445

CARDIOVASCULAR MEDICINE

Cardiovascular, cerebrovascular, and respiratory

changes induced by different types of music in
musicians and non-musicians: the importance of
silence
L Bernardi, C Porta, P Sleight
...............................................................................................................................

Heart 2006;92:445–452. doi: 10.1136/hrt.2005.064600

Objective: To assess the potential clinical use, particularly in modulating stress, of changes in the
cardiovascular and respiratory systems induced by music, specifically tempo, rhythm, melodic structure,
pause, individual preference, habituation, order effect of presentation, and previous musical training.
Design: Measurement of cardiovascular and respiratory variables while patients listened to music.
Setting: University research laboratory for the study of cardiorespiratory autonomic function.
Patients: 12 practising musicians and 12 age matched controls.
Interventions: After a five minute baseline, presentation in random order of six different music styles (first for a
two minute, then for a four minute track), with a randomly inserted two minute pause, in either sequence.
See end of article for Main outcome measures: Breathing rate, ventilation, carbon dioxide, RR interval, blood pressure, mid-
authors’ affiliations cerebral artery flow velocity, and baroreflex.
.......................
Results: Ventilation, blood pressure, and heart rate increased and mid-cerebral artery flow velocity and
Correspondence to: baroreflex decreased with faster tempi and simpler rhythmic structures compared with baseline. No
Dr Luciano Bernardi, habituation effect was seen. The pause reduced heart rate, blood pressure, and minute ventilation, even
Clinica Medica 2,
Universita’ di Pavia, IRCCS below baseline. An order effect independent of style was evident for mid-cerebral artery flow velocity,
S Matteo, 27100 Pavia, indicating a progressive reduction with exposure to music, independent of style. Musicians had greater
Italy;lbern1ps@unipv.it respiratory sensitivity to the music tempo than did non-musicians.
Conclusions: Music induces an arousal effect, predominantly related to the tempo. Slow or meditative
Accepted 18 August 2005
Published Online First music can induce a relaxing effect; relaxation is particularly evident during a pause. Music, especially in
30 September 2005 trained subjects, may first concentrate attention during faster rhythms, then induce relaxation during
....................... pauses or slower rhythms.

M
usic now has an increasing role in several disparate reproducibility and habituation, as well as the non-specific
areas. Music can reduce stress and improve athletic effect of a random order of presentation.
performance, motor function in neurologically
impaired patients with stroke or parkinsonism, or milk METHODS
production in cattle.1–10 Subjects
Listening to music is a complex phenomenon, involving The protocol was approved by the local ethics committee; all
psychological, emotional, neurological, and cardiovascular subjects gave informed consent. We studied 24 healthy right
changes, with behavioural modifications of breathing.11 12 handed white subjects (mainly colleagues or medical
Non-musicians listen by using the non-dominant hemi- students; table 1). Twelve had no previous special training
sphere, whereas musicians (who are probably more atten- in music (non-musician group; table 1), whereas 12 were
tive) use the dominant hemisphere.13 These responses may be advanced conservatoire students or post-conservatoire diplo-
influenced by musical style (for example, classical versus mates, with at least seven years of continuous practice
rock), melody, harmonic structure, rhythm, and tempo but (musician group; table 1). The main instruments played were
also by verbal content—for example, the brain asymmetry violin (four), piano (three), flute (two), clarinet (one), trumpet
shown for language and melody perception has not been (one), and bass (one). Some had experience with other modern
found in rhythm perception.13 Heart rate, blood pressure, or instruments (electric guitar (two) and drums (one)).
respiration have been studied.1 14 15 So far, however, auto-
nomic, cardiovascular, and respiratory changes in response to Study protocol
such a large range of music, order of presentation, or the All tests were carried out in comfortable temperature,
effect of a short interpolated pause, and the responses related humidity, and light, with the subjects supine and wearing
to musical training have not been comprehensively com- headphones (keeping their eyes closed).18 The subjects
pared. Cardiorespiratory variables can be modified by avoided tapping with a finger or foot (to avoid artefactual
rhythmic repetition of a prayer or a yoga mantra or by entrainment), confirmed by continuous visual monitoring.19
recitation of poetry.16 17 We therefore investigated whether After subjects had a 20 minute period of quiet rest, we
listening to music has similar effects. continuously monitored heart rate (RR interval) from the
We investigated the responses to six types of music (with ECG (chest leads) and non-invasive beat to beat blood
differing rhythmic, harmonic, and melodic structures) in
musicians versus non-musicians. We measured cardiovascular, Abbreviations: HF, high frequency; LF, low frequency; TCD,
respiratory, and cerebrovascular variables and their short term transcranial Doppler

