Impact of Prosthetic Valve Regurgitation Assessed by Echocardiography and Magnetic Resonance Imaging on Long-term Clinical Outcomes after TAVR

BACKGROUND

Prosthetic valve regurgitation (PVR) impairs early and mid-term outcomes after transcatheter aortic valve replacement (TAVR). We explored the impact of PVR assessed by transthoracic echocardiography (TTE) and magnetic resonance imaging-regurgitation fraction (MRI-RF) on long-term clinical outcomes.

METHODS

PVR was assessed by TTE applying the Valve Academic Research Consortium criteria and MRI-RF (from velocity-encoded phase contrast magnetic resonance sequence) in 424 patients.

RESULTS

MRI-RF correlated modestly with the echocardiographic grades of PVR (Spearman's rank correlation coefficient= 0.32, p<0.001). Using an MRI-RF≥20% to define ≥moderate PVR, echocardiography and MRI-RF agreed on PVR classification in 412 patients (97.2%; kappa statistic = 0.56, p<0.001). Five-year mortality or reintervention was higher in patients with echocardiographic ≥moderate PVR (83.3% vs. 45.0%, log rank p value= 0.002; HR[95% CI]: 3.18[1.48-6.84]) as well as in patients with MRI-RF≥20% (79.3% vs. 43.2%, log rank p value <0.001; HR[95% CI]: 2.68[1.53-4.70])); while the outcomes of patients with echocardiographic mild PVR was not significantly different from those with none-trace PVR. In the two latter groups (echocardiographic <moderate PVR), MRI-RF≥20% was associated with a significantly higher five-year mortality or reintervention as compared with MRI-RF<20% (79.5% vs. 42.2%, log rank p value=0.023; HR[95% CI]: 2.26[1.10-4.65]).

CONCLUSIONS

Greater than mild PVR as defined by TTE or MRI-RF is associated with impaired long-term clinical outcomes after TAVR. MRI-RF can be used to further risk-stratify patients with echocardiographic less-than-moderate PVR.

Potential emerging chemical risks in the food chain associated with substances registered under REACH

A screening procedure for the identification of potential emerging chemical risks in the food and feed chain developed in a previous EFSA-sponsored pilot study was applied to 15021 substances registered under the REACH Regulation at the time of evaluation. Eligible substances were selected from this dataset by excluding (a) intermediates handled under strictly controlled conditions, (b) substances lacking crucial input data and (c) compounds considered to be outside the applicability domain of the models used. Selection of eligible substances resulted in a considerable reduction to 2336 substances. These substances were assessed and scored for environmental release (tonnage and use information from REACH registration dossiers), biodegradation (predictions from BIOWIN models 3, 5 and 6 evaluated in a battery approach), bioaccumulation in food/feed (ACC-HUMANsteady modelling) and chronic human health hazards (classification according to the CLP Regulation for carcinogenicity, mutagenicity, reproductive toxicity and repeated dose toxicity as well as IARC classification for carcinogenicity). Prioritisation based on the scores assigned and additional data curation steps identified 212 substances that are considered potential emerging risks in the food chain. Overall, 53% of these substances were prioritised due to chronic hazards identified in REACH registrations dossiers only (i.e. hazards not identified in classifications from other sources). Bioaccumulation in food and feed predicted on the basis of ACC-HUMANsteady modelling identified many substances that are not considered bioaccumulative in aquatic or terrestrial organisms based on screening criteria of the relevant ECHA guidance documents. Furthermore, 52% of the priority substances have not yet been assessed for their presence in food/feed by EU regulatory agencies. This finding and illustrative examples suggest that the screening procedure identified substances that have the potential to be emerging chemical risks in the food chain. Future research should investigate whether they actually represent emerging chemical risks as defined in EFSA's mandate.

