Monday, 1 September 2008 - European Heart Journal

Monday, 1 September 2008
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CAN WE PREDICT ATRIAL FIBRILLATION?
1603 Left atrial asynchrony is a major predictor of
recurrence of atrial fibrillation after electrical
cardioversion
G. Dell’era, E. Rondano, G. De Luca, C. Piccinino, G. Bellomo,
P.N. Marino on behalf of NAIF. University of Eastern Piedmont,
Cardiology, Novara, Italy
Background: Dispersed conduction due to atrial fibrillation (AF) is linked to cavity
remodelling and loss of filling and emptying properties, mostly consequence of
atrial fibrosis. The aim of the current study was to evaluate whether left atrial
asynchrony (LAS) is a predictor of recurrence of atrial fibrillation after electrical
cardioversion (EC)
Methods: Atrial volume was calculated from anteroposterior diameter and area
according to the formula: 4.2*diameter/ 2*area/2. 2D strain (speckle tracking technique)
was used to estimate peak and standard deviation (SD) of the time-to-peak
(% of R-R’ interval) of the deformation of 6 segments arbitrarily identified along the
septum, the roof and the lateral wall of the atrial cavity, as imaged in a 4-chamber
view. LAS was quantified according to the SD of the time-to-peak. Patients were
divided in quartiles according to the extent of LAS.
Results: A total of 130 patients undergoing electrical cardioversion for AF were
prospectively enrolled. LAS was linearly related with left atrial dimension (p =
0.052) and left ventricular mass (p = 0.073). No differences were observed between
the groups in terms of clinical and additional echocardiographic variables.
At 1 year follow-up a recurrence of atrial fibrillation was observed in 53.1% of
patients. LAS was linearly related with the rate of recurrence of atrial fibrillation
at 1 year follow-up (Figure). At multivariate analysis only LAS (OR [95 CI] = 1.49
[1.07-2.09], p = 0.019) and left ventricular end-diastolic volume (OR [95 CI] =
1.033 [1.004-1.062], p = 0.025) were identified as independent predictors of recurrence
of AF.
Conclusion: This is the first study showing that left atrial asynhrony before EC
is a major and independent predictor of recurrence of atrial fibrillation in patients
undergoing EC.
1604 Obstructive sleep apnea is an independent predictor of
recurrences after circumferential pulmonary vein
ablation for atrial fibrillation
M. Matiello, A. Berruezo, D. Tamborero, L. Mont, B. Daga, J. Brugada.
Hospital Clinic University, Arrhythmias Section, Barcelona, Spain
Obstructive Sleep Apnea (OSA) has been associated with atrial fibrillation (AF).
However, the efficacy of AF ablation in patients with this condition has not been
evaluated. The aim of this study was to evaluate whether OSA influence the ablation
outcome.
Methods: A series of 120 consecutive patients submitted to circumferential pulmonary
vein (CPVA) ablation were included in the study. All patients underwent
a complete echocardiographic and clinical evaluation, including body mass index
(BMI). Diagnosis of OSA was based on the results of the Berlin questionnaire. The
use of continuos positive airway pressure (CPAP) was also recorded. Follow-up
consisted of outpatient visits and 24-h Holter monitoring at one, four and seven
months, and every six months thereafter if the patient remained asymptomatic.
Any documented episode of AF or left atrial flutter presenting after the threemonths
blanking period was considered as a recurrence.
Results: OSA was diagnosed in 37 patients (30%). Of them, 12 (27%) were
diagnosed through a polisomnography, and 9 (24%) were under treatment with
CPAP. At one year follow-up, 36% of OSA patients were arrhythmia free against
67% of the remaining patients (p=0.005). Obesity and BMI were not related with
procedure failure. At the multivariable Cox analysis, anteroposterior left atrial diameter
(HR= 1.090, 95% CI 1.03-1.16; p=0.005) and OSA (HR= 2.20, 95% CI
1.14-4.26; p=0.019) were identified as independent predictors of arrhythmia recurrence.
Treatment with CPAP did not improve ablation results.
Conclusion: OSA is an independent predictor of CPVA failure.
Can we predict atrial fibrillation? 257
1605 Isolated atrial microvascular dysfunction in patients
with lone recurrent atrial fibrillation
E.I. Skalidis, M.I. Hamilos, I.K. Karalis, G. Chlouverakis, E. Pouli,
E. Koutalas, N.E. Igoumenidis, E.A. Zacharis, G.E. Kochiadakis,
P.E. Vardas. Heraklion University Hospital, Department of Cardiology,
Heraklion, Greece
Aim: Although acute atrial ischemia has been implicated in the pathogenesis of
atrial fibrillation, there are few data concerning human atrial myocardial perfusion
and none for patients with lone recurrent atrial fibrillation (LRAF). The purpose of
this study was to assess atrial myocardial perfusion in patients with LRAF.
Methods: Sixteen patients with LRAF and fifteen control subjects with suitable
coronary anatomy underwent time-averaged peak coronary blood flow velocity
measurements (APV cm/s), using a Doppler guidewire in the proximal left circumflex
coronary artery (LCx) and in the left atrial circumflex branch (LACB), at
baseline (b) and after adenosine administration to achieve maximal hyperemia
(h). Coronary flow reserve was defined as h-APV/b-APV.
Results: Although there were no statistically significant differences in b-APV
between patients with LRAF and control subjects nor between the LACB and
LCx, there were significant group (p=0.002), artery (p=0.001) and interaction
(p

258 Can we predict atrial fibrillation? / Thromboembolic risks and therapeutic approaches in atrial fibrillation
patients with paroxysmal AF, (11.90±4.79 ng/ml vs. 14.98±6.28 ng/ml, p=0.03
and 154.90±44.91 ng/ml vs. 129.75±37.92 ng/ml, p

Thromboembolic risks and therapeutic approaches in atrial fibrillation / Healthy bone marrow for a healthy heart 259
Conclusions: In patients with short-term AF TEE revealed left atrial thrombi in
1.4% and dense spontaneous echo contrast in 10% of patients. Patients with
TEE-guided cardioversion of short-term AF had an 8-fold reduced incidence of
stroke/death after 1 month than patients undergoing conventional approach without
TEE. Thus, in patients with AF < 48 hours, TEE-guided electrical cardioversion
might be useful to reduce the embolic risk.
1612 Beta-fibrinogen 455 G/A gene polymorphism is
associated with the left atrial thrombus and severe
spontaneous echo contrast in atrial fibrillation
V. Bozdemir, O. Kirimli, B. Akdeniz, A. Aslan, V. Kala, E. Ozel,
O. Senaslan, S. Guneri. Dokuz Eylul University Cardiology, Cardiology,
Izmir, Turkey
Purpose: The detection of genetically abnormalities related with the thrombogenic
factors may aid to determine the risk of thromboembolism and mechanism
of thrombus formation in atrial fibrillation (AF). In this study, we aimed to investigate
the effect of the presence of beta fibrinogen gene polymorphism or glycoprotein
IIIa gene polymorphism on the development left atrial (LA) thrombus or
spontaneous echo contrast (SEC) in patients with atrial fibrillation.
Methods: Forty-seven patients with persistent AF, which were scheduled for cardioversion,
in whom transesophageal echocardiography was performed for the
detection of LA thrombus and SEC were included in the study. Patients were divided
in two groups; those with LA thrombus or severe SEC (n=27) consisted to
group I and those without thrombus or severe SEC were in group II (n=20). All
patients were also evaluated in terms of mitral regurgitation (grading were made
according to ASE criteria) and presence of mild to moderate SEC and gene polymorphism.
DNA analysis was conducted to determine the beta-fibrinogen 455
G/A polymorphism and glycoprotein IIIa PlA1/A2 polymorphism, blood samples
were taken from the peripheral venous route.
Results: There were no significance difference regarding to demographic (age,
sex) and clinical characteristics (LA size, LVEF, the prevalence of hypertension,
diabetes etc.) between groups. The frequency of beta-fibrinogen 455 G/A polymorphism
was significantly higher (44.4%) in group I compared to group II (10%)
(p=0.01). Glycoprotein IIIa Pl A1/A2 polymorphism was not different between
groups (22.2% in group I and 25% group II; p=0.82). In patients with left atrial
thrombus, comparing to those without thrombus, mitral regurgitation score was
tend to be lower (p=0.08) and the prevalence of SEC (mild to severe) was found
to be significantly higher (p=0.03).
Conclusion: This cross-sectional study revealed that, beta-fibrinogen 455 G/A
gene polymorphism in patients with atrial fibrillation is associated with the presence
of left atrial thrombus and severe SEC, whereas the glycoprotein IIIa
PlA1/A2 polymorphism is not. Beta-fibrinogen 455 G/A gene polymorphism may
be a promising marker for the prediction of thromboembolism risk in patients with
atrial fibrillation.
1613 Prevalence and clinical impact of left atrial thrombus
and dense spontaneous echo contrast in patients with
atrial fibrillation and low CHADS2 score
T. Kleemann, T. Becker, M. Strauss, S. Schneider, K. Seidl.
Herzzentrum Ludwigshafen, Medizinische Klinik B, Ludwigshafen,
Germany
Aim of the study was to evaluate the prevalence and clinical impact of left atrial
thrombus and dense spontaneous echo contrast (SEC) in patients with atrial fibrillation
(AF) and low CHADS2 score.
Methods and results: A total of 295 consecutive patients with nonvalvular AF
and a CHADS2 score of 0 or 1 from the prospective single center registry ANTIK
who underwent transoesophageal echocardiography (TEE) before cardioversion
were analysed. Median follow-up was 5 years. Left atrial thrombus was present in
3% and dense SEC in 8% of patients.
Independent predictors for the presence of thrombus or dense SEC were ejection
fraction (EF) < 40% and left atrial diameter > 50mm. In anticoagulated patients
thrombus and dense SEC were not independently associated with an increased
risk for stroke or death during the 5-year follow-up (OR 1.73, 95% CI
0.65-4.63).
Table 1. Clinical characteristics of patients with AF and CHADS2 score of 0/1: left atrial thrombus
or dense SEC versus no thrombus/SEC
Thrombus or dense SEC No thrombus and no dense SEC p-value
(n=30) (n=265)
Age (years) 62 (55-72) 61 (54-68) 0.23
Male 77% 78% 0.86
NYHA II+ 50% 21% 0.01
Hypertension 23% 31% 0.41
Diabetes 3% 0.8% 0.18
EF < 40% 30% 11% < 0.01
LA dimension > 50mm 30% 8% < 0.001
LVEDD > 60mm 11% 7% 0.56
Conclusions: Despite a low CHADS2 score of 0/1 3% of patients have left atrial
thrombus and 8% dense SEC. Independent predictors for the presence of thrombus
and dense SEC were EF < 40% and left atrial dimension > 50mm. Thus,
echocardiography might be a useful tool for further risk stratification in patients
with low CHADS2 score.
1614 Thromboembolic risk assessment in persistent atrial
flutter: is it different from atrial fibrillation? A singlecenter
TEE study on 483 consecutive patients
A. Cresti, G. Miracapillo, F. Cesareo, A. Costoli, L. Addonisio,
S. Severi. Division of Cardiology, Misericordia Hospital, Cardiology,
Grosseto, Italy
Objectives: despite a lack of clear evidence, risk assessment and embolic prophylactic
treatment of atrial flutter (AFL) is similar to that of atrial fibrillation (AF).
Recent studies evidenced lower embolic risk in AFL and Transesophageal Echocardiography
(TEE) has been recently considered redundant before cardioversion
(CV) in unselected pts. Aim of our study was to evaluate the presence of auricular
thrombosis risk by TEE in a large series of AFL pts.
Methods: in the period 2000-07, 483 consecutive pts, referred for multiplane TEE
before medical or electrical CV for AF (Group 1, N=382, 79%) or AFL (Group 2,
N=101, 21%), were included. Basal clinical characteristics were the following:
male 60%, mean age 70±10 yrs, hearth disease: valvular 49.4%, hypertensive
25%, ischemic 18.5%, idiophatic dilatative 5.4%, others 1.7%; EF 50±11%, left
ventricular end diastolic diameter (LVED) 52±6 mm, left atrial parasternal diameter
(LA) 49±7 mm, history of cerebral accidents 5.2%, type of arrhythmia: persistent
85.3%, paroxysmal 4.8%, permanent 9.9%. Anticoagulation was recommended
according to standard protocols. Thrombosis risk assessment was evaluated
according to the presence of left or right atrial thrombus, severe spontaneous
echocontrast (SSE) in the left atrium or in the auricle and left atrial appendage
Doppler velocities (LAADV) < 20 cm/sec.
Results: TEE was performed in all pts without complications. Basal clinical
characteristics of Group 1 (AF) vs Group 2 (AFL) were the following: male
56 vs 75%(p=0.000), mean age 69±10 vs 72±9 yrs (p=0.005), EF 52±11 vs
46±11%(p=0.002), LVED 52±6 vs53±7mm (p=0.54), LA 49±7 vs48±6 mm
(p=0.34), hearth disease: valvular 50.8 vs 44.7%(p=0.59), hypertensive 26.9
vs 18.4%(p=0.33), ischemic 14.6 vs 31.6%(p=0.04), idiophatic dilatative 6.2 vs
2.6%(p=0.39), others 1.5 vs 2.6%(p=0.67); history of cerebral accidents 5.8 vs
3.0%(p=0.26); type of arrhythmia: persistent 82.4 vs 95.9%(p=0.29), paroxysmal
5.4 vs 2.7%(p=0.36), permanent 12.3 vs 1.4% (p=0.009); LAADV: 36.1±15.8 vs
46.1±10.8 cm/sec (p=0.000). Thrombosis risk factors of Group 1 vs Group 2 resulted
respectively: presence of left or right atrial thrombus 9.8 vs. 2.0%(p=0.012),
SSE in the left atrium or in the auricle 4.6 vs 3.0%(p=0.49), LAADV

260 Healthy bone marrow for a healthy heart
MI and left ventricular dysfunction. This may contribute to a better outcome after
acute event.
1632 Vascular oxidative stress inhibits mobilization of
circulating stem cells with endothelial progenitor
capacity in mice
T. Suvorava1 ,S.Kumpf1 ,V.Adams2 ,G.Kojda1 . 1Heinrich Heine
University, Institute of Pharmacology, Duesseldorf, Germany;
2University of Leipzig, Heart Center Leipzig, Leipzig, Germany
Purpose: The number of circulating stem cells with endothelial progenitor capacity
(EPCs) was reported to inversely correlate with the number of cardiovascular
risk factors and is reduced in cardiovascular disease. Despite recent advances
in EPC studies, the molecular mechanisms of EPC mobilization remain unclear.
We sought to investigate the effects of increased vascular oxidative stress on
exercise-induced EPCs mobilization.
Methods: Transgenic mice with a vascular-specific overexpression of catalase
and reduced vascular levels of oxidative stress (cat++) and their transgene negative
littermates (catn) were assigned to a sedentary group and a group undergoing
moderate forced exercise training (15 m/min, 30 min, 5 days a week, 3
weeks). The number of EPCs in peripheral blood was measured by Fluorescence-
Activated Cell Sorting (FACS) using anti-mouse CD3, Flk-1 and CD34, CD133 or
Sca-1 antibodies. Additionally, the effects of different amounts of physical activity
on EPC mobilization were investigated in sedentary (singularized), freely moving
(6 mice per cage), voluntary (9.8±0.7 km/night) and forced (15 m/min, 5 days, 30
min/day) running C57BL/6 mice.
Results: There was no difference in circulating EPCs between sedentary and
freely moving C57BL/6 mice (p>0.05, n=5). Three weeks of forced exercise training
failed to mobilize EPCs defined as double positive for Flk-1 and CD34 or more
immature hematopoeitic stem marker CD133 (p>0.05, n=5-9). Similarly, the number
of EPCs was not different between sedentary and voluntary exercised groups
(n=5-8, all p>0.05). FACS analysis of cat++ and catn peripheral blood revealed no
effect of catalase overexpression on the basal level of circulating EPCs (p=0.68,
n=8). Inhibition of catalase by 3 week treatment with catalase inhibitor aminotriazole
(670 mg/kg in drinking water) strongly reduced the number of endothelial progenitors
in blood of sedentary catn, and to a lesser extend also in cat++(p

Healthy bone marrow for a healthy heart / Exercise testing in athletes: new answers from an old test 261
1636 Modifications of reticulocytes and reticulated platelets
in sedentary healthy men after an acute episode of
strenuous exercise
F. Cesari 1 ,F.Sofi 2 , A. Capalbo 1 , N. Pucci 1 ,A.M.Gori 1 , R. Caporale 3 ,
A. Fanelli 3 ,R.Abbate 1 ,G.F.Gensini 1 . 1 University of Florence, Med.
& Surgical Critical Care, Florence, Italy; 2 University of Florence, Faculty of
Medicine, Med. & Surgical Critical Care, Thrombosis Cen., Florence, Italy;
3 Azienda Ospedaliero-Universitaria Careggi, Central Laboratory, Florence, Italy
Introduction: Exercise is considered a physiological stimulus for cells’ release by
the bone marrow. In particular, maximal exercise, carried out under hypoxic conditions,
has been reported to determine reticulocytes’ release, probably due to
the augmented levels of erythropoietin. We aimed to investigate whether physical
exercise can determine, together with reticulocytes, also the release of reticulated
platelets (RP), immature and more reactive platelets that reflect platelet production
from megakariocytes.
Methods: Haematological parameters (red blood count, white blood count,
haematocrit, haemoglobin, platelets), reticulocytes, and RP were measured in
20 healthy sedentary men (median age: 34 years) by using the Sysmex XE-
2100 haematology analyzer (Sysmex, Kobe, Japan). Reticulocytes and RP were
counted according to the measurement of scatter and RNA content was analyzed
using oxazine. The reticulocytes’ fractions with low (L), medium (M), and high (H)
RNA contents were assessed, the M and H fraction being immature reticulocytes.
All subjects performed a maximal incremental graded treadmill test and blood
samples were drawn before (T0), at the end (T1), and 30 minutes after the test
(T2).
Results: All the haematological parameters showed a significant (p=0.002) increase
at T1 with respect to T0, by returning similar to baseline at T2. Reticulocytes
demonstrated a significant trend of increase at T1 with respect to T0
[52,650 (35,900-99,500) vs. 51,000(26,800-105,000) ret/microL; p

262 Exercise testing in athletes: new answers from an old test
The amplitude and duration of the P, Q, R, S, and T waves was measured. Specific
note was made of the presence of deep (>-0.2mV) T-wave inversions (excluding
V1, aVr, isolated III or isolated aVl), pathological q waves (> 40 ms in
duration and > 25% of the height of the proceeding R wave). The Romhilt-Estes
points’ score and Sokolow-Lyon voltage criterion for LVH were calculated in each
athlete.
Results: None of the athletes exhibited features consistent with HCM at echocardiography.
Of the 1719 males, 35 (2%) exhibited deep T wave inversions, 15
(0.9%) showed q waves and 172 (10%) fulfilled the Romhilt-Estes points score of
≥ 5 to indicate LVH. In contrast, none of the females demonstrated deep T wave
inversions, pathological q waves or the Romhilt-Estes points score ≥ 5. Males
exhibited a significantly higher prevalence of the Sokolow-Lyon voltage criterion
for LVH compared with females (41.9%vs 14.7%; p

NEW PROGNOSTIC MARKERS IN ACUTE
CARDIAC CARE
1643 Impact of anemia and reduced left ventricular ejection
fraction on in-hospital outcome of acute coronary
syndromes. Euro heart survey ACS III registry
(2006-2007)
W. Wojakowski1 , M. Tendera1 , M. Tubaro2 ,M.Gierlotka3 , H. Bueno4 ,
B. Lindahl5 , M. Hochadel6 ,Y.Hasin7 , J.P. Bassand8 ,A.K.Gitt6 .
1 2 3 Katowice, Poland; III Division of Cardiology, Rome, Italy; III Division of
Cardiology, Zabrze, Poland; 4III Division of Cardiology, Madrid, Spain; 5III Division
of Cardiology, Uppsala, Sweden; 6III Division of Cardiology, Ludwigshafen,
Germany; 7III Division of Cardiology, Haifa, Israel; 8Besancon, France
Aim: of the study was to examine the impact of anemia and reduced left ventricular
ejection fraction (LVEF) on in-hospital outcome in acute coronary syndromes
(ACS).
Methods: Euro Heart Survey on Acute Coronary Syndromes analyzed 6498
patients (69% males) admitted across Europe in 2006-2007 with diagnosis of
ACS [56.4% NSTE-ACS (29.6% NSTEMI, 26.8% unstable angina) and 43.6%
STEMI/LBBB]. LVEF was assessed during hospitalization in 93% of patients.
Results: LVEF was normal in 57.1% pts, slightly reduced in 22.5%, moderately
reduced in 13.5% and severely reduced in 6.9% of pts. Anemia (Hb

264 New prognostic markers in acute cardiac care / Resuscitation resuscitated!
Conclusion: Patients presenting with acute dyspnea at the ED, with a positive
cTnT were at a very high risk of in-hospital death. Cardiac troponin T positivity
was an independent predictor of in-hospital death, whereas NT pro-BNP was not.
1647 N-terminal pro-B-type natriuretic peptide changes in
patients with acute coronary syndromes
K. Shreyder, R. Shakhnovich, E. Bosikh, M. Ruda. National Cardiology
Research Center, Intensive Cardiology, Moscow, Russian Federation
The purpose of the study was to determine NT-proBNP dynamics in
different treatment strategies in patients with acute coronary syndromes (ACS).
Materials and methods: 52 patients with ST-elevation myocardial infarction
(STEMI) and 61 patients with non-ST-elevation ACS (NSTACS) were included
into the study. NT-proBNP was measured in admission, on the 3d day and before
discharge (7-12 days).
Results: In NSTACS baseline concentration of NT-proBNP was higher than
in STEMI group (751,1 vs. 449,9pg/ml, p=0,05). NT-proBNP level increases
markedly in STEMI during hospitalization and achieves peak at discharge. In
NSTACS baseline concentration of NT-proBNP is the highest and decreases towards
discharge (figure). In STEMI patients with pre-hospital thrombolysis baseline
NT-proBNP level is lower than in cases with in-hospital treatment (140,9 vs.
543,1 pg/ml, p=0,05). The peak concentration of NT-proBNP at discharge was
in the facilitated PTCA group, when compared with pre-hospital thrombolysis, inhospital
thrombolysis and primary PTCA. NT-proBNP was lower in patients with
reperfusion before 4 hours than in cases with later reperfusion (1150,5 vs 2130,2
pg/ml, p

CI 0.2-1.6, p=0.32) after epinephrine and atropine (compared with epinephrine).
On the other hand, the epinephrine and atropine group had significantly higher
rate of return of spontaneous circulation (ROSC) than the epinephrine group
(35% vs. 23%, p

266 Resuscitation resuscitated! / Risk assessment: strengths and weaknesses
resuscitated from cardiac arrest and those without this complication. The higher
mortality rate among resuscitated patients is explained by noncardiac complications.
RISK ASSESSMENT:
STRENGTHS AND WEAKNESSES
1762 Aortic augmentation index: reference values and
association with known cardiovascular risk factors in a
Danish population
J.H. Janner1 , N.S. Godtfredsen2 , P. Lange1 ,J.Vestbo1 ,E.Prescott2 .
1Hvidovre University Hospital, Cardiology and Respiratory Medicine,
Copenhagen, Denmark; 2Bispebjerg University Hospital, Department of
Respiratory Medicine, Copenhagen, Denmark
Background: It has been proposed that aortic augmentation index (AIx) – a measure
of arterial wave reflection – can be used as a surrogate measure of arterial
stiffness. In a selected patient group (end stage renal disease) AIx has been
shown to be a predictor of all-cause mortality. AIx has also been shown to predict
cardiovascular events in patients with hypertension and patients undergoing PCI.
Studies of reference values of AIx are scarce.
Objective: 1) To report reference values of AIx in a population at low risk of CVD
according to Heartscore. 2) To investigate the association between AIx and known
CVD risk factors in a large cohort of the Danish population.
Methods: This population-study is based on 4700 subjects from the Copenhagen
City Heart Study. In those with the lowest risk of CVD as defined by Heartscore
we analysed AIx adjusted for heart-rate and its dependency of sex, age and
height using linear regression. Multivariate linear regression was used to examine
the association between AIx and the following risk factors for CVD – systolic
and diastolic blood pressure, total-cholesterol, LDL cholesterol, HDL cholesterol,
triglycerides, high-sensitive C-reactive protein (hs-CRP), smoking status, years of
smoking, alcohol consumption, diabetes, medication for hypertension, heart disease
or high cholesterol, physical inactivity, familiar history of CVD and education.
All analyses were stratified by sex.
Results: AIx was positively associated with age and negatively with height in
those with lowest risk of CVD in the following manner: Woman: AIx = 26.56 +
0.76 (age) – 0.004 (age 2 ) – 0.19 (height (cm)). Men: AIx = 59.52 + 0.42 (age)
– 0.38 (height (cm)). We found increasing AIx with increasing risk of CVD as
defined by the Heartscore index. In the multivariate analyses AIx was positively
associated with systolic and diastolic blood pressure, hs-CRP and current smoking
and – negatively with weight for both sexes, and positively associated with
total cholesterol for men only. AIx was not associated with other CVD risk factors,
including diabetes.
Conclusions: We propose a novel equation including age, height and sex to
calculate reference values for AIx - based on a large general population sample
with low risk of CVD. AIx is highly dependent on age and both systolic and
diastolic blood pressure, positively associated with hs-CRP and current smoking.
This study is the largest to date evaluating the association between AIx and
known CVD risk factors. We plan to examine AIx as independent predictor for cardiovascular
events and mortality in the Copenhagen City Heart Study – a cohort
with low risk of CVD.
1763 Increased cardiovascular mortality in women with
normal weight obesity
A. Romero-Corral1 , V.K. Somers1 , S. Boarin 2 , J. Sierra-Johnson3 ,
Y. Korenfeld4 , J. Korinek4 , G. Parati 5 , F. Lopez-Jimenez1 . 1Mayo Clinic, Cardiovascular, Rochester, United States of America; 2Mayo Clinic and Istituto Auxologico Italiano, Cardiovascular, Milan, Italy; 3Mayo Clinic
and Karolinska Institute, Cardiovascular, Stockholm, Sweden; 4Mayo Clinic,
Cardiovascular, Rochester, United States of America; 5Istituto Auxologico
Italiano, Cardiovascular, Milan, Italy
Background: We hypothesized that subjects with normal weight obesity (NWO),
defined as those with normal BMI but high body fat (BF) content, in whom we
have previously reported a higher prevalence of metabolic syndrome and cardiovascular
(CV) risk factors, are at higher risk for total and CV mortality.
Methods: We analyzed 2,127 subjects ≥ 20 years of age from the Third National
Health and Nutrition Examination Survey (NHANES III) and mortality study with
normal BMI (18.5-24.9 kg/m 2 ), body composition assessment, fasting morning
blood measurements and CV risk factors data. Survival information was available
for all subjects after 8.7 years of follow-up. We divided our sample into three
groups: low BF (35% in women), defined as NWO. We compared total and
CV mortality across groups.
Results: NWO comprised ∼20% of all subjects with a normal BMI. Table displays
the total and CV mortality rate in men and women according to BF. As BF
increased in men, there was a non-significant increased risk for total and CV mortality.
However, as BF increased in women, there was a significant increased risk
for total and CV mortality. When compared to the low BF group, NWO women
showed a trend towards higher total mortality (HR=1.52; 95%CI, 0.83-2.77), and
after adjustment for age, dyslipidemia, hypertension, diabetes, CV disease and
Total and cardiovascular deaths by BF
Men (n=1,1036) Body fat 25% Age and race adjusted
(n=378) (n=400) (n=248) p-value for trend
Total deaths 39 (5.63%) 42 (6.36%) 37 (12.5%) 0.21
Cardiovascular deaths 15 (2.52%) 20 (2.63%) 13 (4.94%) 0.59 †
Women (n=1,101) Body fat 35%
(n=428) (n=427) (n=246)
Total deaths 20 (3.03%) 31 (5.55%) 22 (8.25%) 0.038
Cardiovascular deaths 5 (0.87%) 12 (2.12%) 12 (4.37%)* 0.044 †
*p-value

Risk assessment: strengths and weaknesses / Prognosis in heart failure: surveys and clinical markers 267
11 European countries and represents over 2.7 million person years of observation,
of these 6,687 from 5 countries were aged 65 or over. Cox proportional hazards
model was used to derive SCORE ELD. Only data from those aged ≥65 were
used and the following variables were included: age, TC, SBP, smoking, HDL-C.
The baseline survival was calculated separately in men and women and in high
and low risk countries. The performance of the two functions was compared using
AUROC (area under receiver operated curve) and NRI (net reclassification
indices), sensitivity, specificity and goodness of fit. The performance of SCORE
ELD was also compared to that of the Framingham function (CVD version, 2008).
Results: AUROC for SCORE ELD was 0.73, superior to that of Framingham
(0.68, p 10%) by the
SCORE high risk chart, are not at high risk according to the Dutch equation. On
the other hand, 80% of those identified to be at high risk by the Dutch equation,
are not identified by the SCORE low risk charts.
Classification by diff. risk equations
SCORE high risk Dutch equation SCORE low risk
< 5% 5-10% > 10% < 5% 5-10% > 10%
30,277 1509 0 < 5% 31,786 0 0
4 645 292 5–10% 653 288 0
0 1 210 > 10% 1 170 40
Conclusions: The number of Dutch patients eligible for drug therapy is overestimated
by SCORE risk charts for high risk regions and underestimated by SCORE
risk charts for low risk regions. This illustrates the need for the use of proper risk
equations in primary prevention of CVD.
1767 Body mass index and total mortality
A. Dudina, M.T. Cooney, I.M. Graham on behalf of SCORE
investigators. Dublin, Ireland
Purpose: The SCORE data set comprises data from 12 European cohort
studies. There were 205 178 persons (88 080 women and 117 098
men) representing 2.7 million person years of follow-up. Data on BMI was available
for 110,902 men and 84,451 women. These data are sufficiently powered
to allow detailed examination of relationships between body weight and prognosis.
We have previously reported the relationship with cardiovascular mortality,
but relation with total mortality may be of more public health importance. We now
examine this aspect.
Methods: The relationship between increasing BMI and total mortality was examined
using Cox proportional hazards model. Hazard ratios were calculated for
each body mass index (BMI) category (under 20, 25-30, 30-35, 35-40 and over
39), compared to normal weight (20-25), for the total mortality endpoint. Analyses
were performed separately in men and women and stratified by country.
The following covariates were introduced into the model in a stepwise manner:
age, smoking, systolic blood pressure (SBP), total cholesterol, diabetes and HDL-
Cholesterol (HDL-C).
Results: The table shows that after adjustment for age and current smoking, BMI
was strongly related to total mortality, especially in women. This relationship was
attenuated by adjustment for cholesterol, systolic blood pressure and diabetes.
Further adjustment for HDL-C resulted minor further attenuation but BMI greater
than 35 remained significant.
Table 1. HR for total Mortality in BMI
BMICategory Males Females
Age, smoking +chol, SBP, diabetes Age, smoking +chol, SBP, diabetes
adjustment adjustment adjustment adjustment
Underweight 40 2.06*** 1.48* 2.39*** 1.79***
HR: Hazard Ratio; BMI: Body Mass Index; ***p

268 Prognosis in heart failure: surveys and clinical markers
the AF group (46.7%) and 11,737 deaths in the SR group (32.3%). As shown
in the figure, meta-analysis of these 13 studies demonstrated an adverse effect
of AF on mortality in these 42,510 patients, with a hazard ratio of 1.29 (95% CI
1.26-1.33; p

Prognosis in heart failure: surveys and clinical markers / Prognostic predictors in acute heart failure 269
in patients post-AMI and in HF. RFP represents an important prognostic marker
among patients with diabetes and cardiovascular disease.
PROGNOSTIC PREDICTORS IN ACUTE
HEART FAILURE
1778 Relationship between body weight change following
hospital discharge and risk for death/rehospitalization:
an EVEREST analysis
M. Gheorghiade1 , C. Zimmer2 , J. Burnett3 ,L.Grinfeld4 ,
A.P. Maggioni5 , K. Swedberg6 , F. Zannad7 , G.C. Fonarow 8 ,T.Cook9 ,
M. Konstam10 on behalf of the EVEREST Investigators. 1Northwestern University, Chicago, United States of America; 2Otsuka Maryland Research
Institute, Rockville, United States of America; 3Mayo Clinic, Rochester, United
States of America; 4TANGO, Buenos Aires, Argentina; 5ANMCO Research
Center, Firenze, Italy; 6Sahlgrenska University Hospital, Goteborg, Sweden;
7 8 CIC-INSERM-CHU, Toul, France; UCLA, Los Angeles, United States of
America; 9University of Wisconsin SDAC, Madison, United States of America;
10Tufts New England Medical Center, Boston, United States of America
Purpose: In patients with chronic heart failure (HF), increases in body weight
(BW) have been shown to begin several weeks prior to hospitalization, and may
identify a period during which intervention may be beneficial. We explored the
relationship between change in BW and subsequent risk for all-cause mortality/cardiovascular
(CV) re-hospitalization following hospitalization for worsening
HF in the EVEREST trial.
Methods: The EVEREST trial randomized 4133 patients (EF

270 Prognostic predictors in acute heart failure / Restenosis: is there an alternative to drug-eluting stents?
the degree of oedema showed no correlation to the duration of dyspnea prior to
presentation (r=-0.168, p=0.393).
Conclusion: Lower extremity oedema in ADHF is not primarily caused by an
elevation of the hydrostatic pressure as depicted by the CVP but might mirror
disease severity depicted by BNP levels. Interestingly, the extent of lower oedema
can not be used as a bedside measurement of disease severity.
1782 Prognostic value and changes in renal function in
patients admitted with acute heart failure - results from
the EVEREST program
J. Blair 1 , J.C. Burnett2 ,M.A.Konstam3 , L. Grinfield4 , A.P. Maggioni5 ,
K. Swedberg6 ,J.E.Udelson3 , F. Znnad7 ,T.Cook8 , M. Gheorghiade1 on behalf of the EVEREST investigators. 1Northwestern University, Internal
Medicine, Division of Cardiology, Chicago, United States of America; 2Mayo Clinic, Rochester, United States of America; 3Tufts New England Medical Center,
Boston, United States of America; 4Hospital Italiano, Buenos Aires, Argentina;
5 6 Associazione Nazionale Medici Cardioligi, Florence, Italy; Sahlgrenska
University Hospital/Oestra, Gothenburg, Sweden; 7INSERM, Nancy, France;
8University of Wisconsin, Madison, United States of America
Introduction: The prognostic value of admission and changes in renal function
has not been well studied in patients admitted with acute heart failure.
Methods: EVEREST was a prospective, international, placebo controlled trial
evaluating the effects of tolvaptan, an oral vasopressin antagonist, in pts admitted
with worsening heart failure and LVEF £ 40%. Pts with a Cr > 3.5 mg/dL or on
hemodialysis were excluded. Pts were receiving standard medical therapy including
ACE inhibitors/ARBs, beta blockers, and diuretics. The 4133 enrolled patients
were grouped into quartiles of baseline BUN, Cr, eGFR, and BUN/Cr ratio, and
outcomes for each quartile were reported. BUN and Cr levels were obtained during
hospitalization and over the course of the study (median 9.9 months)
Results: After adjustment for non-renal baseline characteristics (age, race, SBP,
EF, beta blocker use, geographic region, BNP, and QRS), all four measures of
renal function were highly predictive of 3-month and 1-year mortality (p 24 mg/dL) was 47% on admission,
53% at discharge, and 39% at one year. Similarly, the percentage of pts with
abnormal Cr (>1.1 mg/dL) was 39% on admission, 41% at discharge, and 39%
at one year.
One Year Unadjusted Mortality
Quartile BUN Cr eGFR BUN/Cr
Range Mortality Range Mortality Range Mortality Range Mortality
1 ≤20 16.3% ≤1.0 16.8% >75 16.4% ≤17 19.7%
2 21-26 17.4% 1.0-1.3 21.1% 59-75 21.1% 18-21 21.7%
3 27-35 27.2% 1.4-1.6 29.6% 44-58 26.1% 22-25 24.6%
4 >35 42.8% >1.6 40.3% ≤44 39.2% >25 37.2%
Conclusion: In pts admitted with acute heart failure and reduced LVEF, baseline
renal dysfunction is common, tended to worsen during hospitalization, and is an
independent predictor of short- and long- term mortality.
1783 The presence of an S3 is associated with an increase
rate of all- cause-mortality after one year
M. Potocki, T. Breidthardt, T. Klima, M. Noveanu, T. Reichlin, K. Laule,
C. Stelzig, T. Boldanova, M. Christ, C. Mueller. University Hospital,
Internal Medicine, Basel, Switzerland
Purpose: The S3 heart sound has been shown to be diagnostic in patients presenting
with acute decompensated heart failure (ADHF). We investigated the utility
of the S3 heart sound to predict one year all-cause-mortality in patients presenting
with dyspnea to the emergency department (ED).
Methods: We analyzed the data of 287 consecutive patients with dyspnea enrolled
from April 2006 to March 2007 in our emergency department. The patients
received a clinical evaluation with an S3 evaluation by Audicor ® (Inovise Medical,
Inc, Portland, USA). The diagnosis of ADHF was adjudicated by two independent
cardiologists using all available clinical data including BNP.
Results: Audicor ® results were available in 275 patients. The mean age was
74±12 years and 52% were male. The median follow-up time was 372 days
[IQR 153-430 days]. Hypertension, coronary artery disease, chronic kidney disease
and diabetes was present in 183 (67%), 75 (27%), 72 (26%) and 51 (19%).
ADHF was the adjudicated final diagnosis in 145 patients (53%). Median BNP levels
were significantly higher in patients with an S3 compared to patients without
S3 detection (1081 vs. 263pmol/L, p < 0.001). In the Kaplan-Meier and log-rank
analyses, those patients with an S3 detected had a significantly higher one year
mortality compared to the patients without an S3 (37% vs. 23%, p = 0.046). The
sensitivity, specificity, positive and negative predictive value, and diagnostic accuracy
of an electronic S3 for detection of ADHF were 26%, 92%, 79%, 53% and
57% and for an S3 detected by physician auscultation 9%, 99%, 93%, 49% and
52%. The odds ratio for one year mortality was 2.02 (p = 0.036) for the electronic
detection of an S3, whereas S3 detection by physician failed to reach statistically
significance.
Conclusions: The presence of an electronically detected S3 is a significant predictor
of one year mortality in patients presenting with dyspnea to the emergency
department. The detection of S3, both by auscultation or by electronical devices,
is highly specific for the diagnosis of ADHF and may improve early diagnostic
accuracy in the emergency department.
RESTENOSIS: IS THERE AN ALTERNATIVE TO
DRUG-ELUTING STENTS?
1784 Oral cilostazol prevents restenosis and repeat
revascularization after percutaneous coronary
stenting: A meta-analysis of 15 randomized trials and
4897 patients
G. Biondi-Zoccai1 ,C.Moretti1 , M. Lotrionte2 , P. Agostoni3 ,F.Sciuto1 ,
P. Omede1 , A. Abbate4 ,G.Trevi1 , I. Sheiban1 . 1Turin, Italy; 2Rome, Italy; 3Antwerp, Belgium; 4Richmond, United States of America
Purpose: Drug-eluting stents reduce the risk of restenosis after percutaneous
coronary intervention (PCI), but may pose a risk of thrombosis. Cilostazol, an oral
antiplatelet agent with pleiotropic effects including inhibition of neointimal hyperplasia,
could hold the promise of preventing both restenosis and thrombosis. We
systematically reviewed randomized clinical trials on the angiographic and clinical
impact of cilostazol after percutaneous coronary stenting.
Methods: Pertinent randomized trials were searched in BioMedCentral, CEN-
TRAL, clinicaltrials.gov, EMBASE, and PubMed (January 2007). Co-primary
end-points were binary angiographic restenosis and repeat revascularization,
abstracted and pooled by means of random-effect relative risks (RR). Small
study/publication bias was appraised with multiple methods.
Results: A total of 15 randomized clinical trials were included (4897 patients,
2453 randomized to oral cilostazol for 1-6 months, and 2444 randomized to control
therapy or placebo), with median follow-up of 6 months. Pooled analysis
showed that cilostazol was associated with statistically significant reductions in binary
angiographic restenosis (18.8% for cilostazol vs 26.8% for control, RR=0.60
[0.49-0.73], p

Restenosis: is there an alternative to drug-eluting stents? / Confonding factors influencing outcome after stenting 271
1786 Comparison of efficacy of low (80mg) and high-dose
(160-320mg) valsartan in the prevention of in-stent
restenosis after implantation of bare-metal stents in
type B2/C lesions
S. Peters. Klinikum D. Erxleben Quedlinburg, Innere Medizin I -
Kardiologie, Quedlinburg, Germany
The VALVACE trial suggests that prevention of in-stent restenosis after implantation
of bare-metal stents in type B2/C lesions is possible by administration of
80mg valsartan. A 1:1 matched comparison to higher dosage valsartan (160-
320mg) was initiated in a prospective controlled registry on a case-controlled
basis. 450 patients (241 males, mean age 62.7±9.1 years) with matched demographic
and angiographic characteristics to patients of the VALVACE trial were
treated with high-dose valsartan (160 to 320mg) over 6 months until control angiography.
Angiographic restenosis rate, TLR and TVR rates, MACE rate (death,
myocardial infarction and stent thrombosis) and mean lumen late loss were analysed
after 6 months. Results were compared to the results of the VALVACE
trial. In the whole collective with vlasartan at different doses gender- and dosedependancy
was analysed. In the high-dose group angiographic restenosis rate
in 368 patients with control angiography was 7.3% in comparison to 19.5% in the
low-dose group (VALVACE) with a p value < 0.0001. Mean lumen late loss was
0.37±0.3 mm and in VALVACE 0.53±0.31% (p < 0.01). TLR and TVR rate was
4.3% in comparison to 9% (p < 0.01) and MACE rate was 0% in comparison to
1.5% (p < 0.01). Taking all data with valsartan together in-stent restenosis rate
in males was 23.8% under 80mg, 13.6% under 160mg, 5.7% under 240mg and
4.9% under 320mg. In females restenosis rate was 13.3% under 80mg and 6.3%
under 160mg; no restenosis appeared under higher doses. High-dose administration
of oral valsartan after bare-metal stent implantation in type B2/C lesions
is able to reduce angiographic in-stent restenosis rate, TLR and TVR rate, late
lumen loss and MACE rate more effectively than low-dose (80mg) valsartan.
1787 Do we need DES in all patients? Results of a strategy
combining a simple selection process and the use of
thin strut cobalt chromium bare metal stents
P. Stella, H. Nathoe, S. Hoseyni, T. Wildbergh, H. Meijburg, E. Van
Belle. University Medical Center, Cardiology, Utrecht, Netherlands
Background: The introduction of drug eluting stents (DES) has been a breakthrough
in the prevention of restenosis following PCI. However, the high rates of
late stent thrombosis observed with these devices make alternative preventive
strategies mandatory. The use of thin struts cobalt chromium (TSCC) bare metal
stents has been associated with promising clinical results. We hypothesized that
the use of a strategy combining a simple selection of clinical indications and the
use of TSCC BM stents could achieve very low restenosis rates without compromising
safety.
Methods: From September 2005 to June 2006, among patients referred for a PCI
procedure in our centre, we prospectively selected those in which at least one of
the 2 inclusion criteria was met: 1) de novo coronary lesion not exceeding 20
mm in length; 2) vessel diameter more than 2.6 mm; and excluded 3) those with
diabetes mellitus unless vessel diameter > 3.5 mm; to undergo implantation of
TSCC bare metal stents. Twelve months follow-up was obtained in all patients.
Results: 511 patients; 30% of the total population referred for PCI; matched the
selection criterions and were part of the study. Despite the selection process, the
study population was at relatively high risk including 22% of patients with a history
of MI, 50% with multivessel coronary artery disease and 59% undergoing PCI for
an acute coronary syndrome.
A single TSCC MB-stent was implanted in 88% of patients. The procedural success
rate was 99.6%. A peri-procedural myocardial infarction occurred in 7 (1.4%)
patients.
Clinically driven TLR and TVR at 12 months were observed in 8 (1.6%) and 13
(2.5%) patients, respectively. Cumulative In stent-thrombosis at 1 and 12 months
occurred in 4 (0.08%) and 6 (0.1%) patients, respectively.
Conclusion: Our results demonstrate that a simple selection process, applying
to 30% of a routine PCI population, combined with the use of TSCC bare metal
stents can be associated with a very favourable long-term clinical outcome. The
use of TSCC bare metal stents is an attractive alternative to DES in such a population.
1788 In stent restenosis - benign or dangerous? Clinical
presentation of in-stent restenosis in Sweden
E. Omerovic1 , T. Ramunddal2 , G. Matejka2 ,P.Albertsson2 .
1Wallenberg Laboratory at Sahlgrenska Academy, Departement of
Cardiology, Gothenburg, Sweden; 2Dpt of Cardiology, Sahlgrenska
Univ. Hosp., Gothenburg, Sweden
Background: Restenosis after percutaneous coronary intervention (PCI) is traditionally
thought to be a benign event clinically manifested as stable exertional
angina. However, the presentation of in-stent restenosis (ISR) in "real-life" patients
is not well-studied. The aim of this study was to evaluate to which extent
patients with bare metal (BMS) ISR present as acute coronary syndromes in Sweden.
Methods: We searched Swedish Coronary Angiography and Angioplasty Reg-
istry (SCAAR) data. All cases of PCI for BMS ISR occurring between 1998 and
2004 in Sweden were scrutinized. Both multivessel and single vessel interventions
were included. ISR presentation was classified into three categories: (1) myocardial
infarction, (2) unstable angina requiring hospitalization and (3) exertional
angina. ISR episodes were based on patient’s symptoms and therefore were defined
clinically rather than angiographically as routine angiographic screening after
initial stent placement was not performed.
Results: We identified 4729 cases of bare-metal ISR, 3462 in men and 1267
in women. Of the ISR episodes, 52% (2466) were presented as either unstable
angina or myocardial infarction. Almost 10% of these patients presented as STsegment
elevation MI. Minority of pts with ISR presented as exertional angina
(48%). Women had higher incidence of unstable angina and myocardial infarctions
(49%) at ISR presentation compared to men (55%) (p

272 Confonding factors influencing outcome after stenting
able on the independent role of chronic and acute post procedural renal failure
in predicting mortality in patients with ST-elevation myocardial infarction (STEMI)
treated with primary coronary angioplasty (PCI).
Methods:We studied 453 consecutive patients with STEMI without cardiogenic
shock treated at our institution with primary angioplasty and stent between January
2002 and December 2006. Demographic, clinical, angiographic and hemodynamic
variables were collected prospectively by independent clinicians. Creatinine
concentration and glomerular filtration rate (GFR, estimated by MDRD
equation) were determined at hospital admission (baseline) and 6h, 24h, 48h and
72 h after the procedure. Contrast-induced nephropathy (CIN) was defined as
the increase of creatinine of more than 25% from baseline value within 48h after
the procedure. The mortality rate at 1 and 12 months was obtained by clinical
interview or review of death certificates.
Results:22 (4.8%) patients died within the first month after the procedure, 44
(10.2%) within 1 year. Both 1 month and 1 year mortality were significantly associated
with age, baseline creatinine and GFR, CIN and pre-procedural ejection
fraction (EF) (all p

Confonding factors influencing outcome after stenting / New vessels and changed vessels: angiogenesis and vascular remodelling 273
Interval late luminal loss.
procedure may be observed following DES therapy. There appears to exist a
device-specificity in this late reduction in anti-restenotic efficacy in favour of a
platform devoid of permanent polymer.
1795 Comparison of 18 month clinical outcome of
endothelial progenitor cell capture stent versus drug
eluting and bare metal stents in patients undergoing
primary percutaneous coronary intervention
E. Chong, Liang Shen, K.K. Poh, S.G. Teo, A. Low, C.H. Lee, H.C. Tan.
National University Hospital, The Heart Institute, Singapore, Singapore
Purpose: Endothelial progenitor cell (EPC) capture stent (Genous stent), is designed
to promote rapid endothelization and is potentially most useful in patients
undergoing primary percutaneous coronary intervention (PPCI) for acute
ST-segment elevation myocardial infarction (STEMI). We compare its long-term
clinical efficacy and safety with a sirolimus-eluting (SES) bioabsorbable polymercoated
stent (Cura stent) and a bare metal stent (BMS) (Liberte stent) in patients
with STEMI.
Methods: All patients who presented to our center with STEMI and received PPCI
with either EPC, SES or BMS stents between Jan 2004 and June 2006 were
enrolled in this cohort study. The study endpoints were cumulative major adverse
cardiac events (MACE) defined as a composite end point of death, myocardial
infarction (MI) and target vessel revascularization (TVR) at 18 months.
Results: A total of 365 patients (EPC=95, SES=53, BMS 218) were enrolled.
Baseline demographics in terms of age, gender, diabetes mellitus, baseline renal
impairment, pre-discharge left ventricular ejection fraction, cardiogenic shock
were comparable between the 3 groups. Procedural success rate was high at
a mean of 99.5%. Post-procedural TIMI 3 flow was achieved in EPC 91.6%,
SES 96.2% and BMS 88.5%. The MACE results and stent thrombosis rate at
18-months are shown in table.
Table 1. 18 month clinical outcome
Events EPC (n=95) SES (n=53) BMS (n=218) p value
MACE (%) 13(13.7%) 8(15.1%) 35(16.1%) 0.865
Death (%) 9(9.5%) 2(3.8%) 25(11.5%) 0.208
Non-fatal MI (%) 1(1.1%) 1(1.9%) 4(1.8%) 0.916
TVR 3(3.2%) 5(9.4%) 6(2.8%) 0.070
Acute stent thrombosis 1 (1%) 0 (0%) 0 (0%) ns
Subacute stent thrombosis (SAT) 0 (0%) 0 (0%) 0 (0%) ns
Late stent thrombosis (LST) 0 (0%) 0 (0%) 2 (0.9%) ns
Conclusion: The MACE rates among patients who underwent PPCI were similar
in all 3 stent groups at 18 months follow-up. There was no difference in TVR rate
and stent thrombosis remains a low event occurrence.
NEW VESSELS AND CHANGED VESSELS:
ANGIOGENESIS AND VASCULAR REMODELLING
1814 Neuropilin-1 expressing mononuclear cells (NEMs)
deriving from the bone marrow promote vessel
maturation during therapeutic angiogenesis
S. Zacchigna1 , L. Pattarini1 , L. Zentilin1 , A. Carrer1 ,S.Moimas1 ,
S. Tafuro 1 , M. Sinigaglia1 , G.F. Sinagra 2 , M. Giacca1 . 1ICGEB, Molecular Medicine, Trieste, Italy; 2Unita di Cardiologia Ospedali Riuniti TS,
Trieste, Italy
Purpose: The possibility that bone marrow (BM)-derived cells promote new blood
vessel formation through transdifferentiation has recently aroused much excitement.
Recent evidence however indicates that these cells have less plasticity than
predicted and that their effect is essentially paracrine. To exactly define the role of
BM cells during neovascularization, here we exploited a gene transfer approach
and characterized the in vivo effect of various factors, differing in their capacity to
recruit BM cells and to promote angiogenesis.
Methods: Adeno-Associated Virus (AAV) vectors were used to sustain the longterm
expression of VEGF121, VEGF165 and Sema3A in the mouse skeletal muscle.
Treated muscles were harvested at different times after transduction and the
angiogenic effect was assessed by histological and functional examinations. BM
transplantation, immunoFISH, siRNA-mediated silencing and clodronate depletion
were used to explore the in vivo role of BM cells.
Results: The injection of a vector expressing VEGF165 determined the formation
of an impressive number of new arterioles, paralleled by a massive infiltration
of CD11b+ BM cells. In contrast, VEGF121 induced a potent capillary sprouting,
but neither cellular infiltrates nor arterial vessels were evident. Leading from
the consideration that the main difference between these two VEGF isoforms is
their ability to bind the receptor neuropilin-1 (NP-1), we examined the effect of
semaphorin-3A (Sema3A), another ligand for NP-1. Strikingly, an AAV vector expressing
Sema3A, although not angiogenic, was able to recruit CD11b+ BM cells
similar to VEGF165. Consistent with these findings, we found that CD11b+ cells
migrated in vitro in response to both VEGF and Sema3A, and that their migration
was impaired after NP- 1 silencing both in vitro and in vivo. These CD11b+,NP-1expressing
mononuclear cells (NEMs) were in no case directly incorporated in the
newly formed vasculature nor they were arteriogenic per se, but contributed to arterial
formation through a paracrine effect ensuing in the activation and proliferation
of tissue-resident mural cells in order to promote the maturation of VEGF121induced
capillaries to acquire an arterial phenotype. Consistently, NEM depletion
by clodronate significantly impaired the formationof new arterial vessels.
Conclusions: These findings show that the different isoforms of VEGF are not
redundant, and that BM-derived NEMs, although not directly incorporated into the
newly formed vasculature, are essential for proper arterial formation, thus playing
a key role during therapeutic angiogenesis.
1815 Interferon-beta attenuates collateral artery growth by
inducing monocyte apoptosis and inhibiting smooth
muscle cell proliferation
S.H. Schirmer 1 , P.T.G. Bot 2 , J.O. Fledderus 3 , A.J.G. Horrevoets 4 ,
J.J. Piek 2 , I.E. Hoefer 3 ,N.VanRoyen 2 . 1 Universitaetsklinikum des
Saarlandes, Klinik fuer Innere Medizin III, Homburg/Saar, Germany; 2 Academic
Medical Center, Department of Cardiology, Amsterdam, Netherlands; 3 University
Medical Center, Department of Vascular Medicine, Utrecht, Netherlands; 4 VU
University Medical Center, Department of Molecular Cell Biology and Immu,
Amsterdam, Netherlands
Purpose: Circulating monocytes orchestrate collateral artery growth (arteriogenesis).
In a recent study we demonstrated that monocytes from patients with insufficient
coronary collateral artery growth show increased expression of the interferon
(IFN)-beta pathway compared to patients with well developed collateral
arteries, pointing to an inhibitory role of the IFNbeta-pathway in arteriogenesis
(EHJ suppl. 2007). Here, we investigated the underlying mechanisms of the putative
inhibitory effect of IFNbeta on arteriogenesis and hypothesized that we could
stimulate arteriogenesis by blocking IFNbeta-signaling.
Methods: Three groups of mice (control (129Sv/Ev, n=25), IFNalpha/betareceptor
knockout mice (IFNAR /-, n=25) and IFNbeta treated mice (105 IU/kg s.c,
n=25) underwent unilateral femoral artery ligation. Collateral dependent hindlimb
perfusion was assessed after one week by infusing fluorescent microspheres under
conditions of maximal vasodilation. Hindlimb tissue was analyzed immunohistochemically
for the presence of IFNAR. Both hindlimb tissue and stimulated
peripheral blood monocytes were subjected to gene expression analysis using
RT-PCR. Smooth muscle cells (SMCs) and THP1 monocytes were treated with
interferon-beta to assess the effects of IFNbeta on apoptosis and proliferation
in-vitro.
Results: IFN-beta treatment significantly reduced perfusion restoration compared
to control mice, expressed as percentage ligated/non-ligated hindlimb
(31.46±4.12% vs. 41.88±8.2%, p=0.01), while mice lacking the IFNbeta-receptor
showed significantly increased hindlimb perfusion (54.29±6.55%, p

274 New vessels and changed vessels: angiogenesis and vascular remodelling
Notch ligand Delta-like (Dll) 4 regulates arterial differentiation in embryonic development,
but the key ligand in mature CA remains elusive. Here we identify the
Notch ligand Dll1 as an essential regulator of postnatal coronary arteriogenesis,
which is protective after myocardial infarction.
Methods and Results: To characterize expression and role of Dll1 in adult hearts
we analyzed heterozygous Dll1-lacZ/+ reporter mice, in which one allele of Dll1
has been replaced by lacZ. X-gal staining revealed selective Dll1 expression in
the endocardium and in endothelium of coronary arteries (CA), but not in veins or
capillaries. Interestingly, hearts from Dll1 heterozygous mice were smaller (heart
weight (g)/femur length (cm), wt: 0.13±0.02 vs. het: 0.09±0.02, n=10, p20 um) but an increased number of
small arterioles

New vessels and changed vessels: angiogenesis and vascular remodelling / Syncope: still a lot to learn 275
due to prevention of platelet aggregation. In contrast, complete loss of platelets
appears to be detrimental, suggesting a supportive role for platelet recruitment in
the arteriogenic process. These findings establish the platelet as a major player
in arteriogenesis.
1820 A critical role of platelet function in arteriogenesis
M.L. Von Bruehl1 , J. Pagel2 , W. Schaper3 , E. Deindl2 ,S.Massberg1 .
1Deutsches Herzzentrum, Experimental Cardiology, Muenchen,
Germany; 2Walter-Brendel-Center for Exp. Medicine, Ludwig-
Maximilians-University, Muenchen, Germany; 3Max-Planck-Insitute, Bad Nauheim, Germany
Background: The compensatory growth of blood vessels after major arterial
occlusions (arteriogenesis) describes the remodelling of pre-existing arterioarteriolar
anastomoses to large functional arteries. The growth is triggered by
fluid shear stress initiating endothelial activation and modulating processes, which
control attraction of circulating cells. Although recruitment of monocytes and Tcells
has been identified during arteriogenesis, the exact cellular mechanisms
underlying the arteriogenic process are still ill defined. Platelets play a pivotal
role not only in hemostasis but also in acute and chronic inflammatory processes
of the vascular wall; however, their contribution to arteriogenesis remains unclear.
Methods: To examine the arteriogenic role of the platelets, male or female GPIIb
(αIIb integrin)-deficient mice (n=7) underwent right femoral artery ligation to induce
arteriogenesis. The left femoral artery was sham operated. WT littermates
served as controls. In separate experiments, thrombocytopenia (

276 Syncope: still a lot to learn / Science Hot Line
Figure 1
SS). In conclusion the outcome was similar among pts with high likelihood of neurally
mediated syncope,despite the different modalities of clinical presentation of
spontaneous syncope; HUT results were not helpful in the prediction of syncope
recurrence.
1824 A 1166C polymorphism in angiotensin II receptor gene
is associated with hemodynamic and autonomic
changes during head- up tilt test in patients with
vasovagal syncope
P. Mitro 1 , K. Mudrakova 1 , H. Mickova2 , J. Dudas2 , P. Kirsch2 ,
G. Valocik 2 . 1University Hospital, 3rd Department of Internal Medicine III, Kosice,
Slovak Republic; 2Medical Faculty, Department of Medical Biology, Kosice,
Slovak Republic
Purpose: A familiar occurrence and genetic predisposition may exist in vasovagal
syncope (VVS). Aim of the study was to evaluate the influence of gene polymorphisms
of renin – angiotensin system and serotonin transporter (SERT) gene on
hemodynamic and autonomic changes during head- up tilt test (HUT) in patients
with syncope.
Methods: DNA was collected from 191 patients (mean age 44+ 18 years, 61
men, 130 women). Following genetic polymorphisms were determined in genomic
DNA using the PCR method: ACE insertion/deletion polymorphism (I/D ACE),
angiotensinogen gene polymorphism (M 235), angiotensin II receptor (ATR1)
polymorphism (A 11666C) and polymorphism of serotonin transporter gene (S/L
SERT). Changes in autonomic tone were assessed by the method of heart rate
variability (time – domain- and frequency- domain analysis) in 5 minutes intervals
during HUT. Following parameters were recorded: LF, HF, SDNN a rMSSD.
Results: Only A 1166C polymorphism in ATR1 gene was associated with hemodynamic
and autonomic changes during HUT. A/A genotype of A 1166C polymorphism
was associated with enhanced decline in systolic and diastolic blood
pressure during HUT (minimal systolic BP: AA 59,6±21,8, AC 79,9±22,7, CC
65,4±22,7 mmHg, p=0,007), (minimal diastolic BP AA 36,4±22,7, AC 52,3±22,9,
CC 45,4±19,5 mmHg, p=0,007). A/A genotype of A 1166C polymorphism in ATR1
gene was also associated with higher SDNN in early phase of HUT (SDNN in 5
minute: AA 59,7±24,6 AC 50,6±20,6, CC 46,0±13,2, p=0,01) and at syncope
occurrence (SDNN: AA 71,0±20,9, AC 58,2±17,9, CC 58±1 0, p=0,04) when
compared to other genotypes of A 1166C polymorphism in ATR1 gene.
Conclusion: A/A genotype of A 1166C polymorphism in ATR1 gene is associated
with more pronounced fall in blood pressure and enhanced decline in sympathetic
tone during HUT in syncopal patients. It may play a role in genetic predisposition
to vasovagal syncope.
1825 Atrioventricular block during tilt testing
J. Gajek, D. Zysko, W. Mazurek. Medical University of Wroclaw,
Department of Cardiology, Wroclaw, Poland
Atrioventricular block (AVB) is a rare result during tilt testing (TT) in
patients with vasovagal syncope. Its clinical importance is not known.
Clinical data and tilt testing (TT) findings could differ between patients with and
without AVB during TT. The aim of the study was to compare the medical history
as well TT findings between the patients with and without AVB during positive
TT. The study group consisted of 521 pts with positive TT. The medical history
about the syncope number, traumatic injuries related to syncope, hospitalization
due to these injuries, jerks during spontaneous syncope have been obtained. The
following TT data: necessity for NTG provocation, duration of heart rate slowing
during neurocardiogenic reaction, outcome of TT assessed as total loss of consciousness
(TLOC) or presyncope have been collected.
Results: The patients characteristics and results are shown in table:
The stepwise logistic regression analysis revealed that AVB occurrence have
been independently associated with TLOC (OR - 5.5, CI 1.3-23.5, p

(n=574) served as the cohort where plaque osteopontin levels were examined in
relation to their outcome during follow up. Plaques obtained from patients undergoing
femoral endarterectomy (n=151) served as an external validation cohort.
Results: The primary and secondary endpoints were reached in 137 and 66 patients
respectively. Endpoints involved the cerebral circulation (17%), coronary
circulation (40%) and peripheral circulation (43%) The mean carotid plaque osteopontin
levels differed consistently between plaques obtained from patients who
suffered from any cardiovascular event during follow up (mean level 15.0±1.0
ng/ml) and patients who had no event (mean level 9.2±0.4 ng/ml). Patients were
divided in quartiles based on the carotid plaque osteopontin levels. Comparing the
highest quartile of carotid plaque osteopontin levels with quartile 1+2 showed a
hazard ratio for the primary outcome of 4.0 [95% Confidence Interval (CI) 2.5-6.5].
In quartile 4 >50% of the patients reached a primary endpoint within 3 years compared
with 13% in quartiles 1+2. The outcome did not change after adjustment
for plaque characteristics and traditional risk factors [hazard ratio 4.3, 95%CI 2.7-
6.8]. In subgroup analyses, carotid plaque osteoptin levels were predictive for all
single endpoints of cerebral, myocardial and peripheral origin. Multivariate analyses
revealed that age and plaque osteopontin levels were the only independent
predictors for outcome (both p

278 Science Hot Line / Stress echo in clinical practice
1843 High density lipoprotein (HDL) loses major
vasoprotective properties in patients with stable
coronary disease and acute coronary syndrome as
compared to HDL from healthy subjects - important
novel implications for HDL-targeted treatment
strategies
C. Besler, K. Yonekawa, C. Doerries, Y. Shi, T.F. Luescher, U. Landmesser.
Zurich, Switzerland
Background: Reduced high density lipoprotein (HDL) represents a major cardiovascular
risk factor. HDL isolated from healthy subjects exerts direct vasoprotective
effects, i.e. stimulates endothelial nitric oxide (NO) production, exerts antioxidant
and anti-inflammatory effects. HDL-targeted treatment approaches are
therefore currently intensely studied as a potential novel strategy for cardiovascular
protection. However, the vascular effects of HDL from patients with stable
coronary artery disease (CAD) or an acute coronary syndrome (ACS) remain to
be characterized. This is a critical question because only raising HDL with vasoprotective
properties can be expected to exert beneficial effects.
Methods: HDL was isolated from patients with stable CAD or ACS (n=24) and
age- and sex-matched healthy subjects (n=10) by sequential ultracentrifugation.
The effects of HDL on endothelial cell nitric oxide (NO) and superoxide production
were determined by electron spin resonance (ESR) spectroscopy using the
spin-traps Fe-DETC and CM-H, respectively. The effect of HDL on endothelial repair
was examined by injection of HDL into nude mice with carotid artery injury
and measurement of the re-endothelialized area after 3 days. Anti-inflammatory
properties of HDL were tested by using an endothelial monocyte adhesion assay.
Furthermore, lipid peroxidation and activity of paraoxonase, an important HDLassociated
anti-oxidant enzyme system, were determined.
Results: Whereas HDL isolated from healthy subjects stimulated endothelial NO
production, HDL from both, patients with stable CAD or acute coronary syndrome,
had the opposite effect and inhibited endothelial NO production. Endothelial superoxide
production was markedly reduced by HDL from healthy subjects, an
effect that was largely lost when HDL from patients with stable CAD or ACS was
examined. Importantly, HDL from healthy subjects markedly accelerated endothelial
repair after carotid injury, that was not observed with HDL isolated from patients
with stable CAD or ACS. Moreover, HDL from healthy subjects, but not from
patients with stable CAD and ACS inhibited monocyte adhesion on TNF-alphastimulated
endothelial cells, suggesting a loss of anti-inflammatory effects of HDL
in coronary artery disease. Lipid peroxidation was increased in patients with stable
CAD or ACS as compared to healthy subjects, likely at least in part due to a
profoundly reduced HDL-associated paraoxonase activity in patients with stable
CAD or ACS.
Conclusion: The findings of the present study provide the first evidence suggesting
that HDL from patients with stable coronary artery disease or an acute
coronary syndrome loses important endothelial-protective effects. In particular
HDL from patients with coronary artery disease had lost the beneficial effects on
endothelial NO production, endothelial repair, anti-oxidant and anti-inflammatory
properties. These findings have likely important implications for designing HDLtargeted
therapeutic approaches and suggest that the impact of HDL-targeted
treatments on vascular effects of HDL needs to be characterized, since only raising
HDL with vasoprotective properties can be expected to exert cardiovascular
protective effects.
1844 In vivo measurement of regional and local
aortic pulse-wave velocity in mice with MRI at 17.6
Tesla
M. Parczyk, V. Herold, G. Klug, W. Bauer, E. Rommel, P.M. Jakob.
Wuerzburg, Germany
Background: Aortic stiffness increases in an early state of arteriosclerosis,
assessable by pulse wave velocity (PWV) MR-measurements. Up to now
only studies in larger animals and humans have been reported in literature. As
part of a comprehensive measuring protocol to examine vessel morphology and
function in the mouse two non-invasive MR-imaging techniques measuring the
pulse wave velocity in the murine aorta were developed.
Methods: All measurements were performed on a 17.6 Tesla Bruker AVANCE
scanner equipped with a 1T/m gradient insert and a 27mm TEM resonator. Regional
aortic PWV was measured with a transit time method based on a highresolution
CINE-sequence with flow compensating gradients (TR: 5.0ms, TE:
1.6ms, in plane resolution: 80x80μm 2 , slice thickness: 1mm). Cross-sectional areas
were measured at the descending thoracic aorta and the abdominal aorta.
Local PWV in the ascending aorta and the abdominal aorta was measured using
the QA-method based on the assumption of a unidirectional and reflection-free
incident pulse wave. In this case the pulse wave velocity is given as PWV=dQ/dA
where Q denotes the volume flow through the aorta and A is the cross-sectional
area of the aorta. A PC-Cine-FLASH-sequence was applied to measure the time
dependant parameters Q and A.
Results: Our preliminary studies confirmed the feasibility of MR-PWV measurements
in murine aortas. In vivo regional measurements indicated PWVs of 5.5
m/s. Local PWV were measured to be 2.8 m/s in the ascending aorta and 3.2 m/s
in the thoracic aorta.
Conclusion: This study demonstrates the feasibility of high-field-MRI to measure
local and regional PWV in the murine aorta. After further validation protocols are
incorporated into a comprehensive MR protocol to image mechanisms of plaque
progression and regression in atherosclerotic mice.
STRESS ECHO IN CLINICAL PRACTICE
1845 Positive predictive value of stress echocardiography in
the chest pain unit: what does this test add to a clinical
score?
A. Estevez, M. Martinez-Selles, H. Bueno, R. Del Castillo, J. De
Miguel, J. Andueza, J. Ortiz, L. Gallego, M.A. Garcia-Fernandez,
F. Fernandez-Aviles. hospital general universitario gregorio maran, cardiology,
Madrid, Spain
Introduction: Patients admitted to chest pain units are usually classified on the
basis of the results of non-invasive tests. However, the large number of potential
patients places a strain on limited resources. Thus, we have previously reported
a clinical index (UDT-65) to stratify the risk of coronary artery disease (CAD) of
these patients. The aim of the present study was to evaluate the positive predictive
value of the stress echocardiography when added to the clinical features.
Methods: We studied 700 consecutive patients admitted to the Chest Pain Unit
at our institution, all of whom had an ECG without changes in repolarization and
normal troponin. Chest pain was shorter than 60 minutes in all cases. CAD was
defined as stenosis > 70% of the lumen. We performed coronary angiography to
all patients with a definite positive result on the stress echocardiography.
Results: We performed coronary angiography to 50 patients with positive result
on stress echocardiography. Mean age was 66.1±12.9 years and 74.7% were
male. Chest pain was described as typical in 41.6%, doubtful in 39.3% and atypical
in 19.1%. Stress echocardiography was clinically positive in 25 patients; electrically
positive in 19 and 40 showed worsening in the segment contractility. 17
patients (37.8%) did not have significant CAD. So, the Positive Predictive Value
(PPV) for the stress echocardiography was 0.62. When we only considered the
result of patients with a positive clinical, electrical and echocardiographic test, the
PPV increased to 0.89. Moreover, when we analysed the PPV adjusted to the
clinical index (UDT-65) composed by use of aspirin, diabetes, typical chest pain
and age over 64, scored from 0 to 4, it increased from 0.40 when the score was
0-1 to 0.88 when the score was 3-4.
Conclusions: Our previously described clinical index UDT-65 correlates with the
presence of CAD. Our present study shows that stress echocardiography has a
reduced power to detect CAD in those patients in a Chest Pain Unit with low
clinical risk. The PPV was only high in those patients with high clinical pre-test
probability of CAD. We conclude that the usefulness of the stress ecocardiography
in the chest pain unit to predict CAD is uncertain.
1846 Risk stratification in diabetics by left anterior
descending flow reserve: evidence for shorter warranty
period compared to nondiabetics
G. Athanassopoulos1 , G. Hatzigeorgiou2 ,A.Motsi2 , M. Marinou2 ,
G. Karatasakis2 ,D.V.Cokkinos2 . 1Pireas, Greece; 2Athens, Greece
Background: Non-invasive evaluation of left anterior descending artery (LAD)
flow reserve (CFR) is feasible using transthoracic Doppler echo. LAD CFR, despite
its proven accuracy for LAD patency diagnosis, has not been extensively
validated for prognosis. CFR evaluation has still undefined prognostic value in
diabetics compared to nondiabetics.
Methods: 518 consecutive pts with chronic CAD were studied for LAD CFR (age
62+11, ejection fraction 48+10, 18% with anterior MI, 20% with CABG, 13% with
diabetes). Coronary angiography had 47% of pts with 29% having>70% LAD
diameter stenosis. CFR was estimated using bolus adenosine infusion at
140μg/kg/min.
Results: During a follow up of 9+4.5 months (range 1-26), 52 pts had a cardiac
event (CE): 3 died, 25 had revascularization, and 24 acute coronary syndromes.
UsingROCforpredictionofCE,aCFRvalue>1.8 had sensitivity 0.65, specificity
0.83(p

Using Cox’s proportional hazards model including age, sex, ejection fraction, CFR
and diabetes, then only ejection fraction (exp(b): 0.95, p=0.01) and CFR>1.8
(exp(b):1.87p=0.04) had independent prognostic value for CE in the presence of
diabetes.
With Kaplan Meier analysis, nondiabetics with CFR >1.8 had a sustained decrease
of CE during follow up (log rank: 24.6, p1.8 showed a better outcome only in short term (70% was related with CE only in nondiabetics (log rank=15,
p=0.001)
Conclusion: In diabetics:
1. Noninvasive LAD CFR provides important but mid term diagnostic yield for
cardiac events, independently from the severity of LAD stenosis.
2. Since warranty period does not exceed 9 months, a periodical assessment
of iscemia should be encoureged, especially in the presence of left ventricular
dysfunction.
1847 Synchronicity indexes during exercise are associated
to functional capacity and left ventricular function in
patients with left bundle branch block
P. Pazos, J. Peteiro, A. Bouzas, E. Barge, D. Perez, A. Castro-Beiras.
Juan Canalejo Hospital, Cardiology, A Coruna, Spain
Alterations in synchronicity are commonly seen in patients with left bundle branch
block (LBBB). We hypothesized that synchronicity may improve during exercise
in some of these pts and that such improvement may increase their functional
capacity. 89 pts with LBBB referred for exercise echocardiography were studied
by color Doppler tissue velocity (TV) at rest (R) and in the immediate postexercise
(PE) period (within 45 secs). The time from the onset of the Q or R wave to peak
TV in 9 locations (basal, mid, and apical septum; basal and mid lateral; basal and
mid posterior; basal and mid anterior) were measured to derive a synchronicity
index (SI=mean of the deviation of the 9 locations/9). 27 pts were classified as
having coronary artery disease (CAD, ≥50% stenosis, G1), 5 had non-ischemic
dilated cardiomyopathy (G2) and 57 without dilated cardiomyopathy or CAD were
considered normal subjects (G3, 18 with normal coronary arteries and 39 asymptomatic
with low pre-test probability). At rest the SI (ms) was similar in the 3
groups: G1 35±19, G2 39±11, G3 39±12 (p=NS), despite significant differences
in resting ejection fraction (EF) between groups (G1 46±10, G2 34±4, G3 56±5,
p

280 Stress echo in clinical practice / Non-invasive testing for arrhythmias
chaemia. Therefore, we developed a three-dimensional (3D) analysis tool that
makes it possible to anatomically align 3D rest and stress data systematically,
to generate optimal, non-foreshortened standard anatomical cross sections and
to analyse the images synchronised and side-by-side. The aim of the present
study was to investigate whether this 3D analysis tool could improve interobserver
agreement on myocardial ischaemia during 3D DSE.
Methods: The study comprised 34 consecutive patients (22 men, mean age
57±13 years) with stable chest pain who underwent both non-contrast and contrast
3D DSE. Two observers scored segmental wall motion using a conventional
analysis and the novel analysis with the new 3D tool.
Results: At peak stress, 434 of the 578 segments (76%) could be analysed during
noncontrast 3D imaging. With contrast-enhanced 3D imaging, the number of
available left ventricular segments increased to 526 (91%). The two observers
agreed on the presence of myocardial ischemia in 81 of 102 coronary territories
(agreement 79%, kappa 0.28) during noncontrast 3D imaging and 92 of 102
coronary territories (agreement 90%, kappa 0.65) during contrast-enhanced 3D
imaging. With the new 3D analysis software these numbers improved to 98 of 102
coronary territories (agreement 96%, kappa 0.69) during noncontrast 3D imaging
and 98 of 102 coronary territories (agreement 96%, kappa 0.82) during contrastenhanced
3D imaging.
Conclusion: The use of a 3D DSE analysis tool improves interobserver agreement
for myocardial ischaemia both for non-contrast and contrast images.
NON-INVASIVE TESTING FOR ARRHYTHMIAS
1851 T-wave variability detects abnormalities in ventricular
repolarisation: a prospective study comparing healthy
persons and olympic athletes
L. Heinz1 ,A.Sax2 , F. Robert 2 , A. Urhausen2 , D. Luhm3 ,
R. Ocklenburg3 ,J.O.Schwab4 . 1Bonn, Germany; 2Luxembourg, Luxembourg; 3Muenchen, Germany; 4University of Bonn, Department of
Medicine-Cardiology, Bonn, Germany
Introduction: Sudden cardiac death in athletes is more common than in the general
population. Routine screening procedures are performed to identify competitors
at risk. A new, Holter based parameter, analyses variation of the ventricular
repolarization (TVAR). The aim of the present study was to evaluate differences in
ECG, Echo, and Holter (H) in competitive athletes compared to a healthy control
group consisting of medical students (MS).
Methods: 40 athletes (19 female, Olympic Team, Luxembourg) and 40 MS (22
female) were examined by means of a resting ECG, treadmill exercise (TE),
echocardiogram (Echo), as well as H recordingsduring a routine screening visit.
To analyze TVAR, a 20 min H recording at rest (sampling rate 2000 s -1 )was
performed.
Results: No differences in demographic variables were detected. The Table illustrate
the findings of echo and H computations.
Parameters of Echocardiography/Holter
Parameter Athletes (mean±SD) Students (mean±SD) P-value
Heart rate (bpm) 66±8 77±7

hibitory response, or in pts with positive HUTT during passive or active phases.
At multivariate analysis, the presence of a number of syncopes > 4inthelast12
months before HUTT was a risk factor for syncopal recurrence either in pts with
positive HUTT (p = 0.028; HR: 1.83; CI (95%) = 1.07-3.17) or in all the pts that
evaluated by HUTT (p = 0.023; HR: 1.7; CI (95%) = 1.07-2.69).
Conclusions: This study shows that HUTT results are poorly predictive of syncopal
recurrences. The history of syncope (number of previous syncopal episodes)
is associated to different outcomes in terms of syncopal recurrences. Indeed, a
number of previous syncopal episodes > 4 in the 12 months before HUTT represents
an important risk factor for syncopal recurrence during long-term f-up,
either in pts with a positive HUTT or in all the pts evaluated in this study.
1855 Increased beat to beat variability of QT intervals as an
additional diagnostic marker in long QT Syndrome
B.M. Beckmann1 , M. Hinterseer1 ,M.B.Thomsen2 ,R.Dalla-Pozza1 ,
M. Loeff1 , A. Pfeufer3 ,H.Netz1 , S. Kaab1 . 1Universitaetsklinikum Grosshadern, Medizinische Klinik I, Munich, Germany; 2Columbia University, Department of Pharmacology, New York, United States of America;
3Helmholtz Center Neuherberg and Technical Uni, Institut fuer Humangenetik,
Munich, Germany
Long QT syndrome (LQTS) is one of the most common inheritedcardiac arrhythmias,
and it may serve a a model disease for an impaired repolarisation reserve
as seen in aquired or drug induced LQTS. Usually diagnosis and risk stratification
in LQTS is based on the length of QT interval. Studies indicate that not only
prolongation of QT interval but also an enhanced beat-to-beat variability of the
QT-intervals measured as short-term variabiliy of the QT-interval, is a marker for
a decreased repolarization reserve. In the absence of QTc prolongation, baseline
STVQT characterized patients with documented drug-induced proarrhythmia.
Purpose: To evaluate if LQT mutation carriers (MC) have an increased beat-tobeat
variability of the QT interval measured as STVQT, and if so, to explore if
STVQT could contribute to distinguish mutation carriers from healthy controls.
Methods and Results: 60 MC of a mutation in one of the major LQT disease
genes were compared to 60 age- and sex-matched controls. Lead-II or lead-
V5 RR, and QT intervals from 30 consecutive beats were manually measured.
STVQT was determined from Poincaré plots of QT intervals (STVQT=�|QTn+1-
QTn|/[30* √ 2]). In addition QTc of 3 cycles was determined using Bazett’s formula.
MC had longer QTc intervals and STVQT (461±52 and 6.9±2 ms, respectively)
than controls (408±28 and 4.3±2 ms, respectively; both P50% (n=8), nonstenosing coronary
plaque (n=11), and coronary anomaly (n=1). Effective radiation dose was
2.2±0.7, 2.2±0.1, and 6.2±0.2 mSv for CTCA, stress-SPECT, and rest-SPECT,
respectively. Thus, total radiation dose was significantly lower for CTCA/stress-
SPECT (4.4±0.7 vs 8.5±0.3 mSv for standard stress/rest SPECT, p

282 Multimodality imaging of coronary heart disease
Table 1. Main long-term mortality predictors
Without previous infarction With previous infarction
HR (95% CI) P HR (95% CI) P
Age 1.07 (1.04-1.09)

Multimodality imaging of coronary heart disease / Optimisation of techniques and adjunct therapy in cardiac surgery 283
sitivity, specifity, negative predictive and positive predictive value, and accuracy
for GRE-MRI analysis of myocardial perfusion in the detection of flow-limiting
epicardial coronary artery lesions, as defined as diameter stenosis >50%, were
72%,100%, 54%, 100% and 73%, respectively.
Conclusions: These preliminary results indicate a moderate diagnostic accuracy
of cardiac GRE-MRI perfusion imaging at least during dipyridamole-induced coronary
flow increases in the detection of flow-limiting epicardial artery lesions. The
concordance between 201TI-SPECT and cardiac GRE-MRI imaging in the detection
of stress-induced perfusion defects was relatively low, and 39% of 201TI-
SPECT-determined perfusion defects were not identified by cardiac GRE-MRI,
that deserves further investigations.
P1880 Myocardial T2* estimation techniques in iron overload
disease: relationship with left ventricular function
M. Leung, G. Brown, A. Carbone, S. Worthley. Royal Adelaide
Hospital, Adelaide, Australia
Objectives: Myocardial T2* relaxometry has been proposed as a
measure of myocardial iron accumulation and is associated with fatal heart failure.
Its estimation can be observer dependent, limiting its clinical utility. We developed
explicit rules for data acquisition and analysis and assessed their impact
on myocardial T2* estimate (myoT2*), its reproducibility and relationship with left
ventricular function.
Methods: Mid-septum short-axis segmented FLASH images with 11 TE values
(3.6-18ms) were acquired on 30 patients with congenital haemoglobinopathy.
Mean pixel values at the inter-ventricular septum were graphed against TE.
myoT2* was derived from exponential regression analysis. Comparison between
11 and standard 9 TE values (5.6-18ms), and the inclusion/exclusion of myocardial
signal indistinguishable (signal-1SD < noise+1SD) from background noise
(noise test) was performed by Bland-Altman analysis. Intra-, inter-observer and
inter-study variability were assessed by % coefficient of variation (%CV) and
Bland-Altman analysis.
Results: Observed myoT2* was 16.4±12.2ms (mean±SD). 11 versus 9 TE
demonstrated a myoT2* mean difference (95% limits of agreement) of -0.4ms
(-6.2, 5.4ms), and with/without noise test of 0.3ms (-2.6, 3.2ms). With 11 TE and
noise test, intra-, inter-observer and inter-study %CV were 6.4%, 8.1% and 5%
respectively. Mean difference between observations (95% limits of agreement) for
all myoT2*, myoT2*>20ms (normal) and ≤20ms (abnormal) are shown in Table
1. Logn myoT2* correlated with LVEF (P=0.021, R=0.433).
Table 1. Reproducibility of myoT2*
Reproducibility myoT2* range Mean Difference 95% Limits of Agreement
Intra-observer all myoT2* 0.3ms -5.0 to 5.7ms
myoT2*≤ 20 ms -0.08ms -3.5 to 3.3ms
myoT2*> 20 ms 0.8ms -6.5 to 8.2ms
Inter-observer all myoT2* 0.5ms -3.6 to 4.7ms
myoT2*≤ 20 ms 0.6ms -1.7 to 2.9ms
myoT2*> 20 ms 0.5ms -6.0 to 7.0ms
Inter-study all myoT2* 0.1ms -4.0 to 4.3ms
myoT2*≤ 20 ms 0.1ms -2.2 to 2.5ms
myoT2*> 20 ms 0.08ms -6.9 to 7.1ms
Conclusions: This myoT2* methodology demonstrated high reproducibility and
correlated with left ventricular function.
P1881 Variables associated with contrast enhanced
cardiovascular magnetic resonance in hypertrophic
cardiomyopathy: importance of quantification and
pattern of enhancement
F. Marin Ortuno1 , J. Gonzalez1 , A. Garcia Honrubia2 , A. Romero1 ,
V. Climent2 , F. Ruiz Espejo1 , V. Roldan3 ,J.R.Gimeno1 , G. De La Morena1 ,
M. Valdes1 . 1Hospital Virgen de la Arrixaca, Murcia, Murcia, Spain; 2Hospital General Universitario, Cardiology, Alicante, Spain; 3Universidad de Murcia,
Centro Regional de Hemodonacion, Murcia, Spain
Hypertrophic cardiomyopathy (HCM) shows increased myocardial collagen and
disarray. Late gadolinium-enhancement (LGE) in cardiovascular magnetic resonance
(CMR) is observed in regions of increased myocardial collagen. The extent
of LGE has been associated with higher prevalence of risk factors of sudden
death. The aim of the present study was to describe the clinical characteristics
and the presence of risk factors for sudden death in a series of patients from two
referral centres for HCM in relation to LGE in CMR.
Methods: 120 patients (47±16 years) were included. All patients fulfilled conventional
criteria for HCM. Risk factors for sudden death were evaluated. A blinded
CMR was performed with LGE in the left ventricular short-axis orientation. Quantification
of LGE was performed by Mass Suite software. A qualitative analysis
of the presence of LGE was also done. NT-proBNP and C-reactive protein were
determined in serum samples.
Results: 83 patients (69%) showed LGE. These patients had higher maximal left
ventricular wall thickness (22±5vs.17±3 mm,p

284 Optimisation of techniques and adjunct therapy in cardiac surgery
dure. Demographic profiles, operative data, long term survival and quality of life
by the Short Form 36 Health Survey questionnaire were analysed.
The 30 day mortality was 14.7% in the reoperation group and 8.5% (p=0.43)
in the control group. Average time between previous operation and reoperation
was 10.8±5.6 (range 1.7–30.6 years). Actuarial survival at 1, 3 and 6
years was 77.2±5%, 58.3±6.3% and 36.3±7.8% for patients with reoperation
and 71±5.5%, 58.3±6.3% and 30±8.1% for matched patients with primary cardiac
surgery (p=0.68) (figure). No significant differences regarding the physical
(40.7±9.4 vs. 39.1±10, p=0.55) and the mental health summarized-score
(51.9±10.9 vs. 48±12.9, p=0.24) of the SF-36 were found between groups.
Octogenarians exhibit a similar mortality, long-term survival and quality of life following
primary and redo cardiac surgery. Therefore, this kind of surgery should
not be reserved for younger patients alone.
P1885 Mass-III: a randomized study comparing on-pump and
off-pump coronary artery bypass graft surgery: 3-year
results
N.H. Lopes1 , A.F.T. Gois2 ,F.S.Paulitsch2 , C.L. Garzillo2 ,L.Dallan2 ,
L.A.M. Cesar2 , N.A.G. Stolf2 , W. Hueb2 on behalf of MASS. 1Heart Institute - INCOR, Chronic Coronary Disease Department, Sao Paulo, Brazil;
2Heart Institute, Sao Paulo, Brazil
Introduction: In recent decades, concern has been increasing regarding reducing
mortality and morbidity related to coronary artery bypass graft (CABG)
surgery, particularly related to on-pump procedures. In this scenario, the development
of off-pump techniques might provide advantages.
Objectives: We compared the results of on-pump and off-pump procedures, regarding
data during surgery, clinical evolution after surgery, and mortality and
morbidity at 3-year follow-up.
Methods: Patients with multivessel chronic coronary artery disease (CAD) and
preserved left ventricular function who needed a CABG procedure and were suitable,
according to surgeon’s assessment, for either on-pump or off-pump revascularization
techniques were randomized and followed up. The duration of the
surgery and need of a ventilator, intensive care unit (ICU) and hospital stay, clinical
problems, and need of a blood transfusion were analyzed. The primary endpoints
were cardiac death, myocardial infarction, and refractory angina requiring
a new intervention.
Results: 279 patients were randomized: 140 to on-pump and 139 to off-pump
CABG. Baseline profiles were similar between the groups. Of those in the offpump
group, a significant reduction occurred in the duration of surgery (4,08h vs.
5,04h, p

Conclusions: EVH is a strong independent predictor of VGF in patients who undergo
CABG surgery. The clinical significance of and mechanism behind this observation
requires further investigation. These findings should be weighed against
potential benefits of EVH.
P1888 Incidence and risk factors of early thromboembolic
events after mitral mechanical heart valve
replacement in patients treated with intravenous
unfractionated heparin
N. Allou1 , P. Piednoir2 , C. Berroeta2 , S. Provenchere2 , H. Ibrahim2 ,
L. Etchegoyen2 ,P.Montravers2 ,B.Iung2 , I. Philip2 , N. Ajzenberg2 . 1CHU Bichat-Claude - Bernard, Postcardiac intensive care unit, Paris, France; 2CHU Bichat-Claude -Bernard, Postcardiac intensive care unit, Paris, France
Purpose: The management of postoperative anticoagulation (AC) after mechanical
heart valve replacement (MHVR) remains controversial, even in recent guidelines.
The aim of our study was to evaluate incidence and risk factors of early
thromboembolic events (TE) after MHVR in patients (pts) treated with intravenous
unfractionated heparin (IVUH).
Methods: This study included all patients undergoing MHVR between December
2005 and May 2007. Postoperative AC was performed with IVUH and started the
4th postoperative hour with 100/IU/kg/day and regularly increased to target an
APTT ratio of 2 to 3 on day 2, according to a standardized protocol. Vitamin K
antagonist was started on the second postoperative day. The endpoint was the
occurrence of arterial TE from day 1 to 30. We also collected major bleeding
complications.
Results: 300 pts were studied. Mitral (M) or double MHVR were performed in 149
pts, and aortic (A) MHVR in 151 pts. 24 pts (8%) had an early TE: 11 nonobstructive
prosthetic valve thrombosis, 2 obstructive valve thrombosis, 3 thrombi in the
left atrium and 8 ischemic strokes. Twenty-two (14.8%) TE occurred after a M or
double MHVR and 2 (1.3%) after an A-MHVR (P=0.005).Consequently, we studied
risk factors of TE only in pts with M or double MHVR. In multivariate analysis
diabetes mellitus (OR [95% CI]: 3.9 [1.2-12.9]; p=0.04) and a none effective AC
on day 3 (3.5 [1.1-10.5]; p=0.02) were independent risk factors for TE. 12 major
bleeding events (8.3%) occurred in pts with M or double MHVR. We did not find
any association between the timing of effective AC and bleeding complication.
Conclusion: This study using systematic early post-operative AC with IVUH
shows that: 1) TE rate remains high after mitral MHVR; 2) inadequate AC at day 3
was a predictor of post-operative TE, suggesting that early effective AC is mandatory;
3) patients with diabetes seem at higher risk of TE and might benefit from
more aggressive treatment.
P1889 Bridging therapy to chronic anticoagulant treatment
in patients undergoing cardiac surgery: comparison
between low-molecular-weight heparin and
subcutaneous unfranctionated heparin. A pilot study
C. Rostagno, S. Romagnoli, S. Bevilacqua, F. Puggelli, G. Rosso,
G. Giunti, G.F. Montesi, L. Ghilli, S. Caciolli, P.L. Stefano. AOU Careggi,
Cardiologia 1, Firenze, Italy
Purpose: At present no clear evidence has been provided regarding the superiority
of various heparin regimens as bridging treatment to chronic anticoagulation.
Aim of present pilot investigation was to prospectively compare the safety of
weight adjusted enoxaparin and subcutaneous unfractionated heparin in patents
undergoing valvular heart surgery.
Methods: One hundred and four patients undergoing heart valve surgery between
January 1 and March 31 2007 were randomized to weight adjusted
enoxaparin (group I) or comparable weight adjusted subcutaneous unfractionated
heparin (group II). Treatment was started 12 hours after ICU admission and
maintained until therapeutic range of oral anticoagulation was obtained. Hemorrhagic
and thromboembolic complications, the need for blood transfusions, total
drainage fluid, haemoglobin values and presence and degree of pericardial effusion
at discharge were evaluated.
Results: A total of 104 patients was included, 52 for each group. We did not
find any thromboembolic event in the two groups. Average fluid drainage after
24 hours was similar with the two regimens (401 group I vs 411 ml group II)
while the need of blood unit transfusion in ICU after starting heparin therapy was
higher in patients treated with enoxaparin vs. s.c. unfractionated heparin (40 vs
30% p

286 Atrial fibrillation
P1893 Right ventricular rhythmic cardiomyopathy: about
patients treated by catheter ablation for atrial
fibrillation
R. Ollivier, E. Donal, D. Veillard, D. Pavin, J.-C. Daubert, P. Mabo.
Rennes, France
Background: Left ventricular systolic dysfunction is frequent and is a
well-known problem in atrial fibrillation (AF) patients. No data exist in regard to the
potential involvement of the right ventricle (RV) in that rhythmic cardiomyopathy.
Aims: To determine in witch extent AF affects RV-function and -remodelling and,
if pulmonary vein isolation is efficient to improve them.
Method: We prospectively studied 30 patients (mean age: 58±10 y.o., 77% men
(23)) with paroxysmal (n=22) or persistent (n=8) AF, referred for pulmonary vein
isolation. A control group of 15 patients without any cardiac disease, matched in
age and sex, was also studied. All patients had echocardiographic study at baseline,
at discharge and at 3-months follow-up (f/u). Right ventricle study included
minimal and maximal areas, systolic excursion of the tricuspid annular plane in
M-mode (TAPSE), RV’s lateral wall peak-velocity (Sa) measured by DTI and maximal
longitudinal shortening measured by strain (ε) on RV’s lateral wall.
Results: RV’s areas weren’t different between AF patients and controls, at baseline,
nor at 3-months f/u. AF may not induce significant RV morphological remodelling.
At baseline, AF patients had lower TAPSE than controls (21.2±6.5 mm vs. 28.3±4
mm, p

any antiarrhythmic drug (AAD), Group 2: 62pt class II agent: Amiodarone 30pt,
32pt with Sotalol due to contraindications to Amiodarone, Group 3: 58pt - last ineffective
drug (1pt quinidine, 1pt werapamil+metoprolol, 9pt propafenone + metoprolol,
29pt metoprolol, 15pt propafenone, 3 pt bisoprolol). During 2months of
follow-up after ARF 24-hour ECG recording was performed twice, and standard
ECG was performed each time any symptoms of arrhythmia occurred.
Results: There were no significant differences in coronary artery disease, hypertension,
diabetes mellitus, persistent AF rates among groups. 88pt (48,9%) were
free of any AF episodes. In 36pt (20%) single episode occurred. More than one
episode, but reduction in duration and severity of AF episodes was observed in
41pt (22,7%), no improvement was observed in 15pt (8,4%).
Results in subgroups: G1: no recurrence 34pt (56,7%), 1 AF episode 9pt (15%),
reduction 13pt (21,7%), no improvement: 4pt (6,6%); G2: no recurrence – 28pt
(45,2%), 1 AF episode: 10pt (16,1%), reduction – 17pt (27,4%), no improvement:
7pt (11,3%); G3: no recurrence – 26pt (44,8%), 1 AF episode: 17pt (29,3%),reduction
– 11pt (18,97%), no improvement: 4pt (6,9%). X2 test: G1 vs G2: p=0,32;
G1vsG3: p=0,98; G1vsG3: p=0,42; G1vsG2vsG3: p=0,34. There is no significant
difference between results in subgroups. Proarrhythmia: increase in number of
AF episodes and severity of AF occurred in 1 pt (1,6%) without AAD, new atypical
atrial flutter occurred in 1pt (1,7%) with propafenone and 2pt (3,2%) with sotalol.
Long QT >460ms occured in 2pt (3,2%) with sotalol.
Conclusions: Antiarrhythmic prophylaxis do not improve clinical outcome during
blanking period in patients after radiofrequency ablation due to atrial fibrillation.
P1897 Pill-in-the-pocket strategy on-top of chronic
antiarrhythmic therapy for conversion of recent onset
atrial fibrillation to sinus rhythm
G.L. Botto1 ,M.Luzi2 ,G.Russo2 , B. Mariconti 2 ,F.Ruffa3 ,
G. Cappelletti 2 ,P.L.Pina2 ,K.Sielert2 , M. Guanziroli 2 ,
S.C. Zerboni2 . 1Sant’ Anna Hospital, Cardiology Department, Como, Italy;
2 3 Sant’Anna Hospital, Cardiology, Como, Italy; Manzoni Hospital, Cardiology,
Como, Italy
Background: Data about the use of oral loading of 1C antiarrhythmic drugs (1C-
AADs) on-top of chronic antiarrhythmic therapy to convert atrial fibrillation (AF)
relapses to sinus rhythm (SR), are lacking.
Methods: The study group consisted of 241 patients (pts) with history of paroxysmal
AF without heart failure, coronary heart disease and conduction disturbances,
chronically treated with class 1C-AADs as prophylaxis. When recent onset
(