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446 Bernardi, Porta, Sleight

Table 1 Participants’ characteristics were calculated for each breath. Mean values for heart period
(RR interval) and systolic blood pressure were obtained, after
Musicians Non-musicians p Value discarding the first 30 seconds. Baroreflex sensitivity was
calculated from the same sequences of RR interval and
Number 12 12 NS
Men/women 5/7 7/5 NS systolic blood pressure by autoregressive power spectral
Age (years) 23 (1) 25 (1) NS analysis of the RR interval and systolic blood pressures (a
Weight (kg) 61.5 (3.9) 62.7 (2.3) NS index).21 This method is particularly well suited for relatively
Height (cm) 170.8 (2.5) 169.7 (2.1) NS
short term sequences (two or four minute).
BMI (kg/m2) 20.8 (0.7) 21.7 (0.5) NS
We evaluated sympathovagal balance by the ratio between
Data are mean (SEM). low (LF) (from 0.03 to 0.15 Hz) and high frequency (HF)
BMI, body mass index; NS, not significant. components (0.15 to 0.40 Hz) of heart rate variability.21 This
ratio reflects the sympathovagal balance only when the
respiratory oscillations remain in the HF band.22 To remove
pressure by applanation tonometry at the radial artery (Pilot any spurious LF due to slow respiration, we calculated the LF
model; Colin tonometry, San Antonio, Texas, USA). This and HF power of the respiratory signal and then removed
method faithfully tracks changes in invasive blood pressure.20 from the RR LF power the proportion of the LF due to
Mid-cerebral artery blood flow velocity was monitored by a respiration. Therefore, the LF:HF ratio was obtained by using
2 MHz transcranial Doppler (TCD) probe at a depth of 35– LF oscillations not directly influenced by respiration.
55 mm through the temporal window of the non-dominant
side (DWL, Sipplingen, Germany). Respiratory movements
Statistical analysis
were continuously evaluated by inductive plethysmography
Data are presented as mean (SEM). Analysis of variance for
expressed as a percentage of baseline values. In a steady state
mixed design/repeated measures on two factors tested the
the amplitude of this signal has excellent intrasubject
effects of different music types, of duration/repetition, for the
correlation with tidal volume recorded with a facial mask
two groups.23 By looking at different aspects, or by
or a mouthpiece and a pneumotachograph, but avoids the
recombining the data, we were able to obtain several types
respiratory modifications induced by such devices.12 End tidal
of information. We also evaluated the relation between each
carbon dioxide was monitored by a nasal cannula and side
variable and the tempi of the tracks by linear regression
stream capnography (COSMOplus, Novametrix, Wallingford,
analysis.
Connecticut, USA).
Baseline recordings were taken for five minutes. Then, in
random order with no intervening pauses, presentations of Effect of music style
two minute periods of (1) slow classical, (2) fast classical, (3) An exceedingly high number of potential factors can affect
dodecaphonic, (4) techno, (5) rap, and (6) raga music began. the cardiovascular response to music perception, so we chose
Table 2 shows details of these music tracks. to test the contribution of various factors by comparing
Then the tracks were repeated in a different random order different music styles (table 2): harmonic, melodic, or
but this time for four minutes. In addition, we recorded two rhythmic structure (non-syncopated versus syncopated) and
minutes of silence, randomly inserted into either the short or tempo (rhythm speed). We graded the tracks according to
long music sequences. Lastly we asked the subjects to rate each of these aspects to determine which characteristics were
their preferences for the six music tracks. important for the cardiovascular and respiratory responses.
To obtain a suitably long period of music with a stable Randomisation of order of presentation allowed independent
character and tempo, we chose periods with a steady unbiased assessment of these multiple factors.
orchestral or rhythmic line. Then we appended several
identical sequences together to maintain a two or four Effect of duration of the music and of repetition
minute melodic and harmonic continuity. As a test of reproducibility and habituation, we compared the
initial two minute sequence with the longer four minute
Data acquisition and analysis sequence, as well as the initial versus the final two minutes of
All signals were continuously acquired on a personal four minute tracks.
computer (Apple Macintosh G3, Cupertino, California,
USA) at a frequency of 600 samples/channel. Optical disk Non-specific effect of exposure to music
storage allowed further analysis. Breathing rate, relative tidal To identify any non-specific ‘‘order’’ effect we grouped all
volume, minute ventilation, and end tidal carbon dioxide data in terms of order of presentation (that is, regardless of

