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Objectives This study sought to define the impact of paclitaxel-coated balloon angioplasty for treatment of drug-eluting stent restenosis compared with uncoated balloon angioplasty alone. Background Drug-coated balloon angioplasty is associated with favorable results for treatment of bare-metal stent restenosis. Methods In this prospective, single-blind, multicenter, randomized trial, the authors randomly assigned 110 patients with drug-eluting stent restenoses located in a native coronary artery to paclitaxel-coated balloon angioplasty or uncoated balloon angioplasty. Dual antiplatelet therapy was prescribed for 6 months. Angiographic follow-up was scheduled at 6 months. The primary endpoint was late lumen loss. The secondary clinical endpoint was a composite of cardiac death, myocardial infarction attributed to the target vessel, or target lesion revascularization. Results There was no difference in patient baseline characteristics or procedural results. Angiographic follow-up rate was 91%. Treatment with paclitaxel-coated balloon was superior to balloon angioplasty alone with a late loss of 0.43 ± 0.61 mm versus 1.03 ± 0.77 mm (p Conclusions Paclitaxel-coated balloon angioplasty is superior to balloon angioplasty alone for treatment of drug-eluting stent restenosis. (PEPCAD DES–Treatment of DES-In-Stent Restenosis With SeQuent® Please Paclitaxel Eluting PTCA Catheter [PEPCAD-DES]; NCT00998439 )

Vorhofflimmern (VHF) ist die haufigste Ursache kardial-embolischer Hirninfarkte und wahrscheinlich auch fur einen erheblichen Anteil der bisher als kryptogen bewerteten Hirninfarkte verantwortlich. Methoden zur besseren Detektion und Therapie von paroxysmalem VHF bei Schlaganfall oder transienten ischamischen Attacken (TIA) werden derzeit untersucht. Die orale Antikoagulation (OAK) mit Warfarin und neueren Substanzen ist hochwirksam in der Prophylaxe embolischer Hirninfarkte. Nur ein geringer Anteil der Patienten mit VHF hat ein niedriges Schlaganfallrisiko und kann auf eine OAK verzichten. Zur Beurteilung des individuellen Risikos sollte der CHA2DS2-VASc-Score verwendet werden. Intrakranielle Blutungen sind die gefahrlichste Nebenwirkung der OAK.

Die interventionelle Therapie des Vorhofflimmerns kann je nach Modalitat bei der uberwiegenden Mehrzahl der Falle eine Verbesserung der Symptomatik erreichen. Dabei konkurrieren verschiedene Verfahren. Bei paroxysmalem VHF genugt oft die Pulmonalvenenisolation, bei permanentem VHF kommen meist komplexere Ablationsverfahren zur Anwendung und die Therapieerfolge sind bis dato weniger eindrucklich. Grenzen der Ablationstherapie sind schwer vernarbte Vorhofe, da sich das Mapping aufgrund der fehlenden Signale erschwert und das Substrat fur das Vorhofflimmern nicht mehr nur die Pulmonalvenen umfasst. Das ”Ablate and pace“-Verfahren stellt nach wie vor eine valide risikoarme Therapieoption zur Palliation des Tachy-Bradysyndroms und der schnellen Ventrikelantwort dar. Die Verbesserung der Uberlebensrate, Verbesserung von Herzinsuffizienzfolgen, Langzeiterfolg der Pulmonalvenenisolation und vergleichbarer Methoden werden in andauernden Studien evaluiert.

Die Darstellung der Koronararterien mittels Angiographie bleibt auch zu Beginn des 21. Jahrhunderts der Goldstandard zur Definition des Koronarstatus. Vielfaltige Limitationen dieser 2-dimensionalen Darstellung fuhrten zu einer Reihe von Weiterentwicklungen wie der quantitativen Koronarangiographie und einer 3-dimensionalen Rekonstruktion. Der intravaskulare Ultraschall ermoglichte erstmals eine transmurale In-vivo-Darstellung der Koronargefase durch die Anfertigung von Querschnittsbildern aller Schichten der Koronararterie. Dadurch wurde es moglich, arteriovaskulare Plaques sowie die umgebenden Strukturen suffizient zu beurteilen. Die intravaskulare optische Koharenztomographie ist eine neue, auf Infrarotlicht basierende Technik, welche Gefase sowohl intra- als auch extraluminal mit einer Auflosung von 10–20 µm darstellen kann. Doch selbst diese modernen diagnostischen Verfahren sind in der Beurteilung der Funktionalitat einer Stenose limitiert. Die Bestimmung der fraktionellen Flussreserve erlaubt mit hoher Sensitivitat und Spezifitat einen genauen Nachweis des pathophysiologischen Zustands eines epikardialen Gefases, indem sie den Druck vor und hinter einer epikardialen Stenose in Beziehung setzt. Die sog. „C-arm computed tomography“ (CACT; „DynaCT“ Cardiac; Siemens, Erlangen) ist eine neue Applikationsmoglichkeit einer intraprozeduralen, auf einer Rotation der Rontgenquelle und des Detektors basierenden Technik, die diagnostische Informationen ahnlich eines CT- oder MRT-Bildes erzeugen kann. Sie birgt das Potenzial, die diagnostischen Moglichkeiten im Rahmen einer angiographischen Untersuchung erheblich zu bereichern.

Percutaneous coronary intervention with stent implantation is limited by the occurrence of re-stenosis and the risk of stent thromboses.To define the impact of paclitaxel-coated balloon angioplasty plus endothelial progenitor cell capturing (EPC) stent implantation in de novo coronary artery disease. This combination may reduce neointimal proliferation within the EPC stent and address the risk of stent thrombosis by facilitating rapid endothelialisation.In this prospective single-blind multicentre randomised trial, 120 patients with a de novo lesion in a native coronary artery were randomly assigned to undergo treatment with paclitaxel-coated balloon plus EPC stent or EPC stent alone. Dual antiplatelet therapy was prescribed for 3 months. Angiographic follow-up was scheduled at 6 months. The primary endpoint was in-stent late lumen loss. The secondary clinical endpoint was a composite of death from a cardiac cause, myocardial infarction attributed to the target vessel or target lesion revascularisation.There was no difference in patient baseline characteristics or procedural results. The angiographic follow-up rate was 96%. Treatment with paclitaxel-coated balloon plus EPC stent was superior to EPC stent alone, with an in-stent late loss of 0.34±0.45 mm versus 0.88±0.48 mm (p0.001). The re-stenosis rate was reduced from 23.2% to 5.1% (p=0.006) and the clinical endpoint was reduced from 17.2% to 4.8% (p=0.039). There was no definite or probable stent thrombosis.Paclitaxel-coated balloon plus EPC stent implantation is superior to EPC stent implantation alone for treatment of de novo coronary artery disease.NCT00732953.