288 Atrial fibrillation
modelling characterised by interstitial fibrosis, atrial enlargement, slowed and
heterogenous conduction, increased effective refractory periods and a greater
propensity for AF. These findings highlight the importance of early and aggressive
therapy for hypertension to prevent the development of arrhythmogenic substrates.
P1902 Incidence of atrial fibrillation after percutaneous
closure of patent foramen ovale and small atrial
septal defects in patients presenting with cryptogenic
stroke: a case-control study
R. Bonvini, R. Sztajzel, M. Righini, P.A. Dorsaz, J. Alibegovic,
C. Bonvin, U. Sigwart, E. Camenzind, V. Verin, J. Sztajzel on behalf of NA.
University Hospital of Geneva, Cardiology, Geneva, Switzerland
Background and Purpose: The occurrence of atrial fibrillation (AF) after percutaneous
closure of a patent foramen ovale (PFO) for cryptogenic stroke has been
reported in a variable percentage of patients. However, its precise incidence and
mechanism are presently unclear and remain to be elucidated.
Methods and Results: We started from 2002 onwards an arrhythmia follow-up
(FU) protocol performing a 7-day event-loop-recording (ELR) at day 1, after 6 and
12 months in patients who underwent a percutaneous PFO closure procedure for
cryptogenic stroke. Ninety-two patients (Closure Group) were so far followed and
then compared to a similar Control Group of 51 patients who did not undergo the
PFO closure for several reasons. The incidence of AF was similar in both study
groups during a FU of 12 months, including 7.6% (95% CI: 3.1%-15.0%) in the
Closure Group and 7.8% (95% CI: 2.18%-18.9%) in the Control Group (p=1.0).
The presence of a large PFO was the only significant risk factor for the occurrence
of AF irrespective of the type of the administered treatment (i.e. interventional or
medical). The odds ratio was 6.596 (95% CI, 1.660–26.21; P=0.0051).
Conclusions: Patients with cryptogenic stroke and PFO had a rather high incidence
of AF during a FU of 12 months, irrespective if the PFO was percutaneously
closed or medically managed. The presence of a large PFO was the only
significant predictor of AF occurrence during FU. Meticulous AF detection protocols
should be performed in all cryptogenic stroke patients, especially in those
scheduled for PFO-closure.
P1903 Combined anatomical and electrogram-guided
approach in catheter ablation of atrial fibrillation
G.B. Nam, K.M. Park, K.J. Choi, Y.H. Kim. Asan Medical Center,
Univ Ulsan Coll Med, Cardiology, Seoul, Korea, Republic of
Purpose: Current catheter ablation of atrial fibrillation (AF) is focused
on the elimination of pulmonary vein (PV) potentials. Tailored approach based on
complex fractionated electrograms (CFE) has been proposed. Additive effect of
this electrogram-guided approach in addition to the anatomical PV antral isolation
has not been reported.
Methods: 1. Patients with symptomatic, drug-refractory AF (paroxysmal, 76, persistent,
29 pts) were included. 2. Catheter ablation was guided by fluoroscopy
or 3D mapping system (NavX or CARTO). 3. PV antral isolation (PVAI) was
performed targeting elimination or dissociation of PV potentials. After PVAI,
electrogram-guided ablation was continued targeting CFEs or high-frequency activity
relative to the surrounding areas. 4. End-point of the procedure was noninducibility
of AF in pts with paroxysmal AF (PAF), termination into sinus rhythm
in pts with persistent AF (PeAF).
Results: 1. In PAF, PVAI alone rendered AF non-inducible in 42 of 79 pts (55%).
After electrogram-guided ablation, AF became non-inducible in additional 12 pts
(16%), while only atrial flutters (AFL) were induced in 16 pts (21%). AF persisted
in 6 pts (8%) after this combined ablation procedure. In 16 pts with inducible
AFL (27 AFLs), mechanisms of tachycardia included right isthmus dependent in
5/27, perimitral in 4/27, roof-dependent in 4/27, focal in 8/27, and unknown in
6/27 AFLs. 2. In PeAF, PVAI restored sinus rhythm in 0/29 pts. After electrogramguided
ablation, AF converted directly into sinus rhythm in 2(7%) and into AFLs
in 19 pts (65%), while AF persisted in 8 pts (28%). In 19 pts with AFLs (38 AFLs)
converted from AF, mechanisms of tachycardia were right isthmus dependent in
12/38, perimitral in 11/38, roof-dependent in 5/38, focal in 6/38, and unknown in
4/38 AFLs.
Conclusions: Electrogram-guided ablation targeting CFEs after PVAI resulted in
non-inducibility of AF in pts with PAF, or conversion of AF into AFL in pts with
PeAF. The major mechanism of the induced or converted AFLs during this combined
procedure was macroreentry around the large anatomic obstacles such as
tricuspid/mitral annulus or PVs.
P1905 Anatomical differences in the coronary venous
system in patients with persistent atrial fibrillation
compared to patients in sinus rhythm
E. Arbelo Lainez, E. Caballero Dorta, J. Novoa Medina, A. Garcia
Quintana, A. Delgado Espinosa, C. Amador Gil, M.C. Rios Diaz,
A. Medina Fernandez-Aceytuno. Hospital de Gran Canaria Dr. Negrin, Servicio
de Cardiologia, Las Palmas De Gran Canaria, Spain
Introduction and Objective: The coronary sinus (CS) muscle sleeves have been
suggested to have role in the genesis of atrial fibrillation (AF), having been described
a higher probability of conversion to sinus rhythm (SR) by ablating at that
level in patients (p) with persistent AF. The aim was to describe the anatomy of
the coronary venous system in p with persistent AF.
Methods: The anatomy of the CS and its tributaries was studied by hyperemic
coronary venous return angiography and/or occlusive retrograde senovenography
in 319 p, 47 (15%) of which were in persistent AF (70% male, 64,8±10,5 years
left atrial diameter 47,5±6,6 mm).
Results: The diameter of the CS ostium was 17,3±5 mm with the presence of a
Thebesian valve in 37 p (79%) that covered 45,9±33,8% of the orifice and left an
opening into the right atrium of 12,1±6,3mm. The length of the CS was 42,3±12,8
mm and its diameter 13,3±2,7 mm, whereas that of the great cardiac vein (GCV)
was 10,7±2,7 mm. The oblique vein of Marshall was observed in 27 p (57%) and
the Vieussens valve (ViV) in 33 (70%), being the two associated in 25 p (53%). In
4 p an aneurismatic dilatation of the proximal CS (8,5%) was seen and in 32 (68%)
diastolic compression of the CS was present, 12 of which (25,5%) consisted of
a discrete muscular sleeve of 3 to 7 mm width. 4 p (8,5%) additionally showed
muscular sleeves over the tributary veins of the CS. The mean diameter of the
lateral vein was 4,2±1,4 mm. When comparing this group in persistent AF to the
272 p in SR, statistically significant differences were found in terms of diameter
of the CS ostium, the CS and GCV. The VoM were also more prevalent, with a
greater length and diameter. Finally, the ViV and an aneurismatic dilatation of the
proximal CS were also more frequent.
Conclusions: The anatomy of the CS and its tributaries has differential characteristics
in patients with persistent AF. This might play a role in the mechanisms
of AF or have implications in the design of the ablation procedure.
P1906 Time-dependent regional differences in sources of
oxidative stress in atrial fibrillation-induced
remodelling
S.N. Reilly1 , U. Schotten2 ,N.J.Alp1 , B. Casadei1 . 1University of Oxford, Cardiovascular Medicine, Oxford, United Kingdom;
2University of Maastricht, Physiology, Maastricht, Netherlands
Purpose: Atrial fibrillation (AF) is associated with electrical and structural atrial
remodelling and with increased myocardial oxidative stress, leading to reduced
nitric oxide (NO) bioavailability and NOS uncoupling. To date, it is unclear whether
oxidative stress is a trigger or a by-product of atrial remodeling. We evaluated the
time course and sources of superoxide (O2-) production in the right (RA) and left
(LA) atria of a goat model of pacing-induced AF.
Methods: Atrial O2- was assessed (lucigenin-enhanced chemiluminescence and
2-OH ethidium detection by HPLC) 14 days after the onset of AF (i.e. only electrical
remodeling presents) and after 6 months (electrical and structural remodeling).
The NOS cofactor BH4 and NOS activity were assessed by HPLC.
Results: In early AF O2- release was significanty increased in the LA only (Figure,
n=4). Inhibition of NADPH oxidases normalized O2- production in LA-AF but
had no effect in the RA or in SR. Atrial NOS activity and nNOS protein expression
but not BH4 level were reduced in both atria in AF.
In late AF, O2- release was greater in both atria (Figure). NADPH oxidase inhibition
did not affect O2- production, whereas inhibition of NOS or mitochondrial
Abstract P1905 – Characteristics of the CS in AF and SR
N Diameter Effective orifice Aneurismatic Diameter Diameter Presence of Diameter Presence of
of the CS ostium (mm) of the CS (mm) proximal CS (%) of the CS (mm) of the GCV (mm) VoM (%) of VoM (mm) ViV (%)
AF 47 17,3±5 12,1±6,3 8,5% 13,3±2,7 10,7±2,7 61% 2,04±0,7 75%
SR 272 13,4±4,4 8,9±4,1 2% 10,6±2,8 9,1±2,2 36% 1,6±0,8 57%
p

oxidases decreased O2- by 16±3.1% and 38.1±4.1%, respectively (P

290 Atrial fibrillation
cardioverted episode of persistent LAF, appear to be early and reliable predictors
of SR maintenance during the following year.
P1911 Transoesophageal echocardiographic findings in
patients with persistent atrial fibrillation at low risk for
stroke (CHADS 0 or 1)
I. Karnialiuk, I. Aliakseyeuskaya, M. Belskaya, Y. Persidskikh. The
Center of Cardiology, Minsk, Belarus
Purpose: Atrial fibrillation (AF) promotes the development of atrial thrombus (AT),
which can be revealed by transoesophageal echocardiography (TOE). This study
was aimed to compare various echocardiografic parameters, assessed during
transthoracic (TTE) and TOE in two groups of patients divided according to the
detection of thrombus in left atrial appendage (LAA).
Methods: TTE and TOE were performed in 56 patients with persistent nonrheumatic
AF at low risk for stroke (CHADS 0-1), who were planned to undergo
electrical cardioversion. The following parameters were analyzed: left atrial diameter
(LA), left ventricular endsystolic and enddiastolic diameter (LVes, LVed),
ejection fraction (EF). The presences of spontaneous echocontrast (SEC), LAA
area and flow velocity in the LAA (LAAa, LAA-flow) were measured during TOE.
Results: A thrombus was detected in 20 patients (35.7%) in the LAA. Out of
these patients, 85.0% vs. 16.7% of patients without thrombus showed moderate
or severe SEC (p

Fig. 1. Five types of merge errors.
nical match errors (10 errors, 43%), position change due to movement (5 errors,
21.7%), volume discrepancy with the CT and 3D map (4 errors, 17.4%), rotational
disarrangement (3 errors, 13.0%), and a bad CT image (1 error, 4.3%) (Figure 1).
A significant correlation between the LA size and match statistic data was determined
(r = 0.382, p = 0.01). Excluding patient movement, the match statistic
data showed a significant correlation with the LA size (r = 0.382, p = 0.002) and
practical match accuracy (r = -0.276, p = 0.026).
Conclusion: Although CARTO-Merge is very useful tool for AF ablation, for accurate
integration, more detailed mapping needs to be performed in order to attempt
to prevent movement, and to consider the position of patients, the CT image and
the LA size.
P1917 Coagulation dysfunction can be improved by statin in
atrial fibrillation regardless of cholesterol level
H.W. Park, N.S. Yoon, K.H. Kim, Y.J. Hong, J.H. Kim, Y.K. Ahn,
M.H. Jeong, J.G. Cho, J.C. Park, J.C. Kang. Chonnam National
University Hospital, Cardiovascular Medicine, Gwangju, Korea,
Republic of
Background: Circulating lipids appear to have prothrombotic and endotheliumaltering
properties. Atrial fibrillation is associated with thromboembolism, endothelial
dysfunction and abnormalities in coagulation system. However, it is not
certain whether statin may reverse prothombotic condition in atrial fibrillation.
Methods: Consecutive 306 atrial fibrillation patients were enrolled. Patients of
group I had dyslipidemia and received statin for more than 6 months (n=122,
59±11 years) and group II had not dyslipidemia and did not receive statin (n=184,
56±17 years). Markers for endothelial function (von-Willebrand factor, vWF; factor
8 related antigen and ristocetin cofactor), inflammation [WBCs, ESR, quantitative
and high sensitivity C-reactive protein] and coagulation system (fibrinogen, fibrinogen
degradation product, fibrin d-dimer) and platelet activity (p-selectin) were
measured.
Results: There were no significant differences in levels of markers for endothelial
dysfunction or inflammation between 2 groups. Total and LDL-cholesterol levels
were significantly higher in group I than in group II (185±44 mg/dL vs 169±35
mg/dL, p=0.001; 124±45mg/dL vs 102±29mg/dL, p=0.001). Even though fibrinogen
level was not different between 2 groups (group I; 303±88 mg/dL, group II;
287±84 mg/dL, p=0.107), fibrinogen degradation product level was significantly
lower in group I (1.1±1.7 ug/mL vs 2.2±4.6 ug/mL, p=0.024). D-dimer level also
was significantly lower in group I than group II (0.19±0.19 mg/L vs 0.27±0.29
mg/L, p= 0.013).
Conclusion: Statin showed beneficial effect on coagulation system in patients
with atrial fibrillation regardless of their cholesterol level and statin may reduce
thromboembolism in patients with atrial fibrillation
P1918 Pulmonary veins remodeling and transcatheter
ablation of atrial fibrillation
V. Scarabeo, G. De Simone, F. De Conti, P. Turrini, R. Verlato,
N. Lafisca, A. Zampiero, P. Piovesana. Camposampiero Hospital,
Cardiology, Camposampiero (Pd), Italy
Introduction: Radiofrequency circumferential isolation of the pulmonary veins is
a recently introduced ablation technique for the treatment of atrial fibrillation.
This study evaluated pulmonary veins remodeling at long term follow-up after
transcatheter ablation of atrial fibrillation.
Methods: 81 patients undergoing pulmonary veins isolation procedure were included.
All patients underwent transoesophageal echocardiogram before and
three months after the procedure. Anatomical and functional study of the pulmonary
veins was assessed. In case of abnormal pulmonary veins flow detection
the exam was repeated at 12 months follow-up.
Results: In 80 patients (98,7% of cases) visualization of veno-atrial junction was
successfully done. Before ablation mean diameter of the left superior pulmonary
vein resulted 1,19±0,64cm; left inferior pulmonary vein was 1,07±0,57cm;
right superior pulmonary vein 1,28±0,69cm and right inferior pulmonary vein
0,69±0,52cm. During follow-up there was a significant size reduction only of the
left inferior pulmonary vein (p=0,02), corresponding to a 10% lumen reduction, defined
as a mild stenosis. Venous flow analysis revealed increased flow velocity in
20 patients (≥100cm/s); in 4 patients flow velocity resulted >150 cm/s. Increased
flow velocity involved the left superior pulmonary vein and the right superior pulmonary
vein in the same number of patients (12 patients, 14,8%). 10 patients
Atrial fibrillation 291
(12,3%) had two vessels with increased flow velocity, 5 patients (6,1%) had one
vessel and 3 patients (3,7%) three vessels. One patient presented a 62,5% lumen
reduction compared to baseline value, resulting in a moderate stenosis, not
requiring interventional treatment. All patients were asymptomatic, and didn’t develop
pulmonary hypertension after procedure.
Conclusions: Study of pulmonary veins remodeling after ablation procedure
showed a significant lumen reduction (narrowing by 10%) only in the left inferior
pulmonary vein and a flow velocity increase of one or more vessels, but not
requiring treatment.
P1919 Have the same significance prior or acute atrial
fibrillation in octogenarian patients with acute
myocardial infarction?
J. Galcera Tomas1 , A. Melgarejo-Moreno2 , A. Padilla-Serrano3 ,
N. Alonso-Fernandez2 , J.H. De Egea-Garcia 3 , D. Martinez-Bano3 ,
A. Ortin-Freire3 , R. Jimenez-Sanchez3 , G. Escudero2 , P. Rodriguez-Garcia3 .
1 2 Murcia, Spain; Hospital Universitario Santa Maria del Rosell, Cartagena,
Spain; 3Hospital Universitario Virgen de la Arrixaca, Murcia, Spain
Purpose: To study peculiarities and prognostic significance of atrial fibrillation
(AF) depending of being previous (PAF) or presumed new appearance (NAAF) in
octogenarian patients (OP) with acute myocardial infraction (MI).
Methods: Prospectively in all OP admitted with acute MI from October 1997 to
October 2007 to the Coronary Unit of two hospital of Murcia Region of Spain,
incidence of AF and its classification as PAF or NAAF was established. Survival
was studied by Kaplan-Meier curves and their association with mortality by multivariable
analysis.
Results: Among 775 OP-patients, 211 had AF: PAF N=77 and NAAF N=134. Patients
with PAF were older (84±3 vs82±4, pI (64 vs 38% pII (21 vs 36%, p

292 Atrial fibrillation
Results: LA ejection fraction and fractional shortening were significantly decreased
in PAF. However, LA dimension, A-wave of transmitral flow, and LA emptying
volume were comparable between two groups. The parameters of atrial
dyssynchrony were summarized in Table.
Table 1. Atrial dyssynchrony
Control
Reservoir period
PAF p-value
Ts-SD 16.0±11.4 19.2±15.0 0.258
Tst-SD 29.7±11.9 39.7±15.8 0.001
Tsr-SD
Atrial contraction period
37.3±18.7 41.8±14.1 0.262
Ts-SD 25.9±16.3 33.6±18.6 0.035
Tsr-SD 29.5±14.1 36.9±17.1 0.084
Conclusions: In patients with recent onset PAF, atrial dyssynchrony was present.
Of all parameters, dyssynchronous atrial lengthening assessed by strain during
reservoir period showed the greatest difference between two groups.
P1921 Predictors of mortality in atrial fibrillation
T. Potpara1 ,M.Grujic2 ,J.Marinkovic2 , B. Vujisic2 ,N.Mujovic2 ,
M. Polovina2 . 1Institute for Cardiovascular Diseases, cardiology,
Belgrade, Serbia; 2Institute for Cardiovascular Diseases,KCS,
Belgrade, Serbia
The aim of the study was to assess mortality of patients treated for atrial fibrillation
(AF).
Out of 1100 pts with recently diagnosed AF, aged 52.7±12.0 years, 389 pts
(35.4%) were females, 442 pts (40.2%) had lone AF, 939 pts (85.4%) had normal
left ventricular systolic function and 33 pts (3.0%) had mitral annulus calcification
(MAC), while 104 pts (9.5%) had dilated cardiomyopathy and 58 pts (4.8%)
had coronary disease. AF was permanent from the beggining in 210 pts (19.1%).
Treatment of AF was in concordance with current recommendations, aiming to
control rhythm wherever possible, with 629 pts (57.2%) receiving beta blockers
at some point of the follow up, 656 pts (59.6%) treated with amiodarone, 524 pts
(47.6%) using digoxin at some point of the study, 841 pts (76.5%) received aspirin
for the different time lenght and 677 pts (61.5%) were antikoagulated either
continuously or periodically. We have also administered verapamil to total of 641
pts (58.3%), propafenon to 333 pts (30.3%), sotalol to 82 pts (7.5%) or various
drug combinations to total of 591 pts (53.7%) during the study.
During total follow up of 9.9±12.1 years (prospective 5.7±4.3), 297 pts (27.0%)
developed new cardiac disease and 112 pts (10.2%) noncardiac disorders. Hear
failure was evident in 155 pts (14.1%), 64 pts (5.8%) developed coronary disease
and thromboembolic events occured in 88 pts (8.0%). Total of 531 pts (48.3%) had
permanent AF until the end of the study. There were 85 deaths (7.7%) and 62 of
them (5.6%) were cardiovascular, including 25 sudden cardiac deaths. Mean age
of pts at time of death was 68.0±10.9 years and 10.7±6.6 years elapsed from first
episode of AF. In the time of death 18 pts (21.2%) were in sinus rhythm. Cumulative
5-year survival rate in our study group was 98.1% (95%CI, 97.3-98.9%) and
Cox proportional hazard regression model identified age at diagnosis of AF (HR
1.8, 95%CI 1.4-2.5), reduction of LVEF during follow up (HR 2.0, 95%CI 1.1-3.5),
heart failure during follow up (HR 2.7, 95% CI 1.5-4.6), thromboembolic events
(HR 1.8, 95%CI 1.0-3.3) and MAC (HR 3.8, 95%CI 1.5-9.6) as risk predictors of
all-cause death in patients with AF, while lone AF, use of beta blockers and use
of aspirin had protective impact on mortality (HR 0.2, 95% CI 0.1-0.5, HR 0.5,
95%CI 0.3-0.9 and HR 0.4, 95%CI 0.3-0.5, respectively), adjusted for sex, age
and initial differences among pts with paroxysmal, persistent and permanent AF.
The type of AF at the beggining and during the follow up had no independent,
significant relation to death in our study population.
P1922 Inflammation in lone atrial fibrillation: new insights by
coronary sinus thermography
E. Tsiamis1 , K. Toutouzas2 , M. Drakopoulou1 ,P.Dilaveris1 ,
K. Gatzoulis1 , J. Karabelas1 , S. Vaina1 , E. Stefanadi1 ,K.Vlassis1 ,
C. Stefanadis1 . 1Hippokration Hospital, Athens, Greece;
2Hippokration Hospital, First Department of Cardiology, Athens, Greece
Background: In the clinical setting there are conflicting results regarding the role
of inflammatory activation in atrial fibrillation (AF). Coronary sinus (CS) thermography
assesses myocardial heat production and is correlated with inflammatory
states. We investigated in patients with AF whether 1) there is increased CS blood
temperature and 2) the correlation of heat production with systemic inflammation.
Methods: We included patients with AF and subjects with sinus rhythm. Creactive
protein (CRP) levels were measured in all patients. CS and right atrium
(RA) blood temperature measurements were performed by a dedicated 7F thermography
catheter. �T was calculated by subtracting RA from CS blood temperature.
Results: We included 47 patients with AF and 23 subjects with sinus rhythm. We
stratified patients with AF into two groups: normotensive (AFN) and hypertensive
(AFH). �T was lower in the RA compared with the CS in AFH (37.27±0.52°C vs
37.47±0.54°C, p

manent AF were studied. The number of nerve fiber sections/mm 2 did not differ
in SR and AF pulmonary vein ostial regions (0.29±0.21 versus 0.28±0.20). Immunohistochemical
staining revealed mixed staining (adrenergic and cholinergic
staining) in 62% of all nerve fibers in SR and 56% in AF. Predominantly adrenergic
fibers were documented in 10% in SR and 39% in AF. 28% of nerve fibers
were predominantly stained for cholinergic fibers in SR and 5% in AF. There is a
significant difference in predominantly adrenergic nerve fibers in the left atrium of
patients with SR (0.02±0.17 versus 0.19±0.28, p=0.003) compared to permanent
AF
Conclusions: In patients with SR or AF mixed staining (adrenergic and cholinergic)
appears to be the predominant feature of autonomic nerves. Nerve densitiy
was similar in SR and AF. There are significantly more adrenergic nerve fibers
documented in permanent AF indicating a predmoninance of the adrenergic autonomic
nerve system on the cellular level. In addition there appears to be relative
partial atrial vagal denervation in permanent AF.
P1925 Long-term success of intraoperative ablation of
permanent atrial fibrillation
T. Deneke, K. Khargi, B. Lemke, D. Voss, T. Lawo, A. Laczkovics,
A. Muegge, M. Fritz. University Heart Center Bochum, Bg Klinik
Bergmannsheil, Med. Klinik Ii, Bochum, Germany
Short- and medium term rhythm success rates of intraoperative radiofrequency
ablation to treat permanent atrial fibrillation (AF) are well documented. Is conversion
to sinus rhythm (SR) long-term stable during follow-up of over 3 years?
Methods: 122 patients who had undergone intraoperative radiofrequency cooledtip
endocardial ablation (SICTRA) of permanent AF (> 1 year AF-duration) concomitant
to open heart surgery more than 3 years ago were followed up using
ECG and echocardiography. In 55% of patients only the left atrium and in 45%
both atria were treated using SICTRA. Stable SR was documented based on
ECG and atrial contraction based on atrio-ventricular Doppler-echo profile.
Results: 122 patients underwent mitral valve replacement in 18, mitral valve reconstruction
in 24, aortic valve replacement in 14, CABG procedures in 48 (including
10 patients with additional mitral valve surgery) and complex procedures
in 22 patients 52±14 (range 36-91) months ago. 69% of patients (84/122) were in
stable SR whereas 28% (34/122) were in AF and 3% (4/122) were in atrial flutter.
During the follow-up period 9 patients (7%) converted to AF after having documented
SR and 2 patients (2%) converted to atrial flutter. Comparing patients
after left to biatrial SICTRA no significant difference in rhythm success (74% versus
60%) was documented (p=0.59). Echocardiography revealed 67% of patients
in SR to have biatrial contraction.
Conclusions: SICTRA effectively restores long-term stable SR in 69% of patients.
9% of patients reconverted back to atrial arrhythmia more than 2 years
after first documentation of SR. There is no difference in long-term rhythm efficacy
when limiting the SICTRA to the left atrium alone.
P1926 Outcome after limited ablation concepts to treat long
lasting persistent AF: how much ablation is
necessary?
C. Piorkowski, A. Bollmann, M. Esato, P. Sommer, T. Gaspar,
A.Arya,C.Staab,G.Hindricks.Heart Center Universitiy Leipzig,
Electrophysiology, Leipzig, Germany
Background: Patients with persistent AF often need additional atrial ablation lesions
to modify the extensive substrate in addition to the trigger elimination. Current
treatment approaches tend to extensive procedures with partly biatrial ablations,
defragmentation, CS ablation, SVC isolation and different linear lesions.
The present prospective study analyzed the rhythm outcome after a limited left
atrial ablation concept in patients with persistent AF.
Methods: 48 consecutive patients with highly symptomatic AF (57±10 years,
83% male, AF history for 60 [24;95] months, 13% prior AF ablation, 52% lone
AF, LA size 48±7 mm) received a left atrial ablation. After cardioversion patients
were treated in SR with circumferential left atrial PV ablation. Additionally the
posterior LA was electrically isolated through placement of a "Box lesion", and a
mitral isthmus line was applied without enforcing line continuity through epicardial
ablations.
Results: Procedure, radiation and RF time measured 201±35, 38±15 and
65±20 min, respectively. In 46/48 (96%) patients all PVs and the posterior LA
were sucessfully isolated. In 14/48 (29%) patients ablation of the right atrial inferior
isthmus was performed due to clinically documented typical atrial flutter. At
the end of the procedure 22/48 (46%) patients were inducible for AF and atrial
macroreentrant tachycardia (MRT) on aggressive Burst stimulation at the atrial
refractory period. Postinterventional antiarrhythmic drug treatment was used in
case of symptomatic recurrences of AF/MRT only. Three months after ablation
7/48 (15%) patients received class Ic or class III antiarrhythmic drug treatment.
During 7-day-Holter after 3 and 6 months freedom from AF and/or MRT was documented
in 35/48 (73%) and 34/48 (71%) of the patients.
Conclusions: Using a limited left atrial ablation concept aiming on truly continuous
ablation lesions with electrophysiologically defined endpoints (complete PV
isolation + complete Box-lesion + mitral isthmus line) more than 70% of the patients
with previously persistent AF were free from recurrences of AF and/or MRT
after a single intervention with 3 and 6 months of follow-up. The value of addi-
Atrial fibrillation 293
tional extensive ablation approaches such as atrial defragmentation, CS ablation
and SVC isolation has to be judged against these results.
P1927 Combination method of 3D mapping (CARTO-Merge)
and the use of a large sized-lasso for atrial fibrillation
ablation
Y.S. Oh 1 ,J.H.Kim2 ,W.S.Shin2 ,S.W.Jang2 , Y.S. Choi2 ,C.S.Park2 ,
S.W. Jin 2 , H.J. Youn2 , M.Y. Lee2 ,T.H.Rho2 . 1St. Mary’s Hospital,
Internal Medicine, Seoul, Korea, Republic of; 2Seoul, Korea, Republic of
Background: It is well known that catheter ablation is very effective treatment
modality for the treatment of atrial fibrillation (AF). However many different treatment
strategies have been developed to improve the success rate. We have
produced good results with the combination method of a 3D mapping system
(CARTO) and the use of a large-sized-lasso.
Materials and Methods: A total of 154 patients were enrolled in the study. AF
ablation was performed due to drug refractory paroxysmal, persistent and permanent
AF. Sixty-nine patients underwent segmental pulmonary vein isolation
(PVI) (Group 1), 21 patients received 3D mapping guided circumferential ablation
(Group 2) and 64 patients were treated with the combination method of conventional
electroanatomic mapping (CARTO) or electroanatomic mapping and CT
imaging (CARTO-Merge) and the use of a large-sized (30–35 mm) lasso (Group
3). In the combination method, both a continous antral line on the CARTO map
and electrical conduction block at the antrum was confirmed by the use of the
lasso. We compared the recurrence rates of AF for each group and analyzed
factors affecting recurrence.
Results: There were 97 male patients and the mean age was 57±10 years. The
recurrence rate of paroxysmal AF in group 1, 2, and 3 patients was 29.6%, 23.1%,
and 15.1%, respectively, and recurrence rate of persistent AF was 40.0%, 33.3%,
and 223%, respectively. A significant decrease of recurrence between group 1
and group 3 patients (p = 0.042) was seen, but was not seen for patients in group
2 and group 3 (p = 0.053). The paroxysmal or the chronic AF group of patients
did not show any significant difference for recurrence among the three groups.
By multiple logistic regression, the use of a large sized-lasso was the strongest
predictable factor of recurrence (odds ratio: 2.18, 95% CI: 1.099–7.118) and the
LV ejection fraction was also a predictable factor for recurrence (p = 0.049).
Conclusion: The combination method of CARTO merge and the use of a large
sized-lasso might be a more effective strategy than segmental PVI and conventional
3D mapping guided circumferential ablation.
P1928 Development of depression and quality of life in
patients with atrial fibrillation
N. Rueb, M. Eberle, A. Henning, R. Laszlo, H.J. Weig, M. Gawaz,
J. Schreieck. Tubingen, Germany
Objectives: The development of individual quality of life (QOL) in patients
with atrial fibrillation (AF) considerably varies. This fact has been recognized
in controlled trials but remains poorly understood in clinical practice.
Methods: In a specialized cardiological center 103 consecutive patients (78 m,
25 f, mean age 66 years) with AF were registered and followed. QOL was measured
by the WHO modules "WHO-Five Well Being Index" (WHO-5) and "Major
Depression Inventory" (MDI). In a follow-up visit after 6 months these parameters
were collected again and compared to baseline. The following parameters
were collected at baseline: age, sex, symptoms of AF, type of AF, CAD, valvular
heart disease >II°, cardiomyopathy, left ventricular function, left ventricular hypertrophy,
left atrial dilation, pulmonary hypertension, QRS width, Diabetes, BMI,
physical activity, arterial hypertension, medication. The data presented here have
been documented within the scientific research projects of the Competence Network
on atrial fibrillation in Germany (AFNET). The results are not results of the
AFNET but only represent data of our institution.
Results: Most of the patients showed unchanged levels of their QOL and depression
(40% and 76%). A similar portion of the remaining patients revealed an improvement
or a deterioration respectively: concerning QOL 33% improvement vs.
27% deterioration, concernig depression 14% vs. 10%, respectively. None of the
collected parameters was a statistically significant predictor for an improvement of
QOL or depression. The following parameters were predictors for a deterioration
of QOL or depression:
QRS-width: 44% (12 out of 27) of patients with a wide QRS revealed a deterioration
in WHO-5 versus 21% (16 out of 76) with a narrow QRS (p=0.025).
LA-Dilation: 20% (9 out of 44) of patients with a dilated LA worsened in respect of
the MDI versus 2% (1 out of 42) of patients with normal LA-diameters (p=0.015).
Left ventricular hypertrophy (LVH): 18% (9 out of 51) of patients with LVH showed
a deterioration in respect of the MDI after 6 months versus 3% (1 out of 34) of
patients without LVH.
Severe pulmonary hypertension: All patients (2 out of 2) with PAP sys >60mmHg
got worse in the MDI.
Conclusions: Only a few of the clinical and echocardiographic parameters of
our patients with AF have a predictive significance for the development of well
being and depression in the following 6 months. A widened QRS goes along
with a deterioration in well being, a dilated left atrium, left ventricular hypertrophy
and severe pulmonary hypertension more frequently leads to an increase in the
degree of depression.
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294 Atrial fibrillation
P1929 Effect of rate or rhythm control on quality of life in
persistent atrial fibrillation. Results from the HOT
CAFE study
D.A. Kosior 1 , G. Opolski 1 , J. Kochanowski 1 , D. Rabczenko 2 .
1 Medical University of Warsaw, I Chair And Department of
Cardiology, Warsaw, Poland; 2 National Institute of Hygiene, Warsaw, Poland
Objectives: We studied the influence of rate control or rhythm control in patients
with persistent atrial fibrillation (AF) on quality of life (QoL).
Background: Atrial fibrillation may cause symptoms like fatigue and dyspnea,
which could impair QoL. Treatment of AF with either rate or rhythm control may
influence QoL.
Method: Investigators of HOT CAFE study enrolled 239 pts. (mean age 62,1±8,1
years; 36.0% female) in 7 centers; 62,8% had HT, 43,5% CAD, 17,6% diabetes
and 20,9% lone AF. In 60.3% pts. AF was the first episode of arrhythmia. Mean AF
duration was 165,2±73,2 days. Pts. were assigned randomly to rate-controlling
drugs, allowing AF to persist, or rhythm-controlling antiarrhythmic drugs, to maintain
sinus rhythm. Quality of life and arrhythmia related symptoms intensity was
assessed at initial and one year. Quality of life was studied using the Short Form
(SF)-36 health survey questionnaire. At baseline, QoL was compared with that
of healthy control subjects. Patient characteristics related to QoL changes were
determined.
Results: At baseline, QoL was lower in pts. with AF than in age-matched healthy
controls. Female (p

P1933 Left atrial appendage dominant frequency predicts
termination of atrial fibrillation during pulmonary vein
disconnection
L.F. Atea, A. Arenal, T. Datino, F. Atienza, L. Castilla, E. Gonzalez-
Torrecilla, J. Almendral, F. Fernandez-Aviles. Hospital Universitario
Gregorio Maranon, Cardiology Department, Madrid, Spain
Background: Termination of Atrial fibrillation (AF) during pulmonary vein (PV)
disconnection suggests a single firing pulmonary focus with fibrillatory conduction
to the rest of the atrium as AF mechanism. The left atrium dominant frequencies
(DF) characteristics during fibrillatory conduction from a rapid firing site are not
established yet.
Purpose: The aim of this study was to establish the effect of left atrium DF on PV
disconnection.
Methods: DF analysis was performed in 22 patients (8 women, 54±9 years) with
paroxysmal AF during spontaneous or induced episodes. DF were determined at
each PV antrum, posterior, lateral, septal, superior, inferior walls and at the left
atrial appendage (LAA). During left atrial circumferential ablation around both ipsilateral
PV with the end point of PV disconnection AF terminated in 13 patients
(Group I) in the remaining patients Group II AF continued despite all PV were disconnected.
No differences between groups I and II were found regarding maximal
DF (7,8±1,5 vs. 8,2±1,5 Hz p= ns) and minimal DF (4,6±,57 vs.4,7±,9 Hz p=ns).
In group II DF was significantly higher at the superior wall (6,3±1,1 vs. 5,3±, 5
Hz p 6 Hz at the LAA suggests the presence of extra pulmonary focus maintaining
AF.
P1934 Automatic measurement of fractionated electrograms
and their changes after pulmonary vein antral
isolation in patients with atrial fibrillation
G.B. Nam, K.M. Park, K.J. Choi, Y.H. Kim. Asan Medical Center,
Univ Ulsan Coll Med, Cardiology, Seoul, Korea, Republic of
Purpose: Tailored approach in atrial fibrillation (AF) ablation can be guided by
complex fractionated electrograms (CFE). Role of 3-dimentional mapping system
in the identification of the CFE and the changes of CFE after pulmonary vein (PV)
antral isolation (PVAI) have not been reported.
Methods: 1. NavX CFE map was obtained in 19 patients with AF (paroxysmal,
9, persistent, 10). 2. CFE was defined as electrograms with a mean cycle length
(CL) < 85ms in an 8-second window (P-P sensitivity 0.1mV, width slider 24ms,
refractory period 49ms). 3. To evaluate the reproducibility and validation of the
automatic measurement, CFE maps were repeated twice with each point at least
10 minutes apart, and CFE CLs of the individual points were compared with visual
determination of the fractionation in 260 points (6 patients). 4. PVAI was
performed targeting elimination or dissociation of PV potentials. In 7 patients,
post-PVAI CFE map was created to observe the changes in CFE after antral isolation.
After PVAI, defragmentation was continued at the CFE areas.
Results: 1. CFE maps were highly sensitive (80%) and specific (78%) for identification
of the visually determined fractionated electrograms. 2. Areas of fractionated
electrograms were spatially and temporally stable. CLs of the two CFE reproducibility
maps were highly correlated (correlation coefficient, 0.88) 3. In 5 patients
with paroxysmal AF, pre-ablation CFEs were recorded remote from the PV
antrum, but AF was not inducible after PVAI. In 7 patients (2 paroxysmal AF with
inducible AF after PVAI, 5 persistent AF) with pre/post-PVAI CFE maps, CFEs
that were present remote from the antrum were either abolished or markedly attenuated
after antral isolation.
Conclusions: 1. NavX CFE map was sensitive, specific and reproducible for automatic
identification of the fractionated electrograms. 2. Marked attenuation of
the remote CFEs after PVAI suggests CFE-CFE interaction or dependence of
CFE on the autonomic nervous system activity.
P1935 Effect of Renin-Angiotensin- System blockers on
maintenance of sinus rhythm in patients with
hypertension and atrial fibrillation after pulmonary
vein isolation
A. Berkowitsch, T. Neumann, M. Kuniss, S. Zaltsberg, R. Brand,
C. Hamm, H.F. Pitschner. Kerckhoff-Klinik, Cardiology Department,
Bad Nauheim, Germany
There is little known about the effect of the Renin-Angiotensin- System-blockers
(RASB) on maintenance of sinus rhythm after pulmonary vein isolation (PVI) in
pts with AF. The aim of this retrospective analysis was to detect possible differences
in outcome after PVI in pts with hypertension and AF receiving RASB and
those treated with other antihypertensive drugs. The secondary objective was
identification of patients who may potentially benefit from RASB after PVI. A total
of 182 consecutive pts with symptomatic AF and hypertension (paroxysmal
AF=137, male=113, age=58 yrs, LVEF=60%, CAD=23, median LA size 39x55
mm) were enrolled in the study: 82 pts were treated with a cryoballoon (Cryocath)
and 100 pts were ablated with an irrigated tip catheter (Cordis-Webster). A 7-day
continuous Holter ECG was performed after discharge and every three months.
Atrial fibrillation 295
Follow-up was 2 years. Antihypertensive drug therapy included: β-blockers =142,
50=diuretics, 32=Ca-antagonists, 64=ACE and 46=ARB. AF burden (total duration
of AF episodes within the last 3 months prior to PVI) was stratified as follows:
pts with PAF and AFB< 500 h/3 months were assigned a score of 1; pts with
PAF and AFB≥500 h – score 2; pts with PersAF – score 3. We also stratified patients
according to LA size: LA size< 45x60mm (score 0) and LA size ≥45x60mm
(score 1). Overall risk score was defined based on a scale of 1 to 4, expressed as
sum of individual AF burden and LA size scores. Analysis was based on multivariate
Cox-regression model and subgroup analysis Multivariate analysis showed
that the calculated risk score and the use of RASB were predictors of outcome.
Out of 91 pts with a risk score of 1, 52 pts received RASB. During follow-up, 44 pts
(85%) in this group were in sinus rhythm, compared with only 19 (49%) out of 39
patients with the same risk score who did not receive RASB (p

296 Atrial fibrillation
ment. Platelet P-selectin, platelet-leukocyte conjugates and leukocyte activation
markers were measured by flow-cytometry in basal conditions and after in vitro
ADP/collagen challenge. Plasma D-dimer, soluble P-selectin, IL-6 and ICAM-1
were measured by ELISA.
Results: In AF patients before parnaparin, platelet count and platelet P-selectin
expression were lower than in controls, while both soluble P-selectin and D-dimer
higher. Both basal and stimulated platelet-leukocyte conjugates were lower in
AF; leukocyte activation markers and cytokines were unchanged (Table). Parnaparin
significantly reduced D-dimer (to 192±7, p

hydrolysable, it would dissipate before the more tonic, proarrhythmic effects could
take hold.
Methods: Sustained AF episodes, lasted on average 8.6±2.2 min (n=32), were
elicited in anesthetized Wistar rats by programmed electrical stimulation via transesophageal
catheter. Rats were randomly and blindly assigned with a model drug,
acetylcholine (ACh, n=17), or saline injection (n=15) either via the tail vein or into
the right ventricular cavity, three minutes after the AF initiation.
Results: Intravenous injection of a model hydrolysable muscarinic agonist,
acetylcholine (0.2 mg/kg body weight), converted AF into sinus rhythm within
8.4±1.9 sec (n=10, p < 0.0001). The termination of AF episode was always accompanied
with transient bradycardia; the sinus rhythm gradually accelerated and
reached its pre-AF values within 10-20 sec following the injection.
Conclusion: Our evidence indicates that bolus administration of rapidly hydrolysable
muscarinic agonist could be an effective way for pharmacological conversion
of atrial fibrillation into the sinus rhythm.
P1942 Non-linear heart rate dynamics before sudden-onset
episodes of paroxysmal atrial fibrillation
H. Bonnemeier1 ,F.Kurz2 , M. Barantke 2 , U.K. Wiegand2 ,
H. Schunkert 2 . 1Universitaet zu Luebeck, Medizinische Klinik II,
Luebeck, Germany; 2Luebeck, Germany
Introduction: Beside bradycardia-, tachycardia- and ectopy-related initiation of
paroxysmal atrial fibrillation (pAF), those episodes without preceding rate or
rhythm changes (i.e. sudden onset (SO) episodes) are particulary interesting for
the investigation of autonomic fluctuations before spontaneous onset of pAF. We
hypothesized that there are significant alterations of beat-to-beat RR-interval fluctuations
before SO-pAF and tested this assumption in a large patient population
using parameters of non-linear heart-rate dynamics.
Methods: From a total of 20.546 consecutive Holter-recordings, 715 episodes of
pAF were identified in 350 patients. Detrended fluctuation analysis (DFA), approximate
entropy (APEn), and parameters of heart rate variability (HRV) were analysed
in 5-minute-segments before SO-pAF, and during AF-free day- and nighttime.
Results: A dominant portion of pAF onsets were SO-episodes (n=276; 39%),
299 (41%) ectopy-related, and 140 (20%) heart rate related. Time domain HRV
(SDNNi, SDANN, rMSSD, TI) significantly increased before pAF-onset. The low
frequency component (LF), the LF/HF-ratio, the Poincaré-SD2, and DFA also increased
before pAF-onset, whereas APEn significantly decreased.
Conclusions: In this first study providing detailed analysis of heart-rate dynamics
preceding SO-pAF-episodes, we were able to demonstrate that there are significant
pertubations of autonomic modulation preceding SO-pAF. These transient
abnormal changes of cardiac autonomic nervous control may predispose to the
development of pAF.
P1943 Analysis of atrial fibrillation episode after catheter
ablation of atrial fibrillation: long-term results of
received technology
A. Romanov, E. Pokuschalov, A. Turov, S. Artemenko, P. Shugaev,
V. Shabanov, I. Stenin, D. Elesin, N. Shirokova, V. Selina. Research
Institute of Circulation Pathology, Novosibirsk, Russian Federation
Purpose: The objective of this study was to assess the time course of atrial fibrillation
(AF) episodes before and after left atrial ablation and the percentage of
patients with complete freedom from AF after ablation by using continuously monitors
a patient’s ECG.
Methods: A total of 45 consecutive patients with highly symptomatic drug refractory
PAF (age, 52±10 years) underwent catheter ablation. The Insertable Cardiac
Monitor was implanted to all patients at least 5 days immediately before the ablation.
14 patients underwent PV isolation by segmental ostial catheter ablation
(SOCA), 16 patients underwent left atrial catheter ablation (LACA) to encircle the
Atrial fibrillation / Perspectives in heart failure treatment 297
PVs and 15 patients underwent left atrial GP ablation. During SOCA, ostial PV
potentials recorded with a ring catheter were targeted. LACA was performed by
encircling the left- and right-sided PVs 1 to 2 cm from the ostia and was guided
by an electroanatomic mapping system; ablation lines also were created in the
mitral isthmus and posterior left atrium. Target sites for GP ablation were defined
using the data of their anatomical location. Symptom-based monitoring was approximated
by analyzing days when patients indicated symptoms with an external
activator.
Results: A total of 4119 days were monitored. Out of the total 390 events triggered
by patient’s symptoms, 31% were confirmed as AF events (89) and 69%
were confirmed as non-AF events (198). Before ablation, 36 of 45 patients (80%)
had documented AF episodes. All episodes were symptomatic in 15 patients
(41,7%). In 20 patients (44,4%), both symptomatic and asymptomatic episodes
were recorded, whereas in 1 patients (2,7%) all documented AF episodes were
asymptomatic. After ablation, the percentage of patients with only asymptomatic
AF recurrences increased to 42% (P

298 Perspectives in heart failure treatment
P1945 Intravenous mildronate improves flow-mediated
vasodilatory response in stable chronic heart failure:
double-blind placebo-controlled crossover study
L. Voronkov, I. Shkurat, O. Lutsak. Institute of Cardiology, Heart
Failure, Kiev, Ukraine
Background: Taking to account recently established independent role of endothelial
dysfunction (ED) in chronic heart failure (CHF) progression and mortality,
normalization of ED may be considered as an important therapeutic goal in
CHF. Mildronate (trimethylhydrazinium propionate dihydrate) is a new, now clinically
tested in stable angina, partial fatty acids oxidation inhibitor with concomitant
experimentally established potent endothelium-mediated vasorelaxation properties.
Objective: To evaluate the ability of mildronate to modulate flow-mediated vasodilatory
response (FMVR) in stable CHF.
Method: 30 pts with stable CHF (NYHA II-III, left ventricular EF ≤ 40%) at
chronic (≥ 2 months) ACE-inhibitor/β-blocker/diuretic therapy were examined. All
pts signed informed consent for the participation in trial. A. brachialis diameter
was detected ultrasonographically at Sonoline Omnia system before (D1) and
after (D2) standard forearm cuff test (200 mm Hg during 5 min). FMVR was calculated
by formula: (D2 – D1)/D1 x 100%. Forearm cuff test also was performed
in 30 healthy age-matched controls. Placebo protocol (PP) was represented by
initial FMVR test (A), 30 min recovery period (B), 100 ml saline (0,85% NaCl)
infusion during 30 min (C), repeated FMVR test 30 min after end of infusion (D).
Points A, B and D of active drug protocol (ADP) were similar to PP; C point was
represented by mildronate 1000 mg infusion in 100 ml of saline during 30 min.
The interval between PP and ADP was 48 hours, at that in one group (15 pts) PP
was performed first and in other group (15 pts) – the ADP first. Neither pts nor
FMVR performer knew about presence/absence of active drug in infused solution.
Groups FMVR, % p A vs B
Baseline (A) After infusion (B)
CHF placebo protocol (I) 9,6±0,7 10,4±0,8 NS
CHF active drug protocol (II) 8,3±0,8 14,4±0,9 < 0,001
Controls 11,1±0,8 –
pIvsII NS < 0,001
p I vs controls < 0,01 –
p II vs contols < 0,001 –
Conclusion: Intravenous mildronate dramatically improves impaired FMVR in
conventionally treated stable CHF patients.
P1946 Influence of regeneration of heart muscle by
intracoronary autologous bone marrow cell
transplantation on the BNP levels in patients with
chronic ischemic heart disease
R. Turan, M. Brehm, M. Koestering, S. Steiner, T. Zeus, T. Bartsch,
S. Yokus, C.M. Schannwell, B.E. Strauer. Heinrich Heine University Duesseldorf,
Cardiology, Pneumology And Angiology, Duesseldorf, Germany
Introduction: We recently demonstrated in patients with chronic myocardial infarction
by intracoronary transplantation of autologous bone marrow mononuclear
cells (BMCs) after 3 months follow-up that the infarct size was reduced by 30%,
whereas the global LV ejection fraction increased by 15% and regional infarct wall
movement velocity by 57%. (The IACT Study)
We analyzed the influence of regeneration of human infarcted heart muscle by
intracoronary cell therapy after 3 months follow up on the BNP levels in PB
Methods and Results: Peripheral blood levels of BNP were measured by BNPassay
in 40 patients with chronic ischemic heart disease pre intracoronary cell
therapy as well as 3 months after intracoronary cell therapy. We showed in patients
with chronic myocardial infarction by intracoronary transplantation of autologous
bone marrow cells (BMC) after 3 months follow up a significant reduced
of infarct size and increase of global LV-ejection fraction as well as infarct wall
movement velocity. Clinically we observed significant improvement in NYHA classification
3 months after intracoronary stem cell therapy as compared to before
(p=0.002). Furthermore we found a significant decrease of the BNP levels in peripheral
blood 3 months after intracoronary stem cell therapy as compared to
before (p=0.002)
Conclusion: Selective intracoronary transplantation of autologous bone marrow
mononuclear cells reduces infarct size and improves LV-Function. In Addition
this intracoronary cell transplantation improves clinical symptoms in patients with
chronic ischemic heart disease
P1947 Clinical effects and safety profile of initial
monotherapy with bisoprolol versus enalapril in
elderly patients with heart failure
D. Dobre 1 , D.J. Van Veldhuisen 1 , M.A. Goulder 2 ,H.Krum 3 ,
R. Willenheimer 4 . 1 University Medical Centre Groningen, Clinical
Pharmacology, Groningen, Netherlands; 2 Nottingham Clinical Research Limited,
Nottingham, United Kingdom; 3 Monash University/Alfred Hospital, Melbourne,
Australia; 4 Heart Health Group and Lund University, Cardiology, Malmo, Sweden
Purpose: To assess the clinical effects and safety profile of initial monotherapy
with either bisoprolol or enalapril in elderly patients with heart failure (HF).
Methods: In CIBIS III, 1010 patients with mild to moderate HF, age ≥ 65 years
and left ventricular ejection fraction ≤ 35% were randomized to monotherapy with
bisoprolol or enalapril for 6 months. We evaluated the effect on the combined endpoint
of all-cause mortality or hospitalization, each individual end-point, causes of
death, signs and symptoms of HF, and safety profile. The primary end point of allcause
mortality or hospitalization, and mortality and hospitalizations separately,
were analyzed by Cox proportional hazards model with treatment as the only
independent variable.
Results: Bisoprolol had a similar effect as enalapril regarding the combined endpoint
of all-cause mortality or hospitalization (hazard ratio [HR] 1.02; 95% confidence
interval [CI] 0.78 to 1.33, p=0.90). Slightly fewer patients died on bisoprolol
than on enalapril (23 vs. 32, p=0.24) which was related to the number of sudden
deaths (8 vs. 16; p=0.11). On the other hand, more cases of worsening HF requiring
hospitalization or occurring while in hospital were observed in the bisoprolol
group (HR 1.67; 95% CI 1.04 to 2.70, P=0.03). The two groups were similar with
regard to treatment cessations (7% vs. 10%, p=0.11) and early introduction of the
second drug (8% vs. 7%, p=0.81).
Conclusions: Bisoprolol and enalapril had a similar effect on the combined endpoint
of mortality or hospitalization during 6 months monotherapy. Although a
trend to fewer deaths was observed with bisoprolol, this was offset by more HF
hospitalizations.
P1948 Antithrombotic drugs in patients with chronic heart
failure
M. Lainscak1 , L. Hodoscek-Majc2 , S. Von Haehling3 , W. Doehner3 ,
S.D. Anker 3 . 1University Clinic of Respiratory Diseases, Division
of Cardiology, Golnik, Slovenia; 2General Hospital Murska Sobota,
Department of Internal Medicine, Murska Sobota, Slovenia; 3Charite Campus
Virchow-Klinikum, Division of Applied Cachexia Research, Berlin, Germany
Background: Limited data supports the use of antithrombotic drugs (antiplatelets
and anticoagulants) in patients with chronic heart failure (CHF). According to recent
CHF guidelines, only patients with concomitant atrial fibrillation (AF) could be
treated, whereas AF guidelines suggest risk stratification (e.g. CHADS2 score).
Our aim was to investigate the prevalence and predictors of antithrombotic drugs
prescription in patients with CHF and their prognostic impact.
Methods: In our population based survey, we screened all discharges and deaths
from our community hospital (population 125.000) from 2001 to 2003. We identified
638 patients (73±10 years, 48% men, 74% NYHA class III) who were discharged
alive and had diagnosis of CHF according to ICD 10. Medical charts and
ECG recordings were reviewed in detail, and vital status was obtained from a
Central Population Registry.
Results: AF was present in 330 (52%) patients with CHF, who were older (74±10
vs 72±11 years, p=0.021), had lower eGFR (50±18 vs 53±21 mL/min, p=0.044)
and total cholesterol (4.6±1.6 vs 5.0±1.5 mmol/L, p=0.002) and higher uric acid
(434±145 vs 406±132 mmol/L, p=0.020). At discharge, patients with AF were
prescribed with more optimal treatment: ACE inhibitors (83% vs 75%, p=0.019,
OR 1.60, 95% CI 1.08-2.35), beta-blockers (31% vs 20%, p=0.003, OR 1.71,
95% CI 1.21-2.50), and spironolactone (49% vs 37%, p=0.003, OR 1.63, 95%
CI 1.19-2.24). Overall, antithrombotic drugs and warfarin were prescribed in 430
(67%) and 197 (31%) patients, respectively. CHADS2 score was ≥2 in 85% of
patients with AF. Patients with AF were more likely to receive antithrombotics
(n=274 [83%], OR 4.77, 95% CI 3.31-6.86) and warfarin (n=168 [51%], OR 9.98,
95% CI 6.43-15.48). AF was not associated with higher disk of death (HR 1.13,
95% CI 0.93-1.37). Kaplan-Meier and univariate Cox proportional hazard analysis
showed that use of warfarin (log rank test p=0.0008, HR 0.62, 95%CI 0.47-0.81)
but not of antiplatelet drugs (log rank test, p=0.34, HR 1.16, 95%CI 0.85-1.59)
was associated with reduced mortality in patients with AF. In a Cox proportional
hazard model, adjusted for age, gender, eGFR, total cholesterol, uric acid, and
treatment with ACE inhibitors, beta blockers, and spironolactone, the finding for
warfarin was borderline: HR 0.74, 95% CI 0.53-1.05.
Conclusions: In large unselected cohort of patients with CHF from a community
hospital, AF was very prevalent but it was not predictive of mortality. According to
CHADS2 score, warfarin was underprescribed. Warfarin but not antiplatelet drugs
were associated with better outcome in patients with AF.
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P1949 A first-in-human clinical trial of a novel chimeric
natriuretic peptide, CD-NP, in healthy subjects
C.Y. Lee, H.H. Chen, O. Lisy, S.M. Sandberg, D.M. Heublein,
J.C. Burnett Jr. Mayo Clinic & Mayo Clinic College of Medicine,
Medicine, Physiology, and Pharmacology, Rochester, Minnesota,
United States of America
Objectives: CD-NP is a novel Mayo-designed chimeric natriuretic peptide (NP)
which consists of the full-length 22 amino acids (AA) of human C-type NP (CNP)
and the 15-AA C-terminus of Dendroaspis NP (DNP). The rationale of its design
was to transform CNP, which is a ligand for the natriuretic peptide receptor (NPR)-
B and a venodilating peptide with minimal hypotensive and natriuretic effects, into
a CNP-like peptide with enhanced renal actions without inducing hypotension.
Preclinical canine studies have indeed demonstrated the augmented renal actions
of CD-NP with minimal effects on systemic blood pressure. We conducted a
first-in-human clinical trial to evaluate CD-NP for the first time in healthy subjects.
Methods: This phase I clinical trial consisted of 2 stages: an open-label sequential
dose-escalation study (stage 1) and a randomized, double-blind, placebo
(PLB)-controlled study (stage 2). For stage 1, three cohorts of 4 subjects each
were enrolled in the dose-escalation study (10, 17.5, or 25 ng/kg/min i.v. for 4
hours). For stage 2, ten subjects were randomized in the double-blind study (6:4
for CD-NP vs PLB) which evaluated the maximum tolerated dose (MTD, as determined
in stage 1) of CD-NP vs PLB i.v. for 4 hours. Mean±SE, P

300 Perspectives in heart failure treatment
of negative inotropy which increases FMR through coaptation force reduction.
After 3 month effects of B and I on FMR were comparable, but after 6 month FMR
incidence and severity were less in B with better exercise tolerability probably due
to improved contractility through better myocardial response to catecholamines
after long term use.
P1953 Rapid carvedilol up-titration in hospitalized patients
with systolic heart failure
M. Martinez-Selles, T. Datino, M. Alhama, F. Fernandez-Aviles.
Madrid, Spain
Background: Carvedilol rapid up-titration in patients with systolic
heart failure could have important clinical benefits, however its safety is unknown.
Methods: To evaluate if carvedilol can be safely up-titrated before hospital discharge,
we studied 372 consecutive patients, with left ventricular ejection fraction
(LVEF) 50 mg. Variables related to the discharge dose were also
related to the dose at the end of follow-up except in the case of previous betablockers
use.
Table 1. Discharge dose and dose at the end of follow-up
Carvedilol discharge dose* Carvedilol dose at p Carvedilol >50 mg daily at p
mg daily (n – %) the end of follow-up** the end of follow-up**
(mean±SD, mg daily) n (%)
0 (23 – 6%) 22.7±20.3 50% were randomized to 3 groups (n=40) in order to receive ramipril 10
mg/day (R), losartan 50 mg/day (LL) or losartan 100 mg/day (LH). Transmitral E
wave deceleration time (EDT), IVRT, duration of reversal in the pulmonary vein
(RPV) and transmitral A wave (RPV – A), index of left atrial volumes (LAVI) and
EF (LAEF) were obtained by TEE in 1, 30, 180 day follow up.
Results: Baseline characteristics were comparable between groups. In 30 day
EDT, IVRT and RPV - A were better in R, compare to LL and LH (EDT: R 133±11
ms* vs LL 122±10 ms vs LH 124±9 ms,*p< 0.05; IVRT R 52±6 ms* vs LL
42±4 msvs45±3 ms,*p< 0,05, RPV – A: 24±5 ms* vs 32±3 msvs29±2 ms;
*p < 0.05). In 180 day all parameters were better in LH and comparable between
R and LL (EDT: R 132±12 ms vs LL 129±13 ms vs LH 138±9 ms*,*p< 0.05;
IVRT R 52±6 msvsLL48±4 msvsLH58±5 ms*,*p< 0,05, RPV – A: R 22±4
ms vs LL 26±3 msvsLH18±3 ms*;*p< 0.05, LAVI: R 28±5 ml/m 2 vs LL 32±4
ml/m 2 vs LH 21±5 ml/m 2 *; *p < 0.01, LAEF: R 35±16% vs LL 33±12% vs LH
41±12%*, *p < 0.01)
Conclusion: Thus higher doses of L favorably alter diastolic function parameters
in DHF with decreased compliance probably through better RAAS control.
P1955 Medication adherence and aspects of heart failure
management-a cross sectional study in South Africa
V. Ruf 1 ,S.Stewart2 ,S.Pretorius3 , M. Kubheka3 ,
C. Lautenschlaeger1 ,P.Presek1 , K. Sliwa3 . 1Martin-Luther University Halle-Wittenberg, Halle (Saale), Germany; 2Baker Heart
Research Institute, Melbourne, Australia; 3Soweto Cardiovascular Research
Unit, Department of Cardiology, Soweto, Johannesburg, South Africa
Purpose: Despite its clinical importance there is a paucity of data on treatment
adherence in patients with heart failure (HF) in the African context. We examined
the pattern of treatment adherence in a large cohort of HF patients from Soweto,
South Africa.
Material and methods: The "Patient Compliance and Knowledge on Heart Failure
Survey" was initially developed, validated and then applied to 200 consecutive
HF patients with a left ventricular ejection fraction

P1957 Electrophysiological effects of levosimendan
administration in patients with advanced heart failure
secondary to ischemic or dilated cardiomyopathy
E.M. Kanoupakis, E.M. Kallergis, H.E. Mavrakis, G.M. Lyrarakis,
E.P. Koutalas, C. Goudis, E.G. Manios, P.E. Vardas. Heraklion
University Hospital, Department of Cardiology, Heraklion, Greece
Purpose: Levosimendan administration exerts favourable effects on systolic and
diastolic cardiac function, as well as on neurohormonal and inflammatory activation
of pts with CHF. However, this calcium sensitizing inotrope may have proarrhythmic
effects. The purpose of the present study was to evaluate the effects of
levosimendan infusion, on human cardiac electrophysiological properties.
Methods: In 11 stable pts (68±4.5 years) with left ventricular dysfunction
(EF20 mm Hg)
or heart rate (>20 beats/min), and improvement in quality of life, which would all
correspond to clinical effects of carvedilol, were more likely to be prescribed with
carvedilol target dose. In univariate analysis, patients with baseline NYHA class
III (OR 0.42, 95% CI 0.29-0.60) and with no change in NYHA class during survey
(OR 0.60, 95% CI 0.49-0.74) had lower chance to receive carvedilol target dose at
six months. In multivariate analysis, male gender, treatment with diuretics, arterial
hypertension, and blood pressure drop >20mm Hg were associated with higher
chance of receiving carvedilol target dose at six months. Same model showed,
that treatment with ACEI or angiotensin receptor blockers, arrhytmia, baseline
NYHA class III, no change in NYHA class during survey, experience of any side
effect and hospitalization significantly reduced the chance of receiving carvedilol
target dose at six months.
Conclusions: Carvedilol was well tolerated and improved well-being in patients
with CHF. Titration scheme was not followed in most of the patients and only 29%
of patients were treated with carvedilol target dose after six months of titration
period. Our results suggest that advanced stages of CHF, associated with deteri-
Perspectives in heart failure treatment 301
oration due to CHF severity or treatment side effects may be the main reason for
inadequate implementation of guidelines in clinical practice.
P1959 Blockade of the urotensin II receptor does not
attenuate cardiac remodeling in a model of
pressure-overload hypertrophy: functional and
histological assessment
A.R. Kompa1 , A. Phrommintikul2 , S.A. Douglas3 ,H.Krum1 .
1 2 Monash University, Medicine, Prahran, Australia; Chiang Mai
University, Internal Medicine, Chiang Mai, Thailand; 3GlaxoSmithKline, King of
Prussia, United States of America
Objective: Urotensin-II (UII) has been implicated in heart failure and hypertension.
Studies have shown that UII receptor (UTR) blockade improves survival and
attenuates functional and structural changes in a model of myocardial infarction.
However, there are limited studies examining UTR inhibition in models of cardiac
disease. In this study we examined the functional and histological effect of UTR
inhibition in a model of pressure-overload hypertrophy (POH).
Methods: POH was induced by constriction of the abdominal aorta above both
renal arteries, sham animals did not have their aorta constricted. Treatment with a
UTR antagonist, SB657510 (SB, 1500ppm in food) commenced the following day
and continued for 20 weeks. Cardiac function was assessed by echocardiography
(echo) and catheterization. Immunohistochemistry examined expression of left
ventricular (LV) collagen I and III.
Results: In POH animals, SB did not reduce hypertrophy on echo, or heart
weight, nor did it attenuate measures of diastolic function as assessed by Doppler
indices of E-wave deceleration time and isovolumic relaxation time. Furthermore,
SB did not reduce systemic and intra-cardiac (LV end diastolic and LV end systolic)
pressures. No change was observed in measures of systolic and diastolic
function obtained from pressure-volume (PV) loops (table). LV collagen I and I/III
ratio was significantly increased after POH; SB treatment did not attenuate these
measures (table).
Sham+ Veh Sham+ SB POH+ Veh POH+ SB
End systolic PV relationship (mmHg/μl) 0.74±0.08 0.52±0.07 0.41±0.06* 0.40±0.04
End diastolic PV relationship (mmHg/μl) 0.023±0.005 0.022±0.005 0.037±0.008 0.036±0.006
Preload recruitable stroke work (mmHg) 92.07±11.41 82.70±14.43 71.66±10.69 66.70±12.46
Tau – logistic (msec) 7.45±0.52 7.06±0.34 9.48±0.45* 8.50±0.41*
Collagen I (%age area) 12.27±1.34 12.88±0.86 17.62±1.20* 17.06±1.46*
Collagen III (%age area) 4.71±1.08 4.93±0.69 3.31±0.43 3.21±0.37*
Collagen I/III 3.06±0.58 2.94±0.34 5.82±0.98* 5.87±0.72**
Data presented as mean ± SEM, *p

302 Perspectives in heart failure treatment
P1961 Registry of Heart Failure (HF) and Acute Myocardial
Infarction (AMI) for andalucia: incidence of hf in acute
myocardial infarction and treatment with
antialdosteronic drugs
A. Martinez1 , M. Anguita2 , M. Jimenez Mena3 , J. Fenandez De
Bobadilla4 , R. Munoz4 on behalf of RAICIAM. 1Hospital Universitario Virgen
del Rocio, Sevilla, Spain; 2Hospital Universitario Reina Sofia, Cordoba, Spain;
3 4 Hospital Clinico Virgen de la Victoria, Malaga, Spain; Pfizer, Madrid, Spain
Objective: There is an interest in determining the incidence of Heart Failure (HF)
in patients suffering Acute Myocardial Infarction (AMI), and in assessing the therapeutic
approach, after the publication of the EPHESUS trial (Eplerenone Post-
Acute Myocardial Infarction Heart Failure Efficacy and Survival Study) in which a
mortality benefit for Eplerenone in patients with AMI, left ventricular ejection fraction
(LVEF) ≤ 0.40 and clinical signs of HF/diabetes mellitus was demonstrated.
The objective of the analysis was to determine the incidence of HF in AMI, the
profile of this HF subpopulation, the proportion of patients fitting in EPHESUS
profile and the use of antialdosteronic drugs.
Methods: The first 20 patients admitted with AMI in every hospital participating in
the registry were included. Analysed variables: gender, age, cardiovascular risk
factors, previous morbidities, variables related to the acute event, analytic data,
revascularization procedures and therapeutic approach. Follow-up six months after
discharge was also registered. Incidence of HF at admission and during admission
was evaluated. Profile of HF patients was assessed and compared with
the non-HF population. Prevalence of EPHESUS criteria and the use of antialdosteronic
drugs in this population was assessed.
Results: 906 patients, 71% males, 29% females; age: 67±13 years were included
in the registry. Incidence of HF was 20,4% (n=184 out of 902) and 13,7%
(n=119 out of 866 patients) at admission and at discharge respectively. HF was
more frequent for women (40%) than for men (25%) and HF patients were older
(73 vs 64). Previous HF was more prevalent in those with present heart failure
(21% vs 3%: p

for the population of Tayside, Scotland (400,000 people) was employed. Subjects
with incident CHF (n=774) between 1994 -2003 were identified through administrative
medical records based on ICD-9 code 428, ICD-10 code-50 and through
use of combined CHF medications of loop diuretics and ACE inhibitors. Subjects
were grouped according to oral hypoglycemic agents into three study cohorts:
metformin monotherapy (n= 90), sulfonylurea monotherapy (n= 381) and
combination (n= 303). Cox regression model was used to assess differences in
all–cause mortality, all-cause hospitalization and combination of all-cause hospitalization
or mortality by estimation of relative risks.
Results: Average age of subjects was (75±9.79 yrs), 55% were male. Compared
to sulfonylurea monotherapy, fewer deaths occurred in patients receiving
metformin only: 295 (77.4%) for sulfonylurea monotherapy versus 54 (60.0%) for
metformin monotherapy unadjusted risk ratio (R.R= 0.78, 95% CI 0.57 - 1.06). After
adjusting for differences between groups (age, sex, Creatinine and medication)
the risk ratio was (R.R= 0.90, 95% CI 0.63 - 1.28) and 201(66.3%) for combination
therapy (R.R= 0.72, 95% CI 0.58-0.88). One year mortality was also observed:
fewer deaths occurred in metformin and combination group compared with sulfonylurea
monotherapy the adjusted risk ratio for metformin was (R.R=0.48, 95%
CI 0.24-0.96) and (R.R= 0.66, 95% CI 0.46-0.96) for combination group.
A reduction of hospitalizations was also observed: 346(90.8%) for sulfonylurea
monotherapy versus 70 (77.8%) for metformin (R.R=0.74, 95% CI 0.57 to 0.96)
and 264(87.1%) for combination group (R.R=0.88, 95%CI 0.74-1.04). Combined
end points (all-cause hospitalization or mortality) was lower in metformin group
compared to sulfonylurea monotherapy (R.R= 0.74, 95% CI 0.56-0.99) and (R.R=
0.92, 95% CI 0.77-1.10) for combination group.
Conclusion: In this large observational of CHF patients treated with oral hypoglycemic
agents, those treated with metformin alone or in combination were associated
with a markedly lower risk of morbidity and mortality when compared to
those receiving sulfonylurea alone.
P1966 Effects of levosimendan versus dobutamine on left
atrial function in decompensated heart failure
D. Duman 1 ,F.Palit2 ,E.Simsek1 , B. Karadag3 ,S.Atalay4 ,
F. Akdogan4 ,A.Ozgultekin4 , R. Demirtunc4 . 1Haydarpasa Numune Training and Research Hosp, Cardiology, Istanbul, Turkey;
2 3 Haydarpasa Numune Training and Research Hosp, Istanbul, Turkey; University
of Istanbul, Cerrahpasa Sc. of Med, Cardiology, Istanbul, Turkey; 4Haydarpasa Numune Training and Research Hos, Istanbul, Turkey
Background: Although the effects of levosimendan on the left ventricle (LV) have
been studied, its effect on LA function is poorly understood despite its key role
in optimizing LV function. This study compared the effects of levosimendan and
dobutamine on left atrial (LA) and left ventricular (LV) functions in patients with
decompensated heart failure (DHF).
Methods: Seventy-four patients (mean age 64±10 yrs) with DHF and LV ejection
fraction (EF) ≤ 0.35 were randomized to levosimendan (n=37) and dobutamine
(n= 37) groups. LA active emptying fraction (AEF) and LA passive emptying fraction
(PEF), the ratio of mitral inflow early diastolic velocity to annulus velocity (E/e)
were evaluated with with pulsed wave and tissue Doppler together with plasma
B-type natriuretic peptide (BNP) levels measurements before and after drug infusion.
Results: The mean BNP, AEF and EF decreased in both the levosimendan and
dobutamine groups although, the reductions of BNP and AEF were significantly
greater in levosimendan group (-624±666 pg/ml vs. -281±276, P

304 Perspectives in heart failure treatment / Heart failure: peripheral mechanisms
Afterload-lowering therapy significantly reduced BNP levels during the first 6hours
(1336pg/ml [788-2302] initial vs 1136pg/ml [704-2273] 6hours, p=0.034) and continued
to significantly decrease BNP levels every 6hours until 36hours. Overall,
afterload-lowering therapy decreased BNP levels by 33% (p

P1973 Effect of ursodeoxycholic acid on peripheral blood
flow, immune function & markers of neurohormonal
activation in chronic heart failure: a randomised,
placebo-controlled, double-blind cross-over study
S. Von Haehling 1 ,E.A.Jankowska2 ,A.Vazir1 ,P.R.Kalra1 ,
A. Sandek3 , W. Doehner3 ,H.D.Volk3 , P.A. Poole-Wilson1 , S.D. Anker3 .
1National Heart & Lung Institute, Clinical Cardiology, London, United Kingdom;
2 3 Military Hospital, Wroclaw, Poland; Charite Medical School, Applied Cachexia
Research, Dept. Cardiology, Berlin, Germany
Background: Inflammation contributes to increased mortality and to the development
of endothelial dysfunction in patients with chronic heart failure (CHF). Endotoxin,
a bacterial cell wall component, which enters the circulation through the
oedematous gut wall, could be the responsible trigger. We tested the hypothesis
that ursodeoxycholic acid (UDCA), a bile acid that inhibits endotoxin absorption
through the gut wall, would improve endothelial and immune function in CHF patients.
Methods: In a placebo-controlled, double-blind, cross-overstudy, 16 male CHF
patients (age 66±3y, 75% ischaemic aetiology, NYHA class 2.4±0.1, LVEF
31±2%[all 0.7). UDCA decreased WBC (6.9±0.4
vs 7.6±0.4,p=0.0075), absolute neutrophil (4.6±0.4 vs 5.1±0.4, p=0.025), and
lymphocyte count (1.5±0.1 vs 1.7±0.1, p=0.013) compared to placebo. UDCA
decreased plasma values of aspartate aminotransferase (AST, 19±2 vs22±1,
p=0.025) and gamma-glutamyl transpeptidase (gGT, 29±3 vs37±6,p=0.0094)
compared to placebo.
Conclusions: UDCA administration is safe in patients with CHF. UDCA improves
endothelial function, possibly by micell formation around endotoxin. Furthermore,
UDCA improves liver function and decreases the number of neutrophils and lymphocytes
in patients with CHF.
P1974 The impact of irbesartan on impaired insulin
sensitivity in chronic heart failure - results from a
placebo-controlled, double blinded, randomized proof
of concept-trial
W. Doehner1 , T. Karhausen1 , C. Kennecke 1 , J. Todorovic 1 ,
M. Rauchhaus1 , A. Sandek1 , M. Lainscak2 , S. Von Haehling1 , S.D. Anker1 .
1Charite Medical School Campus Virchow Hosp., Applied Cachexia Research,
Dpt of Cardiology, Berlin, Germany; 2General Hospital Murska Sobota, Internal
Medicine, Murska Sobota, Slovenia
Background: Impaired insulin sensitivity (Si) is common in chronic heart failure
(CHF), contributes to symptomatic status and independently predicts prognosis.
The angiotensin II-receptor antagonist irbesartan (ARA) has been observed to
improve insulin sensitivity via peroxisome proliferator-activated receptor gamma
(PPAR gamma). Whether this effect can be detected in the clinical setting of
chronic heart failure has not been investigated.
Methods: In a placebo-controlled, double-blinded, 2:1-randomized study design
we investigated 36 ambulatory patients with stable ischaemic CHF (age 63±9y,
BMI 28.2±3.9kg/m 2 , peakVO2 16.6±4.8mL/kg/min all mean ±SD). All patients
were free of diabetes and without antidiabetic therapy. Irbesartan or placebo was
given on top of standard optimum CHF therapy including ACE inhibitor (target
dose 300mg/d) for 16 weeks including a 4-week up-titration period. Si (primary
endpoint) was assessed at baseline and after therapy using the minimal modelling
technique from glucose and insulin profiles of a frequently sampled intravenous
glucose tolerance test.
Results: At baseline both groups were similar for age, NYHA class, peak
VO2, BMI, body composition (DEXA scan), and main clinical characteristics.
Si was 2.51±1.58 min-1.μU.mL-1.104 in the study population, which is 30%
lower than in healthy controls of similar age (P

306 Heart failure: peripheral mechanisms
P1977 Skeletal muscle alterations in chronic heart failure:
Differential effects of left ventricular dysfunction on
catabolic activation in the quadriceps and the
diaphragm
N. Mangner1 ,S.Gielen1 ,B.Weikert1 , M. Sandri 1 , R. Hoellriegel1 ,
V. Adams1 , R. Hambrecht2 , G. Schuler1 . 1University Leipzig - Heart
Center, Department for Cardiology, Leipzig, Germany; 2Klinik Links der Weser -
Heart Center, Bremen, Germany
Progressive muscle wasting is recognized as major cause of exercise intolerance
in chronic heart failure (CHF). The catabolic process is in part mediated by the
muscle specific E3-Ligase Murf-1 via activation of the ubiquitin proteasome system.
It is, however, unclear if respiratory muscles are equally affected by muscle
catabolism as compared to peripheral skeletal muscles: Aim of this study was
therefore to examine the differential effects of left ventricular dysfunction on expression
of E3-Ligase Murf-1 and the activity of manganese superoxiddismutase
(Mn-SOD) in quadriceps muscle (Qua) and diaphragm (Dia) in LAD-ligated rats
(MI).
Methods: Twelve weeks after operation left ventricular function was assessed in
MI (n=12) and sham operated (C, n=9) rats using echocardiography and Millarcatheter.
Murf-1 protein expression was quantified using Western Blot and Mn-
SOD activity was measured in Qua and Dia.
Results: Compared to C, LAD-Ligation resulted in a severe left ventricular dysfunction
(EF: 33.4±3.3 vs. 64.8±2.6% (p

=0.31, p=0.0003) and QUICKI (r=0.29, p=0.0008). HOMA identified impaired insulin
sensitivity in CHF vs controls (3.45±0.29 vs 1.39±0.19) as did FIRI (3.10 vs
0.26) and QUICKI (0.34±0.01 vs 0.39±0.004, all p

308 Cardiac surgery and transplantation
P1985 Cellular implant follow-up in chronic cardiopathy
produced by American trypanosomiasis (Chagas’
disease)
J.C. Trainini 1 , N. Lago 2 , J. Bordone 2 , J. Mouras 2 , J. Barisani 2 ,
A. Riarte 2 ,A.Ruiz 2 , J.C. Chachques 3 . 1 Presidente Peron Hospital,
Cardiac Surgery Department, Buenos Aires, Argentina; 2 Presidente
Peron Hospital, Cardiovascular Surgery, Avellaneda, Argentina; 3 Pompidou
Hospital, Cardiovascular Surgery, Paris, France
Objectives: Chagas’disease is presented in very important number of transplantation
candidates in South America. Your etiology is the Cruzi trypanosoma, which
produces in the heart severe arrhythmias, dilated cardiomyopathy, heart failure
with death prognostic. The purpose of this clinical study was to evaluate the performance
of the bone marrow stem cells implant in heart failure for Chagas-Mazza
disease.
Methods: Over 70 patients implanted with bone marrow stem cells 7 had chronic
chagasic cardiopathy. About these last, 5 consecutive patients had a follow-up of
22.8±13.3 months. These patients with an age of 55.8±8.1 years, presented left
ventricular failure. The preoperative data showed an average of functional class:
2.6±0.5 (NYHA), left ventricular ejection fraction: 26.4±5.7%, left ventricular diastolic
diameter: 61.6±5.6 mm and the left ventricular systolic diameter: 46.9±6.3
mm. Enriched suspension of mononuclear stem cells diluted in autologous serum
containing (average) 10.6±7 mlwith1.43±0.6 (E+08) cells; CD34+: 5.07±9.51
(E+06); CD133+: 5.11±4.3 (E+06). The approach was made by intracoronary
way.
Results: There was one mortality at 17 months by arrhythmia. Blind echocardiography
and radioisotopic analysis showed that ejection fraction improved
from 26.4±5.7% to 35.6±5.3% (p=0.05) and the class functional decrease from
2.6±0.5 to 1±0 (p

P1989 Hormonal mechanisms of cachexia in heart failure
and weight gain after heart transplantation
L.H. Lund1 , J.J. Williams2 ,P.Freda2 , J.J. Lamanca3 ,
S.B. Heymsfield4 , T.H. Lejemtel5 , D.M. Mancini 2 . 1Karolinska University Hospital, Cardiology Department, Stockholm, Sweden;
2 3 Columbia University, New York, United States of America; Salisbury University,
Salisbury, United States of America; 4Merck Pharmaceuticals, New Jersey,
United States of America; 5Tulane University, New Orleans, United States of
America
Objectives: Heart failure (HF) is associated with cachexia and heart transplantation
(HTx) with weight gain independent of steroid therapy. The mechanisms may
be related to hormonal changes.
Methods: We examined anabolic (insulin, growth hormone (GH) and its downstream
mediator insulin-like growth factor-1 (IGF-1)), anorexic (leptin) and
appetite-stimulating/anabolic (ghrelin) hormones, hunger and caloric intake, and
body composition in 12 HF patients awaiting HTx, 12 patients who had gained
18±8 kgover13±9 months since HTx and 7 obese controls (Ctrl). Seven of the
12 HF patients were followed for longitudinal analysis post HTx.
Results: Insulin resistance was present in HF and HTx and correlated with BMI
in HTx but not in HF. GH was elevated in HF and IGF-1 in HTx. Leptin was higher
in HTx. Ghrelin over 5 hours prior to a test meal was elevated in HF, hunger was
equal and caloric intake was lower in HF (table). The longitudinal study confirmed
these findings.
Ctrl (n=7) HF (n=12) HTx (n=12) p
Age (years) 42±14 52±16 47±18 0.46
Male/Female (n) 5/2 10/2 11/1 0.54
BMI (kg/m2 ) 28±4 23±3 32±6

310 Cardiomyopathy
death rates in the 2 cohorts were similar in all pts: 2, 5, 7, 10% vs 3, 7, 14, 17%,
p=NS.
Conclusions: An early diagnosis, secondary to the screening program of familial
cases is associated to a better outcomes with respect to sporadic forms. However
the sudden death rate and the overall outcome were similar after risk stratification
between familial and sporadic forms.
P1993 Septic cardiomyopathy: role of iNOS and eNOS in a
murine model of sepsis
A. Van De Sandt1 , A. Goedecke 2 , R. Windler3 , S. Becher1 ,
T. Rassaf3 , C. Weber4 ,M.Kelm3 , J. Schrader2 ,M.W.Merx3 . 1IZKF Biomat RWTH, Aachen, Germany; 2Physiology, University Hospital,
Duesseldorf, Germany; 3Cardiology Dep., University Hospital RWTH, Aachen,
Germany; 4IMCAR, RWTH Aachen, Aachen, Germany
Purpose: Nitric oxide (NO) plays a central role in the pathogenesis of septic cardiomyopathy.
However, the relative contribution of inducible nitric oxide synthase (iNOS) and
endothelial nitric oxide synthase (eNOS) as high-capacity NO-producing enzymes
and their involvement in the detrimental cardiac alterations in the setting
of septic cardiomyopathy remain unclear. Having demonstrated an absence of
hypotension resulting in a significantly improved survival in septic eNOS-/- mice.
The aim of this study is to elucidate the influence of eNOS and iNOS on cardiac
parameters in the clinically relevant polymicrobial cecum ligation and puncture
(CLP) model of sepsis.
Methods: B6/c57 wildtype (WT) and eNOS-/- mice were rendered septic by
CLP or sham-operated. Immediately, treatment with the selective iNOS-inhibitor
1400W (6,6 mg/kg BW i.p. and s.c.) or placebo was initiated. At 12 hours after
sepsis induction heart function was assessed by pressure-volume loops using a
1.4 Fr Millar catheter placed in the left ventricle of anesthetized mice.
Results: dPdTmax was diminished only in septic wildtype (WT clp, n=6 vs.
wt sham, n=7: dPdtmax: 10981±1100,14mmHg vs. dPdtmax: 13408±826,64
mmHg, p

or more of the following ECG changes: repolarization ST/T abnormalities in 209
(80%), pathologic Q waves (Q waves ≥0.04 s in duration or ≥25% of the height of
the ensuing R wave) in 103 (39.6%); left atrial enlargement in 75 (28.8%), intraventricular
conduction abnormalities (QRS duration ≥90 ms) in 71 (27.3%) and
left axis deviation in 9 (3.5%). ECG tracings showed isolated increase of QRS
voltages in 5 HCM patients (1.9%) and were completely normal in 14 (5.4%).
Compared with patients with HCM, trained athletes significantly more often had
isolated voltage criteria for LVH (403, 40%; p

312 Cardiomyopathy
P2000 Cardiac fibrosis and low QRS amplitudes are
mutation specific clinical features in subjects with
hereditary DCM due to mutations in phospholamban
M.G. Posch 1 ,A.Perrot 1 , C. Geier 1 ,G.Schmidt 2 , H.B. Lehmkuhl 2 ,
R. Hetzer 2 ,R.Dietz 1 , M. Gutberlet 3 ,W.Haverkamp 1 , C. Ozcelik 1 .
1 Charite - Universitaetsmedizin Berlin, Cardiogenetic Lab (Haus 129), Berlin,
Germany; 2 German Heart Institute Berlin, Cardiothoracic and Vascular Surgery,
Berlin, Germany; 3 University of Leipzig, Diagnostic and Interventional Radiology,
Berlin, Germany
Purpose: Mutations in phospholamban (PLN) were reported as a rare cause for
familial DCM (FDCM). Low-voltage ECG (LVE) was described as a clinical feature
of PLN mutation carriers in one greek family. Yet, previous reports are inconsistent
about a specific phenotype. The purpose of this study was to assess a specific
cardiac phenotype of subjects affected by FDCM due to a mutation in PLN.
Methods: We prospectively studied twenty relatives of a large German FDCM
family with LVE. The phenotyping protocol included ECG, Holter-ECG, echocardiography
(including TDI), cardiac magnetic resonance imaging (CMR) and
75-lead body surface potential mapping (BSPM). Medical charts of four deceased
family members were reviewed. The coding region of PLN was directly
sequenced.
Results: We identified a heterozygous in frame deletion of codon 14 in the PLN
gene (PLN-R14Del) in seven family subjects. The mutation was previously shown
to be pathogenic for human DCM and cosegregated with the disease in the pedigree.
Penetrance of DCM was age and gender dependent. Affected individuals
suffer from severe heart failure associated with cardiac deaths between ages of
26-50. Interestingly, we identified LVE as an early sign for the disease. Three dimensional
reconstructions of cardiac electrical currents by use of BSPM allowed
us to link LVE to regions of extensive cardiac fibrosis as assessed by Gadolinium
late enhancement (LE) in CMR. Therefore, cardiac fibrosis constitutes the
pathogenic substrate for LVE in patients with the PLN-R14Del mutation.
Conclusion: We present a family suffering from a severe form of fDCM associated
with cardiac fibrosis and LVE due to the PLN-R14Del mutation. According to
our results LVE is a specific phenotype in FDCM patients with the PLN-R14 Del
mutation. Therefore, it is highly recommendable to screen patients with DCM and
LVE in the gene encoding PLN.
P2001 Right ventricular involvement in Fabry Disease
G. Dostalova 1 , T. Palecek2 , P. Kuchynka2 ,D.Karetova2 ,J.Bultas2 ,
M. Elleder2 , A. Linhart 2 on behalf of Cardiovascular research
project of the Charles University Prague, nr. 0021620817. 1General Teaching Hospital, 2nd Department of Internal Medicine, Prague 2,
Czech Republic; 2Prague, Czech Republic
Background: Fabry disease (FD) is characterized by intracellular deposition of
neutral glycosphingolipids. Left ventricular hypertrophy (LVH) is a hallmark cardiac
manifestation of FD, however right ventricular (RV) involvement is far less
known.
Objectives: The purpose of this study was to describe RV structural and functional
changes in FD.
Methods: A detailed echocardiographic examination including the assessment of
RV size, thickness, systolic function and filling pressure together with the evaluation
of right atrial (RA) size was performed in 58 patients with proven FD (mean
age 40±16 years, 24 males).
Results: RV hypertrophy was present in 40% of affected subjects with similar
prevalence in both genders. Almost two thirds of patients with LVH also exhibited
RV hypertrophy. RV dilatation was not present in any subject. RV systolic dysfunction
was noted only in one female. Elevation of RV filling pressure was found
in 9% of the patients. RA dilatation was noted in 48% of subjects, and was frequently
associated with RV hypertrophy. A significant correlation between RV wall
thickness and age (r=0.52, p

P2004 Association between cardiovascular risk factors,
impaired myocardial blood flow and ventricular
remodelling in patients with idiopathic left ventricular
dysfunction
D. Neglia1 ,D.Rovai1 ,E.Rizza2 ,F.Bigazzi1 ,S.Masi1 ,C.Simi1 ,
T. Sampietro 1 ,A.L’abbate1 . 1Pisa, Italy; 2Bologna, Italy
Background: In patients with idiopathic left ventricular (LV) systolic dysfunction,
absolute myocardial blood flow (MBF) is frequently impaired due to coronary microvascular
disease and may predict progressive deterioration of cardiac function.
Purpose: We tested the hypothesis that abnormal MBF and LV dysfunction in
these patients are related with coronary risk factors as combined in the Framingham
estimated coronary heart disease (CHD) risk.
Methods: A group of 64 patients with systolic LV dysfunction (48 males, age
61±9 yrs,LVEF38±9%, range 20-53%) and angiographically normal coronary
arteries were studied. Absolute MBF (ml/min/g) was measured by positron emission
tomography, using 13N-Ammonia as a flow tracer, at rest and during i.v.
dipyridamole infusion (0.56 mg/kg over 4 min). LV function was assessed by 2D-
Echo measurements of LVEF, LV end-diastolic diameter (LVEDD, mm) and LV
mass index (LVMI, g/m 2 ). The estimated Framingham CHD risk was based on
age, sex, blood pressure, cigarette smoking, LDL and HDL cholesterol and diabetes.
Results: CHD risk ranged from 4% to 56%. With increasing tertiles of CHD risk,
MBF decreased, both at rest (P=0.043) and during vasodilation (P=0.026) (Figure).
With increasing CHD risk, LVEDD and LVMI increased (for LVEDD 58±5,
63±9 and 65±6, P=0.010; for LVMI 128±31, 141±29 and 154±26, P=0.037)
while LVEF did not significantly change.
MBF values and CHD risk tertiles.
Conclusion: In patients with idiopathic LV dysfunction, an increase in CHD risk
is associated with a reduction in MBF and an increase in LV dimensions, suggesting
that cardiovascular risk factors are related with the extent of coronary
microvascular dysfunction and LV functional remodelling.
P2005 Preamplification techniques for real-time RT-PCR
analyses of endomyocardial biopsies
M. Noutsias1 , M. Rohde1 , K. Klippert 2 , K. Blunert 1 ,M.Hummel1 ,
R. Hetzer3 , U. Kuehl1 , H.P. Schultheiss1 ,H.D.Volk2 ,K.Kotsch2 .
1Charite - Campus Benjamin Franklin, Department of Cardiology &
Pneumonology, Berlin, Germany; 2Charite - Campus Mitte, Institute of Medical
Immunology, Berlin, Germany; 3German Heart Institute Berlin, Cardiovascular
Surgery, Berlin, Germany
Background: Due to the limited RNA amounts from endomyocardial biopsies
(EMBs) and low expression levels of certain genes, gene expression analyses by
conventional real-time RT-PCR are restrained in EMBs. We applied two preamplification
techniques, the TaqMan ® PreAmp Master Mix (T-PreAmp) and a multiplex
preamplification following a sequence specific reverse transcription (SSRT-
PreAmp).
Results: T-PreAmp encompassing 92 gene assays with 14 cycles resulted
in a mean improvement of 7.24+0.33 Ct values. The coefficients for inter-
(1.89+0.48%) and intra-assay variation (0.85+0.45%) were low for all gene assays
tested (40ms in 11%). At signal averaged ECG late potentials were
present in 58% of pts. At 2D echocardiography, mean right ventricle (RV) enddiastolic
area was 30±8 cm 2 , and RV fractional area contraction (FAC) 30±13%;
RV aneurysms were present in 67%. RV systolic dysfunction (FAC

314 Cardiomyopathy
(11%) experienced death/heart transplantation (D/HTx), 6 (3%) died for refractory
HF; 4 pts (2%) underwent status one heart transplantation; 6 pts (3%) died
suddenly; one (0.5%) for extracardiac disease and 3 (1.6%) for unknown reason.
Conclusions: ARVC is a relatively uncommon disease, frequently with familial
transmission. The disease tipically begins in the early age, clinical presentation
with symptomatic or sustained ventricular arrhythmias is frequent; LV involvement
is present in one third of cases at enrolment. The overall prognosis is not severe
in the long term.
P2008 Changing mortality in dilated cardiomyopathy in the
last 30 years
A. Di Lenarda1 ,M.Merlo1 , G. Barbati 2 ,A.Pivetta1 ,S.Pyxaras1 ,
A. Magagnin1 ,G.Finocchiaro1 , L. Dell’angela1 , G. Sabbadini1 ,
G. Sinagra 1 on behalf of Heart Muscle Disease Study Group.
1Ospedali Riuniti and University, Cardiovascular Department, Trieste, Italy;
2University of Torino, Department of Public Health and Microbiology, Torino, Italy
Purpose: Dilated cardiomyopathy (IDC) is a myocardial disease, characterized
by left and/or right ventricular dilatation and dysfunction and poor outcome.
Evidence-based treatment with ACE inhibitors and beta-blockers (BB) and, in the
last decade, implantable cardioverter defibrillator (ICD) have been demonstrated
to improve significantly heart failure symptoms and prognosis. The aim of this
study was to evaluate the effect of different strategies developed in IDC patients
(pts).
Methods: We analysed the data from 631 patients (pts) (males 75%, mean age
45±15 years, NYHA III-IV 26%, LV ejection fraction 30±10%) with IDC enrolled
in the Heart Muscle Disease Registry from January 1978 to December 2002. Our
population was divided in three groups on the basis of time of enrolment and
therapeutic strategies: group 1 (110 pts) enrolled from 1978 to 1987, group 2
(361) from 1988 to 1997 (pharmacological therapy "era") and group 3 (160 pts)
from 1998 to 2002 (pharmacological and device-therapy "era").
Results: Pts of the three groups did not differ significantly for age, sex, NYHA
class, left ventricular ejection fraction and presence of left bundle branch block.
ACE inhibitors were used in 22 vs 92 vs 96% (p

P2012 Correlations between the degree of portal
hypertension, cardiovascular complications and
some biochemical markers in patients with hepatic
cirrhosis
E.I. Manov1 , H.N. Velinov2 ,M.D.Apostolova2 ,T.I.Donova1 ,
K.G. Tchernev 1 . 1medical university, clinic of cardiology, Sofia,
Bulgaria; 2Institute of Molecular Biology, Medical and Biological Research Lab,
Sofia, Bulgaria
objective: 1.To study correlations between the degree of portal hypertension in
patients with hepatic cirrhosis, cardiovascular complications and levels of endothelin,
brain natriuretic peptide and aldosteron. 2. To establish the predictive
ratio of these biochemical markers for development of cardiovascular complications.
methods: We include 91 men and 35 women at the age of 54±10 years with
histologically documented hepatic cirrhosis (postviral:n=82, alcocholic:n=44) and
different levels of portal hypertension: stage 1- with varices, no ascites (n=50);
2. ascites and varices (n=65); 3. resistant ascites or bleeding episode (n=11).
Ascites were proved by abdominal echography or computer tomography, varicesby
endoscopy. Cardiovascular complications were detected by electrocardiography
and echocardiography. We excluded patients with cardiovascular risk factors
and data for cardiovascular diseases. ELISA was used to detect the biochemical
markers in all patients and healthy subjects (n= 71). Data were analyzed by
ANOVA, Turky’s post-hoc analysis, Pearson, Spearman and Fisher tests.
results: Compromised cardiac function in most of our patients was characterized
mainly as diastolic dysfunction in stage 1 and 2 of portal hypertension. Patients
in stage 3 had mostly systolic disfunction with globally reduced left-ventricle ejection
fraction. The levels of biochemical markers in patients studied were significant
increased (p30 mmHg, vs 8% among those without syncope; p=0.02); moreover,
they showed a trend toward greater prevalence of associated moderate-tosevere
or severe mitral regurgitation (40% vs 16%, respectively; p=0.118), and
pulmonary edema or cardiogenic shock on admission (40% vs 14%, respectively;
p=0.117). In addition, patients presenting with syncope had higher admission Troponin
I values (8±5 ng/ml vs 3±4 ng/ml; p=0.05), and more often required intraaortic
balloon pumping (40% vs 8%, p=0.02). All patients with LV outflow tract
obstruction received beta-blocker therapy with subsequent early regression of the
dinamic obstruction. There were no differences between the 2 groups in terms of
baseline LV ejection fraction (35±10% vs 35±8%, respectively; p=0.991), time
to recovery of normal systolic function (7±4 daysvs7±3 days, respectively;
p=0.872), and one-year mortality (0% vs. 4.5%, respectively; p=0.622). At Cox
analysis the only independent predictor of death was age (p=0.034).
Conclusions: Syncope is an unusual presentation of TTC and it is more common
in the subset developing LV outflow tract obstruction. These data suggest
the need for the assessment of LV outflow tract obstruction in all TTC patients,
in particular in those presenting with syncope, and for beta-blocker therapy of
dinamic obstruction.
P2015 Risk factor profiles in South African patients with
hypertrophic cardiomyopathy caused by distinct
founder mutations
M. Heradien1 ,M.Revera2 , A. Goosen3 ,P.A.Brink3 , J.C. Moolman-
Smook3 . 1University of Stellenbosch, Internal Medicine, Cape
Town, South Africa; 2University of Pavia, Cardiology, Pavia, Italy; 3University of
Stellenbosch, Intenal Medicine, Cape Town, South Africa
Background: Implantable cardioverter defibrillators are increasingly used to prevent
sudden cardiac death (SCD) in hypertrophic cardiomyopathy (HCM) patients
deemed to be at high risk. Risk stratification assesses a number of factors, including
a family history of multiple SCDs, unexplained syncope, non-sustained
ventricular tachycardia on Holter ECG, maximal left ventricular wall thickness
(mLVWT) ≥30mm and abnormal blood pressure response during exercise testing.
Early genetic studies also suggested that correlations exist between genetic
mutation and survival.
Purpose: The aim of this study was to compare risk factor profiles between three
South African HCM founder mutation groups, to assess whether genotype correlated
with risk profile.
Methods: Twenty-one South African families in which one of three HCM
founder mutations segregated participated in this study. Thirty R92WTNNT2, 24
R403WMYH7, and 27 A797TMYH7 HCM mutation-bearing individuals as well
as 67 of their non-carrier relatives were investigated with 2D and M-mode echocardiography
and exercised under a modified Bruce protocol. Patient and family
histories were obtained.
Results: Significantly more R92WTNNT2 individuals failed to increase systolic
blood pressure by more than 20mmHg than did individuals from either the control
or other mutation groups (p=0.015). R92WTNNT2 individuals also demonstrated
more syncope (p=0.007) than did the control or other mutation groups. On the
other hand, significantly more A797TMYH7 individuals demonstrated overt hypertrophy
(mLVWT≥30mm). Most SCDs occurred in R92WTNNT2 families, while
A797TMYH7 families suffered more SCDs than R403WMYH7 families.
Conclusion: Mechanisms underlying SCD for the different mutations are not
clear, but may involve alterations in calcium-handling and/or alterations in autonomic
tone.
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316 Imaging in cardiomyopathy
IMAGING IN CARDIOMYOPATHY
P2016 Prevalence and clinical significance of chronic left
ventricular systolic dysfunction in adolescents
G. Limongelli 1 , G. Pacileo2 , P. Calabro’ 2 , R. Ancona2 , A. D’andrea2 ,
M. Romano2 , G. Romano2 ,G.DiSalvo2 ,A.Rea2 , R. Calabro’ 2 .
1Second University of Naples-Monaldi Hospital, Napoli, Italy;
2Cardiothoracic Sciences, Second University of Naples-Monaldi Hospital, Napoli,
Italy
Aim: Prevalence, etiology and clinical course of progressive left ventricular dysfunction
leading to heart failure (HF) have been widely described in children and
adults with cardiomyopathies. To date, few is known concerning left ventricular
systolic dysfunction developing during adolescence. Here, we sought to analyse
etiology, clinical course and outcome of chronic systolic dysfunction in adolescents
with different type of cardiomyopathies.
Methods: Fifty-two patients (median age 16) who had been diagnosed with
systolic dysfunction (ejection fraction

disease. Familial study was recomended because of a proband diagnosed of: Hypertrophic
Cardiomyopathy (HCM) in 289 (57%), Dilated (DCM) in 69 (14%), Arrhythmogenic
right ventricular (ARVC) in 14 (3%), Left ventricular non-compation
in 14 (3%), Brugada in 77 (15%), SADS in 15 (3%) and LongQT in 12 (3%), other
conditions in 15 (3%). Familial disease was considered when at least 2 individuals
of the same family were clearly affected. 79 (16%) had a family history of sudden
cardiac death.
Results: Familial disease was confirmed in 161 (40%); 45% in HCM, 50% in
DCM, 25% in ARVC, 27% in LVNC, 23% in Brugada, 33% in LongQT.
190 (0.47 per family; 43±20 years old; 60% male) affected relatives were identified
(127 of whom were new diagnosed cases). The new cases were 63 HCM,
39 DCM, 2 ARVC, 5 LVNC, 14 Brugada and 2 LongQT, in whom appropriate risk
stratification and medication if needed was iniciated (5 affected relatives underwent
ICD implantation for primary prevention). 161 individuals (0.4 per family)
were found to have some non-diagnostic features (possibles) and further reviews
were recommended.
Conclusions: The prevalence of familial disease in inherited cardic diseases
is high. Systematic familial study identify asymptomatic affected individuals that
could benefit from early treatments in order to prevent complications. Dedicated
clinics and multidisciplinary teams are needed for proper screening programs.
P2020 Hypercholesterolemia causes systolic and diastolic
dysfunction
J. Rubinstein 1 , A. Vedre2 , R. Huang2 , G.S. Abela2 . 1Michigan State University, Cardiology Dept., East Lansing, United States of
America; 2Michigan State University, Cardiology, East Lansing,
United States of America
Background: Heart failure affects both systolic and diastolic function. We sought
to establish a link between hypercholesterolemia and myocardial dysfunction by
both standard echocardiographic examination and tissue Doppler imaging (TDI).
Methods: 27 rabbits were studied; Group I (GI; n=7) were fed normal chow; GII
(n=10) were fed a high cholesterol diet; GIII (n=10) high cholesterol diet with ezetimibe
(1mg/kg/day). Echocardiographic examination included 2-D echo, Doppler
flow and TDI under anesthesia. Serum cholesterol levels were obtained at baseline
and 3 months. Myocardial tissue cholesterol levels were measured post euthanasia.
Results: A full echocardiographic study was obtainable in 24/27 rabbits. No significant
differences were noted in chamber sizes or ejection fraction among the
groups. E/A was lower in the GII compared to both GI and GIII respectively
(1.55±0.49 vs. 1.89±0.51 and 1.92±0.37; p=0.05). By TDI (picture), E’/A’ was
higher in GPI and GIII compared to GII respectively (1.93±0.42 and 1.89±0.22
vs.1.26±0.62; p=0.01). Also, GI and GIII had higher S’ measurements reflecting
better systolic function compared to GII respectively (6.42±2.5 and 6.55±1.66 vs.
4.6±0.69 p=0.05). In GII serum cholesterol was significantly higher in comparison
to GI and GIII respectively (1073mg/dl±539 vs. 87mg/dl±37 and 179mg/dl±81;
p

