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On behalf of the German Association of Cardiologists in Private Practice (BNK) the Steering Committee of the QuIK Registry reports the results 2010 to 2012 of the voluntary Quality Assurance in Invasive Cardiology (QuIK) and compares them to other data collections. More than 70 % of diagnostic (LHC) and therapeutic (PCI) cardiac catheterization procedures in private practice were entered into the registry. Altogether 225,756 LHC and 63,951 PCI were documented over the three years period. In these years age of patients and percentage of acute coronary syndromes increased as well in LHC as in PCI while consumption of dye solution and application of radiation dose decreased. In PCI the rate of 3-vessel coronary artery disease is still continuously rising. These parameters prove the increasing complexity of the cases. By implemented standardized external auditing (monitoring) to guarantee validity of the data QuIK remains a worldwide unique quality assurance project in cardiology. On a stable data base over all together 17 years the QuIK Registry shows the reality of every day cardiologic care in catheterization laboratories beyond selected study populations as well as a reliable feasibility of internal and external quality assurance.

In two brothers each of two families congestive cardiomyopathy was diagnosed. Left ventricular biopsy showed individually differing degrees of hypertrophy of the myocardial cells together with endocardial fibrosis and circumscribed interstitial fibrosis. In family I clinical symptoms appeared at the beginning of the 4th decade, conduction disturbances being predominant. One brother died after rapid progression of the disease within one year. The other has been treated as an outpatient for 9 years; he received a pacemaker implant half a year ago. In family II initial symptoms appeared in the middle of the 6th decade, progressive heart dilation and insufficiency being the predominant characteristics. In the course of 7 years one brother has developed cardiac decompensation whereas the other brother's condition has remained nearly unchanged for 4 years. The degree of myocardial changes in left ventricular biopsies correlated with the clinical course.

HISTORY AND CLINICAL FINDINGS A 61-year-old man was admitted to hospital because of right-sided hypaesthesia. Additionally he reported a brief speech disturbance some weeks before. Neurological examination indicated right-sided sensomotoric hemiparesis and left-sided upper quadrant anopia. 6 years ago recurrent transient ischaemic attacks (TIA) was diagnosed caused by paradoxical embolism through a persistent foramen ovale (PFO). The PFO was closed with a 45 mm Sideris button occluder device. After this, he reported no symptoms of cerebral ischaemia and he did not take any antiplatelet therapy. INVESTIGATIONS Transesophageal echocardiography (TEE) showed a left atrial thrombus attached to the occluder. Cerebral computed tomography revealed infarction in regions supplied by the right posterior cerebral artery and left media cerebral artery. As additional risk factor for thrombosis a heterozygous factor V Leiden mutation was diagnosed. DIAGNOSIS Multiple cerebral infarctions caused by a thrombus attached to an occluder system 6 years after interventional closure of persistent foramen ovale in a patient with heterozygous factor V Leiden mutation. TREATMENT AND COURSE The patient was anticoagulated (phenprocoumon) and the thrombus gradually dissolved. CONCLUSION A thrombosis on a Sideris occluder device may cause cerebral infarctions even years after transcatheter closure of a PFO.

The authors assess the clinical efficacy of transvenous closure of patent ductus arteriosus (PDA) with a new plug consisting of Ivalon foam and a platinum/iridium frame with four aortic and two pulmonary nitinol struts. The most widely used devices for transcatheter treatment of PDA (Porstmann plug, Rashkind umbrella, Botallo occluder, coils) have specific limitations inherent to their design (e.g., transarterial approach, residual shunts, limited retrieval).Between 1994 and 1997, PDA closure was attempted in 33 children and 67 adolescents and adults in 7 clinical centers; PDA diameter was 2 to 11 mm. Plug diameter was 6 to 20 mm, and 8 to 16 F venous sheaths were used for insertion.Placement was successful in 98% (with a single plug in 88%, and a second or third plug in 10%) and unsuccessful in 2%. Plugs were retrieved after malpositioning in 12 of 12 patients and after pulmonary embolization in 2 of 3 patients. One patient underwent surgery for removal of an embolized plug. Complete PDA closure was proved by aortography and color Doppler echocardiography in 85% (40 of 43 patients with a PDA 2-3.9 mm, 30 of 36 patients with a PDA 4-5.9 mm, and 15 of 21 patients with a PDA 6-11 mm). During a median follow-up interval of 16 months, there were no complications (infection, hemolysis, fracture, embolization).The new plug device can be used successfully in patients with a PDA diameter up to 11 mm. Further investigations are underway to determine the definite clinical value of this technique.

An Ivalon-plug (PDA-plug) has been developed for transvenous closure of patent ductus arteriosus. It can be introduced into the ductus through standard venous sheaths with a diameter of 8-16 French. The plug is fixed in its target position by means of four distal (aortal) and two proximal (pulmonary) nitinol struts. In case of malpositioning the system can be pulled back into and retrieved through the sheath. In animal experiments endothelialization of the implanted material was demonstrated. PDA-closure was attempted in 58 patient; the procedure was successful in 57 cases; a residual ductal flow was present in eight patients. During a follow-up of up to 24 months there were no complications.