Aims Image integration of three-dimensional (3D) reconstructions of left atrial (LA) and pulmonary vein (PV) anatomy into electroanatomical mapping (EAM) plays a major role in atrial fibrillation (AF) ablation. Point-by-point EAM is commonly used for registration of imported LA and PV anatomy. We aimed to assess the accuracy of intraprocedural rotational angiography-based LA imaging registered by spatial reconstruction of intracardiac echocardiography (ICE) in patients undergoing AF ablation. Methods and results Twenty-two patients (11 males, 66 ± 12 years) were studied. Reconstructions of LA and PVs based on rotational angiography were registered by a second 3D reconstruction based on ICE. In a second step, EAM points were added to ICE 3D reconstructions. A 3D image of the LA and PVs was reconstructed in all patients by both imaging modalities. Rotational angiography and ICE-based LA 3D reconstructions took 11.5 ± 5.2 and 20.4 ± 11.2 min, respectively. A total of 17 ± 6 two-dimensional ICE fans were used for spatial reconstruction of ICE. The deviation between the two 3D shells was 2.6 ± 0.5 mm. Integration of 78 ± 58 EAM points into ICE 3D reconstruction did not significantly reduce the deviation to rotational angiography-based reconstructions (2.7 ± 0.6 mm). All PVs were isolated successfully. Conclusions Intraprocedural 3D reconstruction of LA and PVs for ablation of AF is feasible based on both rotational angiography and ICE. LA reconstructions based on rotational angiography can accurately be registered using 3D ICE shells. Additional EAM does not enhance accuracy. Therefore, registration of rotational angiography-based 3D reconstructions by 3D reconstructions from ICE seems to be an alternative technique to support AF ablation.

DynaCT Cardiac Integration into Electroanatomical Mapping. Introduction: Exact visualization of complex left atrial (LA) anatomy is crucial for safety and success rates when performing catheter ablation of atrial fibrillation (AF). The aim of our study was to validate the accuracy of integrating rotational angiography-based 3-dimensional (3D) reconstructions of LA and pulmonary vein (PV) anatomy into an electroanatomical mapping (EAM) system. Methods and Results: In 38 patients (62 ± 8 years, 25 females) undergoing catheter ablation of paroxysmal (n = 19) or persistent (n = 19) AF, intraprocedural rotational angiography of LA and PVs was performed. The subsequent 3D reconstruction and segmentation of LA and PVs was transferred to the EAM system and registered to the EAM. The distances of all EAM points to corresponding points on the LA syngo® DynaCT Cardiac surface were calculated. Segmentation of LA with clear visualization of adjacent structures was possible in all patients. Also, the integrated segmentation of the LA was used to guide the encirclement of ipsilateral veins, which resulted in PV isolation in all patients. Integration into the 3D mapping system was achieved with a distance error of 2.2 ± 0.4 mm when compared with the EAM surface. Subgroups with paroxysmal and persistent AF showed distance errors of 2.3 ± 0.3 mm and 2.1 ± 0.4 mm, respectively (P = n.s.). Conclusion: Intraprocedural registration of LA and PV anatomy by contrast enhanced rotational angiography was feasible and accurate. There were no differences between patients with paroxysmal or persistent AF. Therefore, integration of rotational angiography-based reconstructions into 3D EAM systems might be helpful to guide catheter ablation for AF. (J Cardiovasc Electrophysiol, Vol. 21, pp. 278–283, March 2010)

Background: Purkinje-like potentials (PLPs) have been described as important contributors to initiation of ventricular fibrillation (VF) in patients with normal hearts, ischemic cardiomyopathy, and early after-myocardial infarction. Methods: Of the 11 consecutive patients with VF storm, nonischemic cardiomyopathy (68 ± 22 years, left ventricular ejection fraction 28 ± 8%) who were given antiarrhythmic drugs and/or heart failure management, five had recurrent VF and underwent electrophysiology study (EPS) and catheter ablation. Results: At EPS, frequent monomorphic premature ventricular contractions (PVC) and/or ventricular tachycardia did not occur. With isoproterenol, VF was induced in three patients, and sustained monomorphic PVCs were induced in one patient. Three-dimensional electroanatomical mapping using CARTO (Biosense-Webster Inc., Diamond Bar, CA) revealed posterior wall scar in four of the five patients. PLP in sinus rhythm were recorded around the scar border in these four patients, and radiofrequency ablation targeting PLP was successfully performed at these sites. The patient without PLP did not undergo ablation. During follow-up (12 ± 5 months), only the patient without PLP had four VF recurrences requiring implantable cardioverter-defibrillator (ICD) shocks. Conclusion: In patients with VF and dilated cardiomyopathy, left ventricular posterior wall scar in the vicinity of the mitral annulus seems to be a common finding. Targeting PLP along the scar border zone for ablation seems to efficiently prevent VF recurrence in these patients.

Coronary artery disease is often accompanied with deterioration in left ventricular function. Left ventricular pacing has been shown to improve cardiac function in chronic heart failure. However, data are limited about left ventricular pacing during acute ischemia. Therefore, we studied the effects of acute myocardial ischemia on myocardial function during left ventricular pacing.In 8 anesthetized dogs, the left ventricle was rapidly paced (180 bpm) from a basolateral and apicoseptal site during normal perfusion and mild and severe ischemia of the left anterior descending coronary artery. Effects on myocardial function were measured at each level of ischemia before and during pacing.Significant differences (p0.05) between basolateral and apicoseptal pacing were found for segmental shortening (12.1+/-1.6 vs. 10.8+/-1.6%), and QRS duration (77.3+/-4.1 vs. 85.7+/-3.8 ms) at normal coronary perfusion. During mild ischemia, significant differences (p0.05) were seen for myocardial contractility dP/dt(max) (1277+/-197 vs. 1158+/-156 mm Hg/s), segmental shortening (10.3+/-1.9 vs. 8.1+/-1.7%), left ventricular end-systolic pressure (76.9+/-7.5 vs. 69.6+/-7.9 mm Hg), and QRS duration, and for myocardial contractility dP/dt(max) (1033+/-209 vs. 917+/-207 mm Hg/s) and left ventricular end-systolic pressure (69.2+/-13.5 vs. 62.2+/-15.0 mm Hg) during severe ischemia. There were no significant differences in coronary blood flow during pacing from both sites.During acute myocardial ischemia, depression of left ventricular function was lowest, when pacing from a left ventricular basolateral site. The effects of rapid left ventricular pacing were amplified by reduced coronary perfusion pressures. The choice of pacing site did not relevantly influence coronary blood flow.

