Alexander Lind

Endovascular stent-graft placement for acute and contained rupture of the descending thoracic aorta

Objectives: To identify determinants of postinterventional death after endovascular stent‐graft placement for acute rupture of the descending thoracic aorta, an emerging therapeutic modality for this highly life‐threatening condition. Methods: Between July 1999 and November 2004, 17 patients (14 males; mean age, 65 ± 16 (25–83) years) underwent stent‐graft repair of the descending thoracic aorta for acute rupture from a thoracic aneurysm (TAA, n = 6), acute aortic dissection (AAD, n = 6), penetrating aortic ulcer (PAU, n = 3), or blunt chest trauma (n = 2). Immediate, 30‐day, 1‐year, and 3‐year mortality was assessed. Twenty‐one clinical and procedural variables were evaluated in a post‐hoc analysis regarding their influence on mortality. Of these, four preprocedural factors with the greatest impact were used to construct a rupture score with a scale from 0 (no adverse prognostic factors present) to 4 (all four adverse factors present). Results: Stent‐graft placement was technically feasible in all patients. Complete exclusion of the ruptured aortic pathology could be achieved in only 11 (65%) patients, despite implantation of 1.6 ± 0.9 stent‐grafts per patient, with a median length of 130 mm. There was one procedure‐related early complication (bleeding at the access site). One patient died immediately following the procedure because of progressive mediastinal hematoma, although the rupture site was effectively sealed. Overall survival rates were (76.5 ± 10.3)% at 30 days and (52.9 ± 12.1)% at 1 year and remained at (52.9 ± 12.1)% at 3 years. The four most important preprocedural denominators of death were (1) TAA or AAD as the underlying etiology of aortic rupture (P = 0.024), (2) maximum aortic diameter >5 cm (P = 0.024), (3) presence of mediastinal hematoma (P = 0.056), and (4) an estimated lesion length requiring >1 stent‐graft to be covered (P = 0.009). Furthermore, residual leakage at the conclusion of the procedure (P = 0.009), postprocedural need for dialysis (P = 0.004), and prolonged ventilation (P = 0.043) were significantly associated with postprocedural death. Using a threshold of ≥3, the rupture score constructed on the basis of the four preprocedural denominators of death was found to be well suited to discriminate postprocedural death (1‐year survival: (20.0 ± 12.7)% in patients with a rupture score ≥3 vs. 100% in patients with a rupture score <3, P = 0.001). Conclusion: Endovascular stent‐graft placement in patients with acute aortic rupture was technically feasible, albeit still associated with high mortality. A simple risk score constructed in retrospect, on the basis of preprocedural prognostic factors, appeared to provide a useful separation of candidates who are likely to benefit from a straightforward endovascular procedure and should be tested prospectively in future studies.

Comparison of Collagen-Based Vascular Closure Devices in Patients With vs. Without Severe Peripheral Artery Disease

Purpose To compare complication rates of a collagen-based vascular closure device (VCD) in patients with vs. without significant peripheral artery disease (PAD). Methods A total of 382 patients (268 men; mean age 64.6±10.8 years) undergoing either an endovascular procedure of the lower limb (PAD group, n=132) or a percutaneous coronary intervention (PCI group, n=250) via a common femoral artery access were enrolled in this prospective study if hemostasis was achieved using the collagen-based Angio-Seal. In the PCI group, significant PAD was excluded by measurement of the ankle-brachial index. Inhospital major complications (bleeding, large hematoma, pseudoaneurysm, vessel occlusion, dissection) were recorded. Results Similar and low rates of major complications were observed in both arms of the study: 2 (1.5%) major complications in the PAD group and 3 (1.2%) in the PCI group (p=1.0). There was no significant difference in efficacy of the VCDs in the groups (PAD group 99.2% vs. 100% in PCI group, p=0.35). Conclusion Our study shows no significant differences in the rate of major complications after utilization of a collagen-based VCD for femoral artery access site closure in patients with severe lower limb PAD compared to those without; however, complications in the PAD group tended to be more severe, with the need for surgical repair.