318 Imaging in cardiomyopathy
P2023 Myocardial trabeculation in healthy volunteers.
Cardiovascular magnetic resonance study
A.M. Maceira Gonzalez1 , J. Cosin-Sales2 ,S.K.Prasad3 ,
P.J. Kilner3 . 1ERESA - Hospital Arnau de Vilanova, CMR Unit,
Valencia, Spain; 2Hospital Arnau de Vilanova, Cardiology, Valencia,
Spain; 3Royal Brompton Hospital, CMR Unit, London, United Kingdom
Purpose: Isolated non-compaction of the left ventricle (INCLV) is a rare but potentially
lethal cause of LV dysfunction and arrhythmias. In healthy subjects a
certain amount of myocardial trabeculation, especially in the lateral wall, may exist.
Also, the apical myocardium is usually thin and apical trabeculations can be
misdiagnosed as pathological. Cardiac magnetic resonance (CMR) can detect
hypertrabeculation in cases in which this finding is not obvious with echocardiography.
Our aim was to study with CMR the presence and range of normality of
myocardial trabeculation in healthy volunteers.
Methods: 120 healthy volunteers were included (60 males), 20 in each age decile
(20-29, 30-39, 40-49, 50-59, 60-69, 70-79 yrs). They were studied with medical
history, physical examination, ECG, BP measurement and conventional blood
tests. CMR acquisitions were at 1.5T using retrospective gating. Breath-hold cine
sequences were acquired in the 2, 4, and 3-chamber views, and SA stack of the
ventricles (slice thickness/gap/temporal resolution: 7mm/3mm/22ms). Ventricular
mass and volumes were measured. Trabeculation was considered to be present
where muscular bands 5% was observed
in 70% of subjects, and %Trab>10% in 41% of subjects. The most frequent localization
of trabeculation was the lateral wall (in 72% of subjects), followed by the
anterior wall (51%) and apex (38%), while this finding was very infrequent in the
septum (2.5% of subjects). Table shows %Trab (median; p25-p75) in males and
females according to age.
20-29yrs 30-39yrs 40-49yrs 50-59yrs 60-69yrs 70-79yrs All
Males 6; 4-12 7; 0-11 9; 5-16 8; 4-15 11; 8-17 11; 6-14 10; 6-14
Females 3; 0-7 6; 6-11 8; 0-13 8; 0-11 10; 8-14 9; 6-14 9; 5-14
Conclusions: In healthy subjects with normal LV dimensions and systolic function
CMR can detect myocardial trabeculations within a range of normality. These
trabeculations are mainly seen in the lateral wall. This finding may be important
for the accurate diagnosis of INCLV.
P2024 The relationship between echocardiographic
parameters and plasma N-terminal pro-brain
natriuretic peptide levels in patients with dilated
cardiomyopathy
C. Mornos, A. Ionac, D. Cozma, L. Petrescu, D. Maximov, A. Mornos,
D. Popa, A. Lupu, S.I. Dragulescu. Institute of Cardiovascular
Diseases, Timisoara, Romania
The myocardial performance index (MPI), defined as the sum of isovolumic contraction
and relaxation times divided by ejection time, and N-terminal pro-brain
natriuretic peptide (NTproBNP) have been utilised to express global left ventricular
(LV) function. The ratio between early diastolic transmitral velocity (E, using
pulsed Doppler) and early mitral annular diastolic velocity (Ea, using tissue
Doppler imaging) has been proposed as the best Doppler predictor for evaluating
LV filling pressures in a variety of cardiac diseases.
Purpose: to assess the relationship between echocardiographic parameters
(conventional echocardiography and Tissue Doppler imaging) and NTproBNP in
patients with dilated cardiomyopathy (DCM) in sinus rhythm.
Methods: Conventional echocardiography and tissue Doppler imaging were performed
in 50 consecutive patients (age 63±13 years) with DCM, in sinus rhythm,
concomitent with NTproBNP determination. Patients with inadequate echocardiographic
images, paced rhythm, mitral prosthesis, severe mitral annular calcification
or renal failure were not included. Ea and Sa (peak systolic mitral annular
velocity during ejection) were determined at the lateral site of mitral annulus. MPI
(using conventional echocardiography) and E/Ea were calculated.
Results: The simple regression analysis demonstrated the strongest statistically
significant linear correlation between MPI and NTproBNP (r=0.70, p 3 segments or a LGE score >4
predicted a RC with a sensitivity of 70 and 73%, a specificity of 88 and 75%, a
negative predictive value of 44 and 43% and a positive predictive value of 95 and
91% respectively. Regarding LGE, its presence was significantly correlated with
left ventricular posterior (p= 0.012), septal (p=0.07) wall and interatrial (p=0,032)
thickness, left atrium diameter (p= 0,004).
Conclusions: Restrictive filling pattern on cardiac catheterization and LGE on
CMR are common findings in FAP patients without sign of heart failure. LGE has
a very good positive predictive value for RC but absence of LGE cannot rule out
RC.
P2026 Cardiomyopathy in the course of laminopathy and
emerinopathy, echocardiographic and biochemical
features
M. Marchel 1 , A. Madej 2 , V. Stepien 1 ,R.Steckiewicz 1 ,
J. Kochanowski 1 ,P.Scislo 1 ,R.Piatkowski 1 , K.J. Filipiak 1 ,
I. Hausmanowa-Petrusewicz 2 ,G.Opolski 1 . 1 Medical University of Warsaw, 1St
Dept of Cardiology, Warsaw, Poland; 2 Polish Academy of Science, Warsaw,
Poland
Purpose: Emery-Dreifuss muscular dystrophy (EDMD) is characterized by musculoskeletal
abnormalities, accompanied by cardiac defects (conduction disturbances
and systolic dysfunction). Sudden cardiac death is the most common
mechanism of death in this group. The genetic background of EDMD is a mutation
in nuclear proteins: lamin A/C and emerin. The aim of the study was an
analysis of left ventricular (LV) dysfunction in EDMD patients with the use of tissue
Doppler imaging (TDI) and plasma natriuretic peptides measurements.
Methods: In the present study we included 25 pts with genetically confirmed
EDMD (17 pts with an X-linked inheritance [defect in the STA gene, emerinopathy]
and 8 pts with an autosomal dominant form [defect in LMNA, laminopathy]).
Conventional echocardiography, TDI, and natriuretic peptide levels were measured
in all patients and controls (25 healthy volunteers). Diastolic function was
measured by TDI derived parameter E/E’. For each wall, the peak strain (%) and
strain rate - SR (s -1 ) were assessed in basal and mid LV segments.
Results: The mean left ventricular ejection fraction (LVEF) was 51,3±9,1% and
65,5±2,6 for EDMD pts and for controls respectively (p

P2027 MRI for the detection of restrictive cardiomyopathy in
familial amyloid polyneuropathy
O. De Sauniere1 ,A.Resten1 , M. Mabille1 , S. Bennani1 ,
V. Algalarrondo1 , F. Rouzet2 , S. Dinanian1 , D. Adams3 , D. Musset1 ,
M.S. Slama1 . 1Clamart, France; 2Paris, France; 3Le Kremlin Bicetre,
France
Purpose: To determine cardiac magnetic resonance (CMR) imaging signs predictive
of restrictive cardiomyopathy (RC), as diagnosed by cardiac catheterization,
in patients with familial amyloid polyneuropathy (FAP).
Methods: 38 consecutive patients with FAP without heart failure symptoms
screened for liver transplantation underwent cardiac catheterization, CMR with
study of late gadolinium enhancement (LGE) assessed by phase-sensitive inversion
recovery sequence (PSIR). Patients demonstrating the following criteria were
considered as having a RC: right atrial pressure> 5 mmHg or pulmonary capillary
wedge pressure>15 mmHg or dip and plateau on right ventricular pressure
curve, before or after overload with 500 cc of colloid solution, or decrease of cardiac
output after overload. LGE was quantified by number of segments involved
(16-segment model) and by extension within wall thickness (4 scale score), providing
an individual score. CMR data also comprised LV septal and posterior wall,
right ventricular free wall, interatrial septum thicknesses and left atrium diameter.
Results: 79% of patients had RC and 76% exhibited LGE. We found no correlation
between RC and left atrium diameter or right ventricular thickness. The
posterior wall thickness (p= 0,012), number of segments (p=0,017) and individual
score (p=0,012) of LGE were positively correlated with the presence of RC. In the
9 patients without LGE, 6 (66%) had RC and only 3 (33%) had a normal hemodynamic
profile. In ROC curve analysis, LGE in > 3 segments or a LGE score >4
predicted a RC with a sensitivity of 70 and 73%, a specificity of 88 and 75%, a
negative predictive value of 44 and 43% and a positive predictive value of 95 and
91% respectively. Regarding LGE, its presence was significantly correlated with
left ventricular posterior (p= 0.012), septal (p=0.07) wall and interatrial (p=0,032)
thickness, left atrium diameter (p= 0,004).
Conclusions: Restrictive filling pattern on cardiac catheterization and LGE on
CMR are common findings in FAP patients without sign of heart failure. LGE has
a very good positive predictive value for RC but absence of LGE cannot rule out
RC.
P2028 Myocardial performance index combined with tissue
Doppler imaging could help prediction of early
anthracycline-induced cardiotoxicity
A.A.M. Farrag, M. Meshref. Cairo University, Cardiology, Cairo,
Egypt
Background: Doxorubicin is a known active agent for treatment of various malignancies.
Its subclinical toxicity after lower doses is not fully understood. The
present study was designed to evaluate the diagnostic role of myocardial performance
index (MPI) combined with tissue Doppler imaging (TDI) in asymptomatic
adults receiving chemotherapy regimen including low-dose doxorubicin.
Methods: Twenty four patients (mean age 32±13 years), newly diagnosed as
Hodgkin’s or non-Hodgkin’s lymphoma were eligible for our study. All had baseline
echo-Doppler study within normal limits and all patients were treated with
doxorubicin cumulative dose ≤ 300 mg/m 2 . Left ventricular ejection fraction (EF)
and MPI [(isovolumic relaxation time + isovolumic contraction time)/ ejection time]
were measured. Peak systolic (Sm), early (Em) and late (Am) diastolic myocardial
velocities as well as contraction time (CTm) were recorded at lateral mitral annulus
before (study 1), after completion of therapy (study 2) and at one year follow
up (study 3). We considered MPI >0.4 represent early myocardial dysfunction.
Results: None of our patients developed clinical manifestations of heart failure
after one year. Sm and Em were decreased significantly in studies 2 and 3 when
compared to study 1. The inverse was true regarding Am and MPI (table). MPI
at study 1 had a significant positive correlation with left ventricular end systolic
volume of study 3 (r= 0.770, p= 0.0001), however, a significant inverse correlation
was observed with Em (r= -0.622, p= 0.001). The area under the curve (AUC)
and 95% confidence interval (CI) of the receiver operating characteristic (ROC)
curves for the examined parameters to predict MPI > 0.4 showed that the Am of
study 2 yielded the largest area (AUC 0.757, 95% CI 0.512-0.938, p= 0.035).
Echocardiographic and TDI parameters
Variable Study 1 Study 2 Study 3 p 1 vs. 2 p 1 vs. 3
LVEF 62±5.8 58±5.7 56±5.1 0.002 0.0001
MPI 0.33±0.08 0.38±0.08 0.39±0.07 0.01 0.0001
Sm (cm/sec) 12.7±2.2 11.2±1.9 10.5±1.6 0.0001 0.0001
Em (cm/sec) 15.9±2.6 14.4±2.7 13.5±2.4 0.001 0.006
Am (cm/sec) 8.6±1.7 10.3±2.2 11.0±2.2 0.0001 0.0001
Conclusion: The cardiotoxic manifestations of low dose anthracyclines are frequently
subclinical and could be highlighted by myocardial performance index.
Imaging in cardiomyopathy / Non ST-elevation myocardial infarction 319
P2029 Late gadolinium enhancement detected by
cardiovascular magnetic resonance imaging is
associated with increased inducibility of ventricular
tachyarrhythmias in patients with hypertrophic
cardiomyopathy
S. Fluechter1 , J. Kuschyk1 , C. Wolpert 1 , D. Haghi2 , C. Doesch1 ,
D. Dinter2 , S. Schoenberg1 , T. Sueselbeck2 , M. Borggrefe 2 , T. Papavassiliu2 .
1University Hospital Mannheim, 1st Medical Department, Mannheim, Germany;
2Universitiy Hospital Mannheim, 1st Medical Department, Mannheim, Germany
Purpose: Ventricular tachycardia (VT) and ventricular fibrillation (VF) are established
as the principal mechanisms of sudden death in patients with hypertrophic
cardiomyopathy (HCM). However risk stratification of patients with HCM still remains
a challenge. Myocardial replacement scarring is probably an important
anatomic component of the arrhythmogenic substrate in patients with HCM and
can be assessed by late gadolinium-enhancement (LGE) CMR. Thus, we hypothesized
that myocardial scarring detected by LGE CMR might be associated
with an increased likelihood of inducibility of ventricular tachyarrhythmias in patients
with HCM. The aim of this retrospective study was to investigate whether
presence, extent and location of myocardial scarring assessed by LGE CMR correlates
with the inducibility of ventricular tachyarrhythmias during programmed
ventricular stimulation (PVS) in patients with HCM.
Methods: 67 patients with HCM underwent LGE CMR. 32 of these patients (22
males and 10 females; mean age 56±15 years) were also examined by electrophysiologic
study including PVS. LV function, volumes, myocardial thickness, and
the extent of LGE, were assessed with respect to the inducibility of ventricular
tachyarrhythmias during PVS.
Results: 21 of the 32 patients (66%) showed LGE, 11 patients did not (34%).
Overall, in 11 patients (34%) ventricular tachyarrhythmias were inducible during
PVS. Patients with inducible ventricular tachyarrhythmias showed significantly
more extent of LGE as compared to patients with normal electophysiologic findings
(23% vs. 10%, p=0.037).
Conclusions: The extent of LGE is associated with the inducibility of ventricular
tachyarrhythmias in patients with HCM. Future studies are needed to assess the
potential role of LGE CMR for risk stratification of patients with HCM.
NON ST-ELEVATION MYOCARDIAL INFARCTION
P2030 Cardiogenic shock in NSTEMI and STEMI -
differences in treatment and outcomes in clinical
practice. Results from PL-ACS registry
M. Gasior1 ,M.Gierlotka1 , W. Ruzyllo2 ,R.Gil3 , D. Dudek4 ,
S. Grajek5 ,M.Trusz-Gluza6 ,J.Kubica7 , M. Zembala1 ,
L. Polonski1 . 1Silesian Centre For Heart Diseases, Zabrze, Poland; 2Institute of Cardiology, Warsaw, Poland; 3MSWiA Hospital, Warsaw, Poland; 4Collegium Medicum, Jagiellonian University, Cracow, Poland; 5Institute of Cardiology,
Poznan, Poland; 6Medical University of Silesia, Katowice, Poland; 7Medical University, Bydgoszcz, Poland
The aim of this analysis was to assess differences in treatment and outcomes of
patients with cardiogenic shock (CS) and NSTEMI or STEMI in clinical practice.
Methods: From 10.2003 to 08.2006, a total of 71290 consecutive patients with
NSTEMI (N=33392) and STEMI (N=37898) have been enrolled into the ongoing,
prospective, registry of acute coronary syndromes (PL-ACS). Follow-up deaths
were acquired from the government database.
Results: CS on admission was present in 1158 (3.5%) pts with NSTEMI and in
2986 (7.9%) pts with STEMI. Pts with CS and NSTEMI were younger, less frequently
smokers, more frequently had prior MI, and had higher heart rate than
STEMI patients. The rates of invasive treatment was low in NSTEMI (17%) as
compared to STEMI (41%). One-year mortality was higher in NSTEMI as a consequence
of lower rates of invasive treatment as well as higher mortality after
coronary angiography compared to STEMI patients.
NSTEMI STEMI P value
Age, years 71.0±11.2 67.9±12.2

320 Non ST-elevation myocardial infarction
P2031 Patterns of use and effectiveness of early invasive
strategy in non-ST-segment elevation acute coronary
syndromes
I. Ferreira Gonzalez 1 , G. Permanyer-Miralda 2 , M. Heras 2 ,
J. Cunyat 3 ,E.Civeira 4 ,F.Aros 5 , P.L. Sanchez 6 , J. Marrugat 2 ,
H. Bueno 6 on behalf of MASCARA study group. 1 Vall d’Hebron Hospital,
Cardiology Department, Barcelona, Spain; 2 Barcelona, Spain; 3 Valencia, Spain;
4 Zaragoza, Spain; 5 Vitoria, Spain; 6 Madrid, Spain
Aims: To assess the patterns of use and the benefit of an early invasive strategy
(EIS) in non-ST-segment elevation acute coronary syndrome (NSTEACS)
patients in real life.
Methods: All consecutive patients hospitalized by NSTEACS between November
2004 and June, 2005 in 32 randomly selected hospitals were prospectively
included. Patients were stratified by their baseline risk profile using the GRACE
risk score in two groups. In-hospital mortality, one and six month mortality or rehospitalisation
for acute coronary syndromes were analyzed. To ensure optimal
adjustment logistic regression, propensity score and Cox regression were employed.
Results: Of 2,856 patients 1616 (56%) had low/intermediate risk (GRACE ≤ 140)
and 1,240 high risk (GRACE >140). Patients who underwent EIS had lower risk
than those who did not (GRACE score: 128.2±41 vs 138.5±43; p 0.01-0.07
μg/l) MI groups. Patients with no elevation of troponin above the "new" cutoff values
were classified as unstable angina. Starting in 2005, post-discharge follow-up
information was collected for all patients who provided consent from a subgroup
of 44 hospitals.
Results:
"Classic" MI (n=8701) "New" MI (n=489)
Age 66.4±13.7 y 67.2±13.7 y NS
Male gender 6140/8701 (70.6%) 351/489 (71.8%) NS
Prior history of CAD 2845/7470 (38.1%) 254/447 (56.8%)

P2035 Oxidized low density lipoprotein levels associate with
culprit vessel in ST-elevation myocardial infarction
P. Napoleao1 ,M.Selas2 , A. Andreozzi3 , A. Turkman3 , A. Viegas-
Crespo3 ,A.Toste2 , R. Cruz Ferreira2 , T. Pinheiro4 . 1Instituto Tecnologico e Nuclear, Sacavem, Portugal; 2Hospital St Marta,
CH Lisboa Central, Servico Cardiologia, Lisboa, Portugal; 3Universidade de
Lisboa, Centro de Estatistica Aplicada, Lisboa, Portugal; 4Instituto Tecnologico e
Nuclear, Sacavem, Portugal
Objectives: To study the variations of oxidized LDL (ox-LDL) at the onset of acute
myocardial infarction (AMI) and along the recovery period and explore the relation
with disease severity.
Methods: A follow-up of 30 ST-elevation AMI patients was evaluated against 16
patients with angiographically normal coronary arteries (controls, CTR) and 24
healthy volunteers (reference group, REF). The AMI patients were evaluated at 3
time points: at admission before the administration of IIb/IIIa and angioplasty (day
0), two (day 2) and 40 (day 40) days after intervention. Plasma concentration of
ox-LDL was measured by ELISA.
Results: Plasma levels of ox-LDL were significantly higher in AMI patients
(103±8 U/l) than in healthy subjects (57±6 U/l,p

322 Non ST-elevation myocardial infarction
P2039 Coronary revascularization improves prognosis in
diabetic patients with non-ST-segment elevation
acute coronary syndromes; results from the
EuroHeart survey on ACS-II
R. Parma1 , H. Bueno2 ,A.Gitt3 ,A.Battler4 , N. Danchin5 ,
G. Filippatos6 , D. Hasdai4 ,Y.Hasin7 , J. Marrugat8 ,F.VanDeWerf9on behalf of EuroHeart Survey on ACS-II investigators. 1Medical University of
Silesia, 3rd Division of Cardiology, Katowice, Poland; 2Hospital Universitario
Gregorio Maranon, Department of Cardiology, Madrid, Spain; 3Herzzentrum Ludwigshafen, Institut fur Herzinfarktorschung, Ludwigshafen, Germany;
4 5 Sheba Medical Center, Tel Hashomer, Israel; Hopital Europeen Georges-
Pompidou, Department of Cardiologie, Paris, France; 6Atticon University
Hospital, Department of Cardiology, Athens, Greece; 7Poriah Medical Center,
Cardiovascular Institute, Tiberias, Israel; 8Institut Municipal Investigacio Medica,
Lipids and Cardiovascular Epidemiology Unit, Barcelona, Spain; 9University Hospital Gasthuisberg, Department of Cardiology, Leuven, Belgium
Background: Diabetes mellitus (DM) is an independent predictor of mortality in
patients with non-ST-segment elevation acute coronary syndromes (NSTEACS),
but coronary revascularisation seems to improve prognosis in these patients.
Aims: To evaluate the influence of DM on the use and outcomes of coronary
revascularisation in patients with NSTEACS.
Methods: We analysed data of 3046 patients with NSTEACS enrolled in EuroHeart
Survey on ACS-II registry in years 2004 and 2005, regarding their DM
status (27%) and hospital revascularisation (44%). The outcome measure was
mortality at 1-year.
Results: Coronary revascularization was performed in 40% of patients with DM
and 45% without DM (NS). Revascularised patients were younger, had lower
prevalence of risk factors, comorbidities, and troponin elevation, and similar ECG
presentation in both groups. One-year mortality was significantly lower among
revascularised patients, but the difference was higher in the DM group (2.4%
vs 13.5%, p

P2042 Persistent under representation of the circumflex
artery as infarct related vessel in patients treated with
acute reperfusion therapy
C. Willemse, S. Rasoul, J.P. Ottervanger, E. Kolkman,
J.H.E. Dambrink, M.J. De Boer, J.C.A. Hoorntje, H. Suryapranata,
A.T.M. Gosselink, A.W.J. Van ’T Hof. Isala Klinieken Zwolle, Cardiology, Zwolle,
Netherlands
Background: It is unlikely that the chance of plaque rupture in the circumflex (CX)
artery is lower than plaque rupture in the RCA or LAD coronary artery. Therefore
one would expect an equal distribution of infarct artery involvement between the
three coronary arteries in patients with an acute coronary syndrome. We hypothesized
that the involvement of the CX artery might increase over time with better
recognition of an acute CX occlusion using either electro- (V7-V9) or echocardiographic
diagnostic tools.
Methods: All patients who presented with symptoms suggestive of an acute myocardial
infarction (MI) and who underwent immediate coronary angiography were
included. The 12 lead ECG on admission was analysed by an independent corelab.
The culprit infarct related vessel (IRV) was determined by the intervening
physician. Patients with non-STEMI were defined as having less than 1 mm cumulated
ST segment elevation.
Results: From January 1, 2000 until December 31, 2005, 2.985 patients were
included. Overall 179 patients (6.0%) were diagnosed with non-STEMI. The CX
was the infarct related vessel (IRV) in 13.2%, versus 44.9 and 39.2% for the LAD
and RCA respectively. From the CX related MI, 14% presented as a non-STEMI
as compared to 4.6% of RCA or LAD related MI (p

324 Non ST-elevation myocardial infarction
Figure 1
tively, despite their higher risk profile, were less likely to receive recommended
secondary prevention treatments at discharge than those who underwent PCI.
P2046 Considering criteria for left ventricular hypertrophy in
a continuous manner augments their ability to predict
adverse events in patients with NSTEMI
J.A. Barrabes, J. Figueras, J. Cortadellas, R.M. Lidon, S. Ibars.
Hospital Universitari Vall d’Hebron, Cardiology, Barcelona, Spain
Purpose: Left ventricular hypertrophy (LVH) is associated with a worse outcome
in patients with acute coronary syndromes, but dichotomous categorization of
patients into those having or not LVH has limitations irrespective of the definition
used. We aimed to explore whether considering the components of LVH criteria in
a continuous manner has incremental value to predict in-hospital adverse events
in patients with non-ST elevation acute myocardial infarction (NSTEMI).
Methods: We evaluated 451 consecutive patients with a first NSTEMI. LVH was
defined by Sokolow-Lyon and Cornell (voltage and product) criteria on the admission
ECG and, in 296 of them, by echocardiography (corrected American Society
of Echocardiography [ASE] formula). The association of in-hospital adverse
events (death, reinfarction, severe heart failure, or angina with ECG changes)
with these criteria for LVH, either considered as dichotomous variables or across
quintiles of their components, was assessed.
Results: Patients with LVH (5 to 6% by ECG criteria and 24% by echocardiography)
had more adverse events than those without: 41.7 vs 26.0%, respectively
(P=0.09), by Sokolow-Lyon; 50.0 vs 25.6% (P=0.01) by Cornell voltage;
50.0 vs 25.3% (P=0.004) by Cornell product; and 38.0 vs 22.2% (P=0.008) by the
ASE formula. However, a progressive increase in the rate of events was observed
across quintiles of the components of all LVH criteria (Table). This increase was
not paralleled by differences in the prevalence of multivessel disease or in CK-
MB peak, and was also present after excluding patients with LVH according to
the dichotomous criteria.
Rates of major adverse events (%)
Criterion (units) Quintile 1 Quintile 2 Quintile 3 Quintile 4 Quintile 5 P value for trend
Sokolow-Lyon (mV) 17.8 21.8 26.7 28.7 41.8

P2049 Addition of B-type natriuretic peptide to the
Thrombolysis in Myocardial Infarction (TIMI) risk
score enhances risk stratification in acute coronary
syndrome
S. Ang 1 ,L.Wei2 , C. Lang2 , A. Struthers2 . 1University of Dundee,
Division of Medicine And Therapeutics, Dundee, United Kingdom;
2University of Dundee, Division of Medicine and Therapeutics, Dundee, United
Kingdom
Purpose: In acute coronary syndrome (ACS), both the TIMI (Thrombolysis In
Myocardial Infarction) risk score and B-type natriuretic peptide (BNP) predict adverse
prognosis. However, it is unknown whether the addition of BNP to the TIMI
risk score would enhance risk stratification in ACS.
Methods: We recruited 329 consecutive non ST elevation ACS patients and measured
admission TIMI risk score and bedside BNP levels. The main outcome
measure was either all cause mortality, readmission with ACS or congestive heart
failure, (defined as a cardiovascular event) at 10 months from presentation.
Results: Of the 329 patients, 93 patients presented with unstable angina (28%).
There were 72 cardiovascular events at 10 months. Both higher TIMI risk terciles
and higher BNP terciles predicted cardiovascular events. There was a significant
but partial correlation between the TIMI risk score and LOG BNP (R=0.439,
P80 pg/ml) were more likely to experience cardiovascular
events at 10 months [RR 9.91 (95% CI, 3.56-27.62] compared to
those with low TIMI risk score-high BNP [RR 5.11 (95% CI, 1.72-15.17] or high
TIMI risk score-low BNP [RR 3.52 (95% CI, 1.03-12.02)].
Conclusion: In ACS, BNP predicts cardiovascular events over and above the
TIMI risk score. This suggests that both methods reflect different risk attributes
when predicting adverse prognosis in ACS. In addition, the combined use of both
the TIMI risk score and BNP further identifies a subset of ACS patients at a particularly
high risk. Therefore the synergistic use of both modalities has the potential
to enhance risk stratification in ACS.
P2050 Routine invasive strategy for women with NSTEMI
myocardial infarction? - Results of the Berliner
Herzinfarktregister (BHIR)
J. Ebbinghaus1 ,C.Graf-Bothe2 ,R.Thieme3 ,R.Schoeller2 ,
B. Maier 4 , S. Behrens1 on behalf of Berliner Herzinfarktregister.
1 2 Vivantes Humboldt Klinikum, Berlin, Germany; DRK Kliniken Westend,
Berlin, Germany; 3Juedisches Krankenhaus, Berlin, Germany; 4Zig, Technische
Universitaet Berlin, Berlin Myocardial Infarction Registry, Berlin, Germany
Background: The benefit of a routine invasive strategy for male and female
STEMI patients and for male NSTEMI patients is known. It is
under discussion whether female NSTEMI patients may also benefit from routine
invasive procedures. Therefore we analysed our data concerning the effect of a
routine invasive strategy in consecutive female patients with NSTEMI and STEMI.
Methods: The BHIR is an ongoing myocardial infarction registry which
collected data from 775 female AMI patients (STEMI n=449, NSTEMI n=326)
who were treated between 1.1.04-31.7.06 in Berlin in hospitals with a cath-lab.
The data were analysed stratified for STEMI and NSTEMI. Differences between
patients with a statistically significant influence on hospital mortality for both
STEMI and NSTEMI were adjusted for age, renal failure, diabetes mellitus, CHF,
and cardiogenic shock on admission.
Results: NSTEMI (72.6 years) and STEMI patients (71.3 years) did not show a
significant difference in age (p=0.358). Patients with NSTEMI
showed more concomitant diseases, i.e. diabetes mellitus (NSTEMI: 38.7%;
STEMI: 30.2% p=0.015), previous AMI (NSTEMI: 25.0%; STEMI: 14.9%
p=0.001), atrial fibrillation (NSTEMI: 13.3%; STEMI: 7.8% p=0.013).
NSTEMI patients reached a hsopital only in 49.8% of cases with the physician
escorted rescue system (compared to 62.0% for STEMI p=0.001). NSTEMI received
primary PCI (66.9%) less often than STEMI patients (75.9%) (p=0.006).
There were no major differences in the initial therapy with ASA, beta-blockers,
ace-inhibitors, and cse-inhibitors. Hospital mortality was 5.7% for NSTEMI and
13.1.% for STEMI patients (p=0.001).
The influence of PCI on hospital mortality for STEMI patients was OR=0.33 (95%
CI: 0.15-0.73) after adjustment, the results for NSTEMI patients were not significant
and showed an OR=0.86 (95% CI: 0.21-3.52).
Conclusion: The data of our clinical registry did not show a benefit of a routine
invasive strategy for NSTEMI in comparison to STEMI female
patients. The results should be validated in other studies and registries. Further
research may be needed to determine an appropriate and optimal strategy for
female NSTEMI patients.
Non ST-elevation myocardial infarction 325
P2051 Low use of combined clopidogrel aspirin therapy in
patients undergoing CABG or cardiac rehabilitation
after non ST-elevation ACS. The S-temoin registry
N. Danchin 1 ,F.Dievart 2 , J.F. Thebaut 3 , O. Grenier 3 ,
M.A. Herrmann 3 , J. Ferrieres 4 on behalf of S-Temoin investigators.
1 Hopital Europeen Georges Pompidou (Hegp), Service De Cardiologie, Paris,
France; 2 Dunkerque, France; 3 Paris, France; 4 Toulouse, France
Background: the CURE trial has shown the efficacy of prolonged administration
of clopidogrel and aspirin in the year following an acute coronary syndrome
(ACS).
Aim: to evaluate correlates of prolonged use of combined antiplatelet therapy
versus monotherapy in patients discharged after non ST-elevation ACS.
Population and methods: 512 cardiologists included 2,121 patients seen at their
outpatient clinics 2-13 months after an episode of non ST-elevation ACS. Of those,
2,081 were on either antiplatelet monotherapy (544 patients, 26%) or combination
therapy (aspirin + clopidogrel, 1,537 patients, 74%).
Results: By univariate analysis, combined antiplatelet therapy was more frequently
used in patients

326 Non ST-elevation myocardial infarction / Antithrombotic agent
P2053 Microvascular damage prevention with
thrombaspiration during primary percutaneous
intervention in acute myocardial infarction
A. Berger-Kucza, M. Turski, A. Rybicka-Musialik, K. Wita,
M. Trusz-Gluza. Katowice, Poland
Background: Despite rapid and complete recanalization of infarct related artery
(IRA) with percutaneous coronary intervention (PCI) microvascular integrity is not
often preserved. Several mechanical devices have been proposed to prevent distal
embolization, but the impact of these devices on myocardial perfusion remains
controversial.
The aim of our study was to assess microvascular damage reduction with quantitative
myocardial contrast perfusion echocardiography (QMCE) among patients
with the first anterior AMI treated with thromboaspiration during PCI.
Methods: 42 patients (57,4±10 yrs, 74% males) with first anterior AMI were randomized
1:1 to intracoronary thromboaspiration followed by stenting, or to a conventional
strategy of stenting alone ECHO and quantitative contrast echocardiography
(QMCE) were performed 7 days and one month later (ECHO).Parameter
A (reflecting MBV), β (reflecting velocity MBF) and product of A and β as indicator
of MBF were analysed. For each patient mean value of A, β and A x β from all
dysfunctional segments was calculated.
Results: The study population was divided into two groups: thromboaspiration
(group I, 19 pts) and stenting alone (group II, 23 pts). There was no difference
between the both groups in demographic, clinical, echocardiographic and angiographic
data. Parameter A and Axβ were significantly higher in group I than
in group II: 8,58±2,54 dB vs 5,29±3,18 dB (p

P2058 Genetic variation in CYP2C19 affects exposure to the
active metabolite and P2Y12 inhibition for clopidogrel
but not prasugrel in patients with atherosclerosis
C. Varenhorst 1 ,S.James 1 ,D.Erlinge 2 , O.O. Braun 2 ,K.J.Winters 3 ,
M. Man 3 , A. Siegbahn 4 ,J.Walker 5 , L. Wallentin 1 ,S.L.Close 3 .
1 Uppsala Clinical Research Center, Dept Internal Medicine, Cardiology, Uppsala,
Sweden; 2 Dept of Cardiology, Lund, Sweden; 3 Lilly Research Laboratories,
Indianapolis, United States of America; 4 Coagulation Laboratory, Dept Medical
Sciences, Uppsala, Sweden; 5 Daiichi Sankyo Inc., Parsippany, United States of
America
Purpose: Clopidogrel is a prodrug that is hydrolyzed by esterases to an inactive
metabolite, with only a minor fraction converted to the active metabolite (AM) in
two CYP-dependent steps, compared to prasugrel that requires only one CYPdependent
step to form the AM. We hypothesized that a decrease in CYP2C19
activity affects generation of clopidogrel AM but not prasugrel AM, which results
in a corresponding decrease in the pharmacodynamic response to clopidogrel.
Methods: Samples for genetic analysis were obtained from 98 patients with
coronary artery disease participating in a randomized, double blind comparison
of clopidogrel 600 mg versus prasugrel 60 mg loading doses (LD) on a background
of 75 mg aspirin. DNA was extracted from peripheral blood and genotyped
for CYP2C19. Subjects were grouped into two CYP2C19 genotype functional
groups: normal function metabolizers (EM) and reduced function metabolizers
(RM). Plasma AM concentrations were measured. VASP phosphorylation
(PRI, %) was measured pre-dose and 24h post-LD.
Results: The genotype frequencies were similar in both groups. For prasugrel,
there was no statistically significant difference in the total exposure to
the prasugrel AM or VASP-PRI between groups. For clopidogrel, the exposure
to AM was statistically significantly lower (p0.2), and ST elevation resolution >70%
60 minutes after PPCI (70.7% vs. 68.8%, P>0.2) were not significantly better in
the Early group. MRI data (Table) showed no significant differences in initial and
6-month infarct size between the 2 groups (P>0.20).
Cardiac MRI results
Pre-discharge 6 months
DE, % of Transmurality DE, % of Transmurality Change in DE,
myocardium of DE, % myocardium of DE, % %
Early (n=44) 21±11 26±15 14±9 17±13 -7±6
Late (n=32) 18±12 21±14 12±9 14±13 -6±6
P value >0.20 >0.20 >0.20 >0.20 >0.20
DE = Delayed Enhancement; Early = early abciximab administration; Late = abciximab administration
in Cath Lab.
Conclusions: Our study shows that early abciximab administration is not associated
with either smaller infarct size or greater myocardial salvage after 6 months.
These findings might be explained by the non-significant increase in recanalization
of the infarct-related artery with early abciximab administration, possibly due
to the short time from randomization to angiography.
P2062 Long-term net clinical benefit in favor of fondaparinux
compared with enoxaparin in European patients with
non-ST elevation acute coronary syndromes:
a subgroup analysis of OASIS-5
J.-P. Bassand 1 , A. Budaj 2 ,K.A.A.Fox 3 , S.R. Mehta 4 ,
R.J.G. Peters 5 , P.G. Steg 6 ,L.Wallentin 7 , S. Yusuf 4 on behalf of Oasis-5
Investigators. 1 University Hospital Jean Minjoz, Department of Cardiology,
Besancon, France; 2 Grochowski Hospital, Cardiology, Warsaw, Poland;
3 University of Edinburgh, Cardiovascular Research Division, Edinburgh, United
Kingdom; 4 Hamilton General Hospital, McMaster Clinic, Hamilton, Canada;
5 Academic Medical Centre, Cardiology, Amsterdam, Netherlands; 6 Bichat
Hospital, Cardiology, Paris, France; 7 University Hospital, Uppsala Clinical
Research Centre, Uppsala, Sweden
Purpose: The randomized, double-blind OASIS-5 trial demonstrated a better net
clinical benefit of fondaparinux (fonda) 2.5mg once daily compared to enoxaparin
(enox) in patients (pts) with non-ST elevation acute coronary syndromes
(NSTEACS). Since this trial was performed in 41 countries and because of possible
differences in practice patterns between countries, we analyzed the benefitrisk
ratio of fonda in the subgroup of pts recruited in European Community (EC)
countries.
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328 Antithrombotic agent
Methods: Pts with NSTEACS were randomly assigned to fonda (2.5mg once
daily) or enox (1mg/kg twice daily). Rates of death, myocardial infarction (MI),
refractory ischemia (RI) and major bleeds were efficacy and safety endpoints.
Follow-up was 180 days.
Results: Of 20,078 pts, 11,695 (58.2%) were recruited in EC; 4447 of them
(38.0%) underwent a percutaneous coronary intervention (PCI) procedure. Overall
findings were consistent with data obtained in the total population. The rates
of primary efficacy outcome (death/MI/RI) at 9 days were similar (p=0.79) in pts
treated with fonda (6.1%) or enox (6.0%), irrespective of whether patients underwent
PCI. There was a significant risk reduction for death with fonda at 30
days (HR [95%CI]: 0.80 [0.65-0.99]; p=0.042) and 180 days (HR: 0.86 [0.73-
1.00]; p=0.051). A significant reduction of major bleeding was observed at 9 days,
1.9% with fonda vs 4.3% with enox (HR [95%CI]: 0.43 [0.35-0.54], p

p=0.003). Minor bleeding was also less common in these pts (4.9% vs 19%; p=
0.03). The optimal ROC-defined INR value for all bleeding was 2.6. This value
had a specificity of 89%, a sensitivity of 66%, a negative predictive value of 95%,
and a positive predictive value of 44%. INR > 2.6 was the only independent predictor
of bleeding. There were no significant differences in MACE between groups
(5.8% vs 3.9%; p=0.1).
Conclusions: In pts undergoing coronary stenting, long term triple therapy is
associated with an increased bleeding risk which can be reduced by careful monitoring
and targeting low INR values.
P2066 Fondaparinux administration according to its
European labeling improves outcome in patients with
ST elevation acute myocardial infarction (STEMI): a
subanalysis of the OASIS-6 study
R.J.G. Peters1 ,J.Oldgren2 ,S.R.Mehta3 , L. Wallentin2 , S. Yusuf3 on behalf of The OASIS-6 Investigators. 1Nieuwer Ter Aa, Netherlands;
2University Hospital, Uppsala Clinical Research Centre, Uppsala, Sweden;
3Hamilton General Hospital, McMaster Clinic, Hamilton, Canada
Purpose: In OASIS-6 in patients with STEMI, fondaparinux 2.5 mg once daily was
significantly more effective in preventing death (D) or reinfarction (RI) than control
treatment (unfractionated heparin [UFH] or placebo) without increasing severe
bleeding (SB). We investigated the value of fondaparinux administered according
to its European labeling, i.e. in the subgroup of patients receiving thrombolytics
or non-reperfused.
Methods: 12,092 STEMI patients were randomized to fondaparinux (2.5 mg once
daily for up to 8 days) or control treatment consisting of either UFH for 48 hours
or placebo in patients with no UFH indication. Follow-up was up to 180 days
(minimum 90 days).
Results: 8294 (68.6%) patients did not undergo primary percutaneous coronary
intervention, but received either thrombolytics (n=5437, 45.0%) or were nonreperfused
(n=2857, 23.6%). According to local practice, 5641 patients did not
have an indication for UFH and 2653 did. D or RI at 30 days (primary endpoint)
was reduced from 14.1% in the control group to 11.4% in the fondaparinux group
(hazard ratio 0.80 [95% CI: 0.70 to 0.90]; p

330 Antithrombotic agent
dial infarction (MI), repeat revascularization at 30 days; b) individual components
of the composite end-point (death, MI, death + MI, repeat revascularization); c)
major bleeding; d) minor bleeding. Data were extracted by 2 independent reviewers.
Studies evaluating eptifibatide in the setting of primary PCI were excluded.
Results: A total of 4 trials, including 6297 patients, were found. Triple composite
end-point occurred in 9% of patients receiving eptifibatide vs 11% of those receiving
placebo (pooled OR 0.73, 0.62-0.87; P=0.0003). Patients randomized to
eptifibatide showed 28% risk reduction in the occurrence of death + MI (OR 0.72,
0.59-0.88; P=0.001), decreased incidence of MI (6% vs 8%; P=0.001), a trend
towards a reduction in mortality (0.5% vs 0.7%, OR 0.58, 0.30-1.10; P=0.09) and
lower repeat revascularization (3% vs 4%, OR 0.73, 0.56-0.97; P=0.03). Major
bleeding incidence was not different in the 2 arms (4% vs 3%, OR 1.17, 0.87-
1.56; P=0.29), whereas the eptifibatide group had higher risk of minor bleeding
(OR 1.55, 1.36-1.77; P

Avidin, a protein found in hen eggs, has a high- and specific-affinity for biotin and
can immediately neutralize the anticoagulant activity of biotinylated idraparinux.
This study was designed to evaluate whether a second administration of avidin,
several months after the first administration, is able to rapidly and safely reverse
the pharmacological activity of biotinylated idraparinux.
Methods: In a previous study, TDU5307, the efficacy and safety of a single intravenous
(IV) injection of avidin following a single SC dose of biotinylated idraparinux,
was demonstrated in 40 healthy, young, male subjects. Of these subjects,
8 then underwent the same protocol administration of study drugs 9–13 months
later; SC injection of biotinylated idraparinux (3 mg), followed 4 hours later (tmax
of biotinylated idraparinux) by an IV infusion of avidin (100 mg). The pharmacodynamic
activity (inhibition of Factor Xa without an excess of antithrombin III) was
assessed using a validated chromogenic method.
Results: The large, rapid, and sustained neutralization of biotinylated idraparinux
anti-Xa activity was observed in all 8 subjects who had a second administration
of avidin (including those who presented positive antibody titers). Anti-Xa activity
decreased by 93% (range: 85–100%) within 30 minutes of the avidin infusion,
a decrease similar to that obtained in the first study (87% [range: 86–89%]). In
both studies, there was no evidence of a rebound phase of anti-Xa activity for up
to 14 days after avidin administration (the last sampling time). Total antibodies
against avidin were detectable at baseline in 4 of the 8 subjects, and the titer
increased by 2–3-times in 3 of 4 of these subjects. Among the 4 subjects without
baseline antibodies, 2 became antibody positive after the second avidin injection
and 2 remained negative. More importantly, none of the subjects had a positive
prick or RAST test reaction to egg allergen 1 month after the administration of
avidin and biotinylated idraparinux. Total IgE, circulating immune complex and
complement activation markers did not show relevant changes during the study,
and no hypersensitivity reactions were observed.
Conclusions: A second administration of 100 mg avidin is safe and efficient for
the neutralization of a single dose of biotinylated idraparinux. This allows the
consideration of multiple administrations of avidin in patients receiving long-term
treatment with biotinylated idraparinux.
P2074 Thrombin generation is a possible marker for a
haemostatic action of recombinant factor VIIa to
shorten prolonged bleeding time provoked by a high
dose of a direct factor Xa inhibitor in rats
Y. Morishima, Y. Honda, C. Matsumoto, T. Fukuda, T. Shibano.
Daiichi Sankyo Co., Ltd., Biological Research Laboratories I, Tokyo, Japan
Purpose: Warfarin is the current standard of care for patients requiring chronic
anticoagulation. Direct factor Xa (FXa) inhibitors are in development as a replacement
for warfarin. A key clinical need for all anticoagulants regardless of mechanism
of action is the availability of an antidote. The objective of this study is to
evaluate thrombin generation (TG) assay as a potential biomarker to monitor the
reversal of a direct FXa inhibitor-induced bleeding by recombinant FVIIa (rFVIIa).
Methods: A rat model of template bleeding was used. Rats were anesthetized
with thiopental. An incision was made on the planta with a knife. Blood was blotted
every 30 sec, and bleeding time was defined as the time from the incision to the
first arrest of bleeding. The maximum observation period was 30 min. We used
DU-176b as a direct FXa inhibitor. DU-176b (1 mg/kg/h, a supratherapeutic dose)
was administered by intravenous infusion 2 h before the induction of bleeding to
the end of experiment. Recombinant FVIIa was given as a bolus injection 8 min
before the bleeding induction. Blood samples were collected 3 min before and
30 min after the incision and plasma was prepared. TG in plasma was assayed
by means of the calibrated automated thrombography with the thrombinoscope
software. Plasma sample, 5 pM tissue factor (TF) and 4 μM phospholipids were
mixed, and the reaction was initiated by addition of 16.7 mM CaCl2 and 417 μM
of a fluorogenic substrate. Lag-time of TG and the maximum concentration of
thrombin (peak) were analyzed. Prothrombin time (PT) was also measured.
Results: DU-176b significantly prolonged bleeding time and PT at a supratherapeutic
dose, and suppressed TG (i.e. prolongation of lag-time and decrease
in peak thrombin concentration). Recombinant FVIIa (0.3, 1 and 3 mg/kg, i.v.)
reversed DU-176b-induced prolongation of bleeding time in a dose dependent
manner. Significant shortening of bleeding time was observed at 1 and 3 mg/kg.
Lag-time of TG and PT were completely reversed to control levels at 0.3 mg/kg,
the dose which did not significantly affect bleeding time. Peak thrombin concentration
of TG was dose dependently increased toward control level by rFVIIa. The
dose response relationship of rFVIIa for increase in peak thrombin concentration
corresponded well with that for suppression of bleeding time.
Conclusion: The present study suggests that the peak concentration of TG is a
possible marker to monitor the haemostatic action of rFVIIa in case of accidental
haemorrhage by overdoses of direct FXa inhibitors.
P2075 The reversible oral P2Y12 antagonist AZD6140
inhibits ADP-induced vascular smooth muscle
contractions in mouse and man
D. Erlinge, C. Hogberg, H. Svensson, A. Eyjolfsson, R. Gustafsson.
Lund University Hospital, Cardiology, Lund, Sweden
AZD6140, the first reversible oral P2Y12 antagonist, is currently in a Phase 3
clinical trial (PLATO) for acute coronary syndromes (ACS). P2Y12 receptors are
Antithrombotic agent / Development of new start technology 331
distributed on vascular smooth muscle cells and mediate a contractile function
after ADP stimulation, which may contribute to local vasospasm seen in patients
with ACS or hypertension (Wihlborg et al., ATVB, 2004). We investigated whether
AZD6140, compared to clopidogrel (CLOP), could inhibit ADP-mediated arterial
contractions. Mice were treated with CLOP 50 mg/kg 24h and 2h before the experiment
was begun. Thoracic parts of aorta were used from both CLOP (n=5)
and untreated (n=4) mice. Vessels were dissected free from connective tissue and
denuded. Ring segments were mounted into temperature-controlled tissue baths
containing physiological Krebs buffer. The segments were precontracted with a
submaximal dose of norepinephrine and AZD6140 1 μM was added 20 min before
contraction was stimulated by the stable ADP analog 2-MeSADP. CLOP treatment
per os did not inhibit 2-MeSADP–induced contractions in mice. However,
AZD6140 inhibited 2-MeSADP contraction both in the mice not treated with systemic
CLOP, from 59% to 33% (% of maximal contraction induced by 60 mM K+,
p=0.015), and in the systemic CLOP-treated mice, from 64% to 32% (p=0.002).
AZD6140 also inhibited 2-MeSADP-induced contractions in both human left internal
mammary arteries (52±10% to 29±7%, p < 0.05) and human resistance
arteries (12±3% to 2±1%, p < 0.01), obtained during thoracic surgery.
These data demonstrate that AZD6140 may have an effect on large and small
arteries by blocking the contractile effect of ADP via P2Y12 receptors. These
effects could be beneficial in the prevention of local vasospasm and possibly in
more generalized conditions such as hypertension.
DEVELOPMENT OF NEW START TECHNOLOGY
P2076 Comparison of paclitaxel coated PACCOCATH and
DIOR drug eluting balloon catheters in the porcine
coronary restenosis model
B. Cremers1 , M. Biedermann2 , D. Mahnkopf3 , M. Boehm1 ,
B. Scheller1 . 1Universitaetsklinikum des Saarlandes, Klinik fuer
Innere Medizin III, Homburg, Germany; 2Charite, Campus Mitte, Institut fuer
Radiologie, Berlin, Germany; 3IMTM GmbH, Rottmersleben, Germany
Background: Paclitaxel-coated drug eluting balloon (DEB) catheters based on
the PACCOCATH matrix technology have shown surprising effects in the treatment
and prevention of restenosis in the porcine coronary overstretch model
and recently also in clinical trials. The DIOR balloon is a recently introduced
paclitaxel-coated PTCA catheter. However, no experimental and clinical data regarding
safety and efficacy have been published yet. The aim of the present study
was to compare the safety and efficacy of PACCOCATH and DIOR DEB in
respect of the inhibition of neointimal proliferation in the porcine coronary overstretch
model.
Methods: Twenty-eight stainless steel stents (diameters, 3.0 and 3.5 mm; length,
18 mm) were implanted in LAD and Cx of 14 domestic pigs either with PAC-
COCATH (n=8) or DIOR (n=9) DEB. Uncoated conventional PTCA catheters
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332 Development of new start technology
served as control (n=11). After 28 days, quantitative angiography and histomorphometry
of the stented arteries was performed.
Results: Paclitaxel coated DEB based on the PACCOCATH matrix technology
led to a highly significant (p

flow, and

334 Development of new start technology / Clinical issues after heart transplantation
high-pressure postdilatation with a short, bigger balloon in both groups. Dual
antiplatelet treatment was administered for 30 days in both groups. An inhospital
and 30-day follow-up rates of MACEs (death, myocardial infarction, reintervention
and heart failure) were assessed in both groups.
Results: Baseline demographic, angiographic and procedural characteristics
were well balanced in both groups. All procedures have been performed without
complication in both groups. There were 2 in-hospital deaths (one cardiogenic
shock and one stroke) in the Genous group and 1 in-hospital death ("coma vigile"
after prolonged cardio-pulmonary resuscitation) in the chromium-cobalt group
(p=NS). Furthermore, there was not difference regarding in-hospital heart failure
(12% versus 10%; p=NS) or ejection fraction (55% versus 55%; p=NS). There
was not stent thrombosis neither in the Genous nor in the chromium-cobalt group.
The rate of MACEs at 30-day was comparable in both groups.
Conclusion: The use of EPC capture stent for treatment of STEMI is feasible and
safe. Furthermore, immediate and 30-day outcome is comparable to chromiumcobalt
stents.
CLINICAL ISSUES AFTER HEART TRANSPLANTATION
P2087 Predictors of mortality and major events in heart
transplant recipients treated by bare metal or drug
elting stents for transplant vasculopathy
F. Beygui1 , S. Varnous2 , F. Fernandez2 , G. Montalescot2 ,
P. Leprince2 , C. Aubailly2 ,A.Pavie2 ,C.LeFeuvre1 , J.P. Metzger2 ,
I. Gandjbakhch2 . 1Aphp, Pitie-Salpetriere University Hospital, Cardiology Dept
& INSERM U856, Paris, France; 2Aphp, pitie-Salpetriere university hospital,
Cardiac surgery, Paris, France
Purpose: To assess the correlates of mortality and major acute coronary events
in patients treated by coronary stents for transplant vasculopathy.
Methods: From September 1996 to December 2006, 94 consecutive patients
underwent a first coronary stenting on 105 lesions. On routine basis, all transplant
recipients received drug eluting stents (DES, n=55) from January 2002, while
all received bare metal stents (BMS, n=50) prior to this date. The patients were
followed-up for a mean time of 3.4 years. Multivarible cox analysis, including donor
and recipient parameters was performed to identify correlates of death and major
events.
Results: The mean time between transplantation and stenting was 8.7 years.
During the follow-up 54 major events -33 deaths, 2 myocardial infarctions, 34
coronary revsacularizations of which 17 target lesion revascularization- were reported.
Univariable correlates of death were absence of aspirin treatment, left
ventricular ejection fraction (LVEF), CMV infection, hypertension and transplantation
to PCI time. Univariable correlates of major events were similar except for the
aspirin use.
Multivariable analysis identified LVEF (HR 0.63, p=0.0005), hypertension (HR
4.48, p=0.00004) and transplantation to PCI time (HR 1.1 per year, p=0.04) and,
LVEF (HR 0.80, p=0.04) and hypertension (HR 2.71, p=0.005) as independent
correlates of death and major events respectively. Compared to BMS the use of
DES was associated with lower rates of target lesion revascularization (6.3% vs
30.4% p=0.002), but total revascularization rates were statistically comparable
(43.5% vs 29.2%).
Conclusions: Rates of major events remain high after coronary artery stenting in
heart transplant recipients. The dramatic reduction in rates of target lesion revascularization
by DES contrasts with high rates of remote lesion revascularization
and absence of effect on outcome. The preservation of LVEF and hypertension
control, the major correlates of outcome, may be considered as specific targets
of the management of such patients.
P2088 Coronary flow reserve by contrast-enhanced
transthoracic echocardiography predicts maximal
epicardial intimal thickening in transplant coronary
artery disease
E. Osto1 , F. Tona1 , G. Tarantini1 , M. Napodano1 ,R.Montisci2 ,
A. Gambino1 , A. Ramondo1 , G. Gerosa1 , A.L.P. Caforio1 ,
S. Iliceto1 . 1University of Padova, Cardiology, Padova, Italy; 2University of
Cagliari, Cardiology, Cagliari, Italy
Cardiac allograft vasculopathy (CAV) is the main limiting factor of long-term survival
after heart transplantation (HT). Several noninvasive tests have proven
unsatisfactory in CAV diagnosis. We assessed the role of contrast-enhanced
transthoracic echocardiography (CE-TTE) during adenosine infusion, a new noninvasive
method for determination of coronary flow reserve (CFR).
Methods: CAV was defined as maximal intimal thickness (MIT) assessed by intravascular
ultrasound (IVUS) ≥0.5 mm. CFR was assessed in the left anterior
descending coronary artery by CE-TTE in 12 HT recipients (11 male, aged 55±7
yearsatHT),at6±4 years post-HT. CFR measurements were taken blindly within
24 hours from diagnostic IVUS.
Results: CAV was diagnosed in 5 patients (group A), 8 had normal coronaries
(group B). The median MIT was 0.6 mm (range 0-1.8). MIT was higher in group
A(1.3±0.3 mm vs 0.2±0.1 mm, p

(PCWP) were recorded. In 16 patients, an initial examination was performed 1
month and a follow-up measurement 1 year after heart transplantation (HTX).
Results: Simple regression analysis revealed IMR to directly correlate with
PCWP (r=0.34; p12
mmHg, pulmonary vascular resistance >4 UW]; donor (female gender, age>30
years) and procedural (ischemic time > 240 minutes). Multivariate analysis identified
6 independent predictors shown in Table 1.
Table 1
Prevalence Relative risk CI (95%) p
Recipient age > 60 years 20% 1.99 1.04-3.8 0.037
Recipent diabetes mellitus 12% 2.26 1.08-4.69 0.029
Recipent inotrope therapy 39% 1.94 1.06-3.53 0.029
Recipent RAP > 10 mmHg 42% 2.53 1.30-4.80 0.006
Recipient PSAP > 50 mmHg 37% 1.88 1.01-3.51 0.045
Donor female gender 24% 2.15 1.16-3.96 0.014
Conclusion: Univariate analysis showed multiple recipient, donor and procedural
variables associated to the incidence of PGD, what is consistent with a multifactorial
origin of this syndrome. Multivariate analysis identified 6 independent
predictors with narrow confidence intervals that could be useful for prediction of
the risk of PGD. We hypothesize that these results could help to design strategies
for prevention or early therapy of PGD whenever risk for its development is high.
Further studies on this issue are warranted.
Clinical issues after heart transplantation / Factors influencing outcome after stent placement 335
FACTORS INFLUENCING OUTCOME AFTER STENT
PLACEMENT
P2092 Early endothelialization and neointimal proliferation
in pigs up to 6 months after implantation of BMS by
paclitaxel-coated balloon catheters, Cypher- and
Taxus-stents
B. Cremers1 , M. Braeutigam2 , N. Kaufels3 , D. Mahnkopf4 ,
U. Speck3 , M. Boehm1 , B. Scheller1 . 1Universitaetsklinikum des Saarlandes,
Klinik fuer Innere Medizin III, Homburg, Germany; 2Bayer Schering Pharma
AG, Berlin, Germany; 3Charite, Campus Mitte, Institut fuer Radiologie, Berlin,
Germany; 4IMTM GmbH, Rottmersleben, Germany
Background: Concerns have been raised that sustained drug release by DES
by delaying endothelialization may be associated with an increased incidence of
late thrombotic complications. In contrast, drug-eluting balloon catheters (DEB)
allow for rapid dilution and elimination of antiproliferative active substances after
the short inflation time of the balloon. This study investigated for the first time
endothelialization and neointimal proliferation in the porcine coronary overstretch
model after implan-tation of DEB in combination with bare metal stents (BMS)
compared to Cypher- and Taxus-DES.
Methods: 196 stents were implanted in LAD and Cx of 98 domestic pigs: Control
(BMS, implanted with uncoated PTCA catheter, n=46); DEB+BMS (BMS, implanted
with paclitaxel-coated (3 μg/mm 2 ) PTCA catheter, n=50); Taxus stent
(n=50); Cypher stent (n=50). After 3 and 7 days, as well as after 1, 3 and 6
months quantitative angiography and histomorphometry of the stented arteries
was performed.
Results: DEB+BMS led to early endothelialization with no difference compared
to control. However, Cypher stents showed delayed healing. After one month,
DEB+BMS resulted in a highly significant reduction in neointimal proliferation
compared to control and Taxus stents. At 3 and 6 months follow-up, both DES
showed accelerated neointimal proliferation. In contrast, this effect was considerably
extenuated in coronary arteries, treated with DEB+BMS.
Conclusion: Coronary angioplasty with DEB+BMS resulted in early endothelialization,
effective inhibition of neointimal proliferation and no adverse effects at
later points in time in the porcine coronary overstretch model. This new concept
of local drug delivery could avoid suspected risks of DES in treatment and prevention
of restenosis.
P2093 Risk score for survival after left main percutaneous
coronary intervention
J.A. Gomez Hospital 1 , A. Cequier1 , J. Rondan2 , I. Lozano2 ,
J. Gomez-Lara1 , A. Carro2 , L.M. Teruel Gila 1 , P. Avanzas2 ,
E. Esplugas1 ,C.Moris2 . 1IDIBELL. Hospital Universitari Bellvitge,
Interventional Cardiology Dept., Barcelona, Spain; 2Hospital Central Asturias,
Cardiology, Oviedo, Spain
Background: Left main (LM) percutaneous coronary intervention (PCI) is more
frequently performed due to an increase in revascularization indications, mainly
in patients (pt) with surgical high risk.
Objectives: A series of consecutive pt with significant stenosis in the LM treated
with PCI with stent implantation were included. Pt in cardiogenic shock or treated
during primary angioplasty were excluded. To identify predictive factors associated
to the outcome, a series of clinical, angiographic and procedural variables
were collected. The primary end point was cardiac mortality. The risk score was
derived by selection of the independent prognostic variables identified in the multivariate
logistic regression analysis. To develop the score, the OR values were
assigned to each independent variable identified in the multivariate analysis.
Results: Two hundred seventy seven consecutive pt were included. Mean age
was 71±10 years, 70% male and 35% diabetics. Creatinine Clearance (CrCl)
< 60 ml/min was observed in 45%, previous MI in 40% and previous CABG in
28%. A left ventricular ejection fraction (LVEF) < 45% was documented in 30.7%.
LM bifurcation was involved in 68%. The in-hospital mortality was 4.3%. After
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336 Factors influencing outcome after stent placement
a follow-up of 46±8 months, 53 pt died (19.1%) and 19 pt required additional
additional revascularization procedures (CABG 1%, and re-PCI 6.5%).The independent
predictive factors associated with long-term mortality were expressed in
the table.
The following risk score assignment was developed: LVEF < 45, 3 points; ClCr
< 60, 3 points and Bare Metal Use, 2 points. A progressive increase in mortality
was observed when the risk score increases: Score 0-1, mortality 6.3%; Score
2-4, mortality 24.2% and Score 5-8, mortality 50.49%.
Predictive Factors of Mortality
OR CI 95%
LVEF< 45% 2.8 (1.7-4.5)
ClCr < 60 ml/min 2.5 (1.2-4.9)
Bare Metal Stent 2.3 (1.1-3.2)
Conclusion: In pt with LM stenosis with a PCI indication, the long term prognosis
can be categorized with a simple risk score.
P2094 The acute and three-year clinical outcome according
to gender after sirolimus-eluting stent in the arterial
revascularization therapy study (ARTS) II;
comparison with ARTS I patients
V. Voudris 1 , F.-W. Amann2 , D.V. Cokkinos1 , J. Daemen3 ,
M.-C. Morice4 ,P.Rioux5 , S. Vaina1 ,M.Pieters6 ,H.-P.Stoll6 ,P.-W.Serruys3 on behalf of ARTS II investigators. 1Athens, Greece; 2Zurich, Switzerland;
3 4 5 6 Rotterdam, Netherlands; Massy, France; Nimes, France; Waterloo, Belgium
Background: Compared to men (M), women (W) undergoing percutaneous coronary
interventions (PCI) have a higher rate of in-hospital complications. To determine
whether W have an unfavorable long-term outcome after PCI or surgical
revascularization (CABG) we assessed patients (pts) undergoing revascularization
within the Arterial Revascularization Therapies Studies (ARTS) I and II.
Methods: ARTSI was a randomized multicenter trial of 1205 pts with multivessel
disease (MVD), comparing surgery (ARTSI-CABG, n=605, W=24%) with
bare metal stenting (ARTSI-PCI, n=600, W=23%). ARTSII is a multicenter, nonrandomized
open-label trial of 607 pts (W=23%) with MVD treated with sirolimuseluting
stent (SES). Primary aim was to compare the effectiveness of SES with
ARTSI-CABG (measured as freedom from major cardiac and cerebrovascular
events (MACCE) at 1 year. The clinical presentation, in-hospital complications,
and freedom from MACCE at 1 and 3 year were assessed.
Results: W in ARTSII had a statistically significant higher prevalence of diabetes,
hypertension and 3-vessel disease, compared to ARTSI-PCI and ARTSI-CABG;
the mean number of significant lesions was 3.4 in ARTSII vs. 2.7 in ARTSI-PCI
and 2.7 in ARTSI-CABG (both p

Methods: A prospective, consecutive enrollment study was conducted to gather
demographic, procedural, and discharge data of patients being treated with
a novel "plug-and-play" pCPB system. Patient’s diagnostic codes, procedural
codes, hemodynamic data, and survival rate were analyzed. Femoral arterial and
venous cannulation (15-21F) was used to connect the patient’s circulation to the
device which automatically eliminates air. Up to 6 l/min flow can be provided without
any specially trained personnel.
Results: We included 14 patients with severe coronary artery disease who underwent
high-risk PCI in 2 centers (mean age 79±9 years) under pCPB. 12 patients
(86%) had a history of NYHA Class III or IV, left ventricular ejection fraction
was 44% (± 19%), 9 patients (64%) had an AMI, and 8 patients (57%) were in
cardiogenic shock. 5 patients (36%) were scheduled for elective high-risk PCI for
left main disease. 2 patients also underwent aortic valvuoplasty. Cardiac resuscitation
was unsuccessful in 1 patient prior to receiving PCI. Mean pCPB time
was 187 minutes (range 20-918 minutes). Mean arterial blood pressure was preserved
throughout the intervention (76±25 mmHg before, 79±18 mmHg after 30
minutes, and 77±21 mmHg at procedure end). 13 patients survived, 12 patients
were either discharged or survived seven days after treatment. One cardiogenic
shock patient died during intensive care stay after being successfully treated in
the cath lab. No relevant bleeding complications were reported.
Conclusion: In this early experience, pCPB provided a safe and effective bridge
for interventional therapy and improved survival for these high risk patients. Further
studies should evaluate the appropriate indications and algorithms for use of
pCPB in the catheter laboratory.
P2098 Optical coherence tomographic analysis of
neointimal coverage of sirolimus-eluting stent in
pateints with acute coronary syndrome
M. Habara, M. Terashima, K. Nasu, M. Kimura, Y. Kinoshita,
E. Tsuchikane, T. Matsubara, H. Asakura, O. Kato, T. Suzuki.
Toyohashi Heart Center, Cardiovascular Medicine, Toyohashi, Japan
Back ground: Drug eluting stent in lesions with acute coronary syndrome (ACS)
is one of the major predictors of late stent thrombosis (LST). Whereas, delayed
arterial healing should be responsible for LST. Optical coherence tomography
(OCT) is a high-resolution (approximately10μm) imaging technique. The aim of
this study was to evaluate arterial healing following implantation of Sirolimus-
Eluting-Stent (SES) in ACS lesion, compared to non-ACS lesion.
Method: Motorized OCT pullback (1mm/s) was performed in 10 ACS patients
with 14 SESs and in 12 non-ACS patients with 15 SESs. Neointimal coverage of
stent struts and stent malapposition were evaluated in every observed strut.
Result: In total, 3677 struts analyzed (1728 with ACS and 1949 with non-ACS).
Uncovered struts and malapposed struts were observed more frequently in SES
in ACS patients than in non-ACS patients (22.4% vs 7.1%, p

338 Factors influencing outcome after stent placement
(12.1% vs 17.3%, p=0.2), but a significantly lower target bifurcation revascularization
(TBR) (5.0% vs 12.7%, p=0.003). MC group compared to T-prov 1-stent
group had a similar main branch restenosis (6.4% vs 13.6%, p=0.053) but a significantly
lower side branch restenosis (5.7% vs 18.3%, p=0.002).
Conclusions: Both techniques of bifurcation treatment achieved high procedural
success with low complication rates and similar MACE mid-term outcome. However,
the MC technique yields a lower TBR and restenosis rate at side branch.
These results may confirm the advantage of using two stents technique to give
complete coverage of the ostium of side branches.
P2103 Histological evidence of impaired vascular healing of
restenotic sirolimus-eluting coronary stents: an
antemortem clinical study
H. Jneid, I. Palacios, A.O. Maree, I. Cruz-Gonzalez, R. Cubeddu,
N. Silva, S. Vigo, E. Pomerantsev, S. Houser. MGH-Harvard Medical
School, Cardiology, Boston, United States of America
Purpose: We describe the antemortem histology of drug-eluting stent (DES)
restenosis in patients undergoing directional coronary atherectomy (DCA).
Methods: DCA was performed in 10 patients presenting with clinical restenosis
of sirolimus-eluting stents. Specimens were fixed, paraffin-embedded, cut in
5μm sections, stained and examined with light microscopy. Histological prevalence
of morphologic features was graded as 0 (absent), trace to 1+ (50%). Morphometric analysis was used to
quantify areas of α-smooth muscle actin (SMA)-positive cells and macrophages.
Results: The median time from DES implantation to DCA was 271 days. Nine
specimens were characterized as fibrous, and one contained a lipid pool. The
neointima consisted of mature collagen (2.1+) and acidic proteoglycan mucosubstance
(2.5+), while elastic tissue was scarce (0.6+). Fibrin deposition was noted
in 8 of the 10 specimens (1.3+). No endothelial cells were identified by CD31,
CD34 and Factor VIII stains in any of the DES specimens. T cells ranged from
0 to 1+, and a trace of B cells was identified in 1 specimen. Macrophage staining
accounted for 0.2-13.6% of the total tissue area. SMA-positive spindle cells
accounted for 1.1-65.7% of the total tissue. Ki-67 (0.1+) and PCNA (0.6+) demonstrated
a paucity of active cellular proliferation.
Endothelium of a BMS (A-B) vs. DES (C-E).
Conclusions: The persistence of fibrin deposition and absence of endothelial
staining in neointimal tissue confirm previous reports showing impaired vascular
healing following DES implantation.
P2104 Impact of incomplete stent apposition on long-term
clinical outcome after drug-eluting stent implantation:
an intravascular ultrasound study
P. Eshtehardi1 , S. Cook2 , S. Wandel1 , L. Raeber1 , P. Wenaweser1 ,
R. Corti 1 ,G.Suetsch1 ,F.Eberli1 , P. Jueni1 ,S.Windecker1 .
1 2 Bern, Switzerland; Swiss Cardiovascular Center Bern University H, Invasive
Cardiology, Bern, Switzerland
Background: Late acquired incomplete stent apposition (ISA) is more common
after DES than BMS. However, the impact of ISA on clinical outcome after DES
implantation is not well established. The aim of thepresent study was therefore to
compare long-term clinical outcome in patientswith and without ISA as assessed
by intravascular ultrasound (IVUS) 8 months after implantation of sirolimus-eluting
(SES) or paclitaxel-eluting stents (PES).
Methods and Results: A total of 196 patients underwent IVUS 8 months after
implantation ofDES (SES: 92 patients, PES: 104 patients) and were followed
prospectively for 3 years. IVUS imaging was performed using motorized pullback
(0.5 mm/s) and images were analyzed offline by blinded outcome assessors. ISA
was defined as 1 or more stent struts separated from the vessel wall with evidence
of blood speckles behind the strut. ISA was present in 37 pts (19%) at 8-month
with a higher rate for SES than PES treated pts (14% vs. 6% p=0.001). Baseline
clinical and procedural characteristics were similar for both groups except for
stent length, which was longer in ISA pts (22.1±11.6mm vs. 18.0±8.7,p=0.01).
Clinical outcome at 3 years is summarized in the table below. Therewere no significant
differences regarding death, MI, or repeat revascularization. Late definite
stent thrombosis was encountered in 3 pts (8.1%) with ISA and no patient without
ISA (0%, p

over paclitaxel-eluting stent (PES) was observed with commercially available
stent diameter (≤3.5mm). However whether its efficacy will be maintained in
the treatment of large coronary vessels (≥4.0mm) using overdilatation has not
to been well studied.
Method: We identified 186 consecutive patients who underwent percutaneous
coronary interventions using SESs or PESs and completed follow-up intravascular
ultrasound (IVUS). Patients were divided into 4 groups based on stent diameters
(2.75, 3.0, 3.5, and 4.0/3.5mmSES overdilated with 4.0mm adjuvant balloon
was designated with SES4.0mm). IVUS parameters, including EEM area (EEM),
luminal area (LA), stent area (SA), neointimal hyperplasia area (NIHA) and calculated
percentage of NIH (NIH%=NIHA/MSAx100), were measured at minimal LA
site and compared between SES vs. PES.
Results: 186 patients (92 SES, 94 PES), including nine SES4.0mm and nine
PES4.0mm were enrolled in this study. Baseline clinical and angiographic characteristics
were similar between SES vs. PES in all groups. At 9 months followup,
LA was larger (5.79±1.63mm 2 vs. 4.97±1.89mm 2 , P=0.003) and NIHA was
smaller (0.61±1.18mm 2 vs. 2.31±1.85mm 2 ,P

340 Factors influencing outcome after stent placement / Clinical assessment of new stent technology
on the procedure type, but not on the access site (P = NS). The decline of ORE
was more distinctive in CA as compared to PCI.
Conclusion: Deployment of FPS leads to a markedly reduced radiation exposure
of both operators and patients independent from the access site. Therefore
advantages of transradial approach can be used without increased radiation exposure
P2111 Intravascular ultrasound findings and captured
materials by filtraptm distal protection device at
percutaneous coronary intervention
T. Lee 1 ,T.Kakuta 1 , T. Yonetsu 1 , K. Handa 1 , A. Suzuki 1 ,Y.Iesaka 1 ,
H. Fujiwara 1 ,M.Isobe 2 . 1 Tsuchiura Kyodo Hospital, Division of
Cardiology, Cardiovascular Center, Tsuchiura-Shi, Japan; 2 Tokyo Medical and
Dental University, Division of Cardiology, Tokyo, Japan
Background and Purpose: A new filter-based distal protection device (FiltrapTM)
was investigated with respect to the relation between decreased plaque
volume by PCI and angiographic outcome.
Methods: FiltrapTM was used in 50 consecutive patients (AMI: 21, UAP: 13, SAP:
16). Aspiration thrombectomy was performed before FiltrapTM insertion in ACS
at the operator’s discretion. All patients underwent pre- and post-PCI IVUS and
qualitative and quantitative analyses were performed at the lesion segment. The
difference between pre- and post-PCI plaque volume was defined as the index of
the decrease in plaque volume (�PV). Amount of debris captured by FiltrapTM
was visually inspected first and graded into one of two categories (group E: debris
easily detected, group D: difficult to detected visually). FiltrapTM no reflow (FNR)
was defined as a phenomenon showing final TIMI 3 flow after PCI with TIMI 0-2
flow before FiltrapTM retrieval.
Results: In all cases, FiltrapTM was successfully inserted. Echo signal attenuation
(EA) by IVUS was observed in 35 (70%) patients, and FNR was observed
in 21 (42%) patients. In EA group, �PV was significantly greater (EA: 51.6±17.6
vs. non-EA: 33.0±13.3mm 3 ,p

which proved to be safe and effective in proximal simple lesions resulting in significantly
reduced procedural duration and lower contrast consumption compared
to conventional PCI.
P2115 Efficacy of very short-term exposure to a
paclitaxel-coated balloon in restenosis inhibition
B. Cremers1 , M. Kuehler2 , N. Kaufels3 , D. Mahnkopf4 , U. Speck3 ,
M. Boehm1 ,B.Scheller1 . 1Universitaetsklinikum des Saarlandes,
Innere Medizin III, Homburg, Germany; 2B. Braun Melsungen
AG, Vascular Systems, Berlin, Germany; 3Charite, Campus Mitte, Institut fuer
Radiologie, Berlin, Germany; 4IMTM GmbH, Rottmersleben, Germany
Background: Paclitaxel-coated SeQuent Please balloon catheters based
on the PACCOCATH technology have shown promising effects in inhibiting
restenosis in the porcine coronary overstretch model and recently also in clinical
trials. Nevertheless, little is known about the risk of overdose due to overlapping
balloons and the required duration of contact with the vessel wall. The aim of the
present study was to evaluate the influence of the shortest possible inflation time
and higher doses than those tested in clinical trials.
Methods and results: Fifty-six stainless steel stents (diameters, 3.0 and 3.5 mm;
length, 19 mm) were implanted in the left anterior descending and circumflex
coronary arteries of 28 domestic pigs. Both conventional uncoated and paclitaxelcoated
DEB (5 μg/mm 2 balloon surface) PTCA balloon catheters were used. The
animals were randomized to 5 different treatments with a range of short (10 seconds
inflation using 1 DEB) to extended (2x60 seconds inflation using 2 DEB)
intima contact time; uncoated balloons (60 seconds inflation time) were used
as control. After 28 days, quantitative angiography and histomorphometry of the
stented arteries was performed. Paclitaxel balloon coating led to a marked reduction
of parameters characterizing in-stent stenosis (reduction of neointimal area
up to 61%) independent of inflation time or dose. Despite the marked reduction of
neointimal proliferation, endothelialization of stent struts was present in all samples.
Conclusion: Paclitaxel-coated SeQuent Please balloon catheters were found
to effectively reduce neointimal proliferation regardless of inflation time and dose
within the tested range. No adverse reactions were seen as dose was increased
to more than 3 times the clinically tested dose.
P2116 Magnetic Navigation significantly reduces the
contrast needed to cross a lesion
S. Ramcharitar, R.J. Van Geuns, M.S. Patterson, M. Van Der
Ent, R.T. Van Domburg, P.W. Serruys. Thoraxcenter, Rotterdam,
Netherlands
Magnetic navigation is an innovative technology that can accurately control the
positioning of a guidewire or a catheter in vivo. We conducted the first randomised
comparison of the performance of the Magnetic Navigation System (MNS) versus
conventional wire technique in native coronary arteries. In 111 consecutive
patients admitted with stable and unstable angina, 151 lesions were randomised
to cross the culprit lesion twice, either firstly using a conventional or a magnetically
enabled guidewire. The amount of contrast (ml) used was measured after
first placing a guidewire at the tip of a guide catheter engaged at the ostium and
following the wire passage distal to the lesion. The guidewire was then withdrawn
and the comparative guidewire was then used to coincide with the start and end
position of the first wire. The crossing with the MNS was achieved using a virtual
3-dimensional roadmap superimposed on the live fluoroscopic image. This map
was created from 2 angiographic images using a dedicated software. Lesions
were classified according to the AHA/ACC criteria and comprised of 15 Type A
(10%), 30 Type B1 (20%), 95 Type B2 (63%) and 11 Type C (7%). The operators
had unrestricted access to the choice of either magnetic or conventional
guidewires. All were interventional cardiologists who were also trained with the
MNS. Student T-test was used to determine if there were significant differences
between the parameters assessed using both techniques.
The results showed that in crossing type A lesions there was no significant differ-
Clinical assessment of new stent technology 341
ence in contrast usage (ml) between the magnetic or conventional wires (1.5±1.8
vs. 1.9±2.3 p = 0.59 respectively). However, as lesion complexity increased significantly
less contrast (ml) was needed when the MNS was employed:- Type B1
(2.5±3.2 vs. 4.0±2.6 p = 0.01); Type B2 (2.3±3.8 vs. 4.9±4.9 p < 0.001); Type C
(2.9±3.4 vs. 5.9±4.9 p = 0.03). In addition, no contrast was required when crossing
59 lesions (39%) with the MNS in comparison to 21 lesions (14%) using the
the conventional wire approach
Overall the MNS gave a small but significant reduction in contrast usage (2.3±3.5
vs. 4.5±4.4 p < 0.001) relative to the conventional wire technique. Moreover by
superimposing a virtual roadmap of the vessel on the live fluoroscopic image 39%
of the lesions were crossed without the need for any contrast.
P2117 Implantation of zotarolimus-eluting stent could not be
associated with significant long-term coronary
endothelial dysfunction: the prospective randomized
study between ZES and SES implantation
D.I. Shin, K.B. Seung, P.J. Kim, M.J. Kim, D.S. Jeon, M.Y. Lee. The
Catholic University of Korea, Internal Medicine, Seoul, Korea, Republic of
Purpose: Sirolimus-eluting stent (SES) has been associated with endothelial
dysfunction in recent studies. However, the endothelial function after zotarolimuseluting
stent (ZES) implantation remains largely unknown. We assessed coronary
endothelial function 6 months after ZES implantation compared with SES implantation.
Methods: Thirty patients who had one stent implantation for single de novo lesion
in left anterior descending artery were enrolled to this prospective randomized
study. They were classified into two groups according to the type of the
stents; 15 patients of SES and 15 patients of ZES group. We assessed endothelial
function only in patients who showed no in-stent restenosis on 6 month-follow
up angiography. Endothelium-dependent vasomotion was determined by measuring
the change of diameter after selective intracoronary injection of acetylcholine
(Ach, 10-6 mol/L). Endothelium-independent vasomotion was assessed after injection
of 2mg-nitrates. The measuring was done at 5 segments; near proximal
and proximal, distal and far distal, and stented segments by quantitative coronary
angiography. The endothelial dysfunction was defined as abnormal vasoconstriction
of more than 20% in vessel diameter change from the baseline after infusion
of Ach at any measuring points.
Results: The assessment was performed in total 22 patients (10 of ZES, 12 of
SES). The baseline characteristics were all well matched. In stented segments,
no vasomotion was observed in both groups. In distal and far distal segments,
SES group showed significant vasoconstriction by Ach, but ZES group did not
(SES vs ZES: -36.1% vs 0.6% for distal;p=0.002, -34.7% vs 0.5% for far distal;p=0.001).
In proximal portion, no significant difference was seen between two
groups (SES vs ZES: 1.6% vs 2.4% for near proximal;p=0.26, 1.1% vs 0.6% for
proximal;p=0.39). When comparing change of diameter between near proximal
and far distal segments and between proximal and distal segments after Ach injection,
ZES group showed no differences (p=0.19, 0.98) while SES showed significant
decrease of diameter in distal compared to proximal portion (p=0.001,
0.001). The pattern of vasodilatation by nitrates was similar between the two
groups.
Conclusion: The impairment of endothelium-dependent vasodilatation in the
distal portion was observed in SES group but not in ZES group. Endotheliumindependent
vasodilatation was intact in both groups. The results suggest that
the ZES implantation could not be associated with the long-term coronary endothelial
dysfunction, while it was significant after SES implantation.
P2118 Angiographic late loss in the overlapping site of
multiple overlapping cypher sirolimus-eluting stents
Y. Takamiya 1 , Y. Tsuchiya2 , Y. Fukuda1 , T. Kuwano1 ,A.Ike1 ,
D. Yanagi1 , K. Kubota1 , B. Zhang1 ,K.Shirai1 ,K.Saku1 . 1Fukuoka University Hospital, Department of Cardiology, Fukuoka, Japan;
2Fukuoka University Chikushi Hospital, Department of Cardiology, Fukuoka,
Japan
Background: It has been reported that the overlapping Cypher Sirolimus-Eluting
Stents (SESs) are associated with a greater late lumen loss in stent and more
angiographic restenosis. The purpose of this study is to evaluate whether the
overlapped site in overlapping SES would increase neointimal hyperplasia or be
rather decrease it.
Methods: Between October 2004 and November 2007, SESs were implanted
electively in 297 patients with coronary artery disease. We compared sevenmonth
angiographic late loss of the overlapped site in overlapped-stent-treated
patients (overlapping SES group, N=50) to that in single-stent-treated patients
(single SES group, N=247). Patients with either stable or unstable angina were
included but acute myocardial infarction was excluded.
Results: Baseline clinical and angiographic characteristics of the overlapping and
the single SES groups were similar except longer lesion length in the overlapping
SES group. The length of overlapped stent segment by quantitative coronary angiogram
(QCA) was 4.00±1.72mm. There was no significant difference in death
and myocardial infarction between the two groups. Overlapping SES group was
not associated with the increase of binary restenosis (17% vs. 23%, respectively,
P=0.32) and taget lesion revascularization compared with single SES group (10%
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342 Clinical assessment of new stent technology
vs. 12%, respectively, P=0.76). In-stent late lumen loss did not differ significantly
between the two groups (0.10±0.57mm vs. 0.20±0.61mm, respectively, P=0.34).
Furthermore, the overlapped site in overlapping SES group had lower late lumen
loss (0.10±0.47mm).
Conclusions: The overlapped site of the overlapping SES was not associated
with a greater late lumen loss, nor higher in-stent binary restenosis rate compared
to non-overlapped site. The overlapping of SES itself did not increase neointimal
hyperplasia.
P2119 Is systemic inflammation a main determining factor
for neointimal hyperplasia after drug-eluting stent
implantation?
W.C. Kang1 ,T.H.Ahn1 , C.I. Moon1 ,J.S.Kim2 , D. Choi2 ,Y.Jang2 ,
B.K. Kim3 ,S.J.Oh3 , D.W. Jeon3 ,J.Y.Yang3 . 1Gachon University,
Interventional Cardiology, Incheon, Korea, Republic of; 2Yonsei University,
Interventional Cardiology, Seoul, Korea, Republic of; 3NHIC Ilsan Hospital,
Interventional Cardiology, Koyang, Korea, Republic of
Introduction: Inflammation plays a crucial role in determining in-stent restenosis
via neointimal proliferation. Although DES reduce restenosis by inhibition of
neointimal hyperplasia (NIH), paclitaxel-eluting stent (PES) and silorimus-eluting
stent (SES) showed different effect on suppression of NIH in several studies. So
we compared degree of inflammation, as measured by hs-CRP, IL-6 levels and
NIH volume after PES and SES implantation.
Method: We performed PCI with a single DES in 99 stable angina patients (PES,
n=51; SES, n=48). The hs-CRP and IL-6 levels were determined before and at
24, 72 hours, 4 weeks after PCI. Angiography and IVUS were performed at pre,
post PCI and 9 months after PCI.
Results: There was no difference in the clinical and angiographic baseline characteristics
between the two groups. The hs-CRP and IL-6 levels at baseline did
not differ between the two groups. The hs-CRP increased significantly from baselineat24hr(p

Comparison of neointimal growth among BM.
SES also had less NIT, compared to other stents (52.7±35.6μm, 175.5±43.8μm,
212.2±86.8μm, p 80%.
Results: Data were collected prospectively in 38 patients aged 67.2±12.4 yrs,
diabetic 36%, acute coronary syndrome 31%, in whom 60 stents (length 19.6±6.8
mm; diameter 2.92±0.48 mm) were deployed at a mean pressure of 13.6±2.2
atm. Lesion reference diameter was 3.06±0.50 mm.
5 sec 15 sec 25 sec Deflation
Minimal stent diameter (mm) 2.41+0.47 2.54+0.46 2.58+0.47 2.52+0.48
Mean stent diameter (mm) 2.75+0.45 2.84+0.47 2.90+0.47 2.83+0.49
Maximal stent diameter (mm) 3.06+0.48 3.15+0.50 3.19+0.49 3.15+0.54
Optimal stent expansion (%) 58.3 93.3 95.0 88.3
Conclusion: Better stent implantation may be achieved by increasing the duration
of stent deployment. This may influence the risk of stent thrombosis.
P2124 The vascular pro-healing potential of 17beta-estradiol
drug eluting stent: a pre-clinical study
J.F. Tanguay, P. Geoffroy, I. Cloutier. Institut de Cardiologie de
Montreal, Biomedical Science, Universite de Montreal, Montreal,
Canada
Purpose and objectives: First to evaluate the efficacy of stents
coated with two concentrations (300μg and 500μg) of 17-beta estradiol (E2) to
improve vascular healing and reduce restenosis at 24 hours, 14 days and 28 days
after stent implantation. Their safety and efficacy were compared to control bare
metallic (BM) and polymer-only coated stents. Secondly, to evaluate the reendothelialization
process, a scanning electron microscopy (SEM) analysis was performed
at 28 days following the implantation of E2 coated stents (500μg), taxus
or cypher drug eluting stents.
Methods: Stainless steel (BM) stents were spray coated with 300ug or 500ug
of E2 matrixed with the poly (ester-amide) (MVPEA.I.(Ac)) tempo polymer with a
200ug topcoat of polymer only. cypher and taxus stents were also used. For the
efficacy study, E2 and control stents were implanted in 75 swine following balloon
dilation. For the reendothelialization study, 7 swine distributed into 3 groups
received PEA/500ug E2 stents (n=3), cypher (n=2) or taxus (n=2) stents with 2
stents per animal.
Results: The healing process on the luminal side of the arteries was reflected
by a complete reendothelialization as determined by immunohistology analysis
using an anti-CD31 specific antibody. The reendothelialization was significantly
faster in the 300ug E2 group as compared with the BM group with greater than
90% of reendothelialization at 2 weeks post stent implantation. However, no dif-
Clinical assessment of new stent technology 343
ference in the score of macrophage infiltration (Mac-2 staining) was detected. By
SEM, the best reendothelialization profile was obtained with the PEA/E2 500ug
stent. A more complete coverage of all the struts with tightly connected endothelial
cells was observed with the E2 stents when compared to the cypher stents.
Also, adhesion of platelets and leukocytes on the endothelium was comparable
or even lower with the 500ug E2 stent than with the taxus or cypher stents. At the
28-days time point, the 500 ug E2 stents reduced the expansion of the neointima
(Ni) when compared with the PEA stents.
Conclusions: The healing process of coronaries occurs rapidly in the E2 treated
groups when compared with the BM group with >90% of reendothelialization after
2 weeks. In the reendothelialization study, the PEA/E2 500ug stents gave the
best reendothelialization profile with a more complete coverage of all stent struts
than the cypher stents and less adhesion of platelets and leukocytes to the endothelium
than the taxus stents. At 28 days, the 300ug and 500ug E2 stents had
no significant difference in Ni formation compared with the BM, PEA, taxus and
cypher stents.
P2125 German stereotaxis-guided percutaneuous coronary
intervention study group: first multicenter real world
experience
R. Blindt1 , U. Adamu1 , M. Weber2 ,K.Hertting3 ,C.Hamm2 ,
K.H. Kuck3 ,R.Hoffmann1 ,M.Kelm1 ,K.Krause3 . 1University Hospital RWTH Aachen, Cardiology Dept., Aachen, Germany; 2Kerckhoff-Klinik Bad Nauheim, Cardiology Dept., Bad Nauheim, Germany; 3Asklepios Klinik St.
Georg St. Hamburg, Cardiology Dept., Hamburg, Germany
Introduction: Aim of this observational multicenter study was to systematically
evaluate the capability of the Stereotaxis Niobe Magnetic Navigation system to
facilitate wire navigation during percutaneous coronary intervention (PCI). The
Niobe Stereotaxis system consists of two .8 Tesla magnets and a navigation
software allowing to move specially-designed coronary wires guided by remote
control. The aim of the study was to determine the success rate of magneticallyguided
PCIs in a real-world setting and to analyse procedure-related variables
influencing the results.
Methods: 157 patients underwent magnetically-guided PCI in 3 German centres.
Demographic variables of the patients, lesion quality determined by quantitative
coronary angiography, success rate of the procedure as well as radiation time
were analyzed. A subanalysis was performed for two periods (06/04 - 10/06 and
10/06 - 10/07) owing to a second generation of wires which was introduced at
the beginning of the second period and procured-related learning curves of the
operators.
Results: Mean age of the patients was 66±0.4 years (82% male, 18% female).
34% of the patients were diabetics, 12% had an impaired left ventricular function
(< 45%). The lesions were characterized by high complexity (11% AHA type
A, 25% type B1, 38% type B2, 25% type C). Mean percent lesion stenosis was
85±26%. The overall success rate of the magnetically-guided approach was 87%.
The total fluoroscopy time was 12.4±0.46 min. All failures occurred within the first
period (84 pts) while the success rate between 10/06 -10/07 was 100% (73 pts).
In the first period, 80% of the failures could be successfully treated after switching
to conventional wires. On the other hand, between 10/06 - 10/07 three conventional
PCI failures could be could be successfully treated following utilization of
the Stereotaxis system.
Conclusions: Magnetically-guided PCI represents an interesting tool for the
treatment of dedicated lesions. There is a marked difference in the success rates
of the method between the two different time periods which were analyzed, reflecting
advances in the wire development and learning curves of the respective
operators. Randomized controlled trials are required to determine the method’s
overall value and to identify subgroups that may particularly benefit.
P2126 MAHOROBA I, first-in-man study: four-months results
of a biodegradable polymer taclorimus-eluting stent
in de-novo coronary stenosis
Y. Onuma 1 ,N.Kukreja1 ,S.Tanimoto1 ,P.Smits2 ,P.DenHeijer3 ,
K. Fukaya4 , H. Maeda4 , H. Sakurai4 ,P.W.Serruys. 1Thorax Center,
Erasmus MC, Interventional Cardiology, Rotterdam, Netherlands; 2Medisch centrum Rijnmond-Zuid, Rotterdam, Netherlands; 3Amphia Ziekenhuis,
Research Cardiologie Interventie, Breda, Netherlands; 4Kaneka corporation,
Osaka, Japan
Objective: Tacrolimus is one of the potential pharmacological candidates for
drug-eluting stents. The results of cell culture studies imply that the inhibitory
concentration value 50 (IC 50) of tacrolimus for endothelial cells (EC) is markedly
higher than that for smooth muscle cells (SMC), while the IC50 of sirolimus for EC
is remarkably lower than that for SMC. Accordingly, tacrolimus may have a preferential
effect on ECs as opposed to SMCs if equivalent concentrations for suppressing
SMC are used. Furthermore, unlike sirolimus or paclitaxel, tacrolimus
does not affect tissue factor and e-NOS expression, which might contribute to a
lower risk of stent thrombosis. The combination of tacrolimus with a biodegradeable
polymer coating may produce a safer drug-eluting stent. The aim of the MA-
HOROBA I study is to report angiographic and clinical follow-up at 4 months after
implantation of the second-generation tacrolimus-eluting bioabsorbable PLGA
polymer- coated stent (strut thickness 75μm).
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344 Clinical assessment of new stent technology
Methods: Patients having stable or unstable angina or silent myocardial ischemia
with a de-novo coronary lesion of a length that could be covered by a single 18
mm stent in a native coronary artery of diameter between 3.0 mm and 3.5 mm
were enrolled at 3 sites. The primary endpoints were in-stent and in-segment late
loss at 4 months. Secondary clinical endpoints included major adverse cardiac
events and stent thrombosis at 4 months. Clinical follow-up was planned at 30
days and 4-months with angiographic follow-up at 4 months.
Results: Forty-seven patients (mean age 61.3 years, 63% males and 20% diabetics)
were enrolled between May and November 2007. The majority of patients
had stable angina (75%). Within 30 days, one patient (2.1%) experienced a myocardial
infarction due to subacute stent thrombosis at 4 days after procedure. No
additional events occurred at 30 days follow-up
Conclusion: Tacrolimus-eluting stents are feasible for the treatment of de-novo
coronary artery lesions, with low short-term adverse event rates. The results of
angiographic and clinical follow-up at 4 months are currently being collected and
will be presented at the time of the meeting.
P2127 Culotte stenting technique in coronary bifurcation
disease. Angiographic follow up using dedicated
quantative coronary angiographic analysis and
12-month clinical outcomes
R. Byrne, T. Adriaenssens, R. Iijima, J. Mehilli, A. Dibra, O. Bruskina,
J. Pache, A. Schoemig, A. Kastrati. Deutsches Herzzentrum Muenchen, Munich,
Germany
Background: Percutaneous treatment of coronary bifurcation disease remains
a challenge for the interventional cardiologist. In patient subsets in which a 2stent
strategy is necessary, the culotte technique is a widely used method. We
sought to examine the clinical and angiographic outcomes of patients treated
in this manner at our institution. As quantitative coronary angiographic analysis
using standard measurement programmes is problematic, we used a dedicated
bifurcation analysis system.
Methods: We prospectively enrolled patients undergoing culotte stenting with
drug-eluting stents in 2 German centers. The technique consists of stenting one
of both branches of the bifurcation lesion first, and after balloon dilatation of the
stent meshes, stenting the uncovered branch through the first stent and leaving
the main vessel covered with two overlapped stents. All bifurcation lesions
were classified according to the Medina classification. Angiographic follow-up was
scheduled between 6 and 12 months after the index procedure. Clinical follow-up
was available up to 12 months.
Results: The culotte technique was used in 134 lesions in 132 patients. Of these,
124 (92.5%) represented a true bifurcation lesion morphology, defined as Medina
classification (1,1,1), (1,0,1) or (0,1,1). The median patient age was 64±11
years. Reference vessel diameter was 3.09±0.39 mm in the proximal main vessel,
2.75±0.33 mm in the distal vessel and 2.57±0.42 mm in the side branch.
Kissing balloon inflation was used in 62% of patients. Procedural angiographic
success was achieved in all lesions. Follow-up coronary angiography was performed
in 108 (81.8%) patients. Late lumen loss was 0.15±0.40 mm in the proximal
main vessel, 0.37±0.55 mm in the distal main branch and 0.38±0.64 mm
in the side branch. The incidence of binary angiographic restenosis was 22% for
the whole bifurcation lesion, 0% in the proximal main vessel, 9.1% in the distal
main branch and 16% in the side branch. At 12 months, 26 of 132 (19%) patients
had undergone target lesion revascularization. The incidence of stent thrombosis
(at 1 year) was 1.5%. Predictors of angiographic restenosis were older age
(p=0.01), bifurcation angle larger than 52° (p= 0.03), more severe stenosis in the
distal main branch (p= 0.032), and smaller reference diameter of the side branch
(p= 0.02); kissing balloon postdilation tended to have a protective effect (p=0.07).
Conclusions: The culotte stenting technique is associated with high procedural
success and a relatively low risk of angiographic restenosis. Safety results in our
cohort were favourable in terms of a low risk of stent thrombosis.
P2128 Factors determining use of stents in patients
presenting with acute coronary syndrome and
undergoing PCI: results from the antiplatelet
treatment observational registry (APTOR)
A. Iniguez 1 , A. Bakhai 2 , J. Ferrieres 3 , M. Belger 4 ,C.Schmitt 4 ,
T. Huete 5 ,U.Zeymer 6 on behalf of the APTOR investigators. 1 Vigo, Spain;
2 London, United Kingdom; 3 Toulouse, France; 4 Windlesham, United Kingdom;
5 Madrid, Spain; 6 Ludwigshafen, Germany
Purpose: To identify clinical factors explaining variations in use of stent type in
patients presenting with ACS, the most common cardiac cause of hospital admissions.
Methods: A prospective observational registry in 3 countries, recruited ACS patients
undergoing PCI, Jan – Aug 2007, capturing practice patterns, resource use
and QoL.
Results: 1525 ACS pts (Spain-538, UK-504, France-483), mean age 62 (SD
12), mean wt 80kg (SD 15), 22% female were recruited with co-morbidities
of hypertension-53%, dyslipidemia-52%, diabetes-20% and prior MI-23%. Index
diagnosis: Unstable angina (UA) and non ST-elevation myocardial infarction
(NSTEMI)-62%; ST-elevation myocardial infarction (STEMI)-38%. 95% of 1491
pts with procedural data had PCI with stent implantation (see table). Of the overall
ACS population undergoing PCI with stent implantation, 635 (45%) pts received
a bare metal stent (BMS), 603 (43%) a drug eluting stent (DES) and 160 (11%)
both. The use of DES varied by country: Spain 375 (72%), UK 236 (56%), France
152 (33%). GP IIb/IIIa inhibitor use: abciximab-22%, tirofiban-9%, eptifibatide-
2%. 173 (60%) pts with diabetes received DES compared with 430 (39%) nondiabetics.
DES was used in 125 (56%) pts reporting previous PCI and in 478
(41%) pts with no previous PCI. 95% stent pts received dual antiplatelet therapy
at discharge (94% BMS, 95% DES, 96% BMS+DES). France was the only country
with more than 1% use of a clopidogrel discharge dose > 75mg: 57 (19%) pts
with BMS, 35 (35%) pts with DES, and 14 (29%) pts with both (24% of total stent
pts) (1 pt in each of Spain and UK had >75mg).
Spain % UK % France % UA/NSTEMI% STEMI % Pooled%
(533) (477) (481) (914) (577) (1491)
PCI with stent 98 90 96 94 95 95
PCI with >1 stent 47 42 36 44 38 42
PCI with BMS + DES 16 6 11 13 9 11
PCI with BMS only 28 44 67 37 59 45
PCI with DES only 56 49 23 50 32 43
Conclusions: These high international variations do not seem to be explained by
patient baseline characteristics or by disease epidemiology. These data provide
a useful benchmark for comparison with European ACS management guidelines,
and further results from our registry will provide key information on these patients
in clinical practice.
P2129 Balloon folding, the underestimated cause of
neointimal hyperplasia?
M. De Beule 1 ,P.Mortier 1 , D. Van Loo 2 , P. Segers 1 , Y. Taeymans 3 ,
B. Verhegghe 1 , P. Verdonck 1 . 1 IBiTech, Ghent University, Gent,
Belgium; 2 UGCT, Ghent University, Gent, Belgium; 3 UZGent, Ghent
University, Gent, Belgium
Purpose: Restenosis after (drug-eluting) stent implantation is correlated with
non-uniform stent strut distribution. This observation is related to the protrusion
of the tissue between the struts of the stent (prolapse) and the local drug concentrations
and gradients, resulting from inhomogeneous strut placement. Therefore
efforts should target optimization of the uniformity of the stent strut distribution
upon stent deployment. We hypothesize that the folding pattern of the delivery
balloon contributes to the non-uniform strut distribution.
Methods: We developed an innovative computer tool that allows inflation of balloons
and expansion of stents to predict and optimize stent strut distribution during
the procedure. The procedure was applied to a commercially available and
widely used last generation drug-eluting stent, which was expanded virtually with
both a tri- and six-folded balloon configuration. As validation, the tri-folded scenario
was compared with micro-CT images at the end of the transient expansion
phase.
Results: There was an excellent correspondence between the simulations and
the micro-CT images of the real expansion. For the three-folded balloon (its regular
application), a non-uniform strut distribution pattern was observed (left panel:
simulation; center panel: experiment), whereas a six-folded balloon (right panel:
simulation) results in a homogeneous strut distribution.
Conclusions: The balloon folding pattern is a major factor contributing to nonuniform
stent strut distribution. Our virtual tool allows to assess the most appropriate
balloon folding for a specific stent to minimize stent strut non-uniformity
attributable to balloon unfolding.
P2130 Off-label use of drug-eluted stents: demographic,
clinical and angiographic predictors influencing the
election of DES in real-world practice
J.L. Gutierrez-Chico, A. Ortiz Saez, S. Vazquez Fernandez,
J.A. Baz-Alonso, A. Iniguez-Romo. Complejo Hospitalario
Universitario de Vigo, Unidad de Cardiologia Intervencionista, Vigo (Pontevedra),
Spain
Background: Although DES are approved for some limited indications, their efficacy
to prevent restenosis has widened their use for the most challenging cases,
with worse clinical-angiographic profile. Recent data have raised concern however
about DES safety. Off-label indication should be taken into consideration to
understand the controversial results of trials and metaanalysis.
Methods: We retrospectively analyzed data of 3822 stents implanted in 2101
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patients between October 2006 and January 2008. Demographic, clinical and angiographic
variables were analyzed with step backward logistic regression (likelihood
ratio) to determine their influence in the choice for DES vs. bare metal stent
(dependent variable).
Results: The strongest predictors of DES election were: unprotected left main
PCI (OR 6.023, CI 95% 3.022 – 12.004), chronic total occlusion (OR 5.718, CI
95% 2.243 – 14.579), Diabetes (OR 3.219, CI 95% 2.420 – 4.280), bifurcation
lesion (OR 2.039, CI 95% 1.438 – 2,893), 3-vessels disease (OR 1.598, CI 95%
1.061 – 2,407) and lesion length (OR 1.064, CI 95% 1.049 – 1.079). Variables
preventing the option for DES were prior surgical revascularization (OR 0.173, CI
95% 0.075 – 0.397) and % stenosis (OR 0.983, CI 95% 0.972 – 0.994). Variables
included in the final regression model, but with weak predictive value were hypercholesterolemia,
prior PCI, completeness of revascularization and 2-vessels disease.
No predictive value was found for hypertension, smoke, familiar history of
ischemia, prior infarction, heart failure, age, total length treated in the procedure,
vessel diameter, TIMI flow or type of vessel (native, saphene graft or mammary
artery).
Conclusions: Variables influencing the choice for DES in real practice differ by
far from on-label admitted indications. This fact should be contemplated in the
current debate about the controversial use of these devices.
LIPIDS: STATINS AND BEYOND
P2131 Effects of rosuvastatin and atorvastatin on the
ApoB/ApoA1 ratio in patients with acute coronary
syndrome (CENTAURUS trial)
J.M. Lablanche 1 ,J.C.Tardif 2 , A. Leone 3 ,B.Merkely 4 , J. Morais 5 ,
J. Alonso 6 , M. Santini 7 ,J.Eha 8 ,N.Demil 9 , M. Licour 9 on behalf
of CENTAURUS investigators. 1 Hopital Cardiologique, Lille, France; 2 Montreal
Heart Institute and Universite, Montreal, Canada; 3 Hopital CHU Tivoli, La
Louviere, Belgium; 4 Cardiology, Budapest, Hungary; 5 Hospital de Santo Andre,
Leiria, Portugal; 6 Hospital De Fuenlabrada, Spain; 7 Ospedale S. Filippo Neri,
Roma, Italy; 8 Tartu, Estonia; 9 Astrazeneca, Medical Cardiology Dept., Rueil
Malmaison, France
Background: Recent studies have shown that the ApoB/ApoA1 ratio could be
one of the strongest predictors of acute fatal myocardial infarction. CENTAURUS
is the first study to evaluate the change in ApoB/ApoA1 ratio during the acute
phase of acute coronary syndrome (ACS). Objectives: To assess the efficacy and
safety of rosuvastatin 20 mg (R20) versus atorvastatin 80 mg (A80) in patients
with ACS.
Methods: A randomized, double-blind, international, 2-parallel groups trial that
included patients with non-ST elevation ACS and no cholesterol-lowering medications
during the preceding month. The primary objective was to compare the
efficacy of R20 vs A80 initiated at hospital discharge, in reducing the ApoB/ApoA1
ratio at 3 months. The secondary objective was to demonstrate the non-inferiority
of R20 compared to A80 for percentage reduction in LDL-cholesterol (LDL-C) levels
at 1 and 3 months. The non-inferiority analysis for LDL-C was performed with
the upper limit of 95% IC for the difference between R20 and A80 being less than
3%, on both the Intent To Treat (ITT) and Per Protocol (PP) populations.
Results: Among the 829 patients who took at least one dose of study drug after
hospital discharge, 369 patients in R20 group and 384 patients in A80 group
were included in the ITT analysis, 226 and 252 respectively in PP analysis. At
baseline, median ApoB/ApoA1 ratio was 0.90 and median LDL-C 1.26 g/l (3.3
mmol/l). R20 was more effective in decreasing ApoB/ApoA1 ratio at 1 month but
not at 3 months. LDL-C decreased by nearly 50% after 1 and 3 months in each
group. The non-inferiority of R20 versus A80 was demonstrated after 1 month with
a difference of -0.3% [-2.7; +2.1] [95%CI] in favour of greater reduction in the R20
group. This hypothesis couldn’t be shown after 3 months (+1.0% [-1.6; 3.5]) in
ITT analysis. However, the non-inferiority of R20 was demonstrated both at 1 and
3 months in the PP analysis (-0.7% [-3.5; 2.0] and -0.5% [-3.5;2.5] respectively).
The 2 treatments were well tolerated.
% Change in ApB/ApoA1 R20 median A80 median Estimated difference p
(mean ± std)* (mean ± std)* Median [95% CI]*
At 1 month -44.4 (-43.1±16.5) -42.9 (-40.5±16.3) -2.6 [-4.5;-0,0] 0.02
At 3 months -44.4 (-41.2±20.1) -44.4 (-41.7±17.1) 0.0 [-2.5;+1.7] 0.87
*Data distribution was not normal.
Conclusion: In patients with non-ST elevation ACS, R20 significantly decreases
ApoB/ApoA1 ratio at 1 month compared to A80 whereas no difference is shown
at 3 months.
Clinical assessment of new stent technology / Lipids: statins and beyond 345
P2132 High density lipoprotein cholesterol, low high density
lipoprotein cholesterol and major cardiovascular
events among patients with coronary heart disease in
the scandinavian simvastatin survival study
Q. Zhang1 , V. Sazonov1 ,Y.Cui1 , D.L. Maccubbi 1 , T.J. Cook1 ,
T.R. Pedersen2 . 1Merck & Co, Inc, Whitehouse Station, United States of
America; 2University of Oslo, Oslo, Norway
Purpose: Many coronary heart disease (CHD) patients fail to attain low density
lipoprotein cholesterol (LDL-C) goal despite statin therapy. Over one-third also
have low high density lipoprotein cholesterol (HDL-C). We examined the risk of
major cardiovascular events (MCEs) including revascularization, in statin treated
CHD patients with low HDL-C and elevated LDL-C compared to patients with
elevated LDL-C only.
Methods: This is a post-hoc analysis of the 4S, a 5-year trial of simvastatin
vs. placebo in CHD patients. Patients from the simvastatin arm with LDL-C
≥100mg/dL at year 1 of treatment were included. Patients with MCEs or with
missing LDL-C or HDL-C at year 1 were excluded. MCEs were evaluated over
4 years on average, from year 1 to the end of follow-up. Low HDL-C at year 1
was defined as