Aims Modern implantable cardioverter-defibrillators (ICDs) place increasing demands on the physician, as their complexity requires more and more knowledge and effort in handling them. To overcome this problem an implant-assistant has been developed, which transfers clinical data entered by the physician into a complete set of parameters for programming a dual-chamber ICD (Tachos-DR, Biotronik, Berlin, Germany) at DFT testing (DFT-Prog) and first permanent programming (Perm-Prog) after implant. Methods and results Routine ICD implantations were initially evaluated by clinical experts at 19 centres in USA and Europe from 178 patient files. The rating of parameters was related to the number of parameters available in each patient. For DFT-Prog, 98.4% of parameter suggestions were identical to experts’ expectations, an additional 1.0% were accepted, 0.5% were rejected, and none was considered harmful. This resulted in an overall acceptance of 94.4% of the DFT-Prog. For Perm-Prog, 96.1% of parameters were identical to those advised by experts, an additional 2.4% were accepted, 1.5% rejected, and seven parameters (0.04%) were considered potentially harmful by experts with an overall acceptance of 86.5%. Adaptation of the implant-assistant increased the overall acceptance to 100% for DFT-Prog and 90.6% for first Perm-Prog without any potentially harmful suggestions. Conclusion The ICD implant-assistant, which allows the physician to programme ICDs directly from clinical data, is a promising method to simplify the programming of modern ICDs.

The degree of valvular calcification in patients with aortic stenosis was determined with retrospectively ECG-gated 16-MDCT and correlated with the severity of stenosis assessed at cardiac catheterization.We conducted a prospective study of 72 patients (38 men and 34 women; mean age +/- SD, 69.5 +/- 8.8 years) with aortic stenosis who underwent 16-MDCT and cardiac catheterization. Aortic valve calcification was assessed using the aortic Agatston score, aortic mass score, and aortic volume score. Severity of aortic stenosis was classified at cardiac catheterization. Aortic valve area and peak-to-peak and mean transvalvular gradients were correlated with the degree of calcification determined on MDCT.All measured aortic valve calcification scores were significantly higher in patients with severe aortic stenosis (n = 46) than in patients with moderate (n = 15) or mild (n = 11, p0.001) aortic stenosis. Aortic valve calcification scores were inversely related to aortic valve area (r = -0.67, p0.001 for aortic mass score) and correlated significantly with peak-to-peak (r = 0.70, p0.001) and mean transvalvular (r = 0.72, p0.001) gradients. No correlation between the aortic valve calcification and the total coronary calcium scores was observed.Aortic valve calcification assessed on 16-MDCT is associated with severity of aortic stenosis. Thus, aortic valve calcification scores should be calculated routinely in all patients undergoing MDCT for assessment of coronary calcification. High aortic valve calcification scores indicate possibly severe aortic stenosis and should prompt a further functional evaluation.

We tested a simple noninvasive method for cardiac resynchronization therapy (CRT) optimization using standard finger photoplethysmography (FPPG).CRT can increase left ventricular cardiac output in patients with heart failure and ventricular conduction delay. Optimal therapy delivery depends on an appropriate AV delay. Multiple invasive and noninvasive methods have been attempted to identify patients and the best AV delay for CRT, but all suffer from a combination of high patient risk, cost, complexity, and low reproducibility.FPPG and invasive aortic pressure data were simultaneously collected from 57 heart failure patients during intrinsic rhythm alternating with very brief periods of pacing at 4 to 5 AV delays. After correcting data for artifacts, the median percentage responses for each AV delay were classified as positive, negative, or neutral compared to baseline (Wilcoxon rank test).FPPG correctly identified positive aortic pulse pressure responses with 71% sensitivity (95% CI: 60-80%) and 90% specificity (95% CI: 84-94%) and negative aortic pulse pressure responses with 57% sensitivity (95% CI: 44-69%) and 96% specificity (95% CI: 91-98%). The magnitude of FPPG changes were strongly correlated with positive aortic pulse pressure changes (R(2) = 0.73, P.0001) but less well correlated with negative aortic pulse pressure changes (R(2) = 0.43, P.0001). FPPG selected 78% of the patients having positive aortic pulse pressure changes to CRT and identified the AV delay giving maximum aortic pulse pressure change in all selected patients.FPPG can provide a simple noninvasive method for identifying significant changes in aortic pulse pressure with high specificity, including identifying patients in whom aortic pulse pressure increases with CRT and the AV delay giving the maximum aortic pulse pressure.

Regional and global myocardial blood flow and coronary vascular resistance were determined in patients with idiopathic-dilated cardiomyopathy and left bundle branch block before and during cardiac resynchronization therapy (CRT) using oxygen-15 water positron emission tomography. The investigated parameters did not exhibit regional heterogeneity and were not influenced by CRT. This implies that the beneficial effects of CRT do not require additional oxygen demand or regional reallocation of oxidative metabolism.

Die kardiale Resynchronisationstherapie (CRT) mittels biventrikularer Stimulation ist eine neue, zusatzliche Therapieoption fur Patienten mit schwerer Herzinsuffizienz NYHA III–IV und asynchronem Kontraktionsablauf. Als wichtigstes Selektionskriterium fur die CRT gilt das Vorhandensein eines Linksschenkelblocks. Mittels transthorakaler Echokardiographie konnen wertvolle zusatzliche Hinweise uber den kardialen Kontraktionsablauf und die hamodynamischen Auswirkungen gewonnen werden, welche eine verbesserte Identifizierung geeigneter Patienten fur die CRT und eine optimierte Nachsorge versprechen. Die vorliegende Ubersicht diskutiert die moglichen Verfahren und Limitationen und gibt eine praktische Hilfestellung fur die individuelle Patientenbetreuung.

ObjectivesWe studied the effects of cardiac resynchronization therapy (CRT) on regional myocardial strain distribution, as determined by echocardiographic strain rate (SR) imaging.BackgroundDilated hearts with left bundle branch block (LBBB) have an abnormal redistribution of myocardial fiber strain. The effects of CRT on such abnormal strain patterns are unknown.MethodsWe studied 18 patients (12 males and 6 females; mean age 65 ± 11 years [range 33 to 76 years]) with symptomatic systolic heart failure and LBBB. Doppler myocardial imaging studies were performed to acquire regional longitudinal systolic velocity (cm/s), systolic SR (s−1), and systolic strain (%) data from the basal and mid-segments of the septum and lateral wall before and after CRT. By convention, negative SR and strain values indicate longitudinal shortening.ResultsBefore CRT, mid-septal peak SR and peak strain were lower than in the mid-lateral wall (peak SR: −0.79 ± 0.5 [septum] vs. −1.35 ± 0.8 [lateral wall], p < 0.05; peak strain: −7 ± 5 [septum] vs. −11 ± 5 [lateral wall], p < 0.05). This relationship was reversed during CRT (peak SR: −1.35 ± 0.8 [septum] vs. −0.93 ± 0.6 [lateral wall], p < 0.05; peak strain: −11 ± 6 [septum] vs. −7 ± 6 [lateral wall], p < 0.05). Cardiac resynchronization therapy reversed the septal–lateral difference in mid-segmental peak strain from −46 ± 94 ms (LBBB) to 17 ± 92 ms (CRT; p < 0.05).ConclusionsLeft bundle branch block can lead to a significant redistribution of abnormal myocardial fiber strains. These abnormal changes in the extent and timing of septal–lateral strain relationships can be reversed by CRT. The noninvasive identification of specific abnormal but reversible strain patterns should help to improve patient selection for CRT.