Development of a novel scoring system for identifying emerging chemical risks in the food chain

The European Food Safety Authority (EFSA) is responsible for risk assessment of all aspects of food safety, including the establishment of procedures aimed at the identification of emerging risks to food safety. Here, a scoring system was developed for identifying chemicals registered under the European REACH Regulation that could be of potential concern in the food chain using the following parameters: (i) environmental release based on maximum aggregated tonnages and environmental release categories; (ii) biodegradation in the environment; (iii) bioaccumulation and in vivo and in vitro toxicity. The screening approach was tested on 100 data-rich chemicals registered under the REACH Regulation at aggregated volumes of at least 1000 tonnes per annum. The results show that substance-specific data generated under the REACH Regulation can be used to identify potential emerging risks in the food chain. After application of the screening procedure, priority chemicals can be identified as potentially emerging risk chemicals through the integration of exposure, environmental fate and toxicity. The default approach is to generate a single total score for each substance using a predefined weighting scenario. However, it is also possible to use a pivot table approach to combine the individual scores in different ways that reflect user-defined priorities, which enables a very flexible, iterative definition of screening criteria. Possible applications of the approaches are discussed using illustrative examples. Either approach can then be followed by in-depth evaluation of priority substances to ensure the identification of substances that present a real emerging chemical risk in the food chain.

Comparison of outcomes in patients having isolated transcatheter aortic valve implantation versus combined with preprocedural percutaneous coronary intervention

Coronary artery disease negatively affects the outcome of patients undergoing surgical aortic valve replacement and practice guidelines recommend revascularization at time of surgery. In patients undergoing transcatheter aortic valve implantation (TAVI), the impact of preprocedural percutaneous coronary intervention (PCI) on TAVI outcome has not been examined. We aimed in the present study to assess the feasibility and safety of performing PCI before TAVI and to evaluate procedural, 30-day, and 6-month clinical outcomes. We retrospectively analyzed 125 patients who underwent successful TAVI at a single institution and divided them into an isolated TAVI and a PCI + TAVI group. During the study period, a strategy of preprocedural PCI of all significant (>50%) lesions in major epicardial vessels was adopted. Study end points were adjudicated in accordance with the Valve Academic Research Consortium consensus on event definition. All patients were treated with the Medtronic CoreValve prosthesis (n = 55 with PCI + TAVI and n = 70 with isolated TAVI). Thirty-day mortality was 2% versus 6% for patients treated with PCI + TAVI versus isolated TAVI, respectively (p = 0.27). Neither periprocedural nor spontaneous myocardial infarction occurred in either group. Rates of 30-day stroke, major bleeding, major vascular complications, and the Valve Academic Research Consortium-defined combined safety end point (11% vs 13%, p = 0.74) did not differ between the 2 groups. Patients' symptoms significantly improved in the first month after TAVI, and extent of improvement did not differ between groups. Adverse events at 6 months were comparable. In conclusion, PCI before TAVI appears feasible and safe. Based on these early results revascularization should become an important consideration in patients with coronary artery disease undergoing TAVI.

Methodological characteristics of the national dietary surveys carried out in the European Union as included in the European Food Safety Authority (EFSA) Comprehensive European Food Consumption Database

In 2009 competent organisations in the European Union provided the European Food Safety Authority (EFSA) with data from the most recent national dietary survey at the level of individuals' consumption. Twenty different Member States provided EFSA with data from 22 different national dietary surveys, with consumption figures for adults and, when available, for children. Member States' dietary data were assembled into the EFSA Comprehensive European Food Consumption Database. In this paper an overview of the methodologies and protocols employed in the different national dietary surveys is provided. Specifically, details about dietary assessment methods, interview administration, sampling design, portion size estimation, dietary software, evaluation of under-reporting and non-dietary information collected are described. This information is crucial to evaluate the level of accuracy of food consumption data and to anticipate and acknowledge the utmost important sources of heterogeneity of national databases included in the Comprehensive Database. The Comprehensive Database constitutes a unique resource for the estimation of consumption figures across the European Union and represents a useful tool to assess dietary exposure to hazardous substances and nutrient intake in Europe. Nevertheless, the many substantial methodological differences that characterise the Comprehensive Database are acknowledged and critically discussed.

