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Valvular heart disease is a common comorbidity in patients with impaired renal function, especially in those with end-stage renal disease undergoing dialysis. Sclerosis and calcification of the heart valves and the valve ring are particularly relevant in the etiology of the diseases. These typically occur at the aortic and mitral valves and can lead to both insufficiency and stenosis of the affected valve. In the current guidelines of the European Society for Cardiology published in 2017, surgical treatment remains the standard of care for most forms of severe valvular heart disease; however, the presence of chronic kidney disease impairs clinical outcomes and is associated with higher mortality rates when compared to patients with preserved renal function. Catheter-based treatment options have emerged as an effective and safe alternative for patients75 years and/or with increased surgical risk. Consequently, in patients with appropriate anatomy and elevated risk, interventional treatment options should also be discussed in the heart team.

Paper is made from a congregation of cellulose fibers that are joined to each other by hydrogen bonds. Mechanical and physical properties play a significant role in its runnability and printability, while optical properties play an important role in determining image quality of the print. Print quality can be evaluated objectively through print quality analysis and subjectively using panel or visual ranking of print attributes. Objective print quality analysis uses instruments to determine print characteristics and attributes, which have an impact on perception of print quality. On the other hand, subjective visual assessment allows print quality to be ranked on human perception of print quality. In this article, the runnability, printability and current techniques to evaluate printed image are presented. Recently developed test methods to characterize paper properties, along with more sophisticated image analysis equipment and algorithms, will allow better prediction of print quality.

Das Positionspapier der DGK zu Medikamente freisetzende Stents (DES) und mit Medikamenten beschichtete Ballonkatheter (DCB) fokussiert auf in Deutschland zugelassene und verfugbare Produkte, die in klinischen Studien untersucht wurden. Es sind fur alle Produkte randomisierte, kontrollierte klinische Studien mit primarem angiographischem Endpunkt zum Nachweis der antirestenotischen Wirksamkeit und nachfolgend klinische Endpunktstudien zu fordern. Der Einsatz von DES fuhrt im Vergleich zu unbeschichteten Stents (BMS) zu einer Reduktion erneuter Revaskularisationen, wahrend sich die klinischen Endpunkte wie Tod oder Myokardinfarkt nicht andern. DES sollten bevorzugt bei erhohtem Risiko einer Instentstenose eingesetzt werden. Bei erhohtem Risiko fur eine Stentthrombose oder zu erwartenden Problemen bei einer verlangerten dualen Thrombozytenaggregationshemmung (DTAH) ist der Einsatz von BMS zu bevorzugen. Die Dauer einer DTAH betragt 1 Monat nach BMS-Implantation, 1 Monat nach Therapie der BMS-ISR mit DCB, 6 bis 12 Monate nach DES-Implantation bei allen Patienten sowie grundsatzlich 12 Monate nach akutem Koronarsyndrom (ACS) unabhangig von der Art der Intervention.

Drug-coated balloons (DCB) represent a novel clinical treatment modality for coronary and peripheral artery disease. Advantages over standard angioplasty and stent technologies including homogeneous drug delivery to the vessel wall, immediate drug release without the use of a polymer, the option of using balloon catheters alone or in combination with a bare metal stent, no foreign object that remains in the body, the potential of reducing antiplatelet therapy, and lower restenosis rates in some indications. As with drug-eluting stents (DES), one cannot assume a class effect for DCB. So far, data from randomized clinical trials identify the treatment of coronary in-stent restenosis (ISR) and of de novo and restenotic lesions in peripheral artery disease as viable options. Furthermore, treatment of de novo lesions in small coronary vessels, bifurcation lesions, long lesions, pediatric interventions, and cerebrovascular applications are potential beneficial indications. In the coronary application, a strategy of DCB angioplasty with provisional spot-stenting in the case of severe dissections may become a better alternative in long and complex lesions, bifurcations, or in patients with contraindications for DES.

Periinterventionelle Schlaganfalle sind eine der haufigsten schweren Komplikationen bei Katheterinterventionen und der Katheterablation bei Vorhofflimmern und Kammertachykardien mit einer grosen Wahrscheinlichkeit persistierender neurologischer Defizite. Da viele dieser zerebrovaskularen Komplikationen auf dem Kathetertisch auftreten, bietet sich die Moglichkeit einer akuten Intervention mit dem Ziel der Gefasrekanalisation. Eine sofortige zerebrale Bildgebung und ein interdisziplinares Vorgehen ohne Zeitverzug sind fur jedes Herzkatheterlabor zu fordern. Liegt ein Gefasverschluss zugrunde, so ist eine intraarterielle Thrombolyse, ggf. mit einer mechanischen Thrombusextraktion, die erfolgversprechendste Therapie. Allerdings handelt es sich um eine individuelle Therapieentscheidung, die von der lokalen interdisziplinaren Fachkompetenz abhangt. Das erhohte Risiko einer intrazerebralen Blutung aufgrund der im Regelfall vorbestehenden antithrombotischen Therapie muss gegen das drohende neurologische Defizit abgewogen werden. Aufgrund der hohen Morbiditat und der verschiedenen potenziellen Therapieoptionen besteht der dringende Bedarf fur systematische klinische Studien.