Our objective is to review the epidemiology and proposed pathophysiology of migraine headache and its association with patent foramen ovale (PFO). We further elucidate the technical aspects of PFO closure and its possible impact on migraine headache. Upon reviewing English-language publications listed in MEDLINE relating to migraine headache, PFO; and transcatheter closure of PFO, we selected case series, retrospective and prospective studies relevant to the topic. PFO closure is being performed in annually increasing numbers worldwide for a variety of indications. The percutaneous technique of PFO closure has been shown to be safe and effective in multiple case series. Further, primarily retrospective case-control studies demonstrate a link between PFO closure and improvement of migraine headache. Few prospective data confirm the initialHowever, the only randomized, controlled trial finished to date analyzing the effect of PFO closure on migraine failed to reach its primary outcome of resolution of migraine following the intervention. The evidence of a benefit on migraine headache following PFO closure is not convincing, but certainly intriguing. With currently ongoing trials, more information related to this topic can be expected. In the meantime, the question whether we should close PFOs in patients with migraine headaches cannot be answered.

A 61-year-old man was admitted to hospital because of right-sided hypaesthesia. Additionally he reported a brief speech disturbance some weeks before. Neurological examination indicated right-sided sensomotoric hemiparesis and left-sided upper quadrant anopia. 6 years ago recurrent transient ischaemic attacks (TIA) was diagnosed caused by paradoxical embolism through a persistent foramen ovale (PFO). The PFO was closed with a 45 mm Sideris button occluder device. After this, he reported no symptoms of cerebral ischaemia and he did not take any antiplatelet therapy.Transesophageal echocardiography (TEE) showed a left atrial thrombus attached to the occluder. Cerebral computed tomography revealed infarction in regions supplied by the right posterior cerebral artery and left media cerebral artery. As additional risk factor for thrombosis a heterozygous factor V Leiden mutation was diagnosed.Multiple cerebral infarctions caused by a thrombus attached to an occluder system 6 years after interventional closure of persistent foramen ovale in a patient with heterozygous factor V Leiden mutation.The patient was anticoagulated (phenprocoumon) and the thrombus gradually dissolved.A thrombosis on a Sideris occluder device may cause cerebral infarctions even years after transcatheter closure of a PFO.

Since 1995, the German Society for Cardiac Angiography and Interventions in Private Practice (BNK) has been intensely involved in quality assurance; since 1996, it has registered relevant data for diagnostic left heart catheterization (DIAG) and coronary interventions (PTCA). The following data are based on a total of 72,777 cardiac catheters, of which 54,513 were DIAG and 18,264 were PTCA (DIAG in 1996: 10,316; in 1997: 15,692 and in 1998: 28,505. PTCA in 1996: 2,597; in 1997: 5,600 and in 1998: 10,067). The mean patient age was 61.9 years for males and 65.3 years for females (31%). DIAG was performed on an out-patient basis in 60% of the cases. The proportion of self-referrals is circa one-third and has not increased over time. A s/p PTCA was present in 21% of the DIAG patients; those after coronary bypass surgery showed a steadily increasing trend towards a follow-up DIAG (8% of the patients). There was a distinctive decrease in the use of contrast medium from an average of 164 ml (1996) to 138 ml (1998). The symptoms leading to DIAG did not substantially change in the years from 1996 to 1998; the angiographic range of the coronary disease and the degree of an impaired myocardial function have remained virtually unchanged. The treatment recommendations appear to tend towards medical therapy with decreasing indications for PTCA (20%) and open heart surgery (16%). The mean duration of a PTCA procedure decreased from 57 +/- 8 (1996) to 44.6 +/- 25 (1998) minutes. The success rates remained unchanged for coronary stenoses as well as for recanalization of chronic total occlusions. PTCA complications: the incidence of abrupt coronary occlusions was 2% and of emergency bypass surgery 0.4%; mortality was 0.1%.

Im Jahre 1967 veroffentlichte Porstmann seine Methode zum „Verschlus des Ductus arteriosus persistens ohne Thorakotomie“ [29]. Damit konnte erstmals ein angeborener Herzfehler mit einem interventionellen Verfahren kurativ behandelt werden. Der kathetertechnische Verschlus eines Vorhofseptumdefektes wurde zuerst von King und Mills im Jahre 1975 beschrieben [20]. Diese Pionierleistungen wurden mit — aus heutiger Sicht — sehr einfachen rontgentechnischen Voraussetzungen und Kathetermaterialien verwirklicht. Ihre Bedeutung kann somit kaum hoch genug eingeschatzt werden.

