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The success of a surgical procedure is significantly influenced by several critical factors. The safety of the patient is the primary goal. To this end, the term surgical preparation covers a number of procedures aiming to ensure the safety for the patient and a successful surgical intervention: verifying the indications, planning the intervention, identification of potential harmful factors, risks and countermeasures, patient education and documentation. Trauma surgery poses a particular challenge to preoperative preparation, especially due to urgent surgical interventions. Here, a standardized and evidence-based preoperative evaluation ensures a successful treatment of the patient.Der Erfolg eines chirurgischen Eingriffs wird ganz wesentlich von einigen kritischen Faktoren beeinflusst. Im Vordergrund steht der Schutz der Patientensicherheit. Daher wird unter dem Begriff Operationsvorbereitung (OPV) eine Reihe von Maßnahmen zusammengefasst, die das Ziel haben, die Sicherheit des Patienten sowie einen erfolgreichen operativen Eingriff zu gewährleisten: Sicherung der Indikation, Planung des Eingriffs, Identifikation von potenziellen Störfaktoren, Risiken und Gegenmaßnahmen, Aufklärung und Dokumentation. Die Unfallchirurgie stellt insbesondere aufgrund von dringlichen operativen Eingriffen eine besondere Herausforderung für die präoperative Vorbereitung dar. Hier ermöglicht eine standardisierte und evidenzbasierte OPV, die erfolgreiche Behandlung des Patienten zu gewährleisten.

The TELECOVID study (https://www.telecovid.de) is designed to remotely monitor the physiological health status of COVID-19 positive-risk patients in home isolation. Key vital parameters are measured day and night using an in-ear biosensor technology. These data are streamed to the clinic in real time to enable timely interaction in case of deterioration.

The coronavirus disease 2019 (COVID-19) caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has spread worldwide. Bacterial co-infections are associated with unfavourable outcomes in respiratory viral infections; however, microbiological and antibiotic data related to COVID-19 are sparse. Adequate use of antibiotics in line with antibiotic stewardship (ABS) principles is warranted during the pandemic. We performed a retrospective study of clinical and microbiological characteristics of 140 COVID-19 patients admitted between February and April 2020 to a German University hospital, with a focus on bacterial co-infections and antimicrobial therapy. The final date of follow-up was 6 May 2020. Clinical data of 140 COVID-19 patients were recorded: The median age was 63.5 (range 17–99) years; 64% were males. According to the implemented local ABS guidelines, the most commonly used antibiotic regimen was ampicillin/sulbactam (41.5%) with a median duration of 6 (range 1–13) days. Urinary antigen tests for Legionella pneumophila and Streptococcus peumoniae were negative in all cases. In critically ill patients admitted to intensive care units (n = 50), co-infections with Enterobacterales (34.0%) and Aspergillus fumigatus (18.0%) were detected. Blood cultures collected at admission showed a diagnostic yield of 4.2%. Bacterial and fungal co-infections are rare in COVID-19 patients and are mainly prevalent in critically ill patients. Further studies are needed to assess the impact of antimicrobial therapy on therapeutic outcome in COVID-19 patients to prevent antimicrobial overuse. ABS guidelines could help in optimising the management of COVID-19. Investigation of microbial patterns of infectious complications in critically ill COVID-19 patients is also required.

Background In this retrospective routine data analysis, we investigate the number of emergency department (ED) consultations during the COVID-19 pandemic of 2020 in Germany compared to the previous year with a special focus on numbers of myocardial infarction and acute heart failure. Methods Aggregated case numbers for the two consecutive years 2019 and 2020 were obtained from 24 university hospitals and 9 non-university hospitals in Germany and assessed by age, gender, triage scores, disposition, care level and by ICD-10 codes including the tracer diagnoses myocardial infarction (I21) and heart failure (I50). Results A total of 2,216,627 ED consultations were analyzed, of which 1,178,470 occurred in 2019 and 1,038,157 in 2020. The median deviation in case numbers between 2019 and 2020 was − 14% [CI (− 11)–(− 16)]. After a marked drop in all cases in the first COVID-19 wave in spring 2020, case numbers normalized during the summer. Thereafter starting in calendar week 39 case numbers constantly declined until the end of the year 2020. The decline in case numbers predominantly concerned younger [− 16%; CI (− 13)–(− 19)], less urgent [− 18%; CI (− 12)–(− 22)] and non-admitted cases [− 17%; CI (− 13)–(− 20)] in particular during the second wave. During the entire observation period admissions for chest pain [− 13%; CI (− 21)–2], myocardial infarction [− 2%; CI (− 9)–11] and heart failure [− 2%; CI (− 10)–6] were less affected and remained comparable to the previous year. Conclusions ED visits were noticeably reduced during both SARS-CoV-2 pandemic waves in Germany but cardiovascular diagnoses were less affected and no refractory increase was noted. However, long-term effects cannot be ruled out and need to be analysed in future studies. Graphical abstract