Stroke is a serious complication of percutaneous coronary intervention and atrial fibrillation ablation procedures and patients have a high likelihood of persistent neurological deficits. Although formal criteria speak against intravenous or intra-arterial thrombolysis due to pre-existing antithrombotic and anticoagulation therapy, the conditions for recanalizing therapy are optimal due to the occurrence of vessel occlusion in the catheter suite or the chest pain unit. Brain imaging and an interdisciplinary approach are mandatory. In cases of intracerebral vessel occlusion intra-arterial thrombolysis possibly in combination with mechanical clot fragmentation is the first choice therapy. The management of the patient is always an individual therapeutic decision based on stroke severity, the pretreatment with antithrombotic and anticoagulation drugs, the availability of a neuro-interventionalist and the qualification of the local team.

Medikamentenbeschichtete Stents wirken uber eine verzogerte Freigabe wachstumshemmender Medikamente an die Gefaswand uber mehrere Wochen mit dem Nachteil einer inhomogenen Medikamentenverteilung und verzogerten Endothelialisierung. Mit Medikamenten beschichtete Ballonkatheter auf Basis der PACCOCATH-Technologie fuhren trotz einer kurzzeitigen Medikamentenapplikation zu einer langfristigen Hemmung der Restenose. Der beschichtete Ballon erlaubt eine Vorbeugung und Behandlung der Restenose unabhangig von einer Stentplattform und ermoglicht eine Uberwindung der Nachteile beschichteter Stents. Es eroffnen sich neue Perspektiven in der Behandlung der Herzkranzgefase und auch der peripheren Arterien. Die Kombination „beschichteter Ballon plus unbeschichteter Stent“ konnte langfristig eine Alternative zu den DES sein.

Healthcare personnel may be faced with different degrees of violence and aggression, particularly concerning preclinical care. However, systematic data with respect to the frequency and type of violence in emergency medicine in Germany has not been researched.At an anesthesiology congress, an anonymous survey was distributed about the different kinds and extent of violent acts that the participants had experienced during their work in emergency medicine. Moreover, the participants' subjective feelings toward professional and personal safety when handling emergency cases were explored.Every fourth participant in the survey (25.2 %) had experienced occupational physical violence within the last 12 months. Verbal harassment or insults within the last twelve months were reported by 58.2 % of the participants. While 80 % of the participants feel "entirely" or "mostly" safe with regard to the professional aspect of their occupation, personal safety was considered "entirely" in only 9.3 % and "mostly" in 46.4 % of the cases. Nearly every third participant (31.8 %) feels only "partially" safe and every eighth participant feels "rather not" or "not at all" safe during emergency medicine missions. Men appreciate their expertise as well as their personal safety more so than women (p 0.001).Aggression and violence towards healthcare personnel in emergency medicine occur on a regular basis in the German healthcare system. Little research has been conducted in this area, so the issue has not yet been perceived as a relevant problem. Appropriate training for healthcare personnel in emergency medicine should be targeted at developing the skills needed when encountered with aggression and occupational violence.

According to current understanding the drug-coated balloon carries a sufficient dose of an effective antineoplastic agent, i.e. paclitaxel, to the target lesion.Literature review and report on experimental studies simulating the access of coated balloons to the treatment site and studies in pigs.The drug adheres to the balloon membrane and is partially hidden below the folds which are wrapped around the shaft. Upon inflation solid paclitaxel particles are pushed into the vessel wall. Premature loss of paclitaxel and transfer to the vessel wall is controlled by the formulation including an inactive additive. Particles in the tissue dissolve slowly resulting in a terminal half-life of almost 2 months. Premature loss of the drug, dissolution, elimination, efficacy and tolerance are limited by the very low solubility of paclitaxel. From exemplary DCB approximately 10% of drug is lost before the target lesion is reached, 5-20% is transferred into the vessel wall and 10% remain on the balloon after withdrawal. The difference is distributed in the general circulation. Inhibition of neointimal proliferation in animal models is reliable and as persistent as with drug-eluting stents. Histology reveals slight to moderate dose-dependent downstream effects without functional or clinical symptoms.For the time being paclitaxel remains the drug of choice, the dose varies between 2 and 3.5 μg/mm² balloon surface. Neither in animal experiments nor in clinical trials problems have been detected in vessel segments treated with overlapping balloons. Future developments are expected improving efficacy in additional disease conditions (e.g., calcified vessels) and vessel territories.

Previous studies have indicated that the prevalence of human immunodeficiency virus (HIV), hepatitis B (HBV) and hepatitis C (HCV) virus infections among trauma patients seems to be higher compared to the general population.This study investigated the seroprevalence of blood-borne pathogens among patients with suspected severe multiple trauma in a German university hospital (level I trauma center).Routine blood samples taken from trauma patients at the university hospital Frankfurt were tested for HBV, HCV and HIV (from 1 February 2014 to 31 January 2015).Overall, 275 patients with a median injury severity score (ISS) of 9 points (range 0-54) were included in the study representing 84.4 % of all trauma room admissions during this time period. Altogether 3.3 % (n = 9) of the patients were infected with blood-borne pathogens, where 7 patients were infected with HCV and 2 patients had an active HBV infection. None of the patients were tested HIV positive and only one initial diagnosis for HCV was made. A further six samples (five HCV and one HIV) showed a weak reaction in the screening assay that could not be verified by the confirmatory assay.To the best of our knowledge this study is the first report on the prevalence of blood-borne infections among trauma patients at a level I trauma center in an urban area in Germany. Compared to the general population the prevalence of blood-borne infections was higher but considerably lower than indicated in previous international studies. Considering the broad implications of occupationally transmitted blood-borne infections occupational safety is of paramount importance.

