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AIMS: Atrial fibrillation (AF) reduces quality of life (QoL). We aim to evaluate effects of targeted therapy of underlying conditions on QoL in patients with AF and heart failure (HF). METHODS AND RESULTS: The Routine versus Aggressive risk factor driven upstream rhythm Control for prevention of Early atrial fibrillation in heart failure (RACE 3) study randomized patients with early persistent AF and HF to targeted or conventional therapy. Both groups received guideline-driven treatment. The targeted group received four additional therapies: mineralocorticoid receptor antagonists; statins; angiotensin converting enzyme inhibitors and/or receptor blockers; and cardiac rehabilitation including physical activity, dietary restrictions, and counselling. Quality of life was analysed in 230 patients at baseline and 1 year with available Medical Outcomes Study Short-Form Health Survey (SF-36), University of Toronto AF Severity Scale (AFSS) questionnaires, and European Heart Rhythm Association (EHRA) class. Improvements in SF-36 subscales were larger in the targeted group for physical functioning (Δ12 ± 19 vs. Δ6 ± 22, P = 0.007), physical role limitations (Δ32 ± 41 vs. Δ17 ± 45, P = 0.018), and general health (Δ8 ± 16 vs. Δ0 ± 17, P

BACKGROUND The prescription of physical activity (PA) in clinical care has been advocated worldwide. This “exercise is medicine” (E=M) concept can be used to prevent, manage, and cure various lifestyle-related chronic diseases. Due to several challenges, E=M is not yet routinely implemented in clinical care. OBJECTIVE This paper describes the rationale and design of the Physicians Implement Exercise = Medicine (PIE=M) study, which aims to facilitate the implementation of E=M in hospital care. METHODS PIE=M consists of 3 interrelated work packages. First, levels and determinants of PA in different patient and healthy populations will be investigated using existing cohort data. The current implementation status, facilitators, and barriers of E=M will also be investigated using a mixed-methods approach among clinicians of participating departments from 2 diverse university medical centers (both located in a city, but one serving an urban population and one serving a more rural population). Implementation strategies will be connected to these barriers and facilitators using a systematic implementation mapping approach. Second, a generic E=M tool will be developed that will provide tailored PA prescription and referral. Requirements for this tool will be investigated among clinicians and department managers. The tool will be developed using an iterative design process in which all stakeholders reflect on the design of the E=M tool. Third, we will pilot-implement the set of implementation strategies, including the E=M tool, to test its feasibility in routine care of clinicians in these 2 university medical centers. An extensive learning process evaluation will be performed among clinicians, department managers, lifestyle coaches, and patients using a mixed-methods design based on the RE-AIM framework. RESULTS This project was approved and funded by the Dutch grant provider ZonMW in April 2018. The project started in September 2018 and continues until December 2020 (depending on the course of the COVID-19 crisis). All data from the first work package have been collected and analyzed and are expected to be published in 2021. Results of the second work package are described. The manuscript is expected to be published in 2021. The third work package is currently being conducted in clinical practice in 4 departments of 2 university medical hospitals among clinicians, lifestyle coaches, hospital managers, and patients. Results are expected to be published in 2021. CONCLUSIONS The PIE=M project addresses the potential of providing patients with PA advice to prevent and manage chronic disease, improve recovery, and enable healthy ageing by developing E=M implementation strategies, including an E=M tool, in routine clinical care. The PIE=M project will result in a blueprint of implementation strategies, including an E=M screening and referral tool, which aims to improve E=M referral by clinicians to improve patients’ health, while minimizing the burden on clinicians.

Aims: Atrial fibrillation (AF) is a progressive disease. Targeted therapy of underlying conditions refers to interventions aiming to modify risk factors in order to prevent AF. We hypothesised that targeted therapy of underlying conditions improves sinus rhythm maintenance in patients with persistent AF.Methods and results: We randomized patients with early persistent AF and mild-to-moderate heart failure (HF) to targeted therapy of underlying conditions or conventional therapy. Both groups received causal treatment of AF and HF, and rhythm control therapy. In the intervention group, on top of that, four therapies were started: (i) mineralocorticoid receptor antagonists (MRAs), (ii) statins, (iii) angiotensin converting enzyme inhibitors and/or receptor blockers, and (iv) cardiac rehabilitation including physical activity, dietary restrictions, and counselling. The primary endpoint was sinus rhythm at 1 year during 7 days of Holter monitoring. Of 245 patients, 119 were randomized to targeted and 126 to conventional therapy. The intervention led to a contrast in MRA (101 [85%] vs. 5 [4%] patients, P Conclusions: RACE 3 confirms that targeted therapy of underlying conditions improves sinus rhythm maintenance in patients with persistent AF.Trial Registration number: Clinicaltrials.gov NCT00877643.

