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Funding Acknowledgements Type of funding sources: Other. Main funding source(s): The DEVICE registries were financed by “Stiftung Institut für Herzinfarktforschung (IHF)”, with additional support by grants from Biotronik, Medtronic, and St. Jude Medical. Background Experimental data and early clinical trials suggested that amiodarone may alter the defibrillation threshold of ICD systems. However, because of its potent antiarrhythmic effect and lack of alternatives, amiodarone is frequently used for antiarrhythmic therapy in ICD or CRT-D patients, leading to the question of whether ICD testing with ventricular fibrillation induction should be repeated in these patients after starting amiodarone. Objective This study was designed to assess the impact of amiodarone therapy on the success of ventricular fibrillation induction tests in this "real life" cohort of ICD recipients of the German DEVICE registry. Methods 3,680 patients who underwent ICD implantation, revision, or upgrade in 49 centers participating in the German DEVICE Registry were enrolled 03/2007-02/2014. Results Intraoperative defibrillation testing was conducted in 2,705 patients receiving only beta-blockes as antiarrhythmic therapy and in 422 patients under betablocker plus amiodarone therapy. With regard to ineffective defibrillation tests, no difference could be described between the two groups (0.6% vs. 0.5%; p=0.77). In a similar fashion 488 patients receiving beta-blockers only and 65 patients under beta-blocker plus amiodarone therapy who were scheduled for postoperative defibrillation testing showed comparable rates of ineffective testing (14.5% vs. 15.4%; p=0.86). Conclusions Based on 3,127 intraoperative and 553 postoperative defibrillator testings, our study failed to show a significant association of amiodarone therapy and ineffective defibrillator testings in this "real life" cohort of ICD recipients of the German DEVICE registry. Our results thus underline that, apart from special situations such as right-sided implantation, HCM, extravenous ICD systems, etc., it might not be necessary to perform a DFT test after the start of an amiodarone therapy in ICD patients.

Funding Acknowledgements Type of funding sources: None. Background/Introduction Catheter ablation of symptomatic atrial fibrillation (AF) is an established treatment option. Cryoballoon (CBA) and radiofrequency ablation (RFA) have demonstrated comparable high rates of freedom from atrial arrhythmia recurrence. Comparative data on quality of life (QoL) outcomes with respect to the used energy source are scarce. Purpose To compare QoL changes following CBA versus RFA in symptomatic AF. Methods This is a sub-analysis of the prospective multi-center FREEZE Cohort Study (ClinicalTrials.gov, NCT01360008). QoL changes were assessed by EQ-5D-3L self-report questionnaire and by EHRA symptom score at baseline and follow-up. Five dimensions of QoL were compared between the treatment groups: "mobility", "self-care", "usual activities", "pain/discomfort", and "anxiety/depression". Changes of Visual Analogue Scale (EQ-VAS) and general physical condition (GPC) were assessed. Results From 2011 to 2016, a total of N=4,189 patients were included, and N=2,110 (50.4%) - CBA N=1,590 (75%) and RFA N=529 (25%) - completed all QoL questionnaires. Differences between groups were observed. Mean age was 61.4±10.4 (CBA) and 63.2±10.4 (RFA) years (p/= II in 89.7% versus 92.9% of patients in CBA and RFA group at baseline (p At follow-up, atrial arrhythmia recurrence was documented in 45.0% and 56.9% of patients in the CBA and RFA group (p/= II was documented in 23.7% and 32.0% of patients (p Significant differences in QoL dimensions from baseline to follow-up were observed between the groups (see Figure): Patients in the CBA group showed a statistically significant greater improvement for the QoL dimension "pain/discomfort", „general physical condition", EQ-VAS, and EQ-5D-Score as compared to the RFA group (all p Conclusion Catheter ablation in symptomatic AF was associated with a significant improvement of AF symptoms, "pain/discomfort", "anxiety/depression", and GPC in both groups. However, there was only a small benefit of ablation on „mobility", „self-care", and „usual activities". Interestingly, in the CBA group patients reported significantly more frequently amelioration of "pain/discomfort" and „general physical condition". This finding was confirmed by a higher EQ-VAS and EQ-5D-Score as well as a higher level of satisfaction in the CBA group, and might be related to the lower recurrence rate.

Funding Acknowledgements Type of funding sources: Private company. Main funding source(s): Medtronic, Inc., Minneapolis, MN, USA Introduction Increasing evidence suggests early rhythm-control therapy in atrial fibrillation (AF) results in higher freedom from atrial arrhythmia (AA) recurrence and improved cardiovascular outcomes. However, the impact of specifically early cryoballoon ablation (CBA) is not well known. Purpose To assess the impact of early CBA of atrial fibrillation on efficacy and safety outcomes. Methods We evaluated AA recurrence (≥30 sec after a 90-day blanking period), repeat ablation, and serious procedure-related complications in patients with early vs. later CBA (≤12 vs. >12 months from diagnosis) in patients enrolled in the prospective, multicenter (121 centers in 37 countries). Subjects underwent CBA and were followed either 12 or 24 months per local standard of care. Results A total of 3447 subjects were followed through 12 months and a subset of 1220 through 24 months. In summary, 1573 patients (46%) had early CBA treatment at a median [IQR] of 0.3 [0.1 – 0.6] years from AF diagnosis (age 62±12 years, 35.8% female, 71.4% paroxysmal AF), and 1874 (54%) had later treatment at a median of 3.4 [1.9 – 6.7] years after diagnosis (age 61±11 years, 36.2% female, 75.0% paroxysmal AF). Early treatment patients were less hypertensive (53.5% vs 57.9%, p=0.01), had smaller left atrial diameters (41±7mm vs 42±7mm, p Conclusions After AF diagnosis, early vs. later CBA results in higher freedom from AA recurrence and is associated with fewer safety events in a real-world evaluation. The difference in comorbidities at baseline between the two cohorts may contribute to the CBA being less effective in the later treatment cohort.

