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BACKGROUND: Chronic heart failure (CHF) will become one of the greatest medical challenges during the next decades. This is especially true with regard to elderly patients. Besides medical diagnostics and drug therapy, efficient treatment of CHF must also include exercise training. AIMS: The purpose of our study was 1) to record health-related quality of life (QOL) in elderly patients with CHF and 2) to assess the efficacy of a training program, as well as to evaluate any changes detected during a six month follow-up. METHODS: In our non-randomized study, 116 patients, divided according to age into Group 1 (>70 years) and Group 2 (<70 years), took part in a 4-week training program. RESULTS: There were differences in the clinical parameters and the QOL between the older and the younger patients both after 4 weeks and at the follow-up. After six months, however, the older patients again recorded having an inferior QOL to that of the younger patients. CONCLUSION: Elderly patients can also benefit from physical exercise training, with improvement in clinical parameters and QOL. In order to maintain the subjectively improved QOL in the long term, however, continued special heart failure education and support is required. [ABSTRACT FROM AUTHOR]

Background: Exercise training has now become established practice in patients with chronic heart failure. Women are often under-represented in intervention studies compared to men. For this reason it was our aim to conduct a combined endurance and muscle strength training program to evaluate its effect on clinical performance data and health-related psychosocial factors in women and men., Methods: One hundred and sixteen women, mean age 69 +/- 9 years, body mass index (BMI) 25.8 +/- 4.9, and 169 men, mean age 66 +/- 9 years, BMI 26.6 +/- 3.6 underwent combined endurance/resistance training. The training program lasted 29 +/- 7 days and comprised bicycle ergometer training, a 6-min walk test as a training unit and muscle strength training for the lower and upper extremities., Results: Differences between women and men were found in clinical parameters. In particular, statistically significant differences were revealed between the women and men with regard to cardiopulmonary performance. Quality of life was significantly improved on discharge with regard to both physical and mental health, whereas anxiety and depression showed no significant alteration., Conclusion: A specialized in-hospital program for women and men combining endurance/resistance training and education is feasible. But our program revealed a very low level of cardiopulmonary performance in women. Women need to be encouraged and motivated to participate in such programs.

Background: Lengthy recovery and treatment times following cardiosurgical interventions were the motivation for introducing a pilot procedure to integrate acute and rehabilitative treatment structures. The advantage of such a pilot procedure is the medico-economic link between direct transition from acute care to rehabilitation treatment and cutting average case costs. With this in mind, shared case fees for patients following cardiosurgery are being agreed in a pilot project between health insurance companies, acute-care hospitals and rehabilitation clinics. The aim of this study was thus to investigate whether rehabilitation directly after cardiosurgery without prior transferral to an acute-care hospital is comparable with the conventional procedure involving acute care., Methods: A total of 221 patients were included in the investigation. The pilot project group comprised 159 patients (mean age 70 +/- 6 yrs, 117 men and 42 women) who were transferred directly to rehabilitation following cardiosurgery. The control group, comprising 62 patients (mean age = 71 +/- 6 yrs, 42 men and 20 women), was transferred to an acute-care hospital following cardiosurgery before commencing rehabilitation. Sociodemographic and clinical data were comparable between the two groups., Results: At the end of rehabilitation, the mean maximum ergometric performance in the pilot group was 96 +/- 33 W, significantly higher than the control group's performance of 81 +/- 31 W. One difference between the two groups related to complications. During rehabilitation, complications occurred more frequently within the pilot group. In the pilot group, compared to the control group, postcardiotomy syndrome occurred in 45.3 versus 25.8% and impaired wound healing in 10.1 versus 4.8% of cases. Despite these results, the pilot group demonstrated a significantly shorter overall hospital stay of 39.5 +/- 7.5 days compared to the control group stay of 45.7 +/- 9.7 days., Conclusion: Compared to the control group, the pilot group was at no disadvantage with regard to clinical or performance data by the end of rehabilitation. Cardiac complications occur more often during rehabilitation taking place directly after cardiosurgery than with the conventional procedure. These can be viewed, however, as complications occurring directly in temporal conjunction with the operation and as to be expected. Complications attributed directly to fast-track rehabilitation can be excluded. In the pilot group the overall hospital stay was thus shortened. In an environment of legislative restructuring within the healthcare sector, this shows that adequate treatment of cardiosurgical patients is still guaranteed with fast-track rehabilitation.