Background The prescription of physical activity (PA) in clinical care has been advocated worldwide. This “exercise is medicine” (E=M) concept can be used to prevent, manage, and cure various lifestyle-related chronic diseases. Due to several challenges, E=M is not yet routinely implemented in clinical care. Objective This paper describes the rationale and design of the Physicians Implement Exercise = Medicine (PIE=M) study, which aims to facilitate the implementation of E=M in hospital care. Methods PIE=M consists of 3 interrelated work packages. First, levels and determinants of PA in different patient and healthy populations will be investigated using existing cohort data. The current implementation status, facilitators, and barriers of E=M will also be investigated using a mixed-methods approach among clinicians of participating departments from 2 diverse university medical centers (both located in a city, but one serving an urban population and one serving a more rural population). Implementation strategies will be connected to these barriers and facilitators using a systematic implementation mapping approach. Second, a generic E=M tool will be developed that will provide tailored PA prescription and referral. Requirements for this tool will be investigated among clinicians and department managers. The tool will be developed using an iterative design process in which all stakeholders reflect on the design of the E=M tool. Third, we will pilot-implement the set of implementation strategies, including the E=M tool, to test its feasibility in routine care of clinicians in these 2 university medical centers. An extensive learning process evaluation will be performed among clinicians, department managers, lifestyle coaches, and patients using a mixed-methods design based on the RE-AIM framework. Results This project was approved and funded by the Dutch grant provider ZonMW in April 2018. The project started in September 2018 and continues until December 2020 (depending on the course of the COVID-19 crisis). All data from the first work package have been collected and analyzed and are expected to be published in 2021. Results of the second work package are described. The manuscript is expected to be published in 2021. The third work package is currently being conducted in clinical practice in 4 departments of 2 university medical hospitals among clinicians, lifestyle coaches, hospital managers, and patients. Results are expected to be published in 2021. Conclusions The PIE=M project addresses the potential of providing patients with PA advice to prevent and manage chronic disease, improve recovery, and enable healthy ageing by developing E=M implementation strategies, including an E=M tool, in routine clinical care. The PIE=M project will result in a blueprint of implementation strategies, including an E=M screening and referral tool, which aims to improve E=M referral by clinicians to improve patients’ health, while minimizing the burden on clinicians.

The clinical course of a patient with a left ventricular assist device is described. A total of 6 weeks after device insertion, the lactate dehydrogenase (LDH) level increased to 2801 U/l despite adding low-molecular-weight heparin to acenocoumarol and aspirin. Pump thrombosis was suspected but unconfirmed by computed tomography. Increased pump power requirement did not occur. Instituting unfractionated heparin caused a drop in the LDH level. After discontinuing heparin, the LDH levels rose to 5529 U/l whereupon pump replacement was performed. LDH levels, combined with clinical deterioration and right heart catheterisation, led to the diagnosis of pump thrombosis.

Background: Hepatitis E virus (HEV) has long been known as a major cause of acute hepatitis in developing countries with occasional travel-related cases in developed countries, most of them belonging to genotype 1. Currently, genotype 3 HEV is recognized as an emerging public health issue in developed countries and can cause a chronic hepatitis in immunocompromised patients.Objectives: The aim of this study was to get an overview of the clinical course of HEV infection, from July 2007 to December 2012, and further characterize HEV in patients of the University Medical Center Groningen (UMCG) over a 5-year time period.Methods: Since the second half of 2007, patients in the UMCG with unexplained hepatitis were screened for HEV and clinical data were collected. HEV was characterized by sequencing of the ORF1 and ORF2 regions.Results: In total, 34 patients of the 1129 tested patients showed HEV viremia. The majority of the infected patients were immunocompromised; 18 were solid organ transplant (SOT) patients and 9 were patients immunocompromised for other reasons. Seven patients diagnosed with HEV were immunocompetent. Viral genotyping revealed genotype 3 isolates, mostly genotype 3c.Conclusion: Non-travel related HEV hepatitis is an important diagnosis. In immunocompromised patients HEV infection often has major clinical impact, necessitating medical intervention including antiviral treatment. In immunocompetent patients, the detection could expand our understanding about the route of transmission and the relation with the zoonotic origin. Therefore, besides an increasing awareness for HEV among clinicians and medical microbiologists, diagnostics should be routinely incorporated into standard patients care. (C) 2013 Elsevier B.V. All rights reserved.

Background: Cardiac resynchronization therapy (CRT) is an established therapy for patients with severe heart failure and mechanical dyssynchrony. Response is only achieved in 60-70% of patients.Objectives: To study exercise-related factors predicting response to CRT.Methods: We retrospectively examined consecutive patients in whom a CRT device was implanted. All underwent cardiopulmonary exercise testing prior to implantation and after 6 months. The occurrence of chronotropic incompetence and heart rates exceeding the upper rate of the device, thereby compromising biventricular stimulation, was studied. Response was defined as a decrease in LVESV of 10% or more after 6 months.Results: We included 144 patients. After 6 months 86 (60%) patients were responders. Peak VO(2) significantly increased in responders. Chronotropic incompetence was more frequently seen in nonresponders (21 [36%] vs 9 [10%], P = 0.03), mostly in patients in SR. At moderate exercise, defined as 25% of the maximal exercise tolerance, that is, comparable to daily life exercise, nonresponders more frequently went above the upper rate of the device (13 [22%] vs 2 [3%], P Conclusions: Heart rate exceeding the upper rate during moderate exercise is an independent predictor for nonresponse to CRT in patients with AF, whereas chronotropic incompetence is a predictor for patients in SR.(J Cardiovasc Electrophysiol, Vol. 20, pp. 773-780, July 2009).