Use of cardiovascular magnetic resonance for risk stratification in chronic heart failure: prognostic value of late gadolinium enhancement in patients with non-ischaemic dilated cardiomyopathy

OBJECTIVE

Owing to its variable clinical course, risk stratification is of paramount importance in non-ischaemic dilated cardiomyopathy (DCM). The goal of this study was to investigate the long-term prognostic significance of late gadolinium enhancement (LGE) as detected by contrast-enhanced cardiovascular magnetic resonance (CE-CMR) in patients with DCM.

DESIGN

Observational cohort study. Setting University hospital.

PATIENTS

184 consecutive patients with DCM.

MEASUREMENTS

CE-CMR was performed on a 1.5 T clinical scanner. Presence, extent and patterns of LGE were determined by two independent observers.

OUTCOME MEASURES

Patients were followed for the composite end point of cardiac death, hospitalisation for decompensated heart failure, or appropriate implantable cardioverter defibrillator discharge for a mean±SEM of 685±30 days.

RESULTS

LGE was detected in 72/184 patients (39%) and was associated with a lower left ventricular (LV) ejection fraction (31% (20.9-42.2%) vs 44% (33.1-50.9%), p<0.001), higher LV end-diastolic volume index (133 (116-161) ml/m(2) vs 109 (92.7-137.6) ml/m(2), p<0.001) and higher LV mass (80 (67.1-94.8) g/m(2) vs 65.8 (55.2-82.9) g/m(2), p<0.001). Patients in whom LGE was present were more likely to experience the composite end point (15/72 vs 6/112, p=0.002). Receiver operating characteristic curve analysis revealed a LGE of >4.4% of LV mass as optimal discriminator for the composite end point. When entered into multivariate Cox regression analysis, LGE retained its independent predictive value, yielding an associated HR of 3.4 (95% CI 1.26 to 9).

CONCLUSION

The presence of LGE in this large DCM patient cohort is associated with pronounced LV remodelling, functional impairment and an adverse outcome. Further research is necessary to determine whether these findings will aid the clinical management of DCM patients.

Prognostic value of high-dose dobutamine stress magnetic resonance imaging in 1,493 consecutive patients: assessment of myocardial wall motion and perfusion

OBJECTIVES

This study sought to determine the prognostic value of wall motion and perfusion assessment during high-dose dobutamine stress (DS) cardiac magnetic resonance imaging (MRI) in a large patient cohort.

BACKGROUND

DS-MRI offers the possibility to integrate myocardial perfusion and wall motion analysis in a single examination for the detection of coronary artery disease (CAD).

METHODS

A total of 1,493 consecutive patients with suspected or known CAD underwent DS-MRI, using a standard protocol in a 1.5-T magnetic resonance scanner. Wall motion and perfusion were assessed at baseline and during stress, and outcome data including cardiac death, nonfatal myocardial infarction ("hard events"), and "late" revascularization performed >90 days after the MR scans were collected during a 2 ± 1 year follow-up period.

RESULTS

Fifty-three hard events, including 14 cardiac deaths and 39 nonfatal infarctions, occurred during the follow-up period, whereas 85 patients underwent "late" revascularization. Using multivariable regression analysis, an abnormal result for wall motion or perfusion during stress yielded the strongest independent prognostic value for both hard events and late revascularization, clearly surpassing that of clinical and baseline magnetic resonance parameters (for wall motion: adjusted hazard ratio [HR] of 5.9 [95% confidence interval (CI): 2.5 to 13.6] for hard events and of 3.1 [95% CI: 1.7 to 5.6] for late revascularization, and for perfusion: adjusted HR of 5.4 [95% CI: 2.3 to 12.9] for hard events and of 6.2 [95% CI: 3.3 to 11.3] for late revascularization, p < 0.001 for all).