Background: Multislice spiral computed tomography (MSCT) has evolved as a new promising method for non-invasive visualization of the coronary arteries and detection of native coronary artery stenosis. We determined the value of MSCT to non-invasively detect significant in-stent restenosis after coronary artery stenting. Methods: Twenty patients (age 56.3±8.6 years) were investigated by MSCT (4×1 mm cross-sections, 500 ms tube rotation, table feed 1.5 mm/rotation, intravenous contrast agent, retrospectively ECG-gated image reconstruction) at a mean interval of 9.6±4.2 months after coronary stent implantation. Results were compared with conventional quantitative coronary angiography (QCA). A total number of 32 stents were studied, four different stent types were evaluated. Results: QCA showed in-stent restenosis >50% diameter stenosis in five (16%) stents. Using MSCT it was impossible in all stents, irrespective of stent type or diameter, to directly visualize the stent lumen due to partial volume effects and beam hardening. MSCT allowed the visualization of the coronary vessel proximal and distal to the stent. This allowed confirmation of stent patency in 18/18 cases and correct identification of total stent occlusion in two patients. Conclusions: MSCT allows no direct visualization of coronary in-stent restenosis, but it correctly differentiates between stent patency and stent occlusion. The reasons are mainly partial volume effects and beam hardening, which are induced by the stent material.

ObjectivesWe studied the acute effects of cardiac resynchronization therapy (CRT) on functional mitral regurgitation in heart failure (HF) patients with left bundle branch block (LBBB).BackgroundBoth a decrease in left ventricular (LV) closing force and mitral valve tethering have been implicated as mechanisms for functional mitral regurgitation (FMR) in dilated hearts. We hypothesized that an increase in LV closing force achieved by CRT could act to reduce FMR.MethodsTwenty-four HF patients with LBBB and FMR were studied after implantation of a biventricular CRT system. Acute changes in FMR severity between intrinsic conduction (OFF) and CRT were quantified according to the proximal isovelocity surface area method by measuring the effective regurgitant orifice area (EROA). Results were compared with the changes in estimated maximal rate of left ventricular systolic pressure rise (LV+dP/dtmax) and transmitral pressure gradients (TMP), both measured by Doppler echocardiography.ResultsCardiac resynchronization therapy was associated with a significant reduction in FMR severity. Effective regurgitant orifice area decreased from 25 ± 19 mm2(OFF) to 13 ± 8 mm2(CRT). The change in EROA was directly related to the increase in LV+dP/dtmax(r = −0.83, p < 0.0001). Compared with OFF, TMP increased more rapidly during CRT, and a higher maximal TMP was observed (OFF 73 ± 24 mm Hg vs. CRT 85 ± 26 mm Hg, p < 0.01).ConclusionsFunctional mitral regurgitation is reduced by CRT in patients with HF and LBBB. This effect is directly related to the increased closing force (LV+dP/dtmax). The results support the hypothesis that an increase in TMP, mediated by a rise in LV+dP/dtmaxdue to more coordinated LV contraction, may facilitate effective mitral valve closure.

We sought to determine whether radial left ventricular (LV) asynchrony in patients with heart failure predicts systolic function improvement with cardiac resynchronization therapy (CRT).We quantified LV wall motion by echocardiography to correlate the effects of CRT on LV systolic function with wall motion synchrony.Thirty-four patients underwent echocardiographic phase analysis of LV septal and lateral wall motion and hemodynamic testing before CRT. Phase relationships were measured by the difference between the lateral (Phi(L)) and septal (Phi(S)) wall motion phase angles: Phi(LS) = Phi(L) - Phi(S). The absolute value of Phi(LS) was used as an order-independent measure of synchrony: the absolute value Phi(LS) = the absolute value of Phi(L) - Phi(S).Three phase relationships were identified (mean +/- SD): type 1 (n = 4; peak positive LV pressure [dP/dt(max)] 692 +/- 310 mm Hg/s; Phi(LS) = 5 +/- 6 degrees, synchronous wall motion); type 2 (n = 17; dP/dt(max) 532 +/- 148 mm Hg/s; Phi(LS) = 77 +/- 33 degrees, delayed lateral wall motion); and type 3 (n = 13; dP/dt(max) 558 +/- 154 mm Hg/s; Phi(LS) = -115 +/- 33 degrees, delayed septal wall motion, triphasic). A large absolute value of Phi(LS) predicted a larger increase in dP/dt(max) with CRT (r = 0.74, p0.001). Sixteen patients were studied during right ventricular (RV), LV and biventricular (BV) pacing. Cardiac resynchronization therapy acutely reduced the absolute value of Phi(LS) from 104 +/- 41 degrees (OFF) to 86 +/- 45 degrees (RV; p = 0.14 vs. OFF), 71 +/- 50 degrees (LV; p = 0.001 vs. OFF) and 66 +/- 42 degrees (BV; p = 0.001 vs. OFF). A reduction in the absolute value of Phi(LS) predicted an improvement in dP/dt(max) in type 2 patients for LV (r = 0.87, p = 0.005) and BV CRT (r = 0.73, p = 0.04).Echocardiographic quantification of LV asynchrony identifies patients likely to have improved systolic function with CRT. Improved synchrony is directly related to improved hemodynamic systolic function in type 2 patients.

Introduction: Respiratory sinus arrhythmia (RSA) and heart rate variability (HRV) are parameters of autonomic cardiac innervation. They decrease with age and after atrioventricular nodal modification (AVNM) suggesting vagal denervation in both situations. We hypothesized, however, that AVNM causes only a transient, functional decline in vagal activity, whereas aging causes permanent vagal denervation. A new method of analyzing RSA phase dynamics based on circle maps (CM) can potentially differentiate between both forms of reduced vagal activity.