Background If a COVID-19 patient develops a so-called severe course, he or she must be taken to hospital as soon as possible. This proves difficult in domestic isolation, as patients are not continuously monitored. The aim of our study was to establish a telemonitoring system in this setting. Methods Oxygen saturation, respiratory rate, heart rate and temperature were measured every 15 minutes using an in-ear device. The data was transmitted to the Telecovid Centre via mobile network or internet and monitored 24/7 by a trained team. The data were supplemented by daily telephone calls. The patients´ individual risk was assessed using a modified National Early Warning Score. In case of a deterioration, a physician initiated the appropriate measures. Covid-19 Patients were included if they were older than 60 years or fulfilled at least one of the following conditions: pre-existing disease (cardiovascular, pulmonary, immunologic), obesity (BMI >35), diabetes mellitus, hypertension, active malignancy, or pregnancy. Findings 153 patients (median age 59 years, 77 female) were included. Patients were monitored for 9 days (median, IQR 6–13 days) with a daily monitoring time of 13.3 hours (median, IQR 9.4–17.0 hours). 20 patients were referred to the clinic by the Telecovid team. 3 of these required intensive care without invasive ventilation, 4 with invasive ventilation, 1 of the latter died. All patients agreed that the device was easy to use. About 90% of hospitalised patients indicated that they would have delayed hospitalisation further if they had not been part of the study. Interpretation Our study demonstrates the successful implementation of a remote monitoring system in a pandemic situation. All clinically necessary information was obtained and adequate measures were derived from it without delay.

Background: If a COVID-19 patient develops a so-called severe course, he or she must be taken to hospital as soon as possible. This proves difficult in domestic isolation, as patients are not continuously monitored. The aim of our study was to establish a telemonitoring system in this setting. Methods: Oxygen saturation, respiratory rate, heart rate and temperature were measured every 15 minutes using an in-ear device. The data was transmitted to the Telecovid Centre via mobile network or internet and monitored 24/7 by a trained team. The data were supplemented by daily telephone calls. The patients´ individual risk was assessed using a modified National Early Warning Score. In case of a deterioration, a physician initiated the appropriate measures. Covid-19 Patients were included if they were older than 60 years or fulfilled at least one of the following conditions: pre-existing disease (cardiovascular, pulmonary, renal or hepatic), obesity (BMI >35), diabetes mellitus, hypertension, active malignancy, immunosuppressive medication, or pregnancy. Findings: 153 patients (median age 59 years, 77 female) were included. Patients were monitored for 10 days (median, IQR 6 - 13 days) with a daily monitoring time of 13.3 hours (median, IQR 9.4 – 17.0 hours). 20 patients were referred to the clinic by the Telecovid team. 3 of these required intensive care without invasive ventilation, 4 with invasive ventilation, 1 of the latter died. All patients agreed that the device was easy to use. About 90% of hospitalised patients indicated that they would have delayed hospitalisation further if they had not been part of the study. Interpretation: Our study demonstrates the successful implementation of a remote monitoring system in a pandemic situation. All clinically necessary information was obtained and adequate measures were derived from it without delay. Funding Information: This work was supported by the TUM-Universitatsstiftung, by the Margarete-Ammon-Stiftung and by the Bayerisches Staatsministerium fur Wissenschaft und Kunst (U.7-H4001.1.7/35/3). Declaration of Interests: FK is an employee of cosinuss° GmbH. All other authors declare no competing interests. Ethics Approval Statement: The ethics committees of the Ludwig-Maximilians University and of the Technical University Munich approved the study protocol. The study was conducted in accordance with the principles of the Declaration of Helsinki. All patients gave written informed consent.

BACKGROUND: Implantable cardioverter defibrillators (ICDs) prevent sudden cardiac death. ICD implantation decisions are currently based on reduced left ventricular ejection fraction (LVEF≤35%). However, in some patients, the non-arrhythmic death risk predominates thus diminishing ICD-therapy benefits. Based on previous observations, we tested the hypothesis that compared to the others, patients with nocturnal respiratory rate (NRR) ≥18 breaths per minute (brpm) benefit less from prophylactic ICD implantations. METHODS: This prospective cohort study was a pre-defined sub-study of EU-CERT-ICD trial conducted at 44 centers in 15 EU countries between May 12, 2014, and September 6, 2018. Patients with ischaemic or non-ischaemic cardiomyopathy were included if meeting primary prophylactic ICD implantation criteria. The primary endpoint was all-cause mortality. NRR was assessed blindly from pre-implantation 24-hour Holters. Multivariable models and propensity stratification evaluated the interaction between NRR and the ICD mortality effect. This study is registered with ClinicalTrials.gov (NCT0206419). FINDINGS: Of the 2,247 EU-CERT-ICD patients, this sub-study included 1,971 with complete records. In 1,363 patients (61.7 (12) years; 244 women) an ICD was implanted; 608 patients (63.2 (12) years; 108 women) were treated conservatively. During a median 2.5-year follow-up, 202 (14.8%) and 95 (15.6%) patients died in the ICD and control groups, respectively. NRR statistically significantly interacted with the ICD mortality effect (p = 0.0070). While the 1,316 patients with NRR

Aim The goal is to design and, in a next step, establish a scalable, multi-center telemonitoring platform based on existing systems for monitoring COVID-19 patients in home quarantine. In particular, the focus will be on raw data acquisition, integration of sensor data into the hospital system, structured data storage, and interoperability. Subject and methods Data necessary for monitoring, otherwise provided in various portals, will be continuously queried and integrated into the hospital system via a new interface in this proof-of-concept work. Results Based on extensive preliminary work at Klinikum rechts der Isar with a structured clinical database, we extend our system’s integration of raw data and visualization in dashboards, as well as scientific provision of data from mobile sensors for monitoring patients in home quarantine. Conclusion Based on existing integrated telemonitoring systems supporting semantic and syntactic interoperability, short-term provision of scientific databases is possible. The integration of different mobile sensors into a clinical system for remote monitoring of patients around the clock is still new and to our knowledge unique.