346 Lipids: statins and beyond
baseline in Total C/HDL-C, LDL-C/HDL-C, ApoB/ApoA-I and Non-HDL-C/HDL-C
at 24 wks, compared to N and E/S (p

P2139 Inverse relation of baseline LDL levels to clinical
response to HDL rise in patients with coronary heart
disease
I. Goldenberg, U. Goldbourt, V. Boyco, M. Benderly, S. Behar
on behalf of the BIP Study Group. Sheba Medical Center, Heart
Institute, Tel Hashomer, Israel
Purpose: Recent studies have shown that high-density lipoprotein cholesterol
(HDL-C) levels are a strong inverse predictor of cardiovascular events, and that
this association is maintained in patients with low levels of low-density lipoprotein
cholesterol (LDL-C). The present study was designed to assess clinical response
to HDL-C rise in coronary heart disease (CHD) patients with varying degrees of
baseline LDL-C levels.
Methods: The risk of a major cardiac event (defined as cardiac death or nonfatal
myocardial infarction) during a median 7.9-year follow-up of 3020 CHD patients
enrolled in the Bezafibrate Infarction Prevention trial was related to changes in
lipid levels during the study. Baseline LDL-C levels were categorized according to
National Cholesterol Education Program–Adult Treatment Panel III (NCEP-ATP
III) criteria.
Results: After multivariable adjustment for baseline clinical variables and lipid levels,
the benefit of HDL-C rise was shown to be most pronounced among patients
with baseline LDL-C levels ≤129 mg/dL (29% risk reduction per 5 mg/dL HDL-C
increment [p=0.02]), intermediate in patients with LDL-C levels of 130-159 mg/dL
(13% risk reduction per 5 mg/dL HDL-C increment [p=0.03]), and non-significant
in patients with LDL-C ≥160 mg/dL (HR=0.94 [p=0.57]; Table). A similar relationship
was shown for risk reduction associated triglyceride (TG) decrements,
whereas the benefit of LDL-C reduction was more pronounced in patients with
baseline LDL-C ≥130 mg/dL (Table).
≤129
Baseline LDL-C Levels (mg/dL)
130-159 ≥160
HDL increase (per 5 mg/dL)
Hazard Ratio
TG reduction (per 50 mg/dL)
0.71 0.87 0.94
Hazard Ratio
LDL reduction (per 20 mg/dL)
0.81 0.84 0.96
Hazard Ratio 1.01 0.75 0.81
Conclusions: The current study demonstrates that the clinical response to HDL-
C rise is inversely related to baseline LDL-C levels. These findings suggest that
more focus should be directed at combined assessment of both HDL-C and LDL-
C levels in CHD patients.
P2140 Pitavastatin improves lipid profiles and reduces
high-sensitivity CRP in Japanese subjects with
hypercholesterolemia-KISHIMEN multi-center
prospective study
N. Kume1 ,Y.Fujioka2 , A. Taniguchi3 , S. Kagimoto4 ,K.Hirata2 ,
Y. Nakamura 5 , T. Yamamoto4 , N. Inagaki4 ,Y.Seino3 ,H.Koshiyama3 on behalf of KISHIMEN Investigators. 1Kyoto University, Cardiovascular Medicine
Dept., Kyoto, Japan; 2Kobe, Japan; 3Osaka, Japan; 4Kyoto, Japan; 5Amagasaki, Japan
Background: Pitavastatin is a synthetic statin whose anti-inflammatory effects
have not been explored yet.
Methods: Effects of pitavastatin (1-2mg, for 12 months) on lipid profiles and highsensitivity
C-reactive protein (hs-CRP) levels were examined in 178 Japanese
hypercholesterolemic subjects, including those with type 2 diabetes (DM; n=103,
58%) by a multi-center prospective open-label study.
Results: Serum low-density lipoprotein cholesterol (LDL-C) levels were significantly
decreased by 30.3 and 31.0% in total and DM subjects, respectively.
Remnant-like particle cholesterol (RLP-C) levels were significantly decreased
by 22.8% and 14.0% in total and DM subjects, respectively. In subjects previously
not treated with other statins, pitavastatin (2mg) lowered LDL-C by 39.9%.
In subjects with basal high-density lipoprotein cholesterol (HDL-C) levels below
40mg/dL, pitavastatin significantly raised HDL-C levels by 19.0% and 24.5% in
total and DM subjects, respectively. Pitavastatin significantly lowered hs-CRP levels
(median: 0.69 to 0.45mg/L, -34.8%, p

348 Lipids: statins and beyond
P2143 Hypolipidemic treatment increases blood apelin in
patients with isolated LDL-cholesterol elevation
I. Tasci, G. Erdem, S. Tapan, G. Ozgur, T. Dogru, C. Acikel,
A. Sonmez. Gulhane School of Medicine, Department of Internal
Medicine, Ankara, Turkey
Purpose: Apelin, a newly described peptide with various favorable effects in cardiovascular
system, is associated with insulin resistance and inflammation. We
have recently reported significantly reduced plasma apelin levels in people with
elevated LDL-cholesterol who had no additional disorder or drug usage. In the
presents study, we searched whether plasma apelin increases after hypolipidemia
is attained either with an intensive lifestyle management or statin treatment.
Methods: 134 subjects with LDL-cholesterol >160 mg/dL were enrolled. 116 of
them finished a successful 12 weeks period of therapeutic lifestyle change (TLC)
intervention according to ATPIII Report. Among them, 54 patients achieved target
LDL-cholesterol levels. The remaining 62 were treated with rosuvastatin for an additional
12 weeks, and 56 patients achieved a target LDL-cholesterol level. Blood
apelin, adiponectin, leptin, TNF-alpha, hsCRP and insulin levels were measured
at each time point.
Results: The patients who achieved target LDL-cholesterol levels by the end
of TLC period had significantly higher levels of apelin (p=.000) and adiponectin
(p=.001), and lower leptin (p=.023 for woman and p=.042 for men) and insulin
(p=.031) levels, whereas TNF-alpha (p=.902) and hsCRP (p=.126) levels as well
as HOMA values (p=.109) remained the same compared to baseline. The subjects
who received a statin treatment for 12 weeks because of unresponsiveness
to TLC in terms of LDL-cholesterol reduction also had significantly higher levels
of apelin (p=.020) and adiponectin (p=.011), and lower TNF-alpha (p=.000) and
hsCRP (p=.023) levels, whereas leptin (p=.134 for woman and P=.959 for men)
and insulin (p=.865) levels as well as HOMA values (p=.855) remained the same
compared to the results before treatment. Besides, blood apelin levels remained
the same when LDL-cholesterol reduction did not happen.
Conclusions: Reduced circulating apelin levels in patients with hypercholesterolemia
increases either with TLC intervention or hypolipidemic treatment.
Though it was previously shown that, at least in adipocytes, synthesis of apelin
is positively stimulated by TNF-alpha, in the present study, the patients with increased
TNF-alpha levels and LDL-cholesterol concentrations had lower blood
apelin levels which reversed after LDL-cholesterol reduction. Moreover, serum
apelin concentration behaves in the same direction with adiponectin and leptin.
The association of apelin with atherosclerosis seems to be complex and linked to
dyslipidemia, insulin resistance and/or inflammation.
P2144 Heart rate variability and plasma lipids before and
after treatment with rosuvastatin in
hypercholesterolaemic patients without coronary
artery disease
E.A. Zacharis, M.E. Marketou, E.I. Skalidis, I.K. Karalis,
H.E. Mavrakis, A.P. Patrianakos, G.F. Diakakis, E. Ganotakis,
F.I. Parthenakis, P.E. Vardas. Heraklion University Hospital, Department of
Cardiology, Heraklion, Greece
Purpose: Decreased 24-h heart rate variability (HRV) is associated with increased
risk of cardiovascular morbidity and mortality. The objective of this study
is to examine the relation between plasma lipids and HRV in hypercholesterolaemic
subjects without coronary artery disease (CAD) before and after treatment
with 10 mg rosuvastatin.
Methods: We included 35 hyperlipidaemic subjects (20 men, aged 58±10 years).
Inclusion criteria were hypercholesterolaemia (TCHOL >240 mg/dl) and low density
lipoprotein (LDL-C) cholesterol>160 mg/dl. All had a normal echocardiogram
and no signs of coronary artery disease. Holter recording and fasting blood samples
were performed in all subjects. The subjects were randomized to receive 10
mg/day rosuvastatin (n=25 or placebo n=10) for 1 year and reevaluated.
Total cholesterol and LDL-C levels were significantly reduced (from 287±102
mg/dl and 170±65 mg/dl to 190±64mg/dl and 98±27 mg/dl respectively, p

tive. We sought to determine the effects of low levels of HDL-C on endothelial
function.
Methods:A total of 31 students attending a military school with isolated low HDL-
C(< 40 mg/dL) was taken as a study group. Control group consisted of 31 students
with high HDL-C (>60 mg/dL). Exclusion criteria were smoking, high total
cholesterol (>200 mg/dL), high triglyceride (>150 mg/dL) levels and arterial blood
pressure > 130/85 mmHg. Endothelial function was determined by brachial artery
flow mediated dilatation.
Results: Both groups were similar in terms of age (20.9±1.5 vs 21±1.6) and
body mass index (22.4±1.6 vs 22.3±1.7). Serum lipids and blood glucose are
depicted in the table.
Flow mediated dilatation was less in low HDL-C group compared to controls
(10.4±4.3 vs. 15.3±5.1, p

350 Lipids: statins and beyond
P2151 Modification of in-hospital lipid lowering drug therapy
in primary and secondary
F. Towae 1 , C. Juenger1 , K. Bestehorn2 , M.G. Gottwik1 , R. Zahn1 ,
J. Senges1 ,A.K.Gitt1on behalf of 2L-Study-Group. 1Institut fuer Herzinfarktforschung, Ludwigshafen, Germany; 2Institut fuer
klinische Pharmakologie, Dresden, Germany
Background: Current practice guidelines recommend LDL-cholesterol levels
100 mg/dl
105 111 < 0.01
Increase of statin dose [%] 26.9 24.6 n.s.
Adding ezetemibe [%] 5.9 3.3 < 0.05
Increase of statin dose + ezetemibe [%] 10.2 9.4 n.s
Conclusion: About 40% of high risk patients admitted to hospital already had
achieved the recommended LDL

P2155 A very high prevalence of low HDL-cholesterol in
Spanish patients with acute coronary syndromes
X. Pinto1 ,E.Corbella1 , A. Munoz2 , J.C. Pedro Botet3 ,
A. Hernandez-Mijares 4 , A. Zuniga5 , A. Mangas6 , J. Millan7 on
behalf of Spanish HDL Forum. 1Unitat de lipids Risc CV. Hospital
Bellvitge, Internal Medicine, L’hospitalet Ll. Barcelona, Spain; 2Solvay Pharma,
Medical department, Barcelona, Spain; 3Medicina Interna. Hospital del Mar,
Medicina interna, Barcelona, Spain; 4Servicio Endocrinologia. Hospital Peset,
Valencia, Spain; 5Medicina Interna. Hospital Marques Valdecilla, Santander,
Spain; 6Medicina Interna. Hospital Puerta de Mar, Cadiz, Spain; 7Medicina Interna. H U Gregorio Maranon, Madrid, Spain
The aim of our study was to know the prevalence of low HDL-C in Spanish patients
with acute coronary syndromes and the main factors related with this disorder.
Material and Methods: We examined 648 medical records of patients who were
admitted at the coronary care units of 6 Spanish tertiary hospitals. Clinical and
laboratory data were retrospectively investigated. Blood analyses were done before
the sixth day of the hospital stay. Low HDL-C was defined as a serum concentration
< 1,04 mmol/L in men and < 1,3 mmol/L in women.
Results: Low HDL-C was observed in 404 (62,3%) patients. A decrease of 0,157
mmol/L of HDL-C was estimated (lineal regression) for the every day of time
elapsed from hospital admission until the lipid measurements were done. Patients
with low HDL-C have a higher body weight and triglycerides concentrations, and
a higher prevalence of smoking, hypertension and diabetes. No differences were
observed in the number of patients taking statins or fibrates between those who
had a low HDL-C and those who had not. Only a small percentage of patients
with low HDL-C were on fibrate therapy.
No Low HDL-C244 (37.7%) Low HDL-C404 (62.3%) p
Female 33 (13.5%) 99 (24.5%) 0.001
Age (years) 64±12 62±12 0.080
Body Mass Index 27.98±4.1 28.71±4.2 0.041
Previous Ischemic Disease 100 (41.5%) 174 (44.4%) 0.476
Smokers
Former Smokers
83 (34.9%)
95 (39.9%)
169 (42.5%)
120 (30.2%)
0.036
Hypertension 133 (55.4%) 254 (64.3%) 0.026
Diabetes Mellitus 65 (27.2%) 142 (36.4%) 0.017
Total Cholesterol (mmol/L) 5.06±1.17 4.76±1.19 0.002
LDL-C (mmol/L) 3.14±1.1 3.16±1.1 0.869
Triglyceride (mmol/L) 1.41±0.7 1.87±1.0

352 Lipids: statins and beyond / Gender matters
P2159 Enhancement of angiotensin II forming activity in
mononuclear cells by free fatty acids
Y. Azekosi1 , M. Kobayashi2 ,K.Yamakawa2 ,T.Yasu2 , Y. Tagomori 3 ,
S. Abe 3 ,H.Urata4 ,S.Ueda2 . 1University of Ryukyus School of
Medicine, Clinical Pharmacology And Therpeutics, Nakagami,
Japan; 2University of Ryukyus School of Medicine, Clinical pharmacology and
theraperutics, Nakagami, Japan; 3Fukuoka University, Second Department of
Internal Medicine, Fukuoka, Japan; 4Fukuoka University Chikushi Hospital,
Department of Cardiology, Fukuoka, Japan
Objective: Free fatty acids appear to be a pivotal adipocytokine that are closely
associated with insulin resistance and endothelial dysfunction. We have previously
shown that an elevated free fatty acid (FFA) impairs endothelial function
through activation of renin-angiotensin system (RAS) in human. However, elevated
FFA did not affect any circulating components of RAS. We investigated
effect of elevated FFA on angiotensin II forming activity in human mononuclear
cells ex vivo.
Method and Results: Blood samples were obtained before and after systemic
infusion of lipid/heparin (1 lipid: 20% intralipid, 100ml/hr + heparin: 0.3U/kg/min
for 3hr) or saline in 8 healthy subjects. Angiotensin II forming activities in isolated
mononuclear cells were measured by immunofluorescence technique. Elevated
FFA after lipid/heparin infusion significantly enhanced angiotensin II forming
activities {Total: before: 3253.7±2830.2, after: 11657.0±8686.5 (p

P2163 The influence of estradiol on Bone Morphogenetic
Protein signal pathway in pulmonary vascular
endothelial cells
H. Ichimori, S. Kogaki, J. Narita, H. Ishida, T. Uchikawa, S. Nasuno,
Y. Okada, Y. Yoshida, K. Ozono. Osaka University, Pediatrics, Suita,
Japan
Background: Gender differences in the development of Pulmonary Artery Hypertension
(PAH) have been documented in both human and animal studies. Idiopathic
PAH is predominantly a disease of young women in their child-bearing
years, which suggests a rule of sex hormones in pathogenesis of PAH. However,
the influence of sex hormones in pulmonary vasculatures and the development
of PAH have not been fully understood. Recent advance in understanding IPAH
has revealed genetic predisposition such as BMPR (Bone Morphogenetic Protein
Receptor) and ALK-1.
Purpose: The aim of the present study is to investigate the effect of β-estradiol
(E2) upon BMPR signal pathway in pulmonary vascular endothelial cells in vitro.
Materials and methods: Isolated rat lung vascular endothelial cell (RLEC) were
cultured and we examined the expression of BMPR2, BMP-regulated Smads,
and Id1 under normoxia and hypoxia with BMP2 stimulation. Then, we investigate
changes in the expression of these molecules in the presence of E2 with or
without estrogen receptor antagonist (ICI 182.780.).
Results: First, we confirmed that estrogen receptor α and β were expressed in
RLEC. In exposure to 24 hours’ hypoxia, the expression of mRNA transcripts for
BMPR2, Id1, and Smad6 in RLEC was reduced. In addition, we demonstrated that
E2 decreased the expression of phosphorylated Smad1/5/8 in a dose-dependent
manner and phosphorylated Smad1/5/8 were decreased about 80% by E2 of 10-
7M. The attenuation of phosphorylated Smad1/5/8 was rescued by ICI182.780.
The attenuation of phosphorylated Smads.
Discussion: Under hypoxic condision, the presence of E2 attenuate the BMPR
signal pathway in the endothelium of pulmonary vasculatures. Our observations
provide the first evidence that sex hormone on BMPR signal pathway can offer
new strategies for the treatment of PAH.
P2164 The-129A allele within myeloperoxidase promoter
region exerts a protective role towards myocardial
infarction in women
B. Gigante, E. Zotova, L. Lyrenas, U. De Faire, R. Morgenstern,
A. Bennet. Karolinska Institutet, Division of Cardiovascular
Epidemiology, Stockholm, Sweden
It has recently been shown that myeloperoxidase (MPO) serum levels, a prooxidant
enzyme that converts LDL into the oxidized-LDL, are inversely related to
the presence of coronary artery disease. Genetic factors are known to modulate
MPO serum levels, in particular it has been shown that the rare allele at two genetic
loci -463G/A and -129G/A within the MPO promoter region are associated
with lower MPO serum levels, while male sex, older age and hormone replacement
therapy (HRT) are associated with increased MPO serum levels and activity.
The aim of the present study was to investigate the potential role of the two genetic
variants -463G/A and -129G/A for the occurrence of myocardial infarction
(MI) in the Stockholm Heart Epidemiology Program (SHEEP) a case-control population
recruited in the Stockholm area. SHEEP cases (n=1213) were identified
as non fatal MI patients and controls (n=1561) were sex and age-matched subjects.The
two genetic variants -463G/A and -129G/A have been genotyped by the
RFLP and DASH platform, respectively. Differences in genotype and allele frequencies
were tested by chi2square test. Crude and adjusted odds ratios (OR)
and relative 95%confidence intervals (CI) were estimated by logistic regression
analysis. According to the SHEEP design, data were analyzed in male and female
separately. The two variants were in high linkage disequilibrium (D’=0.9).
The -129A allele was prevalent in women cases 0.09 vs 0.06 (p

354 Gender matters
ders in Finland. However, among young women the decline in case fatality has
been slower than among men or among older women. The reasons for this less
favorable development warrant further research.
P2167 Pronounced adverse effect of abdominal obesity on
hypertensive cardiac sequelae in the female gender.
Insights from the Hippokration Hellenic Hypertension
(3H) Study
D. Tsiachris, C. Tsioufis, C. Thomopoulos, K. Dimitriadis, M. Selima,
E. Andrikou, I. Kallikazaros, C. Stefanadis. First Cardiology Clinic, University of
Athens, Hippokration Hospital, Athens, Greece
Purpose: Obesity and hypertension deteriorate left ventricular (LV) structure
and function in an additive manner increasing the risk of congestive heart failure.
Whether there is a sex-specific role of excess visceral fat accumulation in
hypertension-induced cardiac adaptations is not well clarified. Our aim was to assess
the differential effect of waist circumference on LV structural and functional
alterations, in hypertensive males and females.
Methods: 1789 consecutive, non-diabetic, essential hypertensives (aged
55.8±13.5 years, 966 females) that were included in the 3H Study, an ongoing
registry of hypertension related target organ damage, were classified to obese
and non-obese according to ATP III criteria regarding waist circumference value
(>88 cm for obese women and > 102 cm for obese men). In all participants, LV
mass index (LVMI) and relative wall thickness were determined, while LV diastolic
function was evaluated by means of conventional Doppler and tissue Doppler
imaging (TDI), averaging early and late diastolic mitral annular peak velocities
(Em, Am, Em/Am ratio) from four separate sites of measurement (septal, lateral,
anterior and inferior walls).
Results: Hypertensive obese women (n=599) compared with non-obese (n=367)
exhibited significantly greater LVMI and a higher prevalence of LV hypertrophy
(by 5.5gr/m 2 and 8.8%, p=0.003 and 0.005, respectively), while such differences
were not present between hypertensive obese (n=415) and non-obese (n=408)
men. Among hypertensive women, obese compared to non-obese were accompanied
by significantly lower ratios of transmitral E/A (by 0.08 p

2nd year of follow-up, respectively). There was an improvement in HRQoL at 2
years for both groups, as compared with baseline, the pattern was however, different
for men and women. Among women, significant improvement was observed
only in domains referring to physical health whereas men reported improvement
in domains referring also to mental health. Despite differences in baseline characteristics,
female gender was independently associated with worse outcome in the
following domains, respectively after the 1st and 2nd year of observation: Physical
Functioning - PE (parameter estimate) = -8.13 [95CI, -12.26 to -3.99, p=0.0002]
and PE = -8.85 [95 CI, -12.74 to -4.96, p

356 Gender matters
Conclusions: HT is associated with increased PWV independently of arterial
atherosclerosis, indicating a direct impact of this immunological disorder on arterial
stiffening. This effect may be masked in postmenopausal women possibly due
to their more adverse cardiovascular risk profile.
P2175 Evidence based care for women: big effort small
result
O. Manfrini1 ,E.Rossi1 ,G.DeVitis1 ,M.DeRosa1 ,A.Berti1 ,
F. Fedele2 , F. Romeo2 , R. Bugiardini3 . 1Bologna, Italy; 2Roma, Italy; 3University of Bologna, Dip. Med. Interna, Cardioangiologia,
Bologna, Italy
Purpose: In the past two years the Italian Society of Cardiology launched a campaign
aimed at raising awareness of risk of ischemic heart disease in women.
The current study examined the rates of treatment of acute myocardial infarction
(AMI) in women, to assess the relation between prevention efforts and results
since the campaign settlement.
Methods: We evaluated medical records of 4073 consecutive patients (1475
women) survived from AMI between January 1st 2005 and December 31st 2006.
They were discharged from 5 hospitals located in the North Italy (the CINECA-
ARNO survey). Post-discharge use of aspirin, beta-blocker, angiotensin converting
enzyme (ACE) inhibitor and statin during 10 months follow-up was compared
between women discharged in 2005 and those in 2006.
Results: The rate of consecutive women with discharged diagnosis of AMI was
higher in 2006 than in 2005 (743/1990, 37.3% versus 732/2084, 35.1%). Female
sex was associated with lower use of aspirin (OR, 0.58; 95% CI, 0.49-0.69;
p

P2179 Symptoms of atrial fibrillation by gender and age
classes in a setting of emergency telecardiology
N.D. Brunetti 1 , L. De Gennaro1 ,G.Amodio2 , G. Dellegrottaglie3 ,
M. Di Biase1 , G. Antonelli 2 . 1University of Foggia, Cardiology
Department, Foggia, Italy; 2Azienda Ospedaliera Policlinico,
Emergency Cardiology Department, Bari, Italy; 3Cardio-on-line Europe, Bari,
Italy
Aim: To analyze symptoms of patients with atrial fibrillation (AF) diagnosed with
the support of telecardiology technologies applied to public emergency health
care number "118" (Italy).
Methods: 27,841 patients from all over Apulia (southern Italy, 4 millions inhabitants)
who referred to public emergency health care number "118" underwent
ECG evaluation according to a previously fixed inclusion protocol with a ECG
recorder device. Data recorded were transmitted with a mobile telephone support
to a telecardiology "hub" active 24-hours in a day with a cardiologist (ECG device
did not allow 118 crew members to read ECG). Rate prevalence of AF, age and
symptoms complained by patients were reported and analyzed.
Results: AF was diagnosed in 11.68% of patients who underwent ECG examination.
Typical palpitations were complained by only 14.08% of patients with AF. This
rate significantly decreased with age (80 years 9.62%; 26.50% in patients 70 years, p

358 Gender matters / Ambulatory blood pressure measurement
P2183 Oxidative stress and disturbed glutathione redox
status in females with metabolic syndrome
M. Atalay 1 ,J.Lietava2 ,V.Husarova2 , M. Caprnda2 , P. Blazicek3 ,
G.J. Fodor4 . 1Physiology of University of Kuopio, Institute
of Biomedicine, Kuopio, Finland; 2Comenius University, 2-nd
Department of Internal Medicine, Bratislava, Slovak Republic; 3Military Hospital,
Department of Biochemistry, Bratislava, Slovak Republic; 4University of Ottawa
Heart Institute, Ottawa, Canada
Introduction: Metabolic syndrome (MS) is associated with increased level of oxidative
stress, while the antioxidant defences of the syndrome were less studied.
Glutathione is a central antioxidant involved with the redox regulation and the ratio
of the oxidized glutathione (GSSG) to reduced glutathione (GSH) is a sensitive
marker of oxidative stress. We hypothesized that females with MS have increased
level of glutatione oxidative ratio in addition to the increased other oxidative stress
markers.
Material and methods: Study group was consisted of 104 non-smoking females
aged 61.8±9.42 yrs with MS defined according to IDF 2005 criteria (MS+) and of
40 controls aged 54.8±16.37 yrs enrolled into SLOV-FIN- Glutathione study. We
analysed parameters of oxidative stress and antioxidant defences, including total
homocysteine (THCY), glutathione oxidation ratio, ultrasensitive C-reactive proteine
(uCRP), GSSG, oxidised LDL cholesterol (oLDL), protein carbonyls (PC),
Shiff-base substances (SBS), uric acid and total antioxidant status (TAS).
Results: MS+ females had high glutathione oxidation ratio (GSSG/GSH)
(p

P2187 The relationships of ambulatory arterial stiffness
index with pulse wave velocity in hypertensives:
focus on the superiority of nighttime haemodynamics
C. Thomopoulos, C. Tsioufis, D. Chatzis, E. Andrikou, V. Tzamou,
T. Makris, I. Kallikazaros, C. Stefanadis. First Cardiology Clinic,
University of Athens, Hippokration Hospital, Athens, Greece
Purpose: To evaluate the role of ambulatory arterial stiffness index (AASI) on
aortic pulse wave velocity (PWV) levels in hypertensives.
Methods: We studied 264 consecutive untreated hypertensives (aged 48±6
years, 176 males, 133 smokers, and office BP 149/98mmHg). Subjects underwent
ambulatory BP monitoring and echocardiography, while carotid – femoral
PWV was measured by an automatic device (Complior SP) and accordingly
were divided into two groups (those with high and low PWV levels, cut-off point
7.6 m/sec). From 24h ambulatory BP monitoring, daytime and nighttime AASI
(24hAASI, dAASI, nAASI) were estimated. Metabolic profile and glomerular filtration
rate (GFR) by using the MDRD formula were estimated.
Results: Hypertensives with high PWV (n=136) with respect to those with low
(n=128) had similar body mass index, smoking habits and heart rate (29.8±3
vs. 29.2±3 kg/m2 , 52% vs. 50%, 76±6 vs.77±8 bpm, respectively p=NS for all).
The former group with respect to the latter demonstrated higher total cholesterol
and LDL levels (222±39 vs. 212±35, p=0.046 and 154±32 vs. 39 mg/dl,
p=0.035) while glucose, triglycerides, HDL and GFR did not differ between the
groups (p=NS, for all). Left ventricle mass index, 24h systolic and diastolic BP
and 24h pulse pressure were higher in hypertensives with high PWV compared
to those with low (109±25 vs. 99±23 gr/m2 , 141±9 vs.137±6 mmHg, 87±7 vs.
84±6.5 mmHg and 54±6 vs.52±7mmHg, respectively, p

360 Ambulatory blood pressure measurement
P2191 Masked hypertension is associated with non-dipper
or riser circadian pattern and impaired renal function
in the elderly with hypertension: Analysis of a
1202-patient database
F. Uchida, K. Harada, R. Kuramachi, Y. Yui, T. Ishikawa, Y. Saitou,
H. Maki, Y. Tsubokou, K. Takeda, I. Kuwajima. Tokyo Metropolitan Geriatric
Hospital, Division of Cardiology, Tokyo, Japan
Purpose: Masked hypertension (MHT), which is characterized with normal officemeasured
blood pressure (BP) and elevated 24-hour ambulatory BP monitoring
(ABPM) or home BP, has poor cardiovascular prognosis in treated hypertensives.
Nocturnal BP was shown to convey additional risk information about heart failure.
To study whether MHT is associated with nocturnal hypertension (HT) or not.
Methods: ABPM was performed in 1202 elderly Japanese patients with treated
HT (74.8±0.2 yrs, men 43%) between 2005 and 2007. Abnormal dipping patterns
were diagnosed when the nocturnal systolic BP fall was less than 10% (nondipper),
or less than 0% (riser). The BP recording at the beginning of ABPM was
used for office BP.
Results: Ten percent of patients showed increased values on ABPM with normal
office BP (MHT, n=118), while 19% showed elevated office BP with normal values
on ABPM (white-coat HT, WCHT, n=223), and 28% showed both elevated
office BP and increased values on ABPM (resistant HT, RHT, n=340). Office
systolic BPs were 130±7mmHg (MHT), 152±10 mmHg (WCHT), and 160±15
mmHg (RHT), all of which were significantly higher than 120±13 mmHg of wellcontrolled
HT (NT, n=521). Values on ABPM were 142±6mmHg (MHT), 125±7
mmHg (WCHT), 151±13 mmHg (RHT), and 117±11mmHg (NT), respectively.
The non-dipper or riser circadian patterns were present in 88% of MHT, as compared
with 79% (WCHT), 74% (RHT), and 78% (NT). Moreover, riser patterns
were present in 46% of MHT, as compared with 15% (WCHT), 31% (RHT), and
31% (NT). Serum creatinine levels in MHT and RHT were higher than those in NT
(1.05±0.58 mg/dl and 1.07±0.83 mg/dl vs. 0.90±0.40 mg/dl, p

tension (WCHT) to vascular damage is not yet fully clarified, while urinary albumin
excretion is an established index of atherosclerosis progression beyond
the renal glomerulus. In the present study, we examined the interrelationships of
MHT, WCHT and sustained hypertension (SHT) with urinary albumin excretion
expressed as the albumin to creatinine ratio (ACR).
Methods: 335 consecutive untreated non-diabetic subjects who referred to
our clinic for 24-h ambulatory blood pressure (BP) monitoring, were classified
as subjects with sustained normal BP (office BP

362 On the rescue: circulating stem cells
P2199 The abundance of adipose tissue-derived progenitor
cells in the adipose tissue is affected by age and
blood glucose levels
R. Madonna 1 , C. Cellini 1 , F.V. Renna 1 , L. Rinaldi 1 , R. Ippedico 1 ,
R. Cotellese 1 ,N.Picardi 1 ,R.DeCaterina 2 . 1 G. D’Annunzio
University, Chair of Cardiology, Chieti, Italy; 2 G. D’annunzio University - Chieti,
University Cardiology Division, Chieti, Italy
Adipose tissue-derived stromal cells (ADSCs) are being recognized as a source
of stem cells potentially useful for cardiovascular repair, most likely by differentiating
into vascular cells or by secreting angiogenic cytokines. The influence of
cardiovascular risk factors on ADSC levels and their viability in elderly patients
are currently unknown. We analyzed the abundance and angiogenic activity of
adipose tissue-derived progenitor cells in patients most likely to benefit from this
novel source of stem cells, i.e., elderly patients with cardiovascular risk factors.
Methods: 40 subjects (age 67.9±11.7 years) with variable degrees of cardiovascular
risk, underwent abdominal surgery for intercurrent diseases. Visceral
adipose tissue (3±1 g visceral fat/patient) was processed by collagenase type
I to obtain ADSCs from the stromal-vascular fraction, and immediately used for
analyses, without further amplification in vitro or cell selection. The number of
total ADSCs in primary cultures after digestion was automatically quantified by
a Multisizer Coulter Counter. Progenitor cells (PCs) within ADSCs were quantified
by flow cytometry as %CD45-/CD34+/CD133+ cells of total ADSCs. Matrigel
angiogenesis assay was used to analyze the ability of ADSC to form tubes or
networks.
Increasing age (r = - 0.48, p

in the postero- and midseptal region. Interestingly, much larger MLC2a-positive
APs were additionally found in the right and left lateral free wall regions. Periostin
staining in the annulus fibrosis was however locally interrupted at locations where
these broad lateral MLC2a-positive APs crossed the isolating annulus fibrosis of
EPDC-inhibited hearts.
Conclusion: Periostin expression on the developing annulus fibrosis seems to
indicate AV-junctional myocardium fate. Small septal periostin-positive APs in
the wildtype heart remain only temporarily functionally active, while broad lateral
periostin-negative APs in EPDC-inhibited hearts persist and might provide a
pathological substrate for postnatally persistent APs.
P2203 The status of circulating endothelial progenitor cells
in patients with documented coronary endothelial
dysfunction
B.A. Boilson, T.J. Kiernan, A. Lerman, R.D. Simari. Mayo Clinic,
Interventional Cardiology, Rochester, United States of America
Endothelial dysfunction is an early manifestation of vascular disease and a
marker of atherosclerotic risk burden. There is growing evidence that bone
marrow-derived hematopoietic stem cells may have a diagnostic and reparative
role in vascular disease and may be a source of endothelial progenitors. Recent
studies have shown depleted numbers of these cells both in established vascular
disease and in patients with increased burden of cardiovascular risk. We hypothesized
that hematopoietic stem cell numbers in circulating blood would be altered
in the setting of coronary endothelial dysfunction (CED) in the absence of overt
coronary disease.
Methods: Fifty consecutive patients having undergone diagnostic coronary angiography
for evaluation of chest pain and without significant coronary disease
were enrolled. Presence of coronary endothelial dysfunction was determined by
response to intracoronary acetylcholine. Five ml of whole blood was obtained
from each patient at the time of cardiac catheterization and analyzed by flow cytometry
for CD34 and CD133 using ISHAGE criteria. A group of twelve patients
had 50ml of whole blood drawn at the time of cardiac catheterization and buffy
coat was extracted using density gradient centrifugation. This was subjected to
flow cytometric analysis for CD34 and CD133 and plated on fibronectin coated
wells for colony forming units (CFUs) assay analysis at 7 days.
Results: Thirty-one patients were determined to have CED as assessed by intracoronary
acetylcholine challenge testing. Decreased numbers of CD34+ (whole
blood, 10±1 vs 17±3 cells/100μL; buffy coat, 40±7 vs 81±11 cells/100μL,
p

364 On the rescue: circulating stem cells
Methods and Results: Mononuclear cells (MNC) were isolated from human
blood by Ficoll gradient and were cultured over 4 days using endothelial cell selection
medium. The resulting EPCs were incubated with angII (10-6 M and 10-7
M), which led to a significant reduction of DiI-Ac-LDL/lectin double-positive cells
compared to control (fluorescence microscopy, cell count). This effect could be
inhibited by co-stimulation with an AT1 receptor antagonist, but not with an AT2
receptor antagonist. AngII had no effect on cell proliferation (BrdU-FACS analysis),
but increased apoptosis (histone DNA assay), enhanced intracellular reactive
oxygen species formation (DCF fluorescence), reduced migratory capacity (modified
Boyden chamber), and impaired colony forming unit formation (CFU assay)
in cultured EPCs. Treatment of wild-type mice with angII (0.7 mg/kg/d) for 12d by
osmotic minipumps led to decreased numbers of sca1/flk1-positive EPCs in peripheral
blood and reduced the number, migratory capacity, and CFU formation of
spleen-derived Dil-Ac-LDL/lectin double-positive EPCs, which was accompanied
by a diminished reendothelialization and increased neointima formation after focal
carotid injury. These angII effects were completely abolished in AT1a-/- mice. Salvage
of reendothelialization by intravenous application of spleen-derived MNCs
into angII-treated wild-type mice was more pronounced with AT1a-/- cells than
with wild-type cells.
Conclusions: Angiotensin II causes a reduction of EPC counts and impairs the
functional capacity of these cells in vitro and in vivo. These findings indicate a
relationship between the activation of the renin-angiotensin system and reduced
number and function of circulating EPCs, which may play an important role in
impaired endothelial regeneration and atherogenesis.
P2208 Cyclosporin A suppresses proliferative capacity of
endothelial progenitor cells: involvement of nitric
oxide synthase inhibition
L. Yang, X.-C. Yang, J.-K. Yang, F.-F. Yi, Q. Fan, X.-L. Liu, Y.-G. Ge.
Beijing, China, People’s Republic of
Background: The calcineurin inhibitor cyclosporin A (CsA) is a potent immunosuppressive
agent that has formed the pharmacologic cornerstone of solid organ
transplantation. Vascular injury has generally been considered a common-ground
factor of CsA-induced organ damage. Endothelial toxicity is a feature of CsAinduced
vascular injury. Vascular endothelial progenitor cells (EPCs) are the precursors
of mature endothelial cells, and contribute to postnatal neovasculorization
and re-endothelialization. Endothelial nitric oxide synthase (eNOS) is an important
regulator of EPCs. Thus, we hypothesized that the vasculopathy induced
by CsA may be partly due to its harmful effect on EPCs in which eNOS is involved.
Purpose: To investigate the effects of CsA on proliferative capacity and
eNOS/nitric oxide (NO) in cultured human EPCs from peripheral blood.
Methods: EPCs were obtained from cultured mononuclear cells isolated from
peripheral blood of healthy adults, and stimulated with CsA (10 μg/ml) in the
presence or absence of recombinant human vascular endothelial growth factor
165 (VEGF; 50 ng/ml). Cells’ proliferation and apoptosis were determined by
the Cell Counting Kit-8 (CCK-8) assay and terminal deoxynucleotidyl transferasemediated
dUTP nick end labeling (TUNEL) staining respectively. eNOS was assayed
by reverse transcription-polymerase chain reaction (RT-PCR) analysis. NO
generation was detected by Griess method. To determine the effects of CsA at
the different concentrations on EPCs’ proliferation, some cells were treated with
CsA in a series of final concentrations (0, 10, 100, 1000, and 10000 ng/ml) for 48
h, and cells’ proliferation was detected by CCK-8 assay.
Results: CsA significantly inhibited EPCs’ proliferation at the concentrations from
100 ng/ml to 10000 ng/ml, and the effect was dose dependent. While at the concentrations
of 10 ng/ml, CsA failed to prevent EPCs’ proliferation obviously. VEGF
(50 ng/ml) markedly promoted EPCs’ proliferation, eNOS gene expression, and
NO generation production, which were completely abrogated by pre-treatment
with CsA (10 μg/ml). In the presence or absence of VEGF (50 ng/ml), cells stimulated
with CsA (10 μg/ml) resulted in a decrease of numbers by both ways of
preventing proliferation and promoting apoptosis, eNOS mRNA and NO generation
productions were potently decreased in CsA-treated samples.
Conclusions: CsA significantly inhibits proliferative capacity, prevents eNOS
gene expression, and decreases NO productions in cultured human peripheral
blood EPCs.
P2209 Impaired in-vivo re-endothelialization capacity,
accelerated senescence of endothelial progenitor
cells (EPCs) and endothelial dysfunction in patients
with pre-hypertension
G. Giannotti 1 , M. Mueller2 , C. Doerries3 ,T.Horvath2 ,
S.A. Sorrentino2 , N. Steenken2 , C. Manes3 , M. Marzilli1 ,H.Drexler2 ,
U. Landmesser3 . 1University Hospital of Pisa, Department of Cardiology,
Pisa, Italy; 2Hannover Medical School, Department of Cardiology, Hannover,
Germany; 3University of Zurich, Cardiovascular Center, Zurich, Switzerland
Purpose: Prehypertension, a precursor of stage 1 hypertension, is associated
with increased cardiovascular risk. Endothelial dysfunction has been suggested
to contribute to development of hypertension; however, no data on endothelial
function and functional capacity of EPCs are available in subjects with prehypertension
(systolic blood pressure of 120-139 mmHg). We therefore examined
endothelium-dependent vasodilation, in vivo re-endothelialization capacity and
senescence markers of EPCs in subjects with prehypertension.
Methods: Endothelium-dependent, flow-mediated vasodilation (FDD) of the radial
artery, a highly sensitive measure of endothelial function, was assessed using
high-resolution ultrasound. In vivo re-endothelialization capacity of EPCs was
determined after transplantation of 5 x 105 EPCs into nude mice using a carotid
endothelial injury model, and re-endothelialized area (REA) was assessed after
3 days. EPC senescence was detected by acidic beta-galactosidase staining and
telomere length analysis. Healthy subjects (n=16), prehypertensive (n=16) and
hypertensive subjects (n=20) were matched for age, sex and body mass index.
All participants had no hypercholesterolemia, no diabetes, no known cardiovascular
disease, were non-smokers and did not take any medication.
Results: Endothelium-dependent vasodilation was impaired in prehypertensive
subjects (FDD: 9.0±1.9% vs. 11.4±2.9%; p

elevation myocardial infarction (AMI). However the safety of stem cell transplantation
in patients with severe left ventricular dysfunction after AMI has not been
evaluated.
Methods: The study population consisted of patients who suffered AMI, were
treated with percutaneous coronary angioplasty and stenting and had left ventricular
ejection fraction less than 40% 5 to 10 days after AMI. Peripheral blood stem
cells (PBSCs) were mobilized by G-CSF 10 μg/kg body weight for 5 days and
delivered to infarcted myocardium via intracoronary infusion.
Results: Eleven consecutive patients 54±12 years old with an ejection fraction
of 36±7.8% were treated. Four of those patients were survivors of post MI
cardiogenic shock. G-CSF stimulation led to sustained mobilization of mononuclear
cells, with a 5-fold increase (from 10314±2871/mm 3 at baseline to
50762±15723/mm 3 on day 5; P=0.001). PBSCs transplantation was performed
16±2 days after AMI. An average of 3.1±1.3x109 nucleated cells were infuced
containing 9.8±2.5x106CD34+ cells. Adverse events related to infusion occurred
in 3 patients (27%). One patient with a LVEF of 25% developed temporary occlussion
of the left anterior descending coronary artery (LAD) during the transplantation
procedure which resolved after approximately 30 minutes and a second
patient with a LVEF of 23% developed hemodynamic collapse in every LAD occlusion
with rapid hemodynamic restoration after balloon deflation. A third patient
suffered periprocedural MI diagnosed by troponin elevation.
Conclusion: Intracoronary infusion of PBSCs should be performed with great
caution in patients with significant left ventricular dysfunction after AMI
P2212 Cardiomyogenic differentiation potential of
mesenchymal stem cells declines with increase in
age: rebuilding the heart with old or new bricks?
D.A. Pijnappels, M.J. Schalij, A.A. Ramkisoensing, J. Van Tuyn,
H.A. Farias, C.L. Gomez, A.A.F. De Vries, D.L. Ypey, A. Van Der
Laarse, D.E. Atsma. Leiden University Medical Center, Cardiology Department,
Leiden, Netherlands
Background: In cardiac cell therapy, often autologous stem cells from adult patients
are used as therapeutic agent. However, the correlation between the cardiomyogenic
differentiation potential of stem cells and the host’s age is not studied
in much detail. Therefore we assessed, in an in-vitro model, the capacity of
both neonatal and adult rat mesenchymal stem cells (MSCs) to differentiate into
cardiac cells.
Materials and Methods: Bone-marrow derived MSCs of 2-day old neonatal rats
(nr) and 10-weeks old adult rats (ar) were studied for their surface-maker profile
by flow cytometry. To assess cardiomyogenic differentiation, either 50x10 3
eGFP-labeled nrMSCs or arMSCs were co-cultured with 1.5x10 6 nr ventricular
cardiomyocytes (CMCs) for 10 days on coated glass coverslips. Cardiomyogenic
differentiation of MSCs was assessed both at day 3 and 10 of co-culture by a
combination of immunocytochemical analysis for cardiac protein expression, and
whole-cell patch clamp experiments to study action potential characteristics after
pharmacological gap junctional uncoupling.
Results: Flow cytometric analysis of nrMSCs and arMSCs showed expression
of traditional MSC surface-markers with only minor differences in expression levels.
After 3 days of co-culture with nrCMCs, 34±5% and 30±6% of the nrM-
SCs showed positive diffuse staining for sarcomeric alpha-actinin and cardiac
troponin-I, respectively, while only less than 10% of the arMSCs stained positive.
Interestingly, 10 days after co-culture, positive staining for sarcomeric alphaactinin
and cardiac troponin-I in nrMSCs increased to 60±4% and 63±6%, respectively,
but now including 17±5% (n=65) of positive staining in typical sarcomeric
cross-striation (without signs of cell fusion). In contrast, only 20% (n=75) of
the arMSCs showed positive diffuse staining for both cardiac markers at day 10,
without cross-striation. Importantly, at day 10 of co-culture, nrMSC-derived CMCs
(16%, n=9) were found to be beating independently from surrounding nrCMCs in
the presence of the gap junction uncoupler 2-APB, while showing action potential
characteristics (maximal diastolic potential: -63±4 mV) comparable to native
nrCMCs (n=10). However, arMSCs were non-beating and showed only maximal
diastolic potentials of -16±6 mV.
Conclusion: Neonatal rat (nr) mesenchymal stem cells (MSCs) are able
to undergo functional cardiomyogenic differentiation upon co-culture with nrcardiomyocytes,
in contrast to adult rat MSCs. Therapeutic efficiency of autologous
cell therapy using adult MSCs, aiming at cardiac regeneration, might therefore
be seriously limited.
P2213 Administration of intracoronary bone marrow
mononuclear cells on chronic myocardial infarction
improves diastolic function
Kang Yao1 , R.C. Huang2 , Juying Qian1 ,JieCui1 , Lei Ge1 ,
Yanlin Li1 , Feng Zhang1 , Aijun Sun1 ,Y.Z.Zou1 , Junbo Ge1 .
1Zhongshan Hospital, Fudan University, Cardiology, Shanghai, China, People’s
Republic of; 2First Hospital, Dalian Medical University, Cardiology Department,
Dalian, China, People’s Republic of
Background: Regeneration of the myocardium and improved ventricular function
have been demonstrated in patients with acute myocardial infarction (MI) treated
by intracoronary delivery of autologous bone marrow mononuclear cells (BMC)
a few days after successful myocardial reperfusion by percutaneous coronary
On the rescue: circulating stem cells 365
intervention (PCI); however, the effects of intracoronary cell infusion in chronic MI
patients are still unknown.
Aims: The purpose of the present study was to investigate whether intracoronary
infusion of BMC into the infarct-related artery in patients with healed MI could
lead to improvement in left ventricular (LV) function.
Methods: Among 47 patients with stable ischemic heart disease due to a previous
MI (13±8 months previously), 24 were randomized to intracoronary infusion
of BMC (BMC group) and 23 to a saline infusion (CON group) into the target vessel
after successful PCI within 12 hours after chest pain occurred. LV systolic and
diastolic function, infarct size, and myocardial perfusion defect were assessed
with the use of echocardiography, magnetic resonance imaging (MRI), or 201Tl
single-photon-emission computed tomography (SPECT) at baseline and repeated
at the 6 month follow-up examination.
Results: BMC treatment did not result in a significant increase in LV ejection fraction
in any of the groups by any of the methods used, and the apparent tendency
of an improvement was not statistically different between the two groups. The two
groups also did not differ significantly in changes of LV end-diastolic and systolic
volume, infarct size, or myocardial perfusion. However, there was an overall effect
of BMC transfer compared with the control group with respect to E/A (P

366 On the rescue: circulating stem cells / Tracking and homing
derived mononuclear cell (BMDMNC) implantation on improving 6-month left ventricular
(LV) function and reducing LV remodelling in a mini-pig model of acute
anterior myocardial infarction (AAMI).
Methods: The AAMI was developed by ligation of middle left anterior descending
artery. The BMDMNCs were acquired using bone marrow aspiration from iliac
crest of mini-pig. These cells were then isolated by Ficoll-paque solution and
cultured for 1 week before implantation into infarcted area (IA). Eighteen male
mini-pigs (weight 16-18 kilograms) were equally divided into group 1 (AAMI plus
saline injection in IA), group 2 (AAMI plus 3.0 x 107 BMDMNC transplantation
into the IA), and group 3 (normal control). Autologous BMDMNCs were promptly
implanted into IA following induction of AAMI. The two-dimensional (2-D) echocardiography
was performed before induction of AAMI and on days 7, 30, 90, and
180.
Results: The 2-D echocardiography on 90th and 180th day demonstrated the
LV end diastolic and LV end systolic dimensions were higher, whereas LV ejection
fraction (LVEF) was lower in group 1 than in groups 2 and 3 (all p <
0.01). Six-month LV angiogram identified that LVEF was lower in group 1 than
in groups 2 and 3 (all p < 0.01). In IA and peri-IA, the mRNA expressions of
endothelial nitric oxide synthase, Bcl-2, interleukin-8 and peroximase proliferatoractivated
receptor-γ coactivator (PGC)-1α were lower, whereas caspase-3, Bax
and endothelin-1 were higher in group 1 than in groups 2 and 3 (all p < 0.01).
Additionally, the apoptotic body was higher, whereas the number of small vessels
was significantly lower in group 1 than in groups 2 and 3 (all p < 0.005).
Conclusion: Autologous BMDMNC transplantation improves LV function and reduces
LV remodelling via eliciting molecular-cellular mechanisms.
P2216 Comparison of early and late combined
(intramyocardial and intracoronary) application of
autologous bone marrow stem cells after myocardial
infarction
M. Gyoengyoesi, I. Lang, M. Dettke, G. Beran, S. Graf, H. Sochor,
N. Nyolczas, A. Kaider, G. Maurer, D. Glogar on behalf of MYSTAR
Study investigators. Medical University of Vienna, Internal Medicine II, Dept. of
Cardiology, Vienna, Austria
Purpose: The MYSTAR multicenter randomized study compares the results of
early (E) and late (L) combined (intracoronary+intramyocardial) injections of large
number of unselected autologous bone marrow (BM)-derived mononuclear cells
(MNCs) in 60 patients with a recent first acute myocardial infarction (AMI) with a
reopened infarct-related artery (IRA).
Methods: Patients with a left ventricular (LV) ejection fraction (EF)

assigned to receive either unselected BMCs (n=137) transplant or saline (n=134)
within 3 hours after successful PCI to the distal vessel of the infarct-related artery
through micro-catheter.
Results: All patients were followed up within 12 months. Intracoronary BMCs
application did not incur cardiovascular events, including ventricular arrhythmias
or syncope, occurred during 12-month follow-up. By quantitative LV angiography
at six months, LV ejection fraction (LVEF) significantly increased (p

368 Tracking and homing / Development from primitive to adult progenitor cells
areas. The unipolar voltage of the ischemic area has decreased from 44.1±18%
to 24,2±17.2%. The LLS maps have shown the decrease of akinetic and hypokinetic
areas that resulted in normal contraction of these areas. The percentage
of hypokinetic and akinetic areas has decreased from 39.2±17% to 29,2±15%.
Furthermore, the defect myo-cardial perfusion has decreased from 52.4±17% to
27,1±15% based on SPECT data. The mean LVEF was 35.9±4% at follow up
compared with 29,5±4% at baseline. The CCS and NYHA functional class has
decreased from 2.9 to 1.5 and 3.4 to 2.1 respectively at follow up.
Conclusions: Endocardial stem cells implantation with Noga system in patients
with ischemic heart failure, ejection fraction less then 35%, III-IV NYHA and CCS
angina functional class has showed to be a safe procedure and may improve left
ventricular function and clinical status.
P2224 PET imaging of peripheral stem cell homing after
intracoronary transfer in patients following MI in
acute and chronic conditions
C. Dedobbeleer, D. Blocklet, M. Toungouz, M. Lambermont,
P. Unger, J.-P. Degaute, S. Goldman, G. Berkenboom. Hopital
Erasme, Cardiology, Brussels, Belgium
Purpose: Transcoronary transplantation of progenitor cells seems to be a promising
therapeutical approach of ischaemic cardiomyopathy. As the timing of the
transplantation remains controversial, we aimed to compare the homing of these
cells in acute and chronic conditions and also to assess the feasibility of a peripheral
approach for CD34+ isolation (rather than bone marrow harvesting).
Methods: 12 patients (range age: 41 to 71 years) with a history of reperfused anterior
myocardial infarction underwent intracoronary infusion of purified CD34+
cells 9±3 days (n=6, group A) or 20±5 months (n=6, group B). At baseline,
the ejection fraction was lower in group B than in group A: 41±7% vs 56±7%
(P

was injected. Left ventricular function was determined with a 9.4T animal MRI six
weeks after surgery.
Results: Proliferation was significantly increased when cells were cultured with
conditioned medium of the other cell type, pointing at a paracrine mutual stimulation.
Left ventricular function was preserved after transplantation of EPDCs,
CMPCs, or a combination of CMPCs and EPDCs when compared to vehicle injection
(p

370 Development from primitive to adult progenitor cells / Imaging in coronary heart disease: cardiovascular magnetic resonance
CPC) is lacking, and no efficient, reproducible method exists to isolate CPC from
human hearts.
Objective: To determine which zone within the hearts of patients with ischemic
and non-ischemic heart disease contains larger reservoir of hCPCs with regenerative
capacity.
Methods and Results: We developed an efficient and reproducible method to
isolate hCPCs from the myocardium of patients with ischemic and non-ischemic
heart disease, heart failure and diabetes. Following patients’ consent, tissue samples
were donated during all kinds of open heart surgery and percutaneous RV
septum biopsies. Isolated cells created typical clones, possessed self-renewal capacity
and expressed stem cell markers including c-kit (22%), Isl-1 (7%), progenitor
cell markers such as GATA 4 (60%), cardiac α-actin (60%). In the culture there
are 70%) for the hematopoietic and endothelial marker CD34,
the endothelial marker CD31, the endothelial and mesenchymal stem cell (MSC)
marker CD105, as well as for CD29 and CD49b. Using the primary explant technique,
outgrowth of spindle-shaped cells from the myocardial samples was apparent
at 5-7 days after seeding. Outgrowing cells were highly enriched in ALDHhigh
cells (61±11%; n=24). At 3-6 weeks, spherical cell clusters ("cardiospheres")
were obtained. Cells derived from cardiospheres were expanded by serial passages
from P1 to P5 and characterized by FACS analysis. They showed positive
(>95%) for the MSC markers CD13, CD44 and CD105, as well as for CD29
and CD49b, but negative for lymphoid (CD3), myeloid (CD11b), leukocyte (CD45)
markers, CD117 (c-kit), CD135 and CD150. They contained significant subsets
of CD90, CD31, CD38, CD49a, CD49d, CD71 and CD106-positive cells. Overall,
cells expressing the stem cell marker CD133 were rare but, occasionally, cardiospheres
contained up to 80% of CD133-positive cells. In conclusion, human
myocardium contains ALDH-high cells that can be passaged (>P20) and form
cardiospheres that predominantly consist of MSCs, stromal progenitors and, to a
lesser extent, endothelial progenitors. These findings indicate that high ALDH activity
is a functional marker of adult human cardiac-resident progenitor cells which
can be highly enriched by the primary explant technique.
P2234 Endovascular gingival fibroblast cell therapy reduced
the size of aneurysms in a rabbit model of
elastase-induced carotid injury
E. Durand1 , N. Reynald1 , L. Couty1 , B. Fournier1 ,C.Brasselet1 ,
M. Lemitre 1 , B. Coulomb1 , B. Gogly1 , A. Lafont2 . 1University Paris Descartes, INSERM U849, Paris, France; 2Hopital Europeen Georges
Pompidou, Service De Cardiologie, Paris Cedex 15, France
Background: Aortic aneurisms are associated with excessive enlargement remodeling,
medial elastin degradation and overexpression of MMP-9. We recently
reported that gingival fibroblast prevent medial elastin degradation in vitro and in
an ex-vivo model via overexpression of TIMP-1. We therefore aimed to evaluate
in vivo cell therapy using endovascular gingival fibroblasts in a model of arterial
aneurism.
Methods and Results: Elastase from porcine pancreas (4U/artery) was incubated
during 15 minutes in rabbit carotid arteries (n = 18). Four to 6 weeks later,
carotid arteries were seeded endoluminally at the site of aneurism with either
rabbit gingival fibroblasts (n=7), or culture medium only which served as control
(n=11). Vessel diameter and elastin density were assessed 4 weeks after cell
therapy. Carotid diameter was similar before cell therapy in both group (3.39±0.54
mm vs 3.10±0.37 mm, p=0.30). In contrast, carotid diameters were significantly
decreased in aneurismal arteries seeded with rabbit gingival fibroblast as compared
to control aneurismal arteries (2.59±0.64 mm vs 3.60±0.52, p=0.003).
Moreover, elastin density was significantly higher in the media after endovascular
gingival fibroblast than in controls (40.79±4.70% vs 17.48±8.22%, p=0.001)
Conclusions: Endovascular gingival fibroblast cell therapy restored elastin integrity
and reduced the size of aneurysms in a rabbit model.
IMAGING IN CORONARY HEART DISEASE:
CARDIOVASCULAR MAGNETIC RESONANCE
P2235 Prognostic value of late gadolinium enhancement by
CMR in predicting major adverse events in patients
with or suspected coronary artery disease with
different resting systolic function
A.K.Y. Chan, W.W.M. Lam, Y.Y. Lam, Q. Zhang, W.W.M. Chan,
J.Y.S. Chan, C.M. Yu. The Chinese University of Hong Kong, Hong Kong, Hong
Kong SAR, People’s Republic of China
Background: Clinical utility of myocardial infarct/scar detection by contrast enhanced
cardiac magnetic resonance imaging (CMR) is well validated after myocardial
infarction. The prognostic value of late gadolinium enhancement (LGE)
on major adverse cardiovascular events (MACE) in stable CAD patients with preserved
or depressed left ventricular systolic function is not known.
Methods: Gadolinium-enhanced CMR were performed in 269 consecutive patients
(mean age 62.2±11.1 years) referred for evaluation of systolic function and
detection of infarct/scar by late gadolinium enhancement (LGE). Depending on
left ventricular ejection fraction (LVEF), patients were classified into 2 groups: relative
preserved systolic function with LVEF ≥ 40%; depressed systolic function
with LVEF

of MACE in patients with LGE and depressed systolic function with LVEF

372 Imaging in coronary heart disease: cardiovascular magnetic resonance
Results: At baseline, 329/640 segments were dysfunctional, by displaying

P2243 Blood oxygenation level-dependent magnetic
resonance imaging in patients with coronary artery
disease: a validation study against positron emission
tomography
T.D. Karamitsos 1 , A. Recio-Mayoral2 ,J.R.Arnold1 , L. Leccisotti 2 ,
R.K. Howells1 , M.D. Robson1 , O.E. Rimoldi2 ,P.G.Camici2 , S. Neubauer1 ,
J.B. Selvanayagam1 . 1Oxford Centre for Clinical Magnetic Resonance,
Cardiovascular Medicine, Oxford, United Kingdom; 2Imperial College,
Hammersmith Hospital, MRC Clinical Sciences Centre, London, United Kingdom
Purpose: Elevated deoxyhaemoglobin seen downstream a territory subtended by
a stenotic coronary artery can be assessed by blood oxygenation level-dependent
(BOLD) magnetic resonance imaging (MRI). Previous animal studies have used
a T2-prepared steady-state free-precession (SSFP) sequence to determine the
BOLD signal in the myocardium. We sought to apply this method at 3 Tesla (T)
in patients with documented coronary artery disease (CAD) and compared it to
perfusion measurements by positron emission tomography (PET).
Methods: 13 patients (mean age 62±8 years, 10 men) with angiographically documented
CAD (at least 1 stenosis of > 70% diameter at quantitative coronary
angiography-QCA) underwent 3T BOLD-MRI and PET imaging. For BOLD-MRI
a single midventricular slice was acquired every 30 seconds at rest and during
adenosine stress (140 μg/kg/min). A set of 6 images was acquired at rest and
at peak stress. Using PET imaging with oxygen-15 labelled water, myocardial
blood flow (MBF) was measured at baseline and during hyperaemia following i.v.
adenosine. The BOLD short-axis view was divided into 6 segments, according
to the midventricular segments of the 17-AHA segment model and mean signal
intensities (SI) at rest and stress were calculated using QMass (Medis) software.
SI values were corrected for differences in T1-weighting owing to heart
rate changes at stress and rest. PET images were analysed with MATLAB software
(the MathWorks Inc.) and registered with the BOLD short-axis image using
anatomical landmarks.
Results: Rest MBF in territories (n=34) subtended >70% stenoses (STE;
1.02±0.35 ml/min/g) did not differ from MBF in remote myocardium (REM; n=44)
subtended by non-diseased arteries (0.98±0.32 ml/min/g; p=0.6). By contrast, hyperaemic
MBF in STE was significantly lower than in REM (2.2±1.0 vs 2.9±0.8
ml/min/g; p=0.002). Similarly, BOLD-SI change was 1.9±10% in STE compared
with 7.6±9% in REM (p=0.001). Taking QCA as the gold standard, cut-off values
for stress MBF (≤ 2.45ml/min/g) and BOLD SI change (≤ 3.59%) were determined
in order to define ischaemic myocardial segments. BOLD-MRI and PET
agreed with respect to the presence or absence of ischaemia in 11 of the 13 patients
(85%). With regards to per segment analysis, taking PET as the gold standard
and by applying the determined cut-off values for stress MBF and BOLD
SI, BOLD MRI had good sensitivity (76%) but moderate specificity (62%) for the
identification of ischaemia.
Conclusions: T2-prepared SSFP 3T BOLD imaging is feasible in the clinical setting
and has good agreement with PET perfusion measurements for the detection
of myocardial ischaemia.
P2244 Evaluation of coronary artery disease; coronary
stenosis on MSCT versus myocardial perfusion on
MRI
J.M. Van Werkhoven1 , J.D. Schuijf1 ,J.W.Jukema1 ,J.Schreur2 ,
M. Heijenbrok2 ,E.E.VanDerWall1 ,J.J.Bax1 . 1Leiden University
Medical Center, Cardiology, Leiden, Netherlands; 2Medical Center
Haaglanden, Cardiology, Den Haag, Netherlands
Purpose: Non-invasive computed tomography coronary angiography (CTA) can
accurately assess the presence of coronary artery disease (CAD). Because of
the high negative predictive value it may be particularly effective to rule out CAD.
In patients with abnormal CTA, optimal treatment strategy may remain uncertain
as no information on the hemodynamic effect is obtained. The purpose of this
study was to assess the combined use of CTA and myocardial perfusion imaging
with magnetic resonance imaging (MRI).
Methods: In this prospective study, 55 patients (62% male, average age 57±9
years, pre-test likelihood low to intermediate 62%) underwent 64-slice CTA and
1.5 Tesla MRI within 40 days. CAD (normal 50%) was determined on CTA and first pass perfusion during
adenosine stress was assessed on MRI.
Results: CTA was normal in 15 (27%), 30-50% in 24 (44%) and >50% in 16
(29%) patients. MRI revealed a perfusion defect in 21 (38%) patients, and was
Figure 1
Imaging in coronary heart disease: cardiovascular magnetic resonance 373
normal in 34 (62%). Figure 1 shows the MRI results for the individual CTA cateogies.
In patients with an abnormal perfusion on MRI, CTA was normal in only 1
(5%) patient and showed non-significant and significant CAD in respectively 9
(43%) and 11 (52%) patients. Conversely, in patients with normal perfusion on
MRI, normal CTA was observed in 14 (41%). Non-significant and significant CAD
was noted in 15 (44%) and 5 (15%) patients respectively.
Conclusion: Although the prevalence of abnormal perfusion increases with the
degree of stenosis, a substantial proportion of patients with significant CAD on
CTA have normal perfusion on MRI. Conversely, underlying CAD is present in the
majority of patients with a normal MRI perfusion study. The combination of both
techniques may allow more refined characterization of CAD.
P2245 Contractile reserve by dobutamine cardiac magnetic
resonance imaging of dysfunctional myocardial
segments corresponds well with improvement in
quantitative wall thickening after revascularization
S.W.M. Kirschbaum, K. Gruszczynska, D.J. Duncker, A. Rossi,
G.P. Krestin, P.W. Serruys, P.J. Feyter, R.J. Van Geuns. Erasmus Medical Center,
Cardiology Dept, Rotterdam, Netherlands
Purpose: We investigated the relation between transmural extent of infarction,
contractile reserve and improvement after revascularization in chronic dysfunctional
myocardial segments.
Methods: MRI was performed in 40 patients before recanalisation of a chronic total
coronary artery occlusion and at 6 months follow-up (FU) this was compared
to 21 patients without revascularization. Segmental wall thickening (SWT) was
quantified at rest and with low dose dobutamine (5 and 10 microgram/kg/min)
(LDD). Contractile reserve and the transmural extent of infarction (TEI) were related
to SWT at follow-up.
Results: Mean SWT of all dysfunctional CTO perfused segments increased during
LDD with 15 percentage points 16±19% to 31±34% (p

374 Imaging in coronary heart disease: cardiovascular magnetic resonance
Patients with abnormal MDCT (defined as CT calcium score >0 and/or coronary
artery stenosis >50%) all underwent conventional invasive coronary angiography.
Significant CAD was defined as >70% stenosis on invasive coronary
angiography, or 50-70% stenosis with additional fractional flow reserve
measurement

P2250 Prognostic value of revascularization-related
irreversible myocardial injury
K. Rahimi, A.P. Banning, A.S.H. Cheng, T.J. Pegg, T.D. Karamitsos,
S. Darby, D. Taggart, S. Neubauer, J.B. Selvanayagam. Oxford,
United Kingdom
Background: Myocardial revascularization, either by coronary artery bypass
grafting (CABG) or by percutaneous coronary intervention (PCI), improves outcomes
in patients with coronary artery disease. However, these procedures may
themselves cause irreversible myocardial injury, and their prognostic impact is uncertain.
Delayed enhancement cardiovascular magnetic resonance imaging (DE-
CMR) has been shown to reliably identify areas of irreversible myocardial injury.
Objectives: To evaluate the impact of procedural myocardial injury as measured
by DE-CMR on medium-term prognosis following myocardial revascularization.
Methods: A prospective observational study in a tertiary hospital setting of 152
CABG or PCI patients with clinical follow up of median 2.9 years. The primary
endpoint was defined as death, non-fatal myocardial infarction (MI), ventricular
arrhythmia (VA), or unstable angina or heart failure requiring hospitalization.
Results: 27 patients (18%) reached the primary endpoint. 49 patients (32%) had
evidence of new procedure-related myocardial hyperenhancement (HE) with a
median mass of 5.0g (interquartile range 2.7-9.8). After adjustment for age and
sex, these patients had a 3.1-fold (95% confidence interval 1.4, 6.8; p=0.004)
higher risk of adverse outcome than patients without new HE. Neither periprocedural
cardiac troponin levels nor quantitative measures of left ventriclular function
showed any significant independent association with the primary endpoint after
adjustment for new HE, nor did they alter the independent association of new HE
with the primary endpoint. Exclusion of cases due to hospitalization for angina or
heart failure yielded a similar association between new HE and the outcome.
Conclusion: Myocardial injury during PCI or CABG, identified by DE-CMR, is a
more powerful prognostic marker of adverse clinical outcome than widely-used
biochemical and functional measures of myocardial injury. Particularly in low risk
patients, the competing risk of new myocardial damage caused by the intervention
may well outweigh the benefit of salvaged myocardium.
P2251 Microvascular obstruction over time as a predictor for
left ventricular remodeling
J.F. Rodriguez Palomares1 ,J.T.Ortiz2 , D.C. Lee3 ,E.Wu3 .
1 2 Barcelona, Spain; Hospital Clinic, Cardiology, Barcelona, Spain;
3Northwestern Memorial Hospital, Cardiology, Chicago, United
States of America
Introduction: Microvascular obstruction (MO) can be evaluated using contrastenhanced
CMR and is identified as areas of hypoperfusion in the infarct zone
within 3 minutes. However, a similar phenomenon can be seen on delayed viability
images 10 minutes after contrast injection following acute myocardial infarction
(AMI). Due to its shorter scanning time, the inversion-recovery single-shot true
fast imaging with steady-state precession (ss-IR) allows analysis of any dynamic
changes in infarct and "no-reflow" sizes over time after contrast administration.
Purpose: The aim of this study is to analyze dynamic changes of MO at different
times after contrast administration and the size of hypoperfusion that best
correlates with ventricular remodeling in patients following AMI.
Methods: Subjects were evaluated using CMR within the first week (n= 60), 3
months (n=47) and one year (n= 25) after a ST-segment elevation MI percutaneously
revascularized. Cine CMR was performed to measure left ventricular
function. Additionally, as a gold-standard, segmented inversion-recovery (seg-IR)
were acquired 10 min after the administration of contrast, and ss-IR images were
acquired sequentially at 1, 3, 5, 7, 10, 15, 20, and 25 min after bolus contrast
administration to measure microvascular obstruction. Inversion times were set to
properly null normal myocardium at each time point. All images were blinded,
randomized, and measured for hypo- and hyper-enhancement volumes.
Results: There was a significant reduction of hypo-enhancement volumes over
time (p

376 Imaging in coronary heart disease: cardiovascular magnetic resonance / Contrast echocardiography
-0.39; p= 0.014). Both T2-LGE (r = -0.52; p=0.002) and LGE alone (r = 0.41; p=
0.018) correlated with delta EDV. T2-LGE correlated with delta-ESV (r= -0.39, p=
0.026) but LGE alone did not (p= 0.43). The relation between T2-LGE, delta EDV
and delta-ESV remained significant after correcting for the inter-study duration,
time to reperfusion, ejection fraction and LGE extent.
Conclusion: We propose a myocardial salvage index based on the difference
between T2-weighted abnormality and late gadolinium enhancement. This novel
CMR-based parameter may have the potential to serve as a surrogate end-point
in studies assessing the efficacy of infarct reperfusion strategies.
CONTRAST ECHOCARDIOGRAPHY
P2254 Prognostic significance of perfusion abnormalities
identified by myocardial contrast echocardiography in
diabetics with no significant coronary lesions
C. Aggeli, G. Giannopoulos, G. Roussakis, E. Christoforatou,
G. Marinos, C. Toli, C. Kokkinakis, A. Michaelides, C. Pitsavos,
C. Stefanadis. 1st Dept. of Cardiology, University of Athens, Athens, Greece
Aim: To assess the prognostic significance of myocardial perfusion abnormalities
detected by the combination of dobutamine stress echocardiography (DSE) and
myocardial contrast echocardiography (MCE) in patients with diabetes mellitus,
who were angiographically shown to have coronary arteries free of significant
stenoses.
Methods: 60 (45 men, 68±7 years old) diabetics, who were submitted to coronary
angiography and DSE/MCE within an one-month period without any intervening
clinical events, were retrospectively selected from the database of our
laboratory. Elligible patients were those with type 2 diabetes who were found on
angiography to be free of significant coronary artery stenoses (≥50% reduction
in luminal diameter). The DSE protocol consisted in four 3-minute stages of IV
dobutamine infusion (10-40 μg/kg/min) with atropine as needed to achieve 90%
of age-predicted maximal heart rate. An echo-contrast agent was infused at rest
and at peak stress to better evaluate wall motion, as well as to assess myocardial
perfusion. The patients were followed for two years. The composite endpoint was
an acute coronary event or hospitalization for heart failure or death of cardiac
causes.
Results: 18 patients (30%) were found to demonstrate perfusion abnormalities at
peak stress on DSE/MCE in at least two adjacent myocardial segments (MCE+
subgroup), while the rest 42 (70%) had normal DSE/MCE studies (MCE- subgroup).
The two subgroups did not differ significantly as far as age, gender and
prevalence of hypertension, dyslipidemia and smoking habit were concerned. The
two-year event rate in the MCE+ subgroup was 22.2%(4/18), versus only 4.8%
(2/42) in the MCE- subgroup (p=0.025). In the multivariate binary logistic regression
analysis the result of MCE remained a significant predictor of the composite
endpoint (p=0.045).
Conclusion: This is a report on the potential prognostic significance of perfusion
abnormalities detected by stress-contrast echocardiography in diabetic patients
with "normal" coronary arteries. The observed difference in the event rate could
be linked to microcirculation abnormalities (giving rise to perfusion abnormalities
on MCE) or to non-obstructive coronary artery wall lesions (as demonstrated to
exist by past intravascular ultrasound [IVUS] studies in patients with normal coronary
"luminograms"), which may cause impaired coronary flow reserve and, thus,
perfusion abnormalities at stress. It should be noted that, given the small number
of events and the retrospective nature of the study, these interesting findings need
to be confirmed prospectively in larger series of subjects.
P2255 Unification of the planes of the right ventricle
obtained by contrast echocardiography and
computed tomography
A. Laucevicius 1 , D. Zakarkaite1 ,S.Aidietiene2 , M. Mataciunas1 ,
A.E. Tamosiunas1 . 1Vilnius University Santariskiu Hospital, Centre
of Cardiology and Angiology, Vilnius, Lithuania; 2Vilnius University Medical
Faculty, Clinic of Heart Diseases, Vilnius, Lithuania
Purpose: The aim of our study was to explore methodological aspects of right
ventricle (RV) assessment from multiple echocardiographic (Echo) planes for better
visualization using contrast enhancement and to explore the correspondence
of areas obtained by Echo with those obtained by multislice computer tomography
(CT).
Methods: Conventional parasternal long and short axis views at a different level,
the apical four-chamber view as well as multiple subcostal views of the RV were
obtained in 54 patients (12 women). All the patients underwent Echo examination
without, and then, with contrast enhancement using iE33 (Philips) ultrasound
machine. For the enhancement of the right heart cavities, echocontrast was administered
by: 1) the injection of 10 ml agitated saline solution mixed with small
amount of diluted blood and applying ultrasound oscillations with the mechanical
index (MI) between 0.13 and 1.2; 2) the injection of commercially available
echocontrast Optison (GE Healthcare) and applying ultrasound oscillations with
MI = 0.21.
In 10 patients areas of RV planes on subcostal and parasternal Echo views were
compared with the corresponding areas obtained on CT.
Results: The comparison of Echo and CT data enabled us to separate three
non-parallel (perpendicular) planes of the RV on Echo. The comparison of the
areas of the RV on these Echo planes with the areas of corresponding CT slices
revealed close correlation between both methods (r = 0.88, p = 0.028). When
using echocontrast enhancement with agitated saline solution we were able to
enhance more close to the probe wall contour, the distal contour was obscured
by gas in bubbles. The optimal contrasting of the RV cavity was obtained when
using ultrasound vibrations with MI 0.9-1.1. Standard use of Optison produced
quick rise of echogeneity of RV myocardium and non-homogenous distribution of
echocontrast in the RV cavity. Better results of RV enhancement were obtained
when Optison was combined with agitated saline solution after echocontrast fills
the left ventricle cavity.
Conclusions: 1) RV assessment from three non-parallel (perpendicular) planes
of the RV on Echo can be used for mathematical reconstruction of the RV cavity.
2) The close correlation between both methods was found when comparing the
areas of the RV from Echo planes with the areas of corresponding CT slices.
3) Combination of Optison enhanced by agitated saline solution can be one of the
solutions for optimal echocontrast enhancement of RV endocardial borders.
P2256 Marked decline in clinical use of ultrasound contrast
agents following black box warning: observations
from the clinic
Y.M. Smyth, R.S. Gabriel, E. Mayer Sabik, A.L. Klein, R. Grimm,
J.D. Thomas, V. Menon. Cleveland Clinic, Cardiovascular Imaging,
Cleveland, United States of America
Purpose: The utility of contrast echocardiography is well established. Recent adverse
events have led regulatory agencies in the USA to issue a warning on the
utilization of perflutren containing contrast agents (Definity; BMS and Optison;
GE, USA). We sought to evaluate the impact of this on contrast utilization at our
institution
Methods: Over a 4 week period all transthoracic (TTE) and stress echocardiograms
(SE) in a quaternary referral center and 3 outpatient facilities were studied.
For each echocardiogram, the sonographer indicated whether contrast would
have been given prior to the FDA warning. We analyzed current rates of utilization,
contraindications to utilization and monitored for adverse events as dictated
by the package insert. Actual usage was compared to data from previous years.
Results: Questionnaires on 1381 studies were included, 72% TTE (10% bedside)
and 28% SE. Contrast was indicated in 8.3% of studies, more frequently
for SE (13.4% vs 6.3% TTE, p

needed to achieve 90% of age-predicted maximal heart rate (APMHR). An echocontrast
agent was infused at rest and at peak stress in order to better evaluate
wall motion, as well as to assess myocardial perfusion. All patients remained
under surveillance for at least 30 minutes after the completion of the test. Adverse
events were recorded during the test and for the 24 hours following it. The
diagnostic accuracy of DSE/MCE was assessed on the basis of CAG findings
(stenoses of ≥50% were considered as clinically significant).
Results: As far as adverse events were concerned, no deaths or life-threatening
events were encountered. One patient (0.95%) exhibited an excessive vasovagal
reaction, which responded immediately to atropine administration and placement
in the recumbent position. The most common adverse effects were mild-tomoderate
in severity: xerostomia (N=11, 10.5%), headache (N=4, 3.8%), tremor
(N=2, 1.9%), backpain (N=3, 2.9%), dizziness (N=4, 3.8%) and mild allergic reactions,
consisting in pruritic skin rash (N=2, 1.9%), readily responsive to antihistamines.
Urinary retention lasting for a few hours after the test was observed
in 4 (3.8%) patients (all were men who received atropine to achieve APMHR).
Onset of atrial fibrillation was observed in 2 patients (1.9%), both of whom spontaneously
reverted to sinus rhythm in the first 24 hours after the test. No sustained
supraventricular or ventricular arrhythmias were observed. 71.4% (N=75)
of the patients were found to have significant stenoses on CAG. The sensitivity
of DSE/MCE was 90.7% and its specificity was 80%. Of the 74 patients found
positive for ischemia on DSE/MCE, 68 had significant stenoses on CAG (positive
predictive value 91.9%), while the negative predictive value was 77.4%. The
overall accuracy was 87.6%.
Conclusion: DSE/MCE is a safe and accurate diagnostic technique for the assessment
of coronary artery disease in octogenarians unsuitable for exercise
stress testing.
P2258 Feasibility and safety of contrast-enhanced real-time
3D echocardiography within 24 hours after acute
myocardial infarction
G. Nucifora, N. Ajmone Marsan, H. Siebelink, J.M. Van Werkhoven,
J.D. Schuijf, M.J. Schalij, E.R. Holman, J.J. Bax. Leiden University
Medical Center, Department of Cardiology, Leiden, Netherlands
Objectives: Contrast-enhanced (CE) echocardiography has been demonstrated
to be useful in optimizing endocardial border delineation both for 2D and realtime
3D echocardiography (RT3DE). However, no specific data exist regarding
feasibility, efficacy and safety of CE RT3DE for the evaluation of left ventricular
(LV) function among patients with acute myocardial infarction (AMI). In the present
study we report our experience regarding the use of CE RT3DE performed the
first day after AMI.
Methods: 110 consecutive patients (57±11 years; 76% male) admitted to the
coronary care unit because of ST-elevation AMI were included in the study.
RT3DE with and without contrast was performed within 24 hours from patients’
admission to evaluate LV volumes and ejection fraction (EF). Perflutren was used
as contrast agent. Adequacy of endocardial border visualization was graded for
each of the 16 cardiac segments as follows: 0= border invisible; 1= border visualized
only partially throughout the cardiac cycle and/or incomplete segment length,
and 2= complete visualization of the border. The 3D data sets were analyzed offline
and LV end-diastolic volume (EDV), end-systolic volume (ESV) and EF were
measured using a dedicated analysis software.
Results: During non-CE RT3DE, from the total number of 1760 LV segments,
the endocardial border was invisible in 185 (10%) and visualized only partially in
392 (22%). A complete visualization of the border was possible in 1183 (67%)
segments. During CE RT3DE, adequate-to-full LV opacification was seen in 94%
of patients and a complete visualization of the border was possible in 1493 (85%)
segments (p

378 Contrast echocardiography
mogeneities of the myocardial mechanical properties. The fibers are wound in a
spiral structure around the cavity, generating the rotation of the left ventricle (LV)
during contraction and relaxation. LV rotation tends to equalize the sarcomere
shortening between the myocardial layers. The purpose of this study was to develop
a method of measuring the transmural changes of LV rotation, torsion and
circumferential strain in normal subjects, in order to establish the normal behavior.
Methods:The method is based on B-mode ultrasound cines that underwent post
processing utilizing 2D-Strain program (2DS) of speckle tracking imaging and a
novel signal processing method of 3 dimensional wavelet de-noising (2DS-W).
This new method enabled high temporal and spatial resolution measurements of
the myocardial velocities, so that the circumferential strain and the myocardial rotation
were evaluated during a full heart cycle for 3 myocardial layers. The study
included two stages: validation process of the algorithm utilizing tissue mimicking
phantoms, and a clinical stage. At the clinical stage, three levels of short-axis
ultrasound echo cines (Apical, Papillary muscle and Mitral valve levels) were obtained
from 36 normal subjects in order to measure the circumferential strain and
the myocardial rotation.
Results: The average error of rotation in respect to the real value, as obtained
during the analysis of a software implemented phantom, was 7.5%, 2.9% and
3.4% for the inner, middle and outer layers, respectively. The average error of circumferential
strain in respect to the real value was 3%, 5% and 7% for the inner,
middle and outer layers, respectively. The clinical results show a significant transmural
difference in the myocardial rotation, torsion and circumferential strain. The
rotation is larger for the endocardium (apex 8.7±3.7deg, base -4.9±3.6 deg) and
decreases towards the epicardium (apex 5.1±2.8 deg, base -2.8±2.5 deg), while
the apex and base rotate in counter directions. Similarly, the circumferential strain
is larger at the endocardium (apex -32.7±7.8%, papillary muscles -27.9±5.7%,
base -24.4±6.5%) than at the epicardium (apex -16.3±4.5%, papillary muscles
-14.0±4.1%, base -13.8±4.1%).
Conclusion: 2 dimensional echocardiography contains sufficient information to
allow measurements of LV transmural inhomogeneities of the rotation, torsion
and circumferential strain, providing a simple, affordable and commonly available
diagnostic modality.
P2262 Early end diastolic wall thickness changes after
reperfusion in acute myocardial infarction predict late
infarct transmurality as assessed by cardiac magnetic
resonance
M. Chaparro Munoz, A. Recio, E. Merli, A. Fischer, N. Bunce,
G.R. Sutherland. London, United Kingdom
Purpose: Complete reperfusion of acute infarcted segments results in an immediate
increase in end-diastolic wall thickness (EDWT), which correlates with
reactive hyperemia and extra cellular edema. We sought to determine whether
the magnitude in EDWT after successful reperfusion for acute myocardial infarction
(MI) correlates with transmural necrosis at follow up, as assessed by delayed
enhancement imaging.
Methods: We assessed EDWT and wall motion abnormalities in 26 consecutive
patients with a first acute MI by standard M Mode and 2D echocardiogram performed
within first 12 hours after successful primary angioplasty. After 3 months of
follow up, a repeat echocardiogram was carried out to assess changes in EDWT
and contractile function and magnetic resonance imaging (MRI) was performed to
evaluate location and size of the infarct zone. Necrosis was judged as transmural
when delayed enhancement after gadolinium contrast was extended >50%.
Results: 416 segments were analysed. Compared with remote myocardium,
dysfunctional segments in the infarct territory (n=144) had an increased EDWT
(11±1.9 versus 9.4±1.1 mm, p

presence/absence of VIVC assessed under standard conditions by TDE compared
to CMR using post-contrast saturation (delayed enhancement-DE).
Patient group and methods: In total, 57 consecutive patients with an ischemic
cardiomyopathy (LVEF 33.5±5%) were included in study. All of them were during
09/04-12/07 examined by echocardiography, myocardial gated SPECT and cardiac
MR. A total of 689 LV segments were analyzed with a complete data acquisition
(76% of the total number of segments). Viability of myocardium in individual
segments was evaluated on 3 levels of DE/wall thickness on MR cut-off ratio (25,
50, 75%) and in 3 subgroups according to the extent of DE: 0-24% (MR1), 25-
74% (MR2) a >75% (MR3). Wall thickness (mm) and extent of DE in individual
segments and perfusion SPECT rest score (Q rest) were also evaluated.
Results: 1. Using χ-square test a significantly lower occurrence of VIVC=1 was
found in the MR3 subgroup in comparison with MR1 and MR2 respectively (p =
0.0001 for MR1 vs. MR3 comparison; p = 0.003 for MR2 vs. MR3).
2. Cohen’s kappa coefficient was used for assessment of agreement rate of VIVC
presence/absence and viability on MR (MR1: κ = 0.089, MR2: κ = 0.116, MR3: κ =
0.118). The low values of κ indicate a very poor agreement rate. Statistically significant
correlations of VIVC and MR parameters were as follows: wall thickness
(r=0.262, p0,05) on
the first day but significantly lower in control group after follow-up (0,07 vs. 0,25;
p75%.
The risk of persistent contractility defect after 3 months was related to the grade
of perfusion impairment. For G1, G2 and G3 the risk of persistent akinesis was
higher then in G4 - (OR 7,2; CI 85-97%), (OR 5,7; CI 83-95%) and (OR 1,9;
82-96%) respectively.
The short-term risk of postinfarctional aneurysm development was higher in G1
(OR 4,0; CI 87-94%) segments then G4 and was related to the capacity of nonperfused
myocardium.
3D PE early identifies STEMI patients at risk of persistent contractility disturbances
and aneurysm development regardless of restored TIMI 3.
P2267 The relationship between inflammation biomarkers
and myocardial perfusion assessed by contrast
echocardiography and outcome in patients with
end-stage renal disease
A. Tomaszuk-Kazberuk, B. Sobkowicz, J. Malyszko, T. Hryszko,
J.S. Malyszko, M. Mysliwiec, M. Kalinowski, E. Skibinska, R. Sawicki, W.J. Musial.
Medical University, Cardiology, Bialystok, Poland
Background: Cardiovascular risk stratification in patients with end-stage renal
disease (ESRD) is of great importance as coronary artery disease (CAD) is the
main cause of death in this population. Markers of inflammation predict adverse
outcome in patients with CAD and are also associated with all all-cause mortality
in ESRD patients.
Aim: To evaluate the relationship between C-reactive protein (CRP) and myocardial
perfusion defined by myocardial contrast echocardiography (MCE) and their
impact on clinical outcome in patients with ESRD.
Contrast echocardiography 379
Material and methods: We studied 58 consecutive patients with ESRD (21
women, mean age 59±14 years) on regular hemodialysis. Real-time MCE was
performed using Optison contrast agent. Perfusion assessment was qualitative.
The criterion for MCE was defined as homogenous enhancement in 50% of
wall thickness in each segment. Demographic, clinical and laboratory parameters
(serum C-reactive protein (CRP) levels, full blood count and iron metabolism
parameters such as iron level, total iron blood capacity (TIBC) and ferritine) were
analyzed. Composite clinical endpoint (CCE) included cardiac death, cardiac arrest,
myocardial infarction, myocardial revascularization, hospitalization for cardiac
cause, stroke over 6-month FU. The patients were divided into 2 groups
according to the presence or absence of CCE.
Results: 20 (34%) patients out of 58 experienced CCE. The patients with CCE
were older (65±10 vs. 57±14 years, p=0,016), men in prevalence (p=0,014), DM
in prevalence (56 vs. 18% p=0,007) as well as lower EF (45±12 vs. 58±7%,
p=0,0001) in comparison with those without CCE. 18 out of 20 patients (90%)
who experienced CCE demonstrated perfusion defect on MCE. Out of biochemical
variables CRP levels as well as TIBC were significantly elevated in patients
with CCE. In logistic regression analysis perfusion defects on MCE (p=0,002) and
elevated CRP (p=0,009) were independent predictors of CCE during FU. Moreover
we found the relationship between perfusion defects on MCE and elevated
CRP level (p=0,037). The lower level of iron and higher reticulocytes count were
also associated with perfusion defects on MCE (p=0,022 and p=0,013, respectively).
The level of ferritine was not different between groups.
Conclusions: 1. In patients with ESRD both perfusion defects on MCE and elevated
CRP levels are associated with unfavorable clinical outcome. 2. Risk stratification
in ESRD patients could be extended by an assessment of inflammatory
markers, such as CRP and functional iron deficiency (as a sign of chronic inflammation)
in relation with myocardial perfusion evaluation by MCE.
P2268 Integrated analysis of cardiac tissue structure and
function allows improved identification of reversible
myocardial dysfunction
R. Hoffmann, A. Lenzen, F. Schmitz, H. Kuehl, N. Kraemer,
K. Stempel, G. Krombach, M. Kelm, M. Becker. University Aachen,
Medical Clinic 1, Aachen, Germany
Objective: Myocardial deformation imaging and contrast-enhanced cardiac magnetic
resonance imaging (ceMRI) have been used to define myocardial viability in
ischemic left ventricular dysfunction. This study evaluated the incremental predictive
value of an integrated analysis of function and tissue structure for functional
improvement after revascularization therapy.
Methods: In 59 patients with ischemic left ventricular dysfunction, myocardial viability
was defined by pixel-tracking-derived myocardial deformation imaging and
ceMRI to predict recovery of function at 9±2 months follow-up after revascularization.
For each left ventricular segment in a 16-segment model peak systolic
radial strain was determined from parasternal 2D echocardiographic views using
an automatic frame-by-frame tracking system of natural acoustic echocardiographic
markers (EchoPAC, GE Ultrasound), and extent of hyperenhancement
using ceMRI. 5 categories were generated for each parameter, allowing subsequent
combination. The predictive power for segmental improvement in function
was determined for each of the modalities as well as the combination of both.
Results: From 512 dysfunctional segments at baseline, 251 segments (49%)
demonstrated functional recovery. The accuracy to predict functional recovery
was AUC= 0.846 for peak systolic radial strain, and AUC= 0.834 for extent of
hyperenhancement. A combination of both parameters improved the predictive
accuracy compared to hyperenhancement alone, AUC=0.861, p

380 Contrast echocardiography / Telemonitoring in heart failure
tory of myocardial infarction, mean age 60±12 years), on regular dialysis were included.
Elective coronary angiography was done for the evaluation of CAD symptoms.
Coronary artery stenosis > 75% was defined as significant. TFC for the
three main coronary vessels were calculated. For LAD the corrected TIMI frame
count (CTFC) was applied. Measurements were done with the frame counter on
the HORIZON Cardiology cineviewer.
Results: In 19 pts (48,7%) out of 39 significant epicardial coronary artery disease
was found. 9 of 19 (47%) had single-vessel disease, 10 (53%) multivessel.
11 patients had LAD stenosis, one of them chronic total occlusion (CTO). 13 patients
had Cx stenosis and 9 RCA stenosis (3 of them CTO). In the whole study
group the mean corrected TFC for the LAD was 36,9±19, for the Cx 42,2±25 and
for the RCA 40,0±26 frames. Distribution of the TFC for the three main coronary
arteries reflected prevalence for higher TFC values (slower flow). For the three
main coronary vessels there were no statistically significant differences between
the mean TFC values according to the presence or absence of the severe coronary
artery stenoses on angiography (LAD: 31,9±14 vs 36,9±18; Cx: 38,5±18
vs 44,0±29; RCA: 28,4±13 vs 32,7±21 respectively).
Conclusions: Our results demonstrate for the first time the reduction in velocity
of the blood flow in the coronary arteries in the entire group of ESRD patients
regardless the presence of the significant epicardial coronary artery obstruction.
This finding may reflect microvascular injury in ESRD patients.
P2270 The value of contrast enhancement in quantification
of left ventricular function by realtime 3D
echocradiography
N. Hashemi1 , A. Manouras2 ,R.Winter2 . 1Danderyd Hospital,
Kardiology, Stockholm, Sweden; 2Karolinska Hospital,Huddinge,
Stockholm, Sweden
Left ventricular (LV) volumes and ejection fraction (EF) are strong predictors
of morbidity and mortality in patients with cardiac disease, and important in
therapy guidance. Contrast-enhanced imaging has been proven valuable for
2D-echocardiography. We aimed to study whether contrast enhancement also
improves the accuracy and reproducibility of real time3D echocardiography
(RT3DE).
Methods: 27 consecutive patients referred for echocardiographic examination on
clinical grounds were evaluated by RT3DE echocardiography and image acquisition
before and after contrast enhancement (Sonovue ® , 0.5-0.7 ml/min i.v.). Image
analysis was performed blinded off-line by two independent observers using
(GE EchoPAC) with TomTec 4D LV analysis V2.0. Endocardial borders were
manually traced in a simultaneous apical triplane projection in end-diastole and
end-systole, as automatically deteced by the software.
Results: Interobserver correlation was high and further improved for assessment
of EF when contrast enhancement employed (r2=0.95, SE±2.4) vs (r2=0.86,
SE±3.9) but remained the same for EDV (r2=0.98, SE±2.5) vs (r2=0.98, SE±3.3)
and ESV (r2=0.98, SE±1.4) vs (r2=0.98, SE±1.5). Intraobserver variability was
consistently lower When contrast enhancement was employed (coefficient of variation:
EF 8.9% vs 12.1, ESV 9.4% vs 12.6%, EDV 18.6% vs 19.4%). The analysis
time was the same for both methods (4.5±1 minvs4.1±1 min).
Interobserver regression analysis.
Conclusions: Contrast-enhanced RT3DE improves the accuracy and reproducibility
of the LV function asseeement by improving interobserver correlation
and reducing variability of the results. Contrast-enhanced RT3DE should be considered
when serial accurate estimation of EF is necessary. Quantification of LVvolumes
and EF by RT3DE is rapid and not timeconsuming.
TELEMONITORING IN HEART FAILURE
2339 Intra-thoracic impedance for the assessment of heart
failure hospitalization risk
M. Lunati 1 ,M.Santini2 , M. Landolina3 ,M.Sassara4 , G. Perego5 ,
A. Vado6 , L. Padeletti 7 ,R.Massa8 , S. Marchesini 9 , A. Varbaro10 .
1 2 3 Niguarda, Milano, Italy; San Filippo Neri, Roma, Italy; Policlinico S.
Matteo, Pavia, Italy; 4Osp. Belcolle, Viterbo, Italy; 5Auxologico S. Luca, Milano,
Italy; 6S. Croce e Carle, Cuneo, Italy; 7Careggi, Firenze, Italy; 8Molinette S.
Giovanni Battista, Torino, Italy; 9Medtronic Italia, Sesto S.Giovanni (Mi), Italy;
10Medtronic Italy, Clinical & new Business, Sesto San Giovanni, Italy
Purpose: Some implantable CRT-D devices can provide useful patient diagnostic
information, including an index of pulmonary fluid accumulation based on intrathoracic
impedance monitoring. We studied the association between these information
and heart failure (HF) hospitalization.
Methods: Clinical and device data of 558 HF patients (pts) indicated for CRT-D
therapy, averaging 326±216 days of follow-up, were collected from 34 centers.
Device-recorded fluid index threshold crossing event (TCE), patient activity, night
heart rate (NHR) and heart rate variability (HRV) were compared within pts with
vs. without HF hospitalization.
Results: Kaplan Meier analysis indicated that pts with more TCEs were significantly
more likely to be hospitalized (figure). Multivariate analysis showed
that TCE resulted in a 36% increased risk of HF hospitalization (OR=1.356,
95%CI=1.081-1.700, p=0.008). TCE net duration, the number of days with low
activity or with low HRV were also significantly associated with hospitalization
(respectively OR=1.009 95%CI=1.001-1.018, p=0.037; OR=1.006 95%CI=1.000-
1.011, p=0.032; OR=1.004 95%CI=1.000-1.007, p=0.047). Pts hospitalized for
HF had significantly higher rates of TCE (2.99 vs 1.41, p