Objective—To investigate the safety, efficacy, and clinical application of a new self centring device ("angel wings") for closure of secundum atrial septal defects (ASD II) and persistent foramen ovale in all age groups. Design—Multicentre, prospective, non-randomised study. Patients—Inclusion criteria: defects with an occlusive diameter of ⩽ 20 mm and a surrounding rim of > 4 mm; body weight > 10 kg; and an indication for surgical closure of secundum atrial septal defect. Additionally, there were compassionate indications for closure in patients with persistent foramen ovale. Interventions—Defects were closed by a transcatheter device consisting of two square frames made of superelastic nitinol wire. The frames are covered by elastic polyester fabric, which is sewn together at a central circle. All procedures, except for three interventions that were carried out under sedation, were performed under general anaesthesia using transoesophageal echocardiography and fluoroscopy to monitor intervention. Results—Closure was attempted in 75 (71%) of 105 patients. An ASD II was present in 35 children and 15 adults. A persistent foramen ovale was present in 25 adults with suspected paradoxical embolism. Transcatheter closure was unsuccessful in three children and crossover to surgery was required. Residual shunts were found in 20 patients (27%) immediately after the procedure. A transient atrioventricular third degree block occurred in three patients (4%) and the right atrial disk was not fully deployed in three. A minor shunt (< 3 mm) was present in only three (4%) of 72 patients during follow up of 1-17 months. Blood clots on the right atrial disks in two patients (one required lysis) were seen during follow up transoesophageal echocardiography. Serious complications demanding surgical removal of the device occurred in three patients. One patient had haemopericardial tamponade because of an aortic lesion. Left atrial thrombus formation due to an unfolded right atrial disk was found in a second patient and dislodgement of the left atrial disk resulted in a large residual shunt in a third. Conclusions—Percutaneous closure of a central ASD with a diameter ⩽ 20 mm in paediatric and adult patients is feasible and effective with this new device. It is a promising alternative to surgical closure. Modifications of the design, however, seem to be mandatory as 4% of patients developed serious complications. Keywords: secundum atrial septal defect; persistent foramen ovale; interventional cardiology; transcatheter occlusion

Balloon valvuloplasty of pulmonary stenosis has become the treatment of choice in children and adults. This is a report about the long term results in adult patients. Forty-six patients (mean age 37 +/- 17 years) with pulmonary stenosis were treated between 1984 and 1994 by this method. Thirty-four of 46 patients were re-examined 3 months to 9 years (mean 3.4 years) later by right heart catheterization and echocardiography. These 34 patients were representative for the whole group concerning age, severity of the pulmonary stenosis, and acute results after the intervention. The pressure gradient was acutely reduced by balloon valvuloplasty from 86 +/- 35 to 38 +/- 17 mm Hg (p0.0001) (n = 46) and was 32 +/- 10 mm Hg (n.s.) (n = 34) at follow-up. Within 3 months after the intervention, 8 of 13 patients with a pressure gradientor = 100 mm Hg, showed spontaneously further reduction of the gradient due to the resolution of the subvalvular muscular hypertrophy. During a bicycle exercise test with 9 patients, the gradient rose significantly from 29 +/- 10 to 53 +/- 23 mm Hg (p0.01) as determined by right heart catheterization. All of these patients had normal cardiac output at rest and during exercise. None had signs of right ventricular hypertrophy in the electro- or echocardiogram. It is concluded that balloon valvuloplasty of pulmonary stenosis is the first line treatment in adults.

An Ivalon-plug (PDA-plug) has been developed for transvenous closure of patent ductus arteriosus. It can be introduced into the ductus through standard venous sheaths with a diameter of 8-16 French. The plug is fixed in its target position by means of four distal (aortal) and two proximal (pulmonary) nitinol struts. In case of malpositioning the system can be pulled back into and retrieved through the sheath. In animal experiments endothelialization of the implanted material was demonstrated. PDA-closure was attempted in 58 patient; the procedure was successful in 57 cases; a residual ductal flow was present in eight patients. During a follow-up of up to 24 months there were no complications.

Balloon angioplasty for restenosis has a higher success rate and a lower complication rate as compared to PTCA in de-novo-lesions. The restenosis rate after a second or third PTCA is only slightly higher than after a first PTCA. So far, balloon dilatation is the most effective and most economic treatment for restenosis.

In a 24-year-old female patient suffering from recurrent ischemia, an aneurysm of the atrial septum and a patent foramen ovale with significant right-to-left shunt during the Valsalva maneuver were detected by means of contrast Doppler echocardiography. After other causes had been excluded, paradoxical embolism was suspected to be the cause of the cerebral symptoms. The defect was closed by a 17-mm Rashkind occluder without complications. Six months later no residual shunt was detected and no further neurological event had occurred. This case demonstrates the feasibility of non-operative closure of those defects. This new technique could represent an alternative to long-term anticoagulation or operative procedures in selected patients.

About three and a half years after direct suture of a secundum atrial septal defect (ASD) the now 72-year-old patient developed heart failure with pulmonary congestion and pleural effusion which responded to medical treatment. The electrocardiogram showed atrial fibrillation with an irregular ventricular rate and right bundle branch block. Right heart catheterization established recurrence of the ASD with a left to right shunt of 60% (Qp/Qs = 2.5) and a pulmonary artery pressure of 45/12 mmHg. Because of the clinical state, the risk of re-operation and the suitable anatomy, non-operative percutaneous transvenous catheter closure of the defect with a double-umbrella device was indicated. Following this procedure the cardiomegaly regressed, while colour-Doppler echocardiography demonstrated a minimal residual left to right shunt. The pulmonary artery pressure had fallen to 32/13 mmHg. Three months later the patient was without symptoms and resumed her usual activity. The ECG now showed sinus rhythm, and there was no evidence of a shunt. Anticoagulation with acetyl salicylic acid (100 mg daily) was continued for 3 months.