CONCLUSIONS

DS-MRI can accurately identify patients who are at increased risk for cardiac death and myocardial infarction, separating them from those with normal findings, who have very low risk for future cardiac events. (Prognostic Value of High Dose Dobutamine Stress Magnetic Resonance Imaging; NCT00837005).

Serum levels of NT-proBNP as surrogate for cardiac amyloid burden: new evidence from gadolinium-enhanced cardiac magnetic resonance imaging in patients with amyloidosis

BACKGROUND

The prognostic value of NT-proBNP has been recognized in patients with amyloidosis complicated by cardiac involvement. We aimed to use contrast enhanced cardiac magnetic resonance imaging (CMR) to identify functional and structural alterations related to levels of NT-proBNP better to understand the mechanisms of its release in cardiac amyloidosis.

METHODS AND RESULTS

CMR was performed on a 1.5-T scanner in 34 patients with biopsy proven amyloid light chain (AL; n = 27) or hereditary transthyretin related (TTR; n = 7) amyloidosis. NT-proBNP was higher in patients with (n = 25) compared to patients without cardiac involvement (n = 9) (2931 (IQR: 972-8629; min-max: 25-27,277) pg/ml vs. 177 (IQR: 71-1431; min-max: 22-7935) pg/ml, p = 0.008). ROC analysis identified a NT-proBNP of <2426.5 pg/ml as optimal discriminator for event free survival (682 +/- 65 days). NT-proBNP did not correlate with LV- ejection fraction, end-diastolic and end-systolic volumes or stroke volume. There was a moderate correlation between NT-proBNP and LV-mass (R = 0.52, p = 0.003) and extent of late gadolinium enhancement (LGE; R = 0.41, p = 0.04).

CONCLUSIONS

This study confirms the prognostic value of NT-proBNP in patients with AL and TTR amyloidosis and provides the novel finding that NT-proBNP correlates with surrogates of myocardial amyloid burden such as LV-mass and LGE, supporting the concept of NT-proBNP as a biomarker reflecting the severity of cardiac amyloid infiltration.

Prediction of coronary artery disease by a systemic atherosclerosis score index derived from whole-body MR angiography

BACKGROUND

Whole-body magnetic resonance angiography (WB-MRA) has shown its potential for the non-invasive assessment of nearly the entire arterial vasculature within one examination. Since the presence of extra-cardiac atherosclerosis is associated with an increased risk of coronary events, our goal was to establish the relationship between WB-MRA findings, including a systemic atherosclerosis score index, and the presence of significant coronary artery disease (CAD).

METHODS

WB-MRA was performed on a 1.5T scanner in 50 patients scheduled to undergo elective cardiac catheterization for suspected CAD. In each patient, 40 extra-cardiac vessel segments were evaluated and assigned scores according to their luminal narrowing. The atherosclerosis score index (ASI) was generated as the ratio of summed scores to analyzable segments.

RESULTS

ASI was higher in patients with significant (> 50% stenosis) CAD (n = 27) vs. patients without CAD (n = 22; 1.56 vs. 1.28, p = 0.004). ASI correlated with PROCAM (R = 0.57, p < 0.001) and Framingham (R = 0.36, p = 0.01) risk scores as estimates of the 10-year risk of coronary events. A ROC derived ASI of > 1.54 predicted significant CAD with a sensitivity of 59%, specificity of 86% and a positive predictive value of 84%. Logistic regression revealed ASI > 1.54 as the strongest independent predictor for CAD with a 11-fold increase in likelihood to suffer from significant coronary disease. On the contrary, while 15/27 (55%) of patients with CAD exhibited at least one extra-cardiac stenosis > 50%, only 3/22 (14%) of those patients without CAD did (p = 0.003). The likelihood for an extra-cardiac stenosis when CAD is present differed between vascular territories and ranged from 15% for a carotid stenosis to 44% for a stenosis in the lower extremities.