Emergency department personnel are at risk of occupational exposure to blood-borne pathogens. Previous studies have shown that the prevalence of human immunodeficiency virus (HIV), hepatitis B (HBV) and hepatitis C (HCV) virus infections among trauma patients is higher compared to the general population.The aim of the study was to investigate the compliance rates of trauma team members in applying standard precautions, knowledge about the transmission risk of blood-borne infections and perceived risk of acquiring HIV, HBV and HCV.An anonymous questionnaire was distributed to 100 trauma team members including physicians, nurses and medical students from different medical departments (e.g. surgery, radiology, anesthesia and internal medicine).The results of the questionnaire showed that trauma team members had insufficient knowledge of the risk of blood-borne pathogens, overestimated the risk of HCV infection and underused standard precautions during treatment of emergency trauma patients.Further educational measures for emergency department personnel are required to increase the knowledge of occupational infections and compliance with standard precautions. Every healthcare worker needs to be sufficiently vaccinated against HBV. In the case of injury awareness of all measures of post-exposure prophylaxis is of utmost importance for affected personnel.

The duration of dual antiplatelet therapy (DAPT) after percutaneous coronary interventions (PCI) depends on the type of intervention and the clinical situation of the patient. After angioplasty alone (plain old balloon angioplasty, POBA) DAPT is not yet established but does, however, make sense to continue for 4 weeks. The duration of DAPT after placement of bare metal stents (BMS) is 4 weeks, after drug-eluting stents (DES) 6 months, after bioresorbable vascular scaffold (BVS) systems 6-12 months and after drug-coated balloon catheters (DCB) without a new implant 4 weeks.

Trauma care personnel are at risk of occupational exposure to blood-borne pathogens. Little is known regarding compliance with standard precautions or occupational exposure to blood and body fluids among multiple trauma care personnel in Germany.Compliance rates of multiple trauma care personnel in applying standard precautions, knowledge about transmission risks of blood-borne pathogens, perceived risks of acquiring hepatitis B, hepatitis C and human immunodeficiency virus (HIV) and the personal attitude towards testing of the index patient for blood-borne pathogens after a needlestick injury were evaluated.In the context of an advanced multiple trauma training an anonymous questionnaire was administered to the participants.Almost half of the interviewees had sustained a needlestick injury within the last 12 months. Approximately three quarters of the participants were concerned about the risk of HIV and hepatitis. Trauma care personnel had insufficient knowledge of the risk of blood-borne pathogens, overestimated the risk of hepatitis C infection and underused standard precautionary measures. Although there was excellent compliance for using gloves, there was poor compliance in using double gloves (26.4 %), eye protectors (19.7 %) and face masks (15.8 %). The overwhelming majority of multiple trauma care personnel believed it is appropriate to test an index patient for blood-borne pathogens following a needlestick injury.The process of treatment in prehospital settings is less predictable than in other settings in which invasive procedures are performed. Periodic training and awareness programs for trauma care personnel are required to increase the knowledge of occupational infections and the compliance with standard precautions. The legal and ethical aspects of testing an index patient for blood-borne pathogens after a needlestick injury of a healthcare worker have to be clarified in Germany.

