF change (delta) from baseline to 6months assessed bymagnetic resonance imaging. Bromocriptinewas well tolerated. Left ventricular ejection fraction increased from 28± 10% to 49± 12% with a delta-LVEF ofþ21± 11% in the 1W-group, and from 27± 10% to 51 ± 10% with a delta-LVEF ofþ24± 11% in the 8W-group (delta-LVEF: P = 0.381). Full-recovery (LVEF > _50%) was present in 52% of the 1W- and in 68% of the 8W-groupwith no differences in secondary end points between both groups (hospitalizations for heart failure: 1W: 9.7% vs. 8W: 6.5%, P = 0.651). The risk within the 8W-group to fail full-recovery after 6months tended to be lower.No patient in the study needed heart transplantation, LV assist device or died. ................................................................................................................................................................................................... Conclusion Bromocriptine treatment was associated with high rate of full LV-recovery and low morbidity and mortality in PPCM patients compared with other PPCM cohorts not treated with bromocriptine. No significant differences were observed between 1W and 8W treatment suggesting that 1-week addition of bromocriptine to standard heart failure treatment is already beneficial with a trend for better full-recovery in the 8W group.

Mineralocorticoid receptor antagonists are increasingly used in patients with treatment-resistant hypertension (TRH). There is experimental evidence for blood pressure (BP) independent effects of mineralocorticoid receptor blockade on cardiovascular target organ damage. We hypothesized that low-dose eplerenone (50 mg) will reduce left ventricular mass (LVM) beyond its BP-lowering effects.We performed a randomized, double-blind, placebo-controlled, parallel group study in 51 patients with TRH. Patients were allocated to receive either eplerenone 50 mg or placebo for 6 months, while other antihypertensive agents could be added in both groups to achieve a BP target of less than 140/90 mmHg. LVM was assessed by MRI before and after treatment.Baseline office BP was similar in the eplerenone and the placebo group (166 ± 21/91 ± 15 versus 159 ± 19/94 ± 8 mmHg, n.s.). BP was similarly reduced in the eplerenone versus the placebo group (-35 ± 20/-15 ± 11 versus -30 ± 19/-13 ± 7 mmHg, n.s.). However, LVM was reduced only in the eplerenone group (from 155 ± 33 to 136 ± 33 g, P 0.001), but not in the placebo group (152 ± 32 versus 148 ± 38 g, P = 0.45).Despite similar BP-lowering, only patients with TRH who were allocated to eplerenone experienced a reduction of LVM. Thus, our data suggest that in patients with TRH, mineralocorticoid receptor antagonists should be used preferentially in order to achieve an effective reduction of LVM along with the improvement of BP control.

Entstehungsort: [Wien]. - Entstehungszeit: 1440-1444; [um 1450]

Objective This study evaluated the frequency, severity and outcome of complications in the clinical course of tako-tsubo cardiomyopathy (TTC). Background TTC is regarded as a benign disease since left ventricular (LV) function returns to normal within a short time. However, severe complications have been reported in selected patients. Methods From 37 hospitals, 209 patients (189 female, age 69±12years) were prospectively included in a TTC registry. Results Complications developed in 108/209 patients (52%); 23 (11%) had >2 complications. Complications occurred median 1day after symptom onset, and 77% were seen within 3days. Arrhythmias were documented in 45/209 patients (22%) including atrial fibrillation in 32 (15%) and ventricular tachycardia in 17 (8%). Of 8 patients resuscitated (4%), 6 survived. Additional complications were right ventricular involvement (24%), pulmonary edema (13%), cardiogenic shock (7%), transient intraventricular pressure gradients (5%), LV thrombi (3%) and stroke (1%). During hospitalization, 5/209 patients (2.5%) died. Patients with complications were older (70±13 vs 67±10years, p=0.012), had a higher heart rate (91±26 vs 83±19/min, p=0.025), more frequently Q\ waves on the admission ECG (36% vs 21%, p=0.019) and a lower LV ejection fraction (47±15 vs 54±14%, p=0.002). Multivariate regression analysis identified Q-waves on admission (OR 2.49, 95% CI 1.23–5.05, p=0.021) and ejection fraction ≤30% (OR 4.03, 95% CI 1.04–15.67, p=0.022) as independent predictors for complications. Conclusions TTC may be associated with severe complications in half of the patients. Since the majority of complications occur up to day 3, monitoring is advisable for this time period.