Background After percutaneous mitral-valve edge-to-edge repair (MVER) for mitral regurgitation (MR) in patients with baseline tricuspid regurgitation (TR), about one third of patients shows improvement in TR severity. It is unknown whether this improvement may depend on the presence of a right ventricular (RV) pacemaker (PM) lead. Aim We investigated whether the presence of an existing RV PM lead influences TR severity after successful MVER due to symptomatic secondary MR. Methods and results We retrospectively analyzed 115 consecutive patients with symptomatic secondary high-grade MR (age 78.1±9.4 years, 50 women (43%) and baseline TR grade > or =1 (semiquantitative grading from 0 to 5) treated with MVER using the MitraClipTM device (Abbott, Cardiovascular, USA) and separated them in 2 groups, 43 patients with a PM lead compared to 72 pts without (see Table). TR grading by echocardiography was performed before and 3 months after MVER. (median follow up duration was 3 months). Procedural success with reduction of MR to < or =2/4 grades was 100% in both groups (p Conclusion There was an overall significant change in TR after successful MVER. Although there was a trend towards an increase in TR after MVER in pts with PM lead there was no overall significant correlation between changes in TR severity and the presence of an RV PM lead but rather with baseline RV dilatation. Funding Acknowledgement Type of funding sources: None.

Background A few studies have demonstrated the safety and efficacy of cryoballoon ablation (CBA) in elderly patients (≥75 years old) with atrial fibrillation (AF). However, global utilization and outcomes of CBA in the octogenarian population (≥80 years old) have not been reported. Purpose To evaluate the efficacy and safety of CBA of AF in patients ≥80 years old. Methods The Cryo Global Registry (NCT02752737) is an ongoing, prospective, multicenter registry. In this analysis, 1674 patients with paroxysmal or persistent AF were included in 37 global centers who treated at least one octogenarian with CBA. Analysis cohorts were defined as patients ≥80 and patients Results The average age of the octogenarians (n=101) was 82±2 years vs 62±10 years in the control group (n=1573). More females were found in the octogenarian population (51.5% vs 35.7%, p0.05). Success rates of acute pulmonary vein isolation did not differ between the groups (95.0% vs 96.2%, p=0.59). No differences were observed between ≥80- (5.9%) and Conclusion Cryoballoon ablation for the treatment of AF is a safe procedure in octogenarians, with efficacy and complication rates comparable to younger patients. Funding Acknowledgement Type of funding sources: Private company. Main funding source(s): Medtronic, Inc.

Contains fulltext : 249977.pdf (Publisher’s version ) (Closed access) BACKGROUND: It is important to evaluate whether a new treatment for heart failure with reduced ejection fraction (HFrEF) provides additive benefit to background foundational treatments. As such, we aimed to evaluate the efficacy and safety of empagliflozin in patients with HFrEF in addition to baseline treatment with specific doses and combinations of disease-modifying therapies. METHODS: We performed a post-hoc analysis of the EMPEROR-Reduced randomised, double-blind, parallel-group trial, which took place in 520 centres (hospitals and medical clinics) in 20 countries in Asia, Australia, Europe, North America, and South America. Patients with New York Heart Association (NYHA) classification II-IV with an ejection fraction of 40% or less were randomly assigned (1:1) to receive the addition of either oral empagliflozin 10 mg per day or placebo to background therapy. The primary composite outcome was cardiovascular death and heart failure hospitalisation; the secondary outcome was total heart failure hospital admissions. An extended composite outcome consisted of inpatient and outpatient HFrEF events was also evaluated. Outcomes were analysed according to background use of angiotensin-converting enzyme (ACE) inhibitors, angiotensin II receptor blockers (ARBs) or angiotensin receptor neprilysin inhibitors (ARNIs), as well as β blockers and mineralocorticoid receptor antagonists (MRAs) at less than 50% or 50% or more of target doses and in various combinations. This study is registered with ClinicalTrials.gov, NCT03057977. FINDINGS: In this post-hoc analysis of 3730 patients (mean age 66·8 years [SD 11·0], 893 [23·9%] women; 1863 [49·9%] in the empagliflozin group, 1867 [50·1%] in the placebo group) assessed between March 6, 2017, and May 28, 2020, empagliflozin reduced the risk of the primary outcome (361 in 1863 participants in the empagliflozin group and 462 of 1867 in the placebo group; HR 0·75 [95% CI 0·65-0·86]) regardless of background therapy or its target doses for ACE inhibitors or ARBs at doses of less than 50% of the target dose (HR 0·85 [0·69-1·06]) and for doses of 50% or more of the target dose (HR 0·67 [0·52-0·88]; p(interaction)=0·18). A similar result was seen for β blockers at doses of less than 50% of the target dose (HR 0·66 [0·54-0·80]) and for doses of 50% or more of the target dose (HR 0·81 [0·66-1·00]; p(interaction)=0·15). Empagliflozin also reduced the risk of the primary outcome irrespective of background use of triple therapy with an ACE inhibitor, ARB, or ARNI plus β blocker plus MRA (given combination HR 0·73 [0·61-0·88]; not given combination HR 0·76 [0·62-0·94]; p(interaction)=0·77). Similar patterns of benefit were observed for the secondary and extended composite outcomes. Empagliflozin was well tolerated and rates of hypotension, symptomatic hypotension, and hyperkalaemia were similar across all subgroups. INTERPRETATION: Empagliflozin reduced serious heart failure outcomes across doses and combinations of disease-modifying therapies for HFrEF. Clinically, these data suggest that empagliflozin might be considered as a foundational therapy in patients with HFrEF regardless of their existing background therapy. FUNDING: Boehringer Ingelheim and Eli Lilly and Company.

Background Alcohol septal ablation (ASA) improves symptoms in patients with hypertrophic obstructive cardiomyopathy (HOCM) but gender-disparities have only rarely been investigated. Purpose To assess gender-disparities regarding outcome and procedure-related aspects in HOCM patients undergoing ASA. Methods and results 1,367 consecutive ASAs between 2002 and 2020 were retrospectively analyzed for sex-differences. Females (47.2%) had more advanced age at the timing of ASA (66.0 years [IQR 55.0–74.0] vs. 54.0 years [IQR 45.0–62.0]; p Conclusion Female HOCM patients had more advanced age, more severe symptoms and a higher IVSD when indexed to BSA at the timing of ASA. However, early hemodynamic response was better in females, but procedure-related complete heart block was more often found in women. Gender-disparities in clinical characteristics and procedural outcome of ASA should be taken into consideration. Funding Acknowledgement Type of funding sources: None.

