Andreas Holzamer

Prosthesis sizing for transcatheter aortic valve implantation — Comparison of three dimensional transesophageal echocardiography with multislice computed tomography

BACKGROUND The complex anatomy of the aortic annulus warrants the use of three dimensional (3D) modalities for prosthesis sizing in transcatheter aortic valve implantation (TAVI). Multislice computed tomography (MSCT) has been used for this purpose, but its use may be restricted because of contrast administration. 3D transesophageal echocardiography (3D-TEE) lacks this limitation and data on comparison with MSCT is scarce. We compared 3D-TEE with MSCT for prosthesis sizing in TAVI. METHODS Aortic annulus diameters in the sagittal and coronal plane and annulus areas in 3D-TEE and MSCT were compared in 57 patients undergoing TAVI. Final prosthesis size was left at the operators discretion and the agreement with 3D-TEE and MSCT was calculated. RESULTS Sagittal diameters on 3D-TEE and MSCT correlated well (r=.754, p<.0001) and means were comparable (22.3±2.1 vs. 22.5±2.3 mm; p=0.2; mean difference: -0.3 mm [-3.3-2.8]). On 3D-TEE, coronal diameter and annulus area were significantly smaller (p<.0001 for both) with moderate correlation (r=0.454 and r=0.592). Interobserver variability was comparable for both modalities. TAVI was successful in all patients with no severe post-procedural insufficiency. Final prosthesis size was best predicted by sagittal annulus diameters in 84% and 79% by 3D-TEE and MSCT, respectively. Agreement between both modalities was 77%. CONCLUSIONS Annulus diameters and areas for pre-procedural TAVI assessment by 3D-TEE are significantly smaller than MSCT with exception of sagittal diameters. Using sagittal diameters, both modalities predicted well final prosthesis size and excellent procedural results were obtained. 3D-TEE can thus be a useful alternative in patients with contraindications to MSCT.

Efficiency in Extracorporeal Membrane Oxygenation—Cellular Deposits on Polymethypentene Membranes Increase Resistance to Blood Flow and Reduce Gas Exchange Capacity

Bioline-coated polymethylpentene (PMP) membrane oxygenators (MO) are used for extracorporeal membrane oxygenation (ECMO) to improve gas exchange in patients with severe acute respiratory distress syndrome (ARDS). However, in some patients, long-term durability is limited due to fibrous and cellular accumulations on the gas exchange surface which can increase resistance to blood flow and diffusion path. These surface deposits of PMP MO after removal were studied with scanning electron and fluorescence microscopy techniques. Three of 31 patients supported by a PMP MO in an ECMO setting required a replacement of the oxygenator after a mean support interval of 11 ± 7 days due to an increase in flow resistance and an impairment of the gas exchange capacity. The membrane surface of the MO was covered with a fibrous network with imbedded platelets and red blood cells. A membranous structure composed of single cells and clusters of cells covered large areas of the PMP fibers. We assume that these cellular deposits lower the efficacy of ECMO. The identification of these cells could be a key for future therapeutic interventions and improvements in the development of MO.

Tumor marker carbohydrate antigen 125 predicts adverse outcome after transcatheter aortic valve implantation.

OBJECTIVES This study sought to predict the value of tumor marker carbohydrate antigen 125 (CA125) before and after transcatheter aortic valve implantation (TAVI) for all-cause death and a composite endpoint of death, admission for heart failure, myocardial infarction, and stroke (major adverse cardiac events [MACE]). BACKGROUND Risk stratification after TAVI remains challenging. The use of biomarkers in this setting represents an unmet need. METHODS CA125 was measured in 228 patients before and after TAVI. The association with outcomes was assessed using parametric Cox regression and joint modeling for baseline and longitudinal analyses, respectively. CA125 was evaluated as logarithm transformation and dichotomized by its median value (M1 ≤15.7 U/ml vs. M2 >15.7 U/ml). RESULTS At a median follow-up of 183 days (interquartile range: 63 to 365) and 144 days (interquartile range: 56 to 365), 50 patients (22%) died and 75 patients (33%) experienced MACE. A 3-fold increase in the rates for death and MACE was observed in patients above the median (M2 vs. M1) of CA125 (5.2 vs. 1.6 per 10 person-years and 8.3 vs. 3.3 per 10 person-years, respectively; p for both <0.001). In a multivariable analysis adjusted for logistic EuroSCORE, New York Heart Association functional class III/IV, and device success, baseline values of CA125 (M2 vs. M1) independently predicted death (hazard ratio [HR]: 2.18; 95% confidence interval [CI]: 1.11 to 4.26; p = 0.023) and MACE (HR: 1.77; 95% CI: 1.05 to 2.98; p = 0.031). In the longitudinal analysis, lnCA125 as a time-varying exposure, was highly associated with both endpoints: HR: 1.47; 95% CI: 1.01 to 2.14; p = 0.043 and HR: 2.26; 95% CI: 1.28 to 3.98; p = 0.005, for death and MACE, respectively. CONCLUSIONS Serum levels of CA125 before and after TAVI independently predict death and MACE.