A 29-year-old otherwise symptom-free patient had undergone a partial thyroidectomy 5 years ago followed by an episode of ventricular tachycardia and (after lidocaine injection) ventricular fibrillation requiring external defibrillation. No cause for the arrhythmias had been found at that time. Two subsequent syncopes led to her hospitalization. An asystole occurred while she was being monitored, and during the resuscitation there were several periods of ventricular fibrillation, which responded to external defibrillation. Subsequently several episodes of self-limiting ventricular tachycardia were recorded. A long QT syndrome with torsade-de-pointes tachycardia was diagnosed on the basis of typical ECG changes (QT interval 545 ms). Extensive diagnostic tests failed to find a cause. To prevent further tachycardias she was given propranolol, 40 mg three times daily, and an automatic defibrillator was implanted as a precaution. But no defibrillator discharge has so far been required (more than 10 months).

Wahrend der Fetalzeit stellt der distale Anteil des linken (sehr selten des rechten) 6. Kiemenbogens eine Kurzschlusverbindung zwischen Pulmonalarterie und Aorta her. Hierdurch wird mehr als die Halfte des rechtsventrikularen Schlagvolumens uber die Umbilikalarterie zuruck zur Plazenta geleitet.

Das physiologischerweise gering eingeengte Segment zwischen dem Abgang der A. subclavia sinistra und dem Ubergang des Aortenbogens in die Aorta descendens in Hohe der Einmundung des Ductus arteriosus wird als „Isthmus“der Aorta bezeichnet.

Central venous puncture is required for endomyocardial biopsy to identify rejection after cardiac transplantation. We evaluated our use of the Seldinger technique to determine the safety of this invasive method.In 42 immunosuppressed patients central venous puncture was performed after cardiac transplantation using the Seldinger technique for right heart biopsy. Together with physical examinations, chest X-ray and cardiac ultrasonography were performed during the inhospital follow-up. Outpatient follow-up continues and all reported adverse effects were evaluated by the attending cardiologist.There were a total of 620 central venous punctures, most via the right internal jugular vein (77.9%). The planned puncture could not be performed in 3.2% of the cases and an alternative site was used. The femoral approach was associated with the longest radiation time. No severe adverse effects were observed and no complications (infection, large haematoma, pneumothorax, severe rhythm disorders) were recorded.Even in immunosuppressed patients frequently requiring central venous puncture, right heart endomyocardial biopsy can be safely performed to evaluate rejection.

During the 17th week of gestation a 26-year-old female suffered pulmonary edema following appendectomy. Subsequently, the diagnosis of mitral stenosis was established. Balloon mitral valvotomy was performed in order to reduce the perinatal risk. During the procedure radiation exposure was minimized by means of total abdominal and pelvic shielding and transthoracic echocardiography was used for monitoring. Mitral valve area was increased from 1.4 to 2.1 cm2 without complications and the further course of pregnancy and delivery were uneventful. Balloon mitral valvotomy should be considered as a therapeutic alternative in pregnant women with symptomatic pliable mitral valve stenosis.

Die sogenannte „klassische“ Indikation zur PTCA (stabile Angina pectoris, Eingefaskrankheit mit proximaler, umschriebener, konzentrischer, nicht-verkalkter Stenose, guter LV-Funktion und Indikation zur Bypass-Operation) konnte seit 1977–1979 aufgrund technologischer und technischer Verbesserungen stark erweitert werden. Gegenwartig werden auch Patienten mit eingeschrankter LV-Funktion, instabiler Angina pectoris und akutem Infarkt, voroperierte und nur mit hohem Risiko operable Patienten mit Kathetertechniken revaskularisiert. Mit Hilfe des fortentwickelten Instrumentariums konnen auch komplexe Lasionen behandelt werden. Auch Patienten mit Mehrgefaskrankheit konnen erfolgreich revaskularisiert werden. Allerdings stellt insbesondere hier die Restenose ein - bisher ungelostes - Problem dar. Daher sollten Patienten mit Dreigefaserkrankung (und Hauptstammstenose) operativ revaskularisiert werden.

Postrheumatic mitral stenosis might cause impairment of right ventricular (RV) function due to both an increase in RV afterload and rheumatic myocardial disease. Therefore, we investigated in 19 patients with postrheumatic mitral stenosis and sinus rhythm right ventricular volumes and hemodynamics by a computerized thermodilution catheter during rest and supine bicycle exercise. In 14 patients the investigation was repeated within 2 days after balloon mitral valvuloplasty. Resting RV ejection fraction was decreased (43 (15-53)%, median (range)) and correlated significantly with RV end-systolic volume index (r = -0.90), stroke volume index (r = 0.77), RV end-diastolic volume index (r = -0.76), heart rate (r = -0.69), pulmonary artery resistance (r = -0.69), and mean pulmonary artery pressure (r = -0.68). RV end-diastolic volume index was 107 (81-200) ml/m2. Exercise induced a decrease of RV ejection fraction to 36 (13-48)% at 50 Watt (p0.001), while it increased RV end-diastolic volume index to 131 (78-231) ml/m2 (p0.001). Balloon mitral valvuloplasty improved RV ejection fraction at rest from 41 (15-47)% to 48 (39-55)% (p0.005) and from 30 (13-46)% to 43 (27-56)% during exercise (p0.005). The increase of RV ejection fraction after valvuloplasty was caused by an increase in stroke volume, but not by a reduction in RV end-diastolic volume.Depending on the increased RV afterload, RV function is markedly depressed in mitral stenosis. An immediate and almost complete improvement of RV function occurs with the reduction of RV afterload after balloon mitral valvuloplasty.(ABSTRACT TRUNCATED AT 250 WORDS)