Obwohl Herzschrittmacher und implantierbare Defibrillatoren heute der therapeutische Standard in der Behandlung bradykarder und tachykarder Herzrhythmusstorungen sind, kommt es doch insbesondere durch die transvenosen Stimulations- und Defibrillationselektroden im Langzeitverlauf nicht selten zu Komplikationen wie Elektrodenbruch, Infektionen und Trikuspidalinsuffizienzen. Daher sind in den letzten Jahren sondenlose Herzschrittmacher und rein subkutan implantierbare Kardioverter-Defibrillatoren (S-ICD) entwickelt worden, die ohne transvenose Elektroden implantiert werden und so die Langzeitkomplikationsrate der Implantate reduzieren sollen. Allerdings sind bisher verfugbare sondenlose Herzschrittmacher auf die einfache 1‑Kammer-Stimulation und der S‑ICD auf einen reinen Defibrillator ohne die Moglichkeit der antibrady- bzw. antitachykarden Stimulation oder kardialen Resynchronisation beschrankt. Daher konnen diese Gerate nicht als Mehrkammerschrittmacher bzw. -defibrillatoren dienen, obwohl gerade bei diesen aufgrund der Zahl der transvenosen Sonden auch mit mehr Langzeitkomplikationen zu rechnen ist. Der vorliegende Beitrag fasst die aktuelle Datenlage zu den sondenlosen Schrittmachern und S‑ICD zusammen, diskutiert die Limitationen dieser Systeme und gibt einen Ausblick, wohin sich die Therapien entwickeln konnten.

Die Analgosedierung des Patienten im Rahmen rhythmologischer Eingriffe ist von erheblicher Bedeutung fur einen erfolgreichen und risikoarmen Eingriff und tragt wesentlich zum Komfort des Patienten und Untersuchers bei. Das Spektrum der Kardioanalgosedierung reicht von einer sanften Anxiolyse bis hin zur tiefen Analgosedierung beim spontan atmenden Patienten. Die erste Auflage dieses Positionspapiers zur Kardioanalgosedierung mit Fokus auf Eingriffe in der Rhythmologie gibt Empfehlungen zu deren Anwendung im Rahmen von elektrophysiologischen Eingriffen, Implantationen kardialer Devices, wie z. B. Herzschrittmacher oder Defibrillatoren, sowie anderen kardiologischen Eingriffen. Dieses Papier erlautert Indikationen, Ziele und Patientenselektion inklusive Risikostratifizierung des individuellen Patienten fur Sedierung. Es gibt eine Ubersicht uber die Pharmakologie der unterschiedlichen Sedativa und Analgetika hinsichtlich ihrer Sicherheit und Wirksamkeit. Auch definiert es Standards fur die optimale Patientenvorbereitung und Aufklarung uber die Sedierung. Die personellen und apparativen Voraussetzungen fur die Durchfuhrung und Dokumentation der Sedierung sowie die klinische Uberwachung im Rahmen des Eingriffes werden ebenso definiert wie die Anforderungen an die Aus‑, Fort- und Weiterbildung des Personals.

Kathetergestutzte rhythmologische Eingriffe und Implantationen rhythmologischer Systeme machen einen relevanten Teil der kardiologischen Behandlungen aus. Daher besteht ein nicht unerhebliches Konfliktpotenzial bezuglich Notwendigkeit und Dauer der stationaren Behandlung. Die vorliegende gemeinsame Stellungnahme von Deutscher Gesellschaft fur Kardiologie und Medizinischem Dienst der Krankenversicherung stellt vor dem Hintergrund sozialrechtlicher Vorgaben fur elektive rhythmologische Eingriffe trennscharfe und uberprufbare Kriterien zusammen, die als objektive Entscheidungsgrundlage herangezogen werden konnen, um Notwendigkeit und Dauer von Krankenhausbehandlungen zu bewerten. Sie schliest sich an die 2015 veroffentlichte Stellungnahme zur „Notwendigkeit und Dauer von Krankenhausbehandlungen bei Koronarangiografien und -interventionen“ an. Hierdurch sollen Auseinandersetzungen zwischen Krankenhausern und MDK reduziert und optimierte Ablaufe erleichtert werden. Die aufgefuhrten Kriterien beziehen sich ausdrucklich nicht auf Akutbehandlungen. Zudem besteht Konsens, dass unabhangig von Vergutungsanspruchen letztlich die Entscheidung uber Art und Umfang der medizinischen Behandlung beim behandelnden Arzt verbleibt.

Vorhofflimmern ist die mit Abstand haufigste Herzrhythmusstorung. Schatzungen zufolge entwickeln zumindest 25 % der aktuell 40-Jahrigen im Verlauf ihres Lebens Vorhofflimmern. Es ist mit einer erhohten Mortalitat assoziiert und wesentliche Ursache fur Schlaganfalle. Neue Entwicklungen der letzten Jahre waren Grundlage einer Uberarbeitung der Leitlinien. Die aktuelle 2016 ESC-Leitlinie zum Vorhofflimmern gibt einen detaillierten Uberblick uber den aktuellen Wissensstand in der Behandlung von Vorhofflimmern. Im Vergleich zur letzten Aktualisierung aus dem Jahr 2012 sind der Patient und die interdisziplinare Zusammenarbeit starker in den Vordergrund geruckt. Von insgesamt 154 Empfehlungen wurden ca. zwei Drittel als Evidenz (Evidenzgrad A oder B) eingestuft, wobei allerdings nur 23 (15 %) auf Evidenzgrad A beruhen. Die Klassifikation von Vorhofflimmern hat sich geringfugig geandert. Paroxysmales Vorhofflimmern, das innerhalb von 7 Tagen kardiovertiert wird, wird weiterhin als paroxysmal und nicht als persistierend klassifiziert. In der Schlaganfallpravention treten Blutungsscores im Vergleich zum CHA2DS2-VASc in den Hintergrund und begrunden in der Regel nicht den Verzicht auf eine Antikoagulation. Die Leitlinie spricht eine eindeutige Praferenz zugunsten von NOAK gegenuber Vitamin-K-Antagonisten aus. ASS hat unverandert zur letzten Leitlinie keinen Stellenwert in der Schlaganfallpravention bei Patienten mit Vorhofflimmern. Die Bedeutung des weiblichen Geschlechts als Risikofaktor fur thrombembolische Ereignisse ist abgewertet worden. Frequenzregulation und Rhythmus erhaltende Therapie weisen demgegenuber kaum Anderungen auf, wobei chirurgische Ablationsverfahren in der Leitlinie grosere Bedeutung erlangen. Der vorliegende Kommentar fasst wesentliche Anderungen zusammen und diskutiert die Leitlinie vor dem Hintergrund der Versorgungssituation in Deutschland.