Emergency and prophylactic use of miniaturized veno-arterial extracorporeal membrane oxygenation in transcatheter aortic valve implantation

To report our centers experience using veno‐arterial extracorporeal membrane oxygenation (vaECMO) in transcatheter aortic valve implantation (TAVI).

A unique access for the ablation catheter to treat electrical storm in a patient with extracorporeal life support

AIMS Extracorporeal membrane oxygenation (ECMO) is a very effective bridging therapy in patients with cardiogenic shock. To perform coronary angiography in these patients our group developed an unique system to get urgent vascular access with minimal additional vascular complication risk. The 6 Fr coronary catheters are introduced through a standard Y-connector, which is inserted into the arterial cannula of the ECMO-line close to the patient, the blind end of which is then equipped with a haemostatic valve (Check-Flo Performer accessory adapter, Cook Medical, USA). To the best of our knowledge, we here present the first patient, in whom this system had been used to insert an 8 Fr radiofrequency ablation catheter to treat incessant ventricular fibrillation. METHODS AND RESULTS A 66-year-old patient had been transferred with electrical storm 5 days after an acute MI. After failed interventional and medical therapies an ECMO system had been inserted (right femoral artery cannula 15 Fr, left femoral vein cannula 21 Fr) and an electrophysiological study had been performed because of incessant ventricular fibrillation episodes, which always were induced by the same ventricular premature beat (VPB). During this first EP study over the left femoral artery the VPB could be targeted and successfully ablated. Unfortunately the VPB recovered again after some days so a second EP study had to be performed. This time the left femoral artery could not be used because of a postinterventional complication so we used the arterial cannula of the ECMO system as the access for the ablation catheter using a Y-connector. Using this way again a successful ablation procedure could be performed, after getting familiar with manipulation the ablation catheter over the ECMO cannula and with the help of different curved ablation catheters. The issue of compromising of the effective lumen of the arterial cannula by the ablation catheter`s cross sectional area could be overcome with increasing the rotational speed of the V-A ECMO. CONCLUSION Ablation of ventricular arrhythmias using a Y-connector to insert the ablation catheter into the arterial cannula is feasible in patients with a V-A ECMO system avoiding additional arterial puncture with potentially major vascular complications in critically ill patients. Manipulation of the catheter is not as easy as using a standard sheath but can well be performed after a short habituation.

Emergency extracorporeal membrane oxygenation in transcatheter aortic valve implantation: A two-center experience of incidence, outcome and temporal trends from 2010 to 2015

Although the incidence of periprocedural complications has decreased in transcatheter aortic valve implantation (TAVI), life‐threatening complications occur and emergency veno‐arterial extracorporeal membrane oxygenation (vaECMO) can provide immediate circulatory stabilization. We report our two‐center experience of vaECMO during life‐threatening complications in TAVI.

Long-term survival and quality of life after extracorporeal life support: a 10-year report

OBJECTIVES Information is lacking about long-term survival and quality of life (QOL) after treating patients on extracorporeal life support. METHODS Outcome data were assessed by phone interviews, a QOL analysis using the EuroQol 5-dimensions questionnaire and a retrospective inquiry of the Regensburg ECMO Registry database for the decade 2006-2015. A statistical analysis was obtained by comparing patients with a cardiosurgical intervention (CS = 189 patients) with those without (w/oCS = 307 patients). RESULTS Survival to discharge in the w/oCS group was higher than that in the CS group (w/oCS: 41.7% vs CS: 29.5%; P  = 0.004). A Kaplan-Meier analysis showed a significant difference between both groups in favour of patients w/oCS (log rank P  = 0.02). This difference was no longer statistically significant after propensity score matching ( P  = 0.07). The 1- and 2-year survival rates of discharged patients were 67% and 50% in the w/oCS group vs 60% and 45% in the CS group (log rank P  = 0.29). Eighty-two patients answered the QOL questionnaire after a mean follow-up time of 4.2 ± 2.9 years. A total of 75% could handle their daily life; 57% were not limited in their usual activities. Mobility impairment was noted in 50%; 25% returned to work or school. There were no differences in the EuroQol 5-dimension indices between the patient groups. However, compared to a normative age-matched population, significantly lower indices were calculated. CONCLUSIONS Long-term survival rates in patients requiring extracorporeal life support are acceptable with a probable advantage for patients without an operation and a narrowed QOL. The results are promising and encouraging, but there is also a need for improvement.