In the year 2000 a working group of the German Interdisciplinary Association for Intensive Care Medicine (DIVI) defined a core data set on quality assurance for the first time. In the following years the participating intensive care units sent data to the registry on a voluntary basis and received an annual report on benchmarking data. Alterations in the quality in the field of intensive care medicine have so far only been published to a very low extent.This study analyzed the core date set of the DIVI between 2000 and 2010 in respect to changes in disease severity using the simplified acute physiology score (SAPS II), the sequential organ failure assessment (SOFA), the need for therapeutic interventions with the therapeutic intervention scoring system (TISS 28) and intensive care unit (ICU) mortality.Inclusion criteria were participation in the registry for at least 4 years, SAPS II, SOFA, TISS28 scores available and data on ICU discharge. A standardized mortality rate (SMR) was calculated for each year.The mean SAPS II score including 94,398 patients increased by 0.23 points/year with a standard error (SE) of 0.02 to 26.9 ± 12 points (p 0.001). Similarly, the SOFA score on admission to the ICU increased by 0.14 points/year (SE 0.04) to 3.4 ± 2.7 points (p 0.001), the proportion of patients with a two organ failure doubled to 7.1 % and the number of patients dependent on ventilation increased by 13.6 % to 59.8 %. The mean time on ventilation increased by 0.17 ventilator days/year (SE 0.01, p 0.001) to 3.1 ± 7.5 days/patient. The mean number of therapeutic interventions increased by 8.7 % to 26.3 ± 8.3 TISS 28 points/day. The mean length of stay on the ICU (4.3 ± 8 days) and the age of the patients (63.2 ± 17.0 years) remained unchanged. The readmission rate showed no significant changes between the years 2004 and 2010. The readmission rate to the ICU within 48 h after primary discharge was 3.1 % with a 95 % confidence interval (CI) of 3.0-3.3 in contrast to 1.5 % (95 % CI 1.4-1.6) for readmission to the ICU after 48 h. The length of stay in hospital before admission to the ICU decreased for patients with scheduled surgery (6.3 ± 9.7 days vs. 4.2 ± 6.9 days), increased slightly for patients with medically indicated admission to the ICU (2.4 ± 8.2 days 3.1 ± 8.6 days) and remained unchanged for patients with unscheduled admission to the ICU after surgery (4.1 ± 8.6 days). The SMR decreased between 2000 and 2004 from 0.97 to 0.72 and increased again thereafter to 0.99 (ICU mortality 8.5 %).The severity of disease on admission to the ICU, the proportion of patients on ventilation and the workload of therapeutic interventions increased between 2000 and 2010 in German ICUs but the length of stay of patients in the ICU remained unchanged. The SMR decreased until 2005 and increased thereafter to return to the initial values. The overall ICU mortality was low compared to international data.

In the present study we investigated the contrast medium flow in 8 different types of left heart catheter having two different diameters (each n = 5). Using a 10 ml syringe and the contrast medium Ultravist 370, we calculated a mean value of 94.24 N + 16.01 for the maximum manual injection force in 18 test subjects. For the sake of simplicity, the figure of 100 N was defined as standardized manual force (which is within the standard deviation). If the maximally admissible static pressure of 82.5 bar is not to be exceeded, flow rates of not more than 16-17 ml/s are possible with 5.2 Fr. catheters, and 21-23 ml/s and 1.46 ml/s for 5.2 Fr. catheters, and between 1.99 ml/s and 2.17 ml/s for 6 Fr. catheters. Thus, a 50% higher flow can be achieved with 6 Fr. catheters as compared with 5.2 Fr. catheters at the same injection force. The iodine delivery rates are between 506 mg iodine/s and 539 mg iodine/s for 5.2 Fr. catheters, and between 738 mg iodine/s and 804 mg iodine/s for 6 Fr. catheters. The figures for the jet stream.

Non-stent-based immediate release formulations of paclitaxel have been shown to reduce in-stent restenosis in animal experiments and clinical trials. In the porcine overstretch model paclitaxel dissolved in the contrast medium iopromide inhibited neointimal proliferation in a dose-dependent manner after intracoronary injection and was well tolerated.As a first step entering clinical development, a phase I trial was performed using four ascending paclitaxel dose/concentration levels: samples of up to 100 mL of the contrast medium (iopromide) containing 10, 50, 100 or 200 µM paclitaxel or iopromide (controls) were randomly administered to patients assigned to bare metal stent implantation for single de novo coronary artery lesions. Safety variables, tolerability and angiographic parameters were assessed.Adverse events, ECG, systolic and diastolic blood pressure, left ventricular ejection fraction, leukocyte count, other hematological or clinical chemistry data did not reveal any trend which could be related to the study medication. Short-lasting serum paclitaxel concentrations remained significantly below those known from cancer therapy. Angiographic late lumen loss was 0.72±0.50 mm (N.=7) in controls versus 0.45±0.65 mm (N.=17) in all paclitaxel-treated patients; binary restenosis rate was 5/7(63%) versus 6/17 (35%) and target lesion revascularization rate was 4/8 (50%) versus 4/24 (17%).Intracoronary infusion of paclitaxel dissolved in an X-ray contrast medium was well tolerated. The results show restenosis inhibition, but the number of patients examined was too small to demonstrate a statistically significant inhibition.

The implementation of ATLS® in the daily routine of trauma management in the emergency department is a challenge. This goal cannot be reached by educating ATLS® to a few team members only. In order to enforce the implementation of ATLS® in a level I trauma centre, a generic in-house training was introduced in 2009 with inter-professional integration of all specialists of the trauma team.The TEAM® course (trauma evaluation and management concept of the American College of Surgeons) was the theoretical basis of the training. This educational program was developed for medical students and multidisciplinary team members. Prior training, a questionnaire for self-assessment was completed by n=84 team members to assess their knowledge about ATLS® principles. The hands-on training time was 90 min. N=10 members of the trauma team worked out three scenarios of multiple injured patients. These were provided as near-reality manikin simulations by a specialist trainer. After the training participants re-evaluated and analysed improvement by the training. Duration of trauma management and the number of missed injuries were analysed one year prior and one year after the training and served as a marker of the process and outcome quality of trauma care.Prior the training, 57% of trainees specified their knowledge related to the ATLS® can be improved. Their expectations were generally satisfied by the training. The mean time of trauma management in the ED could not be reduced one year after the training (36±16 min) compared to one year prior the training (39±18 min), however, the detection of missed injuries (5.6% vs. 3.2%, p0.05) was significantly diminished after the training.Apart form education of ATLS® providers the inauguration of an interdisciplinary and interprofessionel team training may enhance implementation of ATLS- algorithms into daily routine.

