Christoph Hammerstingl

Risk and Fate of Cerebral Embolism After Transfemoral Aortic Valve Implantation : A Prospective Pilot Study With Diffusion-Weighted Magnetic Resonance Imaging

OBJECTIVESnThe aim of this study was prospective investigation of silent and clinically apparent cerebral embolic events and neurological impairment after transfemoral aortic valve implantation (TAVI).nnnBACKGROUNDnTAVI is a novel therapeutic approach for multimorbid patients with severe aortic stenosis. We investigated peri-interventional cerebral embolism with diffusion-weighted magnetic resonance imaging (DW-MRI) and its relationship to clinical and serologic parameters of brain injury.nnnMETHODSnCerebral DW-MRI was performed before, directly, and 3 months after TAVI with the current third-generation self-expanding CoreValve (Medtronic, Minneapolis, Minnesota) prosthesis. At the timepoints of the serial MRI studies, focal neurological impairment was assessed according to the National Institutes of Health Stroke Scale (NIHSS), and serum concentration of neuron-specific enolase (NSE), a marker of the volume of brain tissue involved in an ischemic event, were determined.nnnRESULTSnThirty patients were enrolled; 22 completed the imaging protocol. Three patients (10%) had new neurological findings after TAVI, of whom only 1 (3.6%) had a permanent neurological impairment. Of the 22 TAVI patients with complete imaging data, 16 (72.7%) had 75 new cerebral lesions after TAVI presumed to be embolic. The NIHSS and NSE were not correlated with DW-MRI lesions.nnnCONCLUSIONSnThe incidence of clinically silent peri-interventional cerebral embolic lesions after TAVI is high. However, in this cohort of 30 patients, the incidence of persistent neurological impairment was low. (Incidence and Severity of Silent and Apparent Cerebral Embolism After Conventional and Minimal-invasive Transfemoral Aortic Valve Replacement; NCT00883285).

Aortic regurgitation index defines severity of peri-prosthetic regurgitation and predicts outcome in patients after transcatheter aortic valve implantation.

OBJECTIVESnThe aim of this study was to provide a simple, reproducible, and point-of-care assessment of peri-prosthetic aortic regurgitation (periAR) during transcatheter aortic valve implantation (TAVI) and to decipher the impact of this peri-procedural parameter on outcome.nnnBACKGROUNDnBecause periAR after TAVI might be associated with adverse outcome, precise quantification of periAR is of paramount importance but remains technically challenging.nnnMETHODSnThe severity of periAR was prospectively evaluated in 146 patients treated with the Medtronic CoreValve (Minneapolis, Minnesota) prosthesis by echocardiography, angiography, and measurement of the aortic regurgitation (AR) index, which is calculated as ratio of the gradient between diastolic blood pressure (DBP) and left ventricular end-diastolic pressure (LVEDP) to systolic blood pressure (SBP): [(DBP - LVEDP)/SBP] × 100.nnnRESULTSnAfter TAVI, 53 patients (36.3%) showed no signs of periAR and 71 patients (48.6%) showed only mild periAR, whereas 18 patients (12.3%) and 4 patients (2.7%) suffered from moderate and severe periAR, respectively. The AR index decreased stepwise from 31.7 ± 10.4 in patients without periAR, to 28.0 ± 8.5 with mild periAR, 19.6 ± 7.6 with moderate periAR, and 7.6 ± 2.6 with severe periAR (p < 0.001), respectively. Patients with AR index <25 had a significantly increased 1-year mortality risk compared with patients with AR index ≥25 (46.0% vs. 16.7%; p < 0.001). The AR index provided additional prognostic information beyond the echocardiographically assessed severity of periAR and independently predicted 1-year mortality (hazard ratio: 2.9, 95% confidence interval: 1.3 to 6.4; p = 0.009).nnnCONCLUSIONSnThe assessment of the AR index allows a precise judgment of periAR, independently predicts 1-year mortality after TAVI, and provides additional prognostic information that is complementary to the echocardiographically assessed severity of periAR.

