Comparison of mechanical support with Impella or extracorporeal life support in post-cardiac arrest cardiogenic shock: a propensity scoring matching analysis

Background

Out of hospital cardiac arrest (OHCA) is a major public health problem and a leading cause of death in industrialized nations. Post-cardiac arrest cardiogenic shock (CS) occurs frequently after resuscitation from CA and may lead to multi-organ failure and death, even in patients with good neurologic prognosis. Mechanical circulatory support (MCS) may be considered at that time in order to augment cardiac output, stabilize hemodynamics and ensure adequate organ perfusion. However, optimal selection of the device type remains unclear and, so far, no specific guideline recommendation exists. The Impella pump and extracorporeal circulatory support (ECLS) are the most frequently used device types for temporary percutaneous MCS in this context.

Purpose

Our aim was to compare outcomes of Impella with extracorporeal life support (ECLS) in patients with post-cardiac arrest cardiogenic shock (CS) complicating acute myocardial infarction (AMI).

Methods

Reetrospective study of patients resuscitated from OHCA with post-cardiac arrest CS following AMI (May 2015 to May 2020) treated with MCS in terms of Impella or ECLS. Outcomes were compared using propensity score-matched analysis to account for differences in baseline characteristics between groups of MCS.

Results

159 patients were included (Impella, n=105; ECLS, n=54). Hospital and 12-month survival rates were comparable in the Impella and the ECLS group (p=0.16 and p=0.3, respectively). After adjustment for baseline differences, both groups demonstrated comparable hospital and 12-month survival (p=0.36 and p=0.64, respectively) (Figure 1). Impella patients had a significantly greater left ventricle ejection-fraction (LVEF) improvement at 96 hours (p<0.01 vs p=0.44 in ECLS) and significantly fewer device-associated complications than ECLS patients (15.2% versus 35.2%, p<0.01 for relevant access site bleeding, 7.6% versus 20.4%, p=0.04 for limb ischemia requiring intervention). In subgroup analyses, Impella was associated with better survival in patients with lower-risk features (lactate <8,6 mmol/L, time from collapse to return of spontaneous circulation <28 min, vasoactive score <46 and Horowitz index >182) (Figure 2).

Conclusions

In the biggest so far homogenous study of OHCA, the use of Impella 2.5/CP or ECLS in post-cardiac arrest CS after AMI was associated with comparable adjusted hospital and 12-month survival. Impella patients had a greater LVEF improvement than ECLS patients, while it was associated with a better survival in patients with low risk profile after OHCA. Device-related access-site complications occurred more frequently in patients with ECLS than Impella support.

Funding Acknowledgement

Type of funding sources: None.

The MARPELLA risk score for prediction of mortality in all-cause refractory cardiogenic shock treated with microaxial transvalvular pump: the MARPELLA study

Background

Although Impella may serve as an alternative strategy in order to stabilize the heart function without the detrimental effects of catecholamines or to bridge the patients in definite therapies in the setting of cardiogenic shock (CS), leading to a widespread use of this device, data concerning reliable prediction or predefining which patients would benefit from the implantation of such a device are completely lacking.

Purpose

To evaluate and to compare the prognostic accuracy of the Acute-Physiology-And-Chronic-Health II (APACHE II), the Simplified-Acute-Physiology-Score II (SAPS II), the Sepsis-related-organ-failure-assessment (SOFA), the intra-aortic-balloon-pump (IABP), the CardShock Score in refractory CS treated with Impella 2.5/CP. Moreover, we aimed to assess the prediction-of-Cardiogenic-shock-Outcome-foR-AMI-patients-salvaGed by VA-ECMO (ENCOURAGE) and the Survival-after -Veno-Arterial-extracorporeal-membranoxygenation (VA-ECMO) (SAVE) score, though initially for VA-ECMO patients created, in patients with CS as well as to develop a new prognostic score in this setting.

Methods

Single center study of consecutive Impella patients with CS admitted to Cardiology department of our university, from February 2013 until December 2020.

Results

A total of 401 patients were included in the analysis. 31% of the patients were supported with Impella CP, whereas 153 (38,1%) patients were resuscitated prior admission. Causes of CS was acute myocardial infarction in 311 (77,5%) patients, followed by dilatative cardiomyopathy/myocarditis (11,1%) and aortic stenosis (6%). The expected mortality according to scores was: SOFA 50%, SAPS II 70%, IABP Shock 55%, CardShock 60%, APACHE II 65%, ENCOURAGE 75% and SAVE score 70%. We observed a survival of 48,9% on hospital discharge and 45,6% after 12 months follow-up. Among the traditional scores estimated, the ENCOURAGE score was the most effective predictive model of mortality outcome presenting a moderate area under curve (AUC) of 0.72, followed by the CardShock, which derived an AUC of 0,7. The SAPS II, SOFA, IABP and the SAVE scores failed to predict outcome in this setting. According to the main predictors of outcome in our population derived from univariate analysis (vasoactive score >31, lactate>4,7 mmol/l, pH<7,31, Creatinine>1,33 mg/dl, Horowitz Index<238, age>71 years and prior resuscitation) as well as the odds ratio derived from binary regression analysis on mortality, a new score, the MARPELLA score, was created. This score reached an AUC of 0.83 (Figure 1). A mortality of 37%, 62% and 83,2% was observed in the low-, intermediate and high-risk group of the MARPELLA score, respectively (Figure 2).

Conclusion

MARPELLA Score is a new more potent score in the setting of all-cause CS that may guide clinicians to optimize the therapy in this group of patients, outweighing the traditional CS and intensive care unit scores.