Arterial hypertension represents one of the most frequent chronic diseases that can lead to complications, such as stroke, dementia, heart attack, heart failure and renal failure. By 2025 the number of hypertensive patients will increase to approximately 1.6 billion people worldwide. The new guidelines of the European Society of Cardiology (ESC) and the European Society of Hypertension (ESH) on the management of arterial hypertension replace the guidelines of the ESC/ESH from 2013. The 2018 guidelines of the ESC/ESH were adopted by the German Cardiac Society and the German Hypertension League. In these comments national characteristics are worked out and the essential new aspects of the guidelines are critically discussed. These include, for example, the definition of hypertension, the importance of out of office blood pressure measurements, revised blood pressure targets, the modified algorithm for drug treatment and the relevance of device-based hypertension treatments. Important aspects for the management of hypertensive emergencies are also presented.

Die aktuelle Leitlinie der Europaischen Gesellschaft fur Kardiologie „Ventrikulare Arrhythmien und Pravention des plotzlichen Herztodes“ aus 2015 aktualisiert die Leitlinie aus 2006 und beinhaltet eine Vielzahl von Neuerungen und Bewertungen, welche auf aktuellen Studien beruhen. In diesem Kommentar werden die europaischen Empfehlungen unter Berucksichtigung der Bedurfnisse der Versorgungsstrukturen in Deutschland interpretiert und hierfur angepasste Empfehlungen spezifiziert. Die neue Leitlinie fokussiert auf die Pravention des plotzlichen Herztodes unter besonderer Berucksichtigung von strukturell assoziierten ventrikularen Arrhythmien und angeborenen Arrhythmieerkrankungen. Neu sind Empfehlungen zur autoptischen Klarung inklusiver molekularer Untersuchungen bei plotzlichen Todesfallen, detaillierte Empfehlungen zur Anwendung subkutaner und tragbarer Defibrillatoren, das psychosoziale Management nach Implantation von Defibrillatoren sowie der Risikostratifizierung fruh nach einem Myokardinfarkt. Die Empfehlungen zur kardialen Resynchronisationstherapie wurden anhand aktueller Studien adaptiert, die Indikationen zur Versorgung mit implantierbaren Defibrillatoren bei Patienten ohne ischamische Kardiomyopathie wurden anhand aktuellster Studien im Vergleich zur europaischen Leitlinie fur Deutschland modifiziert. Die Leitlinie zeigt eine deutliche Aufwertung der Katheterablation ventrikularer Arrhythmien sowie Empfehlungen zur fruhzeitigen interventionellen Therapie beim Auftreten einer ventrikularen Tachykardie. In diesem Kommentar werden zu jedem Themenkomplex die Neuheiten der aktuellen europaischen Leitlinie herausgestellt sowie in diesem Zusammenhang mogliche Anpassungen der Empfehlungen fur Deutschland nach Meinung der Autoren dargestellt.

Herzschrittmacher und Implantierbare-Kardioverter-Defibrillator(ICD)-Systeme werden weltweit nicht nur von Herzchirurgen, sondern zunehmend auch von Kardiologen implantiert. Neben den theoretischen Grundlagen bezuglich Indikation und Systemauswahl sind fundierte Kenntnisse der Anatomie und der spezifischen Operationstechnik gleichermasen unverzichtbar. Fur die OP-Technik werden die wichtigen Aspekte der Patientenvorbereitung, der perioperativen Uberwachung und der Betaubungsverfahren ebenso wie die Zugangswege zum Venensystem, die Elektrodenauswahl und alternative intrakardiale Implantationsorte beschrieben. Daruber hinaus soll die Diskussion verschiedener intra- und postoperativer Komplikationen helfen, in der Praxis situationsgerecht zu reagieren.

Die retrosternale Infektion des vorderen Mediastinums nach herzchirurgischem Eingriff mit Sternotomie (Poststernotomie-Mediastinitis, PSM) ist eine lebensbedrohliche Komplikation. Sie stellt ein multifaktorielles und komplexes Krankheitsbild dar, an deren Diagnostik und Therapie viele Disziplinen beteiligt sind. Da verschiedene Behandlungskonzepte existieren, die oft auf Erfahrungen einzelner Kliniken beruhen, hat es sich die Deutsche Gesellschaft fur Thorax-, Herz- und Gefaschirurgie (DGTHG) in Kooperation mit der Schweizerischen Gesellschaft fur Herz- und Thorakale Gefaschirurgie (SGHC) zum Ziel gesetzt, eine evidenz- und konsensbasierte Leitlinie zum „Management der Mediastinitis nach herzchirurgischem Eingriff“ zu entwickeln. Unter Einbeziehung aller an Diagnostik und Therapie der PSM beteiligten Berufsgruppen wird eine S3-Leitlinie gemas dem Regelwerk der Arbeitsgemeinschaft der Wissenschaftlichen Medizinischen Fachgesellschaften (AWMF) erarbeitet, um die medizinische Versorgung von Patienten mit PSM zu verbessern. Hier werden die Ziele und die methodischen Verfahren dieser Leitlinie beschrieben.