Aims Present society is constantly ageing and elderly frequently suffer from conditions that are difficult and/or costly to treat if detected late. Effective screening of the elderly is therefore needed so that those requiring detailed clinical work-up are identified early. We present a prospective validation of a screening strategy based on a Polyscore of seven predominantly autonomic, non-invasive risk markers. Methods and results Within a population-based survey in Germany (INVADE study), participants aged ≥60 years were enrolled between August 2013 and February 2015. Seven prospectively defined Polyscore components were obtained during 30-min continuous recordings of electrocardiogram, blood pressure, and respiration. Out of 1956 subjects, 168 were excluded due to atrial fibrillation, implanted pacemaker, or unsuitable recordings. All-cause mortality over a median 4-year follow-up was prospectively defined as the primary endpoint. The Polyscore divided the investigated population (n = 1788, median age: 72 years, females: 58%) into three predefined groups with low (n = 1405, 78.6%), intermediate (n = 326, 18.2%), and high risk (n = 57, 3.2%). During the follow-up, 82 (4.6%) participants died. Mortality in the Polyscore-defined risk groups was 3.4%, 7.4%, and 17.5%, respectively (P Conclusion The Polyscore-based mortality risk assessment from short-term non-invasive recordings is effective in the elderly general population, especially those aged 60–74 years. Implementation of a comprehensive Polyscore screening of this age group is proposed to advance preventive medical care.

Zusammenfassung Hintergrund Seit Ende März wurde deutschlandweit das Gesundheitswesen auf einen Notbetrieb umgestellt, um Ressourcen für die sich ausbreitende Coronavirus-disease-2019-Pandemie (COVID-19-Pandemie) zu schaffen. Ziel der Arbeit ist es, das Aufkommen von Notfallpatienten zur Zeit der Pandemie zu untersuchen, um Rückschlüsse auf den Einfluss der COVID-19-Pandemie auf das Patientenaufkommen in einer Notaufnahme ziehen zu können. Material und Methoden Im Rahmen einer deskriptiven epidemiologischen Studie wurden in dem Zeitraum vom 01.02. bis zum 30.04.2019 sowie vom 01.02. bis zum 30.04.2020 patientenbezogene Daten von insgesamt 19.357 Fällen in der zentralen Notaufnahme des Klinikums rechts der Isar erhoben und anonymisiert ausgewertet. Ergebnisse Trotz steigender Patientenzahlen von 2019 auf 2020 kam es von Februar auf März 2020 zu einem deutlichen Abfall der Notfälle bis auf ein Niveau unter das von 2019, der im April weiter anhielt. Dies betraf insbesondere den Fachbereich Unfallchirurgie mit einem Rückgang des mittleren Patientenaufkommens um etwa 40 %. Im Hinblick auf die Beschwerdebilder im März 2020 zeigte sich, dass ein vermehrtes Aufkommen von Unwohlsein (+47 %) und Atemproblemen (+36 %) zu verzeichnen war, wohingegen Rückenschmerzen (−41 %), Wunden (−29 %), thorakale (−24 %) sowie abdominelle Schmerzen (−23 %) deutlich seltener vertreten waren als im Vorjahr. Bezogen auf den Schweregrad der Beschwerden wirkte sich der Rückgang vor allem auf Beschwerdebilder mit niedriger Dringlichkeitsstufe aus. Schlussfolgerung Im Rahmen der COVID-19-Pandemie kam es zu einem deutlichen Rückgang des Patientenaufkommens in einer der größten Notaufnahmen in München. Dies sollte bei bestehenden Krankenhauskapazitäten vermieden werden, um potenziell gesundheitlichen Schäden durch eine aufgeschobene oder ausbleibende notfallmäßige Vorstellung vorzubeugen.

Durch die weltweit steigenden Zahlen an „coronavirus disease 2019“(COVID-19)-Infektionen besteht fur samtliche Kliniken die Aufgabe, sich der Herausforderung einer Pandemie zu stellen. Es gilt insbesondere auch fur die Notaufnahmen, sich auf vollstandig veranderte Arbeitsablaufe vorzubereiten und sie umzusetzen. Dies betrifft insbesondere den Bereich Patientenscreening und -selektion (Triage). Auch mit anderen Fachbereichen wie der Hygiene, Infektiologie oder Virologie muss Hand in Hand zusammengearbeitet werden, um vor, wahrend und nach Abschluss der Diagnostik entsprechende Behandlungskonzepte zu realisieren. Daruber hinaus sind Kommunikation und Qualitats- und Risikomanagement nebst den klinischen Bereichen von hoher Relevanz. Dieser Artikel beschreibt an einem Beispiel, wie sich Notaufnahmen hier am Beispiel COVID-19 (coronavirus disease 2019) konkret und praxisnah auf eine Pandemie vorbereiten konnen.