2341 Telemonitoring in an elderly, urban, multi-ethnic
population: results of a UK multi-centre randomised
controlled trial. The Home Heart Failure (HOME-HF)
study
O.A. Dar 1 ,J.Riley2 , C. Chapman3 ,S.Dubrey4 ,S.Rosen5 ,S.Morris6 ,
M.R. Cowie1 . 1Imperial College London, Dept. of Clinical Cardiology,
London, United Kingdom; 2Royal Brompton Hospital NHS trust, Post-graduate
Education for Nurses, London, United Kingdom; 3West Middlesex Hospital
NHS trust, London, United Kingdom; 4Hillingdon Hospital NHS trust, London,
United Kingdom; 5Ealing Hospital NHS trust, London, United Kingdom; 6Health Economic Research Group, Brunel Uni, London, United Kingdom
Background:Telemonitoring (TM) is increasingly used to manage heart failure
(HF) in the USA. Evidence for its impact within Europe is limited. HOME-HF, a
multi-centre randomised controlled trial, compared TM with usual care (UC) in
HF patients discharged from 3 hospitals in London, UK.
Methods: HF patients were randomised at discharge to home TM of symptoms
& signs (dyspnoea, weight, oxygen saturation, blood pressure & heart rate) or
UC for 6 months. TM data were reviewed daily by a HF nurse who responded to
change from preset limits with advice on diuretic & lifestyle therapy, or arranged
clinic or primary care review.
Results: 182 patients (40% of all eligible) were randomised: 120 (66%) male,
mean age 71 (SD ±12), 49 (27%) non-White. Medication at randomisation:
ACEi/ARB (89%), beta-blocker (56%), aldosterone antagonist (41%), and diuretic
(93%). 95% of TM patients were monitored >90% of the time. There were 89 hospital
readmissions (TM: 49 & UC: 40), with no difference in the number of days
alive and out-of-hospital between groups (Median [IQR] TM: 178(90-180); UC:
180(165-180) p=0.29). Time to first event (readmision or death) was slightly earlier
in the TM group (p=0.08). There were a greater proportion of unplanned HF
admissions in the UC group [UC:15/16 (94%) versus TM: 8/21(38%), p=0.001].
UC patients made more outpatient visits (733) than TM (622). Quality of life scores
were similar in both groups during follow-up.
Conclusion: Introduction of TM into a well treated, elderly, multi-ethnic, urban
HF population resulted in a similar outcome to UC, but with fewer outpatient visits
and unscheduled HF re-admissions. TM is acceptable to elderly HF patients, with
high adherence rates in a European urban population.
2342 Correlation between Intra-thoracic impedance
monitoring and standard clinical assessment in
detecting acute decompensation in patients with
chronic heart failure
G. Zanotto1 ,R.Ometto2 , C. Bonanno2 , M. Maines3 , G. Vergara3 ,
G. Lonardi4 , W. Rauhe5 , C. Perrone6 , T. De Santo7 , C. Vassanelli 1 .
1 2 Borgo Trento Hospital, Cardiologia, Verona, Italy; S. Bortolo, Cardiologia,
Vicenza, Italy; 3S. Maria del Carmine, Cardiologia, Rovereto, Italy; 4Mater Salutis, Cardiologia, Legnago, Italy; 5S. Maurizio, Cardiologia, Bolzano, Italy;
6 7 ULSS 5, Cardiologia, Arzignano, Italy; Medtronic Italia, Cardiologia, Roma,
Italy
Purpose: During ambulatory follow-up an increase of NT-proBNP plasma levels
and abnormalities in diastolic filling pattern at echo Doppler are commonly considered
clinical markers of acute decompensation in chronic heart failure (CHF)
pts. Recent ICDs are able to daily monitor intra-thoracic impedance and to alert
patients (pts) when its value acutely decreases, potentially indicating heart failure
deterioration. We evaluated the correlation between these standard clinical
markers and intra-thoracic impedance.
Methods: 6 Italian centers collected device and clinical data of 111 CHF pts
(85% male, aged 68±10 years, LVEF=26±5%) implanted with a biventricular ICD,
equipped with impedance monitoring and alert system. During regular follow-ups
and in case of CHF decompensation or device alerts, intra-thoracic impedance,
NT-proBNP plasma levels, echo Doppler trans-mitral flow indices and clinical status
-quantified through an Heart Failure Score (HFS)- were reported. A linear
mixed model for repeated measurements was used to assess the relationship
among all parameters.
Results: Over a mean follow-up of 12.4±3.6 months, 955 visits were performed,
186 because of device alert. Clinical evidence of CHF deterioration were found
by a clinician, blinded to impedance data, in 131 cases and an increment in diuretic
dosage followed (true positive). After the alert visit, only 11 hospitalizations
were reported. Follow-ups without alert and with absence of clinical deterioration
(true negative) were 727, so the negative predictive value was about
94%. The rate of unexplained alert was 0.47 per patient/year. Intra-thoracic
impedance was significantly correlated with standard assessment: NT-proBNP
(p

382 Telemonitoring in heart failure / Heart failure with preserved systolic function: mechanisms and outcomes
Conclusions: The chest x-ray was used in this study to verify the ability of surface
thoracic impedance monitoring to predict AHF at the preclinical stage. It
confirmed that the new method of LI measurement is of sufficient sensitivity to
detect evolving AHF in its pre-clinical stage in patients with AMI. There seems to
be ample time at this stage to initiate therapy in an attempt to prevent AHF.
HEART FAILURE WITH PRESERVED SYSTOLIC
FUNCTION: MECHANISMS AND OUTCOMES
2345 Diastolic versus systolic left ventricular dysfunction as
independent predictors for unfavourable postoperative
evolution in patients undergoing coronary artery
bypass grafting
L. Iliuta, H. Moldovan, D. Filipescu, B. Radulescu, C. Macarie. Institute
of cardiovasc.diseases C.C.Iliescu, Cardiac Surgery I, Bucharest, Romania
Purpose: 1. Assessement of the immediate prognostic implications of the type of
the LV diastolic filling pattern (LVDFP) compared with LV systolic performance in
patients undergoing CABG 2. Defining the echographic parameters which can be
independent predictors for immediate and long term prognosis in these patients
and their value for calculation of a preoperative risk score.
Material: Prospective study on 512 patients undergoing CABG, divided in 4 subgroups:
Group A – 328pts with normal LV systolic function with 2 subgroups (A1:
219pts with nonrestrictive LVDFP and A2: 109pts with restrictive LVDFP); Group
B – 184pts with LV systolic dysfunction (LVEF

Heart failure with preserved systolic function / Electrical and morphological cardiac adaptation in athletes 383
had delayed relaxation, 11 (7%) were pseudonormal and 1 (0.6%) was restrictive.
At 1 year, 50% were unchanged, 26% had progressed and 24% improved; see
Table for correlates of deterioration. Change in Em was independently correlated
with age (p

384 Electrical and morphological cardiac adaptation in athletes
ercise ECG was able to reveal cardiac anomalies in 1,227 athletes that reported
a normal pattern at resting ECG. At the end of the pre-participation screening,
a total of 196 (0.6%) athletes were considered to be ineligible for competitive
sports. Among the 159 athletes disqualified at the end of the screening for cardiac
causes, a large proportion (n=126, 79.2%) reported significant abnormalities
only at the exercise testing. A logistic regression analysis showed that age > 30
years was the major significant predictor of disqualification for cardiac cause at
the exercise testing.
Conclusions: Pre-participation screening program including resting and exercise
ECGs seems to represent an effective preventive measure for identifying high-risk
young and middle-aged athletes.
2369 Abnormal electrocardiographic patterns in elite
athletes: the Greek experience
A. Anastasakis, A. Vouliotis, E. Sevdalis, C. Kotsiopoulou, K. Ritsatos,
N. Protonotarios, C. Stefanadis. Hippokration Hospital, A’ Dpt of
Cardiology, A Dpt of Cardiology, University of Athens, Athens, Greece
Objectives: There is a wide clinical perception that routine implementation of 12
lead electrocardiogram (ECG) will convey a large proportion (40%) of abnormal
findings requiring additional testing to resolve the ambiquity of cardiovascular diagnosis
and raising substantially the cost of screening. In this study, we tried to
evaluate ECG abnormalities in a population of elite athletes.
Methods: We studied the prevalence of ECG abnormalities in 460 highly trained
athletes (275 males) from a broad variety of sports activities, aged 12-38 (mean
age 22,2 years), all of them members of the Greek Olympic Team. All ECG patterns
were evaluated according to European Society of Cardiology adopted criteria.
Results: The most frequent abnormalities were sinus bradycardia (29,13%),
left ventricular hypertrophy (28,40%) and early repolarization pattern (24,13%).
These ECG abnormalities plus incomplete RBBB (3,92%), sinus arrhythmia
(4,14%) and first degree AV block (0,44%), are regarded as part of the spectrum
of benign changes of athlete’s heart. In 57 athletes, ECG patterns were
considered suspect for cardiovascular disease. Distinct ECG abnormalities included
QTc interval > 460ms (1,09%), pre-excitation pattern (1,09%), left axis
deviation/left anterior hemiblock (1,09%), right axis deviation/left posterior hemiblock
(1,52%), right atrial enlargement (0,22%), left atrial enlargement (1,74%)
and supraventricular ectopic beats (0,22%). In addition, we identified ST-segment
and T-wave repolarization abnormalities in 32 athletes (6,96%) and ventricular
ectopic beats (0,65%). T-wave inversion in right precordial leads (V1 – V3) was
present in 5 athletes (1,09%), while 6 more athletes showed T-wave inversion only
in leads V1-V2 (1,30%). Sixteen ECGs (3,48%) accomplished voltage criteria for
LVH and showed repolarization abnormalities as well. With regard to type of sport
discipline, long distance running, football and weight lifting had the largest proportion
of distinctly abnormal ECG patterns, while all individuals engaged in rowing,
sailing and wrestling had normal ECGs. The prevalence of distinctly abnormal
ECGs was almost the same in males and females (12,36% vs 12,43%).
Conclusion: The results show that abnormal ECG patterns, suggestive for further
evaluation, were found in a minority of elite athletes (57 athletes, 12,39%
of the overall study population). ECG changes, suspicious for underlying cardiac
disease, such as inverted T waves in right precordial leads (2,39%), LVH with
repolarization abnormalities (3,48%) or QTc interval > 460ms (1,09%) do not
exceed 7% of the overall study population.
2370 Supraventricular tachycardias in elite athletes:
diagnosis, treatment and long term outcome
C. Berndt, A. Dorszewski, U. Wetzel, J. Vogt, K.P. Mellwig,
D. Horstkotte. Heart Center of Northrhine Westphalia, Cardiology, Bad
Oeynhausen, Germany
Introduction: Diagnosis and treatment of tachyarrhythmias of unknown origin in
elite athletes are very important for prognosis, their physical activity and further
professionel carrier. In our study we characterize symptomatic supraventricular
tachyarrhythmias of top ahtletes, their treatment, outcome and long term follow
up.
Methods: Out of 292 elite athletes (age: range: 17.9±38.9, mean: 25.3±4.42
yrs.) 11 athletes, 9 male and 2 female, age: 25.7±12.9 years, presented with a
history of recurrent highly symptomatic tachyarrhythmias occuring during or after
maximum physical exercise. In all patients (pts.) but one tachycardias led to
termination of active participation and consecutively exchange during the competition.
All pts. underwent electrophysiological study according to a standardized
protocol.
Results: Structural heart disease was ruled out via non invasive testings in all pts.
The electrophysiological study revealed slow-fast AV-nodal reentrant tachycardia
in 10 pts., cycle length of 277.8±26.4 ms. After modulation of the slow pathway
of the AV-node via radiofrequency catheter ablation in typical location there
were no AV-nodal reentrant tachycardias inducible, even not during medical testing
with orciprenaline, mean procedure time 53.7±19.4 min., mean fluoroscopy
time 5.1±2.3 min. 3–4 days after curative radiofrequency catheter ablation the
pts. could start full physical training again. One patient had a WPW-syndrome and
underwent successful ablation of a left posterior accessory pathway. The overall
procedure time for the accessory pathway was 83 min., fluoroscopy duration 19.2
min. In this case the full physical training was started 8 days after ablation due
to the arterial access. During a mean follow up of 9.8±6.5 months all pts. were
free of symptoms. No mild or severe complications occurred. The follow up was
without any rhythm disturbances or complications. All top athletes could continue
their professional carrier.
Conclusion: In elite athletes supraventricular tachycardias occur which are limiting
for their physical activity and may be devestating for their further professionel
sportive carrier. Electrophysiologic study is necessary for classification, diagnosis
and curative therapy of the tachycardias. The slow pathway modulation is a safe
and effective treatment for AV nodal reentrant tachycardia and as well the ablation
of accessory pathways. All top athletes were able to start full physical training 4,
respectively 8 days after the ablation procedure, and continued their carrier with
just minor interruption due to short hospitalization.
2371 Myocardial function and biomarkers in elderly male
amateur marathon runners
F. Knebel1 ,I.Schimke2 , S. Schroeckh2 ,S.Schattke2 , S. Eddicks 2 ,
A. Grohmann2 ,S.Grubitz2 ,J.Schmidt2 , G. Baumann2 , A.C. Borges2 .
1 2 Berlin, Germany; Charite, Berlin, Germany
Background: There is an increasing number of elderly participants in marathons.
Age-related changes in myocardial function after prolonged exercise in the elderly,
who carry an increased cardiovascular risk, have not yet been studied. There is
evidence of myocardial dysfunction after running a marathon in younger runners
and controversy about the extent of myocardial damage. The focus of this study
is to examine Tissue Doppler Echocardiography and myocardial biomarkers before,
immediately after and two weeks after a marathon in elderly male amateur
runners.
Methods and Results: 78 runners of the 2006 Berlin Marathon were included
(28 elderly> 60 years, range 60-72, mean 63±3 years and 50 younger controls;
range 22-59, mean: 53±14 years. They were examined before, immediately and
two weeks after the race by echocardiography including Tissue Doppler Imaging
(TDI) and blood tests. 42 (53.8%) of all runners had increases in TnT and/or
NT-proBNP after the race. There was no correlation of NT-proBNP and TnT increase
(p=0.16). The increases in biomarkers were not correlated to age, training
level, running time or renal function. Immediately after the marathon, there was
an age-independent increase in fractional shortening (39.9±7.6 vs. 46.8±9.2,
p

the most dilated, LA mostly influences PR duration, whereas in strength-trained
athletes, only RR duration acts on PR duration. Some specificities are shown
when sports are classified according to Mitchell’s classification: the highest the
dynamic (volume overload) component is, the highest the LVEDD, IVSWT, and
V’O2max are; the more the static (pressure overload) component is, the highest
LA and V’O2max are (Chi2>1.96; p

386 How about a healthy lifestyle? / Stable angina: risk markers and potential treatments
creased to 10. Only VO2 max remained statistically significantly higher compared
to baseline values (+5.6%, p

Conclusion: In patients with stable angina pectoris despite standard doses of
beta-blockers, the addition of ivabradine further improves exercise capacity. The
combination of ivabradine and beta-blockers is well tolerated.
2381 How good is angiography in selecting stenoses to be
revascularised?
M. Hamilos1 , P. Tonino2 , N. Piljs2 , H. Samady3 , W.F. Fearon4 ,
V. Klauss5 , E. Barbato1 , J. Bartunek1 , W. Wijns1 ,B.DeBruyne1 .
1 2 3 Aalst, Belgium; Einthoven, Netherlands; Atlanta, United States of
America; 4Stanford, United States of America; 5Munich, Germany
Purpose: Angiography is notoriously inappropriate to gauge stenosis severity.
Nevertheless, the vast majority of decisions about the need for revascularisation
are based on visual estimation of coronary angiography. The goal of the
present analysis is to compare quantitative coronary angiography to pressurederived
fractional flow reserve (FFR) in a large patient’s population.
Methods: In 2413 lesions (2225 patients) that were all considered for percutaneous
coronary intervention (PCI), FFR was obtained and off-line QCA was performed.
Patients were part of 2 large randomized studies (FAME and DEFER)
and 2 large registries (‘FFR post stent registry and ‘Aalst FFR registry’).
Results: A significant relationship was found between FFR and both diameter
stenosis (r =-0.54, p

388 Stable angina: risk markers and potential treatments / Diabetes and myocardial infarction: not all sugar
Methods: 4298 patients with a diagnosis of myocardial infarction (MI) or angina
pectoris (AP) were included in the CLARICOR trial and randomized to clarithromycin
500 mg/day versus placebo for two weeks. Patients were categorized
according to serum YKL-40 at entry: Group I under 50% percentile:

2388 Magnitude of glycaemia variation: a new risk tool in
acute coronary syndromes?
S. Monteiro, N. Antonio, R. Teixeira, C. Lourenco, R. Batista, E. Jorge,
P. Monteiro, L. Goncalves, M. Freitas, L. Providencia. Coimbra,
Portugal
Introduction: Hyperglycaemia in acute coronary syndrome (ACS) patients is associated
with an increased risk of death and in-hospital complications. However,
little is known about the prognostic value of the magnitude of glycaemia variations
(MGV) during an ACS.
Aim: To evaluate the relationship between the MGV during hospitalization and
in-hospital and long-term prognosis.
Population and methods: 1210 consecutive patients admitted to a coronary
care unit for ACS, between May 2004 and July 2007. Our population was divided
in diabetics (n=386) and non-diabetics (n=824). Each of these subpopulations
was divided according to MGV: Q1 7.8 mmol/l, 2% had a FG > 7 mmol/l and a PPG < 7.8
mmol/l, and finally 5% had a FG >7 mmol/l and a PPG > 7.8 mmol/l.
Third day FG and PPG were significantly correlated with 6-months death combined
to in-hospital heart failure (c statistic: 0.64±0.05, p = 0.003 and 0.65±0.05,
p = 0.002, respectively). After adjustment for the GRACE (Global Registry of
Acute Coronary Events) risk score and the echocardiographic left ventricular fractional
ejection, both PPG and FG, separately, at day 3, remained strong predictors
of outcomes (OR [95%IC]; 1.70 [1.14-2.54], p = 0.010 and 1.27 [1.07-1.51], p =
0.005, respectively).
Conclusion: Our results show that third day FG or PPG are independent predictors
of outcomes in non-diabetic patients. As regards of the recent data of
DIGAMI II, further studies are needed, in around 50% of patients, after acute
coronary syndrome, to optimize glycemic control in these specific groups.
Diabetes and myocardial infarction: not all sugar / Challenges in valvular heart disease 389
2390 Insulin treatment in patients with type 2 diabetes
mellitus affects the expression of inflammatory
cytokines and subsequently modifies thrombotic
mechanisms in patients with coronary atherosclerosis
C. Antoniades, D. Tousoulis, K. Marinou, K. Toutouzas, S. Brili,
N. Papageorgiou, C. Tsioufis, G. Siasos, G. Latsios, C. Stefanadis. Hippokration
Hospital, Athens, Greece
Introduction: Type 2 diabetes mellitus (T2DM) is characterised by endothelial
dysfunction, increased thrombogenicity and abnormal inflammatory response.
Aim: We examined the impact of insulin dependence/exogenous insulin administration
on thrombotic/inflammatory status and endothelial function in patients with
T2DM and coronary artery disease (CAD).
Methods: Fifty-five patients with T2DM+CAD (26 insulin-treated (INS) and 29
under oral biguanide+sulphonylurea (TABL)) were recruited. Endothelial function
was assessed by gauge-strain plethysmography. Levels of interleukin-6 (IL-6), tumor
necrosis factor-α (TNF-α), soluble vascular cell adhesion molecule (sVCAM-
1), monocytes chemoattractant protein 1 (MCP-1), von Willebrand factor (vWF),
tissue plasminogen activator (t-PA), and plasminogen activator inhibitor-1 (PAI-
1), protein C (PrtC) and protein 2 (prtS) were determined by enzyme linked immunosorbent
assay.
Results: There were no significant differences in endothelium-dependent dilation
(EDD) between the study groups (61.1±4.8% vs 66.2±6.0% respectively,
p=NS), while EDD was correlated with fasting glucose levels in both INS (r=-
0.776, p=0.0001) and TABL (r=-0.702, p=0.0001). However, patients in INS group
had significantly higher levels of IL-6, TNF-a and sVCAM-1 (6.9±0.57 pg/ml,
3.87±0.43pg/ml and 596±43.4ng/ml respectively) compared to patients in TABL
(4.67±0.5 pg/ml, 2.76±0.28pg/ml and 475±26 ng/ml respectively, p

390 Challenges in valvular heart disease
2429 Left ventricular contractile function and aortic valve
stenosis. Is exercise Doppler echocardiography a
relevant tool for asymptomatic patients?
E. Donal, A. Bellouin, R. Gervais, C. De Place, F. Carre, P.H. Mabo,
J.C. Daubert. Rennes, France
Aim: Patients with asymptomatic severe aortic stenosis (AS) and abnormal
hemodynamic responses to exercise testing are at increased risk of cardiac
events. This study assesses left ventricular myocardial function by rest and exercise
Doppler echocardiography in a cohort of asymptomatic patients with AS.
Methods and results: 66 patients (68 years old) with asymptomatic AS underwent
quantitative Doppler echocardiographic measurements at rest and exercise
(standardized bycicle exercise stress test). Of these patients, 39 had an abnormal
response to exercise (positive exercise stress test according to guidelines). Theses
patients had a significantly worse ‘exercise global longitudinal strain’ (-14±4
versus -17±4%, p 20 ml. In the
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patients with RV > 30 ml this correlation was stronger (r=0.97, p=0.005) and additionally
there was a correlation between the RV and posterior mitral leaflet angle
(r=0.90, p =0.037), between tenting area and posterior mitral leaflet angle (r=0.90,
p=0.04), between tenting area and anterior mitral leaflet angle (r=0.82, p=0.08).
Conclusions: Anterior and posterior mitral leaflet angle value may be helpful in
the evaluation of the severity of IMR and mitral apparatus deformation.
2433 Real-time 3 dimensional echocardiography is useful in
the assessment of tricuspid valve dimensions in
patients with right heart dilatation
S. Khan, R. Duehmke, J. Boyd, K. Parker, R.A. Rusk. Papworth
Hospital, Cardiology, Cambridge, United Kingdom
Background: Real-time 3 dimensional echocardiography (RT3DE) is useful in
the assessment of tricuspid annular dimension in normal hearts but little is known
about its role in patients with right heart dilatation.
Methods: 10 consecutive patients (mean age 62 years, 7 males) with right heart
dilatation secondary to mitral valve disease or pulmonary hypertension underwent
2D and 3D transthoracic echocardiographic assessment with an IE33 ultrasound
machine (Philips Ultrasound, Bothell, USA). All datasets were acquired from an
apical window. Tricuspid annulus dimensions were measured off-line by two independent
observers, blinded to the clinical details. Major and minor axes were
obtained from 3D datasets and a single major axis from the 2D dataset.
Results: Measurements could be made in all patients. There was good agreement
between the average of major and minor axes obtained by RT3DE and
the major 2D measurement (3D dimensions 43.5 (5.5)mm vs 42 (5.1)mm by 2D,
r=0.8). However, the maximum diameter measured by RT3DE was greater than
that measured by 2D with a mean difference of 4.8 (5.4)mm, p

392 Newer prognostic approaches in heart failure
Methods: A cohort of 992 consecutive ambulatory CHF patients was prospectively
followed for a median of 44 months, and multivariate Cox models were
developed to predict cardiac mortality (primary end-point, n=213), as well as allcause
mortality (n=267), pump-failure death (n=123) and sudden death (n=90).
Results: The four final models included several combinations of the same 10
independent predictors: Prior atherosclerotic vascular event, indexed left atrial
size >26 mm/m 2 , ejection fraction ≤35%, atrial fibrillation, left bundle branch
block or intraventricular conduction delay, non-sustained ventricular tachycardia
and frequent ventricular premature beats, estimated glomerular filtration
rate 1000ng/L and
Troponin-positive. Model performance was excellent, with a correlation between
predicted and actual survival by deciles of 0.99, and a ROC area under the curve
of 0.80 (95% CI, 0.77-0.83) for both total and cardiac mortality models, 0.79 (0.76-
0.83) for pump-failure death model, and 0.75 (0.70-0.89) for sudden death model.
Risk scores for each type of mortality
All-cause Cardiac Pump Failure Sudden Death
Prior AVE 3 3 8
Indexed LA size>26 mm/m2 8 9 9 11
Ejection fraction≤35% 5 5 5
Atrial Fibrillation 3
LBBB or IVCD 7
NSVT & frequent VPBs 3 4 7
eGFR1.000 ng/L 7 7 10 7
Troponin-Positive
High Risk patient if score > 20.
4 5 7
Conclusions: It is possible to predict mortality in CHF patients, using a simple
score including a limited number of predictors, so that it could be easily used in
clinical practice. None of these predictors require invasive or expensive procedures
to be determined, and all of them are objective variables. Use of this model
identifies a small subgroup of high-risk patients that should be managed closely
by specialized heart failure units.
2489 Clinical determinants and prognostic importance of
glycosylated haemoglobin (Hgb A1c) in chronic heart
failure
P. Rozentryt 1 ,J.Nowak1 ,M.Greif1 , S. Von Haehling2 ,L.Polonski1 ,
S.D. Anker 2 . 1Silesian Centre for Heart Diseases, Iii Department of
Cardiology, Zabrze, Poland; 2Campus Charite, Applied Cachexia Research,
Berlin, Germany
Purpose: Abnormalities in glucose metabolism are frequent in chronic heart failure
(CHF). The prognostic importance of glycosylated haemoglobin (Hb A1c) is
well known in diabetes. In CHF glucose-related protein damage may be dependent
on factors linked to heart failure itself, i.e. inflammation or oxydative stress.
We examined important clinical and laboratory as well as body composition measures
and their relationship to Hb A1c. We assessed prognosticators by Cox proportional
hazard analysis.
Material & Methods: Using the turbidimetric method we measured Hb A1c level
in 369 patients with CHF (308 male; 61 female; age 54±13 years; NYHA: I/II/III/IV
40, 136, 146, 43; ischaemic: 66%; diabetes 23%). All patients underwent routine
laboratory and functional assessment combined with body composition analysis
by DEXA. Patients were optimally treated with beta-blockers, ACE-I/ARB, diuretics
and spironolactone, if appropriate. All patients were followed for a median of
589 days. During follow-up, 42 (11%) of patients died.
Results: In this population, the median Hb A1c was 6.2% (range 4.7 to 12.9%).
There was stepwise increase of Hb A1c according to NYHA class (I: 6.3±1.0%, II:
6.3±1.0%, III: 6.6±1.1%, IV: 6.8±1.7%, ANOVA p

BIOMARKERS: NEW KIDS ON THE BLOCK
2492 Matrix-metalloproteinase-2 predicts mortality and heart
failure following myocardial infarction
K. Ng, O. Dhillon, D. Kelly, S.Q. Khan, P.A. Quinn, I.B. Squire,
J.E.Davies,L.L.Ng.University of Leicester, Cardiovascular Sciences,
Leicester, United Kingdom
Objectives: Matrix metalloproteinases (MMPs) are implicated in adverse ventricular
remodelling after acute myocardial infarction (AMI) but whether they independently
complement NTproBNP in determining prognosis is not established.
We compared MMP-2,-3 and -9 to N-terminal pro-B type natriuretic peptide (NTproBNP),
a marker of death and heart failure post acute myocardial infarction
(AMI).
Methods: We studied 1046 patients with AMI (45.7% STEMI, 71.3% male, median
age 67 years). MMP-2, 3 and 9 was measured on discharge plasma samples.
NTproBNP and MMP levels were determined using non-competitive immunoassays.
Patients were followed-up for the combined endpoint of death or
heart failure (median 478, range 1-1059 days).
Results: MMP-3 was higher in males; MMP-2 and MMP-9 had no gender differences.
MMP-3 correlated better with eGFR (r=-0.212, P

394 Biomarkers: new kids on the block / Stroke and the heart
2496 Presence of microalbuminuria in patients with acute
coronary syndrome identifies a high risk group for
new-onset heart failure
J.M. Garcia Acuna, E. Gonzalez Babarro, M. Gutierrez Feijoo,
A. Lopez Lago, L. Grigorian Samahian, J. Fernandez Villanueva,
M. Alvarez Barredo, E. Abu Assi, J.R. Gonzalez Juanatey. University Clinic
Hospital, Cardiology, Santiago, Spain
Microalbuminuria (MA) is a powerful predictor of cardiovascular disease. In several
studies was observed a particular relationship between MA and heart failure
(HF) but this association was not described in patients with Acute Coronary Syndrome
(ACS).
Patients and Methods: MA presence (defined as albumin excretion 30-300
mg/24 hours) was studied in 24 hours urine test of 478 consecutively hospitalized
patients with SCA. At hospital admission were obtained blood samples to determined
leukocyte count, hemoglobin and hematocrit levels and serum troponin-I,
total cholesterol, HDL-cholesterol, LDL-cholesterol, fibrinogen, high sensitive C
reactive protein (US-CRP), gGlucose and glycosilated hemoglobin (HbA1) levels.
Left ventricular function was determined in all cases by echocardiography and a
coronariography study performed in 95% of patients. We planned a prospective
follow-up of cohort with a maximum of 4 years.
Results: 191 patients showed MA (40%). This subgroup of patients was older
(p=0.001), higher prevalence of hypertension (p=0.001), diabetes (p=0.0001),
prior stroke cases (p=0.04), Peripheral Arteriophaty (p=0.0001) and cchronic
renal failure (p=0.0001). In the MA group 37% presented Killip >I stage
(p=0.0001), worse ejection fraction (51% versus 46%, p=0.001), worse renal function
(p=0.001) and higher glucose blood levels (p=0.0001). During hospital stay
the patients with MA presented higher mortality rate (9% versus 4%; p=0.004),
more cases of HF (46% versus 19%; p=0.0001), atrial fibrillation (25% versus
12%; p=0.004) and stroke (4% versus 1%, p=0.02). During the 4 years of followup,
mortality rate was 19% (p=0.0001). In the multivariate analysis MA was identified
as an independent risk factor of HF (OR: 1.99; IC 95% 1.19-3.33; p=0.009).
Conclusions: MA identifies a subgroup of patients with ACS with a short a longterm
very high cardiovascular risk with a strong relationship with new-onset HF.
2497 Growth differentiation factor-15 (GDF-15) predicts
mortality and morbidity after cardiac resynchronisation
therapy
P.W.X. Foley 1 , S. Chalil1 ,K.Ng2 ,N.Irwin3 , S. Ramachandra3 ,
A. Proudler3 , H. El-Gendi1 , M.P. Frenneaux4 ,L.Ng2 ,F.Leyva1 .
1University of Birmingham, Good Hope Hospital, Cardiology, Heart of England
NHS Trust, Sutton Coldfield, United Kingdom; 2University of Leicester, Leicester,
United Kingdom; 3Good Hope Hospital, Sutton Coldfield, United Kingdom;
4University of Birmingham, Cardiovascular Medicine, Birmingham, United
Kingdom
Background: Growth differentiation factor-15 (GDF-15), a transforming growth
factor-β-related cytokine which is upregulated in cardiomyocytes via multiple
stress pathways, predicts mortality in patients with heart failure. We explored
whether GDF-15 predicts mortality and morbidity in patients with moderate-tosevere
heart failure (HF) undergoing cardiac resynchronisation therapy (CRT).
Methods and results: GDF-15 was measured (immunoluminometric assay)
before and days after implantation in 122 patients with HF and sinus rhythm
(age 68±11 yrs [mean ± SD], LVEF 25.1±11.0%, NYHA class III or IV, QRS
153.7±29.2 ms) undergoing CRT and followed up for a maximum of 5 years for
events. In Kaplan-Meier survival analyses, a GDF-15 ≥2720 ng/L predicted the
composite endpoints of death or unplanned hospitalization for major cardiovascular
events (MCE) and cardiovascular death or unplanned hospitalization for HF
(both p

the importance of calling the emergency medical services (EMS), as well as a
bookmark and a sticker with the EMS telephone number. We fitted a lognormal
survival regression model with frailty terms shared by inhabitants of the same zip
code area.
Results: A total of 75,720 inhabitants received the intervention. Between 2004
and 2005, 741 patients were admitted with stroke from the control areas (n=24)
and 647 from the intervention areas (n=24). A prehospital time ≤ 2(≤ 3) hours
was achieved by 22% (28%) of patients in the control group compared to 26%
(34%) in the intervention group. In the lognormal model, time to hospital was
significantly reduced in the intervention group in women (acceleration factor 0.75;
95% 0.58; 0.96) while we found no effect in men.
Conclusions: The population-based intervention was effective in reducing prehospital
delays in women but not in men. Future research needs to focus on the
transferability of the intervention to other settings and its sustainability as well as
on gender-specific interventions.
2500 Perioperative stroke in non-cardiac surgery; the impact
of prophylactic beta-blocker therapy
S.E. Hoeks1 , O. Schouten1 , M. Dunkelgrun1 , F. Van Lier1 ,
A.E. Durazzo2 , A.N. Neskovich3 , J.B. Froehlich 4 ,J.J.Bax5 ,
E. Boersma1 , D. Poldermans1 . 1Erasmus MC, Rotterdam,
Netherlands; 2Sao Paulo, Brazil; 3Belgrade, Serbia; 4Michigan, United States of
America; 5Leiden University Medical Center, Leiden, Netherlands
Background: Beta-blockers are widely used to improve postoperative cardiac
outcome in patients with coronary artery disease scheduled for non-cardiac
surgery. The recently published POISE (PeriOperative ISchemic Evaluation) trial
using metoprolol controlled release (CR) therapy confirmed their beneficial effects
for myocardial infarction and cardiovascular death. However, metoprolol CR
was associated with an increased overall mortality rate. This was particularly due
to ischemic strokes 41/4174; 1.0% vs 19/4177; 0.5% (odds ratio (OR) 2.2, 95%
CI 1.3-3.7) that might be related to over treatment of beta blockers, resulting in
perioperative hypotension. In the POISE trial metoprolol CR, up to 400 mg, was
administered in four doses starting 2 to 4 hours prior to surgery. This dose is
100% of the maximal recommended therapeutic daily dose (MRTD). In contrast,
in the DECREASE (Dutch Echo Cardiographic Risk Evaluation Applying Stress
Echo) trials the average dose of bisoprolol was 2.5 mg once daily; 12.5% of the
MRTD and started at least 30 days prior to surgery.
Aim: To assess the incidence and risk factors associated with perioperative stroke
in the DECREASE trials.
Methods: All 3889 patients of the DECREASE trials were evaluated for bisoprolol
dose as percentage of MRTD. The MRTD of bisoprolol at the start of the trial
and during surgery was 12.5% and 16.5% respectively. All cardiac risk factors
and medication use were noted. The incidence of stroke, diagnosed on clinical
symptoms and CT scan, within 30 days after surgery is reported.
Results: The incidence of perioperative stroke in the DECREASE trials was
18/3889 (0.46%) compared to 41/4174 (0.98%) in the POISE trial, p=0.006.
Among beta-blocker users, the incidence was 0.5% in the DECREASE trials and
1.0% in the POISE study. In the DECREASE trials all strokes had an ischemic
origin. A history of stroke was associated with perioperative stroke: OR 5.4, 95%
CI 1.9-15.2. Statins and anti-coagulants were not associated with perioperative
stroke; OR 0.9; 95% CI 0.3-2.5 and OR 1.1, 95% CI 0.3-3.9. Importantly, no association
with bisoprolol therapy was assessed, OR 1.5, 95% CI 0.5-4.3.
Conclusion: In the DECREASE trials using low dose bisoprolol regimen starting
at least 30 days prior to surgery, no association was observed between betablocker
use and perioperative stroke, in contrast to high-dose metoprolol CR therapy
in the POISE study.
2501 Cardiovascular risk profile, costs and incidence of
events in patients with stroke in a population attended
in primary care
J. Fernandez De Bobadilla1 ,A.Sicras2 ,R.Navarro2 , D. Ezpeleta3 ,
C. Alvarez 1 , C. Sanchez4 ,J.Soto1 . 1Pfizer, Outcomes Research,
Madrid, Spain; 2Badalona Servicios Asistenciales, Barcelona, Spain; 3Hospital General Universitario Gregorio Maran, Neurology, Madrid, Spain; 4Euroclin Institute, Outcomes Research, Madrid, Spain
Objective: To assess the prevalence of stroke, and the differences between patients
with and without previous stroke, in terms of mortality and cardiovascular
events in Spain.
Methods: Patients aged>30 years, attending to primary care centres in Spain
during 2006 were evaluated. Variables assessed: prevalence of stroke, cardiovascular
risk factors, morbidity budget, costs, family history of cardiovascular heart
disease, incidence of cardiovascular events and death. The population with and
without previous stroke was compared using student’s t test and chi square distribution.
Results: Of the 57,026 patients, 54.8% were female. Prevalence of hypertension
was 26.5%; diabetes 11.1%; dyslipidemia 27.6%, obesity 11.3%, smoking
20.1% and excessive alcohol consumption 2.1%. The prevalence of CVD different
to stroke was 1.4% for angina; 3.4% myocardial infarction and 2.5% peripheral
arteriopathy. Profiles of patients with vs without previous stroke: Age 72.5
(with stroke) and 53.5 (without stroke), females 41.8% vs 55.4%, morbidity bud-
Stroke and the heart 395
get: 3.2% vs 2.53%, number of CVRF 3.4 vs 1.2, angina 5.07 vs 1.22, previous
myocardial infarction 16.17 vs 2.76, annual mortality 4.2 vs 1.2, cardiovascular
events: 19.7 vs 1.8. Total costs were � 2,590 for patients with stroke and � 985.3
in patients without stroke.
Conclusions: The annual incidence of cardiovascular events or death in patients
with stroke in Spain is 20%. The average cost of a patient with antecedents of
stroke is 2590� , 60% more than patients without previous stroke. It would be
advisable to use all therapeutics resources supported by scientific evidence in
the secondary prevention of this population
2502 Percutaneous Left Atrial Appendage Transcatheter
Occlusion (PLAATO) for stroke prevention in atrial
fibrillation: 2-years outcome
J.-W. Park 1 ,U.Gerk1 , B. Leithauser2 , M. Vrsansky1 , F. Jung3 .
1Hoyerswerda Hospital, Cardiology/Angiology, Hoyerswerda,
Germany; 2Clinic For Angiology, Hannover, Germany; 3Berlin-Brdbg Center for
Regenerative Therapy, Charite, Campus Virchow-Klinikum, Berlin, Germany
Purpose: In > 90% of patients with atrial fibrillation (AF), stroke is due to thrombotic
embolisation from the left atrial appendage (LAA). Transcatheter occlusion
with PLAATO, a self-expanding, membrane-covered spherical nitinol cage, is feasible
and an alternative to anticoagulation therapy.
Methods: Single-centre prospective registry study for verification of stroke risk
reduction in patients with AF 2 years after PLAATO.
Results: 73 patients with AF (permanent 65, paroxysmal 8) in whom anticoagulation
therapy was contraindicated or rejected underwent transcatheter LAA occlusion
with PLAATO. LAA angiography revealed residual thrombi in 7 patients
(10%), which have not been detected with prior transesophageal echocardiography
(TEE). One patient died periprocedural due to implant embolization and one
patient underwent open heart surgery because of implant instability. The remaining
71 patients were followed for 24 months. In 52 patients a stable anchoring
of the PLAATO device without migration or dislocation could be documented by
TEE. No thrombotic deposition was found on the LA luminal surface of the device.
Statistically, in our patient cohort 7 strokes would have been expected without any
treatment within 24 months. In fact no stroke was reportet. Ten out of 71 patients
died during follow up, 6 in our hospital, 4 at home. None of them died from stroke.
Conclusions: 97% of AF patients could be successfully treated with PLAATO. After
mechanical LAA occlusion, the 2-years risk of stroke in AF patients is markedly
reduced. Therefore, this therapeutical concept is a clear alternative for patients
with AF and contraindications for oral anticoagulation.
2503 Predictors of ischaemic stroke during acute phase of
ST Elevation Myocardial Infarction (STEMI)
S. Pernencar on behalf of Portuguese Society of Cardiology Acute
Coronary Syndromes Investigators. Leiria, Portugal
Aim: Identify the independent predictors and other complications associated
with stroke during hospitalization for an acute Myocardial Infarction (MI).
Methods: Multicentric and retrospective analysis of a database with 17165 patients
(pts) admitted since 2002 for acute MI and had 6-month follow-up data. Pts
were then subdivided in two groups:
Group A – 17015 pts with acute MI and without stroke during the hospitalization
Group B – 150 pts with acute MI complicated with stroke
Results: Female gender was more prevalent in group B 44% vs 30% (p=0.001).
Pts in Group B had a higher risk profile, with increased prevalence of others CV
risk factors, such as Diabetes (33% vs 23%, p=0.002) and previous stroke (17%
vs 7%, p

396 Sudden death, devices and public awareness
SUDDEN DEATH, DEVICES AND PUBLIC AWARENESS
2526 Long-term mortality in MADIT II patients with
implantable cardioverter defibrillators
I. Cygankiewicz1 , W. Zareba1 , I. Goldenberg1 , J. Gillespi2 ,H.Klein1 ,
S. Mc Nitt 1 , M.L. Andrews 1 ,J.W.Hall1 ,A.J.Moss1on behalf of MADIT
II Investigators. 1University of Rochester Medical Center, Rochester
Ny, United States of America; 2University of Buffalo, Rochester Ny, United States
of America
Objectives: Data on long-term follow-up and factors influencing mortality among
ICD recipients are limited. Therefore, the aim of the study was to evaluate the
survival rate during long term follow up and the predictive value of various risk
markers in MADIT II patients.
Methods: Study involved patients from MADIT II trial randomized to ICD treatment.
Data regarding long-term mortality was retrieved from the National Death
Registry. Several clinical, biochemical and ECG variables were tested in multivariate
Cox model for predicting long term mortality.
Results: Studied population consisted of 655 patients (547M) mean age 64±10
yrs. During a mean of 63 months 294 deaths occurred. According to Kaplan Meier
curves 6-year probability of death was 40%. Compared with surviving patients
those who died were significantly older, had lower LVEF, more frequently presented
diabetes, renal dysfunction, higher NYHA class and non-sinus rhythm.
Multivariate analysis identified age>65 yrs (HR=1.48,p=0.002), NYHA class 3-4
(HR=1.78,p

Sudden death, devices and public awareness / Bone marrow progenitors: filling the bench to bedside gap 397
Results: In all, 863 cases of OHCA were included during the intervention. Another
657 OHCA fulfilled the inclusion criteria and were used as historical controls
during 2004. Baseline characteristics and demographic data did not differ
between the two groups. Among dual dispatches, fire department arrived first
on scene and initiated treatment in 36% of cases. EMS arrived before the fire
department in 50% and simultaneously in 14%. The median time from call to arrival
of first responder decreased from 7.5 to 7.1 minutes during the intervention
(p=0.004). The proportion of patients in shockable rhythm did not change after the
introduction of the program. The proportion of patients alive 1 month after OHCA
rose from 4.4% during the historical control to 6.8% (unadjusted OR: 1.6; 95% C.I:
1.0-2.5) after the introduction of the project (adjusted OR: 1.6; 95% C.I: 0.9-2.9).
The difference in 1-month survival was particularly marked among patients with
witnessed cardiac arrests with a rise from 5.7% to 9.7% (adjusted OR: 2.0; 95%
C.I: 1.1-3.7). Survival after OHCA in the rest of Sweden (Stockholm excluded)
changed from 8.3% to 6.6% during the corresponding time period (p=0.052). In
all, only three OHCA occurred at public venues equipped with AEDs; none of
these patients survived to hospital.
Conclusion: An introduction of a fire department led early defibrillation program
in Stockholm has led to shortened response times and to improved survival for patients
with witnessed OHCA. The increase in survival is mainly believed to be associated
with shortened time intervals (to arrival and defibrillation) and improved
CPR (due to more persons treating the patient with ongoing cardiac arrest).
2530 Gender differences in clinical manifestations of
Brugada syndrome
B. Benito1 ,A.Sarkozy2 , L. Mont1 , S. Henkens2 , P. Berne1 ,
A. Berruezo1 , D. Tamborero1 , R. Brugada3 , P. Brugada2 , J. Brugada1 .
1Hospital Clinic of Barcelona, Cardiology, The Thorax Institute,
Barcelona, Spain; 2UZ Brussel, VUB Brussels, Heart Rhythm Management
Centre, Brussels, Belgium; 3Montreal Heart Institute, Cardiovascular Genetics
Center, Montreal, Canada
Background: Brugada syndrome is an autosomal dominant disease with a male
predominance. No specific data are available, however, concerning gender differences
on the clinical manifestations, phenotype and their role in prognosis.
Methods: Patients were recruited and followed prospectively. A spontaneous
or induced (after sodim-blocker administration) coved-type ECG pattern (type-
1) was required in all patients. Baseline clinical characteristics, ECG parameters
after sodium blockers and events (sudden death [SD] or documented ventricular
fibrillation [VF]) in follow-up were recorded for all patients.
Results: Among 384 patients, 272 (70.8%) were male and 112 (29.2%) female.
At inclusion, males had suffered previously more frequently of syncope (18%) or
aborted SD (6%) than females (14% and 1% respectively, p=0.04). Males also
had higher rates of spontaneous type-1 ECG (47% vs 23%, p=0.0001) and inducibility
of VF during electrophysiological study (32% vs 12%, p=0.0001). The
amount of spontaneous ST-segment elevation was also higher in males (3.5±1.8
mm vs 2.5±0.7 mm, p=0.0001). However, conduction parameters and corrected
QT interval significantly increased more in females in response to sodium blockers.
During a mean follow-up of 58±48 months, SD or documented VF occurred
in 31 males (11.6%) and 3 females (2.8%) (p=0.003) (figure).
Conclusions: Males with Brugada syndrome present with a higher risk clinical
profile than females: at diagnosis, they have had more symptoms, including
aborted SD, have more abnormalities on the spontaneous ECG and have more
frequently inducible VF. Males have a worse prognosis as evidenced by a higher
rate of SD or aborted SD during follow-up.
2531 Comparison between percutaneous extraction of
implantable cardioverter defibrillator leads and
pacemaker leads
D. Klug 1 , C. Marquie2 , F. Brigadeau2 , L. Guedon2 , C. Kouakam2 ,
D. Lacroix 2 ,S.Kacet2 . 1Hopital Cardiologique, CHRU Lille, Service de
Cardiologie A, Lille Cedex 9, France; 2Lille, France
The indications for implantable cardioverter defibrillator (ICD) are increasing. For
some complication the ICDs’ leads have to be extracted. We have compared
our experience in percutaneous extraction of pacemaker (PM) leads and ICD
leads.
Population: Between January 1998 and September 2007 1081 leads in 611 patients
with 81 ICD leads in 81 patients (13%) have been percutaneously extracted.
In 2006 and 2007, ICD leads represent 24% of our extraction procedures.
Results: Leads characteristics and results of extraction are summarized in table
1. ICD leads were single-coils leads in 58%. Failure of ICD leads extraction occurred
in 2 relative young leads (11 and 56 months) and 1 old leads (13 years)
in comparison age of PM leads with failure was 105±53 months. Coils were responsible
of the failure in the 3 cases including a distal coils clung on the tricuspid
valve in a young boy. Laser sheath and femoral extraction were required in 45 and
14% of ICD leads extractions.
PM ICD p
Age of leads 75±62 M 31±37 M

398 Bone marrow progenitors: filling the bench to bedside gap
Methods and Results: Adherent platelets express substantial amounts of SDF-1
and recruit CD34+ cells in vitro and in vivo. A monoclonal antibody to SDF-1 or
to its counter receptor CXCR4 inhibits stem cell adhesion on adherent platelets
under high arterial shear in vitro and after carotid ligation in mice, as determined
by intravital fluorescence microscopy. Platelets adherent on human arterial
endothelial cells enhance the adhesion of CD34+ cells on endothelium under
flow conditions, a process which is inhibited by anti-SDF-1. During intestinal ischemia/reperfusion
in mice, anti-SDF-1 and anti-CXCR4, but not isotype control
antibodies, abolish the recruitment of CD34+ cells in microcirculation. Moreover,
platelet-derived SDF-1 binding to CXCR4 receptor promotes platelet-induced differentiation
of CD34+ cells into endothelial progenitor cells, as verified by colony
forming assays in vitro. When CD34+ cells were cultivated to form colony forming
units, they exhibit similar endothelial surface markers such as CD146, CD144,
or CD31 compared to primary endothelial cell cultures cultivated from human arteries.
PCR-analysis showed that CD34+ cell-derived endothelial progenitor cells
exhibit positive signals for eNOS, Tie-2, and VEGFR-2 similar to those signals
obtained from arterial endothelial cells.
Conclusions: These findings imply that platelet-derived SDF-1 regulates adhesion
of stem cells in vitro and in vivo and promotes differentiation of CD34+ cells
to endothelial progenitor cells. Since tissue regeneration depends on progenitor
cell recruitment to peripheral vasculature and their subsequent differentiation,
platelet-derived SDF-1 may contribute to vascular and myocardial regeneration.
2534 Bone marrow-derived cells are not involved in
reendothelialized endothelium as endothelial cells in
simple endothelial denudation models in mice
M. Tsuzuki. Nagoya University, Department of Cardiology, Nagoya,
Japan
Purpose: It has been shown that bone marrow (BM)-derived cells are involved
in repaired endothelium as endothelialcells in the murine arterial injury models
which produce neointima. However, it has not been shown in simple endothelial
denudation models.
Methods: Male wild-type and green fluorescent protein (GFP)-transgenic
C57BL/6J mice were used. For qualitative studies, at least 4 mice aged 8 to
12 weeks were operated. For BM-transplantation model, recipient wild-type and
donor GFP transgenic mice aged 6-week were used. The recipient mice were irradiated
(10 Gy) and infused GFP-positive donor BM cells (3×1,000,000 cells). BMtransplanted
mice were operated at least 4 weeks after transplantation. A newly
established model of 0.35-mm guide wire-induced endothelial denudation, which
formed no neointima at 14 days after operation, of common carotid artery (CCA
model) and a conventional femoral endothelial denudation model using 0.25-mm
guide wire (FA model) were performed.
Results: In terms of the CCA model, although endothelial detachment in carotid
bifurcation was found, these lesions had continuity with the detachment/neointima
in ligated external carotid artery (ECA). Endothelial detachments were also found
in ECAs of sham-operated mice. At 7 days after operation, the common carotid
arteries (CCAs) were reendothelialized from the aortic arch and the carotid bifurcation
but not completely by Evans Blue extravasation. Scanning electron
microscopy revealed that unendothelialized area was covered with platelets. In
terms of BM transplanted animals, there was no GFP positive endothelial cell in
denuded CCA by whole mount CD31 immunohistochemical staining at 7 or 28
days after operation. On the other hand, GFP positive "dendritic" cells were recruited
in repaired endothelial layer. These GFP positive cells were also seen in
endothelial layer of uninjured side of carotid bifurcation. These "dendritic" cells
were assumed to be vascular dendritic cells and/or pericytes because of morphological
features. In terms of the FA model, neointima formation was observed at 28
days after operation. However, no GFP positive endothelial cells were observed
in neointimal area by whole mount CD31 staining at 7 or 28 days after operation
otherwise "dendritic" cells were seen at the endothelium and in the neointima.
Conclusions: These results suggest that BM-derived cells may not be involved in
reendothelialization as endothelial cells in simple denudation models of endothelium.
2535 Mobilization of bone marrow-derived Oct-4+SSEA-4+
very small embryonic-like cells in patients with acute
myocardial infarction
W. Wojakowski1 ,M.Kucia2 , E. Zuba-Surma2 , E. Paczkowska3 ,
J. Ciosek1 ,M.Kazmierski1 ,A.Ochala1 , B. Machalinski3 ,
M.Z. Ratajczak2 , M. Tendera1 . 1Medical University of Silesia, III Division of
Cardiology, Katowice, Poland; 2University of Louisville, Stem Cell Institute,
Louisville, United States of America; 3Pomeranian Medical University, General
Pathology, Szczecin, Poland
Acute myocardial infarction (MI) induces mobilization of bone marrow stem cells.
Recently rare population of small non-hematopoietic lin-CD133+CD45-CXCR4+
(very small embryonic-like stem cells, VSEL), expressing markers of embryonic
pluripotent stem cells (PSC) was identified in murine bone marrow and human
umbilical cord blood.
Aim: Aim of the study was to assess the mobilization of VSEL in patients with
AMI, isolate VSEL from peripheral blood and measure expression of PSC, cardiac
and endothelial markers.
Methods: 31pts with acute MI and 30 healthy subjects (CTRL) were enrolled.
Blood (20 mL) was sampled on admission, after 24 hours and 5 days, erythrocytes
were lysed and CD34+CXCR4+lin-CD133+CD45- cells were isolated using
live cell sorting system (FACSAria). Plasma levels of SDF-1, HGF, VEGF, G-CSF
were measured.
Results: In healthy subjects number of circulating VSEL is very low (1,1±0,2
cells/μL). In acute MI VSELs were mobilized early (2,77±0,8 cells/μL; p

Bone marrow progenitors: filling the bench to bedside gap / Magnetic navigation for arrhythmia ablation 399
aggregates between platelets and stem cells. Patients with ACS (n=51) showed a
significantly increased number of CD34+ cells (P

400 Magnetic navigation for arrhythmia ablation / Preventing complications in atrial fibrillation ablation
MNS offers further advantages for ablation of the slow pathway since physician’s
radiation exposure is virtually zero with a fairly low radiation exposure to the patient.
2562 Magnetic remote radiofrequency ablation in wpw
patients with left accessory pathways
A. Ardashev, E. Zhelyakov, A. Shavarov, M. Rybachenko, A. Konev.
Burdenko Head clinical hospital, Interventional Cardiology Dept.,
Moscow, Russian Federation
Purpose: to access feasibility of retrograde aortic approach for radiofrequency
catheter ablation (RFA) of left accessory pathways (APs) using NIOBE magnetic
navigation system.
Methods and Results: Study was conducted on 22 consecutive patients (8
women, 34.3±12.5 years of age) with the apparent (17 pts) and concealed leftsided
APs which were verified during electrophysiology study (left lateral APs
in 18 cases, left anterior-lateral in 4 cases). Magnetic 4-mm tip, catheter Helios
was passed through aortic valve and advanced to the target positions (atrial (18
cases) and ventricular (4 cases) insertion sites of AP) guided by using the X-ray
examination and magnetic NIOBE system.
Three step maneuver used for catheter advancement through aortic valve. First
step - catheter was advanced to aortic valve into aortic root using motor drive.
Second step - tip of catheter was positioned near right coronary artery ostium using
uniform magnetic field. Third step – catheter was passed through aortic valve
guided by catheter advancer system (Cardiodrive) while curved by itself. These
maneuvers were successful in all cases (22 pts). RFA was performed (50° C,
maximum 50 W, mean duration 20±7 s) in all cases. There were no complication
associated with catheter advancement through aortic valve and RFA.
Conclusion: Retrograde aortic approach using NIOBE magnetic navigation system
is safe and feasible technique for advancement of mapping catheter towards
either left atrium or left ventricle.
2563 New insights in AVNRT ablation: lower incidence of
junctional rhythm with magnetic navigation compared
to conventional ablation
P. Ricard, D.G. Latcu, N. Zarqane, K. Yaici, C. Turchina, J.P. Rinaldi,
N. Saoudi. Centre Hospitalier Princesse Grace, Cardiology, Monaco,
Monaco
Introduction: The occurrence of accelerated junctional rhythm during radiofrequency
ablation of the slow pathway in patients with atrioventricular nodal re-entry
tachycardia (AVNRT) is frequent. The aim of the present study was to compare
the occurrence of junctional rhythm during magnetic remote catheter ablation to
the conventional manual ablation (CMA) of slow-fast AVNRT.
Methods: Twenty-six patients (Male: 7; age: 51±15) who underwent slow pathway
ablation with a magnetic navigation system (MNS) (Niobe, Stereostaxis)
were compared to a control group of 11 patients (Male: 3; age: 53±16) treated
with CMA. Ablations were performed in both groups with 4-mm non-irrigated tip
catheters. Radiofrequency energy was applied with settings of 30 W and 60°C for
all patients.
Results: Acute success, defined as the absence of inducible AVNRT and no more
than one echo beat, was obtained in all patients. In the MNS group, 3 patients had
no junctional beat (JB) at all and 7 patients had ≤ 10 JB. In contrast, in the CMA
group no patient had ≤ 10 JB. The mean number of JB in the MNS group was
66±94 (0-410) versus 200±243 (43-914) in the CMA group (p=0.019). Duration
of radiofrequency application was not statistically different among groups. In the
MNS group 1 patient had a first degree atrio-ventricular block. No other complication
occurred.
Conclusions: MNS ablation of AVNRT is effective and is associated with less JB
than CMA. Since MNS has been shown to provide lower catheter pressure compared
to CMA, we may suppose that this feature explain our finding. Therefore JB
may not be considered as a mandatory indicator for successful AVNRT ablation
with MNS.
PREVENTING COMPLICATIONS IN ATRIAL FIBRILLATION
ABLATION
2564 Role of intraesophageal temperature monitoring to
prevent esophageal injury during AF catheter ablation
T. Gaspar, C. Piorkowski, C. Staab, A. Bollmann, A. Arya, D. Husser,
M. Esato, S. Kircher, P. Sommer, G. Hindricks. Heart Center Universitiy
Leipzig, Electrophysiology, Leipzig, Germany
Background: The relationship between the posterior left atrium and the esophagus
is a potential hazard for left atrial PV ablation. Esophageal perforation is
a life threatening complication. The current prospective study collected new insights
into clinical effects of radiofrequency ablation on esophageal temperature
using a newly designed intraesophageal temperature probe containing multiple
temperature sensors.
Methods: 20 consecutive patients received a circumferential PV ablation using
irrigated tip ablation within the NavX system. Complete PV isolation with bidirectional
block was the procedural endpoint. Throughout the procedure a catheter
with three circular temperature sensors was placed in the esophagus of the sedated
patient. This catheter was visualized on NavX. In case of temperature increases
above 40°C ablation was discontinued until esophageal temperature had
returned to baseline. Postinterventional gastroscopy was performed to assess for
acute alterations of esophageal mucosa.
Results: Visualization of the temperature probe on NavX provided a reliable analysis
of esophageal course and contact. In 75% of the patients ablation energy and
irrigation flow rate had to be reduced due to esophageal temperature increases.
Still 40% of the patients showed temperature increases above 40°C with an energy
setting of 20W and 20ml/h. In 25% of the patients continuous and transmural
ablation at the posterior left atrium was not possible, and PV isolation had to be
performed on a more distal level within the PV antrum. During postinterventional
gastroscopy none of the patients showed alteration of the esophageal mucosa
with respect to ulceration or erythema.
Conclusion: A temperature probe containing multiple temperature sensors covering
most of the lenght of the posterior left atrium shows surprising intraesophageal
temperature increases even with low RF energy settings. Intraesophageal
temperature response during posterior left atrial ablation shows a large
interindividual variability. Simultaneous visualization of the temperature probe on
NavX combines anatomical information about dangerous ablation target sites with
functional information about actual esophageal heating, in order to individually adjust
ablation energy. With an intraesophageal temperature threshold of 40°C no
damage to the esophageal mucosa could be observed during gastroscopy.
2565 Using delayed-enhancement MRI to detect esophageal
tissue damage following radiofrequency ablation for
atrial fibrillation
T. Badger1 , R.S. Oakes1 ,E.Fish1 , N. Segerson1 ,M.Daccarett1 ,
N. Akoum1 , E. Kholmovski2 , E.V. Dibella2 , R.S. Macleod3 ,
N.F. Marrouche1 . 1AF Program, University of Utah, Cardiology, Salt Lake City,
United States of America; 2Utah Center for Advanced Radiology Research,
Radiology, Salt Lake City, United States of America; 3Scientific Computing
Institute (SCI), Utah, Biomedical Engineering, Salt Lake City, United States of
America
Objectives: Atrioesophageal (AE) fistula is a severe complication of radiofrequency
(RF) ablation in the treatment of atrial fibrillation (AF). Currently, little is
known in regards to how mediastinal structures posterior to the left atrium respond
following ablation. We report the discovery of esophageal tissue damage
three months following RF ablation using delayed-enhancement cardiovascular
MRI (DE-MRI).
Methods: Patients who presented for Pulmonary Vein Antrum Isolation received
a DE-MRI at 3 months follow up. 3D segmentations of the left atrium (LA) and
esophagus were performed with application of a color look-up table (CLUT) to
illuminate tissue with delayed washout kinetics of the contrast agent, gadolinium.
Qualitative assessment was performed to analyze the presence of esophageal
enhancement in regions of close proximity to the LA, as well as quantitative assessment
to analyze esophageal wall thickening.
Results: Of 103 patients who received a DE-MRI at 3 months follow up, 3 (2.9%)
showed hyper-enhancement in the esophagus. All 3 patients showed increased
enhancement in the anterior wall of the esophagus with an average 216% anterior
wall thickening in comparison to the posterior wall. In three dimensional models,
increased esophageal enhancement (red) indicating tissue injury was seen in
regions that shared a common surface with the posterior wall of the LA. All 3
patients were asymptomatic.
Esophagus panel.
Conclusions: Esophageal tissue damage from RF ablation can be detected by
DE-MRI 3 months post-procedure. More research is needed to categorize the
extent and clinical implications of this tissue damage and to detect whether these
patients are high risk for AE fistula in repeat ablation.
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2566 Esophageal capsule endoscopy in consecutive
patients: a new tool to assess esophageal damage
following atrial fibrillation ablation
L. Di Biase 1 ,S.Poe 2 , L.C. Saenz 3 ,M.Vacca 3 ,A.Siu 2 , J. Santisi 2 ,
M. Dodig 2 ,R.Schweikert 2 ,W.Saliba 2 , A. Natale 4 . 1 Cleveland
Clinic/University of Foggia, Cardiovascular Medicine, Cleveland/Foggia, United
States of America; 2 Cleveland, United States of America; 3 Bogota, Colombia;
4 Stanford University, Palo Alto, United States of America
Introduction: Left atrioesophageal fistula is a rare but devastating complication
that can occur following catheter ablation of atrial fibrillation. Little information is
known on the esophageal injury following the procedure and its correlation with
symptoms.
Methods: Consecutive patients undergoing AF ablation for symptomatic atrial
fibrillation refractory to AAD have been enrolled in this study. All patients underwent
esophageal temperature monitoring during the procedure. Radiofrequency
energy was discontinued when the luminal temperature increased. After ablation
all patients had capsule endoscopy (Pillcam Eso) to assess the presence for endoluminal
tissue damage of the esophagus.
Results: 107 consecutive patients (79 males) with a mean age of 60+10.4, mean
LA dimension of 4.2 cm + 0.5 and mean EF 49.6 + 7.1 have been enrolled in this
study (63 paroxysmal and 44 non paroxysmal).
Of the patient 27% reported chest discomfort post ablation. Symptoms during
ablation were non specific and not correlated with the positive findings. We identified
10 positive findings located in distal esophagus at the level of the ablation
catheter as linear erosion with clean base and 3 positive findings described as
mid esophageal ulceration with or without trace of blood, not at the level of the
ablation catheter.
Of the patient with positive findings only one (1) had chest disconfort after ablation.
The Max Esophageal temp was 39.4+ 0.5 C; the time to baseline temperature
Recovery was 17+ 2.4 sec and the time to peak Temperature was 20+ 8 sec.
No complication occurred during and after the administration of the pill cam.
Conclusion: The use of capsule endoscopy is a safe and efficacy tool to identify
patients with esophageal damage. Importantly the positive findings were not
associated with post procedural symptoms. Further studies are required to better
understand whether patients with positive findings following ablation, require
a different follow-up and additional treatment.
2567 Pulmonary vein stenting for the treatment of acquired
severe PV stenosis
T. Neumann, T. Dill, M. Kuniss, G. Conradi, J. Sperzel, S. Zaltsberg,
A. Berkowitsch, C. Hamm, H. Pitschner. Kerckhoff Heart Center,
Cardiology, Bad Nauheim, Germany
Purpose: The preferred therapy for symptomatic pulmonary veins stenosis (PVS)
is pulmonary vein (PV) angioplasty, but this treatment modality is followed by
restenosis in 44 to 70%. Whether there is additional long-term benefit from PVS
stenting is uncertain. The aim of this study was the evaluation of the long-term
success after PV stenting of severe stenosis.
Method: Ten patients with 13 PVS (≥ 70% stenosis) were prospectively evaluated.
PV stenting was performed (diameter 10mm, length 25mm). Magnetic resonance
imaging, lung perfusion scans and multislice CT-scans were performed
before, directly after and every further 12 months. Primary endpoint of the study
was the occurrence of restenosis after PV stenting.
Results: After a median follow-up of 47.7 (IQR’s 25/75 47.2-48.5) months, the primary
endpoint were achieved in 3 out of 13 pulmonary veins (23% of the treated
PVs). We observed one instent restenosis two years after PV stenting. The patient
had dyspnea that arised some weeks before. After an additional balloon
angioplasty the instent restenosis was resolved. In two asymptomatic patients we
observed an occlusion of the PV stent one year after stenting. Normalization of
lung perfusion was noted 4 years after PV stenting versus directly after stenting
in all patients without instent restenosis (n=7).
Conclusion: PVS stenting seems to be superior to balloon angioplasty and effective
at least over a period of 4 years in treating acquired PVS after pulmonary vein
stenosis. Late instent restenosis after PVS stenting can occur. The normalization
of the initially disturbed lung perfusion scan is possible and remains stable, even
4 years after successful PVS stenting.
2568 How close are the atrial arteries to the pulmonary
veins? A potential cooling effect with implications for
catheter ablation of patients with atrial fibrillation
J.A. Cabrera1 , V. Climent2 , B. Fuertes3 , M. Murillo4 , E. Gonzalez5 ,
Y. Ho 6 , M. Vanegas5 , D. Sanchez-Quintana7 . 1Hospital Quiron Madrid,
Cardiology, Madrid, Spain; 2University of Extremadura, Faculty of Medicine,
Badajoz, Spain; 3Hospital Quiron Madrid, Cardiology, Madrid (Pozuelo), Spain;
4 5 University of Extremadura, Faculty of Medicine, Badajoz, Spain; Hospital
Quiron Madrid, Cardiology, Madrid (Pozuelo), Spain; 6Royal Brompton Hospital,
Cardiology, London, United Kingdom; 7University of Extremadura, Faculty of
Medicine, Badajoz, Spain
Introduction: Luminal blood flow of the atrial arteries may produce intramural
cooling reducing the effectiveness of ablative energy to create transmural lesions
Preventing complications in atrial fibrillation ablation 401
around the orifices of the pulmonary veins (PVs) in atrial fibrillation. The presence
of coronary arteries with a close anatomic relation to the PVs and their junctions
with the left atrium has not been previously described.
Methods: In 32 structurally normal human hearts (24 m, 46±18 y) we examined
by disecction techniques and histological sections the arterial vascularization
around the PVs orifices. We measured the external diameters of the arteries
and its distances to the endocardial surface of the left atrium at the veno-atrial
junction.
Results: Histological sections did not revealed significant arteries in close proximity
to the orifices of the right-PVs. On the left veno-atrial junction we observed
in 27 specimens (67%) an arterial branch termed lef intermediate atrial artery
that originated from the left circumflex next to the inferior border of the left atrial
appendage (LAA). This artery ran on the epicardial aspect of the left lateral wall
of the left atrium, over the left lateral ridge between the orifices of the LAA and
left-PVs. The mean external diameter of the left intermediate artery was 1.1±0.3
mm (range 0.5 to 1.6 mm) and ist distance to the endocardial surface of the left
veno-atrial junction ranged between 1.8 to 3.7 mm (2.5±0.5 mm). In most specimens
(62%) the artery ran on the venous side of the ridge closer to the orifice of
the left-PVs than to the appendage.
Conclusions: During ablation around de orifices of the PVs, ablationists should
be mindful of the potentially cooling effect of the left intermediate artery close
to endocardial aspect of the left-PVs, which may protect the surrounding atrial
muscle
2569 Ablation of extra pulmonary atrial foci around or inside
the orifice of the left atrial appendage. The anatomic
risk of induce left phrenic nerve injury
J.A. Cabrera1 ,V.Climent2 , B. Fuertes3 , M. Murillo2 , E. Gonzalez4 ,
Y. Ho 5 , M. Vanegas3 , D. Sanchez -Quintana6 . 1Hospital Quiron
Madrid, Cardiology, Madrid, Spain; 2University of Extremadura, Faculty of
Medicine, Badajoz, Spain; 3Hospital Quiron Madrid, Cardiology, Madrid, Spain;
4 5 Hospital Quiron Madrid, Cardiology, Madrid, Spain; Royal Brompton Hospital,
Cardiology, London, United Kingdom; 6University of Extremadura, Faculty of
Medicine, Badajoz, Spain
Introduction: The risk of induce left phrenic nerve (LPN) injury is a recognized
complication during ablation of atrial fibrillation when creating transmural lesions
inside or around the orifice of the left atrial appendage (LAA). Detailed information
of the anatomic relations between the LPN and the LAA may be useful to perform
the ablation techniques more safely.
Methods: Twenty human cadavers (12 male, 8 female; mean age 70±9 years
old) without obvious signs of thoracic pathology or prior surgery were carefully
dissected. We examined by gross inspection and histological sections the course
of the LPN in relation with the LAA and its distance to the mouth of the left appendage.
Results: The LPN, branch of the cervical plexus runs along the left brachiocephalic
vein. It continues closely applied over the aortic arch, pulmonary trunk
and left atrial appendage and descends in front of the root of the left lung embedded
between the fibrous pericardium and the mediastinal pleura to the diaphragm.
When the LPN course was related to the anterior aspect of the LAA
(5 specimens, 25%) the nerve passed adjacent to its mouth. The mean minimal
distance between the neck of the LAA and the left phrenic nerve was 8.3±3.5 mm
with a range of 2.5 to 14.5 mm
Course of the left phrenic nerve
Conclusions: During ablation of extra-pulmonary atrial foci, ablating tools resulting
in deeper lesions may reach the left phrenic nerve which is in close relation to
the orifice of the left atrial appendage increasing the risk of induce left diaphraghm
paralysis.
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402 Safety is the new efficacy
POSTER SESSION 4
MODERATED POSTERS 1
SAFETY IS THE NEW EFFICACY
P2587 Risk factors for gastroduodenal ulcer during
treatment with acetylsalicylic acid for cardiovascular
risk management
A. Lanas1 , N. Yeomans2 , O. Junghard3 , L.-E. Svedberg3 on behalf
of ASTERIX Investigators. 1University Hospital Lozano Blesa,
Gastroenterology, Zaragoza, Spain; 2University of Western Sydney, School of
Medicine, Sydney, Australia; 3AstraZeneca R&D, Molndal, Sweden
Purpose: Treatment with low-dose acetylsalicylic acid (ASA) is the cornerstone
of cardiovascular (CV) risk management. However, long-term administration of
low-dose ASA is associated with an increased risk of adverse gastrointestinal
events, including peptic ulcers. We have previously reported the efficacy of acidsuppressive
therapy with esomeprazole (ESO) for reducing the risk of such events
in patients (pts) receiving low-dose ASA for CV risk management. We report here
a descriptive analysis of possible risk factors among pts who developed gastroduodenal
ulcers as part of this study.
Methods: ASTERIX was a randomised, double-blind study that enrolled pts aged
≥60 yrs, without baseline gastroduodenal ulcer at endoscopy, who were receiving
continuous low-dose ASA (75-325mg) for CV risk management. Pts were
randomised to ESO 20mg once daily or placebo for 26 wks. The primary study
end point was the development of endoscopic gastroduodenal ulcers among the
intention-to-treat population (ESO, 493 pts; placebo, 498 pts).
Results: A total of 35 pts (placebo, 27; ESO, 8) developed gastroduodenal ulcers
during the study (gastric ulcers, 25 pts [placebo, 19, ESO, 6]; duodenal ulcers, 10
pts [placebo, 8; ESO, 2]). For both treatment groups combined, H. pylori was a
significant risk factor for duodenal ulcer while on low-dose ASA (odds ratio 4.96;
95% confidence interval [CI]: 1.39, 17.76; p=0.014). However, H. pylori was not
a significant risk factor for gastric ulcer while on low-dose ASA (odds ratio 0.87;
95% CI: 0.32, 2.36; p=0.98). Although asymptomatic ulcers often develop in pts
taking NSAIDs, those who developed gastroduodenal ulcers on low-dose ASA
did have almost double the mean antacid consumption (statistically significant in
the placebo group, p=0.005), perhaps reflecting ulcer-related symptoms in some.
The risk of ulcers was almost three times higher at ASA doses >100 mg/d (odds
ratio 2.7; 95% CI: 1.37, 5.32; p=0.0055). There was a trend towards ulcers being
more likely to develop in women (odds ratio 1.81; 95% CI: 0.92, 3.59; p=0.12).
There was no significant effect of age in this study, although all pts were ≥60 yrs
as an entry requirement.
Conclusion: H. pylori is a significant risk factor for developing a duodenal (but
not gastric) ulcer in patients aged ≥60 yrs receiving low-dose ASA for CV risk
management. Aspirin dose also contributes, and female sex may contribute, to
increased risk of gastroduodenal ulcers in these patients.
P2588 Angiotensin-converting enzyme inhibitors and
changes in serum creatinine levels after coronary
angiography and angioplasty
A. Abbate, F. Shaikh, Q. Cheema, A. Nusca, G.W. Vetrovec.
Richmond, United States of America
Background: Contrast-induced nephropathy (CIN) is a dreaded consequence
of cardiac catheterization and an important cause of morbidity and mortality in
hospitalized patients. There have been relatively few and small studies examining
the association between the use of angiotensin-converting enzyme (ACE)inhibitors
and their subsequent effects on the risks of developing contrast-induced
nephropathy. The results of these studies have been mixed. In current practice
and ACE-inhibitors are often held prior to IV dye. The aim of this study is to determine
the effects of ACE-inhibitors on changes in serum creatinine values and
incidence of CIN after coronary angiography/angioplasty.
Methods: A cohort of 600 consecutive patients at high risk of developing CIN because
of baseline impairment in renal function (eGFR100 pg/mL were randomized to
3 months’ double-blind treatment with placebo or aliskiren (150 mg once daily)
added to standard therapy (ACE-I or angiotensin receptor blocker [ARB] and beta
blocker [BB]).
Results: Of the 302 patients enrolled in the study, 106 (35.1%) had diabetes.
Mean age of patients with diabetes was 67.9 years, 20.8% were female, 36.8%
were obese (BMI ≥30 kg/m 2 ) and 36.7% had estimated glomerular filtration rate
(eGFR) 14.28 mmol/L 4 (7.0) 6 (12.2) 0.508 9 (9.1) 9 (9.5) >0.999
Creatinine >176.8 μmol/L 6 (10.5) 3 (6.1) 0.500 5 (5.1) 5 (5.3) >0.999
Potassium 0.999
Potassium >5.5 mmol/L 5 (8.8) 2 (4.1) 0.447 8 (8.1) 10 (10.5) 0.626
Potassium ≥6.0 mmol/L 1 (1.8) 1 (2.0) >0.999 2 (2.0) 5 (5.3) 0.272
Data are number (%) of patients with clinically significant laboratory abnormalities at any time
during the study.BUN, blood urea nitrogen.
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(7.0%) patients receiving aliskiren versus 3/49 (6.1%) patients receiving placebo.
In the aliskiren group, symptomatic hypotension, renal dysfunction and hyperkalemia
occurred in 4, 1 and 5 patients respectively, versus 1, 1 and 1 patients
in the placebo group. The table shows the incidence of predefined laboratory abnormalities.
Conclusion: In ALOFT, addition of aliskiren to optimized medical therapy in patients
with chronic stable HF and diabetes was generally well tolerated.
P2592 Risk assessment of cardiovascular ischemic events
in patients with type 2 diabetes Mellitus receiving
Pioglitazone and Concomitant treatment with nitrates,
ACE/ARBs, or insulin
R.S. Spanheimer 1 , B.C. Charbonnel2 , A.P. Perez1 , S.K. Kupfer1 ,
E.E. Erdmann3 on behalf of PROactive study investigators. 1Deerfield, United
States of America; 2Nantes Cedex, France; 3Koln, Germany
Patients with advanced type 2 diabetes (T2D) are frequently treated with insulin
due to beta cell failure, as well as multiple cardiovascular (CV) agents due
to ischemic complications. PROactive (PROspective pioglitAzone Clinical Trial
In macroVascular Events) was a randomized, double-blind, placebo-controlled
prospective trial that evaluated mortality and CV morbidity in 5238 high-risk
patients with T2D and macrovascular disease. Target HbA1c was 6.5% per
International Diabetes Federation Guidelines. Patients in PROactive were assigned
to pioglitazone (PIO) or placebo in addition to their baseline glucoselowering
and CV medications, including insulin (33.0%), nitrates (39.3%), and
angiotensin-converting enzyme inhibitor (ACE-I)/angiotensin-receptor blockers
(ARBs) (69.7%). Because concomitant use of these medications was associated
with higher CV ischemic risk in another thiazolidinedione (TZD), we evaluated the
effect of PIO on a composite endpoint of all-cause death, nonfatal myocardial infarction
(MI), or stroke in the subgroups of patients using nitrates, ACE-I/ARBs, or
insulin at baseline. Composite CV endpoint risk for PIO treatment was similar regardless
of baseline use of nitrates, ACE-I/ARBs, or insulin (Graph). Additionally,
the interaction between each subgroup and treatment was not significant. Median
HbA1c at final visit was 6.9% in the PIO group and 7.5% in placebo.
The results of this post hoc analysis from the PROactive study did not reveal
an increased risk of all-cause death, MI, or stroke in patients receiving nitrates,
ACE-I/ARBs, or insulin in patients treated with PIO. Rather, patients with these
baseline medications realized the same trend of benefit with PIO as did patients
without these baseline medications.
P2593 The genetic A842G/C50T polymorphism of the
cyclooxygenase-1 gene and the risk of thrombotic
events during aspirin therapy
N. Clappers1 , M.G.A. Van Oijen2 , S. Sundaresan2 , M.A. Brouwer2 ,
R.H.M. Te Morsche2 , W. Keuper2 , W.H.M. Peters2 , J.P.H. Drenth2 ,
F.W.A. Verheugt2 . 1Radboud University Nijmegen Medical Centre, Cardiology
Dept., Nijmegen, Netherlands; 2Radboud University Medical Centre, Gastro
enterology, Nijmegen, Netherlands
Background: Aspirin reduces the risk of thrombotic events by inhibiting platelet
cyclooxygenase-1 (COX-1), consequently reducing thromboxane A2 formation
and platelet aggregation. The C50T genetic polymorphism of COX-1 is associated
with an impaired inhibition of both thromboxane production and platelet aggregation
by aspirin. We studied whether this polymorphism is associated with a
higher risk of clinical thrombotic events in patients using aspirin.
Methods: Patients admitted to our Coronary Care Unit for various indications
and who were prescribed low dose (80-100 mg) aspirin were genotyped for the
COX-1 C50T polymorphism and followed over time. We compared clinical outcomes
between patients with the common genotype and the variant genotype.
The primary endpoint was the composite of myocardial infarction, stroke, or cardiovascular
mortality. Univariate and multivariate hazard ratios were calculated
with Cox regression analysis.
Results: Between April 2002 and January 2004 we included 578 patients in the
total cohort, and 502 of these were treated with aspirin. For 496 patients genotyping
and clinical follow-up was available. The common genotype was present in
86.7%, the variant in 13.3% (12.5% heterozygous, 0.8% homozygous). Baseline
variables were well balanced, except patients with the most common genotype
more frequently already used aspirin prior to the index admission. The median
Safety is the new efficacy / Measuring platelet function: do we need it? 403
(IQR) follow up was 2.5 (1.9-3.2) years, and 98 patients (19.7%) had a primary
endpoint. The unadjusted hazard ratio (HR, 95% CI) for the primary endpoint for
patients with the variant versus most common genotype was 1.07 (0.62-1.85),
P=0.8. The multivariate adjusted HR was 0.86 (0.49-1.50), P=0.6. Independent
predictors of the primary outcome were increasing age, increasing serum creatinine
and diabetes mellitus. With respect to the secondary outcomes, myocardial
infarction occurred in 9.6% of the patients, stroke in 1.6%, cardiovascular death in
12.0%. The rates of these events were not significantly different between patients
with the variant and with the common genotype.
Conclusion: In laboratory studies the genetic C50T polymorphism of COX-1 is
related to an impaired inhibition of thromboxane production and platelet aggregation
by aspirin. However, in this cohort of patients using aspirin for secondary
prevention the polymorphism was not associated with a higher risk of clinical
thrombotic events.
P2594 Laropiprant reduces niacin-induced flushing at
initiation of therapy in Asian patients with
dyslipidemia
D. Kush 1 ,H.S.Kim2 ,D.Hu3 , R. Kirchoff1 , E. Chen1 ,W.Sirah1 ,
C. Mccrary Sisk1 , J.F. Paolini1 . 1Merck Research Laboratories,
New Jersey, United States of America; 2Seoul National University
Hospital, Seoul, Korea, Republic of; 3Peking University, Beijing, China, People’s
Republic of
Purpose: Niacin is underutilized due to prostaglandin D2 (PGD2)-mediated flushing.
Laropiprant, a selective PGD2 receptor (DP1) antagonist, reduces flushing
associated with extended release (ER) niacin. This Phase III randomized, doubleblind,
study compared the acute flushing symptoms with a combination tablet of
ER niacin/laropiprant vs. an ER niacin without laropiprant over one week in lipid
clinic patients in Asia.
Methods: Following a 1-week placebo run-in period, 332 dyslipidemic patients
from China, Korea and Singapore were randomized to ER niacin/laropiprant 1
g/20 mg (designated ERN/LRPT 1 g), Niaspan 1 g (NSP) or placebo (PBO) in
a 2:2:1 ratio for 1 week. Effects of ERN/LRPT vs. NSP on patient-reported flushing
severity were assessed using the validated Global Flushing Severity Score
(GFSS; none/mild [0-3], moderate [4-6], severe [7-9], extreme [10]), captured in a
daily electronic diary.
Results: Compared with NSP, patients treated with ERN/LRPT experienced significantly
less flushing (p

404 Measuring platelet function: do we need it?
aggregometry with thromboxane-specific indexes and point-of-care tests in order
to evaluate the agreement between these platelet function tests.
Methods: Patients with stable coronary artery disease (n=45) were compared
with healthy subjects (n=21) treated with non-enteric coated aspirin 75 mg once
daily for 11 days. Although patients were already treated with aspirin, a run-in
phase was performed. In healthy subjects blood samples were drawn both prior
to and during aspirin treatment. Compliance was optimized by interviews and pill
counting at each visit. Optical platelet aggregometry a.m. Born (OPA) and 3 pointof-care
tests (Multiplate, PFA-100 and VerifyNow) were performed in duplicate
on 4 consecutive days one hour after aspirin ingestion. OPA was induced with
adenosine diphosphat (ADP) 5.0 and 10.0 μM and arachidonic acid (AA) 0.5, 1.0
and 1.5 mM. Additionally, urinary 11-dehydro-TXB2 and serum thromboxane (TX)
B2 were measured during aspirin treatment and at baseline in healthy subjects.
Results: Coefficients of variation (3-46%) and day-to-day variability (3-33%) differed
markedly between tests and was lowest for VerifyNow. The prevalence
of aspirin non-responsiveness was 9% (OPA, 1.0 mM AA), 3% (PFA-100, collagen/epinephrine
cartridge), 0% (Multiplate, 0.75 mM AA) and 0% (VerifyNow,
AA cartridge). The agreement between tests was very low (Kappa ≤ 0.21 for all
comparisons with OPA). Aspirin inhibited serum TXB2 more than 99% in healthy
subjects (median 1.1 ng/mL, interquartile range 0.8;1.9). In patients, mean serum
TXB2 was suppressed to a similar extent (0.9 ng/mL, 0.7;1.5) confirming 100%
compliance as also indicated by interviews and pill-counting. No differences in
urine (p=0.96) or serum (p=0.27) thromboxane metabolites were observed between
aspirin responders and non-responders defined by OPA.
Conclusions: The prevalence of aspirin non-responsiveness was highly assaydependent,
and the agreement between tests was low. Aspirin responsiveness
was high when assessed by thromboxane-specific assays in compliant patients.
However, despite very low levels of thromboxane metabolites in urine and serum,
some patients were "resistant" according to one point-of-care test and optical
platelet aggregometry.
P2597 Assessment of the platelet inhibitory effects of
clopidogrel and prasugrel by the VerifyNow P2Y12
point-of-care device in comparison with LTA and
VASP-phosphorylation in aspirin treated CAD patients
C. Varenhorst1 ,S.James1 ,D.Erlinge2 , O.O. Braun2 ,K.J.Winters3 ,
J.T. Brandt3 , J.A. Jakubowski3 , A. Sugidachi4 , L. Wallentin1 , A. Siegbahn5 .
1Uppsala Clinical Research Center, Dept Internal Medicine, Cardiology, Uppsala,
Sweden; 2Dept of Cardiology, Lund, Sweden; 3Lilly Research Laboratories,
Indianapolis, United States of America; 4Daiichi Sankyo Co., Ltd, Tokyo, Japan;
5Coagulation Laboratory, Dept Medical Sciences, Uppsala, Sweden
Purpose: Prasugrel, a new P2Y12 antagonist, has been reported to achieve
greater inhibition of platelet aggregation (IPA) than clopidogrel. We compared
platelet function by light transmission aggregometry (LTA), whole blood flow
cytometric analysis of platelet vasodilator stimulated phosphoprotein (VASP)phosphorylation
and the point-of-care assay VerifyNow P2Y12 (VN-P2Y12).
Studies were performed in aspirin-treated patients with stable coronary artery
disease (CAD) during administration of the thienopyridines prasugrel and clopidogrel.
Methods: After a run-in on 75 mg aspirin, 110 subjects were randomized to double
blind treatment with clopidogrel (n=55) 600 mg LD followed by 75 mg o.d.
(once daily) maintenance dose (MD) for 28 days or prasugrel (n=55) 60 mg LD
followed by 10 mg o.d. MD for 28 days. Platelet aggregation using 20 μMADPwas
measured by LTA (IPA, %), VASP, platelet reactivity index (PRI,%) and VN-P2Y12
device reported percent inhibition at pre-dose, 2 and 24h post-LD and repeated
pre-dose at days 14 and 29. The relationship between the three methods was
evaluated with Pearson’s correlation.
Results: The correlation between % inhibition (VN-P2Y12) vs. % IPA (LTA) was
0.76 (Figure) and % inhibition (VN-P2Y12) vs. % PRI (VASP) was -0.84 (both
p

P2600 Final aggregation response is a more sensitive
marker of the effects of P2Y12 receptor antagonists
than maximal aggregation response
R.F. Storey 1 , C.P. Cannon 2 , R.A. Harrington 3 , P.M. Sandset 4 ,
S. Heptinstall 5 ,M.Wickens 6 ,G.Peters 7 ,H.Emanuelsson 8 ,
S. Husted 9 . 1 University of Sheffield, Department of Cardiology, Sheffield,
United Kingdom; 2 Brigham and Women’s Hospital, Cardiovascular Division,
Boston, United States of America; 3 Duke Clinical Research Institute,
Medicine/Cardiovascular, Durham, United States of America; 4 Ullevaal
University Hospital, Department of Haematology, Oslo, Norway; 5 University of
Nottingham, Cardiovascular Medicine Department, Nottingham, United Kingdom;
6 AstraZeneca, Research & Development, Charnwood, United Kingdom;
7 AstraZeneca, Research & Development, Wilmington, United States of America;
8 AstraZeneca, Research & Development, Molndal, Sweden; 9 Aarhus University
Hospital, Department of Medicine and Cardiology, Aarhus, Denmark
Background: P2Y12 amplifies and sustains the platelet aggregation (PA) response
to ADP, which is initiated by P2Y1. Clopidogrel (CLOP) and AZD6140,
the first reversible oral P2Y12 antagonist, block P2Y12 and inhibit PA. Measuring
maximal or final PA responses to ADP can assess these effects. To assess
the relationship between these measures, we analysed pooled PA data from the
DISPERSE and DISPERSE2 clinical trials.
Methods: Effects of CLOP (75 mg once daily) and AZD6140 (50-200 mg twice
daily, 400 mg once daily) in patients with stable atherosclerotic disease (DIS-
PERSE, n=200) and non-ST elevation acute coronary syndromes (DISPERSE2
substudy, n=45) were assessed using optical aggregometry and ADP 20 μM. Inhibition
of PA (IPA) was measured at multiple time points after drug treatment
using maximal (max IPA) and final PA response (final IPA). Correlation (Spearman
R) and agreement (Bland-Altman, average vs difference) were analysed by
study and treatment (GraphPad Prism).
Results: All analyses showed good correlation between max IPA and final IPA
(R=0.65-0.93). Correlation was greatest for CLOP in DISPERSE (R=0.93) and
lowest for AZD6140 400 mg once daily in DISPERSE (R=0.65). Agreement fell
with increasing IPA and was poorest for regimens that achieved highest IPA, as
high final IPA was associated with highly variable and lower max IPA (figure).
Conclusion: There is good correlation between max and final IPA for assessing
P2Y12 inhibition. However, max IPA may be limited (in view of a P2Y1-mediated,
P2Y12-independent component) so that agreement between both measures is
poor at high levels of P2Y12 inhibition. This analysis suggests that final IPA is a
more sensitive measure of P2Y12 inhibition than max IPA.
P2601 Optimal pretreatment timing for 600mg clopidogrel
before planned percutaneous coronary intervention
for maximal antiplatelet effectivity
Z. Motovska1 ,P.Widimsky1 ,R.Petr1 ,D.Bilkova1 ,I.Marinov2 ,
S. Simek 3 ,P.Kala4on behalf of the PRAGUE 8 study investigators.
1Third Medical Faculty Charles University, 3rd Internal-Cardiology Clinic, Prague,
Czech Republic; 2The Institute of Hematology and Blood Transf., Prague, Czech
Republic; 3First Medical Faculty Charles University, Prague, Czech Republic;
4Masaryk University & University Hospital, Brno, Czech Republic
Background: The optimal dose and timing of pretreatment to achieve maximum
benefit with clopidogrel during PCI remains controversial. The optimal timing for
600mg clopidogrel before planned PCI in patients with stable coronary artery
disease (CAD) has never been tested in a randomized trial.
Methods: The laboratory substudy of the PRAGUE-8 study was performed. The
PRAGUE-8 study compared two 600mg clopidogrel regimens on the outcomes of
patients undergoing elective coronary angiography (CAG)±ad-hoc PCI:the routine
clopidogrel >6h before CAG (group A) vs. the selective clopidogrel only for
PCI patients in the catheterization laboratory, after the CAG and just prior to PCI
(group B). In group A, the mean duration between clopidogrel administration and
procedure was 21±5h. In a laboratory substudy, the time course of platelet inhibition
was investigated in 105 group A patients. Flow cytometric analysis of the
VASP phosphorylation state was done and Platelet Reactivity Index (PRI) was
calculated before and 12, 28, 36, 60, 84 and 108h after clopidogrel use.
Results: The highest pre-clopidogrel PRI was seen in association with diabetes.
The maximal inhibition of platelet activation was achieved by 28h after drug (PRI
mean 36±23%), and 2/3 of patients had PRI value

406 Measuring platelet function: do we need it? / Atrial fibrillation
the three loading regimens. The rates of suboptimal response (IRPA

Results: Female patients (27.7%) were markedly 11 years older than males.
They had a lower prevalence of prior MI and prior coronary interventions. Despite
the older age no differences in the degree of coronary artery disease were
observed. Adjunctive medical treatment including GPIIb/IIIa blocker was similar
in women and men. Hospital mortality was significantly higher in women as in
men. After correction for age and co-morbidity, no differences in hospital mortality
of primary PCI remained between women and men in clinical practice (OR 1.37,
95% CI 0.91-1.91).
Conclusion: Women undergoing primary PCI in Europe were one decade older
than men. Adjunctive medical treatment did not differ between women and men in
the setting of primary PCI. After adjustment for the marked age difference, female
gender did not impact on hospital outcome of primary PCI.
P2609 Ablation of left atrial flutter guided first postpacing
interval electroanatomical mapping
A. Perez, J.L. Merino, R. Peinado, O. Quintero, A. Viana,
J.A. Carbonell, J.L. Lopez-Sendon. Hospital Universitario La Paz,
Madrid, Spain
Catheter ablation is the therapy of choice for well defined supraventricular arrhythmias.
However, the success rate is significantly lower in more complex arrhythmia
substrates, such as left atrial flutter (LAF), despite the use of voltage and
activation electroanatomical mapping. The first postpacing interval (FPI) is an established
mapping method to determine if an endocardial site is in the reentrant
circuit. However, this mapping method has never been implemented on a virtual
anatomical map of a 3D electrophysiology navigation system.
Methods: 21 consecutive patients who underwent ablation attempt of 34 LAFs
were included in the study. Following anatomical reconstruction with a 3D
non-fluoroscopic mapping system (Ensite-NavX), entrainment mapping was attempted
from at least 10 different sites of the left atrium. Entrainment was attempted
by pacing with a cycle length 10-20 ms shorter than the flutter cycle
length (FCL). Differences between the FPI and the FCL (FPI-FCL) at each site
were marked on the anatomical map as "artificial" activation values, where 0 ms
FPI-FCL difference was coded as -300 ms activation time, 10 ms FPI-FCL difference
as -250 ms activation time, and so on with 50 ms activation time increments
for each 10 ms FPI-FCL increment. Once the reentrant circuit was defined on the
FPI map (an area of 0 to 10 ms FPI-FCL difference, which was coded in white
color) ablation was attempted by radiofrequency application at the slow conduction
area or along the narrowest isthmus of conduction of the circuit.
Results: Frequent conversion into different LAFs or atrial fibrillation at entrainment
attempt precluded FPI electroanatomical mapping in 3 patients. A FPI map
was obtained in 31 LAFs in 18 patients and showed the reentrant circuits in
the following positions: 16 perimitral (with different dispositions), 5 in the roof,
6 septal, 1 in the posterior wall, 3 pulmonary vein related. The perimitral circuits
were located all around the mitral valve orifice except in the lateral and superior
part in some patients. Radiofrequency application successfully ablated 25
out of 29 LAFs (86%). Fifteen LAF were ablated by focal radiofrequency application.
Conclusions: First postpacing interval mapping can be implemented on the
anatomical map of 3D electrophysiology navigation systems. These maps provide
precise information about the location and size of the LAF circuits, which
may increase the success rate of the ablation procedure.
P2610 The natural history of asymptomatic ventricular
preexcitation in children. A long-term
electrophysiologic-based follow-up study for risk
stratification
V. Santinelli, A. Radinovic, G. Paglino, G. Vicedomini, C. Pappone.
San Raffaele University Hospital, Electrophysiology And Cardiac
Pacing, Milan, Italy
Purpose: Sudden death can be the first clinical manifestation in children with ventricular
preexcitation, but no risk stratification has been defined to identify subjects
at risk.
Methods: Between 1997 and 2007 we prospectively collected data from 184
children (66% males; median age, 10 years; range 8-12) incidentally found with
asymptomatic ventricular preexcitation on the ECG, who were referred for electrophysiologic
evaluation and risk stratification. Children were followed as outpatients
taking no medications. Primary end point of the study was the occurrence
of life-threatening events and potential predictors.
Results: Over a median follow-up of 20 months after electrophysiologic testing
(min-max, 8-60), 51 children had the first arrhythmic event, which was lifethreatening
in 19 of them (mean age, 10 years; range, 10-14) while the remaining
133 children during a median follow-up of 57 months (min-max, 32-90) did not
experience arrhythmic events, remaining asymptomatic. Life-threatening events
produced an aborted sudden death (3 patients), syncope (3 patients), uncommon
symptoms (8 patients) or no symptoms at all (5 patients). Children who became
symptomatic were successfully ablated. Inducibility (p=0.012), short anterograde
refractory period of accessory pathways (p=0.017) and multiple pathways
(p=0.021) predicted life-threatening events. By combining these 3 risk factors,
children were stratified into low, moderate, and high-risk groups.
Conclusions: This study has important clinical implications in terms of early iden-
Atrial fibrillation 407
tification of high-risk asymptomatic children with ventricular preexcitation. Subjects
with short anterograde effective refractory period of the accessory pathway,
multiple pathways and inducibility are the best candidates for prophylactic ablation,
being at higher risk.
P2611 Image-integration of intraprocedural rotational
angiography based 3D-reconstructions into
electroanatomical mapping: Accuracy of a novel
modality in atrial fibrillation ablation
G. Noelker1 , S. Asbach2 , K.J. Gutleben1 , H. Marschang1 ,
A.M. Sinha1 ,G.Ritscher1 ,M.Schmidt1 , H. Rittger1 , N.F. Marrouche3 ,
J. Brachmann1 . 1Coburg, Germany; 2Freiburg, Germany; 3Salt Lake City, United
States of America
Purpose: Integration of preprocedural imaging into electroanatomical mapping
has been widely adopted in atrial-fibrillation procedures. Three-dimensional reconstructions
of left atrial (LA) and pulmonary vein (PV)-anatomy are currently
prepared by electroanatomical mapping (EAM) systems themselves as part of
the procedure. However, intraprocedural imaging has been shown to be accurate
in comparison to preprocedural multislice computed tomography and may be
superior in terms of actuality. Furthermore, workflow-improvements can possibly
be made by intraprocedural imaging and direct integration of pre-reconstructed
anatomy.
Patients and Methods: 17 patients (12 male, mean age 62±8) presenting for
ablation of atrial fibrillation (9 paroxysmal, 8 persistent) underwent intraprocedural
DynaCT Cardiac. Reconstructed LA and PV-anatomy was directly importet into
CARTOMerge. 128±77 mapping points were taken and a comparison of EAM
and DynaCT Cardiac was performed by statistical analysis of distances between
the 2 modalities.
Results: Direct image integration of prereconstructed 3D-anatomy was feasible
in all patients. The procedure time was 158±25 minutes including 11±3 minutes
for DynaCT Cardiac registration and segmentation. No acute complications
occured. Deviation of mapping points to intraprocedural DynaCT Cardiac 3Dreconstructions
was 2.2±0.5 mm (2.10±0.46 mm in patients suffering from paroxysmal
atrial fibrillation (AF) vs. 2.34±0.40 mm persistent AF, n.s.)
Conclusions: Direct image-integration of 3D-reconstructions of both LA and PV
into EAM was feasible and not time-consuming. The work-flow seemed to be
improved by skipping preprocedural imaging. Intraprocedural DynaCT Cardiac is
highly accurate in comparison to EAM.
P2612 Ablation of electrogram guided substrate for
persistent atrial fibrillation is not enough
H. Estner, J. Wu, T. Reents, B. Zrenner, G. Hessling, I. Deisenhofer.
German Heart Center Munich, Cardiology, Munich, Germany
Background: Ablation of complex fractionated atrial electrograms
(CFAE) is a new approach for the treatment of atrial fibrillation (AF). The purpose
of the present study was to assess the efficacy of pulmonary vein isolation
(PVI) additive to the CFAEs ablation in patients with chronic AF.
Methods: This study included 77 consecutive patients with chronic AF who underwent
radiofrequency ablation of CFAEs as a sole ablation procedure (CFAE
group, n=23 patients) or a combined approach of CFAE ablation plus PVI (CFAE
plus PVI group, n=54 patients). Procedures were guided by three-dimensional
mapping systems. After the procedure, AF recurrences were evaluated with 7–
day Holter recordings at 1, 3 and 6 months and every 6 months thereafter. Treatment
failure was defined as ≥1 AF episode lasting >30 seconds on Holter recordings
during follow-up.
Results: After a mean follow-up time of 13±10 months 2 of 23 patients (9%) undergoing
CFAE ablation and 22 of 54 patients (41%) patients undergoing CFAE
ablation plus PVI in the absence of antiarrhythmic drug therapy (P=0.008) remained
in sinus rhythm after a single ablation procedure and in the absence of
antiarrhythmic drugs. After undergoing repeat ablation procedures, at the end of
follow-up sinus rhythm was present without antiarrhythmic drugs in 39/54 patients
(72%) undergoing CFAE plus PVI vs 5/23 patients (22%; P

408 Atrial fibrillation
practice. Up to date, the impact of this new technique in the clinical outcome of
atrial fibrillation (AF) ablation has not been clearly demonstrated.
Methods: Procedural and clinical outcome of 549 pts who underwent a first
catheter ablation for paroxysmal AF between January 2005 and April 2007 were
collected from 13 Italian Centers. Three type of procedure were included, all
aimed to obtain pulmonary veins (PVs) isolation documented by circular mapping
catheter: segmental ostial PVs isolation (LASSO, 239 pts); circumferential antral
PVs isolation guided by electoanatomical mapping (CARTO, 95 pts); and circumferential
antral PVs isolation guided by electoanatomical mapping integrated with
MR/CT image of the left atrium (MERGE, 215 pts).
Results: Procedure duration resulted significantly shorter (p

with atrial fibrillation (AF) undergoing radiofrequency catheter ablation (RFCA),
using real-time three-dimensional echocardiography (RT3DE).
Methods: A total of 57 patients referred for RFCA were studied. Paroxysmal AF
was present in 43 patients (75%), while 14 patients had persistent AF. After a
mean follow-up of 7.9±2.7 months, patients were divided into 2 groups: successful
RFCA (SR group) and recurrence of AF (AF group). RT3DE was performed
before, within 3 days and 3 months after RFCA to assess LA volumes (maximum,
minimum and preA) and function (passive, active and reservoir).
Results: A total of 38 patients (67%) had a successful RFCA (SR group). No
differences in baseline characteristics were found between SR and AF groups
except for higher percentage of persistent AF (42 vs. 11%, p