Background Cardiac parasympathetic nerves run alongside the superior vena cava (SVC) and accumulate particularly epicardially adjacent to the orifice of the coronary sinus (CS). In animals, these nerves can be electrically stimulated inside the SVC or CS, which results in negative chronotropic/dromotropic effects and negative inotropic effects in the atria but not the ventricles. Parasympathetic nerve stimulation (PS) with 20 Hz in the CS, however, also excites the atria, thereby inducing atrial fibrillation. The present study overcomes this limitation by applying high-frequency nerve stimuli within the atrial refractory period. Using this technique, we investigated for the first time whether neurophysiological effects similar to those in animals can be obtained in humans. Methods and Results In 25 patients, parasympathetic nerves were stimulated via a multipolar electrode catheter placed in the SVC (stimulation with 20 Hz; n=14) or CS (pulsed 200-Hz stimuli; n=11). A significant sinus rate decrease and prolongation of the antegrade Wenckebach period was achieved during PS in the SVC. During PS in the CS, a graded-response prolongation of the antegrade Wenckebach interval was observed with increasing PS voltage until third-degree AV block occurred in 8 of 11 patients. The negative chronotropic/dromotropic effects started and terminated immediately after the onset and termination of PS, respectively. Atropine abolished these effects (n=11). Conclusions Human parasympathetic efferent nerve stimulation induces reversible negative chronotropic and dromotropic effects. PS may serve as an adjunctive tool for the diagnosis/treatment of supraventricular tachycardias and may be beneficial for ventricular rate slowing during tachycardic atrial fibrillation in patients with congestive heart failure.

Cardiac resynchronization therapy (CRT) using left- (LV) or biventricular pacing is widely applied in selected heart failure patients. However, transvenous LV-lead placement into coronary sinus (CS) branches can be challenging. A 77-year-old female patient with New York Heart Association class III symptoms due to dilated cardiomyopathy [LV ejection fraction (LVEF): 10%, QRS-duration: 150 ms], despite optimal medical treatment presented for CRT. Coronary sinus angiograms were performed after transvenous CS cannulation. Within a large posterolateral vein, low phrenic nerve stimulation thresholds were found. The only alternative smaller tortuous lateral branch showed a significant narrowing, making LV-lead advancement impossible. Angioplasty was performed, using a venoplasty balloon. This caused complete branch occlusion. After recanalization of the vessel by implantation of a bare metal stent, the lead could be advanced through the stent. Optimal pacing parameters without phrenic nerve stimulation were established. Angioplasty of CS branches during CRT implantation procedures bears the risk of complete branch occlusion, but recanalization can acutely be achieved by stent implantation. This is the first report on rescue-stenting of a CS branch after angioplasty-related occlusion. Transthoracic lead implantation, accompanied risks, and slower recovery could thus be avoided.

This study sought to define the impact of paclitaxel-coated balloon angioplasty for treatment of drug-eluting stent restenosis compared with uncoated balloon angioplasty alone.Drug-coated balloon angioplasty is associated with favorable results for treatment of bare-metal stent restenosis.In this prospective, single-blind, multicenter, randomized trial, the authors randomly assigned 110 patients with drug-eluting stent restenoses located in a native coronary artery to paclitaxel-coated balloon angioplasty or uncoated balloon angioplasty. Dual antiplatelet therapy was prescribed for 6 months. Angiographic follow-up was scheduled at 6 months. The primary endpoint was late lumen loss. The secondary clinical endpoint was a composite of cardiac death, myocardial infarction attributed to the target vessel, or target lesion revascularization.There was no difference in patient baseline characteristics or procedural results. Angiographic follow-up rate was 91%. Treatment with paclitaxel-coated balloon was superior to balloon angioplasty alone with a late loss of 0.43 ± 0.61 mm versus 1.03 ± 0.77 mm (p0.001), respectively. Restenosis rate was significantly reduced from 58.1% to 17.2% (p0.001), and the composite clinical endpoint was significantly reduced from 50.0% to 16.7% (p0.001), respectively.Paclitaxel-coated balloon angioplasty is superior to balloon angioplasty alone for treatment of drug-eluting stent restenosis. (PEPCAD DES-Treatment of DES-In-Stent Restenosis With SeQuent® Please Paclitaxel Eluting PTCA Catheter [PEPCAD-DES]; NCT00998439).

Aims In pacemaker patients with preserved atrio-ventricular (AV) conduction, atrial fibrillation (AF) can lead to symptomatic ventricular rate irregularity and loss of ventricular stimulation. We tested if dynamic ventricular overdrive (DVO) as a potentially pacemaker-integrated algorithm could improve both aspects. Methods and results Different settings of DVO and ventricular–ventricular-inhibited-pacing (VVI) with different base rates were tested in two consecutive phases during electrophysiological studies for standard indications. Mean heart rate (HR), HR irregularity and percentage of ventricular pacing were evaluated. A fusion index (FI) indicative of the proportion of fusion beats was calculated for each stimulation protocol. Dynamic ventricular overdrive from the right ventricular apex was acutely applied in 38 patients (11 females, mean age 62.1 ± 11.5 years) with sustained AF and preserved AV conduction. Dynamic ventricular overdrive at LOW/MEDIUM setting increased the amount of ventricular pacing compared with VVI pacing at 60, 70, and 80 beats per minute (bpm; to 81/85% from 11, 25, and 47%, respectively; P < 0.05). It also resulted in a maximum decrease in interval differences (to 48 ± 18 ms from 149 ± 28, 117 ± 38, and 95 ± 46 ms, respectively; P < 0.05) and fusion (to 0.13 from 0.41, 0.42, and 0.36, respectively; P < 0.05) compared with VVI pacing at 60, 70, and 80 bpm. However, the application of DVO resulted in a significant increase in HR compared with intrinsic rhythm and VVI pacing at 80 bpm (to 97 bpm from 89 and 94 bpm, respectively; P < 0.05). Conclusion Dynamic ventricular overdrive decreases HR irregularity and increases ventricular pacing rate compared with VVI pacing at fixed elevated base rates and spontaneous rhythm. Fusion index might help to refine information on pacing percentages provided by device counters.

Aims Rotational angiography (RA) of the coronary sinus (CS) provides more anatomical insights compared with static angiographies. We evaluated intraprocedural three-dimensional (3D) CS reconstruction (RC) based on RA, using syngo® DynaCT Cardiac to guide CS lead implantation. Methods and results In 24 patients with indication for cardiac resynchronization therapy, intraprocedural RA and 3D RC of the CS was performed. Lead placement was guided by 3D image integration into real-time fluoroscopy. Rotational angiography and 3D RCs were evaluated regarding visibility of the CS and tributaries, CS-to-target vein angles, and vessel diameters. The target vein for CS lead implantation, identified by RA, was successfully displayed by 3D RC in 20 (91%) of 22 patients with adequate RA. All lead implantations were guided successfully by 3D image integration into real-time fluoroscopy. Cranial or caudal angulations were used in 95% of the procedures without further angiographies. Rotational angiography displayed a mean of 2.9 ± 1.0 second-order side branches compared with 1.8 ± 1.1 in 3D RCs ( P < 0.05). The CS-to-target vein angle estimated from static projections (right anterior oblique 20°, left anterior oblique 40°, and even optimal RA view) differed substantially from 3D RCs. Main vessel diameters did not differ significantly between both techniques. Conclusion Intraprocedural 3D RC of the CS and 3D image integration-guided lead placement is feasible. Coronary sinus-to-target vein angles seemed to be misestimated even by RA views compared with 3D RC. Thus RA and 3D CS RC should be applied routinely for CS lead implantation.