Background Because insufficient data are available, the overall number of patients treated in German emergency departments can only be estimated. It is evident, however, that case numbers have been rising steadily in recent years, and that a lack of capacity is now leading with increasing freuqency to forced centralized allocation of patients by the emergency medical services (EMS) to emergency departments that are, officially, temporarily "closed". Methods Trends in patient allocation of this type in greater Munich, Germany, over the years 2013-2019 were analyzed for the first time on the basis of data from 904 997 cases treated by the emergency rescue services. Results From 2014 to 2019, the number of forced centralized patient allocations rose approximately by a factor of nine, from 70 to 634 per 100 000 persons per year. In the same period, the overall number of cases treated by the emergency rescue services rose by 14.5%. Peak values for forced centralized allocations were reached in the first quarter of each calendar year (2015: 1579, 2017: 2435, 2018: 3161, 2019: 3990). Of all medical specialties, internal medicine was the most heavily affected (more than 59% of the total). Especially in the years 2017-2019, the free availability of internal medicine declined in hospitals participating in the common greater Munich reporting system. Conclusion The reasons for the sharp rise in forced centralized allocations are unclear. This observed trend seems likely to persist over the coming years, in view of the current staff shortage, the aging population, and diminishing hospital capacities. The relevant decision-makers must collaborate to create emergency plans that will prevent care bottlenecks so that patients will not be endangered.

The evolving dynamics of coronavirus disease 2019 (COVID-19) and the increasing infection numbers require diagnostic tools to identify patients at high risk for a severe disease course. Here we evaluate clinical and imaging parameters for estimating the need of intensive care unit (ICU) treatment. We collected clinical, laboratory and imaging data from 65 patients with confirmed COVID-19 infection based on polymerase chain reaction (PCR) testing. Two radiologists evaluated the severity of findings in computed tomography (CT) images on a scale from 1 (no characteristic signs of COVID-19) to 5 (confluent ground glass opacities in over 50% of the lung parenchyma). The volume of affected lung was quantified using commercially available software. Machine learning modelling was performed to estimate the risk for ICU treatment. Patients with a severe course of COVID-19 had significantly increased interleukin (IL)-6, C-reactive protein (CRP), and leukocyte counts and significantly decreased lymphocyte counts. The radiological severity grading was significantly increased in ICU patients. Multivariate random forest modelling showed a mean &plusmn, standard deviation sensitivity, specificity and accuracy of 0.72 &plusmn, 0.1, 0.86 &plusmn, 0.16 and 0.80 &plusmn, 0.1 and a receiver operating characteristic-area under curve (ROC-AUC) of 0.79 &plusmn, 0.1. The need for ICU treatment is independently associated with affected lung volume, radiological severity score, CRP, and IL-6.

ZusammenfassungDer Baroreflex ist ein Mechanismus zur Aufrechterhaltung der kardiovaskulären Homöostase. Ein Anstieg des Blutdruckes führt, vermittelt durch das vegetative Nervensystem, gegenregulatorisch zu einem Abfall der Herzfrequenz und zu einer Dilatation der Widerstandsgefäße und umgekehrt. Dadurch werden überschießende Blutdruckschwankungen verhindert. Das Ausmaß der Baroreflexantwort ist ein starker und unabhängiger Prädiktor für Überleben und kardiale Ereignisse. Bei Erkrankungen des Herzkreislaufsystems liegt häufig ein pathologisch abgeschwächter Baroreflex vor. Adäquates Therapieansprechen dieser Patienten kann neben einer verbesserten Prognose mit einer Normalisierung der Baroreflexantwort einhergehen. Eine quantitative Beschreibung der Baroreflexantwort auf Blutdruckschwankungen ist die Baroreflexsensitivität (BRS). Es existieren verschiedene Methoden zur Bestimmung der Baroreflexsensitivität. Um die flächendeckende Implementierung dieser Verfahren in der klinischen Routine voranzutreiben, werden in Zukunft eine Optimierung in Bezug auf Messbarkeit und Reliabilität, die Etablierung von Referenzwerten sowie große prospektive Validierungsstudien vonnöten sein.

AIMS: Therapy with an implantable cardioverter defibrillator (ICD) is established for the prevention of sudden cardiac death (SCD) in high risk patients. We aimed to determine the effectiveness of primary prevention ICD therapy by analysing registry data from 14 centres in 11 European countries compiled between 2002 and 2014, with emphasis on outcomes in women who have been underrepresented in all trials. METHODS AND RESULTS: Retrospective data of 14 local registries of primary prevention ICD implantations between 2002 and 2014 were compiled in a central database. Predefined primary outcome measures were overall mortality and first appropriate and first inappropriate shocks. A multivariable model enforcing a common hazard ratio for sex category across the centres, but allowing for centre-specific baseline hazards and centre specific effects of other covariates, was adjusted for age, the presence of ischaemic cardiomyopathy or a CRT-D, and left ventricular ejection fraction ≤25%. Of the 5033 patients, 957 (19%) were women. During a median follow-up of 33 months (IQR 16-55 months) 129 women (13%) and 807 men (20%) died (HR 0.65; 95% CI: [0.53, 0.79], P-value

The stone heart syndrome is defined as an ischemic systolic contracture of the heart and also termed contractile cardiac arrest. It was first described in 1972 by the American cardiac surgeon Denton Cooley, who observed this phenomenon during bypass surgery. It is mostly the result of prolonged cardiac arrest where myocardial cells suffer hypoxia or anoxia. Insufficient forward blood flow and a decreased pressure gradient in the central aorta lead to reduced coronary perfusion. The resulting anaerobic metabolism causes an ischemic contracture as described in the stone heart syndrome. This article presents three cases of patients with traumatic cardiac arrest (TCA) and myocardial contracture in postmortem computed tomography (PMCT) and discuss the origins of the stone heart syndrome as well as its implications in cardiopulmonary resuscitation.Der Begriff Stone heart ist definiert als systolische Kontraktur des Herzens und wird auch als kontraktiler Herzstillstand bezeichnet. Er wurde erstmals 1972 durch den US-amerikanischen Herzchirurgen Denton Cooley bei Patienten mit Bypass-Operation beschrieben. Das Stone heart ist meist Folge eines prolongierten Herz-Kreislauf-Stillstands, welcher zu einer Anoxie bzw. Hypoxie des Myokards führt. Es wird über 3 Traumapatienten berichtet, welche nach kardiopulmonaler Reanimation in der postmortalen Computertomographie (CT) ein Stone-heart-Phänomen zeigten.