In the present study, the torsional moments of 8 different types of catheter having two different calibres (n = 5 in each case) were investigated. The catheters were made of linear polyurethane (Cordis, Netherlands). The transmitted torsional moments of the 5.2 Fr. catheters positioned in a straight line were 1.48 +/- 0.09 Ncm (VK = 6%), positioned in a 90 degree curve 1.39 +/- 0.11 Ncm (VK = 8%). The corresponding figures for the 6 Fr. catheters were 2.43 +/- 0.20 Ncm (VK = 8%) and 2.26 +/- 0.20 Ncm (VK = 9%). The highly stable transmission behaviour in particular of the 5 Fr. catheters--with a variation coefficient of the torsional moments of 6%--is due mainly to the accurate manufacture of the catheters, and the material chosen. The study is a first step towards achieving systematic quality control of the materials used for diagnosis and therapy.

The use of drug-coated balloons (DCB) for preventing restenosis in both coronary and peripheral arteries has received increasing attention. The first successful clinical outcomes in inhibiting restenosis have been reported for paclitaxel-coated balloons. Paclitaxel is a lipophilic substance characterized by rapid intracellular uptake and irreversible binding to microtubules. In this way, paclitaxel alters the cell structure, ultimately reducing proliferation, migration, and signaling. These properties make paclitaxel a very potent antiproliferative drug. Paclitaxel admixed to a small amount of the hydrophilic X-ray contrast medium iopromide (Ultravist™) emerged as a very effective coating matrix from numerous in vitro and in vivo experiments and has been denoted as Paccocath™. The randomized controlled ISR I/II-, Thunder- and FEMPAC studies have been conducted using Paccocath™ balloons. Late lumen loss as the primary endpoint at 6 months proved to be statistically significantly reduced in the coated balloon groups in coronary and peripheral arteries. The slightly modified coating on the SeQuent™ Please balloons (B.Braun, Melsungen, Germany) has been clinically studied in the PEPCAD (Paclitaxel-Eluting PTCA-Catheter in Coronary Artery Disease) clinical trial program. Cotavance™ balloons (MEDRAD Inc, Minneapolis, USA) are also coated with the Paccocath™ formulation. In this review we first outline the development of Paccocath™ balloons to then provide an overview of the clinical results obtained with the modified coating. Furthermore we examine possible mechanism of action by which single administration of an antiproliferative drug dose using paclitaxel-coated balloons inhibits restenosis.

This article addresses current pacing practices and issues. Pacing, sensing, sensing amplifiers, and pacing leads are discussed. Cardiac resynchronization is reviewed. Issues of ventricular pacing avoidance, pacemaker lead infections, ionizing radiation effects on pacing and pacing issues after deterioration and expiration of the patient are considered.

Randomized clinical trials investigating the treatment of coronary in-stent restenosis with paclitaxel iopromide coated balloon catheters have shown favorable results. The aim of the present clinical investigation was to assess the efficacy of a novel paclitaxel urea coated angioplasty balloon in the treatment of coronary in-stent restenosis. A total of 26 restenotic bare metal stents in 23 patients with a lesion length of 22.8 ± 11.1 mm and a reference vessel diameter of 2.64 ± 0.31 mm were treated. Up to six months and including the six-month angiographic control, only one target lesion revascularization was necessary; in total, the rate of major adverse cardiovascular events until six-month follow-up was 4.3 %. In-stent late lumen loss was 0.07 ± 0.37 mm, in-segment late lumen loss 0.02 ± 0.50 mm. Binary restenosis was present in one patient (4.3%). The results of this first-in-human series with a paclitaxel urea coated balloon are comparable to paclitaxel iopromide coated balloon catheters. Randomized, controlled clinical trials are warranted to further evaluate this promising approach.

Restenosis following interventions in the coronary or peripheral arteries develops over weeks to months. In coronary arteries the restenosis rate has been markedly reduced since the advent of drug-eluting stents. Non-stent-based methods for local drug delivery enable restenosis inhibition without the need for stent implantation, does not permanently change the structure of the vessel, are repeatable, and seems to be applicable where drug-eluting stents provide insufficient protection. Preclinical data indicate that short exposure of the vessel wall to a lipophilic inhibitor of cell proliferation is sufficient for preventing restenosis. Initial evidence to this effect emerged from an investigation of paclitaxel embedded in a matrix that enhances the solubility and release of the agent from the balloon coating as well as its transfer to the vessel wall. Further corroborating data from preclinical and clinical studies demonstrating a reduction in late lumen loss and lower restenosis rates led to the market introduction of a variety of paclitaxel-coated angioplasty balloons. The effectiveness of restenosis inhibition is not determined by the active agent alone. Other factors that are crucial for the effectiveness and safety of drug-coated angioplasty balloons are the formulation containing the agent and the coating technique. In this review we first outline the development of paclitaxel-coated balloons to then provide an overview of the preclinical results obtained with different paclitaxel-coated balloons and finally compare these with the outcome in patients. The article concludes with a short outlook on initial results with a zotarolimus-coated angioplasty balloon.