Renal Function as Predictor of Mortality in Patients After Percutaneous Transcatheter Aortic Valve Implantation

OBJECTIVESnThe aim of this study was to determine the influence of baseline renal function and periprocedural acute kidney injury (AKI) on prognosis after transcatheter aortic valve implantation (TAVI).nnnBACKGROUNDnEvidence is growing that renal function is a major predictor of mortality in patients after TAVI.nnnMETHODSnTAVI was performed with the 18-F CoreValve prosthesis via transfemoral access. All-cause mortality was determined 30 days and 1 year after TAVI in 77 patients with a mean Society of Thoracic Surgeons mortality score of 9.3 ± 6.1% and a mean logistic European System for Cardiac Operative Risk Evaluation of 31.2 ± 17.6%.nnnRESULTSnOverall procedural success rate was 98% with 1 periprocedural death. The 30-day mortality was 10%, and 1-year mortality was 26%. The mortality risk increased stepwise across quartiles of baseline serum creatinine. An AKI occurred in 20 of 77 patients: 12 patients (60%) with AKI died during follow-up. The incidence of AKI was related to peripheral arterial disease (65% vs. 39%; p = 0.04), the occurrence of a systemic inflammatory response syndrome (60% vs. 21%, p = 0.002), and post-procedural peri-prosthetic regurgitation ≥2+ (35% vs. 9%, p = 0.02). Impaired renal function at baseline reflected by serum creatinine ≥1.58 mg/dl (hazard ratio: 3.9, 95% confidence interval: 1.6 to 9.5; p = 0.002) and the occurrence of AKI (hazard ratio: 5.9, 95% confidence interval: 2.4 to 14.5, p < 0.001) that was not related to the amount of contrast dye were strong predictors of 1-year mortality after TAVI.nnnCONCLUSIONSnImpaired renal function at baseline and the occurrence of periprocedural AKI, independent whether renal function returns to baseline or not, are strong predictors of 30-day and 1-year mortality after TAVI.

Systemic inflammatory response syndrome predicts increased mortality in patients after transcatheter aortic valve implantation

AIMSnThe outcome of patients undergoing surgical or interventional therapy is unfavourably influenced by severe systemic inflammation. We assessed the impact of a systemic inflammatory response syndrome (SIRS) on the outcome after transcatheter aortic valve implantation (TAVI).nnnMETHODS AND RESULTSnOne hundred and fifty-two high-risk patients (mean age: 80.5 ± 6.5 years, mean logistic EuroSCORE: 30.4 ± 8.1%) with symptomatic severe aortic stenosis underwent TAVI. Proinflammatory cytokines [interleukin-6 (IL-6) and interleukin-8 (IL-8)], and acute phase reactants [C-reactive protein (CRP) and procalcitonin (PCT)] were measured at baseline and 1, 4, 24, 48, 72 h, and 7 days after TAVI. Sixty-one of 152 patients developed SIRS during the first 48 h after TAVI. Systemic inflammatory response syndrome patients were characterized by leucocytosis ≥12 × 10(9)/L (83.6 vs. 12.1%; P < 0.001), hyperventilation (80.3 vs. 35.2%; P < 0.001), tachycardia (37.7 vs. 9.9%; P < 0.001), and fever (31.1 vs. 3.3%; P < 0.001) compared with patients without SIRS. Furthermore, the occurrence of SIRS was characterized by a significantly elevated release of IL-6 and IL-8 with subsequent increase in the leucocyte count, CRP, and PCT. Major vascular complications [odds ratio (OR) 5.1, 95% confidence interval (CI): 1.3-19.6; P = 0.018] and the number of ventricular pacing runs (OR 1.7, 95% CI: 1.1-2.8; P = 0.025) were independent predictors of SIRS. The occurrence of SIRS was related to 30-day and 1-year mortality (18.0 vs. 1.1% and 52.5 vs. 9.9%, respectively; P < 0.001) and independently predicted 1-year mortality risk (hazard ratio: 4.3, 95% CI: 1.9-9.9; P < 0.001).nnnCONCLUSIONSnSIRS may occur after TAVI and is a strong predictor of mortality. The development of SIRS could be easily identified by a significant increase in the leucocyte count shortly after TAVI.