The potential of the MitraClip to prevent from right heart failure or to restore right ventricular (RV) function is still unclear. The aim of the present study was to analyze the impact of the MitraClip implantation on RV function and its association with clinical outcome. After MitraClip implantation patients underwent echocardiography follow-up scheduled between 3 and 6 months after the procedure in the present single-center registry. A total of 93 patients were included. Compared to baseline, RV function declined in 20%, was unchanged in 25% and improved in 55% of the patients. Factors associated with decline in RV performance were atrial fibrillation, decrease in left ventricular function and lack of reduction in pulmonary artery pressure. Patients who experienced worsening in RV function had a significantly lower survival after mean follow-up of 11 ± 7 months compared to those with preserved or improved RV function (15% vs. 83% vs. 83%; p log rank = 0.001). Furthermore, changes in TAPSE were found to be an independent predictor for all-cause mortality [HR 0.88 (0.77–0.99); p = 0.04]. The majority of patients suffering from severe MR benefited from MitraClip with respect to RV remodeling. However, 20% of the patients experienced a decline in RV function, which was associated with poor prognosis. Importantly, changes in RV function after MitraClip were identified as independent predictor for survival in contrast to baseline RV function and, therefore, should be implemented in follow-up routine for better outcome prediction.

BACKGROUND: A small proportion of patients undergoing primary prophylactic implantation of implantable cardioverter defibrillators (ICDs) experiences malignant arrhythmias. We postulated that periodic repolarisation dynamics, a novel marker of sympathetic-activity-associated repolarisation instability, could be used to identify electrically vulnerable patients who would benefit from prophylactic implantation of ICDs by way of a reduction in mortality. METHODS: We did a prespecified substudy of EUropean Comparative Effectiveness Research to Assess the Use of Primary ProphylacTic Implantable Cardioverter Defibrillators (EU-CERT-ICD), a prospective, investigator-initiated, non-randomised, controlled cohort study done at 44 centres in 15 EU countries. Patients aged 18 years or older with ischaemic or non-ischaemic cardiomyopathy and reduced left ventricular ejection fraction (≤35%) were eligible for inclusion if they met guideline-based criteria for primary prophylactic implantation of ICDs. Periodic repolarisation dynamics from 24-h Holter recordings were assessed blindly in patients the day before ICD implantation or on the day of study enrolment in patients who were conservatively managed. The primary endpoint was all-cause mortality. Propensity scoring and multivariable models were used to assess the interaction between periodic repolarisation dynamics and the treatment effect of ICDs on mortality. FINDINGS: Between May 12, 2014, and Sept 7, 2018, 1371 patients were enrolled in our study. 968 of these patients underwent ICD implantation, and 403 were treated conservatively. During follow-up (median 2·7 years [IQR 2·0-3·3] in the ICD group and 1·2 years [0·8-2·7] in the control group), 138 (14%) patients died in the ICD group and 64 (16%) patients died in the control group. We noted a 43% reduction in mortality in the ICD group compared with the control group (adjusted hazard ratio [HR] 0·57 [95% CI 0·41-0·79]; p=0·0008). Periodic repolarisation dynamics significantly predicted the treatment effect of ICDs on mortality (adjusted p=0·0307). The mortality benefits associated with ICD implantation were greater in patients with periodic repolarisation dynamics of 7·5 deg or higher (n=199; adjusted HR 0·25 [95% CI 0·13-0·47] for the ICD group vs the control group; p

Background Left atrial (LA) function predicts clinical outcome in a variety of cardiovascular diseases. However, limited data is available in the setting of mitral regurgitation (MR). Purpose The aim of the present study was to assess potential changes in LA ejection fraction (LA-EF) and its prognostic value in patients following transcatheter mitral valve repair using the mitraclip. Methods A total of 88 consecutive patients undergoing mitraclip implantation with complete echocardiography at baseline and follow-up between 3 and 6 months post-procedure were enrolled. Results LA-EF improved in 58% of the population. Change in LA-EF was associated with residual MR, residual transmitral gradient and left ventricular ejection fraction (LV-EF) changes. Compared to their counterparts, patients with residual MR ≥ grade 2 (−6% [−9 to 1%] vs. 4% [−5 to 15%]; p=0.05) and with residual transmitral gradient ≥5 mmHg (−2% [−9 to 9%] vs. 5% [−4 to 16%]; p=0.03) showed a decline in LA-EF, respectively. Furthermore, LA-EF significantly correlated with changes in LV-EF (r=0.40; p=0.001). With regards to clinical outcome, heart failure symptoms as assessed by NYHA class were more severe in patients with worsened LA-EF at follow-up. Finally, LA-EF change was identified as independent predictor of all-cause mortality (HR 0.94 [0.90–0.98]; p=0.008). Kaplan-Meier estimates for survival Conclusion The present analysis showed changes in LA function in patients undergoing mitraclip implantation to be associated with important measures including residual MR, elevated transmitral gradient and LV function. Importantly, LA function alterations represent a strong predictor for all-cause mortality.

