Herz
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I. The actual data base on the decision-making process of indication for revascularization reveals that angiographic severity of coronary artery disease (CAD) is the primary determinant of referral to coronary interventional procedures. Several recent studies demonstrated that after an acute myocardial infarction, women undergo cardiac catheterization to a lesser extent than men. ⋯ After multivariate analysis, female gender was no independent risk factor of increased mortality. Thus, direct (primary) coronary angiography and PCI eliminate significant gender-specific differences in survival early after acute myocardial infarction. Long-term follow-up (4 years) also revealed no sex-related differences in mortality and cardiac morbidity after direct (primary) PCI for acute ST elevation myocardial infarction.
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The diagnosis of pulmonary hypertension is easy during routine evaluation of patients with chronic heart failure by means of Doppler echocardiography. However, one must remember that an accurate hemodynamic characterization of the pulmonary circulation requires right heart catheterization to measure pulmonary vascular resistance and, if necessary, to test the reversibility of pulmonary hypertension. In addition, the importance of combining the right heart hemodynamic variables with a functional evaluation of the right ventricle is emphasized: in fact, the clinical impact of pulmonary hypertension in advanced heart failure patients (in terms of both exercise intolerance and prognosis) seems to be modulated by right ventricular function.
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With the development of effective drug treatment in the last 2 decades, lung transplantation has become the final option in the management of pulmonary arterial hypertension (PAH). Its main advantage is the curative aspect with recovery of cardiopulmonary capacity. Scarcity of donor organs and chronic graft rejection, however, remain serious limitations to short- and long-term success, and emphasize the need for judicial patient selection. Timely presentation of the patient to the transplant center is of critical importance. ⋯ Thoracic transplantation has become a feasible therapeutic option in terminal PAH patients. Judicious patient selection, choice and timing of procedure are critical to a successful outcome.
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Surgical embolectomy for massive pulmonary embolism (PE) has become a rare procedure. Often, it is viewed as a last-chance option for patients undergoing cardiopulmonary resuscitation after massive PE. Thus thrombolytic therapy has become the treatment of choice. ⋯ These encouraging results have been confirmed by the authors and others in patients with stable systemic hemodynamics but moderate to severe right ventricular dysfunction. The more widespread use of surgical embolectomy seems warranted. A randomized, controlled trial is overdue to determine the benefits of this therapy in stable patients compared with thrombolytic therapy if "best-practice" therapy is to be achieved for the patients' benefit.
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Echocardiography is an important tool for diagnosis and risk assessment in patients with infective endocarditis. In addition to the identification of typical vegetations, echocardiography is crucial for the evaluation of valvar regurgitations, and the early diagnosis of complications. Transesophageal echocardiography is, in nearly every aspect, except with concern to right-sided endocarditis, superior to the transthoracic approach. Thus, transesophageal echocardiography represents, in patients with substantial clinical suspicion for an active infection of endocardial structures, the currently most sensitive diagnostic tool.