Loewe C.,Medical University of Vienna |
Stadler A.,Vienna University Hospital
Journal of Thoracic Imaging | Year: 2014
The need for functional estimation of the relevance of stenosis to guide appropriate treatment in coronary artery disease has recently been shown. Invasive coronary angiography (CA) with invasive measurement of the pressure gradient in patients with coronary stenoses becomes the method of choice for treatment decision-making in invasive cardiology. Coronary computed tomography angiography (CCTA) was established several years ago as a noninvasive alternative to invasive CA; it is used primarily to exclude coronary artery disease and has shown a very high negative predictive value in this regard. During the last several years, in an effort to obtain functional information, CCTA has received much attention. The rationale for this is that with the functional information provided by CT, the positive predictive value for "relevant" stenoses should be improved. In this article, the history and limitations of anatomic grading of coronary stenoses will be discussed. Furthermore, shifts in the treatment paradigm in modern cardiology will be introduced, as well as an overview of the currently used invasive methods to assess the "relevance" of stenosis. The current role and still-existing limitations of CCTA, as well as the systematic problems in comparing CA and CCTA, are addressed. As CCTA is a highly innovative technique, new innovations are currently under clinical evaluation, including myocardial perfusion imaging, attenuation gradient measurement, and assessment of fractional flow reserve with CT. This review article will mainly focus on the technical background of these techniques and the status of their clinical implementation and will attempt to provide some suppositions about the possible future role of these new innovations. © 2014 by Lippincott Williams & Wilkins.
Druml W.,Vienna University Hospital
Current Opinion in Critical Care | Year: 2014
Purpose of review Acute kidney injury (AKI) is a frequent and serious event associated with a high rate of complications, with an increased risk of progression to multiple organ dysfunction and excessive 'attributable' mortality. AKI affects all physiologic functions and organ systems with interrelated mechanisms, including the 'classical' consequences of the uremic state, the inflammatory nature of AKI per se and resulting systemic effects, the modulating effect of AKI in the presence of an (inflammatory) underlying disease process and the multiple untoward effects induced by renal replacement therapy (RRT) and anticoagulation. Recent findings A rapidly increasing body of evidence is clarifying these systemic effects that are the reflection of a broad common pathology that ultimately results in an 'augmented' inflammation and impairment of immunocompetence. This includes the release of cytokines and inflammatory mediators, increase in oxidative stress, activation of various immune cells, neutrophil extravasation, generalized endothelial injury, increased vascular permeability and tissue oedema formation. Summary These systemic phenomena associated with AKI induce distant organ injury affecting all organ systems with clinically the most relevant effects being exerted on the lungs, the intestines and liver and the heart and predispose the progression to multiple organ dysfunction syndrome and death. Currently available renal replacement therapy modalities are incapable of compensating for these systemic consequences of AKI. © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins.
Rand T.,Vienna University Hospital |
Uberoi R.,John Radcliffe Hospital
CardioVascular and Interventional Radiology | Year: 2013
Treatment of infrapopliteal arteries has developed to a standard technique during the past two decades. With the introduction of innovative devices, a variety of techniques has been created and is still under investigation. Treatment options range from plain balloon angioplasty (POBA), all sorts of stent applications, such as bare metal, balloon expanding, self-expanding, coated and drug-eluting stents, and bio-absorbable stents, to latest developments, such as drug-eluting balloons. Regarding the scientific background, several prospective, randomized studies with relevant numbers of patients have been (or will be) published that are Level I evidence. In contrast to older studies, which primarily were based mostly on numeric parameters, such as diameters or residual stenoses, more recent study concepts focus increasingly on clinical features, such as amputation rate improvement or changes of clinical stages and quality of life standards. Although it is still not decided, which of the individual techniques might be the best one, we can definitely conclude that whatever treatment of infrapopliteal arteries will be used it is of substantial benefit for the patient. Therefore, the goal of this review is to give an overview about the current developments and techniques for the treatment of infrapopliteal arteries, to present clinical and technical results, to weigh individual techniques, and to discuss the recent developments. © 2012 Springer Science+Business Media New York and the Cardiovascular and Interventional Radiological Society of Europe (CIRSE).
Schwarz C.,Vienna University Hospital
Transplantation | Year: 2016
BACKGROUND: Allogeneic hematopoietic stem cell transplantation (HSCT) can lead to donor-specific tolerance. Patients reported in the literature that underwent kidney transplantation (KT) after a previous HSCT from the same haploidentical donor typically received short-term immunosuppression, mainly for safety reasons and concerns of triggering graft-versus-host disease. METHODS: We describe the case of a 22-year-old patient who developed chronic kidney failure after receiving haploidentical HSCT from his father for the treatment of metastatic rhabdomyosarcoma. Five years after HSCT, he received a preemptive kidney transplant from his father. Steroid treatment, which had been prescribed for the underlying kidney disease, was withdrawn within 2 months posttransplant, and no de novo immunosuppression was given. Donor-specific tolerance was assessed with mixed lymphocyte reaction and INF-γ ELISPOT before (D0) and after KT (D9). Furthermore, the exact level of donor-derived T cells was measured with real-time polymerase chain reaction before and 1 year after KT. RESULTS: In vitro assays (mixed lymphocyte reaction and ELISPOT) revealed donor-specific tolerance before and after transplantation, respectively. The number of recipient-derived T cells was low before KT and virtually did not change over time (0.0139% ± 0.0039 and 0.0120% ± 0.0067; P = NS). Graft function was excellent throughout the follow-up (36 months post KT: serum creatinine, 1.18 mg/dL). Protocol biopsies performed 1 and 12 months after transplantation confirmed the absence of rejection. CONCLUSIONS: This is one of the first cases of kidney transplantation from the same donor after previous haploidentical HSCT with a corticosteroid taper alone. Our results suggest that immunosuppression can be avoided in such cases. Copyright © 2016 Wolters Kluwer Health, Inc. All rights reserved.
Adams D.H.,Mount Sinai School of Medicine |
Rosenhek R.,Vienna University Hospital |
Falk V.,University of Zurich
European Heart Journal | Year: 2010
Degenerative mitral valve disease often leads to leaflet prolapse due to chordal elongation or rupture, and resulting in mitral valve regurgitation. Guideline referral for surgical intervention centres primarily on symptoms and ventricular dysfunction. The recommended treatment for degenerative mitral valve disease is mitral valve reconstruction, as opposed to valve replacement with a bioprosthetic or mechanical valve, because valve repair is associated with improved event free survival. Recent studies have documented a significant number of patients are not referred in a timely fashion according to established guidelines, and when they are subjected to surgery, an alarming number of patients continue to undergo mitral valve replacement. The debate around appropriate timing of intervention for asymptomatic severe mitral valve regurgitation has put additional emphasis on targeted surgeon referral and the need to ensure a very high rate of mitral valve repair, particularly in the non-elderly population. Current clinical practice remains suboptimal for many patients, and this review explores the need for a 'best practice revolution' in the field of degenerative mitral valve regurgitation. © The Author 2010.