Funding Acknowledgement

Type of funding sources: None.

Biventricular unloading with impella and venoarterial extracorporeal membrane oxygenation in severe refractory cardiogenic shock: prognosis and implications from the combined use of the devices

Background

Patients with refractory cardiogenic shock (RCS) may present with left ventricle (LV)-failure, biventricular failure or even combined cardiopulmonary failure. Mechanical support with Impella or veno-arterial membrane oxygenation (VA-ECMO) have emerged as an alternative strategy in order to stabilize the heart function without the detrimental effects of catecholamines or to bridge the patients in definite therapies. However, the selection of the appropriate MCS should be tailored according to the underlying pathophysiology and properties of the respective MCS device. Patients with Impella who initially presented with univentricular LV failure may develop additionally right ventricle (RV) dysfunction or pulmonary failure whereas patients with VA-ECMO may show signs of LV overloading, causing pulmonary edema, LV distension and thus compromising LV myocardial recovery.

Purpose

To present the main outcomes and predictors of survival and safety in RCS treated with Impella and VA-ECMO.

Methods

Single center study of consecutive patients with biventricular unloading with Impella and VA-ECMO for RCS admitted to Cardiology department of Philipps University in Marburg, Germany, from February 2013 until December 2019. The selection of the device was based on a standard algorithm (Figure 1).

Results

A total of 67 patients was included in the study. Mean age was 61.07±10.7 and 54 (80.6%) patients were male. Main cause of RCS was acute myocardial infarction (AMI) (74.6%), while 44 (65.7%) were resuscitated prior to admission. In 28 patients Impella was implanted first, whereas VA-ECMO was the first MCS device in 39 patients. The mean Simplified Acute Physiology Score II (SAPS II) and Sequential Organ Failure Assessment Score (SOFA) score on admission was 73.54±16.03 and 12.25±2.71, respectively, corresponding to an expected mortality of higher than 80%. Vasopressor doses and lactate levels were significantly decreased within 72 h on biventricular support (p<0.05 for both). Overall, 17 (25.4%) patients were discharged to cardiac rehabilitation and 5 patients (7.5%) were bridged successfully to ventricular assist device implantation, leading to a total of 32.8% survival on hospital discharge. The 6-month survival was 31.3%. Lactate >6 mmol/L, vasoactive score >100 and pH <7.26 on initiation of biventricular support, as well as Charlson comorbity index (CCI) >3 and prior resuscitation were independent predictors of survival (Figure 2).

Conclusions

Biventricular support with Impella and VA-ECMO in patients with RCS is feasible and efficient leading to a better survival than predicted through traditional risk scores, mainly via significant hemodynamic improvement and reduction in lactate levels. Lactate, pH and vasoactive score on initiation of biventricular support, as well as age-adjusted CCI and prior resuscitation are independent risk factors associated with mortality in this group of patients.

Funding Acknowledgement

Type of funding sources: None.

Managing vascular access and closure for percutaneous mechanical circulatory support

Even with current generation mechanical circulatory support (MCS) devices, vascular complications are still considerable risks in MCS that influence patients’ recovery and survival. Hence, efforts are made to reduce vascular trauma and obtaining safe and adequate arterial access using state-of-the-art techniques is one of the most critical aspects for optimizing the outcomes and efficiency of percutaneous MCS. Femoral arterial access remains necessary for numerous large-bore access procedures and is most commonly used for MCS, whereas percutaneous axillary artery access is typically considered an alternative for the delivery of MCS, especially in patients with severe peripheral artery disease. This article will address the access, maintenance, closure and complication management of large-bore femoral access and concisely describe alternative access routes.

Left Ventricle Architecture and Valvular Integrity Following Microaxial Mechanical Support: A Two-Year Follow-Up Study

Although the use of microaxilar mechanical circulatory support systems may improve the outcome of patients with cardiogenic shock (CS), little is known about its effect on the long-term structural integrity of left ventricular (LV) valves as well as on the development of LV-architecture. Therefore, we aimed to study the integrity of the LV valves and architecture and function after Impella support. Thus, 84 consecutive patients were monitored over two years having received Impella^TM CP (n = 24) or 2.5 (n = 60) for refractory CS (n = 62) or for high-risk percutaneous coronary interventions (n = 22) followed by optimal medical treatment. Beside a significant increase in LV ejection fraction after two years (p ≤ 0.03 vs. pre-implantation), we observed a statistically significant decrease in LV dilation (p < 0.001) and severity of mitral valve regurgitation (p = 0.007) in the two-year follow-up period, suggesting an improved LV architecture. Neither the duration of support, nor the size of the Impella device or the indication for its use revealed any devastating impact on aortic or mitral valve integrity. These findings indicate that Impella device is a safe means of support of LV-function without detrimental long-term effects on the structural integrity of LV valves regardless of the size of the device or the indication of support.

Left ventricle unloading and valvular integrity following microaxial mechanical circulatory support: a two year follow-up study

Background

Although the use of mechanical circulatory support (MCS) systems may improve the outcome of patients with cardiogenic shock (CS) due to myocardial infarction, little is known about its effect on the long-term structural integrity of left-ventricular (LV) valves as well as on the development of LV- architecture.

Methods

84 consecutive patients were monitored over 2 years having received microaxillar MCS device (ImpellaTM CP or 2.5) for complete coronary revascularization followed by optimal medical treatment.

