Introduction. Left ventricular outflow obstruction might be part of the pathophysiological mechanism of Tako-tsubo cardiomyopathy. This obstruction can be masked by Tako-tsubo cardiomyopathy and diagnosed only by followup. Case Presentation. A 70-year-old female presented with Tako-tsubo cardiomyopathy and masked obstructive hypertrophic cardiomyopathy at presentation. Conclusion. Tako-tsubo cardiomyopathy typically presents like an acute MI and is characterized by severe, but transient, regional left ventricular systolic dysfunction. Prompt evaluation of the coronary status is, therefore, mandatory. The prognosis under medical treatment of heart failure symptoms and watchful waiting is favourable. Previous studies showed that LVOT obstruction might be part of the pathophysiological mechanism of TCM. This paper supports this theory. However, TCM may also mask any preexisting LVOT obstruction.

Background Pulmonary vein isolation is the cornerstone of catheter ablation in patients with atrial fibrillation (AF). However, with advanced left atrial (LA) structural changes, additional targeted catheter ablation of low‐voltage zones (LVZs) has produced favorable results. Therefore, with the advent of single‐shot techniques, it would be helpful to predict the presence of LVZs before an ablation procedure. Objective We hypothesized that computed tomography (CT)‐derived left atrial volume index (LAVI), in combination with other objective parameters, could be used to develop a score able to predict the presence of LVZs. Methods In a large cohort of patients undergoing their first AF ablations, comprehensive echocardiographic evaluations and cardiac CT were performed. During the electrophysiological studies, LA geometry and electroanatomic voltage maps were created. LVZs were defined as areas ≥1 cm2 with bipolar peak‐to‐peak voltage amplitudes ≤0.5 mV. Results In a derivation cohort of 374 patients, predictors of LVZs were identified by regression analysis and used to build the Zentralklinik Bad Berka and University of L'Aquila (ZAQ) score (age ≥65 years; female sex; and CT‐LAVI ≥57 mL/m2). The ZAQ score of 2 points accurately identified the presence and the extent of LVZs (area under the curve [AUC], 0.809; 95% confidence interval [CI], 0.758‐0.861; P < .001 and 3 [interquartile range, IQR, 1.5‐4.5] vs 7 cm2 [IQR 4‐9]; P = .001). In a validation cohort of 103 patients, the predictive value of the score was confirmed (AUC, 0.793; 95% CI, 0.709‐0.878; P < .001 and 4 [IQR, 2‐7] vs 11.5 cm2 [IQR, 8‐16.5]; P = .001). Conclusions The ZAQ score identifies LVZs and may be useful for planning the ablation strategy ahead of time.

Background. Little research has been conducted to explore the postoperative outcomes of obese patients after transfemoral transcatheter aortic valve replacement (TF-TAVR). Objective. We investigated the influence of body mass index (BMI) on 1-year outcomes after TF-TAVR. Methods. We included retrospectively 1609 high- and intermediate-risk TAVR patients (mean EuroSCORE II 21 ± 11) operated under general anesthesia between March 2014 and March 2018 in central hospital, Bad Berka, Germany. We stratified the patients according to BMI. Results. Our demographic data analysis showed 41% of patients were male and the mean age was 78 (range, 61–92 years). According to the WHO classification, 33% patients had normal weight, 42% were defined as overweight, and 22% were obese. Obese patients showed statistically significant difference in their clinical parameters as having higher incidence of hypertension, diabetes mellitus, pulmonary hypertension, and chronic obstructive pulmonary disease; on the contrary, obese patients were found to be younger than others. We found no differences in valve types and sizes among the different BMI categories. Our mortality rate during the 1-year follow-up period was 17.8% (287 patients). Mortality was significantly higher in patients with BMI < 25 kg/m2 (1 year mortality 149 patients 28.2% in patients with BMI < 25 kg/m2 vs. 138 patients 12.6% in patients with BMI ≥ 25 kg/m2; P=0.0001). Even after considering the confounding risk factors, BMI ≥ 25 kg/m2 was independently associated with reduced 1 year mortality (odds ratio (OR): 0.36, 95% confidence interval (CI): 0.21–0.6; P=0.01) in multivariate logistic regression analysis. The rate of vascular complication was higher in patients with BMI ≥ 25 kg/m2. However, the rate of blood transfusion was higher in patients with BMI < 25 kg/m2. All other serious complications occurred with equal distribution in both groups. Conclusion. In our single-center study, BMI ≥ 25 kg/m2 was independently associated with lower 1 year mortality after TF-TAVR.