The difficult airway remains a challenge especially in emergencies.The use of laryngeal tube suction in 8 cases involving difficult airways in emergencies was reviewed.Use of the laryngeal tube was successful in all cases to bridge patients until a secure airway was established; insertions were successful at the first attempt and classified as easy. In 6 out of 8 patients a secure airway was established by cricothyreotomy or by surgical tracheotomy while using the laryngeal tube for oxygenation and ventilation of the patient.The laryngeal tube allows rapid oxygenation in emergency patients with a difficult airway until a secure airway can be established. In cases of potentially life saving operations successful ventilation via the laryngeal tube might allow the priority of establishing a secure airway to be deferred.

During the last decades considerable advances have been made in intravascular interventions for the treatment of coronary and peripheral arterial disease. However, long-term outcome remains an area of concern in many applications. Restenosis is still a challenge in endovascular medicine and has thus been referred to as the Achilles' heel of percutaneous intervention. Therefore, novel strategies have been developed to overcome this problem. These include drug-eluting stents, though still associated with stent thrombosis and in-stent restenosis, and the more recently introduced non-stent based local drug delivery systems, especially the paclitaxel-eluting balloon. Results of several preclinical and clinical studies indicate that short-term exposure of injured arteries to paclitaxel eluted from regular PTA and PTCA balloons may be sufficient to reduce late lumen loss and restenosis rates during a critical period of time after angioplasty of diseased coronary and peripheral arteries. Although the number of published trials and patients treated is still limited, available data seem to prove that restenosis inhibition by immediate drug release is feasible. This article reviews the rationale for the use of paclitaxel-coated balloons, data from preclinical and clinical studies, and the perspective of drug-coated balloons in peripheral arterial disease.

In these studies, a clone of cells derived from the porcine renal epithelial line LLC-PK1 grown on porous filters was used to evaluate basolateral uptake of the organic cation tetraethylammonium (TEA). (3H) TEA (1 microM) entered cells in a saturable and time-dependent manner achieving a steady-state value at 2 to 2.5 h. Uptake was reduced by hypothermia and the metabolic inhibitors sodium azide and iodoacetate. Several other organic cations in 1 mM concentrations inhibited the majority of TEA uptake. In lower concentrations, the inhibitory potency of these was: verapamil greater than cimetidine approximately amiloride approximately quinidine greater than procainamide approximately N1-methylnicotinamide. When sodium was replaced with potassium in the uptake medium, TEA uptake was also reduced consistent with electrogenic transport. However, uptake was reduced further by 1 mM cimetidine in the presence of both NaCl and KCl buffers. TEA uptake was not significantly different when the media pH was varied from 6.0 to 8.0. In addition, results of experiments in which intracellular pH was altered with NH4Cl were not consistent with the presence of organic cation/proton exchange. TEA/TEA exchange could not be demonstrated in experiments in which cells were preloaded with 1 mM nonradioactive TEA and uptake of (3H)TEA was measured or in which nonradioactive TEA in the external medium failed to enhance efflux from cells preloaded with (3H)TEA. These results indicate that the basolateral membrane of LLC-PKc10 cells has one or more transport processes for the mediated uptake of organic cations. However, the precise mechanism(s) involved in this transport remains to be elucidated.

Stroke is a serious complication of percutaneous coronary intervention and atrial fibrillation ablation procedures and patients have a high likelihood of persistent neurological deficits. Although formal criteria speak against intravenous or intra-arterial thrombolysis due to pre-existing antithrombotic and anticoagulation therapy, the conditions for recanalizing therapy are optimal due to the occurrence of vessel occlusion in the catheter suite or the chest pain unit. Brain imaging and an interdisciplinary approach are mandatory. In cases of intracerebral vessel occlusion intra-arterial thrombolysis possibly in combination with mechanical clot fragmentation is the first choice therapy. The management of the patient is always an individual therapeutic decision based on stroke severity, the pretreatment with antithrombotic and anticoagulation drugs, the availability of a neuro-interventionalist and the qualification of the local team.

We compared the ease of viewing the glottis under direct vision during conventional laryngoscopy with the quality of indirectly viewing on a monitor during laryngoscopy with a Macintosh videolaryngoscope in a multicenter study.After ethical approval and written informed consent of 300 patients with no anticipated difficult airway, conventional laryngoscopy with a Macintosh videolaryngoscopy blade was performed and the quality of the view of the glottis was assessed and documented according to the Cormack and Lehane scoring system as modified by Yentis and Lee. Subsequently, the indirect viewing conditions on the monitor were documented without changing the position of the blade. Differences between both distributions were analyzed using the Bland-Altman Test.Videolaryngoscopy improved the laryngoscopy score by 1 grade in 72 cases, by 2 grades in 17 cases and by 3 grades in 2 cases. A relevant improvement (from grades III/IV to II) was found in 28 patients. Viewing conditions worsened in 3 cases by 1 grade, in 4 cases by 2 grades and in 3 cases by 3 grades. A statistical analysis of the data gave a bias of 0.31 and an SD bias of 0.77.The 95% confidence interval of the distribution ranged from -1.12 to 1.81.Videolaryngoscopy can lead to better viewing conditions but in rare cases it may result in worse viewing conditions.