Our goal was to evaluate acute effects of left atrial lesion formation and volume overload on hemodynamics during pulmonary vein antrum isolation (PVAI) as it might be a potential cause of acute pulmonary edema. In consecutive patients presenting for PVAI, open irrigation ablation was performed (50 W, 48°C, 15 s lesion duration, saline flow rate 30 mL/min). Blood samples were drawn from the left atrium and the pulmonary artery immediately before and 30 min after PVAI. The cardiac output (CO) and stroke volume (SV) were calculated by the method of Fick. We included 61 (27 female, 61 ± 11 years) patients suffering from paroxysmal (px; 33) or persistent (per; 28) atrial fibrillation (AF) in this study. A total of 2,917 ± 242 mL of volume was infused (2,651 ± 223 mL pxAF vs. 3,184 ± 255 mL perAF, (p

Background Patients with atrial fibrillation (AF) are at increased risk for ischemic stroke. In patients who have suffered a stroke, screening for AF is routinely performed only for a short period after the stroke as part of the evaluation for possible causes. If AF is detected after an ischemic stroke, oral anticoagulation therapy is recommended for secondary stroke prevention. In 25% to 30% of stroke patients, the stroke mechanism cannot be determined (cryptogenic stroke). The incidence of paroxysmal AF undetected by short-term monitoring in patients with cryptogenic stroke is unknown, but has important therapeutic implications on patient care. The optimum monitoring duration and method of AF detection after stroke are unknown. The purpose of this study is to evaluate the incidence of AF and time to AF detection in patients with cryptogenic stroke using an insertable cardiac monitor. Study Design The CRYSTAL AF trial is a randomized prospective study to evaluate a novel approach to long-term monitoring for AF detection in patients with cryptogenic stroke. Four hundred fifty cryptogenic stroke patients (by definition, without a history of AF) will be enrolled at approximately 50 sites in Europe, Canada, and the United States. Patients will be randomized in a 1:1 fashion to standard arrhythmia monitoring (control arm) or implantation of the subcutaneous cardiac monitor (Reveal XT; Medtronic, Inc, Minneapolis, MN) (continuous monitoring arm). Outcomes The primary end point is time to detection of AF within 6 months after stroke. The clinical follow-up period will be at least 12 months. Study completion is expected at the end of 2012.

Visualization of the left atrium (LA) and pulmonary veins (PVs) is crucial in PV isolation (PVI). Additional delineation of the esophagus might avoid severe side effects. Cardiac C-arm computed tomography (DynaCT Cardiac, Siemens AG, Forchheim, Germany) has been introduced as a novel intraprocedural imaging modality based on a rotational angiography.The purpose of this study was to prove the quantitative accuracy of DynaCT Cardiac as compared with multislice CT (MSCT) in imaging of the LA and PV in patients undergoing PVI.Thirty-four consecutive patients (22 male, age 64 +/- 12 years) with symptomatic atrial fibrillation (AF) and indication for PVI were studied. Diameters of the PV, the LA appendage (LAA), and the descending aorta were measured, and the position of the esophagus was defined using preprocedural MSCT and intraprocedural DynaCT Cardiac.There was a significant correlation between both measurements for diameters of the LAA (r = 0.86, P.05), PV (r = 0.98, P.05), and the descending aorta (r = 0.98, P.05). The overall correlation of vessel diameters was r = 0.99. The LA volumes correlation was r = 0.86 and P.05. A significant difference of the esophageal position was found between preprocedural MSCT and intraprocedural DynaCT Cardiac (r = 0.53, P.05).DynaCT Cardiac is a novel intraprocedural rotational angiographic technique. It is highly accurate in displaying crucial structures for PVI in comparison with the results of MSCT. Therefore, DynaCT Cardiac can be used as an alternative imaging technique to improve PVI accuracy.

Congestive heart failure (CHF) because of left ventricular systolic dysfunction is a prevalent syndrome and associated with morbidity, mortality, and huge economic cost. Hallmarks of CHF are exercise intolerance, poor prognosis, and poor quality of life (QoL). According to reports from several laboratories, a large number of patients with heart failure also have sleep apnea (SA). SAs cause arousals and sleep disruption, alter blood gases, and increase sympathetic activity. SA has a major impact on QoL, and disturbed sleep itself significantly contributes to depressive syndromes in patients with stable CHF. The correlation of the apnea/hypopnea index (AHI) with most of the QoL measures and depressive syndromes indicates that patients with AHI indices estimated their impaired physical and emotional health status lower as opposed to patients without sleep-related breathing disorder. Fatigue leads to reduced QoL after stroke. Sleep-disordered breathing precedes stroke and may contribute to the development of stroke. It is an independent prognostic factor related to mortality in stroke and associated with fatigue and impaired QoL. Obstructive events seem to be a condition before the neurological disease whereas central events and Cheyne–Stokes respiration (CSR) could be its consequence. In this article, the impact of sleep-disordered breathing on patients with heart failure and stroke and its influence on QoL are discussed.

Aims Oesophageal injury has been reported with delivery of radio-frequency lesions at the left atrium posterior wall in catheter ablation procedures for atrial fibrillation (AF). In this observational study we prospectively assessed endoscopical oesophageal wall changes after pulmonary vein antrum isolation (PVAI) in patients presenting for treatment of AF. Methods and results Twenty eight patients (18 men; mean age 55 ± 11 years) were ablated using either a cooled-tip or an 8 mm tip ablation catheter. Endoscopy of the oesophagus was performed 24 h after PVAI. If oesophageal wall changes were detected post ablation, a proton-pump inhibitor (PPI) was started and repeat endoscopy was considered. Within 24 h post ablation oesophageal wall changes were confirmed in 47% of our study patients. Erythema was identified in 29% and necrotic or ulcer-like changes in 18% of patients. None of study patients experienced left atrial-oesophageal fistula. A significant correlation between Reflux-like symptoms and oesophageal wall changes was demonstrated. Complete recovery of oesophageal lesions was shown in all study patients 2–4 weeks post ablation. Conclusion A significant number of patients experienced oesophageal wall injury post PVAI. Initiating PPIs in this group of patients might facilitate recovery of oesophageal wall injuries caused by radio-frequency energy delivery.