Increasing complexity and new highly differentiated therapeutic procedures in cardiology result in a need for additional training beyond cardiology board certification. The German Cardiac Society therefore developed a variety of certifications of educational curricula and definition of specialized centers. Standardization and structuring in education and patient treatment, as defined by certifications may be helpful; however, introduction of certification can have serious consequences for hospital structure, the side effects of which may impair quality of treatment for individual patients. The current article discusses these issues against the background of the following questions: how is quality defined? How do certifications interfere with patient care on a nationwide level, how do they influence responsibilities and teamwork? Are there conflicts of interests by designing certifications and how good are the organizational structures? Finally, suggestions are made on what has to be considered when designing certifications. Certifications should acknowledge all cardiologists, irrespective of their position in the level of care. There should be a coherent unified concept synchronizing all certifications and administration needs to be transparent and well structured.

Erratum zu: Der Kardiologe 2017 https://doi.org/10.1007/s12181-017-0179-4 Im Abschnitt „Narkotika“, Unterabschnitt „Propofol“ wurde eine fehlerhafte Umrechnung der Medikamentendosis in eine Perfusorlaufrate angegeben. Wir bitten um Beachtung des unten angefugten, korrigierten Abschnitts und bitten …

We report on a 59-year old man with acute myocardial infarction and profound cardiogenic shock in which the successful employment of the transcutaneous left ventricular assist device Impella 2.5 could rapidly establish temporary circulatory support in the catheterization laboratory, and thereby aid a high-risk three vessel revascularization procedure.

Cardiac resynchroinsation therapy (CRT) aims to correct the mechanical dyssynchrony in patients with heart failure and broad QRS complex. Until now, indication for CRT is based mainly on clinical and electrocardiographic criteria. Because QRS width is only weakly correlated to mechanical dyssynchrony, imaging techniques such as echocardiography and magnetic resonance tomography (MRT) seem suitable for analysis of dyssynchrony. Echocardiography has been studied in several studies for identification of suitable CRT candidates. Apart from conventional methods such as M mode-, 2 D-, and Doppler echocardiography other techniques which will be discussed in this article, including tissue Doppler echocardiography, have been used. Despite many positive results in individual studies no single echocardiographic parameter was able to predict positive CRT response in a prospective multicenter trial. Thus, QRS width remains the "gold standard" for CRT patient identification at present. In borderline cases, a combination of several echocardiographic measures of dyssynchrony may prove helpful. The results of studies with new techniques such as 2-dimensional strain analysis or 3D-echocardiography remain to be awaited. In the future, MRT may play a bigger role in this setting.

Eine Verdickung der Herzmuskelwande kann die Folge zahlreicher Krankheitsbilder sein. Die Abgrenzung der Krankheitsbilder mit primarer Myokardhypertrophie von den sekundaren Hypertrophieformen hat weitreichende Konsequenzen fur die Prognose und Therapie. In den meisten Fallen ist fur die Diagnose der genetisch bedingten hypertrophen Kardiomyopathie neben Anamnese, Auskultation und EKG die Echokardiographie ausreichend. In seltenen Fallen kann zur Abgrenzung wichtiger Differenzialdiagnosen eine Gewebedopplerechokardiographie, Myokardbiopsie, Gadolinium-Kontrast-MRT-Untersuchung oder Genanalyse hilfreich sein. Die Linksherzkatheteruntersuchung sollte nur bei echokardiographisch nicht eindeutig zu beurteilender Obstruktion oder bei geplanter transkoronarer Ablation der Septumhypertrophie (TASH) durchgefuhrt werden. Bei der Therapie der hypertroph obstruktiven Kardiomyopathie steht neben den Allgemeinmasnahmen die Behandlung der Obstruktion im linksventrikularen Ausflusstrakt im Vordergrund. Bei symptomatischen Patienten besteht bei Versagen einer medikamentosen Behandlung mit β-Blocker oder Verapamil die Indikation zur TASH oder operativen Myektomie. Die Implantation eines ICD zur Primarpravention des plotzlichen Herztodes hat bei Vorhandensein von Risikofaktoren einen festen Stellenwert. Die hypertensive Herzkrankheit und das Sportlerherz sind durch eine nur milde Myokardhypertrophie gekennzeichnet. Speicherkrankheiten konnen das Bild einer hypertroph nicht obstruktiven Kardiomyopathie imitieren. Bei diesen sekundaren Formen der Myokardhypertrophie steht die Behandlung der Grunderkrankung im Vordergrund.

Mild hypothermia following successful resuscitation from prehospital cardiac arrest has shown to improve patient's short-term neurological outcome. Usually, extracorporal methods are performed to achieve a core temperature of 32–34 °C. Recently, an endovascular cooling device has proven to be safe and feasible to induce mild hypothermia. Because of precise target temperature control in daily clinical routine, the endovascular method might lead to more favorable neurological outcomes than extracorporal cooling using cold packs. We retrospectively studied 39 patients after prehospital cardiac arrest from various causes, who were treated with mild hypothermia for 24 h either by an endovascular cooling device (group 1; n=19) or by an extracorporal method (group 2; n=20) using cold packs. Target temperature was 33 °C in group 1 and 32-34 °C in group 2. The efficiacy of the cooling procedure and patient's neurological outcome (classified by cerebral performance category CPC) at the time of hospital discharge were compared between both groups. Patient's baseline characteristics were comparable between both groups. During hypothermia, the target temperature was reached in all cases in group 1 but only in two cases in group 2 (p