This editorial refers to ‘Self-reported physical activity and major adverse events in patients with atrial fibrillation: a report from the EURObservational Research Programme Pilot Survey on Atrial Fibrillation (EORP-AF) General Registry’ by M. Proietti et al. , doi:10.1093/europace/euw150. Atrial fibrillation (AF) is not a benign condition and contributes importantly to cardiovascular morbidity and mortality. Until recently, only non-vitamin K antagonist oral anticoagulants (NOACs) and vitamin K antagonist OACs have been associated with reduction of mortality,1 but not rhythm control therapy. Regular not-vigorous physical activity and respiratory cardiofitness are protective against cardiovascular diseases and all-cause mortality.2,3 Physical activity, especially vigorous exertion and endurance sports, however, has been associated with an increased risk of AF.4 Yet, there is increasing evidence that moderate physical activity and cardiorespiratory fitness are associated with a reduced risk of AF.5 For example, in obese patients (body mass index ≥27 kg/m2), baseline cardiorespiratory fitness was associated with a higher freedom of AF. Furthermore, an improvement in cardiorespiratory fitness (≥2 metabolic equivalents) during follow-up contributed to a further AF burden reduction in association with weight loss, an improvement of glycaemic and lipid control, a reduction in blood pressure, a decrease of atrial and ventricular sizes, and increase in diastolic function and a reduction of systemic inflammation.5 However, data on the effects of physical activity on outcome in patients with AF are lacking. In the current issue of EP-Europace , Proietti et al. 6 report on the relationship between physical activity and major cardiovascular outcomes in AF patients prospectively enrolled in the EURObservational Research Programme on AF (EORP-AF) Pilot Survey conducted in nine European countries. Their aim was to assess, …

Several studies have reported improved survival rates thanks to the use of an implantable cardioverter defibrillator (ICD) in the treatment of patients with life-threatening arrhythmia. However, the effects of the ICD on health-related quality of life (HR-QoL) of these patients are not clear. The aim of this study is to describe HR-QoL and fear of exercise in ICD patients. Eighty-nine ICD patients from the University Hospital in Groningen, the Netherlands, participated in this study. HR-QoL was measured using the Rand-36 and the Quality of Life After Myocardial Infarction Dutch language version questionnaires. Fear of exercise was measured using the Tampa Scale for Kinesiophobia, Dutch version and the Fear Avoidance Beliefs Questionnaire, Dutch version. Association between outcome variables was analysed by linear regression analyses. Study results show that the HR-QoL of patients with ICDs in our study population is significantly worse than that of normal healthy people. Furthermore, fear of exercise is negatively associated with HR-QoL corrected for sex, age and number of years living with an ICD. After implantation of the ICD, patients with a clear fear of exercise should be identified and interventions should be considered in order to increase their HR-QoL.

OBJECTIVESWe sought to study the influence of frequency of exercise training during cardiac rehabilitation on functional capacity (i.e., peak oxygen consumption [VO2] and ventilatory anaerobic threshold [VAT]) and quality of life (QoL).BACKGROUNDAlthough the value of cardiac rehabilitation is now well established, the influence of the different program characteristics on outcome has received little attention, and the effect of frequency of exercise training is unclear. Functional capacity is regularly evaluated by peak VO2 but parameters of submaximal exercise capacity such as VAT should also be considered because submaximal exercise capacity is especially important in daily living.METHODSPatients with coronary artery disease (n = 130, 114 men; mean age 52 ± 9 years) were randomized to either a high- or low-frequency program of six weeks (10 or 2 exercise sessions per week of 2 h, respectively). Functional capacity and QoL were assessed before and after cardiac rehabilitation. Global costs were also compared.RESULTSCompared with baseline, mean exercise capacity increased in both programs: for high- and low-frequency, respectively: peak VO2 = 15% and 12%, Wmax = 18% and 12%, VAT = 35% and 12% (all p < 0.001). However, when the programs were compared, only VAT increased significantly more during the high-frequency program (p = 0.002). During the high-frequency program, QoL increased slightly more, and more individuals improved in subjective physical functioning (p = 0.014). We observed superiority of the high-frequency program, especially in younger patients. Mean costs were estimated at 4,455 and 2,273 Euro, respectively, for the high- and low-frequency programs.CONCLUSIONSHigh-frequency exercise training is more effective in terms of VAT and QoL, but peak VO2 improves equally in both programs. Younger patients seem to benefit more from the high-frequency training.

Over the past decade, various studies have demonstrated that class I antiarrhythmic drugs should be avoided in patients with heart failure, cardiac ischaemia or a previous myocardial infarction. In contrast, class II drugs (beta-blockers) reduce morbidity and may even lower mortality in patients suffering from moderate to severe heart failure. In these patients, careful titration of the drug dosage, frequently during hospital admission, may be necessary. If in the setting of heart failure ventricular arrhythmias are symptomatic and/or sustained, patients can be treated effectively, after appropriate treatment of the underlying disease, with the class III drug amiodarone. Unfortunately, this drug does not lower overall mortality, implying that prophylactic institution of amiodarone is not indicated. Pure class III antiarrhythmic drugs like d-sotalol, ibutilide and dofetilide show a high rate of torsade de pointes. Currently, only ibutilide has been approved for clinically monitored intravenous administration. Class IV drugs, the calcium channel blockers, are still very useful for rate control of atrial fibrillation and conversion or prevention of atrioventricular nodal re-entrant tachycardias and circus movement tachycardias using a (concealed) bypass tract. Finally, an implantable cardioverter defibrillator seems to improve overall survival in patients with life-threatening ventricular arrhythmias. This may imply that an increasing number of patients will be candidates for such a device. However, it will be necessary to await publication of data involving these devices from current ongoing studies.

