Aims  Myocardial fibrosis (MF) might represent a key player in pathophysiology of heart failure in aortic stenosis (AS). We aimed to assess its impact on left ventricular (LV) remodelling, recovery, and mortality after transcatheter aortic valve implantation (TAVI) in different AS subtypes. Methods and results  One hundred patients with severe AS were prospectively characterized clinically and echocardiographically at baseline (BL), 6 months, 1 year, and 2 years following TAVI. Left ventricular biopsies were harvested after valve deployment. Myocardial fibrosis was assessed after Masson’s trichrome staining, and fibrotic area was calculated as percentage of total tissue area. Patients were stratified according to MF above (MF+) or below (MF−) median percentage MF (≥11% or <11%). Myocardial fibrosis burden differed significantly between AS subtypes, with highest levels in low ejection fraction (EF), low-gradient AS and lowest levels in normal EF, high-gradient AS (29.5 ± 26.4% vs. 13.5 ± 16.1%, P = 0.003). In the entire cohort, MF+ was significantly associated with poorer LV function, higher extent of pathological LV remodelling, and more pronounced clinical heart failure at BL. After TAVI, MF+ was associated with a delay in normalization of LV geometry and function but not per se with absence of reverse remodelling and clinical improvement. However, 22 patients died during follow-up (mean, 11 months), and 14 deaths were classified as cardiovascular (CV) (n = 9 arrhythmia-associated). Importantly, 13 of 14 CV deaths occurred in MF+ patients (CV mortality 26.5% in MF+ vs. 2% in MF− patients, P = 0.0003). Multivariate analysis identified MF+ as independent predictor of CV mortality [hazard ratio (HR) 27.4 (2.0–369), P = 0.01]. Conclusion  Histological MF is associated with AS-related pathological LV remodelling and independently predicts CV mortality after TAVI.

Background Second victims, defined as healthcare team members being traumatised by an unanticipated clinical event or outcome, are frequent in healthcare. Evidence of this phenomenon in Germany, however, is sparse. Recently, we reported the first construction and validation of a German questionnaire. This study aimed to understand this phenomenon better in a sample of young (<= 35 years) German physicians. Methods The electronic questionnaire (SeViD-I survey) was administered for 6 weeks to a sample of young physicians in training for internal medicine or a subspecialty. All physicians were members of the German Society of Internal Medicine. The questionnaire had three domains - general experience, symptoms, and support strategies - comprising 46 items. Binary logistic regression models were applied to study the influence of various independent factors on the risk of becoming a second victim, the magnitude of symptoms and the time to self-perceived recovery. Results The response rate was 18% (555/3047). 65% of the participants were female, the mean age was 32 years. 59% experienced second victim incidents in their career so far and 35% during the past 12 months. Events with patient harm and unexpected patient deaths or suicides were the most frequent key incidents. 12% of the participants reported that their self-perceived time to full recovery was more than 1 year or have never recovered. Being female was a risk factor for being a second victim (odds ratio (OR) 2.5) and experiencing a high symptom load (OR 2). Working in acute care was promoting a shorter duration to self-perceived recovery (OR 0.5). Support measures with an exceptionally high approval among second victims were the possibility to discuss emotional and ethical issues, prompt debriefing/crisis intervention after the incident and a safe opportunity to contribute insights to prevent similar events in the future. Conclusion The second victim phenomenon is frequent among young German physicians in internal medicine. In general, these traumatic events have a potentially high impact on physician health and the care they deliver. A better understanding of second victim traumatisations in Germany and broad implementation of effective support programs are warranted.

URL: https//www.clinicaltrials.gov. Unique Identifier: NCT: 01959451.

Zusammenfassung Hintergrund Die Zeit der ärztlichen Weiterbildung ist der Grundstein für die Karriereentwicklung junger Internisten und für die Aufrechthaltung einer hochwertigen ärztlichen Versorgung. Bereits 2014 haben die Nachwuchsgruppen der Deutschen Gesellschaft für Innere Medizin (DGIM) und des Berufsverbandes Deutscher Internisten (BDI) eine Befragung ihrer jungen Mitglieder durchgeführt und wesentliche Konfliktfelder beschrieben. Mit dieser überarbeiteten Folgeuntersuchung soll ein aktualisiertes Abbild der Konflikte im Arbeitsleben junger Ärzte erstellt und eine Verlaufsbeurteilung ermöglicht werden. Ein neuer Schwerpunkt ist das Spannungsfeld von Beruf und Familie. Methoden Ende 2016 wurde eine webbasierte Befragung aller bei DGIM und BDI organisierten Weiterbildungsassistenten durchgeführt. Dafür wurde der Fragebogen von 2014 modifiziert und um Items zur Untersuchung des Spannungsfeldes von Familie und Beruf ergänzt. Zusätzlich wurde erneut das Modell beruflicher Gratifikationskrisen eingesetzt. Ergebnisse Insgesamt konnten 1587 Fragebögen ausgewertet werden. Im Vergleich zu 2014 ergeben sich keine wesentlichen Änderungen. Die psychosoziale Arbeitsbelastung unter den Teilnehmern ist weiterhin sehr hoch. Ein strukturiertes Weiterbildungscurriculum und qualitativ hochwertige Weiterbildungsgespräche sind mit einer geringeren Ausprägung psychosozialer Arbeitsbelastung und einer höheren Zufriedenheit im Beruf assoziiert. Die Vereinbarkeit von Beruf und Familie wird von der Mehrheit der Teilnehmer mit Kind(ern) als unzureichend empfunden. Das betrifft insbesondere Frauen. Schlussfolgerung Auf Basis dieser Befragung bestehen weiterhin gravierende und System-relevante Belastungen im Arbeitsleben junger Ärzte in internistischer Weiterbildung, die Anpassungen der Arbeits- und Weiterbildungsbedingungen dringlich erfordern. Insbesondere das Potenzial von Frauen in der Medizin muss über eine bessere Vereinbarkeit von Familie und Beruf in Zukunft stärker genutzt werden.

Aortic stenosis (AS) is the most frequently observed valvular heart disease. During the symptomatic stage, the rate of death increases dramatically, so that a precise diagnostic approach is taken to guide therapeutic options. Of patients with severe AS, 30% to 50% present with lowflow/low-gradient AS (LF/LGAS) status. This review focuses on LF/LGAS and the best diagnostic and therapeutic management in either classic LF/LGAS with reduced left ventricular ejection fraction (LVEF) or paradoxical LF/LGAS with preserved LVEF. Current literature demonstrates that in classic LF/LGAS it is crucial to rule out a pseudo-severe AS, because reduced LVEF may result in an incomplete opening of the valve. This can be done by low-dose dobutamine stress echocardiography. Classic LF/LGAS has poor clinical outcomes when managed conservatively; therefore, surgical or interventional aortic valve replacement should be performed. In paradoxical LF/LGAS, the LVEF is preserved (>50%), but impaired filling of the concentric hypertrophied ventricle leads to reduced stroke volume. Therefore, diagnostic and therapeutic decisions in paradoxical LF/LGAS are even more challenging. It is a heterogeneous disease entity, and it is crucial to rule out any diagnostic errors because numerous potential confounders might lead to misdiagnosis. As in classic stenosis, pseudo-severe stenosis must be ruled out as well. Evaluation via multidetector computed tomography or transesophageal echocardiography can help to evaluate the morphologic alterations of the valve (eg, calcification). Further studies are necessary to understand this disease entity and to evaluate the optimal diagnostic and therapeutic approach for these patients.