Objective To assess risk factors for paravalvular leak (PVL) after transcatheter aortic valve implantation in a large single-center cohort, including measurement of aortic valve calcification using a reproducible method. Methods We retrospectively analyzed preoperative contrast-enhanced multidetector computed tomography scans of patients who underwent transcatheter aortic valve implantation in our center between 2009 and 2016. Calcium volume was calculated for each aortic cusp in the aortic valve, left ventricular outflow tract, and device landing zone. Results Overall, 539 patients were included in the study who had experience with 4 prothesis types (SapienXT [Edwards Lifesciences, Irvine, Calif] [n = 192], Sapien3 [Edwards Lifesciences] [n = 206], CoreValve EvolutR [Medtronic, Minneapolis, Minn] [n = 44], and Acurate [Symetis, Ecublens, Switzerland] [n = 97]). Median calcium volume in the device landing zone was 757 mm3, with no significant differences among the 4 prosthesis groups. None of the patients had severe PVL. The overall incidence of mild-to-moderate PVL was 15.8% (95% confidence interval [CI], 12.8%-19.1%). On multivariate logistic regression, device landing zone calcification (P = .00006; odds ratio for an increase of 100 mm3, 1.08; 95% CI, 1.04-1.13) and use of the CoreValve (P = .0028; odds ratio, 4.1; 95% CI, 1.6-10 with SapienXT as reference) prosthesis were found to be associated with mild or greater PVL. In contrast, degree of oversizing (P = .002; odds ratio, 0.97; 95% CI, 0.95-0.99), and use of Sapien3 (P = .00005; odds ratio, 0.23; 95% CI, 0.11-0.47 with SapienXT as reference) were associated with a lower incidence of mild or greater PVL. Conclusions Aortic calcification volume in the device landing zone is associated with residual PVL after transcatheter aortic valve implantation. When taking calcification into account, the balloon-expandable prosthesis Sapien3 seems to be associated with a lower incidence of PVL.

Recently, deep learning based methods appeared as a new paradigm for solving inverse problems. These methods empirically show excellent performance but lack of theoretical justification; in particular, no results on the regularization properties are available. In particular, this is the case for two-step deep learning approaches, where a classical reconstruction method is applied to the data in a first step and a trained deep neural network is applied to improve results in a second step. In this paper, we close the gap between practice and theory for a new network structure in a two-step approach. For that purpose, we propose so called null space networks and introduce the concept of M-regularization. Combined with a standard regularization method as reconstruction layer, the proposed deep null space learning approach is shown to be a M-regularization method; convergence rates are also derived. The proposed null space network structure naturally preserves data consistency which is considered as key property of neural networks for solving inverse problems.

Background— The prognostic significance of papillary muscle infarction (PapMI) on hard clinical outcomes has not been investigated in patients with reperfused ST-segment–elevation myocardial infarction. Noninvasive investigation by gadolinium-enhanced cardiac MRI enables the detection of PapMI with high spatial resolution. The aim of our study was (1) to assess the incidence, determinants, and clinical characteristics of PapMI in a large multicenter cohort of patients with ST-segment–elevation myocardial infarction and (2) to assess the prognostic significance of PapMI at 1-year follow-up. Methods and Results— We enrolled 738 patients with ST-segment–elevation myocardial infarction reperfused by primary angioplasty (P P P P =0.02). Patients with PapMI had a significantly higher mortality (8 [7.7%] versus 12 [1.9%]) and major adverse cardiac events (21 [20.2%] versus 31 [4.9%]) rate at 12-month follow-up ( P P Conclusions— The presence of PapMI is associated with decreased myocardial salvage, larger infarcts, and more pronounced reperfusion injury with subsequent significantly increased major adverse cardiac event rates. Consequently, our data underscore the importance of PapMI as a marker of poor outcome in patients with ST-segment–elevation myocardial infarction. Clinical Trial Registration— URL: http://www.clinicaltrials.gov . Unique identifier: NCT00712101.