We hypothetized that conservative treatment might be justified in asymptomatic adults with a small persistent ductus arteriosus. The data of 100 patients (age, 18-72 years) who later underwent non-operative closure were retrospectively analyzed. Left- and right-heart catheterization as well as angiographic measurement of PDA-size had been performed in all patients. Thirty-five patients were asymptomatic and 65 patients had cardiac symptoms. Six patients had a history of endocarditis. There were no significant differences with respect to Qp/Qs ratio (1.69 +/- 0.45 vs. 1.57 +/- 0.32) and ductus-diameter (4.7 +/- 1.4 mm vs. 4.8 +/- 1.3 mm) between symptomatic and asymptomatic patients. In the six patients with endocarditis the diameter was 4.5-7.0 mm. Symptomatic patients had higher mean pulmonary artery pressures (22.1 +/- 9.7 mm Hg vs. 18.5 +/- 5.1 mm Hg; p0.05) and were older (48.4 +/- 14.3 years vs. 30.9 +/- 11.2 years; p0.001) than asymptomatic patients. Neither from the size of the ductus nor from the Qp/Qs ratio could the development of cardiac symptoms or the risk of endocarditis be predicted individually. From these data it might be concluded that closure should be performed even in asymptomatic adults with small ductus and insignificant left-to-right shunt.

The unprotected left main stenosis still represents one of the contraindications of PTCA; recently developed concepts using percutaneous bypass techniques have not changed this fact so far. However, following bypass grafting the procedure can be done with low risk and may improve prognosis in case of later bypass occlusion. This study should clarify whether a higher rate of bypass occlusion is caused by postsurgical left main PTCA. From October 1981 to January 1991 a left main stenosis was dilated in 41 patients, 2 weeks to 12 years (mean 3.5 years) after bypass grafting. To date, 17/65 venous bypass grafts were already occluded, and 72.4% of the patients suffered from typical angina. In 34/41 patients (82.9%) PTCA was successful, severe complications (death, emergency surgery or myocardial infarction) did not occur and clinical improvement was achieved in 80% of symptomatic patients. Four months later, 26/34 patients (76.5%) had angiographic follow-up. Fifteen restenoses were found and a second PTCA was performed in 9/15. None of the venous bypass grafts, open at the time of the first PTCA, was occluded at follow-up. In one case PTCA of the left main stenosis turned out to be life-saving 7 years later because an occlusion of RCA- and LCX-bypasses occurred and the LAD graft showed a subtotal thrombosis. It is concluded that PTCA of left main stenosis after bypass grafting is a safe procedure and does not lead to a higher rate of venous bypass occlusions. A prognostic indication seems to be justified.

Between May 1985 and April 1991, 30 patients (seven females and 23 males) 14 to 54 years old (median, 25 years) underwent balloon angioplasty for unoperated native (n = 26) or recurrent postoperative (n = 4) coarctation of the aorta. 28/30 patients had systemic hypertension (RR140/90 mmHg). Dilatation of the stenotic segment could be achieved in 28/30 patients. The residual pressure gradient was30 mmHg in six patients. In 2/4 patients with recurrent coarctation the balloon had ruptured, while dilatation was successful in the other two patients. The mean diameter of the stenotic segment increased from 5.8 +/- 2.7 mm to 11.9 +/- 2.5 mm and the peak pressure gradient decreased from 61 +/- 18 mmHg to 20 +/- 13 mmHg. Complications were a small hemorrhagic pleural effusion in one patient and a groin hematoma in another patient. Clinical follow-up studies with retrograde catheterization of the aorta and angiography were performed in all 28 patients with dilated coarctation, 6 months to 6 years after the procedure, representing a total follow-up time of 72 (average, 2.6) patient-years. Multiple follow-up studies (n = 2-4) were performed in 17/28 patients. In one patient the first angiogram revealed aneurysm formation while a small bulge was seen in two others. Intra-aortic pressure measurements revealed a peak gradient of30 mmHg in 24/28 patients with a mean of 14 +/- 10 mmHg. The blood pressure was normal in 23/28 patients. In the other five patients whose pressure gradients were 7, 30, 30, 35, and 60 mmHg moderate hypertension persisted.(ABSTRACT TRUNCATED AT 250 WORDS)

In chronic coronary occlusions the rate of successful reopening seems to be improved with the help of new techniques; the chance of success can be judged by the age of occlusion. Frequently this age cannot be fixed exactly. The purpose of the study was therefore to find out, whether the chance of reopening can be judged by morphology. 60 patients in whom the occlusions could not be passed with a conventional wire were treated with the ROTACS system. Cine angios were reviewed carefully, morphological details in at least two projections were evaluated in graphic representations and correlated with the acute success rate and the estimated age of occlusion. Morphological parameters associated with a higher rate of success (type A) were: 1) a clearcut proximal stump with 2) no sidebranches at the site of occlusion, 3) no bridging collaterals and 4) only a slight filling of the distal vessel. Parameters with a low success rate (type B) were: 1) no proximal stump, 2) sidebranches at the site of occlusion, 3) bridging collaterals and 4) a very good distal filling. 48/60 (80%) of occlusions could be classified in type A or type B. The success rate was 17/21 (81%) (type A) versus 5/27 (18.5%) (type B) (p0.0002). The estimated age of type B occlusions was significantly higher than in type A: median 8 versus median 4 months (p0.002). It is concluded that the rate of success in reopening chronic coronary occlusions can be judged in the majority of patients using morphological parameters.