Background: The molecular mechanisms by which physical training improves peripheral and coronary artery disease are poorly understood. Bone marrow-derived endothelial progenitor cells (EPCs) are thought to exert beneficial effects on atherosclerosis, angiogenesis, and vascular repair., Methods and Results: To study the effect of physical activity on the bone marrow, EPCs were quantified by fluorescence-activated cell sorter analysis in mice randomized to running wheels (5.1+/-0.8 km/d, n=12 to 16 per group) or no running wheel. Numbers of EPCs circulating in the peripheral blood of trained mice were enhanced to 267+/-19%, 289+/-22%, and 280+/-25% of control levels after 7, 14, and 28 days, respectively, accompanied by a similar increase of EPCs in the bone marrow and EPCs expanded from spleen-derived mononuclear cells. eNOS-/- mice and wild-type mice treated with N(G)-nitro-l-arginine methyl ester showed lower EPC numbers at baseline and a significantly attenuated increase of EPC in response to physical activity. Exercise NO dependently increased serum levels of vascular endothelial growth factor and reduced the rate of apoptosis in spleen-derived EPCs. Running inhibited neointima formation after carotid artery injury by 22+/-2%. Neoangiogenesis, as assessed in a subcutaneous disc model, was increased by 41+/-16% compared with controls. In patients with stable coronary artery disease (n=19), moderate exercise training for 28 days led to a significant increase in circulating EPCs and reduced EPC apoptosis., Conclusions: Physical activity increases the production and circulating numbers of EPCs via a partially NO-dependent, antiapoptotic effect that could potentially underlie exercise-related beneficial effects on cardiovascular diseases.

Background: There is now evidence that moderate training plays an important role in the treatment of chronic heart failure. No clear instructions exist to date as to how such training programs should be carried out., Aim: to assess the efficiency of a training program including bicycle ergometer training, moderate muscle strength training and the 6-min walk test and their influence on quality of life, anxiety and depression., Methods and Results: Patients (67 male, 21 female) underwent a standardized 4-week training program., Baseline Data: LVEF=31+/-8%; LVEDD=143+/-59 ml; peak VO(2)=13.9+/-4.6 kg/ml. No adverse side effects could be observed. At discharge LVEF was 37+/-9%, (P=0.001); LVEDD=131+/-44ml (P=0.01); and peak VO(2)=15.4+/-5.0 kg/ml. Quality of life improved significantly in nearly all domains and in summary score. There were no significant changes in anxiety and depression. There is a negative correlation between the initial workload and changes in physical health (r=-0.42, P=0.001) and only a weak correlation between age and positive changes in physical health (r=0.26, P=0.05)., Conclusions: A standardized training program including moderate muscle strength training could be performed safely and demonstrated improvement in clinical parameters and quality of life., (Copyright 2002 European Society of Cardiology)

Background: The rate constant for global fatty acid influx (k(1)) was studied in 12 male patients with dilated cardiomyopathy (DCM)., Method: 10 normal subjects served as controls. 201-Thallium (201TI) and [123I]-phenyl-pentadecanoic acid (IPPA) were administered during bicycle exercise under fasting conditions., Results: All patients showed non-homogeneous tracer uptake defects for 201TI and IPPA. k(1) was significantly higher in DCM patients than controls. k(1) showed significant inverse correlation between cardiac index, left-ventricular ejection fraction, left-ventricular enddiastolic pressure and echocardiographic left-ventricular ejection fraction., Conclusion: We presume that an increased regional rate constant of IPPA influx into the myocardial tissue in patients with DCM reflects a compensatory mechanism of altered myocardium.

Primary tumors of the heart are very rare. We report a case of a 28-year old female patient in whom a tumor of the left ventricle was first diagnosed by transthoracic echocardiography. Angiography, nuclear magnetic resonance imaging and fasting positron emission tomography with 18-fluorodesoxyglucose suggested the diagnosis of a well vascularized tumor. The tumor was subtotally excised during heart surgery under total cardiopulmonary bypass and histological examination identified a predominantly vascular hamartoma.

Patients with mild pulmonary stenosis after infancy rarely have symptoms or develop increasing obstruction. We experienced a 68-year-old woman with severe pulmonary valvar and infundibular stenosis (peak to peak pressure gradient = 80 mmHg). She had been pointed out heart disease at the age of six. Endocarditis at the age of 17 might induce calcification of valve and affect the progression of pulmonary stenosis, and moreover, which might gradually develop severe subvalvar obstruction and poststenotic aneurysm of pulmonary trunk. She refused operative intervention because of mild clinical symptoms (NYHA class II), but we recommended surgical repair due to repeated transient ischemic attacks, which were suspected paradoxical embolism through persistent foramen ovale. She underwent pulmonary valvotomy and infundibular resection and is doing well.