Objective This study evaluated if there are gender differences in the manifestation of tako-tsubo cardiomyopathy (TTC). Background TTC predominantly occurs in elderly females and mimics acute myocardial infarction (AMI) where men and women are known to have a different clinical profile. Methods 324 patients from 37 hospitals were prospectively included in a TTC registry. Clinical, electrocardiographic, angiographic and outcome data from male and female patients were compared. Results Of 324 patients 296 (91%) were female and 28 (9%) male. Mean age (68±12 vs 66±12years) and prehospital delay were similar. A triggering event preceded TTC onset in 76% of women and 86% of men. Physical stress was more frequent in men (30% vs 57%, p=0.005) whereas more women experienced emotional or no stress. The prevalence of angina and dyspnea did not differ. Fewer females were admitted in cardiogenic shock and/or after out of hospital cardiac arrest (1% vs 14%, p=0.0006), and cardiac troponin was lower (median 7.2 vs 10.7 times the upper limit of normal, p=0.03). The QTc interval was longer in females than in males only on the day of admission (468±52 vs 441±51ms, p=0.047). Overall, complications during the acute course (53% vs 40%) were comparable in both sexes. Conclusions In this large TTC registry, males and females showed a similar clinical profile. In males, physical stress as a trigger event and shock or cardiac arrest as presenting symptoms were more frequent. The QTc interval was longer in females only on admission but similar in males and females during the following days.

Left ventricular hypertrophy can be a sequel of numerous clinical entities. Decisive for the diagnosis is the delineation of primary myocardial hypertrophy from secondary forms of hypertrophy since this has far-reaching consequences for the prognosis of and therapy for the individual diseases. Hypertrophic cardiomyopathy in particular requires an especially careful diagnosis with regard to the prevention of sudden cardiac death, above all because mainly younger patient collectives are concerned. Besides the case history, ausculation, electrocardiograhy and 2D echo cardiography, further procedures such as tissue Doppler echo cardiography, endomyocardial biopsy as well as contrast-enhanced cardiavascular MRI are indispensable elements in the differential diagnosis of left ventricular hypertrophy.

We examined the value of renal resistive index (RRI) for prevalence of cardiovascular target organ damage in therapy-resistant hypertension in comparison to low-grade albuminuria.Eighty-four patients with therapy-resistant hypertension (age 59.7 +/- 8.1 years) were screened for cardiovascular target organ damage with coronary computed tomography, cardiac magnetic resonance imaging (MRI), Doppler sonography for the assessment of carotid intima media thickness and, RRI, pulse wave velocity and for low-grade albuminuria of at least 10 mg/day in men and 15 mg/day in women, respectively.In patients with RRI greater than 0.7 pulse wave velocity (11.6 +/- 3.7 vs. 9.8 +/- 2.2 m/s; P = 0.02) intima media thickness (0.85 +/- 0.09 vs. 0.76 +/- 0.1 mm; P = 0.007) and Agatston score of coronary calcification (640 +/- 915 vs. 129 +/- 256; P = 0.05) were increased, whereas left ventricular mass (127 +/- 24.5 vs. 125 +/- 15.0 g; P = 0.70) was similar between the two groups. When patients were categorized according to low-grade albuminuria left ventricular mass was significantly higher in those with low-grade albuminuria (123 +/- 25.8 vs. 135 +/- 15.7 g; P = 0.01), whereas vascular parameters (intima media thickness, Agatston score, pulse wave velocity) did not differ between the two groups.In patients with therapy-resistant hypertension RRI reflects functional and structural vascular parameters, whereas low-grade albuminuria is related to cardiac structural changes. Thus, measurement of RRI in addition to low-grade albuminuria complements screening for target organ damage in therapy-resistant hypertension.