One hundred patients undergoing routine diagnostic or interventional catheterization were randomly assigned to receive either percutaneously applied collagen (group A; n = 50) or conventional pressure dressing (group B; n = 50) for sealing of the femoral artery. Clinical variables were comparable in both groups. The heparin dose was 100 IU/kg in 30 patients and 200 IU/kg in 20 patients of both groups. The average compression time was 4.3 min in group A and 42.3 min in group B (p0.001). In group A, 1/50 patients required pressure dressing compared to 50/50 patients in group B. Bleeding was not observed in group A, but was observed in 6/50 patients in group B. The time to ambulation was 6.4 (range, 4-12) h in group A and 21.6 (range, 10-48) h in group B (p0.001). Hematomas with a diameter of6 cm developed in 4/50 patients in group A and in 11/50 patients in group B (p0.05). Blood-transfusions or surgical interventions were not required and there was no loss of ankle pulses in either group. In conclusion, percutaneously applied collagen reduced compression time and duration of bedrest after diagnostic catheterization and PTCA. Despite earlier ambulation, the incidence of bleeding was lower with collagen than with conventional pressure dressing.

Percutaneously introduced absorbable purified bovine collagen was used to plug the hole at the site of femoral arterial puncture in 50 patients (42 men, 8 women; median age 58 [22-75] after percutaneous coronary angiography (n = 32; heparin dosage 100 IU/kg) or transluminal coronary balloon dilatation (n = 18; heparin dosage 200 U/kg). Local bleeding ceased after compression of 4 min in 48 of the 50 patients. A pressure bandage was needed additionally in the other two. Bed-rest lasted for 1-24 (median 19) hours. A haematoma of more than 6 cm diameter developed in five patients, but required neither transfusion nor surgical intervention. 39 of the 50 patients were re-examined after a median of 39 days: all of them had had a small pain-free swelling for 2-6 weeks over the puncture site. One patient developed a deep-vein thrombosis one week after the procedure, in another fever occurred after the same period, lasting for two days. These early findings are encouraging. The method may significantly shorten the time of arterial compression and bed-rest, as well as reduce the risk of a large haematoma after arterial punctures.

Changes in blood and plasma volumes were investigated in the course of diagnostic cardiac catheterizations, comparing the effect of a high and a low osmolar contrast medium in 30 patients (5 women and 25 men; mean age 53 [19-76] years) with coronary heart disease (n = 27) or valvular defect (n = 3). Using a randomized, double-blind protocol 15 patients received amidotrizoic acid (2.1 osmol/kg; mean dosage 166 +/- 68 or 2.2 +/- 1.1 ml/kg), while 15 patients received iopamidol (0.8 osmol/kg; mean dosage 154 +/- 78 ml or 2.1 +/- 1.0 ml/kg). The indocyanine-green method and the haematocrit were used to measure blood and plasma volumes immediately before and after the angiocardiography. Blood volume after amidotrizoic acid injection increased by a mean of 4.9% (228 +/- 242 ml) and by 0.4% (17 +/- 197 ml) after iopamidol (P less than 0.05). Plasma volume increased by a mean of 11.8% (331 +/- 150 ml) after amidotrizoic acid and 5.7% (157 +/- 97 ml) after iopamidol (P less than 0.01). The increase in plasma volume correlated with the dose of contrast medium: 2 ml per ml amidotrizoic acid (r = 0.93) and 1 ml per ml iopamidol (r = 0.82).--During angiocardiography blood and plasma volume may increase by up to 500 ml, an increase which depends not only on dosage but also on the osmolality of the injected contrast medium.

A persistent ductus arteriosus was occluded with an ivalon-plug introduced through the femoral artery in 14 patients over 60 years old (61 to 70 years). Two patients had previous surgery. The maximum left-to-right shunt was 53%, the maximum pulmonary artery pressure 54/24 mm Hg. In all patients ductus occlusion was successful and permanent. Bleeding at the puncture site in two patients could be stopped by manual compression. During a follow-up period of up to 5 years there were no instances of recanalization.

Coronary arteriography revealed severe stenoses of the proximal part of the anterior interventricular branch with normal ventricular function in two patients (aged 42 and 38 years) with stable angina and ischaemia reaction in the exercise ECG. In the first patient it was a short spur-like 80% narrowing. But percutaneous balloon angioplasty failed to change the angiographic appearance. In the other patient there was an eccentric, apparently elastic, 90% stenosis, about 10 mm long. Here, too, balloon angioplasty had failed. Subsequently directional coronary atherectomy in both patients achieved removal of the stenosis with lasting clinical improvement. Atherectomy should be considered in similar cases after failed balloon dilatation.

Die Angiokardiographie ist wegen ihrer unubertroffenen Abbildungsqualitat auch fur die uberschaubare Zukunft nicht aus der kardiologischen Diagnostik wegzudenken. Sie liefert die besten Informationen uber die morphologischen Gegebenheiten im Herz-Kreislauf-System und kann daruber hinaus auch fur funktionelle Beurteilungen genutzt werden. Voraussetzung fur eine optimale Bildqualitat sind dabei jedoch Kontrastmittelkonzentrationen von 350–400 mg Jod/ml, die bei monomeren Molekulen etwa einmolare Konzentrationen erfordern. Zusatzlich sind hohe Flusraten notwendig, so das die intravasale Kontrastmittelkonzentration unter Umstanden uber 50% liegt. Die als sicher kontrastmittelbezogen einzustufenden Nebenwirkungen der Angiokardiographie treten akut auf und sind vorwiegend auf Storungen der Homoostaseparameter zuruckzufuhren [3].