Results

62 patients were treated for severe cardiogenic shock and compared with 22 patients receiving short-term microaxillar MCS for high risk percutaneous coronary interventions (PCI). 24 patients of the total population received Impella CP (14F motor pump) and the remaining 60 patients received Impella 2.5 (12F motor pump). Beside a significant increase in LV-ejection fraction after 2 years (p≤0.03 vs. pre implantation) in total cohort, we observed a statistically significant decrease in LV-dilation (p&lt;0.001) and the severity of mitral valve regurgitation (p=0.007) in the 2 year follow-up period suggesting an improved LV-architecture. Neither the duration of support, nor the size of the MCS device or the indication for its use revealed any devastating impact on aortic or mitral valve integrity.

Conclusions

These findings indicate that beside complete revascularization and optimal medical treatment, microaxillar transvalvular MCS device supports the restoration of LV-architecture without detrimental long-term effects on the structural integrity of LV valves regardless of the size of the device or the duration of support.

Funding Acknowledgement

Type of funding source: None

Early Impella support in post-cardiac arrest cardiogenic shock complicating acute myocardial infarction improves short and long term survival

Background

Early mechanical circulatory support with Impella may improve survival outcomes in the setting of post-cardiac arrest cardiogenic shock (CS) after out of hospital cardiac arrest (OHCA) complicating acute myocardial infarction (AMI). However, the optimal timing to initiate mechanical circulatory support (MCS) in this particular setting remains unclear.

Purpose

We aimed to compare survival outcomes of patients supported with Impella 2.5 before percutaneous coronary intervention (PCI) (pre-PCI) to those supported after PCI (post-PCI).

Methods

Single center study of patients resuscitated from OHCA due to AMI with post-cardiac arrest CS between September 2014 and June 2018. Survival outcomes were compared between those with Impella support before and after PCI.

Results

A total of 65 consecutive patients with infarct-related post-cardiac arrest shock supported with Impella 2.5 during admission coronary angiogram were included. All patients were in profound CS requiring catecholamines on admission. Overall survival to discharge and at 12-months was 44.6% and 41.5%, respectively. Patients in the pre-PCI group had a higher survival to discharge and at 12-months as compared to patients of the post-PCI group (60.7% versus 32.4%, p=0.03 and 57.1% versus 29.7%, p=0.04, respectively). Moreover, the patients in the early support group demonstrated a greater functional recovery of the left ventricle when Impella support was initiated prior to PCI.

Conclusions

Our results suggest that the early initiation of MCS with Impella 2.5 prior to PCI is associated with improved hospital and 12-month survival in patients with post-cardiac arrest CS complicating AMI.

Figure 1

Funding Acknowledgement

Type of funding source: None

Impact of microaxillar mechanical left ventricular support on renal resistive index in patients with cardiogenic shock after myocardial infarction: a pilot trial to predict renal organ dysfunction in cardiogenic shock

OBJECTIVES

To evaluate the effects of left ventricular support with the microaxial left ventricular pump using the Impella device on the renal resistive index assessed by Doppler ultrasonography in haemodynamically stable patients with cardiogenic shock following myocardial infarction.

METHODS

A non-randomised interventional single-centre study. Consecutive patients with cardiogenic shock supported with an Impella were included during May 2018 and October 2018. The renal resistive index determined as a quotient of (peak systolic velocity - end diastolic velocity)/ peak systolic velocity was obtained using Doppler ultrasound; invasive blood pressure was determined in radial artery simultaneously for safety reasons.

RESULTS

A total of 15 patients were measured. The renal resistive index was determined in both kidneys in 13 patients and for one kidney in two patients, respectively. The mean difference between right and left renal resistive index was 0.026 ± 0.023 (P=0.72). When increasing the Impella microaxillar mechanical support by a mean of 0.44 L/min (±0.2 L/min), the renal resistive index decreased significantly from 0.66 ± 0.08 to 0.62 ± 0.06 (P<0.001) consistently in all patients, whereas systolic or diastolic blood pressure remained unchanged.

CONCLUSIONS

Microaxillar mechanical support by the Impella device in haemodynamically stable patients with cardiogenic shock led to a significant reduction of the renal resistive index without affecting systolic or diastolic blood pressure. This observation is consistent with the notion that Impella support may promote renal organ protection by enhancing renal perfusion.

Clinical scenarios for use of transvalvular microaxial pumps in acute heart failure and cardiogenic shock - A European experienced users working group opinion

For patients with myocardial infarct-related cardiogenic shock (CS), urgent percutaneous coronary intervention is the recommended treatment strategy to limit cardiac and systemic ischemia. However, a specific therapeutic intervention is often missing in non-ischemic CS cases. Though drug treatment with inotropes and/or vasopressors may be required to stabilize the patient initially, their ongoing use is associated with excess mortality. Coronary intervention in unstable patients often leads to further hemodynamic compromise either during or shortly after revascularization. Support devices like the intra-aortic balloon pump failed to improve clinical outcomes in infarct-related CS. Currently, more powerful and active hemodynamic support devices unloading the left ventricle such as transvalvular microaxial pumps are available and are being increasingly used. However, as for other devices large randomized trials are not yet available, and device use is based on registry data and expert consensus. In this article, a multidisciplinary group of experienced users of transvalvular microaxial pumps outlines the pathophysiological background on hemodynamic changes in CS, the available mechanical support devices, and current guideline recommendations. Furthermore, different hemodynamic situations in several case-based scenarios are used to illustrate candidate settings and to provide the theoretic and scientific rationale for left-ventricular unloading in these scenarios. Finally, organization of shock networks, monitoring, weaning, and typical complications and their prevention are discussed.