This study investigated strategies that may increase the yield of drug resistance testing prior to starting antiretroviral therapy (ART), and whether transmitted and polymorphic resistance-associated mutations (RAMs) correlated with virological outcomes.We carried out retrospective testing of baseline samples from patients entering the SENSE trial of first-line ART in Europe, Russia and Israel. Prior to randomization to etravirine or efavirenz plus two nucleos(t)ide reverse transcriptase inhibitors (NRTIs), plasma samples underwent routine Sanger sequencing of HIV-1 RT and protease ((plasma)SS) in order to exclude patients with transmitted RAMs. Retrospectively, Sanger sequencing was repeated with HIV-1 DNA from baseline peripheral blood mononuclear cells (PBMCSS); baseline plasma samples were retested by allele-specific PCR targeting seven RT RAMs (AS-PCR) and ultra-deep RT sequencing (UDS).By (plasma)SS, 16/193 (8.3%) patients showed ≥ 1 transmitted RAM affecting the NRTIs (10/193, 5.2%), non-nucleoside reverse transcriptase inhibitors (4/193, 2.1%) or protease inhibitors (2/193, 1.0%). No additional RAMs were detected by AS-PCR (n = 152) and UDS (n = 24); PBMCSS (n = 91) yielded two additional samples with one RAM each. Over 48 weeks, 4/79 (5.1%) patients on etravirine and 7/78 (9.0%) on efavirenz experienced virological failure; none had baseline RAMs. Conversely, 11/79 (13.9%) patients randomized to etravirine had one polymorphic RAM from the etravirine score in baseline plasma (V90I, V106I or E138A), without any impact on virological outcomes.The detection of resistance increased marginally with PBMC testing but did not increase with sensitive plasma testing. A careful consideration is required of the cost-effectiveness of different strategies for baseline HIV drug resistance testing.

This article aims to give an overview over important articles in the field of implantable cardioverter defibrillator (ICD) therapy in 2012. Important publications concern analyses on therapy efficacy and safety of the subcutaneous ICD, gender-specific differences in the complication rate and prognosis after ICD implantation, the necessity of intraoperative testing of the defibrillation threshold and the impact of preventive measures to reduce ICD therapies on prognosis after device implantation. The relevance of the study findings for daily clinical practice is briefly discussed.

Background: Etravirine is approved for use in treatment-experienced patients at a dose of 200 mg twice daily. Efavirenz has been associated with greater increases in serum lipids compared with other non-nucleosides in randomized trials of first-line treatment. Methods:In this double-blind, placebo-controlled trial, 157 treatment-naive patients with HIV RNA 5000 copies/mL were randomized 1:1 to either 400 mg of etravirine once daily (n79) or 600 mg of efavirenz once daily (n78) plus two nucleoside analogues (either abacavir/lamivudine, zidovudine/lamivudine or tenofovir/emtricitabine) for 48 weeks. Lipids were measured under fasting conditions at baseline and all visits to Week 48. Clinicaltrials.gov identifier: NCT00903682. Results:Overall, the patients had a median baseline CD4 count of 302 cells/mm(3) (range 74722) and a median HIV RNA of 4.8 log(10) copies/mL (range 3.56.6). Both the non-nucleosides and the nucleoside analogues used caused changes in serum lipids. In the efavirenz arm, patients showed significantly larger increases in high-density lipoprotein (HDL) (0.15 mmol/L, P0.004), low-density lipoprotein (LDL) (0.35 mmol/L, P0.005), total cholesterol (0.61 mmol/L, P0.0001) and triglycerides (0.33 mmol/L, P0.03) at Week 48 compared with the etravirine arm. Across the two arms, patients taking abacavir/lamivudine showed greater increases in total cholesterol (0.47 mmol/L, P0.005) compared with patients taking tenofovir/emtricitabine. There were fewer grade 3/4 elevations in total cholesterol, LDL and triglycerides in the etravirine arm (2 patients, 1 patient and 0 patients, respectively) versus the efavirenz arm (8 patients, 6 patients and 2 patients, respectively). Conclusions:In the SENSE trial, first-line treatment with 400 mg of etravirine once daily plus two nucleoside analogues led to fewer grade 3 or 4 lipid elevations compared with efavirenz plus two nucleoside analogues.

Since the first studies on cardiac resynchronization therapy (CRT), the evidence for the benefit of this electrical therapy in heart failure has continuously grown. Thus, CRT has been firmly implemented in current therapy guidelines for heart failure. However, there are distinct differences between the different guidelines published. In addition, indications for CRT are still evolving in certain patient groups. This article aims to give an overview of the current guidelines for CRT and also discusses some of the differences between the different guidelines. It also provides an outlook for potential candidates for CRT in the future where current guidelines do not yet define a clear indication for implantation of such a device.

Cardiac resynchroinsation therapy (CRT) aims to correct the mechanical dyssynchrony in patients with heart failure and broad QRS complex. Until now, indication for CRT is based mainly on clinical and electrocardiographic criteria. Because QRS width is only weakly correlated to mechanical dyssynchrony, imaging techniques such as echocardiography and magnetic resonance tomography (MRT) seem suitable for analysis of dyssynchrony. Echocardiography has been studied in several studies for identification of suitable CRT candidates. Apart from conventional methods such as M mode-, 2 D-, and Doppler echocardiography other techniques which will be discussed in this article, including tissue Doppler echocardiography, have been used. Despite many positive results in individual studies no single echocardiographic parameter was able to predict positive CRT response in a prospective multicenter trial. Thus, QRS width remains the "gold standard" for CRT patient identification at present. In borderline cases, a combination of several echocardiographic measures of dyssynchrony may prove helpful. The results of studies with new techniques such as 2-dimensional strain analysis or 3D-echocardiography remain to be awaited. In the future, MRT may play a bigger role in this setting.

Intracardiac conduction disturbances, mostly manifested as a left bundle branch block (LBBB), are common findings in cardiac failure and associated with a poor prognosis. LBBB is a marker of disease progression and also leads to worsened cardiac hemodynamics by dyssynchronous contraction that can accelerate progression of the underlying disease. Cardiac resynchronization therapy (CRT) can reduce the negative effects of these disturbances leading to improvement in hemodynamics and long-term improvement in cardiopulmonary exercise tolerance, reduction of left ventricular volumes and functional mitral regurgitation. Prospective multicenter studies, such as the CARE-HF and COMPANION trials have demonstrated reduced mortality with CRT or combined treatment with defibrillator capability (CRT-D). Thus, CRT has been adopted in the current guidelines of cardiology societies. Nevertheless, there are a number of open issues with CRT, such as the high number of non-responders or the value of CRT in patients with atrial fibrillation, narrow QRS complex and mild cardiac failure or asymptomatic left ventricular dysfunction. In addition, the question whether every CRT patient needs a device with defibrillating capabilities is not fully resolved, at least for patients with dilative cardiomyopathy.