Seventeen patients with coronary heart disease were included in a double-blind randomized study. They received either 5 mg of carvedilol or 6 mg of propranolol intravenously. Heart rate, aortic pressure, mean coronary sinus pressure and coronary flow (thermodilution) were measured, and coronary resistance and rate-pressure product were calculated before and 15 min after the infusion, which lasted 10 min. Carvedilol lowered significantly (p less than 0.05) heart rate (mean 76 to 69/min), aortic pressure (mean 153/80 to 135/72 mm Hg), rate-pressure product (mean 117 to 93 mm Hg/min) and coronary flow (mean 114 to 94 ml/min). Coronary resistance and coronary flow related to rate-pressure product showed no significant change after carvedilol. Propranolol lowered heart rate (mean 76 to 64/min; p less than 0.05) and rate-pressure product (mean 109 to 96 mm Hg/min; ns). Aortic pressure, coronary flow, coronary resistance, and coronary flow related to rate-pressure product showed no significant change after propranolol. Thus, carvedilol lowered rate-pressure product more markedly than propranolol on account of its acute blood-pressure lowering effect. Neither drug seems to have a direct influence on coronary resistance vessels.

Sixteen patients undergoing PTCA of a significant lesion of the left anterior descending coronary artery received either 0.3 mg nisoldipine or placebo intravenously. Immediately before and during balloon inflation the following parameters were measured: aortic pressure, post-stenotic pressure, coronary occlusion pressure, diastolic pulmonary artery pressure, coronary sinus flow (thermodilution), and intracoronary ECG. After placebo there were no statistically significant changes. Nisoldipine led to a decrease in aortic pressure from 109 +/- 12 to 93 +/- 11 mm Hg (p less than 0.05) before, and from 103 +/- 14 to 92 +/- 8 mm Hg (NS) during balloon inflation. In contrast, coronary occlusion pressure remained unchanged. Heart rate increased from 80 +/- 13 to 96 +/- 16/min before (p less than 0.05), and from 87 +/- 18 to 97 +/- 17/min during balloon inflation (NS). Coronary sinus flow was increased from 95 +/- 16 to 116 +/- 13 ml/min before balloon inflation (p less than 0.01), and from 70 +/- 25 to 86 +/- 26 ml/min during balloon inflation (NS). ST-segment depression or elevation, severity of angina pectoris, and the diastolic pulmonary artery pressure remained unchanged. Thus, 0.3 mg nisoldipine led to a peripheral vasodilatation. While the aortic pressure decreased, coronary occlusion pressure remained unaffected. This could be explained by a marked dilatation of collateral vessels due to nisoldipine. However, myocardial ischemia remained unaffected as a result of the constant coronary occlusion pressure.

Increasing amounts of atropine (0.03 mg + 0.07 mg + 0.01 mg + 0.25 mg + 0.5 mg + 1.0 mg + 1.5 mg; sigma = 3.5 mg, interval between injections: 30 min) were injected intravenously in a cumulative manner in five patients with hyperkinetic heart syndrome and in seven healthy volunteers. The heart rate increased from 93 to 127 beats per min in patients, and from 63 to 104 beats per min. in controls. The diastolic blood pressure slightly increased in both groups, whereas the systolic blood pressure did not change significantly. The accommodation diminished from 6 to 2 dioptries in patients, and from 8 to 5 dioptries in controls. Salivary flow fell from 1.6 to 0.1 g/min in patients with hyperkinetic heart syndrome, and from 1.3 to 0.1 g/min in control persons, respectively. The maximum occupancy of muscarinic receptors (m2-glandular), as measured in plasma specimens by means of a radioreceptor assay, reached more than 80% in each group. The dose-response-curves of atropine were highly comparable in patients and controls. It is concluded that the effects of atropine are essentially the same in patients with hyperkinetic heart syndrome and in healthy control persons. There is no evidence for a diminished vagal tone in such patients.

We report a case of rupture and fragmentation of a PET-balloon catheter during percutaneous transluminal coronary angioplasty of a calcified LAD-obstruction. When the insufflation pressure was increased to 12 atm, the balloon ruptured. During withdrawal of the balloon catheter the tip of the shaft and a fragment of the balloon tore off and remained within the atheroma. Emergency operation was necessary to remove the fragments and to prevent a large myocardial infarction. Although this is an unusual complication of PTCA, care should be taken when PET-balloon catheters are used in calcified coronary obstructions.

Following single breath inhalations of helium 49 simultaneous inlet-outlet pairs of helium dilution curves were recorded in seven dog experiments from the aortic and coronary sinus blood by use of mass spectrometric technique. After numeric deconvolution of the dilution curves the weighting function of tracer transit times was used for calculation of the mean myocardial blood flow per unit of tissue, which closely correlated with directly measured flow. Secondly, the degree of blood flow heterogeneity was estimated from the first moments of the weighting function of transit times and by compartmental analysis based on an inverse Laplace transform. In the intact heart the results suggest a rather constant dispersion of flows relative to the mean flow F in the order of sigma/F = 0.3. The apparent dispersion of flows is increased by alpha-adrenergic stimulation with pressure and volume load, particularly in a state of beta-blockade, a finding, which may be attributed to variations of intercapillary distances and to a heterogeneity of blood flow per unit of tissue.