Rapid Progression of Discrete Type A Intramural Hematoma: Prevention of a “Procedure-Related” Complication by Intraoperative Transesophageal Echocardiography

Purpose: To report a case illustrating the utility of transesophageal echocardiography (TEE) before planned stent-graft placement for chronic type B aortic dissection. Case Report: A 64-year-old man with acute aortic syndrome and an 8-year-old interposition graft in the distal aortic arch for acute type B dissection was referred for dissection of the descending thoracic aorta down to the aortic bifurcation; the false lumen was dilated to 65 mm and was partially thrombosed. The ascending aorta showed discrete, eccentric, 4-mm wall thickening that was not considered clinically significant. Stent-graft closure of the entry tear in the proximal descending thoracic aorta was elected. However, as the endovascular procedure was about to commence, TEE showed striking eccentric thickening of the aortic wall of up to 18 mm. The endovascular procedure was stopped, as it was decided to urgently replace the ascending aorta. The next day, the patient underwent successful ascending aortic replacement and simultaneous antegrade stent-graft implantation over the descending thoracic aortic entry tear via the open aortic arch. The postoperative course was uncomplicated, and the patient was discharged 19 days after surgery. He remains well at 6 months after the procedure. Conclusions: Our case demonstrates that dissection of the ascending aorta may occur not only due to endograft-induced intimal injury, but may also occur due to underlying but undiagnosed or underestimated disease of the ascending aorta or arch. Besides procedural guidance, intraoperative TEE is a useful tool to detect such disease to avoid subsequent “procedure-related” complications.

Transfemoral transcatheter aortic valve implantation in patients with end-stage renal disease and kidney transplant recipients

Transcatheter aortic valve implantation (TAVI) has evolved to a treatment of choice in high-risk patients and is therefore ideal for patients with advanced chronic kidney disease, as patients with end-stage renal disease and kidney transplant recipients. Especially, outcome of this special patient group is very important. 22 patients with chronic kidney disease stage 5 undergoing intermittent hemodialysis treatment (CKD 5D) and 8 kidney transplant recipients (KT) with severe aortic valve stenosis underwent transfemoral TAVI. TAVI was successfully performed in all patients. Postinterventional acute kidney injury (AKI) occurred in four kidney transplant recipients (KDIGO grade 1: n = 3, grade 3: n = 1) but creatinine/eGFR returned to baseline values in all patients. Short-term (30-day) mortality was 3% (1 patient in CKD 5D group). KT had a higher 2-year mortality than CKD5D patients (31% vs. 53%; p = 0.309), and cause of death was non-cardiac because of sepsis in all cases. The amount of contrast medium during TAVI was not associated with the development of acute kidney injury. TAVI is feasible in patients with CKD5D and in KT. Postinterventional AKI in these patients is often mild and does not impact renal function at day 30, while infection/ sepsis is the leading cause of mid-term mortality.

Vortrag Davos 2004, Pericarditis constrictiva mit Perikarderguss Schwierige Diagnose mit erheblichen therapeutischen Konsequenzen