Table 2 Characteristics of music tracks

Tempo Harmonic Melodic Rhythmic
Style (beats/min)* structure structure structure Source

Raga 55 Modal Modal Minimal Debabrata Chaudhuri: introduction from ‘‘Raga Maru Behag’’,
from Sitar music meditations, Music for Pleasure Ltd, Feltham,
UK, 1967
Classical slow 70 Conventional
Conventional Present Ludwig van Beethoven: ‘‘Adagio molto e cantabile’’ from the
Ninth Symphony Op 125, 1823
Dodecaphonic 76 Absent Absent Absent Anton Webern: ‘‘Zart bewegt’’, from Pieces for orchestra Op 6,
1909
Rap 103 Semimodal Rudimentary Strong syncopated Red Hot Chili Peppers: ‘‘The power of equality’’ from Blood
Sugar Sex Magik Warner Bros, 1991
Techno 136 Conventional Rudimentary Strong, obsessive Gigi D’agostino: ‘‘You spin me round’’ from Tecno Fes, vol 2,
non-syncopated Noisemaker, 2000
Classical fast 150 Conventional Conventional Strong non- Antonio Vivaldi: ‘‘Presto’’ from ‘‘Estate’’, Concerto for Violin,
syncopated Orchestra, and Continuo no 2, Op 8, 1725

*Tempo is measured in beats/min, where 1 beat = 1 crotchet (quarter note);
conventional relates to the musical culture of white subjects.

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Cardiovascular and respiratory effects of music 447

Breathing frequency (breaths/min)

20 38
†††

End tidal CO2 (mm Hg)

††† †††

12 34
PAUSE CL. SLOW DODEC. RAP TECHNO CL. FAST PAUSE CL. SLOW DODEC. RAP TECHNO CL. FAST
BASELINE RAGA BASELINE RAGA

25 ††† 75 †††
†† ††† †††
†† ††
(% change from baseline)

TCD velocity (cm/s)

Minute ventilation

Baseline
(0%)

–12.5 65
PAUSE CL. SLOW DODEC. RAP TECHNO CL. FAST PAUSE CL. SLOW DODEC. RAP TECHNO CL. FAST
BASELINE RAGA BASELINE RAGA

Figure 1 Responses in breathing frequency, end tidal CO2, minute ventilation, and transcranial mid-cerebral Doppler (TCD) flow velocity for each
intervention. CL, classical; DODEC, dodecaphonic. *p , 0.05, **p , 0.01, ***p , 0.001 versus baseline;
p , 0.05,

p , 0.01,


p , 0.001
versus pause.

the type of music presented)—that is, we grouped all data by RESULTS

the first track, the second track, and so on. Effect of music styles
Figures 1 and 2 show the effects of different music styles.
Effect of music training Faster tempi induced significant increases in ventilation,
We compared musicians versus non-musicians. breathing rate, TCD, systolic and diastolic blood pressures,

135 75
Diastolic BP (mm Hg)
Systolic BP (mm Hg)

† †† ††
†
†

110 50
PAUSE CL. SLOW DODEC. RAP TECHNO CL. FAST PAUSE CL. SLOW DODEC. RAP TECHNO CL. FAST
BASELINE RAGA BASELINE RAGA
Baroreflex sensitivity (ms/mm Hg)

950 30
†
† †
††
†††
RR interval (ms)

†††

800 0
PAUSE CL. SLOW DODEC. RAP TECHNO CL. FAST PAUSE CL. SLOW DODEC. RAP TECHNO CL. FAST
BASELINE RAGA BASELINE RAGA

Figure 2 Responses in blood pressure (BP), interbeat period (RR interval), and baroreflex sensitivity for each intervention. The tracks are arranged in
order of increased tempo. *p , 0.05, **p , 0.01, ***p , 0.001 versus baseline;
p , 0.01,

p , 0.01,


p , 0.001 versus pause.