Indication and short-term clinical outcomes of high-risk percutaneous coronary intervention with microaxial Impella® pump: results from the German Impella® registry

BACKGROUND

Percutaneous coronary intervention (PCI) is an alternative strategy to coronary artery bypass grafting (CABG) in patients with high perioperative risk. The microaxial Impella^® pump (Abiomed, Danvers, MA, USA), used as prophylactic and temporary support, is currently the most common device for "protected high-risk PCI" to ensure hemodynamic stability during complex coronary intervention.

METHODS

The study is an observational, retrospective multi-center registry. Patients from nine tertiary hospitals in Germany, who have undergone protected high-risk PCI, are included in the present study.

RESULTS

A total of 154 patients (mean age 72.6-10.8 years, 75.3% male) were enrolled. The majority were at a high operative risk illustrated by a logistic EuroSCORE of 14.7-17.4. The initial SYNTAX score was 32.0-13.3, indicating very complex CAD and could be reduced to 14.1-14.3 (p < 0.0001) after PCI. The main reasons for protected PCI were complex coronary anatomy (70.8%), personal impression (56.5%), reduced ventricular ejection fraction (49.4%), comorbidities (47.4%), and surgical turndown (30.5%). Four patients (2.6%) experienced an intrahospital death.

CONCLUSIONS

Data from the study show that protected PCI is a safe and effective approach to revascularize high-risk patients with complex coronary anatomy and comorbidities.

Brucellosis and thrombosis of the inferior vena cava

We describe the case of a 23-year old woman with a newly diagnosed thrombosis of the inferior vena cava associated with a Brucella melitensis infection. We suggest possible mechanisms leading to brucellosis-associated venous thrombosis and review 14 previously reported cases.
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[The perioperative myocardial infarction - an interdisciplinary task]

Cardiovascular complications, particularly perioperative myocardial infarction (PMI), are major contributors to mortaliyt after noncardiac surgery. PMI often occurs unnoticed without symptoms or ECG changes. Despite ist silent presentation, PMI is associated with increased mortality. The combination of high associated mortality and diagnostic challenges mandates increased awareness of PMI. Perioperative myocardial infarction may result from plaque rupture (PMI type I) or be caused by a myocardial supply-demand imbalance of oxygen without plaque rupture (PMI type II). Most PMIs occur within the first 3 days after surgery, highlighting the need for clinical monitoring in order to allow fast diagnosis and initiation of appropriate therapy. Measurement of cardiac troponin and 12-lead ECG are the diagnostic cornerstone. Therapy of PMI represents a challenge for physicians and requires a collaboration of surgeons, anesthesiologists and cardiologists.

Cyclic three-dimensional wall motion of the human ascending and abdominal aorta characterized by time-resolved three-dimensional ultrasound speckle tracking

The aim of this study was to measure, characterize, and compare the time-resolved three-dimensional wall kinematics of the ascending and the abdominal aorta. Comprehensive description of aortic wall kinematics is an important issue for understanding its physiological functioning and early detection of adverse changes. Data on the three-dimensional, dynamic cyclic deformation of the aorta in vivo are scarce. Either most imaging techniques available are too slow to capture aortic wall motion (CT, MRI) or they do not provide three-dimensional geometry data. Three-dimensional volume data sets of ascending and abdominal aortae of male healthy subjects (25.5 [24.5, 27.5] years) were acquired by use of a commercial echocardiography system with a temporal resolution of 11-25 Hz. Longitudinal and circumferential strain, twist, and relative volume change were determined by use of a commercial speckle tracking algorithm and in-house software. The kinematics of the abdominal aorta is characterized by diameter change, almost constant length and unidirectional, either clockwise or counter clockwise twist. In contrast, the ascending aorta undergoes a complex deformation with alternating clockwise and counterclockwise twist. Length and diameter changes were in the same order of magnitude with a phase shift between both. Longitudinal strain and its phase shift to circumferential strain contribute to the proximal aorta's Windkessel function. Complex cyclic deformations are known to be highly fatiguing. This may account for increased degradation of components of the aortic wall and therefore promote aortic dissection or aneurysm formation.

A finite element updating approach for identification of the anisotropic hyperelastic properties of normal and diseased aortic walls from 4D ultrasound strain imaging

Computational analysis of the biomechanics of the vascular system aims at a better understanding of its physiology and pathophysiology and eventually at diagnostic clinical use. Because of great inter-individual variations, such computational models have to be patient-specific with regard to geometry, material properties and applied loads and boundary conditions. Full-field measurements of heterogeneous displacement or strain fields can be used to improve the reliability of parameter identification based on a reduced number of observed load cases as is usually given in an in vivo setting. Time resolved 3D ultrasound combined with speckle tracking (4D US) is an imaging technique that provides full field information of heterogeneous aortic wall strain distributions in vivo. In a numerical verification experiment, we have shown the feasibility of identifying nonlinear and orthotropic constitutive behaviour based on the observation of just two load cases, even though the load free geometry is unknown, if heterogeneous strain fields are available. Only clinically available 4D US measurements of wall motion and diastolic and systolic blood pressure are required as input for the inverse FE updating approach. Application of the developed inverse approach to 4D US data sets of three aortic wall segments from volunteers of different age and pathology resulted in the reproducible identification of three distinct and (patho-) physiologically reasonable constitutive behaviours. The use of patient-individual material properties in biomechanical modelling of AAAs is a step towards more personalized rupture risk assessment.