Coronary angiography is considered to be the most important component in the diagnosis of coronary artery disease. Only the lumen may be visualized using contrast radiography of the coronary arteries, however. With intravascular ultrasound, on the other hand, pathological changes in the vascular wall can be recorded. Despite typical symptoms, an angiographical image of the coronary arteries is sometimes unable to show unambiguous stenotic lesions of the coronary arteries. In such cases, intravascular ultrasound provides a new complementary diagnostic tool for detecting even early forms of arteriosclerosis or angiographically underestimated coronary findings. Two cases are used to illustrate this. In those, angiographic visualization of the coronary arteries was unable to produce an unambiguous finding despite typical clinical symptoms, yet intravascular ultrasound could detect considerable arteriosclerotic wall changes.

Objective: Percutaneous mitral valvuloplasty has been shown to be an acceptable alternative to surgery as treatment for selected patients with severe mitral stenosis. We examined hemodynamic, echocardiographic, and pathomorphologic findings in a series of 308 patients undergoing balloon valvuloplasty, 41 of whom underwent subsequent surgery, in search of possible predictors of an unsuccessful outcome., Intervention and Results: Patients with severe mitral stenosis underwent Inoue single ballon valvuloplasty over a 48-month period and had follow-up for a mean of 14.5+/-16.8 months (range 1 to 64 months). Of the 308 patients, 267 (Group I) were clinically improved and stable throughout follow-up, while subsequent surgery was required in 41 (Group II) after 38.2+/-143.5 days (range 1 to 1212). Significant differences between the groups were observed for NYHA class (2.7+/-0.6 vs 2.9+/-0.6, p<0.05), mitral valve area (1.0+/-0.3 vs 0.9+/-0.2 cm2, p<0.01) and left atrial endsystolic dimension by echo (51.3+/-8.0 vs 55.4+/-10.2 mm, p<0.01). Two of the 41 Group II patients underwent surgery for left to right shunting, 1 for tamponade and 2 were lost to follow-up. The excised mitral valves of the remaining 36 patients all showed calcification and/or fibrosis: 9 homogenous, 5 non-homogenous; 19 were classified as having a funnel-shaped deformity, and 3 did not fit into a discrete category. Among the funnel-shaped valves, 13 had a tear versus 6 where dilation was primarily accomplished by stretching. Only one of 9 valves with homogenous calcification was torn, whereas a tear was noted in 3 of the 5 with non-homogenous calcification., Conclusion: Funnel-shaped valves and those with non-homogenous distribution of calcification and/or fibrosis appear to be least suitable for balloon valvuloplasty.

To determine the feasibility of currently used, intravascular ultrasound catheters (12.5 and 20 MHz, 6F and 9F, Boston Scientific Corp., Watertown, MA) for mitral valve disease, ten excised mitral valves from patients with severe mitral stenosis were examined. The specimens were fixed in a glass cylinder perfused with water. The valves were planimetered with the intravascular ultrasound system and investigated regarding pathomorphological changes. The depth field of penetration was between 1.5 and 2 cm (3 to 4 cm diameter) in the 20 MHz catheter and between 2 and 2.5 cm (4 to 5 cm diameter) in the 12.5 MHz catheter. A good correlation of the experimentally recorded valve areas could be ascertained with the Gorlin formula (r = .71, P < .05), the Doppler echocardiography method (r = .69, time method (r = .75, p < .05), and with the two-dimensional echocardiography method (r = .69, P < .05). These results show a sufficient feasibility of the currently used, intravascular ultrasound catheters and enable further steps to be taken with regard to evaluating mitral valve morphology in vivo.

Background and Aims of the Study: Percutaneous mitral valvulotomy has been shown to be an accept able alternative to surgery as treatment for selected patients with severe mitral stenosis. Uncertainty still exists regarding predictors of unsuccessful outcome., Materials and Methods: 308 patients with severe mitral stenosis underwent Inoue single balloon valvulotomy over a 48-month period and were followed up for a mean of 14.5 +/- 16.8 months (range one to 64 months). Two hundred and sixty-seven (Group I) improved clinically and remained stable throughout the follow up, while subsequent surgery was required in 41 (Group II) after 38.2 +/- 143.5 days (range one to 1,212). Clinical and echocardiographic parameters of the two groups were compared to find significant predictors of an unsuccessful outcome., Results: Significant differences between the groups were observed for NYHA class (2.7 +/- 0.6 vs. 2.9 +/- 0.6, p < 0.05), mitral valve area (1.0 +/- 0.3 vs. 0.9 +/- 0.2 cm2, p < 0.01), left atrial end-systolic dimension by echo (51.3 +/- 8.0 vs. 55.4 +/- 10.2 mm, p < 0.01) and an echocardiographic scoring system including grading for eccentricity of the mitral orifice and distribution of commissural calcification (7.5 +/- 2.0 for Group I and 8.7 +/- 2.0 for Group II, p < 0.001)., Conclusions: Mitral valves that are more likely to have an unsuccessful outcome can be identified by hemodynamic, clinical and echocardiographic criteria, including grading for eccentricity of the mitral orifice and distribution of commissural calcification.