Pulmonary Hypertension in Patients with Chronic Kidney Disease on Dialysis and without Dialysis: Results of the PEPPER-Study

Pulmonary hypertension (PH) is common in patients with dialysis-dependent chronic kidney disease and is an independent predictor of mortality. However, specific hemodynamics of the pulmonary circulation, changes induced by hemodialysis and characterization into pre- or postcapillary PH have not been evaluated in patients with chronic kidney disease. We assessed consecutive patients with end-stage chronic kidney disease in WHO FC≥II with dyspnea unexplained by other causes on hemodialysis (group 1, nu200a=u200a31) or without dialysis (group 2, nu200a=u200a31) using right heart catheterization (RHC). In group 1, RHC was performed before and after dialysis. In end-stage chronic kidney disease, prevalence of precapillary PH was 13% (4/31), and postcapillary PH was discovered in 65% (20/31). All four cases of precapillary PH were unmasked after dialysis. In group 2, two cases of precapillary PH were detected (6%), and postcapillary PH was diagnosed in 22 cases (71%). This is the first study examining a large cohort of patients with chronic kidney disease invasively by RHC for the prevalence of PH. The prevalence of precapillary PH was 13% in patients with end-stage kidney disease. That suggests careful screening for precapillary PH in this selected patient population. RHC should be performed after hemodialysis.

Persistence of iatrogenic atrial septal defect after interventional mitral valve repair with the MitraClip system: a note of caution.

OBJECTIVESnThe purpose of this study was to investigate the persistence rates of iatrogenic atrial septal defect (iASD) after interventional edge-to-edge repair with serial transesophageal echocardiography examinations and close clinical follow-up (FU).nnnBACKGROUNDnTranscatheter mitral valve repair (TMVR) with the MitraClip system (Abbott Vascular, Abbott Park, Illinois) is a therapeutic alternative to surgery in selected high-risk patients. Clip placement requires interatrial transseptal puncture and meticulous manipulation of the steerable sheath. The persistence of iASD after MitraClip procedures and its clinical relevance is unknown.nnnMETHODSnA total of 66 patients (76.7% male, mean age 77.1 ± 7.9 years) with symptomatic mitral regurgitation (MR) at prohibitive surgical risk (EuroSCORE II 10.1 ± 6.1%) underwent MitraClip procedures and completed 6 months of FU.nnnRESULTSnTransesophageal echocardiography after FU showed persistent iASD in 50% of cases. Patients with iASD did not significantly differ from patients without ASD concerning baseline characteristics, New York Heart Association functional class, severity of MR, and acute procedural success rates (p > 0.05). When comparing procedural details and hemodynamic measures between groups, MitraClip procedures took longer in patients without iASD (82.4 ± 39.7 min vs. 68.9 ± 45.5 min; p = 0.05), and echocardiography after FU showed less decrease of systolic pulmonary artery pressures in the iASD group (-1.6 ± 14.1 mm Hg vs. 9.3 ± 17.4 mm Hg; p = 0.02). Clinically, patients with iASD presented more often with New York Heart Association functional classes >II after FU (57% vs. 30%; p = 0.04), showed higher levels of N-terminal pro-brain natriuretic peptide (6,667.3 ± 7,363.9 ng/dl vs. 4,835.9 ± 6,681.7 ng/dl; p = 0.05), and had less improvement in 6-min walking distances (20.8 ± 107.4 m vs. 114.6 ± 116.4 m; p = 0.001). Patients with iASD showed higher death rates during 6 months (16.6% vs. 3.3%; p = 0.05). Cox regression analysis found that only persistence of iASD (p = 0.04) was associated with 6-month survival.nnnCONCLUSIONSnThe persistence rate of 50% iASD after MitraClip procedures is considerably high. Persistent interatrial shunting was associated with worse clinical outcomes and increased mortality. Further studies are warranted to investigate if persistent interatrial shunting is the mediator or marker of advanced disease in these patients.