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448 Bernardi, Porta, Sleight

† Figure 3 Responses in low frequency

(LF) to high frequency (HF) ratio to
3 spectral analysis of heart rate variability
for each intervention.
†

†
LF:HF ratio

0
BASELINE PAUSE RAGA CL. SLOW DODEC. RAP TECHNO CL. FAST

and heart rate (RR interval), tended to reduce baroreflex fast. These results were not influenced by the music
sensitivity, and induced a progressive increase in the LF:HF preferences of the subjects. Table 3 shows that their
ratio (fig 3). No significant changes were seen in end tidal preferences for structured harmonic and melodic music were
carbon dioxide. In contrast, slower music had a proportion- independent of the tempo.
ally smaller effect and raga induced a significantly larger fall
in heart rate (increase in RR interval, p , 0.01), even Effect of repetition of music and reproducibility
compared with baseline or any other music tracks. Later repetition caused no significant overall difference
These effects appeared to depend on the speed of the music (analysis of variance) in response during any individual
rather than on the style. For example, classical and techno track, with the notable exception of TCD, which was notably
styles induced similar results when similarly fast; raga, and significantly (p , 0.001) lower on the second presenta-
classical, and dodecaphonic music, all similarly slow, reduced tion, even below baseline. Except for TCD, repetition of the
cardiorespiratory responses. music induced no other habituation even when listened to for
The breathing rate (fig 4), and the LF:HF ratio (fig 5) a longer period (four versus two minutes), and the same
increased significantly with increasing tempo. No other music style (in short versus longer tracks) induced nearly
aspects of the six music tracks appeared to be relevant. identical effects. Lastly, the effects of the first two minutes of
There ratio of tempo to breathing rate was 4.1 (0.3) for raga, a four minute track were not significantly different from the
4.7 (0.4) for classical slow, 5.2 (0.3) for dodecaphonic, 6.53 effects of the final two minutes or of the original two minute
(0.4) for rap, 8.0 (04) for techno, and 8.7 (0.6) for classical version (except for TCD; see above).

20 Figure 4 Relation between music

tempo and breathing frequency for
musicians (open circles with standard
error and dotted regression line) and
non-musicians (solid circles with
standard error and solid line).
Musicians had larger responses to
Breathing frequency (breaths/min)

tempo. NS, not significant.

Non-musicians: r = 0.15, p:ns

p < 0.05

Musicians: r = 0.35, p < 0.001

12 CL. SLOW TECHNO
PAUSE RAGA DODEC. RAP CL. FAST

0 50 100 150
Tempo (beats/min)

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Cardiovascular and respiratory effects of music 449

Figure 5 Relation between music

tempo and LF:HF ratio for musicians
(open circles with standard error and
dotted regression line) and non-
musicians (solid circles with standard
error and solid line). Musicians had
3 larger responses to tempo.

Non-musicians: r = 0.11, p:ns

LF:HF ratio

p < 0.01

Musicians: r = 0.42, p < 0.001

0 CL. SLOW TECHNO

PAUSE RAGA DODEC. RAP CL. FAST

0 50 100 150
Tempo (beats/min)