Impact of compression stockings on calf-vein diameters and on quality of life parameters in subjects with painful legs

BACKGROUND

Calf vein diameters during compression with two different stocking brands are assessed as well as quality of life.

PATIENTS AND METHODS

60 subjects (53 female) with painful legs were randomized to either wearing the Venotrain micro® (VM) or the Venotrain ulcertec® (VU) compression stocking for 2 weeks. All calf - veins were assessed in cross - sectional plane by Duplexsonography native and through the compression stockings. The diameters of 2 gastrocnemius muscle - veins (GV), the short saphenous vein (SSV) and the posterior tibial vein (PTV) were compared intra - individually, with and without compression.

RESULTS

Mean diameters (± SD) decreased significantly under compression (p < 0.0001) in the standing position: in the antero-posterior (ap) plane of the GV by 6.5 (± 16.6) % under VU and 8.2 (± 16.5) % under VM, in the SSV 9.7 (± 15.8) % under VU and 5.7 (± 19.2) % under VM. No significant change (p = 0.48) was seen in the PTV. In the prone position the relative ap - diameter changes in the medial GV were significantly smaller for the VM (37.5 ± 51.0 %) compared to the VU compression stocking (52.4 ± 51.8 %) (p = 0.016). The quality of life assessment scores improved significantly for the VU - and the VM - compression stocking. Venous diameters did not correlate with quality of life scores.

CONCLUSIONS

Intra - individually tested the calf muscle vein diameters decrease under compression, more pronounced in the prone than in the standing position. In the ankle area the PTV does not decrease in standing subjects. Quality of life assessed increases for both compression stockings.

Viral genomes in the pericardial fluid and in peri- and epicardial biopsies from a German cohort of patients with large to moderate pericardial effusions

The aetiology of pericardial effusion has been generally assessed by clinical work-up only, which leaves a large cohort of patients with "idiopathic" effusions virtually undiagnosed. In accordance with the ESC guidelines, this contribution intends to change this attitude. After therapeutic or diagnostic pericardiocentesis of 259 patients with large to moderate pericardial effusions, pericardial fluid, epicardial and pericardial biopsies, and blood samples were analysed by PCR for cardiotropic microbial agents. Cytology, histology, immunohistology of tissue and fluids and laboratory tests were performed. Of the 259 patients, 35 % suffered from an autoreactive aetiology, 28 % suffered from a malignant and 14 % from an infectious cause. Investigating all samples by PCR, we identified viral genomes in 51 (19.7 %) patients, parvovirus B19 (B19 V) being identified in 25 and Epstein-Barr virus (EBV) in 19 cases. In patients with a sole infectious aetiology (n = 36), B19 V was detected in 21 and EBV in 10 cases. When differentiating with regard to the material investigated for the presence of cardiotropic viruses, parvovirus B19 was most often detected in the epicardium and EBV was most frequently detected in the pericardial fluid independent from the final diagnostic categorisation. Bacterial cultures including tests for tuberculosis were all negative. Molecular techniques improve sensitivity, specificity and diagnostic accuracy for the underlying aetiology in pericarditis patients with effusion. The identification of specific viral signatures will help to understand pathogenetic mechanisms in pericarditis and allow to tailor an adequate therapy beyond antiphlogistic treatment.

Diagnostic value of biochemical biomarkers in malignant and non-malignant pericardial effusion

The aim of this study was to examine the biochemical composition of pericardial effusions of different etiology and to evaluate the diagnostic utility of biochemical parameters and tumor markers to discriminate malignant from benign effusion. Pericardial and serum levels of biochemical parameters and tumor markers were compared in 105 patients who underwent pericardiocentesis and pericardioscopy with targeted epicardial biopsy. Etiologic diagnosis was based on pericardial fluid and epicardial biopsy analysis by cytology, histology, immunohistochemistry, microbiology and polymerase chain reaction. The total of 105 patients comprised 29 patients with malignant and 76 patients with non-malignant pericardial effusions (40 autoreactive, 28 viral, 5 postcardiotomy syndromes and 3 associated with systemic diseases). Malignant pericardial effusions had significantly higher pericardial fluid levels of the tumor markers CEA, CA 19-9, CA 72-4, SCC and NSE (p < 0.001, p = 0.002, p < 0.001, p = 0.004 and p < 0.001, respectively) as well as higher pericardial fluid hemoglobin (p < 0.001), pericardial fluid white blood cells (p = 0.003), pericardial fluid LDH (p < 0.001) and ratio of pericardial to serum LDH levels compared to benign effusions. None of the biochemical or cell-count parameters tested proved to be accurate enough for distinguishing malignant from benign effusions. However, measurement of pericardial CA 72-4 levels offered a high diagnostic accuracy for malignancy, particularly in bloody pericardial effusions. None of the biochemical parameters tested was useful for the discrimination of malignant from benign effusions. However, measurement of pericardial CA 72-4 levels in bloody pericardial effusions yielded a high diagnostic accuracy and thus offers the potential as a diagnostic tool to distinguish between malignant and benign effusions.