A hyperkinetic heart syndrome has been diagnosed in 10 patients by clinical investigation and right-heart catheterization at rest and during exercise. Subsequently, the patients received 3×40 mg alinidine, and 2×40 mg propranolol and placebo, each for 2 weeks in a double-blind cross-over study.

The effects of coronary arteriography with ionic, monomeric diatrizoate (iodine content, 370 mg/ml; osmolality, 2.10 Osm/kg) and nonionic, dimeric iotrolan (iodine content, 280 mg/ml; osmolality, 0.27 Osm/kg) were intraindividually compared in five patients with coronary heart disease. According to an open protocol, both contrast media were injected into the left (LCA) and right coronary arteries (RCA), 8 ml and 5 ml, respectively. Before, during, and 60 seconds after each injection, electrocardiograms (ECG) were recorded and heart rate and aortic pressure were measured. Whereas diatrizoate markedly decreased heart rate (LCA, -36%; RCA, -20%) and aortic pressure (LCA, -26%; RCA, -16%), iotrolan administration kept heart rate virtually unchanged (+/- 1%) and only slightly increased aortic pressure (LCA, 5%, RCA, 8%). After iotrolan injection ECG changes (axis shift of QRS and T waves) were still demonstrable, yet the effects of diatrizoate proved to be more significant (prolongation of QRS and QT intervals as well as shifts of QRS and T axis). The opacification of the coronary arteries was always more pronounced after diatrizoate due to its higher iodine content, but the contrast produced by iotrolan usually was satisfactory. No side effects were observed during the study. Thus, this isosmotic contrast medium prevents bradycardia and hypotension during coronary arteriography. The lower iodine content, however, leads to poorer contrast compared with conventional contrast media.

In a randomized double-blind study, oral doses of 50 mg carvedilol were compared to 40 mg propranolol in 16 male patients with coronary heart disease (12 without significant stenosis after percutaneous transluminal coronary angioplasty) at rest, during and after exercise, and before and 80 min after drug application. Systemic and pulmonary pressures, heart rate, cardiac index, and lower limb blood flow were measured, and systemic and pulmonary resistances calculated. Carvedilol does not lead, as the classical beta-blocker propranolol does, to an increase in systemic or pulmonary resistance, nor to a decrease in cardiac output, or to an increase of the pulmonary capillary wedge pressure during exercise. In contrast to propranolol, the postexercise lower limb blood flow has increased significantly. The differences in action between the two beta-blockers can be explained by the vasodilating properties of carvedilol. Due to these acute effects, carvedilol may be of advantage compared to propranolol in the treatment of peripheral occlusive artery disease, hypertension, and coronary vasospasm.

In a placebo-controlled double blind study the effect of Padma 28, a Tibetan herbal prescription, on patients with intermittent claudication was investigated. After two weeks without vasoactive therapy 23 patients were treated by Padma 28 and 20 by placebo. The patients had a disease history of at least 8 months, a steady state for symptoms (maximum walking distance below 250 m), and were distributed randomly in the two groups. After 16 weeks the patients treated with Padma 28 exhibited on standardized ergometry an increase of some 100% (p less than 0.01) in the maximum as well as painfree walking distance. The control patients showed increases of 21% in maximum (p less than 0.05 as compared to Padma 28), and 46% in painfree walking distance. The drug was well tolerated and no drop-out ensued because of side effects.

The nonionic-dimeric compound lotrolan (0.27 osmol/kg, 280 mg J/ml) is the first contrast medium with plasma-isotonic osmolality and sufficient iodine content for intravascular use. In 15 patients with coronary heart disease, the cardiac side effects of 1) lotrolan, 2) nonionic-monomeric lopromide (0.77 osmol/kg, 370 mg J/ml and 3) ionic-monomeric Amidotrizoate (2.1 osmol/kg, 370 mg J/ml) were compared intraindividually following randomized left coronary artery injections (8 ml). Electrocardiographic indices, aortic pressure, coronary sinus flow (thermodilution method), and coronary vascular resistance were determined before, during, and 60 s after each injection. Heart rate remained almost unchanged with lotrolan (+/- 3%) and lopromide (-8%). Amidotrizoate (-16%), however, caused a significant bradycardia. Aortic pressure decreased markedly after Amidotrizoate (-12%) but only moderately after lopromide (-7%) and lotrolan (-6%). Coronary sinus flow increased to the same extent with lopromide (+66%) and Amidotrizoate (+72%), but less with lotrolan (+43%). Coronary vascular resistance dropped significantly more following lopromide (-38%) and Amidotrizoate (-43%) than after lotrolan (-27%). As opposed to Amidotrizoate and lopromide, lotrolan caused only slight changes in heart rate, blood pressure, and coronary hemodynamics, presumably due to its plasma-isotonic osmolality. Only minor differences were found between the cardiac effects of Amidotrizoate and lopromide. The diagnostic quality of the angiograms, however, was better with Amidotrizoate and lopromide. Thus, due to its reduced cardiac side effects, lotrolan may only be useful in the case of experimental investigations applying digital techniques.