410 Atrial fibrillation
Results: Ninety-two PVAI patients had OSA and CAF. Patient demographics are
given in table 1. There was no significant difference in baseline characteristics.
Twelve patients were lost due to inadequate follow up data. The success rate in
Group 1 (treated) was 53.1% versus 39.5% in Group 2 (untreated) p=0.02.
Conclusion: Our results show that there was a trend suggesting that AF recurrence
is less in OSA treated patients; however, further more extensive and larger
randomized studies are necessary to determine whether this trend is indeed due
to the treatment effect.
P2621 Multi-electrode ablation with duty-cycled low power
bipolar/uniplolar RF energy for chronic AF
L.V.A. Boersma1 , C. Scharf2 ,W.Davies3 , P. Kanagaratnam3 ,
V. Paul4 ,E.Rowland4 ,A.Grace5 ,S.Fyn5 ,H.Oral6 , F. Morady6 .
1 2 St.Antonius Hospital, Cardiology, Nieuwegein, Netherlands; Klinik
im Park, Cardiology, Zurich, Switzerland; 3St.Mary’s Hospital, Cardiology,
London, United Kingdom; 4St.George’s, Cardiology, London, United Kingdom;
5 6 Papworth Hospital, Cardiology, Cambridge, United Kingdom; University of
Michigan, Cardiology, Ann Arbor, United States of America
Background: Widespread adaptation of radiofrequency catheter ablation (RFCA)
of chronic atrial fibrillation (CAF) has been limited by long procedure times and
low efficacy. This study was designed to evaluate the safety and efficacy of multielectrode
catheters delivering low power duty-cycled radiofrequency energy for
RFCA of CAF.
Methods: Fifty-three patients (51 male, 57±6 years) with documented CAF were
enrolled in a multi-center European study. Inclusion criteria included a failed
class I or III AAD and a DCCV. Three anatomically specific catheters (PVAC,
MASC, and MAAC, Ablation Frontiers Inc, Carlsbad CA) were used to isolate
the pulmonary veins (PVI) and eliminate complex fractionated atrial electrograms
(CFAEs) on the septum and left atrial wall. Bipolar/unipolar alternating radiofrequency
energy (GENius, Ablation Frontiers Inc, Carlsbad CA) was delivered simultaneously
through operator selected electrodes at ratios of 1:1, 2:1, or 4:1, depending
on location and the desired lesion depth. All ablations were 60 seconds
with a maximum power limit of 10 W/electrode to produce a target temperature of
60°C at each electrode pair. An early additional procedure (which reset the follow
up period) was allowed for patients if sinus rhythm was not maintained after 2
months. Anti-arrhythmic drugs were discontinued at 3 months. The chronic efficacy
endpoint was measured as an 80% reduction in AF burden, assessed with
a continuous 7-day Holter recording at 6 months post procedure.
Results: Fifty of 53 patients (94%) had documented successful PVI, with CFAE
ablation at the septum, LA roof, posterior wall, and mitral valve annulus, with
SR post procedure. Once trans septal puncture was complete procedure time
was 145±44 minutes, with fluoroscopy time of 49±21 min. Current follow up
is 172±58 days with a 6 month Holter recording completed in 47 patients. No
AF was present in 36 of 47 patients, while 2 additional patients had PAF for
less than 10% of the 7-day Holter recording. The current cumulative efficacy for
CAF at 6 months is 81%, with 34 of 38 patients off all AADs after 4 months.
The two-procedure rate was 51%. Five of the 8 efficacy failures did not receive
a retreatment procedure. Serious complications included 1 transient neurologic
event, 1 cardiac tamponade secondary to the transseptal puncture and 2 groin
hematomas.
Conclusions: Multi-electrode catheters in conjunction with low power duty-cycled
bipolar-unipolar RF energy may allow safe and efficient procedures for RFCA of
CAF, with a current efficacy at 6 months of 81%.
P2622 Relationship between catheter forces, lesion
charactheristics, popping, and char formation:
experience with robotic navigation system
L. Di Biase1 ,J.Cummings2 ,W.Saliba2 ,C.Barrett2 , R. Schwiekert 2 ,
A. Natale3 . 1Cleveland Clinic/University of Foggia, Cardiovascular
Medicine, Cleveland/Foggia, United States of America; 2Cleveland, United
States of America; 3University of Stanford, Palo Alto, United States of America
Introduction: Popping, char and perforation are complications that can occur
following catheter ablation.
We measured the amount of grams applied to the endocardium with a robotic
system. We evaluated the relationship between lesion formation, pressure, and
such complications using different catheter pressure and power settings.
Methods: Using a robotic navigation system, lesions were placed in the LA atrium
at 6 settings (Table 1), using a constant duration (40 sec) and flow rate with an
open irrigated catheter (OIC).
Necropsy was then performed.
Results: Lesions using 30 W were more likely to be transmural at higher (>40 gr)
than lower (40gr of pressure demonstrated "popping" and crater formation as compared to
lesions with 20-30gr of pressure (41.7% vs 16.7%, p40 50% 33.4% 16.7%
Group 6 45 >40 100% 0% 66.7%
Conclusions: Using OIC at lower power settings (< 35 Watts) and at
lower/medium pressure, lesions were more likely have a relatively spared endocardial
surface. Higher catheter pressure at higher power (>45 watss) were likely
to result in a transmural lesion. However, this also appears to be related to char,
crater formation and "popping". Moderate pressures (20-30g) were associated
with transmurality with lower incidence of complications.
P2623 Safety and efficacy of paediatric outpatient
radiofrequency catheter ablations
M. Tomaske, R. Candinas, M. Weiss, U. Bauersfeld. University
Children’s Hospital, Paediatric Cardiology, Zurich, Switzerland
Purpose: Radiofrequency catheter ablations (RFA) are frequently
performed as treatment for supraventricular tachycardia in children older than 4
years of age. Aim of this study was to evaluate safety and efficacy of paediatric
outpatient RFA.
Patients and Methods: Between 06/2002 and 03/2007, 201 RFA were prospectively
analyzed. Exclusion criteria for outpatient procedures were complex RFA
in congenital heart disease, arterial access or distance to home more than 1
hour. All RFA were performed under general anaesthesia. In case of transseptal
puncture, patients received a single-shot dose heparin. All patients underwent
postprocedural echocardiography and electrocardiogram and were discharged
within 6 hours after conclusion of RFA. To identify potential complications after
discharge, parental follow-up phone calls the day after outpatient RFA procedure
were performed.
Results: A total of 65/ 201 (32%) patients aged 13.6±3.8 years qualified for outpatient
RFA. Accessory pathway ablations (n=33) and atrioventricular node modifications
(n=28) were the most common RFA. A transseptal approach was performed
in 24 RFA. Median procedure time was 1.5 hours (range: 1.1 – 4.3), with
a median fluoroscopy time of 10 minutes (range: 5 - 86). RFA was successful in
63/65 (97%) patients. Postprocedural echocardiography with special attention for
intracardiac thrombi, pleural effusion and inflow patterns from systemic veins or
the coronary sinus were normal in all patients. Anaesthetic adverse events, predominantly
post-interventional nausea and vomiting, were observed in 9 (10%)
patients. Hospital discharge within 6 hours after conclusion of RFA was practicable
in all but one patient due to ongoing nausea. Follow-up phone calls did not
reveal further complications. Recurrence of tachycardia after RFA was observed
in 4 of 65 (6%) patients.
Conclusions: Outpatient RFA are feasible and safe in selected paediatric patients.
No RFA related complication was observed. Anaesthetic adverse events
were nausea and vomiting due to general anaesthesia. Success rate and recurrence
rate of tachycardia was favourable after outpatient RFA.
P2624 Feasibility and safety of radiofrequency catheter
ablation in outpatients
E. Marijon1 ,M.Zimmermann2 ,M.Schmutz2 ,S.Boveda1 ,
H. Burri2 , N. Combes1 , J.P. Albenque1 . 1Pasteur Clinic, Cardiology
Department, Toulouse, France; 2Tour-Meyrin Hospital, Cardiology
Department, Geneva, Switzerland
Purpose: Radiofrequency catheter ablation is now the treatment of choice of
most of arrhythmias. Standard clinical practice has been to keep patients in the
hospital for 2 or 3 days after the procedure. We sought to assess safety, feasibility
and short-term outcome of routine radiofrequency catheter ablation (RCA) on an
outpatient basis with discharge from the hospital on the same day.
Methods: The study population comprised 1270 consecutive patients (760 men,
510 women, mean age 57±17 years) who underwent RCA of the slow pathway
for treatment of AV nodal reentrant tachycardia (426), cavotricuspide isthmus for
atrial common flutter (585), atrial tachycardia (73) and accessory pathways (186)
in two different volume activity centers. All patients were hospitalized in the morning,
underwent RCA after venous (1189) or arterial (81) femoral assess, and were
discharged 4 to 8 hours later after systematic clinical exam, ECG and echocardiography
after transeptal approach (28). Patients were scheduled for a one-month
follow-up, and hospitalization and complication rates were prospectively collected.
Results: During the one-month follow-up, no death occurred and the hospitalization
rate was 0.6%: 6 patients had significant local complications (4 hematoma, 2
arterio-venous fistula), requiring surgical repair within one week after the procedure
in 4 cases, and 2 patients developed symptomatic delayed pulmonary embolisms.
No symptomatic pericardial effusion was reported. In intention to treat,
92% of the overall planed outpatients (1380) were really discharged the same
day. Moreover, we observed no significant association between complication rate
and volume center activity (p=0.37).
Conclusions: In view of these findings, RCA for routine arrhythmias appears to
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e feasible and safe. This approach is highly appreciated by patients and should
have important consequences in terms of cost-saving considerations.
P2625 Impact of anatomical factors on cryoballoon
pulmonary vein isolation
C. Herrera Siklody, M. Allgeier, J. Allgeier, R. Weber, P. Fluegel,
C. Restle, D. Kalusche, T. Arentz. Herz-Zentrum Bad Krozingen,
Rhythmologie, Bad Krozingen, Germany
Introduction: Electrical isolation of the pulmonary veins (PV) is the cornerstone
of atrial fibrillation catheter ablation. Balloon-mounted cryoablation devices have
been recently introduced as an alternative to radiofrequency catheters. We aimed
to assess the impact of anatomical factors on feasibility of PV isolation using such
devices.
Methods: We included 18 consecutive patients (88,9% Males, 56±9 years old)
who underwent PV isolation. A CT scan was performed before the procedure,and
3-D models of the left atrium were reconstructed and analyzed. PV antrum was
considered to be oval when the longest diameter was at least twice the shortest
one. Through a single transeptal puncture a cryoballoon (Cryocath, 4x23 mm,
14x28 mm) was advanced into the antrum of every PV and frozen twice over
5 minutes. In patients with a common left pulmonary ostium (CO), the 2 main
branches were consecutively isolated. Electrical isolation was then checked with
a multipolar circular catheter and additional focal cryoablations were performed
when needed (Cryocath).
Results: Two patients (13,3%) presented with a a left CO and another 3 with 1
or 2 supplementary right-sided veins. PV isolation was achieved with the balloon
in 63 of the 72 targeted veins (87,5%). Oval-shaped PV (8/72, 11,1%) could be
primarily isolated in 62,5% of the attempts, whereas round-shaped ones were
isolated in 90,6% of the cases (p=0,023). The mean diameter of primarily isolated
PV was slightly larger than the one of the not isolated ones (19,1±3,0 mm vs
17,0±2,2 mm,p=0,05). The following PV could not be isolated: 5 right lower, 3 left
lower and 1 left upper. Superior PV were more often successfully isolated than
theinferior ones (p=0,013). After 2,7±1,1 focal applications, all 72 targeted PV
could be successfully isolated at the end of the procedure.
Conclusions: Despite complex anatomical substract (CO, supplementary PV),
PV isolation could be safely performed with the combined use of a cryoballoon
and punctual cryoablation applications in all patients. The shape and size of the
PV antrum were predictive factors in the primary achievement of electrical isolation
withthe balloon, and should be taken into account in the design of new
devices.
P2626 Cost-effectiveness of radiofrequency ablation for
supraventricular tachycardia: results of healthcare
database of an Italian region
G. Barbato1 ,E.Berti2 ,V.Carinci1 ,S.Mall2 , G. Di Tanna2 ,
F. Pergolini1 , G. Di Pasquale1 . 1Maggiore Hospital, Cardiology,
Bologna, Italy; 2Agenzia Sanitaria Emilia Romagna, Bologna, Italy
Background: Although Radiofrequency ablation (RFA), is considered the firstline
treatment for symptomatic supraventricular tachycardia (PSVT), there are few
study regarding procedure cost-effectiveness versus medical treatment. We compared
the two different strategies evaluating the regional healthcare administrative
database.
Methods: The study population was drawn from the administrative healthcare
database of the region Emilia-Romagna (Italy). Including criteria were: admission
to one of the hospital of the region for PSVT in 2004. and at least 2 access
for PSVT to the public health service in the past 12 month. Then we follow this
cohort of patients, recording every events or hospitalization, during the following
12 months.
Results: In the 2004 736 pts had an access to our regional facilities for PSVT. Of
these 179 pts presented inclusion criteria. 74 have been discharged on medical
therapy (group A), 105 underwent to RFA (group B). In the following 12 months
67/74 (90%) pts of group A presented at least 1 clinical events (hospitalization
or medical visit). In the group B 42/102 pts (41%) had no clinical events, 56/102
had 1 clinical visit (55%), 4/102 one complication (2 one more hospitalization, 1
pace.maker implantation, 1 other complication). The initial cost for pts, in group
A was 1724.6 euro, in group B 6717.2 euro. In the cost analysis, considering for
group A similar annual rate of events, and for group B no more events related to
procedure, the RFA cost is recouped in 3 years.
Conclusion: On the clinical setting of real-life regional healthcare administrative
database the RFA treatment of pts highly symptomatic for PSVT is cost-effective.
Compared to medical therapy, the initial cost is recouped in 3 years, after then
there is a progressive cost reduction.
P2627 Catheter ablation of atrial fibrillation as first line
therapy? Experience from daily practice
H. Tanner, L. Roten, J. Seiler, N. Schwick, J. Fuhrer, E. Delacretaz.
University Hospital of Bern, Cardiology, Bern, Switzerland
Purpose: Catheter ablation of atrial fibrillation (AF) is generally considered
in patients (pts) with symptomatic AF refractory to class I and III antiar-
Atrial fibrillation 411
rhythmic drug (AAD). However, catheter ablation of AF as first line therapy is an
alternative for selected pts.
Methods: We studied all pts undergoing catheter ablation for symptomatic AF between
2002 and 2007. Pts without AAD pre-treatment (Group 1) were compared
to all others (Group 2). Moreover, reasons for choosing this treatment strategy
were analysed.
Results: From the 284 pts included, 43 (15%, Group 1) underwent AF catheter
ablation as first line therapy, and 241 pts (85%, Group 2) had at least one preceding
AAD trial. In pts with catheter ablation as first line therapy, the main reason
for this strategy was pt’s preference, driven by the fear of AAD side effects, n=32
(74%), accepting the risks of catheter ablation. Almost half of these pts (44%) had
a physically very active lifestyle (i.e. endurance sports). In 11 pts (26%) catheter
ablation as first line therapy was chosen because of medical considerations, i.e.
prolonged sinus pauses on termination of AF. AF duration prior to ablation was
shorter in group 1, but other clinical, procedural, and follow-up data did not differ
significantly (table).
Patient characteristics and outcome
Group 1 (n=43) Group 2 (n=241) P value
Age, years, mean±SD 59±11 58±10 ns
Gender, male, n (%) 35 (81) 189 (78) ns
AF duration, months, mean±SD 45±45 80±86 0.009
Persistent AF, n (%) 13 (30) 80 (33) ns
Structural heart disease, n (%) 22 (51) 104 (44) ns
LVEF,%,mean±SD 60±8 50±10 ns
LA, mm, mean±SD 44±6 45±7 ns
Major complications, n (%)
Success rate (n=164, with serial 7-day-ECG
2 (5) 10 (4) ns
follow-up), % 76 71 ns
Conclusions: Catheter ablation as first line therapy of AF is feasible. The main
reason for first line catheter ablation of AF was pt’s preference because of fear of
drug side effects with respect to their very active lifestyle and to a lesser extent
by medical reasons. Success rates and complications did not differ between first
and second line catheter ablation for AF.
P2628 Pulmonary vein isolation for atrial fibrillation in
patients with brady-tachy type sick sinus syndrome
K. Ishikawa, H. Hirayama, Y. Yoshida, M. Nanasato, Y. Tatematsu,
N. Inoue, Y. Aoyama, T. Hashimoto, T. Yamamoto, N. Kanemura.
Nagoya Daini Red Cross Hospital, Cardiology Dept., Nagoya, Japan
Background: Sick sinus syndrome is commonly associated with tachyarrhythmias
and bradyarrhythmias that often are symptomatic and an indication for pacemaker
implantation. The aim of this study was to assess the effect of pulmonary
vein isolation in patients with sick sinus syndrome and atrial fibrillation (AF).
Methods and Results: Forty three consecutive patients diagnosed as sick sinus
syndrome with AF underwent pulmonary vein isolation between December 2001
and July 2007. Sick sinus syndrome was defined as a prolonged sinus pause
(≥3 seconds) found in any electro cardiography or sinus bradycardia (≤40bpm)
with dizziness or fatigue. Four patients were implanted pacemaker previously to
ablation. Patients had AF for average of 4.3±4.8 years. Their mean age was
64.6±10 years old, left atrium diameter was 37.4±6mm and had ejection fractions
of 60.7±9%. AF reccurred in 13 patients (30%) during the follow up period
(1.5±1.9 years). Eight underwent second pulmonary vein isolation and 5 had successful
result. The overall long-term success rate was 81.4%. Pacemakers were
implanted in seven patients after the procedure (18% of no previous pacemakers).
Conclusion: Cure of AF by pulmonary vein isolation helped resolve the clinical
manifestations of sick sinus syndrome. It may be an alternative therapy to pacemaker
implantation for patients with brady-tachy type sick sinus syndrome.
P2629 Three-dimensional image integration based on gated
vs. non-gated cardiac computed tomography to
assist ablation of atrial fibrillation: evaluation of
integration accuracy and patient radiation dose
J. Ector, S. De Buck, W. Huybrechts, D. Nuyens, S. Dymarkowski,
J. Bogaert, F. Maes, H. Heidbuchel. University Hospital Gasthuisberg, Cardiology,
Leuven, Belgium
Background: We developed methods for real-time biplane integration of threedimensional
(3D) left atrial models with fluoroscopic images to assist catheter
ablation of atrial fibrillation (AF). This approach allows quantitative assessment of
3D image integration accuracy by direct comparison with combined angiographic
images of the four pulmonary veins (PVs).
Methods: Sixty patients underwent AF ablation under biplane fluoroscopic guidance
after selective angiography of the 4 pulmonary veins. CT-based 3D models
were integrated in the fluoroscopic framework using a landmark-based registration
approach. Integration accuracy was quantitatively assessed and compared
for 3D models based on ECG-gated (n=31) vs. non-gated (n=29) 64-slice cardiac
CT. Effective patient radiation dose from cardiac CT was calculated based on the
CT dose-length product and conversion factor for chest examinations.
In 30 of the 60 patients (3D+ group), the integrated 3D model was used for realtime
3D-augmented fluoroscopic catheter navigation and the effects on proce-
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412 Atrial fibrillation
dural parameters and patient radiation dose (as calculated from per-procedural
dose-area product levels) were evaluated.
Results: Low PV alignment errors in the entire patient group (n=60) indicated
accurate 3D-fluoroscopy integration in both planes based on the landmark-based
registration approach (median[IQR] total alignment error: RAO 2 [0.5-5] mm vs.
LAO 2[0-4] mm, p=0.06).
The effects of ECG-gating and respiratory phase during CT-acquisition on integration
accuracy were small and clinically irrelevant. Only the alignment error in
the RAO-plane showed a borderline significant reduction for ECG- gated vs. nongated
CT-acquisitions (2[0-4] mm vs. 2[2-6] mm, p=0.05). ECG-gated CT however
resulted in a very important increase in patient radiation dose vs. non-gated CT
(17.3±5.2 mSv vs. 4.4±3 mSv,p

coagulant therapy (P=0.038; OR=2.424, 95% CI= 1.048 – 5.606) was a predictor
of venous obstruction.
Conclusion: Warfarin prophylaxis reduced the frequency of venous thrombosis
after transvenous devices implantation in high risk patients.
P2634 Impact of RVOT pacing on time course of
inter-ventricular and intra-ventricular dyssynchrony.
A six months follow up
S.K. Dwivedi, A. Makhija, S. Mukerjee, R. Sethi, A. Puri, V.S. Narain,
V.K. Puri, R.K. Saran. KG’s Medical University., Cardiology, Lucknow,
India
Objective: Right ventricular apical (RVA) permanent pacemaker implantation
(PPI) produces abnormal pattern of ventricular depolarization with adverse functional
and structural changes in the left ventricle (LV). Right ventricle outflow tract
(RVOT) as an alternative site for PPI is under investigation. Aim of present study
was to prospectively evaluate the impact of RVOT pacing on LV electromechanical
dyssynchrony using tissue Doppler imaging (TDI) over a follow up of 6 months
in patients with normal LV functions undergoing VVI pacing.
Methods: Seventy four consecutive patients (age 63.6±10.1 years, 65.3% males)
with symptomatic bradycardia were randomized to RVOT pacing (n=37) or
RVA pacing (n=37). Inter-ventricular dyssynchrony (Inter VD) was defined as
time difference between aortic and pulmonary pre-ejection time intervals. Intraventricular
dyssynchrony (Intra VD) was defined as time difference between the
shortest and the longest LV wall electromechanical delays among basal septum,
lateral, anterior and inferior segments on pulsed TDI. Baseline parameters were
taken on RVA pacing in both groups.
Results: RVOT pacing resulted in significantly narrower QRS complex as compared
to RVA pacing (133.3±14.1 vs. 142.8±17.0 msec, p=0.013). Both Inter
VD and intra VD were significantly lesser on RVOT pacing as compared to RVA
pacing (-13.7±0.8 msec, p= 0.004 and -16.7±0.5 msec, p=0.001 respectively) at
6 months follow up. Fall in ejection fraction (EF) was lesser in RVOT pacing as
compared to RVA pacing (-1.4±0.4% vs. -3.4±0.4%, p=0.06). Fall in EF >10%
occurred in four and one patients on RVOT pacing and RVA pacing respectively.
Echocardiographic parameters on follow up
Basal 1 Month 6 Month RVOT
RVOT RVA RVOT RVA RVOT RVA
EF% 56.6±3.8 57.9±4.6 55.4±3.9 54.6±4.9 55.3±3.9 54.2±5.5
Inter VD (msec) 50.9±12.6 49.4±13.0 36.6±10x 50.3±9.9 36.9±7.8x 50.4±12.2
Intra VD (msec) 65.3±24.5 68.5±13.7 48.2±9.5x 69.1±13.3 48.2±10.8x xp value65 ms) and dobutamine stress echo (up to 40 mcg/kg/min,
with presence of CR defined as a wall motion score index, WMSI, increase >0.20)
with core lab reading. "Responders" were identified by clinical (survivors, with
NYHA class improvement ≥1 grade) and/or echocardiographic (LV end-systolic
volume, ESV, decrease ≥15% at 6-months follow-up) criteria.
Results: In the follow-up, 28 (51%) patients were responders to CRT. At individual
patient analysis, CR was more often associated with a favourable outcome
whereas DYS criteria were equally present in the 2 groups: see figure. Changes
in ESV from baseline to 6 months post-CRT were correlated with pre-CRT reststress
changes in ESV (r=.439; p=.003) and in WMSI (r=-.458; p=.001) but not
with baseline DYS values. At multivariate analysis, CR (OR= 6.2, 95% CI= 1.4-
27.6) and ischemic etiology (OR= 0.20, 95% CI= 0.05-0.73) were the best predictors
of clinical and echo response to CRT, regardless of DYS.
Conclusions: Patients with CR during stress echo show a favourable clinical
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414 Cardiac resynchronization therapy: miscellaneous
and reverse LV remodelling response to CRT. This finding shifts the focus from
electrical (DYS) to the myocardial substrate of functional response to CRT: no
muscle, no party!
P2638 Is right ventricular lead positioning important for
cardiac resynchronization therapy?
D. Manolatos, A.M. Sideris, M. Efremidis, S. Xidonas, G. Gavrielatos,
L.K. Pappas, D. Bramos, V. Derveni, D. Kardara, F. Kardaras.
Athens, Greece
Objective: The optimal left ventricular (LV) pacing site for cardiac resynchronization
therapy (CRT) has been investigated, but less is known about the optimal site
in the right ventricle (RV).
Methods: This study compared the acute haemodynamic response to biventricular
pacing (BiV) at two different RV stimulation sites: RV outflow tract (OUT)
and RV apex (APEX) in 15 patients with heart failure and ventricular conduction
delay. Pacing catheters were placed in the high right atrium, lateral wall of the
left ventricle (LV), right ventricular apex (APEX) and right ventricular outflow tract
(OUT). A continuous cardiac output thermodilution catheter was placed in the pulmonary
artery. Patients were studied during: 1) atrio-BiV pacing from APEX and
LV (APEX+LV) 2) atrio-BiV pacing from OUT and LV (OUT+LV) 3) AAI mode (used
as reference). Haemodynamic changes and QRS duration (QRS) with atrio-BiV
pacing, were assessed relative to the AAI pacing data. Pacing was performed at
100 beats/min with an AV delay of 150ms. During each pacing mode the ECG and
haemodynamic parameters [cardiac index (CI), pulse pressure (PP), pulmonary
artery diastolic pressure (PADP)] were recorded. A repeated measures one-way
analysis of variance was used to determine differences in haemodynamics among
the different pacing modalities. Post hoc paired comparisons were made using
Tukey’s HSD test with p set at 0.05.
Results: Haemodynamic measurements and QRS were not significantly
changed during atrio-BiV pacing from OUT+LV when compared to the atrio-BiV
pacing from APEX+LV. Both atrio-BiV pacing modes had a favorable effect on
haemodynamics and QRS compared to AAI pacing (Table 1).
Table 1. The impact of RV pacing site on haemodynamic parameters and QRS during BiV pacing
AAI OUT+LV APEX+LV P value
QRS (ms) 154.93 132.00 128.27

ison between responders and nonresponders (independent T- and Fisher exact
test); defining a ESV decrease of ≥ 15% and being alive without transplant as a
responder.
Results: Overall, CRT induced an immediate increase in dP/dt max during implantation
(721±177 to 932±215 mmHg/s, p

416 Syncope and cardiac pacing: miscellaneous
Methods: The database of the obligatory external quality control program in the
federal state of Hessen was analysed, which includes all stationary primary pacemaker
implantations. Data completeness is > 95%.
Results: In the federal state of Hessen 17.826 patients underwent pacemaker
implantation in 72 hospitals from 2003 to 2006. Of these, 9405 (52.8%) have
been male and 8421 have been female (47.2%).
The data for both genders are shown in table 1 (t-test for continuous variables,
χ 2 -test for nominal scaled variables).
Conclusion: In this large scale cohort, female patients with a primary pacemaker
implant were significantly older, had fewer AV-blocks and more Sick Sinus Syndrome,
compared to men. They received more single chamber devices and had
more operative complications. Atrial pacing thresholds were higher and P-wave
amplitudes were lower in women. Ventricular and procedural parameters showed
no significant difference between both genders.
P2646 Deleterious effect of right ventricle apical dual
chamber pacing on left ventricle diastolic function in
patients with preserved ejection fraction
F. Fang, J.Y.S. Chan, Q. Zhang, J.W.H. Fung, G.W.K. Yip,
W.W.M. Chan, A.K.Y. Chan, C.M. Yu. The Chinese University of
Hong Kong, Hong Kong, Hong Kong SAR, People’s Republic of China
Background: Little is known about the effect of right ventricle apical (RVA) pacing
on LV diastolic function or diastolic dyssynchrony, and whether such impact is
different between patients with and without pre-existing LV diastolic dysfunction
(DD).
Methods: 99 patients with sick sinus syndrome (68±11yrs, 29male) who had
ejection fraction>50% and implanted with permanent pacemakers were examined
by echocardiography with tissue Doppler imaging (TDI) (iE33, Philips) during
ventricular sensing and pacing modes in a random order. LV diastolic function
was assessed by Doppler parameters, mitral annulus early diastolic velocity (E’),
transmitral early diastolic velocity to E’ ratio (E/E’), while diastolic dyssynchrony
was assessed by the standard deviation of time to peak myocardial early diastolic
velocity in 12 LV segments (Te-SD).
Results: During ventricular pacing, LV diastolic function was deteriorated mainly
in those with pre-existing DD with prolongation of deceleration time of E wave, reduction
of E’and increased E/E’and Te-SD (Table). In those with normal diastolic
function, only a mild reduction in E’was observed while E/E’remain unchanged.
There were 12 patients shifted towards more severe patterns of diastolic dysfunction
while 47 patients had E’reduced by≥10%. These changes occurred mainly
in those with pre-existing DD (57% vs 31%, p=0.038). The change in Te-SD was
only weakly correlated with the change in E’(r=0.21, p=0.045). By multivariate
analysis, pre-existing DD was the only independent predictor for reduction of
E’(OR=2.672, p=0.043).
Parameters Without pre-existing DD (n=38) With pre-existing DD (n=61)
V sense V pace P value V sense V pace P value
Deceleration time of E wave,
ms 210±39 231±51 0.018 223±60 240±53 0.028
E’, cm/s 8.0±1.9 7.6±2.0 0.034 6.3±1.9* 5.5±1.5*

Table 1. Systolic, diastolic and dyssynchrony parameters for different AV-intervals
AV-default AV optimal p-value
Stroke volume [ml] 71±18 77±19 0,003
Cardiac index [l/min/m 2 ] 2,58±0,66 2,74±0,78 0,03
Stroke work [mmHg/ml] 5931±1891 6867±2133 0,00004
+dp/dtmax [mmHg/s] 1308±389 1319±377 n.s.
-dp/dtmax [mmHg/s] -1297±233 -1350±331 n.s.
tau [ms] 38±10 38±8 n.s.
Peak filling rate [ml/s] 778±423 832±450 n.s.
Systolic dyssynchrony [%] 17,7±7,0 19,4±7,1 0,01
Global cycle efficiency [%] 62±10 72±29 0,04
chanic efficiency as suggested by the decreased systolic dyssynchrony and the
improved global cycle efficiency.
P2650 Is warfarin pause or bridging therapy necessary for
pacemaker implantation?
H. Lahtela1 , J. Koistinen1 , P. Korkeila1 , P. Karjalainen2 ,A.Ylitalo2 ,
J. Airaksinen1 . 1Turku University Hospital, Department of Internal
Medicine, Turku, Finland; 2Satakunta Central Hospital, Department
of Cardiology, Pori, Finland
Purpose: There are no established guidelines regarding interruption of warfarin
anticoagulant therapy prior to implantation of cardiac pacemakers, but it is a common
consensus to postpone pacemaker implantation to reach INR levels < 1.5-
1.8 and use bridging therapy in patients with high risk of thromboembolism. The
purpose of this prospective multicentre study (FinPAC) is to compare bleeding and
thromboembolic complications of pacemaker implantation during uninterrupted
and interrupted oral anticoagulant treatment. We report interim results from 2
centres.
Methods: A total of 61 patients (mean age 73 years, 34 men) with long-term
warfarin treatment have been randomized to either a interrupted (≥2 days) or
continuous warfarin therapy before implantation. Patients on aspirin (N=33) are
recruited as a control group. Bridging therapy was not allowed.
Results: The periprocedural INR levels were higher without a warfarin pause
(2.28 vs 1.92, p 50 mmHg. Based on
the ability to give a clear history of the accidental fall, patients with femoral fracture
were categorized in two groups: group A included patients who were able to
Syncope and cardiac pacing: miscellaneous 417
fully describe the index event, while group B included subjects with unexplained
falls.
Results: Eighteen patients (35.3%) who presented with hip fracture had a positive
response to carotid sinus massage; six out of 33 (18.2%) patients in group
A and 12 out of 18 (66.7%) patients in group B (p < 0.001). Nine controls
(17.6%) also demonstrated CSH. Patients in group B were older (A: 75.5±8.5
vs B: 80.1±5.9, p = 0.029) and were more likely to have a history of unexplained
falls or syncope in the past (A: 0% vs B: 66.7%, p < 0.0001) than individuals in
group A. When compared with the control group, CSH was still more common in
group B (B: 66.7% vs control: 17.6%, p < 0.0001) but not in group A (A: 18.2%
vs control: 17.6%, p = 1.000).
Conclusions: The prevalence of CSH is increased in elderly patients presenting
with femoral fractures, only in those who present with unexplained fall and report
a history of syncope or unexplained falls in the past. Early identification and treatment
of these patients could possibly prevent the occurrence of femoral fractures
later in their lives.
P2652 Efficacy of an outpatient clinic for high risk syncope
discharged from emergency department
N. Romero Rodriguez1 , G. Baron-Esquivias2 , S. Gomez-Moreno1 ,
F. Errazquin Saez De Tejada1 , A. Pedrote1 , A. Martinez-Martinez1 .
1Virgen del Rocio University Hospital, Cardiology, Sevilla, Spain;
2Virgen del Rocio University Hospital, Cardiology, Seville, Spain
Purpose: Those patients presenting syncope with certain cardiovascular risk
profile (age>65 years, abnormal electrocardiogram, syncope without prodromes
and/or cardiovascular disease in clinical history) are associated with a higher mortality
rate, even though they might be discharged from emergency departments.
In order to optimize the correct diagnosis and follow up of these patients we evaluated
the usefulness of a monographic out-hospital syncope unit.
Methods: those patients discharged from the emergency department that fulfilled
this clinical profile were studied in our unit in less than 72 hours and, following
Europeans syncope guidelines, we analyzed the diagnostic value of each test
once a definite origin of the syncope was established, with a follow up of more
than two years.
Results: A total of 107 consecutive patients were evaluated, out of which we finally
included 82 that fulfilled high risk syncope criteria. We did an echocardiography
to every patient together with completing an ambulatory monitoring. A total of
23 tilt table tests were done, 4 electrophysiological studies developed and 2 Reveals
implanted. A final diagnosis was achieved in 92,7% of them: 50% neurally
mediated, 22% orthostatic, 12,2% arritmogenic, 6,1% neurological, 1,2% cardiac
y 1,2% psychiatric. The overall mortality rate included 9 patients (11%), due to
vascular causes in 5 cases (4 cerebravascular accidents and 1 acute myocardial
infarction), oncologic in 3 and traumatologic in 1. Diagnosis cost was 573� per
patient.
Conclusions: The existence of a syncope unit improves the attention of those
high risk patients, improving the overall management following European syncope
guidelines and significantly increasing the final percentage of patients in which a
final diagnose is achieved with a low final economic cost and risk.
P2653 Is tilt training also an efficacious therapy in older
patients with neurally mediated syncope?
T. Reybrouck, H. Heidbuchel, R. Willems, H. Ector. Gasthuisberg
University Hospital, Department Cardiovascular Rehabilitation,
Leuven, Belgium
Background: Falls with loss of consciousness are frequently observed in older
patients. In many cases the cause of loss of consciousness is a neurally mediated
syncope (NMS). In younger patients tilt training has shown to be a successful first
line therapy. The aim of this study is to analyse whether older patients can also
successfully be treated with tilt training therapy.
Methods: 73 patients above 65 years of age (mean age 73.6±5.1 years, median
72.7) with recurrent neurally mediated syncope were admitted to the hospital for a
program of tilt training. The patients underwent a diagnostic tilt test without pharmacological
provocation, according to the Westminster protocol (60° inclination).
The patients were tilted daily until syncope or maximally 45 min (= normal value).
This patient group was compared to a group of 250 young patients with neurally
mediated syncope (< 35 years, mean age: 19.5 ± median 17.5 years) who also
underwent tilt training therapy. After discharge from the hospital the patients were
instructed to continue tilt training at home for 1 or 2 periods of 30 min per day.
The results show that tilt training is also effective in older patients with NMS. A
negative tilt test could be obtained in all patients. However the time to achieve a
first negative tilt test is slightly longer in older patients compared to younger ones.
All patients became syncope-free during daily life.
Results tilt training (N° = number)
Group N Duration diagnostic tilt test (min) N° first negative tilt test
> 65 years 73 25.7±13.9 3.4±1.3
< 35 years 250 21.4±13.8 2.9±1.3
P = 0.019 P = 0.028
Conclusion: Older patients with NMS can be treated successfully with tilt training
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418 Syncope and cardiac pacing: miscellaneous
therapy. A major advantage of this therapy is the lack of side effects as many
elderly patients have comorbidities and are already taking multiple drugs.
P2654 Reactive vasodilation and the clinical expression of
vasovagal syncope
P. Flevari, K. Fountoulaki, D. Leftheriotis, C. Komborozos, J. Lekakis,
D. Kremastinos. Athens, Greece
Purpose: In an attempt to elucidate the role of vasodilative mechanisms
in VVS, we assessed, in supine patients with VVS, i) peripheral basal flow
and post-ischaemic vasodilative responses, ii) their relation with the syndrome’ s
severity.
Methods: Thirty-four patients were studied, mean aged (±1 SE) 44±4 years, 16
male, with recurrent VVS and a recent, positive head-up tilt test. Seventeen age
and sex-matched healthy subjects served as controls. Venous occlusion plethysmography
was used to assess forearm blood flow (FBF) i) at rest, ii) during reactive
hyperaemia. Hyperaemic FBF corresponded to the mean value of the first 4
measurements observed after arterial occlusion release. FBF was expressed in
ml/100 ml/min. The duration of hyperaemia was the time (sec) at which FBF returned
to 50% of its maximal increase relative to baseline flow. The clinical severity
of the syndrome, as assessed by the total number of syncopal and presyncopal
episodes, was related to the intensity and duration of the vasodilative reflex.
Results: No significant differences were observed between patients and controls
in baseline FBF (3.9±0.3 vs 4.6±1.1, p: NS) or in hyperaemic FBF (8.2±0.7 vs
8.8±1.3, p: NS). The duration of reactive hyperaemia was longer in patients compared
to normal subjects (22.3±4.1 sec vs 14.2±2.6 sec respectively, p

Syncope and cardiac pacing: miscellaneous / Understanding determinants of hemodynamics and ventricular function 419
tion is less clear. This study examines the effect of CRT on diastolic function using
load-independent tissue Doppler measures of diastolic function. As a mitral annular
relaxation velocity (EM)>3 and LV end diastolic filling pressure (LVEDP)
(E/EM)3 and E/Em

420 Understanding determinants of hemodynamics and ventricular function
pairment is related to the severity of HT. These abnormalities were reversed after
L-thyroxine therapy.
P2663 Torsion and rotation rate of left ventricle are related to
cardiac function in experimental canine
W. Wu 1 , H.A.O. Wang2 . 1Cardiovascular Institute and Fuwai
Hospital, Department of Echocardiography, Beijing, China, People’s
Republic of; 2Cardiovascular Institute and Fuwai Hospital, Beijing,
China, People’s Republic of
[Objective] To evaluate the correlation between torsion, rotation rate and cardiac
function in health mongrel dogs. [Methods] Left ventricle (LV) ejection fraction
(EF) by modified Simpson’s method and mitral inflow measurements included
peak early (E), peak late (A) velocities, E/A ratio and other diastolic indices were
measured in 10 health mongrel dogs (range1-2 yr, 22.55±2.78kg weight, 5 females).
Mean rotation, rotational rate were measured at basal, papillary and apex
levels of LV using the two dimensional speckle tracking imaging (STI). Dogs underwent
cardiac catheterization for LV end-diastolic pressure (LVEDP) and the
peak rates of LV pressure decline (–dp/dtmax) using a6Frpigtailcatheter.The
correlations were analyzed between torsion, rotation rate and LVEF, LVEDP, –
dp/dtmax. [Results] 152 of 180 segments were analyzed by 2D-STI successfully.
In normal canine, basal rotation was clockwise (negative) during systole, but apical
rotation was consistently counterclockwise (positive). The difference on Time
to peak rotation and rotation rate among the three short axis views was not significant
but there was the sequential shortening from basal loop to apical loop.
Torsion was correlated well with LVEF (R=0.941, P=0.005). –dp/dtmax inversely
was correlated with the ratio of early and late peak rotation rate (PRRe/PRRa)
(R=-0.805, P=0.05). There were close relations between LVEDP and the indices
of PRRe and PRRa (P=0.018 vs. 0.033). But there was no significant difference
between. –dp/dtmax, LVEDP and torsion. [Conclusions] Torsion is a novel index
to assess LV systolic function; PRRe and PRRe/PRRa have potential to become
a clinical tool for quantifying LV diastolic function.
P2664 Low cardiac output in young adults with chronic
fatigue syndrome and small heart
K. Miwa1 ,M.Fujita2 . 1Nanto Home and Regional Medical Center,
Department of Internal Medicine, Nanto, Japan; 2Kyoto University
Graduate School of Medicine, Human Health Sciences, Kyoto,
Japan
Purpose: "Small heart syndrome", previously referred to so-called "neurocirculatory
asthenia" in young adults associated with a small heart shadow on the chest
roentgenogram, is characterized by weakness or fatigue even after mild exertion,
palpitation, dyspnea and fainting, many of which resemble symptoms in patients
with chronic fatigue syndrome (CFS). We sought to determine the significance of
"small heart syndrome" in the pathogenesis of CFS.
Methods: The study population comprised 42 patients with CFS younger than 40
years of age. Cardiac function was evaluated echocardiographically.
Results: "Small heart" (Cardiothoracic ratio ≤42%) was noted in 26 (62%) of
CFS. Echocardiographic examination revealed significantly smaller mean values
of both the left ventricular (LV) end-diastolic and end-systolic dimensions, stroke
volume indexes and cardiac indexes in CFS patients with "small heart" than in
those without it and also in 20 control subjects. Thus, CFS with "small heart" had
an actually small LV chamber and poor cardiac performance. During a long followup
period of 10 CFS patients with "small heart", all above-mentioned echocardiographic
parameters improved significantly during the remission phase as compared
with exacerbation phase (Table).
Comparison of Echocardiographic Findings
Exacerbatioin Remission p value
Heart rate (beats/min) 71±9 63±60.014 LV end-diastolic dimension (mm) 37.7±3.6 42.8±2.5

their downstream effector, myosin heavy chain, are involved in the pathogenesis
of diabetic cardiomyopathy.
P2667 Acute increase in left ventricular filling pressure
leads to hyperventilation in heart failure patients with
central but not obstructive sleep apnoea
O. Oldenburg, T. Bitter, C. Piper, C. Langer, M. Wiemer, D. Horstkotte.
Heart Center NRW, Ruhr University Bochum, Department of
Cardiology, Bad Oeynhausen, Germany
Purpose: The pathohysiology of Cheyne-Stokes-respiration (CSR) in congestive
heart failure (CHF) is not fully understood. It is supposed that an increase in
pulmonary capillary Wedge pressure (PCWP) leads to stimulation of pulmonary
J-receptors and consecutive hyperventilation and fall in arterial pCO2 below the
apnoea threshold. The present study investigates the influence of an acute increase
in PCWP in CHF pts with central (CSR) and obstructive sleep apnoea
(OSA).
Methods: Simultaneous left and right heart catheterisation were performed in 17
pts with sleep disordered breathing (SDB) and symptomatic compensated CHF
(NYHA ≥ II, LVEF ≤ 40%). PCWP and arterial pCO were measured under standardised
settings at baseline and after left ventricular angio- and/or aortography
to acutely increase intravascular volume. CSR and OSA were determined by cardiorespiratory
polygraphy in the night before heart catheterisation. Central CO2 –
receptor sensitivity was verified by testing the hypercapnic – hyperoxic – ventilatory
response (HCVR) according to Read.
Results: CSR was diagnosed in 11 pts (apnoea-hypopnoea-index [AHI]
29.4±19/h; age 59±11 years; LVEF 31.6±7%) and OSA (AHI 12.7±5.6/h; 67±8
years; LVEF 31.7±5%) in 6 pts. HCVR was significantly higher in pts with CSR
(6.70±6.9 l/min/mmHg) than in OSA pts (2.1±0.6 l/min/mmHg; p < 0.05). PCWP
were elevated at baseline and increased significantly after angiography in both
groups (CSR: 20.6±6.1 mmHg to 23.8±7.6 mmHg; OSA 27.7±5.6 to 31.2±5.4
mmHg; both p

422 Understanding determinants of hemodynamics and ventricular function
P2671 Non-invasive determination of cardiac output by
CW-Doppler ultrasound - comparison with cardiac
magnetic resonance tomography
J. Saur, T. Papavassiliu, S. Fluechter, F. Trinkmann, J. Weissmann,
M. Borggrefe, J.J. Kaden. University Hospital Mannheim, 1st
Department of Medicine, Mannheim, Germany
Objective: Cardiac output (CO) is an important parameter in the diagnosis and
therapy of cardiac diseases. The current standard methods for the determination
of CO, however, are either invasive (e.g. right heart catheterization, PiCCO) or
technically expendable and expensive (cardiac magnetic resonance tomography,
CMR). The traditional non-invasive methods of determining CO by rebreathing of
carbon dioxide or bio impedance cardiography are easily carried out but suffer
from methodical inaccuracies. Therefore the aim of the prospective study at hand
was to evaluate a new method for determining the CO based on CW-Doppler
ultrasound (CWD).
Methods: The CO of 32 consecutive patients scheduled to undergo CMR was
determined in reclining position. The measurements were either performed immediately
before or after the CMR examination using CWD (USCOM, USCOM LTD,
Sydney Australia). The data determined by CMR for cardiac output and stroke
volume (SV) served as reference values which were compared to the arithmetic
mean of two serial CWD measurements. The statistic comparison of the methods
was drawn by means of Bland-Altman analysis.
Results: The patient collective consisted of 20 men (aged 17-80 years, median
51 years) and 12 women (aged 27-78 years, median 64 years). In 29 out of 32
consecutive patients during the investigation period CO and SV could be determined
by CWD, in 3 patients (9%) no acceptable ultrasonic signal could be obtained.
The cardiac output determined by CMR was 5.2±1.1 l/min (mean ± SD,
minimum 3.0 l/min, maximum 7.5 l/min) and 4.7±1.1 l/min (minimum 2.8 l/min,
maximum 8.0 l/min) by CWD. Bland-Altman analysis revealed a good correspondence
of the two methods with a mean bias of 0.5±1.0 l/min for the determination
of CO and 6.9±16 ml for the SV, respectively. CWD showed a good repeatability
with a mean bias of 0.1±0.5 l/min for CO and 0.3±7.7 for SV.
Conclusion: CW-Doppler ultrasound allows reliable non-invasive measurements
of cardiac output and stroke volume with good repeatability. The future importance
of the method for diagnosing and treating cardiac diseases remains to be
assessed in further investigations.
P2672 Increased left ventricular dimensions and lower
ejection fraction are associated with enhanced
cardiac function in patients with growth hormone
deficiency
D. Barker, R. Moisey, N. Lewis, S. Orme, L.B. Tan. Leeds General
Infirmary, Leeds, United Kingdom
Objectives: Echocardiographic left ventricular ejection fraction (EF) and cardiac
dimensions are used to represent cardiac function - low EF or a dilated left ventricle
suggest poor function. Some studies have shown cardiac dimensions and
mass to be lower in patients with growth hormone deficiency (GHD) compared
to controls. The aim of this study was to assess the relationship between directly
measured cardiac function and cardiac dimensions/EF.
Methods: Eighteen patients with severe GHD awaiting growth hormone therapy
(mean age 46 years, range 25-64 years) underwent transthoracic echocardiogram.
Left ventricular (LV) dimensions, volumes and EF were measured using
Simpson’s method. LV mass was calculated and corrected for body surface area
(LV mass index, LVMi). To evaluate cardiac pump function directly, patients also
underwent maximal cardiopulmonary exercise testing with non-invasive assessment
of cardiac output (CO) using the CO2-rebreathing method. Cardiac power
output (CPO) was calculated from peak CO multiplied by mean arterial pressure.
Results: All measurements were within normal reference ranges with none of
the patients showing significant LV systolic or diastolic dysfunction. Peak exercise
CPO positively correlated with LV systolic (r = 0.61, p < 0.01) and diastolic (r =
0.74, p < 0.01) dimensions, LV end-systolic volume (r = 0.82, P = 0.001) and
LVMi (r = 0.69, P = 0.003). There was a negative correlation between peak CPO
and EF (r = -0.68, P < 0.01).
Conclusions: We found that in patients with significant GHD, greater LV dimensions,
volumes or LVMi were paradoxically associated with enhanced cardiac
function. We also found that patients with lower EF had better cardiac function.
These findings contradict the usual belief that higher EF and lower cardiac dimensions
are better.
P2673 Left ventricular geometry after septal anterior
ventricular exclusion and Dor operation among
patients with ischemic cardiomyopathy
Y. Takahara, K. Mogi, M. Hatakeyama, A. Dou. Funabashi Municipal
Medical Center, Cardiovascular Surgery, Funabashi, Japan
Purpose: To demonstrate left ventricular (LV) geometry after endoventricular reconstruction
using septal anterior ventricular exclusion (SAVE) and endoventricular
circular patch plasty (Dor operation) among patients with ischemic cardiomyopathy.
Methods: Twenty-one patients (LVEF < 35%) with preoperative LVDd more than
60 mm or diastolic LV sphericity index (DSI; transversal length/longitudinal length)
more than 60% underwent endoventricular reconstruction. Eleven patients underwent
SAVE and 10 patients underwent Dor operation. The mean age was
65.1±10.5 years old in the SAVE group, and 63.3±9.4 years old in the Dor group.
There were no significant differences in the preoperative characteristics concerning
hypertension, diabetes, hyperlipidemia, and chronic renal failure between the
groups. LV geometry of the two procedures was studied by transthoracic echocardiogram
comparatively.
Result: Preoperative LVEF was 22.8±6.9% (SAVE) vs. 27.4±4.7% (Dor, p
= 0.095), LVDd was 56.2±4.8mm vs. 60.2±4.5mm (p = 0.081), LVDs was
45.2±6.4mm vs. 49.2±4.8mm (p = 0.123), DSI was 56.7±7.2% vs. 59.1±8.1%
(p = 0.497), SSI (systolic LV sphericity index) was 51.0±5.4% vs. 54.8±7.8% (p =
0.206), and the mean grade of mitral regurgitation was 1.45±1.29 vs. 1.90±1.73
(p = 0.509). There was no hospital mortality. In the postoperative evaluation within
3 months after the operation, significant difference in LVDd, LVDS and DSI were
found between the two procedures (table).
Postoperative echocardiogram
SAVE Dor p
LVEF (%) 35.7±5.9 32.2±4.6 0.336
LVDd (mm) 52.8±5.1 59.6±7.1 0.012*
LVDs (mm) 42.6±5.7 50.4±6.8 0.010*
DSI (%) 52.7±8.0 61.2±9.4 0.037*
SSI (%) 48.9±12.8 56.2±10.4 0.172
*Significant difference between both procedures.
Conclusion: Endoventricular reconstruction surgery results in satisfactory outcomes.
Postoperative LVDd, LVDs and DSI were more improved in SAVE procedure
than Dor operation.
P2674 Impact of glycemic control on the short and midterm
outcome in type II diabetic patients undergoing
elective coronary bypass surgery
M.J. Santos1 ,D.Lowenstein1 , H. Sanabria 1 ,F.Robles1 ,
M. Rodriguez Acuna1 , R. Boughen1 , A. Arnedo1 , R.R. Favaloro1 ,
A. Ciccale Smit1 , E. Gabe2 . 1Buenos Aires, Argentina; 2Icycc Favaloro
Foundation, Cardiology Dept., Buenos Aires, Argentina
Background: Patients (pt) with diabetes mellitus (DM) have increased rates of
complications after coronary surgery (CABG).
Purpose: We examined the association between glycaemia control determined
by preprocedural haemoglobin A1c (A1c) on the short and midterm outcome in
type II diabetic pt undergoing elective CABG.
Methods: A total of 80 consecutive diabetic pt were prospectively enrolled from
March 2006 to September 2007. Fifty four nondiabetic pt who underwent elective
CABG during the same period were randomly selected as the control group.
Optimal glycemic control was defined as A1c ≤ 7%, and suboptimal control was
defined as A1c > 7%. We defined major complications as: death sepsis, mediastinitis,
perioperative myocardial infarction, cardiac failure, stroke and renal dysfunction
requiring dialysis.
Results: DM pt more often had peripheral vascular disease (22.5 vs. 5.6%, p
0.008), and impaired Left Ventricular function (15 vs. 1.9%, p 0.01) than pt without
DM. There were no important differences in clinical, angiographic characteristics,
and risk scores (Parsonett and Euroscore) between DM pt with A1c > 7% and <
7%. The mean values of A1c in DM pt with A1c > 7% and < 7% were significantly
different (8.6% vs. 6.1%, p 0.0001). There were 32 pt (40%) with A1c < 7%, and
48 (60%) with A1c > 7%. Diabetic pt with optimal glycemic control had a rate of
in-hospital complications, similar to that of non diabetic pt (3.1% vs 13%, p = NS).
Diabetic pt with A1c > 7% had a significantly higher rate of postoperative complications
than those with A1c < 7% (29.2% vs. 3.1%, p = 0,003). In a multiple
logistic regression analysis, A1c > 7% was found to be a significant independent
predictor of in-hospital complications (odds ratio 1.8, 95% CI 1.12 to 2.8; p
= 0,01).The mean follow up was 12 months (1-20), 66 pt were followed (3 deaths
in-hospital, and 1 pt lost). Although pt with optimal glycemic control had fewer
complications than pt with A1c > 7, we did not find statistically significant differences
(7% vs 23%, Long Rank test p= 0.08)Postoperative length of stay (LOS)
ranged from 4 to 165 days; the median postoperative LOS was 7 days. Patients
with A1c > 7% had a significantly higher postoperative LOS than those with A1c
< 7% (Mann-Whitney U Test. 6 vs. 8 days, mean rank 32 vs 46, p = 0.008)
Conclusions: In diabetic pt undergoing elective CABG, optimal glycemic control
(A1c < 7%) is associated with a lower rate of immediate postoperative complications,
similar to non diabetic pt. These data suggest that aggressive treatment
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Understanding determinants of hemodynamics and ventricular function / Novel insight in heart failure biology and genetics 423
of DM to achieve A1c < 7% is beneficial in improving the clinical outcome after
CABG.
NOVEL INSIGHT IN HEART FAILURE BIOLOGY AND
GENETICS
P2675 Prevalence of chymase and angiotensin converting
enzyme gene polymorphisms and relation to clinical
findings in patients with heart failure
R. Amir1 ,O.Amir2 ,H.Paz2 ,R.Mor1 ,R.Wolff2 ,M.Sagiv1 ,
N. Yaniv2 , R. Ammar2 , M. Sagiv1 ,B.S.Lewis2 . 1Zinman College
of Sports Sciences, Genetics and Molecular Biology, Netanya, Israel; 2Lin and
Lady Davis Carmel Medical Centers, Heart Center, Haifa, Israel
Background: Angiotensin II, which plays a crucial role in the myocardial remodeling
process of heart failure (HF), is generated via the angiotensin-converting
enzyme (ACE) and chymase (CMA) pathways. We investigated the associations
of ACE and CMA1 polymorphisms in patients with systolic HF and the correlation
with clinical status and left ventricular (LV) function.
Methods: We genotyped 191 patients with HF and systolic LV dysfunction (LV
ejection fraction

424 Novel insight in heart failure biology and genetics
mentation and by flow cytometry using Propidium Iodide. Nonapoptotic cell death
was detected by Cytotoxicity Detection Kit. EPCs (CD133/CD34) and c-kit positive
cells were quantified using a cytometer.
Results: Our data showed that TNF-α concentration was significantly higher in
serum sample from severe and mild patients compared to controls (6.09±1.06,
3.57±0.62 vs 1.22±0.83, P

the abundance of profibrotic CCN2 protein was significantly increased in hyperglycaemic
animals (1±0.47 1.67±0.28 respectively p

426 Novel insight in heart failure biology and genetics
signal application and was associated with an increase of LV peak dP/dt. Application
of CCM signals in-vitro for as little as 10 sec increased P-PLB in isolated
cardiomyocytes at both S-16 and T-17.
In-Vivo Studies
Time 0 min 1 min 5 min 10 min
P-PLB at S-16/CSQ 0.23 0.47 0.46 0.56
P-PLB at T-17/CSQ 0.23 0.54 0.55 0.57
LV dP/dt (mmHg/sec)
In-Vitro Studies
1270 1640 1590 1490
Time 0 sec 10 sec 20 sec 30 sec
P-PLB at S-16/CSQ 0.35 0.85 0.96 1.04
P-PLB at T-17/CSQ 0.76 0.96 0.99 1.16
Conclusions: CCM signals rapidly increase P-PLB in-vitro and in-vivo. The exact
mechanism remains unknown. The increase in P-PLB observed in this series of
studies can explain the rapid increase in LV contractility observed with initiation
of therapeutic CCM signal delivery.
P2687 Toll-like receptor is involved in cardiac dysfunction in
angiotensin II-induced hypertension
S.M. Matsuda1 , S.U. Umemoto1 , H.Y. Yoshino1 , S.I. Itoh2 ,
H.A. Aoki3 ,K.Y.Yoshimura3 , T.M. Murata4 , M.M. Matsuzaki1 .
1Yamaguchi University Hospital, Department of Medicine and
Clinical Science, Ube, Japan; 2Yamaguchi University Hopital, Department of
Medicine and Clinical Science, Ube, Japan; 3Yamaguchi University School,
Department of Molecular Cardiovascular Biolog, Ube, Japan; 4Yamaguchi University, Science Research Center, Ube, Japan
Toll-like receptor 4 (TLR4) is associated with innate immunity, and recent evidence
has suggested that TLR4 is expressed in cardiac myocytes and may play
an important role in cardiac hypertrophy and the development of heart failure.
We investigated the role of TLR4 in cardiac hypertrophy and function following
angiotensin II (Ang II) or norepinephrine (NE)-induced pressure overload in mice
in vivo.
TLR4-knocked out mice (C.C3H-Tlr4 (lps-d), n=8∼10), and wild-type (WT) genetic
background mice (BALB/c, n = 8-10) were randomized into two groups of
4-5 rats each and implanted osmotic minipumps of Angiotensin II (AT II) or Norepinephrine
(NE) for 2 weeks. Left ventricular end-diastolic dimension (LVEDd), LV
end-systolic dimension (LVESd), fractional shortening (%FS), the ejection fraction
(EF) and interventricular septum (IVS) as well as LV posterior wall dimension
(LVPWd) calculated by the Teichholtz method were assessed by averaging
three cardiac cycles based on transthoracic echocardiography using a ultrasound
equipped with a 15-MHz probe under light anesthesia with sevoflurane.
In each heart, we evaluated the wall-to-lumen ratio and the perivascular fibrosis
in the heart by analyzing Masson Trichrome-stained sections using a computerassissted
image analysis system.
Both Ang II and NE induced a significant increase in systolic blood pressures
among the four groups (p

parison with IL-8 as well as the existance of correlation among PMN locomotory
response and clinical or hemodynamic parameter of cardiac function.
Seventy-one CHF patients with LVEF

428 Perspectives in diastology
NT-proBNP levels in COPD patients.
Conclusion: Severity of COPD is associated with elevated NT-proBNP levels in
vascular surgery patients with a preserved LVEF.
P2695 Increased Serca2a/PLN ratio can rescue ventricular
diastolic dysfunction which caused by deletion of
Tbx5
Y. Zhu 1 ,A.Gramolini2 , J. Takeuchi2 ,Y.Zhou2 , D. Maclennan2 ,
B. Bruneau2 . 1Xi’an, China, People’s Republic of; 2University of
Toronto, Toronto, Canada
Objective: To investigate the mechanisms involved in increased Serca2a activity
to rescue left ventricular diastolic dysfunction which caused by deletion of Tbx5.
Method and results: First, we have generated Tbx5del/+ and ventricular specific
deletion Tbx5LDN/+; Nkx2.5-Cre (Tbx5V-del/+) mice. In these mice, cardiac function
was impaired and the E/A ratio was decreased and isovolumic relaxation time
was prolonged, suggesting a direct role for Tbx5 in regulating LV diastolic function
by down-regulation of Serca2a expression. The decay of Ca2+ transients
was slower in Tbx5V-del/+ myocytes as indicated by an increased time for 50%
relaxation compared to control myocytes (12.5±0.5 vs. 9.5±0.42 msec, P

and EF (-0.5%) which significantly differed from those of controls: SV (+19%,
p

430 Perspectives in diastology
P2703 Structural and functional determinants of left atrial
volume in essential hypertension
E. Taxiarchou, C. Tsioufis, D. Chatzis, M. Selima, A. Kasiakogias,
D. Tousoulis, I. Kallikazaros, C. Stefanadis. First Cardiology Clinic,
University of Athens, Hippokration Hospital, Athens, Greece
Purpose: Hypertension-induced cardiac adaptations like left ventricular (LV) hypertrophy,
diastolic dysfunction and left atrial (LA) enlargement have been described
in a large number of studies. The aim of our study was to investigate
the interrelationship between LV structural alterations and diastolic dysfunction
indexes and LA size in essential hypertensive subjects.
Methods: We studied 339 consecutive subjects (aged 52±10 years) with untreated
newly diagnosed stage I-II essential hypertension [office BP =152/98
mmHg]. All the participants underwent echocardiography and 24-hour ambulatory
BP monitoring. LA volume and LV mass were indexed for body surface area
to estimate LA volume index (LAVI) and LV mass index (LVMI). Furthermore, LV
diastolic function was estimated by means of TDI echocardiography, averaging
diastolic mitral annular peak velocities (Em, Am, Em/Am ratio) from four separate
LV sites. The study population was divided into those with increased LAVI
(>26ml/m2 , n=117) and those without increased LAVI ≤26ml/m2 , n=222).
Results: Subjects with increased LAVI compared to those without increased LAVI
had significantly increased 24-h pulse pressure (54.1±9.7 vs 50.8±8.0 mmHg,
p=0.001), while there was not difference regarding age, body mass index, 24-h
systolic and diastolic BP and metabolic profile. Moreover, subjects with increased
LAVI compared to those without increased LAVI had significantly increased left
ventricular mass index (112±28 vs 101±26 gr/m2 , p=0.001) while they did not
differ in relative wall thickness (0.44±0.07 vs 0.43±0.08, p=NS), and greater
E/Em (9.8±3.1 vs 8.9±2.3, p

of effects on systemic BP and cardiac hypertrophy. Increased collagen deposition
and gene expression may explain these changes in LV diastolic function. Rho
kinase may in part be involved in the pathogenic LV remodeling leading to diastolic
dysfunction.
P2707 Obesity as an independent risk predictor of mild to
moderate diastolic dysfunction
A. De Guzman1 , E. Demerre2 . 1St Luke’s Medical Center, Heart
Institute, Quezon City, Philippines; 2St. Lukes Medical Center, Heart
Institute, Quezon City, Philippines
Background: Diastolic dysfunction is prevalent among obese individuals hence,
is associated with increased cardiovascular morbidity and mortality risk. As to how
severe in terms of diastolic dysfunction and which among the diastolic function
indices is affected as the level of body mass index remains unclear and elusive.
Objective: To determine correlation and the degree of risk in developing diastolic
dysfunction based on the different diastolic function indices and grades of obesity
in terms of body mass index (BMI)
Methods: 2711 Filipinos were retrospectively reviewed with different grades of
obesity. Multiple linear regression analysis were done with sub-analysis among
subjects with "isolated" obesity.
Results: After adjustment of clinical risk factors, the risk was doubled (Adjusted
OR- 2.02, CI: 0.99 – 4.1, p-value 0.05) among overweight patients as compared
to the normal population. There was a 4-fold increased (Adjusted OR - 4.00, CI:
1.94 – 8.21, p-value

432 Pericardial and myocardial disease
PERICARDIAL AND MYOCARDIAL DISEASE
P2711 Diagnostic value of tumor markers in the pericardial
fluid for the diagnosis of malignant pericardial
effusions
K. Karatolios1 , S. Pankuweit 2 ,N.Timmesfeld3 , A. Richter2 ,
B. Maisch2 . 1University hospital of Marburg, Cardiology, Marburg,
Germany; 2University Hospital of Marburg and Giessen, Cardiology, Marburg,
Germany; 3University of Marburg, Medical Biometry and Epidemiology, Marburg,
Germany
Background: The diagnosis of malignant pericardial effusion is often a vexing
problem, since pericardial fluid cytology findings are positive in only 50-70% of
cases. The assessment of tumor markers in the pericardial fluid may help to establish
the diagnosis of malignant pericardial effusion, but their precise diagnostic
role in differentiating malignant from benign pericardial effusions remains unclear.
The aim of this study was to estimate the value of the assessment of tumor markers
in the pericardial fluid for the recognition of malignant pericardial effusion.
Methods and Patients: We analyzed 88 patients, who underwent pericardiocentesis
and pericardial biopsy with subsequent pericardial fluid and tissue analysis
by cytology, biochemistry, and molecular biology during 1999-2007. The examined
patients’ population consisted of 22 patients with confirmed malignant pericardial
effusion and 66 patients with benign pericardial effusion. Pericardial fluid
samples were assayed for carcinoembryonic antigen (CEA), alpha-fetoprotein
(AFP), carbohydrate antigen (CA) 19-9, carbohydrate antigen (CA) 72-4, squamous
cell carcinoma antigen (SCC) and neuronspecific enolase (NSE).
Results: The median value of all tumor markers, except for AFP, was statistically
significantly higher in the malignant group than in the benign group (Table).
Malignant PE Benign PE Significance
CA 72-4 7,5 kU/l

Conclusion: Compared to previously published data, our survey shows a decrease
of some historical causes of cardiac tamponade such as tuberculosis,
myxoedema or uraemia. The leading cause is currently malignant diseases which
carries a very poor prognosis.
P2715 Tricuspid flow velocity paradox in evolving cardiac
tamponade
E. Siniorakis1 , K. Sfakianakis1 , D. Barlagiannis1 , A. Samaras1 ,
S. Pamouki1 ,E.Tsika1 ,I.Zarreas1 ,D.Mytas2 ,K.Karidis1 ,
N. Exadaktylos 1 . 1Sotiria Chest Diseases Hospital, Cardiology,
Athens, Greece; 2Athens, Greece
Introduction: In severe pericardial effusions (PE), Doppler tricuspid recording of
inflow E velocity presents large respiratory fluctuations. We sought to examine if
progression from the subclinical to the overt form of tamponade in these patients
(pts) is accompanied by any modifications of the aforementioned respiratory pattern.
Methods: Eighty seven pts (M=52, F=35, age = 68±12 yrs) with newly diagnosed
lung cancer and secondary large PE, not in clinical tamponade, were addressed
to us for haemodynamic evaluation. By Doppler echocardiography, E velocities
across the tricuspid valve (EI=inspiratory E, EE=expiratory E) and their respiratory
fluctuations (�E) were measured at baseline and weekly afterwards, for a total of
20 days. 23 pts (group A) evolving to tamponade, had their last assessment just
before surgical drainage. The other pts (group B) remained clinically stable during
the follow-up period. Initial E values (E1) were compared to the final ones (E2) by
t-test.
Results: E and �E remained unchanged in group B, during the follow up period.
Contrarily, group A presented a dramatic decline of E and �E values, progressing
to the final stage (Table 1).
Table 1. Tricuspid flow velocities on the two groups
Parameter Group A Group B p
EI1 (cm/s) 55.4±9.5 51.7±8.8 NS
EE1 (cm/s) 36.1±9.2 33.3±7.6 NS
�E1 (%) 51.3±10.0 48.1±8.3 NS
EI2 (cm/s) 31.6±4.4** 53.2±7.1

434 Pericardial and myocardial disease
sive studies in myotonic dystrophy (MD) with electrocardiographic data of these
patients and to evaluate the nature of arrhythmias during the follow-up. Patients
with MD were reported as at high risk of complete atrioventricular (AV) block or
ventricular arrhythmias development.
Methods: 102 patients, 54 women, 48 men, mean age 45±14 years, with MD
were enrolled; one had sustained ventricular tachycardia (VT), 2 had syncope
and other patients were asymptomatic; 2 men had history of myocardial infarction
(MI). Surface ECG, measurement of left ventricular ejection fraction (EF) at
echocardiography, 24 hour Holter monitoring and study of heart rate variability
(HRV), signal-averaged ECG (SAECG) and electrophysiological study (EPS) (n=
42) were performed.
Results: ECG and Holter monitoring were normal in 59 and 69 patients. HRV was
normal in all patients. Late potentials were present in 18 patients and were not
correlated with spontaneous or induced VT. EF was normal in all, but 3 patients
(60±10%). HV interval was prolonged in 0 of 12 patients with normal ECG, 5 of
9 patients with first d AV block older than 40 years, 7 of 9 patients with hemiblock
(HB), 4 of 7 patients with bundle branch block (BBB) and 3 of 5 patients with
atrial fibrillation (AF). Paroxysmal AF or flutter was noted at ECG in 7 patients,
non sustained AF at Holter ECG in 12 patients and AF was induced in 15 of 42
patients (36%). Non sustained VT was noted at Holter ECG in 2 patients and was
induced in 5 of 42 patients (12%). Sick sinus syndrome was noted in 4 patients
at Holter ECG and in 6 of 42 patients at EPS. During the follow-up (4±4 years),
one patient with MI died suddenly. 8 patients developed chronic AF; 1 of them
was resuscitated from cardiac arrest and 1 died from heart failure; 4 patients died
from respiratory failure and heart failure; 4 patients developed permanent atrial
flutter, requiring ablation. Pace-maker was implanted in 22 patients.
Conclusions: HV interval was normal in patients with normal ECG and those with
first degree AV block younger than 40 years. HV interval was prolonged in half of
patients with HB or BBB independently on the age. Ventricular tachyarrhythmias
were rare and related to associated ischemic cardiomyopathy. The most frequent
arrhythmia during the follow-up was atrial flutter or fibrillation which can induce
dilated cardiomyopathy with a risk of sudden death.
P2720 The prevalence of effusive constrictive physiology
and cardiac tamponade in patients with suspected
tuberculous pericardial effusion
M. Ntsekhe, F. Syed, B. Mayosi, J. Russel, O.E. Usim on behalf
of IMPI study group. Groote Schuur Hospital, Cardiology Dept.,
Observatory, South Africa
Purpose: Effusive constrictive pericarditis occurs when pericardial fluid and visceral
conscriction coexist to cause pericardial tamponade and constrictive physiology.
The hall mark of the syndrome is the finding of persistantly elevated right
atrial pressures despite the normalization of intra-pericardial pressures following
pericardiocentesis. Effusive constrictive pericarditis is thought to be a precursor
to constrictive pericarditis. Because of the difficulty in establishing a definitive diagnosis,
the prevalence of the syndrome in tuberculous pericardial effusions is
unknown. Some have speculated that due to the inflammatory, exudative nature
of tuberculous effusions, effusive constrictive pericarditis may be very common
but under recognized.
Objectives: 1)To determine the prevalence of effusive constrictive pericarditis
in patients with large effusions suspected to be tuberculous in aetiolgy. 2) To
determine the prevalence of cardiac tamponade in patients with large effusions
suspected to be TB in aetiolgy. 3) To determine the frequency of effusive constrictive
pericarditis in those with cardiac tamponade prior to evacuation of the
pericardium.
Methods: Consecutive patients with large effusions suspected to be TB in origin
were enrolled. Right atrial and intra-pericardial pressures were obtained before
and after pericardiocentesis. Effusive constrictive pericarditis was defined as failure
of the right atrial pressure to fall by 50% or to a new level of ≤10mmHg after
the intra-pericardial pressure was lowered to near 0 mmHg. Tamponade was
defined as measured intrapericardial pressures that exceeded the upper limit of
normal right atrial pressure (12mmHg).
Results: 69 patients underwent pericardiocentesis. 55 had intra-pericardial and
right atrial pressure measurements that were of acceptable quality for analysis.
36.5% (20/55) met the haemodynamic criteria for effusive constrictive pericarditis.
51% (28/55) had cardiac tamponade at presentation. Of the patients with cardiac
tamponade, 60.1% (17/28) had evidence of effusive constrictive disease after
evacuation of the pericardium. This compared with only 9% (1/11) of the patients
without features of cardiac tamponade.
Conclusion: In this first and largest study of its kind in the world, effusive constrictive
pericarditis occured in 37% of patients with a suspected tuberculous pericardial
effusion. Approximately half of patients with suspected tuberculous pericardial
effusion have hemodynamic evidence of cardiac tamponade at presentation
and the majority of those patients with tamponade have hemodynamic evidence
of co-existing visceral constriction.
P2721 The utility of enalapril treatement in
anthracyclines-induced cardiac injury in children with
malignancies- preliminary study
C. Mandric 1 , A.G. Dimitriu 1 ,I.Miron 1 ,L.Dimitriu 2 . 1 University
of Medicine and Pharmacy, Pediatric Cardiology, Iasi, Romania;
2 MEDEX Medical Center, Iasi, Romania
Background: Treatement with angiotensin converting enzyme (ACE) inhibitors
in children with malignancies who received high doses of anthracyclines have
been shown useful in order to reduce manifestations of anthracyclines-induced
cardiotoxicity.
Purpose: Study of effects of enalapril treatment on anthracyclines-induced
echocardiographic change in children with malignancies.
Methods: We performed, a prospective clinical study comparing enalapril to
placebo treatement in 30 survivors of pediatric cancer (aged beetwen 6 -14 years)
from the Department of Pediatric Hemato-Oncology from "Saint Mary" Children
Hospital Iasi, treated with certain therapeutical protocols for hematological malignancies,
who included anthracyclines- doxorubicin or adriamicin; all of this patients
had at least one cardiac abnormality identified at any time after anthracyclines
exposure; those chidren were devided in two groups: group A - 10 children
treated enalapril (dose range beetwen 0.2-0.5 mg/kgc/d); it was performed
regular echocardiographic examinations during enalapril therapy, mean age at
cancer diagnosis - 6 years, mean median follow-up since the start of enalapril, 16
month; group B placebo - 20 children treated with similar doses of anthracyclines,
without enalapril treatment, after completion of doxorubicin therapy. Cardiological
evaluation was performed at baseline and at 3, 6, 12, 16 month after initiation of
enalapril/placebo therapy.
Results: Over the 16 month of enalapril therapy, there was progressive improvement
in left ventricular (LV) dimension end-systolic and end-diastolic, fractional
shortening, LV mass, LV per cent posterior wall thickening, interventricular per
cent septal thickening, Tei index, comparative with evolution of the same ecocardiographic
parameters of the controller group, who was constant or it worsened
in course of follow-up
Conclusions: Enalapril treatment improved anthracyclines-induced ecocardiographic
changes in patient included in study, justifing precocious introduction of
enalapril in children with cardiotoxocity anthracyclines induced.
P2722 Myocardial contractility disorders caused by
pericardial inflammatory diseases influence or not left
ventricular haemodynamics and performance?
I.S. Benedek 1 ,T.Hintea 2 ,M.Chitu 2 , C. Matei 2 ,A.Sarbu 2 .
1 University Emergency Hospital Targu-Mures, Cardiology Clinic,
Targu-Mures, Romania; 2 University Emergency Hospital Targu Mures,
Cardiology, Targu-Mures, Romania
In pericarditis, extension of inflammatory process from the pericardium to myocardium
could lead to alteration of wall motion, involving segments located in
contact with the diseased pericardial layer. This study use Computerized 3D
echocardiography (C3DE) for evaluation of myocardial motion disorder associated
with pericarditis.
Materials and methods: 15 pts with chronic pericarditis, in whom 2D echo
showed presence of thick pericardium (4.2±0.5 mm) and pericardial fluid
(5.6±3,2 mm), located at the lateral (7 pts - 46.66%), inferior (5 pts - 33.33%) and
apical segments (3 pts-20%). C3DE was performed with Philips 7.500 and QLab
software. Volumetric curve of each myocardial segment during cardiac cycle and
polar map of time delay from onset till the maximum contraction were obtained.
Intracavitar haemodynamics was evaluated using Doppler flow mapping at 3 levels
(basal, median and apical) along 3 longitudinal axes, and flow decelerations
were calculated.
Results: Contractility disorder (CD) was defined as a flat type of the volumetric
curve, with the difference between the maximum and minimum volume less than
3.5 ml, and a spot on the time delay polar map located at the same segment,
representing a delay in contraction augmentation more than 50 msec. LVEF calculated
by C3DE was normal in all cases (avg. 53.4±4.2%). CD was revealed by
C3DE located at the level of lateral segment in 6 cases (40%), inferior in 5 pts
(33.33%), apical in 3 pts (20%) and lateroapical in 1 patient (6,66%), in accordance
with the location of the pericardial inflammation (p=0.001). Time difference
between maximum and minimum volume during contraction was 375 msec in
segments with CD compared with 323 in the rest of the segments (p=0.002). Delay
in contraction augmentation was 57 msec in segments with CD compared with
normal contracting segments. When performed, coronarography showed normal
coronary arteries. Doppler flow mapping showed no perturbance of intracavitary
flow (gradual decrease of flow velocity from basis to apex uniformly distributed on
the longitudinal axis – 0.12 msec in the basal half and 0.13 msec in the apical half
– p=0.002).
Conclusions: Extension of the inflammatory process from the pericardium to
the myocardial layer could influence myocardial contractility, which was identified
in this study using C3DE, based on objective evaluation and quantification
of contractility parameters. However, these did not influence LV performanced
expressed by LVEF or the intracavitary flow hemodynamics. Further studies are
required to elucidate the impact of inflammatory process on LV performance.
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P2723 Differential virus-associated TRBV dominance in
murine and human acute myocarditis
M. Noutsias1 , M. Rohde1 ,A.Block1 , K. Blunert 1 ,M.Hummel1 ,
D. Lassner2 , U. Kuehl1 ,S.Rutschow1 , H.P. Schultheiss1 ,H.D.Volk3 .
1Charite - Campus Benjamin Franklin, Department of Cardiology &
Pneumonology, Berlin, Germany; 2IKDT,Berlin,Germany; 3Charite - Campus
Mitte, Institute of Medical Immunology, Berlin, Germany
Background: Acute myocarditis can be induced by various cardiotropic viruses,
among others Coxsackievirus (CBV), human herpes virus type 6 (HHV6) and
Parvovirus B19 (B19V). Viral proteins lead to clonal expansions of particular Tcells,
thereby inducing specific dominances of the T-cell receptor Vbeta (TRBVs).
Methods and Results: Using a preamplified real-time RT-PCR system for murine
and human TRBV expression, myocardial tissues from SWR mice and human
EMBs were investigated. In the murine SWR model of CBV induced myocarditis,
a highly significantly increased TRBV4 expression was observed compared
to controls at the time of maximum infiltration at d7 (p

436 Pericardial and myocardial disease
tentials (LP) and in patients without bundle branch block, we used the combination
of any 2 of the 3 parameters, filtered QRS duration > 120 ms, low amplitude signal
duration (LAS) > 40 ms and root mean square voltage of the last 40 ms of
QRS(RMS40)< 20μv.
Results: Surface ECG was normal in 29 patients and remained normal in 20 of
them. First d AV block (n= 5) or bundle branch block were present in 18 patients
and were stable at second study in 14 patients. In other patients AV conduction
disturbance or atrial arrhythmia were noted at second ECG. Holter was normal
in 40 patients and remained normal in 34 of them; 6 developed sinus pauses.
In 7 patients with abnormal Holter ECG, only one with nonsustained (NS) atrial
fibrillation (AF) developed permanent AF. Mean QRS duration did not change significantly
(102±19 vs 105.5±19 ms); RMS 40 decreased significantly from 29±16
μv to20±16 μv(p

Methods: During 2007, 10 patients (46±12 years, 7 males) were referred to our
centre for unexplained new-onset AHF with persistent LV systolic dysfunction (EF
29±9%). EMB specimens were studied by using light and electron microscopy,
immunohistochemical and polymerase chain reaction techniques. All but one patient
with the presence of cardiotropic pathogen or inflammatory infiltrate in EMB
specimens were then specifically treated with antibiotics or antiviral agents or
with combined immunosuppressive therapy (Tx +, n=5); remaining 5 patients (Tx
-) were treated only by conventional AHF therapy.
Results: Cardiotropic (viral or bacterial) pathogen was found in EMB specimens
in 5 patients (50%), isolated inflammatory infiltrate was present in 1 patient (10%).
At admission, there were no differences regarding LV ejection fraction, LV diameters
and NYHA class between Tx + and Tx – patients. After 3 months of follow-up,
the LV ejection fraction and LV end-systolic diameter considerably improved only
in Tx + patients (30±8 vs.45±12%, 59±5 vs.46±8mm, p=0.05). In all but one
Tx + patient the improvement in NYHA class was noted; in contrast only 2 Txsubjects
functionally improved and 2 Tx – patients have had to undergo heart
transplantation.
Conclusions: Inflammatory cardiomyopathy was present in half of the patients
with unexplained new-onset AHF and persistent LV systolic dysfunction. Specific
treatment of these patients was associated with better LV functional improvement
and clinical outcome compared to conventionally treated subjects. Performing
EMB thus has a definite role in the management of the patients with unexplained
new-onset AHF.
P2732 Loss of TIR-domain-containing adaptor protein
inducing IFN-beta (TRIF) leads to interferon beta
dependent exacerbation of viral myocarditis in mice
A. Riad 1 , M. Becher 2 ,O.Lettau 2 , D. Lassner 2 , S. Bereswill 2 ,
M.M. Heimesaat 2 , D. Westermann 2 , H.P. Schultheiss 2 ,
C. Tschope 2 . 1 Charite Berlin, Cardiology Dept., Berlin, Germany; 2 Charite
Universitaetsmedizin Berlin, Cardiology, Berlin, Germany
Introduction: Viral myocarditis leads to intense cardiac inflammation. TIRdomain-containing
adaptor protein inducing IFN-β (TRIF) mediates intracellular
signalling of Toll-like receptor 3 and 4 leading among others to the activation of
interferon (IFN) beta. In the present study we investigated the role of TRIF in
coxsackievirus B3 (CVB3)-induced myocarditis in mice.
Materials and methods: TRIF knock out mice (TRIF-/-) and wildtype (WT) mice
were infected with CVB3 (Nancy strain 5*105 PFU, i. p.). In a mortality study, WT
(n=20), TRIF-/- (n=11) and IFN beta treated (10 MIU/kg, i.p.) TRIF-/- mice were
obtained during 60 days post CVB3 infection. In a further study, left ventricular tissue
was prepared for molecularbiological and immunohistological analyses seven
days after CVB3 infection.
Results: Sixty days after CVB3 infection 100% of TRIF-/-, but none of WT mice
died (P

438 Pericardial and myocardial disease
spectively, p=0.0001), ischemic heart failure (54%;16%,12% vs 1%;2%;1% respectively,
p=0.0001) or normal subjects (54%;16%,12% vs 5%;0%;2.5% respectively,
p=0.0001). Univariate predictors of death/transplantation were: young age,
longer symptom duration, giant cell myocarditis, NYHA II-IV, presentation with
left ventricular (LV) dysfunction, clinical signs/symptoms of heart failure, multiple
echocardiographic and hemodynamic indexes of LV and right ventricular dysfunction
and AECA. Independent negative predictors by Cox regression were higher
mean right atrial pressure (RR 1.3, p=0.02), lower LV ejection fraction (RR 1.03,
p=0.038) and AECA (RR 5.8, p=0.01). AECA was the only independent predictor
for death/transplantation after correction for hemodynamic variables (p=0.02, RR
6.5, 95% CI 1.7-25, p=0.007).
Conclusion: The finding of AECA provides an independent negative serological
predictor in biopsy-proven myocarditis and suggests that immune-mediated
cardiac endothelial dysfunction may have a key role in disease progression.
P2736 Paradox role of the matrix metalloproteinase 2 in
inflammatory cardiomyopathy
D. Westermann, O. Lettau, K. Savvatis, S. Bereswill,
M.M. Heimesaat, C. Tschoepe. University Hospital Benjamin
Franklin, Cardiology Dept., Berlin, Germany
Background: Increased activity of matrix metalloproteinases (MMPs) disturb the
integrity of the cardiac extracellular matrix in different cardiomyopathies and it was
shown that increased MMP levels in cardiac failure are delirious for cardiac function
after myocardial infarction or pressure overload cardiomyopathy. Therefore,
inhibition of MMPs is generally supposed to be beneficial. Nevertheless, MMP-2
(a gelatinases) can also degrade inflammatory cytokines as well as other proteins
and therefore might have anti-inflammatory properties, but whether that is
relevant in vivo is unknown. To further investigate the potential role of MMP-2
in inflammatory cardiomyopathies, we used a viral induced myocarditis model,
which is characterized by invading inflammatory cells and cytokines, and investigated
the effect of gene deletion of MMP-2 after viral myocarditis on cardiac
inflammation and cardiac function utilizing knock out mice.
Methods: 80 MMP-2 knockout mice and their wildtypes littermates were used in
the current study. 40 were infected with coxsackievirus B3 (CVB3) to induced
acute murine myocarditis. We investigated the LV function of all mice after 7
days using pressure volume measurements by conductance catheter in vivo and
measured mortality. Furthermore, myocardial inflammation was analyzed by immunohistochemical
detection of inflammatory cells and by measuring the protein
and mRNA abundance of inflammatory cytokines. Furthermore, cardiac apoptosis
was analyzed by TUNEL staining and by measuring the protein content of bax
and bcl-2 and caspase 3. Moreover, the viralload was analyzed.
Results: Interestingly, MMP-2 gene deletion aggravated cardiac function after
CVB3 myocarditis compared to their CVB3 wildtype littermates. This was accompanied
by increased cardiac inflammation with highly increased numbers of inflammatory
cells (+450%) as well as highly increased abundance of pro inflammatory
cardiac cytokines in the cardiac tissue. Furthermore, we measured increased
apoptosis (+250%) in the cardiac tissue in both knock out mice strains
as well as an increased viral load (+350%) in MMP knock out mice. Additionally,
we observed high mortality in MMP-2 knock mice (survival rate 10%) compared
to wildtypes (95%) after CVB3 induced myocarditis.
Conclusion: During acute viral myocarditis, gene deletion of MMP-2 aggravates
cardiac injury. These data suggest that MMP-2 has beneficial effects in viral induced
cardiomyopathy and might be necessary for virus control in myocarditis,
which is in contrast to their delirious role in non viral induced cardiomyopathies.
P2737 Intermediate dose of pentaglobin eradicates
inflammation in parvo B19 and adenovirus positive
myocarditis
B. Maisch, H. Haake, S. Schlotmann, R. Funck, A. Richter,
S. Pankuweit. Philipps-University, Department of Internal Medicine
- Cardiology, Marburg, Germany
Background and purpose: Treatment of viral myocarditis is a matter of controvery
and discussion.
Patients: 152 consecutive patients with myocarditis according to the quantitative
World Heart Federation Criteria (>14 infiltrating cells/mm2 by endomyocardial
biopsy (EMB)) were analysed for cardiotropic agents. In 90 pts parvoviruses
B19 (59,5%) and in 36 pts adenoviruses (23,8%) were assessed by PCR as
causative viral pathogens. All virus positive patients were treated with 10 g/day
Pentaglobin an i. v., enriched IgG, IgA and IgM preparation, at day 1 and 3. After
six months all patients were reevalutated clinically, 73 patients (48%) in addition
by EMB.
Methods: We compared the following parameters before and after therapy:
left ventricular ejection fraction (LVEF), left ventricular end-diastolic diameter
(LVEDD), shortening fraction (SF) by transthoracic echocardiography and LVEF
or the left ventricular end-diastolic volume index (LVEDVI) using angiography. For
exercise capacity we evaluated exercise ECG by treadmill test and clinical parameters
according to the NYHA classification, before and after therapy.
Results: After Pentaglobin therapy, all patients demonstrated a significant clinical
improvement of the NYHA class, of exercise capacity and of LVEF (from 54,4 to
60,0%, p

cardiomyocyte apoptosis was highest on day 5 (0.16±0.01% vs. 0.03±0.01% in
controls, p

440 Pericardial and myocardial disease
P2744 Late onset valvular and myocardial dysfunction in
Hodgkin lymphoma survivors
T. Wethal1 , M. Lund2 , S.D. Fossa1 , J. Kjekshus1 , T. Edvardsen1 ,
A.H. Pripp2 ,H.Holte2 , A. Fossa2 . 1University of Oslo, Department
of Cardiology., Oslo, Norway; 2Rikshospitalet University Hospital,
Department of Respiratory Medicine, Oslo, Norway
Background: Hodgkin’s lymphoma survivors (HLS) have an elevated risk for cardiovascular
diseases that appear several years after radiotherapy. HLS have frequently
reported valvular dysfunction and many have received anthracyclines,
which increase the risk for cardiomyopathy. Little is known about the progression
of valvular dysfunction in HLS and whether anthracyclines negatively affect myocardial
function beyond 10 years after treatment.
Methods: A longitudinal follow-up study was performed with 47 patients diagnosed
with Hodgkin’s lymphoma. Echocardiography was performed in 1993 and
again in this study between 2005 and 2007, approximately 9 and 22 years after
initial mediastinal radiotherapy. Twenty-seven (57%) of the patients had received
treatment with anthracyclines.
Results: The second echocardiograph indicated 38% of the patients had mild
to severe aortic stenosis not previously reported. Of those without and with mild
valvular regurgitation in 1993, 39% developed moderate regurgitation in the aortic
and/or the mitral valve. Of 24 patients with moderate valvular regurgitation in
1993, 33% progressed to severe valvular regurgitation or developed moderate
to severe valvular regurgitation in a valve unaffected in 1993. Multiple linear regression
analyses demonstrated that use of anthracyclines significantly predicted
deterioration in left ventricular function (left ventricular end systolic diameter, B =
0,089 (95% CI: 0,006 – 0,172), p = 0,036; interventricular septum, B = - 0,161
(95% CI: - 0,297 - - 0,025), p = 0,021; left ventricular posterior wall, B = - 0,178
(95% CI: - 0,325 - - 0,031), p = 0,019; and left ventricular end diastolic diameter,
B = 0,051 (95% CI: - 0,001 – 0,102), p = 0,053).
Discussion: Severe progression of valvular disease was found in four out of ten
HLS ∼22 years after radiotherapy despite normal echocardiographic findings after
9 years. Treatment with anthracyclines markedly aggravated left ventricular
function at 22 years compared to 9 years after treatment, and compared to those
that received mediastinal radiotherapy alone or with adjuvant chemotherapy other
than anthracyclines.
P2745 NS1 specific type-1 and cytotoxic effector T-cells with
TRBV11 dominance in a patient with parvovirus B19
associated inflammatory cardiomyopathy
M. Noutsias 1 ,M.Streitz 2 , R. Volkmer-Engert 2 , M. Rohde 1 ,
G. Brestrich 2 , K. Klippert 2 ,K.Kotsch 2 , U. Kuehl 1 ,H.D.Volk 2 ,
F. Kern 2 . 1 Charite - Campus Benjamin Franklin, Department of Cardiology &
Pneumonology, Berlin, Germany; 2 Charite - Campus Mitte, Institute of Medical
Immunology, Berlin, Germany
Background: Parvovirus B19 (B19V) is the most commonly detected virus in
endomyocardial biopsies (EMBs) from patients with inflammatory cardiomyopathy
(DCMi). Despite the importance of T-cells in antiviral defense, little is known about
the role of B19V specific T-cells in this entity.
Methods & Results: Using B19V proteom-spanning peptide pools, strong CD8+
T-cell responses (intracellular IFNg secretion) were elicited to the 10-amico-acid
peptides SALK (19.7% of all CD8+ cells) and QSAL (10%) in a DCMi patient
with an exceptionally high myocardial B19V viral load (115,091 viral copies/μg
nucleic acids) and B19V viremia in the initial presentation. Additionally, two further
peptides were identified: GLCP (0.53%) and LLHT (0.03%). Real-time RT-PCR of
SALK- and GLCP-reactive T-cells enriched by an IFNg secretion assay revealed
an over proportional T-cell receptor Vbeta (TRBV) 11 expression. Furthermore,
dominant expression of type-1 (IFNg, IL2, IL27 and T-bet) and of cytotoxic T-cell
markers (CTL: Perforin and Granzyme B) were found, whereas gene expression
indicating type-2 (IL4, GATA3) and regulatory T-cells (FoxP3) was low.
Conclusions: Our results show that B19V Ag-specific effector T-cells are involved
in B19V associated DCMi. In particular, a dominant role of TRBV11 and
type-1/CTL effector cells in the T-cell mediated antiviral immune response is suggested.
This novel B19V proteom-spanning peptide pool based approach will lend
itself very well to the in depth study of this phenomenon.
P2746 Molecular pathogenesis of acute rheumatic fever and
rheumatic heart disease
B. Maisch1 , T.G. Loof2 , G.S. Chhatwal2 ,A.Grover3 , V. Ruppert 1 ,
S. Pankuweit 1 . 1University Hospital Giessen and Marburg, Internal
Medicine - Cardiology, Marburg, Germany; 2Helmholtz Center
for Infection Research, Infection Immunology Research Group and Depar,
Braunschweig, Germany; 3Post Graduate Institute of Medical Education,
Department of Cardiology, Chandigarh, India
Acute rheumatic fever (ARF) is an autoreactive disease secondary to a group A
streptococcal infection involving the heart, joints, skin and brain. During an infection
activated antigen presenting cells present the bacterial antigen to helper T
cells, which subsequently activate B cells and induce the production of antibodies
against the cell wall of Streptococcus. These antibodies also react against the
myocardium, producing the symptoms of rheumatic heart disease. The cell wall of
group A streptococcus pyogenes is composed of branched polymers containing
"M proteins" which are highly antigenic and may crossreact with cardiac myosin.
Here we focus on heart specific antibodies in sera from patients with rheumatic
fever.
Methods: Sera from 9 patients with acute rheumatic fever, 17 patients with
chronic/rheumatic heart disease (CHD/RHD) and 17 controls from individuals
without heart disease were probed in one- and two-dimensional Western blots
for reactivity against heart tissue antigens, respectively.
Results: Antibodies against fragments of the myosin heavy chain were demonstrated
in 77% of sera of patients with ARF, in 35% of sera of patients with
CHD/RHD but not in control sera. Antibodies directed against proteins with a
molecular weight of 50kd, 45kd,37 kd and to a much lesser extend of 40kd were
directed against a lysate of cardiac tissue (Fig. 1). Antibodies against 55 kd, 50kd,
45kd proteins from a lysate of streptococcus M-protein were not found in controls
but in 44 - 77% of patients with ARF and in about 12 - 25% of cases in CHD/RHD
(Fig. 2).
Figure 1 and Figure 2
Conclusion: Sequence analysis of the above characterized proteins will possibly
identify additional myocardial antigens involved in the secondary immunopathogenesis
of ARF and CHD/RHD.
P2747 Use of N-terminal pro-B-type natriuretic peptide to
predict mortality and treatment failure in patients with
community-acquired pneumonia
M. Noveanu, T. Breidthardt, M. Potocki, T. Reichlin, M. Christ-Crain,
D. Stolz, K. Laule, M. Tamm, B. Mueller, C. Mueller. University
Hospital Basel, Department of Internal Medicine, Basel, Switzerland
Puropse: Community-acquired pneumonia (CAP) is the most common infectious
disease addressed by clinicians and an important cause of mortality and morbidity
worldwide. Risk stratification in CAP is still complex and time-consuming.
We hypothesized that cardiac stress may determine outcome also in non-cardiac
disease such as CAP.
Methods: N-Terminal Pro–B-Type Natriuretic Peptide (NT-proBNP), a marker of
cardiac stress and inflammation marker (C-reactive protein- CRP, white blood cell
count- WBC, procalcitonin- PCT) as well as the pneumonia severity index (PSI)
were determined in 302 consecutive patients presenting to the emergency department
with CAP. The accuracy of these parameters to predict death was evaluated
as the primary endpoint. Prediction of treatment failure was considered the
secondary endpoint.
Results: NT-proBNP levels were significantly higher in non-survivors compared
to survivors (median 3926 [IQR 790-15500] vs. 643 [170-3436] pg/ml, p

higher for NT-proBNP (area under the curve (AUC) 0.744; 95% confidence interval
CI 0.648-0.840) compared to the PSI (AUC 0.706; 95%CI 0.622-0.791), PCT
(AUC 0.688; 95%CI 0.600-0.755) or CRP (AUC 0.596; 95%CI 0.487-0.705). The
accuracy of NT-proBNP (AUC 0.690; 95%CI 0.607-0.772) to predict treatment failure
was also superior compared to PCT (AUC 0.662; 95% CI 0.589-0.735) and
CRP (AUC 0.590; 95%CI 0.508-0.671), but inferior to PSI (0.739; 95%CI 0.666-
0.812).
Conclusions: In patients with CAP, NT-pro BNP is a more powerful predictor of
death and treatment failure than the routinely determined marker of inflammation
PCT, CRP or WBC. Regarding the prediction of death, NT-proBNP in fact seems
superior to the current gold-standard PSI. Cardiac stress seems to determine
outcome in non-cardiac disease such as CAP.
P2748 Long term cardiac remodelling in chronic Chagas’
heart disease
P.R. Benchimol Barbosa1 , G.S. Duque2 , J. Barbosa-Filho3 . 1Rio de
Janeiro Fire Dept., UERJ, USF (USA), Cardiology, Rio De Janeiro,
Brazil; 2State University of Rio de Janeiro, Cardiology, Rio De
Janeiro, Brazil; 3Gama Filho University, Rio De Janeiro, Brazil
Introduction and Objectives: Cardiac remodeling impacts adverse outcome and
has not been fully investigated in Chagas’ disease. Clinical, echocardiographic
and electrocardiographic variables were assessed in long term longitudinal study
of subjects with chronic Chagas’ disease for adverse outcomes, defined as new
onset atrial fibrillation episode lasting >24h (AF), nonfatal embolic stroke and
cardiac death.
Methods and Results: Fifty adult outpatients (34 to 74 years old, 31 females)
staged according to Los Andes Classification I, II and III and complaining of palpitations
were enrolled. During a follow-up of (mean±SD) 84.2±39.0 months, nine
subjects developed AF (incidence: 3.3±1.0%/year), five had nonfatal embolic
stroke (incidence: 1.3±1.0%/year), and nine died (mortality rate: 2.3±0.8%/year),
five suddenly. The rate of both left ventricular (LV) mass increase and LV ejection
fraction reduction in subjects who experienced adverse outcomes (respectively,
16.4±20.0 g/year and -8.6±7.6%/year) was significantly higher than in those
who did not (respectively, -8.2±8.4 g/year; p = 0.03; and -3.0±2.5%/year; p =
0.04, Fig 1). In a stepwise multivariate Cox proportional-hazard regression model,
Los Andes Class III (HR=20.8; 95%CI [2.7–158.8], p=0.003) and new onset AF:
HR=4.2; 95% CI [1.1–15.7]) were independent predictors for adverse outcomes.
Frequency domain analysis of signal averaged ECG was a significant predictor
for cardiac death (HR: 5.4; 95%CI [1.4-20.5]; p=0.01).
Long term cardiac remodeling.
Conclusion: Los Andes Class III and new onset atrial fibrillation are independent
long-term predictors for adverse outcomes in chronic Chagas’ disease. The rate
of LVM enlargement and LV systolic function deterioration impacts survival, and
myocardial electrical transients underlie death mechanism in this population.
P2749 Exercise training improved myocardial response to
isoproterenol stimulation in rats fed with a
high-fat-diet induced heart triacylglycerols
accumulation
C. Lajoie1 ,J.M.Lavoie2 , M.C. Aubin3 , R. Clement3 , H. Gosselin3 ,
A. Calderone3 . 1UQTR, Kinesiologie, Trois-Rivieres, Canada;
2 3 Montreal University, Kinesiology, Montreal, Canada; Montreal Heart Institute,
Pharmacology, Montreal, Canada
Excessive accumulation of fat within the cardiomyocytes is nefarious for the heart.
The purpose of the present study was to assess the effect of an exercise training
program conducted concurrently with a high-fat (HF)-diet regimen on the effect
of a β adrenergic agonist stimulation on myocardial performance. Two groups of
rats were fed either a standard (SD) or a High fat (HF) diet (42% kcal) for 8 wk
and were additionally assigned either to a sedentary (Sed) or a treadmill-trained
group (HF-Sed; n=9 SD-Sed; n=11 HF-TR; n=10 and SD-TR; n=8). Training (5
days/wk) was initiated at the same time as the HF diet and was progressively increased;
reaching 60 min at 26 m/min, 10% grade, for the last 4 wk. Heart weight
of HF-Sed rats (0,95g) was significantly higher as compared to SD-Sed rats
(0,88g). HW/BW was significantly lower in HF-Sed (2,8mg/g) as compared to SD-
Sed (3,1mg/g). Exercise training normalized HW/BW in HF-diet rats. At the end
of the 8-wk period, HF-Sed rats exhibited 85% higher heart triacylglycerol con-
Pericardial and myocardial disease / Unstable angina 441
centration than SD-Sed rats (means ± sd: 8,5±0,9 vs 4,6±0,5 mg/g; p