Peripartum cardiomyopathy (PPCM) is a major cause of pregnancy-related maternal heart failure that develops towards the end of pregnancy or in the months following delivery. In small retrospective case series, autoimmune responses in the pathogenesis of PPCM have been proposed upon identification of autoantibodies (AABs) to cardiac antigens. However, their clinical and prognostic relevance still remain unclear. In this study, we evaluated the presence of circulating AABs against cardiac sarcomeric myosin (MHC) and troponin I (TnI) in the sera of PPCM patients and in relation to clinical presentation. In this case-control study, 70 patients diagnosed with PPCM and 50 pregnancy-matched healthy women with normal cardiac function were enrolled. Clinical assessment, echocardiography and blood tests were performed at baseline and at 6 ± 2 months follow-up. The presence of serum AABs against MHC (anti-MHC) and TnI (anti-TnI) was determined with a custom-made enzyme-linked immunosorbent assay (ELISA). The seropositivity for these AABs was correlated with the severity of LV dysfunction and the occurrence of pericardial effusion indicative of perimyocardial inflammation at baseline. Potential impact of these AABs on disease progression was evaluated with regard to functional (left ventricular ejection fraction) and clinical improvement at follow-up. Either anti-MHC or anti-TnI or both AABs were detected in the serum of 46 % of PPCM patients and in 8 % of healthy controls. In PPCM the presence of either one of these AABs was associated with significantly lower baseline LVEF and lower rate of full cardiac recovery at follow-up. Patients who were seropositive for anti-TnI AABs showed more frequently pericardial effusion indicative of a more pronounced immune response of the peri-/myocardium in these patients. Further studies are required to clarify cellular and molecular circuits leading to elevated levels of AABs and their pathophysiological relevance for disease initiation and progression in PPCM.

Surgical sutureless and interventional transcatheter aortic valve prostheses are nowadays extensively adopted in high-risk elderly patients. An explorative analysis was carried out to compare the clinical outcome and costs associated to these approaches. Since 2010, a total of 626 patients were distributed between transcatheter aortic valve implantation (TAVI; n = 364) and sutureless (n = 262) groups. Patients of both groups were not comparable for clinical and surgical characteristics, but many patients were in a "gray zone"; therefore, a retrospective propensity score analysis was possible and performed. For the matched pair samples, postoperative, follow-up clinical data, and costs data were obtained. In-hospital death occurred in 5 patients in sutureless group and 3 patients in TAVI group (p = 0.36). Blood transfusions were higher in sutureless group (2.1 ± 2.3 vs 0.4 ± 1.0 U). TAVI group had a shorter intensive care unit and hospital stay (2.2 ± 2.7 vs 3.2 ± 3.5 days, p = 0.037; 12 ± 6 vs 14 ± 6 days, p = 0.017). No differences in postoperative neurologic (p = 0.361), renal (p = 0.106), or respiratory (p = 0.391) complications were observed between groups. At follow-up (24.5 ± 13.8 months), 1 patient in sutureless group and 7 patients in TAVI group died (p = 0.032). Paravalvular leakage occurred more frequently in patients in TAVI group (35 [34%] vs 7 [6.9%]; p

Aims Peripartum cardiomyopathy (PPCM) is a major cause of acute heart failure in the peripartum period and considered potentially life threatening. While many aspects of its clinical profiles have been frequently reported, functional analysis, in particular of the right ventricle, and tissue characterization by cardiovascular magnetic resonance (CMR) imaging have been only sporadically described. The aim of the present study was to analyse pathological alterations and their prognostic relevance found in CMR imaging of patients newly diagnosed with PPCM. Methods and results In this multicenter study 34 patients with confirmed PPCM underwent CMR imaging at the time of diagnosis and at 5 ± 1 months follow-up. Cine imaging of PPCM patients showed moderate to severe reduction of systolic left ventricular (LV) function (mean LVEF: 29.7 ± 12.8%). In 35% of the patients right ventricular (RV) systolic function was also reduced with a mean RVEF of 42.9 ± 13.9%. Dilatation of the LV was observed in 91% (mean LV-EDV/BSA 128.5 ± 32.1 mL/m2), and dilatation of the RV was present in 24% (mean RV-EDV/BSA 87.4 ± 18.5 mL/m2) of the patients. Focal non-ischemic late gadolinium enhancement (LGE) was visible in 71%, and regional wall motion abnormalities were evident in 88% of the patients. LGE and wall motion abnormalities were predominantly located in the anteroseptal and basal to midventricular segments. RV dysfunction at baseline was associated with reduced probability of full cardiac recovery at 5 ± 1 months follow-up. Conclusions Besides LV systolic dysfunction, RV dysfunction and dilatation are observed in about one third of PPCM patients at the time of diagnosis. RV dysfunction is associated with unfavourable outcome. A distinct pattern of LV wall motion abnormalities and myocardial scar is evident in most PPCM patients. The present study may help to establish a set of CMR criteria suitable for diagnosis in patients with suspected PPCM and may add further knowledge to the pathology of the disease.