CONCLUSION

This study provides important new evidence for the close association of extra-cardiac and coronary atherosclerosis. The novel findings that a WB-MRA derived systemic atherosclerosis score index is not only associated with established cardiovascular risk scores but is also predictive of significant CAD suggest its potential prognostic implications and underline the importance to screen for coronary disease in patients with extra-cardiac manifestations of atherosclerosis.

Acute phase reaction to gadolinium-DTPA in dialysis patients

BACKGROUND

Several late sequelae of the administration of gadolinium (Gd)-containing MRI contrast agents have been described in patients with advanced renal failure. In an observational series, we found a remarkable frequency of peracute reactions after administration of Gd-DTPA used for cardiovascular evaluation before renal transplantation.

METHODS

In a 26-month observational period, 13 of 136 haemodialyzed or CAPD patients exhibited onset of fever, chills and nausea within hours after administration of Gd-DTPA peracute. A minority showed persistent cessation of residual diuresis. We performed blood cultures in most patients and evaluated white blood cell (WBC) counts, eosinophils, CRP, heart rate and blood pressure.

RESULTS

Within an average of 12 h (range 12-36 h) after Gd administration, the 13 patients (9 males, 4 females; median age 61 years, range 47-79) developed consistent symptomatology with fever (median 39.0 degrees C, range 37.5-39.5), chills, malaise, hypotension, vomiting, dyspnoea-initially raising suspicion of septicaemia. Subsequent blood cultures on bacterial contamination of the injected product remained negative throughout; bacterial or endotoxin contamination of the reagent was excluded. Steroids were tried in the first two patients without a noticeable effect. In all subsequent patients, symptoms were attenuated during the first 5 h dialysis (F60HPS with 280 ml/min blood flow) and disappeared within 72 h. CRP levels remained markedly elevated up to 14 days. Lymphopenia was seen in all patients, and polymorphic neutrophils (PMN) remained normal. Two polyuric patients developed persistent anuria. After a median of 16 months, none of these patients developed nephrogenic systemic fibrosis.

CONCLUSION

This series with unusually severe acute phase reactions was caused by one specific preparation. Such peracute reactions may be relevant for the so-far largely unresolved pathogenesis of the skin reaction to some Gd products in end-stage renal disease (ESRD) patients. It remains unresolved whether the reaction observed with Gd-DTPA do in principle also occur with other Gd reagents.

Prevalence of different gadolinium enhancement patterns in patients after heart transplantation

OBJECTIVES

Transplant coronary artery disease (TCAD) limits long-term survival after heart transplantation (HTX). We hypothesized that contrast-enhanced magnetic resonance imaging (CE-MRI) detects chronic TCAD-related myocardial infarctions (MIs), even in patients with angiographically classified mild TCAD.

BACKGROUND

Coronary angiography underestimates the TCAD-degree, subsequently missing occluded small coronary arteries and resulting MI. CE-MRI as a noninvasive imaging technique identifies infarct-typical MI and myocardial fibrosis.

METHODS

CE-MRI (gadolinium: 0.2 mmol/kg/bw) was performed in 53 HTX patients on a 1.5-T MRI scanner (Philips, Best, the Netherlands). Infarct-typical CE-MRI areas were classified as: I=<or=25%, II=25% to 50%, III=50% to 75% and IV=>or=75%. Infarct-atypical forms were divided into diffuse, spotted, intramural, and infero-septal. Coronary angiography results were reviewed qualitatively with the TCAD score (TCAD I=mild evidence; II=30% to 75%, III=>or=75% stenosis). Groups were compared with analysis of variance (statistically significant p values<or=0.05).