Jeder funfte Mann in Deutschland weist eine Adipositas auf (Body-mass-Index [BMI] >30 kg/m2). Zwei Drittel der Bevolkerung sind ubergewichtig (BMI > 25 kg/m2) (Bundesministerium fur Gesundheit 1999; Thefeld 2000).

Coronary revascularization using exclusively arterial grafts holds the promise of improved long-term patency. The T-graft approach achieves this goal with only two arterial grafts in coronary 3-vessel disease. Arterial grafts in diabetics, however, exhibit more frequently atherosclerotic wall abnormalities, and higher levels of endothelin-1 were found in diabetic arterial grafts, which may be associated with a higher incidence of vasoconstriction. The objective of this prospective study was to compare functional und angiographic parameters of arterial T-grafts in diabetics and nondiabetics.Coronary angiography was performed consecutively in 20 patients with insulin-dependent diabetes mellitus (IDDM), 20 patients with non-insulin-dependent diabetes mellitus (NIDDM), and 100 non-diabetics one week after complete arterial revascularization with T-grafts. Graft patency was assessed, and the diameter of the proximal left internal mammary artery (IMA) graft was measured using quantitative coronary analysis. Absolute flow volume in the proximal left IMA was measured using the flow-wire technique at baseline and after an adenosine injection into the graft to induce maximal hyperemia. Coronary flow reserve (CFR) was calculated as the ratio of maximal to baseline flow.There was no difference between patients with IDDM, patients with NIDDM and non-diabetics with respect to patency (98.3% vs. 98.8% vs. 97,8%, n.s.), graft lumen diameter (3.42 +/- 0.48 vs. 3.36 +/- 0.50 vs. 3.38 +/- 0.41 mm, n.s.), baseline flow (78.4 +/- 34.3 vs. 83.1 +/- 36.6 vs. 81.5 +/- 39.0 ml/min, n.s.), and CFR (1.85 +/- 0.37 vs. 1.89 +/- 0.44 vs. 1.90 +/- 0.40, n.s.).Baseline parameters (graft diameter and quantitative graft flow), patency and CFR are identical in diabetics and non-diabetics. Our results suggest that diabetic patients with coronary 3-vessel disease take comparable profit from complete arterial revascularization using the T-graft technique as non-diabetics.

The AtheroLink registry sought to observe the effect of plaque burden reduction by directional coronary atherectomy (DCA) prior to stenting on acute lesion success rate, on the clinical success rate and on the incidence of in-stent restenosis six months after intervention.Although coronary stenting has reduced restenosis, its effect has been less favorable in complex lesions with a high plaque burden that results from suboptimal stent expansion. Therefore, plaque removal by DCA may improve the results of coronary stenting.A total of 167 patients with60% stenosis in a native coronary artery of 2.8 to 4.0 mm in diameter were enrolled in 10 study centers on an intention-to-treat basis. All patients underwent DCA aimed at an optimal result (residual diameter stenosis20%) followed by stenting. Angiographic follow-up was performed in 120 (71.8%) patients at 5.3+/-2.8 months.Lesion success was achieved in 164/167 (98.2%) patients, and the clinical success rate was 95.2% (159/167 patients). The overall restenosis rate in the 120 patients with angiographic follow-up was 10.8% (13/120). Incidence of restenosis was lower (8.4%) in patients with optimal stent deployment following DCA compared to patients with a persisting caliber reduction15% (restenosis rate 15.3.%) and restenosis occurred with a significantly higher frequency (p0.04) in distal lesions (37.5%) compared to proximal stenoses (9.0%).This observational multicenter registry points to a potential reduction in restenosis by a synergistic approach of DCA and stenting performed under routinely accessible angiographic guidance. Therefore, multicenter-based randomized clinical trials are clearly warranted to finally clarify the validity of this complex approach versus conventional angioplasty plus stenting.

Atherosclerotic cardiovascular disease is generally accepted to be the result of metabolic disturbances. However, recent studies have suggested an infectious agent, especially Chlamydia pneumoniae or cytomegalovirus, to be involved in the pathogenesis of atherosclerosis. Atherosclerotic plaque specimens obtained from patients with coronary disease either by balloon dilatation catheter (13 cases) or atherectomy (16 patients) were examined for the presence of C. pneumoniae and cytomegalovirus. Using two primer pairs for C. pneumoniae, two primer pairs for the identification of unknown bacteria and primer pairs for the detection of immediate early gene E2 and the late genomic region of cytomegalovirus, we were unable to detect the suspected agents. The absence of C. pneumoniae, other bacteria and CMV in coronary atheromas is against the hypothesis of a pathogenetic role of these agents in coronary atheroma formation in the patients studied.