Neben der antiarrhythmischen Therapie bei Vorhofflimmern kommt der Antikoagulation eine wichtige Bedeutung zu. Denn Morbiditat und Mortalitat bei Vorhofflimmern werden entscheidend durch die embolischen Komplikationen bestimmt: Das Risiko von Thrombembolien ist bei nichtrheumatisch bedingtem Vorhofflimmern 5,6fach, bei Vorhofflimmern auf dem Boden eines rheumatischen Herzklappenfehlers gar 17,6fach erhoht [25]. Als pathophysiologischer Faktor scheint neben der Stase im linken Vorhof, hervorgerufen durch eine herabgesetzte Vorhofkontraktilitat, auch eine Hyperkoagulabilitat eine Rolle zu spielen [22]. Etwa 75% aller Thromboembolien betreffen zudem das zerebrale Stromgebiet. Daher ist verstandlich, dass 6–24% aller ischamischen Insulte auf eine kardiale Embolie bei Vorhofflimmern zuruckgefuhrt werden [12]. Mehrere epidemiologische Analysen und prospektive Studien haben in den letzten Jahren zum besseren Verstandnis der Risikofaktoren fur embolische Komplikationen gefuhrt und den Stellenwert der Antikoagulation bei Vorhofflimmern untersucht. Dabei muss zwischen der chronischen Embolieprophylaxe und der Antikoagulation vor und nach Kardioversion unterschieden werden.

Tachyarrhythmias represent a frequent problem in intensive care medicine. However, considerable uncertainty prevails among physicians regarding optimal pharmacotherapy, due also to numerous negative study results on chronic antiarrhythmic therapy. Moreover, in an emergency situation, the physician faces the dilemma of treating a potentially life-threatening arrhythmia as quickly as possible while simultaneously ensuring adequate diagnostic work-up, which will be decisive for long-term therapy once the patient has survived the crisis. The differential diagnosis between supraventricular and ventricular tachycardias is primarily facilitated by knowledge of a few salient points from the patient's history and 12-lead electrocardiography. This overview presents the most important principles for treating these arrhythmias. Interventional therapy principles (overstimulation, ablation) play an increasing role in these considerations. New insights on the pathogenesis of "malignant" arrhythmias and implementation of new concepts such as defibrillation by lay responders with the automatic external defibrillator will substantially influence emergency treatment of tachyarrhythmias in the coming years.

Cardiac resynchronization therapy (CRT), or biventricular pacing therapy, is the first approved nonsurgical treatment of advanced heart failure (HF) employing implantable device. This therapy is characterized by the implantation of an additional left ventricular (LV) lead, usually through the coronary sinus, to reach the lateral or postero-lateral vein in order to pace the LV free wall. The conventional right ventricular lead is usually needed to pace the septal region while the right atrial lead is placed to provide sensing and back-up pacing when necessary. CRT can be delivered by implantation of a pacemaker (CRT-P) or a defibrillator (CRT-D). In HF population, about one-quarter will exhibit features of prolongation of QRS duration, which is also a marker of poor prognosis. Because of the presence of electrical activation delay within the LV, these patients will develop electromechanical delay in the form of systolic dyssynchrony (i.e., uncoordinated contraction in different regions of the LV). This will accelerate the pathophysiologic process of LV adverse remodeling with cavity dilatation, deterioration of systolic function, elevation of filling pressure and mitral regurgitation. The current guidelines recommend CRT for HF patients with New York Heart Association (NYHA) class III or IV symptoms despite optimal medical therapy, reduced ejection fraction of 120 or 130 ms.

A clinical study investigates the use of Home Monitoring (HM) in pacemaker therapy. For 3 months patients are supervised by daily automatic HM messages. Endpoints are the technical feasibility and the clinical benefit of HM. Ninety three patients have currently been included and followed for 72 +/- 30 days. Three patients were excluded due to insufficient mobile net coverage at their living sites. For the other patients, 5311 of 5911 messages were successfully registered. Interrupts in the sequence of messages occurred 331 times. Two hundred ten of these (63%) lasted just 1 day, 14 interrupts (4%) lasted 5 or more days. Two patients did not show any interrupts, 34 patients (38%) had interrupts of 3 and more days. The clinical benefit of Home Monitoring was found in the remote detection of arrhythmia and lead dislocation.

Radiofrequency ablation of the "slow pathway" in atrioventricular nodal reentrant tachycardia (AVNRT) relies on tachycardia non-inducibility after ablation as success criterion. However, AVNRT is frequently non-inducible at baseline. Thus, autonomic enhancement using either atropine or isoproterenol is frequently used for arrhythmia induction before ablation.80 patients (57 women, 23 men, age 50+/-14 years) undergoing slow pathway ablation for recurrent AVNRT were randomized to receive either 0.01 mg/kg atropine or 0.5-1.0 microg/kg/min isoproterenol before ablation after baseline assessment of AV conduction. The effects of either drug on ante- and retrograde conduction was assessed by measuring sinus cycle length, PR and AH interval, antegrade and retrograde Wenckebach cycle length (WBCL), antegrade effective refractory period (ERP) of slow and fast pathway and maximal stimulus-to-H interval during slow and fast pathway conduction.Inducibility of AVNRT at baseline was not different between patients randomized to atropine (73%) and isoproterenol (58%) but was reduced after atropine (45%) compared to isoproterenol (93%, P0.001). Of the 28 patients non-inducible at baseline isoproterenol rendered AVNRT inducible in 21, atropine in 4 patients. Dual AV nodal pathway physiology was present in 88% before and 50% after atropine compared to 83% before and 73% after isoproterenol. Whereas both drugs exerted similar effects on ante- and retrograde fast pathway conduction maximal SH interval during slow pathway conduction was significantly shorter after isoproterenol (300+/-48 ms vs. 374+/-113 ms, P=0.012).Isoproterenol yields higher AVNRT inducibility than atropine in patients non-inducible at baseline. This may be caused by a more pronounced effect on antegrade slow pathway conduction.