RESULTS

Infarct-typical CE-MRI was already present in TCAD I+II, increased significantly between groups (I=23%, II=33%, III=84%, p<0.05), and involved only single coronary territories in TCAD I but multiple vessels in TCAD II+III. Infarct-atypical CE-MRI was equally distributed across all TCAD stages (I=50% vs. II=58% vs. III=42%, p=NS) without relation to a coronary territory. Patients with only infarct-atypical CE-MRI were associated with significantly better left ventricular function compared with patients with infarct-typical or combined CE-MRI patterns (ejection fraction=66+/-6% vs. 45+/-16% or 60+/-13%; end-diastolic volume=139+/-32 ml vs. 148+/-27 ml or 164+/-43 ml; end-systolic volume=47+/-15 ml vs. 81+/-27 ml or 69+/-38 ml, p<or=0.05).

CONCLUSIONS

CE-MRI allows identification of silent MI in apparently event-free HTX patients and is able to disclose myocardial fibrosis already in patients with absent or mild angiographic TCAD. CE-MRI might be helpful to establish an earlier TCAD diagnosis and to intensify medical treatment. Future studies are necessary to test prognostic implications associated with CE-MRI patterns.

Relative Role of NT-pro BNP and Cardiac Troponin T at 96 hours for Estimation of Infarct Size and Left Ventricular Function After Acute Myocardial Infarction

BACKGROUND

N-terminal brain-type natriuretic peptide (NT-pro BNP) and cardiac troponin T (cTnT) after acute myocardial infarction (AMI) have proven useful for prediction of prognosis and may be valuable for assessment of left ventricular function and infarct size. The aim of the present study was to correlate infarct size and left ventricular function determined by cine and late gadolinium enhanced CMR with plasma levels of TNT and NT-pro BNP levels after AMI.

METHODS

We studied 44 patients (pts) with first ST- and non-ST-segment elevation myocardial infarction (STEMI=23 pts.,NSTEMI=21 pts.). We measured NT-pro BNP and cTnT on a single occasion at 96 hours after onset of symptoms.

RESULTS

There was a moderate inverse correlation between NT-pro BNP and LV-EF in STEMI (r=-0.67, p=0.0009) and NSTEMI (r=-0.85, p<0.0001). Likewise, cTnT showed a significant inverse correlation with LV-EF in STEMI (r=-0.54, p=0.014) but not in NSTEMI. With cTnT there was a strong linear correlation with infarct mass and relative infarct size in STEMI (r=0.92, p<0.0001) and NSTEMI (r=0.59, p<0.0093). NT-pro BNP demonstrated a good relationship with infarct mass (r=0.79, p<0.0001) and relative infarct size (r=0.75, p<0.0001) in STEMI, but not in NSTEMI.

CONCLUSION

A single NT-pro BNP and cTnT value at 96 hours after onset of symptoms proved useful for estimation of LV-EF and infarct size. In direct comparison, NT-pro BNP disclosed a better performance for estimation of LV-EF whereas cTnT was superior for assessment of infarct mass and relative infarct size, suggesting an implementation of a dual marker strategy for diagnostic and prognostic work-up.

Cardiac Troponin T at 96 Hours After Acute Myocardial Infarction Correlates With Infarct Size and Cardiac Function

OBJECTIVES

In clinical practice, myocardial infarct size can be estimated non-invasively by nuclear imaging techniques or contrast-enhanced magnetic resonance imaging (CE-MRI). Due to limited availability and high costs, serologic tests are frequently used as an alternative.

BACKGROUND

We examined the ability of a single value of cardiac troponin T (cTnT) 96 h after onset of ST-/non-ST-segment elevation myocardial infarction (STEMI/NSTEMI) to estimate absolute infarct mass.

METHODS

Functional and CE-MRI were conducted on a 1.5-T whole-body system 4 days after STEMI/NSTEMI using gadolinium (0.2 mmol/kg/bw). Infarct sizes were measured employing a specified software (Philips Medical Systems, Best, the Netherlands) and correlated with TnT measurements 96 h after onset of STEMI/NSTEMI.