Three-Dimensional Speckle-Tracking Analysis of Left Ventricular Function after Transcatheter Aortic Valve Implantation

BACKGROUNDnThe acute and long-term effects of transcatheter aortic valve implantation (TAVI) in patients with aortic valve stenosis on left ventricular (LV) function are controversial. The aim of this study was to determine the effect of TAVI on LV function with two-dimensional (2D) and three-dimensional (3D) speckle-tracking analysis of LV deformation capability.nnnMETHODSnPatients underwent standardized 2D and 3D transthoracic echocardiography before TAVI and after 6 months of follow-up, including 3D and 2D LV deformation imaging.nnnRESULTSnForty-four patients (mean age, 81.7 ± 5.5 years; 21 men [47.7%]; mean body mass index, 26.3 ± 5.1 kg/m(2); mean logistic European System for Cardiac Operative Risk Evaluation score, 24.4 ± 13.7%) undergoing TAVI were prospectively included. After follow-up, mean 3D LV ejection fraction (LVEF) (35.4 ± 13.1% vs 40.6 ± 12.6%, P = .004), 3D LV volumes (end-systolic volume, 85.9 ± 41.8 vs 65.9 ± 33.7 mL, P < .001; end-diastolic volume, 127.6 ± 40.7 vs 106.4 ± 40.9 mL, P = .001), 3D global longitudinal strain (-9.9 ± 3.7% vs -12.6 ± 4.2%, P < .001), and 3D LV twist (6.1 ± 4.3° vs 8.5 ± 6.9°, P = .025) were relevantly improved. LV improvement was pronounced in patients with decreased baseline LV function (area under the curve, 0.78; P < .001), with a cutoff value for 3D LVEF of ≤37% to identify functional responders to TAVI. After follow-up, patients with 3D LVEFs ≤ 37% showed a significant improvements in 3D LVEF (26.0 ± 7.6% vs 35.9 ± 11.7%, P < .001), 3D LV volumes (end-diastolic volume, 147.4 ± 40.6 vs 117.1 ± 45.5 mL, P = .001; end-systolic volume, 110.9 ± 39.2 vs 77.5 ± 37.2 mL, P < .001), 3D global longitudinal strain (-7.8 ± 2.7% vs -11.3 ± 4.2%, P < .001), and 3D LV twist (5.6 ± 4.2° vs 8.0 ± 5.6°, P = .047), whereas in patients with 3D LVEFs > 37%, only 3D global longitudinal strain was relevantly altered (-12.5 ± 3.1% vs -14.2 ± 3.8%, P = .04). Compared with 2D transthoracic echocardiography, 3D LV functional imaging allowed significantly faster image acquisition and data analysis (P < .0001). New York Heart Association functional class improved significantly in both groups (3D LVEF ≤ 37%, from 3.1 ± 0.5 to 2.0 ± 0.6, P < .001; 3D LVEF > 37%, from 2.7 ± 6.7 to 1.5 ± 0.7, P < .001), whereas a significant amelioration of N-terminal pro-brain natriuretic peptide was observed only in patients with baseline 3D LVEFs ≤ 37% (10,314.64 ± 11,682.2 vs 3,398.7 ± 3,598.9 pg/mL, P = .02; 3D LVEF > 37%, 10,306.4 ± 32,000.5 vs 2,868.0 ± 3,816.7 pg/mL, P = .12).nnnCONCLUSIONSnOur results indicate significant improvements of LV global and longitudinal function and clinical parameters 6 months after TAVI that are pronounced in patients with impaired baseline LV function. Compared with 2D LV functional imaging, 3D speckle-tracking imaging allowed significantly faster image acquisition and data analysis.