Giant cell myocarditis (GCM) is a serious condition that warrants immediate diagnosis and treatment. It often presents as rapidly progressive heart failure and/or malignant ventricular arrhythmias. Here, we describe a 34-year-old patient with myasthenia gravis who presented with GCM 2 weeks after resection of a thymoma. A cardiac biopsy confirming the diagnosis was done within 3 days after admission. After institution of an aggressive immunosuppressive drug regimen, implantation of an implantable cardioverter defibrillator, and intensive cardiac rehabilitation, the patient recovered dramatically. In control biopsies after 4 weeks and 6 months, no more giant cells were found. We conclude that, in the case of nonischemic acute heart failure in young patients, a biopsy should be performed as soon as possible to prevent an unfavourable outcome of this often fatal disease. (c) 2006 Elsevier Inc. All rights reserved.

BACKGROUND:: Physical activity is the only nonpharmacological therapy that is proven to be effective in heart failure (HF) patients in reducing morbidity. To date, little is known about the levels of daily physical activity in HF patients and about related factors. OBJECTIVE:: The objectives of this study were to (a) describe performance-based daily physical activity in HF patients, (b) compare it with physical activity guidelines, and (c) identify related factors of daily physical activity. METHODS:: The daily physical activity of 68 HF patients was measured using an accelerometer (SenseWear) for 48 hours. Psychological characteristics (self-efficacy, motivation, and depression) were measured using questionnaires. To have an indication how to interpret daily physical activity levels of the study sample, time spent on moderate- to vigorous-intensity physical activities was compared with the 30-minute activity guideline. Steps per day was compared with the criteria for healthy adults, in the absence of HF-specific criteria. Linear regression analyses were used to identify related factors of daily physical activity. RESULTS:: Forty-four percent were active for less than 30 min/d, whereas 56% were active for more than 30 min/d. Fifty percent took fewer than 5000 steps per day, 35% took 5000 to 10 000 steps per day, and 15% took more than 10 000 steps per day. Linear regression models showed that New York Heart Association classification and self-efficacy were the most important factors explaining variance in daily physical activity. CONCLUSIONS:: The variance in daily physical activity in HF patients is considerable. Approximately half of the patients had a sedentary lifestyle. Higher New York Heart Association classification and lower self-efficacy are associated with less daily physical activity. These findings contribute to the understanding of daily physical activity behavior of HF patients and can help healthcare providers to promote daily physical activity in sedentary HF patients. PMID:23416939 DOI: 10.1097/JCN.0b013e318283ba14

OBJECTIVE: To determine the long-term outcome of serial electrical cardioversion therapy in patients with chronic atrial flutter. DESIGN: Prospective study, case series. SETTING: University hospital. PATIENTS: 50 consecutive patients with chronic (> 24 hours) atrial flutter without a previous relapse on antiarrhythmic drugs. INTERVENTIONS: Elective electrical cardioversion therapy, if necessary repeated, to obtain and keep patients in sinus rhythm. If the first cardioversion resulted in sinus rhythm, patients were not given antiarrhythmic drugs. Relapses were managed by repeated cardioversions then anti-arrhythmic drugs were used serially in a set sequence. MAIN OUTCOME MEASURE: Maintenance of sinus rhythm. RESULTS: Mean (SD) follow up was 3.5 (1.7) years. The first cardioversion was successful in 48 patients (96%). After a single shock and without antiarrhythmic drugs being used, 42% of the patients maintained sinus rhythm in the long-term. Only left atrial size was inversely related to the efficacy of one shock (P = 0.025). With serial cardioversion 90% of the patients were kept in sinus rhythm for 5 years. Univariate analysis showed that a long duration of arrhythmia and impaired cardiac function were both related to poor outcome. During follow up 3 patients died of progression of heart failure and another 5 died suddenly. None of these 5 patients was on antiarrhythmic drugs. CONCLUSIONS: Electrical cardioversion was an effective and safe method of converting chronic atrial flutter to sinus rhythm. To maintain sinus rhythm, more than half of the patients required multiple shocks and prophylactic antiarrhythmic drugs. Sudden death was relatively frequent in the study population; the limited data available from this study suggest that such deaths were caused by the underlying disease and not drug related proarrhythmia.

In patients with acute myocardial infarction (MI), quick initiation of thrombolytic therapy is the best strategy for improvement of survival and reduction of morbidity. Streptokinase, a purified product of haemolytic streptococci, is the most commonly administered agent. The compound anistreplase (a complex of streptokinase to plasminogen), is available but currently not often used. The nonantigenic competitor for these two compounds for the indication of MI is alteplase (recombinant tissue plasminogen activator; rt-PA). Due to former use of streptokinase or its derivative anistreplase, patients may develop specific antibodies to the foreign protein, whereas cross-reacting antibodies may be due to streptococcal infections. These antibodies may neutralise streptokinase or its derivative in case of (re)administration and may mediate adverse events, sometimes serious. Since advanced age by itself is certainly not a contraindication to thrombolytic therapy, and because reinfarction occurs frequently, the benefit-risk ratio of re-exposure to streptokinase or its derivative is decreased in the elderly who present with reinfarction. In the framework of tailored thrombolytic therapy, alteplase or urokinase appear to be the drugs of choice in these patients.

A 37-year-old man with end-stage idiopathic dilated cardiomyopathy underwent an orthotopic heart transplant followed by a reoperation with mitral annuloplasty for severe mitral regurgitation. Shortly thereafter, he developed severe tricuspid regurgitation and severe recurrent mitral regurgitation due to annuloplasty ring dehiscence. The dehisced annuloplasty ring was refixated, followed by tricuspid annuloplasty through a right anterolateral thoracotomy. After four years of follow-up, there are no signs of recurrent mitral or tricupid regurgitation and the patient remains in NYHA class II. Pushing the envelope on conventional surgical procedures in marginal donor hearts (both before and after transplantation) may not only improve the patient’s functional status and reduce the need for retransplantation, but it may ultimately alleviate the chronic shortage of donor hearts.