Non-specific effect of exposure to music (order effect) Effect of music training

When we recombined the entire dataset by order of There were no major differences between musicians and non-
presentation (first music track, second music track, and so musicians but the analysis of variance model showed both at
on) we observed (fig 6) a significant order effect, indepen- baseline and during listening that musicians had a signifi-
dent of music style. This overall effect was highly significant cantly lower respiratory rate (p , 0.05) and increased their
for TCD, which increased slightly at the beginning of the breathing rate more than non-musicians in response to
experiment and then progressively dropped below baseline. increasing tempi (fig 4). During the pause, they had a lower
Breathing rate and ventilation also increased initially at the respiratory rate and lower LF:HF ratios than non-musicians
beginning of the experiment, with subsequent inconsistent (figs 4 and 5). Table 3 shows that the order of music style
changes. Systolic and diastolic pressures and heart rate preferences was identical in the two groups of subjects. No
trends were similar to that of TCD; these did not reach other aspects of the music tracks induced differences in the
significance. No identifiable trends were seen in end tidal two groups.
carbon dioxide, baroreflex sensitivity, or LF:HF ratio.
DISCUSSION
Effect of a randomly inserted pause between music Main findings
tracks This study has discovered several novel features concerning
In contrast, the two minute rest randomly introduced into the effects of music on the autonomic control of breathing
the sequence of tracks was characterised by the lowest and circulation, which may have wider implications beyond
systolic and diastolic blood pressure, heart rate (longest RR cardiorespiratory regulation.
interval), and minute ventilation and (in musicians) An important order effect was seen in both musicians and
LF:HF ratio and by the highest end tidal carbon dioxide non-musicians, which, to our knowledge, has been pre-
(figs 1–5). viously neglected.
Passive listening to music accelerates breathing rate and
increases blood pressure, heart rate, and the LF:HF ratio
(thus suggesting sympathetic activation) proportional to the
Table 3 Musical preferences tempo and perhaps to the complexity of the rhythm. The
music style or a person’s music preference seems less
Musicians Non-musicians
important.
Order of Order of Musicians breathed faster with faster tempi and had
Score preference Score preference p Value
slower baseline breathing rates than non-musicians.
Classical fast 1.5 (0.2) 1 1.3 (0.2) 1 NS A randomly inserted short pause (two minutes) decreased
Classical slow 1.7 (0.2) 2 2.1 (0.3) 2 NS
blood pressure, minute ventilation, heart rate, and the LF:HF
Rap 3.3 (0.3) 3 3.7 (0.3) 3 NS
Raga 4.3 (0.3) 4 4.0 (0.3) 4 NS ratio in trained subjects. This relaxation effect was even
Techno 4.6 (0.3) 5 4.6 (0.5) 5 NS greater than that seen at the end of five minutes of quiet
Dodecaphonic 5.4 (0.2) 6 5.2 (0.3) 6 NS relaxation at baseline. There was no evidence of autonomic
habituation to any given music, except for cerebral blood
Data are mean (SEM).
flow, which progressively fell with time, regardless of the

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450 Bernardi, Porta, Sleight

Breathing frequency (breths/min)

17.6 38.0

End tidal CO2 (mm Hg)

14.0 35.2
Minute ventilation (% from baseline)

20 74

TCD velocity (cm/s)

Baseline
(0%)

–10 65

124.5 67

Diastolic BP (mm Hg)

Systolic BP (mm Hg)

114.5 58
Baroreflex sensitivity (ms/mm Hg)

930 32
RR interval (ms)

825 19
X1 X7 X14 X1 X7 X14
(Baseline) (Baseline)

Figure 6 Responses plotted by presentation order rather than music style. X1 is baseline and X2 to X14 are the serial responses to six music tracks
played twice plus one pause, all presented in random order. Note progressive trends related to order of presentation. *p , 0.05.

order of music presentation. These effects were consistent comparison with the pause.13 Owing to technical limitation,
during longer and shorter presentations of the same music. we could not assess hemispheric differences in our study.
At variance with the rest of the data, the TCD was However, such differences were small in quantitative terms.13
significantly reduced with progression of exposure to music Whether the effects observed in our study were secondary
(order effect). Under resting conditions cerebral blood flow is to respiratory entrainment or to a direct sympathetic
mainly responsive to the local metabolic demand. Thus, stimulation by arousal remains speculative.25 The ratio of
during long continuous exposure to music (fig 6) and tempo to respiratory rate was close to the music structure in
particularly during a pause (fig 1), a major drop in TCD the slowest (in raga and classical slow, about one breath for
velocity may reflect reduced metabolic demand, which is not four crotchets) and fastest tracks (in techno and classical
in contrast with previous findings of a selective increase in fast, one breath for eight crotchets), suggesting respiratory
cerebral blood flow in specific areas during listening to entrainment, but this was clearly absent in the intermediate
music.24 A previous study (during a short term comparison) rhythms. All variables were related to the tempo but not to
reported a slight increase in response to music in the right music preference. This suggests that perhaps both respiratory
hemisphere, which is essentially confirmed in our study, entrainment by music and direct arousal were coexistent and
particularly during more rhythmic tracks (fig 1) and in interrelated—in fact, the increase in breathing rate in itself

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Cardiovascular and respiratory effects of music 451