Resolution of giant left atrial appendage thrombus with rivaroxaban

doi:10.1160/TH12-11-0821 Thromb Haemost 2013; 109: 583–584 A 64-year-old man was transferred to our hospital for external cardioversion (ECV) of symptomatic persistent atrial fibrillation (AF). At the time of hospital admission the patient presented with functional NYHA class III; he had a clinical history of symptomatic coronary artery disease, ischaemic cardiomyopathy with severely impaired left ventricular function, and chronic kidney disease stage 3B to 4 (creatinine clearance [CrCL] 29 ml/minute). Pretreatment with the vitamin-K antagonist (VKA) phenprocoumon was instituted in 2006 due to a high AF related thromboembolic risk with an actual CHA2DS2VASc score of 6. Since the international normalised ratio (INR) was not well controlled before elective ECV we performed a transesophageal echocardiography (TEE), which revealed a small thrombus formation (11 x 12 mm) in the apex of the left atrial appendage (LAA) (▶ Figure 1 A). Therefore, ECV was deferred for six weeks under closely controlled VKA therapy with levels of INR ranging between 2.5 – 3.5 (mean 3.2 ± 0.7, range 2.4 to 4.2). Interestingly, repeated TEE (▶ Figure 1 B) showed a markedly increased giant thrombus mass (12 x 45mm) now protruding into the left atrium. In general VKAs have a slow onset of action and their indirect anticoagulant activity depends on clearance of the vitamin K–dependent clotting proteins and replacement with functionally impaired factors (1). In contrast to current guidelines, there is increasing evidence that VKAs have a poor capability to resolve large intracardiac thrombi. Therefore, we decided to switch oral anticoagulation (OAC) to the direct factor Xa (FXa) inhibitor rivaroxaban dosed with 15 mg once daily. After four weeks of rivaroxaban treatment TEE showed a relevantly decreased thrombus size (▶ Figure 1 C) and a complete thrombus resolution was achieved after six weeks of anticoagulant therapy with the FXa inhibitor (▶ Figure 1 D). Finally, ECV was performed successfully without clinical signs of cardiac embolism and the patient was discharged in good medical conditions under continued anticoagulant treatment with rivaroxaban. To the best of our knowledge this is the first documented case of LAA thrombus resolution under rivaroxaban therapy and illustrates some clinically important characteristics of the new direct acting FXa inhibitor. First, in contrast to indirect acting VKAs, FXa inhibitors have the potential to (a) prevent de novo thrombus formation and more importantly (b) to resolve established thrombi by direct inhibition of free and thrombusassociated FXa. Thereby they reduce clot-induced fibrinopeptide A generation to a similar extent as hirudin, a potent inhibitor of thrombin (2).

Mechanical occlusion of the left atrial appendage.

Introduction: Oral anticoagulation therapy reduces significantly the risk of thromboembolism in patients with atrial fibrillation. However, effective oral anticoagulation therapy is not feasible in all patients. The interventional occlusion of the left atrial appendage may reduce the risk of thromboembolism in the latter patients. The aim of this prospective study was to assess the feasibility, safety, and technical aspects of interventionally occluding the left atrial appendage.

The revised EuroSCORE II for the prediction of mortality in patients undergoing transcatheter aortic valve implantation

BackgroundThe assessment of procedural risk is crucial in patients with severe symptomatic aortic stenosis. Logistic EuroSCORE and STS score are currently used to estimate procedural risk and mortality for surgical and transcatheter aortic valve implantation (TAVI). The recently published EuroSCORE II might provide a helpful tool.MethodsThe new EuroSCORE II was calculated in 206 patients undergoing transfemoral TAVI and compared to the established logistic EuroSCORE and STS mortality score. Discriminative power and calibration of each test was statistically evaluated.Results30-day and 1-year mortality rates were 6.8xa0% (14/206) and 27.2xa0% (56/206). In-hospital mortality rate was 29.2xa0±xa017.8xa0% with logistic EuroSCORE, 9.5xa0±xa06.8xa0% with STS score, and 9.22xa0±xa07.12xa0% with EuroSCORE II: Logistic EuroSCORE and EuroSCORE II were significantly increased in non-survivors compared to survivors at 30xa0days and at 1xa0year. EuroSCORE II and STS score (rxa0=xa00.49, pxa0<xa00.001) showed moderate correlation, whereas strong correlation was found between EuroSCORE II and logistic EuroSCORE (rxa0=xa00.71, pxa0<xa00.001). ROC curve analyses for the prediction of 30-day mortality (AUC 0.79 vs. 0.69 vs. 0.71) and 1-year mortality (AUC 0.72 vs. 0.70 vs. 0.70) were performed. Statistical comparison revealed no difference between the AUCs (pxa0>xa00.05).ConclusionIn percutaneous TAVI patients, 30-day mortality was best approximated by the new EuroSCORE II, whereas the logistic EuroSCORE best reflected 1-year mortality. However, EuroSCORE II does not provide additional prognostic information beyond the established logistic EuroSCORE. For more exact risk prediction in TAVI, a distinct TAVI risk score would be desirable.