Nonrandomized studies suggested lower mortality rates with statin pretreatment in patients with acute ST elevation myocardial infarction (STEMI). However, clinical data are still inconclusive and the mechanisms of these presumed beneficial effects require further exploration. Cardiac magnetic resonance (CMR) imaging offers the possibility of studying a variety of markers of myocardial damage and reperfusion injury after myocardial infarction. The aim of this study was to assess a possible link of statin pretreatment with myocardial damage in acute STEMI. The multicenter Abciximab i.v. versus i.c. in ST-elevation Myocardial Infarction CMR substudy enrolled 795 consecutive patients with acute STEMI who underwent primary angioplasty within 12 hours of symptom onset. CMR studies assessing left ventricular ejection fraction, infarct size, microvascular obstruction, area at risk, and myocardial salvage index were performed in a median of 3 days after the clinical event. We performed a retrospective analysis to evaluate the impact of statin pretreatment on myocardial damage. Information on statin pretreatment was available in 791 of 795 patients (99%). Of these, 122 (15%) had long-term statin pretreatment. CMR results showed no significant differences in the area at risk, left ventricular ejection fraction, infarct size, microvascular obstruction, and myocardial salvage index between patients with and without statin pretreatment. Furthermore, no differences in short- and long-term outcomes could be observed. In conclusion, in this CMR study, statin pretreatment in patients with STEMI was not associated with lesser myocardial damage.

Fast die Halfte der Patienten mit den klinische Zeichen einer Herz insuffizienz leidet an einer diastolischen Dysfunktion. Die Differenzierung von der systolischen Form gelingt durch die Bestimmung der linksventrikularen Funktion (EF > 50%). Bei der medikamentosen Therapie sind einige Besonderheiten zu beachten.

A 25-year-old man presented with atypical thoracal chest pain without typical angina, dyspnoe, syncope or symptomatic cardiac arrhythmias. There was no cardiac risk factors or family history of sudden cardiac death. The ECG (Fig. 1) shows sinus rhythmus, a small Q-wave in V 3-5 but no other abnormalities. All labor parameters including cardiac biomarkers were normal. The transthoracic echocardiography (TTE) was highly suspective of an asymmetric hypertrophy of the lateral left ventricular (LV) wall with normal functional left ventricular parameters without regional wall motion abnormalities. To specify the asymmetric hypertrophy of the LV a cardiac magnetic resonance (CMR) study was performed. Cine-CMR showed a normal size and function of the LV (EDD 146 ml, EDS 37 ml, LV-EF 75%, LV-Cardiac Output 8.6 l/min), but a severe asymmetric hypertropy of the anterolateral left ventricular wall (Figs. 2 and 3) with a maximal diameter of 22 mm and a LV mass of 231 g. There was no morphologic or functional evidence of hypertrophic obstructive cardiomyopathy. Additionally, in contrast-enhanced CMR sequences we found local intramural small areas of delayed enhancement in the hypertrophic left ventricular wall (Fig. 4) [1-3].