In vivo determination of elastic properties of the human aorta based on 4D ultrasound data

Computational analysis of the biomechanics of the vascular system aims at a better understanding of its physiology and pathophysiology. To be of clinical use, however, these models and thus their predictions, have to be patient specific regarding geometry, boundary conditions and material. In this paper we present an approach to determine individual material properties of human aortae based on a new type of in vivo full field displacement data acquired by dimensional time resolved three dimensional ultrasound (4D-US) imaging. We developed a nested iterative Finite Element Updating method to solve two coupled inverse problems: The prestrains that are present in the imaged diastolic configuration of the aortic wall are determined. The solution of this problem is integrated in an iterative method to identify the nonlinear hyperelastic anisotropic material response of the aorta to physiologic deformation states. The method was applied to 4D-US data sets of the abdominal aorta of five healthy volunteers and verified by a numerical experiment. This non-invasive in vivo technique can be regarded as a first step to determine patient individual material properties of the human aorta.

Vascular endothelial growth factor in malignant and benign pericardial effusion

BACKGROUND

The pathogenetic role of vascular endothelial growth factor (VEGF) in malignant pericardial effusion and diagnostic value of pericardial VEGF levels to discriminate malignant from benign pericardial effusions are uncertain.

HYPOTHESIS

We hypothesized that pericardial VEGF levels would be higher in malignant than benign pericardial effusion and that VEGF would be a useful marker for the diagnosis of malignant pericardial effusion.

METHODS

Using an enzyme-linked immunosorbent assay, we assessed pericardial and serum VEGF levels in patients with malignant pericardial effusion (n = 19), in patients with nonmalignant pericardial effusion (n = 30), and for control, in patients without pericardial disease (n = 26).

RESULTS

Vascular endothelial growth factor pericardial levels in malignant pericardial effusion (13 593.8 ± 22 410.24 pg/mL) were significantly higher compared with VEGF in nonmalignant effusion (610.63 ± 1289.08 pg/mL; P = 0.001) and pericardial fluid (5.5 ± 15.97 pg/mL; P < 0.001). In serum, VEGF was significantly higher in patients with nonmalignant pericardial effusion (188.3 ± 240.35 pg/mL) compared with patients with malignant pericardial effusion (67.52 ± 125.77 pg/mL; P = 0.024) and coronary artery disease patients (29.13 ± 76.26 pg/mL; P < 0.001). Pericardial VEGF levels were significantly higher than matched serum levels only in patients with malignant pericardial effusion (P = 0.023). Pericardial VEGF levels ≥2385 pg/mL had 75% sensitivity and 90% specificity for the recognition of malignant pericardial effusion in patients with breast or lung cancer.

CONCLUSIONS

Vascular endothelial growth factor levels in pericardial effusion are markedly elevated in patients with malignant pericardial effusion, indicating abundant local release within the pericardial cavity. It is thus possible that VEGF participates in the pathogenesis of malignant pericardial effusion. Measurement of VEGF in pericardial effusion offers potential as a diagnostic tool to discriminate malignant from benign effusions in patients with breast or lung cancer.

Varicose veins: a critical review of the definition and the therapeutical options

This review intends to give an overview of the present therapeutic options for varicose vein disease. The definition of varicose vein disease and its recurrence are made and discussed with new aspects including duplexsonography assessment. All therapeutic approaches have developed and refined their treatment modalities, the open surgical as well as the endovenous techniques. In particular the “new” endovenous techniques are described with regard to safety and outcome, the published literature in this respect is summarized. The studies comparing the different techniques are listed, the prospective long term studies comparing the new techniques with the so called gold standard (open surgery) shall decide on the fate of the different techniques.

Gender bias revisited: new insights on the differential management of chest pain

Background

Chest pain is a common complaint and reason for consultation in primary care. Few data exist from a primary care setting whether male patients are treated differently than female patients. We examined whether there are gender differences in general physicians' (GPs) initial assessment and subsequent management of patients with chest pain, and how these differences can be explained

Methods

We conducted a prospective study with 1212 consecutive chest pain patients. The study was conducted in 74 primary care offices in Germany from October 2005 to July 2006. After a follow up period of 6 months, an independent interdisciplinary reference panel reviewed clinical data of every patient and decided about the etiology of chest pain at the time of patient recruitment (delayed type-reference standard). We adjusted gender differences of six process indicators for different models.

Results

GPs tended to assume that CHD is the cause of chest pain more often in male patients and referred more men for an exercise test (women 4.1%, men 7.3%, p = 0.02) and to the hospital (women 2.9%, men 6.6%, p < 0.01). These differences remained when adjusting for age and cardiac risk factors but ceased to exist after adjusting for the typicality of chest pain.

Conclusions

While observed gender differences can not be explained by differences in age, CHD prevalence, and underlying risk factors, the less typical symptom presentation in women might be an underlying factor. However this does not seem to result in suboptimal management in women but rather in overuse of services for men. We consider our conclusions rather hypothesis generating and larger studies will be necessary to prove our proposed model.

Accuracy of general practitioners' assessment of chest pain patients for coronary heart disease in primary care: cross-sectional study with follow-up

AIM

To estimate how accurately general practitioners' (GP) assessed the probability of coronary heart disease in patients presenting with chest pain and analyze the patient management decisions taken as a result.

METHODS

During 2005 and 2006, the cross-sectional diagnostic study with a delayed-type reference standard included 74 GPs in the German state of Hesse, who enrolled 1249 consecutive patients presenting with chest pain. GPs recorded symptoms and findings for each patient on a report form. Patients and GPs were contacted 6 weeks and 6 months after the patients' visit to the GP. Data on chest complaints, investigations, hospitalization, and medication were reviewed by an independent panel, with coronary heart disease being the reference condition. Diagnostic properties (sensitivity, specificity, and predictive values) of the GPs' diagnoses were calculated.