might have contributed to the increase in sympathetic health benefit) as a result of this controlled alternation
activity.26 between arousal and relaxation. It may be viewed as an
Thus, overall, we observed an arousal effect proportional to alternative technique of relaxation or meditation, without
the speed of the music, with slower rhythms inducing involving the active participation of the subject. Previous
relaxation. Even greater relaxation was induced by a training in music enhances the subject’s ability to respond to
randomly inserted two minute pause, suggesting that a music rhythm, since musicians learn to synchronise breath-
pause (or perhaps a slowing of music tempo) may be crucially ing with the music phrase. In conclusion, the present study
important in determining some of the relaxing effects of indicates that appropriate selection of music, by alternating
music. fast and slower rhythms and pauses, can be used to induce
One can speculate whether specific types of music are relaxation and reduce sympathetic activity and thus may be
potentially useful as a clinical tool to modulate breathing and potentially useful in the management of cardiovascular
sympathetic arousal. Classical Greek philosophers thought disease.
that music and sports were two fundamental aspects of
health.27 Newer studies emphasise the value of music in
lowering stress.2–4 Meditative or slow classical music can ACKNOWLEDGEMENTS
We gratefully acknowledge the technical assistance of Nicolò
lower neurohumoral markers of stress and thrombotic
Bernardi, Gaia Casucci, MD, Stefano Castoldi, Marianna Boso, MD,
activity at rest, in contrast to the increase found with Francesca Cantoni, and all the subjects who volunteered for the
physical exercise.1 14 28 study.

How does music resemble other relaxation techniques .....................

Previous studies suggested that meditative music decreased Authors’ affiliations
heart rate, blood pressure, and plasma catecholamines.1 Our L Bernardi, C Porta, Department of Internal Medicine, IRCCS S Matteo,
University of Pavia, Pavia, Italy
study confirmed these findings only partially. Slow medita-
P Sleight, Department of Cardiovascular Medicine, John Radcliffe
tive music increased the RR interval but had no significant Hospital, Oxford, UK
effect on respiration and blood pressure. Instead, our data
showed a consistent increase in all these variables (from Competing interests: none declared.
baseline or from the pause) with increasing speed of music.
To maintain a stable style of music we (and most previous
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IMAGES IN CARDIOLOGY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
doi: 10.1136/hrt.2005.069880
Percutaneous transluminal removal of intracardiac vegetations

A
59 year old man was hospitalised for clinical signs of (Cordis) was inserted from the right vena femoralis under
sepsis (methicillin resistant Staphylococcus aureus) with continuous transoesophageal guidance (panel B). For man-
two large bacterial vegetations adherent on his auto- oeuvring the 10 French catheter opening directly in front of
matic implantable cardioverter-defibrillator (AICD) lead in the vegetations, an 8 French Judkins right guiding catheter
the right atrium and superior vena cava (panel A). Eight was used. Using a 50 ml syringe the first vegetation was
weeks earlier, septic ulcers first appeared on both chronic successfully evacuated through the 10 French guiding
ischaemic legs (obstructive peripheral arterial disease) due to catheter. The second (larger) vegetation could only be
a 30 year history of insulin dependent diabetes mellitus evacuated into the tip of the guiding catheter. Through
(including diabetic nephropathy with chronic nephrodialysis continuous vigorous suction, the vegetation could be fixed
since five years previously). The AICD had been implanted 15 there and subsequently removed from the AICD lead by
months earlier, and two cardiac aortocoronary revascularisa- pulling retrogradely. For the final extirpation, a surgical
tion operations had been carried out two and nine years incision of the vena femoralis was done (panel C). The
earlier. infected AICD leads were successfully removed the next day.
Due to the remaining septic source on both ischaemic legs Thrombus with large amounts of fibrin and leucocytes with
which showed no improvement despite antibiotic treatment, basophilic sediment (as a sign of bacterial invasion) were
concerns over the disturbed secondary wound healing, as observed histologically. After the source of the sepsis was
well as the past history of two cardiac revascularisations, the removed, the patient improved dramatically and became
cardiac surgeon refused to extirpate the two vegetations afebrile and aseptic during the following days. For treatment
surgically. The decision for the first percutaneous vegetect- of the secondary source of infection (ischaemic leg ulcers)
omy was made. percutaneous Excimer laser assisted angioplasty was success-
In order to prevent a major pulmonary embolism, an fully carried out subsequently.
Antheor vena cava filter (MediTech, Boston Scientific/ J B Dahm
Scimed, Inc) was inserted into the main pulmonary artery P Hinz
(panel B). For percutaneous extirpation of the two large D Vogelgesang
vegetations, a 10 French multipurpose guiding catheter dahm@mail.uni-greifswald.de

(A) Transversal transoesophageal echocardiography of one of the two vegetations adherent on the AICD lead (arrow) in the right atrium. (B) Posterior
anterior x ray showing the 10 French guiding catheter in the right atrium (black arrow) and the cava filter in the main pulmonary artery (white arrow).
(C) Extirpated vegetation (4.5 6 2.0 cm).

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