A simple enzyme immunoassay for determination of anti-streptokinase antibodies (aSKa) in plasma is described. Commercially available reagents have been used for the assay, which is calibrated with a reference preparation of aSKa containing 100 AU/ml. The assay is specific and reproducible with a variation coefficient of 4.8%. In healthy individuals a broad range of values between 4 and 291 AU/ml was observed with a large difference between the mean and median value (55 AU/ml and 27 AU/ml, respectively). Data from a study on 21 patients with myocardial infarction treated with the streptokinase derivative anistreplase suggest that a high titre of aSKa before treatment is associated with failure of thrombolytic therapy. The assay procedure can be shortened to 0.5 h to screen patients for a high aSKa level. This assay allows a more routine assessment of aSKa in the clinic.

BACKGROUND Infection is the most frequent complication after heart transplantation (HTx) In this report and brief literature review we present a recipient who some 6 weeks post HTx had two donor related infections a "common' primary cytomegalovirus (CMV) infection and simultaneously a highly unusual donor-related Strongyloides stercoralis infectionMETHODS The parasite was discovered by chance in a skin biopsy CMV was treated with ganciclovir and the strongyloidiasis was cured with two courses of anti-helminthic therapy initially with ivermectine and albendazol and, in response to eosinophilia with ivermectine monotherapy The patient s recovery was further complicated by two successive rejection episodes a relapse of the CMV syndrome and a novel influenza A/H1N1 infection These episodes were treated with steroids ganciclovir and oseltamivir respectivelyRESULTS It took almost 9 months before a permanent IgG anti-CMV response was seen At 13 months post-HTx coronary angiography showed only slight vessel wall abnormalities At present the patient is back at home and in good conditionCONCLUSION Until now only 4 recipient-derived strongyloidiasis cases have been described in post HTx patients all diagnosed by autopsies This is the first report of a donor related Strongyloides infection in a patient after HTx J Heart Lung Transplant 2010 29 1433-7 (C) 2010 International Society for Heart and Lung Transplantation All rights reserved

Outpatient cardiac rehabilitation (CR) is offered in at least 100 hospitals in the Netherlands. The majority of cardiac patients are well-served with physical training and education. Some patients with complex cardiac pathology and other problems, including health problems, may however benefit from multidisciplinary in-hospital CR. We present three cardiac patients. The first patient, a 58-year-old man, had coronary and pulmonary disease, suboptimally treated diabetes and psychological problems. He participated in in-hospital CR for 7 weeks, which led to an improved physical and emotional condition. The second patient was 80 years old and did not recover properly following an aortic valve replacement. With in-hospital CR she acquired new skills for mastering the activities of daily life. The third patient we described, a 57-year-old man, suffered from ischaemic heart failure and had had recurrent implantable cardiac defibrillator (ICD) shocks. He was referred for cardiac transplantation but 7 weeks of in-hospital CR resulted in an improved exercise tolerance, significant weight loss and an adequate level of coping with his disease. In-hospital CR is a niche service, but may provide relief for some cardiac patients.

Reporting the results of combined heart-lung transplantation in the University Medical Center Groningen (UMCG), the Netherlands.Retrospective study.Data were retrieved of patients who underwent a combined heart-lung transplantation in the UMCG between December 1996 and December 2007. Demographic, clinical and other relevant characteristics were recorded, as well as post-transplantation morbidity and mortality.The study group consisted of 14 patients (3 men and 11 women) with a mean age of 41 years. Indications for heart-lung transplantation were: congenital heart disease complicated by pulmonary hypertension (6 patients), idiopathic pulmonary hypertension with severe right ventricle failure (4 patients), lung fibrosis with severe right ventricle failure (1 patient), cystic fibrosis with systolic left ventricle failure (1 patient), pulmonary hypertension after thoracic radiation and chemotherapy (1 patient) and re-transplantation after lung-transplant failure (1 patient). The mean waiting time prior to operation was approximately 1.5 years. 9 of the 14 patients (64%) underwent such a marked clinical deterioration during the waiting period that they were given a 'very high urgency status' for transplantation. Almost half of patients became dependent on supplementary intravenous inotropics during the waiting period. At the end of the study 6 of the 14 patients (43%) were alive, with a mean survival period of 58 months (range: 6-132). Infection was the cause of death in 4 of the 8 patients. Of the 8 deceased patients, 4 were underweight preoperatively (BMI18.5 kg/m2) and were cachectic. This was the case in only 1 of the 6 surviving patients.A combined heart-lung transplantation is a rare operation in the Netherlands. The waiting time in this study was long and the post-transplantation mortality was high. Underweight (cachexia), a sign of a poor clinical condition, appears to be associated with mortality.