442 Unstable angina
Results: The incidence at 30 days of the primary endpoint was 60 percent in
the group assigned to immediate PCI and 39 percent in the group assigned to
deferred PCI. (Relative risk 1.5, 95 percent, CI 1.09-2.15; p=0.004). There were
no deaths in both groups. Myocardial infarction was significantly more frequent in
the group assigned to immediate PCI (60 percent vs 37 percent, relative risk 1.6,
CI 1.12-2.28, p=0.005). Unplanned revascularization was similar in both groups.
The observed difference was preserved over a 6 month follow up period. (Figure
1, logrank p=0.008)
Fig 1. primary composite EP at 6 months.
Conclusions: The results showed no benefit associated with routine immediate
intervention in non-refractory intermediate to high risk NSTE-ACS patients. Immediate
PCI was associated with an increased rate of MI as compared to a 24-48
hours deferred strategy.
P2752 Aspirin use is associated with reduction in 15 year
mortality in patients presenting with acute ischemic
chest pain- The olmsted county chest pain study
V. Mathew 1 , R. Lennon1 , A. Aneja2 ,S.Bansilal2 ,H.Wiste1 ,
G. Reeder1 , M.E. Farkouh2 on behalf of Olmsted County Acute
Chest Pain Study Group. 1Mayo Clinic, Cardiology, Rochester, United States of
America; 2Mount Sinai School of Medicine, Cardiology, New York, United States
of America
Purpose: The long-term mortality benefit of aspirin (ASA) in a population-based
cohort with definite unstable angina (UA) has not been well documented.
Methods: We retrospectively identified all residents of Olmsted County (OC),
Minnesota presenting to local emergency departments with acute chest pain from
Jan 1985 through Dec 1992. Medical records were obtained from the Rochester
Epidemiology Project, the OC Health Care Utilization and Expenditures Database
and reviewed by a nurse abstractor. Follow-up mortality data for a median duration
of 16.7 years was obtained through State of Minnesota Electronic Death
Certificates and Death Tapes, OC Electronic Death Certificates, and Mayo Clinic
records. Aspirin therapy had emerged as standard of care during this time period.
Patients were stratified by ASA use at discharge, in hospital, both, and none. Cox
models were used to estimate the adjusted association between ASA use and
deaths.
Results: 1628 (23.9%) patients were identified with definite UA. Mean age of
cohort was 66y, and 60% were men. Aspirin was given both in hospital and at
discharge in 41%, only in hospital in 12%, only on discharge in 5%, and none at
all in 42%. There were 986 deaths over over the median follow-up of 16.7 years.
Survival rates are shown in the Kaplan Meier figure. Risk factor adjusted data
showed that ASA use was associated with a lower mortality rate when given both
in hospital and at discharge, HR 0.75 (95% CI 0.67, 0.84), in-hospital only HR
Aspirin use and long-term mortality.
0.83 (95% CI 0.71, 0.99) and discharge only HR 0.77 (95% CI 0.61, 0.96) when
compared with no ASA at all.
Conclusions: Any ASA use for UA in a population-based cohort is associated
with a reduction in long term mortality. This unique community database confirms
our practice of routine aspirin use to reduce mortality.
P2753 The impact of optimal medical therapy and
revascularization on outcome of patients with chronic
kidney disease and on dialysis who presented with
acute coronary syndrome
L. Bonello1 , A. Delabriolle1 ,P.Roy1 , D. Steinberg1 ,Z.Xue1 ,
R. Torgusson1 ,L.Satler1 ,A.Pichard1 , J. Lindsay 1 , R. Waksman2 . 1Washington hospital center, internal medicine, cardiology, Washington, United States of
America; 2Washington Hospital Center, Cardiovascular Research Institute,
Washington, United States of America
Objectives: We aimed to investigate the prognosis of acute coronary syndrome
(ACS) in chronic kidney disease (CKD) patients with and without dialysis compared
to patients without CKD when receiving optimal contemporary medical
therapy and percutaneous coronary intervention (PCI).
Background: Coronary artery disease (CAD) is the main cause of death in patients
with CKD. The poor prognosis associated with ACS in these patients has
been related to therapeutic nihilism.
Methods: The study included 2357 ACS patients who had PCI. According to their
creatinine level and medical history, they were divided into 3 groups: dialysis = 73;
CKD = 293; and control = 1991. Rates of cardiovascular events were recorded
over a 1-year follow-up period.
Results: Patients in all groups received similar contemporary medical therapy for
ACS and PCI. On admission, CKD patients and patients under dialysis more often
presented with cardiogenic shock (p = 0.05 and 0.02, respectively). A graded increase
in the rate of major adverse cardiovascular events at 1 year was observed
with decreasing renal function (control 13% vs CKD 22.9% vs dialysis 45.2%; p

or higher) in 85 patients (4.2%). Median TnT rise was 0.09ng/ml (range 0.01-
5.62). Patients were split into 3 age groups as shown in table 1. Median troponin
requests per year 410 (range 247-457).
Of the patients with a detectable troponin only 61 (29%) were admitted to hospital
within 7 days of the sample collection. At both 30 days and one year the
Kaplan Meier survival function shows a statistically significant difference (log
rank test 0.1ng/ml.
Table 1
Age (yrs) Number Detectable TnT TnT>0.1 Admitted within 1 week of TnT>0.1
(TnT>0.01ng/ml) (ng/ml) (ng/ml)
75 518 117 (22.6%) 35 (6.8%) 7 (20%)
Conclusions: Patients suspected of having an ACS should be admitted for risk
assessment and treatment. When admission to hospital is inappropriate due to
significant co-morbidity, measurement of TnT will add little to the management of
the patient. We recommend that serum troponin should not be measured within
primary care.
P2755 Efficacy of coronary revascularization in patients with
acute chest pain managed in chest pain unit
P. Merlos Diaz 1 , J. Sanchis Fores 1 ,V.BodiPeris 1 , J. Nunez Villota 1 ,
L. Mainar Latorre 1 ,R.Robles 1 , E. Santas 1 ,A.Cortell 1 ,X.Bosch 2 ,
A. Llacer 1 . 1 Hospital Clinic Universitari, Cardiologia, Valencia,
Spain; 2 Hospital Clinic, Cardiologia, Barcelona, Spain
Purpose: Chest pain unit protocols involve exhaustive evaluation prompting
revascularizations. Our aim was to investigate the safe discharge of patients
deemed at low risk and the prognostic impact of revascularization of patients
deemed at high risk.
Methods: The study population consisted of 1088 patients presenting at the
emergency department with chest pain without ischemia in the electrocardiogram
or troponin elevation. They were managed by a chest pain unit protocol including
early exercise testing. Three groups were distinguished: Group I, patients discharged
after exercise testing (n=424); Group II, unstable angina ruled out after
in-hospital evaluation (n=208); and Group III, unstable angina confirmed or not
ruled out (n=456). In Group III, 183 patients were revascularized at the index
episode. The end point was one-year death or myocardial infarction. Adjustments
were made for patient characteristics and a propensity score for revascularization
(C-statistic=0.83).
Results: Groups I and II showed the lowest end point rate compared with Group
III (Group I: n=7, 1.7%; Group II: n=1, 0.5%; Group III: n=62, 13.6%; p=0.0001). In
Group III, despite the worse baseline risk profile of non-revascularized patients,
revascularization did not improve outcome (HR=1.4, 95% CI 0.7 to 2.5, p=.4)
although decreased post-discharge revascularization (HR=0.3, 95% CI 0.1 to 0.7,
p=0.008). After excluding non-fatal periprocedural infarctions, revascularization at
the index episode reduced the end point (3.8% vs 10.7%, p=0.007).
Conclusions: Chest pain unit protocols are associated with safe discharge. Early
revascularizations, however, do not improve one-year outcome in terms of death
or myocardial infarction mainly because periprocedural events neutralize any potential
benefit.
P2756 CD34+ cells in patients with non-ST elevation acute
coronary syndrome
M.M. Ruda, O.N. Vyborov, T.I. Arefieva, Y.A. Karpov, Y.V. Parfyonova.
Russian Cardiology Research Center, Moscow, Russian Federation
Purpose: Circulating progenitor cells (CPCs) play an important role in endothelial
repair and in angiogenesis. We studied whether CPCs number is associated with
severity of coronary artery disease (CAD) and presence or absence of myocardial
damage, and how CPCs number changes in the early period after non-ST
elevation acute coronary syndrome (ACS).
Methods: CD34+ cells number was measured in peripheral blood of 77 patients
(40-69 years old, mean age 56) by flow-cytometry: in 27 patients with ACS (16
– cardiac troponin-negative (cTn–) and 11 cTn-positive (cTn+)) within 24h after
onset of symptoms; 32 patients with stable angina pectoris (SAP) and 18 subjects
without CAD – control group (CG). Besides, in 18 patients with ACS we
counted the number of CD34+ cells on the 11th day (the 2nd point) after onset of
symptoms as well as in 24h (the 1st point).
Results: All patients with CAD had reduced numbers of CD34+ cells as compared
to CG: decreased by 39.3% in ACS group (p=0.002) and showed the same
tendency (by 18.5%) in SAP group (p=0,076). Furthermore, in patients with ACS
CPCs number was reduced by 20.8% vs. patients with SAP (p=0.032). cTn– ACS
patients had reduced number of CPCs in comparison with CG (p=0.028) and had
no significant difference from SAP group (p=0.251). Most interestingly, cTn+ patients
had further reduced number of CPCs than cTn– patients (by 29%, p=0.041)
Unstable angina 443
(than SAP, p=0.009 and CG, p=0.002). By the 11th day CD34+ cells number in
ACS group had noticeably increased in comparison with the 1st day (p=0.078)
and had almost reached the values of SAP patients (p=0.443), while was still
significantly reduced compared to CG (p=0.043).
Conclusions: In peripheral blood of CAD patients CPCs numbers are reduced.
The association of CPCs number with CAD severity is shown by its progressive
reduction for patients with the following conditions: SAP, ACS cTn– and ACS
cTn+. We suggest that above endothelial damage, myocardial damage plays the
leading role in CPCs number reduction. The CPCs number in ACS patients has
a tendency to recover from the 1st to the 11th day.
P2757 Quality indicators in management of acute coronary
syndromes in Europe. Results from Euro Heart
Survey- ACS registry
F. Schiele1 , M. Tubaro2 ,K.Fox3 ,J.P.Bassand4 ,A.Gitt5 . 1Pole Coeur-Poumons, Department of Cardiology, Besancon, France;
2 3 4 Cardiology, Roma, Italy; Cardiology, Edinburgh, United Kingdom; Cardiology,
Besancon, France; 5Cardiology, Ludwigshafen, Germany
Rationale: Based on guidelines, quality indicators (QI) can be defined. The rate
of use of these indicators, in STEMI and NSTE-ACS patients and their impact on
clinical outcome needs to be documented.
Methods: QI were defined for STEMI and NSTE-ACS by expert consensus for
assessment at admission, in-hospital treatment, time delays, treatment at discharge
and for patients with ACS and heart failure. These QI were applied to
6485 patients (2830 STEMI and 3655 NSTE-ACS) included in the Euro Heart
Survey-ACS Registry. The rate of use and the impact of these
QI was tested on in-hospital survival and expressed as odds ratio.
Results: Definitions and rate of use in STEMI and NSTE-ACS are displayed on
the table. The lowest rates of use were observed for clopidogrel in-hospital and at
discharge, ACE inhibitors or ARB and, in patients with heart failure, betablockers
and aldosterone antagonists. Excepted for patients with acute heart failure, QI
were significantly more often used in STEMI than in NSTE-ACS patients. All QI
related to in-hospital management were univariate predictors of in-hospital survival.
Table 1
Quality indicators Total STEMI NSTEACS OR (95% CI) on survival
6485 2830 3655
Troponin assessment < 48 h 85.1 84.1 85.8 1.82 (1.40-2.37)
Assessment of LV function
In hospital medication
93.0 92.9 93.1 3.61 (2.64-4.94)
Aspirin 96.4 97.2 95.7 3.15 (2.13-4.66)
Clopidogrel 76.4 83.5 70.9 2.23 (1.77-2.80)
ACEI or ARB 82.4 84.3 80.8 4.72 (3.77-5.92)
Anticoagulation
Time delays (median)
96.9 98.9 95.4 0.93 (0.56-1.90)
Time from symptoms to admission 3:15 2:55 3:45 ns
Delay from admission to PCI
Discharge medication
9:30 1:00 42:30 ns
Aspirin 93.3 95.6 91.5
Clopidogrel 66.5 77.7 58.2
Aspirin + clopidogrel 63.6 75.6 54.8
ACEI or ARB 80.3 84.8 77.0
Statins 83.4 89.0 79.3
LVEF < 0.40 or heart failure n=365 n=153 n=182
Betablockers 83.1 85.6 80.6
ACEI or ARB 87.8 91.3 84.4
Aldosterone antagonists 40.4 43.1 37.8
In-hospital mortality 5.1 7.9 3.0
Conclusions: QI, as defined for the EHS-ACS, provide important information on
the degree of application of guidelines-recommended treatment and are related
with survival.
P2758 High-risk markers do not guide treatment strategies
of elderly acute coronary syndrome patients: real-life
data from the Contacts-registry
J. Lumme 1 , K.E.J. Airaksinen 2 , J. Hartikainen 3 ,I.Tierala 4 ,
S. Vikman 5 on behalf of Contacs Study Group. 1 Oulu University
Hospital, Oulu, Finland; 2 Turku University Hospital, Turku, Finland; 3 Kuopio
University Hospital, Kuopio, Finland; 4 Helsinki University Hospital, Helsinki,
Finland; 5 Tampere University Hospital, Tampere, Finland
Purpose: We analyzed factors in the physicians’ decision-making leading to conservative
treatment strategy in acute coronary syndrome (ACS).
Methods: A nationwide, multicenter prospective registry on conservatively
treated ACS patients (n=967) in 49 centers representing the whole health care
system from primary care to tertiary hospitals.
Results: Median age of the patients was 78 years and 49% of them were women.
Coronary angiography was performed in 35% of the patients during the index
hospitalisation. After adjustment for age and gender, angiography was performed
less often in patients with diabetes (29% vs. 38%, p=0.023), polyvascular disease
(16% vs. 38%, p

444 Unstable angina / Reperfusion
of the patients (33%), estimated high risk/benefit ratio (14%) and in 25% of the patients
angiography was considered "unnecessary". Patients referred to coronary
angiography were more often treated with ESC guideline-based medication: aspirin
95% vs. 88%, p=0.0026), clopidogrel (56% vs. 33%, p

teria as a final Thrombolysis In Myocardial Infarction (TIMI) flow ≤ 2 or final TIMI
flow 3 with a myocardial blush grade (MBG) < 2. Electrocardiographic definition
of no-reflow included the lack of ST segment resolution (defined as a reduction

446 Reperfusion / Prognosis in ST-elevation myocardial infarction
gression analysis using this cut-point. Other variables like age, symptoms-needle
time, previous AMI and AMI localisation were included in the model.
Results: During the study period, 80 patients admitted with STEMI were treated
with tenecteplase. The treatment failure rate was 29%. Using plot points from
ROC curve (area under the curve=0,76, p75 years 38.4% 17.5% 16.7%

cantly correlated to in-hospital death. There was a significant interaction between
hemoglobin levels and leukocytosis (p

448 Prognosis in ST-elevation myocardial infarction
Conclusion: Major bleeding complications in ACS are independently associated
with a 2-fold increased hospital mortality in clinical practice in Europe.
P2774 The ratio of contrast load to Glomerular Filtration
Rate (GFR) as a predictor for renal dysfunction and
subsequent mortality following emergent PCI for
STEMI
R. Kornowski, H. Vaknin Assa, T. Bental, I. Ben Dor, D. Brosh,
E. Lev, S. Fuchs, A. Assali. Rabin Medical Center, Petach Tikva,
Israel
Background: The ratio of contrast load utilized during PCI to baseline glomerular
filtration rate (GFR) has been proposed as a surrogate marker for the development
of contrast induced nephropathy post elective PCI. We sought to use
the ratio in order to predict the renal and cardiac prognosis among patients with
STEMI who were treated using primary PCI.
Methods: Data from consecutive patients who underwent PCI for STEMI at our
hospital were imputed into a dedicated clinical database. We compared the clinical
outcome (death, re-MI, TVR, MACE) at 6 month in patients distinguished by
the ratio of contrast load utilized during PCI to baseline GFR prior to PCI.
Results: Results of 871 consecutive (non-shock) patients with STEMI are summarized
in the table:
Contrast Volume/GFR Ratio 0.14-1.5 (N=290) 1.5-2.35 (N=290) >2.35 (N=290)
Age (years) 62±10 63±12 63±11
Males (%) + 83 86 76
Diabetes Mellitus (%) 24 23 28
Anterior MI (%) + 37 46 56
Multivessel Disease (%) + 46 56 70
Killip>1(%) + 11 10 22
Successful PCI (%) 98 98 92
Multivessel PCI (%) + 2.4 8.6 13.8
EF

nosis in patients with myocardial infarction (MI). In this context, left atrial volume
index (LAVI) was shown to be an independant and powerful predictor of mortality
after MI. The aim of this study was to evaluate the prognostic value of LAVI in
patients presenting with first anterior MI, and treated by modern clinical practice.
Methods: This prospective study included 255 patients with inaugural anterior
MI. Clinical and echocardiographic data were collected at baseline. LAVI was
determined in a blinded analysis at a core echocardiographic laboratory. Patients
with LAVI 32 mL/m 2 . The endpoint was a composite of all-cause mortality or
hospitalization for heart failure.
Results: Acute reperfusion was attempted in 210 patients (82%). At discharge,
94% of patients received a beta-blocker, 96% an angiotensin-converting enzyme
inhibitor or angiotensin II receptor blocker. Fifty-one (20%) patients had a LAVI
>32 mL/m 2 . During a median follow-up of 1229 days, 40 patients (16%) died or
were hospitalized for heart failure. LAVI was a significant predictor of all-cause
mortality or hospitalization for heart failure (p=0.001). The Kaplan-Meier survival
curves according to baseline LAVI are shown in the figure below. However LAVI
did not prove to be an independent predictor by multivariate Cox analysis (hazard
ratio 1.41, 95%CI 0.67-2.96, p=0.36).
Kaplan-Meier curves according to LAVI.
Conclusions: Increased LAVI is a powerful, but non independant, predictor of
clinical outcome in term of death or hospitalization for heart failure, after first anterior
MI in patients treated according to modern practice.
P2779 Does the time of primary cardiac arrest in relation to
PCI affect the outcome?
F.M. Szymanski, M. Grabowski, G. Karpinski, A. Hrynkiewicz,
K.J. Filipiak, G. Opolski. Medical University of Warsaw, First
Cardiology Department, Warsaw, Poland
Purpose: No data are available for the prognostic value of primary cardiac arrest
(CA) due to ventricular fibrillation before, during, and after primary percutaneous
coronary intervention (PCI) in patients with acute ST-segment elevation acute
myocardial infarction (AMI) treated with primary angioplasty. We sought to determine
differences in prognosis between patients with primary CA before, during,
and after PCI.
Methods: Among 448 patients with first ST-segment elevation AMI, we selected
34 (7.6%) with primary CA due to ventricular fibrillation (VF) and 6 (1.3%) with
secondary CA. The patients with primary CA were categorized into the groups
according to the time of the first episode of primary CA, either before [12 (35.3%)],
during [18 (52.9%)], and after [4 (11.8%)] PCI procedure. The 30-days all cause
mortality rate was analyzed.
Results: Short-term mortality increased: patients without CA 7.1% (29/408), patients
with primary CA 35.3% (12/34), patients with secondary CA 50% (3/6); P
value for trend < 0.0001. When the patients were categorized into the groups
according to the time of the first episode of primary CA, the mortality also increased:
8.3% (1/12) for patients with primary CA before PCI, 44.4% (8/18) for
patients with primary CA during PCI, 75% (3/4) for patients with primary CA after
PCI procedure; P value for trend = 0.007.
Conclusions: The patients with primary CA have the same poor prognosis as
the patients with secondary CA. The prognosis make worse according to the time
of the episode of primary CA. It might be reasonable to isolate subgroups of STsegment
elevation AMI patients treated with PCI with primary CA according to
time of primary CA which can help to better stratify the risk of these patients.
P2780 Multicenter randomized trial of facilitated
percutaneous coronary interventions with
minimal-dose tenecteplase in patients with acute
myocardial infarction. The ATHENS PCI trial
E.P. Tsagalou1 , I. Kanakakis1 ,N.Agrios1 , M. Anastasiou-Nana1 ,
F. Katsaros1 , A. Masdrakis1 , S. Sarafoglou1 , B. Tzoumerle 2 , S. Rokas1 ,
J. Nanas1 . 1University of Athens, Athens, Greece; 2Pamakaristos Hospital,
Athens, Greece
Background: Facilitated percutaneous coronary intervention (PCI) preceded by
administration of glycoprotein IIb/IIIa inhibitors, full-dose thrombolytics, or both,
is associated with no benefit or a higher incidence of adverse events than PCI
Prognosis in ST-elevation myocardial infarction 449
alone. We hypothesized that minimal-dose tenecteplase might result in early infarct
related artery (IRA) patency, without causing the adverse events of full-dose
thrombolytics.
Purpose: To examine the safety and efficacy of minimal-dose tenecteplase, administered
before PCI to restore Thrombolysis In Myocardial Infarction (TIMI)
grade 2 or 3 blood flow in the IRA, in patients with ST elevation myocardial infarction
(STEMI) scheduled to undergo PCI with a shortest anticipated delay of
30 min.
Methods: Patients with STEMI < 6 h in duration were randomly assigned to PCI
preceded by 10 mg of tenecteplase (facilitated PCI group, n=137) versus standard
PCI (control group, n=135). All patients received aspirin and unfractionated
heparin (70 IU/kg bolus) at time of randomization. Both groups received IIb/IIIa
inhibitors in the catheterization laboratory and for at least 20 h after PCI.
Results: The median door-to-balloon time was 122 min (91-175) in the facilitated
PCI versus 120 min (89-175) in the control group. IRA patency on arrival in the
catheterization laboratory was 60,5% in the facilitated PCI (24.3% TIMI-2, 36.2%
TIMI-3), versus 37% in the control (7.4% TIMI-2, 29.6% TIMI-3) group (P=0.004).
Conclusions: Facilitation with minimal-dose tenecteplase, in patients presenting
with STEMI, was associated with a high IRA patency rate before PCI.
P2781 Prognostic relevance of TIMI flow and Nt-proBNP
concentrations in ST-elevation myocardial infarction:
a substudy of ASSENT IV-PCI
R. Jarai 1 , K.-B. Bogaerts 2 , W.-D. Droogne2 , J.-E. Ezekowitz3 ,
P.-S. Sinnaeve 2 , K.-H. Huber4 , C.-G. Granger5 , A.-R. Ross6 ,
P.-A. Armstrong3 ,F.-W.VanDeWerf2on behalf of ASSENT-4-PCI. 1Wilhelminen Hospital, 3rd Department of Medicine/Cardiology, Vienna, Austria; 2Leuven, Belgium; 3Edmonton, Canada; 4Vienna, Austria; 5Durham, United States of
America; 6Washington D.C., United States of America
Background: We investigated the prognostic significance of Nt-proBNP in addition
to TIMI flow determined prior to coronary intervention in STEMI patients from
ASSENT IV-PCI.
Methods: Plasma Nt-proBNP was available in 1,037 STEMI patients when
pts were randomized to primaryPCI) or to full-dose tenecteplase prior to PCI
(fPCI).The study endpoint was the composite of death, cardiogenic shock or congestive
heart failure at 90 days. The Chi-square (Chi2) Automatic Interaction Detectors
algorithm (CHAID) of classification-tree analysis comprised our statistical
calculations.
Results: Failure of fibrinolytic therapy to achieve TIMI-3 flow prior to PCI (n=296)
was associated with a significantly higher 90-day event rate (22.0%) compared to
pts with successful fibrinolysis (n=228; 12.7%; p=0.006) or primary PCI (TIMI-3
flow n=66: 13.6% p=0.13; TIMI 0-2 flow n=425: 12.0%: p694 pg/ml (>80th percentile) had highest
risk for 90-day events in both treatment arms (pPCI: 30.1%, and fPCI: 36.3%;
p=0.4) irrespective of TIMI-flow grade before PCI (Figure). The lowest 90-day
event rate was observed in patients with a TIMI-3 flow before PCI pre-treated
with fibrinolysis and Nt-proBNP levels ≤694pg/m. However, in fibrinolytic nonresponders
(TIMI 0-2 flow) event rates were significantly higher than in all other
groups.
Conclusion: Clinical outcome of pts with high baseline plasma concentrations of
Nt-proBNP was poor irrespective of TIMI-flow before PCI or the assigned treatment.
By contrast in pts with low Nt-proBNP levels outcome appeared modulated
by prePCI TIMI flow when pre-treated with fibrinolysis.
P2782 Baseline concentrations of the interleukin receptor
family member ST2 add independent prognostic
information to risk scores in STEMI patients treated
with PCI
M. Grabowski1 , F.M. Szymanski1 ,J.Januzzi2 ,A.H.B.Wu3 ,
A. Hrynkiewicz 1 , K.J. Filipiak1 ,G.Opolski1 . 1Medical University
of Warsaw, 1st Department of Cardiology, Warsaw, Poland; 2Massachusetts General Hospital, Department of Cardiology, Boston, United States of America;
3University of California, Department of Laboratory Medicine, San Francisco,
United States of America
Aim: To evaluate hypothesis that baseline serum levels of novel Interleukin-1
receptor family member (ST2) add prognostic information to widely-accepted risk
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450 Prognosis in ST-elevation myocardial infarction
scores in unselected ST-elevation acute myocardial infarction (STEMI) patients
treated with primary angioplasty (PCI).
Methods: SIMPLE, TIMI, GRACE and ZWOLLE risk scores were calculated, and
ST2 baseline levels were obtained in 68 consecutive patients. 1-year follow-up for
all-cause mortality was performed.
Results: There was moderate correlation between baseline ST2 levels and SIM-
PLE (r=0.28; p=0.02), TIMI (r=0.32; p=0.008), GRACE (r=0.4; p=0.0007) and
ZWOLLE (r=0.37; p=0.002) risk scores. The area under the receiver operating
characteristic curve for ST2 to predict death – 0.804 (p=0.003) was comparable
to risk scores: SIMPLE – 0.763, TIMI – 0.669, GRACE – 0.827, ZWOLLE - 0,637;
p for difference vs. ST2, respectively: p=0.75; 0.24; 0.83; 0.12. When patients
were divided into subgroups by low and high values of ST2 and risk scores (quartile
1-3 and 4 for ST2 and each risk score) there was an increase in mortality with
high compared to low ST2 levels in both low and high risk groups by risk scores
(figure). After incorporation of ST2 to models consisting of each risk score (quantitative),
consistent improvement of each C-statistic was noted, with an increase
for SIMPLE to 0.786, TIMI to 0.711, GRACE to 0.84 and ZWOLLE to 0.808.
1-year all-cause mortality
Conclusions: Serum ST2 levels obtained on admission in STEMI patients
treated with PCI add significant prognostic information to widely accepted risk
stratification models, suggesting an important clinical role for this marker.
P2783 Plasma concentration of sphingosine-1-phosphate
and related sphingoid bases after the myocardial
infarction in humans
M. Knapp1 , M. Baranowski2 , D. Czarnowski2 ,A.Lisowska2 ,
W.J. Musial 2 , J. Gorski2 . 1Medical University in Bialystok, Dept.
of Cardiology, Bialystok, Poland; 2Medical University, Physiology Department,
Baialystok, Poland
The major bioactive sphingolipids are: ceramide, sphingosine-1-phosphate (S1P),
sphingosine, sphinganine-1 phosphate (SH1P), sphinganine and ceramide-1phosphate.
S1P has recently attracted much attention as an important factor protecting
the heart against ischemia-reperfusion injury. Increased generation of S1P
was shown to mediate the ischemic preconditioning in the perfused murine heart.
The aim of this study was to evaluate whether concentration of S1P in the plasma
is affected by the myocardial infarction in man.
Material and method: The study comprised two groups of males: 21 healthy
controls (mean age 66.7±6.3) with no specific complains (and no treatment) and
21 patients with STEMI (diagnosed according to the ESC guidelines) treated by
primary PCI (mean age 63.3±8.2). In the control group the blood was taken after
an overnight fast. In the group of patients the blood was taken twice: on admission
to the intensive care unit and at the fifth day of hospitalization. Patients received
aspirin, clopidogrel and unfractionated heparin before the first blood sample was
taken. The concentration of S1P, SH1P, free sphingosine, free sphinganine and
ceramide in the plasma was determined simultaneously by means of high pressure
liquid chromatography. All data are presented as means ±SD. Statistical
comparisons were made by using one-way ANOVA followed by Newman-Keuls
post-hoc test. P

lesion classification, stent type used, stent/lesion length, number of stents used
did not show significant impact on mortality. We developed a prediction scoring
system for outcome (MACE and death) using the significant clinical predictors.
Conclusion: Age, female gender, diabetes, renal impairment, anemia, hypotension
and development of cardiogenic shock, CIN, large rise in CK and lowered
LVEF are clinical predictors of mortality in patients with STEMI post PPCI. A scoring
system can be used to predict the clinical outcomes in these patients.
P2786 Obstructive sleep apnea impairs the myocardial
tissue perfusion in patients with acute myocardial
infarction
H. Nakashima1 ,S.Izumida2 , K. Amenomori 1 , Y. Honda1 ,
S. Suzuki1 . 1Nagasaki Citizens Hospital, Department of Cardiology,
Nagasaki, Japan; 2Nagasaki Citizens Hospital, Cardiology, Nagasaki, Japan
Aims: Vascular endothelial dysfunction is noted in patients with obstructive sleep
apnea (OSA). This study was designed to examine our hypothesis that OSA may
impair the coronary microcirculation in patients with acute myocardial infarction
(AMI).
Methods: This study included 100 consecutive patients with a first AMI who
underwent primary percutaneous coronary intervention (PCI). After reperfusion,
coronary flow velocity at baseline and maximal hyperemia was measured using
by Doppler guidewire. The sum of ST-segment elevation was measured at 30 min
after PCI and compared with that on admission. Tissue perfusion grade was evaluated
by coronary flow velocity reserve (CFVR), the presence of early systolic
reversal flow (SRF), and ST-resolution. All patients underwent polysomnography
and OSA was defined as AHI ≥ 15 events/h, of which more than 50% were obstructive.
Results: Forty-six patients showed OSA. CFVR was comparable between the
two patient groups (1.66±0.57 vs. 1.63±0.47, p=0.840). The incidence of SRF
was significantly higher in OSA patients than in control patients (24% vs.
7%, p=0.021). Patients with OSA showed a significantly lower ST-resolution
(0.17±0.63 vs. 0.48±0.55, p=0.016). Significantly fewer OSA patients showed
ST resolution ≥ 0.50 (37% vs. 61%, p=0.016). Multiple logistic regression analysis
showed that OSA was independent negative predictor for ST resolution ≥
0.50 (p=0.047).
Conclusions: The novel finding in this study is that OSA may impair the tissue
perfusion after primary PCI.
P2787 Efficacy of a 24-hour primary percutaneous coronary
intervention service on outcome in patients with
STEMI in clinical practice
T. Bauer1 , R. Hoffmann2 , C. Juenger3 , R. Zahn1 , O. Koeth1 ,
T. Heer1 ,A.Gitt1 , K. Bestehorn4 , J. Senges3 ,U.Zeymer1on behalf
of ACOS study group. 1Herzzentrum Ludwigshafen, Cardiology Department,
Ludwigshafen, Germany; 2Universitaetsklinik Aachen, Cardiology Department,
Aachen, Germany; 3Institut fuer Herzinfarktforschung, Ludwigshafen, Germany;
4MSD, Munich, Germany
Objectives: Little is known about the influence of a 24-hour, 7-day primary percutaneous
coronary intervention (PCI) service on clinival events in patients with
ST elevation myocardial infarction (STEMI). So far, randomised trials or data from
observational studies are missing. Therefore we sought to investigate the impact
of a 24-hour primary PCI service on in-hospital outcome in patients with STEMI
in clinical practice.
Methods: We analyzed data of consecutive patients with STEMI prospectively
enrolled in the German Acute Coronary Syndromes registry between July 2000
and November 2002 who were admitted to hospitals with catheter laboratory.
Results: Overall 6350 patients were divided into two groups: 2779 (43.8%) were
treated in hospitals with and 3571 (56.2%) without a 24-hour on-call cardiac
catheter laboratory. 83.0% of the patients at facilities with and only 69.9% of the
patients at facilities without 24-hour PCI service received early reperfusion therapy
(p

452 Prognosis in ST-elevation myocardial infarction
Methods: A total of consecutive 304 PPCI patients were prospectively enrolled;
of these, 58 (19.1%) were elderly (≥75 years). Epicardial perfusion was evaluated
by thrombolysis in myocardial infarction (TIMI) flow grade and corrected
TIMI frame count (CTFC), and myocardial perfusion was evaluated by the TIMI
myocardial perfusion grade (TMPG) and myocardial blush grade (MBG).
Results: Compared to younger patients, elderly patients presented with a significantly
higher adverse clinical and angiographic profiles. Despite a similar rate of
procedural success (94.8% vs. 96.7%; P = NS), and a comparable epicardial perfusion
before (TIMI flow grade 3: 8.6% vs. 6.5%, CTFC: 85.5±34.3 vs. 90.2±22.9;
P = NS) and after PPCI (TIMI flow grade 3: 89.7% vs.91.1%, CTFC: 30.7±22.5
vs. 28.3±26.0; P = NS), the rate of successful myocardial perfusion was markedly
lower in the elderly than younger patients (TMPG ≥ 2 grade: 63.8% vs. 79.7%, P
= 0.010; MBG ≥ 2 grade: 67.2% vs. 80.9%, P = 0.023; respectively). Multivariate
analysis showed that advanced age (≥75 years) was the independent predictor
of failure to achieve TMPG grade≥2 (OR 1.72, 95% CI 1.22-2.71, P = 0.016) or
MBG grade≥2 (OR 1.56, 95% CI 1.10-2.24, P = 0.035). The incidence of 30day
major adverse cardiac events (MACE) in elderly patients was 2.8-fold higher
than in younger patients (P=0.001). In the whole population, multivariate analysis
found that both advanced age (age≥ 75 years: OR 2.81, 95% CI 1.20-6.66,
P = 0.011) and unsuccessful myocardial perfusion (TMPG≤1 grade: OR 2.34,
95% CI 1.10-5.62, P = 0.040) were independently associated with 30-day MACE.
In elderly patients, multivariate analysis identified unsuccessful myocardial perfusion
(TMPG≤1 grade: OR 8.95, 95% CI 2.67-29.1, P = 0.003) as the the most
important determinant of 30-day MACE.
Conclusions: Impaired myocardial perfusion and not epicardial perfusion is associated
with the worsened outcomes in elderly patients undergoing PPCI. To
further improve the outcome of elderly patients with STEMI, efforts should be
aimed at improving myocardial perfusion, beyond epicardial recanalization.
P2791 Contrast induced nephropaty after primary or rescue
PCI: prevalence and prognostic impact
A. Perkan, F. Giannini, A. De Monte, B. D’agata, M. Merlo,
G. Vitrella, S. Rakar, E. Della Grazia, A. Salvi, G. Sinagra on behalf
of Primary/Rescue PCI Registry of Trieste. Ospedali Riuniti and
University, Cardiovascular Department, Trieste, Italy
Purpose: Contrast induced nephropathy (CIN) is a possible complication of coronary
diagnostic and interventional procedures. Recent studies evaluated ST elevation
myocardial infarction (STEMI) patients treated with percutaneous coronary
intervention (PCI) as a group at high risk of CIN. Nevertheless the real prevalence
and prognostic impact of CIN in STEMI patients is still unclear. The aim of
this study was to assess prevalence, clinical predictors and outcome of CIN after
primary or rescue PCI for STEMI patients.
Methods: Three hundred and eighty one STEMI patients (73% men, mean age
65±12 yrs; iodixanol was used in 72% of pts., 194±79 cc/procedure), underwent
primary and rescue PCI from December 2003 to June 2007. We measured serum
creatinine levels at baseline and in the following (2 and 3-7) days. CIN was defined
as an absolute increase in creatinine >0,5 mg/dl after PCI in the absence of other
causes of renal failure.
Results: CIN occurred in 25 patients (6,6%). Patients developing CIN were older,
had a higher incidence of diabetes mellitus and lower left ventricular ejection fraction.
An estimated glomerular filtration rate (eGFR)

Prognosis in ST-elevation myocardial infarction / Percutaneous coronary intervention; longterm outcome 453
P2794 Relation of Nt-proBNP and time to treatment to
outcome of patients with ST-elevation myocardial
infarction: an ASSENT IV-PCI substudy
R. Jarai 1 , K.-B. Bogaerts 2 , W.-D. Droogne 2 , J.-E. Ezekowitz 3 ,
P.-S. Sinnaeve 2 , K.-H. Huber 4 , C.-G. Granger 5 , A.-R. Ross 6 ,
P.-A. Armstrong 3 ,F.-W.VanDeWerf 2 on behalf of ASSENT-4-PCI. 1 Wilhelminen
Hospital, 3rd Department of Medicine/Cardiology, Vienna, Austria; 2 Leuven,
Belgium; 3 Edmonton, Canada; 4 Vienna, Austria; 5 Durham, United States of
America; 6 Washington D.C., United States of America
Background: Survival of ST-elevation myocardial infarction (STEMI) pts depends
on time between symptom onset and coronary reperfusion. In the present substudy
from ASSENT-IV PCI pts were randomly assigned to primary PCI (pPCI)
or fibrinolytic-facilitated PCI (fPCI), and we investigated, whether elevated NtproBNP
in the acute phase of STEMI relates to time to reperfusion and independently
predicts outcome irrespective of time.
Methods: Plasma Nt-proBNP was available in 1,037 STEMI patients when
pts were randomized to primaryPCI) or to full-dose tenecteplase prior to PCI
(fPCI).The study endpoint was the composite of death, cardiogenic shock or congestive
heart failure at 90 days. The Chi-square (Chi2) Automatic Interaction Detectors
algorithm (CHAID) of classification-tree analysis comprised our statistical
calculations.
Results: Nt-proBNP concentrations and time-to-treatment showed a weak but
significant linear correlation (r=0.22; p

454 Percutaneous coronary intervention; longterm outcome
of stents was 5.4±2 per patient with a mean stent length of 132±47 mm. Patients
were 64±10 years old (male; 89%), hypertension 68%, hyperlipidaemia 63%,
diabetes 29%, family history 47%, smoker 19%. Patients had unstable angina
27%, prior PCI 31%, prior CABG 19%, prior MI 46% and a mean ejection fraction
53%. There were 4 (0.9%) definite ST; 1 acute (0.2%), 2 sub-acute (0.5%), 1 late
(0.2%) and 0 very late.
Conclusions: This study demonstrates an acceptable occurrence of MI, death
and repeat revascularization in this cohort of complex patients with an incidence
of definite ST similar to real world use in less complex patients.
P2798 Cardiac outcome 8 years after stent implantation
versus off-pump bypass surgery
J.J. Regieli 1 , H.M. Nathoe2 , P.R. Stella2 , E.W.L. Jansen2 ,D.Van
Dijk2 , J.C. Fanggiday 2 , F.D. Eefting3 , D.E. Grobbee2 ,P.P.T.De
Jaegere4 , P.A. Doevendans2 on behalf of OCTOPUS study group.
1University Medical Center Utrecht, Heart-Lung Institute, Dept of Cardiology,
Utrecht, Netherlands; 2UMC Utrecht, Cardiology, Utrecht, Netherlands; 3St Antoinius Hospital, Cardiology, Nieuwegein, Netherlands; 4Erasmus MC,
Cardiology, Rotterdam, Netherlands
Purpose: To compare the long-term clinical effects of a stenting strategy versus
off-pump bypass surgery.
Methods: In the OCTOSTENT study, 280 patients at relatively low risk and in
need of coronary revascularization were randomized. Long-term follow-up data
were obtained by patient interviews and subsequent retrieval of hospital records.
Results: Patients included had a mean age of 60 years, were predominantly
(70%) males with stable angina (70%), one vessel disease (70%) and normal LVfunction
(90%). The surgery group experienced 10% all-cause mortality, and the
stenting group 7% (p=0.43). Stroke, myocardial infarction (MI) or all cause mortality
were equally experienced in both groups (14% vs 13% respectively, p=0.80)
whereas the need of coronary re-interventions was significantly (p=0.03) higher
in patients initially treated with a bare-metal stent (16 vs 27%). The figure displays
plotted Relative Risks representing effect of surgery versus stenting on the
various outcomes.
Effect of surgery versus stenting.
Conclusion: In low risk CAD patients, off-pump surgical revascularization offers
no significant long-term benefit on hard outcomes as compared to bare metal
stenting. However, re-interventions are significantly more frequent after stenting.
A strategy of stent-implantation can therefore safely be recommended as the first
choice coronary revascularization procedure in selected patients.
P2799 Risk factors and clinical outcomes for contrast
induced nephropathy post percutaneous coronary
intervention in patients with impaired baseline renal
function
E. Chong, Liang Shen, K.K. Poh, C.T. Hong, H.Y. Ong, H.C. Tan.
National University Hospital, The Heart Institute, Singapore,
Singapore
Purpose: Baseline renal impairment is a recognized risk factor for developing
contrast nephropathy (CIN) post percutaneous coronary intervention (PCI). We
examine other risk predictors for CIN in patients with impaired baseline renal
function who are already receiving prophylactic treatment.
Methods: A cohort of 770 patients with impaired renal function (estimated
glomerular filtration rate (GFR) < 60ml/min/1.73m 2 ) who received prophylactic
saline hydration and oral N-acetylcysteine treatment undergoing PCI between
May 2001 to March 2007 were recruited. We examine the incidence of CIN in
this cohort and aim to identify clinical risk predictors.
Results: The mean age of the cohort was 65±18 years, 28.6% were older than
70, 65.8% was men, 45.9% was diabetics, 77% was hypertensive, 27.1% had
acute coronary syndrome. CIN occurred in 11.4% of the patients. Clinical predictors
for CIN were age (OR 1.59, 95% CI 1.0-2.52, p=0.049); anemia with
hemoglobin < 11mg/dl (OR 2.26, 95% CI 1.41 – 3.61, p=0.001); post procedural
creatinine kinase rise (OR 1.12, 95% CI 1.07 – 1.16 for every 500 u/l increase,
p

P2802 In-hospital and long-term mortality after emergency
and elective PCI of unprotected left main stem
stenosis with provisional side-branch stenting
strategy. The Krakow experience
J. Legutko 1 ,D.Dykla1 ,M.Suska1 ,L.Rzeszutko1 ,R.Singh2 ,
W. Gutkowski3 ,B.Guzik1 , A. Machnik1 , L. Bryniarski1 , D. Dudek1 . 1Jagiellonian University, Institute of Cardiology, Cracov, Poland; 2Nottingham University
Hospitals, Trent Cardiac Centre, Nottingham, United Kingdom; 3Swietokrzyskie Cardiology Centre, Kielce, Poland
Background: Unprotected left main stem stenosis (UPLMS) is class IA indication
for surgical revascularization. However, there is increasing evidence, that stenting
of UPLMS is safe and feasible. The aim of the study was to evaluate in-hospital
and long-term mortality after emergency and elective UPLMS stenting.
Methods: Data was collected for 246 consecutive patients who underwent UP-
LMS PCI with provisional side-branch stenting strategy. Of these, 170 pts presented
with stable angina (SA), 36 pts with unstable angina (UA), 16 pts with non
ST-elevation myocardial infarction (NSTEMI) and 24 pts with ST-elevation myocardial
infarction (STEMI). Majority of the lesions involved distal bifurcation of the left
main (72%). Stents were implanted in all patients (Drug Eluting Stents: 61%, Bare
Metal Stents: 39%). One stent was used for 97% of pts. In-hospital and long-term
mortality was assessed.
Results: Mean time of follow-up was 26,7 months. In-hospital and long-terrm
mortality is shown in table. Moreover, patients with acute coronary syndromes
(STEMI, NSTEMI, UA) in-hospital mortality was significantly higher in patients
presenting with cardiogenic shock (23% vs. 2%, shock vs. non-shock respectively,
p

456 Percutaneous coronary intervention; longterm outcome
Conclusions: In comparison to BMS, DES were associated with similar longterm
safety (mortality and myocardial infarction) and maintained their efficacy in
reducing repeat revascularisation and MACE.
P2806 Long-term clinical outcome with
titanium-nitride-oxide-coated stents, paclitaxel eluting
stents and bare-metal stents for coronary
revascularization in an unselected population
P.P. Karjalainen1 , A.-P. Annala1 ,A.Ylitalo1 , K.E.J. Airaksinen2 .
1 2 Satakunta Central Hospital, Dept. of Cardiology, Pori, Finland; Turku University
Hospital, Dept. of Internal Medicine, Turku, Finland
Purpose: The main purpose of this study was to compare long-term clinical outcome
of titanium-nitride-oxide-coated bio-active stents (BAS), paclitaxel eluting
stents (PES) and bare-metal stents (BMS) in routine clinical practice.
Methods: Between May 2003 and November 2004 all patients undergoing percutaneous
coronary intervention (PCI) were eligible in this study. The primary end
point of the study was major adverse cardiac events (MACE) at 3 years including
myocardial infarction (MI), cardiac death and target vessel revascularization
(TVR).
Results: A total of 589 patients were included in this analyses of which 201 received
BAS, 204 PES and 184 BMS. Complete follow-up datasets were available
in 100% of patients. After 3 years of follow-up, the rate of MACE was 13.9% for
BAS, 23.5% for PES and 31.5% for BMS (Table). A higher rate of MI was observed
in the PES group (19.1%) compared with BAS (7.5%) group. The rate of
TVR was 8.5% for BAS, 11.3% for PES and 14.1% for BMS. Stent thrombosis
(ST) occurred in 15 patients in the PES (7.4%) group and in 5 patients in the
BMS (2.7%) group. There was no ST in the BAS group.
Outcome events at 3 years
BAS (n=201) PES (n=204) BMS (n=184) P
Myocardial infarction, % 7.5 19.1 14.7 0.002*
Cardiac death, % 1.0 3.4 6.0 0.02 †
Target vessel revascularization, % 8.5 11.3 14.1 NS
Target lesion revascularization, % 5.5 9.3 12.0 NS
MACE, % 13.9 23.5 31.5 < 0.001 †
Stent thrombosis, % 0 7.4 2.7 < 0.001*, 0.03 ‡
All cause death, % 5.5 6.4 8.7 NS
* BAS versus PES; † BAS versus BMS; ‡ BMS versus PES.
Conclusions: After 3 years follow-up, BAS resulted in better long-term clinical
outcome compared with PES or BMS. The incidence of ST tended to be highest
in the PES group.
P2807 High on-treatment platelet reactivity as a risk factor
for clinical events beyond the duration of treatment
with clopidogrel
D. Trenk1 , W. Hochholzer 2 ,C.M.Valina1 ,C.Stratz1 ,H.-
P. Bestehorn1 , H.J. Buettner1 , F.-J. Neumann1 . 1Herz-Zentrum Bad Krozingen, Abt. fuer Klinische Pharmakologie, Bad Krozingen, Germany;
2Universitaetsspital Basel, Internal Medicine, Basel, Switzerland
Background: The EXCELSIOR study demonstrated the impact of residual
platelet aggregation after loading with clopidogrel 600 mg in patients undergoing
elective percutaneous coronary intervention (PCI) with stent placement. Patients
with an attenuated antiplatelet response before discharge at day 1 after
PCI carried a 3-fold increased risk for the 12-months incidence of the composite
endpoint death and myocardial infarction (MI). We investigated if the impact of
high on-treatment platelet reactivity extended beyond the duration of clopidogrel
administration.
Methods: This secondary analysis of the EXCELSIOR-study comprised 765 patients
undergoing coronary stent implantation after loading with 600 mg of clopidogrel.
After PCI, all patients received aspirin (≥100 mg per day), lifelong, and
clopidogrel (75 mg per day) for 30 days after placement of bare-metal stents or
for 6 months after placement of at least one drug-eluting stent. We analyzed the
impact of residual platelet aggregation (RPA) using the cut-point obtained in EX-
CELSIOR (≤14% vs. >14% using ADP 5 μmol/L) on the incidence of death and
MI (primary endpoint) after discontinuation of clopidogrel during a follow-up period
of 12 months after PCI.
Results: We found a significant difference in the incidence of the primary endpoint
after discontinuation of clopidogrel between the strata defined by RPA (4.1%
in patients with RPA >14% and 1.6% in patients with RPA ≤14%; p=0.039). Considering
the period after discontinuation of clopidogrel in the subset with at least
one drug-eluting stent, the incidence of the primary end point differed significantly
(4.3% vs. 0.5%; p=0.018 by log-rank test) between the two strata defined by predischarge
RPA. Among patients who received a bare-metal stent, the difference
in 1-year outcome between the two strata with respect to the primary end point
was substantially smaller (4.1% for RPA >14% versus 2.4% for RPA ≤14%) with
a non-significant hazard ratio for the stratum with RPA >14% of 1.75 (95% CI,
0.6-5.1; p=0.30).
Conclusions: The impact of high on-treatment platelet reactivity extended beyond
the duration of clopidogrel administration. Even after discontinuation of clopidogrel,
the difference in the incidence of death and myocardial infarction was par-
ticularly prominent in patients having received a drug-eluting stent. Our findings
may suggest that robust platelet inhibition during dual antiplatelet therapy may
reduce cardiac complications that occur late after discontinuation of clopidogrel.
P2808 Immediate and long-term outcome of DES
implantation for the treatment of long (>30 mm)
chronic total coronary artery occlusions
V. Tzifos 1 ,A.Gatsis1 , J. Kalpogiannakis2 , H. Mantzouratos2 ,
G. Daveli 1 ,X.Trika1 , A. Eleutheriou1 , P. Papavasilopoulos1 ,
S. Stamatelopoulos1 , G. Theodorakis1 . 1Henry Dunant Hospital, Intervantional
Cardiology, Athens, Greece; 2Thriasion Hospital, Interventional Cardiology,
Athens, Greece
Objective: The long term angiographic patency and the angiographic variables
associated with long term success of coronary artery stenting for chronic (> 6
months) coronary artery occlusion in very long lesions (>30 mm) was associated
with poor prognosis in the bare metal stent era. Aim of the present study was
to evaluate the early results and outcome following the treatment of very long
chronic totally occluded coronary arteries with drug eluting stent implantation.
Methods and Results: In the last 3 years, we treated 178 chronic occlusions;
42 of these (23.6%) being > 30 mm long. Angiographic success with coronary
stenting was obtained in 36 (85.7%) lesions. The number of stents implanted per
patient was 2.1±1.1. A total of 66 drug eluting stents were used. More precisely
38 Cypher, 15 Taxus, 9 Endeavor and 4 Infinnium stents. Mean stent diameter
was 3.2±0.6mm and mean stent length was 44±12 mm. Among the successfully
treated lesions, vessel location was RCA in 18 (50%) patients, LAD in 14 (38.9%)
and Cx in 4 (11%). There were two minor perforations during the procedure without
clinical incidence. At the follow-up period (16±3.2 months), 31 patients remained
asymptomatic (86.1%). Clinical follow up was obtained for all patients.
One patient died of non cardiac cause and 4 had recurrence of angina. Follow-up
angiography nine months after the procedure was obtained in 26 (72%) patients.
Significant restenosis (> 50%) was observed in 5 (19%) patients. Reocclusion
was noted in 1 (3.8%) patient. A significant correlation was noted between the incidence
of restenosis and the MLD < 2.75 mm post procedure (R=0.68) and the
total length of stents used (R=0.76) during the initial percutaneous intervention.
Conclusions: Although recanalization of long (> 30 mm) chronically occluded
coronary arteries is technically feasible, the 9 month restenosis rate remains still
high despite the use of drug eluting stents. High TLR rate was associated with
the total stent length and with a post procedure MLD < 2.75 mm.
P2809 Impact of atherosclerotic disease progression on
repeat revascularization in diabetic patients in the
drug-eluting stent era
P. Tousek1 ,A.Pavei2 ,G.Martin2 , J. Oreglia2 ,B.Farah2 , J. Fajadet2 .
1 2 Prague, Czech Republic; Toulouse, France
Background: Percutaneous coronary interventions (PCI) in patients with diabetes
mellitus (DM) with use of either bare-metal stent (BMS) or drug-eluting
stents (DES) are associated with elevated rates of repeat revascularization (RR).
However, impact of restenosis or atherosclerosis progression on RR in the DES
era is not well known.
Aim: To determinate if RR in diabetic patients treated with prior DES, is the result
of DES restenosis or due to native progression of atherosclerotic disease in the
coronary vasculature.
Methods and Results: We followed 364 consecutive diabetic patients (264 men,
age 68±8.8 years) treated between April 2005 and September 2006 with at least
one DES. Out of these 292 patients (80%) had multivessel coronary disease,
148 patients (41%) had previous coronary revascularization and 109 patients
(30%) had insulin-dependent DM. Only DES stents were implanted in 318 (87%)
of the patients, combination of DES and BMS implantation was performed in
30 (8%) patients and DES implantation with additional balloon angioplasty was
performed in 16 (4%) patients. During the follow-up (range 12-28 months, mean
18±8 months) there were 39 repeat revascularizations (38 PCI, 1 CABG). In 20
patients repeat revascularization was performed for restenosis (18 after DES implantation,
1 after BMS implantation and 1 after balloon angioplasty), out of which
in 3 patients treatment was also required for disease progression. In 19 patients
PCI was performed for symptomatic atherosclerotic disease progression without
restenosis. Thus disease progression contributed to 52% of repeat revascularization
procedures. Furthermore, in 5 of 6 patients (83%) admitted for myocardial
infarction, culprit lesion was caused by atherosclerotic disease progression.
Conclusion: Atherosclerotic disease progression was more than 50% the cause
of repeat revascularization in diabetics patients treated previously with DES and
was the main cause of readmission for myocardial infarction. Major adverse clinical
events in trials with long term follow-up in diabetic patients can thus be influenced
by native disease progression and not by DES failure and therefore should
be interpreted with caution.
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P2810 Long-term clinical results following percutaneous
coronary intervention to the left main stem with bare
metal and drug-eluting stents
Y. Onuma, N. Kukreja, J. Daemen, E. Meliga, P.H. Van Twisk,
N. Piazza, R. Van Domburg, P.W. Serruys. Thorax center, Erasmus
MC, Interventional Cardiology, Rotterdam, Netherlands
Objectives: Long-term clinical outcomes after drug-eluting stent (DES) implantation
for unprotected left main coronary artery disease (ULMCA) in comparison
with bare metal stent (BMS) have not been yet fully investigated. This study
evaluated the long-term (3-year) clinical outcome of patients treated by percutaneous
coronary intervention (PCI) with DES implantation for ULMCA compared
with BMS.
Methods: Between January 1, 2000 and December 31, 2005, 251 consecutive
patients with ULMCA were treated with either BMS (n=84; January, 2000 to April,
2002) or DES (n=167; SES used from April 2000 to February 2003, PES from
March 2003 to December 2005). Annual follow-up on the occurrence of death
(obtained from municipal civil registries) and clinical events were collected. Cox
multivariate regression analysis was performed to account for differences in demographics,
clinical and angiographic variables.
Results: Clinical follow-up was available for 98.4% of patients for a mean of
1020±720 days. At 3 years, all-cause mortality was comparable between BMS
and DES groups (34.5% vs. 26.3%, adjusted hazard ratio [HR] 0.79[95%CI: 0.48-
1.31]) with comparable target lesion revascularisation (TLR) rate (11.9% vs. 7.8%,
adjusted HR 0.81 [95%CI: 0.33-1.97]). The major adverse cardiac event (MACE:
death, myocardial infarction or target vessel revascularisation) rates were 47.6%
in BMS group and 39.5% in DES group (adjusted HR 0.73 [95% CI: 0.48-1.10).
Definite stent thrombosis rates were 1.2% in both groups. In elective cases, DES
group demonstrated lower all-cause mortality (21.9% vs. 15.7%, adjusted HR
0.60 [95% CI: 0.22-1.61]) with lower TLR rate (25% vs 8.6%, adjusted HR 0.11
[0.03-0.40]). MACE rate was significantly lower in DES group (43.7% vs. 27.1%,
adjusted HR 0.43 [95%CI; 0.22-0.87]). There were no cases of definite stent
thrombosis.
Conclusions: Overall, long-term MACE and repeat revascularisation rates at 3
years were high after PCI for the ULMCA with no significant difference between
BMS and DES groups. In elective cases, DES was associated with improved
long-term outcomes.
P2812 Long-term safety and efficacy of sirolimus- versus
paclitaxel-eluting stent implantation for acute
ST-elevation myocardial infarction: 3-year follow-up of
PROSIT trial
H.S. Kim1 , J.H. Lee2 ,J.H.Park2 , Y.J. Choi1 ,G.Y.Cho1 , J.O. Jeong2 ,
I.W. Seong2 ,K.S.Rhee3 ,J.K.Ko3on behalf of PROSIT trial. 1Hallym University
Sacred Heart Hospital, Cardiology, Anyang-Si, Korea, Republic of; 2Chungnam National University Hospital, Cardiology, Daejeon, Korea, Republic of; 3Chonbuk National University Hospital, Cardiology, Jeonju, Korea, Republic of
Purpose: This study compared long-term safety and efficacy of sirolimus- (SES)
versus paclitaxel-eluting stent (PES) implantation for the treatment of acute STelevation
myocardial infarction (STEMI).
Methods: A total of 308 consecutive patients were randomly treated with SES
(n=154) or PES (n=154) in the setting of primary percutaneous coronary intervention
for acute STEMI at three cardiac centers. Thirty-day and long-term (35±10
months) clinical outcomes were assessed. Primary endpoint was incidence of
stent thrombosis and major adverse cardiac events (MACE) including all cause
mortality, myocardial infarction (MI), and ischemia-driven target lesion revascularization
(TLR). We applied a classification of stent thrombosis set by the Academic
Research Consortium (ARC).
Results: The both group had similar clinical and angiographic characteristics. At
30 days, the rate of all cause mortality (2.6% for SES and 5.2% for PES, p=0.25)
and MI (0% for SES and 1.3% for PES, p=0.50) were similar in both groups.
Angiographic in-segment restenosis rate was significantly lower in SES over PES
at 6-month (5.9% vs. 14.8%, p=0.03). During the 3-year follow-up, no significant
differences were seen between two groups in terms of death (6.5% for SES and
10.4% for PES, p=0.219), MI (2.6% vs. 3.9%, p=0.750), TLR (5.2% vs. 8.4%,
p=0.258) and MACE (12.3% vs. 18.8%, p=0.116). Overall cumulative incidence
of stent thrombosis by any ARC criteria was gradually increased; 0.6% at 30
days, 0.6% at 1 year, 1.6% at 2 years, and 2.6% at 3 years. Late stent thrombosis
(> 1 month) occurred in 1.9% for both SES and PES. The incidence of stent
thrombosis was also similar in both groups during the 3-year follow-up (1.9% for
SES versus 3.2% for PES, p=0.723).
Conclusions: SES significantly outperformed PES in preventing angiographic
restenosis in STEMI patients treated with primary angioplasty. However, longterm
safety and efficacy evaluated by incidence of stent thrombosis and MACE
were not different between two groups during the 3-year follow-up.
Percutaneous coronary intervention; longterm outcome 457
P2813 Percutaneous intervention or bypass grafting as
primary revascularization in patients with acute
coronary syndrome: insights from a prospective
cohort study
W. Hochholzer 1 , H.J. Buettner2 , D. Trenk2 , T. Breidthardt1 ,
K. Laule1 ,M.Christ1 , F.-J. Neumann2 , C.H. Mueller1 . 1University Hospital Basel, Department of Internal Medicine, Basel, Switzerland;
2Herz-Zentrum, Bad Krozingen, Germany
Purpose: New European Society of Cardiology/American College of Cardiology
(ESC/ACC) guidelines classify patients with acute coronary syndrome (ACS) and
elevated cardiac troponin levels as non-ST segment elevation myocardial infarction
(NSTEMI) who would have been classified as unstable angina (UA) by older
WHO definition. The optimal revascularization strategy in these patients is poorly
defined.
Methods: This prospective cohort study included 1,024 consecutive patients
with ACS classified into UA, NSTEMI according to the WHO definition ("WHO
NSTEMI"), and NSTEMI additionally identified by the novel ESC/ACC definition
("additional NSTEMI"). All patients underwent coronary angiography within 24
hours and were treated with immediate percutaneous coronary intervention (PCI)
or early coronary artery bypass grafting (CABG). The primary endpoint was allcause
mortality during follow-up of 36 months.
Results: Death occurred in 67 patients. There was a significant interaction between
"additional NSTEMI" group and revascularization strategy regarding longterm
mortality (interaction p

458 Percutaneous coronary intervention; longterm outcome
P2815 Four-year follow-up patients with ST-segment
elevation acute myocardial infarction treated with
Sirolimus-eluting stent and Paclitaxel-eluting stent:
Multicenter registry in Asia
S. Nakamura1 ,J.H.Bae2 , Y.H. Cahyadi3 , W. Udayachalerm 4 ,
D. Tresukosol5 , S. Tansuphaswadikul6 . 1New Tokyo Hospital, Department
of Cardiology, Chiba, Japan; 2Konyang University Hospital, Daejeon, Korea,
Republic of; 3Husada Hospital, Jakarta, Indonesia; 4King Chulalongkorn
Memorial Hospital, Bangkok, Thailand; 5Her Majesty’s Cardiac Center Siriraj
Hospital, Bangkok, Thailand; 6Chest Disease Institute, Bangkok, Thailand
Background: Previous clinical study utilizing Sirolimus-eluting stent (SES) and
Paclitaxel-eluting stent (PES) in simple coronary lesions demonstrated an impressive
reduction in intimal hyperplasia and restenosis. However, clinical efficacy of
SES and PES in treating patients with ST-segment elevation myocardial infarction
(STEMI) has not been validated.
Methods: We assessed baseline clinical and angiographic characteristics, inhospital
and 12, 24 and 36-month major adverse cardiac events (MACE) in 1,838
consecutive STEMI patients who received on SES, PES or bare metal stents
(BMS) without cardiogenic shock undergoing emergent PCI.
Results: The baseline clinical characteristics between 3 groups were similar. See
table for the clinical results.
BMS SES PES p
Number of patients 388 843 607 –
In-hospital Clinical success (%) 98.5 98.8 99.0 NS
Death (%) 1.0 0.8 1.0 NS
Stent thrombosis (%) 0.5 0 0 NS
30 days to 12 mo Death (%) 0.5 0.2 0.3 NS
Angiographic restenosis (%) 16.0 3.8* 4.9* 0.01
Repeat PCI (%) 10.8 3.0* 4.9* 0.01
Stent thrombosis (%) 0 0.2 0.3 NS
30 days to 36 mo Death (%) 0.8 0.8 0.5 NS
Angiographic restenosis (%) 17.5 5.3* 5.9* 0.01
Repeat PCI (%) 11.9 3.8* 5.9* 0.01
Stent thrombosis (%) 0 1.2 0.3 NS
30 days to 48 mo Death (%) 1.0 1.1 0.2 NS
Angiographic restenosis (%) 17.8 5.3* 6.1* 0.01
Repeat PCI (%) 11.9 4.0* 6.1* 0.01
Stent thrombosis (%) 0 1.2 0.2 NS
Conclusion: Implantation of SES and PES in STEMI patients is not associated
with any risk of adverse in-hospital events, and reduced the need for repeat PCI
at follow-up.
P2816 Long-term outcome of coronary bifurcations after
implantation of two drug-eluting stents: is the late
and very late stent thrombosis a real risk?
A. Ielasi1 ,A.Latib1 , G. Bassanelli 1 , C. Godino1 ,J.Cosgrave2 ,
R.T. Gerber2 , A. Chieffo 1 , F. Airoldi1 , M. Montorfano1 , A. Colombo2 .
1 2 San Raffaele Scientific Institute, Interventional Cardiology, Milan, Italy; EMO
Centro Cuore Columbus, Interventional Cardiology, Milan, Italy
Objectives: Drug-eluting stent (DES) implantation in coronary bifurcations has
been identified as a possible risk factor for stent thrombosis (ST). In particular,
there are concerns that implanting two stents in a bifurcation may pose a high
thrombogenic risk. In view of these concerns and lack of convincing data, we
performed this study to examine the long-term safety of implanting two DES in a
bifurcation.
Methods: Retrospective cohort analysis of consecutive non-left main bifurcations
treated with two DES between April 2002 and December 2005 at two centres. ST
was defined according to the Academic Research Consortium definitions.
Results: We identified 315 patients with 331 bifurcation lesions treated with two
sirolimus-eluting stents (SES) in 227 (68.6%), 2 paclitaxel-eluting stents (PES) in
101 (30.5%), and a mixture of SES and PES in 3 (0.9%) bifurcation lesions. Of
these 315 patients, 76 (24.1%) were diabetic and 82 (26%) had unstable angina
at presentation. The site of the treated bifurcation was the left anterior descending
artery (LAD)/diagonal (Diag) in 225 (68%), left circumflex/obtuse marginal in
82 (24.8%), and the right coronary artery in 24 (7.3%). Majority of bifurcations
(71.7%) were stented using the crush technique. During a median follow-up of
968 days (IQR 621-1400), 3 (0.9%) patients had a definite ST: 1 acute, 1 subacute
(4 days), and 1 very late ST (962 days). All 3 patients with definite ST
presented with an acute MI and the patient with acute ST died from the event.
Five (1.5%) patients were adjudicated as having a probable ST due to a MI in the
territory of the stented bifurcation (1 subacute, 2 late and 2 very late ST) and all
of these patients survived from the event. In the 8 patients with definite/probable
ST, 4 occurred while on dual antiplatelet therapy, 5 patients were diabetic, and
all ST involved the LAD/Diag bifurcation. Only diabetes was an independent predictor
of ST (OR=4.68; 95% CI 1.05 – 20.08; p=0.04). At follow-up, a total of 17
(5.4%) patients had died; 13 (4.1%) of cardiac death. Angiographic follow-up was
performed in 245 (77.8%) patients, restenosis occurred in 67 (20.2%) lesions. MI
occurred in 15 (4.8%) and target-lesion revascularisation in 56 (17.8%) patients
during the follow-up period.
Conclusions: Implantation of 2 DES in a coronary bifurcation appears safe with a
1.6% incidence of definite or probable late and very late ST at a median follow-up
of almost 3 years.
P2817 Long term mortality after bare metal stent
implantation: a 12-year single centre experience with
1561 patients
C. Cernigliaro1 , M. Sansa2 , A.S. Bongo2 , E. Novelli3 . 1Interventional Cardiology Clinica S.Gaudenzio, Interventional Cardiology, Novara,
Italy; 2Cardiologia Ospedaliera, Ospedale Maggiore, Novara, Italy; 3Dpt of
Biostatistics, Clinica San Gaudenzio, Novara, Italy
Objectives: the assessment of the long term mortality (up to 12 years), after bare
metal stent (BMS) coronary artery stenting.
Methods: between 1995 and 2003, 1561 patients 63±10.7 years of age, 1235
(79.1%) males, 774 (49.6%) with a family history of ischemic heart disease, 588
(37.7%) current smokers, 824 (52.8%) hypertensive, 178 (11.4%) type 2 diabetic,
109 (7.0%) type 1 diabetic, 763 (48.9%) dyslipidemic, underwent a first stent implantation
(2160 stents, 47 different types of BMS, 1.3 stents per patient). Indication
for percutaneous coronary intervention (PCI) was: stable angina in 460
(29.5%) patients, unstable angina in 478 (30.6%) patients and acute myocardial
infarction in 623 (39.9%) patients. Ejection fraction was 52.0±9.1%. Death certificate
records of study population were obtained from the Regional Mortality Registry
for the years 1995 – 2007, with a mean follow-up period of 7.8±1.8 years
(range, 4.2 – 12.4 years). Fifty-seven (3.7%) patients were lost at follow-up.
Results: coronary angiography, performed 6 months after stent implantation in
1342 (86%) patients, demonstrated restenosis in 349 (26%) patients. Cumulative
death rate during follow-up was 174 (11.6%) patients, causes of death were
cardiac in 84 (5.6%) patients. Cumulative survival rates at 4, 8, 12 years were
95.1%, 87.9% and 83.8% respectively. Survival from cardiac death at 4, 8, 12
years was 97.5%, 94.1% and 92.3% respectively. Cox proportional hazard regression
showed that advanced age (HR 1.06, 95% CI 1.04–1.08, p

Percutaneous coronary intervention; longterm outcome / Bring issues in percutaneous cardiovascular interventions 459
P2819 Mid- to long-term survival in patients with left
ventricular dysfunction undergoing sirolimus- or
paclitaxel- eluting stent implantation
A. Abbate 1 , N. Nusca 2 , D. Appleton 1 ,A.Varma 1 , M.J. Lipinski 3 ,
E. Goudreau 1 ,M.J.Cowley 1 ,G.W.Vetrovec 1 . 1 Richmond, United
States of America; 2 Rome, Italy; 3 Charlottesville, United States of America
Introduction: Drug eluting stents (DES) reduce the rate of in-stent restenosis and
target-vessel revascularization (TVR) without a net effect on mortality or acute
myocardial infarction (AMI) when compared to bare metal stents (BMS). Recent
data has shown a potential increase in mortality associated with DES possibly
due to late stent thrombosis (LST). Left ventricular (LV) dysfunction is considered
a risk factor for LST. Aim of the current study was to assess mid- to long-term
survival rates in high risk patients with LV systolic dysfunction undergoing drugeluting
stent implantation.
Methods and Results: Patients with an ejection fraction < 45% undergoing PCI
between April 2003 and December 2005 who had at least one sirolimus- or
paclitaxel-eluting stent placed were selected for screening. As historical control
patients treated with bare-metal stents prior to the introduction of DES between
May 1996 and March 1999 were studied. Mortality rates were retrieved from the
Social Security database. One hundred twenty three patients who received at
least one DES were selected for inclusion in the study, and compared with 113
historical control patients treated with BMS. Survival at 1-, 2- and 3-year follow
up was 95%, 90% and 86% for patient who received a DES, respectively (see
Figure).
Conclusion: The favorable survival data with DES in patients with left ventricular
dysfunction is reassuring and within the limitations of a retrospective analysis
suggests added benefit of DES (vs BMS) in a higher risk cohort such as those
with LV dysfunction, without showing any signal of late mortality hazard.
P2820 Completeness of revascularization and 3 year event
free survival in the ARTS II trial
B.J. Rensing1 ,P.W.Serruys2 ,M.Morice3 ,B.DeBruyne4 ,
A. Colombo5 ,C.Macaya6 , G. Richardt7 , J. Fajadet8 ,C.Hamm9 ,
K. Wittebol2 on behalf of ARTSII investigators. 1St. Antonius
Hospital, cardiology, Nieuwegein, Netherlands; 2Rotterdam, Netherlands;
3 4 5 6 7 Massy, France; Aalst, Belgium; Milan, Italy; Madrid, Spain; Bad Segeberg,
Germany; 8Toulouse, France; 9Bad Nauheim, Germany
Background: Incomplete revascularization (IR) is a known predictor of outcome
after multivessel (MV) PCI and CABG. Drug eluting stents (DES) might improve
outcome after MV stenting. We conducted a sub analysis of the ARTS2 trial in
which MV disease patients were treated with DES.
Methods: Completeness of revascularisation was assessed by an independent
corelab. The primary end-point was 1 year MACCE free survival (Death, MI, CVA,
revascularization). All events were centrally assessed. The ARTS1 (randomized
MV non-DES PCI vs CABG) surgical arm was used as control.
Results: Of 607 enrolled patients 588 angiograms were available for review. 360
pts had complete revascularization (CR), 228 were incompletely revascularized
(IR).
Outcome (%)
Arts2 30 day Arts 2 1yr Arts2 3yr Arts1 CABG 3 yr
cr ir cr ir cr ir cr ir
n=360 n=228 n=360 n=228 n=360 n=228 n=477 n=90
death 0 0 0,6 1,8 2,5 3,9 4,2 5,6
MI 0,3 1,3 1,4 1,8 3,3 3,9 4,2 7,8
Revasc 0,6 3,9 6,7 9,6 11,9 17,1 4,8 7,8
Death/MI/stroke 0,3 1,8* 2,2 4,8 8,1 8,8 10,3 12,2
MACCE free 99 95* 92 87* 83 78** 86 82
MI = myocardial infarction, MACCE = major adverse cardiac and cerebrovascular events,
*p

460 Bring issues in percutaneous cardiovascular interventions
ger scoring system. Five variables selected from the initial multivariate model
were weighted proportionally to their respective odds ratio for stent thrombosis
(thienopyridines discontinuation [6 points], baseline left ventricular ejection fraction
< 50% [4 points], bifurcation lesion [3 points], angioplasty in the setting of
acute coronary syndromes [3 points], left anterior descending as target vessel [2
points]. Three strata of risk were defined (low risk, 0 to 4; intermediate risk, 5 to
8; high risk ≥ 9) with excellent prognostic accuracy for early, late and very late
thrombosis (c statistic = 0.75, 0.72 and 0.74, respectively) in the derivation set.
Conclusions: The DERIVATION score can stratify patients with very low and
high stent thrombosis rates and it can be used as a simple clinical tool for the
identification of a sizable cohort in whom close monitoring and aggressive therapy
may be beneficial.
P2824 Clinical events after clopidogrel discontinuation in
patients treated with titanium-nitride-oxide-coated
stents, paclitaxel eluting stents or bare-metal stents
P.P. Karjalainen1 , A.-P. Annala1 ,A.Ylitalo1 , K.E.J. Airaksinen2 .
1Satakunta Central Hospital, Dept. of Cardiology, Pori, Finland;
2Turku University Hospital, Turku, Finland
Purpose: The purpose of this study was to evaluate clinical events and stent
thrombosis (ST) after clopidogrel discontinuation in patients treated with titaniumnitride-oxide-coated
bio-active stents (BAS), paclitaxel eluting stents (PES) and
bare-metal stents (BMS).
Methods: Between May 2003 and November 2004 all patients undergoing percutaneous
coronary intervention (PCI) were eligible in this single centre study.
The primary end point of the study was major adverse cardiac events (MACE)
including myocardial infarction (MI), cardiac death and target lesion revascularization
(TLR). All patients who where MACE free at the time of the clopidogrel
discontinuation were followed for an additional 12 months after the clopidogrel
withdrawal.
Results: A consecutive series of 589 nonselected patients underwent PCI during
the study period and 519 of them remained MACE free at the time of clopidogrel
discontinuation (BAS 184, PES 183, BMS 152). Complete follow-up datasets
were available in all patients. During 12 months follow-up, the incidence of MACE
was comparable in the 3 groups, but MI and ST were more common in PES group
(Table). There was no ST observed in the BAS group.
Outcome events during 12 months FU
BAS (n=184) PES (n=183) BMS (n=152) P
Myocardial infarction, % 2.2 8.2 2.0 0.01*, 0.01 †
Cardiac death, % 0 1.6 2.0 NS
Target lesion revascularization, % 1.1 4.9 3.9 NS
MACE, % 3.8 9.3 7.9 NS
Stent thrombosis, % 0 3.8 0.7 0.009*
All cause death, %
* BAS versus PES;
1.6 2.7 2.6 NS
† BMS versus PES.
Conclusions: After the clopidogrel discontinuation, we observed an increased
incidence in MI and ST with the use of PES.
P2825 Comparison between on-label versus off-label use
and results for drug-eluting coronary stents in clinical
practice
R. Zahn 1 , C. Nienaber 2 ,K.Kuck 3 , S. Schneider 1 , J. Senges 1 on
behalf of DES.DE Registry. 1 Ludwigshafen, Germany; 2 Rostock,
Germany; 3 Hamburg, Germany
Background: In clinical practice drug-eluting stents (DES) are often used for "offlabel"
indications. This might be associated with highr complication rates compared
to "on-label" use of DES.
Methods: We analysed data from the prospective German DES.DE registry.
Results: Between September 2005 and Oktober 2006 5315 patients were treated
with DES. In 2170 patients (40,8%) DES were used for "on-label" indications (1
lesion, native arteries, de novo stenosis, lesion length

vessels (DES 16.7%, BMS 6.7%, p=0.06), with no significant difference between
DES and BMS for ST (DES 10.2%, BMS 6.7%, p=0.4).
Conclusions: Thus, after a 3 year follow-up, DES are overall as safe as BMS for
acute stenting in STEMI. However, there seems to be a particular benefit of DES
in STEMI-PCI in patients with small/bypass graft infarct vessels, but not in large
native infarct vessels. If these findings are confirmed in larger randomized data
sets, they may directly impact on DES use in STEMI.
P2828 Angiographic predictors of improvement in left
ventricular regional function after delayed primary
percutaneous coronary intervention
A.M.M. Mahrous, M. Abdelghany, S. Ghareeb, S. Eltobgi. Cairo,
Egypt
Background: There are few data concerning the association between angiographic
parameters and short-term recovery of left ventricular (LV) regional asynergy
after primary percutaneous coronary intervention (PCI)
Objective: To define angiographic predictors of recovery of LV regional function
after primary PCI in patients with acute STEMI.
Methods: Thirty-five consecutive patients with acute STEMI who presented 6
hours after onset of chest pain and scheduled for primary PCI were submitted
for assessment of thrombus scoring system, thrombolysis in myocardial infarction
(TIMI) flow grade, corrected TIMI frame count (cTFC), tissue myocardial perfusion
grading (TMP) and myocardial dye intensity before and after successful PCI. The
X-sizer thrombectomy catheter systems were used in 10pts. The left ventricular
global wall motion index (GWMI) was determined by echocardiography before and
6 months after intervention. Improved regional left ventricular function at follow-up
was defined as GWMI reduction > 0.3.
Gray scale calculation & coloured blush.
The two groups were similar in terms of clinical and pre-interventional angiographic
characteristics. On multivariate analysis, improvement of TMP grade
(0.30±0.73 at baseline Vs 2.20±0.95 after PCI, p=0.007) & use of a thrombectomy
device (p=0.02) were the only independent predictors of 6-months improvement
of GWMI (r2=0.64). GWMI at Fu showed significant correlation with reduction
of the thrombus score (4.40±0.88 at baseline Vs 0.15±0.48 after PCI,
r2=0.42,p=0.012) and with enhanced myocardial dye intensity (5.86±5.95 Vs
10.55±4.72Pixel, r2=-0.65, p 13. During a mean follow-up of 28.0±14.5 months MACE occurred in
26 patients (12.5%): cardiac death in 9 patients (4.3%) and TLR in 17 patients
(8.2%). The cumulative MACE-free survival was 89.0%, 87.4% and 85.4% at 1,
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462 Bring issues in percutaneous cardiovascular interventions
2, and 3 years, respectively. ST occurred in 3 patients (1.4%): one case was definite
and the other two cases were probable/possible ST. There were no cases
of very late ST. Angiographic follow-up was performed in 79.3% of patients. Binary
restenosis occurred in 13 patients (8.3%). In 11 (7.0%) patients restenosis
occurred in the distal LMCA; these were in-stent involving only the ostium of the
LCX in 10 patients (91%) and the ostium of both LAD and LCX artery in 1 patient
(9%). The others 2 patients had ostial LMCA lesion and restenosis occurred in
the proximal segment adjacent to the stent. An Euroscore >6 was the only independent
predictor of MACE [hazard ratio (HR) 2.24, 95% confidence interval
(CI) 1.05-4.77, p= 0.04]. There was a trend toward an increased risk of MACE
associated with distal ULMCA (HR 2.14, 95% CI 0.87-5.29, p= 0.10).
Conclusions: Our study showed DES implantation in ULMCA to be feasible, safe
and effective at long-term. Randomized trials comparing percutaneous versus
surgical revascularization are warranted to better define the treatment of choice
for ULMCA disease.
P2832 Comparison of the cost-effectiveness of
serolimus-eluting versus bare-metal stents in relation
to patient coronary artery disease status
S.N. Willich, D. Mcbride, S. Roll, T. Reinhold, B. Brueggenjuergen.
Charite University Medical Center Berlin, Institute for Social
Medicine, Epidemiology, Berlin, Germany
Objective: To evaluate the cost-effectiveness of serolimus-eluting stents (SES)
to bare-metal stents (BMS) in patients with single-vessel coronary artery disease
(SVD) compared with patients with multi-vessel disease (MVD).
Methods: In the prospective GERSHWIN study (German Stent Health Outcome
and Economics Within Normal Practice) in 35 hospitals in Germany, patients
with coronary artery disease (CAD) undergoing percutaneous coronary intervention
(PCI) were electively treated with SES or BMS (sequential control design).
Standardized questionnaires completed by patients and physicians through 18
months following PCI documented major adverse coronary events (MACE), including
death, myocardial infarction, coronary artery bypass surgery and re-PCI
in target vessel, as well as disease-related direct and indirect costs.
Results: From April 2003 until June 2005, 658 patients were treated with SES
(87% male, mean age 63±9) und 294 patients with BMS (79% male, mean age
64±10). SVD was documented in 34% BMS patients and 29% SES patients. After
18 months, 4% of SES vs 16% of BMS patients with SVD had suffered MACE (p
adjusted

patients receiving a DES and the rate of CV events notably high at almost 5%. A
thorough assessment of the patients’ likelihood of needing a surgical procedure
within 2 years of DES placement should be undertaken and the risk of placing a
bare metal stent versus a DES carefully evaluated.
P2836 Longterm outcomes of Drug-Eluting Stents (DES):
comparision with Bare-Metal Stents (BMS)
Y.-S. Choi1 , K.-B. Seung2 , W.-S. Chung2 ,J.-H.Park2 ,S.-S.Oh2 ,
C.-S. Park 2 ,Y.-S.Oh2 , H.-J. Youn2 ,H.-Y.Kim2 ,P.-J.Kim2 . 1St. Mary’s Hospital, Seoul, Korea, Republic of; 2The Catholic University
of Korea, Internal Medicine, Seoul, Korea, Republic of
Backgrounds: There were no questions about the superiority of DES over BMS
in terms of reducing angiographic restenosis. However, the long-term safety of
DES is far less certain. The aim of this study was to compare the longterm outcomes
of DES and BMS in real world.
Methods: Total 2313 patients [BMS: DES=759 (32.8%): 155 4(67.2%), mean age
DES=62±10 vs BMS=61±10 years, (male %) DES vs BMS=64.6% vs 70.3%]
were enrolled and they were registered to The Catholic University Percutaneous
Coronary Intervention Registry from January 2004 to March 2006. We included
the patients only if the follow up duration was at least 12 months. The primary
objective was all cause mortality and secondary objectives were cardiac mortality
and stent thrombosis. The presence or abscence of such events were investigated
by telephone interview and database from National Health Insurance. Stent
thrombosis was determined based on the definition of the Academic Research
Consortium (ARC).
Results: 1. Mean follow up duration of BMS and DES was 41.9±13.9 month
and 25±8.6 month respectively (p

464 Bring issues in percutaneous cardiovascular interventions
Methods: to test this hypothesis we studied 2429 consecutive pts, 1331 with
acute coronary syndromes, and 1098 with stable angina undergoing PCI in a
multicenter study in Italy. In all pts CRP levels were determined at admission;
troponin I (cTNI) and CK-MB were assessed before and after PCI. End-point of
the study was total mortality at two years follow-up.
Results: after two years 102 pts died. At univariate analysis baseline CRP, creatinine,
ejection fraction and diabetes and post-PCI CK-MB and cTNI elevation were
all significant determinant of prognosis. However, at multivariate survival analysis
CRP > 3 mg/L was an independent determinant (with creatinine, ejection fraction
and diabetes) of future events (CRP OR= 1.81, p

Results: The two groups had similar risk factors for atherosclerosis. The �PTX3
was larger in the DES group than in the BMS group (0.10±0.05 vs. -0.01±0.06
ng/ml, p18mm in length) group (n=18) than in the short group (≤18mm, n=13)
(0.14±0.09 vs. 0.02±0.10 ng/ml, p

466 Bring issues in percutaneous cardiovascular interventions / Cardiovascular effects of diabetes mellitus
Health Survey (SF-36) in patients treated with SES (n=585), BMS (n=483) or
CABG (n=492).
Results: The corresponding participating rates varied from 100% at baseline to
93% at 36 months. Both stenting and CABG resulted in significant improvement
of HRQL and anginal status. There was a trend towards better HRQL after CABG
than BMS beyond 6 months. Already from the first month up to three years, SES
patients had, on average, 10% significant better HRQL than BMS patients on
all HRQL subscales (p

among their non-DM counterparts (HR 1.00, 95%CI 0.86-1.17; zeta score 0.041;
p=0.967).
Conclusion: The present report based on patients with coronary artery disease
is the first to demonstrate that the prognostic capability of resting heart rate is
equally important in patients with and without diabetes.
P2853 Neopterin predicts the risk for fatal ischemic heart
disease in type 2 diabetes mellitus: results from the
HUNT study
I. Vengen1 ,A.C.Dale2 ,R.Wiseth1 , K. Midthjell1 , V. Videm2 .
1 2 NTNU, Laboratory Medicine, Trondheim, Norway; St. Olav’s
Hospital, Cardiology, Trondheim, Norway
Purpose: Neopterin is produced by activated monocytes. Activation of the
monocyte-macrophage system may contribute to plaque instability in subjects
with coronary artery disease. Neopterin has therefore emerged as a novel predictor
of coronary events. Hs-CRP, a marker of low-grade inflammation, has traditionally
been used in prediction of risk for fatal ischemic heart disease (IHD).
However, the predictive value of hs-CRP has been disputed. The aim of this study
was to investigate the predictive value of neopterin and hs-CRP on long-term risk
for fatal IHD in patients with recently diagnosed diabetes, compared to a matched
group of non-diabetic subjects.
Methods: 200 patients with newly detected diabetes and a matched control
group without diabetes were selected from HUNT1, a large population study conducted
in Norway in 1984–86. Blood was drawn at baseline and frozen serum
was stored. The diabetic patients were followed for ten years with annual HbA1cmeasurements.
Fatal IHD was registered until 2004. Neopterin and hs-CRP concentrations
were divided into tertiles, and Cox regression analysis with correction
for age, gender, hypertension, body mass index, previous cardiovascular disease,
total cholesterol and HbA1c was used to estimate hazard ratios (HR) for fatal IHD.
Results: At baseline hs-CRP was significantly increased in the diabetic compared
to the control group (p < 0.0005). Baseline neopterin concentrations did not
significantly differ between the groups (p = 0.65). Neither hs-CRP nor neopterin
emerged as significant predictors of fatal IHD in the control group. In the diabetes
group neopterin was an independent predictor of fatal IHD (HR 2.7, 95% CI 1.2
– 6.3) whereas hs-CRP did not significantly predict fatal IHD (HR 2.2, 95% CI
0.9-5.3).
Conclusions: Neopterin is a novel and robust predictor of fatal IHD in diabetic
patients. In the present study of newly diagnosed diabetic subjects neopterin was
a better predictor of fatal IHD than was hs-CRP. This could be caused by neopterin
being a more plaque-specific marker, whereas hs-CRP reflects non-specific lowgrade
inflammation common both for atherosclerosis and diabetes.
P2854 In-hospital mortality in diabetic and non-diabetic
patients with AMI: a time trend analysis based on the
Chilean National Acute Myocardial Infarction Register,
2001-2006
C. Nazzal1 , R. Corbalan2 , P. Campos3 ,J.Bartolucci4 ,G.Cavada1 ,
J.C. Prieto 5 , F. Lanas6 on behalf of GEMI Group. 1School of Public Health,
Universidad de Chile, Epidemiology Dept., Santiago, Chile; 2Catholic University
Hospital, Santiago, Chile; 3Hospital de Urgencias, Santiago, Chile; 4Universidad de Los Andes, Santiago, Chile; 5Universidad de Chile, Santiago, Chile;
6Universidad de la Frontera, Temuco, Chile
Diabetics with acute myocardial infarction (AMI) are known to have higher mortality
rates than nondiabetics.Therefore we evaluate in-hospital mortality trends
and in-hospital treatment in patients with AMI, diabetics and non-diabetics, of the
Chilean Register of Myocardial Infarction (GEMI).
Methods: 8219 diabetics and non diabetics patients with AMI, admitted in 15
hospitals from the GEMI Group between 2001 and 2006 were analyzed. Demographic
characteristics, in hospital treatment and in hospital mortality were
compared between the two groups. We conducted logistic regresión analyses,
adjusted by age and gender and expressed results as OR and 95% CI.
Results: 25.8% of patients had diabetes, being significantly older (65 vs 62 years,
p

468 Cardiovascular effects of diabetes mellitus
(AMI) has been demonstrated as a strong predictor of short- and long-term
mortality. It has been also recognized that DM is associated with increased rate of
post-infarctional heart failure. Progressive heart failure after acute myocardial infarction
in non-diabetic patients is related mainly with left ventricular (LV) remodeling,
which is a complex process influenced by multiple factors including microvascular
reperfusion. However only few and conflicting data relating the effects of
DM on post-infarctional LV remodeling are available, especially in patients treated
with primary coronary intervention (PCI). The link between LV remodeling and
impaired microvascular reperfusion has been observed in several studies. DM is
associated with abnormal endothelial function, increased inflammatory response,
increased platelets’ and leukocytes’ plugging and seems to be important factor
deteriorating microvascular reperfusion in acute phase of myocardial infarction.
Aim: The aim of our study was to evaluate the relations between diabetes mellitus,
myocardial reperfusion and left ventricular remodeling in patients with acute
myocardial infarction.
Methods: The study population consisted of 189 patients with first anterior AMI
successfully treated with PCI. LV remodeling was defined as an increase in enddiastolic
volume ≥20%, based on repeated measurements in individual patients.
The study population was divided into 2 groups according to the presence n=36
(19%) (DM group) or absence n=153 (81%) (NDM group) of DM.
Results: The impaired myocardial reperfusion measured as myocardial blush
grade 0-1 was observed not significantly more often in DM group (44.4% vs
37.9%, p=0.47). ST-segment resolution >50% was observed in 49.7% of patients
in NDM group and in 19.4% of DM group, p=0.001. LV remodelling was not significantly
more often in DM group (33.3% vs 21.6%, p=0.19). The symptoms of HF
developed in 55.2% of patients with DM and in 27.1% of NDM group (p=0.006).
Diastolic HF was noticed significantly more often in DM group (36,1% vs 18.3%,
p=0.02). Logistic regression analyses revealed impaired myocardial reperfusion
(OR 2.76; p=0,006), basic EDV (OR 0.98; p=0.001) as independent predictors of
LV remodelling.
Conclusion: In patients with myocardial infarction DM was associated with development
of diastolic HF, but not LV remodelling. Impaired myocardial reperfusion
and basic EDV lead to a higher percentage of LV remodelling in AMI patients.
P2857 Prognostic role of the glucometabolic status
assessed in a metabolically stable phase after a first
acute myocardial infarction
I. Janszky1 , J.H. Hallqvist2 , R. Ljung2 , N. Hammar2 . 1Karolinska Institute, Public Health Sciences, Stockholm, Sweden; 2Stockholm, Sweden
Context: The prognostic role of the glucometabolic status evaluated at a metabolically
stable phase after an AMI is not known. Objective: To examine fasting glucose
and insulin levels in patients surviving 3 months after a first AMI in relation
to long-term prognosis. Design, Settings and Patients: A total of 1167 consecutive
patients between 45-70 years with a first non-fatal AMI underwent a standardized
clinical examination and were followed for a mean of 8 years. Impaired
fasting glucose (IFG) was defined as fasting glucose between 5.6-7mmol/L, and a
level ≥7 mmol/L as newly detected diabetes. Patients with a fasting glucose level

tigated the long-term consequences of diabetes on the heart in a prospective
population-based study.
Methods: The population-based MONICA/KORA-Augsburg cohort study provided
anthropometric, biochemical and echocardiographic data for 1005 individuals
examined during a baseline survey in 1994/95 and a follow-up investigation
ten years later. We defined three groups of individuals: who were persistently,
at both examinations, non diabetics (nonDM, i. e.; defined as no history of diabetes
and not using medications for glycemic control at both examinations; n =
811), who were persistently diabetic (PDM, i. e., defined as disease known to the
patient as reported by standard questionnaire or the use of antiglycemic medications
or insulin or non-fasting glucose blood levels ≥200mg/dl; n = 34) and who
presented incident diabetes at follow-up (incDM; n = 19). We evaluated prospectively
the impact of diabetes on the 10-year changes in left ventricular (LV) mass
indexed to height 2.7 (in g/m 2.7 ), left ventricular end-diastolic diameter (LVEDD in
mm), wall thickness (WT = septal + posterior wall thickness in mm), relative wall
thickness (RWT, WT in mm divided by in mm), left atrial diameter (LA in mm) and
the ratio of early diastolic peak transmitral flow and early diastolic peak myocardial
relaxation velocities (E/EM) using linear regression models adjusting for age
and sex and other relevant confounders including systolic blood pressure.
Results: For the relative changes over the ten years period, there was a positive
trend across the three groups for LV mass2.7 (p=0.011), LVEDD (p=0.002) and
LA (p=0.020). Specifically, compared the mean difference with the nonDM group,
the PDM group, had a bigger relative increase of 12.6% (95% confidence interval:
4.20% to 20.9%, p=0.003) in the LV mass2.7, 6.0% (2.70% to 9.30%, p

470 Cardiovascular effects of diabetes mellitus
P2864 Implications of diabetes mellitus for temporal
changes in arterial stiffness. The MONICA/KORA
augsburg cohort study
M.R.P. Markus 1 ,J.Stritzke 1 , S. Duderstadt 1 ,W.Lieb 1 , A. Luchner 2 ,
A. Doering 3 , H. Schunkert 1 , H.-W. Hense 4 on behalf of The
MONICA/KORA Augsburg Cohort Study.. 1 Luebeck, Germany; 2 Regensburg,
Germany; 3 Neuherberg, Germany; 4 Muenster, Germany
Background: Several studies suggest that diabetes mellitus is one of the most
important risk factors for the increase in arterial stiffness which is associated with
cardiovascular events. However, details of the mechanisms of this process are still
unclear. We investigated the impact of diabetes on aorta stiffness in a prospective
population-based study.
Methods: The population-based MONICA/KORA-Augsburg cohort study provided
anthropometric, biochemical and echocardiographic data for 1005 individuals
examined during a baseline survey in 1994/95 and a follow-up investigation
ten years later. In the follow-up study, pulse wave analysis was also realized. We
defined two groups of individuals: persistent non-diabetics (nonDM, no history of
diabetes and not using medications for glycemic control at both examinations;
n = 839) and diabetics at follow-up who either were persistent diabetics at both
examinations or incident diabetic at follow-up (DM, by patient history or use of
antiglycemic medications or insulin, or having non-fasting glucose blood levels
≥200mg/dl; n = 56). We evaluated, by cross sectionally analysing the follow-up
examination, the association of incident plus persistent diabetes with peripheral
and central measures of blood pressure (pulse wave analysis). We adjusted for
sex, age, body fat, height 2.7 and the use of antihypertensive medication.
Results: At the follow-up observation, the peripheral SBP, after adjustment, was
not statistically different between the two groups. Compared to the non-DM group,
the DM group had a higher outgoing pressure wave height (29.1 mmHg [95% Cl:
27.3 to 31.0] vs. 26.8 mmHg [26.4 to 27.3], p=0.019), a lower sub-endocardial
viability index (166.1% [161.1 to 171.1] versus 172.2%[171.0 to 173.5], p=0.021)
and a reduced time to peak of reflected wave (212.3 ms [208.9 to 215.6] vs. 216.0
ms [215.1 to 216.8], p=0.036).
Conclusions: Subjects with prevalent and incident diabetes showed significantly
raised indicators of central aortic stiffness despite similar peripheral blood pressures.
This observation may indicate that diabetes independently contributes to
the alterations of central vascular properties.
P2865 Diabetes is associated with increased extracoronary
atherosclerotic burden in young patients with
coronary artery disease
A.A.M. Farrag, N. Abdel Razek, G. Yousef, A. Zaki. Cairo University,
Cardiology, Cairo, Egypt
Background: Diabetes mellitus is one of several known risk factors to develop
coronary artery disease (CAD) especially in young age. Coronary atherosclerosis
is continued to be one of the major causes for morbidity and mortality worldwide.
In this study we test the hypothesis that diabetes is associated not only with
increased coronary atherosclerotic burden but also extracoronary calcific burden
as well.
Methodology: We studied 111 patients below age 65; scheduled for coronary angiography
(CA) because of presence/suspected coronary artery disease (CAD).
Transthoracic echocardiography was done to assess for the presence of aortic
sclerosis and/or mitral annular calcification. Calcium score in the coronary arteries
(CCS), aortic valve (AVC), mitral annulus (MAC), aortic arch (AAC) and descending
aorta (DAC) were measured by multidetector computed tomography (4detector
system, GE, with a dedicated software for calcium measurement, Smart
Score). We consider the presence of ≥50% diameter stenosis (by quantitative
CA) of any major epicardial vessel to be an obstructive plaque (OP). Patients
were classified into a diabetic group (n= 59) and a non-diabetic group (n= 52).
Data for calcium score was expressed as median.
Results: Echocardiography revealed that 61% of diabetic group had aortic sclerosis
and 30.5% had mitral annular calcification compared to 36.5% and 9.6%
in non-diabetic group with p= 0.01 and 0.007 respectively. CA revealed that diabetics
have a higher prevalence of OP 3.34±2.6 vs. 1.9±1.6, p= 0.005. Diabetic
group had significantly higher levels of CCS, AVC, MAC, AAC and DAC as compared
to non-diabetic group (table).
Clacium score by computed tomography
Variable Diabetics Non-diabetics p value
CCS 133 (0-1571) 90 (0-624)

culogenesis. Reduction of VPC and EPC among BK sensitive cells in diabetic
patients suggests an imbalance among the spectrum of cells recruited by kinins.
P2868 Postprandial hyperglycemia is an important
determinant of platelet activation in early type 2
diabetes mellitus. Evidence from biochemical
measurements and pharmacological intervention with
acarbose
F. Santilli1 ,G.Formoso1 , P. Sbraccia2 ,M.Averna3 ,R.Miccoli4 ,
N. Pulizzi4 , A. Consoli 1 , R. Lauro2 , C. Patrono5 ,G.Davi’ 1 . 1G. d’Annunzio
University Foundation, Center of Excellence on Aging, Chieti, Italy; 2University of Rome Tor Vergata, Department of Internal Medicine, Rome, Italy; 3University of Palermo, Department of Internal Medicine, Palermo, Italy; 4University of Pisa,
Department of Endocrinology and Metabolism, Pisa, Italy; 5Catholic University
School of Medicine, Department of Pharmacology, Rome, Italy
Purpose: Chronic hyperglycemia is a major determinant of in vivo platelet activation
in diabetes mellitus (DM). Acarbose, an α-glucosidase inhibitor, is associated
with a significant reduction in the risk of cardiovascular events in patients with
impaired glucose tolerance. We performed a randomized, double-blind, placebocontrolled,
multicenter study evaluating the effects of acarbose on platelet activation
and its potential determinants in newly-diagnosed type 2 diabetic patients.
Methods: Forty-eight subjects (26 M, 22 F, aged 61±8 yr), with early type 2
DM (baseline HbA1c

472 Cardiovascular effects of diabetes mellitus
Plaque area (PA) was calculated as VA-LA. Percentage plaque area (%PA) was
calculated as PA/VA.
Results: VA in DM, AGT, and NTG group was 14.8±4.1 mm 2 , 16.0±4.1 mm 2 , and
14.9±4.5 mm 2 respectively group (p=ns). LA was 7.3±3.0mm 2 ,8.2±2.2mm 2 ,
and 9.3±3.3mm 2 respectively. LA of DM group was significantly smaller than
that in AGT and NGT group (p

y echo-tracking technique calibrated for blood pressure (Aloka Alpha10). A local
CCA wave speed (WS) was derived by the water hammer equation. Carotidfemoral
pulse wave velocity (PWV, Complior) was measured as an index of aortic
stiffness.
Results: DM1 subjects had, compared to C, higher (p