Hypertrophic cardiomyopathy is the most common genetic disease of the heart. We report a rare case of hypertrophic obstructive cardiomyopathy mimicking an acute anterior myocardial infarction associated with sudden cardiac death. The patient presented with acute ST elevation myocardial infarction and significant elevation of cardiac enzymes. Cardiac catheterization showed some atherosclerotic coronary artery disease, without significant stenosis. Echocardiography showed left ventricular hypertrophy with a left ventricular outflow tract obstruction; the pressure gradient at rest was 20 mmHg and became severe with the Valsalva maneuver (100 mmHg). There was no family history of sudden cardiac death. Six days later, the patient suffered a syncope on his way to magnetic resonance imaging. He was successfully resuscitated by ventricular fibrillation.

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AimsShock coil interaction in patients with multiple implantable cardioverter defibrillator (ICD) leads is occasionally observed. We aimed to evaluate the incidence of shock coil interaction and its clinical relevance.Methods and resultsAll ICD patients (646 patients) who came to follow up control in our ICD ambulance between January 1, 2011, and December 31, 2011 in the department of cardiology in Bad Berka hospital were retrospectively evaluated in this study. All baseline demographic, clinical, and procedural characteristics and postoperative chest x ray in postero-anterior and lateral view as well as clinical and ICD follow up data were evaluated.Among 646 patients 42 had multiple ICD leads (6.5%) of whom 36 patients (5.5% of total cohort patients and 85.7% of patients with multiple ICD leads) had shock coil interaction and presented the study group (Group I). The control group (Group II) consisted of 610 patients without coil-coil interaction including patients with single shock lead (604 patients) or patients with multiple leads but without interaction between shock coils (6 patients).Inappropriate anti-tachycardia therapies and RV lead revisions were more frequent in patients with interaction between shock coils (Group I vs Group II: 27.7% and 5.7%; p = 0.049 and 30.6% vs 6.4; p = 0.0001, respectively).ConclusionsInteraction between shock coils may be one of possible causes of lead failure and resulted in inappropriate therapies and subsequent lead revision.

Purposewe compared between patients with low gradient (LG) and high gradient (HG) severe aortic stenosis (AS) as regard the burden of aortic valve calcium (AVC) using different methodologies. Moreover, we evaluated the accuracy of published thresholds for the diagnosis of severe AS in both groups. Methodswe measured the calcium volume and score using Agatston methodology in non-contrast (n-c) CT and with modified and fixed 850 Hounsfield unit (HU) thresholds in contrast enhanced (ce) CT. ResultsThe medians (IQR) of Agatston score, score with 850 HU and modified thresholds were 1288 AU (750-1815), 101 (65-256), 701 (239-1632), respectively. The calcium volume in ceCT using fixed 850 HU thresholds is significantly lower than the assessed volume in ncCT or in ceCT using modifiable threshold. LG patients were more obese; BMI 31.2 (29.1-35.1) vs 27.6 (26-31) and presented more with coronary artery disease (71.4% vs 40%). AF was documented in 42% in LG-patients vs 30% in HG patients. LVEF was severely depressed (less than 30%) in 28.6% in LG-patients. LG patients were more symptomatic (NYHA ≥ III in 71.4% patients vs 42%).The LG patients had smaller anatomy: annulus diameter 23.5mm (21.5-27) vs 25mm (23-25.5), LVOT diameter 23mm (20-20) vs 25mm (23-26.7mm). The annulus geometry was more eccentric; eccentric index 0.23 (0.19-0.27) vs 0.11 (0.1-0.2). Agatston score and calcium volume were lower in patients with LG; 1641AU (1292-1990) vs 928AU (572-1284) and 1537mm³ (644-1860) vs 286mm³ (160-700), respectively. Only 20% of patients with LG had Agatston score less than the previously supposed AVC score threshold for the diagnosis of severe AS (>2000AU in men and >1200 in women). The elimination of ncCT from the protocol reduced significantly the radiation dose by 400.3 ± 140 mGy*cm and 2.4 ± 2.8mSv.ConclusionThe diagnosis of severe LGAS should not depend on a single parameter as calcium score. The measurement of calcium score in contrast CT underestimate the calcium load significantly.

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