Background: It is unclear if psycho- education on top of physical training is of additional value regarding quality of life in revascularised patients.Design: Prospective randomised study comparing two types of cardiac rehabilitation: exercise based versus a more comprehensive approach including psychological therapy.Methods: One hundred and thirty- seven male patients who underwent an uncomplicated coronary revascularisation procedure and who were mentally in a good condition, were randomised to one of two types of cardiac rehabilitation: physical training plus information about their disease ('Fit' program) during 6 weeks or comprehensive cardiac rehabilitation which, on top of the Fit- program, included weekly psychoeducation sessions and relaxation therapy (` Fit- Plus' program) for 8 weeks. One hundred and four patients were analysed. Quality of life was measured by the ` Leiden Quality of Life questionnaire' and by the RAND- 36 ( quality of life) questionnaire.Results: Quality of life improved in both treatment groups in the course of time up to 9 months after cardiac rehabilitation and there was no difference between the two types of cardiac rehabilitation. Exercise capacity improved likewise, blood lipid profile was unaffected and energy intake decreased in each treatment group but, again, there were no inter- group differences.Conclusion: After an uncomplicated revascularisation procedure, physical training plus information results in a comparable outcome on quality of life when compared to a more comprehensive program including additional psycho- education and relaxation therapy. (C) 2006 Elsevier Ireland Ltd. All rights reserved.

Cardiorespiratory failure just before surgery in critically ill thoracic transplant patients can have catastrophic consequences. We judged the cardiorespiratory condition in three of 160 thoracic transplant procedures performed in our center too unstable for a safe induction of anesthesia. In these 3 patients, extracorporeal membrane oxygenation support was installed before induction of anesthesia to maintain an adequate cardiorespiratory state. This strategy was successful for all 3 patients, and long-term survival was achieved with a good quality of life. Guidelines for indications to follow this strategy are discussed.

Chronic atrial fibrillation (AF) occurs often in the setting of mitral and aortic valve disease. Eventually, these patients undergo valve replacement which improves cardiac function but does not prevent AF. This study investigates which patient may benefit from additional surgery for the cure of AF performed in combination with valve surgery. Seventy-four patients were retrospectively included from our prospective database of patients referred for serial cardioversion therapy between 1986 and 1993. All these patients had chronic AF after valve replacement. After the first electrical cardioversion, patients did not receive antiarrhythmic drugs. Relapses were managed by repeated cardioversions, and then antiarrhythmic drugs were instituted. After a median follow-vp of 7 years (range 1.3 to 23), 39 patients had intractable AF. Multivariate analysis revealed that patients with a history of chronic AF before surgery (risk ratio 5.4, confidence intervals 2.5 to 11.3, p = 0.0001) had a poor arrhythmia outcome. In addition, Kaplan-Meier survival analysis demonstrated a lower success rate (p = 0.0017) in patients with mitral valve disease than in those with aortic valve disease. Congestive heart failure (41% vs 6%, p = 0.0007) and cardiovascular mortality (23% vs 9%, p = 0.09) were seen most often in patients with on unsuccessful cardioversion strategy. Thus, patients scheduled for mitral valve surgery with a history of chronic AF should be considered candidates for additional surgery for AF concomitantly performed during valve surgery. (C) 1996 by Excerpta Medica, Inc.

This article discusses various aspects of cholesterol-lowering therapy using the HMG-CoA reductase inhibitor simvastatin in the light of the large Scandinavian Simvastatin Survival Study (4S). In 4S, patients with proven coronary heart disease (CHD) and plasma total cholesterol >5.5 mmol/L (212 mg/dl) despite dietary measures received statin therapy or placebo for greater than or equal to 5 years. A significant mortality reduction was accomplished in those receiving the statin. Moreover, a significant decrease of nonfatal myocardial infarction and requirement for coronary bypass surgery or angioplasty was demonstrated, which will contribute to the cost-effectiveness of this well tolerated therapy. Plaque stabilisation and improvement of endothelial function are thought to be mediators of this therapeutic success. Responsible drug prescription in the post-4S era may result in the recognition and treatment of more patients with CHD. This is likely to be more beneficial than exhaustive efforts to completely achieve the goals of the most strict guidelines in the individual patient. In patients who carry the highest absolute risk for a recurrent event, aggressive drug therapy may be most justified. Reluctance to initiate lipid lowering drug therapy in patients with proven CHD should now be disputed.

The aim of this study was to investigate whether failure of thrombolytic treatment might be due to inhibition of fibrinolysis by high lipoprotein(a) levels. Fifty-eight patients with acute myocardial infarction were treated intravenously within 4 h after onset of symptoms with anistreplase (30 units) and heparin (30 000 IU/24 h). Blood samples for measurement of coagulation parameters were taken before and 1.5 h after treatment. Coronary angiography was performed after 48 h. Levels of lipoprotein(a) were measured 6 months after discharge from hospital. The patency rate was 74% (4358). Median lipoprotein(a) levels were not different between the patients with a patent and those with a non-patent vessel (10 and 8 mg/dl, respectively), however, in patients with a non-patent infarct-related vessel, a significant inverse correlation was found between the lipoprotein(a) level and the decrease of plasminogen in the first 1.5 h after treatment. It is concluded that high lipoprotein(a) levels, although not directly associated with a poor outcome of anistreplase therapy, might contribute to insufficient fibrinolysis in patients with a non-patent infarct-related vessel.

The relation between coronary thrombolysis and coagulation variables after administration of anistreplase (anisoylated plasminogen streptokinase activator complex, APSAC) was studied in patients with an acute myocardial infarction. Fifty eight consecutive patients with acute myocardial infarction were given 30 U of anistreplase intravenously within 4 hours of the onset of symptoms. A fall in the plasma concentration fibrinogen to less than 1.0 g/l 90 minutes after administration of anistreplase was considered to reflect a systemic lytic state. Coronary angiography was performed 48 hours after thrombolytic treatment. The overall patency rate was 74% (43/58). Patency rates were significantly different in patients with a systemic lytic (83% (43/52)) and a systemic non-lytic state (0% (0/6)). The absence of a systemic lytic state after anistreplase administration seemed to be highly predictive of the failure of coronary thrombolysis. Coagulation studies showed evidence of inhibition of anistreplase induced fibrinolytic activity which may explain the failure of thrombolytic treatment in patients with evidence of a systemic non-lytic state.