474 Diabetes mellitus, predictors and drugs
P2881 Insulin sensitizers decrease adverse events in
diabetic patients with heart failure
J. Luu, C. Gans, P. Mesgarzadeh, T. Stamos, J. Kao. University of
Illinois-Chicago, Medicine, Chicago, United States of America
Background: The mortality rate among patients with heart failure
(HF) is 4-8 times greater than that of the general population. HF patients with
diabetes have even worse outcomes; diabetes increases the mortality risk by
11-25%. Myocardial contractility and filling are depressed in the insulin-resistant
state, but use of insulin sensitizers has historically been precluded in HF patients.
Whether insulin sensitizers can mitigate these adverse cardiovascular effects,
and whether these contraindications are warranted, remain unclear.
Methods: Patients with both diabetes and HF followed in outpatient cardiology
clinic at a single institution from 2000-2007 (n=119) were grouped by diabetic
regimen: insulin-sensitizers (metformin +/- thiazolidinediones [TZD], n = 56) vs.
non-sensitizers (insulin +/- sulfonylureas, n = 63). The sensitizer group consisted
of 36 metformin-only, 2 TZD-only, and 18 metformin + TZD patients. The primary
endpoint was admission for HF exacerbation.
Results: Fewer insulin-sensitizer (IS) patients had HF exacerbations compared
to non-sensitizer (NS) patients, and Kaplan-Meier curves showed longer
exacerbation-free time at 5 years (P < 0.0001). IS patients had fewer total number
of HF exacerbations (0.65 vs. 2.6, P= 0.0035). At baseline, IS patients were
heavier and had lower creatinine levels (1.02 vs. 1.29, P = 0.001); all demographics
were otherwise similar.
Time to Heart Failure Exacerbation
Conclusions: Insulin sensitization improves outcomes in diabetic patients with
HF. Patients have longer times to HF exacerbation and fewer total exacerbations.
Use of insulin sensitizers in HF patients, however, remains controversial.
Our study adds to the body of data that suggests increased benefit, and not risk,
of insulin sensitization in this population.
P2882 Chronic phosphodiesterase 5 inhibition improves
endothelial function in men with type-2 diabetes
C. Vitale 1 ,A.Aversa 2 , M. Volterrani 1 , A. Fabbri 3 , G. Spera 2 ,
M. Fini 1 , G.M.C. Rosano 1 . 1 IRCCS San Raffaele Hospital, Medical
Sciences, Roma, Italy; 2 University La Sapienza, Medical Sciences,
Roma, Italy; 3 University Tor Vergata, Medical Sciences, Roma, Italy
Objective: Diabetic patients have a reduced endothelial response to
phosphodiesterase-5 inhibitors. Aim of this study was to evaluate the effects of
daily Sildenafil (SIL) on endothelial function in patients with type-2 diabetes mellitus
(DM2).
Methods: In a double-blind, placebo-controlled parallel design, 20 patients without
erectile dysfunction randomly received a loading dose of SIL (100 mg) for 3
days followed by either SIL-25 mg three times a day (tds) for 4 weeks or SIL-25
mg tds for four days followed by placebo tds for 3 weeks. Brachial artery flow
mediated dilatation (FMD) with high-resolution Doppler ultrasound and reactivehyperemia
peripheral arterial tonometry by Endopath, were measured, respectively.
Also, variations of bioumoral markers of endothelial function were assessed.
Results: After one week, flow mediated dilatation (FMD) improved significantly
(>50% compared with baseline) in patients allocated to both SIL arms (62% and
64%, respectively). In patients allocated to chronic SIL, progressive increase in
percentage of patients with FMD improvement was noted (78%, 86%, 94% at 2,
3 and 4 weeks respectively) while a progressive decrease in the placebo group
occurred (45%, 18%, 6% at 2, 3 and 4 weeks respectively). At the end of the
study a significant improvement in FMD compared with baseline was noted after
chronic SIL (FMD from 6.8±0.5 to 12.5±0.7%, p=0.01 vs. baseline). A decrease
in endothelin-1 levels and an increase in nitrite/nitrate levels were found after
chronic SIL; significant changes from baseline in CRP, IL-6, ICAM and VCAM
levels were also found.
Conclusions: in DM2 patients, daily SIL administration improves endothelial
function and reduces markers of vascular inflammation. Thus, diabetes-induced
impairment of endothelial function and erectile dysfunction may be improved by
prolonged phosphodiesterase-5 inhibition.
P2883 Effect of allopurinol therapy on endothelial function
in patient with diabetes mellitus
N. Kalay1 , M. Tasdemir 1 ,I.Murat1 , I. Ozdogru 2 , A. Dogan2 ,
M.T. Inanc2 ,M.G.Kaya3 . 1Sorgun State Hospital, Cardiology
Department, Yozgat, Turkey; 2Erciyes University, Cardiology,
Kayseri, Turkey; 3Cardiology, Kayseri, Turkey
Introduction: Endothelial dysfunction and atherosclerosis are common well
known problem in diabetes mellitus (DM). Uric aside is an associated factor with
endothelial function (EF) and atherosclerosis even if physiological range. It was
demonstrated that xanthine oxidase inhibition with allopurinol decreases oxidative
stress and improves EF. We investigated effect of high dose and long term
allopurinol therapy on EF in diabetic patients without hypertension.
Method: This study is a randomized, single-blind, and placebo-controlled trial.
Patients with DM were randomized as treatment and control groups. The patient
group consisted of 34 patients and the control group consisted of 32 patients.
To the patient group, daily oral 900 mg allopurinol was started after randomization
and maintained for 12 weeks. Carotis intima-media-thickness (IMT), brachial
artery flow-mediated-dilatation (FMD), and arterial-waveform patterns were measured
at baseline and after the allopurinol therapy.
Results: There was significant correlation between FMD and IMT (r=0.446,
p=0.03). The baseline FMD level was 6.9 in patients and 6.6 in control group
(p=0.8). After allopurinol therapy, FMD significantly increased in the patient group
but no significant change was observed in the control group (Figure). Carotis-
IMT thickness after allopurinol therapy was significantly lower in the patient group
(respectively 73.7±16.4 vs. 66.9±14.7, p=0.01) however it was similar in control
group (respectively 72.4±16.3 vs. 70.5±15.4, p=0.09). There was no significant
change in arterial-waveform pattern in groups.
Figure 1
Conclusion:In diabetic patients, long term and high dose allopurinol has favorable
effect on EF. Further studies are necessary to confirm the clinical significance
of long term and high dose allopurinol therapy.
P2884 Effects of diabetes on the prevalence of aspirin
resistance during low dose aspirin therapyy
P.A. Gurbel, K.P. Bliden, J. Dichiara, T.A. Suarez, S. Yadev,
S. Chaganti, M.J. Antonino, O. Bailon, U.S. Tantry. Sinai Center for
Thrombosis Research, Center For Thrombosis Research, Baltimore,
United States of America
Background: Controversy exists regarding the relation of diabetes and other demographic
variables on the prevalence of aspirin resistance (AR).
Methods: AR was measured after 81 mg aspirin for four weeks in 120 patients
(diabetes = 23) with coronary artery disease by COX-1 specific assays (arachidonic
acid (AA)-induced light transmittance aggregation (AGG), AA-induced AGG
by thrombelastography (TEG), VerifyNow, urinary thromboxane levels) and COX-
1 nonspecific assays (ADP-and collagen-induced AGG and PFA-100).
Results: In the total group a low prevalence of AR (

P2885 Statins are effective in reducing coronary atheroma
progression in diabetic patients. A serial, volumetric,
intravascular ultrasound study
F. Alfonso Manterola, L. Hernando, A. Suarez, V. Lennie,
M.L. Capote, P. Jimenez, R. Hernandez-Antolin, G. Aleong,
J. Escaned, C. Macaya. San Carlos University Hospital, Cardiovascular Institute,
Madrid, Spain
Objective: The value of statins to prevent coronary atheroma progression is a
subject of major interest. However, the effects of statin therapy in selected high
risk subgroups of patients (Pts), including diabetics (D), remains to be established.
We sought to assess the value of conventional statin treatment on coronary
artery disease progression in D Pts.
Methods: 199 consecutive Pts (Mean age 65±10 years, 45 [22%] female) undergoing
serial intravascular ultrasound (IVUS) studies were analyzed: 109 Pts
(55%) were D and 90 (45%) non-D. According to routine clinical practice 167 Pts
(84%) received statin therapy (89% D and 77% non-D). A validated system for
IVUS analysis was used for volumetric analysis. Baseline characteristics, coronary
atheroma burden, and disease progression at follow-up (median 366 days)
was compared according to a)statin therapy and b) D status. Study end-point was
IVUS-detected percent change in atheroma volume.
Results: Pts with conventional statin treatment had an adverse cardiovascular
risk profile, including diabetes, hyperlipidemia and previous coronary interventions.
At last follow-up, total cholesterol (172±26.8 mg/dL vs 189±22.2 mg/dL)
and LDL cholesterol (98.3±26.6 mg/dL vs 117.3±22.5 mg/dL), were significantly
reduced in the treatment group. Baseline percent atheroma volume (PAV) was
similar in patients with and without statin therapy (44.7±10% vs 47.9±11%,
p=0.12) and in D as compared with non-D (44.9±9.9% vs 45.6±10.8%, p=0.61).
In non-D Pts, change in PAV was similar in patients with and without statin therapy
(p=0.99). However, as illustrated in the Figure, change in PAV was significantly reduced
by statin therapy in D Pts (p=0.007).
�PAV according to therapy and D status.
Conclusions: Statin therapy appears to be particularly effective to reduce disease
progression in D Pts.
P2886 Impact of antidiabetic therapy on infarction size and
viability in diabetic patients with ST segment
elevation myocardial infarction
M. Rayan 1 , M. Ghareeb2 ,M.Fahmy2 ,A.Mosa2 . 1Ain Shams
University„ Cardiology Departement, Cairo, Egypt; 2Ain shams
University, Cardiology, Cairo, Egypt
The prevalence of type II diabetes mellitus is rapidly increasing, and cardiovascular
disease is already present at the time of diagnosis. The diabetic patient has
an unfavourable prognosis following acute coronary events.
Aim: To investigate the effect of anti-diabetic therapy on infarction size and viability
in diabetic patients with ST segment elevation myocardial infarction.
Patients and methods: The study enrolled one hundred diabetic patients receiving
either oral anti-diabetic therapy or insulin as a study group and twenty
non-diabetic patients as a control group. All of the subjects survived their first
documented myocardial infarction. All the patients underwent rest Trimetazidine
99mTc Sestamibi SPECT for the estimation of their infarction size and evaluation
of myocardial viability.
Results: The mean age was 55.2 years ±6.6. Males comprised 81.67% of the
sample size. The infarction size was significantly larger in the diabetic group
(n=100) as compared to control group (n=20), (47.5±13.95% vs. 38.75±15.19%,
P

476 Diabetes mellitus, predictors and drugs
P2889 Medical therapy in heart failure patients with diabetes
- supply shortage in women and HFNEF patients
R. Wachter1 , F. Edelmann2 , H.D. Duengen3 , A. Kockskaemper4 ,
S. Stoerk 5 , C. Lueers2 , G. Gelbrich 6 ,B.Pieske4on behalf
of German Heart Failure Network. 1University of Goettingen,
Cardiology and Pneumology, Goettingen, Germany; 2University of Goettingen,
Cardiology and Pneumology, Goettingen, Germany; 3University Charite
Campus Virchow Klinikum, Cardiology, Berlin, Germany; 4Medical University
Graz, Cardiology, Graz, Austria; 5Medical University Wuerzburg, Cardiology,
Wuerzburg, Germany; 6University of Leipzig, Center for Clinical Trials, Leipzig,
Germany
Background: Diabetes (DM) is a common comorbidity in patients with heart failure
and DM itself is one of the leading predictors of mortality in heart failure
patients (e.g. in the CHARM trial). We therefore analysed pharmacotherapy of
patients with heart failure and DM according to current ESC guidelines which recommend
ACE/AT1-inhibitor therapy, betablockers, diuretics and aldosteron antagonists.
We spotlighted on therapy in women and on patients with heart failure and
preserved ejection fraction (HFNEF).
Methods: 3442 patients with heart failure from the German Heart Failure Network
trial were included (mean age 63.8±13.6 years, 32.7% women). 2429 patients
had systolic heart failure (SHF, ejection fraction below 50%), 1013 patients had
HFNEF (ejection fraction ≥ 50%). 31.3% of patients in the SHF group and 25.1%
of patients in the HFNEF group suffered also from DM (p < 0.001).
Results: Diabetics with HFNEF received an ACE/AT1-inhibitor therapy less often
than patients with SHF (75.8% vs. 90.2%, p < 0.001). Also betablockers (59.1%
vs. 85.8%, p

Conclusions: The patient-centred health programme presented here is suitable
for reducing car-diovascular risk in a sustained fashion.
P2893 The role of gamma-glutamyltransferase as a predictor
of incident diabetes in a cohort of 98,059 men and
women
H. Ulmer1 , C. Kelleher2 , L.J. Brant3 ,H.Concin4 ,G.Diem4 ,
A. Strasak5 , M. Lechleitner6 , E. Ruttmann5 on behalf of VHM&PP.
1Innsbruck Medical University, Department of Medical Statistics, Innsbruck,
Austria; 2Dublin, Ireland; 3Baltimore, United States of America; 4Bregenz, Austria; 5Innsbruck, Austria; 6Zirl, Austria
Purpose: Recent studies have demonstrated an association of serum gammaglutamyltransferase
(GGT) with risk factors for cardiovascular disease, diabetes,
incident morbidity and mortality from heart disease and stroke. Additionally, it was
hypothesized that GGT mediates the relation of overweight with type 2 diabetes
and that overweight itself may not be a sufficient risk factor.
Methods: We assessed whether GGT is an independent predictor for incident diabetes
and whether there is an interaction of GGT with body-mass index (BMI) in
98,059 participants of the Vorarlberg Health Monitoring & Promotion Programme.
Participants (mean age 42 years) had fasting glucose levels < 100mg/dl at baseline
and were longitudinally followed for up to 16.5 years (1989-2005). Fasting
glucose greater than 125 mg/dl (7 mmol/l and higher) was defined as criteria for
a hyperglycaemic condition indicating diabetes. Sex-stratified Cox proportionalhazards
models, adjusted for age, BMI, cholesterol, triglycerides, blood pressure
and smoking, were performed to calculate hazard ratios (HR) and 95% confidence
intervals per quintiles of GGT.
Results: There were 4,675 participants (4.8%) with diabetes during follow-up.
Compared to the lowest GGT quintile, adjusted HR were 1.33 (1.19-1.49) for the
fourth quintile, and 1.68 (1.51-1.87) for the highest quintile. Regarding age, there
was a significant interaction (p=0.015) revealing higher risk of elevated GGT in
older participants. In participants over 65 years and older, HR for diabetes in the
highest quintile of GGT was 2.28 (1.67-3.13). BMI was the strongest risk factor
for diabetes revealing a 1.1 fold increase of risk per index unit. There was no
significant interaction of body-mass index with GGT and other risk factors. The
association of triglycerides with diabetes was strong and even more pronounced
in females and older individuals. Interaction of triglycerides with sex (p=0.001)
and age (p

478 Diabetes mellitus, predictors and drugs
of diabetes14±12 years, HbA1c 7.7±5.4%,NT-proBNP 240±414pg/ml, NYHAclass
I/II/III/IV 86/11/3/0%, proteinuria 24.2%, blood pressure 141±23mmHg, history
of a cardiac disease 17.3%). 30 patients reached the defined endpoint.
In a Cox regression analysis, NT-proBNP was the most potent single predictor
for the defined endpoint, (Exp (B) 1.001p

P2900 Should left ventricular hypertrophy diagnosed by
echocardiography be incorporated into
cardiovascular risk assessment among patients with
type2diabetes?
K.K. Poppe, G.A. Whalley, J. Somaratne, W. Bagg, S. Wells,
R. Jackson, R.N. Doughty. University of Auckland, Medicine,
Auckland, New Zealand
Purpose: Type 2 diabetes (T2DM) is associated with an increased risk of cardiovascular
disease (CVD). New Zealand Guidelines (NZG) recommend that CVD
risk should be estimated using a modified Framingham equation that incorporates
multiple clinical and laboratory variables. NZG risk assessment does not
include ECG-defined left ventricular hypertrophy (LVH) as it is rare in the general
population. We aimed to assess the prevalence of LVH in patients with T2DM at
mild-moderate CVD risk.
Method: We prospectively studied 360 primary care patients with T2DM without
known clinical CVD. Patients underwent clinical assessment, HbA1c, cholesterol
and echocardiography. Absolute 5-year CVD risk was calculated using the NZG
equation. LV mass was measured (American Society of Echocardiography (ASE)
guidelines) and indexed to body surface area (LVMi): LVH was defined by both
ASE (women≤95g/m2 ,men≤110g/m2 ) and European Society of Hypertension
(ESH; women≤110g/m2 ,men≤125g/m2 ) cut-offs.
Results: Mean age 57±11yrs, BP 135/82mmHg, cholesterol 4.8mmol/L, HbA1c
7.6%, diabetes duration 8yrs, LVMi 107ml/m2 . Prevalence of LVH was: ASE 50%;
ESH/ESC 32%. Average NZG 5yr risk was 15.6%: 49% (n=179) were classified
as having mild-moderate (5-15%) risk, of whom 65 (36%) met ASE and 37 (21%)
met ESH LVH criteria (figure).
Conclusion: In these community-based patients with T2DM, half were classified
as having mild-moderate CVD risk, among whom at least 20% had LVH (even
with more conservative LVH criteria). LVH, a significant CVD risk factor, is not
accounted for in current risk assessment of patients with T2DM. Data on the
independent predictive power of LVH diagnosed by echocardiography is required
to determine whether community echo screening for LVH among patients with
T2DM will impact on improved risk prediction and management.
P2901 Hypertensive response during stress test is
associated with impaired glucose regulation in
subjects without hypertension: introducing an
integrated cardio-metabolic clinical tool
M.V. Papavasileiou, C. Thomopoulos, G. Aggelidis, S.M. Karas.
Sismanoglion Hospital, Cardiology, Athens, Greece
Objectives: Subjects suffering from insulin resistance have increased risk for
future cardiovascular disease including hypertension, while normotensives with
exaggerated BP response (EXBPR) compared to those with non-EXBPR during
stress test are more likely to develop hypertension. We investigated the association
between impaired glucose regulation and EXBPR in non hypertensives
undergoing stress test.
Methods: 142 consecutive non hypertensives (aged 46±6 years, 67% males,
34% smokers, office BP 121±6/77±3mmHg) underwent 24h BP monitoring,
echocardiographic study and treadmill stress test according to the Bruce protocol.
Sex and age adjusted criterion for systolic BP at the second stage of exercise
(ex-SBP2) was used to define EXBPR classifying the total population in two subgroups.
Fasting blood samples were obtained for fasting glucose (FG), fasting
insulin (FI), and lipid profile determination. An index of insulin resistance (HOMA)
was estimated, while a standardized oral glucose tolerance test was performed
and glucose levels at 120 minutes (G120) were recorded.
Results: EXBPR occurred in 28.16% of subjects (n=40, aged 48.8±4.9 years,
67% males) while non EXBPR occurred in 71.84% of subjects (n=102, aged
45.01±6.28 years, 65% males) (p

480 Autonomic nervous system in hypertension
AUTONOMIC NERVOUS SYSTEM IN
HYPERTENSION
P2904 Influence of head-up tilt test provocation on
autonomic nervous system in patients suffered from
idiopathic epilepsy during interictal period
T. Zapolski1 , J. Przegalinski1 , A. Wysokinski1 , W. Brzozowski1 ,
A. Tomaszewski1 ,M.Prasal1 ,M.Tynecka2 . 1Department of
Cardiology, Medical University, Chair and Department of Cardiology, Lublin,
Poland; 2Department of Neurology, Medical University, Lublin, Poland
Aim: The neurohormonal disturbances, particularly abnormalities in catecholamines
production and uptake, play an important role in pathophysiology of
epilepsy. The aim of our study was interictal activity of autonomic nervous system
in patients with idiopathic epilepsy.
Material and Methods: Study group consisted with 21 patients (12 men and 9
women, 21 - 72 mean 44,4±11,3 years old), with idiopathic epilepsy. Standard
12-lead EKG and 24-hours EKG monitoring by Holter’s method were performed.
During Holter EKG the following parameters were analyzed: maximal, minimal,
mean heart rate and time domain HRV indices (SDNN, SDANN, SDNN Index,
rMSSD, pNN50). After first 2 hours of Holter EKG the head-up tilt test due to
Westminster’s protocol was performed. Half an hour before tilt test and half an
hour after standard 12-lead EKG was recorded to assess QT length (mean calculated
from 12 leads), QT dispersion index (QTI) due to pattern: QTI = (QT standard
deviation QT: mean QT) x 100. Additionally half an hour before tilt test and
half an hour after 0,5 ml of blood sample was taken to measurement of serum
catecholamines level. Catecholamines concentration was assessed using High
Performance Liquid Chromatography (HPLC).
Results: Rhythm disturbances were found in 6 patients. QTI decreased significantly
after tilt test (3,8±0,87 vs 3,1±0,8). Patients with decreased minimal heart
rate had lower values of QTI. After tilt test all catecholamines level markedly decreased:
noradrenaline (460,1±78,4 vs 392,2±70,7), adrenaline (60,8±10,6 vs
57,15±10,5) and dopamine (35,12±11,9 vs 33,52±11,78). Moreover significant
correlation between noradrenaline concentration and rMSSD as well as pN50
were demonstrated. Patients with higher adrenaline concentration characterized
QT elongation.
Conclusions: In patients with idiopathic epilepsy during head-up tilt test decrease
of noradrenaline, adrenaline, dopamine as well as QT dispersion index
were observed. QT elongation correlated with higher adrenaline concentration
could be a cause of cardiac rhythm disturbances in these patients. Patient with
idiopathic epilepsy require periodic cardiological evaluation including standard 12lead
EKG, Holter’s EKG monitoring and head-up tilt test due to often coexisting
both cardiac rhythm and consciousness disturbances. Those test allow to differentiate
epilepsy ictus form neurocardiogenic syncope.
P2905 Alpha 2b adrenergic receptor deletion polymorphism
is associated with alterations in cardiac autonomic
modulation in obese children
D.M. Prado1 , A.G. Silva1 , M.M. Ribeiro1 , E.S.T. Frazzatto1 ,
M.S. Brasileiro2 , A. Halpern1 , I.C. Trombetta2 ,C.E.Negrao2 ,
S.M.F. Villares1 . 1EndocrinologyHCFMUSP, Endocrinology, Sao Paulo, Brazil;
2InCorHCFMUSP, Sao Paulo, Brazil
α2B-Adrenergic receptor (α2B-AR) polymorphism has been associated with obesity
and alterations in vagal and sympathetic cardiac modulation. Unknown is
whether these associations begin in the childhood. We tested the hypothesis that
obese children carrying α2B-AR deletion polymorphism would have alterations in
the cardiac autonomic modulation.
Methods: A total of 106 obese children were studied (45 M/ 61 F; BMI=30.3
+0.4 kg/m 2 ). From these children, 57 (53.7%) were homozygous for the long form
(Glu12/Glu12), 43 (40.5%) were heterozygous (Glu12/Glu9) and 6 (5.7%) were
homozygous for the short form (Glu9/Glu9). The sympathovagal balance was assessed
by power spectral analysis of heart rate variability at the rest condition.
The genotypes were determined by polymerase chain reaction (PCR) with electrophoresis.
Results: There were no differences in physical characteristics (body weight, BMI,
lean body mass and fat body mass) and metabolic profile (fasting plasma glucose,
fasting plasma insulin, serum total cholesterol, serum triglycerides and leptin)
(P>0.05) among the genotypes. Heart rate was similar among genotypes.
However, low frequency (nu) values were significantly higher in children with
Glu9/Glu9 genotype when compared with Glu12/Glu12 and Glu12/Glu9 genotypes
(73.1 +0.9 vs 45.8 +0.5 and 46.5 + 0.5, respectively, P

P2908 Telmisartan up-regulates the expression of
angiotensin-converting enzyme 2 in human umbilical
vein endothelial cells
L. Wang. The First affiliated Hospital, Cardiology Department,
Guangzhou, China, People’s Republic of
Purpose: To determine the effect of telmisartan on the protein and gene expression
of angiotensin-converting enzyme 2 (ACE2) in human umbilical vein
endothelial cells (HUVECs).
Method: HUVECs were treated with various final concentrations of telmisartan
(10-7,10-6 and 10-5mol.L-1) for 24 h. In a time-control experiment, HUVECs were
treated with telmisartan at the final concentration of 10-6mol.L-1 for 6, 12 and 24
h, respectively. In an another protocol, HUVECs were treated with PD123 319(10-
6mol.L-1) separately or combined with same final concentration of telmisartan for
12h, respectively. Changes in both protein and gene expression of ACE2 were
detected by Western blot analysis and RT-PCR technique, respectively.
Results: Telmisartan caused a concentration- and time-dependent increase in
both protein and gene expression of ACE2 (p0.05).
Conclusion: Telmisartan up-regulates the protein and gene expression of ACE2
in a concentration and time dependent manner in HUVECs. This effect may be
mediated via its specific pathway.
P2909 Effects of chronic electrical baroreceptor stimulation
on the sympathovagal balance in patients with
drug-resistant arterial hypertension
K. Wustmann1 ,J.P.Kucera2 , I. Scheffers 3 , Y. Allemann1 ,
J. Schmidli1 ,E.Delacretaz1on behalf of DEBuT-HT trial. 1University Hospital Bern, Cardiology, Bern, Switzerland; 2University of Bern, Physiology,
Bern, Switzerland; 3University Hospital Maastricht, Cardiology, Maastricht,
Netherlands
Objectives: In patients (pts) with drug-resistant hypertension, electrical stimulation
of the carotid baroreflex (ESCB) is a new device-based therapy that produces
a dose-dependent reduction in blood pressure (BP). The aim of the study was
to investigate the effects of chronic ESCB on the sympathovagal balance using
analysis of heart rate variability (HRV) and heart rate turbulence (HRT).
Methods: 13 pts with drug-resistant hypertension were prospectively included in
this substudy of the DEBuT-HT trial. 24-hour ECG were recorded for HRV and
HRT analyses 1 month after implantation with the stimulator turned off and after
3 months of individually optimized electrical therapy. For HRT analysis, the initial
acceleration (turbulence onset) of sinus rhythm following a postextrasystolic
pause and the subsequent slowing (turbulence slope) were analysed after either
premature atrial or ventricular beats.
Results: Chronic ESCB decreased office BP and heart rate (table). HRV timedomain
and frequency-domain parameters assessed using an autoregressive
model (not shown) and fast Fourier transformation (FFT) were significantly
changed during ESCB, indicating a decreased sympathetic activity and an increased
vagal outflow. Furthermore, HRT analysis (conducted in a subset of patients)
suggested an increased vagal tone.
Stimulator off Stimulator on p-value
Systolic BP, mmHg 194±33 158±23 0.002
Diastolic BP, mmHg 121±21 102±14 0.006
Mean heart rate, bpm 82±11 77±10 0.02
NN50* 1554 4139 0.005
RMSSD 19±7 26±30.002 SDNN Index 39±10 48±13 0.004
FFT HF Normalized 88±21 88±17 0.48
FFT LF Normalized 73±9 70±8 0.01
FFT Ratio LF/HF* 2.7 2.3 0.002
Data are given as mean±SD except *: median; HF, LF, high and low frequency.
Conclusion: Chronic ESCB lowers BP in pts with drug-resistant systemic hypertension
by sustained inhibition of sympathetic activity and by increased vagal
outflow. Whether the modulation of sympathovagal balance has favorable cardiovascular
effects beyond BP control should be investigated with further studies.
P2910 Association of aortic pressures with fasting plasma
glucose in patients with and without impaired fasting
glucose
S. Cay, S. Ozturk, F. Biyikoglu, S. Korkmaz. Yuksek Ihtisas Hospital,
Department of Cardiology, Ankara, Turkey
Background: Diabetes mellitus and also impaired fasting glucose are associated
with future cardiovascular disorders. Aortic pulse and fractional pulse pres-
Autonomic nervous system in hypertension 481
sures are strong and independent indicators of the risk of coronary heart disease.
These conditions have been reported to be associated with endothelial dysfunction.
In the present study aortic pulse and fractional pulse pressures of patients
with and without impaired fasting glucose were evaluated.
Methods: Fifty patients with IFG with a mean age of 56.8±12.2 years and 47 patients
with NFG with a mean age of 53.1±11.2 years were included in the study.
All subjects had angiographically proven normal coronary arteries without coronary
slow flow. Aortic systolic and diastolic blood pressures were measured invasively.
Mean, pulse and fractional pulse pressures (aortic pulse pressure/mean
pressure) were calculated.
Results: All parameters measured were significantly higher in IFG group than in
the control (NFG) group (133±21 mmHg and 117±12 mmHg, p

482 Autonomic nervous system in hypertension / Hypertension: regional and ethnic profiles
Chemoreceptor deactivation in response to the administration of 100% oxygen
induced a reduction in MSNA that was significantly more important in CHF+CHR
group than in control (MSNA decreased by 7,7±3,9% versus -0.76±2.4%; p=
0,005). This led to a slight but significant decrease in systolic blood pressure.
Conclusion: CRF exert tonic activation of excitatory chemoreflex afferents and
thus contributes to increased efferent sympathetic activity to muscle circulation
and to blood pressure control in patients with CHF. These findings may have
important implications for understanding mechanisms underlying the link between
CRF and CHF as the bad prognosis of this morbid association (i.e. increased
mortality or sudden death due to sympathetic overactivity.).
P2913 Symmetric dimethylarginine is an independent
predictor of intradialytic hypotension
A.A. Mangoni1 ,C.L.Hewitson1 , R.J. Woodman1 , M.J. Whiting1 ,
B. Mcateer-Carr1 , J.A. Barbara2 . 1Flinders University, Dept. Clinical
Pharmacology, Adelaide, Australia; 2Flinders Medical Centre,
Nephrology, Adelaide, Australia
Objectives: The plasma concentrations of the methylated forms of the amino acid
L-arginine NG-monomethyl L-arginine (L-NMMA), asymmetric dimethylarginine
(ADMA), and symmetric dimethylarginine (SDMA) 1) are elevated in patients with
end-stage renal disease (ESRD) and 2) significantly decrease during haemodialysis
(HD). We sought to determine whether these abnormalities play a role in
the occurrence of intradialytic hypotension (IDH) through effects on endothelial
function and arterial tone.
Methods: Systolic blood pressure (SBP), L-arginine, L-NMMA, ADMA, and
SDMA were measured at the beginning (pre-HD) and within the last hour of HD
(end-HD) in 52 consecutive HD patients (age 64.4±13.4 years, mean±SD). IDH
was defined as a SBP reduction of > 20 mmHg end-HD vs. pre-HD.
Results: Fourteen patients demonstrated IDH. The mean reduction in SBP during
HD in this group was -35±13 mmHg compared to an increase of +2±12
mmHg amongst the 38 patients without IDH (no-IDH). Baseline demographic,
clinical, and biochemical parameters did not differ between the IDH and no-
IDH groups. However, the IDH group had higher pre-HD SBP (155±17 vs.
132±14 mmHg, p

important sex-based differences in clinical presentation and the development of
advanced forms of heart disease. Primary and secondary prevention programs
will need to be adjusted accordingly to meet the potentially different needs of
men and women in this community.
P2917 High blood pressure in the Australian population:
results of a national blood pressure screening day
M. Carrington, S. Stewart, G. Jennings, G. Lee. Baker Heart
Research Institute, Preventative Cardiology, Melbourne, Australia
Purpose: There are few large-scale population studies in Australia
(and other high income countries) that report the underlying prevalence of hypertension
and other preventable cardiovascular (CV) risk factors: particularly on a
region-by-region basis.
Methods: We established 100 surveillance sites in all States and Territories of
Australia on a single Saturday in high "people traffic areas". Sites were distributed
per 250,000 people in major cities and for each population centre sized > 20,000
people. Registered nurses used a standardised protocol to measure resting blood
pressure (BP) using an A&D digital BP monitor, waist and hip circumference and
body mass index. Self-reported CV risk factors, medical history, and BP treatment
and awareness were also documented.
Results: Overall, data were available for 13,825 participants from 99 sites (1 in
1000 adult Australians) with a mean age of 48±16 years (range 18 to 96 years).
A total of 58% were aged ≥ 45 years and 45% were male. Mean systolic and
diastolic BP was 132±18 and 80±12 mmHg, respectively. Overall, systolic and
diastolic BP was higher than 140 mmHg and 90 mmHg, respectively for 30%
(38% in men and 23% in women) and 18% (22% in men and 15% in women) of
participants. In total, 42% of men and 27% of women had resting BP indicative
of underlying hypertension. Men recruited from rural centres (n = 1,376) compared
to metropolitan centres (n = 4,783) had higher systolic (139±17 vs. 136±17
mmHg) and diastolic BP (83±12 vs. 81±12 mmHg), with 48 vs. 41% found to be
hypertensive (p

484 Hypertension: regional and ethnic profiles
HCTZ, N and T/HCTZ, but better response was in A allele carriers of AGTR1 under
N and T/HCTZ administration. AGTR1 CC-carriers require initially combined
and more "aggressive" therapy for adequate hypotensive efficacy.
P2921 Genetic polymorphism on angiotensin receptor type 2
(A1675G) increases cardiovascular risk in
hypertensive individuals: effects on pro-atherogenic
inflammatory mechanisms
N. Koumallos, D. Tousoulis, C. Antoniades, A.S. Antonopoulos,
D. Mentzikof, C. Vasiliadou, C. Vlachopoulos, E. Stefanadi, C. Tentolouris,
C. Stefanadis. Hippokration Hospital, 1st Cardiology Department, Athens,
Greece
Evidence suggest that there is a balance between angiotensin II effects on
proatherogenic constitutive type 1, and antiatherogenic inducible type 2 (AT2R)
receptors. The AT2R gene is located in chromosome X, and the biological effect
of a newly described polymorphism (A1675G) in this gene is unclear.
Aim: We examined the impact of A1675G polymorphism on AT2R, on the risk
for coronary atherosclerosis, and its effect on the expression of proatherogenic
inflammatory molecules.
Methods: The study population consisted of 437 males: 155 with coronary artery
disease (111 with hypertension) and 282 healthy age-matched controls (121 with
hypertension). The presence of A1675G polymorphism on AT2R gene (located in
chromosome X) was determined by PCR. Serum levels of C-reactive protein and
fibrinogen was measured in all the participants.
Results: The frequency of the A allele was similar among healthy individuals
(41.8% 118/282) and CAD patients (47.7%, 74/155, p=NS). However, presence
of the A allele was more frequent in hypertensives with CAD (55%, 59/107) than
in hypertensives without CAD (35.8%, 43/120, p

Hypertension: regional and ethnic profiles / The endothelium: at the heart of vascular biology (bench) 485
P2925 Upgrading the role of uric acid in essential
hypertension: cross-sectional relationships with
subclinical inflammation, asymmetric
dimethylarginine and arterial stiffening
C. Tsioufis, K. Dimitriadis, E. Taxiarchou, D. Tsiachris, A. Miliou,
D. Tousoulis, I. Kallikazaros, C. Stefanadis. First Cardiology Clinic, University of
Athens, Hippokration Hospital, Athens, Greece
Purpose: Elevated uric acid (UA) levels are associated with enhanced cardiovascular
risk, while low-grade inflammation, arterial stiffening and increased asymmetric
dimethylarginine (ADMA) levels contribute to atherosclerosis progression.
In this study, we investigated the relationships between serum UA levels, highsensitivity
C-reactive protein (hs-CRP), ADMA and arterial stiffness in essential
hypertensives.
Methods: In our population of 185 newly diagnosed untreated non-diabetic patients
with stage I to II essential hypertension [120 men, aged 49 years, office
blood pressure (BP)=152/97 mmHg], the distribution of UA was split by the median
(5.1 mg/dl) and accordingly subjects were classified into those with high
and low values. In all participants, arterial stiffness was evaluated on the basis
of carotid to femoral pulse wave velocity (PWV), by means of a computerized
method (Complior SP) and venous blood sampling was performed to estimate
metabolic profile, hs-CRP and ADMA levels.
Results: Patients with high UA (n=91) compared to those with low UA (n=94)
exhibited higher 24-h systolic BP (139±8 vs 131±11 mmHg, p

486 The endothelium: at the heart of vascular biology (bench)
Nicotine alone does not reproduce the effects seen with SS tobacco smoke suggesting
that other chemical components of tobacco smoke are responsible for the
acute endothelial toxicity of passive smoking.
P2929 Nrf2-dependent upregulation of antioxidative
enzymes – a novel pathway of proteasome
inhibitor-mediated cytoprotection in cardiovascular
cells
H. Dreger, K. Westphal, N. Wilck, G. Baumann, V. Stangl, K. Stangl,
S. Meiners. Charite - Universitaetsmedizin Berlin, Med. Klinik M. S.
Kardiologie Und Angiologie, Berlin, Germany
Purpose: Increased levels of reactive oxygen species cause oxidative stress and
severely damage lipids, proteins, and DNA. We have previously shown that low
dose and non-toxic proteasome inhibition induces a protective antioxidative gene
pattern in endothelial cells. This is associated with a marked protection against
oxidative stress. Here, we elucidate the causal relationship and detailed mechanisms
of proteasome inhibitor-mediated upregulation of antioxidative enzymes
and cytoprotection.
Methods and Results: Non-toxic proteasome inhibition uniformly upregulated
mRNA expression of two key antioxidative enzymes – superoxide dismutase
1 (SOD1) and heme oxygenase 1 (HO-1) – in several human endothelial and
vascular smooth muscle cell types. Inhibition of RNA polymerase II activity by
pretreatment of with alpha-amanitin completely abolished proteasome inhibitormediated
mRNA induction indicating transcriptional activation of these enzymes
in response to proteasome inhibition. Comprehensive deletion and mutation analyses
of the SOD1 promoter revealed that transcriptional upregulation can be
largely confined to an antioxidative response element (ARE), which is not only
essential but also sufficient for transcriptional activation of SOD1. Cotransfection
studies and bandshift analysis confirmed that transcriptional regulation of HO-1
depends on binding of the antioxidative transcription factor Nrf2 to the highly conserved
ARE site in the HO-1 promoter. Western blot analysis revealed that Nrf2
is partly stabilized upon proteasome inhibition. In order to prove the essential role
of Nrf2 for the mediation of the cytoprotective effects of proteasome inhibition in
the vessel, we are currently studying Nrf2-dependent protection against oxidative
stress in Nrf2-knock out mice.
Conclusion: Our data suggest that low and non-toxic proteasome inhibition
protects cardiovascular cells by Nrf2-mediated upregulation of antioxidative enzymes.
P2930 Exposure to cold induces activation of NF-KB in
endothelial cells
E.M. Awad, B.R.B. Binder on behalf of Binder. Centre of
Biomolecular Medicine and Pharmacol, Vascular Biology and
Thrombosis Research, Vienna, Austria
Organs for transplantation are generally stored in the cold for better preservation
of organ function. However, following transplantation and re-perfusion, endothelial
cells in the transplanted organs often appear activated with adherent leukocytes
and micro-thrombi. In this study, we analyzed whether storage in the cold itself
might be responsible for endothelial cell activation. Pre-exposure of human umbilical
vein endothelial cells (HUVECs) to temperatures below 37°C resulted upon
re-warming in increased secretion of plasminogen activator inhibitor-1 (PAI-1). Already
after 20 minutes cold pre-exposure of HUVECs to 8°C, PAI-1 mRNA and
antigen increased upon re-warming. Pre-exposure to 8°C also induced expression
of tissue factor and adhesion molecules indicating a pro-thrombotic, antifibrinolytic
and pro-adhesive state of cold pre-exposed endothelial cells. When
we analyzed NFκB activation as potentially causing endothelial cell activation, we
found that upon re-warming to 37°C of HUVECs pre-exposed for 30 minutes to
8°C IκB was degraded and NF-κB was transiently translocated to the nucleus.
For further evidence that these changes were due to NF-κB activation the BAY
inhibitor (an NF-κB-specific inhibitor) could significantly inhibit PAI-1, E-selectin
and ICAM-1 mRNAs expression after 30 minutes cold exposure and rewarming
at 37°C for 2 and 4 hours. From these data, we conclude that cold exposure itself
leads upon re-warming to activation of NF-κB in endothelial cells and in turn endothelial
cell activation. This might explain the adverse outcome in some cases
of transplantation of cold preserved organs.
P2931 In-vivo activation of myocardial AT2 receptor
expression by endogenous NO and pentaerythrithol
tetranitrate
T.V. Dao, S. Schaaf, T. Suvorava, G. Kojda. Heinrich-Heine-
University, Institute for Pharmacology, Duesseldorf, Germany
Purpose: There are many vascular signaling interactions between the vascular
endothelial NO system and the renin-angiotensin-system. We hypothesized that
endothelial NO might impact on the expression of angiotensin (AT) type 1 (AT-1)
and type 2 (AT-2) receptors.
Methods: We generated mice with an endothelial-specific overexpression of endothelial
NO-synthase (eNOS) using the Tie-2 promotor and backcrossed these
mice to the C57BL/6 background. Two of these lines were characterized by
eNOS-western analyses and blood pressure measurements in comparison to
trangene negative littermates. In addition, C57Bl/6 mice were fed with either 6,
60 or 300 mg pentaerythrithol tetranitrate (PETN)/kg body weight/day for 4 weeks
and characterized as well.
Results: Analysis of line 1 of trangenic eNOS mice (1-eNOS++) showed a
2.3±0.15 fold higher aortic expression of eNOS and a reduction of blood pressure
to 109.6±2.0 mmHg (P

whether the selective mineralocorticoid receptor antagonist eplerenone improves
vascular dysfunction and reduces platelet activation in diabetic rats.
Methods and results: Male Wistar-rats were injected with streptozotocin (STZ,
50 mg/kg body weight i.v.) to induce diabetes. Treatment with eplerenone (100
mg/kg/day) or placebo was initiated 2 weeks after injection of STZ and continued
for another 2 weeks. Thereafter, platelet activation was assessed in freshly
obtained whole blood; vascular function was analysed using isolated aortic segments
in organ bath chambers. Endothelium-dependent, NO-mediated vasorelaxation
induced by acetylcholine was significantly attenuated in diabetic rats
(EC50 in nmol/l: control 19.0±3.7, STZ-Placebo 170.0±44.4, STZ-eplerenone
25.2±2.9; maximum relaxation in % of precontraction: control 95.4±2.8, STZplacebo
82.3±2.6, STZ-eplerenone 99.1±0.4) and was normalized by treatment
with eplerenone.
Treatment with the selective mineralocorticoid receptor antagonist eplerenone
significantly reduced fibrinogen-binding on activated GPIIb/IIIa (mean fluorescence:
control 161.0±6.9, STZ-placebo 207.8±15.9, STZ-eplerenone
173.1±6.0).
Conclusions: We demonstrate that eplerenone improves endothelial dysfunction
and NO bioavailability in diabetic rats. In parallel, in vivo platelet activation
was significantly reduced by treatment with eplerenone. These effects might be a
new potential therapeutic approach for mineralocorticoid receptor antagonism as
treatment of vascular dysfunction in diabetes.
P2934 Aortic stiffness and flow-mediated dilatation in
normotensive offspring of parents with history of
hypertension. Non-invasive indicators of
atherosclerosis
H. Evrengul, H. Tanriverdi, D. Dursunoglu, I.D. Kilic, H.A. Kaftan,
M. Kilic. Pamukkale University, Cardiology, Denizli, Turkey
Objectives: Although hypertension has been shown to be one of the most important
predictors of atherosclerosis, there is not enough data about the presence
of subclinical atherosclerosis in normotensive subjects with parental history
of hypertension. Accordingly, the current study was designated to evaluate flowmediated
dilatation (FMD) and aortic stiffness those are early signs of atherosclerosis
aortic in young subjects with parental history of hypertension.
Material and methods: One hundred two healthy, non-obese subjects (ages 18–
22 years) were included in this study and divided into two groups. Group I included
the 48 offspring of hypertensive parents (ages 20 years, 18 men) and
group II as controls the 54 offspring of normotensive parents (ages 19 years,
22 men). In all subjects endothelium-dependent/-independent vasodilatation of
the brachial artery and aortic elastic parameters were investigated using highresolution
Doppler echocardiography.
Results: The demographic data of the subjects with and without parental history
of hypertension were not significantly different. Offspring of hypertensive parents
had higher systolic blood pressure and pulse pressure than the controls. Normotensive
offspring of parents with history of hypertension demonstrated that
higher values of aortic stiffness (7.1±1.88 vs. 6.42±1.56, respectively) but lower
distensibility (9.47±1.33 vs. 11.8±3.36 cm 2 /dyn/10 6 ) and FMD (4.57±1.3 vs.
6.34±0.83%, p = 0.0001, respectively) than offspring of normotensive parents.
Conclusion: We observed blunted endothelium-dependent dilatation and aortic
stiffness in normotensive offspring of hypertensive parents compared with normotensive
offspring of normotensive parents. This is evident in the absence of
overt hypertension and other diseases, suggesting that parental history of hypertension
a risk of subclinical atherosclerosis and it may contribute to the progression
to hypertension and overt atherosclerosis in later life.
P2936 Sirolimus-induced vascular dysfunction - Detection of
mitochondrial and NADPH oxidase-dependent
superoxide production and decreased vascular NO
formation
A. Jabs, S. Goebel, P. Wenzel, A.L. Kleschyov, M. Hortmann,
M. Oelze, A. Daiber, T. Muenzel. University of Mainz, II. Dept. of Medicine -
Cardiology, Mainz, Germany
Objectives: In view of coronary endothelial dysfunction and impaired reendothelialization
observed following sirolimus-eluting stent implantation, we
sought to analyze mechanisms that could mediate vascular dysfunction induced
by sirolimus.
Methods: To mimic the continuous sirolimus exposure of a stented vessel, Wistar
rats (n=34 in total) underwent drug-infusion (5mg/kg/d) or infusion of vehicle
(DMSO) with a subcutaneous osmotic pump for 7 days.
Results: A marked degree of endothelial dysfunction as well as vascular desensitization
to the endothelium-independent vasodilator nitroglycerin was observed in
aortae from sirolimus-treated animals. Also, sirolimus stimulated intense transmural
superoxide formation as detected by dihydroethidine fluorescence. A marked
stimulation of p67phox/rac1 NADPH oxidase subunit expression as well as increased
rac1 membrane association was found, indicating vascular NADPH oxidase
dependent superoxide production. In addition, rat heart mitochondria in the
sirolimus group showed increased superoxide release, as measured by L012enhanced
chemiluminescence. This effect was partially reversed by mitochondrial
pre-incubation with the mPTP blocker cyclosporine A, the KATP channel inhibitor
The endothelium: at the heart of vascular biology (bench) 487
glibenclamide, and the complex I inhibitor rotenone. As a consequence, electron
paramagnetic resonance showed a 40% reduction in vascular NO bioavailability,
which was further supported by decreased serum-nitrite levels.
Conclusions: In an animal model of sirolimus-induced vascular dysfunction, we
found continuous sirolimus exposure to cause impaired endothelium-dependent
and -independent vascular relaxation, reduced vascular NO formation, and increased
transmural superoxide production. Superoxide was generated by increased
NADPH oxidase expression and membrane association as well as stimulation
of mitochondrial release via the mitochondrial permeability transition pore.
P2937 The effect of pravastatin on microvascular constrictor
responses and the role of nitric oxide (NO)
N. Ghaffari, J.A. Kennedy, J.F. Beltrame. The University of Adelaide,
TQEH, Medicine/Cardiology TQEH, Adelaide, Australia
Purpose: Statin therapy ameliorates vasomotor dysfunction which
arises from an imbalance between vasoconstrictor and vasodilator substances.
Pleiotropic effects of statin therapy include increases NO bioavailability, but
whether such effects extend to the microvasculature is less clear. Accordingly,
this study investigated the effect of pravastatin on rat micro-vascular constrictor
responses and the mechanisms responsible.
Methods: Rat mesenteric arterial rings (250-500mm diameter, n=6/treatment)
were placed in a Mulvany wire myograph and endothelial integrity assessed with
acetylcholine. Concentration-response curves to phenylepherine (PE), thromboxane
analogue (U46619), and endothelin-1 (Et-1) were determined before and after
60min preincubation with a therapeutically-equivalent pravastatin concentration
(112nM). Constrictor responses were expressed as % of depolarizing potassium
responses. To assess the contribution of the endothelium-derived NO in
mediating effects of pravastatin, the experiments were repeated after preincubation
with the NO synthase inhibitor, L-NAME (300μM), and after denuding the
endothelium. ET-1 experiments were repeated with the ETB receptor antagonist
(BQ788; 3μM) to assess the potential influence of concurrent ETB mediated NO
release. Data were expressed as mean ± SEM and analyzed by paired t-test.
Results: In endothelium-intact vessels, pre-treatment with pravastatin reduced
the maximal constrictor response to PE (Baseline = 122±4%, Pravastatin =
90±6%, p = 0.0001) and U46619 (Baseline = 109±5%, Pravastatin = 85±4%,
p = 0.003), but had no effect on ET-1 responses (Baseline= 111±5%, Pravastatin
= 111±5%, p = 0.98). Both endothelial denudation and NOS inhibition abolished
pravastatin effect on PE and U46619 constrictor responses, confirming a central
role of endothelium-derived NO. ET-B receptor blockade unmasked an inhibitory
effect of pravastatin response in Et-1 constricted vessels (Baseline = 117±7%,
Pravastatin = 90±7%, p = 0.0005).
Conclusions: Pravastatin increases NO bioavailability in microvessels thereby
inhibiting constrictor responses. In Et-1 constrictor responses this is masked by
ET-B receptor-mediated NO release.
P2938 Effects of calcium channel blocker and angiotensin2
receptor blocker on endothelial function in porcine
drug eluting stent model
N. Kubota, T. Kasai, T. Iesaki, K. Miyauchi, H. Daida. Juntendo
University School of Medicine, Cardiolody, Tokyo, Japan
Background:Drug-eluting stent (DES) implantation may be related to endothelial
dysfunction and inflammatory reaction. Several drugs such as calcium channel
blocker (CCB) and angiotensinII receptor blocker (ARB) improve endothelial dysfunction
and inhibit inflammatory reaction. However, co-administration effects of
CCB and ARB on endothelial function and improving inflammation reaction after
vascular injury remained unknown.
We investigated whether (1) CCB or ARB could recovery endothelial dysfunction
and inhibit inflammatory reaction after DES and (2) recovery form endothelial
dysfunction and inflammation was accelerated by co-administration of CCB and
ARB in porcine coronary artery.
Methods: Twenty four pigs were randomized to four groups: control, combination
with CCB and ARB, only CCB or ARB group. Drug administration was started
one week before stenting and continued for 4 weeks. Sirolimus eluting stent
was implanted at mid-portion of the left anterior descending (LAD). After euthanasia,
edge of stent site was dissected and, the vessels were contracted,
and then, endothelium-dependent relaxation, elicited by increasing the cumulative
concentration of bradykinin, was examined. Relaxation was expressed as
percent change of steady-state level of contraction. The degree of inflammation
was determined by immunohistological examination. Inflammatory cell infiltration
in the stent site was evaluated with scanning electron microscopy (SEM).
Results:At 4 weeks after stent implantation, there were no significant differences
in blood pressure among four groups. In the control group, the endotheliummediated
vasodilatation of the edge was significantly impaired as compared with
the intact site (78% versus 90.5%, P

488 The endothelium: at the heart of vascular biology (bench)
in the both treated group. In combination with CCB, ARB had a synergic effect on
inflammatory cells infiltration by 70%.
Conclusion:Endothelial dysfunction and prolonged inflammatory reaction after
DES implantation was observed in the porcine coronary artery. However, recover
of endothelial function and suppression of inflammation was enhanced by coadministration
of CCB and ARB.
P2939 Effects of vardenafil, a selective
phophodiesterase-5-inhibitor on endothelial
dysfunction induced by reactive oxidant hypochlorite
R. Arif1 , T. Radovits2 , T. Boemicke 1 ,M.Karck1 , G. Szabo1 .
1University of Heidelberg, Department of Cardiac Surgery,
Heidelberg, Germany; 2Semmelweis University, Budapest, Hungary
Background: Reactive oxygen species, such as myeloperoxidase-derived
hypochlorite (OCl-) induce oxidative stress and DNA injury leading to dysfunction
of the endothelium in the cardiovascular system. It has been recently proposed,
that elevated intracellular cGMP levels may contribute to an effective cytoprotection
against oxidative stress. In this study we investigated the effects of vardenafil,
an inhibitor of the cGMP-degrading enzyme phosphodiesterase-5 (PDE5) on endothelial
dysfunction induced by hypochlorite.
Methods: In organ bath experiments for isometric tension we investigated
the phenylephrine-induced contraction and endothelium-dependent and –
independent vasorelaxation of isolated aortic rings of rats by using cumulative
concentrations of acetylcholine (ACh) and sodium nitroprusside (SNP). Endothelial
injury was induced by exposing the rings to hypochlorite (100, 200 and
400μM). In the treatment groups, rats were pretreated with 30 or 300μg/kg vardenafil
iv. 10 minutes before removal of the aorta. Histochemical analysis was
performed to detect oxidant-induced changes in the aortic wall.
Results: Exposure to hypochlorite resulted in a dose-dependent impairment of
endothelium-dependent vasorelaxation of aortic rings (maximal relaxation to ACh:
86.21±1.57% control vs. 75.39±2.89% 100μM OCl- vs. 66.57±3.14% 200μM
OCl- vs. 54.99±4.05% 400μM OCl-,p

THE ENDOTHELIUM: AT THE HEART OF VASCULAR
BIOLOGY (BEDSIDE)
P2943 Temporal variation of flow mediated dilation in type 2
diabetes. The benefit of serial measurements
M. Misiorna-Boehme1 , E. Soendergaard2 ,K.Egstrup1 . 1Funen Hospital Svendborg, Department of Medical Research, Svendborg,
Denmark; 2Skejby Hospital, Department of Cardiology, Aarhus,
Denmark
Purpose: To investigate the temporal variation of flow mediated dilation (FMD)
assessed within an interval of 50 to 90 s postocclusion in the population of type
2 diabetes subjects with no documented atherosclerotic disease and näive to
HMG-CoA reductase inhibitors. Furthermore, to examine the difference between
the FMD estimated at the fixed time point of 60 s postocclusion and the FMD
yield by serial measurements. Also to assess time to the maximal vasodilatory
response. Additionally, univariate and multiple linear regression analyses were
carried out to determine potential predictors of FMD.
Methods: One hundred and eighty six ultrasonographic studies on the vasoreactivity
of the brachial artery ad modum Celemajer were performed.
Arterial diameter was measured at end diastole from the anterior to the posterior
lumen-intima interface at fixed distance from anatomical markers using electronic
callipers. Three measurements along a wall segment were performed. FMD was
defined as a percent change in arterial diameter after end occlusion. The arterial
diameter was determined prior to and 50, 60, 70, 80 and 90 s after cuff deflation.
The maximal dilation (peak FMD) was computed from the maximal artery diameter
postocclusion. FMD at separate time points was calculated from the corresponding
mean arterial diameter. The cumulative response to hyperemia within
50-90 s postocclusion, area under the curve (AUC, %·s) were assessed. Time to
peak was defined as the shortest time interval from cuff deflation to the detection
of the maximal dilation.
Results: Peak FMD of 1.7% (±1.96) was significantly higher (p

490 The endothelium: at the heart of vascular biology (bedside)
P2947 Effects of atorvastatin 10 mg versus 40 mg in eight
months follow-up pulse wave velocity and clinical
events in patients with acute myocardial infarction
S.J. Hong, W.J. Shim, S.M. Park, J.S. Park, J.I. Choi, S.Y. Lim,
D.S. Lim. Korea University Anam Hospital, Cardiology Department,
Seoul, Korea, Republic of
Purpose: Pulse wave velocity (PWV) had been used as an index of atherosclerosis
and arterial compliance, and many data indicate that statins decrease the progression
of atherosclerosis. We compared the effects of atorvastatin 10 mg versus
40 mg in follow-up clinical events and in restoring PWV during the 8 months
follow-up in patients with acute myocardial infarction.
Methods: Carotid-femoral PWV was measured by using a commercially available
device (PP-1000) in 102 consecutive patients with acute myocardial infarction
5 days after the successful primary coronary intervention with sirolimus-eluting
stents. Stented patients were randomly assigned to either atorvastatin 10 mg
(ATOR10, n=52) or atorvastatin 40 mg (ATOR40, n=50). All patients received aspirin
and clopidogrel. Clinical events such as death, myocardial infarction, and
target lesion revascularization (TLR) were compared during the 8-month followup.
Results: PWV decreased significantly in both groups during the 8 months followup
(7.9±2.5 at baseline vs. 7.3±2.8 m/s at follow-up in the ATOR10, p

P2951 Reproducibility of endothelial function and arterial
stiffness assessed using finger peripheral arterial
tonometry
Y. Reisner, R. Lusky, Y. Shay-El, R. Schnall, S. Herscovici. Itamar
Medical Ltd., Caesarea, Israel
Purpose: Endothelial function and arterial stiffness are recognized markers of
subclinical atherosclerosis. One of the possible limitations for the clinical utilization
of these markers is an excessive inter-measurement variability. The purpose
of this study was to assess the reproducibility of endothelial function and arterial
stiffness indices assessed using finger peripheral arterial tonometry (PAT).
Methods: 113 adult volunteers (40 females), mean age 40.4±12.6, underwent
concurrent vascular function testing of PAT reactive hyperemia and arterial stiffness
on the mornings of 2 consecutive days under similar controlled conditions.
Endothelial function, expressed by the reactive hyperemia response, was assessed
by calculating the ratio of post-occlusion to baseline PAT amplitude. The
score is further compensated for systemic changes using simultaneous recording
from the un-occluded contra-lateral finger. Augmentation index was calculated
from the mean PAT waveform of the baseline period.
Results: Mean values of the log transformed reactive hyperemia index (F_RHI)
were 0.56±0.38 and 0.54±0.37 for days 1 and 2 respectively (p = 0.53) and augmentation
indices (AIs) were 5.7±14.9 and 5.8±16.0 respectively (p = 0.82). Intra
class correlations (ICC’s) for the day-to-day comparison were 0.56 (p

492 The endothelium: at the heart of vascular biology (bedside)
P2955 Chronic treatment with clopidogrel does not improve
endothelial dysfunction in patients with stable
coronary artery disease
A. Warnholtz, M.A. Ostad, E. Nick, V. Paixao-Gatinho, S.E. Ostad,
T. Munzel. Johannes Gutenberg-University, Mainz, Germany
Purpose: Clinical studies have demonstrated beneficial effects for clopidogrel in
patients with atherothrombotic disease. Recently we have demonstrated a dosedependent
improvement of endothelial dysfunction after administration of a single
loading dose of clopidogrel in patients with coronary artery disease (CAD). We
hypothesized that chronic therapy with clopidogrel will improve endothelial dysfunction
in patients with CAD.
Methods: We have conducted a double-blind, randomized, monocentric clinical
trial. One hundred and twenty patients with CAD were randomized to one of the
following treatment arms: Clopidogrel (C) 75mg q.d., acetylsalicylic acid (ASA)
100mg q.d. or a combination of ASA and C. Endothelial function was assessed
by measurement of flow-mediated dilation (FMD) of the brachial artery before
and after 28 days of treatment. Endothelial-independent nitroglycerin-mediated
dilation was measured in order to evaluate vascular dilatory capacity. The effect
of clopidogrel was monitored in-vitro by ADP-induced platelet aggregation in
platelet rich plasma. Effects of treatment on platelet superoxide production were
measured in-vitro by lucigenin enhanced chemiluminescence in washed platelets.
Statistical analysis was performed in the intention-to-treat population.
Results: Treatment groups were comparable regarding age, gender, cardiovascular
risk factor distribution and concomitant medication. Neither of the
three treatments caused a significant effect on FMD (C: +0.23±0.48%; C+ASS
+0.5±0.47%; ASS +0.83±0.56%. p=n.s.), NMD, or platelet superoxide production.
Clopidogrel alone and in combination with ASA significantly inhibited ADPinduced
platelet aggregation as expected.
Conclusion: In contrast to the results of our previous trial that demonstrated significant
improvement of FMD upon a single dose of 300mg and 600mg clopidogrel,
this trial failed to demonstrate a sustained beneficial effect of clopidogrel on
endothelial dysfunction in patients with CAD. In-vitro studies have demonstrated
the expression of the ADP P2Y12 receptor on endothelial cells. One possible
explantation for our unexpected finding in this trial could include the underdosing
of clopidogrel if a receptor-dependent effect was the underlying mechanism
seen upon 300mg and 600mg single dose. Counteracting mechanisms may have
compensated the effect after 28 days of treatment.
P2956 Energy restricted weight loss alone improves conduit
and resistance artery endothelial function in
overweight and obese adults: relation to abdominal
visceral fat, nitric oxide bioavailability and age
G.L. Pierce, S.B. Beske, B.L. Lawson, K.L. Southall, F.J. Benay,
A.J. Donato, D.R. Seals. University of Colorado, Integrative Physiology, Boulder,
United States of America
Purpose: Obesity is associated with vascular endothelial dysfunction, as indicated
by impaired endothelium-dependent dilation (EDD). Presently there is no
direct evidence that energy restricted weight loss alone improves conduit or resistance
artery EDD, the mechanisms involved, or if improvements differ with patient
age.
Methods: 40 overweight or obese (body mass index ≥25

P2959 Brachial flow-mediated dilation is associated with
long-term cardiovascular events in healthy subjects
M. Shechter1 ,A.Issachar1 , I. Marai1 , N. Koren-Morag2 , Y. Shahar1 ,
A. Shechter1 , M.S. Feinberg1 . 1Chaim Sheba Medical Center, The
Heart Institute, Tel Hashomer, Israel; 2Tel Aviv University, Sackler
Faculty of Medicine, Tel Aviv, Israel
Background: Endothelial dysfunction is considered an important prognostic factor
in atherosclerosis. The aim of this study was to find out the long-term association
of peripheral vascular endothelial function and clinical outcome in healthy
subjects with no apparent coronary artery disease (CAD).
Methods and Results: We prospectively assessed flow-mediated dilation (FMD)
in 435 consecutive healthy subjects: 281 (65%) men, mean age 54±12 years. Following
overnight fasting FMD and endothelium-independent nitroglycerin (NTG)mediated
vasodilatation were assessed using high resolution (15 MHz) linear array
ultrasound. Subjects were divided into 2 groups: below (n=221) and above
(n=214) the median FMD of 10.7. The 2 groups were comparable in regard to
CAD risk factors, lipoproteins, fasting glucose, C-reactive protein, and concomitant
medications, with a mean clinical follow-up of 32±2 months. Composite cardiovascular
endpoints (all-cause mortality, non-fatal myocardial infarction, hospitalization
for heart failure or angina pectoris, stroke, coronary artery bypass grafting
and percutaneus coronary interventions) were significantly more common in
subjects with FMD below rather than above the median of 10.7% (11.8% vs 4.7%,
p=0.007, respectively). Univariate analysis demonstrated that the median FMD
significantly predicted cardiovascular events [odds ratio (OR) of 2.78 and 95% CI
(1.35 to 5.71) (p=0.003)]. After multivariate analysis that included conventional
CAD risk factors, median FMD was the best independent predictor of long-term
cardiovascular adverse events [OR of 2.70 and 95% CI (1.16 to 6.32) (p=0.011)]
(Figure).
Conclusions: Brachial artery median FMD independently predicts long-term adverse
cardiovascular events in healthy subjects in addition to traditional risk factor
assessment.
P2960 Effects of early statin treatment on endothelial
function in patients with acute myocardial infarction:
randomized study
V. Giga, M. Ostojic, D. Lepojevic, S. Komnenovic, B. Beleslin,
S. Stojkovic, A. Djordjevic-Dikic, J. Stepanovic, M. Nedeljkovic,
Z. Vasiljevic. Institute for Cardiovascular Diseases, Belgrade, Serbia
Background: It has been shown that statin treatment improves endothelial function
in many cardiovascular conditions. However, it remains unclear wheter the
beneficial effects of statin treatment on endothelial function in patients with acute
myocardial infarction (AMI) are dependent of statin dosage.
The aim of our study was to assess the effects of different statin doses on endothelial
function as assessed by flow mediated vasodilatation of brachial artery
(FMD), in patients with myocardial infarction.
Methods: Ninty patients with acute myocardial infarction were randomized, within
24-72h from hospitalization, in three groups according to the statin dose used-
Group I-commonly used statin dose in CCU, Group II-atorvastatin 40mg, Group III
atorvastatin 80mg. Endothelial function was assessed by FMD of brachial artery
prior to randomization, on day 7, and on day 30 after the randomization, as well
The endothelium: at the heart of vascular biology (bedside) 493
as lipid fractions-total cholesterol (Chol), LDL-cholesterol (LDL), HDL-cholesterol
(HDL) and triglycerides (TG).
Results: There was no difference in clinical characteristics (age, peak-creatinine
kinase, prevalence of smoking and diabetes, p=NS for all), baseline FMD
(2.69±4.32 (group I) vs 4.39±4.76 (group II) vs. 3.39±5.22 (group III), p=NS
for all) and lipid fractions (Chol 6.4±2.1 (I) vs. 5.8±1.3 (II) vs. 5.7±1.1 (III);
LDL 4.3±1.7 (I) vs. 3.8±1.1 (II) vs. 3.7±0.9 (III), HDL 0.98±0.32 (group I)
vs. 0.87±0.24 (group II) vs. 0.93±0.35 (group III); TG 1.23±0.46 (group I) vs.
1.27±0.57 (group II) vs. 1.34±0.53 (group III) p=NS for all comparisons), between
the groups prior to randomization. Overall, statin treatment improved FMD after
7 days (3.18±4.74-baseline vs. 5.21±4.30-day 7 p

494 The endothelium: at the heart of vascular biology (bedside) / Cardiovascular magnetic resonance
Methods: PB samples from patients with AMI were studied by flow cytometry
within 12 hours (n=30), at 6±1 days (n=23) and 30±2 days (n=15) of the event
index. Aditionally, 6 PB samples from healthy subjects were included. Clinical variables
were recorded: gender, age, type of AMI, start-up time of revascularization,
size of infarct (defined by CPK levels) and left ventricular systolic function.
Results: 30 patients have been included and until now 15 patients have completed
the study. 25 patients (83.3%) were males. The mean age were 64.0±2.4
years. In patients suffering AMI the majority of cells detected, among cellular population
expressing CD146 protein, displayed immunophenotypic characteristics of
T lymphocytes (CD146+, CD3+, CD45++) (p

P2966 Detection of late enhancement in cardiac MRI is a
predictor for the occurrence of ventricular
tachycardias in patients with dilated cardiomyopathy
K. Kouraki 1 ,B.Mark 1 , T. Kleemann 1 , B. Cornelius 2 , A. Kilkowski 1 ,
T. Becker 1 ,G.Layer 2 ,K.Seidl 1 ,R.Zahn 1 . 1 Herzzentrum
Ludwigshafen, Kardiologie, Ludwigshafen, Germany; 2 Klinikum Ludwigshafen,
Radiologie, Ludwigshafen, Germany
Objectives: Previous studies have shown that detection of late enhancement
(LE) in patients with dilated cardiomyopathy (DCM) is associated with a worse
prognosis as well as with increased inducibility of ventricular tachycardias. Aim of
this study was to assess whether the presence of LE in DCM is associated with
an increased occurrence of ventricular arrhythmia episodes in patients receiving
an implantable cardioverter defibrillator (ICD).
Methods: Between 06/2003 and 12/2007, 30 consecutive patients with DCM and
an ejection fraction below 40% underwent coronary angiography and cardiac MRI
before receiving an ICD. Ventricular arrythmia was defined as episodes of ventricular
tachycardia (VT) or ventricular fibrillation (VF) which were terminated by
antitachycardia pacing or appropriate ICD-shock. Average follow-up time was 18
months.
Results: LE was seen in 13 patients (43%), the pattern was in 7 cases longitudinal
midwall in the intraventricular septum and in 4 cases patchy diffuse midwall
or transmural. Among those patients, 7 (54%) had VT/VF episodes, whereas in
the control group without LE only 5 patients (18%) had VT/VF episodes (p

496 Cardiovascular magnetic resonance: insights into comprehensive management programme
P2970 Immunohistological basis of late gadolinium
enhancement phenomenon in tako tsubo
cardiomyopathy by cardiac MRI
A. Rolf 1 ,H.Nef 1 , H. Moellmann 1 ,S.Kostin 2 ,S.Voss 2 , G. Conradi 1 ,
J. Rixe 1 ,A.Elsaesser 1 ,C.Hamm 1 , T. Dill 1 . 1 Kerckhoff Heart
Center, Cardiology/Cardiac Imaging, Bad Nauheim, Germany; 2 Max Planck Inst.
of Heart and Lung Research, Bad Nauheim, Germany
Objective: The absence of Late Gadolinium Enhancement (LGE) in patients with
Tako Tsubo Cardiomyopathy (TTC) has been a widely accepted paradigm. Recently
several authors reported single cases of LGE, the reason for this phenomenon
yet unknown. LGE can be attributed to one or more of the following
tissue conditions: edema, necrosis or fibrosis. As published previously we found
transient interstitial fibrosis in myocardial biopsies of TTC patients. We therefore
sought to determine, if the LGE phenomenon in TTC is based on a transient increase
in extracellular fibroid matrix.
Methods: The diagnosis of TTC was based on apical ballooning with hyper contractile
basal segments after rule out of CHD on X-ray coronary angiograms.
Written informed consent was obtained from all patients to undergo biopsy. Viral
myocarditis was ruled out by PCR. We performed collagen-1 staining on the
myocardial biopsies and computed the mean percentage areas of collagen per
field of view. Creatininkinase levels were compared as markers of necrosis. Patients
underwent cardiac MRI (CMR). Late Enhancement was documented on inversion
recovery Fast Gradient Echo Sequences (FLASH, Siemens) and graded
as present or absent. Edema was calculated as mean percentage area of the
myocardium on Turbo Spin Echo Sequences in two long axis orientations. Mann-
Whitney-U-Test were used to compare group differences. Absolute values are
given ± SD. P- values equal or less than 0.05 were considered significant.
Results: Complete data were available for 8 patients, two of which were LGE positive.
There was no significant difference in CK values or edema between groups
(CK: LGE pos. 115.5±48.8 U/L vs. LGE neg. 138.6±41.3 U/l p = 0.7; edema:
LGE pos. 18.7±0.2% vs. LGE neg. 21.3±15.8% p = 0.56). The extracellular matrix
however, as represented by collagen-1 staining, was significantly increased in
LGE positive Patients (LGE pos. 12±4.8% vs. LGE neg. 4.6±1.8% p = 0.046).
Conclusion: The present data suggest that LGE in patients with TTC is caused
by transient increase of extracellular fibroid matrix, contradicting the paradigm,
that LGE rules out TTC. A limitation of the study is the small sample size due
to the low frequency of the disease. Therefore further studies with larger patient
cohorts are warranted to corroborate these findings.
P2971 Cardiovascular magnetic resonance monitors
reversible and irreversible myocardial injuries in
myocarditis and predicts long term LV-remodeling:
Insights from a comprehensive approach
H. Abdel-Aty, A. Zagrosek, P. Boye, R. Wassmuth, D. Messroghli,
W. Utz, A. Rudolf, S. Bohl, R. Dietz, J. Schulz-Menger. Franz-Volhard-
Klinik,Charite Campus Buch, Kardiologie, Universitatsmedizin Berlin, Berlin,
Germany
Purpose: Myocarditis is associated with a wide-range of myocardial tissue injuries
and may lead to long-term left ventricular (LV) remodeling. We sought to
assess the value of CMR to monitor patients over the course of myocarditis and
to explore if myocardial tissue injury assessed by cardiovascular magnetic resonance
(CMR) could predict LV-remodeling.
Methods: We studied 36 patients (31 males, 51±16 y) hospitalized with myocarditis
during the acute phase and 18±10 months thereafter. CMR was performed
on two 1.5T scanners and included the following sequences: steady
state free precession, T2-weighted, early (global relative enhancement, gRE) and
late T1-weighted after gadolinium-DTPA injection (late gadolinium enhancement,
LGE). The primary end-point was 10% or more increase in end-diastolic volume
at follow-up (delta-EDV).
Results: In the acute phase, T2 ratio was elevated in 86%, relative enhancement
in 80% and LGE was present in 63%. There was a significant correlation
between T2 ratio and troponin folds (beta = 0.53; p= 0.005). At follow-up
both T2 ratio (1.9±0.2 vs. 2.4±0.5; p

tissue as an enhanced area. On the other hand, transient inflammatory changes
following thermal injury from radiofrequency ablation and development of scar
tissue would allow a direct comparison of electrophysiologic results and permit
correlation with clinical outcomes.
Methods: Fifty-six patients underwent radiofrequency ablation of the cavotricuspid
isthmus (CTI) for isthmus-dependent atrial flutter (AFL; 12 females,
59±12 years). All patients were performed right atrial conventional angiography
to determine the CTI length and the CTI morphology. During CTI ablation, bipolar
electrograms were recorded along the ablation line during proximal coronary
sinus pacing, and measured an interval of double potential (DP) to determine
complete isthmus block. MRI was performed before, 1 day after, and 1 month after
CTI ablation. The change of CTI wall thickness and the prevalence of delayed
enhancement at the CTI after ablation were analyzed.
Results: The mean CTI length was 44±10 mm. The 30 patients (46%) showed
concave characteristics, and pouch-like recesses were seen in 16 patients (29%).
Complete isthmus block was obtained all 56 patients, and the mean DP intervals
were 102±20 ms. One day after CTI ablation, the contrast-enhanced MRI
revealed delayed enhancement at the CTI in 46 patients (82%), and relative to
baseline CTI wall thickness was significantly increased (1.6±0.1 mm vs. 2.3±0.2
mm, p< 0.0001). In contrast, one month after CTI ablation, those edematous
changes had disappeared, and the CTI wall thickness was not significantly different
from baseline. The delayed enhancement at the CTI was clearly found in
48 patients (86%). No correlation was observed between the prevalence of scar
tissue after CTI ablation and the CTI morphology.
Conclusions: MRI is useful to assess the creation of endocardial edema and
scar tissue resulting from CTI ablation. These results may correlate with anatomical
isthmus block after CTI ablation in a large portion of patients with isthmusdependent
AFL.
P2975 Magnetic resonance imaging identifies myocardial
injury in the course of ablation procedures for atrial
fibrillation
A.M. Sinha1 , C. Mahnkopf1 , G. Ritscher1 , R. Oakes2 , T. Badger2 ,
M. Schmidt1 , H. Marschang1 , E.V.R. Dibella3 , N.F. Marrouche2 ,
J. Brachmann1 . 1Klinikum Coburg, Ii. Medizinische Klinik, Coburg, Germany;
2University of Utah Medical School, Salt Lake City, United States of America;
3Utah Center for Advanced Imaging Research, Salt Lake City, United States of
America
Purpose: Pulmonary vein antrum isolation (PVAI) is regarded as an effective
therapy in patients with atrial fibrillation (AF). Extension and location of ablation
lesions often remain unclear during the procedure. We report a new approach on
visualization of myocardial injury using magnet resonance imaging (MRI) during
PVAI procedure.
Methods: Patients who underwent PVAI, received MRI before and at the terminal
phase of PVAI. Delayed enhancement (DE-MRI) sequences were applied, and
maximum intensity projections (MIP) obtained. Myocardial injury size was then
measured on manually segmented 3D images by a computer algorithm using
dynamic thresholding.
Results: 30 patients received PVAI from December 2007 to February 2008. In a
subset of 10 patients, MRI was performed before and during the procedure. Using
DE-MRI, the average lesion to healthy myocardium ratio was 7.56±1.27% during
PVAI. The figure shows an example of MIP of a DE-MRI scan in 2D (A,D) and
MRI in PVAI patients.
Cardiovascular magnetic resonance: insights into comprehensive management programme 497
3D (C,D) segmentation in a anterior view pre (A,C), and during PVAI procedure
(B,D). Myocardial injury is identifiable as white tissue around PV single ostia (D,
full arrows) and common trunk (D, dashed arrows).
Conclusion: Using MRI is feasible in the course of ablation procedures. In PVAI
patients, DE-MRI allowed identification of location and extension of myocardial
injury. Therefore, this new MRI approach might improve ablation techniques, and
thus long-term success of PVAI.
P2976 Insufficiency in diagnosis and treatment of cardiac
diseases in patients with muscular dystrophy with
conventional evaluation methods: a novel approach
using cardiovascular magnetic resonance imaging
A. Yilmaz1 , H.J. Gdynia2 , H. Baccouche1 , H. Mahrholdt1 ,
A.D. Sperfeld2 , A.C. Ludolph2 , U. Sechtem1 . 1Stuttgart, Germany; 2Ulm, Germany
Purpose: Muscular dystrophy type Becker-Kiener (BMD) represents an X-linked
genetic disease due to dystrophin gene mutations. Apart from skeletal myopathy,
cardiac muscle involvement with the development of dilated cardiomyopathy
(DCM) has been described in BMD patients previously, mainly based on echocardiographic
and nuclear imaging studies. The course of the disease can potentially
be alleviated by timely onset of adequate medication. However, both echocardiography
and nuclear imaging have well known method-inherited limitations. Therefore,
cardiovascular magnetic resonance imaging (CMR) represents a promising
non-invasive tool for comprehensive cardiac evaluation of patients with muscular
dystrophy.
Methods: In a prospective two-center-study, 14 male patients with BMD (mean
age 36.4±14.7; range 11 to 56 years) underwent comprehensive neurological
and cardiac evaluation. Cardiological work-up comprised echocardiography and
CMR (1.5-T). A 16-segment model was applied for evaluation of regional wall
motion abnormalities (rWMA) and quantification of a global systolic wall motion
score index (GWMS). The CMR study included late gadolinium enhancement
(LGE) imaging with quantification of myocardial fibrosis.
Results: Within this study, pathologic echocardiographic results (defined as left
ventricular ejection fraction (LVEF) < 55% and/or rWMA) were found in 8 of 14
(57.1%) patients with all of them demonstrating reduced LVEF and rWMA (mean
GWMS 0.27±0.34). By contrast, CMR revealed pathological findings (defined as
LVEF < 60% and/or rWMA and/or presence of LGE) in 12 of 14 (85.7%) patients
(p = 0.040 compared to echocardiography) with 10 (71.4%) of them having
reduced LVEF (p = 0.16) and 9 (64.3%) demonstrating rWMA (mean GWMS
0.30±0.34; p = 0.43). Importantly, myocardial fibrosis was present in 11 of 14
(78,6%) patients as assessed by LGE imaging with a mean myocardial fibrosis
extent of 11.7±10.0% (range 0 to 31.0%). Correlation analyses revealed a substantial
association between increased myocardial fibrosis and decreased LVEF
(r 2 = 0.46; p = 0.008). Nine patients (64.3%) were actually in need of medical
therapy based on clinical symptoms and CMR results. However, only 4 patients
(28.6%) were already taking heart failure medication (p = 0.019).
Conclusions: Cardiac involvement in patients with BMD is underdiagnosed by
echocardiographic methods resulting in undertreatment of occult heart failure. For
a sensitive diagnosis of cardiac involvement in patients with BMD, comprehensive
CMR studies including LGE imaging are required.
P2977 Left ventricular trabeculae: quantification in different
cardiac diseases with cardiac magnetic resonance
C. Fernandez-Gofin Loban1 , J. Zamorano1 , M. Pachon Iglesias2 ,
C. Corros1 ,L.PerezDeIsla1 , J. Ferreiros1 ,A.Bustos1 ,
B. Cabeza1 , G. Pizarro1 ,C.Macaya1 . 1Hospital Clinico San Carlos,
Cardiovascular Imaging Unit, Madrid, Spain; 2Hospital Virgen de la Salud,
Cardiology, Toledo, Spain
Background: Left ventricle trabeculae are frequently seen in different cardiac diseases
Differential diagnosis with non compaction cardiomyopathy is often difficult.
Cardiac magnetic resonance (CMR) accurately identify left ventricular trabeculations
but normal reference values in different cardiac conditions are not known.
Objective: To calculate with CMR, left ventricle trabecuale mass (LVTM) and
LVTM percentage (LVTM%) in different heart diseases, evaluating its posible
diffrent distribution between groups.
Methods: 59 patients were enrolled: 13(22.0%) controls; 17(28.8%) ischemic
cardiomyopathy; 15(25.4%) idiopathic cardiomyopathy, 7(11.9%), valvular heart
disease and 7(11.9%) hyperthrophyc cardiomyopathy. Cine-MR images (General
Electrics 1.5T.Signa) were acquired with steady-state free precession sequence
(FIESTA) covering left ventricle in a short axis view from base to apex (slice thickness
8 mm, gap 2 mm). LVTM was calculated as the difference between LVM
excluding trabecuale from the blood cavity and left ventricle mass including trabeculae
as part of the blood cavity. LVTM% was then calculated as the percentage
of the whole left ventricle mass excluding trabeculae form the blood cavity.
All analysis were performed using GE Resport Card work Station.
Results: 59 patients (mean age 47.60±22.03; male 62.7%) were included. Main
results are shown in Figure 1.
Conclusions: CMR can accurately determine LVTM and LVTM percentage.
LVTM and LVTM percentage varies among different cardiac conditions being
more prevalent in patients with dilated and ischemic cardiomyopathy. Calculation
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498 Cardiovascular magnetic resonance / New developments in time Doppler imaging
Figure 1. Main results.
and distribution of LVTM and LVTM% with CMR may help in diferencial diagnosis
between non compaction cardiomyopathy and other cardiac diseases.
P2978 Useful of cardiac magnetic resonance in detecting
myocardial features in patients with chest pain and
normal coronary arteries: clinical applications
M. Perazzolo Marra1 , L. Cacciavillani1 , F. Corbetti 2 ,A.Marzari1 ,
A.B. Ramondo1 ,R.Turri1 , S. Iliceto1 . 1Dpt of Cardio, Thoracic and
Vascular Sciences, Padua, Italy; 2Service of Radiology, Padua, Italy
Background: In clinical practice more and more patients presenting symptoms
typical of ischemia accompanied by ECG changes and biomarkers classic for
miocardial infarction (MI) reveal none coronary stenosis. However, coronary angiography
is not a perfect tool and coronary lesion could have missed or understimated.
Cardiac Magnetic Resonance (CMR) is an accurate noninvasive tool
for detecting MI and other causes of myocardial damage.Aim: To evaluate clinical
characteristics in a population presenting with chest pain, enzymatic and ECG
features suggesting acute coronary syndrome (ACS) or myocarditis and to compare
final clinical diagnosis with CMR findings.
Methods: We studied consecutive patients hospitalized in our Cardiologic Intensive
Care from October 2006 to Jannuary 2008 for chest pain, suspected ACS
or myocarditis and normal coronary angiography. All patients undewent coronary
angiography and MRI. CMR was performed with 1.0-T scanner and images were
acquired using a steady-state free-precession sequences,T2-weighted images
for edema evaluation and contrast-enhanced sequences. For each group we analyzed
clinical characteristics, ECG and angiographic findings.
Results: We evaluated 49 patients (mean age 50±17 years;22 female); mean
peak increase of troponin I was 7,6±7 ug/L, mean ejection fraction was 59±16%.
Initial diagnosis was ACS without ST segment elevation (NSTE) in 25 (51%) patients,
ACS with ST segment elevation (STE) in 9 (18%), suspected myocarditis
in 15 (31%). All the patients showed normal coronary arteries on angiography.
Final diagnosis was MI with normal coronary arteries in 15 (31%) patients (only
one patient showed coronary vasomotion), myocarditis in 30 (61%), tako-tsubo
cardiomyopathy in 4 (8%). CMR showed isolated regional wall motion abnormalities
without delayed enhancement (DE) in 2 (4%) patients, and subendocardial
DE, suggesting AMI with normal coronary arteries, in 5 (10%). T2-weighted sequences
and distribution of DE concluded for myocarditis in 31 (64%) patients. In
7 patients (14%) cine, T2-weight and DE sequences CMR suggested tako-tsubo
cardiomyopathy. Negative CMR was found in 4 (8%) patients.
Conclusion: Our experience confirms that in patients presenting symptoms typical
of ischemia with ECG changes and enzymatic increasing classic for MI, but
normal coronary arteries, CMR images is also helpful. CMR patterns can identify
patients with myocarditis allowing a noninvasive follow-up, also in patients with
DE showing subendocardial necrosis suggests a more invasive study of coronary
arteries called as normal.
P2979 Evaluation of marfan syndrome by cardiovascular
magnetic resonance
F. Alpendurada, R. Mohiaddin. Royal Brompton Hospital, CMR Unit,
London, United Kingdom
Introduction: Marfan syndrome (MS) is a rare connective tissue disease
caused by mutations of the fibrillin-1 gene. Cardiovascular Magnetic Resonance
(CMR) plays an important role in identifying and evaluating cardiovascular
manifestations in this population, which is the major source of morbidity and mortality.
CMR was used in this study to assess the prevalence of cardiovascular
manifestations in a Marfan population.
Methods: The study population consisted of 120 consecutive Marfan patients referred
to our centre between January 2003 and June 2007 including 77 males
(64.2%) and 43 females (35.8%), mean age 34.9 years. 33 patients (27.5%) had
history of previous aortic or cardiac surgery. We evaluated thoracic aortic dimensions
and assessed for structural abnormalities of the aorta, aortic arch branches,
and main pulmonary artery. Left ventricular (LV) volumes and mass, and aortic
(AV) and mitral valves (MV) anatomy and function were also evaluated. Assessment
of chest wall deformities was also performed.
Results: The aortic root was dilated in 69 patients (57.5%), the ascending aorta
was dilated in 23 patients (19.2%), the aortic arch was dilated in 19 patients
(15.8%), and the descending aorta was dilated in 18 patients (15.0%). The arch
vessels were dilated in 9 patients (7.5%), and the abdominal aorta was involved in
9 patients (7.5%). The main pulmonary artery was dilated in 16 patients (13.3%).
Aortic dissection was noted in 9 patients, and intramural haematomas were seen
in 2 patients.
There was native aortic regurgitation in 50 patients (49.5%), which was moderate
or severe in 14 patients (13.9%). 43 patients (37.1%) met criteria for MV prolapse.
Mitral regurgitation was identified in 22 patients (19.0%), which was moderate or
severe in 8 patients (6.9%).
LV indexed end-diastolic and end-systolic volumes were increased in 50 (43.1%)
and 48 (41.4%) patients, respectively. LV ejection fraction was decreased in 31
patients (26.7%), and mass index was increased in 32 patients (27.6%).
Fifty three patients (44.2%) had pectus carinatum and 13 patients (10.8%) had
pectus excavatum. Scoliosis was present in half of the patients, being moderate
or severe in 32 patients (26.7%).
Conclusions: This study shows a high prevalence of aortic complications in this
group of patients. Valvular involvement, increased LV volumes and decreased
ejection fraction were frequent findings, warranting regular follow-up in this population.
The prevalence of chest wall deformities highlights the importance of CMR
in assessing the cardiovascular system of these patients in whom echocardiography
is likely to be difficult.
P2980 Characterization of myocardium using in vivo
late-gadolinium enhancement high-resolution
myocardial T1 mapping in mice on a 11,75 magnet
S.S. Bun, F. Kober, J. Kalifa, A. Jacquier, P.J. Cozzone, M. Bernard.
CRMBM, Cardiology Department, Marseille, France
Background: Late-gadolinium enhancement magnetic resonance imaging (LGE)
is an accurate method to assess myocardial fibrosis. T1 relaxation time in normal
mouse myocardium before and after contrast agent is of importance for optimizing
LGE acquisitions. However, at high field strength, T1 of myocardium was reported
quantitatively only without contrast agent, under slice-selective inversion
conditions [1], and no blood T1 values were reported.
Purpose: To establish the normal range and reproducibility of myocardial and
blood T1 as assessed with high-resolution global-inversion myocardial T1mapping
in mice with and without contrast agent at 11.75T.
Methods: Look-Locker Inversion-Recovery GE T1 mapping (resolution 195x390
μm 2 , slice thickness 1.5mm, imaging time 15min [2]) was performed in eight
12-week old C57Bl/6J mice under isoflurane anesthesia using a 11.75T vertical
scanner. The measurements were performed before and 20 min after intravenous
injection of gadolinium-DTPA (0.30 mmol/kg). Blood T1 was measured using a
homogeneous spin-inversion over the entire animal was produced.
Results: Baseline mean ± SD myocardial T1 was 1.95±0.16s, and was reduced
to 1.01±0.15s, 20min after injection of gadolinium. Baseline mean blood T1 was
1.73±0.24s, and decreased to 0.52±0.20s.
T1 maps pre (a) and post (b) Gd
Conclusion: High-resolution myocardial T1-maps were obtained. Myocardial and
blood T1 values pre- and post-contrast were calculated at 11.75T. As a result of
global spin inversion and myocardial perfusion, T1 values were higher than those
previously reported. Quantitative T1 assessment might enable direct quantification
of myocardial fibrosis in cardiomyopathies.
[1] Schneider JE et al. J Magn Reson Imaging. 2003 Dec;18(6):691-701.
[2] Kober F et al. Magn Reson Med. 2005 Mar;53(3):601-6.
NEW DEVELOPMENTS IN TIME DOPPLER IMAGING
P2981 The contribution of Tissue Doppler Imaging (TDI) in
early diagnosis of myocardial dysfunction induced by
the use of cardiotoxic drugs
H. Michalopoulou, P. Stamatis, A. Bakhal, J. Vaitsis, D. Stamatis.
Metaxa Hospital, Cardiology Department, Athens, Greece
Purpose: Treatment with anthracyclines in breast cancer while associated with a
high response contains the risk of cardiotoxicity. The early diagnosis of myocar-
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dial dysfunction is critical for the prognosis of these patients. The present study
evaluated the systolic and diastolic function of the left ventricle in asymptomatic
women with breast cancer who received anthracyclines.
Methods: 66 consecutive women (53±12 years old) suffering from breast cancer
[group A] and 49 healthy volunteers [group B] were studied. The individuals of
the study did not manifest symptomatology related to cardiac disease. They underwent
echocardiographic study (standard and TDI) prior to chemotherapy and
6 months later. The ejection fraction (EF) was evaluated, as well as the systolic
(Sm), early diastolic (Dm) and late-diastolic (Am) myocardial velocities on the longitudinal
axis.
Results: No differences were observed at the systolic performance of the left
ventricle with the use of standard echocardiography (EF: 63.8±3.7% in group A
vs 64.2±2.6% in group B p=NS).
Nevertheless, with TDI an impaired systolic and diastolic function of the left
ventricle was shown in women who received anthracyclines in comparison to
healthy women. Sm:3.92±0.7 in group A vs 4.62±0.9 in group B (p=0.001),
Em:4.82±1.3 in group A vs 5.73±1.4 in group B (p=0.001), Am:5.34±1.2 in group
Avs4.23±0.8 in group B (p=0.001).
Conclusion: Patients who have received treatment with anthracyclines, even
though asymptomatic and with seemingly normal systolic performance with the
use of standard echocardiography, display an impaired function of the left ventricle.
Tissue Doppler echocardiography can help in early diagnosis and consequently
in the timely treatment of myocardial dysfunction.
P2982 The utility of tissue Doppler imaging in predicting
early left ventricular dysfunction in a murine model of
anthracycline-induced cardiomyopathy
C. Hans, A. Sharma, R. Ahmadie, T. Fang, P.K. Singal, D. Jassal. St.
Boniface General Hospital, Winnipeg, Canada
Background: Trastuzumab, an antagonist to the HER-2 receptor, significantly decreases
the rates of breast cancer recurrence and mortality. Despite this benefit,
Trastuzumab (T) and Doxorobucin (Dox) is associated with a 10-15% incidence
of cardiotoxicity and its early detection may improve patient management. Liposomal
encapsulation of Dox (Myocet) is associated with minimal cardiotoxicity; its
effects in combination with T remain unknown.
Objective:To determine whether Myocet+T would be less cardiotoxic as compared
to Dox+T using Tissue Doppler imaging and conventional echocardiography.
Methods: Wild-type C57Bl/6 mice (n=50) received one of the following; i) Dox
(20 mg/kg); ii) Myocet (10 mg/kg); ii) T (20 mg/kg); iv) Dox+T; or v) Myocet+T.
TDI-derived peak endocardial systolic velocity (Vendo), strain rate (SR), and LV
ejection fraction (EF) were measured serially for five days. On day 5, the heart
and liver were removed for histological and biochemical analysis.
Results: Mice treated with Myocet+T was associated with minimal cardiotoxicity
in comparison to Dox alone or Dox+T. Progressive LV dilatation and LV systolic
dysfunction by day 4 of treatment with Dox+Trast was observed, as compared to
preserved LVEF in the remaining groups. TDI parameters decreased within 24
hours in the Dox alone or Dox+T groups and predicted early mortality. There was
a significant increase in apoptosis (Bax/Bcl ratio) in the Dox+T group as compared
to the other groups. The survival rate was only 20% at day 5 of the experiment in
Dox+T, whereas 100% of mice receiving T, Myocet or Myocet + T survived the 5
days.
Conclusion: TDI can detect LV dysfunction prior to alterations in conventional
echo indices and predicts early mortality in mice receiving Dox+T as compared
to Myocet+T in an acute model of chemotherapy induced cardiotoxicity.
P2983 Global strain is superior to mitral annulus
displacement to quantify myocardial infarct mass in
chronic ischemic heart disease
O. Gjesdal, T. Vartdal, T. Helle-Valle, K. Lunde, E. Hopp, H.-J. Smith,
H. Ihlen, T. Edvardsen. Rikshospitalet University Hospital, Dept. of
Cardiology, Oslo, Norway
Purpose: Global longitudinal strain (GS) and mitral annulus displacement (MD)
are markers of longitudinal LV function. We compared the two method’s ability to
quantify LV function in patients with myocardial infarct.
Methods: LV infarct mass was measured by late enhancement MRI in 61 patients
9±5 months after a first myocardial infarction (MI). Longitudinal strain was
assessed in 16 LV segments by speckle tracking echocardiography and mitral annulus
displacement in 6 segments by tissue Doppler imaging. GS and MD were
calculated by averaging the segmental values, and were then compared to LV
infarct mass by regression analysis and tested for ability to separate small (0-30
g), medium (30-50 g) and large (≥50 g) MI.
Results: GS and MD correlated well with infarct mass (Figure). Myocardial func-
Mean values
Small (0-30g) Medium (30-50g) Large (>50g)
Infarct Mass (g) 13±10 41±5 † 74±20*
GS (%) -17±2 -15±2 † -10±3*
MD (mm) 11±1 10±1 8±2*
Mean values ± SD by infarct mass. *p≤0.05 vs medium, † p≤0.05 vs small myocardial infarct.
Correlation plots.
New developments in time Doppler imaging 499
tion was progressively lower in patients with larger infarcts as assessed by both
methods. Both indices separated large from medium sized MI (*p

500 New developments in time Doppler imaging
morphological distinct segments (the basal smooth muscle and the apical trabecular)
and longitudinal deformation was measured for both. This deformation data
were compared to normal values (from 37 controls) and to 4 pts with both severe
LV hypertrophy and pronounced global RV enlargement and systolic dysfunction
detected by angiography and TTE.
Results: All 35 pts had normal RV diameters and function reported by standard
TTE. In all pts severe LV hypertrophy was present (septal wall 22±5 mm). In contrast
to controls (S: basal – 43±11%, apical - 41±11%; peak SR: basal –2,9±1
1/s, apical –2,6±0,9 1/s), the regional systolic deformation values (S: basal –
27±7%, apical -26±9%; peak SR: basal -2±0,5 1/s, apical – 2±0,6 1/s) were significantly
reduced. In the 4 pts with unequivocal RV dysfunction by conventional
methods deformation was even further reduced (S: basal -12%, apical -6%). In a
subset of HCM pts (n = 6) both regional deformation values were >1,5 SD below
the control (S: basal -20±3%, apical -20±5%) values, despite conventional TTE
being normal. In 3 pts basal deformation parameters were > 1,5 as apical; 2 of
these showing apical hypertrophy.
Conclusion: Regional RV deformation analysis is feasible in pts with HCM and
shows pronounced regional impaired systolic deformation, despite conventional
methods (TTE, angiogram) failed to detect these changes. S and SR is a useful
non invasive tool to detect subtle changes in RV/LV function. Additional use of this
methods especially regarding RV involvement and function might help to distinguish
HCM clinically from other cardiac disorders with LV hypertrophy mimicking
its clinical features (i.e. hypertensive heart disease, cardiac storage disease) with
consequences for prognosis and therapy.
P2986 Tissue Doppler echocardiography in persons with
hypertension, diabetes or ischemic heart disease
R. Mogelvang 1 , P. Sogaard 1 , S.A. Pedersen 1 ,N.T.Olsen 1 ,
P. Schnohr 2 , J.S. Jensen 1 . 1 Cardiology, Gentofte, Denmark;
2 Epidemiological Research Unit, Bispebjerg, Denmark
Purpose: Echocardiographic tissue Doppler imaging (TDI) has proven useful in
the hospital setting in various cardiac diseases, but the diagnostic significance
in evaluating cardiac function in the general population is unknown. This study
was performed to evaluate the potential role of tissue Doppler imaging in the
characterization of myocardial function in the general population.
Methods: Within a large, community-based population study, cardiac function
was evaluated in 1,036 men and women both by conventional echocardiography
and by color TDI. An abnormal conventional echocardiographic examination was
defined as hypertrophy, dilatation, low ejection fraction (15 mmHg (Sensitivity 90%,
specificity 80%, positive predictive value 90%) Sensitivity, specificity and positive
predictive value of peak E wave velocity >1 m/s suggesting severe MR were found
to be different in pts with normal (>50%) and low (

for testing the load dependence. The latter was evaluated on a series of 33 patients
daily imaged during ECLS output variations. 22 of them tolerated acute
decrease to 33 or 10% of the initial support (70 load conditions). The haemodynamic
status was assessed with the mean invasive arterial pressure (MAP),
Aortic Doppler VTI, Mitral Doppler E wave (Em), and Ejection Fraction (EF). The
lateral and septal wall motion were assessed using 2DSRI: systolic peak velocity
(Sv), strain (S), strain rate (SR) and early diastolic velocity (Ev). Moreover, systolic
and early diastolic (E’) Tissue Doppler velocities were studied at the mitral
annulus level.
Results: The load manipulation induced by the decrease of the ECLS output
were documented by the significant changes (p≪0.01) of MAP, aortic VTI,
EM and EF: decrease of Em (-25cm s -1 ) and Em/E’ (+2), increase of MAP
(+16mmHg), VTI (+3cm) and EF (+4%). The load dependence of 2DSRI parameters
is shown on Table 1. Similarly, the TD velocities are modified by load
variations (p≪0.01) even if these variations are low (-0.3cm s -1 ).
Table 1. The load dependence of 2DSRI
ECLS output (L min-1 ) SV (cm s-1 ) EV (cm s-1 ) S (cm s-1 ) Systolic SR (%) Diastolic SR (%)
Maximum (3.8 + 1.0) 1.18 + 0.85 1.33 + 0.95 4.06 + 4.80 0.43 + 0.33 0.41 + 0.35
Minimum (0.9 + 0.5) 1.79 + 0.77 1.90 + 1.16 6.71 + 6.00 0.58 + 0.42 0.58 + 0.37
p 0.001 0.004 0.001 0.03 0.01
Conclusion: 2DSRI parameters demonstrate a clear load dependence during
acute manipulations associated with ECLS
P2990 Asymmetrical longitudinal left atrial myocardial
systolic velocities: speckle tracking
echocardiography
Sweden
M.(J.R.) Henein 1 , P. Lindqvist 1 , M. Henein 2 . 1 Heart Centre, Umea
University Hospital, Cardiology, Umea, Sweden; 2 Heart Centre,
Umea and Canterbury University, Cardiology, Umea And London,
Background: Left ventricular velocities vary according to their location in the cavity
with the basal segments, adjacent to the mitral ring, having the highest velocities
with respect to the apical ones. HYOPTHESIS: Since atrial myocardial fibres
are predominantly longitudinal and insert around the circumference of the mitral
ring we hypothesis that their segmental velocities may follow the pattern of their
opponents in the left ventricle.
Methods: We studied 40 normal subjects (age 59±15 years, 19 females) with no
symptoms, signs or history of cardiovascular disease using conventional Doppler
echocardiography and 2D strain technique. Global atrial function was assessed
from left ventricular atrial filling component. Regional left atrial longitudinal function
was studied by 2D strain from the lateral and septal atrial walls at the annular,
mid-cavity and rear levels.
Results: The highest atrial systolic velocities were at the mitral annular level
which fell progressively at the segments away from the mitral annulus; Lateral wall
5.1±1.9 cm/s vs 3.0±1.5cm/svs1.17±1.3 cm/s (P

502 New developments in time Doppler imaging
free of any known cardiovascular disease based on a thorough history, physical
examination and a normal electrocardiogram. Regional longitudinal function was
analysed in an 18-segment model of the left ventricle by extracting peak systolic
strain rate (SRsys) and maximal systolic strain (Ssys) using dedicated software.
Regression coefficients were calculated for SRsys and Ssys in each wall and age.
Results: In contrast with the inferoseptal wall, peak SRsys and Ssys in the anterolateral
wall correlated significantly with age: regression lines: InfSep Ssys =
-0.24 + 0.0003*X vs. AntLat Ssys = -0.25 + 0.0015*X (figure).
Conclusions: Aging does not equally affect all myocardial walls and segments.
The anterolateral wall and apical segments are significantly influenced by aging
while inferoseptal and inferior walls and basal segments are less affected. Differences
in regional wall stress might account for these findings. This can explain
conflicting data in current literature.
P2994 Usefulness of longitudinal myocardial deformation
analysis by two-dimensional echocardiography for
the non invasive diagnosis of cardiac allograft
vasculopathy in heart transplant patients
V. Sanchez Sanchez1 , J.F. Delgado2 , A. Fontenla2 , A. Gonzalez2 ,
F. Lombera2 , S. Fernandez2 , J. Garcia-Tejada2 ,A.Forteza2 , C. Saenz De La
Calzada2 . 1Madrid, Spain; 2Hospital Doce de Octubre, Cardiology, Madrid,
Spain
Cardiac allograft vasculopathy (CAV) is the most frequent complication after heart
transplantation. Up to 58% of heart transplantation (HTx) recipients present significant
intimal thickening in IVUS 1 year later. However, coronary angiography
is still the gold standard for the diagnosis of cardiac CAV for which alternative
non-invasive diagnostic approaches are currently investigated. Two dimensional
strain (2D S) offers a technique for quantifying transmural gradient of function
across ischemic segments.
Aim: To analyse usefulness of 2D S analysis to identify CAV in segments with
normal contractility at rest.
Methods: 48 consecutive HTx recipients with normal contractility at rest (mean
age 55±18 years, 41 men, time post-HTx 86±62 months) scheduled for echocardiography
evaluation were included in the study. 16 presented CAV in angiography
and/or IVUS: 13 severe CAV and 3 moderate CAV. Longitudinal global 2D
S and strain rate (SR) were measured in 4, 2 and 3 chambers views. Sensitivity
(S), specificity (Sp) and area under the ROC curve (AUC) were analyzed for each
parameter
Results: Mean EF was 71±7%. HTx recipients with angiographic CAV showed
significantly lower longitudinal global S than those without CAV (-13.77±6%
vs -16.42±3%, p 0.001). No significant differences were found in SR values
(0.98±0.3 s -1 vs -1.06±0.3 s -1 , p = NS). The most sensitive parameter to identify
CAV by two dimensional strain was global longitudinal S (77%) but with low
specificity (59%): AUC 0, 65 using a cutoff value of -16.85%. If we analyse the
potential usefulness to identify severe CAV, S and SR were significantly lower in
CAV segments: S -13.77±6% vs -16.42±3%, p

diastolic velocity (-12.3±4.9 vs -15.8±5.4 cm/s, p