RESULTS

We enrolled 23 STEMI and 21 NSTEMI patients. Median time delay from onset of symptoms to balloon angioplasty was 6.25 and 9.9 h for STEMI/NSTEMI patients, respectively. Contrast-enhanced magnetic resonance imaging (median 4 days) revealed an absolute mean infarct size of 16.2 g (7.7 to 30.1 g) with a mean ejection fraction of 58% (53% to 63%) and mean stroke volume of 84 ml (75 to 107 ml). Absolute infarct sizes and median cTnT values were larger in STEMI than in NSTEMI (29.3 g [interquartile range (IQR) 16.0 to 53.0] and 1.88 microg/l [IQR 0.7 to 2.57] vs. 8.8 g [IQR 3.3 to 16.4] and 0.83 microg/l [IQR 0.4 to 1.3], both p < 0.02). Linear regression analysis was excellent for STEMI (r = 0.910) and moderate albeit still significant for NSTEMI (r = 0.575).

CONCLUSIONS

A single 96-h cTnT value provides an accurate estimate of absolute infarct mass in myocardial infarction. The ability to quantify and the potential to distinguish effects of novel drug regimens on infarct size make cTnT attractive for routine practice and as a clinical end point.

Very early cardiac magnetic resonance imaging for quantification of myocardial tissue perfusion in patients receiving tirofiban before percutaneous coronary intervention for ST-elevation myocardial infarction

BACKGROUND

Assessment of myocardial blood flow is important for identification and monitoring of microvascular effects of glycoprotein IIb/IIIa inhibitors. Magnetic resonance imaging is a novel noninvasive method providing complementary information on myocardial blood flow and cardiac function.

METHODS AND RESULTS

Patients (n = 53) admitted within 12 (mean, 5.8) hours after onset of symptoms were randomized to tirofiban or standard therapy before primary percutaneous coronary intervention (PCI) with stenting. Myocardial blood flow was graded by measurement of corrected Thrombolysis in Myocardial Infarction frame counts and by semiquantitative analysis of signal intensity curves from first-pass contrast-enhanced magnetic resonance perfusion. Pretreatment with tirofiban proved safe and resulted in a significantly lower corrected Thrombolysis in Myocardial Infarction frame counts (21 vs 34, P = .008) indicating improved myocardial blood flow. Magnetic resonance imaging revealed higher normalized peak signal intensities (2.19 vs 1.63, P = .046) and a trend to steeper upslopes (0.79 vs 0.48, P = .1). Cardiac left ventricular wall motion analysis resulted in a significantly lower number of myocardial segments with abnormal wall thickening (6.4 vs 8.5, P = .025).

CONCLUSIONS

Pretreatment with tirofiban appears safe and improves myocardial flow after primary PCI with stenting. Magnetic resonance imaging proved useful as a complementary method for noninvasive assessment of myocardial blood flow and cardiac function in patients with ST-segment elevation myocardial infarction undergoing primary PCI.

[Decompressive craniectomy for severe intracranial hypertension due to cerebral infarction or meningoencephalitis]

We describe the clinical course and outcome following decompressive craniectomy in six patients. Five patients suffered from severe intracranial hypertension due to middle cerebral artery infarction. In one patient the cause was bacterial meningoencephalitis. Acute clinical and neuroradiological signs of intracranial hypertension were seen in all cases. Following ineffective conventional brain edema therapy, decompressive craniectomy was undertaken. In five cases intracranial pressure was sufficiently lowered. One patient developed transtentorial herniation with subsequent brain death. Four patients with middle artery infarction showed moderate neurological disorders and one patient with bacterial meningoencephalitis recovered completely after treatment. Craniectomy in malignant middle artery infarction should be taken into consideration if conventional brain edema therapy does not sufficiently reduce critically raised intracranial pressure. Craniectomy provides development of brain herniation. This treatment may reduce high lethality rate and high frequency of severe neurological disorders.