RESULTS

GPs diagnosed coronary heart disease with the sensitivity of 69% (95% confidence interval [CI], 62-75) and specificity of 89% (95% CI, 87-91), and acute coronary syndrome with the sensitivity of 50% (95% CI, 36-64) and specificity of 98% (95% CI, 97-99). They assumed coronary heart disease in 245 patients, 41 (17%) of whom were referred to the hospital, 77 (31%) to a cardiologist, and 162 (66%) to electrocardiogram testing.

CONCLUSIONS

GPs' evaluation of chest pain patients, based on symptoms and signs alone, was not sufficiently accurate for diagnosing or excluding coronary heart disease or acute coronary syndrome.

Chest wall syndrome in primary care patients with chest pain: presentation, associated features and diagnosis

BACKGROUND

Chest wall syndrome (CWS) is the most frequent aetiology of chest pain in a primary care setting.

OBJECTIVE

The aims of the study are to describe the epidemiology, clinical characteristics and prognosis of CWS and to provide a simple decision rule for diagnosis.

METHODS

We included 1212 consecutive patients with chest pain aged 35 years and older attending 74 GPs. GPs recorded symptoms and findings of each patient and provided follow-up information. An independent interdisciplinary reference panel reviewed clinical data of every patient and decided about the aetiology of chest pain at the time of patient recruitment. Multivariable regression analysis was performed to identify clinical predictors that help to rule in or out the diagnosis of CWS.

RESULTS

GPs diagnosed pain originating from the chest wall in 46.6% of all patients. In most patients, pain was localized retrosternal (52.0%) and/or on the left side (69.2%). In total, 28.0% of CWS patients showed persistent pain and most patients reported no temporal association of pain (72.3%). In total, 55.4% of patients still had chest pain after 6 months. A simple score containing four determinants (localized muscle tension, stinging pain, pain reproducible by palpation and absence of cough) shows an area under the receiver operating characteristic curve of 0.78 (95% confidence interval: 0.75-0.81).

CONCLUSIONS

This study broadens the knowledge about pain characteristics and the diagnostic accuracy of selected signs and symptoms for CWS. A simple four-point score can help the GP in the diagnostic workup of chest pain patients.

Ruling out coronary artery disease in primary care: development and validation of a simple prediction rule

BACKGROUND

Chest pain can be caused by various conditions, with life-threatening cardiac disease being of greatest concern. Prediction scores to rule out coronary artery disease have been developed for use in emergency settings. We developed and validated a simple prediction rule for use in primary care.

METHODS

We conducted a cross-sectional diagnostic study in 74 primary care practices in Germany. Primary care physicians recruited all consecutive patients who presented with chest pain (n = 1249) and recorded symptoms and findings for each patient (derivation cohort). An independent expert panel reviewed follow-up data obtained at six weeks and six months on symptoms, investigations, hospital admissions and medications to determine the presence or absence of coronary artery disease. Adjusted odds ratios of relevant variables were used to develop a prediction rule. We calculated measures of diagnostic accuracy for different cut-off values for the prediction scores using data derived from another prospective primary care study (validation cohort).

RESULTS

The prediction rule contained five determinants (age/sex, known vascular disease, patient assumes pain is of cardiac origin, pain is worse during exercise, and pain is not reproducible by palpation), with the score ranging from 0 to 5 points. The area under the curve (receiver operating characteristic curve) was 0.87 (95% confidence interval [CI] 0.83-0.91) for the derivation cohort and 0.90 (95% CI 0.87-0.93) for the validation cohort. The best overall discrimination was with a cut-off value of 3 (positive result 3-5 points; negative result <or= 2 points), which had a sensitivity of 87.1% (95% CI 79.9%-94.2%) and a specificity of 80.8% (77.6%-83.9%).

INTERPRETATION

The prediction rule for coronary artery disease in primary care proved to be robust in the validation cohort. It can help to rule out coronary artery disease in patients presenting with chest pain in primary care.

Accuracy of general practitioners' assessment of chest pain patients for coronary heart disease in primary care: cross-sectional study with follow-up

AIM

To estimate how accurately general practitioners' (GP) assessed the probability of coronary heart disease in patients presenting with chest pain and analyze the patient management decisions taken as a result.

METHODS

During 2005 and 2006, the cross-sectional diagnostic study with a delayed-type reference standard included 74 GPs in the German state of Hesse, who enrolled 1249 consecutive patients presenting with chest pain. GPs recorded symptoms and findings for each patient on a report form. Patients and GPs were contacted 6 weeks and 6 months after the patients' visit to the GP. Data on chest complaints, investigations, hospitalization, and medication were reviewed by an independent panel, with coronary heart disease being the reference condition. Diagnostic properties (sensitivity, specificity, and predictive values) of the GPs' diagnoses were calculated.

RESULTS

GPs diagnosed coronary heart disease with the sensitivity of 69% (95% confidence interval [CI], 62-75) and specificity of 89% (95% CI, 87-91), and acute coronary syndrome with the sensitivity of 50% (95% CI, 36-64) and specificity of 98% (95% CI, 97-99). They assumed coronary heart disease in 245 patients, 41 (17%) of whom were referred to the hospital, 77 (31%) to a cardiologist, and 162 (66%) to electrocardiogram testing.

CONCLUSIONS

GPs' evaluation of chest pain patients, based on symptoms and signs alone, was not sufficiently accurate for diagnosing or excluding coronary heart disease or acute coronary syndrome.