In recent years, transcatheter treatment techniques for tricuspid regurgitation (TR) have rapidly evolved. Cardiac remodeling analysis beyond clinical outcome assessment following transcatheter tricuspid repair is still lacking. The aim of the present case series was to analyze cardiac remodeling after tricuspid valve repair using the edge-to-edge MitraClip technique.Echocardiographic analysis was performed prior to MitraClip implantation and at 3-month and 6-month follow-up exams.Six consecutive patients undergoing MitraClip implantation between April 2017 and March 2018 at our institution were enrolled. During follow-up, TR reduction was durable in all patients, without recurrence of severe TR. Compared to baseline, right ventricular function improved in 5 out of 6 patients. Reduction in right ventricular area was observed in the majority of patients and reduction in right atrial volume was observed in all subjects. Patients also experienced beneficial left cardiac remodeling.The present series indicates that transcatheter treatment of severe TR using the edge-to-edge MitraClip technique can lead to reverse cardiac remodeling, which is not commonly seen in surgically treated patients.

Highlights • General stroke care is altered during the COVID-19 pandemic lockdown • Emergency Medical Services seems to perform stable during the public lockdown • Utilization of Emergency Medical Services may have changed within the lockdown • Public education about stroke care is required prior to further lockdowns, Background The COVID-19 pandemic caused public lockdowns around the world. We analyzed if the public lockdown altered the referral pattern of Code Stroke patients by Emergency Medical Services (EMS) to our Comprehensive Stroke Center. Methods Retrospective single-center study at a Bavarian Comprehensive Stroke Center. Patients who were directly referred to our stroke unit by EMS between the 1st of January 2020 and the 19th of April 2020 were identified and number of referrals, clinical characteristics and treatment strategies were analyzed during the public lockdown and before. The public lockdown started on 21st of March and ended on 19th April 2020. Results In total 241 patients were referred to our center during the study period, i.e. 171 before and 70 during the lockdown. The absolute daily number of Code Stroke referrals and the portion of patients with stroke mimics remained stable. The portion of female stroke patients decreased (55% to 33%; p=0.03), and stroke severity as measured by the National Institutes of Health Stroke Scale (median 3 (IQR 0-7) versus 6 (IQR 1-15.5) points; p=0.04) increased during the lockdown. There was no difference of daily numbers of patients receiving thrombolysis and thrombectomy. Conclusions Referral of Code Stroke patients by EMS could be maintained sufficiently despite the COVID-19 pandemic lockdown. However, patients’ health care utilization of the EMS may have changed within the public lockdown. EMS remains a useful tool for Code Stroke patient referral during lockdowns, but public education about stroke is required prior to further lockdowns.

Der QRS-Komplex bildet die Erregungsausbreitung des ventrikularen Myokards elektrokardiographisch ab. Ist sie ungestort, findet sich ein unauffallig konfigurierter QRS-Komplex von normaler Dauer. Ist sie aufgrund pathologischer Veranderungen gestort, kommt es zu einer Verbreiterung des QRS-Komplexes. Bei Unterbrechung eines Tawara-Schenkels findet sich das Bild eines klassischen Schenkelblocks. Ist eine Zuordnung zu einem klassischen Schenkelblock aufgrund einer atypischen QRS-Konfiguration nicht moglich und finden sich Einkerbungen der R- oder der S-Zacken, spricht man von fragmentierten QRS-Komplexen. Das pathophysiologische Korrelat der fragmentierten QRS-Komplexe ist vielfaltig: Es kann sich um Myokardnarben im Rahmen einer koronaren Herzerkrankung, um fibrotische Myokardareale anderer Genese, um primare Herzerkrankungen oder systemische Erkrankungen mit kardialer Beteiligung handeln. Auch Funktionsstorungen auf zellularer Ebene, z. B. von Ionenkanalen, konnen mit fragmentierten QRS-Komplexen einhergehen. Neben der diagnostischen Bedeutung werden fragmentierte QRS-Komplexe zunehmend auch prognostische Eigenschaften zugesprochen, z. B. bei der Identifikation von Hochrisikopatienten bei koronarer Herzerkrankung, Kardiomyopathien, Brugada-Syndrom und Long-QT-Syndrom. Allerdings konnen fragmentierte QRS-Komplexe auch beim Gesunden beobachtet werden.

Objectives Studies addressing optimal postprocedural pharmacological management after endovascular stenting of iliofemoral post-thrombotic venous obstruction are lacking. We report our early clinical experience with a combination of rivaroxaban and clopidogrel in patients after iliofemoral post-thrombotic venous obstruction stenting. Methods Demographic, procedural, and follow-up data of nine patients (seven women; mean age of 32 ± 11 years) undergoing 10 procedures for iliofemoral post-thrombotic venous obstruction performed between August 2012 and January 2014 were retrospectively reviewed. After endovascular intervention, all patients were administered 20 mg rivaroxaban once daily (s.i.d.) and 75 mg clopidogrel s.i.d. or every second day depending on the individual drug responsiveness for at least six months. The adenosine diphosphate-induced platelet aggregation (platelet aggregation, in aggregation units × min) was assessed on a Multiplate analyzer. Patency was verified venographically at procedure end and was evaluated with duplex ultrasound in regular follow-ups. Results Iliofemoral venous flow was successfully re-established by percutaneous endovascular angioplasty and stent implantation in nine left-sided and one bilateral iliofemoral post-thrombotic venous obstruction. Under dual treatment strategy of rivaroxaban and clopidogrel with platelet aggregation control (median (range): 285 aggregation units × min (192; 402)), none of the patients experienced restenosis or stent thrombosis, respectively. After a median follow-up of 14 months (range: 6–26 months), the primary patency rate was 100% and no in-stent restenosis, stent occlusion or relevant minor or major bleeding occurred. Conclusion Combined factor Xa inhibition and tailored antiplatelet therapy after stenting of iliofemoral post-thrombotic venous obstruction were safe and performed favorably in terms of vessel patency.