Thirty consecutive patients with acute myocardial infarction (AMI) were treated with anisoylated plasminogen streptokinase activating complex (APSAC) within 4 hours after onset of symptoms. After 1.5 and 48 hours, patency of the infarct-related vessel and the quantitative degree of residual diameter stenosis were studied by selective coronary angiography. Ventriculograms were made to determine the global left ventricular ejection fraction. Patients showing patency at 48 hours were reevaluated angiographically after 3 months. At 1.5 and 48 hours after APSAC administration patent vessels were demonstrated in 65 and 69% of patients, respectively. Mean residual stenosis decreased significantly from 56 +/- 11% at 1.5 hours to 46 +/- 13% at 48 hours (p less than 0.01). Patients not responding to thrombolytic therapy showed significant deterioration of the left ventricular function during the first 48 hours after AMI. Side effects were minor and mainly associated with invasive procedures. Despite adequate oral anticoagulation, angiographically documented reocclusion at 3 months amounted to 28%. Reocclusion, however, was neither associated with clinically documented reinfarction, nor with a decrease in the left ventricular ejection fraction. Our study shows that APSAC is an effective thrombolytic agent in AMI but that late reocclusion may occur. Oral anticoagulants appear to be less effective in the prevention of reocclusion in the treatment regimen after thrombolysis.

In this study we compared efficacy and safety of prehospital with in-hospital thrombolytic treatment with anistreplase in patients with acute myocardial infarction (AMI). Three-hundred and fifty patients with chest pain were screened for eligibility by the municipal ambulance staff and/or the general practitioner. Patients were included in the absence of contraindications and if the telephone-transmitted ECG showed AMI. In a 6 month period 16 patients (5%) were eligible, but only seven (2%) were randomized. Age over 70 years, duration of chest pain for longer than 4 h and logistic problems were the major factors responsible for the low inclusion rate. The mean time spent at home with and without the ECG procedure was 38 +/- 14 and 14 +/- 8 min, respectively (P less than 0.001). These results demonstrate that in a medium sized town prehospital delivery of intravenous thrombolytic therapy by paramedics and/or the general practitioner is not feasible, leads to unnecessary time delay and may therefore yield no clinical benefits.

OBJECTIVE: Reporting the results of combined heart-lung transplantation in the University Medical Center Groningen (UMCG), the Netherlands. DESIGN: Retrospective study. METHOD: Data were retrieved of patients who underwent a combined heart-lung transplantation in the UMCG between December 1996 and December 2007. Demographic, clinical and other relevant characteristics were recorded, as well as post-transplantation morbidity and mortality. RESULTS: The study group consisted of 14 patients (3 men and 11 women) with a mean age of 41 years. Indications for heart-lung transplantation were: congenital heart disease complicated by pulmonary hypertension (6 patients), idiopathic pulmonary hypertension with severe right ventricle failure (4 patients), lung fibrosis with severe right ventricle failure (1 patient), cystic fibrosis with systolic left ventricle failure (1 patient), pulmonary hypertension after thoracic radiation and chemotherapy (1 patient) and re-transplantation after lung-transplant failure (1 patient). The mean waiting time prior to operation was approximately 1.5 years. 9 of the 14 patients (64%) underwent such a marked clinical deterioration during the waiting period that they were given a 'very high urgency status' for transplantation. Almost half of patients became dependent on supplementary intravenous inotropics during the waiting period. At the end of the study 6 of the 14 patients (43%) were alive, with a mean survival period of 58 months (range: 6-132). Infection was the cause of death in 4 of the 8 patients. Of the 8 deceased patients, 4 were underweight preoperatively (BMI < 18.5 kg/m2) and were cachectic. This was the case in only 1 of the 6 surviving patients. CONCLUSION: A combined heart-lung transplantation is a rare operation in the Netherlands. The waiting time in this study was long and the post-transplantation mortality was high. Underweight (cachexia), a sign of a poor clinical condition, appears to be associated with mortality.

OBJECTIVE—To investigate the occurrence of heart failure complications, and to identify variables that predict heart failure in patients with (recurrent) persistent atrial fibrillation, treated aggressively with serial electrical cardioversion and antiarrhythmic drugs to maintain sinus rhythm. DESIGN—Non-randomised controlled trial; cohort; case series; mean (SD) follow up duration 3.4 (1.6) years. SETTING—Tertiary care centre. SUBJECTS—Consecutive sampling of 342 patients with persistent atrial fibrillation (defined as > 24 hours duration) considered eligible for electrical cardioversion. INTERVENTIONS—Serial electrical cardioversions and serial antiarrhythmic drug treatment, after identification and treatment of underlying cardiovascular disease. MAIN OUTCOME MEASURES—heart failure complications: development or progression of heart failure requiring the institution or addition of drug treatment, hospital admission, or death from heart failure. RESULTS—Development or progression of heart failure occurred in 38 patients (11%), and 22 patients (6%) died from heart failure. These complications were related to the presence of coronary artery disease (p