Gender differences in presentation and diagnosis of chest pain in primary care

Background

Chest pain is a common complaint and reason for consultation in primary care. Research related to gender differences in regard to Coronary Heart Disease (CHD) has been mainly conducted in hospital but not in primary care settings. We aimed to analyse gender differences in aetiology and clinical characteristics of chest pain and to provide gender related symptoms and signs associated with CHD.

Methods

We included 1212 consecutive patients with chest pain aged 35 years and older attending 74 general practitioners (GPs). GPs recorded symptoms and findings of each patient and provided follow up information. An independent interdisciplinary reference panel reviewed clinical data of every patient and decided about the aetiology of chest pain at the time of patient recruitment. Multivariable regression analysis was performed to identify clinical predictors that help to rule in or out CHD in women and men.

Results

Women showed more psychogenic disorders (women 11,2%, men 7.3%, p = 0.02), men suffered more from CHD (women 13.0%, men 17.2%, p = 0.04), trauma (women 1.8%, men 5.1%, p < 0.001) and pneumonia/pleurisy (women 1.3%, men 3.0%, p = 0.04) Men showed significantly more often chest pain localised on the right side of the chest (women 9.1%, men 25.0%, p = 0.01). For both genders known clinical vascular disease, pain worse with exercise and age were associated positively with CHD. In women pain duration above one hour was associated positively with CHD, while shorter pain durations showed an association with CHD in men. In women negative associations were found for stinging pain and in men for pain depending on inspiration and localised muscle tension.

Conclusions

We found gender differences in regard to aetiology, selected clinical characteristics and association of symptoms and signs with CHD in patients presenting with chest pain in a primary care setting. Further research is necessary to elucidate whether these differences would support recommendations for different diagnostic approaches for CHD according to a patient's gender.

[New possibilities of diagnostics and therapy of pericarditis]

Pericarditis is an inflammatory disorder of the pericardium with or without an associated pericardial effusion. The diagnosis is based on the clinical manifestations and typical ECG changes. Echocardiography is essential to reveal the size of the pericardial effusion and to determine its hemodynamic significance. The precise etiology of pericarditis may be established by pericardiocentesis, pericardioscopy and targeted biopsy and consecutive pericardial fluid and biopsy analysis by molecular biology, cytology, microbiology and immunological techniques. Non steroidal anti-inflammatory drugs and/or colchicine are the mainstay of anti-inflammatory treatment of pericarditis. Systemic corticoid treatment should be restricted to patients with associated autoimmune disorder, relapsing pericarditis and as a complementary therapy in tuberculous pericarditis. In autoreactive pericarditis intrapericardial instillation of triamcinolone is effective with few side effects. In malignant pericarditis the intrapericardial administration of cisplatin prevents early recurrences.

Invasive techniques--from diagnosis to treatment

Invasive diagnostic and therapeutic techniques are indispensable for the diagnosis and interventional treatment of coronary artery disease, valvular involvement and, in particular, if the specific components of the inflammatory or degenerative processes in rheumatic disease are to be identified in the different components of the heart. Although impairment of cardiac function and ischaemia can be suspected also by non-invasive techniques, coronary involvement needs the final proof by angiography. Endomyocardial or epicardial biopsy identifies the key players of autoreactivity: the infiltrating cells and the bound and circulating antibodies. Before corticoid treatment is started, a viral or microbial aetiology has to be excluded at the site of cardiac inflammation. This again can only be done by the analysis of cardiac tissue samples.

[Recurrent autoreactive pericardial effusion. Impact of an aetiological classification of pericarditis]

HISTORY

A 36 year-old man suffered from fever, fatigue, pleurodynia and precordial discomfort. His family physician suspected febrile tracheobronchitis and treated it with ampicillin for 5 days. Because symptoms persisted an ECG was done which suggested acute myocardial infarction. The patient underwent an emergency coronary angiography which excluded coronary artery disease and aortic dissection. Pericarditis was suspected and the patient put on aspirin, 500 mg/d. Because of persisting cardiac symptoms an echocardiography was performed which revealed systolic separation between epi- and pericardium, characteristic of a small pericardial effusion after acute pericarditis. The symptoms improved after one week of treatment with diclofenac and the ECG had become normal. Two months later the patient was seen at our cardiac outpatient clinic. He had night sweats, sporadic precordial pain and severe dyspnoe.

INVESTIGATIONS

Further investigations revealed tachycardia (120/min), hypotension (95/70 mm Hg), pulsus paradoxus and jugular vein sustension. Echocardiography revealed a large pericardial effusion ("swinging heart"), which explained the low voltage and the electrical alternans in the ECG.

TREATMENT AND COURSE

Pericardiocentesis was carried out the same day to relieve the tamponade. It was followed by pericardioscopy and epi- as well as pericardial biopsy. 485 ml of a serous effusion were drained. Cytology and histology demonstrated a lymphocytic fibrinous pericarditis. Polymerase chain reaction (PCR) on viral and bacterial RNA and DNA of potentially cardiotropic agents remained negative. The pigtail catheter was left in place and 80 mg of gentamycin were given intrapericardially on day 1 and 2, followed by 500 mg of crystalloid triamcinolone acetate after the PCR was found to be negative. Oral treatment with 0.5 mg colchicine three times a day (off-label use) was started and maintained for 6 months. After 9 months no effusion was detected and the patient was free of symptoms.

CONCLUSIONS

After exclusion of bacterial and viral pericardial infection, a high single dose of intrapericardial triamcinolone combined with long-term oral colchicine has proven to be a highly efficacious treatment of autoreactive pericarditis which will avoid relapses in most cases.