Intimointimal intussusception is a rare type of aortic dissection. The intimal tear occurs circumferentially with intussusception of the intimal flap downstream into the aortic arch causing obstruction of the great supraaortic vessels. A CT diagnosis has only once been reported. CT and angiographic findings of this rare complication of aortic dissection are described.

Seven prospective, epidemiological studies indicate plasma fibrinogen levels (over 300-350 mg/dl) as an important, independent cardiovascular risk factor for subsequent myocardial infarction and stroke. Furthermore, several clinical studies revealed an association between fibrinogen and both the angiographic and clinical degree of coronary heart disease. In addition, a significant relation of fibrinogen with the number of occluded coronary vessels was found. The following pathophysiologic mechanism are of particular importance: Fibrinogen is a main determinant of plasma viscosity and red cell aggregation. Both phenomena deteriorate blood fluidity especially in the microcirculation. Fibrinogen plays a central role in platelet aggregation and performs an essential substrate in the coagulation cascade. Thus, high fibrinogen levels may favor a hypercoagulable state resulting in final thrombotic events of cardiovascular disease. Fibrinogen is also involved in atherogenesis by stimulating proliferation and migration of smooth muscle cells. Several determinants of fibrinogen levels are known. Smoking is the strongest one in healthy persons. This clinically important effect is dose related. Consequently, cessation of smoking is a major step to lower fibrinogen and subsequently the individual cardiovascular risk. Reduction of overweight and maintenance of regular physical activity are further nonpharmacologic means. Fibrates decrease fibrinogen about 10-30% on an average. Finally, intermittent low-dose Urokinase for end-stages of coronary artery disease and LDL-apheresis (HELP) represent additional approaches to reduce fibrinogen.

In 302 consecutively patients fibrinogen (Clauss method) and leucocyte count were related to the angiographic and clinical degree of coronary atherosclerosis. Fibrinogen (mg/dl) was statistically higher compared to control (C, 267 +/- 55) in patients with one-vessel disease (1-vd (306 +/- 67), 2-vd (331 +/- 73), and 3-vd (328 +/- 62)). Patients with coronary sclerosis (Scl, luminal irregularities and/or stenosis under 50%) showed a tendency to higher fibrinogen levels (291 +/- 58) as compared to controls. Leucocyte count (10(9)/L) compared to C (6.7 +/- 1.8) was significantly higher in 1-vd (7.6 +/- 2.0) and 2-vd (7.6 +/- 1.9). A subgroup analysis was performed with 100 patients having severe forms of angina pectoris (AP III according to the CCS classification, unstable angina). Hundred-sixteen patients with unstable angina (390 +/- 79), particularly with angina at rest during the last 48 h were characterized by the highest fibrinogen values (423 +/- 89, class III B/C Braunwald). Leucocyte count in patients with stable angina (7.2 +/- 1.4) and angina at rest (9.3 +/- 2.7) was significantly higher as compared to control (6.7 +/- 1.8). Hyperfibrinogenemia and relative leucocytosis correlate with the angiographic and clinical extent of coronary artery disease and may offer evidence of a higher degree of thrombogenesis associated with components of inflammation.

A 27-year-old man known to have corrected transposition of the great arteries (CTGA) associated with a ventricular septal defect (VSD) was admitted to our hospital with a suspected increase of the shunt volume. The patient is a first class bodybuilder. Heart catheterization confirmed the diagnosis of a "right-ventricular" mass obstructing the "right-ventricular" outflow tract, which had already been seen at echocardiography. The intraoperative finding showed the tumor to be accessory tissue of the anterior tricuspid leaflet prolapsing through the VSD into the subvalvular outflow tract of the right ventricle. The accessory tricuspid valve tissue was removed by transatrial access. The VSD was closed by a dacron patch using the same route. The postoperative course was uneventful.