Predictors of Need for Permanent Pacemaker Implantation and Conduction Abnormalities With a Novel Self-expanding Transcatheter Heart Valve

INTRODUCTION AND OBJECTIVES The incidence of permanent pacemaker implantation (PPI) and new conduction abnormalities (CA) with the ACURATE neo (Symetis S.A., Eclubens, Switzerland) has not been studied in detail. We aimed to analyze their predictors, evaluating patient- and device-related factors, including implantation depth and device-to-annulus ratio (DAR). METHODS Two analyses of a multicenter population were performed: new PPI in pacemaker-naive patients (n = 283), and PPI/new-CA in patients without prior CA or pacemaker (n = 232). RESULTS A new PPI was required in 9.9% of patients, who had a higher body mass index, higher rate of right bundle branch block and bradycardia. Neither implantation depth nor DAR differed in patients with PPI compared with those without. In the multivariable analysis neither DAR (OR, 1.010; 95%CI, 0.967-1.055; P = .7) nor implantation depth (OR, 0.972; 95%CI, 0.743-1.272; P = .8) predicted PPI. Only high body mass index, bradycardia and right bundle branch block persisted as independent predictors. PPI/new-onset CA occurred in 22.8% of patients and was associated with a higher logistic EuroSCORE. Neither implantation depth nor DAR differed in patients with PPI/new-CA vs those without (7.3 ± 1.9 vs 7.1 ± 1.5mm; P = .6 and 41.0 ± 7.9 vs 42.2 ± 10.1%; P = .4). The only predictor of PPI/new-CA was a higher logistic EuroSCORE (OR, 1.039; 95%CI, [1.008-1.071]; P = .013). CONCLUSIONS New PPI and new-onset CA rates were low with the ACURATE neo. These were mainly influenced by patient characteristics and not by device-depending factors.

Improvement in Risk Stratification in Transcatheter Aortic Valve Implantation Using a Combination of the Tumor Marker CA125 and the Logistic EuroSCORE.

INTRODUCTION AND OBJECTIVES Conventional risk scores have not been accurate in predicting peri- and postprocedural risk of patients undergoing transcatheter aortic valve implantation (TAVI). Elevated levels of the tumor marker carbohydrate antigen 125 (CA125) have been linked to adverse outcomes after TAVI. We studied the additional value of CA125 to that of the EuroSCORE in predicting long-term mortality after TAVI. METHODS AND RESULTS During a median follow-up of 59 weeks, 115 of 422 patients (27%) died after TAVI. Mortality was higher with elevated CA125 (> 30 U/mL) and EuroSCORE (> median) (47% vs 20%, P<.001 and 38% vs 16%, P<.001, respectively). In the multivariable analysis, CA125 (> 30 U/mL) remained an independent predictor of mortality (hazard ratio [HR], 2.16; 95% confidence interval [95%CI], 1.48-3.15; P<.001) and improved the predictive capability of the model (C-statistic: 0.736 vs 0.731) and the net reclassification index (51% 95%CI, 33-73) with an integrated discriminative improvement of 3.5% (95%CI, 0.5-8.4). A new variable (CA125-EuroSCORE) was created, with the combinations of the 2 possible binary states of these variables (+, elevated, -, not elevated; C1: CA125- EuroSCORE-; C2: CA125+ EuroSCORE-; C3: CA125- EuroSCORE+; C4: CA125+ EuroSCORE+). Patients in C1 exhibited the lowest cumulative mortality rate (14% [26 of 181]). Mortality was intermediate for C2 (CA125 > 30 U/mL and EuroSCORE ≤ median) and C3 (CA125 ≤ 30 U/mL and EuroSCORE > median): 27% (8 of 30) and 28% (37 of 131), respectively. Patients in C4 (CA125 > 30 U/mL and EuroSCORE > median) exhibited the highest mortality (55% [44 of 80], P-value for trend<.001). CONCLUSIONS CA125 offers additional prognostic information beyond that obtained by the EuroSCORE. Elevation of both markers was associated with a poor prognosis.

TCT-730 A multicenter analysis of incidence and predictors for permanent pacemaker implantations and new conduction abnormalities with a novel self-expandable transcatheter heart valve

METHODS We searched Pubmed/Medline and Cochrane Central Register of Controlled Trials for all studies that evaluated outcomes after TAVR and stratified at least one of the studied endpoints by DM status. Primary end point was all-cause mortality at one year. Secondary end points were early (up to 30 days) mortality, acute kidney injury (AKI), cerebrovascular accidents (CVAs), major bleeding and major vascular complications. Pooled odds ratio (OR) and 95% confidence intervals (CI) were calculated using random effect models.