Objectives: Threedimensional imaging has been widely adopted as a standard component of the AF ablation procedure. We tested the feasibility of the new 3D imaging system (DYNA-CT) using the C-arm to reconstruct the left atrium and the oesophagus and compared it to the established CT-scan imaging modality. Methods and results: We included 14 consecutive patients (7 female, mean age 54 +/− 12) presenting for PVAI in the study. Prior to the ablation procedure ( ). Table 1 demonstrates results of comparison between CT and RTA data. Conclusions: From our initial experience DYNA-CT seems to provide a feasible and reliable left atrial and oesophagus images to help mapping and navigation during the PVAI. Table 1: Anatomical structures demonstrated using the 2 imaging modalities

Purpose To evaluate if computed tomography (CT) coronary calcium scoring is needed after detection of coronary calcifications on conventional chest radiographs. Materials and methods One hundred and five patients (67 men; 57.2 ± 12.8 years) with suspected coronary artery disease underwent conventional chest radiography and non-enhanced, retrospectively ECG-gated multislice spiral CT (MSCT) of the heart (4 mm × 2.5 mm, 120 kV, 133 mAs eff. ). Chest radiographs were assessed independently by two radiologists. Detection of coronary calcifications was compared between both methods. Sensitivity, specificity, negative and positive predictive values, median, 25% and 75% percentiles for the detection of coronary calcifications were calculated. Receiver operating characteristics (ROC) analyses were computed. Results In 90 patients, MSCT revealed coronary calcifications. The mean coronary calcium score was 526.2 (0–4784.5). On chest radiographs, coronary calcifications were correctly detected in 46 (61) patients by observer 1 (observer 2). The corresponding sensitivity was 51.1% in observer 1 and 67.8% in observer 2. Median of detected coronary calcifications was 361.9 (426.4) for observer 1 (observer 2). Corresponding 25% und 75% percentiles were 109.6 (109.6) and 798.5 (898.5). The area under the ROC curve was 0.636 for observer 1 and 0.715 for observer 2. There was no correlation between image quality and the detection of coronary calcifications on plain film radiographs. Conclusion As coronary calcifications of various extents are inconsistently detected on plain chest radiographs, CT calcium scoring may not be omitted even if coronary artery calcifications were detected on conventional chest radiographs.

Implantable cardioverter defibrillators and pacemakers detect an increasing number of silent episodes of AF. In a porcine model, the study evaluated the contractility of the left atrial appendage (LAA) during AF paroxysms as they may occur in patients. Peak outflow velocity of the LA and mean outflow velocity of the LAA (LAA-V(outmean)) (n = 17) were measured before, during, and after induction of self-terminating AF. LAA-V(outmean) was also measured during incremental pacing from different atrial sites using epicardial Doppler probes (n = 6) and during continuous recordings (n = 5) of 40 minutes of pacing maintained AF. Compared to baseline sinus rhythm, LAA-V(outmean) increased during short AF episodes (41 +/- 3 vs 35 +/- 2 cm/s, P < 0.05). After termination of the AF episodes, LAA-V(outmean) further increased (69 +/- 15 cm/s, P < 0.001 vs baseline). This "postfibrillatory enhancement" maintained after repeated induction of short AF paroxysms. During prolonged AF episodes lasting 40 minutes, an initial hypercontractility (44 +/- 2 vs 38 +/- cm/s, P < 0.01) was followed by a hypocontractility after 20 minutes (29 +/- 12 P < 0.05 vs SR) and a postfibrillatory enhancement after cessation of AF (56 +/- 12 vs 27 +/- 9 cm/s at 40 minutes AF, P < 0.001). L-type Ca channel blockade abolished the initial hypercontractility during AF and the postfibrillatory enhancement. Repetitive AF paroxysms up to 2 minutes did not decrease left atrial contractility. During maintained AF up to 40 minutes an initial hypercontractility and a consecutive hypocontractility, which is overcompensated by a postfibrillatory enhancement of atrial inotropy after cessation of AF, are present. The observed phenomenon seems to be related to an increased Ca(2+) influx through the L-type Ca(2+) channel.

Heterogeneous perfusion in left bundle branch block (LBBB) has been demonstrated by (99m)Tc-methoxyisobutylisonitrile (MIBI) SPECT. Locally different contraction is also associated with LBBB. Quantitative analysis of myocardial SPECT is influenced by partial-volume effects depending on systolic wall thickening. Therefore, partial-volume effects may mimic perfusion heterogeneity in LBBB.Fifteen patients with nonischemic dilated cardiomyopathy and LBBB underwent resting (15)O-water PET, (99m)Tc-MIBI SPECT, and gated (18)F-FDG PET for analysis of wall thickening. Myocardial blood flow corrected for rate-pressure product (corrMBF), (99m)Tc-MIBI uptake, and wall thickening were determined in 4 left ventricular wall areas. In 14 patients, M-mode echocardiographic recordings were available for comparison.Homogeneous distribution was found for corrMBF (1.09 +/- 0.41 to 1.19 +/- 0.31 mL x g(-1) x min(-1)). (99m)Tc-MIBI uptake and wall thickening were heterogeneous (P0.0001), with the lowest values septal ((99m)Tc-MIBI, 65% +/- 10%; wall thickening, 16% +/- 14%) and the highest lateral ((99m)Tc-MIBI, 84% +/- 5%; wall thickening, 55% +/- 17%). Similar relationships in systolic wall thickening were observed by M-mode echocardiography (anteroseptal, 20% +/- 11%; posterolateral, 37% +/- 18%; P0.001).Heterogeneity of (99m)Tc-MIBI uptake in LBBB corresponds to differences in wall thickening and does not reflect distribution of corrMBF. Supplementary analysis of wall thickening is recommended when assessing (99m)Tc-MIBI SPECT in LBBB.

Background Quality of life in patients with chronic heart failure (HF) is often severely compromised. Sleep-related breathing disorders (SRBD) like Cheyne–Stokes Respiration (CSR) or obstructive sleep apnea (OSAS) are often observed in patients with severe HF resulting in fragmentation of sleep, excessive daytime sleepiness and an increased mortality. While an apnea/hypopnea-index (AHI) >30/h represents an independent predictor of poor prognosis, clinical relevance of even minor SRBD with an AHI

The aim was to correlate the degree of valvular calcification in patients with aortic stenosis determined by retrospectively electrocardiogram (ECG)-gated multislice spiral computed tomography with stenosis severity assessed by cardiac catheterization.Prospective study on 41 patients (18 men, mean age 71+/-8 years) with aortic stenosis, who underwent four detector row multislice spiral computed tomography and cardiac catheterization. Severity of aortic stenosis was classified by cardiac catheterization. Aortic valve area, peak to peak and mean transvalvular gradients were correlated with the degree of calcification determined by multislice spiral computed tomography. Aortic valve calcification was assessed using aortic Agatston score, aortic mass score and aortic volume score.All measured aortic valve calcification scores were significantly higher in patients with severe aortic stenosis (n=29) than in patients with moderate (n=7) or mild aortic stenosis (n=5, p0.001). Aortic valve calcification scores correlated significantly with aortic valve area (r=-0.49, p=0.001 for aortic mass score) and with peak to peak (r=0.68, p0.001) and mean (r=0.60, p0.001) transvalvular gradients.Severity of aortic valve calcification assessed by cardiac multislice spiral computed tomography is inversely related to aortic valve area and positively correlated with transvalvular gradients. Based on this preliminary data larger studies should be performed with echocardiography as a reference standard in order to validate this new information and its utility in the clinical management of the patient.