Nicht nur das Perikard, sondern auch das Epikard spielen bei der Entwicklung der Pericarditis constrictiva eine Rolle. Eine Verdickung des Perikards muss aber nicht bestehen; das Krankheitsbild kann sogar bei Fehlen des Perikards auftreten [1, 2]. So wird die Erkrankung nach Bypassund Mesotheliomoperationen beobachtet [3]. Liegt ein Perikarderguss oder sogar eine Tamponade vor, wird die Konstriktion erst deutlich, wenn nach Ablassen des Ergusses der rechtsatriale Druck hoch bleibt, der intraperikardiale Druck aber abfällt. Es handelt sich um das klinische Bild der „feuchten Pericarditis constrictiva“, auf die schon früh E.W. Hancock hingewiesen hat [4]. Sinkt nach Ablassen der Perikardflüssigkeit der intraperikardiale Druck auf Normwerte ab und bleibt der zentralvenöse Druck hoch, ist die Diagnose gesichert. Wird der Druck in den beiden Höhlen gemessen, liegt oft der intraperikardiale Druck etwas unter dem intraatrialen Druck [1, 4, 5}. Die Autoren empfehlen wegen der großen Schwierigkeit der Diagnostik sogar die Perikarddrainage im Herzkatheterlabor, um die Drücke messen zu können [5, 6]. Der Vorteil liegt darin, dass bei Persistenz eines erhöhten zentralvenösen und damit rechtsatrialen Druckes die Verdachtsdiagnose eines Rezidivs ausgeschlossen und eine erneute Punktion oder Operation vermieden werden kann [6]. Natürlich kann dies bei Einlegen eines Pigtails zur Drainage gut vermieden und auch bettseitig nach Punktion in einem Eingriffsraum oder im Echokardiographielabor gemessen werden. Im vorliegenden Fall wird die Diagnosestellung einer feuchten Pericarditis constrictiva ohne Tamponadezeichen beschrieben. Im einem auswärtigen Krankenhaus wurde eine koronare Herzerkrankung vermutet, da der Patient auch Risikofaktoren hatte. Bei der Aufnahme auf der Intensivstation imponierten die Pleuraergüsse und weniger der Perikarderguss. Der Patient wurde rekompensiert. Im ersten Echokardiogramm fiel der Erguss, aber keine Konstriktion auf. Detaillierte Doppler-Messungen während Inund Exspiration über der Trikuspidalis und Mitralis lieferten keine Variation der Flussgeschwindigkeit um > 25%, so dass die klassischen Doppler-Zeichen der Konstriktion nicht gegeben waren. Allerdings waren die Vorhöfe vergrößert, die Vena cava inferior ohne inspiratorischen Kollaps erweitert und im subkostalen Anschnitt fiel eine Verdickung von Perikard und Epikard auf. Im Computertomogramm war neben dem Perikarderguss subepikardial eine dicke Fettschicht erkennbar, die auch im Magnetresonanztomogramm auffiel. Letztlich war die Herzkatheteruntersuchung diagnoseweisend, da die Druckdifferenz zwischen rechtem und linkem Ventrikel < 5 mmHg, der rechtsventrikuläre Druck < 50 mmHg und das Verhältnis aus rechtsventrikulärem enddiastolischen und systolischen Druck > 0,33 war [7]. Die Myokardbiospie erfolgte, da kein für die Konstriktion typisches Dip-Plateau-Phänomen erkennbar war. Nach Erhalt eines negativen Befundes wurde der Patient zur Operation angemeldet, da eine restriktive Kardiomyopathie, die nach dem Katheterbefund und dem echokardiographischen Ergebnis vermutet worden war, ausgeschlossen werden konnte. Die Operation bestätigte rein makroskopisch die feuchte Pericarditis constrictiva. Histologisch fanden sich typische Zeichen der Perikardvernarbung und Entzündung, deren Genese leider un-

Infections after transcatheter versus surgical aortic valve replacement: mid-term results of 200 consecutive patients

Background Transcatheter aortic valve implantation (TAVI) is the standard therapy for high-risk patients with aortic stenosis (AS). TAVI-outcomes are widely investigated in comparison to surgical aortic valve replacement (SAVR), but less is known about infectious complications after TAVI. We aimed to compare early and mid-term infectious outcomes of patients undergoing TAVI or SAVR. Methods The present study is a prospective single-centre study including 200 consecutive patients between 06/2014-03/2015 undergoing TAVI (either transfemoral or transapical and transaortic, n=47+53=100) or SAVR (either isolated or concomitant with CABG, n=52+48=100). The mean age and log. EuroSCORE were significantly different between both groups (81±6 versus 69±11 years, P<0.001 and 23.1%±13.8% versus 8.7%±9.5%, P<0.001). Primary endpoints included wound healing disorders, respiratory and urinary tract infections and incidence of endocarditis or sepsis within hospital stay. Secondary endpoints included infectious parameters, infectious related rehospitalisation and 2-year mortality. Results Primary endpoints showed no difference in overall TAVI- versus SAVR-groups regarding respiratory- (14% versus 19%, P=0.45), urinary-tract (7% versus 4%, P=0.54) infections, sepsis (5% versus 6%, P=1.0), endocarditis (0% versus 1%, P=1.0) or 30-day mortality (10% versus 4%, P=0.09), except for wound disorders, which were significantly lower in the TAVI-group (1% versus 8%, P=0.035), respectively. Secondary endpoints reported no difference regarding infectious related rehospitalisation (4% versus 4%, P=1.0), but significantly higher 2-year mortality (28% versus 16%, P=0.048) in the TAVI-group. Conclusions So far, little has been studied about infectious complications after TAVI. This study reports no difference between the overall TAVI and SAVR groups regarding infectious complications. However, SAVR group show more wound healing disorders but less mortality than TAVI group.