J Clin Hypertens (Greenwich). 2011;13:582–587. ©2011 Wiley Periodicals, Inc. Cerebral microangiopathy is a cause of cognitive impairment and indicates high risk for clinically overt cerebrovascular disease. It develops in patients with or without hypertension, and different pathologies may play a supporting role. In this pilot study, the authors aimed to elucidate risk factors contributing to the deleterious action of hypertension on cerebral small vessels. A cross‐sectional study in 42 patients with treatment‐resistant hypertension was performed. Microangiopathy was investigated by cerebral magnetic resonance imaging (MRI). Determinants were identified by clinical investigation, computed tomography, intima‐media thickness and pulse wave velocity measurement, and urinary albumin excretion. Nineteen of 42 patients had cerebral microangiopathy (23 controls). Patients were different with respect to heart rate (60.5±10.2 vs 69.7±15.1 beats per minute; P=.029) and systolic blood pressure during nighttime (138±13 mm Hg vs 126±18 mm Hg; P=.019). In addition, there were significant differences in pulse wave velocity (10.7±2.0 m/s vs 9.4±1.4 m/s; P=.034), peripheral pulse pressure (70.8±16.3 mm Hg vs 59.2±13.6 mm Hg; P=.016), central pulse pressure (62.9±15.8 mm Hg vs 50.3±14.2 mm Hg; P=.012), and aortic augmentation pressure (15.9±6.0 vs 11.8±6.6; P=.040). Systolic blood pressure and signs of hypertensive vasculopathy such as peripheral and central pulse pressure and pulse wave velocity were associated with cerebral microangiopathy in patients with long‐standing treatment‐resistant hypertension.

Background : The German tako-tsubo cardiomyopathy (TTC) registry has been initiated to further evaluate this syndrome in a western population. We aimed to assess different patterns of left ventricular involvement in TTC. Methods : Inclusion criteria were: 1) acute chest symptoms, 2) reversible ECG changes (ST-segment elevation±T-wave inversion), 3) reversible left ventricular dysfunction with a wall motion abnormality not corresponding to a single coronary artery territory, 4) no significant coronary artery stenoses. Results : A total of 258 patients (pts) from 33 centers were included with a mean age of 68±12 years. Left ventriculography revealed the typical pattern of apical ballooning in 170 pts (66%) and an atypical mid-ventricular ballooning with normal wall motion of the apical and basal segments in 88 pts (34%). Mean age (68±11 vs 67±13 years) and gender distribution (150 women/20 men vs 80 women/8 men) were similar in both groups. Triggering events were present in 78% of the pts with apical ballooning (35% emotional, 34 physical and 9% combination) and in 75% of the pts with mid-ventricular ballooning (39% emotional, 25% physical and 11% combination). As assessed by left ventriculography, ejection fraction was significantly lower in pts with mid-ventricular ballooning (50±15% vs 45±13%, p=0.006). There was no difference in right ventricular involvement. Creatine kinase and troponin I were comparable in both groups. The ECG on admission showed ST-segment elevation in 87% of pts with apical ballooning and in 78% of pts with mid-ventricular ballooning. T-wave inversion was seen in 70% of the pts irrespective of the TTC variant. A Q-wave was significantly less present in pts with mid-ventricular ballooning (30% vs 16%, p=0.04). The QTc interval during the first 3 days was not different among both groups. Conclusion : A variant form with mid-ventricular ballooning was observed in one third of the pts with TTC. Left ventricular ejection fraction was significantly lower in these pts, although they revealed significantly less Q-waves on the admission ECG. All other parameters were similar and confirm the concept that apical and mid-ventricular ballooning represent two different manifestations of the same syndrome.

Purpose: Tako-tsubo-cardiomyopathy (TTC), initially described in Japan, has increasingly been recognized in western countries over the past years. Most studies, however, comprise relatively few patients. A German tako-tsubo-registry has been initiated to further characterize the clinical profile of this syndrome in a western population. Methods: So far 119 patients (P) were included according to following criteria: acute chest symptoms, ischemic ECG changes with ST-segment elevation ± T-wave inversion, reversible left ventricular akinesia not corresponding to a single coronary artery territory, absence of significant coronary artery stenoses. Results: Among 119 P (age 68±13 years) 104 were female (87%) and 15 male (13%). Triggering events present in 112 P (94%) consisted of emotional (n=82) or physical stress (n=59); 29 P (24%) experienced combined stress. The admission ECG showed ST-segment elevation (78%), reciprocal ST-segment depression (17%), negative T-waves (47%) and QTc prolongation (498±78 msec). Q-waves present in 27% on admission resolved during follow-up. Cardiac markers were slightly elevated (CK 264±573 U/l, troponin I 15±52 ng/ml). Ejection fraction was reduced (EF 54±15%). Left ventriculography showed apical ballooning in 83 (70%) and mid-ventricular ballooning in 36 P (30%). Except for a lower EF (50±15 vs 56±14%, p Conclusion: TTC predominantly occurs in elderly patients after a stressful event. Atypical mid-ventricular ballooning and right ventricular involvement are common. Cardiac MRI typically shows no late enhancement within the wall motion abnormality. The recurrence rate appears to be low.