[in Dutch: ‘Bewegen is Overleven’] During our clinical or outpatient contacts we often tell patients with coronary heart disease that physical activity will lessen the burden of their disease, reduce their risk of mortality and enhance their quality of life. However, after delivering this one-liner we have no illusions that patients will start moving and stay active straight away. Many practical barriers deter them and behavioural change, such as adopting a physically active lifestyle, is only achieved when various stages of change have been successfully completed [1]. What really helps is referring patients quickly to an outpatient or clinical cardiac rehabilitation (CR) program. This does not always happen properly, but with the help of allied professionals such as the nursing specialist, the situation (in the Netherlands) is better now than 10 years ago. The number of referrals has also increased due to the Netherlands Society of Cardiology/Netherlands Heart Foundation (NVVC / NHS) Cardiac Rehabilitation Guidelines of 2004, updated in 2011 [2], as well as through the encouragement of the Healthcare Inspectorate. At the patient’s intake, the cardiac rehabilitation goals are clarified and established in consultation with the patient. The intake includes an exercise test (ergometry). Then, with the patient’s medical history and exercise test results in hand, a multidisciplinary team decides on a CR program. In Groningen we speak of ‘Short Fit’, ‘Long Fit’ and occasionally ‘Fit Plus’ programs. Underlying the choice is the patient’s single, multiple or complex heart-related problems. Often, the backbone of the CR trajectory is exercise, the component applied by the physiotherapist, which gives this allied professional a crucial role in CR. But in addition to physical therapy (and movement agogics), other allied professionals in social work, psychology, dietetics, nursing, case management (logistics and evaluation) as well as the cardiologist all contribute. In this issue of Netherlands Heart Journal (NHJ), movement scientists, epidemiologists, and members of the Royal Dutch Society of Physiotherapists (KNGF) present a concrete proposal for the contents of the movement program [3]. This is an excellent initiative because their own guidelines, established by the physical therapy professionals themselves, stand a better chance of implementation than the cardiologists’ guidelines [4]. What we like about the guidelines in their present shape is that they include: Recommendations for physiotherapy prior to heart surgery: for example, respiratory muscle and cough training pre-coronary bypass grafting (CABG), preferably 20 minutes/day starting 4 weeks before surgery [5], Recommendations for postoperative patients, not only for regular endurance training and possibly strength training, but also ‘functional exercises’. These exercises enable patients to be more independent for longer and/or able to resume work. Examples here are lifting, carrying, bending over, putting down, pushing, balancing, climbing stairs and turning safely [6]; in other words, physical agility and flexibility. The guidelines explicitly state: ‘The patient knows (learns) how to cope with their symptoms’, meaning how to ‘respond to the demands of life’. With regard to the mobilisation phase, in our opinion, the guidelines correctly point out the opportunities for Clinical Cardiac Rehabilitation offered by a few centres in the Netherlands [7], An option for fatigue-led training, where the familiar Borg scale (Rating of Perceived Exertion, RPE) can give direction. We recommend ‘rather tiring’ (in Dutch ‘tamelijk vermoeiend’) (level 12–13 on a scale of 6–20). For endurance exercise outside the home we regularly advise patients to follow the intensity of the Talk Test: ‘You can talk but not sing while exercising’ [8]. This gives patients something to hold on to in the post-CR phase if, for example, they no longer exercise according to heart rate. Again, in our opinion, the post-CR phase is almost more important than actual CR. After all, prevention of relapse in patients, after 6 weeks of exercise / new movement following a sedentary lifestyle, is but one of the core objectives of CR. This touches on the issue of non-adherence or non-compliance. During the program, the patient and the CR team must look for movement / exercises that fit easily in the patient’s day to day life [9]. Examples are brisk walking, cycling to and from work, swimming, or trying to connect the patient with what the Americans call a ‘Coronary Club’ and we in the Netherlands call a ‘Hart in Beweging’ (HIB, Heart in Motion) club. If patients have anginal symptoms that deter them from making an effort, prophylactic short-acting nitrate use can be considered [10], Acknowledgement of the importance of relaxation, besides training (movement / exercise). In the relaxation part of the CR program, the patient learns how to cope mentally and emotionally with body signals such as rapid breathing and heart beat, shortness of breath and possibly chest discomfort. In our opinion, however, daily aerobic activity (gentle endurance exercises) remains the cornerstone of the exercise program, And, finally, attention for impact assessment, including an exit test and aftercare, for example, by telephone from the case manager and, not forgetting to mention, the CR report to the GP and the referrer. The authors are rightly cautious in their recommendations for high-intensity interval (HIT) training. The guidelines state that HIT training: ‘may be recommended … for patients in poor physical condition’. Research is limited in this area, which is why we think HIT should be supervised very carefully. This does not happen in ‘real life’. However, physiotherapists with knowledge and experience of this method should be able to practise it as long as their patients are also motivated to try this type of exercise. What is rather unusual is how the guidelines use the Physiotherapy Evidence Database (PEDro) scale for rating the quality of randomised studies [11]. Readers of NHJ and relevant literature are more accustomed to three Classes of Recommendation (I, IIa / IIb or III) and three Levels of Evidence (A, B or C). The guidelines described in ‘Exercise-based cardiac rehabilitation in patients with coronary heart disease’ (2013) are an excellent addition to the Multidisciplinary CR Guidelines (2011) [2]. Because these new guidelines have arisen from the discipline of physiotherapy, one of our indispensable allied professions, there is a good chance of wide-scale implementation which will contribute significantly to good care for cardiac patients.