Hemodynamic changes lead to alterations in aortic diameters and may challenge further stent graft sizing in acute aortic syndrome

Background Precise stent graft sizing in Thoracic endovascular aortic repair (TEVAR) is crucial to receive optimal long-term results. Computed tomography (CT), as the current standard in assessing aortic diameters (ADs), is often performed at initial diagnosis. Since several acute aortic diseases are associated with blood loss and/or volume re-distribution, assessed AD might be influenced by impaired hemodynamic conditions. Intravascular ultrasound (IVUS) offers real-time assessment, especially after hemodynamic restoration, and might help for stent graft choice. Methods We investigated the correlation between CT and later IVUS measurements in elective (n=83) and emergency patients (n=32) at the level distal to the left subclavian artery (LSA), a frequent proximal landing zone in TEVAR. Patients were grouped depending on their shock index (heart rate/systolic blood pressure): emergency patients with diagnosis of acute aortic syndrome, urgently required treatment after admission and had a shock index >1, otherwise were grouped as elective. Basic hemodynamics were assessed for both groups at admission and at definite IVUS-procedure. Results At time of admission the emergency group showed lower blood pressure (99±19.8 vs. 141±24 mmHg; P=0.001) and higher heart rate (98±13 vs. 70±12 bpm; P=0.001) compared to elective patients. By hemodynamic stabilization comparable blood pressure and heart rate were achieved in both groups at time of IVUS. In the emergency group, we found a significantly increase in AD after hemodynamic stabilization, whereas the diameters did not change in the elective group (IVUSmeanvs. CTmean: 5.1±1.0 vs. 0.4±2.2 mm; P=0.001 and IVUSminvs. CTmean: 3.9±1.3 vs. -0.3±2.2 mm; P=0.011). Conclusions IVUS for stent graft sizing is a valuable approach during TEVAR, especially in the light of emergency treatment by offering real-time assistance. Impaired hemodynamic conditions might lead to relevant changes in AD and may strongly influence stent graft choice. In these cases, careful stent graft selection might contribute to avoidance of stent graft related complication.

Erratum to: Imaging for planning of transcatheter aortic valve implantation

Erratum to: Herz (2017) DOI 10.1007/s00059-017-4587-9 In the above mentioned article, two authors were missing. The correct list of authors is as follows: H.A. Hildebrandt1, A.A. Mahabadi1, M. Totzeck1, R.A. Janosi1, A.Y. Lind1, T. Schlosser2, M. Forsting2, T. Rassaf1, P. Kahlert1 1 West-German Heart and Vascular Center Essen, Department of Cardiology andVascularMedicine, Essen University Hospital, Essen, Germany 2 Institute for Diagnostic and Interventional Radiology and Neuroradiology, Essen University Hospital, Essen, Germany Theauthorsapologize for thismistake.

Mitral valve endocarditis leading to acute myocardial and cerebellar infarction in a young adult.

Joerg Barkhausen, MD Department of Diagnostic and Interventional Radiology and Neuroradiology University Hospital Essen Essen, Germany Sirs: Despite advantages in diagnosis and therapy, endocarditis still represents a severe cardiovascular disease with often poor prognosis and potentially live-threatening complications [1–3]. The overall embolism rate in infective endocarditis ranges from about 20 to 50% [4, 5]. Cerebral complications such as strokes are relatively frequent at least prior to antibiotic therapy [6, 7]. Although coronary embolism of fragments of valvular vegetations is not an uncommon finding in autopsy studies of infective endocarditis, clinically apparent myocardial infarction is rarely described [8, 9]. Case Presentation

Non-Invasive Coronary Angiography in a Patient with Chronic Type-A Aortic Dissection

Herz 29 · 2004 · Nr. 5