For invasive catheter procedures both ionic and nonionic contrast media (CM) with excellent tolerability are available. The governing practical factors for CM are X-ray opacity and biocompatibility. Tolerability of a contrast medium is governed among its physical properties by its viscosity, osmolality, and ionic concentration. In Germany the nonionic CM are currently preferred. Because of its low thrombotic complications, the ionic CM Ioxaglat is an important alternative in high risk interventions. In patients with known CM incompatibility, the prophylactic application of H1-receptor antagonists and corticosteroids allows catheterization safely without complications. In impaired renal function, hydration is the most effective prophylactic measure to be taken.

The studies presented here investigated the obtainable flows of different contrast media (Iopromide 370 mg iodine/ml, ZK 119 095 370 mg iodine/ml, ZK 139 129 370 mg iodine/ml, Iopamidol 370 mg iodine/ml, Iopromide 300 mg iodine/ml, ZK 119 095 300 mg iodine/ml, ZK 139 129 300 mg iodine/ml, Iopamidol 300 mg iodine/ml, aqua dest.) in 4.1 Charrière coronary catheters. The measurements of the flow achieved by a standardised power of 100 N show that the highest values are reached with the substance ZK 119 095 (both for 300 mg iodine/ml and 370 mg iodine/ml). On comparison of the catheter types there are no differences in the delivery rate. The x-ray contrast-media, however, are significantly different: the lowest iodine delivery rate is found for iopromide 370 with 384.5 mg iodine/s; the highest rate for the test substance ZK 119 095 with 648.9 mg iodine/s. Although contrast media with low viscosity contain considerably less iodine/ml it is possible to achieve an iodine density in coronary vessels by about 86% higher than that achieved by contrast media with 370 mg iodine/ml. Therefore, the possibility to choose a viscosity-adapted x-ray contrast-medium allows the use of very thin cardiac catheter systems without leading to a worsening of picture quality.

In the present study we investigated the contrast medium flow in 8 different types of left heart catheter having two different diameters (each n = 5). Using a 10 ml syringe and the contrast medium Ultravist 370, we calculated a mean value of 94.24 N + 16.01 for the maximum manual injection force in 18 test subjects. For the sake of simplicity, the figure of 100 N was defined as standardized manual force (which is within the standard deviation). If the maximally admissible static pressure of 82.5 bar is not to be exceeded, flow rates of not more than 16-17 ml/s are possible with 5.2 Fr. catheters, and 21-23 ml/s and 1.46 ml/s for 5.2 Fr. catheters, and between 1.99 ml/s and 2.17 ml/s for 6 Fr. catheters. Thus, a 50% higher flow can be achieved with 6 Fr. catheters as compared with 5.2 Fr. catheters at the same injection force. The iodine delivery rates are between 506 mg iodine/s and 539 mg iodine/s for 5.2 Fr. catheters, and between 738 mg iodine/s and 804 mg iodine/s for 6 Fr. catheters. The figures for the jet stream.

In the present study, the torsional moments of 8 different types of catheter having two different calibres (n = 5 in each case) were investigated. The catheters were made of linear polyurethane (Cordis, Netherlands). The transmitted torsional moments of the 5.2 Fr. catheters positioned in a straight line were 1.48 +/- 0.09 Ncm (VK = 6%), positioned in a 90 degree curve 1.39 +/- 0.11 Ncm (VK = 8%). The corresponding figures for the 6 Fr. catheters were 2.43 +/- 0.20 Ncm (VK = 8%) and 2.26 +/- 0.20 Ncm (VK = 9%). The highly stable transmission behaviour in particular of the 5 Fr. catheters--with a variation coefficient of the torsional moments of 6%--is due mainly to the accurate manufacture of the catheters, and the material chosen. The study is a first step towards achieving systematic quality control of the materials used for diagnosis and therapy.

Mechanisms exist in renal proximal tubules for the mediated transepithelial secretion or reabsorption of endogenous and exogenous organic cations. In the studies presented here, the uptake of the organic cation tetraethylammonium (TEA) into confluent monolayers of opossum kidney cells was evaluated to determine if these cells might serve as an in vitro model of this transport pathway. 3H-TEA entered opossum kidney cells in a time-dependent manner. Uptake at early time points was saturable with an apparent Km of 59.1 +/- 11.2 microM and a Vmax of 1,292 +/- 210 fmol/micrograms of DNA. TEA uptake was inhibited in a dose-dependent manner by several other organic cations including amiloride, cimetidine, verapamil, procainamide, quinidine and N1-methylnicotinamide. With 1 mM concentrations of these compounds, uptake was virtually eliminated. However, another organic cation, N9-methylnicotinamide caused only minimal inhibition. TEA uptake was significantly reduced by sodium azide, suggesting dependence on oxidative phosphorylation. An alkaline medium pH enhanced TEA uptake, but, at the same pH, uptake was similar in the presence or absence of bicarbonate. When cellular pH was altered by ammonium chloride addition or removal, TEA uptake was not affected. Thus, organic cation/proton exchange, as has been demonstrated previously in apical membrane vesicles prepared from proximal tubules, is evidently not responsible for TEA uptake. Similarly, uptake does not appear to result from organic cation/organic cation exchange. These results indicate that the plasma membrane of opossum kidney cells contains a transport system(s) for the mediated uptake of organic cations and that these cells may be a useful mode for further study of renal epithelial transport of these solutes.