We sought to investigate the impact of six months of cardiac resynchronization therapy (CRT) on echocardiographic variables of left ventricular (LV) function.Cardiac resynchronization therapy has recently been introduced as a new therapeutic modality in patients with advanced heart failure (HF) and conduction abnormalities. However, most studies have only investigated the early hemodynamic effects of CRT.Twenty-five patients (12 women and 13 men; 59.8 +/- 5.1 years old) with advanced HF caused by ischemic (n = 7) or idiopathic dilated cardiomyopathy (n = 18) and a prolonged QRS complex were analyzed. All patients underwent early hemodynamic testing with a randomized testing protocol; echocardiographic measurements were compared before implantation and after six months of CRT.Left ventricular end-diastolic and end-systolic diameters (LVEDD and LVESD, respectively) were significantly reduced after six months (LVEDD from 71 +/- 10 to 68 +/- 11 mm, p = 0.027; LVESD from 63 +/- 11 to 58 +/- 11 mm, p = 0.007), as were LV end-diastolic and end-systolic volumes (LVEDV from 253 +/- 83 to 227 +/- 112 ml, p = 0.017; LVESV from 202 +/- 79 to 174 +/- 101 ml, p = 0.009). Ejection fraction was significantly increased (from 22 +/- 7% to 26 +/- 9%, p = 0.03). "Nonresponders," with regard to LV volume reduction, had significantly higher baseline LVEDV, compared with "responders" (351 +/- 52 vs. 234 +/- 74 ml, p = 0.018). Overall, there was only mild mitral regurgitation at baseline, with a minor reduction by semiquantitative analysis. The results of early hemodynamic testing did not predict the volume response.Cardiac resynchronization therapy may lead to a reduction in LV volumes in patients with advanced HF and conduction disturbances. Volume nonresponders have significantly higher baseline LVEDV.

Inadequate therapies for supraventricular tachycardia (SVT) by implanted cardioverter defibrillators (ICD) are potentially arrhythmogenic and impair the patient's quality of life. Inadequate detection (ID) of SVT can be reduced by using detection enhancements like the onset- and stability criteria (O + S) or the electrogram width criterion (EGW). 103 patients (85 male, 18 female, mean age 65 +/- 9 years, mean ejection fraction 40 +/- 16%) were initially randomized to O + S active (Onset 12/89%, Stability 30 ms) or O + S inactive in the lowest detection zone. Cross-over between O + S active and O + S inactive occurred every 3 months. In 40 patients (39%) with ICD capable of EGW, this feature was programmed to passive. The number of ID was referred to 1 year of follow-up. During the follow-up period (485 +/- 226 d), 31 patients (32%) developed SVT in the lowest detection zone, 11 patients (11%) ventricular tachycardia (VT) and 14 patients (14%) both. In total, 387 SVT and 127 VT were observed. The mean number of ID was 10.7 +/- 4.8 ID/year with inactive O + S, and was significantly reduced to 1.1 +/- 0.3 ID/year when O + S were active (p0.0001). During the whole study period no delayed or inhibited adequate therapy for VT due to O + S was observed. During follow-up using EGW (n = 40), when O + S were inactivated, resulted in a significant reduction from 19.8 +/- 11.6 to 0.5 +/- 0.2 ID/year (p = 0.007). Even while O + S were active EGW would further reduce ID from 1.2 +/- 0.5 to 0.2 +/- 0.1 ID/year (p = 0.028). However, 2 adequate therapies of VT in 2 patients would have been suppressed if EGW had been activated. This results in a sensitivity of 98% and a specificity of 93% when O + S were inactive and respectively 95 and 79% when O + S were active. The empirical programming of O + S is therefore a safe method for the reduction of ID in patients with ICD. Using EGW leads to further reduction of ID but may lead to underdetection in individual cases.

The high incidence of inappropriate therapies due to supraventricular tachycardia remains a major unsolved problem of the implantable cardioverter defibrillator. A new morphology discrimination (MD) algorithm has been introduced to improve specificity of ICD therapy without loss of sensitivity. It was the aim of this study to systematically analyze sensitivity and specificity of the MD criterion in combination with the enhanced detection criteria sudden onset and rate stability in the detection of ventricular and supraventricular tachycardia. After ICD implantation in 259 patients, 787 detected episodes in 74 patients with available stored electrograms were documented during a follow-up period of 359 +/- 214 days. With a nominal programming of the MD algorithm ator = 60%, sensitivity and specificity for all episodes were 82.6%/77.2%. For sinus tachycardia, atrial fibrillation and atrial flutter the specificities were 80.6%, 69.6% and 75%, respectively. In patients with primarily appropriate MD detection, sensitivity and specificity significantly improved to 95.8%/91.7%. Programming the sudden onset criterion with100 ms and the stability criterion with50 ms, sensitivity and stability of the combined application of the MD algorithm and sudden onset and MD algorithm and stability were 96.2%/52.2% and 94.4%/63.8%, respectively. The MD criterion in combination with other enhanced detection criteria might significantly improve specificity of tachyarrythmia detection of ICD therapy.

Radiofrequency current catheter ablation has gained acceptance as primary long-term therapy for patients with symptomatic accessory pathways and symptomatic atrioventricular nodal reentrant tachycardia (AVNRT) with frequent recurrences. In both arrhythmias, curative treatment is possible in more than 90% of cases at a low complication rate although an incidence of about 1% complete AV block after slow pathway ablation has to be taken into account when this therapy is considered. The recurrence rate is 3-10% for accessory pathways and 0-15% for AVNRT. The high success rate of catheter ablation has already led to a shift in the indications for the procedure where the percentage of patients with accessory pathways is decreasing and there is an increase of patients with AVNRT and newer indications (atrial flutter, focal atrial tachycardias).