ObjectivesWe investigated whether cardiac resynchronization therapy (CRT) affects myocardial glucose metabolism and perfusion in dilated cardiomyopathy (DCM) and left bundle branch block (LBBB).BackgroundPatients with DCM and LBBB present with asynchronous left ventricular (LV) activation, leading to reduced septal glucose metabolism. Cardiac resynchronization therapy recoordinates LV activation, but its effects on myocardial glucose metabolism and perfusion remain unknown.MethodsIn 15 patients (10 females; 61 ± 13 years) with DCM and LBBB (QRS width 165 ± 15 ms), gated 18F-fluorodeoxyglucose (FDG) positron emission tomography (PET) and technetium-99m (99mTc)-sestamibi single-photon emission computed tomography were performed before and after two weeks of CRT. Uptake of FDG and 99mTc-sestamibi was determined in four LV wall areas. Ejection fraction and volumes were calculated from gated PET.ResultsBaseline FDG uptake was heterogeneous (p < 0.0001), with lowest uptake in the septal region (56 ± 12%) and highest uptake in the lateral region (89 ± 6%). During CRT, septal and anterior increases (p < 0.01) and lateral decreases (p < 0.01) resulted in homogeneously distributed glucose metabolism. Baseline heterogeneity (p < 0.0001) in 99mTc-sestamibi uptake was modest (lowest septal 65 ± 10%; maximum lateral 84 ± 5%) and also reduced with CRT, although some heterogeneity (p < 0.05) remained. The septal-to-lateral ratio increased with CRT for FDG (0.62 ± 0.12 to 0.91 ± 0.26, p < 0.001) and 99mTc-sestamibi uptake (0.77 ± 0.13 to 0.85 ± 0.16, p < 0.01). The LV end-diastolic and end-systolic volumes decreased from 293 ± 160 to 272 ± 158 ml (p < 0.05) and from 244 ± 164 to 220 ± 160 ml (p < 0.01), respectively. Ejection fraction increased from 22 ± 12% to 25 ± 13% (p < 0.01).ConclusionsGlucose metabolism is reduced more than perfusion in the septal compared with LV lateral wall in patients with DCM and LBBB. Cardiac resynchronization therapy restores homogeneous myocardial glucose metabolism with less influence on perfusion.

To evaluate the reconstruction interval dependent bandwidth of the coronary calcium score, considering different methods of image reconstruction and quantification of coronary calcifications.Seventy-five patients underwent coronary calcium scoring by use of retrospectively ECG-gated multislice spiral CT. In all patients overlapping and nonoverlapping image reconstruction was performed every 10% of the RR-interval. Coronary calcium score was calculated for every reconstructed image series using the Agatston score and a volumetric scoring method. In 25 patients the analysis was performed twice to determine the reconstruction interval dependent intraobserver variability.For nonoverlapping image reconstruction the median of the calcium score determined by the Agatston method ranged from 125.8 to 216.2 and from 166.9 to 211.7 for the volumetric scoring method. For overlapping image reconstruction the corresponding values ranged from 91.6 to 160.5 for the Agatston score and 128.3 to 175.3 for the volumetric calcium score. Reconstruction interval dependent median (mean) variation of the coronary calcium score ranged from 24.1 (45.5)% for nonoverlapping image reconstruction using the Agatston score to 17.5 (25.2)% utilizing a volumetric calcium score with overlapping image reconstruction. There was no statistical significant (P0.05) difference between the different methods. Intraobserver variability for the different image reconstruction intervals ranged from 0.78% to 21.51%. The least intraobserver variability was found for overlapping image reconstruction during the diastole using the volumetric scoring method.Diastolic image reconstruction at 50% or 60% of the RR-interval is recommendable for retrospectively ECG-gated multislice spiral CT. Volumetric calcium scoring and overlapping image reconstruction are beneficial to reduce the variation of the coronary calcium score.

VVD). The way VVD is defined differs per implantable device. We investigated if this affects improvement of pump function during BiV pacing. Methods: In 8 canine hearts with chronic LBBB, leading to 17 16% LV hypertrophy and 25 19% LV dilation, BiVS pacing was performed with a large number of combinations of AVDs and VVDs. Two commonly used methods to program VVDs are tested; BiVS1; programming an AVD with respect to the ventricle to be paced first and delaying stimulation of the other one and BiVS2; maintaining a fixed AVD for the LV while tuning the VVD with RV stimulation time. To combine the effects of AVD and VVD and intrinsic RV activation during LBBB we calculated an effective VVD (VVeff). VVeff was defined as the difference between time of LV stimulation and (a) time of intrinsic RV activation (RAVDintr) during LBBB or (b) RV stimulation, whichever occurred earlier. RAVDintr was determined during BiV0 pacing with incremental AVD, and defined as the AVD at which the shape of the QRS duration changed as a results of loss of full capture. Results: RAVDintr correlated linearly to PQ-time (r 0.84) and was 35 4 ms shorter than PQ-time. Maximal improvement of LVdPdtmax that could be achieved with BIVS pacing was 12.2 5.9%. The figure shows that LVdPdtmax depends on both AVD and VVD. Especially at long AVD BiVS1 leads to lower LVdP/dtmax values as large as 5% despite identical applied VVDs. LVdPdtmax had a unique relation with VVeff, independent from AVD and definition of VVD (r 0.91). Conclusion: definition of VVD is important for hemodynamic outcome, but use of VVeff avoids such confusion.

Methods 20 patients (14 male, 63,1 ± 9,1 y) with paroxysmal AF were included. 10 patients underwent PVAI with radiofrequency ablation (RFA), whereas the others received ablation with Cryoballoon (CBA). All patients were scheduled for CMR (Espree 1.5 T, Siemens, Germany) before, acute, and 24 hours after PVI. For pulmonary veins, cross sectional diameter, angiography of pulmonary veins and flow measurements of the right inferior pulmonary vein (RIPV) were performed.