Background A 68-year-old male smoker presented with progressive symptoms of vertebrobasilar insufficiency and angina. His past medical history included arterial hypertension, diabetes mellitus, dyslipidaemia as well as diffuse coronary artery disease including left main disease. Of note, he had undergone coronary bypass surgery 12 years earlier utilising the left internal mammary artery. Investigation Physical examination, laboratory tests, duplex ultrasound imaging, contrast-enhanced magnetic resonance imaging and coronary angiography. Diagnosis Severe bifurcation stenosis of the left subclavian and vertebral artery with consecutive subclavian steal syndrome and myocardial ischaemia. Management Bifurcation T-stenting using a self-expandable bare metal and a coronary drug-eluting stent.

This study hypothesizes that a lack of left ventricular ejection fraction (LVEF) recovery after myocardial infarction (MI) would be associated with a poor outcome.A reduced LVEF early after MI identifies patients at risk of adverse outcomes. Whether the change in LVEF in the weeks to months following MI provides additional information on prognosis is less certain.Change in LVEF between the early (2 to 7 days) and later (2 to 12 weeks) post-MI periods in patients with a first MI was assessed in 3 independent cohorts (REFINE [Risk Estimation Following Infarction Noninvasive Evaluation]; CARISMA [Cardiac Arrhythmia and Risk Stratification after Myocardial Infarction]; ISAR [Improved Stratification of Autonomy Regulation]). Patients were categorized as having no recovery (Δ ≤0%), a modest increase (Δ 1% to 9%), or a large increase (Δ ≥10%) in LVEF. The relationship between change in LVEF and risk of sudden cardiac arrest (SCA) and all-cause mortality were assessed in Cox multivariable models.In REFINE, patients with no LVEF recovery had a higher risk of sudden cardiac arrest (hazard ratio: 5.8; 95% confidence interval: 2.1 to 16.6; p = 0.001) and death (hazard ratio: 3.9; 95% confidence interval: 1.5 to 10.1; p 0.001), independent of revascularization, baseline LVEF, and medical therapy compared with patients with recovery. Similar findings were observed in the other cohorts. LVEF reassessments beyond 6 weeks post-MI were more predictive of outcome than were earlier reassessments.The degree of LVEF recovery after a first MI provides important prognostic information. Patients with no recovery in LVEF after MI are at high risk of sudden cardiac arrest events and death.

AIMS The aim of this study was to assess the impact of drug-eluting stents (DES) compared to bare metal stents (BMS) for the endovascular treatment of atherosclerotic renal artery stenosis (ARAS). METHODS AND RESULTS We retrospectively evaluated all of our endovascular BMS and DES implantations performed in de novo ARAS between 2000 and 2014 at our institution. The occurrence of in-stent restenosis (ISR) detected by ultrasound or angiography, kidney function, blood pressure (BP), and the number of antihypertensive drugs were analysed as endpoints. Overall, 338 renal arteries were treated in 298 patients. BMS were implanted in 163 (48%), and DES in 175 lesions (52%). Of the 175 lesions treated with DES, 55 (31%) were treated with a BMS-in-DES hybrid technique. For reasons of comparability, only lesions treated with balloon sizes of 4-6.5 mm were included in the final analysis. After 12 months, the rate of ISR >50% was 18.6% in the BMS group and 7.2% in the DES group (p=0.031). None of the BMS-in-DES-treated (hybrid) lesions developed ISR (hybrid technique vs. BMS only p=0.008, hybrid technique vs. DES only p=0.034). Systolic BP and number of antihypertensive drugs remained unchanged in the BMS group but declined in the DES group (p=0.02). Renal function significantly deteriorated in the BMS group (p=0.03) but did not change significantly in the DES group (p=0.188). CONCLUSIONS DES were superior to BMS in preventing ISR. Overall, the BMS-in-DES-technique (hybrid) achieved the lowest risk for ISR.

Background We recently reported that nocturnal respiratory rate (NRR) predicts non-sudden cardiac death in survivors of myocardial infarction (MI). Here, we present the details of the technique deriving NRR from ECG recordings. Methods Continuous ECG and respiratory chest excursions were simultaneously recorded in 941 MI survivors who were followed-up for 5-years. Mean respiratory rate was derived from the ECG based on RR intervals, QRS amplitudes, and QRS vectors and compared to chest belt measurements. NRR was calculated from Holter-ECGs accordingly using the same ECG processing. Results Directly-measured and ECG-derived respiratory rates were in good agreement. Areas under the ROC curve for 10-min-ECG- and Holter-derived respiratory rate were well in the confidence intervals of that of the chest belt measurement. The optimum dichotomy of NRR for the prediction of mortality was ≥ 18.6 breaths per minute. Conclusions The mean respiratory rate can be precisely derived from continuous ECGs.