Ingrid Bar, MD Institut fur diagnostische und interventionelle Radiologie Klinikum Nurnberg-Sud 90471 Nurnberg, Germany Sirs: A 20-year-old man presented with palpitation without typical angina, dyspnoe, syncope and vertigo. There was no medical history and no family member had a history of syncope. ECG showed sinus rhythm, normal heart rate, normal PR interval and QRS duration, no ST-segment elevation or negative T-waves. 24-h ECG showed no pathological findings. All laboratory parameters including cardiac biomarkers were normal. Echocardiography (TTE) revealed a 21×26 mm large intracardiac tumor localized in the left ventricle (LV) attached to the anterior wall. LV diameter and function were normal. For further characterization of tumor pathology, a cardiac magnetic resonance (CMR) study was performed. Cine-CMR showed a normal size and function of the LV (EDD 153 ml, EDS 64 ml, LV-EF 59%, LV-cardiac output 4.9 l/min). CMR confirmed the echocardiographic findings: the tumor size was measured as 19×26 mm. The tumor was clearly attached to the anterior endocardium (segment 7) by a nar

Purpose: Left ventricular noncompaction (LVNC) cardiomyopathy is usually diagnosed by echocardiography (ECHO) but cardiac magnetic resonance imaging (CMRI) has evolved as an alternative method. This study assessed the diagnostic and prognostic value of CMRI in adults with LVNC. Methods: Twenty eight pts (18m, 10f, age 52±16) with ECHO diagnosis of LVNC underwent cine and contrast-enhanced CMRI with a 1.5 T scanner. LV diameter, volume, ejection fraction, degree of mitral regurgitation, ratio of noncompacted to compacted myocardium (NC/C) and the presence and localization of late gadolinium enhancement (LGE) were determined. CMRI findings were correlated to clinical events, ECHO and angiography. Results: Sixteen pts (57%) were in heart failure NYHA III or IV, 11 (39%) had a left bundle branch block (LBBB) and 6 (23%) documented ventricular tachycardia. In 2 pts a thrombus was seen within the trabecular layer which resolved under anticoagulation, and 4 additional pts without detectable thrombus suffered a stroke. By CMRI, LV diameter in end-diastole (65±8 mm), end-systole (52±10 mm), end-diastolic volume (227±74 ml) and end-systolic volume (145±72 ml) were enlarged and ejection fraction (38±15%) was reduced, with similar values determined by ECHO and angio. The NC/C ratio was 3.3±1.5 in end-diastole and 2.6±1.5 in end-systole. No pt had right ventricular involvement. LGE was detected in 6/27 pts (22%). LGE was present in the compacted myocardial layer (n=3), in the noncompacted trabecular layer (n=5) and within the papillary muscles (n=3). LGE was seen in all 3 areas in 1 and in 2 areas in 3 pts. All 3 pts with papillary muscle LGE also had trabecular LGE and high grade mitral regurgitation, and 1 of these pts died while awaiting HTx. Thrombus and stroke occurred mainly in pts with LGE (4/6 vs 2/21 pts, p=0.01). Three of 11 pts with LBBB and 3/6 pts with ventricular tachycardia exhibited LGE. A high NC/C ratio, however, was not associated with heart failure, thrombus and stroke, LBBB, VT or ejection fraction. Conclusions: In LVNC, evaluation by CMRI and demonstration of LGE identifies pts at high risk for clinical events. Extensive LGE may predispose to thrombus formation and stroke, warranting anticoagulation. LGE within the papillary muscles is associated with high grade mitral regurgitation, aggravating heart failure in these patients.