AIMS Thirty-day results of the double-blind, randomised Intracoronary Stenting and Antithrombotic Regimen -Rapid Early Action for Coronary Treatment (ISAR-REACT) 4 trial showed no difference in ischaemic complications and a reduction in bleeding by bivalirudin versus abciximab and heparin in 1,721 patients with non-ST-segment elevation myocardial infarction (NSTEMI) undergoing percutaneous coronary intervention (PCI). A longer follow-up may be required to assess the whole potential benefit of a periprocedural antithrombotic therapy. METHODS AND RESULTS The primary outcome for this analysis was the composite of death, myocardial infarction or target vessel revascularisation one year after randomisation. Secondary outcome was the composite of death or myocardial infarction. At one year, the primary outcome occurred in 21.3% of patients assigned to abciximab and heparin versus 21.5% assigned to bivalirudin (hazard ratio [HR] 0.99; 95% confidence interval [CI]: 0.80-1.21; p=0.94). The combined incidence of death or myocardial infarction was 15.7% in the abciximab and heparin group versus 16.0% in the bivalirudin group (HR 0.99; 95% CI: 0.78-1.26; p=0.94). The mortality rates were 4.0% and 4.7%, respectively (HR 0.85; 95% CI: 0.54-1.34; p=0.48). At one year, no significant differences in the primary outcome were observed with abciximab and heparin versus bivalirudin in any of the subgroups analysed. CONCLUSIONS In patients with NSTEMI undergoing PCI, abciximab with heparin and bivalirudin provide comparable outcomes at one year, although bivalirudin reduced the rate of bleeding at 30 days. CLINICAL TRIAL REGISTRATION INFORMATION URL www.clinicaltrials.gov; Unique identifier NCT00373451.

Beat-to-beat variability of the QT interval (QTV) measured on surface ECG has emerged as a potential marker for ventricular repolarization instability and has been used along with heart rate variability (HRV) to predict arrhythmic risk. Since measurement modalities of QTV have not been standardized, the objective of this study was to investigate the effect of ECG recording duration on QTV as well as HRV. Using a database of 30 min ECG recorded from 500 patients with acute myocardial infraction during rest, we extracted RR and QT interval time series and estimated different HRV and QTV metrics over windows of varying length. Analysis of variance (ANOVA) and intra-class correlation analyses were computed to investigate the effect of recording length on consistency and short-term reproducibility of HRV and QTV variables. Good consistency (non-significant ANOVA results) and short-term reproducibility (intra-class correlation coefficients >0.8) were demonstrated for all but standard deviation based metrics when at least 200 beats were included in the estimation. In conclusion, QTV can be quantified from resting ECG with good short-term consistency and reproducibility that is comparable to that of HRV.

A 51-year-old man was referred with a 1-year history of reduced exercise tolerance and progressive exertional dyspnoea. Two months ago, he additionally noticed some haemoptysis. Two years earlier he underwent pulmonary vein isolation for paroxysmal atrial fibrillation in another hospital. Initially, he was treated with antibiotics for presumptive pneumonia due to a left lung …

Abstract. Background: High on-treatment platelet reactivity (HPR) predicts adverse cardiovascular events in patients with coronary artery disease. The impact of HPR in patients with peripheral artery disease (PAD) after peripheral endovascular procedures is unclear. Patients and methods: A total of 385 patients with PAD and successful percutaneous endovascular procedure were included. Patients received aspirin as a long-term treatment in addition to the P2Y12 receptor antagonist clopidogrel, as recommended after such a procedure for at least 1 month. Platelet function was assessed on a Multiplate analyzer. The primary endpoint was target lesion revascularization (TLR) at one year. Restenosis (≥ 75 %) in duplex sonography, mortality at one year and identification of independent predictors of TLR were secondary endpoints. Results: TLR rates were similar in HPR and no-HPR patients (14.3 % vs. 12.7 %, hazard rate (HR) 0.94, 95 % CI 0.48 - 1.84, P = 0.86). Restenosis (≥ 75 %) in duplex sonography did not differ between the two study groups (15.6 % vs. 16.9 %, HR 1.16, 95% CI 0.62 - 2.12, P = 0.64). Independent predictors of TLR were intervention of restenotic lesions, total vessel occlusions and critical limb ischemia, but not HPR (adjusted HR 1.07, 95% CI 0.55 - 2.10, P = 0.84). No difference in mortality at one year was observed (1.3 % vs. 1.6 %, HR 1.28, 95 % CI 0.15 - 11.0, P = 0.82). Conclusions: In patients with PAD, HPR did not have a significant impact on outcomes within the first year after percutaneous endovascular intervention.

Background: The debate on whether sex-specific predictive models improve risk stratification after myocardial infarction is ongoing. Methods: This review summarises the current clinical knowledge on sex-specific differences in post-infarction risk stratification parameters. Particular focus is given to electrocardiographic risk factors and indices of cardiac autonomic status. Results: Differences in the underlying pathophysiology between men and women are known. However, clinical findings often lead to uncertain conclusions for a number of risk predictors including, among others, resting heart rate, heart rate variability, heart rate turbulence, QT interval duration, and QRS-T angle. The review links recent findings in prognostic parameters with successful approaches in sex-specific non-invasive risk stratification. Conclusion: Disparities are described in the current clinical opinions on the relevance of investigated parameters in women and possible directions for further research in the field are given.